CHAPTER 15 THERMAL, CHEMICAL, AND ELECTRICAL INJURIES MATTHEW B.

KLEIN
Few areas of medicine are as challenging medically and surgically as burn care. Burn injuries
affect the very young and the very old, both men and women. Burn injuries can vary from small
wounds that can be easily managed in the outpatient clinic to extensive injuries resulting in
multiorgan system failure, a prolonged hospital course, and long-term functional and psychosocial
sequelae.
According to the National Institutes of General Medical Sciences, an estimated 1.1 million burn
injuries require medical attention annually in the United States. Of those injured, about 50,000
require hospitalization and about 4,500 die annually from burn injuries. Survival following burn
injury has significantly improved over the course of the 20th century. Improvements in
resuscitation, the introduction of topical antimicrobial agents, and, most importantly, the practice
of early burn wound excision have all contributed to the improved outcome. However, extensive
burn injuries remain potentially fatal.

BURN MANAGEMENT: OVERVIEW

Etiology
Burn injuries can result from a variety of causes. Scald burns are the most common cause of burn
injury in the civilian population. The depth of scald burn is determined by the temperature of the
liquid, the duration of exposure to the liquid (Table 15.1), and the viscosity of the liquid (there is
usually prolonged contact with more viscous liquids). Scald burns with hot liquids will typically
heal without the need for skin grafting. Grease burns, however, tend to result in deeper dermal
burns and will occasionally require surgical management. Flame burns, the next most common
cause of burn injury, typically result from house fires, campfires, and the burning of leaves or
trash. If the patient’s clothing catches fire, burns will usually be full thickness. Flash burns are
quite common as well and typically result from ignition of propane or gasoline. Flash burns will
typically injure exposed skin (most commonly face and extremities) and usually result in partial
thickness burns. Contact burns occur from contact with woodstoves, hot metals, plastics, or coals.
Contact burns are usually deep but limited in extent of body surface area injured. In addition, burn
injury can result from electrical and chemical agents as well.

Organization of Burn Care

The essence of successful burn care is the team. No individual is capable of meeting the many
acute and long-term needs of the burn patient. Therefore, burn care is best delivered in a
specialized burn center where experienced physicians, nurses, physical and occupational
therapists, nutritionists, psychologists, and social workers can all participate in the care of the
individual. With the exception of small burns, patients with burn injuries should be referred to a
burn center. The American Burn Association has established formal criteria for transfer to a burn
center (Table 15.2). It is important to consider these as only guidelines. Patients who do not have
a local physician comfortable caring for even a minor burn should be transferred to the nearest
burn center.
Evaluation of the Burn Patient
Once a patient arrives at the burn center, a thorough evaluation is performed so that an effective
treatment plan can be initiated. It is important to remember that burn patients are trauma patients,
and they require evaluation in accordance with the Advanced Trauma Life Support (ATLS)
protocol. Airway, breathing, and circulation must be assessed immediately following a burn injury.
In addition to ensuring a patent airway, adequate breathing, and circulation, the presence of
additional injuries—particularly life-threatening injuries—requires exclusion. A thorough history of
the burn injury is critical as it may provide some important information that will ultimately affect
management. Details related to the location of the injury (indoors vs. outdoors), type of liquid
involved in a scald, duration of extraction from fire, as well as details of the patient’s other
medical problems are all elements of an adequate history. Any child who has an injury that is
suspicious for abuse should be admitted to the hospital regardless of burn severity so that social
services can be contacted and the circumstances surrounding the injury investigated. Adults with
burn injuries greater than 15% to 20% are admitted to an intensive care unit for adequate
monitoring and infectious control. Smaller children or elderly patients with less extensive burn
injuries are monitored in an intensive care setting. In addition, patients requiring close airway
monitoring (i.e., suspected inhalation injury) or frequent neurovascular checks are placed in an
intensive care unit setting. Determination of Burn Extent. The extent and depth of burn wounds
are established shortly following admission. The total body surface area (TBSA) burned is
calculated using one of several techniques. When calculating TBSA, one includes those areas of
partial and full thickness burns. Superficial burns are not included in the calculation. The rule of
nines (Figure 15.1) is perhaps the best known method of estimating burn extent. However, it is
important to note that the proportions of infants and children are different than those of adults.
The head of children tends to be proportionately greater than 9% TBSA, and the lower extremities
are less than 18%. In addition, it is important to explain to the inexperienced person that the
percentage assigned to a body part represents a total area, so that a portion of an arm burn is
only a portion of 9%. A second technique of estimating TBSA is using the patient’s hand. The
patient’s hand represents about 1% TBSA and the total burn size can be estimated by
determining how much of the patient’s (not the examiner’s) hand areas are burned. Lund and
Browder charts are a more accurate method of assessing burn extent. They provide an age-based
diagram to assist in more precisely calculating the burn size (Figure 15.2).
Depth of Burn Injury. Thermal injury can injure the epidermis, a portion of or the entirety of the
dermis, as well as subcutaneous tissue. The depth of the burn affects the healing of the wound,
and therefore, assessment of burn depth is important for appropriate wound management and,
ultimately, the decision for operative intervention. The characteristics of superficial, partial, and
full thickness burns are described below and summarized in Table 15.3.
Superficial burns involve the epidermis only and are erythematous and painful. These burns
typically heal within 3 to 5 days and are best treated with a topical agent such as aloe lotion that
will accelerate healing and soothe the patient. In addition, oral analgesics can be helpful.
Sunburns are the prototypical superficial burns.
Partial thickness burns involve the entirety of the epidermis and a portion of the dermis. Partial
thickness burns are further divided into superficial and deep partial thickness based on the depth
of dermal injury. Superficial and deep partial thickness burns differ in appearance, ability to heal,
and potential need for excision and skin grafting. Superficial partial thickness burns are typically
pink, moist, and painful to the touch (Figure 15.3). Water scald burns are the prototypical
superficial partial thickness wound. These burns will typically heal within 2 weeks and will
generally not result in scarring, but could result in alteration of pigmentation. These wounds are
usually best treated with greasy gauze with antibiotic ointment.
Deep partial thickness burns involve the entirety of the epidermis and extend into the reticular
portion of the dermis. These burns are typically dry and mottled pink and white in appearance and
have variable sensation. If protected from infection, deep partial thickness burns will heal within
3 to 8 weeks, depending on the number of viable adnexal structures in the burn wound. However,
they will typically heal with scarring and possible contractures. Therefore, if it appears that the
wound will not be completely reepithelialized in 3 weeks time, operative excision and grafting is
recommended.
Full thickness burns involve the epidermis and the entirety of the dermis. These wounds are
brown-black, leathery, and insensate (Figure 15.4). Occasionally, full thickness burn wounds will
have a cherry red color from fixed carboxyhemoglobin in the wound. These wounds can be
differentiated from more superficial burns because they are usually insensate and do not blanch.
Full thickness burns are best treated by excision and grafting, unless they are quite
small (size of a quarter).

FIGURE 15.3. A superficial partial thickness scald burn is typically moist, pink, and tender. These
burns will usually heal within 1 to 2 weeks.

Determination of burn depth is usually easy for superficial and very deep wounds. However,
determining the depth of deep dermal burns and their healing potential can be more challenging.
It often takes several days to determine whether these are wounds that will heal within 3 weeks
or would be better managed with excision and grafting. A variety of techniques have been
described for precise determination of burn depth including fluorescein dyes, ultrasound, laser
Doppler, and magnetic resonance imaging. However, none of these methods have proven to be
more reliable than the judgment of an experienced burn surgeon.
FIGURE 15.4. Full thickness burn wounds have a dry, leathery appearance and can vary in color
from brown to black to white. Full thickness burns are insensate and will not blanch.

Initial Management
Intravenous Access. Intravenous access is important for patients who will require fluid
resuscitation as well as for those patients who will require intravenous analgesia. Two peripheral
IV lines are usually sufficient for patients with less than 30% burns. However, patients with larger
burns or significant inhalation injury may require central line placement. Both peripheral and
central lines can be placed through burned tissue when required. The burned area is prepared
with topical antimicrobial solution as is done when preparing uninjured skin. Lines should be
securely sutured in place, particularly over burned áreas where the use of tape dressings is
difficult. Typically, a triple lumen catheter is adequate access since large volume fluid boluses are
not a standard component of burn resuscitation. Furthermore, there is usually no need for a
pulmonary artery catheter introducer since these catheters are of little benefit, and carry certain
complication risks, in the resuscitation of the burned patients. Arterial line placement is usually
necessary in the patient who is intubated and is likely to remain intubated for several days.
Escharotomy. The leathery eschar of a full thickness burn can form a constricting band that
compromises limb perfusion. It is important to determine if escharotomy is necessary. During fluid
resuscitation the problem worsens because of swelling. In general, escharotomies are indicated
for full thickness circumferential burns of the extremity or for full thickness burns of the chest wall
when the eschar compromises thoracic cage excursion and, thus, ventilation of the patient.
Escharotomy can be performed at the bedside using a scalpel or electrocautery. Adequate
release occurs when the eschar separates, perfusión improves, and, on occasion, a popping
sound is heard. The ideal location of escharotomy incisions is shown in Figure 15.5. It is important
to avoid major superficial nerves when performing escharotomy. The incision should go through
only eschar, not fascia. Incisions that are too deep can unnecessarily expose vital underlying
structures such as tendons and also increase the chance of desiccation and death of otherwise
healthy tissue.
Topical Wound Agents. Following admission to the burn center, the patient’s wounds are cleansed
with soap and water. Loose tissue and blisters are debrided. Body and facial hair are shaved if
involved in the area of a burn. Daily wound care is performed on a shower table with soap and
tap water or, if the burn wound is small, at the patient’s bedside following a shower. The use of
tanks for wound care has fallen out of favor because of the risks of cross-contamination. Burn
injury destroys the body’s protective layer from the environment and dressings are needed to
protect the body from infection and minimize evaporative heat loss from the body. The ideal
dressing if it existed would be inexpensive, easy to use, require infrequent changes, and be
comfortable. While a number of topical agents are available for burn wound care, it is best to have
a simple, well-reasoned wound care plan.
The choice of topical burn wound treatment is contingent on the depth of burn injury and the goals
of management. Superficial burn wounds (such as sunburns) require soothing lotions that will
expedite epithelial repair such as aloe vera. Partial thickness burn wounds need coverage with
agents that will keep the wound moist and provide antimicrobial protection. Deeper partial
thickness burn wounds should be covered with agents that will protect the eschar from microbial
colonization. Once the eschar has lifted and the wound has begun to epithelialize, a dressing that
optimizes epithelialization (i.e., greasy gauze and antibiotic ointment) is utilized. Full thickness
burns are also covered with a topical agent that protects the burn wound from getting infected
until the time of burn excision.
Prophylactic systemic antibiotics have no role in the management of burn wounds. In fact, the
use of prophylactic antibiotics has been shown to increase the risk of opportunistic infection.1
Since burn eschar has no microcirculation, there is no mechanism for the delivery of systemically
administered antibiotics. Therefore, topical agents need to provide broad-spectrum antimicrobial
coverage at the site of colonization—the eschar.

FIGURE 15.5. The location of escharotomy incisions on the (A) upper extremity; (B) hand; and
(C) lower extremity.

In the early postburn period, the dominant colonizing organisms are staphylococci and
streptococci—typical skin flora. Over time, however, the burn wound becomes colonized with
gram-negative organisms. Thus, topical antimicrobial agents used in early burn care should have
broad-spectrum coverage to minimize colonization of the wound, but they need not penetrate the
burn eschar deeply. sulfadiazine is the most commonly used topical antimicrobial agent. Silver
sulfadiazine has broad-spectrum antimicrobial coverage, with excellent Staphylococcus and
Streptococcus coverage. However, silver sulfadiazine is incapable of eschar penetration, so it is
less useful in the management of the infected burn wound. Wounds treated with silver sulfadiazine
will develop a yellowish-gray pseudoeschar that requires removal by cleansing during daily wound
care. Traditionally, the principal drawback of silver sulfadiazine was thought to be leukopenia.
However, it is not clear whether the leukopenia that occurs results from silver sulfadiazine toxicity
or from the margination of leukocytes as part of the body’s systemic inflammatory response to the
burn injury. Regardless, the leukopenia is typically self-limited, and therefore, the silver
sulfadiazine should not be discontinued. Patients with a documented sulfa allergy may or may not
have a reaction to the silver sulfadiazine. If there is concern about an allergy, a small test patch
of silver sulfadiazine can be applied. Typically, if there is an allergy, the silver sulfadiazine will be
irritating rather than soothing. In addition, a rash could signal a silver sulfadiazine allergy.
Mafenide (Sulfamylon) is another commonly used antimicrobial agent. Mafenide is available as a
cream and, more recently, as a 5% solution. Mafenide, like silver sulfadiazine, has a broad
antimicrobial spectrum, including grampositive and gram-negative organisms. In addition,
mafenide readily penetrates burn eschar, making it an excellent agent for treating burn wound
infections.
Mafenide is commonly used on the ears and the nose because of its ability to protect against
suppurative chondritis; however, silver sulfadiazine appears to be equally effective in this setting.
Since mafenide penetrates eschar well, twicedaily administration is typically necessary.
Mafenide-soaked gauze can also be used as a dressing for skin grafts that have been placed
over an infected or heavily colonized wound bed. There are two well-recognized drawbacks of
mafenide. Mafenide is a potent carbonic anhydrase inhibitor and, therefore, can cause a
metabolic acidosis. This problem can confound ventilator management.
In addition, the application of mafenide can be painful and therefore its use may be limited in
partial thickness burn wounds. Silver nitrate is another commonly used topical antimicrobial
agent. Silver nitrate provides broad-spectrum coverage against gram-positive and gramnegative
organisms. It is relatively painless on administration and needs to be applied every 4 hours to
keep the dressings moist. Silver nitrate has two principal drawbacks. First, it stains everything it
touches black, including linen, floors, walls, and staff’s clothing. Second, since silver nitrate is
prepared in water at a relatively hypotonic solution (0.5%), osmolar dilution can occur resulting in
hyponatremia and hypochloremia. Therefore, frequent electrolyte monitoring is needed. Rarely,
silver nitrate can cause methemoglobinemia. If this occurs silver nitrate should be discontinued.
Bacitracin, neomycin, and polymyxin B ointments are all commonly used for coverage of
superficial wounds either alone or with petrolatum gauze to accelerate epithelialization. These
ointments are also used routinely in the care of superficial face burns. Mupirocin (Bactroban) is
another topical agent that is effective in treating methicillin-resistant Staphylococcus aureus
(MRSA). Mupirocin should be used only when there is a culture-proven MRSA infection to avoid
the development of resistant infections.
Fluid Resuscitation
Significant burn injury not only results in local tissue injury but also initiates a systemic response
that impacts nearly every organ system. The release of inflammatory mediators (including
histamine, prostaglandins, and cytokines) can lead to decreased cardiac output, increased
vascular permeability, and alteration of cell membrane potential. The purpose of fluid resuscitation
is to provide adequate replacement for fluid lost through the skin and fluid lost into the interstitium
from the systemic capillary leak that occurs as part of the body’s inflammatory response.
Therefore, significant volumes of intravenous fluid may be required to maintain adequate organ
perfusion.
An understanding of burn shock physiology is essential to understanding the rationale for the
various formulas that have been described for fluid resuscitation. Burn injury destroys the body’s
barrier to evaporative fluid losses and leads to increased cellular permeability in the area of the
burn. In addition, in cases of larger burns (>20%), there is systemic response to injury that leads
to capillary leakage throughout the body. Arturson2 in 1979 demonstrated that increased capillary
permeability occurs both locally and systemically in burns greater than 25%, and Demling3
demonstrated that half of the fluid administered following 50% TBSA burns ends up in uninjured
tissue. Therefore, burn resuscitation must account not only for the loss of fluid at the site of injury
but also to the leak of fluid throughout the body. These losses are even greater if an inhalation
injury is present since there will be increased fluid leak into the lungs as well as an increased
release of systemic inflammatory mediators. Capillary leak usually persists through the first 8 to
12 hours following injury.
The use of formal fluid resuscitation is reserved for patients with burns involving more than 15%
to 20%. Awake and alert patients with burns less tan 20% should be allowed to resuscitate
themselves orally as best as possible. A number of approaches using a number of different
solutions have been proposed for intravenous fluid resuscitation.
Crystalloid. The Parkland formula, as described by Baxter, is still the most commonly used
method for estimation of fluid requirements (Table 15.4]). The formula (4 cc × weight in kilograms
× %TBSA) provides an estimate of fluid required for 24 hours. The fluid administered should be
Lactated Ringer’s (LR). LR is relatively hypotonic and contains sodium, potassium, calcium,
chloride, and lactate. Sodium chloride is not used because of the risk of inducing a hyperchloremic
acidosis. Half the calculated fluid resuscitation should be administered over the first 8 hours and
the second half administered over the next 16 hours. Children who weigh less than 15 kg should
also receive a maintenance IV rate with dextrose-containing solution since young children do not
have adequate glycogen stores.
It is important to remember that the formula provides merely an estimate of fluid requirements.
Fluid should be titrated to achieve a urine output of 30 cc/h in adults and 1 cc/kg/h in children.
Therefore, a Foley catheter should be used to accurately track urine output. If urine output is
inadequate, the fluid rate should be increased; conversely, if the urine output is greater than 30
cc/h, the fluid rate should be decreased. Fluid boluses should only be used to treat hypotension
and should not be used to improve urine output. Patients with deeper, full thickness burns and
patients with inhalation injury tend to require higher volumes of resuscitation.
Colloid. Protein solutions have long been used in burn resuscitation and have been the subject
of debate for decades. The use of colloid has the advantage of increasing intravascular oncotic
pressure, which could theoretically minimizecapillary leak and potentially draw fluid back
intravascularly from the interstitial space. The Brooke and Evans formulas developed during the
1950s and 1960s both included the use of colloid in the first hours of resuscitation. However, the
use of colloid in the early postburn period can lead to the leakage of colloid into the interstitial
space, which can aggravate tissue edema. Therefore, colloid is typically not used until 12 to 24
hours following burn injury when the capillary leak has started to seal.
Several different colloid formulations have been used. Albumin is the most oncotically active
solution and does not carry a risk of disease transmission.
Fresh frozen plasma has also been used, but since this is a blood product, there is a risk, albeit
small, of disease transmission. Dextran is a nonprotein colloid that has also been used in burn
resuscitation. Dextran is available in both a low and high molecular weight form. Low molecular
weight dextran (dextran 40) is more commonly used. Dextran increases urine output with its
osmotic effect, and therefore, urine output may not be an accurate indicator of volume status. In
addition, dextran has the disadvantage of relatively and potentially catastrophic allergic reactions.
Hypertonic Saline. Hypertonic saline solutions have been used for many years for burn
resuscitation. Advocates of hypertonic saline argue that hypertonic solutions increase serum
osmolarity and minimize the shift of water into the interstitial space. This should theoretically
maintain intravascular volume and minimize edema. However, this theory has not been well
substantiated in the literature.4
Regardless of the type of resuscitation fluid used, urine output is the best indicator of
resuscitation. Tachycardia is often present as a result of the body’s systemic inflammatory
response, pain, or agitation and, therefore, is not as accurate a barometer of volume status. The
use of pulmonary artery catheter parameters to guide fluid resuscitation has been found to lead
to overresuscitation. Serial lactate and hematocrit measurements serve as secondary indicators
of resuscitation. Poor urine output is likely the result of hipovolemia and is therefore appropriately
treated with increased fluid administration, not diuretics or pressors.
The risks of underresuscitation are well understood: hypovolemia and worsening organ
dysfunction. More recently, the risks of overresuscitation are becoming clear as well. The need
for intubation, prolonged ventilation, and increased extremity edema that can extend the zone of
burn injury and the potential for extremity and abdominal compartment syndrome can all result
from excessive fluid resuscitation.5,6
While there are several formulas to guide fluid resuscitation in the first 24 hours following burn
injury, it is important to remember that patients may continue to have large fluid requirements for
several days following injury. At the conclusion of the first 24 hours, fluids should not be
discontinued, but rather titrated for a goal urine output of 30 cc/h. Patients with large burns will
have large volumes of insensible losses that will require replacement with intravenous fluids.

Decision Not to Resuscitate

Despite the significant advances in burn care, some injuries are not survivable. In cases of
extensive burn injury, a decision is made regarding the potential futility of resuscitation and
subsequent surgical management. This is clearly a difficult decision that needs to be based on
several factors: an accurate assessment of the patient’s injury, location of burns, depth of burns,
presence of inhalation injury, the patient’s age and comorbidities, and the typical mortality level
based on these factors.
There have been several formulas described for estimating mortality, but none is perfect. Baux
suggested that adding age and TBSA gives an estimate of mortality. Zawacki’s description of
the Z score is another formula that has been described to estimate mortality. The score is based
on several factors including extent of burn injury, extent of full thickness burn injury, presence of
inhalation, and age.7
Part of the difficulty in determining survivability is that each burn is quite different. In addition,
each patient is quite different. This is particularly true in older patients, since there is great
heterogeneity in patients of the same age. Prior to making a decision regarding resuscitation,
frank discussion with the patient’s family, if possible, should occur. Members of the burn team—
particularly the nurses caring for the patient—should be included in the discussion and comfortable
with the very difficult decision to not resuscitate.
Patients who are awake and alert who are not candidates for resuscitation should also be involved
in the process. These patients should be informed of the decision not to resuscitate and given the
opportunity to talk with family members. Often patients with extensive full thickness burns can be
extubated and be awake and alert enough to have an opportunity to say good-bye to family
members.