: PRESENTATION ON :

Guided by :Dr.Kiran P.S. Submitted by : Aparna Bhagwat

B.P.T. IV year

Date of submission : 02/09/2010

2

CONTENTS• SKIN

• BURNS :

1.) INTRODUCTION

2.) ZONES

3.) PATHOPHYSIOLOGY

4.) CLASSIFICATION

5.) TOXIC EPIDERMAL NECROLYSIS

6.) ASSESSMENT OF A BURN PATIENT

7.) COMPLICATIONS

8.) MANAGEMENT

• PRESSURE SORES :

1.) INTRODUCTION

2.) HISTORY

3.) AETIOLOGY

4.) AREAS PRONE

5.) PATIENTS PRONE

6.) PATHOLOGY

7.) ASSESSMENT

8.) MANAGEMENT

3

SKIN

• Skin is the largest organ of the body.

• The average thickness of skin is about 1-2mm.

• It forms the outermost layer of the body.

• Skin is made up of two layers :

1. EPIDERMIS : made up of stratified epithelium and is further divide into 5 layers , which are as follows –

1. stratum corneum 2. stratum lucidum 3. stratum granulosum 4. stratum spinosum 5. stratum germinativum * It is avascular in nature .

2. DERMIS : made up collagen fibres, fibroblasts, and histocytes. It is made up of two layers : 1. superficial pappillary layer 2. deep reticular layer

HYPODERMIS : made up of subcutaneous tissues and fat layer.

4

5

6

PAPILLARY DERMIS :• Contains vascular networks that have two important functions: 1.) to support the avascular epidermis with vital nutrients 2.) to provide a network for thermoregulation.

• The vasculature interdigitates in areas called dermal papillae (DP).

• Also contains the free sensory nerve endings and structures called Meissner’s corpuscles in highly sensitive areas.

DERMIS

7

RETICULAR DERMIS :

The reticular layer of the dermis (RD) consists of : dense irregular connective tissue

It has following functions:1.) It gives the skin its overall strength and elasticity, 2.) It contains important epithelial derived structures such as: glands and hair follicles.

8

9

INTRODUCTION

• Burn is a wound in which there occurs “coagulative necrosis” of the tissues, resulting from excessive exposure to thermal, chemical, electrical or radioactive agents.

• Can also be defined as a “ permanent “ destruction of tissue proteins by an external agent.

• According to JACKSON’S BURN MODEL , a burn wound can divided into three zones :

1. Zone of coagulation (central)

2. Zone of stasis (middle)

3. Zone of hyperemia (peripheral)

10

ZONES OF BURN WOUND

11

• Zone of coagulation : it is the most central area of burn wound, where destruction is most severe and cellular necrosis is complete. The damage occurred is irreversible.

• Zone of stasis : here cells are less injured and majority are initially intact but gradually becomes dead by the insufficiency of circulation (ischemia). Decreased tissue perfusion.

• Zone of hyperemia : it is the most peripheral area , marked by excessively increased blood flow and minimal cellular injury. This area is not compromised unless infection of the burn wound occurs.

12

PATHOPHYSIOLOGY

• LOCAL CHANGES :

• Severity of burns (superficial or deep)

• Extent of burn (% of TBSA)

• Vascular changes :1. Dilatation of small vessels (due to local liberation of histamine)2. Increase in capillary permeability (leads to edema formation)

• Infection : initially after burn, the skin becomes sterilized, but as the layers of skin gets damaged off, the protective barrier is lost and it makes body highly susceptible to infections.

13

• SYSTEMIC CHANGES :

• SHOCK :1. Oligaemic shock2. Neurogenic shock3. Cardiogenic shock4. Bacterimic shock

• BIOCHEMICAL CHANGES :1. Electrolyte imbalance (low - Na & Cl conc. and high - K levels)2. Hypoproteinemia (due to excessive loss of plasma proteins as a result of increased

permeability of capillary walls)

• CHANGES IN BLOOD :1. Haemoconcentration (due to outpouring of serum). – upto 150% rise is seen in severe burns.2. Aggregation of red cells, white cells, and platelets. (thus increases viscosity of blood)3. Anemia (due to destruction of RBCs )

14

WHEN BURN INJURY OCCURS

IMMEDIATELY HISTAMINE IS RELEASED

INTENSE VASOCONSTRICTION OCCURS

AFTER FEW HOURS, VASODILATATION OCCURS

INCREASE IN CAPILLARY PERMEABILITY

PLASMA ESCAPES INTO THE WOUND

DAMAGED CELLS SWELL UP

PLATELET AND LEUKOCYTE AGGREGATION

THROMBOTIC ISCHEMIA OCCURS

FURTHER DAMAGE OCCURS

15

CLASSIFICATION OF BURNS

Classification of burns is done under following criteria :

1. Causative agent

2. Depth of burn

3. American burn board classification

4. % of total body surface area (TBSA)

16

1. CAUSATIVE AGENTS

• THERMAL BURNS:1. HEATING AGENTS –

a.) dry burn e.g. sunburn, flame burn. (1st degree)

b.) moist heat burn (scald) – due to steam/hot liquids. ( 1st or 2nd degree)

c.) contact burns e.g.- cigarettes, cooking appliances,etc. (1st or 2nd degree)

d.) gas burn e.g.- inhalation of hot gases. (2nd or 3rd degree)

SCALD

17

2. COLD AGENTS -• (FROSTBITE):• actual freezing of tissues with the prolonged exposure to cold and ischemic damage. • the tissue necrosis is mainly due to :-

1. ischemia,

2. cellular dehydration (due to fluid loss) ,

3. microvascular occlusion. (prolonged vasoconstriction)• bluish discoloration of the parts.

FROSTBITE

18

• CHILDBLAIN :• They are acral ulcers (i.e. affecting extremities)• Occurs when exposed to cold and humidity ( prolonged exposure to cold water or ice)• Cold causes damage to capillary beds, • Presents as itching, redness, inflammation & blisters.• Idiopathic in nature.

19

TRENCH FOOT :

• Also called as FAT FOOT.

• Caused by prolonged exposure of feet to damp, unsanitary, and cold conditions.

• Usually seen in soldiers due to their prolonged exposure to extreme cold envt , along with circulatory compromise (due to tight clothing)

• Area is numb, eryhtematous /cyanosed, and has decaying odor

• In advanced conditions, blisters and pen sores develop.

20

• ELECTRIC BURNS :

• Occurs when the electrical energy is converted into thermal energy.• Causes minimal destruction to skin.• The extent of damage depends upon the resistance exerted by the deeper tissues. • Burn injury occurs when electrical voltage is >1000 V.• Children can get injury after exposure to 200 – 1000 V.

21

• CHEMICAL BURNS :

• Caused by any strong acid or base that comes in direct contact with the skin or any other tissues.

• The severity is directly related to:-1. amount of time the chemical was in contact with the skin.2. concentration of chemical agent.

• Types :- 1. acidic 2. alkaline1. Alkaline burns : produce liquefactive necrosis, and higher risk due to their likelihood to penetrate

deeper.2. Acidic burns : result of coagulation necrosis, limiting the depth & penetration of the burn.

• Common sources: silver nitrate, hydrochloric acid ,lime ,etc.

22

• RADIATION BURNS:

• Caused by X-rays or radium exposure for prolonged period.• A type of inflammation of skin which can be regarded as a burn. • Also called as “RADIODERMATITIS”.• Presents with deep ulcers.• These burns are highly liable to grow into skin cancers.

23

2. DEPTH OF BURNS

• 1ST DEGREE ( SUPERFICIAL BURNS)

• 2ND DEGREE (SUPERFICIAL PARTIAL THICKNESS BURNS)

• 3RD DEGREE ( DEEP PARTIAL THICKNESS BURNS)

• 4TH DEGREE (FULL THICKNESS BURNS)

• SUBDERMAL BURNS

24

ASSESSMENT OF DEPTH OF BURNS

1st DEGREE BURNS :•Only epidermis is involved.•Erythematous, pink or red, irritated dermis.•No blisters, dry surface•Painful and tender •Minimal edema•Spontaneous healing within 1 week.•No scarring

2nd DEGREE BURNS :•Epidermis and papillary region of dermis•Bright pink or red skin, inflamed dermis•Erythematous with blanching & capillary refilling•Intact blisters, moist surface•Painful•Moderate edema•Spontaneous healing within 7-21 days.•Minimal scarring •discolouration

25

3rd DEGREE BURNS :•Epidermis and reticular region of dermis•Mixed red, waxy white skin.•Blanching with slow capillary refilling•Broken blisters, wet surface (serous fluid oozes out)•Sensitive to deep pressure but insensitive to light touch or soft pin prick,•Marked edema•Slow healing (heals in 3- 5 weeks) •Excessive scarring.

4th DEGREE BURNS :•Extends into subcutaneous tissue.•White, yellow, brown leathery appearance.•Thrombosed vessels, Hb fixation.•No blanching•Poor distal circulation•Skin is parchment-like, leathery, rigid, and dry.•Anesthetic skin•Body hairs pull out easily.•Area is depressed.•Requires grafting for healing.Scarring is present.

26

SUBDERMAL BURNS :• Extends to muscle and subcutaneous tissues.• Loss of function• Black, charred appearance• Neurological involvement is there.• May require escharotomy and fasciotomy for grafting.• May require amputation• Causes: very prolonged exposure to flame, chemicals, and high voltage.

27

3. AMERICAN BURN BOARD CLASSIFICATION

• MINOR BURNS :• <15% BSA partial thickness / 10% in children• <2% BSA full thickness burn (not involving eyes, ears, face or perineum )

• MODERATE BURNS :• 15-20% BSA partial thickness burn / 10-20% in children• 2-10% BSA full thickness burn (not involving eyes, ears, face or perineum)

• MAJOR BURNS :• >25% BSA partial thickness• burn / 20% in children• All burns to eyes, ears, face and perineum• All electrical burns• All inhalational injuries• All burns with #s or major tissue trauma• All burns with poor risk of healing secondary to age and extent of illness• >10% BSA full thickness burn

28

4. % OF TOTAL BODY SURFACE AREA

• To estimate the % of body area involved in burn injuries, “Polaski and Tennison” developed the “RULE OF NINES.”

• The “rule of nine” divides the body surfaces into areas that are 9%, or multiples of 9%.

29

AREA % OF TBSA• Head, face & neck 9%• Right upper extremity 9%

• Left upper extremity 9%• Right lower extremity 18%

(thigh -9%, leg & foot -9%)• Left lower extremity 18%• Anterior trunk 18%

(chest -9%, abdomen -9%) • Posterior trunk 18%

(upper ½ -9%, lower ½ -9%)• External genitalia 1%

3013.5% BURN

31

• Lund and Browder modified the % of BSA to account for a continuum of age and to accommodate for the growth of the different body segments.• This method is more accurate than the rule of nines.

32

Ant. side : trunk - 6.5%, lower Rt arm -1.5%, Lt thigh -4.25%, Lt & Rt lower leg -3%

Post side : trunk -6.5%, lower Rt arm -1.5%, upper Rt arm -1%

TOTAL : 24.25%

If a boy of age 12 years get burned, how to calculate the % of area burned acc. to Lund & Browder burn chart?

TOXIC EPIDERMAL NECROLYSIS

33

34

ASSESSMENT OF A BURN PATIENT

• Name• Age • Sex• Address• Occupation• Marital status• Date of burn• Place of burn• Causative agent• Mode of injury• History of burn injury• Type of burn• Depth of burn• % of area burned• Smoke inhalation• First – aid given• Date of admission to hospital• Any comorbid condition

35

Surgery :-• Date of surgery• Type of surgery• Donor area of grafting• Dressing • Medication • Pain • Skin color• Blisters• Wound condition• Blanching• Position of patient• Oedema • Cyanosis• Clubbing• Breathing pattern• Chest movements• Consciousness of patient• Any ventillatory support – Mode , source• Bandaging or splinting• Pressure sores

36

• Pulse• Blood pressure• Respiratory rate• Temperature• Breath sounds• Added sounds• Heart sounds• CVP• SpO2• FiO2

• Any contractures present• ROM – active and passive• Any associated pathology – e.g. fracture • Amputation• Condition of donor site

COMPLICATIONS

• Infection• Pulmonary complications• Metabolic complications• Cardiovascular complications• Heterotropic ossification• Neuropathy• Pathological scars

37

38

MANAGEMENT OF BURNS

Management of burns will be done in following steps:

1. First aid or pre-hospital care

2. Emergency department care

3. Clinical treatment

4. Physiotherapy treatment

39

1. FIRST AID OR PRE-HOSPITAL CARE

• Remove the person from source of burn.• Remove constrictive clothing and any accessories to prevent effect as tourniquet.• Cool the burned area by saline or clean water. Avoid ice. (hypothermia)• Elevate patient’s legs 12 inches off the ground to prevent burn shock.• Cover the patient with a clean, dry sheet. (because patients usually complain of chills due to

loss of water and heat from the burned skin )• Don’t apply any ointments, oil or butter to wound. (infections)• Don’t break blisters. (painful & vulnerable to infections)

40

41

42

2. EMERGENCY DEPARTMENT CARE

• Initial assessment of respiratory and cardiovascular status. • Determine the extent of burn and any need for surgery.• ED treatment focuses on :

1. airway and respiratory care

2. fluid resuscitation

Airway & respiratory care :• Inhalation injury : 1. look for signs of inhalation injury ;

a. carbonaceous sputum

b. singed facial or nasal hair

c. facial burns

d. Oropharyngeal oedema

e. changes in voice

f. Alteration in mental status

2. intubate the patient

3. fiberoptic bronchoscopy is done for diagnosis of inhalational injuries.• Mechanical ventilation

43

3. CLINICAL TREATMENT

• TREATMENT OF SHOCK :

1. Sedation

2. Resuscitation

• GENERAL TREATMENT:

1. Escharotomy and fasciotomy

2. Tetanus prophylaxis

3. Drugs

4. Nutritional support

• LOCALTREATMENT :

1. Wound care

2. Skin grafting

44

TREATMENT OF SHOCK :

• SEDATION :

• Sedation is necessary in burn patients bcoz of the intense pain they are having.• this should be administered during first 1-2 hours.• the dosage should be minimal to prevent depression of cardiopulmonary function and to allow

to evaluate the patient.• usually injection MORPHINE 1/4gm or less is given i.v. , where as in children, BARBITURATES

are preferred.

45

RESUSCITATION :

• This should be started as soon as possible .• As the patient is in shock, the veins are usually collapsed and venesection is often

required.

Thus a large-bore cannula is pushed into the vein of sufficient size to permit blood flow unimpeded.

• The amount of fluid resuscitation required is calculated by following methods :

1. Parkland’s formula

2. Brooke’s formula

3. Evan’s formula

• Fluid should be administered at the rate needed to achieve an hourly urinary output of 75 ml to 100 ml.

• commonly used diuretic is MANNITOL 12.5 gm.• For children only, Galveston formula is been used.

46

47

• PARKLAND’S FORMULA:

(4 cm3 of crystalloid) X (% BSA burn) X (body weight in kg)

Example: A man who weighs 70 kg and has a 30% BSA burn would require(30) X (70 kg) X (4 cm3/kg) = 8400 cm3 in the first 24 hours.

One half of the calculated fluid requirement is administered in the first 8hours, and the balance is given over the remaining 16 hours. Thus, fluidswould be given at 525 cm3/h for the first 8 hours, then at 262.5 cm3/h forthe remaining 16 hours.

48

• BROOKE’S FORMULA :

• in 1st hour , RL 1.5 ml/kg/% of burn colloid containing fluid 0.5 ml/kg/% of burn 2000 ml of 5% dextrose solution

• In 2nd 24 hours, RL will be ½ to ¾ of the 1st 24 hours colloid containing fluid will be ½ to ¾ of the 1st 24 hours 2000 ml of 5% dextrose solution

EVANS FORMULA :

in 1st 24 hours, 1 ml/kg/% of burn normal saline 2000 ml of 5% dextrose 1 ml/kg/%burn colloid containing fluid

In 2nd 24 hours, normal saline is given ½ of the 1st 24 hours. colloid containing fluid is also ½ of 1st 24 hors. 2000 ml of 5% dextrose

49

• GALVESTON FORMULA:

5% dextrose in lactated Ringer (5000mL/m2 of TBSA burned plus 2000mL/m2 ) is administered i.v. in the 1st 24 hours.

one half is given in 1st 8 hours & next half is given in next 16 hours.

Dextrose is added to the resuscitation fluid in children so as to prevent hypoglycemia. Children have very little stores of glycogen.

50

GENERAL TREATMENT :

ESCHAR : • it is a devitalised tissue consisting of desiccated coagullum of plasma and necrotic cells.• It feels dry, leathery and rigid.• Its color varies from black to deep red to white. • is developed in case of a full thickness burn.• exerts pressure on the blood vessels, thus causing :

1. diminished peripheral pulses

2. decreased skin temperature with oedema (due to venous obstruction).• removal is necessary.

• ESCHAR FORMATION :

• takes place in following steps:-

1. Skin denaturation i.e. skin becomes hard and leathery.

2. Constriction of skin over the wound.

3. Circulatory compromise ( develops secondary to circumferential eschar around extremities )

51

52

ESCHAROTOMY :

• It is performed as a ward procedure • no anesthesia is required. • the eschar is incised on either mid lateral or mid medial line.• The incision should run along the whole length of the burned area • Should be sufficiently deep to allow the cut edges of the eschar to separate• Usually carried out within 12-18 hours of the injury .

53

54

• In cases where escharotomy does not seems to be useful , in those cases FASCIOTOMY is done.

• When oedema occurs beneath the investing fascia then fasciotomies are required.• They should be performed under GA.• It is required in severe burns with extensive damage to the underlying fat and

muscles for e.g. electrical burns.

55

56

• Tetanus prophylaxis :• All burn injuries are considered as contaminated injuries and tetanus prophylaxis is obligatory.• Intra muscular administration of TETANUS TOXOID in the dose of 0.5 ml usually provides

adequate prophylaxis.

• Drugs :• TOPICAL AGENTS : mafenide, silver nitrate, gentamycin, neomycin, silver sulfadiazine etc.

• PENICILLIN : bcoz usually gram – positive organisms colonise in the burn wound . They should be given on 1st or 2nd day , as the full thickness burn becomes relatively avascular after 48 hours. Subsequently , gram – negative organisms may also colonise.

• NSAIDs : These agents are used most commonly for relief of mild pain.

Other options include:

1. ibuprofen

2. flurbiprofen,

3. ketoprofen,

4. naproxen. • ANALGESICS : morphine sulphate

57

• Nutritional support :

• In case of all major injuries , increased metabolism takes place. The metabolic rate approaches about twice the normal in patients with >50% burn BSA.

• It is manifested by increased oxygen consumption, elevated cardiac output, increased core temperature, wasting of body mass etc.

• Feedings may be accomplished by insertion of a small silastic nasogastric tube with a constant delivery pump.

• Solutions of synthetic amino acids mixed with hypertonic solutions of glucose are primarily used. Keep a watch on blood sugar levels . It should be >200 mg.

• As there is high risk of intravenous sepsis at the site of intravenous cannula, the site of it should be changed every 48 to 72 hours.

58

LOCAL TREATMENT :

• Wound care :

• First the wound is cleansed with the use of a mild soap and gentle scrubbing and all the loose nonviable skin is trimmed off.

• In case of 2nd degree burns where blisters are also present, blisters are punctured and the upper skin is debrided.

• TOPICAL AGENTS :- mafenide, silver nitrate, gentamycin, neomycin, silver sulfadiazine etc. are used to protect the wound.

• After cleansing and debridement of wound, two approaches of treatment can be used :

1. Exposure method – left uncovered.

2. Closed method – wound is covered by dressings in three layers.

1.) inner – contain topical chemotherapeutic agent (chlorhexididne)

2.) second – contain sterile cotton gauze

3.) third – contain cotton bandage

59

• TYPES OF DRESSINGS :

1. BIOLOGICAL DRESSINGS :

It includes skin grafts taken from the cadavers, skin of shark, human fetal membranes, and also the skin of pigs.

The treatment utilizes a special biological dressing called Composite Cultured Skin (CCS). It is designed to stimulate the body to rapidly regenerate its own skin, resulting in less scarring, less post-operative pain and wound contraction.

Advantages : 1.) prevents fluid loss

2.) decreases pain

3.) inhibits bacterial growth on the wound

4.) increases growth of granulation tissues.

60

2. SYNTHETIC DRESSINGS :

To be used effectively, a synthetic dressing should fulfill certain criterias :

1.) non allergic

2.) inexpensive

3.) easily removable

4.) should have a permeable membrane

5.) should come in large sheets

It consists of two analogues / layers / laminas:

1.) epidermal analogue

2.) dermal analogue

the two mostly used materials are –

1.) BIOBRANE

2.) INTEGRA

61

BIOBRANE :• It consists of an epidermal analogue composed of thin sheet of silastic , and dermal

analogue composed of Type 1 procine gel.• Disadvantages : needs to be stapled to the skin.

INTEGRA :• The epidermal analogue is made up of silastic film , and the dermal analogue is a net

of collagen fibrils covered in chondritine-6-sulphate.• Disadvantages : 1.) increased susceptibility to infections

2.) greater scar formation

62

• SKIN GRAFTING :

Skin grafting is the transplanting of skin and, occasionally, other underlying tissue types to another location of the body.

Skin grafts are divided into 2 major categories:

1.) full-thickness skin grafts (FTSGs)

2.) split-thickness skin grafts (STSGs). _____ A.) thin (0.008- to 0.012-mm) B.) medium (0.012- to 0.018-mm) C.) thick (0.018- to 0.030-mm) grafts.

63

• Split-thickness skin grafts :• Once the surgical defect is created and an STSG is

selected to reconstruct the defect, the defect is measured accurately. If feasible, a purse-string suture may be placed around the defect to reduce its overall size, which reduces the size of the donor graft required for coverage6

Once selected, the donor site is prepared in a sterile fashion and infiltrated with local anesthesia, either with or without epinephrine. Raising a wheal in the skin with the anesthesia is helpful in harvesting the graft.

After the graft is harvested, the STSG is trimmed to fit the donor site. Some overlapping of the donor tissue with the recipient bed is acceptable; this overlap can be trimmed later upon suture or bolster removal. The STSG is then secured in place by using either staples or interrupted 6-0 fast-absorbing gut sutures around the periphery

64

65

• Full-thickness skin grafts :• Common donor locations for FTSGs include areas of preauricular and postauricular,

supraclavicular, upper eyelid, nasolabial fold, axillary, antecubital, and inguinal fold skin.

The donor graft tissue is placed in sterile sodium chloride solution until it is used. The graft can remain viable for as long as 24 hours after harvesting if it is refrigerated or kept on ice.

After harvesting the graft, the secondary defect should be closed, and the FTSG defatted

Next, the graft is tacked into place by using 2 interrupted sutures of 6-0 fast-absorbing gut in opposing cardinal directions; then it is trimmed and secured in place along its circumference

66

GRAFT HEALING :

• The process of graft healing takes place in two stages :

1. PLASMATIC IMBIBATION :

It occurs within the first 24-48 hours after the placement of the graft on the recipient bed.

During this process, the donor tissues receive their nutrition through the absorption of plasma from the recipient wound bed via capillary action.

In this phase of healing, the graft is white and may appear somewhat edematous.

In addition, during this phase of healing, a fibrin network is created between the graft and the recipient bed. The recipient bed then generates vascular buds that grow into the fibrin network.

