Burn Unit
Incidence/Etiology/Classification
● Children under 4 hospitalized for burn-related injuries, 65% scald burns (hot food, liquids
spilled, hot tap water), 20% contact burns and remainder flame burns.
● 2/3rds of electric injuries ages 12 and under, due to electric cords/extension cords,
contact with wall outlets
● Boys>Girls
● Burns occur when energy is transferred from a heat source to the body. Tissue damage
begins at temp of 40 deg celsius, at 45 deg celsius cellular necrosis occurs
● Extent of injury due to: 1) heat intensity, 2) duration of exposure, 3) tissue conductance
● Burns categorized: 1) fire/flame, 2) scald, 3) contact, 4) electrical, 5) chemical, 6)
radiation
● Admission to the burn unit: partial thickness burns of greater than 10% of the total body
surface, third degree burns, burns of the hands, face, eyes, ears, feet and perineum,
burns with associated injuries including electrical, chemical or inhalation/fractures/other
trauma.
● TBSA (total body surface area): estimated by rule of 9s, which divides the body surface
into areas representing 9% or a multiple of 9% of body surface area. UNRELIABLE in
children younger than 15 years. Another method: Berkow formula, recognizes that
proportions of body surface area change with age. Computer images of the
body+programs can now accurately calculate body surface area.
● A circumferential burn to an extremity with a clear line of demarcation → abuse
Burn Depth and Wound Healthing
→ Skin thickness varies at different parts of the body. Skin is thickest: back, palms of hands,
and soles of feet.
● Superficial
○ Affect only epidermal layer of the skin
○ Dermis is not injured, therefore fluid is not lost
○ Superficial area NOT included in total body surface area calculations
○ Heal without sequelae
● Partial thickness
○ Affect both the epidermis and the dermis
○ Heal by reepithelialization
○ Basal cells migrate and proliferate across the burn to heal the wound from the
basal layer.
○ Extent of dermal involvement impacts scar formation especially if area crosses a
joint or involves face/neck.
● Superficial partial thickness
○ Involve primarily the papillary dermis
○ Burn to papillary dermis is likely to heal without scar tissue formation
○ Dermal appendages provide basal cells to re-epithelialize the burned area within
10 to 14 days.
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Deep partial thickness
○ Burn extending deeper into the dermis or reticular dermis
○ Can take up to 21 days for complete healing
○ Burns beyond the base of the dermal appendages result in replacement of
normal integument with a mass of metabolically high active scar tissue lacking
the normal architecture of the dermis.
○ Burns that do not heal at 21 days, consider skin graft to minimize hypertrophic
scar formation, scar contracture and physical impairment.
Full thickness
○ Extend beyond the dermis to the subcutaneous adipose tissue
○ May extend into the fascia, muscle or bone
○ Most common seen: digits, hands, feets and over bony prominences (iliac crest,
patella, anterior tib, and cranium)
Burn Unit and Team Approach to Care
● Multidisciplinary approach
● Team consists of: burn center director, physicians, nurse manager, PT, OT, SLP,
pharmacists, nutritionists, social worker, psych, RTs, child life specialists/rec therapists.
Medical Management of Burns
● Upon admission estimation of the following: burn depth, percentage of total body surface
area, and child’s overall condition.
● Damage to integument places the body at risk for infection, impairs body regulation, &
body fluid loss (hypovolemia).
● Shock can occur due to hypovolemia; the goal is to restore vascular volume to preserve
tissue perfusion and minimize tissue ischemia. (placement of IV, catheter is common)
● Loss of capillary integrity can lead to edema formation. Process occurs at partial
thickness burns and areas adjacent to full thickness burns.
● Patients have limited movement due to pain and there is a direct damage to the
lymphatic system, edema can then accumulate in the tissue spaces. If motion is not
restored and edema reduction is not achieved it can lead to adhesions.
● Escharoctomy → full thickness burns to relieve pressure caused by fluid resuscitation
and progress edema in extremities and trunk. Performed when tissue pressure exceeds
40mmhg.
