The Initial Surgical Management of the Critically Ill Burn Patient



The initial surgical management of the critically ill burn patient is a multidisciplinary task that combines the expertise of the Intensive care and Plastic Surgery and Burns team together with a miriad of associated health professionals. The management of these patients according to recognised protocols of trauma resuscitation is an effort to restore anatomy and physiology to pre trauma status. This chapter will discuss the staged progression of a major burn who is critically ill from early admission to the surgical management of the wounds and the modulation of altered physiology in the Burns Intensive Care.


Thermal Injury Surgery Optimisation Burn Wound Debridement 

Summary of Abbreviations


Advanced Trauma Life Support


Emergency Management of Severe Burns


Staphylococcal scalded skin syndrome


Total body surface area


Toxic epidermal necrolysis syndrome


Toxic shock syndrome


  1. 1.
    Association BB (2013) National Burn Care Review Committee report: standards and strategy for burn care. A review of burn care in the British Isles. British Burns Association, Manchester. http://www.britishburnsassociation/org/downloads/NCBR2001.pdf
  2. 2.
    Shariff Z, Rodrigues JN, Anwar U, Austin O, Phipps A (2015) Burns in patients over 90: a fifteen-year series from a regional burns centre. Burns 41:297–300CrossRefPubMedGoogle Scholar
  3. 3.
    Heng JS, Atkins J, Clancy O et al (2015) Geographical analysis of socioeconomic factors in risk of domestic burn injury in London 2007–2013. Burns 41:437–445CrossRefPubMedGoogle Scholar
  4. 4.
    Rutan TC, Herndon DN, Van Osten T, Abston S (1986) Metabolic rate alterations in early excision and grafting versus conservative treatment. J Trauma 26:140–142CrossRefPubMedGoogle Scholar
  5. 5.
    Hart DW, Wolf SE, Mlcak R et al (2000) Persistence of muscle catabolism after severe burn. Surgery 128:312–319CrossRefPubMedGoogle Scholar
  6. 6.
    Venter TH, Karpelowsky JS, Rode H (2007) Cooling of the burn wound: the ideal temperature of the coolant. Burns 33:917–922CrossRefPubMedGoogle Scholar
  7. 7.
    Baldwin A, Xu J, Attinger D (2012) How to cool a burn: a heat transfer point of view. J Burn Care Res 33:176–187CrossRefPubMedGoogle Scholar
  8. 8.
    Tobalem M, Harder Y, Tschanz E, Speidel V, Pittet-Cuenod B, Wettstein R (2013) First-aid with warm water delays burn progression and increases skin survival. J Plast Reconstr Aesthet Surg 66:260–266CrossRefPubMedGoogle Scholar
  9. 9.
    Varley A, Sarginson J, Young A (2013) How to cool a burn: a heat transfer point of view. British Burns Association first aid position statement. Manchester.
  10. 10.
    Aggarwal S, Smailes S, Dziewulski P (2009) Tracheostomy in burns patients revisited. Burns 35:962–966CrossRefPubMedGoogle Scholar
  11. 11.
    Orgill DP, Piccolo N (2009) Escharotomy and decompressive therapies in burns. J Burn Care Res 30:759–768CrossRefPubMedGoogle Scholar
  12. 12.
    Hershberger RC, Hunt JL, Arnoldo BD, Purdue GF (2007) Abdominal compartment syndrome in the severely burned patient. J Burn Care Res 28:708–714CrossRefPubMedGoogle Scholar
  13. 13.
    Association ECoANZB (2012) Emergency management of severe burns course manual (UK Edn). Manchester. British Burns AssociationGoogle Scholar
  14. 14.
    Burd A, Noronha FV, Ahmed K et al (2006) Decompression not escharotomy in acute burns. Burns 32:284–292CrossRefPubMedGoogle Scholar
  15. 15.
    Sherren PB, Hussey J, Martin R, Kundishora T, Parker M, Emerson B (2014) Lethal triad in severe burns. Burns 40:1492–1496CrossRefPubMedGoogle Scholar
  16. 16.
    Corallo JP, King B, Pizano LR, Namias N, Schulman CI (2008) Core warming of a burn patient during excision to prevent hypothermia. Burns 34:418–420CrossRefPubMedGoogle Scholar
  17. 17.
    Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR Jr (2003) Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery. J Clin Anesth 15:119–125CrossRefPubMedGoogle Scholar
  18. 18.
    Wallace AB (1951) The exposure treatment of burns. Lancet 1:501–504CrossRefPubMedGoogle Scholar
  19. 19.
    Lund CC, Browdler NC (1944) The estimation of areas of burns. Surg Gynecol Obstet 79:352–358Google Scholar
  20. 20.
    Du Bois D, Du Bois EF (1989) A formula to estimate the approximate surface area if height and weight be known. 1916. Nutrition 5:303–311; discussion 12–3PubMedGoogle Scholar
  21. 21.
    Berry MG, Evison D, Roberts AH (2001) The influence of body mass index on burn surface area estimated from the area of the hand. Burns 27:591–594CrossRefPubMedGoogle Scholar
  22. 22.
