Team Management

OT Dude Academy’s Free NBCOT® Exam Prep Course Burns Team Management

Burns management by the medical team in the ICU includes intubation, tracheostomy if indicated1 , fluid management (nutrition), infection prevention, analgesia, hemodynamic monitoring and targets, ventilation, and transfusion.2 

Pain

Barriers to pain management include continued pain monitoring, the selection of the pain scale, and patient communication, e.g., verbally reporting pain, or being sedated. Sedated burn patients may be exposed to a higher risk of suffering from insufficient analgesia due to the inappropriate use of pain assessment tools. Procedures that may contribute to pain include dressing changes, catheter manipulation, secretion suctioning, and mobilization.3  Adverse physiological responses to pain have been related to unstable hemodynamic status, alterations in immune system function, hyperglycemia, and increased release of catecholamine, cortisol, and antidiuretic hormones.4 5  Uncontrolled pain can also lead to adverse psychological effects of PTSD, disorientation, and depression, which may affect morbidity and prolong the length of stay.6 7 8  First-line pain control involves the use of medications such as opioids by IV or alternatives such as Oxycodone for moderate to severe pain. Non-pharmacological approaches to pain management include psychological support, music therapy, acupuncture, and relaxation techniques, hypnosis, virtual reality systems have showed encouraging results.9 10 11 

Delirium

Delirium is often overlooked and can result in negative consequences in burn patients. Appropriate assessment tools should be used by the team for delirium estimation combined with medications. Occupational therapy practitioners may help prevent or manage delirium symptoms with early mobilization.12 13 14 15 16 17 

Infection

The healthcare team follows best practices to prevent and control infection. Infection control guidelines include washing hands, and using PPE (gloves, gowns). This applies to the patient, the healthcare team, family members, friends, and caregivers.18 

Nutrition

Healing from burns requires more calories and protein. The team may comprise of a nutritionist to ensure a well-rounded diet.18 

Rehabilitation

  • PT: improving functional mobility, movement, daily tasks, and living independently. Treatment may include exercise, splinting, bandaging, use of assistive devices, massage, and joint mobilization.
  • SLP: promotes swallowing, voice and speech, cognition, and communication.18 

Terminology 19 20 18 

  • Eschar: necrotic tissue, typically caused by burns
  • Debridement: eschar removal, oftentimes a painful process
  • Escharotomy: surgical removal of thin layers of necrotic tissue from deep burns
  • Fasciotomy: an emergency procedure used to treat acute compartment syndrome, often from burns. “Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achievable by primary wound closure, secondary wound healing, or as needed in approximately 50% of wounds split-thickness skin grafting.”21 
  • Hypertrophic scar: a raised scar in the area of the original burn.18 
  • Skin Graft: transferring tissue (without the blood supply) from one portion of the body to another to cover a burn wound to provide protection from the environment, pathogens, temperature, and water loss like normal skin. Skin grafts undergo primary and secondary contractures – an immediate reduction in size after harvest.  Donor sites may be susceptible to morbidity and decreased ability to regrow new skin for harvest. Split-thickness skin grafts are more likely to be pigmented, whereas full-thickness skin grafts may provide a more appropriate color match. Meshing alters the cosmetic appearance of split-thickness skin grafts. 22 
    • Autograft: skin grafts that replace burned skin from another part of the body.
      • Split-thickness skin graft (STSG): a graft that contains the epidermis and a portion of the dermis. Often taken from the lateral thigh and trunk. Less durable than full-thickness skin grafts to withstand forces from demanding areas of the body. May have poor sensation and prolonged wound care.
      • Full-thickness skin graft (FTSG): a graft that contains the epidermis and entire dermis22 
    • Allograft, Homograft: temporary grafts that cover wounds. Donor skin comes from another person, e.g., a cadaver
    • Xenograft: temporary grafts that cover wounds, e.g., donor skin comes from a pig
    • Meshed graft: split-thickness or full-thickness skin grafts in which parallel rows of staggered slits have been cut. Meshed grafts have small slits or holes. The mesh incisions allow the graft to be expanded to cover large areas.23 
    • Sheet graft: grafts that are placed directly from the donor site without being meshed. For small to medium-sized grafts, have the best cosmetic outcome.

