Chapter 5

Outline the events of the cellular response of inflammation in the correct chronological order.

1. chemotaxis 2. margination 3. emigration (diapedesis) 4. phagocytosis and subsequent release of lysosomal enzymes

Identify the four cardinal signs of an inflammatory response and the cause of each.

1. redness due to vasodilation in the injured area and warmth due to hyperemia or increased blood flow to the area 2. swelling or edema due to the shift of protein and fluid into the interstitial space 3. pain resulting from increased fluid pressure on nerve endings and the irritation caused by chemical mediators 4. loss of function if cells lack nutrients or if swelling interferes with joint movement

Chronic Inflammation Treatment

Acetaminophen, NSAIDs, and ACTH, exercise, physiotherapy, and pain modification

Acute Inflammation Treatment

Acetaminophen, glucocorticoids and NSAIDs, RICE, (rest, ice, compression, elevation)

How do the drugs that the injured individual is taking?

Anticlotting medications would limit or impair clotting and hence wound closure; e.g., aspirin and other anti-platelet drugs prior to surgery

How does the degree of immobilization of the injured tissue complicate or delay healing?

Broken bones, if not immobilized, do not heal properly

Chronic Inflammation Signs and Symptoms

Delayed and prolonged over a significant period of time. May be intermittent. Severity varies depending on the cause and pathophysiology and duration

Acute Inflammation Causative Agents

Direct damage (trauma) Chemicals Ischemia Cell necrosis or infarction Allergic reactions Physical agents (burns) Foreign bodies (splinters or dirt) Infection

How does pre-existing disease states that exist in the injured individual complicate or delay healing?

Disease, if chronic and with systemic effects, could impair immune and other normal healing tissue responses. Diabetes, for example, may result in impaired circulation to the damaged area.

List some of the actions that may be taken to aid in the prevention of infection in the healing of a burn.

Excision/removal of damaged tissue, antibiotics, covering of wound

List the systemic effects of inflammation identifying the reason that each of these manifestations occurs.

Fever due to the release of pyrogens by leukocytes and macrophages,; malaise, fatigue, headache, and anorexia.

How does the presence of foreign material in the wound complicate or delay healing?

Foreign bodies, if not removed, impair wound closure and promote scarring as well as predispose to infection; e.g., a large splinter.

Acute Inflammation Outcome

Healing unless it becomes chronic due to persistence of causative agent; regeneration or resolution

Identify additional nonpharmacologic interventions that could be used to treat inflammation, particularly conditions that are chronic, such as arthritis.

Heat, physiotherapy, adequate nutrition and hydration, mild to moderate exercise, elastic stockings to reduce fluid accumulation

How does the blood supply of the injured tissue complicate or delay healing?

If the blood supply is limited or cut off from the damaged tissue, then most of the cellular and blood factors necessary for healing would not reach the affected area; e.g., a thrombus or an embolus.

Acute Inflammation Signs and Symptoms

Immediate or occurring within a few hours (e.g., sunburn) Severity varies with the situation or cause

List some potential complications that may develop as a result of inflammation.

Infection in inflamed tissue, deep ulcers (from severe or prolonged inflammation), skeletal muscle spasms or strong muscle contractions, local complications such as tissue destruction and scarring, immobility due to pain or edema (edema compresses organs such as blood vessels and airways)

How does the presence of infections in the damaged tissue complicate or delay healing?

Infection requires its own cure, before healing can occur; removal of the infectious agent, if impaired or delayed, would prolong the healing process, leading to more extensive scarring and, if untreated, perhaps systemic infection. A puncture to the damaged tissue. Another example is a bite from a rabid animal.

What is inflammation, and what is its basic function? Identify some causes of inflammation.

Inflammation is the body's nonspecific response to injury that involves increased blood flow to the area to localize and remove an injurious agent. Inflammation can cause redness, swelling, warmth, and pain; loss of function is also possible. It may be caused by direct physical damage such as cuts or sprains, caustic chemicals such as acids or drain cleaners, ischemia or infarction, allergic reactions, extremes of heat or cold, foreign bodies such as splinters or glass, and infection.

How does the size and shape of the wound complicate or delay healing?

Large, deep cuts, for example, especially if untreated, or presenting difficult suture closure would facilitate extensive scar formation; e.g., cuts due to broken glass or power tools.

Identify potential complications that may occur during an inflammatory process and subsequent healing.

Loss of function; contractures and obstructions; adhesions; hypertrophic scar tissue; ulceration

Chronic Inflammation Cells Involved

Lymphocytes, macrophages, and fibroblasts

How does the nutritional status of the injured individual of the wound complicate or delay healing?

Malnutrition, especially deficiencies in vitamins such as C, E, and K, would impair the blood-clotting capability of the individual, impairing wound closure and delaying repair of damaged tissues

What is the body's first "line of defense"?

