Burns Lectures Flashcards
there is no greater trauma to the body than what kind of injury?
burns
what should you do if there is a fire?
smoother it, don’t put water on it or try to pick it up
what is the term for the skin coming off a burns wound?
eschar
the darker (more opaque) and more adherent the eschar, the deeper or more superficial the wound?
the deeper the wound
when a burn gets deeper, is it more or less painful?
less painful
what is the most common MOI of burn injuries?
home accidents
almost 1/4 (24%) of all burn injuries occur in …
children bw 1-15 yo
where do most pediatric burns occur?
in the home when unsupervised
where do the hair follicles, sweat glands, and sebaceous glands sit in the skin?
in the dermis
t/f: some of the epidermis extends down into the dermis and wraps around the hair follicles
true
t/f: superficial partial thickness burns can heal on their own with intact hair follicles
true
t/f: full thickness burns can heal on their own
false
what is a burn?
a loss of skin integrity bc of cell exposure to temps that are incompatible with cell life
what are the types of thermal injuries?
flame
scald
contact
what type of burns are contact burns usually?
deep
what are the types of non-thermal burn injuries?
frost bite
electrical
chemical
radiation
how long do burns take to fully express themselves?
12-24 hrs
the severity of thermal and non-thermal burn injuries is related to what factors?
temp to which the skin is exposed
duration of exposure
thickness of the involved skin
what is the thickest skin on the body?
heels/bottom of feet
what is the thinnest skin on the body?
dorsum of hands
what is a epidermal (superficial) burn?
through the epidermis only
what kind of burn is sunburn typically?
superficial burn
what is a superficial partial thickness burn?
a burn through the epidermis and some of the dermis but hair follicles are intact
what are some key signs of a superficial partial thickness burn?
in tact blisters
small shiny dots
epidermal budding
what is a deep partial thickness burn?
burn through the dermis
what is a full thickness burn?
burn through the dermis and into subQ tissue
what burn has VERY adherent aeschar that cannot be easily removed?
full thickness burn
what is a KEY sign of a full thickness burn?
thrombosed veins
what is a subdermal burn?
deepest burn through the subQ tissue into the hypodermis and muscles
what burn has erythematous, is pink/red, and has an irritated dermis?
superficial burn
what burn is bright pink/red/ mottled red, has an inflamed dermis, is erythematous with blanching and brisk capillary refill?
superficial partial thickness burn
what burn is mixed red/waxy white and blanches with slow capillary refill?
deep partial thickness burn
what burn is white (ischemic)/ charred/tan/fawn/mahogany/ black/red (hemoglobin fixation) with no blanching, has thrombosed vessels, and poor distal circulation?
full thickness burn
what burn is charred appearing?
subdermal burn
what burn has no blisters, a dry surface and delayed pain/tenderness?
superficial burn
what burn has intact blisters, moist weeping/glistening surface when blisters removed, is very painful and is sensitive to changes in temp, exposure to air current, light touch?
superficial partial thickness burn
what burn has broken blisters/ wet surface, is sensitive to pressure, but insensitive to light touch or soft pinprick?
deep partial thickness burn
what burn has parchment-like/ leathery/rigid/dry skin is anesthetic, and has body hairs that pull out easily?
full thickness burn
what burn has subQ tissue evident, is anesthetic, has muscle damage, and has neuro involvement?
subdermal burn
what burn has min edema, spontaneous healing, and no scars?
superficial burn
what burn has moderate edema, spontaneous healing, min scarring, and has discoloration?
superficial partial thickness burn
what burn has marked edema, slow healing, and excessive scarring?
deep partial thickness burn
what burn has a depressed area, heals with skin grafting, and leaves scarring?
full thickness burn
what burn has tissue defects, can heal with skin graft/flap, and leaves scarring?
subdermal burn
what types of burns can heal spontaneously?
superficial and superficial partial thickness burns
does a deep partial thickness burn heal fast or slow?
slow
is there scarring with a superficial burn?
nope
what burns requires grafts to heal?
full thickness and subdermal burns
does a superficial partial thickness burn leave scarring?
yes, but minimal
does a deep partial thickness burn leave scarring?
yes, excessive scarring
what are chemical burns?
burns that occur with any substance that causes a chemical rxn with the cutaneous and subQ tissues
the depth of injury with chemical burns is related to what 4 factors?
