Week 4: Burns and Scar Management

Guiding Question: What are the different types of burns?

Thermal, chemical, radiation, electrical

Guiding Question: What are the different types of thermal burns?

Flame, scald, contact, frostbite (i.e., thermal burns include hot AND cold burns)

When it comes to chemical burns, what is the MOI? Which is more severe: strong acids OR strong bases?

MOI: denature skin proteins

Bases are MORE severe (acids create eschar, while bases liquefy tissue)

What is the initial management for a chemical burn?

Remove chemical (duh) --> irrigate w/ COOL water

Which type of burn is common in cancer treatment, with high doses likely to cause permanent damage?

Radiation burns

T/F: there are limited treatment options for radiation burnts, because you can't impede radiation therapy by having stuff in or over the wound

true

Guiding Question: Which of the burn types is potentially the most devastating and why?

Electrical - can affect underlying organs (electrons generate heat, esp. in high-resistance tissues (bone > skin > muscle > blood vessels)

What may an electrical burn result in?

Tetany, fractures, muscle damage --> compartment syndrome, rhabdomyolysis (then myoglobinuria --> renal failure), and hyperkalemia (then cardiac arrhythmias)

True or false: standard burn size estimation is applicable to electrical burns

FALSE!! A patient can have INTERNAL wounds!!

Guiding Question: What are each of the four burn depths?

Superficial (1st degree)

partial thickness (2nd degrees): superficial & deep

full thickness (3rd degree)

Guiding Question: Can you describe the features of each of the burn depths, noting their appearance, blanching, and sensation? What are the typical healing time frames? Which depths carry a risk for scarring and contracture - why?

See below!!

Describe the appearance of a superficial (1st degree) burn.

pink or red, ERYTHEMA

do superficial (1st degree burns) have blanching?

yes

describe the sensation and healing time for superficial (1st degree)

sensation intact and painful, healing time is 3-4 days

is there a risk for scarring and contracture with superficial (1st degree) burns

no

Describe the appearance of a superficial (2st degree) partial thickness burn.

extends to top layer of dermis, pink or red,

is there blanching present in a superficial 2nd degree partial thickness burn

yes

describe the sensation and healing time for superficial (2md degree) partial thickness burn

sensation is intact and painful, healing time is 1-3 weeks

describe the risk of scarring for a superficial (2nd degree) partial thickness burn

low

Describe the appearance of a deep (2nd degree) partial thickness burn.

extends deeper into dermis, marbled/mottled

is there blanching in a deep (2nd degree) partial thickness burn?

no

describe the sensation and healing time for deep (2nd degree) partial thickness burns

sensation is absent/diminished and healing time is 3-9 weeks

describe the risk of scarring and contracture for eep (2nd degree) partial thickness burns

moderate to high

Describe the appearance of a full thickness (3rd degree) burn.

varied, can be white, red, brown/black "leathery"

is there blanching in a full thickenss (3rd degree) burn?

no

describe the sensation and healing time for a full thickenss (3rd degree) burn

sensation is absent and healing time is variable - weeks to months

t/f: risk of scarring and contracture is high in full thickness (3rd degree) burns

true

Guiding Question: What are the referral criteria for a burn center?

Specifically thermal and chemical burns.

IMMEDIATE consultation w/ consideration for transfer:

- full thickness (3rd degree)

- partial thickness (2nd degree) >10% TBSA

- any deep partial or full thickness burns involving the face, hands, genitalia, feet, perineum, or over any joints

- patients w/ burns and other comorbidities (ex: immunocompromised)

- patients w/ concomitant traumatic injuries

- poorly controlled pain

Consultation recommended:

- partial thickness burns <10% TBSA

- all potentially deep burns of any size

Guiding Question: What are the referral criteria for a burn center?

Specifically inhalation injury.

IMMEDIATE consultation w/ consideration for transfer:

- ALL patients w/ suspected inhalation injury

Consultation recommended:

- patients w/ signs of potential inhalation such as facial flash burns, signed facial hairs, or smoke exposure

Guiding Question: What are the referral criteria for a burn center?

Specifically pediatrics <14 years or <30 kg.

IMMEDIATE consultation w/ consideration for transfer:

for all pediatric burns

Guiding Question: What are the referral criteria for a burn center?

Specifically electrical injuries.

IMMEDIATE consultation w/ consideration for transfer:

- ALL high voltage (>1000V) electrical injuries

- Lightning injury

Consultation recommended:

- Low voltage (<1000V) electrical injuries (consultation & consideration for follow-up in a burn center to screen for delayed symptom onset and vision problems)

Guiding Question: What are the three zones of injury? Which area is the most affected? Which area is the least affected? What differences exist between the three areas?

Three zones: zone of coagulation, zone of stasis, zone of hyperemia

Area MOST affected = zone of coagulation

Area LEAST affected = zone of hyperemia

See below for differences!!

