Significant advances in management have resulted in an increase in survival after burn injury in regions of the world with access to current medical and surgical resources. As a consequence, burn survivors with access to up-to-date care and who tend to be young adults have long-term sequelae that impair function and limit return to preinjury function, including work and community reintegration. Up to 1 million burns require treatment annually in North America, and over 10 times as many burns occur worldwide. In low-income and middle-income countries, mortality is significantly greater than in high-income countries.The future of burn care will be challenged by the expense and complexity of treatment, a predicted shortage of qualified burn care providers, and an aging population.

1. BURNS
REHABILITATIO
N
DR JOE ANTONY
PHYSICAL MEDICINE AND REHABILITATION
KGMU, LUCKNOW
1

2. CONTENTS
• Introduction
• Etiology
• Acute burn management
• Immediate assessment and fluid
resuscitation
• Burn referral criteria
• Organisation of a burn centre
• Acute physiatry assessment
• Acute pain management
• Acute surgical procedures
• Inhalational injury
• Tachycardia after burns
• Nutrition
• Chronic burn problem areas
• Heterotopic ossification
• Peripheral neuropathies
• Scar-related complications
• Burns amputation and prosthetics
• Psychosocial adjustment
• Community reintegration
2

3. INTRODUCTION
• A BURN IS AN INJURY TO THE SKIN OR OTHER ORGANIC TISSUE PRIMARILY
CAUSED BY HEAT OR DUE TO RADIATION, RADIOACTIVITY, ELECTRICITY,
FRICTION OR CONTACT WITH CHEMICALS.1
• ACCORDING TO A STUDY2 CONDUCTED IN LUCKNOW FROM 2008 TO 2013
• 2225 DEATHS DUE TO BURNS IN 5YEARS IN LUCKNOW
• 87 % OF BURNS ARE OF FEMALES
• 50.4% BURNS OCCURRED IN NIGHT
• 82% OCCURRED AT HOME
• 60% BURNS DEATH WAS DUE TO FLAME BURNS
1.WHO Burn statistics
2. Kumar S, Ali W, Verma AK, Pandey A, Rathore S. Epidemiology and mortality of burns in the Lucknow Region, India--a 5 year study. Burns. 2013
Dec;39(8):1599-605
3

4. ETIOLOGY
BURNS
THERMAL
SCALD FLAME FLASH CONTACT
ELECTRIC CHEMICAL
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY
4
Other conditions managed in similar principles to burns- Stevens-
Johnson syndrome, toxic epidermal necrolysis (TEN), and necrotizing
fasciitis

5. IMMEDIATE ASSESSMENT AND CARE- AS PER ATLS
PROTOCOL
• Primary survey
• Airway assessment and protection (maintain cervical spine
stabilization when appropriate)- needle cricothyrotomy in
facial and suspected inhalational burns
• Breathing and ventilation assessment (maintain adequate
oxygenation)
• Circulation assessment (control hemorrhage and maintain
adequate end-organ perfusion) – circumferential burns to be
assessed and escharotomy to be done
• Disability assessment (perform basic neurologic evaluation)
• Exposure, with environmental control (undress patient and
search everywhere for possible injury, while preventing
hypothermia), thorough wash of entire patient absolutely
necessary.
Sabistons textbook of surgery- biological principles of modern surgery
5

6. FLUID RESUSCITATION
PARKLAND FORMULA CURRENT PRACTICE
• First 8 hours fluids given as per
parkland formula
• Then fluid titrated with
• Urine output- target of 30ml/hour or
1ml/hour
• With close monitoring to avoid
pulmonary fluid overload
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 6
Other methods- Brooks formula,Evans formula,
Monafa formula
Fluid of choice is Ringers lactate in first 24
hours

7. BURN CENTER REFERRAL CRITERIA BY AMERICAN BURNS ASSOCIATION
Second- and third-degree burns >10% body surface area (BSA) in patients <10
or >50 years old.
Second- and third-degree burns >20% BSA in other groups.
Second- and third-degree burns with serious threat of functional or cosmetic
impairment that involve the face. hands, feet, genitalia, perineum. and major
joints.
Third-degree burns >5% BSA in any age group.
Electrical burns, including lightening injury.
Chemical burns with serious threat of functional or cosmetic impairment.
Inhalation injury with burn injury.
Circumferential burns with burn injury.
Burn injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality.
Any burn patient with concomitant trauma (for example, fractures) in which the
burn injury poses the greatest risk of morbidity or mortality.
Hospitals without qualified personnel or equipment for the care of children
7

