**10. Evaluation of the severity of burn and referral of the patient**

to systemic activation of platelet aggregation and fibrinolysis [1]. After the edema phase, a hypermetabolic state ensues which is characterized by an increase in oxygen consumption, marked protein and lipid catabolism, increase in energy requirements, high cardiac output, tachycardia, severe muscle weakness, cachexia, and decrease in immune functions [3, 15, 16].

Although the wound healing phases are similar to other types of wounds, the prolonged healing time is especially important in burn wounds [1–3]. The severity of burn, the mechanism of injury, and associated diseases of patients influence the wound healing [1]. Inflammatory phase includes the vasodilation and inflammatory cell migration through the cytokine signaling cascade. In proliferative phase, epithelization takes place by the migration of keratinocytes from the epithelium of the wound edges and dermal appendages. Remodeling (maturation) phase is characterized by the deposition of collagen by myofibroblasts, compaction of the connective tissue, and finally the contraction of the wound. Although the wound contraction and scar formation are normal and necessary for the closure of wound, excessive fibrosis and increased tensile stress during remodeling carry the risk of abnormal scar formation. Intense and prolonged inflammatory response with increased release of cytokines, growth factors, and other mediators from the inflammatory cells and platelets are associated with scar formation. The depth of burn, age of the patient, the treatment, and response of wound are important determinants for the development of scar tissue. Wounds that are not healed in 2–3 weeks are generally at risk of

Superficial burn wounds heal completely in 5–7 days during the proliferative phase. As the required dermal components are lost in deep burns, proliferation cannot be provided, and the epithelialization is delayed. The lack of supportive and vascular tissue is associated with abnormal contraction, and these wounds heal with hypertrophic scarring and contractures if

Early and appropriate treatment of burn injury is associated with better prognosis. Prehospital management and the treatment of burn patients in the emergency department fall out of the scope of this chapter and include the general rules for trauma patients. As the airway edema may start soon after burn and unexpectedly, early intubation may be indicated. Since massive edema may develop in extended burns, all jewelry and accessories should be taken off. Specific interventions may be indicated according to the mechanism of burn (electrical, chemical burns). Until the patient is referred to the medical center, wounds should just be covered with clean cloth. Cooling with compress may be done; however, unburned regions should be

As the hypovolemic shock is associated with high morbidity and mortality, fluid resuscitation should be done early and adequately. Several criteria have been described for fluid resuscitation

developing aberrant scar tissue [1–3].

6 Hot Topics in Burn Injuries

left to heal spontaneously [1–3].

of burn patients [11, 17].

**9. Management of the burn patient at first step**

kept warm in order to avoid hypothermia [12, 15].

Assessing the severity of burn injury is important in deciding the need for hospitalization. To assess the severity of damage, special indexes have been described including "Burn Index (BI)" and "prognostic burn index (PBI)" [11].

To assess the extent of burned area, several methods can be used including rule of nines, rule of fives, and Lund-Browder Chart. Lund-Browder Chart is especially used for children which more accurately estimates the age-specific percentage of TBSA [11, 12, 15]. Additionally, for local assessments of small burns, the palm method (palm with fingers accounts for 1% of total body surface area) can be used practically in adults. First-degree burns are not considered in the calculation of TBSA [11, 12].

Although more precise methods including laser Doppler flowmetry and video microscopy have been defined, the depth of burn is mostly estimated clinically (the presence of pain or blister, appearance and color of the skin) in practice [11, 15]. Burns can be classified into three types according to the depth of injury:


Fourth-degree burns involve deeper structures including the subcutaneous tissue, muscle, tendons, ligaments, and bone. There is gangrene of tissue and carbonized appearance [12].

After the prehospital stabilization of the patient, depending on the severity of injury, treatment in a more equipped hospital may be required [11, 12]. The referral criteria may vary across different studies. To explain roughly, while major burns must be managed in hospitals with multidisciplinary burn teams, moderate burns can be managed in minor hospitals. No matter the extent, chemical burns, burns due to lighting strike, burns during pregnancy, and burns with suspicion of child abuse must be hospitalized. On the other hand, minor burns can be treated at outpatient clinics [3, 11, 12].

