Burn Care: Title and subTitle BreakResults of Technical and Organizational Progress

"The patients in the wards presented the usual clinical picture of large exposed burn wounds covered by broken-down eschars, with infected granulating areas on anemic, exhausted and frightened individuals."—Zora Janzekovic reflecting on burn care, 1970¹

Burn care has improved markedly in the decades that have passed since the sad description quoted above. Of the 1.25 million individuals who are treated for burns in the United States each year, about 51 000 require hospital admission.² High-risk groups include infants and young children, elderly persons, and young people in industrial occupations. Care of serious burns progresses through 4 phases, which often overlap in time: (1) initial evaluation and resuscitation; (2) initial excision and biological closure; (3) definitive wound closure; and (4) rehabilitation, reconstruction, and reintegration (Table 1).

The diffuse capillary leak syndrome that characterizes the early period following a burn is unique and will lead to cardiovascular collapse if not addressed promptly and effectively. Elderly and young individuals, as well as individuals with inhalation injury or particularly large or deep burns, or those in whom resuscitation has been delayed, remain at particular risk for burn shock. In the future, modification of this physiology may be possible.³ Patients with injuries covering more than 20% of the total body surface generally will require fluid resuscitation using primarily isotonic crystalloid. At present, a number of formulas roughly guide resuscitation, but none can replace a physician at the bedside adjusting infusions to physiological end points.⁴ Monitoring resuscitation adequacy most commonly is done using clinical end points, such as peripheral temperature and perfusion, vital signs, and urine output. Selected laboratory and invasive parameters, such as hemocrit, base deficit, and central venous pressure, can be helpful. Pulmonary artery catheterization or cardiac ultrasonography less frequently are valuable, except in the setting of coexisting cardiac conditions. Because of timely intervention, death from burn shock is now uncommon.

Inhalation injury remains a major source of morbidity and mortality secondary to early airway obstruction and bronchospasm and later pulmonary infection and respiratory failure. Treatment is supportive, emphasizing effective pulmonary toilet, treatment of secondary pulmonary infection, and avoidance of ventilator-induced lung injury.⁴ Although numerous pulmonary adjunctive therapies have been explored in clinical trials, none has emerged as being clearly beneficial.

Carbon monoxide poisoning can be observed in association with inhalation injury. The value of treatment with hyperbaric oxygen for exposures to carbon monoxide has been long debated, with both detractors⁵ and advocates⁶ publishing recent controlled trials supporting their points of view. A balanced approach is to consider hyperbaric oxygen treatment only after severe carbon monoxide poisoning in otherwise stable patients who can be safely transported to and treated in the limited-access environment of monoplace chambers, without compromising resuscitation or general burn care.⁷ In all other patients, provision of 100% oxygen constitutes reasonable treatment. No clear benefical effect on burn wound healing has been demonstrated with use of hyperbaric oxygen treatments, and such treatments may increase cost and be associated with transport-related complications in patients who are critically ill.⁸

After several early hypodynamic hours, a hyperdynamic and catabolic state predictably develops over the days following burn injury. This hypermetabolic physiological state is driven by a combination of wound-released mediators, increased catecholamine and counter regulatory hormone secretion, bacterial byproducts from the gastrointestinal tract and wound, and some heat loss across wounds. Support of this physiological state, through provision of adequate quantity and quality of nutrient solutions, is an important component of burn critical care. Efforts to modify the physiological state have been less successful. Adverse components of the response, particularly muscle catabolism, have been the target of clinical trials involving administration of conditionally essential amino acids, growth hormone, insulin, insulin-like growth factor,⁹ anabolic steroids, and β-adrenergic blocking drugs.^{10 - 12} No such intervention has emerged as a standard of burn care. At present, the response is best truncated through accurate resuscitation and timely excision and effective closure of wounds.¹³ An effective surgical procedure for burn wounds remains the most powerful modulator of the inflammatory response.

