Burns

Question 1

What is a thermal burn and what factors influence severity?

Answer 1

Contact through a flame, hot liquid, or steam (Scald = wet heat from steam; transfers more heat to the body then a flame)
Contact time, temperature, and type of insult influence the severity

Question 2

What are chemical burns and what factors influences severity?

Answer 2

Exposure to acids, bases, and industrial accidents/assualts

Factors that influence severity are contact time, chemical concentration, and type of chemical

Question 3

What does radiation damage do and what are the symptoms?

Answer 3

Due to direct damage to the DNA

Recurrent exposure to low doses of radiation produce erythema, edema, and severe induration

Question 4

Is an electrical injury a thermal injury?

Answer 4

yes

Question 5

Does dry skin increase the risk of internal injury?

Answer 5

No, it does increase the risk of skin injury

Question 6

What increases the risk of frostbite?

What areas are damaged?

Answer 6

Risk is increased by peripheral artery disease, Raynaud’s disease, DM, smoking, beta blockers, ETOH
Nose, ears, fingers, toes

Question 7

What are the different zones of burns?

Answer 7

Zone of coagulation: most severe injury; irreversible cell injury (may expand 48 hrs after burn)
Zone of stasis: less severe; reversible cells injury
Zone of hyperemia: inflammed area; expected to recover fully within 7-10 days

Question 8

What is a superficial burn?

Answer 8

Damage to the epidermis with erythema, pain, edema (sunburn)

should heal spontaneously, may exfoliate

Question 9

What is a superficial partial thickness burn?

Answer 9

damage to the epidermis and PAPILLARY layer of the dermis

caused by scalds (brief contact and brief flame)

Question 10

What are the characteristics of a superficial partial thickness burn (SPTB)?

Answer 10

erythema, extreme pain, moderate edema, BLISTERING (up to 5 days)
Intact sensory receptors
blanches to pressure with quickly capillary refill
large amounts of drainage
should heal in 10-14 days with minimal scarring

Question 11

What is a deep partial thickness burn?

Answer 11

damage to epidermis and deep into dermis with less pain, edema and eschar
extends into reticular layer of dermis
mottled red and white areas
DECREASED pinprick but intact pressure sensation
blanches to pressure with slow capillary refill
heals in 3 weeks with scarring and pigment changes

Question 12

What is a full thickness burn?

Answer 12

damage to epidermis, dermis, and subcutaneous tissue with LITTLE TO NO PAIN
risk of infection increases
will not heal on own or would take three to four months
grafting is NECESSARY
may have contractures
lacks pain, pressure and temperature sensation
dry, rigid, leathery eschar

Question 13

What is a subdermal burn?

Answer 13

Destruction beyond the subcutaneous tissues
charred, mummified, dry appearance
exposed deep tissues
amputation and paralysis possible
leads to scarring

Question 14

What are the methods to measure burns?

Answer 14

The rule of nines and the Lund and Browder Method (used for infants and young children)

Question 15

What are reasons to be admitted to burn centers?

Answer 15

hand, foot, or groin burn
pain
10-15% total body surface area burn
infection
inhalation injury

Question 16

Who is at risk for a burn?

Answer 16

Kids: abuse, accident, neglect
Elderly
Young males: electricians, plumbers, tree trimmers

Question 17

What are the effects of a burn on the cardiac system?

Answer 17

burn shock - perfusion is unable to meet demands of body tissues; leads to hypovolemia and edema
Decreases cardiac output by 50% for first 2-4 days after severe burn
15% total body surface area at high risk for burn shock

Question 18

What are the effects of a burn on the pulmonary system?

Answer 18

Pulmonary edema, respiratory distress, pneumonia, inflammation
inhalation injuries account for 20% of deaths

Question 19

What are the effects of a burn on metabolism?

Answer 19

Skin temperatures increases to account for a heat loss
increase in resting oxygen consumption
nutrition consult

Question 20

What are the effects of a burn on the immune system?

Answer 20

Sepsis (75% of deaths may be due to infection)
aggressive debridement and wound closure very important
(staph/pseudomonas)

Question 21

If you are preparing a dressing change what must you do to treat a patient?

Answer 21

Must gown, glove, mask, and hat

Question 22

What are the phases of burn care?

Answer 22

Emergent (onset - 48 hrs post)
Sub-acute (48 hours post burn to wound closure)
Rehabilitative (period of scarring and societal reintegration

Question 23

What are some problems and treatments during the emergent phase?

Answer 23

Problems: wounds, edema, pain, associated trauma
Tx: positioning, ROM, splinting

Question 24

What are the goals of the sub-acute phase of burns?

Answer 24

prevent contracture formation (aggressive), functional positioning
prevent neuropathies
maintain function of muscles and joints
mobilize and encourage ambulation

Question 25

What are characteristics of sub-acute patients?

Answer 25

Small burns - less than 20% who are able to ambulate and perform gym activities 
Patient admitted for IV antibiotics
inhalation patients - bag and drag
large burns in ICU
large burns further along in course

Question 26

What are the main functions of PT & OT in the burn center?

Answer 26

wound care
passive stretching
positioning 
splinting/casting
progressive mobility
conditioning/strengthening
scar management

Question 27

How do you manage superficial burns?

Answer 27

Do not require topical antimicrobials

Question 28

How do you treat superficial partial thickness burns?

Answer 28

Can use topical antimicrobial ointment such as bacitracin

Question 29

How do you treat deep partial thickness burns?

Answer 29

Silver sulfadiazine (inhibits wound epitheliazation)

Question 30

What are some of the dressings used in burn centers?

Answer 30

Antibacterial creams (silvadene, silver sulfadiazine, sulfamylon)
Silver impregnated products (acticoat, aquacel Ag)
Enzymatic debriders (santyl)

Question 31

What donor sites are usually used with grafting?

Answer 31

Upper thigh; somewhere not seen

Question 32

What are rehabilitative phase goals?

Answer 32

family/patient education
scar control
ROM - WNL
Independent mobility
Str - WNL
Increase endurance
Complete discharge planning

Question 33

What are some interventions for scarring?

Answer 33

Ace wraps
tubigrip
isotoner/edema gloves
coban
pressure garments
silon/elastomer

Question 34

What are some plastic interventions for scarring?

Answer 34

flaps
tissue expanders
serial excision
full thickness skin grafts
lasers

Question 35

What can improper scar management lead to?

Answer 35

Immobility can lead to adhesive subcutaneous tissue; leads to pain, decrease in ROM and mobility

Question 36

How much pressure to topical garments exert on the tissue?

Answer 36

18-30 mmHg

Question 37

How are silicone sheets utilized after burns?

Answer 37

adhere to clean, dry skin
must be removed for bathing and sleep
expensive but can be reusable
Scars become flatter and less discolored

Question 38

What are the rules for scar mobilization?

Answer 38

Wound must be sufficiently healed
Mobility should be assessed in every direction
should mobilize on scabs (2.5-5 cm away)
May need to be desensitized
Pushed and pulled for 15-30 seconds

Question 39

What are two aggressive scar mobilization techniques?

Answer 39

Plucking (stabilize two areas along a scar while pulling perpendicular)
Rolling (grasping a segment of the scar and pulling the incision parallel to the incision)

Question 40

What should you educate the patient on about burns and subsequent scar?

Answer 40

Lack of melanocytes make scar more susceptible to sun damage
Increased risk of skin cancer
tissue needs to be moisturized

Question 41

What are two overrepair mechanisms?

Answer 41

Hypertrophic scars (rise above level of skin but DO NOT extend beyond the area of injury)
Keloid scar (extends beyond injured area)