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© 2004 WebMD Inc. All rights reserved.                                                        ACS Surgery: Principles and ...
© 2004 WebMD Inc. All rights reserved.                                                        ACS Surgery: Principles and ...
© 2004 WebMD Inc. All rights reserved.                                                      ACS Surgery: Principles and Pr...
© 2004 WebMD Inc. All rights reserved.                                                        ACS Surgery: Principles and ...
© 2004 WebMD Inc. All rights reserved.                                                       ACS Surgery: Principles and P...
© 2004 WebMD Inc. All rights reserved.                                                        ACS Surgery: Principles and ...
© 2004 WebMD Inc. All rights reserved.                                                                       ACS Surgery: ...
© 2004 WebMD Inc. All rights reserved.                                                                      ACS Surgery: P...
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Acs0717 Rehabilitation Of The Burn Patient


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Acs0717 Rehabilitation Of The Burn Patient

  1. 1. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 1 17 REHABILITATION OF THE BURN PATIENT Lee D. Faucher, M.D. Of all the different processes that a burn patient undergoes, reha- It is not surprising that patients with larger injuries have longer bilitation lasts the longest: it begins on the day of the injury and hospital stays, incur more expenses, and usually require years of never truly ends. With current methods of burn care, patients are rehabilitation. This being the case, it is reasonable to consider increasingly able to survive larger, more debilitating burns; accord- whether a person who sustains a massive burn injury and who ingly, the main objective (and primary measure of success) of may suffer irreparable loss of function as a result can be said to quality burn care has shifted from survival per se to restoration of have a good quality of life after recovery. Unfortunately, data com- burn patients to their preinjury level of function, with the best pos- paring the perceived quality of life of severely burned individuals sible cosmesis. Achieving this objective requires a team of highly to that of unburned healthy individuals are scarce.3 trained and knowledgeable physical and occupational therapists, A massive burn injury has both physical and psychological con- under the direction of rehabilitation physiatrists. sequences. The physical consequences include pain, itching, and The specific objectives of a rehabilitation program change over loss of function; the psychological consequences include (but are time. In the early stages, rehabilitation focuses on restoring base- not limited to) depression, anxiety, loss of self-esteem, and inabil- line cardiopulmonary status and preventing musculoskeletal dys- ity to socialize. An accurate assessment of quality of life would take function. In the later stages, rehabilitation focuses on regaining account of both types of consequences. In 1982, the Burn Specific baseline function, returning to work or school, and adjusting to Health Scale (BSHS) was developed in an attempt to quantitate possible aesthetic and psychological changes.This changing focus and evaluate quality of life for all burn survivors.4 In 1987, this underscores the need for an integrated team approach. 114-item inquiry was shortened to an 80-item questionnaire,5 and The qualifications and capabilities of rehabilitation programs for in 1992, it was again revised and renamed the Revised Burn burn patients, as well as similar programs for other injuries and neuro- Specific Health Scale (BSHS-R).6 The BSHS-R measures seven logic disorders, are determined by the Commission on Accredi- domains—simple functional abilities, work, body image, interper- tation of Rehabilitation Facilities (CARF). This independent, not- sonal relationships, affect, heat sensitivity, and treatment regimens for-profit organization is responsible for reviewing and granting ac- [see Table 1]—and has proved to be a valid and reliable outcome creditation requests from facilities. CARF-accredited programs and scale for burn patients. It has also been translated into Finnish and services have demonstrated that they meet internationally recognized Spanish and has proved reliable and valid in those languages as standards and have made a commitment to continual enhancement well.The results of the BSHS-R give a clinician an idea of how an of the quality of their services and programs. More information and a individual patient is affected by the injury and where to focus ther- complete list of accredited providers can be found at the CARF web apy and treatment. Follow-up evaluations can be used to quantify site ( improvements in quality of life, as was shown in a 2002 study that A national agenda for addressing rehabilitation and recovery has analyzed 110 burn-injured patients with the BSHS.7 In this study, been developed, spearheaded by the National Institute