Burn Injury Management Considerations for Rehabilitation Professionals: Difference between revisions
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Treatment involves the following:<ref name=":2" /> | Treatment involves the following:<ref name=":2" /> | ||
* Antidepressants | * Antidepressants | ||
* Anticonvulsants | * Anticonvulsants | ||
* Regional nerve block | * Regional nerve block | ||
* Cognitive behavioural therapy | * Cognitive behavioural therapy | ||
Judkins KC. Pain management in the burned patient. Pain Rev 1998; 5: 133--46 | Judkins KC. Pain management in the burned patient. Pain Rev 1998; 5: 133--46 | ||
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== 3. Management of the Scar == | == 3. Management of the Scar == | ||
Scarring is a common complication following a severe burn wound and affects approximately 70% of patients.<ref>Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. T[https://www.sciencedirect.com/science/article/abs/pii/S1748681507006535 he effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis.] Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009 Jan 1;62(1):77-84.</ref> Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that 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> The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause: <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> | Scarring is a common complication following a severe burn wound and affects approximately 70% of patients.<ref name=":3">Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. T[https://www.sciencedirect.com/science/article/abs/pii/S1748681507006535 he effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis.] Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009 Jan 1;62(1):77-84.</ref> Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that 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> The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause: <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> | ||
* Self image difficulties due to cosmetic changes | * Self image difficulties due to cosmetic changes | ||
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# '''Vancouver Burn Scar Scale (VBSS/VSS)''' | # '''Vancouver Burn Scar Scale (VBSS/VSS)''' | ||
##<u>Aim:</u> Assessment of the scar in 4 categories: 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) | ##<u>Aim:</u> Assessment of the scar in 4 categories: 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)]] | ## <u>Method</u>: [[Burns Scar Index (Vancouver Scar Scale)]] | ||
# '''Patient and Observer Scar Assessment Scale (POSAS)''' | # '''Patient and Observer Scar Assessment Scale (POSAS)''' | ||
## <u>Aim:</u> Assessment of the scar from the patient and the observers perspective | ## <u>Aim:</u> Assessment of the scar from the patient and the observers perspective | ||
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==== Management Options ==== | ==== Management Options ==== | ||
When working with Burns scars, there are three common options selected for the most effective treatment. | When working with Burns scars, there are three common options selected for the most effective treatment. | ||
# '''Silicone''' | # '''Silicone''' | ||
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===== '''<u>1. Silicone</u>''' ===== | ===== '''<u>1. Silicone</u>''' ===== | ||
Silicone can be used in the form of a gel or sheeting. Using silicone in the treatment of hypertrophic scars is relatively new, beginning around 1981<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>. There is not much evidence to support the use of silicone to treat scars, but it does appear to common practice in many areas around the world. Often, practitioners prefer using the gel form as it has an easier application, more adaptable to different body parts and appears to have a higher patient compliance.<ref name=":4">Bloemen MC, van der Veer WM, Ulrich MM, van Zuijlen PP, Niessen FB, Middelkoop E. [https://www.sciencedirect.com/science/article/abs/pii/S0305417908002568 Prevention and curative management of hypertrophic scar formation.] Burns. 2009 Jun 1;35(4):463-75.</ref> Silicone gel sheets can be washed and reused, limiting financial burden to the patient over the 2- to 3-month treatment course.<ref name=":0" /> | |||
'''Physiological Effects of Silicone:''' | |||
# 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<ref name=":0" /> simulate the physiological skin barrier and decrease transepidermal water loss<ref name=":0" /> | |||
# Increase in temperature: | |||
#* A rise in temperature increases collagenase activity thus increased scar breakdown. | |||
# 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<ref name=":0" /> | # Polarized Electric Fields: | ||
#* The negative charge within silicone causes polarization of the scar tissue, resulting in involution of the scar. | |||
