Chăm Sóc Và Điều Trị Bỏng Toàn Diện (Total Burn Care – Tập 5)

Total Burn Care

Total Burn Care
FIFTH EDITION
David N. Herndon, MD, FACS
Chief of Staff and Director of Research, Shriners Hospitals for Children–Galveston,
Director of Burn Services, University of Texas Medical Branch
Jesse H. Jones Distinguished Chair in Surgery
Professor, Department of Surgery and Pediatrics
University of Texas Medical Branch
Galveston, TX, USA
For additional online content visit ExpertConsult.com
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  2018

© 2018, Elsevier Inc. All rights reserved.
First edition 1996
Second edition 2002
Third edition 2007
Fourth edition 2012
Fifth edition 2018
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website:
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Dr. Leopold Cancio is the US Federal employee. His work in the Chapters 3, 5 and 9 is in public domain
Chapter 45 – Molecular and Cellular Basis of Hypertrophic Scarring
Figure 45.3 – (From Desmouli è re A, who retains copyright of the image).
Figure 45.4a-f – (From Coulomb B, Inserm U970, Universit é Paris Descartes, France and Desmouli è re A who
retains copyright of the Images (unpublished data)).
Figure 45.6a-d – (From Desmouli è re A, who retains copyright of the images.) (c, d) (From Casoli P, Plastic
Surgery and Burns Unit, University Hospital of Bordeaux, France, who retains copyright of the images).
Figure 45.7 – (From Desmouli è re A, who retains copyright of the image.)
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-0-323-47661-4
eISBN: 978-0-323-49742-8
Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2  1
Content Strategist: Belinda Kuhn
Content Development Specialist: Nani Clansey
Content Coordinator: Joshua Mearns
Project Manager: SriVidhya Shankar
Design: Amy Buxton
Illustration Manager: Amy Heyden-Naylor
Marketing Manager: Kristin Koehler
The
publisher’s
policy is to use
paper manufactured
from sustainable forests

viii
Preface
techniques as the previous edition, the chapters have been
extensively updated with new data and references to reflect
advances in care and knowledge that have arisen over the
past 5 years. In some cases, the chapters have been com­
pletely rewritten. The new edition also contains new chap­
ters dealing with the care of unique populations, as well as
newer topics in reconstruction and scarring. As before,
demonstrative color illustrations are provided throughout
the book. Moreover, many chapters are accompanied by
online PowerPoint presentations to aid group discussion, as
well as video clips to enhance understanding of complex
concepts and techniques.
This new edition would not be possible without the many
respected colleagues and friends who have volunteered
their time and worked tirelessly to produce the various
chapters. Grateful acknowledgment is also given to Elsevier
publishing staff, who have maintained a high standard in
the development and preparation of this fifth edition.
Special thanks are offered to Dr. Derek Culnan, who gra­
ciously assisted in reviewing and updating material
throughout the book, as well as to Genevieve Bitz and Dr.
Kasie Cole for editorial assistance. Finally, I wish to thank
my wife, Rose, for her invaluable support.
Over the past three decades, vast improvements in survival
from severe burns have been accompanied by a progres­
sively greater understanding of the complex processes
underlying this type of trauma. Basic science, and transla­
tional and clinical discoveries have provided new opportu­
nities to advance burn care along its entire spectrum from
management of burn shock, inhalation injury, sepsis, and
hypermetabolism to scar reconstruction and rehabilitation.
These and other key aspects of care, which are the focus of
this book, share the goal of providing burn survivors more
complete recovery from burns so that they can return to
their communities as fully functioning members. All aspects
of the physiological, psychological, and emotional care of
acutely burned patients evolving through recovery, reha­
bilitation, and reintegration back into society and daily life
are reexamined in this new, fifth edition.
The objective of the fifth edition of this book remains the
same—to serve as a sophisticated instruction manual for a
variety of health care professionals less experienced in
burns. It is intended to be a resource not only for surgeons,
anesthesiologists, and residents, but also for nurses and
allied health professionals. Although this edition of the
book covers many of the same fundamental concepts and

ix
In Memorium of Ted Huang, MD
Derek Culnan, MD, Genevieve Bitz, Karel D. Capek, MD, David Herndon, MD
his career. When a surgical fellow once asked if he could
assist, Dr. Huang responded, “I’ve been operating on burn
scars since before you were born. If I need your help, then
the patient and I both have a big problem. But, if you want,
you can come have fun with me.” We are better for having
known him, and our principal regret is that we never figured
out the recipe for his legendary bread, which, as with every­
thing, he doled out generously to family, friends, patients,
and colleagues. As he would undoubtedly have said, that’s
how the cookie crumbles. This book is a testimonial to his
humanity and skill, from those he collaborated with and
those he mentored. Thank you, Dr. Huang, for everything.
With greatest honor and humility we dedicate this book
to you.
Last year, returning with his wife from a medical mission
trip to Taiwan, Dr. Ted Huang died. On that day, we lost a
colleague; a friend; and a surgeon of unquestioned skill,
passion, and knowledge as well as a teacher unstinting in
his advice and zeal to help others. Following a career as a
leader in the fields of gender reassignment and cosmetic
surgery, Dr. Huang retired to spend the next 20 years
working to revolutionize the practice of surgical recon­
struction of pediatric burns. He left behind a legacy in
research and surgery in the papers he authored and the
surgeons he mentored that few can achieve. He was the
principal author of the previous four editions of the recon­
structive section of this book. Stepping into the OR filled
him with joy, for he was a man who truly loved and lived

x
List of Contributors
Mette M Berger MD PhD
Associate Professor, Burn Center Director, Intensive Care
Service
University Hospital of Lausanne
Lausanne, Switzerland
Eileen Bernal MD
Resident
University of Texas Southwestern
Dallas, TX, USA
Genevieve H Bitz
Adjunct Researcher
JMS Burn and Reconstructive Center
Jackson, MS, USA
Fredrick J Bohanon MD
General Surgery Resident
Department of Surgery
University of Texas Medical Branch
Galveston, TX, USA
Branko Bojovic MD FACS
Chief of Plastic Surgery
Shriners Hospitals for Children–Boston
Member of the Faculty of Surgery
Harvard Medical School
Assistant Surgeon
Massachusetts General Hospital
Boston, MA, USA
Ludwik Branski MD
Assistant Professor
Department of Surgery, Division of Plastic Surgery
University of Texas Medical Branch
Staff Surgeon
Shriners Hospital for Children
Galveston, TX, USA
Elisha G Brownson MD
Burn Critical Care Fellow
Department of Surgery
Harborview Medical Center
Seattle, WA, USA
Michael C Buffalo DNP RN CCRN (A/P) CEN CPN CPEN
ACNP ACPNP
Nurse Practitioner
Department of Surgery
University of Texas Medical Branch Blocker Burn Unit
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Rajeev B Ahuja MS MCh DNB FICS FACS FAMS
Senior Consultant in Plastic Surgery
Department of Plastic Surgery
Sir Ganga Ram Hospital Marg;
Ex-Head, Department of Burns and Plastic Surgery
Lok Nayak Hospital and Associated Maulana Azad
Medical College
New Delhi, India
J F Aili Low MD PhD
Specialist in Plastic Surgery and Surgery
Associate Professor in Plastic Surgery
Art Clinic Uppsala
Uppsala, Sweden
Brett D. Arnoldo MD, FACS
Professor of Surgery
Medical Director Parkland Burn Center
UT Southwestern Medical Center
Dallas, TX, USA
Amina El Ayadi PhD
Department of Surgery
University of Texas Medical Branch
Shriners Hospitals for Children
Galveston, TX, USA
Sarah E Bache MBChB PhD MRCS Ed
Speciality Registrar in Burns and Plastic Surgery
St Andrew’s Centre for Burns and Plastic Surgery
Broomfield Hospital Chelmsford
Essex, UK
Juan P Barret MD PhD
Head of Department
Professor of Surgery
Department of Plastic Surgery and Burns
University Hospital Vall d’Hebron
Universitat Autònoma de Barcelona
Barcelona, Spain
Robert E Barrow PhD
Retired Professor of Surgery, Coordinator of Research
University of Texas Medical Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Debra A Benjamin RN MSN
Nursing Program Manager
University of Texas Medical Branch
Galveston, TX, USA

List of Contributors
xi
Janos Cambiaso-Daniel MD
Resident
Division of Plastic, Aesthetic and Reconstructive Surgery
Department of Surgery
Medical University of Graz
Graz, Austria
Stephanie A Campbell BSN RN CCRN
Burn Program Manager
Parkland Regional Burn Center
Parkland Health & Hospital System
Dallas, TX, USA
Leopoldo C Cancio MD FACS FCCM
Colonel, MC, US Army
Brooke Army Medical Center
Fort Sam Houston, TX, USA
Karel D Capek MD
Clinical and Research Fellow,
Surgical Critical Care, Burns, and Reconstruction Shriners
Hospitals for Children
University of Texas Medical Branch
Galveston, TX, USA
Kelly D Carmichael MD
Associate Professor
Department of Orthopaedic Surgery and Rehabilitation
University of Texas Medical Branch
Galveston, TX, USA
Joshua S Carson MD
Assistant Professor
Division of Burns, Trauma & Acute CARE Surgery
Department of Surgery
University of Florida
Gainesville, FL, USA
Michele Carter PhD
Professor, Institute for the Medical Humanities
Frances C. and Courtney M. Townsend, Sr., MD Professor
in Medical Ethics
University of Texas Medical Branch
Galveston, TX USA
Mario M Celis MS PA-C
Department of Surgery, University of Texas Medical
Branch
Shriners Hospitals for Children
Galveston, TX, USA
Jiake Chai MD PhD
Professor of Burn Surgery
Department of Burn and Plastic Surgery, Burns Institute
of PLA
The First Affiliated Hospital of PLA General Hospital
Beijing, China
Gp Capt Pallab Chatterjee MS DNB (Gen Surg) DNB
(Plastic Surgery)
Sr Advisor (Surgery) & Plastic Surgeon
Associate Professor (Surgery)
Command Hospital Air Force
Bangalore, India
Linda Chilton
Registered Nurse, Surgical Nurse Practitioner
Senior SCP (Plastics)
St Andrew’s Centre for Plastic Surgery and Burns
Broomfield Hospital
Chelmsford
Essex, UK
Dai H Chung MD FACS FAAP
Professor of Surgery
Chairman, Department of Pediatric Surgery
Vanderbilt University Medical Center
Nashville, TN, USA
Kevin K Chung MD FCCM FACP
Medical Director, Burn ICU
US Army Institute of Surgical Research
Fort Sam Houston
San Antonio, TX, USA
Audra T Clark MD
Clinical Research Fellow
Department of Surgery
University of Texas Southwestern Medical Ceneter
Dallas, TX, USA
Amalia Cochran MD
Associate Professor
Vice Chair of Education and Professionalism
Department of Surgery
University of Utah School of Medicine
Salt Lake City, UT, USA
April Cowan OTR OTD CHT
Assistant Professor
School of Health Professions
University of Texas Medical Branch
Galveston, TX, USA
Robert A Cox PhD
Professor
Department of Pathology
University of Texas Medical Branch
Galveston, TX, USA
Beretta Craft-Coffman PA-C
Vice President of Non-Physician Providers
Burn and Reconstructive Centers of America
Augusta, GA, USA

List of Contributors
xii
Derek M Culnan MD
Burn, Plastic, and Critical Care Surgeon
JMS Burn and Reconstruction Center
Merit Health Central Hospital
Jackson, MS, USA
Moayad Dannoun MD
Burn Reconstruction Fellow
University of Texas Medical Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Alexis Desmoulière PhD
Professor of Physiology, Faculty of Pharmacy
University of Limoges
Limoges, France
Matthias B Donelan MD
Chief of Staff
Shriners Hospitals for Children–Boston
Associate Clinical Professor of Surgery
Harvard Medical School
Visiting Surgeon
Massachusetts General Hospital
Boston, MA, USA
Peter Dziewulski FFICM FRCS (Plast)
Clinical Director, Burn Service, Consultant Plastic and
Reconstructive Surgeon
St Andrews Centre for Plastic Surgery and Burns
Chelmsford, Essex, UK
Naguib El-Muttardi FRCS
Consultant Plastic and Burns Surgeon
Department of Plastic Surgery
St. Andrew’s Centre for Burns and Plastic Surgery
Chelmsford, UK
Perenlei Enkhbaatar MD PhD
Professor, Department of Anesthesiology and Charles
Robert Allen Professor in Anesthesiology,
The University of Texas Medical Branch
Galveston, TX, USA
Shawn P Fagan MD
Chief Medical Officer
Burn & Reconstructive Centers of America
Augusta, GA, USA
James A Fauerbach PhD
Associate Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Celeste C Finnerty PhD
Associate Professor
Department of Surgery
University of Texas Medical Branch
Shriners Burns Hospital for Children
Galveston, TX, USA
Christian Gabriel MD
The Ludwig Boltzmann Institute for Experimental and
Clinical Traumatology
Austrian Cluster for Tissue Regeneration
Altenberg, Austria
James J Gallagher MD
Associate Professor
Department of Surgery
Weill Cornell Medical College
New York, NY, USA
Nicole S Gibran
Director, UW Medicine Regional Burn Center
Professor, Department of Surgery
Harborview Medical Center
Seattle, WA, USA
Cleon W Goodwin MD
Director, Burn Services
Western States Burn Center
North Colorado Medical Center
Greeley, CO, USA
Jeremy Goverman MD FACS
Assistant Professor of Surgery
Division of Burns
Massachusetts General Hospital
Shriners Hospitals for Children
Boston, MA, USA
Ashley N Guillory PhD
Assistant Professor
Physician Assistant Studies
University of Texas Medical Branch
Galveston, TX, USA
Herbert L Haller MD
Senior Surgeon
UKH Linz der AUVA
Trauma and Burns
Linz, Austria
Houman K Hassanpour BA
Medical Student
School of Medicine
University of Texas Medical Branch
Galveston, TX, USA

List of Contributors
xiii
Hal K Hawkins PhD MD
Professor, Department of Pathology
University of Texas Medical Branch
Galveston, TX, USA
David N Herndon MD FACS
Chief of Staff and Director of Research, Shriners Hospitals
for Children–Galveston
Director of Burn Services, University of Texas Medical
Branch
Jesse H. Jones Distinguished Chair in Surgery
Professor, Department of Surgery and Pediatrics
University of Texas Medical Branch;
Professor
Department of Surgery
University of Texas Medical Branch
Shriners Hospitals for Children
Galveston, TX, USA
Maureen Hollyoak MBBS MMedSc FRACS
General Surgeon
Brisbane, Australia
Ted T Huang MD FACS (deceased)
Professor
University of Texas Medical Branch
Shriners Hospitals for Children;
Clinical Professor of Surgery
Shriners Burns Hospital
University of Texas Medical Branch
Galveston, TX, USA
Byron D Hughes MD
Resident, General Surgery
University of Texas Medical Branch
Galveston, TX, USA
Gabriel Hundeshagen MD
Research Fellow, Department of Surgery
University of Texas Medical Branch
Galveston, TX, USA;
Resident, Department of Hand, Plastic and Reconstructive
Surgery
BG Trauma and Burn Center Ludwigshafen
University of Heidelberg, Germany
Mohamed E. Ismail Aly MSc MRCS(Ed) MD
FRCSEd(Plast)
Consultant Plastic and Burns Surgeon
Royal Manchester Children’s Hospital and Wythenshawe
Hospital
Manchester, UK
Mary Jaco RN MSN
Hospital Administrator
Shriners Hospitals for Children
Galveston, TX, USA
Marc G Jeschke MD PhD FACS FRCSC
Professor
Department of Surgery, Division of Plastic Surgery and
Department of Immunology
University of Toronto
Sunnybrook Health Sciences Centre
Toronto, ON, Canada
Carlos Jimenez MD
Associate Professor
Department General Surgery
Shriners Burn Institute
Galveston, TX, USA
Andreas Jokuszies MD
Consultant Surgeon for Plastic, Hand and Reconstructive
Surgery
Department of Plastic, Hand and Reconstructive Surgery
Burn Center
Hanover Medical School
Hanover, Germany
Lars-Peter Kamolz MD MSc
Professor and Head: Division of Plastic, Aesthetic and
Reconstructive Surgery,
Department of Surgery
Medical University of Graz
Head of the Research Unit for Safety in Health
Medical University of Graz;
Deputy Chief Medical Officer
LKH- University Hospital Graz
Graz, Austria
Jennifer Kemp-Offenberg OTR
Rehabilitation Services Manager
Shriners Hospitals for Children
Galveston, TX, USA
Michael P Kinsky MD
Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA
Gordon L. Klein MD
Professor, Department of Orthopedics
University of Texas Medical Branch
Galveston, TX, USA
Makiko Kobayashi PhD
Professor
Department of Internal Medicine/Infectious Diseases
University of Texas Medical Branch
Galveston, TX, USA
George C Kramer PhD
Director
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA

List of Contributors
xiv
Maggie J Kuhlmann-Capek MD
Fellow, Division of Maternal Fetal Medicine
Department of Obstetrics and Gynecology
University of Texas Medical Branch
Galveston, TX, USA
Peter Kwan MD PhD
Assistant Professor, Department of Surgery
University of Alberta
Edmonton, Alberta, Canada
Jong O Lee MD FACS
Professor
Department of Surgery
University of Texas Medical Branch
Shriners Hospital for Children
Galveston, TX, USA
Kwang Chear Lee MD MSc
Clinical Research Fellow,
University of Birmingham
Birmingham, UK
Jorge Leon-Villapalos MD FRCS (Plast)
Consultant Plastic and Reconstructive Surgeon, Paediatric
Clinical Lead
Department of Plastic Surgery and Burns, Chelsea and
Westminster Hospital
London, UK
Benjamin Levi MD
Director, Burn/Wound and Regenerative Medicine
Laboratory
Associate Burn Director
Assistant professor in Surgery
University of Michigan
Ann Arbor, MI, USA
William C Lineaweaver MD FACS
Medical Director
JMS Burn and Reconstructive Center
Chief of Surgery
Merit Health Central Hospital
Jackson, MS, USA
Kimberly M Linticum ACNP-BC
Acute Care Nurse Practitioner
Burn and Reconstructive Centers of America
Augusta, GA, USA
Jeffrey Lisiecki MD
Resident, Plastic Surgery
University of Michigan
Ann Arbor, MI, USA
Omar Nunez Lopez MD
General Surgery Resident
Department of Surgery
University of Texas Medical Branch
Galveston, TX, USA
Caroline Martinello MD
Assistant Professor
Department of Anesthesiology
University of Arkansas for Medical Sciences
Little Rock, AR, USA
J A Jeevendra Martyn MD FCCM
Professor of Anesthesia, Harvard Medical School
Anesthesiologist, Massachusetts General Hospital
Chief of Anesthesiology, Shriners Hospitals for Children
Boston, MA, USA
Arthur D Mason Jr MD (Deceased)
Emeritus Chief
Laboratory Division
US Army Institute of Surgical Research
Brooke Army Medical Center
San Antonio, TX, USA
Jillian M McLaughlin MD
Clinical Research Fellow
Division of Plastic Surgery, Department of Surgery
University of Texas Medical Branch
Staff Surgeon, Shriners Hospital for Children
Galveston, TX, USA
Kevin H Merkley MD MBA
Interim Chair, Department of Ophthalmology
University of Texas Medical Branch
Galveston, TX, USA
Walter J Meyer III MD
Gladys Kempner and R. Lee Kempner Professor in Child
Psychiatry, Department of Psychiatry and Behavioral
Sciences
Professor, Departments of Pediatrics and Human
Biological Chemistry and Genetics
The University of Texas Medical Branch, Galveston, TX,
USA
Head, Department of Psychological & Psychiatric Services
for Children & Families, Shriners Hospitals for Children,
Shriners Burns Hospital, Galveston, TX, USA
Esther Middelkoop PhD
Professor Skin Regeneration and Wound Healing
Director Association of Dutch Burn Centers
Plastic, Reconstructive and Hand Surgery Department,
Red Cross Hospital, Beverwijk, the Netherlands
Amsterdam Movement Sciences, VU University Medical
Center
Amsterdam, the Netherlands

List of Contributors
xv
Stephen M Milner MBBS MD
Professor of Plastic and Reconstructive Surgery
Director of the Johns Hopkins Burn Center
Director of the Michael D. Hendrix Burn Research Center
Johns Hopkins Bayview Medical Center
Baltimore, MD, USA
Ronald P Mlcak MBA PhD RRT FAARC
Administrative Director, Shriners Hospitals for
Children–Galveston
Associate Professor, School of Health Professions,
Department of Respiratory Care
University of Texas Medical Branch
Galveston, TX, USA
Naiem S. Moiemen MSc, FRCS(Plast)
Director, the Scar Free Burns Research Centre.
Honorary Professor, University of Birmingham;
Consultant, Burns and Plastic Surgeon, University
Hospital Birmingham
Birmingham Children Hospital
Birmingham, UK
Stephen E Morris
Professor
Medical Director, Burn Center
Department of Surgery
University of Utah School of Medicine
Salt Lake City, UT, USA
David W Mozingo MD FACS
Professor
Department of Surgery
University of Florida College of Medicine
Gainesville, FL, USA
Michael Muller MBBS MMedSci FRACS
Associate Professor in Surgery, University of Queensland
Professor in Surgery, Bond University
Pre-Eminent Staff Specialist: General, Trauma and Burns
Surgeon
Royal Brisbane and Women’s Hospital
Division of Surgery
Brisbane, Queensland, Australia
Robert F Mullins MD
President and Medical Director
Burn and Reconstructive Centers of America
Augusta, GA, USA
Kuzhali Muthumalaiappan PhD
Assistant Professor, Department of Surgery,
Burn and Shock Trauma Research Institute
Loyola University Chicago, Stritch School of Medicine
Maywood, IL, USA
Andreas D Niederbichler MD
Assistant Professor of Plastic Surgery, Burn Center
Hanover Medical School
Hanover, Germany
William B Norbury MD
Assistant Professor
Division of Plastic Surgery, Department of Surgery
University of Texas Medical Branch
Staff Surgeon, Shriners Hospital for Children
Galveston, TX, USA
Sheila Ott OTR
Occupational Therapist
Department of Occupational Therapy
University of Texas Medical Branch
Galveston, TX, USA
Christian Peterlik MD
Anesthesiologist
UKH Linz der AUVA
Department of Anesthesiology and Intensive Care
Linz, Austria
Bruce Philp MA (Cantab) BMBCh (Oxon)
FRCS(I) FRCS(Plast)
Consultant
Burns, Laser and Reconstructive Plastic Surgeon
St.Andrew’s Centre
Broomfield Hospital
Chelmsford, UK
Craig Porter PhD
Assistant Professor
Department of Surgery, University of Texas Medical
Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Basil A Pruitt Jr MD FACS FCCM MCCM
Clinical Professor
Dr. Ferdinand P. Herff Chair in Surgery
UT Health San Antonio
San Antonio, TX, USA
Ravi S Radhakrishnan MD MBA FACS
Associate Professor
Chief, Division of Pediatric Surgery
Departments of Surgery and Pediatrics
University of Texas Medical Branch
Galveston, TX, USA
Ruth B Rimmer PhD
Chief Executive Officer
Care Plans for Life, LLC
Phoenix, AZ, USA

