CME

Acute Burns
Tiffany B. Grunwald, M.D.,
M.Ed.
Warren L. Garner, M.D.
Los Angeles, Calif.

Learning Objectives: After studying this article, the participant should be able
to: 1. Describe the pathophysiology of burn injury. 2. Identify patient criteria for
transfer to a burn center. 3. Calculate burn size and resuscitation requirements.
4. Treat inhalation injury in the acute setting. 5. Describe treatment options for
burn injuries. 6. Describe preoperative selection, intraoperative procedures, and
postoperative protocols for patients who require surgical care for their burn
injuries. 7. Understand the survival and functional outcomes of burn injury.
Summary: The review article summarizes basic issues in the treatment of acute
burn injury as practiced in 2008. The pathophysiology, treatment options, and
expected outcomes for an acute burn are described and discussed. Special attention
is directed to the nonoperative and surgical management of small to moderate-size
burns that might be treated by the practicing plastic surgeon. (Plast. Reconstr. Surg.
121: 311e, 2008.)

ith improvement in surgical technique,

availability of blood bank products, and
improvement in intensive care unit management, burn management has undergone a paradigm shift from death as primary concern to enhancing quality of life for survivors.1 The mortality
rate is best predicted by the size of the burn, the
age of patient, and the worst base deficit in the first
24 hours of hospitalization.2 Long-term outcome
is usually excellent, and most survivors of serious
childhood burns have a satisfying quality of life.3

EPIDEMIOLOGY
According to the National Burn Repository,4
there were 126,000 hospital admissions for burns
from January of 1995 to 2005. This information
was gathered from burn centers throughout the
United States and Canada to facilitate the collection and analysis of patient data within burn centers. From this information, we know that 62 percent of all burns seen in burn centers affected less
than 10 percent of the total body surface area. The
mean burn size was 13.4 percent of total body
From the Division of Plastic and Reconstructive Surgery, University of Southern California, USC Keck School of Medicine,
and LACUSC Burn Unit, LACUSC Medical Center.
Received for publication May 15, 2006; accepted January
24, 2007.
A passing score on this CME confers 0.5 hours of Patient
Safety Credit.
The American Society of Plastic Surgeons designates this educational activity for a maximum of one (1) AMA PRA Category
1 credit. Physicians should only claim credit commensurate
with the extent of their participation in the activity.
Copyright 2008 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318172ae1f

surface area, with 62 percent of the full-thickness

burns covering less than 10 percent of total body
surface area. Sixty-one percent of patients were
transferred to another hospital for a higher level
of care. Six and a half percent of patients admitted
had inhalation injury. The patients were 70 percent male with a mean age of 33 years. Flame and
scald burns accounted for 78 percent of injuries.
The prognostic burn index, a sum of the patients age and percentage of burn, has been used
as a gauge for patient mortality rate for many years.
This index suggests that the patients age plus
their full-thickness total body surface area burn
plus 20 percent for inhalation equaled the likely
mortality rate. Advances from early excision of
burn eschar, skin grafting, early enteral feeding,5
and wound closure with advanced techniques (skin
substitutes) have altered the simple mathematical
calculation. Patients with a prognostic burn index of
90 to 100 now have a mortality rate in the 50 to 70
percent range, with poorer outcomes at both extremes of age.6

TREATMENT OF BURN INJURIES AND

BURN CENTERS
Treatment of thermal injuries should be stratified between simple partial-thickness and small

Disclosure: Warren L. Garner, M.D., is the medical director for Advanced BioHealing, in La Jolla,
Calif. There is no financial interest or commercial
association for the other author that might pose or
create a conflict of interest with the information
submitted in this article.

www.PRSJournal.com

311e

Plastic and Reconstructive Surgery May 2008

full-thickness injuries and those that require specialized care. The practicing plastic surgeon with experience and interest can reasonably, safely, and effectively care for the former. The latter are best cared
for with the involvement of a burn team (Table 1).
The treatment and management of patients with
significant burn injuries are complex. The best, most
successful, and cost-effective treatment is in highvolume programs with a multidisciplinary team.
Transfer to a burn center is an accepted way to
improve patient care. Burn injuries appropriate for
transfer to a burn center include large burns, smaller
burns in areas of higher morbidity, and burns in
patients with comorbidities. The American Burn Association developed burn center referral criteria for
patients suitable for transfer (Table 2). Both extremes of ages have a less predictable systemic response to burns. Adherence to these criteria will
improve outcome and avoid unnecessary medical
expenses. Data from the National Burn Repository
indicate that most burns are minor and that 80 to 90
percent of burn injuries can be treated on an outpatient basis.7 To determine the best mechanism to
deliver care, accurate communication with burn
team members regarding the burn injury is essential.
This is facilitated by calculating the percentage of
burn using the rule of nines (Fig. 1) or the LundBrowder diagram and a careful review of the associated conditions. Before transferring a patient to a
burn unit, communication with the accepting burn
surgeon should include discussion of the following
treatment issues: the airway, nasogastric suction, urinary catheter, and vascular access. In addition, the
calculated fluid resuscitation for transport should be
confirmed. The patient should be placed in dry
dressings for transport to keep the patient warm and
to facilitate burn assessment upon arrival at the burn
center. Unless the transport time is unusually long,
antimicrobial dressings will delay transfer and obscure wound details at the receiving institution.