8. ORGANIZATION OF A BURN CARE CENTER
• Essence of successful burn care is the team.
• No individual Is capable of meeting the many acute and long-term needs of the burn
patient.
• Therefore, burn care is best delivered in a specialized burn center where experienced
• Physicians - Plastic surgeons, Critical care specialists, Physiatrists and
pediatric intensivist
• Nurses
• Physical and occupational therapists
• Nutritionists
• Psychologists
• Social workers
• Patients with burn injuries qualifying the referral criteria should be referred to
a burn center.
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 8

9. ACUTE PHYSIATRIC ASSESSMENT OF BURNED
INDIVIDUAL
•Mortality and
prognosis
•Long term predictor
•Mode of treatment
•Mortality and
prognosis
•Resuscitation
•Mode of treatment
•Mortality and prognosis
•Positioning
•Mode of treatment
•Orthotic prescription
•Mortality and
prognosis
•Resuscitation
•Mode of treatment
AREA LOCATION
DEPTH
INHALATIONAL
INJURY
BRADDOM TEXTBOOK OF PHYSICAL MEDICINE AND REHABILITATION 9

10. CALCULATION OF BURN SURFACE AREA
BORDER AND LUND
CHART RULE OF 9’S
PALM METHOD
• One palm area is
approximately 1
percentage
• Useful only in small
area burns.
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 10

11. ASSESMENT OF DEPTH OF BURNS
BURN DEGREE CAUSE SURFACE
APPEARANCE
COLOR PAIN LEVEL
First(superficial) Flash burn,
ultraviolet (sun
burn)
Dry, no blisters,
no or minimal
edema
Erythematous Painfull
Second(partial
thickness)
Contact,flash.Scal
d, flame ,chemical
and electrical
Moist blebs and
blisters
Mottled white to
pink, cherry red
Very painfull
Third(full
thickness)
Contact,flash.Scal
d, flame ,chemical
and electrical
Dry with leathery
eschar until
debridement,charr
ed vessels under
eschar
Mixed white,
waxy.
Pearly, dark,
khaki,
Mahogany,
charred
No pain. Hair
pullout easily
Fourth(involves
underlying
structure)
Prolonged
contact, flame and
electrical
Same with 3rd
degree, possible
with exposed
bone tendon and
muscle
Same as 3rd
degree
Same as third
degree
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY
11

12. 12

13. IMMEDIATE WOUND CARE
• Wounds are cleansed with soap and water.
• Loose tissue and blisters are debrided.
• Body and facial hair are shaved if involved in the area of a
burn.
• Daily wound care is performed on a shower table with soap
and water.
• If the burn wound is small, at the patient's bedside following
a shower
• Burn injury destroys the body's protective layer from the
environment
• Dressings are needed to protect the body from infection and
minimize evaporative heat loss from the body.
• The ideal dressing if it existed would be inexpensive, easy
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 13

14. Purpose Agents
Superficial burns Soothening of burns Aloe vera based
agents
Partial thickness Keep the wound
moist and provide
antimicrobial
protection.
Silver based
dressings
Full thickness Protect the eschar
from microbial
colonization
Silver based
dressings
After debriding the
eschar
Optimizing the
epithelisation
Greasy gauze (tulle
gras dressing) and
antibiotic ointment
Deep burns Protect upto excision Silver based
dressings
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY
14
Dressing which can be used for all purpose-
Human amniotic membrane and Wet collagen sheet

15. TOPICAL AGENTS
SILVER
SULFADIAZINE
• Broad-spectrum
antimicrobial coverage, with
excellent staphylococcus
and streptococcus
coverage.
• Incapable of eschar
penetration.(Useless in
infected burn)
• Pseudoeschar that requires
removal by cleansing during
daily wound care.( Which is
painful)
• ADR- leukopenia and
allergy
MAFENIDE
(SULFAMYLON)
• Broad antimicrobial
spectrum, including gram-
positive and gram-negative
organisms
• Eschar penetration present
• Have to apply twice daily
• Effective in suppurative
chondritis
• ADR-potent carbonic
anhydrase inhibitor and,
therefore, can cause a
metabolic acidosis
• Painful to apply
SILVER NITRATE
• Broad-spectrum coverage
against gram-positive and
gram-negative organisms
• Painless on administration
• Needs to be applied every 4
hours to keep the dressings
moist
• Drawbacks
• Stains everything black
• Hypo-osmolar-
hyponatremia and
hypochloremia
• Methemoglobinemia
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY
15

