8/12/2019 Burns.doc

1/14

BURNS

General Medical Background

Definition Tissue injury, protein denaturation, edema, and loss of intravascular fluid

resulting from exposure to or contact with a causative agent such as heat, electricity,chemicals, radiation, friction, or cold.

Classification

As to causative agent:

Thermal

Heat

Cold

Chemical

Radiation

lectrical

!echanical

As to depth of involvement:

"ld terminology:

#stdegree $ epidermis only

dema and redness with necrosis

%nddegree $ epidermis up to dermis

&lister formation with su'se(uent epidermal healing

)rddegree $ whole s*in depth

+ecrosis of s*in resulting in full thic*ness s*in loss

thdegree $ su'cutaneous structures -muscles, nerves, 'ones

/angrene of affected area

!ost sources descri'e 'urn depth only up to )rd degree and include thestructures affected in thdegree 'urns

+ew terminology:DEPTH Wound Color /

VascularitySurface Appearance /Pain

Sellin! / Scarrin! /Healin!

Superficial-outerepidermis

rythematous, pin* or red0irritated dermis

+o 'listers, dry surface0delayed pain, tender

!inimal edema0 no scars0spontaneous des(uamationin %1) days

SuperficialPartialT"ic#ness-wholeepidermis 2dermis up topapillarylayer

&right pin* or red, mottledred0 inflamed dermis0erythematous with'lanching and capillaryrefill

3ntact 'listers, moistsurface, weeping orglistening0 most painful0sensitive to changes intemperature, exposure toair currents, light touch

!oderate edema0 minimalscarring -discoloration0spontaneous healing in 41%# days

Deep PartialT"ic#ness-wholeepidermis 2dermis up toreticular layer

!ixed red, waxy white0'lanching with slowcapillary refill

&ro*en 'listers, wetsurface0 sensitive topressure 'ut insensitive tolight touch or pin1pric*

!ar*ed edema0 excessivescarring0 slow healing in )15 wee*s

$ull

T"ic#ness-wholeepidermis 2whole dermis

6hite -ischemic, charred,

tan, fawn, mahogany,'lac*, red0 hemoglo'infixation0 no 'lanching0throm'osed vessels0 poordistal circulation

7archment1li*e, leathery,

rigid, dry0 anesthetic0 'odyhairs pulled out easily

Area depressed0 scarring0

heals with s*in grafting

Su%der&al-whole s*inup tosu'cutaneous

Charred 8u'cutaneous tissueevident0 anesthetic0 muscledamage0 neurologicalinvolvement

Tissue defects0 scarring0heals with s*in grafting

#

8/12/2019 Burns.doc

2/14

tissue orfurther

Comparison 'etween old and new terminologies:'ld Ter&inolo!y Ne Ter&inolo!y

#st9egree 8uperficial

%nd9egree8uperficial 7artial Thic*ness

9eep 7artial Thic*ness)rd9egree ull Thic*ness

th9egree 8u'dermal

As to 'urn severity:

The American &urn Association -A&A has developed the following classificationsystem:

!inor

; #5< &8A 7artial Thic*ness -; #=< child

; %< &8A ull Thic*ness -not involving eyes, ears, face, hands, feet, or

perineum

!oderate

#51%5< &8A 7artial Thic*ness -#=1%=< child %1#=< &8A ull Thic*ness -not involving eyes, ears, face, hands, feet, or

perineum

!ajor

> %5< &8A 7artial Thic*ness -> %=< child

> #=< &8A ull Thic*ness

All 'urns involving eyes, ears, face, hands, feet, or perineum

All electrical 'urns, 'urns with inhalation injuries, 'urns with complications

-fracture, major trauma, poor ris* patients %to age or illness

!ost moderate and major 'urns re(uire hospitali?ation

Epide&iolo!y

or all 'urns:

#@4= hospitali?ed

!ajority are males #4 $ )= y.o.

