Burn sheet

Definition of burn

Burn is tissue destruction

Coagulation zone Stasis zone Hyperemia zone

Minimal cell injury will recover

Irreversible injured cell

death

Cell injured may die without treatment in 24-48 H

Causes of burn

Burn may due to

Thermal dry Thermal wet Chemical

Flame burn Scald burn (hot liquid) Alkaline or acid

Electrical

High or low voltage

Irradiation

Deep X-ray

atomic

Charred bone

1st aids

1- Remove agent which cause the burn

2- Remove victim from contact of electricity by disconnecting the source

3- Use cold water where medical and special treatment are absent. hands, arms and legs are immersed in cold water for 15-20min. advantages: a) decrease pain b) decrease exudation (edema) disadvantage: risk of bacterial infection

4- Remove clothes

5- The burned area should covered with sterile towel

6- Transverse pt to the hospital.

Evaluation

Importance : 1- To determine the pt. status 2- To identify problem list 3- To plan a ttt program 4- To determine pt. status at time of discharge according

to severity and degree of burnTypes : 1- Informal (general overview of the pt) 2- Formal (functional tests) 3- Standardized: *initial evaluation, *progress evaluation (re-evaluation)

and *discharge evaluation.Source of information 1- Medical chart 2- Physician 3- Nurse 4- Pt’s family 5-Pt 6- Other member of burn team

A- History

Factors that may interfere with obtaining a history directly from the pt.:

1- Endotracheal tube 2- Loss of consciousness 3- Age (children) 4- Any previous psychological problems

Personal history: Name : Age : Sex:

Occupation: Address: weight: {(2-4)×wt × TBSA}

height: (bilateral lesion, standard evaluation of edema).

Past history :- 1- Any previous (disease, trauma, surgery, burn) 2- Vision and hearing acuity 3- Balance and co-ordination 4- Neuromuscular or skeletal deficits

Present history:- 1- Date of burn 2- Date of evaluation 3- Date of admission 4- Date of initial pt session.

Special history:- 1- Percentage, extent and depth of burn 2- Associated injuries such as fracture, dislocation, inhalation injuries. 3- Position of the pt.

B- Burn severity index

There are many variable that are associated with increased burned pt. mortality rate:-

1- Age:- burns of very young and aged people are associated with a

high mortality rate ( child---- immature skin rapid rupture, increase dehydration, hypovolumic shock, more scar contracture development), negative relation between age and return to work.

2- Gender :- female more affected than male due to their psychological status and need more time to return to work , while male more exposure to burn causing agents.

3- Burn wound assessment :- a)- estimating the total % of the surface (transceparent) b)- differentiation between partial and full thickness injury (pinprick - volume- photographic---3D- US- LASER Doppler) c)- location of the wound

4- Extent of burn injury:- a)- major burn:- >15% in adult ----- 10 >% in

children b)- minor burn:- < 15% in adult ----- 10<% in

children * Critical --- 10% in third 30% in second * moderate----< 10% in 3rd 15-30% in 2nd * minor------< 2% in 3rd 15% in 2nd There is a direct relationship between the % body

burn and the resultant number of contractures developed. The % total body burn is an important information for:

1- pt. resuscitation 2- survival statistics 3- the therapist to project the amount of time needed for pt. ttt. There are two methods used to determine the % of body burn

A-Rule of nines:-which divides the body into 11 sements each of them accounts for 9% of the total + 1% for perineum:-

face and neck = 9% each UL = 9% each LL = 18% each ant. Trunk = 18% post trunk = 18% perineum = 1%

*It’s used for adults and in the emergency triage of burned pt

B) Lund and browder chart:- Altered the percentages of the body surface area for children to accommodate for growth of the different body segments and allow for more accurate means of determining the extent of burn injury. It provide an accurate assessment of TBSA. It may not be paractical in the emergency triage of the burned pt. We can divide rule of nine (e.g. ant. Up limb----- 4.5)

Area 0-1 1-3 3-7 7-13 adult

Head 19 17 13 11 9

Neck

Ant.thor.

Post.thor.

