Điều Trị Bỏng Toàn Diện (Bản Expert Consult)

Total Burn Care
3
30
injurious fireworks were, in descending order, firecrackers,
sparklers, and rockets. Sparklers, which burn at more than
1000°F, can ignite clothing and cause typical flame burns in
addition to contact burns. Children aged 4 and under are at
the highest risk for sparkler-related injuries.34 A report of
seven patients with burns due to snap-cap pyrotechnic
devices noted that six required hospital admission, with four
undergoing split-thickness skin grafting for closure of burns
to the leg caused by the explosion of multiple devices in one
trouser pocket. Proposed prevention measures include
reducing the explosive units per package, package warnings,
and limiting the sale of the devices to children.123 At the US
Army Institute of Surgical Research Burn Center, only four
(0.1%) of 3628 burn patients admitted during a 15-year
period had been burned by fireworks. In 2008, an estimated
22 500 fires were started by fireworks, which caused $42
million of property damage.124
Burn injury can also be intentional, either self-inflicted or
caused by assault. Data from 16 states evaluated by the
National Violent Death Reporting System revealed that in
those states in the United States in 2007, 15 882 individuals
were fatally injured as a consequence of violence.125 Within
that group fire/burns were the cause of 77 (0.5%) of all
violent deaths, representing an incidence rate of 0.1 /100 000
population. The violent deaths included 30 suicides (21
males and nine females), of which four were current or
former members of the US Military. Only nine of the total
77 violent deaths due to burn injury were in patients aged
50 or over. There were 28 homicides caused by fire/burns,
which occurred in 17 males and 11 females and represented
0.6% of all homicides. Burn injury was considered the cause
of death in 21 patients or 2.7 % of patients killed in multiple
violent death incidents. In another 19 deaths in which a
specific cause of death could not be determined, burn injury
was considered to be the probable cause.
It is estimated that 4% of burns (published range 0.37–
14%) are self-inflicted. A retrospective review of 5758 burn
patients treated at a regional burn center during a 12-year
period identified 51 patients (26 males and 25 females) with
a diagnosis of self-inflicted burns.126 In 42 patients, in whom
the injury was an attempt at suicide, the burn involved from
1% to 84% TBSA, with an average extent of 22%. Twelve
(28%) of those patients died. There were nine patients in
whom the injury was considered a form of self-mutilation.
Those injuries typically caused by flames involved 1% to 5%
TBSA, with an average extent of 1.4%. Forty-three percent of
all the injuries occurred at home, and 14 (33%) occurred
while the patient was in a psychiatric institution. Seventy-
three percent of the patients had a history of psychiatric
disease: in the suicides these were predominantly affective
disorders or schizophrenia, and in the self-mutilators per­
sonality disorders. Fifty-five percent of the suicides had pre­
viously attempted suicide; 66% of the self-mutilators had
made at least one previous attempt at self-mutilation. The
authors concluded that the very act of self-burning warranted
psychiatric assessment.
The extent of such injuries has been reported to be greater
than that of accidental burns, with the head and torso more
frequently involved than in patients with accidental burns.
Consequently, the hospital stay was typically longer
than that of patients with accidental burns.127 Buddhist
ritual burning using contact with smoldering incense is a
States.119 Of those who died, 1125 (85%) were male and 896
(68%) were 15–44 years of age. The annual death rate from
lightning was greatest among patients aged 15–19 (six deaths
per 10 million population; crude rate 3 per 10 million) and
is seven times greater in males than in females. The greatest
number of deaths caused by lightning occurred in Florida
and Texas, respectively 145 and 91. However, New Mexico,
Arizona, Arkansas, and Mississippi had the highest crude
death rates of 10, 9, 9, and 9 per 10 000 000 population
respectively. Lopez and Holle note that National Oceanic
and Atmospheric Administration data identified an average
of 93 deaths and 257 injuries caused by lightning occurring
each year during the period 1959–1990.120 Those authors
also cited a study based on national death certificate data for
1968–1985 which reported an average of 107 lightning
deaths each year, and an annual death rate of 6.1 per 10
million population. Approximately 30% of persons struck
by lightning die, with the greatest risk of death being in those
patients with cranial burns or leg burns. Ninety-two percent
of lightning-associated deaths occur during the summer
months (May to September), when thunderstorms are most
common. Seventy-three percent of deaths occur during the
afternoon and early evening, when thunderstorms are most
apt to occur. Fifty-two percent of patients who died from
lightning injury were engaged in outdoor recreational activ­
ity such as golfing and fishing, and 25% were engaged in
work activities when struck. Sixty-three percent of lightning-
associated deaths occur within 1 hour of injury. Virtually all
lightning injuries and deaths can be prevented by taking
appropriate precautions.
The decrease in lightning-related deaths over the past 20
years appears to be related to a decrease in the farm popula­
tion, better understanding of the pathophysiology of light­
ning injury, and improved resuscitation techniques. Analysis
of data from the Defense Medical Surveillance System by the
US Army and the CDC reveals that the highest lightning-
related injury rate occurred in male members of the US mili­
tary stationed near the East Coast or the Gulf of Mexico,
where lightning occurs frequently, who were subjected to
outdoor exposure to thunderstorms. During 1998–2001,
350 service members were injured and one was killed by 142
lightning strikes. One-half of the lightning strikes occurred
during July and August and three-quarters occurred between
May and September. Two hundred and forty-six (70.1%) of
the lightning injuries involved active duty personnel, with
men being 3.3 times more likely to be struck than women.
The overall lightning casualty rate for military personnel
was 5.8/100 000 person-years. Louisiana, Georgia, and
Oklahoma had the highest rates of lightning injury, i.e., 39.6,
25.2, and 23.5/100 000 person-years, respectively.121
Fireworks are another seasonal cause of burn injury. In the
2008 Fireworks Annual Report published by the US Con­
sumer Product Safety Commission, Greene et al.122 reported
that seven people died and 7000 patients were estimated to
have received treatment in emergency departments for
fireworks-related injuries. Seventy percent of the fireworks-
related injuries occurred between 20 June and 20 July, which
encompassed the 4th of July holidays. A majority of the
injuries, 62%, involved males and 58% occurred in individu­
als under 20 years of age. More than half (56%) of the
fireworks-related injuries were burns and principally involved
the hands, head, and eyes. The three most common

Epidemiological, demographic, and outcome characteristics of burn injury
31
The vast majority, 84, had only partial-thickness injuries.
Fifty-one of the 94 male patients and 12 of the 33 females
had been assaulted by their spouses. In cases of spouse abuse
the face or genitalia are characteristically splashed with
chemicals or hot liquids, whereas cases due to abuse or
neglect in elderly, disabled, and handicapped adults resem­
ble those in child abuse cases.7 In India, a common form of
spouse abuse is burning by intentional ignition of clothing.
When such burns are fatal they have been called ‘dowry
deaths’, because they have been used to establish the
widower’s eligibility for a new bride and dowry.
In 41, or 3.3%, of all patients with significant burns admit­
ted to a German Burn Intensive Care Unit over a 15-year
period assault was the cause of the burn.134 The injuries were
caused by hot liquids, chemicals, or fire, and 33% of the
patients were less than 26 years old. Evaluation by logistic
regression identified younger age, ethnic minority, and
unemployment as independent variables associated with
assault burns.
Assault by paint thinner ignition has been reported as an
infrequent form of burn injury among Turkish street chil­
dren addicted to paint thinner.135 The nine patients with
such injuries who were admitted to a burn center in Turkey
during a 10-year period (0.76% of 1170 major burn admis­
sions) had burns involving from 35% to 90% TBSA. The face
and neck were most often involved (89% of cases), followed
by the trunk and upper limbs. Six patients, of whom three
died, had inhalation injury.
The Burn Unit of The National Hospital of Sri Lanka
admitted 46 patients with acid burns due to assault during
an 18-month period.136 Those patients represented 4% of all
burned admissions and ranged in age from 12 to 60 years,
with a male to female ratio of 2.8:1. Formic acid was the
most common injuring agent, but in more than half the
cases the type of acid was unknown. The average extent of
burn was only 14.6% TBSA, but involved the face in 93% of
cases, the chest in 65% and the upper limbs in 64%. In 43%
of the patients excision and grafting were necessary. A mor­
tality rate of 4.34% reflected the limited nature of the burns.
Disfigurement and blindness caused by chemical assault
with acid have been emphasized by Milton et al.,137 who
noted that the Acid Survivors Foundation reported 180 inci­
dents of chemical assault in 2006 in which 221 patients in
Banani, Dhaka, and Bangladesh were injured. The eye has
been reported as injured in 26% of cases, and visual impair­
ment, including blindness, may result, as well as severe dis­
figurement and long-term psychosocial morbidity.
Child abuse represents a special form of burn injury, most
commonly inflicted by parents but also perpetrated by sib­
lings and child-care personnel. Child abuse has been associ­
ated with teenage parents, mental deficits in either the child
or the abuser, illegitimacy, a single parent household, and
low socioeconomic status (although it can occur in all eco­
nomic groups). Abuse is usually inflicted upon children
younger than 2 years of age who, in addition to burns, may
exhibit signs of poor hygiene, psychological deprivation, and
nutritional impairment.138 The most common form (approx­
imately one-third of cases) of child abuse thermal injury is
caused by cigarettes; because of their limited extent, such
injuries frequently do not require admission to a hospital.139
Child abuse by burning has also been inflicted by placing a
small child in a microwave oven. The burn injuries produced
traditional religious form of self-mutilation.128 Squyres
et al.129 reported their experience in treating 17 people over
a 3-year period for self-inflicted burns. The average extent of
burn in those patients was 29.5% TBSA, and 59% of them
had concomitant inhalation injury. All of those patients had
a psychiatric disorder, which in 47% of the group was related
to substance abuse. The most frequently used means of
injury was ignition of a flammable liquid.
In India self-immolation appears to be a frequent cause of
injury in burn patients requiring hospital admission. A
group of 222 patients admitted for hospital treatment of a
burn injury consisted of 177 adults and 43 children under
13 years, with females outnumbering males 1.7 to 1.130 In
the adults, the burns were due to self-immolation in 44% of
cases. Non-intentional burns in adult women were most
often sustained while refueling a burning stove or by the
ignition of clothing while cooking. In the children, three-
quarters of the injuries were caused by scalds. The mean
extent of burn was 49% TBSA, with 30% of cases said to have
‘predominantly deep burns’. Sixty-one percent of the patients
died, with mortality rising from 13% in patients under 13
to 88% in patients over 60. Mortality as related to burn
extent was 9% for patients with burns less than 20% TBSA,
34% for patients with burns of 21–30% TBSA, more than
65% in patients with burns of more than 30% TBSA, and
100% when the burn involved more than 60% TBSA.
Moniz et al.131 reported their experience in the manage­
ment of 56 patients admitted to a burn unit with self-inflicted
burn injury during a 14-year period. Those patients repre­
sented 4.4% of the 1283 burn patients admitted during that
period. A prior psychiatric history was elicited in 68% of the
self-inflicted burn injury cases, most commonly depression,
schizophrenia, and mental retardation, in that order. The
average age of those patients was 50.4 years (range 22–89
years). Most patients (93%) attempted suicide by self-
immolation with a flammable liquid, 12% by contact with
electricity, and 2% by pouring acid on their skin. The mean
extent of burn was 32.2% TBSA, and all patients had deep
partial or full-thickness burns. The mean length of hospital
stay was 24.8 days (range 1–90 days) and the mortality was
43%, significantly higher than in the general population of
burn patients in that unit.
During a 7-year period, 32 patients were admitted to a
burn center in Turkey for the treatment of burn injury due
to attempted suicide.132 In 20 patients a diagnosis of psychi­
atric illness had been previously made, and 17 patients had
previously harmed themselves. The mean extent of burn
injury was 70% TBSA and the mortality rate was 43.4%. The
authors noted an association between the self-inflicted injury
and unemployment, and what was termed ‘acute mental
affection’ such as marital discord, drug use, and alcohol
abuse.
Assault by burning is most often caused by throwing liquid
chemicals at the face of the intended victim or by the igni­
tion of a flammable liquid with which the victim has been
doused. Relatively uncommon is the infliction of burn injury
by dousing the victim with hot water. Duminy and Hudson133
reported their experience with 127 patients who had been
intentionally injured with hot water. The burns in those
patients involved from 1% to 45% TBSA, with an average
extent of 13.7%. The trunk and arms were burned in 116 of
the patients, the head and neck in 84, and the legs in 27.

Total Burn Care
3
32
instruments used for endotracheal and endobronchial pro­
cedures or anesthetic management.149 Localized high-energy
ultrasound may also produce coagulative necrosis, as exem­
plified by full-thickness cutaneous injury and localized sub­
cutaneous fat necrosis of the abdominal wall in a patient
who had received focused-beam high-intensity ultrasound
treatment for uterine fibroids.150 A common cause of burn
injury, particularly in disoriented hospital or nursing home
patients, is the ignition of bedding and clothing by a burning
cigarette. Smoking should be banned in healthcare facilities,
or at least restricted to adequately monitored situations.
A retrospective review of 4510 consecutive patients admit­
ted to a burn center between January 1978 and July 1997
identified 54 who had sustained burns while undergoing
medical treatment.151 Twenty-two patients sustained their
injuries in a hospital or nursing home, most commonly (12
patients) as a consequence of a fire started by smoking activi­
ties. Fifty-eight percent of those patients died. Another two
patients were scalded while being bathed in nursing homes,
and one of those patients died. Thirty-two patients were
burned as a consequence of home medical therapy, includ­
ing nine vaporizer scald burns, eight burns caused by igni­
tion in therapeutic oxygen, and 11 caused by inappropriate
application of heat. In contrast to other studies, no patients
in this series sustained burns from medical lasers.
Burn patient transport and transfer
As noted above, the concordance of burn treatment facility
location and population density necessitates that many
patients requiring burn center care be transferred from other
locations. For transfer across short distances and in con­
gested urban areas, ground transportation is frequently more
expeditious than aeromedical transfer. Aeromedical transfer
is indicated when the patient requires movement from a
remote area, or when such transfer will materially shorten
the time during which the patient is in transit compared to
ground transportation. Helicopters are frequently employed
for the aeromedical transfer of patients over distances of less
than 200 miles. Vibration, poor lighting, restricted space,
and noise make in-flight monitoring and therapeutic inter­
ventions difficult, a fact which emphasizes the importance
of carefully evaluating the patient and modifying treatment
as necessary to establish hemodynamic and pulmonary
stability prior to undertaking the transfer. When transfer
requires movement over greater distances, fixed-wing aircraft
are used, ideally those in which an oxygen supply is available
to support mechanical ventilation. The patient compartment
of such an aircraft should be well lit, permit movement of
attending personnel, and have some measure of temperature
control.
In general, burn patients travel best in the immediate post­
burn period as soon as hemodynamic and pulmonary stabil­
ity have been achieved by resuscitation. This avoids the
instability caused by infection, secondary hemorrhage,
sepsis, or cardiac insufficiency, all of which may occur later
in the hospital course. The importance of having an experi­
enced burn physician accompany a patient during aeromedi­
cal transfer is indicated by the findings of a study152 that
reviewed the management problems encountered during
124 flights to transfer 148 burn patients. More than half the
in that manner are typically present on the body parts nearest
the microwave-generating element, full-thickness in depth,
and sharply demarcated.140 Child neglect, if not child abuse,
is considered to be a factor in burns to the hand, particularly
those on the dorsum of the hand, due to contact with a hot
clothing iron.141 Most often scalding causes the burns in
abused children who require inpatient care. Such injuries are
often associated with soft tissue trauma, fractures, and head
injury. A distribution typical of child abuse immersion scald
burns, i.e. feet, posterior legs, buttocks, and the hands,
should heighten suspicion of child abuse.
The presence of such burns mandates a complete evalua­
tion of the circumstances surrounding the injury and the
home situation. The importance of identifying child abuse
in the case of a burn injury resides in the fact that if such
abuse goes undetected and the child is returned to the
abusive environment, there is a high risk of fatality due to
repeated abuse. Chester et al.142 recently reported that paren­
tal neglect is far more prevalent than abuse as a causative
factor for burn injury in children. Children with burns that
occurred as a consequence of neglect had deeper burns than
children with accidental burns, and were more apt to require
skin grafting for wound closure; 83% of the children with
burns due to neglect had previously been referred to a child
protection agency.
A review of the records of 457 children with burns treated
at a burn center identified 100 whose injuries were deemed
to be a likely result of abuse or neglect.143 Multivariate analy­
sis revealed that younger age, female gender, burns on the
lower extremities or trunk, longer hospital stay, and death
were factors associated with burning due to abuse. Six of the
children whose injuries were suspected to be a result of
abuse died. The authors note that the prosecution rate of
26% and conviction rate of 11% in their locale are discourag­
ingly low.
Elder abuse can also take the form of burn injury. A con­
gressional report published in 1991 indicated that 2 million
older Americans are abused each year, and some estimates
claim a 4% to 10% incidence of neglect or abuse of the
elderly.144 A recent retrospective review of 28 patients aged
60 and over admitted to a single burn center during a calen­
dar year identified self-neglect in seven, neglect by others in
three, and abuse by others in one.145 Adult protective services
were required in two cases. The authors of that study con­
cluded that abuse was likely to be under-reported because of
poor understanding of risk factors and a low index of suspi­
cion on the part of the entire spectrum of healthcare
personnel.
Patients may also sustain burns while in hospital for diag­
nosis and treatment of other disease.146 In addition to the
electric injuries noted above, chemical burns have been pro­
duced by inadvertent application of glacial acetic acid, con­
centrated silver nitrate, iodine, or phenol solutions, and
potassium permanganate crystals. Application of excessively
hot soaks or towels or inappropriate use of heat lamps or a
heating blanket are other causes of burn injury to patients.147
Infrared heat lamps are often used in conjunction with acu­
puncture, but inappropriate intensity or excessive duration
of exposure may cause full-thickness skin injury.148 Much
more serious are the burns and inhalation injuries caused by
electrocautery or laser devices, explosion of gases (including
ignition of flammable material in oxygen), or ignition of the

Epidemiological, demographic, and outcome characteristics of burn injury
33
patients who, after triage and emergency care, were trans­
ported by aircraft to Australia and treated at various hospi­
tals.156 The casualties produced in terrorist attacks often have
associated blast injury and mechanical trauma in addition
to burns.
Recent non-terrorist mass casualty incidents have been of
greater magnitude in terms of numbers of burn casualties.
In 1994 an airplane collision caused nearby military person­
nel to be sprayed with burning aviation fuel. Of the 130
soldiers injured, 43 required transfer to the US Army Burn
Center for treatment.157 In The Station nightclub fire in
Warwick, Rhode Island, in February 2003, 96 people died at
the scene and 215 were injured; 47 of the 64 burn patients
evaluated at one academic medical center were admitted for
definitive care.158 Lastly, an explosion at a pharmaceutical
plant in North Carolina in January 2003 killed three and
injured more than 30 to an extent that necessitated admis­
sion to a hospital. Ten of the injured patients, all with inhala­
tion injury and six with associated mechanical trauma, were
admitted to the regional burn center.159 To deal effectively
and efficiently with a mass casualty situation, burn treatment
facilities must have an operational and tested mass casualty
disaster plan and be prepared to provide burn care to a
highly variable number of patients injured in either natural
or manmade disasters.
The international burn burden
Worldwide, an estimated 322 000 patients (5.2/100 000)
died as a result of exposure to smoke, fire, and flames in
2002.160 A majority of those were residents of developing
countries, as reflected in the higher incidence rates of fatal
burn injury in the low-/middle-income countries of WHO
regions, i.e. Africa 5.8/100 000, Eastern Mediterranean
6.4/100 000, Europe 7.4/100 000, and Southeast Asia
11.6/100 000. Fifty-seven percent of fatal burns were sus­
tained in Southeast Asia and two-thirds of those occurred
in females. In the Southeast Asia region, fatal burns in
15–45-year-old women represented slightly more than one
in every four fatal burns worldwide, and the incidence of
fatal burns in the 15–29-year age group of females in that
region was 26/100 000. During the 3-year period 2003–2005,
the standardized mortality rate from fires for persons under
20 years of age in the WHO European region ranged from a
high of 3.7/100 000 in Azerbaijan to a low of 0.1/100 000 in
Switzerland.161
In the 2004 WHO Global Burden of Disease update, it was
estimated that worldwide there were 10 900 000 injuries due
to fire, with the greatest number in Southeast Asia (5900 000)
and Africa (1700 000) and the fewest in Europe (800 000),
Western Pacific (700 000), and the Americas (300 000).162 At
that time, the worldwide incidence rate of fatal burn injury
for all patients younger than 20 was 3.9/100 000.163 In the
low- and middle-income countries of the African region the
incidence rate of fatal burn injury for that age group was
8.7/100 000, whereas in the WHO Americas region it was
only 0.7/100 000 for high-income countries and 0.6/100 000
for low- and middle-income countries. That 2004 update
further reported that the incidence rate of fatal burn
injury in patients under 20 years in the low-/middle-income
countries of Southeast Asia, the Eastern Mediterranean,
patients underwent therapeutic interventions by the surgeon
of the burn team prior to aeromedical transfer. Such inter­
ventions most commonly involved placement or adjustment
of a cannula or catheter, modification of fluid therapy, or
endotracheal intubation and modification of ventilatory
management. In slightly more than one-third of the patients
such interventions were considered necessary to correct
physiologic instabilities that would have compromised their
safety during the transfer procedure. Six of the 124 patients
underwent an escharotomy to relieve compression of the
chest or a limb caused by a constricting eschar. The thera­
peutic alterations most commonly used during the aero­
medical transfer procedure itself were changes in fluid
therapy, adjustment of a ventilator, and administration of
parenteral medications exclusive of analgesics. The medical
personnel effecting the transfer must bring with them all the
equipment and supplies needed for pre-flight preparation
and in-flight management of the patient.
Physician-to-physician case review to assess the patient’s
need for and ability to tolerate aeromedical transfer, prompt
initiation of the aeromedical transfer mission, examination
of the patient in the hospital of origin by a burn surgeon
from the receiving hospital, and correction of organ dysfunc­
tion prior to transfer, and in-flight monitoring by burn-
experienced personnel, ensure both continuity and quality
of care during the transport procedure. During the 10-year
period 1991–2000, US Army Institute of Surgical Research
Burn Care flight teams using such a regimen completed 266
helicopter and fixed-wing transfer missions to transport 310
burn patients within the continental United States without
any in-flight deaths. During the same period, the Institute
carried out 12 intercontinental aeromedical transfer mis­
sions in which 17 burn patients were transported, with only
one in-flight death.
Mass casualties
Mass casualty incidents may be caused by forces of nature or
by accidental or intentional explosions and conflagrations.
Interest in manmade mass casualties has been heightened
by recent terrorist activities and the threat of future incidents.
The incidence of burn injury in a mass casualty incident
varies according to the cause of the incident, the magnitude
of the inciting agent, and the site of occurrence (indoors vs
outdoors).
Burn injuries can be sustained during an earthquake and
as a consequence of post-earthquake living conditions. Data
collected by the CDC indicate that in the 3 months following
the Haitian earthquake of January 2010, 111 patients required
treatment for burn injury, 37 of whom were less than 5 years
of age.153 Overall burn injury represented only 0.4% of the
conditions receiving medical treatment during the 3-month
study period.
Terrorist attacks may cause a greater number of burns but
there are typically no post-incident injuries. The terrorist
attacks in which airplanes laden with aviation fuel crashed
into the Pentagon and the World Trade Center on 11 Sep­
tember 2001 produced respectively 10 and 39 patients with
burns requiring treatment at burn centers.154,155 The terrorist
attack on a nightclub in Bali in 2002 caused an explosion
and fire that killed over 200 people and generated 60 burn

Total Burn Care
3
34
13 (18%) of the total group and was fatal in eight. Lung
contusion was sustained by nine (13%) of the patients, five
of whom died. Overall mortality was 21%, which was sig­
nificantly higher than that of all burn patients treated at that
unit, even though the acute burn severity index scores were
comparable.
A study of the epidemiology of ‘minor and moderate’
burns in rural Iran using a pretested questionnaire has docu­
mented that 59% of the patients were female, and that
patients age 6 and under sustained 36.4% of burn injuries.
Spillage of hot water and other liquids was the cause of the
majority of the burn injuries.169 In only 43% of patients was
there a partial-thickness injury with a mean extent of 1.3%
TBSA. A study of 4813 patients treated for burn injury on an
outpatient basis in Iran found that the majority of the burns
were non-intentional, and that 70.5% occurred at home;
scalding was the most common etiology.170 Ninety-six
percent of the burns were partial thickness and, as expected,
of limited extent (mean = 3.16% TBSA).
Torabian and Saba171 illuminated the epidemiology of
pediatric burn injury in an Iranian province. They reviewed
the records of 371 children under 14 years of age admitted
to a provincial referral burn hospital. The incidence rate of
pediatric burns requiring hospital care was 33.4/100 000
annually. Patients less than 4 years constituted 69% of the
pediatric burn population. Overall, males predominated in
the pediatric burn population, and the incidence rate of burn
injury was highest in children below the age of 2. The inci­
dence rate for rural areas was more than twice that for urban
areas. Scalding was the major cause of burn injury overall.
The mean extent of burn injury was 16.36% TBSA, but
slightly more than three-quarters of the patients had burns
of 20% or less TBSA. Thirteen patients (3.5%) died, with a
mortality rate several times higher in patients with flame
burns than in patients with scald injuries.
Developing countries
The demographics of pediatric burns in Vellore, India, have
been compared to those in the United States.172 A review of
119 pediatric burn patients admitted to the Pediatric Burn
Center in Vellore indicated that their average age was 3.8
years and the average extent of burn was 24% TBSA. The
cause of the burn injury was scald 64%, flame 30%, and
electricity 6%. In Vellore, delayed presentation occurred
in 45% of patients and averaged 2 days. Compared with
the pediatric patients entered in the American Burn Associa­
tion National Burn Registry, the average extent of burn was
greater in the patients in Vellore and the extent of burn in
those children who died was less. Electric injury was more
common in Vellore than in the United States, and contact
burns were almost non-existent in Vellore.
Trauma deaths in patients under 20 years in Southern
India have been analyzed by review of medicolegal autopsy
reports.173 ‘Traffic accidents’ and burns were considered to be
the cause of death in 38% and 25% of cases, respectively.
In the cases of burn death, the male to female ratio was 1:1.5.
The 46 burn deaths in the 10–19-year age group were more
than triple the 15 burn deaths that occurred in children
under 10 years of age. The authors reported a ‘substantial
decline’ in burn-related deaths in children and adolescents
between 1994 and 2005.
and the Western Pacific regions was 6.1, 4.7, and 0.6/100 000,
respectively. In 2007 in the US there were 597 fatal burn
injuries in children under the age of 20 years, which
represented 3.5% of all fatal injuries and an incidence rate
of 0.72/100 000.2
Developed countries
The epidemiology of burn injury in the Australian state of
Victoria for the years 2000–2006 has been characterized by
Wasiak and associates.164 During the study period there were
178 fatal burns and 36 430 patients who received treatment
for non-fatal burns, of whom 21% were admitted to hospi­
tals. Children below age 5 and the elderly of 65 or over had
the highest incidence rates for burn injury. Sixty-four percent
of hospital admissions were for treatment of burns caused
by contact with hot objects and fluids. In contrast to the
decreases observed in the United States, the authors reported
no change in the incidence rate or number of hospital
admissions during the study period.
Analysis of state-wide health administrative data has been
used to characterize the 23 450 patients admitted to hospi­
tals in Western Australia during a 26-year period for the
treatment of burn injury.165 There were twice as many males
as females in the study. During the study period, the overall
hospital admission rates for burn injury and the burn-related
mortality each decreased an average of 2% per year. Although
the hospital admission rates were higher for Aboriginal
people, the decrease in hospitalization rate was greater in
that population. Children below 5 years of age, males
between age 20 and 24, and adults were noted to remain at
high risk for burn injury requiring hospital admission.
A retrospective review of the medical records of 14 708
patients admitted for the initial care of burn injury in New
Zealand between 1996 and 2006 indicated that the number
of admissions was greatest in the 0–4 year age group and
highest in the Maori ethnic group.166 Men outnumbered
women by almost 2:1. The number of patients admitted to
hospitals for the care of burn injury increased as the New
Zealand index of deprivation of residence increased, rising
from 19/100 000 per year with a deprivation score of resi­
dence of 1 to a high of 70/100 000 per year with a depriva­
tion score of residence of 10.
Information from the Norwegian Patient Registry reveals
that in 2007 there were a total of 726 patients admitted to
hospitals for acute burn care, representing an incidence rate
of 15.5 /100 000 population.167 The incidence rate of burns
requiring admission to a hospital in children of less than 5
years was 5.3 times greater, i.e. 82.5/100 000 per year. The
mean age of all burn patients was 26.9 years, two-thirds of
them were male, and the mean duration of hospital stay was
11.3 days. The total cost for acute burn care in Norway in 2007
was calculated to be ©10 5
. million. Fifteen of the patients
(2.1%) died of burns in Norwegian hospitals in that year.
A retrospective review of 71 patients burned in civil gas
explosions and treated at a German Burn Center revealed
that such injuries occurred predominantly in males, with the
principal place of injury being a private household.168 Fifty
percent of work-related explosions were associated with
welding and 22% with professional cooking. The mean
extent of burn in those patients was 22% TBSA, and 73%
required excision and grafting. Inhalation injury occurred in

Epidemiological, demographic, and outcome characteristics of burn injury
35
Among 532 patients admitted to a regional referral hospi­
tal in Kabul, Afghanistan, for the treatment of burn injury
during a recent 15-month period, the overall median age was
19 years and, contrary to the case in Western nations, 60%
of the patients were female.174 The frequency of burn injury
was greatest in both males and females in the 16–25-year
age group, but that of females was almost twice that of
males. The mean extent of burn was 36.5% TBSA, with 41%
of patients having burns of less than 20% TBSA and 10%
having burns of 80% TBSA or more. The most common
causes of burn injury were flames and explosion of a gas
cylinder. There were 21 patients who set themselves on fire,
of whom 76% expired. Overall, there were 151 deaths for a
mortality rate of 28%. Burns involving more than 60% TBSA
were invariably fatal.
A recent report from Nigeria has called attention to the
burn and fire disasters caused by the explosion of petroleum
products leaking from pipelines that have either been delib­
erately damaged (56% of cases) or have ruptured spontane­
ously (44% of cases).175 In nine incidents of pipeline fire
disasters, 646 patients were incinerated and died at the site.
Forty-eight patients with burns involving from 32% to 100%
TBSA survived to be admitted and treated at a university
teaching hospital in Lagos. The authors considered poverty,
irregular supply, and the high cost of fuel to be responsible
for the deliberate pipeline damage, and implicated inade­
quate maintenance and surveillance in the cases of sponta­
neous rupture.
To provide more detailed information on nation-specific
epidemiologic and demographic characteristics of burn
injury the International Society for Burn Injury (ISBI)
national representatives were sent a questionnaire and
requested to supply current information about the incidence
of burn injury and burn fatalities in their country, and to
describe any aspects of the burn injuries that were unique
and/or of concern. The information supplied by the repre­
sentatives listed is displayed in Tables 3.9, 3.10, and 3.11. In
aggregate, the data document the importance and universal­
ity of burn injury as a societal problem and illustrate the
inverse relationship between burn injury incidence and eco­
nomic development.
Outcome analysis in burn injury
The importance of extent of injury in determining burn
outcome was recognized by Holmes in 1860, and discus­
sions expressing that extent as either a measured area or as
anatomical parts of the body surface appeared in the later
nineteenth and early twentieth centuries.176,177,178 Formal
expression of burn size as a percentage of TBSA, however,
awaited the work of Berkow in 1924.179 Despite being
accorded little recognition as such, this single advance in
the description of thermal injury, along with the corollary
understanding that burn size is a crucial determinant of
pathophysiological response, made burns the first form of
trauma whose impact could be measured and easily com­
municated. Techniques based on this understanding pro­
duced what were in effect the first trauma indices, making
assessment of the relationship between burn size and mor­
tality, direct comparison of populations of burned patients,
and rational assessment of therapy, possible long before
rigorous outcome analysis became feasible for any other
form of injury.
The earliest comprehensive statistical technique used for
such assessment was univariate probit analysis.180,181 This
approach, laborious in the days of paper files and rotary
calculators, required that the population studied be arbitrar­
ily partitioned into groups which were relatively similar in
burn size and age. Such analyses yield equations describing
the effect of burn size on mortality which are valid for only
the particular age group studied. An early attempt to develop
a multivariate evaluation was made by Schwartz,182 who
used probit plane analysis to estimate the relative contribu­
tions of partial- and full-thickness burns to mortality.
This approach also required arbitrary partitioning of the
population.
The advent of computers of suitable power and the further
development of statistical techniques have reduced the dif­
ficulty of analyzing burn mortality, removed the necessity for
arbitrary partitioning, and made these techniques much
more accessible.183 Their use to assess outcome demands an
understanding of both the techniques themselves and the
population being analyzed. The analysis of a population of
8448 patients admitted for burn care to the US Army Insti­
tute of Surgical Research or to its predecessor, the US Army
Surgical Research Unit, between 1 January 1950 and 31
December 1991 illustrates the concepts underlying such
outcome analysis, and depicts the trends in mortality that
have been characteristic of most major burn centers in this
country.
For validity, an important first step in studies of outcome
is to achieve as much uniformity as possible in the popula­
tion to be analyzed. These patients reached the Institute
between the day of injury and postburn day 531 (mean
5.86d, median 1d), with burns averaging 31% TBSA (range
1–100%, median 26%). Their age distribution was biphasic,
with one peak at 1 year of age and another at age 20; the
mean age of the entire population was 26.5 years (range
0–97, median 23 years). From this group, 7893 (93.4%)
who had flame or scald burns were selected; those with
electric or chemical injuries were excluded.
This group included patients who had sustained thermal
injuries in Vietnam and were first transferred to Japan and
then selectively transferred to the Institute. Arriving at the
Institute relatively late in their courses, these survivors of
temporal cohorts in which some deaths had already occurred
exhibited inordinately low mortality. Outcome is inevitably
biased towards survival as the delay between burn and
admission increases. To avoid this bias, the analysis focused
on the 4870 patients with flame or scald injuries who reached
the Institute on or before the second postburn day, excluding
later arrivals. Burn size in these patients averaged 34% TBSA
(range 1–100%, median 29%), and age was again biphasic,
with peaks at 1 and 21 years and a mean of 27.1 years (range
0–93, median 24 years).
One object of this analysis was to evaluate changes in burn
mortality during the four decades of experience included in
the study. For reliable results, some of the techniques used
required more subjects than were available in single years; a
moving 5-year interval, advancing 1 year at a time, was used
to group the data. The number of patients in each of the
overlapping 5-year intervals is shown in Figure 3.2. In this
and subsequent plots, the data for a 5-year interval are

Total Burn Care
3
36
Table 3.9  Burn injury in Europe
Country (Population)
Annual incidence
Leading cause
Fatal burns
Comments
n
Ratea
n
Ratea
Azerbaijanb (8 238 672)
  Overall burn injury
5730
64
0.30
36–40% treated in specialized burn units in
Baku
    Children (0–15 years)
2055 (36% of all burns)
23
Electric injury: 5%
<6 years. 55% scalds
>6 years. 40% flames
3.70
Fire-jumping burns from Spring Holiday
bonfires
    Young adults (16–40 years)
2723 (47% of all burns)
30
Flames
Severe lower limb and perineal burn injuries
from wattle and daub stoves
    Older adult (41+ years)
952 (17% of all burns)
10.5
Flames
Suicide attempts ‘frequent’ in the elderly
Czech Republicc (10 211 904)
  Hospital admissions for burn injury – 2009
3362
32
0.10
    Children
1606
Scalds: 78%
0.18
    Young adults
738
Scalds: 55%. Flame: 34%
    Older adults
1018
Scalds: 48%. Flame: 40%
Estoniad (1 299 371)
  Overall burn injury (2007–2009 average
per year)
3697
288
0.10
    Children
1062
(29% of all burns)
2.00
‘Big percentage of contact burns’
    Young adults (16–40 years)
1352
(36% of all burns)
Eleven chemical burns admitted to nation’s
adult unit 2007–2009
    Older adults (41+)
1283
(35% of all burns)
Germanye (81 471 854)
  Fire injury – All ages
0.50
    Children (1991)
      All injuries
8.32
      All burns
0.25
Greecef (11 299 183)
Unusual cause: explosion of plastic bottle
when spraying ‘spirit’ to light or
accelerate a fire
  Overall burn injury
0.10
    Children (0–19 years)
0.15

Epidemiological, demographic, and outcome characteristics of burn injury
37
Country (Population)
Annual incidence
Leading cause
Fatal burns
Comments
n
Ratea
n
Ratea
Polandg (38 482 919)
Causes as percentage of total burns: open
flame 37%, hot liquids 26%, contact 10%,
chemical 6%, electric 6%, and structural
fires 12%
  All ages
309 000
811
1200
0.50
  Admitted to hospital
9500 (3.1%)
    Children
138
Hot liquids
0.20
    Young adults
255
Open flame
    Older adults
418
Open flame
Romaniah (22 215 421)
All burn injury
50
0.40
Burns = 6% of all ‘external’ causes of death
  Children (0–15 years)
60
Scalds
0.95
Scalds in one-half of all cases age 0–4 years.
Considerable number of high voltage
electric injuries in teenagers.
  Adults
40
Scalds
More flame, electric, and chemical burns in
adults than in children.
Home fires common in elderly patients.
Russian Federationi (140 041 247)
Specific causes: bath house burns, steam,
contact with ‘red hot’ stove, smoking
while intoxicated.
Overall burn injury
400 000
275.8
12.20
  Children
114 000
Boiling water and flame
1.90
  Young adults
152 000
Boiling water and flame
  Older adults
134 000
Boiling water and flame
Swedenj (9 059 654)
  Burns admitted to hospital: 1987–2004
    Annual mean
1363
15.5
125
Males: 69%
M/F = 2.23:1
Reduction in number with time, decrease
>in males
    Children
0.10
0–4 years – 27% of all burns
20–24 years – 7% of all burns.
aPer 100 000. Data sources: bElmira Panahova PhD MD; cLeo Klein MD; dAin Seimar MD; eProfessor Norbert Pallua MD PhD; fSophia Papadopoulou MD; gStanislaw Sakiel MD; hDan Enescu MD PhD; iMikhail Gordon MD and Professor
Andrey A. Alekseev MD; jFolke Sjöberg MD. Fatal burn incidence rates, see and reference 161

Total Burn Care
3
38
Table 3.10  Burn injury in Asia–Western Pacific
Country (Population)
Annual incidence
Leading cause
Fatal burns
Comments
n
Ratea
n
Ratea
Malaysiab (25 715 819)
  Overall burn injury (2009)
12
0.10
    Children (0–14 years)
62% of all burns
Scalds (71%)
0.39
    Young adults (15–40 years)
30% of all burns
Scalds (67%)
    Older adult (41+ years)
8% of all burns
Scalds (41%)
New Zealandc (4 213 418)
  Overall burn injury (July
2009–June 2010)
27 597
639.43
0.00
    Children (0–14 years)
930.48
Contact with hot object
    Young adults (15–39 years)
703.98
Scalds
    Older adult (41+ years)
456.33
Scalds
South Koread (48 508 972)
Steam burns caused by
‘rice cooker’ are frequent
in children <3 years.
Sharp increase in friction
burns caused by
treadmills since 1993.
  Overall burn injury (2008)
503 000
1048
Scalds
    Children (0–15 years)
141 000
Scalds
    Young adults (16–40 years)
171 000
Scalds
    Older adult (41+ years)
191 000
Scalds
  Overall burn injury (2009)
541 000
1104
Scalds
0.40
    Children (0-15 years)
146 000
Scalds
Increase in hot water
purifier burns in recent
decade.
    Young adults (16-40 years)
184 000
Scalds
    Older adult (41+ years)
212 000
Scalds
Taiwane (29 974 347)
Burns treated at Linkou
Burn Center, Chang
Gung Memorial Hospital
  1989–2008
    Children (0–10 years)
Scald – – 2539
Flame – 241
Electric – 27
Chemical – 18
Contact – 37
    Adults (31–40 years)
Scald – 408
Flame – 894
Electric – 261
Chemical – 445
Contact – 57
    Older adult (81+ years)
Scald – 40
Flame – 22
Electric – 0
Chemical – 4
Contact – 1
  2009
    Children (0–15 years)
Scald – 221
Flame – 19
Explosive burn – 4
Traffic accident – 3
Electric injury – 1
Chemical burn – 0
    Adults (16–40 years)
Scald – 203
Flame – 79
Explosive burn – 44
Traffic accident – 53
Electric injury – 0
Chemical burn – 36
    Older adult (41+ years)
Scald – 274
Flame – 130
Explosive burn – 64
Traffic accident – 24f
Electric injury – 34
Chemical burn – 0
aPer 100 000 population. Data sources: bDr Shah Jumaat Mohd Yussof MB BSh BAO MRCSI MS; cMs Kendra Sanders at Accident Compensation Corporation; dDong-Chul Kim MD
PhD; eJui-Yung Yang, MD. fIncludes chemical. Fatal burn incidence rates;

Epidemiological, demographic, and outcome characteristics of burn injury
39
Figure 3.4 shows the variation in mean burn size during
the study interval, and Figure 3.5 shows the roughly parallel
mortality. Mean burn size peaked in the two intervals span­
ning 1969 to 1974 and decreased steadily after that time.
Mortality, principally due to burn wound sepsis, peaked at
46% during those years. The two data sets are shown together
in Figure 3.6 and suggest a crude index of the results of burn
care in this population. There were two intervals in which
percent mortality exceeded mean percent burn. The first
occurred in the late 1950s and early 1960s, a time when burn
wound sepsis due to Pseudomonas aeruginosa was uncon­
trolled. This was succeeded by a 6-year interval of good
control of wound infection following the introduction of
plotted at the first year of the interval, reflecting that year and
the succeeding four. The number of admissions meeting the
selection criteria was small in the early years of the Institute’s
experience, and rose in somewhat linear fashion during the
second and third decades to a sustained plateau of approxi­
mately 800 (160/year).
Mean patient age is shown in Figure 3.3. Between 1950
and 1965 most of the admissions were young soldiers; their
mean age approximated 22.5 years and was relatively stable.
During the succeeding decade this value rose to an irregular
plateau centering on 30 years of age, a change reflecting a
greater number of civilian emergency admissions and
increasing age in the military population.
Table 3.11  Burn injury in South America
Country (Population)
Annual incidence
Leading
cause
Fatal burns
Comments
n
Ratea
n
Ratea
Argentinab (40 913 584)
  Burn patients admitted to hospital: 2005–2009
  Overall
19
0.5
2005: Total burn admissions
3745 and outpatients
77 050
    Children (0–15 years)
7.6
Scald
    Young adults (16–40 years)
8
Flame
    Older adult (41+ years)
3.4
Flame
Uruguayc (3 344 938)
  Burns treated at National Burn Center: July 10,
1995–April 30, 2010
    Overall burn admissions
1850
LA50 (extent of burn with 50%
mortality) 51% TBSA if
<60 years and 24% TBSA
for elderly
      Children (<15 years)
23
      Young adults (15–45 years)
1027
      Older adult (46+ years)
800
    Outcomes by type of burn
n
Mortality (%)
      Scald
169
9.5
      Fire/flame
1357
24.6
      Electric injury
115
4.5
      Chemical
7
28.6
      Gas explosion
126
20
aPer 100 000 population. Data sources: bAlberto Bolgiani MD; cProfessor Hector Juri, MD. Fatal burn incidence rates, see
estimates_country/en/index.html.
Figure 3.2  Number of patients meeting study criteria. Values are plotted at
the first year of each moving 5-year interval.
Number of patients
Starting year
1000
200
300
400
500
600
700
800
900
100
90
80
70
50
60
Figure 3.3  Mean age of study patients.
Mean age
32.5
30.0
27.5
25.0
22.5
20.0
90
80
50
60
Starting year
70

Total Burn Care
3
40
Figure 3.4  Mean burn size in study patients.
Mean percentage burn
Starting year
45
40
35
30
25
15
20
90
80
70
50
60
Figure 3.5  Percent mortality in study patients in each moving 5-year
interval.
Percent mortality
Starting year
50
45
40
35
30
25
5
10
20
15
90
80
70
50
60
Figure 3.6  Comparison of mean burn size (crosses) and percent mortality
(solid dots).
Percent
Starting year
50
45
40
35
30
25
5
10
20
15
90
80
70
50
60
deaths, but as burn size increases mortality rises steeply and
then plateaus as it approaches its maximum of 100%. Figure
3.7 illustrates this dose–response relationship for 50-year-
old patients admitted to the Institute between 1987 and
1991. Such curves are mathematically intractable and are
usually transformed to more easily managed straight lines
for analysis. Several mathematical transformations have
been used to accomplish this. As previously noted, the
one used in early analyses was probit transformation; in
the present study, a logistic transformation, illustrated
in Figure 3.8, was used. The choice between these is one
of convenience, as either yields essentially the same
information.184,185
The locations of a sequence of such curves for groups of
patients of increasing age move first to the right (toward
larger burn size) as age increases from infancy to young
adulthood, and then to the left, passing through the infant
location at around age 45 and continuing inexorably left­
ward with increasing age. These differing locations reflect the
greater risk of burn mortality at the extremes of age. The
cubic curve in Figure 3.9 describes this curvilinear effect
of age on mortality; the effect was least at age 21. In this
population, the age function was relatively stable over the
entire period of study.186 As noted, earlier analyses began by
Figure 3.7  Effect of burn size on percent mortality.
Percent burn
100
80
60
40
0
20
100
75
50
0
25
Percent mortality
topical wound treatment with mafenide. In turn, this was
followed by a second interval of poor control in the late
1960s and early 1970s, during which both Pseudomonas
and a mafenide-resistant Providencia stuartii were major
causes of sepsis; by the mid-1970s this endemic had been
controlled following changes in topical treatment and
wound management.
Raw percent mortality, even in conjunction with burn size,
is never an adequate index of the effectiveness of treatment,
as the frequency of death after burn injury is also determined
by prior patient condition, age, inhalation injury, and the
occurrence of pneumonia and burn wound sepsis. Each of
these elements, except for prior condition, can be addressed
in analysis, but only burn size, age, and the presence or
absence of inhalation injury are known at the time of admis­
sion. In the studied group, burn size and age were available
for every patient, but data on inhalation injury were missing
for patients admitted in the earlier years; we elected to use
burn size and age for analysis. This choice does not exclude
the impact of complications, but does confound that impact
with those of burn size and age.
For a uniform population of specific age, a plot of the
relationship between burn size and percent mortality is
S-shaped, or sigmoid – small burns produce relatively few

Epidemiological, demographic, and outcome characteristics of burn injury
41
P
L
L
=
+
exp
exp
1
The advantage of this approach, as opposed to previously
used age- and burn size-partitioned analyses, is that it permits
analysis of an entire population without artificial segmenta­
tion, and allows an explicit estimation of expected mortality
for each member of the population. Serial applications of
Figure 3.8  Logistic transformation of ordinate of Figure 3.6.
Percent burn
5
–6
–5
–4
–3
–2
–1
0
1
2
3
4
100
75
50
0
25
Logistic % mortality
Figure 3.9  Effect of age on mortality. Effect is minimal at age 21. Note that
horizontal intersects share a common effect.
Age
150
100
50
–50
–100
0
80
60
40
0
20
Age function
dividing the studied population into arbitrary age and burn
size groups; probit analysis of the relationship between burn
size and percent mortality in each age group then permitted
estimation of the LD50, the burn size lethal to half the
selected age group. To accommodate both age and burn size
simultaneously, without arbitrary partitioning of the popula­
tion, multiple logistic regression was used in this study, with
each member of the population entering the analysis as an
individual data point.
The result of this three-dimensional form of analysis is
most readily visualized as a plane lying within a cube. Figure
3.10 shows the sigmoid response of mortality to burn size
for three discrete ages, and Figure 3.11 shows the curvilinear
variation of mortality with age in patients entering this study
between 1987 and 1991. A best-fitting plane which covers
the tips of spikes representing all of the burn sizes and ages
of interest is generated by the multiple logistic technique,
and it is illustrated for these particular patients in Figure
3.12. The equation representing this plane is of the form
shown below, in which L is the natural logarithm of the odds
of mortality and P the expected fractional mortality rate.
L
a
a
burn
a age
a
age
a
age
=
+
−
+



−




1
2
3
4
2
5
3
100
10 000
(%
)
(
)
,
Figure 3.10  Effect of burn size on percent mortality at three discrete ages
(1987–1991).
0
20
40
60
Burn%
80
100
Mortality %
Age
100
80
60
40
20
70
65
60
55
50
Figure 3.11  Effect of age on percent mortality at three discrete burn sizes
(1987–1991).
50
52
54
56
Burn%
58
60
Mortality %
Age
100
80
60
40
20
70
50
60
40
30
20
10
0

Total Burn Care
3
42
the technique were used to assess mortality in each of the
moving 5-year intervals of the study.
Moreau et al.186 have developed an age risk function (Fage)
based on the Institute’s experience. Expressed as a single
value, this function eases exploration of statistical interac­
tions with other independent explanatory variables and
simplifies mortality analysis:
F
age
age /
age /
age = −
+
−
5
14
100
7
10000
2
3
(
)
(
)
(
)
L
a
a
burn
a F
3
age
=
+
+
1
2(%
)
(
)
P
/
L
L
=
+
exp
(
exp )
1
Following the initial study, 4008 additional patients
meeting the study criteria were admitted between 1992 and
2010. Mortality in these patients did not differ significantly
from that observed between 1987 and 1991. Figure 3.13
reflects the changes in LD50 between 1950 and 2010. This
value began to increase in the mid-1970s and has been rela­
tively stable since 1986. Many aspects of care changed and
improved during these six decades:
•
early resuscitation became more widely understood and
better practiced;
•
the clinical facility was remodeled to permit single bed
isolation;
Figure 3.12  Plane of percent mortality with age and burn size coordinates
(1987–1991).
100
80
60
40
20
70
50
60
40
30
20
10
0
0
20
40
60
Burn%
80
100
Mortality %
Age
Figure 3.13  LD50 in moving 5-year intervals in patients 21 years of age. Increasing values indicate inproving prognosis.
LD50 (% burn)
50
60
70
80
40
90
100
Year (1st of 5 )
1950
1953
1956
1959
1962
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
1995
1998
2001
2004

Epidemiological, demographic, and outcome characteristics of burn injury
43
•
topical chemotherapy with alternating applications of
mafenide acetate and silver sulfadiazine, coupled with
the use of a chlorhexidine-based wash solution
(hibiclens), permitted better control of wound
infection;
•
early wound excision came to be more generally
practiced;
•
better infection control techniques limited cross-
contamination of wounds;
•
new antibiotics, more effective against Gram-negative
organisms, became available;
•
inhalation injury and other pulmonary problems
became better understood and are now managed with
better equipment;
•
improved grafting techniques and the use of biological
dressings facilitated earlier coverage of large wounds.
In essence, through integrated clinical and laboratory
research, we learned how to apply ordinary principles of
trauma and wound care to an extraordinary injury. No single
innovation produced a ‘step’ improvement in mortality, but
the aggregate effect has been improved survival.
This improvement is reflected in Figures 3.14 and 3.15,
which depict early (1950–1963) and more recent (1987–
1991) mortality planes, respectively. The improvement was
not uniform for all burn sizes or ages, nor would one expect
this. Small burns have never been lethal, except at the
extremes of age; little improvement in survival could occur
with such injuries. At the other extreme, very large burns in
older patients have always been lethal and remain so. To
define the age and burn size coordinates of the improvement
in survival, one subtracts one mortality plane from the other;
the result is itself a plane depicting the difference in mortal­
ity in age and burn size coordinates (Figure 3.16). The great­
est differences occurred in the area of the LD80 of the
1950–1963 mortality plane.
Logistic regression permits simple assessment of the odds
ratio for mortality between the individual years and the last
Figure 3.14  Mortality plane for patients admitted between 1950 and 1963.
Note location of contour lines in base of cube.
Mortality %
Age
100
80
60
40
Burn%
20
0
100
90
80
70
60
50
40
30
20
10
–10
0
70
50
60
40
30
20
10
0
Figure 3.15  Mortality plane for patients admitted between 1987 and 1991.
Note contour locations.
100
90
80
70
60
50
40
30
20
10
0
–10
70
50
60
40
30
20
10
0
100
80
60
40
Burn%
20
0
Mortality %
Age
Figure 3.16  Plane of differences in percent mortality between 1950–1963
and 1987–1991. Note location of peak.
60
50
40
30
20
10
0
10
–20
70
50
60
40
30
20
10
0
100
80
60
40
Burn%
20
0
Difference in %
Age
year of this span, with appropriate adjustment for age and
burn size (Figure 3.17). This ratio indexes the effect on mor­
tality of everything beyond burn size and age. Peaks occurred
when sepsis was uncontrolled. The lower ratios beyond 1975
reflect the additive effects of the changes in treatment,
environment, and infection control. No significant differ­
ences in the ratio occurred during the 25 years between 1986
and 2010.
Of 4104 patients meeting the present study criteria between
1950 and 1985, 1320 (32%) died. Of 4895 such patients
admitted between 1986 and 2010, 421 (9%) died. This
reflects, in part, a diminution in mean burn size, but had the
adjusted mortality experienced since 1986 prevailed through

Total Burn Care
3
44
United States each year. Figure 3.18 is based on composite
data from several sources and depicts an estimate of the age
and burn size distribution of these patients. Using the Insti­
tute’s mortality experience between 1986 and 2010 as a basis
for projecting expected mortality yields the data shown in
Figure 3.19, which depicts the age and burn size distribution
of expected deaths. According to this model, patients over
50 with burns of 50% or less TBSA account for 19% of
admissions and 50% of deaths; at the other age extreme,
children under 5 account for 19% of admissions but only
12.5% of deaths.
the earlier interval, only slightly more than half the earlier
number would have succumbed. Although this experience
corresponds with that of most burn centers in the United
States, it should be noted that there are still many areas of
the world where the survival of patients with burns of more
than 40% TBSA is rare.
As previously noted, estimates of the annual total number
of burns in the United States, for which there is little reliable
information, range as high as 2 000 000. A more reliable but
still imperfect estimate is that between 50 000 and 70 000
acutely burned patients are admitted to hospitals in the
Figure 3.17  Odds ratios between individual years and 2010, adjusted for burn size and age.
not sig > 1
sig > 1
Odds Ratio vs 2010
2
4
6
8
10
12
0
14
16
Year
1950
1953
1956
1959
1962
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
1995
1998
2001
2004
2007
2010
Figure 3.18  Estimated age/burn size distribution of 70 000 annual hospital
admissions.
79
49
29
14
4
100 90
80
70
60
50
Burn size
40
30
20
10
Age
7000
6000
5000
4000
3000
2000
1000
0
Number
Figure 3.19  Estimated age and burn size distribution of expected deaths
among patients depicted in Figure 3.18.
79
49
29
14
4
100
90
80
70
60
50
Burn size
40
30
20
10
Age
400
350
300
250
200
150
100
50
0
Number

Epidemiological, demographic, and outcome characteristics of burn injury
45
Much has been accomplished in acute burn care during
the last half century, and further improvement in outcome
will probably occur as inhalation injury and pneumonia
come under better control and new wound coverage tech­
niques are developed, but such improvement will be harder
won and smaller in magnitude. Preservation of function, and
techniques of reconstruction and rehabilitation, areas in
which progress will materially enhance the quality of life for
burn survivors, appear fertile targets for future burn research.
Further reading
CDC. Non-fatal scald-related burns among adults aged >65 years
– United States, 2001–2006. Morbidity and Mortality Weekly Report.
Center for Disease Control and Prevention; 2009;58:993-996.
http:/
Accessed 2/27/11.
Dissanaike S, Wishnew J, Rahimi M, et al. Burns as child abuse: risk
factors and legal issues in West Texas and Eastern New Mexico.
J Burn Care & Res. 2010;31:176-183.
Kramer CB, Rivara FP, Klein MB. Variations in U.S. pediatric burn
injury hospitalizations using the National Burn Repository Data.
J Burn Care Res. 2010;31:734-739.
Mistry RM, Pasisi L, Chong S, et al. Socioeconomic deprivation and
burns. Burns. 2010;36:403-408.
Moreau AR, Westfall PH, Cancio LC, et al. Development and
validation of an age-risk score for mortality prediction after
thermal injury. J Trauma. 2005;58(5):967-972.
The Global Burden of Disease 2004 Update. WHO Press, World
Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland, p. 28.
disease/GBD_report_2004update_full.
Access the complete reference list online at

Epidemiological, demographic, and outcome characteristics of burn injury
45.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Fire Deaths and Injuries. Fact Sheet Centers for Disease Control
and Prevention.
Safety/Fire-Prevention/fires-factsheet.html. Accessed 7/14/2011.
2. Centers for Disease Control and Prevention.
ncipc/wisqars/fatal/help/datasources.html. Accessed 6/22/2011.
3. Centers for Disease Control and Prevention. Web-based Injury
Statistics Query and Reporting System (WISQARS) [Online].
2003. National Center for Injury Prevention and Control,
Centers for Disease Control and Prevention (producer).
Available from: URL Accessed
6/22/2011. /
datasources.html. Accessed 6/22/2011.
4. Vyrostek SB, Annest JL, Ryan GW. Surveillance for Fatal and
Non-fatal Injuries - United States, 2001. Office of Statistics and
Programming. National Center for Injury Prevention and
Control. CDC/NCIPC/OSP, 1600 Clifton Road N.E., MS K-59
Atlanta, GA 30333.
5. National Burn Repository. 2011 Report Dataset. Version 7.0.
American Burn Association, Chicago, IL USA 2011.

6. The U.S. Fire Problem National Fire Protection Association.

Research/Fire%20statistics/x20. Accessed 7/14/11.
7. Pruitt Jr BA, Wolf SE, Mason Jr AD. Epidemiological,
Demographic, and Outcome Characteristics of Burn Injury
Chapter 3. In: Herndon DN, ed. Total Burn Care. 3rd ed.
Philadelphia: Saunders Elsevier; 2007:14-32.
8. Feck GA, Baptiste MS, Tate Jr CL. Burn Injuries, epidemiology
and prevention. Accid Anal Prev. 1979;11:129-136.
9. Finkelstein EA, Corso PS, Miller TR, et al. The Incidence and
Economic Burden of Injuries in the United States. New York: Oxford
University Press; 2006:9-169.
10. Runyan CW, Bangdiwala SI, Linzer MA, et al. Risk factors for
fatal residential fires. N Engl J Med. 1992;337:859-863.
11. Holmes W, Hold P, James M. The Increasing Trend in Alcohol-
Related Burns: Its Impact on a Tertiary Burn Centre. Burns.
2010;36:938-943.
12. Fire and Burns. Home Safety Council.
homesafetycouncil.org/aboutus/Research/re_sohs_w016.asp.
Accessed 7/14/2011.
13. Baker SP, O’Neill B, Ginsberg NJ, et al. Unintentional injury.
The Injury Fact Book. 2nd ed. New York: Oxford University Press;
1992:39-64.
14. Fast Facts About Smoke Alarms and Fires, National Fire
Protection Association.
?categoryID=2022itemID=47397&URL=Research/Fire. Accessed
7/14/2011.
15. National Fire Data Center. Fire in the United States, 1983 to
1990. 8th ed. Emmitsburg: National Fire Data Center; October
1993.
16. US DoH. Injury Mortality: National Summary of Injury Mortality
Data. 1984–1990. Washington DC: U.S. Department of Health
and Human Services; June 1993.
17. Mierley MC, Baker SP. Fatal house fires in an urban population.
JAMA. 1983;249:1466-1468.
18. Edelman LS, Cook LJ, Saffle JR. Burn injury in Utah:
demographic and geographic risks. J Burn Care & Res.
2010;31:375-378.
19. Bell NJ, Schuurman N, Hameed SM. A small-area population
analysis of socioeconomic status and incidence of severe burn/
fire-related injury in British Columbia, Canada. Burns.
2009;35:1133-1141.
20. Mullins RF, Badrul A, Mian MAH, et al. Burns in mobile home
fires – descriptive study at a regional burn center. J Burn Care &
Res. 2009;30:694-699.
21. Deaths Resulting from Residential Fires and the prevalence of
Smoke Alarms – United States, 1991–1995, Morbidity and
Mortality Weekly Report 47(38):803-806.
22. Ballesteros M, Jackson M, Martin MW. Working towards the
elimination of residential fire deaths: CDC’s Smoke Alarm
Installation and Fire Safety Education (SAIFE) Program. J Burn
Care Rehabil. 2005;26:434-439.
HomeandRecreationalSafety/Fire-Prevention/smoke_alarms.html.
23. Marshall S, Runyan CW, Bangdiwala SI, et al. Fatal residential
fires: who dies and who survives. JAMA. 1998;279:1633-1637.
24. NFPA. Report on home fires. National Fire Protection
Association.
?categoryid=488&itemId=52222.
25. Hammond J. The status of statewide burn prevention legislation.
J Burn Care Rehabil. 1993;14:473-475.
26. Baker SP, O’Neill B, Ginsberg NJ, et al. Fire, burns and lightning.
The Injury Fact Book. 2nd ed. New York: Oxford University Press;
1992:161-173.
27. Pruitt Jr BA, Goodwin CW. Thermal injuries. In: Davis JH,
Sheldon GF, eds. Surgery; A Problem-solving Approach. 2nd ed.
St Louis: Mosby; 1995:644.
28. Burn Incidence and Treatment in the United States. 2011 Fact
Sheet. American Burn Association.
resource_factsheet.php. Accessed 2/28/11.
29. Pruitt Jr BA, Mason Jr AD, Goodwin CW. Epidemiology of burn
injury and demography of burn care facilities. In: Gann DS, ed.
Problems in General Surgery. Vol. 7, No. 2. Philadelphia: JB
Lippincott; 1990:235-251.
30. American Burn Association. Advanced Burn Life Support Course
Provider Manual. American Burn Association, 625 N. Michigan
Ave., Suite 2550, Chicago, IL 60611, 2011.
31. Burd A, Yuen C. A global study of hospitalized pediatric burn
patients. Burns. 2005;31:432-438.
32. Centers for Disease Control and Prevention Burns Safety. The
Reality. Accessed
6/28/2011.
33. Burn and Scald Prevention Fact Sheet. Safe Kids USA. http://

prevention-fact-sheet. Accessed 7/14/2011.
34. Burn Injury Fact Sheet, National Safe Kids Campaign, 1301
Pennsylvania Avenue NW, Suite 1000, Washington DC 20014–
21707.
35. Dissanaike S, Boshart K, Coleman A, et al. Cooking-related
pediatric burns: risk factors and the role of differential cooling
rates among commonly implicated substances. J Burn Care Res.
2009;30:593-598.
36. Kramer CB, Rivara FP, Klein MB. Variations in U.S. pediatric
burn injury hospitalizations using the National Burn Repository
Data. J Burn Care Res. 2010;31:734-739.
37. Barillo DJ, Burge TS, Harrington DT, et al. Body habitus as a
predictor of burn risk in children: do fat boys still get burned.
Burns. 1998;24:725-727.
38. Stephen FR, Murray JP. Prevention of hot tap water burns – a
comparative study of three types of automatic mixing valve.
Burns. 1993;19:56-62.
39. Lindblad BE, Mikkelsen SS, Larsen TK, et al. A comparative
analysis of burn injuries at two burns centers in Denmark. Burns.
1994;20:173-175.
40. Han T, Han K, Kim J, et al. Pediatric hand injury induced by
treadmill. Burns. 2005;31:906-909.
41. Abeyasundara SL, Rajan V, Lam L, et al. The changing pattern of
pediatric burns. J Burn Care Res. 2011;32:178-184.
42. Rajan V, Abeyasundara SL, Harvey JG, et al. Exhaust burns in
children. Burns. 2011;37:265-268.
43. McGill V, Kowal-Vern A, Gamelli RH. Outcome for older burn
patients. Arch Surg. 2000;135:320-325.
44. Cadier MA, Shakespeare PG. Burns in Octogenarians. Burns.
1995;21:200-204.

Total Burn Care
3
45.e2
© Copyright 2012 Elsevier, Inc. All rights reserved.
45. CDC. Non-fatal Scald-Related Burns Among Adults Aged ≥65
Years – United States, 2001–2006. Morbidity and Mortality
Weekly Report. Center for Disease Control and Prevention.
2009;58:993-996. http:/
mmwrhtml/mm5836at.html. Accessed 2/27/11.
46. 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.
47. Yin Z, Qin Z, Xin W, et al. The characteristics of elderly burns in
Shanghai. Burns. 2010;36:430-435.
48. Morita S, Higami S, Yamagiwa T, et al. Characteristics of elderly
Japanese patients with severe burns. Burns. 2010;36:1116-1121.
49. Backstein R, Peters W, Neligan P. Burns in the disabled. Burns.
1993;19:192-197.
50. Alden NE, Rabbitts A, Yurt RW. Burn injury in patients with
dementia: an impetus for prevention. J Burn Care & Rehab.
2005;26:267-271.
51. United States Atomic Energy Commission. Effects on personnel.
In: Glasstone S, ed. The Effects of Nuclear Weapons, Department
of the Army Pamphlet No. 39–43. United States Atomic Energy
Commission; June 1957:455-464.
52. Burns sustained in Vietnam, 1965–1973. Data Tables Supplied
by Department of the Army, Washington D.C.: The Chief of
Military History and the Center of Military History; 1980:20314.
53. Allen BD, Whitson TC, Henjyoji EY. Treatment of 1963 Burned
Patients at 106th General Hospital, Yokohama, Japan. J Trauma.
1970;10:386-392.
54. Shafir R. Burn Injury and Care in the Recent Lebanese Conflict.
Presentation on behalf of The Surgeon General, Israeli Defense
Forces and Staff. The Israeli Society of Plastic and Reconstructive
Surgery; 1984.
55. Owen-Smith MS. Armoured fighting vehicle casualties. J Royal
Army Med Corps. 1977;123:65-76.
56. Chapman CW. Burns and plastic surgery in the South Atlantic
campaign 1982. J Royal Navy Med Serv. 1983;69(2):71-79.
57. Eldad A, Torem M. Burns in the Lebanon War 1982: ‘The Blow
and the Cure.’ Military Medicine. 1990;155:130-132.
58. Carlos Sereday, MD, Major, Argentine Navy Medical Corps.
Personal communication, 1990.
59. Renz EM, Cancio LC, Barillo DJ, et al. Long range transport of
war-related burn casualties. J Trauma. 2008;64:S136-S145.
60. Kauvar DA, Baer DG. Effect of a targeted education intervention
on the incidence of waste-burning injuries in a military
population. J Burn Care Res. 2009;30:700-704.
61. Ramasamy A, Harrison SF, Clasper JC, et al. Injuries from
Roadside Improvised Explosive Devices. J Trauma. 2008;65:910-
917.
62. Belmont Jr PJ, Goodman GP, Zacchilli M, et al. Incidence and
epidemiology of combat injuries sustained during ‘the surge’
portion of operation Iraqi Freedom by a U.S. Army Brigade
Combat Team. J Trauma. 2010;68:204-210.
63. Renz EM, MD, Col. MC, Director U.S. Army Burn Center,
Institute of Surgical Research Brooke Army Medical Center Fort
Sam Houston, TX, Personal Communication, July 18, 2011.
64. Foster MA, Moledina J, Jeffery SLA. Epidemiology of U.K.
Military burns. J Burn Care Res. 2011;32:415-420.
65. Donaldson RI, Hung YW, Shanovich P, et al. Injury Burden
During an Insurgency: The Untold Trauma of Infrastructure
Breakdown in Baghdad, Iraq. J Trauma. 2010;69:1379-1385.
66. Creamer KM, Edwards MJ, Shields CH, et al. Pediatric Wartime
Admissions to U.S. Military Combat Support Hospitals in
Afghanistan and Iraq: Learning from the First 2000 Admissions.
J Trauma. 2009;67:762-768.
67. Kopchinski B. U. S. Army Noncombat Munitions Injuries.
Military Medicine. 2001;166:135-138.
68. Hankins CL, Tang XQ, Phipps A. Hot beverage burns: an
eleven-year experience of the Yorkshire Regional Burns Centre.
Burns. 2006;32:87-91.
69. Hankins CL, Tang XQ, Phipps A. Hot oil burns – a study of
predisposing factors, clinical course and prevention strategies.
Burns. 2006;32:92-96.
70. Klein MB, Gibran NS, Emerson D, et al. Patterns of grease burn
injury: Development of a Classification System. Burns.
2005;31:765-767.
71. Barillo DJ, Stetz CK, Zak AL, et al. Preventable burns associated
with a misuse of gasoline. Burns. 1998;24:439-443.
72. Kulahci Y, Sever C, Zor F, et al. Thermal burns associated with
the misuse of flammable liquids in stoves: a continuing
problem. J Burn Care Res. 2011;32:302-308.
73. Chen XL, Guo F, Liang X, et al. Burns caused by alcohol-based
fires in the household coal stove in Anhui Province, China.
Burns. 2010;36:861-870.
74. Kraemer R, Knobloch K, Lorenzen J, et al. Severe burn injuries
caused by bioethanol-design fireplaces – an overview on
recreational fire threats. J Burn Care & Res. 2011;32:173-177.
75. Baker SP, O’Neill B, Karpf RS. The Injury Fact Book. Lexington:
Lexington Books; 1984:139-154.
76. Purdue GF, Hunt JL, Layton TR, et al. Burns in motor vehicle
accidents. J Trauma. 1985;25:216-219.
77. Barillo DJ, Cioffi WG, McManus WF, et al. Vehicle-related burn
injuries. Proceedings of Association for the Advancement of
Automotive Medicine, 2340 Des Plaines Avenue, Suite 106, Des
Plaines 1993;11:209-218.
78. Renz BM, Sherman R. Automobile carburetors- and radiator-
related burns. J Burn Care Rehabil. 1992;1:414-421.
79. Ahrens M. U.S. Vehicle Fire Trends and Patterns. National Fire
Protection Association, Fire Analysis and Research Division,
One-Stop Data Shop. 1 Batterymarch Park, Quincy, MA
02169–7471, U.S.A. 2010.
80. Matzavakis I, Frangakis ZE, Charalampopolulou A, et al. Burn
injuries related to motorcycle exhaust pipes: a study in Greece.
Burns. 2005;31:372-374.
81. Shergill G, Scerri GV, Regan PJ, et al. Burn injuries in boating
accidents. Burns. 1993;19:229-231.
82. Consumer Product Safety Commission. 8th Annual Flammable
Fabrics Report. Washington, DC: Consumer Product Safety
Commission; 1980.
83. Ben DF, Ma B, Chen XL, et al. Burn injuries caused by ship fire:
A 12-year study in Shanghai. Burns. 2010;36:576-580.
84. Neaman KC, Do VD, Olenzek EK, et al. Outdoor recreational
fires: a review of 329 adult and pediatric patients. J Burn Care
Res. 2010;31:926-930.
85. Fraga AMA, Fraga GP, Noordenbos J, et al. Beach and campfire
burns: a site of pleasure and tragedy. J Burn Care Res.
2010;31:184-189.
86. Woodbridge TR, Weisfeld-Adams JD, Wilkins EC, et al.
Epidemiology and severity of paediatric burn injuries occurring
during camping and caravanning holidays. Burns. 2010;36:1096-
1100.
87. Al-Qattan MM. Campfire burns of the palms in crawling infants
in Saudi Arabia: results following release and graft of
contractures: J Burn Care Res. 2009;30:616-619.
88. Sayampanathan AA. Fire walking in Singapore – A Study of the
distribution of burns. Burns. 2011;37:503-507.
89. Chown GA. A retrospective case series study of Deepavali fire
walkers in Singapore. Burns. 2010;36:711-715.
90. Hemington-Gorse SJ, Slattery MA, Drew PJ. Burns related to
sunbed use. Burns. 2010;36:920-923.
91. Washington State Department of Labor and Industries.
Hospitalized burns. Washington State Department of Labor and
Industries.
Burns/default.asp. Accessed 7/1/2011.
92. MMWR. Occupational burns among restaurant workers
– Colorado and Minnesota. MMWR. 1993;42:713-716.
93. Chatterjee BF, Barancik JI, Fratianne RB, et al. Northeastern Ohio
Trauma Study V: Burn Injury. J Trauma. 1986;26:844-847.

Epidemiological, demographic, and outcome characteristics of burn injury
45.e3
© Copyright 2012 Elsevier, Inc. All rights reserved.
94. Rossignol AM, Locke JA, Boyle CM, et al. Epidemiology of
work-related burn injuries in Massachusetts requiring
hospitalization. J Trauma. 1986;26:1097-1101.
95. Personck ME. Profiles in safety and health: Eating and drinking
places. Monthly Labor Review. 1991;114:19-26.
96. Baker SP, O’Neill B, Ginsberg NJ, et al. Occupational injury. The
Injury Fact Book. 2nd ed. New York: Oxford University Press;
1992:114-133.
97. Horwitz IB, McCall BP. An Analysis of Occupational Burn
Injuries in Rhode Island: Workers Compensation Claims,
1998–2002.
98. NOIRS. 2000 – Pittsburgh, Pennsylvania October 17–19, 2000,
NIOSH.
99. Curwick CC. Hospitalized Work-Related Burns in Washington
State Technical Report #86–2-2006; Safety & Health Assessment
& Research for Prevention (SHARP) Program Washington State
Department of Labor and Industries, Olympia, Washington,
USA.
100. Burn Injury Facts – Scald Burns in Restaurant Workers. Safety &
Health Assessment & Research for Prevention (SHARP) Program
Washington State Department of Labor and Industries, Report
#86–7–2009, April 2009.
101. Pruitt Jr BA, Edlich RF. Treatment of bitumen burns (Letter).
JAMA. 1982;247:1565.
102. Renz BM, Sherman R. Hot tar burns: 27 hospitalized cases.
J Burn Care Rehabil. 1994;15:341-345.
103. Al-Qattan MM, Al-Zahrani K, Al-Shanawani B, et al. Friction
burn injuries to the dorsum of the hand after care and industrial
accidents: classification, management, and functional recovery.
J Burn Care Res. 2010;31:610-615.
104. US Consumer Product Safety Commission. Acute chemical
hazards to children and adults. NEISS Data Highlights. Vol. 12,
January–December 1988. Directorate for Epidemiology, US
Consumer Product Safety Commission Washington, DC.
105. Mozingo DW, Smith AA, McManus WF, et al. Chemical burns.
J Trauma. 1988;28:642-647.
106. Hall Jr JR. Deaths and injuries due to non-fire burns, National
Fire Protection Association Fire Analysis and Research Division
One-Stop Data Shop. 1 Batterymarch Park, Quincy, MA
02169–07471. April 2009. Accessed 7/5/2011.
107. Ahern M. Burns Seen in Hospital Emergency Rooms in 2008 by
Burn Type and Victim’s Age. National Fire Protection Association
Fire Analysis and Research Division, One-Stop Data Shop, 1
Batterymarch Park, Quincy, MA 02169–07471. September 2009.
Accessed 7/6/2011.
108. Pool Chemical-Associated Health Events in Public and
Residential Settings – United States, 1983–2007. MMWR Weekly.
May 15 2009;58(18):489-493
preview/mmwrhtml/mm5818al.html Accessed 2/27/2011.
109. Leeming MN, Ray Jr C, Howland WS. Low-voltage direct current
burns. JAMA. 1970;214:1681-1684.
110. Pride HB, McKinley DF. Third-degree burns from the use of an
external cardiac pacing device. Crit Care Med. 1990;18:572-573.
111. Reisin L, Baruchin AM: Iatrogenic defibrillator burns. Burns.
1990;16:128.
112. Arnoldo BD, Purdue GF, Kowalske K, et al. Electrical injuries:
A 20-Year Review. J Burn Care and Rehab. 2004;25:479-484.
113. Cancio LC, Jimenez Reyna JF, Barillo DJ, et al. One hundred
ninety five cases of high-voltage electric injury. J Burn Care and
Rehab. 2005;26:331-340.
114. Fodor L, Bota IO, Abbas Y, et al. Electricity and fishing – a
dangerous mix. Burns. 2011;37:495-498.
115. Patil SB, Khare NA, Jaiswal S, et al. Changing patterns in
electrical burn injuries in a developing country: should
prevention programs focus on the rural population? J Burn Care
Res. 2010;31:931-934.
116. Mashreky SR, Rahman A, Khan TF, et al. Epidemiology of
childhood electrocution in Bangladesh: Findings of national
injury survey. Burns. 2010;36:1092-1109.
117. Curinga G, Pietramaggiori G, Scherer SS, et al. Electrical injuries
due to theft of copper. J Burn Care Res. 2010;31:341-346.
118. Marcucci PA, Smith S, Gomez M, et al. An effective prevention
program to reduce electrical burn injuries caused by the use of
multimeters. J Burn Care Res. 2010;31:333-340.
119. MMWR. Lightning-associated deaths – United States 1980–1995.
Morbidity and Mortality Weekly Report. 1998;47:391-394.
120. Lopez RE, Holle RL. Demographics of lightning casualties.
Seminars Neurol. 1995;15:286-295.
121. Lightning-associated injuries and deaths among military
personnel – United States, 1998–2001. MMWR. 2002;51:859-
862.
122. Greene MA, Granados DV. 2008 Fireworks Annual Report:
Fireworks-related deaths, emergency department treated injuries,
and enforcement activities during 2008. Washington DC: U.S.
Consumer Product Safety Commission; 2009. http://

123. Karamanoukian RL, Kilani M, Lozano D, et al. Pediatric burns
with snap-cap fireworks. J Burn Care & Rehab. 2006;27:218-220.
124. Fireworks-related injuries, 2010.
HomeandRecreationalSafety/Fireworks/index.html.
125. Karch DL, Dahlberg LL, Patel N. Surveillance for Violent Deaths
– National Violent Death Reporting System, 16 States, 2007.
MMWR Weekly Report. Surveillance Summaries, 2010;59(SS04);
1-50.
ss5904al.html.
126. Sonneborn CK, Vanstraelen TM. A retrospective study of
self-inflicted burns. Gen Hosp Psychiatry. 1992;14:404-407.
127. Horner BM, Ahmadi H, Mulholland R, et al. Case-controlled
studies of patients with self-inflicted burns. Burns. 2005;31:471-
475.
128. Budny PG, Regan PJ, Riley P, et al. Ritual burns – the Buddhist
tradition. Burns. 1991;17:335-337.
129. Squyres V, Law EJ, Still Jr JM. Self-inflicted burns. J Burn Care
Rehabil. 1993;14:476-479.
130. Ganesamoni SR, Kate V, Sadasivan J. Epidemiology of
hospitalized burn patients in a tertiary care hospital in South
India. Burns. 2010;36:422-429.
131. Moniz P, Casal D, Mavioso C, et al. The self-inflicted burns
– Typology and its prognostic relevance in a 14-year review of
self-inflicted burns in a tertiary referral centre. Burns.
2011;37:314-319.
132. Uygur F, Sever C, Oksuz S, et al. Profile of self-inflicted burn
patients treated at a tertiary burn center in Istanbul. J Burn Care
& Res. 2009;30:427-431.
133. Duminy FJ, Hudson DA. Assault inflicted by water. Burns.
1993;19:426-428.
134. Theodorou P, Spanholtz TA, Amini P, et al. Cologne burn centre
experience with assault burn injuries. Burns. 2009;35:1152-1157.
135. Kulahci Y, Sever C, Noyan N, et al. Burn Assault With Paint
Thinner Ignition: An Unexpected Burn Injury Caused by Street
Children Addicted to Paint Thinner. J Burn Care & Res.
2011;32:399-404.
136. Karunadasa KP, Perera Ch, Kanagaratnum V, et al. Burns
due to Acid Assaults in Sri Lanka. J Burn Care & Res. 2010;31:
781-785.
137. Milton R, Mathieu L, Hall AH, et al. Chemical assault and skin/
eye burns: Two representative cases, report from the Acid
Survivors Foundation, and literature review. Burns. 2010;36:924-
932.
138. O’Neill Jr JA, Meacham WF, Griffin PP, et al. Patterns of injury in
the battered child syndrome. J Trauma. 1973;13:332-339.
139. Showers J, Garrison KM. Burn abuse: A four-year study. J Trauma.
1988;28:1581-1583.
140. Surrell JA, Alexander RM, Kohle SD, et al. Effects of microwave
radiation on living tissues. J Trauma. 1987;27:935-939.
141. Batchelor JS, Vanjari S, Budny P, et al. Domestic iron burns in
children: a cause for concern? Burns. 1994;20:74-75.

Total Burn Care
3
45.e4
© Copyright 2012 Elsevier, Inc. All rights reserved.
142. Chester DL, Jose RM, Adlayami E, et al. Non-accidental burns in
children – are we neglecting neglect? Burns. 2006;32:222-228.
143. Dissanaike S, Wishnew J, Rahimi M, et al. Burns as child abuse:
risk factors and legal issues in West Texas and Eastern New
Mexico. J Burn Care & Res. 2010;31:176-183.
144. Elder abuse: what can be done? Select Committee on Aging, U.S.
House of Representatives. Washington DC: Government Printing
Office; 1991.
145. Bird PE, Harrington DT, Barillo DJ, et al. Elder Abuse: A Call to
Action. J Burn Care Rehabil. 1998;19:522-527.
146. Pegg SP. Can burns injuries occur in hospital? Presented at 9th
Congress of the International Society for Burn Injuries, 30 June 1994,
Paris, France. Abstract 87 in 9th Congress of International Society
for Burns Injuries, Abstracts Volume.
147. Sadove RC, Furgasen TG. Major thermal burn as a result of
intraoperative heating blanket use. J Burn Care Rehabil.
1992;13:443-445.
148. Gul A, O’Sullivan ST. Iatrogenic burns caused by infrared lamp
after traditional acupuncture. Burns. 2005;31:1061-1062.
149. Chang BW, Petty P, Manson PN. Patient fire safety in the
operating room. Plast Reconstr Surg. 1994;93:519-521.
150. Leon-Villapalos J, Kaniorou-Larai M, Dziewulski P. Full thickness
abdominal burn following magnetic resonance-guided focused
ultrasound therapy. Burns. 2005;31:1054-1055.
151. Barillo DJ, Coffey EC, Shirani KZ, et al. Burns caused by medical
therapy. J Burn Care Rehabil. 2000;21:269-273.
152. Treat RC, Sirinek KR, Levine BE, et al. Air evacuation of
thermally injured patients: principles of treatment and results.
J Trauma. 1980;20:275-279.
153. Launching a National Surveillance System After an Earthquake
– Haiti, 2010. MMWR Weekly. August 6, 2010/59;(30):933-938.

mm5930al.htm?s_cid=mm5930al_w.
154. Jordan MH, Hollowed KA, Turner DG, et al. The Pentagon
Attack of September 11, 2001:A Burn Center’s Experience. J Burn
Care Rehabil. 2005;26:109-116.
155. Yurt RW, Bessey PQ, Bauer GJ, et al. A Regional Burn Center’s
Response to a Disaster: September 11, 2001 and the Days
Beyond. J Burn Care Rehabil. 2005;26:117-124.
156. Kennedy PJ, Haertsch PA, Maitz PK. The Bally Burn Disaster:
Implications and Lessons Learned. J Burn Care Rehabil.
2005;26:125-131.
157. Mozingo DW, Barillo DJ, Holcomb JB. The Pope Air Force Base
aircraft crash and burn disaster. J Burn Care Rehabil.
2005;26:132-140.
158. Harrington DT, Biffl WL, Cioffi WG. The Station Nightclub Fire.
J Burn Care Rehabil. 2005;26:141-143.
159. Cairns BA, Stiffler A, Price F, et al. Managing a Combined Burn
Trauma Disaster in the Post-Nine/Eleven World: Lessons Learned
from the 2003 West Pharmaceutical Plant Explosion. J Burn Care
Rehabil. 2005;26:144-150.
160. Facts about injuries: Burns World Health Organization https//

injury/on/burns_fact/sheet.pdf. Accessed 5/10/2011.
161. Sethi D, Towner E, Vincenten J, et al. European Report on Child
Injury Prevention. WHO Regional Office for Europe, Scherfigsvej
8, DK-2100 Copenhagen Ø Denmark, 2008;49-56.
162. WHO. The Global Burden of Disease 2004 Update. WHO Press,
World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland, p. 28.
burden_disease/GBD_report_2004update_full.
163. WHO. Statistical Annex Explanatory Notes. In: Peden NL,
Oyegbite K, Ozanne-Smith J, et al, eds. World Report on Child
Injury Prevention. World Health Organization Unicef, WHO
Press, World Health Organization, 20 Avenue Appia 1211 Geneva
27, Switzerland 2008:157-202.
164. Wasiak J, Spinks A, Ashby K, et al. The epidemiology of burn
injuries in an Australian setting, 2000–2006. Burns.
2009;35:1124-1132.
165. Duke J, Wood F, Semmens J, et al. A 26-year population-based
study of burn injury hospital admissions in Western Australia.
J Burn Care Res. 2011;32:379-386.
166. Mistry RM, Pasisi L, Chong S, et al. Socioeconomic deprivation
and burns. Burns. 2010;36:403-408.
167. Onarheim H, Jensen SA, Rosenberg BE, et al. The epidemiology
of patients with burn injuries admitted to Norwegian hospitals
in 2007. Burns. 2009;35:1142-1146.
168. Busche MN, Gohritz A, Seifert S, et al. Trauma mechanisms,
patterns of injury, and outcomes in a retrospective study of 71
burns from civil gas explosions. J Trauma. 2010;69:928-933.
169. Bazargani HS, Mohammadi R, Svanstrom L, et al. Epidemiology
of minor and moderate burns in rural Ardabil, Iran. Burns.
2010;36:933-937.
170. Taghavi M, Rasouli MR, Boddouhi N, et al. Epidemiology of
outpatient burns in Tehran: An analysis of 4813 cases. Burns.
2010;36:109-113.
171. Torabian S, Saba MS. Epidemiology of paediatric burn injuries
in Hamadan, Iran. Burns. 2009;35:1147-1151.
172. Light TD, Latenser BA, Heinle JA, et al. Demographics of
pediatric burns in Vellore, India. J Burn Care Res. 2009;30:
50-54.
173. Kanchan T, Menezes RG. Mortalities among children and
adolescents in Manipal Southern India. J Trauma. 2008;64:1600-
1607.
174. Padovese V, DeMartino R, Eshan MA, et al. Epidemiology and
outcome of burns in Esteqlal Hospital of Kabul, Afghanistan.
Burns. 2010;36:1101-1106.
175. Fadeyibi IO, Jewo PI, Opoola P, et al. Burns and fire disasters
from leaking petroleum pipes in Lagos, Nigeria: An 8-year
experience. Burns. 2011;37:145-152.
176. Holmes T, ed. A System of Surgery, Theoretical and Practical. Vol. I.
London: J W Parker & Son; 1860:723.
177. Suzuki S. The injuries in modern naval warfare. Boston Med Surg
J. December 9, 1897;CXXXVII(24):610.
178. Weidenfeld LB. Medizinisches Vademecus. 1912:206-224.
179. Berkow SG. Method of estimating extensiveness of lesions
(burns and scalds) based on surface area proportions. Arch Surg.
1924;8(pt. 1):138-148.
180. Bull JP, Squire JR. A study of mortality in a burns unit: standards
for the evaluation of alternative methods of treatment. Ann Surg.
1949;130(2):160-173.
181. Bull JP, Fisher AJ. A study of mortality in a burns unit: a revised
estimate. Ann Surg. 1954;139(3):269-274.
182. Schwartz MS, Soroff HS, Reiss E, et al. An evaluation of the
mortality and the relative severity of second and third-degree
injuries in burns. Research Report Nr. 12–56. In: Research Reports.
U.S. Army Surgical Research Unit, Fort Sam Houston, TX;
December 1956.
183. SPSS Inc. SPSS for Windows, ver.12.0. Chicago, IL: SPSS Inc.
184. Finney DJ. Probit Analysis. 3rd ed. Cambridge: Cambridge
University Press; 1971.
185. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York:
John Wiley & Sons; 1989.
186. Moreau AR, Westfall PH, Cancio LC, et al. Development and
validation of an age-risk score for mortality prediction after
thermal injury. J Trauma. 2005;58(5):967-772.

This page intentionally left blank

Introduction
The word ‘prevent’ comes from the Latin word ‘praevenire,’
which means to anticipate. The prefix ‘pre’ means before and
‘venire’ means to come. During the last century in the United
States, burn treatment had always come before burn pre­
vention. Because then as now, burns represent such a small
percent of all traumatic injuries, burn prevention has not
been viewed as a high-priority heath issue by a large portion
of society.
Burns are still referred to as accidents by many in the
medical community and by society in general. Believing that
burns and other traumatic injuries are ‘accidents’ (‘accident-
prone’ individual) implies the individual has little or no
fault in the cause of injury. The word ‘accident’ means an
event that takes place without one’s foresight or proceeds
from an unknown cause, an unfortunate occurrence, or
mishap, especially one resulting in an injury.1 Synonyms
include misadventure, mischance, misfortune, mishap, and
disaster. The word ‘injury’ is a more appropriate term.
Historical perspective
In Great Britain in the first decade of the 20th century the
medical community was well aware that burn injuries and
deaths represented a serious public health issue.2 Scalds and
burns were noted to occur predominantly in children.
Unguarded fires and the flammability of flannelette, a cotton
fabric, were recognized as common causes of burns in
children and old women. Legislation was enacted making
parents liable to a fine if a child younger than 8 years was
injured or died as a result of an unguarded open fire. In a
review of over 3600 patients with flame burns and scalds,
two-thirds of cases occurred in and around the home, one-
third were at work, 50% were children, 82% were the result
of clothing fires, cottons were the common fabrics, and the
number of scalds about equalled that from burns, but the
former were more likely to survive.3 Approximately 50% of
‘accidents’ were judged to be preventable. Research was con­
ducted on the design and flammability of clothing. Fabrics
were treated with tin, antimony, and titanium to make them
relatively flame-retardant. Statistics on common locations
and causes for accidents identified the kitchen and cooking,
scald burns from children pulling over containers with hot
liquids, and the use of flammable liquids. Burns as a result
of a seizure were recognized. Prevention efforts included
education and ‘propaganda’ (film, radio, newspapers, exhib­
its, and posters), better design of housing and improving
living conditions (decreasing overcrowding), safer methods
of heating houses (central heating and electric fires), use of
non-flammable materials in girls’ and women’s clothing,
and safer fireguard designs for coal fires. Better design of
teapots, cups, and cooking utensils rendered them more
difficult to tilt over. One author in 1946 expressed quite
clearly that carelessness, neglect of normal precautions, and
stupidity were human factors associated with burns.4 It was
recognized that accurate and comprehensive burn data
were lacking, but necessary if long-term prevention policies
were to be enacted.
Injury control
The five key areas in injury control are:
1. Epidemiology
2. Prevention
3. Injury biomechanics (physical and functional responses
of the victim to the energy)
4. Treatment
5. Rehabilitation.5
The major components of epidemiology include measure­
ment of both the frequency and the distribution of the
injury. This in turn is analyzed and interpreted. Next, risk
factors are identified, an intervention strategy is developed
and tested, and, lastly, the results are analyzed.
Burn injury magnitude
The first step in any prevention program is to identify the
how, who, where, and when of the injury. With this informa­
tion strategic planning and implementation can be directed
at reducing the risk of injury or death. In 2007 the leading
causes of injury deaths, in order of magnitude, were motor
vehicle collisions, drowning, firearms, falls, and finally flame/
fire.6 In 1999 the number of fire deaths and injuries was
3570. In 2002 there were 3363 deaths, a decrease of less than
5.7%. The number of fire deaths increased progressively with
age and peaked at 720 in those over 75. The number of non-
fatal injuries (almost 79 000) was greatest between ages 35
and 44. Males were 1.6 times more likely to die in a fire. In
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00004-7
CHAPTER 4 
Prevention of burn injuries
John L. Hunt, Brett D. Arnoldo, Gary F. Purdue*
Access the complete reference list online at

*We gratefully acknowledge the work of our deceased colleague, Gary F. Purdue.

Total Burn Care
4
48
2008 the numbers of deaths and injuries were 3320 and
167 015, respectively.7 On average in the United States in
2008 fire departments responded to a fire every 22 seconds.
One structure fire was reported every 61 seconds, and every
31 minutes one civilian fire injury was reported. One civilian
fire death occurred every 2 hours and 38 minutes. Between
2003 and 2007 the US Fire Administrations’ national fire
incidence reporting system identified the leading causes of
home structure fires as cooking, heating equipment, inten­
tional, electrical, and smoking. Smoking was the leading
cause of home fire deaths (25%), and heating equipment
ranked second (22%). Heating equipment such as portable
and fixed space heaters and wood-burning stoves resulted in
more fires than central heating. Candles accounted for 10%.
From 1990 to 2001 this figure nearly tripled. One-third of
fatal candle fires occurred when they were used for lighting
when an electrical power outage occurred (hurricanes, torna­
dos, etc.). Children under 5 were nearly eight times more
likely than all other age groups to die in fires caused by
playing with the heat source. Of fire injuries in homes, 43%
were associated with fighting the fire, or attempting rescue;
attempting escape (23%); while asleep (13%); and inability
to act or acting irrationally 6%.8 For comparison, from 1980
to 2007 the death rate for children under 5 declined from
18% to 9% and for adults 65 and over increased from 19%
to 29%. Nearly 50% of all cooking fire injuries occurred
when the victims tried to fight the fire. Home fabric fires
caused by smoking commonly originated in upholstered
furniture, mattresses, or bedding. Older adults (defined as
over 64 years) are at greatest risk of sustaining both fire inju­
ries and death. The elderly are approximately 1.5 times more
likely to suffer fire-related death than the general population.
Those aged 85 and older are 4.5 times more likely to die in a
fire than the general population. Smoking in the presence of
home oxygen is frequently encountered in the elderly. Physi­
cal and mental disabilities often either contribute to the
cause of the fire or hamper the escape. Populations in the
lowest income levels had a greater risk of dying in a fire than
those in higher income levels. The leading causes of fatal fires
in residential property were incendiary/suspicious (27%),
smoking (18%), and open flames (16%). The leading areas
of fire origin in fatal residential structure fires were sleeping
areas (29%), lounge (21%), and kitchen (15%). Fatal fires
were more common in the winter, and the time of day when
most structure fires occurred was between 10 am and 8 pm.
It is well recognized that many burn patients treated in
emergency departments are never admitted to hospital. In
2006 the National Hospital Ambulatory Medical Survey
identified 501 victims of fire, flame, or hot substances per
100 000 emergency room visits. This had changed little since
2003 (516/100 000).9
Risk factors
A number of factors must be considered when determining
the fire risk to the host. Age, location, demographics, and
low economic status represent important factors. The US Fire
Administration (USFA) expresses much of its fire data as
relative risk (RR).10 The RR of a group (example death) is
calculated by comparing its rate to the rate of the overall
population. An RR of 1 is given to the general population.
As a general rule, many statisticians consider an RR of 4 or
more as important, and an RR of 4 or more is used to iden­
tify high-risk burn populations. The RR of fire deaths in 2001
for all ages, with the exception of 0–4 years and 55 or over,
was less than 1. Based on 2006 data, prevention programs
should be directed at everyone over 85 years (RR 3.78),
American-Indian males (RR 5.3) and African-Americans (RR
6.9). The use of RR in injury prevention is useful when
resources are limited.
In 2004 children aged 0–15 years accounted for 560 fire
deaths and 2007 fire injuries: 50% and 43% of deaths and
injuries occurred in children less than 5 years of age. The RR
of fire death for children less than 5 years was 0.74, 0.6 for
ages 5–9, and 0.3 for 10–14 years. The RR of home fire inju­
ries in children under 5 in the US between 2003 and 2007
was 1.4. For comparison, in those over 65 the RR of death
was 2.3.11 The activities of children at the time of a fire injury
were: sleeping (55%), trying to escape (26%), and unable to
act, which implies not understanding what was happening
or how to take action (9%).
Analysis of fatal pediatric fire fatalities in Philadelphia
(1989–2000) revealed four significant independent varia­
bles: age under 15 years, age of housing, low income, and
single parent households.12 The greatest risk was between
12:00 am and 6:00 am. The common causes were playing
with matches, cigarettes or careless smoking, and incendiary.
The common locations were bedroom and living room.
Upholstered furniture, cooking materials, bedding, mat­
tresses, clothing, and curtains were primary materials first
ignited in fatal fires. Playing with cigarette lighters and
candles, or near stoves with hot liquids, were frequent sce­
narios in fatal pediatric burns. The authors stressed that
identifying risk factors by analyzing population characteris­
tics by census tract was important for burn prevention. These
risks are still common 11 years later.
By 2020 it is estimated that people aged 65 years and older
will number approximately 55 million, an increase of 16%
from 2000. By 2050 they will represent 21% of the popula­
tion. In 2006 fire injuries in those over 64 accounted for
11.8% of all ages, and the RR of fire deaths between 65 and
85+ increased from 1.44 to 3.78.13 The leading causes of
both death and injury from fire were smoking, cooking over
an open flame, and heating equipment. Additional risks
included medical conditions associated with physical or
mental illness, e.g. arthritis and stroke (the victim is slow or
unable to escape the fire), poor eyesight and hearing,
systemic diseases such as diabetes (peripheral neuropathy
with decreased or no lower extremity pain perception),
Alzheimer’s disease (confusion, forgetfulness), and psy­
chiatric illness (depression and suicide). Other risk factors
include alcohol and medications such as sleeping pills or
tranquilizers. Fire injury and death commonly occur mid-
morning and early afternoon.
Burn prevention involves more than just the burn com­
munity. Fire safety engineers and legislators (building code
laws) and building inspectors have a vested interest in pre­
vention. An important aspect of fire prevention is the design
of fire-safe buildings. Both the type of fire and the composi­
tion of the material ignited must be identified and analyzed.
These include the ignition factor (misuse of ignited material

Prevention of burn injuries
49
by children), type of material ignited (sofas, chairs, and
bedding) and the source of ignition (electrical equipment,
matches, lighters, cigarettes). Personal factors include condi­
tion preventing escape, physical condition before injury,
activity at the time of injury, and the site of ignition.
Burns rank among the 15 leading causes of death in chil­
dren and young adults.14 The World Health Organization
(WHO) reported that, globally, burns accounted for >300 000
deaths annually. In 2007 WHO recognized there was an
urgent need for public health action to reduce unintentional
injuries, and burns were recognized as a serious global health
problem.15 The WHO strategy for burn prevention and care
includes improving data sources and surveillance, promot­
ing burn prevention strategies, encouraging innovative pilot
programs to address burn prevention priorities in areas with
high risk factors, and strengthening burn care services, which
include acute care and rehabilitation. Risk factors include
cooking at floor level, open kerosene stoves, high population
density, poor house construction, and illiteracy.
Passive strategies for prevention, such as smoke alarms,
sprinkler systems, building construction codes, regulation
of hot water heater temperatures, and flame-resistant sleep­
wear, have proved effective in industrialized countries, but
some segments of the population at risk are not dissimilar
from most low- and middle-income countries (LMICs).16
These include poverty, lack of education and employment,
large and single parent families, substandard housing
including lack of running water, no electricity, crowded
living conditions, and racial and ethnic minorities. For any
global burn prevention strategy to be successful it must be
recognized that differences exist at national, regional and
local levels.17 Over 90% of fatal fire-related burns occur in
these LMICs.18,19 It is understandable that in many LMICs
high priority has been given to disease rather than injury
pre­vention. In many such areas medical resources for burns
are limited, and prevention rather than treatment is the
priority.
Most importantly, children are at increased risk of burn
morbidity and mortality.20,21 Regardless of socioeconomic
status, childhood burns are related to the physical environ­
ment in which they occur. Behavioral changes can be
effective in preventing fire-related burns without changing
lifestyle to any great extent. Active prevention even in high-
income countries has met with limited success. It makes
sense to emphasize specific issues that can modify behavior
without the need for excessive use of resources, both dollars
and personnel. Any program should be tailored to fit
local conditions. Focusing on burn prevention rather than
treatment is key to reducing fatalities and injuries. One
strategy does not fit all.22
Injury prevention comes of age
The science of injury prevention took shape in the middle
of the last century. The energy sources involved in any injury
event are classified into five physical agents: kinetic or
mechanical, chemical, thermal, electrical, and radiation. A
common form of mechanical energy associated with a burn
is a motor vehicle collision. Three risk factors associated with
any injury are:
1. the vector or energy source and the way it is delivered,
2. the host or injured person, and
3. the environment, both physical and social.
A seminal article in modern injury science was published by
Haddon in 1968.23 He identified three phases of an injury
event:
1. Pre-event: preventing the causative agent from reaching
the susceptible host.
2. Event: includes transfer of the energy to the victim.
Prevention efforts in this phase operate to reduce or
completely prevent the injury.
3. Post-event: determines the outcome once the injury has
occurred. This includes anything that limits ongoing
damage or repairs the damage. This phase determines
the ultimate outcome.
Haddon then created a matrix of nine cells which enabled
the three events of the injury to be analyzed against the
factors, related to the host, the agent or vector, and the envi­
ronment24 (Table 4.1). This is a very useful tool for analyzing
an injury-producing event and recognizing the factor(s)
important in its prevention. Haddon also proposed 10
general strategies for injury control (Table 4.2).24
Burn intervention strategy
The emergence of the science of prevention has turned atten­
tion away from individual ‘blame’ and the attitude that
society has no part in the promotion of prevention to the
concept that sociopolitical involvement is necessary.25
All burn injuries should be viewed as preventable. Public
health is defined as the effort organized by society to protect,
Table 4.1  The Haddon Matrix for burn control
Agent or vector
Host
Environment
Physical
Social
Pre-event
Fire-safe cigarette
Control seizure
Non-slip tub surface
Legislation – factory preset water heater
thermostats
Event
Sprinklers, smoke detectors
Flame-retardant cloths
Fire escapes
Fire drill education
Post-event
Water
First aid antibiotics
EMS
Emergency and rehabilitation services
Matrix adapted from Haddon W, Advances in the epidemiology of injuries as a basis for public policy. Public Health Reports 1980; 95: 411–421.24

Total Burn Care
4
50
promote, and restore the people’s health.26 The public health
model of injury prevention and control is divided into:
•
surveillance,
•
interdisciplinary education and prevention programs,
•
environmental modifications,
•
regulatory action, and
•
support of clinical interventions.
Primary prevention is preventing the event from ever occur­
ring. Secondary prevention includes acute care, rehabilita­
tion, and reducing the degree of disability or impairment as
much as possible. Tertiary prevention concentrates on pre­
venting or reducing disability. Disability prevalence and loss
of productive activity are important outcome measures.
There are both active and passive prevention strategies.
Passive or environmental intervention is automatic: the host
requires little to no cooperation or action. This is the most
effective prevention strategy. Examples include building
codes requiring smoke alarms, sprinkler installation, and
factory-adjusted water heater temperature. Active prevention
measures are voluntary; emphasize education to encourage
people to change their unsafe behavior, and require repeti­
tive educational measures to maintain individual action.
Herein lies its weakness. Project Burn Prevention was a
program funded by the Consumer Product Safety Commis­
sion (CPSC) in 1975.27 It was undertaken to determine
whether a burn prevention program would reduce burn
deaths by using an educational program and media mes­
sages involving a large population base. The author con­
cluded that there was no reduction of burn incidence or
severity in their study with either the school education
program or the media campaign. Education to bring about
and maintain personal responsibility was not sufficient.
Active prevention is the least effective and most difficult
strategy to maintain, especially over a long period. Examples
are a home fire-drill plan, and wearing goggles and gloves
when handling toxic chemicals. Passive strategies are not
always successful, however: a homeowner may raise a water
heater thermostat and a sprinkler system or smoke alarm
must be maintained. Once surveillance data have been
established and collected, prioritizing high-risk burn groups
is necessary in order to identify intervention strategies.
The five Es of intervention are Engineering, Economic,
Enforcement, Education, and Evaluation:28
•
Engineering – focuses on the physical environment
(product safety design) and the vector. Examples
include fire-resistant upholstery and bedding, child-
resistant multipurpose lighters (including cigarette
lighters), and insulated electric wire.
•
Economic – influences behavior, i.e. monetary
incentives such as insurance rate reductions if a home
has smoke alarms or sprinklers.
•
Enforcement – influences behavior with laws, building
codes, and regulations, for example requiring fire
escapes, sprinklers/smoke alarms in motels, hotels, and
homes.
•
Education – influences behavior through knowledge
and reasoning. Examples include pamphlets, public
television programs, CPSC News Alerts. These active
measures are the least effective.
•
Evaluate – if a prevention program does not achieve
the stated goal(s), possible reasons include:
n the technique or measurement used may be
inappropriate to identify the reduction caused by the
prevention strategy;
n faulty program design;
n the study design may have been good, but the
program was carried out inappropriately.
With this background in epidemiology and injury pre­
vention, important areas of challenge and opportunity in
burn prevention both past, present, and future will be
discussed.29,30
Flammable clothing
In 1953 legislation regulating the manufacture and sale of
highly flammable clothing (the Flammability Fabrics Act)
was passed in the US. As a result of the Act, contracts were
awarded to burn units to collect epidemiologic data regard­
ing flammable fabric burns. Flammability testing methods
were improved and standardized, and flame-retardant fabrics
were developed. The initial Act covered only fabrics that
came in contact with the body, and therefore excluded indus­
trial fabrics, and in 1967 it was amended to include articles
of clothing and interior furnishings such as paper, plastic,
rubber, synthetic film, and synthetic foam.31 By 1985, 87%
of children’s sleepwear was made of synthetic fabrics and
only about 13% was made of cotton. In 1996 sleepwear
standards for children were amended by the CPSC. The
amendments permitted the sale of tight-fitting children’s
sleepwear (up to size 14 and not exceeding specified mea­
surements for specific areas of the body) and sleepwear for
infants aged 9 months or under, even if the garments did
not meet the flammability standards ordinarily applicable
to such sleepwear. This conclusion was based on staff find­
ings that there were virtually no injuries associated with
single-point ignition incidents of tight-fitting sleepwear, or
of sleepwear worn by infants under 1 year. The commission
emphasized that sleepwear standards were designed to
protect children from burn injuries if they came in contact
Table 4.2  General strategies for burn control
Prevent creation of the hazard (stop producing fire crackers)
Reduce amount of hazard (reduce chemical concentration in commercial
products)
Prevent release of the hazard (child-resistant butane lighters)
Modify rate or spatial distribution of the hazard (vapor-ignition resistant
water heaters)
Separate release of the hazard in time or space (small spouts for hot water
faucet)
Place barrier between the hazard and the host (install fence around
electrical transformers, fire screen)
Modify nature of the hazard (use low conductors of heat)
Increase resistance of host to hazard (treat seizure disorder)
Begin to counter damage already done by hazard (first aid, rapid transport
and resuscitation)
Stabilization, repair rehabilitation of host, example (provide acute care –
burn center and rehabilitation)
General Strategies for Burn Control from Haddon W, Advances in the Epidemiology
of Injuries as a Basis for Public Policy. Public Health Reports 1980; 95: 411–421.24

Prevention of burn injuries
51
with an open flame such as a match or stove. The require­
ment for flame-resistant or snug-fitting clothing does not
apply to sleepwear in sizes of 9 months and under because
infants wearing these sizes are ‘insufficiently mobile to
expose themselves to sources of fire.’32
What about children who do not voluntarily expose them­
selves to an open flame? The safest sleepwear is snug-fitting
and flame-resistant. Loose-fitting clothes have a large air­
space between the fabric and the skin. Oxygen in this space
promotes flame. In order to meet CPSC requirements, flame-
resistant implies garments must not ignite easily and must
self-extinguish quickly. Snug-fitting clothes that comply with
CPSC guidelines are made of fabrics that are not flame-
resistant but also do not create ‘an unreasonable’ risk of burn
injury because they limit the airspace under the garment. The
CPSC requires all snug-fitting children’s sleepwear from 9
months up to size 14 to have a label that reads ‘Wear Snug-
Fitting. Not Flame Resistant.’ A hangtag reads ‘For child’s
safety, garment should fit snugly. This garment is not flame
resistant. A loose-fitting garment is more likely to catch fire.’
The reader is encouraged to read the excellent review of
sleepwear flammability and legislation in both the US and
the United Kingdom by Horrocks et al.33
Nevertheless members of the burn community were dis­
appointed, and in 1999 Congress required the CPSC to
consider revoking the amended standards. It was felt that
under-reporting of sleepwear burn injuries was possible, and
an increase in the number of sleepwear-related burn injuries
was reported by a number of burn units. As a result, in 2003
the CPSC initiated a project whereby any thermal injury due
to clothing in a child under 15 was to be reported. In addi­
tion, if the garment was available an onsite investigation of
the incident and inspection of the garment was to be con­
ducted. Between March 2003 and December 2005, a total
of 462 burn incidents were reported. Characteristics of
the victims, the types of clothing involved, the fabrics and
the causes of fire were tabulated. The results showed that
99% of victims were not wearing sleepwear. The study
did not support the conclusion that the exempted sleepwear
increased the risk of burn injury to children under 15.34
Hot water burns
According to the ABA 2010 National Burn Repository scald
burns accounted for 54% of all burns in children under the
age of 5. Although the majority of scald burns in children
are not fatal, the exact incidence is unknown. Fortunately,
most hot liquid burns are small and do not require hospital
admission. All tap water scalds should be preventable. In
1983 the Washington State legislature required all new home
water heaters to be preset to 49°C (120°F).35 The time of
exposure to this temperature before a severe burn can occur
is sufficiently long that the victim, usually a child or elderly
disabled person, is able to be removed or can climb out of
the water.
An educational program was instituted to persuade people
to reduce water temperature voluntarily, and follow-up in
1988 revealed there had indeed been a reduction in hot
water pediatric burns. Voluntary reduction of thermostat
temperatures to a safe level by manufacturers has not been
uniformly successful. Mandatory regulation would be the
most effective strategy, but until society is educated and
convinced of its benefit, change will be slow. Other preven­
tion methods to reduce tap water scald burns include insert­
ing shut-off valves in the water circuit to detect temperatures
over a certain level, and the use of liquid-crystal thermom­
eters in bathtubs to alert caregivers to the water temperature.
More than 90% of hot water scalds are due to hot cooking
or drinking liquids,36 and only about 25% of hot water burns
are associated with tap water in the US. In LMIC countries
scalds caused by hot food or liquids, for example boiling
water, or cooking over an open fire on the ground, or hot
bathing water placed on the ground to cool, are common.
Unfortunately, prevention of spills is more difficult.37
The effectiveness of active prevention has been called into
question. Burn safety education campaigns directed at
parents to modify behavior are only effective over a short
period. Negligence on the part of the caregiver(s) is the
key issue. Nevertheless, success has been achieved through
a combination of education, legislation and/or litigation
regarding product safety.38 Identifying why specific preven­
tion measures are unsuccessful is as important as identifying
why others are successful.
Not all scald burns involve children. Product design and
installation are important. Burns occurring during bathing
as a result of seizures are not uncommon.39 Avoidable risk
factors identified were shower levers that were easily knocked
out of position, lack of water temperature safety features, and
confining shower cubicles.
Fire-safe cigarettes
Approximately one in five American adults smokes ciga­
rettes. When left unattended and not even puffed, a cigarette
can burn as long as 20–40 minutes. In 2007 140 700 smok­
ing-material fires occurred in the US.40 There were 720 civil­
ian deaths, 1580 civilian injuries and $530 million dollars’
worth direct property damages. Between 2003 and 2007 sta­
tistics on smoking-material fires revealed that upholstered
furniture accounted for 44% of civilian deaths, 26% of civil­
ian injuries, and the largest amount of property damage.
Most fatal smoking-material fires start in bedrooms, and
25% of victims are not the smoker whose cigarette started
the fire. The risk of dying in a home structure fire caused by
smoking materials increases with age (36% of victims are 65
or older) and nearly 40% of fatal home smoking-material
fire victims were sleeping when injured. In 1973 the US
Standard for the Flammability of Mattresses and Mattress
Pads was enacted to reduce the risk of injury, death, and
property damage from fires caused by lighted cigarettes. In
2007 the US Consumer Product Safety Commission unani­
mously approved a new federal mattress flammability stand­
ard. The Commission’s finding was that ‘A mattress with a
limited contribution to the fire, especially early in the fire,
will substantially increase the available time for occupants
to discover the fire and escape and, therefore, substantially
reduce the current risks associated with mattress fires’. (http://
) Between 1980 and 2007 in the US, smoking-
related home fires starting in upholstered furniture, mat­
tresses and bedding declined by 90%, largely owing to the
mandatory flammability standard.

Total Burn Care
4
52
Approximately 7% of fatal home smoking fire victims sus­
tained the injury while using medical oxygen. The times of
day of residential smoking fire deaths and injuries were 2 am
and 6 am, and 12 am to noon, respectively. Falling asleep,
alcohol, and substance abuse were common associated
factors. Smoke alarm performances in residential smoking
fires revealed the following: alarm present and operated
39%, present and not operating 25%, no alarm present 36%.
Alarm performance in fatal fires was: present and operated
43%, present and not operating 25%, no alarm 32%.
The concept of a fire-safe cigarette was explored in the
1920s. The first federal bill mandating fire-safe cigarettes
was introduced in 1974, but no legislation was passed. The
concept remained dormant until 1984, when the Cigarette
Safety Act created a technical study group on the fire
safety of cigarettes and little cigars.41 A number of design
changes have the potential to make cigarettes less fire
prone. These include reduced tobacco density, paper poros­
ity, cigarette circumference, and the addition of citrate.
Every­one is encouraged to read the article by McGuire enti­
tled ‘How the tobacco industry continues to keep the home
fires burning’.42
In 2000 Philip Morris companies announced the develop­
ment of a cigarette with ultrathin concentric paper bands
applied to the traditional paper. These bands are referred to
as ‘speed bumps’ and cause the cigarette to self-extinguish
if not being smoked, as no oxygen can reach the burning
embers. This technology was first reported more than a
decade ago. The production of a safe cigarette should not
be voluntary but be required by law. In 2004 the State of
New York was the first to implement legislation requiring
all cigarettes to be sold with reduced ignition propensity
(RIP); 47 states now have laws making such cigarettes man­
datory. By 7 January 2011 all states will have enacted the
law. Canada passed fire-safe cigarette legislation in 2004,
and in 2007 the 27 EU Member States endorsed plans to
allow the sale of fire-safe cigarettes. Unfortunately, in other
industrialized counties there appears to be no demand for
RIP cigarettes.
As yet there are no data on the effect of RIP cigarettes on
burn injuries and mortality. As more governments imple­
ment laws mandating RIP it will be important to establish
data on smoke-related fire injuries.43
Carbon monoxide poisoning
Carbon monoxide (CO) inhalation is the leading cause of
fatal poisoning in the industrialized world.44 Although acute
CO poisoning is more commonly associated with closed-
space structural fires, it is generally easily treated with no
more than 100% FIO2. Chronic CO poisoning is associated
with poor ventilation. It is more prevalent in the winter
months and is associated with gas furnaces, gas fire places,
portable heaters, and anything that burns coal, kerosene, oil,
propane, or wood. CO detectors are not as prevalent in resi­
dential structures as smoke detectors. In a telephone survey
conducted in 1003 households in the US, 97% of responders
had a smoke alarm but only 29% had a CO detector.45
Is price a factor in this low prevalence? The cost for a
single unit can be as low as $10, and $75 for a combined
smoke and CO detector. A CO alarm near all sleeping areas
represents an effective prevention strategy. Should any home
with a smoke detector have a CO detector? Based on the
success of smoke alarms, the answer is yes, but further
research is needed to answer conclusively a number of ques­
tions: Are they necessary? What type of CO sensor? and What
level of CO gas activates the alarm, specifically the level for
both a caution and dangerous or hazardous levels? It is
important to remember that the lifespan of CO detectors
varies from 2 to 5 years. In addition, the ‘test’ feature on
many detectors only checks the functioning of the alarm and
not the status of the detector. In 2010 the State of California
required placement of CO detectors in all dwelling units. The
bill requires that the presence or absence of the devices must
be disclosed when residential real estate is transferred. Land­
lords are required to install detectors in the properties they
manage or rent. As of July 2011, all existing homes and
dwelling units must have CO alarms. Similar laws are being
adopted in other states, albeit slowly. CO poisoning is largely
preventable by the combination of correct installation,
maintenance, and operation of devices that may emit CO
and the appropriate use of CO detectors. CO detectors may
prevent at least half of all deaths attributable to CO
poisoning.46
Smoke detectors/alarms
The first automatic electric fire alarm was invented in 1890.
The first truly affordable home smoke detector was intro­
duced in 1965. Without question, the use of smoke alarms
has had the greatest impact in reducing fire deaths in the
US. In 1966, 13% of residential fire deaths occurred in
homes with an operating smoke alarm, 11.5% deaths
occurred in homes with a non-operating alarm, and 38.5%
in houses without an alarm.7 Socioeconomic factors
associated with lack of a functioning smoke detector
include living in a non-apartment dwelling, an annual
income of less than $20 000, being unmarried, living in a
non-metropolitan area, and homes with children younger
than 5. Smoke detector ownership was most often associ­
ated with not living in public housing, a level of education
(completing high school), maternal age (not a teenager),
practice fire drills, and larger homes.47 In 1985 McLaughlin48
published ‘Smoke Detector Legislation’. Smoke detector
installation in new houses appeared to be effective when
mandated by a building code. Malone et al.,49in 1996,
collected data on a smoke detector give-away program in
Oklahoma City. The target area for intervention had the
highest rate of injuries related to residential fires in the city,
and the number of injuries per 100 000 population was 4.2
times higher than in the rest of the city. The program dis­
tributed 10 100 smoke alarms to 9291 homes in the target
area, and over the next 4 years the annualized injury rate
per 100 000 population decreased by 80%, compared to
only 8% in the rest of the city. The authors concluded that
target intervention with a smoke alarm give-away program
reduced residential fire injuries.
Smoke alarms represent intervention before the burn
event occurs. Building codes mandating installation in new
homes have been proved to be a practical solution. In 2000
DiGuiseppi and Higgins questioned the benefit of injury
education to promote smoke alarm usage.50 They reviewed

Prevention of burn injuries
53
26 published trials, 13 of which were randomized, and con­
cluded that ‘counselling and educational interventions
had only a modest effect on the likelihood of owning an
alarm.’ Programs that gave away and installed smoke alarms
appeared to reduce fire injuries, but the trials were not con­
clusive and the results were to be interpreted with caution.
DiGuiseppi et al. conducted a randomized controlled trial
to determine the effect of giving free alarms on fire rates and
injuries.51 The study design was similar to that of the previ­
ously discussed study in Oklahoma City: 20 050 alarms, bat­
teries, fittings, and fire safety brochures were distributed and
free installation was offered. No alarms were given to the
control group. Follow-up was 12–18 months after distribut­
ing the alarms. The conclusion of the study was that giving
free smoke alarms did not reduce fire injuries, as many
alarms had not been installed or maintained. Obviously, a
give-away program is not the entire answer and more research
is necessary. Rowland et al.52 performed a randomized con­
trolled trial to determine what types of smoke alarm were
most likely to remain working and how they were tolerated
in households with smokers. Both ionized and photoelectric
alarms were available. The conclusions were that an alarm
with an ionization sensor, a lithium battery, and a pause
button were most likely to remain working. An alarm was
less likely to work in a household with one or more smokers,
and installing smoke alarms might not be effective use of
resources.
Mueller et al.53 conducted a randomized trial comparing
ionized and photoelectric alarms to determine reasons for
both non-functioning and nuisance alarms in low- to mid­
dle-income homes in a US metropolitan area. Conclusions
were that ionized alarms were likely to be non-functioning,
commonly because of either being disconnected or removal
of a battery when the alarming becomes a nuisance; photo­
electric alarms may be preferred when an alarm is used;
designing an alarm that lessens nuisance alarming may
result in long-term functionality.
A photoelectric alarm has an optical sensor and consists
of a light-emitting diode and a light-sensitive sensor in a
chamber. The presence of suspended products of combus­
tion in the chamber scatters the light beam, which is detected
and sets off the alarm. Ionized units use a small amount of
radioactive material to ionize air in the sensing chamber, and
when products of combustion enter the chamber the con­
ductivity of the air decreases. When this reduced conductiv­
ity reaches a predetermined level, the alarm is set off. The
ionized alarm is reportedly prone to produce more false
nuisance alarms. In 2008, 96% of US households had at
least one smoke alarm and 40% of home fire deaths were in
homes with no smoke alarm; and in 23% the smoke alarm
failed to operate.54 In many instances consumers are not
knowledgeable about the number of alarms needed, their
preferred locations, or how to install them properly.55 A fire
escape plan is also important. This should include knowing
ahead of time the safest exit route; immediately leaving the
structure; not wasting time saving property; calling for emer­
gency assistance using 911; knowing whether there is more
than one way out of a room or building; feeling the door
and door knob to identify (by heat) how close the fire may
be; knowing whether a secondary escape route would be
appropriate; having an arranged meeting place; and ‘once
out, staying out.’
Fire sprinklers
Sprinklers complement smoke detectors. Smoke alarms
warn the individual of a nearby fire, but a sprinkler system
can effectively extinguish the fire in an isolated area and are
an intervention strategy that works during the event. They
are the most effective method for fighting the spread of fires
in their early stages. The first automatic sprinkler for fire
fighting was patented in 1872 for use almost exclusively in
textile mills. Automatic fire sprinklers have been in use in
the US since the latter part of the 19th century. Although
there is a range of different types of sprinkler system, only
wet systems should be specified for use in domestic premises
as they are the simplest, easiest to maintain, and the most
cost-effective. The fire death rate per 1000 reported residen­
tial fires is reduced by approximately 83% and property
damage by 40–70% for most properties that use sprinklers.
Structure fire data reported between 2003 and 2007 revealed
that 71% of hospitals and 65% of nursing homes had sprin­
kler systems.10 Unlike non-residential buildings, the use of
sprinkler systems in residential structures has been slow to
be accepted. The NFPA estimates that occupants with a
smoke alarm in the home have a 50% better chance of sur­
viving a fire than those without. Adding sprinklers increases
the chances of surviving a fire to nearly 97%. One sprinkler
was adequate to control fire in over 90% of the documented
sprinkler activations in all residential fires. In 1978, San
Clemente, California, was the first jurisdiction in the US to
require residential sprinklers in all new structures. In 1985,
Scottsdale, Arizona, required a sprinkler system in every
room of all new industrial, commercial, and residential
buildings. In 1996, residential sprinklers were found in less
than 2% of residential fires.6 Residential fire sprinkler ordi­
nances have been adopted in over 200 communities in the
US for use in single-family dwellings. Between 1994 and
1998, only 7% of reported structure fires had any type of
automatic extinguishing equipment. From 2003 to 2007 this
increased to nearly 10%.56 In the US the cost of installing a
home sprinkler system in a new residential structure averages
$1.61.57 Retrofit installation has been undertaken voluntarily
or by legislation in nursing homes (1970s), hotels (1980s),
and university housing (2000s). A sprinkler system is the
only solution for preventing flashover and rapid escalation
of a large hotel fire. Sprinklers typically reduce both the
chance of dying in a fire and the average property loss by
one-half to two-thirds compared to where sprinklers are not
present. The NFPA has no record of a fire death of more than
two people in a public assembly, educational, institutional,
or residential building where the area was completely fitted
with working sprinklers. It is estimated that 75% of high-rise
and 50% of low-rise hotels have sprinkler systems. In March
2008, the USFA, an entity of FEMA, announced their support
for both the use of residential fire sprinklers and code
requirements that would make such sprinklers mandatory in
all new residential constructions. Unfortunately, the USFA
does not directly control building and fire codes. The Inter­
national Code Council (ICC) is a non-profit organization
dedicated to developing a single set of comprehensive and
coordinated national model construction codes. In the 2012
edition of the International Fire Code a recommendation
will be included for fire sprinklers to be a standard feature

Total Burn Care
4
54
in new homes. The ICC’s members rejected efforts by the
National Association of Home Builders to have the require­
ment repealed. Homebuilder associations in many states
tried to block adoption of the IRC sprinkler provisions.
Their arguments included the known effectiveness of
smoke alarms in reducing home fire deaths, and the cost–
benefit ratio of sprinklers in residential property. One issue
that may ultimately shift the perspective of builders towards
residential fire sprinklers is legal liability.58
Evaluating the effect of burn prevention
Three important issues reappear in the injury prevention
literature:
1. Implement what is already known, not necessarily
proven.
2. Passive strategies are more effective than active ones.
3. New programs and their results must be subjected to
more rigorous evaluation.
Successful burn prevention includes collecting, analyzing,
and then interpreting burn statistics, especially mortality,
and even more importantly morbidity. The American Burn
Association’s Burn Data Repository represents a very valua­
ble resource for everyone involved in burn prevention. The
ongoing collection of data will allow:
•
Identification of the magnitude and type of burn
injury,
•
Monitoring the trend of specific areas of burn injury
and their prevalence,
•
Identification if new injury problems arise,
•
Development of methodologies to evaluate burn
prevention or intervention efforts.
Between 1977 and 2008 the number of US home fire deaths
decreased by 53%. The number of home fire incidents
decreased by 47%. Unfortunately, the death rate per 1000
home fire incidents decreased by only 11%, from 8.1 in 1977
to 7.2 in 2008.7 Fire safety initiatives directed at the home
environment are the key to reductions in the overall fire
death toll. Five strategies are recommended:
1. Widespread public fire safety education.
2. Escape plans must be developed and practiced, as there
are still too many instances where either smoke alarms
were absent or malfunctioning, and no plans have been
in place.
3. Increased use of residential sprinkler systems must be
pursued.
4. Continue to make more home products fire safe. This
includes products such as upholstered furniture and
mattresses, as well as house construction.
5. More attention directed at the fire safety needs of
high-risk groups, i.e. young, old and poor.
Many successful burn prevention programs have been devel­
oped at the local level using locally generated data. Behavior
modification at the local level can be instituted more
quickly than waiting for national initiatives and legislation.
Un­fortunately, local efforts affect only a few. Prevention
research should generate information, which can be useful
at a national level, and there must be rigorous methods
of evaluating research so the conclusions may be shared.
Many burn prevention programs have had an insufficient
number of subjects, no controls, inadequate or short follow-
up periods, and no control for confounders – and, of the
utmost importance, few use mortality and morbidity as
outcome measures. Although it is difficult to conduct
prospective, randomized, double-blinded studies (class I
research), rules for good scientific research should neverthe­
less be followed.59 Studies with a single hypothesis should
be conducted over an adequate length of time. The preven­
tion goal should be realistic and achievable, and the results
must be carefully analyzed.60 Resources must not be wasted
collecting and analyzing data unless prevention initiatives
are planned.
The incidence of both burn injuries and deaths is decreas­
ing throughout the US. No single burn unit or community
will have a large enough patient population to conduct
meaningful prospective studies. Wanda et al.61 published a
review article on the effectiveness of prevention inter­ventions
in house fire injuries where various types of intervention
program were reviewed. These included school, preschool,
and community education programs, fire response training
programs for children, office-based counseling, home inspec­
tion programs, smoke detector give-away campaigns, and
smoke detector legislation. The important conclusion was
that morbidity and mortality data must be used for outcome
measures. There was wide variability regarding study design,
data sources, and outcome measures.
Whether home safety education and the provision of
safety equipment such as smoke alarms, fire extinguishers
and educational material reduces the incidence of burns,
and the effect it has across different social groups, is not
known. A Cochrane Review published in 2007 evaluated
whether home safety education and the provision of safety
equipment was effective in reducing childhood injury rates.
The conclusion was there was no consistent evidence that
home safety education with or without providing safety
equipment was less effective in those at greater risk of
injury.62 Kendrick et al.63 presented information from a
meta-analysis of thermal prevention practices. The safety
outcome measures included functioning smoke alarms,
fitted fireguards, fire extinguishers, keeping hot drinks and
food, matches and lighters out of reach of children, and
having a safe water heater temperature. The conclusion
was that home safety education was effective in increasing
some thermal injury prevention practices, but there was
insufficient evidence to show whether this also reduced
injury rates.
Burn injuries and deaths are a world health problem that
represents a major global challenge. The literature is replete
with burn epidemiologic studies, many suggesting interven­
tions that are well known or unique to their victims, but
fewer show that intervention is effective ‘in the real world.’64
Coordination of prevention strategies on both national and
international levels is necessary. Passive prevention programs
are most effective but slow to implement. Active prevention
is not always easy, and requires time, significant organiza­
tional support, and money. Active and passive measures are
not mutually exclusive: both must be utilized. All burns
should be preventable, but unfortunately the aphorism ‘easier
said than done’ is true.

Prevention of burn injuries
55
Further reading
Atiyeh B, Costagliola M, Hayek S, et al. Burn prevention mechanisms
and outcomes: pitfalls, failures and success. Burns. 2009;35:181-
193.
Haddon W. Advances in the epidemiology of injuries as a basis for
public policy. Public Health Reports. 1980;95:411-421.
Judkins DG. Fifteen tips for success in injury prevention. J of Nursing
Trauma. 2009;16(4):184-193.
Mueller BA, Sidman EA, Alter H, et al. Randomized controlled trial of
ionization and photoelectric smoke alarm functionality. Injury
Prevention, 2008;14:80-86.
Parbhoo A, Louw QA, Grimmer-Somers K. Burn prevention programs
for children in developing countries: a targeted literature review.
Burns. 2010;36:164-175.
Peck M, Kruger G, van der Merwe A, et al. Risk factors and potential
intervention strategies can be identified. Burns and Injuries from
non-electric appliance fires in low-middle-income countries. Part
II. A strategy for intervention using the Haddon Matrix. Burns.
2008;43:312-319.
 
Access the complete reference list online at

Prevention of burn injuries
55.e1
© Copyright 2012 Elsevier, Inc. All rights reserved.
References
1. Langley J. The need to discontinue the use of the term ‘accident’
when referring to unintentional injury events. Accident Analysis &
Prevention. 1988;20:1-8.
2. Colebrook L, Colebrook V. The prevention of burns and scalds.
Lancet. 1949;II:181-188.
3. Colebrook L, Colebrook V, Bull JP, et al. The prevention of
burning accidents. Br Med J. 1956;1:1379-1386.
4. Editorial: Death in the fire place. Lancet. 1946:833-834.
5. Hennekens CH, Burning JE. Epidemiology in medicine. Boston:
Little Brown; 1987:3-13, 178-194.
6. Ten Leading Causes of Injury Deaths by Age Group Highlighting
Unintentional Injury Deaths in the U.S. 2007. CDC (
cdc.gov/injury/wisqars/LeadingCauses.html).
7. Karter MJ. Fire Loss in the United States in 2008. Jan 2010 NFPA
Fire Analysis and Research Division.
8. Flynn JD. Characteristics of home fire victims, March 2010. NFPA
Fire Analysis & Research 2010.
9. National Hospital Ambulatory Medical Care Survey: 2006
emergency Department summary. National Health Statistics
Reports #7 August 2008. U.S. Department of Health and Human
services.
10. A Profile of Fire in the United States 2003-2007. U.S. Fire
Administration/National Fire Data Center 15th Edition January
2010.
11. An Overview of the U.S. Fire Problem. NFPA. 2010 [
org/osds.].
12. Shay D, Lupinacci P. Fire fatalities among children: an analysis
across Philadelphia’s census tracts. Public Health Reports.
2003;118:115-126.
13. Pitts SR, Niska RW, Xu J, et al. Fire and the Older Adult. Jan.
2006. U.S.FA/National Fire data enter. Dept. Homeland
Security.
14. Racioppi F, Dinesh S. The role of public health in injury
prevention in the WHO European region. International journal of
injury control and safety promotion. 2007;14(4):271-273.
15. A WHO Plan for Burn Prevention and Care Geneva Switzerland
2008.
16. Forjuoh SN. Burns in low- and middle-income countries. Burns.
2006;32:529-537.
17. Peck M, Molnar J, Swart D. A Global Plan For burn Prevention
and Care. Bull World Health Organ. 2009;87:802-803.
18. Peck M, Kruger G, van der Merwe A, et al. Risk factors and
potential intervention strategies can be identified. Burns and
injuries from non-electric appliance fires in low-middle-income
countries. Part I. The scope of the problem. Burns. 2008;43:
303-311.
19. Peck M, Kruger G, van der Merwe A, et al. Risk factors and
potential intervention strategies can be identified. Burns and
Injuries from non-electric appliance fires in low-middle-income
countries. Part II. A strategy for intervention using the Haddon
Matrix. Burns. 2008;43:312-319.
20. Atiyeh B, Costagliola M, Hayek S, et al. Burn prevention
mechanisms and outcomes: pitfalls, failures and success. Burns.
2009;35:181-193.
21. Edelman LS. Social and economic factors associated with the risk
of burn injury. Burns. 2007;33:958-965.
22. Parbhoo A, Louw QA, Grimmer-Somers K. Burn prevention
programs for children in developing countries: a targeted
literature review. Burns. 2010;36:164-175.
23. Haddon W. The changing approach to the epidemiology,
prevention, and amelioration of trauma: the transition to
approaches etiologically rather than descriptively based. AJPH.
1968;58:1431-1438.
24. Haddon W. Advances in the epidemiology of injuries as a basis
for public policy. Public Health Reports. 1980;95:411-421.
25. McKinlay JB. The promotion of health through planned
sociopolitical change: challenges for research and policy. Soc Sci
Med. 1993;36:109-117.
26. Barss P, Smith GS, Barker S, et al. Injury prevention. Epidemiology,
surveillance, and policy. New York: Oxford University Press,
1998.
27. McLoughlin E, Vince CJ, Lee AM, et al. Project burn prevention:
outcome and implications. Am J Public Health. 1982;72:241-247.
28. Judkins DG. Fifteen tips for success in injury prevention. J of
Nursing Trauma. 2009 16;4:184-193.
29. Liao C, Rossignol AM. Landmarks in burn prevention. Burns.
2000;26:422-434.
30. Grant EJ. Prevention of burn Injury. Problems in General Surgery.
2003;20:16-26.
31. Oglesbay FB. The flammable fabrics problem. Pediatrics.
1969;44:827-895.
32. Cusick JM, Grant EJ, Kucan JO. Children’s sleepwear: relaxation of
the Consumer Product Safety Commission’s flammability
standards. J Burn Care Rehabil. 1997;18:469-476.
33. Horrocks AR, Nazare S, Kandola B. The particular flammability
hazards of nightwear. Fire Safety J. 2004;39:259-276.
34. Rodgers G, Adair P. Exemptions to the children’s Sleepwear
Flammability Standards. J Consumer Policy. 2009;32:59-71.
35. Erdmann TC, Feldman KW, Rivara FP, et al. Tap water burn
prevention: the effect of legislation. Pediatrics. 1991;88:572-577.
36. Lowell G., Quinlan K., Gottlieb LJ. Preventing unintentional scald
burns: moving beyond tap water. Pediatrics. 2008;122:
799-804.
37. Celko AM, Grivna M, Danová J. Severe childhood burns in the
Czech Republic: risk factors and prevention. Bull World Health
Organ. 2009;87:374-381.
38. Drago DA. Kitchen scalds and thermal burns in children five years
and younger. Pediatrics. 2005;115:10-16.
39. Unglaub F, Woodruff S, Ulrich D, et al. Severe burns as a
consequence of seizure while showering: risk factors and
implications for prevention. Epilepsia. 2005;46:332-333.
40. Hall J. The Smoking-Material Fire Problem. March 2010. NFPA
Fire Analysis & Research Division.
41. Brigham PA, McGuire A. Progress towards a fire-safe cigarette.
J Public Health Policy. 1996;16:433-439.
42. McGuire A. How the tobacco industry continues to keep the
home fires burning. Tobacco Control. 1999;8:67-69.
43. Connor RJ, Bauer JE, Giovino GA. Prevalence of behaviors related
to cigarette-caused fires: a survey of Ontario smokers. Injury
Prevention. 2007;13:237-242.
44. Varon J, Marik PE, Fromm RE, et al. Carbon monoxide poisoning:
a review for clinicians. J Emerg Med. 1999;17:87-93.
45. Runyan CW, Johnson RM, Yang J, et al. Risk and protective factors
for fires, burns, and carbon monoxide poisoning in US
households. Am J Prev Med. 2005;28:102-108.
46. Graber JM, McDonald SC, Kass DE. Carbon monoxide: the case
for environmental public health surveillance. Public Health Rep.
2007;122:138-144.
47. Gorman RL, Charney E, Holtzman NA, et al. A successful
city-wide smoke detector give-away program. Pediatrics.
1985;75:14-18.
48. McLoughlin E, Marchone M, Hanger L, et al. Smoke detector
legislation: its effect on owner-occupied homes. Am J Public
Health. 1985;75:858-862.
49. Mallonee S, Istre GR, Rosenberg M, et al. Surveillance and
prevention of residential-fire injuries. N Engl J Med. 1996;335:
27-31.
50. DiGuiseppi C, Higgins JP. Systematic review of controlled trials
of interventions to promote smoke alarms. Arch Dis Child.
2000;82:341-348.
51. DiGuiseppi C, Roberts I, Wade A, et al. Incidence of fires and
related injuries after giving out free smoke alarms: cluster
randomized controlled trial. BMJ. 2002;325:995-997.

Total Burn Care
4
55.e2
© Copyright 2012 Elsevier, Inc. All rights reserved.
52. Rowland D, DiGuiseppi C, Roberts I, et al. Prevalence of working
smoke alarms in local authority inner city housing: randomized
controlled trial. BMJ. 2002;325:998-1001.
53. Mueller BA, Sidman EA, Alter H, et al. Randomized controlled
trial of ionization and photoelectric smoke alarm functionality.
Injury Prevention. 2008;14:80-86.
54. Ahrens M. House Structure Fires. March 2010. NFPA Fire Analysis
& Research Division.
55. Peek-Asa C, Allareddy V, Yang J. When one is not enough:
prevalence and characteristics of homes not adequately protected
by smoke alarms. Injury Prevention. 2005;11:364-368.
56. Hall JR Jr, U.S. Experience with Sprinklers and Other Automatic
fire Extinguishing 52.
57. Butry DT, Brown MH, Fuller SK. cs. February 2010. NFPA Fire
Analysis and research Division. Benefit-Cost Analysis of
Residential Fire Sprinkler Systems. U.S. Department of Commerce
National Institute of standards and Technology. 2007.
58. Frattaroli S, Yee N, Pollack KM, et al. From SAVIR. Inj Prev.
2009;15:430.
59. Wards L, Tenebein M, Moffatt MEK. House fire injury prevention
update. Part II. A review of the effectiveness of preventive
interventions. Inj Prev. 1999;5:217-225.
60. Horan JM, Mallonee S. Injury surveillance. Epidemiology Rev.
2003;25:24-42.
61. Warda L, Tenenbein M, Moffatt ME. House fire injury prevention
update. Part II. A review of the effectiveness of preventive
interventions. Inj Prev. 1999;5:217-225.
62. Coupland KD, Mason-Jones C, Simpson C, et al. Report Home
Safety Education and Provision of Safety Equipment for Injury
Prevention, 2007 Cochrane Systemic Reviews.
63. Kendrick D, Smith S, Sutton JA, et al. The effect of education and
home safety equipment on childhood thermal injury prevention;
meta-analysis & meta-regression. Injury Prevention. 2009;15:197-
204.
64. Pless IB. Three basic convictions: a recipe for preventing child
injuries. Bull World Health Organ. 2009;87:395-398.

This page intentionally left blank

Burn management in disasters
and humanitarian crises
Herbert L. Haller, Christian Peterlik, Christian Gabriel
Introduction
The Universal Declaration of Human Rights states that
‘everyone has the right to a standard of living adequate for
the health and well-being of himself and of his family,
including medical care and necessary social services, and
the right to security in the event of sickness, disability, or
other lack of livelihood in circumstances beyond his
control.’1 Mass fire casualties are events beyond the control
of individuals. Individuals organize themselves into
states, and these states must protect their residents and
provide necessary medical care.
Unfortunately, questions remain about the medical care
that is to be provided. Specifically, what degree of medical
care must be provided? Is it the best available or, preferably,
whatever is necessary? In addition, what kind of care must
the state provide to the uninsured? This question reveals
great disparities, for example between those jurisdictions
that have high incomes and plentiful resources and those
that do not. These factors will determine what is the ‘best
available’ medicine. Furthermore, options in multistate
regions are more limited. This is especially true in unions of
states, such as the USA and the European Union, where
interstate borders may limit availability.
The best burn treatment is in burn centers, which have
specialized staff. Burn victims treated in these centers have
better survival rates and quality of life. However, the number
of burn centers is limited. Countries’ resources are also
usually limited, making cross-border cooperation necessary,
even among countries with many resources. Although burn
centers are usually described by their number of beds, often
no clear definition of these ‘burn beds’ exists. They should
be counted and classified as isolated ICU (intensive care
unit) beds, with specification of whether they are thoroughly
equipped for artificial ventilation and organ substitution in
modern intensive therapy, with air conditioning to warm
patients during treatment, and with a special operating room
always available for burn treatment. Many registered burn
beds do not meet the needs of modern burn therapy. It is
also worth mentioning that ‘beds’ do not treat or heal
patients: patients are treated by individuals such as doctors,
paramedics, and nurses. The mere number of beds does not
indicate how many burn victims a center can treat. The
number of burn specialists of all professions, and their avail­
ability, is also important. This can change hourly, with shifts,
as well as daily and seasonally.2
Definitions are very important with regard to organiza­
tions. Although mass casualties remain in the purview of local
rescue organizations, disasters are for regional authorities.
These terms imply different ways of handling the situation
and the use of different funding resources. Consequently,
emergencies requiring instant decisions are always com­
bined with financially sensitive legal decisions.
Emergencies with many casualties are marked by a period
of disproportion between supply and demand. Rescue
organizations must work to reduce the length of this ‘chaos’
period. During the chaos phase, actions follow the principles
of disaster medicine, that is, the goal is to save the most lives
possible, even if it means neglecting an individual patient.
When structure replaces chaos, the principles of individual
medicine are restored. The organizational aim in mass casual­
ties is to minimize the period between mass medicine and
individual medicine. The length of this period depends on
structural aspects such as the existence and validity of a dis­
aster plan, a regard for disaster capacity in health planning,
and the educational level of medical services. These facts are
often neglected in the political aspect of disaster planning
and the practical aspect of disaster capacity.
Medical treatment should be based on the state of medical
science. Otherwise, treatment with ‘best available means’
weakens individual care for a mass-casualty patient. If
medical resources are lacking, the best available treatment is
no treatment! During mass casualties and disasters, the
infrastructure of a country or region may be unable to cope
with a higher number of victims of special trauma types
while maintaining state-of-the-art treatments. Because state-
of-the-art treatments may not be able to be maintained in a
jurisdiction owing to dwindling resources, help from other
jurisdictions, even international ones, must be planned and
coordinated. Such instances include mass casualties with
burn injuries. Resources available for specialized treatment
are limited, but the demands for state-of-the-art treatment
are high, so even a small number of burn victims from one
accident can push burn treatment systems in an area or
country to their limit.
©2012 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-1-4377-2786-9.00005-9
CHAPTER 5
Access the complete reference list online at

Total Burn Care
5
58
average value over a year gives an overview of a burn center’s
disaster capacity.
Actual capacity
Actual capacity is the number of burn patients that a center
can take in on an actual day. It varies daily and can depend
on season. It is also likely to fluctuate with the seasonal or
accidental presence or absence of patients with severe burns.
Surge capacity
Surge capacity is the increased capacity available during mass
casualty situations and disasters. In burns, it is defined by
the ABA as the capacity to handle, in a disaster, 50% more
than the normal maximum number of burn patients.6 Surge
capacity must be developed and maintained, which requires
action by health systems, and must include continued
medical care of all other patients. Elective medical and surgi­
cal care can be eliminated temporarily to maintain surge
capacity. Surge capacity is not defined by time. When capac­
ity is breached, patients must be transferred safely to other
treatment facilities.
Sustained capacity
Sustained capacity is the maximum capacity that a burn
center can sustain over a longer period without reducing
treatment quality.
Burn capacity of a health system
The burn capacity of a health system is the total capacity of
burns that can be treated in a national health system. This
capacity should be known. It should take into account the
various requirements of burn treatment, such as the number
of victims needing intensive care. The average capacity utili­
zation over 1 year is part of resource planning for a health
system.
Time to establish surge capacity
During mass casualty situations with burn injuries, the time
available to establish surge capacity can be very short. A burn
center should know how much time it needs to attain
maximum surge capacity. A good parameter is the number
of complete burn teams available at various hours. This
number is highly important in a hospital’s organization of
primary care.
National disaster medical system (NDMS)
The NDMS manages a country’s national medical system
during disasters. In the US it is a function of the Federal
Emergency Management Agency, under the Department of
Homeland Security, and it operates in partnership with the
Department of Health and Human Services, the Department
of Defense, and the Department of Veterans Affairs.6 Other
countries have comparable structures. An NDMS has three
functions: 1) medical response at the disaster site, 2) trans­
port of patients to unaffected areas, and 3) definitive medical
care in unaffected areas.
Definitions
Mass casualty
A mass casualty is an emergency with a larger number of
victims than can be accommodated by the rescue forces and
their supplies.3 Infrastructure in the affected area is intact.
With force mobilization, the crisis can be mastered. The
period of disproportion between supply and demand is
short. The goal is to establish treatment according to princi­
ples of individual medicine as fast as possible, and without
transferring the disproportion from the scene to hospitals.
The challenge to save as many lives as possible, even at the
expense of the medical needs of an individual, stands in
contrast to the paradigms of individual medicine, where any
individual life claims the maximum medical effort. Over­
coming this challenge depends upon the selection of patients
based on the urgency of medical procedures, the chance of
success, and distribution among the available qualified treat­
ment centers (i.e., triage).
Disaster
A disaster is defined as an event that is accompanied by an at
least partial destruction of infrastructure and that cannot be
handled by regional rescue means alone (e.g., earthquakes4
and volcanic eruptions). The first goal is to re-establish the
minimal infrastructure to provide medical care.
A disaster situation differs from mass burns treatment in
a resource-poor country where infrastructure never existed.
One way to treat burns successfully in such a place is to bring
infrastructure, staff, and materials to the area. Alternatively,
victims can be transported to a place with existing infrastruc­
ture and given help there. The maximum treatment possible
is determined by the degree of infrastructure and/or resources
in the disaster area or brought to it.
Mass burn casualty disaster
The American Burns Association (ABA)5 has defined a ‘burn
disaster’ as any catastrophic event in which the number of
burn victims exceeds the capacity of the local burn center to
provide optimal care. Capacity includes the availability of
burn beds, burn surgeons, burn nurses, other support staff,
operating rooms, equipment, supplies, and related resources.
This definition is inapplicable in countries such as Germany,
where a central burn-bed bureau always organizes the distri­
bution of burn victims. The definition supposes a very dif­
ferent degree of preparedness in these countries.
Basic capacity
Basic capacity is the normal number of patients who can be
treated, based on the availability of burn beds, burn sur­
geons, burn nurses, other support staff, operating rooms,
equipment, supplies, and related resources.
Capacity utilization
Capacity utilization is the degree of utilization of burn beds
in a center over a certain period. This should be expressed
as use of both intensive-care burn beds and other beds. The

Burn management in disasters and humanitarian crises
59
Kuta, Bali, Indonesia, 12 October 2002
Terrorists also used a double-strike technique: a suicide
bomber detonated a backpack bomb in a nightclub; people
then fled outside, where a car bomb exploded. There were
202 deaths and 209 injured.
The Australian Defence Force (ADF) instigated Operation
Bali Assist, the largest Australian aeromedical evacuation
since the Vietnam War.10 An aeromedical staging facility
(ASF) was prepared in a hangar at Bali’s airport, where five
C-130 planes flew 61 Australian patients to the Royal Darwin
Hospital (RDH). Of the 61 patients, 28 had major injuries
(injury severity score >16). At RDH, 55 escharotomies were
performed along with 43 other surgical procedures. Three
patients had been intubated in Bali, and 12 more were
intubated at RDH. Within 36 hours after first admission to
hospital and 62 hours after the bombing, 48 patients were
evacuated to burn centers. There were no ‘walking wounded.’
BATs were among the primary services at RDH.11
Eleven patients were transferred to Concord Repatriation
General Hospital.12 Total burned surface area (TBSA) was
15–85%, mostly full-thickness burns. All patients sustained
injuries from both the first and second blasts. There were
complications from infections with Acinetobacter baumannii
and Pseudomonas, and from shrapnel injuries. Many ophthal­
mic injuries occurred, some being detected only later.
RDH received its first information about the incident from
a patient who had been treated in Bali and then fled to Aus­
tralia. The hospital learned nothing of the number of patients
or the severity of injuries before the first wave of patients
arrived.13 Palmer13 describes a need for improvement, mainly
in military–civilian communication. Communication in the
hospital was also problematic, as it was dependent upon
mobile phones (no reception), electronic texts (no time to
read), and landlines (not mobile). The ADF provided satel­
lite phones to the medical staff for communication between
the hospital in Bali and the ADF. A method of hands-free
communication in the hospital is recommended.
Disaster medical assistance team (DMAT)
A DMAT is a regional disaster response team. In the US,
DMATs are developed locally, are sponsored by major
medical centers, and have medical and non-medical staff of
about 35. DMATs are not burn specialists.
Burn specialty team (BST) or burn assessment
team (BAT)
BSTs/BATs are a special form of disaster medical team, pro­
viding expertise in burns during primary care. In the US
these teams consist of 15 burn-experienced medical and
non-medical staff. In many countries these teams are not
generally regulated and planned. They can be formed only
when burn experts are numerous and not already engaged
in other parts of the disaster response.
Threats that cause mass casualties
with burn injuries
Even with the best preparation, a disaster remains a disaster
for a certain period; the goal is to minimize this period.
Although retrospectively correcting problems is impossible,
lessons learned from the past should be applied to the
future. Terrorism, indoor fires, transportation crashes, and
explosions can all lead to mass casualties with burn injuries.
Descriptions of exemplary events in each of these categories
are provided below, together with a discussion of problems
that can be typical of such incidents.
Terrorism
Ever since 11 September 2001, terrorist attacks have remained
in the popular mind, as they can strike anywhere on Earth.
Terrorists’ names, goals, and methods change. Al Qaeda is
not the only terrorist body. Groups such as ETA (Spain), the
IRA (Northern Ireland), and the RAF (West Germany) may
seem forgotten, but remain active.
New York City, New York, 11 September 2001
(Fig. 5.1)
A wake-up call for Western society, 9/11 directed attention
to disaster preparedness and burn injuries. In New York, ter­
rorists used the ‘double-strike’ technique, flying two hijacked
airliners directly into the Twin Towers of the World Trade
Center. Although many were injured, few had severe burns.7,8
The victims were primarily sent to two burn centers,
although more centers were easily reachable.8 Of 39 patients
showing significant burn injuries, 19 were triaged at New
York Presbyterian Hospital. At the William Randolph Hearst
Burn Center at this hospital, victims had an average age of
44 years and an average burn size of 52.7%.9
The 39 burn patients were reported by nine hospitals, with
27 being admitted. Although enough burn beds were free
within a 1-hour transport range, only 26% of burned patients
were triaged first to burn centers. Two-thirds of the burn
injuries were ultimately treated in a burn center. The usual
portion of burn victims triaged to burn centers in New York
City in a year is 75.2%.9
Figure 5.1  9/11 was a wake-up call, bringing awareness to disaster
preparedness and demonstrating how a second hit could be used as a
strategy. Courtesy of OOEN/Archiv.

Total Burn Care
5
60
reported the types of injury. Further triage occurred, and
eight people were classified as critically injured. Two of
the seriously wounded and three of the walking wounded
had burns.
The London Assembly still works to improve emergency
care using lessons learned from the incident. Critical state­
ments on the structural and organizational aspects of this
disaster’s management have been published.18
Indoor fires
Gothenburg, Sweden, 30 October 1998 (Fig. 5.2)
A fire in an overcrowded discothèque during a Halloween
party killed 61 teenagers at the scene. Two died later, and
235 were wounded. The average age of people requiring
treatment in the burns ICU was 16 years. Initial information
was poor, resulting in incorrect alerts. No triage officer was
present at the scene. Hospital disaster plans were unknown
or not deployed. Pre-existing disaster plans had the same
personnel simultaneously performing conflicting roles.
Within 2 hours, 150 patients were admitted as inpatients at
four Swedish hospitals: 31 patients presented with signifi­
cant burn injuries, 11 of whom were transferred secondarily
to other burn centers in and outside Sweden.19
Despite the initial chaos at the scene, timely escharotomies
and triage were performed in the hospitals before patients
were transferred to burn centers. Inhalation injuries were
diagnosed in 158 patients. Of these, 54 were treated simply
with suction and expectorants. Thirty-nine did not have
life-threatening injury but needed intensive therapy for
3 or more days. Sixteen patients had life-threatening injuries,
and 47 had additional trauma. A total of 74 youths needed
intensive care.
In 51 of 61 deaths carbon monoxide (CO) was the cause.
Severe burns affected 25 patients, killing two. Both of these
individuals also had inhalation injuries. The mean age of
people with severe burns was 16 years. The mean TBSA with
full-thickness burns was 16% and with partial-thickness
burns was 3%. ICU treatment lasted from 12 to 67 days, and
hospital stay lasted 21–164 days.20
Madrid, Spain, 11 March 2004
Bomb attacks on four commuter trains carrying 6000 people
killed 191 and injured 2051. Thirteen bomb bags each con­
tained 10 kg of dynamite as well as shrapnel. Three bombs
failed to explode. Of the 191 dead, 175 died instantly and
16 died later.
It was not known that unexploded bombs remained on
the trains while ambulance staff performed their duties.
Ambulance staff worked without coordination and were
unaware of overall medical priorities. Patients with only
minor injuries were transported, and ambulances ran out of
all medical supplies. In addition, no joint field command
post for all of the medical services was set up.
Patients were taken to 15 hospitals in Madrid and two field
hospitals, with each hospital receiving anywhere from five
to 312 patients. Triage tags were unavailable, wasting time
and causing a lack of basic patient information.14 Commu­
nication problems arose in hospitals15 and between organi­
zations. Systems existed that allowed different frequencies
for different sites, but they were not used. Although radio
worked, there were communication problems within single
organizations.
Only 33% of patients were transported in ambulances
under medical control: 67% found their way to hospitals
without triage and medical or organizational control.
Most went to the nearest hospital, which received patients
with both serious and minor injuries. As a result, the
primary distribution of patients to available hospitals was
uncontrolled.16
Of 312 patients taken to Gregorio Marañón University
General Hospital, 45 had burns: 16 had first-degree burns
and 29 had second-degree burns. Of the 312 patients, 91
were hospitalized; 89 (28.5% of the 312) remained in hos­
pital for more than 24 hours. The most common injuries
were tympanic perforation (41%); chest injury (40%),
including fracture, blast injury, pneumothorax, and hemo­
thorax; shrapnel injury (36%); fracture of areas other than
the ribcage or head (18%); eye injury (16%); head injury
(12%), including fracture, subdural hematoma, and brain
contusion; abdominal injury (5%); and amputation (5%).
London, England, 7 July 2005
Attacks on the London transport system killed 56 (53 at the
scene) and wounded 775.17 Train bombs exploded in three
locations, and a fourth bomb exploded on a double-decker
bus. The number of explosion sites was initially unclear
because passengers left the Underground at various exits.
Triage was performed, and 55 patients were classified as
severely wounded (P1 and P2). Communication was prob­
lematic, as all but one mobile telephone network failed.
In addition, radio communication between the scenes and
ambulance control was very difficult. The fire brigade estab­
lished an inner cordon and found no signs of chemical
substances threatening the rescuers; however, the presence
or absence of more bombs was not confirmed before rescue
work began. Patients who were mainly in triage groups 1 and
2 were transported to six university hospitals after minimal
triage and treatment.
The Royal London Hospital received 27 of the 55 seriously
wounded, along with 167 walking wounded. This hospital
Figure 5.2  Gothenburg disco fire and the attack of the fire brigades.
Courtesy of OOEN/Archiv.

Burn management in disasters and humanitarian crises
61
Ramos25 describes the experience of Argerich Hospital,
which received 74 patients, average age 20.9 years All had
inhalation injuries. There were no severe burn injuries. Eight­
een patients (24%) were pronounced dead on arrival; 25
showed respiratory insufficiency and reduced awareness, and
these were intubated. Initially, 22 patients were sent to ICU;
the 14 sent to the operating room for mechanical ventilation
were transferred to other hospitals in Buenos Aires Province
within 48 hours. Artificial ventilation averaged 6.5 days.
Transportation crashes
Alcanar, Spain, 11 July 11 197826 (Fig. 5.3)
A tanker truck carrying liquefied flammable gas exploded
beside the Los Alfaques campground, killing 102 at the scene
and injuring 288. The number dead eventually totaled 215.27
The burning tanker divided the scene into two parts: 58
patients were transported north and received adequate care
before transfer to Barcelona; 82 were taken south to Valencia
and did not receive treatment either before or during trans­
port. Both Valencia and Barcelona had state-of-the-art burn
centers.
After the first 4 days Barcelona’s survival rate was 93% and
Valencia’s was 45%. Patients treated at Valencia and those
treated at Barcelona did not significantly differ in terms of
age, the extent of burns, and the depth of burns. Barcelona’s
patients died 1 week after Valencia’s. Overall mortality
after 2 months was 85% due to the severity of burns. There
were great problems in communication, handling the news
media, and caring for victims’ friends and relatives.
Ramstein, West Germany, 28 August 1988
(Fig. 5.4)
Aircraft collisions and crashes during an air show killed 70
and injured more than 1000 of the 300 000 present. Three
pilots and 67 spectators died, and 346 others sustained
serious injuries. Cooperation was hindered by medical
systems that were not adapted to one another. On day one,
12 hospitals were treating the injured, on day two 28, and
on day three 74.28
Two hundred and thirteen patients were treated as out­
patients, 146 were admitted as inpatients, and 84 others
were transferred to ICUs. One hundred and twelve had only
In 25 patients burn injuries required surgery. Eleven
patients received escharotomies in the extremities or thorax,
and five had fasciotomies. Amputations were necessary in
five patients.20 Eight patients had flap coverage (local and
distant), and two had free flaps.
Eleven patients were transferred secondarily to burn centers
in four other cities, with one of these patients being trans­
ferred to Norway by helicopter and C-130 Hercules airplane.21
All 11 had second- and/or third-degree burns >20%.
Volendam, The Netherlands, 1 January 2001
A fire at a New Year’s Eve party killed 14 and injured 24522
of the 350 present. Ages ranged from 13 to 27 years. For
almost 4 hours nobody knew the exact number of victims.
An early error in directing emergency traffic caused transpor­
tation chaos. Emergency services tents were insufficiently
staffed, and tent placement was problematic. A total of 241
patients visited hospitals: 110 by ambulance, 18 by bus, and
113 by self-referral to the nearest hospital.23 Of the 182
admitted, 112 went to ICUs. Nineteen hospitals provided
primary care. The closest hospital, receiving 73 patients, was
severely overwhelmed.
After primary treatment in hospital, burn specialists per­
formed tertiary triage, distributing patients to hospitals and
burn centers in and outside The Netherlands. The decision
to transfer patients was based on both burn extent and inha­
lation injury. The indication for burn center treatment was
the presence of inhalation injury and burn >30% TBSA.
Warwick, Rhode Island, 20 February 2003
A fire at The Station, a Rhode Island discothèque, killed 100
and injured 215 of the 439 present. The building totally col­
lapsed within 30 minutes. First information for Rhode Island
Hospital (RIH) came from breaking news on television.24
Shortly thereafter, RIH received official information that
200–300 burn victims were expected. A triage site was estab­
lished. Sixteen area hospitals evaluated the 215 injured
patients.
Forty-seven patients were admitted to RIH (28 male, 19
female). They had an average age of 31.9 years and an average
burn TBSA of 18.8%. Thirty-three had <20% TBSA, 12 had
21–40% TBSA, and two had >40% TBSA. Thirty-two patients
had inhalation injuries, and 28 required intubation. Twelve
escharotomies were performed, and in just six weeks 184
bronchoscopies were necessary. At least 47 patients needed
intensive care.24
Retrospective analysis called for improvement in commu­
nication with the disaster scene and in specific instructions
for patients’ relocation.24
Buenos Aires, Argentina, 30 December 2004
Fire at the overcrowded República Cromañón nightclub
killed 194 and injured 71425 of the 3000 present. CO and
hydrogen cyanide poisoning were the main causes of death.
At the scene, 46 ambulances and eight fire crews sent the
victims to the eight closest hospitals, which were totally
overwhelmed by critically ill patients within 2 hours. In
Buenos Aires city 38 hospitals were engaged and another five
were engaged elsewhere in Buenos Aires province.
Figure 5.3  Los Alfaques BLEVE and the ensuing situation. Courtesy of OOEN/
Archiv.

