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Total Burn Care

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Total Burn Care
FOURTH EDITION
David N. Herndon
MD FACS
Director of Burn Services, Professor of Surgery and Pediatrics
Jesse H. Jones Distinguished Chair in Surgery, University of Texas Medical Branch
Chief of Staff and Director of Research, Shriners Burns Hospital for Children
Galveston, TX, USA
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Saunders
  British Library Cataloguing in Publication Data
  Total burn care. – 4th ed.
  1. Burns and scalds.  2. Burns and scalds – Treatment.
  I. Herndon, David N.
  617.1’106 – dc22
  ISBN-13: 9781437727869
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v
Contents
Preface
ix
List of Contributors
xi

1. A Brief History of Acute Burn Care Management
1
Ludwik K. Branski, David N. Herndon, Robert E. Barrow

2. Teamwork for Total Burn Care: Burn Centers and Multidisciplinary Burn Teams
9
Ahmed M. Al-Mousawi, Oscar E. Suman, David N. Herndon

3. Epidemiological, Demographic, and Outcome Characteristics of Burn Injury
15
Basil A. Pruitt, Jr., Steven E. Wolf, Arthur D. Mason, Jr.

4. Prevention of Burn Injuries
47
John L. Hunt, Brett D. Arnoldo, Gary F. Purdue*

5. Burn Management in Disasters and Humanitarian Crises
57
Herbert L. Haller, Christian Peterlik, Christian Gabriel

6. Care of Outpatient Burns
81
C. Edward Hartford

7. Pre-Hospital Management, Transportation and Emergency Care
93
Ronald P. Mlcak, Michael C. Buffalo, Carlos J. Jimenez

8. Pathophysiology of Burn Shock and Burn Edema
103
George C. Kramer

9. Fluid Resuscitation and Early Management
115
Glenn D. Warden

10. Evaluation of the Burn Wound: Management Decisions
125
Giavonni M. Lewis, David M. Heimbach, Nicole S. Gibran

11. Enzymatic Debridement of Burn Wounds
131
Lior Rosenberg

12. Treatment of Infection in Burns
137
James J. Gallagher, Ludwik K. Branski, Natalie Williams-Bouyer, Cynthia Villarreal,
David N. Herndon

13. Operative Wound Management
157
Jong O. Lee, Manuel Dibildox, Carlos J. Jimenez, James J. Gallagher, Syed Sayeed,
Robert L. Sheridan, David N. Herndon

14. Anesthesia for Burned Patients
173
Lee C. Woodson, Edward R. Sherwood, Asle Aarsland, Mark Talon, Michael P. Kinsky,
Elise M. Morvant

15. The Skin Bank
199
Richard J. Kagan, Robert Winter, Edward C. Robb

16. Alternative Wound Coverings
209
Robert L. Sheridan, Ronald G. Tompkins

17. The Role of Alternative Wound Substitutes in Major Burn Wounds and
Burn Scar Resurfacing
215
Juan P. Barret

18. The Pathophysiology of Inhalation Injury
219
Daniel L. Traber, David N. Herndon, Perenlei Enkhbaatar, Marc O. Maybauer,
Dirk M. Maybauer
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19. Diagnosis and Treatment of Inhalation Injury
229
Lee C. Woodson, Mark Talon, Daniel L. Traber, David N. Herndon

20. Respiratory Care
239
Ronald P. Mlcak, Sachin D. Hegde, David N. Herndon

21. The Systemic Inflammatory Response Syndrome
249
Edward R. Sherwood, Daniel L. Traber

22. The Immunological Response and Strategies for Intervention
265
Erle D. Murphey, Edward R. Sherwood, Tracy Toliver-Kinsky

23. Hematologic and Hematopoietic Response to Burn Injury
277
Joseph A. Posluszny, Jr., Richard L. Gamelli, Ravi Shankar

24. Significance of the Adrenal and Sympathetic Response to Burn Injury
289
Kuzhali Muthu, Ravi Shankar, Richard L. Gamelli

25. The Hepatic Response to Thermal Injury
301
Marc G. Jeschke, Celeste C. Finnerty

26. Effects of Burn Injury on Bone and Mineral Metabolism
313
Gordon L. Klein, Noe A. Rodriguez, David N. Herndon

27. Vitamin and Trace Element Homeostasis Following Severe Burn Injury
321
Gordon L. Klein, Noe A. Rodriguez, Ludwik K. Branski, David N. Herndon

28. Hypophosphatemia
325
David W. Mozingo, Arthur D. Mason, Jr.

29. Nutritional Support of the Burned Patient
333
Jeffrey R. Saffle, Caran Graves, Amalia Cochran

30. Modulation of the Hypermetabolic Response after Burn Injury
355
Gerd G. Gauglitz, Celeste C. Finnerty, David N. Herndon, Felicia N. Williams,
Marc G. Jeschke

31. Etiology and Prevention of Multisystem Organ Failure
361
Robert L. Sheridan, Ronald G. Tompkins

32. Renal Failure in Association with Thermal Injuries
369
Jeremy Goverman, Naoki Aikawa, Shawn P. Fagan

33. Critical Care in the Severely Burned: Organ Support and
Management of Complications
377
Kevin K. Chung, Steven E. Wolf

34. Burn Nursing
397
Debra A. Benjamin, Mary Jaco, Eric Koch

35. Special Considerations of Age: The Pediatric Burned Patient
405
Jong O. Lee, William B. Norbury, David N. Herndon

36. Care of Geriatric Patients
415
Laura J. Porro, Robert H. Demling, Clifford T. Pereira, David N. Herndon

37. Surgical Management of Complications of Burn Injury
421
Nadja C. Colon, Cameron Schlegel, Dai H. Chung

38. Electrical Injuries
433
Brett D. Arnoldo, John L. Hunt, Jose P. Sterling, Gary F. Purdue*

39. Electrical Injury: Reconstructive Problems
441
Peter M. Vogt, Andreas D. Niederbichler, Andreas Jokuszies

40. Cold-Induced Injury: Frostbite
449
Amalia Cochran, Stephen E. Morris, Jeffrey R. Saffle

41. Chemical Burns
455
Itoro E. Elijah, Arthur P. Sanford, Jong O. Lee
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42. Radiation Injuries and Vesicant Burns
461
Stephen M. Milner, Michael J. Feldman

43. Exfoliative Diseases of the Integument and Soft Tissue Necrotizing Infections
471
Shawn Fagan, Jiake Chai, Marcus Spies, Maureen Hollyoak, Michael J. Muller,
Cleon W. Goodwin, David N. Herndon

44. The Burn Problem: A Pathologist’s Perspective
483
Hal K. Hawkins

45. Molecular and Cellular Basis of Hypertrophic Scarring
495
Peter Kwan, Alexis Desmoulière, Edward E. Tredget

46. Pathophysiology of the Burn Scar
507
Hal K. Hawkins, Celeste C. Finnerty

47. Comprehensive Rehabilitation of the Burn Patient
517
Michael A. Serghiou, Sheila Ott, Christopher Whitehead, April Cowan, Serina McEntire,
Oscar E. Suman

48. Musculoskeletal Changes Secondary to Thermal Burns
551
E. Burke Evans

49. Mitigation of Burn-Induced Hypermetabolic and Catabolic Response
during Convalescence
565
Oscar E. Suman, David N. Herndon, Celeste C. Finnerty, Elisabet Borsheim

50. Reconstruction of Burn Deformities: An Overview
571
Lars Peter Kamolz, Ted Huang

51. The Use of Skin Grafts, Skin Flaps and Tissue Expansion in Burn
Deformity Reconstruction
581
Ted Huang, Manuel Dibildox

52. Microvascular Technique of Composite Tissue Transfer
591
Hiroyuki Sakurai

53. Reconstruction of the Head and Neck
597
Matthias B. Donelan, Eric C. Liao

54. Correction of Burn Alopecia
617
Robert McCauley

55. Reconstruction of the Burned Breast
623
Peter Dziewulski, Jorge Leon Villapalos

56. Management of Contractural Deformities Involving the Shoulder (Axilla),
Elbow, Hip and Knee Joints in Burned Patients
631
Ted Huang, Jui-Yung Yang

57. Care of a Burned Hand and Reconstruction of the Deformities
645
Xin Chen, Ted Huang, Nora Nugent, Yuming Shen, Fengjiun Qin

58. Management of Burn Injuries of the Perineum
661
Ted Huang

59. Reconstruction of Burn Deformities of the Lower Extremity
671
Jui-Yung Yang, Ted Huang

60. The Ethical Dimension of Burn Care
683
Arthur P. Sanford

61. Intentional Burn Injuries
689
Lisa L. Tropez-Arceneaux, Susanne Tropez-Sims

62. Functional Sequelae and Disability Assessment
699
Glenn D. Warden, Petra M. Warner

63. Cost-Containment and Outcome Measures
707
Juan P. Barret

64. Management of Pain and Other Discomforts in Burned Patients
715
Walter J. Meyer III, Shelley Wiechman, Lee Woodson, Mary Jaco, Christopher R. Thomas
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65. Psychiatric Disorders Associated with Burn Injury
733
J.F. Aili Low, Walter J. Meyer III, Mimmie Willebrand, Christopher R. Thomas

66. Psychosocial Recovery and Reintegration of Patients with Burn Injuries
743
Laura Rosenberg, John W. Lawrence, Marta Rosenberg, James A. Fauerbach,
Patricia E. Blakeney
Index
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ix
The last 25 years burn care has improved to the extent that
persons with burns covering 90% of their total body surface
area can frequently survive. In the five years since the publi­
cation of the third edition of this book basic and clinical
sciences have continued to provide information further elu­
cidating the complexities of burn injuries and opportunities
for improvement in care. In this edition advances in the
treatment of burn shock, inhalation injury, sepsis, hyperme­
tabolism, the operative excision of burn wounds, scar recon­
struction and rehabilitation are completely reexamined.
Burn care demands attention to every organ system as well
as to the patient’s psychological and social status. The scope
of burn treatment extends beyond the preservation of life
and function; and the ultimate goal is the return of burn
survivors as full participants back into their communities.
The fourth edition has been extensively updated with
massive additions and new data, new references; almost all
chapters have been totally rewritten and updated. There are
many new chapters and sections in this edition along with
demonstrative color illustrations throughout the book.
Totally new to this edition is a web based support section
for many of the chapters that include powerpoint presenta­
tions and helpful videos. Power points should allow visual
representations of the topics covered in chapters for group
Preface
to the fourth Edition of Total Burn Care
discussions and individual burn units. Video clips should
allow better understanding of complex procedures and
concepts.
New material has been added to this edition reflecting
the varied physiologic, psychological and emotional care of
acutely burned patients evolving through recovery, rehabili­
tation, and reintegration back into society and daily life
activities.
The scope of burn treatment extends beyond the preser-
vation of life and function and the ultimate goal is the
return of burn survivors, as full participants, back into their
communities.
I would like to express my deep appreciation to the many
respected colleagues and friends who have volunteered
tirelessly of their time to produce the various chapters in
this book and especially to the Shrines Hospitals for
Children staff.
Sincere appreciation goes to Shari Taylor for her excellent
secretarial assistance, to Ms. Sharon Nash for her editorial
skills. Finally I would like to thank my wife Rose for her
invaluable personal support.
David N. Herndon
2012

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xi
Asle Aarsland MD PhD
Associate Professor
Department of Anesthesiology
University of Texas Medical Branch at Galveston
Galveston, TX, USA
Naoki Aikawa MD DMSc FACS
Professor Emeritus
Keio University
Visiting Surgeon
Emergency and Critical Care Medicine
Keio University Hospital
Shinjukuku, Tokyo, Japan
Ahmed M Al-Mousawi MBBS MMS MRCS
Clinical Fellow
Department of Surgery
University of Texas Medical Branch
Shriners Burns Hospital for Children
Galveston, TX, USA
Brett D Arnoldo MD
Associate Professor, Division of Burn, Trauma, Critical Care
Department of Surgery
UT Southwestern Medical Center
Dallas, TX, USA
Juan P Barret MD PhD
Professor of Plastic Surgery
Head of Department
Department of Plastic Surgery and Burn Centre
Director Burn Centre
Director Face and Hand Composite
Allotransplantation Program
Hospital Universitari Vall d’Hebron
Universitat Autonoma de Barcelona
Barcelona, Spain
Robert E. Barrow PhD
Retired Professor of Surgery, Coordinator of Research
University of Texas Medical Branch
Shriners Burns Hospital
Galveston, TX, USA
Debra A Benjamin RN MSN
Assistant Director of Clinical Research
Shriners Hospital for Children
Research Program Manager
Department of Surgery
University of Texas Medical Branch
Galveston, TX USA
Patricia E Blakeney PhD
Retired Senior Psychologist
Shriners Hospital for Children
Retired Clinical Professor
University of Texas Medical Branch
Galveston,TX, USA
Elisabet Børsheim PhD
Associate Professor
Dept of Surgery
University of Texas Medical Branch/Shriners Hospitals
for Children
Galveston, TX, USA
Ludwik K. Branski MD MMS
Department of Plastic, Hand and Reconstructive Surgery
Hannover Medical School
Hannover, Germany
Michael C Buffalo DNP RN CCRN ACPNP
Acute Care Pediatric Nurse Practitioner
Department of Surgery
University of Texas Medical Branch/Shriners Burns
Hospital-Galveston
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
Xin Chen MD PhD
Professor of Burn and Plastic Surgery
Department of Burn and Plastic Surgery
Beijing Jishuitan Hospital
Beijing, China
Dai H Chung MD
Professor and Chairman
Robinson and Lee Endowed Chair
Department of Pediatric Surgery
Vanderbilt University Medical Center
Nashville, TN, USA
Kevin K Chung MD
Medical Director, Burn ICU
US Army Institute of Surgical Research
Fort Sam, Houston, TX, USA
List of Contributors

List of Contributors
xii
Amalia Cochran MD MA
Assistant Professor of Surgery
Department of Surgery
University of Utah Hospitals and Clinics / University of
Utah School of Medicine
Salt Lake City, UT, USA
Nadja Colon MD
Pediatric Surgery Research Fellow
Department of Pediatric Surgery
Vanderbilt University Medical Center
Nashville, TN, USA
April Cowan OTR CHT
Occupational Therapy Clinical Specialist
Rehabilitation Services
Shriners Hospital for Children
Galveston, TX, USA
Robert H Demling MD
Professor of Surgery
Harvard Medical School
Brigham and Women’s Hospital
Boston, MA, USA
Alexis Desmoulière PhD
Professor of Physiology
Faculty of Pharmacy
University of Limoges
Limoges, France
Manuel Dibildox MD
Attending Surgeon, Ross Tilley Burn Unit
Lecturer, University of Toronto
Division of Plastic and Reconstructive Surgery
Sunnybrook Health Sciences Centre
Toronto, ON, Canada
Matthias B Donelan MD
Associate Clinical Professor of Surgery
Harvard Medical School
Chief of Plastic Surgery
Shriners Burns Hospital
Associate Visiting Surgeon, MGH
Boston, MA, USA
Peter Dziewulski FFICM FRCS FRCS (Plast)
Professor
Clinical Director Burn Service
Consultant Plastic and Reconstructive Surgeon
St Andrews Centre for Plastic Surgery and Burns
Chelmsford, Essex, UK
Itoro E Elijah MD MPH
Post Doctoral Research Fellow, General Surgery Resident
Surgery
University of Texas Medical Branch/Shriners Hospitals
for Children
Galveston, TX, USA
Perenlei Enkhbaatar MD PhD
Associate Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA
E Burke Evans MD
Professor
Department of Orthopaedics and Rehabilitation
University of Texas Medical Branch
Galveston, TX, USA
Shawn P Fagan MD
Assistant Surgeon
Massachusetts General Hospital
Shriners Hospital for Children
Boston, MA, USA
James A Fauerbach PhD
Associate Professor
Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Michael J Feldman, MD
Associate Director, Evans-Haynes Burn Center
Division of Plastic Surgery
Virginia Commonwealth University
Richmond, VA, USA
Celeste C Finnerty PhD
Associate Director for Research
Shriners Hospital for Children, Galveston
Associate Professor
Department of Surgery
University of Texas Medical Branch
Galveston, TX, USA
Christian Gabriel MD
Medical Director
Red Cross Transfusion Service of Upper Austria
Linz, Austria
James J Gallagher MD
Assistant Professor of Surgery
Weill Cornell Medical College
Assistant Attending Surgeon
NewYork Presbyterian Hospital
New York, NY, USA
Richard L Gamelli MD FACS
Senior Vice President and Provost of Health Sciences
Loyola University Chicago
The Robert J Freeark Professor of Surgery
Director, Burn and Shock Trauma Institute
Chief, Burn Center Loyola University Medical Center
Maywood, IL, USA
Gerd G Gauglitz MD MMS
Resident
Department of Dermatology and Allergy
Ludwig-Maximilians-University Munich
Munich, Germany
Nicole S Gibran, MD
Director, UW 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

