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PART II
WOUND CLASIFICATIONS & MANAGEMENT
STRATEGIES

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BURNS
 Burn Injury
Burn: Transfer energy from a heat source to the body.

• Burn wound occur when there is contact between tissue and an energy

source and destruction of the integumentary system.

• The major cause of fires in the home and burn injury in the USA is

carelessness with cigarettes & hot water from water heater, and in

Pakistan the mostly burn injuries occur from misuse of gasoline heater,

cooking accident & suicidal attack.

 Types of Burn Injury

1. Thermal burns

2. Chemical burns

3. Electrical burns.

4. Inhalation ( smoke ) injury

5. Radiation burns.

6. Cold thermal injury

Thermal Burns

• Can come from explosions, flame,

hot liquids and contact with hot
materials like glass or coals.
• Most common (2/3 burns)

• Examples: flame, hot surface,

sunburn, hot water, hot metal etc.
Chemical Burns
• Caused by strongly acidic or alkali substances, and

require special care to stop injury to the skin.

• Common in industry

• Caused by strong acids or alkali

• Severity of the burn depends on amount of time

chemical was in contact with the skin

Electrical Burns
• Caused by electricity, as the name implies,

and need to be evaluated by a medical

professional even if they look fine, as they

can’t be accurately judged just by the external

appearance.

• Difficult to determine extent of damage since

most of the burn involves deeper layers

• Passage of electrical current may cause

cardiac arrest &/or cardiac dysrhythmias

Inhalation Burns

• Definition: burn of the respiratory

tract

• Caused by inhalation of toxic

products or smoke in an enclosed

space

• Inhalation injury results in direct

cellular damage
Ionizing Radiation Burn

• Often occurs when a patient

receives an overdose of

radiation
Cold thermal injury ( frostbite )
Frostbite – cold burns, damage to the skin due to
freezing.
Caused by freezing temperatures
It can happen when skin comes into direct contact
with something very cold or for very prolong time.
 Classification of burn injury

The treatment of burns is related to the severity of the injury .

Severity is determined by :

1- Depth of burn.

2- Extent of burn calculated in percent of total body surface area

(TBSA).

3- Location of burn.

4- Patient risk factors.

 Depth of burn
According to American Burn Association there are new
categorizing to the burn:
• Superficial burn (first degree burn)

• Superficial partial-thickness burn (second degree): moist,

blister, some blanching.
• Deep partial-thickness burn (second degree): dry, pale, waxy, no
blanching.
• Full thickness (third degree): white, cherry red, black.
 Superficial

•Very painful, dry, red burns which blanch with pressure.

•They usually take 3 to 7 days to heal without scarring.

•Also known as first-degree burns.

•The most common type of first-degree burn is sunburn.

•First-degree burns are limited to the epidermis, or upper layers of skin.

First – degree burns
• Very painful burns sensitive to temperature change and air exposure.

• More commonly referred to as second-degree burns.

• Typically, the blister and are moist, red, weeping burns which blanch with

pressure.

• Scarring is usually confined to changes in skin pigment.

Second – degree burns
• Blistering or easily unroofed burns which are wet or waxy dry, and are

painful to pressure.

• Their color may range from patchy, cheesy white to red, and they do

not blanch with pressure.

• It is sometimes difficult to differentiate these burns from full-thickness

Third – degree burns
• Burns which cause the skin to be waxy white to a charred black and

tend to be painless.

• Healing is very slow, if at all, and may require skin grafting.

Characteristics of burns of various depth
 Extent of body surface area injured

• Various methods are used to estimate the TBSA (total body

surface area ) affected by burns among them are the rule of nines

and the palm method

 Rule of nine
• An estimation of TBSA (total body surface area) involved in a

burn is simplified by using Rule of Nine

• It is a quick way to calculate the extent of burn

• The sytem assigns percentages in multiples of nine to major body

surfaces
 Palm method
• In patient with scattered burns, a method to estimate the percantage of burn

is the palm method

• Small or patchy burns can be approximated by using the surface area of the

patient's palm. The palm of the patient's hand, excluding the fingers, is

approximately 0.5 percent of total body surface area, and the entire palmar

surface including fingers is 1 percent in children and adults

• Use the person’s hand to measure the body surface that has been burned
 Local and systemic resposes to burns

• Burns that do not exceed 25% TBSA produce a primarily local

response
• More than 25% produce both a local and a systemic response
and considered major burn injury
• System response is due to the release of cytokines and other
mediators that signals immune system to work into the
systemic circulation
• The release of local mediators and changes in blood flow, tissue
edema and infection can cause progression of the burn injury
 Medical care
• Laboratory:

• CBC show eleveted hematocrit due to hemoconcentration and

later decreased hematocrit may mean vascular damage to

endothelium, white blood cell count may increase due to

inflammatory response to the trauma and wound infection.

• WBC count may increase due to inflammatory response to the

trauma and wound infection

 Medical care

• Radiography: chest x-ray used to identify complications that may

occur as a result of inhalation injury or with fluid shifting from
rapid replacement
• Arterial blood gases: used to identify hypoxia or acid base
imbalances, acidosis may be noted because of decreased renal
perfusion, hypercapnia and hypoxia may occur with carbon
monoxide poisining
 Medical Care

• Surgery: required for skin grafting, fasciotomy, debridement, or

repair of other injuries

• IV fluid: IV fluids play a crucial role in managing burn injuries

by supporting circulation, maintaining fluid and electrolyte

balance, providing nutritional support, delivering medications,

and facilitating ongoing monitoring and treatment.

BURN MANAGEMENT
 Wound Management
• Pain control through IV

• Cleanse and debride

• Apply topical antimicrobial agent

• Instruct patient/family on home care and expected outcomes

• Teach signs/symptoms of infection

 Topical Antimicrobial Agent

1. Silver sulfadiazine (Silvadene Cream 1%)

2. Mafenide Acetate (Sulfamylon)

3. Nanocrystalline silver (Acticoat)

4. Silver nitrate solution (0.5%)

 Infection Control

• Bathe or clean the whole body

• Debride burned areas

• Shave hair in burned areas

• Wash and cut hair if scalp is burned

Dressings

• Apply topical agent and

cover with dressing
• Elevate burned extremity

• Fit and apply appropriate

splints
Grafts

• Autograft (same individual)

– Split thickness

– Full thickness

– Muscle flaps

• Allograft (same species)

• Xenograft (different species)

Escharotomy
• Procedure used to reduce pressure in

burned area by splitting eschar (dead

tissue) open with surgical scalpel

• Restore blood flow

• Used when there is absence of pulse

or changes in breathing pattern,

compromised circulation

• usually performed where vital

structures are involved

Escharotomy for upper extremity and chest
Escharotomy for lower extremity
Escharotomy for upper extremity post electrical burn
SCAR MANAGMENT

• Early wound care

• Pressure garments
• Silicone therapy
• Massage therapy
• Topical treatment
• Surgical treatment
• Patient education
• Use silicone gel sheets under pressure
garment
• Wear pressure garments 23 hours/day for 1
year
 CRITERIA FOR TRANSFER TO BURN CENTER

• >10% TBSA in patients <10 • Significant chemical burns

years and >50 years of age • Inhalation injury

• >20% TBSA between 11-49 • Pre-existing illness that could

years of age complicate

• Face, eyes, ears, hands, feet,

genitalia, perineum, or joints
• Full-thickness >5% • Require special social,

• Electrical burns emotional, or long-term

rehabilitative support
 Physical Therapist’s Role
• Wound management (extent depends on facility)

• Prevent contractures

– Splinting

– Massage

– Positioning

– Pressure garments

• Maintain or increase ROM

• Maintain or increase muscular strength

• Maintain or increase cardiovascular endurance

• Return to function
Physiotherapy items in the after care of a burn patient

1. Exercising, training and ambulation

2. Mobilisations and oedema control

3. Positioning and splinting

4. Scar management
Physiotherapy items in the after care of a burn patient
1. Exercising, training (and ambulation)
-Mobility and ADL
-Muscle strength and cardiovascular condition!
(24 - 48h after trauma)
Physiotherapy items in the after care of a burn
patient
2. Mobilizations and edema control
-Prevention & treatment contractures
Physiotherapy items in the after care of a burn
patient
3. Positioning and splinting
-Prevention & treatment of contractures
-Static versus dynamic
Physiotherapy items in the after care of a burn
patient
4. Scar management - Pressure Therapy
-Prevention & treatment of hypertrophic scars
-enhance healing, and itch reduction
Physiotherapy items in the after care of a burn
patient
4. Scar management – Silicon
-Prevention & treatment of hypertrophic scars
 Thank you

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