Table 1. Burn Team Members

Burn surgeon
Case worker
Dietician
Intensive care unit nurses
Occupational therapist
Pharmacist
Psychiatrist
Physical therapist
Respiratory therapist
Social worker
Ward nurses

312e

PATHOPHYSIOLOGY OF BURN INJURY

Anatomy/Function of Skin
The skin has two anatomic layers, each with a
separate function. The superficial, epidermal layer is
a barrier to bacteria and vapor (moisture loss). The
dermal layer deep to the epidermis provides protection from mechanical trauma and the elasticity
and mechanical integrity of the skin. Blood vessels
providing nutrition to the epidermal layer run
within the dermis. After skin loss, epidermal cells
regenerate from deep within dermal appendages,
such as hair follicles and sweat glands. The skins
function as a barrier to infection and fluid loss is lost
with burn injury. The treating physician must compensate with appropriate fluid management and local wound care.
Local Tissue Response
Burn injury to tissue encompasses a dynamic
response to the initial insult. Damage depends on
the temperature of the thermal energy source as
well as the duration of contact. Burn injury is
heterogeneous with adjacent areas showing varied
levels of injury.
Systemic Response
When the burn exceeds 20 percent of the patients body surface, the local tissue response becomes systemic. Interstitial edema develops in distant organs and soft tissues secondary to release of
vasoactive mediators from the injured tissue. Activation of complement and coagulation systems
causes thrombosis and release of histamine and bradykinin, leading to an increase in capillary leak and
interstitial edema in distant organs and soft tissue.
Secondary interstitial edema and organ dysfunction
from bacterial overgrowth within the eschar can
then result in systemic infection. Activation of the
proinflammatory cascade and the counterregulatory
anti-inflammatory reaction then lead to immune
dysfunction. This increases the patients susceptibility to sepsis and multiple organ failure.8
The systemic response to burn injury leads to
a hypermetabolic state doubling normal physiologic cardiac output over the first 48 postburn
hours.9 This response is mediated by hugely increased levels of catecholamines, prostaglandins, glucagons, and glucocorticoids, resulting
in skeletal muscle catabolism, immune deficiency, lipolysis, reduced bone mineralization,
and reduced linear growth.10 Herndon et al.11
have suggested that downmodulating this hypermetabolic response is beneficial. Beta-blockers have been shown to reduce the hypermeta-

Volume 121, Number 5 Acute Burns

Table 2. American Burn Association Burn Center Referral Criteria
Partial-thickness burns greater than 10% of total body surface area in patients who are younger than 10 years old
or older than 50 years old
Partial-thickness burns over more than 20% of total body surface area in other age groups
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect
mortality rate
Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the
greatest risk of morbidity or death
Burn injury in children at hospitals without qualified personnel or equipment for the care of children
Burn injury in patients who will require special social, emotional or long-term rehabilitative intervention

Fig. 1. Rule of nines chart.

bolic response to burn in limited studies.12,13

However, the value of limiting this metabolic
response in all burn patients through pharmacologic therapies, such as antipyretics or betablockers, is unknown.
These systemic metabolic alterations in the
burn patient may be present for a year after injury.
Mitigating factors in early treatment to decrease
this effect include early excision of burn and grafting, control of sepsis, maintenance of temperature, good nutrition through continuous feeding
of a high-carbohydrate/high-protein diet, and the
use of anabolic agents.

