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13. Admission of Burn Patients to the Burn Center Including Burn Wound Evaluation
13.1 Introduction
This chapter addresses the treatment algorithms and bundles to be undertaken at the second or last treatment level, the burn center [1, 2]. The burn center provides the last treatment level where also burn surgery is undertaken to cover full-thickness burn wounds. This chapter focuses on the early period of admission at the burn center usually encompassing the first 24–48 h after the burn, whereas the treatment strategies presented in the previous chapter focuses mainly on the triage and patient examination necessary for the acute care and proper prioritization for the next care level. One central aim has then been to do a proper trauma evaluation in line with a trauma triage guideline such as the ATLS and possibly also by a specific burn-based triage algorithm such as the ABLS [3–5] or the EMSB courses [6–8]. It is then important to strictly follow the algorithm so that no specific detail in the patient background or injury profile is overlooked—this strategy is then also continued at the receiving site as will be described below. Prior to referral contact is taken between the refereeing physician and the corresponding person at the receiving unit. As was stressed in the previous chapter, there are concerns that there may be details overlooked or the information may be hampered by at times the lack of experience at the referral site. This especially has been a topic of interest as burn care is constantly being further centralized as incidence numbers decline in most high-income western countries and the chance for different physician categories to be exposed to burns decline [9]. To facilitate the communication between referral and receiving units increasing focus has been directed at telemedicine tools that further enhances and facilitates communications [10–12]. Especially photos of injured tissues have been found valuable. Challenges that need special attentions in the early evaluation of the burn injured is related to the need for intubation, estimation of the burn size and depth and correspondingly the magnitude and titration of fluid treatment, and need of escharotomies. A significant portion of the early assessment that will also ensue at the burn center has already been described in detail in the previous chapter and therefore is only shortly mentioned now, and focus is instead directed to important issues to be examined and dealt with at the burn center.
13.2 Primary Admittance Protocol and Control
When the initial discussion has been undertaken with the burn center and the underlying information details of the patient has been transferred to the burn center, the first action is to prepare resources and equipment for the receiving process at the burn center. In a well-administered and trained burn center that means to activate the regular routines for new admittance. It may be advised that these procedures are well described in standard operating procedures (SOP) based on adequate guidelines [13, 14] as well as having checklist in place to control that each important procedure in the SOP is adequately followed. Such good examples for burn care may be found, e.g., in England [15]. It has been well documented that checklists within healthcare and not least intensive care may improve outcome [16–19]. Also good documentation principles are needed for follow-up purposes, quality assurance, and benchmarking. This includes entering data into quality registries [20–22] and for later follow-up reports used in burn center verification processes such as described for Europe [23], Australia [24], and the USA [25].
When the patient first arrives, control of previously obtained information is ascertained and it is ensured that the proper documentation is in place. In parallel, for the well-being of the patient, it is important that the different steps in the ABLS or the corresponding algorithm are regularly re-evaluated, so that the present medical status is ascertained and is in line with what has been reported earlier or if there are deviations, such as a deterioration in any of the vital parameters, the corresponding action is promptly undertaken.
13.3 Primary and Secondary Assessment
As stressed in the previous chapter, primary and secondary assessment is again made at the burn center. There are however a number of important issues that are relevant at this level where a more detailed and ambitious approach may be advocated.
13.4 ABCDE
Airway. Airway assessment can be more thoroughly evaluated, and the need or possibility to intubate can be more properly assessed using fiber-optic techniques examining the upper airway in detail for thermal injuries and the corresponding risk of immediate or later swelling, e.g., secondary to fluid resuscitation. If intubated acutely at the referring facility a decision on the management of the airway long term can now be made. This airway assessment is made and evaluated in relation to patient history and blood gas analysis (gas exchange/diffusion). In larger burns with bronchoscopy-verified inhalation injury with concomitant gas diffusion difficulties, an early tracheostomy should be considered [26]. It is important to thoroughly evaluate the airway by bronchoscopy and clear as much as possible of soot and debris at an early point. A thorough investigation at this point can also help predict the length of ventilator treatment [27]. Also the use of thoracic CT scans can help in delineating the extents of the inhalation injury [28–30]. Early ARDS development may occur but is not very common especially not in the very early phase after burn [31]. Early tracheostomy may facilitate treatment, based on completely without or with significantly reduced sedation and thus increasing the rehabilitative potential in early care [26]. Here it may be important to consider COPD in older patients with a smoking history, who might have fallen asleep while smoking and being injured, and who may have a pulmonary problem already prior to the accident. Increased fire accidents have also been noted in oxygen-treated COPD population [32].
Breathing. Again the restrictive effects of circular burns need to be re-assessed and the need for complementary escharotomies may be considered. In this situation, the restrictive effect of large fluid volumes may also be appreciated. At this point in time carbon monoxide and cyanide intoxication may be still relevant although oxygen may have been properly provided during transport in cases with suspect carbon monoxide poisoning. Blood levels need to be evaluated and especially in patients who have been extricated unconscious from the fire. It needs to be stressed that that may have been the primary reason for intubation. If carboxyhemoglobin levels in blood are not reduced, extended oxygen treatment is mandatory. There is no evidence for beneficial effects of hyperbaric oxygen treatment additional to an extended oxygen treatment administered through a ventilator or by nasal cannula in patients with smoke inhalation. If still considered it should be noted that treatment in hyperbaric oxygen chamber, including logistics and transport, may delay appropriate acute burn care including resuscitation, monitoring, and the need for additional escharotomies. Notes in the medical charts of cerebral effects, or the patient not having a normal level of consciousness (LOC), are indicators that need to be further examined. In unclear cases, the need of a cerebral CT scan may be mandatory to exclude other cerebral diseases.
Circulation. Is assessed as has been made at the referral site, including blood pressure and ECG, if needed as indicated by the medical history, cardiovascular risk factors, or due to the injury mechanism being an electrical one. Especially extremity perfusion needs to be assessed properly in cases of circular extremity burns with or without previous escharotomies. Here the use of Doppler techniques can improve accuracy although palpation of peripheral pulsation in the arms or audible pulsations using the hand Doppler is not a sure sign to escape escharotomy. The examination should be based on signs of capillary refill in the fingers/toes and on the swelling of the proximal tissues and if there is suspicion of compromised circulation even if suspected in the following few hours. In cases of electrical injuries, the risk of compartment issues needs to be considered and extremities at risk should be repeatedly examined.
Disability. Repeated examinations (e.g., Glascow coma scale) need to be made to ascertain that the LOC remains stable and uncompromised. In an elderly population, stroke, cardiovascular disease, or diabetes may have contributed to the circumstances for the accident and should be excluded in risk patients as it may need specific medical attention in parallel to the burn. Especially intracerebral hemorrhage may pose a challenge at this point [33].
Expose and Examine. This part is most particular for the early examination at the burn center as the organ of injury needs to be fully examined and scrutinized in conjunction with the planning process of wound care and importantly the ensuing surgery.
13.5 Burn Wound Evaluation and Treatment Planning Including Surgery
Evaluating the depth (partial/full thickness) and extent of burn injury (percentage of total body surface area burned, TBSA%) is crucial by many means not only because it is the most important factor for the overall outcome for the patient involving both short and long term [34, 35]; but also as it underlies the calculation for the fluid management. At this point however, from the burn center perspective, we will also focus on some specific details, such as early cleaning and debridement of the wound and also specifically address burn injury depth and the TBSA% estimate.
Cleaning and debridement. For this procedure, the circumstances for the burn wound assessment evaluation need to be optimized. Generally, it is undertaken in an operation like facility, with proper cleaning possibilities (tub) under clean conditions. In order to properly remove debris, blisters, and clean the skin, conscious sedation or general anesthesia is most often preferred. This procedure involves mechanical cleansing using cloth, brushes and scraping tools. It may be debated whether regular soap should be supported by antibacterial/cidal agents. Theoretically, the burn wound immediately after injury is sterile, but colonization may occur during any part of the transport process. Here also ointments with antibacterial properties are often used, but the science supporting either measures in this early phase is almost nonexistent.
Burn depth assessment. Over the years, this has been a hot topic, and not least, it has repeatedly been shown that the burn depth estimate varies between referral sites and burn centers, and importantly, it has also been shown to vary between different skilled surgeons. There are two important issues that need to be stressed today: first, depth estimate may be discussed and conveyed during the referral process between the referral site and the burn center by means of photography/telemedicine [10–12]. This will ensure a better primary estimate and more proper handling of the patient during the referral process. Second, it has been shown that technical instruments as the laser Doppler system can further improve even the skilled surgeons’ estimate of the depth assessment [36–38]. This is today supported by the fact that several large burn centers in Europe use the Laser Doppler system to support decision-making as to the need for surgery. Scientifically it has been shown that by the use of two consecutive measurements in scald injures, 100% both sensitivity and specificity can be obtained [37]. This supports the further use and development of technical adjuncts in the burn depth assessment.
Burn extent estimate. As with the depth estimate, difficulties in getting uniform determinations of burn extent between referring and receiving parties are well acknowledged [39]. To simplify and optimize the process, the historical approach has been the use of the rule of nines and the Lund Browder chart as described in the previous chapter. In present times with an increasing computer capacity and support and Internet availability, other methods are emerging. These being either that the burn wound extent is being plotted on a three dimensional computer model i.e. in an app for fluid resuscitation estimates [40] or more importantly by photography/imaging systems generating three dimensional images of the injury extent on a three dimensional computer model [41]. In this setting, burn estimates in square centimeter can be provided. In the future it can be predicted that the registration of burn injuries using the two above-mentioned technologies may become the standard of care even in developing countries where such functions have already been launched on smartphone devices [41].
13.6 Secondary Assessment
As at the site of accident and the referral hospital, secondary assessment needs to be repeatedly undertaken to exclude a complication from other trauma than the burn. Often when refereed between hospitals and tertiary burn centers, the trauma responsible surgeon at the tertiary hospital is made aware of the burn injured being transported and transferred between institutions, and in case of a complication of the burn by regular trauma, the trauma organization is made aware and updated. Not seldom, the trauma team at the referral hospital has already arranged a trauma CT in unclear cases, and a detailed examination may have been done along the treatment path.
13.7 Early Burn Center Planning (at Admittance or Shortly After, <24–48 h) for Larger Injuries (>20/30%) Needing Surgery and Intensive Care
13.7.1 Very Early Intensive Care Planning at the Burn Center
Temperature. Temperature control is crucial in the burn ICU setting as it among many things may lead to infections; therefore, patients with larger burns need to be actively heated. This is best done by fluid-heated mattresses [42].
Vascular access. As discussed in the previous chapter, recommendations were made that invasive blood pressure measurements, central circulation surveillance, and central venous lines should be inserted and measurements started. If this has not been done previously, complementary instillations needs to be made at the center. Also in cases with early renal failure, a veno-venous line may be installed prior to the start of filtration or dialysis measures.
Early fluid therapy and continuous surveillance in the ICU period. From the fluid balance perspective, especially the risk of fluid over and under resuscitation needs to be acknowledged. In the time period 1995–2010, a significant concern was fluid over resuscitation, called the “fluid creep” also at the burn center level [43–46]. Presently there are indications that fluid under resuscitation is again beginning to be a problem [47, 48]. Urine output remains the main outcome parameter for the early fluid resuscitation.
