Burns Flashcards
At what temperature does cell damage start to occur?
41 degrees
At what temperature does coagulation of protein occur?
> 50 degrees
What are the components of a burn wound?
- Total body surface area %
- Depth (superficial [epidermal], partial [dermal], deep partial and full thickness)
What kinds of burns can occur?
- Thermal
- Chemical
- Electrical
- Radiation
- Inhalation
What are the functions of the skin?
- Protection
- Prevention
- Preservation
- Sensory
- Thermoregulatory
- Communication
What can occur between the epidermis and dermis when burnt?
- Irregular formation (rete ridges) results in mixed depths
Where are the three most likely places that a burn injury will occur?
- Home
- Work
- Roadways
What are the two top reasons for a burn injury occurring?
- Carelessness (42%)
- Accident (36%)
What are the three top sources of burns that occur in children?
- Scald (60%)
- Flame (25%)
- Contact (10%)
What are the three top sources of burns that occur in adults?
- Explosion/flame (48%)
- Scald: oil/water (33%)
- Contact (8%)
What populations is scald injury most likely to occur?
Predominantly evidence in the very young, the elderly, D&A, epilepsy
What is the peak age for likelihood of burns?
Around 20 years old
What is the percentage of burns injury in male and female adults?
Males: 62%
Females: 38%
What are the common surfaces that cause contact burns?
- Irons
- Oven doors
- Heaters
- Exhaust pipes
- Industrial presses
When does a flash burn occur?
Ignition in the vicinity of inflammable material, resulting in a sudden release of energy in the form of heat.
Voltage and temperature of electrical conduction injury
1000-33000V
1000 to 3000 degrees
Is electrical conduction injury always physically visible?
No
What occurs with an acid chemical burn?
Acid coagulates protein and desiccates, so it cannot keep burning
What occurs with an alkali chemical burn?
Alkali produces vesicles and liquefication which allows the chemical to continue to penetrate the tissue.
What are the five classifications of burn depth?
- Epidermal
- Superficial dermal
- Mid-dermal
- Deep dermal
- Full thickness
Which acid is most dangerous and why?
Hydrochloric acid
Penetrates the skin
What is the colour, blister presence, capillary refill, sensation and healing characteristics of a epidermal burn?
Red No blisters Capillary refill present Sensation present Healing capacity
What is the colour, blister presence, capillary refill, sensation and healing characteristics of a superficial dermal burn?
Pale pink Small blisters Capillary refill present Sensation painful Healing capacity
What is the colour, blister presence, capillary refill, sensation and healing characteristics of a mid-dermal burn?
Dark pink Blisters present Slugglish capillary refill Variable sensation Usual healing capacity
What is the colour, blister presence, capillary refill, sensation and healing characteristics of a deep dermal burn?
Blotchy red Variable presence of blisters Capillary return absent Sensation absent No healing capacity
What is the colour, blister presence, capillary refill, sensation and healing characteristics of a full thickness burn?
White No blisters Capillary refill absent Sensation absent No healing capacity
What can determine if surgery is completed on a burn?
Location of the burn
What are the three different zones of burns?
- Zone of coagulation
- Zone of stasis
- Zone of hyperaemia
What are the skins characteristics of a superficial dermal burn?
- Necrosis confined to upper third of dermis
- Zone of necrosis lifted off viable wound by edema
- Small zone of injury
What is the approximate healing time of a superficial dermal burn?
7-14 days
What is the approximate healing time of a mixed dermal burn?
14-21 days
What are the skins characteristics of a deep dermal burn?
- Necrosis involving majority of skin layers
- Zone of necrosis adherent to zone of injury
- Smaller edema layer
What is an indeterminate dermal burn?
A deep burn that cannot be clinically distinguished as a deep dermal or full thickness.
What is the state of the dermis after a full thickness burn?
No remaining viable dermis
What is the most important acute treatment for burns?
Fluid resuscitation
What joint will always be operated on if burnt and why?
Ankle
Capacity to wear shoes and tolerate friction
How is inhalation injury classified?
Extent and location of damage
- Based on anatomical structure: upper or lower respiratory tract
- Based on irritants
What are the three main types of inhalant injury, classified by irritants?