TISSUE INJURY FROM BURN

The multiple treatment algorithms for burn
wounds and resuscitation require quantification
of the extent of the burn. Although many new
modalities are becoming available to assess burn
depth, such as laser Doppler and dielectric measurements, assessment by an experienced practitioner is currently the most reliable judge of burn
depth. A simplistic description of burn type and
depth is presented in Table 3.
It must be noted that burn wounds continue
to mature, and damage to the skin continues for
24 to 48 hours secondary to several factors, in-

313e

Plastic and Reconstructive Surgery May 2008

Table 3. Burn Depth
First-degree burns
Commonly caused by flame flash or ultraviolet exposure
Generally pink, dry, and painful
Epithelium is intact
No risk for scarring
Necrotic epidermis will generally slough within 1 or 2
days, revealing intact epidermis
Require no specific care
Second-degree burns
Signify that the dermis has been damaged
Wet, pink or red, and edematous
Generally heal with local wound care
Further divided into superficial and deep,
corresponding to likelihood of rapid healing and risk
for poor scarring:
Superficial second-degree burns
More sensitive and hyperemic
Deep second-degree burns
Have higher potential for conversion to third degree
(full-thickness) burns
Monitor closely
Early excision limits hypertrophic scarring
Third-degree burns
Involve full thickness of the dermis
Will not heal without surgery
Leathery, dry, insensate, and waxy
Notable absence of tissue edema compared with
surrounding second-degree burned area
Fourth-degree burns
Extend through the subcutaneous soft tissue to tendon
or bone
Associated with limb loss or the need for complex
reconstruction

cluding edema and coagulation of small vessels.

Daily evaluation by a consistent team is currently
the best way to achieve early recognition of fullthickness loss and successful excision. The dynamic nature of burn injury means that a wound
may not appear to be a full-thickness wound until
several days after injury.
Prompt treatment and excision of deep second- and third-degree burn wounds have been
shown to improve outcomes. However, early decisions to proceed to surgery are not always
straightforward.

INITIAL ASSESSMENT OF BURN

INJURIES
Plastic surgeons are consulted for burns that
present to the emergency department. The first decision to be made is whether the injury may be
cared for at the presenting facility or should be
transferred to a designated burn center. This assessment will include the size of the burn, the depth
of the burn, the risk of morbidity and associated
injuries (e.g., inhalation injury or trauma), and
patient comorbidities.

314e

Initial Assessment
The initial assessment of burn size should be
performed with a standardized Lund-Browder diagram for second- and third-degree burns. The
simpler rule of nines is helpful for rapid assessment but is less accurate. The palm is often used
to gauge 1 percent total body surface area, but
studies of body surface area have shown that the
adult palm with fingers corresponds to 0.8 percent
total body surface area in adults and 1 percent in
children.14 Quantifying the degree of injury is an
important initial step in the treatment of burns affecting decisions for resuscitation, transfer, and surgical debridement. Cone found an average overestimate of 75 percent by referring physicians.2 This
corresponds to a review of transfers to burn units
showing air transport costs exceeding the cost of
hospitalization in almost 10 percent of burns transferred to burn units.
Approximately 10 percent of all burns present
with concomitant trauma. Evidence of additional
injuries should be evaluated where appropriate by
a trauma team, orthopedic surgeon, and ophthalmologist. Burns involving extremities must be
checked for circumferential burns and compartment syndrome. Escharotomy involves release of
only burned skin and may be performed in a monitored environment equipped with electrocautery
and conscious sedation. Fasciotomy for release of
edematous muscle should be performed in a more
controlled environment (e.g., operating room) to
allow for appropriate visualization of the anatomy.15
Inhalation Injury
Inhalation injury is the most frequent burnassociated problem and has a great effect on survival. Aggressive diagnosis and early prophylactic
intubation can be life saving. A clinical diagnosis
may be based on a history of the burn occurring
in an enclosed space, significant facial burns,
change in voice quality, singed nasal hair, or carbonaceous sputum seen on examination or in the
pharynx with bronchoscopy. Chest radiographs
are generally negative in the immediate postburn
time and are of little value in diagnosing inhalation injury. Airway edema can continue to worsen
for several days after burn injury; therefore, intubated patients should be monitored closely and
extreme caution should be used when considering
extubation for 48 to 72 hours.16
Acute physiologic deterioration secondary to
carbon monoxide results from competition for
oxygen binding sites on the hemoglobin molecule. Suspected or significant exposure to carbon

Volume 121, Number 5 Acute Burns

monoxide should be treated with administration
of 100% oxygen continued for several half-lives
(45 minutes). In the 10 percent of burns that
present with inhalation injury, ventilation to minimize barotrauma in the damaged, noncompliant
lungs is critical. One such method is highfrequency oscillatory ventilation.1720 This modality allows for oxygenation of stiff pulmonary tissue
through higher inspiratory pressures while minimizing barotrauma by allowing leakage of air
around the endotracheal tube cuff.17