List of Contributors
xvi
Laura Rosenberg PhD
Chief Clinical Psychologist
Shriners Hospitals for Children
Clinical Assistant Professor
Department of Psychiatry & Behavioral Sciences
University of Texas Medical Branch
Galveston, TX, USA
Marta Rosenberg PhD
Clinical Psychologist
Shriners Hospitals for Children
Clinical Assistant Professor
Department of Psychiatry & Behavioral Sciences
University of Texas Medical Branch
Galveston, TX, USA
Arthur P Sanford MD FACS
Associate Professor of Surgery
Department of Surgery
Loyola University Medical Center
Maywood, IL, USA
Kwabena O Sarpong MD MPH
Child Abuse and General Pediatrics
Associate Professor Of Pediatrics
Department of Pediatrics
University of Texas Medical Branch
Consultant Physician
Shriners Children’s Hospital
Galveston, TX, USA
Michael A Serghiou OTR MBA
Clinical Care Specialist
Bio Med Sciences Inc.
Allentown, PA, USA
Robert L Sheridan MD
Medical Director of the Burn Service
Shriners Hospitals for Children
Boston, MA, USA
William C Sherman MD
Burn Fellow
Shriner’s Hospital for Children
Galveston, TX, USA
Edward R. Sherwood MD PhD
Cornelius Vanderbilt Professor
Vice Chair for Research
Department of Anesthesiology
Department of Pathology, Microbiology and Immunology
Vanderbilt University Medical Center
Nashville, TN, USA
Lisa W Smith RPH BCPS
Lead Burn Clinical Pharmacist
Doctors Hospital of Augusta
Augusta, GA, USA
Linda E. Sousse, PhD MBA
Assistant Professor
Department of Surgery, University of Texas Medical
Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Marcus Spies MD PhD
Head
Department of Plastic, Hand, and Reconstructive Surgery
Hand Trauma Center (FESSH)
Pediatric Trauma Center
Breast Cancer Center
Krankenhaus Barmherzige Brueder
Regensburg, Germany
Oscar E Suman PhD MS
Professor, Associate Director of Research
Department of Surgery, University of Texas Medical
Branch
Shriners Hospitals for Children–Galveston;
Professor
Associate Director of Research, Director of the Children’s
Wellness and Exercise Center
Shriners Hospitals for Children
University of Texas Medical Branch
Galveston, TX, USA
Fujio Suzuki PhD
Professor
Department of Internal Medicine/Infectious Diseases
University of Texas Medical Branch
Galveston, TX, USA
Mark Talon, CRNA, MSN, DNP
Chief Nurse Anesthetist
Shriners Hospital for Children
Galveston, TX, USA
Christopher R. Thomas MD
Robert L. Stubblefield Professor of Child Psychiatry
University of Texas Medical Branch
Galveston, TX, USA
Tracy Toliver-Kinsky PhD
Professor
Department of Anesthesiology
University of Texas Medical Branch
Scientific Staff
Shriners Hospitals for Children
Galveston, TX, USA
Edward E Tredget MD MSc FRCS(C)
Professor of Surgery
Director of Surgical Research
University of Alberta
Edmonton, Alberta, Canada

List of Contributors
xvii
Stefan D Trocmé MD
Cornea Consultant, Professor of Ophthalmology (Ret.)
Shriners Hospitals for Children
MD Anderson Cancer Center
Case Western Reserve University
Galveston and Houston, TX, USA
Lisa L Tropez-Arceneaux PsyD MSCP
Pediatric Psychologist
New Orleans, LA, USA
APROQUEN Pediatric Burn Center
Department of Administration
International Consultant
Managua, Nicaragua
Peter M Vogt MD PhD
Professor and Head
Department of Plastic, Hand and Reconstructive Surgery
Burn Center
Hanover Medical School
Hanover, Germany
Charles D Voigt MD
Burn Research Fellow,
University of Texas Medical Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
David W Voigt MD
Co-Medical Director Saint Elizabeth’s Regional Burn and
Wound Care Center
Chief of Surgery, CHI Saint Elizabeth’s Regional Medical
Center
Lincoln, NE, USA
Glen Warden MD MBA FACS
Emeritus Chief of Staff
Shriners Hospitals for Children–Cincinnati
Cincinatti, OH, USA
Shelley Wiechman PhD ABPP
Associate Professor, Harborview Medical Center
University of Washington
Seattle, WA, USA
Mimmie Willebrand MD
Associate Professor
Licensed Psychologist
Department of Neuroscience, Psychiatry
Uppsala University
Uppsala, Sweden
Felicia N Williams MD
Assistant Professor
Department of Surgery
North Carolina Jaycee Burn Center
University of North Carolina, Chapel Hill
Chapel Hill, NC, USA
Stephen Williamson MBA CTBS
Tissue Bank Manager
Shriners Hospitals for Children
Galveston, TX, USA
Steven E Wolf MD FACS
Golden Charity Guild Charles R. Baxter, MD Chair
Professor and Vice-Chairman for Research
Chief, Burn Section, Department of Surgery
University of Texas Southwestern Medical Center
Editor-in Chief, Burns
Dallas, TX, USA
Lee C. Woodson MD PhD
Professor of Anesthesiology, University of Texas Medical
Branch
Chief of Anesthesia, Shriners Hospitals for Children
Galveston, TX, USA
Sue M. Woodson PHD MLIS
Associate Director for User Services and Collections
William H Welch Medical Library
Johns Hopkins University
Baltimore, MD, USA
Paul Wurzer MD
Resident
Division of Plastic, Aesthetic and Reconstructive Surgery
Department of Surgery
Medical University of Graz
Graz, Austria
David Yngve MD
Professor Orthopaedic Surgery
Department General Surgery
Shriners Burn Institute
Galveston, TX, USA
Ramón L. Zapata-Sirvent MD FACS
Burn Reconstruction Clinical and Research Fellow
Department of Surgery
University of Texas Medical Branch
Shriners Hospital for Children
Galveston, TX, USA

xviii
Video Table of Contents
50 Reconstruction of the Head and Neck After Burns
MATTHIAS B DONELAN and BRANKO BOJOVIC
Video 50.1:  Demonstrating The Function of The Scars After
Treatment
Video 50.2:  Demonstrating The Function of The Grafts After
Treatment
17 Diagnosis and Treatment of Inhalation Injury
LEE C WOODSON, LUDWIK K BRANSKI, PERENLEI ENKHBAATAR and
MARK TALON
Video 17.1:  Severe Inhalation Injury and change of Oral to
Nasal Endotracheal tube with Bronchoscope
Video 17.2:  Dynamic Airway Obstruction during Inhalation
47 Burn Rehabilitation Along the Continuum of Care
MICHAEL A SERGHIOU, SHEILA OTT, CHRISTOPHER WHITEHEAD,
APRIL COWAN, SERINA MCENTIRE and OSCAR E SUMAN
Video 47.1:  Burn Hand Splint
Video 47.2:  Exercise Testing
Video 47.3:  Face Mask Fabrication
Video 47.4:  Preparatory Prosthetics

xix
List of Video Contributors
Sheila Ott OTR
Occupational Therapist
Department of Occupational Therapy
University of Texas Medical Branch
Galveston, TX, USA
Michael A Serghiou OTR MBA
Clinical Care Specialist
Bio Med Sciences Inc.
Allentown, PA, USA
Oscar E Suman PhD MS
Professor, Associate Director of Research
Department of Surgery, University of Texas Medical
Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
Professor
Associate Director of Research, Director of the Children’s
Wellness and Exercise Center
Shriners Hospitals for Children
University of Texas Medical Branch
Galveston, TX, USA
Mark Talon CRNA
University of Texas Medical Branch
Galveston, TX, USA
Christopher Whitehead PT
Rehabilitation Services Department,
Shriner’s Hospital for Children – Galveston
Galveston, TX, USA
Lee C Woodson MD
Chief of Anesthesia
Shriners Hospitals for Children
Galveston, TX, USA
Branko Bojovic MD FACS
Chief of Plastic Surgery
Shriners Hospitals for Children–Boston
Member of the Faculty of Surgery
Harvard Medical School
Assistant in Surgery
Massachusetts General Hospital
Boston, MA, USA
Ludwik K Branski MD
Assistant Professor
Department of Plastic Surgery
University of Texas Medical Branch
Shriners Hospitals for Children–Galveston
Galveston, TX, USA
April Cowan OTR OTD CHT
Assistant Professor
School of Health Professions
University of Texas Medical Branch
Galveston, TX, USA
Matthias B Donelan MD
Chief of Staff
Shriners Hospitals for Children–Boston
Associate Clinical Professor of Surgery
Harvard Medical School
Visiting Surgeon
Massachusetts General Hospital
Boston, MA, USA
Perenlei Enkhbaatar MD PhD
Charles Robert Allen Professor in Anesthesiology
Department of Anesthesiology,
University of Texas Medical Branch
Galveston, TX, USA
Serina McEntire PhD
Associate Professor
Valdosta State University
Valdosta, GA, USA

1
A Brief History of Acute Burn
Care Management
LUDWIK K. BRANSKI, DAVID N. HERNDON, and ROBERT E. BARROW
1 
recognized for his pioneering research in treating burns “by
cleansing, exposing the burn wounds to air, and feeding
them as much as they could tolerate.”7 In 1962, his dedica­
tion to treating burned children convinced the Shriners of
North America to build their first Burn Institute for Chil­
dren in Galveston, Texas.7
Between 1942 and 1952, shock, sepsis, and multiorgan
failure caused a 50% mortality rate in children with burns
covering 50% of their total body surface area (TBSA).8
Recently burn care in children has improved survival such
that a burn covering more than 95% TBSA can be survived
in more than 50% of cases.9 In the 1970s, Andrew M.
Munster (Fig. 1.3) became interested in measuring quality
of life after excisional surgery and other improvements led
to a dramatic decrease in mortality. First published in 1982,
his Burn Specific Health Scale became the foundation for
most modern studies in burns outcome.10 The scale has
since been updated and extended to children.11
Further improvements in burn care presented in this
brief historical review include excision and coverage of the
burn wound, control of infection, fluid resuscitation, nutri­
tional support, treatment of major inhalation injuries, and
support of the hypermetabolic response.
Early Excision
In the early 1940s, it was recognized that one of the most
effective therapies for reducing mortality from a major
thermal injury was the removal of burn eschar and imme­
diate wound closure.12 This approach had previously not
been practical in large burns owing to the associated high
rate of infection and blood loss. Between 1954 and 1959,
Douglas Jackson and colleagues at the Birmingham Acci­
dent Hospital advanced this technique in a series of pilot
and controlled trials starting with immediate fascial exci­
sion and grafting of small burn areas and eventually cover­
ing up to 65% of the TBSA with autograft and homograft
skin.13 In this breakthrough publication, Jackson concluded
that “with adequate safeguards, excision and grafting of
20% to 30% body surface area can be carried out on the
day of injury without increased risk to the patient.” This
technique, however, was far from being accepted by the
majority of burn surgeons, and delayed serial excision
remained the prevalent approach to large burns. It was
Zora Janzekovic (Fig. 1.4), working alone in Yugoslavia in
the 1960s, who developed the concept of removing deep
second-degree burns by tangential excision with a simple
uncalibrated knife. She treated 2615 patients with deep
second-degree burns by tangential excision of eschar
between the third and fifth days after burn and covered the
The recognition of burns and their treatment is evident in
cave paintings that are more than 3500 years old. Docu­
mentation in the Egyptian Smith papyrus of 1500 BC advo­
cated the use of a salve of resin and honey for treating
burns.1 In 600 BC, the Chinese used tinctures and extracts
from tea leaves. Nearly 200 years later, Hippocrates
described the use of rendered pig fat and resin-impregnated
bulky dressings, which was alternated with warm vinegar
soaks augmented with tanning solutions made from oak
bark. Celsus, in the 1st century AD, mentioned the use of
wine and myrrh as a lotion for burns, most probably for
their bacteriostatic properties.1 Vinegar and exposure of the
open wound to air was used by Galen (130–210 AD) as a
means of treating burns, while the Arabian physician
Rhases recommended cold water for alleviating the pain
associated with burns. Ambroise Paré (1510–1590 AD),
who effectively treated burns with onions, was probably the
first to describe a procedure for early burn wound excision.
In 1607, Guilhelmus Fabricius Hildanus, a German
surgeon, published De Combustionibus, in which he dis­
cussed the pathophysiology of burns and made unique con­
tributions to the treatment of contractures. In 1797,
Edward Kentish published an essay describing pressure
dressings as a means to relieve burn pain and blisters.
Around this same time, Marjolin identified squamous cell
carcinomas that developed in chronic open burn wounds.
In the early 19th century, Guillaume Dupuytren (Fig. 1.1)
reviewed the care of 50 burn patients treated with occlusive
dressings and developed a classification of burn depth that
remains in use today.2 He was perhaps the first to recognize
gastric and duodenal ulceration as a complication of severe
burns, a problem that was discussed in more detail by
Curling of London in 1842.3 In 1843, the first hospital for
the treatment of large burns used a cottage on the grounds
of the Edinburgh Royal Infirmary.
Truman G. Blocker Jr. (Fig. 1.2) may have been the first
to demonstrate the value of the multidisciplinary team
approach to disaster burns when, on April 16, 1947, two
freighters loaded with ammonium nitrate fertilizer exploded
at a dock in Texas City, killing 560 people and injuring more
than 3000. At that time, Blocker mobilized the University
of Texas Medical Branch in Galveston, Texas, to treat the
arriving truckloads of casualties. This “Texas City Disaster”
is still known as the deadliest industrial accident in Ameri­
can history. Over the next 9 years, Truman and Virginia
Blocker followed more than 800 of these burn patients and
published a number of papers and government reports on
their findings.4–6 The Blockers became renowned for their
work in advancing burn care, with both receiving the
Harvey Allen Distinguished Service Award from the Ameri­
can Burn Association (ABA). Truman Blocker Jr. was also

1  •  A Brief History of Acute Burn Care Management
2
excised wound with skin autograft.14 Using this technique,
burned patients were able to return to work within 2 weeks
or so from the time of injury. For her achievements, in
1974, she received the ABA Everett Idris Evans Memorial
Medal and, in 2011, the ABA lifetime achievement award.
In the early 1970s, William Monafo (Fig. 1.5) was one of
the first Americans to advocate the use of tangential exci­
sion and grafting of larger burns.15 John Burke (Fig. 1.6),
while at Massachusetts General Hospital in Boston, reported
unprecedented survival in children with burns of more
than 80% TBSA.16 His use of a combination of tangential
excision for the smaller burns (Janzekovic’s technique) and
excision to the level of fascia for the larger burns resulted
in a decrease in both hospital time and mortality. Lauren
Engrav et al.,17 in a randomized prospective study, com­
pared tangential excision to nonoperative treatment of
burns. This study showed that, compared to nonoperative
treatment, early excision and grafting of deep second-
degree burns reduced hospitalization time and hypertro­
phic scarring. In 1988, Ron G. Tompkins et al.,18 in a
statistical review of the Boston Shriners Hospital patient
population from 1968 to 1986, reported a dramatic
decrease in mortality in severely burned children that he
attributed mainly to the advent of early excision and graft­
ing of massive burns in use since the 1970s. In a random­
ized prospective trial of 85 patients with third-degree burns
covering 30% or more of their TBSA, Herndon et al.19
reported a decrease in mortality in those treated with early
excision of the entire wound compared to conservative
treatment. Other studies have reported that prompt excision
Fig. 1.1  Guillaume Dupuytren.
Fig. 1.2  Truman G. Blocker Jr.
Fig. 1.3  Andrew M. Munster.
Fig. 1.4  Zora Janzekovic.

1  •  A Brief History of Acute Burn Care Management
3
throughout Europe, but because the results were extremely
variable it quickly fell into disrepute. J. S. Davis resurrected
this technique in 1914 and reported the use of “small deep
skin grafts,” which were later known as “pinch grafts.”22
Split-thickness skin grafts became more popular during the
1930s, due in part to improved and reliable instrumenta­
tion. The “Humby knife,” developed in 1936, was the first
reliable dermatome, but its use was cumbersome. E. C.
Padgett developed an adjustable dermatome that had cos­
metic advantages and allowed the procurement of a consis­
tent split-thickness skin graft.23,24 Padgett also developed a
system for categorizing skin grafts into four types based on
thickness.25 In1964 J. C. Tanner Jr. and colleagues revolu­
tionized wound grafting with the development of the
meshed skin graft;26 however for prompt excision and
immediate wound closure to be practical in burns covering
more than 50% of the TBSA, alternative materials and
approaches to wound closure were necessary. To meet these
demands, a system of cryopreservation and long-term
storage of human skin for periods extending up to several
months was developed.27 Although controversy surrounds
the degree of viability of the cells within the preserved skin,
this method has allowed greater flexibility in the clinical use
of autologous skin and allogenic skin harvested from cadav­
ers. J. Wesley Alexander (Fig. 1.7) developed a simple
method for widely expanding autograft skin and then cover­
ing it with cadaver skin.28 This so-called “sandwich tech­
nique” has been the mainstay of treatment of massively
burned individuals.
In 1981, John Burke and Ioannis Yannas developed an
artificial skin that consists of a silastic epidermis and a
porous collagen–chondroitin dermis and is marketed today
as Integra. Burke was also the first to use this artificial skin
on very large burns that covered more than 80% of the
TBSA.29 David Heimbach led one of the early multicenter
randomized clinical trials using Integra.30 Its use in the
of the burn eschar improves long-term outcome and cos­
mesis, thereby reducing the amount of reconstructive pro­
cedures required.
Skin Grafting
Progress in skin grafting techniques has paralleled the
developments in wound excision. In 1869, J. P. Reverdin, a
Swiss medical student, successfully reproduced skin grafts.20
In the 1870s, George David Pollock popularized the method
in England.21 The method gained widespread attention
Fig. 1.5  William Monafo.
Fig. 1.6  John Burke.
Fig. 1.7  J. Wesley Alexander.

1  •  A Brief History of Acute Burn Care Management
4
burn centers today. With the introduction of efficacious
silver-containing topical antimicrobials, burn wound sepsis
rapidly decreased. Early excision and coverage further
reduced the morbidity and mortality from burn wound
sepsis. Nystatin in combination with silver sulfadiazine has
been used to control Candida at Shriners Burns Hospital for
Children in Galveston, Texas.42 Mafenide acetate, however,
remains useful in treating invasive wound infections.43
Nutritional Support
P. A. Shaffer and W. Coleman advocated high caloric feeding
for burn patients as early as 1909,44 and D. W. Wilmore
supported supranormal feeding with a caloric intake as
high as 8000 kcal/day.45 P. William Curreri (Fig. 1.8) retro­
spectively looked at a number of burned patients to quantify
the amount of calories required to maintain body weight
over a period of time. In a study of nine adults with 40%
TBSA burns, he found that maintenance feeding at 25 kcal/
kg plus an additional 40 kcal/% TBSA burned per day
would maintain their body weight during acute hospitaliza­
tion.46 A. B. Sutherland proposed that children should
receive 60 kcal/kg body weight plus 35 kcal/% TBSA
burned per day to maintain their body weight.47 D. N.
Herndon et al. subsequently showed that supplemental par­
enteral nutrition increased both immune deficiency and
mortality and recommended continuous enteral feeding,
when tolerated, as a standard treatment for burns.48
The composition of nutritional sources for burned
patients has been debated in the past. In 1959, F. D. Moore
advocated that the negative nitrogen balance and weight
loss in burns and trauma should be met with an adequate
intake of nitrogen and calories.49 This was supported by
many others, including T. Blocker Jr.,50 C. Artz, 51 and later
by Sutherland.47
coverage of extensive burns has remained limited partly
due to the persistently high cost of the material and the
need for a two-stage approach. Integra has since become
popular for smaller immediate burn coverage and burn
reconstruction. In 1989, J. F. Hansbrough and S. T. Boyce
first reported the use of cultured autologous keratinocytes
and fibroblasts on top of a collagen membrane (composite
skin graft; CSS).31 A larger trial by Boyce32 revealed that the
use of CSS in extensive burns reduces the requirement for
harvesting of donor skin compared to conventional skin
autografts and that the quality of grafted skin did not differ
between CSS and skin autograft after 1 year. The search for
an engineered skin substitute to replace all of the functions
of intact human skin is ongoing; composite cultured skin
analogs, perhaps combined with mesenchymal stem cells,
may offer the best opportunity for better outcomes.33,34
Topical Control of Infection
Infection control is an important major advancement in
burn care that has reduced mortality. One of the first topical
antimicrobials, sodium hypochlorite (NaClO), discovered in
the 18th century, was widely used as a disinfectant through­
out the 19th century, but its use was frequently associated
with irritation and topical reactions.35 In 1915, Henry D.
Dakin standardized hypochlorite solutions and described
the concentration of 0.5% NaClO as most effective.36 His
discovery came at a time when scores of severely wounded
soldiers were dying of wound infections on the battlefields
of World War I. With the help of a Rockefeller Institute
grant, Dakin teamed up with the then already famous
French surgeon and Nobel Prize winner Alexis Carrel to
create a system of mechanical cleansing, surgical débride­
ment, and topical application of hypochlorite solution,
which was meticulously protocolized and used successfully
in wounds and burns.37 Subsequently concentrations of
sodium hypochlorite were investigated for antibacterial
activity and tissue toxicity in vitro and in vivo, and it was
found that a concentration of 0.025% NaClO was most
efficacious because it had sufficient bactericidal properties
but fewer detrimental effects on wound healing.38
Mafenide acetate (Sulfamylon), a drug used by the
Germans for treatment of open wounds in World War II,
was adapted for treating burns at the Institute of Surgical
Research in San Antonio, Texas, by microbiologist Robert
Lindberg and surgeon John Moncrief.39 This antibiotic
would penetrate third-degree eschar and was extremely
effective against a wide spectrum of pathogens. Simultane­
ously, in New York, Charles Fox developed silver sulfadiazine
cream (Silvadene), which was almost as efficacious as
mafenide acetate.40 Although mafenide acetate penetrates
the burn eschar quickly, it is a carbonic anhydrase inhibitor
that can cause systemic acidosis and compensatory hyper­
ventilation and may lead to pulmonary edema. Because of
its success in controlling infection in burns combined with
minimal side effects, silver sulfadiazine has become the
mainstay of topical antimicrobial therapy.
Carl Moyer and William Monafo initially used 0.5% silver
nitrate soaks as a potent topical antibacterial agent for
burns, a treatment that was described in their landmark
publication41 and remains the treatment of choice in many
Fig. 1.8  P. William Curreri.