- Inhale of chemicals: associated with industrial accidents or home drug laboratory
- Inhale of poison gases: associated with industrial accidents and house fire
- Inhale of hot gases: steam, flame
What is inhalation injury?
An acute respiratory tract insult caused by steam or toxic inhalants
How is inhalation injury best assessed?
- Fibre-optic bronchoscopy
- X-ray
- Intravenous xenon-133 ventilation perfusion scanning
What can a fibre-optic bronchoscopy detect?
Detects airway oedema, mucosal sloughing, charring or soot in the upper airways
How much does inhalation injury increase the rate of mortality?
Increases mortality rate by 40%.
What does the severity of inhalation injury depend on?
Size of the particles and the concentration
How do inhalation injuries mimic COPD symptoms?
Restriction of the airway caused by epithelial lining thickening due to fibrosis, decreases saturation - just as the smooth muscle restricts in COPD
What occurs to the brain after the inhalation of poison gas?
Hypoxic brain damage
What chemical does plastic release when burnt?
Hydrogen cyanide
When is carbon monoxide is produced?
Incomplete combustion
What are the signs and symptoms of CO toxicity?
- Tightness of forehead
- Dilation of blood vessels
- Headache
- Vomiting
- Dimness of vision
- Increased HR and RR
How quickly can CO toxicity be reversed?
Depends on the availability of oxygen and the half life of CO.
- 250 mins in room air
- 40-60 mins if given 100% oxygen
- 30 mins if 3 atm pressure and 100% oxygen given
When is hydrogen cyanide produced?
Produced in fires involving nitrogen i.e. containing polymers
At what point does hydrogen toxicity occur?
Starts at level of 0.1 micrograms/ml (concentration of >20ppm)
What other injuries are gas inhalation injuries associated with?
- Head and neck burns
- Thoracic/abdominal burns
What areas are generally affected by gas inhalation?
Damage to the upper airways and highly ventilated areas
What are common signs of hot gas inhalation?
- Singed hair
- Soot in sputum
Of the three classifications of injury (irritants), which respond to chest physiotherapy?
Hot gas inhalation requires intubation and aggressive chest physiotherapy.
Chemical and poison gas inhalation does not respond.
What location of burn is associated with self-harm?
Axilla burns, but no hand burns
What is the aim of echarotomy?
To release compartment pressure so as to allow blood flow to distal part of the limbs with circumferential burns.
Where are echarotomies of the chest and abdomen made?
Along the edge of the rib cage, laterally and sidways, to allow pressure changes and natural ‘bucket-handle’ action - sometimes under breast line
What does chest physiotherapy for intubated severe burns patients involve?
- Check cervical spine and ribs fracture
- Manual hyper-inflation (check respiratory support parameters) and suctioning
- Postural drainage
- Percussion and vibration techniques (no manual technique after skin grafting until Day 5)
- Early mobilisation
What does chest physiotherapy for extubated severe burns patients involve?
- ACBT and lots of deep breathing exercises
- Continue with manual techniques
- Coughing
- Active exercise and sits out of bed
- Suctioning
- Gradual increase of ambulation (to improve lung function as well as sense of self control)
When are echarotomies done in the neck?
If the carotid or vertebral arteries are compromised.
What are burns patients most at risk of in hospital?
- Infection
- Hospital acquired diseases e.g. pneumonia
- Aspiration
What is the process leading to a echarotomy being performed?
Acute swelling induced by inflammatory responses, resulting in soft tissues being compressed. Blood flow is restricted to distal areas causing avascular nqecrosis.
What other respiratory insults need to be considered when treating an inhalation injury?
- TENS
- Other respiratory problems: asthma, CAL, heavy smoker
- Related cardiac issues leading to pulmonary oedema, pulmonary effusion or insufficiency together with excessive fluid resuscitation
What are the goals of physiotherapy when treating a burns patient?
- Primary: save life
- Preserve potentials
- Prevent contracture development
- Minimise deformities
- Assist in regaining motor functions
- Restore cardio-pulmonary fitness
- Ultimate goal: return to work/ community
What factors affect scarring?
- Children: the younger the patient the more scar activity, elderly less likely.
- Skin type: dark pigmented, Asian.
- Genetic predetermination.
- Length of time to heal: the longer to heal, the more active the scarring process.
- Infection
What kind of burns will scar?
- Partial thickness: if >21 days
- Full thickness
What occurs during the scarring process?
- Increasing vascularity over 2-4 weeks
- Delivery of new skin tissue (fibrocytes, collagen) in a disorganised manner
Why is management of hypertrophic scarring important?
- Prevent contracture
- Increase independence
- Maximise function
- Decrease the need for reconstructive surgery
- Attain the best cosmetic results possible
What does pressure therapy do to help scarring?
Works by blanching or dampening blood flow and limited the deposition of scar tissue, to assist with collagen remodelling
What pressure is ideal for effective pressure therapy? How long should it be continued?
Above capillary pressure (~25mmHg), no more than 40mmHg.
Continuous until scar maturation, except removal for bathing
Clinically, what has pressure therapy shown to help?
- Flatten and soften hypertrophic scarring
- Reduce itching
- Normalise skin colour
- Help maintain joint range of motion and prevent contractures
- Provide a protective shield to new scar tissue
- Relieve “pain” over scar area
What can be used to apply pressure therapy?
- Garments
- Bandages
- Tubigrip
What are the key tips for fitting a pressure therapy garment?
- Cover all graft areas at risk of, or have hypertrophy development
- Extend the garment 10cm beyond scar boundaries
- Do not end garments on muscle bellies
What are the indications for the use of silicone gel?
- Discreet scar areas
- Dense scar over joint surfaces
- Scar band contractures
- Dry and flaky skin with hypertrophy
What are the precautions for the use of silicone gel?
- Excessive moisturiser under silicone
- Unhealed wounds
- Skin reactions
What are the use of inserts beneficial?
Beneficial for thick, rigid scars that are not located over joints and particularly in concave areas.
What effect does sun have on new skin?
- Hyper pigmentation
- Re-burning by damaging new skin cells
- Increased chance of malignant melanoma
What precautions must be taken when around chemicals after a burn?
- Avoid chlorinated swimming pools for six months post-burn
- Wear appropraite grade of disposable gloves or protective clothing
What characterises scar maturation clinically?
- Progressive remodeling of the scar
- Softening
- Flattening
- Decrease in wound tension
- Progressive devascularisation from red to white in colour
What considerations need to be made when fitting a garment for pressure therapy?
- Patient lifestyle and job: leather on gloves, reinforcement
- Fragility of the skin: lining the garment
- Distal oedema: reinforce is present
- Facilitate comfort and self-application
Who might not have a pressure garment placed on the lower limb?
Diabetic patient
What are the common features of a burns patient that may require physio?
- Inhalation injury
- Facial burns
- High % cutaneous burns
- Associated with other medical problems
- Associated trauma
- Fractures/shrapnel wounds
What are the goals of physiotherapy for burns patients?
- Primary: save life
- Preserve potentials
- Prevent contracture development
- Minimise deformities
- Assist in regaining motor functions
- Restore cardiopulmonary fitness
- Return to work/community
What aspects of physiotherapy are likely to be used with a burns patient?
- Aggressive chest physiotherapy
- Splinting and positioning
- Early mobilisation
- Passive and active exercises
- Passive stretches
What considerations need to be made when exercising with burns patients?
- Age
- Previous medical conditions
- Other conditions, such as limb amputation or spinal injury
- Wound healing vs mobility
- Emotional/mental
What aspects of chest physiotherapy may be used with a burns patient?
- DB + C
- Manual techniques
- Suctioning
- Manual hyperinflation
- Early mobilisation
- Facilitate oxygenation and healing
- Regain exercise tolerance and cardiovascular fitness
What aspects of musculoskeletal physio may be important with a burns patient?
- Joint stiffness
- Development of contracture
- Muscle wasting
- Joint pain
- Ossification
- Amputation
What musculoskeletal interventions may be important with a burns patient?
- Splinting and braces
- Passive movement exercise and CPM
- Active strengthening exercise
- Aware of development of ossification and skin tears
- Avoid damage to skin grafting
What aspects of neurological physiotherapy intervention may be necessary with a burns patient?
- Motor re-learning program
- Muscle stimulation
- Tilt table
- Early mobilisation and early weight bearing
What ageing factors may need to be considered when treating a burns patient?
- Dementia
- Associated musculoskeletal problems i.e. arthritis, back pain
- Difficulty walking
- Falling
- Acopia
- Living arrangements
