Điều Trị Bỏng Toàn Diện (Bản Expert Consult)

Reconstruction of burn deformities of the lower extremity
681
Figure 59.9  (a) A large wound resulted from electrical injuries. (b,c) A large piece of soft tissue was harvested from the anterior thigh area, i.e. an
anterolateral thigh flap, and transferred via microsurgical means to cover the wound. (d) Although the wound was covered, additional revision will be
needed to debulk the excess tissues.
A
B
C
D

Total Burn Care
59
682
the foot but also the tissue adjacent, thus negating the pos­
sibility of using the tissues from the area as a flap donor site.
A composite tissue transfer via a microsurgical technique,
though clinically appealing, may not be feasible because of
lack of suitable donor sites.12,13 In contrast, a local flap tech­
nique, i.e. a rotational flap technique and/or an interposi­
tional flap technique, has a logistical advantage over other
techniques. However, a flap fabricated in the leg, especially
in the area below the knee, can be plagued with problems
of flap necrosis attributable to disruption of the vascular
supplies to the skin with flap dissection. Techniques utilizing
a musculocutaneous (MC) flap, a perforator flap or reverse
flow skin flap, advocated more recently14–16 appeared to have
technical advantages over a random skin flap. The tissue
mobilized, however, is generally speaking bulky for the
wound coverage, and excursion of the flap may be limited.
A random fasciocutaneous flap and a random paratenon
cutaneous flap, a composite skin flap that includes the
underlying fascia and/or paratenon, appeared to circumvent
the anatomical limitation of flap fabrication. The skin in
almost any location in the foot and in the lower leg can be
used for designing a skin flap for wound coverage. As we
have noted, the use of this technique is possible in a scarred
area unless the underlying fascia and/or paratenon has been
destroyed.
Summary
Although the task of reconstructing foot and ankle deformi­
ties is difficult, the basic technique of incisional release with
skin graft may be useful. On the other hand, the use of a
local rotational skin flap technique, alias 34 z-plasty, is pre­
ferred, especially in instances where a flap is needed to cover
a wound with exposed tendon and joint structure. The viabil­
ity of skin flap is enhanced by including the fascia and/or
paratenon in flap design.
Further reading
Dhanraj P, Faro O, Phillips LG, et al. Burn scar contractures of the
feet: efficacy of bilateral simultaneous surgical correction. Burns.
2002;8:814-819.
Esselman PC, Thombs BD, Magyar-Russell G, et al. Burn
rehabilitation, state of the science. Am J Med Rehabil 2006;85(4):
383-413.
Feng CH, Yang JY, Chuang SS, et al. Free medial thigh perforator flap
for reconstruction of the dynamic and static complex burn scar
contracture. Burns. 2010;36(4):565-571.
Kuo YJ. Versatility of the free anterolateral thigh flap for
reconstruction of soft tissue defects: Review of 140 cases. Ann Plast
Surg. 2002;48(2):161-166.
Serhgiou MA, Evans EB, Ott S, et al. Comprehensive rehabilitation
of the burned patient. In: Herndon D, Serhgiou MA, Evans EB,
et al., eds. Total burn care. 2nd ed. Philadelphia: WB Saunders;
2002:Ch. 45.
and the postoperative rehabilitative therapy.5 The outcome
of toe-release, for instance, is affected by a treatment that
requires the use of pressure garment and shoe inserts for a
minimum of 6 months. Recurrence of toe deformity could
be drastically reduced by using the Otoform insert as a meta­
tarsal bar for a minimum of 2 months. The modification is
instituted once the positioning K-wires are removed from
the toes.
Other post-surgical care regimens must include a physical
therapy treatment plan with a treatment duration varying
according to the magnitude of injury and the limb deformi­
ties6 and executed under the supervision of trained staff.7
Comments
The task of managing knee, ankle and foot deformities con­
sequent to burn injuries can be difficult. Initially, a physical
therapist is given the task of providing care to regain muscle
strength and joint mobility.8 Attainable therapeutic goals
with physical therapy may be curtailed in individuals with
permanent structural destruction of the foot and ankle
joints. That is, the foot and ankle will remain stiff and
walking will be difficult regardless of the intensity and the
duration of therapy rendered. It is therefore, essential for a
surgeon’s continuous involvement in the care of patients.
Scar contracture is the most common cause of flexion
contraction, stiff foot and ankle joints and in some instances
various talipes-like deformities. Surgical release of contracted
scar around the joint is the most fundamental and the most
common approach used to restore the mobility of the joints.
In practice, maintaining a proper joint alignment is difficult
even though the release of scar tissues around the joint
structures is complete. The difficulty in restoring joint align­
ment could be due to structural alterations in the joint
capsule because of burn injuries and/or protracted abnormal
joint positioning. Release of ligamentous structures sur­
rounding the joint, however, is seldom needed. Instead,
joint alignment can be easily maintained with the use
of Kirschner’s wires of 0.025–0.035 inch in size inserted
percutaneously to ‘re-shape’ altered capsular elements.
Skin grafting is the technique most commonly used to
cover an open wound resulting from scar release or joint
realignment. The usefulness may be compromised if the
wound is located in a pressure bearing area of the foot, i.e.
the sole of the foot. Incomplete or inadequate graft sensory
re-innervation in a pressure-bearing area can lead to break­
down of the graft. Although various techniques to resurface
burned sole have been advocated,9–11 usefulness in burned
foot reconstruction is limited. Similarly, the skin materials
suitable for covering an exposed tendon and joint structure
must have the components of subcutaneous fatty tissues. A
skin flap with assured vascular supplies that can be mobi­
lized from an adjacent area will be an ideal approach for
wound coverage. In practice, burns would damage not only
 
Access the complete reference list online at

Reconstruction of burn deformities of the lower extremity
682.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Kuo YJ. Versatility of the free anterolateral thigh flap for
reconstruction of soft tissue defects: Review of 140 cases.
Ann Plast Surg. 2002;48(2):161-166.
2. Mardini S, Tsai FC, Yang JY. Double free flaps harvested from one
or two donor sites for one or two-staged burn reconstruction:
models of sequential-link and independent-link
microanastomoses. Burns. 2004;30:729-738.
3. Feng CH, Yang JY, Chuang SS, et al. Free medial thigh perforator
flap for reconstruction of the dynamic and static complex burn
scar contracture. Burns. 2010;36(4):565-571.
4. Dhanraj P, Faro O, Phillips LG, et al. Burn scar contractures of the
feet: efficacy of bilateral simultaneous surgical correction. Burns.
2002;8:814-819.
5. Dougherty WR, Coleman JJ III, Sood R. Reconstruction of burns
of the lower extremity. In: Sood R, ed. Achauer and Sood’s burn
surgery: Reconstruction and rehabilitation. Philadelphia: WB
Saunders; 2006:324-337.
6. Esselman PC, Thombs BD, Magyar-Russell G, et al. Burn
rehabilitation, state of the science. Am J Med Rehabil.
2006;85(4):383-413.
7. Achauer BM, Vanderkam VM. Burn reconstruction. In: Achauer
BM, ed. Plastic surgery: indications, operations and outcomes. Vol I.
St. Louis, MO: Mosby; 2000:425-446.
8. Serhgiou MA, Evans EB, Ott S, et al. Comprehensive
rehabilitation of the burned patient. In: Herndon D, Serhgiou
MA, Evans EB, et al., eds. Total burn care. 2nd ed. Philadelphia:
WB Saunders; 2002:Ch. 45.
9. Dahl TD, LeMaster JE, Cram AE. Effectiveness of split thickness
skin grafts of plantar aspect of the feet. J Burn Care Rehabil.
1984;5:463
10. Rooks MD. Coverage problems of the feet and ankle. Orth Clin
North Am. 1989;20:723.
11. Barclay TL, Sharp DT, Chisholm EM. Cross-leg fasciocutaneous
flaps. Plast Reconstr Surg. 1983;72:843.
12. May JW, Gatello GG, Lukash FN. Microvascular transfer of free
tissue for closure of burn wounds of the distal lower extremity.
N Eng J Med. 1982;306:253.
13. Hallock GG. Simultaneous bilateral foot reconstruction using a
single radial forearm flap. Plast Reconstr Surg. 1987;80:836.
14. Reiffel RS, McCarthy JG. Coverage of heel and sole defects:
a new subfascial arterialized flap. Plast Reconstr Surg. 1981;
66:250.
15. Land A, Soragni O, Monteleone M. The extensor digitorum
brevis muscle island flap for soft tissue loss around the ankle.
Plast Reconstr Surg. 1985;75:892.
16. Hong G, Steffens K, Wang FB. Reconstruction of the lower leg and
foot with the reverse pedicled posterior tibial fasciocutaneous
flap. Br J Plast Surg. 1989;42:512.

©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00060-6
The ethical dimension of burn care
Arthur P. Sanford
Introduction
In seeking optimum health for each patient, contemporary
burn care aspires to integrated excellence in multiple dimen­
sions. It is a ‘bio-psycho-social-economic-legal-and-ethical’
enterprise, and the many hyphens indicate that all the
dimensions of care are connected. Too often, the bio-psycho-
social-etc. dimensions are assumed to be interconnected like
railway cars with the biological dimension in front, and the
ethical hooked on only if necessary at the end, like an
optional caboose. This is a misleading assumption.
Optimal burn care is most frequently achieved when it is
assumed that all the dimensions of burn care are always
present and in need of regular attention. Moreover, highly
integrated, team-oriented, interdisciplinary1 burn centers
practice as if all the dimensions of care are always interpen­
etrating, just like the length, width and height of a solid
object. In their daily work, they assume that no one dimen­
sion may be changed without affecting all the others, and
they depend on frequent detailed rounds, interdisciplinary
staff meetings, and ongoing interviews with patients and
families to keep all the dimensions of care coordinated and
up-to-date.
In part because the multiple dimensions of burn care are
so intimately interrelated, decisions involving the ethical
dimension of burn care are extremely common. They are so
common, in fact, that care-providers are usually unaware of
them. Ethics, after all, is critical thinking about right and
wrong, what should or should not be done, etc.2 The words
‘should,’ ‘should not’ and similar words, indicate that ethical
matters are being addressed. For example, whenever we
decide which of several therapeutic alternatives should be
recommended, we are making an ethical decision.3 Should
we spend more time with patient A than with patient B?
Should we catch up on our journal reading as opposed to
getting more sleep? Should we spend more time with our
families and less at work? All are ethical decisions. Ethical
decision-making is therefore like breathing:4 something we
do without even thinking, unless the problem is serious
enough to be singled out for explicit attention.
What is ‘an ethical problem?’
An ethical problem is present when it involves a conflict of
two or more of the following: rights or rights-claims, obliga­
tions, goods and/or values.5 For example, disputes about
writing a ‘comfort-measures-only’ order for a patient without
decision-making capacity and with a very low probability of
survival commonly involve a conflict between a obligation
and a good: the obligation not to abandon aggressive therapy
prematurely, and the good of a maximally pain-free and
unprotracted death. In this case, the burn team and the
patient/surrogate are ordinarily the major stakeholders and
appropriate decision-makers, and they are addressing a
problem in clinical ethics. On the other hand, consider the
burn center’s or healthcare organization’s (HCO’s) responsi­
bility to ICU patients when a safe nurse-to-patient ratio
cannot be consistently met, despite the burn center’s best
efforts? If discerning what should be done in such circum­
stances requires decision-making at the managerial level of
the burn center or HCO, a problem in organizational ethics6 is
the correct term to use.
As indicated, conflicts among rights, obligations, etc. are
very common and vary greatly in difficulty. When should
they be taken seriously? An ethical problem is serious when
there are stakeholders involved who stand to be seriously
affected by the problem or its outcome. Stakeholders working
collaboratively without outside help can successfully manage
the vast majority of such problems. When are such problems
so serious that assistance should be sought from a healthcare
ethics committee/consultant (HEC) or its equivalent? An
ethical problem is serious enough to refer to an HEC:
1. When you suspect the Smell Test would be positive, i.e.
‘What would the action or situation we are considering
smell like if we read about it in a front page news
article or in a popular blog? Would I be comfortable
explaining it to my spouse, or my grandmother?’ The
problem with this, as the olfactory image reminds us,
is that living with bad smells or unethical conduct for a
long time may dull a person’s ability to notice them.
2. When there is persistent disagreement among the
major stakeholders; and codes, rules, laws and more
discussions fail to lead to a resolution within generally
acceptable ethical boundaries in a reasonable amount
of time.
How should clinical ethics problems
be managed?
In the United States, the informed consent process was
developed by the American judiciary to safeguard the legal
rights and welfare of all the stakeholders participating in
CHAPTER 60 
Access the complete reference list online at

IN THIS CHAPTER
PowerPoint Presentation Online

Total Burn Care
60
684
patient before one can feel 100% comfortable with the
decision and where they are coming from.
2. The care-provider must discover if the patient has
decision-making capacity sufficient to participate
meaningfully in deliberation. To have decision-making
capacity, the patient’s (or if necessary, the patient’s/
surrogate’s) consent to, or refusal of, the care-provider’s
recommendations must be: informed (i.e.
comprehending and appreciating relevant information);
free (substantially free of distorting non-rational/
emotional influences; deliberate (decided after
weighing pros and cons in the light of his/her own
value system); voluntary (reflecting his/her own
intentions); and expressed (communicated verbally or
non-verbally).10 Decision-making capacity is enhanced
by optimizing the patient’s physiological stability,
consciousness and pain control as much as possible. It
is typically verified by ascertaining orientation, and by
asking the patient to rephrase the information provided
to him in his own words and to say why he has made
the decision he has. Determination of decision-making
capacity by judicial process (i.e. determination of legal
competency) is rarely necessary. If despite all efforts,
the patient is found to be without decision-making
capacity, an appropriate surrogate should be sought
among the patient’s family or friends, depending on
local laws to determine priority.
3. The care-provider should provide appropriate
information about the patient’s diagnosis and the
therapy proposed, its nature, prognosis, pros and cons,
and similar information about plausible alternatives
including forgoing the therapy proposed. This should
be continuously updated as the patient’s condition
changes throughout hospitalization. Prior investigation
of the patient’s and/or surrogate’s bio-psycho-social-
economic-cultural-etc. background is particularly
helpful in the effort to assure clear communication and
a common understanding among dialogue partners.
The role of the patient or surrogate
The role of the patient is to assimilate this information given
by the caregivers. One cannot expect an unfamiliar patient
in the middle of an acutely injured situation to understand
or have complete background in understanding what medical
information is being given to them. There are limitations in
their understanding and the assimilation of this information
must be taken into account. Also, the patients have the duty
within their own value system to make a decision with their
own best interest at heart. This includes their aforemen­
tioned religious or non-religious background, their family
and what the needs and wants of their family are. It becomes
an obligation of the patient or their surrogate to become a
member of the team responsible for the individual. This
obligation includes the necessity to reveal information com­
pletely and honestly, to become actively involved in their
care, and participate constructively and sincerely in ethical
dialogue about the issues at hand.
We must also consider previous life experiences. For
example, the patient may have had family members or rela­
tives with severe or terminal illnesses, themselves. Such term­
inal illnesses are going to influence people greatly in not
bedside decision-making. Throughout the USA, this legal
process has become the foundation of the healthcare pro­
vider’s approach to avoiding and managing serious ethical
problems at the bedside. Its application in the burn center
was explained and diagrammed in detail in the first edition
of this book,7 and what follows should be considered an
update and development of what is stated there.
On the vast majority of occasions, there is little or no dif­
ficulty achieving agreement and patient consent about a pro­
posed course of burn management. There are many predictors
of clinical outcomes that are without controversy.8 Occasion­
ally, however, the process of obtaining informed consent
leads to problems involving disagreements, anxieties and/or
controversies about what should be done. At this point, the
participants must give careful attention to the quality of the
discussion in attempting to resolve the problem.
Ethical discourse is a skill requiring practice. No one
becomes good at participating in ethical discourse simply by
reading books about the subject, or by letting a consultant
take over when things get difficult. Avoidance of, or reluc­
tance to participate in, discourse with stakeholders about
ethical problems is a suboptimal recourse when at last a
care-provider is forced by circumstances to act.
Contrary to very common practice, ethical discourse at its
best is not merely filling your ‘opponents’’ heads with what
you want them to know so they will say what you want to
hear. Nor is it simply getting your discourse partners to
effectively ‘get things off their chests’ so they will feel better
and then say what you want to hear. This may make them
feel better, but will do nothing for you. Least of all is it
engaging in verbal warfare to win an argument. At its best,
ethical discourse begins by building a safe place for ethical
dialogue, i.e. establishing an interpersonal ‘relationship’
made safe for transparent and self-critical honesty by making
active listening and openness-to-learning the norm.9
The role of the care-provider in
ethical dialogue
1. The care-provider should develop the trust necessary to
establish the safe place for ethical dialogue described
above. To do this the care-provider should learn the
bio-psycho-social-economic-and cultural/religious
information required to approach the patient and his
family and/or surrogate with empathy for their lives
and values. Our western religious backgrounds teach us
that we have certain limitations to this life and look to
the future beyond. The eastern religious backgrounds
teach us that within our lives we will come back and
reflect on what our previous lives have been and also
place extreme respect on the departed spirit. Finally,
there are people who do not have a religious
background that live for different goals and different
aspirations. All of these must be considered early on
when determining what the caregiver’s relationship and
position will be with the patients and their families.
Many patients, given the opportunity and fully
understanding their condition, will decide against
extremes of treatment and continuing care with the
hope of not burdening their family with large hospital
bills. All of these issues must be explored with the

The ethical dimension of burn care
685
they usually can provide or obtain. (Note the similarity of
these early steps to those of the ‘S-P-I-K-E-S’ protocol for
delivering ‘bad news’, described by Buckman; see Foley.13) If
successfully carried out, Steps 1 and 2 transform a potential
or actual power struggle into a collaborative search for the
answers to the next and then the final question listed on
Table 60.1.
The conversation of Step 3 may address principles (like
respect for persons, beneficence, etc.) but more typically cites
relevant laws and rules of the community and or institution,
and/or other values (no unnecessary pain, what the patient
would want if able to speak, etc.) Step 4 is usually best
carried out using a blackboard or equivalent to brainstorm
and record all the plausible alternative courses of action. In
Step 5, the group collaboratively may find a principle, rule,
value, etc., or some combination thereof so compelling that
the proper alternative is clear. For example, because it is
considered unlawful homicide in most locations, large doses
of narcotic primarily intended to stop breathing rather than
control pain may be found unacceptable. If the decision is
still not clear, Steps 6 and 7 will usually lead to a mutually
acceptable decision within boundaries that are acceptable
institutionally, legally and ethically.
Rarely, consensus will elude the most sincere adherence to
the 7-step process. If further discussion, efforts to transfer
care of the patient, etc. fail, an appeal to the courts, or (in
at least one state14) an appeal to relevant legislation for
relief from responsibility for care of the patient, may be
necessary.
The patient without decision-making capacity,
surrogate or advance directive
In such cases, care-providers typically have no way of
knowing or deducing with confidence what the patient’s
wishes might be in a given set of circumstances. In general,
the decision made must seek the best interest of the patient,
but the process required may vary. In some jurisdictions,
consultation with another physician, the healthcare
wanting to see suffering or experience it, thus, desiring to
relieve the family of this burden if they have had a previous
bad experience. A religious background is also mentioned,
which is a large factor in people’s decision. Clergy might be
involved at any step of the way to involve the patient’s reli­
gious resources or spiritual support background in order to
try to make the decisions about care and continuing treat­
ments. Finally, there is the perception of what it would be
like to survive a significant burn. Many people feel that this
is not something that you would wish on anyone, let alone
suffer themselves. Patients may feel that they are not going
to be a functional member of society, or that they will lose
out on many of the things that they had been previously
involved in or hope to achieve. It has been reported that
children with large burn injuries who survive end up at least
as well off as their peers.11 The men when they reach maturity
perform better scholastically and have a better self-image
than their peers. The women perform at least on an equal
level with their peers. So, what we are finding is, as more
patients survive massive burns, that these people do not
become shut-ins but survive and thrive. The philosophy is
that if you help the person get through the crisis, their own
internal tools dictate whether they are going to fail or
succeed. If the patient was going to succeed, they will succeed.
If the patient fails, they were going to fail, regardless of the
burn injury. The burn injury only magnifies their ability to
cope with difficult events.
How should persistent ethical conflict
be managed?
Even when participants make a sincere effort to establish
rational discussions, disagreements about conscientiously
held positions occasionally persist. At this point, patience
and the setting aside of adequate time to walk through care­
fully considered steps in ethical decision-making are neces­
sary, Often, to build up their own skills and enhance chances
of success, the patient/surrogate or care-providers will ask a
HEC to coach them in pursuing a consensus collaboratively
arrived at.
In any serious ethical inquiry, three questions must be
answered: What seems to be the problem? What can be
done? What should be done? A seven-step decision-making
model has been found helpful in answering these questions
and is illustrated in Table 60.1.12
In arranging a conference designed to achieve a consensus
resolving ethical conflict at the clinical level, every effort
should be made to have all the major stakeholders present
to work collaboratively. To discover their current perceptions
and level of understanding, to help equalize power, and to
model civil discourse, the patient/surrogate and their signifi­
cant others are asked to speak first as the care-providers listen
carefully and respectfully. As indicated by Step 1 (Table
60.1), they are asked to introduce themselves, explain the
conflict as they see it, and indicate what they hope to achieve
by the discussion. Thereafter, the care-providers do the same.
This step typically takes the most time, but is the most
important of all the seven steps. It lets off steam, makes the
patient/surrogate and allies feel listened to, and optimally
leads them to ask for the corrective and supplementary infor­
mation they need from the care-providers, which (in Step 2)
Table 60.1  Three questions to be addressed when a clinical ethics
problem is serious and persistent, and the steps appropriate for
answering each question
1.
What seems to
be the
problem?
Step 1.
Discover conflicting values of
stakeholders
Step 2.
Discover the relevant
information
2.
What can be
done?
Step 3.
Identify principles, laws, other
values relevant to the decision
Step 4.
Identify alternative courses of
action
3.
What should be
done?
Step 5.
Compare alternatives and values:
is decision clear?
Step 6.
If not, assess consequences
Step 7.
Make decision, collaboratively, if
possible
Modified from May 1990.12 (With permission of the American Accounting
Association and the author.)

