Burns & its Physiotherapy Management..pptx

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1. BURNS AND ITS PHYSIOTHERAPY MANAGEMENT 1 Dr. Hitiksha Bhalodia (MPT in Women’s Health) Assistant Professor , PIPT Course Name : Physiotherapy in Medical and Surgical Condition Course Code : 07101404 Course Objective : Select strategies for cure, care and prevention; adopt restorative and rehabilitative measures for maximum possible functional independence of a patient at home, work and in community . ( CO2)

2. What is burns…? It is a type of coagulative necrosis of tissue, caused by thermal application transfer from source to body or Tissue injury caused by thermal, electrical or chemical agents 2

3. Risk factors ⚫ Fire/combustion Firefighter Industrial workers Occupant of burning structures ⚫ Chemical exposure □ Industrial workers ⚫ Electrical exposure Electrician Electrical power distribution worker 3

4. Types of burn Injuries 1. thermal burn Skin injury Inhalation injury 4

5. 2. Chemical burn: Skin injury Inhalation injury Mucous membrane injury 5

6. 3. Electrical burn: Skin injury’ Nerves, muscle and bone damage 4. Radiation burn 6

7. Effects: Burn injury causes destruction of tissue, usually the skin from exposure to thermal extremes (either hot or cold), electricity, chemical and radiation The mucosa of the upper GI system (mouth, esophagus, stomach) can be burned with ingestion of chemicals The respiratory system can be damaged if hot gases, smoke or toxic chemical fumes are inhaled Fat, muscle, bone and peripheral nerves can be affected in electrical injuries or prolonged thermal or chemical exposure Skin damage can result in altered ability to sense pain, touch and temperature 7

8. Classification of burn injury and its pathophysiology 8

9. 1. Depending upon depth of burn injury: □ Previously used classification First degree burn : only epidermis affected Second degree burn: epidermis and dermal appendages Third degree burn: epidermis and all dermis Fourth degree burn: epidermis, dermis, and subcutaneous tissues (fat, muscle, bone and peripheral nerves) 9

10. Recent classification of burn depending on depth of tissue injury Epidermal burn Superficial partial thickness burn Deep partial thickness burn Subdermal burn 10

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12. Epidermal burn Cell damage to epidermis This depth of burns correlates to practice pattern 7B; impaired integumentary integrity associated with superficial skin involvement e.g., sunburn 12

13. Clinically skin appears red / erythematous Painful, dry, red burns which blanch with pressure No blister Slight edema may apparent Spontaneous healing (within 7 days) & no scar 13

14. Superficial partial-thickness burn Damage occurs through the epidermis and into the papillary layer of dermis (second-degree burn) The epidermal layer destroyed completely This depth of burn corresponds to APTA pattern 7C; impaired integumentary integrity associated with partial thickness skin involvement and scar formation 14

15. ⚫ Presence of intact blisters Due to blister increased inflammatory response Moist weeping or glistening surface when blisters removed Very painful Sensitive to changes in temperature, exposure to air currents, & light touch Moderate edema, spontaneous healing, minimal scarring & discoloration Heal within 7-21 days 26

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17. Deep partial thickness burn Involves destruction of the epidermis and papillary dermis with damage down into the reticular dermal layer Impairment matches to APTA pattern 7C Deep partial thickness burns appears as a mixed red or waxy white color 17

18. Blanching and brisk capillary refill Broken blisters, wet surface Their color may range from patchy, cheesy white to red and they do not blanch with pressure Sensitive to pressure but insensitive to light touch or soft pinprick Affected area is depressed Healing with skin graft or flap or scarring 18

19. Full thickness burn All epidermal and dermal layers are destroyed along with subcutaneous fat layer This burn depth consistent with practice pattern 7D; i.e., impaired integumentary integrity associated with full-thickness skin involvement and scar formation A full-thickness burn is characterized by a hard, parchment-like Escher covering the area. 19

20. Escher is devitalized tissue consisting of designed coagulum of plasma & necrotic cells Escher feels dry, leathery and rigid the color of Escher can vary from black to deep red to white ; latter indicates total ischemia of the area Hair follicles are completely destroyed 20

21. A major problem arises from deep burns is the damage to the peripheral vascular system Large amount of fluid leak into the interstitial space □ increase pressure in extracellular space □ constriction to deep circulation Very slow healing following this type of burn 21

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23. Subdermal burn Involves complete destruction of all tissue from the epidermis down to and through the subcutaneous tissue Occurs following prolonged contact with a heat source This depth of the injury correlates with APTA practice pattern 7E; Impaired integumentary integrity associated with skin involvement extending into fascia, muscle or bone and scar formation Extensive surgical and therapeutic management is necessary to return a patient to some degree of function 23

24. Electrical burn S/S of an electric burn may vary according to the type of current, intensity of the current and the area of the body the electric current passes through Electric current follows the course of least resistance offered by various tissues. i.e., nerves, followed by blood vessels offers least resistance; bones offers most resistance. Tissue damage results from tissue resistance to the passage of the current or by direct electrical current 24

25. Typically contact sites will exist where the patient first came into contact with the electricity and a second site where the patient was grounded The affected skin appears yellow, ischemic and dry Tissues along the pathway of the current may be damaged owing to heat that developed as a result of tissue resistance to current passage Blood supply to surrounding tissues may be altered and arteries undergo spasm 25

26. ⚫ There can be other consequences of electricity passing through the body such as Cardiac arrhythmias and acute renal failure secondary to fluid and electrolyte imbalances and release of myoglobin into blood The most severe complication following electrical current damage is acute spinal cord damage or vertebral fracture Ventricular fibrillation and respiratory arrest 26

27. Burn wound Zones ⚫ Three zones: Zone of coagulation Zone of stasis Zone of hyperemia 27

28. Zone of coagulation In the zone of coagulation cells are irreversibly damaged & skin death occurs This area is equivalent to a full-thickness burn & will require a skin graft to heal Here, because of lack of viable tissue & the amount of Escher, the risk of infection increased This potential complication emphasizes the need for careful monitoring, use of antibiotics & the treatment of a burned pt. in specialized burn center 28

29. Zone of stasis It contains injured cells that may die within 24 to 48 hrs. without diligent treatment Here, in this zone; Infection, Drying & inadequate perfusion of the wound □ conversion of potentially salvageable tissue to completely necrotic tissue & enlargement of the zone of coagulation Splints or compression bandages, if applied too tightly, can compromise this area 29

30. Zone of Hyperemia Finally in this zone, there is minimal cell damage Tissue should recover within several days with no lasting effects 30

31. Extent of Burned Area A major consideration when determining the severity of a burn is the extent of body surface involved % of Total body surface area(TBSA) burned; calculated by Rule of nines 31

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36. ⚫ The rule of nines divides the body surface into areas of 9% or multiples of 9% of TBSA ⚫ Modified:- according to continuum of age accommodate for growth of different body segments 36

37. Total Burn Surface Area (TBSA): the greater the total burn surface area the poorer the prognosis Percentage chance of Survival =[100 – (Age in years + percentage TBSA)] 37

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40. Other Assessment Details: 40

41. Burn Patient Severity Factors to Consider : Burn Depth classification Body surface area burned Age: adult v/s pediatric Preexisting medical conditions Associated trauma Blast injury Fall injury Airway compromise Child abuse 41

42. Patient Age: Less than 2 or greater than 55 have increased incidence of complication Burn Configuration: Circumferential burns can cause total occlusion of circulation to an area due to edema Restrict ventilation if encircle the chest Burns on joint area can cause disability due to scar formation 42

43. Critical Burn Criteria ⚫ 3 > 10% BSA ⚫ 2 > 30% BSA > 20% pediatric Burns with respiratory injury Hands, face, feet or genitalia Burns complicated by other trauma Underlying health problems Electrical & deep chemical burns 43

44. Moderate burn criteria ⚫ 3 : 2-10 % BSA ⚫ 2 : 15-30 % BSA 10-20% pediatric Excluding hands, face, feet or genitalia Without complicating factors 44

45. Minor Burn Criteria ⚫ 3 0< 2% BSA ⚫ 2 0< 15% BSA 10% BSA ⚫ 1 0< 15% BSA 45

46. Complications of Burn injury Depending on the extent of burn injury, the depth of the burn & the type of burn, there may be secondary systemic complications In addition the health, age, & psychological status of a patient who is burned will affect these complications 46

