Surgical Treatment of Burns

Surgical Treatment of Burns
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Updated: Apr 2, 2012
Background
Traumatic injuries cause more deaths in childhood than all other causes combined. Although motor vehicle injuries are
the foremost cause of death, each year approximately 440,000 children receive treatment for burns in the United
States. More than 75,000 of these children require hospitalization, 10,000 experience severe permanent disability, and
2,500 die from thermal injury. Burn injuries represent the third leading cause of mortality in patients younger than 5
years. The overall morbidity from thermal injury has improved markedly over the years as a result of an aggressive
multidisciplinary approach to care for the pediatric patient with thermal injury.
Etiology
Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years,
scalds are responsible for most burns.[1] Scald burns may occur when a child pulls scalding liquid onto himself or may
result from bathtub submersion injuries, which can often be quite severe. In older children, flame burns are more
common. Space heaters, matches, and house fires are the most common etiologic factors for these burns, which are
often full thickness and constitute most fatal burns.
Pathophysiology
Appreciating the major differences between burn management in children and adults is important. Children have nearly
3 times the body surface area (BSA)-to-body mass ratio of adults. Fluid losses are proportionately higher in children
than in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporative
water loss than adults. The large BSA-to-body mass ratio of the child also predisposes the child to hypothermia, which
must be aggressively avoided.
Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children and
adults. As a result, they lose more heat and water than adults do, and they lose these more rapidly than adults. In very
young children, temperature regulation is partially based on nonshivering thermogenesis, which further increases
metabolic rate, oxygen consumption, and lactate production. In addition, because of disproportionately thin skin, a burn
that may initially appear to be partial thickness in a child may instead be full thickness in depth. Thus, the child's thin
skin may make initial burn depth assessment difficult.
Presentation
The depth of burn is classified as follows (see the image below):
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Skin histology diagram.
Superficial partial thickness

These burns are superficial with injury to the epidermis and superficial dermis. These are second-degree burns and
are characterized by ruptured weeping blisters. They are also erythematous and painful. Superficial partial-thickness
burns spontaneously heal within 1-3 weeks, usually without scarring (see the image below).
Superficial partial-thickness burn.
Deep partial thickness

These are deep burns with injury to the epidermis and deeper dermis, but some viable dermis remains. These are
also considered second-degree burns but are whiter and less erythematous as the depth into the dermis increases.
Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult. Deep partialthickness burns heal spontaneously but often after 3-4 weeks. The degree of scarring is related to the length of time
needed for reepithelialization. See the image below.
Deep partial-thickness burn.
Full thickness
Injury to the epidermis and entire dermis occurs. These are the third-degree burns that typically are white, brown, or
black. The eschar is leathery and insensate. These burns do not heal spontaneously (except for very small wounds
that heal by contraction). See the image below.
Full-thickness burn.
Electrical burns
Low-voltage injuries result from sources of less than 1000 volts and include oral injuries from biting electrical cords,
outlet injuries from placing objects into wall sockets, and injuries from contacting live wires or indoor appliances.
High-voltage injuries are caused by sources of more than 1000 volts and result from contact with a live wire outdoors
or from being struck by lightning.
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Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring,
serial electrocardiography, urinalysis, and determination of creatine kinase and urine myoglobin levels. Myoglobinuria
and hemoglobinuria should be aggressively treated with hydration, osmotic diuretics, and alkalinization of the urine to
avoid renal failure. Extremities must be carefully monitored for the development of compartment syndrome,
necessitating escharotomy or fasciotomy. Appropriate radiographic examinations should be performed to exclude
concomitant long bone injury.
Many children who have sustained low-voltage electrical injury can be treated as outpatients as long as (1) the patient
has no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident; (2) the patient
remains asymptomatic after 4 hours of observation in the emergency department; (3) the wounds are manageable in
an outpatient setting; and (4) the patient can return for a wound check the following day. Parents of children with oral
commissure burns must be instructed in the application of pressure to the lip in the event that the burn erodes into the
labial artery, a complication that usually does not develop until several days after the injury.
Frostbite
Frostbite results from prolonged exposure to severe cold and usually affects the ears, nose, hands, and feet. Ice
crystal formation in the tissues results in cellular dehydration, venous dilation and vasoconstriction causing peripheral
blood pooling, and finally, tissue necrosis.
Signs and symptoms of frostbite include red, blue, or pale skin; a prickling sensation with superficial frostbite; painless
rigid skin with deep frostbite; and functional impairment.
Treatment involves placing the patient in a warm environment, removing clothing from the affected region, and
rewarming the affected region by immersion in water at 100-105F for up to 30-45 minutes. Do not rewarm the frozen
part with massage or dry heat.
Chemical burns
Saturated clothing should be removed, powdered chemicals should be brushed off the skin, and the contaminated
area irrigated with copious amounts of water for at least 20 minutes, and until the patient experiences a decrease in
pain in the wound.[2]
Chemical injuries to the eye are treated by forcing the eyelid open and flushing the eye with water or saline.
With gasoline injuries, the petroleum products may cause severe full-thickness cutaneous tissue damage, and
absorption of the hydrocarbon may cause pulmonary, hepatic, or renal failure.
Indications
Burn excision and grafting are recommended for all full-thickness burns and for deep partial-thickness burns that would
appear to take more than 2-3 weeks to heal.
Relevant Anatomy
See Clinical for a discussion of relevant anatomy in patients with burn injuries.
Contraindications
Any condition that would ordinarily preclude the patient with burn injuries from having general anesthesia, otherwise no
contraindications to surgery are noted.
Contributor Information and Disclosures

Author
Gail E Besner, MD John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research,
Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of
Surgery, Ohio State University College of Medicine
Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association,
American Medical Association, American Medical Women's Association, American Pediatric Surgical Association,
Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical
Care Medicine, Society of Surgical Oncology, and Society of University Surgeons
Disclosure: Nothing to disclose.
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Coauthor(s)
Iyore Amy Otabor, MD Clinical Instructor House Staff, Department of General Surgery, The Ohio State University
College of Medicine
Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, American
Medical Student Association/Foundation, and Student National Medical Association
Specialty Editor Board
Denis Bensard, MD Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery,
Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University
of Colorado School of Medicine
Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic
Surgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal and
Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and Southwestern
Surgical Congress
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting
Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo
Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American
College of Physician Executives, American College of Surgeons, American Medical Association, American
Pediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education
H Biemann Othersen Jr, MD Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery,
Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American
Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical
Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American
Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of
Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical
Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Chief Editor
Harsh Grewal, MD, FACS, FAAP Clinical Professor of Surgery, Temple University School of Medicine; Chief,
Division of Pediatric Surgery, Cooper University Hospital
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics,
American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education,
Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery
Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,
and Southwestern Surgical Congress
References
1. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics.
Oct 2008;122(4):799-804. [Medline].
2. O'Neill TB, Rawlins J, Rea S, Wood F. Complex chemical burns following a mass casualty chemical plant
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incident: How optimal planning and organisation can make a difference. Burns. Feb 20 2012;[Medline].
3. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazene
dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. Sep
2011;4(3):183-7. [Medline]. [Full Text].
4. Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant human
growth hormone and propanol decreases hypermetabolism and inflammation in severely burned children.
Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].
5. Coruh A, Yontar Y. Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns: A
New Source of Auto-Skin Grafting. J Burn Care Res. Nov 10 2011;[Medline].
6. Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9.
[Medline].
7. Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia,
PA: Hanley & Belfus; 2000:246-52.
8. Heimbach D. What's new in general surgery: burns and metabolism. J Am Coll Surg. Feb
2002;194(2):156-64. [Medline].
9. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J
Med. Oct 25 2001;345(17):1223-9. [Medline].
10. Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care.
Philadelphia, PA: WB Saunders Co; 1996:237-45.
11. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial Dressing
Reduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun
2007;28:409-411. [Medline].
12. Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treated
as Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with Silver
Sulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].
13. Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit
Care Med. Jul 2001;2(3):223-224. [Medline].
14. Kraft R, Herndon DN, Al-Mousawi AM, Williams FN, Finnerty CC, Jeschke MG. Burn size and survival
probability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet. Mar
17 2012;379(9820):1013-21. [Medline].
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Surgical Treatment of Burns Treatment & Management
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Author: Gail E Besner, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP more...
Updated: Apr 2, 2012
Medical Therapy
Rapid assessment and treatment of immediate life-threatening conditions is mandatory in patients with burns.
Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway
edema. Because of the small diameter of the pediatric airway, a low threshold for intubation should be maintained.
Children with burns affecting more than 10% of the body surface area (BSA) should receive intravenous fluid
resuscitation. Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physical
examination should be obtained. Wet sheets or cooling packs should not be used because this contributes to
hypothermia. Patients should be kept warm by infusing warm intravenous fluids, elevating room temperatures, and
minimizing patient exposure. Tetanus immunization should be administered as indicated.
