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Chapter 6
Burn Wound
Management
PaigeJ.South, DeepakK.Ozhathil, AminaEl Ayadi ,
andStevenE.Wolf
Introduction
Burn care was first described 3500years ago in ancient cave
paintings. From topical therapies to wound dressings, burn
care has since then significantly advanced. The Edwin Smith
Papyrus from 1600BC Egypt advocated the use of resin and
honey salve for treating burns, and the ancient Chinese
treated burn wounds with extracts from tea leaves in 600BC
[1]. In 400BC, Hippocrates described the use of bulky dressings impregnated with rendered pig fat and resin with alternating warm vinegar soaks, augmented with tanning solutions
made from oak bark [1]. The Arabian physician Muhammad
ibn Zakariya al-Razi established the first description of first
aid for burns in 854AD, recommending cold water for pain
relief from burns [2]. The treatment of topical ointment for
burns was described as an old Calcarea blended with plant oil
or pig fat cooked with willow bark by Hong Ge in 300AD [1].
Ambroise Paré treated burns with onions in the middle of the
sixteenth century and was the first to describe early burn
P. J. South · D. K. Ozhathil · A. El Ayadi · S. E. Wolf (*)
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
e-mail: pjsouth@utmb.edu; amelayad@UTMB.EDU;
swolf@UTMB.EDU
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_6
167
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P. J. South et al.
wound excision. Through these discoveries and many more,
burn care success rates have improved over the years.
Between 1942 and 1952, shock, sepsis, and multiorgan failure
with burns covering 50% of children’s total body surface area
(TBSA) caused a 50% mortality [3]. Currently, a burn covering more than 95% TBSA in children can survive in more
than 50% of cases [4]. The initial care and management of
burn injuries have a significant impact on the lasting outcomes, healing, appearance, and function. This chapter seeks
to describe modern burn wound management for non-burn
specialists.
Skin Anatomy
Understanding the basics of skin anatomy and physiology is
necessary to recognize the effect and proper treatment of
burn wounds. The skin is the largest organ of the body and
serves to maintain nutrients, regulate water and temperature,
and protect against pathogens, mechanical injuries, and ultraviolet light. This organ is composed of three layers: the epidermis, dermis, and hypodermis.
The epidermis maintains hydration and prevents entry of
virulent microorganisms, consisting of five layers: stratum
basale, stratum spinosum, stratum granulosum, stratum
lucidum, and stratum corneum. The deepest portion of the
epidermis, the stratum basale, is the proliferative portion producing keratinocytes and melanocytes. The dermis provides
structural toughness to the skin; it consists of collagen and
extracellular matrix, blood vessels, hair follicles, sensory
neurons, arrector pili muscles, sweat glands, and lymphatic
vessels. The dermis contains two layers, the papillary layer
(upper, thinner layer) and the reticular layer (deeper, thicker
layer). Also known as the subcutaneous fascia, the hypodermis is the deepest layer of the skin and serves to anchor the
dermal and epidermal layers.
Burn wound management should be tailored to the type
and severity of the burn. Partial-thickness burns are defined
Chapter 6. Burn Wound Management
as skin loss involving the epidermis and part of the dermis.
This may appear as a blister, abrasion, or a shallow crater [5].
Contrarily, full-thickness burns affect the epidermis, dermis,
and sometimes, may extend to the subcutaneous tissue. The
importance of proper burn classification is paramount to precise management and treatment of the wound.
During wound healing, four biological phases transpire:
vasoconstriction and hemostasis phase, inflammatory phase,
proliferative phase, and remodeling phase. The initial hemostasis phase occurs about 10 min after the introduction of
thermal insult. Here, the outpouring of lymphatic fluid and
blood activates the immune system [6]. Occurring 1–3 days
after burn, the inflammatory phase usually lasts several days
and can be divided into two stages [7]. The early stage is characterized by hemostasis and chemotaxis phase, triggering the
release of cytokines and neutrophil infiltration into the
wound bed. The late phase occurs as monocytes differentiate
into macrophages, removing bacteria and pathogens from the
wound site, resulting in erythema, swelling, and pain. The
proliferation phase is characterized by two steps in wound
repair: angiogenesis and re-epithelization. This phase occurs
3–10days following the injury and results in granulation tissue if inadequate keratinocytes are present. The final phase of
wound healing is the remodeling or maturation phase. This
process begins 3weeks after the injury and may continue for
up to a year. Here, collagen is produced and remodeled while
the excess collagen, inflammatory cells, and keratinocytes are
removed by apoptosis, thus increasing the strength of the skin
surrounding the wound.
169
Care Algorithm
The initial assessment and treatment of burn injuries are vital
to the healing of the wound. According to the World Health
Organization (WHO), “the first six hours following the injury
are critical” [8]. Prior to the assessment, first aid should be
considered by removing all burned clothing and irrigation of
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P. J. South et al.
the wounds with room temperature water to cool the burn for
up to 20min.
Minor Burns Treatment
Although burns occur frequently, the majority of these injuries are minor, involving a small surface area. Therefore, successful burn management can result from an outpatient visit.
A typical burn outpatient visit will include assessment for
infection, cleaning the wound, providing wound care instructions, and consideration for systemic antibiotics.
During wound cleaning, every effort should be taken to
cleanse the wound with soap and water. For any blisters
that are present, these can be left intact to minimize pain,
but can be unroofed if extensive. The burn is then further
cleaned using a mild water-based antiseptic such as
chlorhexidine solution [8]. A thin layer of antimicrobial
agents such as silver sulfadiazine, bacitracin zinc, or polymyxin B sulfate/bacitracin zinc may be applied. An outer
dressing should then be applied. Several other options are
available for wrapping the burn wound such as dressing the
burn with petroleum gauze with or without antibiotics and
dry gauze [8] or using a simple gauze dressing impregnated
with paraffin followed by a gauze pad over the dressing [9].
Depending on the type of topical agents used, frequency of
dressing change may vary with different agents. Regardless,
the dressing should be inspected and changed at least every
24h or as necessary. Alternatively, one of the many silvercontaining dressings may be applied. The benefit of these
dressings is that these need to be changed only every
4–7days in most cases.
Regardless of the initial dressing method, it is important to
properly instruct patients on wound/dressing monitoring to
have a successful healing process. During each dressing
change, wounds should be inspected for any signs of infection
such as discoloration or cellulitis. Patients may be referred for
surgery if the burn has not healed in 2weeks.
Chapter 6. Burn Wound Management
171
Hospital Admission forMinor Burns
Admission to the hospital due to a burn that involves less
than 10% TBSA may result from three reasons: pain control,
additional injuries that require transfer to a specialist, or consideration for excision and grafting. At times, patients with
recently sustained burns experience significant pain.
Intravenous or oral opioids will be beneficial for pain control
in addition to mild analgesics [10].
Although the burn may involve less than 20% TBSA,
deeper partial-thickness burns may benefit from excision and
grafting. Topical antibiotic ointments such as bacitracin zinc
or polysporin B sulfate/bacitracin zinc can be tried initially.
This conservative treatment allows time for the wounds to
heal on their own [11]. If the wounds are not healing appropriately in this manner, surgery may be the best option.
Although these burns may appear minor, it is best to take
precautions as some may require transfer to a burn center.
According to the American Burn Association (ABA), burns
that involve any special region (face, hands, feet, genitalia,
perineum, or major joints); electrical burns; chemical burns;
burn injuries in patients with preexisting medical disorders;
partial-thickness burns greater than 10% TBSA; full- thickness
burns; inhalation injury; and any burn injury that contributes
to higher risk of morbidity or mortality should be referred for
transfer to a specialized burn center. A burn center will be
able to ensure proper healing and provide necessary resources
specialized for each patient.
Major Burns Treatment
Patients with burns involving more than 10% TBSA are at
risk for hypovolemia associated with edema development
and invasive burn wound infection and sepsis. Such persons
should be hospitalized. Major burn significantly disrupts the
skin barrier, which can result in an infection entering the
bloodstream, and development of an overwhelming inflam-
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P. J. South et al.
matory response. Common indications that burn sepsis has
occurred are high fever, low platelet count, decreased urine
output, and hemodynamic instability [12].
When a patient with a major burn is admitted, treatment
of shock, airway injuries, and additional trauma take precedence over management of the burn wound [13]. The first
hours of treatment for the burn injury are the most critical
for survival and proper healing. Any burn that is greater
than 20% TBSA in adults and greater than 10% TBSA in
children is considered serious and requires airway maintenance, cardiac monitoring, and fluid resuscitation as early
as possible.
Escharotomy andWound Care
Any patient with full-thickness and deep partial-thickness
circumferential burns of the chest or limbs should be
assessed for escharotomy prior to transfer to a burn center
[14]. Circumferential burns and the resulting eschar of
extremity and torso can create circulatory and pulmonary
complications due to loss of normal elasticity of the skin
and generalized edema formation that result in compression of the underlying tissues. Compartment syndromes
may result in the extremities and abdomen from circumferential burns [15]. Escharotomy will relieve this eschar
effect, prevent further injury, and restore proper
circulation.
An escharotomy is performed by creating an incision
through burned eschar and into subcutaneous tissues at lateral and medial aspects of extremities, and along axillary lines
in the chest. Other signs that indicate a need for escharotomy
are numbness and decreased oxygen saturation of digits. Due
to the inflexibility of eschar, the abdominal wall and chest
have movement restrictions [16, 17]. In fact, infants under
12 months experience a predominant abdominal breathing
Chapter 6. Burn Wound Management
F . Escharotomy sites for incision. Incision location-specific
to extremities and thorax [18]
173
pattern, leaving a splinting effect on the diaphragm. Therefore,
any resulting compromised respiration benefits from escharotomy [14].
Escharotomy may be performed at the bedside. The upper
limbs should be placed in a supine position and lower limbs
in a neutral position. When making an incision in the limbs,
electrocautery should be used along the medial and lateral
mid-axial line bilaterally. In the chest wall and abdominal
wall, incisions are made along the mid-axillary lines (Fig.6.1).
Across the abdomen and chest, these lines may be joined by
a transverse elliptical incision. Residual restrictive areas may
then be assessed by running a finger along the incision. The
first 72h following escharotomy are the most crucial due to
possible risks of bleeding or incomplete releases [14]. For this
reason, monitoring limb circulation and ventilator pressure
are necessary.
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Major burn patients do not usually benefit from local
wound treatment if they are in the process of transfer to a
burn center where a more extensive assessment will take
place. Therefore, dry dressing can be applied. In the case that
transfer is not available within 12h, the burn wound should
be kept covered with application of antimicrobial ointment.
Burn Surgery
Burn Excision
Burn excision and grafting begin by removing all non-viable
tissue. Blisters should be unroofed and any non-viable tissue
excised. Early excision has proven beneficial in many aspects.
Removing all damaged tissue has been shown to decrease the
length of hospital stay, morbidity, mortality, bacterial colonization, and healing time [19–25].
Burn eschar can be surgically removed in three ways: tangential excision, fascial excision, or amputation. Regardless of
the method used for burn excision, all excisions should begin
after the patient is hemodynamically normal and has surpassed the acute stage. This is usually accomplished within
the first 72h of injury to prevent sepsis, bacterial contamination, and graft failure. Tangential excision is the most commonly used technique. Here, all burned tissue is removed
while viable tissue is preserved. This technique produces
better-preserved contours and reduces hospital length of stay.
Although tangential excision generates significant blood loss,
tourniquets and other techniques may be used to assist in the
reduction of blood loss.
On the other hand, fascial excision is a more rapid method
that results in less blood loss. This method is carried out for
full-thickness burns, life-threatening burn wounds, and invasive burn wound sepsis. Unlike tangential excision, fascial
excision often leads to significant contour defects and the
development of lymphedema [26]. Lastly, amputation may be
utilized for deep burns in unsalvageable limbs typically asso-
Chapter 6. Burn Wound Management
ciated with electrical injuries. Although many excisional techniques are available, special considerations and measures
should be taken into account for long-term function and
cosmesis.
175
Skin Grafting
Once necrotic tissue has been removed, a donor site is
selected for the procurement of normal skin that will be
transplanted to cover the prepared wound bed. Early grafting
may be practiced via several methods and is divided into two
main categories: skin replacements and skin substitutes. Skin
replacements, such as autografts, are the result of biological
skin application onto the burn wound. Skin substitutes, however, are temporary wound coverings made from a mixture of
biomaterial tissues. As an alternative for autograft skin, skin
substitutes include options such as allografts and xenografts.
Autograft Skin
An autograft skin is a permanent burn wound covering. This
ideal wound coverage is achieved by only using the epidermis and superficial layer of the dermis, minimizing the dermal component of donor skin. Autograft skin comes in two
forms: split-thickness skin graft or full-thickness skin graft.
Split- thickness skin grafts involve the epidermis and superficial layer of the dermis and are usually used to treat
extremity and torso burns. Because the epidermal appendages remain intact, donor site may be re-procured after
healing. To expand the donor skin, skin is often meshed to
increase coverage area by cutting slits into the skin graft
with a number of instruments available for meshing. On the
other hand, full- thickness skin grafts are procured from the
full layer of skin. Characterized with limited stretch, less
propensity for contracture and scarring, full-thickness skin
grafts tend to be associated with higher failure due to their
thicker dermis layer.
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Skin Substitutes
Clean partial-thickness burn wounds are usually covered with
skin substitutes such as an allograft, xenograft, or synthetic
material. A variety of skin substitutes are available as each
type of skin substitutes serves a different purpose.
Allograft Skin
Allograft skin is used as a temporary, biological dressing to
cover the wound when autograft skin is not feasible or due to
lack of available donor sites. While awaiting an autograft
donor skin between procurement, allograft skin temporarily
closes the wounds. Once donor sites are available for procurement, the temporary biological dressing is removed. This
use of an allograft skin not only covers the wound, but also
decreases wound size, decreases infection, and reduces pain.
Allograft skin is more effective compared to other skin substitutes due to their versatility and immune characteristics as
these become vascularized before ultimate rejection. On
occasion, allograft skin is placed onto widely meshed autograft skin to protect and close the wound as the autograft skin
underneath heals the interstices, known as the Alexander
technique.
Other Skin Substitutes
A xenograft skin is a skin substitute where the skin is
removed from another species. A xenograft skin is a costeffective method for temporary wound coverage when compared to an allograft skin. Synthetic skin substitutes are
made from a mixture of non- biological molecules such as
bovine collagen, synthetic element, allograft, and porcine
dermis [27]. Not present in normal skin, the non-biological
components in synthetic skin substitutes are associated with
a higher infection rate compared to autograft skin [27].
However, the materials used provide a stable, biodegradable
temporary wound coverage that is mostly beneficial for
major burns.
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