First aid period
(1) Clinical treatment
It is generally believed that the first aid period of burn is from the occurrence of burn to 72 hours after burn. The focus of clinical treatment in this period is to prevent or treat shock with high incidence and early occurrence in severely burned patients. If the illness is delayed, they will die because of long shock time, severe ischemia and hypoxia, systemic infection, various visceral complications and even multiple organ failure.
(2) Job evaluation
Comprehensive evaluation should be postponed until the patient's injury is stable. At this stage, the therapist should make a general understanding, such as the degree of burn site and the needs of clinical treatment, the functional state of the patient before injury, personal interests, economic situation and social relations.
(3) Occupational therapy methods
1. Use of splint
Collagen synthesis and contracture began 24~48 hours after burn. Therefore, contracture should be prevented as soon as possible. Generally, burns involving superficial second degree and above joints must be treated with splint, and the wearing time of splint depends on the patient's tolerance. If the patient's active activity ability decreases, the wearing time of splint should be increased. For patients who can't take the initiative to use sedatives, in addition to treatment and dressing change, if the patient can use the affected limb for functional activities (such as self-feeding or therapeutic exercise), the patient only needs to use the splint at night, keep the anti-contracture position, put the splint outside the dressing, and fix the splint with bandage or velcro.
Step 2 pose
Patients with extensive burns often stay in bed for a long time, and their joints are often in a non-functional position, which leads to abnormal function when the wound is not healed and produces contracture deformity that is difficult to correct. According to the prone position of scar contracture after deep burn healing, we should keep the position in functional position and anti-contracture position from the early stage to prevent scar contracture from causing deformity or dysfunction. The specific measures are as follows: (1) Lie flat within 48 hours after the injury, and the head of the bed should be raised by 30 in case of facial burns after the shock stage.
(2) Neck: When the neck is burned in front, take off the pillow to make the head fully lean back (a small long pillow can be put on the neck and shoulder) to prevent scar contracture in front of the neck and burn on the back or both sides of the neck, keep the neck neutral and prevent scar contracture deformity on both sides of the neck.
(3) When the upper arm burns on the chest wall behind the armpit, the upper arm should be fully exposed (preferably 90 degrees) to prevent the upper arm from adhering to the armpit and the wound surface of the lateral chest wall and causing scar contracture.
(4) Elbow joint: If the back of the hand is burned, the elbow joint should be straightened. Generally, the elbow joint should be flexed 70 ~ 90 and the forearm should be neutral.
(5) Hand burn: There are many small joints in the hand and the activity intensity is high. After the injury, the patient will have wrist flexion, interphalangeal flexion, thumb adduction deformity and burn of the back of the hand. It is appropriate to put the wrist joint in the palm flexion position, the palm or ring burns, the wrist joint bends slightly, and the fingers are separated by sterile gauze. The metacarpophalangeal joint will naturally bend 40 ~ 50, and the interphalangeal joint will be straight.
(6) Hip perineum burn: keep the hip joint straight and the lower limbs fully abduct.
(7) Lower limb burn: If it is only the front burn, the knee joint slightly flexes 10 ~ 20, and the height can also be raised at the back of the knee joint 15 ~ 30. If the back of the knee joint is burned, keep the knee joint straight, and fix the straight position with splint if necessary.
(8) Lower leg with ankle burn: the ankle joint should be kept in a neutral position. For those who have no self-control ability, a sponge pad or a spring device can be placed at the end of the bed, so that the patient can pedal on the pad or board. When the patient lies on his back in the dorsiflexion position of ankle joint, the support plate should be used to push the sole of foot to prevent foot drop caused by shortening Achilles tendon.
3. Raise limbs and reduce limb swelling. You can use a foam pad or pillow to raise your limbs, and pay attention to prevent the brachial plexus from pulling injury.
The second acute stage is the stage from first aid to wound healing, which may last for several days to several months, depending on the degree of burn and whether skin grafting is needed for wound healing.
Treatment of burns
For small and medium-sized burn patients without shock, early debridement should be carried out within 6 hours after injury. In general, burn patients with shock or possible shock should be treated after shock control and complications are properly handled.
