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5 Pathology > L6 Burn Rehab > Flashcards

L6 Burn Rehab Flashcards

1
Q

Burns Definition

A

injuries resulting from direct contact or exposure to thermal, chemical, electrical, or radiation source

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2
Q

Burns Incidence

A

1.4-2 million burn injuries a year

3rd leading cause of accidental death in all age groups

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3
Q

Thermal burns

A

contact exposure to flames, hot liquids, steam, semisolids, hot objects, frostbite

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4
Q

Chemical burns

A

tissue contact, ingestion, inhalation or injection with strong acids, bases, organic compounds

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5
Q

Electrical burns

A

contact with exposed electrical wiring, high voltage power lines, lightning

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6
Q

Radiation burns

A

exposure to radioactive source such as in industry or therapeutic radiation sources

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7
Q

Mechanism/Etiology of Burns

A

Thermal
Chemical
Electrical
Radiation

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8
Q

Highest risk groups for burns

A

<3 years old, >70 year old

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9
Q

RF For burns

A

inadequate adult supervision
psychomotor dysfunction
mobile home
rural location
occupation
lack of smoke detectors
fireworks
misuse of cigarettes
physical abuse

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10
Q

Burn prevention

A

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

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11
Q

Cooking precautions

A

avoid high heat
don’t wear loose sleeves
use front burners
avoid leaning over oven

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12
Q

Factors that influence severity of burn

A

depth
size
location
age
general health
MOI

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13
Q

Skin Layers

A

Epidermis
Dermis (papillary and Reticular)
Hypodermis/subcutaneous

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14
Q

Superficial depth

A

damage to or loss of epidermis
often 1st degree

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15
Q

Partial thickness burn

A

loss of epidermis, and damage/loss of portion of dermis

superficial = mid dermal
deep = deep dermal

2nd degree burns

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16
Q

Full thickness burns

A

loss of epidermis and entirety of dermis

3rd degree burns

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17
Q

Characteristics of superficial burns

A
  1. sunburn
  2. no blistering
  3. red, painful
  4. blanches w/pressure
  5. not calculated in the total body surface area
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18
Q

Characteristics of partial thickness burns

A
  1. Red, blisters, mod to severe pain, moderate scarring
  2. Epidermal appendages aren’t always damaged
  3. Deep requires surgery
  4. Wound convergence
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19
Q

Superficial partial thickness

A

burn extends into papillary layer

wet and very painful

typically heal in <21 days

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20
Q

Deep partial thickness burn

A

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

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21
Q

Layers of injury (2nd degree)

A

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

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22
Q

Full thickness burns characteristics

A
  1. white, dry
  2. Graft is necessary
  3. no pain
  4. scarring
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23
Q

Indeterminate degree burns

A

MIXED partial and full thickness

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24
Q

Wound conversion

A

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

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25
Q

RF for wound conversion

A

Local: inflammation, decreased blood flow, surface desiccation, excessive exudate, trauma

Systemic: sepsis, hypovolemia, excessive catabolism, chronic illness

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26
Q

Electrical Burn Characteristics

A

-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

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27
Q

Eschar

A

rigid, dead barrier of tissue

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28
Q

Escharotomy

A

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

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29
Q

When is an escharotomy performed?

A

on any full thickness or circumferential partial thickeness or FT burn, especially around neck, thorax, and extremities

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30
Q

Why is an escharotomy necessary?

A

eschar can interefere with circulation, causing loss of limb, limited lung expansion ( lung collapse )

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31
Q

Escarotomy is to…

A

cut INTO the eschar, NOT removing the eschar

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32
Q

Rule of 9s

A

-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

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33
Q

Methods for determining TBSA

A

Rule of 9s
Lund Browder Method

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34
Q

Lund Browder Method

A

-modifies the percentages for body segments
-provides more accurate extimate of burn size in children and infants
-slower to do, but more accurate

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35
Q

Age and severity of burns

A

mortality rates higher for ages <4 and >65

survival rate for older patients is 70%

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36
Q

General health and burn severity

A

obesity, alcoholism, CVD, PVD increase complications and mortality rates

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37
Q

Major burns with >____ TBSA result in …

A

20%, systemic hypermetabolic response

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38
Q

Hypermetabolic response

A

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

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39
Q

Skin response to major burns >20% TBSA

A

massive release of vasoactive substances

immediate and dramatic increase in capillary permeability, leading to massive edema