67

2. INOSCULATION :

• This phase starts 48-72 hours after grafting and may continue for as long as 1 week after grafting.

• During this time, the vascular buds anastomoses with both preexisting and newly formed vessels. This revascularization of the skin graft, which occurs more rapidly in an STSG than in an FTSG

• STSG is initially accompanied by a mottled appearance and then a vascular erythematous blush or, occasionally, a slightly cyanotic appearance.

68

3. PHYSIOTHERAPY MANAGEMENT

• GOALS AND EXPECTED OUTCOMES :

1. Wound and soft tissue healing is enhanced.

2. Risk of infections and complications is reduced.

3. Maximal ROM to be achieved.

4. Restoration of previous cardiovascular endurance.

5. Independent ambulation is achieved.

6. Independent in doing ADLs .

7. Scar formation is minimized.

8. Psychological motivation

69

• INTERVENTIONS:

1. Positioning and splinting

2. Active and passive exercises

3. Resistive and conditioning exercises

4. Scar management

70

1. POSITIONING :

EFFECTS OF POSITIONING :

1.) minimizing the oedema 2.) prevent tissue destruction 3.) maintain soft tissues in an elongated position

• It should begin on the day of admission.

• Burned areas should be positioned in an elongated state or neutral position of function.

STRATAGIES OF POSITIONING:

71

JOINT

COMMON DEFORMITY

MOTION TO BE STRESSED

SUGGESTED APPROACHES

Ant. neck Flexion Hyperextension •Use double mattress

•Position neck in ext .•Use rigid cervical orthoses.

Shoulder & axilla

Adduction and int. rotation

Abduction, flexion, & ext. rotation

•Position with shoulder flexed and abducted (AIRPLANE SPLINT)

Elbow Flexion and pronation Extension and supination •Splint in extension

Hand Claw hand (intrinsic - minus position)

Intrinsic plus position •Wrap fingers separately•Wrist ext, MCP flx, PIP & DIP ext, thumb abducted .

Hip & groin Flexion and adduction All movements, spec. abduc

& ext.•Hip neutral with slight abduction

Knee Flexion Extension •Posterior knee splint

Ankle Plantar flexion Dorsiflexion •Plastic AFO with cutout at achilles

tendon and ankle positioned in neutral

72

2 . SPLINTING :

• Considered as an extension of positioning program.• The splint is been applied in the antideformity positions.

• Indications for splinting:

1.) prevention of contractures.

2.) maintenance of ROM achieved during an exercise session or surgical release

3.) correction of contractures

4.) protection of a joint or tendon

• Design of splint should be kept simple so that a splint is easy to apply, remove & clean.• Usually splints are worn at night, when a patient is resting, or continually for a several

days following skin grafting.• They should be checked routinely for proper fit and revised if necessary.• Care must be taken to ensure that there are no pressure points that may cause a

breakdown in healing.• Most commonly used splints are:

1.) airplane splint

2.) wrist extension splint

73

3. ACTIVE AND PASSSIVE EXERCISES :

• Active exercises should begin on the day of admission. (patient is alert and able to follow the commands.)

• Exercises of whole body should be done.(all extremities and trunk including the unburned areas)

• Dressing changes time is ideal for doing exercises. ( for proper monitoring of wound site)

• After skin grafting, exercise should be discontinued for 3-5 days (only burned area)• ROM in area of unhealed burns can be extremely painful, thus coordinating an

exercise session with the administration of pain medication will lessen the painful episodes for the patient.

• Family counseling should be done for keeping the patient motivated and moving as much as possible.

74

4. RESISTIVE AND CONDITIONING EXERCISE:

• Patients with major burns may lose body weight, and lean muscle mass can decrease rapidly.

• Exercise may consist of isokinetic, isotonic, or other resistive training devices.• Resistive devices such as free weights and pulleys can be used to prevent loss of

strength in areas.• Cycling, rowing machine, treadmill walking, stair climbing should be encouraged.• Stretching of the burned area is done to prevent formation of contractures. • For the purpose of preparation of ambulation, patient should be taken on tilt table so

that the patient won’t get orthostatic intolerance or hypotension.

75

5. Ambulation :

• It should be started as soon as possible .• When initiated after a skin grafting, the lower extremities should be wrapped in

elastic bandages in a figure - of - eight pattern . • This is done to support the new grafts and promote venous return.• Initially a patient may require a assistive devices. (Like walker and canes.)

76

77

6. Scar management :

The aim is to have a scar which is as flat, supple (ie can stretch) and as soft as possible. It can take 1-2 years for a scar to mature. This depends on:

1. How deep the burn is (deeper burns means scars are more likely).2. Time taken for the burn to heal (the longer it takes to heal, the more risk of scarring).3. Skin color (darker skin is more likely to have problem scarring).4. The part of the body (areas over joints are usually more likely to have problem scarring).

There are some special dressings that are often used to help reduce the development of scars:

1. Tubigrip (tube bandage) or compression garments2. Adhesive tape - to provide compression.3. Silicone products - gel sheets and moulds.

• During the first 3-4 months after the injury , newly healed areas becomes raised and firm

• In this case, pressure is been used to hasten the scar maturation and to minimize the hypertrophic scar formation.

• Pressure exerts control over hypertrophic scarring by –

1. thinning the dermis

2. decreasing the blood flow to area

3. reorganizing the collagen bundles

4. decreasing the water content

• Scar management is done under following headings:

1. pressure dressings

2. massage

3. camouflage makeup

78

79

PRESSURE DRESSING

80

CAMOUFLAGE MAKEUP

81

INTRODUCTION

• A pressure sore is a wound caused by unrelieved pressure to the dermis and underlying vascular structures , usually between bone and support surfaces.

OR• A pressure sore an ischemic skin ulcer of variable depths, caused by application of excessive

pressure or shear injury on the skin and subcutaneous tissues.

• When pressure is sustained for a long period of time, irreversible damage occurs to the tissues, and finally develops a visible wound of pressure sore.