● Fasciotomy→ deep burns, high voltage electrical injury
● Partial thickness burns heal with MOIST dressings
● Full thickness burns → autogenous split-thickness skin grafts.
● Cleansing techniques: 1) local care of a specific area using water and cleansing at
beside, 2) spray hydrotherapy or non submersion, using shower head , 3) submersion of
child or burned extremity in tub or tank of water.
● DAILY dressing changes with various antimicrobial creams and solutions to promote
healing and prevent infection. Agents held by gauze, which should be wrapped so
burned surfaces do not touch (ex: fingers and toes wrapped separately)
Surgical Management of Burn
● Autografting
○ Harvesting of one’s own skin for full thickness burns
○ Harvested at any area of the body except for face and hands.
○ SCALP is the best donor site, with reepithelialization in 4 to 5 days with torso and
extremities typically 10 to 14 days.
● Split-thickness grafts (STSG)
○ Used exclusively for full thickness burn wound coverage.
○ Skin harvested at partial thickness depth
○ Burns of the hands, face, and neck take precedence for skin grafting
○ Use of “intact” skin graft for cosmetic purposes
○ With limited donor skin or patients with high % TBSA burns, donor skin is
meshed, cutting small holes in the donor skin to allow for expansion
● Full-thickness skin grafts (FTSG)
○ Used for deep burn wounds (ex: with tendon, bone, muscle involvement)
○ Used later in reconstructive procedures
○ Skin grafts must be undisturbed to adhere to wound bed, accomplished through
immobilization (splint, bulky dressings secured in place)
○ Revascularization between wound bed and graft and nutritive blood flow occurs
in 48 hours.
○ AROM allowed after 5th day of graft application
● Early Excision of burn wound
○ Increased survival of patients with burns up to 98% of TBSA, but problems with
wound closure.
○ Biologic or cadaveric skin grafts may be used temporarily to buy time for
autograft procedures.
○ Autograft necessary for permanent wound closure in large TBSA burn
● Biologic dressings
○ Reduce Risk of wound infection
○ Provide temp wound closure
○ Decrease fluid loss
○ Protect excised burns covered by meshed skin grafts
● Growth factor technology & wound dressings
○ Improve wound healing, function and cosmetic results
○ Allow for thinner donor harvesting an multiple rehavesting of the same donor site
Burn Scar
● Scar Formation
○ Children more susceptible to hypertrophic scarring than adults
○ Darker the patient’s skin more susceptible to hypertrophic scarring
● Collagen & firm inelastic ground substance, coupled with simultaneous contraction of
myofibroblasts contribute to raised appearance of hypertrophic scar, + voluntary
contraction of muscle fibers
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Position of comfort for the patient is flexion of the affected joint, however if flexion is
maintained contracture will occur.
Intensity and duration of vascular response increase likelihood of hypertrophic scarring.
Active phase of scar subsidies and complete in 1.5 to 2 year after a burn
Pressure garments in the form of tubular stockings or custom pressure garments shown
to flatten scar maturation phase, research suggest at 15 mmhg pressure is necessary
with other research suggesting that more pressure has greater impact with custom
garments of 24 to 28 mmhg of pressure.
Skin grafting → there are no hair follicles, sebaceous glands or sweat glands included,
grafted area thus result in excessive dryness and the absence of sweat glads inhibits the
ability to dissipate the core body temp when too high.Parents need to be warned to
avoid environment with heat and humidity.
Musculoskeletal Impairments
● Peripheral nerve damage
● Heterotopic ossification (HO)--> goal for PT is to remobilization of the joint, most
common site is the elbow. PT intervention, pain-free ROM
● Burn to depth of bone
● Necrosis
● Limb amputation → at risk for developing joint contracture especially if there are
adjacent burns and skin grafts
Pressure Garments and Inserts
● Heterophic scarring
● Determining the best method of pressure
○ Healing time of burn
○ Size of unhealed area
○ Fragility or condition of the healed skin
○ Location of the burn
○ Treatment cost
■ All patients with burns that require 14 to 21 days to heal or who have a
skin graft should have prophylactic pressure therapy and should be
applied as early as possible.
