Rehab Unit 5 - Burns

Hot Liquids

What is the primary cause of burns in children between 1-5 years old?

Flammable Liquids

What is the primary cause of burns in adolescents and adults?

Men between 16-40 years old

Who is the highest incidence of burn injury in?

135

There has been a great growth of burn centers in the US and at present there are about _______ specialized burn centers.

- Smoke detectors

- Education

- Better fire Codes

What have decreased the number of incidence of burns?

1. Epidermis

2. Dermis

3. Hypodermis (fat and connective tissue)

What are the 3 layers of skin?

1. Make the body waterproof

2. Protect body from infection

3. Retain water and regulate heat

4. Protection for deeper tissues

5. Contains melanocytes for pigmentation of the epidermis

What are the functions of the epidermis (outermost layer)?

Ridges

The interface between the epidermis and the dermis has _______ that serve to increase the surface area between it and the dermis to help overcome friction that skin is exposed to.

There would be poor adherence of new epidermal tissue; thus healing from a burn or other trauma would be poor.

What would there be without the ridges between epidermis and dermis?

- Blood vessels

- Lymphatics

- Nerve endings

- Collagen elastic fibers

- Enclosures of the sweat and sebaceous glands and hair follicle appendages of the epidermis

What does the dermis (deepest layer) contain?

- Interwoven Parallel Collagen

- Elastic Fibers

The dermis is 20-30x thicker than the epidermis and is and is made primarily of ______ ______ ______ and ______ ______ which gives skin its tensile strength.

Parallel

Normally the collagen has a _______ orientation; however a scar formation is from collagen being in a random direction.

Edema

Destruction of vascular integrity results in _______.

Intravascular Fluid

______ _______ seeps out into the interstitial spaces leading to the edema.

True

T/F

Due to pain, the pt. tends to not want to move the part, thus there can be a greater amt. of fluid buildup in the area due to not having the muscle pump to assist fluids out.

- Fibrosis of joints

- Collagen can form adhesions that will decrease joint ROM

What can the immobility lead to?

1. Temperature to which the skin is exposed.

2. Length of time the skin is exposed to the heat.

What does the amount of skin destruction depend on?

- Superficial Burn

- Superficial Partial Thickness Burn

- Deep Partial Thickness Burn

- Full Thickness Burn

- Subdermal Burn

What are the burn classifications?

Superficial Burn

A ______ ______ is when there is damage only to the epidermis.

Sunburn

What is an example of a superficial burn?

- Red, erythematous

- May have slight edema, but NO blisters

- Tender to touch

- Surface of burn is dry

What is the clinical appearance of a superficial burn?

Desquamation (skin peels off) within 2-3 days.

What is the healing of superficial burns?

True

T/F

Skin with a superficial burn will heal on its own without scarring.

Superficial Partial-Thickness Burn

What is complete damage to the epidermis and some damage to the upper layers of the dermis (papillary layer of the dermis)?

- Blisters

- Bright red and moist once blisters are gone

- Blanching

- Extreme pain due to involvement of nerve endings in the dermis

- Moderate edema

What are the clinical appearances of a superficial partial-thickness burn?

If blisters are removed and an antibiotic ointment is applied to wound.

What do some authorities believe cause superficial partial-thickness burns to heal faster?

It is the body's self-defense mechanism and will keep the wound bathed in fluid to aid healing.

What do others think about the blisters with superficial partial-thickness burns?

Spontaneous Healing

What is the healing of superficial partial-thickness burns?

1. Gelatin-like exudate will peel off. This gelatin-like exudate is a coagulum of the topical antibiotic and serum that has seeped from the wound as a result of capillary destruction.

2. Re-epithelialization from migration from the periphery of the wound

3. Complete healing usually in 7-21 days (1-3 weeks)

4. Scarring is minimal

5. May have slight discoloration due to destruction of melanocytes.

What does the healing of superficial partial-thickness burns include?

Deep Partial-Thickness Burn

What is the destruction of epidermis and severe damage to the dermal layer (through the papillary layer and down into the reticular laver of the dermis) including most nerve ending, hair Follicles, and sweat glands?

