Burns and Wound Healing Overview

Burn Overview

• Burns are the 4th most common type of trauma globally, following traffic accidents, falls, and interpersonal violence.
• Most burns occur at home, often while cooking.
• Pediatric burns happen more commonly at home, usually due to unsupervised situations.
• Adults are equally likely to sustain home, outdoor, or workplace burns.
• Elderly individuals are most likely to experience burns in the bathroom, followed by the kitchen.

Acute vs Chronic Wound

• Acute wounds heal quickly and are typically resolved in a timely manner.
• These wounds follow a clear, orderly process.
• They are usually caused by isolated, non-recurring injuries.
• Chronic wounds do not heal in a timely manner and can be complicated by underlying pathologies
• Absence of healing may be due to minor trauma
• Chronic wounds are characterized by a lack of progressive healing over a protracted period, and may be uniform in depth.

Burn Wound Zones

• Zone of coagulation: The inner zone of the burn wound; characterized by cellular necrosis or death.
• Zone of stasis: Surrounds the zone of coagulation; exhibits decreased blood flow, inflammation, and cellular injury. This area may be salvageable and potentially susceptible to further injury.
• Zone of hyperemia: The outer zone of the burn; shows the least cellular injury and increased blood flow; full recovery is likely in this zone.

Types of Chemical Burns

• Chemical burns are caused by a variety of caustic reactions.
• The alterations of pH, disruption of cellular mechanisms, and direct toxic effects on metabolic processes are important factors in causing injury.
• Factors determining severity include exposure duration and the nature of the chemical agent.

Types of Thermal Burns

• Temperature is a key determinant for the severity of thermal burns, with protein denaturation occurring at 40°C.
• The duration of contact and the thickness of the skin also influence the severity and healing potential of a thermal burn.
• Depth of injury significantly impacts healing potential and the potential need for surgical intervention.

Frostbite Burns

• Frostbite injuries damage skin and underlying tissues due to ice crystals puncturing cells or a hypertonic tissue environment.
• This can disrupt blood flow, leading to hemoconcentration, intravascular thrombosis, and tissue hypoxia.
• Frostnip manifests as whitening of exposed areas but does not frequently result in lasting damage, but it may raise the risk of frostbite with repeated exposure.

Types of Electrical Burns

• Electrical burns result from the transformation of electrical energy into thermal energy because the current passes poorly through body tissues.
• Electrical injury also affects cell membranes, disrupting membrane potential and function.
• Determining severity of injury depends on the voltage and amperage of the current, duration of exposure, and the pathway of the current.
• Cutaneous damage does not consistently reflect the extent of injury.

Burn Depth and Classification

• Burn depth is a significant determinant impacting mortality and long-term function.
• Deeper wounds result in more extensive tissue destruction and longer healing times and tend to result in more scarring.
• Partial thickness wounds usually heal spontaneously without surgery, within 2-3 weeks, with minimal or no functional impairment.

Burn Depth Classification

• Old classification systems usually use terms such as first-degree (or epidermal), second-degree, third-degree (or full-thickness), and fourth-degree burns.
• Newer classifications utilize terms such as superficial, superficial partial thickness, deep partial thickness, and full thickness burns.

Burn Depth Characteristics

• Superficial burns involve only the epidermis layer, healing within days with minimal scarring.
• Superficial partial thickness involves the epidermis and dermis layers, resulting in blistering, pain, moisture, and reduced blanching, with healing time ranging from 7 to 21 days.
• Deep partial thickness involves the epidermis and dermis layers, resulting in blisters that tend to dry, reduced or absent blanching, absent pain sensation, and significant pain with deep pressure, with variable healing time, potential for scarring.
• Full thickness burns involve all skin layers impacting function. Characterized by significant pain with pressure, inelastic, waxy appearance, and the absence of blanching, with healing potentially requiring surgical procedures.

Burn Depth and Total Body Surface Area (TBSA) Calculation

• The average surface area of an adult's skin is ~1.82m2
• Neonates have ~0.25m2.
• Calculating TBSA accurately is crucial for treatment and patient prognosis, utilizing charts tailored to specific age groups (e.g., Lund and Browder Chart).

Burn Severity

• Factors such as patient age, associated injuries like inhalational injuries or head injuries, and co-morbidities are crucial in determining burn injury severity.
• TBSA burned, depth of injury, and location of the burn on the body are other crucial determinants of severity.
• Different severity levels (e.g., minor, moderate, major) are categorized based on these factors..

