BURNS

(Sullivan, Delisa, Seigelman)

Definition: tissue injury or destruction

Etiology: (Sulivan)
1. Thermal
a. Heat (44 111 degrees Celsius) flames, scalds, contact or
flushburns)
b. Cold - frostbites
- CBAN (10mins)
2. Friction
3. Chemicals acids and alkaline chemicals
4. Radiation UVR, radioactive elements (Uranium), radar
Epidemiology:
1. Scalds MC in children
2. Inhalation injury
3. M>F
- Males @ 70% of population
- 20-40 years old
Pathophysiology:
Burn injury

Release of histamine (reaction to injury for balance)

Increase vasoconstriction

Vasodilation
Evaporation due to heat
Plasma loss

Abnormal aggregation of platelets

Thrombus formation

Vascular obstruction

Ischemia

Damage

Clinical manifestations: (CaSH)

1. Zone of Coagulation
- Irreversible cell damage
- (+) infection, if not treated results to deeper burn injury
2. Zone of Stasis
- injured cells die in 24 hrs
3. Zone of Hyperemial
- minimal cell injury
Classification:
BURN SEVERITY CLASSIFICATION
Old Classification
1st degree burn
(Epidermis)

2nd degree burn

(Epidermis
Papillary layer of
dermis)

New
Classification
Superficial
thickness

Appearance/Symp
toms
Erythematous,
dry, mildly
swollen, blanch
with pressure,
painful
Superficial partial Blisters, moist,
thickness
weeping, painful

Course/Treatment

Deep Partial
thickness

Weeks to
months;
(+)scarring

No blisters, wet
and waxy, less
painful, increase
risk for converting

Heal ~ 1 week;
no scar

7-20 days; (+) reepithelialization

rd

3 degree burn
(dermis and
epidermis)

Full thickness

4th degree burn

(muscle to bone)

Subthermal

to full thickness
Waxy to leather
gray to charred
black, no pain,
unblanchable
Black (eschar),
exposed bone,
ligament, tendon

Skin graft

Amputation,
debridement

Phases of Burn Wound Healing:

1. Inflammatory Phase
- 5 cardinal signs
a. rubor
b. calor
c. dolor
d. tumor
e. functionlaesa
- lasts 3-5 days

2. Proliferative Phase
- granulation tissue and fibroblasts formation

3. Maturation Phase
- scar tissue formation
- lasts for 2 years
2 types of scar:
1. Keloid - abnormal scar that grows beyond the boundaries of the
original site of skin injury
- raised amorphous growth and are frequently associated
with pruritus and pain
2. Hypertrophic - widened or unsightly scar that does not extend
beyond the original boundaries of the wound
Complications:
1. Infection
- leading cause of mortality
- ex. Pseudomonas aeruginosa, staphylococcus aureus
2.

Pulmonary Complications

a. pneumonia
b. inhalation injury
- singed nasal hair
- harsh cough
- carbonaceous sputum
- (+) respiratory disorder
- bronchoscopy
c. Tracheal damage
3. Metabolic complications
- increased burn size = increased metabolic rate
- Metabolic activity: protein from muscle is needed for wound
healing which causes atrophy to the said muscle and then muscle weakness

4. Cardiovascular complication
- edema due to shift of fluid at interstitium
- attenuation of platelet count, function clotting factors and WBC
count

5. Heterotrophic Ossification
- (+) in >20% of Total Body Surface Area (TBSA) due to
immobilization, microtrauma, high protein and sepsis
- elbow>hip>shoulder

6. Neuropathy
7. Pathological scars
- scars occur due to higher collagen production than degradation
8. Musculoskeletal complication
- scoliosis/kyphosis (pos. of comfort)

- contractures, subluxation
Diagnosis:
- % of TBSA burned
-depth of burn
Rule of 9s by Pulaski and Tennison
*Adult

*Infant
Head and neck
- Ant: 8.5%
- Post: 8.5%
Anterior Trunk
-Upper: 9%
-Lower: 9%
Posterior trunk
-Upper: 9%
-Lower: 9%

1 Upper Extremity
-Ant: 4.5%
-Post: 4.5%
1 Lower Extremity
-Ant: 6.5%
-Post 6.5%
Perineum
-1%

By Lund & Browder

nd

2 degree
3rd degree

Minor
<15%
<2%

Moderate
15-25%
2-10%

Major
>25%
>10%

Prognosis:
- depends on depth, extent, age, condition, position, location, complication

Med/Surg Management:
1. Topical Medication
- to prevent infection
a. Silver sulfadiazine/Silvadine
-MC unsed topical agent
b. Mafenide Acetate/Sulfamylon
-penetrates thick eschar
c. Bacitracin/Polyspirin
-gram positive organisms
d. Collagenase/Accuzyme
- for enzymatic debriding

e. Travase/Elase
- liquefy thick eschar
2. Grafting
a. Allograft/Homograft
- cadavers (temporary)
b. Xenograft/Heterograft
- animal skin (temporary)
c. Autograft
- own skin (permanent)
d. Biosynthetic graft
-artificial
e. Cultured skin
- laboratory-grown
f. Split thickness graft
-epidermis and dermis (upper layer) from donor site
g. Full thickness
- epidermis and dermis from donor site

Z-plasty
- incision used to lengthen scar from burn injury

Whirlpool (debridement)
- if clean wound: normal saline solution
- infected wound: betadine
- if no betadine: bleech
-if no betadine and bleech: hydrogen peroxide

PT Management and Assessment:

ROM
History
MMT
Skin integrity
Posture
Psychological impact

MANAGEMENT:
PROM for spastic, heavily medicated pts
AAROM/AROM 2-3x/day
PREs involved and adjacent areas
Proper positioning/orthosis

Neck

Deformity
Neck flexion

Correction
Neck
hyperextension

Shoiulder

ADIR

Elbow and FA

Flexion and
pronation
Intrinsic minus,
clawhand

Hip

FAdIR

Abd (90deg)
ER
Slight flex
Extension and
supination
Intrinsuc plus
15-20deg wrist
ext
20 deg MCP flex
IP ext
Thumb slight abd
ExAbER

Knee
Ankle

Flexion
PF

Extension
DF

Wrist and hand

Orthosis
Cervical
extension soft
collar
Airplane splint or
axillary splint
Posterior
arm/elbow splint
Resting hand
splint

Posterior hip
splint
Post. Knee splint
AFO

Stretching contracted area

Massage edema
ADLs and ambulation training

Modalities:
ES- (+) nerve involvement
TENS- for pain relief; brief intense
CPM- increase ROM
IPC relieve edema
Laser for tissue healing and pain