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

647.e1
59  •  Aesthetic Reconstruction in Burn Patients
References
1. Lawrence JW, Mason ST, Aschomer K, Klein MB. Epidemiology and
impact of scarring after burn injury: a systematic review of the lit­
erature. J Burn Care Res. 2012;33:136-140.
2. Burd A. Burns: treatment and outcomes. Semin Plast Surg.
2010;24:262-280.
3. Goverman J, Mathews K, Nadler D, et al. Satisfaction with life
after burn: a burn model system national database study. Burns.
2016;42:1067-1073.
4. Finnerty CC, Jeschke MG, Branski LK, et al. Hypertrophic scar­
ring: the greatest unmet challenge after burn injury. Lancet.
2016;388:1427-1436.
5. Barret JP. Burns reconstruction. BMJ. 2004;329:274-276.
6. Stoddard FJ, Ryan CM, Schneider JC. Physical and psychiatric recovery
from burns. Surg Clin North Am. 2014;94:863-878.
7. Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and treat­
ment: review and advancements. Crit Care. 2015;12:243.
8. Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg.
2012;130:349e-358e.
9. Orgill DP, Ogawa R. Current methods of burn reconstruction. Plast
Reconstr Surg. 2013;131:827e-836e.
10. Klein MB. Burn reconstruction. Phys Med Rehabil Clin N Am.
2011;22:311-325.
11. Wainwright DJ. Burn reconstruction: the problems, the techniques,
and the applications. Clin Plast Surg. 2009;36:687-700.
12. Barret JP, Herndon DN, McCauley RL. Use of previously burned skin
as random cutaneous local flaps in pediatric burn reconstruction.
Burns. 2002;28:500-502.
13. Huang X, Qu X, Li Q. Risk factors for complications of tissue expan­
sion: a 20-year systematic review and meta-analysis. Plast Reconstr
Surg. 2011;128:787-797.
14. Bozkurt A, Groger A, O’dey D, et al. Retrospective analysis of tissue
expansion in reconstructive burn surgery: evaluation of complication
rates. Burns. 2008;34:1113-1118.
15. Guo L, Pribaz JJ. Clinical flap prefabrication. Plast Reconstr Surg.
2009;124:e340-e350.
16. Rose EH. Aesthetic reconstruction of the severely disfigured burned
face: a creative strategy for a “natural” appearance using pre-
patterned autogenous free flaps. Burns Trauma. 2015;3:16.
17. Ahrenholz DH, Clayton MC, Solem LD. Burns and wound manage­
ment. Otolaryngol Clin North Am. 1995;28:1939-1955.
18. Barret JP, Sarobe N, Grande N, et al. Maximizing results for lipofilling
in facial reconstruction. Clin Plast Surg. 2009;36:487-492.
19. Barr L, Barrera A. Use of hair grafting in scar camouflage. Facial Plast
Surg Clin North Am. 2011;19:559-568.
20. Garg G, Thami GP. Micropigmentation: tattooing for medical pur­
poses. Dermatol Surg. 2005;31:928-931.
21. Bernard SL. Reconstruction of the burned nose and ear. Clin Plast
Surg. 2000;27:97-112.
22. Robson MC, Barnett RA, Leitch IO, Hayward PG. Prevention and treat­
ment of postburn scars and contracture. World J Surg. 1992;16:87-96.
23. Kung TA, Gosain AK. Pediatric facial burns. J Craniofac Surg.
2008;19:951-959.
24. Cartotto R, Cicuto BJ, Kiwanuka HN, et al. Common postburn deformi­
ties and their management. Surg Clin North Am. 2014;94:817-837.
25. MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in head and
neck burn reconstruction. Clin Plast Surg. 2000;27:121-132.
26. Gho CG, Neumann HA. Advances in hair transplantation: longi­
tudinal partial follicular unit transplantation. Curr Probl Dermatol.
2015;47:150-157.
27. Ho D, Jagdeo J. Excellent aesthetic and functional outcome after frac­
tionated carbon dioxide laser skin graft revision surgery: case report
and review of laser skin graft revision techniques. J Drugs Dermatol.
2015;14:1285-1288.
28. Klein MD. Burn reconstruction. Phys Med Rehabil Clin N Am.
2011;22:311-325.

648
Laser for Burn Scar Treatment
JILLIAN MCLAUGHLIN, LUDWIK K. BRANSKI, WILLIAM B. NORBURY, SARAH E. BACHE,
LIN CHILTON, NAGUIB EL-MUTTARDI, and BRUCE PHILP
60 
In most lasers, there is a population of atoms known as
an active medium. The active medium of a laser is a mate­
rial of controlled purity, size, concentration, and shape.
This material can be of any state: gas, liquid, solid, or
plasma. The gas lasers consist of the argon, copper vapor,
helium-neon, krypton, and CO2 devices. One of the most
common liquid lasers, the PDL, contains a fluid with
rhodamine dye. The solid lasers are represented by the ruby,
neodymium:yttrium-aluminum-garnet (Nd:YAG), alexan­
drite, erbium, and diode lasers.1
In the atom’s resting state, electrons orbit around the
nucleus at their ground state or lowest energy levels, in
orbitals. When an electron absorbs energy from an energy
source, electrons become excited and orbit into higher
orbitals. The energy source used to excite the electrons can
be a light source, an electrical field, or a chemical. When
these excited electrons fall back into their resting orbitals,
energy is released, generating photons (electromagnetic
radiation). Photons have wavelengths specific to the atom
excited. Since lasers have a consistent population of atoms,
the photons emitted are all identical. These identical
photons are considered monochromatic, meaning that all
photons in a laser beam are of the same wavelength. By
contrast, IPL consists of many different wavelengths.
The resonant chamber consists of two reflective mirrors
between which photons reflect back and forth. If a photon
collides with an excited electron, that electron falls back to
its resting orbital, releasing another photon of the same
wavelength. The two photons are “in phase” or “coherent,”
meaning their wave patterns are synchronized and reinforce
each other. By comparison, the photons in conventional
light travel randomly. As these photons hit other excited
electrons, more photons are released and the light energy
increases. The resonant chamber allows for more and more
atoms to become excited and then return to ground state,
thereby amplifying the energy produced (amplification of
stimulated emission) and allowing for photon coherence.
One of the mirrors is only partially reflective and partially
transparent. Those photons traveling in a perfectly parallel
direction will exit the transparent portion of the mirror,
also known as the optical resonator, taking the form of the
“laser beam.”
Light energy can be visible or invisible depending on its
wavelength. The spectrum of electromagnetic radiation
ranges from long radio waves (wavelength >10 cm) to
extremely short γ rays (<10−11 m). The entire spectrum
includes radio, microwave, infrared, visible (400–700 nm),
ultraviolet, X-ray, and γ rays.
The specific wavelength emitted by a laser will determine
how the laser beam interacts with tissue. When the laser
strikes tissue, a variety of desirable and undesirable effects
result as the laser is reflected, scattered, transmitted, or
absorbed.
History of Laser and Intense
Pulse Light
Albert Einstein was the first to describe the theoretical
physics of the laser in 1917. He described the interaction of
atoms and molecules with electromagnetic energy in terms
of the spontaneous absorption and emission of energy and
concluded that stimulated emission of energy was also pos­
sible. In 1959, the first instrument was developed by Drs.
Townes and Schawlow based on those concepts. It was
known as the microwave amplification through the stimu­
lated emission of radiation (MASER). Shortly thereafter, in
1960, Theodore Maimon developed the first laser light with
use of a ruby crystal. Early clinical studies with the ruby
laser began in 1964, with Dr. Leon Goldman, a dermatolo­
gist considered by many to be the father of laser medicine.
The rapid development of additional lasers occurred with
the helium-neon laser appearing in 1961, the argon laser in
1962, the carbon dioxide (CO2) laser in 1964, the Nd:YAG
laser in 1964, and the erbium-YAG laser in the mid-1990s.1
However, early lasers had limited control of energy param­
eters, leading to frequent thermal injury and scarring. The
concept of selective photothermolysis (SPTL) introduced by
Anderson2 led to the development of the first laser that was
specifically designed to treat a medical condition; it was
named the pulsed dye laser (PDL) and was almost instantly
accepted in treating port wine stains in very young patients,
a condition that had hitherto been very problematic.3
Further developments over the ensuing decades included
the introduction of pulsed energy resulting in decreased
laser exposure time.1 Reliant technologies unveiled the
ability to split the treated zone into specific area, resulting
in multiple microtreatment zones within the target area;
this was termed fractionated laser treatment.4 The advent of
short-duration Er:YAG lasers in the mid-1990s offered an
additional option for resurfacing, either alone or in combi­
nation with the CO2 laser. Around the same time, high-
intensity flashlamp exposure was presented as a suitable
tool for treating vascular lesions;5 this resulted in the release
of intense pulsed light (IPL) as a medical device. In the fol­
lowing years, multiple technical modifications allowed
easier handling, increased safety, and widened the spec­
trum of potential indications.5
Physics of Laser
Lasers are devices that rely on the stimulated emission of
radiation to produce a beam of light. The word LASER is an
acronym for the term light amplification by stimulated emis­
sion of radiation. The device itself consists of an active
medium, an energy source, and a resonating chamber.

60  •  Laser for Burn Scar Treatment
649
Children may require general anesthesia, whereas adults
can be treated with topical anesthesia. This is more often
required when treating areas of hyperpigmentation. Pain
response can be assessed during a test patch procedure. If
necessary, Eutectic mixture of local anesthetic (EMLA; lido­
caine 2.5%/prilocaine 2.5%; AstraZeneca AB, Södertälje,
Sweden) cream can be applied to reduce the stimulation of
the procedure and reduce postoperative pain. The use of
topical anesthetic as part of multimodal analgesia for frac­
tionated laser treatment of burn scars significantly decreases
the requirement for opioid analgesia and reduces procedure
to discharge times.6 Similarly an opioid sparing regime in
children has been shown to have the potential to provide
adequate post-operative pain following laser treatment
under general anaesthesia.7
Patients undergoing ablative fractional laser treatment
routinely receive perioperative antibiotic prophylaxis, which
is typically not indicated for patients undergoing nonabla­
tive laser treatments. Patients undergoing fractional abla­
tive laser are routinely washed with chlorhexidine and
thoroughly dried prior to initiation of laser treatment. All
patients receiving fractional ablative laser to the face are
given acyclovir for herpes simplex prophylaxis.
Ice packs are used on the skin immediately following
treatment. Wound care after laser treatment is initiated on
the first postoperative day and includes a topical antiseptic
wash and application of a generous amount of emollient
for several days. Wound care for IPL consists of aloe vera
cream applied every 15 min for a couple of days or until the
stimulating effect has receded. Hydrocortisone 1% cream is
also provided to those patients undergoing fractional laser
treatment to help with itching. Analgesia is usually achieved
with over-the-counter pain medications; however, some
patients may require a short course of narcotic medication.
Patients may resume normal activity almost immediately,
including physical or occupational therapy. Depending on
the discomfort level and the desired type of activity, patients
may return to school or work after 1–3 days. Compression
garments may be worn once wounds reepithelialize. Sun
avoidance and use of broad-spectrum sunscreens with a
sun protection factor (SPF) of at least 30 are mandatory for
12 months postoperatively to reduce the likelihood of
postinflammatory hyperpigmentation.
PULSED DYE LASER THERAPY
The PDL is the most studied laser for hypertrophic scar­
ring.8 Over the past decade, the PDL has been shown in
multiple studies to provide significant and long-term
improvement in hypertrophic scars.9 However, further
studies have yielded conflicting data, with some more recent
investigations finding no difference in PDL-irradiated hyper­
trophic scars over untreated controls.10,11 Developed several
decades ago, the vascular-specific, flashlamp-pumped 585-
and 595-nm PDLs became the standard of care in the treat­
ment of port wine stains, capillary malformations, and
some hemangiomas.9 This laser selectively targets hemoglo­
bin and coagulates microvasculature in the papillary and
reticular dermis up to a depth of 1.2 mm. Although the
mechanism of action for scar improvements is unknown,
most theories are based on the principle that vascular pro­
liferation plays a key role in hypertrophic scars. The PDL
Reflection is the proportion of laser that bounces off the
surface and is redirected in a different direction. When laser
is directed perpendicular to the skin, approximately 5% of
the laser is reflected. Reflection of laser is one of the reasons
why it is imperative to wear appropriate safety goggles at all
times when performing laser treatments.
Scatter is the increase in spatial distribution of a laser
beam as it passes farther through tissue, leading to irradia­
tion over a larger area of tissue. The main scattering wave­
lengths are between 400 and 1200 nm (those where tissue
water absorption is poor).
Absorption can be described as the conversion of the
energy of the laser to heat when its photons strike a specific
molecular target, known as a chromophore. The mechanism
by which lasers are used to target specific tissue is called
selective photothermolysis (photo = light and thermolysis =
decomposition by heat).
Transmission occurs when a laser that has not been
absorbed is transmitted into deeper tissue beyond the
chromophore.
Multiple variables must be considered when selecting a
type of therapeutic laser, in addition to the appropriate
wavelength. The additional laser parameters that optimize
the result are fluence, or power density (joules/cm2); pulse
width or duration; mode of delivery; and spot size (increas­
ing spot size increases penetration).
The theory of selective photothermolysis first described
by Anderson and Parrish explains the principles behind the
clinical application of photothermal lasers.2 The wave­
length of laser light chosen must be selective and appropri­
ate for the target tissue, which must be destroyed without
damaging the surrounding tissues. The pulse width or
duration of the laser pulse must be within the thermal
relaxation time of the treated tissues. Thermal relaxation
time is the amount of time it takes to transfer two-thirds of
the resultant heat to the surrounding tissues.
The laser’s effect on the epidermis can further be classi­
fied as ablative or nonablative depending on whether or not
the epidermis is left intact. Fractional lasers treat only a
portion (or fraction) of the tissue. Nonablative lasers will
thermally injure the tissue, whereas ablative lasers will
destroy entire columns of tissue, including epidermis.
Overview of Lasers in
Hypertrophic Burn Scar
The ultimate goal in the treatment of hypertrophic scars is
to make improvements both aesthetically and functionally,
as well as reduce itching and pain related to the scars. Tra­
ditional and emerging laser- and light-based technologies
offer new hope for patients with burn scars.
GENERAL CONSIDERATIONS
An important tool in the evaluation of the patient for a resur­
facing procedure is Fitzpatrick’s scale of sun-reactive skin
types, and this should be assessed prior to laser treatment.
The type of anesthesia employed prior to laser therapy
depends on several factors, including the mode of laser
treatment (e.g., ablative lasers are more painful than nonab­
lative lasers), size of the scar, and the age of the patient.

60  •  Laser for Burn Scar Treatment
650
tension in some restrictive scars and appears to facilitate
the subsequent remodeling response more effectively. In
fractional ablative CO2 laser-treated skin specimens, a col­
lagen subtype (types I and III collagen) profile resembling
that of nonwounded skin was found.18 Also, pinpoint bleed­
ing after ablative fractional laser is much less problematic
with the fractional ablative CO2 laser because of the
increased zone of coagulation when compared to the
erbium:YAG laser. The fractional ablative CO2 laser has
been shown to be highly effective in the treatment of hyper­
trophic scars,12,18-28 including cosmetic and functional
enhancement of traumatic scars and contractures, with
treatment ranging between one and six sessions. Improve­
ment of tactile sensation after treatment of burn scars of
the palm has also been reported. Patients who underwent
fractional ablative CO2 laser procedures for treatment of
symptomatic burn scars also had a 49% decrease in pruri­
tus after laser treatment.19 Our institution (UTMB, Galves­
ton) recently performed a review29 of the patient cohort
who underwent treatment with fractional ablative CO2 laser
therapy for postburn hypertrophic scarring. A total of 452
fractional ablative CO2 laser treatments were performed in
245 pediatric patients (126 females and 119 males) in 3
years. Fractional ablative CO2 laser was used 256 times on
the face, 103 on the neck, 164 on the torso, 164 on the
upper limbs, and 74 on the lower limbs. Treatment provid­
ers have seen a reduction in scar thickness and improve­
ment in scar pigmentation, as well as improvement in burn
scar itch in patients treated with fractional CO2 laser.
In 2012, Lumenis introduced a modification to the high-
energy CO2 laser (UltraPulse Encore; Lumenis, Santa Clara,
CA) by adding a module for the treatment of scars—
Synergistic Coagulation and Ablation for Advanced Resur­
facing (SCAAR FX). The device generates hundreds of very
deep microchannels that penetrate up to 4 mm. Usually
after the first procedure patients feel a reduction of tension
and softening of the scar. This is now the mainstay of the
CO2 laser treatment at our institution for thick hypertrophic
scars (for more details on laser settings refer to Table 60.1).
LASERS TO TARGET PIGMENT
There are several lasers available that target pigment
including the Ruby laser which is near infra-red (wave­
length 694 nm) and targets pigment. A long pulse is used
for hair removal (by destroying hair follicle stem cells) and
ultra short (nano-second) pulse for interfollicular and fol­
licular melanocyte destruction. Combination lasers include
the TriVantage and GentleMAX (Candela Laser Corpora­
tion, USA), which both combine an alexandrite laser
(755 nm) and Ng:YAG capabilities (1064 nm. This creates
a broad spectrum of different wavelengths to enable target­
ing of different pigments and depths of melanocytes. They
are thus useful for the removal of pigmentation and pig­
mented hairs to treat burn scar folliculitis.
INTENSE PULSED LIGHT
Although not technically a laser, IPL delivers focused,
controlled light energy through a coupling gel across the
515–1200 nm (visible to near infrared) spectrum and at
a fluence of up to 40 J/cm2. IPL sources are filtered xenon
causes photothermolysis, in which light energy is absorbed
by hemoglobin leading to coagulation necrosis.9 Beneficial
effects of PDL on burn scar pruritus have also been observed.
This may be secondary to either decreased mast cell count
following PDL treatment or decreased amounts of sub­
stance P and calcitonin gene-related peptide (CGRP), which
mediate the vascular response of the skin.11 The settings for
PDL in the treatment of hypertrophic burn scar are found
in Table 60.1.
ABLATIVE/NONABLATIVE FRACTIONAL LASERS
Fractional resurfacing leads to controlled destruction of
tissue columns, also known as microscopic treatment zones
(MTZs), without significant collateral damage. Similar to a
z-plasty, the laser breaks up the thick, disorganized collagen
fibrils that created the scar, allowing these regions to repair
in a more organized fashion. However, a significant amount
of epidermis and dermis remains intact, which assists in
wound healing.
Fractional laser injury has also been shown to induce a
molecular cascade including heat shock proteins and
matrix metalloproteinases as well as inflammatory proc­
esses that lead to a rapid healing response and prolonged
neocollagenesis.
ERBIUM-YAG LASER
In a prospective, single-arm, pilot study, treatment with a
nonablative fractional erbium laser resulted in at least mild
improvement in scar appearance in 90% of subjects and
moderate to excellent improvement in 60% of subjects.13
However, this study did not separate out patients who had
hypertrophic burn scars versus scars from other etiologies.
Two additional studies also investigated 1540-nm nonabla­
tive fractional erbium laser in mature burn scars and found
a similar lack of improvement in thick scars.14,15 Based on
findings in these studies, it is likely that hypertrophic burn
scars benefit from even deeper penetrating laser energy.
There is a significantly greater potential depth of thermal
injury with ablative fractional laser when compared with
nonablative fractional laser devices (approximately 4.0 and
1.8 mm, respectively).16 Ablative erbium:YAG laser emits
infrared light with a wavelength of 2940 nm. The major
innovation of the erbium:YAG laser over the CO2 laser is its
shorter wavelength, which increases its absorption coeffi­
cient through water 10- to 16-fold. Also, there is less
thermal necrosis at the treatment site. One study cited
improvement in hypertrophic burn scars in 24 patients on
face, neck, or low neckline, and eight on the hands.14 The
settings for ablative erbium:YAG lasers in the treatment of
hypertrophic burn scar are found in Table 60.1.
CO2 LASER
The CO2 laser has a wavelength of 10,600 nm and is used
to target water in abnormal collagen several millimeters
below the surface of the skin. The absorption of CO2 laser
by tissue water is significantly less than that of erbium:YAG
leading to a relatively greater potential for surrounding
tissue ablation. However, the increased ablation appears
to induce a modest immediate photomechanical release of

60  •  Laser for Burn Scar Treatment
651
Table 60.1  Common Laser/IPL Settings
PULSE DYE LASER
Wavelength
585–595 nm
Handpiece (spot size)
7-mm or 10-mm spot
Pulse duration
1.5 ms
Cryogenic cooling settings
30-ms spray and 20-ms delay
Fluence (7 mm)
6.0–11.0 J/cm2
Fluence (10 mm)
4.0–5.0 J/cm2
Overlap
Yes
Endpoint
Purpuric skin change
ERBIUM:YAG LASER
Wavelength
2940 nm
Spot size
3–6 mm
Frequency
4–8 Hz
Fluence
11–12 J/cm2
Overlap
No
Endpoint
Pinpoint bleeding
CO2 LASER
Wavelength
10,600 nm
DeepFX Handpiece
SCAARFX
DeepFX
Indication
Severely thickened hypertrophic scar
Intermediate-thickness hypertrophic scar or atrophic scar
Energy
70–100 mJ
15–20 mJ
Frequency
250 Hz
600 Hz
Pattern
2
2
Size
10
10
Density
1%–3%
10%
Overlap
No
No
Endpoint
Pinpoint bleeding
Pinpoint bleeding
Ultrascan CPG
ActiveFX Central
ActiveFX Peripheral
Indication
All central scar
All peripheral scar (feathering)
Energy
60–100 mJ
50 mJ
Frequency
125 Hz
125 Hz
Pattern
3
3
Size
7
5
Density
3%
3%
Overlap
Yes
Yes
Endpoint
Full coverage of scar
Full coverage of peripheral scar
INTENSE PULSED LIGHT
Wavelength Filter
590 nm
Pulse Duration
5 ms
Delay
20 ms
Fluence
15–17 J/cm2
Guide
Large rectangular light guide

60  •  Laser for Burn Scar Treatment
652
would use the CO2 laser in addition to address areas of
tightness.
SCAR CONTRACTURE
Wide contracture bands and thick sheets of scar contrac­
ture can be well addressed with fractionated CO2 laser, with
the addition of steroid injections. This allows the relaxation
of tissues, enabling release of skin around the neck and in
the webspaces of the hand.
HYPERPIGMENTATION
Patients with darker skin types may develop areas of hyper­
pigmentation following burns or on donor sites. This is very
unpredictable. Lasers to target pigmentation such as the
Alexandrite or ND:YAG laser can be used to address these
areas. Patients must be comprehensively consented, as the
laser will cause hypopigmentation which may be equally
distressing.
flashlamps that release pulses of noncoherent polychro­
matic light. The mechanism of IPL is not fully understood,
but it probably targets the vascular proliferation essential
to collagen overgrowth and its effect on pigmentation (both
melanin and artificial pigments) that results in scar devel­
opment (hyperpigmented, erythematous, and proliferative
scars).10 Specific filters in the handpiece allow the user to
select a window of wavelengths, such as 755 nm for col­
lagen stimulation, 695 nm to remove superficial leg veins,
and 515 nm to treat rosacea.12 Multiple studies have shown
IPL to be helpful in the management of burn scar dyschro­
mia, long-standing hypervascularity, and chronic folliculi­
tis without the risks or downtime of PDL photothermolysis
or laser resurfacing.10,12 The settings that we use for IPL
in the treatment of hypertrophic burn scars are found in
Table 60.1.
Treatment of Specific Post Burn
Scar Conditions
FOUR-YEAR REVIEW
A recent review (2011–2014) in our unit (St Anderws,
Chelmsford) demonstrated a wide use of different lasers for
the treatment of various post burn scar conditions.30 We
carried out 194 procedures on 40 patients with an age
range of 3–73 years. The fractionated CO2 laser was used
for 66 (34%) procedures alone and 112 in total, combined
with other lasers in the same sitting. Indications included
hypertrophic scar, contracture bands, unstable or thick,
cracked scars. The PDL was used for 19 (10%) procedures,
137 in total. The main indications were red, itchy symp­
tomatic scars. It was also used to soften scars prior to injec­
tion with dermal steroids. The Ruby laser was used for 30
(15%) of procedures alone and 51 procedures in total, with
indications being hyperpigmentation and folliculitis. In
2014 this was replaced by the TriVantage and Gentlemax.
These were used for 4 procedures alone and 27 in total.
Indications were hyperpigmentation (TriVantage short
pulse) and folliculitis (GentleMAX long pulse).
VASCULAR AND HYPERTROPHIC SCARS
Red scars with visible telangiectasia which blanch on touch
are common in the months and years following healing of
a burn. These are often lumpy and thick, or cracked and
shiny, unstable or non-healing. The patient often complains
of pruritus and pain. We have found that these scars
respond well to PDL to reduce the erythema, followed by
CO2 to flatten the scar and enable stable healing Intrader­
mal steroids may also be applied.
Folliculitis
Commonly, hair becomes trapped under scars or grafts
causing irritation and repeated localized infections, This
can be particularly problematic in the beard area of men.
Fig. 60.1 illustrates this 25 months following a burn. We
use the PDL to soften the scar in order to access the hair and
decrease erythema. Following this a laser targeted at
pigment (in this case Alexandrite laser) is used to remove
the hair. As tight, thickened scar is usually also present, we
Fig. 60.1  Before (above) and after (below) photographs of a man with
hypertrophic scars and follocilitis to the beard area, 25 months follow­
ing burn injury, who was treated with PDL, Alexandrite and CO2 lasers.

60  •  Laser for Burn Scar Treatment
653
The greatest risk when operating a laser is that of eye
injury to either the medical personnel or the patient. Medical
personnel operating lasers should be fully trained and should
cover their skin and wear correct protective eyewear (differ­
ent forms of eyewear filter different wavelengths; therefore it
is important that appropriate eyewear is worn for each spe­
cific laser). The protective specifications (wavelengths and
optical densities) are usually printed on the goggles, gener­
ally near the top of the unit. Protective eyewear should also
be placed on the door(s) outside the laser operating room in
case emergency entrance is required.
To help prevent eye injury, laser procedures should be
restricted to dedicated rooms that are clearly labeled and
only allow the necessary personnel. Those rooms should
limit the amount of reflecting surfaces (e.g., mirrors, com­
puter screens, windows) to avoid scattering laser beams
inside and outside of the room.33
If the procedure is being performed on the head and neck,
metal scleral eye shields that fit the patient’s cornea are
filled with an ocular lubricant and placed directly on the
corneal surface. However, if the procedure is being done
below the neck, burnished stainless steel eye cups are fitted
over the eyelids and secured so that the entire periorbital
area is covered.
Appropriate signage on the laser operating room door(s)
is a requirement. The sign should describe the nature of the
laser being used, its wavelength, and energy. Signs should
only be posted when the laser is in actual use and removed
or covered when the laser is turned off and the key
removed.32 All operating room windows should be closed
and covered. Lasers that have foot pedals are helpful in
allowing expeditious use of the laser. However, accidental
activation of the foot pedal is one of the most commonly
reported accidents.32 Any repositioning of the foot pedal
should take place when the laser is deactivated, and only
the operator of the laser should use the foot pedal. The
control panel of the laser should never be left activated and
unattended. When not in use, the laser should be turned off
and the key removed. The footswitch for activating the laser
must be given only to the credentialed laser user.
Operating room fires and airway fires are both pos­
sible when using a laser. Production of a flame requires
that the triad of heat source (laser), fuel source (patient’s
tissue), and an oxidizer (supplemental oxygen) be present.
The risk of operating room or airway fire is rare, but most
commonly occurs in patients undergoing laser treatment
near the face. The risk is significant when patients who are
under conscious sedation require supplemental oxygen via
standard nasal cannula. Eliminating supplemental oxygen
altogether is the safest way to prevent operating room or
airway fire. However, the risk of fire is significantly reduced
when supplemental oxygen is delivered directly to the pos­
terior pharynx using the nasopharyngeal tube or when
the patient is intubated.32,34,35 Moist towels should cover
areas around the treatment zone to avoid thermal radia­
tion and damage to adjacent tissue. A moist towel can be
safely wrapped around the endotracheal tube if present.
Additionally moist gauzes should also be placed into the
patient’s nares and mouth when operating lasers in close
proximity.
It is best to keep a fire extinguisher either inside or posi­
tioned just outside the room, so it is quickly available for
Laser Complications and
Laser Safety
LASER COMPLICATIONS
Although infrequent, complications do occur. Common
complications of PDL therapy include transient purpura
and mild to moderate erythema or edema that usually
resolves in 7–10 days. However, in some cases, a mild ery­
thema can persist up to 3 months posttreatment. Occa­
sionally skin blistering or crusting may occur in the early
posttreatment phase. Hypo- or hyperpigmentation may also
occur, especially in patients with darker skin types. Over­
treatment of burn scars may induce scarring exacerba­
tion, especially in skin with darker pigmentation, in which
melanin acts as a competing chromophore. Intraproce­
dural cryogenic cooling of the skin may limit these adverse
reactions.31
Fractional ablative lasers have an improved adverse effect
profile compared with nonfractional ablative devices.
However, delayed wound healing, ulceration, postinflamma­
tory hyperpigmentation (PIH), and scarring, particularly in
areas of thinner skin and in decreased adnexal structures
such as the neck, have also been reported with fractional
lasers. Postoperative topical application of ascorbic acid has
been shown to decrease the duration as well as the severity
of erythema. Because PIH can be a major problem for those
undergoing fractional laser therapy, some units attempt to
reduce pigmentation within the target zone prior to applica­
tion of laser therapy using hydroquinone. If a patient is likely
to elicit PIH, then a treatment we have found to be successful
is Azelaic acid gel (15%); this has a tyrosine kinase inhibitory
action that reduces the recurrence of PIH. (I emphasize that
it is not a treatment for PIH but a preventative measure.)
Those wishing to treat PIH with topical therapy often use a
combination of steroid, hydroquinone, and tretinoin.
Patients with a history of herpes who undergo laser treat­
ment around the face may experience an outbreak if not
pretreated as discussed earlier in the chapter.
LASER SAFETY
When performed by properly trained medical personnel,
laser therapy has low risks for harmful outcomes and can
be executed safely. National safety requirements are based
on the American National Standards Institute (ANSI)
Z136.3, Guide to the Safe Use of Lasers in Healthcare. This
document is a benchmark standard for safe practice in the
United States. Although not regulatory and without legal
enforcement, this document is evidence-based and is con­
sidered best practice; as such, it is the foundation for state
laws, Occupational Safety and Health Administration
(OSHA) guidance, the Joint Commission (TJC) surveys, and
professional recommended practices.32 Proper handling
and installation of lasers in hospitals and private practices
is overseen by OSHA, which uses a set of standard guide­
lines issued by the American National Standard Institute.
However, institutional guidelines and state regulations
differ. These regulations determine the licensing require­
ments for who can operate a laser under the supervision of
a physician.

60  •  Laser for Burn Scar Treatment
654
someone either inside or outside the room. All staff should
be notified of its location and operation.
Along with ocular hazards and fire hazards, the laser
smoke plume is a significant occupational hazard. Research
has proved that thermal disruption of viable human cells,
regardless of the instrument used, results in the release of
mutagenic and carcinogenic materials, including carbon
particles, viruses, bacteria, DNA, aerosolized blood, blood-
borne pathogens, and more than 41 known hazardous
gases such as benzene, formaldehyde, toluene, and acro­
lein.32 Masks are not meant to be the first line of protective
devices against plume exposure in the breathing zone.
There are no masks on the market today, including N95
masks, that are capable of filtering out all airborne con­
taminants.32 Laser masks can be used instead of standard
surgical masks, but one should note that the filtration
medium stops working when the mask becomes damp from
breathing, thus defeating its purpose.28 Instead the most
effective way to prevent this occupational hazard is to utilize
a high-efficiency ultra-low-particulate air filter. It should be
rated to 99.999% efficiency and placed within 1–2 cm of
the laser smoke plume source to be effective.
Logistical and Financial
Considerations
Starting a laser practice dedicated to the treatment of burn
patients with hypertrophic scar formation can be quite
daunting.12 The ability to collect revenue from these proce­
dures is absolutely essential for the sustainability of the
practice.36 Third-party insurance carriers specify that
hypertrophic burn scars that cause significant pain or result
in a significant physical functional impairment are candi­
dates for laser.36 Critical to the success in obtaining preau­
thorization from insurance companies is a thorough history
and physical, clinical photography, and the use of accurate,
specific, and complete CPT and ICD-10 codes. Because spe­
cific CPT codes for the laser treatment of burn scars do not
exist, Hultman et al. recommend using 17106, 17107, and
17108 (laser destruction of cutaneous vascular prolifera­
tive lesion, <10 cm2, 10–50 cm2, and >50 cm2, respec­
tively). The rationale for using these codes is that burn scars
are hypervascular, hypertrophic, and hyperpigmented, all
of which are due to a proliferative, neovascular, and hyper­
plastic response of the injured tissues. While not hemangio­
mas or vascular malformations, burn scars act like these
lesions due to similar pathophysiologic mechanisms, result­
ing in similar endpoints.12 Also important for documenta­
tion is using the correct ICD-10 diagnosis terminology to
signify that these scars are from burns and corrosions of
external body surfaces. Use T20 for head, face, and neck;
T21 for trunk; T22 for shoulder and upper limb, except
wrist and hand; T23 for wrist and hand; T24 for lower limb,
except ankle and foot; and T25 for ankle and foot. Also
utilize ICD-10 codes L91.0 to describe keloid or hypertro­
phic scars and L90.5 to describe scar conditions and fibrosis
of skin.
Acquiring the laser platforms may be done through
rental, lease, or purchase, but the capital requirement can
be considerable.12 Because laser technologies can become
obsolete quickly, and because warranties can be quite
expensive, at least in the beginning of the venture, leasing
is one way to start a practice offering laser treatments.36
The clinician must also have access to an accredited sur­
gical facility that includes all of the safety features of an
operating room or surgical suite. Most patients require a
large area of treatment that generally exceeds the area that
could be covered by local anesthesia. These patients require
treatment in an operating room with either monitored
anesthesia or general anesthesia with supervision by an
anesthesiologist.
One element that is particularly attractive to all stake­
holders, patients, providers, and third-party payers is that
laser therapy for hypertrophic burn scars has the potential
to dramatically reduce the cost of care.12 It is possible that
laser treatments might preclude the need for invasive
surgery in some patients with mild to moderate contrac­
tures and permit less aggressive and less costly procedures
in patients with moderate to severe contractures.36 From
experience at our institution, patients expressed preference
for the less-invasive laser treatment compared to a more
invasive surgical scar release.29 Laser treatments can
decrease pharmacologic requirements for such medications
as narcotics, antihistamines, anxiolytics, and antidepres­
sants leading to decreased healthcare costs.12 Also, patients
who have had successful treatment of their hypertrophic
burn scar may return to work or school sooner and require
less clinic follow-up.
Future Investigations
Although the effect of lasers on hypertrophic burn scars
has only been studied in the past few years, this work is very
promising and therefore just beginning. High-quality, pro­
spective, blinded, randomized, controlled trials are neces­
sary to assess which lasers or light-based therapies are best
for hypertrophic burn scar modulation, pruritus, and dys­
esthesias. Within each type of therapy, standardization of
several different laser parameters, such as fluence, pulse
time, density, and timing of surgery, will be developed. Any
additional benefit from adding topical medications to the
treatment area also needs to be standardized. Studies assess­
ing economic benefits will allow for other institutions to
adopt lasers for the treatment of hypertrophic scarring.
Conclusion
Lasers and light-based therapies are safe and effective treat­
ment options for hypertrophic burn scars, and they are now
becoming the standard of care for all burn patients.
Although not a panacea for all scars, they are a worthy
addition to the armamentarium of all burn reconstruction
surgeons.
Although laser treatments are clearly effective, they have
not yet been optimized. Prospective, randomized clinical
studies are necessary to provide evidence-based and quality
care for patients with hypertrophic burn scars.
Complete references available online at

654.e1
60  •  Laser for Burn Scar Treatment
19. Issler-Fisher AC, Fisher OM, Smialkowski AO, et al. Ablative fractional
CO2 laser for burn scar reconstruction: an extensive subjective and
objective short-term outcome analysis of a prospective treatment
cohort. Burns. 2017;43(3):573-582.
20. Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment
of a third-degree burn. J Drugs Dermatol. 2009;8(3):294-297.
21. Hultman CS, Edkins RE, Wu C, Calvert CT, Cairns BA. Prospective,
before-after cohort study to assess the efficacy of laser therapy on
hypertrophic burn scars. Ann Plast Surg. 2013;70(5):521-526.
22. Hultman CS, Friedstat JS, Edkins RE, Cairns BA, Meyer AA. Laser
resurfacing and remodeling of hypertrophic burn scars: the results of
a large, prospective, before-after cohort study, with long-term follow-
up. Ann Surg. 2014;260(3):519-529, discussion 529-532.
23. Lee SJ, Suh DH, Lee JM, Song KY, Ryu HJ. Dermal remodeling of burn
scar by fractional CO2 laser. Aesthetic Plast Surg. 2016;40(5):761-768.
24. Zadkowski T, Nachulewicz P, Mazgaj M, et al. A new CO2 laser tech­
nique for the treatment of pediatric hypertrophic burn scars: an
observational study. Medicine (Baltimore). 2016;95(42):e5168.
25. Levi B, Ibrahim A, Mathews K, et al. The use of CO2 fractional
photothermolysis for the treatment of burn scars. J Burn Care Res.
2016;37(2):106-114.
26. Blome-Eberwein S, Gogal C, Weiss MJ, Boorse D, Pagella P. Prospective
evaluation of fractional CO2 laser treatment of mature burn scars.
J Burn Care Res. 2016;37(6):379-387.
27. Azzam OA, Bassiouny DA, El-Hawary MS, et al. Treatment of hyper­
trophic scars and keloids by fractional carbon dioxide laser: a clini­
cal, histological, and immunohistochemical study. Lasers Med Sci.
2016;31(1):9-18.
28. Ozog DM, Liu A, Chaffins ML, et al. Evaluation of clinical results,
histological architecture, and collagen expression following treatment
of mature burn scars with a fractional carbon dioxide laser. JAMA
Dermatol. 2013;149(1):50-57.
29. Forbes AAWP, Branski LK, Finnerty CC, Herndon DH, Norbury WB.
Ablative CO2 laser treatment of hypertrophic scars for severely burned
children. Austin: Texas Society of Plastic Surgery. 2015.
30. Bache SE, Chilton L, Mack T, Philp B. Using laser therapy to modify
burn scars: a four year review. Presented at British Burns Association
48th Annual Meeting, Birmingham, UK, 2015.
31. Clayton JL, Edkins R, Cairns BA, Hultman CS. Incidence and manage­
ment of adverse events after the use of laser therapies for the treatment
of hypertrophic burn scars. Ann Plast Surg. 2013;70(5):500-505.
32. Goldman MP, Ross EV, Kilmer SL, Weiss RA. Lasers and energy devices
for the skin; Boca Raton (FL): CRC Press; 2013.
33. Franck P, Henderson PW, Rothaus KO. Basics of lasers: history,
physics, and clinical applications. Clin Plast Surg. 2016;43(3):505-
513.
34. Engel SJ, Patel NK, Morrison CM, et al. Operating room fires: part II.
optimizing safety. Plast Reconstr Surg. 2012;130(3):681-689.
35. Wald D, Michelow BJ, Guyuron B, Gibb AA. Fire hazards and CO2 laser
resurfacing. Plast Reconstr Surg. 1998;101(1):185-188.
36. Hultman CS, Edkins RE, Cairns BA, Meyer AA. Logistics of building a
laser practice for the treatment of hypertrophic burn scars. Ann Plast
Surg. 2013;70(5):581-586.
References
1. Goldberg DJ. Laser Dermatology. 2nd ed. Berlin Heidelberg: Springer;
2013:142.
2. Anderson RR, Parrish JA. Selective photothermolysis: precise
microsurgery by selective absorption of pulsed radiation. Science.
1983;220(4596):524-527.
3. Guyuron B, Eriksson E, Persing JA, et al. Plastic Surgery Indications and
Practice. 1st ed. New York: Elsevier; 2009.
4. Neligan PC. Plastic Surgery. 3rd ed. New York: Elsevier Saunders;
2013.
5. Babilas P, Schreml S, Szeimies RM, Landthaler M. Intense pulsed light
(IPL): a review. Lasers Surg Med. 2010;42(2):93-104.
6. Edkins RE, Hultman CS, Collins P, et al. Improving comfort and
throughput for patients undergoing fractionated laser ablation of
symptomatic burn scars. Ann Plast Surg. 2015;74(3):293-299.
7. Wong BM, Keilman J, Zuccaro J, et al. Anaesthetic practices for Laser
rehabilitation of paediatric hypertrophic burn scars. J Burn Care Res.
2017;38(1):e36-e41.
8. Brewin MP, Lister TS. Prevention or treatment of hypertrophic burn
scarring: A review of when and how to treat with the Pulsed Dye
Laser. Burns. 2014;40(5):797-804.
9. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current con­
cepts and future directions. Burns. 2010;36(4):443-449.
10. Erol OO, Gurlek A, Agaoglu G, Topcuoglu E, Oz H. Treatment of hyper­
trophic scars and keloids using intense pulsed light (IPL). Aesthetic
Plast Surg. 2008;32(6):902-909.
11. Allison KP, Kiernan MN, Waters RA, Clement RM. Pulsed dye
laser treatment of burn scars. Alleviation or irritation? Burns.
2003;29(3):207-213.
12. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on:
review of laser- and light-based therapies for the treatment of burn
scars. Dermatol Res Pract. 2012;2012:243651.
13. Waibel J, Wulkan AJ, Lupo M, Beer K, Anderson RR. Treatment of
burn scars with the 1,550 nm nonablative fractional erbium laser.
Lasers Surg Med. 2012;44(6):441-446.
14. Taudorf EH, Danielsen PL, Paulsen IF, et al. Non-ablative fractional
laser provides long-term improvement of mature burn scars: a ran­
domized controlled trial with histological assessment. Lasers Surg Med.
2015;47(2):141-147.
15. Haedersdal M, Moreau KE, Beyer DM, Nymann P, Alsbjorn B. Frac­
tional nonablative 1540 nm laser resurfacing for thermal burn scars:
a randomized controlled trial. Lasers Surg Med. 2009;41(3):189-195.
16. Anderson RR, Donelan MB, Hivnor C, et al. Laser treatment of trau­
matic scars with an emphasis on ablative fractional laser resurfacing:
consensus report. JAMA Dermatol. 2014;150(2):187-193.
17. Eberlein A, Schepler H, Spilker G, Altmeyer P, Hartmann B.
Erbium:YAG laser treatment of post-burn scars: potentials and limi­
tations. Burns. 2005;31(1):15-24.
18. El-Zawahry BM, Sobhi RM, Bassiouny DA, Tabak SA. Ablative CO2
fractional resurfacing in treatment of thermal burn scars: an open-
label controlled clinical and histopathological study. J Cosmet Derma­
tol. 2015;14(4):324-331.

655
The Ethical Dimension of
Burn Care
ARTHUR P. SANFORD and MICHELE A. CARTER
61 
clinicians frequently encounter. It involves critical thinking
about right and wrong and of what should or should not be
done4 in terms of our responsibilities to others. It also legiti­
mates the importance of ethics teaching and ethics dia­
logue in all phases of professional practice, whether that is
in the classroom, the board room, or on “ethics rounds at
the bedside.”5 Clearly caring for burned patients invites
moral reflection and imagination, and clinical ethicists
increasingly are part of the integrated approach.
In general, most healthcare providers hold certain values
in common and are thus not in doubt about what morality
requires. That is, we hold firmly to the conviction that it is
a good thing to preserve life, to cure disease, or to lessen
someone’s pain or suffering. For the most part, we are clear
about what our ethical responsibilities are: to respect the
values and dignity of human life, to tell the truth, to avoid
harming patients, and to treat them and their families fairly
and with compassion. Indeed ethical decision-making for
some is therefore like breathing,6 something we do without
even thinking. At times however disagreements about what
we ought to do or what we ought to value occur. That is,
while we may be clear on the general principles of ethics, it
is not always so clear how to apply them in a particular
case. This uncertainty can give rise to ethical problems and
dilemmas, some of which occur at the bedside of the patient
and others that may involve questions of institutional
policy, resource allocation, or even larger societal issues
about how we ought to distribute goods and services.
What Is an Ethical Problem?
An ethical problem is present when it involves a conflict of
two or more of the following: rights or rights-claims, obliga­
tions, goods, and/or values.7 For example, disputes about
writing a “comfort-measures-only” order for a patient
without decision-making capacity and with a very low
probability of survival commonly involve a conflict between
an obligation and a good: the obligation not to abandon
aggressive therapy prematurely and the good of a maxi­
mally pain-free and unprotracted death. In this case, the
burn team and the patient/surrogate are ordinarily the
major stakeholders and appropriate decision-makers, and
they are addressing a problem in clinical ethics. On the other
hand, consider the burn center’s or healthcare organiza­
tion’s (HCO’s) responsibility to ICU patients when a safe
nurse-to-patient ratio cannot be consistently met despite
the burn center’s best efforts. If discerning what should be
done in such circumstances requires decision-making at
the managerial level of the burn center or HCO, a problem
in organizational ethics8 is the correct term to use.
Introduction
Burns are a leading cause of accidental injury and death in
the United States and worldwide, and they can often raise
profound concerns about autonomy, mortality, quality of
life, and suffering. In seeking optimum health for each
patient, contemporary burn care aspires to integrate the
highest standards of evidence-based medicine with excel­
lence in patient care delivery and clinical research. Optimal
care of patients with burns is a virtuous practice involving
highly integrated, team-oriented, interdisciplinary,1 and
humanistic encounters. It includes adherence to certain
norms of professional conduct as well as a process of
reflection on how to incorporate those norms in individual
patient care or research settings. It involves increasingly
complex layers of technological and professional sophis­
tication, clinical judgment, and expertise and sensitive
attention to the ethical values at the core of medicine.
Clinical situations can be complex, not simply because of
the wide range of medical facts and situational factors
that constitute burn care, but because of the diversity of
human needs that lay coiled beneath the surface of illness
or trauma. Given that patients with burns are among the
most vulnerable of patients and have needs that expand
the full range of the human condition, all members of the
healthcare team are called upon to offer care that is tender,
skillful, comprehensive, and ethically conscientious. The
core ethical ingredient of these encounters is the doctor–
patient relationship and the underlying expectations of
trust that patients and their families bring to the clinical
setting.2
Caring for the burned patient encompasses a long-
standing commitment to the safety, healing, rehabilitation,
and growth of patients. As such it is thoroughly infused
with ethical values and goals. As conceived in ancient
Athens and during most of its history, Western ethics
involves the quest for achieving the good life, living it excel­
lently, and setting forth ideals of human flourishing. In con­
temporary times, these ideals continue to inform the
practice of medicine and contribute to the evolving field of
clinical ethics. Clinical ethics is “the systematic identifica­
tion, analysis, and resolution of ethical problems associated
with the care of particular patients. Its goals include
protecting the rights and interests of patients, assisting cli­
nicians in ethical decision making, and encouraging coop­
erative relationships among patients and those close to
patients, clinicians, and healthcare institutions.”3 Over the
past several decades, the field of clinical ethics has become
an essential part of hospital life and culture, reflecting the
complexity and poignancy of the real-life ethical puzzles

61  •  The Ethical Dimension of Burn Care
656
As indicated, conflicts among rights, obligations, and the
like are very common and vary greatly in difficulty. When
should they be taken seriously? An ethical problem is serious
when there are stakeholders involved who stand to be seri­
ously affected by the problem or its outcome. Stakeholders
working collaboratively without outside help can success­
fully manage the vast majority of such problems. When are
such problems so serious that assistance should be sought
from an ethics consultant or a healthcare ethics committee
(HEC) or its equivalent? An ethical problem is serious
enough to refer to an HEC:
a. When you suspect the Smell Test would be positive;
that is, ”What would the action or situation we are
considering smell like if we read about it in a front
page news article or in a popular blog? Would I be
comfortable explaining it to my spouse, or my grand­
mother?” The problem with this, as the olfactory
image reminds us, is that living with bad smells or
unethical conduct for a long time may dull a person’s
ability to notice them.
b. When there is persistent disagreement among the
major stakeholders and codes, rules, laws, and more
discussions fail to lead to a resolution within gener­
ally acceptable ethical boundaries in a reasonable
amount of time.
How Should Clinical Ethics
Problems Be Managed?
In the United States, the informed consent process was
developed by the American judiciary to safeguard the legal
rights and welfare of all the stakeholders participating in
bedside decision-making. Throughout the United States,
this legal process has become the foundation of the health­
care provider’s approach to avoiding and managing serious
ethical problems at the bedside. Its application in the burn
center was explained and diagrammed in detail in the first
edition of this book,9 and what follows should be considered
an update and development of what is stated there.
On the vast majority of occasions, there is little or no dif­
ficulty achieving agreement and patient consent about a
proposed course of burn management. There are many pre­
dictors of clinical outcomes that are without controversy.10
Occasionally, however, the process of obtaining informed
consent leads to problems involving disagreements, anxiet­
ies, and/or controversies about what should or should not
be done. At this point, the participants must give careful
attention to the quality of the discussion in attempting to
resolve the problem, part of which requires respect for the
patient’s underlying values.
Increasingly, ethics consultants are seen as important
stakeholders in optimizing the care of patients suffering
from burns, especially when treatment decisions are ethi­
cally complex or psychologically difficult. Through facili­
tated dialogue, the rights, interests, and needs of the patient
are brought to the center and deliberated upon, but the
values and concerns of the team are honored as well. Addi­
tionally, ethics consultants facilitate the process of making
and justifying moral judgments on the basis of certain
ethical principles that transcend individual personal opinion
or perspective. That is, a judgment that a certain act—say,
withdrawing life-saving treatment for a dying patient—is to
be performed or not is justified on the basis of some rule or
standard applicable in all relevantly similar cases. In this
way, ethical dialogue becomes more than simply ensuring
that a patient has provided an informed consent for treat­
ment. Instead ethical dialogue becomes the means by which
we examine the full range of our ethical responsibilities to
others, drawing on principles of trust, autonomy, dignity,
beneficence, justice, and care (Fig. 61.1).
THE ROLE OF THE CARE-PROVIDER IN
ETHICAL DIALOGUE
Approaching the resolution of ethical conflict through dia­
logue fosters in the burn team a sense of moral inquiry and
agency and makes explicit the process of respecting the
patient and family. At its best, ethical discourse begins by
establishing an interpersonal “relationship” made safe for
transparent and self-critical honesty and furthered by active
listening and openness to learning about the relevant
norms that constitute good care.11
To do this the care-provider should explore the bio-
psycho-social-economic and cultural/religious information
required to approach the patient and his family and/or sur­
rogate with empathy for their lives and values. One of the
strongest ways we show respect for the patient and family
is to honor religious values, even when such values may
differ from those of the healthcare team. For instance,
Western religions often proclaim that there are certain limi­
tations to earthly life and advocate adherents to look to a
future beyond the present for ultimate value and meaning.
By contrast, Eastern religions hold that our present lives are
reflective of past deeds and future conditions, that life is
oriented to the present. Many confer extreme respect on the
spirit of departed ancestors and live their lives in service to
their honor. Finally, some individuals do not have religious
affiliations at all and may live for different goals or ideals.
These belief perspectives illuminate diverse ways of deriv­
ing meaning in life and understanding those ends that
make life worth living. At times, this diversity can render
decision-making about treatment decisions more challeng­
ing and can give rise to ethical uncertainty or moral distress
in members of the healthcare team. Many patients, based
on personal values and beliefs, may decide against life-
prolonging treatments in hopes of not burdening their
family with large hospital bills. Other patients may demand
care that is arguably futile, care that has no possibility of
conferring any physiological benefit to the patient. For some
practitioners, such reasoning patterns may appear to be
fundamentally flawed and can spawn difficult emotional
contests. In these situations, the ethical dialogue may
expand beyond the doctor–patient relationship and involve
policy-makers, legislators, practice plans, and regulators,
all of whom are stakeholders in the system of trust that
society relies upon. Given that patients with burns reflect
the diversity of the American population and a plurality of
values regarding life and death, care of the burned patient
is complex and challenging. Consideration of patient values
and preferences should occur early on in the plan of care
so that proper respect for patient autonomy, culture, and
religious perspectives can occur.

61  •  The Ethical Dimension of Burn Care
657
patient is capacitated sufficiently to make a health-related
decision. Determination of decision-making capacity by
judicial process (i.e., determination of legal competency) is
rarely necessary. If despite all efforts the patient is found to
lack decision-making capacity, an appropriate surrogate
should be sought among the patient’s family or friends,
depending on local laws to determine priority.
The care-provider has a duty to provide accurate infor­
mation pertaining to the patient’s diagnosis, prognosis, and
treatment plan so that the capacitated patient or appropri­
ate surrogate can properly deliberate. This includes relevant
information about plausible alternatives, including the
option of forgoing proposed therapies. This duty is part of
the ethical standard of care and is an ongoing responsibility
throughout the hospital course. In providing optimal care
for burned patients, allegiance to this ethical norm is an
essential ingredient of the doctor–patient relationship and
the foundation of trust.
The care-provider must assess the patient’s capacity for
decision-making. To have decision-making capacity, the
patient should be able to understand proposed treatments
and their relevant risks and benefits, comprehend the con­
sequences of various actions and/or alternatives, and eval­
uate whether they accord with his or her personal values.
Also patients should be able to meaningfully deliberate and
express their preferences regarding recommended treat­
ments; this standard is often difficult to meet in the emer­
gency or intensive care setting and appropriate surrogate
decision-makers should be identified early in the hospital
course.12 Decision-making capacity is enhanced by optimiz­
ing the patient’s physiological stability, consciousness, and
pain control as much as possible. It is typically verified by
ascertaining orientation and by asking the patient to
rephrase the information provided in his or her own words
and to offer a reason or rationale for the decision. In general,
the physician is authorized to determine whether or not a
Ethical Reasoning
in Clinical Care
A Dialogical Approach
Michele A. Carter, Ph.D.
Identify medical variables, goals of
care and professional
responsibilities
Define ethically relevant
values, principles, and
standards
Recommend ethically permis-
sible options that harmonize
interpersonal relationships and
institutional policies
Clarify important cultural, social,
and/or religious values relevant
to patient/family preferences
Establish appropriate
decision makers and
patient preferences
Fig. 61.1  Ethical Reasoning in Clinical Care—A dialogical approach.

61  •  The Ethical Dimension of Burn Care
658
delivering bad news, described by Buckman; see Foley15.) If
successfully carried out, Steps 1 and 2 transform a potential
or actual power struggle into a collaborative search for the
answers to the next and then the final question listed in
Table 61.1.
The conversation of Step 3 may address principles (like
respect for persons, beneficence, etc.) but more typically
cites relevant laws and rules of the community and/or insti­
tution, and/or other values (no unnecessary pain, what the
patient would want if able to speak, etc.). Step 4 is usually
best carried out using a white board or equivalent to brain­
storm and record all the plausible alternative courses of
action. In Step 5, the group collaboratively may find a prin­
ciple, rule, value, or some combination thereof so compel­
ling that the proper alternative is clear. For example, because
it is considered unlawful homicide in most locations, large
doses of a narcotic primarily intended to stop breathing
rather than control pain may be found unacceptable. If the
decision is still not clear, Steps 6 and 7 will usually lead to
a mutually acceptable decision within boundaries that are
acceptable institutionally, legally, and ethically. Rarely, con­
sensus will elude the most sincere adherence to the seven-
step process. If further discussion, efforts to transfer care of
the patient, and the like fail, an appeal to the courts, or (in
at least one state16) an appeal to relevant legislation for
relief from responsibility for care of the patient, may be
necessary.
The Patient Without Decision-
Making Capacity, Surrogate, or
Advance Directive
In such cases, care-providers typically have no way of
knowing or deducing with confidence what the patient’s
wishes might be in a given set of circumstances. In general,
the decision made must seek the best interest of the patient,
but the process required may vary. In some jurisdictions,
consultation with another physician, the healthcare insti­
tution’s legal counsel, and/or HEC is mandatory. In others,
THE ROLE OF THE PATIENT OR SURROGATE IN
ETHICAL DIALOGUE
Patients and families bring to the clinical encounter previ­
ous experiences with loss and suffering, and these experi­
ences influence decisions about their goals for care and
recovery. The role of the patient is to assimilate information
provided by caregivers into their own value system and to
participate honestly and sincerely in conversations about
their preferences and concerns. One cannot expect an
acutely injured patient to fully understand medical infor­
mation, and most often they will require assistance from the
team before they are able to render a values-based decision.
Behavioral therapists, nurses, social workers, and clergy are
often needed to provide support and counsel, and they often
help patients discover internal resources needed to meet or
revise their life goals. In addition, critically burned patients
are often unable to participate meaningfully in treatment
decisions and must have their right of self-determination
carried out by a surrogate decision-maker. By entering the
patient’s personal world and participating in the unfolding
narrative of his or her experience, care-providers are better
able to arrive at ethically sound decisions.13 Patients and
their surrogates thus are essential participants in the inte­
grated approach to optimal burn care, and, without their
involvement and solicited participation, the ethics dialogue
is incomplete.
HOW SHOULD PERSISTENT ETHICAL CONFLICT
BE MANAGED?
Even when participants make a sincere effort to establish
consensus about treatment decisions, disagreements occa­
sionally persist. To resolve them, a patient care conference
is needed and ideally should include all major stakeholders.
The goal of these conferences is to collaboratively arrive at
ethically appropriate solutions that respect the values of the
patient and accord with appropriate standards of care.
Patient and family conferences are important components
to managing conflict in patient care decision-making. These
conferences usually involve representatives from multiple
disciplines who are involved in the care of the patient and
often are organized to help resolve ethical disagreements or
dilemmas. In any serious ethical inquiry, three questions
must be answered: What seems to be the problem? What
can be done? What should be done? A seven-step decision-
making model has been found helpful in answering these
questions and is illustrated in Table 61.1.14
In Step 1 of this decision-making model patients and/or
their surrogate are asked to speak first, and care-providers
listen carefully and respectfully. This approach helps equal­
ize power and create a safe place for shared understanding.
Participants are asked to introduce themselves, explain the
conflict as they see it, and indicate what they hope to achieve
by the discussion. Thereafter, the care-providers do the
same. This step typically takes the most time but is the most
important of all the seven steps. It lets off steam, makes the
patient/surrogate and allies feel listened to, and optimally
leads them to ask for the corrective and supplementary
information they need from the care-providers, which (in
Step 2) they usually can provide or obtain. (Note the simi­
larity of these early steps to those of the SPIKES protocol for
Table 61.1  Three Questions to Be Addressed When a
Clinical Ethics Problem Is Serious and Persistent and the
Steps Appropriate for Answering Each Question
1.
What seems to be
the problem?
Step 1.
Discover conflicting values of
stakeholders
Step 2.
Discover the relevant
information
2.
What can be
done?
Step 3.
Identify principles, laws, other
values relevant to the decision
Step 4.
Identify alternative courses of
action
3.
What should be
done?
Step 5.
Compare alternatives and values:
is decision clear?
Step 6.
If not, assess consequences
Step 7.
Make decision, collaboratively, if
possible
Modified from May WW. Ethics in the accounting curriculum: cases and
readings. Sarasota, FL: American Accounting Association; 1990:1. With
permission of the American Accounting Association and the author.

61  •  The Ethical Dimension of Burn Care
659
ethical: they involve conflicts of rights, obligations, goods,
and/or other values. They tend to be less dramatically imme­
diate and more deferrable, but they usually affect more
persons and require more resources and follow-up than
clinical ethics decisions.18 They sometimes appear to be
made in the front office, apparently without satisfactory
input from care-providers, patients, or other stakeholders
and without the availability of extensive literature or assis­
tance from a committee or consultant skilled in ethical
analysis and critique applied at the organizational level.
The development of the discipline of “organizational
ethics” is just beginning and is overdue in the judgment of
JACHO19 and other authorities.20 The obligation to be ethical
at every level of healthcare decision making will become
increasingly obvious and pressing, with continuing changes
in the ways health care is delivered. Increasingly institu­
tional leaders are expected to be accountable for their poli­
cies, practices, and decisions and to convey their expectations,
actions, and results in transparent ways.
Conclusion
Illness, trauma from being burned, and hospitalization can
impact a person’s sense of wholeness, integrity, autonomy,
and sense of identity. In cases involving severe burns,
patients are often dependent on others for the most intimate
functions of daily life and must rely on the good will, skills,
and ethical conduct of others. While it is clear that optimal
burn care is infused with technological innovation, clinical
sophistication, and the application of evidence-based
knowledge, it is also a profoundly moral activity. It requires
deliberate sensitivity to the values and needs of others, pro­
found regard for the dignity of each individual, and courage
to enter into the world of a vulnerable human being who is
in need of help. Providing total care to the burned patient
requires an educated heart, an empathic mind, and a
humanistic team.
Complete references available online at

Further Reading
Blakeney P, Herndon D, Desai M, et al. Long-term psychological adjust­
ment following burn injury. J Burn Care Rehabil. 1988;9(6):661-665.
Council on Ethical and Judicial Affairs, American Medical Association.
Medical futility in end of life care: Report of the council on ethical and
judicial affairs. JAMA. 1999;281(10):937-941.
Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New
York: Oxford University Press; 1986:235-381.
Spies M, Herndon D, Rosenblatt J, et al. Prediction of mortality from cata­
strophic burns in children. Lancet. 2003;361(9362):989-994.
Zawacki BE, Imbus S. Enhancing trust and subjective individual dialogue
in the burn center. In: Orlowski JP, ed. Ethics in Critical Care Medicine.
Hagerstown MD: University Publishing Group; 1999:489-512.
a court-appointed conservator might be required. In all
such cases (1) the search for a surrogate should be diligent,
(2) all relevant medical information must be obtained and
reviewed, (3) real or apparent conflicts of interest must be
disclosed, (4) the opinions of the healthcare team and of
one or more physicians in addition to the responsible attend­
ing should be reviewed, (5) the burden versus benefit ratio
must be weighed from the patient’s point of view, and (6)
steps should be taken to ensure the benefit of continued life
to a disabled patient is not devalued or underestimated.17
Some institutions also require that consideration of eco­
nomic impact on healthcare providers and the healthcare
institution be excluded from consideration in such cases.
Eventually a surrogate decision-maker is identified, and,
hopefully, this is a person who has previously known the
patient and his or her values prior to the accident, who has
possibly had discussions about extreme end-of-life issues
and can speak on the patient’s behalf. The surrogate
decision-maker must not make the decision based on what
he or she would want for the patient. However the surrogate
decision-maker must know what that patient would prefer
and act as an advocate in this situation since the patient is
not able to participate in the decision. They should be
expressing the patient’s views, not projecting their own
views onto the patient.
How Should Organizational Ethics
Problems Be Managed?
Currently healthcare decision making affecting burn care
occurs at three levels: in the clinic, in the organization, and
in society.8 The disciplines designed to improve ethical deci­
sion making at the first and third levels are called clinical
and societal ethics, respectively. They discern facts and values
for guiding clinical or societal decisions that affect patient
care and have received wide attention in both the media and
scholarly journals for years. Recently attention has been
called to the need for discernment of facts and values for
guiding managerial decisions that affect patient care.8,18 For
example, at times, problems present as difficulties in clinical
decision making but have their root causes in areas that
require decision making at the managerial level. With dwin­
dling numbers of nurses entering training, increasingly
fewer nurses will be available to provide intensive care, and
managerial decisions will be required to produce or recruit
more nurses and to judge just when it is no longer safe to
admit new patients to beds without adequate staffing. Also,
when rehabilitation services in a given geographical area
have not kept up with the increasing numbers of patients
with large burns who survive but require longer and more
expert rehabilitation, managerial decisions about the distri­
bution of scarce resources will have to be made if adequate
rehabilitation care is to be available. Such decisions are

659.e1
61  •  The Ethical Dimension of Burn Care
References
1. Fulginiti VA. The right issue at the right time. In: Holmes DE, Oster­
weis M, eds. Catalysts in Interdisciplinary Education. Washington DC:
Association of Academic Health Centers; 1999:7-24.
2. Carter MA. A synthetic approach to bioethical inquiry. Theor Med
Bioeth. 2000;21(3):217-234.
3. Ahronheim JC, Moreno J, et al. Ethics in Clinical Practice. Boston, MA:
Little, Brown & Company; 1994.
4. Gillon R. Philosophical Medical Ethics. Chichester: John Wiley & Sons;
1985:2.
5. Boisaubin E, Carter MA. Optimizing ethics services and educa­
tion in a teaching hospital: rounds vs consultation. J Clin Ethics.
1999;10(4):294-299.
6. Maguire DC. The Moral Choice. Garden City, NY: Doubleday; 1978:113.
7. Pellegrino E, Thomasma DC. A Philosophical Basis of Medical Practice.
New York: Oxford University Press; 1981:119-152.
8. Potter RL. On our way to integrated bioethics: clinical/organizational/
communal. J Clin Ethics. 1999;10:171-177.
9. Zawacki BE. Ethically valid decision making. In: Herndon DN, ed. Total
Burn Care. 1st ed. London: Saunders; 1996:575-582.
10. Spies M, Herndon D, Rosenblatt J, et al. Prediction of mortality from
catastrophic burns in children. Lancet. 2003;361(9362):989-994.
11. Zawacki BE, Imbus S. Enhancing trust and subjective individual dia­
logue in the burn center. In: Orlowski JP, ed. Ethics in Critical Care Med­
icine. Hagerstown MD: University Publishing Group; 1999:489-512.
12. Faden RR, Beauchamp TL. A History and Theory of Informed Consent.
New York: Oxford University Press; 1986:235-381.
13. Carter MA, Robinson S. A narrative approach to the clinical reason­
ing process in pediatric intensive care: the story of Matthew. J Med
Humanit. 2001;22(3):173-194.
14. May WW. Ethics in the Accounting Curriculum: Cases and Readings.
Sarasota, FL: American Accounting Association; 1990.
15. Foley K. A 44-year-old woman with severe pain at end-of-life. JAMA.
1999;281:1937-1945.
16. Alquist. Health care decisions. (California) Assembly Bill No. 891, Ch. 4,
sections 4730-4736; operative July 1, 2000.
17. Ad hoc drafting committee. Guidelines for foregoing life-sustaining
treatment for adult patients at the LAC+USC Medical Center. LAC+USC
Medical Center, Los Angeles CA, May 5, 1993.
18. Hirsch NJ. All in the family – siblings but not twins: the relation­
ship of clinical and organizational ethics analysis. J Clin Ethics.
1999;10:210-215.
19. Joint Commission on Accreditation of Healthcare Organizations.
Ethical Issues and Patient Rights. Oakbrook Terrace, IL: Joint Commis­
sion on Accreditation of Healthcare Organizations; 1998:67-90.
20. Society for Health and Human Values/Society for Bioethics Consulta­
tion Task Force on Standards for Bioethics Consultation. Core Com­
petencies for Health Care Ethics Consultation. Glenview, IL: American
Society for Bioethics and Humanities; 1998:24-26.

660
Intentional Burn Injuries
LISA L. TROPEZ-ARCENEAUX and KWABENA O. SARPONG
62 
specific questions regarding reporting suspicious injuries.6
Although it is overwhelming to imagine that so much abuse
occurs, statistics show that it does occur, not only with chil­
dren but also with adults and our elderly population.
Intentional injuries can occur in the form of neglect,
physical abuse, sexual abuse, and emotional abuse. All of
these injuries can occur independently, but they often occur
simultaneously.7 Neglect is the most common form of inten­
tional injury. Of the average 5.5 million referrals made to
CPS each year, 64.5% of these children are neglected.8
Physical abuse occurs in 25% of intentional injury cases.8
More than 15% of victims of abuse suffer more than one
type of abuse, and more than one-third of child fatalities
are attributed to neglect (Fig. 62.1).9 Burn injury is frequent
in both neglect and physical abuse of children. Severe burns
in children are between 10% and 12% of all intentional
injuries.10
Since the last edition of this book, intentional injuries to
adults have increased. It is frequently debated within the
literature as to whether the increase is a valid increase or if
there is an increase in reporting. Violence specifically
against women and young girls has now become a univer­
sal phenomenon. The World Health Organization reported
that, of the women who were partnered at some point
during their lifetime, 15–71% reported experiencing phys­
ical or sexual violence by their partner.11 Within this realm
of violence against women and young girls, acid violence is
the worst form of violence and violation of human rights.12
Although steps are being taken to control the widespread
free sale of acids to the public,13 this act of violence is still
on the rise and warrants discussion in the burn care litera­
ture and sensitivity to this overwhelming problem by all
burn care professionals. Another vulnerable population of
intentional burn injuries is the elderly. In the past 10 years,
burns in the elderly have increased secondary to an increase
in size of the aging population.
In this chapter, we have integrated our experience with
current literature to classify risk factors in the total popula­
tion and to propose validated therapeutic interventions to
treat the burn wounds and the complex social and psycho­
logical familial concerns that both create injury and com­
plicate the recovery and rehabilitation of the patient. It is
essential that burn team clinicians understand their role
and responsibility in assisting not only burn patients but
the perpetrators as well because history and statistics have
shown us that the outcome can be fatal if intervention and
prevention methods are not implemented with sensitivity to
maintain positive relationships with burn patients as well
as with perpetrators.
The authors are well versed in clinical experience and
research experience of child abuse and pediatric burn inju­
ries; however our experience of intentional burn injuries
within the adult population is limited. The literature and our
PowerPoint Presentation Online
Introduction
Forensic medicine has made tremendous advancements in
developing scientific measures to identify child maltreat­
ment and intentional injuries. Despite these advancements,
deliberate injury by burning is often unrecognized. Accord­
ing to the U.S. Department of Health and Human Services
Administration for Children and Families,1a child abuse and
neglect are defined as “any recent act or failure to act on
the part of a parent or caretaker, which results in death,
serious physical or emotional harm, sexual abuse or exploi­
tation, or an act or failure to act which presents an immi­
nent risk of serious harm.” In January 2016, The Children’s
Bureau published the National Child Maltreatment Data
from 2014, which reported that 1580 children died as a
result of abuse or neglect.1b Within the United States alone,
1.5 million children are abused or neglected each year, with
4–39% of these occurrences being reported as intentional
burn injuries and less than half ever being substantiated.2a
In 2015, children aged 0–4 who sustained small burn inju­
ries (total body surface area [TBSA] 0–29%) had a mortality
rate of 0.25%, medium burn injuries (30–59.9% TBSA)
had a mortality rate of 9.6%, and large burn injuries (≥60%
TBSA) had a mortality rate of 29.06%.2b These mortality
rates are significantly higher than in children over the age
of 4, indicating that children younger than 4 years of age
are at greatest risk.
It is imperative that all clinicians be aware of the impor­
tance of recognizing signs and symptoms of intentional
injury presentations because the opportunity for interven­
tion is critical when taking into account that 50%3 of chil­
dren experience recurrent abuse and 30% are ultimately
fatally injured.4 Reporting suspicious injuries to child pro­
tective services (CPS) is mandated by law for all clinicians
working with children.5 Some treating facilities identify
specific treatment team members (i.e., psychologist or social
workers) to be responsible for all reporting. In these situa­
tions, it may be necessary to follow the protocol of the hos­
pital or treating facility first; however it is important to note
that any physician, medical professional, or mental health
professional who encounters a suspicious injury must
ensure that the injury is reported to the appropriate author­
ities. At other times, the concern of reporting is more a
result of ambiguity or vagueness in the information, which
can cause hesitation to report the suspicious injury. In these
incidents of doubt, the most salient point to remember is
that the clinician is responsible for reporting suspicious
injury, not proving or validating abuse. It is always better to
report the suspicion than to ignore it. Most state agencies
also have hotlines that are available to call 24 hours to ask

62  •  Intentional Burn Injuries
661
extensive knowledge of information regarding intentional
injuries against children are reflected in this chapter. We
have included the most recent literature on adult injuries,
but it is not exhaustive. It is important to note that the pedi­
atric population is not the only target for intentional injuries.
Prevalence Rates of Intentional
Burn Injuries
Despite the improvement and use of smoke detectors, invest­
ment in sprinkler systems, and improvement in building
codes in developing countries, burns continue to cause sig­
nificant intentional and unintentional injuries. Smoking
remains the leading cause of death by fire. Cooking is the
number one cause of residential fires. Annually fire-related
injuries claim more than 300,000 deaths and 10 million
disability-adjusted life years worldwide.13 Middle and
low-income countries exceed 95% of fire-related burns.13–15
Approximately half of these countries are in southern parts
of Asia.15 In the United States, burn injuries result in
approximately 1 million emergency department visits and
50,000 hospital admissions, with a 5% mortality rate.13
Fire and burns represent 1% of the incidence of injuries.
Fatal home injury burns and fire deaths rank fifth and third,
respectively, in the United States.16 The incidences of the
causes of burns are flame/fire 46%, scalds 32%, hot objects
8%, chemicals 3%, and other forms 6%. Fires/burns occur
frequently in the home (43%), on the street/highway (17%),
in occupational settings (8%), and in other settings (32%).17
Burn injuries inflicted in Pakistan occur mostly to adult
women: approximately one-third are secondary to stove
burns and 13% are acid burns. Husbands inflict more than
52% of these injuries and in-laws one-quarter of the inju­
ries.18 Victims who are at highest risk of fire-related injuries
and deaths are children aged 4 and younger, adults older
than 65 years, African-Americans and Native Americans,
and the poor or those living in rural areas.16 A literature
review of hospital-based studies of the prevalence of burn
injuries in China revealed similar results with the most vul­
nerable being children younger than 3 years, males more
than females, those living in a rural setting, and the inci­
dence occurring between the hours of 17:00 and 20:00.19
PREVALENCE OF CHILDHOOD BURNS
Over the past 50 years, child abuse has been documented,
especially in the United States. Child abuse characteristics
are composed of physical abuse, neglect, sexual abuse, psy­
chological abuse, and other, which include Munchausen by
proxy and abandonment. Child abuse may present with
multiple characteristics. Major forms of injuries to children
include falls, poisonings, car accidents, foreign body, and
fires/burns.20 Ten percent of child abuse is burns, and 20%
of burns are child abuse.21 The child abuse death rate in the
United States is approximately 1000 children annually,18
with burns and scalds as the most frequent cause of death.10
In China, the mortality rate from abuse ranges from 0.49%
to 3.14%. In Hong Kong, it is 2.3%; in Singapore 4.61%,
and in Iran 6.4%.19 The lowest rates are in the United
Kingdom and the highest rates are in the United States,
where the majority of the studies have been completed.10 In
many cases of burn injuries, it may be difficult to conclude
if the burn injury is an incidence of neglect, intentional, or
truly an accidental event.4 More recent studies10,21–23 have
begun to analyze hospital cases of burns to delineate if they
are intentional or nonintentional. The characteristics of
types of burns include scalding (70%), flame burns (50%),
or electrical (3–4%).19 Bathtub submersions peak at 6–11
months, then again at 12–14 months and remain high
until 33–35 months of age.20 Most studies calculate the
mean ages of children with intentional burns at 2–4 years
of age.18 Boys are 2–3 times more afflicted than girls, with
the youngest of multiple siblings suffering most often.21
There is no ethnic predilection. Of children who are victims
of physical abuse 10–12% suffer severe burns.10 In 2007,
Hicks and Stolfi24 concluded that children with burn inju­
ries are at risk for occult fractures at a significant rate.
Therefore a skeletal survey should be routine in burn
patients presenting to the emergency department, as
Percent
0
100
80
40
20
90
60
70
30
10
50
Percentages by Maltreatment Type
Percentages by Age
Sexual abuse
Unknown
Psychological abuse
Medical neglect
Physical abuse
Neglect
72.3
1 year of age
1–3 years
4–7 years
8–11 years
12–15 years
16 and 17 years
Unborn, unknown,
age 18–21
43.9
49%
32%
10%
4%
3%
2%
0%
7.3
1.1
1.2
21.0
B
A
Fig. 62.1  Abuse and neglect fatality statistics. (A) Child abuse and
neglect fatalities by age, 2006. (B) Forms of intentional injury that
resulted in fatality. (From Child Welfare Information Gateway. June 2008
numbers and trends, child abuse and neglect fatalities: statistics and inter­
ventions. Available at:
cfm.)

62  •  Intentional Burn Injuries
662
parents were responsible for 69.9% of child abuse or neglect
fatalities.31 More than one-quarter (27.1%) of these fatali­
ties were perpetrated by the mother acting alone.31 Child
fatalities with unknown perpetrators accounted for 16.4%
of the total.31 According to the National Child Abuse and
Neglect data system, in 2008, 56.2% of perpetrators were
women, 42.6 % were men, and 1.1% were unknown.32 Of
the reported women perpetrators 45.3% were younger than
30 years of age compared to 35.2% of men younger than
30.32 These percentages have remained consistent for
several years in a row. Some 61% of all perpetrators were
neglected as children.1,31,32 Approximately 13.4% of all per­
petrators were associated with multiple types of abuse.1,31–33
Ten percent of perpetrators experienced physical abuse as
children, and 6.8% were sexually abused as children.33 Of
the children who are abused, 80% were abused by their
parents.31–33 Other relatives accounted for an additional
6.5%.31–33 Unmarried partners of parents were 4.4% of per­
petrators. Of those parents who were perpetrators, more
than 90% were biological parents, 4% were step-parents,
and 0.7% were adopted parents.32,33
Other characteristics of perpetrators commonly include
being adolescent parents, being a single parent, often main­
taining inconsistent expectations for a child’s development,
experiencing a lack of external supports, stressors such as
substance abuse, poor education (no high school diploma),
unemployment, poor housing, mental illness, and being
reliant on children for emotional support (Box 62.2).34 Most
fatalities from physical abuse are caused by fathers or other
male caregivers. Mothers are most often held responsible for
deaths resulting from child neglect.35 In some situations,
there are two “perpetrators,” the actor and the overtly
passive observer who does not stop the abuse.36 Justice and
Justice,37 in their work with families who mistreat children,
identified several erroneous belief systems that are com­
monly held by perpetrators; these are listed in Box 62.3.
Since, as most authorities believe, violence is a multigenera­
tional intrafamily pattern, then it is likely that the belief
systems attributed to child perpetrators can be extrapolated
to perpetrators of adult abuse as well.36
Often in homes where abuse occurs, there is little to no
emotional support for the perpetrators. They are often
dealing with tremendous life stressors and unfortunately
recommended by the American Academy of Pediatrics.
Males are convicted at a greater rate than females, despite
an equal rate as perpetrators.25
PREVALENCE IN ELDERLY
Over the past 10 years, prevalence data of burns in elderly
have increased secondary to recent emerging studies in this
area. As in pediatric burns, geriatric burns are higher in
developed countries at a rate of 20%; in the developing
world, the rate is 5%.15 Results of the review of data from
the U.S. National Burn Repository demonstrated an increase
in the rate of elderly abuse from 1991 to 2005.15,26 Of those
burned, 14% are older than 55 years of age (with 6.2%
between 55–64 years, 3.3% between 65–74 years, and
4.4% >75 years of age). There is a male predominance of
burns of 1.4 : 1. However this decreases with age and is
thought to be secondary to the decrease in life expectancy
of males to females. The most common injuries are flame
burns, accounting for 37%, and scalds at 22%. The TBSA
was 9.6%, and the majority of injuries were residential.15,26
In the United Kingdom, residential settings are the leading
site for burn injuries to the elderly, at a rate of 18.6%. The
occurrences had a 32% higher mortality rate and 33%
more TBSA affected than like-sized burns in aged patients
from other causes than abuse. Over a 4-year period, Borto­
lani and Barisoni27 investigated 53 patients aged 60 and
older who were admitted to a local Italian hospital. It was
noted that 85% of these burns occurred in the home and
11% in nursing homes. Flame burns were the most common
at 55%. The incidences were attributed to preexisting dis­
eases in 85% of patients. These diseases included cardiovas­
cular accidents, neurological problems, and diabetic
comas.27 In addition to illness, lack of adequate supervision
is another major etiology for burns in this age group.18 In
the United States, residential care settings accounted for
one-fifth of geriatric burns.28
With an increase in the aging population, there is concern
about an increase in domestic elderly abuse and, propor­
tionately, an increase in burn victims.29,30 In the United
States, elderly physical abuse was underreported, with a
rate of 2.8% of total cases of abuse in 1988. However, in
1996, residential institutions estimated only one-fourth to
one-fifth of abuse was reported. Another study, from
Canada, estimated the prevalence of abuse at 1%.28 The
abuse is usually kept secret owing to guilt, shame, and fear
of reprisal, especially if the perpetrator is the victim’s adult
child (Box 62.1).
The literature reports controversial results on the most
likely perpetrator: spouse versus adult children. As in child
abuse, disabled adults and those who suffer from dementia
are at higher risk for abuse. Drug and alcohol abuse in care­
takers also increases the rate of abuse. Other characteristics
in caregivers are mental disorder, financial difficulties, and
deviant behavior.28
Distinctive Characteristics of
Perpetrators and Families
Perpetrators are frequently individuals responsible for the
care and supervision of their victims. In 2007, one or both
Box 62.1  Premorbid Indicators of Intentional
Burn Injuries of Adults
■ Physical dependence
■ Psychological dependence
■ Accessibility as a target for abuse, as in institutional living or
living with a caretaker
■ Caretaker(s) with a history of substance abuse and/or other
psychopathology
■ Social isolation
■ An injury that is not consistent with the story described
■ Conflicting reports of the injury
■ Scalds with clear-cut immersion lines and no splash marks
■ Scalds that involve the anterior or posterior half of an
extremity and/or the buttocks and genitals or a flexion pattern
■ Other physical signs of abuse/neglect
■ History of related incidents

62  •  Intentional Burn Injuries
663
Box 62.2  Risk Factors for Abuse/Neglect by Burning
Forced-Immersion Demarcation
■ Symmetrical, mirror-image burn of extremities
■ Glove-like (burned in web spaces)
■ Circumferential
■ Minimal splash marks
■ Uniform depth
■ Full-thickness
■ Clear line of demarcation, crisp margin
■ Doughnut-shaped scars on buttocks/perineum (spared area
forcibly compressed against container thus decreasing contact
with hot liquid if container is not a heated element)
■ Flexion burns, “zebra” demarcation to popliteal fossa, anterior
hip area, or lower abdominal wall
■ Injuries of restraint (e.g., bruises mimicking fingers and hands
on upper extremities)16
Injury Demarcation, Other
■ Incongruent with history of event
■ Pattern of household appliance; note whether the burn
presents as an even pattern versus a brushed, imperfect mark
■ Scald
■ Location of injury: palms, soles, buttocks, perineum, genitalia,
posterior upper body
■ Cigarette burn, if more than one on normally clothed body
parts and if impetigo is ruled out
History of Injury
■ Evasive, implausible explanation
■ Incompatible with child’s developmental age
■ Changes in story; discovered to be burned
■ Rule out dermatologic epidermolysis bullosa (EB), dermatitis
herpetiformis, chemical burn due to analgesic cream,
phytophotodermatitis,17 and birth marks, including Mongolian
spots18
■ Undersupervised: inadequate monitoring, impaired person
supervising, inordinately young babysitter (<12 years of age)
■ Burn is older than history given
■ Water outlet temperature greater than 120°F
■ Mechanism of burn is incompatible with injury (e.g.,
exposure time, history of event, and degree of burn are
inconsistent)
■ Patient’s per-event behavior displeasing to caregiver (e.g.,
inconsolable, failed to meet caregiver’s expectations)
■ Toileting events related to history of injury19
■ Burn attributed to:
■ Child or patient, as per caregiver
■ Caregiver who is not present at the healthcare facility
■ Caregiver, as per patient
■ Delay in seeking medical treatment; note estimated time of
delay
Developmental Associations
■ Preverbal, nonverbal person
■ Vulnerable person (e.g., special needs, failure to thrive, elderly)
■ Caregiver expectations are inconsistent with patient’s
development; caregiver overestimates child’s developmental
skills and safety knowledge; caregiver unaware of patient’s
developmental capacity
■ Patient has symptoms of mental disorder (e.g., ruminating,
aggressive)
■ Patient displays disturbing behaviors related to attachment
(e.g., excessive crying, clinging, apathy/lethargy, excessively
withdrawn, listless, unemotional, submissive, polite, fearful,
vacant stare)
■ Hypersexualized language or behavior as compared to
same-age peers
Caregiver–Patient Relations
■ History of interrupted caregiver–child bonding
■ Adolescent caregiver(s) (e.g., child–child versus adult–child
interactions)
■ Strained interactions; inappropriate expectations of the
patient by the caregiver
■ Role reversal (rely on patient for support)
■ Inappropriate or lack of caregiver concern:
■ Detached
■ Lack of sympathy
■ Lack of physical contact (e.g., fails to hold or pick up child)
■ Inebriated during visits
■ Infrequent visits
Other Physical Signs of Abuse or Neglect
■ Unrelated injuries:
■ Fractures, dislocations; rupture to spleen, liver, or pancreas;
point tenderness; impaired range of motion or function
■ Signs of poisoning
■ Ocular insult (edema, scleral hemorrhage, hyphema, bruise,
blue sclera)
■ Swelling, bogginess, depressions, cephalohematomas
palpable on head or increased intracranial pressure at
fontanelle
■ Blood, infection, or foreign body in ear
■ Edema, bleeding, septal deviation of nose; foreign bodies in
nose; cerebrospinal fluid rhinorrhea from nose
■ Unrelated injuries involving the skin: hematomas, soft tissue
swelling, lacerations, fingernail markings, scars, bruises (check
behind ear), welts, rope burns, strangulation marks, bites,
alopecia; note color, size, shape, and location of each (scalp
most visible while shampooing)
■ Abdominal tenderness, guarding, rebound tenderness, or
bruises
■ Cardiac instability, tachycardia, murmurs, flow murmurs
secondary to anemia, or palpable rib fractures
■ Dehydration or malnutrition; note weight, height, and head
circumference
■ Previous burns
■ Unkempt (e.g., severe diaper rash, dirt under nails or in axillae,
odoriferous, dirt on plantar surfaces of feet in cold weather)
■ Inadequate or no immunization record
■ Inadequate dental care (e.g., caries); trauma to lips, tongue,
gums, frenula, palate, pharynx, or teeth
■ Inadequate medical care
■ Inappropriate dress
■ Assess prior to invasive medical procedures
■ Genital, urethral, vaginal, or anal bruising, bleeding
■ Swollen, red vulva or perineum
■ Foreign body in genital area
■ Positive cultures for sexually transmitted diseases; if herpes
develops, note whether lesions are on unburned body surface
area, on genitals of type II
■ Pregnant minor
■ Recurrent urinary tract infections, streptococcal pharyngitis,
abdominal pain
Family
■ Caregiver abused or emotionally deprived during childhood
■ Limited disciplinary practices (e.g., only uses physical
punishment)
Continued

62  •  Intentional Burn Injuries
664
watching television for long periods until some external
force acts as a stimulus to motivate the adult into action.36
Indicators of Intentional Injuries
In approaching pediatric burn victims, indicators of possi­
ble inflicted burn injuries should be considered (Table 62.1).
Patterns of scald burns are highly suggestive of inflicted
injuries, and healthcare providers have a general agree­
ment of these indicators (Box 62.2):22
a. In scald burns, it is implied that the absence of splash
is suggestive of the victim being held down, although
some children who jump into a hot tub of water may
panic or freeze and not have splash burns. These
scald burns have predominantly symmetric, clear
upper margins. The burns usually involve lower
extremities and the buttocks, without head and neck
injuries (Fig. 62.2),10 although Daria et al. 200423
describe six cases of submersion burns that involve
the head and neck.
b. If there is uniformity of burn, consider that the
patient was held still during the incident.
c. Symmetric bilateral burns (glove and stocking distri­
bution) are highly suggestive of forcible immersion
(Fig. 62.3B).
d. In submersion burns, there may be skin sparing sec­
ondary to joint flexion or the victim forcibly held
against the receptacle. This gives an appearance of a
“doughnut” or “halo sign.”
e. In an Australian study authored by Heaton in 1989,39
bilateral burns of extremities are between 2.4 and
4.8 times more common in inflicted burns.22
f. Accidental cigarette burns are superficial and ill
defined. Yet inflicted wounds are superficial circular
or ovoid macular wounds with distinct depigmented
lesions and hyperpigmented edges.
g. Heated metal objects cause deeper burns (Fig. 62.3A).
h. Electric shock burns are revealed based on the size of
the device and entrance and exit wounds. Areas will
vary from full-thickness necrotic areas to superficial
wounds that are erythematous. One cannot evaluate
these lesions in isolation (Box 62.2). Review of
medical records is necessary to assure the presence
of a pattern of repeated abuse. Also be aware that
perpetrators may frequent a variety of hospitals in
the area to decrease suspicion by medical providers.
Corroboration of history to physical exam is essential
and may suggest indicators of intentional burns.
resort to immature coping styles to deal with frustrations.
Perpetrators resort to abuse as a result of complex behav­
iors derived from a dysfunctional family history, lack of edu­
cation, desperation, and, at times, substance abuse. Children
and elderly are usually dependent on the perpetrator; ironi­
cally, they are a source of stress and therefore become the
victim of intentional injuries. Corporal punishment is “the
use of physical force with the intention of causing a child
to experience pain but not injury for the purpose of correc­
tion or control.”38 Some perpetrators will use this explana­
tion as a form of justification for intentional injuries.36 In
young children learning toilet training, a hot bath to clean
after a toileting accident is often a form of punishment.
Usually the perpetrator’s intent is to clean the child well, not
to burn; however serious burns often occur. They often fail
to seek appropriate and timely medical treatment for an
injured child, not only because they fear punishment but
also because of their learned helplessness and passivity.
They discount the seriousness of the injury, as well as their
ability to take care of the injury. “I didn’t think it was that
bad” is an explanation often given for delay in seeking treat­
ment. By diminishing the significance, they relieve them­
selves of responsibility to act. When the perpetrator does
take the child for help, the perpetrator commonly seeks first
a relative or neighbor rather than a physician because per­
petrators do not believe in their own ability to decide
whether to seek medical treatment. Perpetrators are
observed to interact inappropriately with their children
because they are preoccupied with having their own needs
met. A child who is hurt and demanding is unlikely to
reward the perpetrator with feelings of comfort that the
perpetrator seeks, and so the perpetrator withdraws from
the child. If the child is quiet and compliant, the perpetrator
may be observed to ignore the child and sit passively,
Box 62.3  Erroneous Beliefs of Abusers
Erroneous belief systems commonly contributing to the family
system in which abuse occurs:37
■ If my child cries, misbehaves, or does not do what I want, he
or she does not love me and I am a bad parent
■ My child should know what I want and want to do it
■ My child should take care of me like I took care of my
parents
■ My spouse/lover should know what I want and meet all of
my needs
■ If I have to ask, it does not count
■ You cannot trust anyone
Box 62.2  Risk Factors for Abuse/Neglect by Burning—cont’d
■ Lack of external supports; isolation
■ Mental illness, substance abuse, criminal history
■ Lack of financial self-sufficiency
■ Poor employment history
■ Dependent caregiver; unable to cope with daily responsibilities;
unorganized
■ Violent couples; impulsive, easily frustrated
■ Previous Department of Protective and Regulatory Services
involvement20
■ Prior accidents to dependents
■ Acute family stressors
■ No primary caregiver

62  •  Intentional Burn Injuries
665
D
C
B
A
Fig. 62.2  Newborns who were burned in hospitals by improperly trained hospital personnel.
Table 62.1  Triage Tool for Diagnosis of Intentional Scalds
Evaluate for Intentional Scald
Intentional Scald Should Be Considered
Intentional Scald Unlikely
Mechanism
Immersion
Spill injury; flowing water
injury
Agent
Hot tap water
Non-tap water; other liquids
(beverage)
Pattern
Clear upper limits; uniform depth scald
symmetry (extremities)
Uniform scald depth; skin fold sparing;
central sparing buttocks (doughnut ring
pattern)
Irregular margin; irregular
depth; lacks stocking
distribution
Distribution
Isolated buttock/perineum, ± lower
extremities; isolated lower extremities;
rarely the face
Glove and stocking; 1 limb glove/stocking
Asymmetric involvement of
lower limbs; head, neck,
and trunk or face and
upper body
Clinical features
Associated unrelated injury (recent or old
fractures); history incompatible with
examination findings
Previous burn injury; neglect/faltering
growth; history inconsistent with
assessed development
Historical/social
features
Passive, introverted, fearful child;
previous abuse; domestic violence;
numerous prior accidental injuries;
sibling blamed for injury
Trigger, such as soiling/enuresis/
misbehavior; differing historical accounts;
lack of parental concern; unrelated adult
presenting child; child known to social
services
Adapted from Maquire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns
2008;34(8):1072–1081.

62  •  Intentional Burn Injuries
666
of suicides.21,59,60 Some studies have found that there are no
gender differences in the rates of self-immolation,61,62 but
some have determined that it is most common in females,63–65
specifically Asian and Latin females,47,55,66,67 whereas others
have found that it is more common in males.49,68 Other risk
factors for self-immolation in Western culture include pre­
vious psychiatric treatment, diagnosis of a psychotic disor­
der,61,63,69,70 unemployment,61,69,68 or severe relationship
difficulties.61
The most common mechanism of self-immolation is
flame as a result of fire accelerant such as kerosene, gaso­
line, or rubbing alcohol.13,70 In a 2004 Finnish study, 43%
of all patients used flame, but 93% of women with self-
inflicted burn injuries used flame.70 The reported mean
TBSA among self-inflicted burn injuries is higher (median
42.2%; range, 22–79%) than other burn patients (median
36%; range, 11.8–77%). These burn injuries are usually
deeper full-thickness burns with increased risk of inha­
lation injury, poorer long-term prognosis, and a higher
rate of mortality.21,49,58,59,63,64,66 Self-immolations are
1.5–1.7 times more frequent than reflected in current lit­
erature. This is an area where more studies are needed to
identify more accurate prevalence rates and prevention
interventions.
Clinical Evaluation of Suspicious
Injury With Pediatric Patient
and Family
The history of the burned child is of particular importance
in assessing whether the burn is likely to be intentional or
accidental. Evaluating for intentional burn injuries requires
a multidisciplinary team effort (Box 62.4).
Self-Inflicted Burn Injuries
One of the most violent means of suicide is self-immolation
by burning. Self-immolation can also act as part of a delib­
erate self-harm syndrome consisting of continual, sudden
urges toward self-harm.21 There has been an increase in the
literature on self-immolation, but it is unclear if this empha­
sis is a result of increased rates of occurrence or increased
reporting.13,41 Historically there is a debate as to whether
self-immolations are more acceptable if they are religiously
or politically motivated.21,42–46 Characteristics of females
who self-immolate include substance abuse, a lack of social
support, younger age, and diagnosed eating disorders.21
Males who self-immolate are also younger, with severe
mental illness,21 or pathological family dynamics, or possi­
bly an adherence to fundamentalist religious convictions.13
Regardless of sex, self-inflicted burn patients usually have
some previous psychiatric problems, often depression or
borderline personality disorder; previous failed suicide
attempts with a poor response by others to suicidal ideation;
and recent life stressors with feelings of helplessness.21 One
of the highest rates of this behavior is in Iran among young
females in whom marital conflict is a significant risk factor.
Others risk factors include low literacy, low socioeconomic
status, limited access to mental health services, and post­
traumatic stress disorder.13
Although self-inflicted burn injuries are less frequent in
Western culture, studies report a rate of 0.5–2% in adoles­
cents and up to 25% in adults.21,47,48,46,49–54 In Africa, south
Asia, and the Middle East self-inflicted burn injury rates
account for up to 28% of all burn injuries.55 There is an
estimated range of self-immolation accounting for 9–32%
of all suicides in India, Zimbabwe, and Iran,21,56–58 with
rates for Iranian and Brazilian women being as high as 46%
B
A
Fig. 62.3  (A) Abuse: contact burn in which the markings of an iron are clearly visible. (B) Abuse: classic stocking pattern resulting from feet being
immersed in very hot water. The initial history given by the mother of the 21-month-old infant was that an older sibling had turned on the hot water,
and the patient herself dipped her feet into the tub.

62  •  Intentional Burn Injuries
667
denote concomitant new or old fractures.72,73 The clini­
cian must also be mindful at this time to assess for signs
of abusive head trauma such as intracranial and retinal
hemorrhage.71
A child who presents with suspected unintentional and
intentional burn injury should be evaluated by a child
abuse pediatrician or a pediatrician with experience in the
evaluation of the causes and mechanism of burn injury.
However such an evaluation should be done when the child
is medically stable.74
The evaluation of burn injury should begin with a thor­
ough history, which should be taken directly from a child
who is verbal or developmentally matured enough to give
the history and also from parents and caregivers who were
present at and around the time of the injury. The history of
the injury and the sequence of events should be as detailed
and concise as possible.75
The developmental ability of the child, as well as home
and social environmental factors, should also be taken into
account.
The patient’s past and current medical histories are also
important factors to be considered. Additional specific ques­
tions should be asked depending on the type of burn injury.
Ask about the temperature of the hot water setting at home
in cases of scald burns and the duration of contact in cases
of contact and scald burns.
The next step in the medical evaluation will be a complete
physical examination. The physical exam should include a
good assessment of the general presentation of the child,
looking for signs of adequate nourishment, emotional
status and general well-being, and hygiene.
If possible, a developmental assessment should be done,
although in severe burns it is quite difficult to assess devel­
opment, and the medical history should be relied on or the
developmental assessment done later. All organ systems
should be evaluated to look for bruises, fractures, head
injury, and other signs of trauma.
The burn injury should then be specifically evaluated,
looking at patterns, line of demarcation, distribution,
planes of the body involved, size, and symmetry. Every
injury should be well-documented, and photo documenta­
tion should be done ideally at the time the child is admitted
or as soon as the child is stable.
After the child has been assessed other testing may be
important. The American Academy of Pediatrics recom­
mends that children younger than 2 years who present with
concerns for physical abuse should have a skeletal survey.
For children between 2 and 5 years of age, a skeletal survey
may be done depending on the history and examination;
however a skeletal survey is not indicated after 5 years of
age.76,79
Skeletal surveys are important to diagnose subtle frac­
tures such as classical metaphyseal lesion fractures and rib
fractures that have a high specificity for abuse. Because
such fractures can be subtle and may not be obvious in the
first skeletal survey, a repeat skeletal survey needs to be
done 10–14 days later to look for callus formation.76,77
Recent research shows that the incidence of fractures in
children with inflicted burns is about 33% compared to
those with accidental burns,80 although some have reported
the incidence of fractures in nonaccidental burns to be as
high as 53% in children younger than 24 months.77
PHYSICIAN ASSESSMENT
The physician–patient relationship is paramount in assess­
ing patient injuries and providing an accurate assessment
of an incident to determine if suspicious injuries are inten­
tional or nonintentional. Obtaining a detailed history from
the patient and the caretaker is foremost in assessing the
creditability or plausibility of history to what is seen on
physical exam (Box 62.2). It is essential that providers
are familiar with child development in order to incorpo­
rate child development into the assessment process. Trust
issues may interfere in obtaining a precise history. The
assessment always requires an open mind for the possibil­
ity of intentional injury, which should be thoroughly inves­
tigated when clinical features are present in the history
and examination. Features of the physical exam consist
of identifying the pattern of burn injury, with the distri­
bution and associated features being the more important
aspects to distinguish. The reported method of injury must
be clearly associated with the observed pattern of injury,
burn depth, and appearance on physical examination (Box
62.2).71 Children who are burned are also in a high-risk
group of being subjected to other forms of abuse. Although
a few studies have indicated that pediatric burn patients
are at a lower risk for related fractures from abuse, approxi­
mately 18.6% of children in this subgroup had fractures
on their skeletal survey.72,73 Another study found that
pediatric burns have a 14% risk of fractures.24 This rate
may be underestimated since all patients did not receive
a skeletal survey. These fractures are occult and may not
have physical evidence of their existence. Further evidence
has also revealed that children with burns are less likely to
be evaluated for fractures, reflecting the erroneous belief
that they are a lower-risk group. All children 2 years and
under should receive a skeletal survey on initial exam to
Created by Patricia Blakeney PhD and Rhonda Robert PhD, 2007.
Box 62.4  Documentation for Reporting
In addition to the documentation of first-hand observations, the
following tasks should be delegated:
■ Examine the patient for other signs of maltreatment,
including a skull and long-bone radiological scan. Clearly
state that the radiology consultation is for assessment of
occult trauma
■ Photograph injuries and any possible evidence
■ If the patient has been referred from another hospital, access
information from the staff at that hospital to determine
whether they identified suspicious aspects of the injury and
whether the injury was reported to an investigating agency.
If so, ascertain the number assigned to the patient’s case by
the investigating agency. This number is needed for
subsequent calls related to the patient
■ Interview the patient
■ Interview the family members or caretakers individually and
together for thorough histories of the event, being sensitive
to differences in the story or changes across time
■ Obtain a thorough family history, the patient’s medical
history, and the developmental capacity of the patient
■ Gather other available collateral information (e.g., medical
records from other places of treatment)

62  •  Intentional Burn Injuries
668
2 years of age.75,84 The burn mechanism is normally an
immersion in hot water. These children present with a burn
of uniform depth, with well-demarcated borders and an
absence of the splash or splatter common with accidental
burns. Nonaccidental burns often show bilateral symme­
try and in most cases such burns also spare the flexors83
(Fig. 62.4).
CONTACT
Contact burns are the second most common form of abusive
burns.84 Nonaccidental contact burns normally have very
defined distinct borders. They could also assume the pattern
of the instrument that may have been used to cause the
burn.86
In nonaccidental cigarette burns, the burns are normally
in clusters with ovoid to circular shape and with a circum­
ference of 5–10 mm.87 Reported mechanisms of contact
burns include curling irons and steam irons.86 Such burns
normally leave the distinct pattern of the object used to
cause the burn.
After the history, physical examination, lab and radio­
logical investigations, and sometimes scene investigations
have been done, the medical expert should then make
an assessment of the injuries to determine if the history
explains the mechanism and is consistent with the burn
injury. The assessment should be made with no biased
principles, and the physician or medical health profes­
sional should be focused on his or her role, which is mainly
the care and protection of the child. It is not the role of
medical personnel to find who may have caused the burn
injury or to pass judgment on caregivers or the alleged
perpetrators.81
Types of Burn
SCALD
Scald burn is the most common form of nonaccidental burn
injury. The typical child who has sustained a nonaccidental
burn injury has a history of being potty trained at around
A4
A3
A2
A1
Fig. 62.4  Bilateral symme­try shown in non-accidental burns and in most cases such burns also spare the flexors.

62  •  Intentional Burn Injuries
669
B2
B1
C3
C2
C1
B3
Fig. 62.4, cont’d

62  •  Intentional Burn Injuries
670
The interview with the child is an essential component
to determining if the injury was intentional. The rapport
that is established through a therapeutic relationship is the
key factor to a successful interview. Warm-up questions or
nonthreatening questions should be asked first to establish
rapport: Ask “when is your birthday?”; ask questions about
school or friends, or ask the child to verbalize a story of his
or her best day. Once sufficient rapport is established, asking
open-ended questions about the injury is most effective (i.e.,
“What happened? How did you get hurt?”).36 The child
should be encouraged to tell the story freely. Specific ques­
tions for clarification should be asked only after the child
has told the story. If the child seems unwilling to talk about
what happened, the interviewer can suggest the child raise
a hand or wiggle a finger to signal that they know some­
thing but do not yet want to talk about it. When interview­
ing younger children, short sessions with breaks will allow
rapport-building and trust to develop so that child feels safe
sharing his or her story.36
The suspicious injury assessment should be discussed
confidentially with family members, including the sus­
pected perpetrator.36 Perpetrators should be allowed time to
process their concerns in a nonjudgmental and therapeutic
manner. The family should remain informed of the process
and potential CPS interventions. It is important to share
with families an understanding that often CPS is seen as a
punitive agency but essentially the main goal is the safety
and protection of all children. Sharing information will ini­
tiate a therapeutic relationship. Most perpetrators are reluc­
tant to trust medical teams, especially when they feel as if
they are being judged. Being honest about the process and
the information shared with CPS minimizes mistrust. As
stated previously, perpetrators often have limited emotional
support. When an intentional burn injury occurs, psychol­
ogists are an essential component to providing the initial
support and addressing the fears, sadness, and helplessness
those perpetrators may feel. Regular psychotherapy ses­
sions are critical to making a positive change in family
dynamics.
Reporting Suspected Intentional
Burn Injury
In 1967, state legislatures in every state had laws mandat­
ing that any reasonable suspicion of intentional injury be
reported to the appropriate authorities.36 In 1974, the
Federal Child Abuse Prevention and Treatment Act was
passed. These laws require professionals to report suspected
intentional injuries to a child when there is sufficient infor­
mation that would lead a “competent professional to believe
maltreatment is reasonably likely.”36 It is important to be
knowledgeable of not only state laws but also of local gov­
erning agencies’ policies on reporting suspicious injuries.
Most hospitals have risk management or legal teams that
are well versed in the federal and state laws as well as in the
policies, rules, and regulations of the hospital. Methods of
communications regarding intentional injuries should be
clearly outlined and reviewed prior to sharing any informa­
tion regarding intentional injuries.
Providers who suspect abuse should report to the appro­
priate agency as designated by the state in which they
CHEMICAL BURNS
These burns can be caused by alkali-based, acid-based,
inorganic, and organic agents. It is important to discover
the injury-causing agent so as to prevent further damage.
Alkali burn injuries may seem innocuous at first but may
produce deeper tissue injury and could produce further
damage even after removal of the immediate cause of the
burn.85 Alkali burns may not be painful compared to acid
burns, which produce painful deep ulcers. Chemical burn
injury could be either from supervisory neglect or from an
inflicted intentional injury.
Psychosocial Assessment
Multidisciplinary work is essential for appropriate manage­
ment of children or adult burn/abuse victims. Psycholo­
gists are critical in the initial evaluation and to assist in
interviewing, and social workers are advocates for refer­
ral and follow-up care. Both are skilled at assessing family
dynamics and social situations in greater detail and should
be your focal point for referral to appropriate government
agencies. Psychosocial assessment and interview with the
patient separately (when possible) from the caretaker will
provide a more accurate picture of the injury events. Incon­
sistency is a marker of discrepancies in the history, which
may alert an examiner to possible abuse. The patient and
caretaker must have a detailed interview documented ver­
batim by the historian. Paraphrasing information increases
the likelihood of personal interpretation of history. The
presence of witnesses and the exact timing of events must
be confirmed, and these persons must be interviewed to
assess for correlation in narratives.74 A thorough event
reconstruction soon after admission should be conducted
and documented. This limits the room the suspect has to
alter the events and timeline related to the burn or the
opportunity to collude with witnesses.3 The pattern of
circumstances is extremely important, with suspicions
raised when the adult responsible claims not to have seen
the incident, attributes the injury to a sibling, or presents
late, or when relatives other than the adult supervising at
the time of the burn bring the child for assessment.21 The
clinician conducting the interview must be well versed
in child development to ascertain normal developmental
responses to those that are suspicious of abuse. Observa­
tions of interactions and behavior are equally as important
as the specific questions that are asked during the interview
process.
Abused children often are under the age of 2, making
them vulnerable to their caregivers. Other characteristics
include inconsolable crying, difficulty in toilet training or
associated toilet training accidents, insufficient or strained
parent–child attachment, and inappropriate behavior such
as apathy or apparent tolerance to invasive procedures.
Severely abused children will demonstrate exaggerated
responses by either being overly fearful or overly affection­
ate with the medical team. When requested to provide
immunization records parents or caregivers suspicious
of abuse will often fail to provide or will avoid providing
accurate medical records and records of immunizations
(Box 62.4).3

62  •  Intentional Burn Injuries
671
trust is an essential component of the interview process.
The older adult is likely to be dependent on the abuser in
matters of daily living. Often the perpetrator is a family
member or loved one. Whether the patient is able to express
his emotions or not, he will likely experience fear, worry,
shame, and a desire to protect the perpetrator. The thera­
peutic relationship developed will allow the patient to trust
that the medical team will work in his best interest as well
as the best interest of the perpetrator.
Maintaining Professional
Relationships With Patient
and Family
When approaching a child/adult who is an abuse victim,
the provider must maintain professionalism and self-
control and remain nonaccusatory. Clinicians within the
healthcare profession are natural protectors of children
with the desire to automatically align with the child.
Addressing one’s own feelings is vital to providing the best
care for the patient. Establishing a therapeutic relation­
ship with the family may be difficult, but it is imperative
because many of these children are reunited with their
family at discharge or at some point during outpatient burn
care.
Future Burn Prevention and
Child Safety
Burns and scalds are a significant cause of morbidity and
mortality in children. Some studies have shown successful
countermeasures to prevent burn- and scald-related inju­
ries.75 To prevent accidental burns, the American Burn
Association Scald Injury Prevention Educator’s Guide has
published steps by which physicians can instruct their
patients to assist in burn and scald prevention. Hot food and
beverage scalds are the most common causes of scald inju­
ries in both children and adults. Providing a safe cooking
area and a supervised environment is foremost in preven­
tion. Suggested examples are: do not carry hot liquids when
carrying your child; place children in a playpen or high
chair away from the stove; do not use child walkers; cook
on back burners and remember to turn the pot handles to
the inside; keep appliance cords coiled and out of reach
from the counter; when removing lids, do not forget that
steam can burn the face or arms; wear tight-fitting clothing
or short sleeves when cooking; and, for those with mobility
impairment, use a sturdy, large lap tray to carry hot liquids.
Microwave scald burns have risen significantly since the
1980s.16 Proper placement of the appliance, where the face
is higher than the door of the microwave, is recommended.
Children under 7 years of age should never operate this
appliance. Never heat baby formula in the microwave due
to unevenness of heating. Always allow microwave-cooked
items to sit for 1 minute prior to opening. Prevent tap water
scalds by setting hot water heaters below 120°F (Table
62.2). The American Burn Association reminds us that
“Adequate and constant supervision is the single most
important factor in preventing tap water scalds.” Other tips
practice. As you interview, note the interaction between
caregiver and patient. Providers should document inappro­
priate concerns, lack of sympathy, detachment, delay in
seeking care, or use of drugs or alcohol (Box 62.2). If you
suspect that inconsistency exists, without being confronta­
tional, alert the caregiver and give him or her the opportu­
nity to give a more truthful history. Detailed documentation
of history and physical exam may be used in litigation
charges and should be clear, concise, and accurate. It is
imperative for clinicians responsible for reporting suspected
abuse to be as accurate as possible because there are signifi­
cant consequences for inaccurate assessment and diagnosis
of suspected abuse. Some 50% of children who sustain
intentional injuries have recurrent injuries that are eventu­
ally fatal.3
Ultimately it is not the hospital or any of the medical
staff’s obligation to prove that a suspicious injury was
intentional. It is important to report the suspicion, ensure
continuity of care, and cooperate with the legal process.3
While the child is receiving medical treatment, it is impera­
tive to keep accurate records and document all treatment
and interactions among family members. The prosecuting
attorney is responsible for proving intentional injuries;
however medical records are often a key element. Physician
reporting and cooperation are invaluable to legal prosecu­
tion. The physician’s opinion on likelihood of intentional
injury strongly influences CPS workers and prosecutors.3
Salient to remember with intentional injury cases is that
most attorneys have limited to no experience with burn
injuries, and the expertise of medical investigators, burn
psychologists, and social workers is the foundation for
proving allegations and protecting the child from future
injuries.
There are no federal programs to specifically address the
reporting of suspected abuse in adults. All states have indi­
vidual laws, reporting guidelines, and penalties for adult
abuse. It is best practice to be aware of your state laws if
you work with adults, but, if unsure, following the same
guidelines as for children until the exact information can
be obtained is acceptable. Most states have a statewide
intake office that can be located online, and most states
have online reporting. The National Center on Elder Abuse
provides information and assistance on elder abuse, includ­
ing a listing of state elder abuse hotlines. Child Help USA is a
private charity that established and maintains the National
Child Abuse Hotline (800)-4-A-CHILD (800-422-4453)
and provides a listing of statewide reporting numbers at
their website (). Tele­
communications Device for the Deaf number is (800)-2-A-
CHILD. The U.S. Department of Health and Human Services
Administration for Children and Families provides a listing
of statewide reporting phone numbers at their website
(
.Cfm).
Clinical Interviewing With Other
Vulnerable Populations
When interviewing vulnerable patients, it is important to
provide a safe and confidential environment that is noncon­
frontational and nonjudgmental. Developing rapport and

62  •  Intentional Burn Injuries
672
Table 62.2  Exposure Time to Receive a Severe Burn in
Hot Water; Time and Temperature Relationship
Water Temperature
Time for a Third-Degree
Burn to Occur
155°F
68°C
1 s
148°F
64°C
2 s
140°F
60°C
5 s
133°F
56°C
15 s
127°F
52°C
1 min
124°F
51°C
3 min
120°F
48°C
5 min
100°F
37°C
Safe temperature for bathing
Note: Downward adjustments to time needed for young children.
Data from Moritz AR, Henriques FC. Studies of thermal injury: II. The relative
importance of time and surface temperature in the causation of
cutaneous burns. Am J Pathol. 1947;23(5):695–720. See also American
Burn Association. Scald Injury Prevention Educator’s Guide. Available at

include placing a single-faucet handle always in the cold
water position and avoiding sudden fluctuations in water
temperature (e.g., flushing the toilet while showering). The
CDC has free material that can be downloaded from the web
(/safechild/FactSheets/Burns-Fact-Sheet-a.pdf).
Prevention of nonaccidental burn injuries is more diffi­
cult. Further research and education of physicians and
maltreatment teams are imperative. Since the establish­
ment of the National Burn Repository (NBR) by the Ameri­
can Burn Association, a Burn Registry was established to
create a national database. Physicians need to recognize
suspicious burns and document exam and history in detail.
Further research will assist in identifying clearer indica­
tions and patterns to determine intentional injuries.
Complete references available online at

Further Reading
Definitions of child abuse and neglect: summary of state laws as of 2009.
Available at:
statutes/defineall.pdf [(PDF 1.2MB] (/safechild/FactSheets/Burns-Fact-
Sheet-a.pdf.
Kolko D. Juvenile firesetter intervention clinical training. Pittsburgh, PA:
Department of Psychiatry, University of Pittsburgh School of Medicine;
2000.
National Center on Elder Abuse. Website: and
phone number: (202)-898-2586.
National Clearinghouse on Child Abuse and Neglect Information. What is
child abuse and neglect? US Department of Health and Human Services
Administration for Children and Families; 2004. Available at: http://
nccanch.acf.hhs.gov/pubs/factsheets/whatiscan.cfm.

672.e1
62  •  Intentional Burn Injuries
27. Bortolani A, Barisoni D. Burns in the elderly, epidemiology and mor­
tality: analysis of 53 cases. Ann Burns Fire Disasters. 1997;10(4).
Available at:
vol10n4p197.htm.
28. Keck M, Lumenta DB, Andel H, et al. Burn treatment in the elderly.
Burns. 2009;35:1071-1079.
29. Wasiak J, Spinks A, Ashby K, et al. Epidemiology of burn injuries in
an Australian setting, 2000–2006. Burns. 2009;35:1124-1132.
30. Hansen JC, Barnhill LR. Clinical approaches to family violence. Rockville,
MD: Aspen; 1982:157.
31. National Child Abuse and Neglect Data System (NCANDS); 2007.
32. National Child Abuse and Neglect Data System (NCANDS); 2008.
33. US Department of Health and Human Services Administration for
Children and Families. Child maltreatment, 2008. Available at: http://

34. Schwartz JP, Hage SM, Bush I, et al. Unhealthy parenting and poten­
tial mediators as contributing factors to future intimate violence: a
review of the literature. Trauma Violence Abuse. 2006;7(3):206-221.
35. US Advisory Board on Child Abuse and Neglect; 1995.
36. Robert R, Blakeney P, Herndon DN. Maltreatment by burning. In:
Herndon DN, ed. Total burn care. Edinburgh, Scotland: Elsevier Saun­
ders; 2007:771-780.
37. Justice R, Justice B. Crisis intervention with abusing families: short-
term cognitive coercive group therapy using goal attainment scaling.
In: Roberts AR, ed. Crisis intervention handbook. Belmont, CA: Wad­
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38. Straus MA, Kantor GK. Corporal punishment by parents: a risk factor
in the epidemiology of depression, suicide, alcohol abuse, child abuse,
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39. Heaton PA. The pattern of burn injuries in childhood. N Z Med J.
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world. A review. Burns. 2004;30(3):207-215.
42. Grossoehme DH, Springer LS. Images of God used by self-injurious
burn patients. Burns. 1999;25(5):443-448.
43. Bostic RA. Self-immolation: a survey of the last decade. Life Threat
Behav. 1973;3:66-73.
44. Adityanjee DR. Jauhar: mass suicide by self-immolation in Waco,
Texas. J Nerv Ment Dis. 1994;182(12):727-728.
45. Kumar V. Burnt wives – a study of suicides. Burns. 2003;29(1):31-35.
46. Stoddard FJ, Pahlavan K, Cahners SS. Suicide attempted by self-
immolation during adolescence. Literature Review, case reports, and
personality precursors. Adolesc Psychiatry. 1985;12:251-265.
47. Andreasen NC, Noyes R Jr. Suicide attempted by self-immolation. Am
J Psychiatry. 1975;132(5):554-556.
48. Cameron DR, Pegg SP, Muller M. Self-inflicted burns. Burns.
1997;23(96):519-521.
49. Daniels SM, Fenley JD, Powers PS, et al. Self-inflicted burns: a ten-year
retrospective study. J Burn Care Rehabil. 1991;12(2):144-147.
50. Persley GV, Pegg SP. Burn injuries related to suicide. Med J Aust.
1981;1(3):134.
51. Scully JH, Hutcherson R. Suicide by burning. Am J Psychiatry.
1983;140(7):905-906.
52. Antonowicz JL, Taylor LH, Showalter PE, et al. Profiles and treat­
ment of attempted suicide by self-immolation. Gen Hosp Psychiatry.
1997;19(1):51-55.
53. Wallace KL, Pegg SP. Self-inflicted burn injuries: an 11 year retrospec­
tive study. J Burn Care Rehabil. 1999;20(2):191-194.
54. Forhuoh SN. The mechanism, intensity of treatment and outcomes
of hospitalized burns; issues for prevention. J Burn Care Rehabil.
1998;19(5):456-460.
55. Ahmadi A. Suicide by self-immolation: comprehensive overview,
experiences and suggestions. J Burn Care Res. 2007;28(1):30-41.
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inflicted burns in Tehran, Iran. J Burn Care Rehabil. 2003;24(1):15-20.
57. Adityanjee DR. Suicide attempts and suicides in India: cross-cultural
aspects. Int J Soc Psychiatry. 1986;32(2):64-73.
58. Mzezewa S, Jonsson K, Aberg M, et al. Prospective study on the epide­
miology of burns in patients admitted to the Harare burn units. Burns.
1999;25(6):499-504.
59. Panjeshahin MR, Lari AR, Talei A, et al. Epidemiology and mortality
of burns in South West of Iran. Burns. 2001;27(3):219-226.
60. DeSouzza DA, Marchesan WG, Greene LJ. Epidemiological data and
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89. Reference removed while revising.

673
Functional Sequelae and
Disability Assessment
KAREL D. CAPEK, BYRON D. HUGHES, and GLENN D. WARDEN
63 
the American Medical Association (AMA) formula, the first
diagnosis-based impairment is subtracted from a 100%
whole person, and each subsequent impairment is sub­
tracted as a percentage of the remaining, or fractional,
unimpaired person.3 Disability ratings can only be per­
formed after a patient has reached maximal medical
improvement. This concept is unfortunately both subjective
and undefined but retains its utility when applied with
equal measures of common sense and medical judgment.
Postburn System-Based
Disability Assessment
Description of an alleged impairment should begin before
physician introduction. Careful observation of general
appearance: how an individual is groomed, enters the
building, comports himself while waiting, interacts with
clinical staff during check-in, and completes initial paper­
work all provide useful, global insight into how his life has
been impacted by burn injury and how he has adapted to
it. A whole person’s impairment depends on disruption of
organ system function. For each system, impairment is cat­
egorized into five classes: 0 (no impairment), 1 (minimal),
2 (moderate), 3 (severe), and 4 (very severe). Generally,
these correspond to function and symptoms, where 0 is no
symptoms despite strenuous activity, 1 is symptoms only
with strenuous activity, 2 is symptoms with normal activity,
3 is symptoms with minimal activity, and 4 is unabated
symptoms. In cases where an objective measure is widely
accepted to correlate with experiential symptoms, this
objective measure becomes the key factor (e.g., see the
section on respiratory function, which uses the results of
pulmonary function tests as a key factor).
This classification allows assignment from no impair­
ment to complete impairment of the system being evalu­
ated, which can be expressed as a percentage of whole-person
impairment. Within each diagnosis-based impairment
class, impairment can be modified up or down based on
additional clinical information or supplementary diagnos­
tic tests. These vary somewhat for each condition (for full
details please refer to the individual chapters in the most
recent edition of the AMA’s Guides to the Evaluation of Per­
manent Impairment). The assessment of typical postburn
sequelae is described in the following sections.
CONSTITUTIONAL
Body mass, composition, and growth curves in children
provide important objective data regarding the overall mag­
nitude of the postburn systemic insult. The weight trend,
Introduction
Advances in acute burn care during the past 25 years in
terms of decreased mortality and decreased length of hos­
pital stay have been truly remarkable. Current and histori­
cal perspectives on burn mortality can be found in preceding
chapters. In almost every burn unit in the United States, the
length of stay has decreased from nearly 3 days/% burn to
less than 1 day/% burn. The success can be stated simply:
patients with larger, more severe burns are surviving.
But if patients with larger and more severe burns are
surviving, this has created new problems for patients’
quality of life. Although the problems are magnified in mas­
sively burned patients, they exist also in smaller burns.
These problems are demonstrated in a pediatric burn patient
with a 95% total body surface area (TBSA) burn (Fig. 63.1).
Cultured keratinocytes were utilized to achieve wound cov­
erage. The child survived; however, when we examined the
patient’s current and future reconstructive needs, they
totaled 33 potential reconstructive procedures. Thus the
reconstructive problems are monumental in a child with
very few donor sites. With regard to survival, the results of
this patient are impressive; however, we must ask the ques­
tion: “Has the medical expertise in terms of survival pro­
gressed past the ability to reconstruct and rehabilitate
patients?” Unfortunately the answer is clearly “yes.” Are we
returning our patients to a society that is not ready finan­
cially, psychologically, or socially to accept them? Again,
unfortunately, the answer is clearly “yes.”1
Under Titles II and XVI of the Social Security Act, adult
disability is defined as “the inability to engage in any sub­
stantial gainful activity, by reason of any medically deter­
minable physical or mental impairment(s) which can be
expected to result in death or which has or can be expected
to last for a continuous period of not less than 12 months.”
For children, the definition differs slightly, “a child under
the age of 18 will be considered disabled if she or he has a
medically determinable physical, mental, or combination of
impairments that causes marked and severe functional
limitations and that can be expected to cause death or last
for a continuous period of not less than 12 months.” These
guiding principles of functional assessment require a
further definition. “Medically determinable impairment”
means that the impairment(s) can be demonstrated, wit­
nessed, or otherwise known and described by some third-
party means.2 These may include laboratory tests, physical
examination demonstrating signs of the underlying disease
process, and disease-specific historical information elicited
during the interview. When impairment results from two or
more systems, the ratings should be combined according to
a combined values chart or its underlying formula. Using

63  •  Functional Sequelae and Disability Assessment
674
disfigurement, and distortion of adjacent unburned mobile
structures (nipple, umbilicus, and/or genitalia) by burn
scar contraction. Large burns (>20% TBSA) can result in
homeostatic impairment of the skin. Manifestations may
include subjective heat intolerance, impaired thermoregu­
lation, and loss of sweat function in the scars, or cold intol­
erance owing to loss of adipose tissue insulation. The latter
is of particular concern after deep or infected burns with
fascial excision or other significant adipose tissue débride­
ment in the course of burn care. While a goal of burn care
is rapid, durable wound closure, chronic wounds still occur
after burn injury. If present, these should be described
including size, depth, location, exudate/odor, and status of
the healing process/granulation tissue. Previously applied
wound therapies should be described. If a wound has been
present beyond 3 months, a more detailed assessment of the
reasons for failure of healing is warranted (including mal­
nutrition, pressure, infection/colonization, osteomyelitis,
loss of sensation, tension, and lack of blood flow). This
assessment may include a search for neoplasia (Marjolin’s
ulcer) and related examination of the draining lymph nodes
because nonbasal cell skin cancer (not in remission) is
assigned 58% whole-person impairment.12 The claimant’s
history is the key factor in classifying nonfacial skin/scar-
related impairment, focusing on the impact of the skin-
related conditions on an individual’s ability to perform
activities of daily living. Whole-person impairment result­
ing from nonface skin disorders can range from 0% to
58%.12
FACIAL INJURIES, SCARS, AND EAR/NOSE/
THROAT PROBLEMS
Burn scars involving the face can be a significant cause of
impairment. Beyond aesthetics, these may include cicatri­
cial microstomia (causing weight loss and malnutrition),
loss of facial expression, and nasal deformity/tissue loss
with associated airway dysfunction and loss of humidifica­
tion. Air passage deficits, including nasal injuries and vocal
cord paralysis, are rated from 0% to 58% whole-person
impairment based on the key factor of degree of dyspnea
and interference with daily or work activities.13 Voice and
speech impairment is rated at 0–35% of the whole person,
based on the key factors of speech audibility, intelligibility,
and functional efficiency of speech in everyday communi­
cation.13 Ear loss, in addition to the aesthetic deficit, can
compromise sound localization/lateralization and make it
difficult to wear glasses or similar headgear that rests on the
ears. Auditory function may be compromised in several
ways following burn injury. Significant blast injuries are
associated with tympanic membrane (TM) rupture. Middle
ear infection, often with TM perforation, may complicate
convalescence from severe burns; multidrug-resistant
organisms are usually observed, and clearance can require
prolonged treatment. Resulting TM scarring may reduce
auditory acuity. Several ototoxic medications (especially
aminoglycosides and furosemide) are routinely used during
critical care of the severely burned patient. The key factor
for hearing evaluation is decibel threshold sum audiometry
using 500, 1000, 2000, and 3000 Hertz sounds. Whole-
person impairment from binaural hearing loss ranges from
0% to 35%, with the latter value reflecting complete hearing
particularly compared with a preinjury weight, is helpful in
estimating the loss of lean body mass, although confound­
ing by body compositional changes does occur. In general,
loss of 10–30% of body mass correlates with increasingly
severe manifestations of malnutrition and catabolism,
namely impaired wound healing, pressure sores, and pneu­
monia. Losses approaching 40% of preinjury body mass (in
survivors seen for disability assessment) indicate a near-
fatal systemic insult of malnutrition combined with postin­
jury hypermetabolism.
While the gold standard of body compositional analysis
is potassium-40 scintillation counting coupled with deute­
rium oxide dilution measurement of total body water,4
whole-body dual energy X-ray absorptiometry (DEXA) pro­
vides a useful and more readily available surrogate. Whole-
body DEXA scans provide bone density measurements of
the axial and appendicular skeleton, as well as assessment
of peripheral and visceral fat mass, bone mass, and
extremity/central lean mass.5 Bone metabolism6–10 is mark­
edly disturbed after severe burn injury; accordingly growth
arrest is seen in growing (prepubertal) children.11 This is
attributable to stalled endochondral bone formation.
Patients are also prone to fracture from trivial trauma such
as ground-level falls, and fracture healing is slowed.
SKIN/INTEGUMENT
As the organ most visibly affected by burn injury, photo-
documentation of affected areas can provide efficient
insight into the magnitude of the injury and the status of
the healing process. Scars from healed burn wounds or skin
grafts and donor site morbidity are described by TBSA and
location. It is also important to note associated venous con­
gestion, tissue edema, chronic wounds, pain, itch, tissue
Fig. 63.1  A pediatric burn patient with a 95% total body surface area
burn.

63  •  Functional Sequelae and Disability Assessment
675
impairment classification is the diagnosis itself, supple­
mented with the “functional history,” and comprises the
extent to which the diagnosis-defined problem interferes
with vigorous activity, work, daily living, and basic func­
tioning. It also considers the extent to which another
person is required to accomplish these tasks. Because of
the complexity in rating nonamputation impairments of
the extremities, the reader is advised to obtain and refer
to the most recent edition of the Guides to the Evaluation of
Permanent Impairment.20
HAND FUNCTION
Hand function is both uniquely important to daily and work
activities and frequently impaired by burn injury and scars.
Loss or deformity of digits leads to a variety of deficits. Com­
plete loss (amputation) results in the following impairment
ratings:
■ Ring/small finger: 10% of hand, 9% of upper extrem­
ity, and 5% whole-person impairment
■ Index/middle finger: 20% of hand, 18% of upper
extremity, and 11% whole-person impairment
■ Thumb: 40% of hand, 36% of upper extremity, and
22% whole-person impairment
■ Hand: 90% of upper extremity and 54% whole-person
impairment
■ Entire
upper
extremity:
60%
whole-person
impairment.20
Flexion contracture or boutonniere deformity digit(s)
leads to impairment in dexterous movements, and exten­
sion contracture compromises grip strength and carrying
tasks. Scoring is more complex for partial losses and func­
tional impairments but may not exceed the impairment
rating for amputation.20 Due to the hand’s complex tissues
and their response to splinting, immobilization, and vasoac­
tive medications it is not uncommon for muscle, tendon,
and bone/joint involvement to be demonstrable in addition
to the obvious skin/soft tissue cicatrization.
In the lower extremity, amputation results in the follow­
ing impairment ratings:
■ Lesser toe: 3% of foot/ankle, 2% of lower extremity,
and 1% whole-person impairment
■ Great toe: 17% of foot/ankle, 12% of lower extremity,
and 5% whole-person impairment
■ Foot/ankle: 70% of lower extremity, and 28% whole-
person impairment
■ Entire lower extremity: 40% whole-person impairment.
For nonamputation impairment at the upper and lower
extremities, if none of the diagnosis-based grids reflects the
patient’s impairment (as is often the case with significant
musculoskeletal compromise after burn injury), then
impairment can be rated according to range of motion
testing. A comprehensive description of this process is
beyond the scope of this chapter, but can be found in Ron­
dinelli et al.21
An assessment of gait and balance (i.e., heel/toe, tandem
gait, and Romberg tests) provides insight into the coordi­
nated function of the nervous and musculoskeletal systems.
Impairment of the ability to respond quickly to changing
conditions (general weakness, loss of balance, or
loss.13 Facial disfigurement is rated separately from overall
skin assessment, and the key factor determining classifica­
tion is the degree of facial anatomical distortion, loss of
expression/facial features, and the degree of difficulty expe­
rienced by the patient in social settings due to facial disfig­
urement. Whole-person impairment resulting from facial
scars/disfigurement can range from 0% to 45%.
MUSCULOSKELETAL
Burn-related amputations are not infrequent, especially in
the setting of electrical injury. If an amputation is present,
the requisite description is straightforward, including the
level of the amputation, the condition of the stump (note if
chronic wound present), any prosthetic used, how well it
works for the patient, and specific (work and home) activi­
ties that are difficult or require adaptation due to the
amputation.
The main cause of musculoskeletal impairment after
burn injury is scar contracture across joints. In the acutely
injured state, patients typically assume a “position of
comfort.” Contraction of the burned joint may reduce the
area of the wound to heal but at the cost of losing range of
motion with scar formation. The use of splinting, exercise,
and release with tissue interposition have all been shown to
mitigate this problem, but rarely is function completely
restored to the preburn state. In describing scar contrac­
tures, particularly involving joints, one may note that the
resting position is often abnormal. Range of motion,
strength, associated chronic wounds or ulcers, and pain/
tightness at the scar also provide helpful medical evidence
of impairment. The description of specific daily living or
work activities that the patient finds difficult due to specific
scars/contractures is needed to communicate the experien­
tial severity of impairment.
Prolonged immobilization and excessive use of static
splints may also lead to joint fibrosis and impaired range of
motion. Heterotopic ossification, generally occurring in
patients with burns greater than 30% TBSA, can cause
near complete loss of joint mobility.14 When it occurs, the
joint becomes immobilized in the position in which it was
maintained. It causes significant pain, and the lost range of
motion is generally refractory to surgical intervention and
rehabilitation. For example, at the elbow, the ulnar nerve at
the cubital tunnel can be affected.
Muscular conditions of systemic import may accompany
burn convalescence. Sarcopenia is increasingly diagnosed
after critical illness, sepsis, and prolonged immobilization.15
Rhabdomyolysis and compartment syndromes may lead
to the rapid loss of mass of involved muscles. Especially
common after electrical injury, these may exacerbate the
muscle wasting and skeletal muscle protein catabolism due
to the burn injury proper. Loss of lean muscle mass leads
to decreased strength and endurance and can contrib­
ute to metabolic derangements including altered glucose
homeostasis and decreased insulin sensitivity. Muscle bulk
can be assessed by the examiner and extremity circumfer­
ence measurements reported if they appear grossly abnor­
mal. Ultrasound is increasingly utilized to quantitate the
degree of sarcopenia (e.g., midfemur vastus lateralis thick­
ness), but its role in routine disability assessment is not yet
widely established.16–19 The key factor for musculoskeletal

63  •  Functional Sequelae and Disability Assessment
676
syndrome is present for 4–6 h without adequate release,
irreversible nerve damage may occur anywhere within the
affected compartment(s). Fortunately the dire sequelae of
contracture and complete defunctionalization of the upper
extremity described by Volkman are infrequently encoun­
tered owing to rapid escharotomy and fasciotomy of
impending compartment syndromes as a routine part of
burn center care.23 The rating of impairment owing to
peripheral nerve lesions is based grossly on sensory and
motor findings, and the reader is advised to refer to the
latest edition of the Guides to the Evaluation of Permanent
Impairment for both the upper and lower extremities.20,24
Characterization of gait, station, balance, sudomotor
function, strength, deep tendon reflexes, and sensation
(including as needed pain/temperature, light touch/two-
point discrimination, and vibratory/joint position sense)
deficits should be done; a detailed neuro exam may be sup­
plemented with electromyography or nerve conduction
studies if needed.
CARDIOVASCULAR/METABOLIC
Postburn hypermetabolism has been well described in
multiple preceding chapters. Impairment may result from
decreased exercise capacity (VO2 peak), in turn related to
increased basal energy expenditure. Tachycardia and ele­
vated resting energy expenditure frequently persist for more
than 12 months after major burn injury. Although phar­
macologic treatment may ameliorate aspects of postburn
hypermetabolism, restoration of preinjury metabolism
occurs slowly and often incompletely. The stress of major
burn injury (and frequently sepsis) may also cause cardiac
dysfunction.25 Significantly elevated catecholamine levels
and a chronic high-output state contribute to myocardial
remodeling; a depressed ejection fraction, myocardial fibro­
sis, and diastolic dysfunction are increasingly appreciated
via echo in survivors of major burn injuries. Objective
evidence of the magnitude of a burn survivor’s cardio­
vascular and metabolic derangement are given by pulse,
resting respiratory rate (and depth of respiration), blood
pressure, jugular venous pressure/waveform as assessed
vertically from the sternal angle, presence of hepatojugu­
lar reflux, and precordial palpation. Resulting impairment
is classified using the New York Heart Association (NYHA)
Functional Classification of Cardiac Disease. Whole-person
impairments range from 0% to 65%, and objective testing,
such as echo (ejection fraction and diastolic dysfunction
based on left atrial E-A waves) and exercise testing (VO2
max or METS), are used as the key factors. The exercise test
results are categorized corresponding to NYHA functional
classes, which provide an objective measure of functional
status.26
RESPIRATORY
Burns that occur in an enclosed space, such as a building
structure, often result in some form of inhalation injury to
the respiratory system. Impairment may be limited to a
temporary need for ventilator support or extend to perma­
nent respiratory disease. Chronic and recurrent respiratory
infections and pulmonary insufficiency may limit an indi­
vidual’s ability to perform his or her previous work,
unsteadiness) can impair the ability to safely function in
physically demanding occupations. Exertional tolerance,
although subjectively reported, can be assessed by asking
how far the patient can walk without resting or how many
flights of stairs can be climbed without stopping. The reason
for exertion limitation (e.g., shortness of breath, musculo­
skeletal cramps, general weakness, joint pain, chest pain,
back discomfort, or other) often provides important insight
into the dominant underlying disease state.
NEUROLOGICAL
Both focal and global nervous system problems are possible
after burn injuries. Traumatic brain or spinal injury may be
seen in high-energy automobile crashes, blast injuries, and
escape-related injuries. Burns sustained in closed-space
fires are frequently accompanied by the inhalation of a
cocktail of toxins and combustion byproducts. These cause
inhalation injury (discussed later) but carbon monoxide,
cyanide, and other metabolic poisons may also cause global
hypoxic insults (classically the hippocampi are most vulner­
able to hypoxia, with impairment in learning and memory).
Cerebral edema often accompanies carbon monoxide poi­
soning or hypoxic insult, and herniation syndromes may
lead to neurological devastation. Cardiac arrest may also
accompany severe burn injury (usually hypovolemic) with
hallmark cerebral watershed infarcts between the distribu­
tions of the anterior, middle, and posterior cerebral arteries.
Hypoxic and ischemic insults may lead to alterations in con­
sciousness and awareness. Impairment is rated 0–100% of
the whole person, with continuous impairments (e.g., non­
epilepsy) rated higher, from 31% to 100% of the whole
person.22 Alternatively, if consciousness and awareness
remain intact, alterations in mental status, cognition, and
highest integrative function may be present after traumatic
injury or severe central nervous system (CNS) insult. Result­
ing impairment is rated from 0% to 50% of the whole
person, based on mental status exam and interference with
activities of daily living, occasionally supplemented with
neuropsychiatric testing. Individuals who have suffered an
electrical injury may develop a condition characterized by
progressive degeneration of fine and gross motor coordina­
tion. Resultant complications can range from inability to
perform work-related tasks safely to an inability to perform
the routine activities of daily living. It is a disease process
that takes place over a significant period of time and may
worsen after an individual has returned to work. It can be
particularly vexing to differentiate this entity from the
malingerer, and the objective neurological exam findings
must be cataloged in each case. A polyneuropathy of critical
illness is also described and should be considered when pro­
longed ICU care was needed for recovery. A prolonged sys­
temic inflammatory response syndrome, hyperglycemia,
corticosteroids (which are endogenously elevated for >12
months after burn injuries), and the use of neuromuscular
blocking agents (paralytics) have variously been implicated
in its pathogenesis.
Focal peripheral nerve lesions are also possible owing to
postburn compartment syndromes. In the upper extremity
the ulnar nerve is particularly vulnerable within Guyon’s
canal and at the cubital tunnel, while the median nerve is
vulnerable at the carpal tunnel. If a compartment

63  •  Functional Sequelae and Disability Assessment
677
penile impairment and physical exam findings for testes and
scrotum (separately). Physical findings are the key factor for
vulvar and vaginal impairment, which ranges from 0% to
20% of the whole person.33 Unique to burn convalescence,
severe scarring of the perineum, buttocks, or gluteal cleft
may impair sitting, voiding of urine and stool, and hygiene.
GASTROINTESTINAL
The digestive system is not usually a problem except in
those individuals who have had superior mesenteric artery
syndrome, cholecystitis, pancreatitis, or peptic ulcer disease
during the acute admission. The postdischarge clinical
course of these individuals is unpredictable. Upper GI
impairment (including esophageal problems, peptic ulcer,
and pancreatitis) ranges from 0% to 60% of the whole
person, considering frequency and severity of symptoms
and need/frequency of treatment. Weight loss below ideal
body weight is an important consideration in more severe
impairments.34
ENDOCRINE
Burn convalescence is complicated by a hyperadrenergic
state characterized by elevated catecholamine levels and
cortisol. The pathophysiology is described in Chapter 23,
along with numerous references. Whole-person impair­
ment from adrenal cortex disorders ranges from 0% to 20%
based on signs, symptoms, biochemical abnormalities, and
burden of treatment. Although no therapies are currently
standard for postburn hypercortisolism (best assessed by
24-hour urinary cortisol), the physical stigmata of moon
facies, peripheral muscle wasting, central obesity, and lipo­
dystrophy are familiar to the burn surgeon. Adrenal medul­
lary excess is assessed separately from the adrenal cortex.
The postburn alterations in adrenal medulla function and
resulting catecholamine excess are also covered in Chapter
23, and numerous references documenting the extent/
duration of catecholamine excess postburn are also given.
Whole-person impairment resulting from adrenal medulla
hypersecretion ranges from 0% to 60%, with the key factor
being the presence of symptoms and efficacy of blocking
agents. After burn injury, the nonselective β-blocker pro­
pranolol is usually able to reduce tachycardia, although
supranormal doses (up to 4 mg/kg per dose) may be neces­
sary. Symptoms of catecholamine excess after major burn
injury tend to be moderate to severe and may last for several
years postburn injury. Stress-induced diabetes is seen after
severe burn injury, although the observed elevations in gly­
cosylated hemoglobin are usually mild to moderate. Bio­
chemical evidence includes fasting glucose, insulin levels,
and glucose tolerance testing. Impairment from diabetes
ranges from 0% to 28% of the whole person, and the rating
uses severity and complexity of the required treatment as
the key factor. Central hypogonadism has also been described
in burned men,35 and the role of androgen deficiency/
replacement during burn recovery is an area of active inves­
tigation. Impairment resulting from states of gonadal
hormone deficiency or excess is classified according to the
key factors of biochemical evidence, physical symptoms,
and impact on fertility. Whole-person impairment from
gonadal disorders ranges from 0% to 15%.
especially when toxic chemicals or dust are present in the
workplace. Exposure to irritating gases can also worsen
preexisting asthma or result in irritant-induced asthma.
Although this form of reactive airway disease usually
resolves with time, some individuals may have persistent
respiratory impairment that may also require a change in
vocation in order to avoid continued exposure to irritants
and exacerbation of symptoms.
Furthermore, patients with severe inhalation injuries
may require a tracheostomy long after the burn has healed.
Closure of the stoma is often delayed due to chronic airway
complications or need for future reconstructive surger­
ies. Tracheal stenosis is not an infrequent complication
of tracheostomy and causes increased work of breathing
that is exacerbated with exertion and accompanied by
stridor. Burns/scars of the trunk and chest wall, especially
if circumferential, can impair chest wall mobility result­
ing in dyspnea and related symptoms. An assessment of
chest wall motion, breath sounds,27 adventitious sounds,28
stridor, inspiratory/expiratory time and flow,29 clubbing/
cyanosis, and pulse oximetry provide noninvasive medical
evidence of pulmonary function. However, the classification
of impairment related to pulmonary problems is primarily
through pulmonary function tests. These include spirom­
etry, arterial blood gas analysis, carbon monoxide diffu­
sion limit,30 and exercise testing maximal oxygen uptake
(VO2 max). These tests provide objective descriptions of a
patient’s respiratory problem(s) if correctly performed and
are the key factors determining impairment class.31 Pul­
monary impairment ranges from 0% to 65% whole-person
impairment.
EYES/VISION
Chapter 43 covers burn-related eye pathology in detail. The
principal visual problems seen after burn are corneal ulcer/
scar (after ocular surface infection/exposure), cataract
(after electrical injury), and anterior ischemic optic neu­
ropathy (due to orbital compartment syndrome). The key
factors in determining visual impairment are distance
visual acuity and visual fields. While diagnostic eye care is
more concerned with the vision of each individual eye, bin­
ocular vision is more important for functional status. The
distance visual acuity of each eye and binocular vision is
converted into a visual acuity score. The functional acuity
score is three times the binocular visual acuity score, plus
the right and left visual acuity scores divided by 5. Thus the
score is weighted 60% binocular, and 20% for each indi­
vidual eye. A similar adjustment is made for visual field
defects if present. These scores are used to calculate visual
system impairment, which can be converted into whole-
person impairment ranging from 0% to 85%.32
RENAL/GENITOURINARY
Renal failure and genital/perineal burns constitute a major
burn-related
impairment.
Whole-person
impairment
resulting from kidney disease ranges from 0% to 75% based
on frequency/severity of symptoms and need for dialysis.
Penile, scrotal, and testicular impairments are each rated
separately, although each can comprise 0–15% whole-
person impairment. The key factors are sexual function for

63  •  Functional Sequelae and Disability Assessment
678
ideation, previous traumatic injuries, and substance use
should be detailed. Flat or expansive affect, flight-of-ideas,
loosened associations, and level of psychomotor activity all
comprise signs (medical evidence) that help assess impair­
ment. After burn injury and acute hospitalization, both
acute and posttraumatic stress disorders are frequent. An
abnormally high level of anxiety is also present, perhaps
owing to the prolonged sympathetic hyperactivation that
accompanies burn injury. A description of the content, fre­
quency, and intrusiveness of flashbacks and sensation of
anxiety is helpful in gauging the patient’s burden and level
of impairment. Impairment is calculated as the median
value of scores obtained from the global assessment of func­
tion, brief psychological rating scale, and the psychiatric
impairment rating scale. Whole-person impairment from
mental and behavioral disorders ranges from 0% to 50%.38
OVERALL QUALITY OF LIFE
Survey instruments have been constructed in an attempt to
measure quality of life and subjective disability.39 Of these,
the World Health Disability Assessment Scale II measures
generic function and is useful for comparison across disease
states. The Burn-Specific Health Scale-Brief is, as the name
suggests, constructed to capture the specific difficulties
experienced by burn survivors and is useful in comparing
within a population of burn survivors. In a cohort of 50
large pediatric burns, greater TBSA, male sex, increasing
age at burn, burn after school entry, and survivors transi­
tioning to adulthood were all associated with lower quality
of life using both of these scales.40 From 1994 to 2014, the
Burn Model System Database (established by the National
Institute on Disability, Independent Living, and Rehabilita­
tion Research) has enrolled more than 2000 children and
almost 3500 adults. More than 33 survey instruments have
been administered within this population to better under­
stand and quantitate the experience of the burn survivor.
In 2016, publications resulting from this endeavor were
comprehensively reviewed.41 While these demonstrate pro­
gress toward quantitation and understanding of postburn
quality of life, as suggested at the start of this chapter, these
measurements have not been optimized and accepted as
routine standards in clinical burn follow-up. As the use of
these scales is mainstreamed, it may be instructive to
compare experiential patient quality of life with whole-
person impairment ratings.
Complete references available online at

HEMATOLOGICAL AND LYMPHATIC
Anemia frequently accompanies burn injuries and is of
multifactorial etiology. The reader is referred to Chapter 22
for further descriptions of the related pathophysiology.
Impairment resulting from anemia is classified according to
exertional symptoms experienced by the patient and fre­
quency of need for transfusions or other therapies. Anemia
can cause whole-person impairment ranging from 0% to
75%, although the problems typical of burn convalescence
are generally in the 0–15% range.36 Postburn immunosup­
pression is also discussed in the above-referenced chapter.
Although the magnitude of immune suppression is an
important determinant of survival,37 it tends to be self-
limiting, with resolution occurring concurrently with
wound closure. Significant blood-borne infections (hepati­
tis, human immunodeficiency virus, cytomegalovirus, and
others) do occasionally complicate burn convalescence
owing to significant transfusion and allograft needs in
major burns. Trauma/burns are a risk factor for venous
thrombosis. Whole-person impairment resulting from
thrombotic problems ranges from 0% to 40% and is classed
using the frequency and timing of thrombotic events as the
key factor.36 Full-thickness burns, particularly of the lower
extremities, will also cause damage to the lymphatic system.
Such injured individuals often demonstrate a lack of normal
lymphatic drainage, resulting in chronic edema and the
development of stasis ulcers. There can be little or no
improvement expected posthealing. External support in the
form of elastic garments is necessary to help replace the
normal activity of the lymphatic system in reabsorption of
fluid. These individuals frequently have difficulty in stand­
ing for long periods of time or working in a hot and humid
environment.
PSYCHOLOGICAL
The psychological impact of burn injury is discussed in
Chapter 65. Impairment may result from mental problems
predating (and occasionally causing) the burn injury or be
related to the injury and treatment. Substance abuse, sui­
cidal ideation, and mood disorders are all common comor­
bidities in burn patients. They may predispose the patient to
risk-prone behaviors, impair the ability to escape injury, or
even prompt self-harm such as self-immolation. If present,
an understanding of the patient’s impairment requires
documentation of symptoms and signs, including previous
suicide attempts, psychiatric hospitalization, and self-
injuries. The time course, frequency, and severity of suicidal

678.e1
63  •  Functional Sequelae and Disability Assessment
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23. Chandraprakasam T, Kumar RA. Acute compartment syndrome of
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25. Guillory AN, Clayton RP, Herndon DN, Finnerty CC. Cardiovascular
dysfunction following burn injury: what we have learned from rat and
mouse models. Int J Mol Sci. 2016;17(1).
26. Rondinelli RD, Katz RT, Mayer TG, et al. Guides to the Evaluation of
Permanent Impairment. 6th ed. Chicago: American Medical Associa­
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27. Forgacs P, Nathoo AR, Richardson HD. Breath sounds. Thorax.
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tute on Disability, Independent Living and Rehabilitation Research
burn model system database analysis. J Trauma Acute Care Surg.
2015;79(5):870-876.
15. Mueller N, Murthy S, Tainter CR, et al. Can sarcopenia quantified by
ultrasound of the rectus femoris muscle predict adverse outcome of
surgical intensive care unit patients as well as frailty? A prospective,
observational cohort study. Ann Surg. 2016;264(6):1116-1124.
16. Heckmatt JZ, Pier N, Dubowitz V. Measurement of quadriceps muscle
thickness and subcutaneous tissue thickness in normal children by
real-time ultrasound imaging. J Clin Ultrasound. 1988;16(3):171-176.
17. Paris MT, Mourtzakis M, Day A, et al. Validation of bedside ultrasound
of muscle layer thickness of the quadriceps in the critically ill patient
(VALIDUM Study): a prospective multicenter study. JPEN J Parenter
Enteral Nutr. 2016;41(2):171-180.
18. Takai Y, Ohta M, Akagi R, et al. Applicability of ultrasound muscle
thickness measurements for predicting fat-free mass in elderly popula­
tion. J Nutr Health Aging. 2014;18(6):579-585.
19. Abe T, Loenneke JP, Thiebaud RS. Morphological and functional rela­
tionships with ultrasound measured muscle thickness of the lower
extremity: a brief review. Ultrasound. 2015;23(3):166-173.
20. Rondinelli RD, Katz RT, Mayer TG, et al. Guides to the Evaluation of
Permanent Impairment. 6th ed. Chicago: American Medical Associa­
tion; 2008:408-492.

679
Management of Pain and Other
Discomforts in Burned Patients
WALTER J. MEYER III, J.A. JEEVENDRA MARTYN, SHELLEY WIECHMAN,
CHRISTOPHER R. THOMAS, and LEE WOODSON
64 
activated peripheral circulating macrophages and the
central nervous system microglia.5
Areas of deeper partial-thickness and full-thickness
burns may display a confusing pattern of pain over the first
few days. These areas may show little or no response to
sharp stimuli such as a pinprick initially, yet a patient may
complain of deep, severe pain related to the inflammatory
response. In a full-thickness burn, the dermis is completely
destroyed along with its rich network of nerve endings. This
leads to an initial response of a completely anesthetic
wound when a sharp stimulus (e.g., pin prick) is present on
the dead skin. Over time, patients begin to complain of a
dull or intense pain during manipulation of these areas
(e.g., dressing changes). Once the devitalized tissue (i.e.,
eschar) sloughs and is replaced by granulation tissue, the
patient again experiences the sensation of sharp pain to
noxious stimuli. Thus it appears that, in all types of burn
injury pain, there is an inflammatory and neuropathic
component both resulting from injury to tissues and to
sensory nerves endings. As to which of these (inflammatory
vs. neuropathic) components contributes more to the noci­
ceptive responses is still not understood.
Additional Factors Contributing
to Pain Generation
Ptacek et al.8 found that although there was a general trend
for pain to decrease over time in patients with small or
superficial burns, there was also considerable variability in
the course of pain among adult survivors after major burns.
Persons with large burns showed a higher affective (suffer­
ing) component to the pain, but there was no reliable cor­
relation between the pain scores and burn size. Quite in
contrast to that report, studies in children have shown that
the intensity of pain increased as the burn size increased.9
Whether this is related to the increased anxiety of children
is unclear. Other reports confirm that pain intensity at rest
was correlated with psycho-affective responses such as
anxiety, depression, anorexia, fatigue, and helplessness.10
Choinière et al.11 also noted that pain at rest was signifi­
cantly and positively related to levels of anxiety or depres­
sion (i.e., with elevated anxiety or depression, pain scores
at rest increased). Depression also plays a similar role in the
enhancement of pain.12 Pain leads to depression, and
depression increases the perception of pain.13,14 Confusion
therefore can occur concerning the amount of pain
expressed by burn patients on the role played by psychiatric
disorders that are concomitantly present in any form of
Introduction
The words “burn injury” trigger, for almost anyone, imme­
diate and vivid images of excruciating pain and suffering.
Children are conditioned from early childhood that burn
injuries are painful and can cause great harm. At the time
of the first edition of this book there was still debate about
the importance of pain management in the burn survivor.
Many practitioners believed that the treatment of burn
injury pain, especially in children, was more dangerous
than leaving it untreated. The past 20 years has shown that
children’s pain can be effectively and safely managed with
significant benefits in recovery and long-term outcomes.1,2
There are now data showing that even premature babies
have significant pain that needs to be addressed.3
A series of therapeutic approaches have been developed
to approach both pain and its associated anxiety. There is
justified concern about opiate and benzodiazepine depen­
dence and abuse, but this is offset by the importance of
treating pain aggressively. In addition to pain and anxiety,
practitioners are now focused on pruritus as well. Scales
have been developed to measure pain, anxiety, and itch
separately.
Pathology of a Burn Injury Pain
and Pain-Generating Mechanisms
Pain is the most frequent complaint of burn-injured
patients.4 Injury-induced nociceptive responses can be
described as hyperalgesia and allodynia. Hyperalgesia is
increased nociceptive response to painful stimulus (e.g.,
pinprick). Allodynia is exaggerated pain to nonpainful
stimuli (e.g., touch). All burn injuries are painful. Even first-
degree burns can produce at least mild pain and discomfort,
especially when something such as clothing rubs against
the burned area (allodynia). Even the slightest change in air
currents moving past the injured/exposed skin can cause a
patient to experience excruciating pain. The loss of protec­
tive covering of the epidermis and the associated inflamma­
tion leads to sensitization of the nerve endings. Studies of
humans and monkeys confirm that burn injuries not only
make the injured area but also the surrounding tissue more
painful.5–7 Second-degree, moderate to deep partial-
thickness burns result in variable amounts of pain depend­
ing on the amount of destruction to the dermis. In addition,
as the inflammatory response progresses, the release of
cytokines and chemokines increases the pain not only in
the burned area but also in the surrounding tissues by the

64  •  Management of Pain and Other Discomforts in Burned Patients
680
that have been excised and grafted on a clean and uniform
vascular bed rarely develop one of these chronic pain syn­
dromes. Wounds that heal by granulation and scar forma­
tion seem to be more apt to develop a chronic pain problem
because of the continued stimulation of nerve fibers in the
area with enhancement of the hyperalgesia. Skin biopsies
of granulation tissue have clearly shown neuronal tissue
entrapment.20 Pain in scar tissue subsides over time as the
scar tissue matures.
Tolerance to Opiates and
Opiate-Induced Hyperalgesia
Opioids are highly effective analgesics and are the mainstay
for treatment of moderate to severe burn pain.24 Continued
use of opiates can lead to burned patients developing toler­
ance to their analgesic effects. There is a pharmacokinetic
component to the tolerance to opiates: the clearance and
the volume of distribution of many drugs are increased over
time, resulting in lower therapeutic concentrations.27 The
protein binding of opiates is also increased in burned
patients, resulting in a lower free fraction available to act on
target µ-opioid receptor. The most important reason for the
tolerance is indeed related to µ-opioid receptor changes
induced by the opiates.
Opiates signal their beneficial analgesic effects by inter­
cellular coupling to G-proteins. Just like any other G-protein
coupled receptor (e.g., adrenoceptor), the repetitive admin­
istration of an agonist (e.g., epinephrine or opiate to adre­
noceptor or opiate, respectively) leads to desensitization of
the receptor in which the receptor responses are attenuated
with each subsequent administration.28 The attenuated
response is related to phosphorylation and not to down-
regulation of receptor. The continued administration of
opiates will, with time, result in down-regulation of the
opiate receptor number.
Both the desensitization (phosphorylation) and down-
regulation of opiate receptors lead to tolerance to opiates.
Recent studies indicate that continued administration of
opiates also induces increased nociceptive behaviors (hyper­
algesia and allodynia: a.k.a. opiate-induced hyperalgesia
[OIH]).17 Tolerance can be overcome by increasing the doses
of the opiates, but OIH is made worse by increasing opioid
administration. Studies in burn patients confirm OIH when
pre- and intraoperative use of opiates resulted in worse
postoperative pain.28 Opiates, similar to bacterial peptides,
lead to activation of innate immune responses (activation
of macrophages and microglia) with release of inflamma­
tory cytokines and chemokines. Attenuation of microglial
activation has been shown to decrease OIH, with improved
control of pain.26
Measurement of Pain
in Burned Patients
Although pain cannot be measured directly, it can be quan­
tified by using one of the standardized tools described here.
Using reliable and valid tools allows us to gauge the effec­
tiveness of our treatment for any one patient. Assessing
pain on a scheduled basis and using the same tool for each
injury versus injury-induced biochemical changes at the
local and central nervous system level. Treatment of anxiety
with benzodiazepines may have either beneficial or para­
doxical effects on anxiety and pain.15 Clinical observation
and rodent studies indicate that although benzodiazepines
acutely potentiate the analgesic effects of other opiates, the
prolonged administration of benzodiazepines together with
opiates can induce tolerance or even hyperalgesia.
Another factor that contributes to pain is procedures.
Baseline pain (pain at rest) is invariably present in most
burn patients. This baseline increased nociception can be
aggravated by procedural pain (hyperalgesia) induced by
dressings changes, physical therapy, and other procedures.
Procedural pain is the most intense burn injury pain that is
undertreated.16,17 Thus the anticipation of pain related to
procedures (e.g., wound care) that occurs at least once daily
can increase a patient’s perception of pain, which in turn
can lead to greater anxiety. This reaction may explain some
findings that suggest that pain increases over time in burned
patients.18–20 There could also be another component—
namely, tolerance to analgesics and/or opiate-induced
hyperalgesia (see later discussion)—that explains the
increase in pain over time.7 Finally, exaggerated adrenergic
stimulation with release of catecholamines is part of the
pain and stress response. Stress of any form has paradoxical
effects on pain, initially causing stress-induced analgesia
and then later exacerbation of pain, a feature known as
“stress-induced hyperalgesia.21–23 Thus the stress of burn
injury, with its concomitant release of catecholamines and
adrenoceptor stimulation, leads to exaggeration of pain.21–23
Pain as a Function of the
Healing Process
As deep dermal or full-thickness burn wounds heal, either
by primary intention from excision and grafting or by sec­
ondary intention through granulation tissue and scar for­
mation, the injured neural tissue is reorganized.17 Reflex
neural function returns to grafted burn skin approximately
5–6 weeks after the burn has been covered by autografted
skin.20 Active vasodilatation, vasoconstriction, and pain
sensation all return at this time.24 These functions also
return to the burn wound that heals through scar forma­
tion but may take up to 6 months for complete neural reor­
ganization. This could be an additional basis of neuropathic
pain at the burn wound site and in surrounding tissue.
Despite the healing of tissues, the memory of any form of
trauma-induced pain lasts for a prolonged period. In other
words, subsequent (e.g., reconstructive) surgery on this
area leads to exaggerated nociceptive responses sooner and
longer lasting than that seen at initial injury.32 This memory
seems to be maintained by innate immune cells (macro­
phages and microglia), which seem to be already primed
because of previous injury and become activated sooner
with release of inflammatory cytokines and chemokines.26
Although rare, causalgia, dysesthesia, and phantom pain
syndrome can sometimes develop in healing skin. Phantom
limb sensation and pain are more common following ampu­
tation, which is often associated with large burn injury or
electrical injury.267 The incidence of these chronic pain syn­
dromes seems to be related to the healing process. Burns

64  •  Management of Pain and Other Discomforts in Burned Patients
681
the point representative of the patient’s pain. The visual
analog scale has been used in a number of studies with a
variety of patient samples and has been shown to be a valid
method of measuring the sensory component of a patient’s
pain. The demonstrated validity of the scale allows for com­
parisons of visual analog pain assessments between studies
with different patient samples. However the visual analog
scale is not interchangeable with the graphic numeric
rating scale.29
Motivational-affective and cognitive-evaluative compo­
nents of pain are most frequently measured using the
McGill Pain Questionnaire (MPQ).30 The MPQ consists of 20
sets of adjectives that describe all three components of pain:
sensory, affective, and evaluative. Qualitative profiles and
quantitative scores for each dimension as well as a total
pain score can be derived from the selected adjectives. The
MPQ has been translated into several languages and has
been shown to be a reliable and valid measurement tool.
Since it takes 10–20 minutes to administer, it may not be
as useful for frequent, repeated measurements. Many
studies have employed this measurement on a daily basis to
measure either overall or resting pain. Gordon et al.31 in a
prospective multicenter study, asked 40 adult burned
patients to rate their pain on four scales. These scales were
a visual analog scale, an analog chromatic scale,32 an adjec­
tive scale, and a faces scale.33 At the end of the study patients
were asked to choose their preferred scale. Patients pre­
ferred the faces and analog chromatic scales. Although
further research is needed to validate these findings, the
preference of patients is another variable to be considered.
PAIN MEASUREMENT TECHNIQUES FOR
PEDIATRIC BURNED PATIENTS
The measurement of children’s pain is much more complex
than it is for adults, especially for preverbal children. The
American Academy of Pediatrics and the American Pain
Society issued a joint statement in 2001 that included the
recommendation that, in a hospital setting, “ongoing assess­
ment of the presence and severity of pain and the child’s
response to treatment is essential.”34 The assessment of pain
in children has included physiologic measurements, behav­
ioral assessment, and patient reports of pain. The physio­
logic indicators that have been evaluated are heart rate,34
assessment gives us information about how pain is experi­
enced by a single patient throughout burn treatment; we
can note patterns that emerge and schedule medications
accordingly. Furthermore standardized tools allow us to
compare the pain management of one patient with another,
as well as of one burn unit pain management regime with
that of other burn units in order to determine the effective­
ness of protocols for pain management. Another important
reason for assessing pain regularly and in a standardized
way is that it communicates to the patient that we believe
he or she has pain and that we are trying to do something
about it. This communication reassures the patient, thereby
reducing the likelihood that the patient will escalate pain,
anxiety, and other related behaviors.
Gracely3 reviewed a number of objective modalities for
the measurement of experimental pain. He notes that “pain
arises from and is modulated by, a number of mechanisms.
These mechanisms are not static but change over time and
involve all levels of the central nervous system. In an
attempt to understand these mechanisms, several experi­
mental tools have been employed to further elucidate the
exact pathways involved in pain transmission and to better
understand the therapies used to relieve pain.”
Some of these tools are cortical evoked potentials, func­
tional brain imaging (positive emission tomography [PET]),
functional magnetic resonance imaging (fMRI), source
analysis of evoked activity, and electrophysiological record­
ing from the human brain. As noted by Gracely, comparing
these measures with verbal judgments of pain magnitude
validates these physiologic measures: “This implicitly ele­
vates subjective judgment to the level of a validation stan­
dard.”3 Clinical measurements of pain must continue to
rely on standard subjective measures. A tool to use in the
clinical setting must be quick and easy to use and useful for
frequently repeated assessments.
A major concern in the clinical setting is the use of a
consistent pain measurement tool before and 1–2 hours
after the administration of a pain-relieving medication. For
procedural pain management, the same tool should be used
to measure pain at the beginning of a procedure, during the
procedure, and post-procedure in order to measure the
effectiveness of the pain management regimen used for pro­
cedural pain.
PAIN MEASUREMENT TECHNIQUES FOR
ADULT BURNED PATIENTS
A variety of pain measurement techniques have been used
with adult burned patients. The more common measures
include adjective scales (Table 64.1), numeric scales (i.e.,
rating pain on a scale of 0–5, 0–10, or 0–100), and visual
analog scales (Fig. 64.1). Each of these scales measures the
sensory component of a patient’s pain. Adjective scales and
numeric scales are quick and easy to administer because
they do not require a visual representation of the scale. The
visual analog scale requires a visual representation of the
scale to be presented to a patient. Patients must mark or
point to the place on the scale that represents their level of
pain. This presents a problem for a patient whose hands are
burned, so some investigators have used a technique of
sliding a line or color strip along the scale with instructions
to a patient to direct the movement of the slide, stopping at
Table 64.1  Adjective Scales in English and Spanish.
0
No pain
0
Nada de color
1
Slight pain
1
Dolor leve (ligero)
2
Moderate pain
2
Dolor moderado
3
Severe pain
3
Dolor severo
Fig. 64.1  Visual analog scale (VAS) for children to rate their levels of
pain. (From the Varno/Thompson Pediatric Pain Questionnaire. With per­
mission from the American Society for Clinical Pharmacology and
Therapeutics.)

64  •  Management of Pain and Other Discomforts in Burned Patients
682
Pain during procedures is especially important to assess.
In 1997, the FLACC scale was developed for postoperative
pain.51 This has now been applied for pain related to dress­
ing changes on burn wounds. This scale is now documented
to reflect patient pain intensity as well as nurse clinical
experience.52
A burn-specific observational tool was developed by
Barone et al. at Shriners Hospitals for Children-Cincinnati.53
The Observational Pain Assessment Scale (OPAS) is useful
in children 0–3 years of age. The scale is depicted in Table
64.2.
Research suggests that simple self-report scales can be
used with preschool children. Examples of such scales
include the Oucher Scale (photographs of children with
various facial expressions).54–56 Drawings of faces19,57 have
also been used with preschool-aged children58 and school-
aged children (8 years).59 Preschool children have also used
the Poker Chip Tool,60 color scales,61,62 and a thermometer62
to report the degree of pain or hurt. These simple tools
allow a preschooler to report pain and are easy to use. One
caution with the face scales is that a practitioner must help
a child differentiate between physical pain and sadness
unrelated to pain. Since there is no evidence that any one
of these is more valid than another, it is recommended to
pick one and use it consistently. When self-report scales are
used in conjunction with observational scales, a practitio­
ner gets a better picture of a child’s response to pain and
pain therapies.
A school-aged child’s cognitive development allows for
more abstract thinking. In addition to the Faces Pain Rating
Scales, which they enjoy,19 they can use simple numeric
scales 0–5 in the early school years (ages 7–8)63 and more
complex scales 0–10 or 0–100 in the later years (age 9–12).
Visual analog scales anchored with happy and sad faces62
and simple adjective scales62,64 also can be used with this
age group. In addition to self-reports of pain, observational
scales such as the CHEOPS40 or the Procedure Behavior
Check List65 can be used with a school-aged child. Again,
the important issue is to use one selected scale consistently
since no one has been shown to be more valid than others.
Adolescents can think abstractly and can quantify and
qualify phenomena and so can use the same scales as
adults. One concern with adolescents is that when they are
ill they tend to regress and thus may require the use of a
simpler scale during such times.66
respiratory rate,35 blood pressure,35 endocrine changes,35,36
and changes in PO2.37 None of these shows promise as an
indicator for measuring pain in sick children because all are
affected by a variety of stressors, metabolic changes related
to a burn, and medications in addition to pain.
Behavior scales have been devised to measure pain by
providing standardized instructions and guidelines for
observing behaviors thought to be specific to pain. A
number of investigators38–43 have looked at infants’ cries as
measurable behaviors that can be observed in order to eval­
uate pain. Although these studies demonstrate that length
of cry, pitch, intensity, and other characteristics of crying
may be used to evaluate pain in infants, the analyses of
crying are very time-consuming and require elaborate
audio equipment. Izard et al.,44 Craig et al.,45 and Granau
and Craig42 have attempted to code facial expressions as
measures of pain in infants. Their system characterizes
nine facial actions involved in the expression of pain, but its
use requires videotaping and detailed analyses of an infant’s
facial movements. Although this method offers excellent
research applications, it, like the detailed analyses of crying,
is too cumbersome and not appropriate for the clinical
setting. On the other hand, the studies do provide clinicians
with information about various facial reactions, as catego­
rized by Granau and Craig, which may be helpful in the
clinical identification of pain in infants. Other investigators
have devised multidimensional scales that include length of
cry, facial expressions, and behavioral states in order to
measure pain in infants.46–48 These scales are easier to use
and allow an observer to assess pain as either present or
absent without further quantification.
Examples of observational scales that allow for quantifi­
cation and may be used with toddlers and preverbal chil­
dren are the Children’s Hospital of Eastern Ontario Pain
Scale (CHEOPS)49 and The Observer Scale.50 The CHEOPS is
a scale of six behaviors, each scored on a numeric range; it
yields a total numeric score for pain. This scale has been
shown to be valid and to have good interrater reliability. The
Observer Scale is another standardized instrument that cat­
egorizes overall pain or comfort behaviors on a scale of 1–5.
The five categories are laughing, euphoric; happy, con­
tented, playful; calm or asleep; mild-moderate pain—crying,
grimacing, restlessness, but can be distracted with toy,
food, or parent; and severe pain—crying, screaming, and
inconsolable.
Table 64.2  Observational Pain Assessment Scale (OPAS)44
Assess each of the areas identified in the “Observed Behavior” column rating each behavior using the 0, 1, or 2 rating. Add the
ratings together for each observed behavior. Document your total score.
Observed Behavior
0
1
2
Restlessness
Calm, cooperative
Slightly restless, consolable
Very restless agitated, inconsolable
Muscle, Tension
Relaxed
Slight tenseness
Extreme tenseness
Facial Expression
No frowning or grimacing, composed
Slight frowning or grimacing
Constant frowning or grimacing
Vocalization
Normal tone, no sound
Groans, moans, cries out in pain
Cries out, sobs
Wound Guarding
No negative response to wound
Reaching/gently touching wound
Grabbing vigorously at wound
Used with permission of the authors.

64  •  Management of Pain and Other Discomforts in Burned Patients
683
Measurement of Itching
Itching is very common in burn survivors. Even in small
burns, the prevalence is 35% with moderate pruritus and
14% with severe, and, in many cases, the pruritus impacts
daily living.75–77 Another series of 510 burns reported a
prevalence of 87%.78 The severe itching of burn scars and
wounds has not been discussed much in the literature, but
clinicians can testify that this phenomenon is a very serious
problem. Patients who experience such itching often excori­
ate new grafts or recently healed skin, thus enhancing their
susceptibility to infections. The measurement of itching has
been part of a number of scales that focus on all the prob­
lems that the patient has, such as the Patient and Observer
Scar Assessment Scale (POSAS)79 and the Assessment of
Health Outcomes in Children with Burn Injury.80 When
pruritus is severe, patients can focus on nothing else. Until
very recently there have not been any tools focused on mea­
suring itch. Now, Field et al.81 reported using a visual analog
scale of 1–10 to assess itching. Pat Blakeney and Janet
Marvin at the Shriners Hospital for Children in Galveston
developed an instrument to measure itch called “itch man”
(Fig. 64.3). This instrument was based on a patient’s
drawing of his experience in the hospital.82 Children seem
to be able to relate to “itch man,” and validation has been
completed.83 Several scales have been developed for adults
to use. One from Belgium has been translated and validated
in English and seeks to measure all the aspects of itching
and how it relates to other types of variables.84 Another
coming from the dermatologic literature measuring itching
in five dimensions is named the 5-D itch Scale.85
In summary, symptom assessment and management are
very important in burn care. The experience of pain may
affect the perceptions of other symptoms, including anxiety,
fear, or itch. Each symptom should be assessed within the
context of other symptom assessments. There are many
measurement tools for pain, anxiety, and itch assessment
across the life span that can be useful to the clinician and
the researcher. Further studies need to be completed in all
these areas.
Treatment Considerations
Once pain has been assessed and quantified, treatment can
be considered. Three modalities of treatment are effective
Intubated and sedated children provide more challenges
in the assessment of pain. The more disabilities that a child
has and the more medications that are being given to the
patient create challenges to the clinician. A 2-year-old child
who is blind, with only one extremity that is functioning
and on numerous medications presents a huge assessment
challenge to the clinician. Table 64.3 presents a list of clini­
cally useful tools according to patient age.
“Pain is what the child says it is.”67 What about the case
where the nurse documents a lower number than the child
says because the nurse believes the child is over-rating the
score? Reiman et al.68 surveyed nurses’ knowledge and atti­
tudes regarding pain and their ability to manage pain. The
modified Pediatric Nurses’ Knowledge and Attitude Survey
Regarding Pain tool (PNKAS – Shriners Version 2002)
needs further validation but demonstrates the need to con­
sider the healthcare provider’s attitude and knowledge of
pain.
Measurement of Anxiety
Anxiety is measured in a variety of ways. In 2000, Robert
et al. surveyed 64 burn treatment centers to determine how
they evaluated and treated anxiety, especially in children.69
They found that most centers did not use standardized mea­
sures of anxiety. Based on that survey and other informa­
tion, the Shriners Hospital for Children in Galveston has
been using the Fear Thermometer adapted by Silverman
and Kurtines70 from the Walk’s Fear Thermometer71 (Fig.
64.2).
Taal and Faber introduced a tool to measure burn-specific
pain anxiety (BSPAS).72 It uses a five-item scale used to
measure anxiety associated with anticipated procedural
pain in adult patients.73 Initial reliability, validity, and utility
studies have been completed.73,74 A similar tool is needed for
children.
Table 64.3  Recommended Pain Measurement Tools
for Burned Patients
INFANTS AND TODDLERS
CHEOPS42
The Observer Pain Scale43
PRESCHOOLER
Faces Pain Rating Scale26,48
Oucher45-47
Pediatric Pain Questionnaire52
CHEOPS42
SCHOOL-AGED CHILD
Faces Pain Rating Scale26,54
Visual analog
Numeric scale
Pediatric Pain Questionnaire52
Procedure Behavior Checklist56
ADOLESCENTS AND ADULTS
Visual analog
Numeric scales
Adjective scales
McGill Questionnare23
None
A little
bit
Some
A lot
Very,
very
much
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
Fig. 64.2  Fear thermometer to rate anxiety level. (From Silverman and
Kurtines W. Anxiety and phobic disorders: a pragmatic approach. New York:
Plenum; 1996; Springer Science and Business Media.)

64  •  Management of Pain and Other Discomforts in Burned Patients
684
The newest approach to reducing the pain of a scar is the
use of fat grafting. It was initially developed in animals and
more recently used clinically in humans.101 The fat decreases
local neuroinflammation.
TOPICAL AGENTS
Aloe vera has been used as a home remedy for burns for
many generations, and several recent studies have exam­
ined its efficacy more thoroughly. Maenthaisong et al. con­
ducted a systematic review and meta-analysis and concluded
from the published studies of first- and second-degree burns
that aloe vera was more effective than Vaseline gauze
alone.102 In that study, aloe use was associated with a
shorter healing time by 8.79 days. A more recent random­
ized controlled study in 2009 by Khorasani et al. confirmed
the greater efficacy of aloe over silver sulfadiazine.103
In contrast, topical morphine was not very effective in
reducing the pain of partial-thickness burns.104 The final
word on the effectiveness of topical heparin is still out.105
Physical coverage of the burn wound decreases pain. For
example, blisters left intact lead to less pain,106 but this prac­
tice is questionable because of possible infection associated
with the blisters. One additional issue concerning proce­
dures is the amount of pain created by removing a dressing
from the burned area. These removals are usually facilitated
by soaking the dressings off, but the soaks are sometimes
painful. Some newer dressings are easy and painless to
remove, and moist, exposed-burn ointment dressings107 are
being developed to further reduce pain.
Acticoat was found to be much less painful than silver
sulfadiazine in the treatment of partial-thickness burns by
Varas et al.108 Several new lipido-colloid dressings seems to
show promise for reducing pain.109, 110 Cellulose dressings
also reduce pain.111 Several new products are adherent to
dry skin but not moist skin and therefore much less pain
than has been reported to be associated with silver sulfadia­
zine.112,113 Suprathel is a reabsorbable skin substitute that
goes even further to reduce the pain of dressing by eliminat­
ing the need for dressing changes.114
A more novel technique of painlessly cleaning the burn
wound is to use an ultrasound mist, and there are two short
reports advocating this.115,116
PHARMACOLOGICAL TREATMENT OF
BURN PAIN
Optimal pain management for burn patients requires a
multidisciplinary approach and individualized therapy.
However pharmacologic management of burn pain is the
mainstay of therapy. General rules are helpful in governing
the use of pain medication. The first tenet is that if the
patient says he or she is having pain, he or she is suffering.
The second tenet is that analgesics are most effective when
given on a regularly scheduled basis (not “as needed” or
PRN). The third tenet is that, when avoidable, pain medica­
tion should not be given as an intramuscular injection since
injections themselves cause pain and anxiety. In addition,
initial physiological changes associated with large burns
make uptake from injection sites erratic and unpredictable.
Last, dose and type of medication should be reevaluated
frequently during the hospital course to make sure pain is
with pain secondary to burn injury: surgical, pharmaco­
logical, and behavioral.
SURGICAL TREATMENT OF PAIN
In burn patients, pain is predominately related to the open
wound. Once the wound is closed, the pain subsides. The
use of resection and grafting of open burn wounds signifi­
cantly reduces burn pain. Open wounds should be grafted
as soon as they are clean enough to do so. Even temporary
coverage with cadaver skin or pigskin reduces pain in the
area of the burn. In the case of second-degree wounds, the
use of Biobrane, Opsite, Tegaderm, Dressilk, Polymem,
Copoymer, Acticoat, Mepilex AG, Duoerm, or other wound-
covering dressings almost immediately eliminates pain at
the burn wound site.86–95 Biobrane has also been used for
toxic epidermal necrolysis and was found to reduce pain
significantly; Duoderm is a similar but cheaper product
than Biobrane and has the same beneficial effect on pain.
Cultured allogeneic keratinocyte sheets accelerated healing
and thereby reduced pain and suffering compared to Opsite
treatment. The cultured keratinocyte sheets cut healing
time in half. Pain assessment as early as day 3 revealed
lower pain scores in those sites treated with keratinocyte
sheets. Less costly dressings include honey because it pro­
vides the synergistic interactions of a moist environment,
antibacterial activity, and antiinflammatory action and
thereby promotes healing.96–98
Negative-pressure wound dressing therapy is a relatively
new approach to the closure of wounds. As a byproduct of
that treatment, Fischer et al. claim less pain but give no
data.99 Other new techniques include laser treatment of
scars. The CO2 fractional photothermolysis treatment of
scars does reduce scars and pain. On the other hand,
it reduces neuropathic pain by 54% and pruritus by
49%.100
0
Comfortable,
no itch
1
Itches a little; does
not interfere
with activity
3
Itches a lot; difficult to
be still, concentrate
4
Itches most terribly; impossible
to sit still, concentrate
2
Itches more;
sometimes interferes
with activity
Fig. 64.3  Itch Man Scale to rate itching intensity in children, designed
by Blakeney and Marvin, 2000, at Shriners Hospital for Children.
(Reprinted with permission of Shriners Hospital for Children.)

64  •  Management of Pain and Other Discomforts in Burned Patients
685
to pain control can increase the quality of pain control in
part by reducing the dose and thus the adverse effects of
opiates needed.
Morphine
Morphine has been described as the gold standard for treat­
ing burn pain and remains the first choice in many burn
units. Time to peak effect and duration of action for mor­
phine are appropriate for treating background and break­
through pain most of the time. Although morphine is often
used with PCA, some clinicians prefer drugs with quicker
on–off kinetics, especially for painful procedures. The active
morphine-6-glucuronide metabolite of morphine is excreted
in urine and can accumulate in patients with renal failure.120
Chronic treatment with opiates will result in tolerance
and increasing dosage requirements to control pain. Opiate
tolerance is accompanied by an increased sensitivity to
pain. The central mechanism of this hyperalgesia appears
to involve glutamate transmission mediated by N-methyl-D-
aspartate (NMDA) receptors. In addition to tolerance to
narcotic analgesics, some patients experience a phenome­
non referred to as OIH. OIH differs from tolerance in that,
where patients tolerant to morphine respond to larger
doses, with OIH, increasing doses of morphine are associ­
ated with increased pain.
OIH associated with burns has been reviewed by Holtman
and Jellish.121 Although it may at times be difficult to distin­
guish opiate tolerance from OIH, deteriorating pain control
despite large increases in morphine dosage is suggestive of
OIH. One benefit of a multimodal approach to pain control
is that it allows lower doses of opiates, which also reduces
the risk of OIH. When OIH is suspected, the dose of mor­
phine must be reduced, and additional changes in drug
therapy are needed to compensate for the reduced effect of
morphine. All patients with OIH will not respond in the
same manner to pharmacological interventions. A switch
to methadone has been reported effective in patients poorly
controlled by morphine. This benefit has been explained by
NMDA receptor antagonism by methadone. α-2 Adrenergic
agonists, as well as low-dose ketamine have also been found
effective. Additional agents included in multimodal strate­
gies to reduce narcotic analgesics are benzodiazepines,
acetaminophen, gabapentin, and pregabalin.
Fentanyl
Fentanyl is a potent synthetic opiate with a relatively rapid
onset of action and a shorter duration of effect than mor­
phine. The relatively rapid onset and shorter duration of
action with bolus doses make fentanyl a suitable choice for
analgesia during painful procedures and with PCA. An oral
transmucosal dosage form is also available and has been
found effective in pediatric patients during procedures.122
With continued infusion, however, the drug accumulates,
and, due to its long context-sensitive half-time, prolonged
infusions can delay extubation of ventilated patients. This
can be prevented by the daily wake-up protocols practiced
in many ICUs. Discontinuing sedation in ventilated patients
can also be associated with significant morbidity, such as
unplanned extubations. A benefit similar to daily wake-up
protocols but without associated morbidity is also possible
with a protocol of daily assessment of sedation and dosage
adjustment.123
continuously controlled and that the patient is experiencing
no serious side effects.
Dramatic physiological changes associated with large
burns produce significant pharmacokinetic and pharmaco­
dynamic alterations that affect drug selection and dosing
considerations.117 Two metabolic and hemodynamic phases
are recognized following major burn injury. An initial burn
shock (ebb) phase with decreased circulating blood volume,
decreased cardiac output, and increased systemic vascular
resistance is followed after approximately 48 hours by a
hyperdynamic/hypermetabolic (flow) phase with increased
cardiac output and decreased systemic resistance, increased
oxygen consumption, and intense catabolism. These
changes in cardiac output and organ perfusion also affect
hepatic and renal drug clearance in a biphasic fashion. For
example, during the ebb phase, hepatic and renal blood flow
may be reduced enough to impair drug metabolism and
excretion. Conversely, during the flow phase, increased
hepatic blood flow enhances clearance of drugs such as
fentanyl and propofol that are efficiently extracted by the
liver.118 Likewise renal excretion of some drugs may be
increased enough to require alteration of the dose. Further­
more loss of plasma proteins through open wounds and
extensive edema due to massive fluid resuscitation pro­
foundly alter drug distribution and binding to plasma pro­
teins. Sympathetic tone and drug exposure during the
hospital course alter the up- and downregulation of various
drug receptors. Perception of pain is enhanced by anxiety.
Devastating burn injuries produce intense anxiety that can
be exaggerated or reduced by the effectiveness of pain
control. All these factors ultimately affect responses to anal­
gesic (and other) drugs in ways that are often unpredictable.
Patient response should be closely monitored and drug
selection and dosing adjusted carefully to avoid undertreat­
ment or complications of overdose.
OPIOIDS
Opioid analgesics have been the mainstay of burn pain drug
therapy.119 Burn pain is not a single entity but is experi­
enced in several distinct ways: background, breakthrough,
procedural, and postoperative pain. Drug selection and
dosing are very different for each of these clinical situa­
tions. There are several opiate drugs with widely different
pharmacokinetic profiles. This allows selection of an agent
with speed of onset and duration of action appropriate to
specific clinical needs. For background pain, slower onset
and long duration of action are suitable. For patient-
controlled analgesia (PCA), a rapid onset is desirable. For
procedural pain, it is best that the drug effect (and adverse
effects) not last much longer than the procedure. A variety
of routes of administration are also possible with this large
group of drugs. In most cases, it is better to give a sufficient
dose to control pain over its recommended length of action
rather than smaller doses more frequently. This problem
occurs frequently when physicians are reluctant to pre­
scribe the recommended dose for pain.
The use of opiate analgesics is often limited by their
adverse effects. Continuous use may be limited by pruritus
or constipation. Higher doses needed for intense pain asso­
ciated with procedures may cause unsafe depression of res­
piration. Use of adjuvant drugs and a multimodal approach

64  •  Management of Pain and Other Discomforts in Burned Patients
686
burned patients. These results suggest that although the
clearance of diazepam may be unpredictably slow and
accumulation of doses may be possible in burned patients,
this is not the case with lorazepam. As a result, treatment
of burn patients with lorazepam should be more predictable
than with diazepam and therefore more controllable and
effective. Diazepam has a relatively long half-life and is bio­
transformed to active metabolites. Midazolam is a shorter-
acting agent suitable for brief procedures or infusion and
is the most frequently used sedative in U.S.-based burn
centers.134 Midazolam undergoes extensive first-pass
metabolism by intestinal and hepatic tissues after oral
administration. However its major hydroxylated metabolite,
α-hydroxymidazolam, is at least as potent as midazolam.135
Lorazepam has a duration intermediate between mid­
azolam and diazepam. Lorazepam is metabolized by gluc­
uronidation to inactive metabolites, and, because of this, it
is often preferred for anxiolysis in burn ICUs.
NONOPIATE ANALGESICS
Acetaminophen is a nonantiinflammatory antipyretic
analgesic. Although its analgesic action is too weak to
adequately control pain of more than minor burns by
itself, acetaminophen acts synergistically with more potent
analgesics and is an important component of multimodal
pain protocols. When used in this manner acetaminophen
reduces the dose requirements of opiates. It is effective
when given alone for minor burns. Meyer et  al. found
that 10–15  mg/kg of acetaminophen given orally every
4 hours was effective without producing toxic plasma
concentrations.136
Nonsteroidal antiinflammatory drugs (NSAIDs) also
possess significant analgesic and antipyretic action and are
also antiinflammatory agents. They are not used routinely
in burn patients due to additional adverse effects. NSAIDs
have been found to promote acute kidney injury in hypovo­
lemic patients through inhibition of prostaglandin synthe­
sis, which reduces renal blood flow due to constriction of
afferent renal arterioles.137 Increased bleeding due to an
antiplatelet effect is another concern.
ANTICONVULSANTS
Drugs originally intended as anticonvulsants have also
proved helpful in pain management protocols. Gabapentin
and pregabalin are such drugs that have been found to be
effective for the management of neuropathic pain.138,139
Since neuropathic pain and narcotic-induced hyperalgesia
appear to share pathophysiological etiologies, it is likely that
drugs effective against neuropathic pain should also facili­
tate pain control by reducing hyperalgesia associated with
narcotic administration. The proposed mechanism is not
established, but there is preclinical evidence that these
drugs reduce central sensitization through an interaction
with spinal voltage-gated calcium channels.139 Van Els­
traete and colleagues found that although gabapentin did
not affect the initial analgesic effect of fentanyl in rats, it did
prevent, in a dose-dependent manner, the delayed hyperal­
gesia associated with fentanyl administration.140 In a clini­
cal study Rimaz et al.141 reported that a single preoperative
dose of gabapentin given prior to burn surgery decreased
Remifentanil
Remifentanil is an ultra-short-acting opioid with a rapid
time to peak activity (90 s). Elimination is very rapid by
nonspecific esterases in blood and tissue, which give it a
context-sensitive half-time of approximately 4 min without
regard to duration of infusion.124 The pharmacokinetic
properties of remifentanil make it appropriate when rapid
emergence is desired. The abrupt recovery from remifent­
anil analgesia has been associated with hyperalgesia. This
can be prevented by concomitant doses of α-2 adrenergic
agonists, ketamine, or a longer-acting opiate prior to termi­
nation of infusion.125
Alfentanil
Alfentanil has a short time to peak effect similar to remi­
fentanil (90 s) and shorter duration than fentanyl. With
a Vd of less than one-fourth that of fentanyl, alfentanil
also has a faster clearance and shorter half-life.126 These
properties make it suitable to provide analgesia for brief
procedures and to infuse for longer procedures and yet
provide relatively rapid recovery. The pharmacokinetics of
alfentanil are especially suited for PCA. Sim and others127
used alfentanil alone with PCA for burn dressing and
wound care with excellent satisfaction of patients and
nurses.
Methadone
Methadone is a synthetic opiate that combines µ receptor
agonist, NMDA antagonist, and amine uptake inhibition
properties.128 Preclinical studies have shown that through
its NMDA receptor antagonist action, methadone inhibits
morphine tolerance and hyperalgesia.129 These properties
make it theoretically suited for treating burn pain by reduc­
ing the risks of central sensitization of pain and OIH. In
clinical studies there appears to be a lack of cross-tolerance
with morphine. There are multiple reports of improved pain
control in patients switched from morphine to metha­
done.130,131 The mean bioavailability is about 80% after
enteral administration. Its onset of action is more rapid
than morphine after intravenous injection due to its higher
lipid solubility. Its elimination is quite variable but signifi­
cantly longer (t1/2 7–65 hours) than that of morphine
(t1/2 1.7–3.3 hours).128
BENZODIAZEPINES
Significant burn injuries are associated with considerable
anxiety and psychological stress. Pain sensation is enhanced
by anxiety and, in some cases, pediatric patients for
example, even complete elimination of pain does not make
procedures stress-free. Reducing anxiety can reduce nar­
cotic requirements for pain control. Benzodiazepines are
the most commonly used anxiolytic agents used in burn
centers. Pharmacokinetic considerations influence the
choice of benzodiazepines in burn patients. Martyn et al.
evaluated the clearance of diazepam132 and lorazepam133
in burned patients and in nonburned controls. Diazepam
is metabolized by P450 oxidases (phase I reaction), and its
metabolism and clearance were depressed in burned
patients. In contrast, lorazepam is metabolized by conjuga­
tion (phase II), and its clearance is slightly enhanced in

64  •  Management of Pain and Other Discomforts in Burned Patients
687
available as a solution for injection and can also be admin­
istered as an intranasal mist.146 Clonidine is the more inex­
pensive of the two agents.
The analgesic action of dexmedetomidine and clonidine
is weak, and these drugs are most effective as adjuvants.
They reduce dose requirements for narcotics and counter­
act opiate-induced hyperalgesia. Compared to clonidine,
dexmedetomidine is a more selective adrenergic agonist and
has a higher affinity for the α2 receptor. The elimination
half-life for dexmedetomidine is much shorter than cloni­
dine’s (2 hours vs. >12 hours).147 Intravenous infusion of
dexmedetomidine allows more precise titration of sedation
to the patient’s needs but is more expensive.
Among the advantages of α2 adrenergic agonists are the
lack of effect on airway patency, respiratory drive, and
airway reflexes. Dexmedetomidine is especially effective in
combination with ketamine. Dexmedetomidine limits the
hypertension and tachycardia associated with ketamine,
which can be problematic in older patients. In addition,
dexmedetomidine also potentiates the analgesic effect of
ketamine and in this way reduces the dose of ketamine
needed.
PROPOFOL
Propofol is a nonbarbiturate intravenous anesthetic without
analgesic activity.148 Advantages include rapid onset of
action and a rapid emergence with little cumulative effect
after prolonged infusion.149 A disadvantage is pain when
administered through a peripheral vein. It is most com­
monly used for induction and/or maintenance of general
anesthesia. Propofol has also been used in sub-anesthetic
doses along with an analgesic drug for sedation during
stressful procedures.
Under certain conditions and with limited duration pro­
pofol is given by intravenous infusion for sedation of intu­
bated patients requiring mechanical ventilation in the ICU.
Ronan and others found sedation of intubated patients to
be superior with propofol than with midazolam infusion in
terms of speed of wake-up and quality of sedation.149 The
rate and duration of propofol infusion should be limited,
and patients receiving propofol should be closely observed
for signs and symptoms of propofol infusion syndrome
(PRIS). This is a rare but serious and often fatal complica­
tion of propofol. PRIS has a variable clinical presentation
but includes combinations of metabolic acidosis, arrhyth­
mias, rhabdomyolysis, renal failure, and other disorders.
The total cumulative dose is the main risk factor for PRIS,
and the U.S. Food and Drug Administration (FDA) recom­
mends a maximum dose rate of 4 mg/kg per hour, but case
reports have included dose rates lower than this.150 Some
intensivists limit propofol to provide sedation during
weaning of longer-acting agents or for relatively short-term
infusions of 24–48 hours.
In doses that result in loss of consciousness (general
anesthesia) propofol causes loss of pharyngeal tone, which
may cause airway occlusion.151 It also causes reduction of
respiratory drive and loss of airway reflexes, making patients
vulnerable to hypoventilation or apnea, aspiration, and
laryngospasm. Hypotension is also associated with these
doses. As a result, propofol in these higher doses should only
be administered by personnel with formal anesthesia
the postoperative PCA morphine consumption. These drugs
are often used as part of a multimodal pain control
protocol.
KETAMINE
Ketamine is a potent analgesic with many characteristics
that make it suitable for treating burn patients. It has been
used extensively alone and in combination with other drugs
primarily for controlling pain during procedures related to
burn care, but also low-dose infusions can improve pain
control in some patients tolerant to morphine. It has been
administered orally, intramuscularly, and intravenously.
Ketamine causes pain when administered intramuscularly
or through a peripheral intravenous catheter. It also causes
tachycardia and hypertension, which may be poorly toler­
ated by older patients with hypertension or coronary artery
disease. These side effects can be reduced by concomitant
administration of an α2 adrenergic agonist. Ketamine has
been avoided in patients with increased intracranial pres­
sure because it has been reported to cause increased cere­
bral blood flow that might further increase intracranial
pressure. More recent evidence contradicts this warning.
Clinical and experimental data suggest that, especially for
patients who are mechanically ventilated, ketamine may
offer neurological protection, decreased intracranial pres­
sure, and improved cerebral perfusion.142
In doses above 1–2 mg/kg intravenously ketamine pro­
duces a dissociative state that renders the patient insensible.
At the same time, respiratory drive, airway patency, and
airway reflexes are preserved.
Ketamine has an extensive record of safety in pediatric
emergency departments even when given without regard to
prandial state.143 This combination of features is especially
beneficial in pediatric patients who can experience intense
psychological stress and may be combative even if all pain
is prevented. A more bothersome problem is delirium during
emergence. Midazolam is often described as a remedy, but
dexmedetomidine may be more effective.144 It is best that
midazolam be co-administered with ketamine to avoid
this complication. Ketamine sedation can be associated
with increased salivation that can make laryngospasm
more likely but, in contrast to laryngospasm caused by
inhalation agents, laryngospasm with ketamine is largely
self-limiting.
α2 AGONISTS
The use of α2 adrenergic agonists has increased dramati­
cally for perioperative and ICU applications.145 These drugs
are used for both sedative and analgesic properties. For
these applications α2 agonists’ predominant effect is medi­
ated by central inhibition of norepinephrine release. This
action results in sedation and reduction of sympathetic
tone. Peripheral release of norepinephrine is also inhibited.
If blood pressure is maintained by increased sympathetic
tone, as with decreased circulating blood volume, adminis­
tration of clonidine or dexmedetomidine can cause
hypotension.
Clonidine is available for oral or intravenous use. When
administered by mouth or nasogastric tube, clonidine has
an approximately 85% bioavailability. Dexmedetomidine is

64  •  Management of Pain and Other Discomforts in Burned Patients
688
given later and lead to oversedation and respiratory
depression.
In the case of second-degree wounds, the use of wound-
covering dressings almost immediately eliminates pain in
the burn wound site. As an example, Schwarze and col­
leagues compared the clinical efficacy of two synthetic burn
wound dressings, Suprathel and Omiderm. Both were
highly effective in reducing pain. Omiderm was more cost
effective, but Suprathel was slightly more effective in reduc­
ing pain (10-day average visual analog score [VAS] pain
score was 1.0 for Suprathel, 1.59 in the Omiderm group).158
Although the most widely followed burn shock formula,
the Parkland formula, recommends 4 mL/kg per percent­
age of TBSA burned, Engrav and colleagues reported in
2000 that many burn centers were administering consider­
ably more fluid than this and that patients were experienc­
ing serious morbidity from overresuscitation.159 This trend
of administering increasing amounts of resuscitation fluids
has been termed “fluid creep” by Pruitt and is associated
with significant morbidity due to fluid overload. The mecha­
nism of this phenomenon has not been established, but
Sullivan and colleagues found an association of increased
fluid volumes administered with increased doses and variety
of narcotics given to burn patients.160 They suggested that
higher doses of narcotics could contribute to hypotension
and increase the fluid needs of these patients. Saffle exam­
ined factors associated with “fluid creep” and reasoned that
it is unlikely that narcotics contribute significantly to the
practice of administering larger volumes of fluid to burn
patients.161
Background and
Breakthrough Pain
Pain perception and analgesic requirements for burn inju­
ries vary widely. Adequate pain control requires that each
patient be continuously assessed for pain and anxiety. For a
variety of reasons the simplest effective treatment plan is
optimal. Often morphine in combination with a benzodiaz­
epine is adequate. However the advantages of a multimodal
approach to pain control are generally accepted, especially
for patients with moderate and severe pain. The use of mul­
tiple drugs with different mechanisms of action provides
synergistic effects that improve pain control and allows the
use of lower doses of opiates. For this reason the addition
of scheduled doses of acetaminophen and gabapentin may
reduce OIH and neuropathic pain. Cuignet et al. reported
that if 2400 mg of gabapentin is given to adult burn survi­
vors per day, the amount of morphine needed is less and the
pain control better.138 An unexpected finding was that
improved pain scores and reduced morphine requirements
persisted after treatment with gabapentin was stopped.
During the acute phase of recovery from burn injuries
patients with good pain control often experience transient
periods of sudden intense increase in their pain. This is
referred to as breakthrough pain. A pain management plan
must include orders for as-needed or p.r.n. doses of an anal­
gesic. The intensity of breakthrough pain is usually so great
that an opiate is required.
One technique that can accommodate both background
and breakthrough pain is PCA. PCA requires patient
training or by credentialed personnel who are part of a care
team designed to provide sedation for procedures.
NITROUS OXIDE
Nitrous oxide is the only nonhalogenated anesthetic gas still
in clinical use. Its low potency requires 50–70% inhaled
concentrations to provide significant analgesia. Filkin and
Marvin have reported effective analgesia during burn
wound care with self-administered nitrous oxide.152 More
recently, Ozil et al. used 50% nitrous oxide in combination
with morphine premedication to provide analgesia for 33
children with small (<10% TBSA) burns.153 In these cases
pain scores and patient/parent satisfaction were favor­
able.205 Do Vale et al. found that the use of fentanyl was not
reduced by using nitrous oxide.154 A brief intermittent expo­
sure to nitrous oxide and chronic exposure to trace amounts
appear safe, but repeated exposure to higher concentrations
can result in significant hematopoietic and neurological
toxicity. This results from oxidation by nitrous oxide of the
cobalt in vitamin B12, which impairs its coenzyme function.
Synthesis of methionine and tetrahydrofolate needed for
DNA synthesis and metabolic reactions involving methyl­
ations is inhibited by nitrous oxide inactivation of vitamin
B12. Clinical presentation mimics pernicious anemia, with
megaloblastic anemia and subacute combined degenera­
tion of the spinal cord. Hayden and colleagues reported a
case of myeloneuropathy in a burn patient chronically
exposed to high concentrations when he was given 50%
nitrous oxide in oxygen to self-administer ad lib over approx­
imately 4 months.155,206 Chronic exposure also is possible
for workers chronically exposed to nitrous oxide. Sweeny
et al. found bone marrow changes consistent with nitrous
oxide toxicity in three of 21 dentists who used nitrous oxide
for sedation and analgesia for their patients during long
procedures.156,207 Ambient nitrous oxide concentration
were as high as 4,600 ppm in their work areas. With
modern scavenging systems, operating room personnel are
not considered at risk. If nitrous oxide is used for analgesia
for burn patients, adequate consideration must be given to
chronic exposure of personnel.
Initial Injury
Although areas of full thickness burn injury are initially
insensate, Singer and colleagues157 reported that only 25%
of patients presenting with isolated full-thickness burns
had pain scores of 0; that is, were painless. Of all other
patients with partial or partial plus full-thickness burns,
18% were also painless. The differences in the frequency of
painless wounds between these two groups were not statis­
tically significant. These observations suggest that most
patients with full-thickness burns have significant pain.
If possible, intramuscular injections should be avoided.
Not only is the injection painful, but, during the early stages
of major burns, absorption from tissue sites is highly vari­
able and unpredictable. With decreased intravascular
volume and cardiac output, tissue perfusion may be low
and absorption poor. Later, with fluid resuscitation, drug
may enter the circulation as tissue perfusion is restored.
This can combine with any sedative or analgesic drugs

64  •  Management of Pain and Other Discomforts in Burned Patients
689
neuropathic component of pain that often develops with
healing of burn wounds.
α2 Adrenergic agonists represent another class of drugs
that may dramatically improve pain control in patients no
longer controlled with morphine. Clonidine has been found
effective specifically in burn patients poorly controlled by
large doses of morphine.167 Clonidine is inexpensive, and
bioavailability is very good when given via nasogastric tube.
Fagin and colleagues compared sedation of burned pediat­
ric patients with midazolam or dexmedetomidine infusions.
Patients receiving dexmedetomidine were treated for an
average of just over 3 weeks. They found sedation more
effective with dexmedetomidine and with less hypoten­
sion.168 Caution is necessary when giving α2 adrenergic
agonists to acute burn patients, however. If the patient is
hypovolemic and blood pressure is maintained by increased
sympathetic tone, administration of clonidine or dexme­
detomidine can result in hypotension. In pediatric patients
this may be treated by volume administration, but adults,
especially those with coexisting disease, may need prompter
treatment with vasoactive drugs while hypovolemia is cor­
rected. Dexmedetomidine can also be helpful when increased
doses of morphine are ineffective. It is more expensive than
clonidine but sedation can be more easily titrated with alter­
ations of rate of intravenous infusion.
Not all patients respond in the same manner to analge­
sics, and it is necessary to have alternative choices when
pain control is especially challenging. Ketamine is an effec­
tive NMDA receptor antagonist, and, as a result, it can
reduce central sensitization and improve analgesia for
patients with neuropathic pain or who are experiencing
OIH. Subanesthetic doses (0.1–0.3 mg/kg as bolus or
0.1–0.3 mg/kg per hour infusion) have been found to
improve pain scores and reduce perioperative narcotic
requirement.169 We have found low-dose ketamine infusion
helpful in patients with poorly controlled pain and inade­
quate response to methadone and α2 adrenergic agonists
(unpublished observation).
Analgesia for Procedures
Burn patients require frequent painful procedures to facili­
tate healing of their wounds. Among others, these include
initial wound débridement, daily dressing changes, range of
motion and exercise therapy, wound staple removal, and
placement of intravascular catheters. Providing safe and
effective sedation and analgesia for these procedures can be
challenging for a number of reasons (Table 64.5).
Poorly controlled pain can make it difficult to accomplish
a procedure effectively or safely and increases anticipatory
anxiety, which can impair patient compliance and may con­
tribute to behavioral morbidity such as post-traumatic
stress syndrome.170 Effective pain control in adults can often
be sufficient to reduce anxiety. In pediatric patients, however,
anxiolysis is also needed. For especially stressful procedures,
most pediatric patients must be rendered insensible. For this
reason, the popular term “conscious sedation” is inaccurate
and misleading when treating pediatric patients. A very
young patient who is aware of the procedure will resist
enough to make the procedure difficult or less safe, and the
anxiety associated with this experience makes future
cooperation, which means that the patient is able to under­
stand and perform tasks necessary to self-administer the
medication. When hands are burned and the PCA pump
cannot be activated manually by the patient, a foot pedal
can be used. When neither of these options is possible, pro­
tocols have allowed a nurse to activate the pump at the
patient’s request. To avoid overdose when PCA is used to
cover postoperative pain or background pain in the burn
ICU, it is important that family members or other visitors do
not activate the PCA for the patient. Nilsson and colleagues
evaluated the use of PCA with morphine to control burn-
related background pain and pain associated with mobiliza­
tion.162 Background pain was adequately controlled, but
even a double PCA dose given in anticipation of mobiliza­
tion was not sufficient to control the associated increased
pain. Although subcutaneous administration is generally
to be discouraged in burn patients, Shipton and others
reported safe and effective control of background pain with
PCA morphine administered subcutaneously.163
Fear related to a traumatic injury and apprehension asso­
ciated with pain enhance the perception of pain and make
it more difficult to control. Pain is most effectively treated if
aggressive measures to control pain are accompanied by
consideration for the patient’s anxiety. Complaints of pain
should not be attributed solely to anxiety, however.
Patterson et al.164 reported that in a double-blind placebo-
controlled study of 79 patients, 1 mg lorazepam signifi­
cantly reduced procedural pain ratings in those patients
with high baseline pain, but did not reduce baseline trait
anxiety. In a survey of the use of antianxiety drugs in
burned children, 72% received lorazepam at a dose of
0.03–0.05 mg/kg or higher every 4 hours for much of their
initial hospitalization.165 Lorazepam provided aid in anxiety
control with essentially no side effects.
Occasionally the quality of pain control will deteriorate
to the point that changes in drug dose or selection must be
changed to maintain adequate analgesia. A variety of
mechanisms can account for difficulty or deterioration of
pain control by standard protocol (Table 64.4). Also, intu­
bated patients requiring mechanical ventilation present an
additional challenge for managing pain control.
Burn patients poorly controlled with increasing doses
of morphine have benefited from substitution of metha­
done.130 As discussed earlier, in addition to µ opiate receptor
agonist activity, methadone is an NMDA antagonist and
inhibits amine uptake similar to tricyclic amines.166 These
properties reduce central sensitization and hyperalgesia
that are not sensitive to morphine. Methadone reduces a
Table 64.4  Factors Complicating Quality of Pain
Control
■ Repeated pain of daily wound care
■ Intubation for mechanical ventilation
■ Physical therapy range of motion and exercise therapy
■ Postoperative pain
■ Wound infection
■ Tolerance to narcotics
■ OIH
■ Development of neuropathic pain
■ Exaggerated anxiety
■ Post-traumatic stress disorder

64  •  Management of Pain and Other Discomforts in Burned Patients
690
and found similar analgesic and sedative efficacies.
Humphries et al. found oral ketamine to be effective.172 In
pediatric patients prior to dressing change, Borland and col­
leagues compared analgesia and sedation with morphine
administered orally and fentanyl given intranasally.173
Although both were effective, intranasal fentanyl was more
palatable and had a much more rapid onset. Although
these regimens provide significant analgesia, pain control
is often not optimal. It is difficult to provide sufficient anal­
gesia with enterally administered drugs to control intense
pain without unacceptable risk of adverse effects, especially
prolonged sedation. Remifentanil administered intranasally
is an attractive alternative. Remifentanil is an ultra-short-
acting opioid rapidly metabolized by plasma esterase.174
In our institution 5–10 µg/kg of intranasal remifentanil
enhanced the effectiveness of oral transmucosal fentanyl
as judged by pain scores and the subjective evaluations of
nurses and patients (unpublished observations) and did not
delay recovery. The ultra-short duration of action allows
rapid recovery, which reduces risks of sedation and may
improve patient satisfaction.
When patients have an intravenous catheter in place
there are many more treatment options that allow more
profound analgesia, more rapid onset with shorter duration
of action, and, depending on which drugs are administered,
reversal of drug toxicity with antagonists. Sedative and
analgesic drugs can be given as a bolus with supplemental
doses given as needed, as an infusion to be titrated or sup­
plemented with bolus doses, and by PCA. Infusion of short-
acting opiates such as remifentanil or alfentanil is a logical
choice.
Deep sedation can be associated with the risk of serious
adverse events, including mortality (Table 64.6). These
include airway obstruction, depressed airway reflexes and
respiratory drive, and hemodynamic instability. Loss of con­
sciousness with most sedatives causes reduced pharyngeal
tone and airway obstruction of varied degree depending
largely on the patient’s anatomy.151 If this is not recognized
or attempts to open the airway are not successful (operator
skill or difficult patient anatomy), hypoxia can result. An
airway exam is a critical part of the preprocedure evalua­
tion, and a sedation plan must take into consideration
potential difficulties with airway and respiration. Obstruc­
tion due to laryngospasm can be very difficult to relieve and,
in extreme cases, may require muscle relaxation and intu­
bation. Hypoxia can also result from hypoventilation due to
depressed respiratory drive. If airway reflexes are depressed,
aspiration of gastric contents may occur when passive
reflux or active vomiting occur. In addition, deep sedation
can cause loss of sympathetic tone or direct cardiovascular
depression. These effects can lead to morbidity due to hemo­
dynamic instability (Table 64.7).
procedures more difficult. The level of sedation and analge­
sia required in this situation cannot accurately be described
as “conscious sedation.” A more accurate descriptive term
is “moderate or deep sedation for procedures.” The depth of
sedation must be individualized depending on the intensity
of the pain associated with the procedure and the patient’s
maturity, level of anxiety, and pain tolerance.
Clinical needs of patients presenting for burn procedures
vary widely from outpatient care of small superficial burns
to inpatients with extensive burns who require intensely
painful dressing changes and wound care. Additionally,
availability of staff credentialed to provide deep sedation
varies from hospital to hospital. In Europe and elsewhere
many burn centers are staffed by anesthesiologists who can
provide general anesthesia at the bedside. In the United
States burn centers are staffed by surgeons, and, with some
exceptions, anesthesiologists may not always be available
for these procedures outside of the operating suite. It is not
possible to describe a protocol that is appropriate for all
centers. Each institution must recognize the challenges
faced in controlling pain during burn procedures and plan
care to address these challenges with the resources
available.
Minor injuries treated with outpatient procedures may
need very little medication for preparation. Children may
benefit from low doses of benzodiazepines and/or opiates.
More extensive outpatient procedures become progressively
more problematic as the intensity of pain and associated
anxiety increase. Several effective protocols for delivery of
moderate sedation for procedures have been published
involving a variety of drugs and routes of administra­
tion.122,127 The ideal pharmacological treatment would be
easily administered in a palatable form, produce intense
analgesia with a rapid onset, have a relatively short dura­
tion of action, and produce minimal side effects. Most drugs
in current use will produce prolonged sedation when given
in doses that prevent most of the intense pain during wound
care. On a daily basis, this prolonged period of sedation can
interfere with nutritional support and other therapies. In
the outpatient setting without an intravenous catheter, the
most common technique is to give a preprocedural fixed
dose of an analgesic with or without an anxiolytic by the
oral, transmucosal, or intranasal route. Fentanyl citrate is
available as a flavored Oralet to administer by the oral trans­
mucosal route. The oral transmucosal route has the advan­
tage of direct absorption into the systemic circulation,
which bypasses the first-pass hepatic clearance effect and
improves its bioavailability.
Sharar and colleagues have compared oral transmucosal
fentanyl citrate with hydroxymorphone122 and oxycodone171
Table 64.5  Challenges of Sedation and Analgesia for
Burn Procedures
■ Intense but brief pain requiring rapid onset and short duration of
drug effects to avoid overdose or delayed recovery
■ Lack of intravenous access, especially for outpatient care
■ Nutritional requirements for large burns preclude frequent fasting
periods for deep sedation
■ Exaggerated anxiety states
■ Staffing resources may limit availability of personnel credentialed
to provide deep sedation
Table 64.6  Risks of Deep Sedation for Burn Procedures
■ Decreased respiratory drive (hypoventilation or apnea)
■ Upper airway obstruction
■ Difficult airway (difficult intubation and/or difficult mask
ventilation)
■ Decreased airway reflexes
■ Aspiration after emesis
■ Cardiovascular depression