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Chapter 21. Burn Rehabilitation
443
Assessment
Assessment of scars falls into the realm of rehabilitation.
Their impact on functional, cosmetic, and psychosocial outcomes makes them an important part of the rehabilitation
process.
There are several outcome measures, scar scales, and tools
that have been developed to assist in the process of scar
assessment and evaluation of the efficacy of treatment.
However, “no ideal scale that is suitable for all assessment
purposes has emerged” [3]. The qualities of scar that are
looked at can include, pigmentations, texture, thickness, pliability, size, as well as pain and pruritus [3].
The following table lists simple, easy to use, noninvasive, and
inexpensive scar assessment scales as well as a list of more
technical, expensive, and sometimes invasive tools (Table21.2).
T . Scar
assessment and
outcome tools
Simple, non-invasive, inexpensive
Vancouver Scar Scale
Modified Vancouver Scar Scale
Patient and Observer Scar
Assessment Scale
Manchester Scar Scale
Matching Assessment of Scars
and Photographs Scale
Technical, expensive, invasive
Photography
Ultrasound
Elastometer
Extensometer
Tonometer
Pneumatonometer
(continued)
444
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L. Benavides et al.
T . (continued)
Durameter/Durometer
Cutometer
Laser Doppler
Biopsy
Three-dimensional mould
Dermaspectrometer
Chromameter
Spectrocolorimeter
Infrared camera
Three-dimensional imaging
Oximetry
Planimetry
The simpler scales/tools are rated as more subjective and
the more complex scales/tools are more objective. According
to a study from 2009 by Forbes etal., they found that burn
therapists believe that using a Burn Scar Outcome Measure
is important and that they should be reliable, valid, quick,
easy, and noninvasive [4].
Treatment
Compression or pressure therapy is one of the oldest and most
utilized methods for prevention and treatment of hypertrophic
scars. This can begin early when wounds are healed and skin can
tolerate the shearing forces that can occur from a prefabricated
or custom fabricated garment, wraps such as Coban, silicone or
foam inserts, or conforming orthoses such as a transparent
facial orthosis. Pressure garments can include elastic wrap bandages, tubular pressure bandages, an interim prefabricated garment, and a custom fabricated garment. Benefits of compression
Chapter 21. Burn Rehabilitation
therapy include improvement in scar pliability and thickness,
reduction of itching and pain, and prevention of contractures. It
has been found that a compression pressure of 20–30mmHg is
an effective pressure to achieve the desired results [1, 5, 6]. One
of the biggest threats to the successful outcome of use of compression is patient compliance. Non-adherence to use of compression can be attributed to discomfort, skin irritation/pain,
and length of treatment time with garment. It is recommended
that compression garments be used for 23h per day for about
1year or until the scar has matured.
The use of silicone gel sheets has also been widely used for
burn scars. It can be used in conjunction with pressure garments. Elastomer putties and prosthetic foam are also other
types of inserts available for use under pressure garments to
enhance pressure over anatomical locations that are difficult
to achieve adequate compression.
445
Other Scar Therapies
Scar massage has also been widely used in the treatment of
post-burn scars. This should only be initiated once a scar has
matured enough to tolerate a shearing force. Scar massage
effects include assisting in softening or remodeling of scar
tissue by affecting adherent fibrous bands which can assist in
mobility of tissue as well. Scar massage techniques begin with
pressure to blanch skin and mobilize skin surface without
friction. Once the skin and scar can tolerate greater friction,
the scar massage can include manipulation of tissue in circular, parallel, and perpendicular motions. Patients and families
should be educated regarding scar massage techniques for
optimal outcomes. Therapeutic heat may also be used in conjunction with scar massage as it assists in the extensibility of
connective tissue [7]. Heat modalities can include moist hot
packs, paraffin wax, fluidotherapy, and ultrasound and are
completed prior to initiation of scar massage. Care should be
taken when using a heat modality for patient tolerance and
sensitivity (hypersensitivity or loss of sensation) after a burn
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L. Benavides et al.
injury. Low load prolonged stretching after use of a heat
modality is also a utilized method for obtaining positive
effects on ROM when scar is involved.
Outpatient Rehabilitation ofBurn Injury
Burn rehabilitation does not end with discharge from the
hospital after an acute injury. Burn rehabilitation starts on the
day of admission and continue for several months to years
after burn injury. Burn scar tissue is most active 3–4months
after an injury. Scar maturation can take up to a year or more.
After suffering burn, patients can struggle with psychological
or emotional issues, scars, contractures, and functional
limitations as well as issues with re-entering community,
school, or work. All of these issues can contribute to a
decreased quality of life. Ensuring patients are part of a
multidisciplinary outpatient burn clinic is paramount in helping
them receive the services that they need to assist in improving
quality of life. If the availability of a multidisciplinary clinic is
not possible, ongoing communication between all caregivers is
essential.
Wound care, splinting or casting, scar assessment and
management, including compression garment, range of
motion, stretching, strengthening, endurance, and exercise, as
well as psychological/emotional adjustment, return to work
needs and peer support are all part of an outpatient burn
rehabilitation program. OTs and PTs continue to evaluate
evolving problems during outpatient treatments, and
communication with the burn team or current caregivers
regarding ongoing issues with wounds or contractures can
assist the surgeon in formulating reconstructive plans.
Chapter 21. Burn Rehabilitation
447
Conclusion
Rehabilitation is an important piece of treatment in helping
patients put their lives back together. This is never truer than
in the care of a burn survivor. Burn rehabilitation has unique
challenges and requires persistence, patience, ingenuity, and
compassion. It also requires a multidisciplinary team with
effective communication skills. Taking on the challenges of
burn care and rehabilitation can be overwhelming, however,
knowing that your burn survivors have returned to all of their
pre-burn functions and activities is proof that the challenge of
burn rehabilitation is worth it.
References
1. Cheng JC, Evans JH, Leung KS, etal. Pressure therapy in the
treatment of post-burn hypertrophic scar—a critical look into
its usefulness and fallacies by pressure monitoring. Burns Incl
Therm Inj. 1984;10:154–63.
2. “Scar” Def 1. www.lexico.com. Oxford English and Spanish
Dictionary, Thesaurus, and Spanish to English Translator. 2020
Lexico.com.
3. Tredget E, Shupp JW, Schneider JC.Scar management following
burn injury. J Burn Care Res. 2017;38(3):146–7.
4. Forbes-Duchart L, Cooper J, Nedelec B, Ross L, Quanbury
A. Burn therapists’ opinion on the application and essential
characteristics of a burn scar outcome measure. J Burn Care Res.
2009;30(5):792–800.
5. Sharp P, Pan B, Yakuboff K, Rothchild D. Development of
a best evidence statement for the use of pressure therapy
for management of hypertrophic scarring. J Burn Care Res.
2016;37(4):255–64.
6. Herndon D.Total burn care e-book. Philadelphia: Elsevier; 2017.
7. Ward RS, Richard RL, Staley MJ. The use of physical agents in
burn care. Burn care and rehabilitation principles and practice.
Philadelphia: FA Davis; 1994. p.419–46.
Chapter 22
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Anesthesia forBurn
Patients
JamieL.Sparling andJ.A.JeevendraMartyn
Introduction
Burn patients frequently present to the operating room (OR)
during both the acute and chronic phases of their burn injury.
Anesthesia clinicians are frequently called to undertake specific challenges with respect to airway management and vascular access, but they must also thoroughly understand and
be prepared to address the pathophysiologic changes in each
organ system affected by burn. Clinicians also must accommodate the pharmacologic changes induced by the body’s
response to the injury and adapt their anesthetic plan accordingly. In the chronic phase, anesthesia clinicians may utilize
techniques to mitigate the effect of recurrent general anesthetics in vulnerable populations while accommodating the
psychological impact of burn trauma and the associated pain
and anxiety during repeated returns to the OR. Finally,
knowledge of and experience in burn injury will enable clinicians to plan anesthetics during the chronic phase that facilitate ambulatory reconstructive procedures, when possible.
J. L. Sparling · J. A. J. Martyn (*)
Department of Anesthesiology, Critical Care and Pain Medicine,
Massachusetts General Hospital, Shriners Hospitals for
Children—Boston, Harvard Medical School, Boston, MA, USA
e-mail: jlsparling@mgh.harvard.edu; jmartyn@mgh.harvard.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_22
449
450
J. L. Sparling and J. A. J. Martyn
Anesthesia Considerations
Airway Management
Airway management may prove difficult in both the acute
and chronic phases of burn injury. In the acute phase, direct
thermal skin and inhalation injury may cause macroglossia or
edema of the subglottic airway and the glottis. In the subacute and chronic phases, contractures may limit mouth
opening (microstomia), jaw thrust, and neck extension. Even
nasal passages can be blocked by contractures. Inhalation
injury is more frequent in patients with burns sustained in a
closed space, and clinical signs that predict inhalation injury
include soot in mouth and pharynx, singed nasal hairs, vocal
changes, stridor, and hoarseness. For patients with predicted
difficult intubation, fiberoptic intubation—whether awake,
anesthetized, or under sedation—is advantageous to navigate
edematous airways and narrow mouth openings. Ketamine or
dexmedetomidine may be utilized with minimal respiratory
depression and may be especially useful in children for whom
awake intubation is not possible. Manual distraction of the
tongue utilizing gauze or a suction catheter, as well as jaw
thrust by an assistant, may improve fiberoptic visualization.
Video laryngoscopy with any of a large number of commercially available products (e.g., GlideScope, C-MAC,
McGRATH MAC video laryngoscope) also offers improved
visualization of laryngeal structures; however, their use may
be limited in cases of microstomia [1].
Placement of a supraglottic or laryngeal mask airway
(LMA) may be used as a rescue technique during difficult
intubation, or as a planned conduit through which to intubate the trachea. Alternative airway techniques include
retrograde wires following tracheotomy, fiberoptic stylets,
or lightwand intubation. In patients for whom intubation is
expected to be difficult due to contractures of the neck or
face, the patient may be induced with anesthesia while
maintaining spontaneous ventilation (e.g., ketamine, inhalation induction) until the surgeon releases the contracture
to facilitate airway instrumentation. Finally, as in all difficult intubations, surgical airway equipment and a qualified
Chapter 22. Anesthesia forBurn Patients
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surgeon should be available as a back-up plan, per the
American Society of Anesthesiologists (ASA) Difficult
Airway Algorithm [2].
Vascular Access
Adequate venous access is crucial to support the initial
resuscitation and ongoing care of acutely burned patients.
Several factors may hinder venous access including large
total body surface area (TBSA) affected, peripheral edema
from fluid resuscitation, and multiple graft donor sites.
Ultrasound guidance is the current standard for internal
jugular central venous and femoral vein cannulation and is a
useful adjunct for other types of central lines, peripheral
venous catheters, and arterial lines. Cannulation through
burn wounds is occasionally necessary, and in such cases, it is
important to meticulously disinfect the area. Ultrasound
examination prior to cannulation attempts can evaluate for in
situ clot of either peripheral or central veins, for which burn
patients are at risk due to repeated cannulations, prolonged
immobility, and hypercoagulability. Intraosseous (IO)
catheters may be a useful alternative for up to 48h, if venous
access is difficult or impossible [3]. When transferring from a
peripheral, non- tertiary care hospital, where personnel
experienced in placing central lines may not be available,
intraosseous route is a good temporary alternative.
Volume Status/Fluid Resuscitation
Critically ill burn patients should receive prompt intravascular
fluid resuscitation to reverse hypovolemic shock and prevent
organ failure. Overly aggressive fluid resuscitation, on the
other hand, contributes to pulmonary, gut, and peripheral
edema—and if continued, may result in intra-abdominal
hypertension or abdominal compartment syndrome.
