Burn Injury Management Considerations for Rehabilitation Professionals: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]] based on the course by [TUTOR LINK/ ReLab]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<div class="editorbox"> '''Original Editor '''- [[User:Carin Hunter|Carin Hunter]]<br>'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


== Burn Assessment ==
== Introduction ==
When treating a patient with a burn, the first step is an accurate assessment. The time spent on an assessment will not only optimise their immediate treatment and minimise any long term injury they might be vulnerable to, but it will also help the patient to achieve their highest functional level. A complete assessment also will increase the chance of patient compliance as it offers the multidisciplinary team the opportunity to remind themselves of the patients long term goals and align their therapy to these objectives. A burn injury in unique to every situation and patient, and a clear assessment will help the team to be united in their efforts. The multidiciplinary team should be aware of the importance of an early and adequate assessment of  the burn patients for optimal functional and cosmetic outcomes to minimise the impact of the  trauma long term. For continuity it is helpful for the Initial Assessment to be available to all further disciplines conducting their assessments, and all these assessments be forwarded onto the rehabilitation setting and ideally, into the community setting. This continuity of information will lessen the frustration of the patient having to re-explain the story and it insures the information transferred is as accurate as possible.
Burn injuries are a major cause of pain and disability.<ref name=":2">Norman AT, Judkins KC. [https://academic.oup.com/bjaed/article/4/2/57/271658 Pain in the patient with burns.] Continuing Education in Anaesthesia, Critical Care & Pain. 2004 Apr 1;4(2):57-61.</ref> Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.


'''Flow chart illustrating the assessment and management of the burn'''  
''It is essential to remember that every intervention discussed on this page must be coordinated with the medical / surgical team to ensure tailored management protocols for each patient.''


'''<u>Short Term Goals:</u>'''
== Pain Management for Individuals with Burn Injuries ==
There are many factors to consider when treating pain associated with burn injuries.<ref name=":13">Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. [https://www.physio-pedia.com/File:Burns_and_Plastics.pdf Physiotherapy in Burns, Plastics and Reconstructive Surgery], 2013.</ref> [[General Assessment of a Patient with Burns#Key Aspects of the Objective Assessment of a Patient with a Burn Injury|Pain assessments]] should be performed during each phase of care,<ref name=":7">Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, et al. [https://academic.oup.com/jbcr/article/41/6/1129/5900438 American Burn Association Guidelines on the management of acute pain in the adult burn patient: a review of the literature, a compilation of expert opinion and next steps]. J Burn Care Res. 2020 Nov 30;41(6):1152-1164. </ref> and both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries. 


# Prevent respiratory complications
=== General Points on Pharmacology for Individuals with Burn Injuries ===
# Control Oedema
<blockquote>"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."<ref name=":8">Stapelberg F. [https://journals.sagepub.com/doi/full/10.1177/0310057X20914908 Challenges in anaesthesia and pain management for burn injuries]. Anaesth Intensive Care. 2020 Mar;48(2):101-113. </ref></blockquote>The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",<ref name=":8" /> and patients with burn injuries are often given opioids in higher doses and for longer durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.<ref name=":7" /><ref name=":8" /><ref name=":9">Emery MA, Eitan S. Drug-specific differences in the ability of opioids to manage burn pain. Burns. 2020 May;46(3):503-513.</ref>
# Maintain Joint ROM
# Maintain Strength
# Prevent Excessive Scarring


'''<u>Risk Factors:</u>'''
Romanowski et al.<ref name=":7" /> include the following recommendations in their guidelines on pain management in adult patients with burn injuries:


# '''Injury Factors:'''
* opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)<ref name=":7" />
## Inhalation injury
* while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"<ref name=":7" />
## Burn area - systemic inflammatory reaction syndrome involving the lungs
* opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments<ref name=":7" />
## Depth of burn
For more information, please see: [https://academic.oup.com/jbcr/article/41/6/1129/5900438 American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps]<ref name=":7" />
## Scarring
# '''Patient Factors'''
## Reduced ambulation and mobility
## Increased bed rest
## Increased pain  
## Pre-existing co-morbidities
# '''Treatment Factors'''
## Skin reconstruction surgery
## Invasive monitoring and procedures
## Management in critical care


== Subjective Assessment ==
=== '''Pain Management in Individuals with Burn Injuries Admitted to Hospital''' ===
The following pieces of information should be included in the Subjective Assessment:  
<blockquote>"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."<ref name=":7" /></blockquote>In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain. Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as post-burn pruritus (itching).<ref name=":8" /><ref name=":2" />


# Inhalation injury  
The management for each type of pain can differ.<ref name=":9" /> Pain management, especially in the hospital setting will be affected by the depth of burn injury and what structures are still intact and functioning. To learn more about burn wound classification by depth and size please see: [[Introduction to Burns#Burn Wound Classification|Burn Wound Classification]].
# Total Body Surface Area (TBSA)
# Burn Type and Depth
# Burn Site and Impact
# Present History
# Any surgical or medical management
# Past History (Including Medical/ Drug)
# Social History


===== 1. Inhalation Injury =====
==== Background Pain ====
During the subjective assessment, if the patient was in an enclosed space or is presenting with a reduced level of consciousness<ref name=":1">Siemionow MZ, Eisenmann-Klein M, editors. Plastic and reconstructive surgery. Springer Science & Business Media; 2010 Jan 13.</ref>, it is imperative to make a note to conduct, or speak to the team member who can conduct, an Inhalation Injury Examination which will allow treatment to commence as soon as possible. When conducting a Subjective Assessment, the clinician should note any physical signs of inhalation injury such as charring around the mouth and nostrils.<ref name=":2">Martin H. Immediate management of burn injury. 2007</ref>
This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures".<ref name=":9" /> Thus, it is persistent but usually low-grade.<ref name=":2" /> It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferably given orally).<ref name=":9" />  


(2 - ANZBA 2007; British Burn Association 2005; 1 - Eisenmann-Klein 2010)
==== Breakthrough Pain ====
Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.<ref name=":9" /> It can indicate worsening background pain or can be from another source.<ref name=":10">McGovern C, Puxty K, Paton L. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073309/ Major burns: part 2. Anaesthesia, intensive care and pain management]. BJA Educ. 2022 Apr;22(4):138-45. </ref>


===== 2. Total Body Surface Area =====
==== Pain Associated with Procedures ====
There are many methods on conducting a Total Body Surface Area (TBSA) assessment. The most accurate method is the Rules of Nines and Lund and Brower method. Another commonly used method is the Palmer Surface Method, whereby the patients palm size, (representing 1% TBSA) is used to estimate the total burns coverage. Please note, when assessing the burnt area, oedema should not be included.  
Individuals with burn injuries often require a number of procedures (e.g. mobilisation, skin grafts, debridement, dressing changes, etc). These procedures can add to a patient's pain experience, often causing high-intensity pain that is short to medium in duration.<ref name=":2" />


When conducting the TBSA assessment, there are two main considerations:
'''Important considerations''':<ref name=":2" /> 


# The Parkland Formula for fluid resuscitation
* each procedure causes a new, painful stimulus, which adds to the stress response
# When a patient has more than 20–25% TBSA a systemic inflammatory reaction is seen which is known to affect all body organs. This poses a risk for the respiratory system.
* analgesia should be given at an appropriate time to ensure maximum benefit<ref name=":10" />
* analgesia should be used in a preventive way, especially as some procedures can be predicted
* general anaesthetic may be used for prolonged procedures


Please see [[Introduction to Burns#Burn Classification|Introduction to Burns]] for more information regarding TBSA Assessment
===== Pain Associated with Surgery =====
Early post-operative pain tends to be managed with opioids and other non-opioid medications:<ref name=":2" /> 


===== 3. Burn Type and Depth =====
* patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure<ref name=":9" />), but the patient must be conscious and alert<ref name=":10" /> and be able to understand how to use the device
It is important to regularly re-examine the extent of tissue destruction as it can change up to 48 hours post burn. It is uncommon for a burn to present uniformly with a singe depth throughout<ref name=":2" />. Quick administration of first aid can influence the type and depth to a large extent.<ref name=":1" />   ( British Burn Association 2005)  
* non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
** however, they are used infrequently in individuals who are critically ill<ref name=":10" />
** they "should be used with extreme caution especially in patients with bigger burns and those on intensive care"<ref name=":6" />
* local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied


Click here for more information on [[Introduction to Burns#Jacksons.E2.80.99 Burn Wound Model|Jacksons’ Burn Wound Model]].  
===== Pain Associated with Dressing Changes and Wound Cleaning =====
Pain management during dressing changes and wound care is a significant consideration:<ref name=":2" /> 


===== 4. Burn Site and Impact =====
* a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns
The burn site can have a large impact of the potential functional outcome and the trauma associated with the injury. There are four High Impact areas associated with burns and this requires an awareness of the clinician assessing as these areas require specialised treatment. 
* smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
* nitrous oxide (e.g. Entonox) and opioids can be used for short procedures to help reduce breakthrough pain and avoid long periods of sedation
* using appropriate dressings can help reduce the requirement for procedures - please see [[Burn Wound Injury Dressing Selection]] and [[Advanced Dressing Selection for Burn Wound Injuries]] for more information on burn wound dressings


'''<u>High Impact Areas:</u>'''
===== Pain Associated with Rehabilitation =====
Physiotherapists and occupational therapists commonly work with patients with burn injuries in primary healthcare settings. However, moving the affected area/s can exacerbate pain and trigger the stress response. Rehabilitation interventions are, therefore, often scheduled after pain relief has been administered:<ref name=":2" />


# Hands
* during the acute phase, physiotherapists and occupational therapists may perform passive range of motion exercises or create splints while a patient is in theatre or having their dressings changed
# Face
* during the subacute and chronic phases, oral analgesics are commonly used to ensure patients can actively participate in treatment
# Perineum
# Joints


===== 5. Current History =====
==== Post-burn Pruritus ====
When conducting the current history questioning, please be aware of the emotional trauma that could be associated with a burn injury. If there is a family member or witness around, they can also be asked to fill in areas of the history that either the patient cannot recall, or that they are battling emotionally to elaborate on.  
'''Post-burn pruritus''' (itching sensations on or around the burn, graft, or donor site) is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge.<ref name=":11">Andrade LF, Abdi P, Kooner A, Eldaboush AM, Dhami RK, Natarelli N, Yosipovitch G. Treatment of post-burn pruritus - A systematic review and meta-analysis. Burns. 2024 Mar;50(2):293-301. </ref> It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.<ref>Beecher SM, Hill R, Kearney L, Dorairaj J, Kumar A, Clover AJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310874/ The pruritus severity scale-a novel tool to assess itch in burns patients]. Int J Burns Trauma. 2021 Jun 15;11(3):156-62. </ref>   


Important aspects to cover:
Please note that the use of restraints to prevent a patient from itching are considered an absolute last resort. Depending on your location, the use of restraints may require specific medical orders that need to be regularly reviewed. Other options to try first include:  


* History of the incident
* extra layers of fluffy bandages to protect the primary dressings (but it is essential to ensure that proper air exchange can occur)
** Specific attention paid to the mechanism of injury
* gloves (with fingers) or mitts (without figures)
* First aid
** An accurate account of what treatment was given?
** On site medication administered needs to be explained clearly with amounts and times given as this could react with the medication administered on admission to hospital
** If no adequate first aid was administered, suspect deeper burn injury
* Falls
** Is there any indication that the patient fell?
** What height did they fall from?
** Suspect a possible head  injury, sprain or fracture
* Electrical injury
** What voltage was involved?
** Which parts of the body was in contact with earth?
** Suspect nerve or deep muscle injury with high voltage current  
* Explosions
** Suspect a fall, high velocity injury or possible tympanic membrane injury, as the latter would cause a loss of  hearing and difficulty communicating
* Passage to hospital and time to admission


ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010
Current treatments for post-burn pruritus have not been found to have clinically significant benefits, so further research on post-burn pruritus management is required.<ref name=":11" /> Treatments include:<ref>Chung BY, Kim HB, Jung MJ, Kang SY, Kwak IS, Park CW, Kim HO. [https://www.mdpi.com/1422-0067/21/11/3880 Post-burn pruritus]. Int J Mol Sci. 2020 May 29;21(11):3880. </ref> 


===== 6. Medical and Surgical History =====
* topical treatments
* systemic treatments, such as antihistamines, opioid receptor agonists or antagonists, gabapentin or pregabalin, antidepressants, etc
* extracorporeal shockwave therapy (ESWT)
* pressure therapy
* massage therapy
* education
* cold compresses in the subacute phase<ref name=":2" />
* moisturisers<ref name=":6" />
For more information on post-burn pruritus, please see: [[Burn Wound Healing Considerations and Recovery Care Interventions#Post Burn Wound Injury Care and Rehabilitation|Burn Wound Injury Special Concern: Post-burn Pruritus]]


* Pain medication
==== Persistent / Chronic Pain ====
* Debridement
Some individuals after a burn injury will develop chronic or persistent pain, affecting quality of life, sleep, increasing morbidity and decreasing functional recovery. Chronic neuropathic pain after burn injury has a reported prevalence of 7.3% to 18%.<ref name=":12">Klifto KM, Dellon AL, Hultman CS. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkaa011/5818502 Prevalence and associated predictors for patients developing chronic neuropathic pain following burns]. Burns Trauma. 2020 May 1;8:tkaa011. </ref> It develops as a result of partial or complete peripheral nerve injuries.<ref name=":12" /> Individuals with burn injuries may develop hyperalgesia or allodynia. There is a strong correlation between the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed.<ref>Braza ME, Fahrenkopf MP. [https://www.ncbi.nlm.nih.gov/books/NBK551561/ Split-thickness skin grafts]. 2019.</ref>
* Escharectomy
* Flaps/grafts  
* Any particular MDT instructions to be followed


ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004
Treatments for persistent pain following a burn injury might include:<ref name=":2" />


===== 7. Past History =====
* analgesics
* antidepressants
* anticonvulsants
* regional nerve block
* cognitive behavioural therapy


* Include any medical history
===== Alternative Pain Management Techniques for Burn Injuries =====
* Previous surgical interventions
<blockquote>Romanowski et al. recommend "that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen".<ref name=":7" /></blockquote>There are four broad categories of nonpharmacological techniques:<ref name=":7" />
* Medication
** Amount
** Duration on medication
** Condition controlled or uncontrolled


===== 8. Social History =====
# '''cognitive-behavioral therapy''' (CBT)
ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010
#* "most effective when decatastrophizing and reinterpreting pain signals were targeted"<ref name=":7" />
# '''hypnosis'''
#* can be used to help manage procedural pain and anxiety
#* "most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
# '''distraction'''
#* i.e. redirecting the patient's attention from the pain sensation
#* virtual reality has the most robust evidence
#** the patient is immersed in a virtual world
#** patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"<ref name=":7" />
#** patients using virtual reality can have lower pain scores during dressing changes<ref>de Jesus Catalã CA, Pan R, Rossetto Kron-Rodrigues M, de Oliveira Freitas N. [https://academic.oup.com/jbcr/article-abstract/43/4/880/6425063 Virtual reality therapy to control burn pain: systematic review of randomized controlled trials]. Journal of Burn Care & Research. 2022 Jul;43(4):880-8.</ref><ref>Mott J, Bucolo S, Cuttle L, Mill J, Hilder M, Miller K, Kimble RM. The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns. 2008 Sep 1;34(6):803-8.</ref>
# '''relaxation''' (breathing, music,<ref>Monsalve-Duarte S, Betancourt-Zapata W, Suarez-Cañon N, Maya R, Salgado-Vasco A, Prieto-Garces S, Marín-Sánchez J, Gómez-Ortega V, Valderrama M, Ettenberger M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417921003107 Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis.] Burns. 2021 Nov 16.</ref> stress inoculation, aromatherapy, massage)


* Basic activities of daily living. These vary from person to person, some examples:  
'''Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:'''<ref name=":6" />
** Dressing
** Bathing
** Eating
** Shopping
** Driving
** Home maintenance
* Past physical function
** General mobility
** Stair mobility
** Lifting 
* Past physical fitness
** Strength
** Flexibility
** Endurance
** Balance
* Social support and home situation
* Occupation
** Particularly important for hand burns


===== Psychosocial Factors/ Yellow Flags =====
* education, reassurance, distraction
* splinting
* exercise
* massage
* sensory re-education / desensitisation


* Self-image
'''Sleep normalisation''' also plays a role in pain management:
* Coping style
* Mental health
* Emotional behaviour  


ANZBA 2007; British Burn Association 2005; Hettiaratchy et al 2004
* a night of poor sleep predicts increased pain and greater analgesia use the next day
* increased pain during the day predicts poor sleep quality that night<ref>Rampes S, Ma K, Divecha YA, Alam A, Ma D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386412/ Postoperative sleep disorders and their potential impacts on surgical outcomes]. J Biomed Res. 2019 Aug 29;34(4):271-280. </ref>


== Objective Assessment ==
== Oedema Management for Individuals with Burn Injuries  ==
Burn injuries induce oedema.<ref name=":23">Agency for Clinical Innovation. Statewide Burn Injury Service. Burn physiotherapy and occupational therapy guidelines, 2017. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf [accessed 12 April 2024].</ref> Two interventions for oedema management in burn injuries include elevation and compression.


