Burns and Thermal Injuries Flashcards
Children - Most common injury and death
Scalds and hot liquids
Adolescents - Most common injury and death
Flammable liquids
Adult - Most common injury and death
Building and vechicle fires
____% of burns occur in/around the home
75%
Male ____ years of age have the highest incidence of burn injuries
16-20
More risk taking behavior and general behaviors/jobs putting them at higher risk. Ex: Working with chemical or electrical
Types of burns
- Heat
- Frostbite (Acute and late)
- Radiation
- Electric
Left: Frostbite; Right: Radiation
ABA Criteria for Admission to Burn Center
- Total burns Greater than 10% of BSA:
– Age less than 10 OR greater than 50 - Total burns greater than 20% of BSA:
– All other age groups - Full thickness burns greater than 5% BSA
- Critical locations:
– Face, hands, feet, genitalia, perineum, major joints
– Circumferential burns of extremities, chest
Epidermis - Function
- Prevents moisture loss
- Maintains integrity against bacterial invasion and is a physical barrier
Dermis - Location and Function
Papillary Layer:
* Location: Underneath the epidermis
* Function: Sensation (Sensory receptors), Blood Flow (Capillaries), Nutrients (Capillaries), Lymphatics (Drain fluid), Temperature Regulation (Capillaries)
Reticular Layer
* Location: Below Reticular layer, above muscle
* Function: Structure, Strength, extensibility and elasticity (Collagen), Roots of hair, glands, nails and blood vessels
* Langer’s lines lie here (Wound healing)
Arrector pili muscle
- Located on the bottom of the hair follicles; creates goosebumps (Dermis)
Classifications of Burn Injury
- First degree = superficial (epidermis)
- Second Degree = Superficial partial thickness OR deep partial thickness
- Third Degree = Full thickness
- Fourth degree = Subdermal
Relationship between length of heat exposure and intensity of heat exposure
First Degree - Superficial Burn
- Epidermis ONLY
- Pain and blanching
- No scar
- Heals quickly
Ex: Sunburn
Second Degree - Superficial Partial Thickness
- Papillary Layer
- Pain and blanching
- Skin color changes
- 7-10 days to heal
- May have scarring
Ex: Severe sunburm that causes blistering
Second Degree - Superficial Burn: Proliferative Phase
Epithelization
Replication and migration of epithelial cells across the skin edges in response to growth factors
Regrowth begins at anywhere with kertinocytes such as hair follicles (most common), sweat glands, etc.
Second Degree - Deep partial thickness
- Reticular layer
- Exposed nerve endings
- Decreased deep pressure
- Wet or dry eschar
- Scarring
- 3-5 weeks to heal
Ex: Significant scalding burns or flame/fire burns
Eschar Progression
- Dry to wet
- Generally want to get rid of eschar (few circumstances you don’t)
Third degree - full thickness
- Through dermis to subcutaneous tissues but not to muscle tissue
- No blanching
- May be insensate (insensitive)
- Requires skin gragy or lengthy period of secondary healing
- Scarring
- Recovery takes MONTHS
Fasciotomy
- Surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat resulting loss of circulation to an area of tissue or muscle
- Most common with electrical burns
Escharotomy
- Surgical procedure with incision through the escar to espose the fatty tissue
- Due to the residual pressure the incision with often widen substantially
- Commonly done with circumferential bruns (trunk/chest, arm, leg, etc.)
Fourth Degree - Subdermal Burn
- Necrosis
- Requires surgical intervention
- Grafting/Amputation
- Involves muscle, bone,e tc.
- No spontaneous healing
How many stages of frostbite are there?
3
1st degree frostbite
irritation of skin
2nd degree of frostbite
blistering but no major damage
3rd degree frostbite
- Involves all layers of the skin
- Permanent tissue damage
- Interventions are often similar to 4th degree (Amputation)
3rd degree cold vs 4th degree burn
- Frostbite surgery you wait and see the response of tissues of what is necrotic and what comes back during the warming period
- 4th degree heat interventions are done immediately
Demarcation
- Boundaries of the vascular injury cause a “demarcation” line to occur where normal and damaged tissue meet.
- Occurs with frostbite.
- Tissue up until line is salvageable, everything else is not.
Degree of burn and healing considerations
- Skin involvement
- Signs
- Sensation
- Healing Capacity
- Healing Time
- Scar Formation
Initial Assessment
- Type of Burn (Thermal, electrical, chemical, abrasion)
- Severity of Burns (BSA, depth, classification)
- Co-existing Trauma
- Co-morbidites
Types of thermal burns
Contact: touch hot object
Flame: Most common adults
Scald: Most common peds
Dip Pattern Scald: dipped into something hot; ex: bathtub
What type of burn is most common for pediatrics?
scald
Chemical burns
Causes:
* Battery Acid (car)
* Bleach/Ammonia (Cleansers)
* Fertilizers
Sx:
* Systemic consequences (coughing, SOB, vision issues)
* Blisters, necrosis
* Burn that keeps on burning until back to pH of 7.0
Chemical or Smoke Inhalation
Damages the body by:
* Simple asphyxyation (lack of oxygen)
* Chemical or thermal irritation
* Chemical asphyxiation
* Combination of these^
Smokes contains products that take up space of where oxygen can go (not direct harm)
Need to consider other traumas that may be more systemic than just the burns (heat or chemical injury or CO poisioning)
Electrcal burns
Electricity will follow path of least resistance (most conductive)
Most conductive
- Nerves
- Blood vessels
- Muscles
- Skin
- Fat
- Bone
Least Conductive
4 types of electrical burns
Types of electrical burns
- Flash injuries, caused by an arc flash, are typically associated with superficial burns, as no electrical current travels past the skin.
- Flame injuries occur when an arc flash ignites an individual’s clothing, and electrical current may or may not pass the skin in these cases.
- Lightning injuries, involving extremely short but very high voltage electrical energy, are associated with an electrical current flowing through the individual’s entire body.
- True electrical injuries involve an individual becoming part of an electrical circuit. In these cases, an entrance and exit site is usually found.
Abraisions
- Type of Burn
- Road Rash
- Varying degrees of depth
- Often involves foreign bodies (Ex: Rocks or road)
- May be associated with other traume (Ex: Concussion or broken bones)
Complications of Burn Injuries
Aka causes of burn mortality
- ARDS (adultrespiratory distresssyndrome): smoke or chemical inhalation in lungs leading to poor perfusion and lung function.
- Inhalationinjury (lung injury): injury to lung that no longer functions
- Sepsis and multi-system failure
- Metabolic demand: Room temperatureadjustments to decreasestress response
- Psychological trauma: Depression/ suicide/ self-harm
Rule of 9s
- Assigns a % that’s either 9 or multiple of 9 to determine BSA damaged
- Used for: 2nd deep thickness and 3rd degree.
- Quick Assessment by Physician
- Adult and Pediatric Values are different (A: Genitalia, Head and neck, Legs; P: Head and neck, Legs)
Lund Browder Chart
- More complicated BSA measurement
- Considers age and body composisition of the person (Head, thigh and legs are dependent on the age of the child)
- More accurate for pediatrics
Initial Medical Management
- Establish and maintain anairway
- Prevent cyanosis, shockor hemorrhage
- Establish baseline dataon the patient
- Prevent or reduce fluidloss
- Clean the patient and thewounds
- Assess injuries
- Prevent pulmonary andcardiac complications
Zones of injury and conversion of burn depth
- Zone of coagulation: point of maximum damage, irreversible tissue loss due to constituent proteins.
- Zone of stasis: decreased tissue perfusion, potentially alvageable. Want to increase tissue perfusion and decrease the amount of damage. Hypotension, infection and edema can cause more damage.
- Zone of hyperaemia: outermost layer, tissue perfusion is increased. Tissue will recover unless severe sepsis or hypoperfusion.
PROTECT THE ZONE OF ____
STASIS
Topical Antibiotics and Enzymatic Debridement (Superficial Wounds)
Topical antimicrobals for prevention and treatment of burn would infection:
* Silver sulfadiazine (Silvadene)- MOST COMMON (cream or dressing)
* Silver nitrate solution
* Silver-impregnated dressings
* Mafenide acetate (sulfa antibiotic)
Enzymatic Debridement:
A highly selective method of wound debridement that uses naturally occurring proteolytic enzymes specifically for eliminating devitalized tissue.
* Collagenese Debridement
* Papain Debridemnet
* Papain-urea-chlorophyllin-copper Debridement
Silver sulfadiazine
Applied topically on wound and left either open (without dressing) or closed (with dressing)
Mafenide acetate
Applied topically on wound typically without an additional dressing (open).
Enzymatic Debridement (Superficial)
Collagenase-based products
- Hydrolyzes peptide bonds ans digests all triple helical collagen and will not degreade any other proteins
- Shown to liquefy necrotic tissue without damaging granulation tissue
- Sterile gauze or direct
Papain-based products
- breaks down fibrinous material in necrotic tissue
- Does not digest
- Moisture related dressings
Papain-urea-chlororphyyllin copper complex
- prevents the formation of agglutinated erythrocytes
- Sodium copper chlorophyilin is an historically estabilished would healing
- For wound with long healing times, better for continuous use.
