Burns and pain Flashcards
burn classifications
1st degree: superficial
2nd degree: partial thickness (superficial and deep)
3rd degree: full thickness
4th degree: subdermal
superficial burn
- epidermis
- ex) sunburn, brief contact with hot liquid
- pain: mild discomfort
- peeling, dry, redness (erythema)
- no blisters
- healing: < 1 week
- scar risk: none
partial thickness burn - superficial
- epidermis + 1/3 dermis
- ex) contact with hot metal (curling iron)
- red, wet, blisters
- pain: significant
- healing: <2 weeks
- scar risk: low
partial thickness burn - deep
- epidermis + 2/3 dermis + hair follicles + sweat glands
- ex) flames, exposure to intense heat
- red AND white (poor blood flow)
- pain: the most severe
- healing: >2 weeks
- scar risk: high
full thickness burn
- epidermis + dermis + hair follicles + sweat glands + nerve endings
- ex) chemical, extreme heat
- pale, dry, does not blanche (turn white with pressure)
- pain: none; nerve damage so no sensation
peripheral pain - healing: months
- scar risk: very high
** surgical intervention required **
subdermal burn
- full thickness + underlying tissue (muscle, tendon, fat exposure)
- ex) electrical burn, house fires
- charring, *peripheral nerve damage
- pain: none; nerve damage so no sensation
- healing: months
- scar risk: very high
** surgical intervention required **
posible amputation
phases of burn recovery from medical management perspective
- emergent (survival)
- fluid resuscitation, compartment syndrome
- respiratory management
- temperature and infection control - acute phase (until wound closure)
- non surgical: cleaning therapies, dressing changes, heals on own
- surgical: cut & cover - grafts
types of grafts
xenograft: processed pig skin
allograft: cadaver skin
autograft: person’s own skin
full thickness vs split thickness
meshed vs sheet
rule of 9s
- to assess the extent and severity of the burn
- body percentage; surface area
head: 9
each arm: 9
each leg: 18
trunk/back: 36
groin: 1
OT eval other to include
- occupational profile, ROM (72 hrs post op), joint mobility, strength, sensation, edema (all when wounds are healed)
ROM contraindications
- avoid active flexion with a dorsal hand burn to prevent rupture
- can do PROM of digits
sensation contraindications - electric burns
do a gross sensation screening to assess peripheral nerve damage
edema contraindications
no volometer with an open wound; use a circumferential assessment
OT intervention with burns
- prevent deformity, contractures
- address edema
- positioning and splinting
positioning
- start day 1
- comfort = contracture -> no flexion or adduction (this is naturally what we want to do)
(think of titanic person or da vinci man)
neck: neutral, slight ext
axilla: shoulder abducted to 90 and ER
elbow: extended, forearm neutral
hips: neutral ext, slight abd
knees: ext, slight flex with anterior burn
ankles: neutral or dorsiflexed to prevent foot drop
UE safe position in splint
INSTRINSIC PLUS
dorsal burn –> volar splint
wrist: 15-30 deg ext
MCPs: 50-70 deg flex
IPs: full ext
thumb: abducted
s/p graft
- immobilization and protection
- initiate movement: gentle AROM (or AA or P if can’t tolerate)
what to look out for when starting movement
- heterotopic ossification: bone formation in soft tissue –> do daily AROM in pain free range
- soft tissue contracture –> serial casting or dynamic splint to stretch
things to do in sessions
- skin conditioning: lubricate, massage, stretch, use lotion
- pain management: meds 30 min before, relaxation, visual imagery
- temporary compression: worn at all times except bathing cleaning and dressing changes
hypertrophic scar
- most common with deep second and third degree burns
- appears 6-8 weeks after wound closure
- 1-2 years to mature
- compression garments should be worn 24 hours/day
types of pain
- acute (short)
- chronic (long)
- myofascial (muscles, tendons, or fascia)
- fibromyalgia (musculoskeletal pain and fatigue disorder, tenderness of muscles and tissues
- low back pain (most common work related injury, lumbar, from poor posture and body mechanics)
pain assessment
- determine location
- evaluate intensity on a scale
- onset and duration
- description
- functional assessment
pain scales that commonly address function
- McGill Pain Questionnaire
- Pain Disability Index
- Functional Interference Estimate
OT intervention for pain
- modalities
- proper positioning/postural techniques
- splinting
- gentle ROm
- relaxation
- using proper body mechanics in ADLs and at work
- modify activities
- ADL training
- alternative exercise programs
notes on positioning
NO pillows under head (can roll a towel under neck but want neck slightly flexed)
NO pillows under knees; want them extended
precaution with dorsal hand burns
no composite flexion - flexion of the IPs in conjunction of flexion of MCPs - this could rupture the extensor tendons
want to keep fingers straight (IPs) - in the intrinsic plus position until surgeon clears
precaution to burn intervention
NO thermal modalities - hot or cold
because no sensation
“OT burn checklist”
what we commonly deal with
Feeling (sensory, pain)
Independence (ADLs, new ones with skin care too)
Range of motion (positioning and splinting)
Edema (compression)
Skin care (lubrication, massage, scar)
burn rehab timeline - OT role (4 steps)
- Emergent - R
- Acute - FIRE
- Rehab - RISES
- Outpatient - SIRE
steps post graft surgery
- immobilization phase
- gentle active range (bc they know how it feels)
