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Management of burns
WOUND MANAGEMENT
Management of burns
No age group or gender is immune from burns. Two-thirds of injuries are sustained by males.2 The largest patient group to sustain burn injuries are boys under the age of 2 years who account for 12% of all injuries. The majority of these injuries are hot water and drink scalds, sustained at home in the kitchen. The second largest group are males aged 25e34 years who account for 8% of all patients treated by specialist burns services. While 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).
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 and the pathophysiology of these injuries. In addition it gives the reader an overview of burns management from the emergency department through to the specialist burns centre and describes the latest multidisciplinary approach to treating these injuries.
Pathology and pathophysiology
Keywords Burns; burns surgery; dressings; resuscitation; scalds; scar management; skin grafts
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 C 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. The tissue damage that results following thermal injury results in a marked increase in capillary permeability which is maximal within a 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. Burn oedema is a result of circulating inflammatory mediators including histamine, prostaglandins, leukotrienes and kinins that result in increased capillary permeability. In addition the 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).
Introduction Burns are traumatic injuries caused by coagulative destruction of the skin. Injuries are usually caused by thermal damage (heat and cold), but chemicals, electricity and radiation may also damage tissues in similar ways. The cause of a patient’s burn may be due to flames or explosions, contact with hot (or cold) surfaces, hot liquid spills and submersions, chemicals, electricity, or exposure to ionizing radiation. Whatever the cause for the burn, there is often an underlying patient vulnerability that puts the patient at risk. A patient with diabetes who sustains a contact burn from a fire after a hypoglycaemic episode is vulnerable due to their poorly controlled medical condition. The toddler who is left unsupervised and pulls a cup of tea onto themselves is vulnerable due to lack of attentive supervision. The alcoholic or drug addict who falls asleep with a lit cigarette following drink or drugs and sustains burns is vulnerable due to their addiction. And 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 in order to reduce the burden of burns on individuals and on society.
Epidemiology In the United Kingdom each year there are approximately 300 deaths from burn injuries. Two hundred and fifty thousand 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 Twelve thousand patients are treated by specialist burns services in the UK each year, with about 500 of these injuries being described as severe/complex and requiring the very highest level of critical care at a regional burns centre.
General effects The local and systemic inflammatory mediators released following a burn (particularly injuries greater than 30% BSA) result in profound systemic effects. Because of ongoing fluid losses cardiac output falls due to decreased venous return, inadequate preload and afterload, and decreased myocardial activity. Because of the ‘fight or flight’ effects, the patient experiences a catecholamine rush of sympathetic activity that contributes to increasing systemic vascular resistance. Pulmonary oedema develops as a result of the systemic increase in capillary permeability as well as increasing pulmonary vascular resistance, left-sided heart failure, hypoproteinaemia, direct vascular injury, and the added insult of an inhalational burn.
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 FRCS (Plast) is a Consultant Plastic and Reconstructive Surgeon at 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 an 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 and gluconeogenesis. Furthermore in major burns impaired insulin release and impaired glucose tolerance are seen. The 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 should not be underestimated given the high chance of infection following injury. The burn wound is an easy entry point for bacteria and yeasts. This is compounded by the weakened humoural and cellular responses following damage to the local circulation and the normal inflammatory process. Finally, burns
patients may lose the protective function of the gut following major injury resulting in translocation of gut organisms into the circulation with increasing morbidity and mortality.
Diagnosis History The history of the injury and the circumstances surrounding how the patient sustained their burn are extremely important and can be crucial in predicting the depth of the injury and whether the burn is likely to heal with or without surgery. The time of the injury is very important as the appearance of the burn changes over the subsequent hours and days. What exactly caused the burn is also vital; scalding liquid, flame, explosion, contact, chemical and electric burns will all produce slight differences and this will need to be confirmed during the physical examination. The detail is important; freshly boiled water produces much deeper injuries compared to a cup of tea that has been cooled off. Another detail involves where the burn occurred; if there was an explosion in a confined place such as a building or car, or the patient has been removed from a burning house there will be an inhalational injury until proven otherwise. Essential to the history of the burn is asking about first aid. Burns that have had appropriate first aid are more likely to heal without surgery, whereas those burns that have not been treated are much more likely to need skin grafting. All burns should have cool running water applied (a mixer tap with running water at 15 C is preferred) for 20 minutes following their injury. This is best done immediately after the injury, but it is still effective up to 3 hours following the burn.4 Medicated gel sponges provide symptomatic pain relief to a burn but are not a substitute for running water first aid. Enquiries should be made regarding other injuries the patient may have sustained during the incident and also the presence of medical, surgical and psychiatric comorbidities. A drug history noting any allergies is required, as is tetanus status and other immunizations (particularly children.) A full social history is of utmost importance as it gives an indication as to the patients’
Jackson’s burn model Zone of necrosis
Zone of stasis
Zone of hyperaemia Figure 2
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social and family circumstances, their employment, sports and hobbies such as tobacco, alcohol and recreational drug use.
The rule of nines
Examination, assessment, early management The examination of the patient will be very dependent on the size and severity of the burn. Where the history and initial 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 about 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:
9%
Front 18% Back 18% 9%
9%
Airway and cervical spine control: the patients’ airway should be assessed remembering cervical spine immobilization. Oxygen should be applied via a non-rebreathing mask. The patient’s head and neck area should be assessed for signs of inhalational injury. Burns to the face, singed nasal hairs, soot in the mouth, a change of voice, brassy cough and respiratory difficulty all suggest a likely inhalational burn. The patient should be sat at 45%; this will help minimize any further oedema to the head and neck. Consider an anaesthetic or ENT assessment for consideration of early endotracheal intubation.
1% 18% 18%
Breathing: assess the rate and equality of chest expansion. If there are burns to the chest are they full thickness and likely to need releasing with an escharotomy. Assess oxygen saturations.
Figure 3
Circulation and haemorrhage control: assess pulse, blood pressure and a capillary blanch that should be no less than 2 seconds. IV access should ideally be through non-burnt skin but if this is not possible then it is permissible to go through the burn or perform a venous cut-down. Sometime it may be necessary to get intra-osseous access in massive burns of children. Send blood samples for full blood count (FBC), coagulation, urea and electrolytes (U&E), group and save (G&S), amylase and arterial blood gas checking for carboxyhaemoglobin that may be raised with inhalational injuries.
Epidermal (superficial): these burns involve the epidermis only and are red much like a sunburn. 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: these burns involve the epidermis and superficial (papillary) dermis and appear pale pink. Blistering is a classical appearance of these injuries. Their capillary refill is normal 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 scar very minimally. Deep dermal: these injuries extend into the deep (reticular) dermis and are blotchy red in appearance. Capillary blanch is absent due to poor circulation within the skin. Sensation is variable in these injuries. 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. Full thickness: 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: establish a level of consciousness either using the glasgow coma scale (GCS) or AVPU; 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 where possible.) The burn should be assessed in terms of its’ 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 9s (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 equates to approximately 1% of their BSA in helping determine the size of the burn. It is important to get the size of the burn correct as any fluid resuscitation that may be required is calculated based on the size of the burn. The depth of the burn should also be determined. Burns are described with the following characteristics (Figure 4):
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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
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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.
required is calculated using the Parkland formula: 3e4 ml % BSA burnt patient weight in kg. This figure is the estimated amount of fluid required by the patient in the first 24 hours following their burn. Approximately half of the volume should be given in the first 8 hours after the injury and the other half should be given in the remaining 16 hours. This is a guide only and the success of fluid resuscitation should be based on urinary output and other clinical parameters 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/h are required in adults and 1 ml/kg/h are required in children. The IV resuscitation fluid should be titrated hourly to the urine output during the resuscitation period with further blood tests (U&E) at 8, 16, and 24 hours post burn. Patients also require maintenance fluid in addition to the resuscitation fluid. This may be taken orally, via a nasogastric tube (NGT) or intravenously. Maintenance IV fluids for children should include some 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.
ensuring any full-thickness or circumferential injuries do not require decompressing with an escharotomy (or fasciotomy for deep electrical injuries.) X-rays should be arranged as required. Pain should be managed, usually 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 are appropriate for short transfers (<1 hour). All other patients require an antimicrobial dressing that should be discussed with a burn unit. Discuss and transfer: document the care given thus far and discuss with the specialist burns service. The specialists will advise on dressings and other local protocols. All of 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 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.