on Disability patients had an improved quality of life when overall stress was and Rehabilitation Research (NIDRR). NIDRR is one of the three reduced and the level of pain lowered. Physical quality of life was components of the Office of Special Education and Rehabilitative better at 6 months from the time of injury than at 2 months. Services at the U.S. Department of Education; it operates in concert Fewer than 50% of patients who experience a major burn injury with the Rehabilitation Services Administration and the Office of return to the same job with the same employer without accom- Special Education Programs.The mission of NIDDR is to generate, disseminate, and promote new knowledge so as to improve the op- Table 1—Selected Items from the BSHS-R6 tions available to disabled persons, with the ultimate goal of return- ing individuals to their preinjury status as integrated members of Sample Items Response Format their community. NIDRR is a national leader in sponsoring re- search: in 2001, it supported 344 projects and had a total annual Heat sensitivity 0—Extreme(ly) budget of $141 million.1 More information can be found at the Being out in the sun bothers me 1—Quite a bit NIDDR web site ( Hot weather bothers me 2—Moderate(ly) I can’t get out and do things in hot weather 3—A little bit It bothers me that I can’t get out in the sun 4—None (not at all) Quality of Life after Burn Injury My skin is more sensitive than before Better acute management of patients with massive burns has Work been one of the major advances in trauma care over the past two My burn interferes with my work Being burned has affected my ability to work decades. Before 1970, persons who sustained a burn covering My burn has caused problems with my working more than 30% of their total body surface area (TBSA) nearly al- I’m working in my old job performing old duties ways died; today, only about 12% of those who sustain burns of this magnitude die.2
  2. 2. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 2 modations having to be made.8 Because most health insurance is lized for substantial periods, ranging from a few days to several connected with employment, prolonged time off work can cause weeks, as a consequence of their critical illness. Accordingly, early significant hardship to patients and their families. Little informa- ambulation, its well-established benefits notwithstanding, is not tion is available on the factors that influence return to work after feasible in this population. Even when a critically ill burn patient’s burn injury. This is unfortunate, because such information could condition improves to the point where such mobilization is possi- have a positive impact on quality of life after injury. ble, he or she still usually requires maximal assistance to perform Quality of life remains difficult to measure. Several studies have this task [see Figure 2]. Factors such as severe weakness, impaired demonstrated that many burn survivors are able to return to their motor control, and decreased cognitive status are responsible. preinjury functional status.3,7,9,10 The chances of achieving a posi- Several bed rest studies have determined that the antigravity mus- tive outcome are enhanced if the patient is free of emotional and cles of the lower extremities are the first muscles to weaken dur- physical distress and resumes involvement in some of the same ing periods of inactivity.16 A tilt table can be a bridge to ambula- activities enjoyed before the injury.7,11 Outcome can also be posi- tion by allowing a patient to perform a weight-bearing exercise in tively affected by comprehensive multidisciplinary aftercare10 and a gravity-reduced environment.17 supportive and healthy family dynamics.9 It is important that all wounds be properly dressed and lower- extremity wounds supported with elastic wraps. Wrapping the gravity-dependent areas can decrease edema and thus minimize Components of Rehabilitation pain during periods of ambulation. The patient should be kept well informed of the progress made EXERCISE AND AMBULATION during exercise and ambulation sessions. Before any intervention As noted, rehabilitation is a long and typically painful process.To is started, the goals of each session should be outlined and the get patients through this process, it is essential to inculcate in them a patient told that the goals will be advanced at each session. Many solid understanding of the importance of exercise.The underlying patients do well when there is a visual goal (e.g., a specific loca- principle of the recovery of the burn patient is return to normal tion to which they walk). The use of a toy or a game can some- function.Through exercise, the patient can attempt to maintain nor- times help younger patients reach the desired goal. mal activity from admission through hospital care and beyond.The Many clinicians discontinue range-of-motion exercises and am- specific goals of exercise are to reduce the effects of edema, maintain bulation for 3 to 14 days after autografting to minimize graft trauma. range of motion, stretch the eschar and scar, and achieve an optimal It is my practice to begin range-of-motion exercises 5 days after level of function.12 An aggressive exercise program has been shown grafting for hands and faces and 7 days after grafting for other areas. to improve pulmonary function in severely burned children,13 re- One must remember to weigh the risk of graft loss against the possi- ble loss of function when ordering a period of inactivity. duce the need for scar release after burn,14 and also improve muscle strength, power, and lean body mass.13 PRESSURE AND OCCLUSION Scar is the limiting factor for proper range of motion. Some scar is always made as burns or grafted areas heal. Burns and burn Pressure Garments scars lead to contractures, and the skin that overlies joints is at the The use of pressure garments on grafted burns or burns that highest risk for loss of function.15 A patient with full range of take longer than 14 days to heal is considered standard care in motion can lose a great deal of range overnight after a burn. most burn care centers, despite reports in the literature that ques- Monitoring of range of motion in all joints should be done on a tion its efficacy.18,19 The proponents of the use of pressure assert daily basis so that attention can be directed to specific joints at that it helps reduce hypertrophic scarring by decreasing blood risk. Trained therapists should be brought in to provide instruc- flow and oxygen delivery, thereby lowering the rate of collagen tion about exercise methods tailored to individual patients and varying levels of understanding. Range-of-motion exercises should begin on the day of admission. Ideally, they should be done twice daily on all joints of the upper and lower extremities [see Figure 1]. Care must be taken with especially painful and newly grafted areas. Patients with large burns may be in- capacitated and unable to participate in these exercises. Passive stretching of all extremities should be done during times when pa- tients cannot perform the range-of-motion exercises. It is often helpful to coordinate exercise with administration of pain control medications. Patients frequently undergo general anesthesia for excision and grafting several times during the early postburn period. Such occasions provide a good opportunity to evaluate a patient for range-of-motion limitations, in that the activity will not be hindered by pain. As the patient begins to par- ticipate in range-of-motion exercises, the therapist can begin pas- sive resistance exercises. This step is the beginning of strength training, in which the amount of resistance is increased until the patient (ideally) returns to his or her preinjury state. Early ambulation is known to help maintain range of motion, maintain strength in the lower extremities, and prevent throm- boemboli; it is also known to maintain bone density and promote Figure 1 Shown are range-of-motion exercises being done on the functional independence.12 Patients with large burns are immobi- hand.
  3. 3. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 3 trials have conclusively demonstrated that such therapy minimizes hypertrophic scarring. SPLINTING Splinting can be used as an adjunct to range-of-motion therapy throughout all phases of burn care. It is also used postoperatively to protect newly placed autografts. Many ready-made splints are available, but most therapists prefer to customize splints for the needs of each patient; in this way, changes can easily be made as these needs evolve. In every case, the overall medical status of the patient and any associated injuries must be taken into account in the decision process. Certain positions are generally used for splinting various areas of the body. The neck is splinted in extension; the arms are exter- nally rotated, abducted, and supinated; the trunk is straight; the hip and knee are in neutral rotation and straight; and the feet are in dorsiflexion. Particular patients may have slightly different needs, but this overall plan should be followed. There are several principles that should be followed in design- Figure 2 Patients who have sustained major burn injuries typi- ing a splint [see Table 2]. In particular, the splint should not cause cally cannot be mobilized for days to weeks after their injury. pain and should be easy both to apply and to remove. In addition, Even when they have improved sufficiently to permit mobiliza- it should be lightweight and should allow adequate ventilation so tion, they usually require considerable assistance. as to minimize the risk of skin breakdown. The use of continuous passive-motion devices in conjunction deposition in the healing wound. As a result, a balance is reached with passive splints can provide an additional therapeutic option between production and breakdown of collagen, leading to a flat- for increasing the range of motion of certain joints. ter scar.20 Clinical studies, however, have not found this to be the PAIN CONTROL case and have shown that pressure garments do not alter wound maturation time.19 Moreover, patient compliance with the use of Quantifying pain is notoriously difficult, but it is widely believed pressure garments is generally very poor,21,22 and