Acute Burns


The treatment of Burns is a subject on which many books and articles have been written and perhaps more numerous remedies recommended than in any branch of Surgery. The success has been achieved due to very different and even opposite modes of treatment, which shows that the authors must either be misrepresenting the facts or speaking about different matters. The latter explanation being true as the essential question in the treatment of the burns other than the surface area is “the depth or degree, and the consequent sloughing, ulceration or mere inflammation”. This makes it clear that there is still no single ‘best treatment’ for Burns. To make the best of modern materials and techniques, the doctor must be able to choose the method of treatment most suitable for the individual patient under the particular circumstances.

Burn Shock At the surface of the burn the skin is actually destroyed by the heat, but immediately underneath this, the deeper layers of skin and the subcutaneous tissues are severely affected by the heat, but still viable. In these layers the main changes are in the capillaries which become widely dilated with greatly increased permeability. The fluid is rapidly lost from the plasma into the extracellular space at the site of Burns. The lost fluid appears as Blister if the skin is intact, or as an exudate if the outer layers of skin are lost. When the fluid is lost into subcutaneous tissue it causes oedematous swelling. The fluid lost contains electrolytes as much as in plasma, but protein content varies from 50% to 80%of plasma. The loss of fluid continues at a rapid rate for some hours, and then gradually decreases over the course of one to two days as the capillaries recover their tone and permeability. A number of red blood cells are either actually destroyed by the heat at the time of burns or are rendered abnormally fragile, and then are removed by the reticuloendothelial system.

In the clinical case studies it has been observed that adults with less than 15% and children with less than 10% Burns can be treated simply by administration of extra fluid by mouth. With burns larger than this sizes, intravenous fluid should be started as soon as possible, and continued until the danger of shock is over. The aim is to maintain the blood volume at a sufficient level to ensure an adequate blood supply to the vital organs and particularly to the viscera.

The signs which indicate the state of circulation are :

  • Presence or absence of restlessness.
  • Colour of skin.
  • Body temperature.
  • Pulse rate and blood pressure.
  • C.V.P. ( Central Venous Pressure ).
  • Urine output - volume and concentration.
  • Haematocrit ( P.C.V. ).


Resuscitation Formulae ( Modified Brooke ) The formulae which acts as a guide to determine the quantity and type of fluid required to be infused as described by Brooke and modified is : Day 1 ( first 24 hr. ) Ringer’s Lactate 3 ml. / kg. / % burn
1/2 total in first 8 hr.from time of burn
1/4 total in next 8 hr.
1/4 total in last 8 hr.
Day 2 ( 24 to 48 hr.) Colloids i.e. Plasma, Blood, Dextran - 0.5 ml. / kg. / % burn
Add 5% dextrose sufficient to maintain urine output.

Estimation of the surface area Weight of the patient is either actually measured or an estimate is made of the same. While the percentage of burns is determined by the rule of nine as advised by Wallace (1951) and is recommended for routine use. This does not give very accurate estimation of the area involved but is most practical and again easy to remember

Inhalation Injury : Diagnosis and Treatment Smoke inhalation is one of the two most important causes of death the other being Septicemia. The injury may manifest itself early or late. There may be injury to the airway as a result of hot air or smoke, which causes laryngeal oedema and spasm. In patient with burns of head and neck , findings of soot in the mouth, burned nasal hairs (vibrissae), or intraoral burns are suggestive of inhalation. Inhalation injury if supraglottic in location, is a progressive phenomenon and there is an indication for either intubation or tracheostomy at the earliest.

Other complications which may manifest and need constant monitoring and immediate treatment are, disturbances of electrolytes, massive red cell destruction, renal failure, gastric and duodenal ulceration, or shock lung (A.R.D.S.).

Hopeless cases The facilities available for the treatment of burns shock make it possible for almost all patients, no matter how severe their injuries are, to survive through the shock period. In the present state of our knowledge, however, patients with burns above a critical size invariably succumb to death after having lived in great pain and misery for a few days to some weeks due to complication beyond control. The doctor in charge will sometimes be faced with a situation where the age of the patient and the size of his burns put him in the category where recovery is unknown (Fig.2 ). The question must then be asked whether it is more humane to give only symptomatic treatment and to make the patient as comfortable as possible, while awaiting the inevitable end, than to persevere with resuscitation regardless of the outcome.

Local treatment of the burn wound The very number of different treatments available is a sure indication that no one method has any clear advantage over the other or is universally applicable. For all practical purpose the fate of an area of burned skin depends upon the depth of skin destruction at the time of injury.

Clinical diagnosis of depth of Burns When patient is first seen an attempt is made to assess the depth of the burn in terms of partial or full thickness destruction. This is sometimes easy, but often very difficult. The appearance of the burn usually allows at least a tentative assessment except when there is mottled red and white appearance with loss of the superficial layers of the skin. Presence of sensation (touch is unsuitable but pain on pricking) is a valuable evidence of the existence of a viable layer of the skin since the sensory end-organs are concentrated in the skin.

