Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Burns Part 1: The Trauma Surgeon's Role in Patient Management with Prof Tim Hardcastle
In part 1 of this four part series on burns, Professor Timothy Hardcastle shares his expertise on the role of trauma surgeons in managing patients with burn injuries, exploring everything from emergency department care to long-term follow-up. The episode highlights the complex journey of burn recovery and the vital multidisciplinary approach needed for optimal patient outcomes.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Welcome back to Physiotherapy Trauma Talks. Today is the first of a series of episodes about the management of patients with burn injury. My guest today is Professor Timothy Hardcastle, who is a returning guest to this podcast series. Tim is the head of trauma and burns at Nkosi Albert Latouli Hospital in Durban, south Africa, and if you'd like to know more about Tim, please visit our podcast website. Tim, thank you so much for being available for this discussion about the role of the trauma surgeons. Management of patients with burn injury.
Speaker 2:Thank you for the invite.
Speaker 1:So, as we start our discussion, could you share with our listeners what you feel are the causes of burn injury for adults and children in the communities around your hospital?
Speaker 2:Firstly, we have to say that my hospital is the referral center for the entire KwaZulu-Natal province, but there's two other smaller burn centers, one in Pietermaritzburg and one in Gwela Zaan in Mpangeni but we are the only facility that has ICU capabilities. But we are the only facility that has ICU capabilities. So in our population what we mainly see in children is largely hot water burns from accidental scalds. We see some non-accidental injuries and we see occasionally smoke inhalation and flame burns, but much less so than with adults, but much less so than with adults. The majority of adult burns, and it's probably close to 50-50 in adults, where it's about 90% hot water burns in children.
Speaker 2:In adults we see a lot more electrical burns and a lot more flame burns. A lot of the times it's epileptics who have a seizure and fall into the fire because they're in informal communities where they rely on fires to warm themselves and to cook their food. But also we have the people that fall asleep because they've been drinking too much and they've got a cigarette in their mouth or the candle falls over, catches a light and they burn in their beds, especially in our informal communities. Yeah, so that's kind of the majority, but we also see a fair amount of electrical injury from people that are trying to establish electrical illegal connections, or the so-called Isinyokas who try and steal cables.
Speaker 1:Yeah, okay. Yeah, I can imagine that's quite a unique reason for electrical burns that we see in our South African communities. Tim, in our previous episode we spoke about the trauma surgeon's role in managing patients with injury more in the general sense when we discussed how the acute trauma life support principles are applied when the patient arrives at the emergency department. Would you mind talking a little bit more specifically about how this is applied when a patient with major burns comes into your emergency department?
Speaker 2:Sure. So the principles of advanced trauma life support apply for all injured patients, whether it's burns, motor vehicle crashes, gunshots, stab wounds, and the principles remain the same. There are some additional aspects that we add in the burn patient. So the airway component unless there's an enclosed space, burn or a jump from a height to try and get away from a fire. For the most part, the airway issue is all about hot air inhalation, which can lead to fairly rapid swelling of the airway, so it may require early intubation Once you've secured the airway or assessed the airway. The next aspect is obviously breathing and ventilatory support For patients with burns again, the hot water burns this is usually less of an issue, unless it's a primary steam injury. What gets inhaled and causes the lung damage with burns is the smoke particles, cyanide and carbon monoxide. So quite often you need to administer 100% oxygen, you need to possibly intubate and ventilate the patient for their lung injury and you may have to think about giving them cyanide antidotes, and the antidote to carbon monoxide obviously is high dose, 100% oxygen and full ventilation. And then, from a circulation point of view, it's excluding other sources of bleeding and blood loss. The burn patient generally doesn't go into shock in the same way that a trauma patient does. They're not losing volume rapidly, they're unlikely to have a tension pneumothorax, they're unlikely to have a pulmonary embolus. They're unlikely to have a spinal cord injury unless they've, you know, jumped from a building trying to escape the fire. So the circulation issue check for distal pulses to make sure that if there's burns on the extremities that none of them are circumferential and you're at risk of a compartment syndrome and that you might need to release that tissue. We call that an escharotomy and even more so with electrical burns it burns into the muscle compartments. You might need to do fasciotomy, but that's a very select group of patients. So it's about distal perfusion primarily, and then about gaining intravenous access. So large bore IVs, preferably in an unburnt area, but if necessary you can put the lines through the burnt tissue if the burn is significant. And then the disability is the same as for the general trauma patients. What's their level of consciousness? Is there any impaired consciousness? Is there any obvious injury to the neurological system? Are the pupils equal? So on and so forth, and the exposure obviously is undress the patient.
