Điều Trị Bỏng Toàn Diện (Bản Expert Consult)

Management of pain and other discomforts in burned patients
725
of 10 mg/kg of body weight given every 4 h (up to a
maximum of 2400 mg/day).193 In addition, acetaminophen
is well tolerated and causes almost no side-effects,193,194
although there is some concern about long-term liver prob­
lems with this medication.
The best response was with the younger children and the
smaller burns, but acetaminophen levels should be moni­
tored in very young or extremely ill children. One should
be aware that, because acetaminophen is packaged in
conjunction with hydrocodone in the form of VicodinRX
and LoratabRX, one should be careful not to give acetami­
nophen in addition to either one of these combination
medications.
We have found diazepam to be very useful in providing
background anxiety control when muscle relaxation is
desired (e.g. to facilitate rehabilitative exercise) in addition
to attenuating anxiety. Because of its long half-life, it is ideal
for treating the patient during the rehabilitative period when
the healing burn wound is very uncomfortable and seems to
inhibit doing any activities including sleep.
The second type of pain is neuropathic pain. This type of
pain may either be due to the regeneration of nerve endings,
or may be phantom pain from the loss of digits or limbs.
Individuals with phantom limb pain often have sensations
of the existence of these digits or limbs for many years after
their loss. Neuropathic pain can also be associated with the
damage to the nerve endings in the skin. The neuropathic
pain has many descriptions: pins and needles, like someone
walking on your skin with cleats, burning or the sensation
of having multiple bites of fire ants. The only thing the
patient can do to reduce the pain is to move around or rest.
The pain is brought on sometimes by temperature change,
dependent position, or weight-bearing activities. Often the
pain will not start for many months after the injury (4.3 ± 0.5
months) but some have the pain immediately, especially if
a limb or digit is lost.195
This type of pain will often last more than a year and
usually does not respond to traditional pain management
with nonsteroidal acetaminophen or opioid analgesics. This
neuropathic pain often does respond to the use of tricyclics
or anticonvulsants. Doses of imipramine or amitriptyline of
1 mg/kg body weight often are effective.196 Phantom limb
pain is more common in those with electrical injury than
following flame injury. If the pain does not respond to this,
then carbamazepine might be utilized in doses which are
therapeutic for seizures. Gabapentin has been used for neu­
ropathic pain with good effect with few side-effects.127,197
Most recently, pregabalin, which was developed for the treat­
ment of the neuropathic pain of diabetes, has been used
successfully for neuropathic pain of burns. Some patients
have required the simultaneous use of several of these agents
to get control of their pain. Over time, this neuropathic pain
seems to become more tolerable and slowly dissipate.
Gabapentin is not sedating for most patients but amitriptyl­
ine is. Both amitriptyline and pregabalin are associated with
excessive weight gain.
Itch medications
Itch is one of the most common sequelae of burn injury.
Field et al. reported that pruritus occurs in 87% of patients
who have a burn injury.60 Although it is thought to be
tetrahydrofolate needed for DNA synthesis and metabolic
reactions involving methylations is inhibited by nitrous
oxide inactivation of vitamin B12. Clinical presentation
mimics pernicious anemia with megaloblastic anemia and
subacute combined degeneration of the spinal cord. Hayden
and colleagues reported a case of myeloneuropathy in a
burn patient exposed to high concentrations chronically
when he was given 50% nitrous oxide in oxygen to self-
administer ad lib over approximately 4 months.185 Chronic
exposure is also possible for workers exposed to nitrous
oxide chronically. Sweeny et al. found bone marrow changes
consistent with nitrous oxide toxicity in 3 of 21 dentists who
used nitrous oxide for sedation and analgesia for their
patients during long procedures.186 Ambient nitrous oxide
concentrations were as high as 4600 ppm in their work
areas. With modern scavenging systems, operating room
personnel are not considered at risk. If nitrous oxide is used
for analgesia for burn patients, adequate consideration must
be given to chronic exposure of personnel.
Ventilator patient
Special consideration should be given to managing the pain
of a patient requiring mechanical ventilation. The endotra­
cheal tube causes significant discomfort, and sedation and
analgesia are required to facilitate synchrony with mechani­
cal breaths and minimize ventilator associated injury from
increased airway pressures.187 Morphine or fentanyl along
with midazolam are first-line drugs in most ICUs for venti­
lated patients.188 In some burn patients, opiate tolerance
develops rapidly and is associated with hyperalgesia and
poor pain control. Methadone has been found useful in
burn patients poorly controlled with morphine.189 NMDA
receptor antagonism by methadone has been used to explain
this effect. Alpha-2 agonists (clonidine and dexmedetomi­
dine) and low dose ketamine have been found in other
patients.190,191 When muscle relaxants are used to facilitate
mechanical ventilation it is necessary to ensure that ade­
quate sedation and analgesic medications are also continu­
ously administered.
Rehabilitative phase
There are several types of pain that patients report during the
rehabilitative phase. First, patients report an aching type of
pain, similar to arthritic pain. In this case, mild opioid anal­
gesics, acetaminophen, or nonsteroidal anti-inflammatory
drugs (NSAIDs) may be used for either procedural (exercise)
or background pain. In addition ibuprofen may reduce the
hypermetabolic state.192 There is disagreement between pro­
viders concerning the risk of ibuprofen in causing bleeding
from grafts. Now ibuprofen is available in an intravenous
form so it may be more useful. At the Shriners Hospital in
Galveston, Ibuprofen is used a lot in the rehabilitation phase
to help with muscle pain and seems to be more efficacious
than opiates, which increase somnolence.
Because of the significant side-effect profile of non-
steroidal and anti-inflammatory drugs (NSAIDs) such as
ibuprofen, acetaminophen has been considered for the man­
agement of chronic pain. Acetaminophen at a dose of 10–
15 mg/kg of body weight given every 4 h (up to a maximum
of 4000 mg/day) is equal in efficacy to Ibuprofen at a dose

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suggesting some improvement in itch with naltrexone. Then,
Jung et al.208 reported a significant decrease in itching sensa­
tion and scratching from 9 to 5.9 on a 10-point scale after 2
weeks of treatment with 50 mg of naltrexone at night when
it was given with the usual antihistamines. Side-effects of
headache and nausea were noted in many of the patients.
Development of protocols for comfort
Interest in pain management of burned patients has been a
high priority in the treatment of burns only in the last 10–15
years.209 Beginning in 1995, multiple institutions have
published their pain protocols1,2,64 The protocol currently
used in the Shriners Burns Hospital in Galveston has been
reviewed and up-dated every few years; the most recent
version is shown in Box 64.4, and includes management of
the most common discomforts of burned patients.
Non-pharmacologic therapies
in burned patients
As has been discussed, there is a strong interaction between
psychological and physiological factors contributing to the
pain experience. Anxiety in particular is prevalent among
patients with burn injuries and is known to exacerbate acute
pain. Non-pharmacologic therapies play an important role
in addressing the psychological factors that exacerbate pain,
as well as having a direct impact on the pain itself.211
In understanding how non-pharmacologic approaches can
be used with burn pain, it is important to discuss how behav­
ioral principles contribute to the patient’s experience.212 In
terms of classical (stimulus-response) conditioning, patients
(particularly children) often will develop a conditioned
anxiety response to stimuli associated with painful burn pro­
cedures. One study demonstrated that the simple event of a
healthcare worker wearing scrubs was enough to elicit a
fearful response in children with burns.213 In terms of operant
(reinforcement) conditioning, patients can be thought to
gain reinforcement by avoiding or escaping painful proce­
dures, perhaps by screaming enough to terminate treatment
or to obtain some sort of reinforcement from the staff by
showing pain behaviors. Between the stimulus that precedes
pain and the pain response that follows, there is the cognitive
processing of pain. Such cognitions can be modified, as can
behavior, and can influence how much pain a patient experi­
ences. Classical and operant conditioning principles and
modifying internal cognitions have a bearing on how non-
pharmacologic approaches are applied to burn pain. Martin-
Herz et al. and Thurber et al. provide an excellent overview
and extensive discussion of the theory and application of such
principles in pain management in pediatric wound care.214,215
Classical conditioning
If the stimuli associated with a painful procedure can be
conditioned to evoke anxiety or pain, then a logical goal is
to reduce the impact that pre-wound care stimuli have on
the fear/pain response. An obvious environmental interven­
tion is to make the wound care procedure setting as mini­
mally threatening as possible. For children this might involve
secondary to the injury of the skin, the possibility that mor­
phine is adding to the itch needs to be kept in mind. Itch
can definitely influence the quality of life and duration of
rehabilitation required. Scratching further injures the skin
leading to graft loss and skin breakdown, sometimes requir­
ing further grafting. In addition, it is very common for the
patient to have a significant problem exercising or sleeping
if the itching is intense. Several classes of medications can
be used to treat itch but very few real comparative studies
have been done. The approaches to treatment are as varied
as the presumed causes of the itching.198 Pruritus associated
with burns is poorly understood, so blocking histamine,
kinins, proteases, prostaglandins, substance P and 5HT
release and receptors have all been tried.
The first-line of defense is a series of moisturizing body
shampoos and lotions to alleviate itching due to dry scaly
skin. Then, failing that, Preparation H, which contains a
caine, has been advocated. Topical steroids are not usually
used because of the infection risk, until the skin is well healed.
They are effective in controlling the itching. Only a small area
of skin should be treated with steroids in order to reduce the
risk of systemic adrenal suppression. Antihistamine creams
such as Benadryl (diphenylhydramine) cream are available.
Other topical medications include colloid and oatmeal
baths.63 Newer topicals are tricyclic antidepressants such as
doxipin.199,200 The major side-effect of this preparation is that
too much is absorbed with resultant over sedation.
Several non medication approaches have been used.
Massage seems to have a very beneficial effect.59 In addition
Hettrick et al. reported that Transcutaneous Electrical Nerve
Stimulations (TENS) considerably reduced the perception of
itching in 9 adult patients compared to control.201 The most
recent is the use of pulse dye laser to reduce pruritus in burn
scar.202 Silicone gel sheeting has been reported to also be
effective.203
Usually the antihistamines are given orally. Using only one
antihistamine results in complete relief for only 10% of the
patients.204 Diphenhydramine PO 1.25 mg/kg q.6 h is often
the first oral medicine used because of its sedative effect as
well as helping control the itch. A few children respond
better to loratadine, which is much longer lasting. If the itch
is not well controlled using only one, then another class of
antihistamines can be added such as hydroxyzine PO 0.5/kg
q.6 h. Lastly, if the itch is still not well controlled, an antise­
rotonergic agent, such as cyproheptadine 0.1 mg/kg q.6 h,
can be added, scheduled so that one of the medications is
given every 2 h. This is targeted against the 5HT3 receptors.
Care must be made to not use the cyproheptadine with
patients who are on serotonergic antidepressants.
Recently, gabapentin (10–35 mg/kilo per day in divided
doses) has been found in a pilot study to help with itching
produced by burns.205 Typical individual dose is 5 mg/kilo
during the day and 10 mg/kg for bedtime. Comparative
studies using gabapentin have demonstrated its efficacy.
Goutos et al. demonstrated that it was usually more effective
than antihistamines.206 If this holds, then gabapentin may
move up to be tried if diphenhydramine fails. Like the other
anti-itch medications the main side effects are central
nervous system related, such as sedation and neuropsychiat­
ric symptoms.
Another new class of medications to be used in
chronic itching is naltrexone. First, LaSalle et al.207 reported

Management of pain and other discomforts in burned patients
727
making the hydrotherapy tank a ‘bath tub play area’ with age
appropriate floating toys, etc. Cheerful or relaxing music, a
warm room and pleasing art on the walls can also lessen the
threatening nature of a typical tank room. Our understand­
ing is that some clever children’s hospital staffs have turned
their MRI scan into a ‘cave in a jungle’; obviously such a
setting will be less threatening to a child than will be the
typical location of such radiological procedures. Similar
principles can certainly be applied to burn care.214,215
There are other implications of classical conditioning. The
best way to prevent a conditioned pain response is to
optimize pain control in the first place. By aggressively and
proactively treating pain, the contributions of conditioned
anxiety will be minimized. Conversely, once a patient under­
goes a procedure with inadequate analgesia, concomitant
anxiety can be extremely difficult to treat. Since it is rare that
a child who requires wound care would not find the setting
anxiety-provoking, burn units will often use an anxiolytic
at the first dressing change to prevent this anticipatory
anxiety.
Any attempts to enhance a patient’s control over the situ­
ation can minimize anticipatory anxiety. Patients tell us that
the hospital environment, unlike any other environment,
strips a person of their control. A functioning, independent
adult prior to an injury is suddenly dependent upon others
for almost all aspects of care, including when and what they
eat, what medications they will be taking, the painful pro­
cedures they will undergo and their daily schedule. In addi­
tion, burn care can be quite complicated and the medical
information that patients are required to process can be
overwhelming. When an adult or child feels out of control,
anxiety increases. We can enhance a patient’s sense of control
over the hospital environment by allowing them to have
input into their care as much as possible. For example, adults
and adolescents may be able to work with the nurse to deter­
mine the day’s schedule, to specify techniques that they have
found make wound care go smoother, choose to eat in the
cafeteria instead of having meals served in their room, and
choose the music that is played in wound care. Children
should be offered forced choices as often as possible to
create a sense of control. Forced choice is a technique
whereby a child is give two reasonable options and allowed
to choose the one they prefer. For example, a child might be
given a choice of whether to have wound care before lunch
Background pain
Inpatient
•
IV morphine sulfate 0.03–0.05 mg/kg every 2–4 h if awake; usually
every 2 initially and then every 4.
Note: Begin bowel prep program simultaneously with beginning
opioids.
Outpatient
•
Oral acetaminophen 15 mg/kg q.4 h or Ibuprofen 10 mg/kg q.8 h
•
If inadequate, add hydrocodone 0.2 mg/kg usually in combination
with acetaminophen.
Pre-wound cleaning
First choice
•
Hydrocodone 0.2 mg/kg in combination with acetaminophen
10–15 mg/kg usually given with benzodiazepine 0.5 mg/kg
lorazepam or 0.1 mg/kg diazepam
•
If inadequate, fentanyl buccal mucosa (lollipop) 10 µg/kg.
If NPO:
•
IV morphine 0.05–0.1 mg/kg (if >15 kg) with IV lorazepam
0.5 mg/kg.
Pre-rehabilitation therapy
•
On request of therapist, hydrocodone 0.2 mg/kg in combination
with acetaminophen 10–15 mg/kg usually given with
benzodiazepine 0.5 mg/kg lorazepam or 0.1 mg/kg diazepam.
Postoperative pain
Option A
•
IV morphine infusion via PCA pump (if >5 years), total dose
10–20 mg/kg per 4 h
Option B
•
Attendant administered bolus, slow IV push morphine 0.03–
0.05 mg/dose q.2 h (hold if level of responsiveness is decreased).
Anxiety
Inpatient
•
Lorazepam PO 0.05 mg/kg q.4–6 h
Outpatient
•
If muscle relaxation is also desired, diazepam 0.1 mg/kg usually
initially every 8 h.
Note: Taper benzodiazepines slowly by reducing the dose by 50%
every 2 days.
Acute stress disorder or post-traumatic stress
disorder symptoms210
•
Fluoxetine 5 mg if under 6 years of age; for the older person,
begin with 5 mg and increase slowly to 20 mg as needed or
•
Imipramine 1 mg/kg and increase slowly to 3 mg/kg as needed
(usually used in young children where fluoxetine could not be
easily dosed).
Itch
•
Use skin moistening shampoos and lotions, topical ointments (not
hydrocortisone creams)
•
Begin with diphenhydramine PO 1.25 mg/kg q.4–6 h; if itch not
well-controlled, add hydroxyzine PO 0.5/kg q.4–6 h
•
If itch still not well-controlled add gabapentin begin 5 mg/kilo
once per day then titrate up to 10–35 mg/kilo in three divided
doses.
•
Other meds that may be tried are the following:
– Cyproheptadine 0.1 mg/kg q.6 h so that one of the medications
is given every 2 h.
– Loratadine 10 mg q.day.
– Topical doxepin 5% cream to small areas.
Box 64.4  Shriners Burns Hospital (Galveston): comfort protocol for children
Update of Ratcliff et al. 2006.2

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Children can also be given a predetermined number (usually
five is adequate) of ‘timeout cards’ that they can present at
any time during wound care and it is worth a 1-min timeout
or rest period. Once the cards are used up, they no longer
have any timeouts. This technique can enhance their sense
of control over the environment as well as ensuring that rest
periods do not reinforce pain behaviors. Again, however, the
goal of a burn team should be to provide enough prepara­
tion and analgesia in a pre-emptive fashion that the need for
such escape behaviors do not develop in the first place.
Another common application of operant principles has to
do with token economies for children. It can be extremely
useful to reward children for successful completion of pro­
cedures by using star charts, prize boxes or reinforcement
schedules of this nature. Thus, a child, upon completing a
procedure, may receive a star in a grid that covers a week of
burn care. Older children can use an accumulation of points
to purchase a desired reward. Courage beads have also
become popular in pediatric hospital settings. Different
colored beads are assigned to various painful or unpleasant
procedures (e.g. wound care, physical therapy, X-ray, blood
draws, etc). Each time a child completes one of these unpleas­
ant procedures, they receive the corresponding bead and add
it to a necklace. Both boys and girls have responded posi­
tively to these necklaces and often wear them or display
them as a source of pride. It is important that children are
rewarded for completing procedures rather than for ‘being
brave’ as the latter can serve as a subtle form of punishment
to children; in other words, reinforcement should not be
withheld if children act out and have a bad day during
wound care, as long as wound care is completed (see
before).214,215
One final application of operant principles that is bor­
rowed from the chronic pain literature is the use of a quota
system that rewards activity with rest. This is particularly
useful with patients who are overwhelmed by therapies or
who appear to have poor motivation. Patients complete pre­
determined quotas of activity that are within their capacity,
and then are allowed to rest. A baseline assessment deter­
mines what is within their capacity. For example, a patient
who is trying to walk with burned legs might be instructed
to walk until tired for three therapy sessions. The distance
walked is recorded for those three sessions, the average is
taken, and 80% of that average becomes the starting point.
For example, the patient walks 50, 150, and 100 feet during
three sessions. The average is 100 feet and 80% of that is
80 feet. This (80 feet) becomes the starting point. Patients
start at 80 feet and increase that amount by 5% (about
5 feet) each session. If they fail to meet a quota, they return
to the last successful one. However, they also quit when they
reach the goal. They do not keep exercising even when they
are having a ‘good day.’ This addresses the problem of pacing
and over-fatigue. Ehde et al. have reported the successful use
of the quota with a number of patients with burn injury,
both in terms of increasing therapy performance and reduc­
ing depression.227
Cognitive interventions
How patients think about their pain can be regarded as
a behavior that can be modified and, in turn, can
influence the degree of suffering they experience. As such, an
or after lunch, or whether they prefer to take their medicine
with apple juice or milk. The key is to only provide two
options and to ensure that the healthcare provider and
parent are agreeable to whichever option they choose.
Kavanaugh and colleagues described how giving children
more control during procedures can reduce the effects of
learned helplessness, and enhance pain tolerance.216 He
reported that children who were provided with the opportu­
nity to participate in and make decisions about their wound
care showed lower depression, anxiety, hostility and stress
scores than did controls.
Finally, psychological preparation can also play an impor­
tant role in enhancing control and minimizing anticipatory
anxiety. Patients can be provided with procedural or sensory
preparatory information.217 With procedural-based prepara­
tory information, patients are explained the mechanics of
their procedure (e.g. ‘we will unwrap your bandages, wash
your wounds and débride necrotic skin, apply silver sulfadi­
azine cream and then rewrap your dressings’). With sensory
information patients are prepared as to what they might feel
during a procedure (‘You will likely feel a pulling sensation
as we remove your dressings and a stinging sensation when
we wash your wounds with an antiseptic’). Such information
is usually helpful to patients, but we should stress that some
patients prefer to have as little information as possible, given
their particular coping styles. It is best to follow a patient’s
lead in determining how much detail to provide when
explaining upcoming procedures.212
Another approach based on classical conditioning is relax­
ation training. Patients can be taught deep relaxation and
imagery prior to undergoing painful procedures. The ration­
ale is to counteract the anxiety stimulated by pre-procedural
stimuli with the relaxation response. If anticipatory anxiety
is minimized with deep relaxation, the potential for a cycli­
cal interaction between anxiety and acute pain is reduced.
Clinicians have also reported success administering massage
therapy on non burned areas immediately prior to wound
care.218 Children who received 15 min of massage therapy
reported lower pain scores during wound care than a control
group. A number of studies have applied relaxation training
and stress inoculation techniques, as well as some of the
behavioral techniques discussed below to reduce burn
pain.219–226
Operant conditioning
The consequences that patients receive for showing pain can
have implications for pain control. Since almost all burn
procedures are extremely aversive, it will be the natural ten­
dency of patients, particularly children, to be motivated to
escape such events. Staff members who allow patients to
terminate procedures might be reinforcing, and potentially
exacerbating, such as escape behaviors. When left unchecked,
this process can lead to a distressed patient becoming com­
bative rather than tolerating procedures. While such avoid­
ance behavior should (more importantly) alert the staff that
analgesia is inadequate, and the many potential pharmaco­
logic protocols discussed above should be invoked, it can
also occasionally suggest a need for further limit setting.
Rewarding a patient with rest once a stage of wound care
is completed rather than based on pain behavior can be
a useful means to minimize such escalating behavior.

Management of pain and other discomforts in burned patients
729
is superior in reducing pain. However, there is equivocal
evidence for the effect of virtual reality on reducing anxiety
during these procedures.
Hypnosis
Hypnosis involves a blend of relaxation, imagery and cogni­
tive based approach. The technique deserves special atten­
tion because there are a number of reports on its use with
burn pain and, when it is effective, its impact on burn pain
can be quite dramatic. There are over 100 anecdotal reports
in the literature that indicate that hypnosis can dramatically
reduce pain and at least a dozen have been done with pain
from burn injuries; such studies however lack control groups,
standard measures of pain or information about pain medi­
cations.241 More recently, tightly controlled studies with reli­
able measures of pain have supported hypnosis as an effective
nonpharmacologic approach to burn pain.242,243 Patterson
and Jensen have reported 12 controlled studies on chronic
pain and 17 with acute pain, indicating pain reduction;
indeed, this modality is becoming far more scientifically
acceptable.244
Patients with burn injuries are ideal candidates for hypno­
sis for a number of reasons. In a review of such factors, Pat­
terson et al. listed motivation, regression, dissociation and
hypnotizability as factors that promote hypnotic analgesia
on the burn unit.245 Specifically, patients who are faced with
the excruciating nature of burn pain are motivated to engage
in techniques such as hypnosis. The nature of a burn and its
resulting care can cause a patient to become emotionally
regressed (i.e. more dependent on the burn staff) and dis­
sociated (i.e. removed from their emotions), and both of
these factors seem to be associated with hypnotizability.
Such factors likely account for the frequent dramatic effects
that are seen with hypnosis and burn care. On the other
hand, hypnosis clearly will not benefit some burn patients,
and the degree to which patients are inherently hypnotizable
(or not hypnotizable) almost certainly has some bearing on
this issue.245
Ewin246,247 has strongly argued for providing hypnosis
within 2–4 hours after a patient sustains a burn injury. He
maintains that this approach can serve to impede the pro­
gression of the burn as well as facilitate pain control. Unfor­
tunately, it is difficult to have a clinician available during this
stage of burn care, and Ewin’s findings have yet to be tested
in other settings. The protocol used by Patterson and
colleagues239–244,248–250 is to provide hypnosis prior to wound
care and have nurses provide standard post-hypnotic sugges­
tions during wound care. This approach is efficient for both
the hypnotist and the nurses. Patterson et al. have recom­
mended that hypnosis used in this fashion be an adjunct to,
rather than replacement for, pain medication.243 A rand­
omized controlled trial by Wiechman et al. used this proto­
col for burn wound pain and found that hypnosis significantly
reduced the affective component of pain when compared to
an attention-only control group.251 Further, Shakibaei et al.
conducted a randomized controlled trial of hypnosis for
reducing pain and reducing flashbacks in burn patients.249
They also showed that the hypnotherapy group had signifi­
cantly lower pain ratings and fewer flashbacks than the
control group.
important nonpharmacologic approach is to draw out the
thoughts patients have about their pain and teach them to
modify accordingly. A particularly salient example is cata­
strophizing about pain. Catastrophizing thoughts include
those such as ‘I cannot stand this pain,’ ‘I will never get
better,’ or ‘The pain means I will die.’ Such catastrophizing
thoughts have been associated with greater amounts of pain
and less favorable health outcomes in a variety of studies.
Patients can be taught to challenge and reinterpret such
thoughts. Along the same lines, it can be useful to teach
patients to reinterpret the meaning of their pain sensations.
For example, the appearance of skin buds and enhanced pain
sensation may indicate that a wound is healing and skin
grafts may not be necessary.222
Under the rubric of cognitive interventions patients may
be taught techniques to enhance their ability to cope with
pain. Positive self-talk and imagery designed to facilitate
coping during periods of pain are examples of this. Thurber
et al.215 and Martin-Herz et al.214 have published a two part
series on a conceptualization of psychological approaches to
burn pain, as well as specific examples for treatment. Crucial
in choosing an approach is the assessment of a person’s
coping strategies. Simply, most adult and pediatric patients
have coping styles that fall on an approach-avoidant con­
tinuum. At one end of the continuum is the avoidant coping
style where patients prefer to turn away or be distracted
during painful procedures. Any distraction technique
described in this chapter would be appropriate for this group
of patients. On the opposite anchor of the continuum are
those with an approach coping style who seek information
and like to be involved as much as possible in their care. In
this group, having them participate in wound care, and
giving them as much information as they request will help
to decrease their anxiety. If they are told to close their eyes,
turn away and distract themselves from the procedure at
hand, their anxiety will only increase.
Distraction is another cognitively based approach to pain
control. Processing pain requires a certain amount of con­
scious attention and distracting such patients’ attention can
enable patients to tolerate pain better. Movies, music therapy
and games have all been used with some success as distrac­
tion techniques for burn pain.224,226,228 Music has the addi­
tional benefit of inducing a relaxation response.223,229
Virtual reality
Another form of distraction gaining attention is the use of
virtual reality technology. Several researchers have reported
on the use of immersive virtual reality (VR) as a powerful
analgesic.230,210,231–239 Virtual reality can immerse patients’
attention in a computer-generated world, and engage them
in interaction with that world. These investigators indicate
that VR can significantly reduce pain during wound care and
physical therapy,230,210 even relative to computer game dis­
traction and television231,239 Recently, Morris et al. conducted
a systematic review on the use of virtual reality distraction
for reducing both pain and anxiety in acute burn pain.240
They found nine studies that met their rigorous inclusion
criteria. Results showed that virtual reality distraction is most
often used for burn wound care and physical therapy and is
an adjunct to pharmacotherapy. When compared to phar­
macotherapy alone, it appears that virtual reality distraction

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730
of the studies on hypnosis showed a beneficial effect when
compared to a control group. They concluded that hypnosis
seems to have a strong impact on the affective component
of pain. Their review also showed beneficial effects of distrac­
tion relaxation and found that any technique that enhances
a patient’s control over the situation is beneficial.
The authors of these systematic reviews provided direc­
tions for future researchers that would advance our knowl­
edge of the effectiveness of nonpharmacological interventions.
These suggestions included the need for large sample sizes,
documentation regarding study response rates and randomi­
zation methods, experimental control for premorbid
psychosocial variables, details on instructions given to
patients, cost outcomes, and assurance of treatment integrity/
adherence.253,255
Summary
The current practice of burn pain management would seem
to be based more on personal bias and tradition than on a
systematic, scientific approach. In addition, the number of
pharmacokinetic studies of pain-relieving drugs of any kind
in young children is sparse. Since approximately 35% of all
burn injuries occur in children under 16 years, with a great
majority of these occurring in children under 2 years, we
have almost no information on which to base the use of
pain-relieving drugs in burned children. It is no wonder that
Perry and Heidrick256 found great disparity in what burn care
staff would order or administer to a young child as compared
to an adult with burns of similar size and area of distribution
on the body. More pharmacokinetic studies in both adults
and children with burn injuries must be initiated.
However, significant progress has been made since the last
edition of this book. Both Faucher and Furukawa109 and
Sumner et al.257 have published comprehensive reviews of
burn pain management and have offered some protocols for
clinical use. Another standardized protocol offering guide­
lines for starting doses of medication from the Shriners
Burn Hospital in Galveston is given in Box 64.4.2 Non-
pharmacologic techniques are more frequently included in
a center’s repertoire of tools for managing anxiety, recog­
nized as a definite adjunct to pharmacotherapy. Most burn
centers recognize anxiety as contributing to patient discom­
fort and are beginning to treat both anxiety and pain. The
major problem currently with these techniques is that they
are personnel intensive and therefore are often not offered
or reimbursed in the current managed care environment in
the USA.
Appropriate pain management depends on vigilance in
assessment and flexibility in treatment. Patients show great
individual variation in their responses to the variety of agents
and modalities presented. A fixed and inflexible approach to
treatment is likely to over-medicate on one day and under-
medicate the next.
To avoid over- and under-medication in adults, regimens
which allow patients to control their own therapy seem most
appropriate. This is very important for adults and teenagers,
but children also can benefit from having this control. PCA
can be used safely by many children and should not
be disregarded as a tool on the basis of age alone. For
procedural pain, patient control regimens may include
Virtual reality hypnosis
More recently, investigators have combined immersive
virtual reality with hypnosis in order to control burn pain.
This approach has the advantage of not requiring a trained
hypnotist to be present and appears to work as well as ‘live
hypnosis’.252,250 The technology simply requires patients to
open their eyes and watch the induction presented before
them; minimal cognitive effort or skill is required. Delivering
hypnosis in this addresses several concerns of standard, ther­
apist induced hypnosis. First, this standardized procedure
allows for greater use in that it does not require a trained
therapist to be present at each session. Second, with the
visual images in front of them, it decreases the extent of
cognitive effort that is required. This is important for patients
who are taking opiate medications and cannot concentrate
as effectively. It also helps those who are lower in visual
imagery skills and, therefore, unable to visually imagine
the scenes described by the therapist during traditional
hypnosis.
Empirical support
Recently, there have been several rigorous systematic reviews
of studies that have focused on both pediatric and adult
nonpharmacological pain management strategies. Hanson
and colleagues conducted a systematic review of non-
pharmacological interventions for acute procedural pain in
pediatric patients with burn injuries.253 Using systematic
review methods of the US Preventative Services Task Force,
they found 12 articles that met the study criteria and seven
of the 12 articles were rated as ‘fair or good’. They categorized
these 12 articles into child mediated interventions, parent
mediated interventions and healthcare provider mediated
interventions. Of the child mediated interventions, both
virtual reality distraction and stress management showed
promising effects. Of the healthcare provider interventions,
massage therapy, and optimizing patient control during
wound care were effective at relieving wound care pain when
compared to a control group. Parent mediated interventions
were not found to be effective, and in fact, one study showed
an increase in children’s distress when parents were present.254
Although the study designs in these interventions were rated
as poor, the findings are consistent with those reported by
clinicians, in that parental presence during painful proce­
dures can either help a child or hurt a child depending upon
the parents’ affect and ability to soothe their child. This is a
difficult intervention to study, but one that deserves more
attention in this era of family-centered care and the empha­
sis on increased parental involvement in a child’s care. It
would be a tremendous benefit to the field if we could deter­
mine which variables are necessary to facilitate a positive
parental presence, and which variables serve as barriers to
the success of this practice. Hanson et al.253 acknowledged
that it is very difficult to conduct randomized controlled
trials with adequate sample sizes in this population, but we
need to strive to find empirical support for the techniques
that we choose.
de Jong et al. also conducted a systematic review of the
literature for non-pharmacological interventions for acute
burn pain in adults.255 They found that hypnosis was the
most frequently studied intervention and that the majority

Management of pain and other discomforts in burned patients
731
•
feel comfortable with a process that never ends, but
which can bring many moments of relief for the
patient and satisfaction for the caregivers.
Further reading
Goutos I, Eldardire M, Khan AA, et al. Comparative evaluation of
antipruritic protocols in acute burns. The emerging value of
gabapentin in the treatment of burns pruritus. J Burn Care Res.
2010;31:57-63.
Gray P, Williams B, Cramond T. Successful use of gabapentin in acute
pain management following burn injury: a case series. Pain Med.
2008;9:371-376.
Hanson MD, Gauld M, Wathen N, et al. Nonpharmacological
interventions for acute wound care distress in pediatric patients
with burn injury: A systematic review. J Burn Care Res.
2008;29:730-741.
Morris LD, Louw QA, Grimner-Somers K. The effectiveness of virtual
reality on reducing pain and anxiety in burn injury patients. Clin J
Pain. 2009;25:815-826.
Ratcliff SL, Brown A, Rosenberg L, et al. The effectiveness of a pain
and anxiety protocol to treat the acute pediatric burn patient.
Burns. 2006;32:554-562.
Talon MD, Woodson LC, Sherwood ER, et al. Intranasal
dexmedetomidine premedication is comparable with midazolam
in burn children undergoing reconstructive surgery. J Burn Care
Res. 2009;30:599-605.
self-administered nitrous oxide, PCA, hypnosis, a variety of
behavioral approaches, or a combination of these approaches.
For background pain, the best control seems to be the use
of slow release opioids or other pain cocktails given on a
non-pain contingent basis (i.e. scheduled every 4–6 h), with
the flexibility to supplement this with PRN or ‘as desired’
medication. Another approach would be to use PCA with or
without a continuous low-dose infusion of narcotics. A
variety of non-pharmacologic therapies may also help relieve
background pain. The most important aspect to remember
with all of these regimens, as mentioned before, is flexibility.
The other obvious aspect is to remember that a patient is not
only the best person to assess his pain, but he is also the best
to evaluate the success of the therapies provided.
Burn care professionals who desire to keep their patients
as comfortable as possible can perhaps best prepare them­
selves by learning to:
•
watch and listen to their patients with vigilance;
•
use a standardized assessment tool for measuring
discomfort on a scheduled basis as well as during
moments when the patient is complaining, either
verbally or behaviorally, pre- and post-administration
of treatment;
•
know how discomforts are likely to change as the
patient recovers;
•
include a variety of pharmacologic and non-
pharmacologic methods for managing discomforts and
be prepared to change as the patients’ needs change;
Access the complete reference list online at

Management of pain and other discomforts in burned patients
731.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
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©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00065-5
Psychiatric disorders associated
with burn injury
J.F. Aili Low, Walter J. Meyer III, Mimmie Willebrand, Christopher R. Thomas
Introduction
All members of the treatment team should have a basic
knowledge of psychiatric problems, as they commonly occur
and often play a central role in burn recovery. It is useful to
have mental health professionals as integrated members of
the team, as their expertise and skills are often needed in the
management of patients with burns, to screen and identify
and assist in the treatment of the multitudes of psychiatric
and psychological issues concomitant to burns.
Pre-existing psychiatric disorders and symptoms are rela­
tively common in the histories of burned patients, and
frequently appear to have contributed significantly to the
etiology of the injury itself.1–4
Besides premorbid disorders, a number of patients will
develop psychiatric symptoms during acute treatment for
burns, as also can be seen after other major trauma.4 Pain,
itching and stress during hospitalization can contribute to
problems during acute treatment such as sleep disorders and
depression, starting a vicious circle. Dissociation and anxiety
experienced during the burn have been shown to predict
later psychopathology.5,6 While it is understandable to expect
patients with major burns to be at risk, even minor burns
can result in significant psychological distress and psychiatric
symptoms.7
At the present time, there is no profile that can reliably
predict and identify which patients will suffer psychiatric
symptoms following burns. Furthermore, patients will
seldom actively seek help for psychological distress or psy­
chiatric symptoms, although this can have a strong effect on
outcome and rehabilitation. All members of the burn team
should be aware of this dilemma and be observant of signs
or symptoms.
This chapter will focus on the recognition and treatment
of common mental disturbances that can be expected to
occur in patients suffering serious burns. This includes spe­
cific attention to both pediatric as well as adult patients, as
symptoms and signs may differ between ages. Although pre-
existing psychopathology alters the expression of a patient’s
distress and complicates medical management of the patient,
the common symptoms described in this chapter are not
necessarily indicative of premorbid psychopathology.
Premorbid adult psychiatric disorders
Although a burn can occur to anyone, psychiatric morbidity
greatly increases the risk of sustaining an injury, either
directly (e.g. self-inflicted burns or suicide attempts) or indi­
rectly by reducing vigilance or affecting judgment (e.g. sub­
stance abuse, depression).1,7,8 The knowledge of pre-existing
psychiatric problems is important for burn care mainly for
two reasons: first, to better understand and identify psychi­
atric symptoms occurring during treatment and to recognize
them as ongoing or reactivated problems instead of reactions
to the injury and second, to increase awareness of potential
difficulties during rehabilitation (for a comprehensive review
refer to McKibben et al. 20091).
Patients with pre-injury psychiatric disorders have been
observed to require longer hospitalization, they more fre­
quently experience complications during treatment, prob­
lems with rehabilitation and post-burn adjustment, and
have a higher risk of developing other psychiatric disorders,
e.g. post-traumatic stress disorder (PTSD).3,4,9–11
Psychiatric disorders
Psychiatric morbidity is common in burn patients. Two-
thirds of all patients with burns have at least one psychiatric
disorder, 50% had a psychiatric disorder in the year before
injury, and one third have an ongoing psychiatric disorder
at the time of injury.1
The most frequent preexisting psychiatric disorder in burn
patients is the mood disorder major depression, which is
present in up to 42% of individuals, a proportion much
higher than in the general population.1 Smoking (more than
10 cigarettes daily) has been shown to increase the risk of
burns by up to six-fold. In the use of certain drugs, e.g. the
stimulant drug methamphetamine, highly volatile and flam­
mable substances, which further increases the risk of getting
burned.12
Patients with pre-existing psychiatric morbidity have a
higher risk of sustaining a preventable injury and in indi­
viduals with psychotic disorders self-inflicted burns are over-
represented.1 Personality disorders are also over-represented
in burn patients compared to the general population and
CHAPTER 65 
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IN THIS CHAPTER
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Total Burn Care
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amputation). Larger burns and the presence of parent–child
conflict, parental dissociation, or PTSD symptoms in the
child were strongly correlated with parental PTSD symp­
toms.27,28 This emphasizes the need for psychological atten­
tion to parents of burned children, as well as to the children
themselves.
In-hospital contributing factors
and disorders
Several problems during acute burn treatment can affect the
course of treatment and eventually outcome after burns.
Pain, itching and sleep disorders are caused by both the
injury and its treatment. High levels of stress and anxiety
may contribute to the development of psychiatric morbidity,
e.g. PTSD. In patients with substance dependence, with­
drawal symptoms can occur during acute care and patients
with pre-injury substance abuse have a higher risk of devel­
oping psychiatric symptoms during and after acute care.
There is evidence that in the case of comorbidity of PTSD
and substance abuse concurrent treatment of both disorders
is necessary to achieve improvement.29
After the initial post-burn period, a patient progresses
through a series of operative procedures interspersed with
days of physical therapy. A patient’s world is one of pain or
the sure knowledge of repeated pain in the near future and
feelings of anxiety and powerlessness are predominant.30–33
Every movement, e.g. shifting position and change of bed­
clothes, is painful. Treatment and experience of hospitaliza­
tion may be as traumatic psychologically as the original
burn, and patients who experience high levels of pain not
only have a higher risk of poor adjustment and psychiatric
problems after discharge, but also wound healing can
decrease due to stress.32,34 Furthermore, high levels of stress
and anxiety and PTSD decrease pain tolerance.31
Itching is a common problem during wound healing and
scar maturation, and it can cause considerable distress
and anxiety.33,35,36 Persistent itching can disrupt sleep, which
increases stress levels and also impairs everyday functioning
and participation in rehabilitation.37 Anxiolytic, antidepres­
sant and antipsychotic agents have been used successfully to
treat itch.36
Significant sleep problems are common during and after
treatment for acute burns.38–40 The noise and light on the
unit and interruptions for treatment will disrupt sleep.41
Pain, anxiety and itching can disrupt sleep or affect sleep
quality, and symptoms of stress and PTSD, e.g. nightmares,
can cause both awakening and a fear of going back to
sleep.39,42 Pain severity during hospitalization has been
shown to predict insomnia after discharge and insomnia in
turn predicted long-term pain.40 Burn patients who experi­
ence poor sleep at night will also have lower pain tolerance
during the day.42
In-hospital adult disorders
During treatment for acute burns disorientation, confusion,
delirium, transient psychosis, depression and anxiety, stress
and sleep disorders are commonly observed.3 Causes of
these symptoms are multifactorial: hypoglycemia, sepsis,
and/or a variety of other organic problems can contribute.
persons who score high on the personality traits neuroticism
and extraversion appear to have a higher risk of injury.1
Self-inflicted burns and suicide attempts
Of patients with self-inflicted burns, those attempting suicide
are more likely to have larger burns and longer hospitaliza­
tions than those with the intent of self-mutilation.13
The proportion of self-inflicted burns differs across the
world: whereas it is between 1% and 9% in North America
and Europe with no clear gender distribution, it is a major
cause of burns in females in the Middle East, Africa and
south Asia with a prevalence of up to 28%. Across cultures
psychiatric morbidity is an important risk factor, often in
conjunction with social stress factors such as marital prob­
lems or unemployment.1
Pediatric disorders (ADHD, conduct)
Prior psychological problems can increase risk for pediatric
burns and specific psychiatric disorders have been found to
occur more frequently in pediatric burn survivors than the
general population. Children with attention deficit hyper­
activity disorder (ADHD) appear to be at greater risk for
burns.14–16 Playing with fire and fire setting are symptoms of
conduct disorder17 and can result in burns. In addition,
certain types of inhalant abuse (sniffing) can result in burns.
Commonly, pediatric burn survivors may not exhibit symp­
toms of prior psychiatric disorders during the acute phase of
treatment due to the impact of injuries and other treatments.
When symptoms are evident, continuation of prior treat­
ment or implementation of indicated treatment for a pre-
existing psychiatric disorder may not only control symptoms
but also facilitate patient participation and cooperation with
acute care and long term rehabilitation.
Social (family)
Clearly, parental and family characteristics can both increase
the risk for burns in children as well as influence the subse­
quent recovery and outcome. The presence of child abuse or
neglect can directly result in pediatric burns.1,18,19 The pres­
ence of parental anxiety, depression, poor coping skills or
lack of social support at the time of injury were associated
with poorer child functional outcome in pediatric burn
survivors.20,21 Possibly, high parent anxiety in combination
with ineffective coping strategies, rather than family func­
tioning or burn severity, is most predictive of pediatric burn
outcome.22
Parents are psychologically traumatized by the burns of
their children and face numerous emotional challenges
during subsequent treatment and recovery. Parents report
more feelings of anxiety and being stressed, depressed and
guilty than the normal reference population, not only by
their children’s behaviors but in areas unrelated to their
children.21,23 These stresses can result in psychiatric disorders
in parents up to 2 years following the injury, with mothers
at greater risk for developing mental health problems and
depressive and post-traumatic stress symptoms.24–26 Increased
risk for depression was associated with having an only child
or multiple offspring injured, low family socioeconomic
status and complicated burn injuries (secondary infection or

