Burn Injury Management Considerations for Rehabilitation Professionals

Original Editor - Carin Hunter based on the course by [TUTOR LINK/ ReLab]
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.

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
   • Physiotherapy
2. Resting pain
3. Itching or Pruritus
4. Chronic pain.

1. Pain Associated with Procedures

Procedural pain is usually of short duration but a high intensity. Each procedure will trigger a fresh painful stimulus and further stress response. major or prolonged procedures should always be carried out under general anesthesia. The majority of smaller procedures are predictable, and thus analgesics should be administered as a preventative measure. Therefore, analgesia should be preventive, as some of these events are predictable. 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

Large raw areas, usually as a result of harvesting tissue from the donor site, can be comfortably managed by the surgeon applying a local anaesthetic gel before applying the dressings.

Early postoperative pain management is often with the use of opioids. Alternative analgesic methods that can possibly be used, depending n the extent of the injury and site of the graft area, would be a regional block or NSAIDs. Opioids can be administered transdermally, orally, intramuscularly and intravenously with a combination of background infusion and boluses.

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.

Dressings Changes and Wound Cleaning

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 https://academic.oup.com/bjaed/article/4/2/57/271658 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.

Physiotherapy

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.

2. Resting Pain

Usually of low intensity but longer duration. 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.

3. Itching

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.

4. Chronic Pain

This can be due to changes experienced in nerve fibres. 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.

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

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

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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

1. Pharmacological Pain Management
   1. Opioids
   2. Simple analgesics
   3. NSAIDS
2. Alternative Techniques
   1. Psychological techniques
   2. Hypnosis
   3. Virtual Reality
   4. Sleep Normalisation
   5. Music therapy
3. Paediatric Burn Pain
4. Other causes of pain

1. Pharmacological Pain Management: (Richardson and Mustard 2009)

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:

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

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.

Positive Effects	Side Effects	Examples of Opioids
Pain relief Increased comfort Morphine related to reduced  Post-traumatic stress disorder	Respiratory distress Itch Nausea and vomiting Opioid tolerance – requiring  increasing doses Opioid induced hyperalgesia  (OIH) – increased sensitivity,  throughout the body following  opioid exposure Provide poor defence against  central sensitisation Physical dependence – common in long term use 25	Morphine   Oxycodone 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 https://academic.oup.com/bjaed/article/4/2/57/271658 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.

4. 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

5. 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.

2. Management of Oedema

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

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

Burns and Plastic Surgery Occupational Therapy

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).

3. Management of the Scar

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.

Scar Outcome Measures

1. Vancouver Burn Scar Scale (VBSS/VSS)
   1. Aim: 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)
   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 hypervascular 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)