concentration
duration of skin contact
penetration
quantity of burning agent
t/f: with chemical burns, damage continues until the substance depletes its capacity to damage cellular protoplasm or it’s removed
true
what are the medical interventions for chemical burns?
immediate irrigation with copious amounts of water
tx of systemic toxicity if any
local care of the burn
what is an electrical burn?
a burn that results from the passage of an electrical current through the body after the skin has contacted an electrical source
what is the entrance wound in an electrical burn?
the contact site of the body with electricity
what is the exit wound (ground site) in an electrical burn?
the wound often larger than the entrance wound
is an exit wound always present with an electrical burn?
no
t/f: with electrical burns, much of the damage can be hidden under the intact skin bc of the resistance levels of the tissues in the body
true
what is the PT role in assessing the hidden damage of electrical burns?
testing sensation, ms strength, and pulses bc ms, blood vessels, and nerve are more easily affected than skin
what voltage would cause a low voltage electrical burn?
<1000V
a flash burn is a ____ voltage electrical burn
low
what causes a flash burn?
electric sparks causing direct thermal burns to the skin or through clothes catching fire
what voltage would cause a high voltage electrical burn?
> 1000V
what is a high voltage electrical burn?
a contact burns by entry of electric current into the body through the skin
electrical burns are related to what principles for electricity?
Ohm’s law
Joule’s law
what is Ohm’s law?
electric current is directly proportional to voltage and inversely proportional to resistance
what body tissue has the greatest resistance?
bone
what body tissue has the least resistance?
nerve
order these tissues from most to least resistance: muscle, fat, bone, tendon, skin, nerve, blood vessel
bone, fat, tendon, skin, muscle, blood vessel, nerve
t/f: bone generates more heat than other tissues so it is responsible for causing thermal damage to surrounding tissues
true
what is Joule’s law?
heat is produced when an electrical current meets resistance over time
if an electrical current reaches bone, what happens?
it develops excessive amounts of heat bc of its high resistance
what are the immediate effects of electrical current?
burns
ms damage
cardiac arrythmias (v fib)
acute renal failure
SC damage
vertebral fx
neuro sx
do acute or delayed onset neuro sx have a better pic for recovery?
acute onset neuro sx
what are the long term sequelae of electrical injury? (just know a few, I’m not listing them all)
HA
generalized pain
fatigue/exhaustion
frustration
guilt
tremor
joint stiffness
night sweat, fever, chills
ms spasms
pruritis
anxiety
flashbacks
and many more :)
what are radiation burns?
burns that result from radiation
what are friction burns?
burns that result from being dragged
what are inhalation injuries?
pulmonary trauma caused by inhalation of thermal or chemical irritants (mostly chemical, carbon monoxide)
t/f: inhalation injury causes thermal injury to the upper airways creating edema in the upper airways
true
t/f: inhalation injury causes local chemical irritation through the respiratory tract
true
what chemicals often cause systemic toxicity in inhalation injury?
carbon monoxide (CO)
hydrogen cyanide (HCN)
66% of pts with facial burns have what kind of injury?
inhalation injury
mortality increases 20% for pts with burns and ____ injury
inhalation
mortality increases 40% for pts with burns, ____ injury, and _____
inhalation, pneumonia
how are inhalation injuries diagnosed?
through subjective and objective measures
what subjective/objective things help diagnose an inhalation injury?
flame injury
injury in an enclosed space
disability (unable to leave fire site)
facial burns
singed nose hairs
carbonaceous sputum
soot
stridor
carboxyhemoglobin levels
chest CT
fiberoptic bronchoscopy
what is the tx for inhalation injury?
100% O2 ASAP like rocky
t/f: the half life of COHb varies with concentrations of O2 inhaled
true
t/f: the sooner we get 100% O2 to a pt with inhalation injury, the sooner the CO is to dissipate
true
if on room air, what is the half life of COHb?
320 min
if on 100% O2, what is the half-life of COHb?
