Continuum of Care of a Patient with Burns

Original Editor - Lilly Webster Top Contributors - Ewa Jaraczewska and Jess Bell

Introduction

Burns are a global public health problem, associated with high levels of disability. Recovering from burn injuries can be a long, painful, and traumatic journey. Burn injuries can impact an individual's family life, work, school, recreation, and social life. Therefore, rehabilitation professionals must have knowledge of effective burn management to optimise quality of life in burn survivors. This article reviews the fundamentals of burn injury evaluation and treatment for rehabilitation professionals from the early acute phase to the community/outpatient phase.

Factors Impacting Recovery

Many factors can impact post-burn recovery. The following factors can have a negative impact on successful post-burn recovery.

Medical factors:

• diabetes (can affect wound healing)
• history of depression (can affect motivation)
• inhalation injury (can cause acute respiratory distress or acute respiratory failure)

Psychosocial factors:

• tobacco use
• avoidant coping
• occupation loss
• current unemployment
• lack of participation in recreational activities
• limited or lack of social support
• unknown discharge destination
• emotional barriers (fear of rejection, self-consciousness)
• behavioural barriers (reactions from others, adherence to pressure garment therapy)

The ability to adapt to the post-burn state can be facilitated by (1) good social and peer support, (2) adaptive coping mechanisms, and (3) critical thinking.

Initial Assessment

Burn location and depth: burn wounds are classified by location and depth (superficial, superficial partial thickness, deep partial thickness, full thickness and subcutaneous). Please see Classification by Depth for a detailed discussion.

Total body surface area (TBSA): is commonly calculated using the Lund and Browder chart. This method includes burn areas that are partial thickness and full thickness, but excludes superficial areas.

Wound assessment: it is important to assess the wound when the dressing is taken down. When assessing the wound without the dressing, check for the following wound characteristics:

• colour
• wound environment: wet or dry
• blanchability

Please see Burn Wound Assessment for more information.

Pain assessment: the depth of the burn determines the degree of pain. Superficial burns cause greater pain while areas of full-thickness burns are usually pain-free because of damage to nerve endings. However, full-thickness burns are typically surrounded by areas of more superficial injury. Therefore, patients with full-thickness burns can report as much pain as patients who sustained a superficial injury. This pain can last from several days to several months. Burn pain mechanisms vary, and include:

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

Each type of pain requires different interventions. For in-depth information on pain management in individuals with burn injuries, please see this optional article: Burn Injury Management Considerations for Rehabilitation Professionals.

Preoperative Management

Goals include:

• increasing functional mobility
• preventing pulmonary complications
• decreasing oedema
• initiating proper positioning

Interventions can include:

• active range of motion
• functional mobility
• patient and caregiver education on:
  • current activity restrictions
  • importance of increasing mobility
  • pain and how to manage it
  • activity restrictions after surgery

Surgical Management for Burn Injuries

Early excision and closure of the burn wound help prevent infection and reduce secondary complications associated with burn scars. Reconstructive burn surgery helps to restore function to the affected area, thus improving the quality of life of individuals with burn injuries. It is important to note that patients with burn injuries typically require multiple rounds of surgery.

Surgical Procedures

The International Society for Burn Injury recommends early excision and grafting of deep partial-thickness burns. This approach shortens the recovery time, reduces pain and improves long-term scar outcomes. In addition, early wound closure enables an earlier transition into rehabilitation programmes.

The following treatment strategies are used in burn care:

• escharotomies (or "limb decompression")
  • a "full-thickness incision through the eschar, exposing the subcutaneous fat"
  • maintains perfusion through vessels
  • relieves pressure on the nerves, and thus preserves their function
  • complications include compartment syndrome
• surgical excision and debridement
  • there are typically no movement precautions unless there is tendon exposure
  • the rehabilitation team must discuss precautions with a surgical team
• allograft
  • uses skin from a cadaver
  • is not a terminal (i.e. final) grafting technique, so patients are usually able to move within 24 hours with no restrictions
  • can cover a large burn area
• autograft
  • uses skin from the patient
  • when autografts are applied to skin that crosses a joint, the joint should be immobilised for the first five days
  • general patient activity is encouraged away from the immobilised joint (e.g. following an autograft to the wrist joint, a patient should be able to get up and move even though their wrist is immobilised)
  • custom-made splints can be used to immobilise a skin graft

More information on skin grafts is available here. Please watch the following optional videos if you would like to see how hand and elbow splints are applied:

Splint Schedule

When considering a splint schedule for a patient with burn injuries, remember the following. (1) A splint is typically kept on for five days, (2) daily splint checks should be performed, and (3) the splint should be taken down at the same time as the postoperative dressings are taken down. This enables visualisation of the grafts so a decision can be made on continued splint use and if the patient can begin active range of motion exercises.