    Nagel TR, Schunk JE (1997) Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care 13:254–255CrossRefPubMedGoogle Scholar
  23. 23.
    Freiburg C, Igneri P, Sartorelli K, Rogers F (2007) Effects of differences in percent total body surface area estimation on fluid resuscitation of transferred burn patients. J Burn Care Res 28:42–48CrossRefPubMedGoogle Scholar
  24. 24.
    Martin NA, Lundy JB, Rickard RF (2014) Lack of precision of burn surface area calculation by UK Armed Forces medical personnel. Burns 40:246–250CrossRefPubMedGoogle Scholar
  25. 25.
    Shokrollahi K, Sayed M, Dickson W, Potokar T (2007) Mobile phones for the assessment of burns: we have the technology. Emerg Med J 24:753–755CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Goldberg H, Klaff J, Spjut A, Milner S (2014) A mobile app for measuring the surface area of a burn in three dimensions: comparison to the Lund and Browder assessment. J Burn Care Res 35:480–483CrossRefPubMedGoogle Scholar
  27. 27.
    Jackson DM (1953) The diagnosis of the depth of burning. Br J Surg 40:588–596CrossRefPubMedGoogle Scholar
  28. 28.
    Cubison TC, Pape SA, Parkhouse N (2006) Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury. Burns 32:992–999CrossRefPubMedGoogle Scholar
  29. 29.
    Kim LH, Ward D, Lam L, Holland AJ (2010) The impact of laser Doppler imaging on time to grafting decisions in pediatric burns. J Burn Care Res 31:328–332CrossRefPubMedGoogle Scholar
  30. 30.
    Wang XQ, Mill J, Kravchuk O, Kimble RM (2010) Ultrasound assessed thickness of burn scars in association with laser Doppler imaging determined depth of burns in paediatric patients. Burns 36:1254–1262CrossRefPubMedGoogle Scholar
  31. 31.
    Baxter C (1979) Fluid resuscitation, burn percentage, and physiologic age. J Trauma 19:864–865PubMedGoogle Scholar
  32. 32.
    Demling RH (2005) The burn edema process: current concepts. J Burn Care Rehabil 26:207–227CrossRefPubMedGoogle Scholar
  33. 33.
    Berger MM, Bernath MA, Chiolero RL (2001) Resuscitation, anaesthesia and analgesia of the burned patient. Curr Opin Anaesthesiol 14:431–435CrossRefPubMedGoogle Scholar
  34. 34.
    Latenser BA (2009) Critical care of the burn patient: the first 48 hours. Crit Care Med 37:2819–2826CrossRefPubMedGoogle Scholar
  35. 35.
    Saffle JI (2007) The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res 28:382–395CrossRefPubMedGoogle Scholar
  36. 36.
    (NNBC) NNfBC (2012) Referral guidelines. British Burns Association.
  37. 37.
    Gauglitz GG, Finnerty CC, Herndon DN, Williams FN, Jeschke MG (2012) Modulation of the hypermetabolic response after burn injury. In: Herndon DN (ed) Total burn care, 4th edn. Elsevier, London, pp 355–357CrossRefGoogle Scholar
  38. 38.
    Sterling JP, Heimbach DM (2011) Hemostasis in burn surgery – a review. Burns 37:559–565CrossRefPubMedGoogle Scholar
  39. 39.
    Sheridan RL, Szyfelbein SK (2001) Trends in blood conservation in burn care. Burns 27:272–276CrossRefPubMedGoogle Scholar
  40. 40.
    Kwan P, Gomez M, Cartotto R (2006) Safe and successful restriction of transfusion in burn patients. J Burn Care Res 27:826–834CrossRefPubMedGoogle Scholar
  41. 41.
    Cartotto R, Musgrave MA, Beveridge M, Fish J, Gomez M (2000) Minimizing blood loss in burn surgery. J Trauma 49:1034–1039CrossRefPubMedGoogle Scholar
  42. 42.
    Doufas AG (2003) Consequences of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol 17:535–549CrossRefPubMedGoogle Scholar
  43. 43.
    Prunet B, Asencio Y, Lacroix G et al (2012) Maintenance of normothermia during burn surgery with an intravascular temperature control system: a non-randomised controlled trial. Injury 43:648–652CrossRefPubMedGoogle Scholar
  44. 44.
    Davis JS, Rodriguez LI, Quintana OD et al (2013) Use of a warming catheter to achieve normothermia in large burns. J Burn Care Res 34:191–195CrossRefPubMedGoogle Scholar
  45. 45.
    Cubison TC, Pape SA, Jeffery SL (2006) Dermal preservation using the Versajet hydrosurgery system for debridement of paediatric burns. Burns 32:714–720CrossRefPubMedGoogle Scholar
  46. 46.
    Chang DW, DeSanti L, Demling RH (1998) Anticatabolic and anabolic strategies in critical illness: a review of current treatment modalities. Shock 10:155–160CrossRefPubMedGoogle Scholar
  47. 47.
    Herndon DN, Tompkins RG (2004) Support of the metabolic response to burn injury. Lancet 363:1895–1902CrossRefPubMedGoogle Scholar
  48. 48.
    Hart DW, Wolf SE, Ramzy PI et al (2001) Anabolic effects of oxandrolone after severe burn. Ann Surg 233:556–564CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Plastic Surgery and BurnsChelsea and Westminster HospitalLondonUK

Personalised recommendations