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PHTH 550- Orthopaedic Management Final > Lecture 21: Burns > Flashcards

Lecture 21: Burns Flashcards

1
Q

What is the continuum of care for burn survivors?

A

Acute: Hotel Dieu (CHUM)

Rehab: Villa Medica

Community Reintegration: Entraide Grands Brules. (psychosocial support, awareness, information)

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2
Q

What are the roles of the centre of expertise in burn care?

A
  • Specialized care
  • Continuum of care (outpatient services) throughout QC
  • Social reintegration centre
  • Research and development
  • Public awareness and education
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3
Q

What are the layers of the skin and what glands are in each?

A

Skin is the largest organ in the body!!

Epidermis: protection, skin pigment, growth new skin cells outermost layer

Dermis: sweat glands, cutaneous nerve endings, hair follicles, capillaries, make oil.

  • Papillary layer: Loose connective tissue
  • Reticular layer: Dense connective tissue

Subcutaneous Layer: attach dermis to muscle and bond, store fat, body temp regulation.

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4
Q

What are the functions of the skin?

A

Protect from:

  • Trauma
  • UV rays
  • Infection
  • Protein loss
  • Evaporation/dehydration
  • Excretion
  • Absorption
  • Perception
  • Vit D
  • Personal Identity
  • Durability
  • Pliability
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5
Q

What are the two types of fibers in skin and what are their qualities?

A

Collagen

  • Long aligned fibers
  • Extensible, but very resistant
  • Tensile strength
  • Most abundant fiber

Elastin (interwoven in collagen)

  • Thinner than collagen
  • Brings stretched collagen back to relaxed position
  • Provides elasticity to skin
  • Poorly regenerated in burn scar.
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6
Q

What are the types of burns?

A
  • Thermal (hot or cold)
  • Electric
  • Chemical
  • Friction
  • Allergic Reaction
  • Skin infection
  • Radiation
  • Immune system reaction
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7
Q

When someone sustains a burn, where do they go?

A

Accident->emergency care (stabilization and intubation, want to intubate as soon as possible while airway remains open. Burn survivors swell a lot which can block the airway)-> Acute care (Hotel Dieu)
From Acute care they can go to rehab or their regional centre. After rehab they go to their regional centre.

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8
Q

What are the classifications for the depth of a burn wound?

A

Superficial (1st degree): Just the epidermis, can heal on its own

Partial Thickness (Second degree): 
Superficial: just the papillary layer of the dermis

Deep: dermis the reticular layer is involved which affects blood vessels so surgery is needed.

Full Thickness (Third degree): All of the epidermis and dermis

Subcutaneous Burn (4th degree): Adipose layer, muscle, tendons and bone

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9
Q

What is TBSA?

A

% Total body surface area covered by a burn

  • Larger %-> Worse prognosis
  • > 20% threatens survival
  • The degree of functional impairment is not necessarily connected to the % TBSA b/c it does not represent where the burn is (face or hand vs thigh)
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10
Q
  1. What are inhalation burns?

2. How do they affect prognosis?

A
  1. Injury to the mucous membrane of the lungs via heat (vapour or air) or smoke (toxic gas).

Injury to organs is possible due to inhalation of toxins.

    • Cause oedema in trachea, bronchii, atelectasis (lung collapse possible)
  • Which decreases healing potential by limiting oxygen delivery.
  • Can contribute to long term cardiovascular endurance problems.
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11
Q

How are burns managed surgically?

A
  • Stabilization of vital organs
  • Sedation and intubation (to protect from burn pain)
  • Fasciotomy: cut fascia surrounding ms
  • Escarrotomy: cut through tough tissue.

These two procedures are done to release pressure in response to swelling associated with burns to prevent compartment syndrome.

  • Debridement: remove non-viable tissue
  • Grafting: Take healthy skin and put it over a burn, this helps to manage pain and with wound closure.
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12
Q

What is a donor site?

A
  • Site where healthy skin is harvest for a graft
  • Usually close to donor site so that skin colour is a better match
  • Usually heals quickly <21 days
  • Can develop problematic hypertrophic scaring, so keep an eye on donor site. (most of the time it doesn’t show)
  • Take from a site which is less apparent.
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13
Q

What are the types of grafts or skin substitutes?

What is really important following a graft?