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40
Q

Cardiovascular response to major burns >20% TBSA

A

initial drop in cardiac output due to severe edema

tx: IV fluid, or will go into hypovolemic shock. CO will eventually begin to increase

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41
Q

Renal & GI response to major burns >20% TBSA

A

blood shunted away from these organs

results in decreased urine and intestinal dysfunction. Nutrition is provided parenterally, and peristalsis can stall (ileus)

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42
Q

Immune system response to major burns >20% TBSA

A

massively depressed

infection can occur, which is the most cmmon and life threatening

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43
Q

Respiratory response to major burns >20% TBSA

A

decreased lung compliance and possible pulmonary hypertension

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44
Q

Clinical phases of major burn injuries

A
  1. Emergent phase
  2. Acute phase
  3. Rehab phase
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45
Q

Emergent phase

A

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

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46
Q

Acute phase

A

hemodynamically stable

burn wound coverage, surgical debridements, grafting

phase continues until wound closure is achieved

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47
Q

Rehab phase

A

overlaps acute phase
can continues for years

48
Q

Commonly used meds for pain

A

opioids, benzos, anesthetic agents are used to address background pain, breakthrough pain, and procedural pain

49
Q

Background pain

A

severe pain that comes with injury and has regular pain medication regiment

50
Q

Breakthrough pain

A

breaks through existing pain regiment that helps with background pain

51
Q

Procedural pain

A

medications provided during painful interventions, sometimes called procedural sedation

52
Q

Debridement

A

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

53
Q

Grafting

A

transplantation of skin
Performed when for full thickness and some partial thickness burns

grafts can be temporary or permanent

54
Q

Temporary grafts

A

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

55
Q

Xenograft

A

donor and recipient are of different species

56
Q

Allograft

A

donor and recipient are of the same species

57
Q

Biobrane

A

(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)

58
Q

Integra

A

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

59
Q

Permanent grafts

A

autografts
skin substitutes

provides permanent skin coverage of burned area

60
Q

Permanent Autografts

A

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

61
Q

STSG and FTSG adherence

A

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

62
Q

STSG

A

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

63
Q

Adv and Disadv of STSG

A

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

64
Q

FTSG

A

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

65
Q

Donor site

A

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!

66
Q

Skin Substitutes

A

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

67
Q

Primary goals of PT in burn management

A

maximized functional recovery
cosmetic outcome

68
Q

PT in burn managemen

A
  1. Improve wound healing
  2. Improve graft adherence
  3. Prevent contractures and inhibit scar formation
  4. Maintain/improve aerobic capacity and muscular strength
  5. Maintain ability to perform ADLs and return to life roles
  6. promote positive emotional outlook
69
Q

PTs are concerned with 5 major areas

A

splinting
positioning
exercise
use of pressure
patient and family ed

70
Q

Purpose of splints

A
  1. help maintain proper positioning
  2. help attain better ROM with use of progressive splinting techniques
  3. immobilize a newly grafted area
  4. prevent contractures
71
Q

Splints should be worn

A

if indicated by PT/OT
usually from day of injury or day of grafting

72
Q

Basic info about hand burns

A

all burned hands MUST be elevated above the heart

dorsal hand burns are more common than palmar burns in adults

73
Q

Dorsal hand burn contracture

A

post -burn claw deformity

no longer functional

positioning, ROM, and splinting are what we use to help

74
Q

WHY the exam of dorsal hand burns must be done WITHOUT wound dressings on

A
  1. to get accurate ROM
  2. Thin dorsal skin, pressure from dressings and edema can damage extensor tendons
  3. you cannot do ROM of PIP if you don’t know the integrity of the tendons
  4. Pt can perform active MCP flexion and ABD/ADD of fingers to decrease edema
75
Q

Standard Position for dorsal hand burns

A

0-30° wrist extension
45-70° MCP jt flexion
Completely extended PIP and DIP
Thumb anducted w/web space stretch

76
Q

Initial post-burn period for hands

A

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

77
Q

Other name for standard position

A

intrinsic plus position, resting hand splint, anti-deformity splint, burn hand splint

78
Q

Syndacity

A

losing webspace b/c of contracture

79
Q

Position of ____ is position of ____

A

comfort
contracture

80
Q

Mouth splints

A

keep the mouth from shrinking after serious mouth burns

usually part time wearing schedule, and under face pressure garment

Therabite is an example

81
Q

Basic Splinting

A

splints have to be monitored closely, on at least a daily basis, and altered when necssary

