Chapter 48: Burns and Radiation

BURNS

Introduction

Approximately 1.25 million people burned annually in the United States, where 30,000 patients require admissions to burn centers every year and about 3400 die.^1,2 Burns requiring hospitalization typically include burns greater than 10% of the total body surface area (TBSA) or significant burns of the face, hands, feet, or perineum.

The highest incidence of burn injury occurs during the first few years of life and between 20 and 59 years of age. The major causes of severe burn injury in younger patients are liquid scalds, and flame burns are more common in adult patients.² Most burn deaths are caused by flame burns, while liquid scald burns account for the second largest number of deaths.

Between 1971 and 1991, burn deaths decreased by 40% with a concomitant 12% decrease in deaths associated with inhalation injury.³ Since 1991, burn deaths per capita have decreased 25% according to statistics from the Centers for Disease Control and Prevention (www.cdc.gov/ncipc/wisqars). These improvements were in part due to prevention strategies resulting in fewer burns of lesser severity as well as significant advances in treatment techniques particularly in children. In 1949, Bull and Fisher first reported the expected 50% mortality rate for burn sizes in several age groups based upon data from their unit.⁴ They reported that approximately one-half of children aged 0–14 years with 49% TBSA burns die.⁴ This dismal statistic has dramatically improved, with the latest reports indicating 50% mortality for 98% TBSA burns in children 14 years and younger.^5,6 A healthy child with any size burn might be expected to survive.⁷ Nevertheless, a 60% TBSA burn has been shown to be an important threshold that, if exceeded, can increase the risk of death.^8,9 The same cannot be said, however, for those aged 45 years or older, where improvements have been more modest. This is especially true in patients over 65 years of age, where a 35% burn still kills half of the patients.¹⁰

These dramatic improvements in mortality after massive burns are due to better resuscitation, improvements in wound coverage by early excision and grafting, better support of the hypermetabolic response to injury, early nutritional support, more appropriate control of infection, and improved treatment of inhalation injuries. Future breakthroughs in the field are likely to be in the area of faster and better return of function and improved cosmetic outcomes.

Burn Center Referral Criteria

Some burn patients benefit from treatment in specialized burn centers. These centers have dedicated resources and the required multidisciplinary approach to maximize outcomes from such devastating injuries.¹¹ The American Burn Association and the American College of Surgeons Committee on Trauma have established guidelines to identify patients who should be transferred to a specialized burn center as follows¹²: