Burns and Rehabilitation Detroit Receiving Hospital

Burns and RehabilitationBurns and Rehabilitation

Detroit Receiving HospitalDetroit Receiving Hospital

Burn IncidenceBurn Incidence The NumbersThe Numbers

• How often?How often?

• How many injuries?How many injuries?

• How many How many hospitalizations?hospitalizations?

• How many “major” How many “major” injuries?injuries?

• How many deaths?How many deaths?

Gender*Gender*

*Total N=126,642

Female30.1%

Male69.9%

Race/Ethnicity*Race/Ethnicity*

*Total N = 126,642

Caucasian62.3%

African American

18.0%

Asian2.0%

Hispanic12.4%

Other1.8%

Missing2.9%

Native American

0.6%

Age Group*Age Group*

*Total N=107,685 (Excludes Unknown/Missing)

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

0 - 1.9 2 - 4.9 5 - 19.9 20 - 29.9 30 - 39.9 40 - 49.9 50 - 59.9 60 - 69.9 ≥ 70

Age Group

No.

of C

ases

Etiology*Etiology*

*Total N=76,659 (Cases Where Etiology Was Included)

Fire/Flame46.0%

Scald32.5%

Inhalation Only0.3%

Skin Disease1.4%

Radiation0.3%

Other Burn0.7%

Unknown1.0%

Contact with Hot Object8.1%

Other 2.2%

Electrical4.3%

Chemical3.2%

Place of OccurrencePlace of Occurrence

Home43.2%

Unspecified 19.2%

Industrial8.4%

Other Specified 4.6%

Mine/Quarry0.1%

Residential Institution1.0%

Recreation/Sport4.2%

Public Building (school)

1.8%

Street/Highway16.8%

Farm0.7%

Circumstances of Injury*Circumstances of Injury*

Accid-non work related64.8%

Other5.1%

Suspected: Self-Inflicted; Child

Abuse; Assault/Abuse;

Arson5.0%

Accid-recreation4.9%

Accid-unspecified3.2%

Accid-work related17.0%

*Total N=72,324 (Excludes Unknown/Missing)

Hospital Disposition*Hospital Disposition*

*Total N=126,645

Died5.4%

Lived94.6%

What are the functions of skin?What are the functions of skin? Conservation of body Conservation of body

fluidsfluids Temperature Temperature

regulationregulation Excretion of sweat and Excretion of sweat and

electrolyteselectrolytes Secretion of oils that Secretion of oils that

lubricate the skinlubricate the skin Vitamin D synthesisVitamin D synthesis SensationSensation Cosmetic appearance Cosmetic appearance

and sexual identityand sexual identity

Burn Burn injuries injuries cause loss cause loss to some or to some or all of these all of these functionsfunctions

Types of Burn InjuryTypes of Burn Injury

Thermal burnsThermal burns

Chemical burnsChemical burns

Electrical burnsElectrical burns

Radiation burnsRadiation burns

Thermal BurnsThermal Burns

Two factors are related to the Two factors are related to the extent of thermal injury:extent of thermal injury:•1) Degree of temperature1) Degree of temperature

•2) Length of exposure2) Length of exposure

Scald BurnsScald Burns

Common particularly in childrenCommon particularly in children

Accidental versus AbuseAccidental versus Abuse

Chemical BurnsChemical Burns

Caused by exposure of the skin to Caused by exposure of the skin to noxious substancesnoxious substances

Amount of tissue damage is Amount of tissue damage is dependent upon:dependent upon:

1) Concentration of the agent1) Concentration of the agent 2) Length of exposure2) Length of exposure 3) Mechanism of chemical reaction3) Mechanism of chemical reaction

Chemical BurnsChemical Burns

Caused by acids and alkalisCaused by acids and alkalis

Chemical agents continue to cause Chemical agents continue to cause injury until inactivatedinjury until inactivated

1) Inactivated by local tissue reaction1) Inactivated by local tissue reaction

2) Neutralized by external agent2) Neutralized by external agent

3) Diluted by water3) Diluted by water

Electrical BurnsElectrical Burns Thermal injury incurred via electrical Thermal injury incurred via electrical

contact depends on:contact depends on:

• 1) Type of current-AC more damaging1) Type of current-AC more damaging

• 2) Pathway of current2) Pathway of current

• 3) Local tissue resistance3) Local tissue resistance

• 4) Duration of contact4) Duration of contact

Electrical BurnsElectrical Burns

Death rate and voltage are variableDeath rate and voltage are variable

Electrical current follows a path of Electrical current follows a path of least resistance least resistance

Electrical BurnsElectrical Burns

Severity of injury can be deceptiveSeverity of injury can be deceptive

Complications often occur: Complications often occur: 1) Tetanic muscle contractions1) Tetanic muscle contractions

2) Fractures/ dislocations from falling2) Fractures/ dislocations from falling

3) Cardiac dysfunction3) Cardiac dysfunction

4) Internal organ injuries4) Internal organ injuries

Radiation BurnsRadiation Burns

Occurs as a result of a local accidentOccurs as a result of a local accident

• Laboratory Laboratory • Exposure to therapeutic radiation (cancer)Exposure to therapeutic radiation (cancer)

Dimensions of Burn InjuryDimensions of Burn Injury

Zone of Zone of coagulation coagulation (necrosis)(necrosis)

Zone of stasisZone of stasis

Zone of hyperemiaZone of hyperemia

Degrees of Burn InjuryDegrees of Burn Injury

First Degree First Degree Second Degree (Superficial and Deep Partial Second Degree (Superficial and Deep Partial

