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GENERAL 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
Classification Systems
As to CAUSATIVE AGENT As to DEPTH OF INVOLVEMENT As to SEVERITY

 As to CAUSATIVE AGENT
Thermal
Heat Cold

Chemical Radiation Electrical Mechanical

 As to DEPTH OF INVOLVEMENT
Old terminology New terminology

 OLD TERMINOLOGY
1st degree epidermis only
Edema and redness with necrosis

2nd degree epidermis up to dermis

Blister formation with subsequent epidermal healing

3rd degree whole skin depth

Necrosis of skin resulting in full thickness skin loss

4th degree subcutaneous structures (muscles, nerves, bones)

Gangrene of affected area

 OLD TERMINOLOGY
Most sources describe burn depth only up to 3rd degree and include the structures affected in 4th degree burns

 NEW TERMINOLOGY
Superficial Superficial partial thickness Deep partial thickness Full thickness Subdermal

http://en.wikipedia.org/wiki/Burn_(injury)

 As to SEVERITY
American Burn Association (ABA) Classification of Burn Severity
Minor Moderate Major

Most moderate and major burns require hospitalization

 American Burn Association (ABA) Classification of Burn Severity

Minor
< 15% BSA Partial Thickness (< 10% child) < 2% BSA Full Thickness (not involving eyes, ears, face, hands, feet, or perineum)

 American Burn Association (ABA) Classification of Burn Severity

Moderate
15-25% BSA Partial Thickness (10-20% child) 2-10% BSA Full Thickness (not involving eyes, ears, face, hands, feet, or perineum)

 American Burn Association (ABA) Classification of Burn Severity

Major
> 25% BSA Partial Thickness (> 20% child) > 10% BSA Full Thickness All burns involving eyes, ears, face, hands, feet, or perineum All electrical burns Burns with inhalation injuries Burns with complications (fracture, major trauma) Poor risk patients 2 to age or illness

Epidemiology
For all burns:
1/70 hospitalized Majority are males 17 30 y.o. 66% home-related

For thermal burns:

95% of all burns

For chemical burns:

Common in laboratory/industrial accidents

 For electrical burns:

1/3 electricians, 1/3 construction, 1/3 home 3 4 % high-voltage, rest are low-voltage

For radiation burns

Rare, except for radiation burn 2 to prolonged exposure to UVR (sunburn)

Etiology
Thermal Chemical Radiation Electrical Mechanical

 Thermal
Heat
Due to rapid heating Types:
Flame burns Scalds Contact burns Flash burns

Cold
Due to rapid freezing

 Chemical
Due to exposure to various chemical agents Agents:
Acids Alkali

 Radiation
Usually due to exposure to electromagnetic energy radiating agents Agents:
UVR Electrical Radar Radioactive elements (uranium, plutonium)

 Electrical
Due to exposure to electrical currents Types:
Low-voltage
<1000V usually 110V (US) or 220V (other countries), both with AC 60 Hz current

High-voltage
>1000V

 Mechanical
Usually due to friction

Pathophysiology

 Initial Stage of Inflammation

 Because the skin also serves as protection from infection, the loss of the cutaneous barrier facilitates entry of the patient's own flora and of organisms from the hospital environment into the burn wound. The wound often contains devitalized or frankly necrotic tissue that quickly becomes contaminated with bacteria. Invasive infection (localized and/or systemic) occurs when bacteria penetrate viable tissue, usually below the eschar.

 Epidermal Healing
Occurs if there are viable epithelial cells lining the wound Consists of 3 stages
Epithelial Migration Contact Inhibition Epithelial Proliferation

 Dermal Healing
Scar formation occurs Even if each phase is described separately, they occur on a continuum and one phase often overlaps another Consists of 3 stages
Inflammatory Phase Proliferative Phase Maturation Phase

Clinical Manifestations
Local Effects:
Loss of ability to regulate evaporative water loss Susceptibility to infection Loss of massive amounts of body fluids, especially in open wounds Local burn wound sepsis 2 to bacterial contamination

 Zones of Burn:
Zone of Coagulation Zone of Stasis Zone of Hyperemia

 Zone of Coagulation
Dying cells with irreversible damage If not controlled, affectation may involve next zone

 Zone of Stasis
Injured cells which may die in 1 2 days if no intervention is done Infection, drying, inadequate wound perfusion in this zone will result in conversion of potentially salvageable tissue to completely necrotic tissue

 Zone of Hyperemia
Minimal cell damage with possible recovery up to 7 days without any lasting effects

Complications
SYSTEMIC EFFECTS / PRIMARY COMPLICATIONS:
Acute hypovolemia with loss of fluid to extravascular compartment Pulmonary changes hyperventilation Oxygen consumption If inhalation injury, may lead to pneumonia Acute gastric dilatation/gastrointestinal ileus within 1st 3 days post-burn

