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1st degree

confined to the outer layer only; will heal on their own. Basically sunburn. No "broken" skin. Epidermis only, erythema, painful, heals quickly (3-5 days), physiologically unimportant, therefore not included in the calculation of total body surface area (TBSA) burned.

2nd degree

also involves part of the dermis. Superficial 2nd degree burn - involves the entire epidermis and no more than the upper third of the dermis is heat destroyed. Rapid healing occurs in 1-2 weeks, because of the large amount of remaining skin and good blood supply. Scar is uncommon. Initial pain is the most severe of any burn, as the nerve endings of the skin are now exposed to the air.
Deep 2nd/partial - a deep partial thickness or deep 2nd degree burn extends well into the dermal layer and fewer viable epidermal cells remain. Therefore, re-epithelialization is extremely slow, sometimes requiring months. Grafting is often the preferred treatment for long-term function. Majority of surgical patients are those with deep partial thickness. Typically caused by boiling water, flash, steam. Epidermis and some dermis. Blisters, very red (erythema), edema, painful, wet, weepy, heals in 10-14 days, rare to get permanent changes in skin appearance.

3rd degree

destruction of both layers; red, blisters without roofs, and charring. No remaining viable dermis. Full thickness/3rd degree - destruction of the entire epidermis and ermis, leaving no residual epidermal cells to repopulate. This wound will therefore not re-epithelialize and whatever area of the wound is not closed by wound contraction will require skin grafting. Area around the dead cells will grow back in because adjacent to normal areas . Typically caused by prolonged exposure to flame, hot water, chemicals, cold, or electrical current. Epidermis and dermis affected, white, red, black, or brown in appearance. Dry leathery and firm. Thrombosed veins. Minimal pain initially. Will require skin grafting unless area is very small. If left to heal, there will be poor quality of skin, thick scarring and very prolonged healing.

Epidermis

outer thinner layer, epithelial cells, outermost cells = keratinocytes, deepest epidermal cells= anchored to basement membrane by fibronectin (glue)
Cells mature and migrate to the surface they form keratin which becomes an effective barrier to environmental hazards such as infection and to excess water evaporation. Regenerative process takes 2-3 weeks. Blood vessels and sweating helps to regulate temperature. Seals in fluids in the body. Immune function - effective barrier

Papillary Dermis

upper dermis containing anchoring rete pegs and also is the most biologically active part of the dermis. Rete pegs - top layer of the dermis where epithelial cells grow from

Reticular Dermis

the thicker deeper portion responsible for durability and anchoring of skin appendages. Provides elasticity, movement, tightness, and thickness all affect ability to heal after a burn.

Matrix Proteins

collagen is the predominant protein, mainly collagen Type 1. (besides structure; collagen type 1 provides a contract orientation for dividing and migrating epithelial cells). Fibronectin is the primary adhesive protein playing a major role in healing. Other adhesive proteins. Provides strength

Ground substance

(glycosaminoglycan): carhbohydrates protein complexes, hyaluronic acid

Superficial

no damage beyond epidermis.

Partial Thickness

is a second degree burn consisting of injury to part of the dermis

Full Thickness

is a third degree burn consisting of injury to both layers
If deeper then give descriptor for how deep: full thickness to the bone.

Rule of 9

quickly estimating how much of the body burned - good for EMTs because quick assessment

Lund and Browder

how much of a person was burned influenced how the individual did long term. Also noticed that smaller people and larger people had varying percentages. When younger, your head is a bigger percentage of the body. Much lower percentage for adults. They have a computerized system that allows you to draw on a sample body where the burn is and it will tell you the percentage burned according to the Lund and Browder formula.

Why to refer to a burn center

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. 3rd 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 (diabetes, developmental disabilities, communication disorders) that could complicate management, prolong recovery, or affect mortality.
8. 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.

Heat injury

Heat causes rapid protein denaturation and cell damage. The depth of heat injury is dependent on the depth of heat penetration. Wet heat (scald) travels more rapidly into tissue than dry heat (flame). The dead skin tissue on the surface is known as eschar. The depth of the burn is dependent on: temperature of the heat insult, the contact time and the medium (air-water), and the depth of the skin layer is critical as the thinner the skin, the deeper the burn.