TREATMENT OF MINOR BURNS

A careful examination of the criteria for transfer to a burn center will allow for safe treatment of
most burns outside of regional burn centers. Many
minor burns can be treated on an outpatient basis,
with careful treatment to avoid progression of the
burn and thorough follow-up to avoid postburn
morbidity.
The burn should be debrided at bedside or
with hydrotherapy on initial assessment to allow
determination of burn depth. This requires pain
management and a surgical tray for removal of
sloughing tissue. The raised epidermis of bullae
may be removed with warm water, soap, and abrasive gauze, followed by excision of sloughed tissue
during evaluation. For best healing, the burn
wound should be debrided daily and dressed with
a topical antibiotic. Patients who are unable to
tolerate daily wound care at home may need inpatient care to encourage good healing. Patients need
to maintain good nutrition, use adequate pain control for continued debridement, and return at any
sign of infection. Because burn wounds evolve over
several days, they should be re-evaluated by the treating surgeon within 3 to 5 days. Evaluation should
confirm that the burn wound is progressing toward
healing, that range of motion at involved joints is
maintained, that patient nutrition is adequate, and
that no signs of infection are present.
Related decisions to be made at follow-up include whether the burn needs surgical excision,
whether the patient is doing an adequate job of
wound care, whether the patient needs physical or
occupational therapy, nutritional counseling, or
supplemental feeding, and whether there is a
need for systemic antibiotic therapy (Table 4).
Failure in these areas as an outpatient may necessitate inpatient care.

BURN WOUND MANAGEMENT

Whether or not a burn needs surgical debridement, the wound will need a dressing placed to
keep the wound moist and clean.

Topical Treatments
Although topical antibiotics are used in most
burn centers, treatments include everything from
honey to silver sulfadiazine to duoderm.2126 Topical
antibiotics are used to keep the wound moist, control pain, and slow bacterial growth. Silver is found
in many burn wound dressings, including silver sulfadiazine (cream), Acticoat (fabric), and silver nitrate (solution). Silver has bactericidal activity that
reduces inflammation and promotes healing.23

TREATMENT OF MAJOR BURNS

Resuscitation
Resuscitation is most commonly monitored using clinical end points for volume status, such as
peripheral temperature, blood pressure, heart rate,
and urine output. Minor burns (15 to 20 percent)
need 150 percent of normal maintenance intravenous fluids.2729 The goal of resuscitation is to achieve
enough volume to ensure end-organ perfusion while
avoiding intracompartmental edema and joint stiffness. Patients with preexisting conditions that may
affect the correlation between volume and urine
output require invasive monitoring.30 Central venous pressure or pulmonary capillary wedge pressure should be considered in patients with known
myocardial dysfunction, age greater than 65 years,
severe inhalation injury, or fluid requirements
greater than 150 percent of that predicted by the
Parkland formula.28
The initial fluid rate may be calculated using the
Parkland formula (Table 5). Multiple studies have
reported the inadequacy of standard fluid resuscitation formulas, with needs routinely exceeding the
calculated need.31 This may be attributed to variations in body mass index, accuracy of the calculated
size of the burn, and differences in mechanical ventilation. Resuscitation fluids should be isotonic (lactated Ringers solution) for the first 24 hours, then
colloid after 24 hours, when capillary integrity reTable 4. Burn Treatment Considerations
Nonoperative treatment
Wound care
Daily debridement
Silvadene/acticoat/silver nitrate
Systemic care
Pain management
Nutritional support
Infection prophylaxis
Operative treatment
Surgical debridement
Wound coverage
Wound care
Donor-site care
Physical/occupational therapy

315e

Plastic and Reconstructive Surgery May 2008

turns. Vascular access for these fluids should be two
large-bore peripheral intravenous lines or a central
line.
Infection Prophylaxis
Treatment of burns with topical antibiotics has
been shown to decrease the bacterial overgrowth
and incidence of burn wound sepsis. Current
treatment regimens include silver sulfadiazine,
Bactroban, or Sulfamylon in conjunction with
daily cleaning and debridement. Acticoat is a silver-impregnated material dressing that provides
antibiotic coverage for 3 to 7 days.
Patients who show signs of sepsis should receive a complete work-up, with a special focus on
the most commonly encountered bacteria in burn
units, including Staphylococcus aureus, Pseudomonas
aeruginosa,32 and Acinetobacter. The compromise to
the skin barrier and the overgrowth of bacteria in
the burn eschar leading to sepsis have led to a high
rate of antibiotic resistance in these common organisms.
Surgical Debridement
The timing of surgical debridement has a significant effect on long-term burn wound results.
Early identification, excision, and closure of fullthickness burn wounds help avoid wound sepsis, decrease systemic inflammation, and improve outcomes in wound healing. For mixed-depth wounds,
topical therapy for 5 to 7 days will facilitate any spontaneous wound healing that may occur. Declaration
of the depth of injury during that time, with frequent
assessment of wound progression, should guide surgical planning.
Blood loss from surgical debridement of burns
is estimated at 3.5 to 5 percent of blood volume for
every 1 percent of total body surface area of burn
excised.33 The systemic response to burn injury is
Table 5. Resuscitation Formula
First 24 hours
Adults and children 20 kg
Ringers lactate solution: 2 to 4 ml/kg per percent
burn per 24 hours (first half in first 8 hours)
Colloid solution: none
Children 20 kg
Ringers lactate solution: 2 to 3 ml/kg per percent
burn per 24 hours (first half in first 8 hours)
Ringers lactate solution with 5% dextrose: maintenance
rate (4 ml/kg per hour for first 10 kg, 2 ml/kg per hour
for next 10 kg)
Colloid solution: none
Second 24 hours
All patients
Crystalloid solution: use to maintain urine output