Partial skin thickness burn If infection can be prevented these will heal spontaneously. Bacterial infection can seriously interfere with the healing and may convert a partial thickness burn into a full thickness burn. An important distinction must be made between :

  • Superficial partial thickness burn which will heal leaving no scarring.
  • Deep partial thickness burn which will heal but may do so with scarring

Full skin thickness burn In the ordinary course of events the destroyed skin will separate as a slough leaving a raw wound. It is the infection of this raw area which is the main cause of serious illness, septicemia, toxemia and death. If it heals with out grafting the fibrosis which develops in this raw area is responsible for the hypertrophic scars, contractures and deformities of burns. The aim of the treatment therefore is :

  • To get rid of the destroyed skin as quickly as possible and,
  • To get the raw area healed by skin grafting.

Bacterial infection In spite of the improvement in availability of different antibiotics, bacterial infection of the wound is still the single most important problem in the treatment of burns patients. The large raw surface with its exudate of serum is like a huge culture plate on which organisms can multiply, little affected by the body defense mechanism. Some degree of bacterial contamination of the surface is almost inevitable, but is not necessarily incompatible with satisfactory healing if the body defense can match the virulence of the organisms.

The infection can cause trouble in the following ways :

  • Local healing may be delayed.
  • Viable epithelial cells may get killed and partial thickness defect may be converted into full thickness defect, “take” of the graft may be jeopardized
  • Bacterial toxins may be absorbed causing Toxaemia
  • Bacteria may invade deeper tissues causing Cellulitis and
  • Bacteria may gain entry to the blood stream causing Septicaemia

Functions of burn wound covering

  • Permit normal healing
  • Suppress pathogens
  • Debride surfaces
  • Serve as skin temporarily
  • Serve as skin permanently


Conservative treatment directed towards the prevention of infection

  • Exposure treatment
  • Treatment by dressing


Exposure treatment is the most ‘natural’ method where the burned part, after being cleaned, is left exposed to the air with no covering. The exudate dries and with the layers of dead skin forms a scab (eschar). This scab now protects the underlying tissues from contamination and healing can progress beneath it. There is, of course, no mechanical barrier to infection. under ordinary ward conditions some degree of bacterial contamination is inevitable, but under the conditions of successful exposure the activity of these organisms is so limited that the body defense can deal with them, and healing can take place. Once a satisfactory scab has formed it is inspected every day to look for signs of infection or inflammation.

This mode of treatment is particularly suitable for :

  • Single surface burns of trunk or limb.
  • Burns of Face.
  • Burns near perineum.
  • Extensive and complicated burns which cannot be adequately dressed.


The purpose of treatment by dressings is :

  • To provide mechanical barrier to avoid contamination.
  • To absorb fluid exudate.
  • To act as a vehicle for antibacterial substances.


The quality of a satisfactory absorptive dressing is that it can absorb an adequate amount of fluid and distribute the fluid evenly throughout its substance. The inner most layer will contain an antiseptic which is non-adherent so as to reduce pain and tissue trauma during dressing changes. The outer layer should be porous to allow evaporation of water.

The purpose of an antiseptic in the dressing is to control any multiplication of organisms on the surface of the burn, to prevent ingress of new organism from the exterior and also to reduce dissemination of patient’s own organism into the environment.
Many different antiseptic preparations are available but the ones used routinely are Silver Sulfadiazine, Chlorhexidine, Povidone-iodine, Soframycin, Neosporin, and Eusol.

Silver Sulfadiazine in a cream base is the most widely used antiseptic at the present moment. The main disadvantage being that it alters the appearance of the surface of the burns which often looks unhealthy even when progress is good and hence assesment of depth becomes difficult. Chlorhexidine is active against Gram-positive but not Gram-negative organism and hence mainly used in combination with Silver Sulfadiazine. Neosporin and Soframycin may be used for superficial burns while Eusol may be used to chemically deslough the eschar.

The first dressing should be applied as soon as the patient’s general condition is satisfactory. The burn is cleaned with Cetrimide. All loose skin is debrided and blisters are snipped, the fluid is evacuated and overlying skin is removed. The area is then covered with antiseptic, four layers of gauze, gamgee rolls, and secured by bandage.

The dressings are inspected every day to observe if exudates have soaked through to the outer surface which may only be changed if needed. The dressing is entirely changed at the end of three days and thereafter as often as required and also as per further plan of management. Dressings may need to be changed more frequently if there are any signs of inflammation or infection i.e. pain, fever, smell. If burns are being treated by Silver Sulfadiazine then dressings are changed daily for first three days and later on alternate days. Some degree of bacterial contamination almost always takes place, but if all is well the burn will then become dry and look clean and healthy. However if clinical infection occurs, the discharge becomes wet and purulent with foul smell, burn eschar may turn black and there is redness/erythema at the margin. The dressings should be continued until all slough has separated and the surface is either healed or presents red granulation and is ready to be covered by skin graft. Bacterial swabs are taken on admission, and later twice a week or at least three days before any proposed surgical procedure.

Systemic antibiotics Systemic antibiotics are of great value in the treatment of bacterial invasion of the soft tissues and of the blood stream but it is observed that it fails to prevent bacterial invasion when administered prophylactically. Patients with extensive burns are given antibiotics by injections in large doses for the first few days to make certain that the wound does not get colonised with beta-haemolytic streptococcus. In the later phase antibiotic therapy is guided by the routine culture reports and clinical signs of infection.

Grafting When the slough has separated and healthy granulation, which is characterised by bright red, firm and flat surface with minimal discharge, have been obtained, skin grafts should be applied to obtain quick epithelialization of the raw wound. The grafts are usually thin split skin (Thiersch) cut from any suitable uninjured part of the body. They are harvested with either Humby’s knife or Electric dermatome. The advantage with Electric dermatome is that it can cut good grafts with uniform width and thickness rapidly even from difficult area. Grafts may be applied in long strips, in ‘postage stamp’ size or expanded with mesher before covering over large area. The grafts are covered by dressing of non-adherent tulle as innermost layer followed by layers of gauze, gamgee and crepe bandage. In extensive burns with limited donor area a second crop of grafts may be harvested from the same site once it has healed. Excess grafts may be stored under refrigeration at +4 degree centigrade for up to two to three weeks or at -4 degree centigrade in a skin bank as long as three months.

Early excision and grafting The program outlined earlier of conservative treatment to prevent infection, wet dressings to deslough and later grafting is a well tried routine and gives good result in many cases under ordinary circumstances. However it is possible to shorten the mortality and morbidity of orthodox method by surgical tangential excision of dead skin and cover by immediate grafting. The excision is performed at the earliest convenient time during the Golden period i.e. after the shock period and before infection sets in. This method is most suited for full thickness burns of less then 10%, moderately extensive deep dermal to full thickness burns, and extensive life-threatening burns.

General Care If a patient with extensive burns is to be kept in good shape to withstand the prolonged illness with one or more severe operations, his general condition must be carefully attended to.
The negative nitrogen balance can result in weight loss, debility, anaemia, hypoproteinemia, pressure sores and a greatly enhanced risk of death from sepsis. The healing process is retarded, epithelialisation may stop, skin grafts fail to take, immune mechanism is suspended and an invasive sepsis resistant to antibiotics takes its toll. In practice, patients with extensive burns can seldom eat more than half the normal intake. Hence the supplementary feed providing three-fourths of the enhanced protein and calorie daily requirement, becomes principal method of nutrition, while normal food takes on the supplementary role. Parenteral nutrition should be employed only when enteral nutrition is ineffective due to severe intolerance or impossible due to paralytic ileus. Blood transfusions are usually necessary until skin cover is complete. The aim is to keep haemoglobin above 12 gm %. General physiotherapy, frequent shifts of position, and breathing exercises help shorten the period of debility when recovery has advanced far enough.

Scars and contractures All deep partial thickness burns result in scarring and in full thickness burns scars form at the margins of the graft and in the area which have healed by secondary epithelialisation. Burn scars, like all other scars, go through a series of phases, being initially flat and fairly inconspicuous, then red, thick and hard (hypertrophic scar), and finally flat, pale and soft. The pressure garment, local mild steroid application, systemic antihistaminic or silicone gel sheet cover can minimise the degree of hypertrophy and speed resolution. The secondary surgery, unless for urgent reason, should be delayed until the stage of hypertrophy has passed.
All scars and free grafts tend to shrink; thin grafts shrink more than thick ones. Contractures are, therefore, common sequelae to severe burns and late reconstructive procedures are often necessary. The shrinkage is maximum at three months and some relaxation of scar may take place thereafter. It is possible to immobilize the part which has been grafted or healed with scar to put the joint on full stretch till the tendency to shrink has passed. The necessary position is maintained by an accurately fitting plaster or molded splint and all joints mobilized intermittently. Established hypertrophic scars and contractures need treatment by excision, release and resurfacing by either skin grafts or flaps.
Burns are common injuries, seen and treated by members of many different branches of the medical profession: they come within the ambits of general practitioners, casualty officers, general and trauma surgeons and plastic surgeons. They are usually treated by them singly or jointly on the merit and severity of a given case and the facilities and expertise available in the area. The development of specialized centers for burns care with all infrastructure and allied specialties has resulted in decreasing the mortality and morbidity and hence should be the first choice when feasible.


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