Secondary survey and re-evaluation: all trauma patients should have a secondary survey and reassessment of their injuries
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wound care with regular showers and application of antimicrobial (silver based) dressings such as Acticoat and Flamazine (Smith and Nephew, UK).10 Patients with major burns require dietary support to prevent catabolism and maintain immune function.11 Nasogastric feeds or supplemental protein shakes can be used to supplement oral diet. Other gastrointestinal treatments include the use of proton pump inhibitors to prevent gastric ulceration and prokinetics such as erythromycin or metoclopramide to maintain gastrointestinal motility. Patients with very large burns, airway burns 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%,5 and depression, anxiety and post traumatic stress disorder (PTSD) are highly prevalent after injury.6 Take time to debrief and provide psychosocial support. Non-accidental injury: it is essential to consider deliberate harm in burn injuries. Paediatric scald injuries are the most common, however vulnerable adults are also at risk. Non-accidental injuries caused by paediatric scalds may be represented by burns to the lower limbs with symmetrical immersion marks, while associated fractures and unrelated injuries may be apparent. A systematic review of non-scald physical abuse in children identified contact burns with household items as the most common causative agents, including cigarettes, irons, hairdryers and domestic heaters.7 The item is often clearly demarcated, may be multiple and on the limbs, truck or back.
The small burn Patients with small superficial burns may be managed in the emergency department with first aid, analgesia, cleaning of the burn and debridement of blisters and the application of a dressing. Dressings should be non-adherent and promote wound healing in a moist environment e Mepitel (Molnlycke, Sweden), Urgotul (Urgo, France), or Duoderm (Convatec, USA) for small areas. Superficial burns to the face should be cleaned and kept moist with liquid paraffin 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 should occur until the wound is healed. If the burn 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 function and aesthetics). Telehealth Early access to specialist burn services may be restricted by distance from the burns centre. Over the past ten years there has been increasing use of technology, in particular telephone and video consultation, to seek specialist input. Video link assessment by a burn specialist correlates closely with direct inspection,8 and small burns may be treated and followed up at a distance. Larger burns may be triaged effectively, and reductions in air transfers can improve use of resources through telehealth. Studies in the military have demonstrated the feasibility of video conferencing through Smartphones,9 and developments in technology have the potential to substantially improve burn care. Smartphone applications (apps) have been developed to improve estimation of burn size and fluid requirements, and are available to educate the public on first aid management and seeking burn care.
Surgery Full thickness circumferential burns to the limbs or torso may interfere with circulation to the peripheries or cause restrictive ventilatory difficulties due to the unyielding burn tissue and may require emergency surgical release in the form of an escharotomy. During this procedure the burn tissue is incised to allow the underlying tissue more space and re-establishment of the circulation and oxygenation. Deeper injuries involving muscle compartments (high voltage electrical injuries) may require deeper fascial release as a fasciotomy. If deep dermal and fullthickness burns are allowed to heal with dressings alone they will invariably heal slowly and with significant scarring. The result will be hypertrophic scars, contractures, and poor functional and aesthetic outcomes.12 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 patient’s burn and skin graft donor site are prepped with antiseptic solution. A number of techniques can be used to debride the burn including tangential excision with a Watson knife. 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 or hydrosurgery with Versajet (Smith and Nephew, UK). 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 6 and 10/1000 of an inch are taken most
The large burn Patients with large burns will be transferred to a burns centre for continued resuscitation, critical care and wound management. Fluid resuscitation ensures 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’ to avoid oedema fluid congesting the face. Burnt arms and legs should be elevated. Physiotherapy in the form of active and passive range of movement exercises is essential for maintenance of strength, joint mobility and avoidance of oedema. Prevention of infection remains key within the burn centre. Patients are nursed in single bedrooms to avoid the spread of infection. Strict hygiene and infection control measures supplement attentive
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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.
often with a power dermatome that is able to 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 massive injuries involving >50% BSA burns it may be necessary to do the debridement and skin grafting in stages. This avoids long operations where the patient can become hypothermic and develop coagulation and cardiovascular complications. In large burns where there is insufficient of the patients’ own 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 patient’s temporary immunodeficiency allows for the cadaveric skin to avoid rejection for several months. Other techniques include the use of artificial skins (dermal matrices) namely Integra (Integra life science, USA) and Matriderm (Dr Suwelack, 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 over the top. Tissue-cultured cells can help to heal patients with very large wounds.13 Shortly after admission a small biopsy of skin is taken from the patient and sent to a laboratory for the 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.14 Paediatric scalds The majority of these common injuries are superficial and heal with dressings. Deeper injuries benefit from dermabrasion or Versajet debridement in theatre and application of Biobrane biological dressing (Smith and Nephew, UK). Full-thickness wounds require skin grafting.
