Burn






























General Information


Case no.


3.A Burn


Authors


Brian Stagno, PT


Diagnosis


Thermal burns to 14% total body surface area (TBSA)


Setting


Burn trauma unit in an acute care hospital


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Explain the pathophysiology of the patient’s diagnosis and the multisystem effects of the injury.



  2. Understand medical and surgical management of a patient with partial- and full-thickness burns.



  3. Achieve a general understanding of the timeframe for the introduction and progression of physical therapy interventions with this patient population.
































Medical


Chief complaint


14% TBSA


History of present illness


A 66-year-old male presents to the hospital status post a fall from a stool while using a welding torch overhead. Per patient, once on the ground, his clothes caught on fire. Due to hip pain from the fall, the patient was unable to get up quickly. He did, however, put the flames out by patting them with his gloved hands and rolling his body.


Past medical history


Hypertension, chronic lower extremity edema, dyspnea on exertion


Past surgical history


None


Allergies


Morphine (depresses respiration)


Lisinopril (cough)


Medications


Aspirin, Furosemide, Losartan


Precautions/Orders


Activity as tolerated


Evaluate and treat























Social history


Home setup




  • Resides in a ranch style home with wife



  • One step to enter



  • Flight of stairs plus one handrail to basement, where work area/garage is located


Occupation




  • Auto mechanic, part time, self-employed


Prior level of function




  • Independent with functional mobility and activities of daily living; however, mildly limited by occasional shortness of breath


Recreational activities




  • Projects around the house and in garage: “I’m always working on something.”


































Vital signs


Hospital day 0: direct admit to burn unit


Hospital day 1: burn unit


Blood pressure (mmHg)


190/96


162/88


Heart rate (beats/min)


140


115


Respiratory rate (breaths/min)


26


22


Pulse oximetry on room air (SpO2)


96


96


Temperature (°F)


98.9 (tympanic)


99.0 (tympanic)






































Imaging/Diagnostic test


Hospital day 0: direct admit to burn unit


Hospital day 1: burn unit


Lund and Browder chart


1. Partial-thickness burns:




  • 1% Right thigh



  • 4% Anterior torso


2. Full-thickness burns:




  • 1% left hand



  • 1% right hand



  • 2% left forearm



  • 5% left thigh


1. Unchanged


Right hip X-ray


1. Negative for acute fracture


N/A


CT right hip


1. Hyperdense foci in medial thigh consistent with large hematoma


N/A


CT head without contrast


1. No acute intracranial trauma


N/A


CT cervical spine without contrast


1. Degenerative changes, no acute fractures


N/A


CT of the chest/abdomen/pelvis with contrast


1. No visceral thoracic or abdominal posttraumatic findings


2. Notable cardiomegaly with pulmonary hypertension


N/A



No Image Available!




Fig. 3.1 Example of newly placed split thickness skin autograft.



No Image Available!




Fig. 3.2 Example of donor site appearance.




































Medical management


Hospital day 0: direct admit to burn unit


Hospital day 1: burn unit


Hospital day 2: burn unit


Hospital day 5: burn unit


Medications


1. Fluid bolus: lactated ringer


2. Fentanyl


3. Gabapentin capsule


4. Ibuprofen


5. Cefazolin


6. Tdap vaccine for adult injection


7. Zinc sulfate capsule


8. Ascorbic acid tab


9. Vitamin A


1. Lactated ringer, continued with titration contingent on urine output


2. Continued


3. Continued


4. Continued


5. Continued


6. One time


7. Continued


8. Continued


9. Continued


1. Lactated ringer, continued with titration contingent on urine output


2. Continued


3. Continued


4. Continued


5. Continued


6. N/A


7. Continued


8. Continued


9. Continued


1. Titrate to PRN


2. Continued


3. Continued


4. Continued


5. Continued


6. N/A


7. Continued


8. Continued


9. Continued


Procedures


1. Sharp debridement and deep cleansing of burn injuries; Covered in silver sulfadiazine cream.


1. Operative procedure: excisional debridement of anterior torso, left forearm, bilateral hands, and bilateral lower extremities, with application of split-thickness skin autograft to bilateral hands (Fig. 3.1) and left lower extremity, with donor skin from bilateral thighs (Fig. 3.2).


