B3 L41/42: Management of Burn Injuries Flashcards
What is the function of the epidermis?
Superficial protective layer
Are there blood vessels in the epidermis?
No
What are the 3 things in the epidermis? How do they relate to the function of the epidermis?
- Keratin which toughens and waterproofs
- Melanin (melanocytes) for UV protection
- Rete pegs (undulation) for attachment/adherence to dermis
How many layers are in the dermis?
2
What are the 2 layers of the dermis?
Papillary layer
Reticular layer
What is found in the dermis?
Collagenous network of blood and lymph vessels, nerves, elastin fibres and collage
What is the function of the dermis?
Provides mechanical strength of the skin
What are 3 epidermal appendages? What are they all surround by? What is the function of the epidermal appendages?
• Hair follicles, sweat glands, sebaceous glands
• All are surrounded by epidermal cells & a rich network of capillaries
Centre for regeneration of the epidermis
If _______ intact, then epidermis will heal. If no _______, then healing by secondary intention.
hair follicles; hair follicles
The ______ of dermis and epidermis varies throughout the body. Where is the thinnest and thickest skin found?
thickness
* Thinnest skin – eyelids (0.05mm epidermis and 0.3mm dermis) * Thickest skin – palms and soles (1.5mm epideris) and back (3mm dermis)
What does the Fitzpatrick Skin Type Scale measure? What does it indicate? Which skin types have the worst healing ability?
measures skin’s tolerance to sunlight and tendency to tan or burn.
• Indicates the ability to heal burns. Also depends on genetics.
• Type I & VI have the worst healing ability.
What are 2 features of type I skin?
• Pale white; blond or red hair; blue eyes; freckles;
Always burns, never tans
What are 2 features of type II skin?
• White; fair; blond or red hair; blue, green, or hazel eyes;
Usually burns, tans minimally
What are 2 features of type III skin?
• Cream white; fair with any hair or eye colour; quite common;
Sometimes mild burn, tans uniformly
What are 2 features of type IV skin?
• Moderate brown; typical Mediterranean olive skin tone;
Rarely burns, always tans well
What are 2 features of type V skin?
- Dark brown; Middle Eastern skin types;
* Very rarely burns, tans very easily
What are 2 features of type VI skin?
- Deeply pigmented dark brown to black;
* Never burns, tans very easily
What are 2 features of glabrous skin? Give examples of body parts with this skin?
• Thick epidermis
• No hair
e.g. Palms, soles, lips, genitals
What are 2 features of hairy skin? Give examples of body parts with this skin?
• Thin epidermis
Yes hair follicles
What are the 5 functions of skin?
Interprets sensory input and protects from environment
Prevents excessive water loss
Regulates temperature control
• Allows heat dissipation via conduction, convection and radiation (via papillary plexus)
• Regulation of Sweat glands to control temperature
Provides defence against infection
Maintains moist environment for internal organs
What are 5 implications for the body from skin loss?
Impaired skin sensation - hypersensitivity
Increased evaporation of water from skin
- Increased energy requirements
- metabolic disturbances
- Implications for fluid balance
- Impaired temperature control
Access point for infection
Loss of moist environment for muscles, tendons and nerves - damage, ruptures.
What are the 4 types of burns?
Flame
Scald
Chemical
Electrical
Which type of burn is most common in adults?
Flame
Which type of burn is most common in children and the elderly?
Scald
Which type of burn is most common in the workplace?
Flame
Chemical
Electrical
What is the complication with an electrical/chemical burn?
damage to deeper structures (e.g. muscles, nerves)
What are the 4 depths of burns?
Superficial burn
Superficial partial thickness burn
Deep partial thickness burn
Full thickness burn
What area(s) is destroyed in a superficial burn?