Arm

Forearm

Hand 2.5 2.5 2.5 2.5 2.5

Thigh

Leg

Foot

Genital organs

Rule of nine Lund and Browder

Adult Adult and children

Less accurate More accurate

Used in emergency state Not used in emergency

Less time More time

5- Depth of burn wound:- (volume- 3D photograph- laser Doppler- ultrasonic- ca++

alginate to take the shape of sinus the used 3D photograph)

a) Superficial burn (1st degree):- cell damage occurs only to the epidermis, the classic sunburn is the best example.Clinically:

* skin appears red or erythematous * no injury to dermal layer * surface is dry * no blisters but slight edema may appear * following superficial burn there is usually a

delay in the development of pain at which point the area becomes tender

* healing within few days (2-3)

b) Superfacial partial thickness burn (2nd degree):- In this type the burn extends to the upper layers

of dermis (epidermal layer destroyed completely but the dermal is mild to moderate damage, the basal layer of the skin doesn’t destroy,common signs:-

* the presence of intact bilsters over the area that has been injured,

* healing will occur rapidly if the blisters are evacuated and removed, then antibiotic agents are applied,

* once blisters had removed the surface appear red (due to inflammation of the dermis)

* Edema is minimal * This type of burn is extremely painful as a result of irritation

of nerve endings contained in derms * It heals without surgical interference by means of epithelial

cell production and migration from the wound’s periphery and the surviving skin appendages

* Healing within 7-21 days and without scar formation * Its causes are scald, flash flame and chemical

C- deep partial thickness burn(2nd degree):- In this type the destruction extends to the deeper layer of the dermis, most of nerve endings, hair follicles and sweat glands will be injured

* it appears a mixed red or waxy white color, this red color is due to hemoglobin fixation within the damaged tissue

* the deeper the injury, the more white it will appear * the surface usually is wet from broken blisters and

alteration of dermal vascular network * it is a painful injury because not all nerve endings have

been destroyed * sensation is intact to pressure (deep) but diminished to

light touch (superficial) or soft pinprick * heals in 3-5 weeks with formation of scar (if not infecte

D) full thickness burn (3rd degree) :-all epidermis and dermal layers are destroyed completely and subcutaneous

fatty layer may be damaged to some extent characterized by * hard parchment like Escher (dead tissue that covers a full thickness burn)

* Escher feels dry and leathery to touch, and its color vary from black to white (white color indicates total ischemia of the area

* All peripheral vascular system is destroyed leading to complete vascular occlusion which in turn leads to marked edema

* It needs Escherotomy (mid lateral incision of the Escher), and need skin graft for wound healing.

* There is increase the risk of infection

E) subdermal burn (4th degree):- all the layers have been destroyed (epidermis, dermis and subcutaneous

tissue) * muscle, tendon and bone are involved in the injury * this type of burn due to prolonged contact with a flame or hot liquids and

contact with electricity * destruction of vascular system lead to additional necrosis * extensive surgical and therapeutic management will be needed to return the pt

to some degree of function

6- location of burn :- it is important to anticipate contracture development and to focus the treatment to this areas

* If the burn is near to joint it will lead to more dysfunction and decrease in ROM.

* The primary areas are face, hand, feet and perineum because it leads to specific problems

* Common anatomical sites of burn scar and contractures are :- eye lids, commissures of mouth, anterior neck, anterior and posterior axillary folds, anticubital space, forearm, wrist flexion creases, dorsal and palmer surfaces of hands and fingers, lateral trunk, perineum and popliteal space, Achilles tendon area and dorsal and planter surfaces of the feet.

7- Respiratory state:- the burn severity index associates inhalation injury with a

high mortality rate, it affects the pt’s eventual endurance capacity. In initial evaluation you must determine if there is inhalation or not Suspect an inhalation injury if :-

1- victim injured in closed space 2- pt with burn in face and anterior neck 3- there is coughing with profuse expectoration 4- pt with nasal vibrissae (black color at nose opening)

C-Edema and limb circumference

Record edema formation as minimal to sever Methods to evaluate edema:- a- Water displacement method :- * Difficult in pt with acute burn because it requires pt to place limb in dependent position that may be painful because of vascular compression. * it used for hands and feet * sterilized water must be used. b- Round measurement :- use a sterilized tape measurement as an objective method to record changes in edema and compare with the other side c- Ring method :- it is an objective method and use for neck only.