A
  • Autograft (Self, less chance of rejection)
  • Cultured (grow skin petri dish)
  • Allogenic (temporary graft from another person used until cultured graft is ready)
  • Synthetic (temporary-sheet of silicone w/ college to allow wound to prepare to receive autograft)
  1. After a graph site needs to be immobilized for 5 to 7 days to allow skin to adhere because capillaries need to form anastomosis. If anastomosis breaks, graft will fail.
    IMMOBILIZATION is key. Sedation is used to achieve immobilization, sometimes weeks or months!
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14
Q
  1. What is a split thickness graft?

2. What are the +/- of this graft?

A
  1. It is the top layer of the dermis and the epidermis.
  2. +: durable, does not leave deficit at donor site so it heals on its own.
    -: Higher risk of contraction compared to full thickness graft because it shortens.
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15
Q
  1. What is a mesh graft?

2. What are the +/- of this graft?

A
  1. Skin is meshed to cover a large wound area.
  2. +: Irregular contours, large SA, increase chance the graft will take.
    - : Visible scar (mesh pattern), greatest risk of scar contraction.
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16
Q
  1. What is a full thickness graft?

2. What are the +/- of this graft?

A
  1. Used mostly during reconstructive surgeries.

+: Most durable, over parts needing more protection, least contraction risk (joints, face, hands), good aesthetic results if proper colour match.

-: leaves deficit at donor site.

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17
Q
  1. What is a skin flap graft?

2. What are the +/- of this graft?

A
  1. It is an entire flap of skin with its own blood supply.
  2. +: better blood supply increase the chances the graft will take, used for protection over bones and tendons, can transfer ms, fat and ski w/ free flaps.
    - : Requires many surgeries, bulk of graft or asymmetries can persist in long term.
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18
Q

What is a scar cord?

What is a Z-plasty?

A
  1. A scar cord is a line of skin that forms at a joint limiting ROM.
  2. A procedure to lengthen a linear scar. Can be used if a scar cord is limiting a particular movement.
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19
Q

What are cutaneous problems faced by burn survivors?

A

-Wounds: The longer the wound healing time the greater the risk of developing hypertrophic scaring and scar contraction (optimal wound care is essential). When it takes more than 3 weeks to heal there is an 85% chance of developing hypertrophic scaring.

  • Dryness ( no oil glands, must use cream)
  • Altered perspiration: No sweat glands
  • Hypertrophic scar
20
Q

What is a hypertrophic scar?

Why do hypertrophic scars occur?

A
  1. Presents as a raised, erythematous, pruritic and inelastic mass of tissue.
  2. Body is in overdrive to produce new cells and whatever keeps cell remodelling in check has disappeared.
    - Imbalance between hypercellularity and cell remodelling
    - Excess collagen that is disorganized. Usually collagen has an organized orientation, in hypertrophic scaring there is mixed orientation of scar collagen.
  • Poorly regenerated elastin
  • Hypervascularity
  • Changes in the extracellular matrix (collagen synthesis and delayed cell death): increase in myofibroblasts, proteoglycans, glycoproteins, TGF-beta, decreased interferon.
21
Q

What happens if a wound doesn’t close well?

What is the order of risk of hypertrophic scar retraction by graft type?

A

Wound contraction can lead to scar retraction, which can be present for many months after wound closure, put to 2 years active.

2.Mesh>partial>full

22
Q
  1. How does a hypertrophic scar mature over time?

2. When is a scar mature?

A

Colour: mauve to red to pink to white for caucasian.
Elasticity: variable
Thickness: increases with scar remodelling
Pigmentation: variable

Mixed phases of maturation:
Red-ares of active scaring
Can be areas of hypo and hyper pigmentation.

  1. When it is pale, smoother and more flexible.
    Once scar is mature, surgery would be required if contraction is formed b/c scar is mature so pt interventions are no longer effective.
23
Q
  1. What are critical burn sites?

2. Where are these sites?

A
  1. Areas that are more susceptible to contracture or cord development.
  2. Eyes, lips, neck, axilla, antecubital space, f/a, hands, lateral trunk, perineum, popliteal fossa, achilles tendon area and toes.
    - SCAR retraction can have important functional and aesthetic consequences.
24
Q

What MSK problems are faced by burn survivors?

A

-Posture
-Tendinitis and impingement syndormes (especially at the shoulder)
Capsulitis
-Complications of burns: OP, osteomyelitis, septic arthritis, #, heterotypic bone formation, joint dislocation, amputation, abnormal growth in children (burn shuts down growth plates).

25
Q

What are some neurological problems faced by burn survivors?

A
  • Motor and sensory problems (paraesthesia, hyper or hypo…)
  • Altered sensation impact Q of L
  • 50% report sensory loss
  • Nerve compression
  • Drop foot or wrist
  • Neuropathy
  • Circumferential burns associated w/ compression of nerves or venous return.
26
Q

Other problems faced by burn survivors?

A

Social:

  • Loss, grief
  • Role changes

Psychological:
-Self-image, self-esteem
-Depression, anxiety
PTSD

Sleep disorders (pain, itch)

Hyper metabolism (body goes into overdrive expending a lot of energy to try and heal themselves, this results in energy being taken from the ms which atrophy So initially they loose weight and are on a high caloric and protein diet. They stay in a hyper metabolic state for quite a while and there is a trend towards weight gain which is not well understood)

CV issues: bed rest, inhalation burns, scar tissue retracts at chest.

27
Q
  1. Is pain often associated w/ burns?
  2. What is correlated w/ pain in burns?
  3. What does pain influence?
  4. How does work have to do with pain?
A
  1. Yes, burn pain is considered significant, can last months to years.

18% of adults w/ major burns report chronic pain 5 years post.

  1. Influenced by anxiety, depression and PTSD (pain scores correlated w. PTSD but not injury severity in a study).

Increased pain in acute phase leads to increased PTSD and general emotional distress.

  1. Pain relative to burns is what most influences sleep, work and mood.
  2. People that do not work due to their burns report more pain then those who are working or are retired.
28
Q

What are the types of pain?

A
  1. Procedural *important PT
    - Acute (post-op, dressing changes)
    - Rehab (scar stretch)
  2. Non-procedural
    - Nociceptive
    - Breakthrough (when analgesic wears off)
    - Background or resting (dull ache-inflammation based)
  3. Neuropathic pain: associated w/ nerve damage
    - MSK pain (articular)
    - Emotional/psychological pain
    - Persistent pain
29
Q

Is pain related to the depth of the burn?

A

-Yes and no, pain evolves over the phases of recovery.

Emergent phase: Superficial burns are more painful (hyperalgesia)

Acute: Deep and partial thickness burns require grafting, so there is pain at the donor site.

Rehab: Deeper burns are more likely to result in prolonged hypersensitivity.

30
Q

What is pruritus?

A 
Post-burn itch. 
-Can be very debilitating 
-Common symptom 
Pruritogenic factors: 
-Inflammatory process (mast cells) 
-Loss of sweat glands, ingrown hairs, transepidermal water loss, loss sebaceous glands. 
-Neuropathic/neurogenic (change in PNS and CNS) 
-Psychogenic 
Important not to scratch
31
Q

What are the subjective components of a burn evaluation?

A

OT and PT do joint detailed evaluation so pt does not have to repeat information.

S/
-Pain: VAS, description, McGill Pain ?, BSHS-B (many different pain scales, like Observational Pain Assessment Scale)
-Pruritus
Numbness/paresthesia
-Weakness
-Sleeping position and sleep quality (could affect scar contraction sleeping position and quality could affect healing)
-Morale (anxiety, stress, PTSD)
-QofL: Burn specific health scale (physical, emotional/intimacy, extent of impact of the burn on life)

32
Q

How is Pruritus evaluated?

A
  • VAS
  • Description of: Location, intensity, frequency, duration, what worsens or improves
  • 5-D Pruritus scale (duration, direction, degree, distribution, disability
  • Itch man scale for kids
33
Q

What are the Objective Components of Burn Eval?

A
  • Observations
  • Swelling measurements
  • LE, UE, trunk and neck AROM/PROM, E/F can be scar tightness
  • Strength UE, LE, trunk, grip strength
  • Functional movements
  • Posture
  • Balance
  • Palpation
  • endurance
  • Transfers,gait, walking distance, stairs
  • ADLs, IADLs.
34
Q

What are the specific components of a scar evaluation?

A

-Skin: location of the burn, blisters, grafts, donor sites, wounds.
-Scar tissue: Contracture sites/scord locations
Can use the:
-Modified Vancouver Scar Scale: vascularity, flexibility, pigmentation, height or thickness.
or
-POSAS: This has an observer scale and a patient scale.

35
Q

How is sensation evaluated in burn survivors?

A
  • Graft sites often affected
  • Be careful w/ electric burns b/c damage can be found under the skin where there are no burns
  • Nerve lesions associated w/ later sensations
  • Circumferential scars can cause nerve compression
36
Q

What are the components of a face eval?

