Standard Care and Tratments
- debridement
- cleansing
- dressings
- compression
- antibiotics
- pressure redistribution
Cleansing
syringe vs. gauze
- saline
- betadine
- hydrogen peroxice
- dakin’s solution
- acetic acid
saline
normal body fluid
can use on all wounds
especially good for healthy, well healing wounds
Betadine
- cytotoxic
- for infection and exudate control
- gangrene
- drying effect, good for drainage
Hydrogen peroxide
- cytotoxic
- use within first 48 hours
- only used for infection or inflammation
Dakin’s solution
- cytotoxic
- infection and oder
- bleach
Acetic Acid
- cytotoxic
- infection
- psuedomonas
- vinegar
Mild and gentle cleaning if…
granulation tissue
Aggressive cleaning if…
eschar, slough, infection, biofilm
Match the dressings to the wound
- if it’s wet, absorb it
- if it’s dry, moisten it
- if its a hole, fill it
- if its dirty, clean it
- if its clean, protect it
Tissue load management
- pressure re-distribution
- move pressure from high risk areas to low risk
- bed based pressure reducing surfaces
- seating surfaces
- off loading gait
Foam
- usually the first line of defense
- least expensive
- disadvantages include moisture retention and heat retention
- not good for pts who are incontinent or obese
Fluid-filled surfaces
- high degree of immersion
- air, gel, water
- may retain heat, depending on type of fluid
- better for obese patients
Low-air-loss systems
- connected, air filled cushions, served by an air pump
- many have automatic adjustment to the pt’s body weight distribution
- immersion is moderate
Air-fluidization
-micro-fine silicon beads in a box, covered with a loose sheeting material while warmed air is forced through the beads
-beads take on fluid characteristics
-similar to fluidotherapy
-watch for dehydration
-high level of immersion
-GOLD STANDARD for pressure re-distribution
-expensive
“clinitrons”
Alternating pressure
- air filled chambers with a pump that inflates 1-3-5-7-9 while 2-4-6-8-10 deflate, then reverse cyclically
- changes the bed to body contact points
- not immersion
Other tissue load management ideas
- no surface takes away from the need for good care and turning every 2 hours
- multiple features available
- W/C fitting can be complex
Heel load management
- special attention for heels, due to incidence of breakdown
- poorly vascularized
- gold standard is to float the heels
- pillows
- orthotic heel boots
Pressure mapping
- system used to identify areas of increased pressure or WB
- can be used in any setting
- need patient to act as though they do at home in their environment (ex. let pt ride in wheelchair for a while and get comfortable before assessing, then look at load distribution, then have them show you how they “off load”)
Advantages of pressure mapping
- individualized and specific
- IDs mild to high risk for pressure ulcers
- locates specific areas at risk for breakdown
- allows for adjustment or ordering of equipment to improve pressure
- educates patients and family about positioning for pressure relief
Patients/clients who benefit from pressure mapping
- people with hx of skin breakdown or pressure ulcers that have adaptive equipment or seating
- people working with DME company assessing for needs
- anyone with current pressure ulcer
Pressure mapping positions
- posture
- leaning (sides, forward, back)
- push ups
- glut sets
- reclining and tilting
- equipment adjustments–foot rests, lumbar rolls, air pressure in cushion
Appropriate referrals
- people who have some sort of seating system and risk factors for skin breakdown or ulcers
- people who qualify for new equipment or seating
- previous people who would benefit from additional education and visual aids
Braden scale examines
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
Braden scale scoring
15-16=mild risk
12-14=moderate risk
less than 12=high risk
Skin care education
- bathe daily or every other day with skin inspection
- moisturize daily-no fragrances
- do not rub or massage over bony prominences
- encourage smoking cessation
- positioning/mobility training
- check for moisture and reposition every 2 hours
- clean any incontinece immediately
Re-certifation
- every 4 weeks
- should be re-assessing and revising informally every 2-4 weeks
Palliative care