• Synonyms : 1. decubitus ulcer

2. bed sores

3. black sloughs

4. trophic ulcers

5. necrotic ulcers

6. ischemic ulcers

• The most preferred term is “pressure sores” because it best suggests the true cause of these lesions. In 1980, Scales coined the term “distortion sores” as the synonym for pressure sores. 82

83

HISTORY

• In 1853, Brown – Sequard identified pressure & moisture of skin as the major cause of ulceration.

• In 1873, Paget defined pressure sores as the sloughing and mortification or death of a part produced by the pressure.

• Unfortunately these early insights for the pathogenesis of pressure sore were discarded after Charcot’s views on the problem became famous.

• In 1879, “Charcot’s Theory” stated that ‘nerve injury caused the release of a neurotrophic factor that resulted in tissue necrosis.’

• In 1940, Munro considered that spinal cord injury caused a disturbance of the ANS that resulted in a decrease of the peripheral reflexes and predisposed to skin ulceration. For this reason, he considered pressure sores as an inevitable complication of SCI .

84

AETIOLOGY

• Many factors contribute to the development of pressure sores, pressure leading to ischemia is the final common pathway.

• The aetiological factors of pressure sores are been classified into 2 types of factors :

85

EXTRINSIC FACTORSEXTRINSIC FACTORS INTRINSIC FACTORSINTRINSIC FACTORS

AETIOLOGICAL FACTORS

INTRINSIC FACTORS :

1.) decreased blood supply to the skin

2.) impaired mobility

3.) sensory impairment

4.) paralysis and insensibility

5.) nutritional status – malnutrition

6.) age – old age

7.) pain

8.) co-existing medical conditions such as : diabetes mellitus, chronic lung

diseases and heart failure .

According to Reed et al, the presence of low albumin levels , confusion and a “Do Not Resuscitate” (DNR) order are also the risk factors for pressure ulcers.

86

EXTRINSIC FACTORS : 1.) Nature of support surface on which the patient is lying . 2.) Frequency of turning of patient . 3.) Techniques of lifting and transferring of patient . 4.) Presence in bed of urine , faeces , folds of bed sheet , food crumps , etc.

87

PRONE AREAS

88

• There are some areas which are more prone to get the pressure sores .

• The distribution of risk of developing pressure sores in different areas of body was given by ---

Stapelson (1978)

Jordan & Clark (1977) .

• Above the level of

umbilicus - 4%• Below the level of

umbilicus - 96%

67% 29%

around the hip on lower limb

AREA OF BODY PREVELANCE

1.) Occipital region (protuberance) 0.4%

2.) spinal region 2%

3.) anterior elbow 2%

4.) posterior elbow 6%

5.) hip region 15%

6.) anterior sacral region 27%

7.) posterior sacral region 43%

8.) trochanter region 5%

9.) buttocks 32%

10.) ischial tuberosity 23%

11.) anterior knee region 1%

12.) posterior knee region 2.5%

13.) anterior ankle region 1%

14.) posterior ankle region 9%

15.) heels 30%

• Bony prominences : which have an inadequate cushioning of subcutaneous tissues.

• Ectopic bone formation or metal prostheses such as internal fixation for fractures can also be foci for pressure damage.

• Areas where soft tissues are in opposition , e.g. under the breasts or in genital region, inner surfaces of thigh from catheters are also prone to develop ulcers.

• Muscle spasm and contractures may lead to pressure ulceration of the medial aspects of knees and medial malleoli of the heels.

• In 1980, Phelan has reported the formation of auricular scalp pressure sores on infants with pierced ears.

89

90

91

92

PRONE PATIENTS

• Elderly patients• Persons who are neurologically impaired eg. SCI and stroke

patients.• Patients who are immobilised for prolonged period of time eg.i case

of fracture shaft femur, or comatised patients.• Patients who are acutely hospitalized , incontinent, and

underweight.

93

• Why are elderly patients more prone to develop pressure sores?

• Age related changes I the skin are a factor I the development of pressure sores. Eg. Changes in the collagen synthesis resulting in :

1.) reduction of mechanical strength of tissues

2.) decrease in elastin contents of tissues

3.) thinning of epidermis

4.) flattening of dermal – epidermal junction

5.) increased skin permeability

• Ill old patients are prone to :

1.) vascular insufficiency

2.) immobility

3.) malnutrition

4.) incontinence

5.) sedative drug use

94

PATHOGENESIS• In pathogenesis of pressure sores, 3 factors are been identified as of great importance :

1.) direct pressure

2.) shearing forces

3.) friction• Direct pressure :

The simplest model for the effect of direct pressure is that “ it compresses tissues “.

When the imposed pressure is > capillary filling pressure (30-35 mm Hg), the capillaries are occluded and the dependant tissues are deprived of lack of blood supply.

If this pressure is sustained for a prolonged time – ischemic tissue dies and develops a pressure sore.

• Shearing forces :

These forces causes disturbance and destruction of the microcirculation by thrombosis of the vessels , i.e. by causing capillary wall damage.

• Friction :

It causes stripping of the corneal layer of skin leading to superficial ulceration.

95

96

SHEARING FORCES

DIRECT PRESSURE

FRICTIONAL FORCES

CAPILLARY WALL DAMAGE

INCRESE IN PRESSURE >CFP

STRIPPING OF CORNEUM

ISCHEMIA

NECROSIS

TISSUE ANOXIAINFLAMMATION

Micro- Circulatoryocclusion

PRESSURE ULCER

STAGES OF PRSSURE SORES

• The most widely accepted system of classification is that of Shea, which has been modified to represent the present National Pressure Ulcer Advisory Panel Classification System.

• This system consists of 4 stages of ulceration, and it is designed to describe the depth of a pressure sore at the specific time of examination , in order to facilitate communication among the various disciplines involved in the study and care of such patients.

