Burns Flashcards
Burn
Thermal injury that destroys layers of skin
Rule of 9s
Used with adults
- divides body into 9s or multiples of 9s to calculate total body surface area of burns
Lund-Browder chart
Children/infants
- more accurate method of calculating total body surface area
Superficial/1st degree burn
- involves superficial epidermis
- pain: min to mod, no blistering, min erythema
- healing time: 3-7 days
Superficial partial thickness/superficial 2nd degree burn
- involves epidermis & upper dermis layers
- pain: significant, wet blistering, erythema present
- healing time: 1-3 week
Deep partial thickness/deep 2nd degree burns
- involves epidermis, deep dermis, hair follicles, sweat glands
- pain: severe even to light touch
- erythema present w/without blisters
- burn has high risk of turning into full-thickness burn because of infection; consider grafting to prevent infection
- may have impaired sensation
- high potential for hypertrophic scar
- healing time varies from 3-5 weeks
Full thickness/3rd degree burn
- involves epidermis, dermis, hair follicles, sweat glands, nerve endings
- burn: pain free, no sensation to light touch, pale, nonblanching
- requires skin graft
- extremely high potential for hypertrophic scar
Subdermal burn
- full-thickness burn with damage to underlying tissue (fat, muscles, bone)
- charring present; may have exposed fat, tendons, muscles
- if burn is electrical: destruction of nerve along pathway is present
- peripheral nerve damage is significant
- requires surgical intervention for wound closure or amputation
- extremely high potential for hypertrophic scar
Mechanisms of burns
- Thermal: heat, cold, scald, flame
- Radiation: sunburn, x-ray, radiation therapy for cancer patients
- Chemical: acid (sulfuric acid, hydrochloric acid), alkali (dry lime, potassium hydroxide, sodium hydroxide)
- Electrical burn: high voltage vs low voltage
- Burn results in tissue necrosis rather than direct heat production
Chemical burn
Which is more severe: alkali or acid burn
Alkali
Which is more dangerous: high voltage or low voltage electrical burn?
Low voltage: at the same current
-causes greater muscle contraction, makes it more difficult for person to voluntarily control muscles to release electrified object
Causes single muscle contraction & throws victim from the source, client more likely to have blunt trauma along with burn
High voltage direct current
Emergent phase medical treatment focuses on
Sustaining life, controlling infection, manage pain
— can include IVs, intubation, escharotomy, fasciotomy, wound dressings w/anti microbial ointment for infection control, universal precautions for medical staff & family
Phase 0-72 hrs after injury
Emergent phase
Emergent phase: sustaining life
- Risk of dehydration
- Hypo or hyperthermia: no temp control
- Fluid resuscitation
- Cardiopulmonary stability
- Escharotomy & fasciotomy
Fluid resuscitation
Rapid leakage of IV fluid into surrounding extra vascular tissues = decreased plasma & blood volume, reduced cardiac output
When is cardiopulmonary stability important?
If respiratory tract has sustained smoke inhalation injury
What leads to compartment syndrome?
The inelasticity of the eschar (burned tissue) increasing internal pressure within fascia compartments
Symptoms of compartment syndrome
- paresthesia
- coldness
- decreased/absent pulse in extremities
Escharotomy & fasciotomy
Release pressure within fascia compartments
- Escharotomy: surgical excision of eschars
- Fasciotomy: incision into the fascia
What do wound dressing products do?
- protect wound against infection
- superficially debride wound & provide comfort
Types of wound dressings
- Topical antibiotics
- Biological dressing
- Nonbiological skin-substitute dressings: biosynthetic products such as biobrane
Biological dressing types
- Xenografts: bovine skin, processed pig skin
- Allograft: human cadaver skin
What pharmacological tx is used during emergent phase?