Admission criteria
Hospital admission criteria for patients with thermal injury include the following:
Partial-thickness burns greater than 10% total BSA (TBSA)
Full-thickness burns greater than 2% TBSA
Burns involving the face, hands, genitalia, perineum, or major joints
Circumferential extremity burns
All high-voltage electrical burns, including lightning injury
Admission of low-voltage electrical burns is selective
Chemical burns
Inhalation injury
Burn injuries in patients with preexisting medical disorders that could complicate management, prolong
recovery, or affect mortality (eg, diabetes, immunosuppression)
Suspected child abuse
Cases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for the
burn)
Inhalation injury
Clues to inhalation injury include increased respiratory rate, hoarseness, being burned in an enclosed space, altered
mental status, head and neck burns, singed nasal hairs, inflamed oral mucosa, and carbonaceous sputum. Indications
for intubation include compromised upper airway patency, the need for ventilatory support as manifested by poor gas
exchange or increased work of breathing, or compromised mental status. Correlation of the history and clinical findings
comprise the most practical approach to determining the need for intubation.
Important considerations regarding the pediatric airway include the fact that the larynx is more cephalad in children, that
children deteriorate faster than adults in terms of upper airway edema and alveolar-capillary block, and that repeated
intubation attempts may cause edema and obstruction. For these important reasons, experience in pediatric intubation
is needed. Once an airway is established, securing the airway well is important, especially in patients with facial burns,
to avoid accidental extubation (see the image below).
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Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal
tube in patients with facial burns.
Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct of
combustion that displaces O2 from the hemoglobin (Hgb) molecule. It has 250X the affinity of O2 for Hgb, therefore
shifting the Hgb-O2 disassociation curve to the left. This impairs O2 unloading at the tissue level and causes a switch to
anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected with persistent metabolic
acidosis despite adequate volume resuscitation. Remember that the PaO2 in an arterial blood gas will be normal since
the amount of O2 dissolved in arterial plasma is normal. In addition, the O 2 sat (measured O2 saturation of Hgb) will be
normal on a standard pulse oximeter in the presence of CO toxicity since the oximeter cannot differentiate between
Hgb saturated with O2 and Hgb saturated with CO.
To treat CO toxicity, all patients with inhalation injury should be treated with 100% O2. This lowers the T of CO to
30-90 minutes whereas it would be 4-5 hours in room air. Therefore, all major burns should be treated with 100% O2
until CO toxicity is ruled out or the CO level returns to normal. Hyperbaric oxygen (HBO) therapy (3 atm) leads to even
more rapid displacement of CO within 20 minutes. Its use should be considered for CO greater than 50%, severe
neurologic compromise, and nonresponsiveness to 100% O2.
Cyanide toxicity results from the burning of natural (wool, silk, cotton, paper) or synthetic (polyurethane, plastic, nylon,
acrylic) products, which leads to the production of toxic hydrocyanide gas. Cyanide binds to the cytochrome oxidase
system, inhibiting cellular metabolism and ATP production. It causes a shift to anaerobic metabolism with profound
metabolic acidosis and obtundation. The treatment of cyanide toxicity involves administration of the cyanide antidote
sodium thiosulfate (8 g intravenously if < 12 y; 12.5 g intravenously if 12 y). The antidote converts cyanide to
nontoxic, excretable thiocyanate.
Smoke inhalation can also cause a chemically induced inflammatory reaction in the airways, leading to microbial
colonization and pneumonia. Affected patients may need ventilatory support. In severe cases, oscillating ventilators
and extracorporeal membrane oxygenation (ECMO) have been successfully used in these patients.
Fluid resuscitation
Intravenous access may be obtained percutaneously or by cutdown, either peripherally or centrally. Peripheral access
in an unburned area is preferred. Intraosseous (IO) infusion may be lifesaving in the severely burned patient if
necessary.
Several burn resuscitation formulas can be used in pediatric burn care; the modified Parkland formula is most
commonly used. Ringer lactate solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each percent of
BSA burned for the first 24 hours. One half of the calculated fluid needs are administered in the first 8 hours after the
burn occurs, and the remaining half are administered over the following 16 hours. Maintenance fluids should be
administered concomitantly (this represents the modification to the Parkland formula for pediatric patients).
Representative fluid resuscitation guidelines for pediatric burn patients with burns more than 15% TBSA are as
follows:
Modified Parkland formula (Parkland formula plus maintenance fluids, used in patients who weigh less than 20
kg)
Resuscitation fluids - 3-4 mL Ringer lactate X weight (kg) X %TBSA burned (second-degree and third degree);
half administered over the first 8 hours (from time of injury), remaining half administered over the next 16 hours
Maintenance fluids - Ringer lactate solution with 5% dextrose at 4 mL/kg/h for 0-10 kg, plus 2 mL/kg/h for 10-20
kg, plus 1 mL/kg/h for each kg more than 20 kg
Prehospital fluids must also be considered. If prehospital fluid resuscitation is inadequate, the fluid deficit must be
added to the fluid rate calculated for the first 8 hours of resuscitation.
