Presenter:
- Shawn Tejiram, MD – Burn Surgeon, The Burn Center at MedStar Washington Hospital Center; Assistant Professor of Surgery, Georgetown University School of Medicine
Moderator:
- Christina L. Megal, DNP, APNP, FNP-C, CWON-AP, CFCN – Clinical Director, Integrated Wound Healing Program; Assistant Professor, Department of Surgery, Medical College of Wisconsin
Burns sit at the intersection of trauma, critical care, and wound care, and most clinicians outside dedicated burn centers do not receive sufficient formal training in how to triage and manage them. That gap matters because the decisions made in the first hours after a burn injury, including whether to resuscitate, whether to transfer, and how to estimate burn size and depth, drive mortality outcomes.
Dr. Tejiram’s framing for this session is what he calls “a 50,000-foot view”, an organized introduction to how burn centers think about burn care, what’s worth handling locally, and when to pick up the phone and call. This article distills that framing into a clinical reference.
What Has Changed in Burn Care
The single most useful data point in the session is mortality over time.
In the 1940s, the burn size at which half of patients would survive was about 40 percent of total body surface area (TBSA). By the 1990s, that had risen to roughly 80 percent TBSA. By the 2010s and 2020s, it sits at roughly 90 to 95 percent depending on patient age and comorbidities.
The drivers of that shift:
- Development and use of increasingly broad-spectrum antibiotics
- Modern fluid management and resuscitative practice
- Early excision and grafting rather than waiting for burns to evolve
- Advanced technologies in skin coverage, including skin substitutes
This context matters clinically. Burns that would have been considered fatal a generation ago are now survivable with the right care. That raises the stakes for correct early assessment and appropriate transfer.
The First Step: Systematic Assessment
Burn patients are trauma patients. The starting point is the same primary survey taught in ATLS: Airway, Breathing, Circulation. The specifics diverge from standard trauma because of what burn injury does to the body.
Airway and Breathing
The concern beyond basic airway patency is smoke inhalation injury, which is the leading cause of death from fire. It has three components:
Thermal injury to the airway. The nasopharynx acts as a natural heat sink. When heat exposure overwhelms that capacity, airway swelling follows, typically within 4 hours and nearly always within 24. Burn centers often perform airway watches with direct laryngoscopy or bronchoscopy to evaluate the vocal cords and oropharynx.
Asphyxiation and chemical toxicity. Two chemicals drive most inhalation mortality:
- Carbon monoxide. Binds hemoglobin, displaces oxygen, and blocks delivery to cells. Treatment is 100 percent oxygen to displace the CO, with serial ABGs to track the clearance curve.
- Cyanide. Released when plastics, fabrics, and household materials combust. Blocks cellular oxygen utilization at the mitochondrial level. Treatment is hydroxocobalamin (commonly known as the Cyanokit), which binds the cyanide for renal excretion.
Delayed lung injury. Corrosive particulate destroys the respiratory tract mucosa and bronchial cilia. The typical treatment is a nebulizer cocktail (albuterol, heparin, saline) via endotracheal tube for several days after injury to support pulmonary toilet and clear debris.
Clinical signs that raise concern for inhalation injury include facial hair singeing, soot deposits around the mouth, airway or tongue swelling, elevated carbon monoxide on ABG, and severe metabolic acidosis.
Circulation and Burn Shock
The circulation question in burn care is whether the patient needs a formal resuscitation. Severe burns trigger a whole-body inflammatory response. Up to a certain burn size, the body compensates. Past that threshold, burn shock develops: fluid shifts out of the intravascular space, oxygen delivery drops, and the patient decompensates.
The resuscitation threshold is typically:
- 20 percent TBSA for most adults
- 15 percent or above for special populations (elderly, frail, significant comorbidities)
Below those thresholds, standard supportive care is usually sufficient.
Assessing Burn Size
Burn size assessment has three components: depth, mechanism, and TBSA.
Burn Depth
Depth is graded by degree, though the terminology is used interchangeably with thickness descriptors:
First-degree (superficial). Epithelium only. Red, irritated, painful, no open wounds. Classic example is sunburn. Heals in a few days without intervention.