To continuously have access to central circulation parameters has been increasingly important after the early fluid resuscitation period, and one system advocated and used by many in this respect in the burn setting [49–53] is the arterial thermodilution PiCCO system (Pulsion Medical Systems, Munich, Germany) [54]. It provides many useful surveillance parameters such as intrathoracic blood volume, which well depicts the patient fluid volume needs and can be used to titrate fluids in conjunction with pulse pressure variation (PPV), which also shows fluid volume needs but can be continuously assessed (in between every bolus for thermodilution), systemic vascular resistance (SVR), and extravascular lung water (EVLV). Another good argument for this system is also that it provides long-term intra-arterial assessment and is not usually as transient in function as are lines located in the radial or dorsal foot arteries. If difficult to apply in the femoral vessel due to, e.g., extensive burns, it has also been shown to function properly when either the central venous line is located in the femoral region [55–57] or the arterial catheter is placed in the proximal part of the brachial artery [58, 59]. Importantly, it needs to be stressed that the use of PiCCO system for fluid volume assessment in major pediatric burns have recently shown a positive outcome effect further supporting its general applicability in the burn ICU setting over even extended period of time [60]. It may then be advocated to use this mode of surveillance modality in the planning of the ICU period for larger burn injuries. Competing systems based on ultrasound technique may provide arguments based on ease to apply, but the parameters that may be assessed by this mode are significantly less. An important word of caution however needs be highlighted on invasive monitoring early after burn as the regular Parkland fluid resuscitation strategy provides a hypovolemic situation at 12 h post burn [49], and if not accepted in the resuscitation, a significant fluid over resuscitation will occur on a regular basis. This has been shown repeatedly in RCT trials [50, 51].
Further regarding the fluid balance, the risk of compartment problems, mainly abdominal compartment in very large burns when crystalloid fluid volumes exceed 300 mL/kg/24 h [61], needs to be remembered and the need for adjusted fluid strategies. The most popular approach is by adding colloids known as “colloid rescue” which significantly reduces the total fluid volumes provided [43, 62, 63]. Other and important alternatives include the use of hypertonic resuscitation fluids [64, 65], but caution is warranted as there has been shown risks of kidney affection in one study [66]. A common approach by many to reduce fluid needs in resuscitation of burns is by providing vitamin C. This has repeatedly been found successful and is therefore a strategy used by many, but the timing for the start of this treatment and the dosing is still debated [67].
It is important during the early care at the burn center to ascertain that the fluid resuscitation strategy is successful. This means that urine production is according to plan but also that the base excess and lactate are normalized early (another endpoint may be central venous saturation, SAT%). If not the patient is properly fluid resuscitated, i.e., these parameters normalize, organ failure will ensue and the risk of a mortality outcome increases [48].
If any doubts on the status of the abdominal compartment pressure, intra-abdominal compartment pressure measurements through the urinary catheter is recommended [61, 65].
There is limited risk of sepsis in this early phase after burn but surveillance for such signs of sepsis are important.
It may be underlined that the main use for arterial thermodilution surveillance starts at 24 h after burn in patients with large burns when the early burn shock period is coming to an end and the main focus is being directed to optimizing fluids for surgery and reducing risks of circulatory failure due to sepsis. At this point, 24 h after burn and if resuscitated by the Parkland strategy, the patient should be normovolemic, and the next 24 h should be directed toward reducing tissue edema. It is important to stress that definitions and treatment of sepsis have evolved in general [68], and it is well known that burn-related sepsis constitutes a particular and different challenge [69, 70]. When using the PiCCO system at 24 h after burn, the intrathoracic blood volume index (ITBVI) may serve as an excellent fluid volume estimate, and the fluids provided can properly be titrated against this value. Most often burn injured, even with large burns, should be without vasoactive support, and only when ITBVI is normal or slightly elevated and systemic vascular resistance index is low (together with a MAP <65–70 mmHg), there is a need for use of vasoconstrictors, as these are known to be injurious to both skin and intestine when used improperly.
