Burns

types of burns

• flame

• scald

• contact

• chemical

• electrical

• radiation

• friction

TBSA

total body surface area

flame burn

predominantly house fires

scald burn

hot liquid or steam (predominantly kitchen injuries, bathroom injuries)

contact burn

to touch a hot surface

chemical burn

toxic substances that destroy tissues or cause cell death

• alkali burns

• acid burns

alkali burns

more severe, liquefies skin for deeper penetration

acid burns

penetrate less but cause coagulation injury

electrical burn

current induced burn

radiation burn

radiofrequency energy-induced

friction burn

combination of mechanical disruption of tissues as well as heat generated by friction

largest cause of burns

thermal injury (flame, scald, contact) (86%)

location (geographically) where most burns occur

most occur in home (73%)

gender that is more likely to be burned

males

children and adults relationship to burns

-flame burns are more common in adults

-scald burns are more common in children

why are low income people more likely to get burned

• living in an area that may not have fire alarm, wood burning stove

• more likely to try and fix things themselves

why are white people more likely to get burn

people with money are more likely to do high risk activities

exposure time vs temperature

time is inversely proportional to the temperature in producing a given degree of burn

(the hotter the surface the less time you need to be in contact with the surface)

criteria for a referral to a burn center

• partial thickness burn over 10% TBSA

• full thickness burns in any age group

• burns of face, hands, feet, genitalia, or major joints

• chemical burns, electrical, or lightning strike injuries

• significant inhalation injuries (house fire)

• burns in patients with multiple medical disorders

• burns in patient with associated traumatic injuries

• children in non-pediatric burn hospitals

• requires special social, emotional, or rehabilatative interventions

predictors of mortality in burns

• TBSA

• Depth

• age

• gender

• inhalation injury

• medical history

superficial burn

• only involves the epidermal layer of the skin

• doesnt go through the epidermis completely

• previously considered 1st degree burn

superficial partial thickness burn

• burn involves the epidermis and portions of the dermis

• burn goes to the superficial dermis

• previously considered 2nd degree

deep partial thickness

• burn involves the epidermis and portions of the dermis

• goes deep into the dermis

• previously considered 2nd degree

which gender has a higher risk of mortality from a burn

female

full thickness burn

• extends through and destroys all layers of the dermis with impact to underlying subcutaneous tissue

• burn goes into the subcutaneous layer of skin

• previously considered 3rd degree

structures in the deep dermis

• nerves

• hair follicles

• sebaceous glands

• sweat glands

basal cell layer

• splits the epidermis from dermis

• does regeneration and makes new epithelial cell

burn with absolutely no hair left in the area

deep partial thickness or full thickness

• possible with deep partial to have some hair left

burn with full intact sensation

superficial or superficial partial burn

superficial burn characteristics

• painful, dry, pinkish/red skin

• blanches with pressure

• peeling of dried skin

• no blisters

• no scar

superficial partial thickness burn characteristics

• painful, hyper-esthetic, moist/wet

• pink or mottled-red blisters

• some blanching

• sensation intact

• hair present

• scar possible but rare

deep partial thickness burn characteristics

• sensitive to pressure but not to pinprick

• dry, mottled/cherry red or white

• waxy

• no blanching

• hair present

• scars

full thickness burn characteristics

• painless

• insensate

• leathery

• cracked

• avascular

• white/cherry red/black

• no hair

• scars

healing timeframe for superficial burns

heals in 3-5 days

healing timeframe for superficial partial thickness burns

heals in 14-21 days

healing timeframe for deep partial thickness burns

heals in 3-6 weeks

healing time frame for deep partial thickness burns

heals in 3-6 weeks

healing time frame for full thickness burns

typically grafted

if it blisters it is which type of burn

superficial partial thickness

partial thickness vs full thickness

• burn injury depth may progress over 48 hours

• reclassification may be needed

rule of the palm

• the palm of the patients hand, excluding the fingers, is approximately 0.5% of TBSA

• the entire palmar surface including fingers is 1% of TBSA

• if a person has 3 burns the size of the palm then the person has 1.5% TBSA

rule of nines for adult

• lower limb: 18% each limb

• trunk: 36% on front and 36% on back

• upper limb: 9% each limb

• head and neck: 9%

• genitalia: 1%

rule of nine for child

• head: 18%

• each arm: 9%

• torso: 36%

• each leg: 13.5%

• groin: 1%

Rule of Nines for child

• by the age of 10 year, child has proportions of an adult

Lund Browder

• considered the most accurate method of TBSA assessment

• only 2nd (partial thickness) and 3rd (full thickness) degree burns are included in TBSA calculation

• provides more detailed analysis of location and form of burn injury

• useful tool for tracking of burn evolution and progression over the first 48 hours

Four phases of burn care

Phase I - IV

Phase I: initial/resuscitation phase:

initial 24-72 hours post injury

• immediate fluid resuscitation

• suspected inhalation injury

• splinting, positioning, and elevation (if unable to perform full ROM)

• cleansing, debridement, topical antibiotics, dressings

Phase II timeframe

72 hours post injury to discharge from hospital

Phase III time frame

discharge from hospital to discharge from outpatient rehab

Phase IV timeframe

6 months post injury onward

Parkland formula

amount of fluid given over first 24hrs = 4ml of lactated ringer solution x patients weight (kg) x % tbsa

immediate fluid resuscitation during phase I

• parkland formula

• 50% of calculated amount given in first 8 hours immediately following burn injury

• remaining 50% given over the next 16 hours

• maintain urine output 0.5 cc/kg/hour

if suspecting an inhalation injury during phase I

provide high flow oxygen until carbon monoxide poisoning ruled out

• give hypobaric oxygen if confirmed carbon monoxide

Splinting and positioning

• ears without pressure

• neck extended

• mouth open

• shoulders abducted at 90 deg and externally rotated

• elbow extended

• forearm supinated

• wrists extended (30 deg)

• finger MP flexion (90 deg) w/ pip and dip ext

• straight trunk

• hips extended with neutral rotation

• hips abducted (20-30 deg)

• knees extended

• ankles in neutral

• toe extension and adduction to prevent webbing

Phase II:

• nutrition supplementation

• prevent/manage infection

• continue splinting and positioning

• continue cleansing, debridement, dressing changes, surgical prep

• ROM exercises

• ambulation

nutrition supplementation in phase II

• burns induce hypermetabolic state which requires a significant caloric intake

• if nutrition is not supplemented the body will begin to eat away at muscles to supply organs and not heal the wounds

formula used for nutrition supplementation

curreri formula

what is the number one cause of death in individuals with burn injuries

infection

ROM exercises during phase II

aggressive end range passive motion in the setting of restriction is believed to be a predisposing factor for heterotropic ossification

Heterotropic ossification (HO)

calcium depositis in connective tissue that can lead to fused joints, painful; often requires surgical correction

ambulation for below knee burns

• defer ambulation in patients who have superficial and deep partial thickness burns that are below the knee

• encourage ambulation to tolerance for all others

why does ambulation need to be deferred for patients with superficial/deep partial thickness burns that are below the knee

ambulation increases capillary pressure which can induce vessel rupture and may crease scenario of tissue hypoxia which may slow healing or convert the burn injury to full thickness

• defer until stable

2 types of split thickness skin grafts (STSG)

• sheet grafts

• meshed grafts

Sheet grafts

graft is used as is

• thin and thick sheet grafts (depending on location of transfer)

• advantage: better cosmesis upon healing

meshed grafts

create interstices (noticeable checkerboard appearance upon healing)

• allows smaller tissue graft to stretch and cover larger area

• allows for wound bed drainage

• rapid healing from epithelial borders

• advantage: taking a smaller piece of skin and speeds up epitheliazation

donor site for split thickness skin grafts

• creates equivalent of partial thickness wound

• typically more painful than the site receiving the graft

• match color and thickness to greatest degree possible

STSG recipient site

• graft secured with steri-strips or staples

• cover with nonadherent

• negative pressure wound therapy (NPTW) commonly used

PT implications of STSG recipient site

• immobilize to limit pressure and traction (as can occur with ROM) across graft site and gradually introduce to gravity per facility protocol

• observe and document amount of “take” (extent of viable graft)

primary causes of STSG failure

• sub-optimal recipient bed

• hematoma formation

• infection

• sheer, friction, traction forces from movement

Full thickness skin grafts (FTSG)

• cut to fit a given wound and sutured in place

donor site full thickness skin grafts (FTSG)

• primary closure

• STSG application

Recipient site of full thickness skin grafts (FTSG)

immobilize to limit pressure and traction (as can occur with ROM) across graft site per facility policy

if someone has full thickness burns on the lower half of their legs during phase II can they get up and start ambulating

yes the wounds cant get any worse

Phase III

• wound care

• skin care

• scar management

• functional progression

phase III skin care

• minimize complications from icthyosis and xeroderma

• prevent skin breakdown as able

functional progression of phase III

• ROM

• Strength

• Mobility

• Endurance

characteristics of hypertrophic scar

• red, raised, dense

• loss of tissue extensibility

• hyper or hyposensitive

• keloid scars grow beyond the wound margins

Treatment of hypertrophic scars

• pressure garments, compression masks, splints

• moist heat, massage, prolonged stretch

• silicone gel sheets

• steroid injections

• laser treatment

• surgical interventions (reconstructive surgery)

Treatment of minor burns

• the C approach

• the FACADE approach

The C approach

• Cool: with tap water or saline to prevent progression of burn

• Cleanse: mild soap and water or mild antibacterial wash

• Cover: topical antibiotic ointment or cream

• Comfort: OTC pain meds, splinting of area for support

amount of take

the amount of graft that is adhering and becoming a viable part of the wound

FACADE approach

• First Aid

• Analgesia

• Clean

• Assess

• Dress

• Elevate

how long are patient with burns wearing their pressure garments

23 hours per day