Burn Management

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Burn Management

Trauma
Author Credentials 

Garren M.I. Low, MD, MS
Resident
Otorhinolaryngology – Head and Neck Surgery
The University of Texas Health Science Center at Houston
Houston, TX

Module Summary

Initial treatment of burns to the face is similar to management of burns of the rest of the body. After initial patient stabilization, the next step is operative debridement back to healthy tissue. With burns to the face there is an increased risk of inhalational injury, which compromises the patient’s airway. Due to the complex anatomy of the face, attention during reconstruction must be paid to the facial subunits. If any section of a subunit is damaged, then the entire subunit will be excised and reconstructed en bloc. Areas of additional reconstructive complexity include the ears, eyelids, nose, and oral commissure. During recovery from facial burns, special attention must be paid to physical therapy the psychological recovery of the patient.

Module Learning Objectives 
  1. Review the pathophysiology of cutaneous burn injury.
  2. Describe the anatomy of the face in terms of facial subunits.
  3. Explain the non-surgical treatments for burns.
  4. Describe the surgical treatment of facial burns.
  5. Review the new innovations in facial burns treatment, including imaging modalities and full-face transplant.
  6. Recognize the importance of rehabilitation and treatment of psychological sequelae of facial burns.

Anatomy

Learning Objectives 
  1. Describe the anatomy of the face in terms of facial subunits
References 
  1. Gonzalez-Ulloa M, Castillo A, Stevens E, et al: Preliminary study of the total restoration of the facial skin. Plast Reconstr Surg (1946) 1954; 13: pp. 151-161.
  2. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76:239–247.
  3. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite defect. Plast Reconstr Surg. 2007;120:887–898.

Pathogenesis

Learning Objectives 
  1. Understand the cellular processes of burn healing.
  2. Describe the difference in cellular destruction between different burn etiologies (electrical, heat, etc.)
References 
  1. Kwan PO, Tredget EE. Biological Principles of Scar and Contracture. Hand Clin. 2017 May;33(2):277-292.
  2. Glatstein MM, Ayalon I, Miller E, Scolnik D. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care. 2013 Jun;29(6):737-40.

Basic Science

Learning Objectives 
  1. Understand the process of wound healing and scar formation as it relates to burn injuries
References 
  1. Kwan PO, Tredget EE. Biological Principles of Scar and Contracture. Hand Clin. 2017 May;33(2):277-292.

Incidence

Learning Objectives 
  1. Understand the patient demographics and common causes of facial burns.
References 
  1. Kalantar Motamedi, Mohammad Hosein MH. Prevalence and pattern of facial burns: a 5-year assessment of 808 patients. J Oral Maxillofac Surg. 2015 Apr;73(4):676-82.

Patient Evaluation

Learning Objectives 
  1. Understand the initial evaluation of the facial burns patient, including the need for acute surgical intervention.
  2. Use the rule of nines and the Lund Browder charts for evaluation of total body surface area percentage.
References 
  1. Klein MB, Moore ML, Costa B, Engrav LH. Primer on the management of face burns at the University of Washington. J Burn Care Rehabil. 2005 Jan-Feb;26(1):2-6.
  2. Wachtel TL, Berry CC, Wachtel EE, Frank HA SO. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. 2000;26(2):156.

Measurement of Functional Status

Learning Objectives 
  1. Understand the value of ophthalmologic evaluation for patients with periorbital burns.
References 
  1. Smith SB, Coffee T, Yowler C, Steinemann TL. Risk factors for ophthalmic complications in patients with burns. J Burn Care Res. 2010;31(6):911.

Imaging

Learning Objectives 
  1. Understand the experimental value of MRI in assessing burns.
References 
  1. Khatib M, Jabir S, Fitzgerald O'Connor E, Philp B. A systematic review of the evolution of laser Doppler techniques in burn depth assessment. Plast Surg Int. 2014;2014:621792.
  2. He Z, He W, Wu J, Xu Z. The Novel Design of a Single-Sided MRI Probe for Assessing Burn Depth. Sensors (Basel). 2017 Mar 6;17(3).

Treatment

Learning Objectives 
  1. Understand the types of dressings used for partial and full thickness burns and their advantages and drawbacks.
References 
  1. Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013.
  2. Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2008.

Medical Therapies

Learning Objectives 
  1. Describe the value of topical therapies in the treatment of burns of the face.
References 
  1. Leon-Villapalos J, Jeschke MG, Herndon DN. Topical management of facial burns. Burns. 2008 Nov;34(7):903-11. doi: 10.1016/j.burns.2008.01.025. Epub 2008 Jun 5.
  2. Hoogewerf CJ, Van Baar ME, Hop MJ, Nieuwenhuis MK, Oen IM, Middelkoop E. Topical treatment for facial burns. Cochrane Database Syst Rev. 2013.

Pharmacology

Learning Objectives 
  1. Understand the possible value of post-burn beta-blockade.
References 
  1. Pereira CT, Jeschke MG, Herndon DN. Beta-blockade in burns. Novartis Found Symp. 2007;280:238-48; discussion 248-51.

Surgical Therapies

Learning Objectives 
  1. Understand the process of acute treatment of burns with surgical excision
  2. Understand the similarities and differences between reconstruction after burns and trauma.
  3. Describe the difficulties in treating burns of the ears, eyelids, nose, and oral commissures
  4. Describe the treatment algorithm for surgical repair of a burn to the neck.
  5. Describe the value of laser scar revision in the chronic treatment of burn scars.
  6. Understand the possible role of prosthodontics in oral commissure burns.
  7. Understand the emerging field of full-face transplant as a treatment for massive facial burn injury
References 
  1. Mosier MJ, Gibran NS. Surgical excision of the burn wound. Clin Plast Surg. 2009 Oct;36(4):617-25. doi: 10.1016/j.cps.2009.05.006.
  2. Klein MB, Moore ML, Costa B, Engrav LH. Primer on the management of face burns at the University of Washington. J Burn Care Rehabil. 2005 Jan-Feb;26(1):2-6.
  3. Bernard SL. Reconstruction of the burned nose and ear. Clin Plast Surg. 2000 Jan;27(1):97-112.
  4. Ramachandra T, Ries WR. Management of Nasal and Perinasal Soft Tissue Injuries. Facial Plast Surg. 2015 Jun;31(3):194-200. doi: 10.1055/s-0035-1555619. Epub 2015 Jun 30.
  5. Malhotra R1, Sheikh I, Dheansa B. The management of eyelid burns. Surv Ophthalmol. 2009 May-Jun;54(3):356-71. doi: 10.1016/j.survophthal.2009.02.009.
  6. Tsai FC, Mardini S, Chen DJ, Yang JY, Hsieh MS. The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns. 2006;32(5):626.
  7. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns. 2010 Jun;36(4):443-9. doi: 10.1016/j.burns.2009.08.015. Epub 2009 Dec 21.
  8. Linebaugh ML1, Koka S. Oral electrical burns: etiology, histopathology, and prosthodontic treatment. J Prosthodont. 1993 Jun;2(2):136-41.
  9. Sosin M, Ceradini DJ, Levine JP, Hazen A, Staffenberg DA, Saadeh PB, Flores RL, Sweeney NG, Bernstein GL, Rodriguez ED. Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant: A Reconstructive Solution for the Full Face and Total Scalp Burn. Plast Reconstr Surg. 2016 Jul;138(1):205-19. doi: 10.1097/PRS.0000000000002322.

Rehabilitation

Learning Objectives 
  1. Understand the psychological care involved in burn rehabilitation.
  2. Describe the importance of physical therapy in preventing contracture.
  3. Describe the chronic care of burns sequelae, including itching.
References 
  1. Van Loey NE, Van Son MJ. Psychopathology and psychological problems in patients with burn scars: epidemiology and management. Am J Clin Dermatol. 2003;4(4):245-72.
  2. Clayton NA, Ward EC, Maitz PK. Intensive swallowing and orofacial contracture rehabilitation after severe burn: A pilot study and literature review. Burns. 2017 Feb;43(1):e7-e17. doi: 10.1016/j.burns.2016.07.006. Epub 2016 Aug 26.
  3. Wiechman SA. Psychosocial recovery, pain, and itch after burn injuries. Phys Med Rehabil Clin N Am. 2011 May;22(2):327-45, vii. doi: 10.1016/j.pmr.2011.01.005.

Staging

Learning Objectives 
  1. Describe the stages of burns.
References 
  1. Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin North Am. 1997 Jun;32(2):343-64.

Case Studies

  1. A 54-year-old male was cooking when grease when it splashed up causing blistering burns to the face. The burn involves the left face, including the oral commissure and nasolabial fold. What is the initial treatment for this burn? What areas must be resected and reconstructed?
  2. A 28-year-old woman is a victim of an assault with acid. She was treated appropriately at the nearest burn center and was discharged without incident. She returns to the clinic 6 months after her initial hospitalization and is developing contractures of her neck and mouth leading to restricted extension of the neck and oral incompetence. Her facial and neck scars are now hypertrophic. What are the options for revision of her scars? What kind of function can she expect to regain and on what time frame?

Complications

Learning Objectives 
  1. Understand the relationship between inhalational injury and facial burns.
  2. Describe the ways to attempt prevention of hypertrophic scar formation.
References 
  1. Rehberg S, Maybauer MO, Enkhbaatar P, Maybauer DM, Yamamoto Y, Traber DL. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med. 2009 Jun;3(3):283-297.
  2. Bloemen MC, van der Veer WM, Ulrich MM, van Zuijlen PP, Niessen FB, Middelkoop E. Prevention and curative management of hypertrophic scar formation. Burns. 2009;35(4):463.

Review

Review Questions 
  • A 37 yo man falls from a ladder and strikes his neck on the way down. Several hours after injury, flexible laryngoscopy demonstrates ecchymosis and edema of the vocal aryiepiglottic folds and piriform sinus on the right. The right false vocal fold has a eccymotic bulge, but there are no lacerations. His right vocal fold is sluggish. His airway is patent and no intervention is needed. CT scan demonstrates a right single thyroid cartilage fracture which is displaced. According to the Schaefer classification of laryngeal trauma, what is his injury group?
Resources 

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Academy U: Resident Manual of Trauma to Face, Head and Neck