REHAB 109

LECTURE
BSPT 4
INSTRUCTOR: DANICA BARREDO, PTRP
 PRELIM
MODULE 2: BURNS
A. Definition
E. Symptoms, Prognosis and
B. Causes of Burn Complication of Burn

C. Classificationof Burn G. Intervention

• Medical Management and
D. Test andAssessment Treatment
• Rule of Nines • Surgical Management and
• Lund and Browder Chart Treatment
• Physical Therapy Intervention
DEFINITION
 BURNS

o Phenomenon that skin cells are

destructed or necrotized by heat sources
➢Hot water
➢friction by hot objects
➢high-voltage electricity
➢various chemicals
➢toxic gases
➢carbon monoxide
➢damage of the airway caused by
exhaust fumes
CAUSES OF
BURNS
 A. HOT FLUID BURN

o caused by hot liquids (water, oil, etc.)

or hot steam.
o Mainly second-degree burns and often
occur in young children or elder
people.
o The course of the treatment varies
depending on the contamination range
of the fluid.
A. HOT FLUID BURN
 B. FLAME BURN

o caused by fire or gas explosion

o mainly breaks out in confined areas in
industrial sites or at home
o burn victims are mostly damaged by the
flame, and the depth of the damage is
severe.
o serious damage to the respiratory system
is caused by inhalation of the gas
accompanying the flame
B. FLAME BURN
 C. ELECTRICAL BURN
o caused by exposure to high voltage electricity.
o Mostly caused by electrical shock in the industrial sites
o induces serious damage to internal organs
o Electric current follows the course of least resistance
offered by various tissues (nerves < blood vessels =
least; bone = most)
o initial contact or entrance wound
➢ appear charred and depressed and is smaller than
the ground site
➢ skin appears yellow and ischemic
o ground site or exit wound
➢ appears as though there was an explosion out of the
tissue at the site.
➢ dry in appearance
C. ELECTRICAL BURN
 D. CHEMICAL BURN

o caused by the contact with acid,

alkali, and other toxins.
o severity of damage varies depending
on the nature of the chemical,
concentration, and the duration of the
contact.
D. CHEMICAL BURN
 E. CONTACT BURN

o caused by the direct contact with a

hot grill, cooking utensils, electric iron,
electric blanket, or play equipment
exposed to the sunlight for a long
time.
o damaged area is topical but most lead
to the second-degree deep lamella
burn.
E. CONTACT BURN
 F. INHALATION BURN

o caused by breathing in high temperature heat

directly or inhaling carbon monoxide or harmful
combustion substances directly.
o Inhaling toxic gases produced from harmful
combustion substances → airway resistance
increases due to bronchoconstriction.
o Function of cilia in airway is degraded → alveoli are
necrotized → respiratory failure → air ventilation
declines = pulmonary edema
o High mortality rate due to respiratory failure and high
risk of secondary infection
F. INHALATION BURN
CLASSIFICATION
OF BURN
 A. 1ST DEGREE BURN
o refers to the burn that only the epidermis is damaged
o commonly caused by sunburn
o does not involve blisters but the skin is rubified and inflamed, and it is
accompanied with pain after the skin damage
o It is then accompanied with a slight headache
o be healed in 3–10 days without leaving a scar unless there’s inflammation
o Tx: moisturizer such as lotion
 B. 2ND DEGREE BURN
o Second Degree Superficial Partial
➢ Burn that the epidermis and the papillary layer of the dermis are
damaged (up to papillary region only)
➢ involves blisters, erythema, edema, and pain
➢ takes about 1–3 weeks to be healed
➢ Tx: moisturizer, do not break the blisters

o Second Degree Deep Partial

➢ Burn which the entire epidermis and dermis are damaged, (both papillary
and reticular layer)
➢ formed blisters are destroyed and the burnt area is red or white.
➢ Hypoesthesia and pain may be accompanied
➢ takes about 3–5 weeks to be healed
B. 2ND DEGREE BURN
 C. 3RD DEGREE BURN

