What are the phases of burn recovery?

A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal trauma. It results when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals.1

Etiology

Burn injuries are caused by fire/flames (43%), scald (34%), contact (9%), electrical (4%), chemical (3%) and other (12%). Place of occurrence is mainly at home (73%), occupational (8%), street/highway (8%), recreational/sport (5%) and other (9%). Males (68%) tend to have higher burn rates than females (32%). Caucasian (59%) is the ethnicity with most burn cases followed by African-Americans (20%).2

Epidemiology including risk factors and primary prevention

Each year in the United States, 1.1 million burn injuries require medical attention. Approximately 50,000 of these require hospitalization; 20,000 have major burns involving at least 25 percent of their total body surface, and approximately 4,500 of these people die.1

Vulnerable populations include children, women and older adults. Among risk factors lack of supervision of children, comorbid illness of older adults, clothing made out of flammable material and low socioeconomic status are more common. Other risk factors are occupations that increase exposure to fire, overcrowding, lack of proper safety measures, underlying medical conditions (epilepsy, peripheral neuropathy, and physical and cognitive disabilities), alcohol abuse and smoking.3

Flame/related injuries are the most common reason for admission to U.S. Burn Centers, while scalding is the most common pediatric burn injury. Risk of death is greatest in adults over 60y/o and children under 2y/o. Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and first aid training.2

Patho-anatomy/physiology

The skin provides a barrier to the environment, regulates body temperature and serves as an important component of immune system. It is composed of three layers: dermis, epidermis and subcutaneous layers.

Burn injuries result in local and systemic responses. In local responses there are three zones of a burn: coagulation (irreversible tissue loss due to coagulation of proteins), stasis (decreased tissue perfusion that if managed appropriately prevents irreversible damage), and hyperemia (outermost zone, good recovery except with prolonged hypoperfusion or severe sepsis).4

The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of Total Body Surface Area (TBSA). As for cardiovascular changes ther is increase in capillary permeability, leading to loss of intravascular proteins and extravasation of fluids into the interstitial compartment. Myocardial contractility is decreased, possibly due to release of Tumor Necrosis Factor- α (TNF- α). These changes result in systemic hypotension and end organ hypoperfusion. Patients also present with respiratory changes 2ry to inflammatory mediators that cause bronchoconstriction. There is also evidence where the basal metabolic rate increases up to three times its original rate. Non-specific down regulation of the immune response also tends to occur, which in turn affects both cell mediated and humoral pathways.4

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Initial phase (resuscitation): 1-3 days. Interdisciplinary team at a dedicated burn center, with focus on the burn’s pathophysiology, inhalation injury, and edema formation.5 Fluid resuscitation serves as the mainstay of systemic treatment in moderate and severe burns to maintain organ and tissue perfusion. Acutely, goals are promotion of wound healing, scar suppression, pain reduction and prevention of complications.6

Second phase (wound care): The objective here is excision of nonviable tissue and biological closure, infection prevention, facilitation of wound healing while ensuring adequate pain control. Local wound management includes topical antibiotics and various biologic and non-biologic dressing as means of protection from the environment, drainage absorption, and providing a moist environment for wound healing.6

Third phase (definitive wound closure): This involves replacing temporary wound covers with a definitive cover. Skin grafts are used in treating partial thickness and full thickness burns. Early surgical removal of burned skin followed by skin grafting reduces the number of days in the hospital and usually improves the function and appearance of the burned area.7

Final stage (rehabilitation, reconstruction, and reintegration): Rehabilitation for patients with burn injuries starts from the day of injury, lasting for several years and requires multidisciplinary efforts. It also emphasizes preparing the patient for the psychological and social challenges the patient may face once integration to society occurs.1,2

Specific secondary or associated conditions and complications

Skin and joint contractures, neuropathies, heterotopic ossification, septic arthritis, joint subluxations/dislocations, hypertrophic scarring, pruritus and dry skin, abnormal gait or postures (e.g.,scoliosis), critical care myopathy/neuropathy and heat intolerance (TBSA>40%) are all possible complications that may arise after a burn injury.8

2. ESSENTIALS OF ASSESSMENT

History

After initial assessment, it is important to obtain a history of the event either from the patient or a bystander. An adequate history will help determine the potential of an inhalation injury, concomitant trauma and any preexisting medical conditions that may influence the patient’s outcomes or physical exam. It is crucial to obtain the patients chief complaint, circumstances of the injury (enclosed space, related trauma, non-accidental injuries, etc.) the source of the burning agent (thermal, chemical, electrical, etc.) medications patient is taking, status of tetanus immunization and if there was loss of consciousness at any time during the event.1

