Wound Management And Burns

Question 1

Wound descriptive words

Answer 1

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

Question 2

Acute vs chronic wounds

Answer 2

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

Question 3

Contusions and hematomas

Answer 3

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

Question 4

Cruising injuries

Answer 4

Compartment syndrome and Rhabdomyolysis are common complications

• progressive POOP
• numbeness and parasthesia
• pale foot
• swelling

Compartment syndrome = fasciotomy

is a closed wound

Question 5

Non penetrating superficial tissue

Answer 5

Skin wounds = treat with bacitracin

Eye abrasion = erythromycin ointment

Are examples of open wounds

Question 6

Lacerations

Answer 6

Usually longer than deep
- *check wound margins

Increases risk of infections

Management = cleaning, irrigation, debridement and ABs if you feel its contaminated

Question 7

Human fight bite

Answer 7

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

Question 8

Wound closure types

Answer 8

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

Question 9

Detriments for acute wound healing properly

Answer 9

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

Question 10

Are antibiotics needed for prophylaxis of wounds

Answer 10

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

Question 11

4 phases of wound healing

Answer 11

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

Question 12

Type of ulcers

Answer 12

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

Question 13

3 key points for ulcer prevention

Answer 13

1) risk assessment and skin assessments
2) manage moisture
3) minimization of pressure

High risk:

• Braden scale <12
• elderly
• immobile/spinal cord injury

Question 14

Colors of wounds

Answer 14

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

Question 15

Other causes of decreased chronic wound healing

Answer 15

Diabetes present

Anticoagulant or steroid medications

Poor oxygenation
- COPS, tobacco use

Location is at areas of stretching/tension full

Wound is contaminated

Question 16

Wound edges

Answer 16

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)

Question 17

Signs of infection

Answer 17

Fever

Extensive redness

Edema

POOP

Odor present

Systemic symptoms present (especially tachycardia and hypotension)

Question 18

Treatment of Purulent vs non Purulent

Answer 18

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

Question 19

Necrotizing ST infections

Answer 19

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

Question 20

Factors that increase mortatility from burns

Answer 20

Larger burn size

Very young or very old

Increased in females but unknown reason

Inhalation injuries from burns

Question 21

What factor dictates severity of burns?

Answer 21

Skin thickness

• thinner overall skin = risk of deeper burns
• youth and elderly have higher risk of severe burns

Thicker skin = palms/soles/upper back

Question 22

Burn classifications

Answer 22

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

Question 23

First degree superficial

Answer 23

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)

Question 24

Superfical 2nd degree

Answer 24

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

Question 25

Deep partial thickness (2nd degree)

Answer 25

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

Question 26

Full thickness 3rd degree

Answer 26

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

Question 27

Deep full thickness 4th degree

Answer 27

Is the worst burn Burns everything and requires months-years and surgery to repair

Question 28

Symptoms of inhalation injury

Answer 28

Hoarse voice, stridor wheezing Soot or burns inside the mouth/nose

Question 29

Parkland formula

Answer 29

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

Question 30

High voltage vs low voltage electrical burns

Answer 30

High voltage = >1000V - always requires hospitalization and observation Low voltage = <1000V **most electrical burns cause internal burns that dont look bad from the outside

Question 31

Direct current vs alternating current

Answer 31

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

Question 32

PECARN criteria

Answer 32

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

Question 33

Pressure ulcer stages

Answer 33

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

Question 34

Granulation tissues

Answer 34

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

Question 35

Factors that decrease mortality to burns in public systems

Answer 35

Smoke and CO2 alarms Building codes updated Federal flammable fabric act - requires flame-retardant clothing and interior furnishings

Question 36

Common signs of abuse burns

Answer 36

“Glove/stocking” burns Deep burns on trunk/back or buttocks Single area small and full thickness burns (like cigarette burns)

Question 37

What are indications for escharotomy?

Answer 37

Circumferential deep burns to limbs/chest/neck Compromised circulation or ventilation

Question 38

Wound management highlights

Answer 38

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

Question 39

Complications of high voltage non-burn injuries

Answer 39

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