medical insur- that a burn injury may be the most painful trauma a person can ance often does not cover their cost.23 sustain. Proper treatment of a burn involves daily wound care, Those who elect to use pressure garments in the treatment of exercise, and ambulation, all of which are painful. Initial care is fol- burn scars and tissue edema adhere to the following simple plan. lowed by months of rehabilitation, which often makes patients feel If a burn heals in less than 14 days, pressure is not used. If a burn that their pain is unending. All patients have different thresholds takes 14 to 21 days to heal, pressure is applied only if the wound for pain and different abilities to cope with pain and long-term begins to show signs of hypertrophy. Finally, pressure therapy is rehabilitation. Satisfactory pain control is not always achievable, always used in grafted burns and those that take longer than 21 but it should always be striven for. Poor pain control can render a days to heal. patient unable to complete required tasks during therapy. Pressure garments deliver pressures ranging from 10 to 40 mm A generalized treatment plan for pain control follows a struc- Hg; the usual recommended pressure is about 25 mm Hg, so as tured approach that is unique to each burn patient. The plan to oppose the capillary pressure.24 The garments come in many should cover the three types of pain involved: background pain, colors and are custom-made for each patient for use on any part breakthrough pain, and procedural pain. Narcotics and anxiolyt- of the body. They conform to body movements and can be worn ics should be employed as needed, and nonpharmacologic thera- during therapy or other activities. The garments should be worn pies should be included as appropriate. The plan should also be 23 hours a day. They are quite durable, lasting about 3 months. flexible and capable of conforming to the changing needs of the When the garments no longer feel tight to the patient, they should be replaced. Silicone Table 2—Purpose of General Topical application of silicone has also been employed to treat Splinting Design12 burn-related scarring. Of the various forms of silicone available—flu- ids, gels, and elastomers—elastomer sheets are most commonly used Allows for edema reduction Maintains joint alignment for this purpose today.25 Silicone elastomer sheets easily conform to Supports, protects, and immobilizes joints the contours of the burn wound and can be used either in conjunc- Maintains and/or increases joint range of motion tion with pressure garments or alone. Silicones are not believed to Maintains tissue elongation apply any significant pressure to the wound; rather, they are believed Remodels joint and tendon adhesions to increase the wound temperature and thereby change the oxygen Promotes wound healing tension, thus reducing scarring.26 An alternative theory is that sili- Relieves pressure points cone provides a water barrier that allows the scar to remain hydrated Protects newly placed grafts and thus decreases blood flow, thereby reducing collagen deposition Allows normal function of nonsplinted joints and scar hypertrophy.27 Counteracts gravity to assist in functional activity Much is known about the effect of topical silicone application, Strengthens weak muscles but to date, as with pressure garments, no randomized, controlled
  4. 4. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 4 patient. Each institution should develop its own guideline-based approach to pain control [see Table 3].28 Table 3—Guideline-Based Approach to Opioid agonists are the cornerstones of therapy for burn-related Pain Control in Burn Patients28 pain.These agents provide good flexibility in that they can be admin- istered via different routes and in varying dosages and possess differ- Promise attentive patient care ent durations of action. Nonsteroidal anti-inflammatory drugs Chart and display assessment of pain and pain relief (NSAIDs) and acetaminophen, though rarely indicated in the acute Define pain and relief levels to trigger review setting, can be very useful throughout the rehabilitation period. Survey patient satisfaction Monitor treatment efficacy A number of nonpharmacologic adjuncts to pain control have been studied for use during the acute phase of burn care, includ- ing hypnosis, virtual reality, and cognitive interventions. Each of these has proved to offer some benefit in this setting, but there are occurred around postburn day 30, and that 90% of patients were few data on their use in the rehabilitation and recovery phase. able to tolerate a regular diet at discharge.40 Nevertheless, it would seem logical that learned pain management techniques, such as distraction and relaxation, might assist pa- SKIN CARE tients throughout their entire course of therapy, not just in the Grafted and healed burn skin is not as durable as uninjured acute phase of care. skin. The injury itself depletes the skin of its native ability to remain moisturized, and this depletion increases the likelihood of WEIGHT GAIN AND RECOVERY chapped skin. Liberal use of skin products that contain lanolin can In no other disease or trauma is the postinsult hypermetabolic re- help keep the skin moisturized. These products may also lessen sponse as severe as it is in a major burn injury. A person with a 40% itching and thus reduce the likelihood of trauma from scratching. TBSA area burn may have metabolic requirements that are twice Healed and grafted burns are also at risk for hyperpigmentation normal.29 The hypermetabolic response begins on postburn day 5 if exposed to direct sunlight during the postinjury inflammatory and continues for nearly 1 year afterward.30 phase, which may last as long as 2 years after a burn.41 A sun block Severe catabolism and loss of lean body mass are well-recog- should be used at all times during exposure to sunlight, in combi- nized complications of major burn injury. Approximately 30% of nation with clothing that provides appropriate coverage. Clothing the calories burned during the hypermetabolic state are from mus- by itself does not offer sufficient protection: ultraviolet light can cle, and weight loss rates as high as 1 lb/day have been described.31 penetrate clothing and cause skin damage.42 Continued loss of lean body mass can lead to further complica- tions from depressed immune function, pneumonia, and impaired Itching wound healing.32 Patients recovering from burn injuries can suffer severe dis- The mainstay of treatment is prevention of weight loss by giv- comfort from itching. Itching does not stop when the wound is ing a diet high in calories and proteins. A typical daily intake closed but continues throughout the healing process. Histamine ranges from 30 to 35 cal/kg/day, with 1.8 to 2 g/kg/day of protein. released during the inflammatory phase of wound healing and Close monitoring of daily intake of nutrition and daily measure- during the prolonged phase of collagen deposition is thought to be ment of weight are necessary. A dietitian with special training in the main cause of itching, but stress and opioid medications have the nutritional needs of burn patients can take on the task of daily been implicated as well. monitoring and can be a great asset to the burn care team. A number of studies have attempted to identify the optimal treat- Severe catabolism in a burn patient is the result of increased lev- ment of itching.Therapies evaluated in these trials include antihista- els of catabolic hormones, decreased levels of anabolic hormones, mines, skin moisturizers, distraction therapy, special bath oils, and and direct cell injury caused by inflammatory mediators.33-35 low-dose antibiotics.To date, none of these treatments, either alone Oxandrolone, an anabolic steroid and testosterone analogue, can or in combination with others, has been shown to be effective. increase the rate of weight gain when used in conjunction with an Currently, however, the therapeutic picture is beginning to look aggressive exercise program and appropriate nutrition,32 and its brighter. There are now two topical creams for which there is use is not age-dependent in adults.36 These positive effects have promising preliminary data supporting their efficacy against post- not yet been replicated in children. burn itching. In a 2002 report, topical 5% doxepin cream, applied to healed burn wounds three times daily, significantly decreased SPEECH THERAPY burn itching in comparison with oral antihistamines.43 In a pilot Speech pathologists also fill an important role in the multidisci- study from the same year, topical dapsone gel, applied one to four plinary burn care team.They possess special skills in the early clin- times daily, significantly reduced itching in 84% of patients.44 As ical evaluation and management of dysphagia and can provide an of October 2003, dapsone was being evaluated in phase II trials; it accurate assessment of the efficacy of the pharyngeal phase of is hoped that further promising results will follow. swallowing so as to determine the adequacy of airway protection.37 MASSAGE THERAPY They can also offer useful assistance in stretching and strengthen- ing the facial and oral muscles.38 Although massage has been a part of burn care for some 400 Dysphagia, defined as the inability of a patient to accept and years,45 there is little in the way of high-level evidence to indicate that safely transport food and liquid from the mouth to the stomach, is it is effective in reducing burn scarring. One thorough study found a consistent and prominent impairment associated with all types no difference between a group of patients that received massage and of burn injuries.39 Patients with larger burns may also require pro- a control group that did not,46 but the authors admitted that the 10- longed mechanical ventilation, in which case the initial dysphagia minute treatments administered may not have been long enough. assessment is delayed until extubation. A retrospective review from Massage has, however, been shown to decrease itching,47 pain,47-49 2001 found that the initial dysphagia assessment typically oc- anxiety,47-49 anger,49 and depression47,49 and thus is a useful adjunct curred around postburn day 20, that the first safe oral intake in burn treatment and rehabilitation.
  5. 5. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 5 BODY TEMPERATURE REGULATION One way of possibly reducing hypertrophic scarring and contrac- Core body temperature is regulated through alteration of cuta- ture is to minimize the period over which wound contraction takes neous blood flow and dissipation of heat via sweating. A full-thick- place. Early excision and grafting have been shown to lessen the ness burn destroys the dermis and the elements that are the basis amount and intensity of inflammation59 and reduce the develop- of temperature regulation. The body can compensate for this loss ment of hypertrophic scarring by shortening the duration of the in- through excessive sweating in the unburned areas of the body, but flammatory phase.60 In grafting a wound, it is important to use this compensatory response is believed to be limited to patients enough tissue to cover all of the wound edges and to use sheet grafts whose burns cover less than 40% of their TBSA.50 There are, how- whenever possible.59 A full-thickness skin graft results in less skin ever, current data suggesting that improved cardiovascular fitness contraction during healing than a split-thickness graft does.The thin- may allow patients with larger burns to mount such a response.51 ner the split-thickness graft, the greater the degree of contraction. Because healed and grafted burns have less cutaneous blood The main treatment options for hypertrophic scar are aggressive flow, effective conductive heat loss cannot be achieved through range-of-motion therapy and surgical excision.When therapy fails to vasodilation.50,52 Sweating in these areas does not aid in evapora- stretch the scar and a life-style–limiting contracture develops, surgi- tive heat loss either, because of an isolation effect in the hypovas- cal excision may become necessary. Often, the scar is excised and the cularized area.53 As a consequence of the impairment of both con- defect covered with another skin graft. Alternatively, the scar may be excised and the wound closed primarily, provided that there is ductive and evaporative heat loss mechanisms, patients exercising enough tissue to allow coverage of the wound with a tension-free clo- in climates that are both hot and humid have the greatest difficul- sure. Corticosteroid injection into the wound after scar excision has ty in maintaining their thermoequilibrium. been studied and found to yield a 30% to 100% reduction in scar- Control of ambient temperature is most critical during the ring.61 To date, no prospective, randomized trials have evaluated the acute phase of burn care and in the operating room. In my expe- use of corticosteroid injections in this setting, but the initial results rience, burn patients who are in the rehabilitation phase are not are undoubtedly promising. uniform in their tolerance to heat and cold: some require more clothing to tolerate the cold, and others have the same exercise tol- HETEROTOPIC OSSIFICATION erance after their burn as they had before it. I know of one burn Heterotopic ossification (HO) is a condition in which mature patient whose temperature tolerance changed so drastically that he lamellar bone is laid down in tissues that do not usually ossify. HO had to move to a snow-belt state to get away from the heat, and I was first described in the early 20th century and usually occurs in know of another who had to move out of a snow-belt state to get patients who have medical conditions with poor prognoses. As sur- away from the cold. vival rates have increased in patients with major burns, so too has Whenever patient temperature tolerance negatively affects burn the incidence of HO: it is currently about 3% overall.62 HO tends rehabilitation efforts, the ambient environment must be changed to affect joints underlying areas of full-thickness burns in patients to meet the individual patient’s needs. with burns covering more than 20% of their TBSA,62 but it can occur anywhere. The most common site is probably the upper Special Problems extremity, with the elbow the most frequently involved joint.63 At present, how best to treat HO is as uncertain as what causes it. HYPERTROPHIC SCARRING All treatment modalities remain controversial. Surgical treatment yields less than optimal results. Medical treatment incorporates the When skin is injured, scar is formed in an attempt to rapidly use of steroids and NSAIDs for prophylaxis and treatment.64 restore protective covering to the injured area; the reason why scar Etidronate, an inhibitor of osteoclast bone resorption, has proved ef- is formed instead of the original tissues being regenerated is not fective at reducing HO developing after spinal column65 and hip in- known. During this attempt to form a new protective covering, juries.66 This agent has yet to be prospectively studied in burn pa- new connective tissue is created, which gives