Burns

Burn wounds are classified based on clinical assessment of appearance, sensibility, & pliability

Mechanisms of Burns

• Thermal

  • includes heat (flames, hot liquid, hot object) or cold (dry ice)

• Chemical

  • acid (sulfric/hydrochloric), alkali (potassium hydroxide, sodium hydroxide) resulting in tissue necrosis  

  • severity depends on exposure

  • alkali is more severe than acid

• Electrical

  • High voltage direct current (DC): throws victim from source w/ single muscle contraction

  • Low voltage AC: difficult to voluntarily release w/ greater muscle contraction

• Radiation

  • sunburn, x-rays, radiation therapy with cancer

1st degree - Superficial Burn

• affects epithelial layer 

• mild/moderate pain

• no blisters; dry

• minimal erythema (reddening)

• Healing: 3-7 days

• MOI: sunburn, quick exposure to hot liquids, chemicals

2nd degree - Superficial Burn | Partial-Thickness

• affects epidermis & upper dermis layer 

• significant pain

• wet blistering

• erythema (reddening)

• minimal potential for hypertrophic scar

• Healing: 1-3 wks

• MOI: severe sunburn/radiation, prolonged exposure to hot liquids, brief contact with hot metal

2nd degree - Deep Burn | Partial-Thickness

• affects epidermis, deep dermis, hair follicles, & sweat glands  

• significant pain; even light tough causes erythema w/ or w/o blisters

• high scar potential - do not touch blisters

• burns have high risk to turn into full thickness

• Healing: 3-5 wks

• MOI: flames , viscous liquids, prolonged contact with hot metal

3rd degree - Full Thickness Burn

• affects epidermis, dermis, hair follicles, sweat glands, & nerve endings

• no pain; pale, non-blanching

• Healing: requires skin grafting

• MOI: prolonged exposure to heat, chemicals, hot objects

4th degree - Subdermal Burn

• full thickness burn w/ damage to fat, tendon, and/or bone in addition to involvement of the epidermis, dermis, hair follicles, sweat glands, & nerve endings

• charring present, exposed to deeper structures

• peripheral nerve damage is significant

• very high potential for hypertrophic scar and/or contracture

• Healing: requires surgical intervention, often amputation

• MOI: electrical burns, house fires

Emergent Phase

• Injury to 72 hrs after burn

• medical management focus: stabilization

  • inhalation injury

  • compartment syndrome

  • dressings

  • infection control

  • contracture formation

• OT role: contracture prevention

  • splinting 

  • antideformity positioning

  • **superficial partial-thickness or worse usually requires splinting

Acute Phase

• Following emergent until wound is closed

• medical management focus: skin grafting

  • occurs when medically stable

  • used for full-thickness burns and large, deep partial-thickness burns

  • Types of Grafts

    • Autografts

    • Skin substitutes

• OT role: 

  • Evaluation

    • observation during task performance

    • interviews w/ patients & family

    • continued assessment of ADL/IADL, psychosocial adjustment, communication, AE, education

    • increased risk of:

      • anxiety

      • depression

      • PTSD

    • Assessments:

      • DASH

      • Brief Burn Specific Health Scale (BSHS-B)

  • Intervention:

    • splinting & positioning

    • wound care

    • exercise & activity

    • perioperative care - splinting in support of grafts

    • pain management 

    • patient-family teaching

    • discharge planning

Rehabilitation Phase

• Evaluation

  • MOI, PMH, occupational profile

  • visual assessment of wound, stage of healing, location, measure size/depth, edema

  • assess joint mobility, strength, sensation, functional use w/ PROM, AROM, strength, FM coordination

  • document px, hypertrophic scar, contracture, bulky dressings impacting ROM

    • Sensation

      • newly healed skin/grafts hypersensitive

      • OT: systematic desensitization

    • Coordination

      • affected by limited ROM, strength, or sensation

      • OT: graded coordination activities

    • Scar Management

      • hypertrophic scars & keloid scars

• OT role: prevent/limit hypertrophic scarring

  • Intervention:

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