Epidermis
What area(s) is destroyed in a superficial partial thickness burn? (2)
Epidermis + superficial dermis
What area(s) is destroyed in a deep partial thickness burn? (2)
Epidermis + deep dermis
What area(s) is destroyed in a full thickness burn? (3)
- Epidermis + dermis + underlying structures
- Subcutaneous fat, nerves, tendons, bones
- Bone burn - esp fingers & toes - amputation
What is the appearance of a superficial burn?
Red and blistered
What is the appearance of a superficial partial thickness burn?
Red to pink, blistered. Brown is epidermis peeling off. Hair follicles alive.
What is the appearance of a deep partial thickness burn?
• Creamy moist white appearance
• Pseudomembrane (fluid film) may be present, oedematous
More scarring
What is the appearance of a full thickness burn?
- White, tan, black, bright red
- Redness around wound = infection = cellulitis
- Dry leathery appearance.
- No hair follicles.
What is the sensation like in a superficial burn?
Sensation intact, hypersensitive.
What is the sensation like in a superficial partial thickness burn?
Sensation intact, hypersensitive and painful.
What is the sensation like in a deep partial thickness burn?
• Sensation intact but maybe decreased
• sensation to light touch in some areas (some nerve
endings damaged)
What is the sensation like in a full thickness burn?
No light touch sensation because no nerves.
What is the sensation like in a superficial burn?
Rapid capillary return/blanching, because no capillaries in epidermis - no damage to circulation.
What is the sensation like in a superficial partial thickness burn?
Rapid capillary return/blanching
What is the sensation like in a deep partial thickness burn?
Delayed capillary return/blanching (5-6 seconds)
What is the sensation like in a full thickness burn? What does this cause?
- No capillary return/blanching
* Full thickness burn circumferentially around the limb will constrict blood flow around limb - compartment syndrome.
Is there wound closure in a superficial burn?
Wound closure spontaneously in 7-10-14 days
Is there wound closure in a superficial partial thickness burn?
Wound closure spontaneously in 14 days
Is there wound closure in a deep partial thickness burn?
From wound edge and epidermal appendages in >14 days
Is there wound closure in a full thickness burn?
Takes >3 weeks for closure (healing by secondary intention)
Need grafting
How can the size of the burn be measured?
Total body surface area affected (% TBSA)
Why is the total body surface area affected (% TBSA) important?
essential for accurate calculation of fluid replacement - prevent renal failures especially in bigger burn
What are 2 benefit of the Lund & Browder chart?
Fast (done in the ambulance)
Prioritise skin grafting & rehab by depth of burn
How is a burn measured by the Lund & Browder chart?
Rule of nines gives a quick estimate of % burn
What are 10 criteria for assessing whether burns require treatment in a specialised burns unit?
• Burns >10% TBSA
• Burns of special areas - face, hands, feet, genitalia, perineum, and major joints
• Full-thickness burns >5% TBSA
• Electrical burns
• Chemical burns
• Burns with an associated inhalation injury
• Circumferential burns of the limbs or chest
• Burns in the very young or very old
• Burns in people with pre-existing medical disorders that could complicate management, prolong recovery, or increase mortality
Burns with associated trauma.
What is the time period of the inflammatory phase?
(1-5 days)
What is the time period of the proliferation phase?
3-5days - 3 weeks
What is the time period of the remodelling phase?
3 weeks - 12-18 months - 2 years
What are the 3 features of the inflammatory phase?
• Vasodilation and increased permeability of
• blood vessels
• Oedema
Coagulation - promotes migration of macrophages.
What are the 4 features of the proliferation phase?
- Macrophages release chemotactic agents which attracts fibroblasts
- Fibroblasts produce collagen
- Fibroblasts differentiate into myofibroblasts
- Myofibroblasts first appear day 3-5, peak in number at 4-5/12 post burn.
- Myofibroblasts are contractile and pull edges of wound together - scar contracture especially around joints.
- Wound closed with scar.
- Dermis of disorganised collagen. Thick red hypertrophic scars.
- Epidermis lacks connection with dermis.
- Prone to abrasion and micro trauma.
What are the 3 features of the remodelling phase?
• Collagen forms crosslinks to strengthen the scar.
Collagen organised, more parallel. Exercise helps to line up collagen
What are 12 features of a hypertrophic scar?
• Excessive collagen deposition by fibroblasts into whorl-like haphazard collagen bundles
• Reduced amount of highly cross linked collagen (reduced skin strength)
• Develops within 1-3 months post-injury, progresses for 3-6 months, gradual regression over time
• Increased blood supply in scar (highly vascular/red)
• Build-up of granulation tissue (thick and raised)
• 2-3x rate of normal skin fibroblasts
• No significant difference in collagen degradation
• Minimal regeneration of elastin fibres
• Changes in ground substance (“bony like”)
• Significantly reduced skin stretch
• Constant contraction through myofibroblast activity
Adhesion to underlying structures
What are 11 risk factors for scarring? Explain why?
• Race: Dark skinned = more scarring. Asian and African skin types = less scarring.
• Genetic predisposition: Keloid > hypertrophic scar.
• Site of scar: Head, hands, neck and axilla, across joints
• Depth of wound: Deeper the wound takes longer to heal
• Prolonged inflammation and increased granulation
• Skin grafting: Reduced scar vs wounds > 21 days to heal
• Type of grafting: SSG > full thickness grafts
• TBSA, no. of surgical procedures and anatomical location – increase contracture risk
• Age: Children and adolescents > adults.
○ Children already collagen because growing + additional scar collagen. Scar has to stretch with growth, but it doesn’t stretch well - high risk of contracture.
• Female gender
Compliance or access to early treatment: Non-compliance = high risk of scar.
What are 8 contributing factors to contractures?
• Depth of Wound
• Time to wound healing
• Large % burn wound
○ Muscle catabolism due to hypermetabolic state
○ Multiple areas to address at once
• Duration of joint immobilisation
• Deconditioning and loss of muscle strength to oppose skin contracture
• Muscle weakness e.g. associated neuropathy
• Other soft tissue or bony pathology: e.g. Heterotopic ossification, underlying fractures and need for longer immobilisation
• Decreased access to or compliance with therapy
What are 3 first aid steps (most important) after a burn?
• Stop the burning
○ Stop drop roll / Wrap in blanket / water irrigation
○ Remove heat source
• Copious water irrigation
○ 20 mins cold running water, then cling wrap the wound
○ Avoid dirt/dirty water if possible
Avoid hypothermia: Wrap blanket around patient because skin burn = lose temperature
What are 9 medical management steps after a burn?
• Assessment of size and depth of burn
• Fluid resuscitation if TBSA >15%
• Management of airway +/- inhalation injury: Burns around face & neck.
• Escharatomy prevents compartment syndrome.
• Prevention and management of infection: Tetanus injection
• Nutritional support
○ Early enteral feeding reduced morbidity (<24 hours) - shorter ICU stay and reduced wound infections.
○ >15% TBSA burn should have supplemental feeding via oral route
○ High protein diet helps healing.
• Wound management: Conservative vs skin grafting
○ Early debridement and grafting blunts SIRS response and reduces risk of infection (< 48 hours)
○ Priority areas – line sites, trachea site
• Pain management
○ Long acting (MS contin), short acting for procedures (morphine), ketamine
○ Gabapentin – burning pain. Use from the start.
○ Others – entonox (happy gas), anti-anxiety medications
DVT and ulcer prophylaxis
What is a escharotomy?
Incision through eshar to relieve pressure and improve tissue perfusion in muscle compartment
When and where is an escharotomy done?
- Usually done when circumferential full thickness burns
* Limbs, chest, abdominal (rarely neck/digits)
What are 5 assessments for an escharotomy?
