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

4  •  Prevention of Burn Injuries
31
limited resources with the potential to have the greatest
impact.29
Engineering and Enforcement
In several areas of burn prevention efforts, the manipu­
lation of products or the physical environment (engineer­
ing) is closely linked with legislative efforts (enforcement).
Engineering and enforcement strategies often require
more resources and government involvement, but they are
thought to be more effective than passive effort.5 Smoke
alarms, fire sprinklers, fabric flammability standards, fire-
safe cigarettes, and water temperature controls are historical
examples that may provide insight as the burn community
examines where to focus resources in the future.
SMOKE ALARMS
Smoke alarms act as an early warning of fire, alerting resi­
dents of the need to exit a house or building. Fatalities from
house fires decreased by almost half after the rise in popu­
larity of smoke detectors in the 1980s and 1990s. This
decline in home fire deaths is largely attributed to the wide­
spread adoption of smoke alarms, although other notable
changes during this time period included child-resistant
lighters and flame-resistant upholsteries.32 It has been
reported that 96% to 97% of households now have at least
one smoke alarm installed, leaving an estimated 5 million
homes still unprotected. Households with no smoke alarms
are twice as likely to experience a home fire fatality than are
those with a working smoke alarm.33 Most states have laws
requiring smoke alarm installation for specific conditions
such as new buildings, tenant buildings, and multiple
family dwellings.32 Some community-based efforts at pro­
viding and installing smoke alarms have been successful
in reducing the risk of fire-related deaths and injury.
areas on both the risk factor and fire incidence maps and
identified census tracts that were potentially at the highest
risk of experiencing fires (Fig. 4.5).31 Prevention strategies
can then be designed to target etiologies and population
characteristics or behaviors that are specific to those areas.
The use of GIS is an exciting example of how thoughtful
epidemiological assessment could lead to the focused use of
Low Risk
Medium Risk
High Risk
Severe Risk
Fig. 4.3  The summed risk scores were separated into risk categories
ranging from low to severe risk. The map shows each census tract’s risk
category based on a color gradient, where darker shading represents
higher risk. (From Lehna C, Speller A, Hanchette C, Fahey E, Coty M-B.
Development of a fire risk model to identify areas of increased potential
for fire occurrences. J Burn Care Res. 2016;37(1):12–19.)
0.00-30.14
30.15-43.78
43.79-70.12
70.13-161.00
Fire Incidence Rate
Fig. 4.4  The fire incidence rate for each census tract is shown with
darker shading representing higher fire incidence rates. (From Lehna C,
Speller A, Hanchette C, Fahey E, Coty M-B. Development of a fire risk model
to identify areas of increased potential for fire occurrences. J Burn Care Res.
2016;37(1):12–19.)
Cluster of High Rates
Fig. 4.5  Clusters of significantly high fire incidence rates are shown in
shading. (From Lehna C, Speller A, Hanchette C, Fahey E, Coty M-B. Devel­
opment of a fire risk model to identify areas of increased potential for fire
occurrences. J Burn Care Res. 2016;37(1):12–19.)

4  •  Prevention of Burn Injuries
32
been little evolution of these standards over the years.
Between 1997 and 2006, there were still an average of
4300 burn injuries annually related to the ignition of cloth­
ing, and almost all of the garments involved were within
the minimum clothing flammability standards. Despite the
expansion of the initial legislation beyond clothing to other
textiles (e.g., carpets, mattresses, upholstered furniture,
tents, curtains, sleeping bags), it is estimated that 50% of
fire deaths in the United States involved the ignition of
materials included in the Flammable Fabrics Act.40 The only
notable evolution of these early efforts has occurred with
children’s sleepwear. In the 1970s, regulations were intro­
duced that required children’s clothing from size 0 to 14 be
able to self-extinguish. The introduction of flame-resistant
sleepwear demonstrated a significant decrease in the inci­
dence of burn injuries and deaths related to children’s
pajamas in the 1970s and 1980s. It is believed that parents
began to substitute other clothing as sleepwear due to
limited flame-resistant pajama choices and also a desire for
nontreated cotton fabrics. In 1996, restrictions were relaxed
to allow exemptions for sleepwear for children 9 months
and under and also for any tight-fitting sleepwear of any
size. It is thought that tight-fitting clothing decreases the
risk of the garment coming into contact with an ignition
source and may also slow the burn of the material due to
less oxygen between the clothing and the skin.39 There have
been no other major legislative or industry-driven efforts to
improve the safety of fabrics offered to consumers, place
additional warning labels, or educate the public regarding
the flammability of fabrics. This is concerning because the
number of clothing-related injuries and deaths has
remained steady for decades. With 74% of burn injuries
from clothing ignition related to daywear garments, and
75% of deaths in those 65 years and older, there is clear
potential for growth in the area of both passive and active
prevention strategies in this area.40 Public understanding
of the risks of flammable clothing and knowledge of current
regulations is thought to be low.41
FIRE-SAFE CIGARETTES
Home fires originating from smoking materials comprise
only 5% of all fires reported annually in the United States
but are the leading cause of fire fatalities in the home.42,43
An estimated two-thirds of deaths related to smoking
involved the ignition of furniture upholstery or mattresses
and bedding.43 The idea of “fire-safe” or reduced ignition
propensity (RIP) cigarettes was first proposed in the 1920s
as a way to reduce the number of forest fires and was later
recognized as a potential way to reduce the number of burn
injuries and deaths related to smoking materials.44 Design
factors such as the circumference of the cigarette, type of
paper used, and presence of a filter or accelerant can all
influence the rate of burn. Assisted by legislative efforts
addressing production and testing in the 1980s and 1990s,
it was shown that slow-burning or self-extinguishing ciga­
rettes could be produced without a large economic impact
on manufacturers or a change in taste for consumers.44
After years of failed bills attempting to require tobacco com­
panies to produce safer cigarettes and a decade of stalled
efforts to standardize testing for RIP cigarettes, legislation
finally began to gain traction in 2003. By 2011, all 50
Operation Installation (OI), a Dallas-based community
smoke alarm program, is an excellent example of how a
partnership between community organizations can reduce
risk of harm and death from fires. The program was
designed, implemented, and evaluated through a collabora­
tion of the Injury Prevention Center of Greater Dallas, the
Dallas Fire Rescue Department, and the Dallas chapter of
the American Red Cross. From 2001 to 2011, OI installed
lithium-powered smoke alarms in 8134 homes located in
high-risk areas. The incidence of house fire-related deaths
and injuries in the program houses was then compared to
the 24,346 nonprogram houses in the same census tracts,
with an average of 5.2 years of follow-up. The adjusted
analysis revealed that the incidence of house fire-related
deaths and injuries in the OI houses was 68% lower.34 This
risk of fire-related injury or death in the OI houses was
shown to begin increasing again at around 5 years after
installation.34 Ten years after installation, OI performed an
evaluation on 198 smoke alarms and found that although
108 were still present, only 44 were still functioning. Most
of the nonfunctioning smoke alarms had the battery
removed or had been disconnected, revealing a potential
area for targeted education and an indication that tamper-
proof smoke alarms could be useful.35
FIRE SPRINKLERS
Fire sprinklers are highly effective at reducing property
damage and deaths from fires when present and working.
From 2007 to 2011, only 10% of structure fires reported
that fire sprinklers were present. Although most fire deaths
and burn injuries occur in the home, only 6% of the struc­
ture fires with sprinklers present were houses. Having fire
sprinklers installed in the home was shown to reduce the
death rate per fire by 82%.36 Despite this significant reduc­
tion in harm, only California and Maryland have currently
passed statewide legislation requiring residential fire sprin­
klers in all new-construction one- and two-family homes.
An example of using economic incentive as a complemen­
tary burn and fire prevention strategy is the reduction in
home owner’s insurance offered to some policy holders who
install fire sprinklers in their home. One review concluded
that the average discount in the United States for this safety
feature is 7%.37 While laws exist requiring the installation
of automatic fire sprinklers in new nonresidential build­
ings, retrofitting older high-rise buildings is costly and not
currently mandatory. In September 2015, the Fire Sprin­
kler Incentive Act was introduced into Congress. This legis­
lation would strengthen the tax incentives for building
owners by allowing 100% expensing of the cost of the auto­
matic fire sprinkler system and a 15-year depreciation
recovery.38
FABRIC FLAMMABILITY
Inspired by a series of injuries and deaths related to rayon-
pile fabrics, the U.S. government formally recognized the
risks of flammable clothing with the passage of the Flam­
mability Fabrics Act in 1953.39 This was the beginning of a
passive prevention strategy to prevent burn injuries and
deaths from clothing catching on fire. Although flammabil­
ity standards were developed and standardized, there has

4  •  Prevention of Burn Injuries
33
containing more than 2 g of powder, and firework building
kits.45 The impact of legislation suggests a reduction in the
number of fireworks-related injuries. In the United
Kingdom, the number of firework injuries fell from 707 in
2001 to 494 in 2005, presumably due to the creation of
firework legislation during that time.51 After the repeal of a
law banning private consumer fireworks in Minnesota in
2002, there was a 100% increase in the number of annual
fireworks-related injuries.52
Education
Education is an active prevention process that requires
behavior modification from the targeted population. Public
education programs aimed at reducing the incidence and
severity of burn injuries in the United States can be imple­
mented at the local, state, regional, or national level. At the
national level, the American Burn Association (ABA) spon­
sors Burn Awareness Week annually, a public campaign to
promote safe practices and prevent burn injuries. The ABA
Burn Prevention Committee also recently partnered with
Safe Kids Worldwide, the International Association of Fire
Fighters Charitable Foundation Burn Fund, the Federation
of Burn Foundations, and the International Association of
Fire Chiefs to create the National Scald Prevention Cam­
paign. The website flashsplash.org provides scald preven­
tion resources for burn centers, the public, and the media.
Many burn centers used these resources for local preven­
tion activities during Burn Awareness Week 2016.53 The
National Fire Protection Association also sponsors a Fire
Prevention Week with a special emphasis on one area of
prevention each year. Social media is also a rapidly evolving
and widely accessible platform that may present novel ways
for burn prevention education. In 2013, there were 21
videos on YouTube with technically accurate information
regarding prevention and first aid for pediatric burns.54 Use
of the Internet and social media is a potentially effective and
easy to way to disseminate information and raise public
awareness regarding burn prevention and treatment,
although validation of the material by qualified providers
will be a challenge.
Many burn centers are providing general burn preven­
tion education to the community through health fairs,
public gatherings, and community classes. Some centers
have assessed their community, identified specific educa­
tional gaps, and chosen to provide focused education to a
target population.
In New York City, researchers noted that burns were the
third leading cause of injury-related death among seniors
65 years and older. When surveyed, less than 20% of local
seniors had received any fire safety education within the
last 5 years. A community-based initiative was designed to
reach older adults at recreational centers in this area. After
reviewing the common etiologies for this age group, a pre­
sentation that focused on fire safety and the prevention of
scald burns was designed. Over the course of several
months, the presentation was given at 64 senior centers to
2196 older adults. Almost three-quarters of seniors who
participated in and evaluated the program reported that
they had learned something new about fire and burn safety.
Eighty-five percent of respondents also reported a high
states had passed laws making RIP cigarettes mandatory (a
cigarette must burn out 75% of the time when not in active
use). In 2013, the National Fire Protection Agency released
a report crediting this legislative effort with an astounding
30% reduction in smoking-material fire deaths from 2003
to 2011.43 Although the long-term decrease in smoking-
related fires seen over the past few decades is likely related
to fewer people smoking, the decline in the smoking rate
during the 2003 to 2011 time period was only 4%, leading
researchers to believe that fire-safe cigarettes can be cred­
ited for this decrease in incidence.43 Although the engineer­
ing to produce safer cigarettes was identified years ago,
implementation did not happen until legislative enforce­
ment occurred.
WATER TEMPERATURE REGULATIONS
According to the 2015 National Burn Repository Annual
Report, 34% of burn admissions reported from 2005 to
2014 were scald injuries.23 Most scald injuries are related
to cooking or hot liquids in the kitchen, mechanisms that
are often related to behavior and can be difficult to prevent
with engineering or enforcement strategies. Estimates for
the amount of burn injuries related to hot water from a
tap vary from 12% to 25%.45 There is an opportunity to
prevent scald burns related to tap water with passive engi­
neering and enforcement strategies. An animal study was
performed to identify how long exposure to water at differ­
ent temperatures took to result in a partial-thickness burn.
If the temperature of the water was 140°F (60°C), it took
only 3 seconds of exposure to result in a burn. When the
water was decreased to 120°F (49°C), it took 10 minutes
to cause significant thermal injury to the skin.46 Histori­
cal efforts to reduce water temperature in facilities and
homes include regulating the temperature setting of hot
water heaters and requiring the instillation of antiscald
devices at taps.47 It was demonstrated in Washington state
in the 1980s that requiring newly installed home hot water
heaters to be set at 120°F significantly lowered the mean
household water temperature and reduced the incidence of
tap water injuries.48 Despite evidence that this strategy can
be effective, no nationally recognized and enforced standard
exists today. Almost all U.S. states have legislation related to
water temperature, but many do not regulate water temper­
ature in the home. Types of facilities that are often subject
to state regulations commonly include schools, child care
facilities, and nursing care facilities. Although some plumb­
ing codes at the city or state levels also address water tem­
perature, these also vary widely in source, regulation, and
enforcement.47
FIREWORKS REGULATION
Injuries from fireworks are a problem in several countries
because they are commonly used during national holidays
and traditional festivals.49 In the United States, the Fourth
of July has more fires reported than on any other day of the
year.50 Fireworks often result in hand burns, but flame
burns also occur when clothes catch fire. In an attempt
to decrease fireworks-related injuries, the United States
prohibits the sale of certain types of fireworks including
reloadable shells, cherry bombs, M-80 salutes, firecrackers

4  •  Prevention of Burn Injuries
34
prevention program, rather than a rigid process used only
after program implementation. Evaluation of epidemiologic
data provides the focus for prevention programs. Once the
target etiology and population is identified, potential strate­
gies for reducing the incidence of injury must then be
examined. As discussed previously, Haddon’s Matrix can be
used to organize strategies by injury factors into pre-event,
event, and post-event. Each area then becomes a potential
target for prevention intervention, and practical strategies
to impact each area should be considered. Each strategy can
then be assessed for feasibility and sustainability. When
designing the program, it is essential to create measurable
objectives to be evaluated after implementation.58 Although
historically scientific evaluations of burn prevention efforts
were not prevalent in the literature, recent reviews suggest
this is beginning to change. Determining if prevention
strategies are reducing the incidence of burn injuries can
be challenging, especially at the local level. It is important
to remember that decreasing incidence is not the only
metric available for analysis. Intermediate outcomes, such
as an increase in knowledge or a change in behavior, may
also be evaluated.8 While it might take years to analyze the
impact of a scald prevention campaign on the incidence of
scald injuries in a community, an increase in behaviors
known to prevent scald burns, such as using the back
burners of the stove and turning the pot handles when
cooking with children present, could be more quickly and
easily evaluated. An increase in knowledge regarding scald
prevention could be evaluated with a pre- and post-test. It
should be noted that an increase in burn prevention knowl­
edge has not always correlated with a behavior change or
decrease in burn incidence.5
Global Burn Prevention
Although the focus of this chapter was primarily the United
States, the global incidence of fire and burn injuries in com­
parison is noteworthy. Worldwide in 2004, it was estimated
that approximately 11 million people sought care for burn
injury, which exceeds the combined incidence of HIV and
tuberculosis. Approximately 90% of burns injuries as well
as burn deaths occur in low- to middle-income countries,
with the highest prevalence in the Western Pacific, Eastern
Mediterranean, and Southeast Asia regions.18 These
impoverished areas often suffer from substandard living
conditions, overcrowding, and illiteracy, which have been
shown to be risk factors for burns. They also often lack the
needed infrastructure to reduce the incidence and mini­
mize the damage of burns. Access to burn care is also often
very limited.15,16,59 It costs about U.S.$1,000 per patient
per day to provide adequate burn care in the developed
world, which is clearly not possible for most developing
nations.60,61
The common mechanisms of burns are also often differ­
ent between the developed and developing worlds. In the
developing world, the use of kerosene lamps and stoves is
much more common and will likely continue for years to
come. There is slow progress in providing electricity to
homes in low-income countries, but millions of people still
depend on kerosene for heat, light, and cooking.62 A review
of 11,196 burn admissions in New Delhi, India, in 2002
likelihood of incorporating the new knowledge into their
daily lives.55
Firefighters have also recently been the target of an active
prevention strategy. Thousands of firefighters suffer smoke
inhalation or burn injuries, with an average of 100 fatali­
ties each year.56 A national program, It Happened in
Seconds, was developed by a multidisciplinary team of burn
professionals and firefighters to provide better situational
awareness, instruction on the appropriate use of personal
protective gear, and other strategies for burn prevention
while working. The program was first taught to a group of
core trainers representing different regions across the
United States. As a result, more than 9000 firefighters had
been through the course as of 2015. The impact of this
program on local and national rates of firefighter burn inju­
ries and death will be monitored.56
In another example of targeted education in burn pre­
vention, a burn center identified that Amish children were
at particularly high risk for scald burns and injuries related
to the ignition of clothing or highly flammable materials.
A lack of fire and burn education in Amish schools was
also noted. A tool designed to improve burn prevention
knowledge in Amish children, a storyboard with magnets,
was created in collaboration with an Amish community
and pilot tested. A subsequent multicenter pre- and post-
testing of 15 Amish schools across eight states demon­
strated that the tool was highly successful in increasing
burn prevention knowledge in Amish children in grades 1
through 8.57
Another education strategy that should not be over­
looked is the use of burn center staff to teach burn preven­
tion education not only to patients and their families, but
also to the community at large when participating in out­
reach events or engaging on social media. It is reasonable
for burn center staff members to incorporate prevention
teaching into their daily practice when caring for patients,
although it is possible that many frontline staff have never
received formal injury prevention training.1 A multicenter
assessment of the fire safety and burn prevention knowl­
edge of multidisciplinary burn team members was recently
performed and analyzed. While many of the respondents
reported confidence in their level of prevention knowledge,
the average score on the assessment was only 61.5%, indi­
cating the need to provide more accurate information to
burn center staff.1 It is recommended that burn prevention
programs should be supported by the burn center team and
not solely the responsibility of a designated educator. Hos­
pitals should consider prevention education for burn center
staff to prepare them to provide updated information on the
major fire safety and burn prevention topics in a variety of
situations. The ABA Burn Prevention Committee provides
several ways to increase fire safety and burn prevention
knowledge, including a newsletter, prevention tip sheets,
and other resources on the ABA website, and prevention-
focused sessions at the ABA Annual Meeting.1
Evaluation
The evaluation of prevention programs is critical in the shift
from anecdotal practices to evidence-based strategies. Eval­
uation should be viewed as a continuous component of any

4  •  Prevention of Burn Injuries
35
Future
The relatively small size of the burn community and the
sometimes large geographic distance between neighboring
burn centers can make it challenging for burn center staff
to share prevention ideas and resources. An emerging
theme in injury prevention literature is an emphasis on
partnerships within a community. It is acknowledged that
fire prevention and burn prevention efforts are often closely
linked. Burn centers participating in prevention strategies
can partner with local fire departments for joint projects
and assist each other with efforts toward a common goal:
reducing injuries and deaths from fire and flame. Other
potential partners for burn center prevention programs
include local and national safety associations and child
advocacy organizations. Although difficult to evaluate, it
has been noted that characteristics such as inclusivity,
enthusiasm, and cultural competence among prevention
program leaders can increase the success of the program.65
Burn injuries and deaths are a world health problem that
represents a major global challenge. Coordination of pre­
vention strategies on both national and international levels
is necessary. Passive prevention programs are most effective
but can be slow to implement and heavy on resources.
Active prevention can be tedious and requires significant
organizational support. Both measures should be utilized
and are not mutually exclusive. Evaluation of the success
of prevention efforts is also of utmost importance, although
this can be quite difficult. Despite the many challenges,
burns should be viewed as preventable, and efforts to
decrease their incidence and severity should be continued
at all levels. Prevention is an area of focus where creative
and enthusiastic leaders have the opportunity to grow this
movement by implementing innovative strategies, design­
ing thoughtful evaluations, and sharing the results to move
the science of burn injury prevention forward.
Complete references available online

found that more than 80% of burns were due to flames, and
35% of these were attributed to malfunctioning kerosene
stoves.59 A similar study in Sri Lanka found that 41% of
accidental burns requiring medical attention were due to
flame from a kerosene bottle lamp.63 Three approaches to
prevention of kerosene lamp and stove burns have been
discussed and include educational campaigns teaching safe
use, use of safer oil, and the provision of an inexpensive and
safer lamp to families. A kerosene educational program in
low-income South Africa resulted in a significant increase
in self-reported knowledge and safety practices, but there
are no data showing if this affected kerosene burn injury
incidence.62 The use of safer oil, such as coconut and sesame
oil, has not been adopted because these alternatives are too
heavy to rise to the top of wicks and do not provide as much
heat and light. There is an ongoing program in Sri Lanka to
provide safe and inexpensive kerosene lamps to poor fami­
lies. The lamp was designed by a surgeon in the region in
1992. He designed it to be compact and heavy to avoid
tipping over, with two flat sides to prevent rolling if it does
tip over. It also has a screw top lid to prevent fuel spillage
and much stronger glass. More than 775,000 “safe bottle
lamps” were distributed in Sri Lanka as of 2010, and this
has been credited in the media with a significant reduction
in burn injuries and fires, although no formalized data have
been collection.60
The proportionally high incidence of burns in the devel­
oping world highlights the importance of primary burn
prevention efforts in these regions.64 The World Health
Organization has developed a Burn Plan that is organized
into seven main components corresponding to the chal­
lenges in global burn prevention and care (advocacy, policy,
data and measurement, research, prevention, services,
capacity building). Accurate data on the incidence and
causes of burn injuries are scarce for many developing
countries, and incomplete reporting of burn events results
in an underestimate of the extent of this public health issue.
This understandably makes the development and enact­
ment of effective burn prevention strategies very difficult,
but very essential.

35.e1
4  •  Prevention of Burn Injuries
28. Ryan CM, Thorpe W, Mullin P, et al. A persistent fire hazard for older
adults: cooking-related clothing ignition. J Am Geriatr Soc. 1997;45(10):
1283-1285.
29. Edelman LS. Using geographic information systems in injury research.
J Nurs Scholarsh. 2007;39(4):306-311.
30. Williams KG, Schootman M, Quayle KS, Struthers J, Jaffe DM. Geo­
graphic variation of pediatric burn injuries in a metropolitan area.
Acad Emerg Med. 2003;10(7):743-752.
31. Lehna C, Speller A, Hanchette C, Fahey E, Coty M-B. Development of
a fire risk model to identify areas of increased potential for fire occur­
rences. J Burn Care Res. 2016;37(1):12-19.
32. Peck MD. Structure fires, smoke production, and smoke alarms. J Burn
Care Res. 2011;32(5):511-518.
33. Ahrens M Smoke alarms in U.S. home fires. Quincy, MA: National Fire
Protection Association; 2015.
34. Istre GR, McCoy MA, Moore BJ, et al. Preventing deaths and inju­
ries from house fires: an outcome evaluation of a community-based
smoke alarm installation programme. Inj Prev. 2014;20(2):97-102.
35. McCoy MA, Roper C, Campa E, et al. How long do smoke alarms func­
tion? A cross-sectional follow-up survey of a smoke alarm installation
programme. Inj Prev. 2014;20(2):103-107.
36. Hall JR Jr. U.S. experience with sprinklers. Quincy, MA: National Fire
Protection Association; 2013.
37. FPR Foundation FPR. Home fire sprinkler cost assessment. National
Fire Protection Agency; 2008.
38. National Fire Safety Association. Senate: fire sprinkler incentive act is
filed in 114th congress.
39. Cusick JM, Grant EJ, Kucan JO. Children’s sleepwear: relaxation of
the Consumer Product Safety Commission’s Flammability Standards.
J Burn Care Res. 1997;18(5):469-476.
40. Hoebel JF, Damant GH, Spivak SM, Berlin GN. Clothing-related burn
casualties: an overlooked problem? Fire Technol. 2009;46(3):629-649.
41. Frattaroli S, Spivak SM, Pollack KM, et al. Clothing flammability and
burn injuries: public opinion concerning an overlooked, preventable
public health problem. J Burn Care Res. 2016;37(3):e196-204.
42. Ahrens M Home Structure fires. Quincy, MA: National Fire Protection
Association; 2013.
43. Hall JR Jr. The smoking-material fire problem. National Fire Protection
Association; 2013.
44. Barillo DJ, Brigham PA, Kayden DA, Heck RT, McManus AT. The
fire-safe cigarette: a burn prevention tool. J Burn Care Res. 2000;
21(2):164-170.
45. Liao CC, Rossignol AM. Landmarks in burn prevention. Burns.
2000;26(5):422-434.
46. Moritz AR, Henriques FC. Studies of thermal injury: II. The relative
importance of time and surface temperature in the causation of cuta­
neous burns. Am J Pathol. 1947;23(5):695-720.
47. Peck M, Chang Brewer A, Pressman M, Blank E. Mickalide A.
Hot tap water legislation in the United States. J Burn Care Res.
2010;31(6):918-925.
48. Erdmann TC, Feldman KW, Rivara FP, Heimbach DM, Wall HA.
Tap water burn prevention: the effect of legislation. Pediatrics.
1991;88(3):572-577.
49. Al-Qattan MM, Al-Zahrani K. A review of burns related to traditions,
social habits, religious activities, festivals and traditional medical
practices. Burns. 2009;35(4):476-481.
50. Injuries associated with homemade fireworks: selected states, 1993–
2004. MMWR Morb Mortal Wkly Rep. 2004;53(25):562-563.
51. Edwin AF, Cubison TC, Pape SA. The impact of recent legislation
on paediatric fireworks injuries in the Newcastle upon Tyne region.
Burns. 2008;34(7):953-964.
52. Roesler JS, Day H. Sparklers, smoke bombs, and snakes, oh my! Effect
of legislation on fireworks-related injuries in Minnesota, 1999–2005.
Minn Med. 2007;90(7):46-47.
53. Campaign NSP. It can happen in a flash with a splash. International
Association of Fire Fighters; 2015.
54. Oomman A, Sarwar U, Javed M, Hemington-Gorse S. YouTube as a
potential online source of information in the prevention and manage­
ment of paediatric burn injuries. Burns. 2013;39(8):1652.
55. Leahy NE, Sessler KA, Baggott K, et al. Engaging older adults in burn
prevention education: results of a community-based urban initiative.
J Burn Care Res. 2012;33(3):e142-e147.
56. Kahn SA, Held JM, Hollowed KA, Woods J, Holmes JHI. “It Happened
in Seconds” firefighter burn prevention program: evaluation of a
“train the trainer” course. J Burn Care Res. 2016;37(1):e33-e36.
References
1. Klas KS, Smith SJ, Matherly AF, et al. Multicenter assessment of burn
team injury prevention knowledge. J Burn Care Res. 2015;36(3):
434-439.
2. Barss PSG, Barker S. Injury Prevention: An International Perspective Epi­
demiology, Surveillance, and Policy. New York: Oxford University Press;
1998.
3. Haddon W Jr. Advances in the epidemiology of injuries as a basis for
public policy. Public Health Rep. 1980;95(5):411-421.
4. Haddon W Jr. The changing approach to the epidemiology, preven­
tion, and amelioration of trauma: the transition to approaches etio­
logically rather than descriptively based. American Journal of Public
Health and the Nations Health. 1968;58(8):1431-1438.
5. Atiyeh BS, Costagliola M, Hayek SN. Burn prevention mechanisms
and outcomes: pitfalls, failures and successes. Burns. 2009;35(2):
181-1893.
6. Peden MM. World Report on Child Injury Prevention. New York: World
Health Organization; 2008.
7. McKinlay JB. The promotion of health through planned socio­
political change: challenges for research and policy. Soc Sci Med.
1993;36(2):109-117.
8. Judkins DG. Fifteen tips for success in injury prevention. J Trauma
Nurs. 2009;16(4):184-193.
9. American Burn Association. Database summary description: possible
sources for obtaining burn data; 2015.
Database%20Summary%20Burn%20Data%20Sources%20Final.
pdf.
10. Centers for Disease Control and Prevention (CDC). Ten leading causes
of injury deaths by age group highlighting unintentional injury deaths
in the U.S.; 2014.
11. Haynes H Fire loss in the U.S. during 2014. Quincy, MA: National Fire
Protection Association; 2014.
12. American Burn Association. Burn incidence and treatment in the
United State: 2016; 2016.
php.
13. Ahrens M Characteristics of home fire victims. National Fire Pro­
tection
Agency;
2014.

NFPA%20reports/Victim%20Patterns/oshomevictims.pdf.
14. Aldemir M, Kara IH, Girgin S, Guloglu C. Factors affecting mortality
and epidemiological data in patients hospitalised with burns in Diyar­
bakir, Turkey. S Afr J Surg. 2005;43(4):159-162.
15. Delgado J, Ramirez-Cardich ME, Gilman RH, et al. Risk factors for
burns in children: crowding, poverty, and poor maternal education.
Inj Prev. 2002;8(1):38-41.
16. Edelman LS. Social and economic factors associated with the risk of
burn injury. Burns. 2007;33(8):958-965.
17. Shai D. Income, housing, and fire injuries: a census tract analysis.
Public Health Rep. 2006;121(2):149-154.
18. Forjuoh SN. Burns in low- and middle-income countries: a review
of available literature on descriptive epidemiology, risk factors, treat­
ment, and prevention. Burns. 2006;32(5):529-537.
19. Parbhoo A, Louw QA, Grimmer-Somers K. Burn prevention programs
for children in developing countries require urgent attention: a tar­
geted literature review. Burns. 2010;36(2):164-175.
20. Rossi LA, Braga EC, Barruffini RC, Carvalho EC. Childhood burn inju­
ries: circumstances of occurrences and their prevention in Ribeirao
Preto, Brazil. Burns. 1998;24(5):416-419.
21. Zhu ZX, Yang H, Meng FZ. The epidemiology of childhood burns in
Jiamusi, China. Burns. 1988;14(5):394-396.
22. Learmonth AM. Domestic child burn and scald accidents (analysis
of data from 4 Indian burn units). J Indian Med Assoc. 1979;73(2):
43-47.
23. American Burn Association. 2015 National Burn Repository report
of data 2005–2014. Chicago, IL: American Burn Association;
2015.
24. Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl
J Med. 2013;369(5):448-457.
25. Pressel DM. Evaluation of physical abuse in children. Am Fam Physi­
cian. 2000;61(10):3057-3064.
26. Edgar DW, Homer L, Phillips M, et al. The influence of advancing age
on quality of life and rate of recovery after treatment for burn. Burns.
2013;39(6):1067-1072.
27. Mabrouk A, Maher A, Nasser S. An epidemiologic study of elderly
burn patients in Ain Shams University Burn Unit, Cairo, Egypt. Burns.
2003;29(7):687-690.

35.e2
4  •  Prevention of Burn Injuries
57. Rieman MT, Kagan RJ. Multicenter testing of a burn prevention teach­
ing tool for Amish children. J Burn Care Res. 2013;34(1):58-64.
58. World Health Organization. Burn Prevention: Success Stories and
Lessons Learned. Geneva, Switzerland: World Health Organization;
2011.
59. Ahuja RB, Bhattacharya S. Burns in the developing world and burn
disasters. Br Med J. 2004;329(7463):447-449.
60. Lau YS. An insight into burns in a developing country: a Sri Lankan
experience. Public Health. 2006;120(10):958-965.
61. Hsiao M, Tsai B, Uk P, et al. “What do kids know”: a survey of 420
Grade 5 students in Cambodia on their knowledge of burn prevention
and first-aid treatment. Burns. 2007;33(3):347-351.
62. Schwebel DC, Swart D, Simpson J, Hobe P, Hui SK. An intervention to
reduce kerosene-related burns and poisonings in low-income South
African communities. Health Psychol. 2009;28(4):493-500.
63. Laloe V. Epidemiology and mortality of burns in a general hospital of
Eastern Sri Lanka. Burns. 2002;28(8):778-781.
64. McLoughlin E. A simple guide to burn prevention. International
Society for Burn Injuries in collaboration with the World Health Orga­
nization. Burns. 1995;21(3):226-229.
65. Mallonee S, Fowler C, Istre GR. Bridging the gap between research and
practice: a continuing challenge. Inj Prev. 2006;12(6):357-359.

36
Burn Management in Disasters
and Humanitarian Crises
HERBERT L. HALLER, PAUL WURZER, CHRISTIAN PETERLIK, CHRISTIAN GABRIEL, and
LEOPOLDO C. CANCIO
5 
patients is considered. Finally, the special case of humani­
tarian crisis response is discussed. Every disaster we have
studied is somewhat different. There is, however, a common
theme running through all of them: Prior planning and
realistic training are essential to success.
Definitions
A shared language is critical for the process of planning for
and responding to a disaster. The following provides a basic
vocabulary for burn mass casualty and disaster response.
Mass casualty event: an emergency in which there is a
greater number of victims than can be accommodated by
the rescue forces and their supplies.1 Infrastructure in the
affected area is intact. With force mobilization, the crisis
can be mastered. The period of mismatch between supply
and demand is short. The goal is to reestablish treatment
according to principles of individual medicine as quickly
as possible and without transferring the supply–demand
mismatch from the scene to hospitals. The challenge to
save as many lives as possible, even disregarding the
medical needs of an individual, stands in contrast to the
paradigms of individual medicine in which any individ­
ual life claims the maximum medical effort. The proce­
dure for this challenge is selection of patients—triage,
based on urgency of medical procedures, chance of
success, and distribution among the available qualified
treatment centers (see later discussion).
Disaster: an event in which infrastructure is at least partly
destroyed or degraded and that cannot be handled by
regional rescue means alone. The first goal is to reestab­
lish the minimal level of infrastructure required to
provide basic medical care. (This is different from mass
burns treatment in a resource-poor country, where infra­
structure never existed.) One way to treat burns success­
fully in a disaster is to bring infrastructure, staff, and
materials to the area to treat burns. Another is to move
victims to a place with existing infrastructure. The
maximum treatment possible locally is determined by the
degree of infrastructure and resources in, or brought to,
the disaster area.
Although mass casualty events remain in the purview of
local rescue organizations, disasters are for regional or
national authorities. This means different ways of han­
dling the situation and different funding resources.
Mass burn casualty disaster: defined by the American
Burn Association (ABA) as “any catastrophic event in
Disclaimer: The opinions or assertions contained herein
are the private views of the authors, and are not to be con­
strued as official or as reflecting the views of the Depart­
ment of the Army or the Department of Defense.
Introduction
Mass casualty events and disasters are marked by a period
of mismatch (disproportion) between supply and demand.
Rescue organizations must work to reduce the duration of
this period of mismatch. During the acute phase, actions
follow the principles of disaster medicine: The goal is to save
as many lives as possible even if it means postponing care
for an individual patient. After the mismatch between
supply and demand has been addressed, the principles of
individual medicine can be restored. One goal in mass casu­
alty care is to minimize the period of time it takes to restore
care to the individual medicine paradigm. This period’s
length depends on such structural aspects as the existence
and validity of a disaster plan, a regard for disaster capacity
in health planning, and the educational level of medical
services. These facts are often neglected in disaster plan­
ning, from the political aspect of planning and from the
practical aspect of disaster capacity.
Ideally, treatment should be based on the state of the art
in medical science. During a disaster, treatment with the
“best available means” may weaken the quality of care for
individuals. Therefore, in mass casualties and disasters, the
infrastructure of a country or region may be unable to cope
with a higher number of victims of special trauma types
while maintaining the state of the art. When it is predict­
able that the state of the art cannot be maintained in a
jurisdiction because of dwindling resources, help from
other jurisdictions must be planned and coordinated—the
time for international cooperation has come! Such instances
include mass casualties with burn injuries. Resources avail­
able for specialized treatment are limited, but the demands
of state-of-the-art treatment are high, meaning that even a
small number of victims from one accident can push an
area’s or country’s burn treatment system to its limits.
The purpose of this chapter is to introduce concepts of
disaster medicine as applied to burn patients. A glossary of
disaster medicine terms is provided. Examples of major
burn disasters and the lessons learned are described. Phases
in the typical response to a disaster are summarized. Special
aspects of emergency care during a disaster are discussed.
The role of communication in disaster response is detailed.
The strategic approach to matching burn resources and

5  •  Burn Management in Disasters and Humanitarian Crises
37
which the number of burn victims exceeds the capacity
of the local burn center to provide optimal burn care.”2
Capacity includes the availability of burn beds, burn sur­
geons, burn nurses, other support staff, operating rooms,
equipment, supplies, and related resources. This defini­
tion is inapplicable where, as in Germany, a central burn-
bed bureau always organizes the distribution of burn
victims; the definition supposes a very different degree of
preparedness in these countries.
Triage: the process of sorting individual patients into cat­
egories according to priority of treatment. An example of
triage categories is delayed, immediate, minimal, and
expectant (DIME). Several factors influence triage deci­
sions; these include available resources, number of
patients, the severity of injury of each patient, and the
timeframe during which the injuries must be addressed.
Triage is not a one-time event, but it should be repeated
throughout the mass casualty event (see later).
Basic capacity: the normal number of patients who can
be treated, based on the availability of burn beds, burn
surgeons, burn nurses, other support staff, operating
rooms, equipment, supplies, and related resources
Capacity utilization: the degree of utilization of burn
beds in a center over a certain time. This should be
expressed as use of intensive-care burn beds and other
beds. The average value over a year gives an overview of
a burn center’s disaster capacity.
Actual capacity: the number of burn patients that a
center can admit on an actual day. It varies daily, can
depend on the season, and is likely to fluctuate with sea­
sonal or accidental presence or absence of severe patients.
Surge capacity: the increased capacity available in mass
casualties and disasters. In burns, it is defined by the ABA
as the capacity to handle, in a disaster, 50% more than
the normal maximum number of burn patients.3 Surge
capacity must be developed and maintained, requiring
action by health systems. Surge capacity must include
continued medical care for all other patients. Elective
medical and surgical care can be postponed temporarily
to maintain surge capacity. When capacity is breached,
patients must be transferred safely to other treatment
facilities.
Sustained capacity: the maximum capacity that a burn
center can sustain over a longer time without lowering
treatment quality.
Burn capacity of a health system: the total capacity of
burns that can be treated in a national health system.
This capacity should be known; it should take into
account the various requirements of burn treatment,
such as the number of victims needing intensive care.
The average capacity utilization over the year is part of
resource planning for a health system.
Time to establish surge capacity: how much time a burn
center needs to rise to maximum surge capacity. A good
parameter is the number of complete burn teams avail­
able at various hours. This number is highly important
in a hospital’s organization of care.
National Disaster Medical System (NDMS): manages a
country’s national medical system in disasters. In the
United States, the NDMS is a function of the Federal
Emergency Management Agency (FEMA) under the
Department of Homeland Security. It acts as a partner of
the U.S. Department of Health and Human Services
(HHS), the Department of Defense (DoD), and the Depart­
ment of Veterans Affairs (VA).3 Other countries’ struc­
tures are comparable. The U.S. NDMS has three functions:
(1) medical response at the disaster site, (2) transport of
patients to unaffected areas, and (3) definitive medical
care in unaffected areas.
Burn specialty team (BST) or burn assessment team
(BAT): a special form of disaster medical team that pro­
vides expertise in burns. In the United States, a BST con­
sists of 15 burn-experienced medical and nonmedical
staff. These teams do not exist in many countries. Such
teams can be formed only when burn experts are numer­
ous enough and not already engaged in other aspects of
disaster response.
Technical relief: the general “civil defense” functions
required to support disaster response. In Germany, these
functions are provided by the Bundesanstalt Technisches
Hilfswerk and include lighting, debris removal, search
and rescue, flood mitigation, electricity, water supply,
sewage disposal, catering, command center support,
communications, logistics, equipment repair, and trans­
portation of supplies. In the United States, these func­
tions are provided by FEMA or by equivalent agencies at
the state and local levels.
The Historical Record
Even with the best preparation, a disaster remains a disaster
for a certain period; the goal is to minimize that period.
Although retrospectively correcting problems is impossible,
lessons learned from the past should be applied to the future.
Recurring themes that appear in the following case studies
include the following:
■ Communication problems
■ Need to send major burn patients to burn centers
■ Need for central incident command post
■ Movement of patients to hospitals by private vehicles
■ Importance of control of traffic leaving the disaster area
■ Lack of coordination of patient evacuation from the
scene
■ Value of retriage out of the disaster area to other burn
centers
■ Infection
control
problems;
multidrug-resistant
organisms
■ Lack of experience in burns by nonburn providers
■ Need for psychological support of providers
■ Value of international teamwork
TERRORIST ATTACKS
New York City—September 11, 2001
In New York, two hijacked airliners were flown directly into
the Twin Towers of the World Trade Center. Although many
were injured or killed, few survivors had severe burns.4 The
victims were sent mainly to two burn centers, although
more centers were easily reachable.5 Nineteen were seen at
New York Presbyterian Hospital; there, the victims’ average

5  •  Burn Management in Disasters and Humanitarian Crises
38
wave of patients arrived.9 Palmer et al9 describe a need for
improvement mainly in military–civilian communication.
Communication in the hospital also was problematic:
Mobile phones had no reception, there was no time to read
electronic texts, and land lines were not mobile. ADF pro­
vided satellite phones to the medical staff for communica­
tion between the hospital in Bali and ADF.
Madrid, Spain—March 11, 2004
Bomb attacks on four commuter trains killed 191 and
injured 2051 of 6000 persons present. Thirteen bomb bags
each contained 10 kg of dynamite plus fragments. Three
bombs failed to explode. Of the 191 dead, 175 died instantly,
and 16 died later. It was not known that unexploded bombs
remained on the trains while ambulance staff worked.
Ambulance staff worked without coordination and were
oblivious to overall medical priorities. Patients with only
minor injuries were transported. Ambulances ran out of all
medical supplies. No joint field medical command post was
set up.
Patients were taken to 15 hospitals in Madrid and two
field hospitals, ranging from 5 to 312 patients each.10 Com­
munication problems in hospitals11 and among organiza­
tions arose. Only 33% of patients were transported in
ambulances under medical control; 67% found their way to
hospitals without triage and medical or organizational
control. Most went to the nearest hospital, which received
patients with both serious and minor injuries.12 Of 312
patients taken to Gregorio Marañón University General
Hospital, 45 had burns. The most common injuries were
tympanic perforation (in 41%), chest injury (40%), frag­
ment injury (36%), extremity fracture (18%), eye injury
(16%), head injury (12%), abdominal injury (5%), and
amputation (5%).
London, England—July 7, 2005
Four bombs in the transit system killed 56 (53 at the scene)
and wounded 775.13 Train bombs exploded in three loca­
tions; the fourth bomb exploded on a double-decker bus.
The number of explosion sites was initially unclear because
passengers left the subway at various exits. Triage was per­
formed; 55 patients were classified as severely wounded (P1
and P2). Communication was difficult: All but one mobile-
telephone network failed; radio communication between
the scenes and ambulance control was very difficult. The
fire brigade established an inner cordon and ascertained
that there were no signs of chemical substances threaten­
ing the rescuers, but the presence or absence of more bombs
was not confirmed before rescue work began. Patients
mainly in triage groups 1 and 2 were transported to six
university hospitals after minimal triage and treatment.14
INDOOR FIRES
Gothenburg, Sweden—October 30, 1998
Fire in an overcrowded discothèque during a Halloween
party killed 61 teenagers at the scene; 2 died later; 235 were
wounded (Fig. 5.2). Initial information was poor, resulting
in incorrect alerts. There was no triage officer at the scene.
Hospital disaster plans in some cases were unknown or not
implemented. Preexisting disaster plans had the same
age was 44 years, and the burn size averaged 52.7%.6 In
total, 39 burns were reported by nine hospitals; 27 patients
were admitted. Although enough burn beds within 1 hour’s
transport were available, only 26% of burned patients were
triaged first to burn centers. Two thirds of burn injuries
were ultimately treated in a burn center. The usual portion
of burn victims triaged to burn centers in New York City in
a year is 75.2%.6 BST-1 from Boston, Massachusetts,
responded to this event within hours (Fig. 5.1).
Kuta, Bali, Indonesia—October 12, 2002
A suicide bomber detonated a backpack bomb in a night­
club. People fled to the outside, where a car bomb exploded.
There were 202 deaths and an additional 209 injured. The
Australian Defence Force (ADF) initiated Operation Bali
Assist, the largest Australian aeromedical evacuation since
the Vietnam War.7 An aeromedical staging facility (ASF)
was prepared in a Bali airport hangar, whence 5 C-130
planes flew 61 Australian patients to Royal Darwin Hospital
(RDH). Of the 61 patients, 28 had major injuries (Injury
Severity Score >16). At RDH, 55 escharotomies were per­
formed, along with 43 other surgical procedures. Three
patients had been intubated in Bali; 12 more were intubated
at RDH. Within 36 hours after first admission to RDH and
62 hours after the bombing, 48 patients were evacuated to
burn centers. There were no “walking wounded.” BATs
were used for initial care at RDH.8
Eleven patients were transferred to Concord Repatriation
General Hospital.5 Burn injuries ranged from 15% to 85%
total body surface area (TBSA), mostly full-thickness burns.
All patients showed injuries from both the first and second
blasts. There were complications from infections with Aci­
netobacter baumannii and Pseudomonas aeruginosa and from
fragment injuries. Many ophthalmic injuries occurred,
some being detected only later.
Royal Darwin Hospital received its first information about
the incident from a patient who had been treated in Bali and
then fled to Australia. The hospital learned nothing of the
number of patients or the severity of injuries before the first
Fig. 5.1  New York, New York, 2001. Triage station set up by Burn Spe­
cialty Team 1 from Boston, Massachusetts. (Courtesy of Robert L. Sheri­
dan, MD. Reprinted with permission from Sheridan R, Barillo D, Herndon
D, et al. Burn specialty teams. J Burn Care Rehabil 2005;26:170-173.)

5  •  Burn Management in Disasters and Humanitarian Crises
39
RIH numbered 47. TBSA averaged 18.8%. There were 33
burns of less than 20% TBSA, 12 with TBSA of 21–40%,
and 2 of greater than 40% TBSA. Of 32 patients presenting
with inhalation injuries, 28 required intubation; 12 needed
escharotomies; and in just 6 weeks, 184 bronchoscopies
were necessary.20 Retrospective analysis called for improve­
ment in communication with the disaster scene and in spe­
cific instructions for patient transport.20
Buenos Aires, Argentina—December 30, 2004
Fire at the overcrowded República Cromañón nightclub
killed 194 and injured 714 of 3000 present.21 CO and
hydrogen cyanide poisoning were the main causes of death.
At the scene, 46 ambulances and 8 fire crews sent the
victims to the 8 closest hospitals, which were overwhelmed
by critically ill patients within 2 hours. In Buenos Aires city,
38 hospitals were engaged and another 5 elsewhere in
Buenos Aires province.
Ramos et al describes the experience of Argerich Hospi­
tal,21 to which 74 patients were taken. All had inhalation
injuries. There were no severe burn injuries. Eighteen
patients (24%) were pronounced dead on arrival. Twenty-
five showed respiratory insufficiency and reduced level of
consciousness and were intubated. Initially, 22 patients
were sent to the ICU; the 14 sent to the operating room for
mechanical ventilation were transferred to other hospitals
in Buenos Aires Province within 48 hours.
Kiss Nightclub Fire, Santa Maria, Rio Grande do Sul,
Brazil—January 27, 2013
In this fire, 242 people were killed, and more than 630
others were wounded because of the use of fireworks. Fire­
fighters had to create a hole in the outer wall to help people
to escape. From the estimated 1200–1300 people present
in the disco, 169 were hospitalized because of inhalation
injuries and burns.22 The extent of the disaster was not
communicated to the response workers. Triage was hin­
dered by crowded bystanders and victims. The military
police had to hinder relatives from entering the disaster
site that was filled with smoke and toxic gases. Many of
them were in critical conditions, emergency departments
(EDs) of 5 hospitals, and ICUs of 6 hospitals, and all of the
emergency units were crowded. Fifty-four patients had to be
transported by helicopters and ground transport to hospi­
tals in Porto Alegre and Caxias do Sul and Cachoera do Sul
and Canoas. Transport was supervised and coordinated by
a Brazilian Air Force officer and the Brazilian government
corporation responsible for operating the main commercial
airports. The main issues were with command and control
at the incident scene and the absence of a disaster plan.23
Colectiv Nightclub Fire, Bucharest, Romania—
October 30, 201524
Fire in the nightclub caused by fireworks during a show
killed 26 on the spot, 38 died in hospitals, and 184 were
injured. About 200–400 people present in the club were
engulfed in a stampede when they realized there was fire.
The fire started at 22:30, first and emergency call was sent
over 112. The first ambulances arrived 12 minutes later. A
field hospital was set up. Resuscitation of the unconscious
personnel simultaneously performing conflicting roles.
Within 2 hours, 150 patients were admitted to four Swedish
hospitals. Thirty-one patients presented with significant
burn injuries; 11 patients were transferred secondarily to
other burn centers in and outside Sweden.15
Despite the initial chaos at the scene, there were timely
escharotomies and triage in the hospitals before transfer to
burn centers. Inhalation injuries were diagnosed in 158; 54
of them were treated simply with suction and expectorants.
In 51 of 61 deaths, carbon monoxide (CO) was the cause.
Eleven patients were transferred secondarily to burn centers
in four other cities, one in Norway.16 All 11 had second- or
third-degree burns of more than 20% of the TBSA.
Volendam, the Netherlands—January 1, 2001
A fire at a New Year’s Eve party killed 8 and injured 203
of 350 present.17 An early error in directing emergency
traffic caused transportation chaos. Emergency-services
tents were insufficiently staffed, and tent placement was
problematic. In all, 241 patients went to hospitals: 110
by ambulance, 18 by bus, and 113 by self-referral to the
nearest hospital.18 Of 182 admitted, 112 went to inten­
sive care units (ICUs). Nineteen hospitals provided initial
care. The closest hospital, receiving 73 patients, was
overwhelmed.
After primary treatment in the hospitals, burn specialists
did tertiary triage, distributing patients to hospitals and
burn centers in and outside the Netherlands. Burn center
criteria were adapted on the basis of both burn extent and
inhalation injury: The indications for burn center treat­
ment were greater than 30% TBSA burn with inhalation
injury.
Warwick, Rhode Island—February 20, 2003
Fire at The Station, a nightclub, killed 100 and injured 215
of 439 present. The building totally collapsed within 30
minutes. Rhode Island Hospital (RIH) first became aware of
this incident from breaking news on television;19 shortly
after, RIH got official notification that 200–300 burn
victims were expected. A triage site was established. Sixteen
area hospitals evaluated 215 patients. Patients admitted to
Fig. 5.2  Pope Air Force Base, North Carolina, 1994. Airport fire trucks
extinguish a burning aircraft at the scene of the crash. Rescue efforts
were aided by combat medics who were preparing to participate in
parachute operations. (Reprinted with permission from the Fayetteville
Observer Times.)

5  •  Burn Management in Disasters and Humanitarian Crises
40
liquid expanding vapor explosion after 15 minutes. Sixty-
nine patients were admitted mainly to Dicle University
Faculty of Medicine and Diyarbakir Training and Research
Hospital, including 62 male and 7 female patients. The
average TBSA was 51 ± 32%, including 4 patients with
minor burns (<2%), 9 with moderate burns (2–10%), and
56 with severe burns (>10%). In 75%, fasciotomies had
to be performed. Twenty-seven (48%) required endotra­
cheal intubation, and 13 (23%) needed tracheostomy. A
total of 76% of the patients with severe burns had to be
transferred to a burn ICU. Forty-seven (68%) of the patients
were distributed to 14 different locations. The overall mor­
tality rate was 49%. The length of hospital stay was 19.4
± 19.8 days for the survivors and 6.4 ± 4.2 days for those
who died.
Ramstein, West Germany—August 28, 1988
Aircraft collisions and crashes during an air show killed 70
and injured more than 1000 of 300,000 present (Fig. 5.4).
Three pilots and 67 spectators died; 346 others had serious
injuries. Cooperation was hindered by medical systems that
were not adapted to each other. On day 1, 12 hospitals were
treating the injured; on day 2, 28; and on day 3, 74.28
Outpatients numbered 213; 146 were admitted as inpa­
tients; 84 others were transferred to ICUs. There were 112
with mechanical injuries only; 263 had isolated burn inju­
ries; 68 had both mechanical and thermal injuries.28
Patients with burns of less than 20% TBSA numbered 209
(79.5% of 263). Patients with TBSA of 20–49% numbered
37; 3 of them died. Six of 9 patients with TBSA of 50–70%
died. Another 8 patients, with TBSA greater than 70%,
died. Of the 68 patients with combined injuries, 55 had
TBSA less than 20%. Three of the 9 with TBSA of 20–40%
died. No patient with combined injuries and TBSA burns
greater than 40% survived.
The burn center at Ludwigshafen received 28 victims.
The existing emergency plan was activated; overstaffing
occurred on the first day. Initial care in the burn unit was
provided in the normal way, not according to emergency
plans. Experienced burn teams evaluated the patients. The
disaster plan worked, but incomplete initial documentation
greatly increased the next days’ workload. During
was tried; the effect was not described.19 At 23:30, the
police isolated a perimeter of several streets around the
night club. Seventy-five special vehicles of the Inspectorate
for Emergency Situations and 57 SMURD trucks and ambu­
lances were in place. A total of 500 emergency service per­
sonal were mobilized. Victims accessed hospitals driven by
bystanders, taxis, and ambulances. Twelve hospitals
received between 57 and 15 victims each, and some had to
be redistributed to other hospitals because of overburden­
ing. Ventilation devices had to be moved from other hospi­
tals to the places they were needed. After 1 week, victims
were distributed to burn centers in Israel, The Netherlands,
Belgium, Austria, the United Kingdom, Norway, Germany,
and France. Patients died during or immediately after the
transport because of the severity of their injuries.24 In
Bucharest, enzymatic debridement was used to reduce the
logistic challenge. There were problems in identifying 29 of
146 hospitalized victims because of the severity of their
burns. On March 14, 2016, the last victim treated in a
Romanian hospital died.
TRANSPORTATION CRASHES
Alcanar, Spain—July 11, 1978
A tanker truck carrying liquefied flammable gas exploded
beside the Los Alfaques campground, killing 102 at the
scene and injuring 288; eventually, the dead totaled 215
(Fig. 5.3).25,26 The burning tanker divided the scene into two
parts. The 58 patients transported north to Barcelona
received adequate care before transfer. The 82 patients
taken south to Valencia received minimal treatment before
and during transport. Both Valencia and Barcelona had
state-of-the-art burn centers. There was no significant dif­
ference in age or the extent and depth of burns between
these two groups. After the first 4 days, Barcelona’s survival
rate was 93%, and Valencia’s was 45%. Ultimately, the mor­
tality rate did not differ.
Lyce Diyarbakir, Turkey—July 21, 201427
A driver of a liquid petroleum gas tanker lost control over
the vehicle and caused an over roll followed by a boiling
Fig. 5.3  Ufa, Russia, 1989. Invasive Gram-negative burn wound infec­
tion may be particularly common after a disaster. (Photo courtesy of U.S.
Army.)
Fig. 5.4  Ufa, Russia, 1989: U.S. and Russian teams perform burn wound
care. (Photo courtesy of U.S. Army.)

5  •  Burn Management in Disasters and Humanitarian Crises
41
EXPLOSIONS
San Juanico, Mexico—November 19, 198432
An 11,000-m3 mixture of propane and butane exploded in
San Juan Ixhuatepec (population, 40,000), causing one of
the most severe explosion disasters in history and register­
ing 5 on the Richter scale. In a 25-acre (10-hectare;
100,000-m2) area, 7000 persons needed medical help and
2000 required hospitalization, with 625 severe thermal
injuries. Thirty-three hospitals were involved, with trans­
portation by 363 ambulances and helicopters. Sixty thou­
sand people were evacuated. About 23,000 needed help
with smaller injuries, lodging, and food.
The magnitude of the event meant that during the first
hour, total chaos reigned, and rescue work was unguided.
Secondary explosions, heat from fire, and debris forced res­
cuers into temporary retreat to avoid risking more lives.
Private vehicles fleeing the disaster zone obstructed relief
and evacuation traffic. After triage and initial care, victims
were distributed to 33 hospitals, most of them in Mexico
City. Within 3 days, burn patients had been distributed to
12 hospitals with good burn facilities. After 5 days, only
300 of the 625 burn patients were still in burn units: 140
had died, and 185 had been sent to other hospitals. There
were “rather few” very extensive and deep burns and very
few who needed respirator care.
Centro Médico reported 37 severe burns admitted because
of a silo explosion 3 days before and received 88 more burn
patients from San Juanico. The facility mobilized additional
staff and prepared additional beds near the burn unit. Only
2 of the 88 victims had airway injuries requiring tracheos­
tomy and ventilation. This burn unit’s usual capacity is 48
beds; the maximum number of patients simultaneously
treated was 136. Fifteen patients died within 4 days, whose
burns exceeded 60% TBSA.
Piper Alpha, North Sea—July 6, 198833
An oil fire and gas explosion on an oil rig killed 167 and
injured 189. Information about the event reached Aber­
deen Royal Infirmary in Scotland by television. Sixty-three
were rescued; of 22 who went to the hospital, 15 were
admitted, 11 to the burn unit. There were severe thermal
injuries from molten helmets on victims’ heads. All patients
had some degree of inhalation injury.
All patients were operated on within 72 hours. Opera­
tions were performed by two teams working in two areas
simultaneously. The high number of dead took a grave toll
on the medical and lay teams’ psyches. Psychiatrists, psy­
chologists, and social workers were engaged. The retrospec­
tive recommendation is to distribute patients among other
units. News media were a problem, as was the administra­
tion’s lack of awareness of the need to maintain the high
staffing levels for a long time. Knowledge of basic burn pro­
cedures (e.g., escharotomies and the way to treat a burn) is
important.
Bashkir Autonomous Soviet Socialist Republic—
June 4, 1989
Two trains were passing a methane–propane pipeline when
it exploded, killing 575 and injuring 623.34 Intravenous
(IV) fluid resuscitation was initiated for most patients. Those
treatment, there were no problems with the expanded
nursing staff. Qualified medics who worked double shifts for
weeks were exhausted. Heavy use of burn beds caused
cross-infection problems. The senior surgeon on duty on
day 1 concluded that patients should have been transferred
to other burn units, where free beds were available.28
Kerosene caused difficulties in respiration and in function
of patients’ kidneys, livers, and central nervous systems.
Evaluating cyclic carbohydrates in the blood soon after the
incident may be important for prognosis.29
Pope Air Force Base, North Carolina—March 23, 1994
Two planes collided in the air, attempting to land on the
same runway. The C-130E was able to land; the F-16D,
whose crew ejected, slid into a parked, fully fueled C-141
cargo plane with a crew aboard (see Fig. 5.2). Five
hundred paratroopers, waiting 50–70 feet from the plane,
were sprayed with a fireball of burning aviation fuel,
with flying debris, and with the F-16’s 20-mm ammu­
nition, which began cooking off from the heat.30 Fifteen
to 30 minutes after the incident, casualties arrived at
Womack Army Medical Center (WAMC), a 155-bed hos­
pital 5 minutes away. Fifty-one patients were treated and
released; of 55 admitted, 25 went to ICUs. Six patients
needing urgent surgery were sent to nearby hospitals.
Seven patients were sent to the closest civilian burn center,
Jaycee Burn Center at the University of North Carolina at
Chapel Hill.31
One U.S. Army Burn Flight Team arrived 4 hours after the
accident and another after 9 hours. Escharotomies were
reevaluated; some had to be repeated. Resuscitation was
guided by urine output, but fluid amounts initially were not
documented. Use of the Parkland formula (4 mL/kg/TBSA),
rather than the modified Brooke formula (2 mL/kg/TBSA),
along with untrained personnel’s overestimation of TBSA,
contributed to overresuscitation. Forty-one patients were
transferred to the U.S. Army Institute of Surgical Research
(USAISR) Burn Center for treatment, of whom 13 required
mechanical ventilation. Patients assessed as having non­
survivable injuries stayed at WAMC.
Points from Mozingo et al’s31 review include the
following:
■ Initially, patients with the largest burn sizes were trans­
ferred to a nearby civilian burn center. Most of them later
died. This sapped resources in the burn center with little
impact on outcome.
■ Use
of
different
resuscitation
formulas
caused
difficulties.
■ Patients with obviously lethal injuries were not trans­
ported. This did not meet expectations of the referring
hospital (WAMC).
■ Several burn victims remained at WAMC without burn
specialists because all the burn specialists were needed at
the USAISR.
■ There was a lack of burn experience and training at
WAMC. Knowledge deficits were noted in techniques
(e.g., escharotomy).
■ Training of nonsurgical staff in Advanced Trauma Life
Support (ATLS) and Advanced Burn Life Support (ABLS)
was needed because the surgical staff was busy doing
emergency procedures.

