thermal injury first 24h

8/12/2019 Thermal Injury First 24h

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FOCUS ON: BURNS CARE

Thermal injury The first 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

Keywords:

Thermal

Burns

Emergency

Assessment

Resuscitation

Escharotomy

Area

Depth

s u m m a r y

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 arereferred 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 fluid 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 difficult. 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 third-

world 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 flame

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

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 flame burns. The majority (>60%) of burn

injuries occur in adults of working age (1564 years old) and are

mainly flame burns. Up to a third of these cases may be work-

related in aetiology. The remaining 10% of cases arefrom 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 first 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 verysmall 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 differencebetween

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 them-

selves reflexively 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

* Corresponding author. Tel.: 44 0208 237 2500, 07958 482284 (mobile);

fax:44 0208 237 2510.

E-mail address: [email protected](C.A.T. Durrant).

Contents lists available atScienceDirect

Current Anaesthesia & Critical Care

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / c a c c

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

Current Anaesthesia & Critical Care 19 (2008) 256263
mailto:[email protected]://www.sciencedirect.com/science/journal/09537112http://www.elsevier.com/locate/cacchttp://www.elsevier.com/locate/cacchttp://www.sciencedirect.com/science/journal/09537112mailto:[email protected]


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department or even while en route in an ambulance. Any failing

organ system must be rigorously treated. This usually involves

administering fluid 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; Recon-

struct; Review) are the remit of the receiving specialist service

and beyond the scope of a discussion concerning the care of burnsin the first 24 h.

It is tempting, when a burn arrives in the Accident and Emer-

gency department, to attempt to prognosticate. Although predict-

ing 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 definable group (for example, a relatively small burn that has

significant co-morbidity in an elderly patient may have a worse

prognosis than a much bigger burn in a young patient). There areseveral 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 specificity

when applied to other groups data.12 ITUprognostic 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 first appearance,

but deteriorate significantly as the systemic inflammatory 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 discussionwith a burns specialist.

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 inFig. 2.

2.1. A is for airway with cervical spine control

This is the first 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 commence-

ment of fluid resuscitation, this can lead to oedema and obstruc-

tion.14 At this stage it is wise to take a comprehensive history;

patients with significant inhalational injury may still be able to

communicate on presentation. This can change rapidly as oedema

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

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

Fig. 1. Functions of the skin.

C.A.T. Durrant et al. / Current Anaesthesia & Critical Care 19 (2008) 256263 257


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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 isany 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 cancause damage through mechanisms other than heat; water soluble

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, inflamma-

tion and bronchorrhoea. The pneumocytes become damaged,

impairing their ciliary activity and exacerbating the situation.16 This

can lead to atelectasis or pneumonia17 if the inflammatory exudate

is not adequately cleared. The final insult caused by inhalational

injury is the systemic effect of the gases inhaled, most importantly

carbon monoxide. This colourless, odourless gas binds to deoxy-

genated haemoglobin with approximately 240 times the affinity 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 toensure 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 non-

burned 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. Circumfer-

ential 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 othercauses 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 fluid

from the exposed tissue. These patients need to be warmed quickly

and effectively by any means available (such as blankets, overhead

heaters, warmed intravenous fluids, and air-heated covers). Inad-

equate warming may lead to hypoperfusion and subsequentdeepening of the burn.19

Fig. 3. Key points from a burns history.

C.A.T. Durrant et al. / Current Anaesthesia & Critical Care 19 (2008) 256263258


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2.6. F is for fluids

The amount of fluid 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. 4shows 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 reflexes 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 vaso-

constriction, 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 concomi-

tant 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 conflicting 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 clingfilm is ideal. This

protects the wound, reduces heat and evaporative losses, reduces

pain (particularly in superficial burns), and also leaves the

appearance of the burn unchanged.13 The burn can also be visual-

ised 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 difficult 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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burns at first assessment can turn out to be more complex than first

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 discussedwith 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 tran-

sient finding 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 fingers very

slightly spread, equates to approximately 1% of the patients TBSA.

This is a quick and reliable methodof 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 formeasuring 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 fit and is inaccurate. Therefore, this should only

be used in adult burns patients.

3.3. Lund and Browder chart26

This is the most accurate methodcurrently 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 ofthe forearm. Also, the dermis is relatively thinner in the very old

and very young population).

Burns can be simply classified 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 superficial partial thickness, mid-

dermal and deep-dermal burns. Each category is important in

terms of both management and prognosis. Superficial burns (or

epidermal burns) are different to superficial partial thickness burns.

Superficial burns involve the epidermis only and involve erythema

with no epidermal loss (such as in sunburn). As previouslymentioned, these burns are clinically unimportant and are not

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



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counted as part of the TBSA measurement. Superficial partial

thickness burns extend through the epidermis to the superficial

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 deep-

dermal burns can be difficult, 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 first clue as to the depth of the burn. For example,

one would naturally expect a flash burn to be less deep than

a prolonged flame burn. There are also techniques available to allowfor easier assessment on direct examination:

4.1. Appearance

Superficial 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 thesubsequent pattern of capillary refilling. Only superficial partial

thickness burns and mid-dermal burns will blanch. The more

superficial the burn, the quicker the capillary refill on release of the

pressure. Deep dermal and full thickness burns do not blanch

(when this is associated with red discolouration, it is called fixed

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 findings are

summarised inFig. 8.

5. Resuscitation

Burn injuries can involve dramatic fluid loss, and these losses

must be replaced to maintain homoeostasis. There are many fluid

resuscitation formulae in current use,28,29 with no clear evidence

that one is better than the others. These formulae are only guide-

lines, and their success relies on adjusting the volume and rate of

resuscitation fluid 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 itselfand so prevent it from deepening.19 This can be a complex issue, as

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



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too little fluid will cause hypoperfusion and cellular hypoxia,

whereas too much will lead to cellular and interstitial oedema.

The greatest amount of fluid loss in burn patients is in the first

24 h after injury.30 Over the first 812 h, fluid from the intravas-

cular compartment tends to shift to the interstitial fluid compart-

ment. Therefore, any fluid 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 fluid boluses are unlikely to be of benefit, as the resultant

rapid rise in intravascular hydrostatic pressure will just drive more

fluid 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 fluid requirements over the first 24 h

following a burn and can be titrated according to urine output. The

formula is as follows:

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 first half of this calculated amountshould be given in the first 8 h, with the remainder being given over

the following 16 h. The fluid to be given is Hartmanns solution.

Children also require maintenance fluid at an hourly rate of:

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 fluid such as

milk), or intravenously using 5% dextrose and 0.45% normal saline

solution, but not both together. The amountof fluid 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. 32For 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

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

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



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made and are connected by a chevron-style transverse incision

running alongside the subcostal margin. A further transverse inci-

sion 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 eschar-

otomies 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 quarterof 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 differencebetween a good outcome and a poor one. The mainstay of treat-

ment 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 fluid 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 difficult.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.

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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 2001May;27(3):2339.

28. Baxter CR. Fluid volume and electrolyte changes in the early post-burn period.Clin Plast Surg1974;1:693703.

29. Yowler CJ, Fratianne RB. Current status of burn resuscitation. Clin Plast Surg2000;27(1):110.

30. Hettiaratchy S, Papini R. Initial management of a major burn: IIdassessmentand resuscitation. BMJ2004 July 10;329(7457):1013.

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32. Kao CC, Garner WL. Acute burns.Plast Reconstr Surg2000 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 first five days. 2nd ed. Smith andNephew; 2001.

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