o full-thickness burn refers to the burn that the damages the epidermis,
dermis, and subcutaneous tissue.
o burnt area is white or brown due to the blood clot
o becomes hard and dry like dried leather
o Nerves are damaged → patient cannot feel any pain and the skin becomes
insensible
o (+) eschar - due to necrotic skin tissues
➢ Necrotic skin tissues are naturally eliminated after 2–3 weeks.
o With appropriate treatment: skin tissues will be regenerated → wound can
be healed
o Skin regeneration function destroyed → skin graft is required for extensive
wound treatment.
o shock is the most important issue because of large amount of water loss
C. 3RD DEGREE BURN
 C. 4TH DEGREE BURN
o subcutaneous burn refers to the
burn in which adipose tissues,
muscles, tendons, and even
osseous tissues are completely
destroyed as well as the
epidermis, dermis, and
subcutaneous tissue.
o caused by electrical burn, hot fluid
burn, or flame burn for a long time
o skin becomes barren and dry as it
gets burnt black like a mummy
o damage affects the osseous →
sometimes bones are exposed and
amputation is needed.
o Tx: extensive skin graft is required
 Burn Wound Classification: Differential Diagnosis (Sullivan)
Depth of Burn Color / Vascularity Surface of Appearance / Pain Swelling / Healing /
Scarring
Epidermal Erythematous, pink or red; No blisters, dry surface; delayed Minimal edema;
1st
(sunburn) irritated dermis pain, tender spontaneous healing (2
degree
wks.) ; no scars
2nd Superficial Bright pink or red, mottled red; Intact blisters, moist weeping, or Moderate edema;
degree partial-thickness inflamed dermis; erythematous glistening surface when blisters spontaneous healing;
with blanching and brisk capillary removed; very painful, sensitive minimal scarring;
refill to changes in temperature, discoloration
exposure to air currents, light
touch
Deep partial- Mixed red, waxy white; blanching Broken blisters, wet surface; Marked edema; slow
thickness with slow capillary refill sensitive to pressure but healing; excessive
insensitive to light touch or soft pin scarring
prick
Most painful
Full-thickness White (ischemic), charred, tan, Parchment-like, leathery, rigid, dry; Area depressed; heals
fawn, mahogany, black, red anesthetic; body hairs pull out with skin grafting;
3rd
(hemoglobin fixation); no easily scarring
degree
blanching; thrombosed vessels;
poor distal circulation
Subdermal Charred Subcutaneous tissue evident; Tissue defects; heals with
4th anesthetic; muscle damage; skin graft; scarring
degree muscular or neurological
involvement
 BURN
WOUND
HEALING
 Burn Wound Zones
Zone of o cells are irreversibly damaged and skin death occurs
Coagulation o equivalent to a full-thickness burn
o will require a skin graft to heal
o the lack of viable tissue and the amount of eschar → risk of
infection is increased
o emphasis on: careful monitoring, the use of antibiotics, and
the treatment of a burned patient in a specialized burn
center.
Zone of o contains injured cells that may die within 24 to 48 hours
Stasis without diligent treatment.
o (+) infection, drying, and/or inadequate perfusion of the
wound → conversion of potentially salvageable tissue to
completely necrotic tissue and enlargement of the zone
of coagulation.
o Splints or compression bandages, if applied too tightly, can
compromise this zone
Zone of o site of minimal cell damage
Hyperemia o tissue should recover within several days with no lasting
effects
 Burn Wound Healing
Inflammatory o prepares the wound for healing through hemostatic, vascular, and
Phase cellular events.
o begins at the time of injury, ends in about 3 to 5 days
o characterized by redness, edema, warmth, pain, and decreased
ROM
o Cascade of events:
➢ blood vessel is ruptured → wall of the vessel contracts →
decrease blood flow (transient event only ~5-10 min.)
➢ Platelets aggregate, and fibrin is deposited to form a clot over
the area. Fibrin serves:
✓ to partially retain body fluids
