#

BURNS
General Medical 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
As to causative agent: Thermal Heat Cold Chemical Radiation lectrical !echanical As to depth of involvement: "ld terminology: #st degree $ epidermis only dema and redness with necrosis nd % degree $ epidermis up to dermis &lister formation with su'se(uent epidermal healing )rd degree $ whole s*in depth +ecrosis of s*in resulting in full thic*ness s*in loss ,th degree $ su'cutaneous structures -muscles, nerves, 'ones. /angrene of affected area !ost sources descri'e 'urn depth only up to ) rd degree and include the structures affected in ,th degree 'urns +ew terminology:
DEPTH
Superficial -outer epidermis. Superficial Partial T"ic#ness -whole epidermis 2 dermis up to papillary layer. Deep Partial T"ic#ness -whole epidermis 2 dermis up to reticular layer. $ull T"ic#ness -whole epidermis 2 whole dermis. Su%der&al -whole s*in up to su'cutaneous

Wound Color / Vascularity

rythematous, pin* or red0 irritated dermis &right pin* or red, mottled red0 inflamed dermis0 erythematous with 'lanching and capillary refill

Surface Appearance / Pain

+o 'listers, dry surface0 delayed pain, tender 3ntact 'listers, moist surface, weeping or glistening0 most painful0 sensitive to changes in temperature, exposure to air currents, light touch &ro*en 'listers, wet surface0 sensitive to pressure 'ut insensitive to light touch or pin1pric* 7archment1li*e, leathery, rigid, dry0 anesthetic0 'ody hairs pulled out easily

S ellin! / Scarrin! / Healin!

!inimal edema0 no scars0 spontaneous des(uamation in %1) days !oderate edema0 minimal scarring -discoloration.0 spontaneous healing in 41 %# days

!ixed red, waxy white0 'lanching with slow capillary refill

!ar*ed edema0 excessive scarring0 slow healing in )1 5 wee*s

6hite -ischemic., charred, tan, fawn, mahogany, 'lac*, red0 hemoglo'in fixation0 no 'lanching0 throm'osed vessels0 poor distal circulation Charred

Area depressed0 scarring0 heals with s*in grafting

8u'cutaneous tissue evident0 anesthetic0 muscle damage0 neurological involvement

Tissue defects0 scarring0 heals with s*in grafting

%
tissue or further.

Comparison 'etween old and new terminologies:

'ld Ter&inolo!y
#st 9egree %nd 9egree )rd 9egree ,th 9egree

Ne

Ter&inolo!y

8uperficial 8uperficial 7artial Thic*ness 9eep 7artial Thic*ness :ull Thic*ness 8u'dermal

As to 'urn severity: The American &urn Association -A&A. has developed the following classification system: !inor ; #5< &8A 7artial Thic*ness -; #=< child. ; %< &8A :ull Thic*ness -not involving eyes, ears, face, hands, feet, or perineum. !oderate #51%5< &8A 7artial Thic*ness -#=1%=< child. %1#=< &8A :ull Thic*ness -not involving eyes, ears, face, hands, feet, or perineum. !ajor > %5< &8A 7artial Thic*ness -> %=< child. > #=< &8A :ull Thic*ness All 'urns involving eyes, ears, face, hands, feet, or perineum All electrical 'urns, 'urns with inhalation injuries, 'urns with complications -fracture, major trauma., poor ris* patients % to age or illness !ost moderate and major 'urns re(uire hospitali?ation

Epide&iolo!y
:or all 'urns: #@4= hospitali?ed !ajority are males #4 $ )= y.o. AA< home1related :or thermal 'urns: B5< of all 'urns :or chemical 'urns: Common in la'oratory@industrial accidents :or electrical 'urns: #@) electricians, #@) construction, #@) home ) $ , < high1voltage, rest are low1voltage :or radiation 'urns Rare, except for radiation 'urn % to prolonged exposure to CDR -sun'urn.