Grafting Procedure20 

  1. Recommended for third-degree burns or any burns that require longer than 2-3 weeks to heal.
  2. Excision of the burn down to viable tissue.
  3. Obtaining homeostasis.
  4. Applying skin grafts harvested from another site.
  1. Garside, T. L., Lee, R. P., Delaney, A., & Milliss, D. (2018). Clinical practice variation in acute severe burn injury. Anaesthesia and intensive care, 46(3), 321-325.[↩]
  2. Henschke, A., Lee, R., & Delaney, A. (2016). Burns management in ICU: quality of the evidence: a systematic review. Burns, 42(6), 1173-1182.[↩]
  3. Lavrentieva, A., Depetris, N., & Rodini, I. (2017). Analgesia, sedation and arousal status in burn patients: the gap between recommendations and current practices. Annals of burns and fire disasters, 30(2), 135.[↩]
  4. Shannon K., Bucknall T. Pain assessment in critical care: what we have learned from research. Intensive Crit Care Nurs. 2003;19(3):154–162.[↩]
  5. Puntillo K., Morris A., Thompson C., Stanik-Hutt J. Pain behaviors observed during six common procedures: results from the Thunder Project II. Crit Care Med. 2004;32(2):421–427.[↩]
  6. Barr J., Fraser G.L., Puntillo K., Ely E.W. American College of Critical Care Medicine Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.[↩]
  7. Jacobi J., Fraser G.L., Coursin D.B., Riker R.R. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. 2002;30(1):119–141.[↩]
  8. Myhren H., Ekeberg O., Tøien K., Karlsson S. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care. 2010;14(1):R14.[↩]
  9. Trupkovic T., Kinn M., Kleinschmidt S. Analgesia and sedation in the intensive care of burn patients: results of a European survey. J Intensive Care Med. 2011;26(6):397–407.[↩]
  10. Mott J., Bucolo S., Cuttle L., Mill J. The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes: a randomised controlled trial. Burns. 2008;34(6):803–808.[↩]
  11. Faber A.W., Patterson D.R., Bremer M. Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients. J Burn Care Res. 2013;34(5):563–568.[↩]
  12. Luetz A., Balzer F., Radtke F.M., Jones C. Delirium, sedation and analgesia in the intensive care unit: a multinational, two-part survey among intensivists. PLoS One. 2014;14:e110935,.[↩]
  13. Devlin J.W., Bhat S., Roberts R.J., Skrobik Y. Current perceptions and practices surrounding the recognition and treatment of delirium in the intensive care unit: a survey of 250 critical care pharmacists from eight states. Ann Pharmacother. 2011;45(10):1217–1229.[↩]
  14. Forsgren L.M., Eriksson M. Delirium awareness, observation and interventions in intensive care units: a national survey of Swedish ICU head nurses. Intensive Crit Care Nurs. 2010;26(5):296–303.[↩]
  15. Pandharipande P., Cotton B.A., Shintani A., Thompson J. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65(1):34–41.[↩]
  16. Pandharipande P., Shintani A., Peterson J., Pun B.T. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104(1):21–26.[↩]
  17. Cavallazzi R., Saad M., Marik P.E. Delirium in the ICU: an overview. Ann Intensive Care. 2012;2(1):49.[↩]
  18. Model Systems Knowledge Translation Center. (2019). Burn Injury Fact Sheet Booklet. Retrieved from https://msktc.org/burn/factsheets[↩][↩][↩][↩][↩]
  19. Rosenberg, L., Krieger, Y., Bogdanov-Berezovski, A., Silberstein, E., Shoham, Y., & Singer, A. J. (2014). A novel rapid and selective enzymatic debridement agent for burn wound management: a multi-center RCT. Burns, 40(3), 466-474.[↩]
  20. Greenhalgh, D. G. (2019). Management of burns. New England Journal of Medicine, 380(24), 2349-2359.[↩][↩]
  21. Ormiston RV, Marappa-Ganeshan R. Fasciotomy. [Updated 2021 Apr 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556153/[↩]
  22. Braza ME, Fahrenkopf MP. Split-Thickness Skin Grafts. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551561/[↩][↩]
  23. Pope ER. Mesh skin grafting. Vet Clin North Am Small Anim Pract. 1990 Jan;20(1):177-87. doi: 10.1016/s0195-5616(90)50009-1. PMID: 2405566.[↩]
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