Burn Injury Management Considerations for Rehabilitation Professionals

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

Introduction

When managing a patient with a burn, there are four main categories to consider:

1. Pain
2. Oedema
3. Scar
4. Reconstruction

1. Management of Burn Pain

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:

1. Pain associated with procedures
   • Surgery
   • Dressing Changes and Wound Cleaning
   • Movement Therapy
2. Resting pain
3. Itching or Pruritus
4. Chronic pain

1. Pain Associated with Procedures

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. 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

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

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.

Movement Therapy

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

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

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

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.

Treatment involves the following:

• Antidepressants such as amitriptyline
• Anticonvulsants such as gabapentin and sodium valproate)
• 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:

Alternative pain management techniques entail:

1. Psychological techniques can reduce fear and anxiety associated with activities or environments
   1. Relaxation
   2. Distraction
   3. Cognitive Behavioural Therapy
2. Hypnosis can be used in the management of procedural pain and anxiety
3. Virtual Reality can lower pain scores when undergoing dressing changes
   1. Immersing the patient in a virtual world
   2. Hand-held gaming devices
4. Sleep Normalisation with a bedtime  routine
   1. To promote sleep
   2. Makes use of analgesics and night sedation
5. Music therapy can target pain via the gate control theory
   1. distraction from noxious stimuli
   2. Uses imagery, self-statements and attention-diversion

2. Management of Oedema

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

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 . 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:

• 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

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.

Burns and Plastic Surgery Occupational Therapy

3. Management of the Scar

Scarring is a common complication following a severe burn wound and affects approximately 70% of patients. Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously. The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause:

• 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. 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

1. Vancouver Burn Scar Scale (VBSS/VSS)
   1. 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)
   2. Method: Burns Scar Index (Vancouver Scar Scale)
2. Patient and Observer Scar Assessment Scale (POSAS)
   1. Aim: Assessment of the scar from the patient and the observers perspective
   2. Method: About POSAS
3. Burn Specific Health Scale -Brief (BSHS-B)
   1. Aim: Assessment of general, physical, mental, and social health aspects of the burn survivor
   2. Method: Burn Specific Health Scale -Brief (BSHS-B)

Management Options

When working with Burns scars, there are three common options selected for the most effective treatment. These being:

1. Silicone
2. Pressure Garment Therapy (PGT)
3. Massage

1. Silicone

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. 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.

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).

Silicone gel sheets can be washed and reused, limiting financial burden to the patient over the 2- to 3-month treatment course.

Physiological effects of Silicone:

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. simulate the physiological skin barrier and decrease transepidermal water loss
3. Increase in temperature: A rise in temperature increases collagenase activity thus  increased scar breakdown.
4. Polarized Electric Fields: The negative charge within silicone causes polarization of  the scar tissue, resulting in involution of the scar.
5. 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.
6. 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.
7. 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)

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

1. Reduce scarring by hastening maturation  
2. Pressure decreases blood flow
3. Local hypoxia of hyper vascular scars
4. Reduction in collagen deposition
   1. Decreases scar thickness
   2. Decreases scar redness  
   3. Decreases swelling
   4. Reduces itch
   5. Protects new skin/grafts
   6. Maintains contours (Procter 2010)

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

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)

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)

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

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

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

1. Retrograde massage to aid venous return, increase lymphatic drainage, mobilise fluid 
2. Effleurage to increase circulation
3. Static pressure to reduce pockets of swelling
4. Finger and thumb kneading to mobilise the scar and surrounding tissue
5. Skin rolling to restore mobility to tissue interfaces
6. Wringing the scar to stretch and promote collagenous remodelling
7. 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

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

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).

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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)  

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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).  

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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

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

Based on three factors:

1. Vascularity

2. Anatomical composition

3. Method of relocation (Glassey 2004)