Burn Injuries

Acute Management and Rehabilitation

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

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

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

Classification, cont’d

• 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)

Classification, cont’d

• Extent: Rule of 9’s - head=9%, arms=9%, legs=18% each, chest stomach abdomen=18%, back=18%, perineum=1%; ABA (American Burn Association) minor, moderate, major.

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.

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.

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.

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.

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%)

Psychological Issues, cont’d

• 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.

Psychological Issues

• In sum:

• Distress is common, but s/s don’t 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.

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.

Psychological Issues, cont’d

• Treatment: Relaxation, hypnosis, cognitive restructuring, exposure.

• Don’t 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.

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.

Psychological Issues, cont’d

• 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.