Chapter 87: Rehabilitation of the Burn Patient

INTRODUCTION

ANNUALLY, AN ESTIMATED 11 MILLION INDIVIDUALS worldwide and 400,000 in the United States experience a burn injury.¹ In the past decade, the mortality rate in the United States was 3.3%. Survival rates have improved over the past few decades because of increased understanding of the cellular and systemic response to burns, advances in critical and surgical care, and prevention efforts in work, home, and recreational activities. Currently, the median lethal dose (LD-50) are burns which affect 70% total body surface area (TBSA).² Burn injury is one of the leading causes of disability worldwide (as measured by disability-adjusted life years), and particularly affects low- and middle-income countries.¹ Burn injuries present a unique constellation of rehabilitation issues, which include hypertrophic scarring, contractures, pain, and mobility impairments. Other complications include neuropathies, temperature regulation dysfunction, pruritis, bony abnormalities, psychological impairments, and community integration deficits.

EPIDEMIOLOGY OF BURN INJURIES

Of the 450,000 burn injuries in the United States that receive medical treatment each year, 40,000 require hospitalization. Approximately 75% of hospitalized burn patients are treated at specialty burn centers.³ The survival rate for those treated at a burn center is 96.6%.³ Higher mortality is associated with older age, inhalation injury, and burn size. The mortality rate for burns outside of the United States is higher at 4.8% and varies by geography.^2,4 In the 2014 National Burn Repository report, which collected and analyzed available US hospital data between 2004 and 2013, the distribution of burn etiologies were: 43% from fire/flame, 34% from scald, 9% from hot object contact, 4% from electric, and 3% from chemicals. The etiology frequencies were similar in all age groups except in children less than 5 years, where scalds and contact burns were the most common etiologies.²

The majority of burn injuries occur in men (69%). The average age of the burn population is 32 years. Children younger than 16 years comprised 29% of burn cases and adults older than 60 years comprised 13% of burn cases. Approximately 73% of the burn injuries were reported to occur at home and 71% were reported to be accidental. The large majority of burn injuries (78%) had a TBSA burn less than 20%. In the United States, burns are most common in Caucasians (58.9%), followed by Blacks (19.7%), Hispanics (14.0%), Asians (2.4%), and Native Americans (0.8%).²

PATHOPHYSIOLOGY OF BURN INJURIES

Burn injuries result in unique physiologic changes at the cellular, local, and systemic levels. This is a robust area of current investigation; nonetheless, general knowledge of burn physiology helps one understand the principles of burn care.

Local Response to Burns

There are three locally affected zones after burn injury, originally described in 1947 as: (1) the zone of coagulation, (2) zone of stasis, and (3) zone of hyperemia. The ...