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MultiSystem Management > Exam 2-Burns > Flashcards

Exam 2-Burns Flashcards

1
Q

What are 4 different kinds of burns?

A
  • thermal
  • chemical
  • electrical
  • radiation (cancer)
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2
Q

House fires don’t account for much of total burn hospitalizations, so why do they account for 12% of deaths?

A

inhalation damage/injury

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3
Q

What are the layers of skin, top to bottom? (in copious detail)

A
  • epidermis: stratum basale, spinosum, granulosum, licidum, corneum
  • specialized epidermal
  • dermis: papillary, reticular
  • specialized dermal cells
  • subcutaneous tissues
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4
Q

What are the specialized epidermal cells?

A

melanocytes, Langerhans cells

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5
Q

What do the Langerhans cells do?

A

they help with immunity, so when you lose them from a burn you are immunocompromised

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6
Q

How long to skin cells live?

A

It takes about 2 weeks to move from the bottom to the top, and then they die in 10-14 days.

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7
Q

What’s the biggest risk for burn patients?

A

infection

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8
Q

What kind of burn gets down to the papillary dermal layer?

A

Superficial partial thickness

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9
Q

What is in the papillary layer?

A

collagen-it’s a thin layer

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10
Q

What are components of the reticular dermal layer?

A

Collagen, elastic tissue (for taut skin), reticular fibers (for strength)

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11
Q

Why is ROM important for burn patients?

A

They lose elasticity in their skin

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12
Q

What are the specialized dermal cells?

A

sweat glands, hair follicles, sebaceous glands

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13
Q

What factors indicate the severity of burns?

A 
depth & size
location
age
general health
mechanism of injury
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14
Q

How do cold injuries happen?

A
  • temp drops to 35.6F

- additional thawing injury

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15
Q

What happens to coloring with cold injuries?

A

skin goes from white to purplish blue

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16
Q

What do you see with deep frostbite?

A

pain, blisters, tissue necrosis, and gangrene

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17
Q

How do you treat cold injuries?

A
  • rewarming NO MASSAGING, let them rewarm on their own
  • positioning to avoid WBing
  • gauze betweentoes
  • manage blisters-don’t pop them
  • topical aloe vera cream
  • foam dressings
  • hyperbaric O2
  • smoking cessation
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18
Q

Superficial Burn

A
  • damage only to epidermis, no break in skin
  • ex-sunburn
  • pink, red in color
  • no blisters, dry surface, delayed pain and tender, minimal edema
  • all pain receptors still intact
  • no scars
  • spontaneous healing
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19
Q

if a burn has pain, what depth is it?

A

superficial or superficial partial thickness

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20
Q

Superficial Partial Thickness Burn

A
  • damage through epidermis, into papillary layer of the dermis
  • bright pink or red, mottled red
  • intact blisters, moist surface, weeping
  • very painful; sensitive to temp changes, light touch and exposure to air currents
  • moderate edema
  • spontaneous health with minimal scarring by epithelial cell production and migration from wound periphery (contraction); occurs in 7-14 days
  • some residual skin color change due to destruction of melanocytes
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21
Q

Deep Partial Thickness

A
  • destruction of epidermis and dermal reticular layer (nerve endings, follicles, sweat glands)
  • 15-20x evaporative water loss due to tissue & vascular destruction
  • mixed red and waxy white, blanching with slow capillary refill
  • marked edema, broken blisters, wet surface
  • sensitive to pressure, but insensitive to light touch or soft pin prick
  • heal spontaneously in 3-5 weeks if it doesn’t become infected-can become deeper; occurs through scar formation & reepithelialization from viable epidermal cells; after healing, thin epithelium with decreased sebaceous glands resulting in dry, scaly, itchy skin that can be easily damaged-creams, sensation, number of sebaceous glands
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22
Q

Full thickness burn

A
  • white, charred, tan, black, red, hemoglobin fixation; no blanching
  • thrombosed vessels, poor distal circulation-peripheral edema
  • skin leathery, rigid, dry
  • anesthetic
  • loss of hair, area depressed
  • hospitalized, need skin grafts; scar/hypertrophic; no sites available for re-epithelialization
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23
Q

How is blood flow occluded in a full thickness burn?

A

There is increased fluid in the interstitial space, which results in increased pressure on the deep vascular bed, occluding blood flow with possible necrosis

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24
Q

What is an escharotomy? What is a fasciotomy? Why would you do these?

A

Cutting through the eschar to relieve pressure.
Cutting through fascia to relieve pressure.
You have to relieve pressure or they can get compartment syndrome.

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25
Q

Subdermal/electrical burn

A
  • charred; subcutaneous tissue evident, muscle damage
  • anesthetic; neuro involvement (complete shut down)-can occur days to weeks later
  • arrhythmias, cardiac arrest; can manifest up to 2 hours later-check vitals, EKG
  • entrance and exit wound; course of tissue destruction is unpredictable; tissues defects, heals with skin grafting and scarring
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26
Q

What are the zones of a burn?

A
  • coagulation
  • stasis
  • hyperaemia
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27
Q

What is the zone of coagulation?

A
  • at the point of maximum damage-irreversible

- central area

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28
Q

What is the zone of stasis?

A
  • decreased tissue perfusion
  • tissue can be salvaged
  • minimal blood flow
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29
Q

What is the zone of hyperaemia?

A
  • outermost layer
  • increased tissue perfusion
  • pain fibers
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30
Q

Why do you want to be careful of splints and compression dressings getting too tight?

A

This can increased the zone of coagulation into the zone of stasis. This damage can happen in 2 hours.

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31
Q

What is the rule of nines?

A

divides the body into areas of 9% or multiples for a rapid estimate of TBSA burned for meds and fluids

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32
Q

The rule of nines is good for adults, but what do they use for kids?

A

Lund and Browder made one for age and growth of different segments for babies, adolescents, and adults

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33
Q

What factors effect complications?

A
  • location, age, pre-existing or comorbidities
  • psychosocial: confused, abuse, smoker, lack of social support and sanitary conditions
  • major functional problems: ROM, appearance, work
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34
Q

When do burn victims need to be hospitalized and why?

A

children-30% TBSA
adults- 20%
elderly-15%
After these TBSA % burned, they have to be hospitalized because their bodies can’t handle it

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35
Q

What kinds of bacteria usually infect burns?

A

resistant strains of pseudomonas aeruginosa and staphylococcus aureus

  • smell bad-anaerobic bacteria
  • lead to sepsis
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36
Q

What are pulmonary complications of burns?

A
  • carbon monoxide poisoning
  • pneumonia-high risk of coughing up soot
  • pulmonary edema
  • tracheal damage
  • upper airway obstruction-can come from edema
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37
Q

What are cardiac complications of burns?

A
  • decreases in Hgb and Hct-anemia
  • injured vascular beds
  • fluid shift results in decreased CO
  • poor endurance
  • increased work of heart->beta blockers decreased resting energy expenditure and lean body mass, prevent catabolic state
  • orthostatic
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38
Q

What are metabolic complications of burns?

A
  • rapid weight loss
  • negative nitrogen balance
  • decrease in energy stores
  • increase of 1.8-2.6 degrees F in core temp
  • muscle atrophy-inactivity and catabolism
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39
Q

What might you do to combat metabolic complications?

A
  • nasal feeding tube
  • TPN
  • drug-induced coma
  • keep room temp higher, cooling blanket
  • position of function
40
Q

What are concerns about nutrition with burns?

A
  • stress induced hyperglycemia
  • adequate calories for hypermetabolsim
  • increased intake of protein, glucose, and amino acid
  • glutamine supplementation decreases incidence of infection,length of stay and mortality
  • enteral nutrition preferred over parenteral
41
Q

What is a skeletal complication of burns?

A
  • heterotopic ossification
  • -with >20% TBSA, high protein, microtrauma, spesis and immobilization
  • -sx: decreased ROM, point-specific pain
  • -ectopic bone that matures 6-9 months after trauma
  • -swelling and tenderness that mimics a low grade infection
  • -elbow, hip, shoulders
42
Q

Why would you get polyneuropathy after a burn?

