BRIGHAM AND WOMEN’S HOSPITAL

Department of Rehabilitation Services

Physical Therapy

Standard of Care: Inpatient Physical Therapy Management of Patients with

Burns

ICD 9 Codes:
942 Burn of trunk
943 Burn of upper limb, except wrist and hand
944 Burn of wrist(s) and hands(s)
945 Burn of lower limb(s)
946 Burn of multiple specified sites
948 Burns classified according to extent of body surface involved
949 Burn, unspecified
991 Effects of reduced temperature (i.e. frostbite)
695.1 Erythema multiforme, Toxic epidermal nectolysis (TEN)
Others may also apply (e.g. various extensive wound diagnoses)

Case Type / Diagnosis:

This standard of care applies to patients who are admitted to the Brigham and Women’s
Hospital (BWH) for the management of their burns. A burn injury can be sustained through
a variety of sources including thermal/heat (flame, flash, scald, and steam), chemicals,
radiation, sunlight, or electricity. Burn-like injuries can also occur due to reduced
temperature [frostbite 8] and as a reaction to medication [toxic epidermal necrolysis—TEN,
also known as Steven-Johnson syndrome 8]. In addition to injury to the skin, patients can
also sustain damage to their respiratory system due to inhalation injuries that require
intensive management. Burns can range from a minor injury covering 1% of a patient’s body
to a severe burn covering 90%-100% of the total body surface area. Patients are also
admitted to BWH for ongoing reconstructive procedures in the months and years following a
burn injury; these can include contracture releases, grafting procedures, muscle flaps, and
debridements. The burn service at BWH can also manage patients with extensive non-
healing wounds [i.e. such as those that occur from Graft vs. Host disease (GVHD) involving
the skin]; refer to the integument standard of care for details.

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 Burns are classified by depth of injured tissue as detailed in the table below:

Appearance Area Affected Sensation Blanching Wound Closure

First Degree Pink or red; Epidermis Intact, painful Present Typically heals within 3-5 days
(Superficial) May be dry or with no scarring
moist
Second Degree Bright pink or Epidermis and Intact, painful and Present Heals by re-epithelialization in 10-
(Superficial red, wet, blisters portion of dermis sensitive to change in 14 days; typically no scarring or
partial temperature and grafting needed
thickness) exposure to air or touch

Second Degree Mottled, red and Epidermis and Variable; may be intact Diminished Heals by re-epithelialization in 14-
(Deep Partial waxy white; wet deeper portion of with areas of diminished 21 days or longer; scarring is likely
Thickness) dermis sensation if burn in > 30% TBSA
Third Degree White or tan; dry Entire epidermis Painless; may be Absent Skin graft required
(Full Thickness) and leathery, and dermis sensitive to deep
non-pliable pressure; anesthetic to
temperature

Fourth Degree May be charred Deep soft tissue Absent Absent Excision of necrotic tissue and skin
or dry damage to fat, graft required, possible amputation
muscle, tendon, in some cases
fascia, nerve
and/or bone

• The following criteria categorize patients that require care at a specialized inpatient burn
center 15:
 Patients who sustain partial thickness burns greater than 10% of total body surface
area (TBSA) require more intensive medical monitoring and intervention due to
effects of significant edema. They are more likely to have mobility and
movement issues and will require early PT/OT intervention.
 Patients who sustain burns of the neck and face are at higher risk for significant
edema that can cause respiratory distress. They may need to be intubated for an
extended period.
 Patients who sustain burns involving the hands, feet, genitalia, perineum, or major
joints are at higher risk for decreased healing, hypertrophic scarring and
contractures. These parts of the body are crucial for normal function and require
specialized intervention for best recovery.
 Patients who sustain full-thickness (i.e. third degree) burns are at significantly
higher risk for decreased healing, hypertrophic scarring and contractures. They
almost always need complex wound care and surgical intervention. These
patients also require intensive nutritional support and hemodynamic monitoring.
They require more specialized, intensive PT and OT intervention for optimal
progress.
 Patients with electrical burns, including lightning injury are at risk for cardiac
symptoms such as arrhythmias due to the electrical current. In addition, the path
of an electrical current can cause deeper, less obvious injuries that can affect vital
organs and deep muscles. Frequent surgical debridement as well as hemodynamic
monitoring is essential.

