Burns

A burn injury can be sustained through a variety of sources including thermal/heat (flame, scald, and contact), electricity, chemicals, or radiation (sunlight).

(The Brigham and Women's Hospital, 2009)

Etiology: Mechanisms of Injury

Thermal Burns:

Flame: Inhalation injuries; 50% of adult burns

Scald: Spilled hot drinks, hot bathing water; 70% of pediatric burns; common in older adults

Contact: Object extremely hot or contact extremely long; Hot iron

Common in epileptics, older adults, those abusing substances

Electrical Burns: Current travels through body, creating an entry & exit point, damage is done between two points; 3-4% of burns

"True": Voltage passes through the body; 1000V or greater

"Flash": Caused by the heat of a voltage arc

Chemical Burns: Industrial accidents or household products; 9% of burns

Hydrofluoric acid most common culprit

Radiation Burns: Sunlight; 6% of burns

(Hettiaratchy & Dziewulski, 2004; Hall, 2009)

Superficial burns:

• Damage above the basal layer of the epidermis, the outermost layer of skin

Appear red, dry and painful, like sunburns.

(Spires et al., 2007)

Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg

Superficial partial-thickness:

• Damage to the dermis, the layer of tissue below the epidermis, but leave the hair follicles and oil glands in tact.

Appear moist, red, blistered, blanched or colorless, and are extremely painful.

(Spires et al., 2007)

Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg

Full-thickness burns:

• Destroy the entire epidermis and dermis, into the fat

Appear red, white, brown, or black in color, dry, leathery and cause little pain due to damage of the dermal plexus of nerves

(Spires et al., 2007)

Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg

Burn Classification Con't

• Most burns are a mix of partial and full thickness injury
• Deep burns can intrude into the muscle, tendon and bone and may require amputation or extensive debridement.

(Spires et al., 2007)

TBSA=Total Body Surface Area

Rule of Nines

Head = 9%

Trunk = 36%

Upper extremity = 9% each

Perineum = 1%

Lower extremity = 18% each

(Spires et al., 2007)

Prognosis

Age: Children & young adults have a higher survival rate, but require more fluid per burned TBSA

Clients under the age of 50 have the best prognosis

Pre-existing medical issues: prolong tissues healing

i.e. vascular disease, diabetes, poor nutrition

presence of systemic infection

Lack of a strong social/family network: psychological

Type & Mechanism: Superficial burns have better outcomes than partial, full thickness, or deep burns

Inhalation Injuries worst prognosis

TBSA: <30% fewer complications; burns of only 50% TBSA can be fatal to an elderly adult

(Garren & Kelly, 2009; Greenhalgh, 2011)

Pathophysiology

When >30% TBSA

(Hettiaratchy & Dziewulsk, 2004)

Skin Graft

Surgery involving the transplantation of skin, typically used for treating partial thickness and full thickness burns.

(Pendleton & Schultz-Krohn, 2006)

Autograft: permanent surgical transplant of the body's own skin taken from an unburned donor sight (most common)

Allograft: processed human cadaver skin

Xenograft: processed pigskin

Photo retrieved from: http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/10303.jpg

(Pendleton & Schultz-Krohn, 2006)

Although skin grafts placed as sheets are more aesthetically pleasing, larger area's may require the skin to be "meshed."

Photo retrieved from: http://biomed.brown.edu/Courses/BI108/BI108_2007_Groups/group11/ProcDerm.jpg

(Pendleton & Schultz-Krohn, 2006)

Photo retrieved from: http://www.intechopen.com/source/html/18943/media/image2.jpeg

Photo retrieved from: http://www.medicalexhibits.com/obrasky/2009/09102_08X.jpg

Contractures

A contracture is a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

(Schneider, Holavanahalli, Helm, Goldstein, & Kowalske, 2006)

Joint

Position of Comfort

Therapeutic Position

Shoulder

Joint

Position of Comfort

Therapeutic Position

(University of Colorado Health Sciences Center, 1995)

Elbow

(Procter, 2010)

Joint

Position of Comfort

(University of Colorado Health Sciences Center, 1995)

Wrist/Hand

(Procter, 2010)

Functional deficits resulting from burns:

• Functional mobility
• Loss of independence in performing ADLs & IADLs
• Lack of knowledge & understanding of condition
• Coping/adjustment issues following burn injury

(Garren & Kelly, 2009)

Hypertrophic scarring is common following burn injuries, and is a response of the body’s natural healing process. The body sends high blood flow and increased levels of collagen to these areas, resulting in raised, red, rigid scarring.

(Procter, 2010)

Compression is a common tactic used for managing edema; however, compression techniques can also be used for scar management.

• Decrease itching
• Reduce dryness
• Help protect the skin from further injury

(Procter, 2010)

Use: Pressure Garments are worn to treat & prevent abnormal scarring following a burn injury.