74 min
what can reduce the half life of COHb to 20 min?
hyperbaric chamber O2
t/f: hyperbaric chamber O2 is the gold standard tx for inhalation injury
false, there is insufficient evidence to support the use of hyperbaric oxygen for tx of pts with CO poisoning bc it can take too long to get to one
t/f: chest PT reduces pneumonia following inhalation injury
true
what are the 3 main purposes of chest PT in rehab with an inhalation injury?
expiratory rib cage compression
postural drainage
cough exercises
what are the burn injury sequelae?
immune system
metabolic
CV system
psych
endocrine
MSK
integ
infection
what are the 3 zones that can be identified concentrically around the center of the burn injury?
zone of coagulation
zone of stasis
zone of hyperaemia
what is the zone of coagulation?
the deepest center of the wound
what is the zone of stasis?
the zone around the zone of coagulation that has a 50/50 chance of staying the way it is or becoming deeper and converting into the zone of coagulation
what is the zone of hyperaemia?
the mostly superficial outer burn rim
what zone of a burn has irreversible tissue damage?
the zone of coagulation
what zone of a burn is characterized by decreased tissue perfusion with tissue that is potentially salvageable?
the zone of stasis
what is involved in the immune response to burns?
a more pronounced inflammatory response compared to non-burn trauma
initial pro-inflammatory response (Th1) from the innate immune system
shift to sustained anti-inflammatory state (Th2)
what are the consequences of altered immune response following burn injury?
increased susceptibility to infections
compromised immune cell fxn
persistent elevation of inflammatory markers
t/f: there is an imbalance bw the innate and adaptive immune responses following a burn injury
true
describe the imbalance bw the innate and adaptive immune responses following a burn injury?
we need a constant innate immune response, but the humoral response overpowers and shuts down the innate immune response
describe the color and smell of a pseudomonas infection
green and sweet smelling
t/f: following a burn injury, there is a non-specific down regulation of the immune system
true
what is the immediate metabolic change following a burn injury?
hypermetabolic state
how long can the hypermetabolic state following a burn injury last?
up to 3 yrs post-injury
hypermetabolism following burns results in what?
sustained loss of ms mass
decreased bone density
high protein degradation
reduced ms mitochondrial fxn
chronic ms weakness
t/f: hypermetabolism affects only severe burn pts
false, it affects both severe and non-severe burn pts
lipolysis results in the increase of what things?
total fat and fat %
lipolysis results in the lose of what things?
body weight
lean body mass
bone mineral content
bone mineral density
what is proteolysis?
protein breakdown that increases 3-4 fold bw 1-3 weeks post-burn
proteolysis leads to what?
a negative protein net balance
why is proteolysis increased post-burn?
it is the body’s way of using its AAs to try and help with the hypermetabolic state
there is a ____ in serum glucose following a burn
increase
there is ____ levels of endogenous insulin following a burn
increased
t/f: pts post burn often have insulin resistance and are more likely to develop DM from their injuries
true
t/f: the more severe burn pts eat, the faster they heal
true
nutritional requirements following a burn injury are proportional to what factors?
TBSA burn, age, and weight of the pt
burn pts may require up to how many calories per day?
4000-5000
do children with burn injuries require more or less calories than their adult counterparts with burns?
more calories
what are the CV responses 12-48 hrs post-burn?
increased capillary permeability throughout the entire body
vasoconstriction
increased protein leakage
what is fluid resuscitation?
fluids administered via IV over 24-72 hrs
with fluid resuscitation, we keep adult urine output ____ CC/hr
30-60
what pts get fluid resuscitation?
adults with >20% TBSA burns
children with >10% TBSA burns
pts with pre-existing medical conditions
what are some CVP consequences of burns?
increased HR, cardiac output, and capillary permeability
decreased myocardial contractility, hypotension, and end organ hypo-perfusion
pulmonary dysfxn, bronchoconstriction, and resp failure
what is a severe CV response to burns that causes vascular, neuromuscular, and respiratory compromise?
compartment syndrome
what are red flag signs to look for in CV responses to burns that may indicate compartment syndrome?
diminished pulses and weakness
what are signs to look for in CV responses to burns that may indicate compartment syndrome?
diminished pulses
weakness
change in temp
edema
signs of ischemia
what are the most common contractures that develop from burns
hip IR, flexion, and abduction
cervical flexion
shoulder protraction
what results in contracture development post burn?
pain
position of comfort
ms weakness
what are the principles of tissue (skin) healing?
the position of comfort will be the position of contracture
the location of the contracture depends on the location/depth of the burn, gravity, and pt compliance
the location of the contracture depends on what factors?
the location of the burns
depth of the burns
gravity
pt (non)compliance
t/f: deeper burns are more likely to develop contractures
true
what are the mental health consequences of burns?