List of Contributors
xiii
Jeremy Goverman MD
Assistant in Surgery
Division of Burns
Massachusetts General Hospital
Shriners Burn Hospital for Children
Boston, MA, USA
Caran Graves MS RD CNSC
Clinical Dietitian
Nutrition Care Service
University of Utah Hospital and Clinics
Salt Lake City, UT, USA
Herbert L Haller MD
Specialist for Trauma and Orthopedic Surgery and
Intensive Care in Trauma
Trauma and Burns
Trauma Center Linz of Austrian Workers’
Compensation Board
Linz, Austria
Charles E Hartford, MD
Professor of Surgery, Retired
Department of Surgery
University of Colorado Denver and Health Sciences Center
Denver, CO, USA
Hal K Hawkins MD PhD
Professor
Department of Pathology
University of Texas Medical Branch and
Shriners Hospital for Children
Galveston, TX, USA
Sachin D Hegde MD
Post Doctoral Fellow
Department of Surgery
University of Texas Medical Branch
Galveston, TX, USA
David M Heimbach MD FACS
Professor of Surgery
Department of Surgery, Division of Trauma/Burns
Harborview Medical Center
Seattle, WA, USA
David N Herndon MD FACS
Director of Burn Services
Professor of Surgery and Pediatrics
Jesse H. Jones Distinguished Chair in Surgery
University of Texas Medical Branch
Chief of Staff and Director of Research
Shriners Burns Hospital for Children
Galveston, TX, USA
Maureen Hollyoak MBBS MMedSc FRACS
General Surgeon
Nowra, New South Wales, Australia
Ted Huang MD FACS
Clinical Professor of Surgery
Shriners Burns Hospital
University of Texas Medical Branch
Galveston, TX, USA
John L Hunt MD
Professor, Division of Burn, Trauma, Critical Care
Department of Surgery
UT Southwestern Medical Center
Dallas, TX, USA
Mary Jaco RN MSN
Director Patient Care Services
Shriners Hospitals for Children
Galveston, TX, USA
Marc Jeschke MD PhD FACS FRCSC
Director Ross Tilley Burn Centre
Sunnybrook Health Sciences Centre
Senior Scientist
Sunnybrook Research Institute
Associate Professor
Department of Surgery, Division of Plastic Surgery
University of Toronto
Toronto, ON, Canada
Carlos J Jimenez MD FACS
Assistant Professor Burn Surgery
Assistant Professor Trauma Surgery
Department of Surgery
University of Texas Medical Branch
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
Richard J Kagan MD FACS
Chief of Staff, Shriners Hospitals for Children
Professor of Surgery
University of Cincinnati College of Medicine
Cincinnati, OH, USA
Lars-Peter Kamolz MD Phd MSc
Professor of Plastic, Aesthetic and Reconstructive Surgery Head
Division of Plastic, Aesthetic Reconstructive Surgery
Department of Surgery
Medical University of Graz
Vienna, Austria
Michael P Kinsky MD
Associate Professor of Anesthesiology
Department of Anesthesiology
University of Texas Medical Branch at Galveston
Galveston, TX, USA
Gordon L Klein MD MPH AGAF
Clinical Professor
Department of Orthopaedic Surgery and Rehabilitation
University of Texas Medical Branch
Galveston, TX, USA
Eric Koch RN BSN MBA
Director, Inpatient Services
Shriners Hospitals for Children
Galveston, TX, USA

List of Contributors
xiv
George C Kramer PhD
Director, Resuscitation Research Lab
Professor, Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA
Peter Kwan MD PhD Candidate
Resident in Plastic Surgery
Graduate Student (Surgeon/Scientist)
Department of Surgery
University of Alberta
Edmonton, AB, Canada
John Lawrence PhD
Associate Professor
Psychology Department
College of Staten Island, City University of New York
Staten Island, NY, USA
Jong O Lee MD
Associate Professor of Surgery
University of Texas Medical Branch
Staff Surgeon
Shriners Hospitals for Children
Galveston, TX, USA
Jorge Leon-Villapalos MD FRCS(Plast)
Consultant Plastic Surgeon
Department of Plastic Surgery and Burns
Chelsea and Westminster Hospital
London, UK
Giavonni M Lewis MD
Burn Surgery Fellow
Dept of Burn/Trauma
University of Washington/Harborview Medical Center
Seattle, WA, USA
Eric C Liao MD PhD
Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
Massachusetts General Hospital
Harvard Medical School
Boston, MA, USA
JF Aili Low MD
Associate Professor
Department of Plastic Surgery
Uppsala University Hospital
Uppsala, Sweden
Arthur D Mason Jr MD
Emeritus Chief
Laboratory Division
US Army Institute of Surgical Research
Brooke Army Medical Center
San Antonio, TX, USA
Dirk M Maybauer MD PhD
Associate Professor
Anesthesiology and Critical Care Medicine
Philipps University of Marburg
Marburg, Germany
Assistant Professor
Department of Anesthesiology
Division of Critical Care Medicine
University of Texas Medical Branch
Galveston, TX, USA
Marc O Maybauer MD PhD FCCP
Associate Professor
Department of Anaesthesiology and Critical Care Medicine
Philipps University of Marburg
Marburg, Germany
Assistant Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA
Robert L McCauley MD
Professor, Departments of Surgery and
Pediatrics, University of Texas Medical
Branch
and Chief, Plastic and Reconstructive Surgery
Shriners Burns Hospital
Galveston, TX, USA
Serina J McEntire PhD
Postdoctoral Associate
Department of Emergency Medicine
University of Pittsburgh
Pittsburgh, PA, USA
Walter John 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
University of Texas Medical Branch
Director
Psychological and Psychiatric Services
Shriners Hospitals for Children
Galveston, TX, USA
Stephen M Milner MB BS BDS DSc (Hon) FRCS(Ed) FACS
Professor of Plastic Surgery
Chief, Division of Burns
Chief, Plastic Surgery
Honorary Civilian Consultant Advisor to the British Army in
Plastic Surgery and Burns
Johns Hopkins Bayview Medical Center
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Ronald P Mlcak PhD RRT FAARC
Director Respiratory Care, Associate Professor Respiratory Care
Department of Respiratory Care
Shriners Hospitals for Children-Galveston
University of Texas Medical Branch
Galveston, TX, USA
Stephen E Morris MD FACS
Associate Professor of Surgery
Director of Trauma
University of Utah
Salt Lake City, UT, USA
Elise M Morvant MD
Staff Anesthesiologist
East Tennessee Children’s Hospital
Knoxville, TN, USA

List of Contributors
xv
David W Mozingo MD
Professor of Surgery and Anesthesiology
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
Erle D Murphey DVM PhD DACVS
Assistant Director, Education and Research Division
American Veterinary Medical Association
Schaumburg, IL, USA
Kuzhali Muthu PhD
Research Assistant Professor
Department of Surgery
Loyola University Medical Center
Maywood, IL, USA
Andreas D Niederbichler MD
Assistant Professor of Plastic Surgery, Burn Center
Hannover Medical School
Hannover, Lower Saxony, Germany
William B Norbury MBBSMRCS MMS
Specialist Registrar
Welsh Centre for Burns and Plastic Surgery
Morriston Hospital
Swansea, UK
Nora Nugent FRCSI (Plast)
Plastic Surgery Fellow
St. Vincent’s Hospital
Sydney, Australia
Sheila Ott OTR
Occupational Therapist III
Department of Occupational Therapy
University of Texas Medical Branch
Galveston, TX, USA
Clifford Pereira MBBS FRCS(Eng) FRCSEd
Fellow
Department of Plastic and Reconstructive Surgery
UCLA
Los Angeles, CA, USA
Rudolf C Peterlik MD
Anesthesiologist and Intensive Care Medicine
AUVA – Unfallkrankenhaus
Linz, Austria
Laura J Porro PhD
Post Doctoral Research Fellow
Department of Surgery
University of Texas Medical Branch
Shriners Hospitals for Children
Galveston, TX, USA
Joseph A Posluszny Jr MD
Research Fellow
Loyola University Medical Center
Burn and Shock Trauma Institute
Maywood, IL, USA
Basil A Pruitt Jr MD FACS FCCM
Clinical Professor of Surgery
Dr Ferdinand P Herff Chair in Surgery
University of Texas Health Science Center at San Antonio
Surgical Consultant, US Army Burn Center
San Antonio, TX, USA
Gary F. Purdue MD
Formerly Professor
Department of Surgery
University of Texas
Southwestern Medical Center
Dallas, TX, USA
Fengjun Qin MD
Vice Chief Physician
Department of Burns
Beijing Jishuitan Hospital
Beijing, China
Edward C Robb AA BA. BS MBA
Research Consultant
Shrines Hospital for Children Cincinnati Unit
Cincinnati, OH, USA
Noe A Rodriguez MD
Post-Doctoral Fellow
Department of Surgery
University of Texas Medical Branch
Shriners Hospitals for Children
Galveston, TX, USA
Laura Rosenberg PhD
Chief Psychologist
Shriners Hospitals for Children-Galveston
Clinical Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Texas Medical Branch Galveston, TX, USA
Lior Rosenberg MD
Professor of Plastic Surgery
Chairman Department of Plastic Surgery Including:
The Burn, Craniofacial, Skin Oncology,
Reconstruction, Cosmetic and Hand Units
Soroka University Medical Center
Ben Gurion University
Beer Sheva, Israel
Marta Rosenberg PhD
Psychologist
Shriners Hospitals for Children-Galveston
Clinical Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Texas Medical Branch Galveston, TX, USA
Jeffrey R Saffle MD FACS
Professor, Surgery
Department of Surgery
University of Utah Health Center
Salt Lake City, UT, USA

List of Contributors
xvi
Hiroyuki Sakurai MD PhD
Chief Professor
Department of Plastic and Reconstructive Surgery
Tokyo Women’s Medical University
Tokyo, Japan
Arthur P Sanford MD FACS
Associate Professor of Surgery, Department of Surgery
Loyola University Medical Center
Maywood, IL, USA
Syed M Sayeed MD
Staff Surgeon
Division of Acute Care Surgery
North Shore LIJ Health System
Burn Center
Nassau University Medical Center
Manhasset, NY, USA
Cameron Schlegel, BS
Pediatric Surgery Research Fellow
Department of Pediatric Surgery
Vanderbilt University Medical Center
Nashville, TN, USA
Michael A Serghiou OTR MBA
Director of Rehabilitation and Outpatient Services
Shriners Hospitals for Children
Galveston, TX, USA
Ravi Shankar PhD
Professor
Department of Surgery
Loyola University Medical Center
Maywood, IL, USA
Yuming Shen MD
Associate Professor of Surgery
Fourth Medical College of Peking University
Vice Chief Physician
Department of Burns
Beijing Jishuitan Hospital
Beijing, China
Robert L Sheridan MD
Associate Professor of Surgery
Department of Surgery
Harvard Medical School
Boston, MA, USA
Edward R Sherwood MD PhD
Professor
Department of Anesthesiology
University of Texas Medical Branch
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
Jose P Sterling MD
Assistant Professor, Division of Burn, Trauma, Critical Care
Department of Surgery
UT Southwestern Medical Center
Dallas, TX, USA
Oscar E Suman PhD
Professor
Department of Surgery
University of Texas Medical Branch
Associate Director for Research
Director, Children’s Wellness/Exercise Center
Shriners Hospitals for Children
Galveston, TX, USA
Mark Talon DNP CRNA
Certified Nurse Anesthetist
Department of Anesthesia
University of Texas Medical Branch
Galveston, TX, USA
Christopher R Thomas, MD
Robert L Stubblefield Professor of Child Psychiatry
Assistant Dean for Graduate Medical Education
Director of Child Psychiatry Residency Training
Department of Psychiatry and Behavioral Sciences
University of Texas Medical Branch at Galveston
Galveston, TX, USA
Tracy Toliver-Kinsky PhD
Associate Professor
Department of Anesthesiology
University of Texas Medical Branch
Galveston, TX, USA
Ronald G Tompkins MD ScD
Sumner M Redstone Professor of Surgery
Harvard Medical School
Chief of Staff
Shriners Hospitals for Children – Boston
Chief, Burn Service
Massachusetts General Hospital
Boston, MA, USA
Daniel L Traber PhD FCCM
Charles Robert Allen Professor of Anesthesiology
Professor of Neuroscience and Cell Biology
Director, Investigative Intensive Care Unit
Department of Anesthesiology
University of Texas Medical Branch
Shriners Hospitals for Children
Galveston, TX, USA
Edward E Tredget MD MSc FRCSC
Professor of Surgery
Department of Surgery
University of Alberta
Edmonton, AB, Canada
Lisa L Tropez-Arceneaux PsyD
Pediatric Psychologist
Department of Surgery
Division of Burns
Shriners Burns Hospital for Children
University of Texas Medical Branch
Galveston, TX, USA

List of Contributors
xvii
Susanne Tropez-Sims MD MPH FAAP
Professor of Pediatrics and Associate Dean of
Clinical Affiliations
Department of Pediatrics
Meharry Medical College
Nashville, TN, USA
Cynthia G Villarreal BS PharmD
Retired Director of Pharmacy
Department of Pharmacy
Shriners Hospitals for Children – Galveston Burns Hospital
Galveston, TX, USA
Peter M Vogt MD PhD
Professor and Head
Department of Plastic, Hand and Reconstructive Surgery
Burn Center
Hannover Medical School
Hannover, Germany
Glenn D Warden MD MBA FACS
Emeritus Chief of Staff
Shriners Hospital for Children
Emeritus Professor of Surgery
University of Cincinnati
Cincinnati, OH, USA
Petra M Warner MD
Assistant Professor
University of Cincinnati College of Medicine
Shriners Hospital for Children
Cincinnati, OH, USA
Christopher C Whitehead PT
Physical Therapy Clinical Education Specialist
Rehabilitation Services
Shriners Hospitals for Children – Galveston
Galveston, TX, USA
Shelley A Wiechman PhD ABPP
Associate Professor
Attending Psychologist
Harborview Medical Center
Seattle, WA, USA
Mimmie Willebrand PhD
Associate Professor
Licensed Psychologist
Department of Neuroscience, Psychiatry
Uppsala University
Uppsala, Sweden
Felicia N Williams MD
Resident Physician
Department of Surgery
East Carolina University – Pitt County Memorial Hospital
Greenville, NC, USA
Natalie M Williams-Bouyer PhD
Assistant Professor
Department of Pathology
University of Texas Medical Branch
Galveston, TX, USA
Robert Winter BA
Director of Tissue Operations
LifeCenter Organ Donor Network
Cincinnati, OH, USA
Steven E Wolf MD
Betty and Bob Kelso Distinguished Chair in Burns
and Trauma
Professor and Vice-Chair for Research, Department of Surgery
University of Texas Health Science Center – San Antonio
San Antonio, TX, USA
Lee C Woodson MD PhD
Professor
Department of Anesthesiology
University of Texas Medical Branch
Chief of Anesthesia
Shriners Hospital for Children
Galveston, TX, USA
Jui-Yung Yang MD
Clinical Professor of Plastic Surgery
Linkou Burn Center, Department of Plastic Surgery
Chang Gung Memorial Hospital and University
Taipei, Taiwan

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A brief history of acute burn
care management
Ludwik K. Branski, David N. Herndon, Robert E. Barrow
The recognition of burns and their treatment is evident in
cave paintings which are over 3500 years old. Documenta­
tion in the Egyptian Smith papyrus of 1500 BC advocated 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 ren­
dered pig fat and resin impregnated in bulky dressings which
was alternated with warm vinegar soaks augmented with
tanning solutions made from oak bark. Celsus, in the first
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, who lived from 130 to 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 pro­
cedure for early burn wound excision. In 1607 Guilhelmus
Fabricius Hildanus, a German surgeon, published De Com­
bustionibus, in which he discussed the pathophysiology of
burns and made unique contributions 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
(Figure 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 com­
plication 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 (Figure 1.2) may have been the first
to demonstrate the value of the multidisciplinary team
approach to disaster burns when, on 16 April 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 arriv­
ing truckloads of casualties. This ‘Texas City Disaster’ is still
known as the deadliest industrial accident in American
history. Over the next 9 years, Truman and Virginia Blocker
followed more than 800 of these burn patients and pub­
lished 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 American Burn Asso­
ciation. Truman Blocker Jr was also recognized for his pio­
neering 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 dedication to treating burned children
convinced the Shriners of North America to build their first
Burn Institute for Children 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.8 Recently, burn
care in children has improved survival such that a burn
covering more than 95% total body surface area (TBSA) can
be survived in over 50% of cases.9 In the 1970s Andrew M.
Munster (Figure 1.3) became interested in measuring quality
of life, when 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, nutritional
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 immedi­
ate 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 Accident Hospi­
tal, advanced this technique in a series of pilot and con­
trolled trials, starting with immediate fascial excision and
grafting of small burn areas, and eventually covering 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 (Figure 1.4),
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00001-1
CHAPTER 1 
Access the complete reference list online at

Total Burn Care
1
2
tangential excision to non-operative treatment of burns. This
study showed that, compared to non-operative treatment,
early excision and grafting of deep second-degree burns
reduced hospitalization time and hypertrophic 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 which he attributed mainly to the advent of
early excision and grafting of massive burns in use since the
1970s. In a randomized prospective trial of 85 patients with
working alone in Yugoslavia in the 1960s, who developed
the concept of removing deep second-degree burns by tan­
gential 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 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 achieve­
ments, in 1974 she received the American Burn Association
(ABA) Everett Idris Evans Memorial Medal, and in 2011 the
ABA lifetime achievement award.
In the early 1970s, William Monafo (Figure 1.5) was one
of the first Americans to advocate the use of tangential exci­
sion and grafting of larger burns.15 John Burke (Figure 1.6),
while at Massachusetts General Hospital in Boston, reported
an unprecedented survival in children with burns over 80%
of the TBSA.16 His use of a combination of tangential exci­
sion for the smaller burns (Janzekovic’s technique) and exci­
sion 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, compared
Figure 1.1  Guillaume Dupuytren.
Figure 1.2  Truman G. Blocker Jr.
Figure 1.3  Andrew M. Munster.
Figure 1.4  Zora Janzekovic.

A brief history of acute burn care management
3
medical student, successfully reproduced skin grafts.20 In the
1870s, George David Pollock popularized the method in
England.21 The method gained widespread attention through­
out Europe, but as the results were extremely variable it
quickly fell into disrepute. J.S. Davis resurrected this tech­
nique 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 instrumentation. The
‘Humby knife’, developed in 1936, was the first reliable
dermatome, but its use was cumbersome. E.C. Padgett
developed an adjustable dermatome which had cosmetic
advantages and allowed the procurement of a consistent
split-thickness skin graft.23,24 Padgett also developed a system
for categorizing skin grafts into four types based on thick­
ness.25 In1964 J.C. Tanner Jr and colleagues revolutionized
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 cadavers. J. Wesley Alexander
(Figure 1.7) developed a simple method for widely expand­
ing autograft skin and then covering it with cadaver skin.28
This so called ‘sandwich technique’ has been the mainstay
of treatment of massively burned individuals.
In 1981, John Burke and Ioannis Yannas developed an
artificial skin which 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 which covered over 80% of the TBSA.29
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 of the burn eschar improves long-term
outcome and cosmesis, thereby reducing the amount of
reconstructive procedures required.
Skin grafting
Progress in skin grafting techniques has paralleled the devel­
opments in wound excision. In 1869, J. P. Reverdin, a Swiss
Figure 1.5  William Monafo.
Figure 1.6  John Burke.
Figure 1.7  J. Wesley Alexander.

Total Burn Care
1
4
a treatment that was described in their landmark publica­
tion41 and remains the treatment of choice in many 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 sup­
ported supranormal feeding with a caloric intake as high as
8000 kcal/day.45 P. William Curreri (Figure 1.8) retrospec­
tively 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 main­
tain their body weight during acute hospitalization.46 A.B.
Sutherland proposed that children should receive 60 kcal/kg
body weight plus 35 kcal/% TBSA burned per day to main­
tain their body weight.47 D.N. Herndon et al. subsequently
showed that supplemental parenteral 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
David Heimbach led one of the early multicenter rando­
mized clinical trials using Integra.30 Its use in the 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 cul­
tured 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
An important major advancement in burn care that has
reduced mortality is infection control. 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 Noble Prize winner Alexis Carrel to create a
system of mechanical cleansing, surgical debridement, and
topical application of hypochlorite solution, which was
meticulously protocolized and used successfully in wounds
and burns.37 Subsequently, concentrations of sodium hypo­
chlorite were investigated for antibacterial activity and tissue
toxicity in vitro and in vivo, and it was found that a concen­
tration of 0.025% NaClO was most efficacious as 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 pene­
trate third-degree eschar and was extremely effective against
a wide spectrum of pathogens. Simultaneously, 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 which can cause
systemic acidosis and compensatory hyperventilation 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,
Figure 1.8  P. William Curreri.

A brief history of acute burn care management
5
relating fluid requirements to body weight and surface area
burned.58 From their recommendations, intravenous infu­
sion of normal saline plus colloid (1.0 mL/kg/% burn)
along with 2000 mL dextrose 5% solution to cover insensi­
ble 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 (Figure 1.11) and G. Tom
Shires (Figure 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/kg/% TBSA burned
others, including T. Blocker Jr,50 C. Artz, 51 and later by
Sutherland.47
Fluid resuscitation
The foundation of current fluid and electrolyte management
began with the studies of Frank P. Underhill, who, as Profes­
sor of Pharmacology and Toxicology at Yale, studied 20 indi­
viduals 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 (Figure 1.9 and Figure 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 postu­
lated 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 collected 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
modified the fluid replacement formulas for use in chil­
dren.57 I.E. Evans and his colleagues made recommendations
Figure 1.9  Oliver Cope.
Figure 1.10  Francis D. Moore.
Figure 1.11  Charles R. Baxter.

Total Burn Care
1
6
a direct parenchymal injury that results in early acute respira­
tory 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 diagnosis of
inhalation injury.65,66 When this radioisotope method is used
in conjunction with a medical history, the identification
of an inhalation injury is quite reliable. The fiberoptic
bronchoscope is another diagnostic tool which, under
topical anesthesia, can be used for the early diagnosis of an
inhalation injury.67 It is also capable of pulmonary lavage to
remove airway plugs and deposited particulate matter.
K.Z. Shirani, Basil A. Pruitt (Figure 1.13), and A.D. Mason
reported that smoke inhalation injury and pneumonia, in
addition to age and burn size, greatly increased burn mortal­
ity.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/kg/% TBSA burn
more fluid in the first 24 hours after burn to maintain ade­
quate urine output and organ perfusion. Multicenter studies
looking at patients with adult respiratory distress have advo­
cated 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 inspiratory minute volume, which
provides a vibration to encourage 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 Inhalation 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 inhalation injury is 73% TBSA;
during the first 24 hours after burn. All these formulas advo­
cate giving half of the fluid in the first 8 hours 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 intracel­
lular edema also develops. The excessive disruption 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 substantiated in studies of
burn patients with toxic inhalation injuries.61 After a severe
thermal injury fluid accumulates in the wound, and unless
there is an adequate and early fluid replacement, hypovo­
lemic shock will develop. A prolonged systemic inflam­
matory response to severe burns can lead to multiorgan
dysfunction, sepsis, and even mortality. It has been suggested
that for maximum benefit, fluid resuscitation should begin
as early as 2 hours after burn.9,62 Fluid requirements in chil­
dren are greater with a concomitant inhalation injury,
delayed fluid resuscitation, and larger burns.
Inhalation injury
During the 1950s and 1960s burn wound sepsis, nutrition,
kidney dysfunction, wound coverage, and shock were the
main foci of burn care specialists. Over the last 50 years these
problems have been clinically treated with more and more
success; hence a greater interest in a concomitant inhalation
injury evolved. A simple classification of inhalation injury
separates problems occurring in the first 24 hours after
injury, which include upper airway obstruction and edema,
from those that manifest after 24 hours. These include pul­
monary 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 upon the solubility of the toxic substance and
the duration of exposure. 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
Figure 1.13  Basil A. Pruitt.
Figure 1.12  G. Tom Shires.

A brief history of acute burn care management
7
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 catabo­
lism. The catabolic response was described by H. Sneve as
exhaustion and emaciation, and he recommended a nour­
ishing 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 con­
tinuous feeding to prevent catabolism after trauma and
injury.77 Over the last 30 years the hypermetabolic response
to burn has been shown to increase metabolism, negative
nitrogen balance, glucose intolerance, and insulin resistance.
In 1974, Douglas Wilmore and colleagues defined catecho­
lamines as the primary mediator of this hypermetabolic
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° 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 hypermetabolic
response, and its consuming greed for glucose and other
nutrients was at the expense of the rest of the body.81 Wilmore
also felt that heat was produced by biochemical 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 agent
human recombinant growth hormone, the synthetic ana­
bolic testosterone analog oxandrolone, insulin, and the
glucose uptake modulator metformin, have all shown some
beneficial effects in reducing the hypermetabolic response in
burn patients.
Summary
The evolution of burn treatments has been extremely pro­
ductive over the last 50 years. The mortality of severely
burned patients has decreased significantly thanks to
improvements in early resuscitation, infection control, nutri­
tion, 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 which 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
determinants of mortality in those with severe burns.
Further improvements in the treatment of inhalation
injuries are expected through the development of arterial
venous CO2 removal and extracorporeal membrane oxygen­
ation devices.86 Perhaps even lung transplants will fit into
the treatment regimen for end-stage pulmonary failure.
Research continues to strive for a better understanding of the
pathophysiology of burn scar contractures 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.
Further reading
Baxter CR, Shires T. Physiological response to crystalloid resuscitation
of severe burns. Ann N Y Acad Sci. Aug 14 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. Oct 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. Oct 20
1989;262(15):2125-2130.
Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. Dec 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. Nov 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. Oct
1974;180(4):653-669.
Access the complete reference list online at

A brief history of acute burn care management
7.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Majno G. The healing hand: Man and wound in the ancient world.
Cambridge, Mass.: 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. Nov 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 (1946). Jan 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. May 1959;97(5):
604-617.
7. Bremer J. Giant. The saga of the first man to be called president
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
estimate. Ann Surg. Mar 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. May
1997;225(5):554-565; discussion 565-559.
10. Blades B, Mellis N, Munster AM. A burn specific health scale.
J Trauma. Oct 1982;22(10):872-875.
11. Munster AM, Horowitz GL, Tudahl LA. The abbreviated Burn-
Specific Health Scale. J Trauma. Apr 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. Jan
1947;125(1):1-22.
13. Jackson D, Topley E, Cason JS, et al. Primary excision and grafting
of large burns. Ann Surg. Aug 1960;152:167-189.
14. Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. Dec 1970;10(12):1103-1108.
15. Monafo WW. Tangential excision. Clin Plast Surg. Oct 1974;1(4):
591-601.
16. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and
immediate grafting: a method shortening illness. J Trauma. May
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 randomized prospective study. J Trauma. Nov 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. Nov 1988;208(5):
577-585.
19. Herndon DN, Barrow RE, Rutan RL, et al. A comparison of
conservative versus early excision. Therapies in severely burned
patients. Ann Surg. May 1989;209(5):547-553.
20. Reverdin JP. Greffe epidermique. Bull Soc Chir Paris December 8
and I5, 1869. 1869;101.
21. Freshwater MF, Krizek TJ. Skin grafting of burns: a centennial. A
tribute to George David Pollock. J Trauma. Oct 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 Obst.
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. Jun 1941;113(6):1034-1049.
25. Padgett EC. Indications for determination of the thickness of split
skin grafts. Am J Surg. Nov 1946;72(5):683-693.
26. Tanner JC Jr, Vandeput J, Olley JF. The mesh skin graft. Plast
Reconstr Surg. Sep 1964;34:287-292.
27. Bondoc CC, Burke JF. Clinical experience with viable frozen
human skin and a frozen skin bank. Ann Surg. Sep 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. Jun 1981;21(6):433-438.
29. 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. Oct 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.
Sep 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 collagen-glycosaminoglycan substrate. JAMA. Oct 20 1989;
262(15):2125-2130.
32. Boyce ST. Cultured skin substitutes: a review. Tissue Eng. Winter
1996;2(4):255-266.
33. Supp DM, Boyce ST. Engineered skin substitutes: practices and
potentials. Clin Dermatol. Jul-Aug 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. Nov-Dec 2010;
31(6):874-881.
35. Barillo DJ. Topical antimicrobials in burn wound care: a recent
history of 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. Aug 28 1915;2(2852):
318-320.
37. Haller JS Jr. Treatment of infected wounds during the Great War,
1914 to 1918. South Med J. Mar 1992;85(3):303-315.
38. Heggers JP, Sazy JA, Stenberg BD, et al. Bactericidal and
wound-healing properties of sodium hypochlorite solutions:
the 1991 Lindberg Award. J Burn Care Rehabil. Sep-Oct 1991;
12(5):420-424.
39. Lindberg RB, Moncrief JA, Switzer WE, et al. The successful
control of burn wound sepsis. J Trauma. Sep 1965;5(5):
601-616.
40. Fox CL Jr, Rappole BW, Stanford W. Control of pseudomonas
infection in burns by silver sulfadiazine. Surg Gynecol Obstet.
May 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.
Jun 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. Nov-Dec 1989;10(6):
508-511.
43. Monafo WW, West MA. Current treatment recommendations for
topical burn therapy. Drugs. Sep 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. May 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. Oct 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. Jul-Aug 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. May 1955;141(5):589-597.

Total Burn Care
1
7.e2
© Copyright 2012 Elsevier, Inc. All rights reserved.
51. Artz CP, Reiss E. The treatment of burns. Philadelphia: Saunders;
1957:
Accessed.
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. Jun 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. Dec 1947;
126(6):1010-1045.
56. Moore FD. The body-weight burn budget. Basic fluid therapy for
the early burn. Surg Clin North Am. Dec 1970;50(6):1249-1265.
57. Kyle MJ, Wallace AB. Fluid replacement in burnt children. Br J
Plast Surg. Oct 1950;3(3):194-204.
58. Evans EI, Purnell OJ, Robinett PW, et al. Fluid and electrolyte
requirements in severe burns. Ann Surg. Jun 1952;135(6):
804-817.
59. Reiss E, Stirmann JA, Artz CP, et al. Fluid and electrolyte balance
in burns. J Am Med Assoc. Aug 1 1953;152(14):1309-1313.
60. Baxter CR, Shires T. Physiological response to crystalloid
resuscitation of severe burns. Ann N Y Acad Sci. Aug 14
1968;150(3):874-894.
61. Tasaki O, Goodwin CW, Saitoh D, et al. Effects of burns on
inhalation injury. J Trauma. Oct 1997;43(4):603-607.
62. Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation
improves outcomes in severely burned children. Resuscitation.
Jul 2000;45(2):91-96.
63. Foley FD, Moncrief JA, Mason AD Jr. Pathology of the lung in
fatally burned patints. Ann Surg. Feb 1968;167(2):251-264.
64. Moylan JA, Chan CK. Inhalation injury—an increasing problem.
Ann Surg. Jul 1978;188(1):34-37.
65. Agee RN, Long JM 3rd, Hunt JL, et al. Use of 133xenon in early
diagnosis of inhalation injury. J Trauma. Mar 1976;16(3):218-224.
66. Moylan JA Jr, Wilmore DW, Mouton DE, et al. Early diagnosis of
inhalation injury using 133 xenon lung scan. Ann Surg. Oct
1972;176(4):477-484.
67. Moylan JA, Adib K, Birnbaum M. Fiberoptic bronchoscopy
following thermal injury. Surg Gynecol Obstet. Apr 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. Jan 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.
Dec 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. Aug 1987;102(2):341-349.
71. Fitzpatrick JC, Cioffi WG Jr. Ventilatory support following burns
and smoke-inhalation injury. Respir Care Clin N Am. Mar
1997;3(1):21-49.
72. Cortiella J, Mlcak R, Herndon D. High frequency percussive
ventilation in pediatric patients with inhalation injury. J Burn
Care Rehabil. May-Jun 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. May-Jun 1998;19(3):210-212.
74. Barrow RE, Spies M, Barrow LN, et al. Influence of demographics
and inhalation injury on burn mortality in children. Burns. Feb
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. Feb
1953;137(2):165-174.
77. Moore FD. Metabolism in trauma: the reaction of survival.
Metabolism. Nov 1959;8:783-786.
78. Wilmore DW, Long JM, Mason AD Jr, et al. Catecholamines:
mediator of the hypermetabolic response to thermal injury.
Ann Surg. Oct 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.
Sep 1984;200(3):264-281.
80. Wilmore DW, Mason AD Jr, Johnson DW, et al. Effect of ambient
temperature on heat production and heat loss in burn patients.
J Appl Physiol. Apr 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. Oct
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. Oct 1979;28(10):1031-1039.
84. Hart DW, Wolf SE, Chinkes DL, et al. Determinants of skeletal
muscle catabolism after severe burn. Ann Surg. Oct 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.
Mar 6 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. Nov 1994;18(11):833-839.
87. Gurtner GC, Werner S, Barrandon Y et al. Wound repair and
regeneration. Nature. May 15 2008;453(7193):314-321.

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Teamwork for total burn care:
burn centers and multidisciplinary
burn teams
Ahmed M. Al-Mousawi, Oscar E. Suman, David N. Herndon
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
either by death or by survival encumbered by pronounced
disfigurement and disability, have been the expected seque­
lae 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 sad, 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 associ­
ated with TBSA burns of 70% or greater in this age group.
Over the past decade, mortality figures have decreased 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 advances in burn treatment for many decades, that
goal has now been virtually accomplished. The major goal
is now 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 anti­
microbials in delaying the onset of sepsis, thereby contribut­
ing to decreased mortality in burn patients. Prospective
randomized clinical trials have shown that early surgical
therapy is efficacious in improving survival for many burned
patients by reducing blood loss and diminishing the occur­
rence of sepsis.9–14 Basic science and clinical research have
helped reduce mortality by characterizing the pathophysio­
logical changes related to inhalation injury and suggesting
treatment methods that have reduced the incidence of
pulmonary edema and pneumonia.15–18 Scientific investiga­
tions of the hypermetabolic response to major burn injury
have led to improved management of this life-threatening
phenomenon, not only enhancing survival, but also promis­
ing an improved quality of life.19–32
Optimal treatment of severely burned patients requires
significant healthcare resources and has led to the
development of burn centers. Centralizing services to
regional burn centers has made the implementation of
multidisciplinary acute critical care and long-term rehabilita­
tion possible. It has also enhanced opportunities for study
and research over the past several decades.
Over the past half century the implementation of a wide
range of medical discoveries and innovations has improved
patient outcomes following severe burns. Key areas of
advancement 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 modulation of
hypermetabolic and catabolic responses. These factors have
reduced morbidity and mortality from severe burns by
improving wound healing, reducing inflammation and
energy demands, and attenuating hypermetabolism and
muscle catabolism.
Melding scientific research with clinical care has been pro­
moted 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 US burn center was established at the Medical
College of Virginia in 1946. In the same year, the US Army
Surgical Research Unit (later renamed the US Army Institute
of Surgical Research) was established. Directors of both
centers and later, the founders of the Burn Hospitals of
Shriners Hospitals for Children, emphasized the importance
of collaboration between clinical care and basic scientific
disciplines.1
The organizational design of these centers engendered a
self-perpetuating feedback loop of clinical and basic
scientific inquiry. In this system, scientists receive first-hand
information about clinical problems, and 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
collegial group of basic scientists, clinical researchers, and
clinical caregivers, all asking questions of each other, sharing
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00002-3
CHAPTER 2 
Access the complete reference list online at

Total Burn Care
2
10
observations and information, and seeking solutions 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
stress the utility of a team concept.1 The International Society
of Burn Injuries and its journal, Burns, as well as the Ameri­
can Burn Association and its publication, Journal of Burn Care
and Research, have publicized the notion of successful multi­
disciplinary 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 multi­
disciplinary 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 the skills, knowl­
edge, and energy required for the comprehensive care of
severely injured patients. Thus, reliance is placed on a group
of specialists to provide integrated care through innovative
organization and collaboration.
In addition to burn-specific providers, the burn team
consists of epidemiologists, molecular biologists, micro­
biologists, physiologists, biochemists, pharmacists, patho­
logists, endocrinologists, nutritionists, and numerous other
scientific and medical 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 affect the well­
being of patients and staff. However, the traditional burn
team consists of a multidisciplinary group of direct-care pro­
viders. Burn surgeons, nurses, dietitians, and physical and
occupational therapists form the skeletal core; most burn
units also include anesthesiologists, respiratory therapists,
pharmacists, and social workers. The decrease in mortality
rates in recent years has heightened interest in the quality
of life of burn survivors, both acutely in the hospital and
long term. Consequently, more burn units have added
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).
psychologists, psychiatrists, and more recently, exercise
physiologists to their burn team. In pediatric units, child life
specialists and school teachers are also significant members
of the team.
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 obvious in the case of
children, but also true in the case of adults. Family members
become conduits of information 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 team’ are plentiful, and there is agreement on the
specialists and care providers whose expertise is required
for optimal care of patients with significant burn injuries
(Figure 2.1a and 2.1b).
Burn surgeons
The ultimate responsibility and overall control for the care
of a patient lies with the admitting burn surgeon. 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 leadership and guidance for the rest of the
team, which may include several surgeons. This leadership
is particularly 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 knowledge and skill in medicine, but also be able to
exchange information clearly with a diverse staff of experts
in other disciplines. The surgeon alone cannot provide com­
prehensive care, but must be wise enough to know when and
how to seek counsel as well as how to give clear and firm
direction to activities surrounding patient care. The senior
surgeon 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
Nurses
Nurses represent the largest single disciplinary segment of
the burn team, providing continuous coordinated care to the
patient. They are 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 their
family. 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

Teamwork for total burn care: burn centers and multidisciplinary burn teams
11
respiratory therapists essential to the patient’s welfare.
Respiratory therapists evaluate pulmonary mechanics,
perform therapy to facilitate breathing, and closely monitor
the status of the patient’s respiratory function.
Rehabilitation therapists
Occupational and physical therapists begin planning thera­
peutic interventions on the patient’s admission to maximize
functional recovery. Burned patients require special position­
ing and splinting, early mobilization, strengthening exer­
cises, endurance activities, and pressure garments to promote
healing while controlling scar formation. These therapists
must be very creative in designing and applying the appro­
priate appliances. Knowledge of the timing of application
is necessary. In addition, rehabilitation therapists must
become expert behavioral managers, as their necessary treat­
ments are usually painful to the recovering patient. While
the patient is angry, protesting loudly, or pleading for mercy,
the rehabilitation therapist must persist with aggressive
treatment to combat quickly forming and very strong scar
contractures. The same therapist, however, is typically
rewarded with adoration and gratitude from an enabled
burn survivor.
Nutritionists
A nutritionist or dietitian monitors daily caloric intake and
weight maintenance. They also recommend dietary interven­
tions to provide optimal nutritional support to combat the
hypermetabolic response 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.
Psychosocial experts
Psychiatrists, psychologists, and social workers with expertise
in human behavior and psychotherapeutic interventions
provide continuous sensitivity in caring for the emotional
and mental wellbeing 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, and on occasion, other burn team
members.34 They often assist colleagues from other disci­
plines in developing behavioral interventions for problem­
atic patients, allowing both colleague and patient to achieve
therapeutic success.35 During the initial hospitalization,
these experts manage the patient’s mental status, pain toler­
ance, and anxiety level to provide comfort and facilitate
physical recovery. As the patient progresses toward rehabili­
tation, the role of the mental health team becomes more
prominent in supporting optimal psychological, social, and
physical rehabilitation.
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
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 the hospitalization through the lengthy period of
outpatient rehabilitation.
Anesthesiologists
An anesthesiologist who is an expert in the altered physio­
logic parameters of burned patients is critical to the survival
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 physio­
logic changes to be anticipated as the burn wounds heal.1
Anesthesiologists play a significant role in facilitating comfort
for burned patients, not only in the operating room, but
also during the painful ordeals of dressing changes, staple
removal, and physical exercise.
Respiratory therapists
Inhalation injury, prolonged bed rest, fluid shifts, and the
threat of pneumonia, concomitant with burn injury, render
Figure 2.1a, b  Experts from diverse disciplines gather together with
common goals and tasks, having overlapping values to achieve their
objectives.
A
B

Total Burn Care
2
12
discharge planning, nutritional goals, patient understand­
ing, and patient compliance.
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.39,40 The
team becomes an efficient work group through a process
of establishing mechanisms of collaboration and coopera­
tion that facilitate focusing on explicit tasks rather than
covert distractions of personal need and interpersonal con­
flict.39,41 Work groups develop best under conditions that
allow each individual to feel acknowledged as valuable to
the team.42
Multidisciplinary burn care involves taking into account
all aspects of patient care when treatment decisions
are made, as well as considering subsequent effects and
consequences of decisions. With good communication
and coordination between all members, the team can
optimize outcome for a patient in every aspect of their care
(Figure 2.1a).
Research into the area of multidisciplinary teams has high­
lighted the wide application of such teams in healthcare
settings as well as some of the shortcomings affecting their
efficacy.36 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 functioning are
listed in Box 2.1.
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 validation of
members as they accomplish tasks is necessary. The burn
team consists of many experts from diverse professional
backgrounds, each of which has its own culture, problem-
solving approach, and language.43 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, eventually developing their
own culture and language that all can understand. Attitudes
of superiority and prejudice are most disruptive to the per­
formance 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
institution, the exercise physiologist performs clinical 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.
There is no licensing body and no requirements for exer­
cise physiologists to practice their profession. However,
many organizations, such as the American College of Sports
Medicine and the Clinical Exercise Physiology Association,
offer national certifications. These certifications include the
exercise test technologist, exercise specialist, health/fitness
director, and clinical exercise specialist. We recommend that
if the exercise physiologist is primarily involved in clinical
duties, they should have a minimum of a master’s degree
and be nationally certified.
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 responsibili­
ties. 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 indi­
viduals and the rest of the burn care team yields numerous
benefits, including the conception of new clinical and trans­
lational questions that, when answered, directly improve
patient care.
Dynamics and functioning of the burn team
Simply gathering a group of experts from diverse disciplines
does not create a team.36 In fact, the diversity of the disci­
plines, along with individual differences in gender, ethnicity,
values, professional experience, and professional status,
render teamwork a process fraught with opportunities for
disagreements, jealousies, and confusion.37 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 the professionals. It is
not unusual for the patient to attempt to diminish their
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.38 Time must be devoted to a process
of trust building among team members. It is also imperative
that the team communicate openly and frequently, or the
group will lose effectiveness.
Communicating and discussing daily, weekly, and long-
term management plans between team members allows
for clarification and organization of early plans to flag issues
early on with regard to further surgery, rehabilitation,
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 non-authoritarian)
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)
(From Al-Mousawi et al., Burn Teams and Burn Centers,46 adapted from Schofield &
Amodeo36)

Teamwork for total burn care: burn centers and multidisciplinary burn teams
13
be responsible for the patient’s medical needs. However,
sharing power does not mean giving up control. The
physician shares leadership by seeking information and
advice from other team members and empowers them by
validating 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
continue improving and understanding the rehabilitation
and emotional, psychological, and physiologic recovery of
burn patients.
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 has provided tremendous opportu­
nities 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 encoun­
ter. We also hope that, in the future, burn care will continue
to devote the same energy and resources, which have pro­
duced such tremendous advances in saving lives and opti­
mizing the quality of life for survivors.
Further reading
Al-Mousawi AM, Mecott-Rivera GA, Jeschke MG, et al. Burn teams and
burn centers: the importance of a comprehensive team approach
to burn care. Clin Plast Surg. Oct 2009;36(4):547-554.
Hart DW, Wolf SE, Chinkes DL, et al. Determinants of skeletal muscle
catabolism after severe burn. Ann Surg. Oct 2000;232(4):455-465.
Herndon DN, Barrow RE, Rutan RL, et al A comparison of
conservative versus early excision. Therapies in severely burned
patients. Ann Surg. May 1989;209(5):547-552; discussion 552-543.
Murphy KD, Thomas S, Mlcak RP, et al. Effects of long-term
oxandrolone administration in severely burned children. Surgery.
Aug 2004;136(2):219-224.
Suman OE, Thomas SJ, Wilkins JP, et al. Effect of exogenous growth
hormone and exercise on lean mass and muscle function in
children with burns. J Appl Physiol. Jun 2003;94(6):2273-2281.
with successful team performance in problem solving and
conflict resolution.44 When handled well, conflicts and disa­
greements can increase understanding and provide new per­
spectives, in turn enhancing working relationships and
leading to improved patient care.45
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 (Figure 2.1b).
Empirical studies indicate, with remarkable consistency, that
the functions required for successful leadership can be
grouped into two somewhat incompatible clusters: 1) direct­
ing the group toward tasks and goal attainment, and 2)
facilitating interactions among group members and enhanc­
ing their feelings of worth.39,42,45
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
successful 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 activity.
Studies of group behavior demonstrate that high-
performance teams are characterized by synergy between
task accomplishment and individual need fulfillment.39 As
one formal leader cannot always attend to task and interper­
sonal nuances, groups informally or formally allocate leader­
ship activities to multiple persons.39,41,42 According to the
literature on organizational behavior, the most effective
leader is one who engages the talents of others and empow­
ers them to use their abilities to further the work of the
group.39,41 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 team, he or she must
be prepared to share leadership with one or more ‘informal’
leaders in such a way that all leadership functions are ful­
filled.39,41,42 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, develop­
ing a climate in which the team members are more likely to
cooperate and collaborate toward achievement beyond indi­
vidual capacity.
For many physicians, the concept of sharing leadership
and power initially appears threatening, for it is the
physician, after all, who must ultimately write the orders and
Access the complete reference list online at

Teamwork for total burn care: burn centers and multidisciplinary burn teams
13.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Artz CP, Moncrief JA. The burn problem. The Treatment of Burns.
2nd ed. Philadelphia, PA: W B Saunders Co; 1969:1-21.
2. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised
estimate. Ann Surg. Mar 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.
Mar 2006;202(3):536-548.
4. Baxter CR, Marvin J, Curreri PW. Fluid and electrolyte therapy of
burn shock. Heart Lung. Sep-Oct 1973;2(5):707-713.
5. Carvajal HF. Fluid therapy for the acutely burned child. Compr
Ther. Mar 1977;3(3):17-24.
6. Evans EI, Purnell OJ, Robinett PW, et al. Fluid and electrolyte
requirements in severe burns. Ann Surg. Jun 1952;135(6):
804-817.
7. Curreri PW, Richmond D, Marvin J, et al. Dietary requirements of
patients with major burns. J Am Diet Assoc. Oct 1974;65(4):
415-417.
8. Hildreth MA, Herndon DN, Desai MH, et al. Reassessing caloric
requirements in pediatric burn patients. J Burn Care Rehabil.
Nov-Dec 1988;9(6):616-618.
9. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and
immediate grafting: a method shortening illness. J Trauma. May
1974;14(5):389-395.
10. Desai MH, Herndon DN, Broemeling L, et al. Early burn wound
excision significantly reduces blood loss. Ann Surg. Jun
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.
Sep-Oct 1991;12(5):482-484.
12. Engrav LH, Heimbach DM, Reus JL, et al. Early excision and
grafting vs. nonoperative treatment of burns of indeterminant
depth: a randomized prospective study. J Trauma. Nov
1983;23(11):1001-1004.
13. Herndon DN, Barrow RE, Rutan RL, et al. A comparison of
conservative versus early excision. Therapies in severely burned
patients. Ann Surg. May 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. Dec 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. Jun 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. Oct
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. Aug 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. Jan
1987;205(1):82-87.
19. Hart DW, Wolf SE, Ramzy PI, et al. Anabolic effects of
oxandrolone after severe burn. Ann Surg. Apr 2001;233(4):
556-564.
20. Wilmore DW, Long JM, Mason AD Jr, et al. Catecholamines:
mediator of the hypermetabolic response to thermal injury. Ann
Surg. Oct 1974;180(4):653-669.
21. Hart DW, Wolf SE, Chinkes DL, et al. Determinants of skeletal
muscle catabolism after severe burn. Ann Surg. Oct
2000;232(4):455-465.
22. Celis MM, Suman OE, Huang TT, et al Effect of a supervised
exercise and physiotherapy program on surgical interventions in
children with thermal injury. J Burn Care Rehabil. Jan-Feb
2003;24(1):57-61; discussion 56.
23. Suman OE, Thomas SJ, Wilkins JP, et al. Effect of exogenous
growth hormone and exercise on lean mass and muscle function
in children with burns. J Appl Physiol. Jun 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.
Nov 20 1999;354(9192):1789.
25. Cucuzzo NA, Ferrando A, Herndon DN. The effects of exercise
programming vs traditional outpatient therapy in the
rehabilitation of severely burned children. J Burn Care Rehabil.
May-Jun 2001;22(3):214-220.
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. May-Jun 2004;25(3):287-293.
27. Murphy KD, Thomas S, Mlcak RP, et al. Effects of long-term
oxandrolone administration in severely burned children. Surgery.
Aug 2004;136(2):219-224.
28. Herndon DN, Stein MD, Rutan TC, et al. Failure of TPN
supplementation to improve liver function, immunity, and
mortality in thermally injured patients. J Trauma. Feb
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. Jul-Aug 1989;10(4):309-313.
30. Thomas S, Wolf SE, Murphy KD, et al. The long-term effect of
oxandrolone on hepatic acute phase proteins in severely burned
children. J Trauma. Jan 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. Dec
2003;29(8):793-797.
32. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle
catabolism after severe burn. Surgery. Aug 2000;128(2):312-319.
33. Shakespeare PG. Who should lead the burn care team? Burns. Dec
1993;19(6):490-494.
34. Morris J, McFadd A. The mental health team on a burn unit: a
multidisciplinary approach. J Trauma. Sep 1978;18(9):658-663.
35. Hughes TL, Medina-Walpole AM. Implementation of an
interdisciplinary Behavior Management Program. J Am Geriatr Soc.
May 2000;48(5):581-587.
36. Schofield RF, Amodeo M. Interdisciplinary teams in health care
and human services settings: are they effective? Health Soc Work.
Aug 1999;24(3):210-219.
37. Fallowfield L, Jenkins V. Effective communication skills are the
key to good cancer care. Eur J Cancer. Oct 1999;35(11):1592-
1597.
38. Perl E. Treatment team in conflict: the wishes for and risks of
consensus. Psychiatry. Summer 1997;60(2):182-195.
39. Harris P, Harris DL. High Performance Team Management.
Leadership & Organization Development Journal. 1989;10(4):28-32.
40. Miller E, Rice A. Systems of organization. In: Coleman A, Bexton
W, eds. Group Relations Reader. Sausalito, CA: Grex; 1975:43-68.
41. Yank GR, Barber JW, Hargrove DS, et al. The mental health
treatment team as a work group: team dynamics and the role of
the leader. Psychiatry. Aug 1992;55(3):250-264.
42. Litterer J. The Analysis of Organizations. 2nd ed. John Wiley & Sons
Inc; 1973.
43. Hall P. Interprofessional teamwork: professional cultures as
barriers. J Interprof Care. May 2005;19(Suppl 1):188-196.
44. Jordan PJ, Troth AC. Managing emotions during team problem
solving: emotional intelligence and conflict resolution. Human
Performance. 2004;17(2):195-218.
45. Van Norman G. Interdisciplinary Team Issues – online
publication. 1998.
46. Al-Mousawi AM, Mecott-Rivera GA, Jeschke MG, et al. Burn teams
and burn centers: the importance of a comprehensive team
approach to burn care. Clin Plast Surg. Oct 2009;36(4):547-554.