✓ to protect the underlying cells from desiccation (drying)
✓ to provide a firm coagulum substance from which cells can
infiltrate.
Note: fibrin can be thought of as forming a lattice network, from
which cells can climb and work themselves into the healing
structure.
➢ vessels vasodilate → increase blood flow to the area
→increased permeability of the blood vessels with leaking of
plasma into the interstitial space → subsequent edema
formation
➢ Leukocytes infiltrate the area → rid the site of contamination
➢ (+) macrophage cells → attracting fibroblasts into the area
 Burn Wound Healing
Proliferative o (+) re-epithelialization at the surface of the wound,
Phase o deep within the wound: fibroblasts are migrating and proliferating
➢ Fibroblasts - cells that synthesize scar tissue, which is composed
of collagen and protein polysaccharides.
o collagen is deposited with a random alignment and no true
architectural arrangement of fibers.
o Stress (e.g., a force intended to elongate the scar) applied to the
developing tissue → fibers to align along the direction of force
o tensile strength = rate of collagen synthesis
o Granulation tissue is formed during this phase
➢ consists of macrophages, fibroblasts, collagen, and blood vessels
➢ Newly formed blood vessels → bring a rich blood supply → further
wound healing
➢ Granulation tissue → not necessary for skin graft adherence
➢ excess granulation tissue may lead to an increase in hypertrophic
scarring.
o (+) wound contraction - body attempts to close a wound where a loss
of tissue has occurred.
➢ involves movement of existing tissue at the wound edge toward
the center, not formation of new tissue.
➢ Wound contraction ceases when:
✓ edges of the wound meet,
✓ tension in the surrounding skin equals or exceeds the force
of contraction
 Burn Wound Healing
Maturation o reduction in the number of fibroblasts → decrease in vascularity →
Phase lesser metabolic demand
o collagen → more parallel in arrangement and forms stronger bonds.
o rate of breakdown equals or slightly exceeds the rate of production →
maturation results in a pale, flat, and pliable scar.
o rate of collagen production exceeds breakdown → hypertrophic scar
o Hypertrophic scar - red and raised appearance with rigid texture; it
stays within the boundary of the original wound
o Keloidal scar - a large, firm scar that overflows the boundaries of the
original wound; it is more common in darkly pigmented individuals.
o (+) scar → affect both functional and cosmetic deformities.
o (+) scar contraction during both this maturation phase and the
proliferative phase → risk of contracture formation → over a joint will
limit ROM and affect joint function
 SYMPTOMS,
PROGNOSIS, &
COMPLICATION
OF BURN
 A. SYMPTOMS
Pathophysiological Symptoms During Recovery Stages
Shock Phase o shock lasts over 2 to 3 days after a burn
o ↑ blood cells including red blood cells
o ↓ plasma volume
o Result: blood becomes more viscous → decreased blood circulation and cardiac
output and increased heart rate
Symptoms in Shock Phase Symptoms After the Shock
o Restlessness Phase
o Paleness o pain
o Coldness o decrease in range of motion
o Sweating and thirst. o amputation in some cases
o decrease in blood pressure o dysfunction of the hands
o tachycardia o severe trauma
o cyanosis o being placed in the state of
o respiratory failure socially handicapped
Eschar o skin is replaced with eschar → begins to be detached after 3–4 weeks
Detachment o first-degree burn or second-degree superficial burn: skin healed from the
Phase bottom layers of the skin naturally
o second- degree deep burn or third- to fourth-degree burn: requires surgical
treatment such as skin graft.
Healing Phase o First-degree burn or second-degree superficial burn: healed to normal
without any burnt mark, but scar tissues can be formed in some cases.
o Second-degree deep burn or third- to fourth-degree burn: requires skin graft
or surgical treatment which might take over several weeks or several years.
 A. SYMPTOMS

