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Management of burns
WOUND MANAGEMENT
Management of burns
diabetes with neuropathy who sustains an unnoticed contact burn to their foot is vulnerable due to their poorly controlled medical condition. The unsupervised toddler who pulls a cup of tea onto themselves is vulnerable due to lack of attentive supervision. The intoxicated person who falls asleep with a lit cigarette following drink or drugs and sustains burns is vulnerable due to their lack of cognitive awareness or addiction. Patients who are depressed and self-harm or self-immolate are vulnerable due to their mental illness. Such vulnerabilities are varied, but each requires investigation and management to reduce the burden of burns on individuals and on society.
Helen E Douglas Jonathan A Dunne Jeremy M Rawlins
Abstract Burns are common injuries that vary in severity from small superficial scalds to massive full-thickness flame burns with high morbidity and mortality. The purpose of this article is to review common burn presentations, the pathophysiology of these injuries and to give an overview of multidisciplinary burns management from the emergency department through to the specialist burns centre.
Pathology and pathophysiology Local effects Following a burn, tissue destruction is proportional to the temperature of the burning agent and the duration it is applied to the body. For example, water at 48 C takes 5 minutes to cause a partial thickness burn, but when the water temperature is raised to 70 it takes just 1 second to cause a full thickness injury. Jackson described zones of burn injury related to the degree of tissue damage (Figure 2).3 The inner zone of coagulative necrosis represents unsalvageable burnt tissue where the blood vessels are thrombosed and the skin is dead. The intermediate zone of stasis represents tissue affected by the burn with static blood flow. This area is amenable to first aid, resuscitation measures and good wound care and is therefore salvageable if cared for appropriately. The outer zone of hyperaemia represents red, hyperaemic tissue that surrounds any acute inflammatory process and will return to normal. The tissue damage that results following thermal injury results in a marked increase in capillary permeability which is maximal within the first few hours following injury and resolves within 2e3 days. During this time, small protein molecules leak out of the circulation leading to oedema and significant fluid loss. The fluid loss is proportional to the size of the burn; however, when the size of the burn exceeds 30% body surface area (BSA), the leaking capillaries involve all body tissues and not just the skin, resulting in a systemic inflammatory response. Burn oedema is a result of circulating inflammatory mediators including histamine, prostaglandins, leukotrienes and kinins that result in increased capillary permeability. This oedema is exacerbated by increasing capillary hydrostatic pressure, decreasing tissue hydrostatic pressure, and decreased plasma oncotic pressure (due to loss of albumin from the circulation).
Keywords Burns; burns surgery; dressings; resuscitation; scalds; scar management; skin grafts
Introduction and epidemiology Burns are traumatic injuries caused by coagulative destruction of the skin and are usually caused by thermal damage (heat and cold) but chemicals, electricity and radiation may also damage tissues in similar ways. In the United Kingdom approximately 250,000 people present to primary care and to hospitals with burns each year, though this is an underestimation of total numbers, as many people with small or innocuous burns manage their injuries themselves.1 The number of patients treated by specialist burns services in the UK each year is increasing; admissions to such units numbered around 1000 patients in 2001, rising to 14,000 a decade later in 2011 and reaching over 19,000 in 2015. Mortality from these injuries is decreasing in the UK and across the Western world, with a mortality rate of around 1.4% of these cases or approximately 200 deaths from burn injuries per year in England and Wales.2 No age group or gender is immune from burns, though nearly two thirds of all burn injuries are sustained by males.2 Whilst it used to be the case that scald injuries were most common in childhood and then gave way to increasing flame, flash and contact burns as age increased, this is now less apparent. In children, adults and elderly patients, scald injuries now account for the majority of all burns. The second most common cause of burns in adults and elderly patients are flame injuries, followed by contact burns (Figure 1). Whatever the cause for the burn, there is often an underlying patient vulnerability that puts the patient at risk. The patient with
General effects The local and systemic inflammatory mediators released following a burn (particularly injuries greater than 30% BSA) result in profound systemic effects. Due to ongoing fluid losses, cardiac output falls due to decreased venous return, inadequate preload and afterload, and decreased myocardial activity. Due to the ‘fight or flight’ effects, the patient experiences a catecholamine rush of sympathetic activity that contributes to increasing systemic vascular resistance. Pulmonary oedema develops because of the systemic increase in capillary permeability as well as increasing pulmonary vascular resistance, left sided heart failure, hypoproteinaemia, direct vascular injury, and sometimes the added insult of an inhalational burn.
Helen E Douglas FRCS(Plast) is a Fellow at the State Burns Unit, Western Australia, Australia. Conflicts of interest: none declared. Jonathan A Dunne MRCS(Eng) is a Registrar in Plastic and Reconstructive Surgery in the London Deanery, UK. Conflicts of interest: none declared. Jeremy M Rawlins FRACS FRCS(Plast) is a Consultant Plastic and Reconstructive Surgeon at the State Burns Unit, Western Australia and Royal Perth Hospital, Australia. Conflicts of interest: none declared.
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UK burn epidemiology 1%
1% 1% Scald
1%
Contact
8%
1%
Flame 6% Flash
42% 7%
Chemical Electrical
17%
Friction Radiation
15%
Cold Figure 1
Other systemic effects following major burns include a significant increase in metabolism, nitrogen loss and poor temperature control due to loss of water and heat through the burnt tissue. The early cortisol rush following burn injury results in protein breakdown, gluconeogenesis, and impaired insulin release and glucose tolerance is seen. This catabolic state can last many weeks and months following burns and may result in ongoing weight loss in adults and impaired growth in children. The immunosuppressive effects of a burn are compounded by the weakened humoural and cellular responses following damage to the local circulation and the normal inflammatory process. This can cause increased risks of infection; the raw burn wound is an easy entry point for bacteria and yeasts. In addition, burns patients may lose the protective function of the gut following major injury, resulting in translocation of gut organisms into the circulation with increasing sepsis, morbidity and mortality.
Diagnosis History The history of the injury and circumstances surrounding how the patient sustained their burn are important and can be crucial in predicting the depth of the injury and requirement for surgery. The time of the injury is also significant, as the appearance of the burn changes over subsequent hours and days. Knowing the exact cause of the burn is also key; scalding liquid, flame, explosion, contact, chemical and electric burns will all produce different injuries and this will need to be confirmed during the history and physical examination. The detail regarding the mechanism is important; freshly boiled water produces much deeper injuries compared to a cooled cup of tea. The location where the burn occurred can help predict severity; an explosion in a confined place such as a building or car, or if the patient required extraction from a burning house there will be a very high risk of inhalational injury. Information about first aid is useful, as appropriate first aid reduces the risk of needing a skin graft by 50%.4 All burns should have cool running water applied for 20 minutes as soon as possible following their injury, but it is still effective up to 3 hours following the burn.5 Medicated cooling gel sponges such as those carried by ambulances provide symptomatic pain relief to a burn but are not a substitute for running water first aid. Ice should not be applied as it can worsen the situation by causing a cold injury to the already damaged tissues. Enquiries should be made regarding other injuries the patient may have sustained during the incident (be wary of road traffic accidents and fires where a patient may have jumped from a height to safety) and the presence of medical, surgical and psychiatric comorbidities. A drug history noting any allergies is required, as is tetanus status and tetanus toxoid should be given if unsure. A full social history should explore the patients’ social and family circumstances, their employment, sports and hobbies along with any tobacco, alcohol and recreational drug use.
