1977 F I S I O T E R A P I EsE P TEIVIBER t r e a t m e n t o f b u r n s in a g e n e r a l h o s p it a l * N A R IN A G IL D E R *, B.Sc. (Physiotherapy) (R and), O nderw ysdiplom a in Fisioterapie (Pret.) krvw'mg van ’n behandelingstegniek vir pasiente , hrandwonde in ’n algem ene hospitaal opgeneem '/ 'n il tegniek is o n tw ik k e l terw yl die skryfster E erste nneut in bevel van die F isioterapie A fd e lin g van fi s' ° a , , i uWa H ospitaal naby Pretoria, was. N agenoeg 11“ non nasiente is oor ’n tyd p erk van 12 maande in die " / ese sale opgeneem . T w ee gew one 40-bed sale is (h‘r“rglj er vir kinders en volwasse mans, terw yl die olHL’son. ,n “gem engde” chirurgiese saal behandel is. D ie vr° ue ‘van ’n streng en eenvoudig toe behandelingsm e- 'UY*Sm et vroee eksisie van nekrotiese w eefsel en veloor- I ’t'ne' streng beheer van beta-hem oliktiese strep to ko k f eudomonas infeksie; spanw erk tussen alle personeel rdbespreek, asook die problem e w at ondervind is, ^ o n l bespreek. Ga R a n k u w a , destined as the teaching hospital for M ED U N SA, is situated on th e bo rd er o f B ophutats- ana 30 k m north-w est of P retoria. T h e first wards were mened late in 1973 and I was appointed as Principal P h y s io th e ra p is t in A ugust 1974. T hus, I was fo rtunate to see it grow and expand over a period of two and a half years and was able to build up a Physiotherapy D epartm ent lite ra lly f r o m scratch. 1 would like to concentrate on how we coped w ith the large number of b u rn cases. O ver a period of twelve months, about one thousand patients w ere adm itted. These patients varied from highly sophisticated u rb an to primitive ru ral people, draw n n o t only from nearby townships, but also from country districts, stretching to Northern and N o rth -E astern T ransvaal. T h e high incidence of b u rn tra u m a could be ascribed to crowded living conditions, the use of cheap heating and cooking methods, such as open fires, paraffin cookers, coke tins, etc., the inadequate appreciation of the dangers associated with these and poor p aren tal supervision o f toddlers and young children. At first, these patients were adm itted to th e general (urgical wards. W hen D r. N a th a n C irota, who had pre­ vious experience o f treatin g burns in a plastic surgery jnit, joined the staff, he obtained tw o forty-bed w ards to be used exclusively for th e b u rn cases. A dult males were admitted to one w ard and children to the other, as these formed the bulk of th e patients, whilst females were treated in a “ m ixed” surgical ward. MEDICAL T R E A T M E N T Method: The Israeli m ethod, consisting of early operative treatment with resu ltan t enhanced recovery, was adapted for Ga R ankuw a. E arly excision of dead tissue tPaper presented a t Post-registration C ourse preceding the 12th N ational C ouncil M eeting o f th e.S o u th A frican Society of P hysiotherapy, M ay, 1977. ’Senior lecturer, H ead o f D ep artm en t of Physiotherapy, University o f C ape Town. (sloughectom y) was followed by early skingrafting. As there was no m eans of absolute isolation (such as a special burns unit), a strict but simple nursing technique (closed m ethod) was used routinely. W ith this treatm en t routine hospital stay was decreased by 30% and the com plication rate (except fo r sepsis) was less th an 10%. Probably the most im p o rtan t success facto r was te a m ­ w ork. T his involved the surgeon, interns, bacteriologist, haem atologist, medical technologist, physiotherapist, dietitian and nursing staff. A com prehensive weekly w ardround, w ith as m any m em bers of the team as possible present, was used to review all cases. Causes: T h e com m onest cause of th e b u rn injury was domestic accidents (eight out of ten), followed by assaults, in ­ dustrial accidents, and suicides; careful history taking often gave a strong po in ter to th e battered baby syn­ drom e. D egree: Tw o degrees of burning were recognized; superficial, in w hich only epiderm is was involved, hair follicles and sebaceous glands being spared and no skingraft thus being necessary; and deep, in w hich no skin elem ents survived and healing was by fibrosis (at the ra te o f 1 mm per day), resulting in vulnerable epithelial coverage. F o r a quick assessm ent of the degree o f b u rn , Jack so n ’s pain test was used (positive