===== Pain Intensity Assessment =====
Whenever implementing interventions for burn injuries, remember that all post-operative, consultant and multidisciplinary team advice must be followed.<ref name=":23" /> Care must be taken to reduce the risk of skin breakdown and contracture development, and all indications and contraindications must be considered.
[[File:Sadface vas.jpg|frame|Visual Analogue Scale]]
Observational behavioural pain assessment scales should be used to Measure pain in children aged 0 to 4 years e.g.


* '''Visual Analogue Scale (VAS) and the Wong-Baker FACES pain rating scale'''
===== Elevation =====
** [[Visual Analogue Scale|Visual analogue scale]] can have the faces used alongside but also has numbers assigned below the faces which the patient uses to indicate their pain scores.
In order to decrease oedema, a limb should ideally be elevated above the level of the heart.<ref>Tuca AC, Winter R, Kamolz LP. [https://link.springer.com/chapter/10.1007/978-3-030-39193-5_3 Acute Burn Surgery.] InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.</ref> Sometimes, this may not be possible due to pain and discomfort or lack of range of motion. In these cases, it is important to raise the limb as high as possible through positioning and other adjuncts, such as pillows, towels, splints and slings.<ref name=":23" /><ref name=":13" /><ref>The Royal Children's Hospital Melbourne. Burns. Available from: https://www.rch.org.au/trauma-service/manual/Burns/ (last accessed 12 April 2024).</ref> 
** VAS can be used from age 12 upwards and is suitable for adults.
** Wong-Baker FACES consists of 6 pain assessment cards that vary from a smile to sad to crying facial expressions representing pain behavior rating and is supervised by the Chinese Association for the Study of Pain (CASP). The patient chooses the best card to represent the pain intensity.
** Faces pain rating scale can be used in children aged 5 years and older.  
* '''The FLACC scale<ref>Feng Z, Tang Q, Lin J, He Q, Peng C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6261918/ Application of animated cartoons in reducing the pain of dressing changes in children with burn injuries.] International journal of burns and trauma. 2018;8(5):106.</ref>'''
** 5 categories:
*** Face
*** Legs
*** Activity
*** Cry
*** Consolability
** each of which accounts for scores of 0 to 2. With 10 as the full mark, 0 to 3, 4 to 7 and 8 to 10 scores represent no/light pain, moderate pain and acute pain, respectively


* '''COMFORT scale'''
Patients with severe burns that cover a large Total Body Surface Area (TBSA) are at risk of systematic inflammation. In these cases, the following precautions should be considered:<ref name=":1" />
** 6 categories including
*** Alertness
*** Calmness/agitation
*** Crying
*** Physical movement
*** Muscle tone
*** Facial tension
** With a full mark of 30, each category is scored on a 1 to 5 scale. In practice, suggestive information is offered according to the sum of the scores among the 6 categories. The higher scores one obtains, the more violent the pain (Table S1). Necessary pain interventional therapies shall be taken if the scores add up to more than 17
* '''Pain Observation Scale for Young Children (POCIS)''' 
** used for pain behavioral assessment with points ranging from 0 to 7, in which 0, 1 to 2, 3 to 4 and 5 to 7 are recorded as no pain, slight pain, moderate pain and severe pain, respectively, with 7 categories each contributing 0 or 1 point towards the overall score


For more information regarding Pain Assessment Tools please see:
* elevate the head: in the case of anterior neck burns, do not place a pillow under the head, as this can cause a contracture to develop
* elevate all affected limbs
* maintain the feet at 90 degrees
* maintain the hips in a neutral position
* monitor for pressure sores


* British Pain Society [https://www.britishpainsociety.org/static/uploads/resources/files/Outcome_Measures_January_2019.pdf Outcome Measures]
===== Compression =====
* Physiopedia page on [[Outcome Measures]]
Compression is commonly used to help manage oedema in burn injuries:<ref>Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023 May;49(3):516-53. </ref>  
* Zieliński J, Morawska-Kochman M, Zatoński T. [https://ppm.umed.wroc.pl/docstore/download/UMW638069cf1144472c8bdf253a73a49f24/10.17219!acem!112600.pdf Pain assessment and management in children in the postoperative period: A review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children.] Adv Clin Exp Med. 2020 Mar 1;29(3):365-74.<ref>Zieliński J, Morawska-Kochman M, Zatoński T. [https://ppm.umed.wroc.pl/docstore/download/UMW638069cf1144472c8bdf253a73a49f24/10.17219!acem!112600.pdf Pain assessment and management in children in the postoperative period: A review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children.] Adv Clin Exp Med. 2020 Mar 1;29(3):365-74.</ref>


===== Burn Outcome Measures =====
* pressure garment therapy (discussed below) has been shown to be beneficial in burn injures<ref name=":1" /> - it can be used for both oedema and scar management, depending on the age of the burn and the initial depth of injury 
When treating patients in a multidicsciplinary team, it is useful to use outcome measures that can be retested as the condition progresses. Some examples:
* coban wrap is often used for burn injuries of the hand and is useful in the acute stage of a burn injury because it does not stick to the underlying tissue<ref>Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. [[:File:Burns and Plastics.pdf|Physiotherapy in Burns, Plastics and Reconstructive Surgery]], 2013.</ref>


# [[Burn Specific Health Scale -Brief (BSHS-B)]]: Examine the  physical and psychosocial functioning of burn patients and their quality of life. McMahon 2008;Brusselaers et al 2010; Wasiak et al 2011
For more information on Coban wraps, please see: {{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}.
# [[Burns Scar Index (Vancouver Scar Scale)]]
# Burns Specific Pain Anxiety Scale


Taal LA, Faber AW, Van Loey NE, Reynders CL, Hofland HW. The abbreviated burn specific pain anxiety scale: a multicenter study. Burns. 1999 Sep 1;25(6):493-7. - file:///C:/Users/mamad/Downloads/taal1999BSPAS.pdf  
== Scar Management for Individuals with Burn Injuries  ==
Hypertrophic scarring is a common complication in burn injuries, affecting up to 70% of patients.<ref>Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380137/ Hypertrophic scarring: the greatest unmet challenge after burn injury]. Lancet. 2016 Oct 1;388(10052):1427-36. </ref> Hypertrophic scars are visible, elevated scars. Unlike keloid scars, they do not spread into surrounding tissues, and they often regress spontaneously.<ref>Rabello FB, Souza CD, Farina Júnior JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129552/ Update on hypertrophic scar treatment.] Clinics. 2014;69:565-73.</ref> Hypertrophic scars can have a significant impact on an individual with burn injuries, potentially causing:<ref name=":14">Nischwitz SP, Rauch K, Luze H, Hofmann E, Draschl A, Kotzbeck P, Kamolz LP. [https://onlinelibrary.wiley.com/doi/full/10.1111/wrr.12839 Evidence-based therapy in hypertrophic scars: An update of a systematic review]. Wound Repair Regen. 2020 Sep;28(5):656-65. </ref><ref>Morien A, Garrison D, Smith NK. [https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.600.1039&rep=rep1&type=pdf Range of motion improves after massage in children with burns: a pilot study.] Journal of bodywork and movement therapies. 2008 Jan 1;12(1):67-71.</ref><ref>Polotto S. [http://www.embj.org/wp-content/uploads/2011/12/images_ISSUE_2011_polotto_17_06_11.pdf Use of silicone dressings in post-burn hypertrophic scar therapy: a systematic review]. Capsula Eburnea. 2011 Dec 1;6.</ref>


https://www.sciencedirect.com/science/article/abs/pii/S0305417996001179
* pain
* pruritus
* reduced range of motion (particularly when they occur on or near a joint)
* psychosocial / psychological effects
* cosmetic effects
* altered self-image
==== Scar Outcome Measures ====
'''Vancouver Burn Scar Scale (VBSS/VSS):'''
*assesses vascularity, height, pliability, and pigmentation of the scar
*does not measure a patient's subjective assessment of the scar, such as pain, itching, functional or psychological impact<ref>Park JW, Koh YG, Shin SH, Choi Y, Kim W, Yoo HH, et al. [https://www.jkslms.or.kr/journal/view.html?uid=263&vmd=Full Review of scar assessment scales]. Medical Lasers. 2022;11:1-7.</ref>
*for more information, please see: [[Burns Scar Index (Vancouver Scar Scale)]]
'''Patient and Observer Scar Assessment Scale (POSAS):'''
* measures pigmentation, vascularity, thickness, relief, pliability and surface area, as well as pain, itching, colour, stiffness, thickness and relief
* for more information, please see: [https://www.posas.nl/about/ About POSAS]
==== Management Options for Hypertrophic Scars ====
The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:


Taal LA, Faber AW. The burn specific pain anxiety scale: introduction of a reliable and valid measure. Burns. 1997 Mar 1;23(2):147-50.
* intralesional injection<ref name=":14" /><ref>Choi C, Mukovozov I, Jazdarehee A, Rai R, Sachdeva M, Shunmugam M, et al. [https://onlinelibrary.wiley.com/doi/abs/10.1111/ajd.13790 Management of hypertrophic scars in adults: A systematic review and meta-analysis]. Australas J Dermatol. 2022 May;63(2):172-89.</ref>
===== Inhalation Assessment =====
* laser and light therapies<ref name=":14" /><ref>Klifto KM, Asif M, Hultman CS. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkz002/5706921 Laser management of hypertrophic burn scars: a comprehensive review]. Burns Trauma. 2020 Jan 16;8:tkz002.</ref>
Physical signs are not the most reliable and accurate tools for assessment but they can contribute to the whole assessment of the patient. Physical signs should be included with clinical tests, regular re-assessment and correct initial management.
* topical steroids<ref>Shirakami E, Yamakawa S, Hayashida K. [https://academic.oup.com/burnstrauma/article/doi/10.1093/burnst/tkz003/5706922 Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence]. Burns Trauma. 2020 Jan 27;8:tkz003. </ref>
* moisturisers<ref name=":6">Whitaker IS, Shokrollahi K, Dickson WA. Burns. Oxford: OUP Oxford, 2019. </ref>


'''Initial management:'''  
===== '''Silicone''' =====
Silicone can be applied in the form of a gel or sheeting. While some randomised controlled trials have found that topical silicone gel can be effective in preventing post-operative scarring,<ref name=":15">Wang F, Li X, Wang X, Jiang X. [https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.13337 Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials]. Int Wound J. 2020 Jun;17(3):765-73. </ref> a 2020 Cochrane review notes "there is currently limited rigorous RCT [randomised controlled trial] evidence available about the clinical effectiveness of SGS [silicone gel sheeting] in the treatment of hypertrophic scars"<ref name=":16">Jiang Q, Chen J, Tian F, Liu Z. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013357.pub2/full Silicone gel sheeting for treating hypertrophic scars]. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013357.</ref> and further research is required.<ref name=":16" /> Nischwitz et al.<ref name=":14" /> note that silicone gel appears to be mainly beneficial for post-burn pruritus and pain.<ref name=":14" /> Some important clinical points:


* Quick transportation to the emergency room
* silicone gels tend to be easier to apply than sheets and can also be used on more areas of the body<ref name=":13" />
* Conscious
* silicone gel sheets can be washed and reused, which reduces the financial burden on the patient<ref name=":0">McCarty M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989813/ An evaluation of evidence regarding application of silicone gel sheeting for the management of hypertrophic scars and keloids.] The Journal of clinical and aesthetic dermatology. 2010 Nov;3(11):39.</ref>
* Patent airway 
For more information on silicone products, including procedures for sheet silicone, precautions and considerations, please see page 18 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].
* Chest radiograph
* Arterial blood gases


'''Physical Signs'''<ref name=":0">Foncerrada G, Culnan DM, Capek KD, González-Trejo S, Cambiaso-Daniel J, Woodson LC, Herndon DN, Finnerty CC, Lee JO. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825291/ Inhalation injury in the burned patient.] Annals of plastic surgery. 2018 Mar;80(3 Suppl 2):S98.</ref> (ANZBA 2007; British Burn Association 2005)
===== '''Pressure Garment Therapy (PGT)''' =====
Compression therapy aims to "keep developing scars flat and prevent raised scarring [...]. The type of compression used depends on wound healing, area of body affected, time since healing and individual patient needs."<ref name=":23" />


* Soot stained sputum
Compression can be achieved in different ways, such as pressure garments (off-the-shelf or customised), cohesive flexible bandages, tubular elasticised stockings and bandaging.<ref name=":23" />
* Stridor (Noisy breathing due to an obstructed airway)
* Wheezing
* Facial burns
* Singed nasal hairs
* Anxiety
* Cough
* Stupor
* Dyspnea
* Hoarse vocal quality  
* Singed facial / nasal hair  
* Oedema
* Erythema (Superficial reddening of the skin, usually in patches, as a result of injury  or irritation causing dilatation of the blood capillaries)  
* Inspiratory and end expiratory crackles on auscultation  
* Chest x-ray changes 
* Signs of Hypoxia
** Headache
** Shortness of breath
** Fast heartbeat
** Coughing
** Wheezing
** Confusion
** Bluish color in skin, fingernails, and lips


'''Bronchoscopy Assessment:'''<ref name=":0" />
'''Pressure garment therapy (PGT)''' is widely used in the management of hypertrophic scars.<ref name=":1" /> There have been a number of studies on pressure garment therapy, but they often have different outcomes and may contradict each other.<ref>Merwarth D. Burn Wound Healing and Recovery Care Course. Plus, 2024.</ref> Some recent research suggests:


* Bronchoscopy assists with rapid diagnosis of inhalation injury and grading it be unavailable to the clinician and is considered the gold standard<ref>Long B, Graybill JC, Rosenberg H. [https://link.springer.com/article/10.1007/s43678-021-00222-8 Just the facts: evaluation and management of thermal burns.] Canadian Journal of Emergency Medicine. 2021 Nov 2:1-3.</ref>
* there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"<ref name=":3">De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, et al. Pressure therapy for scars: Myth or reality? A systematic review. Burns. 2023 Jun;49(4):741-56.</ref>
* Inhalation Injury signs on bronchoscopy:
* PGT can help improve a scar's colour, thickness and quality and reduce pain<ref name=":3" />
** Erythema
* De Decker et al.<ref name=":3" /> recommend that PGT should be started ''sooner than'' two months post-burn, but ideally as early as possible
** Edema (which may be seen as a blunting of the carina)
* the wound must have closed and be '''stable enough to tolerate pressure before starting PGT''' (always check with the surgeon)<ref name=":13" />
** Mucosal blisters
* PGT should be worn while the scar remains active<ref name=":23" />
** Erosions
* De Decker et al.<ref name=":3" /> PGT should continue for at least 12 months, preferably for up to 18-24 months<ref name=":3" />
** Hemorrhages
* recommended pressures for PGT vary
** Bronchial secretions
** De Decker et al.<ref name=":3" /> recommend minimal pressures of around 20-25 mmHg
** Soot deposits
** Shirakami et al.<ref name=":24">Shirakami E, Yamakawa S, Hayashida K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175766/ Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence]. Burns Trauma. 2020 Jan 27;8:tkz003. </ref> recommend that pressure should be between 20-30 mmHg (above capillary pressure)
* Indirect laryngoscopy permits visual assessment to the level of the vocal cords and can be a useful, albeit limited, tool should 
** please note that pressures exceeding 30-40 mmHg can have adverse effects (again figures given in the literature vary)<ref name=":24" /><ref name=":13" />
* it is typically recommended that pressure garments be worn at all times apart from showering or bathing, massage and moisturising (i.e. around 23 hours every day)<ref name=":23" />
* adherence can be an issue for pressure garment therapy - it can be uncomfortable to wear the garment, especially in warm weather, and it can cause overheating, wound breakdown and itching<ref>Moiemen N, Mathers J, Jones L, et al. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jun. (Health Technology Assessment, No. 22.36.) Chapter 1, Introduction and background.Available from: https://www.ncbi.nlm.nih.gov/books/NBK507759/</ref>


Three determinants of injury severity<ref name=":0" />
'''How does pressure garment therapy work?'''<ref name=":1">Procter F. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038404/ Rehabilitation of the burn patient.] Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S101.</ref>


* Duration of smoke exposure 
Applying pressure to a burn injury is believed to reduce scarring by "hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars."<ref name=":1" /> It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars. This reduces the influx of collagen and decreases scar formation.
* Temperature of the inhaled smoke
* Composition of the smoke


For the latest recommendations please see:
Pressure garment therapy is believed to help:<ref name=":1" />


* [https://www.liebertpub.com/doi/full/10.1089/wound.2019.0963 A Critical Update of the Assessment and Acute Management of Patients with Severe Burns]<ref>Lang TC, Zhao R, Kim A, Wijewardena A, Vandervord J, Xue M, Jackson CJ. [https://www.liebertpub.com/doi/full/10.1089/wound.2019.0963 A critical update of the assessment and acute management of patients with severe burns.] Advances in wound care. 2019 Dec 1;8(12):607-33.</ref>
* reduce scar thickness
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825291/ Inhalation Injury in the Burned Patient]<ref name=":0" />
* reduce redness
* decrease swelling
* reduce post-burn pruritus
* improve the protection of healed skin grafts
* maintain contours and prevent contractures


===== Oedema Assessment =====
{{#ev:youtube| UCq9JreucIM |300}}<ref>Occupational Therapy UiTM. Pressure Garment Therapy. Available from: https://www.youtube.com/watch?v=UCq9JreucIM [last accessed 31/3/2024]</ref><blockquote>'''Pressure Garment Care'''
WORDS CARIN!!!!!!
{| class="wikitable"
|'''Stage of Oedema'''
|'''Appearance of Oedema'''
|-
|'''Stage 1'''
|Soft, may pit on pressure
|-
|'''Stage 2'''
|Firm, rubbery, non-pitting
|-
|'''Stage 3'''
|Hard, fibrosed
|}Clinical stages and appearance of oedema


When assessing oedema, the subjective component includes when the swelling began and any changes in the oedema with position. The objective assessment needs to be carefully carried out so there is a reduced risk on infection and no increase in pain.  
It is important to educate patients on how to look after their pressure garments.


The most commonly used tools to measure edema are:
Two sets of garments are recommended for hygiene purposes (one in the wash and one being worn).<ref name=":23" />


# Volume measurements (with a water volumeter)
* Washing instructions:<ref name=":5">Nationwide Children's. Burns: Wearing a Pressure Garment. Available from: https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/burns-wearing-a-pressure-garment (last accessed 11 April 2024).</ref><ref name=":22">Chelsea and Westminster Hospital. NHS Foundation Trust. Pressure garments. Available from: https://www.chelwest.nhs.uk/your-visit/patient-leaflets/burns/pressure-garments (last accessed 11 April 2024).</ref>
# Girth measurements (with a tape measure).
** hand wash:
# Pitting edema assessment (based on the depth and duration of the indentation).
*** soak pressure garment in cool water and mild soap
*** rinse well with clean, cool water
*** roll the garment in a towel to soak up excess water
** machine wash:
*** use a mild soap or detergent
*** wash with cool water on a gentle / delicate cycle
* Drying instructions:<ref name=":5" /><ref name=":22" />
** air-dry only: pressure garments cannot be placed in a heated dryer as this will destroy their elasticity and compression ability
** do not put the garment in sunlight or in front of a heater
Pressure garments need to be re-tensioned or remeasured and replaced every three to six months, depending on the level of wear and tear.<ref name=":23" /></blockquote>For more information on compression and pressure garment therapy, including procedures, precautions and contraindications, please see pages 14-17 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].


For more information on how to conduct these measurements, please see [[Edema Assessment#Methods to Quantitatively Assess Peripheral Edema|Oedema Assessment]]
===== '''Scar Massage''' =====
Scar massage is routinely used in many burn rehabilitation units around the world. Reported clinical benefits include:<ref name=":4">Ault P, Plaza A, Paratz J. Scar massage for hypertrophic burns scarring-A systematic review. Burns. 2018 Feb;44(1):24-38. </ref>


===== Physical Assessment =====
* improved pliability and range of motion of the scar
When conducting a physical assessment, it is often helpful to break up the assessment into two section. Firstly the upper limbs, lower limbs and trunk, secondly, general functional mobility. When conducting a physical assessment, it is important to consider complicating factors such as prolonged bed rest, high levels of pain and pre-existing co morbidities.
* reduced pain and skin sensitivity
* reduced post-burn pruritus
* decreased anxiety
* changes in scar characteristics and reduction in scar thickness


(ANZBA 2007; Hettiaratchy et al 2004; Settle 1986; Siemionow and Eisenmann Klein 2010)
Recent research suggests:


* '''<u>Limbs and Trunk</u>'''
* there is low-to-moderate quality evidence that massage can ''reduce pain and the intensity of post-burn scar pruritus''<ref name=":25">Santuzzi CH, Gonçalves Liberato FM, Fachini de Oliveira NF, Sgrancio do Nascimento A, Nascimento LR. [https://www.sciencedirect.com/science/article/pii/S1836955323001169 Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review]. J Physiother. 2024 Jan;70(1):8-15.</ref>
** Assessment of:  
* there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"<ref name=":25" />
*** [[Range of Motion|Joint range of motion]]
* another review by Barnes et al.<ref name=":18">Barnes SP, Ma Y, Patel B, Muthayya P. Efficacy of massage techniques for hypertrophic burn scars - a systematic review of literature. J Burn Care Res. 2024 Mar 4;45(2):356-65.</ref> found that scar massage can help with symptoms associated with hypertrophic burn scars, even when different massage techniques are used
*** [[Muscle Strength Testing|Muscle Strength]]
** when used together, friction and oscillation can improve scar function
*** Muscle Length
** longer sessions of effleurage and petrissage can help with scar visibility and pain 
** Limiting factors:  
** each massage technique helped with scar pruritus
*** Pain
** "massage techniques should be tailored to the patients’ symptoms"
*** Muscle length
* further research is required<ref name=":17">Lin TR, Chou FH, Wang HH, Wang RH. Effects of scar massage on burn scars: A systematic review and meta-analysis. J Clin Nurs. 2023 Jul;32(13-14):3144-54. </ref><ref name=":18" />
*** Trans-articular burns
'''Massage treatment considerations:'''
*** Scar contracture
* there is insufficient evidence to determine protocols on the frequency or duration of treatment
*** Individual  specificity of the burn  
* clean hands are essential
* '''<u>General Functional Mobility</u>'''
* use a lubricant or lotion that is free of irritants  
** The mobility assessment should only be carried out once the patient is medically stable and the focus is:
* clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels
**# Prevention of complications associated with prolonged bed rest
**# Restoration of function & independence.
** Factors to be assessed:
*** Functional transfers
*** Gait
*** Endurance
*** Balance
** Factors to consider:  
*** Posture
*** Activities of daily living
*** Demands of vocational roles
*** Cardiovascular response to mobilisation  
*** Neurological status
*** Pain
*** Concomitant injuries/weight-bearing status


== Management of Burn Pain ==
'''Massage contraindications''':<ref name=":13" /><ref>Shin TM, Bordeaux JS. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1524-4725.2011.02201.x The role of massage in scar management: a literature review.] Dermatologic Surgery. 2012 Mar;38(3):414-23.</ref>
There are many factors to consider when when treating burn pain. Initially, The clinician should understand what pain is currently being treated and the cause of the pain.  


Initially the acute pain experienced is due to the burning tissues. The burn should be cooled with tepid water, not ice ater as this can cause further damage to the area. This helps to end the burning and decrease the pain experienced. Cooling the burn and the evapotarion of oedema fluid can lead to hypothermia. Due to this, the patient should be given sufficient aid to warm themselves
* open wound
* acute infection
* bleeding
* graft failure
* intolerable discomfort
* hypersensitivity to emollient


Once hospitalised, there are a number of factors which should be considered by the clinicians. These being
{{#ev:youtube| hmTLWVBIoBo |300}}<ref>Children's Burns Trust. Scar massage after a burn injury - Children's Burns Trust. Available from: https://www.youtube.com/watch?v=hmTLWVBIoBo [last accessed 31/3/2024]</ref>


* Pain associated with procedures. Usually of a high intensity but short duration
For more information on massage, including procedures, precautions and considerations, please see page 20 of [https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf Burn Physiotherapy and Occupational Therapy Guidelines].
** Surgery
** Wound cleaning
** Dressing changes
** Physiotherapy
* Resting pain. Usually of low intensity but longer duration
* Pruritus
* Chronic pain. This can be due to changes experienced in nerve fibres.  


==== Pain associated with procedures ====
== Surgical Management for Individuals with Burn Injuries ==
Each procedure will trigger a fresh painful stimulus and further stress response. Therefore, analgesia should be preventive, as some of these events are predictable. Pain, and thus poor analgesia, may interfere with sleep, which is felt to be a significant part of the healing process. During the early part of the in-patient stay, prolonged procedures may be best performed under general anaesthesia. This is especially true if access to the patient will be difficult or in the case of children where fear of repeated potentially painful procedures will be a significant barrier to trusting the staff.  
<blockquote>“In deep partial thickness and full thickness burns, the entire epidermis and much of the dermis is lost, dramatically limiting the ability to heal spontaneously.”<ref name=":19">Palackic A, Duggan RP, Campbell MS, Walters E, Branski LK, Ayadi AE, Wolf SE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192152/ The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review]. Semin Plast Surg. 2022 Apr 12;36(1):33-42. </ref> These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.<ref name=":19" /></blockquote>Since the 1970s, the acute management of burn injuries has included early excision and grafting, it is the current standard of care for burn wound injuries. This approach has led to improved survival rates and decreased length of hospital stay.<ref name=":20">Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. [https://www.nature.com/articles/s41572-020-0145-5 Burn injury]. Nat Rev Dis Primers. 2020 Feb 13;6(1):11.</ref>


===== Surgery =====
=== Early Excision ===
Intraoperative and postoperative analgesia will usually be based on opioids. The concept of balanced analgesia will encourage the additional use of regional block and NSAIDs, depending on the extent of injury and site of graft harvest. However, as with other critically ill patients and if large volumes of fluid or blood are required, coagulopathy may occur. This may preclude the use of neuraxial techniques. Likewise, a risk of haematoma formation underneath a critical skin graft may preclude the use of nonspecific COX inhibitors. Large raw areas produced during surgery, in particular donor sites, are amenable to analgesia by a number of methods. At surgery, local anaesthetic gel may be applied under the dressings. Bupivacaine is effective (0.5% plain mixed with an equal quantity of aqueous gel), although there is a theoretical risk of local anaesthetic toxicity following unpredictable absorption over a large area (studies have not demonstrated this to date). An appropriate regional block may be used. However, regional techniques are less often used than might be expected because of practical difficulties such as infection at or close to the insertion site, generalized sepsis and coagulation abnormalities. For the lower limbs and abdomen, a continuous epidural infusion may be possible. Opioids may be added to the regimen, giving a reduced risk of local anaesthetic toxicity and therefore side-effects. Brachial or lumbar plexus block is also an effective technique. Appropriate selection of local anaesthetic agents allows the block to persist into the postoperative period; this may be prolonged further by the addition of a2-antagonistssuch as clonidine. Single-shotregimens are less effective; however, interestis growing in the placement of catheters alongside the nerve plexus to allow repeated bolus doses or infusions. The placement of epidural or limb catheters has a potential for bacterial colonization, and they may fall out if attached to mobile areas of skin or close to the burn where fixation is difficult. Once again, the mainstay of early postoperative pain management is based on opioids. These can be administered transdermally, orally, intramuscularly and intravenously with a combination of background infusion and boluses. All have their merits, but intramuscular administration may be difficult due to the site of surgery, the extent of dressings, injection site discomfort and unpredictable absorption. There is a vogue for patient-controlled analgesia (PCA), which has been found to be effective in burnsin severalstudies. However, thisis not ideal, asit requires a cooperative patient able to use the device (not possible with burned hands) and plasma opioid concentrations may fall during sleep. A background infusion will reduce the likelihood of this; however, opioids have a tendency to accumulate, leading to undesirable side-effects. Nursing vigilance must be maintained and protocols must be in place to prevent or deal with these events. Similar constraints apply to the use of opioids by continuous infusion, which is an effective approach immediately after operation if carefully monitored. The inflammatory component of pain and opioid use can be reduced by regular NSAID analgesia, unless the risk of haematoma formation outweighs the benefits.
Early excision is considered the gold-standard treatment:<ref name=":20" />


===== Dressings changes =====
* there is debate over the optimal timing for early excision
The management of pain during dressings changes is the most extensively investigated aspect of burn pain management, yet no single technique has been shown to be better than any other. A large burn dressing may take 1--2 h and may include active wound debridement or postoperative removal of items such as staples. General anaesthesia is often appropriate; deep intravenous sedation may be given and supervised by an anaesthetist. For smaller dressings, analgesia is commenced before the procedure takes place by a bolus of opioid or local anaesthetic; time is Pain in the patient with burns Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 2 2004 59 Downloaded from <nowiki>https://academic.oup.com/bjaed/article/4/2/57/271658</nowiki> by guest on 14 June 2022 allowed for onset of the analgesia. Depending on the level of stimulus, further doses can be used during the procedure supplemented by a benzodiazepine. Entonox is useful for short procedures to supplement opioids, reduce breakthrough pain and avoid prolonged sedation. Ideally, easily titratable sedative and analgesic agents with few side-effects and short half-lives are required. Few drugs have all these properties. Sedation with many agents has been reported, including lidocaine infusions, benzodiazepines and volatile inhalation agents. Ketamine is analgesic and sedative. Although loss of airway is unlikely at normal doses, its use islimited in adults by side-effects including hallucinations. The latter can be mitigated by adding a small dose of a benzodiazepine. Boluses orinfusions ofshorter-acting opioidssuch as alfentanil and fentanyl are suitable for short procedures. They can nevertheless accumulate and may result in respiratory depression, particularly if given to a patient already receiving opioids. Combination with a low-dose infusion of propofol (administered by an anaesthetist) gives adequate conditions for dressings changes. The effects of propofol terminate within minutes if a target-controlled infusion at a dose range of 1--2 mg mlÿ1 is used. Further flexibility can be introduced by adding remifentanil. Because the half-life of remifentanil is short, supplementation with opioids, NSAIDs, or both, is necessary to control pain in the post-procedural period. The requirement for procedures can be reduced by using suitable dressings, such as a synthetic temporary skin substitute, especially in children. Biobrane1 (a porcine collagen-based material) and similar synthetics are used on superficial wounds that are expected to heal; they are left in place until healthy skin has formed, thus reducing distress and infection risk and also allowing early mobilization.
* surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue


===== Physiotherapy =====
=== Skin Grafts ===
Physiotherapy is an important part of rehabilitation. Moving damaged areas causes pain and further exacerbation of the stress response. On the other hand, the patient is engaged in the process and therefore motivated. This type of pain is predictable and again amenable to multimodal management using oral analgesics. The scope of strong painkillers and anaesthesia is limited because of the requirement for cooperation; however, the physiotherapists will often take the opportunity of a visit to theatre or the dressings station to perform passive range of movement exercises in the early stages.  
A skin graft is an area of skin that is moved from one area of the body to another area.  


