Final Exam Flashcards
How many people are admitted to specialized burn centers per year?
30,000
Hospital stay is decreased from 1 day/% TBSA to average of __ days
11
What are the causes of burns?
43% fire/flame 34% scald 9% contact w/ hot object 4% electrical 3% chemical 7% other
How much does it cost to treat burns per year?
$7.5 billion
What are the criteria for referral to a burn center?
- partial thickness burns greater than 10% TBSA
- burns that involve the face, hands, feet, or genitalia
- third degree burns in any age group
- electrical burns, including lightning injury
- chemical burns
- inhalation injury
- burn injury in patients with pre-existing medical conditions that could complicate management, prolong recovery, or affect mortality
- any patient with burns and concomitant trauma in which the burn poses the greatest risk of morbidity and mortality
- burned children in hospitals w/o qualified personnel or equipment for the care of children
- burn injury in patients who will require special social, emotional, or rehabilitative intervention
How long does it take a burn to fully mature?
2 years
What is the average skin depth?
1-4 mm
Epidermis comprises __% of the skin, while the dermis comprises the other __%
5%; 95%
Where is the skin the thickest? Thinnest?
Palms, soles, and back; eyelids, dorsum of hands and feet
What are the 5 layers of the epidermis (from superficial to deep)?
Stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale
How long does it take for cells to migrate to the stratum corneum?
2-4 weeks
Melanocytes
pigment producing cells; reside in the stratum basale
Keratinocytes
produce keratin which waterproofs the skin
Merkel Cells
increase the strength of the skin
Langerhans Cells
nonspecific immune protection from invading microorganisms; reside in the stratum spinosum layer
Where are the grafts of the face taken?
from the patient’s thigh
How long does it take for the epidermis to return to full strength?
45-75 days
The dermis is composed of:
collagen and elastin
What are the functions of the skin?
- Protection
- Immunological
- Electrolyte balance
- Thermoregulation
- Neurosensory
- Social interaction
- Metabolism
Thermal Burns
flash, flame, scald, contact
Chemical Burns
acidic or alkaline
Electrical Burns
AC, DC, high volt, or low volt
Conduction
most common cause of thermal injuries; results from direct contact of body to a heat source
Dependent on temperature and the time under exposure
How long can burns take to convert to a deeper burn?
24-72 hours
Convection
caused by currents of air used to carry heat; results from flash injuries from explosions; usually a short duration w/ a high intensity
What are the determinants of severity of injury with chemical burns?
- duration of exposure
- concentration and quantity
- local skin characteristics
- underestimating danger and not seeking treatment
- delay in treatment
- failing to irrigate long enough
Acidic Burns
neutralized by the skin and cause coagulation necrosis of soft tissue and bone, producing a dry eschar
Alkaline Burns
more severe and denature proteins in the skin, causing liquefaction necrosis, deeper tissue penetration
How long might alkaline burns need to be irrigated?
Up to 12 hours
What are late sequelae of chemical burns?
hypertrophic scarring and contact dermatitis
Tissues of low resistance
nerve, blood vessels, wet skin
Tissues of high resistance
muscle, dry skin, tendon, fat, and bone
Superficial Burns
involve only epidermis; pink or bright red in color; blanches with pressure; may have small blisters; usually painful; heals in 3 to 5 or 7 days
*first degree burns are not calculated as part of the burn size estimate
Superficial Partial Thickness Burns
involves the epidermis and extends into the papillary dermis; bright red and erythema; extremely painful d/t exposed nerve endings; blanches with pressure; sensation to touch and pain intact; usually heal within 10-14 days through spontaneous re-epithelialization
Deep Partial Thickness Burns
involves the epidermis and extends into the papillary and reticular dermis; pale mottled surface with red capillary appendages; may be painful or have areas of insensitivity; sensation to pressure remains intact with diminished pinprick sensation; edematous; blanching present but diminished
Full Thickness Burns
involves epidermis, papillary, and reticular dermis and may extend into sebaceous tissue, muscle, or bone; charred, mottled, pale, waxy, yellow, brown, or non-blanching red appearance; dry, leathery, firm to touch and rigid
Zone of Coagulation
the area of greatest destruction; region has suffered irreparable damage; coagulation, ischemia, and necrosis
Zone of Stasis
zone of lesser injury lying deep and peripheral to the zone of coagulation; temporarily lacks a normal blood supply, but not avascular; can be divided into a superficial and delayed zone
Zone of Hyperemia
located farthest from injury; peripheral to the zone of stasis; minimal cell injury with vasodilation
Burns heal by which two methods?
Re-epithelialization and scar formation
Re-epithelialization
healing method for superficial, superficial partial, and partial thickness burns; process begins in 24-48 hours;
superficial burns heal through basal cell layer differentiating to recreate the layers, which takes 3-4 days
superficial and partial thickness injuries epithelialization occurs from the wound edges and dermal appendages, which takes 2-3 weeks
Granulation and Scar Formation
Consists of three phases: inflammatory, proliferative, and remodeling phase
What are the three indicators of a hypertrophic scar?
red, raised, and rigid
Split thickness grafts can be either:
meshed or sheet grafts
Sheet graft
contract less because of higher dermal content; better for cosmesis and over joints
Meshed graft
regularly placed incisions throughout the graft (interstices); contracts more d/t greater healing times at interstices
What are causes of graft failure?
infection, inadequate debridement, insufficient mobilization, collection of fluid under graft
How long are temporary grafts left in place?
