Burns - Part 2

acute phase wound care management

1) debridement of necrotic tissue

(soap and water kerlex scrub vs surgical debridement)

- remove slough, prior dressings and topical meds daily!

2) pain management

- significant & multiple forms

(ex. IV, nerve block, pain patch, AND oral)

3) grafts

full/subdermal--> 2-5 days

deep partial--> 1-3+ weeks

PT ASSESSMENT (ACUTE CARE)--> check sites for edges not attaching, hematomas, excessive fluid leakage/drainage

dermatome

instrument used to cut skin in thin slices for skin grafts

*shaves into papillary dermis layer

temporary biologic dressing

What is a "negative" to using cadaver skin?

split thickness skin graft (STSG)

a skin graft that consists of the epidermis and a portion of the papillary dermis

*mesh type

**thinner

thinner

Is there more contraction with thicker or thinner grafts?

broader coverage (and less likely for hematoma)

What is an advantage of "meshing" the skin graft?

mesh graft

STSG

*altered to create a mesh-like pattern to cover larger surface area

PROS:

- 1:3 ratio original size to coverage area

- donor site graft may be used repeatedly (as soon as healed)

- xeno/cadaver grafts can go on top

CONS:

- allografts must be type/crossed

- permanent waffle scarring w/mesh

- CONTRACTURE RISK INCREASED

(shallow, pliable = skin tightness more)

unmeshed graft

full thickness skin graft (FTSG) and some STSG

PROS:

- primary use: deep burn depth compromised vascular, COSMETIC AREA

- minimal shrinkage

CONS:

- provides less coverage

- requires more extensive surgery

PT post-grafting

1) resume ROM to graft area 2-5 days after

2) dangle EOB as early as 1-2 days post-graft

(pending graft status and PHYSICIAN CLEARANCE)

3) positioning

4) splinting

PT focus acute care

1) ROM

GOAL: prevent joint stiffness/contracture formation/hypertrophic scarring

- AVOID AGGRESSIVE PROM during first 3+ weeks

- hold ROM at graft site for first 2+ days post graft

- light AROM preferred!!

- promote venous return

- positioning to prevent contractures (SEE IMAGE)

2) monitor vital signs & check lab values

- renal function

- watch for AMS

3) facilitate lung expansion

4) maintain strength in unaffected limbs

5) regular inspection of wounds/grafts

6) functional mobility

- ADLs--> functional tasks

- slowly increase resistance exercises

7) provide HEP for d/c

as soon as possible (given graft adherence and dressings)

How soon after a graft can you begin working on ambulation?

80

A scar is at ____% of its original strength at 3 months post-injury/burn.

hypertrophic scars

SCAR TYPE

remain confined to border of original wound

*of patients with severe burns, half to two-thirds develop this

**arise in any location; commonly occur on extensor surfaces of joints

ELEVATED RISK DUE TO:

- prolonged healing

- infection

- race/age

- location of wound

*regress with time; flatten spontaneously

**more common in children

***related to TENSION

keloids

SCAR TYPE

extend beyond border of original wound

*commonly occur on the sternal skin, shoulders and upper arms, earlobes, and cheeks

- thick collagen

- remain elevated more than 4 mm

- more common in darker skin types

*GENETIC FACTOR

**teens to 30s

***no etiology

***females > males

pressure garments

used to prevent scarring from moderate to severe burns

*limits collagen synthesis (limits blood, O2, nutrients to scar) by distributing pressure more

**encourages collagen realignment

WORN 23 HRS/DAY

rehabilitation phase

final phase of burn care

*often overlaps with acute care phase and ends once returning to life functions

(work/school/community reintegration)

FOCUS--> gain independence & achieve maximal functional recovery

outpatient rehab PT assessment

SUBJECTIVE

- what surgeries? when?

- subcutaneous tissue damage?

- activity level at discharge?

- ROM tolerated at discharge, any limitations, any MD restrictions?

- current wound care management?

WOUND CARE

- dressings & topical antibiotics

- moisturizing lotion (ex. Eucerin)

- scar massage

(begin 3 weeks post-injury)

*3-4x day

*motion = circular, horizontal, vertical, and pinch & roll

- pressure garments

(6 weeks to 3 months post-injury)

MODALITIES GENERALLY NOT RECOMMENDED

(except use of hydrotherapy with wound cleansing)

circulation, edema, necrotic tissue

Wound healing is affected by what 3 things?

scar massage purposes

1) promotes collagen remodeling

2) decrease itching/pain

3) desensitizes

4) aids tissue pliability

5) helps reduce risk of hypertrophic development

cosmesis

surgical correction of a disfiguring defect

*usually 6 months post-burn or later [reconstruction phase]

OPTIONS:

- excision

(remove eschar)

- z-plasty

(to reorient scar)

- release

(skin opened for contractures and then closed with graft)

- rotation flap

(mobilize large tissue area)

- free-flap

(tissue excised and reattached elsewhere)

- tissue expander

(balloon used to stretch skin to cover area)

NEW TECH = laser treatment

surgery issues

1) waiting for wound closure

2) timing of plastics consult

3) who is ideal candidate?

4) comprehensive planning up front

5) psycho-social aspect