Exam 2-Burns Flashcards
What are 4 different kinds of burns?
- thermal
- chemical
- electrical
- radiation (cancer)
House fires don’t account for much of total burn hospitalizations, so why do they account for 12% of deaths?
inhalation damage/injury
What are the layers of skin, top to bottom? (in copious detail)
- epidermis: stratum basale, spinosum, granulosum, licidum, corneum
- specialized epidermal
- dermis: papillary, reticular
- specialized dermal cells
- subcutaneous tissues
What are the specialized epidermal cells?
melanocytes, Langerhans cells
What do the Langerhans cells do?
they help with immunity, so when you lose them from a burn you are immunocompromised
How long to skin cells live?
It takes about 2 weeks to move from the bottom to the top, and then they die in 10-14 days.
What’s the biggest risk for burn patients?
infection
What kind of burn gets down to the papillary dermal layer?
Superficial partial thickness
What is in the papillary layer?
collagen-it’s a thin layer
What are components of the reticular dermal layer?
Collagen, elastic tissue (for taut skin), reticular fibers (for strength)
Why is ROM important for burn patients?
They lose elasticity in their skin
What are the specialized dermal cells?
sweat glands, hair follicles, sebaceous glands
What factors indicate the severity of burns?
depth & size location age general health mechanism of injury
How do cold injuries happen?
- temp drops to 35.6F
- additional thawing injury
What happens to coloring with cold injuries?
skin goes from white to purplish blue
What do you see with deep frostbite?
pain, blisters, tissue necrosis, and gangrene
How do you treat cold injuries?
- 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
Superficial Burn
- 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
if a burn has pain, what depth is it?
superficial or superficial partial thickness
Superficial Partial Thickness Burn
- 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
Deep Partial Thickness
- 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
Full thickness burn
- 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
How is blood flow occluded in a full thickness burn?
There is increased fluid in the interstitial space, which results in increased pressure on the deep vascular bed, occluding blood flow with possible necrosis
What is an escharotomy? What is a fasciotomy? Why would you do these?
Cutting through the eschar to relieve pressure.
Cutting through fascia to relieve pressure.
You have to relieve pressure or they can get compartment syndrome.
Subdermal/electrical burn
- 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
What are the zones of a burn?
- coagulation
- stasis
- hyperaemia
What is the zone of coagulation?
- at the point of maximum damage-irreversible
- central area
What is the zone of stasis?
- decreased tissue perfusion
- tissue can be salvaged
- minimal blood flow
What is the zone of hyperaemia?
- outermost layer
- increased tissue perfusion
- pain fibers
Why do you want to be careful of splints and compression dressings getting too tight?
This can increased the zone of coagulation into the zone of stasis. This damage can happen in 2 hours.
What is the rule of nines?
divides the body into areas of 9% or multiples for a rapid estimate of TBSA burned for meds and fluids
The rule of nines is good for adults, but what do they use for kids?
Lund and Browder made one for age and growth of different segments for babies, adolescents, and adults
What factors effect complications?
- location, age, pre-existing or comorbidities
- psychosocial: confused, abuse, smoker, lack of social support and sanitary conditions
- major functional problems: ROM, appearance, work
When do burn victims need to be hospitalized and why?
children-30% TBSA
adults- 20%
elderly-15%
After these TBSA % burned, they have to be hospitalized because their bodies can’t handle it
What kinds of bacteria usually infect burns?
resistant strains of pseudomonas aeruginosa and staphylococcus aureus
- smell bad-anaerobic bacteria
- lead to sepsis
What are pulmonary complications of burns?
- carbon monoxide poisoning
- pneumonia-high risk of coughing up soot
- pulmonary edema
- tracheal damage
- upper airway obstruction-can come from edema
What are cardiac complications of burns?
- 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
What are metabolic complications of burns?
- 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
What might you do to combat metabolic complications?
- nasal feeding tube
- TPN
- drug-induced coma
- keep room temp higher, cooling blanket
- position of function
What are concerns about nutrition with burns?
- 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
What is a skeletal complication of burns?
- 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
Why would you get polyneuropathy after a burn?
- don’t know-cause unknown; resolves over time
- peripheral burns, edema
Why would you get local neuropathy?
- treatment issues: splinting, positioning
- brachial plexus,ulnar nerve, common peroneal nerve
What is a microstoma?
lips contract so the mouth doesn’t open very big
What damage can occur to the eyes with burns?
can become contracted open; corneal damage
What’s a burn amputation going to look like?
irregular stump
When do you get a hypertrophic scar?
when collagen production exceeds breakdown
What’s the difference between a hypertrophic and a keloid scar?
hypertrophic is in the wound boundaries, keloid goes beyond
Why are keloid scars bad news?
they are gross looking (raised, firm,large, red/purple), and they can cause functional deformities- they can even dislocate joints
Who is at risk for keloid/hypertrophic scars? How can we treat them?