1. Mixed red or waxy white color (the deeper the burn the whiter it will look)

2. Blanching will be decreased due to involvement of blood vessels

3. Marked edema

4. Pain because not all of the nerve endings have been destroyed (pt. will have deep pressure sensation, but decreased light touch or soft pin prick sensation)

5. Presence of hair follicles and new hair growth

6. Wet surface

What is the clinical appearance of deep partial-thickness burn?

Yes

Can deep partial-thickness burn heal spontaneously?

- Dry

- Scaly

How does the new tissue appear due to destruction of the sebaceous glands with a deep partial-thickness burn?

3-5 weeks

What is the healing time of deep partial-thickness burn if there is no infection?

Full-thickness Injury

What can a deep partial-thickness burn convert to if infected?

Hypertrophic and keloid scars

What do deep partial-thickness burn often lead to?

Full-Thickness Burn

What is the destruction of all the epidermis and dermis completely, and the subcutaneous fat layer may be involved also?

1. Eschar

2. No blanching due to total destruction of the vascular supply

3. Hair follicles destroyed so any hair left can be pulled out easily without pain

4. All nerve endings in the dermis are destroyed, thus the burn is anesthetic. However, the pt. can still experience pain in the areas of bum that are not full-thickness.

5. Significant edema due to complete vascular occlusion distal to the edema and eschar at the burn site.

What is the clinical appearance of full-thickness burn?

Escharotomy (incision of eschar)

What is sometimes performed to improve vascular supply with a full-thickness burn?

Blood Flow

The eschar does not stretch so that when edema is present, it causes constriction to the deep circulation, thus occluding _______ _______.

Check for distal pulses.

How do you check the success of an escharotomy?

Burn Center

Where are pts with full-thickness burn often managed because of potential complications?

Infection

What are patients with full-thickness burns more susceptible to due to no viable skin for re-epithelization?

Skin graft because there are no viable epithelial cells.

What is the healing for full-thickness burns?

Subdermal Burn

What is the complete destruction of all epidermis, dermis, and subcutaneous tissue?

- Muscle

- Bone

What else may be damaged with a subdermal burn?

Prolonged contact with a flame, hot liquid, or electricity.

What causes a subdermal burn?

Surgical management with grafting.

What will subdermal burns require?

Smaller

Electrical burn that have a _________ entrance will look like it is charred, depressed, yellow, and ischemic.

- Explosion

- Dry

An electrical burn with a larger exit wound looks as if there has been an ________ out of the tissue, and it will look _______.

- Arteries may spasm and cause further necrosis

- Cardiac arrhythmias may result

- May cause ventricular fibrillation or respiratory arrest which can lead to death

- May cause other organ failure

- May cause spinal cord damage, which is usually incomplete; vertebral fracture

What may occur with electrical burns?

Extent of Burned Area

What is described by the percentage of the total body surface are that has been burned?

Rule of Nines

What is the rule that divides the body surface area into segments that are approximately 9% of the total area?

- 4.5%

- 18%

Smaller areas are _______ and larger areas are _______.

27%

What percentage of the body was burned if the person sustained burns to the chest, abdomen, and right arm?

36%

What percentage of the body was burned if an adult is burned on the anterior trunk, right arm, and left arm?

- Infection

- Pulmonary Complications

- Metabolic Complications

- Cardiac Function and Circulatory Complications

- Heterotrophic Ossification

- Neuropathy

- Pathological Scars

What are the indirect impairments and complications of a burn injury?

Infection

What is the leading cause of death from burns along with organ system failure?

- Pseudomonas aeruginosa

- Staphyloccus aureus

What are the common virulent strains of infection?

Pseudomonas aeruginosa

What has a sweet, foul oder and greenish drainage?

Systemic Antibiotics

What are used for burn infections?

Topical Antibiotics

What are often used with burns?

- Inhalation injury

- Carbon monoxide poisoning

- Tracheal damage

- Upper airway obstruction

- Pulmonary edema

- Pneumonia

What are the pulmonary complications associated with burns?