47. 1. Infection Infection is conjunction with organ system failure, is a leading cause of mortality from burns Some virulent strains of Pseudomonas aeruginosa & Staphylococcus aureus are resistant to antibiotics & have been responsible for epidemic infections in burn centers Systemic antibiotics are used to treat both burn and general system infections once they have been documented 47

48. 2. Pulmonary complications Inhalation injury: pt who has been burned in closed space Signs of an inhalation injury include facial burns, singed nasal hairs, harsh cough, hoarsness, abnormal breath sounds, respiratory distress, & carbonaceous sputum & hypoxemia The incidence of pulmonary complications is extremely high after severe burns, & death due to pneumonia 48

49. ⚫ The primary complications associated with this injury are carbon monoxide poisoning, tracheal damage, upper airway obstruction, pulmonary oedema, and pneumonia. ⚫ Lung damage from inhaling noxious gases and smoke may be lethal 49

50. 3. Metabolic Complications Metabolic rates may increase up to 50% in a 25% TBSA burn and much more as the burn size increases The consequences of the increased metabolic and catabolic activity following a burn are:- A rapid decrease in body weight Negative nitrogen balance and A decrease in energy stores that are vital t he healing process. 50

51. Following increased metabolic activity there will be increase of 1.8 F to 2.6 F (1 C to 2 C) in core temperature that seems to be due to a resetting of the hypothalamic temperature centers in the brain As a part of pt.'s altered metabolism, protein from muscle tissue is preferentially used as a source of energy muscle atrophy 51

52. 4. Cardiovascular complications Hemodynamic changes result from a shift in fluid to the interstitium, which subsequently reduces the plasma & intervascular fluid volume in a burnt pt. This shift of fluid to the interstitium can result in significant edema Decrease cardiac output Hematological changes : alterations in platelet concentration & function, clotting factors & white blood cell components, RBC dysfunction & decrease hemoglobin & hematocrit 52

53. Heterotopic Ossification Pts. With more than 20% TBSA burn highly susceptible Usually occurs in areas of full-thickness injury or sites that remains unhealed for prolonged period Symptoms: decrease ROM, point specific pain, generalized pain 53

54. Neuropathy ⚫ Peripheral neuropathy: either polyneuropathy or local neuropathy (depending on involvement of TBSA) 54

55. Pathological Scars Burn scar occur in area of deep partial-thickness burn □ where healing is with skin grafting If maturing tissue demonstrates a greater rate of collagen production than degradation, a scar become raised and thick □ hypertrophic scar 55

56. ⚫ Formation of Escher ⚫ Renal or hepatic failure 56

57. Psychological changes Fear/ anxiety Denial Depression Guilt Grief & mourning Loss of will to live Apathy Necrophilous orientation anger 57

58. Management Medical management of burns Initial treatment: Goals: - to address critical life-threatening problems & stabilize the pt. through procedures designed to: Establish & maintain an airway prevent cyanosis, shock & hemorrhage establish baseline data on pt.; extent & depth of burn injury Prevent or reduce fluid losses clean the pt. & wounds Examine injuries Prevent pulmonary & cardiac complications 58

59. ⚫ Transport pt. to burn center from the site of accident Assessment : demographic details, history, calculation of TBSA Fluid volume replacement therapy Wound cleansing Debridement analgesics 59

60. Wound Care: Remove Escher along with sharp debridement Apply topical medications either with open technique or closed technique 60

61. Surgical Management of burn wound Primary Excision: Surgical removal of Escher With excision removal of peripheral layers of Escher until vascular, viable tissue is exposed as the site for skin graft placement Burn wound is closed with a skin graft at time of primary excision Grafts used are: autograft, allograft or xenograft □ Now a days skin substitutes are used for coverage of an excised wound 61

62. Skin grafting Done under anesthesia Skin used for a graft usually is removed with a dermatome It can either split-thickness skin graft (epidermis with variable amount of dermis) or full-thickness skin graft (full epidermis and dermis) Correction of scar contracture 62