- focus shifts to wound management
- also focus on protection from infection (possibly by use of occlusive dressings or topical antimicrobials)
- odor control
- pain control
- pt and caregiver training
Methods of selective debridement
- sharp
- autolytic
- enzymatic
- biologic
Methods of non-selective debridement
- mechanical
- surgical
Sharps debridement
- removal of necrotic tissue by use of sharp instruments (forceps, scissors, scalpel)
- selective
- aggressive
- may be painful
Sharps debridement not appropriate for…
- pts with insufficient vascular supply or nutrition
- precuation if on blood thinners
Role of debridement (stats)
- important to do it within the 1st 4 weeks
- if done within 1st 4 weeks, 54% higher wound reduction
Termination of sharps debridement
- clinician fatigues
- pain is not adequately controlled for patient
- decline in patient status or tolerance
- extensive bleeding
- new fascial plane identified
- nothing remaining to debride
Autolytic debridement
- natural degradation of devitalized tissues with enzymes or moisture
- conservative
- little pain
- slow method
- not appropriate with infection or arterial insufficiency
Enzymatic debridement
- use of enzymatic ointments to loosen and remove devitalized tissues and proteins
- papain-urea
- colagenase
- sometimes slow
- nonselective
- may be painful
Termination of enzymatic debridement
- once satisfactory debridement has occurred
- if necrotic tissue fails to decrease in expected amt of time
Procedure for enzymatic debridement
- follow manufacturer’s guidelines
- physician’s prescription
- eschar to be crosshatched prior to application
- moist environment
- observe for S/S of infection
- prophylactic topical antimicrobial therapy prn
Biological debridement
“larva therapy”
- sterile-lab raised maggots
- definitely requires a secondary dressing
- very selective
- can help to reduce bacterial counts
- of limited application, partially due to the squeamish factor
How biologic debridement works
- larvae release enzymes that degrade/liquefy necrotic tissue
- larvae ingest necrotic tissue and bacteria
- literature supports use for pressure and neuropathic ulcers, traumatic wounds and chronic leg ulcers
Mechanical debridement
- use of external forces to non-selectively remove necrotic tissue
- painful
- non-selective
- can cause bleeding and trauma to wound reducing new cells
- wet to dry
- gauze
- whirlpool
- pulsed lavage
Surgical debridement
- use of scalpels, scissors, lasers in sterile environment
- performed by physician or podiatrist
- allows for extensive exploration of wounds bed and debridement of deeper structures
Indications for surgical debridement
- ascending cellulitis, osteomyelitis, extensive necrotic wounds, undermining
- necrotic tissue near vital organs/structures
Contraindications to surgical debridement
-patients who are unlikely to survive procedure or patients with palliative care plans
Surgical debridement procedure
- shaving of eschar with dermatome
- incision and drainage (i and D)
- possible tissue biopsy
- followed by appropriate antimicrobial therapy
Goals in wound healing debridement
- promote wound cleansing to remove debris and necrosis
- reduce bacterial bioburden and reduce risk of infection
- promote optimal environment for wound healing
- promote inflammation to facilitate angiogenesis
Considerations for debridement
- characteristics of wound
- status of patient
- existing practice acts
- clinican’s knowledge and skill level
Documentation for debridement
- must have specific physician’s orders
- selective vs. non-selective
- distinguish conservative sharps debridement
- location, type, and amount of necrotic tissue present
- type and amount of necrotic tissue removed
- instruments used and settings used if applicable
- CPT codes
Contraindications for debridement
- dry gangrene
- eschar that is intact, without drainage, erythema or fluctuance on a patient with poor circulation
- unidentified structures in wound bed
Steps to prepare patient for debridement
- assemble equipment
- Position patient comfortably
- use proper posture and body mechanics to allow safe techniques and minimize fatigue
- ensure sufficient lighting
- wash hands and don gloves
- remove old bandage and discard
- discard gloves and put new ones on
- inspect wound
- remove gloves
- explain to pt
- don gloves and initiate debridement
Whirlpool benefits
- cleanses wound
- promotes circulation
- promotes debridement
whirlpool precautions
- malignancy in area
- promotes edema
- trauma to healthy tissue
- may promote maceration
- avoid in diabetic wound (because they will macerate)
non-thermal temp
better if patient has edema and you are just trying to cleanse the wound
Whirlpool precautions/contraindications
Wounds that are-
- clean, macerating, actively bleeding (profuse)
- tunneling, undermining
- arterial insufficient wounds (use low temp)
- > 50% clean wound
- moderate-severe edema (venous insufficiency)
- incontinent, confused or combative pt
Whirlpool risks
- infection (contaminated water, cross contimination)
- superhydration/maceration
- changing of skin pH
Hydrotherapy considerations
Water temp
- non thermal (80-92 F)
- neutral (92-96)
- thermal (96-104)
- patient position (dependency promotes edema)
- duration of treatment
- additives/chemicals
Chemical additives
- clinicians must weigh potential benefits of antimicrobial application with known risks of delayed wound healing
- should not be used on chemical wounds
- contraindicated in young, elderly, and those who are sensitive to those agents
- use is not recommended except in isolated patients
Hydrotherapy decision making
- positioning
- temp
- time
- agitation
- contamination
- clean up
Pulsatile lavage
- promotes localized circulation
- reduces bacterial load
- healthy debridement if using high pressure jet system
- 5-15 psi
- must wear protective clothing
Pulsatile lavage with suction
- reliable, focused alternative to whirlpool for wound cleansing
- minimal risk of cross-contamination
- eliminates dependent edema issues
- less time involved for more focused cleansing
- patient specific supplies
- see your PT team member
Wound irrigation
- syringe vs. gauze
- should be irrigated on initial exam and with each dressing change
- saline or tap water
- use minimal force
- recommended pressure is 4-15 psi
- may be performed alone or in combo with other modalities
Electrotherapy benefits
- increases capillary perfusion
- stimulates fibroblast function
- increases wound tensile strength
- antibacterial effect
- debridement effects
- migration of inflammatory cells
Current of injury
- electrical potential across skin
- Na+ ion pump-surface epidermis negative
- current gets messed up with injury
- moisture maintains higher electrical potential
Contraindications to e-stim
-basal or squamous carcinoma
-active osteomyelitis
-residue of silver, iodine, or betadine
-pacemaker
-wound over heart region, carotid sinus or larynx
-acute arterial occlusive disease
-local radiation
-DVT or thrombosis
-pregnancy
-metal implants
-a-fib
-ventricular arrythmia
Precuations–osteo
Positive polarity
- coagulation of protein
- hardening of tissue
- coagulation of blood
- enhancing congealed scar formation
Negative polarity
- liquefying protein
- softening tissue
- bactericidal
- debridement
Parameters
- 45-60 mins
- 3-7x/week
- 50-120 pulses per second
- 80-150 volts
Reimbursement
- must be performed by PT or physician
- must document no changes for 30 days
Ultrasound
- less research to support
- effective in all phases
- not for use over malignancy, gonads, eyes, over RadRx area, DVT
- see your PT team member
US benefits
- stimulates release of chemoattractants by fibroblasts, mast cells, macrophages to reduce inflammation
- may stimulate fibroblast proliferation for collagen deposition, improved gran tissue formation, angiogenesis, wound contraction
- increases wound tensile strength
US contraindications
- osteomyelitis
- active bleeding
- severe arterial insufficiency
- acute DVT
- untreated acute wound infection
Treatment area
-divided into zones 1/5 times greater than sound head and treated 2-3 mins per zone
US debridement
- low frequency US
- cavitation causes destruction of bacteria
- helps with selective dissection and fragmentation of necrosis
- irrigation for cleansing
Vacuum assisted closure or negative pressure wound therapy (NPWT)
- negative pressure to wound
- increases perfusion to wound thereby increasing oxygen and nutrients
- helps with drainage control
- change dressing every 48 hours or 3 times/week