Etiolo!y
Causes of 'urns could 'e: Thermal Heat 9ue to rapid heating Types: :lame 'urns 8calds Contact 'urns :lash 'urns Cold

) 9ue to rapid free?ing Chemical 9ue to exposure to various chemical agents Agents: Acids Al*ali Radiation Csually due to exposure to electromagnetic energy radiating agents Agents: CDR lectrical Radar Radioactive elements -uranium, plutonium. lectrical 9ue to exposure to electrical currents Types: Eow1voltage ;#===D usually ##=D -C8. or %%=D -other countries., 'oth with AC A= H? current High1voltage >#===D !echanical Csually due to friction

Pat"op"ysiolo!y / Pat"o&ec"anics
Regardless of the causative agent, a 'urn initially undergoes the following physiologic responses:

&ecause the s*in also serves as protection from infection, the loss of the cutaneous 'arrier facilitates entry of the patientFs own flora and of organisms from the hospital environment into the 'urn wound. The wound often contains devitali?ed or fran*ly necrotic tissue that (uic*ly 'ecomes contaminated with

, 'acteria. 3nvasive infection locali?ed and@or systemic occurs when 'acteria penetrate via'le tissue, usually 'elow the eschar. &urn wound healing occurs through separate mechanisms in the epidermis and dermis pidermal healing "ccurs if there are via'le epithelial cells lining the wound

9ermal healing 8car formation occurs ven if each phase is descri'ed separately, they occur on a continuum and one phase often overlaps another

Clinical (anifestation)s*
A 'urn injury will present with the following local effects: Eoss of a'ility to regulate evaporative water loss 8uscepti'ility to infection Eoss of massive amounts of 'ody fluids, especially in open wounds Eocal 'urn wound sepsis % to 'acterial contamination Gones of &urn: Gone of Coagulation 9ying cells with irreversi'le damage 3f not controlled, affectation may involve next ?one Gone of 8tasis 3njured cells which may die in # $ % days if no intervention is done 3nfection, drying, inade(uate wound perfusion in this ?one will result in conversion of potentially salvagea'le tissue to completely necrotic tissue Gone of Hyperemia

A !inimal cell damage with possi'le recovery up to 4 days without any lasting effects

Co&plication)s*
8H8T !3C :: CT8@7R3!ARH C"!7E3CAT3"+8: Acute hypovolemia with loss of fluid to extravascular compartment 7ulmonary changes $ hyperventilation "xygen consumption 3f inhalation injury, may lead to pneumonia Acute gastric dilatation@gastrointestinal ileus within #st ) days post1'urn Cata'olism leading to ana'olic activity Core@mean T Hypermeta'olism 8 C"+9ARH C"!7E3CAT3"+8 3nfection E"! % to soft tissue contracture !uscle strength % to disuse or nerve involvement 8ensory loss % to destruction of sense receptors in s*in or nerve involvement Auto1amputation 3n electrical 'urns, usually toes@fingers 9isfigurement, usually % to scarring Heterotopic ossification !ost commonly at el'ow Associated injuries such as: Disual loss +eurovascular damage :racture

Dia!nosis
3n the diagnosis of 'urn injuries, the following are the major concerns as to severity: 7ercentage of total 'ody surface area -T&8A. 'urned 9epth of 'urn !ethods of determining T&8A affected: IRule of +inesJ 'y 7ulas*i and Tennison Eess accurate 'ut more rapid 2 practical if in a general acute care setting A practical application is the use of the palm of # hand to 'ase as #< &8A
RE+,'N
Head 2 nec* :ront of trun* &ac* of trun* ach arm ach leg 7erineum

ADU-T
B< #K< #K< B< #K< #<

PED,A
#4< #K< #K< B< #)< #<

Eund and &rowder :ormula 6as developed due to the relative inaccuracy of the Rule of +ines method !ore accurate 'ut seldom used in general acute care settings !ost often used within a speciali?ed 'urn unit setting
RE+,'N
Head +ec* Ant. Trun* 7ost. Trun* ach &uttoc* /enitalia ach Cpper Arm ach :orearm ach Hand ach Thigh ach Eeg ach :oot