Treatment of superficial burn wound: mainly to relieve pain and protect the wound to prevent infection and promote healing. First degree burns can be exposed. For superficial second-degree burns, dressing or exposure therapy can be used as appropriate. The blister should be drained, and the blister skin without pollution and damage should be removed from the wound infection. If the wound is infected, the wound can be cleaned by soaking and wet compress. If necessary, exposure therapy and antibacterial drugs should be used for deep burns. If the dressing should not exceed 3-5 days, the scab should be cut as soon as possible and the skin graft should be tight.
(2) Job evaluation
1. Understand the medical history and inquire about the whole process of burn treatment in detail. In the past medical history, focus on whether the patient has diabetes, lung disease and mental illness, because these diseases may affect occupational therapy.
Because the general persistence and mental persistence of most burn patients are obviously low, the burn evaluation table shown in table 16-3- 1 can be used to evaluate patients in a short time. Before face-to-face contact with patients, therapists must fully collect patients' relevant information, not only the contents recorded in medical records, but also communicate with doctors and nurses' physical therapists (PT) to understand the treatment objectives and rehabilitation training plans of patients in various professions.
(1) Scope, depth and treatment of the injured part: the burn depth can be marked on the human body diagram according to the diagram, and the tension-reducing incision and skin grafting part can also be marked.
(2) Use artificial respiration machine to burn trachea.
(3) Causes of injury: Mental function is low due to suicide motives or accidents, so it is particularly important to know the situation when the injury occurred.
(4) Complications: It is necessary to know the situation of various organs, whether there is infection and other trauma (fracture, nerve injury, tendon injury, etc. ), whether there is mental illness and other related information.
(5) Clinical examination data: it is important information to master the general state of patients. It is necessary to understand what problems will be predicted if the normal values of inspection items and data are abnormal, and pay attention to whether these data will gradually approach normal or deteriorate further in the future.
2. Ability of daily living
It is necessary to master the degree of completion of daily activities within the scope allowed by doctors, including bed activities, hand activities, walking activities, standing and sitting, personal hygiene, eating and dressing.
3. Behavior and communication skills
4. Cognitive perception state.
5. The neuromuscular state includes joint mobility, muscle strength and sensory measurement.
6. Activity tolerance
7. Psychological function
Mental function not only refers to mental illness, but also includes psychological shock, anxiety and depression caused by injury, as well as the influence of sedatives and tranquilizers used in analgesic treatment. Because of the special environment, patients may be delirious. Therapists should judge whether these factors exist and analyze their degree accordingly.
8. Related treatment and schedule
It is necessary to confirm the contents of burn site treatment and the time schedule of bandage replacement in hydrotherapy, as well as to understand the surgical debridement and scheduled examination.
9. Taboos and preventive measures
Special sports and sports taboos are one of the important items of data collection. It is very important for the effective cooperation of the rehabilitation team to communicate with doctors in advance and get relevant information.
10. Social conditions
It is necessary to confirm the housing structure of family members, the occupation and economic status of caregivers and other related information.
Table 16-3- 1 burn evaluation table
(3) Occupational therapy methods
The purpose of occupational therapy is to improve the daily living ability and skills of patients.
1. Adaptation measures For example, for some burn patients, language communication is difficult due to tracheal intubation or burn around lips, and occupational therapists can communicate with patients through communication board gestures or eye changes.
2. The splint and posture should be kept in emergency posture and posture, and adjusted according to the activity participation ability of each patient.
3. Exercise splint and posture should be combined with exercise. Exercise is especially important for burn patients to control swelling and prevent muscle atrophy, tendon adhesion, joint stiffness and joint capsule shortening. The typical exercise of burn patients should follow the continuous passive exercise; On the other hand, the scheme of putting the patient's activity ability into daily life activities for continuous exercise exercise is: ① Passive ROM; ② Active auxiliary ROM; ③ Active ROM; ④ If the patient can't actively participate in exercise, passive ROM can be used instead. In short, as long as conditions permit, patients should be encouraged to do active physical exercise as much as possible. The role of the therapist is to guide patients to recover their functions and regularly check wound healing and skin reaction to exercise.
Contraindications to exercise: ① bare tendons; ② recent skin grafting (within 10 days after skin grafting); ③ Fracture
4. Perioperative care: 5~ 10 days after skin grafting is a large area burn patient in perioperative period, which may require multiple skin grafting operations. Every skin grafting operation is a new beginning of perioperative period. For example, a burn patient needs skin grafting on upper and lower limbs for three times, and proper perioperative management is needed after each skin grafting survival. The role of OT division in perioperative period is to make splints. The ideal splint for fixing the body skin graft should be made before or during the operation and used at the end of the operation. Generally, the splint should be used with postoperative dressing for 5~ 10 days. During this period, in order to make the skin graft survive, ROM exercise is taboo. When the dressing was opened for the first time after operation, the burn cooperation group evaluated the survival of skin graft and made a recovery exercise plan.
5. Pain management Occupational therapists must pay attention to pain problems. Many severely burned patients can't express their subjective pain orally. For example, in dressing change or treatment practice, the therapist should observe and master the objective reaction indexes of patients to pain, such as changes in blood pressure, heart rate and respiratory expression, and adjust the intensity or time of treatment in time according to these objective reactions. Other pain treatment techniques include distraction and visualization to encourage patients to actively participate in exercise and change dressings.
6. Environmental Adaptation From the acute phase to the whole recovery period, occupational therapists can improve some facilities according to the environment and needs of patients, thus improving the ADL ability and independence of patients.
7. Publicity and education therapists can encourage patients to communicate with family, relatives, friends and colleagues. They can communicate by telephone, letters, recordings, tapes and gifts. They may need to learn new ways to contact or comfort patients. Therapists can provide guidance in this regard. In addition, they can actively provide information about patients' professional hobbies and other related aspects.
8. Discharge plan Due to many factors such as economic situation, it is impossible for burn patients to stay in hospital for a long time. Therefore, in the initial stage of discharge, the factors that need to be considered in the patient's discharge plan are: the available resources in the patient's community (or village), the family environment, and the continued treatment after discharge. Occupational therapists should establish contact with the patient's community to ensure that the patient can continue to receive treatment after discharge.
9. Communication between treatment collaboration groups Communication and information exchange among members of the collaboration group are very important. Occupational therapists can remind members of their knowledge and experience in patient posture, proper use of splint, prevention of contracture, and environmental transformation.
10. Support and psychosocial adjustment in acute phase All burn patients, regardless of their age, will reflect some psychological reactions to varying degrees, including fear of death, anxiety and depression.
The first reaction of burn patients is to be glad that they have survived in a narcissistic way, showing refusal to eat and sleepiness. These are coping mechanisms to concentrate and survive. The child behaves like a baby, stuttering and enuresis, and makes himself very dirty. Uncooperative adults are uncooperative, ask for more hospitalization, and then enter a state of sadness.
Feeling the loss caused by burns is a normal adaptive defense response. Staff and their families don't have to panic and artificially stop this process to avoid falling into deep pathological depression in the future.
Adverse adaptation reactions include rejection of separation. Denial reaction refers to the patient's refusal to admit the severity of his trauma. In fact, the psychological reality of separation means that they know the existence of trauma, but they can't accept it psychologically, so the trauma parts such as disfigurement are separated from the whole. For example, when changing medicine, medical staff should let patients know the root of the problem, gain insight into the reality they are facing, take behavior correction therapy or drug treatment when necessary, and change their separation reaction, as well as psychological obstacles such as nightmares, panic and anorexia.
Finally, patients are afraid of leaving the hospital, worried about how their friends and colleagues at home and school will treat them after leaving the hospital, and worried about whether they are still competitive physically and intellectually. After leaving the hospital, they are unwilling to return to their original jobs, participate in social activities or even go shopping. The main reason is beauty and self-esteem. In addition, there are some objective psychological obstacles, such as decreased attention, decreased interest in daily life, decreased excitability and depression.
In order to alleviate patients' emotional reaction, it is also necessary to do a good job for family members to understand the illness, overcome their shock and anxiety, explain the necessity and correctness of treatment measures, help patients to get through the difficult exciting period and retrogression period, and hold a forum for family members of patients who have been discharged or are about to be discharged to relieve their concerns, so that family members are willing to take patients home. The recovery period refers to 6 months to 2 years after the acute phase, until the scar matures, when the color of the scar fades and collagen synthesis stops.
performance assessment
1. Continue to evaluate the abilities of burn patients, such as joint mobility and muscle strength.
2. Functional evaluation: rehabilitation departments with conditions to take care of their own housework can adopt standard evaluation, such as FIM scale or ValparWorkSamples scale, which has the advantage that these standard tests provide objective information.
(2)scar management.
1. Scar staging
Scar after burn can be divided into hyperplasia type and non-hyperplasia type, the latter is only a few, and its hyperplasia time is short, only a few weeks to several months, and the degree of hyperplasia is light; Most of burn scars is hyperplastic, and the hyperplastic time is long and the degree is serious. Whether hyperplasia or non-hyperplasia, there are two periods from scar formation to maturity, namely hyperplasia period and maturity period.
(1) Proliferative stage: After the wound healing of deep second or third degree burns 1~3 months, the initial stage of scar hyperplasia changed from light red to bright red, and the surface became rough, then induration appeared, and the mild itching gradually increased. After the wound healing, the scar hyperplasia reached its peak, and the color changed from bright red to crimson or purplish red. A capillary network with uneven thickness can be seen on the surface; The epidermis is thin and the stratum corneum is thickened, which is easy to break when it is dry; The thickness of the scar can be increased to several millimeters. Because of the uneven thickness of scar hyperplasia, the surface is uneven, but the thickened edge does not exceed the limit of deep burn. Scar is hard and inelastic, itching intensifies, tingling and tenderness intensifies with burning and contraction, joint movement is partially or completely limited, and scar contracture can cause joint dislocation and deformity. In a word, the characteristics of hypertrophic scar can be summarized as 3R: red bulge and rigidity.
(2) Maturity: After the hyperplastic scar reaches its peak, the hyperplasia begins to decline and gradually matures and softens. However, the sequela of joint dislocation and deformity caused by hypertrophic scar can not restore or correct the slow process of scar maturation, which usually takes 6-24 months. In a few cases, the maturity time of scars in different parts of the same individual can be extended by 3-4 years or more, which is also inconsistent with the sign that scars begin to mature, and the color gradually changes from crimson or purple to brown, and finally becomes purple or brown. The capillaries on the scar surface disappeared; The thickness gradually becomes thinner, the fully mature scar is at the same level as the surrounding skin, the surface roughness becomes inconspicuous or disappears, but the cuticle on the scar surface is still thickened and dry; The texture gradually becomes soft, but it is still harder than the surrounding normal skin; The area where subcutaneous fat was not burned or preserved during escharectomy still has some elasticity after scar maturity; In the process of scar maturation, the pain disappears first, while the itching can last until the scar is completely mature, and the contraction and burning sensation gradually disappear with the scar maturation. In short, the characteristics of mature scars can be summarized as 3P: pale and flexible.
2. Scar evaluation burn scar scale is to judge the scar index according to the flexibility, vascularization, thickness and pigmentation of the scar, which is helpful to guide occupational therapists to evaluate the mature stage of the scar and the therapeutic effect of the scar, and to evaluate the size (length, amplitude and bulge height), color and hardness of the scar after compression (see table 16-3-2).
Table 16-3-2 Scar Assessment
③ tubular bandage compression method (figure 16-3-3): when the wound can bear certain pressure, it is especially suitable for children under 3 years old who grow rapidly during the transition period of elastic bandage and compression suit. This kind of bandage is relatively long and has various specifications, so it can be directly cut and used. According to the size, the pressure is divided into low pressure (5~ 10mmHg) and medium pressure (.
Fig. 16-3-3 compression method of tubular bandage
Material (a) Sponge: It is characterized by softness, low shear force and low price, but it is easy to flatten under pressure and cannot provide enough local pressure.
(b) Plastic sponge: It is characterized by elasticity and can increase local pressure. Its disadvantages are hard texture, easy to increase shear force, high price and occasional allergic phenomenon. However, because it is easy to form at high temperature, it can change its shape according to scar progress, and it is widely used in clinic.
(c) Weak glue: characterized by easy molding, but expensive. Scar can't be adapted, adjusted or reformed when it progresses, so it is rarely used in clinic.
(4) Silica gel: Many clinical studies have confirmed that silica gel can well inhibit or prevent scar proliferation and promote scar maturity. Because its ductility is close to the skin, covering the scar will not affect the joint activity. In addition, the product has stable ingredients and bacteria are not easy to pass through. If properly maintained, it can be used for more than half a month, but it should not be covered on unhealed wounds.
