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Acute Burns
Tiffany B. Grunwald, M.D.,
Learning Objectives: After studying this article, the participant should be able
M.Ed. to: 1. Describe the pathophysiology of burn injury. 2. Identify patient criteria for
Warren L. Garner, M.D. transfer to a burn center. 3. Calculate burn size and resuscitation requirements.
Los Angeles, Calif. 4. Treat inhalation injury in the acute setting. 5. Describe treatment options for
burn injuries. 6. Describe preoperative selection, intraoperative procedures, and
postoperative protocols for patients who require surgical care for their burn
injuries. 7. Understand the survival and functional outcomes of burn injury.
Summary: The review article summarizes basic issues in the treatment of acute
burn injury as practiced in 2008. The pathophysiology, treatment options, and
expected outcomes for an acute burn are described and discussed. Special attention
is directed to the nonoperative and surgical management of small to moderate-size
burns that might be treated by the practicing plastic surgeon. (Plast. Reconstr. Surg.
121: 311e, 2008.)
W
ith improvement in surgical technique, surface area, with 62 percent of the full-thickness
availability of blood bank products, and burns covering less than 10 percent of total body
improvement in intensive care unit man- surface area. Sixty-one percent of patients were
agement, burn management has undergone a par- transferred to another hospital for a higher level
adigm shift from death as primary concern to en- of care. Six and a half percent of patients admitted
hancing quality of life for survivors.1 The mortality had inhalation injury. The patients were 70 per-
rate is best predicted by the size of the burn, the cent male with a mean age of 33 years. Flame and
age of patient, and the worst base deficit in the first scald burns accounted for 78 percent of injuries.
24 hours of hospitalization.2 Long-term outcome The prognostic burn index, a sum of the pa-
is usually excellent, and most survivors of serious tient’s age and percentage of burn, has been used
childhood burns have a satisfying quality of life.3 as a gauge for patient mortality rate for many years.
This index suggests that the patient’s age plus
EPIDEMIOLOGY their full-thickness total body surface area burn
According to the National Burn Repository,4 plus 20 percent for inhalation equaled the likely
there were 126,000 hospital admissions for burns mortality rate. Advances from early excision of
from January of 1995 to 2005. This information burn eschar, skin grafting, early enteral feeding,5
was gathered from burn centers throughout the and wound closure with advanced techniques (skin
United States and Canada to facilitate the collec- substitutes) have altered the simple mathematical
tion and analysis of patient data within burn cen- calculation. Patients with a prognostic burn index of
ters. From this information, we know that 62 per- 90 to 100 now have a mortality rate in the 50 to 70
cent of all burns seen in burn centers affected less percent range, with poorer outcomes at both ex-
than 10 percent of the total body surface area. The tremes of age.6
mean burn size was 13.4 percent of total body
TREATMENT OF BURN INJURIES AND
From the Division of Plastic and Reconstructive Surgery, Uni- BURN CENTERS
versity of Southern California, USC Keck School of Medicine, Treatment of thermal injuries should be strat-
and LAC⫹USC Burn Unit, LAC⫹USC Medical Center. ified between simple partial-thickness and small
Received for publication May 15, 2006; accepted January
24, 2007.
A passing score on this CME confers 0.5 hours of Patient
Safety Credit. Disclosure: Warren L. Garner, M.D., is the med-
The American Society of Plastic Surgeons designates this edu- ical director for Advanced BioHealing, in La Jolla,
cational activity for a maximum of one (1) AMA PRA Category Calif. There is no financial interest or commercial
1 credit.™ Physicians should only claim credit commensurate association for the other author that might pose or
with the extent of their participation in the activity. create a conflict of interest with the information
Copyright ©2008 by the American Society of Plastic Surgeons submitted in this article.
DOI: 10.1097/PRS.0b013e318172ae1f
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Plastic and Reconstructive Surgery • May 2008
full-thickness injuries and those that require special- PATHOPHYSIOLOGY OF BURN INJURY
ized care. The practicing plastic surgeon with expe- Anatomy/Function of Skin
rience and interest can reasonably, safely, and effec- The skin has two anatomic layers, each with a
tively care for the former. The latter are best cared separate function. The superficial, epidermal layer is
for with the involvement of a burn team (Table 1). a barrier to bacteria and vapor (moisture loss). The
The treatment and management of patients with dermal layer deep to the epidermis provides pro-
significant burn injuries are complex. The best, most tection from mechanical trauma and the elasticity
successful, and cost-effective treatment is in high- and mechanical integrity of the skin. Blood vessels
volume programs with a multidisciplinary team. providing nutrition to the epidermal layer run
Transfer to a burn center is an accepted way to within the dermis. After skin loss, epidermal cells
improve patient care. Burn injuries appropriate for regenerate from deep within dermal appendages,
transfer to a burn center include large burns, smaller such as hair follicles and sweat glands. The skin’s
burns in areas of higher morbidity, and burns in function as a barrier to infection and fluid loss is lost
patients with comorbidities. The American Burn As- with burn injury. The treating physician must com-
sociation developed burn center referral criteria for pensate with appropriate fluid management and lo-
patients suitable for transfer (Table 2). Both ex- cal wound care.
tremes of ages have a less predictable systemic re-
sponse to burns. Adherence to these criteria will Local Tissue Response
improve outcome and avoid unnecessary medical Burn injury to tissue encompasses a dynamic
expenses. Data from the National Burn Repository response to the initial insult. Damage depends on
indicate that most burns are minor and that 80 to 90 the temperature of the thermal energy source as
percent of burn injuries can be treated on an out- well as the duration of contact. Burn injury is
patient basis.7 To determine the best mechanism to heterogeneous with adjacent areas showing varied
deliver care, accurate communication with burn levels of injury.
team members regarding the burn injury is essential.
This is facilitated by calculating the percentage of Systemic Response
burn using the rule of nines (Fig. 1) or the Lund- When the burn exceeds 20 percent of the pa-
Browder diagram and a careful review of the asso- tient’s body surface, the local tissue response be-
ciated conditions. Before transferring a patient to a comes systemic. Interstitial edema develops in dis-
burn unit, communication with the accepting burn tant organs and soft tissues secondary to release of
surgeon should include discussion of the following vasoactive mediators from the injured tissue. Ac-
treatment issues: the airway, nasogastric suction, uri- tivation of complement and coagulation systems
nary catheter, and vascular access. In addition, the causes thrombosis and release of histamine and bra-
calculated fluid resuscitation for transport should be dykinin, leading to an increase in capillary leak and
confirmed. The patient should be placed in dry interstitial edema in distant organs and soft tissue.
dressings for transport to keep the patient warm and Secondary interstitial edema and organ dysfunction
from bacterial overgrowth within the eschar can
to facilitate burn assessment upon arrival at the burn
then result in systemic infection. Activation of the
center. Unless the transport time is unusually long,
proinflammatory cascade and the counterregulatory
antimicrobial dressings will delay transfer and ob- anti-inflammatory reaction then lead to immune
scure wound details at the receiving institution. dysfunction. This increases the patient’s susceptibil-
ity to sepsis and multiple organ failure.8
The systemic response to burn injury leads to
a hypermetabolic state doubling normal physio-
Table 1. Burn Team Members logic cardiac output over the first 48 postburn
Burn surgeon hours.9 This response is mediated by hugely in-
Case worker creased levels of catecholamines, prostaglan-
Dietician
Intensive care unit nurses dins, glucagons, and glucocorticoids, resulting
Occupational therapist in skeletal muscle catabolism, immune defi-
Pharmacist ciency, lipolysis, reduced bone mineralization,
Psychiatrist
Physical therapist and reduced linear growth.10 Herndon et al.11
Respiratory therapist have suggested that downmodulating this hy-
Social worker permetabolic response is beneficial. Beta-block-
Ward nurses
ers have been shown to reduce the hypermeta-
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turns. Vascular access for these fluids should be two responsible for the significant blood loss second-
large-bore peripheral intravenous lines or a central ary to an alteration in the coagulation cascade.
line. Operative methods to minimize blood loss during
surgical debridement include injecting diluted
Infection Prophylaxis epinephrine below the eschar, using cautery for
Treatment of burns with topical antibiotics has fascial excision, excising extremities under tour-
been shown to decrease the bacterial overgrowth niquet, and performing excisions early in the post-
and incidence of burn wound sepsis. Current burn period, before significant wound angiogen-
treatment regimens include silver sulfadiazine, esis develops.
Bactroban, or Sulfamylon in conjunction with Surgical debridement is performed using a
daily cleaning and debridement. Acticoat is a sil- Goulian blade for small areas or those with mul-
ver-impregnated material dressing that provides tiple irregular contours (e.g., hand or knee) and
antibiotic coverage for 3 to 7 days. a Watson blade for larger areas. Burned tissue is
Patients who show signs of sepsis should re- excised tangentially and sequentially until the
ceive a complete work-up, with a special focus on wound has been excised down to healthy dermis,
the most commonly encountered bacteria in burn fat, muscle, peritenon, or periosteum. The wound
units, including Staphylococcus aureus, Pseudomonas may then be covered with an autograft, allograft,
aeruginosa,32 and Acinetobacter. The compromise to or synthetic skin substitute. If a healthy recipient
the skin barrier and the overgrowth of bacteria in bed is not available, other reconstructive options
the burn eschar leading to sepsis have led to a high should be considered.
rate of antibiotic resistance in these common or- Burn Wound Coverage
ganisms.
Autografts include full-thickness skin grafts,
split-thickness skin grafts, and cultured epithelial
Surgical Debridement cells, each with their own set of advantages and
The timing of surgical debridement has a sig- disadvantages (Table 6). Full-thickness skin grafts
nificant effect on long-term burn wound results. are rarely used in burn surgery because of the
Early identification, excision, and closure of full- added tissue loss. Split-thickness skin grafts allow
thickness burn wounds help avoid wound sepsis, de- for regrowth of the donor site with minimal scar-
crease systemic inflammation, and improve out- ring. The average graft depth is 8 to 14/1000ths of
comes in wound healing. For mixed-depth wounds, an inch. Thinner grafts heal the donor site faster
topical therapy for 5 to 7 days will facilitate any spon- with less scarring, while thicker grafts provide
taneous wound healing that may occur. Declaration more durable coverage but will have more signif-
of the depth of injury during that time, with frequent icant scarring at the donor site. Graft depth should
assessment of wound progression, should guide sur- be adjusted in pediatric and geriatric populations
gical planning. for their thinner reticular dermis layer. Meshing
Blood loss from surgical debridement of burns of the skin graft has several advantages, including
is estimated at 3.5 to 5 percent of blood volume for expanding the square centimeters of coverage,
every 1 percent of total body surface area of burn allowing for drainage of fluid from under the
excised.33 The systemic response to burn injury is graft, and allowing for placement of the graft over
contoured areas, such as the knee or ankle. The
Table 5. Resuscitation Formula disadvantage of the meshed skin graft includes a
permanent weave-like appearance of the healed
First 24 hours scar site. Sheet skin grafts have a smoother healed
Adults and children ⬎20 kg
Ringer’s lactate solution: 2 to 4 ml/kg per percent appearance but need to be checked frequently for
burn per 24 hours (first half in first 8 hours) hematoma and seroma formation and cannot be
Colloid solution: none used for large burns, where donor sites are scarce.
Children ⬍20 kg
Ringer’s lactate solution: 2 to 3 ml/kg per percent Recently, fibrin spray has been used to improve
burn per 24 hours (first half in first 8 hours) adherence of both sheet and mesh skin grafts.
Ringer’s lactate solution with 5% dextrose: maintenance Cultured epithelial autografts are grown from pa-
rate (4 ml/kg per hour for first 10 kg, 2 ml/kg per hour tient skin samples. Seventy-five square meters may
for next 10 kg)
Colloid solution: none be grown from a 1-cm2 specimen. Few centers have
Second 24 hours large success with cultured epithelial autografts
All patients secondary to lack of take and poor long-term
Crystalloid solution: use to maintain urine output
durability.34
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closely to ensure therapeutic levels, to prevent the return-to-work rate), and type of work done before
development of more drug resistance. injury. The length of time a patient is off work,
their burn size, and their preinjury employment
BURN OUTCOMES: LONG-TERM DATA are the best predictors of eventual return-to-work
status. The Burn Specific Health Scale quantifies
Data from the 2005 Burn Repository show a quality-of-life issues specific to burn injury. An ab-
decrease in mortality rates among all burns from breviated form was developed and validated by
6.2 percent in 1995 to 4.7 percent in 2005.4 The Kildal et al.47 to improve clinical use and gather
biggest factor in burn mortality is inhalation in- more data to help burn centers care for patients.
jury. In the 6.5 percent of burn patients admitted On average, burn patients with a mean total
with an inhalation injury, the mortality rate in- body surface area burn of 5 percent returned to
creased to 26.3 percent. Thirty-eight percent of all work within 1 month, patients with a burn of 10
burn deaths were due to multiple organ failure percent returned to work within 1 to 6 months,
and only 4.1 percent were due to burn wound those with a burn of 20 percent returned to work
sepsis. Mortality rates were much greater at both within 6 months to a year, and those with a burn
ends of the age spectrum. Factors previously of 35 percent returned to work more than a year
thought to influence time to wound healing, such later.43
as percentage burned, sex, age, graft type, and
infection, were not found to be significant in a
study by Jewell et al.42 SUMMARY
The significant increase in burn survival over Interdisciplinary involvement with members
the last several decades6,43 generates important of the burn team and counseling groups is very
questions about quality-of-life issues. Studies of important in maximizing a patient’s clinical out-
quality of life among those surviving serious child- come. Interventions designed to aid adjustment,
hood burns have been surprisingly good.44 In ad- work hardening, and other rehabilitation services
dition, a recent study of patients who sustained and marital/family therapy are also important.
massive burns showed that they had a satisfying CPT codes commonly used in burn surgery are
quality of life 15 years after burn injury.1,45 A 1995 listed in Table 7.
study showed that the most significant predictors
of return to work were hand involvement, grafting, Warren L. Garner, M.D.
and size of the burn46; a 1989 study showed that the LAC⫹USC Medical Center
1200 N. State Street
most significant variables influencing return to Burn Unit, Room 12-700
work after injury were the degree of burn, hand Los Angeles, Calif. 90033
burns, age (those younger than 45 had a higher wgarner@surgery.usc.edu
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Volume 121, Number 5 • Acute Burns
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