Mechanical barrier such as intact skin and mucous membrane

State five differences between non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids or steroidal anti-inflammatory drugs.

NSAIDs are analgesic and antipyretic. They may cause allergic reactions, slow blood clotting, and cause nausea and/or stomach ulceration. Steroids decrease immune responses and increase the risk of infection, high blood pressure, and edema. They may also cause osteoporosis and skeletal muscle wasting.

Identify differences between NSAIDs and acetaminophen.

NSAIDs are anti-inflammatory. They may cause allergic reactions and slow blood clotting. Acetaminophen has no anti-inflammatory action. High doses may cause kidney and liver damage.

Explain why full-thickness burns initially may be painless.

Nerves in the burned area have been destroyed

Acute Inflammation Cells Involved

Neutrophils and macrophages; lymphocytes if an immune response involved

How does the age of the individual complicate or delay healing?

Nutritional status is often inadquate in the elderly, and the aging process itself slows down normal healing responses at many levels.

Describe the classification of burns based on depth of tissue damage.

Partial-thickness burns involve the epidermis and part of the dermis; deep partial-thickness burns involve destruction of the epidermis and part of the dermis; full-thickness burns result in destruction of all skin layers and often underlying subcutaneous tissues as well

Define phagocytosis. Identify types of cells that are phagocytic and where these cells are located within the body.

Process by which neutrophils and macrophages engulf and destroy bacteria, cellular debris, or foreign material. Neutrophils and monocytes are circulating in the blood and enter the interstitial fluid when inflammation occurs. Macrophages are located (fixed) in tissues such as the alveoli, liver, and spleen).

Differentiate between the processes of resolution and regeneration. What factors determine which of these processes will occur following an injury?

Resolution occurs when there is minimal tissue damage, the damage is repaired, and cells recover and resume normal function in a short time. Regeneration is the healing process that occurs in tissues whose cells are capable of mitosis (e.g., epithelial cells of the skin, gastrointestinal tract). The damaged cells are replaced by the proliferation of nearby undamaged cells.

The acronym RICE is sometimes useful in remembering interventions that can be used to treat inflammation, particularly those caused by athletic injuries:

R—rest =Rest allows time for healing, minimizing further pain and irritation to the injured area I—ice =Early application of cold causes vasoconstriction, decreasing pain and edema C—compression =Compression to facilitate blood clotting, prevent or minimize excess fluid accumulation E—elevation =Elevation improves fluid flow away from the damaged area

Chronic Inflammation Outcome

Scarring and/or granuloma Tissue breakdown may occur with bleeding and loss of function

Identify the body's second and third "lines of defense."

Second: processes of phagocytosis and inflammation Third: the immune system response

Other than tissue destruction, what are complications that may arise from a burn?

Shock, respiratory problems, pain, infection

Which of the 3 lines of defense are specific? Explain what is meant by the term "specific defense mechanism."

The immune system is the specific defense mechanism of the body. It provides protection by stimulating a unique response following exposure to foreign substances.

Assessment of burn area using the rule of nines.

Total head - 9% Two arms - 18% Trunk - 36% Perineum - 1 % Two legs - 36%

Identify two main events of the "vascular response" that occur during an inflammatory response. Explain their function as part of the response and the direct effects of each event.

Transient vasoconstriction is followed by vasodilation, hyperemia, and increased capillary permeability in response to chemical mediator (e.g., histamine, serotonin, etc.) released at the site of injury. This allows for the accumulation in the area of fluid (to dilute any toxic substances) and specific plasma proteins such as globulins or antibodies (to react to specific antigens) and fibrinogen (to form a fibrin mesh to localize the problem).

Chronic Inflammation Causative Agents

When the cause persists and is not removed or eradicated

Ulcer

a surface lesion due to breakdown of surface tissue

Eschar

a thick coagulated crust that develops following a full-thickness burn

Adhesion

bands of scar tissue joining two surfaces that are normally separate

Eosinophils

elevated during allergic responses

Monocytes

elevated during chronic inflammation a source of macrophages phagocytic microorganism

Contracture

fixation and deformity of a joint as a result of scar formation and shrinkage

Keloid

hypertrophic scar formation due to excess collagen deposits leading to hard, often eleveated, ridges of scar tissue

How does the nature of the tissue/location of the wound complicate or delay healing?

inoperable bullet wound to the brain may be inaccessible without further tissue damage and loss of function

Exudates

interstitial fluid accumulation in an area of inflammation

B lymphocytes

involved in antibody production

T lymphocytes

involved in cell-mediated immunity

Stenosis

narrowing of structures

Macrophages

phagocytic microorganisms

Basophils

secrete histamine

Mast Cells

secrete histamine

Neutrophils

the first cells to emigrate to an injured area phagocytic microorganisms

Describe the classification of burns based on body surface area.

the percentage of body surface area (BSA) burned, using the "rule of nines" for calculation to determine extent of injury and fluid replacement needs