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
  Patients who sustain chemical burns require more intensive management. The
chemical can be absorbed into the skin and cause damage for an extended period
of time. These patients often require specialized cleansing procedures and close
monitoring.
 Patients with inhalation injuries often require ventilation and intensive pulmonary
hygiene.
 Patients who sustain a burn and also have pre-existing medical disorders require
more intensive management and frequently have slower progress. Their medical
status can complicate management and prolong recovery.
 Patients with burns and concomitant trauma (such as fractures) in which the burn
poses the greatest risk of morbidity or mortality require higher intensity of care.
 Patients with burn injuries who will require special social, emotional, or long-
term rehabilitative intervention.15

Phases of Burn Care:

Burn management can be divided into three phases. An interdisciplinary approach including
Physical and Occupational Therapist involvement is essential in all three phases 9:
o Emergent or Resuscitative Phase
Medical Assessment
 Assess for the presence of an inhalation injury and secure airway
 Assess size of burn (TBSA) using the “Rule of Nines:”
 Head = 9%
 Trunk = 36%
 Upper extremity = 9% each
 Perineum = 1%
 Lower extremity = 18% each
 Assess and classify of burn depth
 Begin fluid resuscitation
 Maintain body temperature (prevent hypothermia)
 Achieve cardiopulmonary stability
 Establish adequate tissue perfusion and monitor for compartment
syndrome. Escharotomies may be necessary to prevent tissue, muscle and
nerve death
 Debridement of necrotic, dirty, or infected wounds
Physical Therapy Management
Intervention may focus on positioning until patient is stabilized.
o Acute Phase: (after emergent phase and until wounds are closed)
Medical Management
 Ongoing wound debridement, assessment for evolution of wound depth
 Skin grafting (when indicated—use of autograft, allograft, cultured skin)
 Infection control and rigorous wound care
 Nutritional support sufficient to meet wound-healing needs

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 Physical Therapy Management
Comprehensive intervention addressing positioning, stretching, mobility,
ongoing skin assessment and scar management, education, balance,
endurance, respiratory conditioning
o Rehabilitative Phase Medical Goals: (follows acute phase until scar maturation)
 Surgical release of contractures
 Nutritional support
 Reconstructive or plastic surgery to maximize function and cosmesis
Physical therapy Management
Intensive rehabilitation program—scar management, range of motion (ROM) and
stretching with techniques, mobility training as needed, education re: self-
management

Indications for Treatment:

Patients with burn injuries involving superficial, partial, or full thickness skin with potential
extension into fascia, muscle, or bone, and at risk for contracture and scar formation will require
intervention. These burns can result in impairments such as loss of joint ROM, peri-articular or
intra-articular joint changes, sensory loss, edema, pain, impaired ventilation/aerobic capacity,
impaired activity tolerance, impaired balance, coordination, and strength. They can cause
functional deficits such as impaired mobility, difficulty performing activities of daily living
(ADL’s) and instrumental activities of daily living (IADL’s). Patients also lack knowledge about
wound healing, self-care, and coping/adjustment strategies following burn injury.

Contraindications / Precautions for Treatment:

Contraindications:
o Presence of femoral IV access
 venous access will make repetitive hip ROM contraindicated as it can
cause introduction of bacteria into access
 arterial access precludes any hip ROM as it increases the risk of arterial
bleeding from site
Precautions:
o Unstable heart rate, blood pressure, respiratory status and fevers of more than 102 degrees
can prevent Physical Therapy intervention. Both tachycardia and fevers can be a result of
the patient’s hypermetabolic state and do not always preclude intervention. Patients with
burns have a harder time maintaining a stable body temperature due to the presence of open
wounds 19
o ROM precautions and restrictions must be known prior to starting each treatment session,
due to one or more of the following reasons:
 Cultured Skin (CEA or “cultured epidermal autografts”)—ROM to area of
CEA is contra-indicated for the first 10-14 days and prior to initial
takedown to avoid graft disruption
 Autologous skin grafts—Differentiate between full and partial thickness
grafts. Joints crossed by grafts are immobilized for 5-7 days
 Flaps—total immobilization to promote viability; await physician
clearance prior to resuming ROM
Standard of Care: Physical Therapy Management of Patients with Burns
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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 o Infection control: All caregivers should practice universal precautions. Additional
measures are taken for burn patients. Due to the fact that their burns cause a large number
of open wounds, they are at higher risk for infection.
 Full burn precautions: All staff must wear a gown, gloves, surgical mask,
and hat when working with a patient who does not have their wounds fully
dressed
 Partial Burn Precautions: Gloves and a gown are required for any patient
 It is necessary to practice excellent hand hygiene and cleaning of all
equipment used during treatment