==== Resting Pain ====
Early autografting (i.e. transplanting skin from a healthy donor site to the burned area) rapidly closes excised wounds, which reduces infection risk and pain and facilitates earlier mobilisation. Allografting (i.e. using skin from another person) is used to temporarily cover debrided tissue when:<ref name=":20" />
After initial treatment and between procedures, the patient most commonly suffers low-grade but persistent discomfort, the nature of which has been repeatedly shown to be under-appreciated even by experienced staff. This is difficult to treat adequately while minimizing the patient’s exposure to side-effects, but adequate treatment is essential to patient well-being. A multimodal approach using low-dose oral opioids in combination with NSAIDs provides best results. Careful titration by measuring the extent of pain relief regularly and adjusting doses accordingly is essential; it can be integrated into the work of the Acute Pain Team or managed by the burns nurses according to well-designed protocols. Pre-emptive, regular dosing with supplemental prescriptions for breakthrough pain is most effective in practice.


==== Itching ====
* there are issues with the viability or bacterial load of the wound bed
Pruritus is another disabling condition that is poorly understood. It may disrupt normal physiology, and scratching may cause damage to forming skin. The mechanism is thought to involve histamine and prostaglandin release. Treatment is again difficult and usually involves combinations of antihistamines and NSAIDs. Empirical observation that heat may trigger the reaction has led to treatment by cold compresses and control of the environmental temperature.
* the patient is not sufficiently medically stable


==== Chronic Pain ====
'''Autologous split-thickness skin grafts''' are the gold standard management approach for deep partial and full-thickness acute burns.<ref name=":19" /><ref name=":20" /> Autologous skin grafts can be split-thickness skin grafts (STSGs) or  full-thickness skin grafts (FTSGs).<ref name=":21">Anyanwu JA, Cindass R. Burn Debridement, Grafting, and Reconstruction. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551717/</ref>
Damaged and regenerating nerve tissues can give rise to complex neuropathic pain syndromes whereby the sensation of the painful stimulus far outlives its expected duration. This can destroy the sleep pattern, result in depressive symptoms and impair rehabilitation. There may be hyperalgesia (an increased response to a painful stimulus) and allodynia (a painful response to a normally innocuous stimulus). This may be a significant problem starting quite early in the post-injury course and persisting for many years afterthe initial injury (Table 1). Thistype of pain is very difficult to treat using conventional analgesics, unlessthere is ongoing inflammation or tissue damage. The severity of chronic symptoms is often related to the size of the burn and the number of skin grafts performed. Treatment includes antidepressants (amitriptyline), anticonvulsants (gabapentin and sodium valproate), regional nerve block and cognitive behavioural therapy.


Norman AT, Judkins KC. Pain in the patient with burns. Continuing education in anaesthesia, critical care & pain. 2004 Apr 1;4(2):57-61.
'''Split-thickness skin grafts (STSG)''':<ref name=":21" />


https://watermark.silverchair.com/mkh016.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAsIwggK-BgkqhkiG9w0BBwagggKvMIICqwIBADCCAqQGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM8hBBA3-YleMTDlsLAgEQgIICdaNAQVJfJDXcu9y0Y_dLG_C_Su3imINuxNtMid7BeV7VT9rtL9o9euY-mwSUdTEVnCO2xjqPweYwsL6sF-SkYZr0QOEYmJg3ZTjsmnykvzHl0s9XDtY73ZsP4nUBpX8beCegifVCpgfpl7238bm93vKnT4oMttbBOfwXyBZif8AUI7IhkyMYb890IRVxaZiLj8UN7rY-9ALP8ZR1rfe_7y3jHxZdWlVyMO-0HVN-KzLVdQ8_5wr7dnVdTuSdHbK91ndOk6DpwTXygibQHglcxDWHlnaA3CgAsu47xSWVMDUJP2-7cKieAt02f55qzv8alYc98u6t-M0t7L4r5ApZX5H8KBj8WLJx3FcVedfItDElgO4T-HsghazGvYaQvkeOiYNwHk0tT72NMs9OJX3b-XS7MIDFnshUN5Zq3K9eFI-YTrNAP1-AeDBDlhuy33b6ezHrvM44fEbkuDm9rDiEyX2E6aXKXG1OQh21TqgR_01zkpNNtFNkZLbZ2RER8fDVz2renloBa9KBLFPeaN0bCxnc-zMpy64mOH737Ol0Ntg5akv7b2du4BlOileiIFkXZt9vI6CdLgGVd0yNvq6wcfxdBiaH_LL2Ana-RU49w-_YWxIOFx0xvOusFTQVwhelH-sC5oF7_rwxt6XJhZTtFqYywuDgCxjmY08BP1ePmRBfIRkrDUk-bsoaDWCfIx7OFafHhK0Hnm4MJGRDj2NyIGk1_6UjRcbUwZy5pj2UUa5Iw-ceqh95Fkf3teP4wpWNPr7PZoT51v-1bqB4Myz-2ra6C070sAN_axjJe_eIbDsca0ZOj04RqHEewNqZmS5BrGPTWeJP
* most commonly used for wound coverage
* include the epidermis and the upper layer of the dermis
* are beneficial when patients have extensive TBSA burns, as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
* '''mesh grafts''' can increase the total surface area of the mesh, but can result in significant scarring<ref name=":20" />
** mesh grafts are processed to "punch" holes or apertures into the graft; this increases its size, allows topical agents through the graft and serous fluid or blood out
** STSGs are often meshed and expanded for burns of more than 30-40%TBSA
** meshed grafts are more commonly used for the back, trunk, legs and arms
* '''sheet grafts''' (i.e. “donor sites that are excised and used as-is”) are used for more cosmetic areas, such as the face, hands and neck<ref name=":20" />
For more information on STSGs, please see: [https://www.nature.com/articles/s41572-020-0145-5 Burn injury].<ref name=":20" />


Judkins KC. Pain management in the burned patient. Pain Rev 1998; 5: 133--46
'''Full-thickness skin grafts (FTSG)''':<ref name=":21" />


Kidd BL, Urban LA. Mechanisms of inflammatory pain. Br J Anaesth 2001; 87: 3--11
* the epidermis and the dermis to the underlying fat layer are harvested using a scalpel
* associated with decreased scar and contracture formation, so they are useful in areas of cosmetic importance and across joints
* however, they lead to full-thickness wounds at the donor site; these must be closed primarily or have reconstructive flap closure
* have a higher failure rate


MalenfantA, ForgetR, Papillon J,AmselR, Frigon J, ChoiniereM. Prevalence and characteristics of chronic sensory problemsin burn patients. Pain 1996; 67: 493--500
The following short, optional video shows the skin graft procedure.
{{#ev:youtube|er9YxF_C60A|300}}<ref>MotionLit. Skin Graft Procedure - Flash Fire Injury. Available from: http://www.youtube.com/watch?v=er9YxF_C60A [last accessed 1/4/2024]</ref>


Pal KS, Cortiella J, Herndon D. Adjunctive methods of pain control in burns. Burns 1997; 23: 404--12
===== Graft Failure =====
A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.<ref name=":13" />


Thurber CA, Martin-Herz SP, Patterson DR. Psychological principles of burn wound pain in children. 1: Theoretical framework. J Burn Care Rehab 2000; 21: 376--86
Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation but without causing damage to the delicate tissue. ''It is essential to consider the dressing pressure needed for successful graft stability and healing. Too much pressure can cause damage to the fragile tissue and a newly placed skin graft to fail.''


# '''Pharmacological Pain Management'''
The area should be immobilised in an “anti-deformity” position to prevent shearing forces that might disrupt the graft. Areas that are highly mobile, such as the hand, might require splinting to ensure immobility.<ref name=":13" />
## Opioids
## Simple analgesics
## NSAIDS
# '''Alternative Techniques'''
## Psychological techniques
## Hypnosis
## Virtual Reality
## Sleep Normalisation
## Music therapy
# '''Paediatric Burn Pain'''
# '''Other causes of pain'''


==== '''1. Pharmacological Pain Management:''' (Richardson and Mustard 2009) ====
Skin grafts are more likely to fail if:<ref name=":20" />
Pharmacological pain management usually begins within the first 48 hours after a burn injury. There is no standard treatment of burns patients, each requires individual assessment. The most common


===== Opioids: =====
* excision of the recipient site is insufficient
the cornerstone of pain management in burns, and are available in a variety of  potencies, methods of administration and duration of action. Opioids used to effectively  manage background pain, with well-timed and effective doses of opioids used separately to  manage procedural pain
* there is shear stress
* there is wound infection
Other causes of graft failure include:<ref name=":13" />


For a patient with a large burn needing immediate, vigorous cleaning, the only viable recourse may be general anaesthesia. This will be especially true if there is an inhalation injury or multiple trauma requiring stabilization, surgery or transfer to an appropriate specialist centre. Continuous intravenous infusions of opioids provide the mainstay of analgesia for this group. For the patient without threat to the airway, the gold standard remains intravenous morphine. This can be titrated in small (1--2 mg) boluses until the patient is comfortable. Due diligence must be exercised to avoid the side-effects of excessive sedation and respiratory depression; nevertheless, high doses are sometimes required. Absorption of opioids given intramuscularly may be unpredictable. Tissue damage releases multiple inflammatory mediators such as hydrogen ions, prostaglandins and bradykinin.
* inadequate blood supply to the wound bed
{| class="wikitable"
* collection of fluid beneath the graft (e.g. haematoma)
|Positive Effects
* the properties of the donor site (e.g. level of vascularity)
|Side Effects
|Examples of Opioids
|-
|Pain relief


Increased comfort
===== Skin Substitutes =====
If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes (biomaterial and engineered tissue grafts).<ref name=":19" /><ref name=":20" />


Morphine related to reduced  Post-traumatic stress disorder
If you would like more information on skin substitutes, please see:
|Respiratory distress


Itch
* [https://www.nature.com/articles/s41572-020-0145-5 Burn injury]<ref name=":20" />
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192152/ The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review]<ref name=":19" />
<blockquote>There are differences in how a newly placed graft is managed versus a healed graft. You will need to consult with the surgeon and medical team for specific management protocols.</blockquote>


Nausea and vomiting
=== Skin Flaps ===
Skin flaps are also used in patients with burn injuries. Unlike skin grafts which are vascularised by the recipient site, a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site).<ref name=":13" />


Opioid tolerance – requiring  increasing doses
Skin flaps might be used on areas such as:<ref name=":13" />


Opioid induced hyperalgesia  (OIH) – increased sensitivity,  throughout the body following  opioid exposure
* bone without periosteum
* tendon without paratenon
* cartilage without perichondrium
The following optional video explains more about skin flaps and shows different types of flap surgery. You can only view this video on YouTube. {{#ev:youtube|T5LOCl0JYbY|300}}<ref>K's Surgery. SKIN FLAP LIVE SURGERY [PLASTIC AND RECONSTRUCTIVE SURGERY]. Available from: http://www.youtube.com/watch?v=T5LOCl0JYbY [last accessed 1/4/2024]</ref>


Provide poor defence against  central sensitisation
=== Reconstruction Surgery ===
<blockquote>“Overall survival of the skin graft is important, but cosmetic outcomes and body image cannot be ignored when treating burn patients.”<ref name=":21" /></blockquote>Burn scars that develop after skin grafting and can lead to:<ref name=":21" />


Physical dependence – common in long term use
* anxiety
* depression
* pain
* itching
* altered pigmentation
* temperature intolerance
* decreased range of motion (from contractures)


25
Surgical scar revision is “the standard of care” for individuals with burn injuries who develop contractures or who have poor cosmetic outcomes. Around 5-20% of individuals with burn injuries go on to have reconstructive surgery.<ref>van Baar ME. [https://link.springer.com/chapter/10.1007/978-3-030-44766-3&#x20;5 Epidemiology of scars and their consequences: burn scars]. Textbook on Scar Management: State of the Art Management and Emerging Technologies. 2020:37-43.</ref> Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.<ref name=":21" />
|Morphine  


Oxycodone
== References ==
 
Fentanyl: potent, rapid onset,  short acting opioid. Used for  procedural pain management.  
 
Remifentaril: ultra-short acting  opiate.  
 
Alfentaril: short acting, used for  post-procedural analgesia.  
 
Table 5: side effects of opioidsMethadone: long acting
|}
 
===== Simple analgesics: =====
paracetamol can be used in conjunction with opioids, to give a synergistic  effect comparable to a higher opioid dose. Paracetamol is an effective anti-pyretic and has  few contra-indications.  
 
Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the formation of prostaglandins and therefore provide analgesia. They may be useful alone in smaller burns or as an adjunct to opioids. However, the severely burnt patient may be hypovolaemic and therefore at risk of gastric erosions. NSAIDs should be used with caution in the Pain in the patient with burns 58 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 2 2004 Downloaded from <nowiki>https://academic.oup.com/bjaed/article/4/2/57/271658</nowiki> by guest on 14 June 2022 shocked patient or the elderly. If NSAIDs are contraindicated, then tramadol may be useful as an intermediately potent analgesic. If there is concern over the patient’s condition, keep it simple (i.e. intravenous morphine with adequate fluid resuscitation).
 
===== Non-steroidal Anti-inflammatory Drugs (NSAIDS): =====
synergistic with opioids and can reduce opioid dose and thus reduce side-effects.  Not used in wide spread burns due to already increased risk of renal failure and peptic  ulceration. There is potential to increase bleeding in large burns also, due to the anti-platelet  effect.
 
===== Other medications: =====
see Richardson and Mustard 2009  
 
Possible side effects of analgesics:
 
- Drowsiness
 
- Adverse reaction
 
- Nausea and increased risk of aspiration
 
- Impaired memory and communication
 
- Postural hypotension, and fainting (ANZBA 2007) 3.2 Non-Pharmacological Management of Pain
 
The following is a synthesis of information form the following articles: Summer et al (2007),  Richardson and Mustard (2009), ANZBA (2007) and de Jong et al (2007)
 
Overall, the levels of evidence to support the use of alternative therapies for pain relief are of  poor quality. However, no negative side effects were reported in the literature reviews and these therapies are all used in conjunction with pharmacological management to optimize  pain relief for the individual.  
 