82
Q

Indications for altering a splint

A

pressure areas
incorrect fit
improper position
complaints of pain due to splint
changes in pts need or condition

83
Q

General Exercise principles for burn patient

A
  1. Eval as soon after admission
  2. numerous short exercise sessions are better than long
  3. Active motion is always more desirable than passive motion
  4. Skin loses elastic property when it has been burned
  5. Granulation tissue contracts and hypertrophies
  6. joints contract ACROSS flexor creases
  7. pt pain threshold varies
  8. avoid contact with burned surfaces
  9. Closely watch skin during exercise to blanching
84
Q

IMPORTANT exercise principles

A
  1. during grafting, exercise is withheld for 4-5 days for jt areas proximal and distal to graft to allow graft to take
  2. an ounce of prevention is worth a pound of cure
  3. ambulation and sample protocol
85
Q

Ambulation after LE grafts

A

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

86
Q

Ace wrap purpose

A

prevent edema
support capillary bed in granulation tissue
prevent sloughing of grafts
prevention conversion of burns

87
Q

Indications for Ace wrapping

A
  1. any 2nd or 3rd degree burns involving LE
  2. any grafted area that is not matured
  3. bloody or moist donor sites
  4. Edema in LE
  5. Prolonged bedrest
  6. advanced age
  7. vascular insufficiency
  8. postural hypotension
88
Q

Contraindications for ambulation

A
  1. Excessive bleeding
  2. Body temp low or high
  3. Hemoglobin is low
  4. less than 7 days since grafting
  5. Thromboplebitis
  6. blood transfusion
89
Q

Day of admission exercise

A

eval, gentle active exercises, passive/active exercises

90
Q

Increasing edema phase exercise

A

active, AA, passive exercises

91
Q

Decreasing edema phase exercise

A

pain is a major problem, active, AA, and passive

92
Q

During grafting exercise

A

increase active motion prior to grafting as much as possible

93
Q

Post-grafting phase exercise

A

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

94
Q

Rehab phase exercises

A

6 mo to 1 year
active, aa, passive for ROM
functional use and resistance

95
Q

Hypertrophic scars

A

red, raised, rigid

96
Q

hypertrophic scare are more likely in

A

children, neck, UE, darker pigmented individuals, wound infection, STSG, multiple surgeries, longer healing

97
Q

Tx of hypertrophic scarring

A

pressure program, silicone sheets, scar massage

98
Q

Hypertrophic scarring and contracture formation

A

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

99
Q

Contracture

A

excessive shrinkage such that ROM across a joint is decreased. Pathological

100
Q

Early hypertrophic scar is

A

influenced by mechanical forces

collagen linkage is less stable, the earlier the scar, the better the response

101
Q

Correcting scar contractures

A

by non-surgical means is a difficult, time-consuming and not always successful

surgery is usually not indicated during active scarring phase

102
Q

Prevention of scars/contractures

A

early and consistent intervention

use pressure garments and splinting/rom

103
Q

Pressure garments are for

A

minimizing hypertrophic scarring

104
Q

Splinting and ROM are for

A

prevent contractures

105
Q

Why are healing burn wounds SO prone to hypertrophic scarring and contractures?

A
  1. Massive increase in vascularity (scars become firmer)
  2. Marked increase in fibroblasts, myofibroblasts, collagen, and interstitial material (distortion of structures)
  3. Voluntary muscle contraction and positiong, (most pts assume poor positions)
  4. Edema, hypertrophic scars have more fluid
106
Q

Pressure garments

A

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

107
Q

Other management for burn scars

A

silicone gel or sheets–> helps improve redness, thickness, pliability

scar massage

glucocorticoids

fractional CO2 laser therapy

108
Q

Silicone gel sheeting

A

used with hypertrophic scars

hypotheses is that it increases temp and hydration

wear 24 hr/day

helps with color, pliability, itching

109
Q

Head/neck will contract to

A

flexion

110
Q

Shoulder will contract to

A

IR (use abduction to correct)

111
Q

elbows will contract to

A

flexion (use extension and supination)

112
Q

Wrists will contract to

A

flexion

113
Q

hands will contract to

A

claw hand (use standard position)

114
Q

Hips will contract to

A

flexion and ER (use neutral rotation)

115
Q

Knees will contract to

A

flexion

116
Q

Ankles will contract to

A

PF

117
Q

Feet will contract to

A

inversion

5 Pathology (9 decks)

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