# Increase in temperature: A rise in temperature increases collagenase activity thus increased scar breakdown. | # Presence of silicone oil: | ||
# Polarized Electric Fields: The negative charge within silicone causes polarization of the scar tissue, resulting in involution of the scar. | #* 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. | ||
# 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. | # Oxygen tension: | ||
# 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. | #* 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. | ||
# 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) | # 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) | |||
===== '''<u>2. Pressure Garment Therapy (PGT)</u>''' ===== | ===== '''<u>2. Pressure Garment Therapy (PGT)</u>''' ===== | ||
There is no recent evidence supporting pressure garment therapy, but it is common practice among therapists in many areas of the world. It is a commonly used technique to reduce oedema and manage hypertrophic scars. <ref name=":1" /> It is generally advise to maintain a pressure of 15 mmHg. Pressure exceeding 40mmHg can cause complications.<ref>Engrav LH, Heimbach DM, Rivara FP, Moore ML, Wang J, Carrougher GJ, Costa B, Numhom S, Calderon J, Gibran NS. [https://www.sciencedirect.com/science/article/abs/pii/S0305417910001129 12-Year within-wound study of the effectiveness of custom pressure garment therapy.] burns. 2010 Nov 1;36(7):975-83.</ref><ref name=":3" /> . Once the wound has closed and the wound can tolerate pressure, usually approximately 14 days post graft, the patient is advised to wear the garment as much as possible, and to only remove it for around one hour per day.<ref name=":1" /><ref name=":3" /> <ref name=":4" /> | |||
'''Aims:''' <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> | |||
# The increased pressure will decrease blood flow to hyper vascular scars. | |||
# Decrease collagen deposits | |||
## Reduces thickness of scar | |||
## Reduces red colouration of scar | |||
## Decreases swelling | |||
## Lessens pruritus | |||
## Offers some protection of new skin/grafts | |||
## Maintains normal body contours | |||
Physiological effects:<ref>Macintyre L, Baird M. [https://www.sciencedirect.com/science/article/abs/pii/S0305417905003463 Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use.] Burns. 2006 Feb 1;32(1):10-5.</ref> | |||
# 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. | # 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. |
Revision as of 14:47, 4 October 2022
Top Contributors - Jess Bell, Carin Hunter, Kim Jackson, Stacy Schiurring and Robin Tacchetti
Introduction[edit | edit source]
When managing a patient with a burn, there are four main categories to consider:
- Pain
- Oedema
- Scar
- Reconstruction
1. Management of Burn Pain[edit | edit source]
There are many factors to consider when when treating burn pain. Initially, the clinician should understand the cause of the current pain. Pain can be controlled either with standard pharmacological management strategies or with alternative methods.
Initially the acute pain experienced is due to the burning tissues. The burn should be cooled with tepid water, not ice water as ice water can cause further damage to the affected area. Tepid water helps to end the burning and decrease the pain experienced. The clinician should always be aware that cooling the burn combined with the evaporation of oedema fluid can lead to hypothermia. Due to this, the patient should be given a blanket or alternative source of warmth to prevent hypothermia.
Once hospitalised, there are four main pain contributing factors which should be considered by the clinicians. These being:
- Pain associated with procedures
- Surgery
- Dressing Changes and Wound Cleaning
- Movement Therapy
- Resting pain
- Itching or Pruritus
- Chronic pain
1. Pain Associated with Procedures[edit | edit source]
This type of pain short in duration but of a high intensity. Every time a patient undergoes a procedure new painful stimulus is applied to the patient which can trigger the stress response. [1] General anaesthesia can be used for any major or prolonged procedures. The majority of smaller procedures are predictable in their timing, and analgesics should be administered as a preventative measure. Pain can often interfere with sleep which is important to the healing process. Pain associated with procedures can also affect the rapport and trust of the patient with the clinician which can pose a barrier to trust of the clinician.
Surgery[edit | edit source]
The donor site, comprising of large, open, raw areas can be managed with a local anaesthetic gel applied after surgery before applying the dressings.