Jackson’s burn model Zone of necrosis
Zone of stasis
Examination, assessment, early management The extent of the examination of the patient will depend on the size and severity of the burn. Where the history and initial
Zone of hyperaemia Figure 2
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assessment suggest the burn to be small and limited to a single area then these injuries can be examined in relative isolation. However, if there is any doubt as to the cause or the nature of the injury, the size of the burn, or polytrauma they should be assessed as per advanced trauma life support (ATLS) or emergency management of severe burns (EMSB) protocols:
The rules of nines 9%
Airway and cervical spine control: the patients’ airway should be assessed remembering cervical spine immobilization and oxygen should be applied via a non-rebreathing mask. The patients’ head and neck area should be assessed for signs of inhalational injury. Significant burns to the face, soot in the mouth, a change of voice, brassy cough and respiratory difficulty are all potential signs of inhalational burn and warrant discussion with a burns team, anaesthetic or ENT review for nasendoscopy and consideration of endotracheal intubation. Intubation can sometimes be avoided if the patient is sat up at 45% to help minimize any further oedema to the head and neck alongside careful fluid titration to avoid excessive airway oedema.
Front 18% Back 18%
1% 18% 18%
Breathing: assess the rate and equality of chest expansion. If burns to the chest are deep and extensive they can restrict the movement of the ribs and hinder ventilation. If this is the case then discussion with a burns surgeon regarding escharotomy is essential. Assess oxygen saturations.
Figure 3
Circulation and haemorrhage control: assess pulse, blood pressure and capillary refill. Intravenous access should be secured with two large-bore cannulas, ideally through non-burnt skin but if this is not possible then it is permissible to go through the burn, perform a venous cut-down or secure intra-osseous access. Send blood samples for full blood count (FBC), urea and electrolytes (U&E), group and save (G&S)and arterial blood gas checking for carboxyhaemoglobin.
burn). They do not blister and have a normal capillary refill and have normal sensation. They heal normally and do not scar. Epidermal burns are not included when calculating the size of a burn. Superficial dermal e these burns involve the epidermis and superficial (papillary) dermis and appear pale pink, wet and very painful. Blistering is a classical appearance of these injuries; however, the underlying dermis has a normal capillary refill and they are painful to touch due to exposed nerve endings. Provided they are kept clean and dressed appropriately these burns heal without the need for skin grafting and they rarely scar but occasionally leave a pigmentation change which can be temporary or permanent. Deep dermal e these injuries extend into the deep (reticular) dermis and are pale or blotchy red in appearance. Capillary blanch is absent due to poor circulation within the skin and sensation is variable. Burn wound healing relies on the presence of epidermal cells surrounding hair follicles, sebaceous glands and sweat glands to migrate over the wound and re-epithelialize it. Because the majority of glands have been burnt in these deeper injuries they do not heal well without surgery and have a high risk of leaving a poor scar. Full thickness e these injuries involve the entire thickness of the skin and extend into the underlying fat and other tissues. They are either white or black and leathery to touch. They have no capillary blanch and are insensate. They require surgery to heal appropriately.
Disability and neurological status: rapidly establish a level of consciousness using the AVPU method; the patient is either Alert, responding to Vocal stimuli, responding to Painful stimuli or Unresponsive. Assess the pupils for a light reflex; these should be brisk and equal. Exposure: remove all clothing and jewellery (but keep the patient warm and maintain modesty with a warm air heater (e.g. Bairhugger) and blankets where possible). The burn should be assessed in terms of size and depth. The size of the burn can be assessed using either the ‘rule of nines’ or a Lund and Browder chart. The rule of nines divides the body into segments or multiples of ‘9%’s (Figure 3). Lund and Browder charts provide more detail and allow differences between children and adults. It is also useful to note that the patients’ palmar surface (area of the palm AND fingers held together) equates to approximately 1% of their BSA in helping determine the size of the burn. It is important to correctly identify the size of the burn as this may mean the difference between a resuscitation or non-resuscitation burn and the amount of fluid they are to receive. The depth of the burn should also be determined. Burn depths are described with the following characteristics (Figure 4). Superficial epidermal e these burns involve the epidermis only and are red and painful (e.g. sunburn or superficial flash
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9%
9%
Fluids: adult patients with burns greater than 15% BSA and children with burns greater than 10% BSA require intravenous Hartmann’s solution fluid resuscitation. The amount of fluid required in the first 24 hours following a large burn injury is
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Figure 4 Burn depth. (a) Top left is an epidermal burn (sunburn with no blistering); (b) top right is a superficial dermal burn (pink and moist); (c) bottom left is a deep dermal burn (blotchy with poor capillary return); (d) bottom right is a full thickness burn.
carbohydrate (1/4 Normal Saline þ 0.5% Dextrose) 100 ml/kg for the first 10 kg, then 50 ml/kg for the next 10 g and finally 20 ml/kg for the next 10 kg.
calculated using the Parkland formula, which traditionally states: 2e4 ml % BSA burnt Patient weight in kg. Current EMSB guidelines suggest that 3 ml % BSA burn Patient weight is appropriate. Approximately half of the volume should be given in the first 8 hours (when the capillaries are at their most ‘leaky’) after the injury and the other half should be given in the remaining 16 hours. This volume and subsequent rate of fluid is a guide only and the success of fluid resuscitation should be based on urinary output and other clinical parameters of adequate tissue perfusion such as pulse, blood pressure and central venous pressure. A urinary catheter must be inserted and urine output measured hourly in all patients receiving fluid resuscitation. Urine volumes of 0.5 ml/kg/hour are required in adults and 0.5e1 ml/kg/hour are required in children. The IV resuscitation fluid should be titrated hourly to the urine output during the resuscitation period with further blood tests (FBC and U&E) at regular intervals to guide fluid administration. Patients also require maintenance fluid in addition to the resuscitation fluid which in adults is approximately 2 L per day. This may be taken orally, via a nasogastic tube (NGT) or intravenously, though enteral administration is preferred to maintain gut integrity and many burns units commence NG feeding in the first few hours post-burn. Maintenance IV fluids for children should include some
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Secondary survey and re-evaluation: all trauma patients should have a secondary survey and reassessment of their injuries, ensuring that any circumferential deep injuries on limbs are assessed, elevated and need for escharotomy is considered. X-rays should be arranged as required. Pain should be managed with intravenous morphine titrated to response. The burn wounds should be cleaned and removed of debris and blisters before dressings are applied. Clean non-adherent dressings such as cling film are appropriate for short transfers (<1 hour) but these should not be applied tightly or wrapped circumferentially. Patients with a longer transfer time may benefit from an antimicrobial dressing and this should be discussed with a burns unit. Discuss and transfer: document the care given thus far and discuss with the specialist burns service, who will advise on dressings and other local protocols. All the following patients need to be referred to a specialist burns service: burns greater than 10% TBSA (adults), 5% TBSA (paediatrics) burns of special areas: hands, face, genitalia
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burn size and fluid requirements, and are available to educate the public on first aid management and pathways to burn care.
full thickness burns greater than 1% TBSA electrical burns chemical burns burns with associated inhalation injury circumferential burns of chest or limbs extremes of age non-accidental injury.
The large burn Patients with large burns will be transferred to a burns centre for continued resuscitation, critical care and wound management. Appropriate fluid resuscitation aims to ensure that all tissues are perfused adequately and the burn is not allowed to ‘extend’ or deepen due to hypovolaemia and hypotension. Similarly, fluid resuscitation should not be excessive and contribute to an already oedematous state, as increasing oedema prevents adequate blood flow to the wound that is trying to heal. Patients should be nursed ‘sat-up’ at 45 to avoid oedema to the head and upper airways, which could worsen an inhalation injury and mean that a patient may have increased requirement for intubation. Burnt arms and legs should be elevated above the level of the heart. Physiotherapy in the form of active and passive range of movement exercises is essential for maintenance of strength, joint mobility and to reduce oedema. Prevention of infection is paramount in burns care; patients are nursed in single bedrooms to avoid the spread of infection and strict hygiene and infection control measures supplement attentive wound care with regular showers and application of antimicrobial (silver based) dressings such as Acticoat (Smith and Nephew, UK).10 Patients with burns over 10e15% BSA require dietary support to reduce the catabolic effects of the burn injury and maintain immune function.11 Nasogastric feeds or supplemental protein shakes can be used to supplement oral diet. Patients with very large burns, airway or inhalational injuries may require intensive care support.
Psychosocial support: burns can cause a multitude of emotional responses from patients, relatives, ambulance staff, accident and emergency staff and other team members. There is an overrepresentation of psychological and psychiatric disorders in burns patient populations, estimated to be at least 20%, and depression, anxiety and post-traumatic stress disorder (PTSD) are highly prevalent after burn injury.6 Take time to ask how the patient is feeling, whether they are having flashbacks or nightmares and refer for psychosocial support. Don’t forget that staff members may require help dealing with difficult cases and occupational health departments can advise on local support networks. Non-accidental injury: it is essential to consider deliberate harm in burn injuries. Paediatric scald injuries are the most common; however, vulnerable adults such as the elderly and the cognitively impaired are also at risk. Non-accidental injuries caused by paediatric scalds may present with burns to the lower limbs with symmetrical immersion marks, while associated fractures and unrelated injuries may be apparent. A systematic review of nonscald physical abuse in children identified contact burns with household items as the commonest causative agents such as cigarettes, irons, hairdryers and domestic heaters.7 The burn area is often clearly demarcated, may be multiple and on the limbs, trunk or 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 maintained, particularly for those patients who present with a delay in seeking care or an inconsistent history or examination findings.7,8
The small burn Patients with small superficial burns may be managed in the emergency department with appropriate first aid, analgesia, cleaning of the burn, debridement of blisters and the application of a dressing. Dressings should be non-adherent and promote wound healing in a moist environment; examples include Mepitel (Molnlycke, Swe), Urgotul (Urgo, Fra), or Duoderm (Convatec USA) for small areas. Superficial burns to the face should be cleaned and kept moist with emollient or liquid paraffin (Vaseline) applied regularly through the day. Patients who have not been referred to a specialist burns service should be seen again within 48 hours by the emergency department and their burn assessed and the dressing changed. Regular review every 2e3 days should occur until the wound is healed. If the burn appears large, deep or is likely to take longer than 14 days to heal the patient should be referred to the burns service for specialist management.
Specialist management Specialist management of burns involves multidisciplinary care to ensure rapid wound healing with the best possible scar, for both function and aesthetics. Telehealth Early access to specialist burn services may be restricted by distance from the burns centre. Over the past 15 years there has been increasing use of technology, telephone and video consultation, to seek specialist input. Video link assessment by a burn specialist correlates closely with direct inspection9 and this can help smaller burns be treated locally by a wound care clinician near to the patient under consultation with a specialist. The use of telehealth in larger burn injuries can allow more informed and effective triage and decisions about air transfer, which can improve use and allocation of resources. Studies in the military have demonstrated the feasibility of video conferencing through smartphones and related developments in technology have the potential to substantially enhance burn care. Smartphone applications (apps) have been developed to improve estimation of
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Surgery As previously mentioned, deep circumferential burns to the limbs or torso may interfere with circulation to the peripheries or restrictive ventilator difficulties due to the unyielding burn tissue and may require emergency surgical release in the form of an escharotomy. During this procedure, the burned tissue is incised to allow the underlying tissue adequate space and to allow unrestricted circulation and oxygenation. Deeper injuries involving muscle compartments (high voltage electrical injuries) may require deeper fascial release as a fasciotomy.
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If deep dermal and full thickness burns are allowed to heal with dressings alone they will invariably produce significant scarring. The result will be a prolonged time in dressings, hypertrophic scars, contractures, and poor functional and aesthetic outcomes. For these reasons, deep injuries are taken to the operating theatre for debridement and split thickness skin grafting at the earliest opportunity. Under anaesthesia the patients’ burn and skin graft donor site are prepped with antiseptic solution. Several techniques can be used to debride the burn including tangential excision with a Watson knife or dermatome. During this technique, sequential ‘shaves’ of the burn are excised until punctuate bleeding is reached and a healthy wound bed is achieved. Other means of excising the burn include dermabrasion with a burr, hydrosurgery with Versajet (Smith and Nephew, UK) or newer techniques such as enzymatic eschar debridement with Nexobrid (MediWound, Israel). Burn excision can be associated with significant blood loss, therefore techniques to minimize blood loss include the use of tourniquets, infiltration of adrenaline solutions (1 ml of 1:1000 adrenaline diluted into 1 L of saline) and topical application of adrenaline solution after debridement.
Split thickness skin grafts are harvested from areas well hidden with clothes; the buttocks and posterior thighs being preferred areas. Grafts of between 4 and 10/1000 of an inch are taken most often with a power dermatome that can take a uniform split thickness skin graft. The skin graft may be applied as a sheet graft onto the face and hands, but more often fenestrated or meshed to allow the skin graft to cover a larger area and to allow for any blood or serous fluid to drain through the holes (Figure 5). Exposed tendon or bone may require flap cover (Figure 6). In larger injuries involving >50% BSA burns it may be necessary to do the debridement and skin grafting in stages. This is because during long operations the patient can become hypothermic and develop coagulation and cardiovascular complications. In large burns where there is not enough of the patients’ own uninjured skin to provide donor skin to cover the burn (even with a very widely meshed skin graft) other techniques to close or cover the burn are required. Cadaveric (allograft) skin grafts can be used as temporary cover. The burn patients’ temporary immunodeficiency allows for the cadaveric skin to avoid rejection for several months, meaning it can cover the burn
Figure 5 Skin graft. (a) Full-thickness burn wound preoperatively; (b) split-thickness skin graft at 1 week; (c) split-thickness skin graft at 4 months.
Figure 6 Freestyle perforator propeller flap to cover exposed extensor pollicis longus tendon following electrical injury. (a) Preoperatively; (b) and (c) intraoperatively; (d) postoperatively.
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wound temporarily and then be replaced in stages with the patient’s own skin graft as donor sites heal and can be reused. Other techniques include the use of artificial skins (dermal matrices) including Integra (Integra LifeSciences, USA) and Matriderm (MedSkin solutions, Germany). These products provide a tissue engineered neodermis that becomes vascularized from the underlying wound bed and is then covered with a thin split thickness skin graft. Tissue cultured cells can help to heal patients with very large wounds. Shortly after admission a small biopsy of skin is taken from the patient and sent to a laboratory for the patient’s epidermal keratinocytes to be cultured. After several weeks, the cells are supplied back to the patient as either sheets of cells or as spray suspensions. These cells help to close down the wound when used in conjunction with widely meshed skin graft. More recently non-cultured autologous cells such as keratinocytes, fibroblasts, undifferentiated dermal/epidermal cells and melanocytes (ReCell e Avita medical, UK) have been developed to allow rapid cell suspensions to be sprayed onto burn wounds to assist in healing.12
Complications and disabilities The most common local complication of a burn is infection, which can cause the burn to deepen and precede systemic sepsis. Good initial cleansing of the burn, antimicrobial dressings and appropriate removal of necrotic tissue (e.g. blisters and eschar) assist in reducing the infection rate in burns. Whilst antibiotics may be indicated in a sick patient with an infected burn and can be considered in the peri-operative setting, prophylactic antibiotics (systemic or topical antibiotics administered immediately after the burn injury) are not recommended in current practice and can increase the risk of creating resistant strains of microorganisms, diarrhoea allergic reactions and hepatic, renal and marrow toxicity.14 Systemic complications of major burns include renal failure, respiratory failure and overwhelming sepsis associated with high mortality. Less common complications include gut failure, Curling’s ulcers and ischaemic enterocolitis, thromboembolic conditions, and heterotopic bone formation (particularly involving the elbows). Late complications include persistent hyper metabolism, psychosocial morbidity and scarrelated problems including hypertrophic and dyspigmented scars, scar contracture and Marjolin’s ulcer formation (late squamous cell carcinoma development in the burns scar).
Paediatric scalds The majority of these common injuries are superficial and heal with dressings. Larger and slightly deeper injuries may benefit from dermabrasion or Versajet debridement in theatre and application of Biobrane biological dressing (Smith and Nephew, UK) which remains in place until the burn has healed and can help reduce the pain of dressing changes.13 Deep burns require skin grafting.
Rehabilitation The rehabilitation of a burns patient begins when they enter the burn centre. Early physiotherapy whilst the acute burn is healing
Electrical injuries These burns are classified as either low voltage (<1000 volts) or high voltage (>1000 volts). Whatever size, most electrical burns are deep and have identifiable cutaneous entry and exit points. Patients are at high risk of muscle damage following high voltage injuries to the arms or legs and these often require fasciotomy decompression for compartment syndrome. If the electrical current has traversed the chest this can damage the muscle of the heart and produce arrhythmias; in low voltage injuries, a normal ECG is sufficient to exclude significant complications but in highvoltage injuries cardiac monitoring is required. Additional complications of high voltage injuries from muscle damage include myonecrosis, myoglobinuria and renal failure and they often require large volumes of intravenous fluid and occasionally renal support. Sometimes ‘flash burns’ result when an electrical arc occurs between a high voltage cable and the patient. Chemical injuries Agents causing chemical burns may be broadly divided into acids and alkalis. Alkali burns tend to be more severe than those caused by acid, as they penetrate deeper through the layers of the skin and tissues via liquefactive necrosis, while acids cause burns through coagulative necrosis which creates a barrier to further tissue penetration. Treatment involves copious water irrigation to restore and maintain a normal skin pH (5.0e5.9). Hydrofluoric acid is a common industrial cleaner and chemical that can be lethal in contact with skin even in small amounts due to its action as a metabolic poison. It precipitates hypocalcaemia and intravenous calcium gluconate injections should be given immediately on suspicion of significant exposure.
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Figure 7 Scar contracture of the dorsum of the hand requiring surgical release and reconstruction.
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helps to minimize oedema, maintain range of movement and reduces scar contracture.15 Scar management techniques should be offered to all patients and includes advice regarding regular scar hydration, massage and the use of sunblock. Silicone sheets and gels help hydrate the burn scar mature by maintaining moisture within it. Compression garments are worn as an aid to scar maturation and are worn full-time for between 6 and 12 months post injury. When a scar becomes hypertrophic despite standard scar therapy it may require additional reconstructive measures such as steroid injections, laser therapy surgical release. Severe and deforming contractures may occur when burn injuries remain untreated (Figure 7).
4 Wood F, Phillips M, Jovic T, Cassidy J, Cameron P, Edgar D. Water first aid is beneficial in humans post-burn: evidence from a Bi-National Cohort Study. PLoS One 2016; 11: e0147259. 5 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. 6 Ter Smitten MH, de Graaf R, Van Loey NE. Prevalence and co-morbidity of psychiatric disorders 1e4 years after burn. Burns 2011; 37: 753e61. 7 Kemp AM, Maguire SA, Lumb RC, et al. Contact, cigarette and flame burns in physical abuse: a Systematic Review. Child Abuse Rev 2014; 23: 35e47. 8 Wibbenmeyer L, Liao J, Heard J, et al. Factors related to child maltreatment in children presenting with burn injuries. J Burn Care Res 2014; 35: 374e81. 9 Saffle JR, Edelman L, Theurer L, et al. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009; 67: 358e65. 10 Khundkar R, Malic C, Burge T. Use of Acticoat dressings in burns: what is the evidence? Burns 2010; 36: 751e8. 11 Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns 2007; 33: 14e24. 12 Gravante G, DiFede MC, Araco A. A randomised trial comparing ReCELL system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns. Burns 2007; 33: 966e72. 13 Vloemans AF, Hermans MH, van der Wal MB, et al. Optimal treatment of partial thickness burns in children: a systematic review. Burns 2014; 40: 177e90. 14 Ahuja RB. ISBI practice guidelines for burn care. Burns 2016; 42: 953e1021. 15 Edgar D, Brereton M. Rehabilitation after burn injury. Br Med J 2004; 329: 343e5.
Conclusions Appropriate referral and treatment of burns patients by specialist teams has improved burn outcomes in recent decades. In the developed world burn mortality rates have fallen due to advances in pre-hospital care, infection control, intensive care and burns surgery. Appropriate and timely wound care, burns surgery and scar management can minimize the final scar and reduce need for later reconstruction. However, despite these improvements prevention is still better than cure, and therefore the need for targeted prevention campaigns and first aid knowledge across communities in both the developed and developing world remains paramount. A REFERENCES 1 National burn care review. National burn injury referral guidelines. In: Standards and strategy for burn care. London: NBCR, 2001. 2 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. http://dx.doi.org/10.1136/bmjopen-2014-006184. 3 Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953; 40: 588e96.
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Management of burns
diabetes with neuropathy who sustains an unnoticed contact burn to their foot is vulnerable due to their poorly controlled medical condition. The unsupervised toddler who pulls a cup of tea onto themselves is vulnerable due to lack of attentive supervision. The intoxicated person who falls asleep with a lit cigarette following drink or drugs and sustains burns is vulnerable due to their lack of cognitive awareness or addiction. Patients who are depressed and self-harm or self-immolate are vulnerable due to their mental illness. Such vulnerabilities are varied, but each requires investigation and management to reduce the burden of burns on individuals and on society.
Helen E Douglas Jonathan A Dunne Jeremy M Rawlins
Abstract Burns are common injuries that vary in severity from small superficial scalds to massive full-thickness flame burns with high morbidity and mortality. The purpose of this article is to review common burn presentations, the pathophysiology of these injuries and to give an overview of multidisciplinary burns management from the emergency department through to the specialist burns centre.
Pathology and pathophysiology Local effects Following a burn, tissue destruction is proportional to the temperature of the burning agent and the duration it is applied to the body. For example, water at 48 C takes 5 minutes to cause a partial thickness burn, but when the water temperature is raised to 70 it takes just 1 second to cause a full thickness injury. Jackson described zones of burn injury related to the degree of tissue damage (Figure 2).3 The inner zone of coagulative necrosis represents unsalvageable burnt tissue where the blood vessels are thrombosed and the skin is dead. The intermediate zone of stasis represents tissue affected by the burn with static blood flow. This area is amenable to first aid, resuscitation measures and good wound care and is therefore salvageable if cared for appropriately. The outer zone of hyperaemia represents red, hyperaemic tissue that surrounds any acute inflammatory process and will return to normal. The tissue damage that results following thermal injury results in a marked increase in capillary permeability which is maximal within the first few hours following injury and resolves within 2e3 days. During this time, small protein molecules leak out of the circulation leading to oedema and significant fluid loss. The fluid loss is proportional to the size of the burn; however, when the size of the burn exceeds 30% body surface area (BSA), the leaking capillaries involve all body tissues and not just the skin, resulting in a systemic inflammatory response. Burn oedema is a result of circulating inflammatory mediators including histamine, prostaglandins, leukotrienes and kinins that result in increased capillary permeability. This oedema is exacerbated by increasing capillary hydrostatic pressure, decreasing tissue hydrostatic pressure, and decreased plasma oncotic pressure (due to loss of albumin from the circulation).
Keywords Burns; burns surgery; dressings; resuscitation; scalds; scar management; skin grafts
Introduction and epidemiology Burns are traumatic injuries caused by coagulative destruction of the skin and are usually caused by thermal damage (heat and cold) but chemicals, electricity and radiation may also damage tissues in similar ways. In the United Kingdom approximately 250,000 people present to primary care and to hospitals with burns each year, though this is an underestimation of total numbers, as many people with small or innocuous burns manage their injuries themselves.1 The number of patients treated by specialist burns services in the UK each year is increasing; admissions to such units numbered around 1000 patients in 2001, rising to 14,000 a decade later in 2011 and reaching over 19,000 in 2015. Mortality from these injuries is decreasing in the UK and across the Western world, with a mortality rate of around 1.4% of these cases or approximately 200 deaths from burn injuries per year in England and Wales.2 No age group or gender is immune from burns, though nearly two thirds of all burn injuries are sustained by males.2 Whilst it used to be the case that scald injuries were most common in childhood and then gave way to increasing flame, flash and contact burns as age increased, this is now less apparent. In children, adults and elderly patients, scald injuries now account for the majority of all burns. The second most common cause of burns in adults and elderly patients are flame injuries, followed by contact burns (Figure 1). Whatever the cause for the burn, there is often an underlying patient vulnerability that puts the patient at risk. The patient with
General effects The local and systemic inflammatory mediators released following a burn (particularly injuries greater than 30% BSA) result in profound systemic effects. Due to ongoing fluid losses, cardiac output falls due to decreased venous return, inadequate preload and afterload, and decreased myocardial activity. Due to the ‘fight or flight’ effects, the patient experiences a catecholamine rush of sympathetic activity that contributes to increasing systemic vascular resistance. Pulmonary oedema develops because of the systemic increase in capillary permeability as well as increasing pulmonary vascular resistance, left sided heart failure, hypoproteinaemia, direct vascular injury, and sometimes the added insult of an inhalational burn.
Helen E Douglas FRCS(Plast) is a Fellow at the State Burns Unit, Western Australia, Australia. Conflicts of interest: none declared. Jonathan A Dunne MRCS(Eng) is a Registrar in Plastic and Reconstructive Surgery in the London Deanery, UK. Conflicts of interest: none declared. Jeremy M Rawlins FRACS FRCS(Plast) is a Consultant Plastic and Reconstructive Surgeon at the State Burns Unit, Western Australia and Royal Perth Hospital, Australia. Conflicts of interest: none declared.
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UK burn epidemiology 1%
1% 1% Scald
1%
Contact
8%
1%
Flame 6% Flash
42% 7%
Chemical Electrical
17%
Friction Radiation
15%
Cold Figure 1
Other systemic effects following major burns include a significant increase in metabolism, nitrogen loss and poor temperature control due to loss of water and heat through the burnt tissue. The early cortisol rush following burn injury results in protein breakdown, gluconeogenesis, and impaired insulin release and glucose tolerance is seen. This catabolic state can last many weeks and months following burns and may result in ongoing weight loss in adults and impaired growth in children. The immunosuppressive effects of a burn are compounded by the weakened humoural and cellular responses following damage to the local circulation and the normal inflammatory process. This can cause increased risks of infection; the raw burn wound is an easy entry point for bacteria and yeasts. In addition, burns patients may lose the protective function of the gut following major injury, resulting in translocation of gut organisms into the circulation with increasing sepsis, morbidity and mortality.
Diagnosis History The history of the injury and circumstances surrounding how the patient sustained their burn are important and can be crucial in predicting the depth of the injury and requirement for surgery. The time of the injury is also significant, as the appearance of the burn changes over subsequent hours and days. Knowing the exact cause of the burn is also key; scalding liquid, flame, explosion, contact, chemical and electric burns will all produce different injuries and this will need to be confirmed during the history and physical examination. The detail regarding the mechanism is important; freshly boiled water produces much deeper injuries compared to a cooled cup of tea. The location where the burn occurred can help predict severity; an explosion in a confined place such as a building or car, or if the patient required extraction from a burning house there will be a very high risk of inhalational injury. Information about first aid is useful, as appropriate first aid reduces the risk of needing a skin graft by 50%.4 All burns should have cool running water applied for 20 minutes as soon as possible following their injury, but it is still effective up to 3 hours following the burn.5 Medicated cooling gel sponges such as those carried by ambulances provide symptomatic pain relief to a burn but are not a substitute for running water first aid. Ice should not be applied as it can worsen the situation by causing a cold injury to the already damaged tissues. Enquiries should be made regarding other injuries the patient may have sustained during the incident (be wary of road traffic accidents and fires where a patient may have jumped from a height to safety) and the presence of medical, surgical and psychiatric comorbidities. A drug history noting any allergies is required, as is tetanus status and tetanus toxoid should be given if unsure. A full social history should explore the patients’ social and family circumstances, their employment, sports and hobbies along with any tobacco, alcohol and recreational drug use.
Jackson’s burn model Zone of necrosis
Zone of stasis
Examination, assessment, early management The extent of the examination of the patient will depend on the size and severity of the burn. Where the history and initial
Zone of hyperaemia Figure 2
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assessment suggest the burn to be small and limited to a single area then these injuries can be examined in relative isolation. However, if there is any doubt as to the cause or the nature of the injury, the size of the burn, or polytrauma they should be assessed as per advanced trauma life support (ATLS) or emergency management of severe burns (EMSB) protocols:
The rules of nines 9%
Airway and cervical spine control: the patients’ airway should be assessed remembering cervical spine immobilization and oxygen should be applied via a non-rebreathing mask. The patients’ head and neck area should be assessed for signs of inhalational injury. Significant burns to the face, soot in the mouth, a change of voice, brassy cough and respiratory difficulty are all potential signs of inhalational burn and warrant discussion with a burns team, anaesthetic or ENT review for nasendoscopy and consideration of endotracheal intubation. Intubation can sometimes be avoided if the patient is sat up at 45% to help minimize any further oedema to the head and neck alongside careful fluid titration to avoid excessive airway oedema.
Front 18% Back 18%
1% 18% 18%
Breathing: assess the rate and equality of chest expansion. If burns to the chest are deep and extensive they can restrict the movement of the ribs and hinder ventilation. If this is the case then discussion with a burns surgeon regarding escharotomy is essential. Assess oxygen saturations.
Figure 3
Circulation and haemorrhage control: assess pulse, blood pressure and capillary refill. Intravenous access should be secured with two large-bore cannulas, ideally through non-burnt skin but if this is not possible then it is permissible to go through the burn, perform a venous cut-down or secure intra-osseous access. Send blood samples for full blood count (FBC), urea and electrolytes (U&E), group and save (G&S)and arterial blood gas checking for carboxyhaemoglobin.
burn). They do not blister and have a normal capillary refill and have normal sensation. They heal normally and do not scar. Epidermal burns are not included when calculating the size of a burn. Superficial dermal e these burns involve the epidermis and superficial (papillary) dermis and appear pale pink, wet and very painful. Blistering is a classical appearance of these injuries; however, the underlying dermis has a normal capillary refill and they are painful to touch due to exposed nerve endings. Provided they are kept clean and dressed appropriately these burns heal without the need for skin grafting and they rarely scar but occasionally leave a pigmentation change which can be temporary or permanent. Deep dermal e these injuries extend into the deep (reticular) dermis and are pale or blotchy red in appearance. Capillary blanch is absent due to poor circulation within the skin and sensation is variable. Burn wound healing relies on the presence of epidermal cells surrounding hair follicles, sebaceous glands and sweat glands to migrate over the wound and re-epithelialize it. Because the majority of glands have been burnt in these deeper injuries they do not heal well without surgery and have a high risk of leaving a poor scar. Full thickness e these injuries involve the entire thickness of the skin and extend into the underlying fat and other tissues. They are either white or black and leathery to touch. They have no capillary blanch and are insensate. They require surgery to heal appropriately.
Disability and neurological status: rapidly establish a level of consciousness using the AVPU method; the patient is either Alert, responding to Vocal stimuli, responding to Painful stimuli or Unresponsive. Assess the pupils for a light reflex; these should be brisk and equal. Exposure: remove all clothing and jewellery (but keep the patient warm and maintain modesty with a warm air heater (e.g. Bairhugger) and blankets where possible). The burn should be assessed in terms of size and depth. The size of the burn can be assessed using either the ‘rule of nines’ or a Lund and Browder chart. The rule of nines divides the body into segments or multiples of ‘9%’s (Figure 3). Lund and Browder charts provide more detail and allow differences between children and adults. It is also useful to note that the patients’ palmar surface (area of the palm AND fingers held together) equates to approximately 1% of their BSA in helping determine the size of the burn. It is important to correctly identify the size of the burn as this may mean the difference between a resuscitation or non-resuscitation burn and the amount of fluid they are to receive. The depth of the burn should also be determined. Burn depths are described with the following characteristics (Figure 4). Superficial epidermal e these burns involve the epidermis only and are red and painful (e.g. sunburn or superficial flash
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9%
9%
Fluids: adult patients with burns greater than 15% BSA and children with burns greater than 10% BSA require intravenous Hartmann’s solution fluid resuscitation. The amount of fluid required in the first 24 hours following a large burn injury is
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Figure 4 Burn depth. (a) Top left is an epidermal burn (sunburn with no blistering); (b) top right is a superficial dermal burn (pink and moist); (c) bottom left is a deep dermal burn (blotchy with poor capillary return); (d) bottom right is a full thickness burn.
carbohydrate (1/4 Normal Saline þ 0.5% Dextrose) 100 ml/kg for the first 10 kg, then 50 ml/kg for the next 10 g and finally 20 ml/kg for the next 10 kg.
calculated using the Parkland formula, which traditionally states: 2e4 ml % BSA burnt Patient weight in kg. Current EMSB guidelines suggest that 3 ml % BSA burn Patient weight is appropriate. Approximately half of the volume should be given in the first 8 hours (when the capillaries are at their most ‘leaky’) after the injury and the other half should be given in the remaining 16 hours. This volume and subsequent rate of fluid is a guide only and the success of fluid resuscitation should be based on urinary output and other clinical parameters of adequate tissue perfusion such as pulse, blood pressure and central venous pressure. A urinary catheter must be inserted and urine output measured hourly in all patients receiving fluid resuscitation. Urine volumes of 0.5 ml/kg/hour are required in adults and 0.5e1 ml/kg/hour are required in children. The IV resuscitation fluid should be titrated hourly to the urine output during the resuscitation period with further blood tests (FBC and U&E) at regular intervals to guide fluid administration. Patients also require maintenance fluid in addition to the resuscitation fluid which in adults is approximately 2 L per day. This may be taken orally, via a nasogastic tube (NGT) or intravenously, though enteral administration is preferred to maintain gut integrity and many burns units commence NG feeding in the first few hours post-burn. Maintenance IV fluids for children should include some
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Secondary survey and re-evaluation: all trauma patients should have a secondary survey and reassessment of their injuries, ensuring that any circumferential deep injuries on limbs are assessed, elevated and need for escharotomy is considered. X-rays should be arranged as required. Pain should be managed with intravenous morphine titrated to response. The burn wounds should be cleaned and removed of debris and blisters before dressings are applied. Clean non-adherent dressings such as cling film are appropriate for short transfers (<1 hour) but these should not be applied tightly or wrapped circumferentially. Patients with a longer transfer time may benefit from an antimicrobial dressing and this should be discussed with a burns unit. Discuss and transfer: document the care given thus far and discuss with the specialist burns service, who will advise on dressings and other local protocols. All the following patients need to be referred to a specialist burns service: burns greater than 10% TBSA (adults), 5% TBSA (paediatrics) burns of special areas: hands, face, genitalia
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burn size and fluid requirements, and are available to educate the public on first aid management and pathways to burn care.
full thickness burns greater than 1% TBSA electrical burns chemical burns burns with associated inhalation injury circumferential burns of chest or limbs extremes of age non-accidental injury.
The large burn Patients with large burns will be transferred to a burns centre for continued resuscitation, critical care and wound management. Appropriate fluid resuscitation aims to ensure that all tissues are perfused adequately and the burn is not allowed to ‘extend’ or deepen due to hypovolaemia and hypotension. Similarly, fluid resuscitation should not be excessive and contribute to an already oedematous state, as increasing oedema prevents adequate blood flow to the wound that is trying to heal. Patients should be nursed ‘sat-up’ at 45 to avoid oedema to the head and upper airways, which could worsen an inhalation injury and mean that a patient may have increased requirement for intubation. Burnt arms and legs should be elevated above the level of the heart. Physiotherapy in the form of active and passive range of movement exercises is essential for maintenance of strength, joint mobility and to reduce oedema. Prevention of infection is paramount in burns care; patients are nursed in single bedrooms to avoid the spread of infection and strict hygiene and infection control measures supplement attentive wound care with regular showers and application of antimicrobial (silver based) dressings such as Acticoat (Smith and Nephew, UK).10 Patients with burns over 10e15% BSA require dietary support to reduce the catabolic effects of the burn injury and maintain immune function.11 Nasogastric feeds or supplemental protein shakes can be used to supplement oral diet. Patients with very large burns, airway or inhalational injuries may require intensive care support.
Psychosocial support: burns can cause a multitude of emotional responses from patients, relatives, ambulance staff, accident and emergency staff and other team members. There is an overrepresentation of psychological and psychiatric disorders in burns patient populations, estimated to be at least 20%, and depression, anxiety and post-traumatic stress disorder (PTSD) are highly prevalent after burn injury.6 Take time to ask how the patient is feeling, whether they are having flashbacks or nightmares and refer for psychosocial support. Don’t forget that staff members may require help dealing with difficult cases and occupational health departments can advise on local support networks. Non-accidental injury: it is essential to consider deliberate harm in burn injuries. Paediatric scald injuries are the most common; however, vulnerable adults such as the elderly and the cognitively impaired are also at risk. Non-accidental injuries caused by paediatric scalds may present with burns to the lower limbs with symmetrical immersion marks, while associated fractures and unrelated injuries may be apparent. A systematic review of nonscald physical abuse in children identified contact burns with household items as the commonest causative agents such as cigarettes, irons, hairdryers and domestic heaters.7 The burn area is often clearly demarcated, may be multiple and on the limbs, trunk or 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 maintained, particularly for those patients who present with a delay in seeking care or an inconsistent history or examination findings.7,8
The small burn Patients with small superficial burns may be managed in the emergency department with appropriate first aid, analgesia, cleaning of the burn, debridement of blisters and the application of a dressing. Dressings should be non-adherent and promote wound healing in a moist environment; examples include Mepitel (Molnlycke, Swe), Urgotul (Urgo, Fra), or Duoderm (Convatec USA) for small areas. Superficial burns to the face should be cleaned and kept moist with emollient or liquid paraffin (Vaseline) applied regularly through the day. Patients who have not been referred to a specialist burns service should be seen again within 48 hours by the emergency department and their burn assessed and the dressing changed. Regular review every 2e3 days should occur until the wound is healed. If the burn appears large, deep or is likely to take longer than 14 days to heal the patient should be referred to the burns service for specialist management.
Specialist management Specialist management of burns involves multidisciplinary care to ensure rapid wound healing with the best possible scar, for both function and aesthetics. Telehealth Early access to specialist burn services may be restricted by distance from the burns centre. Over the past 15 years there has been increasing use of technology, telephone and video consultation, to seek specialist input. Video link assessment by a burn specialist correlates closely with direct inspection9 and this can help smaller burns be treated locally by a wound care clinician near to the patient under consultation with a specialist. The use of telehealth in larger burn injuries can allow more informed and effective triage and decisions about air transfer, which can improve use and allocation of resources. Studies in the military have demonstrated the feasibility of video conferencing through smartphones and related developments in technology have the potential to substantially enhance burn care. Smartphone applications (apps) have been developed to improve estimation of
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Surgery As previously mentioned, deep circumferential burns to the limbs or torso may interfere with circulation to the peripheries or restrictive ventilator difficulties due to the unyielding burn tissue and may require emergency surgical release in the form of an escharotomy. During this procedure, the burned tissue is incised to allow the underlying tissue adequate space and to allow unrestricted circulation and oxygenation. Deeper injuries involving muscle compartments (high voltage electrical injuries) may require deeper fascial release as a fasciotomy.
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If deep dermal and full thickness burns are allowed to heal with dressings alone they will invariably produce significant scarring. The result will be a prolonged time in dressings, hypertrophic scars, contractures, and poor functional and aesthetic outcomes. For these reasons, deep injuries are taken to the operating theatre for debridement and split thickness skin grafting at the earliest opportunity. Under anaesthesia the patients’ burn and skin graft donor site are prepped with antiseptic solution. Several techniques can be used to debride the burn including tangential excision with a Watson knife or dermatome. During this technique, sequential ‘shaves’ of the burn are excised until punctuate bleeding is reached and a healthy wound bed is achieved. Other means of excising the burn include dermabrasion with a burr, hydrosurgery with Versajet (Smith and Nephew, UK) or newer techniques such as enzymatic eschar debridement with Nexobrid (MediWound, Israel). Burn excision can be associated with significant blood loss, therefore techniques to minimize blood loss include the use of tourniquets, infiltration of adrenaline solutions (1 ml of 1:1000 adrenaline diluted into 1 L of saline) and topical application of adrenaline solution after debridement.
Split thickness skin grafts are harvested from areas well hidden with clothes; the buttocks and posterior thighs being preferred areas. Grafts of between 4 and 10/1000 of an inch are taken most often with a power dermatome that can take a uniform split thickness skin graft. The skin graft may be applied as a sheet graft onto the face and hands, but more often fenestrated or meshed to allow the skin graft to cover a larger area and to allow for any blood or serous fluid to drain through the holes (Figure 5). Exposed tendon or bone may require flap cover (Figure 6). In larger injuries involving >50% BSA burns it may be necessary to do the debridement and skin grafting in stages. This is because during long operations the patient can become hypothermic and develop coagulation and cardiovascular complications. In large burns where there is not enough of the patients’ own uninjured skin to provide donor skin to cover the burn (even with a very widely meshed skin graft) other techniques to close or cover the burn are required. Cadaveric (allograft) skin grafts can be used as temporary cover. The burn patients’ temporary immunodeficiency allows for the cadaveric skin to avoid rejection for several months, meaning it can cover the burn
Figure 5 Skin graft. (a) Full-thickness burn wound preoperatively; (b) split-thickness skin graft at 1 week; (c) split-thickness skin graft at 4 months.
Figure 6 Freestyle perforator propeller flap to cover exposed extensor pollicis longus tendon following electrical injury. (a) Preoperatively; (b) and (c) intraoperatively; (d) postoperatively.
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wound temporarily and then be replaced in stages with the patient’s own skin graft as donor sites heal and can be reused. Other techniques include the use of artificial skins (dermal matrices) including Integra (Integra LifeSciences, USA) and Matriderm (MedSkin solutions, Germany). These products provide a tissue engineered neodermis that becomes vascularized from the underlying wound bed and is then covered with a thin split thickness skin graft. Tissue cultured cells can help to heal patients with very large wounds. Shortly after admission a small biopsy of skin is taken from the patient and sent to a laboratory for the patient’s epidermal keratinocytes to be cultured. After several weeks, the cells are supplied back to the patient as either sheets of cells or as spray suspensions. These cells help to close down the wound when used in conjunction with widely meshed skin graft. More recently non-cultured autologous cells such as keratinocytes, fibroblasts, undifferentiated dermal/epidermal cells and melanocytes (ReCell e Avita medical, UK) have been developed to allow rapid cell suspensions to be sprayed onto burn wounds to assist in healing.12
Complications and disabilities The most common local complication of a burn is infection, which can cause the burn to deepen and precede systemic sepsis. Good initial cleansing of the burn, antimicrobial dressings and appropriate removal of necrotic tissue (e.g. blisters and eschar) assist in reducing the infection rate in burns. Whilst antibiotics may be indicated in a sick patient with an infected burn and can be considered in the peri-operative setting, prophylactic antibiotics (systemic or topical antibiotics administered immediately after the burn injury) are not recommended in current practice and can increase the risk of creating resistant strains of microorganisms, diarrhoea allergic reactions and hepatic, renal and marrow toxicity.14 Systemic complications of major burns include renal failure, respiratory failure and overwhelming sepsis associated with high mortality. Less common complications include gut failure, Curling’s ulcers and ischaemic enterocolitis, thromboembolic conditions, and heterotopic bone formation (particularly involving the elbows). Late complications include persistent hyper metabolism, psychosocial morbidity and scarrelated problems including hypertrophic and dyspigmented scars, scar contracture and Marjolin’s ulcer formation (late squamous cell carcinoma development in the burns scar).
Paediatric scalds The majority of these common injuries are superficial and heal with dressings. Larger and slightly deeper injuries may benefit from dermabrasion or Versajet debridement in theatre and application of Biobrane biological dressing (Smith and Nephew, UK) which remains in place until the burn has healed and can help reduce the pain of dressing changes.13 Deep burns require skin grafting.
Rehabilitation The rehabilitation of a burns patient begins when they enter the burn centre. Early physiotherapy whilst the acute burn is healing
Electrical injuries These burns are classified as either low voltage (<1000 volts) or high voltage (>1000 volts). Whatever size, most electrical burns are deep and have identifiable cutaneous entry and exit points. Patients are at high risk of muscle damage following high voltage injuries to the arms or legs and these often require fasciotomy decompression for compartment syndrome. If the electrical current has traversed the chest this can damage the muscle of the heart and produce arrhythmias; in low voltage injuries, a normal ECG is sufficient to exclude significant complications but in highvoltage injuries cardiac monitoring is required. Additional complications of high voltage injuries from muscle damage include myonecrosis, myoglobinuria and renal failure and they often require large volumes of intravenous fluid and occasionally renal support. Sometimes ‘flash burns’ result when an electrical arc occurs between a high voltage cable and the patient. Chemical injuries Agents causing chemical burns may be broadly divided into acids and alkalis. Alkali burns tend to be more severe than those caused by acid, as they penetrate deeper through the layers of the skin and tissues via liquefactive necrosis, while acids cause burns through coagulative necrosis which creates a barrier to further tissue penetration. Treatment involves copious water irrigation to restore and maintain a normal skin pH (5.0e5.9). Hydrofluoric acid is a common industrial cleaner and chemical that can be lethal in contact with skin even in small amounts due to its action as a metabolic poison. It precipitates hypocalcaemia and intravenous calcium gluconate injections should be given immediately on suspicion of significant exposure.
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Figure 7 Scar contracture of the dorsum of the hand requiring surgical release and reconstruction.
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helps to minimize oedema, maintain range of movement and reduces scar contracture.15 Scar management techniques should be offered to all patients and includes advice regarding regular scar hydration, massage and the use of sunblock. Silicone sheets and gels help hydrate the burn scar mature by maintaining moisture within it. Compression garments are worn as an aid to scar maturation and are worn full-time for between 6 and 12 months post injury. When a scar becomes hypertrophic despite standard scar therapy it may require additional reconstructive measures such as steroid injections, laser therapy surgical release. Severe and deforming contractures may occur when burn injuries remain untreated (Figure 7).
4 Wood F, Phillips M, Jovic T, Cassidy J, Cameron P, Edgar D. Water first aid is beneficial in humans post-burn: evidence from a Bi-National Cohort Study. PLoS One 2016; 11: e0147259. 5 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. 6 Ter Smitten MH, de Graaf R, Van Loey NE. Prevalence and co-morbidity of psychiatric disorders 1e4 years after burn. Burns 2011; 37: 753e61. 7 Kemp AM, Maguire SA, Lumb RC, et al. Contact, cigarette and flame burns in physical abuse: a Systematic Review. Child Abuse Rev 2014; 23: 35e47. 8 Wibbenmeyer L, Liao J, Heard J, et al. Factors related to child maltreatment in children presenting with burn injuries. J Burn Care Res 2014; 35: 374e81. 9 Saffle JR, Edelman L, Theurer L, et al. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009; 67: 358e65. 10 Khundkar R, Malic C, Burge T. Use of Acticoat dressings in burns: what is the evidence? Burns 2010; 36: 751e8. 11 Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns 2007; 33: 14e24. 12 Gravante G, DiFede MC, Araco A. A randomised trial comparing ReCELL system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns. Burns 2007; 33: 966e72. 13 Vloemans AF, Hermans MH, van der Wal MB, et al. Optimal treatment of partial thickness burns in children: a systematic review. Burns 2014; 40: 177e90. 14 Ahuja RB. ISBI practice guidelines for burn care. Burns 2016; 42: 953e1021. 15 Edgar D, Brereton M. Rehabilitation after burn injury. Br Med J 2004; 329: 343e5.
Conclusions Appropriate referral and treatment of burns patients by specialist teams has improved burn outcomes in recent decades. In the developed world burn mortality rates have fallen due to advances in pre-hospital care, infection control, intensive care and burns surgery. Appropriate and timely wound care, burns surgery and scar management can minimize the final scar and reduce need for later reconstruction. However, despite these improvements prevention is still better than cure, and therefore the need for targeted prevention campaigns and first aid knowledge across communities in both the developed and developing world remains paramount. A REFERENCES 1 National burn care review. National burn injury referral guidelines. In: Standards and strategy for burn care. London: NBCR, 2001. 2 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. http://dx.doi.org/10.1136/bmjopen-2014-006184. 3 Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953; 40: 588e96.
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