Eschar

The dead skin tissue on the surface

Zone of coagulation

area of full-thickness injury distinguished by tissue necrosis

Zone of stasis

area of partial-thickness burn with a blood supply compromised by cellular and vascular changes. Can convert into full-thickness with insufficient fluid resuscitation or improper wound care

Zone of hyperemia

outermost area of burn with vasodilation and increased blood flow in response to heat stimulus and prolonged cellular activity

burn resuscitation

Burn injuries are systemic. Fluid loss through injured skin is massive. Failure to replete fluids can lead to further tissue loss, worsening systemic inflammatory response or death.
Parkland Formula is a guideline used to determine fluid requirements. 2-4cc/kg/%tbsa of lactated ringer. First half of this given in first 8 hours.
Remaining over following 16 hours. Monitor urine output closely. Adjust each 1-2 hours based on results aka urine output. Risk of over-resuscitation = excessive edema in damaged skin, cardiac failure.

Basal energy expenditure

Burns increase the metabolic state so that all organ systems are taxed at a greater rate. Fluid loss from oozing damaged tissue increases. Replacing losses is paramount. Massive release of inflammatory mediators = systemic injury
Nutrition - burns require significant increase in caloric intake. BEE (basal energy expenditure) may be double with burns 25-50% TBSA. Especially true in old and young.

Surgical Intervention

Infants and the elderly tolerate burn inflammation and infection poorly so early burn removal is preferred. Burns in infants and the elderly are usually deeper than initially perceived. Burns can get deeper over the first several days as a result of necrosis of ischemic areas (conversion). Give it one or two days, and within 7 days decide whether or not to operate.
Burns caused by direct contact flames, hot grease, chemicals, or electricity are invariably deeper than first appearances would suggest.
Burns on the low back, scalp, palms, and soles usually have sufficient remaining dermis to allow primary healing in 3-5 weeks.

Autograft

donor site from patient's own body. Split-thickness skin graft (STSG) = sheet or meshed graft. Full thickness skin graft (FTSG). Permanent

Xenograft

tissue from one species to another (often pig skin, but has a hard time staying on)

Allograft

(cadaver) used mostly to cover full thickness burns

Donor skin sites

Thigh, buttocks. Then upper arms, scalp, back, abdomen. Then lower legs, arms, chest.

Healing times (re-epithelialization)

Healing in 2 weeks - minimal to no scar
Healing in 3 weeks - minimal to no scar except in high risk scar formers
Healing in 4 weeks or more - hypertrophic in more than 50% of patients

risk factor for scar development

Typically early grafting leads to less scar and the thicker the skin graft, the less the scar. Sheet grafts have less scar then meshed grafts. Typically the wider the mesh, the more the scar. Scar will develop at the edges of a graft in high risk scar formers (dark skinned). Monitor maturation of scar. Assess vascularity, pliability, height, pigmentation.

scar management

1st and 2nd degree burns do not usually scar (if healed within 10-14 days). Deep 2nd and 3rd degree burns scar the most. Early healing/grafting decreases scarring. Children scar more than elderly. Darker-pigmented races are more susceptible.

Goal of burn rehab

Prevent or treat complications, promote rapid wound healing, maintain range of motion and function, provide psychological support, pain management.
Short term goal is to preserve the patient's range of motion and functional ability, or at least, to prevent to prevent further loss of motion. A program of positioning, splinting and exercise must be followed 24 hours per day, each day.

Positioning outcomes

Position of comfort is the position of contracture.
Control edema, evaluation is best. Prevent tissue destruction. Maintain soft tissue in an elongated state - opposite contracture development.

positioning for head/neck burn

appropriate position: neck in midline with 10-15 degree extension. Do not use pillow. Roll behind the neck will give you 0-15 degree neck extension.

positioning for shoulder burn

appropriate position: 90 degrees abduction with 15-20 degree horizontal adduction and slight external rotation

positioning for elbow burn

elbow in full extension with the forearm in supination.
• Wrist and hand - wrist in 0-30 degrees extension. MCP joints in 70-90 degree flexion, IP joints in full extension. Thumb is positioned in a combination of palmar and radial abduction maintaining the first web space in a stretched position.

positioning for hip/knee/ankle

hip extended with neutral rotation. Legs abducted. Neutral ankle.

goals for splinting

Protect joints or tendons, immobilize for graft take/protection, prevent contracture deformity, correct contracture, maintain ROM achieved. (an improperly applied splint is worse than no splint at all). May use night splint only.
Compatibility with topical agents, timely application, simple application, removable material, avoidance of pressure, position of function.

