DÄ internationalArchive38/2009Severe Burn Injuries

Review article

Severe Burn Injuries

Acute and Long-Term Treatment

Dtsch Arztebl Int 2009; 106(38): 607-13. DOI: 10.3238/arztebl.2009.0607

Spanholtz, T A; Theodorou, P; Amini, P; Spilker, G

Background: The physician that initially sees a patient with an extensive and deep dermal burn injury must be able to provide initial acute treatment and to make a well-founded decision whether to have the patient transported to a burn care center (BCC). Physicians from a variety of specialities will be involved in the management of long-term sequelae.
Methods: This article provides an overview of the treatment of severe burns and their commonest complications. Special attention is paid to initial emergency treatment (first aid) and to late complications, because physicians from multiple specialties are often involved in these phases of treatment. The data and guidelines that are summarized here were obtained through a selective Medline search and supplemented by the authors' experience in their own burn care center.
Results: Analgesia, careful fluid balance, and early intubation are important elements of the initial emergency treatment. Long-term complications of burns, such as disfiguring scars on exposed areas of skin and functionally significant contractures, often require surgical treatment. Early measures for scar care may improve the outcome.
Conclusions: The effective treatment of severe burns is interdisciplinary, involving general practitioners and emergency physicians as well as plastic surgeons and physicians of other specialties. Knowledge of the basic principles of treatment enables physicians to care for patients with burns appropriately both in the acute setting and in the long term.
Key words: burns, plastic surgery, contractures, tissue transplantation
LNSLNS The present article will give a review of the pathophysiology and treatment of burn traumas.

Epidemiology and pathology
Burns of the body’s surface have complex pathological effects which can influence numerous body functions even shortly after the accident and which may have severe consequences for the affected patients. The expression "burn disease" describes the pathophysiological condition which patients develop, even when only small areas of the body are affected by burns. The body is subject to multifactorial damage, as a result of the sudden release of vasoactive mediators from the burned body parts, including kinins, prostaglandins, catecholamines, and glucocorticoids. Loss of skin integrity leads to loss of body temperature and in turn to increased energy consumption. Disorders of capillary integrity ("capillary leak syndrome") lead to volume displacement into the extravascular space. These changes can result in immune deficiency. Negative predictive factors for the patient’s outcome are advanced age and female gender, as well as the severity of any inhalation trauma (III and IV), together with the size of the affected body surface. All of these parameters are summarized in the "Abbreviated Burn Severity Index" (ABSI). They are a direct measure of the patient's probability of survival. An inhalation trauma is present in 15% to 30% of all patients and this alone increases the mortality rate by a factor of nine (1).

Due to developments in health and safety systems in companies and technical innovations in traffic and at home, the number of severely burned patients in industrial countries is declining. In Germany, about 10 000 to 15 000 people with burn injuries have to be admitted to hospital annually. In 2005, 481 people died as a consequence of burns; a further 141 died as a consequence of a high voltage current injury (source: Deutsche Gesellschaft für Verbrennungsmedizin [German Society for Burn Treatment]). About 60% of all burned patients suffer from burns of intermediate severity, corresponding to less than 10% of the body surface. These patients can often be treated as outpatients. After initial emergency care, about 30% to 40% of burned patients have to be admitted to a burn care center, where they receive intensive care. It is a huge challenge for the primary care physician or emergency physician providing initial care to identify these patients and to treat them correctly.

Based on the experience of the authors in the treatment of severely burned patients, a selective literature search in Medline was performed and complemented with information from current textbooks. The initial care at the site of the accident and the follow-up by the primary care physician are especially important. The aim of this article is to convey current knowledge (especially of these phases of treatment), as they may fall into the area of responsibility of any medical specialty.

Emergency care guidelines
Despite the dramatic conditions under which burns can arise, there are clear therapeutic measures which must be assured by the primary care physician or emergency physician who is present.

The first and most important operational maxim is self-protection. Open fire or active power supply lines jeopardize the rescue maneuver. Is it safe to rescue the injured person? If yes, is it possible to rescue the injured person and other endangered persons from the danger zone? First, burning articles of clothing, shoes and equipment must be removed. Second, the burned skin areas have to be cooled to avoid after-burn of deeper skin layers. The following applies here: If professional cooling systems are present, they should be used. Good alternatives are towels soaked with cold water or cold water from the shower. Cool-packs or even ice are unsuitable, as they can lead to a sustained and harmful decrease in capillary perfusion around the burned skin area (1). Cooling is especially effective in the first 20 to 30 minutes after being burned (2) and after this only has an analgetic effect. Many patients are often mistakenly cooled during the whole transport and arrive at the burn care center with greatly decreased body core temperature, which can lead to an increase in mortality (3).