1. Dressing change and staple removal at skin grafting sites completed under anesthesia with near 100% graft take noted. Graft sites covered with Bacitracin/Cuticerin/gauze/Kerlix web roll; donor sites covered with Mepilex Ag sheet, Kerlix web roll, compression wrap.


Consultations


1. Orthopaedic surgery: no surgical intervention to right hip necessary; will treat conservatively, weight-bearing as tolerated.


1. Cardiology: TTE performed with moderated left ventricle hypertrophy, preserved ejection fraction of 60–64%; given clearance for surgery.


N/A


N/A






































































Lab values


Reference range


Hospital day 0: direct admit to burn unit


Hospital day 1: burn unit


Hospital day 5: burn unit


Complete blood count


WBC


5.0–10.0 × 109/L


12.19


14.4


14.8


Hemoglobin


14.0–17.4 d/dL


15


11.1


9.1


Hematocrit


42–52%


45.8


34.8


28.8


Platelets


140–400 k/μL


390


355


299


Other select labs


Albumin


3.5–5.2 g/dL


3.0


2.7


2.4


BUN


7–20 mg/dL


6


8


8


Creatinine


0.7–1.3 mg/dL


0.7


0.4


0.4


Protein


6–8.3 g/dL


5.5


5.1


4.5












Pause points


Based on the above information, what are the priority




  • Diagnostic tests and measures?



  • Outcome measures?



  • Treatment interventions?

















































































































Hospital Day 5:


Post-Op Day 3 from Excisional Debridement and Split-Thickness Skin Grafting


Post-Op Day 0 from Dressing Change Under Anesthesia:


Physical Therapy Examination


Subjective


“Everything is tight, and it feels like my (left) leg is going to explode when I move it.”


Objective


Vital signs


Pre-treatment


Post-treatment


Supine


Sitting


Standing


Blood pressure (mmHg)


126/74


106/57


N/A


115/67


Heart rate (beats/min)


72


83


93


88


Respiratory rate (breaths/min)


16


18


24


20


Pulse oximetry on 2 L NC (SpO2)


99


98


98


99


Pain


7/10 at bilateral thighs


9/10 at bilateral hands


8/10 at bilateral thighs


9/10 at bilateral hands


10/10 at bilateral thighs
10/10 at bilateral hands


9/10 at bilateral thighs and bilateral hands


General




  • Patient presents supine in bed with dressings to bilateral hands, trunk, and bilateral lower extremities intact.



  • Lines notable for peripheral IV in right antecubital space, telemetry, nasal cannula, pulse ox, and urinary catheter.


Cardiovascular and pulmonary




  • Auscultation: no adventitious breath sounds



  • Normal sinus rhythm and rate



  • Peripheral pulses:


Bilateral upper extremities (BUE): 2 + radial (however, difficult to find due to bandages)


BLE: 2 + pedal


Gastrointestinal




  • Soft, nontender, nondistended



  • No hepatosplenomegaly


Genitourinary




  • Urinary catheter in place


Musculoskeletal


Range of motion




  • L shoulder, active range of motion (AROM): within normal limit (WNL)



  • R shoulder, AROM: WNL



  • Left elbow, AROM: WNL



  • R elbow, AROM: WNL



  • L wrist flexion, active assisted range of motion (AAROM): 0–20 degrees



  • R wrist flexion, AAROM: 0–15 degrees



  • L wrist extension, AAROM: 0–10 degrees



  • R wrist extension, AAROM: 0–15 degrees



  • B metacarpopphalangeal joint/proximal interphalangeal joint/distal interphalangeal joint (MCP/PIP/DIP) flexion/extension: limited and painful