The manufacturing step (a) determines the required pressure pad according to the position and shape to be pressurized; (b) Draw the shape of the scar with transparent plastic, and determine the size and shape of the pressure pad; (c) drawing a determined shape on the pressure pad material; (d) forming by heating or grinding into a required shape; (e) If it is used for joint parts, a gap must be cut on the surface to ensure the normal movement of the joint. Note: the size and shape of the pressure pad depends on the scar. The scar surface should be covered, and the influence of activities and other factors should be considered. Not too big, not too small, to reduce stress. If it is too small, it is best to add a cotton cover on the outside of the scar pressing point to reduce the number of allergies. In addition, it is best to have your own fixed system.
In the production process, we should pay attention to the following problems.
◎ The pressure pad must completely cover the whole scar: for a large scar area, use a full pad; For scattered scars that are far apart, fragments can be used; For hypertrophic scars, cover the edge 3 ~ 4 mm. For keloids, in order to avoid outward growth, cover the edge 5 ~ 6 mm.
◎ Body convex and concave surface problem: Bone protrusion with small radius of curvature should avoid excessive pressure. For example, the styloid process of ulna and radius should fill the concave surface to ensure that the pressure pad is in complete contact with the scar. Put a pad on it as usual to make the scar really compressed (Figure 16-3-5).
A. Fill the facade
B. Establish curvature
Figure 16-3-5 convex-concave principle
◎ Edge inclination: Edge with different inclination has different effects on scar compression (Figure 16-3-7). The edge with small inclination has the greatest pressure (Figure 16-3-7a), which is suitable for placing the opening of the pressure garment, because the pressure produced by the pressure garment is weak there, and the pressure is even under the cushion with large inclination, because the pressure garment contacts at the edge.
Fig. 16-3-7 schematic diagram of edge pressure of pressure pad under different slopes
◎ Trunk pressing pad (figure 16-3-9): chest, abdomen, back, armpit, buttocks and perineum.
Figure 16-3-9 luggage compartment pressure pad
◎ Lower extremity pressing pads (Figure 16-3- 1 1): knees, ankles and instep of legs.
Figure 16-3- 1 1 lower limb pressure pad
(3) the role of pressure therapy The role of pressure therapy mainly includes the following aspects:
1) Control of scar hyperplasia: Pressure therapy can effectively prevent and treat hypertrophic scars.
2) control edema: it can promote blood and lymph reflux and reduce edema.
3) Promote limb shaping: it can promote the shaping of amputated stump and facilitate the assembly and use of prosthesis.
4) Prevention of joint contracture and deformity: Contracture and deformity caused by hypertrophic scar can be prevented and treated by controlling scar hyperplasia.
5) Prevention of deep venous thrombosis: Pressure therapy can prevent deep venous thrombosis of the lower limbs of long-term bedridden people.
6) Varicose veins of lower limbs: It can prevent varicose veins of lower limbs of people who have been sedentary or standing for a long time.
(4) Mechanism and effect of pressure therapy: The important pathological changes of hypertrophic scar after burn: vasodilation, collagen fiber hyperplasia and disordered arrangement. The main function of pressure therapy is that when the local pressure reaches1.33 ~ 2.0 kpa (10 ~15 mmhg), it will cause tissue ischemia and rearrange the spiral collagen. Under hypoxia, mitochondria, which bear the function of biological oxidation of cells, swell and vacuolate, which hinders the proliferation of fibroblasts and greatly reduces the ability to produce collagen fibers. The decrease of α-M globulin after ischemia is beneficial to the appearance of collagenase, thus destroying collagen fibers; After ischemia, the enzymes that synthesize mucopolysaccharide decrease, edema decreases, deposition and synthesis of mucopolysaccharide decrease, and collagen production decreases. The scar tissue under pressure and without pressure was observed by light microscope and electron microscope, and the effect was completely different (see table 16-3-3).
Table 16-3-3 Histological comparison between compressed and uncompressed hypertrophic scars
3) Long-term use: It generally takes 1 ~ 2 years, or even 3~4 years, for the scar that may proliferate, from the basic healing of the wound to the maturity of the scar. In addition, long-term use also means that the application time is long every day, and the effective pressure should be guaranteed for more than 23 hours every day. Stress can only be released in the bath, and the time for releasing pressure should not exceed 30 ~ 60 minutes at a time.
(8) Selection and application of elastic materials:
1) Elastic bandage: suitable for all parts of the body. When dressing, wrap the limb from the distal end to the proximal end. At the beginning, the pressure should not be too high, and then gradually increase after the patient adapts.
2) Elastic cloth: It is woven from fiber fabric containing rubber bands, and made into sleeve-like application after cutting. It has strong elasticity and long elastic duration, but it is durable, but the fiber fabric is thick, rough and not soft. It is suggested that a layer of gauze should be placed on the surface of the initially healed wound to avoid rubbing the initially healed epithelium.
3) Elastic clothing: Jobst elastic clothing, masks, vests, shorts, etc. are made of nylon fabrics with certain elasticity and tension, and beaded three-dimensional fabrics composed of ethylene terephthalate fibers and long-chain polymer fibers containing more than 88% polyurethane, which are fit and light to wear, but not as elastic as elastic fabrics.
4) Wearing method of elastic sleeve: The skin of the newly healed wound is tender, the inner layer is covered with 1~2 layers of gauze, and then the elastic sleeve is worn. In principle, the velcro should be pressed continuously for 24 hours after it is laid flat, and it is forbidden to untie it when sleeping, which will offset the effect of pressing the concave part of the body surface evenly during the day. Pressure pads, such as soft pads such as polyethylene resin sponge, silicone rubber foam or gauze pads or silicone hard pads, must be placed under the elastic sleeve.
In order to obtain the good effect of compression therapy, compression should be started before scar bulge; The pressure is generally 3.3 kpa (25mmhg); Pressurize continuously, and do not untie it except flushing, and pressurize for 6~ 12 months.
Head and face: the compression treatment of head and face scar is to use transparent plastic mask or elastic hood to open the window at the eye, nose and mouth. If the eyelids cannot be closed, an eye mask is needed to moisten the cornea. The elastic headgear is made of nylon fabric and closely covers the whole head. Pad the window at the ear and nose at the uneven gap (as shown in figure 16-4- 18). Neck: A neck orthosis can be used. It is best to make the anterior cervical orthosis with thermoplastic splint, reaching the chin and the inner edge of mandible, and then deform and shape it according to the angle of the neck until the convex front below the neck is fixed to the axilla of the neck with broadband fastening (as shown in figure 16-3- 19): the shoulder joint is fixed about 90o ~1kloc-0/. Fix the elbow joint with a belt (as shown in figure 16-3-20): the elbow fossa is scar contracture, which is prone to elbow flexion and forearm pronation deformity. It is appropriate to fix elbow joint in straight position and supination position with palm elbow splint, and herringbone bandage is only used at night. During the day, the splint can be removed for functional exercise (as shown in figure16-3-2116-3-22). Trunk: Elastic dressings can control scars well, but when pressure dressings are applied to the scapula and hip folds, elastic pads should be added and fixed with sutures to increase local body surface pressure to control and treat hypertrophic scars.
Arms and legs: the limbs are cylindrical, and the cut pressure suit can control the scarred buttocks. Tight briefs can be worn under pressure suits. Orthopedic surgery should be used if the flexion side of the joint tends to scar contracture.
Hip joint: fixation of hip joint in prone position, flexion and extension15 ~ 20 is helpful to relieve flexion contracture.
Knee joint: Use the full contact extension splint behind the knee and add elastic bandage, and only at night can the knee be fixed in a straight position. However, if the knee cannot be completely straightened, it should be used all day, and the splint can only be removed during exercise (Figure 16-3-23). Ankle: When braking at night or during the day, use a long (including the knee) or short (reaching the far part of the knee) back splint to bind and fix it. It is necessary to do ankle dorsiflexion, plantar flexion and varus (Figure 16-3-24). Foot: Hypertrophic scar is rarely formed due to plantar burn, which can cause dorsiflexion of foot or hyperextension of thumb. It is suitable to use splint with sufficient contact between foot and back at night, which can cause thumb flexion deformity. If there is burn scars in the whole foot, it is necessary to use the front and rear splints with sufficient contact between the calf and the foot, and bind them under pressure, and fix them at night or during non-exercise.
Figure 16-3- 18 elastic headgear