Total Burn Care
60
686
stakeholders, and without availability of extensive literature
or assistance from a committee or consultant skilled in
ethical analysis and critique applied at the organizational
level.
The development of the discipline of ‘organizational
ethics’ is just beginning, and overdue in the judgment of
JACHO17 and other authorities.18 The obligation to be ethical
at every level of healthcare decision-making will become
increasingly obvious and pressing, with continuing changes
in the ways healthcare is delivered. More and more, we are
holding our leadership at the institutional level to be trans­
parent in their decisions and ultimately to be held account­
able for their actions.
Specific problems
Human research
Many of the modern progresses in healthcare, particularly
burns, have come through active research protocols. Many
advances including fluid resuscitation, excision and grafting,
temperature and nutritional control, and modulation of
hypermetabolic response are all based on active research in
a clinical setting on human patients. It must be remembered
that these are volunteers first and patients must not be
coerced into the treatment. Institutions that are involved in
human research must have Institutional Review Boards in
place to monitor approved protocols and follow-up on
patients and complaints with their research driven care­
givers. Childhood research is an even more scrutinized area
because it is now the surrogate, as a parent, who is giving
consent for the research. It is a difficult area to approach,
however, with the thorough monitoring of institutional
review boards and the realization that those children have a
great deal to benefit from progress in healthcare. Children
should be included in research so that they can get the ben­
efits of progress in medicine and science at the earliest pos­
sible opportunity. However, this should not be at the expense
of their own rights. Many patients feel, when asked to par­
ticipate in research protocols, that they have a duty to those
who preceded them, who got the physicians to the level of
care that they can provide to them now. They feel they
should try to give something back to the science of medicine.
Patients realize that they cannot do that to the caregivers
who got them to where are now and feel a duty to participate
to help future victims who will also need their assistance.
We must not use such leverage to coerce unsure patients to
participate in investigations.
Futility
The concept of futility and hopelessness in the care of a
patient has changed drastically over the recent past. At one
time, any burn over a significant size offered no hope for
survival.19 Through our efforts in resuscitation, we have
pushed this survivability to current levels, where in the
youngest of age groups, patients with extremely large burns
can function and survive.8 At the same time, we are finding
that there is no simple definition of futility,20 making simple
pronouncements of futility impossible.
institution’s administration, and/or HEC is mandatory. In
others, a court appointed conservator might be required. In
all such cases: (1) the search for a surrogate should be dili­
gent; (2) all relevant medical information must be obtained
and reviewed; (3) real or apparent conflicts of interest must
be disclosed; (4) the opinions of the healthcare team and of
one or more physicians in addition to the responsible attend­
ing should be reviewed; (5) burden versus benefit must be
weighed from the patient’s point of view; and (6) steps
should be taken to ensure the benefit of continued life to a
disabled patient is not devalued or underestimated.15 Some
institutions also require that consideration of economic
impact on healthcare providers and the healthcare institu­
tion be excluded from consideration in such cases. Eventu­
ally a surrogate decision-maker is identified and, hopefully,
this is a person who has previously known the patient and
their values prior to the accident, who has possibly had
discussions about extreme end-of-life issues and can speak
on the patient’s behalf. The surrogate decision-maker must
not make the decision based on what they would want for
the patient. However, the surrogate decision-maker must
know what that patient would prefer and act as an advocate
in this situation, since the patient is not able to participate
in the decision. They should be expressing the patient’s
views, not projecting their own views onto the patient.
How should organizational ethics problems
be managed?
Currently, healthcare decision-making affecting burn care
occurs at three levels: in the clinic, in the organization, and
in society.6 The disciplines designed to improve ethical
decision-making at the first and last levels are called clinical
and societal ethics, respectively. They discern facts and values
for guiding clinical or societal decisions that affect patient
care and have received wide attention in both the media and
scholarly journals for years. Recently, attention has been
called to the need for discernment of facts and values for
guiding managerial decisions that affect patient care.6,16 For
example, at times, problems present as difficulties in clinical
decision-making, but have their root causes in areas that
require decision-making at the managerial level. With
dwindling numbers of nurses entering training, fewer and
fewer nurses will be available to provide intensive care, and
managerial decisions will be required to produce or recruit
more nurses and to judge just when it is no longer safe to
admit new patients to beds without adequate staffing.
Perhaps rehabilitation services in a given geographical area
have not kept up with the ever increasing numbers of patients
with large burns who survive but require longer and more
expert rehabilitation. Managerial decisions about the distri­
bution of scarce resources will have to be made if adequate
rehabilitation is to be available.
Such decisions are ethical: they involve conflicts of rights,
obligations, goods and/or other values. They tend to be less
dramatically immediate and more deferrable, but they
usually affect more persons and require more resources and
follow-up than clinical ethics decisions.16 They sometimes
appear to be made in the front office, apparently without
satisfactory input from care-providers, patients or other

The ethical dimension of burn care
687
Summary
As conceived in ancient Athens and during most of its
history, Western ethics has been an effort to: (1) achieve the
ethical life, i.e. life in all its important dimensions, lived at
its most flourishing, and (2) solve any problems about what
should or should not be done during that quest. The sus­
tained pursuit of excellence in total burn care first achieved
momentum in the USA in the mid-twentieth century. It has
always drawn its most primal motivation from the fact that
burn patients are among the most severely injured and
utterly vulnerable of human beings, and therefore deserving
of the most tender, skillful and comprehensive care. Com­
mitment to the safety, healing, rehabilitation and growth of
patients during their return to as flourishing a life as possi­
ble, has been the spearhead of the quest since its beginning,
and both the fire in its belly and the steel in its resolve ever
since. Clearly, burn care is an ethical endeavor through and
through, not just when and where difficult patients or ethical
problems become evident. It is never just a burn, but a
patient we may not have known previously, but will have
touched for the rest of their life.
Further reading
Blakeney P, Herndon D, Desai M, et al. Long-term psychological
adjustment following burn injury. J Burn Care Rehabil.
1988;9(6):661-665.
Council on Ethical and Judicial Affairs, American Medical Association.
Medical futility in end of life care: Report of the council on ethical
and judicial affairs. JAMA. 1999;281(10):937-941.
Faden RR, Beauchamp TL. A history and theory of informed consent. New
York: Oxford University Press; 1986:235-381.
Spies M, Herndon D, Rosenblatt J, et al. Prediction of mortality from
catastrophic burns in children. Lancet. 2003;361(9362):989-994.
Zawacki BE, Imbus S. Enhancing trust and subjective individual
dialogue in the burn center. In: Orlowski JP, ed. Ethics in Critical
Care Medicine. Hagerstown MD: University Publishing Group;
1999:489-512.
Do not resuscitate (DNR) vs comfort measure
only vs active withdrawal of treatment
Once the definition of futility or no precedent for survival
has been met, decisions about the end-of-life care of an
individual patient have to be made. End-of-life care should
be a mutual and agreeable choice by the patient/surrogate,
with the understanding by the healthcare team that
treatment has become futile. Even if these conditions are
met however, it is important to realize that there is a duty to
care for the patient. A ‘do not resuscitate’ (DNR) order is not
the equivalent of a ‘do not care’ (DNC) consideration.
An allocation of scarce resources
In its simplest terms, this is about who should survive and
what is the price of life, in an area where healthcare dollars
are less and less available to everyone. There is progressive
improvement in survival, given the concerted efforts of all
members of the healthcare team. However, the reality is that
our society is providing limited funds for the care of burned
patients. It becomes a very difficult personal decision:
should the burn unit focus on saving money and decline
treatment of one burn victim to prepare for the next, or
should they expend their resources on a patient who perhaps
has a poorer possibility of survival? The only problem with
holding back on resources is that this next big burn may
never come and you have not provided the full open access
of healthcare to the first patient. It can always be said that
saving for the future in this situation does not benefit either,
and one must advocate the use of the resources until, once
they are exhausted, the patient should be redirected. Argu­
ments can be made for both sides; however, if there is no
other hope for the patient, clearly they must be cared for
in this setting. In the United States at this time, we struggle
with these issues in daily political discourse, searching for
a compromise.
 
Access the complete reference list online at

The ethical dimension of burn care
687.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Fulginiti VA. The right issue at the right time. In: Holmes DE,
Osterweis M, eds. Catalysts in interdisciplinary education.
Washington DC: Association of Academic Health Centers; 1999:
7-24.
2. Gillon R. Philosophical medical ethics. Chichester: John Wiley &
Sons; 1985:2.
3. Pellegrino E, Thomasma DC. A philosophical basis of medical
practice. New York: Oxford University Press; 1981:119-152.
4. Maguire DC. The moral choice. Garden City, New York: Doubleday;
1978:113.
5. May WW. Discerning what’s right in health care at the clinical level.
Lecture at USC Keck School of Medicine, Los Angeles, CA, May 8,
2000.
6. Potter RL. On our way to integrated bioethics: clinical/
organizational/communal. J Clin Ethics. 1999;10:171-177.
7. Zawacki BE. Ethically valid decision making. In: Herndon DN,
ed. Total burn care. 1st ed. London: Saunders; 1996:575-582.
8. Spies M, Herndon D, Rosenblatt J, et al. Prediction of mortality
from catastrophic burns in children. Lancet. 2003;361(9362):
989-994.
9. Zawacki BE, Imbus S. Enhancing trust and subjective individual
dialogue in the burn center. In: Orlowski JP, ed. Ethics in critical
care medicine. Hagerstown MD: University Publishing Group;
1999:489-512.
10. Faden RR, Beauchamp TL. A history and theory of
informed consent. New York: Oxford University Press; 1986:
235-381.
11. Blakeney P, Herndon D, Desai M, et al. Long-term psychological
adjustment following burn injury. J Burn Care Rehabil.
1988;9(6):661-665.
12. May WW. Ethics in the accounting curriculum: cases and readings.
Sarasota, FL: American Accounting Association; 1990:1.
13. Foley K. A 44-year-old woman with severe pain at end-of-life.
JAMA. 1999;281:1937-1945.
14. Alquist. Health care decisions. (California) Assembly Bill No. 891,
Ch. 4, sections 4730-4736; operative July 1, 2000.
15. Ad hoc drafting committee. Guidelines for foregoing life-
sustaining treatment for adult patients at the LAC+USC Medical
Center. LAC+USC Medical Center, Los Angeles CA, May 5, 1993.
16. Hirsch NJ. All in the family – siblings but not twins: the
relationship of clinical and organizational ethics analysis.
J Clin Ethics. 1999;10:210-215.
17. Joint Commission on Accreditation of Healthcare Organizations.
Ethical issues and patient rights. Oakbrook Terrace, IL: Joint
Commission on Accreditation of Healthcare Organizations; 1998:
67-90.
18. Society for Health and Human Values/Society for Bioethics
Consultation Task Force on Standards for Bioethics Consultation.
Core competencies for health care ethics consultation. Glenview,
IL: American Society for Bioethics and Humanities; 1998:24-26.
19. Herndon D, et al. Teamwork for total burn care: achievements,
directions and hopes. In: Herndon DN, ed. Total burn care. 1st ed.
London: Saunders; 1996:1-4.
20. Council on Ethical and Judicial Affairs, American Medical
Association. Medical futility in end of life care: Report of the
council on ethical and judicial affairs. JAMA. 1999;
281(10):937-941.

This page intentionally left blank

©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00061-8
Intentional burn injuries
Lisa L. Tropez-Arceneaux, Susanne Tropez-Sims
Introduction
Deliberate injury by burning is often unrecognized. Accord­
ing to the US Department of Health and Human Services
Administration for Children and Families,1 child abuse and
neglect are defined as ‘any recent act or failure to act on the
part of a parent or caretaker, which results in death, serious
physical or emotional harm, sexual abuse or exploitation, or
an act or failure to act which presents an imminent risk of
serious harm.’ Within the USA alone, 1.5 million children
are abused or neglected each year, with 4–39% of these
occurrences being reported as intentional burn injuries and
less than half ever being substantiated.2 It is imperative that
all clinicians are aware of the importance of recognizing
signs and symptoms of intentional injury presentations, as
the opportunity for intervention is critical when taking into
account that 50%3 of children experience recurrent abuse
and 30% are ultimately fatally injured.4 Reporting suspicious
injuries to child protective services is mandated by law for
all clinicians working with children.5 Some treating facilities
identify specific treatment team members (i.e. psychologist
or social workers) to be responsible for all reporting. In these
situations it may be necessary to follow the protocol of the
hospital or treating facility first; however it is important to
note that any physician, medical professional or mental
health professional that encounters a suspicious injury must
insure that the injury is reported to the appropriate authori­
ties. At other times, the concern of reporting is more a result
of ambiguity or vagueness in the information, which can
cause hesitation to report the suspicious injury. In these
incidents of doubt, the most salient point to remember is
that the clinician is responsible to report suspicious injury
not to prove or validate the abuse. It is always better to report
the suspicion than to ignore it. Most state agencies also have
hotlines that are available to call 24 h a day to ask specific
questions regarding reporting suspicious injuries.6 Although
it is overwhelming to imagine that so much abuse occurs,
statistics show that it does occur not only with children but
with adults and our elderly population.
Intentional injuries can occur in the form of neglect, physi­
cal abuse, sexual abuse, and emotional abuse. All of these
injuries can occur independently but they often occur simul­
taneously.7 Neglect is the most common form of intentional
injury. Of the average 5.5 million referrals made to Child
Protective Services each year, 64.5% of these children are
neglected.8 Physical abuse occurs in 25% of intentional
injury cases.8 More than 15% of victims of abuse suffer more
than one type of abuse and more one-third of child fatalities
are attributed to neglect (Fig. 61.1).9 Burn injury is frequent
in both neglect and physical abuse of children. Severe burns
in children are between 10% and 12% of all intentional
injuries.10
Since the last edition of this book, intentional injuries to
adults have increased. It is frequently debated within the
literature as to whether the increase is a valid increase or if
there is an increase in reporting. Violence specifically against
women and young girls has now become a universal phe­
nomenon. The World Health Organization reported that of
the women who were partnered at some point during their
lifetime, 15–71% reported experiencing physical or sexual
violence by their partner.11 Within this realm of violence
against women and young girls, acid violence is the worst
form of violence and violation of human rights.12 Though
steps are being taken to control the widespread free sale of
acids to the public,13 this act of violence is still on the rise
and warrants discussion in the burn care literature and sen­
sitivity to this overwhelming problem by all burn care pro­
fessionals. Another vulnerable population of intentional
burn injuries are the elderly. In the past 10 years, burns in
the elderly have increased secondary to increase in size of
the aging population.
In this chapter, we have integrated our experience with
current literature to classify risk factors in the total popula­
tion and to propose validated therapeutic interventions to
treat the burn wounds and the complex social and psycho­
logical familial concerns that both create injury and compli­
cate the recovery, and rehabilitation of the patient. It is
essential that the burn team clinicians understand their role
and responsibility in assisting not only burn patients but the
perpetrators as well because history and statistics have shown
us that the outcome can be fatal if intervention and preven­
tion methods are not implemented with sensitivity to main­
tain positive relationships with burn patients as well as the
perpetrators.
The authors are well versed in clinical experience and
research experience of child abuse and pediatric burn inju­
ries; however, our experience of intentional burn injuries
within the adult population is limited. The literature and
our extensive knowledge of information regarding inten­
tional injuries against children are reflected in this chapter.
We have included the most recent literature on adult injuries
CHAPTER 61 
Access the complete reference list online at

IN THIS CHAPTER
Video Content Online • PowerPoint Presentation Online

Total Burn Care
61
690
street/highway 17%; occupational 8%, and other 32%.17
Burn injuries inflicted in Pakistan occur mostly to adult
women: approximately, one-third are secondary to stove
burns and 13% are acid burns. Husbands inflict more
than 52% of these injuries and in-laws one-quarter of the
injuries.18 Victims who are at highest risk of fire-related
injuries and deaths are children ≤4; adults over 65 years;
African-Americans and Native Americans, and the poor or
those living in rural areas.16 A literature review of hospital-
based studies of the prevalence of burn injuries in China,
revealed similar results with children < 3 years more
vulnerable; males more than females; those living in a rural
setting, and incidence occurring between the hours of 17:00
and 20:00.19
Prevalence of childhood burns
Over the past 50 years, child abuse has been documented
especially in the USA. Child abuse characteristics are com­
posed of physical abuse, neglect, sexual abuse, psychological
abuse and other, which include Munchausen by proxy and
abandonment. Child abuse may present with multiple char­
acteristics. Major forms of injuries to children include falls,
poisonings, car accidents, foreign body and fires/burns.20 Ten
percent of child abuse is burns and 20% of burns are child
abuse.21 The child abuse death rate in the USA is approxi­
mately 1000 children annually,18 with burns and scalds as
the most frequent cause of death.10 In China, the mortality
rate from abuse ranges from 0.49% to 3.14%. In Hong Kong,
it is 2.3%; in Singapore 4.61%, and in Iran 6.4%.19 The
lowest rates are in the UK and the highest rates are in the
USA, where the majority of the studies have been com­
pleted.10 In many cases of burn injuries, it may be difficult
to conclude if the burn injury is an incidence of neglect,
intentional or truly an accidental event.4 More recent
studies10,21–23 have begun to analyze hospital cases of burns
to delineate if intentional or non-intentional. The character­
istics of types of burns include scalding (70%); flame burns
(50%), or electrical (3–4%).19 Bathtub submersions peak at
6–11 months, then again at 12–14 months and remain high
until 33–35 months of age.20 Most studies calculate the
mean ages of children with intentional burns from 2 to 4
years of age.18 Boys are 2–3 times more afflicted than girls
with the youngest of multiple siblings suffering most often.21
There is no ethnic predilection. Of children who are victims
of physical abuse 10–12% suffer severe burns.10 In 2007,
Hicks and Stolfi24 concluded children with burn injuries are
at risk for occult fractures at a significant rate. Therefore, a
skeletal survey should be routine in burn patients presenting
to the emergency department, as recommended by the
American Academy of Pediatrics. Men are convicted at a
greater rate than female perpetrators, despite an equal rate
as perpetrators.25
Prevalence in elderly
Over the past 10 years, prevalence data of burns in elderly
has increased secondary to recent emerging studies in this
area. As in pediatric burns, geriatric burns are higher in the
developed countries at a rate of 20%, yet in the developing
world it is 5%.15 Results of the review of data from the US
National Burn Repository demonstrated an increase in rate
but it is not exhaustive. It is important to note that the pedi­
atric population is not the only target for intentional
injuries.
Prevalence rates of intentional burn injuries
Despite the improvement and use of smoke detectors, invest­
ment in sprinkler systems and improvement in building
codes in developing countries, burns continue to cause sig­
nificant intentional and unintentional injuries. Smoking
remains the leading cause of death by fire. Cooking is the
number one cause of residential fires. Annually, fire-related
injuries claim more than 300 000 deaths and 10 million
‘disability-adjusted life years’ worldwide.13 Middle and
low-income countries exceed 95% of fire-related burns.13–15
Approximately half of these countries are in southern parts
of Asia.15 In the USA, burn injuries result in approximately
1 million emergency department visits and 50 000 hospital
admissions, with a 5% mortality rate.13 Fire and burns rep­
resent 1% of the incidence of injuries. Fatal home injury
burns and fire deaths rank fifth and third, respectively in the
USA.16 The incidences of the causes of burns are: flame/fire
46%; scalds 32%; hot objects 8%; chemicals 3%, and other
forms 6%. Fires/burns occur frequently in the home 43%;
Figure 61.1  Abuse and neglect fatality statistics. (a) Child abuse and
neglect fatalities by age, 2006. (b) Forms of intentional injury that resulted
in fatality. (From: Child Welfare Information Gateway: June 2008 Numbers and Trends,
Child Abuse and Neglect Fatalities: Statistics and Interventions. Online. Available at:
).
12%
5% 5%
44%
39.7%
34%
22.9%
31.9%
1.5%
1.5%
1.3%
0.4%
> 1 yrs
1 to 3 yrs
4 to 7 yrs
8 to 11 yrs
12 to 17 yrs
Multiple forms of abuse
Neglect
Physical abuse
Medical neglect
Psychological abuse
Sexual abuse
Unknown
A
B
Child Abuse and Neglect Fatalities by Age, 2006
Forms of intentional injury that resulted in fatality

Intentional burn injuries
691
Distinctive characteristics of perpetrators
and families
Perpetrators are frequently individuals responsible for the
care and supervision of their victims. In 2007, one or both
parents were responsible for 69.9% of child abuse or neglect
fatalities.31 More than one-quarter (27.1%) of these fatalities
were perpetrated by the mother acting alone.31 Child fatali­
ties with unknown perpetrators accounted for 16.4% of the
total.31 According to the National Child Abuse and Neglect
data system in 2008, 56.2% of perpetrators were women and
42.6 % were men and 1.1 % were unknown.32 Of the reported
women perpetrators 45.3% were younger than 30 years of
age compared to 35.2% of men younger than 30.32 These
percentages have remained consistent for several years in
a row. Some 61% of all perpetrators were neglected as
children.1,31,32 Approximately 13.4% of all perpetrators
were associated with multiple types of abuse.1,31–33 Ten
percent of perpetrators experienced physical abuse as
children and 6.8% were sexually abused as children.33 Of
the children who are abused, 80% were abused by their
parents.31–33 Other relatives accounted for an additional
6.5%.31–33 Unmarried partners of parents were 4.4% of per­
petrators. Of those parents who were perpetrators, more than
90% were biological parents, 4% were step-parents and 0.7%
were adopted parents.32,33
Other characteristics of perpetrators include being com­
monly adolescent parents, single parents, often maintaining
inconsistent expectations for a child’s development, experi­
encing a lack of external supports, stressors such as substance
abuse, poor education (no high school diploma), unem­
ployment, poor housing, mental illness, and being reliant
on children for emotional support (Box 61.2).34 Most fatali­
ties from physical abuse are caused by fathers or other male
caregivers. Mothers are most often held responsible for
deaths resulting from child neglect.35 In some situations
there are two ‘perpetrators’, i.e. the actor and the overtly
passive observer who does not stop the abuse.36 Justice and
Justice,37 in their work with families who mistreat children,
identified several erroneous belief systems that are com­
monly held by perpetrators; these are listed in Box 61.3.
Since, as most authorities believe, violence is a multi-
generation intra-family pattern, then it is likely that the
belief systems attributed to child perpetrators can be extrapo­
lated to perpetrators of adult abuse as well.36
Often in homes where abuse occurs, there is little to no
emotional support for the perpetrators. They are often
dealing with tremendous life stressors and unfortunately
resort to immature coping styles to deal with frustrations.
Perpetrators resort to abuse as a result of complex behaviors
derived from a dysfunctional family history, lack of educa­
tion, desperation and at times substance abuse. Children
and elderly are usually dependent upon the perpetrator and
ironically are a source of stress and therefore become the
victim of intentional injuries. Corporal punishment is ‘the
use of physical force with the intention of causing a child to
experience pain but not injury for the purpose of correction
or control’.38 Some perpetrators will use this explanation as
a form of justification for intentional injuries.36 In young
children learning toilet training, a hot bath to clean after a
toileting accident is often a form of punishment. Usually,
of elderly abuse from 1991 to 2005.15,26 Of those burned,
14% are over 55 years of age (with 6.2% between 55–64
years; 3.3% between 65–74 years, and 4.4% >75 years of
age). There is a male predominance of burns of 1.4 : 1.
However, this decreases with age and is thought to be sec­
ondary to the decrease in life expectancy of males to females.
The most common injuries are flame burns, accounting for
37%, and scalds at 22%. The total body surface area (TBSA)
was 9.6% and the majority of injuries were residential.15,26
In the UK, residential settings are the leading site for
burn injuries to the elderly at a rate of 18.6%. The occur­
rences had a 32% higher mortality rate and 33% more TBSA
affected than like-sized burns in aged patients from other
causes than abuse. Over a 4-year period, Bortolani and
Barisoni27 investigated 53 patients aged ≥60 years who were
admitted to a local Italian hospital. It was noted 85% of
these burns occurred in the home and 11% in nursing
homes. Flame burns were the most common at 55%. The
incidences were attributed to pre-existing diseases in 85% of
patients. These diseases included cardiovascular accidents,
neurological problems and diabetic comas.27 In addition to
illness, lack of adequate supervision is another major etiol­
ogy for burns in this age group.18 In the USA, residential care
settings accounted for one-fifth of geriatric burns.28
With increase in an aging population, there is concern
about an increase of domestic elderly abuse and proportion­
ately an increase in burn victims.29,30 In the USA, elderly
physical abuse was underreported, with a rate of 2.8% of
total cases of abuse in 1988. However, in 1996, residential
institutions estimated only one-fourth to one-fifth of abuse
was reported. Another study, from Canada, estimated the
prevalence of abuse at 1%.28 The abuse is usually kept secret
owing to guilt, shame and fear of reprisal, especially if the
perpetrator is the victim’s adult child (Box 61.1).
The literature reports controversial results on the most
likely perpetrator, spouse vs adult children. As in child abuse,
disabled adults and those who suffer from dementia are at
higher risk for abuse. Drugs and alcohol abuse in caretakers
also increase the rate of abuse. Other characteristics in car­
egivers are mental disorder, financial difficulties and deviant
behavior.28
Box 61.1  Premorbid indicators of intentional burn
injuries of adults
•
Physical dependence
•
Psychological dependence
•
Accessibility as a target for abuse as in institutional living or living
with a ‘caretaker’
•
Caretaker(s) with a history of substance abuse, and/or other
psychopathology
•
Social isolation
•
An injury that is not consistent with the story described
•
Conflicting reports of the injury
•
Scalds with clear-cut immersion lines and no splash marks
•
Scalds that involve the anterior or posterior half of an extremity
and/or the buttocks and genitals, or a flexion pattern
•
Other physical signs of abuse/neglect
•
History of related incidents

Box 61.2  Risk factors for abuse/neglect by burning
Forced-immersion demarcation
•
Symmetrical, mirror image burn of extremities
•
Glove-like (burned in web spaces)
•
Circumferential
•
Minimal splash marks
•
Uniform depth
•
Full-thickness
•
Clear line of demarcation, crisp margin
•
Doughnut-shaped scars on buttocks/perineum (spared area forcibly
compressed against container, decreasing contact with hot liquid, if
container is not a heated element)
•
Flexion burns, ‘zebra’ demarcation to popliteal fossa, anterior hip
area, or lower abdominal wall
•
Injuries of restraint (e.g. bruises mimicking fingers and hands on
upper extremities).16
Injury demarcation, other
•
Incongruent with history of event
•
Pattern of household appliance – note whether even pattern versus
brushed, imperfect mark
•
Scald
•
Location of injury: palms, soles, buttocks, perineum, genitalia,
posterior upper body
•
Cigarette burn, if more than one on normally clothed body parts
and if impetigo ruled out.
History of injury
•
Evasive, implausible explanation
•
Incompatible with child’s developmental age
•
Changes in story; discovered to be burned – rule out dermatologic
epidermolysis bullosa (EB), dermatitis herpetiformis, chemical burn
due to analgesic cream, phytophotodermatitis,17 and birth marks,
including Mongolian spots18
•
Under-supervised – inadequate monitoring, impaired person
supervising, inordinately young babysitter (<12 years of age)
•
Burn is older than history given
•
Water outlet temperature greater than 120°F
•
Mechanism of burn is incompatible with injury (e.g. exposure time,
history of event, and degree of burn are inconsistent)
•
Patient’s per-event behavior displeasing to caregiver (e.g.
inconsolable, failed to meet caregiver’s expectations)
•
Toileting events related to history of injury19
•
Burn attributed to:
– Child or patient, as per caregiver
– Caregiver who is not present at the healthcare facility
– Caregiver, as per patient
– Delay in seeking medical treatment – note estimated time of
delay.
Developmental associations
•
Pre-verbal, non-verbal person
•
Vulnerable person (e.g. special need, failure to thrive, elderly)
•
Caregiver expectations are inconsistent with patient’s development;
caregiver overestimates child’s developmental skills and safety
knowledge; caregiver unaware of patient’s developmental capacity
•
Patient has symptoms of mental disorder (e.g. ruminating,
aggressive)
•
Patient displays disturbing behaviors related to attachment (e.g.
excessive crying, clinging, apathy/lethargy, excessively withdrawn,
listless, unemotional, submissive, polite, fearful, vacant stare)
•
Hyper-sexualized language or behavior, as compared to same age
peers.
Caregiver–patient relations
•
History of interrupted caregiver–child bonding
•
Adolescent caregiver(s) (e.g. child–child versus adult–child
interactions)
•
Strained interactions; inappropriate expectations of the patient by
the caregiver
•
Role reversal (rely on patient for support)
•
Inappropriate or lack of caregiver concern:
– Detached
– Lack of sympathy
– Lack of physical contact (e.g. fails to hold or pick up child)
– Inebriated during visits
– Infrequent visits.
Other physical signs of abuse or neglect
•
Unrelated injuries:
– Fractures, dislocations; rupture to spleen, liver, or pancreas; point
tenderness; impaired range of motion or function
– Signs of poisoning
– Ocular insult (edema, scleral hemorrhage, hyphema, bruise, blue
sclera)
– Swelling, bogginess, depressions, cephalohematomas palpable
on head or increased intracranial pressure at fontanelle
– Blood, infection, or foreign body in ear
– Edema, bleeding, septal deviation of nose; foreign bodies in nose;
cerebrospinal fluid rhinorrhea from nose
•
Unrelated injuries involving the skin: hematomas, soft tissue
swelling, lacerations, fingernail markings, scars, bruises (check
behind ear), welts, rope burns, strangulation marks, bites, alopecia
– note color, size, shape, and location of each (scalp most visible
while shampooing)
•
Abdominal tenderness, guarding, rebound tenderness, or bruises
•
Cardiac instability, tachycardia, murmurs, flow murmurs secondary
to anemia, or palpable rib fractures
•
Dehydration or malnutrition – note weight, height, and head
circumference
•
Previous burns
•
Unkempt, e.g. severe diaper rash, dirt under nails or in axillae,
odoriferous, dirt on plantar surfaces of feet in cold weather
•
Inadequate or no immunization record
•
Inadequate dental care (e.g. caries); trauma to lips, tongue, gums,
frenula, palate, pharynx, or teeth
•
Inadequate medical care
•
Inappropriate dress
•
Assess prior to invasive medical procedures
•
Genital, urethral, vaginal, or anal bruising, bleeding
•
Swollen, red vulva or perineum
•
Foreign body in genital area
•
Positive cultures for sexually transmitted diseases – if herpes
develops, note whether lesions are on unburned body surface area,
on genitals of type II
•
Pregnant minor
•
Recurrent urinary tract infections, streptococcus pharyngitis,
abdominal pain.
Family
•
Caregiver abused or emotionally deprived during childhood
•
Limited disciplinary practices (e.g. only physical punishment)
•
Lack of external supports; isolation
•
Mental illness; substance abuse; criminal history
•
Lack of financial self-sufficiency
•
Poor employment history
•
Dependent caregiver; unable to cope with daily responsibilities;
unorganized
•
Violent couples; impulsive; easily frustrated
•
Previous Department of Protective and Regulatory Services
involvement20
•
Prior accidents to dependents
•
Acute family stressors
•
No primary caregiver.

Intentional burn injuries
693
Box 61.3  Erroneous beliefs of abusers
Erroneous belief systems commonly contributing to the family system
in which abuse occurs37:
•
If my child cries, misbehaves or does not do what I want, he or she
does not love me and I am a bad parent
•
My child should know what I want and want to do it
•
My child should take care of me like I took care of my parents
•
My spouse/lover should know what I want and meet all of my
needs
•
If I have to ask, it does not count
•
You cannot trust anyone.
Table 61.1  Triage tool for diagnosis of intentional scalds
Evaluate for intentional
scald
Intentional scald should be
considered
Intentional scald unlikely
Mechanism
Immersion
Spill injury; flowing water injury
Agent
Hot tap water
Non-tap water; other liquids (beverage)
Pattern
Clear upper limits; Uniformed
depth scald symmetry (extremities)
Uniform scald depth; skin fold sparing; central
sparing buttocks (doughnut ring pattern)
Irregular margin; irregular depth; lacks
stocking distribution
Distribution
Isolated buttock/perineum, ± lower
extremities; isolated lower
extremities; rarely the face
Glove and stocking; 1 limb glove/stocking
Asymmetric involvement lower limbs;
head, neck and trunk or face and upper
body
Clinical features
Associated unrelated injury (recent
or old fractures); history
incompatible with examination
findings
Previous burn injury; neglect/faltering growth;
history inconsistent with assessed
development
Historical/social
features
Passive, introverted, fearful child;
previous abuse; domestic violence;
numerous prior accidental injuries;
sibling blamed for injury
Trigger, such as soiling/enuresis/misbehaviour;
differing historical accounts; lack of parental
concern; unrelated adult presenting child;
child known to social services
Adapted from: Maquire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34(8):1072–1081.
the perpetrator’s intent is to clean the child well, not to burn;
however, serious burns often occur. They often fail to seek
appropriate and timely medical treatment for an injured
child, not only because they fear punishment but also
because of their learned helplessness and passivity. They
discount the seriousness of the injury, as well as their ability
to take care of the injury. ‘I didn’t think it was that bad’ is
an explanation often given for delay in seeking treatment.
By diminishing the significance, they relieve themselves of
responsibility to act. When the perpetrator does take the
child for help, the perpetrator commonly seeks first a relative
or neighbor rather than a physician because perpetrators do
not believe in their own ability to decide whether to seek
medical treatment. Perpetrators are observed to interact
inappropriately with their children because they are preoc­
cupied with having their own needs met. A child who is hurt
and demanding is unlikely to reward the perpetrator with
feelings of comfort that the perpetrator seeks, and so the
perpetrator withdraws from the child. If the child is quiet
and compliant, the perpetrator may be observed to ignore
the child and sit passively, watching television for long
periods until some external force acts as a stimulus to moti­
vate the adult into action.36
Indicators of intentional injuries
In approaching pediatric/adult burn victims, indicators of
possible inflicted burns injuries should be considered (Table
61.1). Patterns of scald burns are highly suggestive of inflicted
injuries and healthcare providers have a general agreement
of these indicators (Box 61.2).22 (1) During scald burns, it is
implied that the absence of splash is suggestive of the victim
being held down. Some children who jump into a hot tub
of water may panic or freeze and just remain still and not
have splash burns. There are predominantly symmetric clear
upper margins. The burns involve lower extremities, buttock
without head and neck injuries (Fig. 61.2).10 Daria et al.
200423 describe six cases of submersion burns that involve
the head and neck. (2) If there is uniformity of burn consider
that the patient was held still during the incident. (3) Sym­
metric bilateral burns (glove and stocking distribution) are
highly suggestive of forcible immersion (Fig. 61.3b). (4) In
submersion burns, there may be skin sparing secondary to
joint flexion or victim forcibly held against the receptacle.
This gives an appearance of a doughnut appearance (or ‘halo
sign’). (5) In an Australian study authored by Heaton in
1989,39 bilateral burns of extremities are between 2.4 and
4.8 times more common in inflicted burns.22 (6) Accidental
cigarette burns are superficial and ill defined. Yet inflicted
wounds are superficial circular or ovoid macular wounds
with distinct depigmented lesions and hyperpigmented
edges. (7) Heated metal objects cause deeper burns (Fig.
61.3a). (8) Electric shock burns are revealed based on the
size of the device and entrance and exit wounds. Areas
will vary from full-thickness necrotic areas to superficial
wounds that are erythematous. One cannot evaluate these
lesions in isolation (Box 61.2). Review of medical records is

Total Burn Care
61
694
Figure 61.2  Newborns who were burned in hospitals by improperly trained hospital personnel.
A
B
C
D
Figure 61.3  (a) Abuse. Contact burn in which the markings of an iron are clearly visible. (b) Abuse. Classic ‘stocking’ pattern resulting from feet being
immersed in very hot water. The initial history given by the mother of the 21-month-old infant was that an older sibling had turned on the hot water,
and the patient herself dipped her feet into the tub.
A
B

Intentional burn injuries
695
or politically motivated.21,42–46 Characteristics of females who
self-immolate include substance abuse, a lack of social
support, younger age and diagnosed eating disorders.21
Males who self-immolate are also younger with severe mental
illness21 or pathological family dynamics or possibly an
adherence to fundamentalist religious convictions.13 Regard­
less of sex, self-inflicted burn patients usually have some
previous psychiatric problems, often depression or border­
line personality disorder, previous failed suicide attempts
with a poor response by others to suicidal ideation, recent life
stressors with feelings of helplessness.21 One of the highest
rates of this behavior is in Iran among young females where
marital conflict is a significant risk factor. Others include low-
literacy, low socioeconomic status, limited access to mental
health services and post-traumatic stress disorder.13
Although self-inflicted burn injuries are less frequent in
Western culture, studies report a rate of 0.5–2% in adoles­
cents and up to 25% in adults.21,47,48,46,49–54 In Africa, south
Asia and the Middle East self-inflicted burn injury rates are
up to 28% of all burn injuries.55 There is an estimated range
of self-immolation counting for 9–32% of all suicides in
India, Zimbabwe, and Iran21,56–58 with rates of Iranian and
Brazilian women being as high as 46% of suicides.21,59,60
Some studies have found that there are no gender differences
in the rates of self-immolation61,62 but some have determined
that it is most common in females,63–65 specifically Asian and
Latin females47,55,66,67 while others have found that it is more
common in males.49,68 Other risk factors for self-immolation
in Western culture include previous psychiatric treatment,
diagnosis of a psychotic disorder,61,63,69,70 unemployment61,69,68
or severe relationship difficulties.61
The most common mechanism of self-immolation is
flame as result of fire accelerant such as kerosene, gasoline
or rubbing alcohol.13,70 In a 2004 Finland study, 43% of all
patients used flame but 93% of women with self-inflicted
burn injuries used flame.70 The reported mean TBSA among
self-inflicted burn injuries is higher (median 42.2% range
from 22–79%) than other burn patients (11.8–77%, median
36%). These burn injuries are usually deeper full thickness
burns with increased risk of inhalation injury, poorer long-
term prognosis and higher rate of mortality.21,49,58,59,63,64,66
Self-immolations are 1.5–1.7 times more frequent than
reflected in current literature. This is an area where more
studies are needed to identify more accurate prevalence rates
and prevention interventions.
Clinical evaluations of suspicious injury with
pediatric patient and family
The history of the burned child is of particular importance
in assessing whether the burn is likely to be intentional or
accidental. Evaluating for intentional burn injuries requires
a multidisciplinary team effort (Box 61.4).
Physician assessment
The physician–patient relationship is paramount in assess­
ing injuries of patients and providing an accurate assessment
of incident to determine if suspicious injuries are intentional
or non-intentional. Obtaining a detailed history from
patient and caretaker is foremost in assessing creditability or
necessary to assure presence of a pattern of repeated abuse.
Also be aware patients may frequent a variety of hospitals
in the areas to decrease suspicion by medical providers.
Corroboration of history to physical exam is essential and
may suggest indicators of intentional burns.
Intentional acid burn injuries against women
Violence against women is a growing concern worldwide.
According to the World Health Organization on women’s
health and domestic violence, acid-throwing constitutes a
special case of intentional injury displaying an alarming
increase in cases over the past 2 decades in 48 different
countries including Bangladesh, Pakistan and other South
Asian countries.11 In 1993, the United Nations adopted a
Declaration for the ending of violence against women and
equal rights of men and women. However, the gender-based
violence continues to be a pervasive global issue that con­
tributes significantly to preventable morbidity and mortality
for women across diverse cultures. Women are not only
subjected to burning but they are often tortured,40 disfigured
with acid, endure beatings, sexual violence and ritual honor
killings.9 The most severe and excessive form of gender
based-violence in Pakistan is stove burning by husbands and
in-laws as a result of inadequate dowries.9
Acid burning is the most common form of violence against
women. Acids (hydrofluoric acid, sulfuric acid and nitric
acid) are readily available in schools, textile mills, jewelry
making, battery manufacturers and fertilizer factories and
are easily affordable. These acids are used against females
usually aged between 12 and 15, again in low socioeco­
nomic situations.12 Attacks are often perpetrated by men
against women, with a reported 47 cases in 1996 increasing
to 228 in 2001. The frequent reasons for acid burning include
disputes over rejected sexual advances or marital disputes
(41%), land and family disputes (32%) and dowry dissatis­
faction (13%).21 Isolated cases of disputes between neigh­
bors have culminated in acid attacks on babies.21
Acid burn victims who survive encounter deeper wounds
that often affect muscle tissue, longer hospitalization and
permanent physical disfigurement.9,12 The contact of acid on
the skin and body is devastating. The acid often causes cor­
rosion upon impact. Permanent damage can occur to eyes
causing blindness or death. The psychological trauma that
subsequently follows these burn injuries is overwhelming.
The women experience social isolation, difficulty with body
image, depression, anxiety and public humiliation. The
increase in these violent acts against women indicates a need
for improvement in legal provisions and protection for
women worldwide.
Self-inflicted burn injuries
One of the most violent means of self-immolation is suicide
by burning. It can also be an act as a part of a deliberate
self-harm syndrome, consisting of continual, sudden urges
towards self-harm.21 There has been an increase in the litera­
ture on self-immolation. It is unclear as to whether this
emphasis is a result of increased rate of recurrence or increase
in reporting.13,41 Historically, there is a debate as to whether
self-immolations are more acceptable if they are religiously

Total Burn Care
61
696
Social workers are advocates for referral and follow-up care.
Both are skilled at assessing family dynamics and social situ­
ations in greater detail and should be your focal point for
referral to appropriate government agencies. Psychosocial
assessment and interview with the patient separately (when
possible) from the caretaker will provide a more accurate
picture of the injury events. Inconsistency is a marker of
discrepancies in the history, which may alert an examiner
to possible abuse. The patient and caretaker must have a
detailed interview documented verbatim by the historian.
Paraphrasing information increases the likelihood of per­
sonal interpretation of history. The presence of witnesses and
the exact timing must be confirmed and these persons inter­
viewed to assess for correlation in narratives.74 A thorough
event reconstruction soon after admission should be con­
ducted and documented. This limits the room the suspect
has to alter the events and timeline related to the burn or
the opportunity to collude with witnesses.3 The pattern of
circumstances is extremely important, with suspicions raised
when the adult responsible claims not to have seen the inci­
dent, attributes the injury to a sibling, or presents late, or
when relatives other than the adult supervising at the time
of the burn bring the child for assessment.21 The clinician
conducting the interview must be well versed in child devel­
opment to ascertain normal developmental response to
those that are suspicious of abuse. Observations of interac­
tions and behavior are equally as important as the specific
questions that are asked during the interview process.
Abused children often have similar characteristics; they are
under the age of two making them vulnerable to their care­
givers. Other characteristics include inconsolable crying, dif­
ficulty toilet training or associated toilet training accidents,
insufficient or strained parent–child attachment, inappropri­
ate behavior such as apathy or apparent tolerance to invasive
procedures. Severely abused children will demonstrate exag­
gerated responses by either being overly fearful or overly
affectionate with medical team. When requested to provide
immunization records parents or caregivers suspicious of
abuse will often fail to provide or will avoid providing
accurate medical records and record of immunizations
(Box 61.4).3
The interview with a child is an essential component to
determining if the injury was intentional. The rapport that
is established through a therapeutic relationship is the key
factor to a successful interview. Warm-up questions or non-
threatening questions should be asked first to establish
rapport: When is your birthday?; questions about school,
friends, or asking the child to verbalize a story of their best
day. Once sufficient rapport is established asking open-
ended questions about the injury is most effective, i.e. What
happened? How did you get hurt?36 The child should be
encouraged to tell the story freely. Specific questions for
clarification should be asked only after the child has told the
story. If the child seems unwilling to talk about what hap­
pened, the interviewer can suggest the child raise a hand or
wiggle a finger to signal that they know something but do
not yet want to talk about it. When interviewing younger
children short sessions with breaks will allow rapport build­
ing and trust to develop for the child to feel safe to share
his/her story.36
The suspicious injury assessment should be discussed con­
fidentially with the family members, including the suspected
plausibility of history to what is seen on physical exam (Box
61.2). It is essential that providers are familiar with child
development in order to incorporate child development into
the assessment process. Trust issues may interfere in obtain­
ing a precise history. The assessment always requires an open
mind for the possibility of intentional injury, which should
be thoroughly investigated when clinical features are present
in the history and examination. Features of the physical
exam consist of identifying the pattern of burn injury, the
distribution and associated features being the more impor­
tant aspects to distinguish. The reported method of injury
must be clearly associated with the observed pattern of
injury, burn depth and appearance on physical examination
(Box 61.2).71 Children who are burned are also in a high risk
group of being subjected to other forms of abuse. Although
a few studies have indicated that pediatric burn patients are
at a lower risk for related fractures from abuse, approxi­
mately18.6% of children in this subgroup had fractures on
their skeletal survey.72,73 Another study found pediatric burns
have a 14% risk of fractures.24 This rate may be underesti­
mated since all patients did not receive a skeletal survey.
These fractures are occult and may not have physical evi­
dence of their existence. Further evidence has also revealed
that children with burns are less likely to be evaluated for
fractures reflecting the erroneous belief that they are a lower
risk group. All children 2 years and under should receive a
skeletal survey on initial exam to denote concomitant new
or old fractures.72,73 The clinician must also be mindful at
this time and assess for signs of abusive head trauma such
as intracranial and retinal hemorrhage.71
Psychosocial assessment
Multidisciplinary work is essential for appropriate manage­
ment of children or adult burn/abuse victims. Psychologists
are critical in the initial evaluation to assist in interviewing.
Box 61.4  Documentation for reporting
In addition to the documentation of first-hand observations, the
following tasks should be delegated:
•
Examine the patient for other signs of maltreatment, including a
skull and long-bone radiological scan. Clearly state that the
radiology consultation is for assessment of occult trauma.
•
Photograph injuries and any possible evidence.
•
If the patient has been referred from another hospital, access
information from the staff at that hospital to determine whether
they identified suspicious aspects of the injury and whether the
injury was reported to an investigating agency. If so, ascertain the
number assigned to the patient’s case by the investigating
agency. This number is needed for subsequent calls related to the
patient.
•
Interview the patient.
•
Interview the family members or caretakers individually and
together for thorough histories of the event, sensitive to the
differences in the story or changes across time.
•
Obtain a thorough family history, the patient’s medical history and
the developmental capacity of the patient.
•
Gather other available collateral information, e.g. medical records
from other places of treatment.
Created by Patricia Blakeney PhD and Rhonda Robert PhD, 2007.

Intentional burn injuries
697
however, medical records are often a key element. Physician
reporting and cooperation is invaluable to legal prosecu­
tion. The physician’s opinion on likelihood of intentional
injury strongly influences CPS workers and prosecutors.3
Salient to remember with intentional injury cases is that
most attorneys have limited to no experience with burn
injuries and the expertise of medical investigators, burn
psychologist and social workers are the foundation for
proving allegations and protecting the child from future
injuries.
There are no federal programs to specifically address
reporting of suspected abuse in adults. All states have indi­
vidual laws, reporting guidelines and penalties for adult
abuse. It is best practice to be aware of your state laws if you
work with adults but if unsure following the same guidelines
as for children until the exact information can be obtained
is acceptable. Most states have a statewide intake office that
can be located online and most states have online reporting.
The National Center on Elder Abuse provides information
and assistance on elder abuse, including a listing of state
elder abuse hotlines. Child Help USA is a private charity
that established and maintains the National Child Abuse
Hotline (800)-4-A-CHILD (800–422–4453) and provides
a listing of statewide reporting numbers at their website
at: Telecommunica­
tions Device for the Deaf number is (800)-2-A-CHILD. The
US Department of Health and Human Services Adminis­
tration for Children and Families provides a listing of
statewide reporting phone numbers at their website:

Clinical interviewing with other
vulnerable populations
When interviewing vulnerable patients, it is important to
provide a safe and confidential environment that is non-
confrontational or judgmental. Developing rapport and trust
is an essential component of the interview process. The older
adult is likely to be dependent upon the abuser in matters
of daily living. Often the perpetrator is a family member or
loved one. Whether the patient is able to express their emo­
tions or not, they will likely experience fear, worry, shame,
and a desire to protect the perpetrator. The therapeutic rela­
tionship developed will allow the patient to trust that the
medical team will work in their best interest as well as the
best interest of the perpetrator.
Maintaining professional relationships with
patient and family
When approaching a child/adult who is an abuse victim, the
provider must maintain professionalism, self control and
remain non-accusatory. Clinicians within the healthcare pro­
fession are natural protectors of children with the desire to
automatically align with the child. Addressing one’s own
feelings is vital to providing the best care for the patient.
Establishing a therapeutic relationship with the family may
be difficult but it is imperative as many of these children are
reunited with their family at discharge or at some point
during outpatient burn care.
perpetrator.36 Perpetrators should be allowed time to process
their concerns in a non-judgmental and therapeutic manner.
The family should remain informed of the process and
potential Child Protective Services interventions. It is impor­
tant to share with families an understanding that often Child
Protective Services is seen as a punitive agency but essentially
the main goal is the safety and protection of all children.
Sharing information will initiate a therapeutic relationship.
Most perpetrators are reluctant to trust medical teams espe­
cially when they feel as if they are being judged. Being honest
about the process and the information shared with child
protective services minimizes mistrust. As stated previously,
perpetrators often have limited emotional support. When an
intentional burn injury occurs, psychologists are an essential
component to providing the initial support and addressing
fears, sadness and helplessness those perpetrators may feel.
Regular psychotherapy sessions are critical to making a posi­
tive change in the family dynamics.
Reporting suspected intentional burn injury
In 1967, State legislatures in every state had laws mandating
that any reasonable suspicion of intentional injury be
reported to the appropriate authorities.36 In 1974, the Federal
Child Abuse Prevention and Treatment Act was passed.
These laws require professionals to report suspected inten­
tional injuries to a child when there is sufficient information
that would lead a ‘competent professional to believe mal­
treatment is reasonably likely.’36 It is important to be knowl­
edgeable of not only state laws but local governing agencies’
policies on reporting suspicious injuries. Most hospitals have
risk management or legal teams that are well versed in the
federal and state laws as well as the policies, rules and regula­
tions of the hospital. Methods of communications regarding
intentional injuries should be clearly outlined and reviewed
prior to sharing any information regarding intentional
injuries.
Providers who suspect abuse should report to the appro­
priate agency as designated by the state in which you prac­
tice. As you interview note interaction between caregiver and
patient. Providers should document inappropriate concerns,
lack of sympathy, detachment, delay in seeking care, or use
of drugs or alcohol (Box 61.2). If you suspect that inconsist­
ency exists, without being confrontational, alert caregiver
and give them the opportunity to give a more truthful
history. Detailed documentation of history and physical
exam may be used in litigation charges and should be clear,
concise and accurate. It is imperative for clinicians responsi­
ble for reporting suspected abuse to be as accurate as pos­
sible as there are significant consequences for inaccurate
assessment and diagnosis of suspected abuse. Some 50% of
children who sustain intentional injuries have recurrent
injuries that are eventually fatal.3
Ultimately, it is not the hospital or any of the medical
staff’s obligation to prove that a suspicious injury was inten­
tional. It is important to report the suspicion and ensure
continuity of care and cooperate with the legal process.3
While the child is receiving medical treatment it is impera­
tive to keep accurate records and document all treatment
and interactions among family members. The prosecuting
attorney is responsible for proving intentional injuries;

Total Burn Care
61
698
removing lids do not forget steam can burn the face or arms;
wear tight fitted clothing or short sleeves; for those with
mobility impairment use a sturdy, large lap tray to carry hot
liquids. Microwave scald burns have risen significantly since
the 1980s.16 Proper placement where the face is higher than
the door of the microwave is recommended. Children under
7 years of age should never operate this appliance. Never
heat baby formula in the microwave due to unevenness of
heating. Always allow microwave cooked items to sit for 1
minute prior to opening. Prevent tap water scalds by setting
hot water heater below 120°F (Table 61.2); ‘adequate and
constant supervision is the single most important factor in
preventing tap water scalds’ (American Burn Association); if
a single faucet handle always place in cold water position;
avoid sudden fluctuation of water, e.g. flushing toilet. The
CDC has free material that can be downloaded from the web
(/safechild/Fact Sheets/Burns-Fact-Sheet-a.pdf).
Prevention of non-accidental burn injuries is a little more
difficult. Further research and education of physicians and
maltreatment teams are imperative. Since the establishment
of the National Burn Repository (NBR) by the American
Burn Association, a Burn Registry was established to create
a national database. Physicians need to recognize suspicious
burns and document exam and history in detail. Further
research will assist in identifying clearer indications and pat­
terns to determine intentional injuries.
Further reading
Definitions of Child Abuse and Neglect: Summary of State Laws
as of 2009. Online. Available at:
systemwide/laws_policies/statutes/defineall.pdf [(PDF 1.2MB]
(/safechild/Fact Sheets/Burns-Fact-Sheet-a.pdf).
Kolko D. Juvenile firesetter intervention clinical training. Pittsburg, PA:
Department of Psychiatry, University of Pittsburgh School of
Medicine; 2000.
National Center on Elder Abuse. Website:
and phone number: (202)-898–2586.
National Clearinghouse on Child Abuse and Neglect Information.
What is child abuse and neglect? US Department of Health
and Human Services Administration for Children and Families.
Online. Available at:
whatiscan.cfm, 2004.
Future burn prevention and child safety
Burns and scalds are a significant cause of morbidity and
mortality in children. Some studies have shown successful
counter-measures to prevent burn and scald related
injuries.75 To prevent accidental burns the American Burn
Association Scald Injury Prevention Educator’s Guide has
published steps by which physicians can instruct their
patients to assist in burn and scald prevention. Hot food and
beverage scalds are the most common causes of scald injuries
in both children and adults. Providing a safe cooking area
and a supervised environment is foremost in prevention.
Suggested examples are: do not carry hot liquids when car­
rying your child; place children in the playpen or high chair
away from the stove; no child walkers; cook on back burner
and remember to turn the pot handle to the inside; appli­
ance cords kept coiled and out of reach from counter; when
Table 61.2  Exposure time to receive a severe burn in hot water;
time and temperature relationship
Water temperature
Time for a third-degree
burn to occur
155°F
68°C
1 second
148°F
64°C
2 seconds
140°F
60°C
5 seconds
133°F
56°C
15 seconds
127°F
52°C
1 minute
124°F
51°C
3 minutes
120°F
48°C
5 minutes
100°F
37°C
Safe temperature for bathing
Note: Downward adjustments to time needed for young children.
Data from: Moritz AR, Henriques FC. Studies of thermal injury: II. The relative
importance of time and surface temperature in the causation of cutaneous burns.
Am J Pathol 1947; 23(5):695–720. See also American Burn Association. Scald Injury
Prevention Educator’s Guide. Online. Available at:
Preven/ScaldInjuryEducator’sGuide.pdf.
 
Access the complete reference list online at

Intentional burn injuries
698.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. US Department of Health and Human Services. Administration
for children and families, 2009.
2. Ojo P, Palmer J, Garvey R, et al. Pattern of burns in child abuse.
Am Surg. 2007;73(3):253-255.
3. Peck MD, Priolo-Kapel D. Child abuse by burning: a review of
the literature and an algorithm for medical investigations.
J Trauma. 2002;53(5):1013-1022.
4. Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and
types of burns. BMJ. 2004;328(7453):1427-1429.
5. Reed JL, Pomerantz WJ. Emergency management of pediatric
burns. Pediatr Emerg Care. 2005;21(2):118-129.
6. D’Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries
treated in US emergency departments between 1990 and 2006.
Pediatrics. 2009;124(5):1424-1430.
7. Child Welfare Information Gateway. Recognizing child abuse and
neglect: signs and symptoms; June 2007.
8. National Child Abuse and Neglect Data System (NCANDS);
2004.
9. Nasrullah M, Haqqi S, Cummings K. The epidemiological
patterns of honour killing of women in Pakistan. Eur J Public
Health. 2009;19(2):193-197.
10. Maquire S, Moynihan M, Mann M, et al. A systematic review of
the features that indicate intentional scalds in children. Burns.
2008;34:1072-1081.
11. World Health Organization. WHO multi-country study on women’s
health and domestic violence against women: Summary Report of
Initial Results on Prevalence, Health Outcomes and Women’s
Responses. Geneva: World Health Organization; 2005.
12. Begum AA. Acid violence: a burning issue of Bangladesh – its
medicolegal aspects. Am J Forensic Med Pathol. 2004;25(4):
321-323.
13. McKibben J, Ekselius L, Girasek D, et al. Epidemiology of burns
injuries II: Psychiatric and behavioral prospective. Int Rev
Psychiatry. 2009;21(6):512-521.
14. Mock C, Peden M, Hyder A, et al. Child injuries and violence:
the new challenge for child health. Bull World Health Org.
2008;86(6):420.
15. Dissanaike S, Rahimi M. Epidemiology of burn injuries:
Highlighting cultural and socio-demographic aspects. Int Rev
Psychiatry. 2009;21(6):505-511.
16. Centers for Disease Control and Prevention. Injury prevention
and control: home and recreational safety: fire deaths and
injuries: Fact sheet. (n.d.) Online. Available at: http://

fires-factsheet.html
17. American Burn Association. National burn repository: Fact sheet;
2005.
18. Nasrullah M, Muzzam S. Newspaper reports: a source of
surveillance for burns among women in Pakistan. J Public Health
(Oxf). 2010;32(2):245-249.
19. Kai-Yang L, Zhao-Fan X, Luo-Man Z, et al. Epidemiology of
pediatric burns requiring hospitalization in China: a literature
review of retrospective studies. Pediatrics. 2008;122(1):132-142.
20. Agran PF, Anderson C, Winn D, et al. Rates of pediatric injuries
by 3-month intervals for children 0 to 3 years of age, Pediatric.
2003;111(6):83-92.
21. Greenbaum A, Donne J, Wilson D, et al. Intentional burn injury:
an evidence-based, clinical and forensic review. Burns.
2004;30:628-642.
22. Greenbaum AR, Horton JB, Williams CJ, et al. Burn injuries
inflicted on children or the elderly: a framework for clinical and
forensic assessment. Plast Reconstr Surg. 2006;118:46e-58e.
23. Daria S, Sugar NF, Feldman KW, et al. Into hot water head first;
distribution of intentional and unintentional immersion burns.
Pediatr Emerg Care. 2004;20(5):302-310.
24. Hicks RA, Stolfi A. Skeletal surveys in children with burns caused
by child abuse. Pediatr Emerg Care. 2007;23(5):308-313.
25. Ruth GD, Smith S, Bronson M, et al. Outcomes related to
burn-related child abuse: a case series. J Burn Care Rehabil.
2003;24(5):318-321.
26. Pham TN, Kramer CB, Wang J, et al. Epidemiology and outcomes
of older adults with burn injury: an analysis of the National Burn
Repository. J Burn Care Res. 2009;30:30-36.
27. Bortolani A, Barisoni D. Burns in the elderly, epidemiology and
mortality: analysis of 53 cases. Ann Burns Fire Disasters.
1997;10(4). Online. Available at:
vol_10/num_/text/vol10n4p197.htm
28. Keck M, Lumenta DB, Andel H, et al. Burn treatment in the
elderly. Burns. 2009;35:1071-1079.
29. Wasiak J, Spinks A, Ashby K, et al. Epidemiology of burn injuries
in an Australian setting, 2000–2006. Burns. 2009;35:1124-1132.
30. Hansen JC, Barnhill LR. Clinical approaches to family violence.
Rockville, MD: Aspen; 1982:157.
31. National Child Abuse and Neglect Data System (NCANDS), 2007.
32. National Child Abuse and Neglect Data System (NCANDS),
2008.
33. US Department of Health and Human Services Administration for
Children and Families. Child maltreatment, 2008. Online.
Available at:
index.htm
34. Schwartz JP, Hage SM, Bush I, et al. Unhealthy parenting and
potential mediators as contributing factors to future intimate
violence: A review of the literature. Trauma, Violence, Abuse.
2006;7(3):206-221.
35. US Advisory Board on Child Abuse and Neglect; 1995.
36. Robert R, Blakeney P, Herndon DN. Maltreatment by burning. In:
Herndon DN, ed. Total burn care. Edinburgh: Elsevier Saunders;
2007:771-780.
37. Justice R, Justice B. Crisis intervention with abusing families:
short-term cognitive coercive group therapy using goal attainment
scaling. In: Roberts AR, ed. Crisis intervention handbook. Belmont,
CA: Wadsworth; 1990:153-172.
38. Straus MA, Kantor GK. Corporal punishment by parents: A risk
factor in the epidemiology of depression, suicide, alcohol abuse,
child abuse, and wife beating. Adolescence. 1994;29(115):543-561.
39. Heaton PA. The pattern of burn injuries in childhood. N Z Med J.
1989;102(879):584-586.
40. Kumar V, Kanth S. Bride burning. Lancet. 2004;364(Suppl.1):
18-19.
41. Laloe V. Patterns of deliberate self-burning in various parts of the
world. A review. Burns 2004; 30(3):207-215.
42. Grossoehme DH, Springer LS. Images of God used by self-
injurious burn patients. Burns. 1999;25(5):443-448.
43. Bostic RA. Self-immolation: a survey of the last decade. Life Threat
Behavior. 1973;3:66-73.
44. Adityanjee. Jauhar: mass suicide by self-immolation in Waco,
Texas. J Nerv Ment Dis. 1994;182(12):727-728.
45. Kumar V. Burnt wives – A study of suicides. Burns. 2003;
29(1):31-35.
46. Stoddard FJ, Pahlavan K, Cahners SS. Suicide attempted by
self-immolation during adolescence. Literature Review, case
reports, and personality precursors. Adolesc Psychiatry.
1985;12:251-265.
47. Andreasen NC, Noyes R Jr. Suicide attempted by self-immolation.
Am J Psychiatry. 1975;132(5):554-556.
48. Cameron DR, Pegg SP, Muller M. Self-inflicted burns. Burns.
1997;23(96):519-521.
49. Daniels SM, Fenley JD, Powers PS, et al. Self-inflicted burns: a
ten-year retrospective study. J Burn Care Rehabil. 1991;
12(2):144-147.
50. Persley GV, Pegg SP. Burn injuries related to suicide. Med J Aust.
1981;1(3):134.

Total Burn Care
61
698.e2
© Copyright 2012 Elsevier, Inc. All rights reserved.
51. Scully JH, Hutcherson R. Suicide by burning. Am J Psychiatry.
1983;140(7):905-906.
52. Antonowicz JL, Taylor LH, Showalter PE, et al. Profiles and
treatment of attempted suicide by self-immolation. Gen Hosp
Psychiatry. 1997;19(1):51-55.
53. Wallace KL, Pegg SP. Self-inflicted burn injuries: an 11 year
retrospective study. J Burn Care Rehabil. 1999;20(2):191-194.
54. Forhuoh SN. The mechanism, intensity of treatment and
outcomes of hospitalized burns; issues for prevention. J Burn Care
Rehabil. 1998;19(5):456-460.
55. Ahmadi A. Suicide by self-immolation: Comprehensive overview,
experiences and suggestions. J Burn Care Res. 2007;28(1):30-41.
56. Rastegar Lari A, Alagehehbandan R. Epidemiological study of
self-inflicted burns in Tehran, Iran. J Burn Care Rehabil.
2003;24(1):15-20.
57. Adityanjee DR. Suicide attempts and suicides in India: cross-
cultural aspects. Int J Soc Psychiatry. 1986;32(2):64-73.
58. Mzezewa S, Jonsson K, Aberg M, et al. Prospective study on the
epidemiology of burns in patients admitted to the Harare burn
units. Burns. 1999;25(6):499-504.
59. Panjeshahin MR, Lari AR, Talei A, et al. Epidemiology and
mortality of burns in South West of Iran. Burns. 2001;
27(3):219-226.
60. DeSouzza DA, Marchesan WG, Greene LJ. Epidemiological data
and mortality rate of patients hospitalized with burns in Brazil.
Burn. 1998;24(5):433-438.
61. Davidson TI, Brown LC. Self-inflicted burns: A 5 year retrospective
study. Burns Incl Therm Injury. 1985;11(3):157-160.
62. Layton TR, Copeland CE. Burn suicide. J Burn Care Rehabil.
1983;4:445-446.
63. Scully JH, Hutcherson R. Suicide by burning. Am J Psychiatry.
1983;140(7):905-906.
64. Swenson JR, Dimsdale JE. Substance abuse and attempts at
suicide by burning. Am J Psychiatry. 1990;147(6):811.
65. Hammond JS, Ward CG, Perira E. Self-inflicted burns. J Burn Care
Rehabil. 1988;9(2):178-179.
66. Laloe V. Epidemiology and mortality of burns in general hospital
of Eastern Sri Lanka. Burns. 2002;28(8):778-781.
67. Mabrouk AR, Mahmos Omar AN, Massoud K, et al. Suicide by
burns: A tragic end. Burns. 1999;25(4):337-339.
68. Thombs BD, Bresnick MG, Magyar-Russell G. Who attempts
suicide by burning? An analysis of age patterns of mortality by
self-inflicted burning in the United States. Gen Hospital Psychiatry.
2007;29(3):244-250.
69. Palmu R, Isometsa E, Suominen K, et al. Self-inflicted burns;
An eight year retrospective study in Finland. Burns. 2004;30(5):
443-447.
70. Pham TN, King JR, Plamieri TL, et al. Predisposing factors for
self-inflicted burns. J Burn Care Rehabil. 2003;24(4):223-227.
71. Purdue G, Hunt J, Prescott P. Child abuse by burning – an index
of suspicion. J Trauma. 1988;28(2):221-224.
72. Degraw M, Hicks RA, Lindberg D. Incidence of fractures among
children with burns with concern regarding abuse. Pediatrics.
2010;125(2):e295-e299.
73. Hudson M, Kaplan R. Clinical response to child abuse. Pediatric
Clin North Am. 2006;53(1):27-39.
74. Yuille JC, Hunter R, Joffe R, et al. Interviewing children in sexual
abuse cases. In: Goodman GS, Bottoms BL, eds. Child victims,
child witness: understanding and improving testimony. New York:
Guilford; 1993:95-115.
75. Turner C, Spinks A, McClure RJ, et al. Community-based
interventions for the prevention of burns and scalds in
children (Review). The Cochrane Collaboration. Wiley & Sons;
2009:1-17.

Functional sequelae and
disability assessment
Glenn D. Warden, Petra M. Warner
Introduction
Advances in acute burn care during the past 25 years, in
terms of decreased mortality and decreased length of hospi­
tal stay, have been truly outstanding and amazing. In 1971,
survival statistics at the Institute of Surgical Research in San
Antonio demonstrated an LD50 (lethal dose resulting in a
50% survival rate) with approximately 40% TBSA (total
body surface area) burn. Thus 50% of the patients with
burns of only 40% died. Now, the LD50 approaches 80%
TBSA, and, if no inhalation injury is involved, patients with
burn injuries greater than 80–90% of their TBSA routinely
survive. In almost every burn unit in the United States, the
length of stay has decreased from nearly 3 days/% burn to
less than 1 day/% burn. The success can be stated simply:
patients with larger, more severe burns are surviving; however,
are these patients returning to society to become productive
citizens? What is the real outcome of massively burned
patients? Do pediatric burned patients become functional
adults? How do they function socially later in life? What is
the long-term effect on the patient’s families and society? Are
survival and decreased length of stay really the measure of
productivity for our specialty? The real product or measure­
ments of customer service is a patient who can successfully
return to society and, even more importantly, be a useful,
productive individual who can successfully interact socially
within a community. Yes, patients with larger and more
severe burns are surviving, but this has created new problems
for patients’ quality of life. Although the problems are mag­
nified in massively burned patients, they exist even in smaller
burns. These problems are best demonstrated in a pediatric
burn patient with a 95% TBSA burn (Fig. 62.1). Cultured
keratinocytes were utilized to achieve wound coverage. The
child survived; however, when we examined the patient’s
current and future reconstructive needs, they totaled 33
potential reconstructive procedures. Thus, the reconstructive
problems are monumental in a child with very few donor
sites.1 With regard to survival, the results of this patient are
impressive; however, we must ask the question: ‘Has the
medical expertise in terms of survival progressed past the
ability to reconstruct and rehabilitate patients?’ Unfortu­
nately, the answer is clearly ‘yes’. Are we returning our patients
to a society which is not ready financially, psychologically,
or socially, to accept them? Again, unfortunately, the answer
is clearly ‘yes’.
Although the American Burn Association has made reha­
bilitation a major emphasis, quality work still remains to be
done. It is important and imperative that burn centers evalu­
ate the functional outcome of a thermally injured patient.
This is important not only for disability assessment but also
for evaluation of our medical management. Outcome studies
in the 20th century will not only emphasize survival and
hospital stay but also patient satisfaction and ability to
return to work. The purpose of this chapter is to review the
functional sequelae and disability assessment following
thermal injury.
Basic considerations: impairment,
disability, handicap
The various terms such as ‘impairment’, ‘disability’, and
‘handicap’ appear in laws, regulations, and policies of diverse
origin without proper coordination of the ways in which
they are used.
‘Impairment’ refers to an alteration of an individual’s
physiological, psychological, and anatomical structure or
function that interferes with activities of daily living or a
significant deviation, loss, or loss of use of any body struc­
ture or body function in an individual with a health condi­
tion, disorder, or disease.2
’Disability’, which is assessed by non-medical means,
means an alteration in an individual’s capacity to meet per­
sonal, social, or occupational demands or to meet statutory
or regulatory requirements or activity limitations and/or par­
ticipation restrictions in an individual with a health condi­
tion, disorder, or disease.2 Simply stated, impairment is what
is wrong with the health of an individual; disability is a gap
between what the individual can do and what the individual
needs or wants to do. An individual who is impaired is not
necessarily disabled. Impairment gives rise to disability only
when the medical condition limits the individual’s capacity
to meet the demands which pertain to non-medical fields
and activities. On the other hand, if an individual is able to
meet a particular set of demands, the individual is not disa­
bled with respect to those demands, even though a medical
evaluation may reveal impairment.
The concept of ‘handicap’ is independent of both impair­
ment and disability, although it is sometimes used inter­
changeably with either of those terms. Under the provision
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00062-X
CHAPTER 62 
Access the complete reference list online at

Total Burn Care
62
700
what kinds of medical information are needed and to what
degree of detail to assess an individual’s health with respect
to demand criteria.
Impairment assessment
Before discussing the medical aspects of evaluating thermally
injured individuals, it must be pointed out that no Social
Security and Worker’s Compensation disability program
medical listing exists for burns. Instead, burns must be evalu­
ated under the appropriate body system. Often, more than
one system is involved: in other words, musculoskeletal,
respiratory, and skin all must be considered in the final deci­
sion. Claims must be aimed primarily at resolving the ques­
tion of onset, whether the impairment can be expected to
last 12 months or end in death. The medical evidence needed
to document the existence and severity of a medically deter­
minable impairment due to burns must include a history of
the impairment, which describes the origin and course of the
condition, dates of confinement, nature of treatment, and
the claimant’s response; current objective findings such as
results of examinations, laboratory tests such as blood pres­
sure, electrocardiogram, x-rays, blood tests, range of motion,
medical factual data upon which diagnoses are based; and a
description of the objective findings of the claimant’s limita­
tions and remaining capacities. In other words, how far can
the patient walk, which activities cause breath or chest pain,
what extent of motion is there in affected parts of the body.
Regional specialized burn centers treat many serious burns
annually. These centers are excellent sources of medical evi­
dence as they maintain complete detailed records regarding
the nature of an injury, treatment, complications, and prog­
nosis. Advances in burn care have improved the survival rate
in major burns. Efforts to rehabilitate these survivors and
improve their quality of life represent a significant challenge
for those involved in their care. The rehabilitation of these
survivors is unique and multifaceted, and rarely limited to
one system. Many individuals will experience some type of
long-term physical impairment or mental limitation, and
the rehabilitation process may take years to complete. It
must be emphasized that impairments resulting from a burn
are not restricted to the skin. Complications may affect any
body system; thus, the examiner who is assessing individuals
for disability must be attentive to the systemic sequelae of
burn injury. The evaluation of a burn victim has some unique
features. The necessity to consider such subjective factors
as heat and cold intolerance, sensitivity to sunlight, pain,
chemical sensitivity, and changes in sweating pattern, as well
as the more objective considerations of decreased coordina­
tion, sensation, strength, and contracture, lends itself to a
unique evaluation.
Disfigurement from scarring, a frequent sequela of
burns, may not affect performance and thereby, in and of
itself, causes no impairment. Scarring represents a special
type of disfigurement. Again, no percentage of impairment
is assigned for the existence of a scar per se; however, scars
affect sweat glands, hair growth, and nail growth, and cause
pigment changes or contractures and may affect loss of per­
formance and cause impairment. Sensory deficit, pain or
discomfort from scars needs to be evaluated, as well as
the loss of motion of a scar area. An impairment due to
disfigurement from scarring may also create behavioral or
of federal laws, an individual who is defined as handicapped
has an impairment that substantially limits one or more life
activities, including work, has a record of such impairment,
or is regarded as having such an impairment. As a matter
of practicality, however, a handicap may be operationally
understood as being manifest in association with a barrier
obstacle to functional activity. An individual of limited func­
tional capacity is handicapped if there are barriers to accom­
plishment of tasks or life activities that can be overcome only
by compensating in some ways for the effect of an impair­
ment. If an individual is not able to accomplish a task or
activity despite accommodation, or if there is no accommo­
dation that will enable the accomplishment, then in addi­
tion to being handicapped, the individual is also disabled.
On the other hand, an impaired individual who is able to
accomplish a task or activity without accommodation is,
with respect to the task or activity, neither handicapped nor
disabled. The concept of ‘employability’ deserves special
attention, for, in an occupational setting, if an individual
within the boundaries of medical condition has the capacity,
with and without accommodation, to meet a job’s demands
and conditions of employment as designed by the employer,
the individual is employable and consequently not disabled.
On the other hand, an individual who does not have the
capacity or who is unwilling to travel to and from work, to
be at work, and to perform assigned tasks and duties, is not
employable.
The first critical task in carrying out a medical determina­
tion related to employability is to learn about a job, specifi­
cally the expectations of the incumbent, with respect to
performance, physical activity, reliability, availability, pro­
ductivity, expected duration of useful service life, and any
other criteria associated with qualifications and suitability.
Sufficient detailed information from a job analysis will
provide a basis upon which a physician determines exactly
Figure 62.1  A pediatric burn patient with a 95% TBSA burn.

Functional sequelae and disability assessment
701
joint range of motion. An extremity can exhibit full active
range of motion and still be considered impaired due to
poor skin quality. Although much can be done to restore
function, the skin is never restored to normal. Scar tissue is
less tolerant of the everyday stress imposed on it than
normal skin. Scar epithelium is thin, fragile, and prone to
chronic ulceration. Regardless of the location, these chronic
open areas will not heal and eventually require skin grafting.
This type of lesion can occur at any time, even years after
the initial hospitalization. Skin grafts have the same abnor­
malities as burn scars in that they all involve contracture
formation, have loss of sweat gland function, hair growth,
and altered pigment formation. Although frequently cos­
metically more acceptable, skin grafts are still not normal
skin. Physical limitations such as cold and heat intolerance,
difficulty with sun exposure, altered sensation, or painful
scars may prohibit individuals from performing their past
work or other work.
Musculoskeletal
Functional limitation secondary to burn injury usually
results from an anatomical alteration about a major joint.
The degree to which the function of a joint is affected is
greatly influenced by the amount of soft-tissue loss and the
degree of pain associated with movement. Full-thickness
burns, those involving all layers of skin, may also result in
secondary damage to muscle, bone, tendon, and ligaments.
In the acute phase of treatment of such injuries, a joint may
be exposed, making it vulnerable, and susceptible to a
chronic infection (osteomyelitis), instability, and arthritic
changes. Ectopic calcification, the abnormal deposition of
calcium around the joints, is usually seen in the elbow, but
it can occur in any joint. Symptoms include pain with a
significant decrease in motion. These changes in joint struc­
ture can be verified by X-ray and will require surgery at a later
date for correction. Extensive soft-tissue destruction involv­
ing the loss of muscle mass, as seen in electrical injuries, will
require numerous staged procedures in order to restore func­
tion. An individual may never be restored to full function
and may be excluded from performing certain types of work
which exist in the national economy.
Restriction of normal movement by contracture is not
limited to the extremities. When a scar occurs over the trunk
or anterior chest, severe and chronic postural changes can
result which may cause secondary spinal deformity or altered
respiratory functions. Amputations are another leading
contributor to post-burn impairment. Unlike amputations
which are performed for other medical conditions such as
peripheral vascular disease, amputation following an exten­
sive thermal injury will often require several staged surgical
procedures in order to produce a stump capable of accom­
modating a prosthesis. It is also important to realize that
amputations are not confined to the extremities alone but
may also involve skin appendages such as the ears and nose.
Complicated stage procedures using local or distant full-
thickness skin or muscle-skin flaps are required in order to
restore function and cosmesis in these areas. An understand­
ing of how long it will take for an individual’s function to
be restored is an important factor in deciding about the issue
of disability.
psychological impairments which subsequently may be
rated. The need for intermittent or continuous treatment of
the skin with topical agents and pressure garments can
impair a person’s function and needs to be considered. There
is a surprising lack of published literature which relates
to the impairment evaluation of a burned patient. The
following are concepts which must be kept in mind
when evaluating a post-burn patient for impairment and
resulting deformities.
Skin
Scars and cutaneous abnormalities which result from the
healing of burned tissue may represent a special type of
disfigurement. Scars should be described by giving their
dimensions in centimeters, and by describing their shape,
color, anatomical location, and evidence of ulceration; their
depression or elevation, which relates to whether they are
soft and pliable or hard and indurated, thin or thick and
smooth or rough; and their attachment, if any, to underlying
bone, joints, muscle and other tissues. Good color photo­
graphy with multiple views of a defect enhances the
description of scars.
The tendency of a scar to disfigure should be considered
in evaluating whether impairment is permanent or whether
the scar can be changed, made less visible, or concealed.
Function may be restored without improving appearance
and appearance may be improved without altering anatomi­
cal or physiological function. If a scar involves loss of sweat
gland function, hair growth, nail growth, or pigment forma­
tion, the effect of such loss on performance of an activity of
daily living should be evaluated. Furthermore, any loss of
function due to sensory pain, any sensory defect, pain or
discomfort in a scar should be evaluated.
Burn scar contracture is probably the most frequently seen
cause of impairment in a post-burn individual. Every burn,
regardless of the depth of injury, heals with some element
of contracture. Contractile forces continue long after a
wound is healed and can result in severe skin shortage. Inad­
equate skin prohibits movement to a joint’s normal arc of
motion and will influence not only the joint underlying the
contracture but also those adjacent to the scar. In the early
stages of development, burn scar contractures may often be
corrected through the use of splints and pressure garments
designed to force developing scar tissue into more normal
configurations. In spite of the benefits derived from these
modalities, they may also function as a type of impairment,
both physically and cosmetically. Understanding the splints
which individuals must wear and their limitations are
important factors in the assessment of disability. Often, sur­
gical means must be employed in order to restore function.
When a surgical release of a contracture is performed, the
resultant defect can be of considerable size and will require
closure by means of a skin graft or flap of tissue. Burn scar
contracture frequently requires a series of staged surgical
procedures before optimal function and cosmesis are
achieved. Recovery from surgical intervention must be fol­
lowed by an extensive rehabilitation program. If an indi­
vidual does not participate in a rehabilitation program,
contractures will reoccur.
The definition of functional impairment should not be
limited to an individual’s ability or inability to perform

Total Burn Care
62
702
an electrical injury, are predisposed to stroke, or who exhibit
signs of peripheral neuropathies secondary to thermal
damage. Such patients should be closely monitored for signs
of progressive neurological deficit. Electromyography studies
will chart the development of degenerative peripheral nerve
or spinal cord dysfunction. Dysfunction may be demon­
strated in the form of paresis, paralysis, tremor, involuntary
movement, or ataxia. Individuals who have suffered an elec­
trical injury may develop a condition characterized by pro­
gressive degeneration of fine and gross motor coordination.
Resultant complications can range from inability to perform
work-related tasks safely to an inability to perform the
routine activities of daily living. It is a disease process which
takes place over a significant period of time, and may worsen
after an individual has returned to work. In addition to the
motor deficits caused by electrical injury, those individuals
in whom a current passed above the level of the clavicle have
a high incidence of cataract formation with the first 3 years
post-injury.
Aside from electrical injury, peripheral nerve injury can
also result from deep to full-thickness burns. Symptoms of
sensory deficits and pain from nerve injury include anesthe­
sia, dysesthesia, paresthesia, hyperesthesia, cold intolerance,
and an intense, burning pain. However, behavioral and
psychological issues can make it difficult to assess a
patient’s true impairment and disability due to peripheral
nerve injury. To minimize the subjectiveness of pain-related
impairment, only persistent pain that leads to permanent
loss of function, in spite of maximum effort toward medical
rehabilitation and physiological adjustment, can be classi­
fied as permanent impairment.2
Heme and lymphatic
Full-thickness or deeper burns, particularly of the lower
extremities, will also cause damage to the lymphatic system.
Such injured individuals often demonstrate a lack of normal
lymphatic drainage, resulting in chronic edema and the
development of stasis ulcers. There can be little or no
improvement expected post-healing. External support in the
form of elastic garments is necessary to help replace the
normal activity of the lymphatic system in reabsorption of
fluid. These individuals frequently have difficulty in standing
for long periods of time or working in a hot and humid
environment.
Digestive system
The digestive system is not usually a problem except in those
individuals who have had superior mesenteric artery syn­
drome, cholecystitis, or peptic ulcer disease during the acute
admission. The post-discharge clinical course of these indi­
viduals is never predictable; if affected individuals become
symptomatic, they should be followed up by a specialist.
Genitourinary system
The genitourinary system may be a problem if deep perineal
or buttock burns occurred. Aside from the obvious psycho­
logical problems, partial loss of the penis or scarring of the
external genitalia may result in difficulty voiding. A badly
scarred perineum or buttocks may make sitting in one posi­
tion for prolonged periods painful and difficult.
Special senses and speech
Impairment to the senses of hearing or vision can occur as
a result of a thermal insult, secondary to life-sustaining treat­
ments or as a complication of a healing burn. The loss of
central or peripheral vision may begin at the time of contact
with a burning agent and can cause the destruction of the
eyelids and damage to the cornea. A series of surgical proce­
dures must be performed in order to create a functional
eyelid. Contracture of the eyelids, more commonly the
lower, may develop quickly, resulting in incomplete closure
of the eyelid, and potential damage to the cornea can result
in conjunctivitis or corneal ulceration. In spite of adequate
surgical correction, it is common for such injured individu­
als to have repetitive episodes of recontracture for up to 2
years post-healing, due to ongoing scar contracture process.
Perioral burns that result in lip eversion and microstomia,
or contracture of the mouth, may eventually impair mastica­
tion and result in drooling as well as inhibiting an individual
from producing speech which can be heard or understood.
Hearing impairment due to the acute burn is rare, but there
may be a loss of the external ear, or deafness secondary to
the treatment of life-threatening infections with antibiotics.
Respiratory system
Burns that occur in an enclosed space, such as a building
structure, often result in some form of inhalation injury to
the respiratory system. Impairment may be limited to a tem­
porary need for ventilatory support or extend to permanent
respiratory disease. Chronic and recurrent respiratory infec­
tions and pulmonary insufficiency may limit an individual’s
ability to perform their past work or other work in the
national economy, especially when toxic chemicals or dust
are present in the workplace. Exposure to irritating gases can
also worsen preexisting asthma or result in irritant-induced
asthma. Although this form of reactive airway disease usually
resolves with time, some individuals may have persistent
respiratory impairment that also may require a change in
vocation in order to avoid continued exposure to irritants
and exacerbation of symptoms.
Furthermore, patients with severe inhalation injuries may
require a tracheostomy long after the burn has healed.
Closure of the stoma is often delayed for the purpose of
intubation and anesthesia in future reconstructive surgeries.
Pulmonary function tests are essential in determining respi­
ratory impairment.
Cardiovascular system
A cardiovascular evaluation should include a good history
and electrocardiogram. Patients complaining of chest dis­
comfort thought to be of cardiac origin should have a more
extensive work-up. There is some evidence of increased inci­
dence of cardiovascular disease in the long-term follow-up
of survivors of large thermal injuries.
Neurological system
Neurological impairment caused by a burn may be obvious
at the time of admission to a burn center or become clini­
cally apparent up to 2 years following the injury. Patients
who are considered at risk include those who have sustained

Functional sequelae and disability assessment
703
Impairment evaluation
The physical examination of a burn victim is much the same
as the disability evaluation for any patient. With the infor­
mation gathered from the history and physical examination,
and using the tables in the American Medical Association’s
Guide to the Evaluation of Permanent Impairment, 6th
edition,2 the physician can arrive at an impairment rating.
In addition to the usual range of motion form, a question­
naire regarding the special problems related to burns is
useful (Table 62.1). The 6th edition of the American
Medical Association’s Guide to the Evaluation of Permanent
Impairment is changed from the previous editions in the
following ways.2
Standardized methodology is applied to each chapter to
enhance the relevancy of impairment ratings, improve inter­
nal consistency and promote ease of application to the rating
process. This ordered method enables busy physicians to
become proficient with the ratings for multiple organ systems
and anticipate how each chapter is organized and assimilates
information.
The 6th edition applies both terminology from and an
analytical framework based on the International Classifica­
tion of Functioning, Disability and Health (ICF), to generate
five impairment classes which permit the rating of the patient
from no impairment to most severe. A diagnosis-based grid
has been developed for each organ system. The grid arranges
commonly used ICD-9 diagnoses within the five classes of
impairment severity, according to the consensus-based dom­
inant criterion.
Using the latest evidence in diagnosis and clinical tests,
the 6th edition offers the following key features:2
•
Standardized approach across organ systems and
chapters
•
Expanded use of diagnostic approach to help
physicians consider relevant clinical tests and patient
outcomes in performing the rating
•
Required clinical information needed to rate a given
condition
•
Clear step-by-step grading instructions in each chapter
to promote consistent scoring of impairment ratings
and to improve physician consistency
•
Simplified methodology presented between chapters
•
Contemporary, evidence-based concepts and
terminology of disablement from the ICF
•
The latest scientific research and evolving medical
opinion provided by nationally and internationally
recognized experts
•
More comprehensive and expanded diagnostic
approach
•
Transparent process to allow the evaluator to document
functional assessment, clinical tests and physical
findings
•
Uniform grids to help physicians calculate impairment
ratings.
It is helpful to have members of a rehabilitation depart­
ment, namely physical therapy and/or occupational therapy,
be familiar with this evaluation. A combined approach with
either an occupational therapist or a physical therapist to
evaluate actual objective determination such as range of
motion, and a burn surgeon performing the subjective rating
Psychological
The advances of surgical techniques involving early excision
and grafting as well as the increased ability to prevent infec­
tion allow many patients who would otherwise perish to face
life shattered by psychological problems as a result of disfig­
urement. The onset of a thermal injury is a sudden and fright­
ening experience not only to a patient but also to his family
members. Because of the unexpected nature of onset, all
phases of the patient’s lifestyle are abruptly changed. Often,
the full emotional impact is not felt until the time a patient
is discharged from the protected environment of a hospital.
At this time, the reality of the emotional, physical, and finan­
cial burden of a thermal injury are apparent and must be
faced. The extent to which a person can psychologically deal
with his injuries varies, as do individual personalities. Each
case is unique and must be evaluated as such. Studies on the
psychological adjustment of survivors of burns generally
reflect a biased adjustment to moderate injuries. Few quanti­
fiable data are available concerning the psychological well-
being of long-term survivors of severe injuries. Although
most authors conclude that victims of burns make satisfac­
tory adjustments, others report symptoms of the psycho­
pathological sort which contradict this optimism.3 Public
acceptance is an important problem facing a burn patient.
Goffman, in 1963, stated that the way that burn disfigured
patients have dealt with the world has generally been shown
to be affected by society showing negative responses to visible
scars. The burn-disfigured person has to contend with their
body image as well as the attitudes of the people and the
culture around them. TV and radio have altered not only
family standards, but standards of self-perception as well.
The young and the beautiful are emphasized. Everyone must
be a ‘10’. Patients with burns, like paraplegic or quadriplegic
persons, have injuries which can be seen and understood by
the public; however, there is also marked ambivalence about
a patient with burns as emphasized by the movie industry
which has frequently characterized the evil person as being
deformed. The ‘Phantom of the Opera’ is a burn victim, while
‘A Nightmare on Elm Street’ depicts Freddie Krueger as evil,
deformed, and scarred. The burned patient must deal not
only with his burn injury but also with society’s built-in
impressions which are fostered early in life through cartoons,
advertising, television, and movies. This is especially impor­
tant in the pediatric burned patient for whom returning to
school can be difficult, to say the least. Recent studies from
the Shriners Burns Institutes in Boston and Galveston empha­
size that, in pediatric patients with large thermal injuries,
most children appear to be satisfied with their quality of
life.4–6 This finding was especially true in children with sup­
portive families who had consistent clinical follow-up and
early reintegration into society. However, outcome studies on
psychosocial impairment are difficult to assess. It is encourag­
ing to see that the Galveston study reported psychosocial
adjustment scores within normal limits, with only dimin­
ished social competency skills as issues of concerns among
their patient group. Unfortunately, in-depth feelings regard­
ing disfigurement and social integration may not surface with
the use of present medical evaluation, and further refining
and modification, in addition to our current techniques, may
be needed to bring out the latent fears and detrimental feel­
ings in these patients.

Total Burn Care
62
704
with topical medications AND when signs and
symptoms are present, there is minimal interference
with ADLs.
Class 2 impairment of the whole person is 11–27%. Skin
disorder signs and symptoms are present >30–60% of the
time AND often require treatment with topical or systemic
medications AND when signs and symptoms are present,
there is mild interference with some ADLs.
Class 3 impairment of the whole person is 30–42%. Skin
disorder signs and symptoms are present >60–90% of the
time AND require intermittent to constant treatment with
topical or systemic medications AND when signs and
symptoms are present, there is moderate interference with
some ADLs.
Class 4 impairment of the whole person is 45–58%. Skin
disorder signs and symptoms are present >90% of the time
AND require treatment with topical or systemic
medications on a regular basis AND there is severe
interference with most ADLs to the extent that
confinement may be required.
The impairment evaluation is somewhat subjective;
however, individual patients can be placed into various cat­
egories. The final impairment rating is a combination of the
for the skin or psychological status, is useful. The objective
measurements due to restriction of active motion and ampu­
tations are well outlined in the Guide to the Evaluation of
Permanent Impairment. The techniques of measurement are
simple, practical, and scientifically sound. For the examin­
ation of upper and lower extremities, a large and small
portable goniometer are used. The upper extremity, lower
extremity, the spine, and the pelvis are considered a unit of
the whole person; and tables are available in the manual to
determine impairment ratings of the whole person. The sub­
jective rating for skin or psychological determination is not
precise. The criteria for evaluating permanent impairment of
the skin are divided into five classes and are different from
previous editions of the Guides to the Evaluation of Perma­
nent Impairment:
Class 0 impairment of the whole person is 0%. Skin disorder
signs have been present in the past but are currently
present <1% of the time AND no medication is necessary
AND there is essentially no interference with activities of
daily living (ADLs).
Class 1 impairment of the whole person is 1–9%.
Skin disorder signs and symptoms are present 1–30%
of the time AND may intermittently require treatment
Table 62.1  Patient questionnaire related to burn sequelae
Decreased sensation
Yes __
No __
Areas involved __
Heat intolerance
Yes __
No __
Areas involved __
Cold intolerance
Yes __
No __
Areas involved __
Sensitivity to sunlight
Yes __
No __
Areas involved __
Sensitivity to chemicals
Yes __
No __
Areas involved __
  Area of increased perspiration
  Area of decreased perspiration
Restricted chest motion
Yes __
No __
Restricted abdominal motion
Yes __
No __
Loss of hair
Yes __
No __
Loss of nails or malformed nails
Yes __
No __
Dysesthesias
Yes __
No __
Where __
Hypopigmentation
Yes __
No __
Where __
Hyperpigmentation
Yes __
No __
Where __
Drug use
Yes __
No __
Increased alcohol use
Yes __
No __
Amount __
Donor site scarring
None __
Minor __
Moderate __
Severe __
Approximate body surface area of donor
__ %
Gastric pain
Yes __
No __
Joint pain
Yes __
No __
Where __
Tearing, photophobia
Yes __
No __
Decreased vision
Yes __
No __
Shortness of breath
Yes __
No __
Lack of endurance
Yes __
No __
Hoarseness or other vocal cord problem
Yes __
No __
Describe __

Functional sequelae and disability assessment
705
•
The most common complications arise from burn scar
contracture and cosmetic deformity, and will require
staged surgical procedures for correction.
•
Rehabilitation may take several years to return a patient
to an acceptable level of functioning.
•
Post-burn cosmetic deformity needs to be confined to
areas which are socially acceptable.
•
Resulting disabilities are not proportional to the extent
of cutaneous injury.
•
Certain complications, such as neurological
degeneration, may not arise until a few years following
an injury and are fairly unpredictable.
Many burned patients will have limitations which, indi­
vidually, fall short of the criteria needed for evaluating dis­
ability. It is important to evaluate the comprehensive result
of all limiting factors in order to accurately assess the level
of disability.
Further reading
Abdullah A, Blakeney P, Hunt R, et al. Visible scars and self-esteem
in pediatric patients with burns. J Burn Care Rehabil. 1993;
15:164-168.
Herndon DN, LeMaster J, Beard S, et al. The quality of life after major
thermal injury: an analysis of 12 survivors with greater than 80%
total body, 70% third degree burns. J Trauma. 1986;26:609-619.
Rondinelle Robert, ed. Guides to the evaluation of permanent impairment.
6th ed. New York: American Medical Association; 2009.
Salisbury RE. Burn rehabilitation: our unanswered challenge. The
1992 Presidential Address to the American Burn Association.
J Burn Care Rehabil. 1992;13:495-505.
Warden GD. Burn patients: coming of age. The 1993 Presidential
Address of the American Burn Association. J Burn Care Rehabil.
1993;14:581-588.
actual objective determinations and the subjective rating for
skin and psychological impairment.
Functional outcome
Outcome from thermal injury depends upon many factors
other than severity of illness; this may include social status,
family support, and patient motivation. A determination of
impairment combined with disability is an excellent modal­
ity to determine outcome. Presently, we perform formal
impairment ratings only when asked by insurance compa­
nies, social security, worker’s compensation, or the legal
system. With emphasis on continuous quality improvement
and insurance companies evaluating care by outcome deter­
minations, it is important for burn surgeons to document
their outcome. Impairment ratings are time consuming;
however, they are an excellent way to evaluate outcomes of
care. A systematic approach to evaluating outcomes in this
manner should be initiated.
Summary
Disability determination is a difficult and by no means
objective procedure. It is not within the scope of this chapter
to present all the possible complications and resulting
impairments secondary to burn injury.5,7,8 There are certain
concepts which must be kept in mind when evaluating a
post-burn patient for impairment and resulting deformity.
Most burn injuries which are significant enough to require
admission to a specialized burn care facility will likely result
in some type of temporary or permanent disability. Concepts
unique to burn patients:
 
Access the complete reference list online at

Functional sequelae and disability assessment
705.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Warden GD. Burn patients: coming of age, the 1993 Presidential
Address of the American Burn Association. J Burn Care Rehabil.
1993;14:581-588.
2. Rondinelle Robert, ed. Guides to the evaluation of permanent
impairment. 6th ed. New York: American Medical Association;
2009.
3. Herndon DN, LeMaster J, Beard S, et al. The quality of life after
major thermal injury: an analysis of 12 survivors with greater than
80% total body, 70% third degree burns. J Trauma. 1986;26:
609-619.
4. Salisbury RE, Carr-Collins J, eds. Disability evaluation of the thermally
injured patient. New York: Rehabilitation Committee, American
Burn Association; 1988.
5. Abdullah A, Blakeney P, Hunt R, et al. Visible scars and self-esteem
in pediatric patients with burns. J Burn Care Rehabil. 1993;15:
164-168.
6. Stolov WC, Clower MR. Handbook of severe disability. Washington,
DC: Government Printing Office; 1981.
7. Fisher SV. Disability determination. In: Fisher FV, Helm RA, eds.
Comprehensive rehabilitation of burns. Baltimore: Williams and
Wilkins; 1984:401-411.
8. Salisbury RE. Burn rehabilitation: our unanswered challenge.
The 1992 Presidential Address to the American Burn Association.
J Burn Care Rehabil. 1992;13:495-505.

This page intentionally left blank

©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00063-1
Cost-containment and
outcome measures
Juan P. Barret
Introduction
Medicine is a continuous evolving science. Several develop­
ments in medicine and burn care have occurred during the
last 6 decades, but so has the increase in financial costs of
this delivery of care. The nature of burn injury requires the
participation of many different specialties, thus leading to
the development of ‘burn teams’ and ‘burn centers.’ The
result of such collegial effort is state-of-the-art burn care that
gathers well-trained personnel with ultimate technology. The
drawback of such evolution, though, is complex treatment
with a climb in hospital costs. The complexity of burn
care in the context of the current health economic era has
made outcome measurement, quality assurance, and cost-
containment in the burn unit extremely important compo­
nents of burn care. Current financial restraints, objectivity of
limited economical resources, and in-depth critical evalua­
tion of the provision of health in modern society make
evidence-based burn care mandatory. Unfortunately, the
continuous appraisal that this new approach has introduced
in current medicine evidences the lack of available data in
many, otherwise, widely accepted therapies.
The present chapter gives an insight into the relevance of
outcome measurement as an objective reflection of the
quality of care that is provided in burn centers. The develop­
ment of quality assurance programs and the provision of
evidence-based burn therapy are necessary to maintain
excellent outcomes, while improving cost-containment.
How programs of quality assurance function and how costs
are contained with overall improvement of the quality of
care are explained below.
Socioeconomic impact of burns
The first step for any system for self-evaluation and control
is the recognition of the scope of the problem being evalu­
ated. Knowledge of the incidence, prevalence, and all rele­
vant data of the disease or condition investigated is necessary
to put the health impact into perspective and to determine
the background from which all interventions are instituted,
and audit their performance.
Burn injuries continue to plague the economic systems
of both developed and underdeveloped countries. In
developed countries, severe disabilities secondary to burns
produce significant financial losses; in the developing world,
loss of life from burns is extremely high. The death toll is
highest at the extremes of age; young adults more frequently
survive with disabilities that truncate their production in
society.1 Minor burns represent economic loss in the form
of sick leaves, and their sequelae sometimes interfere
with the productivity of the victim. Survivors of massive
burns are more prone to develop long-term sequelae, and
consequences to their families and to society can be
devastating.2,3
The overall incidence of burns in developed countries is
still relatively high, while the numbers of persons who die
from burns is remarkably low. It is reported that 820/100 000
persons per year are burned, with 30/100 000 persons per
year requiring specialized treatment. Admissions to burn
centers account for 6.5/100 000 persons per year. The gross
burn mortality in developed countries (people who die at
the scene of the accident plus people who die in specialized
units) is only 0.6/100 000 persons per year. LD50 (the body
surface area burned that kills 50% of people) in the pediatric
population4,5 and in young adults6 is over 90% total body
surface area (TBSA) full-thickness burns, and over 40% TBSA
full-thickness burns in the elderly.6 Burn mortality indices
under 4% are common among inpatient populations.
The social cost of minor burns in developed countries is
significant. In Western Europe, these costs, including the loss
of production at work of the individual, social security cost,
and the cost of the entire treatment is around 7000 Euros.
For severe burns, social costs are much higher and are to be
estimated over 40 000 Euros per patient.7 These are underes­
timates because the true social costs of long-term disabilities
resulting from burn injuries are not yet well determined.
The world estimate is more dismal. World statistics put
burn injuries to the level of a major health problem. Burns
described as ‘minor’ in developed countries produce severe
disabilities or even death in developing countries. There are
more than 150 000 fire deaths every year in the world, and
approximately 30 000 000 people in the world require
admission to specialized units. In developing countries,
survival of patients with burns over 40% TBSA burned is
minimal.8
Outcome measures
Outcome measures are the cornerstone of cost-containment
and continuous quality improvement in any given health
system. They serve to evaluate what works and what does
not, they are used for research and for the improvement of
clinical practice and to provide higher quality care in a cost-
effective manner.
CHAPTER 63 
Access the complete reference list online at

IN THIS CHAPTER
PowerPoint Presentation Online

Total Burn Care
63
708
Likewise, the performance of any given burn centre has
to be analyzed. Probit analysis, subgroup mortality audit,
catheter related bacteremia, nosocomial pneumonia, urinary
sepsis, and multiple resistant organism outbreaks are some
of the data to be monitored overtime.
Length of stay (LOS)
Length of stay (number of days admitted to hospital) is a
relevant indicator for hospital administrators. It is a direct
indicator of cost of treatment and its relevance applies to all
patients, regardless their final outcome. As pointed out by
Pereira et al.10 data on burn survival have been available for
decades, but less information has been published on LOS.
Length of stay is an indirect indicator of morbidity (uncom­
plicated patients should leave hospital sooner than compli­
cated patients), although it must be interpreted with caution.
Patients may stay longer for rehabilitation despite being
healed completely, or, conversely, patients may be discharged
home and readmitted soon after as rehabilitation patients to
change insurance coding and reimbursement. The best way
to standardize LOS to allow easy access and comparison is
to express it as a function of burn size (days/%TBSA). It can
be then used as an efficiency indicator of burn care provided,
with the ratio below 1 (<1 day per 1% burn) as a goal for
burn treatment. However, it works very efficiently and as a
good comparison method for massive burns, but it can
produce important bias when considering small burns with
specific locations (hands, face, genitalia, feet); depths (deep
burns requiring flaps), or age (pediatric or geriatric popula­
tion). We have to assume that certain populations will stay
longer than the ‘ideal’ ratio and administrators and insur­
ance companies should be aware of that.
For a long time, burn mortality has been considered a
major outcome measure of the quality of burn care. Improve­
ments in burn mortality, though, have produced a change
in the expectations of burn care providers.5,9 No longer is
survival per se a sufficient outcome measure (mortality is
being questioned as a true outcome measure in current
burn practice10), but psychosocial adaptation and physical
rehabilitation are of prime importance. The need for
some supportive services, therefore, may extend throughout
the patient’s lifetime.
Paralleling the development of modern societies, outcome
measurements in healthcare systems focus more on rehabili­
tation and quality of life than on raw incidence, prevalence
and survival rates. When this principle is applied to trauma
and burn care systems, there are four main outcome meas­
urements that are to be considered:
1. Burn mortality (raw and relative mortality);
2. Length of stay (LOS)
3. Modulation of the hypermetabolic response
4. Quality of life.
Burn mortality
Survival is still one of the major outcome measures in burn
centers. It is the most frequently used measure because data
is easily retrieved and easy to compare among different
centers. Although every burn center has its own particular
limitations, it is clear that there exists a minimum standard
of burn survival (i.e. LD50 of 90% TBSA burned in children
and young adults) that should be met given the social and
economic situations are provided. In order to achieve the
minimal standards of care, it is important to analyze the
comparability of results of every burn center. Local geo­
graphic and social parameters vary, thus the generation of
models of probability of death or probit analysis11,12 with
statistical logistic regression13 has proven useful for surveying
the outcome of burn victims (Fig. 63.1). It has the benefit
of comparability,11 but it presents also the benefit of internal
control of the burn center, since the logistic model represents
the standard of care for that given center. Ideally, the prob­
ability of survival should increase with time, reflecting the
continuous improvement of the quality of care. The respon­
sibility of the burn team is to continuously improve those
results and generate new revised models of probit analysis.
The advantage of this analysis is that it includes all the par­
ticular social and economic situations of the local geographic
area, and on the other hand it is comparable with the results
of other centers. One of the main disadvantages is that the
prediction is based only on age and TBSA burned.
Other indexes, such as the abbreviated burn severity index
(ABSI),14 includes the patient’s sex, depth of the injury, and
inhalation injury as risk factors that determine the severity
of the burn, achieving a more accurate predictive factor. If
additional factors are considered, such as pre-existing disease
or the abuse of toxic substances, the specificity and sensitiv­
ity of the predictors improve.15 However, even though sur­
vival after burn trauma is one of the primary objectives of
burn centers, raw mortality and relative mortality (mortality
index corrected per age and sex groups in the general popula­
tion) are no longer the only outcome measures in burn
health systems.10
Figure 63.1  The generation of computer models of death probabilities
helps in decision-making and in quality assurance programs. Mortality,
though, should not be used alone as outcome measure, but together with
rehabilitation parameters and quality of life.
TBSA burned (%)
Age (years)
0–10%
11–20%
21–30%
31–40%
41–50%
51–60%
61–70%
71–80%
81–90%
91–100%
0
10
20
30
40
50
60
70
80
90
100
0–0.2
0.2–0.4
0.4–0.6
0.6–0.8
0.8–1.0

Cost-containment and outcome measures
709
modern burn care. Only with such evaluation can the quality
of outcomes be improved.
Although disability and impairment assessment is one of
the main outcome measures, it alone does not describe the
quality of life that patients achieve after burns are healed and
all formal treatment is finished. One of the measures that
adapts to healthcare systems is the Quality Adjusted Life
Years (QALY) introduced by Torrance in 1986.17 One QALY
is a measure of all benefits of health treatment that include
increase in life expectancy and enhanced quality of life. The
increase in life expectancy is measured in number of years,
while quality of life is measured in a scale with a maximum
of 1 (perfect health). In this scale, 0 corresponds to death.
There are negative numbers, since there are health situations
that are considered by patients to be worse than death. The
QALY are, therefore, the number of years with perfect health
which are also compared to the number of years lived in a
specified state of health. For example, if a person lived for
70 years in perfect health and died, they would accomplish
70 QALY. Conversely, if a person lived 45 years in perfect
health, and then acquired chronic renal failure, with a
quality of life of 0.4 and died at age 70, they would accom­
plish 55 QALY [45 QALY + 25(0.4)]. There are two sorts of
methods to calculate QALY, the ‘standard gamble’18 and the
‘time trade-off’.19 The second method is the simplest and the
most used. Patients are confronted with two situations:
the situation of disease and/or sequelae for t years and the
situation of perfect health for x years followed by death. The
utility of any treatment of a chronic condition is represented
by x/t. Life expectancy under a certain chronic condition is
compiled from medical literature. This time is converted to
QALY under perfect health, and the risks of the medical
treatment are then evaluated in terms of the effectiveness in
producing QALY.
When QALY are applied to burn patients, it is easy to
assume that the treatment of severe injuries, which will result
in death without treatment, will produce an important
number of QALY. Nevertheless, many burn injuries heal with
sequelae, so that the quality of life achieved is not that of
perfect health, but sometimes quite less than that. Patients
that survive life-threatening injuries acquire a high number
of years in terms of life expectancy, whereas the total number
of QALY is often less than the optimal number. This is
Modulation of the hypermetabolic response
Burn patients exhibit a florid inflammatory and hypermeta­
bolic response that is more intense and prolonged than the
response of similar critical care and trauma patients. The
metabolic rate of a burned person is twice that of an injured
one. It causes a hyperdynamic circulatory response with
increased body temperature, oxygen and glucose consump­
tion and carbon dioxide production, glycogenolysis, prote­
olysis, lipolysis and futile substrate cycling. This will lead to
wasting of lean body mass, muscle weakness, immunode­
pression and poor wound healing. It has been an area of
intense research in the past 2 decades, and the modulation
of this response and the maintenance of lean body mass, a
competent immune system, and muscle tone and strength
are current outcome measures that can be quantified during
hospital course and late in the recovery phase. They are
important end-points that indicate the efficacy of the treat­
ment received and predictive tools for the assessment of new
therapeutic interventions. Furthermore, the modulation of
the hypermetabolic response is one of the few areas in burn
care with evidenced-based data. How to measure this
response and strategies for modulation and abrogation of
the catabolic effects of burn injury can be found elsewhere
in relevant book chapters.
Quality of life
The grade of disability and the quality of life achieved
by burn survivors are also considered main outcome meas­
ures. In modern society, it is not only survival that is impor­
tant, but also the quality of life achieved. Survival at any
price may lead to subtotal or total disability, which may
or may be not acceptable for all persons. The latest reports
of psychosocial adaptation of patients surviving severe or
massive injuries show an optimal response and adaptation
in society.2,3 Moreover, most burn survivors achieve social
adjustment that is within normal limits. Physical disabilities
are certainly common and so is change in body image
acceptance. Location of the injury (hands, face, etc.) and
background personality and premorbid psychological status
are also extremely relevant for coping with the new situation
(Box 63.1).
The physical examination of a burn victim is much the
same as the disability evaluation for any patient. With history
and physical examination, and using the tables of the Ameri­
can Medical Association’s Guide to the Evaluation of Perma­
nent Impairment, a rating of impairment can be made.16 The
techniques of measuring, although complex and time-
consuming, are practical and scientifically sound. A com­
bined approach, with an occupational or physical therapist
who makes the objective determination of physical impair­
ment and a burn surgeon who makes the subjective deter­
minations, is advisable, and, once thorough assessment has
been performed, the patient will be placed in one of the
categories for permanent impairment and disability (Box
63.1). Impairment and disability assessments are most rel­
evant for insurance companies, social security, worker’s com­
pensation, and the legal system. Since the burn team is not
only responsible for the acute care, but also for continuous
quality improvement and the evaluation of outcome charac­
teristics, disability determination is an integral part of
Box 63.1  Categories of burn impairment and disabilities
Class I: Impairment of 0–10%. No limitation or minimal limitation in
the performance of the activity of daily living. Exposure to certain
physical and chemical agents might increase limitation temporarily.
Skin disorders are present, but no treatment is necessary
Class II: Impairment of 10–25%. There is limitation in the performance
of some of the activities of daily living. Skin disorders are present
and intermittent skin treatment is required
Class III: Impairment of 25–50%. There is limitation in performance of
many of the activities of daily living. Skin disorders are present, and
continuous treatment is required
Class IV: Impairment of 55–80%. There is limitation in performance of
many of the activities of daily living. Skin disorders are present, and
continuous treatment is required, which include periodic
confinement to home or healthcare institution
Total impairment.

Total Burn Care
63
710
the best outcomes. The main steps of cost-containment
programs are:
1. Data acquisition, quality assurance, and outcome
measurement
2. Treatment protocols
3. Optimization of resources.
Data acquisition, quality assurance,
and outcome measurement
The first step to control costs in burn centers is the develop­
ment of a QA program to include data acquisition and
outcome measurement. The flow of economic efforts is then
bi-directional, from society to patient care and from burn
centers to society. All investments made in the burn center
are returned to society in the form of excellent outcomes and
social reintegration. On the other hand, the knowledge of
the most recent outcome figures for the burn unit alert the
burn team to know the point of futility of treatment. Expen­
sive efforts to save patients whose burn injuries are fatal
increase costs exponentially, decreasing the resources avail­
able for other burn patients. It is particularly true in develop­
ing countries, where all efforts need to be concentrated only
in those patients who will survive.
However, the equal responsibility of the burn team to
improve the outcome of burn patients mandates that they
push ahead to achieve better survival and better quality of
life for their patients. The line that separates futility from
constant improvement is vague. The only way to define it
and to improve outcomes without increasing futile efforts is
with burn research. Experimental and clinical burn research
produces new data, which, after critical evaluation of results,
will impact and change clinical protocols and pathways.
Quality assurance
Quality assurance (QA) means a critical appraisal of data
collected in the specific system to give assurance to users
and to healthcare providers that quality is achieved. Such
appraisal should also result in better management, lower
complication rates, and better outcomes. The essence of QA
is the idea that real quality improvements involve the con­
tinuous search for opportunities for all processes to get
better.23 Quality assurance is essential in the modern health­
care system where cost-containment and cost-efficacy are
primary end-points. QA programs provide data to support
requests for funding of burn patient care at an appropriate
level. They are primordial to suffice the minimal require­
ments that are to be met by burn centers in order to be
endorsed by national societies and state agencies.
The standard QA program is depicted in Figure 63.2. All
members of the multidisciplinary burn team (Box 63.2) join
together to satisfy common goals and to target all possible
problems encountered in day-to-day work. Should problems
arise, an assessment is made; and committees are organized
to respond if such a formal response is needed. Actions are
carried out in order to solve the problem, and the results of
such actions measured. When responses are shown to be
effective, the actions and changes in protocols are sustained.
Otherwise any new problem that was encountered with the
process is targeted for improvement, and actions carried out
to address those problems.
confusing since the overall assessment of quality of life that
burn patients express in the long run is usually higher than
expected.2,3 One of the main problems of QALY assessment
as a measure of cost-efficacy and cost-utility is that patients
tend to make a short-term estimation of life expectancy and
quality of life.20 Burn sequelae are more dramatic in the first
months and years after the injury, resulting in a low estima­
tion of QALY.
The overall assessment of quality of life has to include few
core domains, which, as a whole, gather more information
on how we do perform in quality of life issues and on how
this is appreciated by burn survivors; these domains, aside
from perceived quality of life, include psychological function
(including pain and sensory alterations), skin integrity
together with neuromuscular function, and physical role
function (disability scoring). Unfortunately, the quality of
life and the quality of delivery of healthcare perceived by
patients often differs from that assumed or measured by
health-carers and providers.
Other widely used tools are the Short form 36 (SF-36),21
which measures global reintegration and socialization and
the Vineland Adaptive Behavior Scales-Survey Form,22 which
measures a broad range of functioning in communication,
daily living skills, socialization, and motor skills.
Burn specific measures that are also helpful in categorizing
the status of health in burn survivors and their appreciation
of such recovery are the Burn Specific Health Scale (BSHS),
the Coping with Burns Questionnaire (CBQ), and the Satis­
faction with Appearance Scale (SWAP).
Cost-containment in the burn unit
Over the last 2 decades, there has been a continuous change
and evolution in health economy. The continuous increase
in world population has been joined with an increase in life
expectancy, which, along with the decrease in births has led
to an increase in the mean age of population. This is particu­
larly true in developed countries where the population pyra­
mids have reversed their shape. The increasing population
of ‘elders’ (along with the economic crisis and the expected
increase in costs of healthcare technology and specialists)
has provoked an exponential increase in health costs. Eco­
nomical analysis and cost-containment with an emphasis on
cost-efficacy and cost-utility are principal pillars of health
economy.
Assessing the maintenance of good outcomes assures that
all economic efforts invested in burn centers produce the
expected benefits with a positive cost-efficacy effect. Our
resources in contemporary society have become limited, so
the best outcomes with good cost-efficacy and cost-utility
ratios are essential. It is clear that insurance companies and
society seek healthcare systems where less investment still
results in the best outcome. It is particularly true in burn
centers; reimbursement will peak in centers that provide the
best functional outcome in a standard period of time. Con­
tracts flow when good return to productive life is achieved.
In order to maintain a dynamic and viable center, a
cost-containment program must be instituted. These pro­
grams are defined as all measures directed to produce the
best cost-efficacy and -utility ratios, i.e. to maintain costs
within expected margins and optimize burn care providing

Cost-containment and outcome measures
711
deviation and develop an appropriate action. Mortality,
probit analysis, disability, and quality of life are outcome
measures that need to be surveyed constantly. Every specialty
involved in burn care must develop their own specific
outcome measures that contribute to overall outcome in
order to assess, maintain, and constantly improve their con­
tribution to care. Examples of these secondary outcome
measures are graft take, pain control, or infection control.
At the Shriners Burns Hospital in Galveston, Texas, QA
staff members are active and indispensable members of the
burn team. Their constant surveillance helps burn patients
and burn team members by assisting to develop protocols
and by monitoring achievements according to protocols.
They promptly detect deviations so that adequate action can
be immediately taken. Their effort assures that no variables
will be left to flow without control, so the expected outcome
will result. The author finds QA staff to be important back-up
aids in helping to prevent unwanted surprises.
Finally, QA programs help to maintain cost-efficacy in the
burn center. By maintaining outcomes, the investment that
society and insurance companies make in the expensive
treatment of burn patients is rewarded by provision of state
of the art treatment and excellent outcomes. Documentation
of such standard of care should result in reimbursement and
funding that are maintained if not increased.
Evidence-based medicine in burn care
As it has been outlined in previous sections, there has been
a burst in wound technology, critical care, and biotechno­
logy during the past 2 decades. It is not uncommon to be
confronted on a daily basis with new technology, pharma­
ceutical novelties, and expensive new treatments. There has
been an exponential improvement in burn care when we
compare current survival outcomes with those published 30
years ago. However, paralleling this exponential improve­
ment there is an escalation in treatment expenses, which is
not always accompanied by clear data supporting the use of
such new technology. In the new era of healthcare, we are
confronted with the necessity of providing state of the art
burn care while containing burn care expenses. The answer
to this ethical and pragmatic dilemma consists in the ration­
alization of treatment provided supported by clear outcome
data. Evidence-based medicine plays a central role in this
model of new healthcare, and consists in the provision of
treatment based on clear protocols supported by data that
warrants cost-efficiency of the therapy used.
Unfortunately, few treatments are evidence-based in burn
care, and, most surprisingly, some evidence-based burn care
that presents with strong data supporting outcome are not
followed by burn practitioners.24 ‘The basis of care should
be that simple things should always be performed well.’ It is
not always so, and even in pre-hospital medicine and acci­
dent retrieval, we find important differences throughout the
world, despite being important outcome data supporting
what should be done in the accident scene and transport.9,25
Another of the few areas where evidence-based burn care
has exploded is resuscitation of burn shock. Resuscitation
end-points and monitoring strategies have produced
data determining when futility of treatment has been
reached, by shifting from fluids and urine-output to ade­
quate end-point monitoring, edema control, adjuvant thera­
pies, and tissue perfusion and oxygenation. This suggests
Figure 63.2  The cycle of quality assurance. The performance of the unit
is continuously assessed. When problems are detected, an action is taken
after complete evaluation of the situation. The responses and the new
performance of the unit are measured again. If the response is deemed
adequate, the action is sustained. Should the response not be appropriate,
a new cycle begins.
Target problems
Measure responses
Assessment and action
Sustain responses if satisfactory
(non-satisfactory
response)
Evaluate
Box 63.2  Members of the burn team
•
Burn surgeons (plastic surgeons and general surgeons)
•
Nurses (ICU, acute and reconstructive wards, scrub nurses,
anesthesia nurses)
•
Case managers (acute and reconstructive)
•
Anesthesiologists (experienced in burn anesthesia)
•
Respiratory therapists
•
Rehabilitation therapists
•
Nutritionists
•
Psychosocial experts
•
Social workers
•
Volunteers
•
Microbiologists
•
Research nurses
•
Support services (secretaries, environmental services, medical
records, material management, informatics, technicians, etc.)
Adapted from Barret JP, Herndon DN, eds. A colour atlas of burn care. London: WB
Saunders; 2001.
Developing a functional QA program requires the produc­
tion of clinical protocols and critical care pathways. Although
time-consuming at first, this planning saves much time in
the long-term. Members of the burn team are well acquainted
with clinical protocols that begin at an exact time point
during patient care. Time points, red flags, and self-stopping
parameters are necessary. Protocols are essential for a QA
program, since deviations from protocols are easily detected,
facilitating evaluation and assessment of the deviations.
Clinical indicators of the overall performance of the unit
must be established. It is the responsibility of every member
and every department involved in the burn care system to
provide the burn team and the QA program with indicators
of the well-functioning unit, essentially defining what the
unit would be if everything performs properly. Deviation
from these performance goals are detected and included in
the evaluation system. Outcome measures are main clinical
indicators of the performance of the burn unit as a whole
and should be evaluated periodically. Changes in outcomes
must be evaluated carefully to detect any malfunction or

Total Burn Care
63
712
optimization of resources. More than 60% of all costs in burn
centers result from the use of topical and systemic treatments,
as opposed to costs in some other surgical subspecialties,
including plastic surgery. The utilization of these expensive
treatments should follow evidence-based guidelines and
strict clinical protocols. However, decisions so as to whether
a specific treatment ought to be used or not are not based
solely on economic reasons. Prospective cost-efficacy research
nursing and medical trials are nowadays key elements in
modern burn centers. In such manner, limited resources are
tested against standards of care. The impact of topical treat­
ment expenses, specific hospital stay for that given treatment,
human resources implications (i.e. nursing requirements),
and quality of delivered care in terms of wound healing and
patient satisfaction is taken into account. Decisions are then
made based on clinical results of best practice together with
the excellency of patient-delivered treatment.32
Optimization of resources
The optimization of resources begins with the organization
and calculation of burn unit requirements. In order to cal­
culate the number of personnel required to treat all burns
in a determined area, the method of necessity is very helpful.
To determine the desired number of personnel (RT), one
must obtain the catchment population (P), the incidence of
burns (I) in persons/year, the number of hours of treatment
per day (A), the mean hospital stay in days (L), and the mean
number of hours that personnel work in the burn unit (W).33
The basic formula is as follows:
RT
P
I
A
L
W
=
× ×
×
[
]/
For example, in a geographic area with a population of 5
million people, a raw burn incidence (patients admitted to
the burn center) of 6.5/100 000 persons per year, and 1
admission/patient per year, a mean hospital stay per patient
of 16.5 days with full-time (40 h/week) personnel working
a total of 1960 h/year to provide continuous care of a patient
per 24 h, the total number of personnel required for the
complete treatment of burn patients is 65.6, calculated as
follows:
RT


people
/

persons/year
h
day
=
×
×
×
[
.
.
5 000 000
6 5 100 000
24
16 5
s
h
]/
.
1960
65 6
=
The number of beds (NB) dedicated to burn treatment is
based on the incidence of burn injuries (I), the mean hos­
pital stay (L), and the ideal index of admissions (IO) esti­
mated as 0.85 (85% of beds used for burn treatment, 15%
of beds unoccupied),34 resulting in:
NB
I
L
[
IO
=
×
×
[
]/
]
365
When this formula is applied to the same example, the
number of beds required are 17.3 beds for a geographic area
with 5 000 000 population and a burn incidence (admis­
sions to burn center) of 6.5 per 100 000 persons/year:
NB


people
/

persons/year
days
=
×
×
[
.
.
]/
5 000 000
6 5 100 000
16 5
365
0 85
17 3
×
=
.
.
Although all parameters are well known for all countries
and the theoretical burn care needs can be calculated with
that traditional methods of monitoring are not supported by
scientific data, and should be replaced by constant physio­
logic monitoring.26,27 However, despite emerging data on the
necessity of shifting to a more monitor based resuscitation,
most burn centers in the world continue to resuscitate based
on tradition and old resuscitation formulas. Similar behav­
iors are encountered in the use of human albumin solutions
and hyperbaric oxygen treatment. Strong epidemiological
data suggests an increase in mortality with the use of albumin
among patients with burns,28 and the beneficial effect of
hyperbaric oxygen in several surgical conditions is an
evidence-based therapy.29 In spite of all this data, albumin
is liberally used, and few facilities use hyperbaric oxygen
therapy. Further evidence exists on the use of diagnostic
technology (laser Doppler imaging),30 external pulse shock
wave therapy,31 alternative wound covers,32 etc. However, few
centers use this technology, despite the existing data that
supports their efficacy. It seems that tradition and personal
belief is stronger than evidence-based therapy in the burn
community. A shift in burn treatment towards evidence-
based practice is necessary to become cost-effective and
provide optimal care.
Treatment protocols and rationalization of
pharmaceutical costs
State of the art technology, pharmacological treatments, and
skin substitutes are at the top of the price ladder in health
treatment. A judicious and clear use of these technologies is
clearly indicated for such costs to provide benefit. Clinical
protocols and critical care pathways are essential elements
to control costs. Protocols and pathways are tools developed
after consensus conferences over treatments and diagnostic
tests. Experts review the quality and effectiveness of these
treatments and techniques, and a consensus is generated
about the rationale for the use of old, current, and new
technology.33 Consensus declarations are included in clinical
pathways. In this way, well thought-out methodology with
predicted costs is used to generate outcomes. If no deviations
are made and new techniques are not tried without thought­
ful consideration, the overall costs of the burn center are
contained – provided the annual number of admissions is
maintained.
The introduction and testing of new techniques need to
be carried out within well-controlled research protocols, and
all results need to be critically reviewed. New treatments
must be tested versus the standard of care at any given time,
and results compared. When better outcomes are achieved
with good cost-efficacy results, the new treatment protocol
can be general and become standard. As an example,
advances that were possible thanks to research supported by
the Shriners of North America are prompt eschar excision
and immediate wound closure, pressure garments, fluid
resuscitation, bacterial translocation control, early enteral
nutrition, and improvements in inhalation injury treatment
among others. This research was conducted as a comprehen­
sive program of experimental research followed by clinical
application in clinical research protocols. Positive results
were then applied to routine clinical protocols improving
standard patient care.
Cost-containment, besides QA programs and clinical pro­
tocols, is based in rationalization of pharmaceutical costs and

Cost-containment and outcome measures
713
Other programs of cost-containment that are very effective
in maintaining low costs and improving the quality of care
are programs to optimize human resources and programs of
day care. Human resources in the burn center can be opti­
mized by planning nurses’ shifts. Morning shifts are usually
the busiest and 8-h shifts are the most effective. Therefore,
morning shifts can be scheduled with the largest number of
nurses, while afternoon and night shifts can be staffed by
fewer. On the other hand, nurses’ shifts with flow capabilities
increase the overall performance of personnel in the burn
center. Personnel that can staff the nursing wards, outpatient
clinics, and social services provide more freedom in the
organization and optimization of resources, diminishing
costs in the burn center.
Another important change in modern healthcare is the
development of day-care programs, i.e. major wound care on
an outpatient basis and day surgery. Both types of programs
diminish the need of admission to the burn center, thereby
decreasing costs and increasing performance. This also
allows the treatment of other injuries in the burn center,
which increases reimbursement via third party payers and
via the budgets of other departments. Patients who present
with burn wounds, even large wounds, who do not need
admission for other causes and whose injuries at not at risk
of infection at home may be treated as outpatients with daily
or periodic dressing changes in the day-care unit of the burn
center. On the other hand, minor burns, with the advent of
new and safer techniques of anesthesia, can be successfully
treated surgically in day surgery. These two programs require
a strict standardization of protocols so only patients who fit
the program are included in the day care unit protocol.
Patients must be able to reach the burn center at any time,
and all risk factors and warning signs need to be explained
verbally and provided in writing to the patient and/or to the
person who will take responsibility for the care of the patient.
them, it is common knowledge that burn incidence and the
index of admissions suffer important oscillations through­
out the year. The calculation of an optimal burn center
occupation at 0.85, which is the index for optimal outcome
and cost-efficacy. Even though it does not affect the actual
function of the burn center (it does affect it if the index is
calculated at 1, with periods of bed occupation over 100%),
it makes an important impact in cost-containment, since the
maintenance of a full functioning burn center with minimal
admissions lowers cost-efficiency, and may produce an
important financial loss.
In order to optimize the index of occupation of the burn
center, and maintain it at 0.85, it is possible to admit patients
at the burn center who present with a spectrum of injuries
suitable for treatment at the burn center. Given the nature
of burn injuries, the burn team is capable of managing
patients with a spectrum of trauma and extensive cutaneous
or soft-tissue losses. Box 63.3 lists all patients suitable to be
treated at the burn center. It must be borne in mind, however,
that the burn center is a super-specialized unit created for
the care of burns, and that, as such, it may be the only facility
for such injuries in that particular area. It is imperative
to reach a balance between optimal function and cost-
containment with optimal treatment of burn injuries. To
achieve that, a set of priorities have to be created for admis­
sion to the burn center so the treatment of other injuries and
patients do not challenge the admission of severe burn inju­
ries. In Box 63.4, all patients suitable for treatment in the
burn unit are divided into three types of priorities. Priority
1 patients include all burn patients whose injuries are cate­
gorized as major injuries by ABA standards. These patients
have priority over all other patients. Patients included in
priority 2 are patients who may be treated in other special­
ized units of the hospital, but also can be treated with the
same standard of care in the burn unit and will benefit from
care by the burn team. These patients are admitted on a bed
availability basis, with the main idea of maintaining an
optimal IO. Patients included in priority 3 are patients who
do not present with acute injuries but who may benefit from
treatment in the burn center. These patients are admitted as
elective cases.
Box 63.3  Patients suitable for treatment in a burn center
•
Acute burns
•
Rehabilitation and reconstructive burn patients
•
Toxic epidermal necrolysis and other life-threatening dermatosis
•
Blunt and penetrating trauma patients
•
Brain trauma
•
Maxillofacial injuries
•
Upper and lower limb reconstruction
•
Craniofacial surgery
•
Free flap reconstruction
•
Traumatic soft-tissue avulsions
•
Pressure sores
•
Chronic wounds
•
Diabetic and vascular ulcers.
Adapted from Barret JP, Herndon DN, eds. A colour atlas of burn care. London: WB
Saunders; 2001.
Box 63.4  Priority of admissions to the burn center
Priority 1
1. Severe burns
2. Electrical injuries
3. Burns with inhalation injury
4. Burns in infants
5. Burns in the elderly
6. Burns in patients with chronic or debilitating disease
7. Toxic epidermal necrolysis
Priority 2
1. Multiple blunt or penetrating traumas
2. Brain trauma
3. Maxillofacial injuries
4. Upper and lower limb reconstruction following trauma
Priority 3
1. Free flap surgery
2. Craniofacial surgery
3. Other plastic surgery procedures.
Adapted from Barret JP, Herndon DN, eds. A colour atlas of burn care. London: WB
Saunders; 2001.

Total Burn Care
63
714
which, eventually, benefit from the limitation of the cost of
treatment per patient.
Summary
The relevant socioeconomic impact of burns and the particu­
lar characteristics of burn injuries made necessary the devel­
opment of teams to provide dedicated and specialized
treatment of burn injuries. The achievement of total burn
care and the current excellent outcomes in burn patients
have paralleled a continuous increase in the complexity of
treatment of burn victims and concomitant increase in costs
of treatment. To contain costs and to prevent decline in
standard of treatment, it is necessary to develop clinical
protocols providing strict guidelines to healthcare providers.
Thus, quality assurance programs are developed. Outcome
measurement is also a part of quality improvement, since it
is the main indicator of the quality of care that is performed
at the burn center. Outcome data are part of the data acquisi­
tion of QA programs, and outcomes are also improved by
the actions of such programs. The climb in costs must be
contained with specific measures following an overall plan
and by implementation of evidence-based medicine. QA
programs provide the tools to insure that measures to control
expenses are applied while maintaining the quality of care
so excellent cost-efficacy can be obtained. In the modern
era of healthcare management, programs of day care, admis­
sion of patients without burn injuries to the center, optimi­
zation of resources (technical and human), and programs of
telemedicine are of paramount importance to maintain the
gold standard of burn care while containing costs.
Further reading
Blakeney P, Meyer W III, Robert R, et al. Long-term psychosocial
adaptation of children who survive burns involving 80% or greater
total body surface area. J Trauma. 1998;44:625-632.
Germann G, Barthold U, Lefering R, et al. The impact of risk factors
and pre-existing conditions on the mortality of burn patients and
the precision of predictive admission-scoring systems. Burns.
1997;23:195-203.
Pereira C, Murphy K, Herndon D. Outcome measures in burn care.
Is mortality dead? Burns. 2004;30:761-771.
Ramzy PI, Barret JP, Herndon DN. Thermal Injury. Crit Care Clin.
1999;15:333-352.
Torrance GW. Measurement of health state utilities for economic
appraisal: a review. J Health Econ. 1986;5:1-30.
Every effort should be made by the burn team to start a
program of day-care, since the benefits in patient care, quality
of life, and cost-containment are spectacular when the
program is fully functioning. Optimization of resources at
the UHVH Burn Center by means of the implementation of
a comprehensive day-care program, optimization of bed
occupancy by patients with large wounds other than burns
and upper and lower limb open fractures and soft tissue
trauma has made an important impact in the cost-efficiency
of the center. A bed occupancy of 0.85 and/or time of 95%
has been achieved. Furthermore, the day-care program
allowed a decrease in the number of physical beds from 39
to 26, while maintaining the quality of care and the provi­
sion of excellent and timely burn service, thus achieving
optimal cost-efficiency.
Telemedicine
The past decades have witnessed one of the most important
developments in human history. With the advent of the
digital era, globalization and the widespread availability of
internet have provided modern medicine with new tools for
optimal delivery of healthcare.33,34 In general terms, burn
centers are responsible for the health of a determined geo­
graphical area with a matched catchment population. Burns
happen anytime, anywhere to anybody. All burn victims
should have treatment granted by experienced and dedicated
burn teams. However, even with specific guidelines for burn
injury retrieval, optimal burn care delivery may implicate, in
many instances, transportation of the patients long distances
with an escalation of costs. The utilization of high speed
digital connection and/or robotics (telemedicine) allows for
the evaluation and treatment of patients without the need
for transportation. During the initial consultation through
a physician to physician connection, a complete medical
history and examination, diagnosis and treatment plan can
be performed and a final decision to evacuate the patient can
be made. Follow-up of patients in outreach digital outpa­
tients’ clinics is also possible. In this manner, the patient
receives optimal treatment directed by the burn team at the
local hospital facility, limiting transportation and loss of
working hours in a cost-efficient manner. At the University
Hospital Vall d’Hebron, such protocol is an ongoing research
project that will modernize burn treatment in our area.
Although initial cost for the setup of the telemedicine project
is high, it is quickly reimbursed by the decreased number of
burn evacuations to the burn centers. Telemedicine projects
need to be organized with the inclusion of third-party payers,
Access the complete reference list online at

Cost-containment and outcome measures
714.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Ramzy PI, Barret JP, Herndon DN. Thermal injury. Crit Care Clin.
1999;15:333-352.
2. Blakeney P, Meyer W III, Robert R, et al. Long-term psychosocial
adaptation of children who survive burns involving 80% or
greater total body surface area. J Trauma. 1998;44:625-632.
3. Haddadin KJ, Kurdy KA, Haddad AI. Long-term psychological
effects of burn unit admission among paediatric patients with
minor burns. Ann Burn Fire Dis. 1999;12:168-173.
4. Barret JP, Desai MH, Herndon DN. Survival in paediatric burns
involving 100% total body surface area. Ann Burn Fire Dis.
1999;12:139-141.
5. Barret JP, Wolf SE, Desai MH, et al. Cost-efficacy of cultured
epidermal autografts in massive pediatric burns. Ann Surg.
2000;231:869-876.
6. Barret JP, Gomez P, Solano I, et al. Epidemiology and mortality of
adult burns in Catalonia. Burns. 1999;25:325-330.
7. Barret JP, Solano I. Socio-economic impact of adult burns in
Catalonia. Proceedings of the 2nd meeting of the Spanish Burns
Association, Barcelona, 1996.
8. Munster AM. The 1996 presidential address. Burns of the world.
J Burn Care Rehabil. 1996;17:477-484.
9. Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in
massive pediatric burns. Ann Surg. 1997;225:554-559.
10. Pereira C, Murphy K, Herndon D. Outcome measures in burn
care. Is mortality dead? Burns. 2004;30:761-771.
11. Gomez-Cia T, Mallen J, Marquez T, et al. Mortality according to
age and burned body surface in the Virgen del Rocio University
Hospital. Burns. 1999;25:317-323.
12. Finney DJ. Probit analysis. 3rd ed. Cambridge: Cambridge
University Press; 1971.
13. Hosmer DW, Lemeshow S. Applied logistic regression. New York:
John Wiley & Sons; 1989.
14. Tobiasen J, Hiebert J, Edlich RF. The abbreviated burn severity
index. Ann Emerg Med. 1982;11:260-262.
15. Germann G, Barthold U, Lefering R, et al. The impact of risk
factors and pre-existing conditions on the mortality of burn
patients and the precision of predictive admission-scoring
systems. Burns. 1997;23:195-203.
16. American Medical Association Committee on Rating of Mental
and Physical Impairment. Guide to the evaluation of permanent
impairment. Chicago: American Medical Association; 1988.
17. Torrance GW. Measurement of health state utilities for economic
appraisal: a review. J Health Econ. 1986;5:1-30.
18. Von Neumann J, Morgenstern D. Theory of games and economic
behavior. Princeton: Princeton University Press; 1947.
19. Torrance GW, Thomas WH, Sackett DL. A utility maximation
model for evaluation of health care programmes. Health Serv Res.
1972;7:118.
20. Ortun-Rubio V. La economia en sanidad y medicina:
Instrumentos y limitaciones. Euge, Barcelona; 1991.
21. McHorney CA, Ware Jr JE, Raczek AE. The MOS 36-item
short-form health survey (SF-36), II. Med Care. 1993;31:247-263.
22. Sparrow SS, Balla DA, Cicchatti DV. Interview edition survey form
manual for the Vineland Adaptive Behavior Scales. Minnesota:
American Guidance Service; 1984.
23. Wood FM. Quality assurance in burn patient care: the James
Laing Memorial Essay 1994. Burns. 1995;21:563-568.
24. Childs C. Is there an evidence-based practice for burns? Burns.
1998;24:29-33.
25. Allison K, Porter K. Consensus on the pre-hospital approach to
burns patient management. Injury. 2004;35:734-738.
26. Ahrns KS. Trends in burn resuscitation: shifting the focus from
fluids to adequate endpoint monitoring, edema control, and
adjuvant therapies. Crit Care Nurs North Am. 2004;16:75-98.
27. Holm C. Resuscitation in shock associated with burns. Tradition
or evidence-based medicine? Resuscitation. 2000;44:157-164.
28. Pulimood TB, Park GR. Albumin administration should be
avoided in the critically ill. Crit Care. 2000;4:151-155.
29. MacFarlane C, Cronje FS, Benn CA. Hyperbaric oxygen in trauma
and surgical emergencies. J R Army Med Corps. 2000;146:185-190.
30. Barret JP, Dziewulski P, Ramzy PI, et al. Biobrane versus 1% silver
sulfadiazine in second degree pediatric burns. Plast Reconstr Surg.
2000;105:62-65.
31. Hornby R, Ray K. Guidelines for health manpower. Geneva: WHO;
1980.
32. Cuervo JL, Varela J, Belenes R. Gestion de Hospitales. Barcelona:
Vicens Vives; 1994.
33. Jones SM, Banwell PE, Shakespeare PG. Telemedicine in wound
healing. Int Wound J. 2004;1:225-230.
34. Paperny DM. Computers and information technology:
implications for the 21st century. Adolesc Med. 2000;11:183-202.

©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00064-3
Management of pain and other
discomforts in burned patients
Walter J. Meyer III, Shelley Wiechman, Lee Woodson, Mary Jaco,
Christopher R. Thomas
Introduction
The words ‘burn injury’ trigger immediate and vivid images
of excruciating pain and suffering. Children are conditioned
from early childhood that burn injuries are painful and can
cause great harm. Until recently, debate continued over the
importance of pain management in the burn survivor. Many
practitioners believed that the treatment of pain, especially
in children, was more dangerous than leaving it untreated.
The past 15 years have shown that children’s pain can be
effectively and safely managed.1–3 There is mounting evi­
dence that effective pain management leads to a better long-
term outcome. Kavanagh et al.4 demonstrated that pain in a
burned patient adds significantly to the physiologic demands
caused by stress. Successful pain management can signifi­
cantly reduce the occurrence of psychological disorders such
as depression and post-traumatic stress disorder.2,5,6
A series of therapeutic approaches have been developed to
address both the pain and its associated anxiety. There is of
course some concern about potential risk for dependence
and addiction with opiates or benzodiazepines but this is
offset by the importance of treating pain aggressively. In
addition to pain and anxiety, practitioners are now focused
on pruritus as well. Scales have been developed to measure
pain, anxiety and itch separately.
Pathology of a burn injury as it relates to pain
All burn injuries are painful. Even first-degree burns can
produce at least mild pain and discomfort, especially when
something such as clothing rubs against the burned area.
Second-degree moderate to deep partial-thickness burns
result in variable amounts of pain depending on the amount
of destruction to the dermis. Superficial dermal burns are the
most painful initially. Even the slightest change in air cur­
rents moving past the exposed superficial dermis usually
causes a patient to experience excruciating pain. Without
the protective covering of the epidermis, nerve endings are
sensitized and exposed to stimulation. In addition, as the
inflammatory response progresses with the increase in swell­
ing and the release of vasoactive substances, pain is increased
and begins to involve the surrounding area.7
Areas of deeper partial-thickness burns may display a con­
fusing pattern of pain over the first few days. These areas may
show little or no response to sharp stimuli such as a pin­
prick; yet a patient may complain of deep soreness related
to the inflammatory response. These wounds are more like
full-thickness burns with respect to the pain they cause. In a
full-thickness burn, the dermis, with its rich network of nerve
endings, is completely destroyed. This leads to an initial
response of a completely anesthetic wound when a sharp
stimulus is present. Yet, patients often complain of a dull or
pressure type of pain in these areas. Once the devitalized
tissue, i.e. eschar, sloughs and is replaced by granulation
tissue a patient again experiences the sensation of sharp pain
to noxious stimuli. While not completely understood, it
appears that some deep burn injuries have a neuropathic
pain component, where regeneration of nerves and or nerve
damage creates a form of pain different from that resulting
from tissue damage.
Pain-generating mechanisms during
an initial injury
Studies of humans and monkeys confirm that burn injuries
not only make an injured area and surrounding tissue more
painful, but also cause hyperalgesia.7–9 Sensory nerve damage
may also play a role in excessively difficult to treat pain. Burn
injury is characterized by release of large amounts of inflam­
matory factors such as interleukins, which probably add to
the perception of pain and the hyperalgesia. The hyperalge­
sia is further enhanced because the burn wound heals slowly
over days or weeks.
Ptacek et al.10 found that, while there was a general trend
for pain to decrease over time, there was also considerable
variability in the course of pain among adult burn survivors.
Persons with large burns showed a higher affective (suffer­
ing) component to the pain, but there is no reliable correla­
tion between the pain scores and burn size. A source of
confusion concerning the amount of pain expressed by
burn patients is the role played by psychological problems
such as anxiety and depression. Choinière et al.11 noted
that pain at rest was significantly and positively related to
levels of anxiety or depression, i.e. with elevated anxiety or
depression, pain scores at rest increased. Although these
studies demonstrate the great variability in pain expression
in burned patients, they do not identify pain-generating
mechanisms, either physiologically or psychologically, in a
burn-injured patient. Charlton et al.12 used the State/Trait
Anxiety Inventory to measure anxiety and reported that the
study sample of adult burned patients was not particularly
anxious. Other studies have suggested that burned patients
have increased levels of anxiety, especially related to
CHAPTER 64 
Access the complete reference list online at

IN THIS CHAPTER
PowerPoint Presentation Online

Total Burn Care
64
716
accordingly. Furthermore, standardized tools allow us to
compare pain management of one patient with another as
well as one burn unit pain management with that of other
burn units in order to determine, for example, the effective­
ness of a new protocol for pain management. Another
important reason for assessing pain regularly and in a stand­
ardized way is that it communicates to the patient that we
believe she/he has pain, and we are trying to do something
about it. This communication reassures the patient, thereby
reducing the likelihood that the patient will escalate pain,
anxiety and other related behaviors.
In an attempt to understand how pain is modulated,
several experimental tools have been employed to further
elucidate the exact pathways involved in pain transmission
and to better understand the therapies used to relieve pain.
Some of these tools are: cortical evoked potentials; func­
tional brain imaging (PET or positive emission tomogra­
phy); functional magnetic resonance imaging (fMRI); source
analysis of evoked activity; and electrophysiological record­
ing from the human brain. Comparison with verbal
judgments of pain magnitude validates these physiologic
measures.
Pain measurement techniques for an adult
burned patient
A variety of pain measurement techniques have been used
with adult burned patients. The more common measures
include adjective scales (Table 64.1), numeric scales (i.e.
rating pain on a scale of 0–5, 0–l0 or 0–l00), and visual
analog scales (Fig. 64.1). Each of these scales measures the
sensory component of a patient’s pain. Adjective scales and
numeric scales are quick and easy to administer because they
do not require a visual representation of the scale. The visual
analog scale requires a visual representation of the scale to
be presented to a patient. Patients must mark or point to the
place on the scale that represents their level of pain. The
demonstrated validity of the scale allows for comparisons of
visual analog pain assessments between studies with differ­
ent patient samples.
Motivational-affective and cognitive-evaluative compo­
nents of pain are most frequently measured using the McGill
Pain Questionnaire (MPQ).22 The MPQ takes 10–20 min
treatment and outcome and that these levels may increase
over time.13–16 Anticipation of pain related to wound care
that occur at least daily can increase a patient’s perception
of pain which in turn can lead to greater anxiety. This reac­
tion may explain some findings which suggest that pain
increases over time in burned patients.17–19 Depression also
plays a similar role in enhancement of pain.20 Pain leads to
depression and depression enhances the perception of
pain.5,6 In burn care units, where very aggressive pain man­
agement is practiced, depression is not a major problem.21
Pain as a function of the healing process
As a deep dermal or full-thickness burn wound heals, either
by primary intention from excision and grafting or by sec­
ondary intention through granulation tissue and scar forma­
tion, the injured neural tissue is reorganized.18 Reflex neural
function returns to grafted burn skin approximately 5–6
weeks after the burn has been covered by autografted skin.19
Active vasodilatation, vasoconstriction, and pain sensation
all return at this time. These functions also return to the burn
wound which heals through scar formation but may take up
to 6 months for complete neural reorganization. This is the
basis of neuropathic pain in the burn wound site.
Although rare, causalgia, dysesthesia, and phantom pain
syndrome can sometimes develop in healing skin. Phantom
limb sensation and pain is more common following ampu­
tation, which is often associated with large burn injury or
electrical injury. The incidence of these chronic pain syn­
dromes seems to be related to the healing process. Burns that
have been excised and grafted on a clean and uniform vas­
cular bed rarely develop one of these chronic pain syn­
dromes. Wounds that heal by granulation and scar formation
seem to be more apt to develop a chronic pain problem
because of the continued stimulation of nerve fibers in the
area with enhancement of the hyperalgesia. Skin biopsies of
granulation tissue have clearly shown neuronal tissue entrap­
ment.19 Pain, in scar tissue, subsides over time as the scar
tissue matures.
Measurement of pain in burned patients
In many studies, patients have been asked to rate overall
pain, pain at rest, overall procedural pain, and worst pain
during the procedure. Such perplexing instructions may
account for some of the variability in pain reports. A more
reasonable approach may be to ask a patient to rate pain as
either procedural or non-procedural (background) pain,
with each given an operational definition. Procedural pain
can be defined as that related to wound care or stretching of
the patient’s scar tissue, activities that seem to cause the
worst pain for burned patients. Background pain is the dis­
comfort experienced at rest or during mild activity.
Although pain cannot be measured directly, it can be
quantified by using one of the standardized tools described
below. Using reliable and valid tools allows us to gauge the
effectiveness of our treatment for any one patient. Assessing
pain on a scheduled basis and using the same tool for each
assessment gives us information about how pain is experi­
enced by a single patient throughout the burn treatment; we
can note patterns that emerge, and schedule medications
Table 64.1  Adjective scales in English and Spanish
0  No pain
0  Nada de color
1  Slight pain
1  Dolor leve (ligero)
2  Moderate pain
2  Dolor moderado
3  Severe pain
3  Dolor severo
Figure 64.1  Visual analog scale (VAS) for children to rate their levels of
pain. (From the Varno/Thompson Pediatric Pain Questionnaire. With permission from the
American Society for Clinical Pharmacology and Therapeutics.)

Management of pain and other discomforts in burned patients
717
useful in children 0–3 years of age.38 The scale is depicted
in Table 64.2.39
Research suggests that simple self-report scales can be used
with preschool children. Examples of such scales include the
Oucher Scale (photographs of children with various facial
expressions).40–42 Drawings of faces25,43 have also been used
with preschool age children44 and school age children (8
years).39 Preschool children have also used the Poker Chip
Tool,45 color scales,46,47 and a thermometer47 to report the
degree of pain or hurt. These simple tools allow a preschooler
to report pain and are easy to use. One caution with the face
scales is that a practitioner must help a child differentiate
between physical pain and sadness unrelated to pain. Since
there is no evidence that any one of these is more valid than
another, it is recommended to pick one and use it consist­
ently. When self-report scales are used in conjunction with
observational scales, a practitioner gets a better picture of a
child’s response to pain and pain therapies.
A school-aged child’s cognitive development allows more
abstract thinking. In addition to the Faces Pain Rating Scales
which they enjoy,25 they can use simple numeric scales 0–5
in the early school years (ages 7–8) and more complex scales
0–10 or 0–100 in the later years (age 9–12). Visual analog
scales anchored with happy and sad faces and simple adjec­
tive scales also can be used with this age group.47,48 In addi­
tion to self-reports of pain, observational scales such as the
CHEOPS36 or the Procedure Behavior Check List49 can be
used with a school-aged child. Again, the important issue is
to use one selected scale consistently since no one has been
shown to be more valid than others.
Adolescents can think abstractly and can quantify and
qualify phenomena and so can use the same scales as adults.
One concern with adolescents is that, when they are ill, they
tend to regress and thus may require the use of a simpler
scale during such times.
and consists of 20 sets of adjectives which describe all three
components of pain: sensory, affective, and evaluative. Qual­
itative profiles and quantitative scores for each dimension as
well as a total pain score can be derived from the selected
adjectives. The MPQ has been translated into several lan­
guages and has been shown to be a reliable and valid meas­
urement tool. Gordon et al.23 in a prospective multicenter
study, asked 40 adult burned patients to rate their pain on
four scales: a visual analog scale; an analog chromatic scale;24
an adjective scale, and a faces scale.25 At the end of the study
patients were asked to choose their preferred scale. The
majority of subjects preferred the faces and analog chromatic
scales. Although further research is needed to validate these
findings, the preference of patients is another variable to be
considered.
Pain measurement techniques for pediatric
burn patients
The measurement of children’s pain is much more complex
than it is for adults, especially for pre-verbal children. The
assessment of pain in children has included physiologic
measurements, behavioral assessment, and patient reports of
pain. The physiologic indicators which have been evaluated
are heart rate,26 respiratory rate,26 blood pressure,26 endocrine
changes,26,27 and changes in PO2.28 None of these shows
promise as an indicator for measuring pain in sick children,
since all are affected by a variety of stressors, metabolic
changes related to a burn, and medications, in addition
to pain.
Behavior scales have been devised to measure pain by
providing standardized instructions and guidelines for
observing behaviors thought to be specific to pain. A number
of investigators29–31 have looked at infants’ cries as measur­
able behaviors that can be observed in order to evaluate
pain. These studies demonstrate that length of cry, pitch,
intensity, and other characteristics of crying may be used to
evaluate pain in infants. Likewise, infant facial expressions
may be used to code pain; a system was developed which
characterizes nine facial actions involved in the expression
of pain, but its use requires videotaping and detailed analy­
ses of an infant’s facial movements.31–33 Both the measure­
ment of crying and facial expression require too much time
and special equipment to be appropriate for the clinical
setting. Other investigators have devised multidimensional
scales that include length of cry, facial expressions, and
behavioral states in order to measure pain in infants.34,35
These scales are easier to use and allow an observer to
assess pain as either present or absent without further
quantification.
Examples of observational scales, which allow for quanti­
fication and may be used with toddlers and pre-verbal chil­
dren, are the CHEOPS (Children’s Hospital of Eastern
Ontario Pain Scale)36 and the Observer Scale.37 The CHEOPS
is a scale of six behaviors, each scored on a numeric range;
it yields a total numeric score for pain. This scale has been
shown to be valid and to have good interrater reliability. The
Observer Scale is another standardized instrument that cat­
egorizes overall pain or comfort behaviors on a scale of 1–5.
The Observational Pain Assessment Scale (OPAS), a burn
specific observational tool, was developed by Barone et al.
at Shriners Hospital for Children, Cincinnati and is very
Table 64.2  Observational Pain Assessment Scale (OPAS)39
Assess each of the areas identified in the ‘Observed behavior’ column
rating each behavior using the 0, 1, or 2 rating. Add the ratings together
for each observed behavior. Document your total score.
Observed
behavior
0
1
2
Restlessness
Calm,
cooperative
Slightly restless,
consolable
Very restless
agitated,
inconsolable
Muscle,
tension
Relaxed
Slight tenseness
Extreme
tenseness
Facial
expression
No frowning
or grimacing,
composed
Slight frowning
or grimacing
Constant
frowning or
grimacing
Vocalization
Normal tone,
no sound
Groans, moans,
cries out in pain
Cries out, sobs
Wound
guarding
No negative
response to
wound
Reaching/
gently touching
wound
Grabbing
vigorously at
wound
Used with permission of authors.39

Total Burn Care
64
718
in adult patients. Initial reliability, validity and utility studies
have been completed.57,52 A similar tool is needed for
children.
Measurement of itching
Itching is very common in burn survivors. Even in small
burns, the prevalence is 35% with moderate pruritus and
14% with severe and in many cases the pruritus impacts
daily living.58 Another series of 510 burns reported a preva­
lence of 87%.59 Patients who experience such itching often
excoriate new grafts or recently healed skin, thus enhancing
their susceptibility to infections. When the pruritus is severe,
patients can focus on nothing else. Field et al.60 reported
using a visual analog scale of 1 to10 to assess itching. Pat
Blakeney, PhD and Janet Marvin, RN at the Shriners Hospital
for Children in Galveston teamed up to develop an instru­
ment to measure itchiness, called ‘itch man’ (Fig. 64.3). This
instrument was based on a patient’s drawing of his experi­
ence in the hospital.61 Children seem to be able to relate to
‘itch man’, and validation has been completed.62 Matheson
et al. used a 5-point descriptive itch rating scale in a study
Intubated and sedated children provide more challenges
in the assessment of pain. The more disabilities that a child
has and the more medications that are being given to the
patient create challenges to the clinician. A 2-year-old child
who is blind, with only one extremity that is functioning
and who is on numerous medications, presents a huge
assessment challenge to the clinician. Box 64.1 presents a list
of clinically useful tools according to patient age.
‘Pain is what the child says it is.’53 What about the case
where the care-provider documents a lower number than the
child says it is because the care-provider believes the child is
over-rating the score? Reiman et al.54 surveyed nurses’ knowl­
edge and attitudes regarding pain and their ability to manage
pain. The modified Pediatric Nurses’ Knowledge and Atti­
tude Survey regarding pain tool (PNKAS – Shriners Version
2002) needs further validation but demonstrates the need
to consider the healthcare provider’s attitude and knowledge
of pain.
Measurement of anxiety
Anxiety is measured in a variety of ways. In 2000, Robert et
al. surveyed 64 burn treatment centers to determine how
they evaluated and treated anxiety, especially in children.50
They found that most centers did not use standardized meas­
ures of anxiety.55 Based on that survey and other informa­
tion, the Shriners Hospital for Children in Galveston has
been using the Fear Thermometer adapted by Silverman and
Kurtines56 from the Walk’s Fear Thermometer.51 That instru­
ment is illustrated in Figure 64.2.
Taal et al. introduced a tool to measure burn specific pain
anxiety scale (BSPAS).57 This tool is a 5-item scale used to
measure anxiety associated with anticipated procedural pain
Figure 64.2  Fear thermometer to rate anxiety level. (From Silverman and
Kurtines W. Anxiety and phobic disorders: a pragmatic approach. New York: Plenum; 1996
with kind permission of Springer Science and Business Media.)
None
A little
bit
Some
A lot
Very,
very
much
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
4
3
2
1
0
Figure 64.3  Itch Man Scale© to rate itching intensity in children, designed
by Blakeney and Marvin 2000 at Shriners Hospital for Children. (Reprinted with
permission of Shriners Hospital for Children.)
0
Comfortable,
no itch
1
Itches a little; does
not interfere
with activity
3
Itches a lot; difficult to
be still, concentrate
4
Itches most terribly; impossible
to sit still, concentrate
2
Itches more;
sometimes interferes
with activity
Box 64.1  Recommended pain measurement tools
for burned patients
Infants and toddlers
•
CHEOPS43
•
The Observer Pain Scale44
Preschooler
•
Faces Pain Rating Scale26,48
•
Oucher45–47
•
Pain Questionnaire50
•
CHEOPS43
School age child
•
Faces Pain Rating Scale26,51
•
Visual analog
•
Numeric scale
•
Pediatric Pain Questionnaire50
•
Procedure Behavior Checklist52
Adolescents and adults
•
Visual analog
•
Numeric scales
•
Adjective scales
•
McGill Questionnare.23

Management of pain and other discomforts in burned patients
719
other age groups.70 In all cases, the respiratory depression
responded well to an opiate antagonist such as naloxone.
Young children may have an increased sensitivity to the res­
piratory depressive effects of opiates.71
Many times with children, it is very difficult to separate
out pain complaints from anxiety or even itching. In this
case, the first step is to make sure that the pain medication
dose and type is appropriate based the response of most
patients, and that it is actually being administered. After
ensuring that the pain medication drug and dosage are ade­
quate, then one can begin to examine carefully for the other
associated problems that can mimic pain.
At the other extreme of age is the elderly patient. Again,
the tendency is to give less medication, either because these
patients do not complain as much or because they are
thought to be ‘more sensitive’ to pain medications. A realistic
and important concern with the elderly is over sedation.
Studies in non-burned elderly people have shown that, with
increased age, the efficiency of the clearance mechanism for
certain drugs is decreased, and repeated doses may lead to
drug accumulation.
Table 64.3 provides a matrix summary of therapies that are
recommended for procedural and background pain over the
three phases of burn care. A variety of routes or methods of
administration are also suggested. The routes or methods
recommended include the intravenous bolus (IVB); intrave­
nous continuous infusion (IVCI); patient-controlled analge­
sia (PCA), and orally administered agents on a time interval
rather than pain contingent (non-pain contingent; NPC)
basis. Whether more or less morphine ends up being given
is not clear. However, many patients especially adolescents,
greatly prefer being in charge with a PCA.
Many patients also require anxiolytic medication along
with the analgesic medication. Therefore, included in Table
64.3 are the anxiolytic agents which are suggested for use by
several authors. In a recent review of the practices of three
pediatric burn hospitals it is clear that the vast majority of
children with moderate and large burns receive both opiates
and benzodiazepines.72 This is also the experience in the
Shriners Hospital for Children in Galveston Texas.2
Emergency phase
If the initial burn injury can be closed surgically, that gives
the best relief of pain. The pain is predominantly related to
the open wound. Once the wound is closed, the pain sub­
sides. The use of resection and grafting of open burn wounds
significantly reduces the burn pain. Open wounds should be
grafted as soon as they are clean enough to do so. Even
temporary coverage with cadaver skin or pigskin reduces
pain in the area of the burn. In the case of second-degree
wounds, the use of BiobraneRX, OpsiteRX, TegadermRX
DuodermRX or other wound-covering dressings almost
immediately eliminates pain in the burn wound site.73–77
Cultured allogeneic keratinocyte sheets accelerated healing
and thereby reduced pain and suffering compared to
OpsiteRX treatment.78
Sometimes the pain can be managed by topical agents.
Aloe vera has been used as a home remedy for many genera­
tions. Recently, there have been several studies to examine
its efficacy more thoroughly. Maenthaisong et al. did a sys­
tematic review with a meta-analysis and concluded from the
comparing effectiveness of shower and bath oil treatments
for severe itch, but that scale does not seem suitable for
children and is not validated.63
In summary, symptom assessment and management are
very important in burn care. The experience of pain may
affect the perceptions of other symptoms, including anxiety,
fear or itch. Each symptom should be assessed within the
context of other symptom assessments. Further studies need
to be completed in all these areas.
Treatment considerations
Once the pain has been assessed and quantified, treatment
can be considered. Three modalities of treatment are effec­
tive with pain secondary to burn injury. They include surgi­
cal, pharmacological and behavioral treatment. The type of
treatment depends on the time since burn. The following
will consider the types of treatment by time after burn:
•
Emergency or resuscitative phase (0–72 h after injury)
•
Acute phase (72 h to 3 or 5 weeks, until the wounds
are closed)
•
Rehabilitative phase (from the time of wound closure
to scar maturity). This phase may last months to years.
Pharmacologic management of pain
Pharmacologic management of burn pain is the mainstay of
therapy. General rules are helpful in governing the use of
pain medication. The first tenet is that if the patient says he/
she is having pain, he/she is suffering. The second tenet is
that analgesics are most effective when given on a regular
scheduled basis (not ‘as needed’ or PRN). Third, pain medi­
cation should not be given as an intramuscular injection,
since injections themselves cause pain and anxiety, and
almost never present an advantage over other routes of
administration. Lastly, dose and type of medication should
be re-evaluated frequently to make sure pain is continuously
controlled and that the patient is experiencing no serious
side-effects. The dosing of medication should be adjusted for
the general clinical condition of the patients, considering
factors of nutritional state, shock, sepsis, age extremes, and
concurrent illnesses such as hepatitis. Review articles1,2,64–69
during the last 14 years recommend a variety of therapeutic
modalities for background and procedural pain during each
phase of burn treatment.
Since the pharmacologic management of burn pain not
only spans the phases of burn care, but also must be tailored
to meet the needs of all age groups, it is important to
comment on pain management in both the very young and
the elderly. There is a tendency to give less medication to
young children because ‘they don’t complain of pain.’ This
opinion is supported by the fact that some children become
very withdrawn rather than screaming when they are receiv­
ing painful stimuli (e.g. abused children). It is unlikely that
a burn is any less painful in a 3-month old than in a 30-year-
old; thus, the same therapeutic modalities adjusted for
age and size are appropriate for burned children. A major
issue of treating pain in young children is the safety risk of
using opiates. One example is a 1998 report of the Seattle
group concerning respiratory depression in three children
treated with standard doses per kilogram of opiates given to

Total Burn Care
64
720
Table 64.3  Pharmacologic therapies for burn pain relief
Emergent phase
Procedural analgesics
Background analgesics
Anxiolytics
Morphine (IVB, IVCI)
Morphine (IVCI, PCA)
Diazepam (IV) (Valium)
Meperidine (IVB)
Meperidine (PCA)
Lorazepam (IV) (Ativan)
Fentanyl (IVB, IVCI)
Methadone (PO, NPC)
Midazolam (IV, IVCI) (Versed)
Hydromorphone (IVB, PO) (Dilaudid)
Nalbuphine (IVB) (Nubain)
Ketamine (IV) (Ketalar)
Nitrous oxide (IH)
Acute phase
Procedural analgesics
Background analgesics
Anxiolytics
Morphine (IVB, IVCI, PCA); Roxanol (oral morphine)
Morphine (IVCI, PCA)
Diazepam (PO) (Valium)
Meperidine (IVB, IM)
Meperidine (IVCI, PCA)
Lorazepam (PO) (Ativan)
Fentanyl (IVB, IM)
Methadone (PO, NPC)
Alprazolam (PO) (Xanax)
Hydromorphone (PO) (Dilaudid)
Sustained release morphine (PO, NPC) (MS Contin)
Nalbuphine (IVB) (Nubain)
Acetaminophen (PO, NPC)
Ketamine (IV, IM) (Ketalar)
NSAIDs (PO, NPC)
Oxycodone (PO) (Percocet)
Choline magnesium trisalicylate
Rehabilitative phase
For severe pain
For mild to moderate pain
Anxiolytics
Hydromorphone (PO) (Dilaudid)
Oxycodone (PO) (Percocet)
Diazepam (PO) (Valium)
Fentanyl (transmucosal)
Non-steroidal anti-inflammatory drugs (NSAIDs) with or
without narcotics
Lorazepam (PO) (Ativan)
Morphine (IVB, IVCI, PCA)
Usually not necessary: Acetaminophen NSAIDs
Alprazolam (PO) (Xanax)
published studies of first- and second-degree burns that aloe
vera was more effective than the control.79 It was associated
with a shorter healing time by 8.79 days. A more recent
randomized controlled study in 2009 by Khorasani
et al. confirmed the greater efficacy of aloe over silver
sulfadiazine.80
As noted under above, physical coverage of the burn
wound decreases pain.81,82 For instance, leaving blisters intact
leads to less pain.83 But this practice is questionable because
of possible infection associated with the blisters. One addi­
tional issue concerning procedures is the amount of pain
created from removing a dressing over the burned area.
These removals are usually facilitated by soaking the dress­
ings off but the soaks are sometimes painful. Some of the
newer dressings are easy and painless to remove; moist
exposed burn ointment dressings84 are being developed to
reduce that pain.
Acticoat was found to be much less painful than silver
sulfadiazine in the treatment of partial thickness burns by
Varas et al.85 Several new lipidocolloid dressings seem to
show promise for reducing pain86,87 Cellulose dressings also
reduce pain.88 Several new products are adherent to dry skin
but not moist skin and therefore cause much less pain.89,90
Suprathel is a reabsorbable skin substitute which goes even
further in reducing the pain of dressing.91
One more novel technique of painlessly cleaning the burn
wound is to use an ultrasound mist. There are two short
reports advocating this.92,93
Sometimes nerve blocks, either local or regional, work;
they are usually done with lidocaine or related compounds.
Pedersen et al.94 reported the use of EMLA cream, a
prilocaine and lidocaine mixture, to burn wounds in a
double-blind randomized manner for 8 h to reduce pain but
it did not reduce late hyperalgesia. Whenever EMLA cream
is applied to disrupted skin or large areas, caution should be
taken to avoid toxicity from systemic absorption. Seizures
and other CNS toxicity have been reported from these
circumstances.95–97
Both bupivacaine and lidocaine infiltration of the burn
wound eschar site or the grafting site have been successfully
used to reduce pain.98–100 In non-randomized and non-
controlled studies, sympathetic nerve blocks with lidocaine
are effective for blocking thermal pain.101–106
Physiological changes and treatment occur in patients with
burns >10% total body surface area (TBSA). During the
emergency phase, the preferred route for most medications
is the intravenous route because of potential problems with
absorption from the intramuscular site and stomach due to
decreased perfusion. Of the agents recommended for the
relief of procedural pain, morphine is the most widely used.
For procedures, IVB and IVCI are the most common methods
of administration used. For extremely painful procedures in
both the emergency and acute phase, fentanyl has a major
advantage, in that it is shorter acting and avoids over seda­
tion following a procedure, as might occur with repeated
doses of morphine. Higher opiate doses during the initial
resuscitations are associated with higher resuscitation
volumes107; this is probably secondary to the vascular effects
of the opiates. As noted above, we have few studies of the
pharmacokinetics of opioids and anti-anxiety drugs in
burned patients. Martyn, in a review of pharmacologic
studies in burned patients, describes a variety of pathophy­
siologic changes accompanying burn injury, which can alter
drug deposition.108 These changes include cardiovascular

Management of pain and other discomforts in burned patients
721
Although the main effect is on the µ-opiate receptor which
alleviates pain, it also stimulates the N-methyl-D-aspartate
(NMDA) receptor, which causes the development of a
hyperalgesic state associated with morphine tolerance and
complications such as bowel obstruction. Changing to
other opiates, such as methadone, or other compounds,
such as ketamine, which block the NMDA receptor path­
ways can improve the management of pain no longer
controlled with morphine.112–116 Other opiates such as
hydromorphone (Dilaudid), levorphanol (Levo-Dromoran),
fentanyl, and methadone are all excellent oral agents for the
relief of moderate to severe pain when given in equianalge­
sic doses to morphine. Fentanyl comes in a convenient fla­
vored Oralet, especially attractive for use with children. The
combination of lorazepam, given with hydromorphone 45–
60 min before a procedure, results in reasonable pain
control for the majority of adult patients. As with other
opioid analgesics, tolerance may develop rapidly, so the
dose of hydromorphone may need to be adjusted fre­
quently. Opiate clearance seems to be faster in individuals
with burn injury.117–119 Methadone has a longer half-life
than morphine and therefore can provide coverage for a
longer time between doses. Also methadone has been noted
to give smoother pain relief for children postoperatively
than morphine.115 Methadone is different from morphine
both pharmacokinetically and pharmacodynamically and
has been reported to be effective in patients tolerant to and
poorly-controlled by morphine. In addition, methadone is
a fraction of the cost of most other opioid analgesics.116 We
do not use meperidine because many individuals report a
rush with IV meperidine, thereby adding to its addictive
qualities.
Pain associated with dressing change is very important to
manage well. Finn suggested adding patient PCA intranasal
fentanyl versus oral morphine.120 In a randomized double
blind placebo controlled study of 26 adults, they concluded
that intranasal fentanyl was as effective and safe as oral mor­
phine. Also Prakash et al. reported using PCA with fentanyl
as an effective alternative.110
From the published literature concerning the use of
opioids in patients with burn injury, one would have diffi­
culty making decisions about the best drug, the best dosage
range, or the best route or method (i.e. PCA, or continuous
infusion) of administration of these drugs.110,117–123 Morphine
or other opioid analgesics are considered mainstays of pain
relief for burned patients, but many reviewers report less
than adequate pain relief for burned patients with the use
of such agents.124,125 The line between enough opioid anal­
gesics to provide pain relief and too much causing respira­
tory depression is difficult to find. Also, the experience of the
authors has shown that even a PCA regimen must be indi­
vidualized and frequently adjusted.
More recently, gabapentin has been advocated for acute
burn pain.126 It may be effective because the nature of a burn
injury is destruction of nerve endings in the skin. Studies by
Cuignet et al. documented that if 2400 mg of gabapentin is
given to adult burn survivors per day, the amount of mor­
phine needed is less and the pain control better.127
Anxiety medication should be considered only after the
patient’s pain has been aggressively treated. The medical staff
can inappropriately attribute the patient’s complaint to
anxiety (‘just anxious’ is a frequently used phrase) when, in
changes, alteration in renal and hepatic function, and fluc­
tuations in plasma protein concentration, which may render
pharmacokinetic studies of non-burned patients not appli­
cable to burned patients. Since it is difficult to predict pre­
cisely how drug responses will be altered, it is important to
monitor responses on drug levels more closely so that dosage
can be titrated to the individual patient’s needs. In addition
to opioid analgesics, anesthetic agents such as ketamine and
nitrous oxide may be used for procedural pain and are dis­
cussed in more detail below.
Acute phase: background pain and anxiety
During the acute phase, the choice of pharmacological
agents used to manage procedural pain encompasses a
number of orally administered opioid analgesics. The pain
management is divided into background pain and proce­
dural pain. To control background pain during the acute
phase, the use of PCA or NPC (non-pain-contingent) medi­
cation regimens are far superior to the PRN (as requested)
method. Allowing a patient to medicate himself as needed
usually results in better and smoother pain control as well
as better staff and patient relationships. For a burned patient
with extensive hand burns, the control cord can be fitted
with a padded pedal-type apparatus that can be positioned
so that the patient can press it with a foot, elbow, etc. Occa­
sional patients will use the highest dose allowed in order to
withdraw from the entire treatment setting. If this occurs,
confrontation and negotiation are important to get the
patient back to the task at hand.
Important caveats for the use of PCA should include:
1. An initial bolus in adults of 0.1 mg/kg of morphine or
equivalent dose of other drugs
2. Increasing the patient-controlled dose as needed to
achieve pain relief (recognizing that tolerance develops
at varying rates in individual patients)
3. Planning for a change in dosing regimens at night to
include:
a. giving a bolus dose at bedtime;
b. doubling the patient controlled dose and
lengthening the time interval between doses so that
when a patient awakens in pain, he or she does not
have to lie awake to push a button several times in
order to get adequate medication;
c. if the increased intermittent dosing is not adequate,
being lenient with bolus doses or to start a patient
on a continuous morphine drip at night.
Opioid analgesics have been the mainstay of burn pain
drug therapy.109 Among the opioids, morphine is the most
commonly used for background pain. Morphine can be
given orally or parenterally but bioavailability of oral doses
is reduced by first pass hepatic metabolism and the dose
must be two- to three-fold higher than the IV dose. For pro­
cedural pain, other opioids with more rapid onset and
shorter duration may be more appropriate for procedural
pain.110,111 Treatment with narcotics has been associated with
tolerance and a hyperalgesic state that makes pain more dif­
ficult to treat.
Of these agents, morphine has continued to be the main­
stay for both background and procedural pain manage­
ment. Long-term use of morphine has several inherent
problems. Morphine binds to more than one receptor class.

Total Burn Care
64
722
These drugs are distinguished by several unique features.
Profound sedation is possible with minimal effects on
respiration.149 Patients sedated with dexmedetomidine can
often be aroused. The α-2 adrenergic agonists are not con­
trolled substances and there are no reports of substance
abuse with clonidine or dexmedetomidine. Use in the ICU
has not been associated with withdrawal symptoms even
when dexmedetomidine was infused for up to 168 h at
0.21–0.49 µg/kg per hour.149 Long-term administration of
dexmedetomidine infusions in burn patients achieved ade­
quate sedation.148,150,149 No tachyphylaxis and no rebound
hypertension or tachycardia were observed when the drug
was discontinued.
In our institution, pediatric burn patients poorly control­
led with morphine and lorazepam have been found to
respond to orally administered (nasogastric tube) clonidine
in doses of 2–5 µg/kg (unpublished observations). When
more profound sedation of intubated patients is required,
we have used continuous infusion of dexmedetomidine
0.3–0.7 µg/kg per hour after a loading dose of 1 µg/kg intra­
venously over several minutes.
Acute phase: procedural pain and anxiety
During the course of the acute phase of injury, burn patients
must endure numerous painful procedures that produce
intense physical and psychic stress. Among others, these
include initial wound debridement, daily dressing changes,
range of motion and exercise therapy, wound staple removal,
and placement of intravascular catheters. For a number of
reasons, adequate control of the pain and anxiety associated
with these procedures is especially challenging (Box 64.2)
Poorly-controlled pain can make it difficult to accomplish a
procedure effectively or safely and increases anticipatory
anxiety that can impair patient compliance and may contrib­
ute to behavioral morbidity such as post traumatic stress
syndrome.151 In addition, increased sympathetic tone which
is associated with exaggerated catabolism, impaired wound
healing and immune function are associated with pain and
can contribute to prolonged hospitalization.152,153 Effective
pain control in adults can often be sufficient to reduce
anxiety. In pediatric patients, however, anxiolysis is also
needed. For especially stressful procedures, most pediatric
patients must be rendered insensible. For this reason, the
popular term ‘conscious sedation’ is usually inaccurate and
misleading when treating pediatric patients. A very young
patient who is aware of the procedure will resist enough to
make the procedure difficult or less safe and the anxiety
associated with this experience makes future procedures
more difficult. The level of sedation and analgesia required
in this situation cannot accurately be described as ‘conscious
fact, the patient is really experiencing pain. For anxiety
during the acute phase, lorazepam is usually used. Martyn
et al.128 studied the pharmacokinetics of lorazepam in
burned patients. After a single dose, there was a rapid decline
in concentration due to the high lipid solubility and rapid
tissue uptake, leading to a shorter hypnotic effect of the drug.
Patterson et al.129 reported that, in a double-blind placebo-
controlled study of 79 patients, 1 mg lorazepam did signifi­
cantly reduce procedural pain ratings in those patients with
high baseline pain, but did not reduce baseline trait anxiety.
Based on Martyn’s work, we would conclude that lorazepam
would be superior to diazepam in treating anxiety in burned
patients.128 Martyn et al. suggest that, in addition to the fact
that the clearance of lorazepam is faster than diazepam in
burned patients. In a recent survey of the use of anti-anxiety
drugs in burned children, 72% received lorazepam at a dose
of 0.03–0.05 mg/kg or higher every 4 h for much of their
initial hospitalization.2 Lorazepam provided aid in anxiety
control with essentially no side-effects. Fewer than 1% of the
children had hallucinations or delirium associated with
rapid changes in dose. The occasional child responds with
increased agitation or delirium rather than sedation, an
occurrence we have also noticed infrequently.130
Occasionally, burn patients are poorly-controlled with
morphine even in conjunction with lorazepam. Clonidine
or dexmedetomidine have been found effective in such clini­
cal situations and provided suitable sedation and dramatic
reductions in morphine dose.131,132 Alpha-2 adrenergic ago­
nists (clonidine and dexmedetomidine) have sedative, anxio­
lytic, analgesic, and sympatholytic properties. Noradrenergic
pathways within the locus ceruleus of the brain stem help
regulate vigilance, wakefulness, and sleep. The locus ceruleus
contains one of the highest densities of α-2 adrenergic recep­
tors in the body. Administration of α-2 adrenergic agonists
produces decreased brainstem norepinephrine turnover
resulting in increased activity of inhibitory (GABA) neurons
which mediates the sedative and anxiolytic effect of these
drugs.133,134 Alpha-2 adrenergic agonists are potent anxio­
lytics and have been used effectively to treat post-traumatic
stress syndrome. Clonidine is also used in controlling
attention deficit disorder. Alpha-2 adrenergic agonists can
produce profound analgesia through central mechanisms.135
Clonidine and dexmedetomidine have both been found to
reduce anesthetic and postoperative analgesic require­
ments.136,137 Intranasal dexmedetomidine (2 µg/kg) has been
found to be equally effective as oral midazolam (0.5 mg/kg)
for preoperative sedation of pediatric patients scheduled for
burn reconstructive surgery.138 Dexmedetomidine has been
found effective as the sole analgesic in ventilated postopera­
tive patients.139,140 Orally administered dexmedetomidine
(2.5 µg/kg given 20–30 min pre-procedure) produced suit­
able sedation and allowed placement of peripheral venous
catheters in pediatric patients with neurobehavioral prob­
lems.141 Clonidine is useful in pain and anxiety management
either alone or in conjunction with opioids.142–144 It has the
advantage of not causing pruritus or respiratory depression.
Much data exists concerning its use in adults and children
in the preoperative and postoperative setting.145,146 Dexme­
detomidine has been used to facilitate withdrawal of opioids
in critically ill patients.147 When administered in higher
doses, dexmedetomidine has been used by itself as a general
anesthetic.148
Box 64.2  Challenges associated with sedation and analgesia
for procedures in burn patients
1. Intense but brief pain
2. Risks of complications with deep sedation
3. Controversy over who should administer deep sedation
4. Prolonged effects of deep sedation
5. Frequent NPO periods disrupt nutritional needs of burn patients.

Management of pain and other discomforts in burned patients
723
open the airway are not successful (operator skill or difficult
patient anatomy) hypoxia can result. An airway exam is a
critical part of the pre-procedure evaluation and a sedation
plan must take into consideration potential difficulties with
airway and respiration. Obstruction due to laryngospasm
can be very difficult to relieve and in extreme cases may
require muscle relaxation and intubation. Hypoxia can also
result from hypoventilation due to depressed respiratory
drive. If airway reflexes are depressed aspiration of gastric
contents may occur when passive reflux or active vomiting
occur. In addition, deep sedation can cause loss of sympa­
thetic tone or direct cardiovascular depression. These effects
can lead to morbidity due to hemodynamic instability.
Adverse events associated with deep sedation during
endoscopy161 led the Joint Commission to set guidelines
for sedation that included restrictions regarding who can
administer deep sedation. A controversy developed since the
American Society of Anesthesiologists (ASA) defines general
anesthesia as a condition induced by medication that results
in the patient’s inability to respond purposefully to com­
mands.162 Since hospital guidelines restrict administration of
general anesthesia to anesthetists, this interpretation pre­
cludes personnel other than anesthetists from administering
deep sedation. Although the Joint Commission adopted the
ASA definition of general anesthesia, other medical special­
ties developed their own guidelines whereby formal training
in anesthesiology is not required to administer drugs and
monitor patients for moderate or deep sedation.163 Requir­
ing the presence of an anesthesiologist or certified nurse
anesthetist during moderate or deep sedation creates prob­
lems in that there are not enough anesthetists available to
provide coverage for all procedures and the added profes­
sional fees significantly increases the costs of these proce­
dures often, it is argued, without proportional added benefit.
Numerous studies have demonstrated that with competency
based credentialing along with appropriate planning and
organization, moderate and deep sedation can be adminis­
tered safely by non-anesthetists. Components of a suitable
program are listed in Box 64.3. Currently (Joint Commission
update from July 10, 2010), Joint Commission standards
require that personnel ‘permitted’ to administer sedation
must be able to rescue patients from the effects of sedation
that intentionally or unintentionally result in a state of
general anesthesia. The Joint Commission now leaves it up
to each organization to decide how to determine which
sedation.’ A more accurate descriptive term is moderate or
deep sedation for procedures. The depth of sedation must
be individualized depending on the intensity of the pain
associated with the procedure and the patient’s maturity,
level of anxiety, and pain tolerance.
Several effective protocols for delivery of moderate seda­
tion for procedures have been published, involving a variety
of drugs and routes of administration.111,154–156 The ideal
pharmacological treatment would be easily administered in
a palatable form, produce intense analgesia with a rapid
onset, relatively short duration of action, and with minimal
side-effects. Most drugs in current use will produce pro­
longed sedation when given in doses that prevent most of
the intense pain during wound care. On a daily basis, this
prolonged period of sedation can interfere with nutritional
support and other therapies. In the outpatient setting without
an intravenous catheter, the most common technique is to
give a pre-procedural fixed dose of an analgesic with or
without an anxiolytic by the oral, transmucosal, or intranasal
route. Fentanyl citrate is available as a flavored Oralet to
administer by the oral transmucosal route. The oral trans­
mucosal route has the advantage of direct absorption into
the systemic circulation which bypasses the first pass hepatic
clearance effect and improves its bioavailability.
Sharar and colleagues have compared oral transmucosal
fentanyl citrate with hydroxymorphone154,157 and oxyco­
done158 and found similar analgesic and sedative efficacies.
Humphries et al. found oral ketamine to be effective.159 In
pediatric patients prior to dressing change, Borland and col­
leagues compared analgesia and sedation with morphine
administered orally and fentanyl given intranasally.155
Although both were effective, intranasal fentanyl was more
palatable and had a much more rapid onset. Although these
regimens provide significant analgesia, pain control is often
not optimal. It is difficult to provide sufficient analgesia with
enterally administered drugs to control the intense pain
without unacceptable risk of adverse effects, especially pro­
longed sedation. Remifentanil administered intranasally is
an attractive alternative. Remifentanil is an ultra short acting
opioid rapidly metabolized by plasma esterase.160 In our
institution 5–10 µg/kg of intranasal remifentanil enhanced
the effectiveness of oral transmucosal fentanyl as judged by
pain scores and the subjective evaluations of nurses and
patients (unpublished observations) and did not delay
recovery. The ultra short duration of action allows rapid
recovery which reduces risks of sedation and may improve
patient satisfaction.
When patients have an intravenous catheter in place there
are many more treatment options that allow more profound
analgesia, more rapid onset with shorter duration of action,
and depending on which drugs are administered, reversal of
drug toxicity with antagonists. Sedative and analgesic drugs
can be given as a bolus with supplemental doses given as
needed, as an infusion to be titrated or supplemented with
bolus doses, and by patient controlled analgesia (PCA).
Deep sedation can be associated with the risk of serious
morbidity and even mortality. Deep sedation can be associ­
ated with airway obstruction, depressed airway reflexes and
respiratory drive, and hemodynamic instability. Loss of con­
sciousness causes reduced pharyngeal tone and airway
obstruction of varied degree depending largely on the
patient’s anatomy. If this is not recognized or attempts to
Box 64.3  Organizational recommendations for provision of
moderate or deep sedation for procedures
1. Pre-procedural evaluation of the patient including airway exam
2. A documented plan for sedation and monitoring
3. Availability of equipment for continuous monitoring of breathing
effort, airway patency, oxygenation, and circulation
4. A designated practitioner with documented airway skills whose
primary responsibility is to administer the sedative drugs and
monitor the patient during the procedure and during recovery
5. Personnel administering and monitoring sedation cannot be the
individual performing the procedure, and can do other tasks only
for brief intervals
6. Resuscitation equipment must be immediately available.