fo r superficial and negative fo r deep burns). Percentage: T his was calculated according to the ru le of fives, w hich was modified fo r children and infants. (Fig. 1). T his was revised on th e fo u rth day a fte r admission and then o n altern ate days w hen indicated. Som e epithe­ lium th a t seems in tact initially m ay not survive and infection increases th e am o u n t of raw epithelium , thus changing a superficial b u rn to a deep one a n d /o r increasing the extent. % e s t i n m i o N o f B u r m r r e f i AdultC h i t - D f 10 U .R E 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) B urn illness: Shock leads to vasodilatation, increased capillary per­ meability, increasing fluid loss and hypovolaem ia. Fluid replacem ent is thus essential in the first 40-50 hours. T h e am o u n t is calculated using the form ula 1,6 x % b u rn x weight in lb. = num ber ml/42 hours. Patients w ith less th a n 15% b urns received R in g er’s solution o r plasm a B (low in potassium ) as follows: | volum e in the first 6 hours, i volum e in th e next 12 hours and th e last | in the next 24 hours. W here the patient had m ore than 15% burns, fluid replacem ent consisted o f plasm a for the first y and o f whole blood fo r th e last T he haem oglobin level was assessed on admission and th ereafter at weekly intervals, as anaem ia has an adverse effect on healing and skin graft taking. W ound swabs were cultured w eekly and all grew some pathogens. Beta haem olytic streptococcal infection was treated w ith local antibiotics (laboratory and sensitivity tested) because it caused breakdow n of recen t granula­ tions and skin grafts. Pseudom onas infection was also treated because o f th e danger o f pseudom onas septi­ caem ia. A tem p eratu re spike above 38°C. was considered an index of potential septicaem ia and treated prophylac- tically by gentam ycin, treatm en t being altered only when a blood culture was available. Excessive catabolism was prevented o r controlled by m eans o f a high protein, high calorie diet, rich in vitam in C and ferrous sulphate, in o rd er to prom ote tissue regeneration. 6 A dmission: All patients with burns o f 10% o r m ore, as well as those w ith burns involving the face, hands, perineum o r joints, w ere adm itted. A standard admission ch art was filled in, giving basic data such as weight, age, p e r­ centage b u rn , estim ation o f the depth o f b u rn , type of burning agent, adequacy o f airw ay, type o f analgesia given, etc. Standardised treatm en t such as fluid replace­ m ent, em ergency blood investigations, indwelling catheter (20% burn and over), prophylactic anti-tetanus injection, w ound swabs, dressings (open o r closed) or splintage o f joints had to be recorded. F u rth e r treatm ent such as change of dressings (for reassessm ent), op era­ tions, physiotherapy requested, com plications, o r progress w ere noted on th e sam e chart. Closed m ethod: T his technique was used because o f the large num ber of patients and the w ard architecture. A dilute solution o f chlorhexidine o r eusol was m ade up daily and used to clean th e burns. N ecro tic tissue was rem oved, but blisters w ere n o t p u n ctu red , as this increased th e risk o f infection. T ulle gras was placed on th e burns, then layers of gauze soaked in one o f th e above-m entioned solutions; this was covered with crepe bandage, and splinting was applied w here indicated and secured w ith fu rth e r crepe bandage. T h e first dressing was rem oved afte r fo u r days, th e percentage and depth o f bu rn re ­ assessed and th ereafter daily dressings were done. In fection: T his usually started locally, w ith a strong tendency to system atic spread. W eekly swabs were sent fo r culture and sensitivity tests. T he technologists m ade use o f an accelerated process so th a t results were available w ithin a few hours (usually th e n ex t day). Local application of antibiotics was used, because the decreased vascularity in burn wounds was th o u g h t to re n d e r th e effectiveness of systemic antibiotics questionable. B urn cream s were n o t used, as these m asked the state o f th e burns. Surgery: A healthy base, viz. optim al n u tritio n , granulation haem oglobin concentration and oxygenation, can be m aintained for 3-4 weeks. T hus, sloughectom y and skin- grafting, when indicated, should