L6 Burn Rehab Flashcards
Burns Definition
injuries resulting from direct contact or exposure to thermal, chemical, electrical, or radiation source
Burns Incidence
1.4-2 million burn injuries a year
3rd leading cause of accidental death in all age groups
Thermal burns
contact exposure to flames, hot liquids, steam, semisolids, hot objects, frostbite
Chemical burns
tissue contact, ingestion, inhalation or injection with strong acids, bases, organic compounds
Electrical burns
contact with exposed electrical wiring, high voltage power lines, lightning
Radiation burns
exposure to radioactive source such as in industry or therapeutic radiation sources
Mechanism/Etiology of Burns
Thermal
Chemical
Electrical
Radiation
Highest risk groups for burns
<3 years old, >70 year old
RF For burns
inadequate adult supervision
psychomotor dysfunction
mobile home
rural location
occupation
lack of smoke detectors
fireworks
misuse of cigarettes
physical abuse
Burn prevention
majority of burns are preventable
provide education about common burns
things to remember: limited temp devices on water heaters, shower curtains vs cubicles, safe use of O2, simple cooking precautions
Cooking precautions
avoid high heat
don’t wear loose sleeves
use front burners
avoid leaning over oven
Factors that influence severity of burn
depth
size
location
age
general health
MOI
Skin Layers
Epidermis
Dermis (papillary and Reticular)
Hypodermis/subcutaneous
Superficial depth
damage to or loss of epidermis
often 1st degree
Partial thickness burn
loss of epidermis, and damage/loss of portion of dermis
superficial = mid dermal
deep = deep dermal
2nd degree burns
Full thickness burns
loss of epidermis and entirety of dermis
3rd degree burns
Characteristics of superficial burns
- sunburn
- no blistering
- red, painful
- blanches w/pressure
- not calculated in the total body surface area
Characteristics of partial thickness burns
- Red, blisters, mod to severe pain, moderate scarring
- Epidermal appendages aren’t always damaged
- Deep requires surgery
- Wound convergence
Superficial partial thickness
burn extends into papillary layer
wet and very painful
typically heal in <21 days
Deep partial thickness burn
extends into reticular layer
typically take >21 days to heal, more likely to need skin graft
often has less edema, less likely to heal. Is often lower in apperance than healthy skin
Layers of injury (2nd degree)
Zone of necrosis (dead tissue)
Edema Layer
Zone of injury
Normal Tissue
Superficial has lots of edema, vs deep that has almost none, so zone of necrosis extends further down
Full thickness burns characteristics
- white, dry
- Graft is necessary
- no pain
- scarring
Indeterminate degree burns
MIXED partial and full thickness
Wound conversion
wound can convert to a deeper or more severe wound
most likely to occur with mid to deep dermal injury b/c of lack of blood flow, longer healing, increased risk of inflammation
RF for wound conversion
Local: inflammation, decreased blood flow, surface desiccation, excessive exudate, trauma
Systemic: sepsis, hypovolemia, excessive catabolism, chronic illness
Electrical Burn Characteristics
-internal tissue damage
-usually looks mild, soft tissue and muscle damage are severe
-entrance and exit occur with direct current
-arcing and contact occur with alternating current
-severity is measured with myonecrosis
AC is more dangerous than DC, AC can cause cardiac arrest
Eschar
rigid, dead barrier of tissue
Escharotomy
incision running the length of the eschar, all the way down to viable tissue to help release pressure over involved deeper tissues to restore circulation
When is an escharotomy performed?
on any full thickness or circumferential partial thickeness or FT burn, especially around neck, thorax, and extremities
Why is an escharotomy necessary?