Initially, the post operative pain is managed with opioids. These can be given transdermally, orally, intramuscularly or intravenously. The least common method of administration is intramuscularly as there are often complications associated (extent of dressings, surgical site and unpredictable absorption). Sometimes NSAIDs or a nerve block can be used in the management.
Some clinics make use of patient-controlled analgesia (PCA). While this can be effective, the patient needs to have a good level of understanding, be adequately responsive and not have hand complications.
Dressings Changes and Wound Cleaning[edit | edit source]
The biggest problem with pain management of a burn patient is addressing the dressing changes and wound care aspect of the injury. A deep, large burn can take up to 2 hours to dress, often with some debridement or staple removal necessary. Sometimes it is in the patients best interest to sedate them for these procedures. Smaller dressing changes can be managed by administering analgesia before the wound dressing begins.
It is advised to reduce the amount of procedures, in paediatric patients especially. One way of achieving this is to use the most appropriate dressings available. A synthetic temporary skin substitute could be left in place until healthy skin has formed, thus reducing distress and infection risk and also allowing early mobilization.[1]
Movement Therapy[edit | edit source]
Physiotherapy and Occupational Therapy are common interventions received in a Primary Healthcare setting and they play and important role in rehabilitation. Moving the damaged area can cause an increase in pain and therefor the stress response, but as both treatments are flexible as to time of day, they can be times for after pain relief has been administered. In the subacute and chronic phase, oral analgesics are used as the patient needs to be aware enough to actively participate in the treatment if possible. Both professions have been known to visit the theatre and perform passive range of motion exercises or create splints, while the patient is under general anaesthetic in the acute phase.
2. Resting Pain[edit | edit source]
This type of pain is usually low intensity but longer duration. Patients often describe their general state as 'low-grade persistent discomfort". This is often managed by using NSAIDs in combination with a low-dose opioid. This is managed by the physician or burns nurse. The patient is managed by regularly dosing the patient to prevent breakthrough pain.
3. Itching[edit | edit source]
As itching, or pruritus, is a common side effect of healing, it can be difficult to understand. But if the patient is reacting by scratching, they could cause damage to forming skin. Treatment may involve a combination of antihistamines and NSAIDs. alternatively a cold compress could help the symptoms in a subacute phase.
4. Chronic Pain[edit | edit source]
Chronic pain, in a burn injury, is often due to damaged or regenerating nerve fibres. The patient often suffers from hyperalgesia (Increased response to a painful stimulus) and allodynia (Painful response to a non-painful stimulus). This can often affects the patients sleeping and result in depressive symptoms and cause barriers to rehabilitation. There is a strong correlation with the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed. [2]
Treatment involves the following:[1]
- Antidepressants
- Anticonvulsants
- Regional nerve block
- Cognitive behavioural therapy
Judkins KC. Pain management in the burned patient. Pain Rev 1998; 5: 133--46
Kidd BL, Urban LA. Mechanisms of inflammatory pain. Br J Anaesth 2001; 87: 3--11
MalenfantA, ForgetR, Papillon J,AmselR, Frigon J, ChoiniereM. Prevalence and characteristics of chronic sensory problemsin burn patients. Pain 1996; 67: 493--500
Pal KS, Cortiella J, Herndon D. Adjunctive methods of pain control in burns. Burns 1997; 23: 404--12
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
Alternative Pain Management Techniques:[edit | edit source]
Alternative pain management techniques entail:
- Psychological techniques can reduce fear and anxiety associated with activities or environments
- Relaxation
- Distraction[3]
- Cognitive Behavioural Therapy
- Hypnosis can be used in the management of procedural pain and anxiety
- Virtual Reality can lower pain scores when undergoing dressing changes [4][5]
- Immersing the patient in a virtual world
- Hand-held gaming devices
- Sleep Normalisation with a bedtime routine
- To promote sleep
- Makes use of analgesics and night sedation
- Music therapy can target pain via the gate control theory[6]
- distraction from noxious stimuli
- Uses imagery[7], self-statements and attention-diversion
2. Management of Oedema[edit | edit source]
When oedema occurs in the acute phase of a burn wound, there are two commonly used options for management, these being elevation and compression.
Elevation[edit | edit source]
When elevating a limb to assist with decreasing oedema, we should aspire to elevate the part above the level of the heart. This means that gravity will assist the removal of oedema[8] . Sometimes this is not always possible due to pain and discomfort. Raise the limb as high as possible. A sling can be used to facilitate elevation. An added benefit of using a sling is it will protect the burn site while allowing a degree of movement. This means the blood flow can be actively increased.
If a patient is experiencing systemic inflammation, which can be common with large, severe burns, consider the following precautions:[9]
- Elevate the head. In the case of an anterior neck burn, do not place a pillow under the head as it could cause a contracture to develop.
- Elevate all affected limbs
- Maintain feet in neutral
- Maintain hips in a neutral position
- Monitor constantly for pressure sores
Compression[edit | edit source]
There is little evidence supporting using compression as a form of oedema relief, but it is commonly used and many therapists will advocate for this technique. When using a wrap or sleeve, make sure the material is self adhesive and will not stick to the tissue below as this could severely impact the healing process. There is evidence that a wrap can decrease oedema, improve dexterity, range of motion and grip strength in hands[10].
Burns and Plastic Surgery Occupational Therapy
3. Management of the Scar[edit | edit source]
Scarring is a common complication following a severe burn wound and affects approximately 70% of patients.[11] Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously.[12] The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause: [13][14]
- Self image difficulties due to cosmetic changes
- Pain
- Itchiness
- Limited range of motion, particularly where they occur on or near a joint
A hypertrophic scar requires treatment from the early stages in hospital, and this can continue with dedicated and specialised treatment many years post injury. [9] When managing a scar passively with pressure garment therapy and massage, it is important to remember continue with correct positioning, massage and mobilisations.
Scar Outcome Measures[edit | edit source]
- Vancouver Burn Scar Scale (VBSS/VSS)
- Aim: Assessment of the scar in 4 categories: 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)
- Aim: Assessment of the scar from the patient and the observers perspective
- Method: About POSAS
- Burn Specific Health Scale -Brief (BSHS-B)
- Aim: Assessment of general, physical, mental, and social health aspects of the burn survivor
- Method: Burn Specific Health Scale -Brief (BSHS-B)
Management Options[edit | edit source]
When working with Burns scars, there are three common options selected for the most effective treatment.
- Silicone
- Pressure Garment Therapy (PGT)
- Massage
1. Silicone[edit | edit source]
Silicone can be used in the form of a gel or sheeting. Using silicone in the treatment of hypertrophic scars is relatively new, beginning around 1981[15]. There is not much evidence to support the use of silicone to treat scars, but it does appear to common practice in many areas around the world. Often, practitioners prefer using the gel form as it has an easier application, more adaptable to different body parts and appears to have a higher patient compliance.[16] Silicone gel sheets can be washed and reused, limiting financial burden to the patient over the 2- to 3-month treatment course.[15]
Physiological Effects of Silicone:
- Hydration Effect:
- Increase in temperature:
- A rise in temperature increases collagenase activity thus increased scar breakdown.
- Polarized Electric Fields:
- The negative charge within silicone causes polarization of the scar tissue, resulting in involution of the scar.
- 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.
- 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.
- 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)
2. Pressure Garment Therapy (PGT)[edit | edit source]
There is no recent evidence supporting pressure garment therapy, but it is common practice among therapists in many areas of the world. It is a commonly used technique to reduce oedema and manage hypertrophic scars. [9] It is generally advise to maintain a pressure of 15 mmHg. Pressure exceeding 40mmHg can cause complications.[17][11] . Once the wound has closed and the wound can tolerate pressure, usually approximately 14 days post graft, the patient is advised to wear the garment as much as possible, and to only remove it for around one hour per day.[9][11] [16]
Aims: [9]
- The increased pressure will decrease blood flow to hyper vascular scars.
