Burns management

Burn is coagulative necrosis of the skin’s tissues, usually caused by excessive heat
Excess heat causes rapid protein denaturation and cell damage
Wet heat (scald) travels more rapidly into tissue than dry heat (flame)
A surface temperature of over 60˚C produces immediate cell death as well as vessel thrombosis
The dead skin tissue is known as Eschar

1. BURNS A Physiotherapeutic Approach Dr.Nidhi Ahya (Asst Prof) Cardiovascular and Respiratory PT DVVPF College of Physiotherapy, Ahmednagar 414111

2. Objectives Normal Skin- Structure & Function Burns Epidemiology Pathophysiology of Burn Injury Assessment of Burn Injury Management of Burns Medical Physiotherapy

3. NORMAL SKIN Skin is a bilayer organ Layers: Epidermis Dermis

4. Epidermis D ermis

5. BURN Burn is coagulative necrosis of the skin’s tissues, usually caused by excessive heat

6. Heat injury Excess heat causes rapid protein denaturation and cell damage Wet heat (scald) travels more rapidly into tissue than dry heat (flame) A surface temperature of over 60˚C produces immediate cell death as well as vessel thrombosis The dead skin tissue is known as Eschar  

7. Inflammatory Mediator Injury (1 to 3 day) Inflammatory response initiated by the heat injury leads to activation of proteases, neutrophil induced tissue hypoxia and is responsible for - Early tissue damage, Increased capillary permeability and Responsible for wound conversion inflammation becomes excessive by deactivating growth factors

8. Ischemia induced injury Instant surface vascular thrombosis occurs along with cell death Injured capillaries can continue to thrombose due to initial heat Subsequent mediator injury to endothelial cells Further ischemia and further tissue necrosis.

9. Classification of Burn Wound Earlier classified based on Severity : First degree Second degree Third degree Currently based on Depth : Superficial Superficial Partial Thickness Deep partial thickness Full thickness Subdermal

10. Complications of Burns

11. Infection Pulmonary complications Metabolic complications Cardiac function & circulatory complications Heterotopic Ossification Neuropathy Pathological Scars

12. ABC’S IN THE BURN PATIENT

13. Stop the Burning Process Treat Carbon Monoxide Toxicity immediately Manage airway injury from Smoke and Heat Manage Pulmonary Problems from Smoke Correct Chest wall Restriction Recognize the Burn Induced Plasma Shift Begin Fluid Resuscitation for Major Burns Correct Blood Flow Restriction from Burn Tissue Compression

14. Assessment Look for other traumatic injuries (falls, explosions, blunt trauma). Estimate percent (%) of body surface burned in order to estimate isotonic fluid requirements "Rule of Nine". Use burn resuscitation formula remembering to add more fluid or blood for other traumatic injuries.

15. Estimating the size of the Burn as a % of the (TBS)

16. Wallace’s Rule of nines -not accurate

17. Emergent Phase (Resuscitative Phase) Lasts from onset to 5 or more days but usually lasts 24-48 hours Begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins Greatest initial threat is hypovolemic shock

18. Management Anaesthetic consultation High flow oxygen Tracheobronchial toiletting [ bronchoscopy ] Physiotherapy Close monitoring [preferably ICU ] Ventilatory support Hemodynamic support, when required

19. Initial Assessment & Management Stridor Retraction or Respiratory Distress present or Deep Burns: Face, Neck

20. MAINTAINING HEMODYNAMIC STABILITY Early fluid resuscitation is required for burns exceeding 20% of body surface.

21. Fluid Resuscitation Protocol Establish and maintain adequate circulation ↓ Maintain : Blood Pressure>90 systolic Urine output 0.5-1.0ml/kg/hr Pulse <130 Temperature >37°C Modify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients

22. Initial Wound Management Assure adequate ventilation and perfusion Remove heat source and any constricting items Maintain body temperature Cool water for small second degree burns only Assess size and depth “Rule of Nine” Tetanus Prophylaxis

23. Escharotomy Full thickness deep dermal burns which are nearly circumferential on the limbs, neck, thorax will act like tourniquets with the development of edema. Escharotomies are longitudinal or crisscross incisions through such deep burns. This can be done without analgesia and on the ward as the affected skin is usually insensate and does not bleed much.

24. Skin Grafting Skin used for a graft removed with a dermatome 2 types: Split Skin Grafting ( SSG ) Full Thickness Skin Graft SSG : Epidermis + Sup. Dermis FTSG : Full dermal thickness

25. Sheet Graft: Graft applied to the recipient bed without alteration after harvesting from donor site Face, neck and hands are covered with this for cosmesis Mesh Graft: Processing the sheet graft – making tiny parallel incisions in linear fashion Graft expands & covers large areas

26. Rehabilitation Phase Defined as beginning when the patient’s burn wound is covered with skin or healed and patient is capable of assuming some self-care activity. Can occur as early as 2 weeks to as long as 2-3 months after the burn injury Goals for this time is to assist patient in resuming functional role in society & accomplish functional and cosmetic reconstruction. Scars may form & contractures. Mature healing is reached in 6 months to 2 years Avoid direct sunlight for 1 year on burn new skin is sensitive to trauma

27. Physical Rehabilitation Prevention of scar contracture Preservation of normal ROM Prevention of hypertrophic scar Minimizing cosmetic deformity Muscular strengthening Cardiovascular endurance Return to function Performing ADL’s

28. Goals (APTA, 1999) Enhance wound & soft tissue healing Reduce risk of infection & complications Reduce risk of secondary impairments Attaining full ROM Restoring cardiovascular endurance Good to normal strength Independent ambulation Independent ADL’s Minimal scar formation Caregiver understanding towards the goals Increasing aerobic capacity Improving self management of symptoms

29. Scar contractures can be prevented by: Positioning Splinting Exercise Following wound closure: Massage Compression therapy

30. Positioning Goals: Minimizes edema Prevent tissue destruction Maintain soft tissue length

31. Splinting Extension of positioning program Anti-deformity positions Indications: Prevent contractures ROM Correction of contractures Protection of a jt or tendon Worn in night Mostly static splinting in burns

32. Exercises Active & passive exercises Grafting done – delay exs for 3 – 5 days After clearance – active 1 st & then passive Active assisted Resistive & conditioning exs

33. Early Active ROM and Mobility ROM- First Active then pasiive overpressure Repetitions- 5 to 7 at one time, gradually increase as per patient tolerance PNF- Hold Relax and Contract Relax techniques can be helpful in maintaining as well for increasing ROM Bed mobility and Transfers should be encouranged as early as possible. Independent Ambulation should be encouraged depending on individual patient’s condition

34. Scar Management Pressure hastens scar maturation & minimizes hypertrophic scar Mech: Thinning the dermis Altering biochemical structure of scar Decreasing blood flow to area Reorganizing collagen bundles Decreasing tissue water content

35. Massage Deep friction massage – loosen scar Skin pliability & texture improves Edges or seams of grafts benefit 5 -10 min , 3 – 6 times daily

36. Summary Normal Skin- Structure & Function Burns Pathophysiology of Burn Injury Assessment of Burn Injury Management of Burns

37. QUESTIONS WRITE THE PATHOPHYSIOLOGY OF BURNS.5MARKS WRITE THE MANEGMENT OF BURNS.

38. Thank you