Birt"./ yr0
#B< %< #)< #)< %L< #< ,< )< %L< 5L< 5< )L<

/.1 yrs
#4< %< #)< #)< %L< #< ,< )< %L< AL< 5< )L<

2.3 yrs0
#)< %< #)< #)< %L< #< ,< )< %L< K< 5L< )L<

/4./1 yrs0
##< %< #)< #)< %L< #< ,< )< %L< KL< A< )L<

/2 yrs0
B< %< #)< #)< %L< #< ,< )< %L< B< AL< )L<

Adult
4< %< #)< #)< %L< #< ,< )< %L< BL< 4< )L<

N'TES
#B0 1%0 1,0 1%0 1%0 1% %< always #)< always #)< always % L < always #< always ,< always )< always % L < always 5 L0 M#0 M# L0 ML0 ML0 ML 50 M=0 ML0 ML0 ML0 ML ) L < always

!ethods of determining depth of injury: Csing either: "ld terminology #st degree $ ,th degree

+ew terminology 8uperficial 8uperficial partial thic*ness 9eep partial thic*ness :ull thic*ness 8u'dermal

+ew terminology is used now due to difficulty in specifying actual tissue involvement using old terminology !ethod of determining 'urn severity is through the A&A classification mentioned earlier The A&A has also identified criteria for admission to a designated 'urn center: 7artial and full thic*ness 'urns > #=< T&8A in patients under #= or over 5= y.o. 7artial and full thic*ness 'urns > %=< T&8A in other age groups :ull thic*ness 'urns > 5< T&8A in any age group 7artial and full thic*ness 'urns involving the hands, feet, face, perineum, or s*in overlying major joints lectrical 'urns, including lightning injury Chemical 'urns 7atients with inhalation injury &urn injury in patients with pre1existing illness that could complicate management Any patient with a 'urn in whom concomitant trauma poses an increased ris* of mor'idity or mortality may 'e treated initially in a trauma center until sta'le 'efore transfer to a 'urn center &urn injury in patients who will re(uire special social and emotional or long1term reha'ilitative support, including cases involving suspected child a'use 3n major 'urns, additional diagnostic examination may 'e re(uired, such as: &ronchoscopy 3f inhalation injuries are suspected 6ound 'iopsy with (uantitative micro'iologic culture 3f infection is suspected after 'urn injury

Differential Dia!nosis
9ifferential diagnosis is often limited to identifying the causative agent

Pro!nosis
:actors affecting the severity of a 'urn injury and itsJ prognosis are: 9epth xtent Age of patient /eneral condition 7osition@location of the 'urn 9elay of treatment Type of first aid given prior to treatment "ther complications present tiologic agent

Medical Management
P"ar&acolo!ic
The main goal is to prevent infection Through the use of topical anti'acterial agents 8ilver nitrate ffective against most gram1positive organisms and most strains of 7seudomonas

B Eimited against some gram1negative organisms 7enetrates only #1% mm of eschar 8ulfamylon -mafenide acetate. ffective against gram1positive and gram1negative organisms asily diffuses through eschar 8ilver sulfadia?ine ffective against 7seudomonas !ost commonly used &etadine ffective against gram1positive and gram1negative organisms and some fungi /entamycin ffective against gram1negative organisms and 8taphylococcal and streptococcal 'acteria :uracin 3ndicated to 'acterial growth Csed in less severe 'urns &acteracin @ 7olysporin ffective against gram1positive organisms Tetanus prophylactics are indicated in full thic*ness 'urns 8edatives may 'e applied in major 'urns due to extreme pain

(edical
3mmediate treatments are: :or minor 2 moderate 'urns 3ce or cold water Cleaned with soap 2 warm water Remove loose epithelium 6ound dressing Anti'acterial agents Tetanus prophylactics if full thic*ness :or major 'urns !aintenance of airway 3ntravenous resuscitation 8edatives Anti'iotics Tetanus prophylactics /astric decompression