For patients with burns of 15% TBSA or less, the following are indicated:
Patients with burns 5-10% TBSA who are taking oral fluids well - Oral fluids only
Patients with burns 5-10% TBSA who are not taking oral fluids well - Maintenance fluids
Patients with burns 10-15% TBSA - 150% maintenance fluids
The above recommendations are guidelines only. Patients with burns of more than 15% TBSA should have a urinary
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catheter placed. Desired urine output is 1 mL/kg/h for patients who weigh less than 30 kg and 30-50 mL/h for patients
who weigh more than 30 kg. For major burns, fluid resuscitation needs to be reassessed hourly based on the patient's
urine output.
Rates of fluid administration should be altered based on the patient's response. If a patient presents after some
period of delay and has not been resuscitated properly during that time, adjustments should be made in the calculated
fluid requirements to take these factors into account. Infants are at risk of developing hypoglycemia because of limited
glycogen stores; therefore, glucose levels should be monitored, and Ringer lactate solution with 5% dextrose should
be used for maintenance fluids. Assess response to fluid administration by measuring urine output via an indwelling
urinary catheter. Monitoring sensorium, peripheral circulation, and blood pH is also helpful to assess the adequacy of
resuscitation.
Temperature regulation
As previously mentioned, children younger than 2 years lose heat and water more rapidly than older children and adults
because of their thinner layers of skin and insulating subcutaneous tissue; temperature regulation in these very young
children is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen
consumption, and lactate production. Therefore, hypothermia in the pediatric burn patients should be avoided by
paying careful attention to increasing the room temperature, minimizing exposure time, and using radiant warmers, fluid
warmers, and other tools.
Systemic antibiotics
Prophylactic systemic antibiotics are not used in the treatment of burn patients because this increases the risk of
infection with resistant organisms. Instead, the use of systemic antibiotics is reserved for the treatment of specific
infections, with antibiotics administered at the first sign of clinical infection. Antibiotic regimens are then modified as
culture results and antimicrobial sensitivity results become available.
Burn wound cellulitis refers to infection spreading in dermal lymphatics in the nonburned skin surrounding a burn,
usually occurring in the first few days after burn injury. Burn cellulitis is commonly caused by Streptococcus pyogenes.
Invasive burn wound sepsis leads to systemic toxicity with high fever, bacteremia, and a hyperdynamic circulatory state
with hypotension and cardiovascular collapse. Diagnosis can be made by either clinical examination, or by quantitative
burn wound cultures or burn wound histology.
Surgical Therapy
Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterial
colonization. Silver sulfadiazine cream (Silvadene) is a commonly used broad-spectrum topical antimicrobial cream. It
is applied as a thin layer with gauze dressings twice daily. It does cause transient neutropenia, which resolves even
with continued use of the agent.[3] Facial burns are usually treated with a combination antimicrobial product containing
polymyxin B, neomycin, and bacitracin (eg, Neosporin ointment) or an immunomodulating cream such as beta-Glucan
(a cream that contains complex carbohydrate isolated from the cell wall of oats). The use of silver sulfadiazine cream
is avoided on the central face because it may cause severe ocular irritation. Ear burns should be treated with mafenide
cream (Sulfamylon) because the thin subcutaneous tissue in the ears predisposes to the development of chondritis.
Hydrotherapy provides wound and body cleansing with gentle removal of loose eschar and topical ointments. If used,
hydrotherapy sessions are limited to 10-15 minutes once a day to decrease promotion of infection. Topical enzyme
preparations such as Santyl (a collagenase-containing debriding ointment) can be applied to the burn surface to
chemically debride devitalized tissue without injuring viable tissue. This allows earlier assessment of the wound bed,
with fewer days to a clean wound bed and reepithelialization.
To avoid the need for painful dressing changes, artificial skin substitutes, such as Aquacel Ag and Acticoat, may be
used for the treatment of partial-thickness burns. Aquacel Ag is a hydrofiber dressing in which antibacterial silver (Ag+)
ions are incorporated into the dressing and released in a continuous sustained-release fashion for continuous topical
antimicrobial effects. The fibers in the dressing hydrate upon contact with the burn surface creating a viscous gel that
prevents fluid loss and traps bacteria. Once adherent to the burn surface, usually within 24-48 hours, the dressing can
be left in place for as long as 2 weeks, during which time reepithelialization is usually complete. If reepithelialization is
not complete by that time, the Aquacel Ag can be reapplied (see the image below).
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Aquacel Ag adherent to burn wounds.
Preoperative Details
Successful burn wound management in children demands conversion of open wounds to closed wounds as soon as
possible. The concept of early removal of burn eschar and immediate wound closure has gained widespread
acceptance. Evidence suggests that early eschar removal is effective in decreasing morbidity and improving the
mortality rate. Full-thickness burns (with the exception of very small injuries that are allowed to heal by contraction)
should be grafted. The goal is to excise the wound within the first week of the injury. Additionally, deep partial-thickness
burns that take longer than 3 weeks to heal usually benefit from grafting, with less hypertrophic scarring and better
cosmetic results.