D- Sensory assessment 1- if there is associated injury for head and neck assess the superficial and deep sensation and reflexes 2- in 2nd degree of burn we use pinprick to determine the amount of pain 3- in 3rd degree of burn we use pinprick to note the depth of burn

E- Joint ROM Assessment It is important for determination of progression and regression. * Use geniometer Causes of limitation are pain, edema, inelastic Escher and disuse of affected part * Once pain, edema decreased and Escher removed, ROM increase.

F- Muscle Strength * If a burned patient at normal level prior to injury, also in minor burn, a specific manual muscle testing my not necessary* We make functional group muscle testing * Manual individual muscle testing considered in cases of electrical burn, severe edema and if a particular injury is suspected* We use tensiometer to detect muscle strength (hand grip). * Pain, edema and anxiety cause a non physiologic decrease in pain strength.

G- Flexibility Assessment * It is a combination between joint ROM and muscle balance (hyper or hypo mobility) * Not the position of the limb and ask for history of arthritis or pervious injury

H- Mobility and Ambulation Assessment * It is the degree to which the patient is able to move about freely in bed or during transverse * Changing position in bed is important to decrease tissue damage * PT determines how and to what extent the burned pt is able to move or transfer, this gives information about the amount of assistance needed to this pt and allow the therapist to begin problem solving.

I- Endurance Assessment * cardiovascular endurance is limited due to systemic and catabolic effect of the burn injury. * Aerobic capacity of the pt is affected by bed rest, immobilization and pain. * Ask pt to begin ambulation early as much as possible to enhance aerobic capacity.

J- Postural Assessment* An upright, relaxed posture is seldom seen in the burn pt early in hospitalization.

Region Common Deformity Correct Position

Neck Flexion Hyperextension by cervical orthosis

Shoulder internal Adduction and rotation Abduction , flexion and external rotation

Elbow Flexion and pronation Extension and supination

Hand Claw hand Extension

Hip Flexion and adduction Extension and abduction

Knee Flexion Extension

Ankle Planter flexion Dorsiflexion

Assessment

Problems list:-

1- pain 2- edema 3-deformity 4- decrease ROM 5- delayed wound healing 6- muscle weakness {systematic response of burn due to activation of mediators (chemical mediators : destruction of m.s protein, decrease mitochondrial function and decrease insulin resistance)

7- loss of ADL 8- postural abnormalities 9- psychological problem 10- gait abnormalities

Plan of treatment:- I- Short term goals:-A- Acute stage: 1- prevent improper position 2- reduce associated complication with burn such as edema B- Wound healing stage 1- help accelerate wound healing 2- avoid wound infection 3- proper positioning to decrease pathological contracture of skin and muscles 4- help to control edema 5- reduce any musculoskeletal problem may associated with burnC- Chronic stage 1- prevent and correct any improper posture and deformity 2- increase ROM of burned part joint 3- improve pt functional activity II- Long term goal To return the patient’s functional abilities as much as pre injury level.

Methods (intervention) :- A- Acute stage

1- proper positioning by using pillow, layers of blankets, rolled towels or soft splint (sponge – foam)

2- active free or assisted exercises with elevation but not use passive movement to avoid tissue damage.

B- Wound healing stage1- electrotherapeutic modalities as LASER , or US to accelerate

wound healing2- therapeutic exercises to reduce musculoskeletal problem and

also to help wound healing.3- Ultraviolet, high voltage current stimulation and Honey

therapy to avoid infection.4- Pumping technique to control edema by static exercises,

elevation, pneumatic compression (inflation 25-40mmHg - deflation 10-20mmHg) 3:1 in time

5- Positioning exercises for deferent body parts and using splinting

C-Chronic stage 1- Warming up technique as hot packs, paraffin wax

(immersion, raping or brushing) and continuous US.2- deferent methods of stretching technique and

splinting (thermoplastic splint)3- strengthens exercises4- mobilization exercises for different joint.