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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 limitation of human resilience. We cannot define the limitation of human resilience.

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Minimizing the Trauma of Burn Injuries: Rehab and Beyond

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  1. 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

  2. We cannot define the limitation of human resilience

  3. We cannot define the limitation of human resilience

  4. 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

  5. Published 2012 for data 2000-2009

  6. Outline Burn Challenges Scar Management Mobility Why psychosocial care is important Future scar revision options

  7. Phases of recovery • Admission • Critical care • In-hospital recuperation • Rehabilitation • Contracture prevention first phase • Re-integration

  8. Phases of recovery • Admission • Critical care • In-hospital recuperation • Rehabilitation • Contracture prevention first phase • Re-integration

  9. Face Burns

  10. Face Burns 2 weeks post burn 6 weeks post burn

  11. 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

  12. Determining factor for success Extent of burn Intelligence Immediate response Socioeconomic status Family and social support Willingness for social risk taking

  13. Poor prognostics • Social shyness • Lack of family cohesion • High family conflict • Acceptance within family • Dependence • Helplessness • Waiting for others to provided

  14. Scar Management Sensitive and fragile skin Break down, infections Splints Contractures Grafts garments

  15. 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

  16. Same format – adorable baby • Bulleted text goes here • Change colors • Less text – • MORE SLIDES!

  17. Original OR date. first view 5 days post graft 5 days post STSG and porcine ~10 day post graft with porcine loss

  18. Second OR trip (5-22) 5 graft post porcine (5 days) 7 days 2nd graft 21 days for first 21 days

  19. Scald burn 3 month post injury

  20. Management • Surgical therapies • Radiation, cryosurgery, lasers • Medical Management • Oral therapies • Methotrexate (MTX) • Tamoxifen citrate • Topical immunomodulators • Intralesional • Corticosteroids, 5-FU, interferons

  21. Future revision • Z-plasty • Contracture release • Skin flaps, rotational flaps • Pedicle flaps • Tissue expanders

  22. 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.

  23. Silicone and hydrogels • Mepiform, TopiGel • Elasto gel, Avogel • Occlusive coverage long periods of time • At least 12hrs/day • 4-6 months duration

  24. 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

  25. Infant total body suit Upper extremity sleeve w/zipper no lines from seams after 15minutes Torso garment

  26. Mobility Physical limitations Contractures Amputations Compliance with routine therapies garments

  27. 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

  28. Psychosocial recovery Death/disfigurement Pain and anxiety Cultural variance Post traumatic stress Hopes and dreams

  29. Pain • Initial injury itself • Developmental stages • Parental response • Dressing change • Excruciating • OR vs bedside • Therapies • Emotional/psychologic

  30. Pain • Initial injury itself • Developmental stages • Parental response • Dressing change • Excruciating • OR vs bedside • Therapies • Emotional/psychologic

  31. Minimizers • Hypnosis • Music therapy • Time out • Electronic devises • iPads • TV • headphones

  32. 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.” Rzucidlo, Campbell, JTN, 2009 www.healthcaretoolbox.org

  33. Post traumatic Stress • Most undiagnosed and untreated • Unable to maintain pre-injury coping levels • Severity of trauma not predictive of PTSD • Risk factors

  34. Same format – adorable baby • Bulleted text goes here • Change colors • Less text – • MORE SLIDES!

  35. 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

  36. Reintegration • Interaction with peers • Social rejection • Community • School • Sports • Mall • Rehearsals

  37. Resources Phoenix Society for Burn Survivors – Resources for Children and Families http://www.phoenix-society.org/resources/familyresources Provides information, support, and resources to children, adolescents, and families who have been impacted by a burn injury. Angel Faces http://www.angelfacesretreat.org/af/about-us.asp Provides 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 Hospitals http://www.shrinershospitalsforchildren.org/ Pain, Pain, Go Away http://painsourcebook.ca/docs/pps80.html Information on helping children with pain from a leading pediatric pain research group.

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