Sur!ical
scharotomy To relieve pressure on underlying arteries and veins

:asciotomy

#= :or persistent impairment of peripheral 'lood flow &iologic dressings :or: 3mmediate coverage of superficial partial thic*ness 'urn Test dressing 6ound coverage after escharotomy Types: 8*in grafts from cadavers Human fetal mem'ranes -homograft or allograft. 8*in grafts from pigs -heterografts or xenografts. 8ynthetic dressings Types: 8pray1on polymerics "nly for superficial partial thic*ness 'urns ; %=< &8A and possi'le donor sites &ilayer artificial s*in &io'rane "psite 9e'ridement Types: !echanical Csually post1hydrotherapy n?ymatic 8utilains Travase @ lase n?ymatic de'riding agent that selectively de'rides necrotic tissue 8urgical :ascial Rarely indicated in severe 'urns Tangential !ost widely used C"% EA8 R xpensive 8*in grafting through autografts /rafts come from the same patient Types: Tanner mesh graft 7ostage stamp grafting 7oor cosmetic result 8heet grafting :or smaller 'urn wounds All grafted parts should 'e immo'ili?ed at least ,15 days

't"er Re"a%ilitati5e
Respiratory therapy may 'e indicated in inhalation injury 8peech pathologists may participate if speech is affected due to an inhalation injury "ccupational therapists provide: 8*ills retraining if affected 9ysphagia management if affected due to an inhalation injury 7sychiatric counseling may 'e indicated if any psychological impact to the injury is noticed

##

Physical Therapy Examination, Evaluation & Diagnosis

Points of E&p"asis in E6a&ination
!ajority of physical therapy examination revolves around examination of the integumentary system, particularly as to s*in integrity "ther points of emphasis in examination are: History of any pre1existing or co1existing illness@injury These illnesses@injuries may affect treatment Cardiovascular system examination 7articularly: Circulation to and from the sites of 'urn 7resence of edema 7ulmonary system examination specially if inhalation injury is suspected !usculos*eletal system examination 3f deeper structures are directly affected Also if immo'ili?ation of the affected region has affected the musculos*eletal system, such as: Noint play R"! !!T E/! !&T :unctional assessment To assess patientJs functionality in performing A9E, including: &asic A9E 3nstrumental A9E

Pro%le& -ist
&urn patients often present with the following pro'lems for physical therapy: 7ain 3mpaired s*in integrity 6ith su'se(uent affectations in musculos*eletal system dema 7oor cosmesis Ris* for integumentary disorders 7articularly infection 3f inhalation injury is suspected Ris* for pulmonary disorders 3mpaired ventilation and respiration@gas exchange "ther patient pro'lems could 'e: Hypertrophic scarring 7oor wound healing

P"ysical T"erapy Dia!nosis

Appropriate physical therapy diagnostic la'els for uncomplicated 'urns are: 3mpaired integumentary integrity associated with superficial s*in involvement 3mpaired integumentary integrity associated with partial1thic*ness s*in involvement and scar formation 3mpaired integumentary integrity associated with full1thic*ness s*in involvement and scar formation

#% 3mpaired integumentary integrity associated with s*in involvement extending into fascia, muscle, or 'one and scar formation 3f other examination findings indicate inclusion in other diagnostic criteria, patients are placed in other diagnostic la'els depending on the other systems affected such as: 3mpaired circulation and anthropometric dimensions associated with lymphatic system disorders 3mpaired ventilation, respiration@gas exchange and aero'ic capacity@endurance associated with airway clearance dysfunction 3mpaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury 3mpaired joint mo'ility, motor function, muscle performance, and range of motion associated with 'ony or soft tissue surgery 3mpaired joint mo'ility, motor function, muscle performance, and range of motion associated with locali?ed inflammation