Evaluation:
Medical History: Pertinent past/ongoing medical issues that may impact response to
treatment
History of Present Illness/Hospital Course:
 Mechanism of injury
 Nature of burn (thermal, chemical, electrical, allergic reaction)
 Extent of Burn (TBSA, location, depth)
 Burns that cross joints
 Evidence of inhalation injury (singed eyebrows, nasal hairs, soot in
sputum)
 Relevant medications (e.g. pressors, fluid resuscitation, pain medications,
sedation)
Social History:
 Specifics about home environment, architectural barriers
 Family support, normal role in family
 Baseline level of function
 Adaptive equipment use
 Psycho/social issues, substance abuse issues
Medications:
 Pressors
 Fluid resuscitation
 Pain medications (Fentanyl, Morphine, Dilautid, Neurontin, NSAIDS)
 Sedation (Versed, Fentanyl)
 Topicals for care of wounds (See Appendix)

Examination:
Integument
 Risk for scarring is related to depth of burn and rate of healing. Also
certain skin types are more prone to scarring, such as skin of darker
pigment20
 Determine if use of cultured skin cells (CEA) is planned and refer to
special precautions and considerations that apply17
 Assessment of scarring16

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 Musculo-skeletal
 ROM is measured using goniometric measurements
 Strength is measured using manual muscle test (MMT) if patient is able to
participate in exam. If not, assess functional and spontaneous motion by
observation and reassess more specifically later in course
 Posture/alignment can be assessed by observation when patient is able to
sit or stand. Asymmetries can indicate scarring
 Functional mobility (assistive devices as needed):
• appropriate assistive devices
• pre-ambulation equipment such as tilt table
• lift devices as needed
Neuro-muscular
 Pain: (if able to communicate by pain scale; if not assess by monitoring
heart rate, blood pressure, respiration rate, facial grimacing, gesturing).
Communicate with nursing re: need for additional pain medication, instruct
patient in deep breathing and relaxation for pain control. Plan treatment
sessions to coincide with either pre-medication or the ability to receive
bolus pain medication. Engage the patient and the staff in coordinating the
optimal time for intervention with their pain control regime. In the acute
phase of treatment, patients are often receiving a large number of narcotic
medications which can be sedating and keep patient obtunded for an
extended period which impacts components of Physical Therapy treatment.
Intervention at this time is often more passive (i.e. passive ROM,
positioning). The medication, Fentanyl, is frequently used during dressing
changes and therapy interventions due to its short half-life. Later in the
course, patients are changed to oral narcotics and NSAIDS.
 Sensation: Assess patients ability to perceive light touch as burns heal
and as patient is able to communicate 7
Cardio-Pulmonary
 Respiratory status including presence of inhalation injury and the level of
ventilatory support required, presence of rhonchi or rales
Mental Status and Cognition
 Level of consciousness
 Orientation
 Safety judgment
 Ability to follow direction
Psychological Considerations
 Coping with altered body image and appearance
 Learning style
 Patient's goals for recovery
 Impact of psychiatric disorders on participation and recovery22

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
Assessment:
Problem List (Impairments and dysfunctions)
 Impaired range of motion/risk for contractures
 Edema
 Risk for hypertrophic scarring
 Impaired mobility
 Impaired respiratory status
 Impaired endurance
 Impaired integument
 Impaired balance
 Need for optimal positioning
 Knowledge deficit re: aspects of burn rehab and self-care
 Pain

