hope it will be helpful.

1. - By Gaurav Malik
BPT

2. It is a wound in which there is coagulative necrosis
of the tissue.
Wounds caused by expose to:
• Excessive heat
• Chemical
• Fire/Steam
• Radiation
• Electricity

3. The skin is the largest organ of the body,
comprising approximately 15% of total body weight.
Anatomically, the skin consists of two distinct layers
of tissue: the epidermis, which is the outermost
layer exposed to the environment, and the deeper
layer, termed the dermis.
The epidermis, composed of multiple layers, is
avascular and performs several vital functions.

4. The layers of the epidermis include
1. The stratum corneum, which gives the skin its
waterproof characteristic and serves the role of
protection from infection;
2. The stratum granulosum, which is the layer
responsible for water retention;
3. The stratum spinosum, which adds a layer of
protection; and
4. The stratum basale layer, which contains cells that
enable the epidermis to regenerate, as well as
melanocytes, the cells that determine skin
pigmentation.
The interface between the epidermis and the
dermis is termed the rete peg region.

6. The dermis is subdivided into two layers: the
superficial papillary layer and the deep reticular
layer. The papillae of the papillary layer project
upward and interlock with the epidermis. The
papillae contain vascular plexuses that serve, in part,
to nourish the epidermis through osmosis.
The reticular dermis lies below the papillary dermis
and is composed of densely interwoven collagen
fibers. The reticular dermis attaches to the
subcutaneous tissue by an irregular interlacing
network of fibrous connective tissue.

7. Although the exact mechanism of the post- burn
microvascular changes and hypovolaemia leading
to low cardiac out -put and poor tissue perfusion
has not been determined.
The following mechanisms have been proposed.
1) Increased capillary permeability leading to fluid and
protein leakage from the intravascular space.
2) Decreased plasma encotic pressure due to
hypoproteinaemia resulting from loss of protein
from the intravascular space.
3) Increased capillary hydrostatic pressure due to
vasoconstriction or partial blockage of vessels with
aggregate of cells and platelets.

8. 4) Reduced clearance of fluid and protein from the
interstitial space by lymphatic ducts due to
blockage by platelet aggregate and fibrin clots.
5) Increase in osmotic pressure in the burned
tissue leading to further fluid accumulation.
6) Increased evaporative water loss.
7) Depressed myocardial function.

9. 1. Fire Burn:
Caused by dry heat with fire, open flame, hot, hot
metal, ignition of clothes.

10. 2. Scald :
It is caused by moist heat. Eg: Hot liquid, Steam.

11. 3. Electric Burn:
Occurs when skin comes in contact with a live wire.

12. 4. Chemical Burn:
It is caused by strong acid or base, which comes in
contact with skin. Eg. Cement

13. 5. Radiation Burn:
It is caused by x-ray or radium. This is infact a type of
inflammation of the skin which can be regarded as burn.

14. 6. Inhalation Burn:
Direct thermal injury can be sustained by inhalation
of flames.
Eg. Carbon Monoxide
7. Cold Burns:
It caused by exposure to cold which include frostbite
(freezing of tissues with the formation of ice
crystals), chilblain (it is a localized painful
erythema in fingers, toes, due to cold weather)

15. 1. Erythema:
Redness of the skin is there, skin remains intact,
no scar formation and it lasts for few days.
2. Superficial Burn/Epidermal Burn:
An epidermal burn, as the name implies, causes cell
damage only to the epidermis. The classic “sunburn”
is the best example of an epidermal burn. Clinically,
the skin appears red or erythematous. The
erythema is a result of epidermal damage and
dermal irritation, but there is no injury to the
dermal tissue.

16. The surface of an epidermal burn is dry. Blisters will be
absent, but slight edema may be apparent. After an
epidermal burn, there is usually a delay in the
development of pain, at which point the area
becomes tender to the touch.
The injured epidermal layers will peel off or desquamate
in 3 to 4 days. Epidermal healing is spontaneous; that is,
the skin will heal by itself, and no scar tissue will form.

17. 3. Partial Thickness Burn:
i) Superficial Partial-Thickness Burn:
With a superficial partial-thickness burn
damage occurs through the epidermis and into
the papillary layer of the dermis. The epidermal
layer is destroyed completely, but the papillary
dermal layer sustains only mild to moderate
damage.
The most common sign of a superficial partial-
thickness burn is the presence of intact blisters
over the area that has been injured.
Healing will occur more rapidly if the damaged
skin is removed and an appropriate topical agent
and wound dressing applied. Edema can be
moderate.