NPWT
- decreased edema
- increased blood flow
- decreased bacterial numbers
- fluffier granulation tissue and more of it
- promotes epithelialization
NPWT indications
- arterial, venous, pressure, mixed, vascular ulcers
- dehisced surgical –wounds with tunneling
- assisting flap survival
NPWT not indicated for…
wounds with more than 20% non-viable tissue present
NPWT intermittent vs. continuous
- intermittent can further increase the amt and speed of granulation tissue formation
- continuous uniformly applied “pull” can assist the release of intracellular messengers that mediate growth factor production
- usually changed after 48 hrs
- closed system with minimal risk of contamination
NPWT Contraindications
- malignancy in wound
- untreated osteomyelities
- non-enteric and unexplored fistulas
- necrotic tissue with eschar
- exposed blood vessels or organs
NPWT precautions
- active bleeding
- anticoagulants
- close proximity to blood vessels, organs, bony fragments
- enteric fistulas
Anodyne
- photo energy that produces nitric oxide in hemoglobin to re-oxygenate blood and wound bed
- vasodilates blood in the area
- approved for improved superficial circulation and pain management
Hyperbaric Oxygen (HBOT)
- full body or multi-place chamber vs. topical therapy
- administering 100% oxygen at a pressure greater than sea level
- daily to BID treatments of 90-120 mins per dive
- promotes angiogenesis and improved oxygen perfusion in blood and plasma hypoxic wounds
Benefits of HBOT
- hyperoxygenation
- increasing chamber preasure while breathing increases alveolar po2, blood o2 transport, tissue po2 and healing
- neovascularization
- increased oxygen transport
- requires 10 treatments for angiogenesis to occur
- antibacterial
HBOT indications
- diabetic LE wounds (wagner grade 3 or higher not responding to conservative treatment for 30 days)
- compromised skin grafts and flaps
- osteoradionecrosis
- soft tissue radionecrosis
- acute arterial insufficiency
- crush injuries
- necrotizing fasciitis
- gast gangrene
- chronic osteomyelitis
Ideal topical treatment/dressing characteristics
- provides a moist wound environment
- provides thermal insulation
- allows removal without causing trauma to wound
- removes drainage and debris
- maintains an environment free of particulates and toxic products
TIME principle of wound bed prep
- Tissue non viable or deficient
- Infection or inflammation
- Moisture imbalance
- Epidermal margin
Tissue non-viable or deficient (time principle)
Defective matrix and cell debris–>debridement–>restore wound base and ECM proteins
Infection or inflammation (time principle)
High bacterial count or prolonged inflammation–>antimicrobials–>low bacterial counts and controlled inflammation
Moisture imbalance (time principle)
Dessication or excess fluid–>dressings compressiong–>restore cell migration, maceration avoided
Epidermal margin (time principle)
impairment of epidermal migration and ECM–>biological agents, cell therapy–>stimulate keratinocyte migration
Primary dressing
comes into direct contact with wound (contact layer)
Secondary dressing
placed over primary dressing for increased protection, cushioning, absorption or occlusion
Dressing considerations
- anatomical site
- drainage amount
- bacterial load
- periwound integrity
- depth
- edema
- caregiver ability
- aggressive vs. conservative care
- cost and reimbursement
Topical treatment strategies
- gauze
- transparent film
- hydrocolloid
- hydrogel
- alginate
- foam
- collagen
- composite
- compression
- combination
- silicone gel sheet
Gauze-advantages
- various shapes and sizes
- can be used for packing
- impregnated
- nonadherent
- primary dressing (dry or impregnated)
- secondary dressing (rolls for wrapping, absorbent options)
- can be used for non-selective debridement (mechanical, wet to dry)
Gauze-disadvantages
- can be painful with removal
- can harm healthy tissue
- can dessicate wound bed
- little absorption capacity
- no barrier to bacteria
- not cost-effective due to frequent changes
Contact layers
- provide wound bed protection with fluid flow-through
- can sometimes be re-used
- usually non-absorptive
- requires secondary dressing
- sometimes impregnated
Transparent films
polyurethane film
clear dressing over IV site, etc.
