MU Physical Therapy – PT 7890 - Medical / Surgical Case Management I
Newspaper excerpt: “Three persons with major burns were hospitalized yesterday following an
apparent murder attempt. George S., 40, of … , received burns over nearly half of his body when a
gasoline can exploded. He allegedly was pouring a flammable liquid around the perimeter of a motel
cottage located at . . . Inside were his mother Barbara, age 65, who sustained burns over about twentyfive percent of her body. His son Johnnie, 7, suffered burns over approximately sixty percent of his body.
Both adults are reported in very serious condition, while the child’s condition is critical.”
Part 1: Emergent (Shock) Phase (first 72 hours)
Johnnie was airlifted, while Barbara and George S. were transported by ambulance to a hospital that
had a specialized burn unit. Initial assessments were carried out in the emergency room. Vital signs for
all three patients were initially within acceptable limits for age and stress level. Initial estimates of their
burn areas were determined, and fluid resuscitation using the Parkland formula was initiated.
All burn wounds were cleaned with room temperature normal saline and gauze. Silvadene Cream ® was
applied to all burned areas, and the extremities were wrapped with occlusive gauze dressings. Johnnie
and Barbara were transferred to the burn unit. George, who had required sedation, was moved to the
medical intensive care unit, and a guard was posted at his door.
Johnnie: An early decision to perform immediate excision and grafting to Johnnie’s neck and hands
was reached; however, there was a delay while social workers determined who was legally responsible for
Johnnie. Since the delay was greater than 24 hours, DFS assumed temporary guardianship. His mother,
who lived in a community two hours away, was ultimately able to authorize surgery. Twelve hours after
admission, Johnnie’s anterior neck and dorsal hand burns were excised and grafted with split thickness
skin taken from his anterior and posterior left thigh. Petroleum impregnated gauze was placed over the
donor sites. Edema subsequent to fluid resuscitation necessitated escharotomies for both of Johnnie’s
arms and the trunk, which sustained circumferential full thickness burns. He remained intubated
following surgery because there was evidence of a respiratory burn.
Barbara: Within 24 hours of the burn, it was noted that a pulse could not be obtained in her left wrist,
and her left forearm required an escharotomy. She had a history of breast cancer managed with a
modified radical mastectomy and L axillary lymph node dissection ten years earlier. She was a Type II
Diabetic that had been managed with Glucophage, but her blood glucose rose to over 300, and insulin was
necessary to bring the level to the low 100’s. Her blood pressure, which had been 170/100 at admission
rose to 220/120. In addition to the deeper burns, she had sizeable areas of superficial burns and
experienced considerable pain. Early excision and grafting of her dorsal hands was discussed, but
deferred until her other medical problems were under control.
George: Psychotropic drugs were necessary to calm his agitation. His facial and neck burns caused
concern about pulmonary involvement; crackles were noted over the lung bases posteriorly. Notes in the
medical chart indicated that he had requested a cigarette several times. He experienced considerable
swelling of the upper extremities and the right lower extremity, but circulation was not noticeably
impaired. Early excision and grafting of his hands was not attempted; standard debridement of the burns
with delayed grafting was planned.
Burn team referrals received for nutrition, psychology, psychiatry, OT, RT, and PT.
MU Physical Therapy – PT 7890 - Medical / Surgical Case Management I
Sub-Acute (Healing) Phase
Johnnie was in a major burn unit for four months. Hydrotherapy for cleansing and debridement for
Johnnie was performed in the burn unit shower tank by nursing staff. Physical therapists were able to
obtain range of motion exercise while his dressings were off by playing games with him in the hydro
room where the air temperature was maintained in the low nineties. He had extensive grafting to the
face, neck, hands, arms, trunk and the genital area. His hospital course was rocky; he was treated for
septicemia, pneumonia, and Curling’s (gastric) ulcers.
In addition to extensive split thickness grafts, a full thickness graft for his chin was transferred from his
shoulder via a flap, a process taking two weeks. Once he was stabilized, in addition to burn management,
he spent an hour a day with a teacher whose effort was to help him keep up with his class and occupy his
time. Physical and recreational therapists spent time encouraging him to move and have fun. His mother
was able to spend time with him occasionally, but his grandmother was his mainstay once her burns were
covered.
Barbara was in the burn unit about one month. Hydrotherapy for cleansing and debridement for Barbara
was performed in the burn unit shower tank by nursing staff. Physical therapists were able to provide 2025 minutes of range of motion exercise while dressings were off. She had grafts to the upper trunk,
neck, arms, and hands. Her face and legs were allowed to heal without grafting.
Housing was located for Barbara, first at the Ronald McDonald house, and then with a local family while
Johnnie’s burn wounds were closed. She received outpatient PT and OT during this period.
George was transferred to a standard, private hospital room. His hands, arms, and the right leg were
grafted following mechanical and enzymatic debridement of eschar. Debridement, cleaning and dressing
of his burns was carried out by the surgeon and the nurses in his room. The upper trunk, neck, and lower
face (including the mouth) were allowed to heal without grafting. Range of motion was performed with
the dressings in place.
George was allowed to walk in his room, including the bathroom, but walks in the hallway were limited,
and the guard was always nearby. Bed positioning was managed by nursing, with input from PT and OT.
Splints were built by OT.
MU Physical Therapy – PT 7890 - Medical / Surgical Case Management I
Reading:
1. Campbell 3rd ed. C.34, p.1025-1049
2. O’Sullivan 5th ed. C.27, p.1091-1112
3. Bottomley 3rd ed. p.395-398
Typo on p.396: the third column should say “Superficial” Partial Thickness
4. Hillegass p.244-245: Distinguish between impairments of the lung parenchyma, and impairments
of the chest wall.
5. Articles, links, and video clips posted on course web site
HSL Reserve:
1. Burn Care and Rehabilitation: Principles and Practice, Reginald Richard PT
2. Total burn care, David Herndon
PCM: the Intervention setting will be in Part 2 - the Rehabilitation (Wound Closure) Phase.
 PBL Groups 1&2 will focus on Johnnie for their PCM
 PBL Groups 3&4 will focus on Barbara
 PBL Groups 5&6 will focus on George
Using the Guide, and other resources you can begin to start working on the first several columns of the
PCM table. Refer to the instructions for completing the PCM (in the syllabus and on the website).
EB search topic: PT intervention for Burns. Don’t report on dressings. Focus on Rehab.
 Assign members to cover each of the databases / journals below.
 Search results are to be reported in a Table of Evidence – download from website, use the
Footnoting Protocols (example on website).
Databases / journals:
1. PubMed / Medline
2. Journal of Physical Therapy: filter PubMed using: physical therapy [ta] AND ______
(Bound PT Journals up to the year 2001are in Lewis 125. Please leave in the room)
3. Journal of Burn Care Rehabilitation: filter PubMed using: journal of burn care rehabilitation [ta] AND
_____ (Hard copy available at HSL).
4. Ovid: CINAHL
5. PEDro
6. Hooked on Evidence