Debridement
- The removal of dead or infected skin tissue to help a wound heal
- Creates a clean wound surface
- Essential for healing
Contact inhibition
Migration of epithelial cells is stopped when cells bump into like cells or foreign body (eschar)
Debridement: Tangential Excision
- Remove burned tissues and create beefy red clean surface for granulation or grafting
- Excision of the necrotic surface of a burn, taking repeated sliced parallel to the skin surface using a skin graft knife
- ONLY for burned tissue
Types of Grafts
Autograft:
- Self
Allograft (Homograft):
- Cadaver
Xenograft:
- Donor of a different species
- Pig is most common
Skin substitutes:
- Lab culture products
- Temporary (waiting on another graft)
Skin Grafting procedure
2 types
Autographs:
* Split thickness graft: Few top layers of skin; recovery in 3 weeks, may have a scar.
* Full thickness graft: All of the dermis; 6-10 weeks
Surgical process of graft
- Harvet graft
- Clean wound bed
- Graft applied
- Pressure dressing (wound vac)
Meshed Graft
- Themeshincisions allow thegraftto be expanded to cover large defects, provide a route for drainage of blood or serum from under thegraft, and increase the flexibility of thegraftso that it can conform to uneven recipient beds.
Hypertrophic scarring
- Body cells called myofibroblasts produce too much collagen during healing. This can happen simply as a result of a person’s skin type and healing tendencies
- Hypertrophic scars are similar to keloid scars but tend to be milder and don’t grow beyond the boundaries of the original skin injury. Keloids grow up and out from the injury, becoming bigger than the original area of injury.
Anticipated Outcomes
- Wound and soft tissue healing is advances
- Risk of infection and complications reduces
- Risk of secondary impairments is reduced
- Attainment of full ROM
- Restoration of pre-injury cardiovascularendurance
- Aerobic capacity is increased
- Good to normal strength
- Independent ambulation
- Independent function in IADLs and ADLsis achieved
- Minimal scar formation
- Patient and family caregivers adequatelyeducated
- Self-managementof symptoms
What will you assess in your examination of a wound victim?
Althings we have learned PLUS burns
Functional mobility
ROM
Strength
Ability to walk
Balance
Skin
Based on where the patient is the healing priorities changes (Ex: ICU vs Outpatient)
The position of comfort =
The position of deformity
Clincial guidelines for splinting/positioning - UE
- 90 degrees abduction
- ER
- Supination
Also called an open position
Why do we splint?
- To immobilise a skin graft after surgery.
- To protect vulnerable structures e.g. exposed tendon.
- To prevent skin and tendon contracture.
- To maintain the joint range when the patient is unable to do so e.g. post-operative, intubated in ICU with ventilation and sedation, sleeping, young children.
- To prevent long term deformity.
Scar Management
Pressure garments (customized)
- Indicated for burns that take more than 10-14 days to heal
- Worn 22-23 hours a day (essentially all the time except to shower)
- Worn until scar is metabolically inactive (up to 2 years)
- Compliance very difficult (long-term)
Pressure garments (non-customized)
- Short term basis
- Better compliance
Scar tissue mobilization
- Only on tissue that has matured or is durable enough for friction
- Later stages of healing or for chronic scarring
What do custom garments do?
- Protect fragile skin
- Promote better circulation of damaged tissues
- Decrease extremity pain through vascular support
- Decrease itching
- Reduce thick, hard scars
- Increase skin length by putting pressure on contracture bands
Non-customized pressure therapy
All provide pressure
- Elastic wrap bandage: Ace Wrap
- Tubular pressure bandages: Tubigrap
- Interim care garments
Scar mobilization - Purpose
- Improve circulation/blood flow
- Increase flexibility
- Increase ROM
- Decrease pain/itching
Scar mobilization - Technique
- Begin with light pressure
- Circular motions
- Increase pressure as able
- Combine with heat, stretching
Mobility - Burn Recovery
- Passive Stretching (stretching muscle tissue)
- Passive range of motion (PROM) (ranging the joint, muscle and tendon)
- Active assistive range of motion (AAROM)
- Active range of motion (AROM)
Do not be overly aggressive; Should be PAIN FREE
Heterotopic Ossification
- Abnormal growth of bone in the non-skeletal tissues including muscle, tendons or other soft tissue. When HO develops, new bone grows at three times the normal rate, resulting in jagged, painful joints.
- Associated with prolonged healing over partial or full-thickness burns
- Etiology unclear
- Need to keep the stretch in a pain-free range!
Symptoms:
* Decreased ROM
* Swelling/warmth in joint
* Pain (joint or muscle)
* Increased spasticity
* Fever
* Autonomic dysreflexia
Strength and Conditioning - Burn Recovery
Considerations for exercise prescription burn rehab:
* Pain - Pressure garments decrease it
* Skin integrity - use creams to prevent dry skin or before Tx
* Water - they do not get rehydrated during exercise
* Heat tolerance - may not tolerate heat well; must have slow exposure to the heat
* Endurance
* Consider precautions and contraindications
HEP
- Exercise and scar massage (self-mobilization)
- ADLs
- Conditioning & Strengthening
- Splints and wearing schedule
- Skin care and wound care
- Support groups and community programs
Other:
- Think about discharge
- Wearing Schedule