Intraoperative Details
Preoperatively, patients must be hemodynamically sound and have optimal acid-base, fluid, and electrolyte balance.
Adequate blood must be available before considering excision and grafting. Preoperative antibiotics are not required
unless patients have other compromising systemic diseases or invasive burn sepsis; however, a prophylactic dose of
a first-generation cephalosporin antibiotic may be used.
Attention to maintenance of body temperature at all times is extremely important. Burn excision involves tangential
removal of thin slices of eschar until profuse pinpoint bleeding from a moist, viable, deep dermal surface or
subcutaneous fat is observed. Meticulous hemostasis is then obtained using epinephrine-soaked (1:100,000)
sponges, topical spray thrombin, and electrocautery, followed by immediate grafting with thin sheets of autograft. Skin
grafting involves harvesting partial-thickness pieces of skin from donor sites on unburned areas using a dermatome.
The thickness of the harvested skin commonly is 8-12 thousandths of an inch, depending on the age and skin
thickness of the patient. The grafts are then applied to the wound bed and secured.
Autograft skin is obviously preferred whenever possible. Unfortunately, patients with large burns may not have enough
autologous skin available for complete coverage. In such patients, burns can be excised and temporarily covered with
numerous biologic dressings (eg, cadaveric skin, pigskin) or skin substitutes. As more donor sites become available,
the temporary wound covers are removed and the wounds are grafted. Studies have shown that growth hormone
(0.15-0.2 mg/kg/d intramuscularly) can speed donor site healing, allowing more rapid reharvesting of healed donor
sites.[4, 5]
Meshed autografts are harvested from donor sites and passed through a meshing machine that cuts a series of
parallel offset slits in the grafts at various expansion ratios (eg, 1.5:1, 2:1). This technique allows expansion of the graft
to cover a larger surface area. In addition, the interstices in the graft allow for drainage of fluids under the graft so that
the grafts do not lift off their beds. Unfortunately, the meshed patterns of the grafts persist after healing and often lead
to suboptimal cosmetic results.
Nonmeshed or sheet grafts are harvested the same way but are not passed through the meshing machine. The use of
sheet grafts leads to a better cosmetic result. Because the grafts do not expand, covering major areas with sheet
grafts alone is difficult. Nonetheless, sheet grafts should be used whenever possible, especially in highly visible and
functional areas, such as the face, neck, hands, and joints. Sheet grafts should be inspected after approximately 48
hours so that any underlying fluid can be aspirated to avoid loss of the graft. Dressings can be left in place for as long
as 5 days if desired on meshed grafts, as long as no suspicion of infection is noted.
Follow-up
Avoidance of scarring and contracture is the best treatment.
Scar prevention
For burns that take longer than 3 weeks to heal, or for wounds that have been grafted, hypertrophic scarring can be
minimized with the use of compression therapy with custom-made garments that apply 25-30 mm Hg pressure to all
wounds. Gel pads can be added underneath or sewn into the garments to apply extra compression. Compression
therapy is continued throughout the wound healing process (approximately 12-18 months). Lotion application with
massage therapy is used to keep the healed or grafted areas soft and supple.
Contracture prevention
Contractures refer to hypertrophic scar formation over joints that result in decreased range of motion. Aggressive
attention to occupational and physical therapy, with appropriate consultation, is necessary to ensure optimal results.
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Active and passive range of motion exercises are instituted and splints are worn at night and between exercise
periods. Patients with burns are at risk for contractures are followed for years to monitor for the development of these
complications.
Psychological sequelae
Burn scarring can lead to significant psychological sequelae and the assistance of a trained psychologist or
psychiatrist can be an important addition to the overall care of these patients.
Patient education
For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education
article Thermal (Heat or Fire) Burns.
Complications
Complications to surgery in patients with burns include bleeding, infection, or graft loss. If infection is suspected,
dressings can be changed to include broad spectrum aqueous Sulfamylon solution.
Outcome and Prognosis

With the exception of infants, the prognosis for survival in children and adolescents is quite good. In the past decade,
the size of a survivable injury has increased from 70% BSA burned to more than 95% BSA burned in children younger
than 15 years.
A large, single-center study of pediatric burn patients analyzed the relationship between burn size and probability of
survival. A cohort of 952 severely burned patients of comparable age and sex distribution were studied. Results
suggest that a burn size of roughly 60% BSA is a crucial threshold for postburn morbidity and mortality. Child burn
victims with greater than 60% BSA burns should be immediately transferred to a specialized burn center to combat the
increased risk of poor outcome associated with this burn size.[14]
Future and Controversies

Numerous areas in both the clinical and basic sciences are undergoing active research. One such area of interest is
the hypermetabolic response to severe burns and the association with increased energy expenditure and muscleprotein catabolism. Studies have investigated different mechanisms to attenuate the muscle-protein catabolism that
occurs frequently, despite appropriate nutritional support, in children with large burns.[6] These studies are promising
because attenuation of muscle-protein losses may improve strength and ability to recuperate.
A prospective randomized controlled trial of recombinant human growth hormone in combination with the beta-blocker
propanolol demonstrated attenuated hypermetabolism and inflammatory and acute phase responses after severe burn
injury.[4] Human growth hormone improves posttraumatic hypermetabolism, but its use alone is associated with
hyperglycemia and increased free fatty acids and triglycerides. Concomitant administration of propanolol improved fat
metabolism and insulin sensitivity and avoided the adverse effects of recombinant growth hormone alone.
Another active area of research is in the development of cultured skin to treat very large burns. At present, cultured
epidermal autografts (CEAs), which are grown from the patient's own uninjured epidermis, are commonly used.
However, these grafts are very thin and fragile. In the future, cultured bilayered skin (epidermis and dermis) should
lead to better functional and cosmetic results.

Author
Gail E Besner, MD John E Fisher Endowed Chair in Neonatal Reseach, Director, Pediatric Surgical Research,
Department of Surgery, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of
Surgery, Ohio State University College of Medicine
Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association,
American Medical Association, American Medical Women's Association, American Pediatric Surgical Association,
Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical
Care Medicine, Society of Surgical Oncology, and Society of University Surgeons
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Coauthor(s)
Iyore Amy Otabor, MD Clinical Instructor House Staff, Department of General Surgery, The Ohio State University
College of Medicine
Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, American
Medical Student Association/Foundation, and Student National Medical Association
Denis Bensard, MD Director of Pediatric Surgery and Trauma, Attending Adult and Pediatric Acute Care Surgery,
Attending Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University
of Colorado School of Medicine
Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic
Surgery, International Society for Minimally Invasive Cardiac Surgery, Society of American Gastrointestinal and
Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Society of University Surgeons, and Southwestern
Surgical Congress
Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting
Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo
Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American
College of Physician Executives, American College of Surgeons, American Medical Association, American
Pediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education
H Biemann Othersen Jr, MD Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery,
Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American
Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical
Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American
Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of
Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical
Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Chief Editor
Harsh Grewal, MD, FACS, FAAP Clinical Professor of Surgery, Temple University School of Medicine; Chief,
Division of Pediatric Surgery, Cooper University Hospital
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics,
American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education,
Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery
Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,
and Southwestern Surgical Congress
References
1. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics.
Oct 2008;122(4):799-804. [Medline].
2. O'Neill TB, Rawlins J, Rea S, Wood F. Complex chemical burns following a mass casualty chemical plant
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incident: How optimal planning and organisation can make a difference. Burns. Feb 20 2012;[Medline].
3. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazene
dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. Sep
2011;4(3):183-7. [Medline]. [Full Text].
4. Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant human
growth hormone and propanol decreases hypermetabolism and inflammation in severely burned children.
Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].
5. Coruh A, Yontar Y. Application of Split-Thickness Dermal Grafts in Deep Partial- and Full-Thickness Burns: A
New Source of Auto-Skin Grafting. J Burn Care Res. Nov 10 2011;[Medline].
6. Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9.
[Medline].
7. Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia,
PA: Hanley & Belfus; 2000:246-52.
8. Heimbach D. What's new in general surgery: burns and metabolism. J Am Coll Surg. Feb
2002;194(2):156-64. [Medline].
9. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J
Med. Oct 25 2001;345(17):1223-9. [Medline].
10. Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care.
Philadelphia, PA: WB Saunders Co; 1996:237-45.
11. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial Dressing
Reduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun
2007;28:409-411. [Medline].
12. Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treated
as Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with Silver
Sulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].
13. Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit
Care Med. Jul 2001;2(3):223-224. [Medline].
14. Kraft R, Herndon DN, Al-Mousawi AM, Williams FN, Finnerty CC, Jeschke MG. Burn size and survival
probability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet. Mar
17 2012;379(9820):1013-21. [Medline].
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Emergency Escharotomy
1 of 5
Medscape Reference
Reference
News
Reference
Education
MEDLINE
Author: Neelu Pal, MD; Chief Editor: Erik D Schraga, MD more...
Updated: Dec 13, 2011
Overview
Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of
burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This
is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the
extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of
the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of
30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent
tissue death.
The circumferential eschar over the torso can lead to significant compromise of chest wall excursions and can hinder
ventilation. Abdominal compartment syndrome with visceral hypoperfusion is associated with severe burns of the
abdomen and torso. Similarly, airway patency and venous return may be compromised by circumferential burns
involving the neck.
Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more
compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue
injury or functional compromise (see image below). For more information on burn treatment, see eMedicine article
Burns, Rehabilitation and Reconstruction.
Escharotomy to release the chest wall and allow for ventilation of the patient.
Escharotomy is considered an emergent procedure in burn treatment protocols. However, it rarely needs to be
performed in the emergency department at the time of initial presentation of the severely burned patient. Advanced
ventilation methods allow the patient to be stabilized to allow for expeditious transfer to the intensive care unit or the
surgical suite, where the procedure can be performed under more controlled circumstances.[1, 2] For more information,
see eMedicine article Burns, Resuscitation and Early Management.
Indications
Indications for emergency escharotomy are the presence of a circumferential eschar with one of the following:
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1. Impending or established vascular compromise of the extremities or digits

2. Impending or established respiratory compromise due to circumferential torso burns[3]
Severely burned extremities should be elevated and range of motion exercises performed every 15-30 minutes as
tolerated by the patient. This can help to minimize tissue edema and elevated tissue pressures.
Neurovascular integrity should similarly be monitored frequently and in a scheduled manner. Capillary refilling time,
Doppler signals, pulse oximetry, and sensation distal to the burned area should be checked every hour. [4] Limb deep
compartment pressures should be checked initially to establish a baseline. Subsequently, any increase in capillary refill
time, decrease in Doppler signal, or change in sensation should lead to rechecking the compartment pressures.
Compartment pressures greater than 30 mm Hg should be treated by immediate decompression via escharotomy and
fasciotomy, if needed.[5, 6] A decision-making algorithm is shown in the image below.
Decision-making algorithm for escharotomy in severely burned extremities.
Contraindications
Patients who have established irreversible gangrene of the extremity or digit in association with a circumferential or
near-circumferential eschar would not likely benefit from an escharotomy. This scenario is likely to be encountered in
patients who have been managed nonoperatively for a prolonged period of time, during which the neurovascular status
of the extremity involved was not monitored adequately. In this group of patients, the risks and potential complications
of performing an escharotomy are to be weighed carefully against the benefits.
Anesthesia
In the severely burned patient who is obtunded and intubated, no anesthesia is required because the eschar is
nonviable tissue with complete destruction of nerve endings.[7]
Patients who are awake or conscious require sedation and, occasionally, general anesthesia, to allow the
procedure to be completed adequately. For more information, see Procedural Sedation.
Equipment
Sterile drapes
Povidone-iodine solution
Electrocautery: Escharotomy can result in substantial blood loss; hence, it should be performed using
electrocautery and in a controlled environment such as the operating room or the intensive care unit.
Dressing materials
Positioning
Position the patient supine.
Maintain the ability to move the patient into lateral positions to allow circumferential access to the extremity or
torso, as needed.
Technique
Clean the proposed surgical site with povidone-iodine solution and drape with sterile drapes.
Use electrocautery to create incisions in the eschar up to the level of the subcutaneous fat.
Severely burned limbs may require performance of fasciotomy concomitantly with the escharotomy.
This may be determined preoperatively by measurement of compartment pressures greater than 30
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mm Hg.
Compartment pressures can be obtained intraoperatively after completion of the escharotomy. If
elevation of pressure above 30 mm Hg is persistent, a fasciotomy should be performed.
Carry the incision of the eschar down through to the level of the subcutaneous fat. An immediate release in
tissue pressure is experienced as a discernible popping sensation.
Carry the incisions approximately 1 cm proximal and distal to the extent of the burn.
Areas overlying joints have densely adherent skin, and the incisions should extend across joints to allow for
decompression of neurovascular structures. Take care to avoid damage to the neurovascular bundles that run
superficially and near joints.[5]
Make escharotomy incisions for the chest, neck, and limbs as shown in the diagram below.
Diagrammatic representation of escharotomy incisions over the chest, neck, and limbs.
Make escharotomy incisions for the digits as shown in the diagram below.
Diagrammatic representation of escharotomy incisions over the digits.
Bleeding from escharotomy incisions should be controlled by use of the electrocautery.

The resulting wounds are a potential source of infection and should be treated, as the burn wound, with
application of topical antimicrobial and dressings.
Adequacy of the escharotomy can be tested after completion by checking capillary filling pressures, using a
handheld Doppler, and by checking compartment pressures.[8]
Improvement in flow and decrease in compartment pressures indicate that the procedure is adequate.
Persistent low Doppler signals or elevated compartment pressures indicate inadequate release of
tissue pressure and a need for additional escharotomy incisions and, possibly, the addition of
fasciotomy.
Pearls
Escharotomy incisions for the limbs should be carried to the level of the thenar and hypothenar eminences for
the upper extremity and to the level of the great toe medially and the little toe laterally for the lower extremity.
Limb escharotomy incisions run in close proximity to superficial veins, and these veins should be identified and
preserved, if possible. If the escharotomy incision transects these veins, adequate hemostasis should be
ensured using electrocautery or ligation.
Digital escharotomy should be performed by a practitioner with experience in hand surgery for burns whenever
possible. The locations of the incisions for decompression are near the digital neurovascular bundles, and
injury to these can lead to profound and permanent loss of function.
Complications
Complications of inadequate decompression[9] or of not performing an escharotomy when indicated are severe.[10]
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They include the following:

Muscle necrosis
Nerve injury
Gangrene resulting in amputation of the limb or digits
Respiratory compromise due to inadequate ventilation as a result of compressive effect of chest and upper
torso burns
Abdominal compartment syndrome with visceral hypoperfusion as a result of abdominal wall and upper torso
burns[11]
Systemic complications of inadequate decompression including myoglobinuria, renal failure, hyperkalemia, and
metabolic acidosis
Complications of an escharotomy are as follows:
Excessive blood loss
Inadvertent fasciotomy: This results in exposure of the underlying viable tissue, which can become desiccated.
Incision/injury to the underlying healthy tissue including neurovascular structures, especially in the extremities
and digits
Bacteremia: Underlying tissue may be infected, and the manipulation can result in bacteremia and septic shock.
If underlying infection is suspected, the escharotomy should be performed under antibiotic coverage.
Infection of the open escharotomy wounds: These wounds are treated with the same degree of care (with
dressings and application of antimicrobial agents) as the burns wounds. These wounds also contribute to the
ongoing insensate fluid losses in a manner similar to the burns wounds.

Author
Neelu Pal, MD General Surgeon
Neelu Pal, MD is a member of the following medical societies: American College of Surgeons, American Medical
Association, and Society of American Gastrointestinal and Endoscopic Surgeons
Chief Editor
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical
Associates
Additional Contributors
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review
and referencing for this article.
References
1. Kupas DF, Miller DD. Out-of-hospital chest escharotomy: a case series and procedure review. Prehosp
Emerg Care. Jul-Sep 2010;14(3):349-54. [Medline].
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2. Rumbach AF, Ward EC, Cornwell PL, Bassett LV, Khan A, Muller MJ. Incidence and Predictive Factors for
Dysphagia After Thermal Burn Injury: A Prospective Cohort Study. J Burn Care Res. Nov
2011;32(6):608-616. [Medline].
3. Yildiz TS, Agir H, Koyuncu D, Solak M, Toker K. Survival of an eight-year-old child with a very severe
high-tension electrical burn injury: a case report. Ulus Travma Acil Cerrahi Derg. Oct 2006;12(4):326-30.
[Medline].
4. Piccolo NS, Piccolo MS, Piccolo PD, Piccolo-Daher R, Piccolo ND, Piccolo MT. Escharotomies,
fasciotomies and carpal tunnel release in burn patients--review of the literature and presentation of an
algorithm for surgical decision making. Handchir Mikrochir Plast Chir. Jun 2007;39(3):161-7. [Medline].
5. Roberts JR, Hedges JR, et al. Burn care procedures. In: Roberts JR, ed. Clinical Procedures in Emergency
Medicine. Vol 1. 4 th ed. USA: Saunders; 2004:39.
6. Burd A, Noronha FV, Ahmed K, Chan JY, Ayyappan T, Ying SY, et al. Decompression not escharotomy in
acute burns. Burns. May 2006;32(3):284-92. [Medline].
7. Feldmann ME, Evans J, O SJ. Early management of the burned pediatric hand. J Craniofac Surg. Jul
2008;19(4):942-50. [Medline].
8. Saffle JR, Zeluff GR, Warden GD. Intramuscular pressure in the burned arm: measurement and response to
escharotomy. Am J Surg. Dec 1980;140(6):825-31. [Medline].
9. Brown RL, Greenhalgh DG, Kagan RJ, Warden GD. The adequacy of limb escharotomies-fasciotomies after
referral to a major burn center. J Trauma. Dec 1994;37(6):916-20. [Medline].
10. Gravante G, Delogu D, Sconocchia G. "Systemic apoptotic response" after thermal burns. Apoptosis. Feb
2007;12(2):259-70. [Medline].
11. Oda J, Ueyama M, Yamashita K, et al. Effects of escharotomy as abdominal decompression on
cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients. J
Trauma. Aug 2005;59(2):369-74. [Medline].
12. Deitch EA. The management of burns. N Engl J Med. Nov 1 1990;323(18):1249-53. [Medline].
8/8/2012 3:16 PM


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