Narcotic analgesics
Phase occurring 72 hours after injury or until wound is closed (days or months)
Acute phase
Acute phase focuses on
Infection control, grafts, biological dressings, psychological support & team communication
Surgical intervention during acute phase
- Escharotomy & debridgement
- removal of burned/dead skin to allow new vascularized skin to close up wound
Autograft
Transplantation of person’s own skin from unburned donor suite to burned receiving site
Split-thickness skin graft
- full epidermal & partial dermal layer taken from donor site
- change of graft survival is high
Full-thickness skin graft
- full thickness of epidermal & dermal layers + % of fat layers taken from donor site
- chance of graft survival less
- outcome functionally/cosmetically better if graft adherence occurs
Meshed versus sheet graft
- meshed: donor graft is “meshed” & stretched to cover greater area of receiving area
- sheet: donor graft removed & laid down on receiving area as is
Rehabilitation phase
- skin grafts
- reconstruction surgery as needed for movement/function
During emergent phase, what is the splinting protocol?
Antideformity positions
- hands: intrinsic plus (MCP hyper flexion, PIP hyperextension)
- oppose client’s posture
- neck, elbows, knees: extension (generally)
- shoulder: abduction
- hip: extension
- anti-frog leg and anti-foot drop for LE
What phase includes clinical observation of bod parts affected by burns and information gathering on PLOF?
Emergent phase
What phase of OT eval includes ADLs, psychosocial aspects, communication, cognition, ROM, muscle strength, pain?
Acute phase
OT intervention during acute phase
Splinting, positioning in antideformity position, edema management, early participation in ADL, client/caregiver ed
Anticontracture positioning during acute phase
- neck: neutral to slight extension
- chest/abdomen: trunk extension, shoulder retraction
- axilla: shoulder abduction 100-120 deg, slight ER
- elbow: extension
-FA: neutral to supination - wrist: (Dorsal: neutral to 30 deg ext), (volar: 30-45 deg ext)
- hand: (Metacarpal: 70 deg flex), (IP: 0 deg ext), thumb: abducted & extended
- hip: 10-15 deg abd, neutral extension
- knee: extension; anterior burn: slight flexion
- ankle: neutral to 5 deg dorsiflexion
How to manage edema during acute phase
Elevation of extremities, AROM if allowed, wrapping with elastic bandage unless bulky wound dressing is used
ROM program during acute phase (precautions)
No PROM or AROM with exposed tendons or recent grafts (wait 5-7 days)
- otherwise implement as tolerated
Protocol for pain during acute phase
- Coordinate with nursing on scheduled pain meds
- Treat 30 min after pain meds administered
- Visual imagery and relaxation to minimize pain
- Respect pain
- Explain procedures before starting
- Address fear factor that can exacerbate perceived pain early in intervention
How to avoid pooling of fluid/blood in LEs in dependent or standing position during acute phase
Apply compression wrapping to provide vascular support to LEs before walking, standing, prolonged sitting w/feet in dependent position
Immobilization period in postop phase
- generally 3-10 days or until graft adherence is conformed
- immobilization of donor site: 2-3 days if no active bleeding occurs
- walking not resumed until 5-7 days for LEs
- confirm with surgeon
Positioning during postop phase
Same as anticontracture positioning
- promote greatest SA for graft placement
- surgeon may specify
- elevation, wrapping with elastic bandage at donor site
Exercise & activity during postop phase
- should be continued for uninvolved extremities
- after immobilization period, start with gentle AROM to avoid shearing of new grafts
What occurs during rehabilitation phase
Wound is healing, wound closure is stable
Skin conditioning during rehabilitation phase
- Skin lubrication several times a day to prevent dry skin from splitting
- Skin massage to desensitize hypersensitive grafting sites/burn scars
- Use sunblock or sun protective clothing, avoid unprotected sun exposure
Scar management during rehabilitation phase
- Compression therapy for edema control & scar compression
- Temporary interim pressure bandages/garments: elastic bandages, Conan wrapping of fingers, elastic aged tubular support bandages, thigh-high/knee-high hose, spandex bike pants, isotonic gloves, elastomer, closed-cell foam, silicone pad inserts
- Custom made compression garments
- Custom made pressure garment & insert
When is use of compression garment indicated?
For all donor sites, grafted sites, burn wounds that take 2+ weeks to heal spontaneously
When should custom-made pressure garments be worn
24 hrs per day except during bathing, massage, other skin care activity
Therapeutic exercise & activity during rehabilitation phase
- Progressively graded
- Client education on skin lubrication & massage before exercise/activity
- Daily stretching, resistive exercises, activity to tolerance, coordination activities
Splinting during rehabilitation phase
- Continue anticontracture positioning
- Use dynamic splint or serial casting to reverse contractures
- For hands: attend to extensor tendon injury and web space contracture management
- Splint of volar surface of hand for dorsal/volar hand burns for better positioning/comfort
ADLs during rehabilitation phase
- Adaptive strategies, AE
- Identify abnormal movement pattern early to allow Pt to relearn normal movement patterns
Client education during rehabilitation phase
Transition from hospital to home
1. Independent skin care protocol
2. Understanding of wound healing process
3. Compression therapy & positioning with practice applying garment & splint
4. Preservation of ADLs & IADLs with continuing exercise, activity program
How long does scar maturation take
From 1-2 years
Community re-entry protocols
- Improve skin tolerance for friction/shear from compression garments & inserts during activities
- activity tolerance training
- Adapt activity demands & environment if limitations in movement result from tight scar band/contractures
What can occur psychosocially following burn?
- PTSD
- Adjustment period
- Counseling, support group, training in pain management, relaxation, stress management
What causes contracture?
- Hypertrophic scar
- Tight scar band
- Prolonged immobilization
How to address contracture
- Early implementation of anticontracture postioning
- Continuous exercise & activity programs
- Serial splinting programs
Hypertrophic scar
- Most apparent 6-8 weeks following wound closure
- Most activity in initial 4-6 months
- Scar firmer/thicker, rises above original surface level of skin
- Can happen at donor site, at original burn area, with wound that doesn’t close spontaneously after 2 weeks
- Apply compression therapy early, continue until scar matures in 1-2 years
- Use scar gel pads/inserts to provide compression
Heterotopic ossification
Formation of bones in abnormal areas (occurs in soft tissue around joint, joint capsule)
- elbow, knee, hip, shoulder
- rapid ROM loss, pain localized/severe
- hard end feel during PROM
- discontinue PROM & use of dynamic splint, begin AROM within pain-free range to preserve as much movement as possible
- usually requires surgical intervention if functional activity is limited
Heat intolerance
- Loss of ability to sweat due to loss of sweat glands with split-thickness skin graft
- Pt may sweat excessively in unburned areas
- Accommodations/modifications (air conditioning) may be required at home, work, school
Sun exposure
- Risk for sunburn is higher- use sun protective clothing, sunscreen, avoid prolonged exposure
- May affect outdoor work, playground activity
Pruritis
Persistent itching
1. May lead to skin maceration, reopening of wound
2. Use compression garment, maintain skin lubrication, cold packs, antihistamine meds
Child discharge plan following a burn
- Community-based therapist working in school system to help with adjustment
- Return-to-school program with or without child present
Gentle AROM/PROM implementation protocols
- begin as early as possible except during post-graft immobilization period
Where to avoid placing splints
- on surface of burned area
- apply standard splinting positioning unless burns are circumferential
Dorsal hand burn precautions
- maintain Boutonnière precaution
- avoid having client form active or passive composite flexion of fingers
- ROM to MP with IP straight, ROM to IP with MP & DIP straight
When should sensory testing for peripheral nerve damage occur
As soon as wounds are closed
How to measure edema with burn
Do not use volumeter until all wounds are closed or with permission
How to treat children with burns
- structured play to achieve full ROM of affected body parts
- child life specialists to reduce fear/stress when treating children