Second-degree (partial thickness). Extends into the dermis. Blisters form because fluid accumulates in the separation between dermal layers.
Third-degree (full thickness). Entire dermis is destroyed, extending into subcutaneous fat. Because keratinocyte regeneration normally comes from dermal appendages, full-thickness burns lose that regenerative reservoir. Healing from wound edges alone is rarely adequate. Skin grafting is typically required.
Fourth-degree. Extends past fat into fascia, muscle, and sometimes bone. Most commonly seen with electrical injury where current tracks through deep tissue. Amputation is frequently required.
How Depth Is Assessed
Depth is harder to determine than it looks, even for experienced clinicians. Standard bedside assessments include:
- Capillary refill and blanching
- Patient sensation on palpation (intact sensation suggests the burn is less deep than feared)
- Hair follicle presence, though this is variable depending on the injury timing
- Pin-prick and proprioception testing
Biopsy with H&E staining is the gold standard but is resource-intensive. Imaging approaches like laser Doppler imaging (LDI) assess wound bed perfusion and can estimate healing time. AI-assisted visual assessment is an active research area.
The clinical truth: Inexperienced clinicians get it right about 50 percent of the time. Experienced burn surgeons get depth right about 75 percent of the time. Serial evaluation is essential because burns are rarely stagnant; they either improve or worsen over time.
The Rule of Nines and Palmer Method
Two methods for estimating TBSA, used in combination:
Rule of Nines. Each arm is 9 percent. The head is 9 percent. The anterior torso is 18 percent, posterior torso is 18 percent, and each leg is 18 percent. Pediatric patients have a proportionally larger head and smaller legs, which the Lund-Browder chart accounts for.
Palmer Method. The patient’s palm equals approximately 1 percent TBSA. This is particularly useful when burns are not well demarcated or present as scattered, discontinuous patches.
Burn Wound Conversion: The Zones of Injury
An important concept from Dr. Douglas Jackson and colleagues: burns have three concentric zones that can evolve over time.
- Zone of coagulation (center). Maximal injury, most tissue destruction, requires surgery.
- Zone of stasis (middle). The critical zone. It’s viable but at high risk of converting to necrosis if not supported properly.
- Zone of hyperemia (outer). Increased blood flow supporting wound healing.
Everything the clinical team does, whether fluid management, infection prevention, or administering appropriate antibiotics, is aimed at saving the zone of stasis. When that fails, the zone converts into necrotic tissue, deepening the wound.
Burn Resuscitation
Once burn size crosses the resuscitation threshold, formal fluid resuscitation is required to counter the inflammatory cascade and restore intravascular volume.
The Formulas
Parkland Formula (historical standard, still widely used globally): 4 mL Lactated Ringer’s × weight (kg) × percent TBSA
ABA Consensus Formula (current US standard): 2 mL LR × weight (kg) × percent TBSA
The shift to lower-volume resuscitation reflects years of evidence that Parkland volumes tended to over-resuscitate patients, producing complications. The Advanced Burn Life Support (ABLS) course, the burn-specific equivalent of ATLS, recommends the consensus formula.
Electrical injury is an exception. When myoglobinuria is present (muscle breakdown), higher fluid volumes are favored to flush myoglobin and support renal perfusion.
Titrating Fluids
Urine output is the primary titration target: 30 to 50 mL per hour, or roughly 0.5 mL/kg/hr for average-sized patients.
Other endpoints include:
- Base deficit. Worsening base deficit signals a more severe inflammatory response and risk of ARDS or multi-organ dysfunction. Normalization correlates with improved survival.
- Lactate. Elevated lactate is associated with mortality, but no clear threshold exists.
Fluid Choices
Lactated Ringer’s is the primary fluid. To restore oncotic pressure, many burn centers use albumin or fresh frozen plasma (FFP). The webinar team favors FFP. Other adjuncts like hypertonic saline, dextran, hetastarch, and vitamin C have been studied but are associated with more complications.
The maximum inflammatory response typically peaks in the first 8 to 12 hours, then declines. Fluid requirements follow that curve.
Special Considerations During Resuscitation
Deep circumferential burns create a mechanical problem: the eschar loses pliability, but underlying tissues continue to swell. Without intervention, compartment pressures climb and tissues become ischemic.
Escharotomy opens the eschar to allow tissue to expand. Common sites include:
- Extremities with circumferential burns
- Torso with circumferential burns (the chest wall cannot expand enough to ventilate)
- Abdomen, where organ swelling can produce abdominal compartment syndrome
When swelling is severe enough to compromise muscle compartments, fasciotomies are added beyond the eschar release.
Topical Wound Care
Once the patient is stabilized, topical wound care and surgical management come to the forefront. A general rule in the burn community: if a wound doesn’t heal within 2 to 3 weeks, it’s unlikely to heal on its own, and the open wound may represent an infection source.
Common topical agents:
Silver sulfadiazine. 1 percent cream. Safe, relatively painless, inexpensive. The most common side effect is neutropenia, though this occurrence is rarely observed. Despite the “sulfa” label, patients with sulfa allergies can generally be treated with silver sulfadiazine without allergic reaction because the sulfamoyl group is covalently bound and not available to interact with allergen receptors.
Mafenide (Sulfamylon). Effective against Pseudomonas and Clostridium. Best eschar penetration of the topical agents, which makes it useful for cartilage-containing areas like the nose and ears. Important cautions: it’s painful on application, and it’s a carbonic anhydrase inhibitor, so large-surface application can produce metabolic acidosis. Requires serial lab monitoring.
Acticoat. Ionic silver-containing cloth, activated silver with controlled release over time. Can be activated with water for dry areas. Broad-spectrum antimicrobial coverage. More costly than other options but useful in specific operative dressing contexts.
Aquaphor. Not an antimicrobial. Used on healed or healing skin as a moisture barrier. Painless, safe, inexpensive, no significant side effects.
Surgical Approaches
The surgical toolkit in burn care:
- Weck blade for tangential excision and incremental eschar removal
- Humby knife for larger, deeper excision
- Dermatome for skin graft harvest
- Versajet (hydrosurgical tool) for precise debridement with a high-velocity water jet
Skin Coverage Options
Autograft. The patient’s own skin. Typically meshed in a grid pattern to expand coverage from a smaller donor site. Wider mesh ratios cover more area but heal more slowly because the diamond gaps must fill in from graft edges.
Allograft. Cadaveric skin. Useful as a temporary cover when the wound bed isn’t ready for autograft, giving inflammation and edema time to settle.
Xenograft. Non-human species skin, traditionally porcine. Fish skin has also emerged as an option at some centers.
Dermal regenerative templates. For very deep wounds reaching muscle, templates like Integra or NovoSorb BTM create a neodermis layer. Without this, skin grafted directly onto muscle adheres to the muscle, and every muscle movement pulls on the graft. Dermal templates create a buffer layer.
Synthetic skin substitutes. Suprathel is a synthetic polylactate indicated for partial-thickness wounds. It provides an epithelial covering, reduces pain burden, and allows patients to leave the hospital earlier by eliminating daily dressing changes.
Autologous skin cell suspension (spray-on skin). A small skin sample is processed into a suspension of keratinocytes that can be sprayed over a wide area. Often combined with widely meshed autograft or Suprathel to improve coverage in patients with limited donor sites.
Graft adherence techniques include negative pressure wound therapy devices (wound vacs) to apply even pressure and suction fluid from the graft bed, and suture tie-over bolsters in areas where these devices are difficult to apply.
Special Populations
Mixed Burn and Trauma
Burn plus trauma dramatically increases mortality. As both TBSA and Injury Severity Score rise, mortality rises exponentially.
Common combinations:
- Motor vehicle collisions with car fires
- Patients jumping to escape structure fires
- Electrical injuries producing tetany-induced long bone fractures
- Falls during escape
- Explosions with associated projectile and shrapnel wounds
Life-threatening injuries (typically bleeding) are addressed first. Burn resuscitation is managed alongside trauma care.
Diabetes
Diabetic burn patients face compounding problems:
- Microvascular disease limits blood flow to the injury
- Neuropathy increases the risk of unrecognized injury
- Length of stay per percent TBSA is higher than in the general population
Management priorities include tight glycemic control and vascular optimization. Angiographic intervention to improve vascular flow before skin grafting can meaningfully improve outcomes.
Cold Injury and Frostbite
Frostbite is a delayed tissue injury combining direct cellular ischemia and lysis with microvascular thrombosis. Initial appearance can be deceiving — wounds often evolve significantly over time.
Clinical presentation: hard, waxy tissue, joint stiffness, clumsiness. In advanced disease, blistering develops as rewarming progresses.
The Hennepin grading system predicts amputation risk from frostbite. The strongest risk factors for amputation are increasing age, increasing frostbite grade, and time to thrombolysis.
Management principles:
- Address hypothermia first
- Rewarm in warm water baths with adequate pain control (opioid plus non-opioid adjuncts)
- Be aware that rewarming dramatically increases oxygen consumption
- Consider thrombolytic therapy when there’s salvageable tissue at risk, ideally within 48 to 72 hours
- Intra-arterial versus IV thrombolysis — whichever is fastest
- Time equals tissue
Surgical timing for frostbite is typically delayed until dry gangrene demarcates. Early surgery risks operating on tissue that will subsequently necrose. Wet gangrene (infection) is the exception that triggers emergent surgery, which often means a guillotine amputation.
The Long Tail: Aftercare and Reintegration
Burn care doesn’t end at discharge. Patients develop scars that produce contractures and functional limitations, require long-term rehab, and face significant psychological consequences including PTSD and anxiety.
Effective burn programs provide:
- Pain management for chronic symptoms
- Wound management for new or recurrent wounds
- Mobility rehabilitation
- Psychological support
- Cosmetic scar intervention (laser scar revision has become a significant modality)
- Support group access
The support group data are notable. Survivors who attend at least one support group scored higher on scales measuring social interaction, social activity, and work/employment reintegration.
When to Call a Burn Center
The American Burn Association’s criteria for transfer to a burn center include:
- Partial-thickness burns greater than 10 percent TBSA
- Burns involving sensitive areas: face, hands, feet, genitals, perineum
- Any third-degree burn (surgery will be required)
- Chemical burns
- Inhalation injury
- Electrical injury
- Significant comorbidities requiring specialty care
- Concomitant trauma
- Patients with special rehabilitation, social, or emotional needs
Dr. Tejiram’s practical guidance: you’re never wrong to call a burn center. Even small-appearing burns can be assessed and the patient integrated into the right follow-up pathway.
Transfer Preparation
- Start Lactated Ringer’s at 500 mL per hour for burns greater than 20 percent TBSA before transfer
- For outpatient follow-up candidates, silver sulfadiazine and daily wash with soap and water is almost always a reasonable bridge
- Antibiotics are rarely indicated unless there are obvious signs of cellulitis or infection
- ABLS is the standard reference for acute burn care preparation
Key Takeaways
- Burns are trauma. Start with ABCs, then layer in burn-specific concerns.
- Smoke inhalation kills more fire victims than the burn itself. Screen aggressively.
- Burn size drives everything downstream. Use the Rule of Nines plus the Palmer method.
- The zone of stasis is a clinical target. Save it with appropriate support.
- Resuscitate burns above 20 percent TBSA using the ABA Consensus Formula, titrating to urine output and other end points of resuscitation.
- Depth assessment is hard. Experienced burn providers get it right 75 percent of the time. Serial evaluation is essential.
- Silver sulfadiazine is almost always a reasonable topical bridge before transfer.
- When in doubt, call a burn center. They would rather help you triage than have you hesitate.
Watch the Full Webinar
The full recording, including clinical photos, case examples, and Q&A, is available on the WHS YouTube channel.