Early identification, excision, and closure of deep burn wounds changes the natural history of burns by preventing otherwise inevitable systemic inflammation and sepsis. Early in their development, these surgical procedures tended to result in considerable blood loss and physiological stress. However, with proper planning and performance, and with attention to the details of intraoperative critical care, excess blood loss can be avoided, and extensive surgical procedures generally are well tolerated.¹⁴

Accurate early identification of deep burn is an essential component of successful management. Despite decades of work with a variety of innovative devices, an experienced examiner can most accurately integrate the multiple variables, in addition to simple burn depth, that influence the ability of a cutaneous burn to heal, including anatomic location, skin thickness, density of appendages, quality of resuscitation, patient age, and nutritional status.

Topical antimicrobial agents play a supportive role in the treatment of burn wounds, preventing desiccation, improving pain control, and slowing bacterial proliferation. None of the many agents available can prevent infection or eliminate the need for surgical treatment of full-thickness injuries.

Temporary skin substitutes are designed to foster healing of partial-thickness burns or donor sites, or to provide temporary coverage of full-thickness injuries while donor sites heal. Human split-thickness allograft and porcine xenograft are most widely used. A number of single- and double-layer synthetic membranes, some containing allogenic cellular elements, are available. No specific membrane has emerged as clearly superior.

Permanent skin substitutes provide epithelial replacement, a dermal analog, or composite coverage. Commercially available epithelial and dermal replacements have an important role in the management of massive burn injuries and in difficult reconstructive problems, although none has replaced split-thickness autografts in reliability, durability, appearance, or practicality. It is hoped that an autologous laboratory-derived composite ultimately will help to address the problem of donor skin that is not adequate for the needs of immediate closure and subsequent reconstruction.¹⁵

Severe pain and anxiety accompany both burn injury and its treatment. Management programs for pain and anxiety have evolved substantially in recent years and may have favorable psychological and physiological consequences. Burn units increasingly have implemented explicit pain and anxiety protocols based on opiate and benzodiazepine synergy, titrating doses to comfort, and monitoring effectiveness with a variety of objective scales.¹⁶ Posttraumatic stress disorder has been reported to occur in almost one third of burn patients, and recent data suggest symptoms of posttraumatic stress disorder may be reduced by effective early treatment of pain and anxiety.¹⁷

As patients with large burn injuries survive in greater numbers, burn wound reconstruction and rehabilitation have evolved into highly specialized disciplines. While the physiology of hypertrophy and contracture of the burn scar remains poorly understood, the clinical consequences should be addressed early in recovery. Contractures that are functionally limiting are addressed surgically, as soon as they are identified, thereby enhancing rehabilitation and minimizing permanent deformity. Therapeutic interventions to limit scar hypertrophy are most effective when applied during the first months after wound closure. These include application of moisturizers and scar massage, custom-fitted compression garments and masks, antipruritic medications, topical silicone gels, and selected use of injectable steroids and vascular lasers.⁴

The concept of the burn center is central to the evolving paradigm of burn care.¹⁸ The burn center functions as a single source for all aspects of burn care, from initial resuscitation through long-term rehabilitation, outpatient care, and reconstruction. Burn center care has been shown to enhance outcomes¹⁹ while reducing length of hospital stay and cost,²⁰ lending further support to the relationship of volume and outcome in complex surgical conditions. These factors, along with the expensive nature of the equipment and personnel infrastructure required to manage serious burns, has driven regionalization of burn care centers over the past decade. Increasingly, seriously injured patients are transported to regional burn centers, rather than receiving care at general hospitals nearest the site of injury ( Article ). Related to its trauma center verification program, the American College of Surgeons has run a burn center verification program for almost 15 years. Reverification is required every 3 years to ensure that centers have adequate personnel, infrastructure, and institutional commitment to assure quality clinical outcomes for seriously burned individuals. Burn surgery has evolved into a specialty incorporating components of general, trauma, pediatric, plastic surgery, and surgical critical care. No single specialty track incorporates all these elements. Increasingly, physicians practicing burn surgery at a high level seek added training. Burn surgery fellowship programs have been developed to meet this important workforce requirement.

