Surgical Treatment of Burns in Children

Updated: May 18, 2022
Author: Renata Fabia, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP 


Practice Essentials

Traumatic injuries cause more deaths in childhood than all other causes combined. Children are particularly vulnerable to thermal injury; burns are the fifth most common cause of nonfatal childhood injuries[1]  and the third leading cause of preventable death in children worldwide.[2]  In 2000, direct costs for the care of children with burns in the United States exceeded US $211 million, according to the World Health Organization.[1]

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. In many high-income countries, burn death rates have been decreasing; however, the rate of child deaths from burns is more than seven times higher in low- and middle-income countries than in high-income countries.[1]

Rapid assessment and treatment of immediate life-threatening conditions is mandatory in children with burns. Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway edema. Children with burns affecting more than 10% of total body surface area (TBSA) should receive intravenous (IV) 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. Patients should be kept warm. Tetanus immunization should be administered as indicated.

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.

For patient education resources, see the First Aid and Injuries Center, as well as Thermal (Heat or Fire) Burns.


Appreciating the major differences between burn management in children and adults is important. In children, the ratio of TBSA to body mass is nearly three times that in adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and experience more evaporative water loss than adults. The higher ratio of TBSA to body mass in the pediatric population also predisposes children 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 do. As a result, they lose more heat and water, and lose these more rapidly, than adults do. 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 the disproportionately thin skin of a child, a burn that initially appears to be a partial-thickness injury may actually be a full-thickness injury. (See Presentation.) Thus, the child's thin skin may make initial burn depth assessment difficult.


Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years, scalds are responsible for most burns.[3] Scald burns may occur when children pull a scalding liquid onto themselves or may result from bathtub submersion injuries, which can often be quite severe. They have also been reported to occur as a consequence of hair braiding.[4]

In older children (eg, >9 years), flame burns are more common.[5] 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.


Boys are more likely to experience burn injuries than girls are.[5] Saeman et al carried out a retrospective review of epidemiology and outcomes in 5748 pediatric burn patients treated over a period of 35 years at a single institution.[6] Roughly two thirds (66.2%) of the patients admitted were male. The annual admission rate rose over this period, but the incidence of pediatric burn admissions fell. The most common causes of admission were as follows:

  • Scald burn (42%)
  • Flame burn (29%)
  • Contact burn (10%)

Decreases in both median duration of hospitalization and median burn size were reported.[6]  Mortality showed a significant positive correlation with inhalation injury, burn size, and history of abuse but a negative correlation with year of admission.


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% of TBSA burned to more than 95% of TBSA burned in children younger than 15 years.

A large single-center study of pediatric burn patients analyzed the relation between burn size and probability of survival.[7] A cohort of 952 severely burned patients of comparable age and sex distribution were studied. Results suggest that a burn size of roughly 60% of TBSA is a crucial threshold for postburn morbidity and mortality. Pediatric patients with burns to a large percentage of TBSA should be immediately transferred to a specialized burn center to combat the increased risk of poor outcome associated with this burn size.

A study by Chong et al reviewed mortality in pediatric burn patients in a tertiary burns center over a period of nearly 60 years (1960-2017).[2] All patients with burns involving less than 40% of TBSA survived. In the 75 patients who sustained burns involving 40% of TBSA or more, overall mortality was 34% (26/75), with 24 of the 26 deaths having occurred in the 1960s.



History and Physical Examination

Burn depth

The depth of a burn is classified according to the extent to which it involves the epidermis and dermis (see the image below):

  • Superficial (first degree)
  • Partial thickness (second degree), which is further divided into superficial, intermediate, and deep
  • Full thickness (third degree)
Skin histology diagram. Skin histology diagram.

Superficial burns

These burns have sunburn-like features with no open wounds and should not be taken into account in calculating the total body surface area (TBSA) burned for resuscitation purposes.

Partial-thickness burns

Superficial partial-thickness burns are characterized by 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. Superficial partial-thickness burn.

Deep partial-thickness burns are characterized by injury to the epidermis and deeper dermis, but with some viable dermis remaining. They are also considered second-degree burns but are whiter and less erythematous as the depth of penetration into the dermis increases. Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult.

Deep partial-thickness 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. 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. (See the image below.) These burns do not heal spontaneously (except for very small wounds that heal by contraction).

Full-thickness burn. Full-thickness burn.

Injury types

Thermal burns

These occur most frequently as a result of scalds (hot liquids, steam), contact with a hot surface, or flash-flame/flame.

Electrical burns

Low-voltage injuries result from sources of less than 1000 V 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 V and result from contact with a live wire outdoors or from being struck by lightning.

Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring, serial electrocardiography (ECG), 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 the following are true:

  • The patient has no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident
  • The patient remains asymptomatic after 4 hours of observation in the emergency department
  • The wounds are manageable in an outpatient setting
  • 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 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 the following:

  • Red, blue, or pale skin
  • Prickling sensation with superficial frostbite
  • Painless rigid skin with deep frostbite
  • 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 100-105°F for up to 30-45 minutes. The frozen part should not be rewarmed 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.[8]

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.



Laboratory Studies

Monitoring of electrolytes and blood counts is often helpful, especially with large burns requiring aggressive fluid resuscitation. Obtaining the carboxyhemoglobin level can be important in patients with inhalation injury, especially in those burned in enclosed spaces. Lactate levels correlate with burn severity and cyanide poisoning, and serial levels could be used to define the endpoint of burn shock resuscitation. Prealbumin levels should be monitored weekly in patients with burns involving more than 20% of total body surface area (TBSA) as a measure of nutritional repletion.

A fever workup (including a complete blood count [CBC]; urinalysis, and blood, urine, sputum, and wound cultures) should be performed as clinically indicated.

If invasive burn wound sepsis is suspected (eg, on the basis of clinical deterioration, a change in the appearance of the burn, or an odor to the burn) definitive diagnosis can be obtained with quantitative burn wound cultures (requiring removal of at least 1 g of burned tissue at the bedside) with the microbiology laboratory alerted that quantitative wound cultures are being sent. Invasive burn wound sepsis is defined as more than 105 organisms/g tissue.

An alternative method of diagnosing invasive burn wound sepsis is by burn wound biopsy with histologic examination showing bacteria invading viable tissue.

Imaging Studies

Chest radiography can be helpful in patients who are intubated and in patients who have a suspected inhalation injury. Chest radiography is also required as part of a complete fever workup, as indicated.

Thermal imaging may prove useful in determining the depth of acute burns in children. A study by Ganon et al found the FLIR One Thermal Imager (FLIR Systems, Arlington, VA)—an inexpensive, noninvasive, and easy-to-use device—to have excellent specificity for measuring dermis perfusion as a reflection of burn depth in children; however, the sensitivity of the device was relatively low.[9]


Calculation of the percentage of TBSA burned can be performed by means of various approaches. The fastest initial estimate of percent BSA burned can be made by employing the pediatric rule of nines (see the image below). This is an adaptation of the adult rule of nines, which takes into consideration the observation that in children, the relative size of the head is larger and the relative size of the lower extremities is smaller.

Pediatric Rule of Nines. Pediatric Rule of Nines.

Next, Lund and Browder charts can be used to more precisely calculate the percentage of TBSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements (see the image below).

Lund and Browder Chart. Lund and Browder Chart.

Finally, burn involvement can also be calculated by using the patient's palm. This approach is particularly helpful for small scattered burns and is based on the estimate that the patient's palm (excluding the fingers) represents approximately 0.5% of TBSA.

Note that these are estimates and should be revised by burn care providers in order to achieve more precise calculation when necessary.



Approach Considerations

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 total body surface area (TBSA) should receive intravenous (IV) 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 IV fluids, elevating room temperatures, and minimizing patient exposure. Tetanus immunization should be administered as indicated.