Prognosis: Over the last thirty years, medical technology and interventions have
improved, increasing the survival rate of patients with large percentage burns. Between
1995 and 2005, 94.4% of patients admitted to a burn center survived 6, 18. This being
said, prognosis can be highly variable. Some considerations that impact prognosis are
depth of burn, surface area involved, type of burn (chemical and electrical may increase
length of stay), presence of an inhalation injury, significant psychiatric or substance
abuse issues and co-morbidities such as history of smoking, diabetes. “Risk factors most
strongly associated with death are increasing total body surface area (TBSA), inhalation
injuries and increasing age”.21
People with first degree (superficial partial thickness such as sunburn) are rarely
admitted to the hospital. Those with second degree burns (partial thickness) may be
admitted for several days for local wound care. Those with deeper burns (full thickness)
may require surgical grafting which increased length of stay and risk of long-term
disability. An inhalation injury may require an extended period of intubation.
Attaining a high quality of life is a challenge for burn survivors. Once they are
medically stable and healed, the goal of regaining their previous roles and activities takes
intensive work, motivation and guidance of healthcare professionals. Little research has
been done on quality of life after a burn injury, but a study done in 2005 showed that
“participants in the present study had little or no difficulty resuming functional mobility
and self-care activities of daily living” 22. This study suggests that patients with larger
burns can "achieve functional independence and reasonable quality of life in the long
term" 22.

Suggested Goals:
Timeline is highly variable depending on prognosis noted above. Goals should be
objective and measurable.
1. ROM WNL
2. optimal positioning
3. appropriate splints/positioning devices, pressure garments/pads
4. minimize hypertrophic scarring
5. strength at least 3/5 in affected areas, 3-5/5 in unburned areas

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 6. optimal posture (upright, symmetrical)
7. independent mobility with appropriate device
8. tolerates full PT treatment with adequate ventilation and oxygen saturation
9. demonstrates knowledge of healing process, activity progression, independent
exercise/stretching program

Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X_ No

Established Protocol ___ Yes, see attached. _X_ No

Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is
not intended to be either inclusive or exclusive of appropriate interventions.
 ROM, stretching
1. AROM attempted, specific measurements
2. stretching
 Positioning:
1. appropriate splints, bivalve casts (prefabricated and custom)12
2. other devices (slings, foam wedges, pillows, rolls)
3. bed options can assist with positioning and intervention (high/low, reverse
trendelenburg, knee and head elevation)
4. can use bedside tables and slings to position UE's in abduction as axillae
are at especially high risk for contractures
 Scar management is managed in several ways:
1. Compression
a. Ace wraps or elastic tubular bandage (e.g. Tubigrip®) use can be initiated
immediately for edema control pre and post grafting
b. Pressure garments (e.g. Jobst®) and silicone gel sheeting use can be
started three weeks after grafting procedure and when open areas are less
than nickel-sized
2. Scar massage can be initiated when areas are fully healed and skin is no
longer “translucent”
3. Positioning/sustained stretch can be initiated at any time
 Mobility progression using appropriate DME, lifts
 Endurance activities
 Respiratory conditioning
 Structured schedule

Frequency & Duration: These patients are typically seen 5-7 times weekly. Duration is
dependent on extent and severity of burns and need for intensive acute care intervention.
Length of stay can vary from 2-3 days for a localized burn (such as partial thickness burn
to hand or foot) to many weeks to months for a high percentage, deep burn that requires
multiple surgical procedures and prolonged intubation.

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
 Patient / family education:
 Burn patient and family education book is available from the Trauma Nurse
Specialist
 Discussion with patient and family re: Physical Therapy involvement with patient
and expected progression
 Discussion with patient and family re: optimizing patient’s independent mobility
and self-care and providing the appropriate level of assistance to the patient
 Instruction of patient and family in appropriate exercises and activities with written
exercise program and exercise/activity log
 Discussion of longer term issues common following a burn injuries
1. phases of burn healing, estimated time line, risk of scarring
2. ways to minimize scarring and contracture
3. proper management of pressure garments, DME
4. proper skin care and protection

Recommendations and referrals to other providers:

 Occupational Therapy
 Speech Therapy
 Social Work/Care Coordination
 Psychiatry
 Orthopedic Technician
 Translators
 Outside resources for the measurement and fit of compression garments (e.g.
Compass Healthcare 617/566-6772)
 Outside Resources such as support groups (e.g. the Phoenix Society). Visits by
known burn survivors that can talk with patient and family can be arranged by the
social worker

Re-evaluation
Standard Time Frame-10 days or less if appropriate
Other Possible Triggers- A significant change in signs and symptoms, new surgical
procedure, significant progress in PT intervention requiring re-assessment

