28.1

Burn Injuries

Chapter 28

Burn Injuries

Introduction

Burns constitute between 5% and 20% of combat casualties

during conventional warfare, and are particularly common

during war at sea and combat involving armored fighting

vehicles. Even relatively small burns can be incapacitating, and

can strain the logistical and manpower resources of military

medical units. Optimal treatment currently results in salvage of

approximately 50% of young adults whose burns involve 80%

of the total body surface area (TBSA) or greater. Thus, in a battlefield

triage scenario, expectant care should be considered for patients

with burns that exceed 80%. Care can be delayed for those patients

with burns of 20% or less who are otherwise stable.

Point-of-Injury Care

The following are key steps in the first aid of burn patients:

 Stop the burning process. Extinguish and remove burning

clothing, and remove the patient from a burning vehicle or

building. In an electrical injury, remove the patient from the

power source, while avoiding rescuer injury. Wash chemical

agents from the skin surface with copious water lavage.

 Ensure airway patency, control hemorrhage, and splint

fractures.

 Remove all constricting articles, such as rings, bracelets,

wristwatches, belts, and boots. However, do not undress the

patient unless the injury has been caused by a chemical agent,

in which case remove all contaminated clothing.

 Cover the patient with a clean sheet and a blanket, if

appropriate, to maintain body temperature and to prevent

gross contamination during transport to a treatment facility;

special burn dressings are not required. Hypothermia is a

complication of large surface area burns.

 Establish intravenous access through unburned skin if

possible, and through burned skin if necessary. Intraosseous

access is also acceptable.
28.2

Emergency War Surgery

 Begin resuscitation with lactated Ringer’s solution (LR) or

similar solution, and continue during evacuation.

 Dress white phosphorus-injured patients with saline-soaked

dressings to prevent reignition of the phosphorus by contact

with the air.

Primary Survey

Do not be distracted by the burn! The priorities of

management for burn casualties are the same as those

for other injured patients, with the addition of burn

pathophysiology.

 The primary survey includes airway management (with

cervical spine control, if appropriate given the mechanism of

injury), diagnosis and management of any breathing

condition, rapid circulatory assessment, and hemorrhage

control. In the burn patient, special attention to exposure,

removal of clothing that continues to burn the victim, and

prevention of hypothermia are important.

 Airway.

 Inhalation injury may be manifested by stridor,

hoarseness, cough, carbonaceous sputum, dyspnea, and

so forth. It may cause airway obstruction at any time

during the first 2 days postburn.

 Patients who may have sustained inhalation injury

should be closely observed in an intensive care unit, and

may be monitored without intubation if minimally

symptomatic.

 Prior to transport, prophylactically intubate patients

having/or who have symptomatic inhalation injury.

 Tubes, such as the orotracheal tube, should be

definitively secured with cloth ties (eg, umbilical tape).

Avoid adhesive tape.

ο Cervical spine injury is uncommon in burn patients, except

in those injured in explosions, high-speed vehicular accidents,

and falls, or by contact with high-voltage electricity.
28.3

Burn Injuries

ο Burns are a “distracting injury,” pain secondary to burns,

and the treatment of pain with narcotics, may make the

clinical diagnosis of spinal injury difficult.

 Breathing.

ο Inhalation injury is more common in patients with

extensive cutaneous burns, a history of injury in a closed

space (eg, building or vehicle), facial burns, and at the

extremes of age.

ο Patients with major burns and/or inhalation injury require

supplemental oxygen, pulse oximetry, chest radiograph

and arterial blood gas measurement.

ο Circumferential burns of the chest may prevent effective

chest motion. If this occurs, perform immediate thoracic

escharotomy as a life-saving procedure to permit

adequate chest excursion (see Fig. 28-1).

ο Definitive diagnosis of lower airway injury requires

fiberoptic bronchoscopy.

Fig. 28-1.The dashed lines indicate the

preferred sites for escharotomy incisions.

The bold lines in the figure indicate the

importance of extending the incision over

involved major joints. Incisions are made

through the burned skin into the

underlying subcutaneous fat using a

scalpel or electrocautery. For a thoracic

escharotomy, begin incision in the

midclavicular lines. Continue the incision

along the anterior axillary lines down to

the level of the costal margin. Extend the

incision across the epigastrium as needed.

For an extremity escharotomy, make the

incision through the eschar along the midmedial or mid-lateral joint line.

ο Carbon monoxide (CO) poisoning causes cardiac and neurologic

symptoms. Patients with CO poisoning require 100% oxygen

for at least 3 hours or until symptoms resolve.

 Circulation.

o Secure all cannulae (peripheral and central) with suture,

because tape will not adhere well.
28.4

Emergency War Surgery

ο Cuff blood pressure (BP) measurements may be inaccurate

in patients with burned or edematous extremities. Arterial

BP is preferred.

Estimation of Fluid Resuscitation Needs

Initiate resuscitation with LR based on the patient’s weight

and the burn size. Then, use the urine output as the primary

index of adequacy of resuscitation (see below). It is equally

important to avoid both over-resuscitation and underresuscitation.

 Determine the burn size based on the Rule of Nines (Fig.

28-2). A patient’s hand (palm and fingers) is approximately

1% of the total body surface area (TBSA). Only 2nd and 3rd

degree burns are included in burn size calculations.

ο Overestimation is common and may lead to overresuscitation and over-evacuation.

Fig. 28-2. Rule of nines, showing distribution of body surface area by

anatomical part in the adult.

9%

9%

18% 18%

9%

1%

18%

18%

 Estimate crystalloid needs for the

first 24 hours, using the following

formula:

Total Volume = (2 mL) • (% burn) •

(kg weight).

 Half of this total volume is

programmed for the first 8 hours

postburn, and half for the second 16

hours postburn:

o Hourly rate, first 8 hours postburn

= (Total Volume /2) /(8h - elapsed

time in hours since burn).
28.5

Burn Injuries

Assume: 40% burn, 70-kg person, time of injury 1 h ago,

(no fluids received yet).

Fluid Requirements for First 24 h = 2 x 40 x 70 = 5600 ml

One half of this to be given over first 8 h = 5600/2 = 2800 ml

But one hour has elapsed, therefore hourly rate =

2800 ml/7 h = 400 ml/h

 These calculations are only an initial estimate. Patients with

inhalation injury, predominantly full-thickness burns, and

delay in resuscitation will have higher fluid requirements.

The rate of infusion of LR must be adjusted every 1–2 hours,

based on physiologic response (see below). Despite the

formula, no abrupt change is made at the 8-hour mark.

 If LR is not available, use other crystalloids such as normal

saline. If crystalloid supplies are severely limited, consider

starting colloid at the 12-hour mark, at the rate recommended

for the second 24 hours (see below).

 Children (< 30 kg) have a greater surface-to-weight ratio, and

their fluid requirements are greater. The formula for children

is based on 3 cc/kg/% burn.

ο In addition, children must be given a standard

maintenance infusion of D5 1⁄2NS concurrently.

Monitoring the Burn Patient

 Two intravenous catheters (IVs), a Foley catheter, continuous ECG,

pulse oximeter, core thermometer, and nasogastric (NG) tube are

needed for ICU care of a patient with burns of 20% TBSA or greater.

 Vital signs and fluid input/output are recorded every hour

on a flow sheet.

 NG decompression is essential for all patients with burns over

20% TBSA, due to potential gastric ileus.

Secondary Survey

 Perform a thorough head-to-toe secondary survey, looking

for nonthermal injuries, to include corneal abrasion, tympanic

membrane rupture, fractures, or dislocations.

 If there is a question of intra-abdominal injury, diagnostic peritoneal

lavage, through burned skin if necessary, is appropriate.
28.6

Emergency War Surgery

Resuscitation Management, First 24 Hours

On an hourly basis, reassess the patient’s urine output,

which is the single most important indicator of the adequacy

of resuscitation.

 Seek a urine output of 30–50 mL/h in adults or 1 mL/kg/h

in children. If the urine output is less than the target for 1–2

consecutive hours, increase the LR infusion rate by about 25%.

If it is greater than the target, decrease it by about 25%.

 Avoid over-resuscitation, which may lead to edema-related

complications (eg, compartment syndromes and pulmonary

edema).

 Other indices of adequate resuscitation include a decreasing

base deficit, a moderate tachycardia (typically a pulse of 100

to 130 is normal in adult burn patients), and an acceptable

mental status.

 Diuretics are never indicated in the treatment of burn shock,

except when gross pigmenturia is present (see below).

 Glycosuria is common following severe thermal injury and may

cause hypovolemia secondary to osmotic diuresis. Check the urine

for glucose and treat hyperglycemia with IV insulin as needed.

Resuscitation Management, Second 24 Hours

At the end of the first 24 hours postburn, discontinue the LR.

For the second 24 hours, use 5% albumin in normal saline.

 The 24–hour albumin volume is as follows:

5% albumin volume = (* mL) • (% TBSA burned) • (preburn wt, kg)

% TBSA burn 30–49 50–69 70+

* mL 0.3 0.4 0.5

For example, in a burn of approximately 40% in a 70 -kg patient:

Albumin volume = (* ml) • (40%) • (70kg) = (0.3) • (2,800) =

840 mL/24 h = 35 mL/h
28.7

Burn Injuries

 Burns < 30% TBSA do not require colloid infusion.

 It is rarely necessary to adjust the colloid infusion rate.

 If albumin is not available, fresh frozen plasma or synthetic

colloid can be used at the same dose. If none of these is

available, continue the LR until the 48th hour postburn,

monitoring urine output, and so forth.

 At 24 hours, start D5W at half the last hourly rate of LR.

 Follow serum sodium closely. Resuscitation is usually

complete by the 48th hour postburn. Continued evaporative

water loss replacement is needed thereafter—beware of

hypo- or hypernatremia!

Burn Wound Care

 The burn wound is not an early management priority, but

must be attended to by 24 hours postburn.

Initial burn wound care includes adequate IV pain

management, removal of foreign bodies, debridement,

cleansing with surgical soap (use only saline around the

face), unroofing of all blisters, and application of a topical

antimicrobial.

 Adequate wound care requires adequate pain control. Small,

intermittent boluses of IV morphine or fentanyl are effective

for background pain control. Ketamine, 1 mg/kg IV, is

generally effective for painful wound care.

 Apply a topical antimicrobial cream twice daily after

thorough cleansing with a surgical detergent such as

chlorhexidine gluconate Hibiclens.

 One-percent silver sulfadiazine (Silvadene), and/or 11.1%

mafenide acetate (Sulfamylon), burn creams should be

used. They are applied as a thick (1/16- to 1/8-in. thick)

layer—not as a lotion.

 Following burn cream application, burns may be treated open

or closed (wrapped in gauze).

ο Extremity wounds can be wrapped in a thick layer of

roller gauze that is changed twice daily.
28.8

Emergency War Surgery

ο During the period of active wound exudation, it is helpful

to place bulky dressings beneath the burned parts to absorb

the exudate.

ο Burn cream should be reapplied to open burns as often as

needed to keep them covered.

Burn victims must be adequately immunized against

tetanus and (if arrival at the burn center will take longer

than 24 hours) should be treated with a 5-day course of

penicillin or similar antibiotic (intravenously for large

burns, orally for small ones).

 Definitive burn surgery in the combat zone is generally not

recommended.

 Prevent thermal (cold) stress by keeping the environment as

warm as possible (> 85°F).

 Corneal abrasions in burn patients can lead to full-thickness

ulceration and blindness, and require aggressive treatment

with antibiotic ointments, preferably gentamicin or a

quinolone every 4 hours, alternating with erythromycin every

4 hours.

 It is common for patients to develop a sterile, chemical

cellulitis, manifested by an erythematous rim of normal tissue

extending 1–2 cm around the wound margin. Erythema

extending beyond this margin, with other clinical evidence

of infection, likely represents beta-hemolytic streptococcal

cellulitis. Consider vancomycin if penicillin has already been

given. Treat with appropriate IV antibiotics.

 Invasive gram-negative burn-wound infection is heralded by

striking changes in the color of the burn wound and a clinical

course consistent with sepsis.

ο Initiate an aminoglycoside and a semi-synthetic antipseudomonal penicillin; apply Sulfamylon cream bid if

available; and plan urgent evacuation.

