Rehabilitation of burn Rehabilitation of burn patientspatients

20122012

Rehabilitation Rehabilitation is the system of actions is the system of actions which aim is to restore (fully or partly), which aim is to restore (fully or partly),

improve function of organs and improve function of organs and systems of the organism, returning systems of the organism, returning

patient to normal life.patient to normal life.

Main anatomic types of post Main anatomic types of post burn resultsburn results׃׃

Scar deformation of skin surfacesScar deformation of skin surfaces Scar defect of tissuesScar defect of tissues Contracture of jointsContracture of joints Post burn trophy ulcersPost burn trophy ulcers

Stages of rehabilitationStages of rehabilitation

FirstFirst – to restore – to restore the skin surfaces the skin surfaces

SecondSecond – to prevent – to prevent and treat pathological and treat pathological scar growthscar growth

II periodperiod– conservative – conservative treatmenttreatment

6-12 month after the 6-12 month after the

traumatrauma

II periodII period – invasive – invasive methodsmethods

not less than a year after the not less than a year after the

traumatrauma

IIIIII period period – – conservative conservative treatmenttreatment

in 2-3- weeks after in 2-3- weeks after last operationlast operation

Type of grows of scar tissueType of grows of scar tissue

Normotrophic stableNormotrophic stable Atrophic stableAtrophic stable, , with thin with thin

areas areas Hypertrophic are growingHypertrophic are growing Keloid are growing with Keloid are growing with

invasion toinvasion to

neighboring tissuesneighboring tissues

Normotrophic scarsNormotrophic scars

Atrophic scarsAtrophic scars

Hypertrophic Hypertrophic scarsscars Keloid scarsKeloid scars

Frostbite and total Frostbite and total freezing. Pathogenesis, freezing. Pathogenesis, diagnostic, treatmentdiagnostic, treatment

20122012

HistoryHistory

A 5000-year-old pre-Columbian mummy A 5000-year-old pre-Columbian mummy discovered in the Chilean mountains offers discovered in the Chilean mountains offers the earliest documented evidence of the earliest documented evidence of frostbite. More recently, Napoleon’sfrostbite. More recently, Napoleon’s surgeon surgeon, , Baron Dominique Larrey, provided the first Baron Dominique Larrey, provided the first description of the mechanisms of frostbite in description of the mechanisms of frostbite in 1812, during his army’s retreat from Moscow. 1812, during his army’s retreat from Moscow. He also noted the harmful effects of the He also noted the harmful effects of the freeze-thaw-freeze cycle endured by soldiers freeze-thaw-freeze cycle endured by soldiers who would warm their frozen hands and feet who would warm their frozen hands and feet over the campfire at night only to refreeze over the campfire at night only to refreeze those same parts by the next morning.those same parts by the next morning.

Although frostbite Although frostbite used to be a military used to be a military problem, it is now a problem, it is now a civilian one as well. civilian one as well.

Most people who get frostbite are males Most people who get frostbite are males aged 30-49 years. The aged 30-49 years. The nosenose, cheeks, , cheeks, ears, fingers, and toes are most commonly ears, fingers, and toes are most commonly affected. Everyone is susceptible, even affected. Everyone is susceptible, even people who have been living in people who have been living in cold cold climates for most of their lives.climates for most of their lives.

Besides low temperature some Besides low temperature some additional factorsadditional factors play role in appearing of frostbiteplay role in appearing of frostbite::

MeteorologicalMeteorological – – high humidityhigh humidity, , wind.wind.

Besides low temperature some Besides low temperature some additional additional factorsfactors play role in appearing of frostbiteplay role in appearing of frostbite::

Mechanical factorsMechanical factors that lead to disorders of that lead to disorders of microcirculationmicrocirculation – – tight shoestight shoes or closeor close,, long lasting long lasting forced positionforced position..

Factors that decrease local tissue resistanceFactors that decrease local tissue resistance – – frostbites frostbites and traumas in the pastand traumas in the past, , increased increased perspirationperspiration of feet of feet, , neuro-trophicneuro-trophic disordersdisorders..

Factors that decrease general resistance of the Factors that decrease general resistance of the organismorganism – – traumatrauma andand blood loseblood lose, , inflammationinflammation, , fatiguefatigue, , lack of vitaminslack of vitamins, , drank stagedrank stage, , lose of consciousnesslose of consciousness, , hypoxia in the mountainshypoxia in the mountains..