Discharge Planning
Commonly expected outcomes at discharge:
 Return to independent function
 Maximal range of motion
 Minimal hypertrophic scarring
 Patient is independent with exercise program and skin management
Transfer of Care (if applicable)
 Rehabilitation facility
 Home with services
 Home with family assistance
 Home with independent program

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
  Upon discharge, most patients are seen regularly at the Burn Clinic which is a
wound care clinic staffed by nurses. They can facilitate referral to other services
as needed. These patients are sometimes seen in the BWH outpatient
rehabilitation clinic by Physical Therapy and Hand Therapy

Authors: Alisa G. Finkel PT Reviewed by: Barbara Odaka PT

October 2008 Melanie Parker PT
Merideth Donlan PT

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
REFERENCES
1. American Burn Association, Burn Incidence Fact Sheet. Available at:
http://www.ameriburn.org/pub/BurnIncidenceFactSheet.htm. Accessed February 23, 2006.
2. Bertek Pharmaceuticals Inc. Biobrane temporary wound dressing. Faxed October 11, 2006.
3. Burn Nursing Dept. Biobrane dressing. Brigham and Women’s Hospital Burn Trauma Unit
Nursing Protocol.
4. Christiansen C, ed. Ways of Living: Self-Care Strategies for Special Needs. 2nd ed.
Bethesda, Md: American Occupational Therapy Association, Inc.; 2000.
5. Galveston Shriners Burn Hospital, The University of Texas Medical Branch Blocker Burn
Unit. Total Burn Care page. Available at:
http://www.totalburncare.com/orientation_burn_shock.htm. Accessed March 15, 2006.
6. Herndon DN, ed. Total Burn Care. London: W. B. Saunders Company Ltd.; 1996.
7. Trombly CA, ed. Occupational Therapy for Physical Dysfunction. 4th ed. Philadelphia, Pa:
Lippincott Williams & Wilkins; 1997.
8. Richard RL and Staley, M., Burn Care and Rehabilitation: Principles and Practice,
Philadelphia, PA: F. A. Davis Company; 1994: chapter 22/622-40.
9.Trombly, CA, Radomski MV, eds. Occupational Therapy for Physical Dysfunction. 5th ed.
Philadephia, PA: Lippincott Williams & Wikins; 2002; 1025-1030.
10. Simons M., King S., Edgar D.Occupational therapy and physiotherapy for the patient with
burns: principles and management guidelines”, Journal of Burn Care & Rehabilitation, Sep/Oct
2003; 24 (5): 323-35.
11. Smith K., Owens K. Physical and Occupational therapy burn unit protocol—benefits and
uses. Journal of Burn Care and Rehabiitation, Nov/Dec 1985; 6 (6):506-8.
12. Malick M., Carr JA, Manual on Management of the Burn Patient, Marmarville
Rehabilitation Center Educational Resource Division, Pittsburgh, PA, Chapter 3, 1982.
13. Ward RS. Pressure therapy for the control of hypertrophic scar formation after burn injury.
Journal of Burn Care & Rehabilitation. May/June 1991; 12 (3): 257-62.
14. MacNeil S. Progress and opportunities for tissue-engineered skin. Nature. February 22,
2007; 445 (7130): 874-880.
15. American Burn Association, Guidelines for the Operation of Burn Centers. Available at:
http://www.ameriburn.org/pub/BurnIncidenceFactSheet.htm. Accessed January 7, 2008.
16. Baryza, MJ and Baryza GA. The Vancouver scar scale: an administration tool and its
interrater reliability. Journal of Burn Care and Rehabilitation. Sep/Oct 1995; 15(5): 535-8.
17. Nursing Instructions on Epicel. 2002.
18. American Burn Association, Burn Incidence and Treatment in the US: 2007 Fact Sheet.
Available at http://www.ameriburn.org/resources_factsheet.php. Accessed June 13, 2008.
19. Richard RL and Staley, M., Burn Care and Rehabilitation: Principles and Practice,
Philadelphia, PA: F. A. Davis Company; 1994: chapter 2/25.
20. Richard RL and Staley, M., Burn Care and Rehabilitation: Principles and Practice,
Philadelphia, PA: F. A. Davis Company; 1994: chapter 14/385-7.
21. Edelman DA,White MT, Tyburski JG, Wilson RF. Factors Affecting Prognosis of Inhalation
Injury. Journal of Burn Care & Research. November/December 2006; 27 (6): 848-853.
22. Druery M, Brown Tim La H, Muller, M. Longterm Functional Outcomes and Quality of Life
Following Severe Burn Injury. Burns. September 2005; 31 (6):692-5.