< home1related

or thermal 'urns:

B5< of all 'urns

or chemical 'urns:

Common in la'oratory@industrial accidents

or electrical 'urns:

#@) electricians, #@) construction, #@) home

) $ < high1voltage, rest are low1voltage

or radiation 'urns

Rare, except for radiation 'urn %to prolonged exposure to DR -sun'urn

Etiolo!y

Causes of 'urns could 'e:

Thermal

Heat

9ue to rapid heating

Types:

lame 'urns

8calds

Contact 'urns

lash 'urns

Cold

%

8/12/2019 Burns.doc

3/14

9ue to rapid free?ing

Chemical

9ue to exposure to various chemical agents

Agents:

Acids

Al*ali Radiation

sually due to exposure to electromagnetic energy radiating agents

Agents:

DR

lectrical

Radar

Radioactive elements -uranium, plutonium

lectrical

9ue to exposure to electrical currents

Types: Eow1voltage

;#===D

usually ##=D -8 or %%=D -other countries, 'oth with AC = H?

current

High1voltage

>#===D

!echanical

sually due to friction

Pat"op"ysiolo!y / Pat"o&ec"anics Regardless of the causative agent, a 'urn initially undergoes the following

physiologic responses:

&ecause the s*in also serves as protection from infection, the loss of the

cutaneous 'arrier facilitates entry of the patientFs own flora and of organismsfrom the hospital environment into the 'urn wound. The wound often containsdevitali?ed or fran*ly necrotic tissue that (uic*ly 'ecomes contaminated with

)

8/12/2019 Burns.doc

4/14

'acteria. 3nvasive infection locali?ed and@or systemic occurs when 'acteriapenetrate via'le tissue, usually 'elow the eschar.

&urn wound healing occurs through separate mechanisms in the epidermis anddermis

pidermal healing

"ccurs if there are via'le epithelial cells lining the wound

9ermal healing

8car formation occurs

ven if each phase is descri'ed separately, they occur on a continuum andone phase often overlaps another

8/12/2019 Burns.doc

5/14

Clinical (anifestation)s*

A 'urn injury will present with the following local effects:

Eoss of a'ility to regulate evaporative water loss

8uscepti'ility to infection

Eoss of massive amounts of 'ody fluids, especially in open wounds

Eocal 'urn wound sepsis %to 'acterial contamination

Gones of &urn:

Gone of Coagulation

9ying cells with irreversi'le damage

3f not controlled, affectation may involve next ?one

Gone of 8tasis

3njured cells which may die in # $ % days if no intervention is done

3nfection, drying, inade(uate wound perfusion in this ?one will result inconversion of potentially salvagea'le tissue to completely necrotic tissue

Gone of Hyperemia

5

8/12/2019 Burns.doc

6/14

!inimal cell damage with possi'le recovery up to 4 days without any lastingeffects

Co&plication)s*

88T!3C CT8@7R3!AR C"!7E3CAT3"+8:

Acute hypovolemia with loss of fluid to extravascular compartment

7ulmonary changes $ hyperventilation

"xygen consumption

3f inhalation injury, may lead to pneumonia

Acute gastric dilatation@gastrointestinal ileus within #st ) days post1'urn

Cata'olism leading to ana'olic activity

Core@mean T

Hypermeta'olism

8C"+9AR C"!7E3CAT3"+8

3nfection

E"! %to soft tissue contracture

!uscle strength %to disuse or nerve involvement

8ensory loss %to destruction of sense receptors in s*in or nerve involvement

Auto1amputation

3n electrical 'urns, usually toes@fingers

9isfigurement, usually %to scarring

Heterotopic ossification

!ost commonly at el'ow

Associated injuries such as:

Disual loss

+eurovascular damage

racture

Dia!nosis

3n the diagnosis of 'urn injuries, the following are the major concerns as toseverity:

7ercentage of total 'ody surface area -T&8A 'urned

9epth of 'urn

!ethods of determining T&8A affected:

IRule of +inesJ 'y 7ulas*i and Tennison

Eess accurate 'ut more rapid 2 practical if in a general acute care setting

A practical application is the use of the palm of # hand to 'ase as #< &8ARE+,'N ADU-T PED,A

Head 2 nec* B< #4 %=< T&8A in other age groups

ull thic*ness 'urns > 5< T&8A in any age group

7artial and full thic*ness 'urns involving the hands, feet, face, perineum, or s*inoverlying major joints

lectrical 'urns, including lightning injury Chemical 'urns

7atients with inhalation injury

&urn injury in patients with pre1existing illness that could complicate management

Any patient with a 'urn in whom concomitant trauma poses an increased ris* ofmor'idity or mortality may 'e treated initially in a trauma center until sta'le'efore transfer to a 'urn center