  • L hip flexion, AROM: 0–60 degrees



  • L hip flexion, AAROM: 0–75 degrees



  • R hip flexion, AROM: 0–65 degrees



  • R hip flexion, AAROM: 0–80 degrees



  • L knee, AROM: 0–40 degrees



  • L knee, AAROM: 0–50 degrees



  • R knee, AROM: 0–90 degrees



  • B ankle DF, AROM: WNL



  • B ankle PF, AROM: WNL


Strength




  • B shoulder flexion: 5/5



  • B shoulder abduction: 5/5



  • L elbow flexion: 3/5 (resistance not applied due to forearm burn)



  • R elbow flexion: 5/5



  • L wrist flexion: not formally assessed



  • R wrist flexion: 2/5



  • L hip flexion: not formally assessed



  • R hip flexion: 2/5



  • L knee extension: 2/5



  • R knee extension: 4/5



  • B ankle DF: 4/5



  • B ankle PF: 4/5


Aerobic




  • Not formally assessed at this time


Flexibility




  • Not formally assessed at this time


Other




  • Muscle guarding with LLE > RLE ROM assessment


Neurological


Balance




  • Static sitting, unsupported: supervision × 10 minutes



  • Dynamic sitting, unsupported: minimal assistance for weight shifting, limited UE reach activity



  • Static standing: moderate assistance twice to maintain upright posture with rolling walker × 20–30 seconds


Cognition




  • Alert and oriented x 4


Coordination




  • Finger-to-nose: grossly intact bilaterally


Cranial nerves




  • II–XII: intact


Sensation




  • Hypersensitive to light touch at bilateral C6, C7, C8, and left L1, L2, L3, L4, L5


Functional status


Bed mobility




  • Rolling either direction: moderate assistance once



  • Supine to sit: maximal assistance once


Upon sitting, patient-reported dizziness, which resolved within ~1 minute.




  • Sit to supine: maximal assistance once


Transfers




  • Sit to/from stand: moderate assistance twice with rolling walker



  • Posture notable for flexed posture.


Ambulation




  • Not assessed at this time

























Assessment


☑ Physical therapist’s


Assessment left blank for learner to develop.


Goals


Patient’s


“Get out of this bed.”“Use my hands again.”


Short term


1.


Goals left blank for learner to develop.


2.


Long term


1.


Goals left blank for learner to develop.


2.














Plan


☐ Physician’s


☑ Physical therapist’s


☐ Other’s


Will follow up patient five to seven times per week to address deficits in range of motion, strength, balance, endurance, and functional mobility through interventions including but not limited to stretching, strengthening exercises, mobility training with assistive device, and general conditioning activities.






























Bloom’s Taxonomy Level


Case 3.A Questions


Create


1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient.


2. Develop two short-term physical therapy goals, including an appropriate timeframe.


3. Develop two long-term physical therapy goals, including an appropriate timeframe.


Evaluate


4. What impact does the TBSA percentage have in medical management of the patient?


5. What steps are medically taken to prevent infection in this patient given the extensive damage to his skin organ?


6. Why was skin grafting surgery delayed until hospital day 2?


Why was a full physical therapy assessment not completed until day 5?


7. What specific intermediate steps should be trialed in subsequent physical therapy sessions to determine best discharge disposition?


Analyze


8. What factors may contribute to the patient’s decreased range of motion at the involved joints?


9. What other obstacles may be limiting the patient’s activity tolerance at the time of initial evaluation?


Apply


10. What specific functional mobility tasks may be impaired by the injuries to the patient’s hands?


11. How can the physical therapist address orthostatic hypotension and lower extremity pain as mobility is reintroduced after prolonged bed rest?


Understand


12. What does the surgical application of an autologous split-thickness skin graft entail?


Remember


13. What are the different classifications of burn injury with regard to depth, and what are their characteristics?


14. What topical agents are used in wound care for this patient, and what are distinctions between their classifications?






























Bloom’s Taxonomy Level


Case 3.A Answers


Create


1. The patient is a 66-year-old male who presents with partial-thickness burns to his right thigh and anterior torso and full-thickness burns to his left hand, right hand, left forearm, and left thigh. On hospital day 2, the patient underwent excisional debridement of left forearm, bilateral hands, bilateral lower extremities, and anterior torso, and application of split-thickness skin autograft to bilateral hands and left lower extremity. On hospital day 5, dressing changes and staple removal at skin grafting sites were performed under anesthesia, with near 100% graft take noted. The patient now presents with significant pain; decreased range of motion of multiple joints from the burn injury, skin grafting, and prolonged immobility; decreased endurance from his injuries and bedrest; and decreased functional mobility. The patient will benefit from continued physical therapy interventions, including but not limited to range of motion and strength training, functional mobility training, and integration of adaptive equipment, to improve the aforementioned deficits. The patient and family will also need extensive education on long-term management of current deficits and self-care strategies to minimize risk of long-term impairments involving areas of skin grafting. Will continue to follow.


2. Short-term goals:




  • Patient will perform a bed to/from chair transfer with moderate assistance × 1 and rolling walker within 1 week to decrease caregiver burden.



  • Patient will achieve AROM of bilateral hip and knees to ≥ 90 degrees of flexion within 1 week to improve comfort and independence with functional mobility tasks.



  • Patient will independently ensure that dressings over donor sites are clean, dry, and intact 100% of the time within 1 week to improve healing.


3. Long-term goals:




  • Patient will perform all functional transfers with supervision and least restrictive assistive device within 3 weeks to improve functional independence.



  • Patient will ambulate 50 feet with minimal assistance and rolling walker within 3 weeks to improve household mobility.



  • Patient will independently verbalize his dressing change process, including order of application and dressing materials, within 3 weeks.


Evaluate


4. The TBSA and depth of injury are first and foremost an indication of the severity of the injury. The systemic effects of a burn injury are proportionally related to the TBSA. The breakdown of the extracellular matrix of the skin organ causes fluid shift and places a large burden on the kidneys and cardiovascular and pulmonary systems. Therefore, the fluid resuscitation that is necessary to keep these systems in balance is guided by the TBSA. The hypermetabolic effects are also proportional to TBSA, which means that calorie and protein needs of wound healing are correlated to the TBSA number.


5. The loss of the protective function of the skin leads to a high risk of infection. The patient’s wounds were immediately debrided to remove necrotic tissue from the wound bed. The application of Silvadene, a topical broad-spectrum antimicrobial cream, further helps prevent infection. Skin grafting of the full-thickness burns provides the necessary coverage over a healthy wound bed to further protect from infection. Prophylactic use of an antibiotic, such as cefazolin (Ancef), as well as immune boosting oral agents, like vitamin A, ascorbic acid (vitamin C), and zinc sulfate, can also be used. Surgical skin donor sites are covered with Mepilex Ag to minimize exposure of these sites to infection. WBC count and temperatures are taken to monitor for signs of infection.


6. Skin grafting was done on hospital day 2 because additional consultation services were warranted to medically clear the patient for surgery. First, orthopaedic surgeon needed to be sure that the trauma to the right hip did not require emergent surgery. Second, cardiologist had to assess the patient and determine any risks given the patient’s chest CT findings. While physical therapist was consulted upon admission for positioning, splinting, and skin integrity management, a full physical therapy evaluation was deferred until after the first dressing change and staple removal at the skin graft site.


The physical therapy evaluation occurred on day 5, as this allowed the skin graft to have sufficient time to adhere to the wound bed. This is especially necessary for a graft that crosses an anatomic joint and will be taught or stretched with functional mobility. For this reason, grafts that do cross a joint are commonly immobilized with splinting or bracing for a 2–3-day period until the dressings are first changed and the surgeons confirm the integrity of the graft. Functional mobility may be assessed in a patient with grafting to an area that is not strained or appropriately immobilized, as the patient’s tolerance allows.


7. It is important to gauge the patient’s response to physical therapy interventions with regard to pain management and activity tolerance (i.e., monitoring of vital signs) to determine discharge disposition. Specifically, time spent out of bed in a seated position and tolerance to stretching, strength, and mobility training will help determine the appropriate level of rehabilitation at discharge.


Analyze


8. The patient’s burn injury, skin grafts, period of immobility, and bulky dressings all limit the available motion at the wrists and hands. The pain related to the orthopaedic injury as well as the skin donor site at the right thigh limit comfort with right hip and knee motion. The burn injury, skin graft, and skin donor site of the left thigh and period of immobility limit comfort with the left hip and knee motion.


9. Acute pain and sedative side effects of pain medications, recent anesthesia administration, orthostatic hypotension, and generalized weakness from prolonged immobility may all be contributing to the patient’s poor activity tolerance on initial assessment.


Apply


10. On the initial evaluation, the patient’s hands are painful, edematous, and wrapped in bulky dressings, all limiting functional grip and weight-bearing tolerance. Specifically, the patient has great difficulty gripping the bedrail and the physical therapist’s hand to achieve rolling and the supine to/from sit task. The patient also has difficulty pushing down with the hands at the edge of the bed to initiate forward weight shift for maintaining sitting balance and for the sit-to-stand task. Lastly, the patient’s poor grip limits the use of the walker to support weight, as the patient does have bilateral lower extremity injuries.


11. To address orthostatic hypotension, the physical therapist can have the patient complete range-of-motion exercises, such as long arc quads and/or ankle pumps, prior to attempting bed mobility. These exercises can again be completed once sitting on edge of bed. Additionally, applying compression (i.e., ace wraps) to the legs over top of the wound care dressings can help mitigate pain and the pooling effect that come with introducing a gravity-dependent position in this patient.


Understand


12. The autologous split-thickness skin graft is the standard of care for full-thickness and deep partial-thickness burns. Surgeons look for healthy donor skin on the patient; preferably a large, flat part of the body such as the thigh, flank, or back. Using a tool called dermatome, they remove the epidermal layer and papillary dermis of the skin. Surgeons then place the donor skin through a meshing machine, which increases the size of the donor skin graft, thus allowing less skin to be taken to cover a larger burn area. The graft is then placed over the borders of the burn injury, and attached at the periphery usually with staples, fibrin glue, or sutures. The meshed appearance of the graft allows for the newly generated epithelial cells to fill in the space at the junction of the wound and graft. The graft is typically left immobilized and in surgical dressings for 48–72 hours. After that period, the dressings are removed, the surgeons examine the attachment of the graft to the wound bed, and staples or sutures are removed as appropriate.


Remember


13. The different classifications of burn injury with regard to depth and their descriptions are as follows:


Superficial (formerly first degree):




  • Damage is to the epidermis.



  • Skin presents as red or erythematous, dry surface, and without blisters.



  • Pain is moderate.



  • Healing occurs within 5–10 days with no scar formation.


Superficial partial thickness (formerly second degree):




  • Damage is to the entire epidermis and superficial (papillary) dermis, with preservation of underlying vasculature.



  • Skin presents as red and blanchable and weeping, with blisters.



  • Pain is severe.



  • Healing occurs within 3 weeks with minimal scarring.


Deep partial thickness (formerly second degree):




  • Damage is to the entire epidermis and superficial (papillary) and deeper (reticular) dermis, with involvement of underlying vasculature.



  • Skin presents as yellow or white (leathery in appearance), dry, and minimal to no blanching.



  • Pain is minimal due to decreased sensation.



  • Healing occurs within 3–8 weeks with scarring present.


Full thickness (formerly third degree):




  • Damage is through the entire skin and subcutaneous structures.



  • Skin presents as white or black/brown (leathery in appearance) and dry with no blanching.



  • Pain is minimal to absent due to decreased sensation.



  • Healing takes greater than 8 weeks and requires skin grafting.


14. The topic agents used in wound care for this patient are enzymatic debriders and antimicrobials. Distinctions between the two are as follows:




  • Enzymatic debriders: Clean the wound bed of necrotic tissue



  • Antimicrobials: preserve the healthy environment of an already clean wound bed

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Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Burn
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