Burn Care

Improved patient care in those that sustained severe burns has also improved
survival. In 1949, Bull and Fisher reported a 50% mortality rate for a burn of 49%
TBSA in children aged 0-14, 46% TBSA for patients aged 15-44, 27% TBSA for
those of age 45 and 64, and 10% TBSA for those 65 and older.5 These dismal
results have improved markedly. The latest reports indicate a 50% mortality rate
for 98% TBSA burns in children 14 and under and 75% TBSA burns in other
young age groups6,7 (Fig. 1.1). These improvements are further illustrated by the
following. Investigators have shown that the significant risk factors for mortality
after burns using modern treatment techniques are age > 60 years, burn size greater
than 40% of the total body surface area (TBSA), and inhalation injury. Using a
logistic regression analysis in their patient population, only someone with all three
risk factors would have a predicted mortality greater than 33%.8 Therefore, a young
patient with almost any size burn using modern treatment techniques should be
expected to live.
Advances in treatment techniques are based on improved understanding of
resuscitation, enhanced wound coverage, better support of the hypermetabolic
response to injury, more appropriate infection control, and improved treatment
of inhalation injuries. Further improvements can be made in these areas, and investigators
are active in all these fields to discover means to further improve survival.



With improvements in mortality, survivors of these devastating injuries will
have special needs. Many of the problems are related to the ravages of scarring
and the psychosocial aspects of reintegration into society. Improvements have been
made in these fields such that a survivor of a massive burn with disfiguring scars
can lead a relatively normal life.9 New advances in skin replacement and scar management
are likely to decrease the effects of scarring. New modalities of psychosocial
care and treatment may improve the well being of these patients.
Many of the improvements in burn care originated in specialized units dedicated
to the care of burned patients. These units consist of experienced surgeons,
physicians, nurses, therapists, dietitians, pharmacists, social workers, psychologists,
and prosthetists with the dedicated resources to maximize outcome from
these often devastating injuries (Table 1.1). Because of the dedicated resources,
burned patients are best treated in such places. The American Burn Association
has established guidelines to determine which patients should be transferred to
specialized burn units. Patients meeting the following criteria should be treated at
a designated burn center:10
1. Second and third degree burns of greater than 10% TBSA.
2. Full-thickness burns over 5% TBSA.
3. Any burn involving the face, hands, feet, eyes, ears, or perineum that
may result in cosmetic or functional disability.
4. High-voltage electrical injury including lightning injury.
5. Inhalation injury or associated trauma.
6. Chemical burns
7. Burns in patients with significant co-morbid conditions (e.g., diabetes
mellitus, COPD, cardiac disease).
Patients meeting the following criteria could be treated in a general hospital
setting:
1. Second and third degree burns of less than 10% TBSA
2. No burns to areas or special function or risk, and no significant associated
or premorbid conditions.