Thickness)Thickness) Third Degree (Full Thickness)Third Degree (Full Thickness) Fourth Degree (Subdermal)Fourth Degree (Subdermal)

First Degree BurnsFirst Degree Burns Cell damage Cell damage

Epidermis onlyEpidermis only

Perfect example: Classic sunburnPerfect example: Classic sunburn

Red in colorRed in color

Skin is drySkin is dry

Delayed onset to painDelayed onset to pain

Desquamation=peelingDesquamation=peeling

Heals spontaneouslyHeals spontaneously

Superficial Second Degree BurnsSuperficial Second Degree Burns

Cell damageCell damage through epidermis and upper dermisthrough epidermis and upper dermis

Epidermis completely destroyedEpidermis completely destroyed

Mild-moderate damage to the dermisMild-moderate damage to the dermis

Blisters are common sign=superficial Blisters are common sign=superficial 22ndnd degree degree

Superficial Second Degree BurnsSuperficial Second Degree Burns

Blisters removed for applying Blisters removed for applying antibioticsantibiotics

Bright red in colorBright red in color

Blanching occursBlanching occurs

Edema is usually minimalEdema is usually minimal

Superficial Second Degree BurnsSuperficial Second Degree Burns Extremely painfulExtremely painful

Highly sensitiveHighly sensitive

Heals spontaneouslyHeals spontaneously

Color change from destruction of Color change from destruction of melanocytesmelanocytes

Scarring is minimalScarring is minimal

Deep Second Degree BurnsDeep Second Degree Burns

Cell damageCell damage Through epidermisThrough epidermis Deep layers of dermisDeep layers of dermis

Mixed red or waxy white colorMixed red or waxy white color

Surface is usually wet=interstial fluidSurface is usually wet=interstial fluid

Edema is moderateEdema is moderate

Deep Second Degree BurnsDeep Second Degree Burns PainfulPainful

Sensation Sensation Intact to pressureIntact to pressure Diminished to light touchDiminished to light touch

Healing occurs with scar formation and Healing occurs with scar formation and reepithelializationreepithelialization

Epidermal cells (follicular) assist with Epidermal cells (follicular) assist with reepithelialization reepithelialization

Deep Second Degree BurnsDeep Second Degree Burns

Surgery or no surgery?Surgery or no surgery?

Spontaneous healing often results in:Spontaneous healing often results in:• 1) Thin epithelium1) Thin epithelium

• 2) Dry, scaly skin2) Dry, scaly skin

• 3) Decreased sensation3) Decreased sensation

• 4) Lack of thermoregulation4) Lack of thermoregulation

Deep Second Degree BurnsDeep Second Degree Burns Healing in 3 to 5 weeks (if NO infection)Healing in 3 to 5 weeks (if NO infection)

Wound care is critical to avoid Wound care is critical to avoid conversion (getting worse to 3conversion (getting worse to 3rdrd))

Hypertrophic scarring (raised scar, Hypertrophic scarring (raised scar, confined to area of wound) is commonconfined to area of wound) is common

Will still have hair follicles. Will still have hair follicles.

Third Degree BurnsThird Degree Burns

Cell damage Cell damage Complete through epidermisComplete through epidermis Complete through dermisComplete through dermis

Characterized by Characterized by eschareschar

Hair follicles completely destroyedHair follicles completely destroyed

Nerve endings are destroyed- What is the Nerve endings are destroyed- What is the result of this?result of this?


Pain from surrounding areas that are Pain from surrounding areas that are only partial thickness burnsonly partial thickness burns

Characterized with complete Characterized with complete vascular occlusion and edema vascular occlusion and edema

• Occlusion of blood flow of even deep Occlusion of blood flow of even deep vascular branchesvascular branches

• Distal pulses must be monitored, because Distal pulses must be monitored, because edema can occuled. edema can occuled.


Highly susceptible to infectionHighly susceptible to infection

Wound care is extremely importantWound care is extremely important

No sites for new skin growthNo sites for new skin growth

Skin grafting is requiredSkin grafting is required

Fourth Degree BurnsFourth Degree Burns

Cell damageCell damage• Complete destruction tissues from epidermis to Complete destruction tissues from epidermis to

subcutaneous layerssubcutaneous layers• Muscle and bone may be damagedMuscle and bone may be damaged

OccurrenceOccurrence• Prolonged contact with flames or hot liquidsProlonged contact with flames or hot liquids• Result of contact with electricityResult of contact with electricity

Extensive surgical Extensive surgical management=amputationmanagement=amputation

Extent of Burn InjuryExtent of Burn Injury

Rule of Nines Rule of Nines developed by Pulaski developed by Pulaski and Tennisonand Tennison

Segments are Segments are approximately 9 approximately 9 percent of total body percent of total body surface area (TBSA)surface area (TBSA)

Rapid assessment of Rapid assessment of TBSA injuredTBSA injured

Extent of Burn InjuryExtent of Burn Injury Altered the Altered the

percentages of body percentages of body surface for childrensurface for children

Accommodates for Accommodates for growth body segments growth body segments with agewith age

Permits for higher Permits for higher accuracyaccuracy

Feasibility in emergent Feasibility in emergent care? care?

Wound DebridementWound Debridement

Purpose:Purpose:• Remove dead tissuesRemove dead tissues• Prevent infectionPrevent infection• Promote revascularization/ epithelializationPromote revascularization/ epithelialization

MechanicalMechanical• Whirlpool (non-selective)Whirlpool (non-selective)• Sharp (selective)Sharp (selective)

EnzymaticEnzymatic• SantylSantyl

Burn Wound Dressing Burn Wound Dressing

Purpose:Purpose:ComfortComfortMaintain a moist, healing Maintain a moist, healing environmentenvironmentProtective barrier towards micro-Protective barrier towards micro-organisimsorganisimsDebridement of eschar/necrotic Debridement of eschar/necrotic tissue. tissue.

Burn Wound DressingBurn Wound Dressing Topicals:Topicals:

• Bacitracin (triple antibiotic)Bacitracin (triple antibiotic)• Silvadene (inappropriate to be applied, outdated)Silvadene (inappropriate to be applied, outdated)

Gauze/FilmGauze/Film• XeroformXeroform• Aquacel Ag (gel Matrix)=great stuff, comes in rolls, Aquacel Ag (gel Matrix)=great stuff, comes in rolls,

has petroleum so wont stickhas petroleum so wont stick• Acticoat AgActicoat Ag

Foam:Foam:• Aquacel foamAquacel foam• Mepilex=for ulcers/woundsMepilex=for ulcers/wounds

Burn Wound DressingsBurn Wound Dressings

Superficial burnsSuperficial burns• Use an occlusive dressingUse an occlusive dressing

Xeroform gauze=mosit, does not stick.Xeroform gauze=mosit, does not stick. Dressing to coverDressing to cover

• No need for antibacterial agentNo need for antibacterial agent• Silvadene only used for minor burnsSilvadene only used for minor burns


Mild to Deep Dermal BurnsMild to Deep Dermal Burns• Most common treatment:Most common treatment:

Use a topical antibacterial cream such as a Use a topical antibacterial cream such as a triple antibiotic (Bacitracin) or Santyl (use till triple antibiotic (Bacitracin) or Santyl (use till there less the 50-40% necrotic tissue)there less the 50-40% necrotic tissue)

Cover with a dry occlusive dressing once or Cover with a dry occlusive dressing once or twice a day (to absorb interstial)twice a day (to absorb interstial)

• Skin substitutes provide best protectionSkin substitutes provide best protection Ie: Alloderm, Epicel, Integra (~Shark Skin), Ie: Alloderm, Epicel, Integra (~Shark Skin),

Oasis (Pig Intestines)Oasis (Pig Intestines) More expensive More expensive


Full Thickness BurnFull Thickness Burn

• Topical antibiotic cream for protectionTopical antibiotic cream for protection• Skin substitutes also used for coverage Skin substitutes also used for coverage

until surgeryuntil surgery• Surgical excision and graftingSurgical excision and grafting

Surgical ManagementSurgical Management

Skin Grafting:Skin Grafting:• AutograftAutograft

• Allograft (Homograft)Allograft (Homograft)

• Xenograft (Heterograft)Xenograft (Heterograft)

• Cultured epidermal autograftCultured epidermal autograft


Skin GraftingSkin Grafting

• Extent and depth of injuries determine grafting Extent and depth of injuries determine grafting needsneeds

• Donor siteDonor site

• Split-thickness skin graft (STSG)-take epidermis Split-thickness skin graft (STSG)-take epidermis and top layer of dermis. and top layer of dermis.

• Full-thickness skin graft: Full-thickness skin graft:


Sheet graft: Applied to recipient Sheet graft: Applied to recipient without alteration of donor skinwithout alteration of donor skin• Cosmetically the best resultsCosmetically the best results

Mesh graft: Donor skin is stretched Mesh graft: Donor skin is stretched prior to placement on the wound bedprior to placement on the wound bed


Survival of the skin graft depends Survival of the skin graft depends upon:upon:

• 1) Circulation1) Circulation

• 2) Inosculation=penetration of vessels 2) Inosculation=penetration of vessels into graftinto graft

• 3) Penetration of host vessels into graft3) Penetration of host vessels into graft


Deeply burned areas will develop Deeply burned areas will develop eschareschar

Eschar has poor elastic quality of Eschar has poor elastic quality of normal skinnormal skin

Edema forms in areas under escharEdema forms in areas under eschar Escharotomy may be necessaryEscharotomy may be necessary


Escharotomy: Escharotomy:

Surgical incisions made across joint Surgical incisions made across joint lineslines

Depth penetrates the escharDepth penetrates the eschar

Done without anesthesiaDone without anesthesia

Z-PlastyZ-Plasty

P.T. management P.T. management Z- shaped incision- to open up and Z- shaped incision- to open up and

allow better cervical mobility. allow better cervical mobility. Grafting post procedureGrafting post procedure

SPECIAL TOPICSSPECIAL TOPICS

INHALATION INJURYINHALATION INJURY

3 Types of Inhalation Injury3 Types of Inhalation Injury

1.1. Damage from Heat Damage from Heat InhalationInhalation

2.2. Damage from Smoke Damage from Smoke InhalationInhalation

3.3. Damage from Systemic Damage from Systemic ToxinsToxins

Damage from Heat InhalationDamage from Heat Inhalation

Caused by hot air or flame, or from a Caused by hot air or flame, or from a forceful high pressure sourceforceful high pressure source

The thermal injury is usually in the The thermal injury is usually in the upper airway onlyupper airway only

If steam is inhaled, patient can have If steam is inhaled, patient can have secondary airway involvement secondary airway involvement because the steam has a higher because the steam has a higher thermal capacity than dry air. thermal capacity than dry air.

Damage from Smoke InhalationDamage from Smoke Inhalation

Can be hidden in patients without Can be hidden in patients without obvious burn injuryobvious burn injury

Can be overlooked in patients with Can be overlooked in patients with burn injuryburn injury

In 1997, 4675 firefighters suffered In 1997, 4675 firefighters suffered burn injury as part of their duties. Of burn injury as part of their duties. Of those, 3770 also suffered an those, 3770 also suffered an inhalation injury. (National Fire inhalation injury. (National Fire Protection Association)Protection Association)

Damage from Systemic ToxinsDamage from Systemic Toxins

Systemic toxins impede our ability to Systemic toxins impede our ability to absorb oxygenabsorb oxygen

Symptoms include confusion or Symptoms include confusion or unconsciousnessunconsciousness

A primary example is Carbon A primary example is Carbon Monoxide PoisoningMonoxide Poisoning

Indications of Inhalation InjuryIndications of Inhalation Injury

1.1. Patient is confused or becomes unconsciousPatient is confused or becomes unconscious

2.2. Patient is found, or evidence of, smoke Patient is found, or evidence of, smoke and/or fire in a small or enclosed areaand/or fire in a small or enclosed area

3.3. Soot is found in, or around, the nose and Soot is found in, or around, the nose and upper airwayupper airway

4.4. Eyebrows, eyelashes or nose hairs have Eyebrows, eyelashes or nose hairs have been singedbeen singed

5.5. Facial or neck burnsFacial or neck burns

6.6. Patient exhibits upper airway distress Patient exhibits upper airway distress (stridor)(stridor)

Carboxyhemoglobin (COHgb) TestCarboxyhemoglobin (COHgb) Test

Blood test to measure the amount of Blood test to measure the amount of COHgb in the bloodCOHgb in the blood

Carbon Monoxide (CO) replaces Carbon Monoxide (CO) replaces oxygen on red blood cells forming oxygen on red blood cells forming COHgbCOHgb

This causes oxygen deficiencyThis causes oxygen deficiency

COHgb ValuesCOHgb Values

Less than 2.3 %:Less than 2.3 %: normal adultsnormal adults 2.1 – 4.2 %:2.1 – 4.2 %: adult smokersadult smokers 8.0 – 9.0 %:8.0 – 9.0 %: heavy smokers (2 packs heavy smokers (2 packs

plus/day)plus/day) 15.0 – 20.0 %:15.0 – 20.0 %: critical value (toxic critical value (toxic

signs/symptoms)signs/symptoms) More than 40 %:More than 40 %: shockshock

Treatment of Inhalation InjuryTreatment of Inhalation Injury

Hyperbaric Oxygen Tx (HBOT)Hyperbaric Oxygen Tx (HBOT)

Enclosed environment, monitored by Enclosed environment, monitored by specially trained staffspecially trained staff

Can be single bed (critical patients) Can be single bed (critical patients) or full room size (multiple patients)or full room size (multiple patients)

Oxygen delivered at high Oxygen delivered at high concentration, higher than 1.0 atm concentration, higher than 1.0 atm pressurepressure

Bronchoscopy VideoBronchoscopy Video

http://www.youtube.com/http://www.youtube.com/watch?v=esjI3jzXO7Ywatch?v=esjI3jzXO7Y


STEVENS JOHNSON SYNDROMESTEVENS JOHNSON SYNDROME

TOXIC EPIDERMAL NECROLYSIS SYNDROME TOXIC EPIDERMAL NECROLYSIS SYNDROME (TENS)(TENS)

SJS: CharacteristicsSJS: Characteristics

Presence of purpuric maculesPresence of purpuric macules Full thickness epidermal necrosisFull thickness epidermal necrosis Mucous membrane involvementMucous membrane involvement Less than 10 % TBSA involvedLess than 10 % TBSA involved Most often caused by medication Most often caused by medication

reactionreaction Mortality approximately 5%Mortality approximately 5%

TENS: CharacteristicsTENS: Characteristics

Presence of erythmatous maculesPresence of erythmatous macules Full thickness epidermal necrosisFull thickness epidermal necrosis Mucous membrane involvementMucous membrane involvement Greater than 30% TBSA involvedGreater than 30% TBSA involved Nearly always caused by medication Nearly always caused by medication

reactionreaction Mortality can near 40%Mortality can near 40%

PathophysiologyPathophysiology SJS and TENS are drug induced, SJS and TENS are drug induced,

pathophysiology remains unknownpathophysiology remains unknown Theories:Theories:

• GeneticGenetic Possibly a predisposition for toxic metabolic Possibly a predisposition for toxic metabolic

accumulationaccumulation• ApoptosisApoptosis

Possibly a cell-mediated cytotoxic reaction of Possibly a cell-mediated cytotoxic reaction of keratinocytes (keratinocyte apoptosis is known keratinocytes (keratinocyte apoptosis is known in TENS)in TENS)

Apoptosis = programmed cell deathApoptosis = programmed cell death Necrosis = uncontrolled cell death (inflammatory Necrosis = uncontrolled cell death (inflammatory

septic response) septic response)

Drug InducedDrug Induced

Short Term Exposure (1-3 weeks)Short Term Exposure (1-3 weeks)• Sulfonamide Abx (Trimethoprim, Sulfonamide Abx (Trimethoprim,

Prontosil) Prontosil) • Aminopenicillins (Amoxicillin, Ampicillin)Aminopenicillins (Amoxicillin, Ampicillin)• Quinolones (Cipro, Levaquin)Quinolones (Cipro, Levaquin)• Cephalosporins (Ancef, Keflex, Ceclor)Cephalosporins (Ancef, Keflex, Ceclor)• Allopurinol (Zyloprim)=GoutAllopurinol (Zyloprim)=Gout

Allopurinol most associated with SJS Allopurinol most associated with SJS and TENS developmentand TENS development

Drug InducedDrug Induced

Long Term Exposure (first 2 months Long Term Exposure (first 2 months of use)of use)• Carbamazepine (Tegretol)Carbamazepine (Tegretol)• Phenobarbitol Phenobarbitol • Phenytoin (Dilantin)Phenytoin (Dilantin)• Valproic Acid (Depakote)Valproic Acid (Depakote)• Corticosteriods (Prednisone, Corticosteriods (Prednisone,

Methylprednisolone)Methylprednisolone)• NSAIDS (Advil, Motrin)NSAIDS (Advil, Motrin)

Mortality and MorbidityMortality and Morbidity

MortalityMortality• SJS: approx. 5%SJS: approx. 5% TENS: up to 40%TENS: up to 40%• Sepsis, respiratory distress, Sepsis, respiratory distress,

complicationscomplications• Inc. TBSA involvement = Inc. mortalityInc. TBSA involvement = Inc. mortality

MorbidityMorbidity• Disease course can be completed in Disease course can be completed in

days but usually up to 3 weeksdays but usually up to 3 weeks

Mortality and MorbidityMortality and Morbidity

Long Term SequelaeLong Term Sequelae• Eye disorders Eye disorders

PhotophobiaPhotophobia Corneal and conjunctival revascularization problemsCorneal and conjunctival revascularization problems As many as 40% TENS survivors may have some As many as 40% TENS survivors may have some

blindnessblindness

• Hyper- or Hypo- pigmentation of the skin post Hyper- or Hypo- pigmentation of the skin post healinghealing

• Finger and toe nail regrowth abnormalitiesFinger and toe nail regrowth abnormalities• Internal mucosal abnormalities (respiratory, GI, Internal mucosal abnormalities (respiratory, GI,

genito-urinary)genito-urinary)

PrognosisPrognosis

Specific prognosticatorsSpecific prognosticators• Increased ageIncreased age

Although reported in all age groupsAlthough reported in all age groups• Increased TBSA % involvedIncreased TBSA % involved• Abnormal lab valuesAbnormal lab values

SCORTENSCORTEN• Severity of illness score (reliable and Severity of illness score (reliable and

validated) validated) • Calculated within 24 hours of admissionCalculated within 24 hours of admission

SCORTENSCORTEN

TreatmentTreatment

Discontinuation of causative agent Discontinuation of causative agent (medication)(medication)

Burn Unit AdmissionBurn Unit Admission• Fluid replacementFluid replacement• Wound care with sterile techniqueWound care with sterile technique

Avoid sulfonamide inciting drugs/dressings Avoid sulfonamide inciting drugs/dressings (Silvadene)(Silvadene)

• Opthomology consultOpthomology consult• Critical care as medical status warrants Critical care as medical status warrants


FROSTBITEFROSTBITE

FrostbiteFrostbite

Cold related injury, actual freezing of Cold related injury, actual freezing of the tissue seen in:the tissue seen in:• HomelessHomeless• People who work outside in the coldPeople who work outside in the cold• Athletes who are outside for training or Athletes who are outside for training or

competitioncompetition• People who enjoy outdoor winter People who enjoy outdoor winter

activitiesactivities

Frostbite:Frostbite:PathophysiologyPathophysiology

Cold exposure leads to:Cold exposure leads to:

• Ice crystal formationIce crystal formation• Cellular dehydrationCellular dehydration• Protein changesProtein changes• Capillary damageCapillary damage

Frostbite:Frostbite:PathophysiologyPathophysiology

Re-warming leads to:Re-warming leads to:• Cell swelling and edemaCell swelling and edema• Platelet aggregationPlatelet aggregation• Endothelial cell damageEndothelial cell damage• ThrombosisThrombosis• Tissue edema and compartment Tissue edema and compartment

syndromesyndrome• Local ischemiaLocal ischemia• Tissue deathTissue death

FrostbiteFrostbite

Long term damages:Long term damages:

• Parasthesias and sensory deficitsParasthesias and sensory deficits• VasospasmVasospasm• Cold sensitivityCold sensitivity• Joint pain and stiffnessJoint pain and stiffness• Phantom pain of amputated extremities Phantom pain of amputated extremities

or digitsor digits

FrostbiteFrostbite

Signs and SymptomsSigns and Symptoms• Coldness and firm tissueColdness and firm tissue• Stinging, burning and numbnessStinging, burning and numbness• Clumsiness of digits/extremitiesClumsiness of digits/extremities

On re-warming:On re-warming:• Pain, throbbing and burningPain, throbbing and burning

Frostbite:Frostbite:Degrees of InjuryDegrees of Injury

First degree: “frost nip”First degree: “frost nip”• ErythemaErythema• EdemaEdema• Hard white “plaques”Hard white “plaques”• Sensory deficitSensory deficit


Second degree:Second degree:• Clear or milky blistersClear or milky blisters• Blisters appear within 24 hoursBlisters appear within 24 hours• ErythemaErythema• EdemaEdema


Third degree:Third degree:• Blood filled blistersBlood filled blisters• Blisters turn into black eschar within a Blisters turn into black eschar within a

few weeksfew weeks

Fourth degree:Fourth degree:• Full thickness, involving muscle, boneFull thickness, involving muscle, bone

Frostbite:Frostbite:TreatmentTreatment

Initiate re-warming, no rubbing or Initiate re-warming, no rubbing or trying to thaw with snowtrying to thaw with snow

Once under medical care: fluid Once under medical care: fluid resuscitationresuscitation

Thawing can take 20-40 minutesThawing can take 20-40 minutes Debride clear blisters, leave Debride clear blisters, leave

hemhorragic blisters alonehemhorragic blisters alone Admit to a burn unit if necessaryAdmit to a burn unit if necessary

FrostbiteFrostbite

Demarcation can take 1-3 months to Demarcation can take 1-3 months to completecomplete

Tissue often heals or mummifies Tissue often heals or mummifies without surgery, so delay amputationwithout surgery, so delay amputation

Lower extremity injury and those Lower extremity injury and those who delay treatment have a higher who delay treatment have a higher incidence of surgical interventionincidence of surgical intervention

HBO: studies are still case specificHBO: studies are still case specific

FrostbiteFrostbite

Complications:Complications:

• InfectionInfection• Tissue lossTissue loss• GangreneGangrene

Frostbite:Frostbite:Prognostic IndicatorsPrognostic Indicators

Good prognosisGood prognosis• Early sensory return with good pinprickEarly sensory return with good pinprick• Healthy looking tissueHealthy looking tissue• Clear blistersClear blisters

Poor prognosisPoor prognosis• CyanosisCyanosis• Hemorrhagic blistersHemorrhagic blisters• Skin has frozen appearanceSkin has frozen appearance

Topics RequestedTopics Requested

1. Stretching and scar management1. Stretching and scar management 2. Mobility training2. Mobility training 3. Pressure garments3. Pressure garments 4. Positioning4. Positioning 5. Splinting/Orthotics5. Splinting/Orthotics

All topics are related across the All topics are related across the continuum of care!continuum of care!

Rehabilitation Services for Burns: Rehabilitation Services for Burns: Who needs Therapy?Who needs Therapy?

Acute HospitalAcute Hospital• Patients who meet Burn Unit criteriaPatients who meet Burn Unit criteria• Patients with decreased mobility Patients with decreased mobility

Inpatient RehabInpatient Rehab• Patients who require functional re-trainingPatients who require functional re-training

Outpatient Outpatient • Patients with scar/contracture Patients with scar/contracture

evidence/potentialevidence/potential• Patients who require pressure garmentsPatients who require pressure garments

Burn Unit Admission RequirementsBurn Unit Admission Requirements

1. 21. 2ndnd and 3rd degree burns > 10% TBSA in and 3rd degree burns > 10% TBSA in patients under the age of 10 or over 50.patients under the age of 10 or over 50.

2. 22. 2ndnd and 3 and 3rdrd degree burns > 20% TBSA in all degree burns > 20% TBSA in all other patients.other patients.

3. 23. 2ndnd and 3 and 3rdrd degree that involve face, hands, degree that involve face, hands, feet, genitalia/perineum and major joints.feet, genitalia/perineum and major joints.

4. 34. 3rdrd degree > 5% TBSA in any age group. degree > 5% TBSA in any age group. 5. Electrical burns, including electrocution.5. Electrical burns, including electrocution. 6. Chemical burns.6. Chemical burns. 7. Inhalation injury. 7. Inhalation injury. 8. Patients with burns and concomitant trauma.8. Patients with burns and concomitant trauma.

Rehabilitation Management TeamRehabilitation Management Team Physical Therapist (PT)Physical Therapist (PT)

• Lower extremity splintingLower extremity splinting• Lower extremity ROM Lower extremity ROM

exercisesexercises• Functional activityFunctional activity

Occupational Therapist (OT)Occupational Therapist (OT)• Upper extremity splintingUpper extremity splinting• Upper extremity ROM Upper extremity ROM

exercisesexercises• ADLs training and ADLs training and

managementmanagement• Functional activityFunctional activity

Nursing (RN, LPN)Nursing (RN, LPN)• Medical managementMedical management• Direct wound care-dressing Direct wound care-dressing

changes, debridementchanges, debridement• HydrotherapyHydrotherapy

Speech-Language Speech-Language Pathologist (SLP)Pathologist (SLP)• Ensures oral motor skills are Ensures oral motor skills are

adequate for speech and adequate for speech and swallowingswallowing

• Treats concurrent injury Treats concurrent injury issues (i.e. head injuries)issues (i.e. head injuries)

Orthotist (CO)Orthotist (CO)• Performs fitting for custom Performs fitting for custom

pressure garments for scar pressure garments for scar managementmanagement

• Evaluates and treats patient Evaluates and treats patient for advanced orthosis needs for advanced orthosis needs (dynamic splints, custom (dynamic splints, custom lower extremity orthotics, lower extremity orthotics, face masks)face masks)

Rehab ManagementRehab Management

Rehabilitation occurs concurrently with wound Rehabilitation occurs concurrently with wound healinghealing

Rehab Management: AcuteRehab Management: Acute

Early stages consist of:Early stages consist of:• 1) Positioning and control of edema1) Positioning and control of edema

• 2) Maintenance of normal ROM and 2) Maintenance of normal ROM and strength (prevent contractures)strength (prevent contractures)

• 3) Prevent functional loss3) Prevent functional loss

• 4) Maintenance of cardio-pulmonary 4) Maintenance of cardio-pulmonary systemsystem


Edema controlEdema control• ElevationElevation

• Early, frequent Early, frequent active motionactive motion

• Prop extremities Prop extremities correctlycorrectly


Positioning in BedPositioning in Bed• Position of Comfort = Position of Position of Comfort = Position of

DeformityDeformity• Contractures and neuropathiesContractures and neuropathies• Individualized to patient needsIndividualized to patient needs• Sustained stretch positions Sustained stretch positions • Pressure Relief Ankle Foot Orthosis Pressure Relief Ankle Foot Orthosis

(PRAFO)(PRAFO)

Positioning: Acute BurnPositioning: Acute Burn


Maintain ROM and Contracture PreventionMaintain ROM and Contracture Prevention• Encourage early AROM whenever possibleEncourage early AROM whenever possible• Assist with PROM/AAROM for patients unable to Assist with PROM/AAROM for patients unable to

complete full range themselves complete full range themselves • Splinting early encourages proper positioningSplinting early encourages proper positioning• Discontinue active exercise 3-5 post graftDiscontinue active exercise 3-5 post graft• Self-stretching for donor site areas: ok to begin Self-stretching for donor site areas: ok to begin

24 hours post op.24 hours post op.

Early Splinting: AcuteEarly Splinting: Acute

Early Splinting: AcuteEarly Splinting: Acute

No splints: loss of functionNo splints: loss of function

Rehab Management: MobilityRehab Management: Mobility

Bed MobilityBed Mobility• Can be very painful, especially with back or Can be very painful, especially with back or

buttock burnsbuttock burns• Exudry utilized for comfortExudry utilized for comfort• Bridging on heelsBridging on heels

TransfersTransfers• OOB as soon as possibleOOB as soon as possible• Use of cardiac chairs Use of cardiac chairs • Abdominal and anterior thigh burns can Abdominal and anterior thigh burns can

impact sit-standimpact sit-stand

Rehab Management: MobilityRehab Management: Mobility

AmbulationAmbulation• Use ACE wrap on LE’s to control edema Use ACE wrap on LE’s to control edema

and decrease pain and decrease pain • Discourage flexed posture: trunk Discourage flexed posture: trunk

positioning, use of ADpositioning, use of AD Exercises for postureExercises for posture

• Trunk rotation and extension Trunk rotation and extension • LE self stretches for donor sitesLE self stretches for donor sites

Scar Management: HealingScar Management: Healing Healing in 2 weeks:Healing in 2 weeks:

• Minimal to no scarringMinimal to no scarring• Superficial second degree burnsSuperficial second degree burns

Healing in 3 weeks:Healing in 3 weeks:• Minimal to no scar except in high risk groups (AA Minimal to no scar except in high risk groups (AA

or Asians)or Asians) Healing in > 4 weeks:Healing in > 4 weeks:

• Hypertrophic scarring in more than 50% of Hypertrophic scarring in more than 50% of patientspatients

• Due to prolonged inflammatory phase, increased Due to prolonged inflammatory phase, increased histamine (fibrous tissue growth)histamine (fibrous tissue growth)

Scar Management: HealingScar Management: Healing

Early grafting = less scarEarly grafting = less scar Thicker graft leads to less scarThicker graft leads to less scar Mesh grafts leave more scarring than Mesh grafts leave more scarring than

sheet graftssheet grafts The wider the mesh (increased ratio) The wider the mesh (increased ratio)

the more scarringthe more scarring Scars will develop at the edge of a Scars will develop at the edge of a

graft in high risk patient groupsgraft in high risk patient groups

Scar Management: StretchingScar Management: Stretching

Stretching with Burn PatientStretching with Burn Patient• Slow, long manual stretch: up to 60 secondsSlow, long manual stretch: up to 60 seconds• Contract-relax techniquesContract-relax techniques• Lubrication: deep-prep or cocoa butterLubrication: deep-prep or cocoa butter• Blanching of wound: “if it’s white, it’s tight”Blanching of wound: “if it’s white, it’s tight”• Contraindications:Contraindications:

1) Exposed joints or tendons1) Exposed joints or tendons 2) Joints with heterotrophic bone formation2) Joints with heterotrophic bone formation

• Elbow most common in burn populationElbow most common in burn population 3) Possible fractures3) Possible fractures 4) Joints with osteopenia, osteoporosis or 4) Joints with osteopenia, osteoporosis or

osteomyelitisosteomyelitis

Burn Stretching:Burn Stretching:

Virtual Reality VideoVirtual Reality Video

www.youtube.comwww.youtube.com

Scar Management: HypertrophyScar Management: Hypertrophy

Occurs in approximately 50% of healed Occurs in approximately 50% of healed deep burnsdeep burns

Males and Females both affected, only Males and Females both affected, only seen in humansseen in humans

Characteristics of the Hypertrophic ScarCharacteristics of the Hypertrophic Scar• Surface erythemaSurface erythema• Raised from original woundRaised from original wound• Lack of elasticityLack of elasticity• Increased collagenIncreased collagen• Painful and itchy Painful and itchy



Hypertrophic scar development peaks Hypertrophic scar development peaks at approximately 3 - 6 months post at approximately 3 - 6 months post burnburn

Scar is partially resolved by 12 – 18 Scar is partially resolved by 12 – 18 months post burnmonths post burn

Treatment: 3 categoriesTreatment: 3 categories• BiophysicalBiophysical• SurgicalSurgical• PharmocologicPharmocologic

Burn Wound HealingBurn Wound Healing

Hypertrophic Hypertrophic scarscar• 1) Red, itchy, 1) Red, itchy,

elevatedelevated

• 2) Confined to 2) Confined to original area of original area of injuryinjury

Burn Wound HealingBurn Wound Healing Keloid scarKeloid scar

• 1) Type of hypertrophic 1) Type of hypertrophic scarscar

• 2) Red, itchy, 2) Red, itchy, painfulpainful

• 3) Extends outside the 3) Extends outside the area of original injuryarea of original injury