97

STAGE DEFINITION APPEARANCE AVERAGE HEALING TIME

INon- blanchable erythema of intact skin

pink skin that does not resolve when pressure is relieved ; discoloration; warmth; induration

14 days

II

Partial-thickness skin loss involving epidermis and /or dermis

Cracking; blistering; shallow crater; abrasion

45 days

III

Full – thickness skin loss into subcutaneous fatty tissues or fascia

Distinct ulcer margin; deep crater

90 days

IV

Full – thickness skin loss with extensive tissue involvement of underlying tissues

Extensive necrosis; damage to underlying structures

120 days

98

99

RISK ASSESSMENT

• There are some pressure sore risk estimator scales , by which we can find out the patients who are at risk of developing pressure sores.

• They are as follows :

1.) Norton scoring system

2.) Braden scale

3.) Douglas scale

4.) Waterlow scale

• The most commonly used is Norton scoring system.

100

101

The Norton Scoring system, shown below, was created in England in 1962 , has been the first pressure sore risk evaluation scale to be created.

> 18 Low risk

14 – 18 Medium risk

10 – 14 High risk

< 10 Very high risk

the risk factor is coded this way:

102

PHYSICAL Good 4

CONDITION Fair 3

Poor 2

Very bad 1

MENTAL Alert 4

CONDITION Apathetic 3

Confused 2

Stuporous 1

ACTIVITY Ambulant 4

Walks with help 3

Chairbound 2

Bedfast 1

MOBILITY Full 4

Slightly impaired 3

Very limited 2

Immobile 1

INCONTINENCE None 4

Occasional 3

Usually urinary 2

Urinary and feacal 1

PREVENTIVE MEASURES

A plan of action must follow to prevent pressure sore formation. This must include following :

1. Decision on the kind of support surface , to minimize the risk. To avoid localized protection , water-filled gloves and doughnut shaped cushions should be avoided.

2. Identification and action on intrinsic factors that can be influenced. Eg correct the anemia and add nutritional supplements.

3. Frequently turn the patient in bed . Usually within every 2 hours.

This 2-hourly turning or repositioning regime which is been widely used had its origin in “ Stoke Mandeville Hospital “ where they determined that the patients who were turned every 2 hours didn’t develop pressure sores.

4. Regular re-examination of risk factors and looking at areas of skin at risk for early warning signs e.g.. Blanching erythema.

5. Application of agreed practices to prevent friction and shearing forces on the body. Proper lifting and handling should be done.

103

6. Ensuring that the patient’s skin is protected from urine, faeces, food crumps and folds in bed sheet. Attention to the details is important. In 1873, “ Paget “ wrote while assessing for risk of pressure sores, “ first of all look to bed. Good bed-making is an indispensable thing in prevention of bed sores. "

7. The use of positioning devices such as pillows or foam wedges to keep bony prominences away from each other, e.g. use of a pillow to separate knees in patients with adductor spasm.

8. Consider “ self – help devices “ such as monkey poles with slings or rope ladders which enable the patient to change the position of areas at risk.

104

MANAGEMENT

105

CLINICAL MANAGEMENT

PHYSIOTHERAPYMANAGEMENT

Conservative :• Use of supportive surfaces• Proper dressing• Nutritional support

Surgical :• Debridement• Release of contractures• Amputation

106

CLINICAL MANAGEMENT

1.) SUPPORTIVE SURFACES :• The first step in treatment is to reduce or eliminate the cause i.e. PRESSURE . For this specialized

support surfaces are available .

• According to FEDERAL REGULATIONS ( Medicare Bulletin 405 ) dictate that patients with bedsores or those who are at risk for bed sores must be placed on an appropriate support surface.

• The motive is to maintain the tissues at pressures < 30 mm Hg .

• There are 3 classes of support surfaces :

1.) CLASS I support surface : it is a simple pressure pad device which is required in :

a. Patients who cannot independently change their body position to effectively reduce the pressure.

b. Patients who have any stage of pressure ulcer on trunk or pelvis + impaired nutritional status,

fecal or urinary incontinence , altered sensory perception or compromised circulatory status.

eg. 3-5 inch foam mattress, gel overlay, egg – crate mattress.

107

Conservative treatment

Foam mattress Gel overlay mattress Egg – crate mattress

2.) CLASS II support surface : it is a pressure-relieving device that reduces the pressure over bony prominences to < 30 mm Hg and that does so for a sustained period . It is required in :

a. Patient who have multiple pressure sores on the trunk or pelvis that does not improve inspite of comprehensive treatment ( i.e. use of class 1 surface for about 1-2 months.)

b. Patients who have large , multiple stage III or IV ulcers.

c. Patients who have undergone a skin flap or skin graft procedure within past 60 days .

It is either a powered or non-powered air overlay for mattress with low air loss feature.

examples : Roho dry floatation mattress system , Pegasus Renaissance mattress.

108

3. ) CLASS III support surfaces : it is an air – fluidized bed , where floatation is done by filtered air flow pumped through porcelein beads .

It may be used only for failure of a comprehensive treatment plan after 30 days.

It is contraindicated for any patient with associated severe pulmonary compromise because the absence of firm back support makes coughing ineffective, and the dry air thickens the secretions.

example : - Clinitron bed

109

110

2.) WOUND DRESSING :

The dressings for the wound may vary with the state of the wound..

stage 1 : no requirement of dressing

stage 2 : treated with occlusive dressings

stage 3 & 4 : surgical treatment required Daily whirlpool :Also may serve to irrigate and mechanically debride the wound.

T he vigorous whirling and agitation of the water contributes to its cleansing action.

Here the turbulence of water flow is thought to assist in removing surface debris.

Occlusive dressings :• Also called as “primary” or “moisture retaining” dressings.• Hydrocolloid dressings : Eg. Granuflex, comfeel.• Hydrogel dressings : eg. Geliperm • Semi permeable film dressings : eg. Tegaderm and opsite.• Alginates : eg : kaltostat and sorbsan• Odour absorbing dressings : eg. Kaltocarb and actisorb.

Non – occlusive dressings :• Also called as “secondary dressings”.• Usually they are unsuitable, but can be used as secondary dressings over the primary

dressing which is next to the wound surface.

111

TYPES OF DRESSINGS

OCCLUSIVE NON - OCCLUSIVE

3.) NUTRITIONAL SUPPORT :• High protein diet is recommended.• The aim is restore a positive nitrogen balance and a serum protein level of

6 mg / 100 ml or higher as shown to facilitate wound healing .

