Rehabilitation of Burns in Disasters and Conflicts

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Introduction

Burn injuries are complex and involved injuries which require immediate and specialised interventions. Burn injuries commonly require a prolonged rehabilitation process to return to functional independence, often with adaptation or compensatory training in the long-term. These patients will require both physical and psychological support throughout their rehabilitation process, this is especially true when injury occurs as a result of disaster or conflict.

Acutely, rehabilitation will be supportive of the medical needs of the patient. However, rehabilitation plays an important role in the acute phase to prepare the patient both physically and mentally for the therapy to come. This article will focus on physical rehabilitation of patients who have had a burn injury, but will include important wound care considerations with regards to mobility and positioning.

Rehabilitation for burn injuries starts from day one of the injury, right through the period of scar maturation, and often for years after the injury, especially relevant to the prevention of contractures and in children where growth is not complete.

Burn Overview

Please read the linked article for background knowledge on the anatomy and physiology of the skin. Understanding the structure of the skin is an important part of burn classification.

Please read the linked article for background knowledge of wound healing. Understanding the expected timeline of wound healing and the body's response to injury is vital in patient education and differentiating normal wound healing from the signs and symptoms of infection. This article also contains links to wound assessment and wound debridement to better understand these procedures. Wound care is a specialised skill and should not be performed without the proper training. Physiotherapists can specialise in wound management with advanced training.

Types of Burns

According to Johns Hopkins Medicine, burns have several common causes which include but are not limited to:

1. Thermal burns: due to heat sources which raise the temperature of the skin and surrounding tissues. This causes tissue cell death or charring. Heat sources can include: hot metals, scalding liquids, steam, and flames.
2. Radiation burns: due to prolonged exposure to ultraviolet rays or to other sources of radiation. Radiation sources can include: the sun, X-rays.
3. Chemical burns: due to strong acids, alkalies, detergents, or solvents which come into contact with the skin.
4. Electrical burns: due to electrical current, either alternating current (AC) or direct current (DC) coming into contact with the body.

Classification of Burns

ADD PHOTO OF BURNS

Depth of burn	Tissues destroyed	Burn Appearance	Pain Sensitivity
Superficial i.e. 1st degree burn	Outer layer of epidermis	red blistering is uncommon slight oedema Capillary refill: affected area blanches with pressure and refills (see video example below)	Painful
Superficial Partial Thickness (SPT) i.e. 2nd degree burn: superficial/intermediate	All of epidermis Upper layers of dermis Some hair follicles and sweat and sebaceous glands destroyed	red blisters moist subcutaneous oedema Capillary refill	Very painful and hypersensitive
Deep Partial Thickness (DPT) i.e. 2nd degree burn: deep	Epidermal and several dermis damage Most nerve endings, hair follicles, and sweat glands destroyed	Variable in colour (mottled) wet or waxy dry Generally blisters No or slow capillary refill Eschar forms	Less sensitive to pain due to destroyed nerve endings
Full Thickness Burn (FTB) i.e. 3rd degree burn	All skin layers damaged or destroyed; fat or bone may be visible.	White, charred, dry, inelastic No blisters	No pain from lost cutaneous pain receptors BUT situation is often painful for the patient.

Immediate Medical Care Needs

In the acute care phase of major burns injuries, medical management will include:

1. Fluid resuscitation
2. Airway management
3. Wound debridement and or surgical procedures such as escharotomy or fasciotomy

Rehabilitation Needs

Acute Burn Injury Mobility Precautions

• Burns encountered in conflict zones or disaster areas are often combined with trauma injuries such as fractures, internal injuries, or brain and or head injuries. Appropriate mobility precautions such as extremity weightbearing status, spinal and or cervical immobilisation, or bedrest needs in the case of internal organ injuries or bleeding need to be determined with the medical team.
• If shrapnel is present in the burn/wound which cannot be easily removed due to risk of further tissue damage, it may be left in place. Defer to medical team regarding mobilisation in these cases.
• Pain will develop following surgical debridements, plan accordingly with pain medication schedule.

Acute Rehabilitation

Continued Rehabilitation

Treatment Red Flags

S/S of sepsis

Resources

References 

see adding references tutorial.