Physical Therapy Prognosis (including Plan o !are" & #ntervention

Plan of Care
Acute care of 'urn patients will most often 'e geared toward achieving the following goals: Allow rapid wound healing Resolve edema 7reserve function 7revent @ minimi?e hypertrophic scarring 7revent respiratory complications Achieve good cosmetic outcome Eong1term -su'1acute and chronic. care of 'urn patients after receiving acute care would 'e geared toward the following: valuate the patientJs home environment and family support and address any necessary home environmental changes valuate and address any related physical dysfunctions valuate and address any ris* for secondary complications

,nter5entions
7hysical therapists provide the following interventions in the care of 'urns: 6ound care Cleansing Eocal wound care :or small areas and areas difficult to treat with hydrotherapy Hydrotherapy 3mmersion 1 6hirlpool 1 High &oy 1 Eow &oy +on1su'mersion -spray techni(ue. 1 8uspended on a stretcher at an angle over a Hu''ard tan* 7ulsatile lavage with suction Alternative to hydrotherapy 9e'ridement !ay 'e done during or after hydrotherapy 7hysical therapists may apply any of the de'ridement techni(ues mentioned

#) Topical agents Applied after cleansing and de'ridement 7hysical therapists may apply any of the topical agents mentioned 9ressings Applied after cleansing, de'ridement, and application of topical agents :unctional activities and exercises "nly during healing All grafted parts should 'e immo'ili?ed at least ,15 days /oals for exercise: Reduce edema !aintain R"! 7revent s*in contractures Activities and exercises: Range of motion and stretching AR"!@AAR"! exercises at 'edside %1) times@day 7R"! $ for critically ill, spastic, heavily medicated patients Am'ulation 8trengthening 7R $ for involved 2 uninvolved areas ndurance 8car management techni(ues 7ositioning and splinting 3ndications: 7atient cannot voluntarily maintain proper positioning dema xposed tendons 7eripheral neuropathy Cnresponsive patients 8uggested 7ositioning /uidelines for 7revention of &urn Contractures: Head 2 nec* $ extended@hyperextended 8houlders $ a'ducted to B= 2 externally rotated l'ows $ extended :orearms $ supinated 6rist 2 hand $ resting position Trun* $ neutral position Hips $ no flexion or external rotation 2 a'ducted to #= from midline Onees $ extended An*les $ dorsiflexed Commonly used splints
Area of %urn
Hands l'ow1cu'ital -volar aspect .

'pti&al position
6rist $ #=1#5P extension !C7 $ A=1A5P flexion 737@937 $ full extension :ull extension and supination

Splint
Dolar splint Anterior volar conforming splint )1point conforming splint 7osterior el'ow extension splint -after grafting. :irm1density foam wedge Conforming axillary splint Airplane splint Triangular foam wedge Hip a'duction, extension splint -primarily in children. 7osterior *nee extension splint )1point extension splint

8houlder and axilla Hip Onee

B=P a'duction, external rotation :ull extension with %=P a'duction, neutral rotation :ull extension

#,
An*le and foot B=P dorsiflexion, neutral as to inversion1eversion 7osterior dorsiflexion splint Anterior conforming splint

Compression garments :or management of hypertrophic scarring and edema 6orn %, hours a day up to # year until scar matures Types: lastic cloth garment 8ilastic mas* Clear plastic mas* :riction massage To align collagen in healing s*in +ot done after grafting for at least 5 days 3nitially gentle and then more aggressive 7ost1healing education !oisturi?ing newly1healed s*in Avoiding direct sunlight Cse of sunscreen Covering affected area with clothing 7lanning activities in early morning and late evening 7rotecting fragile s*in After discharge, the patient is followed1up less intensively in physical therapy 9epending upon the extent of the 'urn, the patient will need only %1) sessions per wee* of supervised 7T :ollow1up the severely 'urned patient for at least #K1%, months until the scar is completely matured and all reha'ilitation complications have 'een resolved 8ome important points: Chec* pressure garments for excessive pressure and s*in 'rea*down Remind patient to avoid prolonged exposure to heat or cold 6arn patient against vigorous outdoor activities until tolerance develops Remind patient to avoid direct sunlight exposure 8unlight exposure can 'egin gradually, with caution, after a'out A months