- Decrease collagen deposits
- Reduces thickness of scar
- Reduces red colouration of scar
- Decreases swelling
- Lessens pruritus
- Offers some protection of new skin/grafts
- Maintains normal body contours
Physiological effects:[18]
- 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.
- 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.
- Prostaglandin E2 release: Induction of prostaglandin E2 release, which can block fibroblast proliferation as well as collagen production
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)
∙ 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
- Physical and Functional limitations caused by garments
- Additional effort” created by the need to care for the garment
- Careful considerations of cost, compliance, patient discomfort, possible complications and the perceived benefits before prescribing this treatment.
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)
3. Massage[edit | edit source]
Five principles of scar massage:
- Prevent adherence
- Reduce redness
- Reduce elevation of scar tissue
- Relieve pruritus
- 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)
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 |
Guidelines for scar massage during healing stages (Glassey 2004)
Morien et al 2008
Field et al 2000
Shin and Bordeaux, 2012 Lit review
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
4. Reconstruction Post Burn Injury[edit | edit source]
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.
Aims[edit | edit source]
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[edit | edit source]
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[edit | edit source]
“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[edit | edit source]
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).
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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
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∙ 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[edit | edit source]
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)
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4.41 Categorisation of Skin Flaps[edit | edit source]
Based on three factors:
1. Vascularity
2. Anatomical composition
3. Method of relocation (Glassey 2004)
- ↑ 1.0 1.1 1.2 Norman AT, Judkins KC. Pain in the patient with burns. Continuing Education in Anaesthesia, Critical Care & Pain. 2004 Apr 1;4(2):57-61.
- ↑ Braza ME, Fahrenkopf MP. Split-thickness skin grafts. 2019
- ↑ Chu H, Brailey R, Clarke E, Sen SK. Reducing pain through distraction therapy in small acute paediatric burns. Burns. 2021 Nov 1;47(7):1635-8.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Aghakhani N, Faraji N, Parizad N, Goli R, Alinejad V, Kazemzadeh J. Guided Imagery: An effective and practical complementary medicine method to alleviate pain severity and pain-related anxiety during dressing change in burn victims. Journal of Burn Care & Research. 2022 May;43(3):756-.
- ↑ Tuca AC, Winter R, Kamolz LP. Acute Burn Surgery. InBurn Care and Treatment 2021 (pp. 27-35). Springer, Cham.
- ↑ 9.0 9.1 9.2 9.3 9.4 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.
- ↑ Godleski M, Yelvington ML. Rehabilitation and Therapy of the Burn Patient. InBurn Care and Treatment 2021 (pp. 137-145). Springer, Cham.
- ↑ 11.0 11.1 11.2 Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009 Jan 1;62(1):77-84.
- ↑ Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics. 2014;69:565-73.
- ↑ 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.
- ↑ Polotto S. USE OF SILICONE DRESSINGS IN POST-BURN HYPERTROPHIC SCAR THERAPY: A SYSTEMATIC REVIEW. Capsula Eburnea. 2011 Dec 1;6.
- ↑ 15.0 15.1 15.2 15.3 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.
- ↑ 16.0 16.1 Bloemen MC, van der Veer WM, Ulrich MM, van Zuijlen PP, Niessen FB, Middelkoop E. Prevention and curative management of hypertrophic scar formation. Burns. 2009 Jun 1;35(4):463-75.
- ↑ Engrav LH, Heimbach DM, Rivara FP, Moore ML, Wang J, Carrougher GJ, Costa B, Numhom S, Calderon J, Gibran NS. 12-Year within-wound study of the effectiveness of custom pressure garment therapy. burns. 2010 Nov 1;36(7):975-83.
- ↑ Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use. Burns. 2006 Feb 1;32(1):10-5.