Acute Burns

Burn severity is assessed on two dimensions: depth and total body surface area (TBSA). Burn depth is classified as: superficial (first degree — epidermis only, healing in 3 to 7 days without scarring); superficial partial thickness (second degree — superficial dermis, painful, blistering, healing in 10 to 14 days usually without significant scarring); deep partial thickness (deep dermis — reduced pain due to nerve damage, requires surgical grafting or biological dressings to avoid hypertrophic scar formation); and full thickness (third and fourth degree — all dermal layers destroyed, requires surgical excision and skin grafting). TBSA is estimated using the Rule of Nines (adults: head 9%, each arm 9%, each leg 18%, trunk 36%) or the more accurate Lund-Browder chart for children. Both parameters determine ICU admission criteria, fluid resuscitation volumes, and surgical priority.

The Parkland Formula (also called the Baxter formula) is the most widely used guide for intravenous fluid resuscitation in the first 24 hours after a major burn injury. The formula prescribes: 4 mL × body weight (kg) × TBSA burned (%) of Ringer's Lactate solution in the first 24 hours from the time of burn (not from hospital admission). Half this calculated volume is given in the first 8 hours, and the remainder over the next 16 hours. Accurate resuscitation is critical: under-resuscitation leads to burn shock, organ failure, and wound conversion (shallow burns deepening due to ischemia); over-resuscitation causes abdominal compartment syndrome, pulmonary edema, and extremity compartment syndrome.

In circumferential full-thickness burns, the inelastic burned eschar (dead, rigid, leathery skin) constricts like a tourniquet as underlying tissues swell during fluid resuscitation — causing compartment syndrome. Escharotomy is the emergency bedside surgical procedure (performed without anaesthesia, as full-thickness burns have no sensation) that incises through the eschar in a longitudinal pattern along the medial and lateral lines of the limb, releasing the constrictive band and restoring distal blood flow. Untreated limb compartment syndrome in burns progresses to ischemia and limb loss within hours. Chest escharotomy is similarly urgent when circumferential trunk burns restrict respiratory excursion and cause ventilatory failure.

Early tangential excision and split-thickness skin grafting within 48 to 72 hours (certainly within 5 days) of injury is now the international standard of care for deep partial and full-thickness burns. Early excision reduces bacterial colonization (which converts partial to full thickness burns and prevents graft take), minimizes the systemic inflammatory response and hypermetabolism, reduces ICU length of stay, reduces scar hypertrophy (early grafted burns scar less than those left to heal by secondary intention), and significantly reduces mortality in large burns. The excised wound is covered with an autologous split-thickness skin graft (STSG) harvested with a dermatome from an unburned donor area.

When a patient cannot undergo immediate grafting (due to haemodynamic instability, inadequate donor sites, or wound status), temporary biological and biosynthetic wound coverings protect the excised wound bed and reduce infection and fluid losses. Options include: allograft (cadaveric skin) — the gold standard temporary cover providing the closest approximation to living skin; Biobrane (nylon-silicone-porcine collagen membrane) for intermediate-depth burns; Integra (bovine collagen-glycosaminoglycan dermal substitute) — a two-stage approach where Integra provides a neodermis and is secondarily grafted with ultra-thin autograft; and RECELL (cell spray technology) using a small autograft biopsy to produce a spray of keratinocytes for large areas. Each technology serves specific wound types and clinical scenarios.

Rehabilitation in burn care begins on day 1 — even before wounds are closed. The hypermetabolic response to major burns (elevated cortisol, catecholamines, and inflammatory mediators) causes aggressive muscle wasting and contracture formation within days of injury. Physiotherapy prevents joint contractures through positioning, splinting, and passive/active exercises from the intensive care unit; occupational therapy maintains hand and face function; nutritional support (high-calorie, high-protein enteral feeding) combats hypermetabolism; psychological support addresses the profound psychosocial impact of disfiguring burns. Long-term challenges include hypertrophic scarring, contracture across joints, pruritus (severe itching), thermoregulation impairment (grafted skin lacks sweat glands), and psychological sequelae including PTSD and depression.