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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to avoid the devastating effect this has on the injury. Systemic complications include renal failure, respiratory failure and overwhelming sepsis associated with high mortality. Intermediate complications include continuing burn wound infection and sepsis, splanchnic conditions such as acalculous cholecystitis, Curling’s ulcers and ischaemic enterocolitis, thromboembolic conditions, and heterotopic bone formation (particularly involving the elbows). Late complications include ongoing hypermetabolism, psychosocial morbidity (often predating the injury) and scarrelated problems including hypertrophic scars, scar contracture, altered pigmentation of the burn scar, and Marjolin’s ulcer formation (SCC development in the burns scar).
Rehabilitation The rehabilitation of a burns patient begins when they enter the burn centre. Early physiotherapy while the acute burn is healing helps to minimize oedema, maintain range of movement, and reduces the chance of contracture.15 Scar management techniques should be offered to all patients and should include advice regarding regular moisturizing, scar massage and the use of sunblock. Silicone sheets and gels help 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 maximal scar therapy it may require additional measures such as steroid injections or surgical release. Severe and deforming contractures may occur when burn injuries remain untreated (Figure 7). Figure 7 Scar contracture of the dorsum of the hand requiring surgical release and reconstruction.
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 better prehospital care, infection control, intensive care and developments in burns surgery. Appropriate early wound care, acute burns surgery and scar management can minimize the final scar and reduce the need for later reconstruction. However, despite our improvements we are only too aware of our need to continue targeted prevention campaigns and first aid knowledge across all communities in both the developed and developing world. A
Electrical injuries These burns are classified as either low voltage (<1000 V) and high voltage (>1000 V). Most electrical burns are deep and have identifiable entry and exit points. Patients are at high risk of muscle damage following high voltage injuries to the arms or legs and often require fasciotomy decompression. They are at high risk for myonecrosis, myoglobinuria and renal failure and require aggressive intravenous fluid following these injuries. Sometimes ‘flash burns’ result when an electrical arc occurs between a high voltage cable and the patient.
REFERENCES 1 National Burn Care Review. National burn injury referral guidelines. In: Standards and strategy for burn care. London: NBCR, 2001. 2 International burn injury database. http://www.ibidb.org/. 3 Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953; 40: 588e96. 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 Patterson DR, Everett JJ, Bombardier CH, et al. Psychological effects of severe burn injuries. Psychol Bull 1993; 113: 362e78. 6 Ter Smitten MH, de Graaf R, Van Loey NE. Prevalence and comorbidity of psychiatric disorders 1 e 4 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.
Chemical injuries Only 3% of burn injuries are caused by chemicals, however they are responsible for 30% of deaths. Agents may be divided into acids and alkalis. Alkali burns tend to be more severe than those caused by acid, as they penetrate deeper through liquefactive necrosis, while acids cause burns through coagulative necrosis. Treatment is through copious irrigation to restore and maintain a normal skin pH (5.0e5.9). Hydrofluoric acid is a common industrial cleaner that can kill rapidly as it is a metabolic poison. It precipitates hypocalcaemia and calcium gluconate injections should be given immediately.
Complications and disabilities Very often the early complications of a major burn are difficult to differentiate from the actual burn itself. The most common local complication of a burn is infection, and everything should be done
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8 Saffle JR, Edelman L, Theurer L, et al. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009; 67: 358e65. 9 Luxton DD, Mishkind MC, Crumpton RM. Usability and feasibility of smartphone video capabilities for telehealth care in the U.S. military. Telemed J E Health 2012; 18: 409e12. 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.
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12 Deitch EA, Wheelahan TM, Rose MP, et al. Hypertrophic burn scars: analysis of variables. J Trauma 1983; 27: 147e50. 13 Gallico GG, O’Connor NE, Compton CC, et al. Permanent coverage of large burn wounds with autologous cultured human epithelium. N Engl J Med 1984; 311: 448e51. 14 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. 15 Edgar D, Brereton M. Rehabilitation after burn injury. Br Med J 2004; 329: 343e5.
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Management of burns
No age group or gender is immune from burns. Two-thirds of injuries are sustained by males.2 The largest patient group to sustain burn injuries are boys under the age of 2 years who account for 12% of all injuries. The majority of these injuries are hot water and drink scalds, sustained at home in the kitchen. The second largest group are males aged 25e34 years who account for 8% of all patients treated by specialist burns services. While 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).
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 and the pathophysiology of these injuries. In addition it gives the reader an overview of burns management from the emergency department through to the specialist burns centre and describes the latest multidisciplinary approach to treating these injuries.
Pathology and pathophysiology
Keywords Burns; burns surgery; dressings; resuscitation; scalds; scar management; skin grafts
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 C 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. The tissue damage that results following thermal injury results in a marked increase in capillary permeability which is maximal within a 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. Burn oedema is a result of circulating inflammatory mediators including histamine, prostaglandins, leukotrienes and kinins that result in increased capillary permeability. In addition the 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).
Introduction Burns are traumatic injuries caused by coagulative destruction of the skin. Injuries are usually caused by thermal damage (heat and cold), but chemicals, electricity and radiation may also damage tissues in similar ways. The cause of a patient’s burn may be due to flames or explosions, contact with hot (or cold) surfaces, hot liquid spills and submersions, chemicals, electricity, or exposure to ionizing radiation. Whatever the cause for the burn, there is often an underlying patient vulnerability that puts the patient at risk. A patient with diabetes who sustains a contact burn from a fire after a hypoglycaemic episode is vulnerable due to their poorly controlled medical condition. The toddler who is left unsupervised and pulls a cup of tea onto themselves is vulnerable due to lack of attentive supervision. The alcoholic or drug addict who falls asleep with a lit cigarette following drink or drugs and sustains burns is vulnerable due to their addiction. And 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 in order to reduce the burden of burns on individuals and on society.
Epidemiology In the United Kingdom each year there are approximately 300 deaths from burn injuries. Two hundred and fifty thousand 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 Twelve thousand patients are treated by specialist burns services in the UK each year, with about 500 of these injuries being described as severe/complex and requiring the very highest level of critical care at a regional burns centre.
General effects The local and systemic inflammatory mediators released following a burn (particularly injuries greater than 30% BSA) result in profound systemic effects. Because of ongoing fluid losses cardiac output falls due to decreased venous return, inadequate preload and afterload, and decreased myocardial activity. Because of the ‘fight or flight’ effects, the patient experiences a catecholamine rush of sympathetic activity that contributes to increasing systemic vascular resistance. Pulmonary oedema develops as a result of the systemic increase in capillary permeability as well as increasing pulmonary vascular resistance, left-sided heart failure, hypoproteinaemia, direct vascular injury, and the added insult of an inhalational burn.
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 FRCS (Plast) is a Consultant Plastic and Reconstructive Surgeon at 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 an 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 and gluconeogenesis. Furthermore in major burns impaired insulin release and impaired glucose tolerance are seen. The 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 should not be underestimated given the high chance of infection following injury. The burn wound is an easy entry point for bacteria and yeasts. This is compounded by the weakened humoural and cellular responses following damage to the local circulation and the normal inflammatory process. Finally, burns
patients may lose the protective function of the gut following major injury resulting in translocation of gut organisms into the circulation with increasing morbidity and mortality.
Diagnosis History The history of the injury and the circumstances surrounding how the patient sustained their burn are extremely important and can be crucial in predicting the depth of the injury and whether the burn is likely to heal with or without surgery. The time of the injury is very important as the appearance of the burn changes over the subsequent hours and days. What exactly caused the burn is also vital; scalding liquid, flame, explosion, contact, chemical and electric burns will all produce slight differences and this will need to be confirmed during the physical examination. The detail is important; freshly boiled water produces much deeper injuries compared to a cup of tea that has been cooled off. Another detail involves where the burn occurred; if there was an explosion in a confined place such as a building or car, or the patient has been removed from a burning house there will be an inhalational injury until proven otherwise. Essential to the history of the burn is asking about first aid. Burns that have had appropriate first aid are more likely to heal without surgery, whereas those burns that have not been treated are much more likely to need skin grafting. All burns should have cool running water applied (a mixer tap with running water at 15 C is preferred) for 20 minutes following their injury. This is best done immediately after the injury, but it is still effective up to 3 hours following the burn.4 Medicated gel sponges provide symptomatic pain relief to a burn but are not a substitute for running water first aid. Enquiries should be made regarding other injuries the patient may have sustained during the incident and also the presence of medical, surgical and psychiatric comorbidities. A drug history noting any allergies is required, as is tetanus status and other immunizations (particularly children.) A full social history is of utmost importance as it gives an indication as to the patients’
Jackson’s burn model Zone of necrosis
Zone of stasis
Zone of hyperaemia Figure 2
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social and family circumstances, their employment, sports and hobbies such as tobacco, alcohol and recreational drug use.