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*From the US Army Institute of Surgical Research, Fort Sam, Houston, Texas, and the
Department of Surgery, University of Texas Health Science Center at San Antonio,
San Antonio, Texas, USA. The opinions or assertions herein are the private views of
the authors and are not to be construed as official or as reflecting the views of
the Department of the Army or the Department of Defense.
Epidemiological, demographic,
and outcome characteristics
of burn injury*
Basil A. Pruitt, Jr., Steven E. Wolf, Arthur D. Mason, Jr.
Introduction
In the United States in 2009 there was a fire/burn death every
3 hours and a burn injury occurred every half hour.1 In 2007,
the most recent year for which numbers and rates of injury
deaths are available, there were an estimated 182 479 deaths
from all injuries in the United States, which in a total popu­
lation of 301 579 895 at that time represented a crude injury
death rate of 60.51/100 000 population. Data supplied by
the CDC in the WISQARS** Injury Mortality Report indicate
that in 2007 there were 3774 (1.25/100 000 population)
fatal fire/burn injuries, which represented 2.1% of all fatal
injuries. There were more fatal fire/burn injuries in men
(2230) than in women (1544), but those in women repre­
sented a greater percentage of all fatal injuries than in men,
2.7 % vs 1.8%, respectively. Unintentional fire/burn deaths
in 2007 represented only 2.7% of all unintentional injury
deaths but were 11.3 times more common than violence-
related fire/burn deaths (Table 3.1).2
As indicated in Table 3.2, in 2007 there were an estimated
266 fire/burn deaths in the 0–4-year age group, 259 as a
consequence of fire and flame and only seven due to contact
with a hot object or substance.2 The number of fire/burn
deaths decreased to a low of 86 in the 10–14-year age group,
rose in the older age groups, and was above 200 in all age
groups of 40 years and over. In all age groups fire/flame was
the predominant cause of fatal injury, and contact with a hot
object or substance caused only 16 or fewer deaths during
that year. The majority of deaths in all age groups were the
consequence of residential fire/flame injury. The table illus­
trates the age-related changes in the relationship of burn
injury and site of burn injury to overall injury fatalities in
2007. The WISQARS Fatal Injury mapping program docu­
ments that fire/burn death rates in the United Sates vary
considerably between states. During the years 2000–2006,
fire/burn death rates per 100 000 population ranged from a
high of 3.39 and 2.70 in Mississippi and Arkansas, respec­
tively, to a low of 0.54 and 0.53 in Colorado and Utah,
respectively. Age less than 4 years, age 65 years and over, rural
residency, and economic deprivation have all been reported
to define groups that are at increased risk of fire-related
injury and death. Differences in these risk factors may
account in part for the differences in burn incidence rates
and mortality between states.2
In 2009, the most recent year for which numbers and rates
of non-fatal injuries are available, there were an estimated
29 636 366 persons with non-fatal injuries in the United
States, which in a total population of 307 006 550 at
that time represented a crude non-fatal injury rate of
9653.33/100 000. Data supplied by the NEISS WISQARS
program indicate that in 2009 there were 381 012 non-fatal
fire/burn injuries (124.11/100 000), which represented 1.3%
of all non-fatal injuries that year. Non-fatal fire/burn injury
as a percentage of all non-fatal injuries in 2009 showed little
gender difference, i.e. 1.2% for men and 1.4% for women.
Unintentional fire/burn injuries in 2009 represented only
1.3% of all unintentional non-fatal injuries but were almost
40 times (39.4) more common than violence-related non-
fatal burns (Table 3.3).3
Overall unintentional non-fatal fire/burn injuries repre­
sent a variable percentage of all injuries and all uninten­
tional injuries as related to the population in various age
groups (Table 3.4). Overall fire/burn injuries represented
2.5% of all non-fatal injuries, and unintentional fire/burn
injuries represented 2.5% of all non-fatal unintentional
injuries in the 0–4-year age group, and 1% of both overall
and unintentional injuries in the 5–9-year age group. The
total number and rates of both all-cause and unintentional
non-fatal fire/burn injury in 2009 were greatest in the 0–4-
year age group, i.e. 58 400 (274.18/100 000) and 57 742
(271.09/100 000). In the 5–19-year age groups both the
number and rate of both overall and unintentional non-fatal
burn injuries decreased, only to rise again in the 20–24-year
group, i.e. 40 655 (188.75/100 000) for overall burn injury
and 38 788 (180.08/100 000) for all unintentional burn
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00003-5
CHAPTER 3 
Access the complete reference list online at

**The National Electronic Injury Surveillance System, NEISS) retrieves data from the
emergency departments of 100 hospitals chosen as a representative sample of the
more than 5300 US hospitals with emergency departments. The NEISS All Injury
Program (AIP), which started in 2000, collects data on fatal and non-fatal injuries at 66
of the NEISS hospitals, selected as representing the spectrum of US hospitals, which are
used to calculate national injury estimates. The CDC Web-based Injury Statistics Query
and Reporting System (WISQARS) is an online database which provides access to the
injury data that have been collected at those hospitals.

Total Burn Care
3
16
Table 3.1  US injury deaths – 2007
n
(%)
Ratea
All injury
182 479
60.51
All fire/burn injury
3774
2.1b
1.25
  Males
2230
  Females
1544
Fire/flame
3680
1.22
Hot object/substance
94
0.03
Residential fire/flame
2902
0.96
All unintentional injury
123 706
41.02
  Males
79 827
  Females
43 879
All unintentional fire/burn
3375
2.7c
1.12
  Males
1996
  Females
1379
All violence-related injury
53 371
17.70
Violence-related fire/burn
298
0.10
aCrude rate/100 000 population. bPercentage of all injury deaths. cPercentage of all
unintentional injury deaths.
Table 3.2  US injury deaths by age group: 20072
Age
group
(years)
All injury
Overall
unintentional
injury
Overall fire/
burn
Fire/flame
Hot object/
substance
Residential
fire/flame
n
Ratea
n
Ratea
n
Ratea
n
Ratea
n
Ratea
n
Ratea
0–4
3760
17.97
2873
13.73
266
1.27
259
1.24
7
0.03
232
1.11
5–9
1118
5.59
965
4.81
150
0.75
148
0.74
2
0.01
128
0.64
10–14
1656
8.15
1229
6.05
86
0.42
85
0.42
1
0.00
72
0.35
15–19
10 403
48.25
6493
30.11
95
0.44
94
0.44
1
0.00
77
0.36
20–24
15 864
74.77
9404
44.32
136
0.64
135
0.64
1
0.00
96
0.45
25–29
14 038
66.79
8134
38.70
149
0.71
147
0.70
2
0.01
104
0.49
30–34
11 979
61.90
6843
35.36
128
0.66
127
0.66
1
0.01
87
0.45
35–39
12 989
61.87
7737
36.86
150
0.71
147
0.70
3
0.01
101
0.48
40–44
15 063
68.91
9194
42.06
223
1.02
220
1.01
3
0.01
150
0.69
45–49
16 844
73.92
10 717
47.03
286
1.26
283
1.24
3
0.01
208
0.91
50–54
14 954
71.34
9598
45.79
297
1.42
292
1.39
5
0.02
217
1.04
55–59
11 070
60.79
7100
38.99
288
1.58
282
1.55
6
0.03
211
1.16
60–64
7796
53.92
5093
35.22
273
1.89
264
1.83
9
0.06
220
1.52
65–69
5921
55.10
4187
38.96
235
2.19
232
2.16
3
0.03
186
1.73
70–74
5876
67.99
4566
52.83
224
2.59
218
2.52
6
0.07
177
2.05
75–79
7337
98.63
5922
79.60
224
3.01
213
2.86
11
0.15
181
2.43
80–84
8925
154.57
7814
135.33
263
4.55
249
4.31
14
0.24
212
3.67
85+
16 813
319.37
15 803
300.19
295
5.60
279
5.30
16
0.30
240
4.56
aCrude rate/100 000 population.
Table 3.3  US non-fatal injuries (2009)3
n
(%)
Ratea
Overall all injury causes
29 636 366
9653.33
  Males
15 968 112
10 543.52
  Females
13 668 254
8783.73
  Overall fire/burn injury
381 012
1.3b
124.11
    Males
195 576
129.14
    Females
185 406
119.19
Unintentional/all injury causes
27 632 781
9000.71
  Unintentional fire/burn injury
371 577
1.3c
121.03
    Males
189 638
125.22
    Females
181 908
116.94
Violence related all injury causes
2 003 585
652.62
  Violence related fire/burn injury
9435
0.5d
3.07
    Males
5937
3.92
    Females
3498
2.25
aCrude rate/100 000 population. bPercentage of all injuries. cPercentage of all
unintentional injuries. dPercentage of all violence related injuries.

Epidemiological, demographic, and outcome characteristics of burn injury
17
injuries. In age groups above 24 years the number and rate
of occurrence of burns decreased with age, and after age 80
were all reported to be unintentional injuries. There were
only 2677 unintentional burn injuries recorded for patients
of 85 years and above, with an incidence rate of 47.54/100 000.3
In 2009, the rank of unintentional fire/burn injury as a
cause of non-fatal injury, 14th for all ages, varied by age in
the United States.3 As indicated in Table 3.5, burn injury
ranged from being the fifth most common cause of non-fatal
injury in the population under 1 year of age to being the
16th in the 10–14- and 15–19-year age groups. The number
and incidence rates for non-fatal burn injury have decreased
overall, and for both males and females over the last three
decades, as shown in Table 3.6. Since 1985, the incidence
rate of non-fatal fire/burn injuries for males decreased from
601/100 000 to 129.14/100 000 in 2009. The incidence rate
for females decreased even more during the same period, i.e.
from 647/100 000 in 1985 to 119.19/100 000 in 2009. A
report by the National Center for Injury Prevention and
Control in 2001 indicated that 95.7% of patients with unin­
tentional fire/burn injuries seen in emergency departments
were ‘treated and released’, and only 3.4% of all patients
Table 3.4  US non-fatal injuries by age group (2009)3
Age
group
(years)
Overall
Unintentional
Overall
Unintentional
Violence related
All injury causes
All injury causes
Fire/burn
Fire/burn
Fire/burn
n
Ratea
n
Ratea
n
Ratea
n
Ratea
n
Ratea
0–4
2 377 345
11 161.42
2 355 207
11 057.93
58 400
274.18
57 742
271.09
657
3.09
5–9
1 715 144
8322.05
1 690 939
8204.61
17 143
83.18
17 043
82.70
100
0.49
10–14
2 235 640
11 193.00
2 132 480
10 676.51
14 207
71.13
14 064
70.41
144
0.72
15–19
2 944 959
13 673.42
2 612 130
12 128.1
31 011
143.98
29 869
138.68
1141
5.30
20–24
2 831 644
13 146.25
2 454 744
11 396.45
40 655
188.75
38 788
180.08
1867
8.67
25–29
2 479 779
11 439.30
2 200 730
10 152.04
36 664
169.13
35 406
163.33
1258
5.80
30–34
2 029 170
10 202.68
1 824 011
9171.14
27 716
139.36
26 882
135.16
834
4.20
35–39
1 916 910
9333.32
1 750 090
8521.08
28 097
136.80
27 378
133.30
719
3.50
40–44
1 888 050
8994.31
1 733 206
8256.66
26 257
125.08
24 996
119.08
1261
6.01
45–49
1 927 873
8444.07
1 783 843
7813.22
26 487
116.01
25 824
113.11
663
2.90
50–54
1 664 164
7647.32
1 571 339
7220.76
23 282
106.99
23 066
105.99
216
0.99
55–59
1 247 593
6574.92
1 198 99
6318.83
16 217
85.46
16 029
84.47
188
0.99
60–64
944 781
5975.12
921 456
5827.60
11 654
73.70
11 416
72.70
238
1.50
65–69
729 202
6187.90
717 395
6087.70
7184
60.96
7162
60.77
22
0.19
70–74
608 196
6751.93
601 133
6673.51
5890
65.39
5763
63.98
127
1.40
75–79
576 581
7870.85
571 975
7807.97
4283
58.46
4283
58.46
0.00
0.00
80–84
639 005
10 975.06
636 085
10 924.92
3167
54.39
3167
54.39
0.00
0.00
85+
877 251
15 579.90
874 268
15 526.91
2677
47.54
2677
47.54
0.00
0.00
aCrude rate/100 000 population.
Table 3.5  Number and rank of unintentional fire/burn as cause of
non-fatal injury by age group: US 20093
Age group (years)
n
Rank
>1
7846
5
1–4
48 896
8
5–9
17 043
12
10–14
14 064
16
15–19
29 869
16
20–24
38 788
13
25–34
62 288
13
35–44
52 374
13
45–54
48 890
14
55–64
27 445
13
65+
23 051
12
All ages+
371 577
14

Total Burn Care
3
18
(1487) as suspected child abuse, and 0.2% (234) as sus­
pected arson.
The NBR data indicate that 93 049 (60%) of the patients
were Caucasian, 29 584 (19%) African-American, 23 230
(15%) Hispanic, 3737 (2%) Asian and 1191 (1%) Native
Americans. The 18.9% registrant rate of African-Americans
exceeds by 53% the 12.33% African-American segment of
the US population. Non-white patients predominated in the
three age groups below 5 years, and in all other age groups
whites predominated. The Caucasian registrant rate of 60%
was slightly less than the 66% Caucasian segment of the US
population, the Hispanic registrant rate of 15% was similar
to the 15% Hispanic segment of the US population, and the
Asian registrant rate of 2.4% was 45% less than the 4.37%
Asian segment of the US population.5
Scalds and fire/flame were the most common causes of
burn injury. There were a total of 44 537 scald injuries, of
which 32 535 (82%) occurred in the home. Scald injury was
most frequent in cases under age 5, and in the older age
groups fire/flame, a total of 60 139 cases, predominated as
the cause of burn injury. There were 5400 cases of electric
injury, of which 1896 (43%) occurred at an industrial site
and 1181 (27%) occurred in the home. Electric injury
occurred with greatest frequency – more than 1000 cases – in
each age group between 20 and 49.9 years. There were a total
of 12 005 contact burns, 72% of which occurred in the
home. Contact burns were most common in patients under
5 years (25.2% of cases less than 1 year old) and represented
less than 10% of burns in all older age groups. There were
4372 chemical injuries, of which 1543 (35%) occurred at
the workplace and 1354 (31%) in the home.5
Seventy-two percent of the cases had burns of less than
10% of the total body surface area (TBSA) and 90% had
burns that involved less than 20% TBSA. The upper limbs,
the head and neck, and the lower limbs were the body parts
most often affected by burns. The most frequent complica­
tions, in order of decreasing frequency, were pneumonia,
cellulitis, urinary tract infection, respiratory failure, and
wound infection. A diagnosis of inhalation injury was made
in 10 216 (6.3%) of all the cases. The use of mechanical
ventilation, common in patients with inhalation injury,
markedly increased the occurrence of clinically related
complications. Those complications increased in both fre­
quency and number as the duration of mechanical ventila­
tion increased. In patients ventilated for more than 4 days,
complications occurred in more than 40% of patients of
all ages and rose to over 60% in patients older than
20 years.5
The most common surgical procedures performed were
split-thickness skin grafting, burn wound excision, applica­
tion of wound dressings (either biologic or non-biologic),
and joint and hand procedures. Early excision with prompt
grafting to close the wound, and the predominance of cases
with limited-extent burns have been largely responsible for
the observed reduction in length of hospital stay. During the
reporting period, the average length of hospital stay decreased
from 10.37 and 10.1 days in 2001 to 8.6 and 9.1 days in 2010
for women and men, respectively. The number of hospital
days averaged 9.6 for patients who survived and 17.7 days
for patients who died.5
The overall mortality of the 124 196 cases for which burn
extent was recorded was 3.7 %. The mortality rate ranged
Table 3.6  Burn injury incidence (1985–2009)3
Year
Non-fatal
Fatal
n
Ratea
n
Ratea
1985
All patients
  Males
601.00
  Females
647.00
1999
All patients
3910
1.40
  Males
2345
1.71
  Females
1565
1.10
2001
All patients
516 821
181.29
3796
1.33
  Males
281 469
201.05
2289
1.64
  Females
235 244
162.14
1507
1.04
2003
All patients
467 929
161.17
3875
1.33
  Males
253 066
177.37
2255
1.58
  Females
214 818
145.37
1620
1.10
2005
All patients
447 905
151.45
3736
1.26
  Males
241 287
165.76
2199
1.51
  Females
206 618
137.57
1537
1.02
2007
All patients
410 871
136.24
3774
1.25
  Males
215 373
144.92
2230
1.50
  Females
195 498
127.80
1544
1.01
2009
All patients
381 012
124.11
  Males
195 576
129.14
  Females
185 406
119.19
aCrude rate/100 000 population.
with fire/burn injuries seen in emergency departments were
hospitalized and or transferred to another treatment facility.4
Those data confirm the facts that the vast majority of non-
fatal burns are of very limited extent, and that in the United
States patients with extensive burns are often transferred to
burn centers.
The number and incidence rate of fatal burn injuries has
decreased only modestly in recent years, i.e. from a total of
3910 (1.40/100 000) in 1999 to 3774 (1.25/100 000) in
2007. That decrease has largely been confined to the male
population, in whom fatal burns decreased from 2345
(1.71/100 000) in 1999 to 2230 (1.5/100 000) in 2007, with
essentially no change occurring in the female population,
i.e. 1565 in 1999 and 1544 in 2007, both of which repre­
sented crude incidence rates of 1.01/100 000 (Table 3.6).2
The American Burn Association has established the
National Burn Repository (NBR), which contains records
of patients treated for burn injuries at 91 hospitals in 35
states and the District of Columbia. For the years 2001–2010,
those hospitals contributed records from 163 771 burn
patients. Analysis of that database provides a more detailed
description of patients treated at burn centers in the United
States.5 In the years reviewed, 2001–2010, 70% of the cases
were males. The mean age of all patients was 32 years,
with 12% being 60 or over and 18% being under 5 years
of age; 68% of the burn injuries occurred in the home and
only 10% were sustained in the workplace. Sixty-seven
percent of cases (89 124) were classified as non-work-related,
16% (20 846) as work-related, 1.4% (1898) as suspected
assault/abuse, 1.1% (1458) as suspected self-inflicted, 1.1%

Epidemiological, demographic, and outcome characteristics of burn injury
19
from 0.6% in cases with burns of less than 10% TBSA and
2.8 % in cases with burns of 10–19.9% TBSA to 74% in cases
with burn of 80–89% TBSA and 82.8% in cases with burns
of 90% and more TBSA. Mortality decreased progressively
during the review period by almost 50% (6.8% to 3.6%) for
females, and from 4.6% to 3.2% for males. The 23% mortal­
ity observed in the 10 216 cases with inhalation injury was
nine times greater than the 2.5% mortality recorded for the
132 020 burn patients without inhalation injury. There were
163 771 surviving cases, of which 137 610 or 84% were dis­
charged home, with only 4% requiring home healthcare.
Almost 5000 (3%) were discharged to a rehabilitation facil­
ity, 2.3% (almost 4000) were discharged to another hospital,
and 1.9%, slightly more than 3000, were discharged to a
nursing home.5
Hospital charges were significantly less ($4,815 per day)
for those cases that survived (mean total charge $69,053)
than for those who died (mean total charge $212,593). Sixty-
nine percent of cases were covered by some form of payment
and 30% were either uninsured or provided no insurance
information. The total annual costs of burn injury are esti­
mated to be $7.5 billion, which includes both medical costs
and the cost of lost productivity. Those costs include $3
billion related to fatal fire/burn injuries, $1 billion for fire/
burn injuries treated in hospitals, and $3 billion for injuries
not utilizing inpatient care. Fires also cause extensive prop­
erty damage. In 2009 there were 1 348 500 reported fires, to
which $12.5 billion in property damage was attributed.6
Epidemiology and demography
Geographic location influences death rates from house fires,
presumably because of regional differences in construction
and heating devices, as well as economic status. House fire
death rates have been reported to be higher in the Eastern
part of the United States, particularly the Southeast com­
pared to the West. In the 377 000 residential fires to which
fire departments responded in 2009, 2565 individuals died
and 13 050 sustained burn injuries.1 The winter months, lack
of smoke alarms, and substandard housing represent risk
factors for residential fires.7 Unattended and/or improperly
positioned cooking and heating devices are the leading
causes of residential fires. House fires cause only approxi­
mately 4% of burn admissions, but the 12% fatality rate of
patients hospitalized for burns sustained in house fires is
higher than the 3% rate for patients with burns from other
causes.8 This difference is presumably the effect of associated
inhalation injury.
Careless smoking, which accounts for one in four residen­
tial fire deaths, is the most common cause of such fatalities.9
Alcohol and drug intoxication, which contribute to careless
smoking behavior by impairing mentation, have been
reported to be a factor in 40% of residential fire deaths and
appear to contribute to the high weekend frequency of house
fires.10 Holmes and colleagues11 reported a statistically sig­
nificant increase in patients with alcohol-related burn inju­
ries admitted to a UK Regional Burn Unit, rising from 6% of
admissions in 2003 to 19% of admissions in 2008. In 60%
of cases the injuries were caused by flames and required a
longer hospital stay than did the injuries in patients with
burns unrelated to alcohol: 7.9 days vs 2.5 days. ‘Fire play’
with matches, cigarette lighters, and other ignition devices
has been incriminated as the cause of one in 20 residential
fires and two in every five fire-related deaths in children.12
House fire death rates have shown little gender predomi­
nance except for a larger number of males in the 2–5-year
age group, a group that has the highest rate of non-fatal
burns due to unsupervised play with matches.13 In fact,
among children of 9 years or less, child-play fires are the
leading cause of residential fire-related death and injury.
Arson, the second most common cause of residential fire
deaths (an estimated 30 000 cases in 2008), is considered to
be an intentional injury.14 Defective or inappropriately used
heating devices, which are the third most common cause,
account for one in six residential fire deaths overall, and an
even greater proportion in low income areas.15 The effect of
low income on fire/burn deaths is also related to residence
in older buildings or manufactured homes, crowded living
conditions, and the absence of smoke detectors.1 In 2007,
432 children aged 14 or under died as a consequence of
residential fires.1 In 1993, minority children aged 0–19 were
reported to be three times as likely to die in a residential fire
as white children; this was considered to be an effect of
economic status, as racial differences in house fire death rates
decrease as income increases.16,17
The linking of databases from five states has enabled inves­
tigators to characterize burn injury in the state of Utah.18
During the years 1997 to 2001, 23 722 residents of Utah
sustained burns that received care at some level in the health­
care system. The causes were scalds (21.5%), contact with a
hot object (21.2%), chemical (19.2%), fire or flame (18.7%),
‘other’ (11.7%), and electricity (3.9%). Thirty-one individu­
als (0.1%) sustained fatal burns. The annual incidence rate
of burn injury in Utah was 212.5/100 000 residents. The burn
injury incidence rate was higher among men than among
women, and highest in the 0–4, 15–19, and 20–44 age
groups and lowest in the 65–84 and 85+ age groups. The use
of geographic information systems mapping enabled the
investigators to identify the Utah counties at high risk for
burn injury. Those counties typically had higher American-
Indian populations, increased poverty levels, and other
indices of economic deprivation.
In a study of the socioeconomic determinants of burn
injury in British Columbia, Canada, Bell and colleagues19
reviewed the records of 119 patients with what was catego­
rized as ‘severe thermal injury.’ The age-standardized injury
rate for all burns in that province was 3.1/100 000, but the
injury rate varied from 2.95/100 000 for all patients in the
highest socioeconomic stratum to 5.4/100 000 among all
individuals in the lowest socioeconomic stratum. The age-
standardized burn injury rate was greater for individuals in
rural areas than for those in urban areas in all socioeconomic
strata. The finding that the age-standardized injury rate for
intentional burn injury was highest in the highest urban
socioeconomic stratum was not explained by the authors.
It has been reported that mobile home fires are associated
with twice the death rate of fires in other forms of housing.
In a group of 65 patients who were burned in mobile home
fires and admitted to a burn center, more than three-quarters
were male, two-thirds were Caucasian, and 70% resided
in the southeastern United States.20 The extent of burn
ranged from 1% to 63% TBSA and averaged 21%. Inhalation
injury was diagnosed in 63% of the patients. One or more

Total Burn Care
3
20
American Burn Association as burn centers, and 14 in
Canada, which are distributed in close relationship to popu­
lation density; between them they are reported to contain a
total of 1788 and 125 beds, respectively (Figure 3.1).5 As
described below, the geographic distribution of burn centers
necessitates the use of aeromedical transfer by both rotary
and fixed wing aircraft to transport patients requiring burn
center care to those facilities from distant and remote areas.
High-risk populations
In addition to economic status and geographic location, the
risk of being burned and the predominant cause of burn
injury are related to age, occupation, and participation in
recreational activities. Scalds are the most frequent form
of burn injury overall and cause over 100 000 patients to
seek treatment in hospital emergency rooms, but fire/flame
is the most frequent cause of burns requiring hospital
admission.7
Children
The number of pediatric burn patients admitted to hospitals
is influenced by cultural differences, resource availability,
and medical practice. Consequently, the number of children
admitted to hospital for burns treatment has varied by geo­
graphic area from a low rate of 4.4/100 000 population in
America (North, Central, and South) to a high of 10.8/100 000
population in Africa. Although the incidence rate for Asia
– 8.0/100 000 population – is similar to that for Europe and
the Middle East, population size determines that Asia pro­
vides care for over half of the global pediatric burn popula­
tion.31 It is currently estimated that 435 children aged 0–19
receive treatment in emergency departments for burn inju­
ries, and that two children die with burn injuries each day
in the United States.32
It was estimated in 2004 that 116 600 children aged 14
and under were treated for fire/burn injuries in hospital
comorbid medical conditions pre-existed in 88% of patients,
which included alcoholism in 64%. Of interest, one-quarter
of the patients had a family history of burn injury. The mor­
tality rate of 12% was higher than the overall mortality rate
at the burn center, but contrary to earlier reports that mortal­
ity rate was similar to that of patients burned in other resi­
dential fires.
During the 5-year period 1991–1995, the residential fire
death rate decreased from 1.3 to 1.1/100 000 and by 2007
had further decreased to 0.94/100 000.2,21 That change has
been attributed to the combined effects of improved build­
ing design, the use of safer appliances and heating devices,
and the increased use of smoke and fire detectors. Data gen­
erated by the CDC’s Smoke Alarm Installation and Fire
Safety Education Program indicate that even though there
are half or fewer fire related deaths in homes with function­
ing smoke alarms as in homes without those devices, only
approximately 75% of US households claim to have at least
one working smoke alarm. Even so, there was no alarm or
no working alarm in two-thirds of home-fire deaths in
2003–2006. The CDC Injury Center provides funds to 16
states to conduct a smoke alarm installation and fire safety
education (SAIFE) program. This includes the installation of
long-lasting lithium-powered smoke alarms, which have
been installed in more than 174 000 high-risk homes and
are estimated to have saved approximately 1218 lives since
the program began in 1998.14,22,23 Having a wet pipe sprin­
kler system in the home affords even greater protection by
reducing the risk of dying in a fire by 83%.24
Unlike fire deaths, the precise number of burn injuries that
occur in the United States is unknown. Twenty-one states
require that burn injuries be reported, but two require that
only burns associated with assaults or arson be reported, and
seven require that only larger burns (usually those involving
more than 15% TBSA) be reported.25 Consequently, the total
number of burns has to be estimated by extrapolating data
collected in less than half of the states to the entire popula­
tion. In the late 20th century, such estimates ranged from
1.4 million to 2 million injuries due to burns and fires each
year.26,27 Because of the general improvement in living condi­
tions made possible by the relatively high income in the
United States, an annual incidence of approximately 500 000
is currently considered to be a realistic estimate, of which
450 000 receive medical care at some level of the healthcare
system.28 The majority of those burns are of limited extent:
72% involve less than 10% TBSA and 90% involve less than
20% TBSA. However, as recently as 1990, it was estimated
that in the United States 270–300 patients per million popu­
lation (67 500–75 000) per year sustained burns which,
because of extent, associated injury or comorbid conditions,
required admission to a hospital.29 In light of the overall
decrease in the incidence of burns, it is currently estimated
that only 145–150 patients per million population (45 000–
50 000) will be admitted to a hospital annually.
A smaller subset of approximately 20 000–25 000 burn
patients with even more severe injuries, as defined by the
American Burn Association (Table 3.7), are best cared for in
a burn center.30 Those patients are now estimated to consist
of 35 per million population with major burns and 40 per
million population having lesser burns but a complicating
cofactor. There are 123 self-designated burn care facilities in
the United States, 54 of which have been verified by the
Table 3.7  Burn center referral criteria
1. Partial thickness burns >10% TBSA
2. Burns that involve the face, hands, feet, genitalia, perineum, or major
joints
3. Full thickness burns in any age group
4. Burns caused by electric current including lightning
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality
8. Any patient with burns and concomitant trauma (such as fractures)
in whom the burn injury poses the greatest risk of morbidity or
mortality. In such cases, if the trauma poses the greater immediate
risk, the patient may be stabilized in a trauma center before transfer
to a burn center
9. Burned children in a hospital without qualified personnel or
equipment for the care of children
10. Burn injury in a patient who will require special social, emotional, or
rehabilitative intervention
Adapted from: American Burn Association. Advanced Burn Life Support Course
Provider Manual American Burn Association, Chicago, IL 60611; 2011, p. 25–26

Epidemiological, demographic, and outcome characteristics of burn injury
21
Burn Care Facilities
in North America 2011*
Verified
Hawaii
1
Arizona
1
California
14
Nevada
1
Oregon
1
Washington
2
British Columbia
1
Alberta
2
Saskatchewan
2
Manitoba
2
Ontario
4
Ohio
8
Québec
1
Vermont
1
Maine
1
New
Brunswick
1
Nova
Scotia
1
Massachusetts
4
New
York
11
Pennsylvania
6
Rhode Island
1
Connecticut
1
New Jersey
1
Maryland
2
District of Columbia
1
North Carolina
1
Virginia
4
West
Virginia
1
Indiana
3
Kentucky
2
Tennessee
2
Minnesota
3
South Dakota
1
Wisconsin
3
Michigan
6
Iowa
1
Nebraska
2
Kansas
2
Oklahoma
2
Arkansas
1
Missouri
6
Illinois
4
Utah
1
New Mexico
1
Texas
6
Louisiana
2
Alabama
3
Georgia
2
Florida
4
Colorado
3
*Information courtesy the American Burn Association (ABA).
Unverified
Figure 3.1  Burn care facilities in North America 2011. The numbers indicate the number of facilities in each state. The facilities indicated by blue dots have
been verified as burn centers by the American Burn Association (Map prepared by G. Gueller at U.S. Army Institute of Surgical Research, Fort Sam Houston,
TX 78234).

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Oregon (1)
Pennsylvania (6)
Rhode Island (1)
South Dakota (1)
Tennessee (2)
Texas (6)
Utah (1)
Vermont (1)
Virginia (4)
Washington (2)
West Virginia (1)
Wisconsin (3)
Alberta (1)
British Columbia (1)
Manitoba (2)
New Brunswick (1)
Nova Scotia (1)
Ontario (4)
Quebec (1)
Saskatchewan (2)
Portland
Baltimore
Boston
Worcester
Ann Arbor
Detroit
Flint
Grand Rapids
Kalamazoo
Duluth
Minneapolis
St. Paul
Columbia
Kansas City
Springfield
St. Louis
Lincoln
Omaha
Las Vegas
Livingston
Albuquerque
Bronx
Buffalo
East Meadow
Elmira
New York City
Rochester
Staten Island
Stoney Brook
Syracuse
Vahalla
Winston Salem
Akron
Cincinnati
Cleveland
Columbus
Dayton
Toledo
Oklahoma City
Tulsa
Portland
Allentown
Philadelphia
Pittsburgh
Upland
Providence
Sioux Falls
Memphis
Nashville
Dallas
Fort Sam Houston
Galveston
Houston
Lubbock
Salt Lake City
Burlington
Charlottesville
Norfolk
Richmond
Seattle
Spokane
Huntington
Madison
Milwaukee
Calgary
Edmonton
Vancouver
Winnipeg
St.John
Halifax
Hamilton
Toronto
Windsor
Montreal
Regina
Saskatchewan
Maine (1)
Maryland (2)
Massachusetts (4)
Michigan (6)
Minnesota (3)
Missouri (6)
Nebraska (2)
Nevada (1)
New Jersey (1)
New Mexico (1)
New York (11)
North Carolina (1)
Ohio (8)
Oklahoma
2
1
1
1
1
1
1
1
1
2
1
1 1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
2
1
1
1
2
1
1
1
1
1
1
1
1
2
3
1
1
1 1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
2
1
1
1
1
1
1
2
1
1
1
1
2
1
1
1
2
1
1
1
2
1
1
1
1
Birmingham
Mobile
Phoenix
Little Rock
Bakersfield
Colton
Fresno
Los Angeles
Orange
Sacramento
San Diego
San Francisco
San Jose
Santa Ana
Torrance
West Hills
Aurora
Greeley
Bridgeport
Washington
Gainesville
Miami
Orlando
Tampa
Atlanta
Augusta
Honolulu
Chicago
Maywood
Springfield
Fort Wayne
Indianapolis
Iowa City
Kansas City
Wichita
Lexington
Louisville
Baton Rouge
Shreveport
Alabama (3)
Arizona (1)
Arkansas (1)
California (14)
Connecticut (1)
District of Columbia (1)
Florida (4)
Georgia (2)
Hawaii (1)
Illinois (4)
Indiana (3)
Iowa (1)
Kansas (2)
Kentucky (2)
Louisiana (2)
United States
United States
United States
City
City
Number
of burn
centres
Number
of burn
centres
City
Number
of burn
centres
Canadian Provinces
City
Number
of burn
centres
Figure 3.1, cont’d.