316e

responsible for the significant blood loss secondary to an alteration in the coagulation cascade.
Operative methods to minimize blood loss during
surgical debridement include injecting diluted
epinephrine below the eschar, using cautery for
fascial excision, excising extremities under tourniquet, and performing excisions early in the postburn period, before significant wound angiogenesis develops.
Surgical debridement is performed using a
Goulian blade for small areas or those with multiple irregular contours (e.g., hand or knee) and
a Watson blade for larger areas. Burned tissue is
excised tangentially and sequentially until the
wound has been excised down to healthy dermis,
fat, muscle, peritenon, or periosteum. The wound
may then be covered with an autograft, allograft,
or synthetic skin substitute. If a healthy recipient
bed is not available, other reconstructive options
should be considered.
Burn Wound Coverage
Autografts include full-thickness skin grafts,
split-thickness skin grafts, and cultured epithelial
cells, each with their own set of advantages and
disadvantages (Table 6). Full-thickness skin grafts
are rarely used in burn surgery because of the
added tissue loss. Split-thickness skin grafts allow
for regrowth of the donor site with minimal scarring. The average graft depth is 8 to 14/1000ths of
an inch. Thinner grafts heal the donor site faster
with less scarring, while thicker grafts provide
more durable coverage but will have more significant scarring at the donor site. Graft depth should
be adjusted in pediatric and geriatric populations
for their thinner reticular dermis layer. Meshing
of the skin graft has several advantages, including
expanding the square centimeters of coverage,
allowing for drainage of fluid from under the
graft, and allowing for placement of the graft over
contoured areas, such as the knee or ankle. The
disadvantage of the meshed skin graft includes a
permanent weave-like appearance of the healed
scar site. Sheet skin grafts have a smoother healed
appearance but need to be checked frequently for
hematoma and seroma formation and cannot be
used for large burns, where donor sites are scarce.
Recently, fibrin spray has been used to improve
adherence of both sheet and mesh skin grafts.
Cultured epithelial autografts are grown from patient skin samples. Seventy-five square meters may
be grown from a 1-cm2 specimen. Few centers have
large success with cultured epithelial autografts
secondary to lack of take and poor long-term
durability.34

Volume 121, Number 5 Acute Burns

Alternatives to Autografts
Several substitutes for coverage of partialthickness wounds are available. The main purpose
of these products is to provide a moist environment that stimulates epithelialization for faster
healing. Synthetic products are best reserved for
clean wounds. An excellent, comprehensive review of biological skin substitutes was performed
by Jones et al.35
Full-thickness skin substitutes act to replace
the dermis. They provide wound closure, protection from mechanical trauma, and a barrier to
vapor and bacteria. Integra has a collagen proteoglycan matrix that acts as a scaffold for infiltration
by fibroblasts and capillaries. Once the neodermis
is created, the temporary silicone epidermis is
removed and a thinner (6 to 8/1000ths of an inch)
split-thickness skin graft may be placed. The disadvantages of using Integra include the need for
a second-stage surgery with a minimum interval of
3 weeks, dressing changes during this maturation
phase, possible prolonged hospitalization, and
product cost. Integra has recently been used with
success for deep skin defects with partial exposure
of bone or muscle.35,36
Donor-Site Dressings
Donor sites are partial-thickness wounds. Coverage may be with a dressing that will dry, such as
Xeroform, beta-glucan, or Scarlet Red impregnated
gauze. These dressings should be covered with absorbent gauze for 24 to 48 hours, and then removed
and allowed to dry. Edges may be trimmed by staff
or the patient to avoid painful snaring of firm edges.
Dressings that create a moist wound environment,
such as hydrocolloid or Tegaderm, facilitate re-epithelialization and decrease pain. Wound monitoring
is required to drain fluid collections under the dressing and watch for infection.
Postoperative Care
The success of skin grafts depends on not only
surgical technique but also postoperative care, inTable 6. Mesh versus Sheet Graft
Mesh graft
Advantages
Expanded skin coverage
Allows for drainage of fluid
Better contour over difficult areas
Disadvantages
Permanent weave-like appearance
Sheet graft
Advantages
Smooth appearance
Disadvantages
Predisposition for fluid collection
Larger donor sites

cluding postoperative dressings, frequent assessment of graft viability, and close involvement of
occupational and physical therapy teams. A viable
graft may be mobilized on postoperative day 4 or
5. Grafts to the lower extremities should be protected from venous hypertension by double Ace
bandage wraps. Grafts to the upper extremities,
especially the fingers, should be protected with an
elastic wrap, such as Coban.

