Burn is coagulative necrosis of the skin’s tissues, usually caused by excessive heat Excess heat causes rapid protein denaturation and cell damage Wet heat (scald) travels more rapidly into tissue than dry heat (flame) A surface temperature of over 60˚C produces immediate cell death as well as vessel thrombosis The dead skin tissue is known as Eschar

1. BURNSA Physiotherapeutic Approach
Dr.Nidhi Ahya (Asst Prof)
Cardiovascular and Respiratory PT
DVVPF College of Physiotherapy,
Ahmednagar 414111

2. Objectives
• Normal Skin- Structure & Function
• Burns
• Epidemiology
• Pathophysiology of Burn Injury
• Assessment of Burn Injury
• Management of Burns
 Medical
Physiotherapy

3. NORMAL SKIN
• Skin is a bilayer organ
• Layers:Epidermis
Dermis

4. Epidermis
Dermis

5. BURN
Burn is coagulative necrosis of the skin’s
tissues, usually caused by excessive heat

6. Heat injury
• Excess heat causes rapid protein denaturation and
cell damage
• Wet heat (scald) travels more rapidly into tissue
than dry heat (flame)
• A surface temperature of over 60˚C produces
immediate cell death as well as vessel thrombosis
• The dead skin tissue is known as Eschar

7. Inflammatory Mediator Injury (1 to 3 day)
Inflammatory response initiated by the heat injury
leads to activation of proteases, neutrophil
induced tissue hypoxia and is responsible for -
• Early tissue damage,
• Increased capillary permeability and
• Responsible for wound conversion inflammation
becomes excessive by deactivating growth factors

8. Ischemia induced injury
• Instant surface vascular thrombosis occurs
along with cell death
• Injured capillaries can continue to thrombose
due to initial heat
• Subsequent mediator injury to endothelial cells
• Further ischemia and further tissue necrosis.

9. Classification of Burn Wound
• Earlier classified based on Severity :
First degree
Second degree
Third degree
• Currently based on Depth:
Superficial
Superficial Partial Thickness
Deep partial thickness
Full thickness
Subdermal

10. Complications of
Burns

11. • Infection
• Pulmonary complications
• Metabolic complications
• Cardiac function & circulatory
complications
• Heterotopic Ossification
• Neuropathy
• Pathological Scars

12. ABC’S IN THE BURN PATIENT

13. • Stop the Burning Process
• Treat Carbon Monoxide Toxicity
immediately
• Manage airway injury from Smoke and
Heat
• Manage Pulmonary Problems from Smoke
• Correct Chest wall Restriction
• Recognize the Burn Induced Plasma Shift
• Begin Fluid Resuscitation for Major Burns
• Correct Blood Flow Restriction from Burn
Tissue Compression

14. Assessment
• Look for other traumatic injuries (falls,
explosions, blunt trauma).
• Estimate percent (%) of body surface
burned in order to estimate isotonic fluid
requirements "Rule of Nine".
• Use burn resuscitation formula

15. Estimating the size of the Burn as a %
of the (TBS)

16. Wallace’s Rule of nines -not accurate

17. Emergent Phase
(Resuscitative Phase)
• Lasts from onset to 5 or more days but
usually lasts 24-48 hours
• Begins with fluid loss and edema
formation and continues until fluid
motorization and diuresis begins
• Greatest initial threat is hypovolemic
shock

18. Management
• Anaesthetic consultation
• High flow oxygen
• Tracheobronchial toiletting [ bronchoscopy]
• Physiotherapy
• Close monitoring [preferably ICU ]
• Ventilatory support
• Hemodynamic support, when required

19. Initial Assessment & Management
• Stridor
• Retraction or
• Respiratory Distress present or
• Deep Burns: Face, Neck

20. MAINTAINING HEMODYNAMIC
STABILITY
Early fluid resuscitation is required for
burns exceeding 20% of body
surface.

21. Fluid Resuscitation Protocol
Establish and maintain adequate circulation
↓
Maintain : Blood Pressure>90 systolic
Urine output 0.5-1.0ml/kg/hr
Pulse <130
Temperature >37°C
Modify protocol in the presence of massive
burns, inhalation injury, shock, and in elderly

22. Initial Wound Management
• Assure adequate ventilation and perfusion
• Remove heat source and any constricting items
• Maintain body temperature
• Cool water for small second degree burns only
• Assess size and depth “Rule of Nine”
• Tetanus Prophylaxis

23. • Escharotomy
• Full thickness deep dermal burns which
are nearly circumferential on the limbs,
neck, thorax will act like tourniquets with
the development of edema.
Escharotomies are longitudinal or
crisscross incisions through such deep
burns. This can be done without analgesia
and on the ward as the affected skin is
usually insensate and does not bleed
much.

24. Skin Grafting
• Skin used for a graft removed with a
dermatome
• 2 types:
Split Skin Grafting ( SSG )
Full Thickness Skin Graft
• SSG : Epidermis + Sup. Dermis
• FTSG : Full dermal thickness

25. • Sheet Graft:
Graft applied to the recipient bed without
alteration after harvesting from donor site
Face, neck and hands are covered with
this for cosmesis
• Mesh Graft:
Processing the sheet graft – making tiny
parallel incisions in linear fashion
Graft expands & covers large areas

27. Rehabilitation Phase
• Defined as beginning when the patient’s burn wound is
covered with skin or healed and patient is capable of
assuming some self-care activity.
• Can occur as early as 2 weeks to as long as 2-3 months
after the burn injury
• Goals for this time is to assist patient in resuming
functional role in society & accomplish functional and
cosmetic reconstruction.
• Scars may form & contractures.
• Mature healing is reached in 6 months to 2 years
• Avoid direct sunlight for 1 year on burn
• new skin is sensitive to trauma

28. Physical Rehabilitation
• Prevention of scar contracture
• Preservation of normal ROM
• Prevention of hypertrophic scar
• Minimizing cosmetic deformity
• Muscular strengthening
• Cardiovascular endurance
• Return to function
• Performing ADL’s

29. Goals (APTA, 1999)
• Enhance wound & soft tissue healing
• Reduce risk of infection & complications
• Reduce risk of secondary impairments
• Attaining full ROM
• Restoring cardiovascular endurance
• Good to normal strength
• Independent ambulation
• Independent ADL’s
• Minimal scar formation
• Caregiver understanding towards the goals
• Increasing aerobic capacity
• Improving self management of symptoms

30. • Scar contractures can be prevented by:
Positioning
Splinting
Exercise
• Following wound closure:
Massage
Compression therapy

31. Positioning
• Goals:
Minimizes edema
Prevent tissue destruction
Maintain soft tissue length

32. Splinting
• Extension of positioning program
• Anti-deformity positions
• Indications:
Prevent contractures
ROM
Correction of contractures
Protection of a jt or tendon
• Worn in night
• Mostly static splinting in burns

33. Exercises
• Active & passive exercises
• Grafting done – delay exs for 3 – 5 days
• After clearance – active 1st & then passive
• Active assisted
• Resistive & conditioning exs

34. Early Active ROM and Mobility
• ROM- First Active then pasiive overpressure
• Repetitions- 5 to 7 at one time, gradually
increase as per patient tolerance
• PNF- Hold Relax and Contract Relax
techniques can be helpful in maintaining as
well for increasing ROM
• Bed mobility and Transfers should be
encouranged as early as possible.
• Independent Ambulation should be
encouraged depending on individual patient’s
condition

35. Scar Management
• Pressure hastens scar maturation &
minimizes hypertrophic scar
• Mech:
Thinning the dermis
Altering biochemical structure of scar
Decreasing blood flow to area
Reorganizing collagen bundles
Decreasing tissue water content

38. Massage
• Deep friction massage – loosen scar
• Skin pliability & texture improves
• Edges or seams of grafts benefit
• 5 -10 min , 3 – 6 times daily

39. Summary
• Normal Skin- Structure & Function
• Burns
• Pathophysiology of Burn Injury
• Assessment of Burn Injury
• Management of Burns

40. QUESTIONS
1. WRITE THE PATHOPHYSIOLOGY OF
BURNS.5MARKS
2. WRITE THE MANEGMENT OF BURNS.

41. Thank you