PTSD and depression (not important how severe the incident was)
does the epidermis regenerate or repair?
regenerates
intact epithelium in epidermal healing attempts to cover the wound through what methods?
miosis and movt of the cells from the basal layer
t/f: moving epithelial cells always maintain contact with normal epithelium
true
what causes the dryness and itching in burns?
the damage to sebaceous glands
what is a sign that the wound can heal through epidermal healing?
epidermal buds
does the dermis heal through regeneration or repair?
repair
what are the 3 phases of scar formation?
inflammatory phase
proliferative/fibroblastic phase
maturation phase
what causes hemostasis in phase one of dermal healing?
vasoconstriction and platelet aggregation
what is involved in the inflammatory phase of dermal healing?
release of histamine leading to increased capillary permeability and vasodilation
phagocytosis
what is involved in the fibroblastic (proliferative) phase of dermal healing?
accumulation of fibroblasts in the wound
collagen production
neovascularization
what is the difference bw a hypertrophic scare and a keloid?
ahypertrophic scar stays within the og wound boundaries, while a keloid goes outside of these boundaries
what causes a hypertrophic scar in burns?
the collagen is laid out in disorganized bundles and myofibroblasts cause the tissue to contract and elevate
imbalance bw collagen production and lysis
rich blood supply
what is scar maturation in dermal healing? how long does it last?
the period during which the scar continues to change in form, bulk, and strength for 1-2 yrs
what are the indications for surgery with burns?
partial-full thickness injury
crosses joints
potential to limit fxn
large area
what are the types of permanent grafts?
autografts
cultured skin
what is the only type of temporary graft?
homograft (allograft)
what are the 2 types of autografts that can be used in burns?
full thickness autograft
split thickness autograft
what is a full thickness autograft?
a graft using all the dermis from the donor site
which autograft results in less scarring?
full thickness autograft
does the donor site heal on its own with a full thickness autograft?
no, it needs a split thickness graft
what is a split thickness skin graft (STSG)?
a meshed skin graft that doesn’t use the entire dermis of the donor site
t/f: we can harvest from the donor sites over and over again with STSGs
true
when would we use a STSG?
for a large area
for a dirty wound so that exudate can come through
does the donor site heal on its own with STSGs?
yes
what is an allograft/homograft?
cadaver skin
most often, allografts/homografts are used for what burns?
burns that are 50% or greater
what are the indications for allograft/homograft?
temporary biologic coverage (reduce pain, decrease water/electrolyte/protein loss, stimulate vascularization, protect wound from bacterial contamination, promote dermal matrix)
dressing for partial thickness wounds
wound bed prep for autografting
what are the alternative methods for wound closure?
xenografts
artificial skin substitutes
what is a xenograft?
a graft obtained from an unrelated species
are xenografts used very often in the US anymore?
nope
what are artificial skin substitutes composed of?
biological, synthetic, and biosynthetic materials
what do artificial skin substitutes do?
provide scaffold and substitutes for the extracellular matrix
framework for neovascularization
cell adhesion
proliferation
is there motion restrictions for the donor site
nope
how many days of post-op immobilization is there for the graft site?
3-5 days
bc pts have to be immobilized for 3-5 days post graft, what do we as PTs have a role in doing?
putting them in a position of fxn
what is involved in phase 1 (initial assessment and triage) of medical tx of burns?
stop the burning process
primary survey
secondary survey
begin fluid resuscitation
what is the primary survey in burns assessment?
airway, breathing, and circulation assessment
what is the secondary survey in burns assessment?
assessment of other injuries, estimating % TBSA
with fluid resuscitation, how do we calculate the initial fluid rate?
either 2-4 mL/kg per 24 hrs to estimate 24 hr volume or using the rule of tens
when does fluid resuscitation occur?
0-48 hrs post injury
what are the phases of medical tx of burns?
phase 1: initial assessment and triage
phase 2: fluid resuscitation
phase 3: burn wound care and coverage
what is involved in burn wound care and coverage?
use of topical antimicrobial creams or dressings to prevent infection
surgical debridement, burn wound excision, and autografting
optimize conditions for wound healing
cleansing, debridement, dress/bandage
when is the most ideal time for PT/OT to get ROM measurements for a burn pt?
when they are getting bathed for wound cleansing
what debridement may be used for burns?
mechanical
enzymatic
sharp
biologic
what form of debridement is the best source of wound care due to the fact that it only affects the necrotic tissue and doesn’t disrupt the good tissue?
biologic debridement (maggots)