Epidemiological, demographic, and outcome characteristics of burn injury
23
under the fifth percentile for height were also over-represented
among pediatric burn patients. The authors considered the
latter finding to reflect, at least in part, the effect of concomi­
tant malnutrition or neglect.
The occurrence of tap-water scalds can be prevented by
adjusting the temperature settings on water heaters or by
installing special faucet valves so that water does not leave
the tap at temperatures above 120°F (48.8°C).34 Thermo­
static valves, which shut the hot water off if the cold water
fails, are the most dependable.38 The results of a survey in
Denmark indicated that the kitchen, not the bathroom, is
the most common site of burn injury (39% of burns).39
Those burns were most commonly due to contact with hot
liquids.
Home exercise treadmills represent another source of burn
injury in children. These injuries are a consequence of
contact with a moving treadmill, most commonly involved
the volar surface of the hand, and in two-thirds of patients
surgical intervention in the form of skin grafting was
required.40
A change in the pattern of pediatric burns in Australia to
resemble that in the United States has recently been reported.
A review of 3621 children treated at the Children’s Hospital
Burns Unit at Westmead, NSW, Australia, indicated that
scalds accounted for 56% of pediatric burns and that contact
burns, which accounted for 31% of pediatric burns, had
displaced flame burns, which accounted for only 8%, as the
second most frequent cause of pediatric burns.41 As expected,
contact burns were typically of very limited extent (99% < 5%
TBSA) and only 12% required operative intervention. The
most common objects causing contact burns were, in
descending order, clothing irons, stoves, oven doors, gas or
electric heaters, exhaust pipes, combustion heaters, and bar­
becues. The same authors from the Children’s Hospital
Burns Unit reviewed the management of 97 children admit­
ted for the treatment of burn injuries caused by contact with
automotive exhaust systems during a 6-year period.42 The
patients’ ages ranged from 5 months to 15 years and the
exhaust systems contacted were those of motorbikes, cars,
lawnmowers, and quad bikes. The injuries were most often
sustained during the summer, and in 60% of cases involved
1% or less of TBSA, ranging in extent from 0.5% to 8%. Over
66% of the burns were on the lower limbs, with the calf
being the part most frequently involved. Excision and/or
grafting was necessary in one-third of the patients. The
authors’ emphasized prevention by the use of protective
clothing and placement of an insulated guard on the
exhaust pipe.
The elderly
The elderly represent an increasing segment of the popula­
tion, the members of which have an increased risk of being
burned and higher morbidity and mortality rates than
younger patients. A review of medical records of patients
admitted to a burn center during a 7-year period revealed
that 221 of 1557 (11%) patients admitted were 59 years or
older.43 Ninety-seven (44%) of that group were women, a
reflection of the higher percentage of women in the elderly
population. Two-thirds of the injuries were caused by flames
or explosions, 20% by scalds, 6% by electricity, 2% by
chemicals, and 6% by ‘other causes.’ Forty-one percent of the
emergency rooms in the United States.33 Of those injuries,
scald burns were more common in the younger children (<5
years) and flame burns more common in older children.
Children under 5 years account for nearly all scald burn
deaths.34 Of the children age 4 and under who are hospital­
ized for burn-related injuries, 65% have scald burns, 20%
contact burns, and the remainder flame burns.33 The major­
ity of scald burns in children, especially those age 6 months
to 2 years, are from hot foods and liquids, particularly coffee
which may be dispensed at temperatures of up to 180°F
(82.2°C), spilled in the kitchen or other places where food
is prepared and served.34 Hot tap-water burns, which typi­
cally occur in the bathroom, tend to be more severe and
cover a larger portion of the body surface than other scald
burns. Consequently, such burns, which account for nearly
one-quarter of all childhood scald burns, are associated with
higher hospitalization and death rates than other hot liquid
burns.34 Ninety-five percent of burns in children due to the
operation of microwave devices are scald burns resulting
from the spillage of hot liquids or food.34
In a study of 541 children with burn injury, 125 were
considered to be cooking injuries. The patients with such
burns were, on the average, older than those with scalds
related to other mechanisms (i.e. toddlers vs infants).35 The
burns were typically caused by hot liquids spilling from a
container on an elevated table or counter on to the child’s
head, neck, and trunk. The authors call attention to the dif­
ference in cooling curves for the various substances and
liquids involved, which they postulate influences the severity
of the burn injury.
A recent review of the American Burn Association National
Burn Registry records of all pediatric patients burned between
1995 and 2007 (46 582) revealed differences in burn etiol­
ogy associated with age and race.36 Fifty-four percent of the
patients studied were Caucasian, but non-Caucasian popula­
tions incurred 54% of the burn injuries that occurred in
children younger than 5 years. Scalding was a common etiol­
ogy in older African-American, Asian, and Hispanic children,
and significantly less common in Caucasians. The frequency
of inhalation injury was highest in African-American chil­
dren and lowest in Asian children. In 4.5% of the children
the injury was reported to have been intentional, with the
frequency in populations of color greater (greatest in African-
American children) than in Caucasian children.
Among children 14 years and under, hair curlers and
curling irons, room heaters, ovens and ranges, irons, gaso­
line, and fireworks are the most common causes of product-
related burn injuries.34 Nearly two-thirds of electric injuries
in children aged 12 and under are caused by household
electric cords and extension cords.34 Contact with the current
in wall outlets causes an additional 14% of such injuries.34
Boys are at higher risk of burn-related death and injury than
girls, and children aged 4 and under and children with a
disability are at the greatest risk of burn-related death and
injury, especially from scald and contact burns.34 Heavy-for-
age boys are more burn prone than their normal-sized coun­
terparts. A retrospective study of 372 children admitted to a
single burn center from January 1991 to July 1997 confirmed
that boys who were large for age on the basis of weight or
height were over-represented in the burn population.37 Inter­
estingly, that same study indicated that boys at or under the
fifth percentile for weight, and both boys and girls at or

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24
intervention was undergone in 87 patients and 16 (8%) of
the entire group died. Morita et al.48 contrasted the charac­
teristics and outcomes in 35 patients of 65 years and over
with those of 41 adult patients of lesser years. The average
age of the elderly patients was 78 years, and 24 of the 35
had pre-existing comorbid conditions. Compared with the
younger adult patients, the elderly had a higher incidence of
accidental bath tub-related burns and a lower incidence of
suicide attempts. ‘Severe burns’, defined as partial-thickness
burns of 30% or more TBSA, or full-thickness burns of 10%
or more TBSA, were fatal in the elderly patients.
The disabled
The disabled are a group of patients considered to be burn
prone. The majority of burns in the disabled occur at home
and are most often scalds. The effects of disability and pre-
existing 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).49 A report on burn injury in patients, generally
elderly, with dementia has emphasized the need for preven­
tion measures to reduce the incidence of burn injuries
incurred when such patients are performing the activities of
daily living.50
Military personnel
In wartime military personnel are at high risk for burn injury,
both combat related and accidental. Over the past six decades
the incidence of burn injury, which is related to both the
type of weapons employed and the type of combat unit
engaged, has ranged from 2.3% to as high as 85% of casual­
ties incurred in various periods of conflicts (Table 3.8). The
detonation of a nuclear weapon at Hiroshima in 1945
instantaneously generated an estimated maximum of 57 700
burn patients and destroyed many treatment facilities,
thereby compromising the care of those burn patients.51 In
the Vietnam conflict, as a consequence of the total air super­
iority achieved by the US Air Force and the lack of armored
fighting vehicle activity, patients with burn injuries repre­
sented only 4.6% of all patients admitted to army medical
treatment facilities or quarters from 1963 to 1975.52 The
majority (58%) of the 13 047 burn patients treated in those
years were non-battle injuries, only 5536 (42%) being battle
injuries. The overall incidence of burns as the cause of injury
in all United States military forces in Vietnam during those
years may well have been higher. Allen et al.53 reported that
during calendar years 1967 and 1968 a total of 1963 military
burn patients from Vietnam were admitted and treated at a
burn unit established in a United States Army General Hos­
pital in Japan. In accordance with the data from US Army
hospitals in Vietnam, the burns in 847 (43.2%) of those
patients were the result of hostile action. In the Panama
police action in late 1989, the low incidence of burn injury
(only six (2.3%) of the total 259 casualties had burns) has
been attributed to the fact that the action involved only
infantry and airborne infantry forces using small arms
weaponry.
As exemplified by the Israeli conflicts of 1973 and 1982,
and the British Army of the Rhine experience in World
War II between March 1945 and the end of hostilities in
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 pre-existing
medical conditions, and 64 patients (29%) had smoke inha­
lation. In 57% of patients judgment and/or mobility were
impaired. Ten percent of patients tested positive for ethanol
and 29% for other drugs by toxicology screening. Survival
advantage was conferred by younger age, absence of inhala­
tion injury, absence of pre-existing medical conditions, and
smaller burns.
Among 111 octogenarians admitted to a burn center
between 1983 and 1993, scalds caused 32% of the burns,
flames 30%, contact 29%, bath immersion 7%, electricity
2%, and hot oil 1%.44 In 18% a disease such as a stroke was
considered to be directly responsible for the burn injury, and
in an additional 50% of the patients a pre-existing disease
was considered to be contributory. The average length of
hospital stay was almost twice that of younger adults, and
rehabilitation of survivors was markedly prolonged.
Scalds are responsible for 33–58% of all patients hospital­
ized in the United States for burns each year.45 Data from
the NEISS-All Injury Program for 2001 to 2006 revealed that
51 700 adults aged 65 or over received care in emergency
departments for non-fatal scald burns during that period,
representing an annual frequency of 8620 and an estimated
annual rate of 23.8 visits per 100 000 population. Three-
quarters of the non-fatal scald injuries occurred at home,
42% were due to contact with hot food, and 30% were
caused by hot water or steam. Two-thirds of the patients were
women. The burns, which involved predominantly the
upper and lower limbs, were relatively minor, with 7970
(93%) being treated and released and only 510 (6%) requir­
ing inpatient care.
A recent review of 23 180 records in the American Burn
Association National Burn Repository has characterized the
epidemiology and outcomes of older adults with burn
injury.46 The mean extent of burn (9.6% TBSA) and the fre­
quency of inhalation injury (11.3%) did not significantly
vary among the age groups evaluated, i.e. 55–64 years, 65–74
years, and 75 years and over. Overall, there was a male pre­
ponderance of 1.4:1, but women dominated in the oldest
age group. The length of hospital stay per percent of body
surface burned increased with age, as did hospital charges,
even though the number of operations per patient decreased.
As the group age increased, mortality also increased, as did
discharge to a non-independent status. The adjusted odds
ratios for mortality as calculated by logistic regression were
2.3 and 5.4 in the 65–74-year age group and the 75-years
and above group, respectively, using the 55–64-year group
as the reference group. The authors reported that ‘mortality
decreased dramatically after 2001’ in all three groups; that
reduction was attributed to a tripling of patient entry into
the registry since 2001.
Yin and colleagues characterized elderly burn patients
treated at a Burn Center in Shanghai.47 In 201 patients with
a mean age of 69.3 years (range 60–90 years), the majority
were men; flame was the cause of burn in 53% and scalds
in 40%. Almost three-quarters (73.6%) of the burns were
sustained in the home, and the median extent of burn was
12% TBSA. The areas most frequently involved, in decreasing
order, were the legs, arms, head, neck, and hands. Surgical

Epidemiological, demographic, and outcome characteristics of burn injury
25
In the current armed conflicts, Operations Iraqi Freedom
and Enduring Freedom, the US Army Burn Center has pro­
vided care for all of the patients from all branches of the
armed forces who sustained severe burns in the theaters of
operation. Surgeons from the Burn Center have provided
care at the Center and an Army general hospital in Land­
stuhl, Germany, at hospitals within the theaters of operation
and during aeromedical transfers from the hospital in Europe
to the Burn Center in San Antonio, Texas.
During the four-year period 1 March 2003–1 March 2007,
540 combat casualties with a mean extent of burn of 16.7%
TBSA (range 0.1–95%) were admitted to the US Army Burn
Center.59 In 149 (27.6%) of the patients the burns involved
more than 20% TBSA and inhalation injury was documented
in 69 (13%). The burns were the consequence of an explo­
sion in 342 (63%) of the patients, commonly due to detona­
tion of an improvised explosive device (IED). The mean ISS
was 16 or above in 169 patients as a reflection of significant
associated injuries. Slightly more than half of the patients
(51%) had mechanical trauma, most often fractures, in
addition to their burn injuries. Even with the frequent
presence of associated mechanical injury, only 30 (6%) of
the patients died.
The 24 of the 540 patients who were burned while incin­
erating waste represented 10% of military burn casualties
admitted to the US Army Burn Center.60 Admission of 20
patients with such injuries during the first year of the study
period prompted the distribution of a memorandum to mili­
tary units in the theater of operations. This described the
dangers associated with the burning of waste and articulated
safety procedures. In the following year only four patients
were admitted with such injuries, which represented a statis­
tically significant decrease in the occurrence of such burns.
Aeromedical transport was used to transfer 380 (70%) of
the 540 patients with combat-related burns from the US
Army Landstuhl Medical Center in Germany to the Burn
Center in San Antonio, Texas. Of these transported patients,
48% received mechanical ventilatory support throughout
the transfer procedure. The burn patients accompanied by
the Army burn flight team arrived at the burn center on
average late on the third postburn day, with no in-flight
fatalities.59
Injuries caused by IEDs were characterized in a study of
100 consecutive combat casualties admitted to a British field
hospital in Iraq during 2006.61 IEDs were the cause of injury
in 53 of these, 12 of whom (23%), considered to have been
in the trajectory of the exploding projectile, were either killed
or died of wounds. Among the 41 survivors, only eight
(15%) had burns and two (4%) had primary blast injury.
Even though they were sited adjacent to the trajectory of the
IED, all but one of the survivors had returned to military
employment within 18 months.
Belmont and colleagues62 analyzed the injuries sustained
by a US Army brigade combat team of 4122 soldiers deployed
to Iraq for 15 months during the ‘surge’ phase of Operation
Iraqi Freedom. There were 500 combat wounds in 390 casu­
alties, 12 of whom had burns sustained in explosions. Seven
of the burn patients, four with burns of 10–15% TBSA, were
aeromedically transferred to a higher echelon of care.
In the past two years (1 July 2009 to 30 June 2011), as the
intensity of the conflicts in Southwest Asia has decreased, the
number of combat-related burns has decreased and only 93
Northwest Europe, the personnel in armored fighting vehi­
cles have been at relatively high risk for burn injury.54,55
Burns have also been common in war at sea. In the Falkland
Islands campaign of 1982, 34% of all casualties from the
British Navy ships were burns.56 The increased incidence of
burn injuries – 10.5% and 8.6% in the Israeli conflicts of
1973 and 1982, respectively, compared to the 4.6% inci­
dence in the 1967 Israeli conflict – is considered to reflect
what has been termed ‘battlefield saturation with tanks and
anti-tank weaponry.’54,57 The decreased incidence of burn
injuries – 8.6% in the 1982 Israeli conflict compared to the
10.5% in the 1973 Israeli conflict – has been attributed to
enforced use of flame-retardant garments and the effective­
ness of an automatic fire extinguishing system in the Israeli
tanks.57 Those factors have also been credited with reducing
the extent of the burns that did occur. In the 1973 Israeli
conflict, 29% of the patients with burns had injuries that
involved 40% or more TBSA, and only 21% had burns less
than 10% TBSA. In the 1982 Israeli conflict those same cat­
egories of burn represented 18% and 51%, respectively, of
all burn injuries. Modern weaponry may have eliminated the
differential incidence of burn injury between armored fight­
ing vehicle personnel and the personnel of other combat
elements. In the 1982 Falkland Islands conflict, in which
there was little if any involvement of armored fighting vehi­
cles, one of every seven and every six casualties in the British
and Argentinian forces, respectively, had burns.56,58 Con­
versely, there were only 36 (7.8%) burn casualties in the total
458 casualties sustained by US Forces in 1990 and 1991
during Operation Desert Shield/Desert Storm, in which
there was extensive involvement of armored fighting
vehicles.
Table 3.8  Incidence of burn injury in armed conflicts
Conflict
Casualties
(%)
n
World War II – Hiroshima40
65–85
45 500–59 500
Vietnam conflict 1965–197347
4.6
13 047
Israeli Six-Day War 196746
4.6
Yom Kippur War 197343
10.5
Falkland Islands War 1982
  British casualties45
14.0a
112
  Argentinian casualties47
17.5
34 of 194
Lebanon War 198243
8.6
Panama police action 1989
2.3
6 of 29
Operation Desert Shield/Storm
1990–1991
7.9
36 of 458
Operation Iraqi Freedom and
Operation Enduring Freedom
2003–June 2011
2.0
1015 of 50 694b
a34% of all casualties from ships. bData from Renz EM, MD, Col. MC, Director U.S.
Army Burn Center, Institute of Surgical Research Brooke Army Medical Center Fort
Sam Houston, TX, Personal Communication, July 18, 2011 and Directorate for
Information Operations and Reports, Department of Defense. Available at: http://
siadapp.dmdc.osd.mil/personnel/CASUALTY/eastop.html. Accessed July 20, 2011.

Total Burn Care
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26
non-combat munitions incidents were reported in which
894 soldiers were injured.67 The most common types of
injury were burns, which occurred in 261 or 26.7% of all the
patients injured. The high incidence of burn injury in mili­
tary personnel in both war and peace will generate a subset
of extensively burned patients who will require tertiary burn
center care to ensure optimum functional outcome and
maximum survival.
Burn etiologies
Burns due to hot liquids may occur in any age group, but
77% of all hot liquid scalds have been reported to occur in
children under 3 years of age. Full-thickness injury is present
in less than half of patients with hot water scalds, but in 58%
of patients with hot oil burns. Young children are most com­
monly injured by pulling a container of hot water or hot
cooking oil onto themselves, whereas older children and
adults are most commonly injured by improper handling of
hot oil appliances.68–70 The case fatality rate of scald injury
is low (presumably owing to the usually modest extent and
limited depth of the burn), but scalds are major causes of
morbidity and associated healthcare costs, particularly in
children less than 5 years of age and in the elderly.
Even though the burns of 30% of all patients requiring
admission to a hospital are caused by scalding by hot liquids,
flame is the predominant cause of burns in patients admitted
to burn centers, particularly in adults.5 The misuse of fuels
and flammable liquids is a common cause of burn injury. A
retrospective review of admissions to one burn center for the
period 1978 to 1996 identified 1011 (23.3% of 4339 acute
admissions) as being gasoline related.71 The average total
extent of burn was 30% TBSA, with an average 14% full-
thickness burn component; 144 of those patients died. The
unsafe use of gasoline was implicated in 87% of patients in
whom the cause of the burn could be identified, and in 90
(63%) of the 144 fatalities.
The ignition of alcohol and other flammable liquids which
are used to kindle coal stoves, barbecue devices, and fire­
places is a cause of burn injury in both developing and
developed countries. A review of admissions to a Turkish
Burn Center over a 20-year period identified 82 patients who
sustained burns when flammable liquids were being used to
kindle or accelerate a stove ignited.72 A 10-year review of
admissions to a Chinese University Hospital identified 180
patients burned by ignition of alcohol used to kindle house­
hold coal stoves.73 A recent report from Scandinavia identi­
fied a similar etiology of burns caused by ignition of
bioethanol being used to refill a ‘contemporary design’ fire­
place.74 The common theme in all three reports is that the
person burned was attempting to refill or accelerate an
already or still-burning fire within the device.
In one epidemiologic study in New York State in the
1980s, the largest number of admissions in the age group
15–24 years was related to automobiles. Ignition of fuel fol­
lowing a crash, steam from radiators, and contact with hot
engine and exhaust parts were the most frequent causes.75 In
a review of 178 patients who had been burned in an auto­
mobile crash, it was noted that slightly more than one-third
had other injuries, most commonly involving the muscu­
loskeletal system, and that approximately one in six had
burn casualties have been transferred and admitted to the
Army Burn Center.63 In that period, 79 (85%) of the burns
were due to fire/flame, two (2%) were the result of scalds,
and 12 cases (13%) had limited and scattered burns in the
presence of complex soft tissue injury. During that time
another 45 military personnel were admitted with burns
unrelated to combat. In that group the burns were due to
fire/flame in 35 (78%), scalds in five (11%), electricity in two
(4%), and ‘other’ causes in three (7%). Overall, 1015 military
patients have sustained burns in Iraq (Operation Iraqi
Freedom) and Afghanistan (Operation Enduring Freedom)
and received care at the Army Burn Center since March 2003.
Those burns represent 2% of all combat casualties.63
A report from the UK confirms the variable admixture of
combat and non-combat burns in military personnel.64
During the period 2001–2007 134 UK military personnel
were evacuated to the Royal Center for Defence Medicine
(RCDM) for the treatment of burn injury. The median age
of the patients was 27 years and the mean extent of burn was
5% TBSA, range 1-70% TBSA. Sixty percent of the burns were
unrelated to combat and were classified as ‘accidental’, e.g.
sustained while preparing hot food and drinks, burning
waste, or misusing flammable liquids. There was one fatal
electric injury. During 2006–2007, 56 (59%) of the burn
patients evacuated to the UK from Iraq and Afghanistan had
burns sustained in combat. Those patients represented 5.8%
of all combat casualties in the UK military during that time.
Their burns were typically of limited extent (mean 5% TBSA)
and these patients often had associated mechanized injuries.
25 or 26% of all the burn patients transferred to the RCDM
during the study period underwent skin grafting. All of the
evacuated patients survived.
In addition to military casualties, the infrastructure break­
down caused by armed conflict increases the injury burden
in the indigenous population.65 Information derived from a
questionnaire survey administered in 1172 Baghdad house­
holds containing 7396 individuals indicated that the
respondents could recall 103 injuries as having occurred
during a specific 3-month period. Only four of those injuries
were fire/burn-related and five were due to ‘electric shock’. In
the current conflicts in Iraq and Afghanistan, up to one-third
of the admissions to combat-support hospitals are for
humanitarian or civilian emergency care. Analysis of 2060
children admitted to combat-support hospitals between
2002 and 2007 revealed that 204 (13.3%) of the 1537
injured patients had burns.66 Almost twice as many children
with burn injury were seen in the combat-support hospitals
in Afghanistan as in Iraq. The care of such patients, which
may revert to the military during armed conflicts, should be
considered when planning combat medical support.
Although the risk of burn injury in the combat population
is relatively high, the distribution of burn size in other than
armored fighting vehicle personnel is comparable to that in
the civilian population, i.e., more than 80% of the patients
have burns of less than 20% TBSA. Even so, the number of
burns that can be rapidly generated necessitates that plan­
ning for combat casualty care include augmentation of
in-theater medical treatment facilities with personnel having
burn-specific expertise, as was done by the US Army Medical
Department in Operation Desert Shield/Storm.
Even in peacetime non-combat munitions incidents are
common in the US Army. During a 7-year period 742

Epidemiological, demographic, and outcome characteristics of burn injury
27
assess the effect of this deregulation on sleepwear-related
burns.
Ben and associates83 have characterized the burn injuries
caused by fires on ships in 105 patients admitted to a Chinese
burn institute during a 12-year period. The mean age of
those patients was 30.2 years and the mean extent of burn
injury was 46.5% TBSA. The injuries were considered to be
‘mostly deep burns’ with a mean extent of full-thickness
injury of 18.6% TBSA. The head, neck, and upper limbs were
the areas most commonly burned, and 57 (54.3%) of the
patients had inhalation injury of whom 42 required trache­
otomy and 38 mechanical ventilation. The interval between
injury and initiation of resuscitation, which appeared to be
related to the location of the ship, averaged 5.9 hours, but
could be as long as 67 hours. Fifty-three percent of patients
were considered to be inadequately resuscitated because of
hypotension and ‘severe shock’ on admission. Nine patients
(8.6%) died. The authors called for the establishment of fire
safety regulations, regular inspection of electrical circuits,
and enforcement of burn prevention measures such as main­
tenance of adequate passageway clearance and scheduled fire
prevention exercises on board ship.
Outdoor recreational fires, most common during the
warm summer months, are another cause of burn injury. In
2010, Neaman and colleagues84 identified 329 patients
treated during an 8-year period who sustained burns in
outdoor recreational fires. Almost three-quarters (73.3%)
were male and 40% were children; 12% were considered to
be intoxicated at the time of emergency department treat­
ment and more than 35% required admission to hospital.
The hands were the most frequently involved body part, and
almost 30% required split-thickness skin grafts. Fraga et al.85
reported a group of 241 patients with burns caused by camp­
ground bonfires and beach fire pits. Alcohol was incrimi­
nated as a causative factor in 61% of the adult burns;
34% of those patients were male, and the burns involved
the upper extremities, trunk, lower extremities, and hands,
in rank order. Although the burns were limited in extent
(mean size 6.1% TBSA), skin grafting was required in 37%.
Woodbridge et al.86 compared 30 children with burns sus­
tained during camping and caravanning to 121 children with
burns received in other situations. The burned campers had
more extensive partial-thickness burns (5.5% vs 3.0%) and
a higher percentage of the campers required the application
of a collagen-based skin substitute. The burned campers also
needed significantly more general anesthetics, principally for
painful dressing changes, and a longer duration of hospital
stay. A report from Saudi Arabia indicated that desert camp­
fires are a particular risk to unsupervised crawling infants.87
Full-thickness burns of the palm sustained when a child
unknowingly crawls into the fire pit can result in severe
contractures requiring subsequent operative release.
Fire walking across a burning charcoal pit is a religious
ritual practiced principally by Indians and some of the
Chinese population of Singapore. Sayampanathan reported
that only 18 of 3794 men who participated in a fire walking
ceremony sought medical care for burns which, in 17 cases,
were limited to the soles of their feet.88 One of the patients
who had fallen in the fire pit had sustained burns to the right
leg, both upper limbs, and the back, in addition to his feet.
None of the plantar burns required grafting. In an earlier
report of fire walking injury Chown noted that the burns
inhalation injury (one in three of those who died).76 A
review of patients admitted to a referral burn center revealed
that burns sustained 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 incurred in the course of vehicle main­
tenance activities, which involved an average of less than
30% TBSA.77 Automotive-related flame burns can also be
caused by fires and explosions resulting from ‘carburetor-
priming’ with liquid gasoline; and such burns have been
reported to account for 2–5% of burn unit admissions.78
During the 5-year period 2003–2007 fire departments in
the United States responded to an average of 287 000 vehicle
fires annually.79 Each year those fires caused an average of
1525 burn injuries, 480 burn deaths, and $1.3 billion in
direct property damage. Fifty-eight percent of the fire-related
deaths were associated with collisions or overturns, which
represented only 3% of vehicle fires. Between 1980 and
2008, the number of vehicle fires decreased by 55%, with a
proportional decrease in burn deaths and burn injuries. An
estimated 207 000 vehicle fires in 2008 caused 350 fire
deaths and 850 fire injuries, representing an accumulative
70% decrease since 1980.
Contact burns from motorcycle exhaust pipes are another
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 females than in males. As would
be 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 in incidence could be achieved by wearing long
pants and the use of an external exhaust pipe shield.80
The burns sustained in boating accidents are most often
flash burns due to an explosion of gasoline or butane, and
typically affect the face and hands.81 As noted above, bonfire
and barbecue burns caused by flash ignition of a flammable
liquid used to start or accelerate a fire affect those same areas
as well as the anterior trunk. 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.
The ignition of clothing is the second leading cause of
burn admissions for most ages.75 The burn injury rate due
to the ignition of clothing is influenced by poverty and is
inversely related to income. The fatality rate of such patients
is second only to that of patients with burns incurred in
house fires.75 Burns caused by ignition of synthetic fabrics,
which melt and adhere to the skin, are commonly deeper
than burns caused by other fabrics and typically exhibit a
gravity-dependent ‘runoff’ pattern. More than three-quarters
of deaths due to the ignition of clothing occur in patients
over 64 years.26 Clothing ignition deaths, which were a fre­
quent cause of death in young girls, have decreased as cloth­
ing styles have changed, and are now rare among children,
with little overall gender difference at the present time. From
1975, when it became mandatory for sleepwear sizes 0 to
6X to pass a standard flame test, until 1999 when that law
was repealed, the percentage of clothing burns caused by
sleepwear in children aged 0–12 decreased from 55% to
27%.75,82 Sleepwear-related burns are being monitored to

Total Burn Care
3
28
burns during the period September 2000 to December 2005.
Twenty-three percent of these injuries were due to flame, fire,
and smoke, 11% due to electricity, and 10% due to hot water.
The overall incidence rate of hospitalized work-related burns
was 24.5 per million workers per year. The incidence rate was
highest (59.3) per million workers per year in the 22–24-
year age group. The incidence rate for male workers, 43.2 per
million workers per year, was more than eight times higher
than that for female workers, 5.0 per million workers per
year. The highest rate of hospitalized work-related burns was
associated with the construction industry. The manufactur­
ing industry sector and the food service sector shared the
second highest frequency of hospitalized burns, with 49
cases each, thereby indicating the relatively high risk of burn
injury in restaurant workers.
During the period 1 January 2000 to 1 December 2008,
59 restaurant food workers in the State of Washington sus­
tained scald burn injuries in the workplace that required
admission to a hospital.100 The burning agent was cooking
oil in 49%, water in 32%, other sources 12%, and steam 7%.
More than 30% of the burns were associated with a fall, slip,
or trip.
As would be anticipated, the risk of burn injury due to hot
tar is greatest for roofers and paving workers. Of all accidents
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. In the state of California, in 1979, 366 roofers and
slaters sustained burn injuries.101 The majority of hot tar
burns involved the hand and upper limb.102 Another occupa­
tion associated with an increased risk of burn injury is
welding, in which flash burns and explosions are the most
common injury-producing events.
Friction burns, most often involving the dorsum of the
hand, can occur as a result of an industrial accident or a
vehicle crash.103 Industrial friction burns are usually isolated
injuries caused by rotating belts, and non-industrial friction
burns usually occur when the hand and/or arm are trapped
outside a car in a ‘rollover’, and are commonly associated
with other mechanical trauma.
In the United States in 1988, there were 236 200 patients
with chemical injuries of all types treated in emergency
rooms. Of those, 35 000 (15%) were patients of all ages with
chemical burns, and 6500 (5%) were children younger than
five years with chemical burns. The limited extent of burns
due to chemical content is indexed by the fact that only 800,
or 2%, of the chemical burns required admission to a hos­
pital. The effect of age (in the very young, removal of the
offending agent may be delayed) on the severity of chemical
injury is evident in the fact that 400 of the patients requiring
admission to a hospital for the care of chemical burn injuries
were children under 5.104 The greatest risk of injury due to
strong acids occurs in patients who are involved in plating
processes and fertilizer manufacture. The greatest risk of
injury due to strong alkalis in the workplace is associated
with soap manufacturing, and in the home with the use of
oven cleaners. The greatest risk of phenol injuries is associ­
ated with the manufacture of dyes, fertilizers, plastics, and
explosives. The greatest risk of hydrofluoric acid injury is
associated with etching processes, petroleum refining, and
air-conditioner cleaning. Anhydrous ammonia injury is
most common in agricultural workers, and cement injury
were typically confined to the feet and, if the patient carried
coals on his hands, to the palms, and typically healed
without surgical intervention.89 Skin grafting was required
only for the full-thickness injuries of those fire walkers who
had fallen while in the fire pit.
Hemington-Gorse et al. have drawn attention to the recent
increase in burns related to the use of tanning devices.90 In
a 7-year period, 12 patients required hospital admission for
the management of extensive erythema, most commonly
involving the trunk, resulting from ‘sunbed’ use. The authors
propose greater regulation of tanning devices to reduce the
increased risk of cutaneous and ocular melanoma associated
with the use of such devices.
Work-related burns account for an estimated 20–30% of
hospital admissions for burn injury.91 A Bureau of Labor
Statistics survey in 1985 indicated that 6% of all work-related
thermal burns occurred in adolescents (16–19 years).92 In a
1986 study in Ohio, it was noted that the majority of
hospital-treated burns in teenagers/young adults occurred at
work.93 A study in that same year revealed that six out of 10
hospitalized burn injuries in employed men in Massachu­
setts were work related.94 Restaurant-related burns, particu­
larly 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.75 It has
been estimated that almost 700 deaths annually are caused
by occupation-related burns.95,96
A review of compensation claims by Rhode Island workers
has identified that the highest claim rate for burn injury was
for workers in food service occupations. Evening and night-
shift workers were at an increased risk for chemical burn
injuries. The overall claim rate for burn injury was 24.3/10 000
workers, and ranged from a high of 51/10 000 for workers
under 25 years to a low of 16.5/10 000 workers between the
ages of 40 and 54.97
During a 5-year period in the state of Alabama, 345 occu­
pational burn cases were admitted to the University of
Alabama Burn Center.98 The majority, 96.5%, of the patients
were male and 76.2% were Caucasian, with a mean age of
37.5 years. Causes of the burn injuries were flame, electricity,
and scalds, in that order. The occupations in which burn
injury occurred most often were ‘manufacturing’ (19.1%),
‘electrician’ (16.2%), and ‘laborer’ (16.2%). As would be
anticipated, 70% of the injuries to electricians were caused
by electricity. Flame and chemical burns were the principal
causes of injury in manufacturing employees and laborers,
contact with hot bitumen in roofers, scald burns in cooks,
and flame burns in mechanics. Sixteen (4.6%) of the patients
with occupational burn injury died.
A state-managed Workers Compensation database has
been used to estimate the incidence of work-related burn
injuries and identify patients at high risk.99 The incidence
rate of occupational burn injury was estimated as 26.4 per
10 000 workers per year, with the highest rate for men in
manufacturing and for women in service occupations. Com­
pared to other occupations, higher incidence rates of burn
injury were noted in welders, cooks, food service workers,
laborers, and mechanics. The majority of burn injuries
involved the wrist and hand, and full-thickness burns
were most frequently present on the upper extremities.
The Department of Labor and Industries of the State of
Washington identified 350 cases of hospitalized work-related