1  •  A Brief History of Acute Burn Care Management
5
Fluid Resuscitation
The foundation of current fluid and electrolyte manage­
ment began with the studies of Frank P. Underhill, who, as
Professor of Pharmacology and Toxicology at Yale, studied
20 individuals burned in a 1921 fire at the Rialto Theatre.52
Underhill found that the composition of blister fluid was
similar to that of plasma and could be replicated by a salt
solution containing protein. He suggested that burn patient
mortality was due to loss of fluid and not, as previously
thought, from toxins. In 1944, C. C. Lund and N. C. Browder
estimated burn surface areas and developed diagrams by
which physicians could easily draw the burned areas and
derive a quantifiable percent describing the surface area
burned.53 This led to fluid replacement strategies based on
surface area burned. G. A. Knaysi et al. proposed a simple
“rule-of-nines” for evaluating the percentage of body
surface area burned.54 In the late 1940s, O. Cope and F. D.
Moore (Figs. 1.9 and 1.10) were able to quantify the amount
of fluid required per area burned for adequate resuscitation
from the amount needed in young adults who were trapped
inside the burning Coconut Grove Nightclub in Boston in
1942. They postulated that the space between cells was a
major recipient of plasma loss, causing swelling in both
injured and uninjured tissues in proportion to the burn
size.55 Moore concluded that additional fluid, over that col­
lected from the bed sheets and measured as evaporative
water loss, was needed in the first 8 hours after burn to
replace “third space” losses. He then developed a formula
for replacement of fluid based on the percent of the body
surface area burned.56 M. G. Kyle and A. B. Wallace showed
that the heads of children were relatively larger and the legs
relatively shorter than in adults, and they modified the fluid
replacement formulas for use in children.57 I. E. Evans and
his colleagues made recommendations relating fluid
requirements to body weight and surface area burned.58
From their recommendations, intravenous infusion of
Fig. 1.9  Oliver Cope.
Fig. 1.10  Francis D. Moore.
Fig. 1.11  Charles R. Baxter.
normal saline plus colloid (1.0 mL per kg/% burn) along
with 2000 mL dextrose 5% solution to cover insensible
water losses was administered over the first 24 hours after
burn. One year later, E. Reiss presented the Brooke formula,
which modified the Evans formula by substituting lactated
Ringer’s for normal saline and reducing the amount of
colloid given.59 Charles R. Baxter (Fig. 1.11) and G. Tom
Shires (Fig. 1.12) developed a formula without colloid,
which is now referred to as the Parkland formula.60 This is
perhaps the most widely used formula today and recom­
mends 4 mL of lactated Ringer’s solution per kg/% TBSA
burned during the first 24 hours after burn. All these for­
mulas advocate giving half of the fluid in the first 8 hours

1  •  A Brief History of Acute Burn Care Management
6
parenchymal injury that results in early acute respiratory
death.64
With the development of objective diagnostic methods,
the incidence of an inhalation injury in burned patients
can now be identified and its complications identified.
Xenon-133 scanning was first used in 1972 in the diagno­
sis of inhalation injury.65,66 When this radioisotope method
is used in conjunction with a medical history, the identifica­
tion of an inhalation injury is quite reliable. The fiberoptic
bronchoscope is another diagnostic tool that, under topical
anesthesia, can be used for the early diagnosis of an inha­
lation injury.67 It is also capable of pulmonary lavage to
remove airway plugs and deposited particulate matter.
K. Z. Shirani, Basil A. Pruitt (Fig. 1.13), and A. D. Mason
reported that smoke inhalation injury and pneumonia, in
addition to age and burn size, greatly increased burn mor­
tality.68 The realization that the physician should not under-
resuscitate burn patients with an inhalation injury was
emphasized by P. D. Navar et al.69 and D. N. Herndon et al.70
A major inhalation injury requires 2 mL per kg/% TBSA
burn more fluid in the first 24 hours after burn to maintain
adequate urine output and organ perfusion. Multicenter
studies looking at patients with acute respiratory distress
syndrome (ARDS) have advocated respiratory support at
low peak pressures to reduce the incidence of barotrauma.
The high-frequency oscillating ventilator, advocated by C. J.
Fitzpatrick71 and J. Cortiella et al.,72 has added the benefit of
pressure ventilation at low tidal volumes plus rapid inspira­
tory minute volume, which provides a vibration to encour­
age inspissated sputum to travel up the airways. The use of
heparin, N-acetylcysteine, nitric oxide inhalation, and
bronchodilator aerosols have also been used with some
apparent benefit, at least in pediatric populations.73 Inhala­
tion injury remains one of the most prominent causes of
death in thermally injured patients. In children, the lethal
burn area for a 10% mortality without a concomitant
after burn and the other half in the subsequent 16 hours.
Baxter and Shires discovered that after a cutaneous burn,
not only is fluid deposited in the interstitial space, but
marked intracellular edema also develops. The excessive dis­
ruption of the sodium–potassium pump activity results in
the inability of cells to remove excess fluid. They also showed
that protein, given in the first 24 hours after injury, was not
necessary and postulated that, if used, it would leak out of
the vessels and exacerbate edema. This was later substanti­
ated in studies of burn patients with toxic inhalation inju­
ries.61 After a severe thermal injury fluid accumulates in the
wound, and, unless there is adequate and early fluid replace­
ment, hypovolemic shock will develop. A prolonged sys­
temic inflammatory response to severe burns can lead to
multiorgan dysfunction, sepsis, and even mortality. It has
been suggested that, for maximum benefit, fluid resuscita­
tion should begin as early as 2 hours after burn.9,62 Fluid
requirements in children are greater with a concomitant
inhalation injury, delayed fluid resuscitation, and larger
burns.
Inhalation Injury
During the 1950s and 1960s, burn wound sepsis, nutri­
tion, kidney dysfunction, wound coverage, and shock were
the main foci of burn care specialists. Over the past 50
years, these problems have been clinically treated with
increasing success; hence a greater interest in a concomi­
tant inhalation injury evolved. A simple classification of
inhalation injury separates problems occurring in the first
24 hours after injury, which include upper airway obstruc­
tion and edema, from those that manifest after 24 hours.
These include pulmonary edema and tracheobronchitis,
which can progress to pneumonia, mucosal edema, and
airway occlusion due to the formation of airway plugs
from mucosal sloughing.63,64 The extent of damage from
the larynx to tracheobronchial tree depends on the solu­
bility of the toxic substance and the duration of expo­
sure. Nearly 45% of inhalation injuries are limited to the
upper passages above the vocal cords, and 50% have an
injury to the major airways. Less than 5% have a direct
Fig. 1.12  G. Tom Shires.
Fig. 1.13  Basil A. Pruitt.

1  •  A Brief History of Acute Burn Care Management
7
agent human recombinant growth hormone, the synthetic
anabolic testosterone analog oxandrolone, insulin, and the
glucose uptake modulator metformin, have all shown some
beneficial effects in reducing the hypermetabolic response
in burn patients.
Conclusion
The evolution of burn treatments has been extremely pro­
ductive over the past 50 years. The mortality of severely
burned patients has decreased significantly thanks to
improvements in early resuscitation, infection control,
nutrition, attenuation of the hypermetabolic response, and
new and improved surgical approaches. In burned children,
a 98% TBSA burn now has a 50% survival rate.74 It is hoped
that the next few years will witness the development of an
artificial skin that combines the concepts of J. F. Burke 29
with the tissue culture technology described by E. Bell.85
Inhalation injury, however, remains one of the major deter­
minants of mortality in those with severe burns. Further
improvements in the treatment of inhalation injuries are
expected through the development of arterial venous
carbon dioxide removal and extracorporeal membrane oxy­
genation devices.86 Research continues to strive for a better
understanding of the pathophysiology of burn scar con­
tractures and hypertrophic scarring.87 Although decreases
in burn mortality can be expected, continued advances to
rehabilitate patients and return them to productive life are
an important step forward in burn care management.
Complete references available online at

Further Reading
Baxter CR, Shires T. Physiological response to crystalloid resuscitation of
severe burns. Ann N Y Acad Sci. 1968;150(3):874-894.
Burke JF, Yannas IV, Quinby WC Jr, et al. Successful use of a physiologically
acceptable artificial skin in the treatment of extensive burn injury. Ann
Surg. 1981;194(4):413-428.
Hansbrough JF, Boyce ST, Cooper ML, et al. Burn wound closure with
cultured autologous keratinocytes and fibroblasts attached to a
collagen-glycosaminoglycan substrate. JAMA. 1989;262(15):2125-
2130.
Janzekovic Z. A new concept in the early excision and immediate grafting
of burns. J Trauma. 1970;10(12):1103-1108.
Tompkins RG, Remensnyder JP, Burke JF, et al. Significant reductions in
mortality for children with burn injuries through the use of prompt
eschar excision. Ann Surg. 1988;208(5):577-585.
Wilmore DW, Long JM, Mason AD Jr, et al. Catecholamines: mediator
of the hypermetabolic response to thermal injury. Ann Surg. 1974;
180(4):653-669.
inhalation injury is 73% TBSA; however with an inhalation
injury, the lethal burn size for a 10% mortality rate is 50%
TBSA.74
Hypermetabolic Response
to Trauma
Major decreases in mortality have also resulted from a
better understanding of how to support the hypermetabolic
response to severe burns. This response is characterized by
an increase in the metabolic rate and peripheral catabolism.
The catabolic response was described by H. Sneve as exhaus­
tion and emaciation, and he recommended a nourishing
diet and exercise.75 O. Cope et al.76 quantified the metabolic
rate in patients with moderate burns, and Francis D. Moore
advocated the maintenance of cell mass by continuous
feeding to prevent catabolism after trauma and injury.77
Over the past 30 years, the hypermetabolic response to
burn has been shown to increase metabolism, negative
nitrogen balance, glucose intolerance, and insulin resis­
tance. In 1974, Douglas Wilmore and colleagues defined
catecholamines as the primary mediator of this hypermeta­
bolic response and suggested that catecholamines were five-
to sixfold elevated after major burns, thereby causing an
increase in peripheral lipolysis and catabolism of peripheral
protein.78 In 1984, P. Q. Bessey demonstrated that the stress
response required not only catecholamines but also cortisol
and glucagon.79 Wilmore et al. examined the effect of
ambient temperature on the hypermetabolic response to
burns and reported that burn patients desired an environ­
mental temperature of 33°C and were striving for a core
temperature of 38.5°C.80 Warming the environment from
28°C to 33°C substantially decreased the hypermetabolic
response, but did not abolish it. He suggested that the
wound itself served as the afferent arm of the hypermeta­
bolic response, and its consuming greed for glucose and
other nutrients was at the expense of the rest of the body.81
Wilmore also believed that heat was produced by biochemi­
cal inefficiency, which was later defined by Robert Wolfe as
futile substrate cycling.82 Wolfe et al. also demonstrated
that burned patients were glucose intolerant and insulin
resistant, with an increase in glucose transport to the
periphery but a decrease in glucose uptake into the cells.83
D. W. Hart et al. further showed that the metabolic response
rose with increasing burn size, reaching a plateau at a 40%
TBSA burn.84
In the past three decades, pharmacologic modulators,
such as the β-receptor antagonist propranolol, the anabolic

7.e1
1  •  A Brief History of Acute Burn Care Management
33. Supp DM, Boyce ST. Engineered skin substitutes: practices and poten­
tials. Clin Dermatol. 2005;23(4):403-412.
34. Butler KL, Goverman J, Ma H, et al. Stem cells and burns: review and
therapeutic implications. J Burn Care Res. 2010;31(6):874-881.
35. Barillo DJ. Topical antimicrobials in burn wound care: a recent history.
Wounds. 2008;20(7):192-198.
36. Dakin HD. On the use of certain antiseptic substances in the treatment
of infected wounds. Br Med J. 1915;2(2852):318-320.
37. Haller JS Jr. Treatment of infected wounds during the Great War, 1914
to 1918. South Med J. 1992;85(3):303-315.
38. Heggers JP, Sazy JA, Stenberg BD, et al. Bactericidal and wound-heal­
ing properties of sodium hypochlorite solutions: the 1991 Lindberg
Award. J Burn Care Rehabil. 1991;12(5):420-424.
39. Lindberg RB, Moncrief JA, Switzer WE, et al. The successful control
of burn wound sepsis. J Trauma. 1965;5(5):601-616.
40. Fox CL Jr, Rappole BW, Stanford W. Control of pseudomonas infec­
tion in burns by silver sulfadiazine. Surg Gynecol Obstet. 1969;
128(5):1021-1026.
41. Moyer CA, Brentano L, Gravens DL, et al. Treatment of large
human burns with 0.5 per cent silver nitrate solution. Arch Surg.
1965;90:812-867.
42. Heggers JP, Robson MC, Herndon DN, et al. The efficacy of nystatin
combined with topical microbial agents in the treatment of burn
wound sepsis. J Burn Care Rehabil. 1989;10(6):508-511.
43. Monafo WW, West MA. Current treatment recommendations for
topical burn therapy. Drugs. 1990;40(3):364-373.
44. Shaffer PA, Coleman W. Protein metabolism in typhoid fever. Arch
Intern Med. 1909;IV(6):538-600.
45. Wilmore DW, Curreri PW, Spitzer KW, et al. Supranormal dietary
intake in thermally injured hypermetabolic patients. Surg Gynecol
Obstet. 1971;132(5):881-886.
46. Curreri PW, Richmond D, Marvin J, et al. Dietary requirements of
patients with major burns. J Am Diet Assoc. 1974;65(4):415-417.
47. Sutherland AB. Nitrogen balance and nutritional requirement in the
burn patient: a reappraisal. Burns. 1976;2(4):238-244.
48. Herndon DN, Barrow RE, Stein M, et al. Increased mortality with
intravenous supplemental feeding in severely burned patients. J Burn
Care Rehabil. 1989;10(4):309-313.
49. Moore FD. Metabolic Care of Surgical Patients. Philadelphia: Saunders;
1959.
50. Blocker TG Jr, Levin WC, Nowinski WW, et al. Nutrition studies in the
severely burned. Ann Surg. 1955;141(5):589-597.
51. Artz CP, Reiss E. The Treatment of Burns. Philadelphia: Saunders; 1957.
Available at:
52. Underhill FP. The significance of anhydremia in extensive surface
burns. JAMA. 1930;95:852.
53. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol
Obstet. 1944;79:352-358.
54. Knaysi GA, Crikelair GF, Cosman B. The role of nines: its history and
accuracy. Plast Reconstr Surg. 1968;41(6):560-563.
55. Cope O, Moore FD. The redistribution of body water and the fluid
therapy of the burned patient. Ann Surg. 1947;126(6):1010-1045.
56. Moore FD. The body-weight burn budget. Basic fluid therapy for the
early burn. Surg Clin North Am. 1970;50(6):1249-1265.
57. Kyle MJ, Wallace AB. Fluid replacement in burnt children. Br J Plast
Surg. 1950;3(3):194-204.
58. Evans EI, Purnell OJ, Robinett PW, et al. Fluid and electrolyte require­
ments in severe burns. Ann Surg. 1952;135(6):804-817.
59. Reiss E, Stirmann JA, Artz CP, et al. Fluid and electrolyte balance in
burns. JAMA. 1953;152(14):1309-1313.
60. Baxter CR, Shires T. Physiological response to crystalloid resuscitation
of severe burns. Ann N Y Acad Sci. 1968;150(3):874-894.
61. Tasaki O, Goodwin CW, Saitoh D, et al. Effects of burns on inhalation
injury. J Trauma. 1997;43(4):603-607.
62. Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation
improves outcomes in severely burned children. Resuscitation.
2000;45(2):91-96.
63. Foley FD, Moncrief JA, Mason AD Jr. Pathology of the lung in fatally
burned patients. Ann Surg. 1968;167(2):251-264.
64. Moylan JA, Chan CK. Inhalation injury—an increasing problem. Ann
Surg. 1978;188(1):34-37.
65. Agee RN, Long JM 3rd, Hunt JL, et al. Use of 133xenon in early diag­
nosis of inhalation injury. J Trauma. 1976;16(3):218-224.
66. Moylan JA Jr, Wilmore DW, Mouton DE, et al. Early diagnosis of inha­
lation injury using 133 xenon lung scan. Ann Surg. 1972;176(4):
477-484.
References
1. Majno G. The Healing Hand: Man and Wound in the Ancient World. Cam­
bridge, MA: Harvard University Press; 1975.
2. Dupuytren G, Brierre de Boismont A-J-F, Paillard ALM. Leçons Orales
de Clinique Chirurgicale, Faites à l’Hôtel-Dieu de Paris. Paris: Baillière;
1839.
3. Curling TB. On acute ulceration of the duodenum, in cases of burn.
Med Chir Trans. 1842;25:260-281.
4. Blocker V, Blocker TG Jr. The Texas City disaster: a survey of 3,000
casualties. Am J Surg. 1949;78(5):756-771.
5. Hendrix JH Jr, Blocker TG Jr, Blocker V. Plastic surgery problems in the
Texas City disaster. Plast Reconstr Surg. 1949;4(1):92-97.
6. Blocker TG Jr, Blocker V, Graham JE, et al. Follow-up medical survey
of the Texas City disaster. Am J Surg. 1959;97(5):604-617.
7. Bremer J. Giant. The saga of the first man to be called presi­
dent of UTMB: Truman Graves Blocker Jr., M.D. UTMB Quarterly.
2000;(Summer/Fall):6-13.
8. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised esti­
mate. Ann Surg. 1954;139(3):269-274.
9. Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive
pediatric burns. An analysis of 103 children with > or = 80% TBSA
burns (> or = 70% full-thickness). Ann Surg. 1997;225(5):554-565,
discussion 565-559.
10. Blades B, Mellis N, Munster AM. A burn specific health scale. J Trauma.
1982;22(10):872-875.
11. Munster AM, Horowitz GL, Tudahl LA. The abbreviated Burn-Specific
Health Scale. J Trauma. 1987;27(4):425-428.
12. Cope O, Langohr JL, et al. Expeditious care of full-thickness
burn wounds by surgical excision and grafting. Ann Surg. 1947;
125(1):1-22.
13. Jackson D, Topley E, Cason JS, et al. Primary excision and grafting of
large burns. Ann Surg. 1960;152:167-189.
14. Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;10(12):1103-1108.
15. Monafo WW. Tangential excision. Clin Plast Surg. 1974;1(4):591-601.
16. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and immediate
grafting: a method shortening illness. J Trauma. 1974;14(5):389-395.
17. Engrav LH, Heimbach DM, Reus JL, et al. Early excision and grafting
vs. nonoperative treatment of burns of indeterminant depth: a ran­
domized prospective study. J Trauma. 1983;23(11):1001-1004.
18. Tompkins RG, Remensnyder JP, Burke JF, et al. Significant reductions
in mortality for children with burn injuries through the use of prompt
eschar excision. Ann Surg. 1988;208(5):577-585.
19. Herndon DN, Barrow RE, Rutan RL, et al. A comparison of conserva­
tive versus early excision. Therapies in severely burned patients. Ann
Surg. 1989;209(5):547-553.
20. Reverdin JP. Greffe epidermique. Bull Soc Chir Paris. 1869;101.
21. Freshwater MF, Krizek TJ. Skin grafting of burns: a centennial. A
tribute to George David Pollock. J Trauma. 1971;11(10):862-865.
22. Davis JP. The use of small deep skin grafts. JAMA. 1914;63:985-989.
23. Padgett EC. Calibrated intermediate skin grafts. Surg Gynecol Obstet.
1939;69:779-793.
24. Padgett EC. Skin grafting and the ‘three-quarter’-thickness skin graft
for prevention and correction of cicatricial formation. Ann Surg.
1941;113(6):1034-1049.
25. Padgett EC. Indications for determination of the thickness of split skin
grafts. Am J Surg. 1946;72(5):683-693.
26. Tanner JC Jr, Vandeput J, Olley JF. The mesh skin graft. Plast Reconstr
Surg. 1964;34:287-292.
27. Bondoc CC, Burke JF. Clinical experience with viable frozen human
skin and a frozen skin bank. Ann Surg. 1971;174(3):371-382.
28. Alexander JW, MacMillan BG, Law E, et al. Treatment of severe burns
with widely meshed skin autograft and meshed skin allograft overlay.
J Trauma. 1981;21(6):433-438.
29. Burke JF, Yannas IV, Quinby WC Jr, et al. Successful use of a physi­
ologically acceptable artificial skin in the treatment of extensive burn
injury. Ann Surg. 1981;194(4):413-428.
30. Heimbach D, Luterman A, Burke J, et al. Artificial dermis for
major burns. A multi-center randomized clinical trial. Ann Surg.
1988;208(3):313-320.
31. Hansbrough JF, Boyce ST, Cooper ML, et al. Burn wound closure with
cultured autologous keratinocytes and fibroblasts attached to a colla­
gen-glycosaminoglycan substrate. JAMA. 1989;262(15):2125-2130.
32. Boyce ST. Cultured skin substitutes: a review. Tissue Eng. 1996;2(4):
255-266.

