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Burns

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by

Olivia George

on 19 November 2014

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Transcript of Burns

Upper Extremity Burns
Shoulder, Elbow, Wrist, & Hand
Burns
Contractures
Protocol #1
Pressure Garments
Evidence Summary
Pressure

garments
and
silicone

gel

sheeting
are two optimal techniques for managing and preventing hypertrophic scarring. Although they are individually effective, some research demonstrates that
combining
the two techniques may be most effective, especially in instances where burns cover
concave

areas
such as on top of joints and between fingers.
Diagnosis
TBSA
=Total Body Surface Area
Olivia George

Functions of the Skin
Environmental barrier
(UV rays, chemical contamination, bacterial invasion)
Moisture barrier
Temperature regulation
Perceives injury & infection
through sensory receptors
Influences an individual's
personal identity
Wound Healing
Inflammatory Phase:

3-10 days after onset
Painful, warm, erythematous (red), develops edema
Reconstruction Phase:
Maturation Phase:
By day 3 post injury-healed wound
Erythematic, raised, rigid, scars form, easily excoriated
By week 3 post injury-2 years post injury
Scar softens and flattens, tensile strength up to 80% of original skin
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
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)
(Hettiaratchy & Dziewulsk, 2004)
When >30% TBSA
Skin Graft
Burn Classification

Rule of Nines

Head = 9%
Trunk = 36%
Upper extremity = 9% each
Perineum = 1%
Lower extremity = 18% each
Protocol #2
Silicone Gel Sheeting
Surgery involving the
transplantation of skin
, typically used for treating
partial thickness
and
full thickness burns.

Managing Scar Formation
Shoulder
Elbow
Wrist/Hand
(Spires et al., 2007)
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
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
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)
(Atiyeh, 2013)
(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.
Care
: Clean silicone sheeting twice daily with mild soap & water and rinse well. To dry, pat with a non-fluffy towel.
(Momeni, Hafezi, Rahbar, & Karimi, 2009)
(Momeni, Hafezi, Rahbar, & Karimi, 2009; Burn Care Centre, 2006)
(Garren & Kelly, 2009)
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
Although skin grafts placed as sheets are more aesthetically pleasing, larger area's may require the skin to be "
meshed
."
(Pendleton & Schultz-Krohn, 2006)
(Pendleton & Schultz-Krohn, 2006)
(Pendleton & Schultz-Krohn, 2006)
(Spires et al., 2007)
Joint
Position of Comfort
Therapeutic Position
Joint
Position of Comfort
Therapeutic Position
Joint
Position of Comfort
Therapeutic Position
A
contracture
is a condition of
shortening
and
hardening
of muscles, tendons, or other tissue, often leading to
deformity
and
rigidity
of joints.
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
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
(Kockrow, 2006)
(Schneider, Holavanahalli, Helm, Goldstein, & Kowalske, 2006)
*Prevent contractures - place in the THERAPEUTIC POSITION!

Use custom made or prefabricated
splints
or everyday
household

objects
.
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)
(Momeni, Hafezi, Rahbar, & Karimi, 2009)
(Momeni, Hafezi, Rahbar, & Karimi, 2009)
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.
References
(Momeni, Hafezi, Rahbar, & Karimi, 2009; Burn Care Centre, 2006)
(Pendleton & Schultz-Krohn, 2006)
(Hettiaratchy & Dziewulski, 2004; Hall, 2009)
(Schneider et al., 2006)
(Hettiaratchy & Dziewulski, 2004)
(Procter, 2010)
(Procter, 2010)
(Procter, 2010)
(Procter, 2010)
(Procter, 2010)
(Procter, 2010)
(University of Colorado Health Sciences Center, 1995)
(University of Colorado Health Sciences Center, 1995)
(University of Colorado Health Sciences Center, 1995)
Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg
Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg
Photos retrieved from: http://media-cache-ak0.pinimg.com/236x/04/e4/70/04e4706eb801649960cbb6dda870fd40.jpg
Superficial burns:

Damage above the basal layer of the epidermis, the outermost layer of skin
Appear red, dry and painful, like sunburns.
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.
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)
(Spires et al., 2007)
(Spires et al., 2007)
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.
Burn Classification Con't
(Spires et al., 2007)
Photo retrieved from: http://biomed.brown.edu/Courses/BI108/BI108_2007_Groups/group11/ProcDerm.jpg
Photo retrieved from: http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/10303.jpg
Photo retrieved from: http://www.medicalexhibits.com/obrasky/2009/09102_08X.jpg
Photo retrieved from: http://www.intechopen.com/source/html/18943/media/image2.jpeg
Photo retrieved from: http://cirrie.buffalo.edu/encyclopedia/images/pediatricburns_9.jpg
Photo retrieved from: http://www.gottfriedmedical.com/custom_compression-garments/boleros/images/441-FR.png
Retrieved from: http://images.alfresco.advanstar.com/alfresco_images/HealthCare/2014/03/27/6e6ee7d5-fbc3-4c21-b125-046312d019ee/Hypertrophoic_Burn_Scar_SP3_Laser_Treatment.png
Retrieved from: http://www.rejuveness.com/mc_images/product/image/armscarsiliconesheet.JPG
Early ROM/Stretching
Early stage scars are extremely active & dynamic and the contractile force is at its highest.

If a burn is close to/over a joint, it must be
stretched
to avoid loss of ROM and to prevent contracture

Stretching to end of functional range
+
splinting
=
elongate scar tissue and maintain ROM
(Procter, 2010)
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