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S. F. Oluwole and O. O. Oluwole
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How toProvide Acute Burn Care
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inLow- andMiddle-Income
Countries
CameronGibson, MeghanHoyle,
andJamesGallagher
Do not worry if others do not understand you. Instead worry if you do not understand
others.
– Confucius
31
Abbreviations
ATLS Advanced Trauma Life Support
GBR Global Burn Registry
HICs High-income countries
LD50 Lethal dose of 50%
LMICs Low- and middle-income countries
LR Lactated Ringers
TBSA Total body surface area
WHO World Health Organization
C. Gibson (*)
UCHealth Burn and Frostbite Center, University
of Colorado Anschutz Medical Campus,
Aurora, CO, USA
e-mail: cameron.2.gibson@cuanschutz.edu
M. Hoyle
North Colorado Medical Center, Greeley, CO, USA
e-mail: meghan.hoyle@bannerhealth.com
J. Gallagher
William Randolph Hearst Burn Center,
NewYork- Presbyterian Weill Cornell Medical Center,
New York, NY, USA
e-mail: jag9027@med.cornell.edu
Introduction
While the incidence of burns has decreased over the
past few decades in high-income countries (HICs),
burn injury continues to plague low- resource settings. Worldwide, burns represent the fourth most
common type of traumatic injury and are a common
cause of severe disability and death in low- and
middle-income countries (LMICs) [1]. With over
11 million burn injuries and >250,000 deaths annually (>90% of which occurred in LMICs), burns
represent a signicant burden on the healthcare system [2]. The economic impact is also disproportionately severe due to the high incidence of disability
related to even minor neglected burns.
The unfortunate reality is that the true impact
of burn injuries may be underrepresented because
there is a paucity of epidemiological data from
LMICs. In order to address this problem, the
WHO created the Global Burn Registry (GBR) in
2018 which collects burn data using a standardized form on a publicly available platform.
Utilization of the GBR has been sporadic with
LMICs and underrepresented compared to HICs
[3]. Regardless of what platform is used, any
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery,
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C. Gibson et al.
effort to improve burn care in LMICs needs to
begin with an accurate data collection which
should be an integral part of any international
collaborative effort.
Burn care at the local level is likely to be different from one country to another, and even
between different regions of a country. It is
important to realize that the vast majority of
patients will present days, weeks, or even months
after the burn occurred, having cared for the burn
at home using potentially harmful remedies, ointments, and potions. Without a dedicated ward,
which is rare in LMICs, burn patients are often
scattered throughout the medical and surgical
wards rather than cohorted. Nearly all mission
style trips in plastic and reconstructive burn surgery will focus on congenital (cleft lip) or
acquired (contracture) surgical backlog rather
than on hospitalized acute burn patients. In most
underserved areas hospitalized acute burn
patients will t into one of ve groups
(Table31.1).
Table 31.1 Types of burn
patients
The rst group is patients whose burns have
fully re-epithelialized and no longer have any
open wounds, but for some reason have not been
discharged for reasons that may be difcult to
determine. Understanding why they are not discharged can provide valuable insight into the system that is being visited. The second group is
patients with burn injuries who are unlikely to
require surgery for best outcome but need ongoing inpatient care for medical management,
wound care, and/or pain control. The third group
is patients with a surgical need (infected eschar,
chronically granulating wounds or contracture
with or without open wounds, and the rare early
smaller third degree burn, etc.) who are deemed
medically stable for surgery (Fig.31.1). This is
your target surgical group if your outreach
includes acute surgical burn care. The fourth
group is patients who have a surgical need but are
not medically stable or cannot safely undergo
surgery at their stage of healing. The nal group
is patients with a non-survivable burn injury. This
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group can sometimes be difcult to determine
because it is dependent upon the resources available locally, regionally, and nationally. While the
LD50 for burn injuries in HICs is ~65–70%
TBSA, the LD50 can be 30–40% or lower in
LMICs [4]. A common mistake that HIC surgeons make when working in LMICs is to categorize patients into group 3 or 4 who really t
into group 5, or try to apply sound principles of
care used in HICs that may not be available or
safe in LMICs. Having a clear understanding of
Fig. 31.1 Example of a category 3 patient – partially
healed burn wound with healthy granulation tissue ready
for skin grafting
your local resources – what is possible medically/surgically and what is not– will prevent one
from miscategorizing a patient and potentially
causing undue harm.