The rule of nines
Examination, assessment, early management The examination of the patient will be very dependent on the size and severity of the burn. Where the history and initial 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 about 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:
9%
Front 18% Back 18% 9%
9%
Airway and cervical spine control: the patients’ airway should be assessed remembering cervical spine immobilization. Oxygen should be applied via a non-rebreathing mask. The patient’s head and neck area should be assessed for signs of inhalational injury. Burns to the face, singed nasal hairs, soot in the mouth, a change of voice, brassy cough and respiratory difficulty all suggest a likely inhalational burn. The patient should be sat at 45%; this will help minimize any further oedema to the head and neck. Consider an anaesthetic or ENT assessment for consideration of early endotracheal intubation.
1% 18% 18%
Breathing: assess the rate and equality of chest expansion. If there are burns to the chest are they full thickness and likely to need releasing with an escharotomy. Assess oxygen saturations.
Figure 3
Circulation and haemorrhage control: assess pulse, blood pressure and a capillary blanch that should be no less than 2 seconds. IV access should ideally be through non-burnt skin but if this is not possible then it is permissible to go through the burn or perform a venous cut-down. Sometime it may be necessary to get intra-osseous access in massive burns of children. Send blood samples for full blood count (FBC), coagulation, urea and electrolytes (U&E), group and save (G&S), amylase and arterial blood gas checking for carboxyhaemoglobin that may be raised with inhalational injuries.
Epidermal (superficial): these burns involve the epidermis only and are red much like a sunburn. 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: these burns involve the epidermis and superficial (papillary) dermis and appear pale pink. Blistering is a classical appearance of these injuries. Their capillary refill is normal 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 scar very minimally. Deep dermal: these injuries extend into the deep (reticular) dermis and are blotchy red in appearance. Capillary blanch is absent due to poor circulation within the skin. Sensation is variable in these injuries. 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. Full thickness: 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: establish a level of consciousness either using the glasgow coma scale (GCS) or AVPU; 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 where possible.) The burn should be assessed in terms of its’ 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 9s (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 equates to approximately 1% of their BSA in helping determine the size of the burn. It is important to get the size of the burn correct as any fluid resuscitation that may be required is calculated based on the size of the burn. The depth of the burn should also be determined. Burns are described with the following characteristics (Figure 4):
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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
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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.
required is calculated using the Parkland formula: 3e4 ml % BSA burnt patient weight in kg. This figure is the estimated amount of fluid required by the patient in the first 24 hours following their burn. Approximately half of the volume should be given in the first 8 hours after the injury and the other half should be given in the remaining 16 hours. This is a guide only and the success of fluid resuscitation should be based on urinary output and other clinical parameters 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/h are required in adults and 1 ml/kg/h are required in children. The IV resuscitation fluid should be titrated hourly to the urine output during the resuscitation period with further blood tests (U&E) at 8, 16, and 24 hours post burn. Patients also require maintenance fluid in addition to the resuscitation fluid. This may be taken orally, via a nasogastric tube (NGT) or intravenously. Maintenance IV fluids for children should include some 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.
ensuring any full-thickness or circumferential injuries do not require decompressing with an escharotomy (or fasciotomy for deep electrical injuries.) X-rays should be arranged as required. Pain should be managed, usually 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 are appropriate for short transfers (<1 hour). All other patients require an antimicrobial dressing that should be discussed with a burn unit. Discuss and transfer: document the care given thus far and discuss with the specialist burns service. The specialists will advise on dressings and other local protocols. All of 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 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.