A
  • don’t know-cause unknown; resolves over time

- peripheral burns, edema

43
Q

Why would you get local neuropathy?

A
  • treatment issues: splinting, positioning

- brachial plexus,ulnar nerve, common peroneal nerve

44
Q

What is a microstoma?

A

lips contract so the mouth doesn’t open very big

45
Q

What damage can occur to the eyes with burns?

A

can become contracted open; corneal damage

46
Q

What’s a burn amputation going to look like?

A

irregular stump

47
Q

When do you get a hypertrophic scar?

A

when collagen production exceeds breakdown

48
Q

What’s the difference between a hypertrophic and a keloid scar?

A

hypertrophic is in the wound boundaries, keloid goes beyond

49
Q

Why are keloid scars bad news?

A

they are gross looking (raised, firm,large, red/purple), and they can cause functional deformities- they can even dislocate joints

50
Q

Who is at risk for keloid/hypertrophic scars? How can we treat them?

A
  • African Americans; genetic

- laser therapy

51
Q

Give a general overview of burn treatment.

A
  • initially stabilize and maintain airway
  • replace fluids
  • wound care
  • coordinate pain meds
52
Q

How do we clean burn wounds?

A
  • hydrotherapy
  • disinfectant in water for infection with a temp at 98.6-104
  • clean technique and sterile instruments
53
Q

What kind of dressing should we avoid for burns?

A

Gauze! Cause it sticks!

54
Q

What kind(s) of dressings do we want?

A
  • non adherent and moisture retentive

- Hydrocolloids, Hydrogels, foams (mepilex), hydrophillics, alginates, film dressings, antimicrobials-silver

55
Q

What can hydrocolloids be used for?

A

They’re good for donor sites, but limit the ability to observe the site, so aren’t recommended for burns

56
Q

What are film dressings best for?

A

simple partial thickness burns or donor sites

57
Q

When do we use antimicrobials like silver?

A

To minimize infection; best for burn patients

58
Q

Why are hydrogels good?

A

they add fluid to the wound to soften them for easier debridement

59
Q

What’s a bad thing about hydrophillics and alginates?

A

they can give you a “diaper rash” or maceration

60
Q

What kinds of membranes are there? What are they used for?

A

Used for: decreasing number of dressing changes and pain meds; facilitate growth factors
Types: synthetic (partial thickness, split thickness donor sites), biosynthetic (superficial), amnion (temporary)

61
Q

What’s a benefit of amnion?

A

It has healing properties with excellent long term cosmetics

62
Q

What don’t we use membranes for?

A

full thickness burns

63
Q

What is xeroform?

A

a jelly that keeps dressings from adhering

64
Q

What is Oasis?

A
  • replacement skin
  • for donor sites
  • synthetic, has fibroblasts and such
  • makes harvesting easier
  • done in operating room
65
Q

What is the most common antibacterial for burns?

A

-silver sulfadiazine

66
Q

Why is silvadene kind of sketchy?

A

A Cochrane review said it might increase risk of infection and hospital times

67
Q

Why is silvadene good?

A
  • it can be OP

- its cheaper than silver dressing

68
Q

What is Mafenide/sulfamylon?

A

a topical antibacterial; white cream applied 12mm to wound; effective for gram positive and negative pseudomonas

69
Q

What’s a bad thing with any of these creams?

A

psuedo-eschar

70
Q

What is bacitracin?

A
  • topical med
  • effective against gram +
  • if the wound will heal spontaneously, its used with nonadherent dressing
  • but there’s not a lot of evidence
71
Q

What is santyl?

A

enzyme that helps break down the wound

-easier and less painful

72
Q

What is the gold standard of biological material dressings?

A

Allograft, bitch

73
Q

What is allograft?

A
  • cadaver skin
  • temporary, but it provides good vascularization of the wound bed
  • but it’s expensive, and maybe can transmit viral infections
74
Q

What is Xenograft?

A
  • skin from pigs
  • temporary until enough for normal skin
  • doesn’t provide good vascularization
  • less expensive
75
Q

What are 3 dermal substitutes?