Speaker 2:Cool the burn if you can, especially if it's hot water burns and fairly superficial flame burns, we would recommend 15 minutes of cold water flush and once that's done, then obviously your F, which gets added. So it's A, b, c, d, e, f with burns, and the F is fluid resuscitation. And what we use there is the same fluid as in trauma but it's different volumes. So it's using ringers lactate, but it's 2 milliliters per kilogram per percent burn. You work that out. So if you've got a 50% burn and it's 2 mils per kilogram per percent burn, you work that out.
Speaker 2:So if you've got a 50% burn and it's 2 mils per kilogram, it's 100 mils per kilogram. Now if you've got a 100-kilogram patient, that's 10 liters of fluid that you're probably going to be giving that patient. It's a lot more than your 1-liter stat. But you're giving that over 24 hours, half of it over the first 8 hours hours, ideally from the time of the burn. So you might have to give the first bit a little bit quicker and then the other half over the subsequent 16 hours, guided by urine output, pulse rate and all the other markers. And so that's. That's where the primary survey comes in. The secondary survey is documenting the injuries, the same as for any other trauma patient.
Speaker 1:Okay, so I gather from what you've shared that it's really important to be accurate with determining the extent of the patient's burn. Is there a particular tool that is quick and easy to use in the emergency room setting that helps you to determine the extent of the burn?
Speaker 2:So when you're looking at the extent of the burn, you're looking at three different aspects. You're looking at time from burn, you're looking at percentage body surface area and then you're looking at depth of burn. So for percentage body surface area there are three methods that you can use. The easiest one to remember for adults is the so-called Wallace rule of nines. So the whole body is divided up into nine or 18s, et cetera, and so you get the head is nine, each arm is nine, each leg is 18. The anterior trunk is 18. The posterior trunk is 18. And that leaves you with one vital percent and that's your perineum. That works fairly well for adults. For children it's better to use the age and weight adjusted percentages of the Lund and Browder system. And then for patients with either massive burns particularly those you're palliating or where the burn is very small, the patient's hand with the fingers extended is 1% of the patient's body surface area. It's called Palmer's palm rule, so the palm can measure 1%. Again, that's more useful in children than it is in adults, but it can be used across the board. Then the next aspect is the depth of the burn, and that is identified, at least in the acute phase, by the presence or absence of blisters, the presence or absence of firm, charred sort of leathery skin and or deeper burns where you can see exposed muscle and or bone. So we divide it up today into a superficial partial, a deep partial, a full thickness, and then the one thing that's still called a grade four, or the really deep burns, is where it goes below the dermis. So superficial burns involve redness.
Speaker 2:A classical one is a sunburn. It might be some small blisters, it'll heal. It doesn't matter what you do to it, it'll heal. Deep partial is where there's quite thick walled blisters. The underlying tissue is very painful and very wet. The deep, full thickness burns. The skin is leathery, might be sort of superficially moist but is usually insensate because it's burntis dermis and you've got exposed or damaged underlying muscle and or subcutaneous fat and or bone and that we often see with the high voltage electrical burns as a rule.
Speaker 1:Okay, yeah, so there's a lot of aspects to consider when determining the extent of the patient's burn. I suppose one of the priorities of care in the emergency room is pain management. Is there a particular protocol that you follow with regards to pain management?