eschar can interefere with circulation, causing loss of limb, limited lung expansion ( lung collapse )
Escarotomy is to…
cut INTO the eschar, NOT removing the eschar
Rule of 9s
-rule to calculate TBSA for adults
-based on division of body into anatomic sections
-each body section represents 9% or multiples of ( of TBSA
-less accurate in persons with cachexia or obesity
only partial and full-thickness burns are included in TBSA calculations
Methods for determining TBSA
Rule of 9s
Lund Browder Method
Lund Browder Method
-modifies the percentages for body segments
-provides more accurate extimate of burn size in children and infants
-slower to do, but more accurate
Age and severity of burns
mortality rates higher for ages <4 and >65
survival rate for older patients is 70%
General health and burn severity
obesity, alcoholism, CVD, PVD increase complications and mortality rates
Major burns with >____ TBSA result in …
20%, systemic hypermetabolic response
Hypermetabolic response
extensive and excessive inflammation that causes generalized catabolic state with delayed healing
amount of stress increases proportionally to the extent of the injury and strongly influences a patient’s nutritional requirement
characterized by increased blood pressure and heart rate, peripheral insulin resistance, and increased protein and lipid catabolism, which lead to increased resting energy expenditure, increased body temperature, total body protein loss, muscle wasting
Skin response to major burns >20% TBSA
massive release of vasoactive substances
immediate and dramatic increase in capillary permeability, leading to massive edema
Cardiovascular response to major burns >20% TBSA
initial drop in cardiac output due to severe edema
tx: IV fluid, or will go into hypovolemic shock. CO will eventually begin to increase
Renal & GI response to major burns >20% TBSA
blood shunted away from these organs
results in decreased urine and intestinal dysfunction. Nutrition is provided parenterally, and peristalsis can stall (ileus)
Immune system response to major burns >20% TBSA
massively depressed
infection can occur, which is the most cmmon and life threatening
Respiratory response to major burns >20% TBSA
decreased lung compliance and possible pulmonary hypertension
Clinical phases of major burn injuries
- Emergent phase
- Acute phase
- Rehab phase
Emergent phase
first 48-72 hours post burn, characterized by swelling
phase ends when capillary integrity returns to near-normal levels and large fluid shifts have decreased
Acute phase
hemodynamically stable
burn wound coverage, surgical debridements, grafting
phase continues until wound closure is achieved
Rehab phase
overlaps acute phase
can continues for years
Commonly used meds for pain
opioids, benzos, anesthetic agents are used to address background pain, breakthrough pain, and procedural pain
Background pain
severe pain that comes with injury and has regular pain medication regiment
Breakthrough pain
breaks through existing pain regiment that helps with background pain
Procedural pain
medications provided during painful interventions, sometimes called procedural sedation
Debridement
removal of burned or destroyed tissue
occurs in operating room with patient under anesthesia
purpose is to create a clean, healthy tissue surface that will accept a skin graft
Grafting
transplantation of skin
Performed when for full thickness and some partial thickness burns
grafts can be temporary or permanent
Temporary grafts
removed when the wound bed is ready for permanent grafting
purpose is to speed healing time, prevent infection, minimize fluids and protein loss from burned skin, reduce pain
xenograft, allograft, biosynthetic wound dressings
Xenograft
donor and recipient are of different species
Allograft
donor and recipient are of the same species
Biobrane
(biosynthetic wound dressings)
made from silicone, nylon, collagen
removed daily
has 2 layers, inner of nylon mesh (allows growth) and outer silastic layer (serves as a barrier)
Integra
2 layer membrane –> inner of dermal bovine (matrix for fibroblasts), and outer of silicone (barrier)
after 2-3 weeks, silicone layer is removed, autograft is placed over wound
Permanent grafts
autografts
skin substitutes
provides permanent skin coverage of burned area
Permanent Autografts
donor and recipient are the same
skin is harvested from unburned part of pts body and transferred onto excised burn site
can be split thickness or full thickness
STSG and FTSG adherence
graft begins to grow and adhere to wound bed within 48hrs
after 4-5 days, graft should be adherent
therapy role is to position and splint
STSG
gold standard
once autograft is harvested, skin is put through a mechanical meshing instrument
allows expansion of graft up to 9x donor site surface area
Adv and Disadv of STSG
Adv: indicated when insufficient donor skin available, good adherence because fluid can escape through expansion slits
Disadv: secondary contraction and poor cosmesis, less resistant to trauma
FTSG
contains 100% of epidermis and dermis
Adv: more resistant to trauma, better cosmesis, resists contraction
disadv: lower chance of graft survival, edema under graft, donor site requires long healing time, deformation is common
Donor site
area of patient’s skin from which autograft was harvested
usually heals in 2 weeks, split thickness
leaves small punctate bleeding spots
remember donor sites are new wounds!
Skin Substitutes
cultured epithelial autografts
biopsy of patients healthy skin is harvested and epidermal cells are grown into skin sheets in a lab
at 3 weeks, cells are palced over clean burn injury site
less durable than autografts because there is no dermis
Primary goals of PT in burn management
maximized functional recovery
cosmetic outcome
PT in burn managemen
- Improve wound healing
- Improve graft adherence
- Prevent contractures and inhibit scar formation
- Maintain/improve aerobic capacity and muscular strength
- Maintain ability to perform ADLs and return to life roles
- promote positive emotional outlook
PTs are concerned with 5 major areas
splinting
positioning
exercise
use of pressure
patient and family ed
Purpose of splints
- help maintain proper positioning
- help attain better ROM with use of progressive splinting techniques