7.e2
1  •  A Brief History of Acute Burn Care Management
67. Moylan JA, Adib K, Birnbaum M. Fiberoptic bronchoscopy following
thermal injury. Surg Gynecol Obstet. 1975;140(4):541-543.
68. Shirani KZ, Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury
and pneumonia on burn mortality. Ann Surg. 1987;205(1):82-87.
69. Navar PD, Saffle JR, Warden GD. Effect of inhalation injury on
fluid resuscitation requirements after thermal injury. Am J Surg.
1985;150(6):716-720.
70. Herndon DN, Barrow RE, Traber DL, et al. Extravascular lung water
changes following smoke inhalation and massive burn injury. Surgery.
1987;102(2):341-349.
71. Fitzpatrick JC, Cioffi WG Jr. Ventilatory support following burns and
smoke-inhalation injury. Respir Care Clin N Am. 1997;3(1):21-49.
72. Cortiella J, Mlcak R, Herndon D. High frequency percussive ventila­
tion in pediatric patients with inhalation injury. J Burn Care Rehabil.
1999;20(3):232-235.
73. Desai MH, Mlcak R, Richardson J, et al. Reduction in mortality in
pediatric patients with inhalation injury with aerosolized heparin/N-
acetylcystine [correction of acetylcystine] therapy. J Burn Care Rehabil.
1998;19(3):210-212.
74. Barrow RE, Spies M, Barrow LN, et al. Influence of demograph­
ics and inhalation injury on burn mortality in children. Burns.
2004;30(1):72-77.
75. Sneve H. The treatment of burns and skin grafting. JAMA.
1905;45(1):1-8.
76. Cope O, Nardi GL, Quijano M, et al. Metabolic rate and thyroid
function following acute thermal trauma in man. Ann Surg.
1953;137(2):165-174.
77. Moore FD. Metabolism in trauma: the reaction of survival. Metabo­
lism. 1959;8:783-786.
78. Wilmore DW, Long JM, Mason AD Jr, et al. Catecholamines: media­
tor of the hypermetabolic response to thermal injury. Ann Surg.
1974;180(4):653-669.
79. Bessey PQ, Watters JM, Aoki TT, et al. Combined hormonal
infusion simulates the metabolic response to injury. Ann Surg.
1984;200(3):264-281.
80. Wilmore DW, Mason AD Jr, Johnson DW, et al. Effect of ambient tem­
perature on heat production and heat loss in burn patients. J Appl
Physiol. 1975;38(4):593-597.
81. Wilmore DW, Aulick LH, Mason AD, et al. Influence of the burn
wound on local and systemic responses to injury. Ann Surg.
1977;186(4):444-458.
82. Wolfe RR, Durkot MJ, Wolfe MH. Effect of thermal injury on energy
metabolism, substrate kinetics, and hormonal concentrations. Circ
Shock. 1982;9(4):383-394.
83. Wolfe RR, Durkot MJ, Allsop JR, et al. Glucose metabolism in severely
burned patients. Metabolism. 1979;28(10):1031-1039.
84. Hart DW, Wolf SE, Chinkes DL, et al. Determinants of skeletal muscle
catabolism after severe burn. Ann Surg. 2000;232(4):455-465.
85. Bell E, Ehrlich HP, Buttle DJ, et al. Living tissue formed in vitro
and accepted as skin-equivalent tissue of full thickness. Science.
1981;211(4486):1052-1054.
86. Zwischenberger JB, Cardenas VJ Jr, Tao W, et al. Intravascular
membrane oxygenation and carbon dioxide removal with IVOX:
can improved design and permissive hypercapnia achieve adequate
respiratory support during severe respiratory failure? Artif Organs.
1994;18(11):833-839.
87. Gurtner GC, Werner S, Barrandon Y, et al. Wound repair and regen­
eration. Nature. 2008;453(7193):314-321.

8
Teamwork for Total Burn Care:
Burn Centers and
Multidisciplinary Burn Teams
JANOS CAMBIASO-DANIEL, OSCAR E. SUMAN, MARY JACO, DEBRA A. BENJAMIN, and
DAVID N. HERNDON
2 
Optimal treatment of severely burned patients requires
significant healthcare resources and has led to the develop­
ment of highly specialized burn centers over the past
decades. Centralizing services to regional burn centers has
made implementation of multidisciplinary acute critical
care and long-term rehabilitation possible. It has also
enhanced opportunities for study and research over the
past several decades. This has led to great advances both in
our knowledge and in clinical outcomes, with further
advancements being expected.
Implementation of a wide range of medical discoveries
and innovations has improved patient outcomes following
severe burns over the past half century. Key areas of
advancements in recent decades include fluid resuscitation
protocols; early burn wound excision and closure with
grafts or skin substitutes, nutritional support regimens,
topical antimicrobials and treatment of sepsis, thermally
neutral ambient temperatures, and pharmacological mod­
ulation of hypermetabolic and catabolic responses. These
factors have helped to decrease morbidity and mortality
following severe burns by improving wound healing, reduc­
ing inflammation and energy demands, and attenuating
hypermetabolism and muscle catabolism.
Melding scientific research with clinical care has been
promoted in recent burn care history largely because of
the aggregation of burn patients into single-purpose units
staffed by dedicated healthcare personnel. Dedicated burn
units were first established in Great Britain to facilitate
nursing care. The first U.S. burn center was established at
the Medical College of Virginia in 1946. The same year,
the U.S. Army Surgical Research Unit (later renamed the
U.S. Army Institute of Surgical Research) was established.
Directors of both centers and later, the founders of the burn
centers at University of Texas Medical Branch in 1947 and
Shriners Hospitals for Children–Galveston in 1963 empha­
sized the importance of collaboration between clinical care
and basic scientific disciplines to improve the patient’s
outcome.1
The organizational design of these centers engendered a
self-perpetuating feedback loop of clinical and basic scien­
tific inquiry. In this system, scientists receive first-hand
information about clinical problems, while clinicians receive
provocative ideas about patient responses to injury from
experts in other disciplines. Advances in burn care attest to
the value of a dedicated burn unit organized around a col­
legial group of basic scientists, clinical researchers, and
Introduction
Severe burn injuries evoke strong emotional responses in
most people including health professionals who are con­
fronted by the specter of pain, deformity, and potential
death. Intense pain and repeated episodes of sepsis, followed
by either death or survival encumbered by pronounced dis­
figurement and disability, have been the expected sequelae
to serious burns for most of mankind’s history.1 However,
these dire consequences have been ameliorated so that,
although burn injury is still intensely painful and tragic, the
probability of death has been significantly diminished.
During the decade prior to 1951, young adults (15–43
years of age) with total body surface area (TBSA) burns of
45% or greater had a 49% mortality rate (Table 2.1).2 Forty
years later, statistics from the pediatric and adult burn units
in Galveston, Texas, show that a 49% mortality rate is asso­
ciated with TBSA burns of 70% or greater in the same age
group. Over the past decade, these mortality figures have
improved even more dramatically, so that almost all infants
and children can be expected to survive when resuscitated
adequately and quickly.3 Although improved survival has
been the primary focus of burn treatment advancement for
many decades, today the major goal—since survival rates
have highly increased—is rehabilitation of burn survivors
to maximize quality of life and reduce morbidity.
Such improvement in forestalling death is a direct result
of the maturation of burn care science. Scientifically sound
analyses of patient data have led to the development of
formulas for fluid resuscitation4–6 and nutritional support.7,8
Clinical research has demonstrated the utility of topical
antimicrobials in delaying onset of sepsis, thereby contrib­
uting to decreased mortality of burn patients. Prospective
randomized clinical trials have shown that early surgical
therapy is efficacious in improving survival for many burned
patients by decreasing blood loss and diminishing the
occurrence of sepsis.9–14 Basic science and clinical research
have helped decrease mortality by characterizing the patho­
physiological changes related to inhalation injury and sug­
gesting treatment methods that have decreased the
incidence of pulmonary edema and pneumonia.15–18 Scien­
tific investigations of the hypermetabolic response to major
burn injury have led to improved management of this life-
threatening phenomenon, not only enhancing survival,
but also promising an improved quality of life.19–32

2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
9
clinical caregivers, all asking questions of each other,
sharing observations and information, and seeking solu­
tions to improve patient welfare.
Findings from the group at the Army Surgical Research
Institute point to the necessity of involving many disciplines
in the treatment of patients with major burn injuries and
emphasize the utility of a team concept.1 For this reason the
International Society of Burn Injuries and its journal,
Burns, as well as the American Burn Association and its
publication, Journal of Burn Care and Research, have publi­
cized the notion of successful multidisciplinary work by
burn teams to widespread audiences.
Members of a Burn Team
The management of severe burn injuries benefits from con­
centrated integration of health services and professionals,
with care being significantly enhanced by a true multidis­
ciplinary approach. The complex nature of burn injuries
necessitates a diverse range of skills for optimal care. A
single specialist cannot be expected to possess all skills,
knowledge, and energy required for the comprehensive care
of severely injured patients. For this reason, reliance is
placed on a group of specialists to provide integrated care
through innovative organization and collaboration.
In addition to including burn-specific providers, the burn
team consists of epidemiologists, molecular biologists,
microbiologists, physiologists, biochemists, pharmacists,
pathologists, endocrinologists, and numerous other scien­
tific as well as medical specialists. Because burn injury is a
complex systemic injury, the search for improved treat­
ments leads to inquiry from many approaches. Each scien­
tific finding stimulates new questions and the potential
involvement of additional specialists.
At times, the burn team can be thought of as including
the environmental service workers responsible for cleaning
the unit, the volunteers who may assist in a variety of ways
to provide comfort for patients and families, the hospital
administrator, and many others who support the day-to-
day operations of a burn center and significantly impact the
well-being of patients and staff. However, the traditional
burn team consists of a multidisciplinary group of direct-
care providers. Although burn surgeons, plastic surgeons,
nurses, nutritionists, and physical and occupational
therapists form the skeletal core; most burn units also
include anesthesiologists, respiratory therapists, pharma­
cists, spiritual therapists, and music therapists. The increas­
ing number of survivors has consequently also added
psychologists, psychiatrists, and, more recently, exercise
physiologists to the burn team. In pediatric units, child life
specialists and school teachers are also significant members
of the team of caregivers.
Patient satisfaction can be formally measured through
questionnaires to provide positive feedback to caregivers
and highlight potential areas of improvement. Allowing
patients to feel as if they are part of decisions about their
care, listening and responding to concerns, providing
encouragement, and displaying empathy are all important
for maintaining satisfaction in patients and their families.
These approaches also reduce fear, apprehension, and
misunderstandings.
Healing relies on a complex array of factors. These
include individual factors such as motivation, pre-existing
health status, obesity, malnutrition, comorbidities, family
support, and social support. They also include wider soci­
etal factors such as reintegration, individual perception,
and coping strategies as well as factors specific to the
mechanism of injury such as trauma, bereavement, grief,
and loss.
Patients and their families are infrequently mentioned as
members of the team but are obviously important in influ­
encing the outcome of treatment. Persons with major burn
injuries contribute actively to their own recovery, and each
brings individual needs and agendas into the hospital
setting that may influence the way treatment is provided by
the professional care team.33 The patient’s family members
often become active participants. This is even more impor­
tant in the case of children, but is also true in the case of
adult patients. Family members become conduits of infor­
mation from the professional staff to the patient. At times,
they act as spokespersons for the patient, and, at other
times, they become advocates for the staff in encouraging
the patient to cooperate with dreaded procedures.
With so many diverse personalities and specialists poten­
tially involved, purporting to know what or who constitutes
a burn team may seem absurd. Nevertheless, references to
“burn teams” are plentiful, and there is agreement on the
specialists and care providers whose expertise is required for
the optimal care of patients with significant burn injuries
(Fig. 2.1).
BURN SURGEONS
Ultimate responsibility and overall control for the care of a
patient lies with the admitting burn surgeon, the key figure
of the burn team. The burn surgeon is either a general
surgeon or plastic surgeon with expertise in providing
emergency and critical care, as well as in performing skin
grafting and amputations. The burn surgeon provides lead­
ership and guidance for the rest of the team, which may
include several surgeons. The surgeon’s leadership is par­
ticularly important during the early phase of patient care
when moment-to-moment decisions must be made based
on the surgeon’s knowledge of physiologic responses to
injury, current scientific evidence, and appropriate medical/
surgical treatments. The surgeon must not only possess
Table 2.1  Percent total body surface area (TBSA) burn
producing an expected mortality of 50% in 1952, 1993,
and 2006
Age (years)
1953†
(% TBSA)
1993*
(% TBSA)
2006°
(% TBSA)
0–14
49
98
99
15–44
46
72
88
45–65
27
51
75
65
10
25
33
†Bull, JP, Fisher, AJ. Annals of Surgery 1954;139.
*Shriners Hospital for Children and University of Texas Medical Branch,
Galveston, Texas.
°Pereira CT et al. J Am Coll Surg 2006; 202(3): 536–548 and unpublished data.
PP. 1138–1140 (PC65).

2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
10
comfort for burned patients, not only in the operating room,
but also during the painful ordeals of dressing changes,
staple removal, and physical exercise.
NURSES
Nurses represent the largest single disciplinary segment of
the burn team, providing continuous coordinated care to
the patient. The nursing staff is responsible for technical
management of the 24-hour physical treatment of the
patient. They control the therapeutic milieu that allows the
patient to recover. They also provide emotional support to
the patient and patient’s family.34 Nursing staff are often the
first to identify changes in a patient’s condition and initiate
therapeutic interventions. Because recovery from a major
burn is rather slow, burn nurses must merge the qualities
of sophisticated intensive care nursing with the challenging
aspects of psychiatric nursing. Nursing case management
can play an important role in burn treatment, extending
the coordination of care beyond hospitalization through
the lengthy period of outpatient rehabilitation.
PHYSICAL AND OCCUPATIONAL THERAPISTS
Occupational and physical therapists begin planning thera­
peutic interventions at the patient’s admission to maximize
functional recovery. Burned patients require special posi­
tioning and splinting, early mobilization, strengthening
exercises, endurance activities, and pressure garments to
promote healing while controlling scar formation. These
therapists must be very creative in designing and applying
the appropriate appliances. Knowledge of the timing of
application is necessary. In addition, rehabilitation thera­
pists must become expert behavioral managers since their
necessary treatments are usually painful to the recovering
patient who will resist in a variety of ways. While the patient
is angry, protesting loudly, or pleading for mercy, the reha­
bilitation therapist must persist with aggressive treatment
to combat quickly forming and very strong scar contrac­
tures. The same therapist, however, is typically rewarded
knowledge and skills in medicine, but also be able to clearly
exchange information with a diverse staff of experts in
other disciplines and lead the team. The surgeon alone
cannot provide comprehensive care but must be wise
enough to know when and how to seek counsel as well as
how to clearly and firmly give directions to direct activities
surrounding patient care. The senior surgeon of the team
is accorded the most authority and control of any member
of the team and thus bears the responsibility and receives
accolades for the success of the team as a whole.33
PLASTIC SURGEONS
Next to burn surgeons, who are particularly involved in the
immediate and acute phase of surgical treatment, are the
plastic surgeons, who are typically involved instead in long-
term surgical treatment. The plastic surgeons aim to deliver
care that yields the best functional and aesthetic results for
the burn survivor. The burn surgeon should always work in
close collaboration with the plastic surgeon. Most burn sur­
geons are plastic surgeons, but in instances where this is not
the case, the presence of plastic surgeons in the team is
essential. Ideally, this collaboration should start during the
initial phase of surgical treatment. The plastic surgeon’s
duty is primarily to care for the patient in terms of func­
tional improvement through surgeries that aim to lessen
scarring and decrease the functional limitations created by
scarring. This surgical treatment often requires numerous
operations that may take place for years after the burn
injury.
ANESTHESIOLOGISTS
An anesthesiologist who is an expert in the altered physio­
logic parameters of burned patients is critical to the sur­
vival of the patient who usually undergoes multiple acute
surgical procedures. Anesthesiologists on the burn team
must be familiar with the phases of burn recovery and the
physiologic changes to be anticipated as burn wounds heal.1
Anesthesiologists play significant roles in facilitating
B
A
Fig. 2.1  (A, B) Experts from diverse disciplines gather together with common goals and tasks and overlapping values to achieve their objectives.

2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
11
interventions provide continuous sensitivity in caring for
the emotional and mental well-being of patients and their
families. These professionals must be knowledgeable about
the process of burn recovery as well as human behavior
to make optimal interventions. They serve as confidants
and supports for patients, families of patients, and, on
occasion, other burn team members.35 They often assist
colleagues from other disciplines in developing behav­
ioral interventions for problematic patients, allowing the
colleague and patient to achieve therapeutic success.36
During initial hospitalization, these experts manage the
patient’s mental status, pain tolerance, and anxiety level to
provide comfort to the patient and facilitate physical recov­
ery. As the patient progresses toward rehabilitation, the
role of the mental health team becomes more prominent
in supporting optimal psychological, social, and physical
rehabilitation.
SPIRITUAL THERAPISTS
Not all patients and relatives are religious, but for those
who are religious, the presence of a spiritual therapist can
be extremely important and can help to overcome or deal
with the difficult times the burn survivors are experienc­
ing. The power and efficacy of prayer and religious-spiritual
involvement during illness and recovery have been often
discussed and have been demonstrated to be very impor­
tant for many patients.37 For these reasons, hospitals and
especially burn centers should have a spiritual therapist in
the team to assist not only the burn survivors but also their
relatives.38
MUSIC THERAPISTS
Music therapy is the use of music interventions to accom­
plish individualized goals within a therapeutic relationship
between the patient and the figure of the music therapist.
The principal goals and interventions can be designed to
promote wellness, manage stress, alleviate pain, express
feelings, enhance memory, improve communication, and
promote physical rehabilitation.39 As reported, music
therapy can improve a patient’s range of motion and help
during the hospitalization and rehabilitation periods.40 The
music therapist has an important role to play for burn
patients and should be considered an essential member of
the burn team.
STUDENTS, RESIDENTS, AND FELLOWS
Medical students, graduate students, postdoctoral fellows,
and residents are vital members of the burn care team.
Burn care professionals often do not have the time or
energy to perform activities outside of work hours or
set responsibilities. However, these young students,
fellows, and residents frequently have the time, energy,
and desire to take on additional work, whether in the
form of clinical work or research. The close working
relationship between these individuals and the rest of
the burn care team yields numerous benefits, includ­
ing the conception of new clinical and translational
questions that, when answered, directly improve patient
care.
with adoration and gratitude from an enabled burn
survivor.
RESPIRATORY THERAPISTS
Inhalation injury, prolonged bed rest, fluid shifts, and the
threat of pneumonia, all concomitant with burn injury,
render respiratory therapists essential to the patient’s
welfare. Respiratory therapists evaluate pulmonary mechan­
ics, perform therapy to facilitate breathing, and closely
monitor the status of the patient’s respiratory functioning
and improvements during the recovery.
EXERCISE PHYSIOLOGIST
The exercise physiologist has recently been recognized as a
key member of the comprehensive burn rehabilitation
team. Traditionally, exercise physiologists study acute and
chronic adaptations to a wide range of exercise conditions.
At our institution, the exercise physiologist performs clini­
cal duties and conducts clinical research.
Clinical duties include monitoring and assessing cardio­
vascular and pulmonary exercise function, as well as muscle
function. Additional clinical duties include writing exercise
prescriptions for cardiopulmonary and musculoskeletal
rehabilitation. Clinical research conducted by the exercise
physiologist mainly focuses on the effect of exercise on burn
sequelae and the mechanisms by which exercise can reduce
or reverse burn-induced catabolic and hypermetabolic con­
ditions and improve a patient’s quality of life.
There is no licensing body or requirements for exercise
physiologists to practice their profession. However, many
organizations, such as the American College of Sports Med­
icine and the Clinical Exercise Physiology Association, offer
national certifications. These certifications include the exer­
cise test technologist, exercise specialist, health/fitness
director, and clinical exercise specialist. We recommend
that if the exercise physiologist is primarily involved in clini­
cal duties, he or she should have a minimum of a master’s
degree and be nationally certified by a well-known and
respected organization. If clinical or basic research will be
part of his or her duties, then we recommend a doctorate
degree as well as a national certification.
NUTRITIONISTS
A nutritionist or dietitian monitors daily caloric intake and
weight maintenance. These specialists also recommend
dietary interventions to provide optimal nutritional support
to combat the hypermetabolic and catabolic responses to
burn injury. Caloric intake as well as intake of appropriate
vitamins, minerals, and trace elements must be managed to
promote wound healing and facilitate recovery. Nutrition­
ists and exercise physiologists may work together in imple­
menting methods to increase daily physical activity (caloric
expenditure) to counteract any sequelae due to a sedentary
lifestyle.
PSYCHOSOCIAL EXPERTS
Psychiatrists, psychologists, and social workers with
expertise in human behavior and psychotherapeutic