The work of global surgery can be broadly
grouped into three pillars: clinical care, education, and capacity building. A true “global surgeon” works in all three, although a given trip or
intervention may have a primary focus on only
one or two. Each of these pillars has unique
issues for burn surgeons (Fig.31.2). For instance,
you may determine that the staff at the hospital is
well educated on burn care and has the necessary
basic tools, but the surgical backlog, urgent cases,
and limited OR time are burdening the healthcare
system so much that patients are having to wait
weeks or months to undergo skin grafting or scar
contracture release. In fact, burn reconstructive
surgery alone accounts for almost 50% of surgical backlog cases in LMICs [5]. This backlog has
been the main focus of mission style global outreach programs and, if done well, including
teaching, can help to ease the surgical burden of
the local teams (i.e., “give a man a sh”).
Alternatively, one may nd that the local staff has
only rudimentary knowledge of appropriate burn
care and very limited ability to provide surgical
burn care. Therefore, focus needs to be on education prevention, rst aid, acute burn care, teach
principal skills for basic skin grafting, scar contracture prevention, etc. (i.e., “teach a man to
sh”). Or perhaps the local team in LMIC has the
know-how and simply needs the pre-requisite
tools to start skin grafting, in which case your
focus should be primarily on partnership and on
capacity building (i.e., “give the man a shing
rod so he can ACTUALLY sh”). In each one of
Fig. 31.2 Pillars of the
“Global Burn Surgeon”
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Fig. 31.3 Suggested
topics that should be
included in a needs
assessment survey on
burn care in a specic
country or region.
NSOAP, National
Surgical, Obstetric and
Anesthesia Plan; NGO,
non-governmental
organization; WHO,
World Health
Organization
C. Gibson et al.
these scenarios, asking questions, listening, and
collaborating is critical to determine how best to
help. Decisions on the degree of commitment
going forward, and on how one can integrate and
work together with other surgical disciplines to
elevate the surgical capacity of the community
must be primary goals of the visiting team. Longterm partnership by a visiting organization from a
HIC to help form a stable burn team and burn unit
creates a home for future mission trips and
enables the local burn teams to provide acute
burn care and more fully address the needs of its
current patients.
Preparation
Prior to a visit– whether for burns or any other
specialty, as has been dened in previous chapters – the visiting individual or team need to
determine the extent and nature of planned work.
Is this a one-off medical mission trip or will there
be future trips to the same facility or region? Is
the team’s focus purely clinical or is there an educational component? Have leaders or “local
champions” on the ground been identied that
wish to collaborate with the team? What sort of
follow-up will the patients have once the team
has left? Answering these and many other important questions prior to departure will ensure a
successful and effective visit and, most importantly, that no unintended harm comes to the
healthcare professional or their patients that one
partners to help.
If the team is looking to develop a long-term
collaboration with a health center, it is impor-
tant to start with an assessment of the current
state of burn care in the locality. A needs assessment will help determine the strengths and
weaknesses of the local healthcare system and
guide future interventions. Figure31.3 recommends specic topics that should be addressed
in a needs assessment survey; however this list
represents a minimum that should be included
and recommend tailoring your survey to address
the realities on the ground. Answers to survey
questions as well as interviews with stakeholders (patients, medical staff, local/regional/
national health ofcials) should guide the nature
of your work. Ultimately, any intervention needs
to be driven by local stakeholders as this leads
to enduring change that will be durable beyond
the visits and nancing from outside the host
country.
