46 Burns

ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT
ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia
Acute Analgesia is a vital part of  burns management. Small burns, especially superficial burns, respond well to simple oral anal gesia, paracetamol and non-steroidal anti-inflammatory drugs. Topical cooling is especially soothing. Large burns require intravenous opiates for the initial management; intram administration should be avoided as uptake is variable. Subacute In patients with large burns, continuous analgesia is required, beginning with infusions and continuing with oral tablets. Powerful, short-acting analgesia should be administered before dressing changes. Administration is guided by anaesthetists, as in the case of  general anaesthesia or midazolam and ketamine, or less intensive supervision, as in the case of  morphine and nitrous oxide. Early support by colleagues from the pain team is beneficial in controlling pain.

ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia
ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia
Acute Analgesia is a vital part of  burns management. Small burns, especially superficial burns, respond well to simple oral anal gesia, paracetamol and non-steroidal anti-inflammatory drugs. Topical cooling is especially soothing. Large burns require intravenous opiates for the initial management; intram administration should be avoided as uptake is variable. Subacute In patients with large burns, continuous analgesia is required, beginning with infusions and continuing with oral tablets. Powerful, short-acting analgesia should be administered before dressing changes. Administration is guided by anaesthetists, as in the case of  general anaesthesia or midazolam and ketamine, or less intensive supervision, as in the case of  morphine and nitrous oxide. Early support by colleagues from the pain team is beneficial in controlling pain.

ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT
ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia
Acute Analgesia is a vital part of  burns management. Small burns, especially superficial burns, respond well to simple oral anal gesia, paracetamol and non-steroidal anti-inflammatory drugs. Topical cooling is especially soothing. Large burns require intravenous opiates for the initial management; intram administration should be avoided as uptake is variable. Subacute In patients with large burns, continuous analgesia is required, beginning with infusions and continuing with oral tablets. Powerful, short-acting analgesia should be administered before dressing changes. Administration is guided by anaesthetists, as in the case of  general anaesthesia or midazolam and ketamine, or less intensive supervision, as in the case of  morphine and nitrous oxide. Early support by colleagues from the pain team is beneficial in controlling pain.

ASSESSMENT OF THE BURN WOUND Assessing size
ASSESSMENT OF THE BURN WOUND Assessing size
The defining feature of  any burn referral and usually the first question to seek clarification is ‘What is the size of  the burn?’ From this simple question the burn team can establish the correct method of  transfer and the resources needed to appro priately manage the patient with burn on arrival. The standard method of estimating burn size is to use percentage body surface area. As per the Emergency Man agement of  Severe Burns (EMSB) the distal wrist crease to fin gertips of  an adult patient’s hand is approxima tely 1% TBSA (1.25%), due to the inherent error in measurement this is useful for small burns of  up to 10% TBSA. An estimation of  burn size (greater than 15% in an adult; 10% in extr emes of  age) will also determine whether fluid resuscitation is required. A useful aide-memoire in the prehospital and emergency setting is the Wallace rule of  nines. In this schematic each body part is assigned a burn percentage: each upper limb is 9%, head is 9%, lower limbs are 18% each, posterior torso and buttocks is 18% and the anterior torso 18% (chest 9% and abdomen 9%). The remaining 1% is assigned to the genitalia. The rule of  nines has been in established clinical practice for 70 years but it is not without drawbacks. In terms of accuracy there is a tendency to overestimate burn size, and in the obese patient the proportion of  surface area of  the arms and head decreases as the surface area of the torso and legs increase. A modification of  5% for the arms, 20% for the legs and 50% for the torso has been suggested but is not widely used. However, the rule of nines is an excellent means to quickly and reliably assess the size of  a burn in an emergency setting, providing the clinician is aware of  the limitations; it is not suitable for children under 10 years of  age. On arrival at a burns unit, the standard formatting for assessment and documentation is the Lund and Browder chart ( Figure 46.2 ). Developed in 1942 f ollowing a mass casualty burn event at a nightclub in Boston, MA, USA, the chart is a schematic representation of  the anterior and posterior body . It further subdivides body areas and allows for di ff erentiation of burn depth by shading. The Lund and Browder chart can be completed at multiple points during a burn admission to document changes in burn size/depth and can also be used as an adjunct to surgical notes, when skin graft donor sites and grafted areas can be shaded. In an increasingly digital era, it is worth noting the easy a vailability of burn management apps that are readily com patib le with smart phones. These invariably involve shading Alexander Burns Wallace , 1906–1974, Scottish plastic surgeon and founding member of  the British Association of  Plastic Surgeons. Charles C Lund , 1895–1972, American surgeon, Boston City Hospital, Boston, MA, USA. Newton C Browder , 1893–1969, American surgeon, Boston City Hospital, Boston, MA, USA. Lund and Browder developed the chart based on their experiences in treating over 300 burn patients injured in a fire in Boston in 1942. - - - a pictorial representation of  the body , which then calculates a burn size. Additional features include adding age and weight to allow automatic estimation of  fluid resuscitation requirements.
A
A
1
1
2
2
13
2
2
13
1
½
1
½
1
½
1
½
1
2
½
2
½
1
½
1
½
1
½
1
½
B
B
B
B
C
C
C
C
1
¾
1
¾
1
¾
1
¾
Relative percentage of area affected by growth
0 1 5 10 15 Adult
Age in years
9 8 6 5  4  3
A Head
2 3 4 4  4  4
B Thigh
2 2 3 3 3 3
C Leg
Figure 46.2
Modi
/f_i
ed Lund and Br
owder table and diagram.
ASSESSMENT OF THE BURN WOUND Assessing size
The defining feature of  any burn referral and usually the first question to seek clarification is ‘What is the size of  the burn?’ From this simple question the burn team can establish the correct method of  transfer and the resources needed to appro priately manage the patient with burn on arrival. The standard method of estimating burn size is to use percentage body surface area. As per the Emergency Man agement of  Severe Burns (EMSB) the distal wrist crease to fin gertips of  an adult patient’s hand is approxima tely 1% TBSA (1.25%), due to the inherent error in measurement this is useful for small burns of  up to 10% TBSA. An estimation of  burn size (greater than 15% in an adult; 10% in extr emes of  age) will also determine whether fluid resuscitation is required. A useful aide-memoire in the prehospital and emergency setting is the Wallace rule of  nines. In this schematic each body part is assigned a burn percentage: each upper limb is 9%, head is 9%, lower limbs are 18% each, posterior torso and buttocks is 18% and the anterior torso 18% (chest 9% and abdomen 9%). The remaining 1% is assigned to the genitalia. The rule of  nines has been in established clinical practice for 70 years but it is not without drawbacks. In terms of accuracy there is a tendency to overestimate burn size, and in the obese patient the proportion of  surface area of  the arms and head decreases as the surface area of the torso and legs increase. A modification of  5% for the arms, 20% for the legs and 50% for the torso has been suggested but is not widely used. However, the rule of nines is an excellent means to quickly and reliably assess the size of  a burn in an emergency setting, providing the clinician is aware of  the limitations; it is not suitable for children under 10 years of  age. On arrival at a burns unit, the standard formatting for assessment and documentation is the Lund and Browder chart ( Figure 46.2 ). Developed in 1942 f ollowing a mass casualty burn event at a nightclub in Boston, MA, USA, the chart is a schematic representation of  the anterior and posterior body . It further subdivides body areas and allows for di ff erentiation of burn depth by shading. The Lund and Browder chart can be completed at multiple points during a burn admission to document changes in burn size/depth and can also be used as an adjunct to surgical notes, when skin graft donor sites and grafted areas can be shaded. In an increasingly digital era, it is worth noting the easy a vailability of burn management apps that are readily com patib le with smart phones. These invariably involve shading Alexander Burns Wallace , 1906–1974, Scottish plastic surgeon and founding member of  the British Association of  Plastic Surgeons. Charles C Lund , 1895–1972, American surgeon, Boston City Hospital, Boston, MA, USA. Newton C Browder , 1893–1969, American surgeon, Boston City Hospital, Boston, MA, USA. Lund and Browder developed the chart based on their experiences in treating over 300 burn patients injured in a fire in Boston in 1942. - - - a pictorial representation of  the body , which then calculates a burn size. Additional features include adding age and weight to allow automatic estimation of  fluid resuscitation requirements.
A
A
1
1
2
2
13
2
2
13
1
½
1
½
1
½
1
½
1
2
½
2
½
1
½
1
½
1
½
1
½
B
B
B
B
C
C
C
C
1
¾
1
¾
1
¾
1
¾
Relative percentage of area affected by growth
0 1 5 10 15 Adult
Age in years
9 8 6 5  4  3
A Head
2 3 4 4  4  4
B Thigh
2 2 3 3 3 3
C Leg
Figure 46.2
Modi
/f_i
ed Lund and Br
owder table and diagram.
ASSESSMENT OF THE BURN WOUND Assessing size
The defining feature of  any burn referral and usually the first question to seek clarification is ‘What is the size of  the burn?’ From this simple question the burn team can establish the correct method of  transfer and the resources needed to appro priately manage the patient with burn on arrival. The standard method of estimating burn size is to use percentage body surface area. As per the Emergency Man agement of  Severe Burns (EMSB) the distal wrist crease to fin gertips of  an adult patient’s hand is approxima tely 1% TBSA (1.25%), due to the inherent error in measurement this is useful for small burns of  up to 10% TBSA. An estimation of  burn size (greater than 15% in an adult; 10% in extr emes of  age) will also determine whether fluid resuscitation is required. A useful aide-memoire in the prehospital and emergency setting is the Wallace rule of  nines. In this schematic each body part is assigned a burn percentage: each upper limb is 9%, head is 9%, lower limbs are 18% each, posterior torso and buttocks is 18% and the anterior torso 18% (chest 9% and abdomen 9%). The remaining 1% is assigned to the genitalia. The rule of  nines has been in established clinical practice for 70 years but it is not without drawbacks. In terms of accuracy there is a tendency to overestimate burn size, and in the obese patient the proportion of  surface area of  the arms and head decreases as the surface area of the torso and legs increase. A modification of  5% for the arms, 20% for the legs and 50% for the torso has been suggested but is not widely used. However, the rule of nines is an excellent means to quickly and reliably assess the size of  a burn in an emergency setting, providing the clinician is aware of  the limitations; it is not suitable for children under 10 years of  age. On arrival at a burns unit, the standard formatting for assessment and documentation is the Lund and Browder chart ( Figure 46.2 ). Developed in 1942 f ollowing a mass casualty burn event at a nightclub in Boston, MA, USA, the chart is a schematic representation of  the anterior and posterior body . It further subdivides body areas and allows for di ff erentiation of burn depth by shading. The Lund and Browder chart can be completed at multiple points during a burn admission to document changes in burn size/depth and can also be used as an adjunct to surgical notes, when skin graft donor sites and grafted areas can be shaded. In an increasingly digital era, it is worth noting the easy a vailability of burn management apps that are readily com patib le with smart phones. These invariably involve shading Alexander Burns Wallace , 1906–1974, Scottish plastic surgeon and founding member of  the British Association of  Plastic Surgeons. Charles C Lund , 1895–1972, American surgeon, Boston City Hospital, Boston, MA, USA. Newton C Browder , 1893–1969, American surgeon, Boston City Hospital, Boston, MA, USA. Lund and Browder developed the chart based on their experiences in treating over 300 burn patients injured in a fire in Boston in 1942. - - - a pictorial representation of  the body , which then calculates a burn size. Additional features include adding age and weight to allow automatic estimation of  fluid resuscitation requirements.
A
A
1
1
2
2
13
2
2
13
1
½
1
½
1
½
1
½
1
2
½
2
½
1
½
1
½
1
½
1
½
B
B
B
B
C
C
C
C
1
¾
1
¾
1
¾
1
¾
Relative percentage of area affected by growth
0 1 5 10 15 Adult
Age in years
9 8 6 5  4  3
A Head
2 3 4 4  4  4
B Thigh
2 2 3 3 3 3
C Leg
Figure 46.2
Modi
/f_i
ed Lund and Br
owder table and diagram.

Breathing
Breathing
Inhalational injury Time is a major factor; anyone trapped in a fire for more than a couple of  minutes must be observed for signs of  smoke inhalation. Other signs that raise suspicion are the presence of soot in the nose and the oropharynx and a chest radiograph showing patchy consolidation. The clinical features are a progressive increase in respira tory e ff ort and rate, rising pulse, anxiety and confusion and decreasing oxygen saturation. These symptoms may not be apparent immediately and can take 24 hours to 5 days develop. Treatment starts as soon as this injury is suspected and the airway is secure. Physiotherapy , nebulisers and warm humid ified oxygen are all useful. The patient’s prog ress should be monitored using the respiratory rate, together with blood gas measurements. If  the situation deteriorates, continuous or intermittent positive pressure may be used with a mask or T-piece. In the severest cases, intubation and management in an intensive care unit will be needed. Nebulised heparin can be useful in preventing the formation of  the fibrin casts, although heparin requires antithrombin for its e ffi cacy (which is defi - cient after burn injury) and some providers suggest additional antithrombin administration. The e ffi cacy of  inhaled heparin therapy may be enhanced by the simultaneous administration of  the mucolytic agent N -acetylcysteine. Bronchodilators, such - as albuterol, may also be of  value, additionally stimulating mucosal repair, demonstrating anti-inflammatory properties and decreasing inflammatory mediators such as histamine, leukotrienes and tumour necrosis factor. The key , therefore, in the management of  inhalational injury is to suspect it from the history , institute early manage - ment and observe carefully for deterioration. Thermal burn injury to the lower airway These rare injuries can occur with steam injuries. The manage - ment is supportive and the same as that for an inhalational injury . Metabolic poisoning Any history of  a fire within an enclosed space and any history of /uni00A0 altered consciousness are important clues to metabolic poisoning. Blood gases must be measured immediately if  poison - ing is a possibility . Carboxyhaemoglobin levels raised above 10% must be treated with high inspired oxygen for 24 /uni00A0 hours to speed its displacement from haemoglobin. Metabolic acidosis is a feature of  many forms of poisoning. Modern treatment of - cyanide poisoning involves the intravenous administration of vitamin B12 (hydroxycobalamin), which interacts with cyanide to form cyanocobalamin, which is water soluble and excreted to in the urine. Once again the key to diagnosis is the history and blood gas measurement will confirm the diagnosis. - Mechanical block to breathing Any mechanical block to breathing from the eschar of  a significant full-thickness burn on the chest wall is obvious from
Figure 46.1
Burns to the face and neck with inhalation injury requiring
intubation.
and high inspiratory pressures if  the patient is ventilated. The treatment is to make some scoring cuts through the burned skin to allow the chest to expand (escharotomy). Breathing
Inhalational injury Time is a major factor; anyone trapped in a fire for more than a couple of  minutes must be observed for signs of  smoke inhalation. Other signs that raise suspicion are the presence of soot in the nose and the oropharynx and a chest radiograph showing patchy consolidation. The clinical features are a progressive increase in respira tory e ff ort and rate, rising pulse, anxiety and confusion and decreasing oxygen saturation. These symptoms may not be apparent immediately and can take 24 hours to 5 days develop. Treatment starts as soon as this injury is suspected and the airway is secure. Physiotherapy , nebulisers and warm humid ified oxygen are all useful. The patient’s prog ress should be monitored using the respiratory rate, together with blood gas measurements. If  the situation deteriorates, continuous or intermittent positive pressure may be used with a mask or T-piece. In the severest cases, intubation and management in an intensive care unit will be needed. Nebulised heparin can be useful in preventing the formation of  the fibrin casts, although heparin requires antithrombin for its e ffi cacy (which is defi - cient after burn injury) and some providers suggest additional antithrombin administration. The e ffi cacy of  inhaled heparin therapy may be enhanced by the simultaneous administration of  the mucolytic agent N -acetylcysteine. Bronchodilators, such - as albuterol, may also be of  value, additionally stimulating mucosal repair, demonstrating anti-inflammatory properties and decreasing inflammatory mediators such as histamine, leukotrienes and tumour necrosis factor. The key , therefore, in the management of  inhalational injury is to suspect it from the history , institute early manage - ment and observe carefully for deterioration. Thermal burn injury to the lower airway These rare injuries can occur with steam injuries. The manage - ment is supportive and the same as that for an inhalational injury . Metabolic poisoning Any history of  a fire within an enclosed space and any history of /uni00A0 altered consciousness are important clues to metabolic poisoning. Blood gases must be measured immediately if  poison - ing is a possibility . Carboxyhaemoglobin levels raised above 10% must be treated with high inspired oxygen for 24 /uni00A0 hours to speed its displacement from haemoglobin. Metabolic acidosis is a feature of  many forms of poisoning. Modern treatment of - cyanide poisoning involves the intravenous administration of vitamin B12 (hydroxycobalamin), which interacts with cyanide to form cyanocobalamin, which is water soluble and excreted to in the urine. Once again the key to diagnosis is the history and blood gas measurement will confirm the diagnosis. - Mechanical block to breathing Any mechanical block to breathing from the eschar of  a significant full-thickness burn on the chest wall is obvious from
Figure 46.1
Burns to the face and neck with inhalation injury requiring
intubation.
and high inspiratory pressures if  the patient is ventilated. The treatment is to make some scoring cuts through the burned skin to allow the chest to expand (escharotomy). Breathing
Inhalational injury Time is a major factor; anyone trapped in a fire for more than a couple of  minutes must be observed for signs of  smoke inhalation. Other signs that raise suspicion are the presence of soot in the nose and the oropharynx and a chest radiograph showing patchy consolidation. The clinical features are a progressive increase in respira tory e ff ort and rate, rising pulse, anxiety and confusion and decreasing oxygen saturation. These symptoms may not be apparent immediately and can take 24 hours to 5 days develop. Treatment starts as soon as this injury is suspected and the airway is secure. Physiotherapy , nebulisers and warm humid ified oxygen are all useful. The patient’s prog ress should be monitored using the respiratory rate, together with blood gas measurements. If  the situation deteriorates, continuous or intermittent positive pressure may be used with a mask or T-piece. In the severest cases, intubation and management in an intensive care unit will be needed. Nebulised heparin can be useful in preventing the formation of  the fibrin casts, although heparin requires antithrombin for its e ffi cacy (which is defi - cient after burn injury) and some providers suggest additional antithrombin administration. The e ffi cacy of  inhaled heparin therapy may be enhanced by the simultaneous administration of  the mucolytic agent N -acetylcysteine. Bronchodilators, such - as albuterol, may also be of  value, additionally stimulating mucosal repair, demonstrating anti-inflammatory properties and decreasing inflammatory mediators such as histamine, leukotrienes and tumour necrosis factor. The key , therefore, in the management of  inhalational injury is to suspect it from the history , institute early manage - ment and observe carefully for deterioration. Thermal burn injury to the lower airway These rare injuries can occur with steam injuries. The manage - ment is supportive and the same as that for an inhalational injury . Metabolic poisoning Any history of  a fire within an enclosed space and any history of /uni00A0 altered consciousness are important clues to metabolic poisoning. Blood gases must be measured immediately if  poison - ing is a possibility . Carboxyhaemoglobin levels raised above 10% must be treated with high inspired oxygen for 24 /uni00A0 hours to speed its displacement from haemoglobin. Metabolic acidosis is a feature of  many forms of poisoning. Modern treatment of - cyanide poisoning involves the intravenous administration of vitamin B12 (hydroxycobalamin), which interacts with cyanide to form cyanocobalamin, which is water soluble and excreted to in the urine. Once again the key to diagnosis is the history and blood gas measurement will confirm the diagnosis. - Mechanical block to breathing Any mechanical block to breathing from the eschar of  a significant full-thickness burn on the chest wall is obvious from
Figure 46.1
Burns to the face and neck with inhalation injury requiring
intubation.
and high inspiratory pressures if  the patient is ventilated. The treatment is to make some scoring cuts through the burned skin to allow the chest to expand (escharotomy).

Burn prevention
Burn prevention
Legislation, health promotion and appliance design have reduced the incidence of  burns: regulations regarding flame-retardant clothes and furniture; the promotion of  smoke alarms; the design of  cookers and gas fires; the almost universal use of  cordless kettles; and the education of  parents to set their hot water thermostat to 60°C all play their part. Recent campaigns have included highlighting the dangers of  leaving - hot hair straighteners near children and the slogan ‘hot water burns like fire’ in relation to the danger of  scald injuries. - Summary box 46.2 Prevention of burns /uni25CF - /uni25CF /uni25CF
A signi
/f_i
cant proportion of burns can be prevented by:
Implementing good health and safety regulations
Educating the public
Introducing effective legislation
Burn prevention
Legislation, health promotion and appliance design have reduced the incidence of  burns: regulations regarding flame-retardant clothes and furniture; the promotion of  smoke alarms; the design of  cookers and gas fires; the almost universal use of  cordless kettles; and the education of  parents to set their hot water thermostat to 60°C all play their part. Recent campaigns have included highlighting the dangers of  leaving - hot hair straighteners near children and the slogan ‘hot water burns like fire’ in relation to the danger of  scald injuries. - Summary box 46.2 Prevention of burns /uni25CF - /uni25CF /uni25CF
A signi
/f_i
cant proportion of burns can be prevented by:
Implementing good health and safety regulations
Educating the public
Introducing effective legislation
Burn prevention
Legislation, health promotion and appliance design have reduced the incidence of  burns: regulations regarding flame-retardant clothes and furniture; the promotion of  smoke alarms; the design of  cookers and gas fires; the almost universal use of  cordless kettles; and the education of  parents to set their hot water thermostat to 60°C all play their part. Recent campaigns have included highlighting the dangers of  leaving - hot hair straighteners near children and the slogan ‘hot water burns like fire’ in relation to the danger of  scald injuries. - Summary box 46.2 Prevention of burns /uni25CF - /uni25CF /uni25CF
A signi
/f_i
cant proportion of burns can be prevented by:
Implementing good health and safety regulations
Educating the public
Introducing effective legislation

Burn size calculation  children
Burn size calculation: children
The body proportions of  children necessitate adjustment of the above-mentioned scales. An infant’s head is proportionally larger than an adult’s and this adjustment is represented on the modified Lund and Browder chart for children, where at birth the head represents 18% and the lower limbs 13.5% each. For each year 1% is subtracted from the head, with 0.5% being added to each lower limb until the age of  10, when the body proportions are roughly equivalent to those of  an adult. Summary box 46.11 Assessing the area of a burn /uni25CF /uni25CF - /uni25CF
The patient’s hand is 1% TBSA, and is a useful guide in small
burns
The Lund and Browder chart is useful in larger burns
The ‘rule of nines’ is adequate for a
/f_i
rst approximation only
The first indication of  burn depth comes from the history ( Table 46.2 ). The burning of  human skin is temperature and time dependent. It takes 6 hours for skin maintained at 44°C to su ff er irreversible changes, but a surface temperature of  70°C for 1 second is all that is needed to produce epidermal destruc tion. Taking an example of  hot water at 65°C: exposure for 45 seconds will produce a full-thickness burn; for 15 seconds a deep partial-thickness burn; and for 7 seconds a superficial partial-thickness burn ( Figure 46.3 ). Summary box 46.12 Assessing the depth of a burn /uni25CF /uni25CF /uni25CF /uni25CF Superficial partial-thickness burns The damage in these burns goes no deeper than the papillary dermis. The clinical features are blistering and/or loss of  the epidermis. The underlying dermis is pink and moist and will exudate fluid for up to 36 hours post burn injury . The capillary return is clearly visible when blanched. There is little or no fixed capillary staining. Pinprick sensation is normal. Super ficial partial-thickness burns heal without residual scarring in 2 /uni00A0 weeks ( Figure 46.4 ). The treatment is supportive. Deep partial-thickness burn These burns involve damage to the deeper parts of  the reticular dermis. Clinically , the epidermis is usually lost. The exposed dermis is not as moist as that in a superficial burn. There is often abundant fixed capillary staining, especially if  examined after 48 hours. The colour does not blanch with pressure under the examiner’s finger. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle. Deep dermal burns take 3 weeks or more to heal without surgery and usually lead to hypertrophic scarring. - -
TABLE 46.2
Causes of burns and their likely depth.
Cause of burn
Probable depth of burn
Scald
Super
/f_i
cial, but with deep dermal patches in
the absence of good
/f_i
rst aid. Will be deep in
a young infant or the elderly
Fat burns
Deep dermal to full thickness
Flame burns
Mixed deep dermal and full thickness
Alkali burns,
Often deep dermal or full thickness
including cement
Acid burns
Weak concentrations super
/f_i
cial; strong
concentrations deep dermal
Electrical contact
Full thickness
burn
The history is important: temperature, time and burning
material
Super
/f_i
cial burns have capillary
/f_i
lling
Deep partial-thickness burns do not blanch, but have some
sensation
Full-thickness burns feel leathery and have no sensation
Figure 46.3
Photograph showing the difference between super
/f_i
cial
dermal (S/D) and deep dermal (D). The burn wound is less than
24 hours old and has been meticulously cleaned in theatre.
(a)
(b)
(c)
Figure 46.4
(a)
A super
/f_i
cial partial-thickness scald 24 hours after
injury. The dermis is pink and blanches to pressure.
(b)
At 2 weeks,
the wound is healed but lacks pigment.
(c)
At 3 months, the pigment
is returning.
Full-thickness burns The whole of  the dermis is destroyed in these burns. Clinically , they have a hard, leathery feel. The appearance can vary from that similar to the patient’s normal skin to charred black, depending upon the intensity of  the heat. There is no capillary return. Often, thrombosed vessels can be seen under the skin. These burns are completely anaesthetic – a needle can be stuck deep into the dermis without any pain or bleeding. Concept of two burn depths In treatment terms, there are two burn depths. There are those burns which, with optimal support and good wound manage ment, are superficial enough to heal spontaneously and quickly (within 14 days), leaving an excellent functional and cosmetic result, defined in this chapter as group A. Group B includes those burns that ar e su ffi ciently deep to undergo prolonged healing by secondary intention. This process takes weeks or months and involves the degradation and separation of  the eschar (burned tissue), the formation of  granulation tissue and the process of  wound contraction. The course of  healing by secondary intention must be aborted and replaced as closely as possible by a process of  primary intention healing with direct closure, skin graft and skin substitutes. Figure 46.5 is a pictorial representation of  this with burns in the pink section to the left of  the line belonging to group A and burns in the blue section to the right to group B. Pyotr Nikolsky , 1858–1940, Russian dermatologist.
Epidermal
Yes
Thin walled or popped Type of blister
Thick walled
Superficial dermal
Other signs: blanches
Mid-dermal
with pressure; very
painful; very oozy
Other signs: some mottling;
blanching sluggish; darker
red base; some anaesthesia;
less oozy
Figure 46.5
Protocol for assessing depth of burn. The Nikolsky sign refers to detachment of the epidermis from the dermis when lateral pressure
is applied to the skin.
Is there epidermal integrity
No
(Nikolsky sign)?
Run a gloved finger
over the burn
Yes
No
Is it
slippery?
Red
Burn colour
White
Deep dermal
Other signs: decreased
Full thickness
sensation; absent or reduced
refilling after blanching; fixed
Other signs: anaesthesia; no
mottling; little or no ooze
refilling after blanching; may be
amber and translucent with visible
black vessels; may be waxy; hairs
fall out easily; dry
Burn size calculation: children
The body proportions of  children necessitate adjustment of the above-mentioned scales. An infant’s head is proportionally larger than an adult’s and this adjustment is represented on the modified Lund and Browder chart for children, where at birth the head represents 18% and the lower limbs 13.5% each. For each year 1% is subtracted from the head, with 0.5% being added to each lower limb until the age of  10, when the body proportions are roughly equivalent to those of  an adult. Summary box 46.11 Assessing the area of a burn /uni25CF /uni25CF - /uni25CF
The patient’s hand is 1% TBSA, and is a useful guide in small
burns
The Lund and Browder chart is useful in larger burns
The ‘rule of nines’ is adequate for a
/f_i
rst approximation only
The first indication of  burn depth comes from the history ( Table 46.2 ). The burning of  human skin is temperature and time dependent. It takes 6 hours for skin maintained at 44°C to su ff er irreversible changes, but a surface temperature of  70°C for 1 second is all that is needed to produce epidermal destruc tion. Taking an example of  hot water at 65°C: exposure for 45 seconds will produce a full-thickness burn; for 15 seconds a deep partial-thickness burn; and for 7 seconds a superficial partial-thickness burn ( Figure 46.3 ). Summary box 46.12 Assessing the depth of a burn /uni25CF /uni25CF /uni25CF /uni25CF Superficial partial-thickness burns The damage in these burns goes no deeper than the papillary dermis. The clinical features are blistering and/or loss of  the epidermis. The underlying dermis is pink and moist and will exudate fluid for up to 36 hours post burn injury . The capillary return is clearly visible when blanched. There is little or no fixed capillary staining. Pinprick sensation is normal. Super ficial partial-thickness burns heal without residual scarring in 2 /uni00A0 weeks ( Figure 46.4 ). The treatment is supportive. Deep partial-thickness burn These burns involve damage to the deeper parts of  the reticular dermis. Clinically , the epidermis is usually lost. The exposed dermis is not as moist as that in a superficial burn. There is often abundant fixed capillary staining, especially if  examined after 48 hours. The colour does not blanch with pressure under the examiner’s finger. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle. Deep dermal burns take 3 weeks or more to heal without surgery and usually lead to hypertrophic scarring. - -
TABLE 46.2
Causes of burns and their likely depth.
Cause of burn
Probable depth of burn
Scald
Super
/f_i
cial, but with deep dermal patches in
the absence of good
/f_i
rst aid. Will be deep in
a young infant or the elderly
Fat burns
Deep dermal to full thickness
Flame burns
Mixed deep dermal and full thickness
Alkali burns,
Often deep dermal or full thickness
including cement
Acid burns
Weak concentrations super
/f_i
cial; strong
concentrations deep dermal
Electrical contact
Full thickness
burn
The history is important: temperature, time and burning
material
Super
/f_i
cial burns have capillary
/f_i
lling
Deep partial-thickness burns do not blanch, but have some
sensation
Full-thickness burns feel leathery and have no sensation
Figure 46.3
Photograph showing the difference between super
/f_i
cial
dermal (S/D) and deep dermal (D). The burn wound is less than
24 hours old and has been meticulously cleaned in theatre.
(a)
(b)
(c)
Figure 46.4
(a)
A super
/f_i
cial partial-thickness scald 24 hours after
injury. The dermis is pink and blanches to pressure.
(b)
At 2 weeks,
the wound is healed but lacks pigment.
(c)
At 3 months, the pigment
is returning.
Full-thickness burns The whole of  the dermis is destroyed in these burns. Clinically , they have a hard, leathery feel. The appearance can vary from that similar to the patient’s normal skin to charred black, depending upon the intensity of  the heat. There is no capillary return. Often, thrombosed vessels can be seen under the skin. These burns are completely anaesthetic – a needle can be stuck deep into the dermis without any pain or bleeding. Concept of two burn depths In treatment terms, there are two burn depths. There are those burns which, with optimal support and good wound manage ment, are superficial enough to heal spontaneously and quickly (within 14 days), leaving an excellent functional and cosmetic result, defined in this chapter as group A. Group B includes those burns that ar e su ffi ciently deep to undergo prolonged healing by secondary intention. This process takes weeks or months and involves the degradation and separation of  the eschar (burned tissue), the formation of  granulation tissue and the process of  wound contraction. The course of  healing by secondary intention must be aborted and replaced as closely as possible by a process of  primary intention healing with direct closure, skin graft and skin substitutes. Figure 46.5 is a pictorial representation of  this with burns in the pink section to the left of  the line belonging to group A and burns in the blue section to the right to group B. Pyotr Nikolsky , 1858–1940, Russian dermatologist.
Epidermal
Yes
Thin walled or popped Type of blister
Thick walled
Superficial dermal
Other signs: blanches
Mid-dermal
with pressure; very
painful; very oozy
Other signs: some mottling;
blanching sluggish; darker
red base; some anaesthesia;
less oozy
Figure 46.5
Protocol for assessing depth of burn. The Nikolsky sign refers to detachment of the epidermis from the dermis when lateral pressure
is applied to the skin.
Is there epidermal integrity
No
(Nikolsky sign)?
Run a gloved finger
over the burn
Yes
No
Is it
slippery?
Red
Burn colour
White
Deep dermal
Other signs: decreased
Full thickness
sensation; absent or reduced
refilling after blanching; fixed
Other signs: anaesthesia; no
mottling; little or no ooze
refilling after blanching; may be
amber and translucent with visible
black vessels; may be waxy; hairs
fall out easily; dry
Burn size calculation: children
The body proportions of  children necessitate adjustment of the above-mentioned scales. An infant’s head is proportionally larger than an adult’s and this adjustment is represented on the modified Lund and Browder chart for children, where at birth the head represents 18% and the lower limbs 13.5% each. For each year 1% is subtracted from the head, with 0.5% being added to each lower limb until the age of  10, when the body proportions are roughly equivalent to those of  an adult. Summary box 46.11 Assessing the area of a burn /uni25CF /uni25CF - /uni25CF
The patient’s hand is 1% TBSA, and is a useful guide in small
burns
The Lund and Browder chart is useful in larger burns
The ‘rule of nines’ is adequate for a
/f_i
rst approximation only
The first indication of  burn depth comes from the history ( Table 46.2 ). The burning of  human skin is temperature and time dependent. It takes 6 hours for skin maintained at 44°C to su ff er irreversible changes, but a surface temperature of  70°C for 1 second is all that is needed to produce epidermal destruc tion. Taking an example of  hot water at 65°C: exposure for 45 seconds will produce a full-thickness burn; for 15 seconds a deep partial-thickness burn; and for 7 seconds a superficial partial-thickness burn ( Figure 46.3 ). Summary box 46.12 Assessing the depth of a burn /uni25CF /uni25CF /uni25CF /uni25CF Superficial partial-thickness burns The damage in these burns goes no deeper than the papillary dermis. The clinical features are blistering and/or loss of  the epidermis. The underlying dermis is pink and moist and will exudate fluid for up to 36 hours post burn injury . The capillary return is clearly visible when blanched. There is little or no fixed capillary staining. Pinprick sensation is normal. Super ficial partial-thickness burns heal without residual scarring in 2 /uni00A0 weeks ( Figure 46.4 ). The treatment is supportive. Deep partial-thickness burn These burns involve damage to the deeper parts of  the reticular dermis. Clinically , the epidermis is usually lost. The exposed dermis is not as moist as that in a superficial burn. There is often abundant fixed capillary staining, especially if  examined after 48 hours. The colour does not blanch with pressure under the examiner’s finger. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle. Deep dermal burns take 3 weeks or more to heal without surgery and usually lead to hypertrophic scarring. - -
TABLE 46.2
Causes of burns and their likely depth.
Cause of burn
Probable depth of burn
Scald
Super
/f_i
cial, but with deep dermal patches in
the absence of good
/f_i
rst aid. Will be deep in
a young infant or the elderly
Fat burns
Deep dermal to full thickness
Flame burns
Mixed deep dermal and full thickness
Alkali burns,
Often deep dermal or full thickness
including cement
Acid burns
Weak concentrations super
/f_i
cial; strong
concentrations deep dermal
Electrical contact
Full thickness
burn
The history is important: temperature, time and burning
material
Super
/f_i
cial burns have capillary
/f_i
lling
Deep partial-thickness burns do not blanch, but have some
sensation
Full-thickness burns feel leathery and have no sensation
Figure 46.3
Photograph showing the difference between super
/f_i
cial
dermal (S/D) and deep dermal (D). The burn wound is less than
24 hours old and has been meticulously cleaned in theatre.
(a)
(b)
(c)
Figure 46.4
(a)
A super
/f_i
cial partial-thickness scald 24 hours after
injury. The dermis is pink and blanches to pressure.
(b)
At 2 weeks,
the wound is healed but lacks pigment.
(c)
At 3 months, the pigment
is returning.
Full-thickness burns The whole of  the dermis is destroyed in these burns. Clinically , they have a hard, leathery feel. The appearance can vary from that similar to the patient’s normal skin to charred black, depending upon the intensity of  the heat. There is no capillary return. Often, thrombosed vessels can be seen under the skin. These burns are completely anaesthetic – a needle can be stuck deep into the dermis without any pain or bleeding. Concept of two burn depths In treatment terms, there are two burn depths. There are those burns which, with optimal support and good wound manage ment, are superficial enough to heal spontaneously and quickly (within 14 days), leaving an excellent functional and cosmetic result, defined in this chapter as group A. Group B includes those burns that ar e su ffi ciently deep to undergo prolonged healing by secondary intention. This process takes weeks or months and involves the degradation and separation of  the eschar (burned tissue), the formation of  granulation tissue and the process of  wound contraction. The course of  healing by secondary intention must be aborted and replaced as closely as possible by a process of  primary intention healing with direct closure, skin graft and skin substitutes. Figure 46.5 is a pictorial representation of  this with burns in the pink section to the left of  the line belonging to group A and burns in the blue section to the right to group B. Pyotr Nikolsky , 1858–1940, Russian dermatologist.
Epidermal
Yes
Thin walled or popped Type of blister
Thick walled
Superficial dermal
Other signs: blanches
Mid-dermal
with pressure; very
painful; very oozy
Other signs: some mottling;
blanching sluggish; darker
red base; some anaesthesia;
less oozy
Figure 46.5
Protocol for assessing depth of burn. The Nikolsky sign refers to detachment of the epidermis from the dermis when lateral pressure
is applied to the skin.
Is there epidermal integrity
No
(Nikolsky sign)?
Run a gloved finger
over the burn
Yes
No
Is it
slippery?
Red
Burn colour
White
Deep dermal
Other signs: decreased
Full thickness
sensation; absent or reduced
refilling after blanching; fixed
Other signs: anaesthesia; no
mottling; little or no ooze
refilling after blanching; may be
amber and translucent with visible
black vessels; may be waxy; hairs
fall out easily; dry

Changes to the intestine
Changes to the intestine
The inflammatory stimulus and shock can cause microvascular damage and ischaemia to the gut mucosa. This reduces gut motility and can prevent the absorption of food. Failure of enteral feeding in a patient with a large burn is a life-threatening complication. This process also increases the translocation of  gut bacteria, which can become an important source of infection in large burns. Gut mucosal swelling, gastric stasis and peritoneal oedema can also cause abdominal compartment syndrome, which splints the diaphragm and increases the airway pressures needed for respiration. Changes to the intestine
The inflammatory stimulus and shock can cause microvascular damage and ischaemia to the gut mucosa. This reduces gut motility and can prevent the absorption of food. Failure of enteral feeding in a patient with a large burn is a life-threatening complication. This process also increases the translocation of  gut bacteria, which can become an important source of infection in large burns. Gut mucosal swelling, gastric stasis and peritoneal oedema can also cause abdominal compartment syndrome, which splints the diaphragm and increases the airway pressures needed for respiration. Changes to the intestine
The inflammatory stimulus and shock can cause microvascular damage and ischaemia to the gut mucosa. This reduces gut motility and can prevent the absorption of food. Failure of enteral feeding in a patient with a large burn is a life-threatening complication. This process also increases the translocation of  gut bacteria, which can become an important source of infection in large burns. Gut mucosal swelling, gastric stasis and peritoneal oedema can also cause abdominal compartment syndrome, which splints the diaphragm and increases the airway pressures needed for respiration.

Chemical injuries
Chemical injuries
There are over 70 /uni00A0 000 di ff erent chemicals in regular use within industry . Occasionally , these cause burns. Ultimately , there destruction of  the skin and the second is any poisoning caused by systemic absorption. The initial management of  chemical burns is to ascertain whether it is in a solid powder or liquid state. Water irrigation should not be used for solid powders as this will result in further reaction, these substances require removal with forceps. Exam ples include phosphorous, a component of military devices and elemental sodium, which is occasionally present in laboratory explosions. It is rare that a medical practitioner will encounter these bur ns. The more common injuries are caused by either acids or alkalis. Alkalis are usually the more destructive and are especially dangerous if  they have come into contact with the eyes. After copious lavage, the next step in the management of any chemical injury is to identify the chemical and its concen tration and to elucidate whether there is any underlying threat to the patient’s life if  absorbed systemically . Summary box 46.20 Chemical burns /uni25CF /uni25CF /uni25CF One acid that is a common cause of  acid burns is hydro fluoric acid, although generally a weak acid, it chelates cal cium and magnesium in tissues. Burns a ff ecting the fingers and caused by dilute acid are relatively common. The initial management is with calcium gluconate gel topically; how ever, severe b urns or burns to large areas of  the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10% gel. If  the patient has been burnt with a con centration greater than 50%, the threat of  hypocalcaemia and subsequent arrhythmias then becomes high, and this is an indication for acute early excision. It is best not to split-skin graft these hydrofluoric acid wounds initially , b ut to do this at a delayed stage.
Damage is from corrosion and poisoning
Copious lavage with water helps in most cases
Then identify the chemical and assess the risks of absorption
Chemical injuries
There are over 70 /uni00A0 000 di ff erent chemicals in regular use within industry . Occasionally , these cause burns. Ultimately , there destruction of  the skin and the second is any poisoning caused by systemic absorption. The initial management of  chemical burns is to ascertain whether it is in a solid powder or liquid state. Water irrigation should not be used for solid powders as this will result in further reaction, these substances require removal with forceps. Exam ples include phosphorous, a component of military devices and elemental sodium, which is occasionally present in laboratory explosions. It is rare that a medical practitioner will encounter these bur ns. The more common injuries are caused by either acids or alkalis. Alkalis are usually the more destructive and are especially dangerous if  they have come into contact with the eyes. After copious lavage, the next step in the management of any chemical injury is to identify the chemical and its concen tration and to elucidate whether there is any underlying threat to the patient’s life if  absorbed systemically . Summary box 46.20 Chemical burns /uni25CF /uni25CF /uni25CF One acid that is a common cause of  acid burns is hydro fluoric acid, although generally a weak acid, it chelates cal cium and magnesium in tissues. Burns a ff ecting the fingers and caused by dilute acid are relatively common. The initial management is with calcium gluconate gel topically; how ever, severe b urns or burns to large areas of  the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10% gel. If  the patient has been burnt with a con centration greater than 50%, the threat of  hypocalcaemia and subsequent arrhythmias then becomes high, and this is an indication for acute early excision. It is best not to split-skin graft these hydrofluoric acid wounds initially , b ut to do this at a delayed stage.
Damage is from corrosion and poisoning
Copious lavage with water helps in most cases
Then identify the chemical and assess the risks of absorption
Chemical injuries
There are over 70 /uni00A0 000 di ff erent chemicals in regular use within industry . Occasionally , these cause burns. Ultimately , there destruction of  the skin and the second is any poisoning caused by systemic absorption. The initial management of  chemical burns is to ascertain whether it is in a solid powder or liquid state. Water irrigation should not be used for solid powders as this will result in further reaction, these substances require removal with forceps. Exam ples include phosphorous, a component of military devices and elemental sodium, which is occasionally present in laboratory explosions. It is rare that a medical practitioner will encounter these bur ns. The more common injuries are caused by either acids or alkalis. Alkalis are usually the more destructive and are especially dangerous if  they have come into contact with the eyes. After copious lavage, the next step in the management of any chemical injury is to identify the chemical and its concen tration and to elucidate whether there is any underlying threat to the patient’s life if  absorbed systemically . Summary box 46.20 Chemical burns /uni25CF /uni25CF /uni25CF One acid that is a common cause of  acid burns is hydro fluoric acid, although generally a weak acid, it chelates cal cium and magnesium in tissues. Burns a ff ecting the fingers and caused by dilute acid are relatively common. The initial management is with calcium gluconate gel topically; how ever, severe b urns or burns to large areas of  the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10% gel. If  the patient has been burnt with a con centration greater than 50%, the threat of  hypocalcaemia and subsequent arrhythmias then becomes high, and this is an indication for acute early excision. It is best not to split-skin graft these hydrofluoric acid wounds initially , b ut to do this at a delayed stage.
Damage is from corrosion and poisoning
Copious lavage with water helps in most cases
Then identify the chemical and assess the risks of absorption

Cold injuries
Cold injuries
Cold injuries are principally divided into two types: acute cold injuries from industrial accidents and frostbite. Exposure to liquid petroleum gas (LPG), liquid nitro - gen and other such liquids will cause epidermal and dermal destruction. The tissue is more resistant to cold injury than to heat injury , and the inflammatory reaction is not as marked. The assessment of  depth of  injury is more di ffi cult, so it is rare to make the decision for surgery early . Frostbite injuries a ff ect the peripheries in cold climates. - The initial treatment is with rapid rewarming in a bath at - 42°C. The cold injury produces delayed microvascular dam - age similar to tha t of  ischaemia–reperfusion injury . The level of  damage is di ffi cult to assess, and surgery usually does not - play a role in its management, which is conservative, until there is absolute demarcation of  the le vel of  injury . - Cold injuries
Cold injuries are principally divided into two types: acute cold injuries from industrial accidents and frostbite. Exposure to liquid petroleum gas (LPG), liquid nitro - gen and other such liquids will cause epidermal and dermal destruction. The tissue is more resistant to cold injury than to heat injury , and the inflammatory reaction is not as marked. The assessment of  depth of  injury is more di ffi cult, so it is rare to make the decision for surgery early . Frostbite injuries a ff ect the peripheries in cold climates. - The initial treatment is with rapid rewarming in a bath at - 42°C. The cold injury produces delayed microvascular dam - age similar to tha t of  ischaemia–reperfusion injury . The level of  damage is di ffi cult to assess, and surgery usually does not - play a role in its management, which is conservative, until there is absolute demarcation of  the le vel of  injury . - Cold injuries
Cold injuries are principally divided into two types: acute cold injuries from industrial accidents and frostbite. Exposure to liquid petroleum gas (LPG), liquid nitro - gen and other such liquids will cause epidermal and dermal destruction. The tissue is more resistant to cold injury than to heat injury , and the inflammatory reaction is not as marked. The assessment of  depth of  injury is more di ffi cult, so it is rare to make the decision for surgery early . Frostbite injuries a ff ect the peripheries in cold climates. - The initial treatment is with rapid rewarming in a bath at - 42°C. The cold injury produces delayed microvascular dam - age similar to tha t of  ischaemia–reperfusion injury . The level of  damage is di ffi cult to assess, and surgery usually does not - play a role in its management, which is conservative, until there is absolute demarcation of  the le vel of  injury . -

Colloid resuscitation
Colloid resuscitation
The most commonly used colloid is human albumin solution. Plasma proteins are responsible for inward oncotic pressure that counteracts the outward capillary hydrostatic pressure. Albumin should be preferably administered after the first 12 hours post burn as the massive fluid shifts drive proteins out of  the cells. The most common colloid-based formula is the Muir and Barclay formula, which estimates the amount of fluid tha needs to be infused during the first 36 hours post burn: /uni25CF the basic formula is: TBSA% × weight (kg) × 0.5 = one portion; /uni25CF six portions are given in total over 36 hours: /uni25CF give one infusion 4 hourly for 12 hours (three portions in total); Alexis Frank Hartmann , 1898–1964, pediatrician, St Louis, MO, USA, described the solution; should not be confused with the name of  Henri Albert Charles Antoine Hartmann, French surgeon, who described the operation that goes by his name. Sidney Ringer , 1835–1910, Professor of  Clinical Medicine, University College Hospital, London, UK. Parkland Memorial Hospital , Dallas, TX, USA. Ian Fraser Kerr Muir , 1921–2008, plastic surgeon, Aberdeen Royal Infirmary , Aberdeen, UK, referred to as ‘a gentle giant of  plastic surgery’. Thomas Laird Barclay , 1925–2007, plastic surgeon, Royal Infirmary , Bradford, UK. in total); /uni25CF the final infusion to be given over 12 hours. The original Muir and Barclay formula utilised fresh-frozen plasma as the colloid of  choice. Both albumin and fresh- frozen plasma are maintained in the blood bank and are more expensive; excessiv e use can cause additional pressure on the renal system. Colloid resuscitation
The most commonly used colloid is human albumin solution. Plasma proteins are responsible for inward oncotic pressure that counteracts the outward capillary hydrostatic pressure. Albumin should be preferably administered after the first 12 hours post burn as the massive fluid shifts drive proteins out of  the cells. The most common colloid-based formula is the Muir and Barclay formula, which estimates the amount of fluid tha needs to be infused during the first 36 hours post burn: /uni25CF the basic formula is: TBSA% × weight (kg) × 0.5 = one portion; /uni25CF six portions are given in total over 36 hours: /uni25CF give one infusion 4 hourly for 12 hours (three portions in total); Alexis Frank Hartmann , 1898–1964, pediatrician, St Louis, MO, USA, described the solution; should not be confused with the name of  Henri Albert Charles Antoine Hartmann, French surgeon, who described the operation that goes by his name. Sidney Ringer , 1835–1910, Professor of  Clinical Medicine, University College Hospital, London, UK. Parkland Memorial Hospital , Dallas, TX, USA. Ian Fraser Kerr Muir , 1921–2008, plastic surgeon, Aberdeen Royal Infirmary , Aberdeen, UK, referred to as ‘a gentle giant of  plastic surgery’. Thomas Laird Barclay , 1925–2007, plastic surgeon, Royal Infirmary , Bradford, UK. in total); /uni25CF the final infusion to be given over 12 hours. The original Muir and Barclay formula utilised fresh-frozen plasma as the colloid of  choice. Both albumin and fresh- frozen plasma are maintained in the blood bank and are more expensive; excessiv e use can cause additional pressure on the renal system. Colloid resuscitation
The most commonly used colloid is human albumin solution. Plasma proteins are responsible for inward oncotic pressure that counteracts the outward capillary hydrostatic pressure. Albumin should be preferably administered after the first 12 hours post burn as the massive fluid shifts drive proteins out of  the cells. The most common colloid-based formula is the Muir and Barclay formula, which estimates the amount of fluid tha needs to be infused during the first 36 hours post burn: /uni25CF the basic formula is: TBSA% × weight (kg) × 0.5 = one portion; /uni25CF six portions are given in total over 36 hours: /uni25CF give one infusion 4 hourly for 12 hours (three portions in total); Alexis Frank Hartmann , 1898–1964, pediatrician, St Louis, MO, USA, described the solution; should not be confused with the name of  Henri Albert Charles Antoine Hartmann, French surgeon, who described the operation that goes by his name. Sidney Ringer , 1835–1910, Professor of  Clinical Medicine, University College Hospital, London, UK. Parkland Memorial Hospital , Dallas, TX, USA. Ian Fraser Kerr Muir , 1921–2008, plastic surgeon, Aberdeen Royal Infirmary , Aberdeen, UK, referred to as ‘a gentle giant of  plastic surgery’. Thomas Laird Barclay , 1925–2007, plastic surgeon, Royal Infirmary , Bradford, UK. in total); /uni25CF the final infusion to be given over 12 hours. The original Muir and Barclay formula utilised fresh-frozen plasma as the colloid of  choice. Both albumin and fresh- frozen plasma are maintained in the blood bank and are more expensive; excessiv e use can cause additional pressure on the renal system.

Crystalloid resuscitation
Crystalloid resuscitation
Hartmann’s solution or Ringer’s lactate is the most commonly used crystalloid as it most closely replicates the osmolality of plasma. It is considerably less expensive than colloid and can maintain intravascular volume. The modified Parkland formula is the most commonly used: TBSA% burn × weight (kg) × 4 = volume in mL The first half is given in 8 hours and the second over 16 hours to complete the 24-hour resuscitation time frame. In children maintenance fluid must also be given. This is normally dextrose–saline given as follo ws: /uni25CF 100 /uni00A0 mL/kg for 24 hours for the first 10 /uni00A0 kg; /uni25CF 50 /uni00A0 mL/kg for the next 10 /uni00A0 kg; /uni25CF 20 /uni00A0 mL/kg for 24 hours for each kilogram over 20 /uni00A0 kg body weight. Crystalloid resuscitation requires eight-fold greater vol umes than colloid which can result in increased tissue oedema. Crystalloid resuscitation
Hartmann’s solution or Ringer’s lactate is the most commonly used crystalloid as it most closely replicates the osmolality of plasma. It is considerably less expensive than colloid and can maintain intravascular volume. The modified Parkland formula is the most commonly used: TBSA% burn × weight (kg) × 4 = volume in mL The first half is given in 8 hours and the second over 16 hours to complete the 24-hour resuscitation time frame. In children maintenance fluid must also be given. This is normally dextrose–saline given as follo ws: /uni25CF 100 /uni00A0 mL/kg for 24 hours for the first 10 /uni00A0 kg; /uni25CF 50 /uni00A0 mL/kg for the next 10 /uni00A0 kg; /uni25CF 20 /uni00A0 mL/kg for 24 hours for each kilogram over 20 /uni00A0 kg body weight. Crystalloid resuscitation requires eight-fold greater vol umes than colloid which can result in increased tissue oedema. Crystalloid resuscitation
Hartmann’s solution or Ringer’s lactate is the most commonly used crystalloid as it most closely replicates the osmolality of plasma. It is considerably less expensive than colloid and can maintain intravascular volume. The modified Parkland formula is the most commonly used: TBSA% burn × weight (kg) × 4 = volume in mL The first half is given in 8 hours and the second over 16 hours to complete the 24-hour resuscitation time frame. In children maintenance fluid must also be given. This is normally dextrose–saline given as follo ws: /uni25CF 100 /uni00A0 mL/kg for 24 hours for the first 10 /uni00A0 kg; /uni25CF 50 /uni00A0 mL/kg for the next 10 /uni00A0 kg; /uni25CF 20 /uni00A0 mL/kg for 24 hours for each kilogram over 20 /uni00A0 kg body weight. Crystalloid resuscitation requires eight-fold greater vol umes than colloid which can result in increased tissue oedema.

Danger to peripheral circulation
Danger to peripheral circulation
In full-thickness burns, the collagen fibres are coagulated. The normal elasticity of  the skin is lost. A circumferential full- thickness burn to a limb acts as a tourniquet as the limb swells. If  untreated, this will progress to limb-threatening ischaemia. Summary box 46.7 Other complications of burns /uni25CF /uni25CF /uni25CF
Infection from the burn site, lungs, gut, lines and catheters
Malabsorption from the gut
Circumferential burns may compromise circulation to a limb
Danger to peripheral circulation
In full-thickness burns, the collagen fibres are coagulated. The normal elasticity of  the skin is lost. A circumferential full- thickness burn to a limb acts as a tourniquet as the limb swells. If  untreated, this will progress to limb-threatening ischaemia. Summary box 46.7 Other complications of burns /uni25CF /uni25CF /uni25CF
Infection from the burn site, lungs, gut, lines and catheters
Malabsorption from the gut
Circumferential burns may compromise circulation to a limb
Danger to peripheral circulation
In full-thickness burns, the collagen fibres are coagulated. The normal elasticity of  the skin is lost. A circumferential full- thickness burn to a limb acts as a tourniquet as the limb swells. If  untreated, this will progress to limb-threatening ischaemia. Summary box 46.7 Other complications of burns /uni25CF /uni25CF /uni25CF
Infection from the burn site, lungs, gut, lines and catheters
Malabsorption from the gut
Circumferential burns may compromise circulation to a limb

Delayed reconstruction and scar management
Delayed reconstruction and scar management
Delayed reconstruction of  burn injuries is common for large full-thickness burns. These techniques were pioneered by McIndoe and Gillies. In the early healing period, acute contractures around the eye need particular attention. Eyelids must be grafted at the first sign of  di ffi culty in closing the eyelids, and this must be done before the patient has any symptoms of  exposure keratitis. Other areas that require early intervention are any contracture causing significant loss of range of  movement of  a joint. This is particularly important in the hand and axilla. An established contracture can be treated in a number of ways. Burn alopecia is best treated with tissue expansion of the unburned hair-bearing skin. Tissue expansion is also a use - ful technique for isolated burns and other areas with adjacent nor mal skin. Z-plasty is useful where there is a single band and a transposition flap is useful in wider bands of  scarring ( Figure 46.11 ). In areas of  circumferential or very broad ar eas of scarring, the only real treatment is incision and replacement with tissue. By far the best tissue for replacement is from either a full-thickness graft, dermal substitute with split-skin graft or vascularised tissue as in a free flap. Summary box 46.18 Delayed reconstruction of burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Eyelids must be treated before exposure keratitis arises
Transposition
/f_l
aps and Z-plasties with or without tissue
expansion are useful
Full-thickness grafts and free
/f_l
aps may be needed for large or
dif
/f_i
cult areas
Hypertrophy is treated with pressure garments
Pharmacological treatment of itch is important
ments. These need to be worn for a period of 6–18 months. Where it is di ffi cult to apply pressure with pressure garments, or with smaller areas of  hypertrophy , silicone patches will speed scar ma turation, as will intralesional injection of steroid. Itching and dermatitis in burn scar areas are common. Pharmacological treatment of itch is an essential adjunct to therapy . Delayed reconstruction and scar management
Delayed reconstruction of  burn injuries is common for large full-thickness burns. These techniques were pioneered by McIndoe and Gillies. In the early healing period, acute contractures around the eye need particular attention. Eyelids must be grafted at the first sign of  di ffi culty in closing the eyelids, and this must be done before the patient has any symptoms of  exposure keratitis. Other areas that require early intervention are any contracture causing significant loss of range of  movement of  a joint. This is particularly important in the hand and axilla. An established contracture can be treated in a number of ways. Burn alopecia is best treated with tissue expansion of the unburned hair-bearing skin. Tissue expansion is also a use - ful technique for isolated burns and other areas with adjacent nor mal skin. Z-plasty is useful where there is a single band and a transposition flap is useful in wider bands of  scarring ( Figure 46.11 ). In areas of  circumferential or very broad ar eas of scarring, the only real treatment is incision and replacement with tissue. By far the best tissue for replacement is from either a full-thickness graft, dermal substitute with split-skin graft or vascularised tissue as in a free flap. Summary box 46.18 Delayed reconstruction of burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Eyelids must be treated before exposure keratitis arises
Transposition
/f_l
aps and Z-plasties with or without tissue
expansion are useful
Full-thickness grafts and free
/f_l
aps may be needed for large or
dif
/f_i
cult areas
Hypertrophy is treated with pressure garments
Pharmacological treatment of itch is important
ments. These need to be worn for a period of 6–18 months. Where it is di ffi cult to apply pressure with pressure garments, or with smaller areas of  hypertrophy , silicone patches will speed scar ma turation, as will intralesional injection of steroid. Itching and dermatitis in burn scar areas are common. Pharmacological treatment of itch is an essential adjunct to therapy . Delayed reconstruction and scar management
Delayed reconstruction of  burn injuries is common for large full-thickness burns. These techniques were pioneered by McIndoe and Gillies. In the early healing period, acute contractures around the eye need particular attention. Eyelids must be grafted at the first sign of  di ffi culty in closing the eyelids, and this must be done before the patient has any symptoms of  exposure keratitis. Other areas that require early intervention are any contracture causing significant loss of range of  movement of  a joint. This is particularly important in the hand and axilla. An established contracture can be treated in a number of ways. Burn alopecia is best treated with tissue expansion of the unburned hair-bearing skin. Tissue expansion is also a use - ful technique for isolated burns and other areas with adjacent nor mal skin. Z-plasty is useful where there is a single band and a transposition flap is useful in wider bands of  scarring ( Figure 46.11 ). In areas of  circumferential or very broad ar eas of scarring, the only real treatment is incision and replacement with tissue. By far the best tissue for replacement is from either a full-thickness graft, dermal substitute with split-skin graft or vascularised tissue as in a free flap. Summary box 46.18 Delayed reconstruction of burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Eyelids must be treated before exposure keratitis arises
Transposition
/f_l
aps and Z-plasties with or without tissue
expansion are useful
Full-thickness grafts and free
/f_l
aps may be needed for large or
dif
/f_i
cult areas
Hypertrophy is treated with pressure garments
Pharmacological treatment of itch is important
ments. These need to be worn for a period of 6–18 months. Where it is di ffi cult to apply pressure with pressure garments, or with smaller areas of  hypertrophy , silicone patches will speed scar ma turation, as will intralesional injection of steroid. Itching and dermatitis in burn scar areas are common. Pharmacological treatment of itch is an essential adjunct to therapy .

Energy balance and nutrition
Energy balance and nutrition
Any adult with a burn greater than 15% (10% in children) of TBSA has an increased nutritional requirement. All patients with burns of  20% of  TBSA or greater should receive a nasogastric or nasojejunal tube and feeding should start within 6 hours of  the injury to reduce gut mucosal damage. The advantage of  the nasojejunal tube is that fasting is not necessary for trips to theatre. A number of  di ff erent formulae are available to calculate the energy requirements of  patients. This should be managed by a specialist dietician as part of  the multidisciplinar y team. n injuries are catabolic in the acute episode. Success - Bur ful management of  the patient’s energy balance involves a number of strategies. The catabolic drive continues while the wound r emains unhealed and, therefore, rapid excision of  the - burn and stable coverage of  the wound are the most significant factors in reversing this. Obligatory energy utilisation must be reduced to a minimum by keeping the patient warm with good uscular environmental control. The excess energy requirements must be provided for and the nutritional balance monitored by mea - suring weight and nitrogen balance.
Day 200
Day 200
Energy balance and nutrition
Any adult with a burn greater than 15% (10% in children) of TBSA has an increased nutritional requirement. All patients with burns of  20% of  TBSA or greater should receive a nasogastric or nasojejunal tube and feeding should start within 6 hours of  the injury to reduce gut mucosal damage. The advantage of  the nasojejunal tube is that fasting is not necessary for trips to theatre. A number of  di ff erent formulae are available to calculate the energy requirements of  patients. This should be managed by a specialist dietician as part of  the multidisciplinar y team. n injuries are catabolic in the acute episode. Success - Bur ful management of  the patient’s energy balance involves a number of strategies. The catabolic drive continues while the wound r emains unhealed and, therefore, rapid excision of  the - burn and stable coverage of  the wound are the most significant factors in reversing this. Obligatory energy utilisation must be reduced to a minimum by keeping the patient warm with good uscular environmental control. The excess energy requirements must be provided for and the nutritional balance monitored by mea - suring weight and nitrogen balance.
Day 200
Day 200
Energy balance and nutrition
Any adult with a burn greater than 15% (10% in children) of TBSA has an increased nutritional requirement. All patients with burns of  20% of  TBSA or greater should receive a nasogastric or nasojejunal tube and feeding should start within 6 hours of  the injury to reduce gut mucosal damage. The advantage of  the nasojejunal tube is that fasting is not necessary for trips to theatre. A number of  di ff erent formulae are available to calculate the energy requirements of  patients. This should be managed by a specialist dietician as part of  the multidisciplinar y team. n injuries are catabolic in the acute episode. Success - Bur ful management of  the patient’s energy balance involves a number of strategies. The catabolic drive continues while the wound r emains unhealed and, therefore, rapid excision of  the - burn and stable coverage of  the wound are the most significant factors in reversing this. Obligatory energy utilisation must be reduced to a minimum by keeping the patient warm with good uscular environmental control. The excess energy requirements must be provided for and the nutritional balance monitored by mea - suring weight and nitrogen balance.
Day 200
Day 200

Escharotomy
Escharotomy
Circumferential full-thickness burns to the limbs and torso require emergency surgery . The burn has a tourniquet-like e ff ect compromising respiration (torso) and peripheral circu lation (limbs). The tourniquet e ff ect of  this injury is treated by incising the whole length of  full-thickness burns ( Table 46.3 For the chest this comprises two longitudinal and two hor izontal incisions. Perfor mance of chest escharotomy should show evidence of  immediate improvement of  respiration and, if  intubated, the ventilation pressures. F or the limbs the escharotomy incision is performed in the midaxial line, avoid ing major nerves ( Figure 46.7 ). An escharotomy can cause sig nificant blood loss; therefore consider use of  cutting diathermy and have appropriate dressings and blood available. Escharotomy
Circumferential full-thickness burns to the limbs and torso require emergency surgery . The burn has a tourniquet-like e ff ect compromising respiration (torso) and peripheral circu lation (limbs). The tourniquet e ff ect of  this injury is treated by incising the whole length of  full-thickness burns ( Table 46.3 For the chest this comprises two longitudinal and two hor izontal incisions. Perfor mance of chest escharotomy should show evidence of  immediate improvement of  respiration and, if  intubated, the ventilation pressures. F or the limbs the escharotomy incision is performed in the midaxial line, avoid ing major nerves ( Figure 46.7 ). An escharotomy can cause sig nificant blood loss; therefore consider use of  cutting diathermy and have appropriate dressings and blood available. Escharotomy
Circumferential full-thickness burns to the limbs and torso require emergency surgery . The burn has a tourniquet-like e ff ect compromising respiration (torso) and peripheral circu lation (limbs). The tourniquet e ff ect of  this injury is treated by incising the whole length of  full-thickness burns ( Table 46.3 For the chest this comprises two longitudinal and two hor izontal incisions. Perfor mance of chest escharotomy should show evidence of  immediate improvement of  respiration and, if  intubated, the ventilation pressures. F or the limbs the escharotomy incision is performed in the midaxial line, avoid ing major nerves ( Figure 46.7 ). An escharotomy can cause sig nificant blood loss; therefore consider use of  cutting diathermy and have appropriate dressings and blood available.

FLUID RESUSCITATION
FLUID RESUSCITATION
As the understanding of  ‘fluid shifts’ developed, the intro - duction of  fluid resuscitation guidelines greatly improved the survival rates for patients with large burns. Standard guidelines and formulae are taught to emergency department and first - r esponder personnel. Resuscitation fluid should commence from time of  burn injury and any delay in commencement must be caught up. Intravenous resuscitation is appropriate for any adult with a b urn greater than 15% TBSA and any child with a burn greater than 10% TBSA. Extremes of  age require extra car e: for children, additional maintenance fluid is required; in the - elderly , judicious monitoring is necessary owing to concurrent comorbidities and the inherent physiology of  ageing. Depending on resources available, the commencement of intravenous fluid resuscitation approaches 30% TBSA in some countries. If  oral resuscitation is necessary then additional salt solutions (such as Dioralyte) are required as hyponatraemia and wa ter intoxication can be fatal. There are three variables in the calculation of  fluid require - ments: the percentage of  TBSA burned, the weight of  the patient and the rate/type of  fluid. Fluid loss is maximum in the first 8 hours and slows by 24–36 hours, by which stage normal fluid replacement is r equired. There are three main fluids used in the resuscitation stage: crystalloid (by far the most common), colloid and, in advantages and disadvantages. FLUID RESUSCITATION
As the understanding of  ‘fluid shifts’ developed, the intro - duction of  fluid resuscitation guidelines greatly improved the survival rates for patients with large burns. Standard guidelines and formulae are taught to emergency department and first - r esponder personnel. Resuscitation fluid should commence from time of  burn injury and any delay in commencement must be caught up. Intravenous resuscitation is appropriate for any adult with a b urn greater than 15% TBSA and any child with a burn greater than 10% TBSA. Extremes of  age require extra car e: for children, additional maintenance fluid is required; in the - elderly , judicious monitoring is necessary owing to concurrent comorbidities and the inherent physiology of  ageing. Depending on resources available, the commencement of intravenous fluid resuscitation approaches 30% TBSA in some countries. If  oral resuscitation is necessary then additional salt solutions (such as Dioralyte) are required as hyponatraemia and wa ter intoxication can be fatal. There are three variables in the calculation of  fluid require - ments: the percentage of  TBSA burned, the weight of  the patient and the rate/type of  fluid. Fluid loss is maximum in the first 8 hours and slows by 24–36 hours, by which stage normal fluid replacement is r equired. There are three main fluids used in the resuscitation stage: crystalloid (by far the most common), colloid and, in advantages and disadvantages. FLUID RESUSCITATION
As the understanding of  ‘fluid shifts’ developed, the intro - duction of  fluid resuscitation guidelines greatly improved the survival rates for patients with large burns. Standard guidelines and formulae are taught to emergency department and first - r esponder personnel. Resuscitation fluid should commence from time of  burn injury and any delay in commencement must be caught up. Intravenous resuscitation is appropriate for any adult with a b urn greater than 15% TBSA and any child with a burn greater than 10% TBSA. Extremes of  age require extra car e: for children, additional maintenance fluid is required; in the - elderly , judicious monitoring is necessary owing to concurrent comorbidities and the inherent physiology of  ageing. Depending on resources available, the commencement of intravenous fluid resuscitation approaches 30% TBSA in some countries. If  oral resuscitation is necessary then additional salt solutions (such as Dioralyte) are required as hyponatraemia and wa ter intoxication can be fatal. There are three variables in the calculation of  fluid require - ments: the percentage of  TBSA burned, the weight of  the patient and the rate/type of  fluid. Fluid loss is maximum in the first 8 hours and slows by 24–36 hours, by which stage normal fluid replacement is r equired. There are three main fluids used in the resuscitation stage: crystalloid (by far the most common), colloid and, in advantages and disadvantages.

FURTHER READING
FURTHER READING
Australian and New Zealand Burn Association. Emergency management of  severe burns (EMSB) Course manual , 19th edn, pre-course reading. - Australian and New Zealand Burn Association, 2021. Herndon D (ed.). T otal burn care , 5th edn. Philadelphia, PA: Saunders and Elsevier, 2017. FURTHER READING
Australian and New Zealand Burn Association. Emergency management of  severe burns (EMSB) Course manual , 19th edn, pre-course reading. - Australian and New Zealand Burn Association, 2021. Herndon D (ed.). T otal burn care , 5th edn. Philadelphia, PA: Saunders and Elsevier, 2017. FURTHER READING
Australian and New Zealand Burn Association. Emergency management of  severe burns (EMSB) Course manual , 19th edn, pre-course reading. - Australian and New Zealand Burn Association, 2021. Herndon D (ed.). T otal burn care , 5th edn. Philadelphia, PA: Saunders and Elsevier, 2017.

Group A burns  superficial dermal partial-thickness burns
Group A burns: superficial dermal partial-thickness burns
There are two key concepts for managing partial-thickness burns: /uni25CF prevent any factor that may result in the burn ‘changing group’, predominantly infection; /uni25CF control pain, particularly during dressing changes and therapy . An array of  treatment options are used worldwide for the treatment of  these wounds, ranging from honey and simple dressings to synthetic biological dressings with porcine collagen or live cultured keratinocytes . The ideal dressing should be easy to apply , non-painful, pain-reducing, simple to manage and locally available. The crucial factor is to prevent the borderline mid-dermal burns from prog ressing to deep dermal. Here, the choice of  dress ing can make the di ff erence between scar and no scar and/or operation and no operation. If  the wound is heavily contaminated as a result of  the accident, then it is prudent to clean the wound formally under a general anaesthetic. With more chronic contamination, silver sulphadiazine cr eam dressing f or 2 or 3 days is very e ff ective and can be changed to a dressing that is more e ffi cient at pro moting healing after this period. The simplest method of  treating a superficial burn wound is by exposure, but this is usually only suitable for small burns on the face as this method is painful and requires an inten sive amount of  nursing support. A v ariation on this theme is to cover the wound with a permeable wound dressing, such ® ® as Mefix or Fixomull . This allows the wounds to dry but, because it is a covering, it avoids the problems of  the wound adhering to sheets and clothes. A similar method of  managing these types of  burn is to place a Vaseline-impregnated gauze (with or without an antiseptic, such as chlorhexidine) over the wound. An alternative is a fenestrated silicone sheet (e.g. ® Mepitel ). To provide antibacterial cover Acticoat dressings with silver nanocrystals are also used. They can be left in place for up to 7 days. More interactive dressings include hydrocolloids and bio logical dressings. Hydrocolloid dressings need to be changed every 3–5 days. They are particularly useful in mix ed-depth burns as the high protease levels under the occlusive dressing aids debridement of  the deeper areas of  burn. They also pro vide a moist environment, which is good for epithelialisation. ® Duoderm is a hydrocolloid dressing. There is good evidence for its role in burns. ® Biosynthetic (e.g. Biobrane ) and natural (e.g. amniotic membranes) dressings also provide good healing environments and do not need to be changed. They are ideal for one-stop management of  superficial burns, being easy to apply and com fortable ( Figure 46.6 ). However, they will become detached if applied to deep dermal wounds as the eschar needs to separate. They are therefore not as useful in mixed-depth wounds. - - - - - -
(b)
(c)
Figure 46.6
Treatment of partial-thickness burns with Biobrane.
(a)
Prior to surgical scrubbing and shaving.
(b)
Following surgical
debridement and application of Biobrane; note that the Biobrane is
adherent to the wound.
(c)
As the burn wound re-epithelialises the
Biobrane lifts and can be trimmed at each dressing change. Normally
the Biobrane is fully removed by 3 weeks.
Treatment goals for group A burns /uni25CF /uni25CF /uni25CF /uni25CF
Prevent burn becoming infected
Use of appropriate dressings
Manage pain
Prevent progression to deeper burn (group B burns)

Group A burns  superficial dermal partial-thickness
Group A burns: superficial dermal partial-thickness burns
There are two key concepts for managing partial-thickness burns: /uni25CF prevent any factor that may result in the burn ‘changing group’, predominantly infection; /uni25CF control pain, particularly during dressing changes and therapy . An array of  treatment options are used worldwide for the treatment of  these wounds, ranging from honey and simple dressings to synthetic biological dressings with porcine collagen or live cultured keratinocytes . The ideal dressing should be easy to apply , non-painful, pain-reducing, simple to manage and locally available. The crucial factor is to prevent the borderline mid-dermal burns from prog ressing to deep dermal. Here, the choice of  dress ing can make the di ff erence between scar and no scar and/or operation and no operation. If  the wound is heavily contaminated as a result of  the accident, then it is prudent to clean the wound formally under a general anaesthetic. With more chronic contamination, silver sulphadiazine cr eam dressing f or 2 or 3 days is very e ff ective and can be changed to a dressing that is more e ffi cient at pro moting healing after this period. The simplest method of  treating a superficial burn wound is by exposure, but this is usually only suitable for small burns on the face as this method is painful and requires an inten sive amount of  nursing support. A v ariation on this theme is to cover the wound with a permeable wound dressing, such ® ® as Mefix or Fixomull . This allows the wounds to dry but, because it is a covering, it avoids the problems of  the wound adhering to sheets and clothes. A similar method of  managing these types of  burn is to place a Vaseline-impregnated gauze (with or without an antiseptic, such as chlorhexidine) over the wound. An alternative is a fenestrated silicone sheet (e.g. ® Mepitel ). To provide antibacterial cover Acticoat dressings with silver nanocrystals are also used. They can be left in place for up to 7 days. More interactive dressings include hydrocolloids and bio logical dressings. Hydrocolloid dressings need to be changed every 3–5 days. They are particularly useful in mix ed-depth burns as the high protease levels under the occlusive dressing aids debridement of  the deeper areas of  burn. They also pro vide a moist environment, which is good for epithelialisation. ® Duoderm is a hydrocolloid dressing. There is good evidence for its role in burns. ® Biosynthetic (e.g. Biobrane ) and natural (e.g. amniotic membranes) dressings also provide good healing environments and do not need to be changed. They are ideal for one-stop management of  superficial burns, being easy to apply and com fortable ( Figure 46.6 ). However, they will become detached if applied to deep dermal wounds as the eschar needs to separate. They are therefore not as useful in mixed-depth wounds. - - - - - -
(b)
(c)
Figure 46.6
Treatment of partial-thickness burns with Biobrane.
(a)
Prior to surgical scrubbing and shaving.
(b)
Following surgical
debridement and application of Biobrane; note that the Biobrane is
adherent to the wound.
(c)
As the burn wound re-epithelialises the
Biobrane lifts and can be trimmed at each dressing change. Normally
the Biobrane is fully removed by 3 weeks.
Treatment goals for group A burns /uni25CF /uni25CF /uni25CF /uni25CF
Prevent burn becoming infected
Use of appropriate dressings
Manage pain
Prevent progression to deeper burn (group B burns)
Group A burns: superficial dermal partial-thickness burns
There are two key concepts for managing partial-thickness burns: /uni25CF prevent any factor that may result in the burn ‘changing group’, predominantly infection; /uni25CF control pain, particularly during dressing changes and therapy . An array of  treatment options are used worldwide for the treatment of  these wounds, ranging from honey and simple dressings to synthetic biological dressings with porcine collagen or live cultured keratinocytes . The ideal dressing should be easy to apply , non-painful, pain-reducing, simple to manage and locally available. The crucial factor is to prevent the borderline mid-dermal burns from prog ressing to deep dermal. Here, the choice of  dress ing can make the di ff erence between scar and no scar and/or operation and no operation. If  the wound is heavily contaminated as a result of  the accident, then it is prudent to clean the wound formally under a general anaesthetic. With more chronic contamination, silver sulphadiazine cr eam dressing f or 2 or 3 days is very e ff ective and can be changed to a dressing that is more e ffi cient at pro moting healing after this period. The simplest method of  treating a superficial burn wound is by exposure, but this is usually only suitable for small burns on the face as this method is painful and requires an inten sive amount of  nursing support. A v ariation on this theme is to cover the wound with a permeable wound dressing, such ® ® as Mefix or Fixomull . This allows the wounds to dry but, because it is a covering, it avoids the problems of  the wound adhering to sheets and clothes. A similar method of  managing these types of  burn is to place a Vaseline-impregnated gauze (with or without an antiseptic, such as chlorhexidine) over the wound. An alternative is a fenestrated silicone sheet (e.g. ® Mepitel ). To provide antibacterial cover Acticoat dressings with silver nanocrystals are also used. They can be left in place for up to 7 days. More interactive dressings include hydrocolloids and bio logical dressings. Hydrocolloid dressings need to be changed every 3–5 days. They are particularly useful in mix ed-depth burns as the high protease levels under the occlusive dressing aids debridement of  the deeper areas of  burn. They also pro vide a moist environment, which is good for epithelialisation. ® Duoderm is a hydrocolloid dressing. There is good evidence for its role in burns. ® Biosynthetic (e.g. Biobrane ) and natural (e.g. amniotic membranes) dressings also provide good healing environments and do not need to be changed. They are ideal for one-stop management of  superficial burns, being easy to apply and com fortable ( Figure 46.6 ). However, they will become detached if applied to deep dermal wounds as the eschar needs to separate. They are therefore not as useful in mixed-depth wounds. - - - - - -
(b)
(c)
Figure 46.6
Treatment of partial-thickness burns with Biobrane.
(a)
Prior to surgical scrubbing and shaving.
(b)
Following surgical
debridement and application of Biobrane; note that the Biobrane is
adherent to the wound.
(c)
As the burn wound re-epithelialises the
Biobrane lifts and can be trimmed at each dressing change. Normally
the Biobrane is fully removed by 3 weeks.
Treatment goals for group A burns /uni25CF /uni25CF /uni25CF /uni25CF
Prevent burn becoming infected
Use of appropriate dressings
Manage pain
Prevent progression to deeper burn (group B burns)

Group B burns  full-thickness and deep dermal burn
Group B burns: full-thickness and deep dermal burns
The management of  the burn wound remains the same, irre spective of  the size of  the injury . The burn needs to be cleaned, and the size and depth need to be assessed. For full-thickness burns and deep partial-thickness burns an escharotomy may be required. All b ut the very smallest of  full-thickness burns are likely to involve excision. Smaller deep dermal burns of intermittent depth may require 48 hours to declare but will require appropriate dressing management. Group B burns: full-thickness and deep dermal burns
The management of  the burn wound remains the same, irre spective of  the size of  the injury . The burn needs to be cleaned, and the size and depth need to be assessed. For full-thickness burns and deep partial-thickness burns an escharotomy may be required. All b ut the very smallest of  full-thickness burns are likely to involve excision. Smaller deep dermal burns of intermittent depth may require 48 hours to declare but will require appropriate dressing management.

Group B burns  full-thickness and deep dermal burns
Group B burns: full-thickness and deep dermal burns
The management of  the burn wound remains the same, irre spective of  the size of  the injury . The burn needs to be cleaned, and the size and depth need to be assessed. For full-thickness burns and deep partial-thickness burns an escharotomy may be required. All b ut the very smallest of  full-thickness burns are likely to involve excision. Smaller deep dermal burns of intermittent depth may require 48 hours to declare but will require appropriate dressing management.

Hospital care
Hospital care
The principles of  managing an acute burn injury follow the advanced trauma life support (ATLS) principles as per any major trauma: /uni25CF A, airway control; /uni25CF B, breathing and ventilation; /uni25CF C, circulation; /uni25CF D, disability – neurological status; /uni25CF E, exposure with environmental control; /uni25CF F , fluid resuscitation. The possibility of  injury additional to the burn must be sought both clinically and from the history , and treated appro - priately . The major determinants of  severity of  any bur n injury are the percentage of  total body surface area (TBSA) that is burned, the presence of  an inhalation injury , the depth of  the bur n and the age/comorbidities of  the patient. Not all burned patients will need to be admitted to a burns unit, but the main criteria are given in Table 46.1 . Summary box 46.8 Major determinants of the outcome of a burn /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Percentage surface area involved
Depth of burns
Presence of an inhalational injury
Age and comorbidities of the patient
TABLE 46.1
The criteria for acute admission to a burns
unit.
Suspected airway or inhalational injury
Any burn likely to require
/f_l
uid resuscitation
Any burn likely to require surgery
Patients with burns of any signi
/f_i
cance to the hands, face, feet
or perineum
Patients whose psychiatric or social background makes it
inadvisable to send them home
Any suspicion of non-accidental injury
Any burn in a patient at the extremes of age
Any burn with associated potentially serious sequelae,
including high-tension electrical burns and concentrated
hydro
/f_l
uoric acid burns
Summary box 46.9 Recognition of the potentially burned airway /uni25CF /uni25CF /uni25CF /uni25CF The burned airway creates problems for the patient by swelling and, if  not managed proactively , can completely occlude the upper airway . The treatment is to secure the airway with an endotracheal tube until the swelling has subsided, which is usually after about 48 hours ( Figure 46.1 ). The indications of laryngeal oedema, such as a change in voice, stridor, anxiety and respiratory di ffi culty , are very late symptoms. Intubation at this point is often di ffi cult or impossible owing to swelling, so acute cricothyroidotomy equipment must be at hand when intubating patients with a delayed diagnosis of  airway burn. Because of  this, early intubation of  suspected airway burn is the treatment of  choice in such patients. The time frame from burn to airway occlusion is usually between 4 and 24 hours, so there is time to make a sensible decision with senior sta ff and allow an experienced anaesthetist to intubate the patient. Although antidotes exist to some specific components of  smoke (carbon monoxide and cyanide), the treatment of smoke inha lation usually involves endotracheal intubation and ventilatory support (sometimes for several weeks). Summary box 46.10 Initial management of the burned airway /uni25CF /uni25CF /uni25CF
A history of being trapped in the presence of smoke or hot
gases
Burns on the palate or nasal mucosa, or loss of all the hairs in
the nose
Deep burns around the mouth and neck
Hoarseness/change in voice
Early elective intubation is safest
Delay can make intubation very dif
/f_i
cult owing to swelling
Be ready to perform an emergency cricothyroidotomy if
intubation is delayed
Hospital care
The principles of  managing an acute burn injury follow the advanced trauma life support (ATLS) principles as per any major trauma: /uni25CF A, airway control; /uni25CF B, breathing and ventilation; /uni25CF C, circulation; /uni25CF D, disability – neurological status; /uni25CF E, exposure with environmental control; /uni25CF F , fluid resuscitation. The possibility of  injury additional to the burn must be sought both clinically and from the history , and treated appro - priately . The major determinants of  severity of  any bur n injury are the percentage of  total body surface area (TBSA) that is burned, the presence of  an inhalation injury , the depth of  the bur n and the age/comorbidities of  the patient. Not all burned patients will need to be admitted to a burns unit, but the main criteria are given in Table 46.1 . Summary box 46.8 Major determinants of the outcome of a burn /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Percentage surface area involved
Depth of burns
Presence of an inhalational injury
Age and comorbidities of the patient
TABLE 46.1
The criteria for acute admission to a burns
unit.
Suspected airway or inhalational injury
Any burn likely to require
/f_l
uid resuscitation
Any burn likely to require surgery
Patients with burns of any signi
/f_i
cance to the hands, face, feet
or perineum
Patients whose psychiatric or social background makes it
inadvisable to send them home
Any suspicion of non-accidental injury
Any burn in a patient at the extremes of age
Any burn with associated potentially serious sequelae,
including high-tension electrical burns and concentrated
hydro
/f_l
uoric acid burns
Summary box 46.9 Recognition of the potentially burned airway /uni25CF /uni25CF /uni25CF /uni25CF The burned airway creates problems for the patient by swelling and, if  not managed proactively , can completely occlude the upper airway . The treatment is to secure the airway with an endotracheal tube until the swelling has subsided, which is usually after about 48 hours ( Figure 46.1 ). The indications of laryngeal oedema, such as a change in voice, stridor, anxiety and respiratory di ffi culty , are very late symptoms. Intubation at this point is often di ffi cult or impossible owing to swelling, so acute cricothyroidotomy equipment must be at hand when intubating patients with a delayed diagnosis of  airway burn. Because of  this, early intubation of  suspected airway burn is the treatment of  choice in such patients. The time frame from burn to airway occlusion is usually between 4 and 24 hours, so there is time to make a sensible decision with senior sta ff and allow an experienced anaesthetist to intubate the patient. Although antidotes exist to some specific components of  smoke (carbon monoxide and cyanide), the treatment of smoke inha lation usually involves endotracheal intubation and ventilatory support (sometimes for several weeks). Summary box 46.10 Initial management of the burned airway /uni25CF /uni25CF /uni25CF
A history of being trapped in the presence of smoke or hot
gases
Burns on the palate or nasal mucosa, or loss of all the hairs in
the nose
Deep burns around the mouth and neck
Hoarseness/change in voice
Early elective intubation is safest
Delay can make intubation very dif
/f_i
cult owing to swelling
Be ready to perform an emergency cricothyroidotomy if
intubation is delayed
Hospital care
The principles of  managing an acute burn injury follow the advanced trauma life support (ATLS) principles as per any major trauma: /uni25CF A, airway control; /uni25CF B, breathing and ventilation; /uni25CF C, circulation; /uni25CF D, disability – neurological status; /uni25CF E, exposure with environmental control; /uni25CF F , fluid resuscitation. The possibility of  injury additional to the burn must be sought both clinically and from the history , and treated appro - priately . The major determinants of  severity of  any bur n injury are the percentage of  total body surface area (TBSA) that is burned, the presence of  an inhalation injury , the depth of  the bur n and the age/comorbidities of  the patient. Not all burned patients will need to be admitted to a burns unit, but the main criteria are given in Table 46.1 . Summary box 46.8 Major determinants of the outcome of a burn /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF - /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Percentage surface area involved
Depth of burns
Presence of an inhalational injury
Age and comorbidities of the patient
TABLE 46.1
The criteria for acute admission to a burns
unit.
Suspected airway or inhalational injury
Any burn likely to require
/f_l
uid resuscitation
Any burn likely to require surgery
Patients with burns of any signi
/f_i
cance to the hands, face, feet
or perineum
Patients whose psychiatric or social background makes it
inadvisable to send them home
Any suspicion of non-accidental injury
Any burn in a patient at the extremes of age
Any burn with associated potentially serious sequelae,
including high-tension electrical burns and concentrated
hydro
/f_l
uoric acid burns
Summary box 46.9 Recognition of the potentially burned airway /uni25CF /uni25CF /uni25CF /uni25CF The burned airway creates problems for the patient by swelling and, if  not managed proactively , can completely occlude the upper airway . The treatment is to secure the airway with an endotracheal tube until the swelling has subsided, which is usually after about 48 hours ( Figure 46.1 ). The indications of laryngeal oedema, such as a change in voice, stridor, anxiety and respiratory di ffi culty , are very late symptoms. Intubation at this point is often di ffi cult or impossible owing to swelling, so acute cricothyroidotomy equipment must be at hand when intubating patients with a delayed diagnosis of  airway burn. Because of  this, early intubation of  suspected airway burn is the treatment of  choice in such patients. The time frame from burn to airway occlusion is usually between 4 and 24 hours, so there is time to make a sensible decision with senior sta ff and allow an experienced anaesthetist to intubate the patient. Although antidotes exist to some specific components of  smoke (carbon monoxide and cyanide), the treatment of smoke inha lation usually involves endotracheal intubation and ventilatory support (sometimes for several weeks). Summary box 46.10 Initial management of the burned airway /uni25CF /uni25CF /uni25CF
A history of being trapped in the presence of smoke or hot
gases
Burns on the palate or nasal mucosa, or loss of all the hairs in
the nose
Deep burns around the mouth and neck
Hoarseness/change in voice
Early elective intubation is safest
Delay can make intubation very dif
/f_i
cult owing to swelling
Be ready to perform an emergency cricothyroidotomy if
intubation is delayed

Hypertonic saline
Hypertonic saline
Hypertonic saline is used in some centres; it produces hyper osmolality and hypernatraemia, resulting in a reduction in the shift of  intracellular water to the extracellular space. Propo nents of  this resuscitation fluid cite advantages that include less tissue oedema and a resultant decrease in esc harotomies and intubations. However, prolonged h ypernatraemia without careful monitoring can be problematic and lead to renal dysfunction. Hypertonic saline
Hypertonic saline is used in some centres; it produces hyper osmolality and hypernatraemia, resulting in a reduction in the shift of  intracellular water to the extracellular space. Propo nents of  this resuscitation fluid cite advantages that include less tissue oedema and a resultant decrease in esc harotomies and intubations. However, prolonged h ypernatraemia without careful monitoring can be problematic and lead to renal dysfunction. Hypertonic saline
Hypertonic saline is used in some centres; it produces hyper osmolality and hypernatraemia, resulting in a reduction in the shift of  intracellular water to the extracellular space. Propo nents of  this resuscitation fluid cite advantages that include less tissue oedema and a resultant decrease in esc harotomies and intubations. However, prolonged h ypernatraemia without careful monitoring can be problematic and lead to renal dysfunction.

IMMEDIATE CARE OF THE BURN PATIENT Prehospital car
IMMEDIATE CARE OF THE BURN PATIENT Prehospital care
Good prehospital care is essential in ensuring rapid assessment and transfer. The key principles are: /uni25CF Ensure rescuer safety . This is particularly important in the case of  electrical and chemical injuries and building fires. /uni25CF Stop the burning process . Stop, drop and roll is a good method of  extinguishing fire burning on a person. /uni25CF Check for other injuries . A standard ABC (airway– breathing–circulation) check followed by a rapid second ary survey will ensure that no other significant injuries are missed. Patients burned in explosions or even escaping from fires can have coexisting fractures or blast pattern injuries. /uni25CF Cool the burn wound . This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury . Cooling should occur for a minimum of  20 minutes and is e ff ective up to 1 hour after the burn injury . It is a particularly important first aid step in climates, cooling should be at about 15°C – tepid water – and hypothermia must be avoided, particularly in the extremes of age. /uni25CF Give oxygen . Anyone involved in a fire in an enclosed space should receive oxygen, especially if  there is an al - tered consciousness level. /uni25CF Elevate . Sitting a patient up with a burned airway may prove life-saving in the event of  a delay in transfer to hos - pital care. Elevation of burned limbs will reduce swelling and discomfort. /uni25CF Analgesia . Administration of  analgesia prior to or during transfer will alleviate pain. IMMEDIATE CARE OF THE BURN PATIENT Prehospital care
Good prehospital care is essential in ensuring rapid assessment and transfer. The key principles are: /uni25CF Ensure rescuer safety . This is particularly important in the case of  electrical and chemical injuries and building fires. /uni25CF Stop the burning process . Stop, drop and roll is a good method of  extinguishing fire burning on a person. /uni25CF Check for other injuries . A standard ABC (airway– breathing–circulation) check followed by a rapid second ary survey will ensure that no other significant injuries are missed. Patients burned in explosions or even escaping from fires can have coexisting fractures or blast pattern injuries. /uni25CF Cool the burn wound . This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury . Cooling should occur for a minimum of  20 minutes and is e ff ective up to 1 hour after the burn injury . It is a particularly important first aid step in climates, cooling should be at about 15°C – tepid water – and hypothermia must be avoided, particularly in the extremes of age. /uni25CF Give oxygen . Anyone involved in a fire in an enclosed space should receive oxygen, especially if  there is an al - tered consciousness level. /uni25CF Elevate . Sitting a patient up with a burned airway may prove life-saving in the event of  a delay in transfer to hos - pital care. Elevation of burned limbs will reduce swelling and discomfort. /uni25CF Analgesia . Administration of  analgesia prior to or during transfer will alleviate pain.

IMMEDIATE CARE OF THE BURN PATIENT Prehospital care
IMMEDIATE CARE OF THE BURN PATIENT Prehospital care
Good prehospital care is essential in ensuring rapid assessment and transfer. The key principles are: /uni25CF Ensure rescuer safety . This is particularly important in the case of  electrical and chemical injuries and building fires. /uni25CF Stop the burning process . Stop, drop and roll is a good method of  extinguishing fire burning on a person. /uni25CF Check for other injuries . A standard ABC (airway– breathing–circulation) check followed by a rapid second ary survey will ensure that no other significant injuries are missed. Patients burned in explosions or even escaping from fires can have coexisting fractures or blast pattern injuries. /uni25CF Cool the burn wound . This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury . Cooling should occur for a minimum of  20 minutes and is e ff ective up to 1 hour after the burn injury . It is a particularly important first aid step in climates, cooling should be at about 15°C – tepid water – and hypothermia must be avoided, particularly in the extremes of age. /uni25CF Give oxygen . Anyone involved in a fire in an enclosed space should receive oxygen, especially if  there is an al - tered consciousness level. /uni25CF Elevate . Sitting a patient up with a burned airway may prove life-saving in the event of  a delay in transfer to hos - pital care. Elevation of burned limbs will reduce swelling and discomfort. /uni25CF Analgesia . Administration of  analgesia prior to or during transfer will alleviate pain.

INFLAMMATION AND CIRCULATORY CHANGES
INFLAMMATION AND CIRCULATORY CHANGES
The circulatory changes initiated by a burn injury are complex and multifactorial, originating from both the actual injury of  burned skin (eschar) and the inflammatory cascade. It is governed by a complex series of  events. The release of neuropeptides and the activation of  complement are initiated by the stimulation of  pain fibres and the alteration of  proteins by heat. The activation of  Hageman factor initiates a number of  protease-driven cascades, altering the arachidonic acid, thrombin and kallikrein pathways. Fluid is lost from capillaries and oedema formation occurs. Summary box 46.6 The shock reaction after burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Burns produce an in
/f_l
ammatory reaction
This leads to vastly increased vascular permeability
Water, solutes and proteins move from the intra- to the
extravascular space
The volume of
/f_l
uid lost is directly proportional to the area of
the burn
Above 15% of surface area, the loss of
/f_l
uid produces shock
requiring resuscitation
INFLAMMATION AND CIRCULATORY CHANGES
The circulatory changes initiated by a burn injury are complex and multifactorial, originating from both the actual injury of  burned skin (eschar) and the inflammatory cascade. It is governed by a complex series of  events. The release of neuropeptides and the activation of  complement are initiated by the stimulation of  pain fibres and the alteration of  proteins by heat. The activation of  Hageman factor initiates a number of  protease-driven cascades, altering the arachidonic acid, thrombin and kallikrein pathways. Fluid is lost from capillaries and oedema formation occurs. Summary box 46.6 The shock reaction after burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Burns produce an in
/f_l
ammatory reaction
This leads to vastly increased vascular permeability
Water, solutes and proteins move from the intra- to the
extravascular space
The volume of
/f_l
uid lost is directly proportional to the area of
the burn
Above 15% of surface area, the loss of
/f_l
uid produces shock
requiring resuscitation
INFLAMMATION AND CIRCULATORY CHANGES
The circulatory changes initiated by a burn injury are complex and multifactorial, originating from both the actual injury of  burned skin (eschar) and the inflammatory cascade. It is governed by a complex series of  events. The release of neuropeptides and the activation of  complement are initiated by the stimulation of  pain fibres and the alteration of  proteins by heat. The activation of  Hageman factor initiates a number of  protease-driven cascades, altering the arachidonic acid, thrombin and kallikrein pathways. Fluid is lost from capillaries and oedema formation occurs. Summary box 46.6 The shock reaction after burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Burns produce an in
/f_l
ammatory reaction
This leads to vastly increased vascular permeability
Water, solutes and proteins move from the intra- to the
extravascular space
The volume of
/f_l
uid lost is directly proportional to the area of
the burn
Above 15% of surface area, the loss of
/f_l
uid produces shock
requiring resuscitation

INJURY TO THE AIRWA Y AND LUNGS
INJURY TO THE AIRWA Y AND LUNGS
Burns can also damage the airway and lungs, with life-threat ening consequences. Inhalation injury of  hot, smoked-filled air has three components, each of  which can present alone or in any combination. They are: upper airway injury , lower airwa y injury (true smoke inhalation) and metabolic poisoning. Airway injuries occur when the face and neck are burned; the significance of  being trapped in an enclosed space (burning room or car) cannot be underestimated. Summary box 46.4 Warning signs of burns to the respiratory system /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Burns around the face and neck, blistering inside the mouth
A history of being trapped in an enclosed space
Change to/hoarseness of voice
Stridor
Singeing of facial and nasal hair
INJURY TO THE AIRWA Y AND LUNGS
Burns can also damage the airway and lungs, with life-threat ening consequences. Inhalation injury of  hot, smoked-filled air has three components, each of  which can present alone or in any combination. They are: upper airway injury , lower airwa y injury (true smoke inhalation) and metabolic poisoning. Airway injuries occur when the face and neck are burned; the significance of  being trapped in an enclosed space (burning room or car) cannot be underestimated. Summary box 46.4 Warning signs of burns to the respiratory system /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Burns around the face and neck, blistering inside the mouth
A history of being trapped in an enclosed space
Change to/hoarseness of voice
Stridor
Singeing of facial and nasal hair
INJURY TO THE AIRWA Y AND LUNGS
Burns can also damage the airway and lungs, with life-threat ening consequences. Inhalation injury of  hot, smoked-filled air has three components, each of  which can present alone or in any combination. They are: upper airway injury , lower airwa y injury (true smoke inhalation) and metabolic poisoning. Airway injuries occur when the face and neck are burned; the significance of  being trapped in an enclosed space (burning room or car) cannot be underestimated. Summary box 46.4 Warning signs of burns to the respiratory system /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Burns around the face and neck, blistering inside the mouth
A history of being trapped in an enclosed space
Change to/hoarseness of voice
Stridor
Singeing of facial and nasal hair

INJURY TO THE SKIN
INJURY TO THE SKIN
Burns cause a multisystem injury , but by far the most common organ a ff ected is the skin. An understanding of  the function and the structure of  the skin is essential when assessing and treating a burn injury (see Chapter 45 ). Summary box 46.3 Functions of the skin /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Waterproo
/f_i
ng and protection from ultraviolet light
Immune response
Thermoregulation
Vitamin D production
Facilitates movement, sensation and cosmesis
INJURY TO THE SKIN
Burns cause a multisystem injury , but by far the most common organ a ff ected is the skin. An understanding of  the function and the structure of  the skin is essential when assessing and treating a burn injury (see Chapter 45 ). Summary box 46.3 Functions of the skin /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Waterproo
/f_i
ng and protection from ultraviolet light
Immune response
Thermoregulation
Vitamin D production
Facilitates movement, sensation and cosmesis
INJURY TO THE SKIN
Burns cause a multisystem injury , but by far the most common organ a ff ected is the skin. An understanding of  the function and the structure of  the skin is essential when assessing and treating a burn injury (see Chapter 45 ). Summary box 46.3 Functions of the skin /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Waterproo
/f_i
ng and protection from ultraviolet light
Immune response
Thermoregulation
Vitamin D production
Facilitates movement, sensation and cosmesis

Incidence and mechanism of burn injury
Incidence and mechanism of burn injury
The incidence of  burn injury varies greatly among countries and cultures. In the UK (with its population of  67 million), each year around 175 /uni00A0 000 people visit accident and emergency departments with burns; of  these, about 13 /uni00A0 000 need to be admitted. About 1000 have severe burns requiring fluid resus citation, and half  of  the victims are under 16 years of  age. The mechanism of burn injury varies according to age, with the extremes of  age being particularly vulnerable. The majority of  burns in children are scalds caused by accidents with kettles, pans, hot drinks and ba th water. It is important in this age group to screen for non-accidental injury as this may become a safeguarding issue. Delay in presentation, inconsis tent history from care givers or an unexpected burn pattern/ depth should trigger a concern and further investigation; alert ing senior sta ff is essential. Among adolescent patients, burns are usually caused b y experimentation with matches and flammable liquids. In adults flame b urns are more frequent, and scald burns and contact burns (such as a fall against a radiator and an inability to extract) become more common with age. Often a burn injury in the elderly is the trigger point at which increasing frailty and inability to self-care are rec ognised. Again, non-accidental injuries should be screened for in this vulnerable age group. The majority of  electrical and chemical injuries occur in adults and are frequently associated with occupation. Cold and radiation are rarer thermal inju - ries. Associated conditions in adults , such as mental disease (attempted suicide or assault), epilepsy and alcohol or drug abuse, are underlying factors in as many as 80% of  patients with burns admitted to hospital in some populations. Summary box 46.1 Screening for non-accidental burn injury /uni25CF /uni25CF /uni25CF /uni25CF
To understand:
The pathophysiology of burn injury and the systemic effects
•
Methods for calculating the rate and quantity of
/f_l
uids required
•
Principal techniques for treating burns and the patient
•
The pathophysiology of electrical and chemical burns
•
Delay in presentation, perceived lack of concern by the care
giver
Inconsistency with the history of the burn and the burn
pattern/depth
Other unexplained injuries such as bruises/fractures
Frequent hospital attendances
Incidence and mechanism of burn injury
The incidence of  burn injury varies greatly among countries and cultures. In the UK (with its population of  67 million), each year around 175 /uni00A0 000 people visit accident and emergency departments with burns; of  these, about 13 /uni00A0 000 need to be admitted. About 1000 have severe burns requiring fluid resus citation, and half  of  the victims are under 16 years of  age. The mechanism of burn injury varies according to age, with the extremes of  age being particularly vulnerable. The majority of  burns in children are scalds caused by accidents with kettles, pans, hot drinks and ba th water. It is important in this age group to screen for non-accidental injury as this may become a safeguarding issue. Delay in presentation, inconsis tent history from care givers or an unexpected burn pattern/ depth should trigger a concern and further investigation; alert ing senior sta ff is essential. Among adolescent patients, burns are usually caused b y experimentation with matches and flammable liquids. In adults flame b urns are more frequent, and scald burns and contact burns (such as a fall against a radiator and an inability to extract) become more common with age. Often a burn injury in the elderly is the trigger point at which increasing frailty and inability to self-care are rec ognised. Again, non-accidental injuries should be screened for in this vulnerable age group. The majority of  electrical and chemical injuries occur in adults and are frequently associated with occupation. Cold and radiation are rarer thermal inju - ries. Associated conditions in adults , such as mental disease (attempted suicide or assault), epilepsy and alcohol or drug abuse, are underlying factors in as many as 80% of  patients with burns admitted to hospital in some populations. Summary box 46.1 Screening for non-accidental burn injury /uni25CF /uni25CF /uni25CF /uni25CF
To understand:
The pathophysiology of burn injury and the systemic effects
•
Methods for calculating the rate and quantity of
/f_l
uids required
•
Principal techniques for treating burns and the patient
•
The pathophysiology of electrical and chemical burns
•
Delay in presentation, perceived lack of concern by the care
giver
Inconsistency with the history of the burn and the burn
pattern/depth
Other unexplained injuries such as bruises/fractures
Frequent hospital attendances
Incidence and mechanism of burn injury
The incidence of  burn injury varies greatly among countries and cultures. In the UK (with its population of  67 million), each year around 175 /uni00A0 000 people visit accident and emergency departments with burns; of  these, about 13 /uni00A0 000 need to be admitted. About 1000 have severe burns requiring fluid resus citation, and half  of  the victims are under 16 years of  age. The mechanism of burn injury varies according to age, with the extremes of  age being particularly vulnerable. The majority of  burns in children are scalds caused by accidents with kettles, pans, hot drinks and ba th water. It is important in this age group to screen for non-accidental injury as this may become a safeguarding issue. Delay in presentation, inconsis tent history from care givers or an unexpected burn pattern/ depth should trigger a concern and further investigation; alert ing senior sta ff is essential. Among adolescent patients, burns are usually caused b y experimentation with matches and flammable liquids. In adults flame b urns are more frequent, and scald burns and contact burns (such as a fall against a radiator and an inability to extract) become more common with age. Often a burn injury in the elderly is the trigger point at which increasing frailty and inability to self-care are rec ognised. Again, non-accidental injuries should be screened for in this vulnerable age group. The majority of  electrical and chemical injuries occur in adults and are frequently associated with occupation. Cold and radiation are rarer thermal inju - ries. Associated conditions in adults , such as mental disease (attempted suicide or assault), epilepsy and alcohol or drug abuse, are underlying factors in as many as 80% of  patients with burns admitted to hospital in some populations. Summary box 46.1 Screening for non-accidental burn injury /uni25CF /uni25CF /uni25CF /uni25CF
To understand:
The pathophysiology of burn injury and the systemic effects
•
Methods for calculating the rate and quantity of
/f_l
uids required
•
Principal techniques for treating burns and the patient
•
The pathophysiology of electrical and chemical burns
•
Delay in presentation, perceived lack of concern by the care
giver
Inconsistency with the history of the burn and the burn
pattern/depth
Other unexplained injuries such as bruises/fractures
Frequent hospital attendances

Introduction
INTRODUCTION
The last 50 years have seen great strides made to reduce both morbidity and mortality from burn injuries. The coming years will see a better understanding of  the control of physiology along with improvements in reconstruction and rehabilitation and utilising new technology . A large burn injury will have a significant e ff ect on the patient’s family and friends and the patient’s future. The importance of  multidisciplinary care needs to be stressed for the adequate and e ff ective care of the burn patient.

Ionising radiation injury
Ionising radiation injury
These injuries can be divided into groups depending on whether radiation exposure was to the whole body or localised. The management of  localised radiation damage is usually conservative until the true extent of  the tissue injury is appar ent. Should this damage have caused an ulcer, then excision and coverage with vascularised tissue is required. August Karl Gustav Bier , 1861–1949, Professor of  Surgery , Berlin, Germany . and may be fatal. A patient who has su ff ered whole-bod y irradiation and has acute desquamation of  the skin has received a lethal dose of  radiation, whic h can cause a particularly slow and unpleasant death. Non-lethal radiation has a number of systemic e ff ects related to the gut mucosa and immune system dysfunction. Other than giving iodine tablets, the management - of  these injuries is supportive. Summary box 46.21 Radiation burns /uni25CF - /uni25CF
Local burns causing ulceration need excision and vascularised
/f_l
ap cover, usually with free
/f_l
aps
Systemic overdose needs supportive treatment
Ionising radiation injury
These injuries can be divided into groups depending on whether radiation exposure was to the whole body or localised. The management of  localised radiation damage is usually conservative until the true extent of  the tissue injury is appar ent. Should this damage have caused an ulcer, then excision and coverage with vascularised tissue is required. August Karl Gustav Bier , 1861–1949, Professor of  Surgery , Berlin, Germany . and may be fatal. A patient who has su ff ered whole-bod y irradiation and has acute desquamation of  the skin has received a lethal dose of  radiation, whic h can cause a particularly slow and unpleasant death. Non-lethal radiation has a number of systemic e ff ects related to the gut mucosa and immune system dysfunction. Other than giving iodine tablets, the management - of  these injuries is supportive. Summary box 46.21 Radiation burns /uni25CF - /uni25CF
Local burns causing ulceration need excision and vascularised
/f_l
ap cover, usually with free
/f_l
aps
Systemic overdose needs supportive treatment
Ionising radiation injury
These injuries can be divided into groups depending on whether radiation exposure was to the whole body or localised. The management of  localised radiation damage is usually conservative until the true extent of  the tissue injury is appar ent. Should this damage have caused an ulcer, then excision and coverage with vascularised tissue is required. August Karl Gustav Bier , 1861–1949, Professor of  Surgery , Berlin, Germany . and may be fatal. A patient who has su ff ered whole-bod y irradiation and has acute desquamation of  the skin has received a lethal dose of  radiation, whic h can cause a particularly slow and unpleasant death. Non-lethal radiation has a number of systemic e ff ects related to the gut mucosa and immune system dysfunction. Other than giving iodine tablets, the management - of  these injuries is supportive. Summary box 46.21 Radiation burns /uni25CF - /uni25CF
Local burns causing ulceration need excision and vascularised
/f_l
ap cover, usually with free
/f_l
aps
Systemic overdose needs supportive treatment

Learning objectives
Learning objectives
To assess: The area and depth of burns in adults and • children The requirement for transfer to a specialist burn • unit Learning objectives
To assess: The area and depth of burns in adults and • children The requirement for transfer to a specialist burn • unit Learning objectives
To assess: The area and depth of burns in adults and • children The requirement for transfer to a specialist burn • unit

Metabolic poisoning
Metabolic poisoning
Incomplete combustion of carbonaceous materials may produce /uni00A0 carbon monoxide, and burning of  nitrogen-containing polymers releases hydrogen cyanide. Carbon monoxide poisoning is the most common immediate cause of  death from fire. It is an odourless, colourless gas that binds with erythro cyte haemoglobin approximately 250 times more avidly than oxygen. Carboxyhaemoglobin is inactive in oxygen transport and impairs oxygen deliver y at the tissue level. Additionally , it competes with, and inhibits, oxygen binding to cytochrome oxidase. This disrupts aerobic metabolism and decreases the capacity for cellular respiration. The treatment for carbon monoxide poisoning is early recognition and therapy with high-flow , high-concentration oxygen. Cyanide combines with trivalent iron in the mitochondrial cytochrome A3 complex, inhibiting electron transport and cellular respiration. John Hageman was a 37-year-old railroad brakeman, in whom this factor deficiency was discovered by Dr Oscar Ratno ff in 1955. Full-thickness burned skin loses its elasticity , becoming sti ff and leathery in appearance. This, combined with subcutaneous oedema, can physically stop rib expansion when the burn extends across the chest, compromising respiratory function. Summary box 46.5 Dangers of smoke, hot gas or steam inhalation /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Inhaled hot gases can cause supraglottic airway burns and
laryngeal oedema
Inhaled steam can cause subglottic burns and loss of
respiratory epithelium
Inhaled smoke particles can cause chemical pneumonitis and
respiratory failure
Inhaled poisons, such as carbon monoxide, can cause
metabolic poisoning
Full-thickness burns to the chest can cause mechanical
blockage to rib movement
Metabolic poisoning
Incomplete combustion of carbonaceous materials may produce /uni00A0 carbon monoxide, and burning of  nitrogen-containing polymers releases hydrogen cyanide. Carbon monoxide poisoning is the most common immediate cause of  death from fire. It is an odourless, colourless gas that binds with erythro cyte haemoglobin approximately 250 times more avidly than oxygen. Carboxyhaemoglobin is inactive in oxygen transport and impairs oxygen deliver y at the tissue level. Additionally , it competes with, and inhibits, oxygen binding to cytochrome oxidase. This disrupts aerobic metabolism and decreases the capacity for cellular respiration. The treatment for carbon monoxide poisoning is early recognition and therapy with high-flow , high-concentration oxygen. Cyanide combines with trivalent iron in the mitochondrial cytochrome A3 complex, inhibiting electron transport and cellular respiration. John Hageman was a 37-year-old railroad brakeman, in whom this factor deficiency was discovered by Dr Oscar Ratno ff in 1955. Full-thickness burned skin loses its elasticity , becoming sti ff and leathery in appearance. This, combined with subcutaneous oedema, can physically stop rib expansion when the burn extends across the chest, compromising respiratory function. Summary box 46.5 Dangers of smoke, hot gas or steam inhalation /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Inhaled hot gases can cause supraglottic airway burns and
laryngeal oedema
Inhaled steam can cause subglottic burns and loss of
respiratory epithelium
Inhaled smoke particles can cause chemical pneumonitis and
respiratory failure
Inhaled poisons, such as carbon monoxide, can cause
metabolic poisoning
Full-thickness burns to the chest can cause mechanical
blockage to rib movement
Metabolic poisoning
Incomplete combustion of carbonaceous materials may produce /uni00A0 carbon monoxide, and burning of  nitrogen-containing polymers releases hydrogen cyanide. Carbon monoxide poisoning is the most common immediate cause of  death from fire. It is an odourless, colourless gas that binds with erythro cyte haemoglobin approximately 250 times more avidly than oxygen. Carboxyhaemoglobin is inactive in oxygen transport and impairs oxygen deliver y at the tissue level. Additionally , it competes with, and inhibits, oxygen binding to cytochrome oxidase. This disrupts aerobic metabolism and decreases the capacity for cellular respiration. The treatment for carbon monoxide poisoning is early recognition and therapy with high-flow , high-concentration oxygen. Cyanide combines with trivalent iron in the mitochondrial cytochrome A3 complex, inhibiting electron transport and cellular respiration. John Hageman was a 37-year-old railroad brakeman, in whom this factor deficiency was discovered by Dr Oscar Ratno ff in 1955. Full-thickness burned skin loses its elasticity , becoming sti ff and leathery in appearance. This, combined with subcutaneous oedema, can physically stop rib expansion when the burn extends across the chest, compromising respiratory function. Summary box 46.5 Dangers of smoke, hot gas or steam inhalation /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF -
Inhaled hot gases can cause supraglottic airway burns and
laryngeal oedema
Inhaled steam can cause subglottic burns and loss of
respiratory epithelium
Inhaled smoke particles can cause chemical pneumonitis and
respiratory failure
Inhaled poisons, such as carbon monoxide, can cause
metabolic poisoning
Full-thickness burns to the chest can cause mechanical
blockage to rib movement

Monitoring and control of infection
Monitoring and control of infection
Patients with major burns steadily become immunocom - promised, having large portals of  entry to pathogenic and opportunistic bacteria and fungi via the burn wound. They have compromised local defences in the lungs and gut owing to oedema, and usually have monitoring lines and catheters, which themselves r epresent portals for infection. Control of  infection begins with policies on handwashing and other cross-contamination prevention measures. Bacteriological surveillance of  the wound, catheter tips and sputum helps to build a picture of  the patient’s flora. If  there are signs of infection, then further cultures need to be taken and antibiotics started. This is often initially on a best guess basis, hence the usefulness of  prior surveillance; close liaison with a micro - biologist is essential. In patients with large burns who remain catabolic, the core temperature is usually reset by the hypo thalamus above 37°C. Significant temperatures are those above 38.5°C, but often other signs of  infection are more useful to the clinician. These include significant rise or fall in the white cell count, thrombocytosis, incr easing signs of catabolism and decreasing clinical status of  the patient.
Figure 46.11
(a)
Scar band contracture marked with multiple Z-plasties.
when the Z-plasties are sutured.
Monitoring and control of infection
Patients with major burns steadily become immunocom - promised, having large portals of  entry to pathogenic and opportunistic bacteria and fungi via the burn wound. They have compromised local defences in the lungs and gut owing to oedema, and usually have monitoring lines and catheters, which themselves r epresent portals for infection. Control of  infection begins with policies on handwashing and other cross-contamination prevention measures. Bacteriological surveillance of  the wound, catheter tips and sputum helps to build a picture of  the patient’s flora. If  there are signs of infection, then further cultures need to be taken and antibiotics started. This is often initially on a best guess basis, hence the usefulness of  prior surveillance; close liaison with a micro - biologist is essential. In patients with large burns who remain catabolic, the core temperature is usually reset by the hypo thalamus above 37°C. Significant temperatures are those above 38.5°C, but often other signs of  infection are more useful to the clinician. These include significant rise or fall in the white cell count, thrombocytosis, incr easing signs of catabolism and decreasing clinical status of  the patient.
Figure 46.11
(a)
Scar band contracture marked with multiple Z-plasties.
when the Z-plasties are sutured.
Monitoring and control of infection
Patients with major burns steadily become immunocom - promised, having large portals of  entry to pathogenic and opportunistic bacteria and fungi via the burn wound. They have compromised local defences in the lungs and gut owing to oedema, and usually have monitoring lines and catheters, which themselves r epresent portals for infection. Control of  infection begins with policies on handwashing and other cross-contamination prevention measures. Bacteriological surveillance of  the wound, catheter tips and sputum helps to build a picture of  the patient’s flora. If  there are signs of infection, then further cultures need to be taken and antibiotics started. This is often initially on a best guess basis, hence the usefulness of  prior surveillance; close liaison with a micro - biologist is essential. In patients with large burns who remain catabolic, the core temperature is usually reset by the hypo thalamus above 37°C. Significant temperatures are those above 38.5°C, but often other signs of  infection are more useful to the clinician. These include significant rise or fall in the white cell count, thrombocytosis, incr easing signs of catabolism and decreasing clinical status of  the patient.
Figure 46.11
(a)
Scar band contracture marked with multiple Z-plasties.
when the Z-plasties are sutured.

Monitoring of resuscitation
Monitoring of resuscitation
Although fluid resuscitation has defined guidelines it is critical to understand that the process is dynamic and rigid adherence to protocols should be avoided. The key to monitoring of resuscitation is urine output. Urine output should be between 0.5 and 1.0 /uni00A0 mL/kg body weight per hour. If  the urine output drops and the patient is showing signs of hypoperfusion (tachy - car dia, cool peripheries and a high lactate/metabolic acidosis), then a bolus of  10 /uni00A0 mL/kg body weight should be given. It is important that patients are not over-resuscitated; urine output in excess of  2 /uni00A0 mL/kg body weight per hour should warrant a decrease in infusion. Other measures of  tissue perfusion such as lactate levels - can be useful, particularly in larger burns. A persistent raised lactate/metabolic acidosis can indicate a missed systemic tox - icity from cyanide or carbon monoxide. Patients with under - lying comorbidities , particularly cardiac or renal, will require further intensive monitoring such as central venous pressure - measurement in an intensive care setting. - Summary box 46.13 Fluids for resuscitation /uni25CF /uni25CF /uni25CF /uni25CF
In children with burns over 10% TBSA and adults with burns
over 15% TBSA, consider the need for intravenous
/f_l
uid
resuscitation
If oral
/f_l
uids are to be used, salt must be added
Fluids needed can be calculated from a standard formula and
start from time of burn
The key is to monitor urine output
Monitoring of resuscitation
Although fluid resuscitation has defined guidelines it is critical to understand that the process is dynamic and rigid adherence to protocols should be avoided. The key to monitoring of resuscitation is urine output. Urine output should be between 0.5 and 1.0 /uni00A0 mL/kg body weight per hour. If  the urine output drops and the patient is showing signs of hypoperfusion (tachy - car dia, cool peripheries and a high lactate/metabolic acidosis), then a bolus of  10 /uni00A0 mL/kg body weight should be given. It is important that patients are not over-resuscitated; urine output in excess of  2 /uni00A0 mL/kg body weight per hour should warrant a decrease in infusion. Other measures of  tissue perfusion such as lactate levels - can be useful, particularly in larger burns. A persistent raised lactate/metabolic acidosis can indicate a missed systemic tox - icity from cyanide or carbon monoxide. Patients with under - lying comorbidities , particularly cardiac or renal, will require further intensive monitoring such as central venous pressure - measurement in an intensive care setting. - Summary box 46.13 Fluids for resuscitation /uni25CF /uni25CF /uni25CF /uni25CF
In children with burns over 10% TBSA and adults with burns
over 15% TBSA, consider the need for intravenous
/f_l
uid
resuscitation
If oral
/f_l
uids are to be used, salt must be added
Fluids needed can be calculated from a standard formula and
start from time of burn
The key is to monitor urine output
Monitoring of resuscitation
Although fluid resuscitation has defined guidelines it is critical to understand that the process is dynamic and rigid adherence to protocols should be avoided. The key to monitoring of resuscitation is urine output. Urine output should be between 0.5 and 1.0 /uni00A0 mL/kg body weight per hour. If  the urine output drops and the patient is showing signs of hypoperfusion (tachy - car dia, cool peripheries and a high lactate/metabolic acidosis), then a bolus of  10 /uni00A0 mL/kg body weight should be given. It is important that patients are not over-resuscitated; urine output in excess of  2 /uni00A0 mL/kg body weight per hour should warrant a decrease in infusion. Other measures of  tissue perfusion such as lactate levels - can be useful, particularly in larger burns. A persistent raised lactate/metabolic acidosis can indicate a missed systemic tox - icity from cyanide or carbon monoxide. Patients with under - lying comorbidities , particularly cardiac or renal, will require further intensive monitoring such as central venous pressure - measurement in an intensive care setting. - Summary box 46.13 Fluids for resuscitation /uni25CF /uni25CF /uni25CF /uni25CF
In children with burns over 10% TBSA and adults with burns
over 15% TBSA, consider the need for intravenous
/f_l
uid
resuscitation
If oral
/f_l
uids are to be used, salt must be added
Fluids needed can be calculated from a standard formula and
start from time of burn
The key is to monitor urine output

NON-THERMAL BURN INJURY Electrical injuries
NON-THERMAL BURN INJURY Electrical injuries
Electrical injuries are usually divided into low- and high-volt age injuries, the threshold being 1000 /uni00A0 V . Summary box 46.19 Electrical burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Low-tension injuries Low-tension or domestic appliance injuries do not have enough energy to cause destruction to significant amounts of  subcutaneous tissues when the current passes through the body . The resistance is too great. The contact point, normally in the fingers, su ff ers small deep burns; these may cause under lying tendon and nerve damage, but there will be little damage between. The alternating current creates a tetany within the uscles, and thus patients often describe how they were unable m to release the device until the power was turned o ff . The main danger with these injuries is from the alternating current interfering with normal cardiac pacing. This can cause cardiac arrest. The electricity itself  does not usually cause significant underlying myocardial damage, so resuscitation, if  successful, should be lasting. High-tension injuries High-tension electrical injuries ( Figure 46.12 ) can be caused by one of  three sources of  damage: the flash, the flame and the current itself. When a high-tension line is earthed, enormous energy is released as the current travels from the line to the earth. As the current travels through the air, the air is heated and expands hich can propel the victim. A flash in an explosive manner, w burn is the contact of  superheated air with the skin for a short duration. The flash, however, can go on to ignite the patient’s clothes and so cause a normal flame burn. - In accidents with overhead lines, the patient often acts as the conduction rod to earth. In these injuries, there is enough current to cause damage to the subcutaneous tissues and mus - cles. The entry and exit points are damaged but, importantly , the current can cause huge amounts of  subcutaneous dam - - age between these two points. These can be extremely serious injuries. in the a ff ected limb The damage to the underlying muscles can cause the rapid onset of  compartment syndrome requiring lobin will cause urgent fasciotomies. The release of  the myog herefore, myoglobinuria and subsequent renal dysfunction. T during the resuscitation of  these patients, e ff orts must be made to maintain a high urine output of  up to 2 /uni00A0 mL/kg body weight per hour. Severe acidosis is common in large electrical burns and may require fluid and bicarbonate boluses. These patients are also at risk of  myocardial damage as a result of  direct mus - cle damage, rather than by interference with cardiac pacing. This gives rise to significant electrocardiogram changes, with raised cardiac enzymes. If  there is significant damage, there vere injury is rapid onset of  heart failure. In the case of a se through a limb, primary amputation is sometimes the most e ff ective management.
Low-voltage injuries cause small, localised, deep burns
They can cause cardiac arrest through pacing interruption
without signi
/f_i
cant direct myocardial damage
High-voltage injuries damage by
/f_l
ash (external burn) and
conduction (internal burn)
Myocardium may be directly damaged without pacing
interruption
Limbs may need fasciotomies or amputation
Look for and treat acidosis and myoglobinuria
(c)
Figure 46.12 (a, b)
High-voltage electrical injury resulting in ampu
tation of the lateral three toes and the lateral foot.
(c)
One year
post injury after treatment with a dermal substitute (Biodegradable
Temporising Matrix [BTM]) and skin grafting.
NON-THERMAL BURN INJURY Electrical injuries
Electrical injuries are usually divided into low- and high-volt age injuries, the threshold being 1000 /uni00A0 V . Summary box 46.19 Electrical burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Low-tension injuries Low-tension or domestic appliance injuries do not have enough energy to cause destruction to significant amounts of  subcutaneous tissues when the current passes through the body . The resistance is too great. The contact point, normally in the fingers, su ff ers small deep burns; these may cause under lying tendon and nerve damage, but there will be little damage between. The alternating current creates a tetany within the uscles, and thus patients often describe how they were unable m to release the device until the power was turned o ff . The main danger with these injuries is from the alternating current interfering with normal cardiac pacing. This can cause cardiac arrest. The electricity itself  does not usually cause significant underlying myocardial damage, so resuscitation, if  successful, should be lasting. High-tension injuries High-tension electrical injuries ( Figure 46.12 ) can be caused by one of  three sources of  damage: the flash, the flame and the current itself. When a high-tension line is earthed, enormous energy is released as the current travels from the line to the earth. As the current travels through the air, the air is heated and expands hich can propel the victim. A flash in an explosive manner, w burn is the contact of  superheated air with the skin for a short duration. The flash, however, can go on to ignite the patient’s clothes and so cause a normal flame burn. - In accidents with overhead lines, the patient often acts as the conduction rod to earth. In these injuries, there is enough current to cause damage to the subcutaneous tissues and mus - cles. The entry and exit points are damaged but, importantly , the current can cause huge amounts of  subcutaneous dam - - age between these two points. These can be extremely serious injuries. in the a ff ected limb The damage to the underlying muscles can cause the rapid onset of  compartment syndrome requiring lobin will cause urgent fasciotomies. The release of  the myog herefore, myoglobinuria and subsequent renal dysfunction. T during the resuscitation of  these patients, e ff orts must be made to maintain a high urine output of  up to 2 /uni00A0 mL/kg body weight per hour. Severe acidosis is common in large electrical burns and may require fluid and bicarbonate boluses. These patients are also at risk of  myocardial damage as a result of  direct mus - cle damage, rather than by interference with cardiac pacing. This gives rise to significant electrocardiogram changes, with raised cardiac enzymes. If  there is significant damage, there vere injury is rapid onset of  heart failure. In the case of a se through a limb, primary amputation is sometimes the most e ff ective management.
Low-voltage injuries cause small, localised, deep burns
They can cause cardiac arrest through pacing interruption
without signi
/f_i
cant direct myocardial damage
High-voltage injuries damage by
/f_l
ash (external burn) and
conduction (internal burn)
Myocardium may be directly damaged without pacing
interruption
Limbs may need fasciotomies or amputation
Look for and treat acidosis and myoglobinuria
(c)
Figure 46.12 (a, b)
High-voltage electrical injury resulting in ampu
tation of the lateral three toes and the lateral foot.
(c)
One year
post injury after treatment with a dermal substitute (Biodegradable
Temporising Matrix [BTM]) and skin grafting.
NON-THERMAL BURN INJURY Electrical injuries
Electrical injuries are usually divided into low- and high-volt age injuries, the threshold being 1000 /uni00A0 V . Summary box 46.19 Electrical burns /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Low-tension injuries Low-tension or domestic appliance injuries do not have enough energy to cause destruction to significant amounts of  subcutaneous tissues when the current passes through the body . The resistance is too great. The contact point, normally in the fingers, su ff ers small deep burns; these may cause under lying tendon and nerve damage, but there will be little damage between. The alternating current creates a tetany within the uscles, and thus patients often describe how they were unable m to release the device until the power was turned o ff . The main danger with these injuries is from the alternating current interfering with normal cardiac pacing. This can cause cardiac arrest. The electricity itself  does not usually cause significant underlying myocardial damage, so resuscitation, if  successful, should be lasting. High-tension injuries High-tension electrical injuries ( Figure 46.12 ) can be caused by one of  three sources of  damage: the flash, the flame and the current itself. When a high-tension line is earthed, enormous energy is released as the current travels from the line to the earth. As the current travels through the air, the air is heated and expands hich can propel the victim. A flash in an explosive manner, w burn is the contact of  superheated air with the skin for a short duration. The flash, however, can go on to ignite the patient’s clothes and so cause a normal flame burn. - In accidents with overhead lines, the patient often acts as the conduction rod to earth. In these injuries, there is enough current to cause damage to the subcutaneous tissues and mus - cles. The entry and exit points are damaged but, importantly , the current can cause huge amounts of  subcutaneous dam - - age between these two points. These can be extremely serious injuries. in the a ff ected limb The damage to the underlying muscles can cause the rapid onset of  compartment syndrome requiring lobin will cause urgent fasciotomies. The release of  the myog herefore, myoglobinuria and subsequent renal dysfunction. T during the resuscitation of  these patients, e ff orts must be made to maintain a high urine output of  up to 2 /uni00A0 mL/kg body weight per hour. Severe acidosis is common in large electrical burns and may require fluid and bicarbonate boluses. These patients are also at risk of  myocardial damage as a result of  direct mus - cle damage, rather than by interference with cardiac pacing. This gives rise to significant electrocardiogram changes, with raised cardiac enzymes. If  there is significant damage, there vere injury is rapid onset of  heart failure. In the case of a se through a limb, primary amputation is sometimes the most e ff ective management.
Low-voltage injuries cause small, localised, deep burns
They can cause cardiac arrest through pacing interruption
without signi
/f_i
cant direct myocardial damage
High-voltage injuries damage by
/f_l
ash (external burn) and
conduction (internal burn)
Myocardium may be directly damaged without pacing
interruption
Limbs may need fasciotomies or amputation
Look for and treat acidosis and myoglobinuria
(c)
Figure 46.12 (a, b)
High-voltage electrical injury resulting in ampu
tation of the lateral three toes and the lateral foot.
(c)
One year
post injury after treatment with a dermal substitute (Biodegradable
Temporising Matrix [BTM]) and skin grafting.

Nursing care
Nursing care
Burns patients require particularly intensive nursing care. Nurses are the primary e ff ectors of  many decisions that directly a ff ect healing. Bandaged hands and joints that are sti ff and painful need careful coaxing. Personal hygiene, baths and showers all become time-consuming and painful, but are vital parts of the patient’s physiotherapy . Their success or failure has a powerful psychological impact on the patient and his or her family . Nursing care
Burns patients require particularly intensive nursing care. Nurses are the primary e ff ectors of  many decisions that directly a ff ect healing. Bandaged hands and joints that are sti ff and painful need careful coaxing. Personal hygiene, baths and showers all become time-consuming and painful, but are vital parts of the patient’s physiotherapy . Their success or failure has a powerful psychological impact on the patient and his or her family . Nursing care
Burns patients require particularly intensive nursing care. Nurses are the primary e ff ectors of  many decisions that directly a ff ect healing. Bandaged hands and joints that are sti ff and painful need careful coaxing. Personal hygiene, baths and showers all become time-consuming and painful, but are vital parts of the patient’s physiotherapy . Their success or failure has a powerful psychological impact on the patient and his or her family .

OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS The immune system and infection
OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS The immune system and infection
The inflammatory changes caused by the burn have an e ff ect on the patient’s immune system. Cell-mediated immunity is significantly reduced in large burns, leaving them more potential sources of  infection, primarily from the burn wound and from the lung if  this is injured, but also from any central venous lines, tracheostomies or urinary catheters present.

OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS The
OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS The immune system and infection
The inflammatory changes caused by the burn have an e ff ect on the patient’s immune system. Cell-mediated immunity is significantly reduced in large burns, leaving them more potential sources of  infection, primarily from the burn wound and from the lung if  this is injured, but also from any central venous lines, tracheostomies or urinary catheters present. OTHER LIFE-THREATENING EVENTS WITH MAJOR BURNS The immune system and infection
The inflammatory changes caused by the burn have an e ff ect on the patient’s immune system. Cell-mediated immunity is significantly reduced in large burns, leaving them more potential sources of  infection, primarily from the burn wound and from the lung if  this is injured, but also from any central venous lines, tracheostomies or urinary catheters present.

Physiotherapy and occupational therapy
Physiotherapy and occupational therapy
All burns cause swelling, especially burns to the hands. Elevation, splintage and exercise reduce swelling and improve the final outcome. The physiotherapy needs to be started on day /uni00A0 1, so that the message can be reinforced on a daily basis. As the burn wounds heal scar management and rehabilitation to previous activities of  daily living become increasingly important. Physiotherapy and occupational therapy
All burns cause swelling, especially burns to the hands. Elevation, splintage and exercise reduce swelling and improve the final outcome. The physiotherapy needs to be started on day /uni00A0 1, so that the message can be reinforced on a daily basis. As the burn wounds heal scar management and rehabilitation to previous activities of  daily living become increasingly important. Physiotherapy and occupational therapy
All burns cause swelling, especially burns to the hands. Elevation, splintage and exercise reduce swelling and improve the final outcome. The physiotherapy needs to be started on day /uni00A0 1, so that the message can be reinforced on a daily basis. As the burn wounds heal scar management and rehabilitation to previous activities of  daily living become increasingly important.

Psychological
Psychological
A major burn is an overwhelming event, outside the normal experience, which stretches the patient’s coping ability , suspends the patient’s sense of  safety and causes post-traumatic reactions. These are normal and usually self-limiting, receding as the patient heals. The features of  this intensity of  experience are of intrusive reactions, arousal reactions and avoidance reactions. Early intervention with psychology and development of  coping strategies is of  vital importance. The Guinea Pig Club. Sir Archibald McIndoe , 1900–1960, born in New Zealand, was appointed in 1938 as Consultant Plastic Surgeon to the Royal Air Force. He trained with his cousin, Sir Harold Delf  Gillies , another internationally reputed plastic surgeon. McIndoe became world famous for his pioneering work on Battle of Britain pilots who were badly burnt. His work on these airmen, who needed several operations, and using his innovative technical and psychologi cal methods, was the start of  a lifelong service. The young fighter pilots were therefore referred to as ‘guinea pigs’ – thus was formed The Guinea Pig Club. McIndoe referred to his patients as ‘the boys’, who in turn called him ‘the boss’ or ‘the maestro’. To this day , some of  the members of  the Guinea Pig Club from all over the w orld still meet on an annual basis in Sussex. McIndoe founded the British Association of  Plastic Surgeons (BAPS). -
(b)
Release of the scar intraoperatively.
(c)
Reorientation of the scar
Psychological
A major burn is an overwhelming event, outside the normal experience, which stretches the patient’s coping ability , suspends the patient’s sense of  safety and causes post-traumatic reactions. These are normal and usually self-limiting, receding as the patient heals. The features of  this intensity of  experience are of intrusive reactions, arousal reactions and avoidance reactions. Early intervention with psychology and development of  coping strategies is of  vital importance. The Guinea Pig Club. Sir Archibald McIndoe , 1900–1960, born in New Zealand, was appointed in 1938 as Consultant Plastic Surgeon to the Royal Air Force. He trained with his cousin, Sir Harold Delf  Gillies , another internationally reputed plastic surgeon. McIndoe became world famous for his pioneering work on Battle of Britain pilots who were badly burnt. His work on these airmen, who needed several operations, and using his innovative technical and psychologi cal methods, was the start of  a lifelong service. The young fighter pilots were therefore referred to as ‘guinea pigs’ – thus was formed The Guinea Pig Club. McIndoe referred to his patients as ‘the boys’, who in turn called him ‘the boss’ or ‘the maestro’. To this day , some of  the members of  the Guinea Pig Club from all over the w orld still meet on an annual basis in Sussex. McIndoe founded the British Association of  Plastic Surgeons (BAPS). -
(b)
Release of the scar intraoperatively.
(c)
Reorientation of the scar
Psychological
A major burn is an overwhelming event, outside the normal experience, which stretches the patient’s coping ability , suspends the patient’s sense of  safety and causes post-traumatic reactions. These are normal and usually self-limiting, receding as the patient heals. The features of  this intensity of  experience are of intrusive reactions, arousal reactions and avoidance reactions. Early intervention with psychology and development of  coping strategies is of  vital importance. The Guinea Pig Club. Sir Archibald McIndoe , 1900–1960, born in New Zealand, was appointed in 1938 as Consultant Plastic Surgeon to the Royal Air Force. He trained with his cousin, Sir Harold Delf  Gillies , another internationally reputed plastic surgeon. McIndoe became world famous for his pioneering work on Battle of Britain pilots who were badly burnt. His work on these airmen, who needed several operations, and using his innovative technical and psychologi cal methods, was the start of  a lifelong service. The young fighter pilots were therefore referred to as ‘guinea pigs’ – thus was formed The Guinea Pig Club. McIndoe referred to his patients as ‘the boys’, who in turn called him ‘the boss’ or ‘the maestro’. To this day , some of  the members of  the Guinea Pig Club from all over the w orld still meet on an annual basis in Sussex. McIndoe founded the British Association of  Plastic Surgeons (BAPS). -
(b)
Release of the scar intraoperatively.
(c)
Reorientation of the scar

RECENT ADVANCES
RECENT ADVANCES
Advanced technology , newer drugs and skin substitutes are the major advances in burn care. The next steps will focus on cultured autologous skin incorporating the patient’s own kera - tinocytes and fibroblasts. An intelligent use of  these modalities is essential to make an e ff ective case for cost–benefit ratios. RECENT ADVANCES
Advanced technology , newer drugs and skin substitutes are the major advances in burn care. The next steps will focus on cultured autologous skin incorporating the patient’s own kera - tinocytes and fibroblasts. An intelligent use of  these modalities is essential to make an e ff ective case for cost–benefit ratios. RECENT ADVANCES
Advanced technology , newer drugs and skin substitutes are the major advances in burn care. The next steps will focus on cultured autologous skin incorporating the patient’s own kera - tinocytes and fibroblasts. An intelligent use of  these modalities is essential to make an e ff ective case for cost–benefit ratios.

Surgical treatment
Surgical treatment
Early versus staged full-thickness burn excision Opinion varies on the timing of  burn eschar excision. Early total burn excision refers to excision of  the entire burn on arrival at the burns unit or as soon as logistically possible. Once the patient is cleared of  trauma in the emergency department, the airway is secure and intravenous access and monitoring achieved, then the decision is whether to take the patient straight to theatre for burn wound debridement/escharectomy or to transfer the patient to the intensive care unit. The advantage of  early burn excision is to exploit the time period or ‘window’ before the overwhelming systemic response to the burn reaches a crescendo. The ‘anaesthetic’ window refers to the e ff ect of the burn on the airway – an upper airway burn can be bypassed by endotracheal intubation but a lower airway burn inhalational injury can cause chemical pneumonitis tha t may progress to acute respiratory distress syndrome. This usually becomes - problematic after 48 hours; therefore, it is prudent to exploit this window and perform the burn excision during the time prior to lung injury decompensation. The ‘haemodynamic’ window refers to the progressive inflammatory vasodilation and potential coagulopathy . This leads to an increasing resistance to vasoconstrictor agents in tumescence fluids with the potential for blood loss and need for blood transfusion which can drive further immunocom - promise. Excising a full-thickness burn early , prior to these - changes, can result in less blood loss. Additionally removing the eschar, which plays a role in driving the fluid shifts, will ). result in less oedema and low er fluid requirements. - Finally the ‘bacterial’ window is also important. Excising a full-thickness burn, which is essentially necrotic material, can help to reduce the bacterial load, thereby reducing the risk of infection. - - Summary box 46.15 Early burn excision /uni25CF /uni25CF /uni25CF /uni25CF Early burn excision is dependent on the appropriate sta ff , resources, equipment and time. When these are not readily available a staged approach is also utilised. This involves serial debridement of  the burn over several operating sessions in the first week of  the burn. Proponents of  this approach advocate shorter operating times and reducing the requirements for blood transfusions. This technique also relies on managing the remaining burn eschar until excision to prevent bacterial colonisation and to prepare for surgery . This is achiev ed by using silver-based dressing/creams containing antibacterial properties including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus .
Upper limb Midaxial. Anterior to the elbow medially to avoid
the ulnar nerve
Hand Midline in the digits
Release muscle compartments if tight
Best done in theatre
Midaxial. Posterior to the ankle medially to avoid
Lower limb
the long saphenous vein and anterior to the head
of the
/f_i
bula to avoid the common peroneal nerve
Down the chest lateral to the nipples, across the
Chest
chest below the clavicle and across the chest at
the level of the xiphisternum
Extend the wound beyond the deep burn
General
Diathermy any signi
/f_i
cant bleeding vessels
rules
Apply haemostatic dressing and elevate the limb
postoperatively
Removal of eschar reduces bacterial load
Majority of surgery is performed prior to substantial lung injury
Allows effective use of vasoconstrictive
/f_l
uids
Requires adequate theatre, staff and facilities
Dressings with silver that are commonly used include: /uni25CF Silver sulphadiazine cream (1%) . This gives broad-spectrum prophylaxis against bacterial colonisation. /uni25CF Mafenide acetate cream . This is popular, especially in the USA, but is painful to apply and has been associated with metabolic acidosis. It is usually used as a 5% topical solution. /uni25CF Silver sulphadiazine and cerium nitrate induces a sterile eschar on the burned skin and has been shown in certain instances, especially in elderly patients, to reduce some of  the cell-mediated immunosuppression that occurs in burns. It is especially useful in treating burns when a conservative treatment option has been chosen. Cerium nitrate has also been shown to boost cell-mediated immunity in these patients. /uni25CF Acticoat . This is a nanocrystalline silver barrier dressing and is an e ff ective antimicrobial against a broad spectrum of  bacteria. The keystone of  burns surgery is control, regardless of whether early or staged excision is the plan. A wide-bore Summary box 46.16 Staged burn excision /uni25CF /uni25CF . This cannula should be used and the patient’s blood pressure must be monitored adequately . If  a large excision is considered, then an arterial line (to monitor blood pressure) and central venous access are needed. The anaesthetist also needs measurements and control of  the acid–base balance, clotting time and haemoglobin levels. The core temperature of  the patient must not drop below 36°C, otherwise clotting irregularities will be compounded. For most burn excisions, subcutaneous injection of  a dilute solution of  adrenaline (epinephrine) 1:1 /uni00A0 000 /uni00A0 000 or 1:500 /uni00A0 000 and tourniquet control are important for controlling blood loss. har and The tumescence fluid is injected into both the burn esc the donor sites.
Figure 46.7
(a-d)
Extensive full-thickness burns at
/f_i
rst operation. Note the placement of the escharotomies on the chest and the lower limb.
The leg had an escharectomy followed by escharotomy.
(d)
Shorter but more frequent surgical theatre trips
Will require managing/binding of remaining eschar
In deep dermal burns, tangential excision is performed until punctate bleeding is observed and the dermis can be seen to be free of  any small, thrombosed vessels. A topical solution of  1:500 /uni00A0 000 adrenaline also helps to reduce bleeding, as does the application of  the skin graft/substitute. Full-thickness burns require full-thickness excision of  the skin. In certain circumstances, it is appropriate to go down xcision is down to to the fascia but, in most cases, the burn e viable fat. Wherever possible, a skin graft/substitute should be applied immediately ( Figure 46.8 ). the plane deep to the graft and at the horizontal margins where it meets unburned skin. Split-skin grafts can be left as intact sheets where function (over major joints, hands and fingers , anterior neck), cosmesis (face , dorsum of  hands) and future growth (developing breasts) are particularly important; however, skin grafts can never result in ‘normal’ skin. Because we rely on spontaneous healing of the site from which they are harvested (the donor site), they are thin, consisting of the epidermis and a variable proportion of  the superficial dermis. They are often harvested as between 0.30 and 0.38 /uni00A0 mm and thus their application into the burn wound creates a donor defect. Because the dermal component of  the graft is raft contraction post application occurs. The thinner thin, g the harvested graft, the greater the degree of  contraction and the greater the degree of  functional disability and dysaesthe - sia. The donor site is painful; as a result techniques must be employed to reduce the size of  the donor site in an e ff ort to minimise the pain. These include meshing the graft by putting it through a series of  blades mounted on rollers that create o ff - raft in horizontal lines. Post meshing, set incisions in the skin g these cuts can be pulled open, extending the graft and resulting in diamond-shaped defects. This has the advantage of  reduc - ing the likelihood of  graft haematoma/seroma. Meshing can be performed at di ff erent ratios. As the ratio increases, the size of  the diamond defect increases. deep burn does not Since the burn bed after excision of contain tissue capable of  healing without modification of  the bed structure, a small bleb of  granulation tissue forms in these esults in a character - diamonds between the graft struts. This r istic mesh pattern scarring. The wider the mesh, the worse the appearance. Although the epidermis can regenerate, the dermis removed from the donor site during skin graft harvesting can scar forms under the new epidermis only repair and a layer of at the donor site, which is ‘thinner’ than it was pre-harvest. The donor site is thus not an infinite resource. With serial graft harvesting, the donor site can become so deep a wound that adnexal structures are no longer present and the donor site has to heal by secondary intention, or receive a skin graft itself. In very extensive burns, where the burn size exceeds donor site availability , the surgeon tends to rely on higher ratios (1:3, up to 1:9) and harvests the skin grafts more thinly . This allows the donor site to heal more rapidly , facilitating earlier reharvest when serial grafting is required. Postoperative management of  these patients requires care - ful evaluation of  fluid balance and levels of  haemoglobin. The outer dressings will require attention and regular changing because of  expected fluid leaks. Physiotherapy and splints are important in maintaining ement and reducing joint contracture. Eleva - range of  mov tion of  the appropriate limbs is important. The hand must be splinted in a position of  function after grafting, although the raft needs to be applied in the position of  maximal stretch. g Knees are best splinted in extension; axillae in abduction. vement by the physiotherapists, usually under Supervised mo direct vision of  any a ff ected joints, should begin after about 5 days.
(b)
(c)
Figure 46.8
Full-thickness leg burns.
(a)
Marked for excision;
/uni00A0
(b)
excised to healthy tissue fat/fascia;
(c)
skin graft at
/f_i
rst dressing
change.
Burn excision surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Deep dermal burns need tangential shaving and split-skin
grafting or dermal substitutes
All but the smallest full-thickness burns need surgery
The anaesthetist needs to be ready for signi
/f_i
cant blood loss
Tumescence
/f_l
uid and topical adrenaline reduces bleeding
All burnt tissue needs to be excised
Stable cover, permanent or temporary, should be applied
Surgical treatment
Early versus staged full-thickness burn excision Opinion varies on the timing of  burn eschar excision. Early total burn excision refers to excision of  the entire burn on arrival at the burns unit or as soon as logistically possible. Once the patient is cleared of  trauma in the emergency department, the airway is secure and intravenous access and monitoring achieved, then the decision is whether to take the patient straight to theatre for burn wound debridement/escharectomy or to transfer the patient to the intensive care unit. The advantage of  early burn excision is to exploit the time period or ‘window’ before the overwhelming systemic response to the burn reaches a crescendo. The ‘anaesthetic’ window refers to the e ff ect of the burn on the airway – an upper airway burn can be bypassed by endotracheal intubation but a lower airway burn inhalational injury can cause chemical pneumonitis tha t may progress to acute respiratory distress syndrome. This usually becomes - problematic after 48 hours; therefore, it is prudent to exploit this window and perform the burn excision during the time prior to lung injury decompensation. The ‘haemodynamic’ window refers to the progressive inflammatory vasodilation and potential coagulopathy . This leads to an increasing resistance to vasoconstrictor agents in tumescence fluids with the potential for blood loss and need for blood transfusion which can drive further immunocom - promise. Excising a full-thickness burn early , prior to these - changes, can result in less blood loss. Additionally removing the eschar, which plays a role in driving the fluid shifts, will ). result in less oedema and low er fluid requirements. - Finally the ‘bacterial’ window is also important. Excising a full-thickness burn, which is essentially necrotic material, can help to reduce the bacterial load, thereby reducing the risk of infection. - - Summary box 46.15 Early burn excision /uni25CF /uni25CF /uni25CF /uni25CF Early burn excision is dependent on the appropriate sta ff , resources, equipment and time. When these are not readily available a staged approach is also utilised. This involves serial debridement of  the burn over several operating sessions in the first week of  the burn. Proponents of  this approach advocate shorter operating times and reducing the requirements for blood transfusions. This technique also relies on managing the remaining burn eschar until excision to prevent bacterial colonisation and to prepare for surgery . This is achiev ed by using silver-based dressing/creams containing antibacterial properties including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus .
Upper limb Midaxial. Anterior to the elbow medially to avoid
the ulnar nerve
Hand Midline in the digits
Release muscle compartments if tight
Best done in theatre
Midaxial. Posterior to the ankle medially to avoid
Lower limb
the long saphenous vein and anterior to the head
of the
/f_i
bula to avoid the common peroneal nerve
Down the chest lateral to the nipples, across the
Chest
chest below the clavicle and across the chest at
the level of the xiphisternum
Extend the wound beyond the deep burn
General
Diathermy any signi
/f_i
cant bleeding vessels
rules
Apply haemostatic dressing and elevate the limb
postoperatively
Removal of eschar reduces bacterial load
Majority of surgery is performed prior to substantial lung injury
Allows effective use of vasoconstrictive
/f_l
uids
Requires adequate theatre, staff and facilities
Dressings with silver that are commonly used include: /uni25CF Silver sulphadiazine cream (1%) . This gives broad-spectrum prophylaxis against bacterial colonisation. /uni25CF Mafenide acetate cream . This is popular, especially in the USA, but is painful to apply and has been associated with metabolic acidosis. It is usually used as a 5% topical solution. /uni25CF Silver sulphadiazine and cerium nitrate induces a sterile eschar on the burned skin and has been shown in certain instances, especially in elderly patients, to reduce some of  the cell-mediated immunosuppression that occurs in burns. It is especially useful in treating burns when a conservative treatment option has been chosen. Cerium nitrate has also been shown to boost cell-mediated immunity in these patients. /uni25CF Acticoat . This is a nanocrystalline silver barrier dressing and is an e ff ective antimicrobial against a broad spectrum of  bacteria. The keystone of  burns surgery is control, regardless of whether early or staged excision is the plan. A wide-bore Summary box 46.16 Staged burn excision /uni25CF /uni25CF . This cannula should be used and the patient’s blood pressure must be monitored adequately . If  a large excision is considered, then an arterial line (to monitor blood pressure) and central venous access are needed. The anaesthetist also needs measurements and control of  the acid–base balance, clotting time and haemoglobin levels. The core temperature of  the patient must not drop below 36°C, otherwise clotting irregularities will be compounded. For most burn excisions, subcutaneous injection of  a dilute solution of  adrenaline (epinephrine) 1:1 /uni00A0 000 /uni00A0 000 or 1:500 /uni00A0 000 and tourniquet control are important for controlling blood loss. har and The tumescence fluid is injected into both the burn esc the donor sites.
Figure 46.7
(a-d)
Extensive full-thickness burns at
/f_i
rst operation. Note the placement of the escharotomies on the chest and the lower limb.
The leg had an escharectomy followed by escharotomy.
(d)
Shorter but more frequent surgical theatre trips
Will require managing/binding of remaining eschar
In deep dermal burns, tangential excision is performed until punctate bleeding is observed and the dermis can be seen to be free of  any small, thrombosed vessels. A topical solution of  1:500 /uni00A0 000 adrenaline also helps to reduce bleeding, as does the application of  the skin graft/substitute. Full-thickness burns require full-thickness excision of  the skin. In certain circumstances, it is appropriate to go down xcision is down to to the fascia but, in most cases, the burn e viable fat. Wherever possible, a skin graft/substitute should be applied immediately ( Figure 46.8 ). the plane deep to the graft and at the horizontal margins where it meets unburned skin. Split-skin grafts can be left as intact sheets where function (over major joints, hands and fingers , anterior neck), cosmesis (face , dorsum of  hands) and future growth (developing breasts) are particularly important; however, skin grafts can never result in ‘normal’ skin. Because we rely on spontaneous healing of the site from which they are harvested (the donor site), they are thin, consisting of the epidermis and a variable proportion of  the superficial dermis. They are often harvested as between 0.30 and 0.38 /uni00A0 mm and thus their application into the burn wound creates a donor defect. Because the dermal component of  the graft is raft contraction post application occurs. The thinner thin, g the harvested graft, the greater the degree of  contraction and the greater the degree of  functional disability and dysaesthe - sia. The donor site is painful; as a result techniques must be employed to reduce the size of  the donor site in an e ff ort to minimise the pain. These include meshing the graft by putting it through a series of  blades mounted on rollers that create o ff - raft in horizontal lines. Post meshing, set incisions in the skin g these cuts can be pulled open, extending the graft and resulting in diamond-shaped defects. This has the advantage of  reduc - ing the likelihood of  graft haematoma/seroma. Meshing can be performed at di ff erent ratios. As the ratio increases, the size of  the diamond defect increases. deep burn does not Since the burn bed after excision of contain tissue capable of  healing without modification of  the bed structure, a small bleb of  granulation tissue forms in these esults in a character - diamonds between the graft struts. This r istic mesh pattern scarring. The wider the mesh, the worse the appearance. Although the epidermis can regenerate, the dermis removed from the donor site during skin graft harvesting can scar forms under the new epidermis only repair and a layer of at the donor site, which is ‘thinner’ than it was pre-harvest. The donor site is thus not an infinite resource. With serial graft harvesting, the donor site can become so deep a wound that adnexal structures are no longer present and the donor site has to heal by secondary intention, or receive a skin graft itself. In very extensive burns, where the burn size exceeds donor site availability , the surgeon tends to rely on higher ratios (1:3, up to 1:9) and harvests the skin grafts more thinly . This allows the donor site to heal more rapidly , facilitating earlier reharvest when serial grafting is required. Postoperative management of  these patients requires care - ful evaluation of  fluid balance and levels of  haemoglobin. The outer dressings will require attention and regular changing because of  expected fluid leaks. Physiotherapy and splints are important in maintaining ement and reducing joint contracture. Eleva - range of  mov tion of  the appropriate limbs is important. The hand must be splinted in a position of  function after grafting, although the raft needs to be applied in the position of  maximal stretch. g Knees are best splinted in extension; axillae in abduction. vement by the physiotherapists, usually under Supervised mo direct vision of  any a ff ected joints, should begin after about 5 days.
(b)
(c)
Figure 46.8
Full-thickness leg burns.
(a)
Marked for excision;
/uni00A0
(b)
excised to healthy tissue fat/fascia;
(c)
skin graft at
/f_i
rst dressing
change.
Burn excision surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Deep dermal burns need tangential shaving and split-skin
grafting or dermal substitutes
All but the smallest full-thickness burns need surgery
The anaesthetist needs to be ready for signi
/f_i
cant blood loss
Tumescence
/f_l
uid and topical adrenaline reduces bleeding
All burnt tissue needs to be excised
Stable cover, permanent or temporary, should be applied
Surgical treatment
Early versus staged full-thickness burn excision Opinion varies on the timing of  burn eschar excision. Early total burn excision refers to excision of  the entire burn on arrival at the burns unit or as soon as logistically possible. Once the patient is cleared of  trauma in the emergency department, the airway is secure and intravenous access and monitoring achieved, then the decision is whether to take the patient straight to theatre for burn wound debridement/escharectomy or to transfer the patient to the intensive care unit. The advantage of  early burn excision is to exploit the time period or ‘window’ before the overwhelming systemic response to the burn reaches a crescendo. The ‘anaesthetic’ window refers to the e ff ect of the burn on the airway – an upper airway burn can be bypassed by endotracheal intubation but a lower airway burn inhalational injury can cause chemical pneumonitis tha t may progress to acute respiratory distress syndrome. This usually becomes - problematic after 48 hours; therefore, it is prudent to exploit this window and perform the burn excision during the time prior to lung injury decompensation. The ‘haemodynamic’ window refers to the progressive inflammatory vasodilation and potential coagulopathy . This leads to an increasing resistance to vasoconstrictor agents in tumescence fluids with the potential for blood loss and need for blood transfusion which can drive further immunocom - promise. Excising a full-thickness burn early , prior to these - changes, can result in less blood loss. Additionally removing the eschar, which plays a role in driving the fluid shifts, will ). result in less oedema and low er fluid requirements. - Finally the ‘bacterial’ window is also important. Excising a full-thickness burn, which is essentially necrotic material, can help to reduce the bacterial load, thereby reducing the risk of infection. - - Summary box 46.15 Early burn excision /uni25CF /uni25CF /uni25CF /uni25CF Early burn excision is dependent on the appropriate sta ff , resources, equipment and time. When these are not readily available a staged approach is also utilised. This involves serial debridement of  the burn over several operating sessions in the first week of  the burn. Proponents of  this approach advocate shorter operating times and reducing the requirements for blood transfusions. This technique also relies on managing the remaining burn eschar until excision to prevent bacterial colonisation and to prepare for surgery . This is achiev ed by using silver-based dressing/creams containing antibacterial properties including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus .
Upper limb Midaxial. Anterior to the elbow medially to avoid
the ulnar nerve
Hand Midline in the digits
Release muscle compartments if tight
Best done in theatre
Midaxial. Posterior to the ankle medially to avoid
Lower limb
the long saphenous vein and anterior to the head
of the
/f_i
bula to avoid the common peroneal nerve
Down the chest lateral to the nipples, across the
Chest
chest below the clavicle and across the chest at
the level of the xiphisternum
Extend the wound beyond the deep burn
General
Diathermy any signi
/f_i
cant bleeding vessels
rules
Apply haemostatic dressing and elevate the limb
postoperatively
Removal of eschar reduces bacterial load
Majority of surgery is performed prior to substantial lung injury
Allows effective use of vasoconstrictive
/f_l
uids
Requires adequate theatre, staff and facilities
Dressings with silver that are commonly used include: /uni25CF Silver sulphadiazine cream (1%) . This gives broad-spectrum prophylaxis against bacterial colonisation. /uni25CF Mafenide acetate cream . This is popular, especially in the USA, but is painful to apply and has been associated with metabolic acidosis. It is usually used as a 5% topical solution. /uni25CF Silver sulphadiazine and cerium nitrate induces a sterile eschar on the burned skin and has been shown in certain instances, especially in elderly patients, to reduce some of  the cell-mediated immunosuppression that occurs in burns. It is especially useful in treating burns when a conservative treatment option has been chosen. Cerium nitrate has also been shown to boost cell-mediated immunity in these patients. /uni25CF Acticoat . This is a nanocrystalline silver barrier dressing and is an e ff ective antimicrobial against a broad spectrum of  bacteria. The keystone of  burns surgery is control, regardless of whether early or staged excision is the plan. A wide-bore Summary box 46.16 Staged burn excision /uni25CF /uni25CF . This cannula should be used and the patient’s blood pressure must be monitored adequately . If  a large excision is considered, then an arterial line (to monitor blood pressure) and central venous access are needed. The anaesthetist also needs measurements and control of  the acid–base balance, clotting time and haemoglobin levels. The core temperature of  the patient must not drop below 36°C, otherwise clotting irregularities will be compounded. For most burn excisions, subcutaneous injection of  a dilute solution of  adrenaline (epinephrine) 1:1 /uni00A0 000 /uni00A0 000 or 1:500 /uni00A0 000 and tourniquet control are important for controlling blood loss. har and The tumescence fluid is injected into both the burn esc the donor sites.
Figure 46.7
(a-d)
Extensive full-thickness burns at
/f_i
rst operation. Note the placement of the escharotomies on the chest and the lower limb.
The leg had an escharectomy followed by escharotomy.
(d)
Shorter but more frequent surgical theatre trips
Will require managing/binding of remaining eschar
In deep dermal burns, tangential excision is performed until punctate bleeding is observed and the dermis can be seen to be free of  any small, thrombosed vessels. A topical solution of  1:500 /uni00A0 000 adrenaline also helps to reduce bleeding, as does the application of  the skin graft/substitute. Full-thickness burns require full-thickness excision of  the skin. In certain circumstances, it is appropriate to go down xcision is down to to the fascia but, in most cases, the burn e viable fat. Wherever possible, a skin graft/substitute should be applied immediately ( Figure 46.8 ). the plane deep to the graft and at the horizontal margins where it meets unburned skin. Split-skin grafts can be left as intact sheets where function (over major joints, hands and fingers , anterior neck), cosmesis (face , dorsum of  hands) and future growth (developing breasts) are particularly important; however, skin grafts can never result in ‘normal’ skin. Because we rely on spontaneous healing of the site from which they are harvested (the donor site), they are thin, consisting of the epidermis and a variable proportion of  the superficial dermis. They are often harvested as between 0.30 and 0.38 /uni00A0 mm and thus their application into the burn wound creates a donor defect. Because the dermal component of  the graft is raft contraction post application occurs. The thinner thin, g the harvested graft, the greater the degree of  contraction and the greater the degree of  functional disability and dysaesthe - sia. The donor site is painful; as a result techniques must be employed to reduce the size of  the donor site in an e ff ort to minimise the pain. These include meshing the graft by putting it through a series of  blades mounted on rollers that create o ff - raft in horizontal lines. Post meshing, set incisions in the skin g these cuts can be pulled open, extending the graft and resulting in diamond-shaped defects. This has the advantage of  reduc - ing the likelihood of  graft haematoma/seroma. Meshing can be performed at di ff erent ratios. As the ratio increases, the size of  the diamond defect increases. deep burn does not Since the burn bed after excision of contain tissue capable of  healing without modification of  the bed structure, a small bleb of  granulation tissue forms in these esults in a character - diamonds between the graft struts. This r istic mesh pattern scarring. The wider the mesh, the worse the appearance. Although the epidermis can regenerate, the dermis removed from the donor site during skin graft harvesting can scar forms under the new epidermis only repair and a layer of at the donor site, which is ‘thinner’ than it was pre-harvest. The donor site is thus not an infinite resource. With serial graft harvesting, the donor site can become so deep a wound that adnexal structures are no longer present and the donor site has to heal by secondary intention, or receive a skin graft itself. In very extensive burns, where the burn size exceeds donor site availability , the surgeon tends to rely on higher ratios (1:3, up to 1:9) and harvests the skin grafts more thinly . This allows the donor site to heal more rapidly , facilitating earlier reharvest when serial grafting is required. Postoperative management of  these patients requires care - ful evaluation of  fluid balance and levels of  haemoglobin. The outer dressings will require attention and regular changing because of  expected fluid leaks. Physiotherapy and splints are important in maintaining ement and reducing joint contracture. Eleva - range of  mov tion of  the appropriate limbs is important. The hand must be splinted in a position of  function after grafting, although the raft needs to be applied in the position of  maximal stretch. g Knees are best splinted in extension; axillae in abduction. vement by the physiotherapists, usually under Supervised mo direct vision of  any a ff ected joints, should begin after about 5 days.
(b)
(c)
Figure 46.8
Full-thickness leg burns.
(a)
Marked for excision;
/uni00A0
(b)
excised to healthy tissue fat/fascia;
(c)
skin graft at
/f_i
rst dressing
change.
Burn excision surgery /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF
Deep dermal burns need tangential shaving and split-skin
grafting or dermal substitutes
All but the smallest full-thickness burns need surgery
The anaesthetist needs to be ready for signi
/f_i
cant blood loss
Tumescence
/f_l
uid and topical adrenaline reduces bleeding
All burnt tissue needs to be excised
Stable cover, permanent or temporary, should be applied

Temperature management
Temperature management
When undergoing burn assessment and fluid resuscitation it is vital that the patient maintains an adequate core temperature. A key function of skin is thermoregulation and in large burns t this is severely impacted. Hypothermia is a component of  the ‘lethal triad of  trauma’, which includes acidosis and coagu - lopathy; the combination of  all three significantly increases mortality . Measures to counteract hypothermia include infusing warmed fluids, external warmers such as the ‘Bair Hugger’ and increasing the ambient room temperature in the emer gency department/assessment room. Temperature management
When undergoing burn assessment and fluid resuscitation it is vital that the patient maintains an adequate core temperature. A key function of skin is thermoregulation and in large burns t this is severely impacted. Hypothermia is a component of  the ‘lethal triad of  trauma’, which includes acidosis and coagu - lopathy; the combination of  all three significantly increases mortality . Measures to counteract hypothermia include infusing warmed fluids, external warmers such as the ‘Bair Hugger’ and increasing the ambient room temperature in the emer gency department/assessment room. Temperature management
When undergoing burn assessment and fluid resuscitation it is vital that the patient maintains an adequate core temperature. A key function of skin is thermoregulation and in large burns t this is severely impacted. Hypothermia is a component of  the ‘lethal triad of  trauma’, which includes acidosis and coagu - lopathy; the combination of  all three significantly increases mortality . Measures to counteract hypothermia include infusing warmed fluids, external warmers such as the ‘Bair Hugger’ and increasing the ambient room temperature in the emer gency department/assessment room.

The use of skin grafts and skin substitutes
The use of skin grafts and skin substitutes
Until very recently , the early definitive closure of  wounds proved problematic when full-thickness burns exceeded 50% of  the TBSA. The mainstay of  burn wound repair has been the split-skin autograft and, at >50% TBSA, the burn area exceeds the donor site area. A number of  manoeuvres have been established to facilitate coverage of  these wounds by grafting, all of  which are utilised in patients with the most extensive burn wounds. Techniques include serial episodes of  grafting surgery , harvesting very thin autografts (to allow more rapid re-epithelialisation of  the donor sites, facilitating earlier rehar vest and allowing a greater number of harvests from the same Cicero Parker Meek , 1914–1979, general practitioner with a special interest in the treatment of  burn patients, Aiken County Hospital, SC, USA. SP Wall Jr , engineer, developed the Meek–Wall microdermatome with CP Meek in 1963. John F Burke , 1922–2011, medical researcher, Harv ard University , Boston, MA, USA, widely known for his co-invention of  synthetic skin substitute in 1981 with Ioannis V Yannas. technique (Meek, Humeca, Enschede, the Netherlands). This latter technique involves using small pieces of  g raft, placed in a specialised holder on a cork board and run through a series of  blades perpendicular to each other, to create small squares of  graft each 3 /uni00A0 mm /uni00A0×/uni00A0 3 /uni00A0 mm. Once cut, the holding platform can be pulled apart (to di ff ering distances – the ‘mesh ratio’), separating the tiny grafts. Although ‘fiddly’ and laborious, this technique minimises graft wastage, since even small pieces of graft can be meshed in this way . The use of cadaver skin to cover the non-grafted wounds pending donor site re-epithelialisation and ‘reharvestability’ gained popularity in the late twentieth century as issues of consent and techniques for harvest and storage (banking) were refined. The use of  cadaver skin has a number of  limitations. Skin banks are frequently short, or devoid, of  stock. Its pres - ence ‘passively’ temporises the wound, ‘buying time’ but not improving the wound bed, merely allowing undirected gran - ulation. It cannot be used unless the patient is pathologically immune suppressed. The dermal matrix stra tegy , pioneered by Jack Burke, sought to redress some of  these issues . In producing a ‘sca ff old’ to allow autologous tissue in-growth and establish a ‘neo - dermis’ (‘active’ temporisation), he impro ved the outcome of the thin, meshed skin graft. A completely synthetic, biodegradable polymer version has also been developed - ( Figures 46.9 and 46.10 ).
Day 28
Figure 46.9
Day 28 post-full-thickness burns treated with early skin grafting using the Biodegradable Temporising Matrix (BTM) (a synthetic,
biodegradable polyurethane dermal matrix) on the arms and immediate skin graft to chest.
Day 28
Figure 46.10
Day 38 picture shows a mesh graft on the arm after the dermal substitute has been removed. The day 200 pictures show the
difference in scar outcome between the immediate skin graft to the chest and a Biodegradable Temporising Matrix (BTM) and skin graft to the
arm and axilla. Both skin grafts had the same mesh ratio.
The use of skin grafts and skin substitutes
Until very recently , the early definitive closure of  wounds proved problematic when full-thickness burns exceeded 50% of  the TBSA. The mainstay of  burn wound repair has been the split-skin autograft and, at >50% TBSA, the burn area exceeds the donor site area. A number of  manoeuvres have been established to facilitate coverage of  these wounds by grafting, all of  which are utilised in patients with the most extensive burn wounds. Techniques include serial episodes of  grafting surgery , harvesting very thin autografts (to allow more rapid re-epithelialisation of  the donor sites, facilitating earlier rehar vest and allowing a greater number of harvests from the same Cicero Parker Meek , 1914–1979, general practitioner with a special interest in the treatment of  burn patients, Aiken County Hospital, SC, USA. SP Wall Jr , engineer, developed the Meek–Wall microdermatome with CP Meek in 1963. John F Burke , 1922–2011, medical researcher, Harv ard University , Boston, MA, USA, widely known for his co-invention of  synthetic skin substitute in 1981 with Ioannis V Yannas. technique (Meek, Humeca, Enschede, the Netherlands). This latter technique involves using small pieces of  g raft, placed in a specialised holder on a cork board and run through a series of  blades perpendicular to each other, to create small squares of  graft each 3 /uni00A0 mm /uni00A0×/uni00A0 3 /uni00A0 mm. Once cut, the holding platform can be pulled apart (to di ff ering distances – the ‘mesh ratio’), separating the tiny grafts. Although ‘fiddly’ and laborious, this technique minimises graft wastage, since even small pieces of graft can be meshed in this way . The use of cadaver skin to cover the non-grafted wounds pending donor site re-epithelialisation and ‘reharvestability’ gained popularity in the late twentieth century as issues of consent and techniques for harvest and storage (banking) were refined. The use of  cadaver skin has a number of  limitations. Skin banks are frequently short, or devoid, of  stock. Its pres - ence ‘passively’ temporises the wound, ‘buying time’ but not improving the wound bed, merely allowing undirected gran - ulation. It cannot be used unless the patient is pathologically immune suppressed. The dermal matrix stra tegy , pioneered by Jack Burke, sought to redress some of  these issues . In producing a ‘sca ff old’ to allow autologous tissue in-growth and establish a ‘neo - dermis’ (‘active’ temporisation), he impro ved the outcome of the thin, meshed skin graft. A completely synthetic, biodegradable polymer version has also been developed - ( Figures 46.9 and 46.10 ).
Day 28
Figure 46.9
Day 28 post-full-thickness burns treated with early skin grafting using the Biodegradable Temporising Matrix (BTM) (a synthetic,
biodegradable polyurethane dermal matrix) on the arms and immediate skin graft to chest.
Day 28
Figure 46.10
Day 38 picture shows a mesh graft on the arm after the dermal substitute has been removed. The day 200 pictures show the
difference in scar outcome between the immediate skin graft to the chest and a Biodegradable Temporising Matrix (BTM) and skin graft to the
arm and axilla. Both skin grafts had the same mesh ratio.
The use of skin grafts and skin substitutes
Until very recently , the early definitive closure of  wounds proved problematic when full-thickness burns exceeded 50% of  the TBSA. The mainstay of  burn wound repair has been the split-skin autograft and, at >50% TBSA, the burn area exceeds the donor site area. A number of  manoeuvres have been established to facilitate coverage of  these wounds by grafting, all of  which are utilised in patients with the most extensive burn wounds. Techniques include serial episodes of  grafting surgery , harvesting very thin autografts (to allow more rapid re-epithelialisation of  the donor sites, facilitating earlier rehar vest and allowing a greater number of harvests from the same Cicero Parker Meek , 1914–1979, general practitioner with a special interest in the treatment of  burn patients, Aiken County Hospital, SC, USA. SP Wall Jr , engineer, developed the Meek–Wall microdermatome with CP Meek in 1963. John F Burke , 1922–2011, medical researcher, Harv ard University , Boston, MA, USA, widely known for his co-invention of  synthetic skin substitute in 1981 with Ioannis V Yannas. technique (Meek, Humeca, Enschede, the Netherlands). This latter technique involves using small pieces of  g raft, placed in a specialised holder on a cork board and run through a series of  blades perpendicular to each other, to create small squares of  graft each 3 /uni00A0 mm /uni00A0×/uni00A0 3 /uni00A0 mm. Once cut, the holding platform can be pulled apart (to di ff ering distances – the ‘mesh ratio’), separating the tiny grafts. Although ‘fiddly’ and laborious, this technique minimises graft wastage, since even small pieces of graft can be meshed in this way . The use of cadaver skin to cover the non-grafted wounds pending donor site re-epithelialisation and ‘reharvestability’ gained popularity in the late twentieth century as issues of consent and techniques for harvest and storage (banking) were refined. The use of  cadaver skin has a number of  limitations. Skin banks are frequently short, or devoid, of  stock. Its pres - ence ‘passively’ temporises the wound, ‘buying time’ but not improving the wound bed, merely allowing undirected gran - ulation. It cannot be used unless the patient is pathologically immune suppressed. The dermal matrix stra tegy , pioneered by Jack Burke, sought to redress some of  these issues . In producing a ‘sca ff old’ to allow autologous tissue in-growth and establish a ‘neo - dermis’ (‘active’ temporisation), he impro ved the outcome of the thin, meshed skin graft. A completely synthetic, biodegradable polymer version has also been developed - ( Figures 46.9 and 46.10 ).
Day 28
Figure 46.9
Day 28 post-full-thickness burns treated with early skin grafting using the Biodegradable Temporising Matrix (BTM) (a synthetic,
biodegradable polyurethane dermal matrix) on the arms and immediate skin graft to chest.
Day 28
Figure 46.10
Day 38 picture shows a mesh graft on the arm after the dermal substitute has been removed. The day 200 pictures show the
difference in scar outcome between the immediate skin graft to the chest and a Biodegradable Temporising Matrix (BTM) and skin graft to the
arm and axilla. Both skin grafts had the same mesh ratio.