Contents
13.1 Epidemiology 389 13.2 The Acute Phase 389 13.2.1 Nature of Injury 389 13.2.2 Goal of Treatment 389 13.2.3 Prognostic Factors 390
13.2.4 Increased Susceptibility in Major Burns to Sepsis and Shock Lung 390 13.2.5 Tackling the Hyper-Catabolic State 390
13.2.6 Shock Lung 390 13.2.7 Mortality 390 13.3 Infection Control 391 13.3.1 Introduction 391 13.3.2 Epidemiology 391
13.3.3 Reasons for Predisposition to Infection 391 13.3.4 Organisms Involved 391
13.3.5 Situations in Which Occurrence of Multi-Bacterial Resistance Are More Likely 392
13.3.6 General Management Strategies 392 13.3.7 Policy of Antibiotics 392
13.3.8 Policy of Tackling an Outbreak 393
13.3.9 Extra Precautions in Two Patient Subgroups 393 13.4 Rehabilitation in the Subacute and Chronic Phase 393 13.4.1 Introduction 393
13.4.2 Key Areas of Assessment: an Overview 393 13.4.2.1 Checking Patient’s Life History and Priorities 13.4.2.2 Assessing Basic ADL 394
13.4.2.3 Assessing Instrumental ADL and Community Integration 394 13.4.2.4 Motor Testing 394
13.4.2.5 Sensory Testing 394
13.4.2.6 Psychosocial and Perceptual Skills 394
13.4.2.7 If More Detailed Psychosocial Assessment Deemed Necessary 395 13.4.2.8 Pre-Discharge Preparation and Post-Discharge Support 395 13.4.3 Summary of Key Problem Areas in Rehabilitation Phase 395 13.4.3.1 Resurfacing of Burn Wounds 395
13.4.3.2 Hypertrophic Scar 396 13.4.3.3 Key Physiotherapy Pearls 400
Burn Rehabilitation
13
13.4.3.4 Pain Control 400
13.4.3.5 Psychological Problems 401
13.4.3.6 Psychological Adjustment and Support 401 13.4.3.7 Community Re-Integration 401
13.5 Additional Management Pearls for Different Regions 402 13.5.1 Scalp 402
13.5.2 Face 402 13.5.3 Neck 402 13.5.4 Axilla 403 13.5.5 Back 403 13.5.6 Hand 403
13.5.6.1 Useful Tools for Assessing the Burnt Hand 403 13.5.6.2 Challenging Scenario: Post-Burn Thumb Deformity
with Loss of Prehension 403 13.5.7 Lower Limb 404
13.6 Treatment Outcome and Prevention of Burns 404
13.6.1 Recent 10-Year Report of Outcome of Burns Care in Children 404 13.6.2 Prevention of Burns 404
General Bibliography 404
Selected Bibliography of Journal Articles 405
13.1 Epidemiology
n
Statistics in UK reveal a figure of 250 000 cases each year; 5% need hospitalisation
n
The figure in US amounts to 750 000 emergency room visits, with 45 000 hospitalisations each year (J Burn Care Rehabil 1996)
n
Mortality rate of burnt inpatients in UK is around 2%, but can be much higher in some developing countries
n
Discussion in this chapter mainly centres on rehabilitation in sub- acute and chronic phases
13.2 The Acute Phase
13.2.1 Nature of Injury
n
Flame burns and scalds are most common
n
Other forms like chemical and electric burns rarer 13.2.2 Goal of Treatment
n
Acute phase: removal from the burn scene, resuscitation, referral to burn centre if severe
n
Subacute:
– General
1treatment: of acute complications – physical (e.g. inhala- tion injury, organ dysfunction) and psychological
– Local treatment: e.g. prevention of deformity, aim at maintaining perfusion to zone of stasis
n
Chronic: set functional goals, efforts towards reconstruction and re- surfacing
n
But rehabilitation should start immediately after hospitalisation, in all the three phases
a 13.2 The Acute Phase 389
1
General body response in most cases with 30% burns
13.2.3 Prognostic Factors
n
Worse if:
– Advanced age
– High surface area involved – Inhalation injury
– Presence of significant complications, like generalised sepsis
13.2.4 Increased Susceptibility in Major Burns to Sepsis and Shock Lung
n
Research in this area revealed that depletion of complement pathways (classic and alternate) was associated with sepsis, pneumonia and
“shock lung”
n
Alternative pathway deficiency depletion was especially pronounced 1 week post-burn, and may contribute to the susceptibility of burn pa- tients to bacterial sepsis (Gelfand et al., Ann Surg 1983)
13.2.5 Tackling the Hyper-Catabolic State
n
Many severe burn patients suffer rapid loss of muscle mass from the hypercatabolic state
n
This can further jeopardise the body’s defence to infection
