Burns

Question 1

First-Degree Burn

Answer 1

• Aka superficial burns
• Involves the superficial epidermis
• Pain is minimal to moderate
• No blistering, minimal erythema
• Healing time is 3 to 7 days

Question 2

Second-Degree Burn

Answer 2

• Partial-thickness burn
• Can be superficial or deep

Question 3

Superficial Second-Degree Burn

Answer 3

• Aka superficial partial-thickness burn
• Involves the epidermis and upper dermis layers
• Pain is significant
• Wet blistering and erythema are present
• Healing time is 1 to 3 weeks

Question 4

Deep Second-Degree Burn

Answer 4

• Aka deep partial-thickness burn
• Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands
• Pain is severe, even to light touch
• Erythema is present, with or without blisters
• Burns has a high risk of turning into a full-thickness burn because of infection; grafting may be considered to prevent wound infection
• Client may have impairment of sensation
• Potential for hypertrophic scar is high
• Healing time varies from 3 to 5 weeks

Question 5

Third-Degree Burn

Answer 5

• Aka full-thickness burn
• Involves the epidermis and dermis, hair follicles, sweat glands, and NERVE ENDINGS
• Burn is PAIN-FREE, no sensation to light touch
• Burn is pale and non-blanching
• Requires skin graft
• Potential for hypertrophic scar is extremely high

Question 6

Subdermal Burn

Answer 6

• Full-thickness burn with damage to underlying tissue such as fat, muscles, and bone
• Charring is present; may have exposed fat, tendons, and muscles
• If the burn is electrical, destruction of nerve along the pathway is present
• Peripheral nerve damage is significant
• Requires surgical intervention for wound closure or amputation
• Potential for hypertrophic scar is extremely high

Question 7

Emergent Phase

Answer 7

• Zero to 72 hours after injury
• Medical treatment focuses on:
  1. Sustaining life (including minimizing risk of dehydration and hypo- or hyperthermia; fluid resuscitation; achieving cardiopulmonary stability; and escharotomy &/or fasciotomy if needed)
  2. Controlling infection
  3. Managing pain

Question 8

Acute Phase

Answer 8

• 72 hours after injury until wound is closed (may be days or months)
• Treatment focuses on:
  1. Infection control, including non-surgical wound care & surgical options (i.e., escharotomy & debridement, and skin grafts)
  2. Pain management (often including narcotic analgesics)
  3. Proper nutrition and hydration (high-protein diets promote wound healing)
  4. Cardiopulmonary stability is maintained

Question 9

Rehabilitation Phase

Answer 9

• Medical treatment continues with skin grafts and reconstruction surgery as needed for movement and function

Question 10

Emergent Phase - OT Role/Focus

Answer 10

• Evaluation = Clinical observation of body parts affected by burns & information gathering on prior functional status
• Treatment = Focused on splinting in ANTI-DEFORMITY positions:
  1. Intrinsic plus for hands
  2. Opposite client’s posture
  3. Generally in extension for neck, elbows, and knees
  4. Shoulder in ABduction
  5. Hip in extension
  6. Anti-frog leg and anti-foot drop for lower extremity

Question 11

Acute Phase - OT Role/Focus

Answer 11

• Evaluation = ADLs, psychosocial aspects, communication, cognition, ROM, muscle strength, and pain
• Interventions:
  1. Splinting and positioning in antideformity postions (typically opposite the position of comfort)
  2. Edema management (elevation, AROM if movement is allowed, wrapping with elastic bandages if no bulky wound dressings)
  3. Early participation in ADLs (adaptive strategies and/or equipment as needed; ROM & activity as tolerated **NO PROM or AROM with exposed tendons or within 5 to 7 days of recent grafts; respect pain; use compression wrapping on LE to provide vascular support)
  4. Client and caregiver education (stages of burn recover, pain management, importance of IND activity and exercise participation)

** Gentle AROM and PROM to client’s tolerance should be implemented as early as possible, with the exception of the post-graft operation immobilization period
** IMMOBILIZATION is important after skin graft operations to allow for graft adherence; generally is between 3 to 10 days for graft and 2 to 3 days for donor site
** After immobilization period, will begin initially with gentle AROM to avoid shearing of new grafts; and resume PROM after graft adherence has been confirmed

Question 12

Rehabilitation Phase - OT Role/Focus

Answer 12

• Wound is healing and wound closure is stable during this phase!
• Interventions:
  1. Skin conditioning (lubrication, desensitization massage, sunblock)
  2. Scar management (massage, pressure/compression garments fitting and wearing)
  3. Therapeutic exercise and activity (stretching, progressive resistive exercise, and coordination activities as tolerated)
  4. Splinting (anticontracture positions continued; also, use of dynamic splint or serial casting to reverse contractures if needed)
  5. ADLs (promote independence and identify abnormal movement patterns early)
  6. Client education (skin care, wound-healing process, etc.)

Question 13

Outpatient & Community Reintegration Phase - OT Role/Focus

Answer 13

Interventions:
1. Scar management (continue compression, skin conditioning, splinting/position and exercise program until scar is mature – can take 1 to 2 years!)
2. Community reentry (improve skin tolerance, promote ROM & strength, and adapt activity demands/environment if needed)
3. Psychosocial adjustment (clients may experience symptoms of PTSD, need an adjustment period, and/or require counseling or support groups, etc.)

Question 14

Anticontracture Positions

Answer 14

1. Neck = neutral to slight extension
2. Chest and abdomen = trunk extension, shoulder retraction
3. Axilla = shoulder ABducation to 100 - 120 degrees, slight external rotation
4. Elbow = extension
5. Forearm = neutral to supination
6. Wrist = Dorsal (wrist in neutral to 30 degrees extension) or Volar (wrist in 30 to 45 degrees extension)
7. Hand = Intrinsic Plus (metacarpals 70 degrees flexion; IP joints 0 degrees extension; thumb abducted and extended)
8. Hip = 10 to 15 degrees ABduction, neutral extension
9. Knee = extension; with anterior burn, slight flexion
10. Ankle = neutral to 5 degrees dorsiflexion

Question 15

Possible Complications from Burns

Answer 15

1. Contractures
2. Hypertrophic scarring
3. Heterotopic ossification (loss of ROM is rapid and pain is localized and severe, with hard end feel dring PROM)
4. Pain
5. Heat intolerance (loss of ability to sweat possible as a result of loss of sweat glands with split-thickness skin graft)
6. Sun exposure (higher risk of sunburn)
7. Pruritus (persistent itching; may lead to skin maceration and reopening of wound)
8. Psychosocial adjustment difficulties – may include primary stressors (contracture, disfigurement, pain); psychological reactions (depression, anxiety, PTSD, withdrawal); parental guilt if child sustains a burn (can also lead to feelings of incompetence); reintegration issues (especially with children for student and playmate roles)

Question 16

Dorsal Hand Burns

Answer 16

• Splint on volar side (intrinsic plus)
• Must take care to maintain Boutenniere precaution and AVOID having client form active or passive COMPOSITE flexion of fingers
• Do ROM to MP with IPs straight; and ROM to PIP with MP and DIPs straight
• The integrity of the extensor hood should be confirmed before composite flexion is allowed