the scar strength. tients but is widely used to treat HO in this population nonetheless. When scar formation becomes extensive, it leads to a hypertrophic scar. A hypertrophic scar is a raised, erythematous, pruritic, and PSYCHOLOGICAL PROBLEMS inelastic mass of tissue that is the result of a large amount of extra- A burn injury can be the most aesthetically devastating traumatic cellular matrix whose composition and organization are altered event a person can experience. Given society’s emphasis on youth from those of normal dermis. Microscopically, there is a whorllike and beauty, a severely impaired appearance can be socially incapaci- pattern of collagen, an abundance of immature connective tissue, tating. Furthermore, the very process of being treated for a major and a prolonged chronic inflammatory reaction.54 The extracellu- burn can cause psychological difficulties. Patients with burn injuries lar matrix is composed of a multitude of cell types that are main- essentially lose control of their lives upon arrival at the burn center. tained in a hyperactive state by inflammatory mediators. Every moment of every day is planned for them: they undergo thera- Formation of hypertrophic scars is generally considered common py, wound care, nutritional supplementation, and operations accord- after a burn injury; surprisingly, however, published data on the ing to a strict schedule for an indeterminate period. prevalence of hypertrophic scarring after burn injury are scant.55 Es- Accordingly, it is not surprising that psychological problems are timates range from 4% in burns that heal spontaneously56 to 75% in identified in a significant number of burn patients. Effective treat- grafted burns.57 Eventually, all hypertrophic scars undergo some ment may include psychological debriefing, use of appropriate spontaneous resolution, but such resolution is unpredictable. pharmacologic interventions, exposure therapy, or desensitiza- Tissue contraction is a normal and necessary part of wound tion.67 It is important to provide psychiatric services as soon as the healing. Contracture, however, is an abnormal process resulting need arises, so that early and effective interventions can support from long-term shrinkage of a scar. This process can continue the patient through this traumatic event. indefinitely until it either achieves a comfortable position or meets Previous psychiatric diagnoses have been shown both to an equal opposing force.58 If allowed to progress uncontrolled, increase mortality and to prolong length of stay.68 Preexisting psy- contracture can lead to a loss of function in the affected area. chological disorders can be exacerbated during rehabilitation, and
  6. 6. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 17 Rehabilitation of the Burn Patient — 6 new ones can arise even in the absence of risk factors. Any previ- The first priority in burn reconstruction is to obviate further ous psychiatric diagnosis warrants early and effective intervention reconstruction by providing proper postoperative care.The second in the acute phase of burn care.The clinician, the pharmacist, and priority is to restore active function, and the third is to restore pas- the psychiatrist must have a firm understanding of burn physiolo- sive function. To address these priorities requires a systematic gy and burn pharmacokinetics to ensure that an effective medical approach that includes all members of the multidisciplinary burn treatment plan is established. team, as well as the patient. By following a rational and orderly Depression, anxiety, and guilt often arise during the early plan of possible reconstruction and considering the patient as a course of rehabilitation. Posttraumatic stress disorder (PTSD) whole, the question of what is to be reconstructed and in what may develop in as many as 43% of patients during the hospital order can be clarified. phase of burn care. Alteration of the patient’s self-image is thought Primary closure is preferred with any wound, whether the to be the most common predisposing factor for PTSD; other fac- wound is being repaired directly or is undergoing reconstruction. tors include poor pain control and associated physical impair- In many burn patients, however, the wound is too large to allow ments. Often, PTSD develops only after hospital discharge, and it primary closure. Occasionally, large hypertrophic scars that are is difficult to identify patients at risk.69 Therefore, it is imperative surrounded by uninjured tissue can be excised through multiple for clinicians to provide education and psychological intervention excisions and primary closure. This is a time-consuming process to all patients during the hospital course and maintain aggressive but will lead to a good result. follow-up after discharge. Z-plasty may be employed to gain length along a scar or skin fold The most effective way