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MC III > burn PT > Flashcards

burn PT Flashcards

1
Q

epidermis

A
  • provides protection
  • consists of 5 layers
  • avascular in nature
  • regenerated by keratinocytes
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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
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3
Q

subcutaneous layer

A

adipose and connective tissue

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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
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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 %
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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
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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
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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
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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%
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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
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11
Q

types of burns

A
  • thermal: scald, flame, friction
  • electrical
  • chemical
  • radiation
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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
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13
Q

flame burn

A
  • may involve inhalation injury in closed doors (vs outside at campfire and fell in)
  • patterns vary
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14
Q

friction burn

A
  • road rash usually from motorcycle, motor vehicle accidents, or bikes
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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
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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
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17
Q

radiation burn

A
  • sunburn
  • radiation therapy
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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
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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
Q

gastrointestinal system and burns

A
  • 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
Q

burn wound coverage

A
  • burn excision: surgical
  • temporary coverage: allograft, xenograft, skin substitutes
  • definitive coverage: autograft
27
Q

burn excision

of any nonviable tissue

A
  • burn eschar causes system inflammation (and infection)
  • creates healthy, bleeding wound base
28
Q

allograft and xenograft

temporary coverage

A
  • allgraft (cadaver skin) and xenograft (usually pig)
  • large TBSA: temporary coverage
  • small TBSA: test readiness of wound bed for autograft
29
Q

skin substitutes

temporary coverage

A
  • integra
  • silicone outer layer with bovine collagen matrix
  • used over joints, bones, tendons, and cartilage
  • provides scaffolding for cellular invasion and capillary growth
30
Q

definitive coverage - autograft

types

A
  • split thickness skin graft (STSG) – 99%
  • full thickness skin graft (FTSG) – less common
31
Q

split thickness skin graft (STSG)

autograft

A
  • dermatome, 0.007-0.16 inches thick
  • heal in 10-14 days
  • sheet graft, mesh graft

99%

32
Q

full thickness skin graft (FTSG)

autograft

A
  • entire thickness of skin down to subcutaneous tissue
  • problem areas
  • eyelids, palmar aspect of hand/fingers
  • reconstruction/cosmetic
33
Q

mesh graft

split thickness skin graft - autograft

A
  • 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
Q

sheet graft

split thickness skin graft - autograft

A
  • graft is unaltered
  • more cosmetically appealing
  • requires large donor site
  • watch for “bleeders”
35
Q

donor site

A
  • partial thickness wound
  • heals by re-epithelialization
  • 10-14 days
  • reharvest
36
Q

cultured epidermal autograft (CEA)

autograft

A
  • 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
Q

RECELL ASCS (autologous skin cell suspension)

A
  • 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
Q

where do PTs fit in on a burn unit

A
  • throughout continuum of care
  • ICU > step-down > floor level of care
  • wound care
  • interdisciplinary rounds
  • family meetings
  • in OR
  • outpatient
39
Q

PT burn evaluation

A
  • 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
Q

edema management

PT interventions specific to burns

A
  • 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
Q

positioning

PT interventions specific to burns

A
  • 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
Q

splinting

PT interventions specific to burns

A
  • 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
Q

casting

PT interventions specific to burns

A
  • serial casting: remediate skin/joint contractures
  • total contact casts: immobilize joint and redistribute ground forces during ambulation, allows for weightbearing during healing
44
Q

ROM/stretching

PT interventions specific to burns

A
  • 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
Q

scar management

PT interventions specific to burns

A
  • 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
Q

exercise

PT interventions specific to burns

A
  • 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

MC III (12 decks)

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