Burn Injuries

1
Burn Injuries

• Acute Management and Rehabilitation

2
Incidence

• 1.25M burn injuries in the US per year
• 5500 fatal 51K require hospitalization
• House fires account for 75 of fatalities 20-25
  occur in the workplace
• 1971-1991 saw 50 decline in fatalities
• 50 chance of disability with household burn
  reduced to 20 with workplace burns
• Common sites of burn (in order) UE, head, neck

3
Causes

• Exposure to temperature extremes
• Hot liquid most common (water, steam, cooking
  oil, tar, etc.) open flame second, and hot
  surface contact third
• Cold is usually frostbite
• 5-10 electrical/chemical (work)
• Flame - longest delay in return to work
  electrical burns produce the longest
  hospitalizations

4
Classification

• Classification systems combine cause depth
  extent or TBSA (total body surface area)
• Depth which layers of skin destroyed (may take
  3-5 days post injury to determine)
• Old system - 1st thru 4th degree burns

5
Classification, contd

• New system Superficial (only epidermis)
  Superficial Partial Thickness (epidermis and
  dermis, excluding dermal appendages) Deep
  Partial Thickness (epidermis and most of dermis)
  Full Thickness (epidermis and all of dermis)

6
Classification, contd

• Extent Rule of 9s - head9, arms9, legs18
  each, chest stomach abdomen18, back18,
  perineum1 ABA (American Burn Association)
  minor, moderate, major.

7
Rehabilitation

• Rehab treatment begins during the acute
  hospitalization, may involve acute rehab
  techniques, and may last several months post
  acute discharge.
• Treatment wound care, positioning, splinting,
  exercise, ambulation, family care teaching,
  adjustment intervention - goal is to minimize
  problems with scarring and contracture.

8
Rehab

• Daily wound care dressing changes, wound
  cleaning, debridement of dead tissue, weaning
  hydrotherapy in tank to shower.
• Positioning Extension is favored over flexion to
  discourage joint contractures.
• Passive stretching extremities and face, moving
  to active movement - facilitates ambulation and
  self-care.

9
Rehab

• Skin care water soluble lotioning several times
  per day massage to increase new skin flexibility
  and decrease sensitivity, and deep massage over
  hypertrophic scar bands helps organize newly
  forming tissue silicone or fabric (Jobst brand)
  compression garments used up to 20 hours/day for
  18 months - until the new skin is mature
  contracture control - stretching, splinting,
  serial casting, tendon-release surgery.

10
Psychological Issues

• Premorbid psychopathology incidence ranges from
  28-75 - depression, Cluster B personality
  disorders, AOD abuse tend to have maladaptive
  coping skills on burn unit and in rehab.

11
Psychological Issues

• Impaired awareness shock, delirium (19),
  induced coma, narcotic analgesics critical care
  stage
• Emotional reactions acute care stage
  dependency, lack of personal/environmental
  control, chronic pain distress, fear of dying -
  resulting in dysphoria/depression (23-61),
  agitation/acting out, anxiety/panic (13-47)

12
Psychological Issues, contd

• PTSD criteria are met at some time during an
  admission by 30 of patients, but the vast
  majority are resolved by discharge Patterson, et
  al (1990) PTSD related to lg. TBSA, more severe
  pain, hi guilt and experienced delirium
  Mancusi-Ungaro (1986) - PTSD more common with
  electrical burns Tucker (1987) found
  delayed-onset PTSD after d/c give patients
  control over selected schedules/trx options -
  reduces anxiety.

13
Psychological Issues

• In sum
• Distress is common, but s/s dont often reach
  diagnostically significant levels.
• Rates of depression/anxiety similar to those of
  hospitalized patients.
• Delirium/PTSD more frequent in burn patients, but
  are transient reactions.

14
Psychological Issues

• Long-term effects a) first year post-d/c sees
  high distress than abates with time b)
  adjustment, QOL, self-esteem improvement
  independent of TBSA/severity of injury c)
  decreased QOL linked to low ROM mobility d)
  non-compliance in rehab linked with low QOL e)
  low awareness of burn circumstances and high
  social support buffer against psychopathology.

15
Psychological Issues, contd

• Treatment Relaxation, hypnosis, cognitive
  restructuring, exposure.
• Dont challenge defense mechanisms focus on
  immediate concerns over-pathologizing in staff.
• Dissociated state and distress/grief (acute
  care) external losses, former lifestyle s/s
  depression, ASD, nightmares, intrusive thoughts
  of the injury, repression, hostility and
  dependence - supportive treatment and medications
  often necessary.

16
Psychological Issues

• Self-inflicted burns increasing incidence
  (0.67-9) often linked to Borderline PD
  frequent flyers in burn units use behavior
  management coordinate staff contact to minimize
  splitting limit staff contact (use
  time-contingent response) utilize centralized,
  consistent care across staff caution against
  under-medication for pain.

17
Psychological Issues, contd

• Long-term outcomes persistent emotional problems
  rare (10 incidence in large population samples)
  - ie., therapy non-compliance, disfigurement,
  self-esteem social-vocational problems include
  unemployment, reduced occupational status
  (50-60), social avoidance behaviors, reduced
  recreational activities, low sexual satisfaction
  in women.
• Vocational issues 70-85 return to work after
  occupational injuries latency to return 2-8 mo.
  hand burns have most vocational impact
  electrical burns most likely to be permanently
  disabled.