2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
12
culture, problem-solving approach, and language.48 For the
team to benefit fully from the expertise of its members,
every expert voice must be heard and acknowledged. Team
members must be willing to learn from each other, eventu­
ally developing their own culture and language that all can
understand. Attitudes of superiority and prejudice are most
disruptive to the performance of the team.
Disagreement and conflict will be present, but these can
be expressed and resolved in a respectful manner. Research
suggests that intelligent management of emotions is linked
with successful team performance in problem-solving and
conflict resolution.49 When handled well, conflicts and dis­
agreements can increase understanding and provide new
perspectives, in turn enhancing working relationships and
leading to improved patient care.50
The acknowledged formal leader of the team is the senior
surgeon, who may find the arduous job of medical and
social leadership difficult and perplexing (Fig. 2.1). Empiri­
cal studies indicate, with remarkable consistency, that the
functions required for successful leadership can be grouped
into two somewhat incompatible clusters: (1) directing the
group toward tasks and goal attainment and (2) facilitating
interactions among group members and enhancing their
feelings of worth.44,47,50
At times, task-oriented behavior by the leader may clash
with the needs of the group for emotional support. During
those times, the group may inadvertently impede the suc­
cessful performance of both the leader and the team by
seeking alternate means of establishing feelings of self-
worth. When the social/emotional needs of the group are
not met, the group begins to spend more time attempting
to satisfy individual needs and less time pursuing task-
related activities.
Studies of group behavior demonstrate that high-
performance teams are characterized by synergy between
task accomplishment and individual need fulfillment.44,51
Since one formal leader cannot always attend to task and
interpersonal nuances, groups informally or formally allo­
cate leadership activities to multiple persons.44,46,47 Accord­
ing to the literature in organizational behavior, the most
Dynamics and Functioning of the
Burn Team
Gathering a group of experts from diverse disciplines does
not form a team.41 In fact, the diversity of the disciplines,
along with individual differences in gender, ethnicity,
values, professional experience, and professional status,
render such teamwork a process fraught with opportunities
for disagreements, jealousies, and confusion.42 The process
of working together to accomplish the primary goal (i.e.,
returning burn survivors to a normal, functional life) is
further complicated by the fact that the patient and the
patient’s family must collaborate with these professionals.
It is not unusual for the patient to attempt to diminish his
or her immediate discomfort by pitting one team member
against another or “splitting” the team. Much as young
children will try to manipulate parents by first going to one
and then the other, patients will complain about one staff
member to another or assert to one staff member that
another staff member allows less demanding rehabilitation
exercises or some special privilege.43 Time must be devoted
to a process of trust building among the team members. It
is also imperative that the team communicate openly and
frequently or the group will lose effectiveness.
Communicating and discussing a daily, weekly, and long-
term management plan among team members allows for
clarification and organization of early plans to flag issues
early on with regard to further surgery, rehabilitation, dis­
charge planning, nutritional goals, patient understanding,
and patient compliance. Such issues are all simultaneously
addressed in a holistic approach.
The group becomes a team when they share common
goals and tasks as well as when they have overlapping
values that will be served by accomplishing their goals.44,45
The team becomes an efficient work group through a
process of establishing mechanisms of collaboration and
cooperation that facilitate focusing on explicit tasks rather
than on covert distractions of personal need and interper­
sonal conflict.44,46 Work groups develop best under condi­
tions that allow each individual to feel acknowledged as
valuable to the team.47
Multidisciplinary burn care involves taking into account
all aspects of patient care when treatment decisions are
made as well as considering subsequent effects and conse­
quences of decisions. With good communication and coor­
dination among all team members, the team can optimize
outcome for a patient in every aspect of their care (Fig. 2.1).
Research into the area of multidisciplinary teams has
highlighted the wide application of such teams in health-
care settings as well as some of the shortcomings affecting
their efficacy.41 Clearly defining the various components of
these teams will allow improved analysis. Some of the
factors that are useful for assessing how well a team is func­
tioning are listed in Box 2.1.
A burn team has defined and shared goals with clear
tasks. For a group of burn experts to become an efficient
team, skillful leadership that facilitates the development of
shared values among team members and ensures the vali­
dation of team members as they accomplish tasks is neces­
sary. The burn team consists of many experts from diverse
professional backgrounds; each profession has its own
(From Al-Mousawi et al., Burn Teams and Burn Centers,52 adapted from
Schofield & Amodeo41)
Box 2.1  Factors for analyzing multidisciplinary
team effectiveness and function
Size of team
Composition (professions represented)
Specific responsibilities
Leadership style (individual or co-leadership/voluntary or
assigned/stable or rotating/authoritarian or nonauthoritarian)
Scope of work (consultation or intervention or both/idea
generating/decision-making)
Organizational support
Communication and interactional patterns within the team (e.g.,
frequency/intensity/type)
Contact with the patient, family, or care system (e.g., frequency/
intensity/type)
Point in treatment process when team is involved (e.g., intake
through to discharge, one phase only, only if case not
progressing)

2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
13
continue improving and understanding the rehabilitation
and emotional, psychological, and physiologic recovery of
burn patients. Tremendous scientific and technological
advances have led to dramatic increases in the survival of
burn victims.
Wider issues to be considered by leaders in the field
include burn prevention, access to care in rural regions and
developing countries, and promotion of investment and
funding for burn care. Centralization of care at burn centers
as well as enhanced care have provided tremendous oppor­
tunities for research and education.
We hope that, in the future, scientists and clinicians will
follow the same model of collaboration to pursue solutions
to the perplexing problems that burn survivors must
encounter. Physical discomforts such as itching still inter­
fere with patient rehabilitation. New techniques for control­
ling hypertrophic scars and surgical reconstruction could
do much to diminish disfigurement.52 The use of treatments
to attenuate hypermetabolism, use of anabolic agents,19,27
and supervised strength and endurance training22,23 are all
currently being investigated as means of enhancing the
well-being of survivors of massive burn injuries. Further
development of psychological expertise within burn care
and increased public awareness of the competence of burn
survivors may ease the survivor’s transition from an inca­
pacitated patient to a functional member of society. We
hope that, in the future, burn care will continue to devote
the same energy and resources that have produced such
tremendous advances in saving lives and optimizing the
quality of life for survivors.
Complete references available online at

effective leader is one who engages the talents of others and
empowers them to utilize their abilities to further the work
of the group.44,46 Failure to empower the informal leaders
limits their ability to contribute fully.
For the identified leader of the burn team (i.e., the senior
surgeon) to create a successful, efficient burn team, the
leader must be prepared to share leadership with one or
more “informal” leaders in such a way that all leadership
functions are fulfilled.44,46,47 The prominence and identity of
any one of the informal leaders will change according to
the situation. The successful formal leader will encourage
and support the leadership roles of other members of the
team, developing a climate in which the team members are
more likely to cooperate and collaborate toward achieve­
ment beyond individual capacity.
For many physicians, the concept of sharing leadership
and power initially appears threatening, for it is the physi­
cian, after all, who must ultimately write the orders and be
responsible for the patient’s medical needs. However,
sharing power does not mean giving up control. The physi­
cian shares leadership by seeking information and advice
from other team members and empowers them by validat­
ing the importance of their expertise in the decision-making
process. However, the physician maintains control and
responsibility over the patient’s care and medical
treatment.
Summary
Centralized care provided in designated burn units has pro­
moted a team approach to both scientific investigation and
clinical care that has demonstrably improved the welfare of
burn patients. Multidisciplinary efforts are imperative to

13.e1
2  •  Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
26. Suman OE, Mlcak RP, Herndon DN. Effects of exogenous growth
hormone on resting pulmonary function in children with thermal
injury. J Burn Care Rehabil. 2004;25(3):287-293.
27. Murphy KD, Thomas S, Mlcak RP, et al. Effects of long-term oxan­
drolone administration in severely burned children. Surgery.
2004;136(2):219-224.
28. Herndon DN, Stein MD, Rutan TC, Abston S, Linares H. Failure of TPN
supplementation to improve liver function, immunity, and mortality
in thermally injured patients. J Trauma. 1987;27(2):195-204.
29. Herndon DN, Barrow RE, Stein M, et al. Increased mortality with
intravenous supplemental feeding in severely burned patients. J Burn
Care Rehabil. 1989;10(4):309-313.
30. Thomas S, Wolf SE, Murphy KD, Chinkes DL, Herndon DN. The long-
term effect of oxandrolone on hepatic acute phase proteins in severely
burned children. J Trauma. 2004;56(1):37-44.
31. Demling RH, DeSanti L. Oxandrolone induced lean mass gain during
recovery from severe burns is maintained after discontinuation of the
anabolic steroid. Burns. 2003;29(8):793-797.
32. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism
after severe burn. Surgery. 2000;128(2):312-319.
33. Shakespeare PG. Who should lead the burn care team? Burns.
1993;19(6):490-494.
34. Callejas Herrero A, Cuadrado Rodriguez C, Pena Lorenzo A, Diez Sanz
MJ. [Psychosocial nursing care patient with major burns]. Rev Enferm.
2014;37(2):59-64.
35. Morris J, McFadd A. The mental health team on a burn unit: a multi­
disciplinary approach. J Trauma. 1978;18(9):658-663.
36. Hughes TL, Medina-Walpole AM. Implementation of an inter­
disciplinary behavior management program. J Am Geriatr Soc.
2000;48(5):581-587.
37. Ameling A. Prayer: an ancient healing practice becomes new again.
Holist Nurs Pract. 2000;14(3):40-48.
38. Saad M, de Medeiros R. Programs of religious/spiritual support in
hospitals: five “whies” and five “hows”. Philo Ethics Humanit Med.
2016;11(1):5.
39. Koelsch S. Music-evoked emotions: principles, brain correlates, and
implications for therapy. Ann NY Acad Sci. 2015;1337:193-201.
40. Neugebauer CT, Serghiou M, Herndon DN, Suman OE. Effects of a
12-week rehabilitation program with music & exercise groups on
range of motion in young children with severe burns. J Burn Care
Res. 2008;29(6):939-948.
41. Schofield RF, Amodeo M. Interdisciplinary teams in health care
and human services settings: are they effective? Health Soc Work.
1999;24(3):210-219.
42. Fallowfield L, Jenkins V. Effective communication skills are the key to
good cancer care. Eur J Cancer. 1999;35(11):1592-1597.
43. Perl E. Treatment team in conflict: the wishes for and risks of consen­
sus. Psychiatry. Summer 1997;60(2):182-195.
44. Harris P, Harris DL. High performance team management. Leadership
Org Dev J. 1989;10(4):28-32.
45. Miller E, Rice A. Systems of organization. In: Coleman A, Bexton W,
eds. Group Relations Reader. Sausalito, CA: Grex; 1975:43-68.
46. Yank GR, Barber JW, Hargrove DS, Whitt PD. The mental health treat­
ment team as a work group: team dynamics and the role of the leader.
Psychiatry. 1992;55(3):250-264.
47. Litterer J. The Analysis of Organizations. 2nd ed. John Wiley & Sons;
1973.
48. Hall P. Interprofessional teamwork: professional cultures as barriers.
J Interprof Care. 2005;19(suppl 1):188-196.
49. Jordan PJ, Troth AC. Managing emotions during team problem
solving: emotional intelligence and conflict resolution. Hum Perform.
2004;17(2):195-218.
50. Van Norman G. Interdisciplinary team issues – online publication.
1998. Available from:
team.html.
51. Al-Mousawi AM, Mecott-Rivera GA, Jeschke MG, Herndon DN. Burn
teams and burn centers: the importance of a comprehensive team
approach to burn care. Clin Plast Surg. 2009;36(4):547-554.
52. Constable JD. The state of burn care: past, present and future. Burns.
1994;20(4):316-324.
References
1. Artz CP, Moncrief JA. The burn problem. In: The Treatment of Burns.
2nd ed. Philadelphia, PA: W B Saunders; 1969:1-21.
2. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised esti­
mate. Ann Surg. 1954;139(3):269-274.
3. Pereira CT, Barrow RE, Sterns AM, et al. Age-dependent differences in
survival after severe burns: a unicentric review of 1,674 patients and
179 autopsies over 15 years. J Am Coll Surg. 2006;202(3):536-548.
4. Baxter CR, Marvin J, Curreri PW. Fluid and electrolyte therapy of burn
shock. Heart Lung. 1973;2(5):707-713.
5. Carvajal HF. Fluid therapy for the acutely burned child. Compr Ther.
1977;3(3):17-24.
6. Evans EI, Purnell OJ, Robinett PW, Batchelor A, Martin M.
Fluid and electrolyte requirements in severe burns. Ann Surg.
1952;135(6):804-817.
7. Curreri PW, Richmond D, Marvin J, Baxter CR. Dietary requirements
of patients with major burns. J Am Diet Assoc. 1974;65(4):415-417.
8. Hildreth MA, Herndon DN, Desai MH, Duke MA. Reassessing
caloric requirements in pediatric burn patients. J Burn Care Rehabil.
1988;9(6):616-618.
9. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and immediate
grafting: a method shortening illness. J Trauma. 1974;14(5):389-395.
10. Desai MH, Herndon DN, Broemeling L, et al. Early burn wound exci­
sion significantly reduces blood loss. Ann Surg. 1990;211(6):753-
759, discussion 759-762.
11. Desai MH, Rutan RL, Herndon DN. Conservative treatment of
scald burns is superior to early excision. J Burn Care Rehabil.
1991;12(5):482-484.
12. Engrav LH, Heimbach DM, Reus JL, Harnar TJ, Marvin JA. Early
excision and grafting vs. nonoperative treatment of burns of
indeterminant depth: a randomized prospective study. J Trauma.
1983;23(11):1001-1004.
13. Herndon DN, Barrow RE, Rutan RL, et al. A comparison of conserva­
tive versus early excision. Therapies in severely burned patients. Ann
Surg. 1989;209(5):547-552, discussion 552-543.
14. Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;10(12):1103-1108.
15. Cioffi WG Jr, Rue LW 3rd, Graves TA, et al. Prophylactic use of high-
frequency percussive ventilation in patients with inhalation injury.
Ann Surg. 1991;213(6):575-580, discussion 580-572.
16. Herndon DN, Barrow RE, Linares HA, et al. Inhalation injury
in burned patients: effects and treatment. Burns Incl Therm Inj.
1988;14(5):349-356.
17. Herndon DN, Barrow RE, Traber DL, et al. Extravascular lung water
changes following smoke inhalation and massive burn injury. Surgery.
1987;102(2):341-349.
18. Shirani KZ, Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury
and pneumonia on burn mortality. Ann Surg. 1987;205(1):82-87.
19. Hart DW, Wolf SE, Ramzy PI, et al. Anabolic effects of oxandrolone
after severe burn. Ann Surg. 2001;233(4):556-564.
20. Wilmore DW, Long JM, Mason AD Jr, Skreen RW, Pruitt BA Jr. Cat­
echolamines: mediator of the hypermetabolic response to thermal
injury. Ann Surg. 1974;180(4):653-669.
21. Hart DW, Wolf SE, Chinkes DL, et al. Determinants of skeletal muscle
catabolism after severe burn. Ann Surg. 2000;232(4):455-465.
22. Celis MM, Suman OE, Huang TT, Yen P, Herndon DN. Effect of a super­
vised exercise and physiotherapy program on surgical interventions in
children with thermal injury. J Burn Care Rehabil. 2003;24(1):57-61,
discussion 56.
23. Suman OE, Thomas SJ, Wilkins JP, Mlcak RP, Herndon DN. Effect of
exogenous growth hormone and exercise on lean mass and muscle
function in children with burns. J Appl Physiol. 2003;94(6):2273-
2281.
24. Low JF, Herndon DN, Barrow RE. Effect of growth hormone on
growth delay in burned children: a 3-year follow-up study. Lancet.
1999;354(9192):1789.
25. Cucuzzo NA, Ferrando A, Herndon DN. The effects of exercise pro­
gramming vs traditional outpatient therapy in the rehabilitation of
severely burned children. J Burn Care Rehabil. 2001;22(3):214-220.

14
Epidemiological, Demographic
and Outcome Characteristics of
Burns
STEVEN E. WOLF, LEOPOLDO C. CANCIO, and BASIL A. PRUITT
3 
are interesting. The total number of burns have generally
decreased in those aged 0–45, whereas the total number of
burns in those older than 45 have increased dramatically,
31% from 2005 to 2014 in those aged 46–65, and 12% in
those aged over 65 (Table 3.1).
The spike seen in total injuries between 2010 and 2012
is parallel with burns in those aged 0–4 but has settled back
to a 6% decline in this age group from that in 2005. For
those aged 5–18, we see a similar steady decline in the
number of burns, and also in those aged 19–45. However
the numbers of burns in those aged 46–65 and in those
older than 65 years have seen a steady and dramatic
increase. When indexed to population, this is almost com­
pletely accounted for by the increase in population in these
age groups. Therefore no increase in per capita rate has
occurred, and the increased numbers are from an increase
in the population of those aged over 45 years.
When considering plans in health care utilization to
respond to changes in the incidence of burns, strategies
should be for the total number of burns likely to be encoun­
tered. For regional plans, per capita estimations should be
used as specific regions grow and contract. In this light, the
past 10 years have seen a significant decrease in the total
number of burns in those aged 45 years and younger. Popu­
lations in the United States are generally stable for these age
groups in the past 10 years, thus the decline in total
numbers of burns must be attributed to cultural changes
and prevention efforts, both legislative and educational.
Therefore future resource utilization for the care of burns
in this age group in the United States will likely continue to
diminish unless some change occurs in the population.
However those older than 45 years continue to increase in
many areas, and thus considerations might be made to plan
for further growth in burns in older persons.
We then analyzed the epidemiologic data from the
National Burn Repository (NBR) available from the Ameri­
can Burn Association for the years 2006–2015.2 In this, we
examined recent trends in burn incidence and qualities in
the United States. The NBR contains data from 96 of the128
self-designated burn centers in the United States as well as
7 burn centers in Canada, Sweden, and Switzerland. Of
these 96 centers, 65 were verified as a burn center using
American Burn Association criteria. The data we include
here come only from the reporting US centers.
The distribution of burns among age groups in the NBR
data has more granularity than does the WISQAR data.
Burn distribution has a major grouping in those younger
than 10 years of age. Those aged 11–20 have a smaller
incidence, which then increases in those aged 21–60;
Introduction
In 2014, approximately 200,000 deaths occurred in the
United States from all injuries, and 31 million sustained
nonfatal injuries. In a population of 318,857,056 persons,
this represents a per capita death rate from injury of
0.063% (or approximately 6 per 10,000), and a nonfatal
injury rate of 9.73% (or approximately 1 in 10). Therefore
injury is common but related death is uncommon. For inju­
ries from fire and burns specifically, 3,194 deaths occurred
(1/100,000 population), which represented 1.6% of all
injury fatalities but only 1.3% of injuries. In all, 408,945
nonfatal burns occurred in the United States in 2014,
giving a rate of 0.129% of persons in the United States
sustaining a burn, or about 1 per 1000.
We constructed trend lines in addition to the preceding
data in the rate of reported injuries and death since 2005.
These data were found on the WISQAR database produced
by the U.S. Centers for Disease Control and Prevention
(CDC).1 We found that total injuries were relatively
unchanged in this period from 2005 to 2009, then saw a
large spike (a 10% increase) from 2010 to 2012. This spike
has since receded (Fig. 3.1). When seen on a per capita
basis, a 7.5% increase in the rate of reported injury occurred
in the 2010–2012 period; therefore the spike in reported
injuries was not from an increase in population; this is an
interesting societal trend. Of further interest is the increase
in injury fatalities which began at the same time and is
mostly associated with an increased injury mortality rate (a
12.3% increase from 0.57% to 0.64%). This continues to
rise despite a subsequent decline in total and per capita
injuries. Whether this is from an increase in injury severity
or age distribution cannot be answered in these data. A
potential reason is a perceived increase in the use of pallia­
tive withdrawal of care, suggesting that those who might
live with known treatments are unnecessarily adding to the
mortality rate.
The incidence of total burns saw a similar spike in the
2010–2012 period, but this was not reflected in the per
capita statistics, likely because of blunting by the relatively
low incidence of burns (Fig. 3.2). Interestingly burn fatali­
ties continue to decrease overall with a flattening trajectory
in 2013–2014. The per capita numbers also showed a
decline that has leveled at 0.001% (1 in 100,000). What is
not seen is an increase in burn fatality rate that is evident
in the all-injury fatality rate.
Burns occur unequally among the age groups in the
WISQAR data, and the interim changes from 2005 to 2014

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
15
A
B
C
E
D
29000000
29500000
30000000
30500000
31000000
31500000
32000000
32500000
33000000
Total injuries
2004
2006
2008
2010
2012
2014
9.60%
9.70%
9.80%
9.90%
10.00%
10.10%
10.20%
10.30%
10.40%
10.50%
Per capita injuries
2004
2006
2008
2010
2012
2014
0.56%
0.57%
0.58%
0.59%
0.60%
0.61%
0.62%
0.63%
0.64%
0.65%
Injury fatality rate
2004
2006
2008
2010
2012
2014
0.057%
0.058%
0.059%
0.060%
0.061%
0.062%
0.063%
Injury fatalities per capita
2004
2006
2008
2010
2012
2014
170000
175000
180000
185000
190000
195000
200000
205000
Injury fatalities
2004
2006
2008
2010
2012
2014
Fig. 3.1  Injury statistics taken from the WISQARS database maintained by the U.S. Centers for Disease Control and Prevention. Panel A describes the
total number of reported injuries from the period 2005–2014. The y-axis is the total number of injuries. The trendline is the moving average of the
adjoining two values. Panel B describes the per capita incidence of reported injuries in %, calculated by dividing the number of injuries by population
for that year. Panel C describes the total number of fatalities ascribed to injury for the years 2005–2014. Panel D is the injury fatality rate by year cal­
culated by dividing the number of fatalities by the number of reported injuries. Panel E is the injury fatalities per capita, calculated by dividing the
number of fatalities by the population for that year.

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
16
A
B
C
E
D
380000
390000
400000
410000
420000
430000
440000
450000
460000
Total burns
0.000%
0.020%
0.040%
0.060%
0.080%
0.100%
0.120%
0.140%
0.160%
0.180%
Per capita burns
0
500
1000
1500
2000
2500
3000
3500
4000
Burn fatalities
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
0.90%
1.00%
Burn fatality rate
0.0000%
0.0002%
0.0004%
0.0006%
0.0008%
0.0010%
0.0012%
0.0014%
Burn fatalities per capita
2004
2006
2008
2010
2012
2014
2004
2006
2008
2010
2012
2014
2004
2006
2008
2010
2012
2014
2004
2006
2008
2010
2012
2014
2004
2006
2008
2010
2012
2014
Fig. 3.2  Burn injury statistics taken from the WISQARS database maintained by the U.S. Centers for Disease Control and Prevention. Panel A describes
the total number of injuries from the period 2005–2014. The y-axis is the number of injuries, with the included trendline the moving average of the
two adjoining values. Panel B describes the per capita incidence with a trendline similarly calculated. Panel C is the number of fatalities with Panel D
as the corresponding fatality rate. Finally, Panel E is the per capita burn fatalities.