ideally be done within twenty-one days o f sustaining b u rn tra u m a , so as to tak e advantage of th e optim um base. P a rtia l thickness grafts w ere used because these tak e better; however they give a poorer cosm etic result th an full thickness grafts, w hich w ere used on the face and neck. Where large areas had to be covered and only sm all donor sites w ere available, eith er a mesh derm atom e was used o r strips of skin were laid on at right-angles to th e line o f stress, m ovem ent or pull o f underlying tissue. Plaster o f P aris splints w ere applied in th e a tre a fte r th e dressings if joints were involved in the burn. T he g ra ft was in­ spected fo r viability afte r five days and immobilised fo r a fu rth e r five days if it had taken. If sloughectomy proved necessary (usually A serbine dressings w ere tried first), skingrafting was done im m ediately afterw ards. H bleeding was excessive, grafting was delayed fo r four days. In suitable cases, do n o r skin was stored at 5°C. and applied in th e ward under local anaesthesia. P H Y S IO T H E R A P Y T he following is th e ideal physiotherapy treatm en t as one would like to see it, but obviously is n o t always possible. All patients, except those w ith m ore than 35% b urns o r w here th e face, neck o r genitalia w ere involved, w ere started on full physiotherapy as soon as possible a fte r admission. F irst fo u r days: T he burns were covered by dressings, splints were applied to joints involved in the burn and th e p atien t was put on a drip if the b u rn was over 15%; an indwelling cath e ter was used if it was over 20% . T h e length and frequency and often tim e of tre a tm e n t depended very m uch on the p a tie n t’s general condition, the depth of sedation, level o f consciousness and when sedation was given. T reatm en t was fitted in w ith ward ro u tin e so as to cause as little disturbance of th e p atien t as possible. B reathing exercises were done routinely w here burns involved face, neck and large areas o f the tru n k , and w here patients were extensively burnt. M ovem en ts aimed a t obtaining full R O M (range o f m ovem ent); thus splints were rem oved for treatm en t and replaced immediately afterw ards. E ach joint involved in the burn was put thro u g h a full R O M fo r each m ovem ent at least once a day. A t first this was often assisted active or passive movem ent. A ccessory m ovem ents w ere used where in­ dicated (fo r exam ple, o f fingers). All joints not directly involved in th e burn were moved actively w here possible, otherw ise passively. T he movem ents were repeated up to five times each twice a day, p referably i to 1 h o u r after routine sedation an d /o r analgesia. A ssessment: R O M was accurately recorded by m eans o f a gonio­ m eter and w here possible m uscle strength assessed according to the O xford scale. A ny abnorm ality, such as existing deform ity, c o n tractu re, o r abnorm al tone, was noted (a fair num ber o f epileptics w ith neurological sym ptom s, patients w ith cerebro-vascular disorder and som e w ith a congenital deform ity were am ong those adm itted). T h e p a tie n t’s general state, degree o f co­ operation, functional independence, etc., were noted. A fter fo u r days: B andages w ere rem oved, and the percentage and depth o f b u rn were reassessed; th e re a fte r dressings were done daily. M ovem ents were then carried o u t when th e burns w ere exposed and again once dressings had been re­ applied. W hilst th e burns were exposed, g reater ROM SEPTEMBER, 1977P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) c0uld be obtained, b u t the b u rn t area becam e dry and niore painful and was difficult to handle. A layer of tulle gras was left on th e b u rn to ease this problem. After dressings had been done, all patients th a t were ambulant o r could tolerate tran sp o rt in a w heelchair were taken to th e d epartm ent fo r individual exercises and self-exercise, using apparatus, to build up strength and endurance. Class-w ork was done successfully with ^ale adults and children. Som e w om en also becam e interested and joined th e class. T hese classes enabled us to cope with a large num ber o f patients and the patients s e e m e d to enjoy the com petition and com panionship. SEPTEMBER 1977 If contractures developed o r were present