Prevention of scarring should be the aim of burn management. For every member of the burn team, rehabilitation must start from the time of injury. Having a substantial burn injury is frightening, particularly as patients will not know what to expect and will be in pain. Consistent and often repetitive education is a vital part of patient care. Oedema management, respiratory management, positioning, and engaging patients in functional activities and movement must start immediately. Patients need to be encouraged to work to their abilities and accept responsibility for their own management. Functional outcome is compromised if patients do not regularly engage in movement.
In order to achieve desired outcomes and movement habits, ensuring adequate pain control is important. The aim of analgesic drugs should be to develop a good baseline pain control to allow functional movement and activities of daily living to occur at any time during the day. The use of combined analgesics such as paracetamol, non-steroidal anti-inflammatory drugs, Tramadol, and slow release narcotics reduces the need for increasing doses of narcotics for breakthrough pain. Codeine should be avoided if possible because of its negative effects on gut motility. Other pain control methods that may be helpful include transcutaneous electrical nerve stimulation (TENS).
Aggressive, prophylactic chest treatment should start on suspicion of an inhalational injury. If there is a history of burn in a closed space or the patient has a reduced level of consciousness then frequent, short treatments should begin on admission. Treatment should be aimed at removing lung secretions (oedema), normalising breathing mechanics, and preventing complications such as pneumonia.
Initial treatment should include:
* Normalisation of breathing mechanics—such as using a positive expiratory pressure device, intermittent positive pressure breathing, sitting out of bed, positioning
* Improving the depth of breathing and collateral alveolar ventilation—such as by ambulation or, when that is not possible, a tilt table, facilitation techniques, inspiratory holds.
Movement is a habit that should be encouraged from admission to the burns unit. If a patient can accept the responsibility of self exercise and activities of daily living then the most difficult aspects of rehabilitation are easily achieved. If there is suspected tendon damage from the burn, then protected movement is appropriate and resting splints may be necessary.
Oedema removal should be encouraged from admission. The only body system that can actively remove excess fluid and debris from the interstitium is the lymphatic system. Oedema collection in the zone of stasis of a burn may promote the progression of depth of a burn. The principles of reduction of oedema should be adhered to in totality and not just in part.
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