○ Pain/paraesthesia/loss of function ○ Cap refill/pulse oximeter < 90% O2 ○ Peripheral pulse/doppler pulses ○ Compartments feel tight (compartment pressures >25mmHg) Increased ventilatory pressures
When are abdominal and chest escharotomies required?
May be necessary to improve ventilation
Escharotomies can extend to ________ if pressures not corrected – more common in _________injury
fasciotomy; electrical
What is the Conservative Wound Management?
Silver based dressings
What are the 2 benefits of the Silver based dressings?
- Provides antibacterial effects
* Promotes wound healing
What are the 2 types of Silver based dressings? How are they different?
- Acticoat and Mepilex Ag can stay intact for 3-7 days (outpatient dressing, waterproof)
- Silvazine / Flamazine cream 24 hours effect, changed daily
What are 5 surgical treatments for a burn (Early excision and wound closure)?
• Autograft • Cultured autologous keratinocytes • Homograft – Cadaver allograft • Skin Substitutes ○ Integra ○ Biobrane Flaps
How is an autograft post burn done?
- Burn wound bed is debrided to viable tissue
- Donor skin taken usually from anterolateral thigh- absolute thickness is variable (8/1000 - 24/1000 inch)
- Skin graft secured (usually with staples but also use glue or sutures)
- Surrounding joints immobilised with splints for 3 days to allow take of the graft
What are 3 features of a Full thickness graft?
- Thick donor site of all layers of skin - uncommon
- Take graft from somewhere that closes easily (e.g. webspace of hand)
- Needs a split thickness graft to cover the defect left at donor site
What are 2 features of a split thickness graft?
• Epidermis + superficial dermis
• Burn wound heals quickly
Donor site heals 2/52
What are 4 features of a meshed graft?
- Mesh stretches skin graft 4x size - greater coverage, need less skin graft.
- Better earlier take of graft
- Mesh allows exudate to be evacuated from under graft
- Cosmetically always left with a mesh pattern
What are 4 features of a non-meshed graft?
- Cannot spread skin - need more skin grafts.
- More fragile, purple in earlier stages as no mesh to allow escape of exudate from under graft
- Nurses may need to prick graft and roll exudate or haematoma out from under graft to improve graft take
- Better aesthetically as no mesh pattern – usually used for face or hands
What are 3 factors in graft take/
• Appearance: Pink skin, securely adhered and blanches with pressure
• Adherence: Fibrin is responsible in first 48 hours
• Revascularisation
○ First 48 hours - plasmic imbibition
○ 48-72 hours: Anastomoses of vessels in graft and wound bed. Growth of new endothelial buds.
○ Day 3 start exercise
Complete at day 5-6
What is the process of Cultured Autologous Keratinocytes?
- Biopsy of epidermal cells taken behind ears
- Cells cultured in lab to form skin sheets (2-3 weeks) or cell suspension (5 days)
- Indication: TBSA >50%, then not enough autografts.
What are 2 advantages of Cultured Autologous Keratinocytes?
- Cover large %TBSA burns without need for donor sites
* Nil rejection, heal quickly (patient’s own skin)
What are 2 disadvantages of Cultured Autologous Keratinocytes?
- Skin remains fragile - lack of dermal attachments
* Inflammation can cause blistering and sloughing off of cells
What is an indication to use Cultured Autologous Keratinocytes?
TBSA >50%, then not enough autografts
What are 4 factors to consider for a homograft (Cadaver Allograft)?
• Temporary cover - used as biological bandaid.
○ Over debrided wound bed
○ Sandwich graft: Deep autograft + mesh + superficial homograft. Homograft will slough off later. Autograft will adhere.
• Rejection occurs in 7-14 days
• Risk of transmitting viruses/infection
• Expensive, short supply, needs cryopreservation
What is integra?
• 2 layer artificial skin substitute
○ Dermal replacement layer provides scaffold for patient’s own dermis to grow into
○ Epidermal substitute - silicone layer
• Artificial dermis is allowed to vascularise (14-21 days), then silicone layer is removed and replaced with a thin epidermal autograft
What are 6 advantages of intergra?
• Early wound closure without donor sites
• Large TBSA covered in one operation
• Less hypertrophic scarring
• Thinner donor sites needed for coverage - less donor site pain, faster healing, frequent reharvesting
• No rejection
Grows with children
What are 2 disadvantages of intergra?
• Poor resistance of dermis to infection
• Less drainage of exudate through solid sheet of silastic
Need for a second operation in smaller burns
What are 5 features of biobrane?
• Synthetic nylon mesh fabric covered with silicone rubber membrane
• Semi-permeable to water
• Protective barrier to micro-organisms
• Temporary cover for partial thickness burns
May still require grafting after removal of biobrane
What are 6 features of flaps (plastic surgery)?
• Performed when a simple skin graft is not enough to cover a wound
• Used to cover exposed bone, tendon or other structures.
• Flaps are classified as either
○ Skin flaps (skin and subcutaneous tissue with or without underlying fascia)
○ Muscle flaps (flap created from muscle with or without attached overlying skin).
• Difference between a flap and a graft
○ Flap usually transferred with its own blood supply
○ Skin graft blood supply has to come from the underlying wound bed
• Free flap vs Pedicle flap vs Rotational flap
• More prolonged immobilisation – 10 days
What are 3 reasons for an increased risk of respiratory complications after burn injuries?
• Bed rest ○ Reduced FRC ○ Increased risk of pneumonia • Multiple anaesthetics • Inhalation injury: Lower respiratory tract damage due to chemical compounds in smoke ○ Damage to mucosal lining ○ Mucosal oedema ○ De-epithelialisation ○ Pseudomembrane formation - airway plugging and compromised alveolar ventilation ○ Deactivation of surfactant
What are 12 signs and symptoms of Inhalation Injury?
• Burn injury occurred in enclosed space
• Lowered consciousness at time of fire
○ Alcohol use
○ Drug use
○ Pre-existing condition eg HI, CP
• Facial / oral burns
• Singed nasal hairs
• Soot in mouth or nose
• Hoarse voice
• Respiratory distress: #RR, # accessory muscle use, SOB
• Bronchospasm/stridor
• Carbonaceous / sooty sputum
• Auscultation - wheezes initially and then fine crackles
• ABGs - high levels of carboxyhaemoglobin, decreased PaO2
• Chest X-ray - patchy atelectasis and pulmonary oedema
How can an inhalation injury be diagnosed? What are 5 clinical presentations?
Bronchoscopy • Airway oedema • Airway inflammation • Mucosal necrosis • Pseudomembranous plugs Soot or char in the airways
What are 3 symptoms of an acute pulmonary insufficiency
(first 36 hours post injury) of an inhalation injury?
• Hypoxia / atelectasis / CO poisoning
• Fire consumes available oxygen
• CO disturbs O2 carrying capacity
• Atelectasis compounded by laryngeal spasm and coughing
• Bronchospasm - due to acids / aldehydes
Laryngeal and upper airway oedema compromise airway
What are 3 symptoms of a pulmonary oedema
(6-72 hours post injury - peaks at 12 hours) of an inhalation injury?
• Massive inflammatory reaction - increased vascular permeability - oedema
Presence of pulmonary oedema and deactivation of surfactant leads to decreased lung compliance
What are 3 symptoms of a bronchopneumonia
(3-10 days post injury) of an inhalation injury?
- De-epithelialisation of mucosa
- Pseudomembrane forms on airway wall
- Separation of pseudomembrane
- Obstruct airway
- Prevention of normal mucous clearance
- Pooling of secretions
- Distal atelectasis and bronchopneumonia
What are 8 Medical Management of Inhalation Injury?