Periods of frostbite’s clinicPeriods of frostbite’s clinic

Before reactive Before reactive -- or or hypothermiahypothermia, , few few hours till day or more. Skin of injured hours till day or more. Skin of injured extremity is pailextremity is pail, , cyanoticcyanotic. . Cold on touchCold on touch, , decreased sensitiveness, painfuldecreased sensitiveness, painful. .

During warming of the extremity blood During warming of the extremity blood circulation is restoring and circulation is restoring and reactivereactive period period startsstarts. . It’s symptoms are warming of the It’s symptoms are warming of the extremity, hyperemia, extremity, hyperemia, pain, edema.pain, edema.

Frostbite of the I stageFrostbite of the I stage

Duration of cold action is shortDuration of cold action is short. . Paleness Paleness changes into hyperemiachanges into hyperemia. . Sensitiveness is Sensitiveness is savedsaved. . Moves of fingers of hand and feet Moves of fingers of hand and feet are activeare active. . Edema is progressingEdema is progressing. . Pain is Pain is severesevere. . Full recoveryFull recovery in 5in 5-7 -7 daysdays. .

Frostbite of the II stageFrostbite of the II stage

During firstDuring first days severe pain and itchingdays severe pain and itching. . Edema of tissues is bigger than injured Edema of tissues is bigger than injured areaarea. . Main sign is formation of blisters with Main sign is formation of blisters with plasma like transparent liquidplasma like transparent liquid. . Blisters Blisters appear on 2 day after the injuryappear on 2 day after the injury. . Derivates Derivates of skin are saved that is why full restoring of skin are saved that is why full restoring of skin cover is possible and it takes 1-2 of skin cover is possible and it takes 1-2 weeksweeks. . Nails will be restoredNails will be restored. . Scars are Scars are not permanent.not permanent.

Frostbite ofFrostbite of the I-the I-II II stagestage

Frostbite ofFrostbite of the the III III stagestage

NecrosisNecrosis of all skin layersof all skin layers sometimes even sometimes even injury of subcutaneous tissueinjury of subcutaneous tissue. . Blisters with Blisters with hemorrhage hemorrhage liquidliquid. . Decreasing of Decreasing of sensitivenesssensitiveness. . Skin in reactive period is Skin in reactive period is red and cyanoticred and cyanotic. . Cold on touchCold on touch. . If proper If proper treatment with autoplastic is not used, big treatment with autoplastic is not used, big connective tissue scars appear.connective tissue scars appear.

Frostbite of the IV stageFrostbite of the IV stage

Injury includes destroying of bones and Injury includes destroying of bones and jointsjoints. . Temperature of skin in bTemperature of skin in bееfore fore reactive period is extremely decreasedreactive period is extremely decreased. . Edema appears during first Edema appears during first 1-2 1-2 hourshours, , thanthan - - dry or wet gangrene of injured areasdry or wet gangrene of injured areas. . Demarcation line appears after Demarcation line appears after 1-2 1-2 weeksweeks. . Edema takes much larger area than Edema takes much larger area than gangrenegangrene. .

Frostbite of the III-Frostbite of the III-IIVV stagestage

DiagnosticDiagnostic The doctor will take note of the vital signs, The doctor will take note of the vital signs,

including temperature, including temperature, pulsepulse, , blood pressureblood pressure, , and and respiratory raterespiratory rate in order to exclude or treat in order to exclude or treat any immediate life threats such as hypothermia any immediate life threats such as hypothermia or severe or severe infectioninfection. .

DiagnosticDiagnostic

The doctor will collect data in order to classify The doctor will collect data in order to classify the injury as superficial or deep and the the injury as superficial or deep and the prognosisprognosis as favorable or poor. as favorable or poor.

A A good prognosisgood prognosis is heralded by intact is heralded by intact sensation, normal sensation, normal skin colorskin color, blisters with , blisters with clear fluid, the ability to deform the skin clear fluid, the ability to deform the skin with pressure, and the skin becoming pink with pressure, and the skin becoming pink when thawed. when thawed.