10-14 days
Escharotomy
an incision made into insensate, full-thickness burned tissue and into the subcutaneous tissue to relieve constricting circulation
Fasciotomy
an incision to muscle fascia beneath burned tissue performed in patients with very deep burns involving the fascia and muscle, associated traumatic limb injuries, high-voltage electrical injury
How long do surgeons prefer to wait before grafting full thickness or deep partial burns of the face?
2 weeks to allow some healing to occur
Tarsorrhaphy
a surgical procedure where the eyelids are partially or completely sewn together to narrow the opening to prevent ocular damage; left in place for 3 weeks
Severe burns create a hypermetabolic state by:
- elevating body temperature
- increased oxygen consumption
- increased glucose production
- muscle weakness
- cardiopulmonary deconditioning
Tissue degradation in burn patients:
- decreased lean body mass
- decreased bone mineral content
- decreased bone mineral density
Metabolic response
10% loss of lean body mass has impaired immunity
20% loss of lean body mass impairs wound healing
30% loss of lean body mass leads to pressure ulcers
40% loss lean body mass leads to 50-100% mortality
Fluid resuscitation is required when:
At least 20% of fluid is lost through third spacing and burned areas; 50% of the fluid is administered in the first 8 hours, while the other 50% is administered over the next 16 hours
Edema Timeline
edema formation is rapid in the first 2-3 hours post burn; edema is maximal by 8-12 hours (small burns) or 12-24 hours (large burns); edema persists at a high level for 24-72 hours
resorption begins and should resolve in 7-10 days, but ma persists for 2-3 weeks
Cardiac Effects of Burns
Increased CO to normal by 12-24 hours but then doubles until wounds are closed; increased HR leaves lower cardiac reserves for increase in activity such as ROM and mobility; low MAP indicates reassessment of fluid volume
What is the ideal position to prevent injury to the brachial plexus?
abduction just to 90˚ and 30˚ horizontal adduction in the scapular plane
What are the MSK complications in the acute phase of burn injuries?
- contractures
- septic arthritis
- tendonitis
- heterotopic ossification
What are the MSK complications in the late phase of burn injuries?
- osteoporosis
- bone spurs
- amputations
What are the predictors of pruritis?
- females
- burn size >20-40%
- healing time > 3 weeks
- increased tissue requiring grafting
- younger age
What are potential ways to decrease pruritis?
- Vitamin E cream, Eucerin cream, Aloe
- Antihistamines
- Compression garments
What are physical therapy interventions in the acute or sub-acute phase of wound healing?
- facilitate wound healing
- positioning
- initiate mobility
- control edema
- splinting
- AROM (PROM w/ caution)
What are physical therapy interventions in the intermediate phase of wound healing?
- gait training
- exercise
- modalities
- stretching, strengthening
- functional activities
- compression
- wound care
What are physical therapy interventions in the late phase of wound healing?
- compression
- soft tissue mobilization
- exercise
- modalities
- scar massage
- industrial activities
Why is it important to splint the hand? What position should the wrist and hand be splinted?
Prevents contracture of the wrist and hand and helps push out of the hand; ideal position for immobilization is MCP joint flexion to 50˚-70˚; IP joint at neutral; thumb in opposition; wrist extension 20˚-30˚
How should a hip burn be positioned?
Fully extended and abducted w/ 10˚-20˚ of flexion
What are the identified risk factors for hypertrophic scarring?
- young age
- female
- dark skin
- neck or UE burns
- multiple surgical procedures
- > 3 weeks to heal (unless 5% of less TBSA)
- meshed skin graft use
- burn severity >20% TBSA burn
Timeline of Hypertrophic Scar Formation
develops within the first few months post burn and accelerates and peaks in about 6 months, matures in about 18-24 months
What are the complications of scars?
- cosmetic changes
- decreased quality of life
- contraction of scar while it matures
- altered sensation
- itching
- cracking
- pigment changes
- higher risk of sunburn
What are the four components of the Vancouver Scar Scale?
pigmentation, vascularity, pliability, and height; good prognosis is under 3 mm w/in the first year
Goals of Compression Therapy
- relieve edema
- inhibit the growth of hypertrophic scarring
- promote scar maturation
- protect newly healed skin
- relieve itching
- relieve pain
How much pressure do custom compression garments apply to the wound?
25 mmHg
How often should custom compression garments be replaced?
every 2-3 months
What are the three P’s of a mature scar?
pale, planar, and pliable
What are concerns specific to burn patients?
- muscle atrophy, strength, endurance
- ROM
- cardiopulmonary deconditioning
- immobilization
- burn wound healing
- impaired mobility and disfigurement
- impaired ADLs
- social and psychological concerns
How long should a burn be stretched once end range is achieved?
3 minutes
T/F: PROM to exposed tendon is prohibited
True
What are contraindications to exercise?
- nonstabilized fractures
- cardiovascular instability
- extubation within 8 hours of treatment
- exposed tendons
- recent graft placement
- finger burns of indeterminate depth
- heterotopic bone formation
- resistive or combative patient
Effects of hydrotherapy on burn patients
- soften eschar
- remove topicals
- assists with ROM
Silvadene
broad-spectrum antimicrobial including Pseudomonas; limited eschar penetration, but can be used to soften eschar; apply 1/16” thick 1-2x per day
Sulfamylon
bacteriostatic for gram + and - organisms, especially Pseudomonas; penetrates eschar
used mainly for deep partial thickness, full thickness burns or infected wounds; apply 1/16” thick 1-2x per day
Topical agents used for enzymatic debridement can be divided into what three categories:
- proteolytic
- fibrinolytic
- collagenase