NUTRITIONAL SUPPORT
In recent decades, studies have substantiated
the need for early feeding in burn patients. A huge
rise in metabolic rate occurs after a burn injury,9,37
as does enhanced gluconeogenesis, insulin resistance, and increased protein catabolism. Patients
with minor burns who are able to tolerate a diet
should be encouraged to eat healthy foods high in
protein. Patients with minor burns who are unable
to eat because of age, pain medication, or noncompliance should be followed by a dietician and
intake should be supplemented by tube feedings
as necessary. Prealbumin provides a contemporary
measurement of nutritional state more useful in
acute care of burns than albumin alone. In critically ill burn patients, beginning tube feedings
immediately upon admission can prevent atrophy
of the gastrointestinal mucosa and bacterial translocation in the gut. Duodenal tube feeding may be
superior to gastric feeding but is usually reserved
for those patients intolerant of gastric feeding.38

PHARMACOTHERAPY
Multiple advances in pharmacotherapy have
been achieved for burn patients. Burn patients
show significant interpatient and intrapatient variations in distribution of medications.39 Pharmacist
help in ensuring correct dosing based on blood
levels and blood volume is invaluable. Horton
showed that antioxidants reduced burn- and burn
sepsisrelated mortality rates by inhibiting free radical formation and scavenging free radicals.40 The
anabolic steroid oxandrolone has been shown to
decrease acute-phase proteins, and long-term administration improved lean body mass and bone
mineral density in pediatric burn populations.10
Judicious use of topical and systemic antibiotics
is recommended to avoid development of opportunistic nosocomial bacterial resistance.10 Because of increasing multidrug-resistant, nosocomial pathogens41
(P. aeruginosa, methicillin-resistant S. aureus, and
vancomycin-resistant enterococcus), antibiotic usage in burn units is discouraged in the absence of
sepsis or identification of a specific pathogen. Patients receiving antibiotics should be monitored

317e

Plastic and Reconstructive Surgery May 2008

Table 7. CPT Codes Commonly Used in Burn Surgery
CPT Code
15002
15003
15004

15005

15100
15101
15120
15121

Descriptor
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar
(including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100
sq cm or 1% of body area of infants and children
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar
(including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each
additional 100 sq cm or each additional 1% of body area of infants and children
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar
(including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body
area of infants and children
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar
(including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm or
each additional 1% of body area of infants and children
STSG,
STSG,
STSG,
STSG,

trunk, arms, legs; first 100 sq cm or less

trunk, arms, legs; each additional 100 sq cm
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet; first 100 sq cm or less
face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet; each additional 100 sq cm

STSG, split-thickness skin graft.

Add-on codes.

closely to ensure therapeutic levels, to prevent the

development of more drug resistance.

BURN OUTCOMES: LONG-TERM DATA

Data from the 2005 Burn Repository show a
decrease in mortality rates among all burns from
6.2 percent in 1995 to 4.7 percent in 2005.4 The
biggest factor in burn mortality is inhalation injury. In the 6.5 percent of burn patients admitted
with an inhalation injury, the mortality rate increased to 26.3 percent. Thirty-eight percent of all
burn deaths were due to multiple organ failure
and only 4.1 percent were due to burn wound
sepsis. Mortality rates were much greater at both
ends of the age spectrum. Factors previously
thought to influence time to wound healing, such
as percentage burned, sex, age, graft type, and
infection, were not found to be significant in a
study by Jewell et al.42
The significant increase in burn survival over
the last several decades6,43 generates important
questions about quality-of-life issues. Studies of
quality of life among those surviving serious childhood burns have been surprisingly good.44 In addition, a recent study of patients who sustained
massive burns showed that they had a satisfying
quality of life 15 years after burn injury.1,45 A 1995
study showed that the most significant predictors
of return to work were hand involvement, grafting,
and size of the burn46; a 1989 study showed that the
most significant variables influencing return to
work after injury were the degree of burn, hand
burns, age (those younger than 45 had a higher

318e

return-to-work rate), and type of work done before

injury. The length of time a patient is off work,
their burn size, and their preinjury employment
are the best predictors of eventual return-to-work
status. The Burn Specific Health Scale quantifies
quality-of-life issues specific to burn injury. An abbreviated form was developed and validated by
Kildal et al.47 to improve clinical use and gather
more data to help burn centers care for patients.
On average, burn patients with a mean total
body surface area burn of 5 percent returned to
work within 1 month, patients with a burn of 10
percent returned to work within 1 to 6 months,
those with a burn of 20 percent returned to work
within 6 months to a year, and those with a burn
of 35 percent returned to work more than a year
later.43

SUMMARY
Interdisciplinary involvement with members
of the burn team and counseling groups is very
important in maximizing a patients clinical outcome. Interventions designed to aid adjustment,
work hardening, and other rehabilitation services
and marital/family therapy are also important.
CPT codes commonly used in burn surgery are
listed in Table 7.
Warren L. Garner, M.D.
LACUSC Medical Center
1200 N. State Street
Burn Unit, Room 12-700
Los Angeles, Calif. 90033
wgarner@surgery.usc.edu

Volume 121, Number 5 Acute Burns

REFERENCES
1. Pereira, C., Murphy, K., and Herndon, D. Outcome measures
in burn care. Is mortality dead? Burns 30: 761, 2004.
2. Cone, J. B. Whats new in general surgery: Burns and metabolism. J. Am. Coll. Surg. 200: 607, 2005.
3. Herndon, D. N., Lemaster, J., Beard, S., et al. The quality of
life after major thermal injury in children: An analysis of 12
survivors with greater than or equal to 80% total body, 70%
third-degree burns. J. Trauma 26: 609, 1986.
4. Miller, S. F., Jeng, J. C., Bessey, P. Q., et al. National Burn
Repository. Chicago, Ill.: American Burn Association, 2005.
Pp. 151.
5. Rose, D. D., Jordan, E. B. Perioperative management of burn
patients. A.O.R.N. J. 69: 1211, 1999.
6. Aikawa, N., Aoki, K., and Yamazaki, M. Recent advances in
the management of severely burned patients (in Japanese).
Nippon Geka Gakkai Zasshi 100: 424, 1999.
7. Moss, L. S. Outpatient management of the burn patient. Crit.
Care Nurs. Clin. North Am. 16: 109, 2004.
8. Schwacha, M. G. Macrophages and post-burn immune dysfunction. Burns 29: 1, 2003.
9. Yu, Y. M., Tompkins, R. G., Ryan, C. M., and Young, V. R. The
metabolic basis of the increase of the increase in energy
expenditure in severely burned patients. J.P.E.N. J. Parenter.
Enteral Nutr. 23: 160, 1999.
10. Murphy, K. D., Lee, J. O., and Herndon, D. N. Current
pharmacotherapy for the treatment of severe burns. Exp.
Opin. Pharmacother. 4: 369, 2003.
11. Herndon, D. N., and Tompkins, R. G. Support of the metabolic response to burn injury. Lancet 363: 1895, 2004.
12. Herndon, D. N., Hart, D. W., Wolf, S. E., Chinkes, D. L., and
Wolfe, R. R. Reversal of catabolism by beta-blockade after
severe burns. N. Engl. J. Med. 345: 1223, 2001.
13. Arbabi, S., Ahrns, K. S., Wahl, W. L., et al. Beta-blocker use
is associated with improved outcomes in adult burn patients.
J. Trauma 56: 265; discussion 269, 2004.
14. Jose, R. M., Roy, D. K., Vidyadharan, R., and Erdmann, M. Burns
area estimation-an error perpetuated. Burns 30: 481, 2004.
15. Wong, L., and Spence, R. J. Escharotomy and fasciotomy of
the burned upper extremity. Hand Clin. 16: 165, 2000.
16. Rabinowitz, P. M., and Siegel, M. D. Acute inhalation injury.
Clin. Chest Med. 23: 707, 2002.
17. Cartotto, R., Ellis, S., and Smith, T. Use of high-frequency
oscillatory ventilation in burn patients. Crit. Care Med. 33(3
Suppl): S175, 2005.
18. Cartotto, R., Ellis, S., Gomez, M., Cooper, A., and Smith, T.
High frequency oscillatory ventilation in burn patients with
the acute respiratory distress syndrome. Burns 30: 453, 2004.
19. Cartotto, R., Cooper, A. B., Esmond, J. R., Gomez, M., Fish,
J. S., and Smith, T. Early clinical experience with high-frequency oscillatory ventilation for ARDS in adult burn patients. J. Burn Care Rehabil. 22: 325, 2001.
20. Cartotto, R. High frequency oscillatory ventilation in burn patients (Letter). Acta Anaesthesiol. Scand. 47: 495; reply 496, 2003.
21. Molan, P. C. Potential of honey in the treatment of wounds
and burns. Am. J. Clin. Dermatol. 2: 13, 2001.
22. Edwards-Jones, V., and Greenwood, J. E. Whats new in burn
microbiology? James Laing Memorial Prize Essay 2000. Burns
29: 15, 2003.
23. Dunn, K., and Edwards-Jones, V. The role of Acticoat with
nanocrystalline silver in the management of burns. Burns
30(Suppl. 1): S1, 2004.
24. Silver, S. Bacterial silver resistance: Molecular biology and
uses and misuses of silver compounds. F.E.M.S. Microbiol. Rev.
27: 341, 2003.

