Lecture 21 - Burn Rehab Flashcards
villa medica burn victim statistics
what are the 3 layers of skin and its functioning?
what are the functions of the skin?
protects from:
– Evaporation/dehydration (prevents shock)
– Protein loss (prevents loss of oncotic pressure and edema)
– Infection
– UV rays, wind, cold – Trauma
• Excretion, Absorption, Perception, VitD, Personal ID, Durability, Pliability
what are physical properties of the skin? - 2 fibre types - what is the most abundant fibre type?
1) Collagen: provides strength and foundation
– long aligned fibers
– extensible but very resistant
– tensile strength
– most abundant fiber
2) Elastin - interwoven with collagen fibres
– Thinner than collagen
– Brings stretched collagen back to its relaxed position
– Provides elasticity to skin
– Poorly regenerated in burn scar
what are the types of burns (what can cause burns)
Thermal (heat and cold)
Electrical
Chemical (from strong acid or base)
Allergic reaction
Skin infection (flesh eating disease - same treatment as burn victim)
Radiation
Friction (degloving - being dragged along the road)
Immune system reaction
what are the different burn degree depths?
Subcutaneous burns / 4 degree burn – Adipose layer
– Muscles
– Tendons
– Bone
how does % total body surface area affect healing?
describe inhalation burns
describe the process of surgical management of burns - define fasciotomy, escarrotomy, and debridement
note that sedation can last weeks or months!
describe the donor site for a skin graft - whre is it taken from - what to look out for - healing process
A hypertrophic scar is a cutaneous condition characterized by deposits of excessive amounts of collagen which gives rise to a raised scar
what are different sources of skin grafts?
what are the different types of skin grafts?
1) Split thickness graft - usually in emergrnt phase
2) Mesh graft
3) Full thickness graft
4) skin flap
pros and cons to split thickness grafts
pros and cons to mesh grafts
pros and cons to full thickness grafts
pros and cons to skin flap
for covering tendon = skin with its own blood supply - requires many surgeries, bulky
what is a z-plasty?
to lengthen a linear scar
problems faced by the burn survivor and team - what are some cutaneous issues?
problems faced by the burn survivor and team - describe a hypertrophic scar (what tissue types it consists of)
what increases the risk of hypertrophic scar contraction - how long can it last for?
Wound contraction leads to scar retraction
Scar contraction: can be present for many months after wound closure and can be active up to 2 years
describe the maturation of a hypertrophic scar over time
– Color: mauve -> red -> pink -> white (for Caucasian skin)
– Elasticity: variable
– Thickness: with scar remodelling
– Pigmentation: variable
– Mature when the scar is pale, smoother, and more flexible
- there is a mixed phase and a maturation phase
what areas are more susceptible to contacture/cord development?
what are other problems faced by the burn survivor and team?
- sleep disorders (sleep helps with healing)
- hypermetabolism (body trying to hel itself and therefore requiers more energy - take energy from muscle cells and muscles hypertrophy - after muscles, take energy from fat - need lots of protein to heal wounds - bc easier to convert muscle to sugar than fat)
- cardiovascular issues (because of prolonged bedrest, stiff chest from scar tissue, inflammation not good for heart)
- itchiness and Pruritus (severe itchy skin)
- pain
- musculoskeletal (correct as a result of scar tissue formation: Posture, Tendinitis / impingement syndromes, Capsulitis)
- neurological
- social (loss, grief, role changes)
- physiological (self-image, self-esteem, depression, anxiety, PTSD)
- complications (OP, Osteomyelitis, Septic arthritis, Fractures, Heterotopic bone formation - bone formation where there shouldn’t be - mostly at elbows, Joint dislocations, Amputations, Abnormal growth-growth plates in children can be shut down)
what are the neurological problems faced by burn survivors?
CRPS = complex regional pain syndrome
describe itch vs pruritis as experienced by burn victims
Itch
Post-burn itch is considered by some to be a form of neuropathic pain
- especially on graft site - can last months-years
57-100% of children: 25-87% of adult burn survivors suffer from itch
45% c/o itch 47.3±22.9 months post-burn
Can be severely debilitating
European survey of burn survivors - #1 research priority
Pruritis
Pruritogenic (severe itching of skin!)