16. ACUTE PAIN MANAGEMENT
• Acute burn pain is typically significant and is
magnified by procedural pain associated with
dressing changes, mobility, stretching, and surgery.
• Opioids remain the mainstay of acute pain
management.
• Treatment requires frequent reassessment because
an individual’s pain may change drastically around
events, such as wound closure or participation in
therapies.
• Adjuncts to opioids, such as distraction, or
anxiolytics, may be used, particularly for the pediatric
burned individual.
Braddoms textbook of PMR 16

17. ACUTE SURGICAL PROCEDURES
ESCHAROTOMY
• Circumferential burns
• Wound edema, stiff eschar, and the fluids
required for resuscitation– precipitate
compartment syndrome of limbs
• Eschars on chest affecting respiration
• Wound left open and closed at later stage
• Splinted for 24hours in neutral position
• Then passive and active ROM exercises has to
be started
EARLY DEBRIDEMENT AND
AUTOLOGOUS SSG
Braddoms textbook of PMR
17
• Reduces the inflammatory stimulation from
burn eschar and other necrotic tissues and
limits the risk of infection.
• Recipient site- excision/debridement
• Donor site- unburnt skin
• Donor preparation-meshing
• Compressive dressing – avoid shearing force
at any cost
• Immobilize for 5 days
• Then passive as well as active exercises can
be started
Other surgeries patient might need are Tracheostomy and surgeries of
concomitant trauma

18. INHALATIONAL INJURY
• Burned individuals with inhalation injuries are at risk for developing pneumonia, adult
respiratory distress syndrome, and multisystem organ failure.
• Early tracheostomy in individuals likely to require prolonged intubation has not been
shown to change pulmonary outcomes, but it does offer advantages for oral hygiene and
management of facial burns.
• No evidence that inhalation injury predisposes burned individuals to pneumonia in the
rehabilitation setting
• Routine oxygen monitoring during therapies in not necessary if otherwise not indicated
Braddoms textbook of PMR 18

19. TACHYCARDIA AFTER BURNS
Systemic Inflamatory
Response
Stress Response Post Burn Hypermetabolic
State
Tachycardia Tachycardia Tachycardia
Tachypnea Increased endogenous
glucocorticoids production
Muscle wasting
Leukocytosis or
leukocytopenia
Increased sympathetic drive
leading to increased
catecholamine production
Increased oxygen
consumption
Hyperglycemia Increased lipolysis and fatty
acid metabolism
Abnormal sarcomere
functioning- uncoupling of
mitochondrial
High CRP Bone mineral loss
Thrombocytopenia Insulin resistance
Bleeding disorders Browning of white adipose
tissue
The role of the musculoskeletal system in post-burn hypermetabolism,Metabolism, 2019-08-01, Volume 97, Pages 81-86
19

20. POST BURN HYPERMETABOLIC STATE
• Results in prolonged catabolic effects on the body, including growth failure in
children that can last for at least a year following discharge from hospital.
• Can cause death due to hypertrophic cardiomyopathy.
• Management
• Nutritional- high-calorie diet
• Physical therapy- early mobilization
• Pharmacological
• Anabolic drugs- Oxandrolone- adults - 10 mg twice a day and 0.1 mg/kg for children.
• Beta blockers- Propranalol- Started at 10mg TDS and titrated to bring heart rate less than
120/min
• Human growth factor
The role of the musculoskeletal system in post-burn hypermetabolism,Metabolism, 2019-08-01, Volume 97, Pages 81-86 20

21. NUTRITION
• Enteral feeding should be instituted early after injury.
• Start with NG tube or OG tube if oral feeding is not possible
• This helps maintain gut immunity and motility while providing the necessary calories
and nutrients to counter the hypermetabolic response to burn injury.
• Total calorie requirement (by Curreri Formula)
• Adults- 25KCAL/KG BODY WT + 40KCAL / 1%TBSA
• Children- 60KCAL/KG BODY WT + 35KCAL / 1%TBSA
• Protein requirement- 2gm/kg body weight (in normal GFR)
• Vitamin A,C E, Zinc and selenium supplements are beneficial
• Iron supplement can cause higher concentrations of ferrous ions on wound bed and
can increase rates of infection
GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY 21
• Curreri formula overestimate
• Harris Benedict formula
underestimates
• Better practice to use average

22. HETEROTOPIC OSSIFICATION(HO)
• In individuals with burn injuries greater
than 30% TBSA, there is a risk of
development of heterotopic ossification .
• The most common site of HO in burned
individuals is the posterior elbow.
• More common in an affected limb and
can be associated with edema and
delayed wound closure over the elbow.
• Management is similar to HO in other
conditions
Braddoms textbook of PMR 22

23. PERIPHERAL NEUROPATHIES
• Approximately 10% of individuals with
major burns will develop Peripheral
neuropathies
• Direct thermal injury, Electrical current,
Compression, and metabolic
derangements
• Median sensory nerve neuropathy is
the most common neuropathy
described in post burns.
• Shows improvement in about 1 year
• Surgical management not indicated
Etiology Common pattern
seen
Deeper & large TBSA Axonal neuropathy
Electric burn Mononeuropathy
Long ICU stay Peripheral
polyneuropathy (
Critical illness
polyneuropathy)
Braddoms textbook of PMR 23
Changes in Elctrodiagnostic studies due to burns
Increased skin thickness
due to hypertrophic
scarring
Inversely related to
amplitude of responses
Upregulation of Ach
receptors distal to burn
area
Findings S/o acute
denervation or
membrane instability

24. Scar related
complications
Dermo
proliferative
diseases
Hypertrophied
scar
Keloid
Burn Scar Pruritis Scar contracture Marjolin’s ulcer
24

25. DERMO PROLIFERATIVE DISORDERS
HYPERTROPHIC SCAR
• Excessive scar tissue that does not extend
beyond the boundary of the original incision or
wound.
• Can be painful , itchy and self limiting by 1
year
• Aetiology- prolonged inflammatory phase of
wound healing and from unfavorable scar
siting (i.e. Across the lines of skin tension)
KELOID
• Excessive scar tissue that extends beyond the
boundaries of the original incision or wound.
• Aetiology- Unknown
Sabiston textbook of surgery and biological basis of modern surgery 25

26. MANAGEMENT OF HYPERTROPHIC SCAR AND
KELOID
PREVENTION
• Silicone sheeting
• Intralesional steroid
injections (
Triamcinalone)
• Topical imiquimod 5%
cream
• Fluorouracil cream
• Pulsed dye laser
FIRST LINE
TREATMENT
• Triple keloid therapy (
excision, steroid and
silicone sheeting)
• Pressure dressing (24-
20mmhg) worn for 6-24
months
• Intralesional inj
triamcinalone
• Silicone sheets
• Pulsed dye laser
SECOND LINE
TREATMENT
• Intralesional verapamil
with excison
• Flurouracil intralesional
injection
• Post surgical
intralesional interferon
alpha 2 b
• Post surgical radiation
therapy
Sabiston textbook of surgery and biological basis of modern surgery
26

27. BURN SCAR PRURITIS
• Onset of pruritis- >3months burn
• Suggested mechanism-
• Increased mast cell and histamine presence in the burn scar.
• Increased nerve endings and substance p
• Management-topical moisturizer should be applied to all burned areas several times per day
• Small areas
• Colloidal oatmeal, and topical creams (diphenhydramine, doxepin, and gabapentin)
• Large areas
• Oral diphenhydramine, selective antihistamines, doxepin, hydroxyzine, and gabapentin
• Non pharmacological- LASER, massage and TENS ( not as efficacious as pharmacological mx)
Braddoms textbook of PMR 27

28. SCAR CONTRACTURE
• Most common joints involved- shoulder, elbow, and knee
• Pathology- myofibroblasts and actin filaments seen in scar
• Prevention- splinting, positioning, and ROM exercises
• In acute setting- splints applied when patient is sleeping or sedated
• Once patient improves splints can be used whenever patient is not doing exercises
• Splints can be applied over fresh skin grafts also
Braddoms textbook of PMR 28

29. RECOMMENDED POSITIONS TO PREVENT
CONTRACTURE
Joint Position
Neck Extension, No Rotation
Shoulder Abduction (900),Ext rotation, Flexion (150)
Elbow and
Forearm
Extension and supination
Wrist Neutral / Extention
Hand Position of safety( intrinsic plus) ; Not
Functional position
Trunk Straight postural alignment
Hip No flex/ext, no rotation, Abduction 200
Knee Extension
Ankle and foot Neutral or slight DF, No inversion/eversion,
Toes neutral
Orthotics and prosthetics in rehabilitation,Kevin k Chui, 4 th edition
Green’s operative hand surgery, 8th edition
29

30. SPLINTS FOR FACE AND NECK BURNS
FACIAL PRESSURE GARMENT
WITH NECK CONFORMER SPLINT
Prevention of neck flexion
and facial scar hypertrophy
MICROSTOMIA PREVENTION
APPLIANCE
In addition to stretching
exercises
Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th
edition
30

31. SPLINTS UPPER LIMB BURNS
3 PIECE AEROPLANE
SPLINT
To prevent axillary
contracture
ELBOW GUTTER SPLINT
To prevent elbow
contractures
CUSTOM MADE
GLOVES
To use after SSG
Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th edition 31

32. SANDWICH SPLINT
Hand is “sandwiched” between
these two padded supports,
which are held in place with a
circumferential wrap
THERMOPLASTIC PAN
HAND SPLINT
CUSTOM MADE SILVER
IMPREGNATED GLOVE
Orthotics and prosthetics in rehabilitation, Kevin K Chui, 4th edition 32

33. SPLINTS FOR LOWER EXTREMITY BURNS
• Any foot drop splint with toe slings to prevent toe contracture
• Rest of the positions can be maintained without splints
33

34. ALGORITHM FOR
MANAGEMENT OF
BURNS
CONTRACTURE
Green’s operative hand surgery, 8th edition 34

35. ALGORITHAM FOR
MANAGEMENT OF
BURNS
CONTRACTURE
Green’s operative hand surgery, 8th edition 35

36. MARJOLINS ULCER
• Malignant transformation of long-
standing burns keloid.
• Referred to an oncosurgeon for
surgical and adjuvant management
36

37. BURNS AMPUTATION AND PROSTHETICS
• Electrical burn injuries – more likely lead to
amputation.
• Electrical current damages nerve tissue,
vascular tissue, and other deep structures
more than skin structures
• Current can cause destruction of cells,
coagulation of tissues, thrombosis of blood
vessels, neuropathies, and tissue necrosis.
Special considerations in prosthetic fitment
Delayed fitting- due to scars,
ulcers,multiple surgeries and
hypermetabolic state
More susceptible to bony spurs and HO
Scars and poor skin condition- Anti shear
liners and suspension materials will be
needed
Hypermetabolic state causes stump
atrophy- should wait till weight is stabilized
Contractures has to be accommodated
Orthotics and prosthetics in rehabilitation, Kevin k Chui, 4th edition 37

38. PSYCHOSOCIAL ADJUSTMENT
• Psychopathologies- depression, anxiety , PTSD,
Sexuality concerns, and Body image problems
• Treatment will include behavioural therapies,
pharmacological management, and peer group
counseling.
Braddoms textbook of PMR,6th edition
38
Risk factors for depression in burn survivors
Pre-burn affective disorders ( mood disorders)
Coping styles ( people who engage in both
avoidance and approach strategies)
Demographic characteristics such as female sex,
adolescents
Burn characteristics- head or neck burns
Disposition variables- longer hospital stays
Risk Factors for PTSD
Pre-burn characteristics
-Personality
-History of alcohol and substance abuse
disorders
-history of depression and other
affective disorders
Acute stress symptoms
Anxiety related to pain
Types and severity of baseline symptoms
of PTSD
Injury Characteristics
Female sex
Visibility of burn injury
Social support
Coping strategies

39. COMMUNITY REINTEGRATION
Risk Factors
Pre-burn Psychiatric history
Extremity Burns
Electrical etiology
Longer stay at hospital
Burn injury occurred at work
Barriers
Wound issues
Neurologic problems
Physical abilities and impaired mobility
Working conditions – temperature humidity
and safety
Psychosocial factors
-Drug and alcohol dependence
-insomnia
-Depression
-PTSD( nightmares and flashbacks)
-anxiety
Appearnce issues and concers over body
image
Braddoms textbook of PMR,6th edition 39

40. THANK YOU
REFERENCES
1. BRADDOMS TEXTBOOK OF PMR,6TH EDITION
2. SABISTON TEXTBOOK OF SURGERY AND BIOLOGICAL
BASIS OF MODERN SURGERY,21ST EDITION
3. GRABB AND SMITH TEXTBOOK OF PLASTIC SURGERY,7TH
EDITION
4. ORTHOTICS AND PROSTHETICS IN REHABILITATION,
KEVIN K CHUI, 4TH EDITION
5. THE ROLE OF THE MUSCULOSKELETAL SYSTEM IN POST-
BURN HYPERMETABOLISM, METABOLISM, 2019-08-01,
VOLUME 97, PAGES 81-86
6. GREEN’S OPERATIVE HAND SURGERY, 8TH EDITION
40