Psychiatric disorders associated with burn injury
735
Table 65.1  Criteria for post-traumatic stress disorder (PTSD)
A.
The person has been exposed to a traumatic event in which both of the following were present:
1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated
behavior.
B.
The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play
may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative
flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may
occur.
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C.
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by
three (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g. unable to have loving feelings)
7. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response.
E.
Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
With delayed onset: if onset of symptoms is at least 6 months after the stressor.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th edn. 2000.17
The altered state of consciousness may be transitory, wax
and wane over several days, or, with large burns, persist
for weeks.
A significant number of burn survivors will experience
acute or post-traumatic stress disorder symptoms, including
intrusive memories of the injury, during their acute
recovery.1,43
Symptoms of depression and agitation related to excessive
pain will subside with adequate pain management. The
experience of pain has been found to be a mediating risk
factor for PTSD in both pediatric and adult burn patients.32,44
After severe burns patients are at risk for the development
of substance abuse in the wake of PTSD.3,29 In contrast, the
use of opioids and other pain medication will not cause
dependence per se if adequately administered and tapered
when pain levels decreases.31,45
Delirium
Delirium is a state of acute brain dysfunction. It is a transient
and usually reversible syndrome with disturbance of con­
sciousness and cognition compared to previous levels of
functioning. Hallucinations and delusions can occur and
patients in delirium can become suicidal or combative. Early
symptoms can be restlessness, anxiety, disorientation or
sleep disorders.
Delirium in burn patients has been found to occur more
often in individuals with a history of substance abuse or
other psychological problems and with larger burns.46,47
Another potential cause of disorientation, hallucinations,
and agitation may be medications used in the treatment of
the acute burn patient.47 Sleep deprivation has also been
discussed as a cause for delirium in ICU-patients.48
Sepsis and metabolic conditions can also result in
hallucinations.
Acute stress disorder (ASD)
Acute stress disorder is the most common psychiatric
disorder seen in survivors of major burns besides post-
traumatic stress disorder (PTSD), with a prevalence as
high as 19%.4,33,43,49 Acute stress disorder symptoms appear
immediately following the trauma, last for at least two days
and usually resolve within 4 weeks after the trauma. The
criteria for ASD and PTSD according to DSM-IV-TR are
shown in Table 65.1.17
The
presence
of
avoidant
symptoms
during
the
acute phase of recovery is reported to predict chronic

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hallucinations, and are a more frequent cause of this than
psychiatric disorder in young burn patients.
In contrast to delirium and psychosis, burn encephalopa­
thy is often observed in children,56,57 characterized by leth­
argy, withdrawal, or coma. EEGs in such cases typically reveal
diffuse, nonspecific slow waves. Causative factors probably
are the same as those for delirium.58
Even young children can experience severe anxiety follow­
ing burns, with up to a third of patients reporting symp­
toms of acute stress disorder in the immediate aftermath of
burns.59 Mediating factors for the appearance of anxiety
symptoms appear to be size of burn, parental stress and the
experience of pain. In a study of pediatric burn patients, a
high resting heart rate, lowered body image and parental
stress symptoms were found to be significant risk factors in
development of ASD.60
Pain in children appears to dramatically increase the
risk for development of anxiety symptoms and subsequent
anxiety disorders; appropriate pain management can reduce
or resolve anxiety symptoms.61,62 A smaller but still signifi­
cant number of burn survivors will experience post-traumatic
stress disorder symptoms, including intrusive memories of
the injury, during their acute recovery.63,64
Long-term post-burn disorders
The main factors that have been suggested as reasons for
psychiatric problems beyond the time of the discharge from
the burn care center are pain and previous psychiatric illness.
Pain and depression seem to be linked in such a way that
they can cause each other.65 Also acute pain at the time
post-traumatic disorder in burn patients.50,51 It is of great
importance to recognize symptoms of ASD and PTSD at an
early stage, as ASD has been shown to be a predictor for
PTSD and once PTSD is established it usually will persist.43
Depression
Although depression is a reaction most observers would
expect of burned patients, only a relatively small number of
patients with burns have been observed to have symptoms
of severe depression.49,52,53 In most studies pre-injury depres­
sion or lower levels of well-being were stronger predictors
than burn size for subsequent depression. All the same,
those individuals who experience symptoms of depression
during hospitalization will continue to do so after discharge,
so that early recognition and treatment may improve their
situation considerably.52
The criteria for major depression according to DSM-IV-TR
can be found in Table 65.2.17 This is an extremely difficult
diagnosis to make during the acute burn period, since many
of the criteria are linked to physical symptoms. Even beyond
the acute phase, the diagnosis is often complicated by grief.
The critical symptoms in a burned patient are depressed
mood and anhedonia.
In-hospital pediatric disorders
Symptoms of delirium and transient psychosis rarely occur
among children under the age of 10 years.54 True hallucina­
tions are uncommon in children, but when they do occur,
the most likely cause is stress, followed by pain and medica­
tions.55 Sepsis and metabolic conditions can also result in
Table 65.2  Criteria for major depressive episode
A.
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning;
at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by
others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account
or observation made by others).
3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in 1 month), or decrease or increase in
appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed
down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.
B.
The symptoms do not meet criteria for a Mixed Episode.
C.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g.
hypothyroidism).
E.
The symptoms are not better accounted for by Bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor
retardation.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th edn. 2000.17

Psychiatric disorders associated with burn injury
737
Not infrequently, anxiety spills over to other situations
and/or becomes focused on specific objects; thus, phobias
develop that are characterized by excessive persistent fear in
response to specific stimuli. In a burned patient, difficulty
controlling anxiety which is so distressful that it interferes
with important functioning, restlessness, and difficulty in
concentrating, are diagnostic of anxiety disorders since some
other symptoms can be related to burn injuries specifically,
e.g. being easily fatigued.
Although adults may express anxiety through ‘panic’
symptoms such as sweating, palpitations, trembling, or
nausea, children may express anxiety by crying, tantrums,
freezing, or clinging. A differential diagnosis of these anxiety
disorders distinct from post-traumatic stress disorder is
difficult and requires a careful interview. An over-anxious
patient is afraid of what might happen; the post-traumatic
stress disorder patient re-experiences and fears what has
happened.
Major depression
The critical symptoms in a burned patient are depressed
mood and anhedonia and sometimes the mood is seen as
irritable rather than depressed. Due to an overlap in symp­
toms of depression and somatic problems caused by the
burn itself (fatigue, sleeplessness) it can be difficult to assess
the ‘true’ proportion of patients with depression after burns.
A number of approaches have been used to determine the
incidence among adult survivors of major burns using self
report measures like the Beck Depression inventory.
A review of the literature on depression in burn survivors
found a prevalence of major depression at 1 year post-
discharge of between 4% and 7%. At more than 1 year post-
discharge the prevalence ranged between 9% and 23% (for
a comprehensive review refer to Thombs et al. 2006).80
It has been observed that depressive symptoms were linked
to physical limitations at 5 years after injury.81 The appear­
ance and location of the burn scar may be predictive for
post-traumatic stress disorder symptoms of avoidance and
emotional numbing82 or depression, especially in women.83
In contrast, other studies found that neither the severity nor
the visibility of burn scars influence long-term adjustment,
but rather social introversion, which predicted the develop­
ment of pathological shame.84,85 Many patients with PTSD
have comorbid depression;86 both are sequelae of trauma
and they share many symptoms, but they develop independ­
ently of each other.87
Dysthymia
A smaller percentage of burned patients, around 4%, will
develop a milder but more protracted type of depression
called ‘dysthymia’.80,88 This condition is characterized by a
depressed or irritable mood on most days and must be
present for at least 2 years in adults in order to be diagnosed.
Patients often report chronic anger, appetite changes, sleep
difficulties, fatigue, low self-esteem, poor concentration,
difficulty making decisions and feelings of hopelessness.
The same combination of medication and psychotherapy
is recommended for dysthymic patients as for major
depression.
of discharge from the hospital seems to produce long
term suicidal ideation.66,67 There is a reciprocal relationship
between pain and depression or anxiety.67
Another predictor of psychiatric problems is the presence
of psychiatric or personality disorders pre-burn.2 Cognitive
processes may play an important role as, for example, burn-
related attentional bias has been shown to be strongly
associated with PTSD 1 year post-injury.68 Skull burns are
associated with cognitive as well as affective disorders post-
burn,69 but there does not seem to be a relationship to facial
burns or even very large burns.
Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is the most common
psychiatric disorder seen in survivors of major burns70 with a
prevalence as high as 45%.33,43,70,71 The diagnostic criteria for
PTSD are shown in Table 65.1. About one-third of burn sur­
vivors develop post-traumatic stress disorder within 2 years
of their injury72 and this was true for even small burns.73 ASD
seems to predict PTSD in most adult burn survivors.43,74
The patient should be interviewed about sleep patterns
and startle response, as nightmares and altered sleep patterns
are usually the symptoms first noted. In fact, one of the most
important pieces of information for screening for PTSD is
nightmares in adults.75 A significant number of burn survi­
vors will experience post-traumatic stress disorder symp­
toms, including intrusive memories of the injury, during
their acute recovery.63,64 The presence of avoidant post-
traumatic disorder symptoms during the acute phase of
recovery is reported to predict chronic post-traumatic disor­
der in burn patients.50,51,72,74,76 Patients should be given ample
opportunity to explore their feelings and fears about the
traumatic event. Concerns that midazolam administration
might interfere with this process and actually enhance PTSD
could not be substantiated.77
Other anxiety disorders
Many patients continue beyond acute hospitalization to
have periods during which they appear extremely anxious
and express fear. These periods often recur in association
with return to a hospital for reconstructive surgeries. General
anxiety is characterized by excessive worry for more days
than not, for at least 6 months, difficulty in controlling the
anxiety, clinically significant distress or impairment in social
occupation or other important areas of functioning, and
anxiety with three or more of the following: restlessness,
feeling on edge, easily fatigued, difficulty concentrating –
mind going blank, irritability, muscle tension or sleep
disturbance.
In the literature, the prevalence of anxiety disorders in
adults during the year after burn – usually generalized
anxiety disorder or agoraphobia without panic – is below
20% and those with very small burns had even less anxiety.7,78
Avoidant coping style was significantly correlated with the
level of anxiety at 3 months.6 In a study of young adults
burned as children and with much larger burns than the
other studies all the anxiety disorders were found and they
were twice as common as in matched controls: 12.9% of the
subjects had a specific phobia, 6.9% had generalized anxiety
and 20.8% had PTSD.79

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young adults mentioned above,79 personality disorders were
common and significantly associated with comorbid Axis I
diagnoses.98
Diagnosis (screening instruments, SCID)
The psychiatric diagnoses that have been noted as part of the
long-term process of recovery from burns are usually acute
stress disorder, post-traumatic stress disorder, generalized
anxiety, depression and dysthymia.4 These diagnoses may be
affected by major psychological issues directly related to the
burn, e.g. loss, pain, anxiety, grief, loss of self-esteem, loss of
job or society role, disfigurement, major financial issues and
major legal problems.29,99
Two techniques are used to determine the prevalence of
psychiatric disorders in burn survivors. The one most com­
monly used has been the self report questionnaire, e.g.
Beck Depression Inventory, Impact of Event Scale-Revised,100
Davidson Trauma Scale, Brief Symptom Inventory, McGill
Pain questionnaire and Quality of Life surveys such as
the Short Form 36 (SF-36) or the EQ-5D, which has been
validated with burn survivors.101
For a more complete diagnostic survey the gold standard
is the Structured Clinical Interview for DSM-IV-Axis I Disor­
ders (SCID I) interview.
Treatment
Delirium and agitation
Due to the problems which have been associated with
phenothiazines, benzodiazepines have been used to a
greater extent in recent years for the combative, delirious
patient.102–104 The two most commonly used benzodiazepines
are diazepam and lorazepam. Lorazepam (0.03 mg/kg)
orally or intravenously can usually be given every 4–8 h;
for a very combative patient it can be given hourly. A third
benzodiazepine which is frequently used is midazolam at
0.05 mg/kg IV, typically used in conjunction with morphine
for procedures such as tubbing and staple removal. Mida­
zolam is also used for sedation as a continuous infusion for
intubated patients. When using the benzodiazepine class of
medications, a clinician must balance the desired effects of
relaxation with oversedation. Visual and auditory hallucina­
tions may occur if the dose of benzodiazepine is too high.
In cases of excessive anxiety in the presence of adequate pain
control, lorazepam can be added to a patient’s treatment.
Nighttime doses usually enhance sleep. Diazepam may be
used in place of lorazepam if simultaneous muscle relaxa­
tion is desired.105 Diazepam has an extremely long half-life,
40 h, and therefore should be used sparingly. To avoid exces­
sive sedation by benzodiazepines, a patient should not be
awakened for the next dose.
ASD and PTSD
Therapy is the same for the two disorders and usually
includes a combination of psychotherapy and pharmaco­
therapy. Cognitive behavioral therapies have been specifi­
cally developed for treatment of anxiety disorders. They
assist patients in mastering PTSD symptoms and typically
Substance and alcohol abuse
There are almost no studies that indicate the prevalence of
substance abuse or alcohol abuse in adults. Maes et al.78
reported an incidence of new onset psychoactive substance
use disorders of 6%. Certainly prior abuse leads to present
abuse. In a study in young adults who were burned as chil­
dren the prevalence of the use of alcohol and substances was
7.9% for alcohol and 35.7% for other substances; however
this rate later fell to 3% for alcohol and 9.9% for other sub­
stances.79 These young adult prevalence rates are lower than
the reference population in the USA for alcohol but were
higher for substance abuse/dependence, which may reflect
the socioeconomic background of the subjects studied.
Comorbidity and problems beyond
psychiatric illness
PTSD and depression are both linked to poor long-term
outcomes in adults.33,34,71 PTSD and pain together predicted
poor functional outcome and increased disability after major
burns. PTSD symptoms led to greater physical and psycho­
social disability, poorer social functioning and less vitality.34
Pain is linked to poor concurrent physical functioning and
depression can predict decreased physical health 2 months
post-discharge.66,89
Pediatric: psychiatric disorders
and social adjustment
A significant number of the children and adolescents who
survive major thermal injury develop a variety of significant
behavioral and emotional problems at some point in their
lives, but good adjustment is achieved by the majority of
individuals.90–93 In studies in adolescent and young adult
survivors of pediatric burns about half of the individuals met
criteria for one or more psychiatric disorders.79,94 Compared
to a group of survivors of flood trauma, a community sample
of burned children had significantly more phobic disorders,
over-anxious disorders, enuresis, encopresis, major depres­
sion, PTSD, and substance/ethanol abuse.53,95 Sleep disor­
ders and psychotic disorders were also slightly more common
among the burned children.
Parents usually report more problems than do the children
themselves or the teachers.90,96,97 This observation could be
explained by increased problems of the children following
severe burns that would not be easily observed by persons
who do not live with the patient, or by the fact that parents
became overly sensitive to any indication of difficulty for
their children following burns.
Children may express anxiety differently to adults, and
their anxiety is often evidenced by crying, tantrums, freezing,
or clinging. A differential diagnosis of anxiety disorders dis­
tinct from post-traumatic stress disorder is difficult and
requires a careful interview. Depression is a rare long-term
sequela of burns in children; fewer than 50% of the children
had ever suffered symptoms of major depression and in a
sample of adolescent survivors only 6% met criteria for a
major depressive disorder.53,94
Another area of long-term psychiatric outcome following
pediatric burns that has received little attention, is the devel­
opment of personality disorders. In the same sample of

