Burns Rehabilitation

Significant advances in management have resulted in an increase in survival after burn injury in regions of the world with access to current medical and surgical resources. As a consequence, burn survivors with access to up-to-date care and who tend to be young adults have long-term sequelae that impair function and limit
return to preinjury function, including work and community
reintegration. Up to 1 million burns require treatment annually in North America, and over 10 times as many burns occur worldwide. In low-income and middle-income countries, mortality is significantly greater than in high-income countries.The future
of burn care will be challenged by the expense and complexity of treatment, a predicted shortage of qualified burn care providers, and an aging population.

1. Burns Rehabilitation Dr Joe antony Physical medicine and rehabilitation KGMu , Lucknow 1

2. Contents Introduction Etiology Acute burn management Immediate assessment and fluid resuscitation Burn referral criteria Organisation of a burn centre Acute physiatry assessment Acute pain management Acute surgical procedures Inhalational injury Tachycardia after burns Nutrition Chronic burn problem areas Heterotopic ossification Peripheral neuropathies Scar-related complications Burns amputation and prosthetics Psychosocial adjustment Community reintegration 2 If you want to live, consult an intensivist ! If you want to have good scars, see a plastic surgeon ! If you want to enjoy the life, Consult a Physiatrist

3. Introduction A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. 1 According to a study 2 conducted in Lucknow from 2008 to 2013 2225 deaths due to burns in 5years in lucknow 87 % of burns are of females 50.4% burns occurred in night 82% occurred at home 60% burns death was due to flame burns 1.WHO Burn statistics 2. Kumar S, Ali W, Verma AK, Pandey A, Rathore S. Epidemiology and mortality of burns in the Lucknow Region, India--a 5 year study. Burns. 2013 Dec;39(8):1599-605 3

4. etiology GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 4 Other conditions managed in similar principles to burns- Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), and necrotizing fasciitis

5. Immediate assessment and care- As per atls protocol Primary survey Airway assessment and protection (maintain cervical spine stabilization when appropriate)- needle cricothyrotomy in facial and suspected inhalational burns Breathing and ventilation assessment (maintain adequate oxygenation) Circulation assessment (control hemorrhage and maintain adequate end-organ perfusion) – circumferential burns to be assessed and escharotomy to be done Disability assessment (perform basic neurologic evaluation) Exposure, with environmental control ( undress patient and search everywhere for possible injury, while preventing hypothermia), thorough wash of entire patient absolutely necessary. Sabistons textbook of surgery- biological principles of modern surgery 5

6. Fluid resuscitation Parkland formula Current practice First 8 hours fluids given as per parkland formula Then fluid titrated with Urine output- target of 30ml/hour or 1ml/hour With close monitoring to avoid pulmonary fluid overload GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 6 Other methods- Brooks formula,Evans formula, Monafa formula Fluid of choice is Ringers lactate in first 24 hours

7. BURN CENTER REFERRAL CRITERIA BY AMERICAN BURNS ASSOCIATION Second- and third-degree burns >10% body surface area (BSA) in patients <10 or >50 years old . Second- and third-degree burns >20% BSA in other groups. Second- and third-degree burns with serious threat of functional or cosmetic impairment that involve the face. hands, feet, genitalia, perineum. and major joints . Third-degree burns >5% BSA in any age group. Electrical burns , including lightening injury. Chemical burns with serious threat of functional or cosmetic impairment. Inhalation injury with burn injury. Circumferential burns with burn injury. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. Any burn patient with concomitant trauma (for example, fractures) in which the burn injury poses the greatest risk of morbidity or mortality. Hospitals without qualified personnel or equipment for the care of children should transfer burned children to a burn center with these capabilities. 7

8. ORGANIZATION OF a BURN CARE center Essence of successful burn care is the team . No individual Is capable of meeting the many acute and long-term needs of the burn patient. Therefore, burn care is best delivered in a specialized burn center where experienced Physicians - Plastic surgeons, Critical care specialists, Physiatrists and pediatric intensivist Nurses Physical and occupational therapists Nutritionists Psychologists Social workers Patients with burn injuries qualifying the referral criteria should be referred to a burn center. GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 8

9. Acute physiatric assessment of burned individual BRADDOM TEXTBOOK OF PHYSICAL MEDICINE AND REHABILITATION 9

10. CALCULATION OF BURN SURFACE AREA BORDER AND LUND CHART RULE OF 9’S PALM METHOD One palm area is approximately 1 percentage Useful only in small area burns. GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 10