112

• Reconstruction of a pressure ulcer is aimed at :1. Improvement of patient’s hygiene and appearance

2. Prevention and resolution of osteomyelitis and sepsis

3. Reduction of fluid and protein loss through the wound

4. Prevention of future malignancy ( Marjolin’s ulcer)

1.) DEBRIDEMENT :• It is defined as the removal of foreign material and dead or damaged tissue, especially in a

wound.• It is an important intervention to :

1.) prevent and to control bacterial growth,

2.) enhance the rate of tissue healing

3.) enhancing cellular activity in the wound bed . • It can be of three types :

1.) mechanical

2.) enzymatic

3.) autolytic

113

Surgical treatment

114

1.) MECHANICAL DEBRIDEMENT

115

2.) ENZYMATIC DEBRIDEMENT

116

3.) AUTOLYTIC DEBRIDEMENT

2.) AMPUTATION :• It may be required for a non-healing wound and usually stage 4 ulcers.• The whole area of wound is been amputed so as to prevent further spreading of it.

3.) RELEASE OF CONTRACTURES :• The release of flexion contractures resulting from spasticity may assist with

positioning strategies.

117

CHARTING OF PRESSURE SORE HEALING

Length X width (in cm2 )

0 0

1 <0.3

2 0.3-0.6

3 0.7-1.0

4 1.1-2.0

5 2.1-3.0 score

6 3.1-4.0

7 4.1-8.0

8 8.1-12

9 12-24

10 >24

Exudate amount 0 none

1 light

2 mod.

3 heavy score

Tissue type 0closed

1Epithelial tissues

2Granulation tissue

3slough

4Necrotic tissues

Score

Total score : ( ranges from 0 to 17 )

118

PUSH ( pressure ulcer scale for healing )

119

INTRODUCTION

• A break in the continuity of body structures caused by violence or trauma to the tissues.

• A wound is a type of injury in which the skin is torn, cut or punctured ( open wound ) , or where blunt force trauma causes s contusion ( closed wound ).

• A wound is a type of injury usually involving division of tissues or rupture of the integument or mucus membrane, due to external violence or some mechanical agency rather than disease.

120

CLASSIFICATION

121

WOUNDS

OPEN WOUNDS CLOSED WOUNDS

1. INCISED WOUNDS2. LACERATIONS3. ABRASIONS4. PUNCTURE WOUND5. PENETRATION WOUND6. GUNSHOT WOUND

1. CONTUSIONS2. HEMATOMAS3. CRUSH INJURIES

• INCISED WOUND : Any sharp cut in which the tissues are not severed ; a clean cut caused by a keen cutting

instrument.

it may be either aseptic or infected , depending on the circumstances that caused it.

122

123

LACERATED WOUND

ABRASIONS

124

PUNCTURE WOUND

GUN SHOT WOUND

125

CONTUSION

HEMATOMA

126

CRUSH INJURY

WOUND HEALING

127

128

1. FIRST INTENSION : ( PRIMARY )

It is the healing that occurs when a clean laceration or a surgical incision is closed primarily with sutures, steri – strips, or skin adhesive.

2. SECOND INTENSION : ( SECONDARY )

It is the healing that occurs when a wound is left open to heal by granulation, contraction, and epithelialisation.

3. DELAYED PRIMARY CLOSURE :

It is a combination of primary and secondary healing. This term is often applied to the lacerations that are not considered clean enough for primary closure. The wound is now left open for 5-10 days, and then it is sutured closed to decrease the risk of wound infection.

TYPES OF HEALING :

• Diabetes • Infection

• Drugs ( steroids and antimetabolites )• Nutrition problems• Tissue necrosis• Hypoxia• Excessive tension on wound edges• Another wound area• Low temperature

129

FACTORS ADVERSLY AFFECTING HEALING :

• Cleansing• Debridement• Topical agents• Mechanical modalities• Dressings• Manual lymphatic drainage• Compression therapy

• Pressure relieving devices

130

MANAGEMENT

CLEANSING :• Optimal wound healing cannot proceed until all foreign material is removed from the wound.• Cleansing has 2 components :

1. cleansing agents

2. irrigation techniques

1. Cleansing agents : the most commonly used is isotonic saline ( 0.9% NaCl)

2. Irrigation techniques :

wounds need to be irrigated with enough force to enhance cleansing without traumatising the wound bed.

an ideal pressure for flushing necrotic tissues from a wound is 8 psi.

following irrigation techniques can be used :

a.) whirlpool b.) pulsatile lavage with suction c.) non-forceful irrigation

131

TOPICAL AGENTS :

• ANTISEPTICS : povidone – iodine , hypochlorite solution , acetic acid solutions , H2O2.• ANTIBACTERIALS : bacitracin , neosporin , silvadene , furacin , gentamycin.• ANALGESICS : Lidocaine and amitryptylin.• GROWTH FACTORS : application of exogenous growth factors in conjunction with good

wound care increases wound healing. Eg. Procuren.

MECHANICAL MODALITIES :

• ULTRASOUND• ELECTRICAL STIMULATION• ULTRAVIOLET RADIATIONS• HYPERBARIC OXYGEN THERAPY• NEGATIVE PRESSURE WOUND THERAPY• COLD LASER THERAPY

132

MANUAL LYMPHATIC DRAINAGE :

COMPRESSION THERAPY : 1. UNNA’S BOOT 2. 4-LAYER BANDAGE

3. PRESSURE GARMENTS

133

POSITIONING :• The patient’s heel should be protected and elevated off the surface of the bed.• The head of the bed should not be elevated past 30 degree unless medically necessary.• An individualized turning program cycling from 30 to 120 minutes should be provided.• Pressure relieving devices should be used in conjunction with a turning schedule.• Positioning with full weight – bearing over an existing wound should be avoided.• Pillows and wedges should be used to separate bony prominences from bed and other body

parts.

PRESSURE RELIEVING SUPPORT SURFACES

134

135