Continuum of Care of a Patient with Burns

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Introduction[edit | edit source]

Recovery from burn injury can be long, painful, and traumatic. New disability as a result of scarring or deformities may have an impact on family life, work, school, recreation, and social life. The high incidence of burn injuries and associated with burns morbidity demands effective burn management that requires skills resources to improve the quality of life of burn patients. This article discusses

Factors Impacting Recovery[edit | edit source]

Multiple factors can impact postburn recovery. The following factors may have a negative impact on successful post-burn recovery:

Medical:[1]

  • diabetes (affecting wound healing)
  • history of depression (affecting motivation)
  • inhalation injury (causing acute respiratory distress or acute respiratory failure)

Psychosocial:

  • tabacco use[1]
  • avoidant coping [2]
  • occupation loss[3]
  • current unemployment[3]
  • lack of participation in recreational activities[4]
  • limited or lack of social support
  • unknown discharge destination
  • emotional barriers (fear of rejection, embarrassment)[3]
  • behavioural barriers (pressure garments)[3]

Ability to adapt to the pre-burn state can be facilitated by (1)good social and peer support, (2) adaptive coping mechanisms [5][6], and (3) critical thinking.[3]

Initial Assessment[edit | edit source]

Burns location and depth:[1]

The burn assessment is based on the system that indicates the need for surgical intervention and describes the depth of the burn and its location.[7]

  • The Lund and Browder chart:
    • allows to calculate total body surface area (TBSA)
    • includes areas that are partial- and full-thickness and excludes superficial areas. For a detailed characteristics of burn by depth see this Physiopedia article.

Wound assessment:[1]

  • it is important to assess the wound when the dressing is taken down. When assessing the wound without dressing, check for the following wound characteristics:[1]
    • colour
    • wound environment: wet or dry
    • blanchability

Pain assessment:[1]

The depth of the burn determines the degree of pain. The superficial burns resulting in greater pain. The areas of full-thickness burns are usually pain-free. However full-thickness burns are typically surrounded by areas of more superficial injury therefore patients with full-thickness burns can report as much pain as patients who sustained a superficial injury. [8] The pain can last from few days to several months. Burn pain mechanisms vary and requires different interventions. They include the following mechanisms:[8]

  • acute burn pain
  • inflammatory burn injury pain
  • neuropathic burn injury pain

Preoperative Management[edit | edit source]

Goals[1]

  1. To increase functional mobility
  2. To prevent pulmonary complications
  3. To decrease oedema
  4. To initiate proper positioning

Interventions[1]

  • Active range of motion
  • Functional mobility[9]
  • Patient and caregiver education on:
    • current activities restrictions
    • importance of increasing mobility
    • pain and how to manage it
    • activities restrictions after the surgery

Reconstructive Burn Surgery[edit | edit source]

Early excision and closure of the burn wound prevents infection and reduces secondary complications due to burn scars. Reconstructive burn surgery restores the function of an affected area thus improving the quality of life for a patient with burn. [10]When choosing between skin grafts, tissue expansion or other tissue repairing techniques, the surgeon must consider the missing tissue area and the effected structures.[10]

General Guidelines:

  • patient typically undergoes multiple rounds of surgery
  • various surgical procedures may take up to three to four weeks

Surgical Procedures[edit | edit source]

The International Society for Burn Injury recommends early excision and grafting of deep partial-thickness burns. It shortens the recovery time, reduces pain and improves long-term scar outcomes. [11] In addition early wound closure leads to earlier transition to the rehabilitation program. [12]

The following treatment strategies are used in burn care:[1]

  • escharotomies (or "limb decompression")[13]
    • a "full-thickness incision through the eschar, exposing the subcutaneous fat."[14]
    • maintains perfusion through vessels [14]
    • relieves pressure on the nerves thus preserves their function [14]
    • complication includes compartment syndrome [13]
  • surgical excision and debridement
    • there is no movement precautions unless there is tendon exposure
    • rehabilitation team must discuss precautions with surgical team
  • allograft
    • graft is from the cadaver skin
    • it is not a terminal grafting technique
    • it allows to cover a large area of the burn
    • patient is allowed to move within 24 hours with no restrictions
  • autograft
    • any areas that cross joints covered with autograft should be immobilised for the first five days
    • patient's activity is encouraged. If a patient is immobilised over their wrist and their hand, they should be able to get up and walk
    • activities of daily living can be performed using other hand, while keeping the hand that has been grafted immobilised
    • custom-made splints will maintain grafted area immobilised:[15]
      • resting hand splint, which will hold the hand in an intrinsic plus position and the wrist in slight extension.
      • elbow brace to hold the elbow in an extended position as this is typically what is first lost after grafting
      • knee brace to hold the knee in an extended position

Splints Schedule[edit | edit source]

Initial splint schedule after surgery includes (1)keeping the splint on for five days,(2) performing daily splint checks , and (3) taking down the splint at the same time that the postoperative dressings are taken down to visualise the graphs and decide if the splint needs to be continued to use. [1]

Postoperative Management[edit | edit source]

Goal[1]

  1. To maintain the patient's mobility while protecting the graft sites
  2. To increase range of motion

Physiotherapy Interventions[edit | edit source]

General Guidelines[1]

  • Before starting the interventions, ask the surgical team if they feel that the graft is healing well enough to start doing some targeted mobility in that area.
  • Perform graft assessment during wound care. Elements of the assessment should include the following:
    • adherence of the graft
    • the colour of the graft
      • pale vs pink or purple colour. The latter indicates good vascularisation
      • presence of haematomas

Interventions[1]

  • Range of motion exercises
    • start with active range of motion.
    • progress to passive range of motion and more static stretching interventions based on graft assessment results
  • Functional mobility to achieve as much independence as possible with bed mobility, transfers, and activities of daily living
  • Goniometric assessment of the range of motion in functional positions rather to address the changes in the cutaneous functional unit when burns are healing.[16][17]
  • Stretching
    • hold a low-load prolonged stretch for about two minutes.
    • observe blanching over the joint that's being stretched (good sign)
    • moisturise the area with a water-based moisturiser before and after the stretching is performed
  • Patient and caregiver education on (1) scar massage to also help to break up the skin adhesions, (2) home exercise programme, (3) signs and symptoms of infection, and (4) expectation from the outpatient rehabilitation process.

Discharge to Home[edit | edit source]

Patient is discharged home with prefabricated compression garments. The plan is to measure the patient for custom compression through the outpatient phase.

Outpatient and Community Phase of Burn Rehabilitation Process[edit | edit source]

During the outpatient and community phase of burn rehabilitation, the rehabilitation team establishes the individualized patient-centered exercise program to achieve measurable and lasting outcomes. The following interventions can be included in the programme:

  • Scar management
    • Management of hypertrophic scarring (scars that raised within the bed of the wound).
    • Reduction of scar banding. Scar banding:
      • is common when grafting and burns have crossed joints
      • commonly occurs in the axilla or in the posterior knee
      • can inhibit joint motion and function
      • usually requires surgical management
    • Scar massage:
      • can be performed over any area that was burned or grafted
      • moisturisation should be performed before and after scar massage
      • teach the patient to perform scar massage in a vertical, a horizontal, and circular manner, with applying enough pressure to blanch the skin
      • reduces hypersensitivity, increases pliability of the skin, and helps to break up adhesions.
  • Custom compression garments[18][19]
    • Should provide 25 millimetres of mercury of compression
    • Must be worn for 23 hours a day for at least the first year after burn injury depending on the rate and type of healing
  • Fine motor skills incorporating the functional tasks that the patient need for school, work, or leisure.
  • Education about sun protection:[20]
    • avoid outdoor activities between 10 am and 4 pm when sun is intense. It also applies to cloudy days.
    • wear clothing and accessories that protect your body, like long sleeves, long pants, wide-brim hats
    • use sunglasses with 100% UVA and UVB protection
    • apply a broad-spectrum, water-resistant sunscreen with an SPF of at least 15 to dry skin 15 to 30 minutes before sun exposure
    • reapply sunscreen every two hours or earlier when sweating, swimming, or towel-drying
    • do not use sunscreen older than three years

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Webster L. Rehabilitation of a Patient with Burns from Hospital to Home. Plus course 2024
  2. ↑ Dukes K, Baldwin S, Assimacopoulos E, Grieve B, Hagedorn J, Wibbenmeyer L. Influential Factors in the Recovery Process of Burn Survivors in a Predominately Rural State: A Qualitative Study. J Burn Care Res. 2022 Mar 23;43(2):374-380.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Woolard A, Bullman I, Allahham A, Long T, Milroy H, Wood F, Martin L. Resilience and Posttraumatic Growth after Burn: A Review of Barriers, Enablers, and Interventions to Improve Psychological Recovery. European Burn Journal. 2022; 3(1):89-121.
  4. ↑ Browne G, Byrne C, Brown B, Pennock M, Streiner D, Roberts R, Eyles P, Truscott D, Dabbs R. Psychosocial adjustment of burn survivors. Burns Incl Therm Inj. 1985 Oct;12(1):28-35.
  5. ↑ Zare-Kaseb A, Hajialibeigloo R, Dadkhah-Tehrani M, Otaghsara SMT, Zeydi AE, Ghazanfari MJ. Role of mindfulness in improving psychological well-being of burn survivors. Burns. 2023 Jun;49(4):984-985.
  6. ↑ Al-Ghabeesh SH. Coping strategies, social support, and mindfulness improve the psychological well-being of Jordanian burn survivors: A descriptive correlational study. Burns. 2022 Feb;48(1):236-243.
  7. ↑ Rice PL, Orgill DP. Assessment and classification of burn injury. Available from https://www.uptodate.com/contents/assessment-and-classification-of-burn-injury [last access 8.5.2024]
  8. ↑ 8.0 8.1 Morgan M, Deuis JR, Frøsig-Jørgensen M, Lewis RJ, Cabot PJ, Gray PD, Vetter I. Burn Pain: A Systematic and Critical Review of Epidemiology, Pathophysiology, and Treatment. Pain Med. 2018 Apr 1;19(4):708-734.
  9. ↑ Cartotto R, Johnson L, Rood JM, Lorello D, Matherly A, Parry I, Romanowski K, Wiechman S, Bettencourt A, Carson JS, Lam HT, Nedelec B. Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients. J Burn Care Res. 2023 Jan 5;44(1):1-15.
  10. ↑ 10.0 10.1 Żwierełło W, Piorun K, Skórka-Majewicz M, Maruszewska A, Antoniewski J, Gutowska I. Burns: Classification, Pathophysiology, and Treatment: A Review. Int J Mol Sci. 2023 Feb 13;24(4):3749.
  11. ↑ Salemans RFC, van Uden D, van Baar ME, Haanstra TM, van Schie CHM, van Zuijlen PPM, Lucas Y, Scholten-Jaegers SMHJ, Meij-de Vries A, Wood FM, Edgar DW, Spronk I, van der Vlies CH; National Burn Care, Education & Research group, the Netherlands. Timing of surgery in acute deep partial-thickness burns: A study protocol. PLoS One. 2024 Mar 11;19(3):e0299809.
  12. ↑ Wong L, Rajandram R, Allorto N. Systematic review of excision and grafting in burns: Comparing outcomes of early and late surgery in low and high-income countries. Burns. 2021 Dec;47(8):1705-1713.
  13. ↑ 13.0 13.1 Niţescu C, Calotă DR, Florescu IP, Lascăr I. Surgical options in extensive burns management. J Med Life. 2012 Oct-Dec;5(Spec Issue):129-136.
  14. ↑ 14.0 14.1 14.2 Wong L, Robert J. Spence RJ. Escharotomy and fasciotomy of the burned upper extremity. Hand Clinics 2000; 16(2):165-174.
  15. ↑ Parry IS, Schneider JC, Yelvington M, Sharp P, Serghiou M, Ryan CM, Richardson E, Pontius K, Niszczak J, McMahon M, MacDonald LE, Lorello D, Kehrer CK, Godleski M, Forbes L, Duch S, Crump D, Chouinard A, Calva V, Bills S, Benavides L, Acharya HJ, De Oliveira A, Boruff J, Nedelec B. Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines. J Burn Care Res. 2020 May 2;41(3):503-534.
  16. ↑ Parry I, Richard R, Aden JK, Yelvington M, Ware L, Dewey W, Jacobson K, Caffrey J, Sen S. Goniometric Measurement of Burn Scar Contracture: A Paradigm Shift Challenging the Standard. J Burn Care Res. 2019 Jun 21;40(4):377-385.
  17. ↑ Richard RL, Lester ME, Miller SF, Bailey JK, Hedman TL, Dewey WS, Greer M, Renz EM, Wolf SE, Blackbourne LH. Identification of cutaneous functional units related to burn scar contracture development. J Burn Care Res. 2009 Jul-Aug;30(4):625-31.
  18. ↑ Robertson K, Wang D, Tran K, Yun E, Stevens K, Hartman B. 571 Effectiveness of Compression Garments with Silicone versus Compression Garments Alone on Hypertrophic Scar. J Burn Care Res. 2023 May 15;44(Suppl 2):S118.
  19. ↑ Van den Kerckhove E, Anthonissen M. Compression Therapy and Conservative Strategies in Scar Management After Burn Injury. 2020 Dec 8. In: Téot L, Mustoe TA, Middelkoop E, Gauglitz GG, editors. Textbook on Scar Management: State of the Art Management and Emerging Technologies [Internet]. Cham (CH): Springer; 2020. Chapter 27.
  20. ↑ Lanham JS, Nelson NK, Hendren B, Jordan TS. Outpatient Burn Care: Prevention and Treatment. Am Fam Physician. 2020;101(8):463-470.
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