of treating PTSD is to attempt to min- at the expense of surrounding tissues [see 3:7 Surface Reconstruction imize its occurrence. To this end, control of pain and anxiety is Procedures].The angles of the limbs of the Z dictate how much length essential. As stated (see above), opioids are the cornerstone of pain can be gained over the original scar: approximately 25% for 30° an- management. The addition of benzodiazepines can facilitate pain gles, 50% for 45° angles, and 75% for 60° angles. control considerably.Withdrawal from these medications can pro- If these approaches are not feasible, the alternative is excision of duce symptoms similar to those of PTSD, but this concern should the scar or contracture with placement of a skin graft [see 3:7 Surface not dissuade clinicians from using them when appropriate. Nearly Reconstruction Procedures]. After excision of the scar, the wound usu- every psychotropic medication has been tried as therapy for ally retracts quite widely, leaving a much larger skin deficit. The PTSD; none has yet proved more effective than any of the others. thickness of the graft depends on the need for the reconstruction. Thinner grafts are more likely to survive but are at higher risk for NEUROLOGIC COMPLICATIONS wound contracture during the maturation phase. Full-thickness Peripheral neuropathy is a well-known complication after major grafts have the best color matching and hair pattern, but they require burn injury, but its incidence is unknown. In 1971, when this com- near-perfect conditions to survive, and the donor sites do not heal plication was first described, the incidence was reported to be 15% spontaneously. If a full-thickness graft is needed for reconstruction in the 249 burn patients studied.70 Since then, multiple studies and the donor site cannot be closed primarily, the donor site can be have been done, reporting incidences ranging from 2% to 84%.71-75 closed with a split-thickness skin graft. In all of these studies, peripheral neuropathy was correlated with A flap may be used for reconstruction when primary closure increased length of stay, increased percentage of TBSA burned, and skin grafting either are not possible or are undesirable. and electrical injury. Exposed bones or tendons must be covered with a vascularized In a 2001 retrospective review of cross-sectional data from 572 section of tissue because they lack the vascular supply required patients with major burn injuries, the incidence of peripheral neu- to support a skin graft. Contour defects are also managed with ropathy was 11%.76 The patients who were more likely to exhibit flaps. peripheral neuropathy were those whose burns covered more than Several types of flap are used in burn wound reconstruction [see 15% of their TBSA, those who spent more than 20 days in the 3:7 Surface Reconstruction Procedures]. A random flap receives its intensive care unit, and those who sustained electrical injuries.76 blood supply from the musculocutaneous arteries penetrating its Precisely what causes peripheral neuropathy is not known. It is base; the Z-plasty (see above) is an example of this type of flap. An important that all burn patients, especially those with known risk fac- axial flap receives its blood supply from a direct cutaneous artery; tors, receive comprehensive neurologic examinations aimed at de- the pivot point of the flap is the artery itself. A radial forearm flap tecting this devastating complication. It is often possible to limit the is the classic example of this type of flap. Axial flaps are very use- progression of peripheral neuropathy—and sometimes to prevent ful in burn reconstruction, but an exact knowledge of cutaneous it—by paying particular attention to (1) prevention of compartment arterial anatomy is necessary to design one. A free flap can be syndrome, (2) proper patient positioning (to prevent nerve compres- divided from its vascular pedicle and used to cover a distant defect. sion), (3) use of the shortest feasible tourniquet times, and (4) avoid- Free flaps are highly useful in burn patients because very often, the ance of prolonged use of compressive dressings. tissue surrounding a defect is also damaged and cannot be used for reconstruction. Tissue expanders may also be used to achieve wound coverage. Burn Wound Reconstruction An expandable device is surgically placed beneath the skin and Reconstruction of a burn wound is postponed until the wound gradually increased in size, thus stretching the uninjured skin so is fully matured, which can take as long as 2 years.59 If, however, that it may be used to cover the defect.This technique is best suit- contracture is causing a severe functional deficit, early reconstruc- ed to parts of the body with a bony background (e.g., the skull or tion is indicated to correct the problem. the chest wall).
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