burns Flashcards
what is a burn?
traumatic injury to the skin or other organic tissue primarily caused by heat or exposure to electrical discharge, friction, chemicals, and radiation
hot liquids
scalds
hot solids
contact burns
how many burns a year require medical attnetion?
1 mil
Burn Classification by depth
Superficial/Epidermal Burn (first-degree)*
Partial-thickness Burn (second-degree)*
Full-thickness Burn(third-degree)*
Deep Burn involves fascia and/or muscle (fourth-degree burns)*
Most common of burns
Full recovery is expected 3-6 days, full recovery and excellent prognoses
Tissue damage usually minimal, no scarring
Superficial/Epidermal Burn (1st Degree)
Example Sunburns
Causes minimal skin damage
Superficial/Epidermal Burn (1st Degree)
Pain, erythema (redness), slight swelling, no blisters
Superficial/Epidermal Burn (1st Degree)
Soak in cool water for 5 minutes, do not use ice
OTC analgesics for pain relief
Antibiotic ointment as needed
Superficial/Epidermal Burn (1st Degree) Intervention
Burns that go through the epidermis and reach the dermis, varying depth.
Partial-thickness Burn (2nd Degree)
Full recovery is expected, skin heals may take up to 3 weeks, skin may change color, especially with sun exposure.
Rarely need OT intervention.
Partial-thickness Burn (2nd Degree)
Skin infection may develop
Red, white or splotchy skin, swelling
Partial-thickness Burn (2nd Degree)
Blister, swelling and are generally more painful.
Partial-thickness Burn (2nd Degree)
Requires medical treatment, especially if deep or over large area, on face, neck or, over joint.
Cool injured area for 15 minutes, no ice
Use OCT analgesics
Antibiotic ointment to blistered areas
Keep wound clean and bandaged to prevent infections.
Skin will heal on its own- Skin epithelial cells are intact.
Partial-thickness Burn Treatment.
Epidermis and dermis are completely burnt.
Extensive fluid loss and metabolic effects
Full-thickness Burn (3rd Degree)
No pain in immediate area, possibly adjacent areas if burnt at 2nd degree.
Affected area may appear white (like burned charcoal)
Full-thickness Burn (3rd Degree)
Waxy, white color, may be charred or dark brown
Raised leathery texture
Full-thickness Burn (3rd Degree)
Requires medical intervention, hospitalization
In some case “specialized burn units”
Skin grafts are required.
Other surgeries may be required in Rehab stage.
LT Physical and psychological implications.
Long term rehab is needed.
OT can intervene at all 4 stages of Burn Rehab.
the skin graft covers the wound and attaches itself to the cells beneath and begins to grow in its new location.
Full thickness Treatment Cont.
Goes through all layers of skin and damages muscle, bones, nerves, and fat lying underneath
There is no pain due to nerve damage
Recovery depends on extent of damage.
Deep Burn (4th degree burn)
Causes of Burn
Boiling liquids: water, steam & other liquids,
Dry burns: flame, house fires, car fires etc
Chemical burns, Cleaning supplies, household chemicals
Electrical burns
Friction burns
Sunburn/radiation
Explosions, Fireworks
Mechanical/friction
Thermal Burns
Heat sources raise the temperature of the skin and tissues and cause tissue cell death or charring Dry burn (flames, hot metals or other hot material) Moist heat burn (steam, hot liquids) Gas burn (inhaling hot gases)
1 cause of burn injuries in children
scalds! (1st and 2nd degree)
chemical burns
strong acids, alkalines, detergents, solvents coming into direct contact with the skin or eyes
often common household chemicals (drain cleaners, oven cleaners, toilet bowl cleaners, batteries, ammonia, bleach, dishwasher liquids, etc.)
includes the liquid or dry chemical and its fumes
Immediate treatment
Remove the chemical agent and contaminated clothing
Immediately and thoroughly flush the burn area with a steady stream of water for 10 or more minutes. A thorough shower may be effective.
If eyes are contaminated, immediately flush the eyes with running water, continue for 15 minutes. Go to the ER.
from electrical current, lightening
Adult electrical injuries usually occur in occupational settings, downed powerlines d/t storms
Full extent of tissue damage, may not be know for 10 days after the injury
Burns marks may initially be at the entry and exit of the elec. current
Usually involves internal tissue damage, initially unseen .
electrical burns
Prolonged exposure to ultraviolet rays of the sun (solar), or to other sources of radiation such as X-ray
UVA: Ultraviolet A: weakest, Can cause skin aging, damage, wrinkles.
UVB: Ultraviolet: more energy, damage cells’ DNA, main cause of sunburns. Thought to cause most skin cancers.
UVC: Ultraviolet C: most energy, react with ozone in atmosphere, don’t reach the ground, thus cause no skin cancer.
radiological burns
Estimating Extent of body surface are BSA of Burn
Rule of Nines ( Wallace Rule of Nines) accurate with Adults.
Rule of One (Palmar surface) &
Lund—Browder method: used mostly with children.
What is Rule of Nines?
Quick estimate of how much body surface area BSA is burned.
Assess Surface area (Breadth) not the depth (Burn Degree )
Quick, reasonable accuracy, subjective and tends to overestimate, poor interrater reliability.
Used to help guide treatment decisions, fluid resuscitation
Helps determine whether a person requires transfer to a burn unit *Approximate Criteria/ may vary >= 20% TBSA, high-voltage electrical injuries, multiple trauma including burn, burns w/ inhalation injury
Adult Percentages for Rules of Nines
Adults: Arms: (shoulder to hand).9% each - Torso:(18% Back, 18% front) 36% - Lower Extremity: (Groin to foot) 18% each- Head (entire surface area) 9% Genital area 1%
Lund Browder Rule for kids
takes into account age
Trunk is 13%X2, UEs 5%X2. - Feet 1.75%X2. - Decreasing percentage BSA for the head (a) and - increasing percentage BSA for the legs(b and d) as the child ages.- making it more useful in pediatric burns.
Four Phases of Burns
Emergent Phase (onset to 24/48 hrs): goal is fluid resuscitation & adequate airways): OT does elevation, positioning to counteract edema, anti- deformity position.
Acute Phase:(0- Epithelialization, 12 to 14 days) splint “oppose deforming force”, Don FT, except for ROM, wound care. Gentle AROM-especially with dorsal hand burns.
Skin Graft Phase: Don splint for 5+days in OR, anti-deformity position, gentle exercises
Rehab Phase: nighttime splinting, “oppose deforming force”, may use dynamic splint.
Emergent Phase
(onset to 24/48 hrs): goal is fluid resuscitation & adequate airways): OT does elevation, positioning to counteract edema, anti- deformity position
Acute Phase
(0- Epithelialization, 12 to 14 days) splint “oppose deforming force”, Don FT, except for ROM, wound care. Gentle AROM-especially with dorsal hand burns.
Skin Graft Phase
Don’t splint for 5+days in OR, anti-deformity position, gentle exercises
Rehab Phase
nighttime splinting, “oppose deforming force”, may use dynamic splint.
Evaluation and Management—Critical Care Services (emergency room/ICU)
The management of clients with burns requires significant attention to pathophysiologic changes caused by the systemic response to the burn injury.
Patients need meticulous evaluation and correction of fluid & electrolytes, metabolic levels, cardiopulmonary, homeostasis and avoidance of infection.
This labor-intensive daily critical care evaluation and management service is absolutely necessary to achieve satisfactory outcomes.
Team (YOU as an OT) needs to know that things are likely to get worse before they get better
In other words the way things appear at time of injury are not indicative of the magnitude of the effect the injury is going to have on the body.
ICU condition
Intubated Orthotics Feeding tube IV fluids Medications: Analgesics, Antibiotics, Antacids, Cardiac medications Meticulous wound healing Appropriate fluid and nutritional intake Early surgical excision and grafting
Major Problems to be Addressed Include….
Hypovolemia low blood volume in body (decreased blood plasma levels) Massive loss of fluids/blood fluid resuscitation Massive body edema cardiac dysfunction Burn shock – organs deprived of oxygen (septic, build up of waste, hypovolemia, cardiac stress) Airway passage obstruction
SURGICAL TREATMENT OF BURNS
Debridement of Burn Wounds: the removal of damaged tissue. Mechanical/whirlpool, Larger burns require serial debridment with skin grafting
Escharotomy: surgical procedure, treat full-thickness (third-degree) circumferential burns. To combat compartment syndrome
Excision of Burn Wounds: removal or Cutting out traumatized area, happens initially to prepare for grafting
Single- and Multiple-Stage Excision and
grafting
Escharotomy
eschar –> leathery tissue
surgical procedure, treat full-thickness (third-degree) circumferential burns. To combat compartment syndrome
Temporary Wound Coverage
The gold standard temporary skin substitute is cadaver Allograft (cells are still alive or viable)
Can stay on as long as 4 weeks until rejected
Skin Xenografts (heterograft): Skin from a different species (pig). Xeno- relating to others/foreigner
Biobrane synthetic covering (made from silicone)
Transcyte is similar to Biobrane, but the inner layer has a knitted nylon scaffold layered with human skin cells to facilitate healing- such as Stem cell
BURN WOUND COVERAGE
Skin Substitutes vs Skin Replacements
Skin Substitutes vs Skin Replacements
Skin replacement: A tissue or graft that permanently replaces lost skin with healthy skin.
Autograft (graft of tissue from one point to another of the same person’s body)
Allograft (tissue from the same species- can be from a cadaver, living related or unrelated donor).
Skin substitute [commercial product]: A biomaterial, engineered tissue or combination of materials and cells or tissues that can be substituted for skin.
auto vs allograpt
AUTOGRAFT
A graft of persons own tissue from one point to another on own body
Allograft
A graft form donor of same species but not genetically identical
Permanent Skin Substitutes: Epicel
Skin cells from superficial layer are harvested and made to grow and multiply
Results in a thin layer of skin cells that is 10,000 times larger than the harvested piece(1” square)
May take up to 2 - 3 weeks till the products are ready
Permanent Skin Substitutes: Integra
a bi-layer product. The inner layer is a scaffold made from proteins and fibres.
In this scaffolding, the patients own cells migrate and grow
takes around 2-3 weeks till blood vessels form and patients own cells start to grow into the scaffold
Rehab phase: scarring
Dealing with Scarring.
Scars form when the dermis is damaged. The body forms new collagen fibers (a naturally occurring protein in the body) to mend the damage.
KELOID and HYPERTROPHIC SCARRING
- Keloid is defined as an abnormal scar that grows beyond the boundaries
- Hypertrophic scar is defined as a widened scar that does not extend beyond the original boundaries of the wound
Burn Wound Healing and Scarring
Scarring is related to age, ethnicity, and the depth and location of the burn
Body forms a protein called collagen to help heal the damaged skin
Normally the collagen fibers are laid down in a very organized manner, but in hypertrophic scars these fibers are created in a very disorganized manner, which gives the new skin/scar a different texture and appearance.
Scar healing can take a long time
Scarring usually develops within the first few months after the burn,
peaks around 6 months and will resolve or “mature” in 12-18 months.
As scars mature they generally fade in color, become flatter, softer and generally less sensitive
OT intervention :
Scar massage to realign collagen fibers. May work on surgical scar, small scars.
Silicone gel sheet scar management: transparent, soft, elastic and self-adhensive silicone. preventing the formation of hyptrophic scars by
Pressure garments: OT precise measurements and application.
Kinesiotape may be beneficial- mostly for surgical wound/scars
Moving to discussion of OT role in managing burn survivor..
Positioning : Head, Neck, AnkleLower extremity, Upper extremitySplinting for anti-deformity.
What does microstomia mean?
micro = small . stomia = mouth
mouth splints to prevent oral microstomia
Tissue Expansion w/ saline
Saline solution inserted to “grow” (expand) skin surface area
Additional Occupational Therapy Considerations
Splint to prevent deformity legs, arms, neck, etc. Wound care ROM (passive and active) Determine need for and measure for garments Scar management Lifestyle redesign Deal with psychosocial issues Depression & anxiety, anger, post traumatic stress, body image, social stressors, sleep disturbances, substance abuse, grieving, stress management, etc.
Additional Occupational Therapy Considerations Cont.
Occupational Performance Issues Home evaluation Work or school evaluation/comm. re-entry Psychosocial support Cosmetics – permanent makeup Support groups/caregiver/survivor Introduction to other burn survivors
