burn PT Flashcards
(46 cards)
1
Q
epidermis
A
- provides protection
- consists of 5 layers
- avascular in nature
- regenerated by keratinocytes
2
Q
dermis
A
- sweat glands, nerve endings, hair follicles
- 2 layers
- papillary dermis: loosely distributed collagen and elastin
- reticular dermis: densely packed collage “lattice work”
- fibroblasts
3
Q
subcutaneous layer
A
adipose and connective tissue
4
Q
burn depth classification
A
- superficial (first degree): epidermis
- partial thickness (second degree): subcategories - superficial partial [papillary] or deep partial [reticular], epidermis, dermis
- full thickness (third degree): epidermis, dermis, subcutaneous layer
5
Q
superficial thickness
A
- really bad sunburn
- surface appearance: dry, no blisters, blanches with pressure
- color: red, bright pink
- sensation: painful
- histologic depth: epidermis only
- heals on its on: 3-7 days, may peel
- not included in TBSA %
6
Q
superficial partial thickness
papillary
A
- surface appearance: blistered, weeping
- color: bright red
- sensation: very painful
- histologic depth: epidermis, papillary dermis
- healing: 7-21 days by re-epithelization, minimal to no scarring, pigment change unlikely
7
Q
deep partial thickness
A
- surface appearance: psudoeschar - white
- color: mottled white to pink, blanching indicates healing
- sensation: pain indicates healing, no pain indicates deep burn
- histologic depth: epidermis, papillary and reticular dermis
- healing: 21-35 days, may develop severe hypertrophic scarring
- seesaw: know within a few days, will either heal on its own or convert to full thickness – due to risk factors, age burn size
8
Q
full thickness burns
A
- surface appearance: dry, leathery, charred
- color: mixed white, waxy, pearly, khaki
- sensation: no pain, hair pulls out easily – past reticular dermis, past sensation
- histologic depth: epidermis, dermis to subcutaneous tissue, beyond
- healing: skin grafting
9
Q
lund and browder
A
- most accurate method of determining total body surface area (TBSA)
- necessary to calculate fluid resuscitation requirements: liquid/edema shunted outward, so inside dry
- superficial burn NOT included in calculations - only partial and full thickness burns
- inhalation injuries can add to TBSA depending on degree on injury: 85% + 20% inhalation burn = 105%
10
Q
rule of 9s
A
- body surface of an adult, divided into 11 segments
- segments of 9% or multiples of 9%; 1% for perineum
- easy to remember
- different table for children
- palm of patient’s hand (including fingers) = 1% of TBSA
- small areas may be estimated in this manner
11
Q
types of burns
A
- thermal: scald, flame, friction
- electrical
- chemical
- radiation
12
Q
scald burn
A
- most common from hot liquids and grease: deeper burns because retains heat longer
- common in children and elderly
- patterns: downward with splash marks is accident, circumferential abuse
13
Q
flame burn
A
- may involve inhalation injury in closed doors (vs outside at campfire and fell in)
- patterns vary
14
Q
friction burn
A
- road rash usually from motorcycle, motor vehicle accidents, or bikes
15
Q
electrical burns
A
- “tip of the iceberg” – contact points may be small, internal damage may be more severe
- follows a pattern of least resistance: bone > fat > tendon > skin > muscle > blood vessels > nerve
- job related/power lines: high voltage (1000+ V)
- flash/flame/contact
16
Q
chemical burns
A
- treat by massive dilution – get chemical off – continuous showering for a prolonged period after the injury
- attempts to chemically neutralize the burn can have an adverse affect
- household cleaning agents
- industrial - sodium hydroxide
17
Q
radiation burn
A
- sunburn
- radiation therapy
18
Q
necrotizing fasciitis
A
- bacterial infection: usually group A streptococcus (flesh eating bacteria)
- point of entry: cut, needle, bug bite
- progresses quickly: red, warm, swollen area, severe pain, fever
- antibiotics and daily surgical debridement necessary - deep excision
- complications: sepsis, shock, organ failure, life or limb
19
Q
SJS and TEN
A
- SJS = < 10% TBSA
- TEN = > 30%
- allergic reaction to meds: chemo, antibiotics
- affects mucosal areas: lips, eyes, genitals, gut
- stop meds: patient heals on their own or skin starts to slough
- less worried about scarring and loss of function: become medically sick – heart and lungs
- oral/IV pain meds usually, maybe topical lidocaine
20
Q
frostbite
A
- dif scoring sheet
- Hennepin score - quantifies injury and tissue loss of FB injury
- largely affects homeless population
- t-PA protocol, bone scan, rewarming
- heal vs amputation - if not managed
- timing very important: tiny vessels getting little clots, t-PA busts clots and restore perfusion
21
Q
renal system in burns
A
- hypovolemic shock
- most immediate life-threatening response to injury
- marked fluid loss - from organs (acute kidney failure)
- fluid shift from intravascular space to extravascular (3rd) space: decreased blood pressure, increase heart rate, decreased urine output
- urine output closely monitored - acute renal failure
22
Q
integumentary system with burn
A
- similar temperatures cause different depths of injury to different body parts: palm of hand/soles of feet, volar forearm/eyelids/ears
- temperature regulation: patients always cold acutely, hot subacturely - don’t sweat from grafted skin
- infection: not if but when for large burns
- dressing choises: dry vs wet wounds
- special consideration to pediatric and geriatric population: difficult to graft thin skin
- escharotomy: fluid accumulates in extracellular space, circumferential burn/eschar acts as tournigquet - fluid shunted out has no where to go, prevent ischemic extremities, compartment syndrome - fluid weeps out
23
Q
respiratory system with burns
A
- airway management: edema formation does not spare airway
- inhalation injury: enclosed space vs open area, mechanical clearance of mucous with bronchoscopy
- pre-existing conditions: COPD, emphysema, smoking
- ventilator associated pneumonia (VAP): with large burns and multiple trips to OR, extubate as soon as possible
24
Q
cardiovascular system with burns
A
- tachycardia: 140s RHR normal with age, hypovolemia (initial injury), pain (HR increased with pain), monitor during therapy session
- bedrest/deconditioning: associated with loss of plasma volume (PV) and left-ventricular (LV) atrophy
- pre-existing cardiac conditions
25
gastrointestinal system and burns
* bowel management: opiates slow GI motility, prevent bowel obstruction, rectal tube, stool softener
* nasogastric (NG) tube placement: NG tube feeds, patient with only 20% TBSA burn - difficult to meet nutritional requirements with a regular diet
* increased protein and caloric needs: wound healing, body in hypermetabolic state -> muscle catabolism for protein
26
burn wound coverage
* burn excision: surgical
* temporary coverage: allograft, xenograft, skin substitutes
* definitive coverage: autograft
27
burn excision
| of any nonviable tissue
* burn eschar causes system inflammation (and infection)
* creates healthy, bleeding wound base
28
allograft and xenograft
| temporary coverage
* allgraft (cadaver skin) and xenograft (usually pig)
* large TBSA: temporary coverage
* small TBSA: test readiness of wound bed for autograft
29
skin substitutes
| temporary coverage
* integra
* silicone outer layer with bovine collagen matrix
* used over joints, bones, tendons, and cartilage
* provides scaffolding for cellular invasion and capillary growth
30
definitive coverage - autograft
| types
* split thickness skin graft (STSG) -- 99%
* full thickness skin graft (FTSG) -- less common
31
split thickness skin graft (STSG)
| autograft
* dermatome, 0.007-0.16 inches thick
* heal in 10-14 days
* sheet graft, mesh graft
| 99%
32
full thickness skin graft (FTSG)
| autograft
* entire thickness of skin down to subcutaneous tissue
* problem areas
* eyelids, palmar aspect of hand/fingers
* reconstruction/cosmetic
33
mesh graft
| split thickness skin graft - autograft
* graft run through a "mesher"
* insterstices allow for wound drainage
* expanded over a large area of skin
* less durable than sheet graft - more fragile than sheet grafts but still tough
* waffle-like appearance
34
sheet graft
| split thickness skin graft - autograft
* graft is unaltered
* more cosmetically appealing
* requires large donor site
* watch for "bleeders"
35
donor site
* partial thickness wound
* heals by re-epithelialization
* 10-14 days
* reharvest
36
cultured epidermal autograft (CEA)
| autograft
* patients with large TBSA % (>30%)
* skin biopsies taken upon admission and sent to lab in Boston to grow skin cells
* extremely fragile: 2-8 cell layers thick
* surgeon places "cassettes" over a larger meshed (6:1) STSG -- $7500/cassette
* skin cells fill in the gaps of the mash
* period of immobilization (~2 weeks)
37
RECELL ASCS (autologous skin cell suspension)
* small donor site (size of a postage stamp)
* donor skin placed into an enzymatic solution
* after 15-20 minutes the surgeon scrapes the epidermis from the dermis
* surgeon draws up solution and sprays onto a meshed STSG
* advantages/uses: small donor, used in combination with STSG for faster healing, used on deep partial thickness burns, used on donor sites to promote faster healing in order to re-harvest, less expensive and more readily available than CEAs, quicker time to rehabilitative interventions and less bedrest
38
where do PTs fit in on a burn unit
* throughout continuum of care
* ICU > step-down > floor level of care
* wound care
* interdisciplinary rounds
* family meetings
* in OR
* outpatient
39
PT burn evaluation
* patient history: PMH, PSH, comorbidities, MOI - inhalation injury, trauma, mental health, drug/alcohol abuse
* PLOF: family dynamics, social history
* edema
* ROM
* burn assessment: size/depth estimate, Lund and Browder (TBSA), blanching vs non-blanching, pain, sensation, location/circumferential involvement (joint involvement)
* vital signs: resting and with burn assessment, PROM, oftentimes only indicator of pain (wound care and PT are generally most painful parts)
* position of invovled extremities, head, neck
* strength and functional mobility, if able
40
edema management
| PT interventions specific to burns
* limb elevation, positioning
* functional wrapping: use of conform and kerlix during wound care
* compression: ACE, isotoner gloves, tubigrip, tensoflex
* lymphedema bandaging for improve wound healing - short stretch bandaging and foam better when patient is up and moving -- high work P, low resting P
* (ACE is opposite)
41
positioning
| PT interventions specific to burns
* begins day 1
* maintain ROM of joints
* position of comfort - position of contracture
* skin and nerve protection: off-load bony prominences, avoid pressure on or overstretching of nerves
* vascular support - elevation
42
splinting
| PT interventions specific to burns
* types: off the shelf, custom, non-conventional
* autograft protection: immobilize grafts that cross joints (5 days), at all times until POD5 for autografts
* maintain ROM: prevent contractures and deformities, don when at rest and at night, promote AROM and functional use when doffed
* joint protection: exposed joint - immobilize with splint
43
casting
| PT interventions specific to burns
* serial casting: remediate skin/joint contractures
* total contact casts: immobilize joint and redistribute ground forces during ambulation, allows for weightbearing during healing
44
ROM/stretching
| PT interventions specific to burns
* **AROM**
* encouraged prior to grafting for edema reduction
* POD5 after autografting - if good graft take, may start AROM (patient controlled)
* gain as much as A/PROM before strengthening
* may start 24 hours after allografting
* **PROM**
* may do prior to grafting, keeping in mind available ROM given edema
* may start gentle PROM 5-7 days after autografting
* may start 24 hours after allografting
* be mindful of end-feels, skin blanching, speed/duration of passive stretching
* during wound care/OR
* **AAROM**
* AROM with PT assisting with overpressure
45
scar management
| PT interventions specific to burns
* scar massage: identify hypertrophic scars and banding, combine with stretching
* compression: initiate with off the shelf options, if tolerating and compliant, then custom compression garments, silicone - moisture retaining, foam inserts for added compression
* CO2 laser therapy: outpatient
* Z- plasty: to elongate skin
46
exercise
| PT interventions specific to burns
* necessary but painful: being day 1
* prevent contractures, maintain ROM/function
* important to appreciate current medical status and where the patient is in their healing course
* monitor vital signs
* stretch > strengthen within given ROM > splint to maintain (stretch then strengthen)
* be aware of the patient's medical history
* know your patient's injuries: exposed joint/tendon, fresh grafts, orthopedic issues
* large TBSA% = high risk of deconditioning (per 1% TBSA expect 1 day in ICU)
* initially therapist led: HEP, home stretching program