Secondary survey and re-evaluation: all trauma patients should have a secondary survey and reassessment of their injuries
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wound care with regular showers and application of antimicrobial (silver based) dressings such as Acticoat and Flamazine (Smith and Nephew, UK).10 Patients with major burns require dietary support to prevent catabolism and maintain immune function.11 Nasogastric feeds or supplemental protein shakes can be used to supplement oral diet. Other gastrointestinal treatments include the use of proton pump inhibitors to prevent gastric ulceration and prokinetics such as erythromycin or metoclopramide to maintain gastrointestinal motility. Patients with very large burns, airway burns 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%,5 and depression, anxiety and post traumatic stress disorder (PTSD) are highly prevalent after injury.6 Take time to debrief and provide psychosocial support. Non-accidental injury: it is essential to consider deliberate harm in burn injuries. Paediatric scald injuries are the most common, however vulnerable adults are also at risk. Non-accidental injuries caused by paediatric scalds may be represented by burns to the lower limbs with symmetrical immersion marks, while associated fractures and unrelated injuries may be apparent. A systematic review of non-scald physical abuse in children identified contact burns with household items as the most common causative agents, including cigarettes, irons, hairdryers and domestic heaters.7 The item is often clearly demarcated, may be multiple and on the limbs, truck or back.
The small burn Patients with small superficial burns may be managed in the emergency department with first aid, analgesia, cleaning of the burn and debridement of blisters and the application of a dressing. Dressings should be non-adherent and promote wound healing in a moist environment e Mepitel (Molnlycke, Sweden), Urgotul (Urgo, France), or Duoderm (Convatec, USA) for small areas. Superficial burns to the face should be cleaned and kept moist with liquid paraffin 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 should occur until the wound is healed. If the burn 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 function and aesthetics). Telehealth Early access to specialist burn services may be restricted by distance from the burns centre. Over the past ten years there has been increasing use of technology, in particular telephone and video consultation, to seek specialist input. Video link assessment by a burn specialist correlates closely with direct inspection,8 and small burns may be treated and followed up at a distance. Larger burns may be triaged effectively, and reductions in air transfers can improve use of resources through telehealth. Studies in the military have demonstrated the feasibility of video conferencing through Smartphones,9 and developments in technology have the potential to substantially improve burn care. Smartphone applications (apps) have been developed to improve estimation of burn size and fluid requirements, and are available to educate the public on first aid management and seeking burn care.
Surgery Full thickness circumferential burns to the limbs or torso may interfere with circulation to the peripheries or cause restrictive ventilatory difficulties due to the unyielding burn tissue and may require emergency surgical release in the form of an escharotomy. During this procedure the burn tissue is incised to allow the underlying tissue more space and re-establishment of the circulation and oxygenation. Deeper injuries involving muscle compartments (high voltage electrical injuries) may require deeper fascial release as a fasciotomy. If deep dermal and fullthickness burns are allowed to heal with dressings alone they will invariably heal slowly and with significant scarring. The result will be hypertrophic scars, contractures, and poor functional and aesthetic outcomes.12 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 patient’s burn and skin graft donor site are prepped with antiseptic solution. A number of techniques can be used to debride the burn including tangential excision with a Watson knife. 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 or hydrosurgery with Versajet (Smith and Nephew, UK). 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 6 and 10/1000 of an inch are taken most
The large burn Patients with large burns will be transferred to a burns centre for continued resuscitation, critical care and wound management. Fluid resuscitation ensures 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’ to avoid oedema fluid congesting the face. Burnt arms and legs should be elevated. Physiotherapy in the form of active and passive range of movement exercises is essential for maintenance of strength, joint mobility and avoidance of oedema. Prevention of infection remains key within the burn centre. Patients are nursed in single bedrooms to avoid the spread of infection. Strict hygiene and infection control measures supplement attentive
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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.
often with a power dermatome that is able to 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 massive injuries involving >50% BSA burns it may be necessary to do the debridement and skin grafting in stages. This avoids long operations where the patient can become hypothermic and develop coagulation and cardiovascular complications. In large burns where there is insufficient of the patients’ own 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 patient’s temporary immunodeficiency allows for the cadaveric skin to avoid rejection for several months. Other techniques include the use of artificial skins (dermal matrices) namely Integra (Integra life science, USA) and Matriderm (Dr Suwelack, 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 over the top. Tissue-cultured cells can help to heal patients with very large wounds.13 Shortly after admission a small biopsy of skin is taken from the patient and sent to a laboratory for the 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.14 Paediatric scalds The majority of these common injuries are superficial and heal with dressings. Deeper injuries benefit from dermabrasion or Versajet debridement in theatre and application of Biobrane biological dressing (Smith and Nephew, UK). Full-thickness wounds require skin grafting.