Prehospital Burn Care
Prevention
Most burns are avoidable accidental injuries, and
the best prehospital treatment for a burn is prevention. Compared to other injuries, burns on
average are more costly, labor-intensive, and
have signicantly longer length of stays. As
countries develop, technology and safety protocols improve, leading to fewer burn injuries. This
is evident in HICs where the incidence of burn
injuries has been decreasing for several decades.
It is strongly recommended that any long-term
intervention or collaboration should include a
prevention outreach component. As the old adage
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goes, “an ounce of prevention is worth a pound of
treatment.”
Burn First Aid
Prehospital care for burn injuries including rst
aid is essential. Done properly it will decrease the
depth of burn injury and lessen infection and the
need for surgery [6]. There are multiple different
burn rst aid courses offered around the world,
each tailored specically for their local environment, but the basic tenets of burn rst aid in any
setting are:
1. Cool the burn with cool running water (preferably for 20mins or more).
2. Remove all jewelry and clothing around the
burned area.
3. Cover the burn with clean cloth or bandage.
4. Administer oral analgesia for pain control.
5. Seek immediate medical advice if the burn is
large (>5% TBSA) or in a sensitive area of the
body (face, hands, feet, genitalia, over major
joints) [7].
Simply providing burn rst aid training somewhere that previously had none can have a huge
impact on the clinical outcome of burn patients.
Additionally, burn rst aid training has been
shown to be long lasting. Even 5 years after
attending a course, attendees’ burn rst aid
knowledge was signicantly better than those
who did not attend [8].
Barriers toCare
Several barriers are likely to be encountered in
providing high-quality, effective prehospital burn
care. One common barrier consists of local
beliefs and practices surrounding burn care.
Whether you are in Boston, Massachusetts, or
Lilongwe, Malawi, society at large often has preconceived notions, developed over many generations prior to the modern era of effective burn
care, about how to care for burns. Oftentimes,
these practices are not helpful (e.g., applying egg,
milk, or butter to a burn wound) and sometimes
can even be harmful (e.g., applying animal dung
or hair as a dressing over a burn wound). These
practices may be long standing, strongly believed
in and practiced by local traditional healers in
some LMICs. It is important to know what is the
local practice and who in the community outside
of the hospital is administering burn care. One is
likely to be more successful with community outreach if the team collaborates with local leaders
and traditional healers. Any community outreach
about burn care should address prevention, rst
aid, and local wound practices. It must be culturally sensitive to the local practices while highlighting important principles of appropriate burn
rst aid and wound care.
Another barrier which is likely to be encountered in the prehospital setting is delays in seeking appropriate burn care. The Lancet
Commission estimates that more than 5 billion
people worldwide do not have access to needed
safe, affordable surgical and anesthesia care [9].
This number is likely equal, if not larger when
considering access to safe, affordable burn care.
This lack of access is multidimensional, not simply bound by geographic proximity to a burn center. Someone may only live 10km away from a
health center but not have the money to pay for
transportation, or they might even live close by
but not have the funds to pay upfront for their
treatment. Using the “Three Delays Framework”–
delay in seeking care, delay in reaching care, and
delay in receiving care– you can imagine how
each delay can affect and exacerbate the other.
One can also use this framework as a tool to better categorize barriers specic to any one area
that delay care and then address them accordingly. Many international organizations concentrate on the third delay – delay in receiving
care– by providing a certain specialty (such as
burn surgery) that may not be present in the community. This model highlights the importance of
having a plan in place to overcome all three forms
of delay in order to be truly effective and successful. Many well-intentioned humanitarian projects
have failed because they focused on one barrier
to care only to uncover another barrier that was
neither foreseen nor budgeted for.
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C. Gibson et al.
Preoperative Management
Preoperative management of the burn injured
patient begins as soon as they arrive at the health
center and progresses in a stepwise fashion. The
rst step is stabilization of the burn injury and
identication of any other traumatic injuries that
could be life-threatening. Developing a regimented approach, such as the one in advanced
trauma life support (ATLS) courses in the United
States (primary survey, secondary survey, then
adjuncts/imaging and tertiary survey), helps the
team to avoid being distracted by the burn injury
when the patient may have other traumatic injuries that are more acute. Once the patient is stabilized, then the burn injury can be properly
addressed.
Unfortunately, most patients in LMICs present days or even weeks after the burn injury
occurred, sometimes even with large burns and
therefore are unable to be immediately resuscitated. Oftentimes, patients present chronically
dehydrated and only after they have developed a
complication related to their burn injury. They
may exhibit signs of local infection of their burn
wound or be frankly septic. They may also have
other underlying undiagnosed medical comorbidities that require acute management before the
burn wound can properly heal or be addressed
surgically.
Fluid Resuscitation
If the patient suffers a burn >15% TBSA and
presents to the health center within hours of the
burn injury, then one can properly resuscitate the
patient using one of several available burn uid
resuscitation formulas. The best known is the
Parkland formula. There are several resuscitation
formulas that have been developed for burn
resuscitation (Table 31.2) [10]. The common
endpoint for all of these formulas is an hourly
urine output of 30–50ml/hr. or 0.5ml/kg/hr. for
adults and 1ml/kg/h for children (<5years old).
The uid of choice in burn resuscitation is
Lactated Ringers (LR) as it is an isotonic solution
with physiologic electrolytes and does not cause
metabolic acidosis like normal saline in large
quantities. If LR is unavailable, however, any iso-
Table 31.2 Fluid
resuscitation formulas
during the rst 24h for
major burns (>20% TBSA)
ABLS Advanced Burn Life Support
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tonic solution will sufce to maintain intravascular volume during burn shock. It is important to
note that these formulas help determine initial
volume resuscitation for the rst 24h, i.e., they
are meant as a guide to begin resuscitation at an
appropriate volume rate. Frequent re-evaluation
of the patient’s urine output during the rst
24–48h is important to conrm that resuscitation
is proceeding according to plan.
Once the patients are ~24–48 h post-injury
and they no longer require large volumes of uid,
they can be transitioned to maintenance uids
such as 0.45% normal saline with or without dextrose. If the patient is not intubated, then oral
intake should be encouraged with the addition of
oral rehydration salts to maintain appropriate
electrolyte balance. If available, a nasogastric
tube should be placed for enteral access in any
burn patient with a TBSA >20% (in children,
>15% TBSA) both for administering enteral uids and for nutrition.
Wound Evaluation
Determining overall burn size and depth is essential to burn resuscitation and all subsequent surgical planning and medical management. The most
common way to estimate burn size is to use the
“Rule of Nines” or a Lund and Browder chart
(Fig.31.4) [11]. It is essential to stress that only
second and third degree burns are included in
TBSA estimates, not rst degree burns.
Alternatively, you can use the Palmar method to
measure burn size (where the patient’s palm and
ngers are equal to 1% TBSA). This is a useful
method for patients with scattered burns on multiple parts of the body, such as scald burns. Burn
depth is much more difcult to assess because the
true extent of injury is often not visible on the
surface for several days. Table31.3 lists common
characteristics of each burn depth from rst to
fourth degree. In general, most second degree
burns will heal with just good wound care, early
Fig. 31.4 “Rule of Nines,” Palmar method, and Lund and Browder chart for burn estimation
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Table 31.3 Evaluation of burn size and depth
C. Gibson et al.
physiotherapy, and time, whereas third degree
burns of any signicant size (>1% TBSA) will
require skin grafting surgery; otherwise, the
wound will take weeks to months to fully heal
and likely develop scar contractures. For burns of
indeterminate depth (i.e., deep second degree
with possible third degree injury), you often have
to wait for them to “declare” themselves, which
generally occurs by post-burn day 5. Once the
true extent of the injury is determined, then you
can begin operative planning if deemed
necessary.
Wound Care
All burn wounds should be appropriately cleaned
with either saline or chlorhexidine and dressed
with a topical antimicrobial to prevent infection
of the wound. There are a plethora of topical
agents available, but likely there are only a few
options available at the local pharmacies near
your health center. Once the burn wound is covered with a topical antimicrobial, then you must
decide what type of dressing to use. These can be
separated into two broad categories: the exposure or “open” method and the occlusive dressing or “closed” method. The “open” method
consists of leaving the burn wound open to air
and not letting anything except for a topical antimicrobial or possibly vaseline gauze come in
contact with the wound. The wound will weep
and a dry eschar will form over top, acting as an
occlusive dressing until new skin grows underneath (if it is second degree). The patient may
have a metal cage placed over them that is then
covered with clean cloth in order to maintain an
ambient temperature for the patient. This method
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is still commonly used in LMICs because it is
simple, is low-cost, and takes signicantly less
time and personnel to manage. The trade-off is
that patients remain on bedrest until their wounds
fully heal and therefore cannot participate in
physiotherapy. There also is a theoretical
increased infection risk (although not proven in
studies) because the eschar that develops can just
as easily trap bacteria underneath rather than
keeping them out.
The occlusive dressing or “closed” method is
what is practiced almost exclusively in HIC burn
centers. It comprises a primary non-adherent
dressing that is placed over the wound after the
topical antimicrobial is applied, followed by a
secondary absorbent layer of coarse mesh gauze
+/− cotton. This dressing can be left in place for
2–3days unless it becomes saturated with wound
exudate, then it must be changed more frequently. If done well, this method is preferable
since patients are not conned to their bed and
can participate in physiotherapy. The downside
to the “closed” method is that it is more expensive, more labor intensive, and if done improperly can lead to infection and possibly convert a
partial thickness burn into a full thickness one.
Whatever wound care method is chosen, one
must always keep in mind the local practices and
capabilities.
Since many patients present in a delayed fashion, their burn wounds often have the appearance
of being infected. They may present with a crusty
wound that is draining “pus.” If the wound is large,
the patient may exhibit systemic signs and symptoms that mirror sepsis (e.g., tachycardia, fever,
leukocytosis). Additionally, it can be difcult to
discern between burn wound erythema, which is a
normal physiologic response versus early cellulitis. In general, if the burn occurred within the past
24hours, then it is highly unlikely to be infected
and only requires topical antimicrobials. If it has
been longer than 24hours, then the probability of
infection increases signicantly and a short course
of IV antibiotics would be prudent. If after several
days of proper cleaning and wound care the
appearance of the burn wound improves, then IV
antibiotics can be discontinued.
Nutrition
Equally as important as good wound care is
proper nutrition support. Without adequate nutritional intake, a partial thickness burn wound can
convert to full thickness and wound healing will
be stunted. An initial nutritional assessment
should be done when the patient is admitted; they
should be weighed at least weekly. For patients
with burns <10% TBSA no signicant changes
need to be made to their diet, unless they were
malnourished before the injury. Patients with
large burns (>15% TBSA) have a hypermetabolic
response to the injury that increases their resting
energy expenditure 1.5–2 times above normal
[10]. There are multiple formulas that have been
developed to estimate caloric requirements for
burn patients, ranging from complex to nearly
impossible to use without a calculator. The
following simple formulas can be used to estimate your patient’s daily caloric need:
Adults: 20kcal/kg+70kcal/% TBSA burn; pro-
tein 1.5–2g/kg.
Children: 60 kcal/kg + 35 kcal/% TBSA burn;
protein 2.5–4g/kg [12, 13].
The overall composition of macronutrients
should be approximately 50–60% carbohydrates,
30% protein, and 10% fats. Patients should be
encouraged to eat calorie-rich foods, such as eggs,
milk, legumes, and groundnuts. Oftentimes the family has to provide the patient’s food so educating the
family on appropriate foodstuffs is critical. If their
caloric needs are greater than they can consume, it
can be supplemented with tube feeds (if tubes are
available) that the kitchen prepares with a blender. If
a blender is not available, then you can give liquid
calories such as milk, eggs, oil, and dissolved sugar.
Operative Planning andManagement
Timing ofSurgery
The vast majority of burn patients will heal without the need for surgery if they receive good
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