Parallel to cooling, it is necessary to prepare several venous accesses with as large a lumen as possible, accompanied by fluid therapy with crystalloid solutions according to Baxter (4) (Table gif ppt) or using more advanced calculation formulas (5). Within 30 minutes, the water content in the burn increases by 80%, which can lead to massive redistribution of the body fluid in large burns. If early analgesia with sedation—normally with S+-ketamine and midazolam—is insufficient, or the general condition of the patient deteriorates due to the severity of the inhalation trauma, quick intubation (best before transport) is sensible. The importance of inhalation trauma as a factor determining survival cannot be overstated (e1). Clinical signs for inhalation trauma (IHT) include burns in the area of the face, soot in the oral cavity and in the throat, as well as inspiratory stridor. The classification of severity of the IHT is performed bronchoscopically after admission to the burn care center. In the case of carbon monoxide intoxication, pulse oxymetry supplies falsely high values, as the device cannot differentiate between CO-Hb and oxygenated hemoglobin.

After performing life-saving measures, a standardized polytrauma check must be performed while still at the site of accident, in order to be able to detect less obvious injuries. The ambulance service central office should reserve an available bed at the burn care center after these measures; then transport by air or by land can be carried out.

Which patient should be sent to a burn care center?
A variety of different basic information about the burn is essential for the decision as to whether admission to a burn care center is indicated (Box gif ppt) (e2). Patients in Germany who meet these criteria must be registered at a burn care center through the Central Office for Burn Injuries in Hamburg after receiving initial care. Generally the differentiation must be made between four degrees of burns, which are summarized in Figure 1 (jpg ppt). Even specialized plastic surgeons need many years of experience to assess the degree of burns successfully. Cone et al. reported that non-specialist physicians providing first aid wrongly assessed the degree of burns in 75% of cases, whereby in two thirds of all cases the degree of burns was classified as too deep (6). Blistering (degree IIa), the whitish discoloration of the insensitive skin in the affected area (degree Ib/III) and black carbonization (degree IV) can help in the rough determination of the degree of burns (Figure 1).

The assessment of the affected body surface is performed by sight. This is best done using Wallace's "Rule of Nine". Here different body areas correspond to a percentage of the body surface (arms and head 9% each, chest/abdomen/back and legs 18% each, palms, including fingers and genital area 1% each). In this context, the rule that the palm size of the patient corresponds to about 1% of his total body surface area (TBSA) is also helpful.

Therapies on the burns ward
Severely burned patients are cared for on specialized intensive wards which have semi-sterile laminar flow boxes, their own operating rooms, and special bathrooms for patients. After admission to hospital, the skin is often contaminated and is normally cleaned by hand in a sterile admission bath. One specific danger is that a compartment syndrome of the extremities or the trunk may develop from deep dermal burns. For example, the abdominal compartment syndrome has a mortality of over 40%. If this seems possible, a rapid escharotomy (separation of superficial burned layers of the skin) or even a fasciatomy is carried out (separation including muscle fascia) (Figure 2 jpg ppt).

Professional intensive care therapy is a basis for further plastic surgery therapy and plays an important role for the survival of the patient. Controlled fluid and electrolyte management with continuous and close meshed monitoring of various laboratory parameters decreases the risk of common complications of the burn injury. The most common complications are

- pneumonia (in 4.6% of all cases),
- sepsis (2.7%),
- lung failure (2.5%),
- infection of the wound (2.2%) (7), and
- acute respiratory distress syndrome (ARDS) (1.2%).

Severe complications such as cholecystitis (8) or acute renal (e3) and organ failure (9) must be detected early and treated adequately. Due to the necessary analgesia, patients often receive long term respiration. Therefore, the use of a tracheotomy tube is sensible.

In view of the greatly increased nutritional requirements of severely burned patients, appropriate nutrition must be initiated rapidly through a duodenal tube. The patient loses massive quantities of proteins as part of his burn injury—on the one hand through his burn wounds which release abundant quantities of protein into the bandages and on the other hand through the resulting consumption of available protein depots. Early and adequate provision of proteins not only improves the resulting osmotic gradients from intra- to the extravascular space but also the wound healing competence in affected patients (e4). No guidelines are available for the nutrition of burned patients. Enteral food supply should be targeted as early as possible, in order to avoid regression of intestinal villi (10). The capillary leak, which is responsible for the massive displacement of fluids, spontaneously ceases after 24 hours. Till then, intensive fluid therapy must be continued, in order to counteract the increased cardiac output, the reduced perfusion of the kidney, the liver and the intestine, and the rapid increases in hematocrit (1).

Surgical therapy uses skin replacement products such as Biobrane™ in the area of superficial burns (degree IIa). These products can be left on the injured skin until a new epithelium has been completely formed (e6). More deeply burned areas (degree IIb to IV) are initially dressed in a sterile manner after cleaning and are usually treated according to the principle of early tangential excision, i.e. removal of necrotic skin (about three to four days after the accident) with wound cover as soon as possible. Different techniques must be considered here. These techniques have to be selected according to the size, texture and thickness of the defect in the soft tissue. One possibility is to use 0.2 to 0.4 mm split-thickness skin grafts and the area of these can be increased by a lattice (the so-called mesh graft) by a factor of 1:1 to 1:9 (Figure 3 jpg ppt). Another possibility is to use MEEK grafts. These grafts are able to cover large wound areas as small free skin grafts (Figure 4 jpg ppt). The sampling sites of the skin graft required for both techniques are available again as donor areas after a new epithelium has been formed. "Cultured skin" (keratinocyte transplantation) is used in special cases when the donor area is too small to conduct autologous skin transplantation (11, 12). As an alternative, cadaver or pig skin can be used, in order to obtain temporary cover when donor areas are inadequate. This cover can later be replaced by autologous skin grafts. Depending on depth and localization, pedicled or free tissue grafts (flaps) may be used as well (e7).

On the throat, in the face, on the hands and over the joints, only cover techniques are used which later lead to satisfactory texture, color, and elasticity of the grafted skin. Thus, stigmatizing scars in visible skin areas are avoided and contractures of the scars near the joints are prevented (13).

Bacterial infection is a common complication which can endanger the burned patient and threaten his life. The partially damaged integrity of the skin allows devastating superficial infection which, however, is rarely the direct cause of death. In contrast, if bacteremia and consecutive sepsis develop, mortality greatly increases. 75% of patients with extensive burns die as a consequence of a severe infection (14). Invasive forms of infection of subcutaneous tissue layers play an especially important role, as well as surgery-related infections and superficial wound infections. These infections, which are mostly evoked by staphylococci, streptococci and pseudomonads, must be detected without delay and aggressively treated with broad spectrum antibiotics (7, 15). In this context, enterococci of group D and the increasingly common colonization with multiresistant bacteria are especially feared. Due to these multiresistant bacteria, the early use of combined broad spectrum antibiotics is necessary. These antibiotics must be administered early at high dosage, in order to protect the life of the patient (15, 16).

Follow-up and rehabilitation
After completion of the intensive care period, the patients are transferred in-house to a follow-up ward where further wound care, physiotherapy, ergotherapy, and psychiatric care help to maximize the patients' autonomy. Generally, rehabilitation therapy for patients with burn injuries begins on the day of the burn. As soon as possible, rehabilitation measures should be implemented in the therapy. All physiotherapy requires adequate analgesia. Early respiration training deepens inhalation and therefore prevents pulmonary infections. Edema prophylaxis and therapy, scar care, for example through external agents, compression garments and the specific prophylaxis of scarred contractures in critical locations (throat, face, hands, and joints) are the fundamental pillars of multimodal rehabilitation (17, 18). Although physical deficiencies are most important, the diagnosis and treatment of posttraumatic stress symptoms play a significant role in rehabilitation therapy as well (19). Over 60% of all severely burned patients develop posttraumatic psychological problems (e9). Therefore, psychiatrists and psychotherapists are permanent team members on burn wards.

Late complications and secondary therapies
Generally in severely burned patients, a differentiation must be made between functional and aesthetic late complications. The extensive and deep loss of skin is the source of most problems. Scarring of areas not given surgery, or scar formation within the graft, lead to symptoms which can affect patients’ quality of life. If deep dermal burns are not identified as such and are wrongly given conservative treatment, scar contractures may form. These contractures may lead to disfigurement and/or functional impairment, depending on the localization.