25. Naoum, J. J., Roehl, K. R., Wolf, S. E., and Herndon, D. N.

The use of homograft compared to topical antimicrobial
therapy in the treatment of second-degree burns of more
than 40% total body surface area. Burns 30: 548, 2004.
26. Kumar, R. J., Kimble, R. M., Boots, R., and Pegg, S. P. Treatment
of partial-thickness burns: A prospective, randomized trial using
Transcyte. Aust. N. Z. J. Surg. 74: 622, 2004.
27. Cartotto, R. C., Innes, M., Musgrave, M. A., Gomez, M., and
Cooper, A. B. How well does the Parkland formula estimate
actual fluid resuscitation volumes? J. Burn Care Rehabil. 23:
258, 2002.
28. Yowler, C. J., and Fratianne, R. B. Current status of burn
resuscitation. Clin. Plast. Surg. 27: 1, 2000.
29. Sheridan, R. L. Burn care: Results of technical and organizational progress. J.A.M.A. 290: 719, 2003.
30. Holm, C. Resuscitation in shock associated with burns. Tradition or evidence-based medicine? Resuscitation 44: 157, 2000.
31. Engrav, L. H., Colescott, P. L., Kemalyan, N., et al. A biopsy
of the use of the Baxter formula to resuscitate burns or do
we do it like Charlie did it? J. Burn Care Rehabil. 21: 91, 2000.
32. Alekseev, A. A., Iakovlev, V. P., and Fedorov, V. D. Infection
in burn patients: The problems of pathogenesis, prevention
and treatment (in Russian). Khirurgiia (Mosk.) 6: 4, 1999.
33. Sheridan, R. L. Comprehensive treatment of burns. Curr.
Probl. Surg. 38: 657, 2001.
34. Chester, D. L., Balderson, D. S., and Papini, R. P. A review
of keratinocyte delivery to the wound bed. J. Burn Care Rehabil. 25: 266, 2004.
35. Jones, I., Currie, L., and Martin, R. A guide to biological skin
substitutes. Br. J. Plast. Surg. 55: 185, 2002.
36. Suzuki, S. Artificial dermis (in Japanese). Nippon Geka Gakkai
Zasshi 100: 534, 1999.
37. Williams, G. J., and Herndon, D. N. Modulating the hypermetabolic response to burn injuries. J. Wound Care 11: 87,
2002.
38. Andel, H., Kamolz, L. P., Horauf, K., and Zimpfer, M. Nutrition
and anabolic agents in burned patients. Burns 29: 592, 2003.
39. Weinbren, M. J. Pharmacokinetics of antibiotics in burn
patients. J. Antimicrob. Chemother. 44: 319, 1999.
40. Horton, J. W. Free radicals and lipid peroxidation mediated
injury in burn trauma: The role of antioxidant therapy. Toxicology 189: 75, 2003.
41. Steinstraesser, L. Sepsis: New strategies with host defense
peptides? Crit. Care Med. 32: 2555, 2004.
42. Jewell, L., Guerrero, R., Quesada, A. R., Chan, L. S., and
Garner, W. L. Rate of healing in skin-grafted burn wounds.
Plast. Reconstr. Surg. 120: 451, 2007.
43. McDonald-Smith, G. P., Saffle, J. R., Edelman, L., et al. National Burn Repository. Chicago: American Burn Association,
2002. Pp. 126.
44. Sheridan, R. L., Hinson, M. I., Liang, M. H., et al. Long-term
outcome of children surviving massive burns. J.A.M.A. 283:
69, 2000.
45. Anzarut, A., Chen, M., Shankowsky, H., and Tredget, E. E.
Quality-of-life and outcome predictors following massive
burn injury. Plast. Reconstr. Surg. 116: 791, 2005.
46. Wrigley, M., Trotman, B. K., Dimick, A., and Fine, P. R.
Factors relating to return to work after burn injury. J. Burn
Care Rehabil. 16: 445; discussion 444, 1995.
47. Kildal, M., Andersson, G., Fugl-Meyer, A. R., Lannrestam,
K., and Gerdin, B. Development of a brief version of
the Burn Specific Health Scale (BSHS-B). J. Trauma 51:
740, 2001.

319e