– Inflammatory process
– sebaceous/sweat glands/ingrown hairs/ transepidermal water loss
Neuropathic / Neurogenic (peripheral + CNS) • Psychogenic
***Important not to scratch - bc skin is more fragile - can create wound then infection
describe pain porblems faced by burn victims (and importance of treating)
– Burn pain is considered as very significant
– Pain is very present in burn survivors, and can last a few months to a few years
– 20% of subjects experienced shooting pain in their burn scars at > 30 years post-burn
– Influenced by anxiety and depression
– Pain scores correlated with PTSD but not injury severity, TBSA, heart rate or blood pressure
– 18% of adult major burn victims report having chronic pain related to the burns 5 years post- burn.
– Pain in acute phase PTSD and general emotional distress
– Pain relative to burns is what most influences sleep, work and mood
– Major burn victims who are not working due to their burns report more pain than those who are working or who are retired.
what are the types of burn pain?
Neuropathic pain
– Associated with nerve damage (central, peripheral, or mixed)
– Ex: tissue reorganization/regeneration
1-3 months for capsules to retract
1-4 days for burn tissue to retract
Muskuloskeletal pain (ex: articular)
Emotional/psychological pain
Persistent pain
is the pain related to the depth od the burns?
describe the subjective evaluation for burn victim rehab and the specific componenets to address
slides 1-12
– *Pain: VAS, description, McGill Pain Questionnaire, BSHS-B
– *Pruritus (5-D Pruritus scale)
– Numbness/ paresthesia
– Weakness
– Sleeping position and sleep quality
– Morale
– *QOL (burn specific health scale)
what is assessed in the O section for a burn victim?
note: EF will come on much quicker and have less give
PT - specific “O” evaluation componenets for the burn victim - skin
PT - specific “O” evaluation componenets for the burn victim - scar tissue
Scar tissue
Contracture sites / cord locations
Modified Vancouver Scar scale (use sparingly)
– vascularity
– flexibility
– pigmentation
– height or thickness
POSAS: Observer scale and Patient scale (pt and PT have very different ratings of this!
*see slides p 23-27
PT - specific “O” evaluation componenets for the burn victim - sensation
PT - specific “O” evaluation componenets for the burn victim - face
describe the overlap btw PT and OT for burn treatment
education for burn victims
what are pharmacologic pain modalities for burn victims?
what are non-pharmacologic pain modalities for burn victims?
slides 38-45
what are some pruritis modalities? - pharmacologic and non-pharmacologic
Pharmacologic
– Antihistamines(ex: Benadryl, Atarax, Doxepin cream)
– Naltrexone
– Local anasthetics
– Corticosteroid injections
Nonpharmacologic
– Avoid scratching!
– Moisturizer (can be put in fridge)
– Ice, cold compresses
– Distraction
– TENS (needs to be further studied)
– Vibration
– Massage
– Compression
– Hydration
– Air humidity control / avoid overheating
– Stress management
what are some scar management techniques?
Goals of hypertrophic scar massage
- Maintain joint mobility re contractures • Soften scar tissue
- Break down adhesions
- Promote remodeling of scar tissue
- Desensitisation
- Clinically, alleviate pruritis
what are the goals of pressure garments?
– decrease oedema
– Minimise development and appearance of hypertrophic scars (decrease vascularity and collagen synthesis, reorients collagen)
– Improve esthetic aspect of the scar
– Avoid scar migration
– Limit loss of movement
– Favour optimal function
*slides 56-59
what are some other modalities used for burn care?
– Therapeutic activities: biometrics, gait and stair training, biodex, functional balance, Wii (yoga, balance, sports, etc)
– Strengthening of weak muscles and/or opposite to contractures: weights, open and closed kinetic chain exercises, active, active- assisted, isometric and resisted exercises, motor control
– Endurance training: nu-step, elliptical trainer, treadmill, bike, Wii- be careful of altered thermoregulation!
– Edema control (elevation, AROM>PROM, compression (bandages->transition garments->made to measure), lymphatic drainage, Intermittent pressure?)
– Hydrotherapy: hand shower with waterproof stretcher-cleans skin, cleanses of the skin
Whirlpool bath: not used anymore due to risk of infection!
– Wound care:
- High voltage current + laser
- Basic dressings
what is the in-patient/out-patient environment for burn victims?
In-patient and out-patient in same room
OT, PT, out-patient MD work in the same room aware of each other’s treatments-
- Ex: PT notices hypertrophic scars during massage, OT can add compression
- Ex: PT stretches in one direction and OT follows with AROM activities in the same direction
Psychologist, social worker, nursing and research teams are close by
Out-pt
Similar to in-patient approach: modalities and evaluation techniques focus on fine-tuning of function, movement, activities and sports
Slower progression
Can last for months- years depending on the number of reconstructive surgeries (5x/week to 1x/ few months)
Inter-disciplinary team approach