Psychiatric disorders associated with burn injury
739
These disorders like PTSD can be treated with a combina­
tion of antidepressant and psychotherapy, with psychother­
apy being the most useful.
Major depression
Major depression, with or without grief reaction, should be
treated by a team approach. A patient should be involved in
scheduled daily activities. Psychotherapy should begin to
identify and address appropriate issues. Medication with
SSRIs or TCAs, as described for acute and post-traumatic
stress, is often helpful. Once the symptoms have responded
to medication, treatment should continue for nine months
to a year in order to avoid relapse on discontinuation.
Often, the depression is comorbid with PTSD. Therefore
medications which affect both are preferred. Fluoxetine and
the other SSRIs are the first-line medications for treatment
of patients with depressive symptoms.107,114
Sleep disturbances
After discharge, many burn survivors have significant sleep
problems. Like in the hospital setting this may be secondary
to PTSD symptoms, depression, itch or pain. Pain in the
hospital before discharge will predict insomnia.40 When
sleep disturbance with nightmares is associated with post-
traumatic anxiety, as described above, antidepressant medi­
cations are the drugs of choice. Imipramine and doxepin are
both sedating antidepressants that are effective treatments
for sleep problems in burn patients. Trazodone and nefazo­
done are alternative medications for insomnia and do not
appear to alter sleep architecture as much as other antide­
pressants. Mirtazapine is another antidepressant that has
been used for insomnia although little is known about its
effects on sleep architecture. Pain and itch are other prob­
lems that can interfere with sleep and should be addressed
with appropriate analgesic or antipruritic medications.115 If
a patient continues to have significant sleep problems, sleep
can be induced with diphenhydramine. Diphenhydramine
doses of 1.5 mg/kg are often used throughout the day for
itching and may be used alone for sleep at night or as an
adjunct to other sleep medications. Usually, doses of 25 or
50 mg in the evening are adequate. Recently, Quetiapine
fumarate (Seroquel XR) PO has been found to be safe and
useful in this setting.
Special aspects in pediatric treatment
As with adults, pediatric patients suffering with psychiatric
symptoms can benefit from psychotherapy, with appropriate
indicated treatment for their specific problems. A number of
specific therapies have been adapted for treatment of anxiety,
PTSD and depression in children and adolescents. In addi­
tion, specific treatments for pediatric burn survivors have
been developed, such as social skills training addressing
disfigurement.116
Pediatric burn patients appear to have a much higher rate
of adverse reactions to haloperidol and alternative manage­
ment of agitation should be considered.117 Chlorpromazine
and thioridazine may be used in place of haloperidol in the
dosage range of 25–100 mg per dose. Chlorpromazine and
thioridazine have strong sedative effects and interfere with
include techniques such as role play, imagined exposures
and most recently virtual reality. Also training in anxiety
management using stabilizing and calming techniques are
important for recovery from PTSD.
Pharmacotherapy developed over the past 2 decades with
the use of SSRIs such as sertraline and fluoxetine as first line
drugs. Other useful medications are tricyclic antidepressants
(TCAs), antipsychotics such as risperidone and quetiapine
fumarate, and α-2 adrenergic agonists such as clonidine.
Antidepressants such as selective serotonin re-uptake inhibi­
tors (SSRI) like fluoxetine, or a TCA like imipramine should
be considered for ASD.106 Both SSRIs and TCAs are helpful
in reducing the nightmares and improving the sleep pattern.
Treatment with a SSRI or TCA should be continued for at
least 9 months to 1 year following the improvement of
symptoms because of the risk of relapse.
One of the major issues for TCAs is that cardiac arrhyth­
mias, associated with a prolonged PR interval, can be life-
threatening.107 When medication is discontinued, it should
be reduced over time, to avoid uncomfortable, although not
medically threatening, discontinuation symptoms. The rela­
tively long half-life of fluo­xetine usually protects patients
from any discontinuation symptoms, but requires extended
vigilance for any drug–drug interactions.
Typically, the SSRIs are given in the morning rather than
the evening as they may interfere with sleep onset. Side-
effects of SSRIs include gastrointestinal upset, increased
agitation, headaches, and sweating. A rare but potentially
life-threatening side-effect is serotonergic syndrome,108 char­
acterized by at least three of the following symptoms: delir­
ium, agitation, sweating, fever, hyperreflexia, myoclonus,
tremor, incoordination, diarrhea and shivering. Severe cases
can result in hyperpyrexia, shock or death. The risk of sero­
tonergic syndrome increases when patients are on multiple
medications that potentiate central nervous system serot­
onin, such as an SSRI and a monoamine oxidase inhibitor.
There is a reported case of serotonin syndrome in a pediatric
burn patient who was receiving fluoxetine and linezolid,
a broad spectrum antibiotic with monoamine oxidase
inhibition.109
In an emergency room setting, propranolol has been tried
with some success for those with minor injuries. It has been
reported to be very helpful in the treatment of PTSD and
ASD and to prevent their occurrence following a variety of
different types of trauma. Longer term studies with larger
injuries have not shown propranolol to be helpful for the
prevention or treatment of ASD or PTSD.110,111 Benzodi­
azepines will control some immediate symptoms but are not
useful long term.
Other anxiety disorders
Most burn patients, certainly those who qualify for the diag­
nosis of generalized or overanxious disorder, will benefit
from lorazepam therapy in addition to supportive psycho­
therapy. If anxiety is associated with other symptoms of
post-traumatic stress, such as hypervigilance or poor sleep,
antidepressants such as a SSRI106 or a TCA112 should be con­
sidered. The SSRIs have the advantage of being safer drugs
for outpatient treatment since an overdose is unlikely to
cause significant cardiac problems as have been attributed to
the TCAs.113

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65
740
growth.123 Resilient individuals have an ability to ‘bounce
back’ and regain balance in all aspects of life, as well as
endurance in the face of adverse events.123–126 Three catego­
ries of protective factors, which also are predictive of resil­
ience, have been identified125: Individual characteristics,
relationships and social network.
In contrast, post-traumatic growth (PTG) is the develop­
ment of new behavior and attitudes that were not
present before the event. It is a positive psychological devel­
opment as the result of struggles in the face of hardship or
traumatic events.123,127 The Post-traumatic Growth Inven­
tory127 identifies five different aspects of post-traumatic
growth: ‘New Possibilities, Relating to Others, Personal
Strength, Spiritual Change, and Appreciation of Life.’ Post-
traumatic growth appears to be somewhat related to the
personality traits optimism and extraversion. Female gender
and social support are strongest predictors of PTG and
higher levels of education and higher socioeconomic status
also are predictive.123
Resilience and PTG can both occur concurrently with
distress and lower quality of life, in fact PTG may not
occur without some level of distress, but distress diminishes
over time in individuals who experience PTG. Longitudinal
studies show that PTG levels out at about 6 months after
trauma.123
Interventions to foster PTG
While alleviating distress does not foster PTG, growth can
protect from further distress. The patient’s own experiences
and psychological development appear to play a central role
in PTG. The caregiver’s role should be to support and improve
coping, strengthen self-image and enhance social support;
caregivers ‘must be comfortable in allowing the patient to
struggle with the event’.123,128 Common aspects of PTG in
burn patients appear to be the use of active and flexible
coping, social support, enhanced self-image and the success­
ful search for meaning.129,130
Summary
Pre-injury psychiatric morbidity can have a major effect on
outcome after a burn. Furthermore, psychiatric symptoms
occur commonly as part of the complex systemic response
to burn injuries. Psychological and pharmacologic treatment
is important in the successful recovery of a burned person,
and may reduce the risk of long-term psychiatric sequelae of
the injury. It is important to note that psychological adapta­
tion is a lengthy process occurring over months or years.
During the post-burn years, it is imperative that the burn
team assesses the mental and affective states of patients
while assessing their physical recovery. In most cases, patients
with sleep disorders, depression or withdrawal from previ­
ous activities will not seek psychiatric attention and treat­
ment, although these problems can be ameliorated by
treatment. It therefore becomes a responsibility of the expert
in burn care and the entire burn team to be aware of fre­
quently occurring problems, to ask the right questions to
assess a patient’s status, and to assist a patient in receiving
psychological and psychiatric assistance.
learning, but are less likely than haloperidol to produce
associated dystonia, pseudo-Parkinsonism, and akathisia. If
more than 2 mg of haloperidol per day are used, attention
must be given to simultaneous administration of I or 2 mg/
day of benztropine or 2–5 mg/day of trihexyphenidyl in
divided doses. Benztropine or trihexyphenidyl are used
to avoid dystonia, pseudo-parkinsonism, and akathisia.102
Occasionally, dystonia takes the form of an oculogyric crisis,
which resembles an acute neurological catastrophe118 and
can be a true medical emergency if respiration is impaired.
These reactions are usually alleviated by 50 mg IV
diphenhydramine.
The treatment of anxiety and depression in children with
SSRIs and TCAs requires closer attention to dosage and
potential side effects. The usual starting dose of fluoxetine is
5 mg for children <40 kg; 10 mg for children between 40
and 60 kg; and an adult dose for any children >60 kg. The
usual starting dose of imipramine is 25 mg/day unless the
patient weighs <25 kg. The beginning dose is 12.5 mg for
those under 25 kg. The dose can be increased rapidly over
the next few days to a dose of 1 mg/kg. If the symptoms are
still uncontrolled, the dose may be increased stepwise to
3 mg/kg, but only with frequent checking of the plasma
level and EKG changes with each increment of dose. A steady
state is usually not reached until a given dose is maintained
for 3–5 days. The preferable time of administration is in
the evening to aid with sleep. Major side-effects of the TCAs
are anticholinergic effects (dry mouth and dry nasal pas­
sages, constipation, urinary hesitance, and occasional
esophageal reflux).102 Autonomic complications such as
orthostatic hypotension, palpitations, and hypertension
have been reported in adolescents with this medication.119
Cardiac arrhythmias, associated with a prolonged PR inter­
val, can be life-threatening.107,114 Sudden death has been
reported for teenagers and children receiving desipramine
and other TCAs.120 Amitriptyline or doxepin may be used
in place of imipramine. The dosages are similar; however,
both these medications may cause more sedation than
imipramine.102
Following clinical reports of increased suicidal ideation in
pediatric patients treated with certain antidepressant medi­
cations and a review of clinical trial data, the US Food and
Drug Administration instructed all manufacturers to include
a ‘black box’ warning with all antidepressant medications.121
Pediatric patients and their caretakers must be aware of these
risks and clinicians should closely monitor children and
adolescents on these medications for possibly increased
suicidal ideation and behavior.122
Resilience, post-traumatic growth
Although it has become generally accepted knowledge
that trauma and injury can lead to psychological and psy­
chiatric problems, the fact that a considerable proportion
of individuals do not develop problems after trauma
and injury has found much less attention and to date, there
are only an extremely small number of studies in burn
patients.
Resilience and post-traumatic growth are two separate
constructs. Resilience is a trait that exists before exposure
to trauma or adverse events that enables posttraumatic

Psychiatric disorders associated with burn injury
741
Thomas C, Blakeney P, Holzer CE 3rd, et al. Psychiatric disorders in
long-term adjustment of at-risk adolescent burn survivors. J Burn
Care Res. 2009;30(3):458-463.
Thomas C, Russell W, Robert R, et al. Personality disorders and traits
in young adult survivors of pediatric burn injury. J Pers Disord.
2012;26(2):255-266.
Willebrand M, Andersson G, Ekselius L. Prediction of psychological
health after an accidental burn. J Trauma. 2004;57(2):367-374.
Further reading
Hall E, Saxe G, Stoddard F, et al. Posttraumatic stress symptoms in
parents of children with acute burns. J Pediatr Psychol.
2006;31(4):403-412.
McKibben JB, Ekselius L, Girasek DC, et al. Epidemiology of burn
injuries II: psychiatric and behavioural perspectives. Int Rev
Psychiatry. 2009;21(6):512-521.
Meyer WJ, Blakeney P, Thomas CR, et al. Prevalence of major
psychiatric illness in young adults who were burned as children.
Psychosom Med. 2007;69(4):377-382.
Access the complete reference list online at

Psychiatric disorders associated with burn injury
741.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
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100. Sveen J, Low A, Dyster-Aas J, et al. Validation of a Swedish
version of the Impact of Event Scale-Revised (IES-R) in patients
with burns. J Anxiety Disord. 2010;24(6):618-622.
101. Oster C, Willebrand M, Dyster-Aas J, et al. Validation of the
EQ-5D questionnaire in burn injured adults. Burns.
2009;35(5):723-732.
102. Schatzberg AF, Cole JO. Manual of clinical psychopharmacology,
2nd edn. Washington, DC: American Psychiatric Press; 1991.
103. Still J, Friedman B, Law E, et al. Neuroleptic malignant
syndrome in a burn patient. Burns. 1998;24(6):573-575.
104. Coffey BJ. Anxiolytics for children and adolescents: traditional
and new drugs. J Child Adolesc Psychopharmacol. 1990;1(1):57-83.
105. Martyn JA, Greenblatt DJ, Quinby WC. Diazepam kinetics in
patients with severe burns. Anesth Analg. 1983;62(3):293-297.
106. Tcheung WJ, Robert R, Rosenberg L, et al. Early treatment of
acute stress disorder in children with major burn injury. Pediatr
Crit Care Med. 2005;6(6):676-681.
107. Ryan ND. Heterocyclic antidepressants in children and
adolescents. J Child Adolesc Psychopharmacol. 1990;1(1):21-31.
108. Chiu S, Leonard HI. Antidepressants I: selective serotonin
reuptake inhibitors. In: Martin A, et al. eds. Pediatric
psychopharmacology: principles and practice. New York: Oxford
University Press; 2003:274.
109. Thomas CR, Rosenberg M, Blythe V, et al. Serotonin syndrome
and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;
43(7):790.
110. Sharp S, Thomas C, Rosenberg L, et al. Propranolol does not
reduce risk for acute stress disorder in pediatric burn trauma.
J Trauma. 2010;68(1):193-197.
111. McGhee LL, Maani CV, Garza TH, et al. The effect of propranolol
on posttraumatic stress disorder in burned service members.
J Burn Care Res. 2009;30(1):92-97.
112. Robert R, Blakeney PE, Villarreal C, et al. Imipramine treatment
in pediatric burn patients with symptoms of acute stress
disorder: a pilot study. J Am Acad Child Adolesc Psychiatry.
1999;38(7):873-882.
113. Glassman AH. The newer antidepressant drugs and their
cardiovascular effects. Psychopharmacol Bull. 1984;20(2):272-279.
114. Glassman AH, Bigger JT Jr. Cardiovascular effects of therapeutic
doses of tricyclic antidepressants. A review. Arch Gen Psychiatry.
1981;38(7):815-820.
115. Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances,
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116. Blakeney P, Thomas C, Holzer C 3rd, et al. Efficacy of a
short-term, intensive social skills training program for burned
adolescents. J Burn Care Rehabil. 2005;26(6):546-555.
117. Ratcliff SL, Meyer WJ 3rd, Cuervo LJ, et al. The use of
haloperidol and associated complications in the agitated, acutely
ill pediatric burn patient. J Burn Care Rehabil. 2004;25(6):
472-478.
118. Huang V, Figge H, Demling R. Haloperidol complications in
burn patients. J Burn Care Rehabil. 1987;8(4):269-273.
119. Teicher MH, Glod CA. Neuroleptic drugs: indications and
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120. Popper CW, Elliott GR. Sudden death and tricyclic
antidepressants: clinical considerations for children. J Child
Adolesc Psychopharmacol. 1990;1(2):125-132.
121. Kondro W. FDA urges ‘black box’ warning on pediatric
antidepressants. CMAJ. 2004;171(8):837-838.
122. Bridge JA, Salary CB, Birmaher B, et al. The risks and benefits of
antidepressant treatment for youth depression. Ann Med.
2005;37(6):404-412.
123. Wiechman Askay S, Magyar-Russell G. Post-traumatic growth
and spirituality in burn recovery. Int Rev Psychiatry.
2009;21(6):570-579.
124. Zautra AJ. Resilience: one part recovery, two parts sustainability.
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125. Ong AD, Bergeman CS, Boker SM. Resilience comes of age:
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1777-1804.
126. Bonanno GA, Wortman CB, Lehman DR, et al. Resilience to loss
and chronic grief: a prospective study from preloss to 18-months
postloss. J Pers Soc Psychol. 2002;83(5):1150-1164.
127. Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory:
measuring the positive legacy of trauma. J Trauma Stress.
1996;9(3):455-471.
128. Calhoun LG, Tedeschi RG. Facilitating posttraumatic growth: A
clinician’s guide. New Jersey: Lawrence Erlbaum Associates; 1999.
129. Rosenbach C, Renneberg B. Positive change after severe burn
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130. Zhai J, Liu X, Wu J, et al. What does posttraumatic growth mean
to Chinese burn patients: a phenomenological study. J Burn Care
Res. 2010;31(3):433-440.

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©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00066-7
Psychosocial recovery and
reintegration of patients
with burn injuries
Laura Rosenberg, John W. Lawrence, Marta Rosenberg, James A. Fauerbach,
Patricia E. Blakeney
Introduction
The process of psychosocially adapting to a severe burn is
complex. Common issues faced by burn survivors include
traumatic stress, depression, body image disturbance, social
anxiety, grief, pain, itching, sleep disturbance, substance
abuse, adapting to physical limitations and coping with per­
manent burn scarring. In addition, burns often interfere with
a person’s ability to work and perform familial responsibili­
ties. Sometimes the survivor’s family is also traumatized, and
the family’s material and social resources can be greatly taxed
during the course of burn recovery. Despite the sudden life-
altering nature of burn injuries, studies of the psychological
morbidity for burn survivors suggest that most burn survi­
vors are resilient and adjust well over time. However, approx­
imately 30% of both adult and children burn survivors
experience moderate to severe long-term psychosocial diffi­
culties.1,2 The current chapter reviews the challenges of
providing quality psychosocial treatment for burn survivors
through the course of recovery. The goal is to assist individu­
als in attaining optimal psychological, emotional and social
functioning (Figs 66.1, 66.2).
Integrating psychological treatment
with physical treatment
Comprehensive burn treatment requires a coordinated inter­
disciplinary team. Usually the burn team consists of physi­
cians, nurses, care coordinators, physical and occupational
therapists, and mental health professionals such as child life
specialists, social workers, and psychologists. It may be con­
venient to think of physical and psychosocial recovery as
being two different processes overseen by different sets of
professionals, but the two are so intertwined that a team
approach to burn recovery is essential. The mental health
professionals both consult with other caregivers about the
patient’s psychological and social issues and implement
psychosocial interventions psychotherapy, and a community
reintegration plan. Thus, the mental health professionals on
a burn team work both indirectly through consultation and
provide patient direct care.
Integrating the patient’s family into the treatment plan
from the beginning also facilitates successful outcomes.3 For
the psychotherapist on the burn team, the family unit is
often the patient. Each individual within the family, includ­
ing the burn survivor, is an essential element of this unit
whose needs must be addressed as they all adapt to the
changes in the family.
Assisting with grief following trauma
Traumatic events are frightening experiences that create
uncertainty, anxiety, and a sense of threat for victims and
their families.4,5 An individual who experiences a burn injury
may face multiple changes and losses including separation
from one’s support network and home environment, uncer­
tainty regarding the length of hospitalization and process,
changes with physical appearance, and in certain circum­
stances death of loved ones. On the burn unit, these issues
often become the focus of psychosocial intervention. Suc­
cessful grief therapy requires mental health professionals to
have an understanding of the traumatic event, knowledge of
the individual’s past experiences with loss and coping styles,
and cultural and religious beliefs.4 Mental health profession­
als can assist re-establishing a sense of equilibrium following
trauma by facilitating the grieving process.
The terms bereavement, grief, and complicated grief may
be confusing and merit clarification. Bereavement refers to
coping with the death of a loved one; whereas grief is a
broader term referring to coping with loss in general.6 For
example, a burn survivor may grieve the loss of his or her
physical abilities or his or her pre-scarred skin. Grief reac­
tions are individually unique and age dependent.5,7 Com­
plicated grief occurs in adults when the grieving process is
compromised by trauma. Prigerson and Jacobs (2001)
described complicated bereavement as difficulty compre­
hending and accepting the death of a loved one, persistent
and intense longing for the deceased, intrusive thoughts
about the deceased, and avoidance of painful memories.8
Children can also experience childhood traumatic grief
when there is traumatic loss or bereavement.5,9,10 This con­
struct evolved from the literature in child development and
trauma and occurs when trauma symptoms interfere with
the child’s ability to grieve normally. The child may engage
in avoidance behaviors which interfere with the normal
grieving process.5,9,10 Traumatic grief can co-occur with
psychiatric disorders such as depression and posttraumatic
CHAPTER 66 
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IN THIS CHAPTER
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Total Burn Care
66
744
children and adolescents who experienced the death of a
loved one and found significant correlations between child­
hood traumatic grief scores and PTSD, depression, and
anger. In addition, the severity of the traumatic grief response
was associated with the view of the death as traumatic.10
On the burn unit, mental health professionals may need
to inform the burn survivor about multiple losses and life
changes which may include changes in appearance, loss of
body parts, the death of others such as family and friends,
loss of a pet, loss of a home, etc. In some circumstances, it
requires informing, supporting, and preparing the family for
bereavement of the burn trauma victim. This is a delicate
process that requires appropriate timing and psychosocial
planning. Important factors to consider when planning the
disclosure process with patients and families include the
patient’s medical stability and ability to participate in con­
versations; the readiness of the patient and family to hear
the news; identification of what they know about the trauma
and the factors related to the traumatic event; their wishes
regarding disclosure; and knowledge of their cultural, reli­
gious and spiritual needs.12 Bronson and Price (2007) in
their article for the Phoenix Society discussed important
principles to keep in mind when working with grieving chil­
dren after burn trauma. They suggest a process which includes
supportive and compassionate truth-telling, acceptance,
respectfulness of individual differences and feelings, and
giving the individual an opportunity to say good-bye.13
If death occurs on the burn unit, staff can psychologically
support the family by obtaining desired spiritual assistance,
assisting them with paperwork for the burial process, allow­
ing them quiet, private time with the deceased, and provid­
ing distraught family with memory items if they wish to
have them.
Cultural sensitivity
Burn patients come from diverse cultures, and burn care
teams must be sensitive as to how cultural issues can affect
patients and families in all the phases of the recovery process.
‘Culture’ refers to the socially transmitted expectations,
beliefs, traditions, and behavioral patterns typical of a given
community at a point in time.14 Some of the factors influenc­
ing culture include country of origin, geographical location
within the country, ethnicity, and socioeconomic back­
ground. Staff must also be aware of their own biases, values,
and assumptions that stem from their cultures.15,16
Acculturation is the process in which individuals from one
culture embrace patterns, customs, beliefs, values, and the
language of the dominant culture.17,18 Patients and their
families on first arriving at a burn care facility must rapidly
adapt to the culture of the hospital environment. Even if the
hospital is within their own community, they experience
some level of culture shock and acculturation. This process
is even more complicated for those who are transported for
care to communities far removed from their homes and
perhaps in another country. For some patients, this traumatic
situation is also the first time they have traveled to another
country, and the first time they have had to deal with
differences in language, currency, living accommodations,
and foods. Individuals’ concepts of time and space, appro­
priate hospitality, importance of greetings, how non-verbal
stress disorder.5,9,11 The prevalence of burn survivors and
family members who experience traumatic grief is unknown.
Clinical experience suggests that many burn survivors pro­
gress through the grieving process without complications
and are resilient when faced with loss.
Emerging research has focused on differentiating normal
grief reactions from those of traumatic grief responses.
Brown and Goodman (2005) studied 83 children who lost
their fathers in the tragedy of the World Trade Center on
September 11th and identified normal and traumatic grief
as distinct constructs. Significant positive correlations were
found between traumatic grief scores and secondary adversi­
ties related to the trauma, symptoms of PTSD, general anxiety
and depression, and less adaptive coping styles.5 The authors
reported that children who retained a positive memory and
ongoing presence of their loved one were able to grieve nor­
mally. A subsequent study by Brown et al. (2008) substanti­
ated these previous findings. The investigators evaluated 132
Figure 66.1  Quinceañera cutting cake with parents. (Reprinted from: Herndon
DN, ed. Total burn care. London: WB Saunders; 2007).
Figure 66.2  A relaxing day before attending college.

Psychosocial recovery and reintegration of patients with burn injuries
745
members and patients to anticipate the development of psy­
chosocial issues, view concerns as normal reactions to the
trauma instead of symptoms of psychological impairment,
and facilitate coping with these issues. The following sec­
tions address psychosocial issues patients deal with in each
phase of the recovery process.
Pre-injury adjustment
Shortly after being admitted to the burn unit, a psychosocial
assessment is done through a clinical interview with the
patient and/or family to gather information regarding
variables which may influence the patient’s recovery and
treatment plan. These variables include previous stressful
events, risk factors, pre-burn physical and psychological
health, coping skills, family and social support, and family’s
strengths and weaknesses.29,30 Gathering information about
factors which contributed to the circumstances of the burn
is emphasized in instances of suspected abuse and neglect.
Part of the clinical interview involves initiation of a thera­
peutic alliance with those who are most likely to be involved
in assisting a patient’s recovery.
Because patients will be dependent to some extent on
family or other caretakers during recovery, it is essential to
identify risk factors in the family system. Historical risk
factors which may predispose individuals to burn injury and
which may affect post-burn recovery include: physical illness,
substance abuse, psychiatric illness, behavioral problems,
poverty, inadequate social support, and heightened family
disruption.30–33
Admission crisis
On admission to the ICU, individuals with burns may expe­
rience terror, confusion, shock, disbelief, pain, anxiety, and
may believe death is imminent. The hospital environment
can be confusing and frightening. While the physiological
emergency is treated medically, the psychological crisis must
be addressed. The goals at this time are to establish thera­
peutic rapport with the patient, help decrease anxiety, and
assess strengths and needs of the patient. The first two tasks
are addressed immediately by orienting the patient, assisting
the patient to focus on immediate priorities, and assuring
the patient the burn team is composed of knowledgeable
experts who will provide excellent care. The patient’s height­
ened anxiety can be expected to interfere with his/her com­
prehension, so it is usually necessary to repeat statements of
reassurance. To prevent a patient from becoming emotion­
ally overwhelmed, it may be necessary initially to avoid or
limit talking about trauma-related content. Patients, espe­
cially children, in this early stage of recovery, may exhibit
signs of cognitive and emotional regression, and it is impor­
tant to respond to them on that level. Techniques such as
hypnotherapy and relaxation with focused imagery can help
decrease patients’ anxiety.
Family members are also traumatized and typically experi­
ence difficulty eating and sleeping for the first days. Other
symptoms of trauma response often experienced by family
members include problems focusing and concentrating, a
feeling of loss of control, and a generalized sense of incom­
petence and helplessness. They may need frequent repetition
of information and direction in providing comfort to the
gestures are interpreted, and ways of expressing gratitude
may differ greatly among cultures. Ideas of what caused the
burn injury and what is necessary for healing to occur also
are determined by cultural values.19,20
Coping with such a multitude of unfamiliar experiences
in a traumatic situation is an extraordinary challenge that
can inhibit a patient’s or family’s ability to participate in the
recovery process. The burn team must be aware of cultural
differences and make culturally appropriate accommoda­
tions to a patient’s treatment plan. Cultural traditions can
be incorporated into treatment plans to enhance participa­
tion toward recovery. For example, if a Latino family believes
that the burn incident was a result of ‘evil eye’ they may
request a cleansing ritual.17 It is impossible for providers to
know the beliefs and expectations of every culture; however,
cultural sensitivity and a willingness to learn are necessary
for good patient–provider communication and improves
outcomes. Staff can acknowledge their lack of familiarity and
pose a question to the patient/family of whether there is
anything the team can do to help meet their cultural, spir­
itual, and religious needs. The question conveys respect for
cultural differences and a desire to help through the accul­
turation process.
Knowledge and sensitivity of cultural practices is also
important when focusing on safety and prevention edu­
cation with patients and their families. Epidemiological
research has focused on identification of sociodemographic
risk factors and cultural practices that have contributed to
burn injuries in developed and developing countries and
found differences among these countries.21–24 The highest
incidence of severe burns occurs in low and middle income
countries25 with children being at highest risk.21 In develop­
ing countries, factors such as poverty, crowding, food prepa­
ration practices, unstable cooking methods, and inconsistent
supervision practices place young children at high risk for
scald burns.22,26,27 Identification of these modifiable risk
factors and cultural practices during the course of treatment
can facilitate prevention education for the patient/family
and hopefully this education will be disseminated through­
out their communities.
Approach to assessment and intervention
Our general approach to assessment and care of burn survi­
vors is described throughout the chapter as we suggest
interventions to deal with specific difficulties commonly
experienced at each phase of recovery. It is basically a behav­
ioral approach based on learning principles (e.g. operant
conditioning, cognitive restructuring, and social learning
theories) where maladjusted behavior is the target of inter­
vention. Assessment and treatment are integrally related and
both occur simultaneously throughout the recovery and
rehabilitation process.
The longitudinal pattern
of psychological recovery
Psychological healing occurs across time commensurate
with physical healing in a relatively predictable and con­
sistent pattern.28 Awareness of this process permits family

Total Burn Care
66
746
participate in wound debridement. The presence of a sup­
portive person can be effective in decreasing pain as well.
Instructing a family member on how to comfort their loved
one is important during these procedures.
Interventions which redirect a patient’s attention away
from painful procedures can facilitate pain and anxiety man­
agement. Music therapy is an excellent adjunct to analgesia
during burn care with pediatric patients.38–40 Fratianne et al.
(2001) found that music therapy interventions significantly
decreased the perception of pain in children during wound
care. Although anxiety also decreased, results were not sig­
nificant.41 On the other hand, Haythornthwaite et al. (2001)
reported a sensory focused intervention was more effective
in reducing pain in comparison to music distraction with
adult burn survivors.42
Other interventions which have been effective in decreas­
ing pain and distress associated with burn treatment include
deep breathing, progressive relaxation, visual imagery, bio­
feedback, hypnosis and virtual reality. Hypnosis induces
a relaxed and focused state of awareness which can be
extremely helpful in facilitating comfort for adult and pedi­
atric patients. Hypnotic inductions and suggestions must
be modified to facilitate a patient’s use of imagery. Some
patients will respond well to suggestions of imagining a
‘favorite place’. Children aged 3 and over respond well to
storytelling, with suggestions for comfort and mastery
interwoven into the story.43 Recent research reported that
immersive virtual reality, in which individuals’ attention was
immersed in a computer generated world, was effective in
reducing pain during wound care.44,45 This intervention may
also be helpful during physical therapy.46,47 Mott et al. (2008)
found that augmented reality, where a character is viewed on
a screen, was also effective in decreasing pain ratings of
pediatric burn patients during prolonged wound care.48 In
addition, child life interventions such as medical play which
gives children control by having them role play and mani­
pulate medical equipment, preoperative preparation about
procedures or surgeries, and procedural support can facili­
tate coping in children and decrease anxiety during burn
care. The child’s age and development need to be considered
when selecting the intervention.49
Although over time family members may become more at
ease with hospital routines, they will continue to have dif­
ficulty coping, feel anxious, and need updates about their
patient’s present and future status,50 and may develop new
concerns as they are placed in new roles and responsibilities.
Being away from support systems can be difficult. It is helpful
to provide information about what to expect in the immedi­
ate future, to facilitate patient interaction, and to provide
honest information while allowing family members to
protect themselves from overwhelming despair. Family may
be reluctant to touch the patient for fear of causing pain and
may feel uncomfortable talking aloud to a non-responsive
patient. Staff can find ways to allow family members to
nurture their loved one and can assist them in becoming
comfortable in caring for their patient’s needs. Taking the
time to treat the family is a very important part of treating
the patient. In addition, this treatment facilitates the family’s
resumption of feelings of competence and control, desensi­
tizes them to the sights and odors in the room, and encour­
ages them to join with the burn team in the healing and
rehabilitation of the patient. A family must find reason to
patient. The psychotherapeutic tasks to be accomplished
with the family are similar to those for the patient, i.e. to
establish a therapeutic relationship and diminish anxiety.
This can be done by assisting with orientation to the hospi­
tal, and providing information about the normal reactions
and responses to trauma. Validating that their distress is
normal and temporary helps communicate empathy and
understanding. Learning about the injury and its treatment
helps restore a family’s sense of competence and provides
opportunities for them to experience the reality of their roles
in helping the patient. The manner in which an individual
and family will ultimately adjust to long-term sequelae of a
burn is often determined in the early stages of recovery.
Critical care phase
In this phase, intensive medical and surgical care is provided
until the majority of open wounds are covered. This period
is important psychologically. Patients experience pain,
anxiety, and fear of treatment procedures. Organic factors
stemming from the injury and its treatment can contribute
to psychological symptoms of disorientation, confusion,
sleep disturbance, transient psychosis, and delirium. Helpful
interventions include repeated orientation to person, place
and time; placing comforting objects in the patient’s view or
so that he/she can touch them; and making the patient’s
environment as soothing as possible. Visits from family and
friends can provide familiarity and reassurance to a patient.
A schedule that approximates a regular wake/sleep cycle
helps a patient begin to feel normal.
Reassurance from staff about the normal aspects of recov­
ery can help decrease a patient’s anxiety. Information about
the recovery process, treatment plan, and how staff plan to
help improve function can provide a sense of hope. When a
patient is alert, the psychotherapist can facilitate grief work
to help the patient adjust to the effects of the burn. Patients
with altered mental states may be hearing although not
responding and discretion should be used regarding what is
said near them. Psychological interventions are aimed at
diminishing anxiety and increasing comfort instead of cor­
recting the person’s perception of reality.34
Pain and anxiety management are crucial in this stage of
recovery. Providing good pain control enhances the burn
care staff’s effectiveness in promoting psychological recovery.
Routine and scheduled assessments of background and
procedural pain,35–37 and anxiety,35,37 validates a patient’s
concerns but also sets an expectancy of relief. The use of
standardized scales provides the message that to experience
a range of pain is normal, and allows the patient to partici­
pate to some degree in mastering discomfort. When staff
assess comfort as routinely as vital signs, patients are less
likely to feel anxious about their pain management.
Psychological interventions should be used in conjunction
with pharmacological management for both pain and
anxiety. The perception of pain can be influenced by antici­
patory anxiety over procedures. Cognitive and behavioral
interventions which enhance a patient’s mastery or control
can help decrease pain and anxiety. Patients often tolerate
procedures better when the reasons for each procedure are
explained. They may feel more comfortable by participating
in their own care; they may gain some mastery over pain
when they are allowed to remove their own dressings or

Psychosocial recovery and reintegration of patients with burn injuries
747
and acceptance of the patient while also helping the patient
to exercise control over destructive behaviors. Responses to
questions should be honest but hopeful regarding the expec­
tations of treatment and recovery. Interventions aimed at
facilitating grief work, coping with body image concerns,
management of anxiety and depression, and social skills
training to facilitate social interactions are helpful during
this phase of recovery.
Much psychotherapeutic work during this phase is accom­
plished with patient and family together. Families must learn
how to assist a patient in adjusting to the new situation,
and the family system must accommodate to the changed
situation. Research has shown the high importance of
strengthening the family unit, facilitating family closeness,
and supporting their attempts to organize their lives to incor­
porate the additional duties involved in providing continued
care for their patient.3,53 Families must plan and implement
adjustments in their relationships and in their home envi­
ronments that will be necessary for the continuation of the
patient’s recovery and rehabilitation after discharge.
Reintegration phase
Preparing for a patient’s discharge to outpatient status and
eventually home begins upon admission to the burn unit. A
major objective is to facilitate a patient’s reintegration to life
at home and his/her community. Community reintegration
is the process of becoming involved in the community, in
school and work, and in leisure activities.54 Returning home
signifies social interactions with the larger community of
extended family, friends, and strangers. Patients as well as
family must prepare for those encounters. Patients often feel
ambivalent and anxious, fear social rejection, worry about
being accepted and receiving social support.55 Returning to
a cohesive and supportive family environment3,56 and loyal
friends57 can make this transition easier.
Psychotherapeutic activities in this phase involve educa­
tion and preparation of patient and family about difficulties
which may be anticipated at discharge. Coping skills that can
help are discussed and practiced. Patients and families often
deny that they will have problems; however, psychothera­
pists can help prepare such patients by offering suggestions
to address problems that other people have experienced.
Issues such as recurrence of posttraumatic stress symptoms,
sleep disturbance, irritability, or fear of resuming sexual
activities should be discussed prior to discharge.
Social skills programs are available to facilitate positive
reintegration to society, improve social comfort, and increase
confidence in social interactions. The program Be Your Best
by Barbara Kammerer Quayle and The Phoenix Society for
Burn Survivors Inc. (2006) was developed to help burn sur­
vivors with community reintegration.58 Another program
Changing Faces by James Partridge, an organization dedicated
to assisting persons with facial disfigurement, recommends
a brief social skills training program called ‘3–2–1-GO!’59
Both programs provide strategies to prepare patients to
answer questions related to the burn, and for dealing with
staring and stigmatizing behaviors. The patient may benefit
from rehearsal using these skills on brief outings outside the
hospital. If difficulties are encountered, the patient can
consult with the burn team for direction and support to
develop an alternate plan. Groups of inpatients, outpatients,
hope, and staff can assist them by suggesting realistic
and optimistic outcomes. Psychotherapeutic work with the
family should also identify and plan for management of
family issues which may impede a patient’s recovery and
rehabilitation, such as financial support, family alliances,
historical family events, and beliefs that influence current
perceptions and behaviors.
In-hospital recuperation phase
In this phase of recovery, patients become physically stronger
yet face new challenges. Patients often reminisce about
the past, begin to comprehend the extent of their injury,
and experience difficulty adapting to physical limitations
and changes in their appearance. They may feel anxious
about the future and grieve losses. They can also experience
a loss of control and autonomy because they have now
become dependent on others for their care, yet be ambiva­
lent about resuming self-care to increase independence.
The team can help motivate the patient to participate in
treatments and assume responsibility for his/her recovery.
Patients who desire optimal recovery need to comply with
the medical team’s instructions, many of which require sig­
nificant physical discomfort. Pain continues to be a concern
as patients become increasingly active in rehabilitative exer­
cises, and pain and anxiety management are important to
regain optimal physical functioning. As in the previous
phase of recovery, music therapy, hypnosis, relaxation tech­
niques, and virtual reality can facilitate pain and anxiety
management.
Emotional lability and cognitive and behavioral regression
may also occur, especially with younger children. Because
children often have difficulty expressing verbally their feel­
ings and frustrations, they may exhibit behavioral outbursts.
Parents may be relieved to find out such behaviors are
normal, and often require guidance with implementation of
treatment plans that target and positively reinforce desirable
behaviors (e.g. reinforcement plans with short-term goals
such as star charts). Patients may feel frustrated, angry,
hopeless, and depressed. These emotional reactions can be
difficult for family members to cope with. Hopelessness is
more likely to result when patients feel a lack of control and
eventually give up trying, which can lead to chronic depres­
sion. Although depressive symptoms may decrease during
the initial hospitalization,51 Ullrich et al. (2009) found
depression during hospitalization was related to physical
functioning of patients up to the first year post-burn.52 Psy­
chotherapeutic work with the patient may involve helping
the patient experience control, combat feelings of hopeless­
ness and helplessness, facilitate healthy expression of emo­
tions, achieve success, and feel rewarded while progressing
through difficult procedures. Desired behaviors (e.g. pres­
sure garment use or walking on treadmill) can be reinforced
through verbal praise.
A psychotherapeutic challenge of this phase is to accept
and validate the patient’s emotional demonstrations as
normal behaviors in the recovery process while also setting
limits on the ways in which emotions are expressed. Early in
this phase, as the patient begins to ask about the future, the
psychotherapist can describe the predictable pattern of emo­
tional vicissitudes indicating they are normal and can be
endured and managed. Staff can demonstrate positive regard

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Grief work continues as burn survivors cope with losses;
delayed grief reactions occur. Symptoms of post-traumatic
stress may recur upon leaving the protective hospital envi­
ronment. Body image concerns may become more acute
as burn survivors confront stigmatizing reactions to their
scars. Also, the family’s social and emotional resources may
become taxed as the family transitions into becoming the
patient’s primary caregivers.
Factors to consider during rehabilitation in burn care are
the patient’s functional impairment and/or disability. Injury,
impairments and functional limitations represent poten­
tially disabling conditions, while disability itself is a func­
tion of the interaction between the person’s limits and the
environment.76 Factors that moderate the relationship of
injury to disability are biology (e.g. genetic, congenital),
environment (e.g. physical, social, psychological), and life­
style (e.g. expected behaviors). The goal of rehabilitation is
to enable full social-environmental integration, including
access to social opportunities (e.g. roles) and physical space
(e.g. absence of physical barriers). The National Institute of
Disability and Rehabilitation Research (NIDRR) presents a
paradigm for conceptualizing and conducting rehabilitation
research that places environmental factors on an equal
footing with person factors.77
Regarding burn injury, there are some data to suggest that
the most important long-term (>2 years post-injury) disabil­
ity is at the interface of the burn survivor and social environ­
ment. A study of young adult survivors of childhood burns
(mean years post-burn, 14 years) found that on standardized
behavioral scales the young people were rated by others to
be doing well. However, in individual standardized psychi­
atric interviews, an unexpectedly high percentage reported
psychiatric disorders, specifically anxiety related to social
situations,78 and personality disorders79 severe enough to
warrant diagnoses. Similar results were found in a study of
adolescents (mean years post-burn, 10 years).80 In these
studies, the young people were rated by a physical therapist
to have no physical limitations that prevented their abilities
to care for themselves and to participate in ordinary activi­
ties, but their anxieties were severe enough to limit their
achievement of full capacity. Even if most burn survivors
eventually function satisfactorily by external criteria, clini­
cally they may be suffering significant distress that is not
easily observable. A goal of psychosocial care providers in
working with survivors is to understand the sources of sur­
vivors’ distress and to develop interventions that enable sur­
vivors to become full participants in society.
It would be extremely valuable to patients leaving the
hospital, as well as their social network, employers, and care
providers, if there were a set of predictors that could reliably
estimate when and to what degree functional improvement
could be expected over time. Fauerbach et al. (2006) evalu­
ated functional impairment of burn survivors from discharge
and across 2 years. They found that psychological impair­
ment was predicted by prior alcohol abuse, psychological
distress, and psychological function both before the burn
and at discharge.81 These data can inform providers and adult
patients about factors that could be modified to effect more
desirable outcomes. Conducting such studies in burn care
requires multisite studies over several years to gather suffi­
cient data. For pediatric patients, such studies are underway
but take many years because they must also consider
and their families can be extremely helpful in the process of
anticipating difficulties at discharge and rehearsing solutions
while also providing emotional support.
The burn team may prepare the community to which a
patient will return (e.g. extended family, neighbors, church
groups, social clubs, a patient’s workplace, and for pediatric
patients, the school). Instructing those unfamiliar with
burns in what to say or do to ease a survivor’s re-entry may
assist with reintegration.60–62 Variables that may affect burn
survivors’ ability to return to work once they are discharged
from the hospital include size and severity of burn,63,64 dura­
tion of hospitalization,64,65 location of burn,63,64 physical
impairment,64–67 pain,66,67 prior employment history,63,64,67
lack of vocational training,68 work environment impedi­
ments,65 and psychosocial difficulties.64–68 Variables found to
assist with return to work were psychosocial support, posi­
tive thinking and vocational training.67,68 A recent literature
review reported 66% of burn survivors returned to work
within the first 2 years post-burn.64 In a study of young adults
who sustained burns during childhood, Meyer et al. found
that 65% of the sample were employed either full-time or
part-time.69 Individuals who do work report improved
quality of life.70,71
Factors that affect adults’ return to work can also influence
school re-entry for pediatric burn survivors. Staley et al.
(1998) reported children with small burns returned to
school within the first week or month post-burn, and most
performed well academically.72 However, pediatric burn sur­
vivors often require assistance to return to school so they can
learn, develop, and form peer relationships. Many burn
centers in the USA have developed school re-entry programs.
These programs are designed to educate staff and students
about aspects of burns, provide generic information about
treatment and recovery, emphasize the child’s abilities and
needs, clarify ways in which the child may require assistance,
and address the importance of normalizing school activities
and providing support. Working with the family and the
school, burn professionals develop a plan to integrate
the child burn survivor back into school. Usually, part of
the process includes the burn professionals visiting the
child’s classroom, explaining the nature of burns and burn
rehabilitation, engendering compassion and support for the
burn survivor, and answering questions. Burn professionals
running school re-entry programs have received a good deal
of positive feedback from schools and families; however, the
long-term efficacy of school re-entry programs has not been
empirically demonstrated.62,73 A few studies have reported
that interventions developed around specific children,
on-site school visits73 and educational videos/DVDs73,74 are
beneficial. The Journey Back by The Phoenix Society for Burn
Survivors (2006) is a comprehensive program providing
generic materials designed to help pediatric burn survivors,
families of burned children, and school communities with
the re-entry process.75
Rehabilitation phase, post-discharge
Discharge from acute inpatient treatment does not signify
that a patient is well. Rehabilitation may require several
months to years. Burn survivors’ wounds may be vulnerable
to breakdown and may require dressing changes, exercises,
and application of special splints and pressure garments.

Psychosocial recovery and reintegration of patients with burn injuries
749
severity, facial injury) have been associated with poorer
outcome.102 High levels of trait neuroticism appear to be
at greater risk of PTSD symptomatology following burn
injury while high levels of extraversion appear protective
against PTSD.63,103
It might be assumed that PTSD is related to greater initial
injury; however, PTSD among burn survivors has not been
found to be related to severity of injury.104 On the other
hand, high levels of acute post-trauma stress symptomato­
logy have been shown to be positively related to perception
of more intense pain among hospitalized burn patients.105,106
High emotional distress and acute stress disorder symptoms
during hospitalization are risk factors for PTSD 2 years
post-burn.95,107
Body image, stigmatization,
and social integration
Body image is one’s self-evaluation of one’s physical appear­
ance.108 Negative body image or body dissatisfaction is the
belief that one is unattractive or ‘ugly.’ Body image is highly
correlated with self-esteem particularly among adolescents
and young adults. Negative body image is a component of
or is highly associated with a number of psychiatric disorders
including depression, social anxiety, eating disorders and
drug abuse.108 Due to the fact that burn survivors are perma­
nently scarred by their injuries, it is commonly hypothesized
that burn survivors are at high risk of developing a negative
body image.109–112
Like disability, body image is a consequence of the interac­
tion between a person and his/her social environment.108,113
In order to understand the challenge of adapting one’s body
image to having burn scars, it is necessary to be familiar with
the appearance norms of the burn survivor’s culture. These
sociocultural norms establish criteria for the importance of
appearance, how one should appear, and the room for devia­
tion from the norms.108,111,113,114
In the USA and in most industrialized nations, there is a
cultural obsession with physical appearance, especially for
women, which is driven by the cosmetic industry and the
commoditization of appearance.108 Consequently, there is
great deal of social pressure to be beautiful and what
constitutes ‘beauty’ is narrowly defined as: a thin body
shape, angular facial features, tall, young, and unblemished,
smooth, light-colored skin. Appearance norms are commu­
nicated to the individual both through the mass media and
interpersonal behavior. Via the mass media (e.g. magazines,
television, and the internet) people are exposed to hun­
dreds of images daily of ‘beautiful people’ technologically
enhanced through processes such as airbrushing, soft-focus
camera shots, and manipulated digital images. The message,
implicit or explicit, of cosmetic product advertisements is
that you are an inadequate person unless you are very
attractive, and this product will enhance your appearance.
There is also interpersonal pressure to conform to appear­
ance norms. One review of the literature on appearance
concluded that people tend to both make positive assump­
tions about ‘good looking’ people and treat them more
favorably than less attractive people.115 On the other hand,
people that deviate from the beauty standard are more
likely to experience stigmatization and discrimination
behavior.116 For example, children are most frequently
developmental stages and physical growth in addition to the
multitude of factors that impact rate of recovery.82
Manifestations of psychosocial distress
Among the most common manifestations of psychosocial
distress are: sleep disturbance,83,84 depression,85,86 body
image dissatisfaction,87 acute and posttraumatic distress,84,88
as well as more heterogeneous symptoms.89 The mean level
of psychological distress among those with major burn inju­
ries is reported to be significantly higher than that of a
normative sample.90 Evidence indicates that psychological
distress in the hospital can have an enduring impact on
health and function.88,90,91 In one study, psychological dis­
tress while in the hospital was found to be associated with
significantly greater impairment of physical and psychologi­
cal function and slower rates of recovery over the course of
the first year following a major burn injury, even when pre-
burn physical and psychological health and function were
statistically controlled.91 In a second longitudinal study fol­
lowing burn survivors over the first year of recovery, psycho­
logical distress was highly correlated with poor quality of life
throughout the study.89 Previous research has used question­
naires and standardized measures to evaluate long-term
distress of burn survivors. Recently, Wiechman Askay et al.
(2009) used ‘QMethodology’, a qualitative approach, to
identify the primary reasons of distress experienced by adults
post-burn. Participants were asked to rank order a list of 50
possible causes of distress. Four main categories emerged:
physical difficulties; physical concerns and family’s adjust­
ment; body image, social issues and concerns about the
future; and a combination of physical and psychosocial
difficulties.92 Future studies should focus on qualitative
methodology to identify patterns of distress among burn
survivors.
Acute and post-trauma distress
Acute stress disorder (ASD) and posttraumatic stress disorder
(PTSD) following exposure to trauma are common. ASD
and PTSD are characterized by three symptom clusters:
re-experiencing, avoidance, and increased arousal symp­
toms.93 In various studies, the prevalence rate of ASD among
adult burn survivors has varied between 10% and 23%,88,94,95
whereas the rate among pediatric survivors has been between
8% and 31%.35,96,97 It is estimated that between 15% and
45% of adult burn survivors meet the criteria for PTSD in
the first year post-burn,95–97 and almost 50% meet the criteria
for at least one of the PTSD symptom clusters.87,98 The current
and lifetime incidence of PTSD in pediatric burn survivors
are 7% and 30%, respectively,99 whereas Meyer et al. (2007)
found these rates in young adults who sustained childhood
burns to be 9% and 21%, respectively.78
Post-trauma distress has been found to be associated with
greater lengths of acute hospitalization,98 enhanced sense of
distress, and impaired adjustment to injury.100 In the popula­
tion of patients surviving severe burns, certain aspects of
pre-trauma adjustment (e.g. history of mood disorder) and
coping style101 can influence the risk of developing PTSD
following trauma exposure.30 Individual factors (e.g. avoid­
ance of reminders) and aspects of the injury (e.g. injury

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to body image dissatisfaction because burn survivors with
visible scars will experience more frequent stigmatizing reac­
tions from others. The ‘hidden scar’ hypothesis posits that
because the person has fewer opportunities to learn how to
deal with the reactions of others, he or she will live in fear
of the scar being revealed and thus have a negative body
image. There is little empirical evidence for either hypothe­
sis. In the studies that have been completed, the correlation
between facial scarring and body image has ranged from
0.00 to 0.20.124 Gender has also been investigated as a pos­
sible risk factor. In comparison to men, women burn survi­
vors tend to have lower body image; however, the gender
difference in burn survivors has not been as great or as
consistent across studies as it is in the general population.
Across studies, the strongest correlates of body image among
burn survivors have been social and emotional variables
such as social support, perceived social stigmatization,
importance of appearance, and depression (r ranging from
0.30 to 0.60).87,123–125,127
In regards to stigmatization of burn survivors, the few
studies that have been completed have focused on pediatric
burn survivors. Among pediatric burn survivors, there is
some evidence that appearance-related stigmatization is a
common concern. In a survey of 250 pediatric burn survi­
vors, 60% of participants reported being bullied within the
last 6 months. A total of 25% of the sample indicated that
bullying was a ‘big problem’.128 However, to date, there is not
enough evidence to conclude that burn survivors experience
stigmatizing interpersonal behavior more frequently than
the general population. First of all, appearance-related
teasing appears to be very common in the general popula­
tion. In a survey of adolescents in Britain, 52% of the sample
had experienced distress related to appearance-related
teasing and 10% reported at least one incidence of avoiding
going to school fearing appearance-related teasing.112 No
studies compare burn survivors’ experience of stigmatizing
behaviors to that of a comparison group. Two studies com­
paring the frequency with which children with craniofacial
differences experienced teasing and other victimization
behavior to a comparison group found no differences
between groups.129,130
To date, there is no empirical evidence that burn survivors
as a group experience higher levels of negative body image
or more stigmatizing behavior than non-burn comparison
groups. However, relatively few studies have been completed
and these findings need to be replicated before they are
accepted as fact. Over the last decade, a number of new
questionnaires have been validated to measure body image,
perceived stigmatization, and social comfort among people
with visible differences.126,131–133 Hopefully, these instru­
ments will facilitate future body image research among burn
survivors. Clinical experience suggests that approximately
20–30% of burn survivors struggle with body image and
social integration issues. For these burn survivors, the emo­
tional pain that results from body image dissatisfaction and
the social discomfort can be very intense.
Distress of families of burn survivors
Long-term impact on families of burn survivors has not been
well studied, but clinical experience and scanty empirical
data indicate the sequelae to be significant. Family members
teased about their appearance in comparison to all other
aspects of their person or behavior.
Social stigmatization is a process in which people are
socially rejected and ostracized based on a negative stereo­
type.117 People with visible differences have long been stig­
matized in the mass media. In many movies and video
games, the villain is a person with a physical difference, often
burn scars. Thus, the scars of villains such as ‘Two-Face’ in
the Batman series are the physical mark of the dehumanized
‘other.’ Stigmatizing interpersonal behaviors experienced by
burn survivors include: an absence of friendliness and cour­
tesy, staring, pointing, startled and disgusted reactions,
ignoring, avoidance, confused behavior, teasing, bullying,
and discrimination.110,111,116,118 There is evidence that people
with visible differences are more likely than people without
visible differences to experience stigmatizing interpersonal
behavior. For example a number of studies have investigated
whether people’s behavior differed when they interacted
with an actor who had or did not have a made-up facial
disfigurement. When interacting with the actor with a mock
disfigurement, participants were less likely to offer assist­
ance, sit or stand close to the actor, and limit their interac­
tions with the actor.119–121
What are the psychosocial consequences for burn survivors
to live in a highly beauty conscious society? Few studies have
investigated the frequency of body image dissatisfaction and
perceived stigmatization and their correlates among burn
survivors. Studies that have compared the body image of
burn survivors to a non-burn comparison group have found
no normative differences.122,123 For example, in one study
comparing a group of long-term pediatric burn survivors
between the ages of 8 and 18 (M age  =  14.7) to an age-
matched non-burn comparison group on a body image
measure, there was no difference between the males in the
two groups. Among the females, on average the burn group
had higher body image scores than the comparison group.123
This surprising find needs to be interpreted with caution
given that it has not been replicated. Further research is
required to determine if burn survivors as group have
different rates of body image dissatisfaction than the general
population.
In regard to risk factors for negative body image, severity
of burn scarring has proven to have a modest relationship
with body image among both adult and child burn survi­
vors. Across studies, the correlation between burn severity
and body image has ranged from 0.00 to 0.40.87,123–125 One
study suggested that the relationship between perceived scar
severity and body image is moderated by importance of
appearance.126 For those burn survivors who placed little
value on physical appearance, self-rated scar severity had no
relationship with body image. For those burn survivors who
highly valued physical appearance, scar severity was highly
predictive of body image. All studies investigating the rela­
tionship between scar severity and body image have been
limited by the fact that there is no reliable standardized
measure of scar severity. Studies to date have used proxy
variables to measure scar severity such as total body surface
area (TBSA) burned or numbers of burn-related surgeries.
Within the literature there has been a theoretical debate
regarding the relationship between burn scar location and
body image. The ‘visible hypothesis’ poses that socially
visible scars, such as scars on the face, will be highly related

Psychosocial recovery and reintegration of patients with burn injuries
751
of significant extended problems with adjustment during
subsequent phases of recovery.143,144 In conclusion, the
quality of life research points to the importance of early
detection and treatment of psychosocial problems among
burn survivors.
Interventions for burn survivors
beyond acute care
Moving beyond general social support, psychologists and
psychiatrists specializing in burn recovery have been working
to develop theoretically-based empirically-testable interven­
tions that can be tailored to the individual needs of both
pediatric and adult patients. As stated above, the psychoso­
cial sequelae of a burn are quite varied. Survivors may experi­
ence PTSD, body image concerns, social anxiety, depression,
guilt, anger, grief, substance abuse, family conflict, homeless­
ness, joblessness, etc. In order to create effective individual
treatment plans, there need to be effective treatment proto­
cols for treating specific common problems. Within recent
years detailed psychotherapy treatment programs have been
described to treat PTSD,145 acute stress disorder,146 and social
skills training for coping with disfigurement.147,148 However,
much more research is needed to empirically demonstrate
the efficacy of these interventions among burn survivors and
other groups with physical differences.149
Cognitive therapy for the treatment of body image and
social integration concerns of people with visible differences
is an example of a tailored psychotherapy.147,148,150,151 Though
much has been learned about the risk and protective factors
for body image issues and social adjustment, there remain
few empirically validated treatments.152 The therapy is based
on a detailed conceptualization of how a survivor’s social
environment, thoughts, behaviors and emotions interact to
maintain the survivor’s distress. Given the sociocultural
premium placed on appearance, it is understandable that
some burn survivors adopt personal values that prioritize
physical appearance. Consequently, these individuals often
ruminate about the discrepancy between their appearance
and the ideal (or their lost appearance). Self-conscious about
their appearance, the burn survivor may act in ways that
confirm their belief that their appearance is socially unac­
ceptable. For example, they may minimize or avoid social
interactions with others. This social avoidance may be inter­
preted by others as curt or rejecting behavior by the burn
survivor. Thus, brief awkward social encounters turn into
self-confirming experiences which validate the survivor’s
belief that their burn scars make them a socially inadequate
person.
Based on this model, cognitive behavioral therapists have
developed several techniques for treating negative body
image and social anxiety related to a physical difference.
Likely, the most important is teaching a specific set of social
skills.147,148,153 As mentioned previously, these social skills
include having a short precise answer to explain ‘what hap­
pened,’ guiding the topic of conversation, using confident
body language and eye contact, and assertively confronting
confused and rude behavior. After mastering these skills
through in-therapy practice, the survivor is encouraged to
practice the skills by engaging in social activities. This
may continue to experience symptoms of posttraumatic
stress after a patient has returned home.50 Parents of survi­
vors of massive injuries appear extraordinarily stressed even
several years after their children’s recoveries.29,134 A series of
studies at the Shriners Hospital for Children in Galveston
found that parents of recovering pediatric burn patients
reported significant depressive symptoms at 2 years post-
injury, and they attributed their distress to their burned
children.29,135 Although parental distress appears to improve
with time for most, parents of the most troubled burned
children continued across time to be troubled themselves.135
Parents also express concern for their unburned children
whom some felt had been deprived of attention and time
while the burned sibling presented an extensive drain on the
family system. Even free medical and surgical care did not
eliminate the burden of direct and indirect costs of burn
injury, and many families experience financial difficulties
attendant to the injury and treatment of their child.29
Long-term outcome: quality of life
After survival is assured, quality of life is arguably the most
important outcome to individuals who are seriously ill or
injured. Health-related quality of life has been defined as a
multifactorial construct that involves an individual’s degree
of satisfaction and level of health and functioning in several
core domains including: physical-behavioral (e.g. ability to
perform self-care behaviors) and psychological wellbeing
(i.e. subjective sense of contentment and the absence of
emotional distress); social and role functioning (e.g. ability
to fulfill family, work, and community responsibilities), and
personal perception of health (i.e. satisfaction with one’s
health status).136
Quality of life has been investigated using general health
questionnaires or measures that focus on specific behaviors.
Recent research has begun to focus on the overall quality of
life.137–139 As with self-report behavioral scales, most long-
term (over 2 years) burn survivors appear to have eventually
developed satisfactory adjustment and are within normal
range on domain subscales of the SF-36, a widely used
measure which assesses general health quality of life.136,137,139
Rosenberg et al. (2006) examined quality of life of young
adults who sustained burns as children using the Quality of
Life Questionnaire by Evans et al.,140 which measures specific
behaviors. They found that young adults rated their overall
quality of life and general wellbeing lower than the normal
population. In a study with the same sample, Meyer et al.
examined sexual attitudes and behaviors of burn survivors
and found that overall they felt positive about their sexual
experiences.141
A number of studies suggest that early psychological dis­
tress predicts poor quality of life outcomes. Fauerbach et al.
(1997) found that pre-burn psychiatric disorder predicts
poorer psychosocial adjustment and health-related quality
of life after the burn.98 Body image dissatisfaction at time of
discharge is associated with prolonged periods of poorer
mental health-related quality of life among adult patients
following disfiguring injuries.142 The impact of body image
dissatisfaction on psychosocial quality of life is independent
of distress, injury, and pre-injury adjustment variables. Post-
trauma distress during the reintegration phase is predictive

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(and the helper) cannot expect much in the way of
improvement.
Given the limited access to effective psychotherapy, perhaps
a more effective strategy for improving psychosocial out­
comes for burn survivors are interventions that create more
accepting and tolerant social environments. Programs or
organizations with the mission of engendering social accept­
ance for burn survivors and other people with physical dif­
ferences include school re-entry programs, burn camps, the
‘Phoenix Society for Burn Survivors’ in the United States154,
and ‘Changing Faces’ based in the United Kingdom.155
School re-entry programs were previously discussed. Burn
camps provide an opportunity for pediatric burn survivors
to socialize with other burn survivors, participate in recrea­
tional activities in a supportive environment, and may
increase self esteem.156,157 There are different types of burn
camps and the goal depends on the purpose of the camp.
For example, some camps were designed to provide mental
health and rehabilitation services to children once they have
left the hospital; whereas, other camps are for recreational
purposes only.158
The Phoenix Society for Burn Survivors is ‘a nonprofit
organization dedicated to empowering anyone affected by a
burn injury.’ In conjunction with regional burn centers, the
Phoenix Society coordinates over 30 burn support groups.
Figure 66.3  Color collage. Survivors of severe burn injuries can return to active, interesting, and productive lives in spite of scars and amputations. Recovery
is a long and difficult process, challenging the physical and psychological resilience of the individual. Burn care professionals must provide guidance and
support to survivors and to their families during the years of recovery. (Reprinted from: Herndon DN, ed. Total burn care. London: WB Saunders; 2002.)
A
B
practice helps break the social avoidance-depression cycle
which maintains the burn survivor’s negative body image.
Though promising psychosocial interventions are being
developed, many burn survivors lack access to mental health
care in general and access to mental health providers with
expertise in treating burn survivors in particular. Most burn
survivors who suffer psychological symptoms of distress
following discharge from a burn center and who desire
treatment must rely on mental health professionals in the
community. However, it may be difficult for them to find
helpful resources. Of the 101 young adults who had been
burned as children in the Meyer et al. (2007) study, none
were receiving professional help for their difficulties.78 Such
treatment is expensive and often not affordable by an indi­
vidual without insurance or other financial assistance. In the
USA, there is no universal healthcare. Many burn survivors
do not have health insurance because they cannot afford the
premiums. In addition, burn survivors do not always qualify
for financial assistance because their ‘disabilities’ are declared
insufficient to require such aid. Even when they can afford
such treatment, they may be unable to find a mental health
professional to work with them. Mental health professionals
who are naïve regarding burn survivors’ needs sometimes
believe that it is inevitable that scarred survivors will feel
depressed and/or anxious; thus, they act as if the survivor

Psychosocial recovery and reintegration of patients with burn injuries
753
(especially pediatric survivors who change constantly) to ask
about such common symptoms and to provide an opportu­
nity for intervention.
That most burn survivors do amazingly well should never
be interpreted as indicative of ease in adaptation. We would
never want to diminish the pain and suffering they endure
from physical and psychological wounds. As psychothera­
pists to a large number of burn survivors, we know very well
the struggles of survivors. They have moments of true despair
and hopelessness, moments of rage, and moments of joy.
Probably at some level, burn survivors always feel some
sadness about their scars; eventually they attend to other
things most of the time and do not obsess over their scars.
Fortunate psychotherapists can know them through all
extremes, looking for glimmers of hope, validating anger,
celebrating victories, and gaining deep respect for the resil­
ience of human beings (Fig. 66.3).
Further reading
Blakeney P, Thomas C, Holzer C 3rd, et al. Efficacy of a short-term,
intensive social skills training program for burned adolescents.
J Burn Care Rehabil. 2005;26(6):546-555.
Fauerbach JA, McKibben J, Bienvenu OJ, et al. Psychological distress
following major burn injury. Psychosom Med. 2007;69:473-482.
Lawrence JW, Fauerbach JA, Heinberg L, et al. The reliability and
validity of the Perceived Stigmatization Questionnaire (PSQ) and
the Social Comfort Questionnaire (SCQ) among an adult burn
survivor sample. Psychol Assess. 2006;18:106-111.
McKibben J, Bresnick MG, Askay Wiechman SA, et al. Acute stress
disorder and posttraumatic stress disorder: A prospective study of
prevalence, course and predictors in a sample with major burn
injuries. J Burn Care Research. 2008;29(1):22-35.
Rosenberg M, Blakeney P, Robert R, et al. Quality of life of young
adults who survived pediatric burns. J Burn Care Rehabilitation.
2006;27:773-778.
Thompson A, Kent G. Adjusting to disfigurement: process involved in
dealing with being visibly different. Clin Psychol Rev. 2001;21(5):
663-682.
‘In addition, they host the annual World Burn Congress, a
conference that brings together burn survivors, their families,
firefighters, and burn care professionals to address the
aftercare and reintegration issues of burn survivors.’154
Recently, the Phoenix Society for Burn Survivors and the
American Burn Association have formed a joint committee,
The Aftercare and Reintegration Committee, devoted to
improving psychological health and social reintegration fol­
lowing burns.
Changing Faces is a charity based in the UK dedicated to
creating ‘a culture of inclusion for people with disfigure­
ment.’155 In addition to providing counseling and supporting
research, they organize sustained political campaigns in
support of the civil and human rights of people with visible
differences. For example they have organized the ongoing
‘face equality’ campaign with the goal of challenging ‘media,
advertisers, and the film industry [to] adopt more factual and
unbiased portrayals of people with disfigurements, actively
avoiding language and imagery that creates prejudice.’ In
addition, the campaign has asked politicians and policy-
makers to ‘ensure that facial prejudice and discrimination
are effectively outlawed by improving anti-discrimination
law and promoting best practice.’155
Summary
Most burn survivors do eventually adapt well and resume
lives of productive activity with satisfactory self-esteem and
social interactions. Empirical data indicate that the first year
or so post-burn is fraught with discomfort and distress, but
much of the difficulty is transient. The process of psychologi­
cal adaptation often continues for several years. Symptoms
of disturbance that linger among burn survivors are likely to
be such that only intimate friends and family members will
observe them (e.g. nightmares, flashbacks, body image dis­
satisfaction, social anxiety), so it is valuable for persons with
expertise in burn adaptation to periodically assess survivors
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Page numbers followed by ‘f’ indicate figures,
‘t’ indicate tables, and ‘b’ indicate boxes.
Notes
To save space in the index, the following
abbreviations have been used:, SIRS
– systemic inflammatory response
syndrome
A
AAG (α-acid glycoprotein), 185
AAPCC (American Association of Poison
Control Centers), 455
AATB see American Association of Tissue
Banks (AATB)
ABA (American Burn Association), 138
Abbreviated burn security index (ABSI), 708
ABCDE (Airway, Breathing, Circulation,
Disability, Environment), 65–66
Abdomen
electrical burns, 437, 445–446
sepsis, 146–147
Abdominal compartment syndrome, 395, 421
acute renal failure, 371
edema, 112
Abdominal flap coverage, hand burn
management, 169, 169f–170f
ABI (ankle–brachial index), 423
ABLS, mass casualty events, 69
ABLS 2010 Fluid Resuscitation Formula, 95
ABSI (abbreviated burn security index), 708
Abuse see Intentional injuries
Acalculous cholecystitis, 426–427
multisystem organ failure prevention,
365
ACCP (American College of Chest
Physicians), 138
Acculturation, 744–745
Acetaminophen, 725
Acetic acid, 456
Acetylserine–heparin combination, bronchial
hygiene therapy, 242
Acid–base abnormalities, blood transfusion
complications, 196
Acid burns, 455–460
evaluation, 129
intentional injuries, 695
Acidosis, electrical burns, 130
Acinetobacter, multidrug resistance, 141–142
ACLS (advanced cardiac life support), 379
Acrolein, 225t
Acrylonitriles, 225t
ACTH see Adrenocorticotrophic hormone
(ACTH)
Acticoat AB, 155, 720
Activated partial thromboplastin time (APTT),
disseminated intravascular
coagulation, 283
Active-assisted range of motion exercise, 537
Active range of motion, 537
Index
Active withdrawal of treatment, 687
Actual capacity, 58
Acute Dialysis Quality Initiative (ADQI), 389
acute renal failure, 369
Acute Kidney Injury Network (AKIN), 389
acute renal failure, 369, 370t
Acute lung injury (ALI), 391
Acute phase proteins, 308–309
pharmacodynamics/pharmacokinetics,
148–149
Acute phase response
hypophosphatemia, 327
liver, 303, 308–309
Acute Physiology and Chronic Health
Evaluation (APACHE), SIRS, 249
Acute radiation syndrome, 464
Acute rehabilitation phase
infection control, 148
scar therapeutic exercise, 537–538
Acute renal failure (ARF), 182, 369–376,
370f, 388–391
abdominal compartment syndrome, 371
acute tubular necrosis, 388
cardiac dysfunction, 370f, 371
definition, 369
denatured proteins, 371
diagnosis, 372–374
creatinine, 373, 373t
urinary electrolytes, 372–373, 373t
urinary output, 372
differential diagnosis, 373, 373t
disseminated intravascular coagulation,
371–372
etiology, 369–372
hypovolemia, 370–371
incidence, 371–372, 372f, 372t
intra-abdominal hypertension, 371
pathophysiology, 388–391
sepsis, 371–372
treatment, 374–376
continuous hemofiltration, 376
continuous renal replacement therapy,
375
continuous venovenous hemofiltration,
390
dopamine, 389
electrolyte homeostasis, 389
fenoldopam, 389
fluid replacement therapy, 374, 374t,
389
intermittent hemodialysis, 375, 390
loop diuretics, 389
mannitol, 389
peritoneal dialysis, 390–391
renal replacement therapy, 374–376
sustained low-efficiency dialysis, 375
Acute respiratory distress syndrome (ARDS)
acute renal failure, 369
etiology, 391
inhalation injury, 231
Acute stress disorder (ASD), 735–736, 749
treatment, 738–739
Acute tubular necrosis (ATN), 388
Adaptic®, 88
Adaptive immune response, 272
ADHD (attention deficit hyperactivity
disorder), 734
Adjective pain assessment scales, 716, 716t
ADMA (asymmetric dimethylarginine),
224–225
Admission crisis, psychosocial recovery,
745–746
ADQI see Acute Dialysis Quality Initiative
(ADQI)
Adrenaline see Epinephrine
Adrenal response, 289–300
cortical steroids, 296–300
metabolic pathways, 297–298
α-Adrenergic receptor agonists, 725
α2 Adrenergic receptor agonists, 722
β-Adrenergic receptor(s), 293
β-Adrenergic receptor blockers
cardiovascular system, 394
geriatric patients, 418
hypermetabolic response, 292
see also specific drugs
Adrenocorticotrophic hormone (ACTH), 289
hypothalamopituitary–adrenal axis, 297
Adults
mortality, 157
pain assessment, 716–717
therapeutic exercise, 566–567
Advanced cardiac life support (ACLS), 379
Advanced trauma life support (ATLS), 421
mass casualty events, 69
Aerobic exercise capacity, 540
Aeromedical transport, 32, 99–100
military personnel, 25
Aerosolized acetylcysteine, 242
Aesthetic units, head and neck reconstruction,
602
Afghanistan, 35
AFO (ankle-foot orthotics), 517–518, 526f
Africa, 20
Aftercare
breast reconstruction, 625
tissue expansion, 588
Afterload, 393
Age groups
burn size vs., 44, 44f
epidemiology (of burns), 15, 16t, 39, 39f,
48
outpatients, 81–82
see also Adults; Elderly; Pediatric patients
Agitation
in-hospital adult disorders, 735
treatment, 738
Air-cell mattress, 519
Airplane splint device, 634, 634f
shoulder (axillary) contracture, 634f, 635

Index
756
Airway(s)
anesthesia, 175–178
patency, chemical burns, 456
prone positioning, 518
Airway, Breathing, Circulation, Disability,
Environment (ABCDE), 65–66
Airway epithelium, inhalation injury,
488–489
Airway hyperemia, 221, 221f
Airway management, 186–194
chest and neck burns, 398
endotracheal tubes, 187–188, 187f
esophageal tracheal Combitube, 188
fiberoptic intubation, 187
laryngeal mask airway, 188
mass casualty events, 72
pediatric patients, 410
postoperative care, 197–198
standard techniques, 186–187
ultrathin bronchoscopes, 187
Airway pressure-release ventilation (APRV),
244–245, 384–385
inhalation injury treatment, 235
Airway suctioning, 241
AKIN see Acute Kidney Injury Network
(AKIN)
Alanine aminotransferase (ALT), 304–305,
305f
Albumin, liver, 303–304
Albumin solutions, 119
Albuterol, 242
Alcanar, Spain (11 July 1978), 61
Alcohol(s), ventilator sterilization/
disinfection, 247–248
Alcohol abuse, 738
Alcohol burns, 26
Aldehydes, 227
ventilator sterilization/disinfection, 247
Alexander, J Wesley, 3f
skin grafting, 3
Alginate sheets, 164
ALI (acute lung injury), 391
Alkalemia, hypophosphatemia, 326
Alkali burns, 455–456, 458
evaluation, 129
Alkaline phosphatase (ALKP), 304–305, 305f
ALKP (alkaline phosphatase), 304–305, 305f
Alkyl mercuric compounds, 459
AlloDerm®, 162, 202, 212–213, 213f,
573–574
Allogenic amnion, 89
Allogenic epithelial sheets, 211
Allografts (homografts), 164, 200–202,
209–210, 210f
advantages, 200b
autograft tests, 202
disadvantages, 202–203
donor screening, 204–205, 204b
exfoliative disorders, 474, 475f
fresh vs. preserved, 200–201, 200b
full-thickness wounds, 200–201
hand care/reconstruction, 646–647
indications, 200b
keratinocyte template, 202
meshed skin autografts, 201–202, 201f
micrografting, 202
partial-thickness wounds, 202
pediatric patients, 412
products, 207–208
scald burns, 413
synthetic membrane combination, 211
use statistics, 200f
Allopurinol, 109–110
Aloe vera, 719–720
frostbite, 451
Alopecia correction, 607, 617–622
classification, 618–619, 619f–621f, 619t
primary closure, 618, 619t
principles, 619–620
supragaleal approach, 619–620
tissue expansion, 588–589, 589f,
620–621
α-Acid glycoprotein (AAG), 185
Alpha particles, 461
α-SMA, hypertrophic scars vs. keloids,
498–500
ALT see Anterior lateral thigh (ALT) perforator
flap
ALT (alanine aminotransferase), 304–305,
305f
Alternating current, electrical burns,
433–434
Alternative complement pathway, 269–270,
269f
Alternative wound coverings, 209–218, 216t
biological actions, 217
large amounts of tissue, 215
large wounds, 216–217
wound bed preparation, 216, 216f
see also specific types
Altitude, oxygenation problems, 100
Aluminum, 323
AmBd see Amphotericin B dexolate (AmBd)
Ambient humidity, pediatric patients, 411
Ambient temperature, pediatric patients, 411
Ambulation
intermittent phase, 539
scar therapeutic exercise, 537–538
tilt tables, 538, 538f
wound dressings, 538
American Association of Poison Control
Centers (AAPCC), 455
American Association of Tissue Banks (AATB)
infection control, 202
skin banks, 203
American Burn Association (ABA), 138
American College of Chest Physicians
(ACCP), 138
Amino acids, branched-chain, 341
Aminoglycosides, 151
Ammonia, 225t, 227–228
Amniotic membranes, wound closure, 164
Amphotericin B dexolate (AmBd), 152
colloidal dispersion, 152
lipid complex, 152
liposomal (Amb-L), 152
Amphotericin-resistance, Fusarium, 142
Amputations, 528, 563
electrical burns, 446–447, 563
pediatric patients, 563
phantom pain, 530
phantom sensation, 530
prostheses, 563
see also Prostheses
Amyl nitrate inhalation, cyanide poisoning
treatment, 178, 233
Anabolic agents
catabolic response management, 567
hypermetabolic response management,
358
Anal burns, 662
Analgesia see Pain management
Anal stricture reconstruction, 667, 668f
Ancient Egypt, 1
Anemia, 278–280
clinical implications, 279–280
diagnosis, 278–279
erythropoiesis, 279
etiology, 278–280
treatment, 279–280
Anerobic bacteria, 152
Anesthesia, 173–198
airway management see Airway
management
blood transfusions, 175t, 192–194
face and neck injury, 175
fluid management, 192–193
induction agents, 191–192
mass casualty events, 70–75
monitoring, 188–189
patient transport, 191
pharmacology, 184–186
muscle relaxants, 185–186
preoperative evaluation, 174t, 195
airway function, 175–178
circulation assessment, 178–179
initial evaluation, 174–175, 175t
metabolic changes, 182–183
pulmonary function, 175–178
renal function, 182
respiratory support, 177
thermoregulation, 183–184,
183f–184f
selection of, 191–192
vascular access, 189–191
arterial catheters, 189
catheter-related infections, 189–190
central venous catheters, 189
dorsalis pedis artery, 189
femoral artery catheters, 189
femoral vein, 190
pediatrics, 189
posterior tibial artery, 189
subclavian vein catheters, 190
temporal artery, 189
thrombotic complications, 190
vascular insufficiency, 189
volatile, 192
see also Sedation
Anesthesia machines, mass casualty events, 74
Anesthesiologists, multidisciplinary teams, 11,
173
Angiotensin II, 290–291
shock, 109t, 110
Animal studies
electrical burns, 433
shock, 103
Ankle, 675, 676f–677f
anterior contractures, 671–672
contracture, skin flaps, 584, 588f
dorsiflexion contractures, 672
patient positioning, 525–526
talipes equines-like deformity, 675
talipes vera and vagus-like deformity, 675

Index
757
Ankle–brachial index (ABI), 423
Ankle equinus, 525
Ankle-foot orthotics (AFO), 517–518, 526f
Anterior contractures, ankle, 671–672
Anterior lateral thigh (ALT) perforator flap
contractures, 639
knee flexion deformities, 677, 681f
Anti-anxiety drugs, 721–722
Antibacterial agents, outpatients, 87–88
Antibiotics
immunodepression, 266
infection, 485
multisystem organ failure prevention,
364–365
Anticoagulants, inhalation injury treatment,
234
Antidiabetic drugs, 359
Antidiuretic hormone see Vasopressin
Anti-endotoxin antibodies, 367
Antigen presentation, 272
Antihistamines, itching, 726
Antimicrobial compounds, topical,
153–155
Antioxidants, 109
electrical burn compartment syndrome,
443–444
multiple organ dysfunction syndrome,
387
Antipyretic agents, 476–477
Antithrombin III (ATIII), 259, 282
Anti-tumor necrosis factor antibodies
multisystem organ failure therapy, 367
SIRS therapy, 257
Anxiety, 737
assessment, 718, 718f
in-hospital psychiatric disorders, 736
pediatric patients, 738, 740
treatment, 739–740, 746
Anxiolytic medication, 720t
AP-1, SIRS, 254, 255f
APACHE (Acute Physiology and Chronic
Health Evaluation), SIRS, 249
Apoptosis, liver trauma, 305f–306f, 306
Appendicitis, 146–147
APRV see Airway pressure-release ventilation
(APRV)
APTT (activated partial thromboplastin time),
disseminated intravascular
coagulation, 283
Aquacel-Ag, 211
Arachidonic acid, multisystem organ failure,
363, 363f
Arachidonic acid metabolites, vascular
permeability, 261
Arcing, electrical burns, 441
ARDS see Acute respiratory distress syndrome
(ARDS)
ARF see Acute renal failure (ARF)
Argentina, 39t
Arginine
depletion, lung parenchyma injury,
223–224
multisystem organ failure therapy,
366–367
nutritional support, 341
Arginine vasopressin (AVP), 290–291
Armed conflict, 78
Arson, 19
Arterial blood gases
inhalation injury diagnosis, 230
pediatric patients, 405–406
Arterial blood pressure, 379
systolic, 379–380
Arterial blood sampling, anesthesia
monitoring, 188
Arterial catheters
anesthesia monitoring, 188
anesthesia vascular access, 189
complications, 380
intensive care units, 379–381
Arterial CO2 tension, 385–386
Arterial injuries, upper limb electrical burns,
656–657
Arthroscopic debridement, 563
Artz, C, 4–5
Ascorbic acid see Vitamin C (ascorbic acid)
ASD see Acute stress disorder (ASD)
Asia, 38t
Aspartate aminotransferase (AST), 304–305,
305f
Aspergillus, 142, 152
Asphalt burns see Tar burns
Aspirin, frostbite, 451
Assault, 31
Assessment
burn depth see Burn depth assessment
Emergency Departments, 94
extensive exercise in pediatric patients, 402
on-site see On-site assessment
pain see Pain assessment
primary see Primary assessment
psychosocial recovery, 745
radiation injuries, 465
reconstructive care, 403
secondary, 94
skin, nursing, 399
tissue damage, electrical burn
reconstruction, 442, 442t
transport/transfer, 101–102
work-hardening programs, 402
Assist-control mechanical ventilation, 243,
381–382
AST (aspartate aminotransferase), 304–305,
305f
Asymmetric dimethylarginine (ADMA),
224–225
Asymmetry, breast reconstruction, 629
Atelectasis, 231
ATLS see Advanced trauma life support (ATLS)
ATN (acute tubular necrosis), 388
Attempted suicide, 31
see also Self-immolation
Attention deficit hyperactivity disorder
(ADHD), 734
Australia, 23
Autografts, 209, 210b
historical aspects, 199
wound closure, 161, 162f
wound healing, 511
Autograft tests, 202
Autologous fat transfer, breast mound
reconstruction, 626–628
Automobile burns, 26–27
Autonomy, psychosocial recovery, 747
Autopsy, 493
AVP (arginine vasopressin), 290–291
Awareness, mass casualty events, 78–79
Axial skin flap, 575, 575f, 583f
Axilla, patient positioning, 521–522
Axilla contracture, skin flaps, 584, 587f
Azerbaijan, 36t–37t
Azole drugs, 152–153
Azotemia, 348t–349t, 349
B
Baciquent®, 88
Bacitracin/polymyxin (Polysporin), 154, 164
Bacterial enzymes, enzymatic wound
debridement, 132
Bacterial infections
adrenergic stimulation, 294
see also specific bacteria
Bacteroides, 152
BAL (bronchoalveolar lavage), 145–146
Barbiturates, geriatric patients, 417t
Base deficit, 380
fluid resuscitation monitoring, 180
Bashkir, Autonomous Soviet Socialist
Republic (4 June 1989), 63
Basic capacity, 58
BAT see Burn Assessment Team (BAT)
Baxter, Charles R, 5f
fluid resuscitation, 5–6
B cell(s), 273
function impairment, 281
glucocorticoid effects, 299
Behavioral regression, psychosocial recovery,
747
Behavior pediatric pain assessment scales,
717
Benzodiazepines
delirium treatment, 738
geriatric patients, 417t
outpatient treatment, 85
Bereavement grief, 743–744
Bessey, P Q, 7
Beta blockers see β-Adrenergic receptor
blockers
Beta particles, 461
Be Your Best (Quayle), 747–748
BIA (bioimpedance analysis), 347
BICS (burn-induced compartment syndrome),
131
Biglycans, 496–497
Bilaminar dermal substitutes, 217, 217f
Bile secretion, 302
Biliary system, 302, 306
Bilirubin, 302
Biobrane®, 89, 211
exfoliative disorders, 474
Bioimpedance analysis (BIA), 347
Biologic wound dressing, outpatients, 88–89
Biophysics of burns, 509–511
Bisphosphonates, 318
Bladder catheters, pediatric patients, 406
Blindness, exfoliative disorders, 473–474,
474f
Blisters, outpatients, 85–86
Blocker, Truman G Jr., 1, 2f
nutritional support, 4–5
Blocker, Virginia, 1
Blood centers, mass casualty events, 75–76
Blood gases, arterial see Arterial blood gases

Index
758
Blood groups, 197t
Blood lactate, fluid resuscitation monitoring,
180
Blood loss
anemia, 279
anesthesia evaluation, 175, 175t
control see below
pediatric patients, 410
Blood loss control, 194
anemia treatment, 279–280
epinephrine, 194, 279–280
excision of burns, 160–161, 160f–161f
thrombin soaked pads, 279–280
tourniquets, 279–280
Blood pressure measurement
anesthesia monitoring, 188
arterial, 379
pediatric patients, 406
primary assessment, 94
Blood sampling, arterial, 188
Bloodstream infection (BSI), 146
Blood supply
liver, 302
tracheobronchial injury, 221–222, 222f,
222t
wound healing, 511
Blood temperature maintenance, 400
hypermetabolic response management,
357
Blood transfusions
anemia treatment, 280
anesthesia, 175t, 192–194
complications, 195–197
acid–base abnormalities, 196
citrate toxicity, 196
coagulopathy, 195–196
hypothermia, 196
infection, 197
oxygen transport alterations, 196
potassium abnormalities, 196
pulmonary complications, 196
transfusion reactions, 196–197, 197t
components, 194–195
see also specific components
hypocalcemia, 193–194
hypothermia, 193–194
infection, 266
mass casualty events, 75–76
radiation injuries, 466
whole see Whole blood transfusions
Blood vessels, tissue expansion, 618
Body composition measurement, 541
Body image problems, 749–750
risk factors, 750
Body temperature maintenance, 67
mass casualty events, 72
Body weight, nutritional support monitoring,
346
Bone catabolism, 318–319
Bone density, 317–318, 317f–318f
Bone loss, 169–170
Bone marrow transplantation, 466
Bone metabolism, 313–320, 317f
glucocorticoids, 299, 317
inflammatory response, 316
interleukin-1β, 317
interleukin-6, 317
Boost™, 337t–340t
Bowel necrosis, enteral nutrition, 350
Bowel obstruction, 146–147
Bowel perforation, enteral nutrition, 350
Boyce, S T, 3–4
Bradykinin, shock, 108, 109t, 115–116
Branched-chain amino acids, 341
Breast burns, 172
Breast cancer treatment, radiation injuries,
464
Breast reconstruction, 623–630
acute care, 624–625
aftercare, 625
anatomy, 623
asymmetry, 629
chest wall burns, 623–624
debridement, 624
dermal regeneration templates, 626
epidemiology, 623–624
inframammary fold distortion, 626
lactation, 624
large breasts, 624–625
mound reconstruction, 626–628,
628f–629f
nipple-areola complex, 627f, 628–629
partial thickness burns, 624
pregnancy, 624
prepubescent girls, 623
principles, 625–629, 626b
scar release, 625–626
scar resurfacing, 625–626
sequelae classification, 625, 625t
skin grafts, 624
Bromelain extracts, 133–135
Bronchi
direct injury, 486–487
inhalation injury, 231
Bronchial blood flow, inhalation injury, 231
Bronchial drainage/positioning, chest
physiotherapy, 240, 240f
Bronchial hygiene therapy, 239–242
airway suctioning, 241
chest physiotherapy, 240
early ambulation, 240, 241f
education, 242
pharmacology, 241–242
therapeutic bronchoscopy, 241
therapeutic coughing, 239
Bronchoalveolar lavage (BAL), 145–146
Bronchodilators, 241–242
Bronchoscopy
fiberoptic, inhalation injury, 177, 230,
231f, 234–235
inhalation injury, 397–398
therapeutic, 241
ultrathin, 187
Bronchospasm, inhalation injury, 236
Browder, N C, 5–6
BSI (bloodstream infection), 146
BSPAS (burn specific pain anxiety scale), 718
BST see Burn Speciality Team (BST)
Buddy aid, 78
Buenos Aires, Argentina (30 December 2004),
61
Building inspectors, 48–49
Bupivacaine, 720
Burke, John, 3f
early excision, 2–3
skin grafting, 3–4
Burn Assessment Team (BAT), 59
mass casualty events, 76
Burn capacity, 58
Burn centers, 9–14
admission priority, 713b
burn bed availability, 65f, 77–78
day-care programs, 713–714
disasters, 57
human resources, 713
index of occupation, 713
mass casualty events, 76
patients, 713b
primary transfer, 76
referral rate, 20, 20t
triage, 77
Burn depth
anesthesia evaluation, 175
Emergency Department assessment, 95
hand care/reconstruction, 645, 646f
outpatients, 82
reconstructive surgery, 571, 572f
Burn depth assessment, 126–127
clinical observation, 126–127
Burn distribution, outpatients, 83–84, 84f
Burn extent
age group vs., 44, 44f
Emergency Department assessment, 95
epidemiology, 39–40, 39f
heterotropic bone, 556
hypermetabolic response vs., 355, 411
infection vs., 265
mortality rates vs., 18–19
mortality vs., 39–40, 40f–41f
outcome analysis, 35
outpatients, 82
patient positioning, 517–518
prevention of burns, 47–48
reconstructive surgery, 571, 572f
Burn-induced compartment syndrome (BICS),
131
Burn location, heterotropic bone, 556
Burn Speciality Team (BST), 59
mass casualty events, 76
Burn specific pain anxiety scale (BSPAS), 718
Burn wound colonization, 139, 140f
Burn wound erythema, 138
Burn wound impetigo, 138–139, 139f
C
C3 complement protein, 269–270
exfoliative disorders, 472
C5a complement protein, 269–270
C5 complement protein, 269–270
C19 steroids, 297
Calcilytics, 319
Calciphylaxis, 480–481, 480b, 480f
Calcitonin gene-related peptide (CGRP), 231
Calcium
homeostasis, 313–315, 314f
see also Hypocalcemia
hypercalcemia, 316
metabolic actions, 313
Calcium EDTA, 456–457
Caloric needs, 182
Caloric requirement formulas, 334f, 335–336,
335t
Cancer, radiation injuries, 463

Index
759
Candida infections, 142, 142f
treatment, 152–153
urinary tract, 147
Candiduria, 147
Capacity utilization, 58
Capillary filtration coefficient (Kf), edema,
105, 105t
Capillary pressure (Pc), edema, 105
Capillary refill, pediatric patients, 408
Capnography, mass casualty events, 72
CaR (Ca-sensing receptor), 313–314
Carbohydrate metabolism
hypophosphatemia, 327
liver, 303
Carbohydrates, nutritional support, 336
Carbolic acid (phenol), 456
Carbon dioxide
overproduction, 349
production, 182
Carbon monoxide (CO), 225t, 226
hemoglobin binding, 226
see also Carboxyhemoglobin
Carbon monoxide poisoning, 177–178
CNS effects, 226
diagnosis, 226, 226t
mass casualty events, 72
pediatric patients, 410
prevention, 52
primary assessment, 422
symptoms, 226
treatment, 233
blood transfusions, 75
Carboxyhemoglobin, 177–178, 233
measurement of, 226, 226t
pediatric patients, 405–406, 410, 411t
Cardiac arrest
lightning strikes, 437
succinylcholine toxicity, 186
Cardiac contractility, 393
Cardiac dysfunction
acute renal failure, 370f, 371
hypophosphatemia, 328
Cardiac hypertrophy, 489–490
Cardiac monitoring, electrical burns, 443,
443t
Cardiac output (CO), 290–291
fluid resuscitation monitoring, 121
intensive care units, 380
pediatric patients, 409–410
reduction of, 110–111
Cardiopulmonary exercise test (CPET), 540
Cardiopulmonary reserve, geriatric patients,
416
Cardiovascular collapse, management,
466–467
Cardiovascular disease, geriatric patients,
418
Cardiovascular monitoring, intensive care
units, 379–381
Cardiovascular system, 393–394, 489–490,
490f
afterload, 393
β-adrenergic blockers, 394
cardiac contractility, 393
functional difficulties, 702
heart rate, 393
heart rhythm, 393
inotropes, 394
preload, 391f, 393–394
response to burns, 184
Care-provider, ethical problems, 684
Carrel, Alexis, 4
CARS see Counter anti-inflammatory response
syndrome (CARS)
Ca-sensing receptor (CaR), 313–314
Casts, fractures, 554–555
Catabolic response, 565–570
management, 566–567
anabolic agents, 567
therapeutic exercise see Therapeutic
exercise
Cataracts, electrical burns, 438, 447–448
Catecholamines, 290–296
effects, 290t
erythropoiesis effects, 279
hypophosphatemia, 325
infection, 292
proinflammatory cytokines, 293
shock, 108, 109t
Catheter-related bloodstream infection
(CR-BSI), 146
Catheters
arterial see Arterial catheters
central venous see Central venous catheters
femoral artery see Femoral artery catheters
related infections, 189–190
Causes (of burns), 26–32
alcohol burns, 26
assault, 30–31
attempted suicide, 31
automobile burns, 26–27
chemical burns, 28–29
child abuse, 31–32
clothing ignition, 27
elder abuse, 32
electrical burns, 29
fire walking, 27–28
fireworks, 30
friction burns, 28
hot tar burns, 28
lightning strikes, 29–30
motorcycle exhaust pipe burns, 27
outdoor recreational fires, 27
restaurant workers, 28
self-immolation, 31
self-inflicted, 30
ships/boating accidents, 27
tanning devices, 28
work-related burns, 28
see also specific causes
CBT see Cognitive behavioral therapy (CBT)
CC chemokines, 272t
CCN2 (connective tissue growth factor), 503
C-CSF see Granulocyte colony-stimulating
factor (G-CSF)
CD4+ T helper cells see T-helper cells (Th)
CD8+ T helper cells see Cytotoxic T-cells
C/EBPs, transcription factors, 287
Cell influx, wound healing, 509
Cellular telephones, 68
Cellulitis, 140, 140f
Cement burns, 458
evaluation, 129
Central nervous system (CNS), 492–493
carbon monoxide, 226
electrical burn complications, 447
Central venous access (CVA), 429
Central venous catheters
anesthesia monitoring, 188
anesthesia vascular access, 189
infection, 265–266
Central venous pressure (CVP), fluid
resuscitation monitoring, 121
Cephalosporins, 151–152
Cerebropathy, 111
Ceruloplasmin, 322
Cervical deformities, acute-phase
reconstruction, 605–606, 607f–608f
Cervical spine injuries, 422
CFA see Cultured epidermal autograft (CFA)
CGRP (calcitonin gene-related peptide),
231
Changing Faces (Partridge), 747–748
Changing Faces society, 753
Chaos and alarm phase, mass casualty events,
64
Charcot’s paralysis (keraunoparalysis), 437
Chemical burns, 28–29, 455–460
evaluation, 129–130
initial management, 93
management, 456
outpatients, 84
pathophysiology, 455–456
removal, 405
see also specific agents
Chemokines
innate immune response, 270–271, 270t
innate immunity, 272t
SIRS, 252–254, 254t
CHEOPS (Children’s Hospital of Eastern
Ontario Pain Scale), 717
Chest burns, airway management, 398
Chest physiotherapy, bronchial hygiene
therapy, 240
Chest radiography, 230
Chest wall, electrical burns, 437
Chickenpox (varicella zoster), 145, 471
Child abuse, 31–32
‘Child fire play’, 414
Child Protection Services, 696–697
Children see Pediatric patients
Children’s Hospital of Eastern Ontario Pain
Scale (CHEOPS), 717
China, 1
Chin reconstruction, 609
Chlorhexidine, 70
Chlorine, 227–228
Chlorpromazine, 739–740
Cholecystitis, acalculous see Acalculous
cholecystitis
Cholestasis, intrahepatic, 306
Cholesterol, liver, 303
Cholinergic anti-inflammatory pathway,
SIRS therapy, 258, 258f
Chondritis, 147, 147f
Chromic acid, 456–457
Chromium, 323
Chymotrypsin, enzymatic wound
debridement, 132
Cicatricial deformities, microvascular surgery,
593
Cigarette burns, 693–695
Circumferential hand burns, 523–524, 524f
Citrate toxicity, blood transfusions, 196

Index
760
Classical complement pathway, 269–270,
269f
Classical conditioning, pain management,
726–728
Claw deformity, 522, 522f–523f
Cleaning, inserts, 534
Clearance, pharmacodynamics, 185
Clinical interviews, intentional injuries, 697
Clinical observation, burn depth assessment,
126–127
Clinical studies, shock, 103
Clonidine, 722
Clostridium difficile infection, 146–147
gastrointestinal system, 490–491, 491f
necrotizing enterocolitis, 428
Clostridium histolyticum enzymes, 132
Clothing ignition, 27
Clothing removal, vesicants, 459–460
CLP (common lymphoid progenitors),
277–278
CMP (common myeloid progenitors),
277–278
CMV see Cytomegalovirus (CMV) infection
c-Myb transcription factor, 287
c-Myc transcription factor, 287
CNS see Central nervous system (CNS)
CO see Carbon monoxide (CO); Cardiac
output (CO)
Coagulation cascade
activation during inflammation, 258–260,
259f
disorders see Coagulopathy
multisystem organ failure, 362–363
Coagulation factors
liver, 304, 309–310
purpura fulminans, 479–480
Coagulopathy, 281–283, 484–485
blood transfusion complications,
195–196
see also specific diseases/disorders
Coban™ wraps, 533–534, 533f
Coding, triage, 64, 65t
Cognitive behavioral therapy (CBT)
post-discharge rehabilitation, 751–752
post-traumatic stress disorder treatment,
738–739
Cognitive regression, psychosocial recovery,
747
Cognitive therapy
pain management, 728–729
post-discharge rehabilitation, 751
Coleman, W, 4
Colistimethate sodium, 151
Collagen(s)
extracellular matrix, 495
isoforms, hypertrophic scars, 515
wound healing, 509, 510f
Collagenase, enzymatic wound debridement,
132
Collagen fibers, skin, 618
Collagen type III, hypertrophic scars, 512–513
Colloids, 119, 174
following shock resuscitation, 123
hypertonic saline with, 118
mass casualty events, 71
Combat lifesavers, 78
Combination drug therapy, geriatric patients,
417–418
Comfort care, 726
geriatric patients, 417–418
pediatric patients, 727b
Comfort measures, 687
Common lymphoid progenitors (CLP),
277–278
Common myeloid progenitors (CMP),
277–278
Communication, multidisciplinary teams, 12
Community preparation, reintegration, 748
Comorbidities, geriatric patients, 416
Compartment syndrome, electrical burns,
435–436, 436f, 443–444
Complement cascade
alternative pathway, 269–270
classic pathway, 269–270
diffuse alveolar damage, 488
innate immune response, 269–270
mannan-binding lectin pathway, 269–270
multisystem organ failure, 362–364
SIRS, 254, 256f
see also specific complement proteins
Complicated grief, 743–744
Complication management, 421–432
Composite skin flaps, toe plantar flexion
deformities, 675
Composite skin substitutes, 213
Computed tomographic angiography (CTA),
423
Computed tomography (CT)
injuries, 422–423
necrotizing fasciitis, 478
thoracic complications, 430
Computer-generated clear face masks,
598–599, 599f
Conduct disorder, 734
Conduction abnormalities, electrical burns,
443
Confinement period, heterotropic bone, 556
Conflicts, 24, 25t
Connective tissue growth factor (CTG), 497
Connective tissue growth factor (CTGF/
CCN2), 503
Consent, 683–684
Conservative debridement, electrical burns,
443
Consultants, intensive care units, 378
Contact burns, 129, 129f
epidemiology, 18
pediatric patients, 129
Contact points, electrical burns, 433, 434f
Continuous hemofiltration, acute renal failure
treatment, 376
Continuous passive motion (CPM) device,
537
Continuous renal replacement therapy
(CRRT), 375
Continuous venovenous hemodialysis
(CVVHD), 257
Continuous venovenous hemofiltration
(CVVH)
acute renal failure treatment, 390
SIRS therapy, 257
Contraction type, resistive training, 545
Contractures, 536–537, 631–644, 701
acute phase management, 632–633
anterior, ankle, 671–672
exercise, 633
head and neck reconstruction, 601–602
intermediate phase management, 634–635
lower limb reconstruction, 682
pathophysiology, 631, 632f
patient positioning, 632–635
pressure dressings, 634–635
splinting, 634–635
surgical management, 635–639
free flaps, 643f–644f
incisions, 638
interposition skin flaps, 638–639,
640f–641f
muscle flaps, 639, 643f–644f
patient evaluation, 635
primary closure, 638
skin grafts, 634–635, 639f
skin-muscle flaps, 639, 642f–643f
z-plasty, 638
wound coverage, 638–639
see also specific anatomical features
Control mechanical ventilation, 243,
381–382, 383f
Conventional telephones, 68
Cooking injuries, pediatric patients, 23
Cool-down stage, therapeutic exercise, 542
Cooling
hand care/reconstruction, 645
mass casualty events, 69
outpatients, 84–85
Cope, O, 5f
fluid resuscitation, 5–6
hypermetabolic response, 7
Copper, 322–323
deposition in electrical burns, 442
losses, 322
nutritional supplements, 274
requirements, 324t
supplementation, 322–323
Core tissues, thermoregulation, 183
Corneal ulceration, vesicants, 469
Coronary artery disease (CAD), 418
Corrosive agents, 455
Corticosteroids, exfoliative disorders, 475
Corticotrophin-releasing factor (CRF), shock,
110
Corticotrophin-releasing hormone (CRH),
289
Cortiella, J, 6–7
Cortisol, 395
Cosmetic prostheses, 529
Cosmetic units, face burn management, 171,
171f
Cost-containment, 707–714
data acquisition, 710–714
outcome measurement, 710–714
pharmaceutical costs, 712
quality assurance, 710–712, 711b, 711f
resource optimization, 712–714
treatment protocols, 712
Coughing
stimulation, 239
therapeutic, 239
Counter anti-inflammatory response
syndrome (CARS), 265
SIRS, 251, 251f
CPET (cardiopulmonary exercise test), 540
CPK (creatinine phosphokinase), 442–443
CPM (continuous passive motion) device, 537