- immobilize a newly grafted area
- prevent contractures
Splints should be worn
if indicated by PT/OT
usually from day of injury or day of grafting
Basic info about hand burns
all burned hands MUST be elevated above the heart
dorsal hand burns are more common than palmar burns in adults
Dorsal hand burn contracture
post -burn claw deformity
no longer functional
positioning, ROM, and splinting are what we use to help
WHY the exam of dorsal hand burns must be done WITHOUT wound dressings on
- to get accurate ROM
- Thin dorsal skin, pressure from dressings and edema can damage extensor tendons
- you cannot do ROM of PIP if you don’t know the integrity of the tendons
- Pt can perform active MCP flexion and ABD/ADD of fingers to decrease edema
Standard Position for dorsal hand burns
0-30° wrist extension
45-70° MCP jt flexion
Completely extended PIP and DIP
Thumb anducted w/web space stretch
Initial post-burn period for hands
follow extensor tendon precautions for hand burns
NO passive PIP joint flexion
NO fist making
followed until healing is tabled in order to decrease tendon damage
Other name for standard position
intrinsic plus position, resting hand splint, anti-deformity splint, burn hand splint
Syndacity
losing webspace b/c of contracture
Position of ____ is position of ____
comfort
contracture
Mouth splints
keep the mouth from shrinking after serious mouth burns
usually part time wearing schedule, and under face pressure garment
Therabite is an example
Basic Splinting
splints have to be monitored closely, on at least a daily basis, and altered when necssary
Indications for altering a splint
pressure areas
incorrect fit
improper position
complaints of pain due to splint
changes in pts need or condition
General Exercise principles for burn patient
- Eval as soon after admission
- numerous short exercise sessions are better than long
- Active motion is always more desirable than passive motion
- Skin loses elastic property when it has been burned
- Granulation tissue contracts and hypertrophies
- joints contract ACROSS flexor creases
- pt pain threshold varies
- avoid contact with burned surfaces
- Closely watch skin during exercise to blanching
IMPORTANT exercise principles
- during grafting, exercise is withheld for 4-5 days for jt areas proximal and distal to graft to allow graft to take
- an ounce of prevention is worth a pound of cure
- ambulation and sample protocol
Ambulation after LE grafts
external compression has to be applied before
must be initiated asap
can ambulated once lower limbs can tolerate wrapping, usually 5-10 post grafting
if graft crosses joint, joint should be immobolized until first dressing change
Ace wrap purpose
prevent edema
support capillary bed in granulation tissue
prevent sloughing of grafts
prevention conversion of burns
Indications for Ace wrapping
- any 2nd or 3rd degree burns involving LE
- any grafted area that is not matured
- bloody or moist donor sites
- Edema in LE
- Prolonged bedrest
- advanced age
- vascular insufficiency
- postural hypotension
Contraindications for ambulation
- Excessive bleeding
- Body temp low or high
- Hemoglobin is low
- less than 7 days since grafting
- Thromboplebitis
- blood transfusion
Day of admission exercise
eval, gentle active exercises, passive/active exercises
Increasing edema phase exercise
active, AA, passive exercises
Decreasing edema phase exercise
pain is a major problem, active, AA, and passive
During grafting exercise
increase active motion prior to grafting as much as possible
Post-grafting phase exercise
AROM, AAROM, PROM, resisted exercises
begin with active exercises with new grafts visualized to observe effects of motion of new graft
continue this for at least 2 days, then add aassisted and resisted exercises as tolerated to increase ROM
Rehab phase exercises
6 mo to 1 year
active, aa, passive for ROM
functional use and resistance
Hypertrophic scars
red, raised, rigid
hypertrophic scare are more likely in
children, neck, UE, darker pigmented individuals, wound infection, STSG, multiple surgeries, longer healing
Tx of hypertrophic scarring
pressure program, silicone sheets, scar massage
Hypertrophic scarring and contracture formation
generally true prognosis cannot be known until a minimum of four months post-burn because healed burn wound does not become elvated and hard until 2 or 3 motnths after healing
Contracture
excessive shrinkage such that ROM across a joint is decreased. Pathological
Early hypertrophic scar is
influenced by mechanical forces
collagen linkage is less stable, the earlier the scar, the better the response
Correcting scar contractures
by non-surgical means is a difficult, time-consuming and not always successful
surgery is usually not indicated during active scarring phase
Prevention of scars/contractures
early and consistent intervention
use pressure garments and splinting/rom
Pressure garments are for
minimizing hypertrophic scarring
Splinting and ROM are for
prevent contractures
Why are healing burn wounds SO prone to hypertrophic scarring and contractures?
- Massive increase in vascularity (scars become firmer)
- Marked increase in fibroblasts, myofibroblasts, collagen, and interstitial material (distortion of structures)
- Voluntary muscle contraction and positiong, (most pts assume poor positions)
- Edema, hypertrophic scars have more fluid
Pressure garments
pressure should be applied early
should be worn 23 hr/day for 12-18 mo post burn
pressure required is = capollary pressure of 24 mm
Pressure works by creating hypoxic condition
provide uniform pressure
Other management for burn scars
silicone gel or sheets–> helps improve redness, thickness, pliability
scar massage
glucocorticoids
fractional CO2 laser therapy
Silicone gel sheeting
used with hypertrophic scars
hypotheses is that it increases temp and hydration
wear 24 hr/day
helps with color, pliability, itching
Head/neck will contract to
flexion
Shoulder will contract to
IR (use abduction to correct)
elbows will contract to
flexion (use extension and supination)
Wrists will contract to
flexion
hands will contract to
claw hand (use standard position)
Hips will contract to
flexion and ER (use neutral rotation)
Knees will contract to
flexion
Ankles will contract to
PF
Feet will contract to
inversion