Traditionally, initial fluid resuscitation has been guided
by estimates based on the TBSA affected by burn. The
“Rule of Nines” is used in adults, while the Lund-Browder
chart may be useful in children who have variable body pro-
452
J. L. Sparling and J. A. J. Martyn
portions depending on age. Patients with burns affecting less
than 15% TBSA may receive oral hydration or intravenous
fluids at 100–150% of the calculated maintenance rate. The
Parkland and modified Brooke formulas have historically
been used to guide initial fluid resuscitation for larger burns
based on TBSA estimate, but more recent literature suggests that less aggressive resuscitation may be associated
with improved survival and less edema. More important
than following calculated volume targets, clinicians must
incorporate clinical and laboratory parameters to guide
resuscitation. Conventionally used parameters include urine
output (target 0.5–1.0mL/kg/h in adults), heart rate, blood
pressure, lactate, base deficit, central venous pressure (CVP),
BUN/Cr ratio, and fractional excretion of sodium (FENa).
Several caveats are notable, however—for instance, urine
output may be deceptively low due to the release of arginine
vasopressin with acute burn, or it may be elevated despite
hypovolemia due to the increased glomerular filtration rate
during hyperdynamic state (48–72 h after injury), osmotic
effects of breakdown products, and tubular dysfunction.
FENa may be unreliable after administration of sodiumcontaining fluids or after diuresis.
Because of the limitations of these measures, novel
methods have been studied to assess fluid status, and
specifically to predict fluid responsiveness. Such examples
include the use of a “mini” fluid bolus, a straight leg raise, or
the end- expiratory occlusion (EEO) test [4]. The EEO test
consists of pausing the ventilator for 15–30s at the end of
expiration, and cardiac output is assessed to determine
whether the increase in right ventricular preload transmitted
to the left ventricle improves stroke volume and thus cardiac
output [5]. Pulse pressure variation (a surrogate for stroke
volume variation) and inferior vena cava (IVC) size and
collapsibility have been studied extensively, but both are
reliable only under strict conditions [6]. Non-invasive cardiac
output monitors (NICOM) utilize these and other principles.
Crystalloid is typically administered for initial resuscitation,
with balanced crystalloid solutions preferred over normal
saline to avoid its propensity for causing hyperchloremic
metabolic acidosis. Colloid solutions, however, may reduce the
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degree of peripheral edema, at least transiently, and many
burn centers have begun to incorporate colloid into earlier
resuscitation [7]. Recent meta-analysis concluded that albumin infusion in the first 24 h was associated with reduced
mortality and decreased occurrence of compartment syndrome [8]. Non-glucose containing fluids are typically utilized
due to the insulin resistance and resultant hyperglycemia seen
in major burns; however, glucose should be added for infants
and others at risk for hypoglycemia.
Capillary wall permeability returns to normal in nonburned tissue around 36–48h after burn, and consequently,
peripheral edema begins to resolve over the subsequent
1–2weeks. Fluids are restricted during this time, and diuretics
may be administered to augment mobilization of the edema.
Blood product administration is frequently required in
patients with major burns. As no standard hemoglobin threshold for transfusion in burn patients is established, clinicians
must make individualized decisions based on levels required to
restore circulation and maintain metabolic homeostasis. A survey of United States burn center directors revealed that the
hemoglobin level below which respondents would transfuse
increased with increasing TBSA, history of cardiac disease,
acute respiratory distress syndrome (ARDS), and age [9].
Considerable bleeding may occur during excision and grafting
procedures, and blood loss may be underrecognized due to
losses into the surgical drapes, soaked wet sponges, and onto
the floor. Thus, blood products may be transfused preoperatively in anticipation of blood loss or preemptively in the OR
at the beginning of these procedures. Massive transfusion,
when required, should occur in a balanced fashion with one
fresh frozen plasma (FFP) for every one or two packed red
blood cells (RBC), 1:1 or 1:2 transfusion ratio.
Temperature Regulation
Maintenance of normal body temperature in the severely
burned patient requires the communication and collaboration of
the perioperative team in both the OR and the ICU. Burn
patients are particularly vulnerable to heat loss due to the lost
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