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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to avoid the devastating effect this has on the injury. Systemic complications include renal failure, respiratory failure and overwhelming sepsis associated with high mortality. Intermediate complications include continuing burn wound infection and sepsis, splanchnic conditions such as acalculous cholecystitis, Curling’s ulcers and ischaemic enterocolitis, thromboembolic conditions, and heterotopic bone formation (particularly involving the elbows). Late complications include ongoing hypermetabolism, psychosocial morbidity (often predating the injury) and scarrelated problems including hypertrophic scars, scar contracture, altered pigmentation of the burn scar, and Marjolin’s ulcer formation (SCC development in the burns scar).
Rehabilitation The rehabilitation of a burns patient begins when they enter the burn centre. Early physiotherapy while the acute burn is healing helps to minimize oedema, maintain range of movement, and reduces the chance of contracture.15 Scar management techniques should be offered to all patients and should include advice regarding regular moisturizing, scar massage and the use of sunblock. Silicone sheets and gels help 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 maximal scar therapy it may require additional measures such as steroid injections or surgical release. Severe and deforming contractures may occur when burn injuries remain untreated (Figure 7). Figure 7 Scar contracture of the dorsum of the hand requiring surgical release and reconstruction.
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 better prehospital care, infection control, intensive care and developments in burns surgery. Appropriate early wound care, acute burns surgery and scar management can minimize the final scar and reduce the need for later reconstruction. However, despite our improvements we are only too aware of our need to continue targeted prevention campaigns and first aid knowledge across all communities in both the developed and developing world. A
Electrical injuries These burns are classified as either low voltage (<1000 V) and high voltage (>1000 V). Most electrical burns are deep and have identifiable entry and exit points. Patients are at high risk of muscle damage following high voltage injuries to the arms or legs and often require fasciotomy decompression. They are at high risk for myonecrosis, myoglobinuria and renal failure and require aggressive intravenous fluid following these injuries. Sometimes ‘flash burns’ result when an electrical arc occurs between a high voltage cable and the patient.
REFERENCES 1 National Burn Care Review. National burn injury referral guidelines. In: Standards and strategy for burn care. London: NBCR, 2001. 2 International burn injury database. http://www.ibidb.org/. 3 Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953; 40: 588e96. 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 Patterson DR, Everett JJ, Bombardier CH, et al. Psychological effects of severe burn injuries. Psychol Bull 1993; 113: 362e78. 6 Ter Smitten MH, de Graaf R, Van Loey NE. Prevalence and comorbidity of psychiatric disorders 1 e 4 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.
Chemical injuries Only 3% of burn injuries are caused by chemicals, however they are responsible for 30% of deaths. Agents may be divided into acids and alkalis. Alkali burns tend to be more severe than those caused by acid, as they penetrate deeper through liquefactive necrosis, while acids cause burns through coagulative necrosis. Treatment is through copious irrigation to restore and maintain a normal skin pH (5.0e5.9). Hydrofluoric acid is a common industrial cleaner that can kill rapidly as it is a metabolic poison. It precipitates hypocalcaemia and calcium gluconate injections should be given immediately.
Complications and disabilities Very often the early complications of a major burn are difficult to differentiate from the actual burn itself. The most common local complication of a burn is infection, and everything should be done
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8 Saffle JR, Edelman L, Theurer L, et al. Telemedicine evaluation of acute burns is accurate and cost-effective. J Trauma 2009; 67: 358e65. 9 Luxton DD, Mishkind MC, Crumpton RM. Usability and feasibility of smartphone video capabilities for telehealth care in the U.S. military. Telemed J E Health 2012; 18: 409e12. 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.
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12 Deitch EA, Wheelahan TM, Rose MP, et al. Hypertrophic burn scars: analysis of variables. J Trauma 1983; 27: 147e50. 13 Gallico GG, O’Connor NE, Compton CC, et al. Permanent coverage of large burn wounds with autologous cultured human epithelium. N Engl J Med 1984; 311: 448e51. 14 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. 15 Edgar D, Brereton M. Rehabilitation after burn injury. Br Med J 2004; 329: 343e5.
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