Goals for exercise

Reduce edema and promote circulation, prevent scar tissue contractures, preserve muscle joint mobility, promote maximal function, preserve muscle strength, prevent deconditioning.

AROM for burn pt

most desirable. Edema reduction, exposed tendons, 1st week after skin graft

AAROM for burn pt

scar tissue elongation. Following skin graft adherence

PROM for burn pt

scar tissue elongation, peripheral nerve injury, when patient is unable to actively participate. Precautions/contraindications: finger burns of indeterminate depth, especially over PIP joints. Heterotropic bone formation is suspected or present. Exposed tendon - really at therapist discretion. Extremely resistive or combative patient.

ROM considerations

area of escharotomy. Involve multiple joint skin creases - emphasize the extreme, to maintain the mean.
How much stress? If it's white - it's tight (scar tissue will blanch); banding.
Range joint in direction of scar tissue elongation - pinching/bunching versus stretching
Pain management - collaborate with team regarding timing of medication. Pain is expected and need to find manageable range.

functional movement incorporation

So that when they are returning to function, you are ensuring success in movement patterns.

scarring timeline

Following wound closure, burn scar undergoes a remodeling process that may last 6 months to 2+ years

rehab goals for scars

control hypertrophic scar tissue formation, maximize cosmetic result of healed/grafted area, decrease the need for and extent of reconstructive surgery, support the patient through the adjustment to the injury.

tissue restriction timeline

Timelines for development of tissue restrictions
Burn scar contracture - 1-4 days
Tendon and sheaths - 5-21 days
Adaptive muscle shortening - 2-3 weeks
Ligament and joint capsule - 1-3 months

LE in dependent position

Inadequate venous return, tissue engorgement, edema, bleeding, pain

immature scar

(3 Rs): red, raised, rigid

mature scar

(3 P's): pale, planar, pliable

effects of scar compression

accelerates scar maturation, flattens the scar, increases pliability, decreases blood flow, realigns collagen bundles by decreasing rate of collagen synthesis, decreases edema

non-custom methods of compression

elastic bandages, self-adherent elastic bandage, tubular support bandages, soft material/interim garments

frequency, amount, and duration of compression

Pressure is applied 23 hours a day for approximately 1 year, until scars are mature. Begins when wounds are healed/closed. Patient should have 2 sets of garments, one to wear, one to wash.
Duration of use - until scar maturation, minimum of 6-8 months, usually 9-11 months, longer in children. As long as scar is red, it is vascular. It can contract and hypertrophy.

tubular support bandages

Advantages - used to healed burns that can not tolerate shearing forces, interim pressure devices, comfortable, can be placed over dressing, controls edema
Disadvantages - limited to cylindrical body parts, improper application or bunching can cause skin breakdown or edema, some patients are allergic to elastic, some diameter through out a tapered extremity.

compression garments

Advantages - can be fit for every part of the body, customized closures, materials, styles, multiple options, variety of colors, multiple companies.
Disadvantages - expensive, not all insurances reimburse, fit - dependent on accurate measurements, difficult to don/doff, may cause skin breakdown, may retard/alter bone growth, weight gain/loss should be stable.

custom garment fit

extend 2-3" beyond scar, avoid stopping garment over muscle belly or joint, anchor garment so it does not slip, avoid zippers when possible, if zippers are needed, avoid placing them over scar and bony prominences.
Initial fitting should not be done by patient at home. Should be tight enough that it's difficult to pull away from skin, but does not compromise neurovascular status. Avoid wrinkles.

psychological ramifications of burn scarring

Change in self-image, decreased confidence, increased chance of fear moving the area as well as fear of fire or heat. Decreased attachment or recognition of the affected area.

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