on admission (0ld cases from outlying hospitals), surgical release was done w ithin 14-21 days w hen response to physiotherapy was unsatisfactory. A fter sloughectom y, gentle exercises (to prevent fu rth e r haem orrhage) w ere perm itted. A fter skingraft, no m ovem ent o f the g raft was perm itted fo r ten days. I f th e graft had not ta k e n a fte r five days, jhysiotherapy could begin again. Patients w ith extensive -turns still had exercises to m aintain function and mobility of areas not involved in skingrafting. Splinting: This was applied on adm ission o r in th eatre after surgery. P O P (Plaster of Paris) was used. Splints were renewed or strengthened by the physiotherapist, as in­ dicated. Shoulders were splinted in full elevation if the axilla was involved; and elbows, in extension; wrists and hands were placed in th e functional position (wrist in 30° dorsiflexion, th u m b in full abduction, m etacarpo­ phalangeal and inter-phalangeal joints in 30° flexion); the neck was p u t in a collar to m ain tain extension; hips and knees were extended to 180°; and ankles in mid­ position. Scarring: Hypertrophic scarring in this series developed m ainly on the neck and face. A p art fro m th e splinting (with pressure), ultrasound therapy, som etim es com bined with icepacks and always followed by massage with lanolin, was used to tr e a t hypertrophic scars. D aily doses of ultrasound (1-1.5 W /cm 2) were given, tim e depending on the extent of th e a rea involved. U ltrasound was also used to soften contractures, to prevent puckering of skingrafts and to mobilise hands and fingers. PROBLEMS / The sheer bulk o f patients and lim ited num ber of physiotherapists precluded ideal tre a tm e n t and it was found to be im practical to do weekly accurate assessments of m ovem ent by m eans o f a goniom eter. 2. As routine w eek-end w ork was impossible, m ainly owing to the geographical situation of the hospital, lack of physiotherapists and sm all num bers o f em er­ gencies (for which f was usually called o u t) patients did regress over week-ends. 3- The nursing staff had a trem endous load with the number o f dressings to be done. T hey changed every m onth and it to o k a while to re tra in each new set, even if the sister in charge did n o t change. 4- The medical interns also ro ta te d every fo u r weeks, and at nights and week-ends patients were adm itted by the m edical officer covering all surgical services and were thus not always treated according to the standard technique. • Adult fem ales were in a “ m ixed” surgical w ard and the technique was never adhered to as strictly as in the o th er w ards. b- D uring the w inter m onths, adm ission rates were very high and the paediatric w ard in particular suffered from overcrow ding w ith a resu ltan t increase in cross-infection. 7 CONCLUSION D espite the problem s m entioned above, results were still encouraging and the system th o u g h t w orthw hile. T he m ain factors in determ ining the success seem ed to be: 1. An enthusiastic surgeon w ho insisted on meticulous observance o f technique. 2. High quality nursing. 3. Liaison and team w ork in all respects fro m all m em ­ bers concerned. Acknowledgements: M y thanks to D r. N . G illiland, S uperintendent o f G a R ankuw a, for perm ission to p rin t th e article. Also to D r. C irota fo r his help and encouragem ent. A p articu lar word o f thanks to physiotherapy staff and students at G a R ankuw a who treated the patients. S P E C I A L I N T E R E S T G R O U P S South African Society o f Physiotherapy Obstetric Association of S.A.S.P.: S ecretary: Mrs. B. K astell, 11 B ath A venue, P arkw ood, Johannesburg, 2193. T el.: 42-7410. Manipulative Therapists Group o f S.A.S.P.: S ecretary: Miss C. de Sm idt, E rin Villa, 5 L ow er T rill R oad, O bservatory, 7925. N ational Hospital Group o f S.A.S.P.: Secretary: Miss P. B ow erbank, P.O . Box 28697, Sunnyside, P retoria, 0132. Private Practitioners’ Association o f S.A.S.P.: Secretary: Mrs. A. M iot, P.O . Box 6681, Johannesburg. P hone 784-3328. Lecturers Group o f S.A.S.P.: S ecretary: Miss S. Irw in-C arruthers, Physiotherapy D ep artm en t, P.O . Box 63, Tygerberg, 7505. S.A. Neurodevelopmental Therapy Association: S ecretary: Mrs. L. F reeling, P.O . Box 792, K rugersdorp, 1740. F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )