Current Anaesthesia & Critical Care 19 (2008) 256263

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Current Anaesthesia & Critical Care

journal homepage: www.elsevier.com/locate/cacc

FOCUS ON: BURNS CARE

Thermal injury The rst 24 h

C.A.T. Durrant*, A.R. Simpson, G. Williams
Burns Service, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom

s u m m a r y
Keywords: Thermal Burns Emergency Assessment Resuscitation Escharotomy Area Depth

Thermal burn injuries have devastating potential. In the United Kingdom alone, a quarter of a million people suffer burns each year. Flame and scald injuries are the most common aetiology. The vast majority of burns present to the primary care and emergency sectors, and only a small proportion of these are referred on to a specialist burns service. Appropriate initial management can make the difference between a good outcome and a poor one. The mainstay of treatment remains the Advanced Trauma Life Support (ATLS) guidelines. As part of airway management it is essential to recognise the likelihood of inhalational injury, as this contributes to mortality. Circumferential burns to the chest area can restrict ventilation and this is an indication for emergency escharotomy. Circumferential burns to the limbs can often be treated conservatively until transferred to a specialist burns service. Formal uid resuscitation should be started in adults with 15% Total Body Surface Area (TBSA) burns and children with 10% TBSA burns. The Parkland resuscitation formula is the formula of choice in the UK. The TBSA should be calculated objectively using a Lund and Browder chart and erythema is not included. The burned patient must be kept warm throughout their assessment. Burn depth can be assessed by appearance, sensation, and blanching, although this can be difcult. There should be a low threshold for discussing any burn with the local burns service. Accurate and clear documentation at all stages of the initial treatment is essential. Crown Copyright 2008 Published by Elsevier Ltd. All rights reserved.

1. Introduction Few injuries have the same devastating potential as burns. There is no social class that is unaffected; there is no age group that is exempt; there is no population from either developed or thirdworld countries that is without risk. The assault is not only a physical one, but also a psychological one.13 In the United Kingdom alone, approximately 250 000 people suffer burns each year, of which 13 000 are admitted to hospital. 1000 of these cases would be severe enough to warrant formal resuscitation and half of these would be children under 12 years of age.4 Skin is not merely an envelope; it is part of a complex organ system and so injury to it can have widespread effects (Fig. 1). Most burns seen in the United Kingdom are due to ame injuries. Scalds from hot liquids are the next most common, with electrical burns and chemical burns being relatively infrequent events. Only thermal burns will be discussed in this review. Burns can occur in any age group. Children up to 4 years old comprise 20% of cases seen in the Accident and Emergency department, with the majority (70%) of injuries being related to scalds. A further 10% of

* Corresponding author. Tel.: 44 0208 237 2500, 07958 482284 (mobile); fax: 44 0208 237 2510. E-mail address: charlie2@thedurrants.org (C.A.T. Durrant).

burn patients are in the 514 age group and the more experimental nature of children in this group increases the incidence of petrol and accelerant-related ame burns. The majority (>60%) of burn injuries occur in adults of working age (1564 years old) and are mainly ame burns. Up to a third of these cases may be workrelated in aetiology. The remaining 10% of cases are from the elderly population and this cohort of patients can introduce further issues that need to be considered as part of their care such as co-morbidity and social factors.5 The vast majority of thermal injuries will rst present to the primary care or emergency sectors. It is, therefore, essential that medical, nursing and support staff are adequately trained in the assessment and initial management of such insults. It is only a very small minority of acute burns that present to the Accident and Emergency department that are referred to a specialist burns service, and appropriate early care can make the difference between death, or debilitating long-term sequelae, and a good outcome.6 The National Burn Care Review7 described the seven Rs relating to burn care: Rescue refers to the initial removal of the victim from the thermal insult itself. For example, this may be the patient themselves reexively withdrawing their hand from a hotplate or a bystander pulling a person from a burning building. Resuscitate refers to the immediate support that should be given to a burns patient on arrival at the accident and emergency

0953-7112/$ see front matter Crown Copyright 2008 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cacc.2008.09.014

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SKIN FUNCTION
Thermoregulation Fluid, protein and electrolyte homeostasis Physical Protection UV Protection (melanocytes) Immune Regulation (Langerhans cells) Vitamin D Synthesis Neurosensory Function Identity and Social Interaction

2. Initial management of a thermal injury Although burns can be visually dramatic and present complex issues to the receiving hospital, the principles of treatment are much the same as for any trauma injury. The ABCs of the Advanced Trauma Life Support (ATLS) are as important in this setting as for the polytrauma patient.13 This treatment pathway is summarised in Fig. 2. 2.1. A is for airway with cervical spine control This is the rst step and it is critical to identify inhalational injury in burns patients. Inhalation of hot gases can cause direct damage above the vocal cords and, particularly after commencement of uid resuscitation, this can lead to oedema and obstruction.14 At this stage it is wise to take a comprehensive history; patients with signicant inhalational injury may still be able to communicate on presentation. This can change rapidly as oedema

Fig. 1. Functions of the skin.

department or even while en route in an ambulance. Any failing organ system must be rigorously treated. This usually involves administering uid to maintain the circulatory system but may also involve supporting the cardiac, renal, and respiratory systems. Retrieve refers to the transfer of appropriate patients to a specialist burns service. It is essential that there is good communication between the Primary Care service and the Burns service to ensure the safest handover possible. The indications for onward referral and important information that needs to be shared will be covered later in this review. The remaining four Rs (Resurface; Rehabilitate; Reconstruct; Review) are the remit of the receiving specialist service and beyond the scope of a discussion concerning the care of burns in the rst 24 h. It is tempting, when a burn arrives in the Accident and Emergency department, to attempt to prognosticate. Although predicting the mortality of a burn is important in terms of deciding the most appropriate level of care, it is not an easy exercise either practically or ethically. For example, it would be inappropriate to aggressively treat a patient with a burn that has no survival precedent. On the other hand, it would be equally unethical to forego treatment on a patient with a severe, but potentially survivable injury. Unfortunately, the complex burns attending the Accident and Emergency department will often not fall into an easily denable group (for example, a relatively small burn that has signicant co-morbidity in an elderly patient may have a worse prognosis than a much bigger burn in a young patient). There are several formulas that have been published in an attempt to predict the mortality of a burn,811 but these have been limited by their small sample size and the fact that their formulae are derived from local data and tend not to have the same sensitivity and specicity when applied to other groups data.12 ITU prognostic indices such as APACHE II and the Injury Severity Score, are also unhelpful in the acute setting as burns patients can be quite well at rst appearance, but deteriorate signicantly as the systemic inammatory response progresses. However, the more contemporary studies all agree that mortality increases with age and burn size, as well as the presence of inhalational injury. These formulae are most useful as an adjunct to clinical impression and also as an audit tool but, ultimately, there is no substitute for experience and there are few situations where the decision for palliative care is made prior to extensive discussion with a burns specialist.

Fig. 2. The treatment pathway for a burn presenting to the emergency department.

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gases such as ammonia, sulphur dioxide and chlorine react with the water on the respiratory epithelium to produce acids and alkalis that cause direct damage; lipid soluble gases such as aldehydes and hydrogen chloride are carried into the lower airways on carbon particles, causing mucosal adherence and cell membrane damage; smoke particles themselves that are inhaled into the deeper part of the lung have lost most of their destructive thermal component, but they can act as a direct irritant, causing bronchospasm, inammation and bronchorrhoea. The pneumocytes become damaged, impairing their ciliary activity and exacerbating the situation.16 This can lead to atelectasis or pneumonia17 if the inammatory exudate is not adequately cleared. The nal insult caused by inhalational injury is the systemic effect of the gases inhaled, most importantly carbon monoxide. This colourless, odourless gas binds to deoxygenated haemoglobin with approximately 240 times the afnity of oxygen. It also binds to intracellular proteins, particularly those of the cytochrome oxidase pathway, and these effects together cause both extracellular and intracellular hypoxia and a metabolic acidosis. Pulse oximetry cannot differentiate between normal oxyhaemoglobin and carboxyhaemoglobin and has limited use in this setting. Blood gas analysis should be used to identify and monitor the levels of carboxyhaemoglobin in the blood, and very high levels of carbon monoxide warrant ventilation in order to ensure that a maximum concentration of inspired oxygen is given. Treatment is with 100% oxygen in order to displace the carbon monoxide from the haemoglobin in exchange for oxygen and this should be continued until the metabolic acidosis has resolved.18 2.3. C is for circulation As per Advanced Trauma Life Support (ATLS) guidelines, adequate intravenous access is essential, preferably through nonburned tissue. At the same time, blood can be sent for full blood count, urea and electrolytes, clotting, and blood group matching. It is important to also check the peripheral circulation. Circumferential burns to the limbs and neck can jeopardise perfusion as the inelastic quality of the burned skin acts as a tourniquet. If there is any doubt at all as to the distal circulation, then escharotomies are indicated, but the timing of these should be discussed with the burns specialist. If a burned patient is hypotensive on admission, then other causes for the hypotension must be excluded. This might be due to cardiogenic or neurogenic shock, or possibly occult blood loss (such as into the chest, abdomen, or pelvis).13 It is important to appreciate that a collapse may have precipitated the burn rather than vice versa. 2.4. D is for disability Conditions such as hypoxia and hypovolaemia, as well as concurrent head trauma can cause the patient to be variably obtunded. Carbon monoxide poisoning, drug use, and alcohol intoxication can also present with a decreased conscious level. All patients should be assessed with a baseline Glasgow Coma Score, and this can often be done while the airway is being assessed and the history taken. 2.5. E is for exposure with environmental control Burns patients rapidly become hypothermic due to the loss of their protective thermoregulatory skin and evaporation of uid from the exposed tissue. These patients need to be warmed quickly and effectively by any means available (such as blankets, overhead heaters, warmed intravenous uids, and air-heated covers). Inadequate warming may lead to hypoperfusion and subsequent deepening of the burn.19

Fig. 3. Key points from a burns history.

develops and intubation becomes necessary, and this may be the only chance the clinician gets to obtain vital information from the patient, such as past medical history, GP and next of kin contact numbers, and details about the accident. Fig. 3 summarises the main points that should be elucidated from the history. If there is any suggestion of inhalational injury, the patient should have an anaesthetic review.

2.2. B is for breathing Even patients without an inhalational injury can have their ventilation compromised. Deep circumferential burns to the chest decrease the skins elastic properties and limit chest excursion causing a mechanical restriction of breathing; blast injuries related to the burn can cause lung contusions and alveolar trauma, potentially leading to adult respiratory distress syndrome. Flying shrapnel from the blast can also cause pneumothorax and direct lung damage.15 Inhalational components of thermal injury can cause damage through mechanisms other than heat; water soluble

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2.6. F is for uids The amount of uid that the patient requires depends on the surface area of the burn and the size of the patient. This will be covered in more detail in the next section. Formal resuscitation is required for adults with greater than 15% total body surface area (TBSA) burns, and children with greater than 10% TBSA burns. All patients undergoing formal resuscitation should have urinary catheters placed in order to monitor urine output as a function of organ perfusion.13 Fig. 4 shows an algorithm to summarise the primary survey of a major burn. Burns can be extremely painful. Pain is an evolutionary feature that has a protective function; it warns of damage, and promotes careful treatment of the affected area. However, pain can also be destructive: by increasing the cellular stress response, the somatic, autonomic and endocrine reexes are diminished. This results in a catabolic state, with platelet aggregation, nausea, ileus and a suppressed immune system.20,21 Restricted breathing due to pain can lead to low-grade hypoxia, and severe pain can cause vasoconstriction, both of which ultimately impair wound healing. It is important, therefore, that all burns patients get adequate analgesia; an intravenous opiate such as morphine would be appropriate (titrated to the patients weight). This is easily done in the Accident and Emergency setting and is often overlooked.22

Following the primary survey, a secondary survey should be performed. The patient is thoroughly examined for any concomitant injury and the full extent of the burn can be assessed. Care should be taken when assessing the burn that the patient does not lose too much heat. This can be ensured by revealing areas of skin sequentially to minimise the time exposed to the open air. At this stage, any specialist investigations can be arranged. Once the patient has been stabilised, and the size and depth of the burn has been determined, the burns should be dressed. Prior to dressing, the area should be washed thoroughly and all loose skin should be gently removed. There are conicting opinions as to whether blisters should be debrided or left intact. Evidence for each remains poor; however, the most recent guidelines suggest that small blisters less than 6 mm, and thicker blisters on the palms and soles of the feet, may be left intact while all others should be debrided.23 For acute burns that warrant referral to a specialist burns service, a simple dressing such as clinglm is ideal. This protects the wound, reduces heat and evaporative losses, reduces pain (particularly in supercial burns), and also leaves the appearance of the burn unchanged.13 The burn can also be visualised through the dressing without the need to remove it. Flamazine should never be used prior to transfer as it can mask the true depth of the burn, making it difcult for the receiving service to assess. The National Burn Care Review7 has published guidelines for referral to a specialist burns unit (Fig. 5). Even the most simple of

Fig. 4. Algorithm for the primary survey of a major burn.

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Fig. 5. Indications for referral to a burns service.

burns at rst assessment can turn out to be more complex than rst imagined, so any burns that have taken longer than 2 weeks to heal should also be referred onwards. If there is any doubt as to whether a burn should be referred or not, that burn should be discussed with the local burns service and appropriate advice can be given. 3. Assessment of burn area There is great variability among clinicians when assessing the same burn and even area-plotting charts (such as the Lund Browder) are prone to variation between users.24 When assessing the area of a burn, it is important to understand that erythema without overlying epidermal loss is never counted as it is a transient nding and usually settles within a matter of hours. There are 3 commonly used methods for measuring a burn, and each has advantages and disadvantages. 3.1. Palmar surface The palmar surface of the patients hand, with ngers very slightly spread, equates to approximately 1% of the patients TBSA. This is a quick and reliable method of assessing burn area. However, it loses its accuracy beyond about 15%. In this way it can be used to measure relatively small burns up to 15% or extensive burns greater than 85% (by simply measuring the unburned areas), but it will not give an accurate measurement for the more intermediate sized burns. 3.2. Wallace rule of 9s25 The body is divided into areas of 9%. It is a good method for measuring medium to large burns, although it does tend to

overestimate the area burned.24 Due to the different proportions in children, who have relatively larger heads and smaller limbs, the rule of 9s does not t and is inaccurate. Therefore, this should only be used in adult burns patients. 3.3. Lund and Browder chart26 This is the most accurate method currently and readily available. It allows for changing body proportion with age and so can be used with children (Fig. 6). 4. Assessment of burn depth There are three major determinants as to the thickness of a thermal injury: the temperature of the insulting mechanism; the duration of contact; the thickness of the skin (for example, the thicker skin of the back will withstand more than the thin skin of the forearm. Also, the dermis is relatively thinner in the very old and very young population). Burns can be simply classied according to their depth of penetration. Partial thickness burns do not extend through all layers of the skin and can therefore heal from the adnexae present in the wound bed; full thickness burns extend through all layers of the skin and may involve subcutaneous tissues and so rely on healing from the edges of the wound only. Partial thickness burns can be further sub-divided into supercial partial thickness, middermal and deep-dermal burns. Each category is important in terms of both management and prognosis. Supercial burns (or epidermal burns) are different to supercial partial thickness burns. Supercial burns involve the epidermis only and involve erythema with no epidermal loss (such as in sunburn). As previously mentioned, these burns are clinically unimportant and are not

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Fig. 6. Lund and Browder chart for estimating area of burn.

counted as part of the TBSA measurement. Supercial partial thickness burns extend through the epidermis to the supercial part of the dermis. Mid-dermal and deep-dermal burns extend deeper through the dermis, but do not affect the full thickness of the dermis. Fig. 7 shows the levels of these burns diagrammatically. Correct assessment of the depth of mid-dermal and deepdermal burns can be difcult, even for the specialists. Laser Doppler scanning of burns has recently increased diagnostic accuracy of burn depth and has decreased the likelihood of over-operating.27 Often, it is only at surgery that the true depth of a burn is revealed. The history is the rst clue as to the depth of the burn. For example, one would naturally expect a ash burn to be less deep than a prolonged ame burn. There are also techniques available to allow for easier assessment on direct examination: 4.1. Appearance Supercial partial thickness burns tend to be uniformly pink and wet; mid-dermal burns are not uniform in colour and have a mottled cherry-red colour due to damaged capillaries in the deeper layer of the dermis; deep-dermal burns are pale and only very slightly moist; full thickness burns are dry and leathery, or waxy. 4.2. Blanching This describes the whitening of the skin upon pressure and the subsequent pattern of capillary relling. Only supercial partial

thickness burns and mid-dermal burns will blanch. The more supercial the burn, the quicker the capillary rell on release of the pressure. Deep dermal and full thickness burns do not blanch (when this is associated with red discolouration, it is called xed staining). 4.3. Sensation The deeper the burn, the less sensate it will be. Differentiation of mid-dermal from deep-dermal injuries (where the surface appearance can be similar) can be aided by the use of gentle pressure with a hypodermic needle. With mid-dermal burns, it is still possible to appreciate a pinprick sensation; with deep-dermal burns, often only a sensation of pressure is felt. These ndings are summarised in Fig. 8. 5. Resuscitation Burn injuries can involve dramatic uid loss, and these losses must be replaced to maintain homoeostasis. There are many uid resuscitation formulae in current use,28,29 with no clear evidence that one is better than the others. These formulae are only guidelines, and their success relies on adjusting the volume and rate of resuscitation uid against monitored physiological parameters. The main aim of resuscitation is to support the patients vital organs and also to maintain adequate tissue perfusion to the burn itself and so prevent it from deepening.19 This can be a complex issue, as

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Fig. 7. Diagram showing the penetration of different burns through the layers of the skin.

too little uid will cause hypoperfusion and cellular hypoxia, whereas too much will lead to cellular and interstitial oedema. The greatest amount of uid loss in burn patients is in the rst 24 h after injury.30 Over the rst 812 h, uid from the intravascular compartment tends to shift to the interstitial uid compartment. Therefore, any uid given during this time rapidly leaves the intravascular compartment. Colloids have not been shown to have any advantage over crystalloids in maintaining circulatory volume and fast uid boluses are unlikely to be of benet, as the resultant rapid rise in intravascular hydrostatic pressure will just drive more uid into the interstitial space. Although systematic capillary leak tends to occur with burns greater than 2530% TBSA,31 all adult burns of 15% TBSA or more and all paediatric burns of 10% TBSA or more require formal resuscitation. The most commonly used formula in the United Kingdom is the Parkland formula.28 This is a crystalloid-based formula that calculates uid requirements over the rst 24 h following a burn and can be titrated according to urine output. The formula is as follows:

4 ml=kg for the 1st 10 kg 2 ml=kg for the 2nd10 kg 1 ml=kg for every kg thereafter
This can be given orally (preferably as a nutritious uid such as milk), or intravenously using 5% dextrose and 0.45% normal saline solution, but not both together. The amount of uid given should be constantly adjusted to maintain a urine output of 0.51 ml/kg/h in adults and 12 ml/kg/h in children. 6. Escharotomy As previously mentioned, deep dermal and full thickness burns are inelastic. Therefore they will not stretch as the subcutaneous tissues become oedematous, as will happen over the course of resuscitation. This is of concern for burns that are circumferential. On a limb this can lead to constriction and hypoperfusion, placing the extremity in jeopardy. Around the chest, this can lead to impaired ventilation, hypoxia and death. In these situations, it is important to recognise the potential complications and act swiftly and decisively. Escharotomy involves incising through the burn to the fat beneath. This allows the burn eschar to move independently, relieving the underlying tissue pressure. Note that the fascia remains unbreached, differentiating this procedure from a fasciotomy, although in patients with large burns and massive tissue oedema, fasciotomy may also be necessary.32 For the limbs, incisions are made along the medial and lateral aspects, taking care to avoid damaging any important underlying structures. For the chest, longitudinal mid-axillary incisions are

Total fluid requirement in 24 h 4 ml TBSA% Weightkg

The 24 h resuscitation period starts from the time of the burn and not from the time the patient presents to the Accident and Emergency department. The rst half of this calculated amount should be given in the rst 8 h, with the remainder being given over the following 16 h. The uid to be given is Hartmanns solution. Children also require maintenance uid at an hourly rate of:

Fig. 8. Table illustrating the key features in the assessment of burn depth.

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made and are connected by a chevron-style transverse incision running alongside the subcostal margin. A further transverse incision is made below the level of the clavicles (inferior to the potential placement of subclavian central lines). This creates a mobile breastplate that moves with ventilation. For the most part, escharotomies are performed by the receiving burns unit and simple elevation of the affected limb is all that is required from the referring hospital. However, if transfer is likely to be delayed by several hours, then there is no choice but to perform the escharotomies on site. This should be done in the controlled environment of the operating theatre with the most experienced staff available. Since escharotomies bleed a great deal, they should ideally be performed with electrocautery. Following surgery, they can be packed with Kaltostat alginate dressing and dressed with the burn. 7. Summary Thermal burn injuries have devastating potential. In the United Kingdom alone, a quarter of a million people suffer burns each year. Flame and scald injuries are the most common aetiology. The vast majority of burns present to the primary care sector, and only a small proportion of these are referred on to a specialist burns service. Appropriate initial management can make the difference between a good outcome and a poor one. The mainstay of treatment remains the ATLS guidelines. As part of airway management it is essential to recognise the likelihood of inhalational injury, as this contributes to mortality. Circumferential burns to the chest area can restrict ventilation and this is an indication for emergency escharotomy. Circumferential burns to the limbs can often be treated conservatively until transfer to a specialist burns service. Formal uid resuscitation should be started in adults with 15% TBSA burns and children with 10% TBSA burns. The Parkland resuscitation formula is the formula of choice in the UK. The TBSA should be calculated objectively using a Lund and Browder chart and Erythema is not included. The burned patient must be kept warm throughout their assessment. Burn depth can be assessed by appearance, sensation, and blanching, although this can be difcult. There should be a low threshold for discussing any burn with the local burns service. Accurate and clear documentation at all stages of the management is essential. References
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6. Khan AA, Rawlins J, Shenton AF, Sharpe DT. The Bradford burn study: the epidemiology of burns presenting to an inner city emergency department. Emerg Med J 2007 Aug;24(8):5646. 7. National burn care review, <http://www.bapras.org.uk/UploadFiles/ National%20Burn%20Care%20Review.pdf>. Available from:. 8. Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998 Feb 5;338(6):3626. 9. Smith DL, Cairns BA, Ramadan F, Dalston JS, Fakhry SM, Rutledge R, et al. Effect of inhalation injury, burn size and age on mortality: a study of 1447 consecutive burn patients. J Trauma 1994;37:6559. 10. Tobiasen J, Hiebert JH, Edlich RF. Prediction of burn mortality. Surg Gynecol Obstet 1982 May;154(5):7114. 11. Roi LD, Flora Jr JD, Davis TM, Cornell RG, Feller I. A severity grading chart for the burned patient. Ann Emerg Med 1981 Mar;10(3):1613. 12. Stavropoulou V, Daskalakis J, Ioannovich J. A new prognostic burn index. Ann Burns and Fire Disasters 1993 June;6(2):7683. 13. Hettiaratchy S, Papini R. Initial management of a major burn: Idoverview. BMJ 2004 June 26;328(7455):15557. 14. Tredget EE, Shankowsky HA, Taerum TV, Moysa GL, Alton JD. The role of inhalation injury in burn trauma: a Canadian experience. Ann Surg 1990 Dec;212(6):7207. 15. Avidan V, Hersch M, Armon Y, Spira R, Aharoni D, Reissman P, et al. Blast lung injury: clinical manifestations, treatment, and outcome. Am J Surg 2005 Dec;190(6):92731. 16. Burns TR, Greenberg SD, Cartwright J, Jachimczyk JA. Smoke inhalation: an ultrastructural study of reaction to injury in the human alveolar wall. Environ Res 1986 Dec;41(2):44757. 17. Edelman DA, Khan N, Kempf K, White MT. Pneumonia after inhalation injury. J Burn Care Res 2007 MarApr;28(2):2416. agas KA. Carbon monoxide poisoning. Med Clin North Am 2005 18. Kao LW, Nan Nov;89(6):116194. 19. Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953;40:58896. 20. Goodwin SA. A review of preemptive analgesia. J Perianesth Nurs 1998;13(2):10914. 21. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78(5):60617. 22. Singer AJ, Thode Jr HC. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil 2002 NovDec;23(6):3615. 23. Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res 2006 JanFeb;27(1):6681. 24. Wachtel TL, Berry CC, Wachtel EE, Frank HA. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns 2000 Mar;26(2):15670. 25. Kyle MJ, Wallace AB. Fluid replacement in burnt children. Br J Plast Surg 1951;3:194. 26. Lund CC, Browder NC. Estimation of areas of burns. Surg Gynecol Obstet 1944;79:3528. 27. Pape SA, Skouras CA, Byrne PO. An audit of the use of laser Doppler imaging (LDI) in the assessment of burns of intermediate depth. Burns 2001 May;27(3):2339. 28. Baxter CR. Fluid volume and electrolyte changes in the early post-burn period. Clin Plast Surg 1974;1:693703. 29. Yowler CJ, Fratianne RB. Current status of burn resuscitation. Clin Plast Surg 2000;27(1):110. 30. Hettiaratchy S, Papini R. Initial management of a major burn: IIdassessment and resuscitation. BMJ 2004 July 10;329(7457):1013. 31. Arturson G. Microvascular permeability to macromolecules in thermal injury. Acta Physiol Scand Suppl 1979;463:11122. 32. Kao CC, Garner WL. Acute burns. Plast Reconstr Surg 2000 Jun;105(7):248292.

Further reading
1. Herndon DN, editor. Total burn care. 3rd ed. London: Saunders; 2007. 2. Hettiaratchy S, Papini R, Dziewulski P, editors. ABC of burns. BMJ Books; 2002. 3. Pape SA, Judkins K, Settle JAD. Burns: the rst ve days. 2nd ed. Smith and Nephew; 2001.