63. The Z-plasty serves to lengthen a scar by interposing normal tissue in the line of the scar. 63

64. Physical Therapy Management PT interventions are directed towards: - Prevention of scar & contracture Preservation of normal ROM Prevention or minimization of hypertrophic scar formation and cosmetic deformity Maintenance or improvement in muscular strength Improvement in cardiovascular endurance Return to pre-burn function and performance of activities of daily living 64

65. ASSESSMENT Demographic details: Review of medical records History Observation Palpation Examination Initial examination for the depth of burn Percentage of burn (TBSA) & percentage chance of survival 65

66. Screening/assessment for complications: □ Hypovolemic shock:- Hypotension Oliguria Tachycardia Sweating, Pallor Clouding of consciousness □ Septic Shock :- Increased temperature Hypotension Oliguria Dry & pink extremities Altered pulmonary functions 66

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68. Skin Assessment: Appearance Temperature Moisture/Dryness Texture Color Size Pulses Sensations 68

69. Assessment of ROM Tightness/contracture Functional mobility Gait and functional status (FIM) 69

70. Special tests Pigmentation of the scar: 0 = normal 1 = hypopigmentation 2 = hyperpigmentation Height of scar: 0 = normal 1 =< 2mm 2 =<5 3 =>5 70

71. Vancouver Scar Scale(VSS) 71

72. ⚫ ICF: Condition Body structures and function Activities Function Contextual factors: personal and environmental facilitators and barriers 72

73. Anticipated Goals and Expected outcomes (In general) Risk of infection and complications is reduced Wound and soft tissue healing is enhanced. Risk of secondary impairments is reduced. Maximal range of motion is achieved. Pre injury level of cardiovascular endurance is restored. Good to normal strength is achieved. 73

74. Independent ambulation is achieved. Independent function in ADL and IADL is increased. Scar formation is minimized. Patient, family, and caregivers’ understanding of expectations and goals and outcomes is increased. Aerobic capacity is increased. Self-management of symptoms is improved 74

75. Positioning And Splinting Positioning begin on the day of admission Concept: positioning burned areas in place and maintain the body part in the opposite plane and direction to which it will potentially contract Goals : - To minimize edema To prevent tissue destruction maintain soft tissues in elongated state preserve function 75

76. Positioning in bed of pt. with burn of the anterior neck 76

77. Positioning in bed of pt. with burns of the axilla 77

78. Positioning of upper extremities to reduce edema while seated 78

79. Splinting given to provide anti-deformity positions Indications :- Prevention of contracture Maintenance of ROM Reduction of developing contracture Protection of jt. or tendon Reduce pain 79

80. Splinting usually worn at night following skin grafting Static or dynamic splint can be used □ Dynamic splint apply low load, prolonged stress that can be adjusted to pt.'s tolerance 80

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84. Therapeutic Exercises Active and passive exercises: Can be initiate from the day of admission Before starting exercise look for the complications and vital stability and consciousness/alertness Perform AROM of all extremities and trunk including unburned areas Avoid ROM exercise of injured area in case of recent skin grafting & allow the graft to adhere 84

85. Dosages: AROM should be done twice daily For sedated pts. PROM can be initiated and given thrice/day Repetitions and degree of movement depends on pt. tolerance and limit of stretch 85

86. Contraindications: 86 ⚫ Active or Passive range of motion exercises should not be carried out if there is suspected damage to any tendons e.g., flexion of PIP should be avoided at all to prevent extensor tendon rupture ⚫ Range of motion exercises are also contraindicated post skin grafting as a period of 3-5 days immobilisation is required to enable graft healing

87. Practical considerations while mobilizing burn patient Be aware of dressing clinic/daily dressing changes. Mobilisation should coincide with this as it is important to monitor the wound during AROM frequently. Timing of pain relief. This should be timed appropriately to ensure maximal benefit during treatment sessions. Observe the patient carrying out the AROM and PROM exercises prior to beginning treatment. Also observe the patient taking on/off splints. 87

88. Always monitor for post exercise pain and wound breakdown. Avoid blanching for long period as you may compromise vascularity. The patient may present with a reduced capacity for exercise secondary to increased metabolic rate, altered thermoregulation and increased nutritional demands. Postural hypotension may be present due to prolonged bed rest and low haemoglobin 88

89. Ambulation It should be initiated at the earliest appropriate time If LEs are skin grafted ambulation may be discontinued until it is safe to resume Wrap elastic bandages after skin grafting while ambulation (supports new graft and promote venous return) If orthostatic hypotension is there use tilt table to make pt. standing gradually 89

90. “The rewards of a successful POC are tremendous when a patient who has suffered a life-threatening burn is able to walk out of the hospital and return to productive community 90 involvement.”