Blisters with dark fluid, skin turning dark Blisters with dark fluid, skin turning dark blue when thawed, and an inability to blue when thawed, and an inability to indent the skin with pressure indent the skin with pressure indicateindicate a a poor prognosispoor prognosis. .

Zones of pathologic processZones of pathologic process in case of frostbitesin case of frostbites

1) 1) total necrosistotal necrosis 2) 2) zone of non reversible changeszone of non reversible changes, ,

where later trophic ulcers will where later trophic ulcers will appearappear; ;

3) 3) zone of reversible degeneration zone of reversible degeneration processesprocesses, , where tissues will where tissues will restore their functions and level of restore their functions and level of life processeslife processes; ;

4) 4) zone ofzone of ascendant ascendant pathologic pathologic processesprocesses – – where development of where development of neuro-trophic and vascular neuro-trophic and vascular disorders is possibledisorders is possible ( (neuritisneuritis, , endarteritisendarteritis, , osteoporosisosteoporosis, , disorders disorders of trophicof trophic, , sensationsensation).).

First aid in case of frostbitesFirst aid in case of frostbites To To dressdress the victim into the victim into dry closedry close, , not to make additional injury during not to make additional injury during

dressingdressing and changing of footwearand changing of footwear..

To To warmwarm injured extremity in the bath. The temperature should be injured extremity in the bath. The temperature should be increasing from increasing from +37+37°°С С tilltill +40 +40°°С. С. At the same time, by hands and soft At the same time, by hands and soft soap sponge make gentle massage of the extremity from periphery to soap sponge make gentle massage of the extremity from periphery to centercenter..

GGrindingrinding of skin by of skin by camphorcamphor alcohol, glycerin, or just by wet hand for alcohol, glycerin, or just by wet hand for stimulation and restoring of blood circulation stimulation and restoring of blood circulation

After the extremity become warmer and pink (30After the extremity become warmer and pink (30-40 -40 min)min), , it should be it should be dried and handled by alcohol or strong antiseptic solutiondried and handled by alcohol or strong antiseptic solution, , dressed with dressed with antiseptic bandageantiseptic bandage, wrap, wraped by ed by thickthick layer of grey gauze layer of grey gauze ( (thermal thermal isolating dressingisolating dressing). ). This method stops cooling of tissues from the outside This method stops cooling of tissues from the outside and gradual warming from inside, parallel to restoring of normal blood and gradual warming from inside, parallel to restoring of normal blood circulationcirculation. . This dress should not be taken off during This dress should not be taken off during 8-20 8-20 hourshours. .

Victims with frostbites should get Victims with frostbites should get warm drinkswarm drinks ( tea, coffee), warm food ( tea, coffee), warm food. .

SURGICAL TREATMENTSURGICAL TREATMENT

1. 1. NecrotomyNecrotomy – – cutting through necrotic tissues cutting through necrotic tissues for decreasing of edema and circulatory disorders for decreasing of edema and circulatory disorders ( first 3 days( first 3 days after the trauma)after the trauma). .

2. 2. NecrectomyNecrectomy – – cutting off the necrotic tissues cutting off the necrotic tissues : :

а) а) earlyearly ( 1 ( 1stst day day ). ). In case of gangreneIn case of gangrene, , total total injury of big segments of extremitiesinjury of big segments of extremities, , toxemiatoxemia, , risk risk of sepsisof sepsis; ;

б) б) delayeddelayed (15-30 (15-30thth dayday after the traumaafter the trauma )) – – in in case of gangrene with clear limitscase of gangrene with clear limits; ;

в) в) latelate ( (more than more than 1 1 monthmonth) – ) – in case of in case of gangrene with osteolisis or osteonecrosisgangrene with osteolisis or osteonecrosis. .

SURGICAL TREATMENTSURGICAL TREATMENT 3. 3. AmputationAmputation of injured segmentof injured segment - - besidesbesides cases that cases that

can be decided during necrectomy, and formation of can be decided during necrectomy, and formation of functionally good stumpfunctionally good stump. . Always should be provided Always should be provided proximally than demarcation lineproximally than demarcation line. .

4.4. Surgical restoring of the skin coverSurgical restoring of the skin cover. . In case of In case of granulation wounds with size of more than granulation wounds with size of more than 1,5 1,5 sm2sm2. . Terms of providing Terms of providing – – depending on wounds.depending on wounds.