n
Recent literature on the use of anabolic steroids like oxandrolone ap- pear promising (Burns 2003) via its role in decreasing nitrogen loss, increasing lean body mass and muscle protein synthesis
13.2.6 Shock Lung
n
Pathogenesis probably involved increased neutrophil aggregating ac- tivity in the plasma, neutrophil aggregates in the lungs, increased pul- monary vascular permeability, and increased lung oedema formation
n
The underlying mechanism is likely to be related to massive activa- tion of the alternative complement pathway (J Clin Invest 1982)
13.2.7 Mortality
n
Animal research indicated that the severe activation of the alternative
complement pathway not only predisposes to sepsis, or shock lung,
but to increased mortality rate, but whether this can be extrapolated
to humans is unsure (Gelfand et al., 1982). Possible role of strict gly- caemic control in preventing mortality
n
Recent studies point to the possible beneficial effects of better hyper- glycaemic control in preventing infection and even mortality in adults and children (J Trauma 2005)
n
Control of sepsis is important to prevent mortality and improve out- come, and will be discussed in the following section
13.3 Infection Control
13.3.1 Introduction
n
Infection remains a leading cause of morbidity and mortality
n
As such, proper strategies for prevention and management (particu- larly management of outbreaks) are important
13.3.2 Epidemiology
n
Infection rate is higher in those with burns involving > 30% of total body area
n
In one big series involving 831 burn patients, the rate was 1.2% in those with < 30% burn (755 patients), and 75% in those with > 30%
burn with regard to catheter-related blood stream infection (Car- rougher, Burn Care Ther 1998)
13.3.3 Reasons for Predisposition to Infection
n
Patients with significant burns have altered immunity, particularly ex- cessive depletion of the alternate complement pathways that will pre- dispose to sepsis
n
Instrumentation and invasive monitoring by catheters sometimes act as route of entry for organisms
n
Patients with extremes of age are also more infection-prone due to lowered defences
13.3.4 Organisms Involved
n
Most prevalent gram-positives: Staphylococcus aureus (can be MRSA) and enterococci
n
Most prevalent gram-negatives: Pseudomonas, E. coli, Enterobacter, Acinetobacter and Klebsiella spp.
a 13.3 Infection Control 391
n
In many outbreaks, the importance of the colonised patient as a major reservoir for the epidemic strain was identified
n
Overall, Gram-negative bacteria are more prone to causing invasive types of sepsis than Gram-positives
13.3.5 Situations in Which Occurrence
of Multi-Bacterial Resistance Are More Likely
n
Long hospital stay
n
Critically ill patient with immunosuppression
n
Routine use of prophylactic antibiotics
n
Use of some antibiotics may predispose to certain strains (e.g. routine use of vancomycin may predispose to vancomycin-resistant Staphylo- coccus aureus)
13.3.6 General Management Strategies
n
Strategies to prevent transferring exogenous organisms to patients:
– Strict aseptic techniques in wound handling – Sterile gloves and dressings, and hand washing – Policies of isolation as required
– Spatial separation between patients
n
Strengthen the host: maintain proper nutrition and strengthen the in- trinsic defences of the patient
n
Strategies to control the transfer of endogenous organisms of the at- risk sites, and periodic surveillance culturing
n
Stopping the breeding of bacteria resistance: avoid the routine use of prophylactic antibiotics
13.3.7 Policy of Antibiotics
n
The burn wound (especially large ones) is frequently colonised by mi- cro-organisms until wound is either closed or epithelialised
n
Routine antibiotics will not eliminate colonisation, but invite bacterial resistance
n
If antibiotics are needed, selection according to susceptibility pattern is needed, avoid broad coverage if possible and be on the look-out for other non-bacterial sepsis super-infection such as fungi
n
Prophylactic antibiotics are mostly reserved to cover surgical proce-
