WOUND MANAGEMENT
Management of burn
injury
Eunsol Kim
Peter J Drew
Abstract
Burns are a major cause of morbidity and mortality worldwide. Vulner-
able people such as children, the frail and elderly, and the socially
deprived are at particular risk. Most burns are caused by thermal injury
to the skin, but electrical and chemical burns can be very severe.
Fortunately, most burns are minor and superficial and can be managed
by primary health care professionals. However, major and severe
burns require in-hospital management from a team of surgeons and
other specialists. Life-threatening conditions such as smoke inhalation
airway damage and severe fluid loss should be addressed during the
initial resuscitation. Prevention of further thermal damage by cooling is
important along with prevention of secondary infection of burn injuries.
A wide variety of dressings is available for the management of burns
and expert nursing care is vital. Surgical intervention may be urgently
required for fasciotomy or escharotomy in cases of compartment syn-
drome or circumferential burns, respectively. Debridement, skin graft-
ing and reconstructive procedures will be required over the medium or
long term for patients with severe or complex burns and should be
planned with appropriate multidisciplinary expertize. The functional
and psychological impact of major burn injury should not be
underestimated.
Keywords Burns; burns surgery; chemical; cold; dressings; elec-
trical; reconstruction; scar management; skin grafts; thermal
Introduction
A burn is an injury caused by thermal, electrical, chemical or
radiant energy coming into contact with the skin. Its physiolog-
ical impact on the patient depends on the depth of injury and
area of skin involved. In practice, the majority of burns pre-
senting in primary care are small and can be treated with
dressings. Larger, deep burns (especially when they occur in
combination with smoke inhalation injury) are complex life-
threatening injuries, which provoke profound physiological
changes. Managing such injuries requires a prompt, systematic
and multidisciplinary approach in order to maximize survival
and optimize outcome. In this chapter we explore the patho-
physiology, acute assessment and surgical management of burn
injury.
Eunsol Kim MRCS is a Specialist Registrar in Burns and Plastic
Surgery at St. George’s Hospital, London, UK. Conflicts of interest:
none declared.
Peter J Drew FRCS FRCS(Plast) is a Consultant Burns and Plastic
Surgeon at Morriston Hospital, Swansea, UK. Conflicts of interest:
none declared.
SURGERY 40:1
Burn injuries primarily affect the skin, changing the way this
vital organ functions. The skin and its pilo-sebaceous append-
ages play an essential role in body homeostasis, controlling
temperature, water and salt content, mediating sensory percep-
tion, forming a barrier to ingress of micro-organisms and syn-
thesizing vitamins and hormones. Burn wounds can be caused
by thermal, electrical, chemical or radiant energy. The severity is
proportional to the size and depth of the injury and this disrup-
tion to the function of the skin can be life-threatening.
Incidence and aetiology
Minor burns injuries are common, with the majority not
requiring contact with medical services. However, in the United
Kingdom (UK), around 250,000 people present to primary health
care providers with burn injuries each year, 19,000 of whom are
referred on to specialized burn care services for treatment. This
number represents an increase of 90% over the 14-year period to
2015. Around 500 patients annually present with severe burns
(i.e. >15% total body surface area [TBSA] in adults or >10%
TBSA burn in children
16 years old) requiring fluid
resuscitation.
Mortality from burn injury has decreased over recent decades,
with the most marked improvement being among younger pa-
tients. Despite this, death remains a significant risk in severe
burn injury. In the UK, 67,000 patients of all ages were treated for
burns between 2003 and 2011, with a mortality rate of 1.27%.1 In
global terms, burn injury remains a leading cause of mortality
and morbidity. The World Health Organization (WHO) estimates
that in 2018, 180,000 people died from burn injury. Non-fatal
burn injury is among the leading causes of morbidity world-
wide, with the majority being in low and middle-income
countries.
The majority of burns are non-intentional, resulting from
carelessness, inattention, alcohol or drug misuse or from pre-
existing medical conditions. Vulnerable patient groups at
particular risk include the very young, the elderly and those in
the lowest socio-economic groups. Intentional burn injury is
most commonly self-inflicted by patients with mental illness. The
mechanism of burn injury has changed little over recent decades,
with scalds from hot liquids (especially hot drinks) representing
the majority in most age groups, followed by flame, flash and
contact burns. Less common causes include chemical, electrical,
friction and radiation burns (e.g. sunburn).
Pathophysiology
Local effects
The local effects of thermal energy on an area of skin vary
depending on factors including the amount of energy, duration of
exposure and the proximity to the energy source. Jackson’s burn
wound model2 is based on histological findings and describes
three concentric zones of injury (Figure 1).
