Erin P. Frazier, OTR/L Occupational Therapist Jessica Maher, PT, MSPT Physical Therapist

Transcription

1 Management of Burns for The Pediatric Patient Erin P. Frazier, OTR/L Occupational Therapist Jessica Maher, PT, MSPT Physical Therapist Mt. Washington Pediatric Hospital 1708 West Rogers Ave Baltimore, MD 21209

2 Objectives Summarize the differences that exist between the adult and pediatric burn patient. To identify and utilize the different tools available for scar management. To be able to implement proper positioning of a patient for maximal functional outcomes based on the area of the burn. Describe how the interdisciplinary approach can best be integrated into a patient s care and discharge planning.

3 Pediatric Burn Patient Thinner skin; greater severity of injury Body surface to weight ratio is larger Decreased metabolic reserves Airways are difficult to secure small Immune response is immature May be the result of neglect/ abuse

4 Calculating Total Area of Burn Lund Browder Chart Based on age /growth Rule of Nines More accurate for children

5 Phases of Burn Care Four General Phases: I. Initial evaluation and resuscitation II. Initial wound excision and biologic closure III. Definitive wound closure IV. The final stage of care is rehabilitation, reconstruction, and reintegration Sheridan,R.L. burn rehabilitation.emedicine,dec 16,2004

6 Burn Depth Partial thickness (1 st degree) Red and painful, warm Partial thickness (2 nd degree) Red, blistered, painful, blanches to touch, may weep fluid Full thickness (3 rd & 4 th degree) Black, brown or white, firm, no blanching, no pain, 4 th degree may extend into fat, muscle, bone or nerve

7 Skin Grafting Wound Closure Skin Grafts: Full thickness Split Thickness Xenograft Allograft Synthetic Dressings: healing, prevent infection, decrease pain

8 Wounds in Children with Burns

9 Silicone Dressings Mepiform Oleeva Oleeva Fabric Silon-TEX sewn within garments, no other silicone dressings needed under Otoform-K/c soft putty like substance with silicone Wound Dressings Mepilex Ag Mepilex Border Lite Dressings Used

10 Team Approach to Therapy On admission, patient is evaluated by all disciplines to determine plan of care and appropriate therapeutic techniques Therapeutic interventions may include : scar massage, splinting, pressure garments, psychosocial therapy, nutrition, and community re-entry.

11 Non-Pharmacological Pain Management Distraction Use of external stimuli such as TV, video games Relaxation training Breathing exercises Guided imagery Controlling mental focus

12 Hypertrophic Scarring Scar formation which rises above the skin surface Molded face mask Compression garments Silicone sheeting Scar massage Exercise

13 Scar Management

14 Scar Massage Rationale maintain mobility improve circulation alleviate itching prevent skin breakdown decrease hypertrophic scarring.

15 Scar Massage Procedure complete only on healed areas per physician orders use Eucerin Cream for body or lotion for face as directed massage in circular, horizontal, vertical directions over scar pressure applied should cause blanching of the skin (whitening) remove excess cream with a soft towel wait 30 to 60 minutes after massage before reapplying pressure garments and/or mask complete 1-2 times per day

16 Scar Massage Precautions and Contraindications Not to be completed over open areas or new skin Report any new open areas or intolerance to massage to therapist or physician * Note that some patients may initially have limited tolerance and will not tolerate desired pressure.

17 Pressure Garments Rationale Decrease hypertrophic scarring Alleviate itching Provide protection to skin Goal is to gradually increase wear time up to 23 hours per day Garments are worn for up to 2 years post injury and additional time after reconstruction

18 Pressure Garments Procedure for donning/doffing Skin should be free of creams and dry Place directly on skin except when wearing diapers Continue with dressings per physician order; Silon TEX may be sewn into garments which would take place of silicone dressings No wrinkles; especially when Silon TEX is present Adjust by making sure foot and hand glove fits snugly into all web spaces Remove for bathing and scar massage

19 Pressure Garments Contraindications/Precautions Non-silicone based dressings may be used on open areas under garments per physician order Note that creasing and indentations are normal however monitor for indications of skin breakdown Monitor fit and integrity (i.e. too tight, swelling, skin discoloration, tears, holes, broken zippers)

20 Face Mask Rationale To decrease hypertrophic scarring and itching Procedure for donning/doffing Make sure face is free of creams and dry Position mask in center of face and secure straps snug. Straps are in a five point system with a top strap and 2 side straps Mask should be snug on area of face which was burned and cause blanching of the skin

21 Face Mask Mask care instructions Mask should be cleaned at least once daily using alcohol and air dried Mask should be removed for eating Mask should be removed when patient is sweating and dried Mask should not be placed on or near direct heat Contraindication/Precautions Do not place over open wounds Monitor fit and integrity (i.e. too tight, swelling, skin discoloration, or irritation)

22 Proper Positioning With Burns Burn To Upper Body: Anterior Neck: extension of cervical spine (NO pillows, monitor position of shoulders, place wedge under back to promote extension Shoulders: abducted at 90 degrees or below (NEVER above), airplane splint may be used Circumferential Arms: extend arms, supinate forearms (palms up), elbow extension splints may be used Hand: 30 degrees wrist extension, 60 degrees MCP flexion, extension of IP s, may use a variety of wrist cock-up/hand splints Palm: extend MCP s and abduct thumb Serial casting for upper or lower extremities

23 Proper Positioning With Burns Continued Burn To Lower Body: Anterior Hip: extend hip with neutral rotation, encourage prone lying, keep bed flat Perineum: abduct lower extremities with neutral rotation, may use abduction pillow Posterior Leg: extension of knee, may use a variety of knee extension splints Anterior Ankle: neutral, dorsiflexion with heels off surface, may use a variety of splints in dorsiflexion or plantar flexion depending on patient s contractures Anterior Toes: neutral toe position, toes flat on floor/surface, may use a variety of splints to encourage MTP flexion

24 Airplane Splint Splints Resting Pan Splint Focused Rigidity splints Ultraflex knee splint Ultraflex elbow splint TOT-Collar Knee immobilizer

25 How Burns Influence Function

26 Discharge Planning Establish ongoing goals Burn Clinic Follow up Equipment Patient and family education Community/school reintegration Regional Burn Camps

27 Community Re-Entry Goals are to address psychosocial skills, coping, and safety as well as to improve functional independence in preparation for discharge Therapeutic outings completed during inpatient stay (i.e. grocery store, mall) Focus on safety, endurance, and ambulation within the environment

28 School Re-Entry Goal is to educate the school, students, patient and family, assess safety and ease transition back to educational environment Identified by Rehabilitation Team Includes parent involvement Completed by child life specialist, therapist and psychologist as needed

29 Any Questions? Erin P. Frazier, OTR/L Occupational Therapist Jessica Maher, PT, MSPT Physical Therapist Mt. Washington Pediatric Hospital 1708 West Rogers Ave Baltimore, MD Thank you.