Inhalation Injury

______ ______ is from smoke inhalation.

- Any facial burns

- Singed nasal hairs

- Harsh cough

- Hoarseness

- Abnormal breath sounds

- Respiratory distress

- Carbonaceous sputum and/or hypoxemia

What are the signs of inhalation injury?

Bronchoscopy

What is often performed to help diagnose pulmonary complications?

High Metabolic Requirements

What does the body have after a burn?

Nutrition

Because of the metabolic requirements for healing, it is essential to have adequate ________ for the production of the energy required for metabolism.

Protein

Make sure a dietitian is consulted after a burn because it is very important to have a high _______ content in the diet.

2°

Because of the metabolism and catabolism that is occurring during the healing process, the pt's core temperature may increase by up to ________, thus if a pt is in a room of normal temperature (approx. 72° F).

86° F

Increased metabolism as it will be perceived as cold; thus it is important to keep the room a little warmer, such as approximately ________ to lower the metabolic demands.

Cardiac Output

Initially, there is decreased ______ ______ due to fluids seeping out into the interstitial spaces.

Hetertropic Ossification

What is the presence of bone in soft tissue where bone normally does not exist?

True

T/F

Neuropathy can be local neuropathy or polyneuropathy.

- Too tight compression bandages

- Poor fitting splints

- Prolonged inappropriate positioning of pt

- Edema/eschar

What causes local neuropathy?

- Brachial plexus

- Ulnar nerve

- Common peroneal nerve

What does neuropathy commonly involve?

Polyneuropathy

______ has an unknown cause; however may be associated with infection.

Pathological Scars

_______ ________ occur in areas of deep partial thickness burns that are allowed to heal spontaneously and full-thickness burns that haven been skin grafted, but where graft coverage is incomplete.

Hypertrophic Scars

______ ______ is scar overgrowth that stays within the boundaries of a wound that is characteristically described as red, raised, and firm.

Contracture Scar

_______ _______ is a scar that contracts and limits movement that may or may not be hypertrophic or keloid.

Keloid Scars

______ ______ is overgrowth of large, firm scar tissue that develops around a wound that is more common in darkly pigmented patients.

Epithelial Cells

_____ _____ will migrate from the periphery of the wound toward the center and continue until they contact others, and when they make this contact they stop migrating.

True

T/F

Protection of new epithelial tissue is critical.

Epithelial Islands

_______ _______ may be present in the center of the wound from intact hair follicles and glands in the partial thickness burn.

Re-epithelialization

Epithelial islands produce ________, which migrate toward the periphery of the wound.

- Inflammatory

- Proliferative

- Maturation

What are the 3 phases of wound healing?

Inflammation

What is the primary reaction to begin healing that lasts for 3-5 days?

- Redness (erythema)

- Swelling (edema)

- Warmth (calor)

- Pain (dolor)

What are the characteristics of the inflammatory phase?

Fibrin

_______ begins laying down the framework so new cells can begin to build the new tissues.

- Vasoconstriction

- Vasodilation

Initially after the trauma, there is ________, then there is ________ to increase blood flow to the area to bring in 02, WBCs, and other nutrients to aid in healing.

Edema

Because of the increased permeability of the blood vessels, there is leakage of plasma into the interstitial space, thus _______ is formed.

- Leukocytes

- Macrophages

_______ and _______ infiltrate the area to begin phagocytizing the necrotic tissue and bacteria.

- Re-epithelialization

- Fibroblasts produce collagen

- Granulation tissue formation

- Wound contraction

What occurs in the proliferative phase?

Re-epithelialization

_______ is occurring at the surface of the wound as the epithelial cells migrate from the periphery toward the center of the wound to try to close the wound.

Scar

Fibroblasts produce collagen, which will form the ________.

Random

Collagen is being laid down in a _________ fashion instead of the parallel orientation, which is strongest and normal.

Apply stress which will assist the collagen in the more normal parallel orientation (ROM & stretching).

What is important during scar formation?

- Fibroblasts

- Blood vessels

What is granulation tissue made from?

Beefy Red

Healthy granulation tissue appears ______ _______, meaning it has good vascularization.

Hypertrophic Scarring

What can excessive granulation tissue lead to?