______: zone of burn injury; experiences irreversible damage and requires immediate mechanical or operative debridement

Zone of Coagulation (i.e., the center - experiences the MOST damage)

______: zone of burn injury; experiences potentially reversible damage w/ early intervention (i.e., early intravascular resuscitation, infection prevention, debridement, nutrition optimization, and body temperature stabilization)

Zone of Stasis

______: zone of burn injury; experiences NO DIRECT INJURY but presents as adjacent inflamed tissue

Zone of Hyperemia

Guiding Question: Can you calculate the rule of 9's based on a patient case scenario?

We sure can try ;)

A 68 y/o male patient has superficial and deep partial thickness burns to the front and back of the right and leg leg, front of right arm, and anterior trunk. Using the Rule of 9's, calculate the total BSA % that is burned.

a. 40.5%

b. 49.5%

c. 58.5%

d. 67.5%

58.5% (right and left leg = 36% + FRONT of right arm = 4.5% + anterior trunk = 18)

List the initial medical assessment of burns.

1. Immediate classification

2. ABC's of trauma: airway, breathing, circulation

3. Check respiratory and circulatory systems

4. Palpation

what are the important nutrition needs for burn patients

hypermetabolic state in large burns, protein supplementation CRITICAL, fluid resuscitation

T/F: goal for pain control is pain relief w/o sedation to allow comfortable participation in dressing change AND rehab

true

what are the 3 pain aspects to focus on for pain control

breakthrough, background, procedural pain

how is infection risk managed

w/ debridement, skin grafting, and topical antimicrobials

how are burns surgically managed

as needed (full thickness and deep partial) to remove non-viable tissue, restore a barrier asap, restore aesthetics, and prevent/reduce scarring

What is the GOLD standard for surgical management of burns?

Skin grafts (split-thickness or full thickness)

Guiding Question: What is the most appropriate treatment for each burn depth?

See below!!

Describe the treatment for superficial burns.

Initial treatment w/ cool compress for relief, topical moisturizing lotions (treats "peeling"), aloe vera (cooling and analgesic effects)

T/F: ice packs, while they may provide relief, can actually cause burn wounds to convert to deeper injuries!!

true

Describe the treatment for superficial partial thickness burns: __________ & remove all serous blisters (use caution w/ hemorrhagic blisters, as they may indicate deeper injury), use _____ _____ _____ _____, incorporate _____ wound healing, apply compression w/ figure-8 _____-_____ wrapping

Examples: silver based cream or gel antimicrobial, impregnated gauze, etc.

debride, serous, standard wound bed prep, moist, short-stretch

Describe the treatment for deep partial thickness burns: If they do NOT demonstrate signs of re-epithelialization within ______ they are best treated w/ ________ ____________ ____ _____ _______ w/ _____ wound healing - donor site (autologous)

3 weeks, surgical debridement and skin grafting, moist

Describe the treatment for full thickness burns.

Surgical debridement and skin grafting IS necessary w/ moist wound healing - donor site (autologous)

Guiding Question: Which two burn depths are most prone to scarring and contracture? Why?

Deep partial thickness = reticular dermis contains skin appendages, so injury to this area can cause permanent damage to hair follicles and sebaceous glands. Damage also occurs to the fibroblast population --> delayed healing and a mix of contraction and epithelialization --> extended periods of inflammation and subsequent hypertrophic scarring and wound contracture.

Full thickness burns = NO POSSIBILITY OF HEALING FROM WOUND BASE since all dermal regenerative cells have been obliterated. Tissue is nonviable and shrinks or contracts, and so it requires early excision of necrotic tissue and grafting procedures --> scarring and contracture.

What is the purpose of splinting in early rehab management of a burn?

Prevent wound contractures, protect skin grafts, maintain appropriate joint position & functional limitations

Guiding Question: Can you describe the optimal joint positions for splinting?

Open-packed position and stretch:

- shoulder AB + ER

- elbow extension + supination

- functional position of the hand

- neutral trunk/lumbar

- hip ABD + ext + neutral rotation

- knee extension

- ankle DF

Guiding Question: What preventative considerations are of primary importance to reduce negative functional outcomes for patients who have sustained burn injuries?

Nutrition (catabolism of muscle), fluid balance (loss of epidermis and fluids through evaporation), skin grafts, psychology, pain control and itching

When can PT begin s/p burn?

Once the patient is cleared & hemodynamically stable

What are implications for movement dysfunction s/p burn?

Inflammation (pain and edema), wound contraction, scar formation, cardiopulmonary/aerobic condition compromise

List principles of burn rehab "highlights."

Infection control, prevention of deformity, max recovery of function, scar mgmt., patient education

What are considerations to prevent loss of function related to hypertrophic scarring?

ROM/mobility, sensory integrity, integumentary integrity, diminished sensation, pain, pruritic (itchy)

How do we promote mgmt. to prevent loss of function due to hypertrophic scarring?

Exercise and stretching, silicone gel, compression therapy, drugs