○ Signs that pressure program has been successful
■ Can be seen as early as 24 to 48 hours after initial application
■ Blanching of scar tissue
■ Flattening of scar
■ Increased softness
■ Decreased edema
○ If pressure tx is unsuccessful evaluate the following
■ Fit of garment, if patient has gained or loss 10+ pounds can decrease
garment effectiveness
■ Condition, average life of PC is 3 months
■
If garment loses stretch and doesn't cause blanching of the scar, new
garment must be made
○ External pressure support is prescribed to be worn 23 hours a day until the
remodeling phase of healing is complete; may need to be worn for up to 2 years.
○ D/C if hyperemia fades,scar flattens and becomes more pliable and persists for
several weeks after removal of garment.
Types of Garments
● Hand Garments
○ Infants, better pressure achieved through the use of self-adherent elastic wraps
○ Narrow strips of foam padding worn between the fingers under compression
gloves work well to preserve web space
○ If burn is only on the palm not impacting web space, a compression glove alone
is CONTRAINDICATED, as gloves pull the thumb into adduction and fold the
palm. Custom molded insert of silicone putty attached to a palmar extension
splint recommended.
● Face Garments
○ Require frequent monitoring and modification
○ Serious complication with head and neck burns
○ Changes in growth direction of mandible and maxilla can occur after face mask
○ Can also lead to sleep apnea due to pressure on the mandible, particular chin
straps
● Inserts
○ If hypertrophy areas remain, additional pressure may be required
○ Common areas: sternum, face, volar aspect of the hand, angle of the mandible,
web spaces, and across flexor joints
○ Custom garments + inserts can be used
○ How to chose insert consider: 1) texture, 2) flexibility, 3) compressibility, 4) ability
to conform
○ Must be worn same amount of time as the pressure garment (23 hours per day)
● Silicone gel sheeting
○ Used to treat immature burn scars
○ Silicone gel needs to be in place for at least 12 hours a day for 3 to 6 months
Scar Assessment
● Numeric scar-rating scale evaluates: scar surface, thickness, border height, and color
differences between a scar and adjacent normal skin.
PT Exam
● Refer to tables 31-3 & 31-4
● For children with burns that will heal in less than 21 days and don’t need grafting,
therapist can anticipate meeting goals for acute care and following up in clinic as
needed.
● For deeper burns, child likely to require outpatient PT with addition to follow up at burn
center.
Pain management
●
Use of self report tools such as Oucher,Faces scale, and FLACC or COMOFOT score
can aid in pain management
● Two types of pain associated with burn: Background pain (dull, throbbing, and low
intensity, managed with long acting narcotics) and procedural pain (during wound
cleansing, dressing changes, or range of motion, which is stabbing and severe).
● Scheduled medications: opioids, non-steroidal, anti-inflammatory, benzos, etc.
● Non-pharmacologic management: educating child about procedure, enhancing child
predictability and control, distraction, promotion of self-cleansing and debridement,
parent participation and hypnosis.
Positioning
● Important for reducting edema, protecting weakened or exposed structures &
maintain/increasing ROM
● During the resuscitation phase, use of gravity when elevating and placing extremities in
extension (particularly for hands and feet)
● Claw hand deformity, associated with dorsal hand burns, important to place burned area
in lengthened position.
● Positioning achieved with pillows, bath blankets, towel, foam wedges. Speciality
mattresses and beds can also provide optimal positioning.
Splinting
● Pliable, lightweight, low-heat thermoplastic material is desirable
● Splints to be checked once a day for any adjustments needed
● Pain, numbness, tingling, inflammation, or maceration of tissue indicate a poor-fitting or
improperly applied splint which can cause pressure necrosis of burned and unburned
areas.