5  •  Burn Management in Disasters and Humanitarian Crises
42
ambulances, fire trucks, and police cars; landing and take-
off of helicopters; decontamination areas; areas for triage,
treatment, and minor injuries; and a temporary morgue.
Divide the scene into rescue areas, and make schedules for
technical-support teams.
In this phase, cooperation among medical teams, fire bri­
gades, police, and technical-relief teams is crucial. Local
command, control, and communication (C3) structures
must be established; they are the coordination hub for pre­
clinical treatment. A central C3 structure coordinates pre­
clinical and clinical treatment and transport and
disseminates up-to-date information. At hospitals, disaster
plans are implemented, and staff is called in.
SEARCH AND RESCUE
The first goal of search and rescue (SAR) is to bring victims
to a safe casualty collection point (CCP) out of the way of
imminent danger (hostile action or environmental hazards).
In-field triage and tagging must occur at the CCP. This
primary evaluation should take less than 30 seconds per
patient and should be limited to life-threatening conditions.
TRIAGE AND FIRST AID
Triage is a process whereby patients are sorted according to
treatment priority, the purpose of which is to do the greatest
good for the greatest number. Several schemes exist to
define levels of triage. The Advanced Disaster Medical Response
course37 is field oriented and outlines the following:
■ Level 1 triage occurs at the point of injury.
■ Level 2 triage occurs at the scene (or nearby) by the most
experienced medical provider.
■ Level 3 triage is performed to determine evacuation
priorities.
The Fundamental Disaster Management course37 is ICU ori­
ented and describes the following levels of triage:
■ Primary triage occurs at the scene.
■ Secondary triage occurs upon arrival at the hospital.
■ Tertiary triage occurs in the ICU.
Finally, the ABA approach is burn center oriented and
defines the following:
■ Primary triage is that occurring at the disaster scene or
at the ED of the first receiving hospital.
■ Secondary triage is the selection for transfer of burn
patients from one burn center to another when surge
capacity is reached.
Clearly, triage is not a one-time operation but has to be
repeated at each step of the way. There are several different
algorithms for triage. Paramedics may use simple triage and
rapid treatment (START) in both emergency medicine and
mass casualties. The sensitivity for START varies from
85%38 to 62%.39 Medic in-field triage is another approach.
This is done in an established triage area by medics assisted
by teams of helpers. It consists of a brief history (time of
accident, mechanism of injury, condition, how the patient
was found, primary measures taken, actual discomfort, pre­
existing condition, medications, and allergies) and a quick
head-to-toe examination:
with serious but potentially survivable injuries were then
evacuated to Chelyabinsk, Sverdlovsk, and Ufa. Later, the
military and Aeroflot took most of them to Gorky, Lenin­
grad, and Moscow. Most had burns of 30–40% TBSA.
Several international teams deployed to assist.35 In Ufa, a
team from Galveston, Texas, under Dr. David Herndon
found four children with burns of 30–68% TBSA and 12
with moderate burn size (15–30% TBSA). The team began
treatment in cooperation with Russian personnel; the
earlier, conservative therapy was changed to an operative
one, using dermatomes and meshers brought from Galves­
ton. A U.S. Army team was deployed to treat adults in Ufa.
The U.S. Army selected 28 patients for burn-wound excision
and coverage. The team reported many infected wounds
(see Fig. 5.3). A microbiological program was set up. Cross-
infection between burn victims was common, mostly by
multiresistant Pseudomonas and Staphylococcus spp. Local
therapy was done with mafenide acetate and silver sulfadia­
zine (SSD) (see Fig. 5.4).35 This effort was one of the very
successful international joint operations in a burn
disaster.36
Phases of Mass Casualty Events
CHAOS AND ALARM
Initially, information about the event is unavailable; even
those involved often cannot verify the incident’s dimensions
and sometimes cannot even describe the location. False
information leads to inaccurate alerts and is disastrous for
all who then must cope with unexpected situations.15,18
Questions to be answered include the exact time, place, and
type of accident; the estimated number of casualties and
expected pattern of injuries; hazards (e.g., contamination,
toxic smoke); and the number of persons potentially
exposed.
Immediately after the accident, victims often flee to the
nearest hospitals, overcrowding them before any official
alarm. This influences the execution of emergency plans
because everyone is busy with arriving victims, and there
may be no resources available to carry out those plans.
Contaminated victims can bring severe risks to hospitals;
this can cause a partial loss of medical resources.
ORGANIZATION
After verification, the incident command system and the
in-field command post must be established and must coor­
dinate the work of rescue, security, medical, and technical
relief teams to enable working in the damaged area and to
protect the teams and their work from hazards, violence,
and distracting demands made by victims and their friends
and relatives.
Medical care at the scene and in alerted hospitals should
be established. First, the scene must be cleared of further
hazards, or rescue workers must be outfitted for the risk. A
cordon should be established to control victims’ departure
to hospitals and to prevent onlookers’ and news media’s
interference in rescue work.
Traffic regulation must begin, and all teams must under­
stand it: It must include movement and assembly of

5  •  Burn Management in Disasters and Humanitarian Crises
43
prepared and IV fluids warmed up. Ambulance doors should
be kept closed to retain heat! The transport order must
accord with urgency status determined in triage.
Transporting the dead steals resources from the living.
The dead, and where they are found (important for iden­
tification41) should be registered; when they have to be
removed, they should be taken to a temporary morgue.
One strategy for distributing patients from a mass casu­
alty event is based on proximity to the scene and classifies
hospitals as first, second, or third line. As much as possible,
first-line hospitals (those closest to the scene) should be
avoided. They will be overcrowded with people arriving as
walking wounded or by private vehicles and will have been
neither triaged nor registered.3,16 Second-line hospitals are
the main destinations for those in need of emergency treat­
ment. Third-line hospitals, those far from the incident, are
ideal for patients in triage group 3 (“delayed treatment,”
“walking wounded” with only minor burns). Mass trans­
port means (e.g., buses) can be used.
BURN CENTER REFERRAL
Central incident command should already know the
number of available burn beds and at least the number and
locations of victims. Burn extent and severity, need for ven­
tilator support, quality of treatment for shock, CO poison­
ing, and quality of escharotomies all must be evaluated
with the goal of getting reliable data. BATs may play a role
in this phase by gathering information from outlying hos­
pitals and assisting in emergency care. With central collec­
tion and distribution of data, the best treatment option
allowed by the resources available can be chosen for the
patient. This can be supported by information technology
(IT) solutions that enable central registration of burn
cases.42
Depending on resource availability, burn patients are
either distributed to burn centers with free resources or,
when burn-center resources are limited, criteria for burn-
center treatment must be established. These criteria should
include burn size, age, and the need for ventilator support.
The survival grid published by the ABA is recommended for
this purpose.2 Patients meeting these criteria are to be
transported to burn units; the rest either stay in the primary
hospital or are transferred to nonburn centers.
Whether to transport patients whose care has been clas­
sified as futile to burn centers must be decided in advance.
They are a burden for the primary hospital in terms of
workload, psychological effect, and legal aspects.31 In burn
centers, they tie up resources needed for treating patients
who are likelier to survive. The pairing of two recommenda­
tions in the United States—to send any third-degree burn
to a burn center and not to send to a burn center anyone
with a severe, life-threatening, nonsurvivable burn—may
produce conflict. At any rate, these patients, their relatives,
and the staff caring for them need both psychosocial support
and support from experienced burn personnel.
EVACUATION TO OTHER BURN CENTERS
Depending on the number of casualties and the available
burn beds, it may be necessary to transfer patients out of
the local burn center. There are three possible scenarios:
■ Physical examination—external bleeding; penetrating
injuries; thermal burns; chemical burns; neurologic
status; and investigation of head, spine, thorax, abdomen,
pelvis, and extremities
■ Vital signs, including respiration rate, pulse oximetry,
and temperature
■ Burn size is estimated by the rule of nines, and there is
evaluation of suspected inhalation injury and of the need
for intubation.
Triage classifies patients according to the following treat­
ment urgency groups shown in Table 5.1. An easy-to-
remember acronym is DIME, which stands for delayed,
immediate, minimal, and expectant. The main factors to
consider in burn patient triage are TBSA burn and age.
Emergency treatment at the scene is done in a treatment
area by appropriately trained providers. Burns needing
treatment for shock or intubation should be classified for
urgent treatment. Because of the need to resuscitate as
soon as possible, resuscitation should begin here!
In mass casualties, cardiopulmonary resuscitation (CPR)
is not performed as it binds resources for mostly futile efforts
for victims initially classified as dead (no ventilation after
airway opened, no pulse). This is especially after rescue from
indoor fires (because deadly CO poisoning can be assumed)
and in the setting of massive trauma.40
Triage group 4 (in Austria, Germany, Switzerland, and
some other countries) includes the unsalvageable, who
deserve “expectant” treatment. This may be controversial
because the duration of the disparity between supply and
demand should be short and, when the period is over, this
group’s priority may change to 1 or 2. Group 4 needs staff
at least for comfort care. Dead victims need neither staff nor
transports in the acute phase.
If available, tags are attached to each patient. Tags are
used not only to indicate triage category but also to provide
each patient with a unique number. These tags facilitate
victim identification and registration; tell about patients’
history, medical treatment, injuries, urgency of treatment,
and classification of injury; and specify the hospital for
treatment. The tags must not be removed until all the fol­
lowing have occurred: hospital arrival, identifying the
patient, and registering the tag number and treatment data.
INITIAL TRANSPORT
For burn patient transport from the scene to the hospital,
ambulance heating should be maximized to avoid cooling
the patients. Warming pads and extra blankets should be
Table 5.1  Triage Color Code and Urgency
Group
START
Medic Triage
1
Immediate
Immediate
2
Urgent
Urgent (2a and 2b)
3
Delayed
Delayed
4
Expectant
4
Expectant or dead
No number, no color
Dead

5  •  Burn Management in Disasters and Humanitarian Crises
44
psychologically and to reflect on its effects. Optimally, it is
conducted near the site of the event and begins within the
first 24–72 hours. The preferred approach is one-on-one
interviews and small-group sessions, after which the psy­
chosocial specialist decides whether debriefing should be
offered. It is suggested to contact people again after 4–6
weeks for reevaluation.40
The Critical Incident Stress Debriefing (CISD) system has
three parts—preparation, attendance, and aftercare. CISD
is offered by many institutions and organizations. Although
minimum standards are rather clear, quality control is
sometimes lacking.40
Emergency Care: Special
Considerations in Disasters
FIRST AID
Bystanders, hurt and unhurt, give first aid according to
their experience and training. Basic measures that can be
performed by trained lay persons include the following:
■ Stop bleeding.
■ Open the airway.
■ Extinguish fire on persons; cool wounds while preventing
hypothermia.
■ Prevent wound contamination.
In mass casualty events, clean polyethylene film (e.g.,
Saran wrap, a plastic wrap used for food) is suggested for
protection of areas other than the face. This occlusive dress­
ing prevents wound dehydration and evaporative heat loss.
Care must be taken not to stop circulation or hinder
ventilation.
FLUID RESUSCITATION
An approach to initial care of burn patients in EDs is pro­
vided in Tables 5.2 and 5.3. To simplify fluid resuscitation
by nonburn providers, who possibly have to resuscitate a lot
of patients at the same time, Chung et al46 implemented a
new formula known as the rule of 10 (for adult patients
weighing between 40 and 80 kg):
■ Estimate burn size to the nearest 10.
■ % TBSA × 10 = Initial fluid rate in milliliters per hour.
■ For every 10 kg above 80 kg, increase the rate by 100
milliliters per hour.
During the next hours, fluid administration should be
adjusted to physiologic response. The target is a urinary
output of 30–50 mL/h. The crystalloid infusion rate (e.g.,
lactated Ringer’s solution [LRS]) is adjusted up and down
by about 25% every hour or two to achieve this goal. The
formula is not suitable for resuscitation of burned children
(weighing <40 kg body weight); for children, a weight-
based formula should be used along with a maintenance
fluid.
Mass casualty events and disasters make it difficult to
provide fluid resuscitation at the right time and in sufficient
quantities. A 70-kg patient with a 40% TBSA burn, for
example, needs approximately 6000 mL of LRS during the
first 8 hours. Because supply is a bottleneck in disasters,
1. If the number of patients is within the local burn cen­
ter’s surge capacity, then the local burn center can do
primary stabilization and treatment and afterwards can
decide whether to distribute some patients to other burn
centers.
2. If the number of patients exceeds the surge capacity of
the local burn center but can be handled by the national
system of burn centers, then initial care must occur in
local trauma centers or burn centers. Dispersal of
patients to national burn centers must come later.
3. If the number of victims exceeds national resources,
international resources must be evaluated to determine
which patients are to be treated in burn centers nation­
ally and which could be evacuated internationally. This
scenario can be facilitated by preexisting conventions
and treaties.
SECONDARY TRANSPORT
During transport, the patient must be protected from bacte­
rial contamination and from cooling. This requires special
dressings and devices that prevent cooling. Klein and asso­
ciates reported that the most common complications during
air transport were loss of venous access and inability to
secure an airway. Hypothermia below 35°C was reported in
about 10%, mostly in patients with larger TBSA burns.43
TRANSPORT HOME
For patients whose treatment occurred far from their
homes, transport to home hospitals should be arranged.
Central disaster management must conduct a general
survey of treatment centers to identify survivors and space
available in the home area. Patients should be transported
if they are stable and the situation in the home area is suit­
able. Transport funding must be obtained.
LONG-TERM FOLLOW-UP AND REHABILITATION
After treatment in a burn center, further care must be
planned. Regular follow-ups, surgical interventions, reha­
bilitation, and psychosocial support must be initiated. These
should be long-lasting measures to give the patient a point
of care that she or he trusts.
Rehabilitation must be coordinated for all patients. The
primary shortage in burn beds will be followed by a second­
ary shortage in rehabilitation centers. Follow-ups must be
planned far into the future; projects should be established
and funded. Care—physical, psychological, and social—
should be given not only to the victims but also to their
relatives.
DEBRIEFING
Debriefing is part of psychosocial preventive care in emer­
gency response. Staff in mass casualties have a higher risk
of illness than the average population. Contributing factors
include the need to make triage decisions, bad information,
lack of routine, lack of resources, inability to provide help,
and contact with aggressive news media.44,45 Debriefing
allows those involved in the incident to overcome the event

5  •  Burn Management in Disasters and Humanitarian Crises
45
TBSA) has been underused. This mainly reflects concerns
about disturbed gastric emptying and impaired peristalsis
after the burn injury, exacerbated by the side effects of
opioid analgesics. In the early 1970s, Monafo resuscitated
a small group of adults and children with burns of 22–95%
TBSA using a 600-mOsm/L hypertonic oral solution.47 In
the 1990s, experience with early enteral feeding48 demon­
strated that, if feeding is begun no more than 2 hours post­
burn, the gastrointestinal effects are favorable, and even
major burns could be managed with enteral, rather than
parenteral, feeding.
Today, the main focus is on the World Health Organiza­
tion’s oral resuscitation solution (ORS). It is a small packet
containing glucose, sodium, potassium, chloride, and
buffer, with a slightly hypertonic osmolarity of 331 mmol/L
when dissolved in water. It was first developed to treat the
massive loss of volume and electrolytes in cholera, dysen­
tery, and so on. With a feeding catheter placed in the intes­
tine of 40% TBSA burned anesthetized pigs, Thomas et al
demonstrated resuscitation with the WHO ORS according
to the Parkland formula.49 Michell et al reported similar
results.50 El-Sonbaty reported good results using WHO ORS
for oral resuscitation of children with burns of 10–20%
TBSA.51 More research into both the ideal enteral fluid and
the quantities to administer is necessary. But in early burn
resuscitation in disasters with IV fluid shortages, there may
be a role for oral rehydration solutions, such as the WHO
ORS or one of the following:52,53
■ 5.5 g of salt as undissolved tablets swallowed with 1 L of
water
■ 1 L of water with 1 tsp of salt (or 1/2 tsp of salt and 1/2
of baking soda) and 8 tsp of sugar
■ 1 L of LR with 8 tsp of sugar.
The importance of beginning fluid resuscitation (orally,
enterally, or intravenously) as early as possible must be
emphasized.
AIRWAY MANAGEMENT
In burn disasters, oxygen and ventilators often are scarce,
increasing the importance of correctly assessing which
patients need oxygen or intubation.
OXYGEN
In disasters, oxygen (O2) requirements rise rapidly. Deliver­
ing small bottles of liquid O2 is logistically difficult; the avail­
able capacity is strained by the weight, space, and the need
to refill bottles. Even hospitals’ large bulk liquid-oxygen
systems may be damaged or inaccessible. In such cases,
alternatives must be implemented as soon as possible. Por­
table bulk systems (1000–5000 L of liquid oxygen) or
mobile cylinder banks are helpful, but are often unavailable
in disasters.
Two other options are portable oxygen generators (POGs)
and nonportable oxygen generators, often used in military
field hospitals. If electrical power is present, oxygen genera­
tors can deliver oxygen with a concentration of 93% or
more. They can be connected to patients or ventilators.
With a booster system to provide enough pressure, oxygen
generators can be used to refill oxygen tanks.
Table 5.2  Primary Assessment of Burns in Hospitals
■ A—Airway
■ Intubation?
■ Tracheotomy
■ Inhalation
■ B—Breathing
■ Pneumothorax
■ Escharotomy thorax
■ Remove necrotic plates from thorax
■ C—Circulation
■ Resuscitation fluid
■ TBSA recalculated
■ Urine output
■ Core temperature
■ Hemorrhage
■ Escharotomy
• D—Disability
■ CO—Carboxyhemoglobin
■ Hydrogen cyanide
■ Shock
■ Trauma
■ E—Environment
■ Additional injury
■ (Trauma CT scan)
CO, Carbon monoxide; CT, computed tomography; TBSA, total burn surface
area.
Table 5.3  Important Items During Primary Hospital
Assessment in Burns
VENTILATION
■ If ventilation is impaired: Check the need for intubation,
tracheotomy, or coniotomy.
■ If patient is intubated and ventilation is disturbed: Check tubus
position; exclude pneumothorax; consider thoracic escharotomies
and fasciotomies.
■ Check for inhalation injury and aspiration: Bronchoscopy may
be needed.
■ If carboxyhemoglobin is high: Oxygen appliance is needed.
CIRCULATION
■ If perfusion of extremities is disturbed or pressure is high: Check
the need for escharotomy and fasciotomy.
■ Recalculate TBSA.
■ Recalculate fluid requirement: Present corrected fluid amount.
■ If blood pressure is disturbed: Correct fluid administration. Other
medication? Additional injuries?
ORGAN PERFUSION
■ Check urine output.
■ Core temperature: Warm up.
OTHER INJURIES
■ Is other medical treatment (besides burn treatment) necessary?
Complete the diagnosis and give treatment according to urgency.
LOCAL TREATMENT
■ Clean; apply disinfectants: Take primary swabs.
NUTRITION
■ Nasogastric or nasoenteric tube in intubated patients.
TBSA, Total burn surface area.
facility with how to resuscitate patients using fluids other
than LRS may be important.
ORAL RESUSCITATION
Since the development of IV resuscitation formulas in the
early 1950s, oral resuscitation in major burns (>15–20%

5  •  Burn Management in Disasters and Humanitarian Crises
46
experience showed that an uncoordinated surge in blood
donation may generate, several weeks later, an unusual
drop in the supply.56 Managing blood in disasters and catas­
trophes is therefore a tricky matter.57
Hospital blood banks possess a certain inventory, which
usually is not more than the amount of blood products
needed for 2–3 normal days, including additional units for
major trauma. Burn disasters immediately deplete the
available stocks and lead to urgent requests to the local
blood center. Triaging mass casualties, especially in burn
disasters, results in the dissemination of patients to differ­
ent trauma centers, so that multiple hospital blood banks
are involved. High-volume and high-priority requests con­
centrate in a spiraling sequence in one blood center, which
is greatly strained to coordinate the distribution to its hos­
pital blood banks.
Supplies are usually sufficient to meet the urgent first
requests, but many blood centers hold an average of blood
products to meet the regular demand of 1 week or less.
Burn disasters are characterized by the urgent need for
platelet products and erythrocyte concentrates in the early
phase. A blood center’s stocks may be depleted within
hours—platelets first and then erythrocyte concentrates.
Plasma products are usually available even in bigger
disasters.
Deliveries from other blood centers and national coordi­
nation may help to mitigate the center’s own insufficiency.
More often, a blood center acts without information about
the disaster and the estimated need for blood products.
Communication between emergency services and blood
centers is rare.
WOUND CARE AND ESCHAROTOMIES
Whereas courses such as ABLS emphasize early transfer of
individual patients to a burn center, where debridement of
wounds and escharotomies (if needed) are done by the burn
experts, this may not be possible in a mass casualty event.
Initial wound debridement should be thorough and aggres­
sive and should use a surgical antiseptic such as chlorhexi­
dine gluconate solution. After debridement, the patient
should be prescribed a topical antimicrobial. SSD (Silvad­
ene, Flamazine) has the advantage of widespread availabil­
ity and familiarity. Mafenide acetate (Sulfamylon; Mylan
Institutional, Rockford, IL) has the advantage of deep pen­
etration into eschar. A silver-impregnated dressing (Silver­
lon; Argentum Medical, Geneva, IL; others) is a less
labor-intensive option than the creams. For mass casualty
situations, SSD with cerium nitrate (Flammacerium; Alli­
ance Pharma, Chippenham, United Kingdom) is an attrac­
tive option based on the concept that the resulting eschar
may permit a delay in excision with diminished ill effect.58
An enzymatic debriding agent, NexoBrid (MediWound Ltd,
Yavne, Israel), is under evaluation as a topical alternative
to surgical wound debridement, which would be useful in
mass casualty events.
Communication
Communication is an essential component of successful
disaster response and a component that frequently
For safe work with diminished resources, there are several
requirements: organizing a sufficient supply, ensuring the
right connections between the systems, rechecking differ­
ent systems during exercises, and evaluating actual oxygen
needs to minimize wasted gas.54
ANESTHESIA
In disasters with few fully equipped anesthesia worksta­
tions, relatively stable patients without threatened airways
or inhalation injuries and no major surgery of thorax or
abdomen can be managed safely with (1) ketamine, (2) ket­
amine and midazolam, or (3) ketamine and low-dose pro­
pofol.55 Ketamine preserves spontaneous ventilation; airway
reflexes are mostly intact. The drug induces dissociative
anesthesia and is a potent analgesic. Increasing central
sympathetic tone helps stabilize hemodynamics. It is a
bronchodilator but increases mucus production. It there­
fore may require concomitant administration of glycopyr­
rolate or atropine. To avoid dysphoria and hallucinations, it
can be combined with midazolam (0.03–0.15 mg/kg) or
low-dose propofol (0.25–0.5 mg/kg). As a racemate, ket­
amine has a loading dose of 0.25–1 mg/kg IV or 0.5–2 mg/
kg intramuscularly for analgesia; the anesthetic dose is
0.75–3 mg/kg IV. S (+) ketamine, with less psychomimetic
effect, can be administered at half the dose of the racemate.
The effect lasts 5–15 minutes.
Acute surgery of wounds on upper and lower limbs and
reduction of open fractures can be done under peripheral
single-shot regional anesthetic techniques if the region
where the block must be performed is clean and not burned.
The same can be done with smaller burns on the
extremities.
The availability of ventilators and anesthesia machines
depends on the scale of disaster. If field hospitals are
required, providers must be familiar with the equipment
available therein. First-line field anesthesia machines are
draw-over systems. They are used in the forward deployed
medical units in the army but also in civil units like the
German Red Cross “ziviles Feldlazarett.” Their main advan­
tage is their extremely low weight (5 lb or 2.3 kg). For ven­
tilation in a controlled mode, however, they have to be
connected to a ventilator. Another disadvantage is their
failure to meet American Society of Anesthesiologists (ASA)
safety standards. Therefore, training with the devices is dif­
ficult and requires connection to the safety and monitoring
systems of standard anesthesia machines.
Recently, field-deployable versions of standard anesthesia
machines were developed and introduced. They are of a
robust and lightweight design, are able to operate under
extreme temperatures, have extended battery capacities,
require little maintenance, and are able to ventilate in dif­
ferent modern ventilation modes. The same applies to some
modern transport ventilators, which are easy to transport
and able to replace a heavy ICU ventilator.
BLOOD
Few publications describe the responsiveness and efficacy of
transfusion services in catastrophes and disasters. Blood
supply is mentioned as scarce in the first and prolonged
phases of disaster response.12 But the 9/11 terror

5  •  Burn Management in Disasters and Humanitarian Crises
47
interorganizational communication. In Europe, TRSs are
being established for emergency organizations.
Satellite Telephone
Satellite phones are independent of local infrastructure and
can be helpful in cases of uncertain or overloaded infra­
structure. However, even a call made from a satellite phone
will not go through if the telephone system at the receiving
end is not functioning.
Internet
Internet communication is an option only if connections
are intact.64 The Internet can be helpful in building up
information structures for victims’ relatives and to provide
information to large audiences.
Electronic News Media
These are important in disasters, especially when locales
must be evacuated and when staff are needed. News reports
sometimes constitute burn centers’ first information source
about incidents before the official alarm arrives.
COMMUNICATION WITH NEWS MEDIA
News media shape the public face of the disaster. Informa­
tion should originate from a desire to be as correct and as
complete as possible.59 Training in crisis communication
should be given. The central incident command should
appoint spokespersons to provide regular, scheduled press
conferences and bulletins. The press should be kept away
from victims and their relatives. The hunt for headlines does
not stop at the hospital door.
When spokespersons start their work, they should express
first their concern about the situation and their condo­
lences to those who have lost loved ones; they should provide
assurance that everything possible is being done to help.
Methods of supplying information to the media include
websites, press releases, press conferences, and radio and
television interviews.
The media want people for interviews and photos. This
should be kept in mind and prepared for, with forethought
given to what aspects can be discussed without causing
problems. The following is a list of things to avoid when
interacting with the press:59
■ Guessing; presenting your own theories; communicating
falsehoods
■ Becoming upset or angry
■ Using jargon
■ Discussing classified information
■ Saying, “No comment”
■ Speaking about issues outside your area of expertise.
Communication with the media should be done in an
environment outfitted for information transfer by media
and away from patient treatment areas.
COMMUNICATION WITH RELATIVES
AND FRIENDS
Centers should be established at hospitals for friends and
relatives to gather in private. Crisis counselors and com­
munication tools (e.g., telephones) should be available here.
malfunctions during a crisis. Hospitals and burn centers
often learn first of an incident through the media or other
unofficial channels.19 Victims arriving on their own some­
times give the first information.9 News media also can be
faster than the designed information structure sometimes
video is a better source of information than mere words.
When patients arrive tagged or telling certain stories, it
indicates a mass casualty event. Measures to establish hos­
pital preparedness should be taken, including checking sup­
plies and the local situation and not allowing staff to go
home after shifts until the situation is cleared.
Crisis communication is the exchange of information
among public authorities, organizations, news media, and
affected individuals and groups—before, during, and after
a crisis.59
MEANS OF COMMUNICATION
In disasters and mass casualties, many factors increase the
need for communication—and communication resources
are limited. Sequential failure of various communica­
tion methods was described in many disasters such as
Enschede,60,61 London, and Madrid.10,11 Communication
problems are reported in almost all mass casualties and
disasters.
Cellular Telephone
Cellular networks usually are overwhelmed because victims,
news media, relatives, friends, and others all quickly begin
dialing to or from cell phones. This leads to breakdown
within minutes. Cell phones should not be used near explo­
sive devices;62 a 50-ft (15.2-m) safety radius is suggested.
People trying to use cell phones may be endangered by secu­
rity forces, who know that cell phones can be used to trigger
bombs. In case of suspected bombs, cell phones can be
jammed by security forces.63 Amateur videos, often shot on
cell phones, are important in mass casualties for recon­
structions and intelligence.
Conventional Telephone
In most hospitals, the number of incoming and outgoing
landlines is limited. A manual switchboard, as opposed to
automatic switching, can become overloaded very quickly.
For alerting staff, an alarm server with call-center function
makes sense.
Voice over Internet Protocol
Voice over Internet Protocol (VoIP) permits conference
calls. For security reasons, public VoIP systems are usually
disabled in hospital IT systems.
Two-Way Radio
Reception and transmission can be poor or nonexistent
indoors and underground (e.g., 9/11, London). In hospitals,
the number of persons who can talk at the same place and
time over one circuit can be limited, causing problems when
an area includes many persons exchanging information.
Trunked Radio System
Such systems use computer control to allow almost unlim­
ited talk groups with only a few channels. Relief units
use trunked radio systems (TRSs) for intra- and

5  •  Burn Management in Disasters and Humanitarian Crises
48
above the normal capacity can cause complications, such
as an infection control problem.28
THE ROLE OF TRAUMA CENTERS
Trauma centers will always be part of disaster response.
Trauma centers, being much more numerous than burn
centers, can cope more easily with initial treatment of an
unknown number of casualties.66 In special cases, patients
with combination injuries (e.g., mechanical injuries) may
benefit from transfer to a trauma unit.
Although initial care of burns is part of ATLS, many
emergency doctors, trauma surgeons, and other medical
personnel are not experienced in burns.31 Trauma centers
without burn units therefore need support from experts and
seem to be the place where BATs can be most effective. BATs
act as experts and can support other surgeons. Because
they are busy not with details but with directing treatment
by others, they are in a position to improve results. They
also can help determine the extent and severity of burns for
central data collection and for redistribution of patients to
burn centers or other hospitals. This assumes that BATs are
readily deployable on short notice.3,8
THE ROLE OF BURN-BED DATABASES
Burn-bed databases are a necessity for knowing quickly
who should go where. These databases should include the
different burn-bed types (adult or pediatric; ICU or ward). It
takes too much time during an incident to ask each center
individually how many beds are free for use; therefore, an
online system is preferable.
At present, few data exist on the real availability of burn
beds in case of disaster. Germany has the highest ratio of
burn beds to population. In the Enschede fireworks explo­
sion, Germany could offer 19 burn ICU beds of 127 for
adults and 15 for children.61 There are national burn-bed
bureaus in Germany and the United Kingdom, and there
are networking facilities for cooperation (e.g., the Mediter­
ranean Burns Club).
THE ROLE OF INTERNATIONAL COOPERATION
Transfer of burn patients across international boundaries
has worked well in some mass casualty events, particularly
in Europe. The European Union has a “Community Mecha­
nism for Civil Protection,” which regulates disaster support
among nations both in and outside the European Union.
This process covers sending disaster-relief staff to countries
with disasters, but it does not address transferring victims
to other countries. There are exchange treaties between
some countries, and there is actual cross-border hospital
cooperation, but there is no general regulation thereof.
Humanitarian Crises
A humanitarian crisis is an event causing critical threats to
health, safety, or human well-being, usually over a wide
area. For burn injuries, armed conflicts and natural disas­
ters are the likeliest forms. Natural disasters can not only be
directly linked to fire (as in wildfires) but also cause burn
Access to this area should be restricted to identified relatives
and friends. Information here should be exact, honest, and
never speculative. A contact person for relatives and friends
should be nominated. Relatives coming to visit their badly
injured loved ones should be given psychosocial help and
should be supported by the offer of guest rooms and con­
tinuous, fact-based information. Patients and relatives
should be protected from news media, which often consti­
tute a big problem in this phase.
Strategies for Distribution of
Patients and Resources
Fundamental to disaster planning and response are strate­
gies for admitting burn patients, for redistributing burn
patients away from the disaster zone, and for bringing addi­
tional resources into the disaster zone. Strategies differ by
country, depending on the resources available. A funda­
mental principle in any successful disaster strategy is that
of a tiered response. This means that higher and higher tiers
of support are brought into play as the magnitude of the
event increases. Most mass casualty events are handled at
the local level; regional, national, and then international
resources are programmed as needed.
THE ROLE OF BURN CENTERS
Individual-medicine criteria for admitting to burn centers
are rather extensive. For example, the German-Speaking
Association for Burn Treatment (DGV) and the European
Burns Association (EBA) have guidelines stating that burns
in functionally or aesthetically important areas should be
treated in burn centers regardless of their degree and
extent. According to the ABA, all third-degree burns should
be treated in burn centers. It may not be possible to follow
these guidelines in mass casualties and disasters, at least
not initially; the available burn beds must be filled by victims
who will get the maximum survival advantage from burn
center treatment.
In theory, admitting all burn patients to burn centers is
reasonable in resource-rich jurisdictions, with many burn
centers, many burn beds, and lots of staff. In reality, the
availability of burn beds varies among nations. Usually it
can be assumed that burn beds are in short supply and high
demand. Even in the United States, many burn centers have
fewer than 15 beds65 and even fewer ICU beds.
The advantages of admitting all burn patients to burn
centers are lost when the number of victims is so high that
quality cannot be maintained. Burn center staff then get
tied up treating many patients with non-life-threatening
burns. Likewise, admitting only the most severely burned
patients to burn centers is of little use, as demonstrated in
the case of Pope Air Force Base. There, an influx of lethally
injured patients monopolized the Jaycee Center’s resources.
Burn beds are scarce and so must be reserved for victims
with the best chance of survival. The ABA published a
benefit-to-resource ratio table to optimize this process.
Transferring patients elsewhere can be reasonable even
for burn centers because surge capacity cannot be main­
tained indefinitely. “Medical vanity” should never be a
reason to avoid transferring patients elsewhere. Workload

5  •  Burn Management in Disasters and Humanitarian Crises
49
In other words, relatively low-cost interventions (e.g.,
prevention of invasive Gram-negative burn wound infec­
tion by use of topical antimicrobial burn creams and basic
hygiene) are likely to have a greater impact than some of
the higher cost, high-tech interventions.74
Conclusions
Recent events have raised worldwide awareness of burn
disasters. Ongoing wars and terrorist attacks, along with
several indoor fires, have shown that preparedness for such
events is necessary.75,76 No one is immune to such risks. The
question is not whether such disasters will happen but
when they will happen and how we can cope.
Preparedness requires plans, and it requires staff, stuff,
and structure (the three Ss). Plans include international
disaster plans, national disaster plans, coordinated disaster
plans at the state level, and local disaster plans for locales
and institutions. Structure is the national or international
health system. Stuff is emergency supplies ready for disas­
ters. Staff includes medical, paramedical, rescue, and
technical-relief organizations. On the basis of these plans,
legal preconditions must be established, and resources must
be planned and funded. Both the planning and the execu­
tion require money, which is an investment in a society’s
future and security.
Burn societies can aid this procedure because they com­
prise the experts in these fields. Planning without the
experts in burn treatment is futile, but working on their
own, burn experts lack the resources to plan for mass
casualties.
Disaster drills for hospitals and rescue organizations must
be performed realistically. Education in burn treatment
(e.g., Advanced Burn Life Support (ABLS), Emergency Man­
agement of Severe Burns (EMSB)) is essential for effective
coping with mass casualties—not only for medical staff but
also for hospital administrations. Burn surgeons are scarce
in burn disasters, and surgeons are not the only personnel
to be trained. We encourage readers to learn from the expe­
riences described in this chapter; we hope that these experi­
ences will motivate them to plan assiduously and to train
diligently.
Complete references available online at

injuries through atypical use of energy: When people are
not used to open fire but they need it because their electric­
ity resource has failed, burn incidence rises. The same
happens when people try to get electricity by throwing
wires over power lines. After a severe storm, the increased
use of internal-combustion emergency generators and
internal-combustion power saws causes a higher rate of
burn injuries and of burns related to burn accelerants.67
In disasters and humanitarian crises, medical treatment
can often begin only after minimal infrastructure and order
are reestablished. Where looting or political or religious
rivalry occurs, medical work can be dangerous.68 Therefore,
cooperation with security forces, at least in the early stages,
may be necessary.69 Minimum requirements for work are
shelter, safe water, food, and electricity.70 One of the basic
problems in medical aid work in disasters and low-resource
countries is sterility: There usually is a high rate of infec­
tions with hepatitis and HIV, which must not be spread.71 It
may be helpful to conceptualize burn injuries during a
humanitarian crisis as follows:
■ Those that can be treated with minimal efforts (e.g., by
clean dressings and available analgesics).
■ Those that are not survivable without specialized care.
Such specialized care must first be instituted.
■ Those that cannot be treated successfully in this environ­
ment. Patients must be transported to facilities where
successful treatment can be performed and is funded, or
they are deemed futile, and “comfort care” should be
provided.
To prepare medical systems for burn treatment during a
humanitarian crisis, history provides data on what inter­
ventions are most likely to improve outcome at the lowest
cost. At the end of World War II, only 50% of young adult
patients survived burns of greater than 40% TBSA.72 Step­
wise improvements in survival were the result of the follow­
ing advances:73
■ Fluid resuscitation techniques
■ Safe blood support
■ Topical antibacterial treatment with mafenide acetate or
silver-containing products
■ Early excision and grafting; cadaver skin as a temporary
skin substitute
■ Enteral nutrition
■ Improvements in mechanical ventilation and general
critical care.

49.e1
5  •  Burn Management in Disasters and Humanitarian Crises
26. Banuelos Roda JA. Our Experience in the Treatment of a Great
Number of Burns Due to Two Catastrophes. In: Zellner P-R, ed. Die
Versorgung des Brandverletzten im Katastrophenfall. 1st ed. Darmstadt:
Steinkopff; 1990:25-27.
27. Zengin Y, Dursun R, İçer M, et al. Fire disaster caused by LPG tanker
explosion at Lice in Diyarbakır (Turkey): July 21, 2014. Burns [Inter­
net]. 2015;41(6):1347-1352. Available from:
rect.com/science/article/pii/S0305417915000406.
28. Steen M, Uhlemann PR, Zellner R. Die Versorgung der Opfer des
Unglücks von Ramstein. In: Zellner PR, ed. Die Versorgung des Brand­
verletzten im Katastrophenfall. Steinkopff; 1990.
29. Steen M, Uhlemann PRH. Die Auswirkungen von Kerosin bei
Großschadensereignissen mit Flugzeugbeteiligung. In: Zellner PR,
ed. Die Versorgung des Brandverletzten im Katastrophenfall. Steinkopff;
1990:71-74.
30. Condon-Rall ME, Washington D, S U. Disaster on Green Ramp the
Armys response. Disaster Green Ramp Armys response xvi 145 p C
Cent Mil Hist Rep No. 1996;0–70.
31. Mozingo DW, Barillo DJ, Holcomb JB. The Pope Air Force Base Aircraft
Crash and Burn Disaster. J Burn Care Rehabil. 2005;26(2):132-140.
32. Arturson G. The tragedy of San Juanico-the LPG disaster in history.
Burns. 1987;87-102.
33. Rayner CRH. Offshore disaster on a fixed installation-The Piper Alpha
Disaster on July 6th. In: Zellner R, ed. Die Versorgung des Brandverletz­
ten nim Katastrophenfall. Steinkopff; 1990.
34. Wikipedia authors. Ufa Train disaster [Internet]. Available from:
Accessed 30 May
2016.
35. Herndon DN. A survey of the primary aid response to the Bashkir
train-gas pipeline disaster. Burns. 1990;16(5):323-324.
36. Kulyapin AV, Sakhautdinov VG, Temerbulatov VM, Becker WK,
Waymack JP. Bashkiria train-gas pipeline disaster: a history of the
joint USSR/USA collaboration. Burns. 1990;16(5):339-342.
37. SM B, ed. Advanced Disaster Medical Response: Manual for Providers.
Boston MA: Harvard Medical International Trauma and Disaster
Institute; 2003.
38. Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis
of multiple-casualty incident triage algorithms. Ann Emerg Med.
2001;38(5):541-548.
39. Schenker JD, Goldstein S, Braun J, et al. Triage accuracy at a mul­
tiple casualty incident disaster drill: the Emergency Medical Service,
Fire Department of New York City experience. J Burn Care Res.
2006;27(5):570-575.
40. Ortenwall P, Sager-Lund C, Nyström J, Martinell S. Disaster manage­
ment lessons can be learned from the Gothenburg fire. Lakartidningen.
2000;97(13):1532-1539.
41. Prize N, Korn A. Disaster victim identification – a need to create zone-
wise scientific working groups Some drawbacks of the higher educa­
tion system in India. Curr Sci. 2015;109(12):2173-2174.
42. Haller HL, Dirnberger J, Giretzlehner M, Rodemund C, Kamolz L.
Understanding burns”: research project BurnCase 3D–overcome
the limits of existing methods in burns documentation. Burns.
2009;35(3):311-317.
43. Klein MB, Nathens AB, Emerson D, Heimbach DM, Gibran NS. An
analysis of the long-distance transport of burn patients to a regional
burn center. J Burn Care Res. 2003;28(1):49-55.
44. Helmerichs J, Luitz T, Lackner CK, Peter H, Schmidt J. Psychosoziale
Notfallversorgung. In: Luitz T, Lackner CK, Peter HSJ, eds. Medizinische
Gefahrenabwehr. 1st ed. München: Urban & Fischer; 2010.
45. Crisis Communications Handbook. In: Agency SEM, ed. SEMA’s Edu­
cational Series 2008:3. Swedish Emergency Management Agency;
2008.
46. Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned
military casualties: fluid begets more fluid. J Trauma [Internet]. 2009.
47. Monafo WW. The treatment of burn shock by the intravenous and
oral administration of hypertonic lactated saline solution. J Trauma.
1970;10(7):575-586.
48. Raff T, Hartmann B, Germann G. Early intragastric feeding of seri­
ously burned and long-term ventilated patients: a review of 55
patients. Burns. 1997;23(1):19-25.
49. Bergwall S Thomas Quick : the Swedish serial killer who never was.
2012;1–9.
50. Michell MW, Oliveira HM, Kinsky MP, et al. Enteral resuscitation of
burn shock using World Health Organization oral rehydration solu­
tion: a potential solution for mass casualty care. J Burn Care Res.
2006;27(6):819-825.
References
1. Weidringer JW, Weiss W, eds. Aspekte zur Katastrophenmedizin und Defi­
nition ihrer Inhalte und Aufgaben. Katastroph. Berlin: 2003:25-28.
2. ABA. Disaster Management and the ABA Plan. J Burn Care Rehabil.
2005;26(2):102-106.
3. Jordan MH, Mozingo DW, Gibran NS, Barillo DJ, Purdue GF. Plenary
Session II: American Burn Association Disaster Readiness Plan. J Burn
Care Rehabil. 2005;26(2):183-191.
4. Rapid assessment of injuries among survivors of the terrorist attack
on the World Trade Center-New York City, September. Mortal Wkly
Rep. 2002;51:1-5.
5. Kennedy PJ, Haertsch PA, Maitz PK. The Bali burn disaster: implica­
tions and lessons learned. J Burn Care Rehabil. 2005;26(2):125-131.
6. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response
to a disaster: September 11, 2001, and the days beyond. J Burn Care
Rehabil. 2005;26(2):117-124.
7. McLaughlin M Hospital staff looking back on Bali bombing aftermath.
2004. Available from:
s1218623.htm. Accessed 30 May 2016. 0–12.
8. Greenwood JE, Pearce AP. Burns assessment team as part of burn
disaster response. Prehosp Disaster Med. 2006;21(1):45-52.
9. Palmer DJ, Stephens D, Fisher DA, et al. The Bali bombing: the Royal
Darwin Hospital response. Med J Aust. 2003;179(7):358-361.
10. Carresi AL. The 2004 Madrid train bombings: an analysis of pre-
hospital management. Disasters. 2008;32(1):41-65.
11. Bolling R, Ehrlin Y, Forsberg R, et al. KAMEDO Report 90: terrorist
attacks in Madrid, Spain, 2004. Prehospital disaster Med Off J Natl
Assoc EMS Physicians World Assoc Emerg Disaster Med Assoc with Acute
Care Found. 2004;22(3):252-257.
12. de Ceballos JPG, Turégano-Fuentes F, Perez-Diaz D, et al. 11 March
2004: The terrorist bomb explosions in Madrid, Spain – an analysis of
the logistics, injuries sustained and clinical management of casualties
treated at the closest hospital. Crit Care. 2005;9(1):104-111.
13. Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mor­
tality in urban mass casualty incidents: analysis of triage, surge,
and resource use after the London bombings on July 7, 2005. Lancet
(London, England). 2006;368(9554):2219-2225.
14. Hughes G. The London bombings of 7 July 2005: what is the main
lesson? Emerg Med J. 2006;23(9):666.
15. Cassuto J, Tarnow P. The discotheque fire in Gothenburg 1998:
A tragedy among teenagers. Burns. 2003;29(January 2001):
405-416.
16. Gewalli F, Fogdestam I. Triage and initial treatment of burns in
the Gothenburg fire disaster 1998. On-call plastic surgeons’ expe­
riences and lessons learned. Scand J Plast Reconstr Surg Hand Surg.
2003;37(3):134-139.
17. van Harten SM, Bierens JJLM, Welling L, et al. The Volendam
fire: lessons learned from disaster research. Prehosp Disaster Med.
2006;21(5):303-309.
18. Alders C Investigators Report The New Years Eve fire in Volendam
[Internet]. 2003. Available from:
mentatiecentrum.nl/rapporten/overige-rapporten/commissie-onder­
zoek-cafebrand/. Accessed 1 Jan 2016.
19. Digi24 R. Reanimieren und weinen [Internet]. 2015. Available from:

la+Maternitatea+Bucur+printre+primii+salvatori+Era+. Accessed 5
Aug 2016.
20. Mahoney EJ, Harrington DT, Biffl WL, et al. Lessons Learned from a
Nightclub Fire: Institutional Disaster Preparedness. J Trauma Inj Infect
Crit Care. 2005;58(3):487-491.
21. Ramos G, Flageat G, Queiroz G, et al. Massive hospital admission
of patients with respiratory failure resulting from smoke inhala­
tion injury: the Cromagnon Republic Tragedy. J Burn Care Res.
1994;27(6):842-847.
22. Dal Ponte ST, Dornelles CFD, Arquilla B, Bloem C, Roblin P. Mass-casu­
alty Response to the Kiss Nightclub in Santa Maria, Brazil. Prehosp
Disaster Med [Internet]. 2015;30(1):93-96. Available from: http://

Accessed 21 Mar 2016.
23. Atiyeh B. Brazilian kiss nightclub disaster. Ann Burns Fire Disasters
[Internet]. 2013;26(1):3-4. Accessed 21 Mar 2016.
24. Wikipedia F. Colectiv nightclub fire [Internet]. Wikipedia. 2015;Avail­
able from:
25. Baux S, Saizy R, Porte A, et al. The Los Alfaques disaster. Ann Chir
Plast. 1981;26(2):185-187.

49.e2
5  •  Burn Management in Disasters and Humanitarian Crises
51. El-Sonbaty MA. Oral rehydration therapy in moderately burned chil­
dren. Ann Mediterranian Burn Club. 1991;4:29-32.
52. Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey.
Burns [Internet]. 2010;36(2):176-182. Accessed 10 Nov 2012.
53. Cancio LC, Kramer GC, Hoskins SL. Gastrointestinal fluid resuscitation
of thermally injured patients. J Burn Care Res. 2006;27(5):561-569.
54. Swift D. Oxygen delivery during a mass casualty incident. What a gas? Vol.
2. SRC-G; 2010.
55. Ashraf M, Sheik I. Anesthetic management of mass casualties—what
should be the drug of choice? Pakistan Armed Force Med J. 2006;4.
56. Sass RG. Toward a More Stable Blood Supply: Charitable Incentives,
Donation Rates, and the Experience of September 11. Am J Bioeth
[Internet]. 2013;13(6):38-45.
57. Erickson ML, Champion MH, Klein R, et al. Management of blood
shortages in a tertiary care academic medical center: the Yale-
New Haven Hospital frozen blood reserve. Transfusion [Internet].
2008;48(10):2252-2263. Accessed 26 Jun 2017.
58. Rosenberg L, Krieger Y, Bogdanov-Berezovski A, et al. A novel rapid
and selective enzymatic debridement agent for burn wound manage­
ment: A multi-center RCT. Burns [Internet]. 2014;40(3):466-474.
59. Swedish Emergency Management Agency. Cris Communication
Handbook. 2008.
60. van Walsum AD, Rödel SG, Klaase JM, Vierhout PA. Local and
regional in-hospital trauma care following fireworks depot explosion
in Enschede. Ned Tijdschr Geneeskd. 2001;145(48):2330-2335.
61. Woltering HP, Schneider BM. Great damage event of the Dutch
Enschede on May 13th, 2000. Unfallchirurg. 2002;105(11):961-967.
62. Associated Press F. Cell Phone Triggered Bombs. Vol. 59207. SRC;
2003:6-11.
63. Netline: Cell Phone Blocking.
cell_phone_blocking.aspx. Accessed 2010.
64. Kabbo: Undersea Internet Cables damaged by Taiwan Earthquake.

aged-by-taiwan-earthquake.xhtml. Accessed 2010.
65. ABA. Burn Care Facilities [Internet]. 2017. Available from:
ymcdn.com/sites/ameriburn.site-ym.com/resource/resmgr/bcrd/
USBurnCareFacilities.pdf.
66. Rivara FP, Nathens AB, Jurkovich GJ, Maier RV. Do trauma centers have
the capacity to respond to disasters? J Trauma. 2006;61(4):949-953.
67. Rainey S, Cruse CW, Smith JS, et al. The occurrence and seasonal
variation of accelerant-related burn injuries in central Florida. J Burn
Care Res. 2007;28(5):675-680.
68. Smith J: Mob justice in Haiti
article/751792--haiti-street-justice-the-worst-in-people.
Accessed
17 Jan 2010.
69. Greene RA: Aid workers heading to Haiti fear for their safety. http://
edition.cnn.com/2010/WORLD/americas/01/14/haiti.aid.hurdles/
index.html. Accessed 2010.
70. Le Saout E: Haiti earthquake: health priorities and challenges in large-
scale
disasters.

haiti-earthquake-interview-150110. Accessed 2010.
71. Fontham ETH. Infectious diseases and global cancer control. CA
Cancer J Clin. 2009;59(1):5-7.
72. Saffle JR. Predicting outcomes of burns. N Engl J Med.
1998;338(6):387-388.
73. Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;2(12):1103-1117.
74. Young AW, Graves C, Kowalske KJ, et al. Guideline for Burn Care
Under Austere Conditions. J Burn Care Res [Internet]. 2016;1.
75. Dai A, Carrougher GJ, Mandell SP, et al. Review of Recent Large-Scale
Burn Disasters Worldwide in Comparison to Preparedness Guidelines.
J Burn Care Res [Internet]. 2017;38(1):36-44. Accessed 7 Nov 2016.
76. Chim H, Yew WS, Song C. Managing burn victims of suicide bombing
attacks: outcomes, lessons learnt, and changes made from three
attacks in Indonesia. Crit Care [Internet]. 2007;11(1):R15.

50
Care of Outpatient Burns
CHARLES D. VOIGT, MARIO CELIS, and DAVID W. VOIGT
6 
body proportions, do not follow the rule-of-nines. A more
accurate method of estimating burn size is the Lund-
Browder chart.1 It is important to note that hand size may
overestimate the size of the burn,2 and both the rule-of-
nines and Lund-Browder chart may have significant error
when estimating the burn size of obese patients.3,4 There­
fore, it is important to understand that these methods of
determining burn involvement are not exact and to know
the limits of your facility and staff.
DEPTH OF THE BURN
The depth of the burn injury is important to note during
the evaluation of the patient because it is recommended
that any patient with a third-degree burn be referred to a
burn center due to the additional care needed. First-degree
burns and third-degree, full-thickness burns are relatively
easy to identify at the time of presentation. First-degree
burns, like sunburns, only involve the epidermis and are
dry, painful, and do not blister. Third-degree burns involve
the epidermis, dermis, and the subcutaneous tissues. These
wounds can appear black, white, or leathery, and they will
not blanch to the touch or be sensate or painful (Fig. 6.1).
It is still possible to elicit pain because manipulation of a
full-thickness burn may stimulate the edges of the burn,
which is inflamed and sensate. Second-degree burns can be
divided into superficial partial-thickness and deep partial-
thickness injuries. The difference between these two can be
subtle during the initial evaluation. All partial-thickness
burns will be painful and moist and can have blisters (Fig.
6.2). However superficial wounds will have clear fluid in
blisters, and deeper wounds may have bloody fluid with late
presentation. Superficial wounds will also blanch to pres­
sure as opposed to deeper wounds. Occasionally wounds
that appear perfused with ruptured blisters that initially
appear to be superficial may progress to a more severe
injury due to thrombosis of the small blood vessels in the
wound, leading to the wound becoming a deeper injury.5,6
Superficial partial-thickness wounds will heal within 3
weeks, while deep partial-thickness wounds may take
longer to heal or require excision and grafting.
Burn injuries can be divided into three zones (Fig. 6.3).
At the point of greatest damage is the zone of coagulation,
in which there is irreversible tissue damage. Surrounding
this is the zone of stasis, an area of the wound that can
potentially necrose with inadequate treatment or heal if the
area is properly perfused. Should the patient be underresus­
citated, this region of the burn wound may progress to
become part of the zone of coagulation. The third zone, at
the edge of the burn injury, is the zone of hyperemia, which
will likely heal with treatment if the region maintains per­
fusion and infection is not involved.7
Introduction
Many small burn injuries can be treated in the outpatient
clinic once it is determined that there are no other injuries,
complicating medical problems, or suspicion of abuse. As
with burn care in the hospital setting, the goals of outpa­
tient burn care are to adequately heal wounds with minimal
scarring or deformity, as well as reducing pain, the risk of
infection, and impaired function. To achieve these, outpa­
tient burn care encompasses wound management, rehabili­
tation, and psychosocial support.
Outpatient burn care extends to follow-up treatment of
patients with larger burns following discharge. Care for
these patients is similar, with evaluation for proper wound
healing and monitoring for areas that may need surgical
revision, along with ongoing physical and psychosocial
therapy and scar control management.
Who Can Be Managed as
an Outpatient?
Patients should be carefully evaluated to determine whether
outpatient management of the burn would be sufficient for
the course of medical treatment. Careful medical history
and physical examination will help to guide decision-
making whether the patient should be admitted or can be
treated as an outpatient. Important factors to note include
the extent and depth of burn injury, cause of the burn,
associated trauma, and premorbid diseases. Patients who
require intravenous fluid resuscitation should be treated in
the hospital, as should those in whom it will be difficult to
properly manage pain as an outpatient. However, once
resuscitated and pain controlled with oral pain medication,
subsequent treatment may be performed in the community
setting depending upon the severity of the burn injury. The
American Burn Association (ABA) provides guidelines to
assist in identifying patients who should be referred for
treatment at a burn center, and this will be discussed in
more detail later (Table 6.1).
PERCENT OF THE BURN
The ABA recommends referral to a dedicated burn center
for all patients with greater than 10% total body surface
area (TBSA) burn.1 The TBSA may be estimated by using
the Wallace “rule-of-nines”(2), or the “rule-of-palm,” which
estimates the body surface area involvement by using the
size of the patient’s palm and fingers, with the thumb
extended and all fingers adducted, as a guide to estimate
approximately 1% of the TBSA for that patient. The rule-of-
palm is useful especially in children who, because of their

6  •  Care of Outpatient Burns
51
DISTRIBUTION OF THE BURN
According to ABA guidelines, burns involving the hands,
feet, face, genitalia, and perineum, and those that cross
major joints should also be treated in a burn center.8 Lasting
damage to these areas can have a severe impact on patient
outcomes. Impairments to the hands can affect grip and
can therefore have deleterious effects upon the ability to
work or handle activities of daily living. Burns of the feet or
those that cross joints can severely limit mobility, while
burns to the face can impair vision and the ability to eat, as
well as having an emotional impact due to altered appear­
ance. Finally burns to the genitalia and perineum can
restrict patient autonomy, hindering urinary and sexual
function or the ability to defecate. While burns to these
areas may not necessitate specific inpatient treatment, they
should be treated at a burn center with the proper resources
to handle the special reconstructive and rehabilitative needs
of these patients.
Special consideration should be given to burns that are
completely circumferential around a part of the body, such
as a limb or the trunk. Due to the tissues beneath the wound
becoming edematous, circumferential wounds can cause
increased pressure, resulting in compartment syndrome
and leading to ischemia.9 The classic symptoms are the five
“P’s” which are pain, pallor, paresthesia, pulselessness, and
paralysis. The physician should have a high index of suspi­
cion for compartment syndrome, which necessitates inpa­
tient treatment.
INJURING AGENT
Electricity
Fatal cardiac dysrhythmias are a major risk following elec­
trical injury; therefore all patients with electrical injuries
should have an electrocardiogram (ECG) performed, and all
meet the criteria for referral to a burn center. Injuries due
to low voltages are usually smaller, therefore, these patients,
as long as no ECG abnormalities are present and no loss of
consciousness occurred, can be treated as an outpatient
should there be no other indication for admission.10 The
presence of dysrhythmia, ECG abnormalities, or a history
of loss of consciousness is grounds for admission to the
hospital for monitoring. A common means of injury from
Table 6.1  American Burn Association Burn Center
Referral Criteria.
BURN INJURIES THAT SHOULD BE REFERRED TO A BURN
CENTER INCLUDE:
1. Partial thickness burns greater than 10% total body surface area
(TBSA)
2. Burns that involve the face, hands, feet, genitalia, perineum, or
major joints
3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders that
could complicate management, prolong recovery, or affect
mortality
8. Any patient with burns and concomitant trauma (such as
fractures) in which the burn injury poses the greatest risk of
morbidity or mortality. In such cases, if the trauma poses the
greater immediate risk, the patient may be initially stabilized in a
trauma center before being transferred to a burn unit. Physician
judgment will be necessary in such situations and should be in
concert with the regional medical control plan and triage
protocols.
9. Burned children in hospitals without qualified personnel or
equipment for the care of children
10. Burn injury in patients who will require special social, emotional,
or rehabilitative intervention
Fig. 6.1  Third-degree burn. Note the leathery appearance of this burn.
Fig. 6.2  Second-degree burn.
Zone of coagulation
Zone of stasis
Zone of hyperemia
Fig. 6.3  Zones of injury.

6  •  Care of Outpatient Burns
52
should be injected with calcium gluconate to alleviate pain
as well as prevent tissue necrosis.15 The author uses intra­
arterial calcium gluconate, slowly injecting into the artery
supplying the affected part until the patient is pain-free.
This may have to be repeated in a few hours. Dermal expo­
sure to hydrofluoric acid results in the absorption of the
dissociated fluoride anion and subsequent insoluble salt
formation by binding with calcium and magnesium. The
patient may then develop hypocalcemia and hypomag­
nesemia accompanied by hyperkalemia due to potassium
efflux from cells. Hypocalcemia is the main cause of death
following hydrofluoric acid poisoning via the induction
of fatal dysrhythmias. As little as 1% TBSA exposure to
50% concentration hydrofluoric acid or 5% TBSA expo­
sure to any concentration is enough to result in poten­
tially fatal hypocalcemia.16 Identification of the chemical
and communication with local poison control centers is
recommended if needed. After the appropriate removal of
the causative chemical, treatment is the same as for any
other wound.
RESPIRATORY COMPLICATIONS
Inhalation injury is one of the criteria for referral to a
burn center, and the physician must have a high index of
suspicion concerning inhalation injury and carbon mon­
oxide poisoning based on the circumstances surrounding
the burn injury because there may be little to no exterior
sign of injury.17,18 The sequelae of both of these complica­
tions may not be initially present and may develop over
time. Of note, airway obstruction may occur following
burns of the oropharynx, face, or neck as the tissues of
the upper airway become edematous.19 Therefore, observa­
tion is warranted if there is any suspicion of inhalation
injury.
ASSOCIATED TRAUMA
Due to the often accidental nature of burn injuries, there is
frequently concomitant trauma at the time of presentation.
Assessment should be made whether the associated trauma
or the burn injury is of greater threat to the patient’s mor­
bidity or mortality, with the decision of the need for direct
admission or stabilization and referral to a burn center
made at the discretion of the treating physician.8
COMORBID DISORDERS
A comprehensive medical history of the burned patient
should be performed to identify those with preexisting
medical conditions that would complicate the ability to
properly care for the patient in a community setting or have
an impact on recovery, morbidity, and mortality.
The stress of the burn may exacerbate previous medical
conditions such as diabetes mellitus, asthma, or coronary
artery disease.
SOCIAL CIRCUMSTANCES
Proper outpatient management of burns requires that
there are sufficient resources available to care for the wound
and provide for proper follow-up care. Such resources
low-voltage energy sources is that of children sucking on a
defective electrical cord, resulting in damage to the lips,
tongue, gums, or dentition. Such patients may need admis­
sion because oral intake may be hindered. Such injuries to
the mouth are at risk of resulting in rupture of either the
superior or inferior labial arteries, especially from days 4
through 7 post burn (Fig. 6.4). If treating as an outpatient,
the caregiver should be educated on this risk and instructed
in proper first aid, which consists of pinching the labial
commissure between the index finger and thumb.
All patients exposed to high-voltage electricity should be
referred to a burn center due to increased deep-tissue injury
and subsequent increased amputation rates, organ failure,
and mortality as compared to patients with comparable
TBSA thermal burns.10
Chemicals
While not caused by thermal injury, chemical burns are
treated by burn surgeons, and chemical injury is one of the
criteria for referral to a burn center. Initial management of
a patient with a chemical injury involves brushing off dry
chemicals and copious flushing of areas affected by wet
chemicals.11,12 The author recommends flushing until the
patient is pain-free, and, with alkaline exposure, until the
skin pH is 7, which is the pH of water. The normal skin pH
is around 5, but once the pH has reached 7 further injury
seems unlikely. As with thermal injuries, prompt irrigation
of chemical injuries results in decreased full-thickness
injury as well as shorter hospital stays.13 Irrigation of the
chemical burn may need to continue in excess of 1 hour.14
In the author’s experience, it often takes longer in alkaline
exposures to reach a pH of 7.
Specific considerations need to be made depending on the
causative substance. Phenol compounds do not flush well
with water, so polyethylene glycol or vegetable oil followed
by water lavage may be used. Water needs to be avoided
if metallic sodium or potassium is suspected because the
resultant exothermic chemical reaction may worsen the
burn injury. Hydrofluoric acid injuries are treated with
calcium following water lavage, and a calcium gel can be
used to cover the injury. Some recommend that the tissues
Fig. 6.4  Labial burn.

6  •  Care of Outpatient Burns
53
Management of Minor Burns
COOLING THE BURN
First aid for burn wounds should begin with removing
clothing from the burned area and subsequently cooling
the wound with cool, running tap water or saline.20–22 The
burn wound should be cooled as close to the time of injury
as possible because damage continues while the tissue
remains above 44°C.23 A study by Rajan et al. has shown
that even cooling initiated 60 min following burn injury
will still have a beneficial effect on burn wound outcomes.24
Excessive cooling, such as through the use of ice, may actu­
ally result in a deeper wound when compared to uncooled
burn wounds in an animal model.25
Cooling is also important in the first aid of thermal inju­
ries because cooling stabilizes mast cells in the skin, result­
ing in decreased histamine release and subsequent reduced
edema of the burn wound. The application of cool, moist
compresses can also be effective in relieving the pain associ­
ated with partial-thickness burns.26–29 While patients with
large surface area involvement may experience hypother­
mia if too aggressively cooled, patients who are eligible to
be treated as an outpatient, with a smaller TBSA, should
have little risk of this occurring. It is still prudent to monitor
the patient’s core temperature during active cooling.
A limit to the surface area that is cooled is arbitrary,
but a practical limit is about 10% of the TBSA. A recent
study concluded that 20 min was the optimal time to cool
a burn.30
PAIN CONTROL
First-line treatment for pain in the emergency setting is
usually narcotics. Intravenous doses of morphine can be
given incrementally to titrate for the desired effect. Other
pain relief options include acetaminophen with codeine,
oxycodone, or similar analgesics that can be used individu­
ally or in combination. However due to growing concerns
about the overuse of opioids and the risk of addiction and
overdose, the physician may consider the use of medica­
tions such as acetaminophen or nonsteroidal antiinflam­
matories (NSAIDs), especially in smaller burns that are
more appropriate for outpatient management. Partial-
thickness wounds are the most painful burn wounds
because the injury leaves the wound without epidermis.
The pain is severe initially, but will partially subside in the
following hours. During dressing changes or physical activ­
ity when the wound is manipulated, pain will again be exac­
erbated. Wounds with eschar will not be painful unless the
eschar is removed or separated, exposing the viable tissue
beneath.31 Therefore additional analgesia may be required
during physical activity and dressing changes. Should oral
medication be unable to control the patient’s pain, the
patient should be admitted for adequate pain management.
For additional information on management of pain in the
burn patient, see Chapter 63.
BLISTERS
There is no clear consensus on the management of blisters,
and therefore treatment depends on the experience of the
include either persons, such as family members or visiting
nurses, who can assist with dressing changes, as well as the
ability to easily access medical care and receive proper reha­
bilitation and psychosocial services. Should these resources
be unavailable to the patient in the community setting,
referral to a burn center should be considered.
Of serious concern when considering the social circum­
stances surrounding the patient is the possibility that the
injury was nonaccidental. If there is any suspicion that the
injury to the patient was intentional, admission to the hos­
pital and notification of the proper agencies is warranted
for their protection (Figs. 6.5 and 6.6).
HOSPITAL RESOURCES
Available resources should be taken into account in the
decision-making process. Pediatric burn patients should be
treated at hospitals with qualified personnel and equipment
to treat children.
Fig. 6.5  Nonaccidental scald burn. Note the area that is not burned on
this child. She was held down in a tub of hot water. The area of the
buttocks that is not burned was in contact with the bottom of the tub
and the heat had dissipated, thus not burning the child.
Fig. 6.6  Nonaccidental contact burn. This burn was caused by a clothes
iron; note the triangular shape.

6  •  Care of Outpatient Burns
54
triple-antibiotic ointment (containing neomycin, bacitracin
zinc, and polymyxin B sulfate) and Polysporin (containing
polymyxin B sulfate and bacitracin zinc), which both have
coverage against gram-positive cocci and some aerobic
gram-negative bacilli. When using these compounds, small
superficial pustules may form on uninjured or healed skin
due to yeast. Discontinuation of the compound will clear
these pustules. When compared to petrolatum-impregnated
gauze alone, the addition of a topical antibiotic ointment
may decrease odors. For partial-thickness facial burns, bac­
itracin can be applied several times a day without a second­
ary dressing, making it less likely the patient will attract
unwanted attention from strangers.
DRESSING THE WOUND
There are few comparative studies concerning available
wound dressing options therefore individual preference and
comfort will be the determining factors in which option is
selected. Wound dressings primarily serve to protect the
wound from the outside environment, decrease pain, absorb
drainage, and provide a moist environment to promote
wound healing. Whatever dressing is used, as long as these
qualities are met, the wound should properly heal. As
Ambroise Paré said, “Je le pansai, Dieu le guérit” (“I treated
him, but God healed him”).45
Management of first-degree wounds may include the use of
emollients or light dressings if needed. Follow-up care
should monitor how the wound is healing.
Second-degree wounds can be managed with daily
washing of the wound, along with the use of emollients
and dressings that are changed daily. Alternatively these
wounds can be covered with a polyurethane foam dress­
ing, biologic dressing (discussed later), a silver-impregnated
dressing, alginate dressing, or a 3% bismuth tribromo­
phenate and USP petrolatum gauze. These allow for longer
intervals between dressing changes and outpatient visits,
and they are helpful in areas that require long travel times
for patients to be seen in the outpatient setting. As with
first-degree wounds, follow-up care of second-degree burns
should monitor the progression of wound healing. Third-
degree wounds, if small, will heal by epithelial ingrowth
and contraction. However most will require referral for sur­
gical intervention.
Patients should be seen at follow-up within several days
in order to examine the progression of wound healing.
The follow-up visit also serves to confirm the patient’s
adherence to wound care instructions and provides the
opportunity to ensure the proper resources are available to
the patient to provide an adequate environment for proper
healing. Should any concerns arise, changes to the treat­
ment plan, including types of dressing or frequency of visits,
may be needed to optimize care. Otherwise, weekly intervals
of follow-up visits provide adequate wound observation.
SYNTHETIC WOUND DRESSINGS
Synthetic wound dressings are popular in the treatment of
superficial, partial-thickness burn wounds because they
reduce pain, reduce healing time, and cost less than their
biologic alternatives. There are many products in this cat­
egory, with the following discussion representing a small
burn care team. Options for blister management include
leaving the blister intact,32 removing the blistered skin
during the initial wound care,33 removing the blister at a
later time,34 or aspirating the fluid from the blister.32 Labora­
tory studies suggest that blister fluid may have detrimental
effects via suppression of immunologic responses and
inhibited fibrinolysis.33 Others advocate that the blister can
be left intact to serve as a biological wound dressing, with
spontaneous resorption of the blister fluid beginning within
1 week. The devitalized skin from a ruptured blister can also
be left in place in a similar fashion to serve as a dressing.
The author removes blisters that are felt likely to rupture on
their own and leaves the others intact, but covers them with
an antimicrobial dressing.
CLEANSING THE WOUND
For thermal injuries, cleansing of the burn would should be
performed using room temperature to tepid (100°F) sterile
water or normal saline with a mild soap. In injuries involv­
ing tar or asphalt, cooling should be performed first, and the
solidified tar or asphalt should be removed through the use
of a solvent. Solvents with affinity for the substance to be
removed should be used. One such product is Medi-Sol
Adhesive Remover, a nontoxic, nonirritating, citrus-based
Category I Medical Device solvent approved by the U.S. Food
and Drug Administration (FDA), which has been shown to
be effective in the removal of both tar and asphalt.35 Other
options include using polysorbates (a class of emulsifiers),
which can be used on their own or in conjunction with
topical antibiotics, and topical antibiotics in petroleum jelly.
However these options may require multiple applications to
be effective.36,37 The author prefers the use of mineral oil
because it is inexpensive and works well without causing
additional skin irritation.38
TOPICAL AGENTS
Antibacterial agents are used to prevent burn wound infec­
tions.39 Prophylactic use of topical agents such as these
have not shown benefit in preventing infections or septice­
mia versus other dressing options, such as petrolatum-
impregnated gauze40,41; however the author recommends
that these substances should be used when the physician
has suspicion that an infection is present. Should topical
antimicrobial agents be warranted, there are several options
available. A popular agent used in the treatment of burn
wounds is 1% silver sulfadiazine, which has antiseptic prop­
erties due to the presence of silver, but also results in delayed
wound healing.42,43 This delay in wound healing has been
shown to be alleviated through the co-administration of
nystatin or aloe vera in an animal model.44 Use of silver
sulfadiazine should be discontinued once reepithelialization
is noted because the agent impairs epithelialization. If the
wound is covered with eschar, however, silver sulfadiazine
may be used with few side effects. Care must be taken that
the patient is not allergic to sulfa products or that the patient
is not pregnant, nursing, or an infant under 2 months of
age due to the risk of kernicterus.
Combinations of antibiotics in ointments have been of
increasing interest because there have been no noted effects
on wound healing in these medications. Examples include

6  •  Care of Outpatient Burns
55
accumulation of excess wound exudate. When applied to
the wound surface, Suprathel becomes translucent, allow­
ing for the wound to be visually inspected for healing and
infection without removal of the dressing. The dressing is
applied to the burn wound after débridement and is left in
place without changing because it will detach on its own as
reepithelialization occurs. Petroleum gauze is placed on top
of the Suprathel, which is then held in place by gauze and
elastic bandages. During follow-up visits, everything except
the Suprathel and petroleum gauze may be removed and
changed to allow inspection of the wound. In unpublished
data from our institution comparing Suprathel with Mepilex
AG, Suprathel was shown to be a safe alternative wound
dressing with similar healing time; however it has signifi­
cant advantages, such as reduced pain and decreased
wound bed disturbance due to the ability to leave the dress­
ing in place. These results are similar to those reported in
comparison with other wound dressings.53–56
Hydrocolloid Dressings
Hydrocolloid dressings are composed of cross-linked matrix
gelatin, pectin, and carboxymethyl-cellulose and can be for­
mulated in wafers, pastes, or powders. They adhere to the
burn wound on their own and provide a moist environment
by trapping water in the matrix, thereby promoting wound
healing. Compared with 1% silver sulfadiazine, these dress­
ings show improvements in wound healing and reductions
in pain and number of dressing changes.57,58 Such dress­
ings can be used for small partial-thickness burns and can
be left in place for several days.
SYNTHETIC TISSUE-ENGINEERED
WOUND DRESSINGS
Biobrane
Biobrane is a biosynthetic skin consisting of an outer sili­
cone membrane and an inner nylon mesh bonded with
porcine dermal collagen. This dressing allows gases to per­
meate it, but not liquids or bacteria.59 This helps to keep the
burn wound moist to improve healing, but care must be
taken to not cover infected wounds or those with eschar or
debris. The wound must also have sensation and appropri­
ate capillary blanching and refill; thus, its use for partial-
thickness wounds. When used in this manner, compared to
1% silver sulfadiazine, Biobrane resulted in decreased pain,
reduced pain medication requirements, and decreased
healing time.42,60 At the time of writing, Biobrane is not
currently available in the United States, but the manufac­
turer indicates that it, or a newer product called Perme­
aDerm, will be available shortly.
After cleansing the wound, Biobrane is applied so that it
overlaps itself and is fixed to the surrounding unburned
skin with sterile strips of tape or with drops of cyanoacry­
late adhesive. Then the wound is dressed and splints applied
if the wound crosses a joint to prevent shearing. Within a
day, the Biobrane should be adherent to the wound surface,
although any loose sections can be trimmed and new Bio­
brane applied. At follow-up, sterile fluid accumulating
underneath the Biobrane can be aspirated and purulent
fluid drained by opening the Biobrane. After reepithelializa­
tion, the Biobrane can be removed gently.
selection of what is available. Choice of dressing is at the
discretion of the provider based on personal preference and
experience.
Mepitel
Mepitel is a wound contact dressing that adheres to dry skin
but not to the wound bed. After application, it can be left in
place for up to 2 weeks. Secondary dressings may be placed
on top of the Mepitel. These secondary dressings may then
be changed when necessary, leaving the Mepitel in place
and not disturbing the wound bed.46 In a comparison with
silver sulfadiazine, Mepitel has been shown to decrease
healing times in pediatric burn patients.47
Mepilex AG
Mepilex AG is a synthetic wound dressing commonly used
in the treatment of partial-thickness burn wounds. It is
composed of three layers, with a silicone layer facing the
wound, an absorbant polyurethane foam layer, and a pro­
tective waterproof film to keep the wound environment
moist while allowing gases to permeate the dressing.48 The
foam layer in this dressing contains silver sulfate, providing
antimicrobial action. After cleansing of the wound, the
dressing is cut to size and applied onto the burn wound,
followed by wrapping with gauze and elastic bandages to
hold the dressing in place. Follow-up visits for dressing
changes can be scheduled for every 3–7 days. In a recent
randomized study comparing Mepilex AG with silver sulfa­
diazine, it was shown that a significantly higher number of
burn wounds treated with Mepilex AG had healed after 1
week, although overall healing rates were similar.48 In the
same study, patients with Mepilex AG reported less pain
associated with dressing changes.
Acticoat
Acticoat is a dressing composed of three layers, with an
inner layer of rayon/polyester and outer layers of polyeth­
ylene coated with elemental silver. This silver is ionized into
its bactericidal form when the dressing is moistened. The
dressing can be left in place longer, requiring dressing
changes every 3–7 days depending on which form of Acti­
coat is chosen. The dressing must be kept moist to be active.
Studies suggest that Acticoat may reduce healing time
when compared with silver sulfadiazine.49,50
TheraBond 3D
TheraBond 3D is a woven, silver-impregnated fabric with a
perforated wound contact surface. The dressing is designed
to allow fluid and exudate from the wound to be transferred
through the dressing to an absorbent, secondary dressing.
This dressing can be left in place for up to 14 days.51
Silverlon
Silverlon is a silver-nylon dressing that has been used exten­
sively in the treatment of burn wounds in the military.52
Similar to other listed wound dressings, Silverlon may be left
in place for 3–7 days between dressing changes.
Suprathel
Suprathel is a newer synthetic burn wound dressing con­
sisting of a thin, porous membrane composed of polylactic
acid. The porous nature of the membrane prevents the

6  •  Care of Outpatient Burns
56
outpatient setting to monitor for changes in the appear­
ance. Early discolorations are likely to occur in the first few
days following injury after injured blood vessels thrombose
and wound perfusion is decreased. Discolorations, includ­
ing black or gray spots, are suspicious for infection, and
patients should be admitted and wound biopsies and micro­
biological studies performed for proper treatment of the
infection.76
VACCINATIONS
All burn wounds are susceptible to tetanus infection.77 If
the patient has not received a dose of tetanus toxoid within
the past 5 years, then tetanus immunization should be
administered. For patients who have received less than
three doses or have unknown immunization status, both
tetanus toxoid and tetanus immune globulin can be given.78
INSTRUCTIONS AND FOLLOW-UP CARE
Before discharge from emergency care, patients should be
instructed in proper techniques for wound care, positioning,
and physical therapy. Warning signs of infection should also
be described, and patients should be instructed about whom
to contact for appropriate medical care if signs of infection
occur. Finally physicians should ensure that patients have
adequate pain medication and wound dressings.
DEFINITIVE WOUND CLOSURE
The goal for wound closure is to have all burn wounds
healed within 1 month, which is easily attainable by the
outpatient with smaller burns. Burn wounds that heal
spontaneously within 3 weeks will have better outcomes,
such as improved elasticity and reduced risk of hypertro­
phic scarring or pigmentation changes. Poorly healing
wounds that take longer, however, have increased risk of
scarring79 or pigmentation alterations. In addition, wounds
that take a very long time to heal spontaneously may have
unstable epithelium. Careful attention should be paid to
the rate of wound healing during follow-up appointments
because wounds that are healing slowly may have improved
outcomes with excision of necrotic and granulation tissue
with subsequent grafting.80–82 At 10 days after burn injury,
partial-thickness wounds without necrotic tissue that
show evidence of squamous reepithelialization should heal
within the month. Reepithelialization can be recognized by
small opalescent islands of epithelium scattered across the
wound. If these features are not seen, the partial-thickness
wound may be a deeper injury that would benefit from
surgery. The author tells patients, “If your burn heals in
less than 2 weeks, it is better off without an operation. If it
takes more than 3 weeks, it is better off with an operation.”
PRURITUS
Itching is a common sequela of healing burn wounds and
may persist after the wound has healed. Pruritus causes sig­
nificant distress in burn patients, and resultant scratching
may result in reopened wounds. Pruritus is more common
in children, most frequently affects the lower extremities
compared to the upper extremities, and rarely involves the
BIOLOGIC WOUND DRESSINGS
Allogenic Amnion
Allogenic amnion is a biologic wound dressing composed
of the innermost fetal amniotic membranes whose first
reported use was in 1910,61,62 although its use as a tem­
porary burn wound covering was first described in 1952.63
Following donor screening, the amniotic membrane is
harvested during caesarian section, and the donor tissue
is screened for transmissible diseases.62,64 For additional
information on the harvesting of amnion, see Chapter 14.
Amnion can be used in the treatment in partial-thickness
burns, where it has been shown to promote wound healing,
relieve pain, reduce scar formation, and reduce burn wound
infections.62,63,65–70 It can also be used as a temporary dress­
ing to protect a clean, excised wound prior to skin grafting.71
Xenograft
In the treatment of partial-thickness burns, porcine xeno­
graft reduces pain and decreases hypertrophic scarring.72,73
It has been shown to be as effective as either human
allograft or human fibroblast-derived temporary skin sub­
stitute, with the advantage of being more cost-effective.74
The application is the same as discussed in the section on
Biobrane.
Allograft
The authors do not recommend the use of allograft in
small burn wounds, such as those that would be treated in
an outpatient setting, due to high cost and limited supply.
The application and use is the same as for xenograft, just
discussed.
ELEVATION OF THE BURNED PART
Edema is one of the main sources of pain following burn
injury, therefore reduction of this edema is an effective
method of pain control. Injured extremities may be kept
immobile by the patient in an effort to reduce discomfort,
but this may result in exacerbation of edema and therefore
pain. To relieve edema, injured parts should be placed
slightly above the level of the heart. Regular exercise and
physical therapy are also important factors in reducing
edema. Should edema persist for longer than 3 days in
patients with small burns, the likely culprit is immobiliza­
tion and dependent positioning.
INFECTION AND USE OF SYSTEMIC ANTIBIOTICS
The use of prophylactic topical or systemic antibiotics has
not been shown to decrease the incidence of burn wound
infections, sepsis, or mortality40,75 and should therefore
only be used when there is clinical suspicion for infection.
Although the risk of developing sepsis is quite low in
patients who are able to be treated in the outpatient setting,
patients should be instructed in the warning signs for infec­
tion before discharge. Patients should be advised to contact
the physician should they experience temperatures higher
than 38°C, malaise, increasing pain, erythema, foul odor,
or anorexia.
Wounds should be examined both at follow-up by the
physician and by those performing dressing changes in the

6  •  Care of Outpatient Burns
57
indicated initially, such as in burns that cross joints or those
that involve the hands or feet. When treating those with
burns of the face, speech pathologists may need to be
referred. Just as with patients treated in the hospital, outpa­
tients should be monitored for hypertrophic scarring and
contractures, as surgical intervention may be required.89
Outpatient Treatment of
Moderate and Major Burns
Some patients with larger burns may be treated with out­
patient care later in the course of their treatment.90 Physi­
cians may opt for this course due to the advantages of
decreased costs and increased physical and emotional
comfort for the patient, along with decreased exposure to
drug-resistant organisms. Outpatient treatment may be
appropriate for patients when intravenous fluid resuscita­
tion has been completed, the patient is able to receive ade­
quate nutrition enterally, pain is controlled, and there is no
present wound or systemic infection. Should these condi­
tions be met, the physician may opt to complete wound care
and physical and occupational therapy in the ambulatory
setting.
Conclusion
This chapter discussed the options for outpatient manage­
ment of the burn patient. Depending on the expertise of the
treating physician and the resources of the facility, some or
all the options may be available. If the patient fails to meet
criteria for referral to a burn center and does not require
admission for another reason, outpatient management is
appropriate, following these recommendations for immedi­
ate treatment:
■ Wash the wound with soap and water.
■ Dress with an appropriate dressing, as discussed earlier.
■ Place the wound in Xeroform with a secondary dress­
ing; having the patient follow-up in 24–48 hours is
reasonable.
■ If the Xeroform is adherent, it can be left in place and
trimmed as it lifts off; if not, an alternate dressing
should be considered.
■ Another option is to use a silver-impregnated
dressing.
■ Depending on the dressing selected, the patient may
follow-up in 3–7 days.
■ If resources are available, daily to twice-daily wound
cleansing and dressing changes may be utilized with
follow-up in 1–3 days.
■ Burns that do not heal in 2 weeks should be referred to
a designated burn center for evaluation.
Complete references available online at
inkling.com
face.83 Environmental triggers may bring on or exacerbate
pruritus, including heat, physical activity, or stress. For
most patients, the pruritus is worst immediately following
wound healing and diminishes after healing is complete,
sometimes lasting up to 18 months. In those with persis­
tent itching, one should consider an ongoing psychosocial
trigger.
Pruritus is a primary sensory modality that has multiple
causative factors, such as the increased synthesis of hista­
mine in burn wounds, as well as bradykinin and
endopeptides.84–86 Management of itching may include
antihistamines, cool compresses, or lotions as needed. Most
commonly, the initial treatment is diphenhydramine hydro­
chloride,83 which also provides mild sedation that may be
of benefit. Other antihistamines, such as cyproheptadine or
hydroxyzine hydrochloride, may also be used as the physi­
cian feels appropriate. Analgesics may alter the perception
of itching, and combinations of the two medications may
be considered. Environmental treatments may include air
conditioning, cool compresses, and loose fitting, soft cotton
clothing. Other options include aloe vera, which is antiin­
flammatory and antimicrobial,87 or skin moisturizing
creams that are free of alcohol. Penicillin may even be used
in the management of pruritus; Phillips and Robson88 noted
in a study of post-burn hypertrophic scars that these scars
were more frequently colonized with β-hemolytic strepto­
coccus, Staphylococcus aureus, and S. epidermidis. Because
inflammation is a major source of pruritus, 250 mg of oral
penicillin was given twice daily along with topical aloe vera
to reduce itching. For further information on the treatment
of pruritus in burns, see Chapter 63.
TRAUMATIC BLISTERS IN
REEPITHELIALIZED WOUNDS
During reepithelialization, the thin epithelium may be
easily damaged by itching or trauma brought about by, for
example, movement, resulting in traumatic blisters that
may rupture. As healing progresses, this epithelium will
strengthen and traumatic blisters will stop occurring. Rup­
tured blisters can be left exposed to form a crust, or a light
dressing may be applied.
REHABILITATIVE PHYSICAL CARE
Prior to discharge, plans for rehabilitative care should be
made for the patient to ensure that there is access to this
necessary part of burn treatment. Although burns treated
in the community tend to be of smaller area, rehabilitation
should still be utilized to preserve and restore both strength
and function in the burned area.89 The patient should also
be instructed in range of motion and strength exercises to
perform on his or her own.
Strength, range of motion, and function should be con­
tinually assessed at follow-up visits, and if there are compli­
ance issues or worsening function, referral for physical and
occupational therapy may be warranted. Depending on the
location of the burn injury, supervised therapy might be

57.e1
6  •  Care of Outpatient Burns
31. Osgood PF, Szyfelbein SK. Management of burn pain in children.
Pediatr Clin North Am. 1989;36(4):1001-1013.
32. Swain AH, Azadian BS, Wakeley CJ, Shakespeare PG. Management
of blisters in minor burns. Br Med J (Clin Res Ed). 1987;295(6591):
181.
33. Rockwell WB, Ehrlich HP. Should burn blister fluid be evacuated? J
Burn Care Rehabil. 1990;11(1):93-95.
34. Demling RH, LaLonde C. Burn trauma. In: Blaisdell FW, Trunkey
DD, eds. Trauma Management. IV. New York: Thieme Medical; 1989:
55-56.
35. Stratta RJ, Saffle JR, Kravitz M, Warden GD. Management of tar and
asphalt injuries. Am J Surg. 1983;146(6):766-769.
36. Ashbell TS, Crawford HH, Adamson JE, Horton CE. Tar and grease
removal from injured parts. Plast Reconstr Surg. 1967;40(4):330-331.
37. Demling RH, Buerstatte WR, Perea A. Management of hot tar burns.
J Trauma. 1980;20(3):242.
38. Carta T, Gawaziuk J, Liu S, Logsetty S. Use of mineral oil Fleet enema
for the removal of a large tar burn: a case report. Burns. 2015;41(2):
e11-e14.
39. Hartford CE. The bequests of Moncrief and Moyer: an appraisal of
topical therapy of burns – 1981 American Burn Association Presi­
dential Address. J Trauma. 1981;21(10):827-834.
40. Barajas-Nava LA, Lopez-Alcalde J, Roque i Figuls M, Sola I, Bonfill
Cosp X. Antibiotic prophylaxis for preventing burn wound infection.
Cochrane Database Syst Rev. 2013;(6):CD008738.
41. Heinrich JJ, Brand DA, Cuono CB. The role of topical treatment as
a determinant of infection in outpatient burns. J Burn Care Rehabil.
1988;9(3):253-257.
42. Barret JP, Dziewulski P, Ramzy PI, et al. Biobrane versus 1% silver
sulfadiazine in second-degree pediatric burns. Plast Reconstr Surg.
2000;105(1):62-65.
43. Hansbrough JF, Achauer B, Dawson J, et al. Wound healing in par­
tial-thickness burn wounds treated with collagenase ointment versus
silver sulfadiazine cream. J Burn Care Rehabil. 1995;16(3 Pt 1):
241-247.
44. Muller MJ, Hollyoak MA, Moaveni Z, et al. Retardation of wound
healing by silver sulfadiazine is reversed by aloe vera and nystatin.
Burns. 2003;29(8):834-836.
45. Hernigou P. Ambroise Paré’s life (1510–1590): part I. Int Orthop. 2013;
37(3):543-547.
46. White R, Morris C. Mepitel: a non-adherent wound dressing with
Safetac technology. Br J Nurs. 2009;18(1):58-64.
47. Bugmann P, Taylor S, Gyger D, et al. A silicone-coated nylon dress­
ing reduces healing time in burned paediatric patients in comparison
with standard sulfadiazine treatment: a prospective randomized trial.
Burns. 1998;24(7):609-612.
48. Tang H, Lu G, Fu J, et al. An open, parallel, randomized, compara­
tive, multicenter investigation evaluating the efficacy and tolerabil­
ity of Mepilex Ag versus silver sulfadiazine in the treatment of deep
partial-thickness burn injuries. J Trauma Acute Care Surg. 2015;78
(5):1000-1007.
49. Huang Y, Li X, Liao Z, et al. A randomized comparative trial between
Acticoat and SD-Ag in the treatment of residual burn wounds, includ­
ing safety analysis. Burns. 2007;33(2):161-166.
50. Cuttle L, Naidu S, Mill J, et al. A retrospective cohort study of Acti­
coat versus Silvazine in a paediatric population. Burns. 2007;33(6):
701-707.
51. Friedman SG. Use of a new antimicrobial dressing (TheraBond) on a
non-healing wound. Wounds. 2011;23(2):E1-E3.
52. Barillo DJ, Pozza M, Margaret-Brandt M. A literature review of the
military uses of silver-nylon dressings with emphasis on wartime
operations. Burns. 2014;40(suppl 1):S24-S29.
53. Highton L, Wallace C, Shah M. Use of Suprathel® for partial thickness
burns in children. Burns. 2013;39(1):136-141.
54. Rahmanian-Schwarz A, Beiderwieden A, Willkomm LM, et al. A
clinical evaluation of Biobrane® and Suprathel® in acute burns and
reconstructive surgery. Burns. 2011;37(8):1343-1348.
55. Schwarze H, Kuntscher M, Uhlig C, et al. Suprathel, a new skin sub­
stitute, in the management of partial-thickness burn wounds: results
of a clinical study. Ann Plast Surg. 2008;60(2):181-185.
56. Schwarze H, Kuntscher M, Uhlig C, et al. Suprathel, a new skin substi­
tute, in the management of donor sites of split-thickness skin grafts:
results of a clinical study. Burns. 2007;33(7):850-854.
57. Hermans MH. HydroColloid dressing (Duoderm) for the treatment
of superficial and deep partial thickness burns. Scand J Plast Reconstr
Surg Hand Surg. 1987;21(3):283-285.
References
1. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol
Obstet. 1944;79:352-358.
2. Rossiter ND, Chapman P, Haywood IA. How big is a hand? Burns.
1996;22(3):230-231.
3. Neaman KC, Andres LA, McClure AM, et al. A new method for estima­
tion of involved BSAs for obese and normal-weight patients with burn
injury. J Burn Care Res. 2011;32(3):421-428.
4. Livingston EH, Lee S. Percentage of burned body surface area determina­
tion in obese and nonobese patients. J Surg Res. 2000;91(2):106-210.
5. Gatti JE, LaRossa D, Silverman DG, Hartford CE. Evaluation of the burn
wound with perfusion fluorometry. J Trauma. 1983;23(3):202-206.
6. deCamara DL, Raine TJ, London MD, Robson MC, Heggers JP. Pro­
gression of thermal injury: a morphologic study. Plast Reconstr Surg.
1982;69(3):491-499.
7. Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and
types of burns. BMJ. 2004;328(7453):1427-1429.
8. American Burn Association/American College of S. Guidelines for the
operation of burn centers. J Burn Care Res. 2007;28(1):134-141.
9. Waymack JP, Pruitt BA Jr. Burn wound care. Adv Surg. 1990;23:
261-389.
10. Arnoldo B, Klein M, Gibran NS. Practice guidelines for the manage­
ment of electrical injuries. J Burn Care Res. 2006;27(4):439-447.
11. Curreri PW, Asch MJ, Pruitt BA. The treatment of chemical burns:
specialized diagnostic, therapeutic, and prognostic considerations. J
Trauma. 1970;10(8):634-642.
12. van Rensburg L. An experimental study of chemical burns. S Afr Med
J. 1962;36:754-759.
13. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of
prompt first aid. J Trauma. 1982;22(5):420-423.
14. Gruber RP, Laub DR, Vistnes LM. The effect of hydrotherapy on the
clinical course and pH of experimental cutaneous chemical burns.
Plast Reconstr Surg. 1975;55(2):200-204.
15. Dibbell DG, Iverson RE, Jones W, Laub DR, Madison MS. Hydrofluoric
acid burns of the hand. J Bone Joint Surg Am. 1970;52(5):931-936.
16. Dalamaga M, Karmaniolas K, Nikolaidou A, Papadavid E. Hypocalce­
mia, hypomagnesemia, and hypokalemia following hydrofluoric acid
chemical injury. J Burn Care Res. 2008;29(3):541-543.
17. Heimbach DM, Waeckerle JF. Inhalation injuries. Ann Emerg Med.
1988;17(12):1316-1320.
18. Thompson PB, Herndon DN, Traber DL, Abston S. Effect on mortality
of inhalation injury. J Trauma. 1986;26(2):163-165.
19. McManus WF, Pruitt BA Jr. Thermal injuries. In: Mattox KL, Moore
EE, Feliciano DV, eds. Trauma. Norwalk, CT: Appleton & Lange;
1988:675-689.
20. Blomgren I, Eriksson E, Bagge U. The effect of different cooling temper­
atures and immersion fluids on post-burn oedema and survival of the
partially scalded hairy mouse ear. Burns Incl Therm Inj. 1985;11(3):
161-165.
21. Jandera V, Hudson DA, de Wet PM, Innes PM, Rode H. Cooling the
burn wound: evaluation of different modalites. Burns. 2000;26(3):
265-270.
22. Saranto JR, Rubayi S, Zawacki BE. Blisters, cooling, antithrombox­
anes, and healing in experimental zone-of-stasis burns. J Trauma.
1983;23(10):927-933.
23. Moritz AR, Henriques FC. Studies of thermal injury: II. The relative
importance of time and surface temperature in the causation of cuta­
neous burns. Am J Pathol. 1947;23(5):695-720.
24. Rajan V, Bartlett N, Harvey JG, et al. Delayed cooling of an acute scald
contact burn injury in a porcine model: is it worthwhile? J Burn Care
Res. 2009;30(4):729-734.
25. Sawada Y, Urushidate S, Yotsuyanagi T, Ishita K. Is prolonged and
excessive cooling of a scalded wound effective? Burns. 1997;23(1):
55-58.
26. King TC, Zimmerman JM. First-aid cooling of the fresh burn. Surg
Gynecol Obstet. 1965;120:1271-1273.
27. Ofeigsson OJ. Water cooling: first-aid treatment for scalds and burns.
Surgery. 1965;57:391-400.
28. Purdue GF, Layton TR, Copeland CE. Cold injury complicating burn
therapy. J Trauma. 1985;25(2):167-168.
29. Pushkar NS, Sandorminsky BP. Cold treatment of burns. Burns Incl
Therm Inj. 1982;9(2):101-110.
30. Wood FM, Phillips M, Jovic T, et al. Water first aid is beneficial in
humans post-burn: evidence from a bi-national cohort study. PLoS
ONE. 2016;11(1):e0147259.

57.e2
6  •  Care of Outpatient Burns
74. Hermans MH. Porcine xenografts vs. (cryopreserved) allografts in the
management of partial thickness burns: is there a clinical difference?
Burns. 2014;40(3):408-415.
75. Durtschi MB, Orgain C, Counts GW, Heimbach DM. A prospec­
tive study of prophylactic penicillin in acutely burned hospitalized
patients. J Trauma. 1982;22(1):11-14.
76. Pruitt BA Jr. The diagnosis and treatment of infection in the burn
patient. Burns Incl Therm Inj. 1984;11(2):79-91.
77. Larkin JM, Moylan JA. Tetanus following a minor burn. J Trauma.
1975;15(6):546-548.
78. Ross SE. Prophylaxis against tetanus in wound management; 1995.
Available from:
grams/trauma/publications/tetanus.ashx.
79. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic
burn scars: analysis of variables. J Trauma. 1983;23(10):895-898.
80. Burke JF, Bondoc CC, Quinby WC Jr, Remensnyder JP. Primary surgi­
cal management of the deeply burned hand. J Trauma. 1976;16(08):
593-598.
81. Engrav LH, Heimbach DM, Reus JL, Harnar TJ, Marvin JA. Early exci­
sion and grafting vs. nonoperative treatment of burns of indeter­
minant depth: a randomized prospective study. J Trauma. 1983;23
(11):1001-1004.
82. Janzekovic Z. A new concept in the early excision and immediate
grafting of burns. J Trauma. 1970;10(12):1103-1108.
83. Bell L, McAdams T, Morgan R, et al. Pruritus in burns: a descriptive
study. J Burn Care Rehabil. 1988;9(3):305-308.
84. Herndon JH Jr. Itching: the pathophysiology of pruritus. Int J Derma­
tol. 1975;14(7):465-484.
85. Kahlson G, Rosengren E. New approaches to the physiology of hista­
mine. Physiol Rev. 1968;48(1):155-196.
86. Keele CA, Armstrong D. Substances Producing Pain and Itch. London:
Edward Arnold Ttd; 1964:297-298.
87. Heimbach DM, Engrav LH, Marvin J. Minor burns: guidelines for suc­
cessful outpatient management. Postgrad Med. 1981;69(5):22-26,
8–32.
88. Phillips LG, Robson MC. Pruritus in burns. Comments from Detroit
Receiving Hospital, Detroit, Michigan. J Burn Care Rehabil. 1988;9
(3):308-309.
89. Helm PA, Kevorkian CG, Lushbaugh M, et al. Burn injury: rehabilita­
tion management in 1982. Arch Phys Med Rehabil. 1982;63(1):6-16.
90. Warden GD, Kravitz M, Schnebly A. The outpatient manage­
ment of moderate and major thermal injury. J Burn Care Rehabil.
1981;2:159-160.
58. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid
dressing and silver sulfadiazine cream in the outpatient management
of second-degree burns. J Trauma. 1990;30(7):857-865.
59. Tavis MJ, Thornton JW, Bartlett RH, Roth JC, Woodroof EA. A new
composite skin prosthesis. Burns. 1980;7(2):123-130.
60. Gerding RL, Emerman CL, Effron D, et al. Outpatient management of
partial-thickness burns: Biobrane versus 1% silver sulfadiazine. Ann
Emerg Med. 1990;19(2):121-124.
61. Rejzek A, Weyer F, Eichberger R, Gebhart W. Physical changes of
amniotic membranes through glycerolization for the use as an epi­
dermal substitute. Light and electron microscopic studies. Cell Tissue
Bank. 2001;2(2):95-102.
62. Kesting MR, Wolff KD, Hohlweg-Majert B, Steinstraesser L. The role
of allogenic amniotic membrane in burn treatment. J Burn Care Res.
2008;29(6):907-916.
63. Maral T, Borman H, Arslan H, et al. Effectiveness of human amnion
preserved long-term in glycerol as a temporary biological dressing.
Burns. 1999;25(7):625-635.
64. AATB Standards for Tissue Banking. 14th ed. McLean, VA: American
Association of Tissue Banks; 2016.
65. Branski LK, Herndon DN, Celis MM, et al. Amnion in the treatment of
pediatric partial-thickness facial burns. Burns. 2008;34(3):393-399.
66. Ninman C, Shoemaker P. Human amniotic membranes for burns. Am
J Nurs. 1975;75(9):1468-1469.
67. Quinby WC Jr, Hoover HC, Scheflan M, et al. Clinical trials of amni­
otic membranes in burn wound care. Plast Reconstr Surg. 1982;70
(6):711-717.
68. Robson MC, Krizek TJ. The effect of human amniotic membranes on
the bacteria population of infected rat burns. Ann Surg. 1973;177
(2):144-149.
69. Robson MC, Krizek TJ, Koss N, Samburg JL. Amniotic membranes
as a temporary wound dressing. Surg Gynecol Obstet. 1973;136
(6):904-906.
70. Salisbury RE, Carnes R, McCarthy LR. Comparison of the bacterial
clearing effects of different biologic dressings on granulating wounds
following thermal injury. Plast Reconstr Surg. 1980;66(4):596-598.
71. Atiyeh BS, Hayek SN, Gunn SW. New technologies for burn wound
closure and healing–review of the literature. Burns. 2005;31(8):
944-956.
72. Bukovcan P, Koller J. Treatment of partial-thickness scalds by skin
xenografts–a retrospective study of 109 cases in a three-year period.
Acta Chir Plast. 2010;52(1):7-12.
73. Burkey B, Davis W 3rd, Glat PM. Porcine xenograft treatment of
superficial partial-thickness burns in paediatric patients. J Wound
Care. 2016;25(2):S10-S15.

58
Prehospital Management,
Transportation, and
Emergency Care
RONALD P. MLCAK, MICHAEL C. BUFFALO, and CARLOS J. JIMENEZ
7 
should be removed because they can retain heat and
produce a tourniquet-like effect with digital vascular ische­
mia.5 If water is readily available, it should be poured
directly on the burned area. Early cooling can reduce the
depth of the burn and reduce pain, but cooling measures
must be used with caution since a significant drop in body
temperature may result in hypothermia with ventricular
fibrillation or asystole.6 Cold water treatment over large
body surfaces has been shown to trigger clinically relevant
hypothermia.6 Ice or ice packs should never be used because
they may cause further injury to the skin or produce
hypothermia.
Initial management of chemical burns involves remov­
ing saturated clothing, brushing the skin if the agent is a
powder, and irrigation with copious amounts of water,
taking care not to spread chemical on burns to adjacent
unburned areas. Irrigation with water should continue
from the scene of the accident through emergency evalua­
tion in the hospital. Efforts to neutralize chemicals are con­
traindicated due to the additional generation of heat, which
would further contribute to tissue damage. A rescuer must
be careful not to come in contact with the chemical (i.e.,
gloves, eye protectors, etc. should be worn).
Removal of a victim from an electrical current is best
accomplished by turning off the current and by using a
nonconductor to separate the victim from the source.7
Onsite Assessment of
a Burned Patient
Assessment of a burned patient is divided into primary and
secondary surveys. In the primary survey, immediate life-
threatening conditions are quickly identified and treated.
The primary survey is a rapid, systematic approach to
identify life-threatening conditions. The secondary survey
is a more thorough head-to-toe evaluation of the patient.
Initial management of a burned patient should be the same
as for any other trauma patient, with attention directed
at airway, breathing, circulation, and cervical spine
immobilization.
PRIMARY ASSESSMENT
Exposure to heated gases and smoke from the combustion
of a variety of materials results in damage to the respiratory
tract. Direct heat to the upper airways results in edema
Introduction
Advances in trauma and burn management over the past
three decades have resulted in improved survival and
reduced morbidity from major burns. The cost of such care,
however, is high; it requires conservation of resources such
that only a limited number of burn intensive care units with
the capabilities of caring for such labor-intensive patients
can be found; hence, regional burn care has evolved. This
regionalization has led to the need for effective prehospital
management, transportation, and emergency care. Pro­
gress in the development of rapid, effective transport
systems has resulted in marked improvement in the clinical
course and survival for victims of thermal trauma.
For burn victims, there are usually two phases of trans­
port. The first is the entry of the burn patient into the emer­
gency medical system with treatment at the scene and
transport to the initial care facility. The second phase is the
assessment and stabilization of the patient at the initial care
facility and transportation to the burn intensive care unit.1
With this perspective in mind, this chapter reviews current
principles of optimal prehospital management, transporta­
tion, and emergency care.
Prehospital Care
Immediate burn care by first responders is important and
can vastly alter outcomes, and it can significantly limit
burn progression and depth. The goal of prehospital care
should be to ease the burning process as well as prevent
further complications and secondary injuries from burn
shock. Identifying burn patients appropriately for immedi­
ate transfer is an important step in reducing the morbidity
and mortality.2 Prior to any specific treatment, a patient
must be removed from the source of injury and the burning
process stopped. As the patient is removed from the injuring
source, care must be taken so that a rescuer does not become
another victim.3 All caregivers should be aware of the pos­
sibility that they may be injured by contact with the patient
or the patient’s clothing. Universal precautions, including
wearing gloves, gowns, masks, and protective eye wear,
should be used whenever there is likely contact with blood
or body fluids. Burning clothing should be removed as soon
as possible to prevent further injury.4 It has been shown that
prompt removal of clothing after scald injuries may reduce
postburn morbidity.5 All rings, watches, jewelry, and belts

7  •  Prehospital Management, Transportation, and Emergency Care
59
established, Ringer’s lactate (LR) solution should be infused
at the following rates:
■ 14 years and older: 500 mL/h
■ 6–13 years old: 250 mL/h
■ 5 years and younger: 125 mL/h
Prehospital care of wounds is basic and simple because it
requires only protection from the environment with an
application of a clean dressing or sheet to cover the involved
part. Covering wounds is the first step in diminishing pain.
If it is approved for use by local/regional EMS, narcotics
may be given for pain, but only intravenously in small doses
and only enough to control pain.13 It has been shown that
despite training of medical staff, provision for analgesia for
children with burns is lacking and needs further clarifica­
tion.14 Intramuscular (IM) or subcutaneous routes should
never be used because fluid resuscitation could result in
unpredictable patterns of uptake.5 No topical antimicrobial
agents should be applied in the field.5,15 The patient should
then be wrapped in a clean sheet and blanket to minimize
heat loss and to control temperature during transport.
Transport to Hospital Emergency
Department
Rapid, uncontrolled transport of a burn victim is not the
highest priority, except in cases where other life-threatening
conditions coexist. In the majority of accidents involving
major burns, ground transportation of victims to a hospital
is available and appropriate. Helicopter transport is of
greatest use when the distance between an accident and a
hospital is 30–150 miles or when a patient’s condition war­
rants.15 Whatever the mode of transport, it should be of
appropriate size and have emergency equipment available
as well as trained personnel, such as a nurse, physician,
paramedic, or respiratory therapist.
An estimate of burn size and depth assists in making a
determination of severity, prognosis, and disposition of a
patient. Burn size directly affects fluid resuscitation, nutri­
tional support, and surgical interventions. The size of a
burn wound is most frequently estimated by using the rule-
of-nines method (Fig. 7.1). The American Burn Association
identifies certain injuries as usually requiring a referral to
a burn center. Patients with these burns should be treated
in a specialized burn facility after initial assessment and
treatment at an emergency department. Questions about
specific patients should be resolved by consultation with a
burn center physician (Box 7.1).4,16
Keeping the Patient Warm and Dry
Hypothermia is detrimental to traumatized patients and
can be avoided or at least minimized by the use of sheets
and blankets. Wet dressings should be avoided.
Pain Control
The degree of pain experienced initially by the burn victim
is inversely proportional to the severity of the injury.11 No
medication for pain relief should be given intramuscularly
or subcutaneously. For mild pain, acetaminophen 650 mg
orally every 4–6 hours may be given. For severe pain, mor­
phine, 1–4 mg intravenously every 2–4 hours, is the drug
formation, which may obstruct the airway. Initially, 100%
humidified oxygen should be given to all patients when no
obvious signs of respiratory distress are present. Upper
airway obstruction may develop rapidly following injury,
and the respiratory status must be continually monitored
in order to assess the need for airway control and ventilator
support. Progressive hoarseness is a sign of impending
airway obstruction. Endotracheal intubation should be
done early before edema obliterates the anatomy of the
area. Intubation should be performed by the most experi­
enced provider.4,8
The patient’s chest should be exposed in order to ade­
quately assess ventilatory exchange. Circumferential burns
may restrict breathing and chest movement. Airway
patency alone does not assure adequate ventilation. After
an airway is established, breathing must be assessed in
order to ensure adequate chest expansion. Impaired ventila­
tion and poor oxygenation may be due to smoke inhalation
or carbon monoxide intoxication. Endotracheal intubation
is necessary for unconscious patients, for those in acute
respiratory distress, or for patients with burns of the face or
neck that may result in edema, which causes obstruction of
the airway.4,8 The nasal route is the recommended site of
intubation. Assisted ventilation with 100% humidified
oxygen is required for all intubated patients.
Blood pressure is not the most accurate method of
monitoring a patient with a large burn because of the
pathophysiologic changes that accompany such an injury.
Blood pressure may be difficult to ascertain because of
edema in the extremities. A pulse rate may be somewhat
more helpful in monitoring the appropriateness of fluid
resuscitation.9
If a burn victim was in an explosion or deceleration acci­
dent, there is the possibility of a spinal cord injury. Appro­
priate cervical spine stabilization must be accomplished by
whatever means necessary, including a cervical collar to
keep the head immobilized until the condition can be
evaluated.
SECONDARY ASSESSMENT
After completing a primary assessment, a thorough head-
to-toe evaluation of the patient is imperative.10 A careful
determination of trauma other than obvious burn wounds
should be made. As long as no immediate life-threatening
injury or hazard is present, a secondary examination can
be performed before moving the patient; precautions such
as cervical collars, backboards, and splints should be used.11
Secondary assessment should examine the patient’s past
medical history, medications, allergies, and the mecha­
nisms of injury. Any suspicion of nonaccidental injury
should lead to immediate admission of a child to the hospi­
tal, irrespective of how trivial the burn injury is, and noti­
fication of social services.12
There should never be a delay in transporting burn
victims to an emergency facility due to an inability to estab­
lish intravenous (IV) access. If the local/regional emergency
medical system (EMS) protocol prescribes that an IV line is
started, then that protocol should be followed. The Ameri­
can Burn Association recommends that if a patient is less
than 60 min from a hospital, an IV is not essential and can
be deferred until a patient is at the hospital. If an IV line is

7  •  Prehospital Management, Transportation, and Emergency Care
60
of choice, although meperidine (Demerol) 10–40 mg by IV
push every 2–4 hours may be used.5 Recommendations for
tetanus prophylaxis are based on the patient’s immuniza­
tion history. All patients with burns should receive 0.5 mL
of tetanus toxoid. If prior immunization is absent or unclear,
or if the last booster was more than 10 years ago, 250 units
of tetanus immunoglobulin is also given.5
Transferring a Burn Patient
The appearance of burned skin is rather obvious and has
the potential to mask or cover any other potential inju­
ries that the burn patient could have. The burn patient
is a trauma patient with burns and should be promptly
and effectively evaluated to include other potential inju­
ries. It is important to establish effective communication
between the transferring unit and the receiving center. The
American Burn Association has referral guidelines that
identify those patients needing to be transferred to a burn
center.7,16
Once the need to transfer the patient is identified, the
transferring process begins. The doctor-to-doctor referral
process starts with the initial care facility. Available phone
numbers and doctor information should be available to
centers, and the center should promptly call and ask for all
the information needed for the transfer.
The referring physician should give a brief and concise
history of the event that includes the time of injury and all
resuscitation efforts prior to the call. The ABCs of trauma
resuscitation should be discussed and the most current vital
signs and physical examination findings should be pre­
sented. The accepting facility should then fill out an intake
form that details all the information. Understanding the
patient’s current status is essential for a successful and
uneventful transfer. It is imperative that physicians partici­
pate in the process by adding to the already available infor­
mation gathered by other personnel.
Transferring a patient without the needed information
can potentially lead to bad outcomes and/or unnecessary
expense. For example, a burn patient with an underlying
anoxic brain injury could be transferred to a burn center
when instead the diagnosis of brain death could have been
made at the initial care facility.
Physicians can access patient information utilizing differ­
ent technologies. Although a doctor-to-doctor phone call is
preferred by many, today’s technology allows patient data,
including pictures and laboratory results as well as any
other clinical information needed to further assess the
patient’s needs, to be transferred.17 While some physicians
still prefer the immediacy of the telephone, secure elec­
tronic messaging tools are beginning to supplement phone
calls and beepers to facilitate communication among
physicians.7,18
Privacy and Security Issues
Perhaps the most fundamental choice physicians must
make when selecting tools to communicate electronically
with each other and with patients is how they will manage
the privacy and security of the information exchanged.
Adult body
Part
Arm
Head
Neck
Leg
Anterior trunk
Posterior trunk
% of total
BSA
9%
9%
1%
18%
18%
18%
Child body
Part
Arm
Head and neck
Leg
Anterior trunk
Posterior trunk
% of total
BSA
9%
18%
14%
18%
18%
9%
1%
Front
18%
Front
18%
Back
18%
Back
18%
18%
18%
18%
9%
9%
14%
14%
9%
9%
Fig. 7.1  Estimation of burn size using the rule-of-nines. (From American
Burn Association. Advanced Burn Life Support Providers Manual. Chicago, IL:
American Burn Association; 2011)
From American Burn Association. Advanced Burn Life Supporters Manual.
Chicago, IL: American Burn Association; 2011.
Box 7.1  Criteria for Transfer of a Burn Patient to
a Burn Center
■ Second-degree burns >10% total body surface area (TBSA)
■ Third-degree burns
■ Burns that involve the face, hands, feet, genitalia, perineum,
and major joints
■ Chemical burns
■ Electrical burns including lightning injuries
■ Any burn with concomitant trauma in which the burn injuries
pose the greatest risk to the patient
■ Inhalation injury
■ Patients with pre-existing medical disorders that could
complicate management, prolong recovery, or affect mortality
■ Hospitals without qualified personnel or equipment for the
care of critically burned children

7  •  Prehospital Management, Transportation, and Emergency Care
61
Whether or not electronic communication is encrypted
or secure, physicians should guard against being lulled by
the casual nature of e-mail which, unlike a conversation or
phone call, is not erased from a computer’s hard drive when
deleted and is potentially discoverable in litigation.
In the future, the use of telemedicine may allow more
accurate and timely access to critical information that may
adjunct the care given during the golden hour of trauma
care. In the absence of a skilled burn specialist, the use of
telemedicine services can expedite the process and aid in the
treatment plan. Telemedicine has already gained accep­
tance and support from many public funding projects. It is
considered user-friendly, almost infinitely adaptable, and
cost effective.20
Transportation Guidelines
The primary purpose of any transport teams is not to bring
a patient to an intensive care unit but to bring that level of
care to the patient as soon as possible. Therefore, the critical
time involved in a transport scenario is the time it takes to
get the team to the patient. The time involved in transport­
ing a patient back to a burn center becomes secondary.
Communication and teamwork are the keynotes to an effec­
tive transport system.
When transportation is required from a referring facil­
ity to a specialized burn center, a patient can be fairly well
stabilized before being moved. Initially, the referring facil­
ity should be informed that all patient referrals require
physician-to-physician discussion. Pertinent information
needed includes patient demographic data, time, date,
cause and extent of burn injury, weight and height, baseline
vital signs, neurological status, laboratory data, respiratory
status, previous medical and surgical history, and allergies.
A referring hospital is informed of specific treatment pro­
tocols regarding patient management prior to transfer. To
ensure patient stability, the following guidelines are offered:
■ Establish two IV sites, preferably in an unburned upper
extremity, and secure IV tubes with sutures.
■ Insert a Foley catheter and monitor for acceptable
urine output (30 mL/h adult; 1 mL/kg/h child.
■ Insert a nasogastric tube and ensure that the patient
remains NPO.
■ Maintain body temperature between 38°C and 39.0°C
(taken rectally).
■ Stop all narcotics.
■ For burns less than 24 hours old, only use LR solution.
The staff physician will advise on the infusion rate,
which is calculated based on the percentage of total
body surface area burned.
Following physician-to-physician contact and collection
of all pertinent information, the physicians will make rec­
ommendations regarding an appropriate mode of transpor­
tation. The options are based on distance to a referring unit,
patient complexity, and comprehensiveness of medical care
required. Options include:
■ Full medical intensive care unit transport with a com­
plete team consisting of a physician, a nurse, and a
respiratory therapist from the burn facility
The Health Insurance Portability and Accountability Act
(HIPAA) is technology neutral, in that it does not require
any set form of encryption or information safeguarding. It
is also scalable, in that it allows small practices to do what
they can afford to do without requiring them to purchase
expensive communication security systems.17,19
For electronic communications, the physician should
have an informed consent form signed by each patient spe­
cific to the form of communication being used, such as
e-mail. The form should verify the patient’s e-mail address;
should discuss the security risks involved (e.g., that other
parties on the patient’s end might have access to their
e-mail accounts and that standard [unencrypted, nonse­
cure] e-mail can be intercepted by unintended parties);
should discuss allowable content of the communication;
and should include a provision to hold the physician harm­
less if security is breached.
While there is no private right of action under the HIPAA
(i.e., a patient cannot sue physicians for breach of HIPAA’s
privacy or security provisions), the federal agencies that
oversee the HIPAA have recently announced plans to step
up their audits, and they could conduct an inquiry if a
patient files a complaint. Although federal investigations
seem more likely to focus on hospitals than physician offices,
carelessness could also have legal repercussions. For
example, information could be sent to the wrong recipient
because of failure to verify the address field before sending
the message. Physicians using standard e-mail should use
as many practical safeguards as possible to minimize liabil­
ity exposure. This could include a privacy and security dis­
claimer footer on each e-mail, requesting the patient’s
permission before continuing to respond to certain issues by
e-mail, limiting the amount of medical detail in the mes­
sages, and password-protecting e-mail access on office and
home workstations, as well as on portable devices such as
PDAs and Blackberries, in case they are lost.
Another way to alleviate security or HIPAA compliance
concerns is to leave out protected health information (PHI)
in standard e-mail: data that both personally identifies a
patient and reveals a specific diagnosis or condition. While
standard e-mail works and is offered free of charge by
service providers such as Yahoo, Gmail, Comcast, and many
others, vendors of secure messaging networks are quick to
point out multiple deficiencies (Box 7.2).
Box 7.2  Deficiencies of Electronic Mail Services
for the Transmission of Medical Information
■ Lack of encryption or authentication
■ Can be used by anyone to access a physician if they simply
know the physician’s e-mail address
■ Have no “terms of service” or legal disclaimers to protect
physicians
■ Can easily expose patient e-mail addresses and identities to
unintended third parties
■ Can breach patient privacy by using employer e-mail networks
■ Offer no charge capture function
■ Have no template or medical records features
■ Lack of consistency with HIPAA or medical liability insurance
company standards

7  •  Prehospital Management, Transportation, and Emergency Care
62
Because all the care rendered by a transport team outside
a hospital is given as an extension of care from a
transporting/receiving facility, specific steps must be taken
to protect staff and physicians from medical liability and to
provide consistent care for all patients. Strict protocols are
used to guide all patient care; team members should be in
constant communication with an attending physician
regarding a patient’s condition and the interventions to be
considered. Team members must be proficient in a number
of procedures that may be needed during transport or while
stabilizing a patient prior to transport. To keep up with
current technology and changes, team members should be
included in discussions of recent transports and current
management techniques so that they can discuss patient
care issues, receive ongoing in-service education, and par­
ticipate in a review of the quality of transports.
MODES OF TRANSPORTATION
Once the need for transport of a burned patient is estab­
lished, the decision must be made concerning what type of
transportation vehicle is to be used (Table 7.1). There are
two models of transport commonly used: ground
(ambulance/transport vehicle), air (helicopter, fixed wing),
or a combination of both. Factors to be considered when
selecting a mode of transportation are the condition of the
patient and the distance involved. The level of the severity
of the burn mandates the speed with which the team must
arrive in order to stabilize and transport a patient.
Ground Transport
Ground transport should be considered to cover distances
of 70 miles or less; however sometimes a patient’s condition
may require air transport, particularly helicopter transport,
even though the distance is within the 70-mile range. The
ground transport vehicle should be modified with special
equipment needed for intensive care transport, and there
must be enough room to comfortably seat team members
and hold equipment.
Air Transport
Air transport is used primarily when long distances or the
critical nature of an injury separate a team from a patient.
Air transport does, however, present its own unique set of
problems. Aviation physiology is a specialty unto itself, and
the gas laws play an important role in air transport and
must be taken into consideration.
Dalton’s law states that, in a mixture of gases, the total
pressure exerted by the mixture is equal to the sum of the
pressures each would exert alone.21 This is important when
changing a patient’s altitude because as altitude increases,
barometric pressure decreases. The percentage of nitrogen,
oxygen, and carbon dioxide remain the same, but the partial
pressures exert change.22
Altitude is an important factor in the oxygenation of a
transported patient, and constant monitoring by a team is
required under such circumstances. Boyle’s law states that
the volume of gas is inversely proportional to the pressure
to which it is subject at a constant temperature. This gas
law significantly affects patients with air leaks and free air
in the abdomen because, as altitude increases, the volume
of air in closed cavities also increases.23 For this reason, all
■ Medical intensive care transport via fixed wing aircraft
or helicopter with a team from the referring facility
■ Private plane with medical personnel to attend patient
■ Commercial airline
■ Private ground ambulance
■ Transport van with appropriate personnel.
TRANSPORT TEAM COMPOSITION
Because stabilization and care for a burned patient is so
specialized, team selection is of the utmost importance. Tra­
ditionally, these patients were placed in an ambulance with
an emergency medical technician and transported with
little effort made to stabilize the patient prior to transfer. As
levels of care and technology have evolved, the need for
specialized transport personnel has increased. Today most
transport teams are made up of one or more of the follow­
ing healthcare members: a registered nurse, a respiratory
therapist, and/or a staff physician or house resident.
Because a large number of burned patients require some
type of respiratory support due to inhalation injury or
carbon monoxide intoxication, the respiratory therapist
and nurse team have proved to be an effective combination.
The background and training of nurses and therapists
differ in many ways, so such a team provides a larger scope
of knowledge and experience when both are utilized. Team
members ideally should be cross-trained so that each
member can function at the other’s level of expertise.
TRAINING AND SELECTION
Because the transport team will work in a high-stress envi­
ronment, often with life-or-death consequences, these indi­
viduals must be carefully selected. The selection process
should involve interviews with a nursing administrator, a
director of respiratory therapy, and a medical director of a
transport program.
Minimum requirements for transport team members
should include:
■ Transport nurse qualifications:
■ a registered nurse;
■ minimum of 6 months burn care experience;
■ current
cardiopulmonary
resuscitation
(CPR)
certification;
■ advanced cardiac life support (ACLS) or pediatric
advanced life support (PALS) certification;
■ ability to demonstrate clinical competency;
■ observation of two transports;
■ a valid passport for international response.
■ Transport respiratory therapist qualifications:
■ registered respiratory therapist with 6 months burn
care experience;
■ licensed by appropriate regulatory agency as a respi­
ratory care practitioner;
■ have current BLS;
■ ACLS or PALS certification;
■ ability to demonstrate clinical competency;
■ observation of two transports;
■ demonstrate a working knowledge of transport
equipment;
■ a valid passport for international response.

7  •  Prehospital Management, Transportation, and Emergency Care
63
disadvantages include noise, vibrations, reduced air speed,
small working space, lower weight accommodation, and
high maintenance requirements.24
When long distances must be traveled (more than 150
miles) or when increased altitude is necessary, fixed-wing
aircraft are considered a viable mode of transport for
patients. The advantages of using fixed-wing aircraft
include long-range capabilities, increased speed, ability to
fly in most weather conditions, control of cabin pressure
and temperature, larger cabin space, and more liberal
weight restrictions. Disadvantages of fixed-wing aircraft
include the need for an airport with adequate runway
length, difficulty in loading and unloading patients and
equipment, and the pressure of air turbulence and noise.
EQUIPMENT
Because medical equipment used in intensive care units has
evolved tremendously in the past 10 years, there is no
reason that these advances should not be extended to the
equipment used in a transport program. The transport team
must be able to provide ICU-level care whenever needed.
Most hospitals are well stocked and able to provide neces­
sary supplies for initial patient stabilization and resuscita­
tion; however, specialty items relating to the care of burn
patients may not be present or adequate to meet the needs
of burn victims. It is imperative that adequate equipment
be available to handle any situation that may arise during
a transport process (Fig. 7.2). Extra battery packs and elec­
trical converters on fixed-wing aircraft are recommended
air that can be reached should be evacuated prior to an
increase in altitude. Intrathoracic air and gastric air must
be removed via functional chest tubes or nasogastric tubes
and periodically checked during transport. Other factors
that should be considered during air transport are reduced
cabin pressure, turbulence, noise and vibration, changes in
barometric pressure, and acceleration/deceleration forces.
Physiologic changes that affect a patient and team members
include middle ear dysfunction, pressure-related problems
with sinuses, air expansion in a gastrointestinal tract, and
motion sickness. Utilizing transport vehicles that have pres­
surized cabins can reduce or eliminate most of these
problems.21–23
Helicopters and Fixed-Wing Aircraft.  Helicopters and
fixed-wing aircraft have both advantages and disadvan­
tages related to patient care. Helicopters are widely used for
short-distance medical air transport. Medical helicopters,
because they are usually based on hospital premises, have
no need to use airport facilities or ambulance services and
therefore reduce team response time. Helicopters are able to
land close to a referring hospital. Additionally, helicopters
provide ease in loading and unloading patients and equip­
ment.24 The disadvantages of helicopter transport include
its limited range, usually less than 150 miles,24 and its non­
pressurized cabin, which limits the altitude at which patients
can be safely carried. The low-altitude capabilities also
subject the aircraft to variability in weather (i.e., fog, rain,
and reduced visibility); therefore, helicopter flights experi­
ence much more interference due to weather. Other
Table 7.1  Transport Criteria: Mode and Team Composition, Burns ≤6 Days Postburn
Weight (kg)
% Burn
Distance (miles)
Teama
Transport Mode
≤3
Any
≤75
C
Van, helicopter
76–250
C
Turboprop airplane
≥251
C
Learjet
3.1–20
≤10
≤75
N-RT
Van, helicopter
76–500
N-RT
Commercial flight or turboprop airplane
≥501
N-RT
Commercial airplane or Learjet
>10
≤75
C
Van, helicopter
76–250
C
Turboprop airplane
≥251
C
Learjet
≥20
≤20
≤75
N
Commercial flight or turboprop airplane
76–500
N-RT
≥501
N-RT
Commercial airplane or Learjet
>20
≤75
N
Van, helicopter
76–500
C
Turboprop plane
≥501
C
Jet
If any of the following criteria exist, the transport shall be changed to the fastest mode with a complete team:
■ depressed mental status;
■ drug depression;
■ respiratory support;
■ unstable cardiovascular system;
■ presence of associated diseases;
■ decreased urine output/unresponsiveness to appropriate fluid administration;
■ absent or marginal venous access;
■ hypothermia unresponsive to corrective measures.
aC, complete team (doctor, nurse, respiratory therapist); N, nurse; RT, respiratory therapist.

7  •  Prehospital Management, Transportation, and Emergency Care
64
(Percussionaire Corporation, Sand Point, ID) is a portable
pressure-limited time-cycled ventilator and is approved for
in-flight use by the US Air Force. The transport ventilator
weighs 1.5 pounds (0.68 kg), can be set to provide respira­
tory rates of between 6 and 250 breaths per minute and
provides tidal volumes of between 5 and 1500 cc. This ven­
tilator is powered entirely by oxygen and requires no electri­
cal power. All timing circuit gases are delivered to the patient
so that operation of the ventilator does not consume addi­
tional oxygen. The inhale to exhale (I:E) ratios are preset at
the factory from 1 : 1 at frequencies of 250 cycles per minute
to 1 : 5 at a rate of 6 cycles per minute. As a result, breath
stacking and undesired overinflation due to air trapping
may be avoided.23–25
Stabilization
One of the primary reasons for a specialized transport team
is so that a patient can be transported in as stable condition
as possible. Current practice has evolved to embrace the
concept that events during the first few hours following
burn injury may affect the eventual outcome of the patient;
this is especially true with regard to fluid management and
inhalation injury. Stabilization techniques performed by the
transport team have been expanded to include procedures
that are usually not performed by nursing or respiratory
personnel. Such techniques include interpreting radio­
graphs and laboratory results and then conferring with
fellow team members, referring physicians, and the team’s
own medical staff to arrive at a diagnosis and plan for sta­
bilization. The transport team may perform such proce­
dures as venous cannulation, endotracheal intubation,
arterial blood gas interpretation, and management of
mechanical ventilators. Team members may request new
radiographs to assess catheter or endotracheal tube place­
ment or to assess the pulmonary system’s condition. Team
members may aid in the diagnosis of air leaks (pneumotho­
rax) and evacuate the pleural space of the lung by needle
aspiration as indicated. All of these procedures may be
immediately necessary and life-saving. Cross-training of all
team members so that they are able to perform the others’
jobs is recommended to safeguard patients in the event that
any team member becomes incapacitated during transport.
All these skills can be learned via experience in a burn
intensive care unit, through formal training seminars, and
via a thorough orientation program. Mature judgment,
excellent clinical skills, and the ability to function under
stress are characteristics needed when selecting candidates
for a transport program.
Patient Assessment Prior to
Transport to a Specialized
Burn Care Unit From a
Referring Hospital
Initial assessment on arrival of a flight team should include
a list of standard procedures for determining a burned
patient’s current condition. First, a thorough review of the
patient’s history concerning the accident and past medical
due to long transport times and delays caused by unforesee­
able circumstances of weather or logistics.
Portable Monitor
A portable electrocardiogram (ECG) monitor capable of
monitoring two pressure channels should accompany all
patients in transport. This allows for continuous monitor­
ing of heart rate, rhythm, and arterial blood pressure. The
second pressure channel may be used for patients with a
pulmonary artery catheter or those who need intracranial
pressure monitoring. This monitor should be small and
lightweight but able to provide a display bright enough to
be seen from several feet away. The monitor should have its
own rechargeable power supply that continuously charges
while connected to an alternating current (AC) power
supply. One suitable unit is the Protocol Systems Propaq
106 portable monitor. This monitor has two pressure chan­
nels; it provides a continuous display of ECG; heart rate; and
systolic, diastolic, and mean blood pressure; it can display
temperature and oxygen saturation; and it is also capable
of operating a non invasive blood pressure cuff. High and
low alarms for each monitored parameter can be set,
silenced, or disabled by a trained operator.
Infusion Pump
Continuous delivery of fluids and pharmacological agents
must not be interrupted during transport. Infusion pumps
can be easily attached to stretchers and are usually capable
of operating for several hours on internal batteries. These
devices should have alarms to warn of infusion problems
and should be as small and lightweight as possible.
Ventilator
Size, weight, and oxygen consumption are the primary con­
cerns in selecting transport ventilators. A weight under 5
pounds (2.2 kg) is desirable, and a ventilator’s dimensions
should make it easy to mount or to place on a bed. Orienta­
tion of controls should be along a single plane, and inad­
vertent movement of dials should be difficult.23 The
ventilator breathing circuit and exhalation valve should be
kept simple, and incorrect assembly should be impossible.
One type of transport ventilator that has become popular is
the TXP transport ventilator. The TXP transport ventilator
Fig. 7.2  Typical equipment used in transport of a patient.

7  •  Prehospital Management, Transportation, and Emergency Care
65
circulation should be kept in the field and en route to the
hospital. This information is vital for a referring facility to
better understand and anticipate the condition of the
patient. Additionally, all treatments, including invasive pro­
cedures, must be recorded, along with a patient’s response
to these interventions.
Summary
Burn injuries present a major challenge to a health care
team, but an orderly, systematic approach can simplify sta­
bilization and management. A clear understanding of the
pathophysiology of burn injuries is essential for providing
quality burn care in the prehospital setting, at the receiving
health care facility, and at the referring hospital prior to
transport. After a patient has been rescued from an injury-
causing agent, assessment of the burn victim begins with a
primary survey. Life-threatening injuries must be treated
first, followed by a secondary survey, which documents and
treats other injuries or problems. Intravenous access may
be established in concert with logical/regional medical
control and appropriate fluid resuscitation begun. Burn
wounds should be covered with clean, dry sheets, and the
patient should be kept warm with blankets to prevent hypo­
thermia. The patient should be transported to an emer­
gency room in the most appropriate mode available.
At the local hospital, it should be determined if a burn
patient needs burn center care according to the American
Burn Association Guidelines. In preparing to organize the
transfer of a burn victim, consideration must be given to
the continued monitoring and management of the patient
during transport. In transferring burn patients, the same
priorities developed for prehospital management remain
valid. During initial assessment and treatment and through­
out transport, the transport team must ensure that the
patient has adequate airway/breathing, circulation, fluid
resuscitation, urine output, and pain control. Ideally, trans­
port of burn victims will occur through an organized,
protocol-driven plan that includes specialized transport
mechanisms and personnel. Successful transport of burn
victims, whether in the prehospital phase or during inter­
hospital transfer, requires careful attention to treatment
priorities, protocols, and details.
Complete references available online at

Further Reading
American Burn Association. Advanced Burn Life Support Providers Manual.
Chicago, IL: American Burn Association; 2010.
American Burn Association. Radiation injury. In: Advanced Burn Life
Support Manual (Appendix 1). Chicago, IL: American Burn Association;
2010.
Brooks RG, Menachemi N. Physician’s use of email with patients: factors
influencing electronic communication and adherences to best practices.
J Med Internet Res. 2006;8(1):e2.
Herndon DN, Rutan RL, Rutan TC. Management of the pediatric patient
with burns. J Burn Care Rehabil. 1993;14(1):3-8.
Mandl KD, Kohane IS, Brandt AM. Electronic patient–physician commu­
nication: problems and promise. Ann Intern Med. 1998;129(6):495-500.
history must be done. This process provides the transport
team with an excellent base from which to begin to formu­
late a plan of action. The patient will certainly have been
diagnosed by a referring physician; however a transport
team often finds problems overlooked in initial evaluations.
Since burn care is a specialized field, modes of treatment
may vary greatly outside the burn treatment community.
Frequently, a referring hospital is not well-versed in the
treatment of burn victims and should not be expected to
display the expertise found among clinicians who work
with such patients every day. Thus the next step in stabiliz­
ing a burn patient is a physical assessment done by the
transport team. These procedures should always be per­
formed in the same order and in a structured fashion.
Assessment of a burn patient begins with the ABCs of a
primary survey, including airway, breathing, circulation,
cervical spine immobilization, and a brief baseline neuro­
logical examination. All patients should be placed on sup­
plemental oxygen prior to transport in order to minimize
the effects of altitude changes on oxygenation. Two IV lines
should be started peripherally with a 16-gauge catheter or
larger. Ideally, IV lines should be placed in nonburned areas
but may be placed through a burn if they are the only sites
available for cannulation. Intravenous lines should be
sutured in place because venous access may not be available
after the onset of generalized edema. The fluid of choice for
initial resuscitation is LR solution.
In addition to initial stabilization procedures, blood
should be obtained for initial laboratory studies if not
already done. Initial diagnostic studies include hematocrit,
electrolytes, urinalysis, chest X-ray, arterial blood gas, and
carboxyhemoglobin levels. Any correction of laboratory
values must be done prior to transfer and verified with
repeat studies. ECG monitoring should be instituted on any
patient prior to transfer. Placement of electrode patches
may be a problem because the adhesive will not stick to
burned skin. If alternative sites for placement cannot be
found, an option for monitoring is to insert skin staples and
attach the monitor leads to them with alligator clips. This
provides a stable monitoring system, particularly for the
agitated or restless patient who may displace needle elec­
trodes. A Foley catheter with an urometer should be placed
to accurately monitor urine output. Acceptable hydration
is indicated by a urine output of more than 30 mL/h in an
adult (5 mL/kg/h) and at least 1 mL/kg/h in a child.
With the exception of escharotomies, open chest wounds,
and actively bleeding wounds, management during trans­
port consists of simply covering wounds with a topical anti­
microbial agent or a biological dressing. Wet dressings are
contraindicated because of the decreased thermoregula­
tory capacity of patients sustaining large burns and the
possibility of hypothermia. To combat the problem of a
gastric ileus, a nasogastric tube should be inserted in all
burn patients in order to decompress the stomach. This is
especially important for patients being transferred at high
altitudes. Hypothermia can be avoided or minimized by the
use of heated blankets and/or aluminized Mylar space blan­
kets. The patient’s rectal temperature must be kept between
37.5°C and 39.0°C.
A clear, concise, chronological record of the mechanism
of injury and assessment of airway, breathing, and

65.e1
7  •  Prehospital Management, Transportation, and Emergency Care
References
1. Boswick JA, ed. The Art and Science of Burn Care. Rockville, MD: Aspen;
1987.
2. Vivo C, Galerias R, del Caz MD. Initial evaluation and management of
the critical burn patient. Med Intensiva. 2016;40(1):49-59.
3. Dimick AR. Triage of burn patients. In: Wachtel TL, Kahn V, Franks
HA, eds. Current Topics in Burn Care. Rockville, MD: Aspen Systems;
1983:15-18.
4. Wachtel TL.
Initial
care
of
major
burns.
Postgrad
Med.
1989;85(1):178-196.
5. Lau EY, Tam YY, Chiu TW. Triage of burn patients. Hong Kong Med J.
2016;22(2):152-157.
6. American Burn Association. Advanced Burn Life Support Providers
Manual. Chicago, IL: American Burn Association; 2011.
7. reference removed at revises
8. American Burn Association. Radiation injuries. In: Advanced Burn Life
Support Providers Manual. Chicago, IL: American Burn Association;
2011.
9. Eastman AL, Arnold BA, Hunt JL, Purdur GF. Pre-burn center man­
agement of the burned airway: do we know enough? J Burn Care Res.
2010;31(5):701-705.
10. Bartholomew CW, Jacoby WD. Cutaneous manifestations of lightning
injury. Arch Dermatol. 1975;26:1466-1468.
11. Committee on Trauma, American College of Surgeons. Burns. In:
Advanced Trauma Life Support Course Book. Chicago: American College
of Surgeons; 1984:155-163.
12. Rauscher LA, Ochs GM. Pre-hospital care of the seriously burned
patient. In: Wachtel TL, Kahn V, Franks HA, eds. Current Topics in Burn
Care. Rockville, MD: Aspen Systems; 1983:1-9.
13. Hettiatatchy Shenan, Dziewulski Peter. ABC of burns: Pathophysiol­
ogy and types of burns. BMJ. June 12, 2004;328-335
14. Marvin JA, Heinback DM. Pain control during the intensive care phase
of burn care. Crit Care Clin. 1985;1:147-157.
15. Rutkowska A, Skotnicka-Klonowicz G. Pre-hospital pain man­
agement in children with traumatic injuries. Pediatr Emerg Care.
2015;31(5):317-320.
16. Goldfarb JW. The burn patient. In: Air Medical Crew National Standards
Curriculum. Phoenix: ASHBEAMS; 1988.
org/Chapter14.pdf. Accessed 19 October 2016.
17. Fotsch EV. Online physician communication. Phys News Digest. 2008.
Accessed
18. Mandl
KD,
Kohane
IS,
Brandt
AM.
Electronic
patient–
physician communication: problems and promise. Ann Intern Med.
1998;129(6):495-500.
19. Brooks RG, Menachemi N. Physician’s use of email with patients:
factors influencing electronic communication and adherences to best
practices. J Med Internet Res. 2006;8(1):e2.
20. Atiyeh B, Dibo SA, Janom HH. Telemedicine and burns: an overview.
Ann Burns Fire Disast. June 2015;27(2): Accessed
nlm.noh.gov/pmc/articles/PMC4396801/pfd/Ann-Burns-and-Fire-
Disasters-27-87.pdf.
21. McNeil EL. Airborne Care of the Ill and Injured. New York: Springer-
Verlag; 1983.
22. Federal Regulations for Pilots. Government publication; 1987.
23. Branson RD. Intrahospital transport of critically ill, mechanically ven­
tilated patients. Respir Care. 1992;37:775-793.
24. Jacobs B. Emergency Patient Care, Pre-Hospital Ground and Air Proce­
dures. New York: Macmillan; 1983.
25. Johannigman JA, Branson RD, Cambell R, et al. Laboratory and
clinical evaluation of the MAX transport ventilator. Respir Care.
1990;35:952-959.

66
Pathophysiology of Burn Shock
and Burn Edema
PAUL WURZER, DEREK CULNAN, LEOPOLDO C. CANCIO, and GEORGE C. KRAMER
8 
multiple mediators of inflammation, with effects on both the
microcirculation and the function of the heart and lungs.
Subsequently burn shock continues as a significant patho­
physiologic state even if hypovolemia is corrected. Increases
in pulmonary and systemic vascular resistance (PVR, SVR)
and myocardial depression occur despite adequate preload
and volume support.7–11 Such cardiovascular dysfunc­
tions can further exacerbate the whole-body inflamma­
tory response into a vicious cycle of accelerating organ
dysfunction.6,7,12
This chapter examines our current understanding of the
pathophysiology of the early events in burn shock, focusing
on the many facets of the microcirculatory, organ, and sys­
temic effects resulting directly from burns and circulating
mediators. Intracellular pathways are not presented.
Inflammatory shock mediators, both local and systemic,
that are implicated in the pathogenesis of burn shock
include histamine, serotonin, bradykinin, nitric oxide,
oxygen radicals, tumor necrosis factor (TNF), interleukins,
and products of the eicosanoid acid cascade including
prostaglandins and thromboxanes. Additionally certain
hormones and mediators of cardiovascular function are
elevated several fold after burn injury: these include epi­
nephrine, norepinephrine, vasopressin, angiotensin II, and
neuropeptide-Y. Other mediators and unknown factors yet
to be defined are also involved.
Hypovolemia and Rapid
Edema Formation
Burn injury causes extravasation of plasma into the burn
wound. Extensive burn injuries are hypovolemic in nature
and are characterized by hemodynamic changes similar to
those that occur after hemorrhage, including decreased
plasma volume, cardiac output, and urine output and an
increased SVR with resultant reduced peripheral blood
flow.5,7,13–15 However, whereas in hemorrhage there is a fall
in hematocrit with blood loss due to autotransfusion of
interstitial fluid into the vasculature, in burn shock hema­
tocrit may rise due to plasma extravasation. This is particu­
larly common when fluid therapy is inadequate.
As in the treatment of other forms of hypovolemic shock,
the primary initial therapeutic goal is to promptly restore
intravascular volume and to preserve tissue perfusion and
minimize tissue ischemia. However burn resuscitation is
complicated not only by severe burn wound edema, but also
by extravasated and sequestered fluid and protein in
unburned soft tissue. Large volumes of resuscitation solu­
tions are required to maintain intravascular volume during
the first several hours after an extensive burn.
Introduction and Historical Notes
Extensive cutaneous thermal injury invariably results in the
severe derangements of cardiovascular function and end-
organ perfusion known as burn shock. Shock is an abnormal
physiologic state in which tissue perfusion is insufficient for
oxygen and nutrient delivery and cellular waste removal.
Before the 19th century, investigators demonstrated that,
after a burn, fluid is lost from the blood and the blood
becomes thicker; in 1897, saline infusions for severe burns
were first advocated.1,2 Frank Underhill derived a more com­
plete understanding of burn pathophysiology3 when he
demonstrated that unresuscitated burn shock was associ­
ated with increased hematocrit values, which are second­
ary to fluid and electrolyte loss after burn injury. Thus
increased hematocrit values after severe burn injury are a
consequence of a plasma volume deficit. Cope and Moore4
furthered these finding, demonstrating that the hypovole­
mia of burn injury resulted from fluid and protein translo­
cation into both burned and unburned tissues.
Animal and clinical studies have established the impor­
tance of fluid resuscitation for burn shock. Investigations
have focused on correcting the rapid and massive fluid
sequestration in the burn wound and the resultant hypovo­
lemia. The literature contains a large experimental and
clinical database on the circulatory and microcirculatory
alterations associated with burn shock and edema genera­
tion in both the burn wound and unburned tissues. Sub­
stantial research has focused on identifying and defining
the mechanisms and effects of the many inflammatory
mediators produced and released after burn injury.4
Burn shock occurs from the coalescence of three car­
dinal causes: (1) hypovolemia resulting from intravascu­
lar fluid leaking into the interstitial space causing burn
edema, (2) cardiac depression due to humoral factors and
loss of preload, and (3) increased systemic vascular resis­
tance. Later in the resuscitation process vasoplegia can
replace the increase in system vascular resistance. Burn
shock is a complex process of circulatory and microcir­
culatory dysfunction that is not easily or fully repaired by
fluid resuscitation. Severe burn injury results in significant
distributive shock and substantial tissue trauma, both of
which cause the formation and release of many local and
systemic mediators.5–7 Burn shock results from the inter­
play of direct tissue injury, hypovolemia, and the release of
Note: The opinions or assertions contained herein are the private views of
the authors, and are not to be construed as official or as reflecting the
views of the Department of the Army or the Department of Defense.

8  •  Pathophysiology of Burn Shock and Burn Edema
67
Edema develops when the rate at which fluid is filtered
out of the capillaries exceeds the flow in the lymph vessels.
Edema formation often follows a biphasic pattern. An
immediate and rapid increase in the water content of
burned tissue is seen in the first hour after burn injury.15,18
A second and more gradual increase in fluid flux of both the
burned skin and unburned soft tissue occurs during the first
12–24 hours after burn injury.6,16 The amount of edema
formation in burned skin depends on the type and extent of
injury,14,16 on whether fluid resuscitation is provided, and
on the type and volume of fluid administered.17 Fluid resus­
citation elevates blood flow and capillary pressure thereby
contributing to further fluid extravasation. Without sus­
tained IV replacement of intravascular fluid losses edema
formation is somewhat self-limited, as tissue blood flow and
capillary pressure decrease.
Edema formation in thermally injured skin is character­
ized by an extremely rapid onset. Tissue water content can
double within the first hour after burn.14,18 Leape found
a 70–80% increase in water content in a full-thickness
burn wound 30 minutes after burn injury, with 90% of
this change occurring in the first 5 minutes.15,19,20 There
was only a modest increase in burn wound water content
after the first hour in nonresuscitated animals. In resus­
citated animals or animals with small wounds, adequate
tissue perfusion continues to “feed” the edema for several
hours. Demling et al.16 used dichromatic absorptiometry
to measure edema development during the first week after
an experimental partial-thickness burn injury on one hind
limb in sheep. Although edema formation was rapid, with
more than 50% occurring in the first hour, maximum
water content was not present until 12–24 hours after
burn injury. The mass of the burned tissue is significantly
less than that of the remainder of the body. As such most
fluid shifts likely occur from the blood into the unburned
tissue due to the humoral actions of inflammatory
mediators causing endothelial activation and glycocalyx
injury.
Normal Microcirculatory
Fluid Exchange
An understanding of the physiologic mechanisms of the
rapid formation of burn edema requires an understanding
of the mechanisms of microvascular fluid balance. Under
physiologic steady-state conditions blood pressure in capil­
laries causes filtration of fluid into the interstitial space. The
bulk of the filtrate is removed from the interstitial space by
lymphatic drainage.21–23 Fluid transport across the micro­
circulatory wall in normal and pathological states has been
described by the original “classic” Starling equation that did
not include the glycocalyx:
J
K
P
P
v
f
c
if
p
if
=
−
−
−
[(
)
(
)]
σ π
π
Starling sought to explain the interaction of physical
forces that govern fluid transfer between intravascular and
extravascular compartments. Jv is the flux (flow rate) of
fluid that crosses the microvasculature barrier. Kf is the cap­
illary filtration coefficient, which is the product of the
surface area and hydraulic conductivity (water permeabil­
ity) of the capillary wall; Pc is the capillary hydrostatic pres­
sure; Pif is the interstitial fluid hydrostatic pressure; πp is the
colloid osmotic pressure of plasma; πif is the colloid osmotic
pressure of interstitial fluid; σ is the osmotic reflection coef­
ficient. Edema occurs when the lymphatic drainage rate (JL)
does not keep pace with the increased Jv (Fig. 8.1). Fig. 8.1
shows the key structures and microvascular forces of the
classic Starling equation.
There is now evidence that suggests the plasma colloid
osmotic pressure does not exert its full effect at the capillary
wall because of a protective barrier that excludes protein:
the glycocalyx on the luminal endothelium.24–26 The effec­
tive colloid osmotic absorptive force is generated by the gra­
dient across the glycocalyx. However the role of the
glycocalyx in burns is largely unexplored. It remains useful
Hydrostatic
pressure
Interstitial fluid
pressure
Interstitial fluid
colloid osmotic
pressure
Net capillary
filtration
Plasma colloid
osmotic pressure
Capillary
Glycocalyx
Proteoglycan
Lymph flow
Cell–collagen
attachment
integrin 21
Collagen
bundles
Hyaluronan
COPif
COPc
Pif
Kf, 
Jv
Pc
Fig. 8.1  The classic Starling equation and microvascular forces.

8  •  Pathophysiology of Burn Shock and Burn Edema
68
and venous pressures decrease. However in studies using
the vascular occlusion technique in the scalded hindlimb of
dogs, Pc doubled from approximately 25 mm Hg to approxi­
mately 50 mm Hg during the first 30 minutes after burn
injury and slowly returned to baseline over 3 hours.28
INTERSTITIAL HYDROSTATIC PRESSURE (Pif)
Burned tissue has been demonstrated to have a significantly
decreased interstitial hydrostatic pressure. Using micropi­
pettes and a tissue oncometer, Lund29 reported that dermal
Pif was rapidly reduced from its normal value of −1 mm Hg
to less than −100 mm Hg in isolated nonperfused samples
of skin. This large negative interstitial hydrostatic pressure
constitutes a powerful “suction force” or imbibition pres­
sure promoting microvascular fluid filtration and sustained
burn wound edema. In vivo measurements show a tempo­
rary reduction of −20 to −30 mmHg; the less negative Pif in
vivo is due to the continued tissue perfusion and fluid
extravasation that relieves the imbibition pressure. Kinsky30
reported a continued negative pressure providing a partial
explanation for the sustained edema during the first 4 hours
post injury.
The mechanism for the large decrease in Pif is due, at least
in part, to the release of cellular tension exerted on the col­
lagen and microfibril networks in the connective tissue via
the collagen-binding β1-integrins. This tends to expand the
interstitial space and induces the imbibition pressure. The
integrins are transmembrane adhesion receptors that
mediate cell–cell and cell–matrix adhesion, thereby allow­
ing the glycosaminoglycan ground substance, which is nor­
mally underhydrated, to expand and take up fluid.31 McGee
et al. confirmed this hydration potential with T2-weighted
MRI32 and noted that it is reversible by application of nega­
tive pressure treatment. This supports the mechanism of
interfascial rather than colloidal osmotic fluid transfer as a
mechanism for burn edema and supports the collagen
structural transitions as therapeutic targets.33
OSMOTIC REFLECTION COEFFICIENT (σ)
The osmotic reflection coefficient is an index of the propor­
tion of the full osmotic pressure generated by the concen­
tration gradient of plasma proteins across the microvascular
blood-to-tissue barrier. A value of σ = 1.0 represents a
barrier impermeable to protein but permeable to water and
σ = 0 represents a barrier that is completely permeable to
to review each term of the classic Starling equation and its
role in burn edema before addressing the possible the impli­
cations of a modified Starling equation.
Mechanisms of Burn Edema
Transvascular blood-to-tissue transport of fluid and protein
increase with elevation in Kf, Pc, or πif, and with decreases
in Pif, or σ. Burn edema is unique in its rapidity compared
to other types of edema because it is only in burn edema
that all of these variables change significantly in the direc­
tion required to increase fluid filtration. Each Starling vari­
able is discussed individually next.
CAPILLARY FILTRATION COEFFICIENT (Kf)
Burn injury causes direct and indirect mediator-modulated
changes in the permeability of the blood–tissue barrier of
the capillaries and venules. Arturson and Mellander27
showed that, in the scalded hindlimb of dogs, Kf immedi­
ately increased two to three times, suggesting that the
hydraulic conductivity (water permeability) of the capillary
wall increased. Kf is a function of both hydraulic conductiv­
ity and the capillary surface area. Thus local vasodilation
and microvascular recruitment contribute to the increased
Kf in addition to increased hydraulic conductivity. Measur­
ing Kf and the rate of edema formation (Jv) allowed Artur­
son and Mellander to determine the changes in transcapillary
forces necessary to account for the increased capillary filtra­
tion. Their calculations indicated that a transcapillary pres­
sure gradient of 100–250 mm Hg was required to explain
the extremely rapid edema formation that occurred in the
first 10 minutes after a scald injury. They concluded that
only a small fraction of the early formation of burn edema
could be attributed to the changes in Kf and permeability.
They further suggested that osmotically active molecules
generating sufficiently large osmotic reabsorption pressures
are released from burn-damaged cells. This hypothesis was
never confirmed, and subsequent studies described herein
show that large increases in filtration forces result from an
increased Pc, and from a large decrease in Pif (Table 8.1).
CAPILLARY PRESSURE (Pc)
In most forms of shock, arteriolar vasoconstriction results in
transfer of less arterial pressure to the capillaries; capillary
Table 8.1  Effect of Burn Injury on Changes in the Classic Starling Equation Variables
Variable
Normal or Baseline
Post-Burn
Δ
References
Pc
~25 mm Hg
~50 mm Hg
↑ ~25 mm Hg
28
ΠP
25–30 mm Hg
15 to 18 mm Hg
↓ ~10 mm Hg
22, 36, 37
Pif
−2 to 0 mm Hg
~100 mm Hg non-resuscitated
non-perfused skin and −5 mm Hg perfused skin
↓ ~100 mm Hg
↓ 3–5 mm Hg
29, 30
Πif
10–15 mm Hg
13–18 mm Hg in burn wound
↓ and with resuscitation hypoproteinemia in unburned skin
↑ ~3 mm Hg
22, 35, 37
σ
~0.9
~0.5
↓ ~0.4
22, 28, 34, 35
Kf
~0.003 mL/min/mm Hg/100 g (leg)
↑ 2–5×
27

8  •  Pathophysiology of Burn Shock and Burn Edema
69
of plasma despite an increased permeability. The osmotic
reflection coefficient, σ, decreases with burns but never
equals zero; thus protein concentration in capillary filtrate
is always less than in plasma even in burn-injured skin.35
Compared to unburned skin, the πi remains significantly
higher in the burn wound, supporting the view that sus­
tained increases in protein permeability contribute to the
persistence of burn edema.13,22,30 However, compared with
the large changes in Pc and particularly Pif, increased micro­
vascular protein permeability is not the predominant mech­
anism for the early, rapid rate of edema formation in injured
skin.43
ENDOTHELIAL DYSFUNCTION AND THE
GLYCOCALYX
Demling and colleagues44,45 suggested that the edema
caused by burns and hypoproteinemia alone could be par­
tially attributed to alterations in the structure of intersti­
tium increasing water transport and hydraulic conductivity
across the entire blood–tissue–lymph barrier. Similar
changes occur when hypoproteinemia is induced by plas­
mapheresis. Several clinical and animal studies have estab­
lished that maintaining higher levels of total plasma protein
concentration can ameliorate the overall net fluid retention
and edema.6,46,47 Endothelial activation and endothelial
dysfunction play a major role in burn edema and the resul­
tant distributive shock, particularly as it pertains to edema
remote from the area of direct thermal trauma. Turk et al.
prospectively investigated the endothelial dysfunction asso­
ciated with burn injury in a cohort of burned patients in
which they demonstrated an in vivo alteration of flow-
mediated dilation reaching a nadir on post burn day 7.
These clinical data support experimental findings on endo­
thelial dysfunction after burn injury.48 The value of colloid
osmotic pressure under the glycocalyx (πg) before or after
burn injury has not been measured.
Plasma is further diluted and πp is further reduced after
crystalloid resuscitation. Increased fluid filtration is less due
to the fall in πp and more likely attributed to increased Kf
and reductions in Pif and σ due to a damaged glycocalyx.
Many of these changes in endothelial and interstitial
function can be attributed to the glycocalyx—a glycopro­
tein and polysaccharides layer on the luminal side of endo­
thelial cells that maintains the barrier between the
endothelium and plasma by reducing the osmotic gradient
and thereby reducing filtration. The thickness of the glyco­
calyx varies from 20 nm in capillaries to 3000 nm in larger
vessels. Based on studies of the glycocalyx, the paradigm of
the classic Starling equation of microcirculatory forces has
been challenged, and a revised equation has been proposed.
Levick and Michel, along with others, proposed the revised
Starling equation shown here and in Fig. 8.2:25,49–51
Jv
K
P
P
f
c
if
=
−
−
−
[(
)
(
)]
σ π
π
p
g
In the revised Starling equation the fluid flux across the
blood–tissue barrier is driven primarily by differences in
hydrostatic pressures, (Pc − Pif) and by a colloid osmotic
gradient between the fluid in the glycocalyx and just below
the glycocalyx (πp − πg). Further studies by Kozar et al.52
have demonstrated that crystalloid resuscitation of hemor­
rhagic shock in rats causes a loss of glycocalyx that can be
protein and water. The reflection coefficient is traditionally
attributed to the endothelial cellular junctions but may well
be primarily determined by the glycocalyx. In skin, the
normal σ of albumin is reported to be 0.85–0.99.22,34
Thermal injury causes an increase in capillary permeability
to protein, resulting in a reduced σ, an effective reduction
in the absorptive oncotic gradient across the microvascular
barrier, and a resulting increase in net fluid filtration.
Lymph sampled from burned skin has shown elevated
protein concentrations consistent with the large and sus­
tained increases in capillary permeability,14,34,35 whereas a
transient and smaller increase in microvascular permeabil­
ity occurs over 8–12 hours following injury in other soft
tissue not directly burned.35 Pitt et al.28 estimated the σ for
skin from dog hindpaw using a lymph wash-down tech­
nique and reported a normal σ of 0.87 for albumin and a
reduction to 0.45 after scald injury.
PLASMA COLLOID OSMOTIC PRESSURE (πp)
The normal plasma protein concentration of 6–8 g/dL and
its associated πp of 25–30 mm Hg, would produce a signifi­
cant transcapillary absorptive force counterbalancing the
other Starling forces that favor filtration.13,22 However, the
glycocalyx blocks most of the impact of πp on transendothe­
lial fluid movement,24–26 as described later. Plasma colloid
osmotic pressure decreases in nonresuscitated burn-injured
animals as protein-rich fluid extravasates into burn wounds
and a significant volume of protein-poor interstitial fluid
initially enters the circulation from transvascular reabsorp­
tion and lymph of unburned tissue, such as skeletal
muscle.13,36–38 Plasma is further diluted and πp is further
reduced after crystalloid resuscitation. Increased fluid filtra­
tion is less due to the fall in πp and more likely attributed to
increased Kf, reductions in Pif and σ due to a damaged gly­
cocalyx. Initial therapy with colloid solution has always
been advocated by some clinicians6 but is often delayed
8–24 hours after injury based on the reasoning that nor­
malization of microvascular protein permeability in injured
tissue must occur before colloid therapy is cost effective.7
However, the ability of plasma protein and, in particular,
albumin to repair the permeability of the glycocalyx sug­
gests a rationale for the earlier use of albumin therapy for
burn resuscitation. Evidence for the use of albumin for
resuscitation is also covered in Chapter 9 on burn
resuscitation.39–41 Animal studies have shown that albumin
use during burn resuscitation does not reduce the edema in
the tissue of burn wounds, but it does reduce total fluid
needs and thus reduces edema in unburned tissues.42 Fur­
thermore, as discussed later, albumin can have a trophic
effect on the endovascular glycocalyx, acting to stabilize it.
INTERSTITIAL COLLOID OSMOTIC
PRESSURE (πif)
The πif in skin is normally 10–15 mm Hg or about one-half
that of plasma.13,22 Experimental studies in animals using
lymph as representative of interstitial fluid suggest that the
colloid osmotic pressure in lymph from burned skin initially
increases 4–8 mm Hg after burn injury.35 With crystalloid
resuscitation, πp and πif decrease because the protein con­
centration of microvascular filtrate remains less than that

8  •  Pathophysiology of Burn Shock and Burn Edema
70
microvascular permeability of the lung (lymph from caudal
mediastinal node) showed no increase. Maximum increased
lymph flow and tissue water content were observed to cor­
relate with the severe hypoproteinemia that occurred
during the early resuscitation period of a 40% burn injury
in sheep.7,54
The mechanism by which burn injury induces microvas­
cular hyperpermeability remote from the injury has been
the subject of extensive study utilizing plasma from burned
animals transfused into unburned recipients by Kremer et
al.55 These transfusions cause endothelial activation,
albumin leakage, and leukocyte adhesion and rolling via an
undefined transfused circulating factor. This model allows
testing of the effects of various inhibitory and therapeutic
agents in ameliorating the resultant physiologic derange­
ments. High-dose vitamin C, an antioxidant, administered
to the recipient rat was found to significantly reduce capil­
lary leakage but not leukocyte-endothelial interactions.55,56
Ketanserin, a 5-HT2a antagonist, reduced plasma extravasa­
tion and leukocyte-endothelial interactions after burn
plasma transfer.57 These findings were further confirmed
with the serotoninergic receptor-blocking agents cinanse­
rin and methysergide.58,59 When the burn wounds of donor
burned rats were bathed in cerium nitrate, a topical antimi­
crobial and putative anti-inflammatory agent, the resulting
plasma no longer induced injury in transfused rats.60 In
further burn plasma transfer studies Hernekamp et al.61,62
also demonstrated that the cholinergic anti-inflammatory
pathway stimulated by cbp-choline or pretreatment with
physostigmine can similarly attenuate albumin efflux and
leukocyte adhesions.
Altered Cellular Membranes and
Cellular Edema
In addition to a loss of microvascular barrier integrity,
thermal injury also causes changes in the cellular mem­
brane. In skeletal muscle cellular transmembrane poten­
tials decrease at sites distant from the injury.9 It would be
expected that the directly injured cell would have a damaged
cell membrane thus increasing sodium and potassium
fluxes and resulting in cellular swelling. However this
process also occurs in cells that are not directly heat-injured.
Micropuncture techniques in hemorrhaged animals have
demonstrated partial depolarization in the skeletal muscle
membrane potential of −90 mV to levels of −70 to −80 mV;
cell death occurs at −60 mV. These shock-induced decreases
in membrane potentials are associated with increases in
intracellular water and sodium.63–65 Similar alterations in
skeletal membrane functions and cellular edema have been
reported in hemorrhagic shock63,65 and in cardiac, liver, and
endothelial cells.66–68 Action potentials become dampened
or nonexistent, with likely delays in signal propagation in
nerves, brain, skeletal muscle, heart, diaphragm, and
gastrointestinal organs. Encephalopathy, muscle weakness,
impaired cardiac contractility, and gut dysfunction are
associated with major burn injury and may be due in part
to reduced membrane potentials.
Early investigators of this phenomenon postulated that a
decrease in adenosine triphosphate (ATP) levels or ATPase
activity was the mechanism for membrane depolarization.
largely prevented by plasma resuscitation. Fig. 8.3 shows a
photomicrograph of the glycocalyx.
Unburned Tissue
Generalized edema in soft tissues not directly injured is
another characteristic of large cutaneous burns. Brouhard
et al.53 reported increased water content in unburned skin
even after a 10% total body surface area (TBSA) burn, with
the peak edema occurring 12 hours postburn. Arturson
reported an increased transvascular fluid flux (lymph flow)
from unburned tissue and a transient increase in permea­
bility as measured by an increase in the lymph concentra­
tion of plasma protein and macromolecular dextran infused
as a tracer.14,34 Harms et al.35 extended these findings by
measuring changes in lymph flow and protein transport in
noninjured soft tissue for 3 days after injury. They found
that skin and muscle permeability (flank lymph from sheep)
were elevated for up to 12 hours postburn for molecules the
size of albumin and immunoglobulin G, but the
Plasma
Pc
p
Pi
i
g
Glycocalyx
network
Endothelial
cells
Subglycocalyx space
Intercellular cleft
Interstitial
fluid
Plasma
ultrafiltration
rate Jv
Fig. 8.2  The forces of the New Starling Equation taking into account
the role of the glycocalyx.
Fig. 8.3  A healthy vascular endothelium showing the fuzz-like coat of
transmembrane and membrane bound molecules of the glycocalyx.

8  •  Pathophysiology of Burn Shock and Burn Edema
71
stabilizers when tested in animal models.74 Friedl et al.42
demonstrated that the pathogenesis of burn edema in the
skin of rats appears to be related to the interaction of his­
tamine with xanthine oxidase and oxygen radicals. Hista­
mine and its metabolic derivatives increased the catalytic
activity of xanthine oxidase in rat plasma and in rat pulmo­
nary artery endothelial cells.76 In thermally injured rats,
levels of plasma histamine and xanthine oxidase rose in
parallel, in association with the increase in uric acid. Burn
edema was greatly attenuated by treating rats with the
mast cell stabilizer cromolyn, complement depletion, or the
H2 receptor antagonist cimetidine but was unaffected by
neutrophil depletion.76–78 Despite encouraging results in
animals, beneficial antihistamine treatment of human
burn injury has not been demonstrated.
PROSTAGLANDINS
Prostaglandins are potent vasoactive autocoids synthesized
from the arachidonic acid released from burned tissue and
inflammatory cells, and they contribute to the inflamma­
tory response following burn injury.79,80 Activated macro­
phages and neutrophils infiltrate the wound and release
prostaglandin as well as thromboxanes, leukotrienes, and
interleukin-1 (IL-1). These wound mediators have both
local and systemic effects. Prostaglandin E2 (PGE2) and leu­
kotrienes LB4 and LD4 increase microvascular permeability
both directly and indirectly.81 Prostacyclin (PGI2) is pro­
duced in burn injury and is also a vasodilator, and it may
cause direct increases in capillary permeability. PGE2
appears to be one of the more potent inflammatory prosta­
glandins, causing postburn vasodilation and increased
microvascular surface area in wounds that, when coupled
with the increased microvascular permeability, amplifies
edema formation.82,83 Prostacyclin (PGI2) is a vasodilator
and may cause increases in capillary permeability.
THROMBOXANE
Thromboxane A2 (TXA2) and its metabolite, thromboxane
B2 (TXB2) are produced locally in burn wounds by plate­
lets.74 Vasoconstrictor thromboxanes may be less important
in edema formation; however by reducing blood flow they
can contribute to a growing zone of ischemia under the
burn wound and may be responsible in part for the conver­
sion of a partial-thickness wound to a deeper, full-thickness
wound. The serum level of TXA and TXA2/PGI2 ratios are
significantly increased in burn patients.84 Heggers showed
that TXB2 is released at the burn wound and is associated
with local tissue ischemia, while thromboxane inhibitors
prevented the progressive dermal ischemia associated with
thermal injury and thromboxane release.85,86 The TXA2
synthesis inhibitor anisodamine also showed beneficial
microcirculatory effects by restoring the hemodynamic and
rheological disturbances toward normal. LaLonde83 showed
that topically applied ibuprofen (which inhibits the syn­
thesis of prostaglandins and thromboxanes) reduces both
local edema and prostanoid production in burned tissue
without altering systemic production. On the other hand,
systemic administration of ibuprofen did not modify early
edema, but did attenuate the postburn vasoconstriction
that impaired adequate oxygen delivery to tissue in burned
However more recent research suggests that it may result
from an increased sodium conductance in membranes or
that an increase in sodium–hydrogen antiporter activity is
the primary mechanism.64,67 Resuscitation of hemorrhage
rapidly restores depolarized membrane potentials to normal,
but resuscitation of burn injury only partially restores the
membrane potential and intracellular sodium concentra­
tions to normal levels, demonstrating that hypovolemia
alone is not totally responsible for the cellular swelling seen
in burn shock.69 A circulating shock factor(s) is likely to be
responsible for the membrane depolarization.70–72 When
plasma from a burn-injured animal is superfused to an iso­
lated muscle preparation, membrane depolarization occurs.
Furthermore, the depolarization can be reversed by chang­
ing the superfusate to normal plasma or saline.69 Surpris­
ingly the molecular characterization of such circulating
factors has not been elucidated, suggesting that they have
a complex and perhaps dynamic structure. Data suggest a
large molecular weight, greater than 80 kDa.73 Membrane
depolarization may be caused by different factors in differ­
ent states of shock. Very little is known about the time
course of the changes in membrane potential in clinical
burns. Furthermore, we do not know the extent to which
the altered membrane potentials affect total volume require­
ments and organ function in burn injury.
Inflammatory Mediators of
Burn Injury
Many local and circulating mediators are produced in the
blood or released by cells after thermal injury. These media­
tors play important but complex roles in the pathogenesis
of edema and the cardiovascular abnormalities of burn
injury. For example, mediators alter vascular permeability
and transvascular fluid flux, either directly or indirectly, by
increasing the microvascular hydrostatic pressure and
surface area via the arteriolar vasodilation superimposed
on an already injured endothelial barrier. The exact
mechanism(s) of mediator-induced injury are of consider­
able clinical interest because this understanding would
allow for the development of pharmacologic modulation of
burn edema and shock by mediator inhibition. Unfortu­
nately most strategies directed at mediator blockage have
only been effective in small localized burn wounds in
patients or in animal studies and have had no clinical
impact on the care of patients with major burns.
HISTAMINE
Histamine is a key mediator of very early increases in micro­
vascular permeability following thermal injury. Histamine
is released from mast cells in thermally injured skin; however
the increase in histamine levels and its actions are only
transient. Histamine causes large endothelial gaps to tran­
siently form as a result of the contraction of venular endo­
thelial cells.74,75 Histamine is released from mast cells in
thermally injured skin; however the increase in histamine
levels and its actions are only transient. Histamine also can
cause the rise in capillary pressure (Pc) by arteriolar dilation
and venular contraction. Reductions in localized edema
have been achieved with histamine blockers and mast cell

8  •  Pathophysiology of Burn Shock and Burn Edema
72
SEROTONIN
Serotonin is released early after burn injury.92 This agent is
a smooth-muscle constrictor of large blood vessels. Antise­
rotonin agents such as ketanserin have been found to
reduce peripheral vascular resistance after burn injury but
not to reduce edema.92 On the other hand, pretreatment
with methysergide, a serotonin antagonist, reduces hyper­
emic or increased blood flow response in the burn wounds
of rabbits and reduces burn edema.90 Ferrara et al.93 found
a dose-dependent reduction in burn edema when methyser­
gide was given to dogs prior to burn injury but claimed that
this was not attributable to blunting of the regional vasodi­
lation response. Zhang et al. reported a reduction in skin
blood flow after methysergide administration to burned
rabbits.94
CATECHOLAMINES
Circulating catecholamines epinephrine and norepineph­
rine are increased several fold after burn injury.6,95,96 On
the arteriolar side of the microvessels these agents cause
sheep.87 Although cyclooxygenase inhibitors have been
used after burn injury, they have not entered into routine
clinical use.
KININS
Bradykinin is a local mediator of inflammation that increases
venular permeability. It is likely that bradykinin production
is increased after burn injury, but its detection in blood or
lymph can be difficult because of the simultaneous increase
in kininase activity and the rapid inactivation of free kinins.
The generalized inflammatory response after burn injury
favors the release of bradykinin.88 Pretreatment of burn-
injured animals with aprotinin, a general protease inhibi­
tor, should have decreased the release of free kinin, but no
effect on edema was noted.89 On the other hand, pretreat­
ment with a specific bradykinin receptor antagonist was
reported to reduce edema in burn wounds in rabbits (Table
8.2).90 Tao et al. demonstrated that blocking neurokinin-1
decreased the vascular permeability tissue around the
wound and remotely in the jejunum of burned rats and
that treated rats recovered more quickly than controls.91
Table 8.2  Cardiovascular and Inflammatory Mediators of Burn Shock
Mediators
Central Cardiovascular Effects
(at High Concentrations)
Load Tissue Effects
References
Histamine
↓ Blood pressure; hypovolemia
Arteriolar dilation; Venular constriction
↑ Blood flow
↑ Permeability
42, 74, 76, 77, 92, 160
Prostaglandin E2 (PGE2)
↓ Systemic arterial and pulmonary
arterial blood pressure
Vasodilation
↑ Blood flow
↑ Permeability
74, 79, 85
Prostacyclin (PG12)
↓ Blood pressure
↑ Permeability
81, 83
Leukotrienes
  LB4
  LD4
Pulmonary hypertension
74
Thromboxane A2 (TXA2)
Thromboxane B2 (TXB2)
GI ischemia
Pulmonary hypertension
Vasodilation
↑ Blood flow
↑ Permeability
84–87
Bradykinin
↓ Blood pressure
Hypovolemia
Vasodilation, ↑ Permeability
74, 160
Serotonin
↑ Permeability
92–94
Catecholamines
  Epinephrine
  Norepinephrine
↑ Heart rate
↑ Blood pressure
↑ Metabolism
Vasoconstriction (receptors); Vasodilation (β2
receptors in muscle); block ↑ permeability due to
histamine & bradykinin via β receptors
74, 161
Oxygen radicals:
  Superoxide
  Anion (O2
−)
  Hydrogen peroxide
(H2O2)
  Hydroxyl Ion (OH−)
  Peroxynitrite (ONOO−)
Cardiac dysfunction
Tissue damage
↑ Permeability
42, 74, 76, 97, 99, 100
Platelet aggregation factor
↑ Blood pressure
Vasoconstriction
89, 113
Angiotensin II
GI ischemia
↑ Blood pressure
Vasoconstriction
114, 115, 117
Vasopressin
GI ischemia
↑ Blood pressure
Vasoconstriction
117
Enhanced microvascular blood flow typically opens recruits capillaries and increases surface area of exchange vessels.
Permeability refers to protein permeability of the microvascular barrier, which is often linked to hydraulic conductivity.