Initiation: 2 weeks following wound closure

Total Wear Time: 6-12 months, minimum

Wear Duration: 23-24 hours/ day; remove for bathing or interference with therapy

Wear Frequency: 7 days/week

(Atiyeh, 2013)

Photo retrieved from: http://www.gottfriedmedical.com/custom_compression-garments/boleros/images/441-FR.png

Photo retrieved from: http://cirrie.buffalo.edu/encyclopedia/images/pediatricburns_9.jpg

Fit: Garments should fit tightly & apply direct pressure to the skin.

Avoid: garments that are too tight or cause numbness, tingling, or pain, as this will result in additional damage.

Custom Fit: Circumferential dimensions of a wounded body part are obtained using a truncated measuring tape.

• Cut & fabricated from elastic fabrics such as powerknit or sleeknit materials.

Exerted Pressure: Manufacturers of custom pressure garments report that they provide 25 mm HG of pressure.

• Lose tension overtime; up to 50% of their compression in one month
• Measurements should be monitored regularly
• Garments should be replaced every 2-3 months, minimum

(Atiyeh, 2013)

Care:

Hand Wash: Wash daily with warm water & mild soap and allow to drip-dry.

OR

Machine Wash: Wash garment daily with laundry detergent in warm water on gentle cycle & allow for air-dry only.

• Having 2 garments to rotate between is advisable.

Avoid: Clothes drier, sunlight, heaters, hot water, bleach, dish washing soap, coco butters, vitamin E lotions & oils

All of which can weaken the elastic

(Atiyeh, 2013)

Fit: Apply the silicone sheet, adhesive side down, to the scarred area.

• It can be bandaged down or secured with a garment, splint or cast.
• Ensure the silicone sheet is not bandaged too tightly to avoid irritation.

Avoid open wounds, infected areas, or unhealed tissues. Avoid contact with eyes.

In rare instances, an allergic reaction leading to rashes or irritation may occur. Discontinue use and contact therapist.

Retrieved from: http://www.rejuveness.com/mc_images/product/image/armscarsiliconesheet.JPG

(Momeni, Hafezi, Rahbar, & Karimi, 2009)

References

Atiyeh, B., El Khatib, A., & Dibo, S. (2013). Pressure garment therapy (PGT) of burn scars: evidence-based efficacy Annals of Burns and Fire Disasters, 26(4), 205-2012.

Burn Care Centre, U. K. (2006). Recovering: Silicone Products. Retrieved from: November 11, 2014, 2014, from http://burncentrecare.co.uk/silicone_products.html

Garren, L., & Kelly, N. (2009). Standard of care: Inpatient occupational therapy intervention for burns. The Brigham and Women's Hospital, Inc. Retrieved November 3, 2014, from http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/occupational therapy standards of care-protocols/general - burn inpatient.pdf

Greenhalgh, D. (2011, 2011). Chemical Hazards Emergency Medical Management. Burn Triage and Treatment - Thermal Injuries. Retrieved November 3, 2014, from http://chemm.nlm.nih.gov/burns.htm - diagnosis

Hall, J. R. (2009). Deaths and and injuries due to non-fire burns National Fire Protection Association, 1-7.

Hettiaratchy, S., & Dziewulski, P. (2004). ABC of burns: Pathophysiology and types of burns. British Medical Journal, 328(7453), 1427-1428.

Kockrow, E. (2006). Surgical Wound Care Basic Nursing Skills (pp. 1-32): Mosby Inc

Momeni, M., Hafezi, F., Rahbar, H., & Karimi, H. (2009). Effects of silicone gel on burn scars. Burns, 35(1), 70-74. doi: 10.1016/j.burns.2008.04.011

Nationwide Children's Hospital. (2005). Burns: Wearing a Pressure Garment (pp. 1-2). Columbus, Ohio, Nationwide Children's Hospital.

Pendleton, H. M., & Schultz-Krohn, W. (2006). Pedretti's Occupational Therapy: Practice Skills for Dysfunction: Mosby Elsevier

Procter, F. (2010). Rehabilitation of the burn patient. Indian J Plast Surg, 43(Suppl), S101-113. doi: 10.4103/0970-0358.70730

Schneider, J. C., Holavanahalli, R., Helm, P., Goldstein, R., & Kowalske, K. (2006). Contractures in burn injury: defining the problem. J Burn Care Res, 27(4), 508-514. doi: 10.1097/01.BCR.0000225994.75744.9D

Spires, C. M., Kelly, B. M., & Pangilinan, P. H. (2007). Rehabilitation methods for the burn injured individual. Phys Med Rehabil Clin N Am, 18(2007), 925–948.

University of Colorado Health Sciences Center. (1995). Rocky Mountain Model System for Burn Injury Rehabilitation. Denver, Colorado: University of Colorado Health Sciences Center.

*Prevent contractures - place in the THERAPEUTIC POSITION!

Use custom made or prefabricated

splints or everyday household objects.

(Schneider et al., 2006)