Other Systems: Burns

compare the depth of partial thickness burns and full thickness burns

1. partial thickness burns - enter the dermis but do not extend into the hypodermis; can be superficial partial thickness if in the top 1/2 of the dermis or deep partial thickness if in the lower portion of the dermis 2. full thickness burns extend into the hypodermis, and have burn all through the epidermis and dermis

compare long term effects of partial thickness and full thickness burns

1. partial thickness typically heal without residual effects in absence of infection or other exacerbating factors 2. full thickness: higher mortality rates for kids under 4 and over 65 yo; highly related to other comorbidities: cardiac, alcoholism, PVD, obesity; garments can be worn up to 2 years after injury, without complication, pt should achieve ind in a few month

what are the levels of burns?

1. superficial burn 2. superficial partial thickness 3. deep partial thickness 4. full thickness 5. subdermal burn

allograft (homograft)

A temporary skin graft taken from another human, usually a cadaver, in order to cover a large burned area

The rule of nines is not appropriate to assess which type of burn? superficial-partial thickness superficial deep-partial thickness full thickness

B The "rule of nines" is commonly utilized to assess the percentage of the body surface affected by partial thickness and full thickness burns. Each area of the body has a specific percentage allocated to it in order to approximate the total percentage of the body surface affected. A patient should be referred to a burn center if they have sustained a partial thickness burn to greater than 10% of their total body surface area or if any percentage of the total body surface area has sustained a full thickness burn.

Using the rule of nines, what percentage of the body is affected if there is a burn to the posterior trunk, posterior left lower extremity, and the entire left upper extremity? 31.5% 36.0% 40.5% 45.0%

B The rule of nines is a method used to approximate the percentage of the body affected by a burn. The posterior trunk constitutes 18% of the total body surface area, the posterior portion of the left lower extremity constitutes 9%, and the entire left upper extremity constitutes 9% (4.5% for each side). 18%+9%+9% = 36%

Which burn classification is most likely to result in hypertrophic and keloid scarring after the healing process is complete? superficial superficial partial-thickness deep partial-thickness full-thickness

C A deep partial-thickness burn involves complete destruction of the epidermis and the majority of the dermis. The involved area may appear discolored with broken blisters and edema. Healing occurs with hypertrophic scars and keloids. A full-thickness burn would not present with hypertrophic scars and keloids since this type of burn requires grafts for healing to take place.

T/F: PT is typically indicated for patients with superficial partial thickness burns

FALSE. for deep partial thickness and full thickness to prevent scarring and contracture

T/F: rule of nines is a reliable prognostic indicator for recovery from burns

FALSE. only comments on the extent of burns, not their severity. so it is not a tool for prognostics.

radiation burn

- DNA is altered in exposed tissues - complications include severe blisters, desquamation, non-healing wounds, tissue fibrosis, permanent discoloration, and new malignancies

third degree burns

- burns that destroy the entire thickness of the skin - either full thickness (into hypodermis) OR subdermal (past hypodermis into subdermal muscle, tendon, etc.

anticipated deformity with knee burn (best type of splint?)

- flexion - conforming splint, 3 point splint or air splint

anticipated deformity with hip burn (best type of splint?)

- flexion and adduction - splints: anterior hip spica and hip abduction splint

what are the adult values for the rule of 9s?

1. Head and neck = 9% 2. Anterior trunk = 18% 3. Posterior trunk = 18% 4. Bilateral anterior arm, forearm and hand = 9% 5. Bilateral posterior arm, forearm and hand = 9% 6. Genital region = 1% 7. Bilateral anterior leg and foot = 18% 8. Bilateral posterior leg and foot = 18%

what are the zones of injury?

1. Zone of Coagulation 2. Zone of Stasis 3. Zone of hyperemia

what would be the estimated % of burned skin if an adult patient sustained burns head and neck and anterior trunk and entire LUE? 18 8 36 45

C

Zone of stasis

area of less severe injury that possesses reversible damage and surrounds the zone of coagulation

povidone-iodine advantages and disadvantages

betadine advantages: - broad spectrum - anti-fungal - easily removed with water disadvantages: 3 - not effective against pseudomonas - may impair thyroid function - painful application

types of burns

thermal, chemical, electrical, radiation

What is the primary cause of burns in adolescents and adults? hot liquids electricity chemicals fire

A Contact with hot liquids is the primary cause of burns in adolescent and adults. Men and boys between the ages of 16 and 40 have the highest incidence of injury.

According to the rule of nines, what percentage of the total body surface area would be allocated to the posterior surface of the bilateral legs and feet? 9% 18% 27% 36%

B According to the rule of nines, an entire leg is 18% of the total body surface area. As a result, two (i.e., bilateral) posterior surfaces of the legs would also be 18%.