● Acute Phase
○ Used in this phase to protect joints, tendons, and ligaments
○ Protective splints put exposed tendons & ligaments on slack until wound closure
or integrity of the structure is restored
○ Wound-healing phase, splints can be used to prevent contractures and grafted
splints act to immobilize the area to prevent graft interruption
○ New grafts/biologic dressings protected by immobilizing adjacent joints &
gentle/direct pressure to graft
○ Splints kept in place until graft is stable & movement is tolerated, around 5 to 7
days post op. Children can still play with splints donned.
● Intermediate Phase
○ Splint still required after graft is healed during sleep, or when other positions that
contribute to deformity are assumed
○ If child assumes full ROM during play activities, splint needed for naps and at
night
○ If voluntary movement is impaired, such as in the presence of peripheral
neuropathies a splint must be worn continuously except during PT and wound
care to avoid contractures.
● Long-Term Use
○
Splint wearing schedule long after wound closure; to counteract the detrimental
effects of skin contraction and scar formation.
○ Splints used to realign scar tissue or to stretch contracted skin
○ May be applied at all times to provide constant stretch with silicone application
Serial Casting
● Effective alternative to splinting when proper splint alignment cannot be maintained or
poor adherence to wearing splint
● Goal: realignment of collagen in a parallel and lengthened state by constant
circumferential pressure from the cast.
● Good success with bi weekly cast changes until normal ROM is achieved.
● Procedural intervention to follow, such as weight bearing activity in walking for PF
contractures, ROM ex and splinting.
● Has also seen effectiveness for burned hands.
Fixators
● External fixators for severe ankle and foot deformities
● Most common is Ilizarov fixators which allow for multidimensional application of force to
achieve correct positioning.
● Superior to splinting due to propensity for formation of decubitus ulcers when rigid splints
are used.
ROM and Ther Ex
● Emergent Phase
○ Emphasis placed on PROM, positioning, and splinting
○ If child is alert, can engage in bed mobility and positioning of extremities for
dressing application.
○ ROM exercise initiated as soon as patients medically stable
● Acute Phase
○ Follows emergent care through skin grafting, when scarring begins to form.
○ Exercises are performed with each joint separately, then with all joints combined
in a sustained stretch that elongates the burned area.
○ Ex: Important to consider if the burn crosses more than one joint
○ Multiple vigorous reps of movement should be avoided.
○ Reps should be performed slowly with prolonged end-range hold.
○ Start with no pain/less painful exercises and gradually progress to those known
to be painful
○ AROM and AAROM with terminal stretch assist in maintaining joint mobility and
tissue pliability and minimize loss of strength.
○ Play and play groups can encourage desired movement.
● Anesthesia Assisted ROM
○ Used to determine the extent of joint restriction
○ Can allow therapist to determine if the child’s pain, fear, apprehension or
behavior is interfering with achieving the goal
● ROM post grafting
○ After graft, exercises are discontinued to the graft area for 3 to 5 days.
○ Grafted areas are immobilized.
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Exercise to joints proximal and distal grafted area contraindicated
AAROM to all other non-grafted areas is continued.
If graft appears stable at 3-5 days, gentle AAROM and AROM is resumed,
requires approval from attending physician
○ Patients who maintain essentially normal ROM during the regrafting phase are
expected to have full ROM at 7 to 10 days.
○ As healing progresses, with or without grafting, functional strengthening is
introduced, even with open wounds/bandages, therapist can apply minimal
manual resistance
○ Low load, prolonged stretching is most effective exercises for lengthening bands
of scar tissue and increasing ROM
Walking
○ Children begin to walk as soon as their physical and medical condition warrant
○ For non grafted lower extremity burns walking is initiated when child is medically
stable
○ If LEs are burned vascular support should be provided to reduce venous
congestion and aid with pain management (elastic bandages are applied from toe
to groin in figure 8 pattern)
○ walking supported for pulmonary function for intubated patients and walking after
graft
○ ADs such as walkers, crutches, and cane are not encouraged; a normal gait
pattern is encouraged.