Postoperative Management

Goals include:

• maintaining the patient's mobility while protecting the graft sites
• increasing range of motion

Physiotherapy Interventions

General guidelines:

• before starting an intervention, ask the surgical team if the graft is healing well enough to start targeted mobility in that area
• perform a graft assessment during wound care. The assessment should include the following elements:
  • adherence of the graft
  • colour of the graft
    • pale vs pink, red or purple colour, with pink, red and purple indicating good vascularisation
    • presence of haematomas

Interventions include:

• range of motion exercises
  • start with active range of motion
  • progress to passive range of motion and static stretching interventions based on graft assessment results
• functional mobility to achieve as much independence as possible with bed mobility, transfers, and activities of daily living

• stretching
  • hold a low-load prolonged stretch for about two minutes
  • observe blanching over the joint that is being stretched (good sign)
  • moisturise the area with a water-based moisturiser before and after stretching
• it is important to assess range of motion using a goniometer pre- and post-intervention to measure changes over time
  • goniometric assessment of range of motion in functional positions rather than standard positions is useful after burn injuries
  • measuring movement at a single, isolated joint does not take into account "the cutaneous biomechanical interaction between the position of adjacent joints and the influence of skin (or scar) to accommodate terminal positioning of two consecutive joints together"

• patient and caregiver education on: (1) scar massage to help break up skin adhesions, (2) home exercise programme, (3) signs and symptoms of infection, and (4) expectations from the outpatient rehabilitation process

If you want to learn more about interventions in burn injuries, please see: Burn Wound Healing Considerations and Recovery Care Interventions and Burn Injury Management Considerations for Rehabilitation Professionals.

Outpatient and Community Phase of Burn Rehabilitation Process

Once discharged home, burn survivors will transition to outpatient and community-based care. The rehabilitation team will establish an individualised patient-centred exercise programme to achieve lasting outcomes. The following interventions may be included in the programme:

• scar management
  • management of hypertrophic scarring (scars that are raised within the bed of the wound).
  • reduction of scar banding. Scar banding:
    • is common when grafting and burns have crossed joints
    • commonly occurs in the axilla or the posterior knee
    • can inhibit joint motion and function
    • usually requires surgical management
  • scar massage
    • can be performed over any area that was burned or grafted
    • the area should be moisturised before and after scar massage
    • the patient can be taught to perform scar massage in a vertical, horizontal, and circular manner, applying enough pressure to blanch the skin
    • reported clinical benefits of scar massage are reduced hypersensitivity, increased skin pliability, and improved scar range of motion
    • please watch the following optional video if you would like to learn about scar massage techniques for an individual with burn injuries on the upper limb and torso:

• custom compression garments / pressure garment therapy
  • patients may be discharged home with prefabricated compression garments. During the outpatient phase, they are often measured for custom compression garments
  • ideal pressures for compression vary in the literature
    • de Decker et al. recommend using a minimal pressure of 20-25 mmHg
  • while wearing schedules for compression garments have not been standardised, it is often recommended that they be worn for 23 hours a day for at least the first year after burn injury, depending on the rate and type of healing
• fine motor skills incorporating the functional tasks that a patient needs for school, work, or leisure
• education about sun protection
  • avoid outdoor activities between 10 am and 4 pm when the sun is intense, including on cloudy days
  • wear clothes and accessories that protect your body, like long sleeve shirts, long pants, wide-brim hats
  • wear sunglasses with 100% UVA and UVB protection
  • apply a broad-spectrum, water-resistant sunscreen of at least SPF 50 - this should be applied to dry skin 15 to 30 minutes before sun exposure
  • reapply sunscreen every two hours or earlier when sweating, swimming, or drying off with a towel
  • do not use a sunscreen that is more than three years old

Resources

• Burn Wound Healing Considerations and Recovery Care Interventions
• Burn Injury Management Considerations for Rehabilitation Professionals
• Assessment and classification of burn injury
• Lanham JS, Nelson NK, Hendren B, Jordan TS. Outpatient burn care: prevention and treatment. Am Fam Physician. 2020 Apr 15;101(8):463-470.