Modern burn care is a multistage process and can be divided into four phases. Rehabilitation begins from Day 1 as achieving optimal function is a goal that needs to be considered at all phases:

• Phase 1 (Days 1–3): Initial evaluation and resuscitation. Evaluation of percentage and degree of burns (Rule of nines, Lund and Browder chart), other injuries (eg. airway) plus co-morbid conditions. Airway maintenance, accurate fluid resuscitation as well as Hb monitoring +/- blood transfusion is required. Specific wound dressings are usually required as advised by plastic surgery team.
• Phase 2 (first few days post injury): Staged operations for wound excision/ debridement, cover and closure.
• Phase 3: Definitive wound closure (including replacement of temporary wound covers) and reconstruction of high complexity areas such as the face and hands.
• Phase 4: Reintegration

→ Section 10.b

Burns

Clinical management issues to consider

In acute burn rehabilitation

• Management is individualised by burn location, depth of injury, percentage of body surface injured, associated injuries (eg. airway, fractures), complications and patient’s previous functional level and health.
• Burn patients with inhalation injuries may have a tracheostomy and are at risk of developing:
• pneumonia
• adult respiratory distree syndrome
• multisystem organ failure
• Patients who suffered an electrical injury may be susceptible to:
• myocardial necrosis (consider CK monitoring)
• arrythmias (consider ECG monitoring)
• peripheral and central nervous system complications (consider MRI scans, EMG studies etc).
• Patients with burn injuries may be in a catabolic state (especially if burn injuries are >30% total body surface area (TBSA)).
• Address nutritional needs. Dysphagia can be an issue. Early enteral feeding and dietician input is essential (daily caloric requirements for adults: 25kcal/kg plus 40kcal/1% TBSA burn/day).
• Monitor for metabolic abnormalities and increased insulin resistance. Monitor FBC, electrolytes, LFTs and bone function tests, blood glucose and inflammatory markers (ESR, CRP).
• consider and address sleep disturbances
• consider psychology / psychiatric input as necessary
• consider previous history
• patient might suffer from post-traumatic stress disorder or depression
• Promote wound healing (liaise with plastic surgery team / tissue viability nurse regarding appropriate dressings to use at every stage. Do not forget donor sites).
• Prevent complications such as joint contractures, weakness, decreased endurance and loss of functional abilities. Heterotopic ossification is another complication but preventative management is controversial.

Wound care principles

• decrease pain
• prevent infection
• prevent and suppress scarring
• prevent contractures
• prepare wounds for grafting if necessary

Positioning principles

• fundamental to prevent contractions and compression neuropathies
• patients usually adopt positions of comfort namely flexion and adduction
• keep tissues in an elongated state
• ideally, positions of extension and abduction should be chosen but these need to individualised to the patient’s specific injuries

Splinting principles

• used to prevent joint contractures (eg. joints with overlying deep partial thickness or full thickness burns are at risk), maintain proper positioning and protect new skin grafts
• should be done with functional goals in mind
• can be done with off the shelf or custom made splints
• a good splint:
• is easy to don and doff
• avoids pressure on bony prominences and nerves
• is made of remoldable materials and can be modified according to the patient’s needs (review splinting as necessary)
• is compatible with wound dressings and topical medications
• exercise principles
• initial goal is to maintain range of movement (ROM) and strength
• programme depends on stage of wound healing, skin graft status (if applicable) and patient’s participation ability. Consult plastic surgeon as necessary
• stretching programme is indicated when there is loss of ROM
• once ROM is achieved, active exercise is preferred
• strengthening / endurance training should begin as tolerated
• do not forget analgesia

Early ambulation principles

• maintains independence, balance, lower extremity ROM and decreases risk of DVT
• if lower limb skin grafting is present, do not start ambulation until a stable circulation of the graft sites is established – discuss with plastic surgeon first
• prior to walking, begin with dangling the lower extremities to assess if the graft tolerates the dependent position
• discuss the use of compression with plastic surgeon
• check the graft before and after dangling/walking
• monitor for gait deviations which may be due to pain, focal or generalised weakness, contractures, impaired sensation/proprioception or central nervous system causes

Discharge planning

• Ensure plastic surgery, physiotherapy, OT, nursing and psychiatric / psychology follow-up as necessary.