Systemic Symptoms
Symptoms on o ↑ water loss through the skin
Skin o Easy invasion of pathogens through the burnt wound (eschar in
full thickness burn)
Symptoms on the o ↑ capillary permeability → ↓ blood flow rate, ↑ interstitial fluid =
Blood and edema
Cardiovascular o Major burns:
System ➢ ↑ blood cells including red blood cells
➢ ↓ plasma volume
➢ Result: blood becomes more viscous → decreased blood
circulation and cardiac output and increased heart rate →
hypovolemia and urinary frequency → if untreated: acute
renal failure
Symptoms on the o Catabolism state - tissue breaks down until the wound caused by
Circulatory and burn is completely covered → consumes a lot of energy → large
Immune Systems amount of water evaporation and heat loss
o Loss of protein due to ↑ capillary permeability
o More severe burn = ↑ risk of infection
 B. PROGNOSIS

o Factors to consider: age, % of total burn

surface area (TBSA), inhalation burn
o Poor prognosis: elders over 70 y.o and
children below 10 y.o
o Over 20% TBSA: ICU tx
o Inhalation burn caused by burn on face:
higher mortality rate
 C. COMPLICATIONS
o Hypertrophic Scar
➢ occurs in second-degree deep burn or severe burns
➢ a scar that becomes thicker and projected in the process the wound is
being recovered.
➢ aesthetically ugly and very itchy
➢ causes severe discomfort due to pain
➢ red in an early stage → blackish red and hard as it develops
➢ Burn patients start to have a hypertrophic scar from 1 to 2 weeks later as
the wound becomes healed and lasts up to 2 years
➢ if left untreated: can last permanently → secondary skin contracture or
joint contracture
➢ To soften the hypertrophic scar: use of ultrasound
o Contracture
➢ stretching should be applied to maintain or extend the range of motion
➢ paraffin bath or infrared before stretching
o Amputation
➢ For severe burn such as third-degree burn or high-voltage electrical burn
because nerves, blood vessels, and even osseous tissues including the
skin are damaged and the recovery is impossible.
 C. COMPLICATIONS
o Photosensitivity
➢ Second-degree deep burn patients have an abnormal skin reaction to
sunlight
➢ Melanogenesis continues over 6 months after the burn, and
melanization lasts up to 2–3 years after the burn
➢ burn can be discolored due to the exposure to sunlight; thus, it is
important to block the sunlight so that the burn is not exposed through
wearing long sleeves or a hat.
o Pruritus
➢ lasts about 6 month to 2 years after the burn
➢ burn site becomes dry due to destroyed sebaceous glands → pruritus
➢ serious problem: patients scratch the wound severely because of
itchiness, and it badly deteriorates the wound and prolongs the
recovery period.
➢ Tx: applying oil regularly to prevent skin from drying and constant skin
care such as taking antihistamine agents or implementing
desensitization treatments are needed.
 C. COMPLICATIONS
o Infection
➢ leading cause of mortality from burns
➢ some strains of Pseudomonas aeruginosa and Staphylococcus aureus are resistant
to antibiotics → epidemic infections in burn centers
➢ Microbial invasion from the burn wounds to other healthy tissue → create sepsis
➢ Tx: Systemic antibiotics
o Pulmonary Complications
➢ Signs of an inhalation injury:
✓ facial burn
✓ singed nasal hair
✓ harsh cough
✓ hoarseness
✓ abnormal breath sounds
✓ respiratory distress
✓ carbonaceous sputum and/or hypoxemia
➢ Primary complications:
✓ carbon monoxide poisoning
✓ tracheal damage
✓ upper airway obstruction
✓ pulmonary edema
✓ pneumonia
 C. COMPLICATIONS

o Metabolic Complications
➢ rapid decrease in body weight
➢ negative nitrogen balance
➢ protein from muscle tissue used as source of energy → muscle
atrophy → weakness
➢ decrease in energy stores
➢ increase of 1.8°F to 2.6°F (1°C to 2°C) in core temperature → due to
a resetting of the hypothalamic temperature centers in the brain
✓ recommended room temperature: 86°F (30°C),
o Cardiovascular Complications
➢ Shift in fluid to the interstitium → edema
➢ ↓ CO → manage with fluid replacement therapy
➢ Alterations in platelet concentration and function, RBC dysfunction, ↓
hemoglobin & hematocrit
 C. COMPLICATIONS
o Heterotopic Ossification
➢ abnormal development of bone in areas of soft tissue → pain and
functional impairment
➢ unknown etiology
➢ MC area affected: elbow
➢ ↑ risk if burn size > 30% TBSA
o Neuropathy
➢ Can be polyneuropathy or local neuropathy
✓ Polyneuropathy suggested causes: direct thermal injury, vascular
occlusion, compressive nerve entrapment, edema
✓ Local neuropathy causes: compression bandage applied too
tightly, portly fitting splints, prolonged and inappropriate
positioning
➢ MC sites of involvement: brachial plexus, ulnar nerve, common
peroneal nerve
 MEDICAL &
SURGICAL
MANAGEMENT &
TREATMENT
 A. INITIAL TREATMENT