Speaker 2:Yes, we internally have a specific protocol for burns. We like to use ketamine. It's a very safe drug. You can use quite high doses. You can give it intranasally, intramuscular. We will combine it with, especially if we're giving it intravenously. We'll combine it with an opioid, usually morphine or fentanyl, and we certainly believe in giving a good dose of analgesia before we start scrubbing the wounds and debriding the blisters and so on. Burn wounds are particularly painful, so one has to be very careful about that.
Speaker 1:Yeah, I can imagine. So, when you've stabilized the patient in the emergency department, is your decision on where to transfer the patient to based solely on the extent of the burn, or are there other factors that help you to decide whether this patient needs immediate admission to ICU or whether they can go to the burns ward?
Speaker 2:So generally if the patient is not requiring intubation and ventilation and the burns are less than 30%, we'll admit them to the burn ward. In our state practice we have a palliation cutoff of 40 to 45%. So anything more than that we know from our research is not going to survive, especially if it's deep, partial and full thickness. So we palliate early. We don't accept those from the base hospital. We give them palliation instructions. If they phone us and say I've got a patient with 85% flame burns with inhalation, we say look, that is 100% mortality.
Speaker 2:Put up a drip, give the patient morphine infusion, call the family, call the pastor and allow nature to take its course through the, the post-mortem, etc. For patients that are salvageable so anything between sort of 30 to up to 45 percent with inhalation injury or where they are already and where they've maybe been in a district hospital for a day or two and they've gone septic, those we will admit to ICU. But the majority of patients who don't have an A and a B problem, if they're just needing fluid resuscitation and dressing care for the first 48 hours, they will be admitted to the designated burn wards. But a burn ward has got special facilities so it's kept at a warmer temperature. It has isolation rooms. It has special dressing rooms with usually special baths that you can use sprayers to spray down the wounds, so it's not just a normal general ward in the hospital.
Speaker 1:Yeah, and I'm glad you've explained that. It's important that people realize that, and infection control is extremely important. So you touched earlier on the fact that patients with inhalation burns can develop swelling of the airways quite quickly and would need intubation and management in the ICU. Is there any other type of management apart from airway support that is particularly given to patients with inhalation burns?
Speaker 2:Apart from the antidotes if you're worried about cyanide poisoning or the use of high concentration oxygen. In the case of carbon monoxide, the inhaled smoke particles cause quite a severe inflammatory response with deposition of debris in the airways which kind of blocks the airways, and here I'm talking about the lung level airways. So trachea, bronchi and bronchioles, and really the only additional therapy apart from intubating them and ventilating them that has been shown to make a difference is nebulized heparin 5,000 sexile in kids and 10,000 sexile in adults. And there's some evidence that adding N-acetylcysteine as a mucolytic supposedly improves things. I personally don't use the N-acetylcysteine because my experience is that it has quite a nasty side effect in some patients of pulmonary edema, and if you've already got soggy lungs that you're struggling to ventilate, you really don't need an additional pulmonary edema on top of that.
Speaker 1:Yes, definitely. Do you impose any restrictions on your physiotherapists who work in the Burns ICU with regards to when they can become involved in the management of patients with inhalation burns, or is it safe for them to be involved from the start?
Speaker 2:I like to get them involved by the next morning Most of the time these patients are arriving at weird hours when the physios are not in-house but certainly by the next day on. All our ICU patients, and including our burn patients, we want chest physio. They help to get rid of all that inspissated mucus. We might do bronchoscopies early on to assess the severity and suck out what we can. But there's no benefit in doing daily bronchoscopies, which a couple of years back was mooted as an option. Early physiotherapy, nebulization of the heparin combined with nebulization of bronchodilators. We alternate them every six hours. So we'll do heparin and then three hours later salbutamol, ipratropium, three hours later heparin and so on and so forth, and then combine that with early Vibramat, early chest physiotherapy. It helps with the recruitment, it helps with clearing the inspissated mucus and we certainly have seen the value in it.
Speaker 1:Okay, that's great to hear you touched on management of the patient's burns in the emergency department through cleaning and scrubbing and removing the blisters, and what additional wound care do you practice with patients in the Burns ICU now, 48 hours and longer after the incident happened?
