Burns and Wounds

Layers of the skin (superficial to deep)

- epidermis

- dermis

- hypodermis

What is a burn

Injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals

Causes of burns

- thermal (heat or cold)

- chemicals

- electricity

- sunlight

- nuclear radiation

Pathophysiological consideration

- age

- location, duration, intensity

- alteration of vascular integrity

- amount of skin destruction

Burn severity is related to:

- total body surface that is burned

- depth of burn

- burn on the face or perineum

- if there is an inhalation injury

Admissions to burn units

- moderate to severe burns

- electrical burns

- chemical burns

- burn injury with pre-existing illness that could complicate

- children

Classification of burns

- superficial

- superficial partial thickness

- deep partial thickness

- full thickness

Superficial burn

- epidermis

- sunburn

- erythematous (pink or red)

- dry surface

- no blisters

- minimal edema

- spontaneous healing

- no scar

Superficial partial thickness burn

- epidermis + papillary layer of dermis

- inflamed dermis

- bright pink or red; mottled red

- erythmatous with blanching

- intact blisters

- very painful

- minimal scarring

- complete healing within 7-10 days

- moderate edema

Deep partial thickness burn

- epidermis and dermis

- mixed red or waxy white

- blanching with slow capillary refill

- broken blisters

- wet surface

- slow healing (3-5 weeks)

- excessive scarring

Full thickness burn

- epidermal and dermal layers

- white, charred, tan, fawn, mahogany, red, black

- no blanching

- poor distal circulation

- like parchment

- heals with skin grafting

- scarring

Subdermal burn

- epidermis through subcutaneous tissue

- charred

- subcutaneous tissue evident

- muscle damage

- tissue defects

- heals with skin grafting

- scarring

Causes of superficial burns

- sunburn, UV light exposure, short flash fire

Cause of superficial partial thickness burn

- scalds, spills, flashes of flame

Cause of deep partial thickness burns

- immersion, scalds and flames

Cause of full thickness burns

- flame, electrical, chemical

Rule of nines

Average adults skin surface adds up to 100% and the body’s parts are usually around 9% or divisible by 9%

Major burn

- >20% TBSA (child, partial thickness)

- >25% TBSA (adult, partial thickness)

- > 10% TBSA (full thickness)

- injury to face, eyes, ears, feet and perineum

- inhalation injury

- electrical injury

- co-morbidity factors

Moderate burns

- 10-20% TBSA (child, partial thickness)

- 15-20% TBSA (adult, partial thickness)

- 2-10 TBSA (full thickness)

Minor burn

- <10% TBSA (child, partial thickness)

- < 15% TBSA (adult, partial thickness)

- <2 % TBSA (full thickness)

Common complications of burns

- infection

- pulmonary complications

- cardiovascular complications

- metabolic complications

- contractures

- pathological scars

- neuropathy

- amputations

Hypertrophic scar

- too much collagen

- thick, raised, erythematous

Keloid

- overgrowth of dense fibrous tissue

- extends beyond the borders of the original wound

Motor functional implications

- contractures

- decreased ROM

Sensory functional implications

- pain, altered sensation

Scar managment

compression

External factors contributing to skin breakdown

- pressure

- friction

- shear

- thermal damage

- radiation

- iatrogenic (due to healthcare provider)

- smoking

- drugs

- malnutrition

Internal factors contributing to skin breakdown

- systemic

- aging

- obesity

Types of wounds

- vascular ulcers (arterial and venous ulcers)

- pressure ulcers

- neuropathic/diabetic ulcers

Manifestations of arterial ulcers

- Etiology: diabetes, smoking, hyperlipidemia

- round, defined edges, eschar covering wound

- minimal granulation tissues

- deep

- minimal drainage, yellow or purple t

- absent or weak pulse

- pain at rest

- pain on elevation, elevation ineffective

- pallor on LE, cracked shiny skin

Manifestations of venous ulcers

- Etiology: thrombosis of vein, venous valve insufficiency

- irregular shape, may be large

- granulation tissue at base of wound

- superficial

- moderate to profuse drainage

- normal pulse

- pain on standing, relieved by elevation

- elevation and ankle pumps to decrease swelling

Management of arterial ulcers

- head of bed raised

- no support hose, nothing tight around leg

- no compression bandage

- no compression pumps

- cool water in whirlpool

- no massage

Management of venous ulcers

- foot of bed raised

- support hose is used

- compression bandage

- compression pump to help reduce edema

- mild warm water in whirlpool

- massage for swelling

Wound stage 1

- non blanchable erythema

- intact skin

Wound stage 2

- partial thickness skin loss

- involves epidermis and or dermis

- appearance of abrasion, blister, split skin

Stage 3 wound

- full thickness skin loss

- damage/necrosis of subcutaneous tissue

- does not extend past fascial layer

Wound stage 4

- full thickness skin loss

- tissue necrosis or damage to muscle, bone or other supporting structures

- may have sinuses

Unstagable

- encompasses large bursa involving joint capsule or body cavities

Primary intention healing

- edges are closely related or skin graft is applied

- less infection

- faster healing

- decreased scar formation

Secondary intention healing

- letting a burn/wound heal in this method increased healing time, likelihood of dysfunction and scarring

- more painful

- easily infected as wound is open to external environment

Third intention wound healing

- delayed primary wound healing

- occurs when the process of secondary intnetion is intentional interrupted and the wound is mechanically closed

Phases of healing

1. HomeostasiS

2. Inflammatory

3. Proliferation

4. Maturation

Basic goals of wound care

- protect wound and surrounding tissue

- decrease strain

- decrease risk of infection

- speed up healing process

- decrease scar tissue formation