A
  • cultured autologous skin substitute
  • integra (bovine collagen and glucosaminoglycans that allow fibrovascular ingrowth-aka a matrix for fibroblasts)
  • alloderm (cadaver dermis)
76
Q

What are in skin substitues?

A
  • autologous keratinocytes and integra
  • added melanocytes to decreased production time and spotting
  • maybe someday sweat glands and hair follices
77
Q

What is an autograft?

A

A skin graft from the patient

78
Q

Is it permanent?

A

So far.

JK it is

79
Q

What is split-thickness autograft? A full-thickness?

A
  • contain epidermis and superficial layer of dermis

- full dermal thickness

80
Q

What are advantages of sheet grafts and mesh grafts?

A
  • sheet: more cosmetic

- mesh: cover a larger area

81
Q

What’s a tissue expander?

A

a thing they put under the skin so that it makes the skin grow real big

82
Q

What is a z-plasty?

A

A surgicat treatment to lengthen scar contractures by interposing normal tissue in the line of the scar

  • realign fibers to increase ROM
  • for if they have functional impairments
83
Q

Dear Anna,

A

You have a lovely doc of other information. In that is a very important section on PT Interventions. Please read that now. Thank you!

84
Q

What’s a general plan for PT and burns?

A
  • edema control
  • positioning to minimize edema, prevent tissue destruction, maintain soft tissue in elongated state or neutral position of function
  • ROM
85
Q

Why do we splint?

A
  • prevent or correct of contractures
  • maintenance of ROM achieved during exercise or surgical release
  • protect joint or tendon
86
Q

When do pts wear splints?

A

at night, while resting, or continuously after skin graft

87
Q

What are considerations for ROM for burns?

A
  • painful but as reps increase, pain decreases; coordinate with meds
  • begin in first 48 hours
  • best at dressing changes
  • S/P skin graft-hold 3-5 days, then proceed gently with AROM
  • healed burn area should be kept moist
88
Q

What are considerations for strengthening/endurance for burns?

A
  • lose body weight and lean mm mass
  • monitor vitals
  • increase CV endurance by walking, cycling, stair climbing, rowing
  • isokinetic or isotonic
  • free weights or pulleys
  • incorporate breathing exercises
89
Q

What are considerations for ambulation for burns?

A
  • LEs should be wrapped in elastic bandages in a figure 8
  • graft may need to hold gait
  • ambulate as soon as stable
  • tilt tables are your friend
  • ADs, orthotics
90
Q

What can compression do for scars?

A
  • early: pressure therapy >25mmHg worn 23 hours/day for 12-18 months
  • Have to use compression for full or partial deep thickness
91
Q

What else can you do for scars besides pressure?

A
  • silicon gel: 12-24 hr/day for 2-3/6-12 months
  • deep friction massage: 5-10 mins/ 3-6x/day
  • maderma>vitamin E
92
Q

What does deep friction massage do?

A
  • makes tissue more pliable
  • assists with ROM
  • edges of grafts benefit
93
Q

What are contraindications to deep friction massage?

A
  • wound that isn’t healed or is inflamed
  • tissue fragility
  • infection
  • pain
94
Q

What are types of pressure dressings?

A
  • elastic wrap: vascular support, controls edema & scars
  • self-adherent elastic wrap: used over dressings
  • tubular support bandages: cheap; various circumferences and garment styles; 10-20mmHg; prior to custom fitted; good for little kids
95
Q

How do you measure for compression garments (CG)?

A

measure circumference of extremity every 1 1/2 in

96
Q

Why do we need OP burn care?

A
  • healing can take up to 2 years
  • HEP stressing importance of ROM
  • education about splinting, positioning, skin care
  • encourage independent ADLs
  • massage scar daily
  • superficial wound opening should be cleaned 2x daily then apply antibiotic ointment followed by non adherent dressing
  • avoid scratching
  • monitor kids because they are still growing
97
Q

What do you need to talk to pts about skin care?

A
  • use at least spf 35, protect with clothing/hats
  • unable to work in sunlight, extreme temps, around chemicals
  • skin is fragile
  • hydration
  • no swimming, hot tubs

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