List the topical agents used for burn care (6)

1. silver sulfadiazine: anti-yeast 2. sliver nitrate 3. providone iodine: anti-fungal 4. mafenide acetate: 5. gentamicin 6. nitrofurazone: bacteriocidal

what would be the estimated % of burned skin if an adult patient sustained burns to anterior portion of each LE and genitals? 19 36 37 45

A

Zone of hyperemia

The area surrounding the zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage

split thickness graft

a skin graft that contains only a superficial layer of the dermis in addition to the epidermis

full thickness graft

a skin graft that contains the dermis and epidermis

heterograft (xenograft)

temporary skin graft taken from another species

thermal burn

- via conduction or convection - ex. hot liquid, fire or steam

mesh graft

A skin graft that is altered to create a mesh-like pattern in order to cover a larger surface area

Zone of coagulation

The area of the burn that received the most severe injury with irreversible cell damage

autograft

skin graft from a person's own body

first degree burns

- only epidermis is damaged - superficial, - Mild sunburn is an example

compare secondary impairments of partial thickness and full thickness burns

1. partial thickness - depends on the size, mechanism and location of burn b) deep partial thickness (not superficial) can also present with infection, hypertrophic scarring and contracture 2. full thickness - infection, hyptrophic scarring or keloids, contractures are the most common; other impairments include CVP, renal system, GI system, respiratory, and immune system; damage to these systems can cause metabolic disorders, acidosis, sepsis or dehydration

compare the appearance of full thickness burns and partial thickness burns

1. partial thickness burns a) superficial partial thickness: red, BLANCHABLE (cap refill intact, no damage to deeper blood vessels), blisters present, b) deep partial thickness: red, but NOT blanchable (no cap refill + damage to vessels), can use scar tissue or grafting 2. full thickness burns: variable colors (deep red, black or white); eschar forms, edema present **during initial stage, pt will experience thermoregulation impairment, SOB, electrolyte disturbances, poor urine output and varying level of consciousness

compare medical management for partial thickness vs. full thickness burns

1. partial thickness: a) superficial partial thickness: pt is ability to maintain hemodynamic stability as the dermis is not fully destroyed; healing through re-epithelization in 5-21 days; goal is to keep wound bed moist, PT follow up typically not required b) deep partial thickness: healing via scar tissue formation, may require grafting; PT follow up may be req'd to prevent hypertrophic and keloid scarring or if burns involve joints 2. full thickness: pt must first be medically stabilized, typically autograft is req'd; PT intervention starts after grafting

When using the rule of nines for a young child, which part of the body makes up a larger percentage as compared to an adult? head and neck trunk upper extremity lower extremity

A According to the rule of nines, 36% of the body is made up of the trunk, 18% for each lower extremity, 9% for each upper extremity, 9% for the head and neck, and 1% for the genitals. When using this method for a child, the head and neck make up 18% of the body and the lower extremities each make up 14%.

Which burn classification would most likely affect the pH of systemic tissue? chemical burn electrical burn flash burn scald burn

A Chemical burns can significantly alter systemic tissue pH and metabolism. These changes can create potentially serious pulmonary and metabolic complications. The severity of the complications is heavily influenced by the concentration of the chemical, duration of contact, and mechanism of action.

According to the rule of nines which body segment would occupy the greatest percentage of the total body surface area? anterior trunk arm head posterior leg

A The rule of nines allows for a gross approximation of the percentage of the body affected by a burn. The anterior trunk represents approximately 18% of the total body surface area. The rule of nines does not account for severity.

Which of the following is a skin graft that has a waffle appearance and stretches over a large wound area? mesh graft full-thickness skin graft sheet graft lamellar graft

A A mesh graft is a type of split-thickness graft in which many tiny splits have been made in the skin to allow it to be stretched over a larger area which gives it a waffle-like appearance. Mesh grafts are indicated for infected wounds or wounds with irregular contours.

what is the rule of nines?

quick way to determine how much of the skin's surface has been burned

thumb spica splint

stabilizes and supports CMC joint, IP joint free, includes wrist

silver sulfadiazine advantages and disadvantages

- Silvadene advantages: 5 - used with or without dressing - painless - applied directly to wound - broad use - effective against yeast disadvantages: 1 - does NOT penetrate eschar

superficial burn

- a burn that involves only the epidermis, the outer layer of the skin; area may be red with slight edema - healing within 2-5 days without scarring

full-thickness burn

- complete destruction of epidermis and dermis; and partial damage to the hypodermis - typically presents with eschar formation and minimal pain (bc all the nerve endings are gone) - require grafts and are susceptible to infection - healing time varies from weeks to months

subdermal burn

- complete destruction of epidermis, dermis and subcutaneous, consequently can involve muscle and bone - typically require multiple surgical interventions and extensive healing time

deep partial thickness

- complete destruction of the epidermis and the majority of the dermis. - skin is discolored with broken blisters and edema. only moderate levels of pain d/t damage to nerve endings - healing within 21-35 days with potential for hypertrophic scars and keloids

what is PT management for burns?

- edema management - splinting and positioning - scar mobilization techniques - massage - ROM - stretching - dressing manangement - wound care - monitoring elastic garment use - functional mobility training full thickness: - pulmonary exercises - positioning - immobilization for first 3-5 days - early mobility to decrease complications like atelectasis, pneumonia or contracture

anticipated deformity with elbow burn (best type of splint?)

- flexion and pronation - gutter splint, conforming splint, 3-point splint, air splint

what are the child values for the rule fo 9s?

- for a child less than 1 yo: LEs = 27% and head + neck = 18% - for each year of life, 1% is distributed (evenly) to the LEs until 9yo, when they are considered proportional to an adult When using this method for a child, the head and neck make up 18% of the body and the lower extremities each make up 14%.

what is the approximate % of the hands, feet, and neck, based on the rule of nines?

- hands, feet or neck are each 2-3% (front and back)

anticipated deformity with anterior neck burn (best type of splint?)

- into a flexed position, possibly lateral flexion - splint: soft collar, molded collar, Philadelphia collar

superficial partial thickness burn

- involves the epidermis and the upper part of the dermis - involved area is very painful with blisters - healing in 5-21 days with min to no scarring

anticipated deformity with ankle burn (best type of splint?)

- plantarflexion - splint: posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splint

chemical burn

- rxn will continue until chemical is diluted - compounds include sulfuric acid, lye, hydrocholoric acid, and gasoline

anticipated deformity with anterior chest and axilla burn (best type of splint?)

- shoulder adduction, extension and IR - axillary or airplane splint, shoulder abduction brace

electrical burn

- typically has an entrance and exit wound - complications include cardiac arrhythmias, respiratory arrest, renal failure, neurological damage and fractures

anticipated deformity with hand and wrist burn (best type of splint?)

- wrist: flexion - MCP: extension or hyperextension - IP: flexion - thumb: fleixon and adduction - wrist splint, thumb spica splint, palmar or dorsal extension splint

According to the rule of nines, what percentage of the body would be affected by burns covering the anterior surface of the arms and legs bilaterally? 18.0% 22.5% 27.0% 36.0%

According to the rule of nines, each arm is approximately 9% of the total body surface area and each leg is 18%. Therefore the bilateral, anterior surfaces of all four extremities would represent 27.0% of the total body surface area.

A burn that presents with significant pain and blistering is most likely to be classified as a: superficial burn superficial partial-thickness burn deep partial-thickness burn full thickness burn

B A superficial partial-thickness burn involves the epidermis and the upper portion of the dermis. The involved area may be extremely painful and exhibit blisters. Healing occurs with minimal to no scarring in 5-21 days.

Which classification of burn could potentially cause ventricular fibrillation? chemical burn electrical burn flash burn scald burns

B Electrical burns are caused by exposure to low or high voltage current and usually exhibit an entrance and exit wound. Alterations in the electrical activity of the heart caused by an electrical burn most often include ventricular fibrillation, systole or sinus tachycardia.

A burn that blanches and exhibits brisk capillary refill would most likely be classified as: epidermal superficial partial-thickness deep partial-thickness full-thickness

B Superficial partial-thickness burns are typically pink or red in color. They present with an inflamed dermis that is erythematous with blanching and brisk capillary refill.

Which of the following types of burns would be the least painful? superficial superficial partial-thickness deep partial-thickness full-thickness

D A full-thickness burn would be the least painful due to the destruction of the sensory nerves. Hypertrophic scarring and wound contractures are likely to develop without preventative measures at this level.

According to the rule of nines, a burn affecting the posterior trunk and posterior left arm, forearm and hand, would constitute what percentage of the total body surface area? 9% 13.5% 18% 22.5%

D Correct Answer: 22.5% The posterior trunk constitutes 18% of the total body surface area. The posterior surface of one arm, forearm and hand constitutes 4.5%.

silver nitrate advantages and disadvantages

advantages: 3 - broad use - non-allergenic - painless application disadvangtages: - poor penetration - discolors skin and wound, making assessment difficult - can cause severe electrolyte imbalance - removal of dressing is painful

pseudomonas

The most common organism in burn-related infections.

mafenide acetate advantages and disadvantages

advantages: 3 - broad spectrum - penetrates burn eschar - may be used with or without occlusive dressing disadvantatges: 4 - may cause metabolic acidosis - may compromise respiratory fxn - may inhibit epitheliazation - painful application

escharotomy

a surgical procedure that removes eschar from a burn site & subsequently enhances circulation, and relieve interstitial edema

Z plasty

a surgical procedure to eliminate a scar contracture, an incision in the shape of a z allows the contracture to change configuration and lengthen the scar

gentamicin advantages and disadvantages

advantages: - broad spectrum - may be covered or left open disadvantages: - has caused resistant strains - ototoxic (damaging to the ear/hearing) - nephrotoxic

Nitrofurazone (furacin) advantages and disadvantages

advantages: 2 - bacteriocidal - broad-spectrum disadvantages: 2 - can lead to overgrowth of fungus and pseudomonas - painful application

type of burn that may produce respiratory arrest or renal failure

electrical

second degree burns

epidermis and upper dermis are damaged, skin is red with blisters - aka superficial partial thickness