A
  • Facial expression: see if movement are complete, partial or not present (such as frowning, eyebrow movement)
  • Mouth aperture (horizontal and vertical)
  • Other deformities (ability to close eyelids)
37
Q

What aspects of treatment are OTs responsible for? Pt? Both?

A

OT: Dexterity, ADLs, work/leisure potential

PT: Endurance, gait, stairs

Both: Skin, strength, pain, pruritus, ROM, Posture, transfers, balance, sensation, edema control, education, scar.

38
Q

What are important aspects of education for burn survivors?

A
  • Self-massage
  • Scar process
  • Expectations and objectives
  • Importance of stretch and compression
  • Sun protection
  • Pain/pruritus management techniques.
  • Note that major burn victims w/ more pain are less satisfied w/ information they receive on the treatment of pain compared to those w/ out pain.
39
Q
  1. Why is pain management important?

2. What are the types of pain management?

A
  1. Allows for better participation and adherence to treatment so it should start from day one.
  2. Includes a combination of pharmacologic and non-pahramcologic approaches.

Pharmacologic: Regular meds

  • Analgesics
  • Anxiolytics, anti-depressants
  • Corticosteroid injections in scar tissue.

Non-Pharmocalogic:

  • Motor Imagery
  • TENS
  • Thermal Modalities (Ice, Heat, Fluidotherapy), Psychotherapy, sensory re-education, art and music therapy, massage.
40
Q

What are some important pain management principles to implement during treatment?

What are some cognitive interventions to deal with pain?

What are some behavioural techniques to deal with pain?

A
    • Environment: pleasant and relaxed position.
    • Prevention: Pain meds before Tx
    • Discussion: Explain what you are going to do, be honest that there may be pean and help them know what good and bad pain is
    • Relaxation training w/ OT or psychologist.
    • Do not reinforce pain behaviours
    • Provide rewards for progress, not pain behaviours
    • STOP catastrophising pain
    • Give pt control

Other:

  • Distractions
  • Hypnosis
    • Quota system
    • Work to and not past tolerance
    • Support the support system (help family members, so they can support the pt this has a big impact on recovery)
    • Feel comfortable w/ a process that never ends
    • Address sleep disturbance, anxiety and depression
41
Q

What are the two methods for manage pruritus?

A

Pharmacological:

  • Antihistamines
  • Naltrexone
  • Local anesthetic
  • Corticosteroid injections

Non-pharmacological:

  • Avoid scratching
  • Tens
  • Cold
  • Moisturize
  • Stress management
  • Vibration
  • Message
  • Compression
  • Hydration
  • Air humidity control
  • Distractions
42
Q

What are scar management techniques?

A
  1. Therapeutic heat: Hot pack, wax, fluidotherapy.
  2. Massage in conjunction w/ stretching
    Goals of massage: maintain joint mobility (contracture), soften scar tissue, break down adhesions, promote remodelling of scar tissue, desensitization, alleviate pruritus.
  3. Compression
    Goals: decrease swelling, minimize develop of hypertrophic scars, improve ethics of scar, avoid scar migration, limit loss of movement, optimal function, prevent scare retraction.

Types: transition garments, made to measure garments, gels/moulds.

  1. Positioning and splints
  2. Stretching: low load, long time, contract-relax, manual therapy, combined stretches (need 1-2 min 2 to 3 times for scar to stretch)

HEP is important

43
Q

What are some other modalities that are used?

A
  1. Therapeutic activities: gait, stairs, biometrics, wii, functional balance.
  2. Strength of weak muscles: weights, OKC or CKC, active, AA, isometrics, resisted, motor control
  3. Endurance: nu-step, elliptical, treadmill, bike, wii (be careful not to overheat)
  4. Edema control: elevation, compression, bandages.
  5. Hydrotherapy: hand shower clean skin,
  6. Wound care: High voltage current and laser, basic dressing.
44
Q

What is the nature of rehab at villa medica?

A

Interdisciplinary-everyone in the same room so aware of each others treatment

Outpatient pt: focus on function and can last a long time

45
Q

What is Entrained Grands Brules?

A

A non-profit organization associated w/ the centre of expertise
-Mission to assist burn victims through healing process and their family and friends.
-For children and adults w/ burn injuries and their loved ones
Services offered: social, financial support, information, public awareness, events, mentoring program.
-Takes a different approach than the health care network.

PHTH 550- Orthopaedic Management Final (13 decks)

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