o Goals: address critical life-threatening problems

through procedures designed to:
➢ establish and maintain an airway
➢ prevent cyanosis, shock, and hemorrhage
➢ establish baseline data, such as extent and depth
of burn injury
➢ prevent or reduce fluid losses
➢ clean the patient and wounds
➢ examine injuries
➢ prevent pulmonary and cardiac complications
 A. INITIAL TREATMENT
Initial Transportation Phase
o Burn injury patient → transported to treatment facility (if possible,
directly to a burn center rather than ER)
o Goal: stabilize patient and maintain airway
o Gather patient history and personal data → Note type of agent that
caused the burn → IE of burn injury
o Emergency medical personnel use Rule of 9 to estimate burn
percentage
o Prepare for triage: remove all burned clothing and jewelry
➢ If clothes stuck on burn → do not remove by force
o Cover burn with sterile gauze or cloth
➢ Do not apply unascertained medicines → cause secondary
infection
➢ If chemical burn: dilute chemical by applying running water →
careful not to transfer chemical to other parts of body
o Initiate administration of fluid via IV
 A. INITIAL TREATMENT
Arrival at Burn Center
o Determination of extend and depth of injury → wound cleansing using
showers, spraying over a tub or bed baths
➢ Note: Hydrotherapy tubs no longer recommended
o determine body weight, fully examine the patient, remove hair where
necessary, and start the débridement process by removing any loose
skin
o Goal: remove dead tissue, prevent infection, and promote
revascularization and/or epithelialization of the area
o Take note of appearance, depth, and size are determined and the
presence of exudate or odor
➢ Infection: thick purulent drainage, odor, fever, a brownish-black
discoloration, rapid separation of eschar, boils in adjacent tissue, or
conversion of a deep partial-thickness burn to a full-thickness
injury.
o Patient kept warm → reduce any further metabolic demand
o Application of topical medication and/or dressing
 A. INITIAL TREATMENT

Dressings
o Purpose:
➢ hold topical antimicrobial agents on the wound
➢ reduce fluid loss from the wound
➢ protect the wound
o Changed once or twice a day
o Layers:
➢ 1st – nonadherent to protect fragile healing surface from
disruption
➢ 2nd – cotton passing to absorb wound drainage
➢ 3rd – roll gauze or elastic bandages → holds other layers in
place but allow movement
 A. INITIAL TREATMENT
Wound Care Techniques
Sharp Mechanical Close
Open Technique Autolysis
Debridement Debridement Technique
o the use of o Use of o applying a o applying o use of
surgical pressure topical cream dressing enzyme
scissors or irrigation, or ointment s over a (patient’s
scalpel and water without topical own
forceps to therapy, dressings agent immune
remove eschar and o allows for system)
o sloughed stimulation ongoing
epidermis and of electrical inspection of
loose eschar therapy the wound and
are removed examination of
and pockets of the healing
pus are drained process
o performed o topical
carefully so that medication
bleeding is must be
minimal reapplied
throughout the
day
A. INITIAL TREATMENT
 B. SURGICAL MANAGEMENT

o Primary excision
➢surgical removal of eschar
➢includes removal of peripheral
layers of eschar until vascular,
viable tissue is exposed as the
site for skin graft placement
 B. SURGICAL MANAGEMENT
Skin Grafts
removal of skin to graft onto a burn wound surgically under anesthesia
Split Thickness Skin o contains epidermis and a variable amount of dermis
Graft
Full Thickness Skin o consists of the full dermal thickness
Graft o disadvantage: leaving a full-thickness wound at the donor site → require either primary closure
or grafting with a split-thickness skin graft.
Common donor sites: thighs, buttocks, and back.
Autograft o patient’s own skin, taken from an unburned area and transplanted to cover a burned area.
o Desirable because they provide permanent coverage of the wound.
Allograft (homograft) o skin taken from an individual of the same species, usually cadaver skin
o Skin can be kept frozen in skin banks for prolonged periods.
o temporary grafts used to cover large burns when there is insufficient autograft available
Xenograft o skin from another species, usually a pig
(heterograft) o used until there is sufficient normal skin available for an autograft (temporary)
Cultured Skin o grown in a laboratory from a biopsy of a patient’s own tissue, the use of altered cadaver skin,
or other biologically engineered tissues
o used when large areas of burn exist and coverage is necessary for a patient’s survival
Sheet Graft o applied to a recipient bed
o without alteration following harvesting from a donor site
o for face, neck, and hands → optimal cosmesis and function
Mesh Graft o When limited donor skin is available
o processing the sheet graft through a device that makes tiny parallel incisions in a linear
arrangement.
o allows coverage of a larger area
 B. SURGICAL MANAGEMENT
o Survival of a skin graft depends on several factors:
➢ Circulation → nutritive supply to the graft
➢ Inosculation → process by which a direct connection is established
between a graft and the host vessels
➢ Penetration of the host vessels into a graft site.
 B. SURGICAL MANAGEMENT
o Correction of Scar Contracture
➢ Burn plastic surgery - prevents hypertrophic scars or make the scars
smaller as much as possible.
➢ Z-plasty - serves to lengthen a scar by interposing normal tissue in the line
of the scar.
References:
1. Park, J,; Jung, D. (2016) Integumentary Physical Therapy, Springer-Verlag
Berlin Heidelberg
2. O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. (2019). Physical rehabilitation.
F.A. Davis.