91. Resistive and conditioning exercises Pts. With major burns may lose body weight and lean muscle mass can decrease rapidly Exercise consist of isometric, isokinetic, isotonic or using other resistive training devices can be started at rehabilitation stage General principles of exercise training and strength improvement should be followed, but they may need to be modified on the basis of a patient’s condition and stage of wound healing 91

92. Initially Isometrics used to maintain muscle properties & with that help to prevent further muscle atrophy In progression use weights and resistive equipments to improve muscle strength Regular and accurate monitoring of vitals (including PR,RR, BP, SPO2, RPE) before, during and after exercises. 92

93. Scar Management Pressure Garment Therapy (PGT) Following wound closure, a skin graft or healed burn wound is vascular, flat and soft. To achieve this following 3-6 months, dramatic changes may occur – the newly healed areas may become raised and firm If wound healing takes longer than 10 to 14 days or skin grated, pressure usually is indicated Pressure has been used successfully to hasten scar maturation and minimize hypertrophic scar formation 93

94. ⚫ Pressure may exert control over hypertrophic scarring by; Pressure decreases blood flow Local hypoxia of hypervascular scars Reduction in collagen deposition All three together causes: Decreases scar thickness Decreases scar redness Decreases swelling Reduces itch Protects new skin/grafts Maintains contours ⚫ The earlier the scar tissue is exposed to pressure, the better result 94

95. Method of application: For LE – fig. of eight pattern For UE – spiral wraps For trunk – circular wrap Hand and toes – self-adherent bandages 95

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97. Practical recommendations and safety considerations Pressure exerted around 15 – 40 mmHg Time : Worn up to 23 hrs./day Worn as soon as wound closure has been obtained ( Post grafting after 10-14 days it is recommended and it should be worn up to one year or until scar maturation ) 97

98. 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 98

99. Silicone Gel: Sheets of silicone polymer gel may be applied directly over an actively maturing scar. ⚫ Complication: local rash, rarely skin breakdown 99

100. Mechanism: unknown but possible mechanisms are as follow Hydration: decreases capillary activity and collagen production, through inhibition of proliferation of fibroblasts Rise in temperature increases collagenase activity and scar breakdown polarized electric fields creates negative charge within silicone causes polarization of scar tissue, resulting in involution of scar Presence of silicone oil Oxygen tension inhibit hypoxia signal Increase in mast cell helps in remodeling of tissue 100

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102. Massage: Mechanisms on which Scar massage works: Prevent adherence Reduce redness Reduce elevation of scat tissue Relieve pruritus Maintain/restore moisture 102

103. Scar Massage Techniques: ⚫ Deep friction massage□ to loosen scar adhesions Finger and thumb kneading □ mobilize the scar and surrounding tissue Effleurage □ to increase circulation Skin rolling □ restore mobility to tissue interfaces Wringing □ stretches scar and promote collagenous remodeling Retrograde massage to aid venous return, increase lymphatic drainage, mobilize fluid 114 □ Massage techniques can be used in conjunction with ROM exs

104. Guidelines for massage during 3 stages of healing: Inflammatory phase: helps to decrease oedema and increase blood supply Proliferative phase: applies gentle stress to the healing scar; to ensure correct alignment of collagen tissues Remodeling phase : massage should be progressed to include prolonged stretching to minimize adhesions; that aids in scar tissue breakdown 115

105. Practical considerations and safety : Clean hands essential Use non irritating lubricant Modify practice according to pt. stage of healing and pain levels Contraindications: Compromised integrity of epidermis Acute infection Bleeding Graft failure Intolerable discomfort 116

106. Camouflage Make-up Used for scars of face, neck and hands Mostly used when a person has either hyperpigmentation or hypopigmentation It can also be used before scar maturation; so if pt. wants to go out in public The cosmetics are opaque, color-correct burn scars and are available in multiple shades to accommodate various skin colors They also are waterproof and worn during all activities 106

107. The Role of Physiotherapist in rehabilitation of the chronic Burn patient Scar management is initiated in the sub-acute phase, but it may need to be continued long term, as many patient suffer from continuing limitation of ROM Healing process may continue for up to two years, or more, as scar tissue remodels and matures Patient may require functional retraining and integration back into the community and activities 107

108. Aerobic and Resistance Training Post Burn Rationale for training: Low cardiovascular endurance Lower aerobic capacity measured by VO2 max and time to fatigue at one year post burn compare to age matched healthy control (adults and children > 15% TBSA) Muscular strength and lean body mass has been found to be significantly less in pts. Suffering from burns of 30% TBSA Reduced lean body mass, endurance and strength has been associated with limited standing/walking tolerance Reduced upper limb function and lower health related QOL and ability to participate in activities 108

109. Aerobic capacity and muscular strength is diminished by the following factors : ⚫ Prolonged bed rest necessary in the early recovery process 109 ⚫ Hyper metabolism; which may lead to: - Exhaustion Protein catabolism Loss of lean body mass Impaired thermoregulation Inhalation injuries and compromised respiratory function Fatigue Pain Psychological factors

110. Aerobic training recommendations for practice: Frequency: 3 days/week; (3-5 days/week) Intensity : moderate to high intensity i.e., 65%% 85% of MHR Type: Interval, continuous; using treadmill, walking, running exercises Time: 20-40 minutes/session 6-12 week programme 110

111. Resistance training recommendations for practice: Frequency: 3 times/week (break of more than 48 hrs. must be given between bouts of resistance training as; resistance exs . Causes microtrauma to muscles already in compromised state resistance exs . In burned pts. stimulates protein synthesis ) Intensity/Type/time: 1 set of 50-60% of 3 RM at 1 st week 70-75% of 3 RM for next 2-6 weeks (4-10 reps) 80-85% of 3 RM for 7-12 weeks (2-6 reps) 111

112. Mixed and functional strengthening 112 Given for specific targeting muscle groups for desired functional goal Progression made by aiding resistive devices and finally using free weight training Initiate with 50-60% of 1 RM for 10-15 reps and than progress further as per pt.’s need over 12 weeks

113. Safety considerations for strength and aerobic training: Post burn 6 months to 2 years time given before initiation of programmes or In case of 40% TBSA it can be started after; 95% healed wounds/scars ambulatory psychological status Ensure patient is taking Optimal nutrition and other medications Monitoring of HR, BP, SPO2 & RPE before during and after 124 exercises

114. Psychological Aspects of Burn patient 125 Depression and post traumatic stress disorder are most common disorders following burn Pain and cosmetic appearance of individual Treatment Psychotherapy CBT Medications (SSRI) Social skills training and community intervention Vocational rehabilitation

115. Ultrasound Therapy after skin grafting 127 UST can be given on alternate day started from 14 th day to 21 st day after skin grafting Dosage: 1MHz, 0.5-0.8 W/cm 2 , for 5 min □ (EFFECTIVENESS OF PHYSIOTHERAPY AFTER SKIN GRAFTING- Indian journal of physiotherapy & occupational therapy, dec-16 )

116. First Aid in burns DO’s 128 Stop the burning process by removing clothing and jewelry In electrical burns, put the main switch off as quick as possible and use wooden chair to push victim away from electricity Extinguish flames by pouring plain water; if water is not available by applying a blanket & removing the blanket as soon the flames are put off In chemical burns, remove or dilute the chemical agent by irrigating large amount of water Use cool running water to reduce the temperature of the burn Take care of fractures and probable injuries during transportation. Ensure A,B, C before transportation to higher center

117. Don’ts 129 Don’t start first aid before ensuring your own safety Don’t apply ice it may damage the injured tissues Avoid prolonged cooling with water it may causes hypothermia Don.t apply any ointments Don’t open blisters with pin, needle until topical antimicrobials can be applied