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
APPENDIX TOPICAL BURN THERAPY (from Stefan Strojwas, BWH Nurse Educator, 7CD)
AGENT DESCRIPTION ACTIONS ADVANTAGES DISADVANTAGES CONSIDERATIONS
Acticoat Silver impregnated Antimicrobial Can remain in place up to Needs to be applied wet -deep dressing moist with
gauze 3 days so decreases sterile water
dressing time -monitor pt. Temperature
due to wet dressings
Bacitracin Bactericidal ointment Gram +/- effective Nonpainful and easy to May be nephrotoxic Monitor serum BUN and
apply Cre
Betadine Iodine complex, Antimicrobial for gram Effective against May cause metabolic May form crust around
solution or ointment +/- organisms not controlled acidosis, can be painful to would which needs to be
by Silvadene apply removed
Biobrane Bio-synthetic wound Controls water loss & Decreases pain, remains Wound surface must be Need to observe for
covering, good for minimizes bacteria in place until re- debrided and clean before signs/symptoms of
partial thickness burns, growth epithelialization occurs. application infection and adherence
clean wound beds Allows for movement
Cadaver Temporary wound Reduces heat and water Easy to apply, prepares Not always available Need to observe for
Skin covering loss, controls pain wounds for grafting infection
Fine Mesh Sterile Carrier for Allows for specific May stick to wounds
Gauze ointments/creams. placement causing pain
Gentle debridement
when removed

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
AGENT DESCRIPTION ACTION ADVANTAGES DISADVANTAGES CONSIDERATIONS
Gentamycin Antibiotic cream Antibiotic, effective Effective against May be nephrotoxic Monitor serum BUN and
against many pseudomonas Cre
organisms
Lotrimin Antifungal cream Interferes with fungal Can be used with other May cause burning and redness Affected area must be
DNA topicals fully covered
Neomycin Antibiotic solution Wide spectrum, used Combats most Can cause shivering Monitor Cre, Check pt.
after grafting organisms, easy to For temperature changes
apply
Pig skin Temporary wound Reduces heat & water Readily available, May cause sensitivity reaction Observe for infection
covering loss, reduces pain, easily applied
prepares wound for
grafting
Silvadene Antimicrobial Binds to organism’s Wide spectrum for Shallow penetration, depresses Check for sulfa allergies,
(Silver cream cell membranes and gram +/-. Does not granulocyte formation
sulfadiazine interferes with DNA delay eschar separation
Silver nitrate 5% silver salt Antimicrobial Easy application, Shallow penetration, stains and Keep dressings wet,
antimicrobial delays granulation stings. May cause check daily electrolytes
solution hypertrophy hyponatremia, hypochloremia,
hypocalcemia
Sulfamylon Water based Effective against Effective against May cause metabolic acidosis Monitor blood gases and
Mafenide bacteriostatic crem gram +/- organisms pseudomonas, and rash, can be painful, delays electrolytes
Acetate penetrates thick eschar eschar separation

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved
AGENT DESCRIPTION ACTION ADVANTAGES DISADVANTAGES CONSIDERATIONS
Transcyte Bi-layer, temporary Contains active Controls pain, retains Wound must be debrided Monitor for adhesion
Dermagraft-TC skin substitute human wound heat and moisture, prior to placement. Has no and infection
healing factors stimulates wound re- antibacterial effects
epitheliazation
Triple antibiotic Mixture of Bactericidal for No pain on applications Cannot be used for full Monitor for infection
ointment neomycin, gram +/- organisms thickness burns
polymixin, for partial
bacitracin thickness burns
Vitamin A&D Petroleum based Fat soluble Moisturized newly healed No antibacterial effects
ointment vitamins assist tissue
with healing
Xeroform Yellow substance on Debrides and Conforms to wound, Can stick to wounds, no Careful removal from
bismuth Vaseline protects wounds, nontoxic antibacterial new grafts essential
tribromphenate impregnated gauze donor sites and
grafts

Standard of Care: Physical Therapy Management of Patients with Burns

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Copyright © 2008 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved