Burn Patients

Overview

Burn injuries are as ancient as fire itself. All afflicted individuals need help and many require psychiatric consultation; their psychiatric care may be as challenging as their surgical care. Depending on their experience, physicians, nurses, and trainees new to a burn unit may experience trepidation and fear, but these feelings moderate as they relieve pain, help patients survive, and see the repair of disfiguring scars. Nevertheless, the burn unit is stressful for all—viewing an acutely burned infant, child, or adult can satisfy the stressor criteria for post-traumatic stress disorder (PTSD) and evoke nightmares in staff and patients.

Burn units and clinics bring together specialists from several disciplines, and have long been practicing collaborative care. The Massachusetts General Hospital (MGH) Level 1 Trauma Center treats burned adults at the MGH and treats children at the affiliated Shriners Burns Hospital. Since 9/11, all burn centers in the United States have enhanced their disaster preparedness; psychiatric education regarding disasters is important for staff on burn units in order to enhance resilience and increase preparedness.

History

The current era of burn treatment and research began about 75 years ago at the MGH after the Cocoanut Grove fire on November 28, 1942. Cobb and Lindemann, eminent early MGH psychiatrists, collaborated with other physicians and chronicled the deliria and post-traumatic reactions of the survivors of that tragedy in which 491 people died. Lindemann, in a classic paper (based in part on his work with 13 bereaved disaster victims of the Cocoanut Grove fire and their close relatives, and with relatives of members of the armed forces), reported for the first time the symptoms and psychotherapeutic management of acute grief. Their studies involved psychiatric treatment of grief that would be applied to soldiers, civilians, and the bereaved.

Burn injuries challenge hospital staff and hospital systems. In 2003, as in the Cocoanut Grove fire, The Station nightclub fire in Rhode Island wreaked havoc. It resulted in 100 deaths and tested emergency and burn trauma disaster plans at the MGH, the Shriners Burns Hospital, and the entire region; fortunately, the triage system worked superbly. Unlike the September 11, 2001 terrorist attacks when staff readied for transfers to their burn units but were surprised by how few survived to be treated, scores survived this nightclub fire (despite severe burns to the lungs, face, hands, and upper body) because of the emergency response and advances in modern burn care. As described earlier by Cobb and Lindemann, some of these survivors, their children, and other relatives developed and were treated for survivor guilt, traumatic grief, and what is now recognized as PTSD.

In the last 40 years, strong leadership and new research have led to improved methods of resuscitation and transportation; excision and grafting; anesthesia; pain control and opiate management; anxiety management; pulmonary care; cardiovascular and infection control; application of artificial skin and skin substitutes; psychiatric assessment and treatment ( Table 32-1 ); plastic surgery techniques; and rehabilitative efforts that include interventions for those with disfiguring facial and body burns. Taken together, these innovations have dramatically improved both mortality rates and the morbidity associated with burn injuries in the United States.

Just as Cobb, Lindemann, and Adler did for adults, Bernstein and others pioneered the psychiatric care of burned children and their families; moreover, they conceptualized consultations to the burn team. Childhood injuries, including burns, are now, after years of neglect, a priority for medical research and treatment. Both adult and child injury rates have dramatically dropped. A key resource regarding education and research for burn care is the American Burn Association, which is linked to federal agencies, a variety of foundations, and the International Society for Burn Injuries. Many patients also benefit from self-help groups, like the Phoenix Society, which is the international self-help organization for children and adults with burns, and their families. Its mission is to increase the understanding of burned individuals and to support their care.

Epidemiology

According to the American Burn Association Fact Sheet, approximately 486,000 people are seen and treated annually for burn-related injuries in the United States. About 40,000 patients are admitted for treatment of burn-related injuries and approximately 30,000 of these are treated at designated burn centers. There are 128 designated burn treatment centers in the United States and the average number of admissions to these centers is approximately 200 annually. According to the National Burn Repository 2015 report, the overall survival rate for burn injuries is 96.8%. Roughly two-thirds (68%) of burn victims are male. The mean age of burn victims was 32 years; children under the age of 5 years accounted for 19% of the cases, while patients age 60 years or older accounted for 13% of the cases. Most burns occur in the home (73%). The remainder of burn injuries occur at work (8%), in the street or on the highway (5%), while recreational activities account for 5%, and the remaining 9% are designated as “other.” Among inpatient admissions, the most common burn type is scald injury (34%), while other injuries are due to contact (9%), electrical (4%), chemical (3%), fire/flame (3%), and other.

Between 2005 and 2014, the mortality rates for males increased from 3.1% to 3.2% while for females, rates decreased from 4.4% to 3.6%. Advancing age and the presence of inhalation injury pose significant mortality risks. For patients under the age of 60 with a total body surface area (TBSA) burn between 0.1% and 19.9%, the presence of inhalation injury increases the likelihood of death by nearly 24-fold. The most common complications of burn treatment are pneumonia, respiratory failure, cellulitis, septicemia, and wound infection; these clinical complications are in large part a function of the number of days spent on the ventilator (with the risk increasing dramatically after ≥4 days). The average length of hospital stay for survivors is best approximated by figuring on one day per percentage TBSA burns.

Types of Burns

Burns are classified by the depth of the injury (from first–fourth-degree burns). First-degree burns are characterized by an intact epithelium (that is pink, dry, and painful); these burns require no specific care. Second-degree burns are wet, pink to red, and edematous; these changes signify that the dermis is damaged. These burns are further categorized into superficial and deep and they must be monitored closely. Laser Doppler imaging is a widely accepted method for early and accurate assessment of burn depth. Third-degree, or full-thickness (of dermis) burns are leathery, dry, and lack sensation; these burns require surgical treatment. The most severe burns are fourth-degree burns; these extend through the subcutaneous tissue to the tendons, muscles, and bones, and they require complex surgical reconstruction.

The operative treatment of burns includes wound debridement, escharotomy and fasciotomy (release of burned skin and muscle, respectively) and grafting. The non-operative treatment involves daily wound care (performed multiple times each day), and systemic care and management of associated medical and surgical problems.

Risk Factors

Risk factors for burn injuries are different for children, adults, and the elderly, although poverty is a risk factor in all populations. A combination of developmental and familial factors contributes to the risk of burns in children. Increased exploration by young children, access to scalding or flammable liquids or flames, childhood depression, behavioral disturbances, and parental psychopathology each predispose children to burns. Burns to children should not be indiscriminately labeled as due to neglect or to abuse because, on careful assessment, they may be the result of a combination of developmental, environmental, and family variables. However, child neglect or abuse accounts for between 6% and 20% of pediatric burns; the age of maximum risk of abuse is 13 to 24 months, and scalds are the most common type of inflicted burn. Factors suggestive of abuse include a burn distribution inconsistent with the history; a carer changing the story of what occurred (from one interview to the next); prior injuries or accidents; a parent who neither visits nor is attentive; a consistently awake but withdrawn child who appears immune to pain; and other signs of abuse, such as fractures. Suspected abuse must be reported to the appropriate state agency in most states.

Among adults, risk factors for burns include drug and alcohol intoxication and dependence, major mental illness, antisocial personality disorder, and exposure to occupational hazards ( Tables 32-2 and 32-3 ). Certain populations, such as the homeless and the elderly, have an increased risk of burns. Homeless people are more likely to be assaulted by burning and to have higher rates of substance abuse and psychiatric illness as compared with domiciled burn patients. Demented elders are also at risk for burns; scalds are much more common than flame burns and typically occur during routine activities of daily living.

Pre-Burn Psychopathology

Psychiatric illness is over-represented in individuals with burn injuries. Depressive symptoms are common after a burn. Frequency rates within the first year vary, depending on measures and definitions of severity versus meeting diagnostic criteria. Weichman et al. reported that prevalence ranges from about 4% at discharge to between 10% and 23% 1 year after injury, with increasing prevalence through the first year after discharge. These rates are much higher than in the general population. Few studies have examined depression for longer than 1 year, but one found that prevalence increased between the first and second year, and that up to 42% of survivors have moderate to severe depression 2 years after injury. Female gender and facial burns were associated with more depression. Dyster-Aas and associates, in a prospective case series of 73 patients with burns, used structured clinical interviews and found that two-thirds of patients had at least one life-time psychiatric diagnosis (i.e., major depression [41%]; alcohol abuse or dependence [32%]; simple phobia [16%]; and panic disorder [16%] were most common). Wisely and co-workers looked at 72 patients admitted to a burn unit over a 5-month period and found that 35% had a psychiatric diagnosis before the burn; depression, drug and alcohol abuse, personality disorders, and psychotic disorders were the most often detected.

Individuals with self-inflicted burns often have a high prevalence of severe mental illness (e.g., schizophrenia or major depression). One review of 582 patients with self-inflicted burns found that 78% had a psychiatric history, an increased likelihood of psychotic symptoms, of being prescribed psychotropic medication at the time of the burn, and of being a psychiatric inpatient. Our experience also shows that patients with bipolar disorder (while manic), schizophrenia, conduct-disorder, and alcoholism are at risk for self-immolation. Sometimes it is difficult to discern whether a burn was accidental, a parasuicidal gesture, or a bona fide suicide attempt. Attempts at suicide via self-immolation occur worldwide and often result in massive, disfiguring burns.

A study of adolescent self-immolators revealed serious untreated or partially treated psychopathology (including drug abuse, psychosis, intense conflict with parents, and physical or sexual abuse). Studies of adults have similarly found elevated rates of alcohol use disorder, depression, psychosis, and personality disorder as pre-existing factors. These patients tend to arouse intense feelings in caregivers and are among the most difficult surgical and psychiatric patients. Despite their burns and severe psychopathology, most patients cope well with psychiatric treatment that is initiated on the burn unit. Their prognoses are very guarded, since self-immolation, as with a severe overdose, is an indicator of affective or other disorder and ongoing suicide risk, although those who later commit suicide do not necessarily do so by burning.

Finally, suicide attempts may turn out to be homicide attempts as part of the “honor killing” or maiming, such as acid burns to the face of victims accused of incest or of seducing a rapist. The psychiatrist, consulting to units where patients may be admitted from around the world, must be aware of patients' cultural and ethnic background, in order to understand the circumstances surrounding the burn injury. Unfortunately, because of barriers in reporting, including undiagnosed and unreported abuse, an exact estimate of prevalence of these injuries is not known.

Assessment and Management of Patients With Burns

Psychiatrists who work in the general hospital are frequently called to assess burned patients, as for any other surgical patients. The role of the psychiatrist changes in parallel with the patient's recovery; in general, it begins with a brief assessment in the acute phase that focuses on management of delirium and pain, then it morphs to the evaluation and treatment of symptoms of PTSD in the months after the burn, and then it targets psychosocial adjustment to disfiguring burns in the years after the burn. These phases can be divided into acute, intermediate, and long-term recovery.