• 4) Tumor-like appearance4) Tumor-like appearance

• 5) More common in 5) More common in African-American and African-American and Asian-American Asian-American populationspopulations

Scar Management: TreatmentScar Management: Treatment

Biophysical TreatmentsBiophysical Treatments• Compression: pressure garmentsCompression: pressure garments• Ultrasound or microwave heat: possibly Ultrasound or microwave heat: possibly

increases collagenase acivityincreases collagenase acivity• Gel sheeting: silicon sheets held in place Gel sheeting: silicon sheets held in place

by ACE wrapsby ACE wraps• Scar massage: break down of the scar Scar massage: break down of the scar

matrixmatrix

Scar Management: CompressionScar Management: Compression

Pressure GarmentsPressure Garments

• Custom fitted to the Custom fitted to the patientspatients

• Used as soon as wound Used as soon as wound closure is achievedclosure is achieved

• Continuum from acute Continuum from acute care to outpatientcare to outpatient

Scar Management: CompressionScar Management: Compression Pressure GarmentsPressure Garments

• TheoryTheory 1) Decrease scar blood flow1) Decrease scar blood flow 2) Decrease protein 2) Decrease protein

depositiondeposition 3) Increase lysis3) Increase lysis 4) Decrease edema4) Decrease edema

• GoalsGoals 1) Decreasing redness1) Decreasing redness 2) Flattening raised areas2) Flattening raised areas 3) Increasing scar pliability3) Increasing scar pliability 4) Preventing contractures4) Preventing contractures 5) Decreasing itching5) Decreasing itching 6) Relieving hyperesthesia6) Relieving hyperesthesia 7) Speeding up healing 7) Speeding up healing

processprocess


• Wearing ScheduleWearing Schedule

1) Progressive up to 23 1) Progressive up to 23 hours per dayhours per day

2) Continue process 2) Continue process for up to 2 years until for up to 2 years until Maturation Phase Maturation Phase completedcompleted


• MaintenanceMaintenance Monitored frequently Monitored frequently

at outpatient clinicsat outpatient clinics

Measured/refitted Measured/refitted with muscle growth with muscle growth and weight changesand weight changes

Observed for skin Observed for skin breakdownbreakdown

2 sets so that 1 set 2 sets so that 1 set is always cleanis always clean


Transparent Facial Orthoses (TFOs)Transparent Facial Orthoses (TFOs)• Work under the same theory and goals Work under the same theory and goals

as pressure garmentsas pressure garments• Can be utilized prior to complete wound Can be utilized prior to complete wound

closureclosure• Worn for a progressive schedule up to Worn for a progressive schedule up to

23 hours per day23 hours per day• Covers areas of injury only Covers areas of injury only • Conventional vs. Computer generatedConventional vs. Computer generated

Scar ManagementScar Management Conventional MethodConventional Method

• Petroleum jelly placed Petroleum jelly placed directly over face in OR directly over face in OR or bedsideor bedside

• Plaster or casting Plaster or casting material placed over material placed over faceface

• Plaster negative is Plaster negative is allowed to dry and allowed to dry and filled with plaster to filled with plaster to create positive moldcreate positive mold

• Plastic mask vacuum-Plastic mask vacuum-formed to the moldformed to the mold

• Mask fit and trimmed Mask fit and trimmed to the patientto the patient

Computer ScanningComputer Scanning• Facial features scanned Facial features scanned

by computer (15 by computer (15 seconds)seconds)

• Scanner catches Scanner catches topographic data topographic data

• Mold created via Mold created via stereolithography in stereolithography in plasticplastic

• Plastic vacuum-formed Plastic vacuum-formed to moldto mold

• Patient is fit and Patient is fit and trimmed to the masktrimmed to the mask


Examples of the use of a TFO in a child Examples of the use of a TFO in a child and a Transparent Neck Orthosis (TNO) for and a Transparent Neck Orthosis (TNO) for an anterior neck burn injuryan anterior neck burn injury

Scar Management: SurgeryScar Management: Surgery ExcisionExcision

• Small scarsSmall scars• High recurrence rate, more than 50% returnHigh recurrence rate, more than 50% return

LaserLaser• Thermal tissue reaction occursThermal tissue reaction occurs• Improves elasticity, less redness and less itchingImproves elasticity, less redness and less itching• 50% improvement in half the cases50% improvement in half the cases

Cryo-therapyCryo-therapy• Similar to laser, causes microcirculatory changes Similar to laser, causes microcirculatory changes

that damage fibroblasts that damage fibroblasts • 50 to 70% of patients report some improvement50 to 70% of patients report some improvement

Cold Laser VideoCold Laser Video Berns TripletsBerns Triplets

http://www.youtube.comhttp://www.youtube.com

Scar Management: PharmacologicScar Management: Pharmacologic

CorticosteriodsCorticosteriods• Reduces histamine and reduces itchingReduces histamine and reduces itching• Injected into the scar itselfInjected into the scar itself

InterferonInterferon• Reduces scar forming growth factor TGF-betaReduces scar forming growth factor TGF-beta• IV or injected into the scarIV or injected into the scar

Protein kinase C inhibitorsProtein kinase C inhibitors• Calcium channel blockers reduce protein Calcium channel blockers reduce protein

deposited into wounddeposited into wound

Questions?Questions?

E-mail: E-mail: [email protected]

Documents

Burns and Rehabilitation Detroit Receiving Hospital