Speaker 2:Well, it will depend on what wound dressing has been put on at the time of the emergency department.
Speaker 1:Okay, so it can fluctuate from one person to the next?
Speaker 2:Yes, so you know, if we scrub the wounds nicely with crohexidine or sterile saline, we often add ProntoSan, which is a biofilm lytic agent to get rid of any early biofilms. Then we cover them with a silver-containing dressing. We try and use ActiCoat 5, so then you've got five days of wound coverage before you need to change dressings. But other than that, at the subsequent dressing change we will assess the wounds and decide if surgical excision is required, because we try and get surgical excision within the first week.
Speaker 2:If surgical excision is not required and it looks like the wounds may heal without the need for debridement and excision and grafting, then we will carry on with the dressings. And you know if, if it looks like the silver containing dressings are not working, then we'll go to our next option, which is something like acticode silver. If that's not showing a good response, then we'll go to either medical honey or even just traditional honey, especially if we have pseudomonas we find good old off-the-shelf honey works brilliantly for that my goodness so, yeah, we put the honey on and cover it with gelonet and a couple of days later the pseudomonas is dead and we can actually skin graft the patients.
Speaker 2:That's amazing. And then there's various other more advanced dressings that we will use on occasion again with or without silver, depending on how exudative the wound is something that's got like Drortex or biotane that can absorb the fluid. So the idea is you want to have a moist surface, but it mustn't have excessive slough on it.
Speaker 1:Okay, and just to come back to physiotherapy management, when your patients have had surgical interventions, such as fasciotomy for instance, am I correct in saying that movement can occur immediately after the surgery, from day one post-op, but that you just need to be careful with looking at how much the patient is bleeding and restricting your rehabilitation within those parameters, or do you have other thoughts about that?
Speaker 2:I think it depends on where the graft is and what kind of graft it is. If it's a straightforward meshed skin graft on a fairly flat surface like the thigh or the forearm or the upper arm or the trunk, and you're not going to be expecting the patient to move excessively and the joints are not involved, expecting the patient to move excessively and the joints are not involved, then there's no reason not to do early physiotherapy, early mobility, early occupational therapy. But if it's hands, fingers, neck and over the joint spaces, yes, you risk a little bit of stiffness, but it's probably better to wait a day or two to make sure that the graft is holding before you start mobilizing things. The chest physio and stuff can continue without a problem.
Speaker 1:Okay, and after fasciotomy, are there any restrictions to rehabilitation?
Speaker 2:After fasciotomy? Definitely After escharotomy? Probably not, because if you've escharotomized tissue in the acute phase it's to allow perfusion and if that perfusion is restored, the tissue that you've escharotomized is going to require excision and grafting anyway. So then you'll be putting healthy skin on there. But if you've got a fasciotomy, particularly a forearm fasciotomy, there may well be some reduced muscle function. There may have been some nerve damage, depending on how long the compartment was under strain, and especially with the high voltage electrical burns. There may be primary nerve damage or myonecrosis from the actual electrical injury. But I mean, once the wound is treated and it's granulated, then, especially if it's skin grafted or secondarily sutured, no then there's no reason that you shouldn't be aggressively mobilizing and exercising those limbs.
Speaker 1:And I suppose the take-home message from all of this is it's really important for the physiotherapist to be in constant communication with the surgeon to find out what is safe to do and what not.
Speaker 2:Absolutely, and you'll find that the type of surgeon that does the burn care varies between the private sector and the public sector. A lot of times in public sector it will be the general surgeons and the trauma surgeons that manage the burn services, whereas in the private sector it seems to be very much taken over by plastic surgeons, maybe in the acute phase with the help of a general surgeon, because the plastic surgeons are not always up to speed on intensive care. So they just need to find out who's the primary decision-maker, and I would advise regular MDTs. So the physio, the OT, the dietician, the surgeon, the rehab doctor, the nurse manager, the nurse that's nursing the patient, all gets together.