Pain management is important in burn patients since the discomfort from pain results in anxiety, increases the risk of prolonged hospitalization, leads to loss of patient confidence, and complicates the interventional procedures [12, 18]. Burn patients may suffer from different types of pain including background and procedural pain. In severe burns, moderate to potent opioids (fentanyl, morphine, ketamine, and others) are preferred, and non-steroidal antiinflammatory drugs (NSAIDs) may be added to reduce the overall dose of opioids. NSAIDs may be sufficient to relieve pain in patients with mild to moderate burns. As they reduce the perception of pain, anxiolytics such as benzodiazepines may also be used. Although mild anesthetics are adequate for simple procedures, deeper anesthesia (with tramadol, ketamine, etc.) is required for the patients with severe burns during excision and grafting. Antidepressants and anticonvulsants are used as first-line therapies for neuropathic pain that may be seen in burn patients. Psychological therapies have also been reported with various successes for management of pain [12, 18].

As the infection risk is increased in burn patients due to immunosuppression and the wounds can be rapidly contaminated by the organisms, prevention of infection should be the primary strategy in burn wound care [3, 11, 12]. Disinfectants can be used without inhibiting wound healing, and wounds should be cleaned with tap water, saline, and non-irritant soaps [11, 12]. Early covering of burn wound with topical antimicrobial agents may prevent the invasion or contamination of wound [3]. In deep burns, microorganisms may colonize the tissue below the eschar producing a source for infection. As the standard topical antimicrobials cannot penetrate the eschar tissue, early excision of the eschar is important in prevention of infection. Furthermore, early detection of infection is crucial especially in patients with deep and extensive burns [1–3]. Prophylactic antibiotics are not recommended for burn wounds unless there is high probability of infection. In case of wound contamination and in immunocompromised patients (pediatric, perioperative, and diabetic patients), prophylactic antibiotics can be

Introductory Chapter: An Introduction to Burn Injuries http://dx.doi.org/10.5772/intechopen.71973 9

As the burn injury results in a profound hypermetabolic state, nutritional support is recommended in order to enhance wound healing [2, 3, 21]. Although the periodical clinical examination of the wound by the specialist stays the primary way of tracking wound healing, simple measurement tools, sophisticated techniques, and various serum parameters can be used to predict the likelihood of healing and for the follow-up of improvement in healing

For the first-degree wounds, topical antibiotics are not necessary. Moisturizing agents are sufficient, and topical anesthetics may be given depending on the patient's condition [12].

Although the burn wounds are sterile at the beginning of injury, the wound begins to be invaded by the organisms from the patient's flora or from the environment. Therefore, topical antimicrobials are recommended for superficial second-degree burn wounds. As silver sulfadiazine delays epithelialization, it can be used only for the first days to prevent infection. Wounds should be covered with non-adherent dressings including paraffin-impregnated gauze or ointments containing 0.2% nitrofurazone, zinc oxide, or dimethyl isopropylazulene. Several alternative topical agents have also been suggested to be effective [12]. Various types of dressing materials are available for the local care of burn wounds. Wound dressing selection should be tailored according to the amount of wound exudate, the presence of fibrin or necrotic tissue, and the depth of the wound. Hydrocolloids, hydrogels, chitin, polyurethane foams, alginates, and hydrofibers all have been recommended as treatment options for the local care of second-degree burn wounds [11]. Blisters that may be seen in superficial seconddegree burns may serve as an excellent environment for the growth of microorganisms and increase the risk of infection. Small blisters may be left intact; however, large blisters should

considered [11, 12].

**11.3. Burn wound coverage and grafting**

*11.3.2. For superficial second-degree burn wounds*

be removed, and the wound should be dressed [3, 12].

*11.3.1. For the first-degree burn wounds*

[2, 22, 23].