&urn injury in patients who will re(uire special social and emotional or long1termreha'ilitative support, including cases involving suspected child a'use

3n major 'urns, additional diagnostic examination may 'e re(uired, such as:

&ronchoscopy 3f inhalation injuries are suspected

6ound 'iopsy with (uantitative micro'iologic culture

3f infection is suspected after 'urn injury

Differential Dia!nosis

9ifferential diagnosis is often limited to identifying the causative agent

Pro!nosis

actors affecting the severity of a 'urn injury and itsJ prognosis are:

9epth

xtent

Age of patient

/eneral condition

7osition@location of the 'urn

9elay of treatment

Type of first aid given prior to treatment

"ther complications present

tiologic agent

Medical Management

P"ar&acolo!ic

The main goal is to prevent infection

Through the use of topical anti'acterial agents

8ilver nitrate

ffective against most gram1positive organisms and most strains of

7seudomonas

K

8/12/2019 Burns.doc

9/14

Eimited against some gram1negative organisms

7enetrates only #1% mm of eschar

8ulfamylon -mafenide acetate

ffective against gram1positive and gram1negative organisms

asily diffuses through eschar

8ilver sulfadia?ine

ffective against 7seudomonas

!ost commonly used

&etadine

ffective against gram1positive and gram1negative organisms and some

fungi

/entamycin

ffective against gram1negative organisms and 8taphylococcal and

streptococcal 'acteria

uracin

3ndicated to 'acterial growth sed in less severe 'urns

&acteracin @ 7olysporin

ffective against gram1positive organisms

Tetanus prophylactics are indicated in full thic*ness 'urns

8edatives may 'e applied in major 'urns due to extreme pain

(edical

3mmediate treatments are:

or minor 2 moderate 'urns

3ce or cold water Cleaned with soap 2 warm water

Remove loose epithelium

6ound dressing

Anti'acterial agents

Tetanus prophylactics if full thic*ness

or major 'urns

!aintenance of airway

3ntravenous resuscitation

8edatives

Anti'iotics Tetanus prophylactics

/astric decompression

Sur!ical

scharotomy

To relieve pressure on underlying arteries and veins

asciotomy

B

8/12/2019 Burns.doc

10/14

or persistent impairment of peripheral 'lood flow

&iologic dressings

or:

3mmediate coverage of superficial partial thic*ness 'urn

Test dressing

6ound coverage after escharotomy Types:

8*in grafts from cadavers

Human fetal mem'ranes -homograft or allograft

8*in grafts from pigs -heterografts or xenografts

8ynthetic dressings

Types:

8pray1on polymerics

"nly for superficial partial thic*ness 'urns ; %=< &8A and possi'le donor

sites

&ilayer artificial s*in &io'rane

"psite

9e'ridement

Types:

!echanical

sually post1hydrotherapy

n?ymatic

8utilains

Travase @ lase

n?ymatic de'riding agent that selectively de'rides necrotic tissue 8urgical

ascial

Rarely indicated in severe 'urns

Tangential

!ost widely used

C"%EA8R

xpensive

8*in grafting through autografts

/rafts come from the same patient

Types: Tanner mesh graft

7ostage stamp grafting

7oor cosmetic result

8heet grafting

or smaller 'urn wounds

All grafted parts should 'e immo'ili?ed at least 15 days

't"er Re"a%ilitati5e

Respiratory therapy may 'e indicated in inhalation injury

8peech pathologists may participate if speech is affected due to an inhalationinjury

"ccupational therapists provide:

8*ills retraining if affected

9ysphagia management if affected due to an inhalation injury

7sychiatric counseling may 'e indicated if any psychological impact to the injuryis noticed

#=

8/12/2019 Burns.doc

11/14

Physical Therapy Examination, Evaluation & Diagnosis

Points of E&p"asis in E6a&ination

!ajority of physical therapy examination revolves around examination of theintegumentary system, particularly as to s*in integrity

"ther points of emphasis in examination are: History of any pre1existing or co1existing illness@injury

These illnesses@injuries may affect treatment

Cardiovascular system examination

7articularly:

Circulation to and from the sites of 'urn

7resence of edema

7ulmonary system examination

specially if inhalation injury is suspected

!usculos*eletal system examination

3f deeper structures are directly affected Also if immo'ili?ation of the affected region has affected the musculos*eletal

system, such as:

Noint play

R"!

