BRIGHAM AND WOMENS HOSPITAL

Department of Rehabilitation Services

Physical Therapy

Standard of Care: Inpatient Physical Therapy Management of Patients with Burns ICD 9 Codes:
942 Burn of trunk 943 Burn of upper limb, except wrist and hand 944 Burn of wrist(s) and hands(s) 945 Burn of lower limb(s) 946 Burn of multiple specified sites 94 Burns classified accordin! to extent of bod" surface in#ol#ed 949 Burn, unspecified 99$ %ffects of reduced temperature (i&e& frostbite) 695&$ %r"thema multiforme, 'oxic epidermal nectol"sis ('%() )thers ma" also appl" (e&!& #arious extensi#e wound dia!noses)

Case Type / Diagnosis:

'his standard of care applies to patients who are admitted to the Bri!ham and *omen+s ,ospital (B*,) for the mana!ement of their burns& - burn in.ur" can be sustained throu!h a #ariet" of sources includin! thermal/heat (flame, flash, scald, and steam), chemicals, radiation, sunli!ht, or electricit"& Burn0like in.uries can also occur due to reduced temperature 1frostbite 2 and as a reaction to medication 1toxic epidermal necrol"sis3'%(, also known as 4te#en05ohnson s"ndrome 2& 6n addition to in.ur" to the skin, patients can also sustain dama!e to their respirator" s"stem due to inhalation in.uries that re7uire intensi#e mana!ement& Burns can ran!e from a minor in.ur" co#erin! $8 of a patient+s bod" to a se#ere burn co#erin! 9980$998 of the total bod" surface area& :atients are also admitted to B*, for on!oin! reconstructi#e procedures in the months and "ears followin! a burn in.ur"; these can include contracture releases, !raftin! procedures, muscle flaps, and debridements& 'he burn ser#ice at B*, can also mana!e patients with extensi#e non0 healin! wounds 1i&e& such as those that occur from <raft #s& ,ost disease (<=,>) in#ol#in! the skin2; refer to the inte!ument standard of care for details&

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

Burns are classified y depth of in!ured tissue as detailed in the ta le elow:

"ppearance $irst Degree %Superficial& Second Degree %Superficial partial thic'ness& Second Degree %Deep Partial Thic'ness& Third Degree %$ull Thic'ness& :ink or red; Ca" be dr" or moist Bri!ht pink or red, wet, blisters "rea "ffected %pidermis %pidermis and portion of dermis Sensation 6ntact, painful 6ntact, painful and sensiti#e to chan!e in temperature and exposure to air or touch =ariable; ma" be intact with areas of diminished sensation :ainless; ma" be sensiti#e to deep pressure; anesthetic to temperature -bsent Blanching :resent :resent #ound Closure '"picall" heals within 305 da"s with no scarrin! ,eals b" re0epithelialiDation in $90 $4 da"s; t"picall" no scarrin! or !raftin! needed ,eals b" re0epithelialiDation in $40 2$ da"s or lon!er; scarrin! is likel" if burn in E 398 'B44kin !raft re7uired

Cottled, red and wax" white; wet *hite or tan; dr" and leather", non0pliable

%pidermis and deeper portion of dermis %ntire epidermis and dermis

>iminished -bsent

$ourth Degree

Ca" be charred or dr"

>eep soft tissue dama!e to fat, muscle, tendon, fascia, ner#e and/or bone

-bsent

%xcision of necrotic tissue and skin !raft re7uired, possible amputation in some cases

'he followin! criteria cate!oriDe patients that re7uire care at a specialiDed inpatient burn center $5F :atients who sustain partial thickness burns !reater than $98 of total bod" surface area ('B4-) re7uire more intensi#e medical monitorin! and inter#ention due to effects of si!nificant edema& 'he" are more likel" to ha#e mobilit" and mo#ement issues and will re7uire earl" :'/)' inter#ention& :atients who sustain burns of the neck and face are at hi!her risk for si!nificant edema that can cause respirator" distress& 'he" ma" need to be intubated for an extended period& :atients who sustain burns in#ol#in! the hands, feet, !enitalia, perineum, or ma.or .oints are at hi!her risk for decreased healin!, h"pertrophic scarrin! and contractures& 'hese parts of the bod" are crucial for normal function and re7uire specialiDed inter#ention for best reco#er"& :atients who sustain full0thickness (i&e& third de!ree) burns are at si!nificantl" hi!her risk for decreased healin!, h"pertrophic scarrin! and contractures& 'he" almost alwa"s need complex wound care and sur!ical inter#ention& 'hese patients also re7uire intensi#e nutritional support and hemod"namic monitorin!& 'he" re7uire more specialiDed, intensi#e :' and )' inter#ention for optimal pro!ress& :atients with electrical burns, includin! li!htnin! in.ur" are at risk for cardiac s"mptoms such as arrh"thmias due to the electrical current& 6n addition, the path of an electrical current can cause deeper, less ob#ious in.uries that can affect #ital or!ans and deep muscles& Gre7uent sur!ical debridement as well as hemod"namic monitorin! is essential&

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

:atients who sustain chemical burns re7uire more intensi#e mana!ement& 'he chemical can be absorbed into the skin and cause dama!e for an extended period of time& 'hese patients often re7uire specialiDed cleansin! procedures and close monitorin!& :atients with inhalation in.uries often re7uire #entilation and intensi#e pulmonar" h"!iene& :atients who sustain a burn and also ha#e pre0existin! medical disorders re7uire more intensi#e mana!ement and fre7uentl" ha#e slower pro!ress& 'heir medical status can complicate mana!ement and prolon! reco#er"& :atients with burns and concomitant trauma (such as fractures) in which the burn poses the !reatest risk of morbidit" or mortalit" re7uire hi!her intensit" of care& :atients with burn in.uries who will re7uire special social, emotional, or lon!0 term rehabilitati#e inter#ention&$5

Phases of Burn CareF Burn mana!ement can be di#ided into three phases& -n interdisciplinar" approach includin! :h"sical and )ccupational 'herapist in#ol#ement is essential in all three phases 9F o (mergent or )esuscitati*e Phase Medical "ssessment -ssess for the presence of an inhalation in.ur" and secure airwa" -ssess siDe of burn ('B4-) usin! the +)ule of ,ines: ,ead H 98 'runk H 368 Ipper extremit" H 98 each :erineum H $8 Jower extremit" H $ 8 each -ssess and classif" of burn depth Be!in fluid resuscitation Caintain bod" temperature (pre#ent h"pothermia) -chie#e cardiopulmonar" stabilit" %stablish ade7uate tissue perfusion and monitor for compartment s"ndrome& %scharotomies ma" be necessar" to pre#ent tissue, muscle and ner#e death >ebridement of necrotic, dirt", or infected wounds Physical Therapy Management 6nter#ention ma" focus on positionin! until patient is stabiliDed& o "cute Phase: (after emer!ent phase and until wounds are closed) Medical Management )n!oin! wound debridement, assessment for e#olution of wound depth 4kin !raftin! (when indicated3use of auto!raft, allo!raft, cultured skin) 6nfection control and ri!orous wound care (utritional support sufficient to meet wound0healin! needs Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

Physical Therapy Management ?omprehensi#e inter#ention addressin! positionin!, stretchin!, mobilit", on!oin! skin assessment and scar mana!ement, education, balance, endurance, respirator" conditionin! o )eha ilitati*e Phase Medical .oalsF (follows acute phase until scar maturation) 4ur!ical release of contractures (utritional support Beconstructi#e or plastic sur!er" to maximiDe function and cosmesis Physical therapy Management 6ntensi#e rehabilitation pro!ram3scar mana!ement, ran!e of motion (B)C) and stretchin! with techni7ues, mobilit" trainin! as needed, education reF self0 mana!ement

Indications for Treatment:

:atients with burn in.uries in#ol#in! superficial, partial, or full thickness skin with potential extension into fascia, muscle, or bone, and at risk for contracture and scar formation will re7uire inter#ention& 'hese burns can result in impairments such as loss of .oint B)C, peri0articular or intra0articular .oint chan!es, sensor" loss, edema, pain, impaired #entilation/aerobic capacit", impaired acti#it" tolerance, impaired balance, coordination, and stren!th& 'he" can cause functional deficits such as impaired mobilit", difficult" performin! acti#ities of dail" li#in! (->J+s) and instrumental acti#ities of dail" li#in! (6->J+s)& :atients also lack knowled!e about wound healin!, self0care, and copin!/ad.ustment strate!ies followin! burn in.ur"&

Contraindications / Precautions for Treatment:

?ontraindicationsF o :resence of femoral 6= access #enous access will make repetiti#e hip B)C contraindicated as it can cause introduction of bacteria into access arterial access precludes an" hip B)C as it increases the risk of arterial bleedin! from site :recautionsF o Instable heart rate, blood pressure, respirator" status and fe#ers of more than $92 de!rees can pre#ent :h"sical 'herap" inter#ention& Both tach"cardia and fe#ers can be a result of the patient+s h"permetabolic state and do not alwa"s preclude inter#ention& :atients with burns ha#e a harder time maintainin! a stable bod" temperature due to the presence of open wounds $9 o B)C precautions and restrictions must be known prior to startin! each treatment session, due to one or more of the followin! reasonsF ?ultured 4kin (?%- or Kcultured epidermal auto!raftsL)3 B)C to area of ?%- is contra0indicated for the first $90$4 da"s and prior to initial takedown to a#oid !raft disruption Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

-utolo!ous skin !rafts3>ifferentiate between full and partial thickness !rafts& 5oints crossed b" !rafts are immobiliDed for 50M da"s Glaps3total immobiliDation to promote #iabilit"; await ph"sician clearance prior to resumin! B)C 6nfection controlF -ll care!i#ers should practice uni#ersal precautions& -dditional measures are taken for burn patients& >ue to the fact that their burns cause a lar!e number of open wounds, the" are at hi!her risk for infection& Gull burn precautionsF -ll staff must wear a !own, !lo#es, sur!ical mask, and hat when workin! with a patient who does not ha#e their wounds full" dressed :artial Burn :recautionsF <lo#es and a !own are re7uired for an" patient 6t is necessar" to practice excellent hand h"!iene and cleanin! of all e7uipment used durin! treatment

(*aluation:
Medical /istoryF :ertinent past/on!oin! medical issues that ma" impact response to treatment /istory of Present Illness//ospital CourseF Cechanism of in.ur" (ature of burn (thermal, chemical, electrical, aller!ic reaction) %xtent of Burn ('B4-, location, depth) Burns that cross .oints %#idence of inhalation in.ur" (sin!ed e"ebrows, nasal hairs, soot in sputum) Bele#ant medications (e&!& pressors, fluid resuscitation, pain medications, sedation) Social /istoryF 4pecifics about home en#ironment, architectural barriers Gamil" support, normal role in famil" Baseline le#el of function -dapti#e e7uipment use :s"cho/social issues, substance abuse issues Medications: :ressors Gluid resuscitation :ain medications (Gentan"l, Corphine, >ilautid, (eurontin, (4-6>4) 4edation (=ersed, Gentan"l) 'opicals for care of wounds (4ee -ppendix)

(0amination:
6nte!ument Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

Bisk for scarrin! is related to depth of burn and rate of healin!& -lso certain skin t"pes are more prone to scarrin!, such as skin of darker pi!ment29 >etermine if use of cultured skin cells (?%-) is planned and refer to special precautions and considerations that appl"$M -ssessment of scarrin!$6

Cusculo0skeletal B)C is measured usin! !oniometric measurements 4tren!th is measured usin! manual muscle test (CC') if patient is able to participate in exam& 6f not, assess functional and spontaneous motion b" obser#ation and reassess more specificall" later in course :osture/ali!nment can be assessed b" obser#ation when patient is able to sit or stand& -s"mmetries can indicate scarrin! Gunctional mobilit" (assisti#e de#ices as needed): appropriate assisti#e de#ices pre0ambulation e7uipment such as tilt table lift de#ices as needed (euro0muscular :ain: (if able to communicate b" pain scale; if not assess b" monitorin! heart rate, blood pressure, respiration rate, facial !rimacin!, !esturin!)& ?ommunicate with nursin! reF need for additional pain medication, instruct patient in deep breathin! and relaxation for pain control& :lan treatment sessions to coincide with either pre0medication or the abilit" to recei#e bolus pain medication& %n!a!e the patient and the staff in coordinatin! the optimal time for inter#ention with their pain control re!ime& 6n the acute phase of treatment, patients are often recei#in! a lar!e number of narcotic medications which can be sedatin! and keep patient obtunded for an extended period which impacts components of :h"sical 'herap" treatment& 6nter#ention at this time is often more passi#e (i&e& passi#e B)C, positionin!)& 'he medication, Gentan"l, is fre7uentl" used durin! dressin! chan!es and therap" inter#entions due to its short half0life& Jater in the course, patients are chan!ed to oral narcotics and (4-6>4& 4ensation: -ssess patients abilit" to percei#e li!ht touch as burns heal and as patient is able to communicate M ?ardio0:ulmonar" Bespirator" status includin! presence of inhalation in.ur" and the le#el of #entilator" support re7uired, presence of rhonchi or rales Cental 4tatus and ?o!nition Je#el of consciousness )rientation 4afet" .ud!ment Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

 -bilit" to follow direction :s"cholo!ical ?onsiderations ?opin! with altered bod" ima!e and appearance Jearnin! st"le :atientAs !oals for reco#er" 6mpact of ps"chiatric disorders on participation and reco#er"22

"ssessment:
Pro lem 1ist (6mpairments and d"sfunctions) 6mpaired ran!e of motion/risk for contractures %dema Bisk for h"pertrophic scarrin! 6mpaired mobilit" 6mpaired respirator" status 6mpaired endurance 6mpaired inte!ument 6mpaired balance (eed for optimal positionin! Nnowled!e deficit reF aspects of burn rehab and self0care :ain Prognosis: )#er the last thirt" "ears, medical technolo!" and inter#entions ha#e impro#ed, increasin! the sur#i#al rate of patients with lar!e percenta!e burns& Between $995 and 2995, 94&48 of patients admitted to a burn center sur#i#ed 6, $ & 'his bein! said, pro!nosis can be hi!hl" #ariable& 4ome considerations that impact pro!nosis are depth of burn, surface area in#ol#ed, t"pe of burn (chemical and electrical ma" increase len!th of sta"), presence of an inhalation in.ur", si!nificant ps"chiatric or substance abuse issues and co0morbidities such as histor" of smokin!, diabetes& KBisk factors most stron!l" associated with death are increasin! total bod" surface area ('B4-), inhalation in.uries and increasin! a!eL&2$ :eople with first de!ree (superficial partial thickness such as sunburn) are rarel" admitted to the hospital& 'hose with second de!ree burns (partial thickness) ma" be admitted for se#eral da"s for local wound care& 'hose with deeper burns (full thickness) ma" re7uire sur!ical !raftin! which increased len!th of sta" and risk of lon!0term disabilit"& -n inhalation in.ur" ma" re7uire an extended period of intubation& -ttainin! a hi!h 7ualit" of life is a challen!e for burn sur#i#ors& )nce the" are medicall" stable and healed, the !oal of re!ainin! their pre#ious roles and acti#ities takes intensi#e work, moti#ation and !uidance of healthcare professionals& Jittle research has been done on 7ualit" of life after a burn in.ur", but a stud" done in 2995 showed that Kparticipants in the present stud" had little or no difficult" resumin! functional mobilit" and self0care acti#ities of dail" li#in!L 22& 'his stud" su!!ests that patients with lar!er Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

burns can Oachie#e functional independence and reasonable 7ualit" of life in the lon! termO 22& Suggested .oalsF 'imeline is hi!hl" #ariable dependin! on pro!nosis noted abo#e& <oals should be ob.ecti#e and measurable& $& B)C *(J 2& optimal positionin! 3& appropriate splints/positionin! de#ices, pressure !arments/pads 4& minimiDe h"pertrophic scarrin! 5& stren!th at least 3/5 in affected areas, 305/5 in unburned areas 6& optimal posture (upri!ht, s"mmetrical) M& independent mobilit" with appropriate de#ice & tolerates full :' treatment with ade7uate #entilation and ox"!en saturation 9& demonstrates knowled!e of healin! process, acti#it" pro!ression, independent exercise/stretchin! pro!ram

Treatment Planning / Inter*entions

%stablished :athwa" %stablished :rotocol PPP Qes, see attached& PPP Qes, see attached& PRP (o PRP (o

Inter*entions most commonly used for this case type/diagnosis2

'his section is intended to capture the most commonl" used inter#entions for this case t"pe/dia!nosis& 6t is not intended to be either inclusi#e or exclusi#e of appropriate inter#entions&

B)C, stretchin! $& -B)C attempted, specific measurements 2& stretchin! :ositionin!F $& appropriate splints, bi#al#e casts (prefabricated and custom)$2 2& other de#ices (slin!s, foam wed!es, pillows, rolls) 3& bed options can assist with positionin! and inter#ention (hi!h/low, re#erse trendelenbur!, knee and head ele#ation) 4& can use bedside tables and slin!s to position I%As in abduction as axillae are at especiall" hi!h risk for contractures 4car mana!ement is mana!ed in se#eral wa"sF $& ?ompression a& -ce wraps or elastic tubular banda!e (e&!& 'ubi!ripS) use can be initiated immediatel" for edema control pre and post !raftin! b& :ressure !arments (e&!& 5obstS) and silicone !el sheetin! use can be started three weeks after !raftin! procedure and when open areas are less than nickel0siDed 2& 4car massa!e can be initiated when areas are full" healed and skin is no lon!er KtranslucentL 3& :ositionin!/sustained stretch can be initiated at an" time

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

Cobilit" pro!ression usin! appropriate >C%, lifts %ndurance acti#ities Bespirator" conditionin! 4tructured schedule

$re3uency 4 DurationF 'hese patients are t"picall" seen 50M times weekl"& >uration is dependent on extent and se#erit" of burns and need for intensi#e acute care inter#ention& Jen!th of sta" can #ar" from 203 da"s for a localiDed burn (such as partial thickness burn to hand or foot) to man" weeks to months for a hi!h percenta!e, deep burn that re7uires multiple sur!ical procedures and prolon!ed intubation& Patient / family education: Burn patient and famil" education book is a#ailable from the 'rauma (urse 4pecialist >iscussion with patient and famil" reF :h"sical 'herap" in#ol#ement with patient and expected pro!ression >iscussion with patient and famil" reF optimiDin! patient+s independent mobilit" and self0care and pro#idin! the appropriate le#el of assistance to the patient 6nstruction of patient and famil" in appropriate exercises and acti#ities with written exercise pro!ram and exercise/acti#it" lo! >iscussion of lon!er term issues common followin! a burn in.uries $& phases of burn healin!, estimated time line, risk of scarrin! 2& wa"s to minimiDe scarrin! and contracture 3& proper mana!ement of pressure !arments, >C% 4& proper skin care and protection )ecommendations and referrals to other pro*iders: )ccupational 'herap" 4peech 'herap" 4ocial *ork/?are ?oordination :s"chiatr" )rthopedic 'echnician 'ranslators )utside resources for the measurement and fit of compression !arments (e&!& ?ompass ,ealthcare 6$M/56606MM2) )utside Besources such as support !roups (e&!& the :hoenix 4ociet")& =isits b" known burn sur#i#ors that can talk with patient and famil" can be arran!ed b" the social worker

)e5e*aluation
4tandard 'ime Grame0$9 da"s or less if appropriate )ther :ossible 'ri!!ers0 - si!nificant chan!e in si!ns and s"mptoms, new sur!ical procedure, si!nificant pro!ress in :' inter#ention re7uirin! re0assessment Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

Discharge Planning
Commonly e0pected outcomes at dischargeF Beturn to independent function Caximal ran!e of motion Cinimal h"pertrophic scarrin! :atient is independent with exercise pro!ram and skin mana!ement Transfer of Care (if applicable) Behabilitation facilit" ,ome with ser#ices ,ome with famil" assistance ,ome with independent pro!ram Ipon dischar!e, most patients are seen re!ularl" at the Burn ?linic which is a wound care clinic staffed b" nurses& 'he" can facilitate referral to other ser#ices as needed& 'hese patients are sometimes seen in the B*, outpatient rehabilitation clinic b" :h"sical 'herap" and ,and 'herap"

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$9

"uthors: -lisa <& Ginkel :' )ctober 299

)e*iewed y: Barbara )daka :' Celanie :arker :' Cerideth >onlan :'

)($()(,C(S
$& -merican Burn -ssociation, Burn 6ncidence Gact 4heet& -#ailable atF http://www2ameri urn2org/pu /BurnIncidence$actSheet2htm & -ccessed Gebruar" 23, 2996& 2& Bertek :harmaceuticals 6nc& Biobrane temporar" wound dressin!& Gaxed )ctober $$, 2996& 3& Burn (ursin! >ept& Biobrane dressin!& Brigham and Womens Hospital Burn Trauma Unit Nursing Protocol. 4& ?hristiansen ?, ed& Ways of Living: elf!"are trategies for pecial Needs. 2nd ed& Bethesda, CdF -merican )ccupational 'herap" -ssociation, 6nc&; 2999& 5& <al#eston 4hriners Burn ,ospital, 'he Ini#ersit" of 'exas Cedical Branch Blocker Burn Init& 'otal Burn ?are pa!e& -#ailable atF httpF//www&totalburncare&com/orientationPburnPshock&htm& -ccessed Carch $5, 2996& 6& ,erndon >(, ed& Total Burn "are. JondonF *& B& 4aunders ?ompan" Jtd&; $996& M& 'rombl" ?-, ed& #ccupational Therapy for Physical $ysfunction. 4th ed& :hiladelphia, :aF Jippincott *illiams T *ilkins; $99M& & Bichard BJ and 4tale", C&, Burn "are and %eha&ilitation: Principles and Practice, :hiladelphia, :-F G& -& >a#is ?ompan"; $994F chapter 22/622049& 9&'rombl", ?-, Badomski C=, eds& #ccupational Therapy for Physical $ysfunction. 5th ed& :hiladephia, :-F Jippincott *illiams T *ikins; 2992; $9250$939& $9& 4imons C&, Nin! 4&, %d!ar >&)ccupational therap" and ph"siotherap" for the patient with burnsF principles and mana!ement !uidelines'( )ournal of Burn "are * %eha&ilitation, 4ep/)ct 2993; 24 (5)F 323035& $$& 4mith N&, )wens N& :h"sical and )ccupational therap" burn unit protocol3benefits and uses& )ournal of Burn "are and %eha&iitation, (o#/>ec $9 5; 6 (6)F5960 & $2& Calick C&, ?arr 5-, Canual on Cana!ement of the Burn :atient, Carmar#ille Behabilitation ?enter %ducational Besource >i#ision, :ittsbur!h, :-, ?hapter 3, $9 2& $3& *ard B4& :ressure therap" for the control of h"pertrophic scar formation after burn in.ur"& )ournal of Burn "are * %eha&ilitation& Ca"/5une $99$; $2 (3)F 25M062& $4& Cac(eil 4& :ro!ress and opportunities for tissue0en!ineered skin& Nature& Gebruar" 22, 299M; 445 (M$39)F M40 9& $5& -merican Burn -ssociation, <uidelines for the )peration of Burn ?enters& -#ailable atF http://www2ameri urn2org/pu /BurnIncidence$actSheet2htm & -ccessed 5anuar" M, 299 & $6& Bar"Da, C5 and Bar"Da <-& 'he =ancou#er scar scaleF an administration tool and its interrater reliabilit"& )ournal of Burn "are and %eha&ilitation& 4ep/)ct $995; $5(5)F 5350 & $M& (ursin! 6nstructions on %picel& 2992& Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$$

$ & -merican Burn -ssociation, Burn 6ncidence and 'reatment in the I4F 299M Gact 4heet& -#ailable at httpF//www&ameriburn&or!/resourcesPfactsheet&php& -ccessed 5une $3, 299 & $9& Bichard BJ and 4tale", C&, Burn "are and %eha&ilitation: Principles and Practice, :hiladelphia, :-F G& -& >a#is ?ompan"; $994F chapter 2/25& 29& Bichard BJ and 4tale", C&, Burn "are and %eha&ilitation: Principles and Practice, :hiladelphia, :-F G& -& >a#is ?ompan"; $994F chapter $4/3 50M& 2$& %delman >-,*hite C', '"burski 5<, *ilson BG& Gactors -ffectin! :ro!nosis of 6nhalation 6n.ur"& )ournal of Burn "are * %esearch& (o#ember/>ecember 2996; 2M (6)F 4 0 53& 22& >ruer" C, Brown 'im Ja ,, Culler, C& Jon!term Gunctional )utcomes and Uualit" of Jife Gollowin! 4e#ere Burn 6n.ur"& Burns. 4eptember 2995; 3$ (6)F69205&

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$2

-::%(>6R '):6?-J BIB( ',%B-:Q (from 4tefan 4tro.was, B*, (urse %ducator, M?>) -<%(' >%4?B6:'6)( -?'6)(4 ->=-('-<%4 >64->=-('-<%4 -cticoat 4il#er impre!nated -ntimicrobial ?an remain in place up to (eeds to be applied wet !auDe 3 da"s so decreases dressin! time Bacitracin Betadine Biobrane Bactericidal ointment 6odine complex, solution or ointment Bio0s"nthetic wound co#erin!, !ood for partial thickness burns, clean wound beds 'emporar" wound co#erin! 4terile <ram V/0 effecti#e -ntimicrobial for !ram V/0 ?ontrols water loss T minimiDes bacteria !rowth Beduces heat and water loss, controls pain ?arrier for ointments/creams& <entle debridement when remo#ed (onpainful and eas" to appl" %ffecti#e a!ainst or!anisms not controlled b" 4il#adene >ecreases pain, remains in place until re0 epithelialiDation occurs& -llows for mo#ement %as" to appl", prepares wounds for !raftin! -llows for specific placement

?)(46>%B-'6)(4 0deep dressin! moist with sterile water 0monitor pt& 'emperature due to wet dressin!s Ca" be nephrotoxic Conitor serum BI( and ?re Ca" cause metabolic Ca" form crust around acidosis, can be painful to would which needs to be appl" remo#ed *ound surface must be (eed to obser#e for debrided and clean before si!ns/s"mptoms of application infection and adherence (ot alwa"s a#ailable Ca" stick to wounds causin! pain (eed to obser#e for infection

?ada#er 4kin Gine Cesh <auDe

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$3

-<%(' <entam"cin Jotrimin (eom"cin :i! skin

>%4?B6:'6)( -ntibiotic cream -ntifun!al cream -ntibiotic solution 'emporar" wound co#erin! -ntimicrobial cream 58 sil#er salt antimicrobial solution *ater based bacteriostatic crem

-?'6)( -ntibiotic, effecti#e a!ainst man" or!anisms 6nterferes with fun!al >(*ide spectrum, used after !raftin! Beduces heat T water loss, reduces pain, prepares wound for !raftin! Binds to or!anism+s cell membranes and interferes with >(-ntimicrobial

->=-('-<%4 %ffecti#e a!ainst pseudomonas ?an be used with other topicals ?ombats most or!anisms, eas" to appl" Beadil" a#ailable, easil" applied *ide spectrum for !ram V/0& >oes not dela" eschar separation %as" application, dela"s !ranulation h"pertroph" %ffecti#e a!ainst pseudomonas, penetrates thick eschar

>64->=-('-<%4 Ca" be nephrotoxic Ca" cause burnin! and redness ?an cause shi#erin! Ca" cause sensiti#it" reaction

?)(46>%B-'6)(4 Conitor serum BI( and ?re -ffected area must be full" co#ered Conitor ?re, ?heck pt& Gor temperature chan!es )bser#e for infection

4il#adene (4il#er sulfadiaDine 4il#er nitrate

4hallow penetration, depresses !ranuloc"te formation 4hallow penetration, stains and stin!s& Ca" cause h"ponatremia, h"pochloremia, h"pocalcemia Ca" cause metabolic acidosis and rash, can be painful, dela"s eschar separation

?heck for sulfa aller!ies, Neep dressin!s wet, check dail" electrol"tes Conitor blood !ases and electrol"tes

4ulfam"lon Cafenide -cetate

%ffecti#e a!ainst !ram V/0 or!anisms

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$4

-<%(' 'ransc"te >erma!raft0'? 'riple antibiotic ointment =itamin -T> Reroform bismuth tribromphenate

>%4?B6:'6)( Bi0la"er, temporar" skin substitute Cixture of neom"cin, pol"mixin, bacitracin :etroleum based ointment Qellow substance on =aseline impre!nated !auDe

-?'6)( ?ontains acti#e human wound healin! factors Bactericidal for !ram V/0 or!anisms for partial thickness burns Gat soluble #itamins assist with healin! >ebrides and protects wounds, donor sites and !rafts

->=-('-<%4 ?ontrols pain, retains heat and moisture, stimulates wound re0 epitheliaDation (o pain on applications

>64->=-('-<%4 *ound must be debrided prior to placement& ,as no antibacterial effects ?annot be used for full thickness burns

?)(46>%B-'6)(4 Conitor for adhesion and infection Conitor for infection

CoisturiDed newl" healed (o antibacterial effects tissue ?onforms to wound, nontoxic ?an stick to wounds, no antibacterial ?areful remo#al from new !rafts essential

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 299 'he Bri!ham and *omenAs ,ospital, 6nc&, >epartment of Behabilitation 4er#ices& -ll ri!hts reser#ed

$5