○ Dr. Paul’s Unna’s boot has been used with LEs wounds after grafting to allow
patients to ambulate
Desensitization of scared areas
○ Desensitization treatment is recommended when healed or scarred areas of the
hand are hypersensitive evidenced by extreme discomfort or irritability in
response to normally non-noxious tactile stimulation.
○ Techniques as follows
■ Dowel textures with different textures of material glued onto dowel sticks
■ Contact with use of particles such as rice or beans
■ vibration
Adjunct therapies
● Scar Massage
○ Most effective on small area or linear scar bands.
○ Limited evidence to refute or support
● Therapeutic heat
○ Use intended to increase blood flow and pliability of scar tissue.
○ warm paraffin has been used in contraction with stretching for improved tissue
extensibility
○ Thought to reduce scar pain an improve extensibility
○ Paraffin helpful when painful and contracting scar limits joint ROM
○
Paraffin mix is used when it reaches a temp of 46 deg c to 48 deg c or when a
light skin covers the top of the mix
○ Caution for newly healed scar tissue, which will blister easily in paraffin bath,
pouring or patting of the paraffin is done after the patient is positioned with the
affected part in sustained stretch.
○ US over growth plates is contraindicated for children and no evidence to improve
tissue extensibility
Outpatient Therapy
● After d/c from the burn unit, post acute rehab are variable, acute hospitals patients may
continue to be seen in outpatient therapy.
● Some burn centers have rehab beds or step down units that provide care until the child
and family are ready for d/c
● Other centers have transition units, in which children and their families assume
responsibility for care in protective environments
● Outpatient therapists should contact the burn center with questions and concerns and
prioritize interventions aimed at increasing ROM and preventing contractures.
Reconstruction & LT follow up
● Children will require frequent follow ups at burn center
● Common problems addressed at follow up: skin breakdown, maceration, dryness, itch,
sun intolerance and impaired thermoregulation.
● COntinued fit of pressure garments, splints, application of cosmetics and plans for
further surgical procedures.
● For families that don't live near the burn facility, local follow up can be arranged, family
members should be encouraged to contact burn unit staff when they have concerns.
● Reconstructive procedures are often required after growth spurts and until bony growth
is complete.
● Hand, central body regions of the head neck and axilla are likely to have the highest
incidence of contracture formation (central body regions have the poorest outcomes after
reconstruction)
Family & Caregivers
● Essential for family members to be instructed in all aspect of care upon d/c home (can
create manuals for caregivers, which are reviewed with the family prior to d/c)
● Parents have a hard time carrying out the rigorous stretching home program and parents
with children who have acquired burns reported more depression and anxiety (to be
monitored by therapy staff)
Activity & Participation
● ICF: Body function and structure goal: minimize extent and severity of contracture
● Personal factors that impact activity and participation: poor problem solving, inadequate
compensatory strategies and increased anxiety with physical demands
● Limitations in self-care, mobility and fine motor skills can restrict social interaction,
learning and leisure pursuit at school and in the community
● PTs are part of the burn team to assist with return to school transition, provide school
personnel with information regarding the child’s current abilities and provide
recommendations to the school PTs and physical educators (can do this with videotapes,
or onsite school visits when necessary)
● Five principle guides for school reentry:
○ Preparation begins as soon as possible
○ Planning includes child and family
○ Each program is individualized
○ The child is engaged to return to school quickly after hospital discharge
○ Burn team professionals remain available for consultation
Psychologic Adjustment
● ALthough most children do not have significant psychological problems despite visible
sequelae of their burn injuries, the burn team should carefully observe and inquire about
the child and family distress and provide support and guidance.
● Patients with severe burns resulting in extended hospitalization are particularly
vulnerable to development of psychological distress.
● Symptoms seen in children: regression, anxiety , decreased physical activity, withdrawal
behavior problems decreased social interaction and play.
Alternative Wound Closure Options and Topical Agents (31-2)