Nutrition and mitigation of the hypermetabolic syndrome and its side effects. Important in the early burn center admittance period is to start enteral feeds as an early start increases the success rate [71–73]. Many advocate also putting the feeding tube beyond the pyloric region to increase the success rate however as of yet the scientific support for this is limited. In this perspective also, opioid receptor antagonists may be added to the gastrointestinal canal together with motility-stimulating agents to reduce the risk of opioid-induced obstipation and gut standstill—a not uncommon situation in burn care. Rectal catheters for fecal collection in patients with perineal injuries may be advocated, and some units even perform colostomies to reduce bacterial burden in the perineal burn wound. Nutrition may start at 25 kcal/kg/24 h and should be increased as data is emerging from indirect calorimetry readings on days 4–5 when most of the hypermetabolic effects are fully expressed, usually at a caloric level of +40% resting energy expenditure (REE) [74].
The hypermetabolic syndrome seen in larger burns carries a number of negative consequences for the burn injured [75, 76]. Importantly, a number of therapies have during the last 20 years been shown to mitigate the majority of the aspects of the hypermetabolic response [74, 77–83]. Interventions range from very early physical (early wound closure, thermoregulation, or exercise) to pharmacological; some strategies should be employed early during the acute hospitalization and can continue well into the rehabilitative stage. Early studies of β-blockade claim that although reduced adrenergic stress reduces hypermetabolic response after burns [77, 80, 81], modulation of additional mediators may lead to even greater reduction of the hypermetabolism. The combination of β-blockade with other therapies, including insulin, growth hormone, or oxandrolone, shows positive effects for the burn injured. The administration of growth hormone and propranolol reduces energy consumption, attenuates the systemic inflammatory response, reduces peripheral lipolysis, and alleviates side effects seen with rhGH alone [81]. When propranolol and insulin are given together, improvements in glucose turnover and growth are observed. More recently also positive long-term effects of propranolol and oxandrolone have been shown. The results of these studies show that mitigation of several aspects of the hypermetabolic response can further benefit patient recovery even more than when only based on a single treatment, and these interventions should start early. The expansion of these results, which mostly have been obtained in large pediatric burns, needs however to be further explored and confirmed in larger patient samples including burned adults and especially elderly as well.
Antibiotics. The use of prophylactic antibiotics early in care have been debated, and there are arguments supporting to wait for signs of infection prior to starting antibiotic treatment. This however makes close patient surveillance very important [84]. The use of antibiotic prophylaxis for newly burned patients upon admission to burn center has been studied extensively. In such a setting, two types of antibiotic prophylactic strategies were identified. First, local antibiotic prophylaxis in the form of creams and ointments, e.g., silver sulfadiazine. This however did not show any beneficial effects. Systemic prophylaxis has shown decreasing mortality in some studies but a review in 2010 concluded that the methods used in these studies were weak, and therefore, the role of systemic prophylactic antibiotics is still not validated. And in light of this, there is today no recommendation to use prophylactic antibiotics in burns [84]. The perioperative antibiotic prophylaxis has however shown a beneficial effect in the improvement in the survival of skin grafts.
Pain. From the pain perspective, there is a high variability of the pain perception among the patients early after burn, and pain remains a big concern for this patient group and a challenge throughout the care period [85, 86]. Most often background pain can be properly addressed but mobilization pain and pain during dressing changes constitute a major problem [85, 86]. A multimodal management approach is used to address nociceptive and neuropathic pain symptoms and contributing psychological factors. A combination of long-acting opioids for background pain and short-acting opioids for procedural and breakthrough pain is the standard of care. Dosing is titrated to account for altered pharmacokinetics due to impaired perfusion [87], metabolism, and plasma protein levels as well as opioid tolerance. Alternative treatments are increasingly used to avoid opioid misuse. Acetaminophen is efficacious in combination with opioids for minor burn. Adjuvant medications include NSAIDs, muscle relaxants, and anti-epileptics. However, also the use of gabapentin and other substances addressing specifically neuropathic pain components may be considered early, and these drugs are recommended as significant treatment effects are present [88] albeit pain remains a major issue in burn centers [89].
Ventilation. The need for continued invasive ventilations should be scrutinized early, and planning for longer such periods may be important on to which to base an early tracheotomy. If needed, a 6–8 mL/kg tidal volumes should be aimed for. Trying to avoid sedation is important to reduce the risk of PICS (post intensive care syndrome) [87] and the risk of developing delirium [90]. Unfortunately, as larger burn patients are often ventilator-dependent longer than general ICU patients, the risk for developing delirium and concomitantly cognitive dysfunction is larger; hence, adhering to a restrictive sedation strategy is important [90]. Presently there are arguments supporting sedation based on dexmedetomidine, which can possibly further reduce its incidence and consequences [91–93]. Early tracheostomy may thus be advantageous in this setting [26].
Laboratory investigations. Laboratory test has not seldom been issued already at the referring hospital, but still there is a need to follow the course of the burn, and therefore, a complete set of admittance laboratory test are usually issued at admittance to the burn center and should be specified in the SOPs. In this aspect, also a protocolized laboratory surveillance of the burn patients during the length of stay may be recommended and also for follow-up reasons [94]. Of specific importance is to assess if the patient is infected by hepatitis B/C, HIV as knowledge of these are important for safety reasons. Carboxyhemoglobin is another important test that needs to be controlled in the perspective both of oxygen treatment and prognostic as high levels of carboxyhemoglobin may herald the risk of later negative cognitive effects. Focus later in the care process should be directed to assessing signs of infection [68] (e.g., CRP/PCT and platelets) as well as markers for organ failure, i.e., if recording of SOFA (sequential organ failure score assessment) score is a standard at the unit, e.g., bilirubin and creatinine need to be taken on a regular basis (every third day). When taking laboratory samples from the patient, bacterial cultures are also very important. First, to assess any colonization of bacteria that has unfavorable resistance patterns, e.g., MRSA, which now can be transferred endemically and that may complicate the course of treatment. Such repeated cultures are also important as they can help in reducing the risk for obtaining opportunistic bacteria which may be difficult to isolate and eradicate from within the facility even after extensive cleaning procedures (e.g., Acinetobacter baumanii) [95].
13.8 Early Burn Wound Treatment and Surgery Planning
Early after admission and assessment of the burn extent and depth, proper planning for the ensuing dressing changes, burn excision, and grafting is a necessity. This constitutes the main stem and will most directly influence the effectiveness of the treatment plan. It involves both partial- and full-thickness wounds, which are treated by different protocols. According to recent ISBI guidelines, these procedures should be undertaken by an appropriately trained, prepared, and equipped burn team [14].
Different treatment approaches are available, and they vary between burn centers and at times between surgeons. One of the most important factors in this early planning is the depth of the injury.
Partial-thickness burns are treated conservatively with dressing changes, and spontaneous healing is expected to occur within 14 days unless invasive infection has complicated the healing course resulting in deepening of the burn and the need for excision. There is no universal consensus regarding dressing materials, and therefore, the materials that are used tends to vary between burn centers, national and internationally. However, a recent review has advocated the superiority of biological membranous dressings [96].
In case of full-thickness burns , planning for the excisional strategy is important. Simplifying this strategy it may be claimed to be based on two separate strategies, either early or late excision with the ensuing autografting. Also the timing of the auto grafting may vary, with some centers doing mostly early autografting after excision and others, who prefer to wait or at least have a observational period prior to grafting to ascertain a stable and proper wound bed to be present at grafting occasion [97].
13.8.1 Early Excision
Early excision and grafting is known to improve the outcome of burn care such as duration of hospital stay and scarring, and it is cost-effective. The early excision technique is widely known to have the best survival rates [98, 99]. Timing for early excision of burns varies, and it can start from the first day after injury, and even excisions up to day 10 after injury can be considered early excisions. Again there is a lack of consensus although most would consider early excision before day 3 after injury. The depth of excision may also vary, and generally tangential excision as first described by Janzekovic is most often used [100], and the less popular alternative excision method “fascial excision” is reserved for significantly deeper wounds in not seldom medically compromised patients, as the cosmetic outcome is less favorable [101].
The extent of burn injury often influences the strategy chosen for excision. Limited burns can most often and more easily be excised in one session with coverage with, e.g., temporary dressing until the wound bed is considered optimized, and then skin grafts are applied, or if the wound bed is considered optimal, direct skin grafting is made. With burns of larger extent, the strategy varies even more. In the early 90s, total excision of the burns was advocated in one or maximum two sessions with subsequent skin grafting [98, 99]. Nevertheless, another approach was proposed later by Still et al., where excisions were made in successions with temporary skin coverage followed by skin grafts after the wound bed was considered optimal [97]. This method proved a reduction of the duration of hospital stay in this specific study.
Temporary coverage of excised burns is otherwise a highly debated topic. Most authors would agree at times that optimization of the wound bed is needed. However, the timing and choice of covering materials are controversial. Most popular materials include donor skin (allografts), porcine xenografts, collagen-based scaffolds, and in the low cost range, Vaseline gauze. Research is limited in this area, and no study yet has convincingly shown superiority of any one procedural aspect or material. The choice of material today still depends mainly on the experience and training of the treating surgeon in conjunction with the availability and cost [102–105].
A later comparison by Elmasry and coworkers between delayed and an immediate total excision plan has not shown any superiority of either techniques in terms of duration of hospital stay [102, 103].
Present ISBI guidelines [14] states that “The first early excision should be aimed at excision and coverage of a large portion of the full thickness burn, and the largest areas that can be safely excised are to be chosen.” Typically, these involve the front or back of the trunk or large areas on the limbs. The extent of the burn area excised in each operation is determined by the experience and approach of the surgical team in conjunction with the availability of autograft donor sites or skin substitutes. If the team is relatively inexperienced and/or there is little autograft available, less % TBSA burn is recommended to be excised during one surgical procedure to reduce operative risk and the risk of graft loss. After excision, all excised burn areas must be covered with autografts, skin allograft, or other skin substitutes [104, 105].
Technically early excision is not difficult; however, a well-trained surgical and anesthesia team should be available to carry out this task. In many areas where lack of training and resources exists, this task seems to be more difficult and do not provide the same outcomes [7, 106]. A specific recurring challenge is graft take and especially in previously grafted areas with graft loss [107].
Bleeding is also a considerable risk in excision burn surgery, and the whole team should have enough experience to control this situation rapidly and efficiently. This involves access to a blood bank with sufficient capacity. Usually, tangential excision is made using handheld dermatomes as Watson or Downy knives, and hemostasis is regularly achieved by the application of adrenaline-soaked dressings in conjunction with precise hemostasis of larger bleeding points by diathermy. The bipolar type is often the primary choice to limit the extent of tissue injury inflicted by the apparatus.
13.8.2 Late Excision
One rather uncommon technique, which needs to be mentioned in the area of late excision, is based on the chemical eschar binding properties by cerium. This approach is used by a smaller number of centers in Europe [108, 109].
Contrary to the previously described early excision plan, late excision is associated with lower costs and risk as long as the patient is not seriously infected or septic, the rates of which increases with burn size. Bleeding is less, and there is a possibility of doing direct skin grafting . In places with significantly reduced experience and resources, this technique may be recommended.
Summary Box
This chapter examines the treatment trajectory that the burn injured experience after having been triaged and stabilized at the scene of the accident or at the first receiving hospital. The early assessment and treatment at the tertiary treatment level, the burn center, is presented, which in many aspects is a further extrapolation and detailed approach extending and repeating the practices of the early ATLS/ABLS concepts that were used at the location of the accident or referring hospital. The start of the burn center-specific procedures are described, and it involves issues such as primary admittance protocol and control, extended primary and secondary assessment burn wound evaluation and treatment planning including surgery, early burn center planning (at admittance or shortly after, <24–48 h) for larger injuries (>20/30%) needing surgery and intensive care, and early burn wound treatment and surgery planning.
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