Management of Burns

Original Editor - Carin Hunter
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson and Robin Tacchetti
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (27/03/2024)

Introduction[edit | edit source]

Burn injuries are a major cause of pain and disability,[1] particularly in low- and middle-income countries.[2] Optimal rehabilitation care for individuals with burn injuries requires a multifaceted, multidisciplinary approach. This page explores some of the key elements that must be considered in a rehabilitation plan when working with individuals with burns, including pain management, oedema management, scar management and surgical considerations.

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

There are many factors to consider when treating pain associated with burn injuries, and the clinician must understand the cause of the current pain. There is no standardised treatment for patients with burn injuries.[3] Pain assessments should be performed throughout the day and during different phases of care.[4] Both pharmacological and alternative management strategies can be used to manage pain in patients with burn injuries.

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

"Pain distress is common during the acute phase [of a burn injury] despite the use of opioids and/or ketamine."[5]

The general consensus is that "opioid therapy is an essential tool for pain management in thermal injuries",[5] and patients with burn injuries are often given opioids in higher / longer doses and durations than typical dosing guidelines. However, many patients with burns continue to experience pain and are at risk for opioid tolerance.[4][5][6]

Romanowski et al. include the following recommendations in their guidelines on pain management in adult patients with burn injuries:[4]

  • opioid therapy needs to be individualised to each patient and continuously adjusted during their care (considering individual responses, adverse effects, and narrow therapeutic windows)
  • while the reasonable use of opioids is supported to manage severe pain, attempts should be made to use "as few opiate equivalents as needed"[4]
  • opioid pain medications should be used in conjunction with other treatments, including non-opioid medications and non-pharmacological treatments

For more information, please see: American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps[4]

Initial Acute Pain[edit | edit source]

"The energy from the burn source causes cell damage and release of inflammatory mediators [...] Descending pathways from the thalamus and release of endorphins and other neurotransmitters in the spinal cord may result in there being little or no pain for the first few hours after injury".[1]

First aid strategies:[1]

  • cool the burn with tepid or cold water to end the burning process and decrease pain (do not use ice water, as this causes further damage to the affected area)
  • prevent general heat loss: hypothermia can be caused by cooling the burn and evaporation of oedema fluid, so provide the patient with a blanket or alternative source of warmth

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

"Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridement of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy."[4]

In the initial phases, pain associated with burn injuries tends to be described as background pain, breakthrough pain and procedural pain (e.g. associated with surgery, dressing changes, wound cleaning, rehabilitation). Patients may go on to experience persistent or chronic pain, as well as specific types of pain such as pruritus (itching).[5][1] The management for each type of pain can differ.[6] It is also important to consider the impact of pain on sleep - sleep is important for healing, so appropriate pain management is also essential.

Background Pain[edit | edit source]

This type of pain is defined as "pain at rest that is almost always present and not caused by specific medical procedures"[6] Thus, it is persistent but usually low-grade.[1] It can be present at the injury site and in other areas (i.e. primary and secondary pain). Background pain tends to be managed with moderate-potency opioids (preferrably given orally).[6]

Breakthrough Pain[edit | edit source]

Breakthrough pain is a transient increase in pain in individuals who are experiencing background pain.[6] It can indicate worsening background pain or may be from another source.[7]

Pain Associated with Procedures[edit | edit source]

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

Important considerations:[1]

  • each procedure causes a new, painful stimulus, which adds to the stress response
  • analgesia should be given at an appropriate time to ensure maximum benefit[7]
  • analgesia should be used in a preventive way, especially as some of these procedures can be predicted
  • general anaesthetic may be used for prolonged procedures
Surgery[edit | edit source]

Early post-operative pain tends to be managed with opioids and other non-opioid medications. Opioids may be given transdermally, orally, intramuscularly or intravenously:[1]

  • intramuscular administration can be difficult because of the extent of dressings, surgical site, pain at the site of injection, unpredictable absorption
  • patient-controlled analgesia (PCA) can be used (particularly for breakthrough pain after a procedure[6]), but the patient must be conscious and alert[7] and be able to use the device - this can prevent its use in individuals with hand burns
  • non-steroidal anti-inflammatory drugs (NSAIDs) and regional blocks may also be used to help manage pain after surgery, but they are used infrequently in individuals who are critically ill[7]
  • local anaesthetic gels may be applied after surgery to large, raw areas, such as donor sites, before the dressing is applied
Dressing Changes and Wound Cleaning[edit | edit source]

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

  • a general anaesthetic or deep intravenous sedation may be required while dressing large, deep burns, as they can take up to two hours to dress and may need to be debrided, or staples may need to be removed
  • smaller dressings can be managed by administering analgesia (e.g. opioids, local anaesthetics) before starting the procedure - nitrous oxide (e.g. Entonox) can be used for short procedures in addition to opioids to help reduce breakthrough pain and avoid long periods of sedation
  • using appropriate dressings (e.g., a synthetic temporary skin substitute) can help reduce the requirement for procedures, which is particularly beneficial for pediatric patients
Rehabilitation (Physiotherapy, Occupational Therapy, Movement Therapy)[edit | edit source]

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

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

Pruritus / Itching[edit | edit source]

Pruritus or itching is a common side effect of healing, affecting up to 93% of individuals with burn injuries by the day of their discharge.[8] It can have a significant impact on recovery, causing distress and affecting quality of life. Patients can also potentially cause trauma to their wounds by scratching, which can delay healing.[9]

Current treatments for pruritus have not been found to have clinically significant benefits and Andrade et al.[8] note that further research is required on treatment for pruritus. Treatments can include:[10]

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

Persistent / Chronic Pain[edit | edit source]

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

Pharmacological and medical treatments for persistent pain following a burn injury might include:[1]

  • analgesics
  • antidepressants
  • anticonvulsants
  • regional nerve block
Alternative Pain Management Techniques for Persistent or Chronic Pain[edit | edit source]

Alternative pain management techniques include:

  1. Psychological techniques can reduce fear and anxiety associated with activities or environments
    1. Relaxation
    2. Distraction[13]
    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 [14][15]
    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[16]
    1. distraction from noxious stimuli
    2. Uses imagery[17], 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[18] . 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:[19]

  • 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[20].

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.[21] Hypertrophic scars (HTSs) are defined as visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously.[22] The difficulties experienced by many individuals with hypertrophic scars is that often have a psychosocial effect on the individual. They can cause: [23][24]

  • 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. [19] 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]

  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[edit | edit source]

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

  1. Silicone
  2. Pressure Garment Therapy (PGT)
  3. 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[25]. 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.[26] Silicone gel sheets can be washed and reused, limiting financial burden to the patient over the 2- to 3-month treatment course.[25]

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[25] simulate the physiological skin barrier and decrease transepidermal water loss[25]
  2. Increase in temperature:
    • A rise in temperature increases collagenase activity thus  increased scar breakdown.
  3. Polarized Electric Fields:
    • The negative charge within silicone causes polarization of  the scar tissue, resulting in involution of the scar.
  4. Presence of silicone oil:
    • The presence of silicone has been detected in the stratum  corneum of skin exposed to silicone. However other researchers suggest occlusive  products without silicone show similar results.
  5. Oxygen tension:
    • After silicone treatment the hydrated stratum corneum is more  permeable to oxygen and thus oxygen tension in the epidermis and upper dermis rises.  Increased oxygen tension will inhibit the ‘‘hypoxia signal’’ from this tissue. Hypoxia  is a stimulus to angiogenesis and tissue growth in wound healing, as a consequence  removing the hypoxia stops new tissue growth. This theory has been contraindicated  by other researchers.
  6. Mast cells:
    • It is suggested that silicone results in an increase of mast cells in the  cellular matrix of the scar with subsequent accelerated remodelling of the tissue. 7) Static electricity: Static electricity on silicone may influence the alignment of collagen  deposition (negative static electric field generated by friction between silicone  gel/sheets and the skin could cause collagen realignment and result in the involution  of scars. (Bloemen et al 2009; Momeni et al 2009)
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. [19]  It is generally advise to maintain a pressure of 15 mmHg. Pressure exceeding 40mmHg can cause complications.[27][21] . 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.[19][21] [26]

Aims: [19]

  1. The increased pressure will decrease blood flow to hyper vascular scars.
  2. Decrease collagen deposits
    1. Reduces thickness of scar
    2. Reduces red colouration of scar
    3. Decreases swelling
    4. Lessens pruritus
    5. Offers some protection of new skin/grafts
    6. Maintains normal body contours

Physiological effects:[28]

  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

Patient Adherence to Pressure Garment Therapy  

Poor patient adherence to pressure garment therapy has been observed. This can be due to:[28]

  • Physical limitations and discomfort caused by the garments,
  • Additional garment care requiredand h
  • High cost of the garment
  • Heat generated
  • Skin breakdown
  • Allergies
3. Massage[edit | edit source]

Aims of scar massage:

  1. Prevent adherence
  2. Reduce redness
  3. Reduce elevation of scar tissue
  4. Relieve pruritus
  5. Moisturise (Glassey 2004)
  6. Improve range of motion(Morien et al 2008)

Scar Massage Techniques[29]

  1. Retrograde massage
    • Aids venous return
    • Increases lymphatic drainage
    • Mobilises fluid 
  2. Effleurage
    • Increase circulation
  3. Kneading, Skin rolling and wringing
    • Mobilises the scar and surrounding tissue
  4. Frictions
    • Loosen adhesions
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

[Presentation: Suggestions for practice include: (Shin and Bordeaux, 2012, Morien et al, 2008)  

  • Clean hands essential
  • Use non irritating lubricant, free of any irritants  
  • Modify practice according to patient stage of healing, sensitivity and pain levels.]

Contraindications:[30]

  • Open wound
  • Acute infection
  • Bleeding
  • Open wound
  • Graft failure
  • Intolerable discomfort
  • Hypersensitivity to emollient

4. Reconstruction Post Burn Injury[edit | edit source]

Burn injured patients are seriously impacted by reconstructive surgery. Working as part of an MDT, allied health professionals aim to establish successful surgery with long term function and health. Acute burn surgical management entails timely wound excision and skin grafting. (Klein 2010). It typically takes 48 hours after injury to determine the depth of the burn and thus whether surgery is warranted. Evidence of necrotic tissue is the only exception that may justify early excision. Reconstruction surgery facilitates the injured area to be cosmetically acceptable, extensible and sensate. (Glassey 2004). Plastic surgeons may also have to replace or rebuild muscles, nerves, tendons and joints to establish everything is intact.

REPHRASE: 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]

  • Achieve would closure
  • Prevent infection
  • Re-establish the function and properties of an intact skin
  • Reduce the effect of burn scars causing joint contractures
  • Reduce the extent of a cosmetically unacceptable scar

Skin Grafts[edit | edit source]

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. A graft can be split thickness, often from the thigh, which a specialised tool is used or full thickness, often from the groin, where a scalpel is used. The tissue can be used as is, known as a sheet graft, or it can be run through a machine which makes small holes in the skin (fenestrations) to increased the surface area, known as a meshed graft. Before the graft is laid in place, the would should be debrided and any necrotic tissue for foreign bodies should be removed. This will increase the chance of the graft adhering the the surface below or "taking". The donor site should heal within 10 -14 days, this would would be a superficial or a superficial partial thickness wound. The donor site is often more painful due to the exposure of the nerve endings.

There are five different types of grafts that can be used:

  1. Autograft which is the patients own skin
  2. Allograft which is comprised of donor skin
  3. Heterograft or xenografts which is comprised of animal skin
  4. Cultured skin
  5. Artificial skin
Pre-Graft Criteria[edit | edit source]
  • Diagnosis of DEEP tissue loss
  • Patient is systemically fit for surgery
  • Patient has no coagulation abnormalities
  • Sufficient donor sites available
  • No infections
The Recipient Site[edit | edit source]

The graft which will become a permanent covering of the injury should take within five days. The best chance for graft survival is by ensuring it is vascularised. To safeguard vascularisation, the graft should always be placed over healthy, bleeding tissue. (Glassey 2004)

REPHRASE: 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.

Graft Failure[edit | edit source]

Graft failure means that the grafted tissue did not adhere to the surface below and become vascularised. The following could be reasons for this[31]:

  1. Inadequate blood supply to wound bed
  2. Graft movement
  3. Collection of fluid beneath graft (e.g. haematoma)
  4. Infection (e.g. streptococcus)
  5. The grafts properties (e.g. vascularity of donor site)

Skin Flaps[edit | edit source]

A skin flap will remain attached to it's blood supply[32] and is used in cases where the wound bed is avascular[31].

Tissues which a skin graft will not take over include and which a skin flap will include[31]:

  1. Bone without periosteum
  2. Tendon without paratenon
  3. Cartilage without perichondrium

References[edit | edit source]

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  2. Opriessnig E, Luze H, Smolle C, Draschl A, Zrim R, Giretzlehner M, et al. Epidemiology of burn injury and the ideal dressing in global burn care - Regional differences explored. Burns. 2023 Feb;49(1):1-14.
  3. Hale A, O’Donovan R, Diskin S, McEvoy S, Keohane C, Gormley G. Impairment and Disability Short Course. Physiotherapy in Burns, Plastics and Reconstructive Surgery, 2013.
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  22. Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics. 2014;69:565-73.
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  30. Shin TM, Bordeaux JS. The role of massage in scar management: a literature review. Dermatologic Surgery. 2012 Mar;38(3):414-23.
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  32. Prohaska J, Cook C. Skin grafting. 2018