A Survey of Current Rehabilitation Trends for Burn Injuries to the Head and Neck

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region. The face is the area central to a person's identity that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

In this first update, we included 12 RCTs, comprising 507 participants. Most trials included adults admitted to specialised burn centres after recent burn injuries. Topical agents included antimicrobial agents (silver sulphadiazine (SSD), Aquacel-Ag, cerium-sulphadiazine, gentamicin cream, mafenide acetate cream, bacitracin), non-antimicrobial agents (Moist Exposed Burn Ointment (MEBO), saline-soaked dressings, skin substitutes (including bioengineered skin substitute (TransCyte), allograft, and xenograft (porcine Xenoderm), and miscellaneous treatments (growth hormone therapy, recombinant human granulocyte-macrophage colony-stimulating factor hydrogel (rhGMCS)), enzymatic debridement, and cream with Helix Aspersa extract). Almost all the evidence included in this review was assessed as low or very low-certainty, often because of high risk of bias due to unclear randomisation procedures (i.e. sequence generation and allocation concealment); lack of blinding of participants, providers and sometimes outcome assessors; and imprecision resulting from few participants, low event rates or both, often in single studies. Topical antimicrobial agents versus topical non-antimicrobial agents There is moderate-certainty evidence that there is probably little or no difference between antimicrobial agents and non-antimicrobial agents (SSD and MEBO) in time to complete wound healing (hazard ratio (HR) 0.84 (95% confidence interval (CI) 0.78 to 1.85, 1 study, 39 participants). Topical antimicrobial agents may make little or no difference to the proportion of wounds completely healed compared with topical non-antimicrobial agents (comparison SSD and MEBO, risk ratio (RR) 0.94, 95% CI 0.68 to 1.29; 1 study, 39 participants; low-certainty evidence). We are uncertain whether there is a difference in wound infection (comparison topical antimicrobial agent (Aquacel-Ag) and MEBO; RR 0.38, 95% CI 0.12 to 1.21; 1 study, 40 participants; very low-certainty evidence). No trials reported change in wound surface area over time or partial wound healing. There is low-certainty evidence for the secondary outcomes scar quality and patient satisfaction. Two studies assessed pain but it was incompletely reported. Topical antimicrobial agents versus other topical antimicrobial agents It is uncertain whether topical antimicrobial agents make any difference in effects as the evidence is low to very low-certainty. For primary outcomes, there is low-certainty evidence for time to partial (i.e. greater than 90%) wound healing (comparison SSD versus cerium SSD: mean difference (MD) -7.10 days, 95% CI -16.43 to 2.23; 1 study, 142 participants). There is very low-certainty evidence regarding whether topical antimicrobial agents make a difference to wound infection (RR 0.73, 95% CI 0.46 to 1.17; 1 study, 15 participants). There is low to very low-certainty evidence for the proportion of facial burns requiring surgery, pain, scar quality, adverse effects and length of hospital stay. Skin substitutes versus topical antimicrobial agents There is low-certainty evidence that a skin substitute may slightly reduce time to partial (i.e. greater than 90%) wound healing, compared with a non-specified antibacterial agent (MD -6.00 days, 95% CI -8.69 to -3.31; 1 study, 34 participants). We are uncertain whether skin substitutes in general make any other difference in effects as the evidence is very low certainty. Outcomes included wound infection, pain, scar quality, adverse effects of treatment and length of hospital stay. Single studies showed contrasting low-certainty evidence. A bioengineered skin substitute may slightly reduce procedural pain (MD -4.00, 95% CI -5.05 to -2.95; 34 participants) and background pain (MD -2.00, 95% CI -3.05 to -0.95; 34 participants) compared with an unspecified antimicrobial agent. In contrast, a biological dressing (porcine Xenoderm) might slightly increase pain in superficial burns (MD 1.20, 95% CI 0.65 to 1.75; 15 participants (30 wounds)) as well as deep partial thickness burns (MD 3.00, 95% CI 2.34 to 3.66; 10 participants (20 wounds)), compared with antimicrobial agents (Physiotulle Ag (Coloplast)). Miscellaneous treatments versus miscellaneous treatments Single studies show low to very low-certainty effects of interventions. Low-certainty evidence shows that MEBO may slightly reduce time to complete wound healing compared with saline soaked dressing (MD -1.7 days, 95% CI -3.32 to -0.08; 40 participants). In addition, a cream containing Helix Aspersa may slightly increase the proportion of wounds completely healed at 14 days compared with MEBO (RR 4.77, 95% CI 1.87 to 12.15; 43 participants). We are uncertain whether any miscellaneous treatment in the included studies makes a difference in effects for the outcomes wound infection, scar quality, pain and patient satisfaction as the evidence is low to very low-certainty.