Physical examination

Post critical-care examination includes:

General: Evaluate mental status, cognition, appearance, vital signs and pain level.1

Skin: Describe burn location, size, depth and burn pattern. Body surface area may be calculated using the Rule-of-Nines and the Lund and Browder chart (takes into account changes in body surface area with age and growth). Evaluate for cyanosis, circulation, edema, redness, warmth, scarring, ulcerations, document skin graft location and status, and assess donor sites.1,2

Neurological : Evaluate cranial nerves, changes in sensation, reflexes, tone, proprioception and coordination. 1

Musculoskeletal: Range of motion (ROM), strength, joint deformity (contractures), and bony abnormality (heterotopic ossification (HO).1

Functional assessment

Monitor skin healing and scar development, which may be limiting patients ability to ambulate adequately and/or perform daily activities and self-care. Follow development of contractures and or ulceration/infection of burns or graft area. With inhalation injury or known cardiopulmonary disease the Borg Exertion Scale and vital signs (heart rate, respiratory rate, and blood pressure) can help assess the patients tolerance to daily activities or exercise. Psychological distress occurs in many burn patients for whom adequate evaluation needs to be performed in order to identify depression, anxiety (Depression Anxiety Stress Scale), PTSD and/or body image issues (Rosenberg Self-Esteem Scale).9

Laboratory studies

Pre-albumin and albumin are useful for assessing protein/nutritional status. White blood cell (WBC) count, neutrophil percentage, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may help detect the presence of infection, although early on they may have a low yield because of the inflammatory response associated with the burn itself. Monitor for development of HO, with sedimentation rate and serum alkaline phosphatase may be ordered, although they are nonspecific. 1

Imaging

Bone scintigraphy is highly sensitive in the early diagnosis of HO. X-ray is highly specific, but does not show evidence of HO until soft tissue calcification occurs. Assessment of peripheral pulses in burn patients can be performed with a Doppler ultrasound.1

Supplemental assessment tools

The Burn Specific Health Scale (BSHS) is as a specific outcome measure for burn injuries including physical, psychological, and social aspects. Jebsen Hand Function Test helps assess a broad range of uni-manual hand functions required for activities of daily living (ADLs). The West-Haven-Yale Multidimensional Pain Inventory may be used in conjunction with behavioral and psycho-physiological strategies to help assesses chronic pain in individuals. Craig Handicap Assessment and Reporting Technique is a simple objective measure of the degree to which impairments and disabilities result in handicaps.9 Electrodiagnostic test may be performed to evaluate for neuropathy or myopathy. Sequential photography can be taken in order to help assess burn and scar progression.

Early predictions of outcomes

The progress that has been made in burn care over the past few decades has dramatically increased survivial rates for burn victims such as; antibiotic therapy, techniques to excise burn eschar and new technology/clinical skills in the management of burn wounds, resuscitation and nutrition.10 Outcomes are poorer as burn depth and TBSA increase (>40%).2 Associated injuries, such as head injury, inhalation injury, and certain comorbidities tend to worsen outcomes. Associated injuries, such as head injury and inhalation injury, and comorbidities, such as diabetes, worsen outcomes. Young age (<2 y) or olderage (>60 y) increase mortality.7

Environmental

Healed burn skin is fragile and sensitive to the sun and chemicals. With a deep partial thickness or full thickness burn, sweat glands are destroyed and are not replaced when the skin heals. This type of damage can lead to problems with thermoregulation in hot and humid conditions, because sweating is crucial in controlling body temperature. Precaution with certain forms of exercise, recreation, or working conditions should be followed in order to avoid complications such as heat stroke.7 Inhalation injury may preclude an individual from returning to environments with dust, fumes or respiratory irritants.

Social role and social support system

Burn patients face social, emotional, vocational and physical challenges. Peer counseling groups for support and mutual problem solving are often helpful.11 See “Patient and Family Education.”

Professional Issues

Employment outcomes after burn injury depends if injury was at or outside of works. For those burned at work pain (72%), neurologic problems (62%), and psychiatric problems (53%) are the most limiting factors. Those burned outside of work demonstrate limitations 2ry to pain (63%), neurologic problems (59%), and impaired mobility (54%) Barriers to return to work early after burn injuries are physical and wound issues, while long term disabilities are 2ry to working conditions (temperature, humidity, safety) and psychosocial factors.12

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Surgical treatment guideline is provided by the American Burn Association. Currently, no consensus guideline exists for burn rehabilitation.