- Oxygen
- Intubation and ventilation
- PEEP (positive end expiratory pressure) / CPAP / BiPAP (bilevel positive airway pressure)
- Escharotomies to chest wall
- Bronchodilators
- Humidification
- Nebulised heparin/mucomist break down secretion.
- Regular chest physiotherapy 3-4 times/day, overnight service.
What are 5 Physiotherapy Respiratory Techniques
for ventilated Patients after a burns injury?
- Manual hyperinflation
- Percussion and Vibrations with towel on skin + analgesia
- Suctioning
- Positioning
- Passive/Active limb movements assisted demand ventilation
What are 5 Physiotherapy Respiratory Techniques
for non-ventilated Patients after a burns injury?
- Active mobilisation staged basal expansion ex with insp holds
- Incentive spirometry
- Demand ventilation and mobility
- Positive pressure devices – NIV - BiPAP, PEP masks, flutter. Non-invasive ventilation. High pressure so they can cough.
- Percussion, vibration, postural drainage
What are 4 Physiotherapy Respiratory Techniques after a burns injury?
• Prior to grafting: Can perform percussion / vibrations over burns to anterior chest
• Post grafting: Recommencement of manual techniques depends on grafting technique
○ Post-op day 5 - percussion & vibrations
○ If risk of death, then percussion at post-op day 2, but no vibrations because it shears off the graft from chest wall.
• Inhalation injury
○ Ensure humidification
○ Nebulised heparin
○ Positive pressure techniques are helpful to assist with secretion removal
• Once well enough, then gym CVS fitness.
What are 3 Oedema Management techniques after a burns injury?
• Bandaging – distal to proximal
• Positioning in elevation
Active exercise to activate muscle pum
What are 3 steps to Finger bandaging (2.5cm bandage) after a burns injury?
• anchor at the wrist (no pressure)
• cross up and back on DORSUM, not palmer
spiral 50% overlap down fingers
What are 7 steps to hand bandaging (5-6cm bandage) after a burns injury?
• Spread the fingers • 1st – around MCP’s • 2nd – 50% overlap to thumb web • 3rd – around base of thumb • 4th – through thumb web • 5th + - spiral 50% overlap from base of thumb anchor between fingers
What are 4 steps for Initial ROM and Mobility after a burns injury?
• Start day 0
• Assess level of consciousness (LOC) / cognitive state
• Precautions to movement
○ Other injuries e.g. Fractures, tendon repairs
○ Escharotomies / Fasciotomies
○ Exposed Tendons
• Monitor vital signs
○ Remember high baseline resting HR – this is not a contraindication to early mobility
○ Monitor changes
What are 5 aims of exercise after a burns injury?
• Minimise Contractures / Maintenance of ROM
○ Exercises / Movement in opposite direction to potential contracture
○ Elongation and stretching of skin and underlying structures to minimise risk of contracture
○ Allow collagen to lay down in lines of movement and tension - oriented in a more parallel fashion with scar maturation
• Overcome effects of deconditioning / bed rest
• Minimise effects of hypermetabolism/ muscle catabolism
• Minimise oedema
• Decrease fear of movement
○ Adequate pain relief for exercise session
What are the sessions like (after a burns injury)?
• 1st ROM session whilst dressings down
○ Skin blanching vs skin banding
○ Explain exercises do not cause harm. they can see oedema decreasing - positive feedback. therapist can assess status of burn too.
• 2nd session with dressing on.
• Multiple times a day, once with dressing on, once with dressing off.
• Assess depth of burn and potential contracture
What 6 importants techniques after a burns injury?
• Active / active assisted repeated movements until achieve full ROM day 1
○ Improve muscle strength and endurance to oppose ongoing contracture force
• Passive ROM if patient sedated
• Slow sustained stretch with EOR holds – 1 minute minimum (tissue elongation)
○ Allows gradual creep in tissues
• Hold relax / contract relax
• Encourage functional use of affected areas - encourage adherence
• Education
What are 5 early mobility techniques after a burn injury?