!!T

E/!

!&T

unctional assessment

To assess patientJs functionality in performing A9E, including:

&asic A9E 3nstrumental A9E

Pro%le& -ist

&urn patients often present with the following pro'lems for physical therapy:

7ain

3mpaired s*in integrity

6ith su'se(uent affectations in musculos*eletal system

dema

7oor cosmesis

Ris* for integumentary disorders 7articularly infection

3f inhalation injury is suspected

Ris* for pulmonary disorders

3mpaired ventilation and respiration@gas exchange

"ther patient pro'lems could 'e:

Hypertrophic scarring

7oor wound healing

P"ysical T"erapy Dia!nosis

Appropriate physical therapy diagnostic la'els for uncomplicated 'urns are:

3mpaired integumentary integrity associated with superficial s*in involvement

3mpaired integumentary integrity associated with partial1thic*ness s*ininvolvement and scar formation

3mpaired integumentary integrity associated with full1thic*ness s*in involvementand scar formation

##

8/12/2019 Burns.doc

12/14

8/12/2019 Burns.doc

13/14

Topical agents

Applied after cleansing and de'ridement

7hysical therapists may apply any of the topical agents mentioned

9ressings

Applied after cleansing, de'ridement, and application of topical agents

unctional activities and exercises "nly during healing

All grafted parts should 'e immo'ili?ed at least 15 days

/oals for exercise:

Reduce edema

!aintain R"!

7revent s*in contractures

Activities and exercises:

Range of motion and stretching

AR"!@AAR"! exercises at 'edside %1) times@day

7R"! $ for critically ill, spastic, heavily medicated patients

Am'ulation

8trengthening

7R $ for involved 2 uninvolved areas

ndurance

8car management techni(ues

7ositioning and splinting

3ndications:

7atient cannot voluntarily maintain proper positioning

dema

xposed tendons

7eripheral neuropathy

nresponsive patients

8uggested 7ositioning /uidelines for 7revention of &urn Contractures:

Head 2 nec* $ extended@hyperextended

8houlders $ a'ducted to B=2 externally rotated

l'ows $ extended

orearms $ supinated

6rist 2 hand $ resting position

Trun* $ neutral position Hips $ no flexion or external rotation 2 a'ducted to #=from midline

Onees $ extended

An*les $ dorsiflexed

Commonly used splintsArea of %urn 'pti&al position SplintHands 6rist $ #=1#5P extension

!C7 $ =15P flexion737@937 $ full extension

Dolar splint

l'ow1cu'ital -volar aspect ull extension and supination Anterior volar conformingsplint

)1point conforming splint7osterior el'ow extension

splint -after grafting8houlder and axilla B=P a'duction, external

rotationirm1density foam wedgeConforming axillary splint

Airplane splintHip ull extension with %=P

a'duction, neutral rotationTriangular foam wedgeHip a'duction, extension splint

-primarily in children

Onee ull extension 7osterior *nee extension splint)1point extension splint

#)

8/12/2019 Burns.doc

14/14

An*le and foot B=P dorsiflexion, neutral as toinversion1eversion

7osterior dorsiflexion splintAnterior conforming splint

Compression garments

or management of hypertrophic scarring and edema

6orn % hours a day up to # year until scar matures

Types: lastic cloth garment

8ilastic mas*

Clear plastic mas*

riction massage

To align collagen in healing s*in

+ot done after grafting for at least 5 days

3nitially gentle and then more aggressive

7ost1healing education

!oisturi?ing newly1healed s*in

Avoiding direct sunlight se of sunscreen

Covering affected area with clothing

7lanning activities in early morning and late evening

7rotecting fragile s*in

After discharge, the patient is followed1up less intensively in physical therapy

9epending upon the extent of the 'urn, the patient will need only %1) sessionsper wee* of supervised 7T

ollow1up the severely 'urned patient for at least #K1% months until the scar iscompletely matured and all reha'ilitation complications have 'een resolved

8ome important points:

Chec* pressure garments for excessive pressure and s*in 'rea*down

Remind patient to avoid prolonged exposure to heat or cold

6arn patient against vigorous outdoor activities until tolerance develops

Remind patient to avoid direct sunlight exposure

8unlight exposure can 'egin gradually, with caution, after a'out months

#