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
17
Table 3.1  Burn Mortality Rates Over Time.
BURNS
ALL
FATAL
Age
Year
Nonfatal
Fatal
Total
Mortality (%)
Population
Per Capita Burn (%)
Per Capita Burn (%)
0–4
2005
71935
279
72214
0.4
19917400
0.36
0.0014
2006
64821
250
65071
0.4
19938883
0.33
0.0013
2007
63207
266
63473
0.4
20125962
0.32
0.0013
2008
60571
219
60790
0.4
20271127
0.30
0.0011
2009
58400
208
58608
0.4
20244518
0.29
0.0010
5-yr Avg
63787
244
64031
0.4
20099578
0.32
0.0012
2010
61091
212
61303
0.3
20201362
0.30
0.0010
2011
67225
172
67397
0.3
20125958
0.33
0.0009
2012
68130
141
68271
0.2
19980310
0.34
0.0007
2013
63297
165
63462
0.3
19867849
0.32
0.0008
2014
57117
151
57268
0.3
19876883
0.29
0.0008
5-yr Avg
63372
168
63540
0.3
20010472
0.32
0.0008
10-yr Avg
63579
206
63786
0.3
20055025
0.32
0.0010
5–18
2005
74159
312
74471
0.4
57831395
0.13
0.0005
2006
66652
279
66931
0.4
58119881
0.12
0.0005
2007
61400
300
61700
0.5
58288081
0.11
0.0005
2008
63831
229
64060
0.4
58421598
0.11
0.0004
2009
52910
208
53118
0.4
58424283
0.09
0.0004
5-yr Avg
63790
266
64056
0.4
58217048
0.11
0.0005
2010
60711
198
60909
0.3
58480960
0.10
0.0003
2011
61699
187
61886
0.3
58193935
0.11
0.0003
2012
62847
154
63001
0.2
58091861
0.11
0.0003
2013
58077
197
58274
0.3
58038492
0.10
0.0003
2014
55991
170
56161
0.3
57932325
0.10
0.0003
5-yr Avg
59865
181
60046
0.3
58147515
0.10
0.0003
10-yr Avg
61828
223
62051
0.4
58182281
0.11
0.0004
19–45
2005
208907
929
209836
0.4
112647339
0.19
0.0008
2006
203442
878
204320
0.4
112514315
0.18
0.0008
2007
191442
874
192316
0.5
112442872
0.17
0.0008
2008
182288
694
182982
0.4
112505361
0.16
0.0006
2009
173432
717
174149
0.4
112716130
0.15
0.0006
5-yr Avg
191902
818
192721
0.4
112565203
0.17
0.0007
2010
190820
632
191452
0.3
112814655
0.17
0.0006
2011
194082
627
194709
0.3
113358991
0.17
0.0006
2012
197541
549
198090
0.3
114032337
0.17
0.0005
2013
181735
620
182355
0.3
114758868
0.16
0.0005
2014
178110
628
178738
0.4
115429655
0.15
0.0005
5-yr Avg
188458
611
189069
0.3
114078901
0.17
0.0005
10-yr Avg
190180
715
190895
0.4
113322052
0.17
0.0006
46–65
2005
70827
1028
71855
1.4
70711525
0.10
0.0015
2006
72704
1124
73828
1.5
72928734
0.10
0.0015
2007
74386
1132
75518
1.5
74994337
0.10
0.0015
2008
79990
1110
81100
1.4
76870172
0.11
0.0014
2009
74215
1035
75250
1.4
78416768
0.10
0.0013
5-yr Avg
74424
1086
75510
1.4
74784307
0.10
0.0015
2010
79685
1068
80753
1.3
79661338
0.10
0.0013
2011
84717
1095
85812
1.3
81352090
0.11
0.0013
2012
82370
1044
83414
1.3
82417467
0.10
0.0013
2013
79213
1120
80333
1.4
82497447
0.10
0.0014
2014
92813
1081
93894
1.2
82759431
0.11
0.0013
5-yr Avg
83760
1082
84841
1.3
81737555
0.10
0.0013
10-yr Avg
79092
1084
80176
1.4
78260931
0.10
0.0014
>65
2005
22054
1183
23237
5.1
34408940
0.07
0.0034
2006
22277
1136
23413
4.9
34878099
0.07
0.0033
2007
20393
1196
21589
5.5
35379955
0.06
0.0034
2008
23449
1127
24576
4.6
36025708
0.07
0.0031
2009
22034
1026
23060
4.4
36969830
0.06
0.0028
Continued

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
18
increase significantly with burn size (as expected), which
was almost linear with increasing burned area (regression
formula y = x – 13.7, r2 = 0.97) (Fig. 3.4). This is a change
from previous mortality rates, which was mostly a first-
order distribution. According to this formula, probability of
mortality for a burn (without considering age) can be esti­
mated at %TBSA burned minus 14.
We did a probit analysis on the overall mortality data
which revealed an LD50 for a 55% TBSA burn among all
age groups. Thus a 55% TBSA burn would be expected to
have a mortality rate of 50%; this is an improvement from
previous reports.3 When the Baux score (age plus TBSA
burned) was examined for mortality, a 50% mortality was
reported at about 105 and a 90% mortality was reported
at 130.
Demography
Geographic and housing tract location significantly influ­
ences the rate of house fires and the subsequent death rates
from associated burns. Age of the home, economic status,
number of vacant houses, and immigration status affect
the house fire rate.4–5 House fire death rates are higher in
Table 3.1  Burn Mortality Rates Over Time.—cont’d
BURNS
ALL
FATAL
Age
Year
Nonfatal
Fatal
Total
Mortality (%)
Population
Per Capita Burn (%)
Per Capita Burn (%)
5-yr Avg
22041
1134
23175
4.9
35532506
0.07
0.0032
2010
19872
1083
20955
5.2
37587223
0.06
0.0029
2011
21465
1087
22552
4.8
38690658
0.06
0.0028
2012
26219
1021
27240
3.7
39590103
0.07
0.0026
2013
25449
1114
26563
4.2
41334875
0.06
0.0027
2014
24914
1164
26078
4.5
42858762
0.06
0.0027
5-yr Avg
23584
1094
24678
4.5
40012324
0.06
0.0027
10-yr Avg
22813
1114
23926
4.7
37772415
0.06
0.0030
Burn incidence (2006–2015)
Age (yrs)
0–10
11–20
21–30
31–40
41–50
51–60
61–70
71–80
> 80
n
0
10000
20000
30000
40000
50000
Fig. 3.3  Burn-specific injury statistics taken from the WISQARS data­
base. These are the number of recorded injuries in each age group.
Mortality by burn size
TBSA burned (%)
0
20
40
60
80
100
Mortality rate (%)
0
20
40
60
80
100
Fig. 3.4  Reported mortality by burn size.
thereafter the total numbers decline (Fig. 3.3) for a bimodal
distribution when grouped in this way. Among these, 67%
were in men, which is similar to previous reports of burns
by gender. In terms of ethnicity, 58% of burns in the United
States were in European-Americans, 21% in African-
Americans, 13% in Hispanic-Americans, 5% in other eth­
nicities, and 3% in Asian-Americans.
Most burns were below 10% total body surface (TBSA),
which included 78% of the burned population. Another
14% measured 11–20% TBSA, and the remaining 8% were
greater than 20% TBSA. These numbers are all from desig­
nated burn centers, and it is likely that many additional
burns below 10% TBSA were treated in nonburn centers.
With this in mind, it is likely that almost all burns over 10%
were treated at burn centers, thus the distribution in the
NBR data is likely to be biased to larger burns from the true
incidence in the United States.
Most burns were the result of injuries due to fire and
flame at 41% of the total. Scalds accounted for another
33%, followed by contact with hot objects at 9%, and then
chemical and electrical burns at 3% each. Overall mortality
for those with burns was 3.1% during this period, which
declined by almost 25% from 4.0% in 2006. Mortality was
generally higher in women, except in 2015. Deaths did

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
19
geographic area from a low rate of 1.4/100,000 population
in North America to a high of 10.8/100,000 population in
Africa.1,10 It has been estimated that 113,108 children aged
18 and younger were treated for burns in the United States
in 2014. Of those injuries, approximately 60% were scald
burns in those under 5 years of age; contact burns, 20%;
fire/flame, 15%; and 5%, other.2 For those aged 5–18, scalds
accounted for approximately 33% of injuries; fire/flame,
45%; contact, 10%; and other, 12%, demonstrating a shift
from scalds to fire and flame with increasing age. In 2013,
334 children died from fires or burns, and 44% of these
were 4 years of age and younger.9
Scald burns are the most common cause of burns in the
particularly young. The occurrence of tap water scalds can
be prevented by adjusting the temperature settings on hot
water heaters or by installing special faucet valves so that
water does not leave the tap at temperatures above 120°F
(48.8°C).9,11 All code-making bodies at the national and
regional levels have established standards for new or recon­
structed dwellings requiring antiscald technology and a
maximum water temperature of 120°F.
Home exercise treadmills represent a recently identified
source of burns in pediatric patients. The injuries are a con­
sequence of contact with a moving treadmill and almost
always involve the upper extremity (97%), often the volar
surface of the hand.12 Approximately 50% undergo surgical
intervention in the form of skin grafting, and some develop
hypertrophic scars.13
ELDERLY
The elderly represent an increasing population segment, as
previously described, and they have an increased preva­
lence in the burned population due to increased numbers
as well as increased risk of being burned. Furthermore mor­
tality from burns increases with age. The WISQAR data
demonstrate that about 6% of all burns occur in those older
than 65 years, although other reports from single centers
approach 16% of all admissions for burns,14 and mortality
in this age group is significantly higher than that of all
other ages, at 4.7% of all over 65 years of age who are
burned compared to between 0.4% and 1.4% in all other
age groups.
Interestingly the rates of burn by gender are almost even
in the elderly who are burned, 51% in men and 49% in
women. In an older paper, it was noted that 67% of injuries
in the elderly are caused by flame or explosion, 20% by
scalds, 6% by electricity, 2% by chemicals, and 6% by other
causes. Forty-one percent of the injuries occurred in the
bedroom and/or living room, 28% out of doors or in the
workplace, 18% in the kitchen, 8% in the bathroom, and
5% in the garage or basement. Seventy-seven percent of the
patients had one or more preexisting medical conditions.15
Examination of predictors of mortality revealed that the
usual signals such as increasing age, burn size, and inhala­
tion injury continue to remain the most useful in this age
group, but each of these had much more impact on mortal­
ity than in other age groups, as reflected by the much higher
mortality rate.14 Several authors reported lower mortality
rates in the elderly than expected from standard prediction
models, such as those from Bull, ASBI, and Ryan,16 indicat­
ing that we are improving in this age group as well.
the Eastern part of the United States, particularly the
Southeast, compared to the West.6 Cooking is the leading
cause of house fires in the United States: 46% of house fires
and 44% of fire-related injuries are by this cause.7 Another
leading cause of house fires is from heating equipment at
16% of instances. Other causes include electrical system
fires (9%), intentional fires (8%), and fires from cigarette
smoking (5%). Interestingly the cause of fire with the
highest mortality is that from cigarette smoking, compris­
ing 22% of residential fire-related deaths (Table 3.2). The
ratio of deaths compared to other causes is also much
higher in this group, at 4.4.
Gratifyingly the number of residential fires has dramati­
cally decreased since 2004, falling 22%; similarly related
fire death rates have fallen by the same amount. Injuries,
however, have only gone down by 7%, suggesting that in
those fires that do occur, more injuries are occurring.8
Interestingly fire death rates are reduced by 50% with
working fire alarms.9 When the rate of fire deaths is consid­
ered by state, we find these are highest in Alabama, Alaska,
Arkansas, District of Columbia, Mississippi, Oklahoma,
Tennessee, and West Virginia. The lowest rates are Arizona,
California, Colorado, Florida, Massachusetts, Nevada, New
Jersey, Texas, and Utah.
The economic consequences of residential fires are also
great. The highest fire-related losses in recent history were
in 2008, with $16.7 billion in property damage and other
direct costs. This has significantly fallen since then, with a
reported $11.5 billion in losses in 2013.8 The healthcare
costs of burns are also prodigious. Each year in the United
States, 40,000–60,000 people undergo in-hospital care for
burns. The average charges for hospital care of a burned
patient range from $47,557.00 to $1,203,410.00 (average
$92,377), with much higher costs incurred by patients
with extensive burns. The length of hospital stay ranges
from one day to hundreds of days (mean 9.7), and, for
patients 80 years and older is more than twice as long as
that for children under 5.2
High-Risk Populations
CHILDREN
The number of pediatric burn patients admitted to hospitals
is influenced by cultural differences, resource availability,
and medical practice. Consequently the number of pediatric
burn patients admitted to a hospital for treatment varies by
Table 3.2  Causes of Burn Injuries.
Fires
(%)
Injuries
(%)
Deaths
(%)
Odds Ratio
of Death
Cooking Equipment
46
44
19
0.4
Heating Equipment
16
12
19
1.2
Electrical Equipment
9
9
16
1.8
Intentional
8
7
14
1.8
Smoking
5
10
22
4.4

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
20
of burned patients had injuries of more than 40% TBSA,
and only 21% had burns of less than 10% TBSA. After
institution of garment and fire-extinguisher policies, in the
1982 Israeli conflict those same categories of burns repre­
sented 18% and 51%, respectively, of all burn injuries.
Modern weaponry may have eliminated the differential
incidence of burns between armored fighting vehicle per­
sonnel and those in other combat elements. One of every
seven casualties had burns in the British and Argentinean
forces in the 1982 Falkland Islands conflict in which there
was little if any involvement of armored fighting vehi­
cles.24,25 Conversely only 36 (7.8%) burns were sustained in
the total 458 casualties in the U.S. Forces during Operation
Desert Shield/Desert Storm in 1990–1991, in which there
was extensive involvement of armored fighting vehicles.
In the most recent armed conflicts, Operations Iraqi
Freedom and Enduring Freedom, the U.S. Army Burn Center
(U.S. Army Institute of Surgical Research [ISR]) in San
Antonio, Texas, provided care for all military patients who
sustained burns. Trained burn surgeons from the ISR pro­
vided care at the Burn Center in San Antonio; at a general
hospital in Landstuhl, Germany, while in transit from the
theater of operations to the continental United States; as
well as at the Level III hospital in-theater (Balad, Iraq).
During this conflict, approximately 900 combat casualties
were admitted to the burn center, among whom 34 expired
(3.9%).27 Interestingly another 11 expired within 10 years
of injury from either a drug overdose (5), another combat
injury (3), or a motor vehicle crash (3).28 Therefore about
10% of deaths occurred from self-induced overdose, which
should be investigated further and mitigated. On average,
definitive care was administered in the United States within
96 hours of injury, which was accomplished through active
use of the Global Patient Movement Regulating Center and
the Burn Flight Team. This team consists of Army person­
nel who work with existing Air Force crews to support and
rapidly transport severely burned patients from theater.
In this conflict, more than 250 critically ill patients were
transported successfully, with only one mortality during the
flight.29
The U.S. Army Burn Center maintains readiness by
caring for civilians in south Texas, and this activity contin­
ued during the conflict. When examined, these two popula­
tions who were cared for by the same personnel with the
same equipment showed no differences in outcomes when
those of the same ages were compared. Interestingly the
burn size distributions of both groups were the same and
were similar to that reported from the general databases at
the beginning of this chapter.30
Burn Etiologies
FIRE/FLAME
Flame is the predominant cause of burns (43%) in patients
admitted to burn centers, particularly in the adult age
group.2 Misuse of fuels and flammable liquids is a common
cause of burns, constituting 66% of flame injuries.31 The
predominant affected population is young men, and the
distribution of burn sizes is similar to that of all burns.32
However mortality rates are higher than in the general
A recently identified factor in burns in the elderly are
those in relation to dementia. Harvey and others identified
a 1.6 odds ratio of burns between the aged with and without
dementia. In addition, the burns were more likely to be
larger, were more likely associated with ignition of clothing
or scalds, and hospital length of stay was twice as long.17
DISABLED
The disabled are a group of patients considered to be burn-
prone and are often injured in the home in incidents associ­
ated with scalds. From a report in 1993, the effects of
disability and preexisting disease in those patients are
evident in the duration of hospital stay (27.6 days on
average) and the death rate (22.2%) associated with the
modest average extent of burn (10% TBSA).18 Another
report on burns in generally elderly patients with dementia
(who were also disabled) emphasized prevention measures
to reduce the incidence of burns when such patients are
performing the activities of daily living.19
MILITARY PERSONNEL
In wartime, military personnel are at high risk for burns
both related to combat and nonintentional causes. The inci­
dence of burns is associated with the types of weapons
employed and combat units engaged and has ranged from
2.3% to as high as 85% in a number of conflicts over the
past 8 decades. The detonation of a nuclear weapon at Hiro­
shima in 1945 instantaneously generated an estimated
57,700 burned patients and destroyed many treatment
facilities, which thereby compromised their care.20 In the
Vietnam conflict, as a consequence of the total air superior­
ity achieved by the U.S. Air Force and the lack of armored
fighting vehicle activity, those with burns constituted only
4.6% of all patients admitted to Army medical treatment
facilities from 1963 to 1975.21 Approximately 60% of the
13,047 burned patients were nonbattle injuries. Further­
more in the Panama police action in late 1989, the low
incidence of burns (only 6 or 2.3% of the total 259 casual­
ties had burns) has been attributed to the fact that the
action involved only infantry and airborne forces using
small-arms weaponry.
Burns during conflicts have not always been this low, as
exemplified by the Israeli conflicts of 1973 and 1982, and
the British Army of the Rhine experience in World War II.
Both of these conflicts were dense, with personnel in
armored fighting vehicles who had a relatively high inci­
dence of burns.22,23 Burns have also been common injuries
in war at sea, such as in the Falkland Islands campaign of
1982: 34% of all casualties from the British Navy ships
were burns.24,25 The increased incidence of burns, 10.5%
and 8.6% in the Israeli conflicts of 1973 and 1982, respec­
tively, as compared to the 4.6% incidence in the 1967 Israeli
conflict, was considered to reflect what has been termed
“battlefield saturation” with tanks and antitank weap­
onry.22,26 Decreasing incidence of burns in armored vehicle
combat has been attributed to enforced use of flame-
retardant garments and the effectiveness of an automatic
fire extinguishing system within tanks.26 Those factors have
also been credited with reducing the extent of the burns
that did occur. For example, in the 1973 Israeli conflict 29%

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
21
particularly in children younger than 5 years of age and in
the elderly.
CONTACT
Contact burns are the third most encountered cause of
injury and are most common in children and young adults.
For children, the incidence is higher due to lack of safety
awareness and grasping hot objects. Another cause recently
identified was contact burns due to glass-fronted fire­
places.44 In this study, 402 children were identified with this
injury in the United States in a 5-year period. This rate was
20 times higher than that estimated by the U.S. Consumer
Product Safety Commission.
For younger adults, motorcycle exhaust pipes are another
common cause of injury related to the use of vehicles. In
Greece, the incidence of burns from motorcycle exhaust
pipes has been reported to be 17/100,000 person-years, or
208/100,000 motorcycle-years. The highest occurrence
was in children. In adults, the incidence is 60% higher in
women than in men. As anticipated, the most frequent
location of the burns was on the right leg below the knee,
where contact with the exhaust pipe occurs. The authors
concluded that a significant reduction of incidence could be
achieved by wearing long pants and by the use of an exter­
nal exhaust pipe shield.45
WORK-RELATED BURNS
Work-related burns account for 20–25% of all serious
burns and also account for about 2% of all workplace
injuries.46 Interestingly, in a recent study from Michigan,
accommodation and food services as well as the health-
care and social assistance industries accounted for more
than 50% of the injuries.47 Restaurant-related burns, par­
ticularly those due to deep fryers, represent a major and
preventable source of occupational burn morbidity and,
in restaurants, account for 12% of work-related injuries.6
Other significant causes of work-related injuries are associ­
ated with electrical injuries, chemical injuries, and contact
burns. Also as anticipated, the risk of burns due to hot
tar is greatest for roofers and paving workers. Of all inci­
dents involving roofers and sheet metal workers, 16% are
burns caused by hot bitumen, and 17% of those injuries are
of sufficient severity to prevent work for a variable period
of time.
CHEMICAL BURNS
Chemicals are a well-known cause of burns, and these
burns are generally caused by either acidic or alkali chemi­
cals, although chemical burns can also occur with organic
solvents. In a recent review of the literature for chemical
burns, the reported percentage of burns related to chemical
agents is between 2% and 10% of injuries. Most of those
affected are men who were injured either in the workplace
or domestic setting. Acids caused about 25% of the inju­
ries and bases 55%.48 The limited extent of burns reported
from chemicals may be affected by many being treated as
outpatients.
The greatest risk of injury due to strong acids occurs in
patients who are involved in plating processes and fertilizer
burn population (50% increase), and length of hospital stay
is up to twice as long as for other causes of burns. This
might be related to a higher incidence of full-thickness
burns due to the higher temperatures associated with gaso­
line, which results in more excision and grafting proce­
dures, ICU care, and the like.33 Because of these findings,
the use of gasoline for purposes other than as a motor fuel,
and any indoor use of a volatile petroleum product, should
be discouraged as part of any prevention program.
Another commonly encountered cause of flame burns is
that associated with automobile crashes. A comprehensive
study done in Germany demonstrated that about 1% of car
crashes had associated burns; these injuries were more
common in frontal and high-energy collisions.34 In a review
of 178 patients who had been burned in an automobile
crash, it was noted that slightly more than one-third had
other injuries, most commonly involving the musculoskel­
etal system, and that approximately 1 in 6 had inhalation
injury (1 in 3 of those who died).35 A review of patients
admitted to a referral burn center revealed that burns sus­
tained while operating a vehicle involved an average of
more than 30% TBSA and were associated with mechanical
injuries (predominantly fractures) much more frequently
than those burns incurred in the course of vehicle mainte­
nance activities, which involved an average of less than
30% TBSA.36
Automotive-related flame burns can also be caused by
fires and explosions resulting from “carburetor-priming”
with liquid gasoline, although this is much less common
now that almost all automobile engines are equipped with
fuel injectors. The burns sustained in boating accidents are
also most often flash burns due to an explosion of gasoline
or butane and typically affect the face and hands.37
The ignition of clothing is the second leading cause of
burn admissions for most ages. The fatality rate of patients
with burns due to the ignition of clothing is second only to
that of patients with burns incurred in house fires.9 More
than three-quarters of deaths due to the ignition of cloth­
ing occur in patients older than 64.6 Clothing ignition
deaths, which were a frequent cause of death in young girls,
have decreased as clothing styles have changed and are
now rare among children, with little overall gender differ­
ence at the present time.
SCALD
Burns due to hot liquids cause approximately 33% of all
burns in any age group, but this incidence in much higher
in children, particularly those under 4 years of age, at
up to 60% of admissions.38–40 These injuries are gener­
ally partial-thickness; however full-thickness injury can
occur. In particular, full-thickness burns have a much
higher incidence with hot oil burns. Young children are
most commonly injured by pulling a container of hot
liquid onto themselves,40 while older children and adults
are most commonly injured by improper handling of hot oil
appliances.41–43
Burns from scalds and contacts with hot materials cause
approximately 100 deaths per year.6 The case fatality rate
of scald injury is low (presumably due to the usually modest
extent and limited depth of the burn), but scalds are major
causes of morbidity and associated healthcare costs,