• Mobilise from Day 1 post burn injury if able
• Mobilisation with full WB
○ Improve ambulation, balance, co-ordination and proprioception
○ Restore patient to their premorbid functional level
• Minimise effects of deconditioning
• Minimise effects of catabolism from hypermetabolic response to burns
• Use appropriate compression (e.g. Coban)
○ External support when skin cannot support
○ Decrease blood rush pain, so they can mobilise more easily
○ 50% overlap and 50% stretch
○ Don’t stop at mid-calf – tourniquet effect
○ Don’t leave gaps where swelling can accumulate
○ Monitor capillary refill, sensation
What are 4 Precautions to Exercise - Acute Phase (after a burns injury)?
• Exposed Tendons
○ Avoid activities that will produce high tension in tendons eg combined movements across 2 joints
• Care to protect for potential tendon damage
○ E.g. Full thickness burns to dorsum of hand
○ Avoid combined movements eg fist and fist with Wr F
○ Isolated movements can be done eg MCP Flex with PIP/DIP Ext and MCP Ext with PIP/DIP Flex (no full fist + wrist flext)
• Take care with Full weight bearing Mobilisation if
○ IV line in foot – need to secure line
○ Escharotomies down legs – need adequate compression
○ Exposed achilles tendon – don’t want combined DF with knee E. Isolated ankle movement with knee flexed. NWB/PWB to offload Achilles tendon
○ Full thickness burn to soles of feet – need adequate protection and footwear
○ Cellulitis – wait until IV antibiotics have commenced and Drs happy
Slow ROM exercises to avoid overstretching and tissue bleeding
What are the 3
ROM Post-grafting techniques?
- Consider surgical technique/Graft take time frames
- Protocols
- See with dressings down for initial ROM if possible
What are 5 Physiotherapy Management techniques in Grafting period?
• Maintain Full ROM prior to skin grafting
• Immobilise (3-5 days) joints above and below grafts immediately following skin graft – protocols to follow
○ Then debulk in bath, reveal the wound - start mobilisation
○ Can have review surgeries, or more grafts
• Maintain ROM at all other areas
• Recommence ROM – usually commence with full view of grafted tissue
• Progress back to full ROM
What are 2 Physiotherapy Management in Subacute/Rehabilitation Phase?
• Usually outpatient with dressings
Up to 2 years post injury
What are 5 aims in the Physiotherapy Management in Subacute/Rehabilitation Phase?
• increase ROM • increase strength • improve CVS endurance • scar management return to function
What are the 9 Exercise Progression in the subacute/rehabilitation phase?
- Regular / multiple exercise sessions per day – 3-6/12 hourly exercises.
- Consider movement patterns / watch for compensatory movements (cheating activities) / correct and isolate appropriate movement
- After day 5-7 Combined stretches to ensure full excursion of the skin as soon as possible
- After 2-4/52 Add scar massage to EOR stretch to assist in improving skin pliability
- Early strengthening programs using resistance eg light weights
- Add endurance programs as soon as possible
- Encourage functional use of affected areas – incidental exercise
- Incorporate patients hobbies / interests into exercise program e.g. golf – trunk rotation / grip activities
- Work in conjunction with positioning, splinting program
What are 5 features of Hypermetabolism?
• Most patients with large %TBSA have spent either a long time in ICU or on bed rest and are debilitated
• Burns > 20% TBSA - hypermetabolic response
○ Metabolic rates ↑ 150-200%
○ Increased energy and protein requirements
○ Significant wasting of skeletal muscles
○ Loss of up to 15% of lean body mass
○ Can continue for 9 to 12 months post injury or longer
• Need early mobility, resisted and aerobic exercise to
○ Minimise deconditioning
○ Minimise effects of catabolism from hypermetabolic response to burns
• CV exercise program is important to build up fitness levels in preparation for return to work
• Early gym programs – resisted and aerobic exercise improve patient outcomes
○ Decreased contracture release surgery
○ Increased Strength, ROM, endurance
Imp roved Quality of Life
What are 6 signs of a Signs of Hypertrophic Scar?