dures where indicated
13.3.8 Policy of Tackling an Outbreak
n
Identify the organism and the type of bacterial resistance
n
Trace the source of transmission, such as:
– Hospital personnel (carrier)
– Equipment (e.g. hydrotherapy units)
– Items with potential to act as a source (e.g. pots of flowers) – Statistics from Boston burn centre indicated that in 85% of cases
the source is endogenous flora
(Mostly, the mode of transmission is contact, very occasionally droplets)
13.3.9 Extra Precautions in Two Patient Subgroups
n
Those with major burns of > 30% area
n
Those patients colonised with multi-resistant bacteria
n
(In children’s burns unit, precautions against varicella and proper iso- lation as needed are required)
13.4 Rehabilitation in the Subacute and Chronic Phase
13.4.1 Introduction
n
We will start by giving an overview of the process of assessment dur- ing the rehabilitation phase
n
Then we will highlight the key problem areas and their management 13.4.2 Key Areas of Assessment: an Overview
n
Checking patient’s life history and priorities
n
Assessing basic ADL
n
Assessing instrumental ADL
n
Motor testing
n
Sensory testing
n
Psychosocial and perceptual skills
n
Pre-discharge preparation and post-discharge support 13.4.2.1 Checking Patient’s Life History and Priorities
n
COPM (Canadian Occupational Performance Measure) can be used to assess the patient’s priorities
a 13.4 Rehabilitation in the Subacute and Chronic Phase 393
n
COPM is usually used with Goal Attainment Scaling to help identify and agree upon goals of rehabilitation as the process of rehabilitation proceeds between the patient and the multidisciplinary team
13.4.2.2 Assessing Basic ADL
n
Assessment by FIM (Functional Independence Measure) is recom- mended rather than simply using the Barthel Index
n
Alternatives include: “Performance Assessment of Self-Care Skills”, or
“Klein-Bell Daily Living Scale”
13.4.2.3 Assessing Instrumental ADL and Community Integration
n
Kohlman Evaluation of Living Skills is recommended
n
Also, during later stage of rehabilitation assess community integration by “Community Integration Questionnaire”
13.4.2.4 Motor Testing
n
Check:
– ROM
– Muscle tone and manual muscle testing – Document affected skin area and depth – Soft tissue status evaluation
– If burns affecting arm/hand, serial charting of: nine-hole peg test of coordination (or use Purdue Pegboard) or Minnesota Rate of Manipulation Test. In addition, Jebsen Hand Function Testing was found to be very useful by many researchers in the literature on burns
13.4.2.5 Sensory Testing
n
Somatosensory screening
n
In later rehabilitation phase, assess need for more detailed testing, e.g. by monofilament testing
13.4.2.6 Psychosocial and Perceptual Skills
n
Psychosocial problems if detected should be brought up in multidisci- plinary team meetings and proper referral to psychiatrist and/or so- cial service workers
n
If brain function is altered, use mini-mental state testing and/or Low-
enstein Occupational Therapy Cognitive Evaluation
13.4.2.7 If More Detailed Psychosocial Assessment Deemed Necessary
n
Consider further assessment by:
– Allen Cognitive Level Test-90 (ACLS-90)
– Occupational Case Analysis and Interview Rating Scale (OCAIRS) 13.4.2.8 Pre-Discharge Preparation and Post-Discharge Supports
n
Pre-discharge home visit
n
Meeting of the team with the family
n
Pre-discharge home leave during weekends to assess coping level
n
If return to work planned, assessment by the Worker’s Role Interview
n
Home modification as required
13.4.3 Summary of Key Problem Areas in Rehabilitation Phase
n
Wound resurfacing
n
Hypertrophic scar management
n
Physiotherapy
n
Pain control
n
Control of infection (discussed already)
n
Psychological disturbance and support
n
Others: e.g. management of neuropathy, HO, pruritus (Occupational assessment was just mentioned) 13.4.3.1 Resurfacing of Burn Wounds
n
Split skin graft
n
Full thickness skin graft
n
Local flap
n
Free flap
n
Selective use of tissue expanders (mostly at scalp to help preserve hair-bearing skin areas)
13.4.3.1.1 New and Experimental Techniques
n
Hydrogel with adhesive semi-permeable film (Arch Surg 2006)
n
Tissue-engineered skin (Med Device Technol 2005)
n
Cryopreserved allodermis (J Burn Care Rehabil 1998)
n
Epidermal growth factor-impregnated collagen sponge in second de- gree burns (Arch Pharm Res 2005)
a 13.4 Rehabilitation in the Subacute and Chronic Phase 395
13.4.3.1.2 Use of Free Flaps in Reconstruction
n
Free flaps may be indicated in severe and deep wounds
n
The use of preoperative magnification angiography for both donor and recipient sites or transfer of free flaps or even digits is possibly a useful adjunct to increase the rate of success (May et al., Plast Re- constr Surg 1979)
13.4.3.2 Hypertrophic Scar
n
Hypertrophic scarring is a major source of morbidity in patients with burns
n
The physiologic characteristics are poorly understood, but increased neovascularity is typically seen in those wounds destined to become hypertrophic
13.4.3.2.1 Prevalence
n
Studies indicate the prevalence of hypertrophic scarring of between 32 and 67% being commoner in non-white population (J Trauma 1983), correlation with age was inconclusive among different studies 13.4.3.2.2 Areas of the Body Less Prone to Scarring
n
Palms of hand
n
Soles of feet
13.4.3.2.3 Areas of the Body More Prone to Scarring
n
Root of neck
n
Sternal area
n
Chest cage
13.4.3.2.4 Possible Pathogenesis of Hypertrophic Scarring
n
Biochemical research from Harvard University indicated that burn wound healing abnormalities and scarring may be related to a change in the level of PGs or proteoglycan synthesis, and may be modified by IL-1 beta treatment (Garg et al., Biochem Mol Biol Int 1993)
n
The same group of researchers also showed that the hypertrophic scar
tissue after burns contained higher proportions of dermatan sulphate
(DS), and chondroitin sulphate (CS) than normal skin fractions
(Burns 1991)
13.4.3.2.5 Treatment Options for Hypertrophic Scarring
n
Prevention: best strategy
n
Pressure therapy/garment
n
Proper patient positioning
n
Use of splints and serial casting (with adjunctive physiotherapy)
n
Tension-relieving surgery, e.g. Z plasty
n
Excision and grafting (FTSG/PTSG) and/or flaps
n
Use of newer coverage material like Integra (as dermal regeneration template) after contracture release (Plast Reconstr Surg 2004)
n
Role of lasers
A Word About Pressure Treatment
n
Pressure garments as prevention are worn 23 h a day for 9–12 months usually, and garments are replaced once every 3 months to ensure ade- quate pressure (J Trauma 1983)
Use of Lasers in Hypertrophic Scars
n
Use of laser ablation of neovascularisation in sites of evolving hyper- trophic scars, i.e. before the scar has matured (see Fig. 13.1), with the necessary eye precautions (Fig. 13.2)
a 13.4 Rehabilitation in the Subacute and Chronic Phase 397
Fig. 13.1. This laser system is some-
times used to manage hypertrophic
burns scars
n
Preliminary safety and feasibility studies are encouraging (J Burn Care Rehabil 1997)
Classification: the Vancouver Scar Scale
n
Widely used in clinical practice and in documenting changes in scar appearance
n
Good inter-rater reliability for research (Baryza et al., J Burn Care Re- habil 1995)
Further Classification of Highly Destructive Burn Wounds
n
Based on a series of cadaver dissections, the Index of Deep Burn In- jury (IDBI) was recently developed (Burns, 1997)
n
The initial experience with the IDBI in a group of locally destructive
“fourth degree” wounds was analysed with cadaveric dissections. This new index has the potential to improve our ability to describe very highly destructive burn wounds – the so-called fourth degree burn wounds
Key Concept
n
Avoid tension in the scar
Fig. 13.2. Adequate
eye protection is
needed during laser
treatment
n
Lasers may sometimes be useful in the management of forming hyper- trophic scars, particularly those with persistent surrounding erythema that fails to go away, by ablation of neovascularisation
n