5. 5. Reconstructive operationsReconstructive operations – – increase functional increase functional capacities of stumps and future cosmetic aimscapacities of stumps and future cosmetic aims. . Terms of Terms of providing providing – – more than more than 2 2 monthsmonths. .

FrostbiteFrostbite I-III-II stst.. NecrectomyNecrectomy

XenoplasticXenoplastic EpithelizationEpithelization

Frostbite III-IV stFrostbite III-IV st.. XenoplasticXenoplastic

Auto graftingAuto grafting EpithelizationEpithelization

Total overcoolingTotal overcooling / /freezingfreezing/ / 1) 1) adynamic stageadynamic stage – – decreasing of body temperaturedecreasing of body temperature toto

3535°°С, С, total fatiguetotal fatigue, , paleness of the skinpaleness of the skin, , chillschills, А, АPP andand breezing ratebreezing rate are normalare normal..

2) 2) stupor stagestupor stage – – decreasing of body temperaturedecreasing of body temperature toto 3232°°С, С, sleepiness, absence of sleepiness, absence of mimicrymimicry, , hallucinations,hallucinations, problems with movesproblems with moves. . Pulse is decreasing to Pulse is decreasing to 50 /50 /minmin, , breezingbreezing toto 12 / 12 /minmin, А, АPP decreaseddecreased. . SkinSkin is pailis pail, , cold on cold on touchtouch..

3) 3) cramp stagecramp stage - - decreasing of body temperaturedecreasing of body temperature lower lower than than 3030°°СС – – strong disordersstrong disorders of breezing and blood of breezing and blood circulationcirculation, , unconsciousness unconsciousness ,, pulse lower pulse lower 34 34 /min/min, , breezing is superficialbreezing is superficial, , AP is decreasedAP is decreased. .

4) 4) terminal stageterminal stage - - decreasing of body temperaturedecreasing of body temperature lower lower 25 25 °°СС. For the treatment . For the treatment artificial breezing should be artificial breezing should be used, used, aim of care is to fight with hypoxia of brainaim of care is to fight with hypoxia of brain, , problems of heart function.problems of heart function.

IIncreased risk for the injuryncreased risk for the injury

1.1. Most cases of frostbite are seen in Most cases of frostbite are seen in alcoholics, people with alcoholics, people with psychiatricpsychiatric illness, car accidents or car illness, car accidents or car breakdowns in bad weather, and breakdowns in bad weather, and recreational drug misuse. recreational drug misuse.

2.2. All of these conditions share the All of these conditions share the problem of cold exposure and either problem of cold exposure and either the unwillingness or inability of a the unwillingness or inability of a person to remove himself or herself person to remove himself or herself from this threat. from this threat.

IIncreased risk for the injuryncreased risk for the injury

3. 3. TobaccoTobacco smokers and people with smokers and people with diseases of the blood vessels also are diseases of the blood vessels also are at increased risk because they have at increased risk because they have an already decreased amount of blood an already decreased amount of blood flow to their arms and legs. flow to their arms and legs.

4. 4. Homelessness, Homelessness, fatiguefatigue, dehydration, , dehydration, improper clothing, and improper clothing, and highhigh altitudealtitude are are additional risk factors. additional risk factors.

PreventionPrevention

Dress for the weather. Dress for the weather.

PreventionPrevention

LayersLayers are best, and mittens are better are best, and mittens are better than gloves (keeps your warm fingers than gloves (keeps your warm fingers together while warming each other). together while warming each other).

Wear 2 pairs of socks, with the inner Wear 2 pairs of socks, with the inner layer made of synthetic layer made of synthetic fiberfiber, such as , such as polypropylene, to wick water away from polypropylene, to wick water away from the skin and the outer layer made of the skin and the outer layer made of wool for increased insulation. wool for increased insulation.

PreventionPrevention

Shoes should be waterproof. Shoes should be waterproof.

Cover your head, face, nose, and ears at all Cover your head, face, nose, and ears at all times. times.

Clothes should fit loosely to avoid a Clothes should fit loosely to avoid a decrease in blood flow to the arms and legs. decrease in blood flow to the arms and legs.

Always travel with a friend in case help is Always travel with a friend in case help is needed. needed.

Avoid smoking and alcohol. Avoid smoking and alcohol.

Thank you Thank you for attentionfor attention