Speaker 2:If the patient's conscious, they need to be involved. The family needs to be involved. What people need to realize? Unlike a broken femur that you put a nail in, get some physio, he goes home and he's fine after five, six weeks. The burn is going to keep you involved with that patient for, depending on the size of the burn, somewhere between 18 months and three years before there's full resolution. So it's not a short-term process, it's very much a labor of love.
Speaker 1:Yes, I can imagine, and often people have disfigurement as a result of burn injuries, so I can just imagine how important it is to have a psychologist on board as well, oh, absolutely yeah.
Speaker 2:The problem for us in the state sector is we just don't have psychologists. We're lucky if we have a social worker sometimes. But you know, there's usually one psychologist per academic hospital and maybe one or two social workers and they have to cover the whole hospital, not just Burns.
Speaker 1:Yeah.
Speaker 2:Whereas in the private sector you know you just contract someone in. So it's very, very much a pleasure in the private sector.
Speaker 1:Yeah, now, a vast difference in the quality of care that can be provided between public and private in South Africa, unfortunately, tim, as these patients reach the point of being discharged from the hospital at Albert Lutuli Hospital, where you work. Is there a follow-up service for these patients to come back to, especially seeing that you mentioned your journey with a patient doesn't end when they're discharged from the hospital?
Speaker 2:Yeah, so we have a clinic once a week where we see follow-ups For those that have had skin graft. We'll see them two weeks after discharge and then monthly until we're happy that the grafts are almost completely healed and that the mobilizations have been done. And we then get the plastic surgeons in the state sector like to get involved when the scar is a little bit more mature, if they need to do releases around about 18 months. But between that time we get our occupational therapists involved and they get the pressure garments made and make sure the patients wear those. The challenge is always getting spares out to the district hospitals and getting adequate follow up out to the district hospitals and getting adequate follow-up. But yes, there is a clinic and I think some of the other hospitals have clinics twice a week. We only have one a week. We generally are seeing between 12 and 15 patients a week at the clinic of which one or two will be new.
Speaker 2:The rest are follow-ups.
Speaker 1:Okay, yeah, so quite a comprehensive follow-up service that you provide. That's wonderful, and it's great to hear that there's a multidisciplinary input and it's not just from a surgical point of view. Tim, as we wrap up our discussion, are there any last thoughts that you'd like to share? Maybe some words of encouragement for physios that are not so familiar with a burns environment, which can be quite scary to work?
Speaker 2:in.
Speaker 2:It can certainly be a little bit nerve-wracking if you haven't got much experience in that field, especially when you have a patient with extensive burns who's wrapped up like a mummy and the question is where do I touch to actually do what I need to do?
Speaker 2:You know, what you need to understand is it's a journey with the patient. For every 1% burn, especially if it's a full thickness burn, your patient is likely to spend 1.5 days in hospital. Okay. So if you've got a 20% burn, 1.5 days in hospital, okay. So if you've got a 20% burn, you're looking at a minimum of 30 to 35 days in hospital, and certainly a lot more if it's anything bigger than 35, 40%. And then they have all the risks for sepsis and so on. So the physiotherapist role is actually a profoundly important role because by doing early chest physio, by joint mobilization along with the occupational therapists, by getting the patients up and moving, you're preventing DVTs, you're preventing poor breathing, you're preventing secondary chest infections, you're helping to get that patient hospital stay reduced, because less complications mean shorter hospital stay, means we can get them to theater early, graft them early and hopefully get them out of hospital early yeah, yeah and I.
Speaker 1:What you mentioned about early mobilization, I think is crucial, because it also helps with lung ventilation. It helps to reduce the risk of loss of muscle mass and muscle strength. So early activity is really important and, in that sense, teamwork with the nurses that are by the patient's bedside as well. And one of our follow-up episodes is going to be an in-depth discussion about the physiotherapy management of adults with burns and also about pediatrics with burns. So look out for those episodes that will be released soon. Tim, thank you so much for your time. I know that you are on call tonight and that your phone has been buzzing while we've been chatting. I really appreciate your commitment to this podcast series. Thanks so much.
Speaker 2:Yeah, thank you, helena, for inviting me, and thank you to your listeners for sitting and listening to what the doctor has to say.