Indications and contraindications for surgery

Burn excision and grafting are generally recommended for all full-thickness burns and for deep partial-thickness burns that would appear to take more than 2-3 weeks to heal. A study by Khang et al found that in pediatric patients admitted with burns involving 20% of TBSA or more, the pivotal predictors of the probability that surgery would be required were percent of full thickness, infection, and erythrocyte loss.[10]

Any condition that would ordinarily preclude the patient with burn injuries from having general anesthesia may be a contraindication; otherwise, no contraindications to surgery are noted.

Areas of investigation

Numerous clinical and basic science burn research initiatives are undergoing active investigation. One such area of interest is the hypermetabolic response to severe burns and the association with increased energy expenditure and muscle-protein catabolism. Studies have investigated different mechanisms to attenuate the muscle-protein catabolism that occurs frequently, despite appropriate nutritional support, in children with large burns.[11] 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 (HGH) in combination with propranolol demonstrated attenuated hypermetabolism and inflammatory and acute-phase responses after severe burn injury.[12] HGH improves posttraumatic hypermetabolism, but its use alone is associated with hyperglycemia and increased free fatty acids and triglycerides. Concomitant administration of propranolol improved fat metabolism and insulin sensitivity and avoided the adverse effects of recombinant HGH alone.

Oxandrolone, an anabolic steroid, has been shown to increase muscle protein net deposition and to decrease length of stay in patient with major burns.[13]  In a randomized clinial trial of long-term (up to 24 months) administration of oxandrolone to severely burned pediatric patients, Reeves et al found that at 5-year follow-up, this approach yielded significant improvements on whole-body bone mineral content (BMC), lumbar-spine BMC, lumbar-spine bone mineral density (BMD), and height velocity.[14]

The extent of initial resuscitation efforts and the subsequent care of a burn-injured patient have a significant impact on whether the patient recovers or experiences complications, including the development of multiple organ dysfunction syndrome (MODS) and death. The Burn Research Group developed standardized protocols for patient care based on management principles derived from published clinical and laboratory studies.[15] Studies continue to investigate new ways to address current fluid therapy needs, to monitor the end points of resuscitation, and to prevent the negative effects of current therapies[16]

Smoke inhalation injury, either by itself or in conjunction with a dermal burn, results in severe lung-induced morbidity and mortality. Presently, the most common cause of death in burn patients is respiratory failure.[17] A large focus of burn-related research involves important pathophysiologic pathways and therapeutic targets for the treatment of acute inhalational injuries.[18] The mechanisms for secondary infection after burn injury, including respiratory infection, continue to be subjects of investigation.[19]

Another active area of research is in the development of cultured skin to treat very large burns. 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.

Optimum healing of a burn wound requires well-coordinated integration of the complex biologic and molecular events of cell migration and proliferation, as well as of extracellular matrix deposition and remodeling. Future treatment options could include stem cell therapy, which has been shown to improve the quality of burn wound healing, reduce the formation of scars, and reestablish the normal function of the skin and its appendages. Although treatment of burn wounds with adult stem cells is improving, issues remain to be addressed before stem cell therapy can be widely used clinically.[20, 21]

Another important area of research aimed at ensuring improved outcomes in children with burn injuries focuses on achieving a better understanding of the posttraumatic stress induced by burns.[22, 23]

Medical Therapy

Recommendations for management of severe thermal injuries in the acute phase in children and adults have been published by the Société Française d'Anesthésie et de Réanimation (SFAR; French Society of Anesthesia and Intensive Care Medicine).[24]  (See Guidelines.)

Criteria for hospitalization

Hospital admission criteria for patients with thermal injury include the following:

  • Partial-thickness burns larger than 10% of TBSA
  • Full-thickness burns larger than 2% of 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 the following:

  • Increased respiratory rate
  • Hoarseness
  • Being burned in an enclosed space
  • Altered mental status
  • Head and neck burns
  • Singed nasal hairs
  • Inflamed oral mucosa
  • Carbonaceous sputum

Indications for intubation include the following:

  • Compromised upper airway patency
  • Need for ventilatory support as manifested by poor gas exchange or increased work of breathing
  • Compromised mental status

Correlation of the history and the clinical findings is the most practical approach to determining the need for intubation.