Local Response to Burn Injury

• Local responses to burns include vasodilation, increased extravascular osmotic activity, impaired cell membrane function, and microvascular permeability, which lead to edema.
• Decreased blood flow, ischemia, and necrosis occur within the burn wound, involving endothelial cells, platelets, and leukocytes.

General Response to Burn Injury

• Hypovolemia is a major concern in burn patients.
• Systemic changes in hemodynamics typically include initial cardiac output depression..
• Burn victims may experience altered thermoregulation; and inhalational injuries greatly impact pulmonary function.

Inhalational Injury

• Significant risk factor for morbidity due to reduced oxygen availability from exposure to toxic smoke components, particularly carbon monoxide and cyanide, which can be risk factors in some burns.
• Inhalational injuries increase the risk for pneumonia, adult respiratory distress syndrome (ARDS), and multi-organ system dysfunction.

Phases of Modern Burn Care

• Modern burn care is staged in phases:
• Initial evaluation and resuscitation (first phase), which involves evaluation, fluid resuscitation, and assessment for other injuries and comorbidities on the first three days after the injury.
• Wound excision and biologic closure (second phase), involving the serial staged operations such as debridements.
• Definitive wound closure and reconstruction (third phase), characterized by skin grafting or other reconstructive surgeries, including for the face and hands.
• Rehabilitation and reintegration (fourth phase), where the patient undergoes various rehabilitation and reintegration efforts to rebuild their lives and get to their normal activities.

Acute Burn Rehabilitation Positioning

• Proper positioning prevents contractures and compression neuropathies, keeping tissues elongated.
• Tailored positioning, including flexion, abduction, and extension, is crucial during rehabilitation.

Acute Burn Rehabilitation Splinting

• Splinting is indicated to maintain joint position, prevent deformities, and manage edema.
• Splints must be made of moldable materials and are compatible with dressings and topical medications
• Important: Easy to don and doff

Acute Burn Rehabilitation Exercises

• Maintaining normal range of motion (ROM) and strength is the initial goal of exercise programs.
• Stretching is indicated when ROM is limited.
• Strengthening exercises commence as soon as tolerated, with post-grafted patients requiring additional considerations.

Post-Acute Burn Rehabilitation Skin Care

• Immediately after a burn, the skin is easily damaged and susceptible to sun and chemical exposure, so moisturizing with sun blocks helps.
• Advise patients about using mild soaps and detergents, and not prolonged water exposure.
• Massage skin frequently to stimulate blood circulation.

Post-Acute Burn Rehabilitation Scarring

• Within 1-3 months, hypertrophic scars that are raised, irregular, and red, often regress spontaneously over time.
• Differentiate from keloids, which persist and grow beyond the original wound boundaries.

Post-Acute Burn Rehabilitation Scar Management

• Pressure techniques help align collagen fibers, thereby promoting a relatively normal scar appearance.
• Custom compression garments maintain at least 25 mmHg pressure to promote proper collagen maturation and reduce scar-related edema.
• Custom-fitted face masks, when applicable, can maintain facial contour and other appropriate adjustments are helpful for burn rehabilitation.

Neuromuscular Complications in Burn Injuries

• Focal and multiple peripheral neuropathies can occur in burns.
• Faulty positioning, improperly applied bandages, or bulky dressings can cause these complications.
• Factors such as age and extent of burns correlate with the incidence of such neuropathies.

Neuromuscular Burn Complications: Heterotopic Ossification

• Heterotopic ossification involves abnormal calcification in tissues surrounding joints.
• Risk factors include TBSA burned, open wounds, and immobility.
• The posterior elbow is frequently affected, followed by the hip or shoulder in children and adults, respectively.

Burn-Induced Amputation

• Electrical burns commonly cause amputations, disproportionately affecting upper extremities.
• Patients experience skin fragility, hypertrophic scarring, and burn contractures.
• Altered skin sensation also increases the difficulty of the rehabilitation.
• Early amputee and burn patient prosthetics result in better long-term outcomes.

Functional Training

• Functional training integrates therapeutic exercises with age-appropriate activities like ADLs and play.
• This approach promotes functional development.

Return to Work

• Factors such as the extent of TBSA injured, presence or absence of a hand burn, and patient age correlate with the length of time required for return to work post-burn injuries.
• Proper considerations of the patient's strength, range of motion, and endurance levels during work adjustment are crucial to returning to work, and this may necessitate a change in occupation in some cases.

This quiz covers key aspects of burns, including their common causes and characteristics in different age groups. It also distinguishes between acute and chronic wounds, highlighting their healing processes and underlying issues. Test your knowledge on burn wound zones and their implications for treatment.