 SYSTEMIC EFFECTS / PRIMARY COMPLICATIONS:

Catabolism leading to anabolic activity Core/mean T Hypermetabolism

 SECONDARY COMPLICATIONS
Infection LOM 2 to soft tissue contracture Muscle strength 2 to disuse or nerve involvement Sensory loss 2 to destruction of sense receptors in skin or nerve involvement Auto-amputation
In electrical burns, usually toes/fingers

 SECONDARY COMPLICATIONS
Disfigurement, usually 2 to scarring Heterotopic Ossification Associated injuries such as:
Visual loss Neurovascular damage Fracture

Diagnosis
Major concerns as to severity:
Percentage of total body surface area (TBSA) burned Depth of burn

 Methods of determining TBSA affected:

Rule of Nines Lund and Browder Formula

 Rule of Nines by Pulaski and Tennison

Less accurate but more rapid & practical if in a general acute care setting A practical application is the use of the palm of 1 hand to base as 1% BSA

 Lund and Browder Formula

Was developed due to the relative inaccuracy of the Rule of Nines method More accurate but seldom used in general acute care settings Most often used within a specialized burn unit setting

 Methods of determining depth of injury:

Using either:
Old terminology New terminology

New terminology is used now due to difficulty in specifying actual tissue involvement using old terminology

 Method of determining burn severity

ABA Classification of Burn Severity

 ABA Criteria for Admission to a designated burn center:

Partial and full thickness burns > 10% TBSA in patients under 10 or over 50 y.o. Partial and full thickness burns > 20% TBSA in other age groups Full thickness burns > 5% TBSA in any age group Partial and full thickness burns involving the hands, feet, face, perineum, or skin overlying major joints

 ABA Criteria for Admission to a designated burn center:

Electrical burns, including lightning injury Chemical burns Patients with inhalation injury Burn injury in patients with pre-existing illness that could complicate management Any patient with a burn in whom concomitant trauma poses an increased risk of morbidity or mortality may be treated initially in a trauma center until stable before transfer to a burn center

 ABA Criteria for Admission to a designated burn center:

Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases involving suspected child abuse

 In major burns, additional diagnostic examination may be required, such as:

Bronchoscopy
If inhalation injuries are suspected

Wound biopsy with quantitative microbiologic culture

If infection is suspected after burn injury

Differential Diagnosis
Often limited to identifying the causative agent

Prognosis
Factors affecting the severity of a burn injury and its prognosis are:
Depth Extent Age of patient General condition Position/location of the burn Delay of treatment Type of first aid given prior to treatment Other complications present Etiologic agent

MEDICAL MANAGEMENT

Pharmacologic
The main goal is to prevent infection
Through the use of topical antibacterial agents

Tetanus prophylactics are indicated in full thickness burns Sedatives may be applied in major burns due to extreme pain

Medical
Immediate treatments are:
For minor & moderate burns
Ice or cold water Cleaned with soap & warm water Remove loose epithelium Wound dressing Antibacterial agents Tetanus prophylactics if full thickness

 Immediate treatments are:

For major burns
Maintenance of airway Intravenous resuscitation Sedatives Antibiotics Tetanus prophylactics Gastric decompression

Surgical
Escharotomy
To relieve pressure on underlying arteries and veins

Fasciotomy
For persistent impairment of peripheral blood flow

 Biologic dressings
For:
Immediate coverage of superficial partial thickness burn Test dressing Wound coverage after escharotomy

Types:
Skin grafts from cadavers Human fetal membranes (homograft or allograft) Skin grafts from pigs (heterografts or xenografts)

 Synthetic dressings
Types:
Spray-on polymerics
Only for superficial partial thickness burns < 20% BSA and possible donor sites

Bilayer artificial skin Biobrane Opsite

 Debridement
Types:
Mechanical Enzymatic
Sutilains Travase / Elase

Surgical
Fascial Tangential

CO2 LASER

 Skin grafting through autografts

Grafts come from the same patient Types:
Tanner mesh graft Postage stamp grafting Sheet grafting

All grafted parts should be immobilized at least 45 days

Other Rehabilitative
Respiratory therapy may be indicated in inhalation injury Speech pathologists may participate if speech is affected due to an inhalation injury Occupational therapists provide:
Skills retraining if affected Dysphagia management if affected due to an inhalation injury

 Psychiatric counseling may be indicated if any psychological impact to the injury is noticed

P.T. EXAMINATION, EVALUATION & DIAGNOSIS

Points of Emphasis in Examination

Majority of physical therapy examination revolves around examination of the integumentary system, particularly as to skin integrity