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
22
down to less than 30 deaths per year in the United States.
Most lightning strikes (70%) occur between clouds; however
approximately 30% hit the ground or other site. In the
United States, these are most common in Florida and the
Southeast coast and occur most often in the warmer
months. Only about 3–5% of injuries result from a direct
lightning strike; instead most of the energy is mediated by
other objects, such as the ground or a tree.58 Most injuries
in survivors are superficial, and deep injuries are rare.
Lightning injuries and deaths occur most often in indi­
viduals who work outside or participate in outdoor recre­
ational activities. Thus men are five times more likely to be
struck by lightning than are women.59 In some older studies,
the annual death rate from lightning was greatest among
those aged 15–19 years (6 deaths per 10 million popula­
tion; crude rate: 3 per 10 million) and is seven times greater
in men than in women. Approximately 30% of those struck
by lightning die, with the greatest risk of death being in
those patients with cranial or leg burns. Fifty-two percent
of patients who died from lightning injury were engaged in
outdoor recreational activity, such as playing golf or fishing,
and 25% were engaged in work activities when struck.60
FIREWORKS
Fireworks are another seasonal cause of burns. Approxi­
mately 8% of patients with fireworks injuries undergo hos­
pitalization for care, and approximately 60% of those
injuries are for burns of specific areas, mostly those of the
hands, head, and eyes.61 Other data estimate that 1.86–5.82
fireworks-related burns per 100,000 persons occurred in
the United States during the Fourth of July holiday.62 Spar­
klers, firecrackers, and bottle rockets caused the greatest
number of burns.63 Of note, the incidence of injuries has
decreased by 30% over the past 25 years. Boys, especially
those aged 10–14, are at the highest risk for fireworks-
related injuries. Children aged 4 and under are at highest
risk for sparkler-related injuries.9 Proposed prevention mea­
sures include reducing the explosive units per package,
package warnings, and limiting the sale of the devices to
children.64
INTENTIONAL BURNS
Burns can be intentional, either self-inflicted or done pur­
posefully by another. It is estimated that 4% of burns (pub­
lished range 0.37–10%) are self-inflicted. The region of the
world has great import in determining the rates of inten­
tional burns, with a particularly high rate in young women
in India and middle-aged men in Europe. The average burn
size in intentional burns is larger than other causes, at
approximately 20% TBSA. The reasons for intentional
burns, specifically assaults, are reported to be due to conflict
between persons including spouses, elderly abuse, and eco­
nomic transactions. For self-inflicted injuries, these are
related to domestic discord, difficulty between family
members, and social distress from unemployment. Mortal­
ity rates worldwide for intentional burns are reported at
65%.65 Rates for Europe and the United States are also
higher, with a twofold increase in the risk of mortality com­
pared to nonintentional injuries.66 Data from the NBR in
2007 indicated that 3% of admitted burns were intentional,
manufacture, whereas the greatest risk from alkalis is asso­
ciated with soap manufacturing and in the home with the
use of oven cleaners. The greatest risk of organic solvent
injuries is associated with the manufacture of dyes, fertil­
izers, plastics, and explosives, and that for hydrofluoric acid
injury is associated with etching processes, petroleum refin­
ing, and air conditioner cleaning. Anhydrous ammonia
injury is most common in agricultural workers and cement
injury (an alkali injury with associated thermal injury) is
most common in construction workers.
ELECTRICAL CURRENT INJURY
Electrical current is another cause of injury seen in burn
centers. Approximately one-third of electrical current inju­
ries occur in the home, with another one-quarter occurring
on farms or industrial sites and the rest occurring in the
occupational setting.6 A once common cause of electrical
injury by household current occurred in children who
inserted uninsulated objects into electrical receptacles or bit
or sucked on electrical cords in sockets, resulting in oral
commissure burns;49 this has significantly diminished with
the universal adoption of alternating electrical current for
household use. Low-voltage direct current injury can be
caused by contact with automobile battery terminals or by
defective or inappropriately used medical equipment such
as electrical surgical or external pacing devices,50 or defi­
brillators.51 Although such injuries may involve the full
thickness of the skin, they are characteristically of limited
extent.
Employees of utility companies, electricians, construc­
tion workers (particularly those working with cranes), farm
workers moving irrigation pipes, oil field workers, truck
drivers, and individuals installing antennae are at greatest
risk of work-related high-voltage electric injury.52 The
greatest incidence of electrical current injury occurs during
the summer as a reflection of farm irrigation activity, con­
struction work, and work on outdoor electrical systems and
equipment.53
During the period 1994 to 2008, 26 patients with high-
voltage injury and 30 with low-voltage injury were treated
at a regional burn center. Mortality was only 3.6%, which
is likely biased in that those who died at the scene of injury
were not included.54 In another study, about one-half of
patients with high-voltage injury underwent fasciotomy,
and, even so, amputation was necessary in almost all of
these. Of note, about 15% developed some long-term neu­
rologic deficit, and 3% developed cataracts.55 Another study
reported the outcome of 195 patients with high-voltage
electrical injury treated at a single burn center during a
19-year period. A total of 187 (95.9%) of the 195 patients
survived and were discharged. Fasciotomy was undertaken
in the first 24 h following injury in 56 patients, and 80
patients underwent an amputation because of extensive
tissue necrosis. The presence of hemochromogens in the
urine predicted amputation with an overall accuracy of
73.3%.56
LIGHTNING BURNS
Death due to lightning strikes has now fallen to the third
most common cause of death during storms57 and is now

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
23
protective services were required in two cases. The authors
of that study concluded that abuse was likely to be under­
reported because of poor understanding of risk factors and
a low index of suspicion on the part of the entire spectrum
of healthcare personnel.
HOSPITAL BURNS
Patients may also sustain burns while in the hospital for
diagnosis and treatment of other disease. Approximately
2% of surgical anesthesia malpractice claims involve fire
incidents, and 85% of these were in head and neck surgery.
These were most commonly associated with the use of elec­
trocautery around oxygen sources.75,76 Application of
excessively hot soaks or towels or inappropriate use of heat
lamps or a heating blanket are other causes of burn injury
to patients.77 Localized high-energy ultrasound may also
produce coagulative necrosis, as exemplified by full-
thickness cutaneous injury and localized subcutaneous fat
necrosis of the abdominal wall in a patient who had received
focused-beam high-intensity ultrasound treatment for
uterine fibroids.78 A common cause of burn injury, particu­
larly in disoriented hospital or nursing home patients, is the
ignition of bed clothes and clothing by a burning cigarette.
Smoking should be banned in healthcare facilities or at least
restricted to adequately monitored situations.
Burn Patient Transport
and Transfer
As noted earlier, distance between viable burn centers and
variable population density implies that many burned
patients undergo transfer to burn centers from other loca­
tions. For transfer across short distances and in congested
urban areas, ground transportation is frequently the most
expeditious. For longer distances, aeromedical transfer for
major burns is often indicated when ground transportation
takes more than 2 hours.79 In the United States, helicopters
are most frequently employed for distances of less than 200
miles. The instance of vibration, poor lightning, restricted
space, and high noise make in-flight monitoring and thera­
peutic interventions difficult, a fact that emphasizes the
importance of carefully evaluating the patient and modify­
ing treatment prior to the transfer. If distances of more than
200 miles are considered, fixed-wing aircraft are often a
better option. The patient compartment of such an aircraft
should be well lighted, permit movement of attending per­
sonnel, and have some measure of temperature control. In
general, burned patients travel best in the immediate period
after the burn injury has occurred, as soon as hemody­
namic and pulmonary stability has been attained. This is
particularly true in those with inhalation injury, whereby
an increased mortality rate was shown in those taking more
than 16 hours to arrive at definitive care.80
Physician-to-physician case review to assess the patient’s
need for and ability to tolerate aeromedical transfer, prompt
initiation of the aeromedical transfer mission, examination
of the patient in the hospital of origin by a burn surgeon
from the receiving hospital and correction of organ dys­
function prior to undertaking aeromedical transfer, and in-
flight monitoring by burn-experienced personnel ensure
with about 50% self-inflicted and the other 50% from
assault. Similar to the prior report, burn size was on average
22% TBSA compared to 11% for nonintentional and exhib­
ited a fourfold higher mortality rate.67
In some other studies, interesting findings were noted. In
those with self-inflicted injuries, 43% occurred at home and
another 33% occurred while in a psychiatric institution.
Importantly 73% had a history of psychiatric disease; these
were predominantly affective disorders or schizophrenia in
the suicide attempts and personality disorders in self-
mutilation. Also, 55% of suicide attempts had previously
attempted suicide; 66% of the self-mutilators had made at
least one previous attempt at self-mutilation. The authors
concluded that the very fact of self-burning warranted psy­
chiatric assessment.68
Assault by burning is most often caused by throwing
liquid chemicals at the face of the intended victim or by the
ignition of a flammable liquid with which the victim has
been doused. These types of injuries are generally rare in
the developed world but are quite common in low- and
middle-income countries.65 In those injuries that do occur
in such places as the United States, most are African-
American women who were unemployed and are associ­
ated with premorbid substance abuse.69 Occasionally
injuries will be induced by spouses characteristically
dousing the face or genitalia.70 In India, a common form of
spouse abuse is burning by intentional ignition of clothing.
When such burns are fatal, they have been called “dowry
deaths” because they have been used to establish the wid­
ower’s eligibility for a new bride and her dowry.
Child abuse represents a special form of burns perpe­
trated by parents, siblings, caregivers, or child care person­
nel. Child abuse has been associated with teenage parents,
mental deficits in either the child or the abuser, illegitimacy,
a single-parent household, and low socioeconomic status,
although child abuse can occur in all economic groups.
Abuse is usually inflicted on children younger than 2 years
of age who, in addition to burns, may exhibit signs of poor
hygiene, psychological deprivation, and nutritional impair­
ment.71 The most common form of child abuse involving
burns is caused by hot water in bathing. In a recent report,
it was noted that about 5% of pediatric burn admissions
were associated with abuse, and most were due to scalds
(90%). Mortality was double that of patients with nonin­
tentional injuries (5.4% vs. 2.3%).72
A distribution typical of child abuse immersion scald
burns (i.e., feet, posterior legs, buttocks, and hands) should
heighten the suspicion of child abuse. The presence of such
burns mandates a complete evaluation of the circum­
stances surrounding the injury and the home situation.
The importance of identifying child abuse in the case of a
burn injury resides in the fact that if such abuse goes unde­
tected and the child is returned to the abusive environment,
there is a high risk of fatality due to repeated abuse.
Elder abuse can also take the form of severe burn. A
congressional report published in 1991 indicated that 2
million older Americans are abused each year, and some
estimates claim a 4–10% incidence of neglect or abuse of
the elderly.73 A recent retrospective review of 28 patients 60
years and older admitted to a single burn center during a
calendar year identified self-neglect in seven, neglect by
others in three, and abuse by others in one.74 Adult

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
24
should be prepared for such an event with established plans
that are reviewed regularly and drilled.
Outcome Analysis in Burns
The importance of the extent of injury to burn outcomes
was recognized by Holmes in 1860, and further evidence
was produced to relate either measured area or the specific
parts of the body to outcomes in the latter 19th and early
20th centuries.89,90 Formal expression of burn size as a per­
centage of total body surface area, however, awaited the
work of Berkow in 1924.91 Although not well known, this
single finding in accurately estimating severity of injury
made burns the first form of trauma in which the injury
was measured and easily communicated. This measure­
ment, then, was the first “trauma score” and made assess­
ing burn size the basis for the accurate prediction of
mortality, direct comparison of populations of burned
patients, and the measurement of the effects of treatment
on outcomes.
The earliest comprehensive statistical technique used for
such assessment was univariate probit analysis.92,93 Before
the age of desktop computing, this approach was quite labo­
rious and thus uncommon. An early attempt at multivari­
ate evaluation was made by Schwartz, who used probit
plane analysis to estimate the relative contributions of
partial- and full-thickness burns to mortality.94 The advent
of computers of suitable power and the further develop­
ment of statistical techniques has reduced the difficulty of
analyzing burn mortality, removed the necessity for arbi­
trary partitioning, and made these techniques much more
accessible.
One of the first comprehensive analyses of this sort was
done on a population of 8448 patients admitted for burn
care to the U.S. Army ISR between January 1, 1950, and
December 31, 1991. To ensure the validity of such studies,
an important first step is to achieve uniformity among the
population to be analyzed. Variables of interest include time
from injury, burn size, and age; these patients were encoun­
tered between the day of injury and day 531 after burn
(mean 5.86 days, median 1 day), with burns averaging
31% (range 1–100%, median 26%) TBSA. The ages were
biphasic, with one peak at 1 year of age and another at age
20; the mean age of the entire population was 26.5 years
(range 0–97 years, median 23 years). From this group,
7893 (93.4%) who had flame or scald burns were selected,
excluding patients with electrical or chemical injuries.
Some of these were from the Vietnam conflict and were first
transferred to Japan and then selectively transferred to the
Institute; arriving late at the Institute biased this cohort
toward survival. To account for this, the analysis focused on
the 4870 with flame or scald burns who reached the Insti­
tute on or before the second day after burn. Burn size in
these patients averaged 34% TBSA (range 1–100%, median
29%), and age was again biphasic, with peaks at 1 and 21
years and a mean of 27.1 years (range 0–93 years, median
24 years).
Between 1950 and 1965, most of the admissions were
young soldiers; mean age approximated 22.5 years and was
relatively stable. During the succeeding decade, this value
rose to an irregular plateau centering on 30 years of age, a
both continuity and quality of care during the transport
procedure. During the first half of the Iraq/Afghanistan
conflicts (2003–2007), the U.S. Army ISR Burn Care Flight
Teams using such a regimen completed 380 patient trans­
fers from theater to the burn center in San Antonio using
dedicated burn transport teams including physicians,
nurses, respiratory therapists, and support personnel. One-
third of the patients (33.6%) received ventilatory support
throughout the transport, but no in-flight deaths occurred.81
This demonstrates that burned patients can be transported
safely throughout the world if indicated.
Mass Casualties
Mass casualty incidents may be caused by forces of nature
or by accidental or intentional explosions and conflagra­
tions. Interest in man-made mass casualties has been
heightened by recent terrorist activities and the threat of
future incidents. The incidence of severe burns in a mass
casualty incident varies with the cause of the incident,
the magnitude of the inciting agent, and the site of occur­
rence (indoors vs. outdoors). The terrorist attacks in which
airplanes laden with aviation fuel crashed into the Penta­
gon and the World Trade Center on September 11, 2001,
produced 10 and 39 patients with burns, respectively, for
treatment at burn centers.82,83 Since then, many events
have occurred throughout the world, with the most recent
taking place at a festival in Taiwan in 2015, where 499
persons were burned who were between the ages of 12 and
38: 281 sustained burns over 40% TBSA. These patients
were distributed between many hospitals, and the eventual
mortality rate was 3%, akin to that normally seen in burn
centers. The assembled response was massive, including
thousands of providers, and was effectively coordinated at
the federal level.84 Another prominent burn event occurred
in Bali, in 2002, caused by an explosion and fire that killed
more than 200 people and generated 60 burn patients
who, after triage and emergency care, were transported
by aircraft to Australia and treated at various hospitals.85
The casualties produced in terrorist attacks often have
associated blast injury and mechanical trauma in addition
to burns.
Recent nonterrorist mass casualty incidents have been of
greater magnitude in terms of numbers of burn casualties.
In the Station nightclub fire in Warwick, Rhode Island, in
February 2003, 96 people died at the scene and 215 people
were injured. Forty-seven of the 64 burned patients were
evaluated at one burn center and admitted for definitive
care.86 Additionally an explosion at a pharmaceutical plant
in North Carolina in January 2003 killed 3 and injured
more than 30 to an extent that necessitated admission to a
hospital. Ten of the injured patients, all with inhalation
injury and 6 with associated mechanical trauma, required
admission to the regional burn center.87
To deal effectively and efficiently with a mass casualty
situation burn treatment facilities must have an operational
and tested mass casualty disaster plan and be prepared to
provide burn care to a highly variable number of patients
injured in either natural or man-made disasters.88 In reality,
mass casualty events are likely to involve some form of
burns, particularly in those with explosions. All regions

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
25
spanning 1969 to 1974 and decreased steadily after that
time. Mortality peaked at 46% during those years. The
two datasets are shown together in Fig. 3.5C and suggest
a crude index of the results of burn care in this popula­
tion. When comparing the polynomial lines derived from
change reflecting a greater number of civilian admissions
and increasing age in the military population.
Fig. 3.5A shows the variation in mean burn size during
the study interval, and Fig. 3.5B shows the roughly paral­
lel mortality. Mean burn size peaked in the two intervals
A
B
C
1950
1955
1960
1965
1970
1975
1980
1985
1990
1950
1955
1960
1965
1970
1975
1980
1985
1990
1950
1955
1960
1965
1970
1975
1980
1985
1990
0
5
10
15
20
25
30
35
40
45
50
Mean TBSA burned (%)
Year
0
5
10
15
20
25
30
35
40
45
50
Mortality (%)
Year
0
5
10
15
20
25
30
35
40
45
50
TBSA burned (%)
Mortality (%)
Poly. (TBSA burned (%))
Poly. (mortality (%))
Fig. 3.5  U.S. Army Institute for Surgical Research Burn Incidence and Outcomes Data (1950–1988). Panel A describes the mean burn size encountered
among admissions. The figure includes a polynomial trendline. Panel B shows the overall mortality rate and also includes a polynomial trendline. Panel
C is a combination of these curves over time and shows both trendlines.

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
26
risk occurring over time from 1950 to 2013. In this analy­
sis, only patients admitted to the burn center on the day of
burn or 1 or 2 days after burn were included. Furthermore
only patients with fire/flame and scald injuries were
included; those with electrical, chemical, or other thermal
processes and exfoliative dermatitides were excluded.
Patients of all ages and burn sizes were included. Mortality
was assessed as death at any time during the index hospi­
talization at the burn center, regardless of cause.
Data were analyzed using binomial logistic regression
(backward likelihood-ratio method). In the analysis, age
was represented as cubic age function, given by the equation
Age Function
AGE
AGE
AGE
= −∗
+
∗
−∗
(
)
5
14
100 7
10000 100
2
3
This permits use of a single term that captures the observa­
tion that the relationship between age and outcome is not
linear but rather “bathtub-shaped,” with a nadir at about
20 years and a leveling off in advanced age.95 Year of admis­
sion was entered into the analysis as a categorical variable,
permitting calculation of odds ratios for mortality for each
individual year from 1950–2013.
A total of 9755 patients met study inclusion criteria and
were analyzed. The mortality rate was 18.1%. The mean
age was 31.6 years (standard deviation [SD] 19.8 years).
Mean total burn size was 24.4% (SD 23.5%). Odds ratios
of mortality as a function of year of admission are shown
in Fig. 3.6. The graph is remarkable for two peaks in mor­
tality risk, marked “A” and “B.” Peak A, in the late 1950s
and early 1960s, represents increased mortality associated
with invasive Gram-negative burn wound infections. This
peak was followed by a striking decrease in mortality risk
in 1964 with the introduction of topical mafenide acetate
cream for antimicrobial chemoprophylaxis. Peak B, in
1969–72, reflects the emergence of other virulent Gram-
negative organisms less sensitive to mafenide acetate (e.g.,
Klebsiella spp.). With the introduction of silver sulfadiazine
cream, first as a single agent and then as an alternating
the data, it appears that a separation favoring improved
survival occurred in about 1970. This was about the
time of the development of effective topical antimicrobial
chemotherapy.
Raw percent mortality, even in conjunction with burn
size, is never an adequate index of the effectiveness of treat­
ment since the frequency of death after burn injury is also
determined by prior patient condition, age, inhalation
injury, and the occurrence of pneumonia and burn wound
sepsis. Each of these elements, except for prior condition,
can be addressed in analysis, but only burn size, age, and
the presence or absence of inhalation injury are known at
the time of admission. Furthermore the definition of signifi­
cant comorbidities and development of complications are
constantly being revised, making addition of these to pre­
diction formulas difficult, and this must be kept in mind by
the reader.
For a uniform population of specific age, a plot of the
relationship between burn size and percent mortality is
S-shaped, or sigmoid: small burns produce relatively few
deaths, but, generally, as burn size increases mortality rises
steeply and then plateaus as it approaches its maximum of
100%. Of note, in our recent analysis presented early in the
chapter (Fig. 3.4), this appears to be more linear as burn
size increases when age is not considered. When age is
added, children and young adults will fit this more accu­
rately, and older adults will have a more first-order distribu­
tion. When these are added, the curve flattens, yielding that
is seen in Fig. 3.5. Although this experience conforms with
that of most burn centers in the United States, it should be
noted that there are still many areas of the world where the
survival of patients with burns of more than 40% TBSA is
rare.
The U.S. Army Burn Center (at the U.S. Army ISR, Fort
Sam Houston, Texas) is the second oldest continuously
operating burn center in the United States. Thus data from
this burn center provide an invaluable opportunity to
understand long-term changes in patient care and their
effects on outcome. To further address the changes previ­
ously found up to 1991, we analyzed changes in mortality
Odds ratio of mortality
1950
1960
1970
1980
1990
2000
2010
0
2
4
6
8
10
12
14
16
18
20
Fig. 3.6  Odds ratio of mortality distributed across a 63-year period from a single center (U.S. Army Institute of Surgical Research). These data show
two spikes, in the 1960s and 1970s, that have subsequently significantly diminished in size to reach the current ratios.