 Zone of coagulation/necrosis: The area nearest the point of
energy application (zone of coagulation/necrosis) exhibits pro-
tein denaturation, coagulation and cell death. Tissue in this zone
is deemed unsalvageable.
 Zone of stasis: This is an intermediate zone where blood
flow becomes static. Tissue in this zone is deemed salvageable
with appropriate first aid and fluid resuscitation, but is otherwise
62 Ó 2021 Published by Elsevier Ltd.
 WOUND MANAGEMENT
at risk of transitioning to extend the zone of necrosis e the
phenomenon of burn ‘progression’ (i.e. deepening) over the first
48e72 hours from injury.
 Zone of hyperaemia: An outer zone of hyperaemia showing
reversible changes as a result of local release of inflammatory
mediators. Vasodilation and increased capillary permeability
cause a disturbance in Starling’s equation resulting in fluid shift
from intravascular to tissue interstitial spaces, producing tissue
oedema. The extent of the zone of hyperaemia depends on the
severity of the burn.
Systemic effects
When large areas of skin are burned (e.g. >20% TBSA), this may
affect the whole body. Depletion of intravascular volume triggers
hypovolaemic shock, with decreased venous return, inadequate
preload, a fall in cardiac output and decreased myocardial ac-
tivity. This is known as burn shock.
Major burns cause a significant increase in metabolism, ni-
trogen loss and poor temperature control. To counteract this,
patients are nursed in temperature-controlled rooms and are
provided with a protein-rich diet. The early cortisol rush
following injury results in protein breakdown, gluconeogenesis
and impaired insulin release. This catabolic state can last many
weeks and may result in on-going weight loss and impaired
growth in children. Oxandrolone, an anabolic steroid, has been
shown to be effective in regain of weight, bone mineral density
and lean body mass, while decreasing wound healing time for
graft donor sites.3
Major burn injury has immunosuppressive effects including
weakened humoral and cellular responses. Burn-induced
immunosuppression together with an increased risk of bacterial
and yeast infection, increases the risk of sepsis, morbidity and
mortality. Furthermore, loss of the protective function of the gut
can result in translocation of gut organisms into the circulation,
increasing this risk. To counteract this, enteral feeding (e.g. via
nasogastric tube) is commenced as early as possible along with
protein pump inhibitors to reduce the risk of gastroparesis and
Curling’s ulcers respectively.
Presentation
In the UK, most patients with minor or moderately large burns
present to their local emergency departments (ED) for treatment.
Increasingly, patients with severe burns receive their initial
assessment and treatment from specialist pre-hospital critical
Jackson’s burn wound model
Zone of coagulaon
Zone of stasis
Zone of hyperaemia
Figure 1
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care doctors at the scene of injury, before transfer to the local ED
or direct to a specialist burn service by road or air ambulance.
Whatever the mode of presentation, a targeted history and ac-
curate assessment are key initial steps in management.
History
A detailed and accurate history is vital (Box 1). This can usually
be gained from the patient, parents or carers. Establishing the
time of injury is important, as are details of the mechanism of
injury, as these may help predict the depth and extent of injury,
e.g. information on the type and temperature of hot fluids and
the duration of skin exposure. Knowledge of the circumstances
and environment in which burns occur can raise awareness of
the potential for complications. A history of flame burns sus-
tained in an enclosed space should prompt suspicion of a smoke
inhalation injury, with the potential for airway compromise. A
history of burns from an explosion may indicate co-existing
pulmonary blast injury.
Information on first aid administered at the scene should be
sought. Thermal burns should be cooled with running water (10
e15  C) for 20 minutes as this may reduce tissue damage by
minimizing conversion of the zone of stasis to the zone of ne-
crosis.4 Cooling is effective up to 3 hours following injury.5 If not
already done at the scene or in transit, cooling should be per-
formed at the first site of medical contact. Cooling gels provide
symptomatic relief but are not a substitute for cool running
water. Ice should not be applied, as it can cause cold injury to
already damaged tissues.
In vulnerable patients with burns, non-accidental injury should
be considered. Burns in children under 6 months of age should
trigger safeguarding protocols. These children are usually non-
mobile and unable to cause accidental injury to themselves.
Other concerning signs include limb burns in a glove and stocking
distribution indicating an emersion scald injury or a contact burn
in hard-to-reach areas, e.g. an iron mark on the back. Burns at an
early age are associated with a sevenfold increased risk of abuse or
neglect and therefore a high index of suspicion should be main-
tained, particularly for those patients who present after a delay or
with inconsistent history or examination findings. If there are
concerns, a safeguarding specialist should be consulted.
The patient’s past medical history, medication, allergies and
tetanus status should be documented. A full social history should
explore the patient’s social and family circumstances, their
Key features of a targeted burns history
C Patient demographics (name, age, DOB, hospital number)
C Mechanism of injury
C Details about perpetrating substance
C Date and time of injury
C Details of first aid
C Concerns for non-accidental injuries
C Social history
C Past medical history and comorbidities
C Drug history
C Allergies
Box 1
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 WOUND MANAGEMENT

employment, hobbies, use of tobacco, alcohol and recreational

drug use.

Burn wound assessment

The two key features of any burn injury are its area (size) and
depth. Assessing these can be difficult but is important as they
indicate the degree of physiological insult the injury is likely to
cause. This in turn will determine what treatment the patient
requires and where this would be best delivered.

Burn area
The burn area is usually described as a percentage of the patient’s
total burn surface area (TBSA) and should include blistered areas
but not areas of simple erythema. Many aids to burn area assess-
ment have been described. Wallace’s ‘Rule of 9s’6 divides the body
into areas equivalent to either 9% TBSA or multiples of 9% TBSA.
While this is a useful aide memoire, it does not account for the
changes in body proportion that occur with age and body habitus. Figure 2 Superficial partial-thickness (SPT) burn from a pull-over
scald.
When assessing the area of small or scattered burns, it can be
useful to remember that the size of the patient’s (not the exam-
iner’s) palm and fingers is roughly 1% of their TBSA. thickness of the skin and extend into subcutaneous tissues. The
The most accurate burn area assessments are made using a layer of dead skin (eschar) feels leathery to the touch, is insen-
Lund and Browder chart. These charts adjust for changes in body sate on pinprick and does not blanch (Figure 3).
proportion that occur with age in the head and legs. Numerous  With experience, it is usually possible for clinicians to di-
variations have been published, for example that published by agnose burn depth with reasonable accuracy based on their
Neaman et al.,7 which allow adjustment of adult body pro- appearance, capillary refill (blanching) and sensitivity on
portions with body mass index (BMI). Numerous technological pinprick. Many objective technical methods of assessing burn
aids are also available. The Mersey Burns smartphone app8 al- depth have been described, but most have not been adopted
lows rapid calculation of burn area and resuscitation fluid re- widely in clinical practice and are limited to use in a research
quirements based on a burn area sketched onto a digital body context. Laser Doppler imaging (LDI) is the exception.9 It works
chart. by measuring the frequency shift when laser light interacts with
moving bloods cells. This measurement is expressed as a colour
Burn depth (red ¼ high blood flow, blue ¼ low blood flow) and is super-
The depth of a burn is the extent to which energy penetrates imposed onto an image of a burn. This blood flow estimation has
tissues causing cellular injury (see Pathophysiology above). Burn been shown to be a good predictor of burn depth and healing
depth ranges from the epidermis to the base of the reticular time. However, as burn wounds are dynamic in the early stages
dermis and into subcutaneous fat, fascia, muscle or bone and post-burns circulatory changes are not complete until
depending on the severity of the injury. In practice, burn wounds
are seldom totally uniform in depth.
In the UK, a descriptive anatomical classification of burn
depth is commonly used, rather than the numerical scale fav-
oured in the USA and elsewhere.
 Epidermal burns (e.g. sunburn) affect the epidermis only
and present as erythema. They do not blister but may desqua-
mate (‘peel’) after several days before resolving without scarring.
 Superficial partial-thickness (SPT) burns involve the
epidermis and superficial (papillary) dermis. They present clini-
cally as blisters beneath which the raw dermal surface appears
pink and wet with prompt capillary refill (blanching). SPT burns
are painful but usually heal by re-epithelialization within
2 weeks without scarring (Figure 2).
 Deep dermal (DD) burns penetrate to the deepest (reticular)
dermal layer. The burn surface often appears deep (‘cherry’ or
‘brick’) red with mottling due to ruptured erythrocytes within the
dermis. They do not blanch with pressure. They may appear dry
and exhibit reduced sensitivity on pinprick.
 Full-thickness (FT) burns may appear white, brown or
black in colour and generally, do not blister. They involve the full Figure 3 Full-thickness (FT) contact burn.

SURGERY 40:1 64 Ó 2021 Published by Elsevier Ltd.

 WOUND MANAGEMENT
48 hours after the injury, the LDI assessment is only useful be-
tween 2 and 5 days post injury.
Referral to specialist burn care
Clear guidance on referral from primary care to specialized burn
care services in the UK is available.10 This is based on burn area,
depth, anatomical site, mechanism of injury and other factors,
and describes thresholds for referral to and discussion with
specialist services (Box 2).
UK burn services are increasingly using telemedicine and tele-
referral systems to make specialist care more accessible and
reduce the need for patients with small burns to travel for assess-
ment. In some cases, this has been accelerated by the need to reduce
footfall through hospitals in the 2020 Coronavirus pandemic.11
Using online tele-referral platforms (e.g. MDSAS), patients are
referred digitally with demographic and injury details accompanied
by images of the burn wound through a secure encrypted system.
This has been shown to reduce the monthly number of ward
attenders seen at specialist services by up to one third.12
Treatment
Small burns
Small burns (<5% TBSA) are very common and make up the ma-
jority of the workload of most specialist burn services. Superficial
burns of <2% TBSA in children and <3% TBSA in adults can usu-
ally be managed in the ED, with appropriate cleaning, wound care,
analgesia and dressings, although specialist advice should be sought
in specific cases (see Box 2).
Localized wound infection can occur in any small burn, but life-
threatening systemic sepsis is rare. Toxic shock syndrome (TSS) is
a rare, acute toxin-mediated illness well recognized in children
with small burns.13 Classically, it develops at around 2e4 days
post injury, with the onset of malaise, fever, rash, diarrhoea and
vomiting. As the disease evolves the child becomes hypotensive,
with signs of shock, coagulopathy and multi-organ failure. The
organism responsible is usually a Staphylococcus aureus or group A
UK National Burn Care Referral Guidance (2012)
Suggested minimum threshold for referral to a specialized burn care
service
C All burns 2% TBSA in children or 3% in adults
C All full-thickness burns
C All circumferential burns
C Any burn not healed in 2 weeks
C Any burn with suspicion of non-accidental injury should be referred
to a burn unit/centre for expert assessment within 24 hours
Suggested threshold for discussion with a specialized burn care
service and consideration given to referral
C All burns to hands, feet, face, perineum or genitalia
C Any chemical, electrical or friction burn
C Any cold injury
C Any unwell/febrile child with a burn
C Any concerns regarding burn injuries and comorbidities that may
affect treatment or healing of the burn
Box 2
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streptococcus which produces toxins that activate T cells, causing
massive cytokine release and coagulopathy. TSS should be
managed promptly in a high dependency setting, led by burns and
paediatric teams. Mainstays of treatment include prompt wound
cleaning, administration of antibiotics, fresh frozen plasma and
immunoglobulins.
Large burns
A systematic approach to assessing larger injuries (i.e. burns of
>10% TBSA in children and >15% TBSA in adults) is essential.
The ‘ABC’ approach described in Emergency Management of
Severe Burns (EMSB) and Advanced Trauma Life Support
(ATLS) courses aims to identify and treat in order of immediately
life-threatening injuries before addressing the burn itself.
Airway and cervical spine control: The patient’s airway is
assessed while the cervical spine is immobilized. High flow ox-
ygen is given via a non-rebreathing mask. Symptoms suggestive
of smoke inhalation injury include hoarseness, cough and diffi-
culty breathing. Signs include swelling or burns to the face and
lips, singed facial or nasal hair, stridor and visible sooty secre-
tions in the oropharynx. These patients require urgent attention
from an anaesthetist, as acute airway obstruction secondary to
oedema may be imminent. The burned airway can be extremely
difficult to manage, and clinicians should have a low threshold
for endotracheal intubation. Tubes should be firmly secured but
left long to allow for facial oedema in the days to come.
Breathing and ventilation: Respiratory rate and equality of chest
expansion should be recorded and the oxygen saturation
measured. The latter can be falsely high in carbon monoxide
poisoning. An arterial blood gas (ABG) is needed to assess car-
boxyhaemoglobin. Circumferential deep chest burns may restrict
ventilation, necessitating escharotomy (see below and Figure 3).
Circulation and haemorrhage control: Obvious bleeding is
addressed, while pulse, blood pressure and capillary refill are
assessed. Circulatory insufficiency in a limb with circumferential
FT burns signals the requirement for escharotomy. Intravenous
access should ideally be through non-burnt skin.
Disability: The patient’s level of consciousness should be
assessed using the Glasgow Coma Score (GCS) or AVPU (Alert/
Vocal/Pain/Unresponsive) method. The pupillary light reflexes,
temperature and blood glucose level should also be measured
and recorded.
Exposure and environment: The patient’s clothing and jewel-
lery are removed in a warm and private environment while
maintaining their dignity and temperature. Good lighting is
required to assess burn wounds accurately. A ‘log roll’ is
required to examine the back, buttocks, posterior scalp and legs.
At this stage it is prudent to clean the patients’ skin and photo-
graph burn wounds before applying dressings.
Fluids: Large burns require fluid resuscitation, as the volume of
fluid lost through the burn is likely to be larger than which can be
replaced orally. A urinary catheter is required for burns >20%
TBSA.
65 Ó 2021 Published by Elsevier Ltd.
 WOUND MANAGEMENT
Much has been written about the type and volume of fluid
required following burn injury. Fluid loss into the tissues
through oedema formation is proportionate to the burn area and
is thus predictable. Various formulae have been designed to
calculate the timing and volume of resuscitation fluid required,
based on the burn area and patient’s weight. In some cases,
additional maintenance fluid is required. It is important to
remember that the calculation starts at the time of the injury
and thus additional fluid may be required to ‘catch up’ when
presentation is delayed.
The Parkland formula (Box 3)14 calculates the volume of crys-
talloid fluid (Hartmann’s solution) required over the first 24 hours
from the point of injury, while the Muir and Barclay formula15
(Box 4) calculates the volume of colloid (4.5% human albumin so-
lution) required over the first 36 hours. The latter is divided into
consecutive 4, 4, 4, 6, 6 and 12 hour ‘periods’. Maintenance fluid is
usually given as 5% dextrose solution in adults and can be admin-
istered orally, via nasogastric tube (NGT) or intravenously (Box 5).
Some burn centres use hybrid resuscitation protocols (e.g.
Hunter et al.16) using crystalloid, followed by colloid-based
resuscitation. The advantage of these regimes is that crystal-
loids are more readily available in EDs, before transfer to a
specialized burn centre where colloids are kept on hand.
It is important to remember that formulae only provide an
estimate of fluid requirement and as such should be used as a
The Parkland formula
3e4 3 patient weight (kg) 3 % TBSA burn [ total fluid volume
(mls) required in first 24 hours
C First half given over 8 hours
C Second half given over 16 hours
C Add maintenance fluid in children
C Give colloid after the first 24 hours
Box 3
The Muir and Barclay formula
0.5 3 patient weight (kg) 3 % TBSA burn [ fluid required (mls) per
period
C 3  4 hour periods then
C 2  6 hour periods then
C 1  12 hour period
C Add maintenance fluid
Box 4
Maintenance fluid calculation
Maintenance fluid
required (mls) in 24 hours ¼ 100 ml/kg for the first 10 kg plus
50 ml/kg for the second 10 kg plus
20 ml/kg for each additional kg
Box 5
SURGERY 40:1
guide. Fluid volumes administered in practice should be titrated
according to clinical parameters such as urine output, CVP, etc.
Urine output should be maintained at around 0.5 mls/kg/h in
adults and 0.5e1 mls/kg/h in children. Fluid resuscitation re-
quires close monitoring and regular electrolyte checks. Under-
resuscitation may cause renal failure, while over-resuscitation
may cause life-threatening complications such as hypona-
tremia, hypoglycaemia, pulmonary oedema and compartment
syndromes.
Secondary survey and re-evaluation: This should include
reassessment of the need for escharotomy or fasciotomy. X-rays
or CT scans should be arranged as required. Pain should be
managed with intravenous morphine titrated to response.
Dressings (see also pages 25e32 of this issue)
Burn dressings aim to provide optimum local conditions for
wound healing and play a central role in treatment. The principal
properties of the ‘ideal’ burns dressing are non-adhesiveness,
absorbency, moisture retention, low cost, antibacterial and/or
antiseptic properties and low bulk.
In the acute setting, cling film or a similar clear plastic film
can provide a cheap, effective dressing, allowing burn wounds to
be assessed without removal. Thereafter, a ‘traditional’ burn
dressing usually includes two to three layers of tulle gras (cotton
gauze impregnated with soft paraffin), gauze, cotton wool
(Gamgee) and crepe bandages to retain the dressing in place.
Tulle gras keeps wounds moist and is relatively non-adherent,
while gauze and Gamgee absorb wound exudate. Burn dress-
ings should be inspected daily for signs of ‘strike through’ of
exudate onto the outer crepe bandage. If present, this should
prompt a dressing change.
Modern alternatives to tulle gras include silicone or lipid-
coated materials (e.g. Mepitel or Urgotul). Small burns in mo-
bile areas can be dressed using materials with an adherent
border, negating the need for retentive crepe bandages. Adherent
hydrocolloid dressings (e.g. Duoderm) can be effective for hand
burns. Larger areas can be dressed with bordered polyurethane
foam dressings with a silicone contact layer (e.g. Mepilex and
Allevyn).
Many antiseptic agents have been used in burn dressings, but
in the modern era, silver is probably the most commonly applied.
Silver ions have high affinity for bacterial cell walls, causing
disruption and cell death. Silver can be used in liquid form (silver
nitrate solution), in creams or impregnated dressing materials.
Flamazine is a cream containing silver sulfadiazine (SSD), a
sulphonamide with antibiotic properties. It has been used since
the 1970s and is a cheap and reliable dressing, applied every 24
e48 hours. Flammacerium contains silver sulfadiazine (SSD) and
cerium nitrate. This penetrates burn eschar, reducing inflam-
mation and bacterial colonization. Acticoat is a sheet dressing
material containing silver in nano-crystalline form.
In some situations, other dressing materials offer advantages.
Facial burns are normally treated exposed, with regular appli-
cation of paraffin or other moisturizing agents. Some large,
confluent partial-thickness burns can be treated effectively using
Biobrane, a synthetic temporary skin substitute comprising a
nylon mesh impregnated with porcine dermal collagen with a
silicone membrane on one side. When applied to a clean wound,
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 WOUND MANAGEMENT
Biobrane allows healing to proceed before the sheet comes away.
It has been shown to reduce pain, decrease length of hospital stay
and increase mobility compared with traditional dressings.
Ideally, it is applied within 12 hours of injury following thorough
wound cleaning.
Surgery
Emergency surgery e escharotomy and fasciotomy
Burnt skin loses the elasticity that normally allows it to stretch.
Circumferential full-thickness burns to the limbs or chest may
thus have a constrictive effect, compounded by oedema forma-
tion and swelling beneath the burn. In the limbs, increasing
pressure in the tissues causes first venous, then arterial
compromise of distal perfusion. In the chest, respiratory excur-
sion may be limited, causing hypoxia. In both cases, emergency
decompression is required.
An escharotomy (Figure 4) is an incision through burned skin
designed to decompress swollen limbs or allow unrestricted
ventilation in the torso. Burned skin (eschar) is incised down to
subcutaneous fat, allowing the skin edges to separate as widely
as is necessary. Occasionally, fasciotomy may also be required to
release tight fascial compartments in deeply burned limbs or in
high-voltage electrical injury (see below).
Debridement
Extensive deep dermal and full-thickness burns usually require
debridement (excision), as they are a source of on-going
inflammation and potential infection. In general, this should be
completed as soon as possible after the injury, ideally within the
first five days. In burns >20% TBSA, excision may need to be
staged over several days.
Burn debridement requires the removal of all non-viable cuta-
neous and subcutaneous tissue and can be achieved in several
ways. Enzymatic debridement using compounds containing pro-
teolytic enzymes (e.g. Nexobrid) offers the advantage of optimal
dermal preservation, removing only non-viable tissue. Surgical
debridement is more appropriate in larger injuries. Depending on
the type and depth of burn, either tangential (shaved layer by
layer) or fascial (en-bloc) excision may be required.
Extensive burn debridement can be challenging and requires
experienced and fully prepared surgical, anaesthetic and nursing
Figure 4 Escharotomy of right medial arm.
SURGERY 40:1
teams supported by a blood bank and a properly equipped
intensive therapy unit (ITU). The operating theatre must be
warmed with facilities on hand to preserve the patients’ body
temperature through the procedure. Techniques used to reduce
blood loss include pre-infiltration with adrenaline solution,
tourniquets, suspension of limbs from ceiling supports and
wrapping in adrenaline soaked swabs. Debridement should be
performed as quickly as possible; thus, multiple surgical teams
working simultaneously are an advantage.
Wound closure
Debrided wounds require closure to prevent infection and
encourage healing. Closure may be temporary or definitive,
depending on the patient’s condition and size of the wound. Burn
wounds of
20% TBSA can usually be debrided and closed
definitively using skin autograft at the same operation. Other-
wise, temporary closure will allow the patient to recover before
definitive closure.
Temporary wound closure can be achieved using synthetic or
biological materials. Synthetic skin substitutes (e.g. Biobrane)
are relatively cheap but can only be left in situ for several days.
Xenograft (i.e. skin graft taken from another species) materials
have been used in the past (e.g. pig skin). Human skin allograft is
considered by many as the ‘gold standard’ but is expensive and
requires access to a tissue bank.
Definitive wound closure is achieved using skin autograft,
either alone or in combination with permanent skin substitutes.
When possible and in cosmetically sensitive areas (e.g. the face),
split-thickness autograft is applied as a sheet. However, when
wounds are large and donor sites limited, grafts can be meshed to
increase the surface area, depending on the mesh ratio used (e.g.
1:1.5, 1:3 etc) (Figure 5a). The ‘holes’ in the mesh allow for
egress of fluid which is beneficial, but long-term cosmetic
appearance of SSG may not be acceptable in some exposed body
areas. The Meek technique17 can expand autograft even wider
(up to 1:9) (Figure 5b). Once healed, areas of split-thickness graft
are often less pliable than normal skin and can cause reduced
range of movement if sited over joints (a contracture). A variety
of dermal substitutes (e.g. Matriderm, Integra, BTM) have been
developed to improve appearance and pliability of a healed SSG.
These provide a scaffold onto which native collagen is deposited,
forming a, pliable bed (neo-dermis) for split-thickness skin
autografts.
Burns scars
Superficial partial-thickness burns will usually heal by re-
epithelialization from the lining cell layers of hair follicles and
sweat glands within 10e14 days, leaving little or no true scar-
ring. As the new epidermis is thin, these areas may initially
appear red, but usually return to a relatively normal colour over
time. Deep dermal burns take longer to heal. The frequency of
hypertrophic scarring in these areas increases if they take longer
than 3 weeks to heal. If left untreated, full-thickness burns heal
by granulation and contraction and can result in significant
scarring, changes in pigmentation and contracture (i.e. restric-
tion in the range of movement at a joint due to scar tightness).
Therefore, DD or FT burns usually benefit from surgical excision
and skin grafting.
67 Ó 2021 Published by Elsevier Ltd.
 WOUND MANAGEMENT
Figure 5 (a) Skin Autograft Meshed 1:3. (b) Skin Autograft prepared using the Meek Technique.
Abnormal scarring ranges from mild hypertrophic scarring
(HS) to severe keloid scarring (KS). HS is common and presents
as red, lumpy and itchy scar. HS is, to some extent, self-limiting
and tends to improve over time. KS is defined as scarring which
extends outside the margins of the original injury which can be
treated with steroid injections or surgical excision.
Moisturizing, massage and sun protection are simple but
important steps in optimizing scar outcomes. Other treatments
include silicone (applied as sheets or gels) that maintains moisture
in the maturing scar tissue. Additionally, compression garments
can be worn to apply pressure to areas of prominent scarring to
flatten scars during the maturation phase. Other interventions that
may be of benefit include laser therapy which is particularly useful
for red, itchy active scars. Scar contracture may require surgical
release and reconstruction using a wide range of techniques, from
simple skin grafts to complex free flaps.
Non-thermal burns
Electrical injury
Electrical injuries are categorized as low voltage (<1000 volts),
high voltage (>1000 volts) and ultra-high voltage (>33,000
volts). Most electrical injuries are low voltage and stem from the
domestic supply (approx. 230 V). Burn wounds occur frequently
on the hands and are often small but deep, occasionally
involving tendon or nerves. Patients should have an electrocar-
diogram (ECG) to exclude cardiac arrhythmias before referral for
specialist care.
High voltage injuries are much more complex. Transmission
of current through the body may cause injury at the points of
entry and exit, as the current seeks earth. While the skin and
subcutaneous injuries are obvious, deep tissue damage along the
path of the current is not. Deep muscle injury within the limbs is
often most severe adjacent to bone (the Joule effect). Swelling in
the injured muscle may cause compartment syndrome, while
rhabdomyolysis leads to the myoglobinuria. Myocardial damage
may cause cardiac arrhythmia or arrest. High voltage electrical
injury may be accompanied by thermal burns, from arcing of the
current or clothing ignition. Such injuries often occur in electrical
engineers working at height and are thus at higher risk of con-
current fractures or blunt trauma. These patients require careful
assessment and on-going cardiac monitoring.
Formulae for fluid resuscitation based on burn surface area
are not applicable in high voltage electrical injury. However,
SURGERY 40:1
it is important for a high urine output to be maintained to
prevent acute kidney injury from myoglobinuria. Intravenous
crystalloid is given to produce a urine output of at least 1
e2 ml/kg/h. Fasciotomy may be required if compartment
syndrome is suspected. Severe limb injuries frequently
require amputation.
Chemical burns
Many caustic chemicals are used in domestic and industrial
settings. Broadly, they can be grouped as acids, alkalis and
others. Acid burns (e.g. from hydrochloric, sulphuric or nitric
acid) are immediately painful and thus tend to present early.
These chemicals cause coagulative necrosis of the skin, forming a
tough eschar. Conversely, alkali burns may not be immediately
painful and often present late. They cause damage by liquefactive
necrosis and can penetrate deep into subcutaneous tissues.
Contact with subcutaneous fat produces a saponification reac-
tion, generating a soapy residue that gives the wound a slimy
feel. Common examples include burns from caustic soda (sodium
hydroxide) used as drain cleaner and lime (calcium hydroxide) in
cement.
Patients presenting with chemical burns are assessed in the
same way as those with thermal burns. Those with injuries
affecting the face must undergo a careful eye examination. The
pH of the burn should be assessed using pH-sensitive paper
strips. Initial management almost always involves irrigation with
copious volumes of water (once any chemical crystals have been
safely removed) or amphoteric buffering solutions (e.g.
Diphoterone).
Burns from hydrofluoric acid (HF) deserve special mention.
This agent is used in industry as a de-greasing and cleaning
agent. Burns usually affect the hands and are small but extremely
painful. Topical treatment with calcium gluconate gel is
commonly commenced at the scene, but continuing pain in-
dicates that more aggressive treatment is required. Sub-ungual
pain may require nail removal for treatment to be effective.
Larger skin exposures are rare but potentially life-threatening, as
fluoride ions chelate calcium causing profound hypocalcaemia
and cardiac arrhythmia.
The burns multidisciplinary team (MDT)
Burns are best managed by a multidisciplinary team involving,
burns surgeons, anaesthetists, nurses, physiotherapists,
68 Ó 2021 Published by Elsevier Ltd.
 WOUND MANAGEMENT
occupational therapists, psychologists and social workers to
optimize patient care and outcome. Psychological support is a
crucial part of rehabilitation, helping burn patients to re-integrate
back into society.
Conclusion
Burns injuries are common, the majority requiring only dress-
ings. Severe burns can be life threatening and carry the risk of
long-term sequelae. Appropriate and timely first aid, wound care
and surgery are crucial in optimizing outcome. A nosis and management. Arch Dis Child 2007; 92: 97eep100.
REFERENCES
1 Stylianou N, Buchan I, Dunn KW. A review of the international
Burn Injury Database (iBID) for England and Wales: descriptive
analysis of burn injuries 2003e2011. BMJ Open 2015; 5: e006184.
https://doi.org/10.1136/bmjopen-2014-006184.
2 Jackson DM. The diagnosis of the depth of burning. Br J Surg
1953; 40: 588e96.
3 Ring J, Heinelt M, Sharma S, Letourneau S, Jeschke MG. Oxan-
drolone in the treatment of burn injuries: a systematic review and
meta-analysis. J Burn Care Res 2020; 41: 190e9.
4 Cuttle L, Kempf M, Liu PY, et al. The optimal duration and delay of
first aid treatment for deep partial thickness burn injuries. Burns
2010; 36: 673e9.
5 Wood FM, Phillips M, Jovic T, et al. Water first aid is beneficial in
humans post-burn: evidence from a bi-national cohort study.
PLoS One 2016; 11: e0147259.
6 Wallace AB. The exposure treatment of burns. Lancet 1951-03-
03; 257: 501e4. Originally published as Volume 1, Issue 6653.
7 Neaman KC, Andres LA, McClure AM, Burton ME, Kemmeter PR,
Ford RD. A new method for estimation of involved BSAs for obese
and normal-weight patients with burn injury. J Burn Care Res
2011; 32: 421e8.
8 Barnes J, Duffy A, Hamnett N, et al. The Mersey Burns App:
evolving a model of validation. Emerg Med J 2015 Aug; 32: 637e41.
9 Shin JY, Yi HS. Diagnostic accuracy of laser Doppler imaging in
burn depth assessment: systematic review and meta-analysis.
SURGERY 40:1
Burns 2016 Nov; 42: 1369e76. https://doi.org/10.1016/j.burns.
2016.03.012. Epub 2016 May 20. PMID: 27215151.
10 National Burn Care Referral Guidance. National network for burn
care (NNBC), 2012.
11 Toh VV, Antrum JHG, Sloan B, Austin O, Muthayya P. Manage-
ment of COVID-19 in burns patients: the experience of a UK burn
centre. Burns 2020; 46: 1710e2.
12 Wong R, Dunn K. Real-world use of telemedicine e a picture is
worth a thousand words. PMFA News 2018; 5.
13 Young AE, Thornton KL. Toxic shock syndrome in burns: diag-
14 Baxter CR, Shires T. Physiological response to crystalloid resus-
citation of severe burns. N Y Acad Sci 1968; 150: 874e94.
15 Muir IA, Barclay TL. Burns and their treatment. Chicago, IL: Year
Book Medical Publishers, 1974.
16 Hunter JE, Drew PJ, Potokar TS, Dickson WA, Hemington-
Gorse S. Albumin resuscitation in burns: a hybrid regime to miti-
gate fluid creep. Scars, Burns & Healing 2016; 2: 1e5.
17 Meek CP. Successful microdermagrafting using the Meek-Wall
microdermatome. Am Surg 1958; 29: 61.
Practice points
C Burns are a common cause of morbidity and mortality worldwide
C Thermal burns are the most common type of burn, but chemical
and electrical burns can be severe
C Most burns are relatively minor and can be managed in a com-
munity setting with appropriate dressings
C Severe burns should be managed by a multidisciplinary team in a
burns specialist centre
C Cooling of thermal burns is the primary therapeutic intervention
C Fluid losses from thermal burns should not be underestimated
and aggressive fluid replacement is essential
C Care should be taken to avoid secondary infection of burn
wounds
C Electrical and chemical burns require specialized management
69 Ó 2021 Published by Elsevier Ltd.