Since scars cannot always be avoided, attempt to make them “more friendly” by taking tension off them (e.g. Z plasty) or sometimes using methods like lasers to avoid scars from getting out of hand Skin Contractures and Scarring on the Growing Skeleton
n
This can sometimes have a profound effect on the joint and the un- derlying soft tissue
n
This effect of contracture has even more effect in the case of children who may be left with deformed, shortened and/or rotated bone and joints if not properly treated (see Fig. 13.3)
a 13.4 Rehabilitation in the Subacute and Chronic Phase 399
Fig. 13.3. The encasement induced by
the hypertrophic integument caused
abnormal bone growth in this growing
child with upper extremity burns injury
many years back
13.4.3.3 Key Physiotherapy Pearls
n
Early ROM and weight-bearing
n
Friction massage of scars is well described
n
Early splinting throughout the hospital stay (protocol depends on dif- ferent regions)
n
Physiotherapy modalities to decrease pain
n
Use of ultrasound to increase response to physical therapy is reported (Ward, J Burn Care Rehabil 1994)
n
Selective use of: axial pin fixation and flaps
n
Most papers report the use of early scar excision and sheet autograft wound closure
n
But occasional use of other modalities in burn wounds such as LLLT lasers can be useful (Hawkins, Ann NY Acad Sci 2005)
13.4.3.4 Pain Control
n
Pain is present in partial thickness, but not usually in full thickness burns, from damaged nerve endings
n
Pharmacologic approaches work well for controlling tonic pain for many patients, but may be inadequate for controlling more severe phasic pain associated with burn treatment procedures, the latter may require additional short-acting opioid pain medications (Esselman et al., Phys Med Rehabil 2006)
n
Nerve damage can produce neuropathic pain as well as sensorimotor disturbance from the associated neuropathy. Neuropathy is more com- monly seen in electrical burns, alcohol abuse, or prolonged stays in intensive care units (J Burn Care Rehabil 2001)
13.4.3.4.1 Proper Pain Assessment
n
McGill Pain Questionnaire – provides a subjective assessment of pain via the use of sensory, affective and evaluative word descriptors (Pain 1975)
n
Visual analogue thermometer – adapted from Visual Analogue Scale and obviating the need for writing by means of plastic colour sliding strips (Burns 1994)
n
Burn-Specific Pain Anxiety Scale (BSPAS) – used in assessing pain-re-
lated anxiety (Burns 1999)
13.4.3.4.2 Non-Pharmacological Interventions
n
Virtual reality used as a distraction technique was recently reported to be useful in terms of pain control relative to controls (Hoffman et al., Pain 2000)
n
Use of cognitive interventions, sensory focusing or music distraction was tried by Haythornthwaite, but not effective
n
Other reported techniques include hypnosis (J Consult Clin Psychol 1997) and anxiety reduction techniques (Burns 2001)
13.4.3.5 Psychological Problems
n
Common psychological problems include:
– Sleep disorders
– Post-traumatic stress reactions – Body-image dissatisfaction – Depression
13.4.3.6 Psychological Adjustment and Support
n
Recent research has shown that even slight functional limitations were linked to severe depressions, similar to values found with patients with serious functional impairment. Interdisciplinary cooperation be- tween plastic surgeons and psychosomatic specialists will optimise early intervention with patients exposed to social maladaptation (Pal- lua et al., Burns 2003)
13.4.3.7 Community Re-Integration
n
The Community Integration Questionnaire was used by Esselman (J Burn Care Rehabil 2001) to assess areas like home integration, social integration and productivity (which measures school, work and vol- unteer activities)
n
Productivity can be predicted by the patient’s age, burn severity, and pre-injury job satisfaction (according to Esselman)
n
Community re-integration is an important aspect of every burn-care rehabilitation program. There is evidence that a patient’s ability to re- turn to work is predicted by burn severity, and psychological prob- lems. Also, the employment status at the time of the injury and co- morbid conditions such as substance abuse can limit the success of any vocational rehabilitation programme (Esselman et al., Phys Med Rehabil 2006)
