Tissue Healing After Burns PDF

PThomegroup 1.6 Tissue Healing 1.61 Normal Healing  Use knowledge of tissue healing to decide when rest is required and when exercise, stretching and strengthening will be beneficial to the patient....

PThomegroup 1.6 Tissue Healing 1.61 Normal Healing  Use knowledge of tissue healing to decide when rest is required and when exercise, stretching and strengthening will be beneficial to the patient.  Timescales are variable according to the size of the burn and surgical intervention. Clinical reasoning is essential when applying the following in practice. STAGE TIMESCALE PROCESS SIGNS AND TREATMENT SYMPTOMS Inflammation 0-5 days Vasoconstriction Redness, Heat, Swelling, Reduce heat and followed by Pain oedema and pain. vasodilatation and influx of inflammatory Prevent infection mediators and WBCs. and disruption of Increased capillary wound. permeability. Exudate (immobilisation, leaks into tissues. Pus positioning, may be produced. splinting) Proliferation Begins day 3- Fibroblasts synthesize Moist red raised tissue Early: positioning (fibroplasia) 5. Lasts 2-6 collagen. Laid down over wound and weeks. haphazardly. immobilisation Angiogenesis continues. Later: gentle stress (splinting, exercise) Reduce oedema and prevent contracture Remodelling Begins week Synthesis of collagen Wound closure Optimise function (maturation) 4-6. balanced by degradation. Organisation of collagen Scar red and raised Splinting Lasts up to 2 fibres along lines of progresses to flat pale and years. pliable. Scar tissue Positioning stress. tightens. Exercise Stretching Strengthening. Table 2 Tissue healing process following burn injury (Glassey92004)  PThomegroup Figure 4 Time scale for the stages of the healing process, showing increasing collagen production over time, and decreasing fibroblast activity. (Glassey 2004) 1.62 Complications of Healing in Burn Patients 1.621 Oedema Oedema may increase post burn for up to 36 hours  Increased vascular permeability which occurs during the inflammatory response  Exacerbated if the burn is severe enough to warrant fluid resuscitation (Weinzweig and Weinzweig 2004; Kamolz et al 2009). Post severe burn  The resulting scar (eschar) is inflexible  Does not allow skin expansion  Tissue beneath continues to expand as oedema increases  Rapid increase in compartment pressure Figure 5. Hand escharotomy (Weinzweig  May result in circulatory compromise/nerve and Weinzweig 2004) Damage/ necrosis of distal muscles.  Severe cases require a surgical procedure known as an escharotomy o Splits the scar and allows for the expansion of the tissues beneath, relieving pressure (Kamolz et al 2009,Weinzweig and Weinzweig 2004).. 10  PThomegroup Recognising Vascular Insufficiency: Where oedema and compartment syndrome is causing vascular insufficiency, the following symptoms may be present  Pain  Loss of sensation  Pale white skin on the dorsum of the hand/ distal to eschar  Loss of peripheral pulses (may also be caused by hypovolaemia or insufficient fluid resuscitation) (Kamolz et al, 2009) As compartment syndrome requires immediate attention, all health care professionals must remain vigilant. Oedema and the Hand: Oedema in the hand results in the position of intrinsic minus (Kamolz et al 2009)  Wrist flexion  MCP extension  PIP/DIP flexion MCP joint extension primary position assumed  Joint contact areas minimised  Joint capsules and ligaments lax Figure 6 Intrinsic Minus hand position (American Society for  Therefore, in this position, the joint accommodates Surgery of the hand 2013) the maximum amount of intra articular fluid  Increases tension in finger/wrist flexors , relaxes extensors Therefore, PIP/DIP/ Wrist flexion follow (Weinzweig and Weinzweig 2004)  Joint predisposed to contracture  May have significant functional implications  Even after wound healing appears complete, sub-acute and chronic oedema may be caused by scar maturation and contraction: therefore, oedema management is a long term concern. 11  PThomegroup 1.7 Burn Associated Pain “The quality of outcome must be worth the pain of survival” ~Prof FM Wood, James Laing Memorial Essay, 1995  84% of major burn patients suffer “severe or excruciating pain”  100% suffer daily pain  92% are woken at night with pain (ANZBA 2007) 1.71 Types of Pain in Burns: (Summer et al 2007; Richardson and Mustard 2009) Procedural pain: (Primary mechanical hyperalgesia): intense burning and stinging that continues to a lesser degree, but may be accompanied by intermittent sharp pain for minutes or hours following dressing changes or physiotherapy/occupational therapy. Throbbing, excruciating pain may be associated with positioning of burned extremities (i.e. positioned below the level of the heart); this is thought to be related to pressure associated with inflamed, oedematous tissue. Procedural pain is the most intense and most undertreated pain associated with burn injuries. Procedural pain and associated pain anxiety: research indicates pain-anxiety increases over time in burn injured patients. Strong correlations have been established between pain, physiological distress and physical and psychological outcomes in both adults and children. Background pain: patients with high anxiety have increased levels of background pain. There is a wide variability in the pain intensity following injury. Background pain is characterised by prolonged duration, relatively constant mild-moderate intensity pain. The pain has been described as continuous burning or throbbing, present even when the patient is relatively immobile. This pain is best treated with regularly scheduled analgesics. Breakthrough pain: transient worsening of pain frequently associated with movement. Patients also report spontaneous pain that may be related to changing mechanisms of pain, over time or inadequate analgesia. The pain can be described as stinging, shooting, pricking or pounding. Pain following movement can be associated with primary mechanical hyperalgesia, but most care providers for those with burns consider pain with movement to be breakthrough pain. Breakthrough pain can be much worse following periods of immobility, particularly if skin over joints is affected. 