 History of any pre-existing or co-existing illness/injury

These illnesses/injuries may affect treatment

Cardiovascular system examination

Particularly:
Circulation to and from the sites of burn Presence of edema

Pulmonary system examination

Especially if inhalation injury is suspected

 Musculoskeletal system examination

If deeper structures are directly affected Also if immobilization of the affected region has affected the musculoskeletal system, such as:
Joint play ROM MMT LGM MBT

 Functional assessment
To assess patients functionality in performing ADL, including:
Basic ADL Instrumental ADL

Problem List
Burn patients often present with the following problems for physical therapy:
Pain Impaired skin integrity
With subsequent affectations in musculoskeletal system

Edema Poor cosmesis Risk for integumentary disorders

Particularly infection

 If inhalation injury is suspected

Risk for pulmonary disorders Impaired ventilation and respiration/gas exchange

 Other patient problems could be:

Hypertrophic scarring Poor wound healing

Physical Therapy Diagnosis

Appropriate physical therapy diagnostic labels for uncomplicated burns are:
Impaired integumentary integrity associated with superficial skin involvement Impaired integumentary integrity associated with partial-thickness skin involvement and scar formation

 Impaired integumentary integrity associated with full-thickness skin involvement and scar formation Impaired integumentary integrity associated with skin involvement extending into fascia, muscle, or bone and scar formation

 If other examination findings indicate inclusion in other diagnostic criteria, patients are placed in other diagnostic labels depending on the other systems affected such as:
Impaired circulation and anthropometric dimensions associated with lymphatic system disorders

 Impaired ventilation, respiration/gas exchange and aerobic capacity/endurance associated with airway clearance dysfunction Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury Impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery Impaired joint mobility, motor function, muscle performance, and range of motion associated with localized inflammation

P.T. PROGNOSIS (including Plan of Care) & INTERVENTION

Plan of Care
Acute care:
Allow rapid wound healing Resolve edema Preserve function Prevent / minimize hypertrophic scarring Prevent respiratory complications Achieve good cosmetic outcome

 Sub-acute and Chronic Care:

Evaluate the patients home environment and family support and address any necessary home environmental changes Evaluate and address any related physical dysfunctions Evaluate and address any risk for secondary complications

Interventions
Wound care Functional activities and exercises Scar management techniques Post-healing education

 Wound care
Cleansing Debridement Topical agents Dressings

 Cleansing
Local wound care Hydrotherapy
Immersion Non-submersion (spray technique)

Pulsatile lavage with suction

Alternative to hydrotherapy

 Debridement
May be done during or after hydrotherapy

Topical agents
Applied after cleansing and debridement

Dressings
Applied after cleansing, debridement, and application of topical agents

 Functional activities and exercises

Only during healing All grafted parts should be immobilized at least 45 days Goals for exercise:
Reduce edema Maintain ROM Prevent skin contractures

 Activities and exercises:

Range of motion and stretching
AROM/AAROM exercises at bedside 2-3 times/day PROM for critically ill, spastic, heavily medicated patients

Ambulation Strengthening
PRE for involved & uninvolved areas

Endurance

 Scar management techniques

Positioning and splinting Compression garments Friction massage

 Positioning and splinting

Indications:
Patient cannot voluntarily maintain proper positioning Edema Exposed tendons Peripheral neuropathy Unresponsive patients

 Suggested Positioning Guidelines for Prevention of Burn Contractures:

Head & neck extended/hyperextended Shoulders abducted to 90 & externally rotated Elbows extended Forearms supinated Wrist & hand resting position Trunk neutral position

 Hips no flexion or external rotation & abducted to 10 from midline Knees extended Ankles dorsiflexed

 Compression garments
For management of hypertrophic scarring and edema Worn 24 hours a day up to 1 year until scar matures Types:
Elastic cloth garment Silastic mask Clear plastic mask

 Friction massage
To align collagen in healing skin Not done after grafting for at least 5 days Initially gentle and then more aggressive

 Post-healing education
Moisturizing newly-healed skin Avoiding direct sunlight
Use of sunscreen Covering affected area with clothing Planning activities in early morning and late evening

Protecting fragile skin

 After discharge, the patient is followed-up less intensively in physical therapy Depending upon the extent of the burn, the patient will need only 2-3 sessions per week of supervised PT Follow-up the severely burned patient for at least 18-24 months until the scar is completely matured and all rehabilitation complications have been resolved

 Some important points:

Check pressure garments for excessive pressure and skin breakdown Remind patient to avoid prolonged exposure to heat or cold Warn patient against vigorous outdoor activities until tolerance develops Remind patient to avoid direct sunlight exposure
Sunlight exposure can begin gradually, with caution, after about 6 months

THANK YOU!!!