a 13.4 Rehabilitation in the Subacute and Chronic Phase 401
13.5 Additional Management Pearls for Different Regions
13.5.1 Scalp
n
Tissue expanders sometimes of use here because of:
– Inherent convex surface
– Relatively unyielding deep surface – Rich vascular supply
13.5.2 Face
n
Klein and others propose decision-making at around day 10 to select areas that are not likely to heal within 3 weeks of injury to undergo excision and grafting (Fig. 13.4; J Burn Care Rehabil 2005)
n
Other commonly prescribed treatment like devices to prevent micro- stomia via stretching and wearing of facial masks, usually starting at 2 weeks postoperatively (Serghiou et al., J Burn Care Rehabil 2004) 13.5.3 Neck
n
The usual methods used in contracture prevention like pressure, stretching, splinting and surgery can be used to tackle troublesome scarring
n
Use of collars can be an adjunct in managing torticollis associated with neck burns (J Burn Care Rehabil 2003)
n
Position of the neck should either be in neutral or slight extension
Fig. 13.4. Facial burns
are not uncommonly
associated with respi-
ratory embarrassment
as well as microstomia
13.5.4 Axilla
n
Normal individuals have relatively thin skin in the axillary region
n
Although reports of flap usage are sometimes reported in plastic sur- gery journals, try to avoid flaps in this area
n
Whenever possible, use skin grafting, followed by postoperative splint- age in abduction for adequate periods
13.5.5 Back
n
The skin of the back of humans is very thick
n
Seldom do we see really deep burns on the back
n
In most cases skin grafting suffices
n
An occasional patient may be considered for tissue expanders 13.5.6 Hand
n
Burns involving the hand commonly cause deformity due to the superficial locations of the tendons. Examples include claw-hand, mal- let finger and boutonnière deformities
n
The principle of managing these burns includes early excision and grafting, ROM exercise, splinting, pressure garments and reconstruc- tion (Burns 1998). In addition, adjunctive use of axial Kirschner wires to maintain functional joint positioning like 70–908 metacarpophalan- geal joint flexion and proximal interphalangeal joint extension (J Trauma 1995)
13.5.6.1 Useful Tools for Assessing the Burnt Hand
n
ROM: many researchers prefer to document the “total active motion”, besides noting the motion of individual hand joints
n
Jebsen Hand Function test: useful tool to predict hand function after burn injuries (Van Zuijlen et al., Burns 1999)
n
Michigan Hand Outcome Questionnaire (Umraw et al., J Burn Care Rehabil 2004)
13.5.6.2 Challenging Scenario: Post-Burn Thumb Deformity with Loss of Prehension
n
Reconstruction of thumbs so affected can be carried out by advance- ment and transferral of the second ray remnant onto the remaining metacarpal stump of the proximal thumb
a 13.5 Additional Management Pearls for Different Regions 403
n
This technique combines the advantages of thumb lengthening and pollicisation procedures in a single operation and has been a useful method of restoration of single hand prehension in the severely burned hand (May et al., J Hand Surg 1984)
13.5.7 Lower Limb
n
One of the major goals here is to aim at management options that al- low the patient early weight-bearing, as recommended by workers like Burnsworth (J Burn Care Rehabil 1992) and Grube (J Trauma 1992)
13.6 Treatment Outcome and Prevention of Burns
13.6.1 Recent 10-Year Report of Outcome of Burns Care in Children
n
Normal functional results were seen in 97% of second-degree and 85% of third-degree injuries; in children with burns involving under- lying tendon and bone, 70% could perform ADL and 20% had normal function
n
Reconstructive hand surgery was required in 4.4% of second-degree burns, 32% of third-degree burns and 65% of those with injuries in- volving underlying bone and tendon (Sheridan et al., Ann Surg 1999) 13.6.2 Prevention of Burns
n
Most important since many cases are preventable
n