13  PThomegroup For optimal analgesia, it is recommended that patients are assessed for each type of pain separately and repeatedly throughout the course of the recovery. Pre-disposition: Genetics Psychosis Substance abuse Personality type Context: Drugs factors: Expectations Timing Culture Tailoring Past experience Side effects Environment Rapport with staff Burn wound: Cognition: Dressing type Attention Dressing tension Distraction Infection Self-belief Movement reappraisal Donor sites Mood: Depression Anxiety Catastrophising Figure 8. Factors influencing the patient’s perception of pain from a burn wound. (Richardson and Mustard 2009) 14  PThomegroup 1.72 Pain Mechanisms (Richardson and Mustard 2009) The pain mechanisms associated with the inflammation process post burn are:  Primary hyperalgesia  Secondary hyperalgesia  Neuropathic pain  Chronic pain/Central Sensitisation Other factors to consider in pain are: 1.73 Pain intensity: As the inflammation recedes, the quality of the pain may change. The reporting of pain intensity varies widely and is reported highest in areas of upper/mid-dermal skin loss, such as areas of skin donation and decreases with wound closure. Infection may result in increased pain again following revival of the inflammatory process. Growth of new tissue is associated with paraesthesia and local discomfort. The healed areas show enhanced mechanical hyperalgesia following subsequent injury. 1.74 Anxiety and pain experience: result in increased pain perception. The pain experience will alter according with the burn treatment. Surgery/debridement/excision of the burn will alter the depth of the burn injury. Covering the burn with grafts or synthetic dressings typically reduce pain, with the harvest site often being more painful than the burn injury itself. Poor pain management during therapeutic procedures is associated with poor compliance with treatment and post-traumatic stress disorder. It then increases anxiety and worsens the pain experience in subsequent treatment. 15  PThomegroup Section 2: Burn Assessment A burn is a unique injury to the individual patient. The assessment and management of an initial burn by the multidisciplinary team is crucial to minimise long term injuries and enhance optimal functioning. For the purpose of this handbook the information detailed throughout the assessment of the burn patient is a synopsis of the following papers: ANZBA 2007; British Burn Association 2005; Eisenmann-Klein 2010; Hettiaratchy et al 2004; Settle 1986; Siemionow and Eisenmann-Klein 2010 Figure 9. Flow chart illustrating the assessment and management of the burn (Germann et al 1999) 16  PThomegroup Section 3: Management of Burn Pain 3.1 Pharmacological Pain Management: (Richardson and Mustard 2009)  During the first 48 hours  Decreased organ blood supply alters the clearance of drugs  The body then enters a hyper metabolic state, o Associated with increased clearance of analgesia.  Variations in levels of acute phase plasma and total body water volume further impact upon effectiveness an analgesia.  Regular and repeated pain assessments are used to monitor the effectiveness of analgesia. Thus there is no standard treatment of burns patients, each requires individual assessment. Opioids: the cornerstone of pain management in burns, and are available in a variety of potencies, methods of administration and duration of action. Opioids used to effectively manage background pain, with well-timed and effective doses of opioids used separately to manage procedural pain Positive Effects Side Effects Examples of Opioids Pain relief Respiratory distress Morphine Increased comfort Itch Oxycodone Morphine related to reduced Nausea and vomiting Post-traumatic stress disorder Opioid tolerance – requiring increasing doses Fentanyl: potent, rapid onset, short acting opioid. Used for Opioid induced hyperalgesia procedural pain management. (OIH) – increased sensitivity, throughout the body following opioid exposure Remifentaril: ultra-short acting opiate. Provide poor defence against central sensitisation Physical dependence – common Alfentaril: short acting, used for in long term use post-procedural analgesia. 25 Table 5: side effects of opioids Methadone: long acting  PThomegroup Simple analgesics: paracetamol can be used in conjunction with opioids, to give a synergistic effect comparable to a higher opioid dose. Paracetamol is an effective anti-pyretic and has few contra-indications. NSAIDS: synergistic with opioids and can reduce opioid dose and thus reduce side-effects. Not used in wide spread burns due to already increased risk of renal failure and peptic ulceration. There is potential to increase bleeding in large burns also, due to the anti-platelet effect. Other medications: see Richardson and Mustard 2009 Possible side effects of analgesics: - Drowsiness - Adverse reaction - Nausea and increased risk of aspiration - Impaired memory and communication - Postural hypotension, and fainting (ANZBA 2007) 3.2 Non-Pharmacological Management of Pain The following is a synthesis of information form the following articles: Summer et al (2007), Richardson and Mustard (2009), ANZBA (2007) and de Jong et al (2007) Overall, the levels of evidence to support the use of alternative therapies for pain relief are of poor quality. However, no negative side effects were reported in the literature reviews and these therapies are all used in conjunction with pharmacological management to optimize pain relief for the individual. 3.21 Psychological techniques: beneficial for reducing anxiety and providing patients with coping methods for pain levels and durations. These include relaxation, distraction and cognitive behavioural therapy (CBT). CBT is beneficial in the management of complex pain problems and can reduce fear and anxiety associated with activities or environments. 3.22 Hypnosis: a state of “increased suggestibility, attention and relaxation”. In the burn patient hypnosis is used in the management of procedural pain and anxiety. The use of hypnosis clinically is increasing but its usefulness is dependent on the individual’s hypnotic 26  PThomegroup susceptibility, high baseline pain and the skill of the practitioner. The current best available evidence for management of procedural pain was found for active hypnosis, rapid induction analgesia and distraction relaxation. 3.23 Virtual Reality: immersing the patient in a virtual world has shown some effect on procedural pain control and is better than hand-held gaming devices. However, the equipment is costly and bulky and not always suitable for paediatric intervention. A paediatric intervention, using hand-held game devices which provide augmented reality was trialled among 3-14 year olds. This has shown significantly lower pain scores than standard distraction and relaxation when undergoing dressing changes (Mott et al 2008). 3.24 Sleep Normalisation: disrupted sleep occurs in up to 50% of burn patients and links have been established between poor sleep quality and pain severity, as well as pain and prolonged experiences of sleep disturbance. Normalisation of the 24hour day, with a bedtime routine, within the limits of the hospital environment is aimed for to promote sleep, with the use of analgesics and night sedation. 3.25 Music therapy: this is thought to target pain via the gate control theory. This suggests that music serves as a distraction from noxious stimuli. Also, the anxiety related to the rehabilitation of burns can increase the activation of the sympathetic nervous system. Music uses all three cognitive strategies employed in pain and anxiety management (imagery – envisioning events that are inconsistent with pain, self-statements and attention-diversion devices to direct attention away from the pain ad redirects it to another event) (Ferusson and Voll 2004; Presner et al 2001). A systematic review of music therapy among pregnant women, medical-surgical patients and critical care patients showed statistically significant reductions in pain scores. Of the seventeen studies reviewed by Cole and LoBiondo-Wood (2012), 13 studies demonstrated the positive effects of music on pain. Other positive findings of the studies included reduced anxiety, muscle tension, blood pressure and heart rate. A burn specific study included showed reduced pain levels during and after the debridement, reduced anxiety and decreased muscle tension during and after dressing changes. The Cochrane Review of music as an adjunct to pain relief concluded that “music and other non-pharmacological therapies could have a synergistic effect to produce clinically important 27  PThomegroup benefits on pain intensity or analgesic requirements” and thus requires further study. This is based on the studies indicating that music resulted in reduced pain intensity and reduced opioid requirements. The reported changes in both of these outcomes were small however, and their clinical importance is unclear (Cepeda et al 2006). 3.26 Paediatric Burn Pain (Richardson and Mustard 2009)  children 0-4 years represent approx. 20% all hospitalised burn patients  In preschool aged children the half-life of opioids (morphine and alfentanyl) are 50% those in adults. Higher dosage required.  Risk of accidental overdose due to difficulties with pain evaluation resulting in overestimation of child’s pain  Childs environment has huge effect on pain perception. Parents’ presence and aid during dressing change can have beneficial for procedural pain and reducing anxiety. 3.3 Considerations Pre Physiotherapy Treatment  Pain relief is key. Timing physiotherapy to correspond with analgesia is essential for the patient, particularly to avoid the pain-anxiety avoided.  Knowledge of pain medications, short-acting pain relief may be required in addition to long-acting background pain relief prior to physiotherapy. Also, the side-effects possible due to the medications, and vigilance for signs of these.  Daily assessment of therapy input and pain management to ensure on-going management of pain. (ANZBA 2007) 28