Wounds and Burns
What signifies successful wound healing?
*Granulation tissue* that helps fill the defect and the new vascularization that delivers nutrients and oxygen to the new cells
Resuscitation of burn victims: __ hours, fluid choice should be ____, fluid resuscitation paramount bc edema formation due to leaky capillaries. Burn shock occurs when a burn covers more than __TBSA causing total body edema.
-24-28 -isotonic crystalloid -15-20%
How long does it take a first degree burn to heal? scar? increased risk of___
-3-5 days as epidermis peels off -no scar -skin cancer
Protein synthesis: Synthesis and deposition of proteins and wound contraction begins to occur ____ days after initial injury ___constitutes more than 50% of the protein in scar tissue synthesis continues at a maximal rate 2 to 4 weeks then slows ___ is not synthesized in response to injury and its absence contributes to the increased stiffness and decreased elasticity of scar when compared with normal dermis
-4 to 5 -Collagen -Elastin
When is a scar fully matured? How long does remodeling continue for? When does tensile strength of a scar peak?
-After 1 year -the life of the wound -afetr 1 yr
What is the result of hemostasis? What does this do?
-Clot Formation -prevents further fluid and electrolyte loss from the wound site and limits contamination from the outside environment
TBSA and depth: used to calculate the patient's fluid and nutritional needs. Its usually done in the ___ and determines wheteher there is need for a transfer to a burn unit. Burn depth dictates ____
-ED -local and surgical treatment of b urn wounds
What make up most of clean wounds? what does this mean?
-Elective surgery incisions -No break in aseptic technique, and the surgeon does not enter the oropharyngeal, respiratory, alimentary or genitourinary tracts Made under sterile conditions and not predisposed to infection
First degree burns are also known as what? What happens to dermal capillaries? Limited physiologic effects.
-Epidermal burns (involve only epidermis) -dermal capillaries dilate causing a red, painful area that blanches
Third degree burns are also known as what? How many layers of skin are destroyed? Dry, avascular coagulum covers deeper layers Insensat- AKA NO PAIN Variable wound surface color ¡Waxy white- _____burns ¡Black and charred- ___ injury Dermal proteins coagulate ¡Contract like tourniquet on extremities
-Full thickness burns -all of them -chemical -flame
Proliferation: Damaged tissue replaced with scar tissue Collagen is produced in the wound (fibroblasts) Collagen defects with certain deficiencies Less edema/ inflammation Granulation tissue is characteristic _____ helps fill the defect and the new vascularization that delivers nutrients and oxygen to the new cells. (This signifies successful wound healing) There will be less granulation tissue in a small defect than a large one. Skin sutured together will have a smaller defect to heal than if allowed to close on its own
-Granulation tissue
What is characterized by erythema, edema, heat and pain? At the tissue level it is characterized by increased vascular ___ and the migration of ___ into the extravascular space
-Inflammation -permeability -leukocytes
What are the main cells that are involved in inflammation in the first 48 hours? What do they do? Substrates for collagen fiber synthesis are organized About 4 days in primary wound healing
-Macrophages and PMNs -monocytes migrate into wound and macrophages secrete growth factor
Secondary intention: may be necessary why? Healing isuualy more complicated and prolonged. Excessive granulation tissue may build up and require treatment if it protrudes above the surface of the wound, preventing ____ Granulation tissue in ___ may also need debridement
-May be necessary due to infection, excessive trauma, tissue loss or imprecise approximation of tissue -epithelialization -stomas
When does a tertiary intention occur? What is this also known as? What type of wounds are these normally done for?
-When two surfaces of granulation tissue are brought together -delayed primary closure -contaminated, dirty, infected, traumatic wounds
How are secondary intention wounds treated? What occurs in wounds left to heal by secondary intention?
-Wound is left open and allowed to heal spontaneously\-Contraction occurs by centripetal force from the margins of the wound
Physiologic responses to burns: fall in ___, increased _____, progressive ___ in CO and SV, early compensatory mechanism of circulatory reflexes to restore nterm-100ormal vascular function.
-arteral pressure -pulse rate -decrease
What determines the type of wound closure?
-based on time of epithelia coverage -primary intention, secondary itnenion, territory intention/delayed primary closure
Tangential excision of eschar: layered, sequential think skin slices removed w/ __ until viable tissue is discovered, requires skill, SIGNIFICANT BLEEDING, 2 pros?
-dermatome -superior cosmetic and functional results, salvage dermal elements in deep burns
Partial-thickness burns: deep damage: ___ texture from coagulation necrosis of upper dermis. ___ absent. Color varies, usually waxy ___. ___ painful then superficial. Dmaged dermis replaced by sir tissue if often rigid, tender, friable. Excess damaged tissue and skin graft. __ weeks to heel. __- scars
-dry, leathery -eryhtma -white -less -3+ =hypertrophic
Partial-thickness burns: superficial damage: ___ is a thick coating of dead tissues,, coagulated serum, and debris. If circumferential it can cause vascular compromise. Eschar sepeaterd in ___days. Skin ___ develop w/in the surface and gradually spread, closing the wound
-eschar -10-14 -buds
Early excision of eschar: ___ excision: scalpel/cautery to excise down to the underlying fascia, bloodless, good skin graft take, disfiguring, remove __, leads to stiffness and joint immobility
-fascial -subq fat
Parkland formula: initial calculation for ___, subsequently guided by patient response. formula for 24 hrs? how much to give in 1st 8 hours? 2nd 8 hours? 3rd 8 hours? Guide further fluid resuscitation w/ repeated clinical eval. Fluid contineues to leak into interstitial, accumulates beneath __ value pulses, sensaition, ,motor function, pain, escharotomy???
-fluids -4mL LR xBW x $TBSA burned= total body fluid/24 hours -1/2 volume in 1st 8 hours -1/4 volume in 2nd 8 hours -1/4 volume in 3rd 8 hours -eschar
Secondary survey of burn victims: dramatic burn wounds can distract the examiner from detecting more urgent injuries. Pain, swelling, discoloration of burns may obscure findings like Abdominal tenderness, fractures, cyanosis. Head-to-toe exam Only when completed then debride and wash wounds Protect from ____by exposing only one area at a timterm-107e Document location, extent and depth of burns No antibiotic creams, ointments, dressings until____is complete
-hypothermia - secondary survey
Territory intention: Involves debridement of nonviable tissues and leaves them ___ Eventually an uncomplicated closure is used post injury Goal is very low ____
-open -bacterial counts
Excision and skin grafting: grafting is used for both ___ and ___ burns. Burns are a great burden physiologically--- ___site for infection increased evaporative fluid loss, serve pain, intents infllamtory response. Deep ___ separates spontaneously over time but it can take ___, increasing risk of infection. Burn center employ early excision
-partial thickness -full thickness -eschar -eschar -weeks
Primary survey of burn victims: smoke inhalation Injury is a major source of morbidity and mortality, suspect whenever patient has been exposed to smoke, includes edema of ___ w/ serve __ burns. Edema is progressive- signs of airway compromise may be absent for several __ after injury. Rexamine patients regularly. Intubate early if any sign of compromise. Look for evidence of circulatory compromise like ___ or ____.
-respiratory tract/lungs -facial burns 0hours -severe edema -constricting burn wound
Vessel loops are used to keep skin from ____permanently. Skin closure will occur after the deeper space has filled.
-retracting
Cellular migration: As healing progresses, fibroblasts and endothelial cells begin to predominate Re-establishment of the epithelial surface as well as _____ is initiated within the first several days after injury Migrating keratinocytes use appendages like hair follicles using pseudopods An intact monolayer may be present between well-approximated tissues within ____ Important to keep the wound ___ within this time to aid in migration
-revascularization -24 hours -moist
Dressing and infection control: ___ controls microbial growth. Resistant bacteria, particularly in hospitalized patients increase the risk of infection Coverage with ___substitutes the best infection control ____dressings protect sensitive nerve endings from air. Dressing changes must occur frequently and are painful.
-silver sulfadiazine -skin/skin -Occlusive
What are the phases of wound healing?
1. Hemostasis 2. Inflammation 3. Cellular migration and proliferation 4. Protein synthesis and wound contraction- matrix synthesis, angiogenesis 5. Remodeling
A current infection can increase the chance of a post-op infection by how much?
4 fold
When does wound contraction occur?
4-5 days after the initial injury and continues for 2 weeks -more relaxed skin, the faster the contraction
Burn Centers ◦Criteria determined by the ACS and ABA ◦Guidelines determine which patients are referred
?
Burns continue to burn: tissue damage continues for minutes to hours after initial burn. Smoldering clothing may reignite in the presence of o2. Extinguish flames completely ¡Douse, smother, roll on ground Hot liquids- Tar, plastic, grease etc., Cool water, moist compress to decrease temperature ¡Leave in place if necessary but cool it off Caustic chemicals- Dilute, Large amounts of water Electrocution Pts can conduct electricity to rescue workers, remove source of current first
?
Physiologic responses to burns: §Metabolic responses are complex úMetabolic acidosis, hyperventilation, respiratory alkalosis, cellular accumulation of sodium, calcium and water with K loss §Immunogenic responses úAltered macrophage function and changes in cellular and humoralimmunity úHematologic responses Altered coagulation
?
referral to burn unit criteria:A burn unit may treat adults or children or both. Burn injuries that should be referred to a burn unit include the following: 1. Partial thickness burns greater than 10% total body surface area (TBSA) 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third-degree burns in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. 9. Burned children in hospitals without qualified personnel or equipment for the care of children 10. Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention
?
§Early tangential excision and wound closure represent the most significant change in recent years úImproved mortality rates úLower costs úShortened hospital stay úDecreased infection rate úFaster healing decreases hypertrophic scarring, joint contractures and stiffness, quicker rehabilitation
?
§Interstices of mesh are prone to desiccation úTo avoid this large mesh autografts are covered with skin substitutes Cadaver allograft skin (tissue banks) Freeze-dried pig's skin Human amniotic membrane Integra (matrix of collagen and glycosaminoglycan) Research ongoing with "artificial dermis" Growth of patient's epidermal cells in culture $$$$ Fragile, lose if infection occurs
?
primary survey of burn victims: quick exam by removing all clothing and covering to keep warm, detect and tx immediately life-threatening conditions, ABC, CO (MC killer of hoste fire victims)
??
____________ is a superficial loss of epithelial elements, deeper structures intact
Abrasion
Incisions made ______ the rows of fibers disrupts the collagen and the wound tends to gape open and heal in a broad, thick scar
Across
_________ wounds tend to progress through the phases of wound healing in an orderly fashion and without delays
Acute
When is skin grafting performed? 2 types of autograf?T
At the same time as the eschar excision -full-thinkess and split thickness
______ is when an entire area of skin and often tissue are removed from an area
Avulsion
When does wound dehiscence occur?
Because of poor surgical technique: improper placement Overly tight sutures Inappropriate type of suture Too much stress on the suture line
What is the hallmark of a second-degree burn?
Blistering Extreme pain (blanching dermis)
What is the MC killer of house fire victims? what oragans are most vulnerable to damage secondary to o2 deprivation? ◦Pulse oximetry does NOT detect CO poisoning, ABGs with direct measurement of hemoglobin saturation is required
Carbon monoxide poisoning -heart and brain
__________ wounds will progress through the phases of wound healing at a much slower rate
Chronic
_________ wounds have usual normal flora without unusual contamination (pus or foreign bodies).
Clean-Contaminated
________ wounds are fresh traumatic injuries such as soft tissue lacerations, open fractures, and penetrating wounds. Operative procedures with gross spillage from gastrointestinal tract or performed in the presence of infection Also in wounds in which a major break in aseptic technique has occurred Microorganisms multiply so rapidly that a contaminated wound can become infected within __ hours
Contaminated wounds -6
_______ is an area of soft tissue swelling and hemorrhage with violation of the skin elements
Contusion
________ May have large area of necrotic tissue. Multiple debridements Long healing time Grafts or flaps
Crush injuries
__________ must be done because dead tissue is a good medium for bacteria, and foreign bodies impede healing
Debridement
The _______ is a dense layer of connective tissue whose primary function is to attach to underlying structures.
Deep Fascia
The ________ is composed of connective tissue containing collagen and elastic fibers. It also contains fibroblasts, macrophages, and adipocytes. Outer layer is papillary and deeper layer is ____.
Dermis -reticular layer
When does the wound coverage period begin? How long does it last? Most of patients hospital care/ intensive tx Wound closure leads to greater survival Prolonged rehabilitation
Directly after fluid resiscitation -days- weeks0 until burn heals or is replaced by skin graft
__________ are heavily contaminated or clinically infected prior to operation
Dirty or Infected Wounds
When is Total Body Surface Area the most important? Why are tBSA and depth important?
During the initial assessment -most important predictors of clinical outcome
The ________ is the nonvascular, nonsensitive, outer and thinner epithelial layer. It overlies the dermis. Serves as a protective barrier against the environment. Epithelial surfaces are constantly exposed to trauma and are constantly ____
Epidermis -regenerating
What are different causes of burns?
Flames-direct heat Scalding liquids-direct heat Contact with hot objects -direct heat Corrosive chemicals Electrical current
What must happen for wounds to progress to the proliferation phase/
Foreign bodies must be removed
Name the graft: Excise piece from ground/flank. Close donor site with suture
Full thickness
________ is a clot in the wound does not permit the orderly removal of debris or of the laying down or collagen. Good medium for bacteria to proliferate
Hematoma
All significant trauma creates a vascular injury and initiates the molecular and cellular responses that establish __________
Hemostasis
What is involved in wound closure by direct approximation of wound edges? (primary intention)
Immediate coverage with epithelial elements in some form (approximation, skin grafts or flaps) -Ideally has minimal edema no local infection or serious discharge no separation of wound edges minimal scar formation
What is the remodeling and maturation phase of wound healing characterized by?
Increased strength without an increase in collagen content
In a VERY severe burn patient, how do you treat them?
Intubate if inhalation injury is present, 2 large bore IVs, Foley, Remove clothing/jewelery
_______ is a classic wound
Laceration
__________ are lines that can be determined by the orientation of the subcutaneous connective tissue (collagen) fibers of the dermis. Skin tends to be much stiffer along these lines than across them
Langer's lines
_________ are lines in the skin indicate the predominant direction of underlying collagen fibers
Lines of cleavage
BURN INJURY PATIENT =___VICTIM USE THE SAME TREATMENT PRIORITIES AND ALGORITHMS AS YOU WOULD FOR A TRAUMA VICTIM vATLS
MULTIPLE TRAUMA
How long does tissue damage continue after the initial burn as occurs?
Minutes to hours
How do you treat a first degree burn? (3)
Oral analgesics Fluids Topical compound (neosproin)
What areas of the body are not entered by clean wounds?
Oropharyngeal, respiratory, alimentary or genitourinary tracts
Incisions running ______ to the collagen fibers with heal with a fine scar
Parallel
Second degree burns are also known as what?
Partial-thickness burns (extend partially into dermis but not all the way thru)
What are the 4 types of chronic wounds?
Pressure ulcers Venous stasis ulcers Arterial insufficiency ulcers Diabetics ulcers **Common in the elderly -Chronic wounds require specialized care, normal wound care techniques are inadequate.
________ is a deep wound. Need to make sure heals from the inside out
Puncture wound
What is the final phase of wound healing?
Remodeling and Maturation
What is burn care divided into 3 periods: Name when each occurs
Resuscitation (first 24-48 hours) Wound closure (days to weeks after the burn) Rehab
Total Body Surface Area only includes what types of burns? guides fluid resuscitation, nutrition etc
Secondary and tertiary
wound dehiscence
Secondary to poor surgical technique: Improper placement Over tightened suture Inappropriate type Too much stress on the suture line Poor healing ability
What are symptoms of circulatory compormise in a burn pt?
Severe edema, constricting burn wounds
What do you do if theres no enough donor skin to cover the area that needs the graft and there is a ;are area of eschar?
Skin stretchers Expanding mesh (meshing or cutting multiple slits in skin) Cadaver allograft
What should you suspect whenever a patient has been exposed to smoke?
Smoke inhalation injury
Name the graft: Use dermatome to harvest the intact skin at level of dermis. Donor site heals in 7-14 days
Split thickness
The __________ attaches the dermis to underlying organs and consists of both superficial and deep fascia
Subcutaneous layer
What are the 2 types of Patial thickness burns?
Superficial and deep
The _______ contains loose connective tissue with varying amounts of adipose tissue, sweat glands, blood and lymphatic vessels and nerves.
Superficial fascia
Which layer of the skin MUST be included in the suture/stitch?
The dermis
What is the largest organ in the body?
The skin
What does the skin provide? It is a barrier to mechanical, chemical and thermal insults, ultraviolet light and foreign bodies
Thermoregulation, sensation, excretion, vit d synthesis, and protection
How deep is the damage of a third degree burn?
Through all layers of the skin
What is the primary function of the inflammation phase of a wound? Leukotrienes, prostaglandins, histamine and kinins (kallikrein) all contribute to this process
To bring inflammatory cells to the area to destroy bacteria and to eliminate debris from dying cells and the damaged matrix
What occurs during hemostasis?
Vasoconstriction Platelet aggregation Fibrin deposition resulting from coagulation cascade
_________ occurs about 10-15 minutes after the initial vasoconstriction when an injury occurs. It allows the development of ___ which contributes to pain. Small surgical bleeders will show up later in surgery. Wound is edematous and erythematous ◦Inflammation vs. infection
Vasodilation -edema
How are primary intention wounds treated?
Wound is closed by direct approximation of the wound edges
Clean contaminated wounds include what type of surgeries?
appendectomies, vaginal operations, entering the oropharyngeal cavity, respiratory, alimentary, genitourinary, and biliary tracts
When should you intubate a burn pt?
before respiratory compromise begins- the pulmonary edema can occur massibvey and rapidly
When an avulsion wound involves an extremity it is deemed _____________.
degloving
Second degree burns cause superficial and deep damage (appearance varies depending on depth). What develops 24-48 Horus later?
eschar
Pink, soft, granular appearance on the surface of wounds histological characteristics include the proliferation of new capillaries and fibroblasts, and variable numbers of inflammatory cells
granulation tissue
In a severe burn patient, only after a ________ to ________ _______ is done can you then move onto debridement and washing
head to toe exam
In what phase do chronic wounds tend to arrest?
inflammation phase and fail to progress
What types of wounds usually become dirty or infected?
perforated viscera, abscesses, old traumatic wounds in which devitalized tissue or foreign material have been retained
How are clean wounds closed?
primary intention
How do you treat a large third degree burn?
skin graft
How do you treat a small third degree burn?
via contraction
Burn patients require what?
◦Fluid shifts ◦Electrolyte imbalances ◦Proper wound care ◦Respiratory support ◦Treating infections ◦Possible developments of sepsis/ MODS