11. ASSESMENT OF DEPTH OF BURNS BURN DEGREE CAUSE SURFACE APPEARANCE COLOR PAIN LEVEL First(superficial) Flash burn, ultraviolet (sun burn) Dry, no blisters, no or minimal edema Erythematous Painfull Second(partial thickness) Contact,flash.Scald , flame ,chemical and electrical Moist blebs and blisters Mottled white to pink, cherry red Very painfull Third(full thickness) Contact,flash.Scald , flame ,chemical and electrical Dry with leathery eschar until debridement,charred vessels under eschar Mixed white, waxy. Pearly, dark, khaki, Mahogany, charred No pain. Hair pullout easily Fourth(involves underlying structure) Prolonged contact, flame and electrical Same with 3 rd degree, possible with exposed bone tendon and muscle Same as 3 rd degree Same as third degree GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 11

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13. Immediate wound care Wounds are cleansed with soap and water. Loose tissue and blisters are debrided . Body and facial hair are shaved if involved in the area of a burn. Daily wound care is performed on a shower table with soap and water. If the burn wound is small, at the patient's bedside following a shower Burn injury destroys the body's protective layer from the environment Dressings are needed to protect the body from infection and minimize evaporative heat loss from the body. The ideal dressing if it existed would be inexpensive, easy to use, require infrequent changes, and be comfortable. GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 13

14. Purpose Agents Superficial burns Soothening of burns Aloe vera based agents Partial thickness Keep the wound moist and provide antimicrobial protection . Silver based dressings Full thickness Protect the eschar from microbial colonization Silver based dressings After debriding the eschar Optimizing the epithelisation Greasy gauze (tulle gras dressing) and antibiotic ointment Deep burns Protect upto excision Silver based dressings GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 14 Dressing which can be used for all purpose- Human amniotic membrane and Wet collagen sheet

15. Topical agents Silver sulfadiazine Broad-spectrum antimicrobial coverage, with excellent staphylococcus and streptococcus coverage. Incapable of eschar penetration .(Useless in infected burn) Pseudoeschar that requires removal by cleansing during daily wound care.( Which is painful) ADR- leukopenia and allergy Mafenide ( Sulfamylon ) Broad antimicrobial spectrum , including gram-positive and gram-negative organisms Eschar penetration present Have to apply twice daily Effective in suppurative chondritis ADR-potent carbonic anhydrase inhibitor and, therefore, can cause a metabolic acidosis Painful to apply Silver nitrate Broad-spectrum coverage against gram-positive and gram-negative organisms Painless on administration Needs to be applied every 4 hours to keep the dressings moist Drawbacks Stains everything black Hypo-osmolar -hyponatremia and hypochloremia Methemoglobinemia GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 15

16. Acute pain management Acute burn pain is typically significant and is magnified by procedural pain associated with dressing changes, mobility, stretching, and surgery. Opioid s remain the mainstay of acute pain management. Treatment requires frequent reassessment because an individual’s pain may change drastically around events, such as wound closure or participation in therapies. Adjuncts to opioids, such as distraction, or anxiolytics , may be used, particularly for the pediatric burned individual. Braddoms textbook of PMR 16

17. Acute surgical procedures Escharotomy Circumferential burns Wound edema, stiff eschar, and the fluids required for resuscitation– precipitate compartment syndrome of limbs Eschars on chest affecting respiration Wound left open and closed at later stage Splinted for 24hours in neutral position Then passive and active ROM exercises has to be started Early debridement and Autologous ssg Braddoms textbook of PMR 17 Reduces the inflammatory stimulation from burn eschar and other necrotic tissues and limits the risk of infection. Recipient site- excision/debridement Donor site- unburnt skin Donor preparation-meshing Compressive dressing – avoid shearing force at any cost Immobilize for 5 days Then passive as well as active exercises can be started Other surgeries patient might need are Tracheostomy and surgeries of concomitant trauma

18. Inhalational injury Burned individuals with inhalation injuries are at risk for developing pneumonia, adult respiratory distress syndrome, and multisystem organ failure. Early tracheostomy in individuals likely to require prolonged intubation has not been shown to change pulmonary outcomes, but it does offer advantages for oral hygiene and management of facial burns . No evidence that inhalation injury predisposes burned individuals to pneumonia in the rehabilitation setting Routine oxygen monitoring during therapies in not necessary if otherwise not indicated Braddoms textbook of PMR 18

19. Tachycardia after burns Systemic Inflamatory Response Stress Response Post Burn Hypermetabolic State Tachycardia Tachycardia Tachycardia Tachypnea Increased endogenous glucocorticoids production Muscle wasting Leukocytosis or leukocytopenia Increased sympathetic drive leading to increased catecholamine production Increased oxygen consumption Hyperglycemia Increased lipolysis and fatty acid metabolism Abnormal sarcomere functioning- uncoupling of mitochondrial High CRP Bone mineral loss Thrombocytopenia Insulin resistance Bleeding disorders Browning of white adipose tissue The role of the musculoskeletal system in post-burn hypermetabolism, Metabolism , 2019-08-01, Volume 97, Pages 81-86 19

20. Post Burn Hypermetabolic State Results in prolonged catabolic effects on the body, including growth failure in children that can last for at least a year following discharge from hospital. Can cause death due to hypertrophic cardiomyopathy. Management Nutritional- high-calorie diet Physical therapy- early mobilization Pharmacological Anabolic drugs- Oxandrolone - adults - 10 mg twice a day and 0.1 mg/kg for children . Beta blockers- Propranalol - Started at 10mg TDS and titrated to bring heart rate less than 120/min Human growth factor The role of the musculoskeletal system in post-burn hypermetabolism, Metabolism , 2019-08-01, Volume 97, Pages 81-86 20

21. Nutrition Enteral feeding should be instituted early after injury. Start with NG tube or OG tube if oral feeding is not possible This helps maintain gut immunity and motility while providing the necessary calories and nutrients to counter the hypermetabolic response to burn injury. Total calorie requirement (by Curreri Formula) Adults- 25kcal/Kg body wt + 40kcal / 1%tbsa Children - 60kcal/Kg body wt + 35kcal / 1%tbsa Protein requirement- 2gm/kg body weight (in normal GFR) Vitamin A,C E, Zinc and selenium supplements are beneficial Iron supplement can cause higher concentrations of ferrous ions on wound bed and can increase rates of infection GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 21 Curreri formula overestimate Harris Benedict formula underestimates Better practice to use average

22. Heterotopic ossification(HO) In individuals with burn injuries greater than 30% TBSA , there is a risk of development of heterotopic ossification . The most common site of HO in burned individuals is the posterior elbow. More common in an affected limb and can be associated with edema and delayed wound closure over the elbow. Management is similar to HO in other conditions Braddoms textbook of PMR 22

23. Peripheral neuropathies Approximately 10% of individuals with major burns will develop Peripheral neuropathies Direct thermal injury, Electrical current, Compression, and metabolic derangements Median sensory nerve neuropathy is the most common neuropathy described in post burns. Shows improvement in about 1 year Surgical management not indicated Etiology Common pattern seen Deeper & large TBSA Axonal neuropathy Electric burn Mononeuropathy Long ICU stay Peripheral polyneuropathy ( Critical illness polyneuropathy) Braddoms textbook of PMR 23 Changes in Elctrodiagnostic studies due to burns Increased skin thickness due to hypertrophic scarring Inversely related to amplitude of responses Upregulation of Ach receptors distal to burn area Findings S/o acute denervation or membrane instability

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25. Dermo proliferative disorders Hypertrophic scar Excessive scar tissue that does not extend beyond the boundary of the original incision or wound. Can be painful , itchy and self limiting by 1 year Aetiology- prolonged inflammatory phase of wound healing and from unfavorable scar siting (i.e. Across the lines of skin tension) Keloid Excessive scar tissue that extends beyond the boundaries of the original incision or wound. Aetiology - Unknown Sabiston textbook of surgery and biological basis of modern surgery 25

26. Management of hypertrophic scar and keloid Prevention Silicone sheeting Intralesional steroid injections ( Triamcinalone ) Topical imiquimod 5% cream Fluorouracil cream Pulsed dye laser First line treatment Triple keloid therapy ( excision, steroid and silicone sheeting) Pressure dressing (24-20mmhg) worn for 6-24 months Intralesional inj triamcinalone Silicone sheets Pulsed dye laser Second line treatment Intralesional verapamil with excison Flurouracil intralesional injection Post surgical intralesional interferon alpha 2 b Post surgical radiation therapy Sabiston textbook of surgery and biological basis of modern surgery 26

27. Burn Scar pruritis Onset of pruritis- >3months burn Suggested mechanism- Increased mast cell and histamine presence in the burn scar. Increased nerve endings and substance p Management- topical moisturizer should be applied to all burned areas several times per day Small areas Colloidal oatmeal, and topical creams ( diphenhydramine, doxepin, and gabapentin ) Large areas Oral diphenhydramine, selective antihistamines, doxepin, hydroxyzine, and gabapentin Non pharmacological- LASER, massage and TENS ( not as efficacious as pharmacological mx) Braddoms textbook of PMR 27

28. Scar contracture Most common joints involved- shoulder, elbow, and knee Pathology- myofibroblasts and actin filaments seen in scar Prevention- splinting, positioning, and ROM exercises In acute setting- splints applied when patient is sleeping or sedated Once patient improves splints can be used whenever patient is not doing exercises Splints can be applied over fresh skin grafts also Braddoms textbook of PMR 28

29. Recommended positions to prevent contracture Joint Position Neck Extension, No Rotation Shoulder Abduction (90 ),Ext rotation, Flexion (15 ) Elbow and Forearm Extension and supination Wrist Neutral / Extention Hand Position of safety( intrinsic plus) ; Not Functional position Trunk Straight postural alignment Hip No flex/ ext , no rotation, Abduction 20 Knee Extension Ankle and foot Neutral or slight DF, No inversion/eversion, Toes neutral Orthotics and prosthetics in rehabilitation,Kevin k Chui, 4 th edition Green’s operative hand surgery, 8 th edition 29

30. Splints for face and neck burns Facial pressure garment with neck conformer splint Prevention of neck flexion and facial scar hypertrophy Microstomia prevention appliance In addition to stretching exercises Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th edition 30

31. Splints upper limb burns 3 piece aeroplane splint To prevent axillary contracture Elbow gutter splint To prevent elbow contractures Custom made gloves To use after SSG Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th edition 31

32. Sandwich splint Hand is “sandwiched” between these two padded supports, which are held in place with a circumferential wrap Thermoplastic pan hand splint Custom made silver impregnated glove Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th edition 32

33. Splints for Lower extremity burns Any foot drop splint with toe slings to prevent toe contracture Rest of the positions can be maintained without splints 33

34. Algorithm for management of burns contracture Green’s operative hand surgery, 8 th edition 34

35. Algoritham for management of burns contracture Green’s operative hand surgery, 8 th edition 35

36. Marjolins ulcer Malignant transformation of long-standing burns keloid. Referred to an oncosurgeon for surgical and adjuvant management 36

37. Burns amputation and prosthetics Electrical burn injuries – more likely lead to amputation. Electrical current damages nerve tissue, vascular tissue, and other deep structures more than skin structures C urrent can cause destruction of cells, coagulation of tissues, thrombosis of blood vessels, neuropathies, and tissue necrosis. Special considerations in prosthetic fitment Delayed fitting- due to scars, ulcers,multiple surgeries and hypermetabolic state More susceptible to bony spurs and HO Scars and poor skin condition- Anti shear liners and suspension materials will be needed Hypermetabolic state causes stump atrophy- should wait till weight is stabilized Contractures has to be accommodated Orthotics and prosthetics in rehabilitation, Kevin k Chui, 4th edition 37

38. Psychosocial adjustment Psychopathologies- depression, anxiety , PTSD, Sexuality concerns, and Body image problems Treatment will include behavioural therapies, pharmacological management, and peer group counseling . Braddoms textbook of PMR,6 th edition 38 Risk factors for depression in burn survivors Pre-burn affective disorders ( mood disorders) Coping styles ( people who engage in both avoidance and approach strategies) Demographic characteristics such as female sex, adolescents Burn characteristics- head or neck burns Disposition variables- longer hospital stays Risk Factors for PTSD Pre-burn characteristics -Personality -History of alcohol and substance abuse disorders -history of depression and other affective disorders Acute stress symptoms Anxiety related to pain Types and severity of baseline symptoms of PTSD Injury Characteristics Female sex Visibility of burn injury Social support Coping strategies

39. Community reintegration Risk Factors Pre-burn Psychiatric history Extremity Burns Electrical etiology Longer stay at hospital Burn injury occurred at work Barriers Wound issues Neurologic problems Physical abilities and impaired mobility Working conditions – temperature humidity and safety Psychosocial factors -Drug and alcohol dependence -insomnia -Depression -PTSD( nightmares and flashbacks) -anxiety Appearnce issues and concers over body image Braddoms textbook of PMR,6 th edition 39

40. Thank You References Braddoms textbook of PMR,6 th edition Sabiston textbook of surgery and biological basis of modern surgery,21 st edition GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY,7 th edition Orthotics and prosthetics in rehabilitation, Kevin k Chui, 4th edition The role of the musculoskeletal system in post-burn hypermetabolism, Metabolism, 2019-08-01, Volume 97, Pages 81-86 Green’s operative hand surgery, 8 th edition 40