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Minimizing the Trauma of Burn Injuries:
Rehab and Beyond
MaryAlice McCubbins, CPNP, TNS, LtCol,USAF(ret)
Trauma Nurse Practitioner
Washington University, St. Louis Children’s Hospital
We cannot define the limitationof human resilience
We cannot define the limitationof human resilience
Objectives
• Identify unique challenges of burn trauma• Define the relationship between acute intervention
and scar formation/management• Explain the importance of early therapy to enhance
mobility• Describe the psycho-social aspects of burn injury
and rehabilitation• Discuss pain as a contributor of long term recovery
Published 2012 for data2000-2009
Outline
• Burn Challenges• Scar Management• Mobility• Why psychosocial care is important• Future scar revision options
Phases of recovery
• Admission• Critical care• In-hospital recuperation• Rehabilitation
– Contracture prevention first phase
• Re-integration
Phases of recovery
• Admission• Critical care• In-hospital recuperation• Rehabilitation
– Contracture prevention first phase
• Re-integration
Face Burns
Face Burns2 weeks post burn 6 weeks post burn
Bilateral Lower extremities. Grafts. Splinting, decreased mobility, scarring, emotional factors of abuse
Young, deep, future hair growth, progressive intervention with age, parent guilt, adjustment, etc
Determining factor for success
• Extent of burn• Intelligence• Immediate response• Socioeconomic status• Family and social support• Willingness for social risk taking
Poor prognostics
• Social shyness• Lack of family cohesion• High family conflict• Acceptance within family
– Dependence– Helplessness– Waiting for others to provided
Scar Management
• Sensitive and fragile skin• Break down, infections• Splints• Contractures• Grafts• garments
Extreme scar contraction, keloid scar formation. Benign fibrous growth characterized by overgrowth of scar tissue beyond the borders of original wound
Hypertrophic scarring of lower extremities showing exaggerated proliferative response within the boundaries of original wound. History suggest good compliance from family
Same format – adorable baby
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Original OR date. first view 5 days post graft
5 days post STSG and porcine
~10 day post graft with porcine loss
Second OR trip (5-22) 5 graft post porcine (5 days)
7 days 2nd graft 21 days for first
21 days
Scald burn 3 month post injury
Management• Surgical therapies
– Radiation, cryosurgery, lasers
• Medical Management• Oral therapies
– Methotrexate (MTX)– Tamoxifen citrate– Topical immunomodulators
• Intralesional– Corticosteroids, 5-FU, interferons
Future revision
• Z-plasty– Contracture release
• Skin flaps, rotational flaps• Pedicle flaps• Tissue expanders
9yo male working with grandfather. Used a flame throwing instrument to clear ants from a hole. Exploded back onto child who suffered nearly 45% burns to upper body. Longterm treatment and management. Multiple scar revisions, non-compliance, transition to adulthood and cares.
Silicone and hydrogels
• Mepiform, TopiGel• Elasto gel, Avogel• Occlusive coverage long periods of time
– At least 12hrs/day– 4-6 months duration
Pressure garments
• First line therapy for hypertrophic scars• Used to produce thinning and pliability • 20-30 mmHg above cap pressure without
reducing peripheral circulation• 18-24 hrs/day• 4-6month minimum, upwards of 2 years
Infant total body suit
Upper extremity sleeve w/zipper no lines from seams after 15minutes Torso garment
Mobility
• Physical limitations• Contractures• Amputations• Compliance with routine therapies• garments
Physical Therapy as a huge role in burn recovery. Additional involvement for family is key
No extension tightness despite not having burns to posterior popliteal fossa
Psychosocial recovery
• Death/disfigurement• Pain and anxiety• Cultural variance• Post traumatic stress• Hopes and dreams
Pain • Initial injury itself
– Developmental stages– Parental response
• Dressing change– Excruciating – OR vs bedside
• Therapies• Emotional/psychologic
Pain• Initial injury itself
– Developmental stages– Parental response
• Dressing change– Excruciating – OR vs bedside
• Therapies• Emotional/psychologic
Minimizers
• Hypnosis• Music therapy• Time out• Electronic devises
– iPads– TV– headphones
Pediatric medical traumatic stress
“A set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures and invasive or frightening treatment experiences.”
www.healthcaretoolbox.orgRzucidlo, Campbell, JTN, 2009
Post traumatic Stress
• Most undiagnosed and untreated• Unable to maintain pre-injury coping levels
– Severity of trauma not predictive of PTSD
• Risk factors
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Pediatric Acute Wounds Service (PAWS)
• Stand alone unit– Independent staff, In and out-patient ,
multidisciplinary
• 2 sedation rooms– Ketamine– Nitrous
• Decreasing length of stay• Increasing parent participation, comfort
Reintegration
• Interaction with peers– Social rejection
• Community– School– Sports– Mall
• Rehearsals
ResourcesPain, Pain, Go Awayhttp://painsourcebook.ca/docs/pps80.htmlInformation on helping children with pain from a leading pediatric pain research group.
Phoenix Society for Burn Survivors – Resources for Children and Familieshttp://www.phoenix-society.org/resources/familyresourcesProvides information, support, and resources to children, adolescents, and families who have been impactedby a burn injury.
Angel Faceshttp://www.angelfacesretreat.org/af/about-us.aspProvides healing retreats and ongoing support for adolescent girls with burn/trauma injuries to achieve their optimum potential and develop meaningful relationships for themselves, their families and their communities
American Burn Association (www.ameriburn.org)
Shriners Hospitalshttp://www.shrinershospitalsforchildren.org/
We cannot define the limitationof human resilience
Same format – teen girl
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Day one OR débridement, day 2 post burn
Grafting completed 2wks post burn after failure to progress. This is POD5
1 month later
Donor site