ο Consider subeschar clysis (injection via a spinal needle)

with the daily dose of an antipseudomonal penicillin

(ticarcillin, piperacillin) in a suitable volume of

crystalloid solution (eg, 500 mL). This is done at time of

diagnosis, and then immediately prior to excision to fascia.
28.9

Burn Injuries

Daily inspection of the burn wound by a surgeon is

essential to identify early infection complications.

Extremity Care

 Carefully monitor the extremities throughout the

resuscitation period. The management of the burned

extremity can be summarized as follows:

ο Elevate;

ο Exercise burned extremities hourly;

ο Evaluate pulses and neurologic status hourly; and

ο Perform escharotomy as indicated.

 In extremities with full thickness, circumferential burns,

edema formation beneath the inelastic eschar may gradually

constrict the venous outflow and, ultimately, arterial inflow.

Adequate perfusion must be assessed hourly during resuscitation.

Progressive diminution of audible arterial flow by

Doppler flowmetry is the primary indication for

escharotomy. Doppler pulses should be sought in the

palmar arch, not the wrist.

 Pulses may be difficult to palpate in edematous, burned

extremities. However, in the absence of a Doppler

flowmeter, and in the appropriate clinical setting, loss of

palpable pulses may indicate a need for escharotomy.

 Patients requiring escharotomy often present with a tight and

edematous extremity. They may have progressive neurologic

dysfunction such as unrelenting deep tissue pain or

paresthesias, and/or distal cyanosis.

 Prior to prolonged transport, strongly consider prophylactic

escharotomy.

 Note that loss of the palmar arch Doppler signal, in the presence

of adequate radial and ulnar pulses, is an indication for dorsal

hand escharotomies. These are performed over the dorsal

interossei. Digital escharotomies may be useful in some cases.

 Following escharotomy, document restoration of normal

pulses and continue to monitor the patient. If one incision

fails to restore pulses, make a second incision on the other

side of the limb.
28.10

Emergency War Surgery

 After escharotomy, cover wounds, including the escharotomy

incisions, in burn cream.

 The patient may still develop a true intramuscular, subfascial

compartment syndrome requiring fasciotomy.

 Fractures associated with thermal injury are best treated

by skeletal traction or by external fixation to permit

exposure of the burns and their treatment with topical

antimicrobials. Plaster, if used, should be bivalved

immediately to permit access for wound care and to

accommodate edema of the burned limb.

Other Considerations

 Burn patients manifest a hypermetabolic state, with

hyperthermia, tachycardia, and hypercatabolism, which may

be difficult to distinguish from early sepsis.

 Stress ulcer prophylaxis is critical (see Chapter 19, ICU Care).

 Early enteral nutrition—once hemodynamically stable,

generally at 24 hours.

 Respiratory care.

ο About one week after injury, patients with subglottic

inhalation injury may develop obstructing bloody casts.

Inhaled heparin sodium, at a dose of 10,000 units, may be

given by nebulization every 4 hours in order to prevent

the formation of these casts.

ο Subglottic inhalation injury may persist longer than

clinically evident. Extubation must be performed with

caution after adequate airway assessment.

 Patients with large burns are at risk for abdominal

compartment syndrome.

Electrical Injury

 High-voltage electrical injury (>1,000 volts) causes muscular

damage that often is much greater in extent than the overlying

cutaneous injury.

 Examine the extremities for compartment syndrome and

perform urgent fasciotomy as needed.

 Gross pigmenturia (myoglobinuria) may result, and fluid

resuscitation must be modified to protect against renal injury.
28.11

Burn Injuries

ο Pigmenturia is diagnosed by reddish-brownish urine, with

a dipstick test which is positive for blood, but with

insignificant numbers of red blood cells on microscopy.

ο Increase the hourly LR rate until a urine output of 100 ml/

h is achieved.

ο If this fails to cause a progressive clearing of the urinary

pigmenturia over 3 to 4 hours, add 12.5 g mannitol to each

liter of LR infused and consider invasive monitoring.

ο Infusion of sodium bicarbonate in water (150 mEq/L) in

order to alkalinize the urine may be useful.

 Hyperkalemia may occur as a result of rhabdomyolysis, and

must be carefully assessed and treated, with calcium

gluconate infusion, insulin, and glucose.

 Surgical debridement of nonviable muscle is the definitive

treatment of myoglobinuria.

High-voltage electric injury requires consideration of

deep muscle injury, with resultant rhabdomyolysis,

hyperkalemia, acute renal failure, and compartment

syndrome. Cardiac monitoring, aggressive fluid and

electrolyte management, fasciotomy, and debridement

are often required.

 Patients with electrical injuries are also at high risk for spinal

fractures.

Chemical Burns

 Initial treatment requires immediate removal of the offending

agent.

ο Brush any dry materials off the skin surface before copious

water lavage.

ο In the case of alkali burns, lavage may need to be continued

for several hours.

ο Resuscitate and manage just as a thermal burn.

White Phosphorus Burn

 Most of the cutaneous injury resulting from phosphorus burns is

due to the ignition of clothing, and is treated as a conventional burn.
28.12

Emergency War Surgery

 Fragments of this metal, which ignite upon contact with the

air, may be driven into the soft tissues.

 First aid treatment of casualties with imbedded phosphorus

particles includes copious water irrigation, and placement

of a saline-soaked dressing that must be kept

continuously wet.

 Profound hypocalcemia, and hyperphosphatemia, have been

described as effects of white phosphorus injury. Treat with

IV calcium.

 Rapid surgical removal of the identifiable particles is often

required. UV light can be used to help locate them.

ο A dilute (1%) freshly mixed solution of copper sulfate has

been used to help identify white phosphorus particles.

However, this is no longer recommended because if the

solution is absorbed, it can cause fatal hemolysis. If it is

used, immediately wash it off with copious saline

irrigation. Never apply it as a wet dressing.

 Liberally apply topical antimicrobial burn creams

postoperatively.

“How I Do It”: Excision and Grafting

Definitive burn care, including surgery and rehabilitation, is

manpower and resource intensive; therefore it is generally

inadvisable to perform excision and grafting of burns in a theater

of operations. However, under certain circumstances, this may

be unavoidable.

Patient Selection

Do not attempt to autograft patients with grossly colonized or

infected wounds. Such patients are best treated with deep

tangential excision or primary excision to fascia, followed by

immediate placement of a biologic dressing such as gammairradiated allograft (Gammagraft, Promethean LifeSciences, Inc.,

Pittsburgh, PA). Many second-degree (partial thickness) wounds

are likely to heal in 14–21 days with acceptable cosmetic and

functional outcomes. Partial-thickness wounds which take longer

to heal, are likely to heal with fragile or hypertrophic scar, and

should be considered for grafting. Likewise, full-thickness burns

will only heal by contracture and should be considered for grafting.
28.13

Burn Injuries

Preparation

When performing burn surgery in a theater of operations, it

is preferable to perform several limited procedures (eg, 10%

TBSA or less at each operation) in order to limit the

physiologic stress of the operation. Plans for the operation

must be discussed and rehearsed with all personnel involved,

and the availability of OR equipment and postoperative

dressings and splints must be ascertained. At least 4 units of

PRBCs should be available for a patient undergoing a 10%

TBSA excision. A single dose of prophylactic intravenous

antibiotic, such as a first-generation cephalosporin, should

be administered. (However, antibiotics effective against

Pseudomonas and other gram-negative wound pathogens

should be considered for patients with heavily colonized

wounds.) Total IV general anesthesia (TIVA), based on

ketamine, is very effective in burn patients. Select the donor

sites to be used. Often, the anterior thighs are available and

easy to harvest. However, any area of clean unburned skin

can be harvested. Hair is removed from the donor site, and

both the area to be excised and the donor site are prepped.

Tangential vs Fascial Excision

Many surgeons recommend that extensive burn wound excision

of the extremities be performed after exsanguination and

pneumatic tourniquet application to limit blood loss. Using a

Weck knife for small areas, or a Blair knife (or similar) for large

areas, the burn is tangentially excised to the level of viable tissue.

