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BURN INJURIES By Reham Elkalla Lecturer of physical therapy for surgery, BUC By the end of this lecture the student will be able to Recognize List the anatomy of integumentary system the functions of integumentary system Identify the incidence of burn injury Identify The different types of burn inju...

BURN INJURIES By Reham Elkalla Lecturer of physical therapy for surgery, BUC By the end of this lecture the student will be able to Recognize List the anatomy of integumentary system the functions of integumentary system Identify the incidence of burn injury Identify The different types of burn injuries Conduct the proper first aids for burn injuries Classify the degree of burn injuries Apply Conduct the proper evaluation for burned patient The proper rehabilitation program ANATOMY AND FUNCTION OF INTEGUMENTARY SYSTEM Skin is the Largest organ of the body and the first line of defense. In the average person, the skin weighs more than 4–5 kg. Receives roughly one-third of resting cardiac output. The thinnest skin is located on the eyelids and eardrums, while the thickest skin is located on the palms of the hands and the soles of the feet. Worldwide : an estimated 6 million people seek medical treatment for burns annually, but most are treated in outpatient clinics. In developing low- and middle-income countries, burn injuries are an indomitable problem than in the USA and Europe or other high income. INCIDENCE OF BURN INJURIES One-third of burn victims are children. In fact, fire and burn injuries are the second leading cause of death in children between 1 -4 yrs, and the third leading cause death in children under 19 yrs. Most burn injuries occur in the home, primarily in the kitchen and bathroom. In Egypt, Burn injuries represent a major problem However, the exact number of burns is difficult to determine. SKIN ANATOMY 1- Epidermis Outer layer of the skin. Avascular (has no blood vessels and receives nourishment from dermis. Thickness from 0.06 to 0.6 mm, with the thickest portions located on the palms of the hands and the soles of the feet. Consists of 5 stratums The deepest layer, the stratum basale, is attached to the dermis below by a thin, acellular basement membrane. Has three appendages located within the dermis: hair, glands, and nails. 2- Dermis Inner layer of skin. Highly vascular (has blood vessels) The dermis is 2–4 mm thick Consisting of two layers, papillary dermis (thin and superficial ) and The deeper, Reticular dermis makes up 80% of the dermal thickness. The papillary layer of the skin is responsible for fingerprints Contains blood vessels , Oil glands, Sweat glands, Hair follicles, Fat tissue, Nerves, Connective tissue. Superficial lymphatics are also located within the dermis. 3- Subcutaneous tissue (Hypodermis). Supports the skin and consists of adipose tissue and fascia. Adipose tissue is highly vascular, loose connective tissue that stores fat, which provides energy, cushioning, and insulation. Fascia is highly fibrous connective tissue and separates and surrounds structures and facilitates movement between adjacent structures, including muscle, tendon, and bone. Deeper lymphatic vessels are located within the subcutaneous tissue Functions of the Skin Protection Sensations Synthesis of vit. D Excretion of wastes Temperature regulation Determines characteristics FUNCTION OF THE SKIN Functions of the Epidermis Functions of the Dermis Provides a physical and chemical barrier Supports and nourishes epidermis Regulates fluid Houses epidermal appendages Provides light touch sensation Assists with thermoregulation Assists with infection control Assists with excretion Assists with thermoregulation Critical to endogenous vitamin D production Provides sensation Contributes to cosmesis/appearance Functions of the Subcutaneous tissue (Hypodermis). Gives smoothness and contour to the body, contains fat for use as energy production and provides insulation for body. Mechanical shock absorber Fat-soluble vitamins, A, D, E, and K are stored in adipose tissue of this layer. It provides cushioning over bony prominences, such as the greater trochanter of the femur, thus decreasing the risk of pressure ulcers. Deeper lymphatic vessels are located within the subcutaneous tissue Age-related changes in skin Sweat glands diminish in number. Atrophy of epithelial and fatty layers of tissue and become thin. Diminishing of the thickness of subcutaneous fat on the legs or forearms, even if abdominal or hip fat remains abundant. Fat loss from the subcutaneous tissue is causing the relative prominence of the bony protuberances of the thorax, scapula, trochanters, and knees. The loss of this valuable padding contributes to the development of pressure ulcers. Collagen and elastin shrink and degenerate. Collagen content of the skin decreases by approximately 1% per year throughout adult life. The net effect of all these changes is thin, dry, and inelastic skin that is increasingly susceptible to separation of dermis and epidermis as minor friction or shearing forces cause an injury known as skin tear elated Changes BURN INJURY It is a coagulation destruction of the skin or other body parts due to thermal, chemical, electrical, irradiation or atomic causes. Etiology of burn injuries ETIOLOGY OF BURN INJURIES Table 1: Types of burn injures 2-CHEMICAL BURN Acidic burn Occur if acidic chemicals come in contact with the integument, skin proteins neutralize the acid, causing coagulation necrosis and limiting the extent of tissue injury. Alkaline burn Occur when the alkaline chemicals denature the proteins within the skin causing liquefaction necrosis and deeper penetration of tissue damage. Therefore, burns resulting from alkaline chemicals tend to be more severe than burns due to acids. N.B. In addition to direct cutaneous damage from chemicals, inhalation of the fumes created by chemical spills can lead to pulmonary dysfunction. 3-ELECTRICAL BURN Recall that resistance is the impedance to the flow of electricity. Dry skin has a high resistance, whereas wet or moist skin has less resistance. Blood vessels and nerves have low resistance and are good conductors of electricity. Bone and muscle have higher resistances. Resistance to electrical flow results in heat production. The skin, because of its large external surface area, can dissipate this heat better than deeper tissues. Electrical injuries commonly present with a depressed or charred entrance wound and a larger, explosive appearing exit wound. Early and late neurological injuries, such as carpal tunnel syndrome and other mono- and polyneuropathies, are common. The flow of electricity through the body may also induce cardiac dysrhythmias, cardiac arrest, and pulmonary arrest. 4- RADIATION BURNS High-energy radiation is used to shrink or kill cancerous cells, and when it passes through the body, skin cells may be damaged, skin cells may not have enough time to regenerate, and sores or ulcers may develop. Chemical burn Scald burn Thermal burn Radiation burn Electrical Burns Electrical Burns FIRST AIDS FOR THERMAL BURN 1. Remove victim away from source of heat 2. Burning Clothes, A. If victim’s clothing is on fire, their airway will be at risk. B. Try to get the victim on the ground (stop, drop and roll) to put out the flames. C. If available, use a fire blanket to extinguish flames. Start at the victim’s head and work towards their feet. 3. Cool burned areas with cool running water (not ice). Cover burned area when cooled. 4. Call for medical assistance. FIRST AID FOR CHEMICAL BURN 1 2 3 4 1. Flush the affected area with cool running water for 20 minutes, repeat if necessary. No ice. 2. Make sure chemical does not reach unaffected areas. 3. Remove contaminated cloths away from the skin. 4. Call for medical assistance and tell them what type of chemical burn. First aids for electrical burn Don't touch the injured person if he is still in contact with the electrical current. Turn off the source of electricity if possible. If not, move the source away from both you and the injured person using a dry, non conducting object made of cardboard, plastic or wood. Call local emergency if the source of the burn is a high-voltage wire or lightning. Stay at least 20 feet (about 6 meters) away if wires are jumping and sparking. Don't move Don't move a person with an electrical injury unless he is in immediate danger and cover the affected area. Begin CPR if the person shows no signs of circulation (breathing, coughing or movement). Outpatient Management For 1st and 2nd degree burns less than 10% TBSA. Blisters should be left intact and dressed with silver sulfadiazine cream. Dressings should be changed daily washing to remove any cream left. Initial emergency(hospital) Procedures Fluid infusion must be started immediately NGT insertion to prevent, vomiting and aspiration. Urinary catheter to measure urine output Weight important and has to be taken daily. Local treatment delayed till respiratory distress and shock controlled Complete blood count and bacterial cultures necessary Local and systemic response to burn injury The local effect involves 3 burn zones 1- Zone of coagulation: The point of maximum damage. Irreversible tissue loss due to coagulation of constituent proteins. Characterized by coagulation, ischemia, and necrosis. 2- Zone of stasis: Surrounds the central necrotic region and represents an area of cellular injury and compromised tissue perfusion Red blood cells and platelets aggregate and may form microemboli, further impeding local circulation. Unless adequate perfusion is restored within 1 to 2 days after injury, these cells will not survive. Problems such as prolonged hypotension, infection or edema can convert this area into one of complete tissue loss. N.B This process of widening and deepening of the original area of necrosis is known as conversion 3- Zone of hyperemia The outer edges of tissue affected by the burn injury. These tissues receive the least thermal energy and sustain only minimal cellular injury. Characterized by erythema due to vasodilation and generally recovers within 7 to 10 days of injury. Systemic effect of burn injury Signs and symptoms of hypovolemic shock Restlessness, anxiety Skin – pale, cold, clammy Temperature below 37 oC Pulse is weak, rapid, systolic BP Urinary output < 20 mL/hr Urine specific gravity >1.025 Thirst Hematocrit 35; Blood urea nitrogen (BUN) BURN MANAGEMENT EVALUATION FOR BURNED PATIENT Is a continuing process of collecting and organization relevant information in order to plan and implement an effective treatment. Components of evaluation 1- Patient demographic data and history. 2- Burn severity index. 3- Edema and limb circumference 4- Sensory assessment. 5- Muscle strength assessment. 6- Joint ROM assessment. 7- Flexibility assessment. 8- Mobility and ambulation assessment 9- Endurance assessment. 10- Function activities assessment. 11- Neurological and psychological factors assessment. 1- Patient demographic data and history 1-Personal history 1- Patient demographic data and history 2-Present history Date of burn. Date of evaluation Date of admission. Date of initial P.T. Date of operation. 3-Special history Extent and depth of burn Associated injury Skin graft (donor and receipt site) 4-Past history Previous disease Trauma Surgery and burn Vision and hearing acuity Balance and coordination. Neuromuscular or skeletal deficit. 2- BURN SEVERITY INDEX (BSI) The Abbreviated Burn Severity Index (ABSI) is a five variable scale to help assess burn severity. These variables are associated with increased burned patient mortality rate. (1) Percentage of total body surface area burned (TBSA) BSI (2) Presence of a full-thickness burn (3) Age (4) Sex (5)Presence of inhalation injury 1- EXTENT OF BURN (TBSA or BBSA) To determine whether it is major or minor burn (triage)  There is a direct relation between the BBSA & the number of anticipated contractures to develop.  To calculate the mount of fluid needed for patient resuscitation {(2 or 4) ml x kg bodyweight x % BBSA} + 2000 ml saline of which 50% to be administered in the initial 8 hours.  Methods to calculate TBSA Rule of nine Lund & Browder chart Palmar method RULE OF NINE The rule of nines divides the integument into areas roughly equivalent to 9% of TBSA.. The fastest and easiest method of determining the percent of TBSA involved in a burn wound. Universally recognized method of assessing burn size Disadvantages The rule of nines consistently overestimates the size of a burn injury. There is also some variability in the estimates of burn size. LUND & BROWDER CHART It considers the variations in the distribution of body surface area with age Infants and young children have different body proportions than adults, as infants and young children have larger heads and smaller lower extremities. More appropriate for children under 16 years of age. Disadvantages More complex PALMAR METHOD Uses the area of the palmar surface of the patient’s hand to determine the burn size. The size of the palm represents 1% of TBSA. Preferred for small burn areas. Most suitable to measure burn at anterior thigh and trunk. Disadvantage Unreliable method. DEPTH OF BURN HOW TO ASSESS BURN DEPTH? Subjective assessment of the characteristics of the burn to diagnose its depth. Sensation (pinprick test) Colour and appearance Bleeding 1st degree 2nd degree superficial 2nd degree deep 3rd degree 4th degree Depth od burn injury 1st degree burn Third degree burn Superficial partial thickness burn Fourth degree burn Deep partial thickness burn Signs and symptoms of smoke inhalation include Burns to the head and neck. Singed nasal hairs, darkened oral and nasal membranes, carbonaceous sputum, stridor, hoarseness, and difficulty swallowing. History of being burned in an enclosed space. Exposure to flame, including having clothing catch fire near the face out of doors. N.B The most critical period for patients with inhalation injuries is 24 to 48 hours post-burn. The airway becomes edematous and there is increased airway resistance. The respiratory mucosa sloughs, along with loss of ciliary function and poor diffusion of gases What is the triage? It is a decision making about admission of Pt. to hospital or discharge Pt. should be admitted to hospital in the following cases:1. In major burn 2. In electrical or chemical burn 3. In inhalation injury 4. In burn of vital areas (face, hand, foot & genitalia) 5. In deep burns. 3- Edema and limb circumference 1- By observation by comparison to the sound limb 2- By palpation to determine the type of edema (pitting or non-pitting) 3- By measurement Water displacement method, Girth measurement , and Ring method Edema (pitting or non-pitting) Grade 0+: No pitting edema Grade 1+: Mild pitting edema. 2 mm depression that disappears rapidly. Grade 2+: Moderate pitting edema. 4 mm depression that disappears in 10—15 seconds. Grade 3+: Moderately severe pitting edema. 6 mm depression that may last more than 1 minute. Grade 4+: Severe pitting edema. 8 mm depression that can last more than 2 minutes. VOLUMETRIC MEASUREMENT METHOD It is the gold standard tool for the measurement of edema Utilizes the same principle of water displacement discovered by Archimedes, which states that the water volume displaced is equal to the volume of the object immersed in the water. Disadvantages – It is time taking as it has to be set up several minutes before the test as the water level needs to be stable. It is difficult to move once filled with water. It requires specialized equipments. It is messy as they require the patients to immerse their hands in water, and it is therefore unsuitable for certain patient population B) Girth measurement (WITH A TAPE MEASURE) Girth measurements are simple, efficient and clinically useful. For consistent measurements, each upper extremity or lower extremity is marked with a semi-permanent marker at a certain part with reference to the bony prominences 1- The Circumferential Method common assessment are : 7-point measurement 5-point measurement 4 2 2- Figure-of-eight method It is more reliable than the circumferential method as it covers a bigger area. A figure of 8 method is usually preferred in ankle and hand swelling. It has its own specific points across for consistency. 3 1 2 3 1 4 5 C) Ring method. It is an objective method, but it used for the neck only. Used for prognosis and fellow up 4- SENSORY ASSESSMENT  Use pinprick to test the cutaneous sensation, mainly to determine the depth of the burn injury In 3rd degree burn (painless) use pinprick to determine the depth of burn. Assessment of deep sensation + reflexes Should be done in electrical burn, massive edema & associated injury. In 2nd degree burn (painful) use pinprick to determine the amount of pain. 5- MUSCLE STRENGTH ASSESSMENT Done through Functional or group muscle test. Individual muscle test is done only in case of:- Sever edema - Electric burn - Particular injury is suspected. Do comparison for the other side specially in acute stage. Then ROM ass. can be done by using either electronic or standard goniometer to assess the patient progression. It is may be limited by:- pain , edema, inelastic escher and disuse of the affected part. 7- Flexibility assessment Burn injury can cause muscle shortening OR contracture. It includes active range of motion assessment to determine whether the patient can move in a pain free range of motion without pain in the joints. It is used to assess whether individual muscles or groups may need some flexibility training. 8-MOBILITY AND AMBULATION ASSESSMENT Ability to move in bed Ability to transfer out of bed Note gait Deviations N.B Permission to patient to walk after burn injury is a medical decision. 9- ENDURANCE ASSESSMENT Cardiovascular endurance is limited due to systemic & catabolic effect of burn injury Aerobic capacity of Pt. is affected by bed rest, immobilization & pain SO, encourage patient to ambulate as early as possible. 10- Functional activities assessment Assess patient's ability to perform ADL Eating 3 Dependent Bathing 2 Requires assistance Bed mobility 1 Has difficulty but does by self 0 Normal Dressing Toilet activity School or work activity 11- Neurological and psychological factors assessment. Burn injury can cause negative long-term psychological effects such as acute stress disorder, depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after injury. Psychological factor will affect patient’s adherence to the treatment program and prognosis. 1- Emergent phase(1-2 days after injury) (airway management, fluid therapy and initial wound care) BURN MANAGEMENT 2- Acute phase (Management of any complications during the recovery period and closure of the burn wound.) 3- Rehabilitative Phase (Working the patient to return him/her to a state of optimal physical and psychosocial functioning) 1- MEDICAL AND SURGICAL INTERVENTIONS ▪ First, management of burn shock through Rapid fluid resuscitation. ▪ Second, physicians must monitor and manage cardiac dysfunction including dysrhythmia and arrhythmia that may be a direct or indirect. ▪ Third, management inhalation injuries and pulmonary dysfunction through administration of 100% oxygen if burns are 20 % body surface area or greater, Suctioning and ventilatory support. Fourth, Local wound care (Surgical Debridement- skin graft ) 2- PHARMACOLOGICAL MANAGEMENT Medications to prevent and manage infection. Medication to address patient pain and anxiety. N.B Patient pain should be maintained at less than 4 on a 0–10 pain scale (0 no pain, 10 most intense pain imaginable). Physical therapy role Monitor for signs consistent with abuse Prevent complications Pulmonary dysfunction independently. Deconditioning indoors in 2 minutes. Contractures Increase range of motion in affected areas and prevent deformity. Infections use sterile technique Pressure ulcers Control and resolution of oedema. Preserving range of motion Improve respiratory abilities and allow patient to clear secretions Improve mobility to allow patient to independently ambulate 100 feet Patient will be independent in bed mobility. PHYSICAL THERAPY MANAGEMNT Breathing exercises ▪ Deep breathing exercise & incentive spirometry exercises may work well for adults. ▪ The use of straws, singing games, and bubble blowing may be more appropriate for young children. Pulmonary hydergine ▪ Suctioning, Cough training and Postural drainage. Positioning and Splinting To place the burned body part in a position opposite to the direction of the anticipated deformity. Limb elevation to control edema. Body part Anticipated deformity Desired position Techniques to achieve desired Position Head Inability to open or close mouth and inability to close eyes fully. If facial or inhalation injury has been sustained, elevate the head above the level of the heart for the first 48 hrs to minimize facial edema Elevate head of bed up to 30 degrees Neck Cervical flexion Slight extension, and neutral rotation. Avoid hyperextension which creates difficulty with coughing, breathing and swallowing No pillow, Neck conformer Shoulder Adduction , extension and internal rot Shoulder abduction 90 degrees. In sidelying, flex shoulders to 90 degrees to prevent pull on brachial plexus Foam wedges, airplane splints, bedside table when sitting, pillows Chest/Abdo men Shoulder protraction/kyphosis Trunk extension, shoulder retraction Towel roll lower spine, Clavicle/Shoulder strap Cubital fossa Elbow and forearm flexion/pronation Elbow extension, forearm supination Pillows, splints, bedside table Wrist and hands Wrist extension 30, MCP flexion 75, IP Extension & thumb abduction Splints, foam rolls, hand cones, dressings Wrist flexion Body part Anticipated deformity Desired position Techniques to achieve desired Position Head Inability to open or close mouth and inability to close eyes fully. If facial or inhalation injury has been sustained, elevate the head above the level of the heart for the first 48 hrs to minimize facial edema Elevate head of bed up to 30 degrees Neck Cervical flexion Slight extension, and neutral rotation. Avoid hyperextension which creates difficulty with coughing, breathing and swallowing No pillow, Neck conformer Shoulder Adduction , extension and internal rot Shoulder abduction 90 degrees. In sidelying, flex shoulders to 90 degrees to prevent pull on brachial plexus Foam wedges, airplane splints, bedside table when sitting, pillows Chest/Abdo men Shoulder protraction/kyphosis Trunk extension, shoulder retraction Towel roll lower spine, Clavicle/Shoulder strap Cubital fossa Elbow and forearm flexion/pronation Elbow extension, forearm supination Pillows, splints, bedside table WRIST AND HANDS Wrist extension 30, MCP flexion 75, IP flexion 0-5 & thumb abduction Splints, foam rolls, hand cones, dressings Wrist flexion Therapeutic Exercises ▪ Range of Motion Exercises (active and active assisted ) N.B: ROM exercises may be better tolerated when combined with immersion hydrotherapy and well-timed pain and/or anxiety medications. In addition to straight plane range of motion exercises, functional movement patterns and purposeful activities may increase patient adherence, increase the frequency of movement, and enhance overall patient function. ▪ Mobility Training (bed mobility and ambulation training). ▪ Aerobic Exercise: include walking, cycling and jogging. Swimming can be commenced once all wounds are healed and should be guided by the burn specialist. Long-term restrictive lung injury is common in patients with inhalation injury should be considered when prescribing aerobic exercise. N.B: During the acute stage of rehabilitation, the exercises should be modulated to prevent heart rate from exceeding 20 beats per minute above the patient’s resting heart rate. As healing occurs and burn shock resolves, the physical therapist should strive to attain and maintain the patient’s target heart rate between 50% and 70% of maximum predicted heart rate. ▪ Flexibility exercise (self stretching- active inhibition techniques and passive stretching) ▪ Strengthening training. It is similar to strength training following other injuries e.g. musculoskeletal injuries (Antigravity functional exercises, Use the patient’s own body weight as resistance or using resistance bands, pegs and free weights. Bed exercises can be used when the patient is unable to perform other more effective strengthening exercise. Axilla stretch with banding Contraindications to Range of Motion Exercises include Non-stabilized fractures. Cardiovascular instability. Extubation within 8 hours of treatment. Exposed tendons. 4–5 days after graft placement. Neck stretch with assistance Management of hypertrophic scar. Apply moisturizer. Protect from friction and shear forces. Perform scar mobilization. Use compression garments. Consider silicone gel sheets or pads for smaller areas. Consider ultrasound or paraffin to help scar remodel. Educate patient/caregivers Local wound care. Skin/scar management. Positioning ( elevating extremities and encouraging active movements especially hand & ankle) Nutritional support The burned patient experiences a state of hyper catabolism in which lean body mass is broken down to provide amino acids for gluconeogenesis. Nitrogen loss through urine and wounds is a concern, as are the heightened requirements for protein necessary for anabolism, wound repair and improved immune response. When bowel sounds return in about 48 –72 hours post-burn, the patient can be fed using the most appropriate route, based on stage of recovery and size of burn. Nutrition plays an important role in burn recovery. Patients require a diet high in calories and protein to counteract the hypermetabolic response noted after injury and to support the growth of healthy tissue. A burn patient’s metabolic rate increases in proportion to the size of the injury. Burn patients require fat in the form of lipids, vitamins and trace minerals. Inadequate nutrition can negatively impact upon an individual’s immune response, wound healing, metabolic function and survival.