AUTHORS' CONCLUSIONS

There is mainly low to very low-certainty evidence on the effects of any topical intervention on wound healing in people with facial burns. The number of RCTs in burn care is growing, but the body of evidence is still hampered due to an insufficient number of studies that follow appropriate evidence-based standards of conducting and reporting RCTs.

Head and Neck Reconstruction

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

The antimicrobial spectrum of Xeroform®

INTRODUCTION/BACKGROUND

Xeroform^® is a petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate. Bismuth, similar to other metals, has antimicrobial properties. Xeroform^® has been used for decades in burn and plastic surgery as a donor site dressing and as a covering for wounds or partial thickness burns. Despite this, the antimicrobial spectrum of Xeroform^® remains largely unknown. We examined the in-vitro efficacy of Xeroform^® against common burn pathogens using zone-of-inhibition methodology in a commercial research facility.

METHODS/DESIGN

Pure strains of 15 common burn pathogens including Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Staphylococcus epidermidis, Pseudomonas aeruginosa, Enterobacter cloacae, Escherichia coli, Candida albicans, Vancomycin resistant Enterococcus, Acinetobacter baumennii, Klebsiella pneumonia, Extended spectrum beta-lactamase producing Klebsiella, Beta hemolytic Streptococcus pyogenes, Proteus mirabilis, Serratia marcescens, and Salmonella enterica ssp. Enterica were inoculated at a strength of 10⁶-10¹⁰ CFU/ml onto appropriate agar plates. A sterile 1 in² Xeroform^® square was placed in the center of each plate, and the Zone of Inhibition (ZOI) was measured following 18-24h of incubation at 37°C. A second bismuth pharmaceutical (bismuth subsalicylate, Pepto-Bismol^®) was then tested using the same methodology against the same strains of MRSA, MSSA, E. coli, K. pneumonia and S. marcescens. Finally, 3% w/v bismuth tribromophenate in glycerol suspension was tested against 13 burn pathogens for antimicrobial activity independent of the Xeroform^® dressing by measure of Zone of Inhibition.

RESULTS/FINDINGS

For Xeroform^®, none of the fifteen pathogens had a measurable zone of inhibition on any plate. Bismuth subsalicylate showed a zone of inhibition for MSSA in 3 plates (mean of 47.2mm), in one of three plates for MRSA (13.8mm), and in one of three plates for S. marcesens (89.6mm). There was no zone of inhibition seen for K. pneumonia or E. coli. Bismuth tribromophenate, when not bound to Xeroform^® showed activity against 12 of 13 pathogens.

CONCLUSIONS/IMPLICATIONS

While bismuth subsalicylate, and bismuth tribromophenate unbound to Xeroform^® demonstrate antimicrobial activity, it appears that Xeroform^® dressings do not. The utility of Xeroform^® in burn medicine may relate more to use as an impervious dressing than to antimicrobial effect. Donor sites are clean surgical wounds and clean partial thickness burns may have minimal colonization present. In such circumstances, an inactive and impervious dressing may be all that is necessary to promote wound healing.

