minimizing the trauma of burn injuries: rehab and beyond

Minimizing the Trauma of Burn Injuries:

Rehab and Beyond

MaryAlice McCubbins, CPNP, TNS, LtCol,USAF(ret)

Trauma Nurse Practitioner

Washington University, St. Louis Children’s Hospital

We cannot define the limitationof human resilience

We cannot define the limitationof human resilience

Objectives

• Identify unique challenges of burn trauma• Define the relationship between acute intervention

and scar formation/management• Explain the importance of early therapy to enhance

mobility• Describe the psycho-social aspects of burn injury

and rehabilitation• Discuss pain as a contributor of long term recovery

Published 2012 for data2000-2009

Outline

• Burn Challenges• Scar Management• Mobility• Why psychosocial care is important• Future scar revision options

Phases of recovery

• Admission• Critical care• In-hospital recuperation• Rehabilitation

– Contracture prevention first phase

• Re-integration

Phases of recovery

• Admission• Critical care• In-hospital recuperation• Rehabilitation

– Contracture prevention first phase

• Re-integration

Face Burns

Face Burns2 weeks post burn 6 weeks post burn

Bilateral Lower extremities. Grafts. Splinting, decreased mobility, scarring, emotional factors of abuse

Young, deep, future hair growth, progressive intervention with age, parent guilt, adjustment, etc

Determining factor for success

• Extent of burn• Intelligence• Immediate response• Socioeconomic status• Family and social support• Willingness for social risk taking

Poor prognostics

• Social shyness• Lack of family cohesion• High family conflict• Acceptance within family

– Dependence– Helplessness– Waiting for others to provided

Scar Management

• Sensitive and fragile skin• Break down, infections• Splints• Contractures• Grafts• garments

Extreme scar contraction, keloid scar formation. Benign fibrous growth characterized by overgrowth of scar tissue beyond the borders of original wound

Hypertrophic scarring of lower extremities showing exaggerated proliferative response within the boundaries of original wound. History suggest good compliance from family

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Original OR date. first view 5 days post graft

5 days post STSG and porcine

~10 day post graft with porcine loss

Second OR trip (5-22) 5 graft post porcine (5 days)

7 days 2nd graft 21 days for first

21 days

Scald burn 3 month post injury

Management• Surgical therapies

– Radiation, cryosurgery, lasers

• Medical Management• Oral therapies

– Methotrexate (MTX)– Tamoxifen citrate– Topical immunomodulators

• Intralesional– Corticosteroids, 5-FU, interferons

Future revision

• Z-plasty– Contracture release

• Skin flaps, rotational flaps• Pedicle flaps• Tissue expanders

9yo male working with grandfather. Used a flame throwing instrument to clear ants from a hole. Exploded back onto child who suffered nearly 45% burns to upper body. Longterm treatment and management. Multiple scar revisions, non-compliance, transition to adulthood and cares.

Silicone and hydrogels

• Mepiform, TopiGel• Elasto gel, Avogel• Occlusive coverage long periods of time

– At least 12hrs/day– 4-6 months duration

Pressure garments

• First line therapy for hypertrophic scars• Used to produce thinning and pliability • 20-30 mmHg above cap pressure without

reducing peripheral circulation• 18-24 hrs/day• 4-6month minimum, upwards of 2 years

Infant total body suit

Upper extremity sleeve w/zipper no lines from seams after 15minutes Torso garment

Mobility

• Physical limitations• Contractures• Amputations• Compliance with routine therapies• garments

Physical Therapy as a huge role in burn recovery. Additional involvement for family is key

No extension tightness despite not having burns to posterior popliteal fossa

Psychosocial recovery

• Death/disfigurement• Pain and anxiety• Cultural variance• Post traumatic stress• Hopes and dreams

Pain • Initial injury itself

– Developmental stages– Parental response

• Dressing change– Excruciating – OR vs bedside

• Therapies• Emotional/psychologic

Pain• Initial injury itself

– Developmental stages– Parental response

• Dressing change– Excruciating – OR vs bedside

• Therapies• Emotional/psychologic

Minimizers

• Hypnosis• Music therapy• Time out• Electronic devises

– iPads– TV– headphones

Pediatric medical traumatic stress

“A set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures and invasive or frightening treatment experiences.”

www.healthcaretoolbox.orgRzucidlo, Campbell, JTN, 2009

Post traumatic Stress

• Most undiagnosed and untreated• Unable to maintain pre-injury coping levels

– Severity of trauma not predictive of PTSD

• Risk factors

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Pediatric Acute Wounds Service (PAWS)

• Stand alone unit– Independent staff, In and out-patient ,

multidisciplinary

• 2 sedation rooms– Ketamine– Nitrous

• Decreasing length of stay• Increasing parent participation, comfort

Reintegration

• Interaction with peers– Social rejection

• Community– School– Sports– Mall

• Rehearsals

ResourcesPain, Pain, Go Awayhttp://painsourcebook.ca/docs/pps80.htmlInformation on helping children with pain from a leading pediatric pain research group.

Phoenix Society for Burn Survivors – Resources for Children and Familieshttp://www.phoenix-society.org/resources/familyresourcesProvides information, support, and resources to children, adolescents, and families who have been impactedby a burn injury.

Angel Faceshttp://www.angelfacesretreat.org/af/about-us.aspProvides healing retreats and ongoing support for adolescent girls with burn/trauma injuries to achieve their optimum potential and develop meaningful relationships for themselves, their families and their communities

American Burn Association (www.ameriburn.org)

Shriners Hospitalshttp://www.shrinershospitalsforchildren.org/

We cannot define the limitationof human resilience

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Day one OR débridement, day 2 post burn

Grafting completed 2wks post burn after failure to progress. This is POD5

1 month later

Donor site