==== 2. Alternative Techniques: ====
 
===== Psychological techniques: =====
beneficial for reducing anxiety and providing patients with  coping methods for pain levels and durations. These include relaxation, distraction and  cognitive behavioural therapy (CBT). CBT is beneficial in the management of complex pain  problems and can reduce fear and anxiety associated with activities or environments.  
 
===== Hypnosis: =====
a state of “increased suggestibility, attention and relaxation”. In the burn  patient hypnosis is used in the management of procedural pain and anxiety. The use of  hypnosis clinically is increasing but its usefulness is dependent on the individual’s hypnotic susceptibility, high baseline pain and the skill of the practitioner. The current best available  evidence for management of procedural pain was found for active hypnosis, rapid induction  analgesia and distraction relaxation.
 
===== Virtual Reality: =====
immersing the patient in a virtual world has shown some effect on  procedural pain control and is better than hand-held gaming devices. However, the equipment  is costly and bulky and not always suitable for paediatric intervention. A paediatric  intervention, using hand-held game devices which provide augmented reality was trialled  among 3-14 year olds. This has shown significantly lower pain scores than standard  distraction and relaxation when undergoing dressing changes (Mott et al 2008).  
 
===== Sleep Normalisation: =====
disrupted sleep occurs in up to 50% of burn patients and links  have been established between poor sleep quality and pain severity, as well as pain and  prolonged experiences of sleep disturbance. Normalisation of the 24hour day, with a bedtime  routine, within the limits of the hospital environment is aimed for to promote sleep, with the  use of analgesics and night sedation.
 
===== Music therapy: =====
this is thought to target pain via the gate control theory. This suggests  that music serves as a distraction from noxious stimuli. Also, the anxiety related to the  rehabilitation of burns can increase the activation of the sympathetic nervous system. Music  uses all three cognitive strategies employed in pain and anxiety management (imagery –
 
envisioning events that are inconsistent with pain, self-statements and attention-diversion  devices to direct attention away from the pain ad redirects it to another event) (Ferusson and  Voll 2004; Presner et al 2001).  
 
A systematic review of music therapy among pregnant women, medical-surgical patients and  critical care patients showed statistically significant reductions in pain scores. Of the  seventeen studies reviewed by Cole and LoBiondo-Wood (2012), 13 studies demonstrated the  positive effects of music on pain. Other positive findings of the studies included reduced  anxiety, muscle tension, blood pressure and heart rate. A burn specific study included showed  reduced pain levels during and after the debridement, reduced anxiety and decreased muscle  tension during and after dressing changes.  
 
The Cochrane Review of music as an adjunct to pain relief concluded that “music and other  non-pharmacological therapies could have a synergistic effect to produce clinically important benefits on pain intensity or analgesic requirements” and thus requires further study. This is  based on the studies indicating that music resulted in reduced pain intensity and reduced  opioid requirements. The reported changes in both of these outcomes were small however,  and their clinical importance is unclear (Cepeda et al 2006).  
 
==== 3.Paediatric Burn Pain (Richardson and Mustard 2009) ====
∙ children 0-4 years represent approx. 20% all hospitalised burn patients ∙ In preschool aged children the half-life of opioids (morphine and alfentanyl) are 50%  those in adults. Higher dosage required.
 
∙ Risk of accidental overdose due to difficulties with pain evaluation resulting in  overestimation of child’s pain
 
∙ Childs environment has huge effect on pain perception. Parents’ presence and aid  during dressing change can have beneficial for procedural pain and reducing anxiety.
 
The whole experience of trauma, hospital admission and treatment cycles is especially distressing for children. They require the same standard of analgesia and treatment as adults but are more difficult to assess in terms of pain. Behavioural assessments are important, especially in babies and toddlers where, for instance, quiet inactivity should be considered abnormal; administration of analgesia may restore play. Instead of a Visual Analogue Score, several scales are available, the best known of which is the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) which uses ‘smiley faces’. It has been shown that PCA can be used successfully in children as young as 4 yrs old. Psychological strategies have also been shown to work in children. The role of the Hospital Play Specialist is crucial in this respect; every burn unit should have at least one. The role of appropriate dressings material in children (e.g. Biobrane1) has been emphasized previously. Propofol is not licensed for younger children, so other intravenous techniques must be used for dressings changes. For a first procedure, general anaesthesia is a kindness that minimizes later aversion to procedures. Ketamine is still widely used for children, in whom side-effects seem to be less of a problem. Addition of a small dose of benzodiazepine reduces the incidence of hallucinations.
 
== 3.3 Considerations Pre Physiotherapy Treatment ==
∙ Pain relief is key. Timing physiotherapy to correspond with analgesia is essential for the  patient, particularly to avoid the pain-anxiety avoided.  
 
∙ Knowledge of pain medications, short-acting pain relief may be required in addition to  long-acting background pain relief prior to physiotherapy. Also, the side-effects possible  due to the medications, and vigilance for signs of these.  
 
∙ Daily assessment of therapy input and pain management to ensure on-going management  of pain. (ANZBA 2007)
 
28
 
==== 4. Other causes of pain ====
The burn wound and donor sites are not the only possible causes of pain in the burned patient, especially in major or multiple injuries. In the initial assessment, a secondary survey must performed to locate other injuries. Pain from fractures may be severe. Current guidelines recommend the stabilization of the fracture and the titration-to-effect of intravenous opioid. Likewise, the pain of abdominal injuries should be managed appropriately. Compartment syndrome in a limb may be a concern with a circumferential burn or in association with a fracture and can be caused or exacerbated by fluid resuscitation. If untreated this will result in limb ischaemia. Surgical decompression is required. Pain should be also considered as a harbinger of infection in the recovery phase. Hot, erythematous, swollen areas may indicate cellulitis or pusformation, which necessitates systemic antibiotics, surgical incision and drainage, or both. Major burns are associated with a multitude of complications including perforation of an abdominal viscus, colonic pseudo-obstruction, abdominal compartment syndrome and heterotopic bone deposition; in all of these scenarios, a change in the magnitude or type of pain may be the first indicator of trouble.
 
== Oedema Management ==
 
==== 1. Elevation ====
Elevation of the hand above heart level is the most simple and effective ways to prevent and  decrease oedema (Kamolz 2009). A Bradford sling can be used to facilitate elevation. This  type of sling facilitates both elevation and protection of wound area while still allowing  movement. Its foam design also reduces the risk of the development of pressure points or  friction (Glassey 2004).
 
Fig 21. Bradford sling in a position  
 
of elevation (Microsurgeon 2013)
 
When a patient is admitted with severe burns of a large TBSA they are at risk of systemic  inflammation. Therefore, not only must the affected limb be placed in elevation, the  following precautions should also be taken
 
∙ Elevation of the head: This aids chest clearance, reduces swelling of head, neck and  upper airways. It is important not place a pillow underneath the head in the case of  anterior neck burns as there is a risk of neck flexion contractures
 
∙ Elevate all limbs effected
 
∙ Feet should be kept at 90
 
∙ Neutral position of hips
 
∙ Care must be taken to reduce the risk of pressure sores. (Procter 2010) 
 
==== 2. Compression ====
 
===== 2.1 Coban Wrap =====
A Coban Wrap is a self-adhesive bandage. the advantage of this is that it will not stick to the underlying tissue and interrupt the healing process. This makes it suitable for decreasing hand oedema, particularly in the acute stages of a burn. There is evidence that the Coban Wrap assists in decreasing oedema, improving dexterity, range of motion and grip strength in hands.
 
Lowell 2003
 
{{pdf|Coban - English.pdf|Burns and Plastic Surgery Occupational Therapy}}
 
===== 2.2 Oedema Glove/Digi Sleeve =====
These are hand specific oedema management products. There is currently no specific  evidence available to support the efficacy of oedema gloves or digi sleeves in the reduction of  oedema. However it is common practice in Irish hospital to provide these products to  patients with excessive hand and finger oedema. Their use is based on the principle of  compression to reduce oedema which is heavily supported by evidence (Latham and  Radomski 2008).
 
== Scar Management ==
Abnormal scarring is the most common complication of burn injuries, with the estimated  prevalence of > 70% of those who suffer burn injuries (Anzarut et al, 2009). Not only do  hypertrophic scars cause psychosocial difficulties through their cosmetic appearance, they  may also be painful, pruritic, and they may limit range of motion where they occur on or near  a joint (Morien et al 2009; Polotto 2011).
 
Hypertrophic scars require a continuum of dedicated and specialised treatment from the acute  stage to many years post treatment (Procter, 2010, ANZBA 2007).
 
The following is an examination of the evidence and recommendations for use in the most  common of these, including silicone gel, pressure garment therapy, and massage. The  positioning and mobilisation advice above is all applicable, and should be continued in the  management of hypertrophic scars where necessary.
 
===== 5.221 Scar Outcome Measures =====
 
# '''Vancouver Burn Scar Scale (VBSS/VSS)'''
## <u>Aim:</u> Assessment of the scar in 4 catagories: Vascularity, height/thickness, pliability, and pigmentation, relief, and surface  area. Also includes assessment of patient pain, itching, colour, stiffness,  thickness and relief. The only scale to measure subjective aspects of pain and  pruritus (severe itching) (Fearmonti et al 2010).(Fearmonti et al 2010)(Durani et al 2009)(Brusselaers et al 2010)
## Method: [[Burns Scar Index (Vancouver Scar Scale)]]
# '''Patient and Observer Scar Assessment Scale (POSAS)'''
## <u>Aim:</u> Assessment of the scar from the patient and the observers perspective
## <u>Method:</u> [https://www.posas.nl/about/ About POSAS]
# '''Burn Specific Health Scale -Brief (BSHS-B)'''
## <u>Aim:</u>  Assessment of general, physical, mental, and social health aspects of the burn survivor
## <u>Method:</u> [[Burn Specific Health Scale -Brief (BSHS-B)]]
 
===== 5.222 Silicone =====
Silicone Overview
 
The use of silicone gel or sheeting to prevent and treat hypertrophic scarring is still relatively  new. It began in 1981 with treatment of burn scars (O’Brien & Pandit 2008). The  physiological effects of silicone in the treatment of scarring remain unclear. Below is a  summary of the current hypotheses surrounding the physiological effects of silicone. This  summary has been adapted from the most recently published literature on this topic.
 
1) Hydration Effect: Hydration can be caused by the occlusion of the underlying skin. It  decreases capillary activity and collagen production, through inhibition of the  proliferation of fibroblasts
 
2) Increase in temperature: A rise in temperature increases collagenase activity thus  increased scar breakdown.
 
51
 
3) Polarized Electric Fields: The negative charge within silicone causes polarization of  the scar tissue, resulting in involution of the scar.
 
4) Presence of silicone oil: The presence of silicone has been detected in the stratum  corneum of skin exposed to silicone. However other researchers suggest occlusive  products without silicone show similar results.
 
5) Oxygen tension: After silicone treatment the hydrated stratum corneum is more  permeable to oxygen and thus oxygen tension in the epidermis and upper dermis rises.  Increased oxygen tension will inhibit the ‘‘hypoxia signal’’ from this tissue. Hypoxia  is a stimulus to angiogenesis and tissue growth in wound healing, as a consequence  removing the hypoxia stops new tissue growth. This theory has been contraindicated  by other researchers.
 
6) Mast cells: It is suggested that silicone results in an increase of mast cells in the  cellular matrix of the scar with subsequent accelerated remodelling of the tissue. 7) Static electricity: Static electricity on silicone may influence the alignment of collagen  deposition (negative static electric field generated by friction between silicone  gel/sheets and the skin could cause collagen realignment and result in the involution  of scars. (Bloemen et al 2009; Momeni et al 2009)
 
Evidence
 
Momeni et al 2009: RCT, double blind placebo controlled trial
 
Subjects: N=38, with hypertrophic scars post thermal burn. All were 2-4 months post burn,  with areas including upper limb (n=14) lower limb (n=8) trunk (n=3) and face (n=9).  
 
Intervention: Patients acted as their own control, with the scar area being randomly divided  into two sections: one received silicone sheets, and the other a placebo. Both were applied for  4hrs/day initially, with this incrementally increased to 24 hrs/day over the course of the study,  for a four month period.  
 
Outcome measures: assessed at one and four months, by a blinded assessor using the  Vancouver Scar Scale and by Clinical Appearance.
 
Results: No significant differences in baseline characteristics. At one month the silicone  group had lower scar scores than the placebo group, however they were not statistically
 
52
 
significant. At four months, the silicone group had significantly lower scores on VSS for all  dimensions except pain compared to placebo.
 
Limitations: Small heterogeneous cohort. No discussion of clinical significance of the  reduction in scar scales. 4 subjects lost to follow up with no intention to treat analysis.  
 
Brien and Pandit 2008: Cochrane Systematic Review Investigating the Efficacy of  Silicone Gel Sheeting in Preventing and Treating Hypertrophic and Keloid Scars
 
Studies Included: 15 RCTs, n=615, only 3 studies specific to burn patients. 12 compared  silicone to no treatment, and the remainder silicone was compared to placebo or laser  treatment.  
 
Outcome Measures: Primary outcome measures included scar length, width and thickness; secondary outcomes include scar appearance, colour, elasticity, relief of itching/pain
 
Results: No significant difference between silicone gel sheeting and control in reducing scar  length and width. Significant results for reducing scar thickness, though these were thought  not to be clinically relevant. No statistically significant difference between silicone gel and controls in secondary outcomes.  
 
Limitations: Large age range, heterogeneous sample, poor quality of trials in general, with  most at high risk of selection and detection bias. Only three studies used blinded outcome  measures. 6 studies lost >10% of participants to follow up.  
 
Conclusion on Silicone
 
It is unclear whether silicone gel help prevent scarring. Many of the studies advocating the  use of silicone gel are of poor quality and are susceptible to bias. However, it is currently  common practice in Ireland to administered silicone gel as an adjunct to treatment of  scarring. Silicone gel as opposed to sheets is the preferred product to use as it is easier to  apply can be used on more areas of the body and gives a higher patient compliance (Bloemen  et al 2009).
 
53
 
===== 5.223 Pressure Garment Therapy (PGT) =====
Though the effectiveness of PGT has never been proven, it is a common treatment modality  for reducing oedema and managing hypertrophic scars (Procter, 2010).  
 
Aims
 
o Reduce scarring by hastening maturation  
 
o Pressure decreases blood flow
 
o Local hypoxia of hypervascular scars
 
o Reduction in collagen deposition
 
o Therefore
 
o Decreases scar thickness
 
o Decreases scar redness  
 
o Decreases swelling
 
o Reduces itch
 
o Protects new skin/grafts
 
o Maintains contours (Procter 2010)
 
The exact physiological effects of how pressure positively influences the maturation of  hypertrophic scars remain unclear. Below is a summary of the current hypotheses  surrounding the physiological effects of pressure garments. This summary has been adapted  from the most recently published literature on
 
1) Hydration effect: decreased scar hydration results in mast cell stabilization and a  subsequent decrease in neurovascularisation and extracellular matrix production.  However this hypothesis is in contrast with a mechanism of action of silicone, in  which an increase of mast cells causes scar maturation.
 
2) Blood flow: a decrease in blood flow causes excessive hypoxia resulting in fibroblast  degeneration and decreased levels of chondroitin-4-sulfate, with a subsequent increase  in collagen degradation.  
 
3) Prostaglandin E2 release: Induction of prostaglandin E2 release, which can block  fibroblast proliferation as well as collagen production
 
(MacIntyre & Baird 2006)
 
54
 
Evidence
 
The evidence for PGT is limited.
 
∙ Early studies found significant benefit from their use in terms of scar maturation and  necessity of surgery for correction
 
∙ These were not RCTs, and were conducted in a time where inefficient surgical  debridement resulted in scar loads much worse than those seen today (Engrav et al  2010)
{| class="wikitable"
|Article citation and  design
|Anzarut et al (2009)
 
Systematic Review+ Meta-Analysis
|Engrav et al (2010)  
 
Within wound RCT
|-
|Selection criteria
|6 trials with 316 patients located  3 between-subject design
 
3 studies within-subject design
 
Adult and paediatric populations
|54 patients recruited over 12 years
 
Forearm burn requiring >3 weeks  to heal/skin grafting. Mean age,  36 yrs, mean length of follow up,  9.5 months
|-
|Intervention
|3 studies wore pressure garments for  23h/day
 
3 studies did not describe length of  pressure garment treatment
|Randomised normal compression  (17- 25mmHg) and low  
 
compression (<5 mmHg) to  proximal/distal area of scar. 23  hrs/ day to wound maturity, or up  to 1 yr
|-
|Outcome measures
|Primary Outcome:
 
Global scar score
 
Secondary outcome:
 
Scar height, vascularity, pliability,  colour
|Durometry (hardness)  
 
colorimetry (colour)  
 
ultrasonography (thickness)  Clinical appearance: judged by a  panel of 11 experts in burn care
|-
|Results
|Global Scar Score:
 
∙ No significant differences  
 
between PGT & control  
 
interventions
 
Secondary Outcome:
|∙ Statistically significant  decrease in scar hardness  
 
and height
 
∙ 3/19 and 5/28 patients  
 
respectively achieved a  
 
decrease which could be
|}
55
{| class="wikitable"
|
|∙ Scar height showed a small but  statistically significant decrease  in height for pressure garment  
 
therapy.
 
∙ Questionable if this is clinically  significant.
 
∙ Scar vascularity, pliability and  colour failed to demonstrate a  
 
different between groups
|clinically detected
 
∙ In only 3/41 patients  
 
could the zone of normal  
 
and low compression be  
 
identified correctly by a  
 
panel of 11 experts
 
However, the authors concluded  by recommending that PGT  should continue to be used.
|-
|Limitations
|Publication bias present with only 1  trial reported negative effect
 
In 5 of the 6 studies, concealment of  allocation was unclear
 
All studies had inadequate reporting of  randomisation and did not comment on  withdrawals and dropouts.
|Some data lost for different  parameters over the space of 12  years. Noted that in this time,  staff and equipment changed,  which could have confounded  results. Evidence of bias in  interpretation of results. Low risk  of bias from randomisation, not  all assesors blinded.
|}
Table 9 Available Evidence for PGT
 
∙ The authors’ bias was evident in both of the above articles. Though their results were  similar, Anzarut et al, 2009 concluded that there was no evidence to justify this  ‘expensive source of patient discomfort’, while Engrav et al, 2010 concluded that its  use was justified.
 
Patient Adherence to Pressure Garment Therapy  
 
In 2009 Ripper et al carried out a quantitative study on adult burn patient’s adherence to  pressure garment therapy.
 
Subjects: 21 participates interviewed concerning their experiences with pressure garments.  Time since burn ranged from 5months to 4years and 2 months.
 
Methodology: Randomised selection of patients 21 patients segregated into 3 groups:  Patients who had completed PGT, Patients who were still in the course of therapy, and  Patients who refused to wear the garments and had stopped PTG completely.
 
56
 
Results: Complaints most frequently mentioned were: “Physical and Functional limitations”  caused by garments. “Additional effort” created by the need to care for the garment.  Motivating factors for the patients: ‘expectation of success’ ‘emotional support’ ‘practical  support’ and experiencing ‘good outcome’.
 
Limitation: Unclear method of randomised selection, variation in time elapsed since burns,  body parts affected by burns not established
 
Careful considerations of cost, compliance, patient discomfort, possible complications and  the perceived benefits before prescribing this treatment.  
 
Recommendations for practice and safety considerations
 
Pressure: 15 mmHg has been noted as the minimum to elicit change, and pressures of  above 40 mmHg have been found to cause complications. Both Anzarut et al (2009) and  Engrav et al (2010) used pressures of between 15 and 25 mmHg.
 
Time: It is recommended that garments are worn for up to 23 hours a day, with removal for  cleaning of the wound and garment, and moisturisation of the wound. (Procter 2010; Anzarut  et al 2009 and Bloeman et al 2009).
 
Duration: garments can be worn as soon as wound closure has been obtained, and the scar is  stable enough to tolerate pressure. Post grafting, 10-14 days wait is recommended, at the  discretion of the surgeon (Bloeman et al 2009). Garments should be worn for up to one year,  or until scar maturation (Anzarut et al 2009; Engrav et al 2010 and Bloeman et al 2009).
 
Possible complications/ confounding factors for use of PGT
 
∙ Lack of a scientific evidence to established optimum pressure
 
∙ Non-Compliance ( due to comfort, movement, appearance)
 
∙ Heat and perspiration
 
∙ Swelling of extremities caused by inhibited venous return
 
∙ Skin breakdown
 
∙ Web space discomfort
 
∙ Inconvenience
 
∙ Personal hygiene difficulties possibility of infection
 
∙ Allergies to material (MacIntyre & Baird 2006; Glassey 2004)
 
57
 
5.224 Massage
 
Five principles of scar massage:
 
1. Prevent adherence
 
2. Reduce redness
 
3. Reduce elevation of scar tissue
 
4. Relieve pruritus
 
5. Moisturise (Glassey 2004) Scar Massage Techniques
 
∙ Retrograde massage to aid venous return, increase lymphatic drainage, mobilise fluid  ∙ Effleurage to increase circulation
 
∙ Static pressure to reduce pockets of swelling
 
∙ Finger and thumb kneading to mobilise the scar and surrounding tissue ∙ Skin rolling to restore mobility to tissue interfaces
 
∙ Wringing the scar to stretch and promote collagenous remodelling
 
∙ Frictions to loosen adhesions
 
(Holey and Cook 2003)
{| class="wikitable"
| colspan="2" |Guidelines for Massage during 3 Stages of healing
|-
|Inflammatory Phase
|gentle massage to decrease oedema and increase blood supply  (currently no high level evidence to support this)
|-
|Proliferative Phase
|Massage that applies gentle stress to the healing scar is recommended  to ensure collagen is aligned correctly.
|-
|Remodelling Phase
|Massage should be progressed to include prolonged stretching to  minimise adhesions. This is proposed to aid in scar tissue breakdown
|}
Table 10 Guidelines for scar massage during healing stages (Glassey 2004)
 
58
 
Table 11. Evidence for the use of massage in scar management
{| class="wikitable"
|Article
|Field et al 2000
 
RCT
|Morien et al 2008
 
Pilot Study
|Shin and Bordeaux,  2012 Lit review
|-
|Subjects
|20 subjects in remodelling phase of  wound healing.  Randomly assigned into  2 groups
 
Massage Vs Control
|8 Children  
 
Mean age 13.5 years  (10-17years)
 
All thermal burns  including hand burns
|Not burn specific,  though the majority  of scars were of this  origin
 
10 articles: n=144  adult and children
|-
|Intervention
|Massage Therapy Group:
 
30minutes massage with  cocoa butter twice  weekly for 5 weeks
 
Control Group:
 
Standard Treatment
|20-25 minute  massage session  once daily for 5 days
 
(effleurage,  
 
petrissage, friction,  lengthening rolling)
 
Session followed by  discussion of  psychosocial issues
|Time to Rx: mean  4.3 months. +  variation in  protocols. 20  mins/day- 30 mins 2x  weekly. 1 Rx-6  months Rx
|-
|Outcome  
 
measures
|Itching: VAS
 
Pain: McGill Pain
 
Questionnaire
 
Anxiety: State Trait  Anxiety Inventory
 
Mood: Profile of Mood  States
|Likert pictorial scale  
 
Goniometry Range of  Motion
|Patient and observer  scar assessment  scale, Vancouver  scar scale, thickness,  vascularity, colour,  pain, pruritus, mood,  anxiety, and  depression.
|-
|Results
|Massage Therapy Group  Reported: decreased  itching, pain, anxiety and  increased mood  
 
Ratings improved from  the 1st-last day of the  study
|Increased ROM in  massaged tissue.  Decreased ROM in  unmassaged tissue
 
No significant  difference in mood  across time
|45.7% improved in at  least one of the above  parameters. 54.7%  had no improvement.  
 
Noted massage was  more economical  than silicone/PGT.
|}
59
{| class="wikitable"
|Limitations
|Small Sample Size
 
No follow up
|Paediatric  
 
population. Mood Instrument may have  been influenced by  other factors.  Recruitment and area  to be massaged not  random
 
Small sample size
 
No follow up
|No discussion of  quality or statistical  tests.
|}
Conclusion on Scar Massage
 
Evidence suggests that burn patients receive psychological benefits from massage in terms of  altered mood (decreased depression, anger), decreased pain, and anxiety (Field et al 1998).  Evidence also indicates that massage increases ROM in non-burned patients, but little  evidence exist examining the effect of massage on ROM in burn patients (Morien et al 2008).
 
Recommendations for practice and safety considerations.
 
Insufficient consistency in literature with regards to protocols on frequency or duration of  treatment. Suggestions for practice include (Shin and Bordeaux, 2012, Morien et al, 2008)  
 
∙ Clean hands essential
 
∙ Use non irritating lubricant, free of any known sensitisers.  
 
∙ Modify practice according to patient stage of healing, sensitivity and pain levels. Contraindications: Shin and Bordeaux 2012
 
∙ Compromised integrity of epidermis
 
∙ Acute infection
 
∙ Bleeding
 
∙ Wound dehiscence,  
 
∙ Graft failure
 
∙ Intolerable discomfort
 
∙ Hypersensitivity to emollient
 
== Reconstruction Post Burn Injury ==
The impact of reconstructive surgery post burn injury has a major impact on a patient. As an  allied health professional, we must work as part of an MDT in order to ensure successful  surgery while at the same time ensuring long term health and function. Timely burn wound  excision and skin grafting form the cornerstone for acute burn surgical management (Klein  2010).Surgery for burned patients is not normally indicated until 48 hours after injury, when  the depth of the burn has been established. The only exception is when necrotic tissue is  evident then early excision may be required. A plastic surgeon must reconstruct the injured  body part in a way that is extensible, sensate and cosmetically acceptable (Glassey 2004). In  addition to this, they must rebuild or replace muscles, tendons, joints and nerves to ensure  they are appropriately intact.  
 
4.1 Aims
 
1. Achieve would closure
 
2. Prevent infection
 
3. Re-establish the function and properties of an intact skin
 
4. Reduce the effect of burn scars causing joint contractures
 
5. Reduce the extent of a cosmetically unacceptable scar
 
(Glassey 2004; BBA Standard 6 2005)
 
4.2 Choosing the Correct Method of Reconstruction
 
The simplest management involves conservative wound care and dressings, while the most  complex is free-flap reconstruction. When deciding on the most appropriate intervention, a  surgeon must consider the extent of the missing tissue and the structures effected (Glassey  2004). Generally, a superficial partial thickness burn will heal with conservative treatment  (secondary intention) in 10 days to 3 weeks, unless infection occurs. Primary intention occurs  if a wound is of such size that it can be closed directly without producing undue tension at the  wound site. Delayed primary closure occurs once a suspected infection has been cleared.  Deep partial and full thickness burns both require surgical intervention. Surgery normally  takes place within the first 5 days post injury to prevent infection which could extend the  depth of the tissue loss (Glassey 2004).
 
29
 
Figure11. The reconstructive ladder, procedures ranging from simplest to most complex. (Ataturk University School of Medicine 2009)
 
4.3 Skin Grafts
 
“A skin graft is the transportation of skin from one area of the body to another.” (Glassey 2004)  
 
A graft is an area of skin that is separated from its own blood supply and requires a highly  vascular recipient bed in order for it to be successful. Prior to grafting, the process of wound  debridement must take place. Wound debridement involves removing necrotic tissue, foreign  debris, and reducing the bacterial load on the wound surface (Cardinal et al 2009).This is  believed to encourage better healing. The following are the methods available for grafting  onto a debrided wound to obtain closure:
 
∙ Autograft (‘split skin graft’) (own skin)
 
∙ Allograft (donor skin)
 
∙ Heterograft or xenografts (animal skin)
 
∙ Cultured skin
 
∙ Artificial skin (Glassey 2004)  
 
30
 
4.31 Meshed vs. Sheet Grafts
 
Sheet grafts are those which are not altered once they  have been taken from the donor site.  
 
Meshed grafts are those which are passed through a  machine that places fenestrations (small holes) in the  graft. Meshed grafts have advantages over sheet  grafts of 1) allowing the leakage of serum and blood  which prevents haematomas and seromas and 2) they  can be expanded to cover a larger surface area.
 
(Klein 2010)
 
4.311 Criteria to be met Pre- Grafting
 
∙ Diagnosis of DEEP tissue loss
 
∙ Patient is systemically fit for surgery
 
∙ Patient has no coagulation abnormalities ∙ Sufficient donor sites available
 
Figure12. Diagrams illustrating the process  of mesh graft procedure (www.beltina .org)
 
∙ Would clear of streptococcus (Glassey 2004) 4.312 The Donor Site
 
The thigh is the most common donor site for split thickness skin grafts (STSG). A split  thickness graft involves a portion of the thickness of the dermis while a full thickness skin  graft (FTSG) involves the entire thickness of the dermis (Klein 2010). The most common site  for full thickness skin grafts is the groin. Cosmetic areas such as the face should be avoided  for graft donation.
 
The donor site should just be left with a superficial or a superficial partial thickness wound  which will heal in 10-14 days and may be reused if necessary. Often, the donor site can be  more painful than the recipient due to exposure of nerve endings (Glassey 2004).  
 
31
 
4.313 Skin Substitutes
 
“Skin Substitutes are defined as a heterogeneous group of wound cover materials that aid in  wound closure and replace the functions of the skin either temporarily or permanently”
 
(Halim et al 2010)
 
Conventionally, STSG and FTSG have been found to be the best option for burn wound  coverage (Halim et al 2010). However, in cases of extensive burn injury, the supply of  autografts is limited by additional wound or scarring at donor sites. For this reason, skin  substitutes will be required. Skin substitutes require higher cost, expertise and experience  than autografts. However, they also offer numerous advantages in the form of rapid wound  coverage requiring a less vascularised wound bed, an increase in the dermal component of a  healed wound, reduced inhibitory factors of wound healing, reduced inflammatory response  and reduced scarring (Halim et al 2010).  
 
Currently, there are various skin substitutes on the market but scientists and engineers are  working towards producing the optimal skin substitute. As a general rule, skin substitutes are  classified as either temporary or permanent and synthetic or biological. A very clear and  concise overview of the different skin substitutes available for burn injuries is provided in  Halim et al (2010).  
 
4.314 The Recipient Site
 
The graft should take within 5 days and will provide a permanent covering of the injury. A  graft should always be placed over bleeding, healthy tissue to ensure it is vascularised for  survival (Glassey 2004).  
 
Post-operatively the graft site is dressed to ensure pressure is created over the graft to limit  haematoma formation. The body part is immobilised in an anti- deformity position at first in  order to prevent shearing forces that could disrupt the graft (Edgar and Brereton 2004). Some  very mobile body parts, such as the hand, may require splinting to ensure joint immobility.
 
4.315 Process of Graft ‘Take’
 
∙ Serum Inhibition (24-48hrs): fibrin layer formation and diffusion of fluid from the  wound bed
 
32
 
∙ Inoscultation (day 3): capillary budding from the wound bed up into the base of the  graft
 
∙ Capillary in-growth and remodelling (Glassey 2004) 4.316 Reasons for Graft Failure
 
∙ Inadequate blood supply to wound bed
 
∙ Graft movement
 
∙ Collection of fluid beneath graft (e.g. haematoma)
 
∙ Infection (e.g. streptococcus)
 
∙ The grafts properties (e.g. vascularity of donor site) (Glassey 2004)
 
4.4 Skin Flaps
 
The difference between a skin graft and a skin flap is that “a skin flap contains its own  vasculature and therefore can be used to take over a wound bed that is avascular”. A skin  graft does not have this ability (Glassey 2004). When speaking about grafts and flaps in the  research, skin flaps is often incorporated into the term ‘skin grafts’.  
 
Fig 13: skin flaps  
 
(MicroSurgeon, 2012)
 
Tissues which a skin graft will not take over include and which a skin flap will include:
 
∙ Bone without periosteum
 
∙ Tendon without paratenon
 
∙ Cartilage without perichondrium (Glassey 2004)
 
33
 
4.41 Categorisation of Skin Flaps
 
Based on three factors:
 
1. Vascularity
 
2. Anatomical composition
 
3. Method of relocation (Glassey 2004)
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Burns]]
[[Category:Burns]]
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[[Category:SRSHS Course Pages]]
[[Category:Integumentary System]]

Latest revision as of 12:35, 1 May 2024

Original Editor - Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Stacy Schiurring and Robin Tacchetti

Introduction[edit | edit source]

Burn injuries are a major cause of pain and disability.[1] Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.

It is essential to remember that every intervention discussed on this page must be coordinated with the medical / surgical team to ensure tailored management protocols for each patient.

Pain Management for Individuals with Burn Injuries[edit | edit source]

There are many factors to consider when treating pain associated with burn injuries.[2] Pain assessments should be performed during each phase of care,[3] and both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.

General Points on Pharmacology for Individuals with Burn Injuries[edit | edit source]

"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."[4]

The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",[4] and patients with burn injuries are often given opioids in higher doses and for longer durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.[3][4][5]

Romanowski et al.[3] include the following recommendations in their guidelines on pain management in adult patients with burn injuries:

  • opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)[3]
  • while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"[3]
  • opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments[3]

For more information, please see: American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps[3]

Pain Management in Individuals with Burn Injuries Admitted to Hospital[edit | edit source]

"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."[3]

In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain. Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as post-burn pruritus (itching).[4][1]

The management for each type of pain can differ.[5] Pain management, especially in the hospital setting will be affected by the depth of burn injury and what structures are still intact and functioning. To learn more about burn wound classification by depth and size please see: Burn Wound Classification.

Background Pain[edit | edit source]

This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures".[5] Thus, it is persistent but usually low-grade.[1] It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferably given orally).[5]

Breakthrough Pain[edit | edit source]

Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.[5] It can indicate worsening background pain or can be from another source.[6]

Pain Associated with Procedures[edit | edit source]

Individuals with burn injuries often require a number of procedures (e.g. mobilisation, skin grafts, debridement, dressing changes, etc). These procedures can add to a patient's pain experience, often causing high-intensity pain that is short to medium in duration.[1]

Important considerations:[1]

  • each procedure causes a new, painful stimulus, which adds to the stress response
  • analgesia should be given at an appropriate time to ensure maximum benefit[6]
  • analgesia should be used in a preventive way, especially as some procedures can be predicted
  • general anaesthetic may be used for prolonged procedures
Pain Associated with Surgery[edit | edit source]

Early post-operative pain tends to be managed with opioids and other non-opioid medications:[1]

  • patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure[5]), but the patient must be conscious and alert[6] and be able to understand how to use the device
  • non-steroidal anti-inflammatory drugs (NSAIDs) have been used to help manage pain after surgery:
    • however, they are used infrequently in individuals who are critically ill[6]
    • they "should be used with extreme caution especially in patients with bigger burns and those on intensive care"[7]
  • local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied
Pain Associated with Dressing Changes and Wound Cleaning[edit | edit source]

Pain management during dressing changes and wound care is a significant consideration:[1]

  • a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns
  • smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure
  • nitrous oxide (e.g. Entonox) and opioids can be used for short procedures to help reduce breakthrough pain and avoid long periods of sedation
  • using appropriate dressings can help reduce the requirement for procedures - please see Burn Wound Injury Dressing Selection and Advanced Dressing Selection for Burn Wound Injuries for more information on burn wound dressings
Pain Associated with Rehabilitation[edit | edit source]

Physiotherapists and occupational therapists commonly work with patients with burn injuries in primary healthcare settings. However, moving the affected area/s can exacerbate pain and trigger the stress response. Rehabilitation interventions are, therefore, often scheduled after pain relief has been administered:[1]

  • during the acute phase, physiotherapists and occupational therapists may perform passive range of motion exercises or create splints while a patient is in theatre or having their dressings changed
  • during the subacute and chronic phases, oral analgesics are commonly used to ensure patients can actively participate in treatment

Post-burn Pruritus[edit | edit source]

Post-burn pruritus (itching sensations on or around the burn, graft, or donor site) is a common issue after burn injury, affecting up to 93% of individuals by the day of their discharge.[8] It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.[9]

Please note that the use of restraints to prevent a patient from itching are considered an absolute last resort. Depending on your location, the use of restraints may require specific medical orders that need to be regularly reviewed. Other options to try first include:

  • extra layers of fluffy bandages to protect the primary dressings (but it is essential to ensure that proper air exchange can occur)
  • gloves (with fingers) or mitts (without figures)

Current treatments for post-burn pruritus have not been found to have clinically significant benefits, so further research on post-burn pruritus management is required.[8] Treatments include:[10]

  • topical treatments
  • systemic treatments, such as antihistamines, opioid receptor agonists or antagonists, gabapentin or pregabalin, antidepressants, etc
  • extracorporeal shockwave therapy (ESWT)
  • pressure therapy
  • massage therapy
  • education
  • cold compresses in the subacute phase[1]
  • moisturisers[7]

For more information on post-burn pruritus, please see: Burn Wound Injury Special Concern: Post-burn Pruritus

Persistent / Chronic Pain[edit | edit source]

Some individuals after a burn injury will develop chronic or persistent pain, affecting quality of life, sleep, increasing morbidity and decreasing functional recovery. Chronic neuropathic pain after burn injury has a reported prevalence of 7.3% to 18%.[11] It develops as a result of partial or complete peripheral nerve injuries.[11] Individuals with burn injuries may develop hyperalgesia or allodynia. There is a strong correlation between the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed.[12]

Treatments for persistent pain following a burn injury might include:[1]

  • analgesics
  • antidepressants
  • anticonvulsants
  • regional nerve block
  • cognitive behavioural therapy
Alternative Pain Management Techniques for Burn Injuries[edit | edit source]

Romanowski et al. recommend "that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen".[3]

There are four broad categories of nonpharmacological techniques:[3]

  1. cognitive-behavioral therapy (CBT)
    • "most effective when decatastrophizing and reinterpreting pain signals were targeted"[3]
  2. hypnosis
    • can be used to help manage procedural pain and anxiety
    • "most effective when the affective component of pain was targeted in posthypnotic suggestions and for patients who had high pain"
  3. distraction
    • i.e. redirecting the patient's attention from the pain sensation
    • virtual reality has the most robust evidence
      • the patient is immersed in a virtual world
      • patients who "feel more “present” in the virtual world have lower pain scores during wound care and physiotherapy"[3]
      • patients using virtual reality can have lower pain scores during dressing changes[13][14]
  4. relaxation (breathing, music,[15] stress inoculation, aromatherapy, massage)

Rehabilitation strategies to help with pain, post-burn pruritus and altered sensation include:[7]

  • education, reassurance, distraction
  • splinting
  • exercise
  • massage
  • sensory re-education / desensitisation

Sleep normalisation also plays a role in pain management:

  • a night of poor sleep predicts increased pain and greater analgesia use the next day
  • increased pain during the day predicts poor sleep quality that night[16]

Oedema Management for Individuals with Burn Injuries[edit | edit source]

Burn injuries induce oedema.[17] Two interventions for oedema management in burn injuries include elevation and compression.

Whenever implementing interventions for burn injuries, remember that all post-operative, consultant and multidisciplinary team advice must be followed.[17] Care must be taken to reduce the risk of skin breakdown and contracture development, and all indications and contraindications must be considered.

Elevation[edit | edit source]

In order to decrease oedema, a limb should ideally be elevated above the level of the heart.[18] Sometimes, this may not be possible due to pain and discomfort or lack of range of motion. In these cases, it is important to raise the limb as high as possible through positioning and other adjuncts, such as pillows, towels, splints and slings.[17][2][19]

Patients with severe burns that cover a large Total Body Surface Area (TBSA) are at risk of systematic inflammation. In these cases, the following precautions should be considered:[20]

  • elevate the head: in the case of anterior neck burns, do not place a pillow under the head, as this can cause a contracture to develop
  • elevate all affected limbs
  • maintain the feet at 90 degrees
  • maintain the hips in a neutral position
  • monitor for pressure sores
Compression[edit | edit source]

Compression is commonly used to help manage oedema in burn injuries:[21]

  • pressure garment therapy (discussed below) has been shown to be beneficial in burn injures[20] - it can be used for both oedema and scar management, depending on the age of the burn and the initial depth of injury
  • coban wrap is often used for burn injuries of the hand and is useful in the acute stage of a burn injury because it does not stick to the underlying tissue[22]

For more information on Coban wraps, please see: Burns and Plastic Surgery Occupational Therapy.

Scar Management for Individuals with Burn Injuries[edit | edit source]

Hypertrophic scarring is a common complication in burn injuries, affecting up to 70% of patients.[23] Hypertrophic scars are visible, elevated scars. Unlike keloid scars, they do not spread into surrounding tissues, and they often regress spontaneously.[24] Hypertrophic scars can have a significant impact on an individual with burn injuries, potentially causing:[25][26][27]

  • pain
  • pruritus
  • reduced range of motion (particularly when they occur on or near a joint)
  • psychosocial / psychological effects
  • cosmetic effects
  • altered self-image

Scar Outcome Measures[edit | edit source]

Vancouver Burn Scar Scale (VBSS/VSS):

  • assesses vascularity, height, pliability, and pigmentation of the scar
  • does not measure a patient's subjective assessment of the scar, such as pain, itching, functional or psychological impact[28]
  • for more information, please see: Burns Scar Index (Vancouver Scar Scale)

Patient and Observer Scar Assessment Scale (POSAS):

  • measures pigmentation, vascularity, thickness, relief, pliability and surface area, as well as pain, itching, colour, stiffness, thickness and relief
  • for more information, please see: About POSAS

Management Options for Hypertrophic Scars[edit | edit source]

The following sections discuss approaches used to help manage hypertrophic scars, such as silicone, compression / pressure garment therapy (PGT) and massage. Other treatments include:

Silicone[edit | edit source]

Silicone can be applied in the form of a gel or sheeting. While some randomised controlled trials have found that topical silicone gel can be effective in preventing post-operative scarring,[32] a 2020 Cochrane review notes "there is currently limited rigorous RCT [randomised controlled trial] evidence available about the clinical effectiveness of SGS [silicone gel sheeting] in the treatment of hypertrophic scars"[33] and further research is required.[33] Nischwitz et al.[25] note that silicone gel appears to be mainly beneficial for post-burn pruritus and pain.[25] Some important clinical points:

  • silicone gels tend to be easier to apply than sheets and can also be used on more areas of the body[2]
  • silicone gel sheets can be washed and reused, which reduces the financial burden on the patient[34]

For more information on silicone products, including procedures for sheet silicone, precautions and considerations, please see page 18 of Burn Physiotherapy and Occupational Therapy Guidelines.

Pressure Garment Therapy (PGT)[edit | edit source]

Compression therapy aims to "keep developing scars flat and prevent raised scarring [...]. The type of compression used depends on wound healing, area of body affected, time since healing and individual patient needs."[17]

Compression can be achieved in different ways, such as pressure garments (off-the-shelf or customised), cohesive flexible bandages, tubular elasticised stockings and bandaging.[17]

Pressure garment therapy (PGT) is widely used in the management of hypertrophic scars.[20] There have been a number of studies on pressure garment therapy, but they often have different outcomes and may contradict each other.[35] Some recent research suggests:

  • there is "sufficient evidence to support the prophylactic and curative use of pressure therapy for scar management"[36]
  • PGT can help improve a scar's colour, thickness and quality and reduce pain[36]
  • De Decker et al.[36] recommend that PGT should be started sooner than two months post-burn, but ideally as early as possible
  • the wound must have closed and be stable enough to tolerate pressure before starting PGT (always check with the surgeon)[2]
  • PGT should be worn while the scar remains active[17]
  • De Decker et al.[36] PGT should continue for at least 12 months, preferably for up to 18-24 months[36]
  • recommended pressures for PGT vary
    • De Decker et al.[36] recommend minimal pressures of around 20-25 mmHg
    • Shirakami et al.[37] recommend that pressure should be between 20-30 mmHg (above capillary pressure)
    • please note that pressures exceeding 30-40 mmHg can have adverse effects (again figures given in the literature vary)[37][2]
  • it is typically recommended that pressure garments be worn at all times apart from showering or bathing, massage and moisturising (i.e. around 23 hours every day)[17]
  • adherence can be an issue for pressure garment therapy - it can be uncomfortable to wear the garment, especially in warm weather, and it can cause overheating, wound breakdown and itching[38]

How does pressure garment therapy work?[20]

Applying pressure to a burn injury is believed to reduce scarring by "hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars."[20] It potentially creates localised hypoxia to the scar, thus reducing blood flow to hyper-vascular scars. This reduces the influx of collagen and decreases scar formation.

Pressure garment therapy is believed to help:[20]

  • reduce scar thickness
  • reduce redness
  • decrease swelling
  • reduce post-burn pruritus
  • improve the protection of healed skin grafts
  • maintain contours and prevent contractures

[39]

Pressure Garment Care

It is important to educate patients on how to look after their pressure garments.

Two sets of garments are recommended for hygiene purposes (one in the wash and one being worn).[17]

  • Washing instructions:[40][41]
    • hand wash:
      • soak pressure garment in cool water and mild soap
      • rinse well with clean, cool water
      • roll the garment in a towel to soak up excess water
    • machine wash:
      • use a mild soap or detergent
      • wash with cool water on a gentle / delicate cycle
  • Drying instructions:[40][41]
    • air-dry only: pressure garments cannot be placed in a heated dryer as this will destroy their elasticity and compression ability
    • do not put the garment in sunlight or in front of a heater

Pressure garments need to be re-tensioned or remeasured and replaced every three to six months, depending on the level of wear and tear.[17]

For more information on compression and pressure garment therapy, including procedures, precautions and contraindications, please see pages 14-17 of Burn Physiotherapy and Occupational Therapy Guidelines.

Scar Massage[edit | edit source]

Scar massage is routinely used in many burn rehabilitation units around the world. Reported clinical benefits include:[42]

  • improved pliability and range of motion of the scar
  • reduced pain and skin sensitivity
  • reduced post-burn pruritus
  • decreased anxiety
  • changes in scar characteristics and reduction in scar thickness

Recent research suggests:

  • there is low-to-moderate quality evidence that massage can reduce pain and the intensity of post-burn scar pruritus[43]
  • there is low-to-moderate quality evidence that massage has "negligible or unclear effects for improving scar elasticity and vascularisation"[43]
  • another review by Barnes et al.[44] found that scar massage can help with symptoms associated with hypertrophic burn scars, even when different massage techniques are used
    • when used together, friction and oscillation can improve scar function
    • longer sessions of effleurage and petrissage can help with scar visibility and pain
    • each massage technique helped with scar pruritus
    • "massage techniques should be tailored to the patients’ symptoms"
  • further research is required[45][44]

Massage treatment considerations:

  • there is insufficient evidence to determine protocols on the frequency or duration of treatment
  • clean hands are essential
  • use a lubricant or lotion that is free of irritants  
  • clinicians must adapt treatment based on the patient's stage of healing, sensitivity and pain levels

Massage contraindications:[2][46]

  • open wound
  • acute infection
  • bleeding
  • graft failure
  • intolerable discomfort
  • hypersensitivity to emollient

[47]

For more information on massage, including procedures, precautions and considerations, please see page 20 of Burn Physiotherapy and Occupational Therapy Guidelines.

Surgical Management for Individuals with Burn Injuries[edit | edit source]

“In deep partial thickness and full thickness burns, the entire epidermis and much of the dermis is lost, dramatically limiting the ability to heal spontaneously.”[48] These burns require surgical intervention to remove devitalised tissue and to promote regeneration by providing the injured skin with a new source of epidermis.[48]

Since the 1970s, the acute management of burn injuries has included early excision and grafting, it is the current standard of care for burn wound injuries. This approach has led to improved survival rates and decreased length of hospital stay.[49]

Early Excision[edit | edit source]

Early excision is considered the gold-standard treatment:[49]

  • there is debate over the optimal timing for early excision
  • surgery aims to ensure there is no full-thickness necrotic tissue with debridement down to viable tissue

Skin Grafts[edit | edit source]

A skin graft is an area of skin that is moved from one area of the body to another area.

Early autografting (i.e. transplanting skin from a healthy donor site to the burned area) rapidly closes excised wounds, which reduces infection risk and pain and facilitates earlier mobilisation. Allografting (i.e. using skin from another person) is used to temporarily cover debrided tissue when:[49]

  • there are issues with the viability or bacterial load of the wound bed
  • the patient is not sufficiently medically stable

Autologous split-thickness skin grafts are the gold standard management approach for deep partial and full-thickness acute burns.[48][49] Autologous skin grafts can be split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs).[50]

Split-thickness skin grafts (STSG):[50]

  • most commonly used for wound coverage
  • include the epidermis and the upper layer of the dermis
  • are beneficial when patients have extensive TBSA burns, as the same donor sites can be re-harvested after one to two weeks (this can, however, lead to hypopigmentation)
  • mesh grafts can increase the total surface area of the mesh, but can result in significant scarring[49]
    • mesh grafts are processed to "punch" holes or apertures into the graft; this increases its size, allows topical agents through the graft and serous fluid or blood out
    • STSGs are often meshed and expanded for burns of more than 30-40%TBSA
    • meshed grafts are more commonly used for the back, trunk, legs and arms
  • sheet grafts (i.e. “donor sites that are excised and used as-is”) are used for more cosmetic areas, such as the face, hands and neck[49]

For more information on STSGs, please see: Burn injury.[49]

Full-thickness skin grafts (FTSG):[50]

  • the epidermis and the dermis to the underlying fat layer are harvested using a scalpel
  • associated with decreased scar and contracture formation, so they are useful in areas of cosmetic importance and across joints
  • however, they lead to full-thickness wounds at the donor site; these must be closed primarily or have reconstructive flap closure
  • have a higher failure rate

The following short, optional video shows the skin graft procedure.

[51]

Graft Failure[edit | edit source]

A graft should be stable within five days. It should be placed over bleeding, healthy tissue to ensure adequate vascularity.[2]

Post-operatively, the graft site will be dressed with sufficient pressure to limit haematoma formation but without causing damage to the delicate tissue. It is essential to consider the dressing pressure needed for successful graft stability and healing. Too much pressure can cause damage to the fragile tissue and a newly placed skin graft to fail.

The area should be immobilised in an “anti-deformity” position to prevent shearing forces that might disrupt the graft. Areas that are highly mobile, such as the hand, might require splinting to ensure immobility.[2]

Skin grafts are more likely to fail if:[49]

  • excision of the recipient site is insufficient
  • there is shear stress
  • there is wound infection

Other causes of graft failure include:[2]

  • inadequate blood supply to the wound bed
  • collection of fluid beneath the graft (e.g. haematoma)
  • the properties of the donor site (e.g. level of vascularity)
Skin Substitutes[edit | edit source]

If the excised area requires more skin than is available, temporary skin cover is required. There are many types of skin substitutes (biomaterial and engineered tissue grafts).[48][49]

If you would like more information on skin substitutes, please see:

There are differences in how a newly placed graft is managed versus a healed graft. You will need to consult with the surgeon and medical team for specific management protocols.

Skin Flaps[edit | edit source]

Skin flaps are also used in patients with burn injuries. Unlike skin grafts which are vascularised by the recipient site, a skin flap has its own vasculature (i.e. it brings its own blood supply from the donor site).[2]

Skin flaps might be used on areas such as:[2]

  • bone without periosteum
  • tendon without paratenon
  • cartilage without perichondrium

The following optional video explains more about skin flaps and shows different types of flap surgery. You can only view this video on YouTube.

[52]

Reconstruction Surgery[edit | edit source]

“Overall survival of the skin graft is important, but cosmetic outcomes and body image cannot be ignored when treating burn patients.”[50]

Burn scars that develop after skin grafting and can lead to:[50]

  • anxiety
  • depression
  • pain
  • itching
  • altered pigmentation
  • temperature intolerance
  • decreased range of motion (from contractures)

Surgical scar revision is “the standard of care” for individuals with burn injuries who develop contractures or who have poor cosmetic outcomes. Around 5-20% of individuals with burn injuries go on to have reconstructive surgery.[53] Surgical scar revision can involve skin substitutes, laser therapy, flaps, biomaterials, etc.[50]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Norman AT, Judkins KC. Pain in the patient with burns. Continuing Education in Anaesthesia, Critical Care & Pain. 2004 Apr 1;4(2):57-61.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. Physiotherapy in Burns, Plastics and Reconstructive Surgery, 2013.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, et al. American Burn Association Guidelines on the management of acute pain in the adult burn patient: a review of the literature, a compilation of expert opinion and next steps. J Burn Care Res. 2020 Nov 30;41(6):1152-1164.
  4. ↑ 4.0 4.1 4.2 4.3 Stapelberg F. Challenges in anaesthesia and pain management for burn injuries. Anaesth Intensive Care. 2020 Mar;48(2):101-113.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Emery MA, Eitan S. Drug-specific differences in the ability of opioids to manage burn pain. Burns. 2020 May;46(3):503-513.
  6. ↑ 6.0 6.1 6.2 6.3 McGovern C, Puxty K, Paton L. Major burns: part 2. Anaesthesia, intensive care and pain management. BJA Educ. 2022 Apr;22(4):138-45.
  7. ↑ 7.0 7.1 7.2 7.3 Whitaker IS, Shokrollahi K, Dickson WA. Burns. Oxford: OUP Oxford, 2019.
  8. ↑ 8.0 8.1 Andrade LF, Abdi P, Kooner A, Eldaboush AM, Dhami RK, Natarelli N, Yosipovitch G. Treatment of post-burn pruritus - A systematic review and meta-analysis. Burns. 2024 Mar;50(2):293-301.
  9. ↑ Beecher SM, Hill R, Kearney L, Dorairaj J, Kumar A, Clover AJ. The pruritus severity scale-a novel tool to assess itch in burns patients. Int J Burns Trauma. 2021 Jun 15;11(3):156-62.
  10. ↑ Chung BY, Kim HB, Jung MJ, Kang SY, Kwak IS, Park CW, Kim HO. Post-burn pruritus. Int J Mol Sci. 2020 May 29;21(11):3880.
  11. ↑ 11.0 11.1 Klifto KM, Dellon AL, Hultman CS. Prevalence and associated predictors for patients developing chronic neuropathic pain following burns. Burns Trauma. 2020 May 1;8:tkaa011.
  12. ↑ Braza ME, Fahrenkopf MP. Split-thickness skin grafts. 2019.
  13. ↑ de Jesus Catalã CA, Pan R, Rossetto Kron-Rodrigues M, de Oliveira Freitas N. Virtual reality therapy to control burn pain: systematic review of randomized controlled trials. Journal of Burn Care & Research. 2022 Jul;43(4):880-8.
  14. ↑ Mott J, Bucolo S, Cuttle L, Mill J, Hilder M, Miller K, Kimble RM. The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns. 2008 Sep 1;34(6):803-8.
  15. ↑ Monsalve-Duarte S, Betancourt-Zapata W, Suarez-Cañon N, Maya R, Salgado-Vasco A, Prieto-Garces S, Marín-Sánchez J, Gómez-Ortega V, Valderrama M, Ettenberger M. Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis. Burns. 2021 Nov 16.
  16. ↑ Rampes S, Ma K, Divecha YA, Alam A, Ma D. Postoperative sleep disorders and their potential impacts on surgical outcomes. J Biomed Res. 2019 Aug 29;34(4):271-280.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17.7 17.8 Agency for Clinical Innovation. Statewide Burn Injury Service. Burn physiotherapy and occupational therapy guidelines, 2017. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-occupational-therapy-guidelines.pdf [accessed 12 April 2024].
  18. ↑ Tuca AC, Winter R, Kamolz LP. Acute Burn Surgery. InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.
  19. ↑ The Royal Children's Hospital Melbourne. Burns. Available from: https://www.rch.org.au/trauma-service/manual/Burns/ (last accessed 12 April 2024).
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 Procter F. Rehabilitation of the burn patient. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India. 2010 Sep;43(Suppl):S101.
  21. ↑ Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023 May;49(3):516-53.
  22. ↑ Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. Physiotherapy in Burns, Plastics and Reconstructive Surgery, 2013.
  23. ↑ Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. Hypertrophic scarring: the greatest unmet challenge after burn injury. Lancet. 2016 Oct 1;388(10052):1427-36.
  24. ↑ Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics. 2014;69:565-73.
  25. ↑ 25.0 25.1 25.2 25.3 25.4 Nischwitz SP, Rauch K, Luze H, Hofmann E, Draschl A, Kotzbeck P, Kamolz LP. Evidence-based therapy in hypertrophic scars: An update of a systematic review. Wound Repair Regen. 2020 Sep;28(5):656-65.
  26. ↑ Morien A, Garrison D, Smith NK. Range of motion improves after massage in children with burns: a pilot study. Journal of bodywork and movement therapies. 2008 Jan 1;12(1):67-71.
  27. ↑ Polotto S. Use of silicone dressings in post-burn hypertrophic scar therapy: a systematic review. Capsula Eburnea. 2011 Dec 1;6.
  28. ↑ Park JW, Koh YG, Shin SH, Choi Y, Kim W, Yoo HH, et al. Review of scar assessment scales. Medical Lasers. 2022;11:1-7.
  29. ↑ Choi C, Mukovozov I, Jazdarehee A, Rai R, Sachdeva M, Shunmugam M, et al. Management of hypertrophic scars in adults: A systematic review and meta-analysis. Australas J Dermatol. 2022 May;63(2):172-89.
  30. ↑ Klifto KM, Asif M, Hultman CS. Laser management of hypertrophic burn scars: a comprehensive review. Burns Trauma. 2020 Jan 16;8:tkz002.
  31. ↑ Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. Burns Trauma. 2020 Jan 27;8:tkz003.
  32. ↑ Wang F, Li X, Wang X, Jiang X. Efficacy of topical silicone gel in scar management: A systematic review and meta-analysis of randomised controlled trials. Int Wound J. 2020 Jun;17(3):765-73.
  33. ↑ 33.0 33.1 Jiang Q, Chen J, Tian F, Liu Z. Silicone gel sheeting for treating hypertrophic scars. Cochrane Database Syst Rev. 2021 Sep 26;9(9):CD013357.
  34. ↑ McCarty M. An evaluation of evidence regarding application of silicone gel sheeting for the management of hypertrophic scars and keloids. The Journal of clinical and aesthetic dermatology. 2010 Nov;3(11):39.
  35. ↑ Merwarth D. Burn Wound Healing and Recovery Care Course. Plus, 2024.
  36. ↑ 36.0 36.1 36.2 36.3 36.4 36.5 De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, et al. Pressure therapy for scars: Myth or reality? A systematic review. Burns. 2023 Jun;49(4):741-56.
  37. ↑ 37.0 37.1 Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. Burns Trauma. 2020 Jan 27;8:tkz003.
  38. ↑ Moiemen N, Mathers J, Jones L, et al. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jun. (Health Technology Assessment, No. 22.36.) Chapter 1, Introduction and background.Available from: https://www.ncbi.nlm.nih.gov/books/NBK507759/
  39. ↑ Occupational Therapy UiTM. Pressure Garment Therapy. Available from: https://www.youtube.com/watch?v=UCq9JreucIM [last accessed 31/3/2024]
  40. ↑ 40.0 40.1 Nationwide Children's. Burns: Wearing a Pressure Garment. Available from: https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/burns-wearing-a-pressure-garment (last accessed 11 April 2024).
  41. ↑ 41.0 41.1 Chelsea and Westminster Hospital. NHS Foundation Trust. Pressure garments. Available from: https://www.chelwest.nhs.uk/your-visit/patient-leaflets/burns/pressure-garments (last accessed 11 April 2024).
  42. ↑ Ault P, Plaza A, Paratz J. Scar massage for hypertrophic burns scarring-A systematic review. Burns. 2018 Feb;44(1):24-38.
  43. ↑ 43.0 43.1 Santuzzi CH, Gonçalves Liberato FM, Fachini de Oliveira NF, Sgrancio do Nascimento A, Nascimento LR. Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review. J Physiother. 2024 Jan;70(1):8-15.
  44. ↑ 44.0 44.1 Barnes SP, Ma Y, Patel B, Muthayya P. Efficacy of massage techniques for hypertrophic burn scars - a systematic review of literature. J Burn Care Res. 2024 Mar 4;45(2):356-65.
  45. ↑ Lin TR, Chou FH, Wang HH, Wang RH. Effects of scar massage on burn scars: A systematic review and meta-analysis. J Clin Nurs. 2023 Jul;32(13-14):3144-54.
  46. ↑ Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Dermatologic Surgery. 2012 Mar;38(3):414-23.
  47. ↑ Children's Burns Trust. Scar massage after a burn injury - Children's Burns Trust. Available from: https://www.youtube.com/watch?v=hmTLWVBIoBo [last accessed 31/3/2024]
  48. ↑ 48.0 48.1 48.2 48.3 48.4 Palackic A, Duggan RP, Campbell MS, Walters E, Branski LK, Ayadi AE, Wolf SE. The role of skin substitutes in acute burn and reconstructive burn surgery: an updated comprehensive review. Semin Plast Surg. 2022 Apr 12;36(1):33-42.
  49. ↑ 49.0 49.1 49.2 49.3 49.4 49.5 49.6 49.7 49.8 49.9 Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020 Feb 13;6(1):11.
  50. ↑ 50.0 50.1 50.2 50.3 50.4 50.5 Anyanwu JA, Cindass R. Burn Debridement, Grafting, and Reconstruction. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551717/
  51. ↑ MotionLit. Skin Graft Procedure - Flash Fire Injury. Available from: http://www.youtube.com/watch?v=er9YxF_C60A [last accessed 1/4/2024]
  52. ↑ K's Surgery. SKIN FLAP LIVE SURGERY [PLASTIC AND RECONSTRUCTIVE SURGERY]. Available from: http://www.youtube.com/watch?v=T5LOCl0JYbY [last accessed 1/4/2024]
  53. ↑ van Baar ME. Epidemiology of scars and their consequences: burn scars. Textbook on Scar Management: State of the Art Management and Emerging Technologies. 2020:37-43.
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