Important considerations with regard to the pediatric airway include the following:

  • The larynx is more cephalad in children
  • Children deteriorate faster than adults in terms of upper-airway edema and alveolar-capillary block
  • 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. A multitude of approaches have been developed to ensure better stabilization of endotracheal tubes, such as anchoring the tube to the teeth with a dental device (see the images below).

Endotracheal tube immobilization in children. The Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
Dental device to anchor the endotracheal tube. Dental device to anchor the endotracheal tube.

Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct of combustion that displaces oxygen from the hemoglobin molecule. It has 250 times the affinity for hemoglobin that oxygen does, thus causing a left shift in the hemoglobin-oxygen disassociation curve. This impairs oxygen unloading at the tissue level and causes a switch to anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected when metabolic acidosis persists despite adequate volume resuscitation.

It must be kept in mind that arterial oxygen tension (PaO2) will be normal because the amount of oxygen dissolved in arterial plasma is normal. In addition, arterial oxygen saturation (SaO2) will be normal on a standard pulse oximeter in the presence of CO toxicity because the oximeter cannot differentiate between hemoglobin saturated with oxygen and hemoglobin saturated with CO.

To treat CO toxicity, all patients with inhalation injury should be treated with 100% oxygen. This lowers the half-time (t1/2) of CO to 30-90 minutes, as opposed to 4-5 hours in room air. Therefore, all major burns should be treated with 100% oxygen 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 (≤ 20 min). Its use should be considered for CO greater than 50%, severe neurologic compromise, and nonresponsiveness to 100% oxygen.

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 adenosine triphosphate (ATP) production. It causes a shift to anaerobic metabolism with profound metabolic acidosis and obtundation.

Treatment of cyanide toxicity has commonly involved administration of the cyanide antidote sodium thiosulfate (250 mg/kg IV, not to exceed 12.5 g; if symptoms persist, this may be repeated at 30 min at 50% of the original dose, not to exceed 6.25 g), which converts cyanide to nontoxic, excretable thiocyanate. Currently, however, hydrocobalamin (typically 70 mg/kg IV infusion over 15 minutes; an additional 35 mg/kg IV may be given, depending on severity of poisoning and clinical response) is preferred by many for this purpose, and the use of sodium thiosulfate has decreased.[25, 26]

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

IV 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 has been most commonly used. Lactated Ringer solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each 1% of TBSA burned for the first 24 hours. One half of the calculated amount of fluid needed is administered in the first 8 hours after the burn occurs, and the remaining half is 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 larger 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 lactated Ringer solution × weight (kg) × %TBSA burned (second-degree and third-degree), with half administered over the first 8 hours (from the time of injury) and the remaining half administered over the next 16 hours
  • Maintenance fluids - Lactated Ringer solution with 5% dextrose at 4 mL/kg/hr for patients weighing 0-10 kg, plus 2 mL/kg/hr for those weighing 10-20 kg, plus 1 mL/kg/hr for each 1 kg above 20 kg

Additional guidance is available in the Advanced Burn Life Support (ABLS) program develped by the American Burn Association (ABA).[27]  The ABLS program stresses that the rate and volume of fluid administration are determined by the patient’s response to fluid therapy and notes that the traditional 8- vs 16-hour approach may lead to insufficient adjustments when resuscitation is performed by ninexperienced providers. Accordingly, the program now emphasizes that hourly titration is far more important than the 8- vs 16-hour concept. 

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 involving 15% of TBSA or less, the following are indicated:

  • Patients with burns to 5-10% of TBSA who are taking oral fluids well - Oral fluids only
  • Patients with burns to 5-10% of TBSA who are not taking oral fluids well - Maintenance fluids
  • Patients with burns to 10-15% of TBSA - 150% maintenance fluids

The above recommendations are guidelines only. Patients with burns larger than 15% of TBSA should have a urinary catheter placed. Desired urine output is 1 mL/kg/hr for patients who weigh less than 30 kg and 30-50 mL/hr for those who weigh more than 30 kg. For major burns, fluid resuscitation must be reassessed hourly on the basis of the patient's urine output.

Rates of fluid administration should be altered in accordance with the patient's response. If a patient presents after some delay and has not been resuscitated properly before presentation, the calculated fluid requirements should be adjusted so as to take these factors into account. Infants are at risk for hypoglycemia because of their limited glycogen stores; therefore, glucose levels should be monitored, and lactated Ringer solution with 5% dextrose should be used for maintenance fluids. Evaluate the response to fluid administration by measuring urine output via an indwelling urinary catheter. Monitoring the sensorium, peripheral circulation, and blood pH is also helpful in assessing 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

Systemic antibiotic prophylaxis is not used in the treatment of burn patients, because it increases the risk of infection with resistant organisms. Instead, the use of systemic antibiotics is reserved for the treatment of specific infections, with the agents 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. Large burns are prone to fungal infections as well. The diagnosis can be made on the basis of clinical examination, quantitative burn wound cultures, or burn wound histology.

Surgical Therapy

Topical treatment

Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterial colonization. Silver sulfadiazine cream 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.[28]

Facial burns are usually treated with a combination antimicrobial product containing polymyxin B, neomycin, and bacitracin 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. Significant ear burns should be treated with mafenide cream 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.[29] 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 frequent painful dressing changes, sustained-release (continuous topical antimicrobial) silver-impregnated dressings, which can be left in place for several days, may be used for the treatment of partial-thickness burns. Many such dressings are currently available in various forms (eg, foam, hydrofiber, hydrocellular dressing, synthetic mesh or gel) and silver concentrations. Examples include the following:

  • Foam - Mepilex Ag (a silver-impregnated foam that can be easily applied and removed and can be left in place for 7 days; see the first image below)
  • Hydrofiber - Aquacel Ag (creates a viscous gel upon contact with burn surface, which prevents fluid loss and traps bacteria; can be left in place for 2 wk; see the second image below)
  • Hydrocellular dressing - Allevyn (a highly absorbant dressing with a high concentration of ionic sustained-release silver that is active up to 7 days)
  • Synthetic mesh - Acticoat Ag (a low-adherent silver-coated polyethylene net used as an antimicrobial barrier for up to 3 days; Acticoat 7 can be used for up to 7 days; Acticoat-Flex has increased flexibility)
  • Gel - Nanoparticle silver gel with a lower concentration of silver, therefore potentially avoiding adverse effects of long-term silver use such as argyria and delayed wound healing
  • Combination foam - Acticoat Moisture Control (polyurethane foam layer and a nanocrystalline silver-coated polyurethane layer, which is active up to 7 days)
Application of Mepilex Ag foam dressing. Application of Mepilex Ag foam dressing.
Aquacel Ag adherent to burn wounds. Aquacel Ag adherent to burn wounds.

If reepithelialization is not complete by the time the product must be removed, the product can be reapplied.

In a prospective randomized controlled trial that included both pediatric and adult patients with partial-thickness burns, Hundeshagen et al compared Mepilex Ag with the polylactic acid–based polymer Suprathel.[30] Both dressings were found to be feasible and efficacious. Suprathel was associated with significantly reduced pain during the first 5 days and with better overall scar quality; Mepilex Ag was associated with elevated viscoelasticity of burned skin compared with unburned skin at 1 month and with lower treatment cost per square centimeter.

Biobrane, a biologic dressing consisting of nylon mesh integrated with elements of porcine collagen, has also been used in pediatric burn patients.[31]  Generally, it can be left intact for up to 14 days, but, depending on the clinical picture and the surgeon's preferences, the overlying secondary dressings may require earlier review. In children, application of Biobrane usually requires general anesthesia and an inpatient hospital stay, whereas most applications of Acticoat do not. Hence, Biobrane is significantly more costly to use.

Products for wound closure

Temporary wound closure for major burns can be obtained by using allograft (cadaveric human skin). Additionally, developments in tissue bioengineering have provided temporary skin substitutes that avoid the need for allograft use. A number of products are commercially available, and many others are in development.

Epidermal products include the following:

  • Epicel (cultured autologous epidermal autograft cultivated by the patient's own skin)
  • Cultured allogeneic epidermal cells

A newer option that may be considered is the ReCell autologous cell harvesting system, a device that uses a small sample of the patient's own skin to create an epidermal suspension that may be directly applied to acute partial-thickness thermal burn wounds in patients aged 18 years or older or may be applied in combination with meshed autografts to acute full-thickness thermal burn wounds in pediatric and adult patients.[32]

Dermal products include the following:

  • AlloDerm (allogeneic acellular dermal matrix with an intact basement membrane complex obtained from human skin that prepares the wound bed for grafting)
  • Integra (extracellular matrix composed of bovine collagen and other wound-healing promoting substances that generate new dermis)
  • TransCyte (extracellular matrix generated by allogeneic neonatal foreskin fibroblasts with nonporous silicone layer)
  • ACell, an extracellular matrix (epithelial basement membrane layer harvested from pig bladders that promotes repair and remodeling of damaged tissue)

Combined epidermal and dermal products include the following:

  • Apligraf (a living allogeneic bovine product containing keratinocytes, fibroblasts, and bovine type I collagen)
  • OrCel (known as composite cultured skin; a bilayered cellular matrix composed of epidermal keratinocytes and dermal fibroblasts cultured in two separate layers into a type I bovine collagen sponge)

Preparation for surgery

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 mortality.

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.

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.

Operative details

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. A newer technique of burn wound debridement is Versajet hydrosurgery, which allows more precise debridement and reduced blood loss.[33, 34]

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 0.008-0.012 in. (0.2-0.3 mm), 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) or skin substitutes. As more donor sites become available, the temporary wound covers are removed and the wounds are grafted. Studies have shown that human growth hormone (HGH; 0.15-0.2 mg/kg/day intramuscularly [IM]) can speed donor-site healing, allowing more rapid reharvesting of healed donor sites.[12, 35, 36, 37]

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.

A full-thickness skin graft consists of both epidermal and complete dermal skin layers. It can offer a better cosmetic outcome and a smaller chance of contraction or trauma to the tissue, but it carries an increased risk of graft loss. It is used for cosmetically and functionally critical areas, such as the face, hands, and joints.[38]

In the case of burns affecting more than 50% of TBSA, the patient has insufficient areas of unaffected skin from which split-thickness skin grafts can be harvested. Cultured epidermal autografts produced from a small skin biopsy can provide permanent coverage of large areas.[39] However, a period of 3 weeks is needed for graft cultivation, and the take rate of cultured epidermal autografts may be poor, especially in chronically infected areas. Providing temporary coverage with allograft skin or application of the acellular dermal matrices may increase the chances for graft take.[40]


Complications of surgery in patients with burns include the following:

  • Bleeding
  • Infection [41]
  • Graft loss

Bleeding can be limited by means of various techniques, including subcutaneous infiltration of donor sites with epinephrine solution, the use of topical thrombin spray when excising, or the application of VersaJet techniques for excision of burns when possible. If infection is suspected, dressings can be changed to include a broad-spectrum antimicrobial agent along with systemic antibiotic treatment.

Complications of nonsurgical treatment include the following:

  • Infection
  • Compartment syndrome
  • Metabolic disorders
  • Feeding difficulties
  • Narcotic withdrawal

Abdominal compartment syndrome can result from aggressive fluid resuscitation and can be treated by using a percutaneous peritoneal drain. If this is not effective, laparotomy for decompression may sometimes be needed.

Long-Term Monitoring

Scar prevention

For burns that take longer than 3 weeks to heal or for wounds that have been grafted, hypertrophic scarring can be minimized by employing 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 (~12-18 months). Lotion application with massage therapy is used to keep the healed or grafted areas soft and supple.

If scars develop despite the application of preventive methods, various techniques are available for treatment, including surgical excision or dermabrasion, ultrasound therapy, and fractional carbon dioxide laser therapy.

Contracture prevention

Contractures refer to hypertrophic scar formation over joints that results in decreased range of motion (ROM). Aggressive attention to occupational and physical therapy, with appropriate consultation, is necessary to ensure optimal results. Active and passive ROM 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.

Treatments for contractures include various surgical techniques, such as Z-plasty and excisions with full-thickness skin grafts.

Psychological sequelae

Burn scarring can lead to significant psychological sequelae. The assistance of a trained psychologist or psychiatrist is an important addition to the overall care of these patients. Acute propranolol therapy has been suggested as a potential treatment for posttraumatic stress in children with large burns, but in a study by Rosenberg et al, this approach was not shown to be clearly effective.[23]



SFAR Recommendations for Management of Severe Thermal Burns During Acute Phase

In March 2020, the Société Française d'Anesthésie et de Réanimation (SFAR; French Society of Anesthesia and Intensive Care Medicine) published the following recommendations regarding the management of severe thermal burns during the acute phase in adults and children.[24]

Assessment, admission to specialized centers, and telemedicine

The standardized method of Lund and Browder (suitable for both adults and children) should be used to measure the total body surface area (TBSA) that is burned. 

Referral to a burn specialist should be sought to determine whether the patient should be admitted to a burn center.

Telemedicine should be used to improve the initial assessment of severely burned patients.

If there is an indication for admission to a burn center, the patient should be admitted directly to the center.

If a deep burn induces compartment syndrome in the limbs or trunk that compromises the airways and respiration and/or circulation, an escharotomy should be performed. Ideally, the escharotomy should be performed in a burn center by an experienced provider. 

Hemodynamic management

Adult burn patients with burn to ≥ 20% of TBSA and pediatric burn patients with a burn of ≥10% of TBSA should receive 20 mL/kg of an intravenous (IV) crystalloid solution within the first hour of management.

Balanced crystalloid solutions should be used.

To estimate the initial crystalloid infusion rate, a formula should be used that includes at least body weight and %TBSA burned. 

In fluid resuscitation for severe burns, the infusion rate should be adjusted as soon as possible on the basis of clinical and hemodynamic parameters.

Human albumin should be administered to patients with severe burns involving >30% of TBSA after the first 6 hours of management.

Airway management and smoke inhalation

Patients with burns involving the face or neck should not be routinely intubated.

Intubation of patients with burns involving the entire face should be considered if one or more of the following features are also present:

  • Deep and circular burn on the neck
  • Symptoms of airway obstruction (ie, change in voice, stridor, laryngeal dyspnea)
  • Very extensive burns (ie, ≥40% of TBSA)

If smoke inhalation is suspected, bronchial fibroscopy should not be performed outside burn centers, so as to avoid transfer delays. 

Hydroxocobalamin should not be routinely administered after smoke inhalation.

Aadministration of hydroxocobalamin should be restricted to adult patients with smoke inhalation and a high suspicion of severe cyanide poisoning and to children with smoke intoxication and moderate intoxication from cyanide. 

Hyperbaric oxygen therapy should not be routinely administered for cases of suspected carbon monoxide poisoning after smoke inhalation. 

Anesthesia and analgesia

Multimodal analgesia can be used to control pain in patients with severe burns, but all analgesic medications must be titrated on the basis of validated comfort and analgesia assessment scales.

Titrated IV ketamine can be combined with other analgesics to treat severe burn-induced pain.

If the patient is stable, nonpharmacologic techniques should be combined with analgesic drugs for dressings, where appropriate. 

Local treatment

In the absence of shock, cooling is appropriate for adults with burns involving < 20% of TBSA and for children with burns involving < 10% of TBSA. 

Burn wounds should be covered in the initial phase to reduce the risk of hypothermia and microbial contamination. The dressing should be maintained until expert advice can be obtained. 

Antibiotic prophylaxis should not be routinely administered to burn patients. 

Other treatments

Nutritional support should be started within 12 hours after burn injury. The oral and enteral routes are preferred to the parenteral route. 

Thromboprophylaxis should be routinely prescribed for severe burn patients in the initial phase.