19. ii) Deep Partial-Thickness Burn:
A deep partial-thickness burn involves destruction
of the epidermis and papillary dermis with
damage down into the reticular dermal layer. As
this burn nears the deepest dermis it begins to
resemble a full-thickness burn.
Most of the nerve endings, hair follicles, and
sweat ducts will be injured because most of the
dermis is destroyed.
Deep partial-thickness burns appear as a mixed
red or waxy white color. The deeper the injury,
the more white it will appear.
The surface usually is wet from broken blisters.

21. 4. Full Thickness Burn:
In a full-thickness burn all of the epidermal and
dermal layers are destroyed completely. In
addition, the subcutaneous fat layer may be
damaged to some extent.
A full-thickness burn is characterized by a hard,
parchment-like eschar covering the area.
Hair follicles are completely destroyed, so body
hairs pull out easily. All nerve endings in the
dermal tissue are destroyed so the wound will
be insensate (without feeling); however, a patient
still may experience a significant amount of pain
because adjacent areas of partial-thickness burn
usually surround a full-thickness injury.

23. 5. Subdermal Burn:
The subdermal burn, involves complete
destruction of all tissue from the epidermis
down to and through the subcutaneous
tissue. This type of burn occurs with
prolonged contact with a heat source and
routinely occurs as a result of contact with
electricity.

24. I) At the site of Burn:
i. Redness or erythema
ii. Weeping of plasma (straw color)
iii.Blackened crispy tissue
iv. Blisters
2) Inhalation Injury:
i. Burned lips, nose
ii. Soot in the nostrils and mouth
iii. Hoarseness of voice
iv. Sorethroat

25. 3) Upto 3 days of post Burn( During shock):
i. Restlessness and disorientation
ii. Coldness and paleness of skin
iii. Collapsed vein and rapid pulse
iv. Sweating
v. Cyanosis
vi. Thirst
vii. Hypotension
viii. Rapid Breathing
4) Post Shock phase:
i. Contractures
- Scars
- Joint deformity
- Decrease ROM
ii. Loss of function

26. 1. A burn wound typically consists of three zones
In the zone of coagulation cells are irreversibly
damaged and skin death occurs. This area is
equivalent to a full-thickness burn and will require
a skin graft to heal. Because of the lack of viable
tissue and the amount of eschar, the risk of
infection is increased.

27. 2. The zone of stasis contains injured cells that may
die within 24 to 48 hours without diligent
treatment. It is in the zone of stasis that infection,
drying, and/or inadequate perfusion of the wound
will result in conversion of potentially salvageable
tissue to completely necrotic tissue and
enlargement of the zone of coagulation. Splints
or compression bandages, if applied too tightly, can
compromise this area.
3. Finally, the zone of hyperemia is a site of minimal
cell damage, and the tissue should recover within
several days with no lasting effects.

29. To calculate rapidly an estimate of the percentage of
total body surface area (TBSA) burned, Pulaski and
Tennison36 developed the Rule of Nines. The Rule
of Nines divides the body surface into areas of 9%,
or multiples of 9%, of the TBSA.
Formula:- 100 ( age + %TBSA )

31. 1. Infection:
Infection, in conjunction with organ system failure,
is a leading cause of mortality from burns. Some
virulent strains of Pseudomonas aeruginosa and
Staphylococcus
aureus are resistant to antibiotics and have been
responsible for epidemic infections in burn centers.
Microbial invasion from the burn wounds to other
healthy tissue can create sepsis. Systemic
antibiotics are used to treat both burn and general
system infections once they have been
documented. Most wounds are treated with topical
antibiotics.

32. 2. Pulmonary Complication:
Any patient who has been burned in a closed
space should be suspected of having an inhalation
injury.
Among patients with burns, the incidence of smoke
inhalation may be in excess of 33%,44 and this
rises to 66% in patients with facial burns.
Signs of an inhalation injury include facial burns,
singed nasal hairs, harsh cough, hoarseness,
abnormal breath sounds, respiratory distress, and
carbonaceous sputum and/or hypoxemia.

33. The primary complications associated with this
injury are carbon monoxide poisoning, tracheal
damage, upper airway obstruction, pulmonary
edema, and pneumonia. Lung damage from
inhaling noxious gases and smoke may be lethal.
To determine the extent of inhalation injury, several
diagnostic procedures can be performed. The
most helpful diagnostic procedure is bronchoscopy.
3. Metabolic Complication:
Thermal injury causes a great metabolic and catabolic
challenge to the body. The consequences of the
increased metabolic and catabolic activity following a
burn are a rapid decrease in body weight, negative
nitrogen balance, and a decrease in energy stores
that are vital to the healing process.

34. As a result of the increased metabolic activity, there
will be an increase of 1.8°F to 2.6°F (1°C to 2°C) in
core temperature that seems to be due to a
resetting of the hypothalamic temperature centers in
the brain.
4. Cardiovascular Complication:
Hemodynamic changes result from a shift in fluid to
the interstitium, which subsequently reduces the
plasma and intravascular fluid volume in a patient
with a burn. these fluid shifts, there will be a
tremendous initial decrease in cardiac output, which
may reach as low as 15% of normal within the first
hour after injury.

35. Hematological changes also occur after a severe burn
injury. These changes include alterations in platelet
concentration and function, clotting factors, and white
blood cell components; red blood cell dysfunction; and
decreases in hemoglobin and hematocrit.
5. Heterotopic Ossification:
Patients with burns greater than 20% TBSA are highly
susceptible to development of heterotopic ossification. It
is a bone tissue form outside the skeleton. The most
common areas affected are the elbows, followed by the
hips and shoulders; however, HO can appear anywhere
throughout the body.

36. Usually HO occurs in areas of full-thickness injury or
sites that remain unhealed for prolonged periods of
time. Symptoms appear late in a patient’s course of
recovery and include decreased ROM.
6. Neuropathy:
Peripheral neuropathy in patients with burns can
take two forms: polyneuropathy or local neuropathy.
The cause of polyneuropathy is unknown. As with
patients with HO, patients with peripheral
neuropathy generally have a large TBSA burn, and
the condition may be associated with sepsis.

37. Local neuropathies can be caused by a number of
factors, most of which center around burn treatment
issues, such as compression bandages applied too
tightly, poorly fitted splints, or prolonged and
inappropriate positioning.
7. Pathological Scars:
Burn scars occur in areas of deep partial-thickness
burn that are allowed to heal spontaneously and in
full-thickness burns that have been skin grafted, but
where graft coverage is incomplete. Scars become
pathological when they take on the form of
hypertrophy, contracture, or both. Later on it may
lead to contracture and joint deformity also.

39. Skin Grafting Procedure
The removal of skin to graft onto a burn wound is
done surgically under anesthesia. The skin used for
a graft usually is removed with a dermatome. A split
thickness skin graft contains epidermis and a
variable amount of dermis, as opposed to a full-
thickness skin graft, which consists of the full dermal
thickness. The site from which a skin graft is taken
is called a donor site. Common donor sites include
the thighs, buttocks, and back. These wounds heal
by re- epithelialization , like a partial-thickness burn,
and require appropriate care to prevent additional
dermal damage with resultanst scar formation.

41. The goals in the initial management of a patient with
a burn are to address critical life-threatening
problems and stabilize the patient through
procedures designed to:
(1) Establish and maintain an airway
(2) Prevent cyanosis, shock, and hemorrhage
(3) Establish baseline data on the patient, such as
extent and depth of burn injury
(4) Prevent or reduce fluid losses
(5) Clean the patient and wounds
(6) Examine injuries
(7) Prevent pulmonary and cardiac complications.

42. (1) Wound and soft tissue healing is enhanced.
(2) Risk of infection and complications is reduced.
(3) Risk of secondary impairments is reduced.
(4) Maximal range of motion is achieved.
(5) Pre-injury level of cardiovascular endurance is
restored.
(6) Good to normal strength is achieved.
(7) Independent ambulation is achieved.
(8) Independent function in ADL and IADL is increased.
(9) Scar formation is minimized.
(10) Patient, family, and caregivers’ understanding of
expectations and goals and outcomes is increased.
(11) Aerobic capacity is increased.
(12) Self-management of symptoms is improved.

43. 1. Examination
(1) The therapist needs to obtain an
accurate history from the patient and family
members about the condition.
(2) After the initial examination for depth of burn and
percent of TBSA involved, the physical therapist
then examines the patient to determine the
presence of impairments and activity limitations.
(3) The therapist must also anticipate the potential
for development of indirect impairments as the
burn wounds heal and mature.
(4) The therapist check the active or passive ROM
may be limited as a result of edema or pain.

44. (5) The therapist must examine and monitor patients
routinely for changes in skin integrity, ROM and
mobility.
(6) Respiratory Assessment
(7) Check Joint ROM
(8) Check muscle strength
2. Positioning and Splinting
A positioning program should begin on the day of
admission.
The goals of a positioning program are to:
(1) Minimize edema
(2) Prevent tissue destruction
(3) Maintain soft tissues in an elongated state
(4) preserve function.

46. Splinting can be viewed as an extension of a positioning
program. There are certain “anti-deformity” positions
in which patients generally are splinted; however,
positioning is individualized based on the location of the
burn and which movements are difficult for the patient
to achieve.
General indications for the use of splints include:
(1) Prevention of contractures,
(2) Maintenance of ROM achieved during an exercise session
or surgical release,
(3) Reduction of developing contractures,
(4) Protection of a joint or tendon, and
(5) To reduce the overall pain experience. Splint design
should be kept simple so that it is easy to apply, remove,
and clean.

48. 3. Active and Passive Exercise
Active exercise begins on the day of admission.
Any patient who is alert and able to follow
commands is encouraged to perform active
exercises of involved body parts frequently
throughout the day. A patient should perform active
exercise of all extremities and trunk, including
unburned areas. Active-assistive and passive
exercise should be initiated if a patient cannot fully
achieve active ROM. To keep the healed burned
area moist, it should be lubricated before exercise
is initiated.

49. 4. Resistive and Conditioning Exercise
As a patient continues to recover, the rehabilitation
program can be progressed to include strengthening
exercises. Patients with major burns may lose body
weight, and lean muscle mass can decrease rapidly.
Exercise may consist of isokinetic, isotonic, or other
resistive training devices. Resistive devices such as
free weights and pulleys can be used to prevent loss
of strength in areas not burned.
5. Breathing Exercise
1. Diaphramatic B.E.
2. Pursed lip B.E.

50. 1) Diaphragmatic (Abdominal/Belly) Breathing
i) This technique is best used when you’re feeling
rested and relaxed, and while sitting back or lying
down.
ii) Relax your shoulders.
iii) Place one hand on your chest and the other on your
belly.
iv) Inhale through your nose for about two seconds.
v) As you breathe in, your belly should move outward. vi)
Your belly should move more than your chest.
vii) As you breathe out slowly through pursed-lips, gently
press on your belly. This will push up on your
diaphragm to help get your air out.
viii) Repeat.

51. 2. Pursed lip breathing
i) Breathe in through your nose for about 2
seconds.
ii) Pucker your lips like you are getting ready to blow
out candles on a birthday cake.
iii) Breathe out very slowly through pursed-lips, two
to three times as long as you breathed in.
iv) Repeat.

52. 6. Ambulation
Ambulation activities should be initiated at the
earliest appropriate time. If the lower extremities
(LEs) are skin grafted, ambulation may be
discontinued until it is safe to resume. When
ambulation is initiated after a skin graft, the LEs
should be wrapped in elastic bandages in a figure-
of-eight pattern to support the new grafts and
promote venous return. If a patient cannot tolerate
the upright position because of orthostatic
intolerance or pain from the LEs being in a
dependent position, gradual increases in tilt-table
treatment time will assist in preparing the patient for
standing. Initially, a patient may require an assistive
device to ambulate. However, independent
ambulation without an assistive device should be
achieved as soon as possible.

53. 7. Scar Management
(pre & post surgical management)
1. Pressure Dressings
Elastic wraps can be used to provide vascular support of
skin grafts and donor sites, as well as to control edema
and scarring. Elastic wraps should be used until a
patient’s skin or scars can tolerate the shearing force of
pressure garment application, and open areas are
minimal. Elastic wraps are applied in a figure-of-eight
pattern on the LEs. A spiral wrap can be used on the
upper extremities (UEs) and a circular wrap on the trunk.
A self-adherent elastic bandage can be used for the hand
and toes. This bandage adheres only to itself and can be
used over dressings before the wounds have healed. It
helps to minimize edema and control scar formation.

54. 2. Massage
Massage is an intervention that clinically appears
useful to assist with ROM exercise by making the
tissue more pliable. Deep friction massage is
thought to loosen scar tissue by mobilizing
cutaneous tissue from underlying tissue and acting
to break up adhesions. When massage is used in
conjunction with ROM exercise, the immature scar
can be elongated more easily, and a developing
contracture can be corrected.
3. U.S. and I.R.R. ( pre operative management)
U.S. and I.R.R are used for healing and make the
scar soft.