At different disease stages

Initial phase (resuscitation): Critical care services to monitor and correct fluid and electrolyte, metabolic, cardio-pulmonary, hemostatic derangements and infections.13

Second phase (wound care, surgical care, positioning, pain relief & splinting): Debridement can be performed to remove eschar and necrotic tissue to prepare a viable base for wound healing, grafting and prevent infections. Escharotomy is indicated in circumferential and partial thickness burns that present with pressure of at least 40mmHgG to prevent necrosis of underlying tissues.14

Topical wound care topical agents (silver sulfadiazine, gauze with bacitracin or mupirocin, mafenide ace-tate and acetic acid soak). Synthetic dressings with Duoderm, Tegaderm, Xeroform, silver coated gauze (Aquacel, Mepilex, Acticoat) reduce dressing change frequency and patient discomfort.13

Regular pain relief, should be provided, especially prior to all interventions such as dressing changes and exercise. Pain management goals are to provide a good level of control so functional movement and daily living activities can occur at any time during the day. Treatment options include short and long acting opioids or non pharmacological options such as distraction, virtual reality, imagery, hypnosis, progressive muscle relaxation, positive reinforcement and cognitive restructuring.14

Patients will favor resting in a shortened, flexed position therefore correct alignment is crucial to prevent contractures. Anti-contracture positioning is determined by location and direction of contracture of the affected burn area.15 Splinting assist in maintains anti-contracture positioning in patients experiencing pain, poor compliance or when positioning alone is not sufficient. They help remodel scar tissue and maintain anatomical contours by applying controlled forces to soft tissues (inducing remodeling) 14

Third phase (definitive wound closure):

Temporary skin grafts include cadaveric allograft, Xenograft, Biobrane, or Transcyte. Autografts are permanent skin grafts and are the gold standard in skin substitutes.13 They provide wound closure, help modulate metabolic needs, reduce evaporation and serves as a mechanical barrier to infection.14

Final stage (rehabilitation, reconstruction, reintegration):

Rehabilitation needs change through the various stages of recovery. Acute rehabilitation needs to include elevation of extremities to reduce swelling, prevention of pressure sores, anti-contracture positioning, splinting, stretching, ROM, exercise and early mobilization.15 Primary goal is to maintain or achieve normal range of motion.

Long term rehabilitation program is composed of a structure exercise program which includes aerobic and resistance training which leads to increase function, muscle mass, strength, cardiovascular, respiratory capacity, coordination and balance. It has been described that, independent ambulation is an important predictor for patient’s discharge from an acute burn center.14

Coordination of care

An interdisciplinary team approach by health care providers specialized in burn care is ideal. It should include: physical/occupational and speech pathology therapists, physiatrist, experienced burn/reconstructive surgeon, psychologist, social worker, the patient and their family (as appropriate). Communication is critical to ensure treatment coordination and establishment of goals are met during and between the rehabilitation process.16

Patient & family education

Recovery and rehabilitation after major burns may require multiple surgeries and may take years until the patient is able to achieve optimal outcome. It is essential that the patient is educated at every stage of his rehabilitation process so that the goals of their rehabilitation treatment are clear and how their participation is essential to ensure the best possible outcome. Education to the patient and the caregiver about possible long term physical, physiological and vocational challenges is of outmost importance, as well as a consistent approach from all members of the multidisciplinary team.15

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

1. Patients should receive optimal treatment and care during the different stages of his injury, as this will assure that the patient has a favorable recuperation, decreasing the likelihood of developing long term complications.
2. It is crucial to take adequate measures to avoid long term complications such as contractures and psychological problems which may interfere with the patient’s ability to have a successful re-integration into the community.
3. In order to offer patients a successful treatment and an optimal recovery, a coordinated multidisciplinary approach is needed at all stages.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Photobiomodulation involves inducing wound healing by illuminating wounds with light emitting diodes or lasers.17 Oxandrolone is an anabolic steroid that has been extensively studied in the burn population and has been shown to significantly increase lean body mass retention and decrease length of hospital stay.18 Glutamine is a nutritional supplement which has been shown to decrease infection rates, improve wound healing, and decrease hospital length of stay for burn patients.19

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