Presentation

1. BURN AND THEIR
COMPLICATIONS
Presented by :
GURWINDER KAUR.

2. BURN
• The burn is defined as the physical injury caused by heat,
cold, electricity, radiation or caustic chemicals resulting in
loss of skin with impairment of skin functions.

5. EPIDEMIOLOGY
• The most common cause of injury in children 1-5yrs of age is from
scalds from hot liquids.
• The primary cause of burn injury in adolescents and adults is
accidents with hot liquids
• Most of deaths associated with home or structure fires are due to
inhalation injury.
• The burn centre is staffed by specialists from multiple disciplines -
physician,nurses,physical therapist, dietitians, psychiatrist,
psychologist, social workers,child life therapist, pharmacist,
vocational rehabilitation specialist.

8. SKIN ANATOMY
• The skin is largest organ of the body, comprising approximately 15% of total
body weight.
• Anatomically the skin consist of two distinct layers:
Epidermis or outer layer exposed to environment.It is composed
of stratum corneum,stratum granulosum,stratum spinosum,stratum basale layer.
Dermis( subdivided into papillary and reticular dermis)
• Interface between epidermis and dermis is termed as rete peg region.

11. CLASSIFICATION OF BURN INJURY
• EPIDERMAL BURN:
1. It causes cell damage only to epidermis.
2. The classic sunburn is the best e.g of this burn.
3. The erythema is the result of epidermal damage and dermal irritation ,but no
injury to dermal tissue.
4. Blisters are absent but slight odema may be apparent.
5. In this type of burn the skin will heal by itself , no scar tissue will firm.
6. Following epidermal damage , the injured epidermal layers will heal off or
desquamate in 3-4 days.

13. • SUPERFICIAL PARTIAL- THICKNESS BURN:
• In this damage occurs through epidermis and into papillary layer of dermis.
• The common sign of this burn is presence of intact blisters over the injured
area.
• Healing will occur more rapidly if damaged skin is removed and appropriate
topical agent and wound dressing applied.
• The wound will blanch.
• Edema is moderate, the burn is extremely painful and fever may be present if
area is infected.
• This burn will heal without surgical intervention by means of epithelial cell
production and migration from wound periphery and skin appendages.
• Complete healing occurs within 7-10 days.

15. •
• DEEP PARTIAL THICKNESS BURN:
1. Destruction of epidermis and papillary dermis with damage into reticular dermal
layer.
2. It appears as mixed red or waxy white color.
3. Marked odema is a Hallmark sign of this burn.
4. Affected area has diminished sensation to light touch or sharp /dull
discrimination.
5. Healing occurs by scar formation.
6. Demarcation becomes evident after several days as the dead tissu begins to
slough.
7. It will heal in 3-5 weeks if it doesn’t become infected.
8. Development of hypertrophic and keloid scars is a frequent consequence of this
burn.

17. • FULL – THICKNESS BURN:
1. In this all of epidermal and dermal layers are destroyed completely.
2. This burn is characterised by patchment – like eschar covering the
area.
3. Hair follicles and nerve endings are completely destroyed.
4. The eschar doesn’t have elastic quality of normal skin, edema that
forms in Ana area of circumferential burn can cause compression of
the underlying vasculature.
5. If this compression is not received it may lead to eventual occulusion
with possible necrosis of tissue distal to site of injury.
6. In this escharotomy i.e lateral midline incision of eschar is done
7. In this burn skin grafting will be necessary.

19. • SUBDERMAL BURN:
• Involves complete destruction of all tissue from the epidermis down
to and through the subcutaneous tissue.
• Muscle and bone are subjected to necrosis when burned.
• It occurs due to prolonged contact with heat or as a result of contact
with electricity.
• Extensive surgical and therapuetic management is necessary to
return a patient to some degree of function.

21. PATHOLOGICAL CHANGES
• There are three stages:
1. Stage of shock:this last for 2-3 days, longer in elderly The main changes are-
reduced reduced plasma volume, increased proportion of RBC to plasma in
blood vessels resulting in increased blood viscosity and slowing of circulation,
decreased cardiac output, increased heart rate..
2. Stage of eschar removal:the burned skin becomes crustled and leathery.It
separates in 3-4 weeks. Following deeper burn , tissues are exposed which
require skin grafting.
3. Stage of healing and reconstruction: After superficial burns the skin heals and
can be normal . Following burns that have destroyed the epidermis there is scar
tissue. Over a number of weeks this tissue can become contracted and bound
down or may be excessive in growth as in keloid scaring. there is extensive
destruction the patient undergoes grafting and reconstructivery surgery which
may take months.

22. CLINICAL FEATURES
• At the site of burn:-redness, blisters, blackened skin( later leathery in
nature), weeping of plasma( straw colored).
• During shock(2-3 days after burn):-restlessness,coldness, sweating, thirst,
reduce blood pressure, cyanosis.
• Later(about 4 weeks):-scar tissue forms, pain due to traction on sensory
nerve endings, limitation of joint movement, loss of function.

23. COMPLICATIONS OF BURN:-
1. Congestive cardiac failure.
2. Left ventricular failure.
3. Cardiac arrhythmias.
4. Pneumonia.
5. Septicaemia.
6. Renal and liver failure.
7. Neuropathies.
8. Joint effusion and periarticular swelling.
9. Calcification of periarticular tissues.
10. Inhalation injuries from:- hot steam, noxious chemicals , carbon monoxide ,
overheated air.
11. Infection:- of the wound site, of urinary tract.

24. DETERMINATION OF EXTENT OF BURN
To measure the surface area of burn the Rule of nine is used.A formula assist the surgeon in
knowing the quantity of fluid to transfuse but this is only a guide and the patient must be
monitored at regular intervals to see whether he shows any signs of shock. These are:- cold
clammy skin, restlessness, vomiting, rapid pulse and lowered blood pressure , reduced urine
output.
• Blood may be needed if there is a 10% or larger full thickness skin loss.
EXTENT:- The greater the extent the poorer the prognosis the formula is:-
Percentage chance of survival=100-(age+ % of body arae), e.g.100-(60 years+
30% area)=10. Therefore ,10% chance of survival.
100-(20 years+ 30% area)= 50. Therefore , 50% chance of survival.
• This formula does not apply to children aged under 10 years
• The rule of nine divides the body surface into 11 areas, each constituting9% of total the
perineum is counted as 1%.
• It is interesting to note that if both legs are burnt 36% of body surface is affected.therefore
50 year old patient with extensive burns has (50+36=86)1100-86=14% Chan ce of recovery.

26. MANAGEMENT Of BURNS
• MEDICAL MANAGEMENT:-
(a)Initial management:-establish and maintain an airway.
(Goals) prevent cyanosis, shock and haemorrhage.
- establish baseline data on patient such as extent and depth of burn injury
- prevent fluid losses
- clean the patient and wounds.
- examine injuries
- prevent pulmonary and cardiac complications.
nitially a patient must be transported from site of injury to a treatment facility.emergency medical
personnel may use the rule of nine to estimate percent of burn injury and all burned clothing is
removed as well as initial administration of fluid through intravenous lines, wound clrnsing is
performed.
(b)Wound care:- After dressing is removed , the wound should be inspected carefully.It is carried
out by Clea technique and sterile instruments.If sharp debridement is performed , sloughed
epidermis and loose eschar are removed and pocket of pus drained.
-open technique :- consist of applying topical cream without dressing.
- Closed technique:- consist of applying dressing over topical agent.

28. • SURGICAL MANAGEMENT:-
-Primary excision: It is surgical removal of eschar. The excision generally includes
removal of peripheral layers of eschar until vascular,viable tissue is exposed.
-Skin grafting:- Skin grafts are taken from the unburned areas of the patient. The
thighs are the best donor areas whereas abdominal wall and the scalp are difficult
sites from which to remove skin. The thinner the skin the better it takes but it will
contract more than a thick graft which is disadvantage.
-Skin culture:- Patient own skin can now be cultured in laboratories so that sheets
of skin can be produced over a three or fourth week period.
• BURN DRESSING :- Usually a wound needs protection, this is achieved by
using dressing consisting of a non stick layer against the burn , with an
absorbable material outside this. The dressing is held firmly with a bandage .
Exidate appearing through the dressing is called strike through and necessitates
redressing to prevent infection. The dressing is changed every 48 hrs.Silver
Sulphadiazine is used as an antibacterial crem.

