Wound Management And Burns Flashcards
Wound descriptive words
Acute/chronic
Type and etiology
Location
Size
Skin depth (how deep)
Wound edges and tunneling
Contamination/foreign
Purulent or infectious
Wet vs dry
Peri-wound apperance
Acute vs chronic wounds
Acute:
- caused by trauma or surgery
- heal easily by themselves
- require limited local care
- progress through 3 phases of healing quickly (inflammation, proliferation, maturation)
- caused by contusions/abrasions/lacerations/incisions/penetrating wounds and burns
Chronic:
- healing takes longer than 21 days
- usually stalls between inflammation and proliferative phases
- caused by ulcers as #1
Contusions and hematomas
Contusions usually from trauma
- blood vessel and tissue damage
Can induce hematomas
- can be an indicator of TBI in patients less than 2 years old with isolated hemorrhages and cerebral contusion
Treatment = ice and time usually. Also treat secondary symptoms if they arise
Both are closed wounds
Cruising injuries
Compartment syndrome and Rhabdomyolysis are common complications
- progressive POOP
- numbeness and parasthesia
- pale foot
- swelling
Compartment syndrome = fasciotomy
is a closed wound
Non penetrating superficial tissue
Skin wounds = treat with bacitracin
Eye abrasion = erythromycin ointment
Are examples of open wounds
Lacerations
Usually longer than deep
- *check wound margins
Increases risk of infections
Management = cleaning, irrigation, debridement and ABs if you feel its contaminated
Human fight bite
Open wound
High risk of staph/strep and Elkenella corrodens infections
Management = amoxicillin/clavulanate acid = #1
- always do even if its just prophylaxis
if signs of tenosynovits is present (erythema and infection signs as well extreme pain) consult hand surgeon
Wound closure types
Primary = suturing, grafting, surgery procedure
- used in non infection wounds
- heals faster
Secondary = spontaneous intention by re-epithelization and contraction of the wound naturally
- used for contaminated or high risk of contamination wounds
- takes longer and scars more
Tertiary (delayed primary closure)
- repeated debridement and negative pressure wound therapy w/ antibiotics. Then after time = revision of the wound and then suture/great the wound close
- only for highly contaminated wound
Detriments for acute wound healing properly
Wound Is in areas under tension and pressure or are loaded areas (FEET)
Wound is prone to dishiscence
- splinting when necessary
If wound gets contaminated/ foreign body is retained
Are antibiotics needed for prophylaxis of wounds
Not in uncomplicated patients
Only if you feel the wounds have high risk of contamination or if it is contaminated
- also if patient is immunodeficiency is present should also consider prophylaxis
**be careful with C. Diff infections if using antibiotics
**compulsive wound cleaning is more importaint than ABs in post wound repair
4 phases of wound healing
Hemostasis
- 5-10 minutes
- vasoconstriction and fibrin clot formation with coagulation occurs
- releases inflammatory mediators and growth factors
Inflammatory
- up to 3 days after wound
- increased vascular and cellular permeability
- pain and swelling occurs
- releases of cytokines
- **chronic wounds get arrested here and dont move on often due to alteration in balance of inflammation and impaired cytokine function
Proliferative
- 3-12 days
- fibroblast migration occurs
- fibrin matrix and collagen synthesis occurs and angiogenesis as well if needed
- **greatest increase in wound strength occurs here
Maturation
- scarring period beings here with collagen cross-linking and remodeling with scar relation
- **overall approximately 80% of tensile strength exists at 6 week mark when healed (easy to reinjure so be careful
Type of ulcers
Venous insufficiency
- due to edema being present from venous status
- common in elderly and venous HTN
- hemosiderin deposits and staining occurs (looks bluish)
Arterial insufficiency
- develops due to narrowing of arteries in the pelvis and legs
- pulses may be absent and edema is ABSENT
- shows atrophic skin and is painful
- common in diabetics
Neuropathic/diabetic ulcers
- develops due to loss of sensation or callous formation in the extremity
- common diabetes and are the most likely to get infected
Pressure ulcers
- develops due to limited mobility
- causes local ischemia and associated necrosis
3 key points for ulcer prevention
1) risk assessment and skin assessments
2) manage moisture
3) minimization of pressure
High risk:
- Braden scale <12
- elderly
- immobile/spinal cord injury
Colors of wounds
Red wound = trauma or surgical wound with healing
- tx = symptomatic or monitor
Pink tissues = healing wound as epithelial tissue forms
- tx =monitor and symptomatic
Yellow tissues = soft necrotic and stuck in prolonged inflammation phase of healing
- tx = debridement if needed and then wound cleaning
Black tissues = adherent necrotic tissues what may be Purulent
- tx = debridement
Other causes of decreased chronic wound healing
Diabetes present
Anticoagulant or steroid medications
Poor oxygenation
- COPS, tobacco use
Location is at areas of stretching/tension full
Wound is contaminated
Wound edges
Epithelial = healthy tissue from edge of wound
Rolled = edges are not connected to base of wound
Shape = distinct, irregular, diffuse, defined, etc.
Hyper keratotic or calloused wounds
Macerated (white/boggy tissue from moisture)
Signs of infection
Fever
Extensive redness
Edema
POOP
Odor present
Systemic symptoms present (especially tachycardia and hypotension)
Treatment of Purulent vs non Purulent
2 most common organisms = staph aureus and strep
Moderate disease of suspected MRSA infection = vancomycin IV, doxycycline or SMP-TMX if oral route
Uncomplicated cellulitis = cephalexin is #1
Necrotizing ST infections
May appear as cellulitis early on but progresses very quickly
Spreads rapidly along all fascial plans and is very erythema and edematous beyond the redness
Treatment = surgical consultation and ABs
Factors that increase mortatility from burns
Larger burn size
Very young or very old
Increased in females but unknown reason
Inhalation injuries from burns
What factor dictates severity of burns?
Skin thickness
- thinner overall skin = risk of deeper burns
- youth and elderly have higher risk of severe burns
Thicker skin = palms/soles/upper back
Burn classifications
1st-4th degree
- 4th degree = entire epidermis and dermis and fat/muscle have all been breached
Thickness degree
- superifical = 1st
- partial thickness = 2nd degree
- full thickness = 3rd degree
First degree superficial
Usually only includes sunburns Or burns that only affect the epidermis
Induces localized pain with dry/swelling
- no blisters are present
Heals says without scarring (usually 48-72 hrs)
Superfical 2nd degree
Epidermis and superfical dermis affected
- is more painful and blanches with pressure
- blisters take 12-24 hrs to appear and almost always appears**
- heals 14-21 days without scarring
Deep partial thickness (2nd degree)
Includes the epidermis/deep dermis and sweat glands/hair follicles
Is wet and waxy/dry with variable color
- white/red/yellow are common colors
- also shows blisters and very painful
Is very painful (most painful burn)
Healing takes 3-8 weeks
- always permanently scars as well
- also typically presents with fluid loss
Full thickness 3rd degree
NO PAIN PRESENT**
Entire epidermis and dermis destroyed
- no epithelial cells can repopulate and therefore requires surgery and skin grafts
- always severe scarring
- doesnt blanch and only sensation to deep pressure intact
Deep full thickness 4th degree
Is the worst burn
Burns everything and requires months-years and surgery to repair
Symptoms of inhalation injury
Hoarse voice, stridor wheezing
Soot or burns inside the mouth/nose
Parkland formula
4mL x total body surface burnt (% (but use full number, not decimal)) x total body weight in (kg)
Helps determine estimation of total IV solution needing to be given to this patient
- 50% of this = first 8 hrs
- other 50% of this = second 16 hrs
High voltage vs low voltage electrical burns
High voltage = >1000V
- always requires hospitalization and observation
Low voltage = <1000V
**most electrical burns cause internal burns that dont look bad from the outside
Direct current vs alternating current
DC = batteries and lightening
- causes asystole
AC = household electricity
- causes ventricular fibrilation and muscle tetany
- also potentially respiratory muscle paralyze and suffocation
- MORE DANGEROUS
**complications = rhabdomyolysis, myoglobinuria and compartment syndrome
PECARN criteria
Used in any injury to a Pediatric patient that you suspect a TBI may be present
Red flags: MUST get CT (especially if patient under 2 years old)
- AMS
- GCS <15
- palpable skull fracture
Yellow flags: MAY get CT or just monitor
- LOC > 5 sec
- nonfrontal hematoma
- severe mechanism of injury
If none of these are present = NO CT
Pressure ulcer stages
Stage 1:
- skin intact
- non-blanchable erythema present
- treatment = skin care and off-loading
Stage 2:
- partial loss of dermis
- shallow open ulcerations
- treatment = same as stage 1 but can also use barrier creams or hydrocolloid
Stage 3:
- full thickness skin loss and fat exposed
- treatment = consult wound care and apply dressing
Stage 4:
- full thickness skin loss and exposed bone/muscle/tendon
- treatment = consult surgery and do stage 3 treatments
Extra stages:
1) unstagebale pressure injury
- covered with slough or eschar so cant determine
2) Deep tissue pressure injury
- purplish skin discoloration and potential for deeper tissue damage
Granulation tissues
Is viable healthy tissue found in in stage 3/4 pressure injuries and full thickness wounds.
Non viable tissue = eschar or slough
- also only seen in stages 3/4 pressure injuries and full thickness wounds
Factors that decrease mortality to burns in public systems
Smoke and CO2 alarms
Building codes updated
Federal flammable fabric act
- requires flame-retardant clothing and interior furnishings
Common signs of abuse burns
“Glove/stocking” burns
Deep burns on trunk/back or buttocks
Single area small and full thickness burns (like cigarette burns)
What are indications for escharotomy?
Circumferential deep burns to limbs/chest/neck
Compromised circulation or ventilation
Wound management highlights
Over 20% TBSA = high risk of infection and cross contamination
Burned scalps should be shaved daily if possible to promote GFR oath
Foley catheter should be considered in genitalia and perineal burns
- must check sulfa allergies before applying sulfadiazine creams
- if allergic = neomycin/bacitracin/polysporin
Elevate burned extremities above the heart level
** DONT use silver sulfadiazine creams on face and keep creams out of eyes
Complications of high voltage non-burn injuries
CV: cardiac arrest, HTN, PVCs, VFib
CNS: cerebral edema, hemorrhage, seizures, mood changes, depression and paralysis
MSK: rhabdomyolysis and myoglobinuria
Renal: renal failure
Ocular complications
