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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD



   Once the patient's survival has been assured, function and cosmesis become the biggest factors for subsequent quality of life.  However, if consideration of these goals is not begun in the initial management, the ultimate outcome will be less than desirable despite successful resuscitation and burn wound closure.  Rehabilitation of the burn patient should begin during the acute resuscitation period and continue until the patient's scars mature and occupation resumes.  Rehabilitation plans are carried out principally by the Occupational and Physical Therapists.

   There are principles which must be applied soon after burn to ensure the earliest and optimal rehabilitation of the patient.  Rehabilitative care should commence on the day of the injury and the goals of burn patients' rehabilitation are to limit or prevent loss of motion, prevent or minimize anatomic deformities, prevent loss of lean muscle mass, and return the patient to work or normal activity as soon, and as completely, as possible.

   Much consideration must be given to a program of rehabilitation for the burn patient, and every patient needs an individually tailored plan of care.  There are 4 principles for the rehabilitation of the burn patient:

  The program should start early, preferably the day of injury.
  A program of care should avoid prolonged periods of immobility, and any body part that is able to move freely should be moved frequently.
  Range of motion exercises should be started the day of injury.
  There should be a planned program of daily activity and rehabilitative care.  The plan should be reviewed daily as rehabilitative needs change.

   On admission, plans should consider the prevention of skin and muscle contracture and anatomic deformity.  The institution of such plans should be individually tailored.  Early standing and ambulation and participation in daily living activities is important and all extremities should be actively moved frequently throughout the day.  Proper positioning is essential for the prevention of contractures.  It has not been uncommon in the past for burned patients to develop contractures of both burned and non-burned joints.  The incidence of contractures in healing patients has been significantly reduced through the use of frequent active or appropriate passive motion exercises and proper positioning.  Burned patients and their families should be taught the importance of early active exercise and proper positioning during rest and sleep.

   Standing and ambulation should be instituted as soon as possible.  Such exercise can reduce the loss of muscle mass and help stimulate the appetite.  Frequent standing and ambulation will also reduce the risks of pressure necrosis.  Additionally, requiring the patient to get out of bed and sit in a chair for some part of the day will increase respiratory tidal volumes and the patient's sense of normalcy.

   The joints of all extremities should be frequently moved throughout the 24 hour day, unless there is a strong contraindication (e.g. fracture or open joints).  Patients with open wounds from escharotomies or fasciotomies can usually move these parts actively, especially if therapy is instituted early.  When early active motion is insufficient or impossible, passive motion is indicated.  However, passive motion to an edematous or stiff hand is a delicate procedure, best left to the physical or occupational therapist.

   Active exercise to the patient with burns should begin early each day.  A schedule of planned activities should be implemented with frequent exercise periods of short duration (3-5 minutes) each hour.  If the patient is able to tolerate such a schedule without undue fatigue for 2-3 days, the periods may be slowly increased in duration and decreased in frequency.  Long periods of exercise will increase muscle tone and prevent loss of lean mass.

   Range of motion can be encouraged by allowing the patient to accomplish all possible activities of daily living himself.  Brushing his hair or teeth, feeding himself, ambulating to the bathroom or hydrotherapy room, and assisting with wound care can facilitate active range of motion of the hands, legs and arms and give the patient some measure of control over environment.  Any apparatus necessary to make this easier, such as feeding blocks or plate rails should be made available.  The use of these tools will allow the patient a sense of accomplishment, improve his self-esteem, and  further encourage his participation by decreasing his dependence.

   However, even in the most cooperative of patients, programs of active and/or passive range of motion may be insufficient to prevent the development of deformities and contractures.  In these situations, proper positioning becomes necessary and important.

   While active range of motion is the most important factor in preventing loss of motion, muscle mass, and anatomic deformities; adjunctive measures may also be necessary.  Proper positioning is critical for the maintenance of joint motion.  The benefits gained from frequent exercise can be lost after 8 hours sleep in a 'comfortable' position.

   Most patients will try to assume comfortable and undesirable positions while at rest.  Patients will request, find, or create a pillow for their heads.  This position is contraindicated with burn injuries to the lower face and neck.  A flexion contracture of the neck is often accompanied by deformities of the lower face.  This can be minimized with the neck placed in neutral extension during rest and sleep periods.

   Sleeping persons generally assume undesirable positions of their joints.  In healthy, mobile persons this is usually not a problem as most will frequently change positions during sleep.  However, the discomfort associated with recovery from burns will usually prevent the patient from moving much.  It may be difficult for the patient to voluntarily maintain an appropriate position, thereby necessitating the use of splints.

   The patient's shoulders should be abducted to 80-90, with the elbow fully extended, and the wrist extended to 30-40, thus preventing undesirable position of the small joints in the hand and wrist.  With the wrist extended 30-40, the metacarpophalangeal joint (MCP) will assume a flexed position from the pull of intrinsic muscles.  In this position, the interphalangeal joints (IP) will be in mid-flexion or placed in extension (position of rest) and the thumb will be pulled into a mid-abducted position.

   Patients resting or sleeping in the supine position will usually maintain the hip and knees in an extended position.  However, this may not always be the situation, especially if there are burn injuries to the anterior trunk and thighs, or the posterior thighs and calves.  Burns to the lower anterior trunk and thighs tend to pull the hips into flexion, with the knees being intrinsically pulled into flexion as well.  If there are concomitant burns to the posterior thighs and legs, knee flexion will be augmented by the contraction of the burned tissue.

   Proper positioning will also be modulated by peripheral edema.  Any edematous part should be elevated above the level of the heart, to allow for lymphatic drainage.  Arms may need to be elevated to encourage venous return.  Elastic wraps may be required when the patient is out of bed.

   Principles and consideration in using splints are the same used in proper positioning.  Splints are indicated for the prevention of further damage to exposed structures, nerves, comatose patients, edematous areas, and for the stabilization of minor fractures.

   Splints are made from a number of materials, probably most common are the lower temperature, thermoplastic materials.  These can be custom fit and molded directly on the patient for optimal fit.  Splints should be applied after appropriate dressings have been placed and secured with elastic wraps.

   Management of concomitant fracture, if the surrounding area is burned, presents special problems.  Simple fractures can usually be maintained immobile within splints.  However, more complicated fractures require better stabilization than afforded by splints.  Routine cost materials, such as plaster and fiberglass, interfere with proper burn wound management, therefore the most common treatment is external fixation.  The pin insertion sites required can be treated with the same topical antimicrobial agents as are being applied to the burn wounds.  External fixation allows the wound to be directly visualized and skin grafting can be performed around the pin sites.

   Hands and wrists are the areas which require splinting early in the post-burn course.  Flexion is considered the position of comfort for the wrist, with the tendency for the MCP joints to hyperextend with flexion of the IP joints, loss of thumb abduction and rotation.  These deformities are usually overcome with the wrist splinted into extension.  In patients with dorsal hand burns, correction of the wrist flexion will not correct the MCP's hyperextension, the IP's flexion, or thumb abduction.  Such burns require splints extending from the mid-forearm to the fingertips, molded to hold the MCP's in at least 70 flexion, with the IP's almost fully extended and the thumb widely abducted and slightly opposed.  As with all splints, it should be worn only when the patient is at rest, and active range of motion encouraged during working hours, if the patient is medically able.

   Splints are frequently applied to freshly grafted extremities to maintain position for optimal graft take.  In these cases, splints are applied in the operating room after dressings are applied.  Range of motion should be curtailed to the affected extremity for 4-5 days; after which active, and then passive, range of motion can be instituted.  Usually within 7-10 days the patient should be able to perform active range of motion.

Control of Scarring
   Studies have demonstrated that the application of pressure dressings can decrease hypertrophic scarring.  Hypertrophic scarring can be defined as an elevated scar with a Swiss cheese-like appearance.  This type of scar is a consequence of inappropriate collagen deposition within the wound during healing.  Hypertrophic scarring is known to occur more frequently in darker complected individuals, however, the true etiology is unknown.  Elastic wraps, stockinette with elastic reinforcement, or custom made garments should be applied to all burn-injured areas to decrease hypertrophic scar formation.

   During the acute post-burn period, elastic wraps can be applied to the healing wounds.  Stockinette with elastic reinforcement can be used after most wounds have healed, but some spots remain open.  Measurements for elastic garments should be made just prior to discharge and stockinette can be used until their receipt.

   Elastic garments should be worn 24 hours a day over all burned areas until the scar fully matures.  Two garments should be made for each patient, so a clean one will be available after the daily bath.  Scar maturation usually occurs within 1-2 years post-injury, occasionally longer, and is signaled by loss of scar erythema and a softening of the scar tissue.  Until the scar matures, there is the potential for the formation of hypertrophic scars and subsequent joint contracture.

Psychosocial Recovery - What the burn surgeons should know
   Concern with the psychosocial aspects of burn recovery begins with the admission of the acute patient and continues throughout that patients recovery and rehabilitation.  The cognitive and emotional status of the patient and of the patient's family play an important role in the success or failure of burn treatment at every stage of recovery.

   Although everyone interacts with the patient, the psychosocial aspects of treatment are managed by team members with expertise in these areas.

   At SBH, a coordinated group of psychologists, social workers, a child psychiatrist, and a school teacher work with the other members of the burn team.  A member of this group assesses every patient and family and makes recommendations about the psychosocial considerations for the treatment plan.  Through the generosity of the Shrine Temples, families may be provided with financial help for food and shelter.  Family Services also provide emotional support, education about burn treatment, and psychotherapeutic interventions, if necessary, to enhance the family's ability to provide an appropriate milieu for the patients recovery. Work with the patient includes both psychotherapy and pharmacotherapy to help with fear, pain, anxiety, anger, depression and self-esteem as appropriate for the developmental age of the patient.

   Of particular concern in pediatric burns is the case of injury in which there is some reason to suspect abuse or neglect.  Whenever the origin of the burn seems suspicious, it is extremely important that the reasons for suspicion be documented and the child be carefully examined for signs of past injuries (e.g. long-bone x-rays).  The child should not be discharged until such a discharge has been approved by the protective services in the child's community and/or by our Family Services staff.

   Because the psychological well-being of the patient is tightly intertwined with the physical, good communication among team members is of the utmost importance.  Members of the family services staff attend morning rounds, discharge planning conferences, rehabilitation rounds and all other multi-disciplinary conferences.  In addition, a staff member is always on-call.

   At the Blocker Burn Unit, psychosocial issues are addressed the same with issues of pain, anxiety, anger, grief, depression and self-esteem for the patient.  Each patient receives a social worker consult and a psychiatry consult for assessment.  Following assessment, the social worker and psychiatric team will make recommendations for treatment.  They will also continue to follow the patients, as needed, until discharge.  Although these people are unable to make daily rounds with the residents and students, they do communicate regularly in the 'progress note' section of the chart.  In addition, the psychologists at Shriners Burn Hospital for Children-Galveston serve in a consultant role and are available to the Blocker Burn Unit staff and patients.


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