When an area has been exsanguinated, absence of hemosiderin

staining of the dermis or fat is the usual endpoint for tangential

excision. When an area has not been exsanguinated, the usual

endpoint is diffuse punctuate bleeding (in the dermis) or viableappearing fat. When the surgeon believes that all nonviable

tissue in the surgical field has been excised, gauze soaked in a

1:100,000 solution of epinephrine in lactated Ringer’s can be

applied, followed by a tight ace wrap. The tourniquet is released

and the wound is reassessed after 5–10 minutes. Hemostasis in

the bed is then achieved by electrocautery. If available, topical

hemostatic agents such as spray thrombin and fibrin sealant can

be applied before letting the tourniquet down.
28.14

Emergency War Surgery

Alternatively, if the burn extends into fat and/or demonstrates

evidence of invasive burn wound infection, the burn wound

can be excised to the level of the investing muscle fascia, using

electrocautery.

Donor Site Harvesting

The subcutaneous space of the selected donor site is clysed with

a saline solution containing a 1:1,000,000 dilution of epinephrine.

This technique reduces bleeding and can be used to round out

irregular contours of the donor site when skin must be harvested

from bony or irregularly shaped areas. It is particularly

important to do this prior to harvesting the scalp to control

bleeding. It is optional for most other locations. A pneumatic

or electric dermatome is loaded with a wide blade and the

thickness of the skin to be harvested is adjusted to a depth

between 8/1,000 and 15/1,000 inch. It would be appropriate to

use 10/1,000 for grafting of most sites. Many surgeons use skin

harvested at a depth of 12/1,000 to 15/1,000 inch for the hands.

If a powered dermatome is not available, skin grafts can be

harvested using a manual dermatome or a Weck knife.

Hemostasis of the donor site is achieved with the application of

warm gauze packs, soaked in a 1:100,000 solution of

epinephrine.

At the end of the procedure, the packs are removed and the

donor site is dressed with a single sheet of rolled, fine-mesh

gauze or xeroform (petrolatum and 3% bismuth

tribromophenate) gauze. Donor sites can alternatively be

dressed in a biosynthetic membrane material such as Biobrane.

When the donor site is small, another alternative is to apply an

occlusive transparent film dressing such as a large OpSite (Smith

& Nephew, Largo, FL) to the donor wound.

Application and Securing of the Graft

The harvested split-thickness skin may be meshed. It would be

appropriate in this case to use 1.5:1 or 2:1 for the arms; but

unmeshed skin, or skin meshed 1:1 or 1.5:1, is preferred for the

hands. If a mesher is not available, the graft can be pie-crusted
28.15

Burn Injuries

using a scalpel. The graft is applied to the prepared bed and

stapled in place. Over the hands, the graft is minimally

expanded. Bridal veil (or another product to prevent shear, such

as fine-mesh gauze) is applied over the grafted areas, followed

by a moist gauze dressing. Dressings should be kept slightly

moist, for example, by application of normal saline or aqueous

5% Sulfamylon solution (Bertek Pharmaceuticals Inc.,

Morgantown, WV) every 6–8 hours. Another option, when the

grafted area is surrounded by normal skin, is the use of a

vacuum-assisted closure device (V.A.C., Kinetic Concepts, Inc.,

San Antonio, TX).

Following dressings, the extremities are splinted, with the axilla

at 90° horizontal with bedside troughs or in an airplane splint,

elbow fully extended. Hands and wrist are splinted in the “beer

can” position: wrist slightly extended (10°), metatarsophalangeal

joints of the fingers flexed, interphalangeal joints fully extended,

and thumb in 40°–50° of abduction with interphalangeal joint

extended.

Postoperative Care

Donor sites dressed with fine-mesh gauze are treated open, with

a heat lamp applied until the gauze is dry. Grafted extremities

are immobilized for 4–5 days. Grafted sites are inspected 4–5

days after surgery. They should be inspected sooner in case of

fever, malodor, or other evidence of infection. Moist dressings

are continued until the interstices of the grafted area have

entirely closed.

Physical and occupational therapy are begun as soon as graft take

is sufficient to discontinue immobilization, usually 5 days after

surgery. Extremities are splinted in the position of function at night.

The dried gauze on the donor site is allowed to separate

spontaneously, at which time the donor site can be recropped as

necessary for further grafting. After all wounds are closed, the

patient is fitted for custom compression garments. If garments are

not available, compression can be achieved with ace bandages.