Burns: Types, Etiology, and Classification

• Burns can be caused by heat, electricity, chemicals, friction, or radiation leading to skin injury

Types of Burns According to Etiology

• Thermal burns are caused by conduction or convection
• Electrical Burns are caused by the passage of electrical current through the body
• Chemical Burns occur when chemical compounds contact the body
• Radiation Burns are most commonly associated with exposure to external beam radiation therapy

Classification of Burns

Epidermal Burn

• Only damages to the epidermis
• Sunburn is a common example
• Skin will appear red or erythematous
• The surface will be dry
• Blisters will be absent, but slight edema may occur
• Epidermal layers will peel off within 3-4 days
• Epidermal healing occurs spontaneously

Superficial Partial Thickness Burn

• Damage extends through the epidermis into the papillary layer of the dermis
• Intact blisters will be present
• Surface is moist if blisters are removed
• Wound will be bright red and will blanch
• Moderate edema can occur
• Wound is extremely painful
• Complete healing takes approximately 7-10 days
• Minimal scarring

Deep Partial Thickness Burn

• Involves destruction of the epidermis and papillary dermis with damage down into the reticular dermal layer
• Nerve endings, hair follicles, and sweat ducts will be injured
• Appearance is mixed red or waxy white
• Capillary refill will be sluggish
• Surface is usually wet from broken blisters
• Diminished sensation to light touch or sharp/dull discrimination exists
• It will heal in 3-5 weeks if infection does not occur
• Hypertrophic and keloid scars can occur

Full Thickness Burn

• All epidermal and dermal layers are completely destroyed
• Subcutaneous layer may be damaged
• Characterized by a hard, parchment-like eschar (scab) covering the area
• Eschar color may vary from black to deep red to white
• No blanching of the tissue is observed
• Wound will be insensate
• Requires skin grafting

Subdermal Burn

• Complete destruction of all tissues from the epidermis down through the subcutaneous tissue
• Muscles and bones are subjected to necrosis when burned
• Occurs with prolonged contact with a heat source and often results from contact with electricity

Electrical Burn Details

• A burn results from the passage of electric current through the body after making contact with an electric source
• Electric current follows the path of least resistance offered by various tissues
• Entrance wound will appear charred, depressed, smaller than the exit wound, yellow, and ischemic
• Exit wound is the ground site, it appears as though there was an explosion out of the tissue in the site, and is dry in appearance

Burn Wound Zones

Zone of Coagulation

• Cells are irreversibly damaged and skin death occurs
• Equivalent to a full-thickness burn, requiring a skin graft

Zone of Stasis

• Contains injured cells that may die within 24-48h without sufficient treatment
• Infection, drying, or inadequate perfusion in this zone may convert salvageable tissue to necrotic tissue, enlarging the coagulation zone

Zone of Hyperemia

• Site of minimal cell damage as tissue should recover within several days with no lasting effects

Complications of Burn Injury

• Infection
• Pulmonary Complications
• Metabolic Complications
• Cardiovascular Complications
• Heterotopic Ossification
• Neuropathy
• Pathologic Scars

Medical Management of Burns

Initial Management Goals

• Address critical life-threatening problems
• Stabilize the patient
• Establish and maintain an airway
• Prevent cyanosis, shock, and hemorrhage
• Establish baseline data on the patient (extent and depth of the burn injury)
• Prevent or reduce fluid losses
• Clean the patient and wounds
• Examine injuries
• Prevent pulmonary and cardiac complications

Initial Wound Care

• Establish body weight
• Fully examine the patient
• Remove hair where necessary
• Start debridement by removing loose skin

Cleansing and Debridement Goals

• Remove dead tissue
• Prevent infection
• Promote revascularization and or epithelialization

Wound Care

• Wound cleansing is often done using a large hydrotherapy tank or whirlpool tub, usually containing a disinfectant

After Dressings are Removed

• Inspect it carefully checking for appearance, depth, size, exudate, and odor

Wound Care

• It is carried out using clean technique and sterile instruments
• Keep the patient warm to reduce further metabolic demand

Open Technique

• Applying a topical cream or ointment without dressings which allows consistent observation of the wound and examination of the healing process

Closed Technique includes

• Applying dressings over a topical agent

Dressings Serve Several Purposes

• Holding topical antimicrobial agents on the wound
• Reducing fluid loss from the wound
• Protecting the wound

How Often

• Dressings are changed once or twice a day depending on the size and type of wound
• Dressings consists of several layers
• First layer is nonadherent to protect the fragile healing surface from disruption.
• This may be followed by cotton padding to absorb wound drainage
• The final layer consists of roll gauze or elastic bandages, which hold the other layers in place but allow movement

Surgical Management for Burns

Primary Excision

• Surgical removal of eschar, including removing peripheral layers of eschar until vascular, viable tissue is exposed for skin graft placement
• Promotes faster healing, reduces infection and scarring, is more economical in terms of staff and hospital time
• Autograft; patient's own skin, taken from an unburned area and transplanted to cover a burned area is permanent
• Allograft; skin taken from an individual of the same species, usually cadaver skin is temporary
• Xenograft skin from another species, usually a pig

Physical Therapy Management

• Rehabilitation begins once admitted and throughout the process
• Physical therapy interventions are directed toward prevention of scar contracture
• Preservation of normal ROM
• Prevention or minimization of hypertrophic scar formation and cosmetic deformity
• Maintenance or improvement in muscular strength and cardiovascular endurance
• Return to pre-burn function
• Performance of activities of daily living (ADL)

Physical Therapy Examination

• After the initial examination for depth of burn and involved TBSA, the PT assesses for impairments and activity limitations
• Examined and monitored routinely because the dynamic nature of healing may occur daily, and the Therapist needs to examine and monitor patients routinely for changes in skin integrity, ROM, and functional mobility
• In addition to the physical damage imposed by a burn, there also may be an enormous psychological impact

Physical Therapy Intervention

• Positioning and Splinting
• Goals are to minimize edema; prevent tissue destruction, maintain soft tissues in an elongated state; and preserve function
• General indications for the use of splints include prevention of contractures
• Maintenance of ROM achieved during an exercise session or surgical release
• Reduce developing contractures
• Assist with protection of a joint or tendon
• Reduce the overall pain experience

Therapeutic Exercise

• Active and Passive Exercise
• Resistive and Conditioning Exercise
• Ambulation
• Scar Management