Transparent films-advantages
- wound can be visible
- can stay in place 3-5 days
- promotes autolytic debridement
- semi-occlusive
- protection from friction or shear
- waterproof (good for incontinent patients as a secondary dressing)
- primary or secondary dressing
Transparent films-disadvantages
- minimal absorptive capacity (bad for pt with lots of drainage)
- can cause maceration
- can promote skin irritation
- can be traumatic upon removal
- should not be used on infected wounds
Hydrocolloid
- “duoderm”
- thick fluid that interacts with wound fluid
- over the counter as “second skin”
Hydrocolloid-advantages
- occlusive dressing
- promotes autolytic debridement
- minimal to moderate absorbent capacity
- can be used under compression
- can stay in place 5-7 days
- primary or secondary dressing
Hydrocolloid-disadvantages
- can cause wound odor
- risk of hypergranulation
- can macerate periwound
- can cause skin irritation
- can melt down or have edges roll
- should not be used with infected wounds
- not used for wounds with undermining or tunneling (creates an abscess)
Hydrogel
- water based gel
- good for arterial ulcers
- can go on almost any wound
- perfect to keep in an OP clinic just in case
Hydrogel-advantages
- promotes moist wound environment
- soothes and assists with pain management
- can assist with autolytic debridement
- primary dressing
- can be used for viable and non-viable tissue
Hydrogel-disadvantages
- varies in viscosity
- can cause maceration (esp in a draining wound)
- not for heavily draining wounds
- usually require a secondary dressing
Alginates and Hydrofibers
seaweed derived dressings
Alginates and hydrofibers-advantages
- moderate to heavy draining wounds
- can be used with viable or non-viable tissue
- can reduce frequency of dressing change
- can assist with debridement
- can be used with compression
- can be used with infection
- can be used for packing
- may have hemostatic properties
Alginate and hydrofiber-disadvantages
- can dessicate wound
- can cause alginate scab
Foam-advantages
- moderate to heavy draining wounds
- semi-occlusive
- may be adhesive or non-adhesive
- designed for longer wear times
- designed to wick away moisture
- can be used with compression
- protects wound
- insulator
- may retard hypergranulation tissue
- perfect for bony prominences and keeps normal body temp
Foam-disadvantages
- can cause maceration
- may dessicate wound bed
- may require secondary dressing
- expensive
Collagen-advantages
- moderate to heavy draining wounds
- multiple forms
- works to reduce MMPs which may attract necessary components for healing
Collagen-disadvantages
-sensitivities to bovine
Composites
- two in one dressing
- bandaid is a form of a composite
Composite-advantages
- multiple features or function in one dressing
- easy to use
- various forms and sizes
Combination
-two in one dressing with multiple function.
Combination-advantages
- multiple activities available in one dressing
- provides multiple functions
Combination-disadvantages
- may be confusing for caregiver
- must clarify primary function for reimbursement
Silicone gel sheets
- mederma is the over the counter form
- silicone dressing used in the maturation phase
- used by many plastic surgeons
Silicone gel sheet-advantages
- assists with scar management
- may reduce or prevent hypertrophic changes and keloid scars
- increases scar mobility and elasticity to reduce contractures
- reduces discoloration of scars
Antibiotic ointments
- triple antibiotic ointment
- bacitracin–water based, good for hands and face
- bactroban-effective against MRSA (only one)
- neosporin-watch allergies to neomycin
Silvadene
- primary ingredients–sulfa and silver
- watch allergies to sulfa
- can look purulent when ready to remove
- can turn wounds dull or gray in appearance due to silver
- good for burns
Silver dressings
- effective against pseudomonus, MRSA, staph, strep, enterococcus
- can stain wound and periwound
- some require activation with sterile water
- some can be rinsed and re-applied
- some are absorbent
- effectiveness varies
Hydrofera blue
- bacteriostatic foam-methylene blue and crystal violet
- bacteriostatic against MRSA, VRE, staph, seratia, e-coli, etc.
- requires moisteing with saline or sterile water
- can overlap edges of wound
- requires rehydration–usually daily
- turns light or white on either side when ready to be replaced
- only antimicrobial dressing that can be used in conjunction with enzymatic debriding ointment
- active ingredients are blue and they will transfer into the wound and the dressing will turn white (time to take off)
Cadexamer Iodine
-effective against pseudomonus, MRSA, staph, strep, enterococcus
-time release iodine so not cytotoxic but antimicrobial
-for moderate to heavy draining wounds
-can assist with debridement
-looks like rust colored play doh when applied
-looks like yellow applesauce when ready to be removed
-indicated for sloughy, drainage wounds
“ooey-gooey wounds”
-changed every 3 days
-greater than 50% slough with excessive drainage
Honey
- medihoney
- promotes a moist wound environment
- highly absorptive
- cleanses and debrides due to its high osmolarity
- helps to lower the wound pH for optimal environment
- non-toxic, natural, safe
- alginate or gel
Honey indications
- diabetic foot ulcers
- venous leg ulcers
- arterial leg ulcers
- leg ulcers of mixed etiology
- pressure ulcers
- burns (not full thickness)
- donor sites
- traumatic and surgical wounds
Growth factors
-utilize platelet derived growth factor (PDGF) to stimulate proliferative phase of wound healing
Oasis
- acellular xenograft made from submucosal lining of small intestine of porcine (applied by physician, only used for diabetic foot ulcers and venous leg ulcers bc medicare covers it for this)
- derived from porcine small intestinal submucosa
- collagenous, extracellular matrix
- temp dressing for partial and full-thickness loss
Topical growth factors
- regranex
- part of comprehensive treatment program
- indicated for LE diabetic neuropathic ulcers
- not inexpensive
Packing wounds
- fill dead space
- do not ‘stuff’ the wound
- do not traumatize the wound
- gauze
- foam
- packing strips
- pack with only 1 piece of dressing
Skin sealants
- provide additional protection and stickiness to skin for dressing retentions
- pad, spray, lollipop forms
- some are alcohol-free
Barrier ointments
- may be petrolatum, dimethicone, zinc oxide
- used to protect skin from moisture, and possibly friction
Adhesives
- variable adhesive properties
- latex-free is available
- some advanced adhesives are safe for fragile skin
Peak incidences of burns
- children 1-5 (scalds)
- adolescents (flammable liquids)
- Men 16-40 (burn injury) highest incidence due to occupation and hobbies
Burns-devestating injuries
- prolonged and intense pain
- physically and psychologically draining for pt, family, therapist
- psychosocial issues
- crucial to follow up for one year or more
- lower economic status
First degree/superficial
- sunburn
- no blisters
- epidermis
- tender to touch
- spontaneous healing 2-3 days no scar
First degree/superficial S/S
- dry
- bright red or pink
- blanchable
- no edema (unless on face) or blisters
Superficial partial thickness burn
- epidermis and papillary layer of dermis
- intact blisters, bright pink or red inflammation
- will blanch under pressure
- painful and sensitive bc of exposed nerve endings
- heals without surgical intervention in 7-10 days with min scarring
Superficial partial thickness S/S
- moist
- weeping
- blistering
- local erythema and edema
- immediate capillary refill
- exposed nerve endings
- wound drainage
- healing within 10-14 days, minimal scarring
Taut blister
- natural biological covering
- do not debride or pop
- cover, wrap, and protect
Deep partial thickness burn
- epidermis and dermis down to reticular layer
- nerve endings, hair follicles, sweat glands
- mixed red/waxy appearance, may be white
- significant edema with decreased sensation
- heals 3-5 weeks
- STSG usually required
- hypertrophic scarring common
STSG
split thickness skin graft
Deep partial thickness S/S
- mottled areas with white eschar
- may have ruptured blisters
- sluggish capillary refill
- decreased pinprick
- some pain receptors intact
- healing time 3+ weeks
Full thickness Burn
- epidermis and dermis completely destroyed
- subcutaneous tissue may be involved
- covered with eschar (black/deep, red/white)
- STSG necessary, scarring
- peripheral vascular system is damaged and fluid leaks into interstitial space causing edema
Full thickness burn S/S
- red, mottled white, gray, black
- necrotic, charred
- leathery, dry, rigid
- exposed deep tissues: tendon or bone or muscle
- insensate
- surgical debridement
- grafting usually required
- these burns are out of your scope, need a plastic surgeon
Escharatomy
- same as fasciotomy
- swelling secondary to circumferential burn compromises circulation
- escharatomy must be performed to decrease pressure, restore circulation, save limb
Subdermal burn
- even deeper than full thickness
- destruction from dermis through subcutaneous tissue, muscle, bone
- prolonged contact with flame, hot liquid, electricity, exposure to strong chemicals
- charred or mummified appearance
- requires extensive surgery and therapy
Subdermal burn S/S
- charred, mummified
- exposed tendons, muscle, fascia
- insensate
- will not heal without intervention
- fasciotomy, escharatomy, grafting
- usually requires amputation
conversion of burns
- widening and deepening of the original area of necrosis
- damage already happened, but didn’t show up later
Rule of 9’s
head-9% anterior torso-18% post torso-18% UE-9% each LE-18% each genitals-1%
Thermal burns
-direct/indirect contact with flame, liquid, steam Severity factors: -contact time -temp -type of insult
Chemical burns
-acids, bases, industrial accidents, assaults (pepper spray) Severity factors: -alkali burns greater than acid -contact time -concentration -amt of chemical
Electrical burns
-low volt vs high volt Severity factors: -AC burn worse than DC -contact time -voltage
Types of burns
- chemical
- electrical
- immersion/scald
- grease
- abrasion
- inhalation
- flash
- steam
- contact
- flame
Electrical burn-detailed
- destructive!
- entrance and exit wounds
- cardiac arrhythmias, respiratory distress
Inhalation injury
- significantly increases the morbidity and mortality of burns
- may acct for 60-80% of fire related deaths in the US
- associated with prolonged ventilation and bed rest
- absence of smoke detector increases the risk of death in fire 60% of the time
Stevens Johnson Syndrome (SJS)/TENS
- immune complex mediated hypersensitivity disorder
- involves skin and mucous membranes
- caused by drugs, viral infections
- TENS is the more severe version where there’s more than 30% of TBSA involved
Severity of burns
- TBSA burned
- depth of wound
- age of patient
- PMH
- part of body burned
Complications of Burn Injuries
- infectoin
- pulm
- metabolic
- heterotrphic ossification
- neuropathy
- scarring
- microstomia and burned eye lids
- amputations
- exposed jts
More burn complications
- shock
- CV
- pulm
- hypermetabolism
- thermoregulation
- infection
Medical management of a burn
- maintain airway
- determine extent and depth of injury
- prevent fluid loss
- prevent pulm and CV issues
- clean pt and wounds
- place dressings
- surgical management
Phases of burn management
- resuscitive
- wound coverage
- reconstructive (this is the phase we will work with the pt in)
STSG sheet advantages and disadvantages
Advantage-durable, limits contraction, cosmetic
Disadvantage-difficult adherence
STSG Mesh advantage and disadvantage
Advantage-donor skin covers more of burn, wound bed irregular in shape, wound bed contaminated
Disadvantage-less durable, contracts more
STSG Donor Site
- preferred sites (thigh, leg, back, buttock)
- heals by re-epithelization
- heals in 7-14 days
- can be harvested 3-4 times
- treat as partial thickness wound
Graft recipient area
- adequately vascularized
- complete contact bw graft and wound bed (wound vac can help with this)
- adequate immobilization
- few bacteria
PT Burn Goals
- decrease edema
- prevent contracture (positioning, splinting, ROM)
- maintain/improve strength and activity tolerance
- gait-3 day hold after STSG, but can mobilize with others on day 1
- use ace wraps on LE before gait
- AD are used seldom with burn pts
- minimal activity limitations
- education
- discharge planning
- manage scarring
Ace Wraps
Why?
- supports graft or burned area
- promotes circulation
- prevents hemorrhaging
- first phase of scar control
Figure 8 or spiral
Must ace wrap whenever OOB while wound is open
No sleeping in ace wraps
LE Burn and Ambulation
- lack of dermal support for BVs
- pain, edema, venous insufficiency
PTs should consider
- prior level of function
- ROM
- strength
- mobility and ambulatory status
- goals for hospitilation
- D/C recommendations
- comorbidities
Exercise principles for burns
- deeper burn injury=greater chance of scar contracture
- burn scar tissue is 1/3 less pliable as normal skin
- stretched scar tissue will blanch
Precautions for exercise with burns
- PMH
- jt disease
- exposed tendons
- IV lines
- ventilation
Contraindications for exercise with burns
- exposed joints
- exposed tendon over
- PIPs
- DVT
- compartment syndrome
Graft and exercise
- immobilized 5-14 days
- can exercise non-grafted areas as long as tension avoided at graft
Auto release of scar tissue
- scar may separate with forceful stress, resulting in open wound
- typically not painful
- if small, allowed to heal spontaneously
- if large, may be grafted
Contracture body areas
Face-microstomia Neck-flexion Shoulder-adduction, protraction Elbow-flexion Wrist-flexion Hand-MCP ext, PIP flex, DIP flex or hyperext, thumb add Hip-flexion Knee-flexion Ankle-plantarflexion Toes-hyperext
Facial Complications
Ectropion of eye-excessive tear production, conjunctivits, keratitis
Ectropion of mouht-difficulty managing secretions, liquids
Shoulder complications
- flexion or adduction contracture
- scapular retraction or protraction
- limited chest wall expansion
Wrist complications
- flexion or ext contracture
- inability to ulnarly deviate
Z-plasty
scar band has formed in axilla
zplasty releases contracture
Scar management
- every burn will scar
- we cannot prevent scarring but we can potentially change the function of the scar
- 80% of burn pts will develop hypertrophic scarring–use of compression indicated in most burns
- scar will mature over course of teh year
- massage
Compression therapy-why it works
- mechanical thinning effect
- decreases blood flow to area
- reorganizes collagen bundles
- decreases tissue water content