REHABILITATION IN CRITICALLY ILL BURN PATIENT
To attain the objective of optimal long-term function, rehabilitation efforts must begin at the outset of burn care. Physical and occupational therapists play essential roles in the acute treatment of all burn patients, even in the critically ill and during resuscitation of those with large injuries.
The following are the 3 principal priorities for the burn therapist in the acute setting:
Ø Performing ROM
Ø Splinting and antideformity positioning
Ø Establishing a long-term relationship with the patient and family members to ensure compliance with therapy goals and to increase the patient's morale for recovery
If a body part is left immobile for a protracted period of time, capsular contraction and shortening of tendon and muscle groups (which cross the joints) occur.
This rapid process can be prevented by a program of passive ROM, antideformity positioning, and splinting.
Passive ROM is best performed twice daily, with the therapist taking all joints through a full ROM. The therapist must be sensitive to the patient's pain, anxiety, wound status, extremity perfusion, and security of the patient's airway and vascular access devices.
These procedures should be performed in coordination with the ICU staff. Attention to the security of endotracheal tubes, nasogastric tubes, and arterial and central venous catheters is paramount, as unexpected loss of these devices can contribute to morbidity and mortality.
Although these procedures are important, they cannot be accomplished effectively (or humanely) if they cause excessive pain and anxiety. Performing ROM often can be timed to coincide with dressing changes and wound cleansing, thereby minimizing the need for medication.
Proper antideformity positioning minimizes shortening of tendons, collateral ligaments, and joint capsules; it reduces extremity and facial edema. Although splints are used less frequently, there are several predictable contractures that occur in patients with burns that can be prevented by a proper ROM, positioning, and splinting program. These contractures (Image 2) generally are associated with the flexed position of comfort, except in the hands.
Flexion deformities of the neck can be minimized with thermoplastic neck splints, conformers, and split mattresses. In critically ill patients, positioning the neck in slight extension is often all that can be done. Do not allow the ventilator tubing to pull the head so that a contracture develops; without proper care, a rotary contracture can develop, generally with the patient turned toward the ventilator.
Ø Contractures are especially likely to develop if wounds are not closed promptly (Image 3). The speed at which contractures can develop is astonishing, if prevention strategies are not part of routine care.
Ø Axillary adduction contractures can be prevented by positioning the shoulders widely abducted with axillary splints, padded hanging troughs of thermoplastic material, or a variety of support devices mounted to the bed.
Ø Elbow flexion contractures are minimized by statically splinting the elbow in extension. Elbow splints can be alternated with flexion splints to help retain a full ROM.
Ø Flexion contractures of the hips and knees are particularly common in young children but can be prevented by careful positioning and ROM. Prevention of contractures is important even in infants, as these contractures can interfere with subsequent ambulation. Prone positioning, although poorly tolerated by some, can assist in minimizing hip flexion contractures; knee immobilizers can minimize knee flexion contractures.
Ø The equinus deformity, in which the ankle is plantar flexed and the foot is in a varus position, is a serious problem that can occur even if the ankles are not burned. This position can be prevented, however, with static splinting of the ankles in the neutral position and performing ROM twice daily. Splints designed for this purpose can cause pressure injury over the metatarsal heads or calcaneus if improperly designed. These injuries can be prevented by using padding to distribute pressure evenly across the metatarsal heads and by extending the footplate of the splint beyond the heel and cutting out the area around the calcaneus (Image 4).
Inspect all splints at least twice daily for evidence of poor fit or pressure injury; improperly used splints can cause injury. A nursing staff in-service minimizes splint-related skin injury. Positioning affected extremities just above the level of the heart reduces edema, which is another important aspect of antideformity positioning.
The therapist should articulate his or her role in the critical care team by providing regular communication about problems and progress updates.