Orofacial Contracture Management: Current Patterns of Clinical Practice in Australian and New Zealand Adult Burn Units

Burn injury to the face can lead to scarring and contractures that may impair oral competence for articulation, feeding, airway intubation access, oral/dental hygiene, aesthetics, and facial expression. Although a range of therapy interventions has been discussed for preventing contracture formation, there is minimal information on current practice patterns. This research examined patterns of clinical practice for orofacial burns management during a 4-year period to determine the nature and extent of clinical consistency in current care. Allied health clinicians involved in orofacial contracture management in Australia and New Zealand were surveyed at two time points (2010 and 2014). Twenty and 23 clinicians, respectively, across a range of allied health professions completed the surveys. Both surveys revealed multiple allied health disciplines, predominantly occupational therapy, speech language pathology, and physiotherapy, were involved orofacial burn management. A high degree of variation was observed across clinical practices in the 2010 survey. In the 2014 survey, although, greater consistency in practice patterns was observed with more clinicians commencing intervention earlier, with greater treatment intensity observed and more treatment modalities being used. Furthermore, in 2014, there was an increased use of assessment tools and clinical indicators to guide patient treatment. Agreement regarding clinical practice pathways for orofacial contracture rehabilitation is still emerging, and treatment continues to be predominantly guided by clinical experience. There is an urgent need for treatment efficacy research utilizing validated outcome measure tools to inform clinical consensus and practice guidelines.

The speech-language pathologist's role in multidisciplinary burn care: An international perspective

PURPOSE

To explore international practices of speech-language pathology (SLP) within burn care in order to provide direction for education, training and clinical practice of the burns multidisciplinary team (MDT).

METHOD(S)

A 17-item online survey was designed by two SLPs experienced in burn care with a range of dichotomous, multiple choice and open-ended response questions investigating the availability and scope of practice for SLPs associated with burn units. The survey was distributed via professional burn association gatekeepers. All quantitative data gathered were analysed using descriptive statistics and qualitative data were analysed using content analysis.

RESULT(S)

A total of 240 health professionals, from 6 different continents (37 countries) participated within the study. All continents reported access to SLP services. Referral criteria for SLP were largely uniform across continents. The most dominant area of SLP practice was assessment and management of dysphagia, which was conducted in concert with other members of the MDT.

CONCLUSION

SLP has an international presence within burn care that is currently still emerging.

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region - the area central to a person's identity, that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of partial-thickness burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 12 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to November Week 1 2012); Ovid MEDLINE - In-process & Other Non-Indexed Citations (searched November 12, 2012); Ovid EMBASE (1980 to 2012 Week 45); and EBSCO CINAHL (1982 to 9 November 2012) for relevant trials. We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and included the references identified by the search strategy. Included trials were assessed using a risk of bias form, and data were extracted using a standardised data extraction sheet. For dichotomous and continuous outcomes, we calculated risk ratios and mean differences, respectively, both with 95% confidence intervals (CI).

MAIN RESULTS

We included five RCTs, comprising a total of 119 participants. Two studies compared two different antimicrobial agents and three compared a biological or bioengineered skin substitute with an antimicrobial agent. All studies had small sample sizes and were at high risk of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In three studies time to complete wound healing was significantly shorter for those using a skin substitute than for those using an antibacterial agent, but the quality of the evidence was low. Pain was significantly reduced with the use of skin substitutes in both studies that reported this outcome in all groups, range mean differences -2.00 (95% CI -3.82 to -0.18) to -4.00 (95% CI -5.05 to -2.95) on a 10-point scale.

AUTHORS' CONCLUSIONS

There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

A survey on the current status of burn rehabilitation services in China

BACKGROUND

In China, there is a very long history of burn wound treatment, but the specialised burn care units were set up only from 1958. With more than 50 years of practice, great achievements have been made in burn wound care and operations in the country. However, in terms of burn rehabilitation, the development appears to be slow. In order to determine the current status of burn rehabilitation services in China, a survey was conducted to various burn centres in China.

METHODS

A comprehensive survey was conducted as well as to collect data related to (1) the admissions and staffing of the burn centres; (2) availability of rehabilitation services, number and educational background of specialised personnel dedicated in burn rehabilitation therapy; and (3) the difficulties leading to the lag of the burn rehabilitation services. The survey was sent to the chiefs of 87 burn centres via e-mail and they were requested to fill out the survey questionnaire and to send it back. For those who did not respond within 1 month, a reminder was sent.

RESULTS

There are totally 39 (44.8%) burn centres responding to our survey. These centres were geographically distributed in nearly 70% of the administrative provinces in China; hence, the results could well represent the current burn care system. Most centres have recognised the importance of rehabilitation therapy and remarkable improvements of outcome in burn patients have been achieved. There are a very huge number of burn patients that need rehabilitation therapy, but most centres face the problems of shortage of rehabilitation therapists, which apparently could lead to the difficulties in delivering a quality rehabilitation programme for patients. Although the time of rehabilitation therapy is instituted far earlier than before, it is still not widely accepted in the acute burn care stage. There are more specialists joining the burn centre and becoming members of the professional burn team. However, professional education and training in the burn specialty appear to be sparse. There is room for improvement. Problems that impede the progress of rehabilitation therapy are: lack of rehabilitation knowledge in medical staff as well as the public, the shortage of specialised personnel and relatively low educational background of this team, lack of standard guidelines for rehabilitation treatment instructions and lack of funding from the government.

CONCLUSION

After 20 years of clinical practice, rehabilitation concepts are well accepted and many forms of rehabilitation techniques are carried out in most burn centres that responded to the survey. Yet, the results also indicate that there is a short history of rehabilitation practice among the burn centres. There is a burning need to enhance the development of rehabilitation services so as to meet the demands of management of severely burned patients in China. Some suggestions are made to improve the current burn rehabilitation services which would include: (1) provide rehabilitation education programmes for burn surgeons, therapists, nurses, as well as patients, families and the public; (2) set up standard guidelines for clinical instruction of rehabilitation therapy; (3) build an interdisciplinary burn team; (4) more investigation and research on the physical and psychological outcomes of burn patients; and (5) implement administrative measures in terms of staffing, funding and offering insurance to burn survivors.

An overview of war-related thermal injuries

Thermal injuries have always been a source of morbidity and mortality in times of war. Historically, they constitute 5% to 20% of all injuries and approximately 4% mortality. Although burn patients constitute a small number of casualties, they consume a disproportionate amount of resources and require specialized care. The current conflicts in the Middle East report similar numbers for thermal injuries despite improvement in predeployment education to reduce noncombat-related burns, flame retardant military clothing, and decline of war patterns usually associated with increased thermal injuries. However, the increased use of improvised explosive devices and vehicle-borne improvised explosive devices presents a new source of potential thermal injury. Indeed, the burden of explosion-related burns has increased as has its associated Injury Severity Score. As has been the case in previous conflicts, most burns are hand and head burns. Although usually not life threatening, burns to hands and face lead to significant physical and psychologic morbidities. In this paper, we will review the currently available literature on war-related thermal injuries in Operation Iraqi and Operation Enduring Freedom. We will describe the epidemiology of burn injuries, prewar preparation to prevent and treat thermal injuries, and the assessment, triage, and final treatment of burn patients. In addition, we will discuss the associated physical and psychologic morbidities and, finally, the role of plastic surgeon in burn rehabilitation and reconstruction.

Burn rehabilitation and research: proceedings of a consensus summit

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

A comparison between two burn rehabilitation protocols

INTRODUCTION

Injury from burns is very common and must be treated with considerable care by the rehabilitation team to prevent contractures that may occur. Physiotherapy is vital in rehabilitation of burn-injured patients.

PURPOSE

The aim of this study is to compare a burn rehabilitation treatment (BRT) protocol with a routine burn rehabilitation treatment to find out rehabilitation related problems.

METHODS

For all burn-injured patients admitted to a general hospital in Tehran on 2005, a group match clinical trial was done and then randomly divided into two groups. For the first group, ordinary physiotherapy was done according to the routine prescription and the BRT protocol has been carried out for the second group. At the time of patient registration, a questionnaire was completed which consisted of gender, age, TBS, depth and cause of injury. On the other hand, post burn contractures, thrombosis and duration of staying in hospital was measured at discharge.

RESULTS

There was not any significant difference (p>0.05) in gender, age, TBS, cause and depth of injury between two groups. In addition, there was not any significant difference (p>0.05) between thrombosis and duration of staying patients in hospital. However, these results show significant difference (p<0.01) in burn contractures between two groups. In the BRT group, 6% had burn contractures, with 73% routine rehabilitation treatment.

CONCLUSION

The result of this study indicates that intensive rehabilitation decreased burn complications. Burn rehabilitation teams could consider the BRT protocol.

Burns sustained in combat explosions in Operations Iraqi and Enduring Freedom (OIF/OEF explosion burns)

BACKGROUND

Burns comprise 5% of casualties evacuated from Operations Iraqi and Enduring Freedom (OIF and OEF). Many OIF/OEF burns result from the enemy's detonation of explosives. We reviewed these to evaluate mission impact and provide recommendations for improved combat burn protection. Data were compared to those from the Vietnam War.

METHODS

All OIF/OEF patients with significant burns are treated at the U.S. Army Institute of Surgical Research (ISR). A review from April 2003 to April 2005 was undertaken. Records were obtained and demographics, burn severity and pattern, and early outcomes recorded.

RESULTS

Two hundred and seventy-four OIF/OEF burn patients were treated, 142 (52%) sustained burns in explosions from hostile action. Age was 26+/-7 years (mean+/-S.D.). Mortality was 4%. The annual rate of combat explosion as a cause for burns increased from 18% to 69%, total body surface area burned increased from 15+/-12 to 21+/-23%, injury severity score rose from 8+/-11 to 17+/-18, and frequency of inhalation injury rose from 5% to 26%. Improvised explosive devices caused 55% of casualties, car bombs 16%, rocket-propelled grenades 15% and 14% other. The hands (80% of patients) and the face (77%) were the most frequently burned body areas. Burns were isolated to the hands in 6% of patients and to the face and hands in 15%. An average of 52+/-30% of the surface area of the hands and 45+/-26% of the face was burned. Mean length of stay was 24+/-25 days (median 14). Though 77% of patients were discharged without global disability, only 36% returned to full military duty. A similar pattern of injury and disposition was seen at the Army burn center in Vietnam (1966-1968), but mortality was higher (7.9%).

CONCLUSION

Burns resulting from combat explosions increased in frequency, size and injury severity. Burns were concentrated on areas not protected by clothing or equipment. These injuries created long hospital stays and frequently prevented soldiers from returning to duty. While wound distribution has not changed, combat burn care has improved, and continued emphasis on military protective equipment for the hands and face is warranted.

Comparison of combat and non-combat burns from ongoing U.S. military operations

BACKGROUND

Military burns result from either combat or non-combat causes. We compared these etiologies from patients involved in ongoing conflicts to evaluate their impact and provide prevention recommendations.

METHODS

All military patients with significant burns treated at the United States Army Institute of Surgical Research from April 2003 to May 2005 were reviewed. Injuries were categorized as having resulted from combat or non-combat causes. Demographics, burn severity and pattern, mortality, and early outcomes were compared.

RESULTS

There were 273 burn patients seen with 63% injured in combat. A high early rate of non-combat injuries was noted. Feedback on non-combat burn prevention was provided to the combat theater, and the incidence of non-combat burns decreased. Mean age and time from injury to admission did not differ. The majority of combat injuries resulted from explosive device detonation. Waste burning, ammunition handling, and gasoline caused most non-combat injuries. Combat casualties had more associated and inhalation injuries and greater full-thickness burn size; total body surface area burned was equivalent. The hands and the face were the most frequently burned body areas. Mortality was 5% in combat and 2% in non-combat patients. The majority of survivors in both groups returned to military duty.

CONCLUSIONS

The disparity in full-thickness burn size and incidence of inhalation and associated injuries resulted from differing mechanisms of injury, with explosions and penetrating trauma more common in combat wounds. Despite the severity of combat burns, mortality was low and outcomes generally good. Non-combat burns are preventable and have decreased in incidence.