Management of Burns
Introduction[edit | edit source]
When managing a patient with a burn, there are four main categories to consider:
1. Management of Burn Pain[edit | edit source]
There are many factors to consider when when treating burn pain. Initially, the clinician should understand the cause of the current pain. Pain can be controlled either with standard pharmacological management strategies or with alternative methods.
Initially the acute pain experienced is due to the burning tissues. The burn should be cooled with tepid water, not ice water as ice water can cause further damage to the affected area. Tepid water helps to end the burning and decrease the pain experienced. The clinician should always be aware that cooling the burn combined with the evaporation of oedema fluid can lead to hypothermia. Due to this, the patient should be given a blanket or alternative source of warmth to prevent hypothermia.
Once hospitalised, there are four main pain contributing factors which should be considered by the clinicians. These being:
- Pain associated with procedures
- Dressing Changes and Wound Cleaning
- Movement Therapy
- Resting pain
- Itching or Pruritus
- Chronic pain
1. Pain Associated with Procedures[edit | edit source]
This type of pain short in duration but of a high intensity. Every time a patient undergoes a procedure new painful stimulus is applied to the patient which can trigger the stress response.  General anaesthesia can be used for any major or prolonged procedures. The majority of smaller procedures are predictable in their timing, and analgesics should be administered as a preventative measure. Pain can often interfere with sleep which is important to the healing process. Pain associated with procedures can also affect the rapport and trust of the patient with the clinician which can pose a barrier to trust of the clinician.
Surgery[edit | edit source]
The donor site, comprising of large, open, raw areas can be managed with a local anaesthetic gel applied after surgery before applying the dressings.
Initially, the post operative pain is managed with opioids. These can be given transdermally, orally, intramuscularly or intravenously. The least common method of administration is intramuscularly as there are often complications associated (extent of dressings, surgical site and unpredictable absorption). Sometimes NSAIDs or a nerve block can be used in the management.
Some clinics make use of patient-controlled analgesia (PCA). While this can be effective, the patient needs to have a good level of understanding, be adequately responsive and not have hand complications.
Dressings Changes and Wound Cleaning[edit | edit source]
The biggest problem with pain management of a burn patient is addressing the dressing changes and wound care aspect of the injury. A deep, large burn can take up to 2 hours to dress, often with some debridement or staple removal necessary. Sometimes it is in the patients best interest to sedate them for these procedures. Smaller dressing changes can be managed by administering analgesia before the wound dressing begins.
It is advised to reduce the amount of procedures, in paediatric patients especially. One way of achieving this is to use the most appropriate dressings available. A synthetic temporary skin substitute could be left in place until healthy skin has formed, thus reducing distress and infection risk and also allowing early mobilization.
Movement Therapy[edit | edit source]
Physiotherapy and Occupational Therapy are common interventions received in a Primary Healthcare setting and they play and important role in rehabilitation. Moving the damaged area can cause an increase in pain and therefor the stress response, but as both treatments are flexible as to time of day, they can be times for after pain relief has been administered. In the subacute and chronic phase, oral analgesics are used as the patient needs to be aware enough to actively participate in the treatment if possible. Both professions have been known to visit the theatre and perform passive range of motion exercises or create splints, while the patient is under general anaesthetic in the acute phase.
2. Resting Pain[edit | edit source]
This type of pain is usually low intensity but longer duration. Patients often describe their general state as 'low-grade persistent discomfort". This is often managed by using NSAIDs in combination with a low-dose opioid. This is managed by the physician or burns nurse. The patient is managed by regularly dosing the patient to prevent breakthrough pain.
3. Itching[edit | edit source]
As itching, or pruritus, is a common side effect of healing, it can be difficult to understand. But if the patient is reacting by scratching, they could cause damage to forming skin. Treatment may involve a combination of antihistamines and NSAIDs. alternatively a cold compress could help the symptoms in a subacute phase.
4. Chronic Pain[edit | edit source]
Chronic pain, in a burn injury, is often due to damaged or regenerating nerve fibres. The patient often suffers from hyperalgesia (Increased response to a painful stimulus) and allodynia (Painful response to a non-painful stimulus). This can often affects the patients sleeping and result in depressive symptoms and cause barriers to rehabilitation. There is a strong correlation with the severity of chronic pain symptoms and the total burn surface area and number of skin grafts performed. 
Treatment involves the following:
- Regional nerve block
- Cognitive behavioural therapy
Alternative Pain Management Techniques:[edit | edit source]
Alternative pain management techniques entail:
- Psychological techniques can reduce fear and anxiety associated with activities or environments
- Cognitive Behavioural Therapy
- Hypnosis can be used in the management of procedural pain and anxiety
- Virtual Reality can lower pain scores when undergoing dressing changes 
- Immersing the patient in a virtual world
- Hand-held gaming devices
- Sleep Normalisation with a bedtime routine
- To promote sleep
- Makes use of analgesics and night sedation
- Music therapy can target pain via the gate control theory
- distraction from noxious stimuli
- Uses imagery, 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 . 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[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.
