Burns and Thermal Injuries

thermal injury to the skin is the result of

direct energy to the tissue in relation to temp and contact time

burn pathophysiology

denaturing of proteins, vaporization of water, thrombosis of blood vessels = tissue death, potentiated by patients premorbid condition, injury status and local inflammatory factors

severity of burn depends on

temp and length of time exposure, age of victim, location of wound, comorbidities affecting healing

coagulation zone of injury

area of max contact to thermal source, cells wont recover and emphasis is debridement and prevention of infection

statis zone

area of hypoperfusion and hypometabolism as the number of viable cells is reduced, risk for progression of necrosis

hyperemia zone

appears as erythema as the result of vasodilation

classification and depth of injury

superficial, superficial partial thickness, deep partial thickness, full thickness, deep thermal necrosis

superficial burn at epidermis

pink/red, erythematous, dry surface no blisters, painful/sensate, minimal to no edema, heals in 3-5 days, no scarring

superficial partial thickness

blisters, moist, bright red surface, blanches with normal capillary refill, sensate/painful and sensitive to touch, pressure, temp, min to mod edema, into papillary dermis, heals in 2-3 weeks, rarely form scarring

deep partial thickness burn

broken blisters, mottled white appearance, moist/no blanching, insensate, mod to large edema, extends into reticular dermis, heals in 3-9 weeks, scarring/typically requires debridement and grafting

full thickness burn

dry, firm leathery brown or black eschar, insensate to touch, pain associated with inflammation of adjacent viable tissue, atleast 3 weeks to heal, scarring

escharotomy

when burn covers the circumference of the limb the vascular status can become compromised due to increasing edema - make slits to allow natural swelling to occur

calculating total body surface area is used ot help estimate

total fluid and caloric requirements - predictor of mortality

rule of 9's

head, right arm and left arm 9%, front torso, back torso and buttocks, left and right legs 18%, genitals 1%

when to admit to a burn center

partial thickness >10% TBSA, burns involving major body parts/regions, third degree, electrical, chemical and inhalation burns, burns with pre-existing conditions, etc

mechanisms of thermal injury

flame, scald, hot objects, electrical, chemical, friction, radiation, inhalation

patients who sustain burns over 15-20% of TBSA

risk circulatory abnormalities including burn shock

75% of burn injuries

happen in or around the home

flame/flash burns

44% burn admissions, inhalation, intense burns will destroy, absence of blister bc of fluid evaporation

scald burns

result of contract with hot liquids - extent depends on temp and viscosity of liquid and duration of exposure (grease is worse than water - more viscous)

most common etiologies of burn injury are

flames and scalds together (78.5)

children can burn in temps as low as

130 degrees if exposed for long enough (set water heater temp in home to max at 120)

electrical burns

severity depends on voltage, type of current, pathway traveled through the body, resistance, and muscle trauma

3 components of electrical burns

source site, current arching from source to ground, flame injury from ignition (if present)

with electrical burns, there will typically be a visible

entry and exit wounds - local wounds may need debridement and a graft/flap

internal burns sometimes requires

fasciotomy because the muscle swells outward in response to heat

chemical injuries can be caused by

chemicals, household solutions, automotive cleaning/polishing chemicals (acid, alkaline, organic)

treatment for chemical injuries is

irrigation/lavage for 20min for acids and 30-45min for alkaline burns

radiation burns

Occur from the absorption of radiation into the body - usually manifests within 6 weeks after radiation exposure

frostbite

causes freezing of the tissue - forming ice crystals and damage to blood vessels resulting in arterial insufficiency

if theres any chance the areas of frostbite area freeze again

dont thaw them

treatment frostbite

TPA, hyperbaric oxygen (pain management, no ambulation of frostbitten feet)

assessment priorities of burns - ABCC

airway stabilization, breathing/support of ventilation, circulation/volume resuscitation, circulation/escharotomy/fasciotomy

partial thickness wounds will

heal independently unless infection is present - may need to use topical local antiseptics/antibiotics

treat burns wounds with

nonadherent dressings for improved pain management and less risk of trauma with dressings

enzymatic debridement for wounds

silvadene (NPTE), collagenases is most common

good topical antimicrobials for burns

silver sulfadiazine, fulamylon, bactroban, xeroform, polysporin, silver dressings

skin grafts

autografts preferred - typically taken from back or anterior thigh, scalp is used for facial to maintain tissue color

split thickness grafts

epidermis and part of dermis - donor site becomes a new wound

full thickness grafts

epidermis and entire dermis

full thickness grafts are preferred in areas where

significant scarring/contracture could occur leading to aesthetic or functional consequences

if a graft takes longer than two to three weeks to heal

more likely to have hypertrophic scarring

role of PT for burn wounds

early/continued attention to positioning of burned, management/prevention of joint/soft tissue contractures, improved functional mobility

hold ROM to grafted areas

for 5-7 days after autograft

position of comfort is

position of contracture

neck positioning

use of pillows be avoided, in neutral or slight hyperextension, lateral flexion contractures occur with asymmetrical burns to the neck

trunk positioning

foam wedges/blanket rolls can be used to prevent scoliosis, anterior chest burn add rolled sheet along the length of the spine to reduce protraction of shoulder, straight postural alignment

shoulder positioning

axillary burns 90 degrees abduction and 15-20deg horizontal adduction, want to reach 125deg for good functional outcome shoulder, in sitting use a lap tray for proper positioning

elbow positioning

full extension with supination or neutral and intrinsic plus position

hip positioning

hips in neutral with slight abduction, risk of frog position/fibular nerve palsy, if tolerated position pt in prone to stretch hip flexors

knee positioning

full extension

ankle/foot positioning

neutral ankle/toes, splints to prevent plantar flexion contractures

splints are typically applied in

endg ranges and adjusted as gains are made - can be applied after grafting through reconstruction phase of healing

hypertrophic scarring three R's

red, raised, rigid (NOT a keloid)

treatment of hypertrophic scars

compression garments - 23 hours/day for 12 to 18 months