Partial-thickness burns greater than 10% of total body surface area
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality
Burn injury in children at hospitals without qualified personnel or equipment for the care of children
Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention

*Reproduced with permission from the American Burn Association (http://www.ameriburn.org).

Several nonburn disease processes, in addition to the traditional thermal, electrical, and chemical injuries, are well served by the resource set of critical care and wound expertise in burn centers. The most common of these is toxic epidermal necrolysis, the outcome of which is enhanced by early transfer to burn centers.^{21 - 22} Patients with soft tissue infections, major mechanical soft tissue injuries, and purpura fulminans also may benefit from burn center treatment.

Aftercare programs based in burn centers have evolved to incorporate outpatient wound care, burn rehabilitation, and reconstruction. As patients progress through wound closure, physical and occupational therapy interventions increase from ranging and antideformity positioning through active motion, strengthening, and preparation for work, school, and play. Therapists remain involved after patients are discharged, supporting their needs for reconstruction and reintegration, and implementing strategies to manage burn scars. The reconstructive needs of burn patients are being addressed early in recovery, rather than allowing them to progress to established deformity and disability. Aftercare programs are coordinated with local rehabilitation resources and emphasize reintegration, with prompt return to school, work, and community.

Terrorist incidents, natural disasters, and military operations can generate large numbers of patients with burns and soft tissue injuries. A credible burn capability is an important part of disaster response planning. Both the terrorist attack on the World Trade Center and the Station Night Club fire in Rhode Island demonstrated the need for burn care following disasters. In both cases, Burn Specialty Teams from the National Disaster Medical System were deployed to augment regional burn centers that were overwhelmed with seriously burned victims. Currently, 3 Burn Specialty Teams are sponsored by the National Disaster Medical System that are staffed by volunteers from regional burn centers. On activation, these volunteers become federal employees who assist to provide initial resuscitation and triage of burn victims, to coordinate transfer to capable facilities, and to augment the staff of burn units caring for many extra patients.

Although many formulas have been developed in an effort to predict individual survival, none has kept pace with the changes in the field of burn care. In adults, advanced age now carries a greater risk of death than burn size.²³ In children, full-thickness burns covering more than 80% of the total body surface are reported to have a mortality rate of only 40%,²⁴ and young age is no longer an independent risk factor for death.²⁵ Individual mortality rates in children are poorly predicted from available demographics and are better predicted based on early physiological findings and response to resuscitation.²⁶

In a long-term outcome study of 80 adults who experienced massive burns (≥70% of total body surface) as children an average of 15 years earlier, most were found to be productive and generally satisfied members of society, with Short Form 36 scores no different than their age- and sex-matched peers.¹⁹ Early reintegration efforts, an intact family, and long-term participation in burn center–based aftercare emerged as statistically significant predictors of outcome quality.

Outcomes following specific anatomic injuries also have been studied. Research on persons with hand burns demonstrated that even very destructive injuries can be treated so that functional independence will result, but that optimal outcomes are highly dependent on long-term follow-up, staged reconstruction, and skilled burn hand therapy.^{27 - 28} Research on survivors of inhalation injury has shown that exercise rehabilitation can enhance endurance.²⁹

Despite recent progress, many unresolved problems in burn care remain. Among the most prominent are the lack of a practical permanent skin substitute, the inability to modify adverse aspects of the hypermetabolic response, and the ineffective control of hypertrophic scarring. Other needs include better understanding and description of outcomes, early determination of the ability of wounds to heal, improved techniques of wound excision, better control of bacterial colonization of burn wounds, improved management of pain and emotional distress, and improved critical care technologies.

Substantial improvements in the results of burn treatment have followed both technical progress and better organization of treatment. Seriously burned patients increasingly have been concentrated in regional centers of excellence that provide the full range of burn treatment in one location by a dedicated staff.