Total Burn Care
5
62
Fifteen to 30 minutes after the incident, casualties arrived
at Womack Army Medical Center (WAMC), a 155-bed hospi­
tal 5 minutes away. Fifty-one were treated and released, and
55 were admitted. Of these, 25 went to ICUs. Six patients
requiring urgent surgery were sent to nearby hospitals. Seven
patients were sent to the closest civilian burn center, Jaycee
Burn Center at the University of North Carolina, Chapel Hill.
Ten victims died immediately, nine died soon at the scene,
two died in transit to WAMC, one died within 30 minutes
of arrival, one died within 12 hours of arrival, 10 died within
3 days (these included five of the seven sent to Jaycee),
and one died after 10 months.32
One burn flight team arrived after 4 hours and another
after 9 hours. Escharotomies that had been done were evalu­
ated; some had to be repeated. Resuscitation was guided
by urine output, but fluid amounts could not initially
be tracked. Use of the Parkland Formula (4 mL/kg/TBSA),
rather than the Modified Brooke Formula (2 mL/kg/TBSA),
and untrained personnel’s overestimation of TBSA, led to
initial over-resuscitation. Patients with mortal injuries were
rejected for transfer to the US Army Institute of Surgical
Research (USAISR) Burn Center. Forty-one patients were
transferred to the USAISR Burn Center for burn treatment,
and 13 of these required mechanical ventilation.
In a review of this burn disaster, Mozingo32 made the fol­
lowing points:
•
Initially, patients with the largest TBSA burn were
transferred to the burn center. Most of them later died.
This sapped resources in the burn center, diminishing
the chances of success.
•
Use of different resuscitation formulas caused
difficulties.
•
Patients with injuries that were obviously deadly were
not transported. This did not meet the expectations of
the facility at which they were being treated.
•
Several burn victims remained at WAMC without burn
specialists, because all burn specialists were needed at
the USAISR.
•
Means of communication were deficient.
•
There was a lack of burn experience and training at
WAMC.
•
Knowledge deficits were noted in techniques (e.g.,
escharotomy).
•
Training of non-surgical staff in advanced trauma life
support (ATLS) and advanced burn life support (ABLS)
is needed, as the surgical staff were busy with
emergency procedures.
•
The additional ventilators needed were incompatible
with the electrical requirements of the transport aircraft
and had to be replaced by pressure-controlled transport
ventilators, though this caused no delay.
•
The surgical staff at USAISR was augmented, and
excisions of up to 40% were performed in one long,
two-team operation.
Explosions
San Juanico, Mexico, 19 November 198433
An 11 000-m3 mixture of propane and butane exploded,
causing one of the most severe explosion disasters and
registering 5 on the Richter scale. Gas entered houses in
mechanical injuries, 263 had isolated burn injuries, and 68
had both mechanical and thermal injuries.28
Patients suffering from <20% TBSA burns numbered
209 (79.5% of 263). Thirty-seven patients had 20–49%
TBSA burns, and three died. Nine patients had 50–70% TBSA
burns and six died. Another eight patients with >70% TBSA
burns also died. Of the 68 patients with combined injuries,
55 had <20% TBSA burns. Three of nine patients with 20–
40% TBSA burns died. No patient with combined injuries
and >40% TBSA burns survived.
The burn center at Ludwigshafen received 28 victims.
Information came from ambulance radio conversations. The
existing emergency plan was activated; overstaffing occurred
on the first day. Primary care in the burn unit was provided
in the normal way, not according to emergency plans. Expe­
rienced burn teams evaluated the patients. The disaster plan
worked, but incomplete primary documentation greatly
increased the next days’ workload. During treatment, no
problems occurred with the expanded nursing staff. However,
qualified medics who worked double shifts for weeks
were exhausted. In addition, high-capacity use of burn beds
caused cross-infection problems. In retrospect, the senior
surgeon on duty on day one concluded that patients should
have been transferred to other burn units, where free beds
were available.29
Kerosene caused difficulties in respiration and in kidney,
liver, and central nervous system function. Evaluating cyclic
carbohydrates in the blood soon after the incident may be
important for prognosis.30
Pope Army Airfield, North Carolina,
23 March 1994
Two planes collided in the air while attempting to land on
the same runway. The C-130E was able to land, but the
F-16D, whose crew ejected, slid into a parked, fully fueled
C-141 cargo plane with a crew on board. Five hundred para­
troopers, waiting 50–70 feet from the plane, were sprayed
with a fireball of burning aviation fuel. They were also
exposed to flying debris and the F-16’s 20-mm ammunition,
which began firing from the heat.31
Figure 5.4  An airplane crash during a flight show demonstrated difficulties
in cooperation among different, non-adapted systems. Courtesy of OOEN/Archiv.

Burn management in disasters and humanitarian crises
63
dispatched for medical aid. Intravenous (IV) fluid resuscita­
tion was initiated for most patients. Those with serious but
potentially survivable injuries were then evacuated to Chely­
abinsk, Sverdlovsk, and Ufa. Later, the military and Aeroflot
took most of them to Gorky, Leningrad, and (the greatest
number, 161) Moscow. Most had 30–40% TBSA burns. On 8
July the Soviet government accepted an American initiative to
organize a burn team, mainly for children’s medical care.36 In
Ufa, the team from Galveston, Texas (including Dr Herndon),
evaluated four children with 30–68% TBSA burns and 12
with moderate burns (15–30% TBSA). The team began treat­
ment in cooperation with Russian experts. The earlier, very
conservative therapy was changed to an operative one, using
dermatomes and meshers brought from Galveston. A US
Army team was also deployed to the Soviet Union and began
treating adults in Ufa. British and French teams were dis­
patched to Chelyabinsk. Israeli and Cuban teams went to the
major burn centers in Moscow. However, Children’s Hospital
9 in Moscow had still received no help. Dr Herndon did
further organizational work so that, after the Galveston team
returned home, Dr Remensnyder (from Shriners Burns Insti­
tute, Boston) and Dr Ackroyd (from Massachusetts General
Hospital) continued relief efforts at Hospital 9.
Twenty-six burned children were first admitted to Hospital
9. When Dr Remensnyder arrived, three children had died
from sepsis. Modern techniques such as topical adrenaline
splinting, use of air-driven dermatomes, and primary wound
excision and grafting were introduced.
The US Army selected 28 patients for burn-wound excision
and coverage. The team discovered many infected wounds,37
and a microbiological department was set up. Cross-infection
between burn victims was common and mostly attributable
to multiresistant Pseudomonas and Staphylococcus species.
Techniques for minimizing blood loss had to be perfected
as there were insufficient amounts of cross-matched blood.
Local therapy with mafenide acetate and silver sulfadiazine
was administered.
This effort was one of the very successful international
joint operations in a burn disaster.38
Critical dimensions of disasters and planning
In mass casualties and disasters with burn injuries, three
possible scenarios exist:
•
If the number of victims is within the local burn
center’s surge capacity, that center can perform primary
stabilization and treatment. Afterwards, they can decide
whether to transfer some patients to other burn centers.
•
If the number of victims exceeds the surge capacity
of the local burn center but can be handled by the
national system of burn centers, primary care must take
place in hospital emergency departments and/or burn
centers. Dispersal of patients to national burn centers
must come later.39
•
If the number of victims exceeds national resources,
primary care must take place in emergency departments
and/or burn centers. National and international
resources must then be evaluated to determine which
patients are to be treated in burn centers nationally and
internationally. This scenario is greatly facilitated by
pre-existing conventions and treaties.
San Juan Ixhuatepec (population 40 000) and set fire to
everything. In a 25-acre (10-hectare; 100 000-m2) area 7000
persons needed medical help, 2000 required hospitaliza­
tion, and 625 had severe thermal injuries. Thirty-three hos­
pitals were involved, with transportation being provided by
363 ambulances and helicopters. Sixty thousand were evacu­
ated. About 23 000 needed help with smaller injuries,
lodging, and food.
The magnitude of the event meant that, for the first hour,
total chaos reigned and rescue work was without guidance.
Secondary explosions, heat from fire, and debris forced res­
cuers into temporary withdrawal to avoid risking more lives.
After triage and primary care, victims were distributed to 33
hospitals, most of them in Mexico City. Within 3 days, burn
patients had been distributed to 12 hospitals with good burn
facilities. After 5 days, only 300 of the 625 burn patients were
still in burn units: 140 had died and 185 had been sent
to other hospitals. ‘Rather few’ extensive and deep burns
occurred, and very few patients needed respirator care.
Centro Medico reported that 37 patients with severe burns
were admitted because of a silo explosion 3 days before, and
they received 88 other burn patients. The facility mobilized
additional staff and prepared additional beds near the burn
unit. Only two of the 88 victims had airway injuries requir­
ing tracheotomies and ventilators. This burn unit’s usual
capacity is 48 beds. The maximum number of patients
simultaneously treated was 136. No shortages occurred in
beds, personnel, or medication. Fifteen patients with >60%
TBSA burns died within 4 days.
Piper Alpha, North Sea, 6 July 198834
An oil fire and gas explosion on an oil rig killed 167 and
injured 189. The temperature was estimated at 3500°C.
Information about the disaster reached Aberdeen Royal Infir­
mary, Scotland, by television. Sixty-three were rescued: 22
went to the hospital, 15 of whom were admitted, with 11
going to the burn unit. Primary triage was difficult because
neither the thermal effect nor pulmonary injury could be
evaluated immediately after the incident. Severe thermal
injuries occurred from helmets melting on victims’ heads,
even running down over their faces. All patients had some
degree of inhalation injury, presumably from heated air.
All patients underwent surgery within 72 hours. No sig­
nificant graft loss occurred. Operations were performed by
two teams working in two areas simultaneously. The high
number of dead took a grave toll on the medical and lay
teams’ psyches. Psychiatrists, psychologists, and social
workers were included in the team and proved to be highly
valuable. The retrospective recommendation was to distrib­
ute patients among other units. News media were a problem,
as was the administration’s unawareness of the need to
maintain high staffing levels for an extended period. Knowl­
edge of basic burn procedures (e.g., escharotomies and the
way to treat a burn) is important if an administration is to
plan and support sufficiently.
Bashkir Autonomous Soviet Socialist Republic,
4 June 1989
Two trains were passing a methane–propane pipeline when
it exploded, killing 575 and injuring 623.35 Helicopters were

Total Burn Care
5
64
may be to bring victims to a safe collection place, free from
imminent danger (e.g., battle, hostile action, or environmen­
tal hazards). Tagging must begin here. In-field triage must
take place. This primary evaluation should take less than 30
seconds per patient and should be limited to life-threatening
conditions.
With mass casualties, no resuscitation usually takes place
in victims first classified as dead (no ventilation after freeing
airways and no pulse, according to Simple Triage and Rapid
Treatment—START). This is especially true when victims are
salvaged from indoor fires (because deadly CO poisoning is
assumed) or when lack of pulse or capillary refill is coupled
with limb amputation (because massive violence is assumed
to be fatal).39
Depending on the number of victims, salvaged victims
are brought to collection points or to the triage area. In
victims with extensive burns, the time in low-temperature
environments must be minimized to reduce the chance of
hypothermia.
Triage
Do the very best for as many as possible.
Different systems use different triage algorithms.
Paramedic systems may use START in both emergency
medicine and mass casualties. According to findings,
emergency treatment is as follows: free airways, emergency
intubation, cricothyrotomy, decompression of tension
(pneumothorax), and mask ventilation, styptics.40 The sen­
sitivity for START varies from 85%41 to 62%.42
Medic in-field triage is another type. This is performed in
an established triage area by medics assisted by teams of
helpers. It consists of minimal anamnesis: time of accident,
mechanism of injury, condition, how the patient was found,
primary measures taken, actual discomfort, pre-existing
conditions, medications and allergies, and the following
systematic medical check:
•
Physical investigation: external bleeding, penetrating
injuries, burns, chemical burns, neurological status, and
investigation of the head, spine, thorax, abdomen,
pelvis, and extremities.
•
If possible, a few measurements are taken, e.g.,
respiration rate, pulse oximetry, and temperature.40
In burn victims, the TBSA burn is estimated by the Rule of
Nines, and strictures, suspected inhalation injury, and the
need for intubation are evaluated. Emergency treatment is
performed in a treatment area by emergency physicians.
Burn victims needing treatment for shock or intubation
should be classified for urgent treatment. Because of the
need to resuscitate as soon as possible, resuscitation should
at least begin here.
Triage depends upon easily verifiable vital parameters
and clear types of injury to filter and classify patients
according to the four treatment urgency groups shown in
Table 5.1.
In Austria, Germany, Switzerland, and some other coun­
tries, triage group 4 includes the hopeless or unsalvageable
who deserve ‘expectant’ treatment. This is very controversial
because the duration of the disparity between supply and
demand should be short, and when this period is over this
group’s priority changes to 1 or 2. In such countries, the dead
Phases of mass casualty events
Chaos and alarm
Initially, information about the event is unavailable. Even
those involved often cannot verify the incident’s dimensions,
and sometimes cannot even describe the place.23 Details
must be obtained immediately. Information to be collected
includes the exact time, place, and type of accident;
estimated numbers of casualties and expected pattern of
injuries; hazards (e.g., contamination or toxic smoke); and
the number of persons potentially exposed.
After verification, the incident command system and
in-field command post must be established and must coor­
dinate the work of rescue, security, technical relief, and
medical relief forces. They can then enable work to proceed
in the damaged area and protect the team and their work
from hazards, violence, and the distracting demands of
victims, their friends, and their relatives.
False information leads to inaccurate alerts (e.g., ‘yellow
red’ instead of ‘red’) and is disastrous for all who then must
cope with unexpected situations.19
Immediately after the accident, victims flee to the nearest
hospitals, overcrowding them before any official alarm. This
influences the execution of emergency plans, because every­
one is busy with arriving victims and no resources may be
available to carry out disaster plans. Contaminated victims
fleeing contaminated areas can bring severe risks to hospi­
tals, causing a partial dropout of medical resources.
Organization
Medical care should be established at the scene and in
alerted hospitals. First, the scene must be cleared of further
hazards or rescue workers must be outfitted for the risk.
Next, a cordon should be established to control victims’
departure to hospitals and to prevent onlookers and the
news media from interfering in rescue work.
Traffic regulation must begin, and all teams must under­
stand it. It must include movement and assembly of ambu­
lances, fire trucks, and police cars; landing and take-off of
helicopters; decontamination areas; areas for triage, treat­
ment, and victims with minor injuries; and a temporary
morgue. The scene should be divided into rescue areas, and
schedules should be created for technical support teams.
During this phase, cooperation among medical teams, fire
brigades, police, and technical relief teams is crucial. Local
command-and-information structures must be established,
as they serve as the coordination hub for preclinical treat­
ment. A central command-and-coordination structure
coordinates preclinical treatment, clinical treatment, and
transport. It also disseminates up-to-date information. At
hospitals, disaster plans are engaged and staff called in. The
quality of the performance of all teams depends mainly on
information.
Salvage and triage
Search and rescue
A salvage triage can be important for directing technical and
medical relief because it determines urgencies. The first goal

Burn management in disasters and humanitarian crises
65
wounded or as transports with individual means.6,21 These
hospitals should be spared from primary transports.
Second-line hospitals
Second-line hospitals should be reserved for completing the
primary treatment of patients who have already been treated.
Each hospital to which victims first are admitted must
perform a second triage to assess and complete primary
treatment. The condition of burns patients often deteriorates
quickly. Therefore, re-evaluating victims brought to these
hospitals is mandatory!
Third-line hospitals far from the scene
Patients in triage group 3 (’delayed treatment,’ ‘walking
wounded with only minor burns’) should be taken to hos­
pitals far from the incident. Mass transportation (e.g., buses)
can be used.
Primary hospital or burn center
triage and treatment
Measures should be taken to stabilize the patient and
perform all immediate necessary surgery, so that the need
for interventions is minimized and personnel are then avail­
able for other work. Outside burn centers, admission triage
and treatment are usually performed by medical specialists
who are more or less familiar with the emergency manage­
ment of severe burns. Support from burn experts will be
necessary later.
When a burn patient arrives at hospital, an assessment
must be performed, and prior measures must be completed
or corrected (Table 5.2).
This evaluation and treatment are based on the ABCDE
(Airway, Breathing, Circulation, Disability, Environment)
are in no triage group. Thus, group 4 requires staff at least
for comfort care. Dead victims need neither staff nor trans­
port in the acute phase.
Tagging
First, each patient is given a tag with a unique number. These
tags facilitate victim identification and registration; provide
information about patients’ history, medical treatment, inju­
ries, urgency of treatment, and classification of injury; and
specify the hospital for treatment. The tags must never be
removed until all the following have taken place: definitive
treatments have been initiated, the patient has been identi­
fied, the diagnosis has been made, and the tag number and
all treatment data have been registered.
Different types of tag and label exist. Treatment urgency
is evaluated first. Transport urgency follows emergency
treatment.
First medical treatment
Necessary resuscitation, intubation, and minimum wound
treatment should begin in accordance with triage findings.
Often this must take place with limited resources and little
knowledge of what the next minutes will bring. The lack of
resources (e.g., IV fluid, infusion systems, tubes, respirators)
limits their use to acute emergencies, leaving primary care
for the hospitals where victims are sent.
First transport
For transporting burn victims, ambulance heating should be
maximized to avoid cooling patients. Warming pads and
extra blankets should be prepared, and IV fluids should be
warmed. Ambulance doors should also be kept closed to
retain heat.
Transport order must be in accordance with the urgency
status determined in triage. Transporting the dead steals
resources from the living. The dead and where they are
found (important for identification) should be documented.
When they have to be removed, they should be brought to
a temporary morgue.
First-line hospitals
The closest hospitals should be avoided as much as resources
will permit, as they will be overcrowded with people who
are neither triaged nor registered and who arrive as walking
Table 5.1  Color code and urgency
Group
START
Medic triage
1
Immediate
Immediate
2
Urgent
Urgent (2a and 2b)
3
Delayed
Delayed
4
Expectant
4
Expectant, dead
No number, no color
Dead
Table 5.2  Primary assessment of burns in hospitals
• A – Airway
s Intubation?
 Tracheotomy
 Inhalation
• B – Breathing
 Pneumothorax
 Escharotomy thorax
 Remove necrotic plates from thorax
• C – Circulation
 Resuscitation fluid
 TBSA recalculated
 Urine output
 Core temperature
 Hemorrhage
 Escharotomy
• D – Disability
 CO–Carboxyhemoglobin
 Hydrogen cyanide
 Shock
 Trauma
• E – Environment
 Additional injury
(TRAUMA CT SCAN)

Total Burn Care
5
66
systemic inflammatory response syndrome and to the hygro­
scopic effect of the eschar. Postponing necessary escharoto­
mies while waiting for BATs or BSTs to perform escharotomy
greatly increases the risk that extremities will be lost, and
that the patient’s condition will deteriorate severely. In
burns, osteosynthesis procedures performed during the first
24 hours do not carry higher complications than those
performed in non-burn patients.48 When the risk is low,
intramedullary stabilization should be performed, giving a
better approach for handling burns, that is, it makes kinetic
therapy and burn dressings easier. If a higher risk is present,
external fixation is the appropriate method.
Wounds should be cleaned under sterile conditions. This
should be followed by topical treatment with disinfectants
and burn dressings.
Enteral feeding – at least by nasogastric tube but preferably
by nasoenteric tube – should be started.
Secondary burn re-evaluation and treatment
in hospital or primary burn center
Evaluation
Central incident command should already know the number
of available burn beds. They should also know, at minimum,
the number and locations of victims. Burn extent and
sequence and are carried out through interdisciplinary
means at a hospital. Securing the airway can require trache­
otomy. Improving ventilation often requires escharotomies
and fasciotomies in the thorax – sometimes even removal of
necrotic plates strictly adjacent to the fascia.
Neglecting escharotomies in patients with impaired
ventilation leads to more or less circumferential eschar
in the thoracic area and death within hours. Indicated
escharotomies and fasciotomies improve lung function
almost immediately. Delayed escharotomies can lead to
hyperkalemia with successive cardiac problems and massive
influx of edema fluid, causing acute fluid overload.
Impaired circulation can result from strictures created by
burn scars or from incorrect resuscitation. Strictures created
by burn scars require escharotomies and fasciotomies in the
extremities. Incision should make fasciotomies feasible and,
if possible, should be done through third-degree burns,
which must be removed over time, to minimize scarring.
Resuscitation should always be started according to a
formula. Unfortunately, most burn victims receive too much
resuscitation fluid initially.43 This seems to stem from two
main factors. One is the overestimation of TBSA44 by the
Rule of Nines. Even Lund–Browder charts overestimate burn
size.45 The other is use of the Parkland Formula (4 mL/kg/
TBSA). Combining this formula with overestimation of
TBS,A46 either by Rule of Nines or by Lund–Browder charts,
can cause heavy fluid loads, initiating edema or abdominal
compartment syndromes. Calculation of initial fluid require­
ments can be supported by easy-to-use 3D computer charts
combined with the Modified Brooke Formula. The fluid-
needs calculation should then be guided by physiological
parameters as soon as possible, mainly to the urine output
of 0.5–1 mL/kg/h47 (Table 5.3 and Table 5.4).
Discussion
Additional injuries demanding treatment should, if pos­
sible, be definitively treated within the first 24 hours, before
burn treatment. These injuries should be treated at minimum
with the goal of damage control, or better, by definitive
surgery. In cases of an unclear history of injury, explosions,
and trauma caused by external forces apart from flames, a
trauma CT scan should be performed to ensure that no other
severe injuries are missed during the primary evaluation.
Escharotomies and fasciotomies should be performed
before osteosynthesis. Escharotomies should be done when
there is increased swelling occurring within hours due to
Table 5.3  Fluid need calculation error from overestimation and
different formulas
TBSA
Patient
weight
Formula
Resulting
resuscitation
fluid
30%
(actual)
75 kg
Modified Brooke
2 mL × 75 × 30
4500 mL
36%
(overestimation
by 20%)
75 kg
Parkland 4 mL ×
75 × 36
10 800 mL
Table 5.4  Important items during primary hospital
assessment of burns
Ventilation
• If ventilation is impaired, check the need for intubation,
tracheotomy, or coniotomy
• If patient is intubated and ventilation is disturbed, check tubus
position, exclude pneumothorax, and consider thoracic escharotomies
and fasciotomies
• Check for inhalation injury and aspiration. Bronchoscopy may be
needed
• If carboxyhemoglobin is high, oxygen administration is needed
Circulation
• If perfusion of extremities is disturbed or pressure is high, check
the need for escharotomy and fasciotomy
• Recalculate TBSA
• Recalculate fluid requirement. Adjust fluid amounts accordingly
• If blood pressure is disturbed, correct fluid administration. Other
medication? Additional injuries?
Organ perfusion
• Check urine output
• Core temperature: Warm up
Other injuries
• Is other medical treatment (besides burn treatment) necessary?
Complete diagnosis, and give treatment according to urgency
Local treatment
• Clean. Apply disinfectants: Take primary swabs
Nutrition
• Nasogastric or nasoenteric tube in intubated patients

Burn management in disasters and humanitarian crises
67
even when ventilated (e.g., the MedEvac Airbus can transport
six patients in intensive care and 38 more in the supine
position).
Problems with air transport have been reported. These
include bacterial cross-contamination as well as relatives’
being delayed or prevented from accompanying their dying
family members.23 Klein46 reported that the most common
complications during air transport are loss of venous access
and inability to secure an airway. Hypothermia (<35°C) has
been reported in about 10% of patients, most of whom have
a larger burned TBSA. Mass transports can be supported by
armies and their matériel.
Definitive treatment
Definitive treatment is given in predetermined places. Rela­
tives coming to their badly injured loved ones should be
given psychosocial help and supported by the offer of guest
rooms and continuous, fact-based information. Patients and
relatives must be protected from news media, which often
present a big problem during this phase.
During surgery, blood-saving methods must be empha­
sized to conserve blood stocks. This can be helped by local
application of epinephrine; tumescent techniques in necro­
sectomy and donor areas; local application of thrombin; and
use of tourniquets. Performing operations on larger areas
and with more teams can reduce the amount of preparation
time between operations by reducing the absolute number
of operations. Because resources such as cadaver skin can be
limited in mass casualties, definitive covering as soon as
possible is the goal.
Transport home
For patients whose early treatment occurred far from their
homes, transport to home hospitals should be arranged after
treatment. Central disaster management must conduct a
general survey of treatment centers, who has died, living
victims’ conditions, and spaces available in the home area.
Patients should be transported if they are stable and the situ­
ation in the home area is expected to be suitable. Transport
funding must be cleared.
Long-term treatment
After treatment in a burn center, patients’ further care must
be organized and planned. Regular follow-ups, surgical
interventions, compression therapy, and psychosocial
support must be planned and initiated. These should be
long-lasting measures to give the patient a point of care that
they trust and to make them feel welcome to go there for
any reason.
Rehabilitation
Rehabilitation must be planned and coordinated for all
patients. The primary shortage in burn beds will be followed
by a secondary shortage in rehabilitation centers. Follow-ups
must be planned far into the future; projects should be
established and funded. Physical, psychological, and social
care should be given not only to the victims but also to their
relatives.
severity, need for ventilator support, quality of shock treat­
ment, CO poisoning, and quality of escharotomies must all
be evaluated with the goal of obtaining reliable data. This is
the ‘golden hour’ of BATs and BSTs.
Patients’ temperature should be maintained by maximally
warming operating rooms. Air-conditioning systems with
target temperatures that cannot be raised beyond a certain
level can be a problem. Warming the operating room beyond
the target temperature (e.g., with space heaters) simply
causes the system to work harder to maintain its cooler,
target temperature. Such systems must be turned off.
During the evaluation period, staff should be prepared to
evaluate fluid regimens, ventilation, perfusion, escharotomy,
and TBSA. They should also expect to begin feeding, cleaning
the surface, using disinfectants, and applying dressings to
reduce heat loss.
Central collection of corrected data
With central data collection and distribution the best treat­
ment option allowed by the available resources can be
chosen for the patient. This can be supported by information
technology (IT) solutions that enable surface calculations
and central registration of burn cases.49
Treatment options
Patients should be distributed to burn centers with free
resources. However, when resources are limited, special cri­
teria for burn center treatment must be set. These criteria are
based on the survival grid published by the ABA5 and usually
depend on TBSA, the need for ventilator support, and age.
Patients meeting these (temporary) criteria should be trans­
ported to burn units. The rest should either stay in the
primary hospital or be transferred to non-burn units.
Secondary transport
Transports to burn centers have the highest priority.
Whether to transport patients whose care has been classi­
fied as futile to burn centers must be decided in disaster
planning. They are a burden for the primary hospital in
terms of workload, psychological effect, and legal aspects.32
In burn centers, they tie up resources needed for treating
patients who are likelier to survive. The pairing of two rec­
ommendations in the US – to send any patient with a third-
degree burn to a burn center and not to send anyone with a
severe, non-survivable burn to a burn center – produces
conflicts. At any rate, these patients, their relatives, and the
staff caring for them need both psychosocial support and
support from experienced burn medics.
Depending on the severity of burns, patients should be
transported through appropriate means. Ventilated patients
should be transported by air or, for shorter distances, by
mobile ICUs.
During transport, the patient must be protected from bac­
terial contamination and from cooling. This requires special
dressings and devices that hinder cooling. Minimal monitor­
ing should be possible: respiration rate, urine output, oxygen
saturation, and in longer flights, PaO2 and PaCO2. Some
helicopters can transport several patients simultaneously.
Armies usually can offer airplanes to transport many victims

Total Burn Care
5
68
suspected explosive. People trying to use cell phones may be
endangered by security forces, who know that cell phones
can also be used to trigger bombs. If bombs are suspected,
cell phones can be jammed by security forces.55 Amateur
videos, often shot on cell phones, are important in mass
casualties for reconstructions and intelligence.
Conventional telephone
In most hospitals, the number of incoming and outgoing
landlines is limited. If there is a manual switchboard but no
automatic switching, this system can be overloaded very
quickly. An alarm server with a call center function can be
useful for alerting staff, as in the early phases of a mass casu­
alty everyone is needed to help prepare the hospital before
the surge.
Voice over internet protocol (VoIP)
VoIP permits conference calls. For safety, public systems that
could be used are usually disabled in hospital IT systems.
Two-way radio
Reception and transmission can be poor or non-existent
indoors and underground (e.g., 9/11, London). In hospitals,
the number of people who can talk at the same place
and time over one circuit can be limited. This causes
problems when an area includes many persons exchanging
information.
Trunked radio system (TRS)
TRSs use computer control to allow almost unlimited talk
groups with only a few channels. Relief units use TRSs for
intra- and interorganizational communication. In Europe,
TRSs are being established for emergency organizations.
Satellite telephone
Satellite phones operate independently of local infrastruc­
ture and can be helpful in cases of uncertain or overloaded
infrastructure. However, even a call made from a satellite
phone will not go through if the telephone system on the
receiving end is not functioning.
Internet
Internet communication is an option only if connections are
intact.56 The internet can be helpful in building up informa­
tion structures for victims’ relatives and to provide informa­
tion to extremely large audiences.
Electronic news media
These are important in disasters, especially when locales
must be evacuated and when staff are needed. News reports
sometimes provide burn centers with their first information
about an incident, before the official alarm arrives.
Communication with news media
The news media shapes the public face of the disaster. Infor­
mation for the media is important and should originate in
Debriefing
Debriefing is part of psychosocial preventive care in an emer­
gency response. Staff involved in mass casualties have a
higher risk of illness than the average population because
of confrontation with severely hurt or mutilated victims,
especially children; injuries (sometimes fatal) to colleagues;
fetidness; and cries for help. It is also attributable to pain,
the need to make triage decisions, bad information, lack of
routine, lack of resources, inability to provide help, and
contact with aggressive news media.50 Debriefing allows
these individuals to overcome the event psychologically and
reflect on its effects. Optimally, it is conducted near the event
site and begins within the first 24–72 hours. General group
sessions after incidents are not recommended, as on their
own they do not prevent post-traumatic stress reactions.50
One-on-one interviews and small group sessions are prefer­
able. After these meetings, the psychosocial specialist decides
whether debriefing should be offered. Re-contacting people
after 4–6 weeks and re-evaluating the first decision is
recommended.
In many countries, institutions and organizations offer
debriefing based on the Critical Incident Stress Debriefing
system. This system has three main parts: preparation,
attendance, and aftercare. Although minimum quality stand­
ards are rather clear, quality control is sometimes lacking.50
Information and communication
Hospitals and burn centers often learn of the incident first
through irregular channels.28 Victims arriving on their own
sometimes provide the first information.13 The news media
can also be faster than the designed information structure.
Moreover, video is sometimes a better source of information
than mere words. When patients arrive tagged or telling
certain stories, this may indicate that a mass casualty event
has occurred. Measures to establish hospital preparedness
should be taken. For example, supplies and the local situa­
tion should be checked. In addition, staff should not be
permitted to go home after shifts until the situation is
cleared.
Crisis communication is the exchange of information
among public authorities, organizations, the news media,
and affected individuals and groups before, during, and after
a crisis.51
Means of communication
In disasters and mass casualties many factors increase the
need for communication, and communication resources
are limited. Sequential failure of various communication
methods has been described in many disasters (e.g.,
Enschede,52 Eschede,53 London, Madrid,14,16).
Cellular telephone
Cellular networks are usually overwhelmed because victims,
the news media, relatives, friends, and others all quickly
begin dialing to or from cell phones, leading to breakdown
within minutes. Cell phones should not be used near explo­
sive devices.54 A 50-foot (15.2-m) safety radius is recom­
mended for cell phones and radios being used near a

Burn management in disasters and humanitarian crises
69
Water and cooling
Applying water helps to reduce pain by reducing surface
temperature (thereby reducing nociceptor activity) and by
hindering nociceptor desiccation. Water cooler than 8°C
(46.4°F) can aggravate cell destruction.57 Water should be
clean, but sterility is not necessary. Water from containers in
which warm water is stored long-term can be contaminated
with Legionella, causing severe problems (e.g., atypical pneu­
monia) very quickly.
The effectiveness of wet dressings is limited by their drying
out. Therefore, periodic moistening is necessary to maintain
the effect. Gel preparations do not dry and can make the
wet-dressing pain-reduction method more comfortable.
Although gels cool the body more slowly than does running
water, they do not prevent hypothermia. In extensive and
large burns, the application of tap water should be limited
to extinguishing the fire and cooling surfaces to normal
temperatures.
Hypothermia is a serious problem in burns and should be
guarded against. If a patient starts shivering, cooling must be
stopped and core temperature must be maintained by all
available means. No wet dressings should be applied.
Advanced trauma life support (ATLS)
Doctors and advanced paramedics perform ATLS in preclini­
cal treatment areas and emergency rooms. ATLS procedures
are to be followed first; however, burn injuries require special
care in the treatment of shock, evaluation, local treatment,
and special knowledge of indications about where to treat.
Advanced burn life support and emergency
management of severe burns
Burns are best treated with certain protocols:
•
EMSB – developed by the Australian and New Zealand
Burn Association and adopted by the British Burn
Association
•
ABLS – developed by the ABA, with training being
available online.58
These protocols include ascertaining the magnitude and
severity of an injury; identifying and establishing treatment
priorities; physiological monitoring; determining the appro­
priate guidelines for patient transfer, including time, destina­
tion, and transport method; and treatment of the burn area,
associated injuries, and common complications within the
first 24 hours after burn.
Preventing hypothermia, wound
contamination, and evaporative heat loss
Hypothermia, wound contamination, and evaporative heat
loss are usually prevented with special burn dressings
(absorbent cotton with an applied aluminum surface) and
with plastic film as used in operations. In mass casualties,
saran film (the plastic wrap used for food) is suggested for
areas away from the face. It must be at least clean, if not
sterile. This occlusion prevents wound dehydration and
evaporative heat loss. Care must be taken not to stop circula­
tion or hinder ventilation.
a desire to be as correct and as complete as possible.51
Training in crisis communication should be given.
No excessive information on certain events should be
provided, but important information must be given.
The central incident command should appoint spokesper­
sons to provide regular, announced press conferences and
bulletins. The press should be kept away from victims and
their relatives – the hunt for headlines does not stop at the
hospital door.
When spokespersons start their work, they should first
express their concern about the situation and their condo­
lences to those who have lost loved ones. They should then
provide assurance that everything possible is being done
to help.
Methods of supplying information to the press include
Web newspapers, press releases, press conferences, radio, and
television. The press want people for interviews and photos.
This should be kept in mind and prepared for, with fore­
thought being given to what aspects can be discussed without
causing problems. Guidelines for communication with the
press are as follows:
•
Never lie.
•
Never guess, or present your own theories.
•
Never become upset or angry.
•
Never let the situation or reporter affect you.
•
Never use jargon.
•
Never discuss classified information.
•
Never say ‘No comment.’
•
Never speak about issues outside your competence.51
Press communications should be made in an environment
outfitted for information transfer by the media and away
from patient treatment areas.
Communication with relatives and friends
As at the scene, centers should be established at hospitals for
friends and relatives to gather in private, and crisis coun­
selors and information tools (e.g., telephones) should be
available. Access to these areas should be restricted to identi­
fied relatives and friends. Information here should be exact,
honest, and never speculative. A contact person for relatives
and friends should be nominated.
Medical treatment
Different medical standards are used in treating mass-
casualty victims, beginning with help from bystanders to
ATLS from medical emergency teams, ABLS, and emergency
management of severe burns (EMSB).
First aid at the scene and basic life support
Bystanders, hurt and unhurt, give first aid according to their
education and ability. Basic measures include positioning,
stopping bleeding, and securing respiration. In burns, addi­
tional measures include extinguishing fires on individuals,
stopping the influence of heat, cooling surfaces, and hinder­
ing hypothermia. If available, oxygen should be given. Extin­
guishing and stopping thermal influence without causing
hypothermia are the most important of these measures.

Total Burn Care
5
70
Flammacerium
Flammacerium is silver sulfadiazine combined with
cerium(III) nitrate. It makes the eschar more supple.
The antibacterial spectrum of this compound is the same as
that of silver sulfadiazine, but its potency is higher. Methe­
moglobinemia arises rarely.69
Mafenide acetate
Mafenide acetate is a sulfonamide with excellent activity
against Gram-positive bacteria, including Clostridium. It has
a broad-spectrum activity against Gram-negative bacteria but
is not so effective against fungi and methicillin-resistant S.
aureus. Application of this compound can result in systemic
toxicity, often causing hyperchloremic metabolic acidosis
and pulmonary complication if used over a long period.
Because mafenide acetate is excellent at penetrating dead
tissue, it is useful for the short-term control of invasive burn
infections. This compound is not available in Europe.
Povidone-iodine
Povidone-iodine is used as a cream or solution.70 It pene­
trates the eschar, changing the surface so that evaluation is
difficult. It must be applied at least twice daily.
Anesthesia
Early care: the part of the anesthesiologist
Major burn injuries are characterized by a rapid deteriora­
tion in hemodynamics and in vital systems such as the
respiratory system. With the breakdown of the skin barrier
hypothermia and infections become major, immediate
threats. Second-degree burns are usually extremely painful.
Fluid resuscitation
Immediately after burn trauma, collagen breakdown in the
dermis leads to a large increase in osmotic pressure in the
interstitial fluid compartment, followed by the rapid forma­
tion of edema in the burned tissue.71 One to two hours later
the capillary permeability in both the burned and the
unburned tissue increases, reaching a maximum at 6–12
hours post burn. This reinforces edema formation and aggra­
vates shock development.
Early management of burn shock is critical for surviving
burns >20–25% TBSA. In children in particular, beginning
fluid resuscitation within 1 hour after burn dramatically
reduces mortality. This depends more on timing than on the
type of fluid infused.72
To deliver adequate quantities of fluid, one must estimate
the extent of TBSA burned. The Rule of Nines is widely used
for this purpose. The most commonly used formulas for
estimating fluid requirement in major burns are the Park­
land Formula and the Modified Brooke Formula. Parkland
recommends 4 mL lactated Ringer’s solution (RL) per kg/
TBSA for the first 24 hours. The first half is administered
during the first 8 hours post burn, and the rest is adminis­
tered during the subsequent 16 hours. The Modified Brooke
Formula is the same, except that 2 mL is used instead of
A separation layer must be applied between sterile and
non-sterile dressings. Outside this layer, blankets should be
used to reduce heat loss. Patients at greatest risk of hypother­
mia are those who are intubated and sedated, as they cannot
regulate their own temperature.
Topical treatment
Chlorhexidine
Chlorhexidine is a chemical antiseptic. It is effective on both
Gram-positive and Gram-negative microbes, although it is
less effective with some Gram-negative microbes. It reduces
surface colonization of burns; however, its effect on deep
colonization is limited.59 In a 4% solution it has good effects
against Staphylococcus aureus and Pseudomonas.60
Sodium hypochlorite
Sodium hypochlorite is recommended as primary treatment
for burn wounds before treatment in burn units.61 Its clinical
effectiveness does not increase in concentrations >1%.62
Polihexanide
Polihexanide is a biguanide polymer with disinfectant and
antiseptic properties. It has very low cytotoxicity and is
clinically and microbiologically superior to silver nitrate
and povidone-iodine.63
Silver nitrate
Silver nitrate is usually used in 0.5% solution and has
good effects on Pseudomonas, Staphylococcus, and many
Gram-negative microbes. It can cause methemoglobinemia.
It is painless and should be applied by soaked dressings
re-moistened every 2 hours. The resultant film on the surface
can frustrate evaluation. Because of ionic silver’s quick inac­
tivation, the effect is brief. 64
Nanocrystalline silver
Nanocrystalline silver works in wet surroundings by setting
silver free over a long period. It can be applied and left in
place for some days. Complications can be caused by stric­
ture.65 One case with argyria-like symptoms has been
described.66 It has been shown to be more effective than
silver sulfadiazine in treating superficial burns.67,68
Silver sulfadiazine
Silver sulfadiazine inhibits DNA replication and induces
membrane changes in S. aureus, Escherichia coli, Klebsiella
species, Pseudomonas aeruginosa, Proteus species, and Candida
albicans. It is available as a 1% cream. It can cause acute
hemolytic anemia in patients with glucose-6-phosphatase
enzyme deficiency. When applied in higher doses over a
longer period sulfonamides can cause crystalluria and meth­
emoglobinemia. This chemical changes the surface of burn
eschar, hindering evaluation of burned surfaces.69

Burn management in disasters and humanitarian crises
71
reported that the use of colloids (albumin) in early resuscita­
tion in major burns produces an increase in lung water.
During the last 30 years, crystalloid resuscitation was the
main form recommended, to avoid causing lung edema.
Newer data on the use of albumin, plasma, and hetastarch
in early resuscitation have shown no increase in lung edema
and support the use of colloids after 12 hours.80,81
Hypertonic saline
Hypertonic solutions can rapidly restore plasma volume.
The volume needed for resuscitation during the first 8–24
hours is much less than estimated by the Parkland Formula.82
In the 1970s, mild to moderate hypertonic solutions were
investigated.83 In the 1990s, new hypertonic–hyperoncotic
solutions (7.5% NaCl with dextran or with HES) were
used for ‘small-volume resuscitation’.84 Because the relative
volume effect of hypertonic saline dextran (HSD) is 8.5
times that of RL,85 it rapidly improves hemodynamics, as
seen in a sheep model with 40% TBSA.86 In addition, hyper­
tonic saline tends to moderate the upregulation of leuko­
cytes and adhesion molecules, and may lower microvascular
permeability.87
The first use of hypertonic solutions in major burns, using
very high doses, led to renal failure and increased mortality.88
In traumatic shock, 4–8 mL/kg of HSD or Hyperhes is
usually delivered as a bolus. However, for major burns,
administration of a limit of 8–10 mL/kg over 2–4 hours86
seems safer and causes prolonged volume expansion. It also
has logistic advantages in an evacuation center or staging
area, where large volumes are not available.89 Small-volume
resuscitation solutions (HSD, Hyperhes) must be supple­
mented with isotonic fluids (with the aim of having a urinary
output of 0.5–1 mL/kg). Because of the danger of hyperos­
molarity (Na >160 mVal/L) and renal failure, they cannot be
recommended for routine use in major burns.
Oral fluid replacement
Since the development of formula-based IV resuscitation in
the early 1950s, oral resuscitation in major burns (>15–20%
TBSA) has had no significant effect on early therapy. This is
mainly due to disturbed gastric emptying and impaired peri­
stalsis caused by the burn injury, along with the analgesics
and anesthetics delivered for pain, which have well-known
effects on the intestine.
In the early 1970s, Monafo83 resuscitated a small group of
adults and children with 22–95% TBSA using a 600-mOsmol/L
hypertonic oral solution. In the 1990s, a revival of enteral
fluids in terms of ‘early enteral feeding’90 revealed that, if
feeding began no more than 2 hours post burn, the gastro­
intestinal effects were favorable, and even major burns
could be managed partly or wholly with enteral, rather
than parenteral, feeding.
Today, the main focus is on the World Health Organiza­
tion’s oral resuscitation solution (ORS). This is a powder
solute that is provided in a small packet and is suspended
in water. It contains glucose, sodium, potassium, chloride,
and buffer, having a slightly hypertonic osmolarity of
331 mmol/L. It was first developed to treat the massive loss
of volume and electrolytes accompanying conditions such
as cholera and dysentery.
4 mL. No colloids are infused during the first 24 hours.
Considerably more fluids must be delivered in the case of
additional inhalation injury, delayed resuscitation, or com­
bined traumatic injuries.
Children usually require more fluid resuscitation than
adults with the same extent and degree of burn injury. Burn
shock may occur with burns 10–20% TBSA.
Children weighing <30 kg should be given maintenance
fluid in addition to the calculated resuscitation fluid73
(Table 5.5 and Table 5.6).
Other, more sophisticated formulas exist.
Mass casualties or disasters make it difficult to provide
fluid resuscitation both at the right time and in sufficient
quantities. For example, a 70-kg patient with a 40% TBSA
needs approximately 6000 mL of RL during the first 8 hours.
Using alternative fluids for resuscitation to reduce early fluid
requirements is very important, because supply is the bot­
tleneck during disasters.
Early use of colloids
Data about using colloids, especially synthetic colloids, in
the early resuscitation of patients with burn shock are rare.
However, new hetastarch solutions, especially the balanced
solutions (6% HES 130/0.42), are widely used in Europe as
a rescue solution when resuscitation with RL fails.74 Both the
rapid metabolism and the milder disruption of kidney func­
tion offer a better safety profile than those seen with the
older, more highly substituted types of hetastarch. The rapid
metabolism is accompanied by a much smaller risk of accu­
mulation in the plasma and tissue (75% less than HES
200/0.5),75 a less negative effect on thromboelastographic
indicators and on activated partial thromboplastin time, as
well as a reduced interaction with factors VIII:C and vWF.76
Kidney function is disrupted less, even after repeated extreme
doses (70 mL/kg/d).77 It is also disrupted less in patients
presenting with mild to severe renal dysfunction.78 There­
fore, in 2005, the European regulatory authorities increased
the maximum daily dose to 50 mL/kg.
The volume-sparing and hemodynamic-stabilizing effect
of colloids, when administered according to the Evans
Formula, the Brooke Formula, and even the early Parkland
Formula, has long been known. In the early 1980s, Goodwin79
Table 5.5  Fluid resuscitation in children
Resuscitation fluid
Modified Parkland Formula
3–4 mL RL/kg/TBSA for the first 24 hours
First half during the first 8 hours; the rest during the next 16 hours
Table 5.6  Fluid maintenance in children
Patient weight
Maintenance fluid: D5RL
Up to 10 kg
100 mL/kg/day
10–20 kg
1000 mL, plus 50 mL/kg/day for each kg over
10 kg
20–30 kg
1500 mL, plus 20mL/kg/day for each kg over 20 kg

Total Burn Care
5
72
With new IO devices access is easily gained, even in adults,
and crystalloid and colloid solutions can be rapidly infused.
Caution should be exercised with hypertonic fluids, as soft-
tissue and bone necrosis can develop.
Physiological monitoring
Several types of monitoring should be carried out:
1. Basic hemodynamic monitoring: heart rate, blood
pressure, and urinary output are fundamental in major
burns. The goal of in-field resuscitation is a heart beat of
<140/min, normal blood pressure, and urinary output
of 0.5–1 mL/kg/h (1–1.5 mL/kg/h in children). After
evacuation to a burn center, the input/output ratio
should be calculated every hour to prevent ‘fluid creep.’
More sophisticated protocols can be implemented.
2. Frequent body temperature measurement.
3. Pulse oximetry if any signs of inhalation injury exist.
Note that COHb and MetHb are not detected by
pulse oximetry, and the measured values for oxygen
saturation may be far too optimistic. For this reason,
arterial blood gas tests should be performed as early as
possible. If possible, 100% O2 should be supplied.
4. Invasive monitoring of unstable patients via arterial
lines, SvO2, Picco, Cardio Q, etc. should begin as soon
as possible to guide fluid resuscitation.
5. Capnography for intubated patients is desirable.
6. Relaxation monitoring: train-of-four test.
7. Laboratory tests, including, at minimum, blood cell
count, platelets, coagulation, electrolytes, and basic
renal parameters.
Devices for in-field monitoring are small and robust,
having an extended battery capacity and a display exhibiting
many digital data and curves that cover almost all important
critical care parameters. In civilian hospitals they are used as
transport monitors for critical care patients. The smallest
monitors (e.g., the Philips IntelliVue MMS X2) weigh no
more than 1.2 kg.
Airway management
CO and cyanide intoxication, head and neck burns, circum­
ferential third-degree burns of the thorax and abdomen, as
well as inhalation injury can all rapidly endanger the lives
of burn victims. Intubation is often the only way to secure
airways and hence oxygenation and ventilation. Because
burn edema increases over the first 24–48 hours, patients at
risk are normally intubated early, sometimes even prophy­
lactically. In burn disasters oxygen and ventilators are often
scarce, increasing the importance of correctly identifying
patients needing oxygen or intubation.
CO intoxication
CO has a 200 times higher affinity for hemoglobin than
oxygen. It displaces O2 and shifts the oxygen–hemoglobin
dissociation curve to the left, impairing tissue oxygenation.
Early symptoms such as headache occur at COHb levels of
15–20%, followed by dizziness, confusion, and agitation.
Having COHb levels >50–70% for a longer period is lethal.
In this case, immediate O2 is mandatory, as it markedly
reduces the half-life of COHb.
Thomas89 demonstrated that, by placing a feeding catheter
in the intestine of 40%-TBSA anesthetized pigs, these animals
could be resuscitated with the WHO ORS according to
the Parkland Formula. Michell91 reported similar results.
El-Sonbathy92 reported good results using the WHO ORS for
oral resuscitation of children with 10–20% TBSA.
Without a gastrointestinal catheter, greater volumes of oral
resuscitation fluids may be necessary because gastric empty­
ing may be delayed. More research into both the ideal enteral
fluid and the quantities to administer is necessary. However,
in disasters with IV fluid shortages, oral rehydration solu­
tions may have a role in early burn resuscitation. Such solu­
tions include the WHO ORS, or, if this is not available, 5.5 g
of an undissolved salt tablet can be swallowed with 1 L of
water as reported by Sorenson,93 1 L of water with 1 tea­
spoon of salt (or 0.5 teaspoon of salt and 0.5 teaspoon of
baking soda) and eight teaspoons of sugar as reported by
Cancio,94 or 1 L of RL with eight teaspoons of sugar, which
is available everywhere and is easy to transport.
Conclusion
A staged approach has been set forth for fluid resuscitation
in the military, as reported by Thomas.89 A similar process
should be outlined for civilian mass casualty incidents:
•
Patients with <20% TBSA and no immediate need
for intubation could be resuscitated orally or by
nasogastric tube (NGT) with the WHO ORS or a
similar solution (500-mL bolus with one packet of
rehydration solution) and then subjected to bolus
feeding of 2–4 mL/kg every 20 minutes. This should
maximize gastric emptying.
•
Patients with 20–50% TBSA and no immediate need
for intubation could benefit from administration of 1
or 2 HSD or Hyperhes units (250–500 mL) over 2–4
hours, combined with enteral resuscitation with WHO
ORS and/or IV RL administered with the goal of a
stable macro-hemodynamic and urinary output of
0.5–1 mL/kg/h.
•
Patients with >50% TBSA and inhalation injury,
combined injuries, etc. often require intubation, so IV
fluid resuscitation should begin as soon as possible.
The fluid requirements estimated by the Parkland and
Modified Brooke formulas can be reduced during the
first 24 hours by administration of hypertonic saline
and colloids, as discussed above.
The importance of beginning fluid resuscitation as early as
possible, using just what is to hand, must be emphasized.
Moreover, because hypothermia is among the greatest threats
in the early course of major burns, fluids should be warmed
whenever possible.
Venous access
Early venous access with two or more 14- or 16-gauge IV
lines should be obtained immediately. If this is not feasible,
other options should be considered:
•
Central veins
•
Intraosseous (IO) access
•
Surgical cutdown.