Introduction

Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body.¹ The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock.² The risk of infection is also elevated in patients with severe burn wounds.² Therefore, prevention of these complications is a key component of care for these patients.³

Emergency Care and Stabilization of the Patient

Emergency care for patients with severe burns begins with the Advanced Trauma Life Support guidelines (ATLS) and an initial assessment to identify other life-threatening conditions.⁴ Before the patient is transferred to a burn care facility, respiratory and cardiovascular support, fluid resuscitation, pain management, and initial burn wound care should be provided as needed.⁴ To maintain adequate urine output in the patient, clinicians should begin fluid resuscitation.⁵ This regimen should be adjusted as needed in response to the patient’s vital signs, urine output, and concurrent illnesses or injuries.⁵ Pain management is essential for patients with burns.¹ Although opioids are commonly used to manage pain, long-term use of these drugs can lead to opioid-induced hyperalgesia.¹Alternatives to opioids include the following¹:

• Ketamine (an anesthetic, analgesic, or amnestic agent)
• Sedative agents
• Anxiolytic agents
• Anticonvulsant agents (pregabalin and gabapentin)

A patient who has a severe burn injury will need a referral to a specialized burn care facility after stabilization.³ If there is a delay in transfer to a burn care facility, interim treatment should take place in an intensive care unit.⁴

Burn Wound Assessment

After stabilization, a clinician may then perform a comprehensive evaluation, starting with a history and physical examination followed by an assessment of the patient’s burn wound(s), including burn depth and total body surface area (TBSA).⁵

Classification of Burn Depth

Clinicians may use the following classification to characterize burn depth³:

• Superficial burns: affecting the epidermis, which usually stays intact
• Superficial partial-thickness burns: extending through the epidermis to the upper (papillary region) dermis
• Deep partial-thickness burns: extending through the epidermis and upper dermis to the lower (reticular region) dermis
• Full-thickness burns: destroying the epidermis and dermis and extending subcutaneously to fat, muscle, and sometimes even bone

Total Body Surface Area Involvement

Burn severity assessment also includes determining the extent of TBSA affected. The Rule of Nines is a common method that calculates TBSA involvement in the area of partial- and full-thickness burn injuries³:

• Head: ~ 9%
• Torso front: ~ 18%
• Torso back: ~ 18%
• Each leg: ~ 18%
• Each arm: ~ 9%
• Genital area and perineum: ~ 1%
• Palm of the hand: 1%

With the Rule of Nines, if more than 15% of the body is affected, then the patient will require at least one intravenous (IV) line for fluid resuscitation.³ Another method used for TBSA burn calculation, especially in children, is the Lund and Browder Chart.⁵ In this method, each arm accounts for 10%, the anterior trunk and posterior trunk each account for 13%, and head and leg calculations depend on the patient's age. The Palmar Surface Method of TBSA calculation is often used for small burns. In this method, the palm of the hand accounts for 0.5%, and the entire hand surface, fingers included, accounts for 1%.⁵ A burn wound with a TBSA greater than 20% is considered severe.⁵

Causes of Burn Injury

The clinician should ascertain the cause of the burn injury when taking the patient’s history and assessing the wound. Although more than 80% of burns are thermal (eg, from fire, steam, or hot objects),⁵other causes of burn wounds include the following³:

• Electrical sources
• Radiation (sunlight, x-ray exposure, or radiation therapy)
• Chemical contact
• Friction
• Inhalation injury

Early Burn Wound Care

Sometime between 24 and 72 hours after the injury, debridement, wound excision, and wound coverage will likely take place in the operating room.⁴ Wire mesh, temporary grafts, or skin substitutes may be used for wound coverage.⁴ For full-thickness burns of the extremities, patients may be at risk for neurovascular compromise, such as compartment syndrome, and escharotomy or compartment release may be necessary, sometimes urgently.⁴ For other wounds, an escharotomy is indicated in patients with possible respiratory or vascular compromise.⁴

Ongoing Care and Support of Patients With Severe Burns

Rehabilitation of patients with these complex injuries may take years, and optimal long-term care requires a multidisciplinary team.⁴Specific issues include the following:

• The patient’s metabolic rate may rise with the size of the wound.⁴ These patients need nutritional support, often including pharmacologic agents to counter hypermetabolism.⁴
• Although burn-related immunocompromise increases the risk of infection, systemic antimicrobial therapy is administered only when the wound is infected.⁴ Topical antimicrobial ointments, silver-containing agents, bismuth-impregnated petroleum gauze, chlorhexidine, and mafenide may be indicated for certain partial-thickness burns.⁶
• In addition to grafts, surgical procedures to correct contractures may be necessary.
• Patients may need psychosocial support as they heal to adjust to the burn-related changes in their lives and reenter daily living activities and the workforce.⁴

Challenges in Managing Patients with Severe Burns

As mentioned earlier, severe burns, or the body’s response to them, may exhibit an impact on every organ system.^2,7 These effects include airway and pulmonary damage, cardiovascular dysfunction that can lead to hypovolemic shock or cardiac arrest, acute kidney injury, ileus and stress ulcer formation, and neuroendocrine disorders, including increased metabolic rate, immunosuppression, and musculoskeletal contractures.⁷ The often surgical nature of burn treatment can result in prolonged healing and rehabilitation needs that one must consider. Infection prevention is another challenge because the loss of the skin means loss of protection against infection.

Conclusion

Care of patients with severe burn wounds requires clinicians to think quickly and multitask. The stakes are very high for these critically ill patients. A holistic view, encompassing all aspects of the burn injury, its systemic effects, and the patient’s psychosocial milieu, is crucial to ensure the best possible outcome.

References

1. Wang Y, Beekman J, Hew J, et al. Burn injury: challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev. 2018;123:3-17. doi:10.1016/j.addr.2017.09.018
2. National Institute of General Medical Sciences. Burns. Accessed January 31, 2023. https://www.nigms.nih.gov/education/fact-sheets/Pages/burns.aspx
3. WoundSource Editors. An overview of burns: symptoms, causes, and treatments. WoundSource. Published December 31, 2010. Accessed January 31, 2023. https://www.woundsource.com/blog/overview-burns-symptoms-causes-and-tre…
4. Gauglitz GG, Willliams FN. Overview of the management of the severely burned patient. Up to Date. Updated April 6, 2022. Accessed January 31, 2023. https://www.uptodate.com/contents/overview-of-the-management-of-the-sev…
5. Schaefer TJ, Szymanski KD. Burn Evaluation and Management. StatPearls Publishing; Published August 6, 2022. Accessed January 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430741/
6. Tenenhaus M, Jeschke MG, Collins KA. Topical agents and dressings for local burn wound care. Up to Date. Updated August 6, 2022. Accessed January 31, 2023. https://www.uptodate.com/contents/topical-agents-and-dressings-for-loca…
7. Culleiton AL, Simko LM. Caring for patients with burn injuries. Nurs Crit Care. 2013;8(1):14-22. doi:10.1097/01.CCN.0000423824.70370.fa