3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
27
probably occur as inhalation injury and pneumonia come
under better control and new wound coverage techniques
are developed, but such improvement will be harder won
and smaller in magnitude. Preservation of function, recon­
struction, and rehabilitation, areas which have received less
attention in the past, appear the more likely primary targets
of future burn research and may be expected to materially
enhance the quality of life for burn survivors.
Complete references available online at

agent along with mafenide acetate, a subsequent decline
in mortality risk occurred. Further decreases in mortality
risk were observed with the introduction and then essen­
tially standardized use of burn wound excision in the late
1970s, enhanced infection control in the early 1980s,
and improvements in mechanical ventilation in the early
1990s. The reduction in mortality risk has been maintained
over the past two decades.
Conclusion
Much has been accomplished in acute burn care during the
past half century, and further improvement in outcome will

27.e1
3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
31. Williams JB, Ahrenholz DH, Solem LD, et al. Gasoline burns: the
preventable cause of thermal injury. J Burn Care Rehabil. 1990;11:
446-450.
32. Gough J, Cheng ES, Pegg SP. Ten-year Brisbane experience in petrol
burns: a preventable health burden. Burns. 2006;32:597-601.
33. Barillo DJ, Stetz CK, Zak AL, et al. Preventable burns associated with
the misuse of gasoline. Burns. 1998;24:439-443.
34. Brand S, Otte D, Stubig T, et al. Mechanisms of motor vehicle crashes
related to burns – an analysis of the German in depth accident study
(GIDAS) database. Burns. 2013;39:1535-1540.
35. Purdue GF, Hunt JL, Layton TR, et al. Burns in motor vehicle acci­
dents. J Trauma. 1985;25:216-219.
36. Barillo DJ, Cioffi WG, McManus WF, et al. Vehicle-related burn inju­
ries. Proc Assoc Adv Automot Med. 1993;11:209-218.
37. Shergill G, Scerri GV, Regan PJ, et al. Burn injuries in boating acci­
dents. Burns. 1993;19:229-231.
38. Battle CE, Evans V, James K, et al. Epidemiology of burns and scalds in
children presenting to the emergency department of a regional burns
unit: a 7-year retrospective study. Burns Trauma. 2016;4:19.
39. Rimmer RB, Weigand S, Foster KN, et al. Scald burns in young chil­
dren – a review of Arizona burn center pediatric patients and a pro­
posal for prevention in the Hispanic community. J Burns Care Res.
2008;29:595-605.
40. Sanyaolu L, Javed MU, Eales M, et al. A 10-year epidemiological study
of pediatric burns at the Welsh Centre for burns and plastic surgery.
Burns. 2017;43:632-637.
41. Hankins CL, Tang XQ, Phipps A. Hot beverage burns: an eleven-
year experience of the Yorkshire Regional Burns Centre. Burns.
2006;32:87-91.
42. Hankins CL, Tang XQ, Phipps A. Hot oil burns-a study of predis­
posing factors, clinical course and prevention strategies. Burns.
2006;32:92-96.
43. Klein MB, Gibran NS, Emerson D, et al. Patterns of grease burn injury:
development of a classification system. Burns. 2005;31:765-767.
44. Wibbenmeyer L, Gittelman MA, Kluesner K, et al. A multicenter study
of preventable contact burns from glass fronted fireplaces. J Burns
Care Res. 2015;36:240-245.
45. Matzavakis I, Frangakis ZE, Charalampopolulou A, et al. Burn inju­
ries related to motorcycle exhaust pipes: a study in Greece. Burns.
2005;31:372-374.
46. Clouatre E, Gomez M, Banfield JM, et al. Work-related burn injuries
in Ontario, Canada: a follow-up 10-year retrospective study. Burns.
2013;39:1091-1095.
47. Kica J, Rosenman KD. Multisource surveillance system for work-
related burns. J Occup Environ Med. 2012;54:642-647.
48. Hardwicke J, Hunter T, Staruch R, et al. Chemical burns – an his­
torical comparison and review of the literature. Burns. 2012;38:383-
387.
49. Leeming MN, Ray C, Howland WS. Low-voltage direct current burns.
JAMA. 1970;214:1681-1684.
50. Pride HB, McKinley DF. Third-degree burns from the use of an exter­
nal cardiac pacing device. Crit Care Med. 1990;18:572-573.
51. Reisin L, Baruchin AM. Iatrogenic defibrillator burns. Burns.
1990;16:128.
52. Baker SP, O’Neill B, Ginsberg NJ, et al. Unintentional injury. In: Baker
SP, O’Neill B, Ginsberg NJ, eds. The Injury Fact Book. 2nd ed. New York:
Oxford University Press; 1992:39-64.
53. Vierhapper MF, Lumenta DB, Beck H, et al. Electrical injury: a long-
term analysis with review of regional differences. Ann Plast Surg.
2011;66:43-46.
54. Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries: a
20-year review. J Burn Care Rehabil. 2004;25:479-484.
55. Cancio LC, Jimenez Reyna JF, Barillo DJ, et al. One hundred ninety
five cases of high-voltage electric injury. J Burn Care Rehabil.
2005;26:331-340.
56. Jensenius JS. A detailed analysis of recent lightning deaths in the
United States. 23rd International Lightning Detection Confer­
ence, 2014. Available at:
Scientific%20papers.
57. Roeder WP. Lightning has fallen to third leading source of US storm
deaths. National Weather Association annual meeting, 2012. Avail­
able
at:

NWA2012_P2.29_Roeder.pdf.
58. Cooper MA, Holle RL. Mechanisms of lightning injury should affect
lightning safety messages. 3rd International Lightning Meteorology
Conference, Orlando, Florida, 2010.
References
1. WISQARS Data and Statistics, Centers for Disease Control and Preven­
tion. Available at:
2. National Burn Repository, American Burn Association. Available at:

3. Olser T, Glance LG, Hosmer DW. Simplified estimates of the probability
of death after burn injuries: extending and updating the Baux score.
J Trauma. 2010;68:690-697.
4. Shai D. Income, housing, and fire injuries: a census tract analysis.
Pub Health Rep. 2006;121:149-154.
5. Schachterle SE, Bishai D, Shields W, et al. Proximity to vacant build­
ings is associated with increased fire risk in Baltimore Maryland
homes. Inj Prev. 2012;18:98-102.
6. Baker SP, O’Neill B, Ginsberg NJ, et al. Fire, burns, and lightning.
In: The Injury Fact Book. 2nd ed. New York: Oxford University Press;
1992:161-173.
7. National Fire Protection Association, News and Research Page. Avail­
able at: NFPA.org/news-and-research/fire-statistics-and-reports.
8. United States Fire Administration, US Fire Statistics. Available at: usfa.
fema.gov/data/statistics.
9. Safe Kids Worldwide, Burn Injury Fact Sheet 2015. Available at:

sheet_feb_2015.pdf.
10. Albertyn R, Berg A, Numanoglu A, et al. Traditional burn care in
sub-Saharan Africa: a long history with wide acceptance. Burns.
2015;41:203-211.
11. Baptiste MS, Feck G. Preventing tap water burns. Am J Public Health.
1980;70:727-729.
12. Lohana P, Hemington-Gorse S, Thomas C, et al. Pediatric injuries due
to home treadmill use: an emerging problem. Ann R Coll Surg Engl.
2012;94:121-123.
13. Goltsman D, Li Z, Connolly S, et al. Pediatric treadmill burns: assessing
the effectiveness of prevention strategies. Burns. 2016;42:1581-1587.
14. Lumenta DB, Hautier A, Desouches C, et al. Mortality and morbidity
among elderly people with burns – evaluation of data on admission.
Burns. 2008;34:965-974.
15. McGill V, Kowal-Vern A, Gamelli RH. Outcome for older burn patients.
Arch Surg. 2000;135:320-325.
16. Khadim MF, Rashid A, Fogarty B, et al. Mortality estimates in
the elderly burn patients: a Northern Ireland experience. Burns.
2009;35:107-113.
17. Masud D, Norton S, Smailes S, et al. The use of a frailty scoring system
for burns in the elderly. Burns. 2013;39:30-36.
18. Harvey L, Mitchell R, Brodaty H, et al. Dementia: a risk factor for
burns in the elderly. Burns. 2016;42:282-290.
19. Backstein R, Peters W, Neligan P. Burns in the disabled. Burns.
1993;19:192-197.
20. Glasstone S Effects on personnel. In: The effects of nuclear weapons.
Department of the Army Pamphlet No. 39-3. United States Atomic
Energy Commission; June 1957: 455–464.
21. Burns sustained in Vietnam, 1965–1973. Data tables supplied by
Department of the Army, the Chief of Military History and the Center
of Military History, Washington D.C. 20314;1980.
22. Shafir R Burn injury and care in the recent Lebanese conflict.
Presentation on behalf of the Surgeon General, Israeli Defense Forces
and staff. The Israeli Society of Plastic and Reconstructive Surgery;
1984.
23. Owen-Smith MS. Armoured fighting vehicle casualties. J R Army Med
Corps. 1977;123:65-76.
24. Chapman CW. Burns and plastic surgery in the South Atlantic cam­
paign 1982. J R Navy Med Serv. 1983;69:71-79.
25. Sereday C MAJ, Major, Argentine Navy Medical Corps. Personal com­
munication; 1990.
26. Eldad A, Torem M. Burns in the Lebanon War 1982: “the blow and
the cure”. Mil Med. 1990;155:130-132.
27. Renz EM, King BT, Chung KK, et al. The US Army burn center: profes­
sional service during 10 years of war. J Trauma. 2012;73:S409-S416.
28. Escolas SM, Archuleta DJ, Orman JA, et al. Postdischarge cause of
death analysis of combat related burned patients. J Burns Care Res.
2017;38:e158-e164.
29. Chan RK, Aden J, Wu J, et al. Operative utilisation following severe
combat-related burns. J Burns Care Res. 2015;36:287-296.
30. Wolf SE, Kauvar DS, Wade CE, et al. Comparison between burns and
combat burns from Operation Iraqi Freedom and Operation Enduring
Freedom. Ann Surg. 2006;243:786-792.

27.e2
3  •  Epidemiological, Demographic and Outcome Characteristics of Burns
79. Nicholson B, Dhindsa H. Helicopter transport in regionalized burn
care: one program’s perspective. Air Med J. 2016;35:355-359.
80. Cassidy TJ, Edgar DW, Phillips M, et al. Transfer time to a special­
ist burn service and influence on burn mortality in Australia and
New Zealand: a multicenter hospital based retrospective cohort study.
Burns. 2015;41:735-741.
81. Renz EM, Cancio LC, Barillo DJ, et al. Long-range transport of war-
related casualties. J Trauma. 2008;64:S136-S144.
82. Jordan MH, Hollowed KA, Turner DG, et al. The Pentagon attack of
September 11, 2001: a burn center’s experience. J Burn Care Rehabil.
2005;26:109-116.
83. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response
to a disaster: September 11, 2001 and the days beyond. J Burn Care
Rehabil. 2005;26:117-124.
84. Yang CC, Shih CL. A coordinated emergency response: colour
dust explosion at a 2015 concert in Taiwan. Am J Public Health.
2016;106:1582-1585.
85. Kennedy PJ, Haertsch PA, Maitz PK. The Bali Burn Disaster:
implications and lessons learned. J Burn Care Rehabil. 2005;26:
125-131.
86. Harrington DT, Biffl WL, Cioffi WG. The Station Nightclub fire. J Burn
Care Rehabil. 2005;26:141-143.
87. Cairns BA, Stiffler A, Price F, et al. Managing a combined burn
trauma disaster in the post-Nine/Eleven world: lessons learned from
the 2003 West Pharmaceutical plant explosion. J Burn Care Rehabil.
2005;26:144-150.
88. Petinaux B, Valenta AL, Deatley C, et al. District of Columbia Emer­
gency Healthcare Coalition burn mass casualty plan: development to
exercise date. J Burn Care Rehabil. 2017;38:e299-e305.
89. Holmes T, ed. A System of Surgery, Theoretical and Practical. Vol. I.
London: J W Parker & Son; 1860:723.
90. Deleted at revises
91. Berkow SG. Method of estimating extensiveness of lesions (burns
and scalds) based on surface area proportions. Arch Health.
1924;8:138-148.
92. Bull JP, Squire JR. A study of mortality in a burns unit: standards
for the evaluation of alternative methods of treatment. Ann Surg.
1949;130:160-173.
93. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised esti­
mate. Ann Surg. 1954;139:269-274.
94. Schwartz MS, Soroff HS, Reiss E, et al An evaluation of the mortality
and the relative severity of second and third-degree injuries in burns.
Research Report Nr. 12–56. In: Research reports. US Army Surgical
Research Unit, Fort Sam Houston, TX; 1956.
95. Moreau AR, Westfall PH, Cancio LC, et al. Development and valida­
tion of an age-risk score for mortality prediction after thermal injury.
J Trauma. 2005;58(5):967-972.
59. Ritenour AE, Morton MJ, McManus JG, et al. Lighting injury: a review.
Burns. 2008;34:585-594.
60. Lightning-associated injuries and deaths among military personnel–
United States, 1998–2001. MMWR Morb Mortal Wkly Rep.
2002;51:859-862.
61. Billock RM, Chounthirath T, Smith GA. Pediatric firework-related
injuries presenting to United States emergency departments, 1990–
2014. Clin Pediatr (Phila). 2017;56(6):535-544.
62. McFarland LV, Harris JR, Kobayashi JM, et al. Risk factors for fireworks-
related injury in Washington state. JAMA. 1984;251:3251-3254.
63. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics.
1985;75:877-882.
64. Karamanoukian RL, Kilani M, Lozano D, et al. Pediatric burns with
snap-cap fireworks. J Burns Care Res. 2006;27:218-220.
65. Peck MD. Epidemiology of burns throughout the world. Part II: inten­
tional burns in adults. Burns. 2012;38:630-637.
66. Varley J, Pilcher D, Butt W, et al. Self-harm is an independent predictor
of mortality in trauma and burns patients admitted to the ICU. Injury.
2012;43:1562-1565.
67. Modjarrad K, McGwin G, Cross JM, et al. The descriptive epidemiology
of intentional burns in the United States: an analysis of the National
Burn Repository. Burns. 2007;33:828-832.
68. Sonneborn CK, Vanstraelen TM. A retrospective study of self-inflicted
burns. Gen Hosp Psychiatry. 1992;14:404-407.
69. Kaufman MS, Graham CC, Lezotte D, et al. Burns as a result of assault:
associated risk factors, injury characteristics, and outcomes. J Burns
Care Res. 2007;28:21-28.
70. Krob MJ, Johnson A, Jordan MH. Burned-and-battered adults. J Burn
Care Rehabil. 1986;7:529-531.
71. O’Neill JA Jr, Meacham WF, Griffin PP, et al. Patterns of injury in the
battered child syndrome. J Trauma. 1973;13:332-339.
72. Hodgman EI, Pastorek RA, Saeman MR, et al. Burns. 2016;42:
1121-1127.
73. Elder abuse: what can be done? Select Committee on Aging, U.S.
House of Representatives, Washington DC, Government Printing
Office, 1991.
74. Bird PE, Harrington DT, Barillo DJ, et al. Elder abuse: a call to action.
J Burn Care Rehabil. 1998;19:522-527.
75. Rinder CS. Fire safety in the operating room. Curr Opin Anesthesiol.
2008;21:790-795.
76. Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a
closed claims analysis. Anesthesiology. 2013;118:1133-1139.
77. Sadove RC, Furgasen TG. Major thermal burn as a result of intra­
operative heating blanket use. J Burn Care Rehabil. 1992;13:443-445.
78. Leon-Villapalos J, Kaniorou-Larai M, Dziewulski P. Full thickness
abdominal burn following magnetic resonance-guided focused ultra­
sound therapy. Burns. 2005;31:1054-1055.

28
Prevention of Burn Injuries
AUDRA T. CLARK, STEPHANIE CAMPBELL, and BRETT D. ARNOLDO
4 
and should be applied to burn prevention because they
highlight that society is capable of reducing injury and can
do so at more than one stage of an injury event.
Public health is the effort organized by society to protect,
promote, and restore the people’s health. The public health
model of injury prevention and control is divided into:
■ surveillance,
■ interdisciplinary education and prevention programs,
■ environmental modifications,
■ regulatory action, and
■ support of clinical interventions.2
Prevention strategies are commonly described as either
passive or active. Passive or environmental intervention is
a strategy that provides protection against injury and
requires little to no cooperation or action from the individ­
ual at risk.2 Examples of passive burn prevention strategies
include building codes requiring smoke alarms, sprinkler
installation, and factory-adjusted water heater tempera­
ture. Active prevention measures are voluntary, and they
emphasize education to encourage people to modify unsafe
behavior. Examples are home fire drill plans and wearing
goggles and gloves when handling toxic chemicals. Passive
prevention is more effective because active prevention can
be a very difficult strategy to maintain, especially over a
long period of time5 (Fig. 4.1).
Identified prevention strategies can also be classified as
primary, secondary, and tertiary, and these are similar to
the Haddon Matrix phases of injury. Primary prevention is
preventing the event from ever occurring. Secondary pre­
vention includes reducing the severity of injury via acute
care of the injury. Tertiary prevention concentrates on pre­
venting or reducing disability.6
Burn Intervention Strategy
Prevention science has turned attention away from indi­
vidual blame and the attitude that injuries are random
“accidents” and toward the view that sociopolitical involve­
ment is necessary.7 All burn injuries should be viewed as
preventable. Prevention programs should target high-risk
groups and also be implemented with patience, persistence,
and precision.5 The current approaches to burn prevention
will be discussed in the framework of the five E’s of Injury
Prevention: Epidemiology, Engineering, Enforcement, Edu­
cation, and Evaluation (Fig. 4.2).8
■ Epidemiology: identify the demographics and situa­
tions involved with burn injuries.
■ Engineering: focuses on modification of the phys­
ical environment. Examples include fire-resistant
Introduction
Prevention is the cure for the epidemic disease of injury.1
Burns are one of the most devastating of all injuries and a
major global public health issue. Treatment of burn injuries
has historically received more focus than burn prevention,
but this perspective is starting to shift. Burn centers and
other partners in burn prevention efforts face a number of
challenges including scarce resources, legislative delays,
and the need to develop high-quality research methodology
to further define the ideal ways to educate and promote
safety. Despite these challenges, the potential impact of
burn injury prevention efforts is now being recognized and
examined on a larger scale.
Injury Prevention Models
The science of injury prevention emerged in the middle of
the 20th century. Injuries became recognized as avoidable
events resulting from a combination of adverse environ­
mental conditions, equipment, behavior, and personal risk
factors, rather than unpredictable accidents.2 William
Haddon developed a system, known as the Haddon Matrix,
to apply the principles of public health to the problem of
road traffic safety.3 Since its introduction, it has been used
as a means of developing ideas to prevent injury of all types.
The matrix enables analysis of the contributing factors of
the injury in relationship to the phases of the injury event.
The contributing factors studied are:
a. The host or injured person,
b. The agent or vehicle,
c. The physical environment,
d. The social environment.
The identified phases of an injury event are:
a. Pre-event: preventing the causative agent from reach­
ing the susceptible host.
b. Event: includes transfer of the energy to the victim.
Prevention efforts in this phase operate to reduce or
completely prevent the injury.
c. Post-event: determines the outcome once the injury
has occurred. This includes anything that limits
ongoing damage or repairs the damage. This phase
determines the ultimate outcome.4
The resulting matrix provides a tool to identify strategies
and priorities for injury prevention, areas of needed
research, and how to best allocate resources (Table 4.1).
Haddon further described 10 general strategies for injury
prevention and control (Box 4.1). Both of these models can

4  •  Prevention of Burn Injuries
29
Epidemiology
Prevention program planning begins with an assessment
identifying the scope of the problem, the mechanisms of
injury, and the populations at risk. With this information
strategic designing and implementation can be directed at
reducing the risk of injury or death. Epidemiologic data
specific to burn injuries are accessible through multiple
sources including the National Burn Repository, state and
local health departments, and reports from the National
Fire Protection Association (NFPA).9
OVERVIEW OF BURN INJURIES IN THE
UNITED STATES
In the United States in 2014, the leading causes of injury
deaths, in order of magnitude, were motor vehicle colli­
sions, falls, drowning, and fire/burns.10 This same year, fire
departments responded to an estimated 1,298,000 fires,
which is an increase of 4.7% from the previous year.11 The
American Burn Association estimates that, in 2016, there
were 486,000 burn injuries that received medical treat­
ment and 3275 fatalities due to fire or smoke inhalation.
This represents a death due to fire every 2 hours and 41
minutes.12 Approximately 40,000 people were hospitalized
because of a burn injury. More than 60% of the acute hos­
pitalizations for burn injury were admitted to the 128 burn
centers in the United States. These centers average more
than 200 admissions annually, while the other 4500 U.S.
acute care hospitals average less than three burn admis­
sions per year. In addition to the human cost, fires in 2014
in the United States resulted in $11.6 billion in property
loss.11
upholstery and bedding, child-resistant multipurpose
lighters, and insulated electric wire.
■ Enforcement: influences behavior with laws, building
codes, and regulations. Examples include requiring fire
escapes and sprinklers/smoke alarms in motels, hotels,
and homes.
■ Education: influences behavior through knowledge
and reasoning. Examples include fire safety education
programs, public television programs.
■ Evaluation: assessment of the impact of a prevention
strategy and areas of success or reasons for failure.
From Haddon W. Advances in the epidemiology of injuries as a basis for
public policy. Public Health Rep. 1980;95:411–421.
Box 4.1  General Strategies for Burn Control
Prevent creation of the hazard (stop producing firecrackers)
Reduce amount of hazard (reduce chemical concentration in
commercial products)
Prevent release of the hazard (child-resistant butane lighters)
Modify rate or spatial distribution of the hazard (vapor-igni-
tion-resistant water heaters)
Separate release of the hazard in time or space (small spouts
for hot water faucet)
Place barrier between the hazard and the host (install fence
around electrical transformers, fire screen)
Modify nature of the hazard (use low conductors of heat)
Increase resistance of host to hazard (treat seizure disorder)
Begin to counter damage already done by hazard (first aid,
rapid transport, and resuscitation)
Stabilization, repair/rehabilitation of host (provide acute care;
burn center and rehabilitation)
STRATEGIES TO REDUCE
HARM FROM INJURIES
PARAMETERS OF
INJURY OCCURRENCE
Education
Product design/
environmental change
Legislation and regulation
Pressure groups
Lobbying
ACTIVE
PASSIVE
Agent
Host
Environment
Fig. 4.1  Strategies to reduce harm from injury. (From Atiyeh BS, Costa­
gliola M, Hayek SN. Burn prevention mechanisms and outcomes: pitfalls,
failures and successes. Burns 2009;35(2):181-193.)
Epidemiology
Engineering
Enforcement
Education
Evaluation
Prevention
Strategies
Fig. 4.2  The five ‘E’s of injury prevention. (From Judkins DG. Fifteen tips
for success in injury prevention. J Trauma Nurs. 2009;16(4):184–193.)
Table 4.1  The Haddon Matrix for Burn Control
Agent or Vector
Host
Environment
Physical
Social
Pre-event
Fire-safe cigarette
Control seizure
Nonslip tub surface
Legislation—factory preset water heater thermostats
Event
Sprinklers, smoke detectors
Flame-retardant cloths
Fire escapes
Fire drill education
Post-event
Water
First aid antibiotics
EMS
Emergency and rehabilitation services
Matrix adapted from Haddon W. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep. 1980;95:411–421.