3. Management of the Scar[edit | edit source]
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
- 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[edit | edit source]
- Vancouver Burn Scar Scale (VBSS/VSS)
- Aim: Assessment of the scar in 4 categories: Vascularity, height/thickness, pliability, and pigmentation, relief, and surface area. Also includes assessment of patient pain, itching, colour, stiffness, thickness and relief. The only scale to measure subjective aspects of pain and pruritus (severe itching) (Fearmonti et al 2010).(Fearmonti et al 2010)(Durani et al 2009)(Brusselaers et al 2010)
- Method: Burns Scar Index (Vancouver Scar Scale)
- Patient and Observer Scar Assessment Scale (POSAS)
- Aim: Assessment of the scar from the patient and the observers perspective
- Method: About POSAS
- Burn Specific Health Scale -Brief (BSHS-B)
- Aim: Assessment of general, physical, mental, and social health aspects of the burn survivor
- Method: Burn Specific Health Scale -Brief (BSHS-B)
Management Options[edit | edit source]
When working with Burns scars, there are three common options selected for the most effective treatment.
- Pressure Garment Therapy (PGT)
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. 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. 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:
- Hydration Effect:
- Increase in temperature:
- A rise in temperature increases collagenase activity thus increased scar breakdown.
- Polarized Electric Fields:
- The negative charge within silicone causes polarization of the scar tissue, resulting in involution of the scar.
- Presence of silicone oil:
- The presence of silicone has been detected in the stratum corneum of skin exposed to silicone. However other researchers suggest occlusive products without silicone show similar results.
- Oxygen tension:
- After silicone treatment the hydrated stratum corneum is more permeable to oxygen and thus oxygen tension in the epidermis and upper dermis rises. Increased oxygen tension will inhibit the ‘‘hypoxia signal’’ from this tissue. Hypoxia is a stimulus to angiogenesis and tissue growth in wound healing, as a consequence removing the hypoxia stops new tissue growth. This theory has been contraindicated by other researchers.
- Mast cells:
- It is suggested that silicone results in an increase of mast cells in the cellular matrix of the scar with subsequent accelerated remodelling of the tissue. 7) Static electricity: Static electricity on silicone may influence the alignment of collagen deposition (negative static electric field generated by friction between silicone gel/sheets and the skin could cause collagen realignment and result in the involution of scars. (Bloemen et al 2009; Momeni et al 2009)
2. Pressure Garment Therapy (PGT)[edit | edit source]
There is no recent evidence supporting pressure garment therapy, but it is common practice among therapists in many areas of the world. It is a commonly used technique to reduce oedema and manage hypertrophic scars.  It is generally advise to maintain a pressure of 15 mmHg. Pressure exceeding 40mmHg can cause complications. . 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. 
- The increased pressure will decrease blood flow to hyper vascular scars.
- Decrease collagen deposits
- Reduces thickness of scar
- Reduces red colouration of scar
- Decreases swelling
- Lessens pruritus
- Offers some protection of new skin/grafts
- Maintains normal body contours
- Hydration effect: decreased scar hydration results in mast cell stabilization and a subsequent decrease in neurovascularisation and extracellular matrix production. However this hypothesis is in contrast with a mechanism of action of silicone, in which an increase of mast cells causes scar maturation.
- Blood flow: a decrease in blood flow causes excessive hypoxia resulting in fibroblast degeneration and decreased levels of chondroitin-4-sulfate, with a subsequent increase in collagen degradation.
- Prostaglandin E2 release: Induction of prostaglandin E2 release, which can block fibroblast proliferation as well as collagen production
Patient Adherence to Pressure Garment Therapy
Poor patient adherence to pressure garment therapy has been observed. This can be due to:
- Physical limitations and discomfort caused by the garments,
- Additional garment care requiredand h
- High cost of the garment
- Heat generated
- Skin breakdown
3. Massage[edit | edit source]
Aims of scar massage:
- Prevent adherence
- Reduce redness
- Reduce elevation of scar tissue
- Relieve pruritus
- Moisturise (Glassey 2004)
- Improve range of motion(Morien et al 2008)
Scar Massage Techniques
- Retrograde massage
- Aids venous return
- Increases lymphatic drainage
- Mobilises fluid
- Increase circulation
- Kneading, Skin rolling and wringing
- Mobilises the scar and surrounding tissue
- 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.]
- Open wound
- Acute infection
- 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:
- Autograft which is the patients own skin
- Allograft which is comprised of donor skin
- Heterograft or xenografts which is comprised of animal skin
- Cultured skin
- 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:
- 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)
Skin Flaps[edit | edit source]
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
References[edit | edit source]
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