- African Americans; genetic
- laser therapy
Give a general overview of burn treatment.
- initially stabilize and maintain airway
- replace fluids
- wound care
- coordinate pain meds
How do we clean burn wounds?
- hydrotherapy
- disinfectant in water for infection with a temp at 98.6-104
- clean technique and sterile instruments
What kind of dressing should we avoid for burns?
Gauze! Cause it sticks!
What kind(s) of dressings do we want?
- non adherent and moisture retentive
- Hydrocolloids, Hydrogels, foams (mepilex), hydrophillics, alginates, film dressings, antimicrobials-silver
What can hydrocolloids be used for?
They’re good for donor sites, but limit the ability to observe the site, so aren’t recommended for burns
What are film dressings best for?
simple partial thickness burns or donor sites
When do we use antimicrobials like silver?
To minimize infection; best for burn patients
Why are hydrogels good?
they add fluid to the wound to soften them for easier debridement
What’s a bad thing about hydrophillics and alginates?
they can give you a “diaper rash” or maceration
What kinds of membranes are there? What are they used for?
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)
What’s a benefit of amnion?
It has healing properties with excellent long term cosmetics
What don’t we use membranes for?
full thickness burns
What is xeroform?
a jelly that keeps dressings from adhering
What is Oasis?
- replacement skin
- for donor sites
- synthetic, has fibroblasts and such
- makes harvesting easier
- done in operating room
What is the most common antibacterial for burns?
-silver sulfadiazine
Why is silvadene kind of sketchy?
A Cochrane review said it might increase risk of infection and hospital times
Why is silvadene good?
- it can be OP
- its cheaper than silver dressing
What is Mafenide/sulfamylon?
a topical antibacterial; white cream applied 12mm to wound; effective for gram positive and negative pseudomonas
What’s a bad thing with any of these creams?
psuedo-eschar
What is bacitracin?
- topical med
- effective against gram +
- if the wound will heal spontaneously, its used with nonadherent dressing
- but there’s not a lot of evidence
What is santyl?
enzyme that helps break down the wound
-easier and less painful
What is the gold standard of biological material dressings?
Allograft, bitch
What is allograft?
- cadaver skin
- temporary, but it provides good vascularization of the wound bed
- but it’s expensive, and maybe can transmit viral infections
What is Xenograft?
- skin from pigs
- temporary until enough for normal skin
- doesn’t provide good vascularization
- less expensive
What are 3 dermal substitutes?
- cultured autologous skin substitute
- integra (bovine collagen and glucosaminoglycans that allow fibrovascular ingrowth-aka a matrix for fibroblasts)
- alloderm (cadaver dermis)
What are in skin substitues?
- autologous keratinocytes and integra
- added melanocytes to decreased production time and spotting
- maybe someday sweat glands and hair follices
What is an autograft?
A skin graft from the patient
Is it permanent?
So far.
JK it is
What is split-thickness autograft? A full-thickness?
- contain epidermis and superficial layer of dermis
- full dermal thickness
What are advantages of sheet grafts and mesh grafts?
- sheet: more cosmetic
- mesh: cover a larger area
What’s a tissue expander?
a thing they put under the skin so that it makes the skin grow real big
What is a z-plasty?
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
Dear Anna,
You have a lovely doc of other information. In that is a very important section on PT Interventions. Please read that now. Thank you!
What’s a general plan for PT and burns?
- edema control
- positioning to minimize edema, prevent tissue destruction, maintain soft tissue in elongated state or neutral position of function
- ROM
Why do we splint?
- prevent or correct of contractures
- maintenance of ROM achieved during exercise or surgical release
- protect joint or tendon
When do pts wear splints?
at night, while resting, or continuously after skin graft
What are considerations for ROM for burns?
- 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
What are considerations for strengthening/endurance for burns?
- 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
What are considerations for ambulation for burns?
- 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
What can compression do for scars?
- early: pressure therapy >25mmHg worn 23 hours/day for 12-18 months
- Have to use compression for full or partial deep thickness
What else can you do for scars besides pressure?
- silicon gel: 12-24 hr/day for 2-3/6-12 months
- deep friction massage: 5-10 mins/ 3-6x/day
- maderma>vitamin E
What does deep friction massage do?
- makes tissue more pliable
- assists with ROM
- edges of grafts benefit
What are contraindications to deep friction massage?
- wound that isn’t healed or is inflamed
- tissue fragility
- infection
- pain
What are types of pressure dressings?
- 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
How do you measure for compression garments (CG)?
measure circumference of extremity every 1 1/2 in
Why do we need OP burn care?
- 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
What do you need to talk to pts about skin care?
- 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