• Colour and Vascularity (purple ➢ red ➢ pink)
• Height: Thickened texture of scar
○ Bumpy & irregular scar texture
• Pliability: Hard, non supple or pliable feel
○ ↓ ROM & function
• Sensation: Altered sensation, hypersensitivity, itch, pain
• Associated Oedema
Scar Maturation – 18 months to 2 years
What are some Acute Anti-deformity Positions (Rest in positions with skin stretch)?
Image
ADD CONTRACTURES
ADD
What are the 6 features of pressure garments?
• Worn 23 hours per day • Continued for 18 months - 2 years. ○ Could be hot - need compliance • 2 sets: Interim to customised garments. • Pressure = 25mmHg • Replaced every 3-6 months to maintain adequate pressure • Multiple colours Silicon under pressure garments
What are 2 psychosocial aspects for scar management?
• Depression, body image concerns
Cosmetic camouflage products: Microskin-simulated second skin which is formulated individually to colour correct for patient’s skin. Is sprayed on, is waterproof and lasts several days.
What are the 4 rationales for scar massage?
• Remodels/softens collagen bundles and adhesions
• Scar desensitisation including where itch is present
• Increased joint / skin mobility
Reduction in oedema
What are the 5 indications for scar massage?
• Skin well healed – ≥2 weeks post skin graft
• Scarring with underlying adhesions or blocking lymphatic flow
• Scar nodules/bands
• Performed with non-perfumed moisturising cream
Enough pressure for scar blanching
What are the 4 contraindications for scar massage?
• Scar inflammation
• Fragile scar
• Newly healed skin
Check before and after massage for blistering
What are the 6 outcomes for scar massage?
• Decrease in pain • Decrease in itch • Decrease in scar height • Decreased scar vascularity • Increased scar pliability Improved levels of depression
What are 5 important general information about the skin post burn?
• Skin care: Keep skin well moisturised
• Water based moisturiser – no perfumes
○ Oatmeal based moisturiser may help with decreased itch (e.g. dermaveen products)
• Sun protection: Skin will now always be more susceptible to sun burn – need SPF30+ sunscreen and long sleeves even over pressure garments (garments do not provide full sun protection).
• Swimming
○ Majority of wounds healed
○ Sun protection
○ Garment vs no garment
• Contact sports
○ The burnt skin is still only 80% as strong as normal skin at 12 months post injury
Contact sports need to be avoided for first 6-8 months but all other activities can be continued (e.g. running, gym program etc)
Heterotopic Ossification ADD
ADD
How does burns affect the other parts of the body? (not just skin)
ADD
What are the 3 main things for physiotherapy in a burns unit/
• Ongoing respiratory management
○ Positive pressure techniques
○ Long term effects of inhalation injury
○ Referral to respiratory physician
• Ongoing contracture management
○ Effective pain relief – liaise with chronic pain team
○ Stretch programs – long stretch times at EOR
○ Work with occupational therapist
○ Problems with compliance with therapy – liaise with social work and psychology
• Improve muscle strength/CVS endurance/mobility
○ Strengthening opposite to potential contracture
○ Early gym programs – resisted and aerobic exercise
○ Gait re-education
○ Hydrotherapy once majority wounds healed
What are the 3 main things for physiotherapy for Long Term Rehabilitation/Outpatients after a burns injury?
• Ongoing issues of skin contracture/hypertrophic scar
○ Long term exercise program (minimum of 6-12 months)
○ Pressure garments (18 months – 2 years)
○ Referral to OPD Physiotherapy and Occupational Therapy
• Psychology and Social Work Follow Up
○ Referral to and liaison with local psychology services
○ Updates to GP
• Burn OPD Clinic Follow Up
• Return to work / School / Re-integration