30. CORRECTION OF SCAR CONTRACTURE:-- In this case if physical
intervebs are unsuccessful then surgery is required. Many surgical
treatment options are available to eliminate scar CONTRACTURE, like
skin grafts and Z-plasties. The Zplasty serves to lengthen the scar by
interposing normal tissue in line of scar. Skin grafts are used afer
surgical release for more severe contracture.

32. • PHYSIOTHERAPY MANAGEMENT(Goals)
1. Wound and soft tissue healing is enhanced.
2. Risk of infection and complications is reduced.
3. Risk of secondary impairment is reduced.
4. Maximum ROM is achieved.
5. Preinjury level of cardiovascular endurance is restored.
6. Good to normal strength is achieved.
7. Independent ambulation is achieved.
8. Scar formation is minimized.
9. Aerobic capacity is increased .
10. Self management of symptoms is improved.

33. • Positioning and splinting
• Goals of positioning:-= minimize odema.
= prevent tissue destruction.
. =preserve function.
The burned areas should be positioned in an elongated state or neutral position of
function.
• Indications for splinting:-
• Prevention of CONTRACTURE
• Maintenance of ROM.
• Reduction of developing CONTRACTURE.
• Protection of joint, tendon.
• Reduce overall pain experience.
Splints are worn at night. Most splints used for burn injuries are static . This type of splints has no
moveable parts, and maintain a position or immobilises an area following skin graft.Dynamic
splints are also used in case of patients with burn injury . These splints have moveable parts that
allow movement

34. • THERAPUETIC EXERCISES
(a)Active and passive exercises:- Active exercises begin on the day of admission.
A patient should perform active exercises of all extremities and trunk, including
unburned area. Active-asdistive and passive exercises should be initiated if a
patient can’t fully achieved active ROM.If burn wounds are well healed, heting
madalities ( paraffin wax, ultrasound) may be used to increase the pliability of
tissue before exercise therapy.
(b)Resistive and conditioning exercise:- As the patient continues to recover , he
rehab program can be progressed to include strengthening exercises i.e isokinetic
and other Resistive training devices.Initially he vitals of the patient has to be
monitored by the therapist. Cycling, treadmill, walking, stair climbing should be
encouraged.
(c) Ambulation:- When the ambulation is initiated after a skin graft, the lower
extremity should be wrapped in elastic bandages in afigure of eight pattern to
support the new grafts and promote venous return.

35. (d) Scar management:- Pressure has been used successfully to hasten scar
maturation and minimize hypertrophic scar formation. Pressure may exert control
over hypertrophic scarring by- thinking dermis, decreasing blood flow to area,
reorganising collagen,decrease tissue water content.
The earlier the scar tissue is exposed to pressure, the better the result.
(e)Pressure dressings :-
• Elastic wraps can be used to provide vascular support of skin graft and donor
sites,as well as to control odema,scarring.Elastic wraps are applied in figure of
eight pattern on the L.E, spiral wraps on U.E and circular wrap on trunk. These
are worn 23 hrs a day for as long as 12-18 months to assist with scar
remodelling and should be washed daily to prevent perspiration.
(f)Silicone gel:- This is effective in managing hypertrophic scar. Sheets of silicone
polymer gel may be applied directly over an actively maturing scar.But the
complication with this gel is the local rash.

37. (g) Massage:-
-Deep friction massage is taught to loosen scar tissue by mobilising cutaneous
tissue and acting to break up adhesions
.When massage is used in conjunction with ROM exercises, the immature scar can
be elongted more easily and developing CONTRACTURE so can be corrected.
(h)Follow-Up care:-
1. Well before patients are discharged from the hospital, the therapist should
provide information regarding home exercise program, a splinting and
positioning program and a skin care.
2. The HEP should continue to stress frequent ROM exercises in combination with
massaging area involving burn injury.
3. Proper skin care requires specifying the type of soap and cream a patient is to
use.
4. Patient is cautioned to avoid sun
5. Itching may intensify when wounds have healed. A patient should be instructed
to Pat, rather than scratch, the irritated areas.