Functional complications
The acute phase of burn injury may impair organ function or even lead to multiorgan failure. However, this rarely leads to long-term restriction in function. Inflammatory mediators may flood into the kidney, often leading to acute tubular renal failure. This occurs in about 20% of severely burned patients (20) and can lead to tubular necrosis (21). In practice, this necrosis is almost never followed by chronic renal insufficiency.

The consequences of the loss of skin and the resulting surgery are more severe: Burns near joints can often make them less mobile. Scarred strands along longitudinal axes over the flexor and extensor sides of joints cause overextension or flexion contractures, preventing adequate mobility. Smaller joints may be permanently and irreversibly damaged by contractures (Figure 5 jpg ppt); this is commonly observed in the treatment of patients from developing countries. After the acute phase, this may have to be corrected by plastic surgery which should be performed at the center which provided initial care. Numerous techniques have been described for the prolongation of scar strands.

In some cases, it may be necessary to pre-stretch healthy adjacent skin (expander). The resulting excess skin can be used to replace the scar strand. As transplanted skin often develops contractures, skin transplantation should not be repeated, as this can lead to relapses. In some cases, the use of dermal replacement materials can be sensible. These materials leave a sub-epidermal sliding layer and allow, for example, frictionless movement of tendons on the back of the hand. Special problems related to facial burns require treatment in departments of plastic surgery, where modern techniques assure an optimal result (e10).

Further complications are intolerance of heat and cold in the transplant area, as well as pain from solar radiation or warmth (chimney, sauna). As there is no specific therapy available for this, patients should avoid extreme temperatures.

Esthetic complications
In the long term, many patients suffer from their changed appearance. Burns of the face and hands are felt as especially disturbing, as they are continuously visible to other people (Figure 5). In primary care, it is essential to consider this in the operation plan and only those techniques should be used which can optimally influence the subsequent esthetic result. Therefore, for example, no meshed split-thickness skin grafts should be used on the face and hands. The donor skin site should have the same texture as the recipient site. For example, a donor site with low pigmentation should be selected for a site with low pigmentation. This avoids hyperpigmentation (Figure 5).

Scar care is an important part of the follow-up in the primary care setting. Fresh (active) scars are initially given regreasing ointment therapy with simple silicone-based preparations or similar material. In this early stage, the scar tissue should be massaged in a circular fashion several times a day (e11). In this way, consistent orientation of the collagen fibers can be obtained, leading to a softer and flatter scar. The scarred tissue should not be exposed to the sun for at least six months. If necessary, this can be assured by a plaster or a sun blocker with sun protection factor over 50. In the course of treatment, silicone-based plasters may be useful. These lead to softening and flattening of the scar through occlusive hydration of the stratum corneum (e12). Other topical immune modulatory substances, such as retinoids, calcineurin inhibitors and imidazolaquinolines, are also used as external agents for the treatment of hypertrophic scar tissue. However, these drugs should only be prescribed by a plastic surgeon (22). Furthermore, injectable substances such as corticosteroids, 5-fluorouracil, interferons and bleomycin (22), are used in the local therapy of hypertrophic scars.

If these methods are unsuccessful or local treatment is not indicated, surgical procedures must be used. The excision of the scarred tissue can be extended to redirect the tensile stresses by using different local flap techniques such as Z plasty. In addition, dermal abrasion and laser therapy can help to achieve sustained improvement in the appearance of the scars. However, these kinds of therapies must be carried out by experienced physicians.

Conclusions
The therapy of burned patients is classified into five sections:

- Emergency care
- Intensive care burn unit
- Follow-up ward
- Rehabilitation
- Follow-up in the primary care setting.

The first and last of these therapeutic stages, as they are provided by primary care physicians, are of particular importance.

Primary care by the emergency physician includes rescuing the patient from the danger zone, then cooling him for a short period and providing the burned skin with a sterile cover. Calculated fluid therapy is carried out through several wide intravenous accesses. The patient receives analgesia, is sedated and, if necessary, intubated. Depending on the above mentioned factors, the patient is rapidly admitted to a special department. The organization is carried out through the Central Office for Burn Injuries in Hamburg. There are about 100 beds for severely burned patients in Germany. Ten of these beds belong to the center for severely burned patients of the Clinic Cologne Merheim of Witten/Herdecke University. If the physician who provides initial care is not certain what to do, he should contact a burn care center through the ambulance service center by phone. When a physician with experience in burn care is involved, they can reach a well-founded decision about further procedure together.

Functional and esthetic aspects play important roles in the follow-up by the primary care physician. Scar contractures with functional restrictions must be detected and adequately treated. Normally the patient should be returned to the burn care center which provided initial care, as the physicians there are familiar with the patient and his injuries. Esthetic aspects of the scars can only be treated in close collaboration between primary care physicians and clinics for burn injuries. Scar treatment—often started in the hospital—should be continued and extended by silicone and compression products if this had not already been done. Unstable, painful or esthetically disturbing scars may be treated again by a plastic surgeon. In such cases, after the wound has completely healed, the patient should return to the hospital for plastic surgery.

Detailed guidelines, organization charts and current events are available from the German Society for Burn Treatment (www.verbrennungsmedizin.de). Two newly published textbooks (Spilker/Wappler and Kamolz) provide a detailed overview of the pathology, therapy and follow-up of burned patients.

Conflict of interest statement
The authors declare that there is no conflict of interest in the sense of the guidelines of the International Committee of Medical Journal Editors.

Manuscript received on 15 December 2008, revised version accepted
on 24 March 2009.

Translated from the original German by Rodney A. Yeates, M.A., Ph.D.


Corresponding author
Timo Alexander Spanholtz, M.D.
Klinik für Plastische und Rekonstruktive Chirurgie, Handchirurgie, Zentrum für Schwerverbrannte Universität Witten/Herdecke, Campus Köln-Merheim
Ostmerheimer Str. 200
51109 Köln, Germany
timo@spanholtz.net

For e-references please refer to:
www.aerzteblatt-international.de/ref3809
1.
Buhre W, Wappler F: Initial care of the severely burned patient. Anasthesiol Intensivmed Notfallmed Schmerzther 2009; 44: 100–7. MEDLINE
2.
Bartlett N, Yuan J, Holland AJ, et al.: Optimal duration of cooling for an acute scald contact burn injury in a porcine model. MEDLINE J Burn Care Res 2008; 29: 828–34.
3.
Lonnecker S, Schoder V: Hypothermia in patients with burn injuries: influence of prehospital treatment. Chirurg 2001; 72: 164–7. MEDLINE
4.
Baxter CR: Sixth National Burn Seminar. Fluid therapy of burns. J Trauma 1967; 7: 69–73. MEDLINE
5.
Benicke M, Perbix W, Lefering R, et al.: New multifactorial burn resuscitation formula offers superior predictive reliability in comparison to established algorithms. Burns 2009; 35: 30–5. MEDLINE
6.
Cone JB: What's new in general surgery: burns and metabolism. J Am Coll Surg 2005; 200: 607–15. MEDLINE
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Polavarapu N, Ogilvie MP, Panthaki ZJ: Microbiology of burn wound infections. J Craniofac Surg 2008; 19: 899–902. MEDLINE
8.
Theodorou P, Maurer CA, Spanholtz TA, et al.: Acalculous cholecystitis in severely burned patients: Incidence and predisposing factors. Burns 2009; 35: 405–11. MEDLINE
9.
Sheridan RL, Ryan CM, Yin LM, Hurley J, Tompkins RG: Death in the burn unit: sterile multiple organ failure. Burns 1998; 24: 307–11. MEDLINE
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Chen Z, Wang S, Yu B, Li A: A comparison study between early enteral nutrition and parenteral nutrition in severe burn patients. Burns 2007; 33: 708–12. MEDLINE
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Dorai AA, Lim CK, Fareha AC, Halim AS: Cultured epidermal autografts in combination with MEEK micrografting technique in the treatment of major burn injuries. Med J Malaysia 2008; 63 Suppl A: 44.
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Spilker G, Reifenrath MW, Kaiser HW: Skin cultivation in treatment of severely burned patients. Langenbecks Arch Chir Suppl Kongressbd 1996; 113: 1149–55. MEDLINE
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Horch RE, Jeschke MG, Spilker G, Herndon DN, Kopp J: Treatment of second degree facial burns with allografts—preliminary results. Burns 2005; 31: 597–602. MEDLINE
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Leseva M, Khadzhiiski O, Grigorov G, Dimitrova A: The basic principles of the antibiotic therapy of burn patients. Khirurgiia (Sofiia) 1995; 48: 8–11.
17.
Edgar D, Brereton M: Rehabilitation after burn injury. BMJ 2004; 329: 343–5. MEDLINE
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Kamolz LP, Kitzinger HB, Karle B, Frey M: The treatment of hand burns. Burns 2009; 35: 327–37. MEDLINE
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Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA: Burn rehabilitation: state of the science. Am J Phys Med Rehabil 2006; 85: 383–413. MEDLINE
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Kim GH, Oh KH, Yoon JW, et al.: Impact of burn size and initial serum albumin level on acute renal failure occurring in major burn. Am J Nephrol 2003; 23: 55–60. MEDLINE
21.
Oudemans-van Straaten HM: Circulating pro-apoptotic mediators in burn septic acute renal failure. Crit Care 2008; 12: 126. MEDLINE
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Berman B, Viera MH, Amini S, Huo R, Jones IS: Prevention and management of hypertrophic scars and keloids after burns in children. J Craniofac Surg 2008; 19: 989–1006. MEDLINE
e1.
Grunwald TB, Garner WL: Acute burns. Plast Reconstr Surg 2008; 121: 311e–9e. MEDLINE
e2.
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e3.
Mustonen KM, Vuola J: Acute renal failure in intensive care burn patients (ARF in burn patients). J Burn Care Res 2008; 29: 227–37. MEDLINE
e4.
Gore DC, Chinkes DL, Wolf SE, Sanford AP, Herndon DN, Wolfe RR: Quantification of protein metabolism in vivo for skin, wound, and muscle in severe burn patients. JPEN 2006; 30: 331–8. MEDLINE
e5.
Ishihara H, Otomo N, Suzuki A, Takamura K, Tsubo T, Matsuki A: Detection of capillary protein leakage by glucose and indocyanine green dilutions during the early post-burn period. Burns 1998; 24: 525–31. MEDLINE
e6.
Machens HG, Berger AC, Mailaender P: Bioartificial skin. Cells Tissues Organs 2000; 167: 88–94. MEDLINE
e7.
Iglesias M, Butron P, Chavez-Munoz C, Ramos-Sanchez I, Barajas-Olivas A: Arterialized venous free flap for reconstruction of burned face. Microsurgery 2008; 28: 546–50. MEDLINE
e8.
Ekrami A, Kalantar E: Bacterial infections in burn patients at a burn hospital in Iran. Indian J Med Res 2007; 126: 541–4. MEDLINE
e9.
Dyster-Aas J, Willebrand M, Wikehult B, Gerdin B, Ekselius L: Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma 2008; 64: 1349–56. MEDLINE
e10.
Spanholtz TA, Theodorou P, Phan V, Perbix W, Spilker G: [Reconstruction of the oral commissure in microstomia patients with deep dermal facial burns: a modified technique]. Handchir Mikrochir Plast Chir 2007; 39: 350–5. MEDLINE
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e12.
Mustoe TA: Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg 2008; 32: 82–92. MEDLINE
Klinik für Plastische und Rekonstruktive Chirurgie, Handchirurgie, Zentrum für Schwerverbrannte, Universität Witten/Herdecke, Campus Köln-Merheim:
Dr. med. Spanholtz, Dr. med. Theodorou, Dr. med. Amini, Prof. Dr. med. Dr. habil. Spilker
1. Buhre W, Wappler F: Initial care of the severely burned patient. Anasthesiol Intensivmed Notfallmed Schmerzther 2009; 44: 100–7. MEDLINE
2. Bartlett N, Yuan J, Holland AJ, et al.: Optimal duration of cooling for an acute scald contact burn injury in a porcine model. MEDLINE J Burn Care Res 2008; 29: 828–34.
3. Lonnecker S, Schoder V: Hypothermia in patients with burn injuries: influence of prehospital treatment. Chirurg 2001; 72: 164–7. MEDLINE
4. Baxter CR: Sixth National Burn Seminar. Fluid therapy of burns. J Trauma 1967; 7: 69–73. MEDLINE
5. Benicke M, Perbix W, Lefering R, et al.: New multifactorial burn resuscitation formula offers superior predictive reliability in comparison to established algorithms. Burns 2009; 35: 30–5. MEDLINE
6. Cone JB: What's new in general surgery: burns and metabolism. J Am Coll Surg 2005; 200: 607–15. MEDLINE
7. Polavarapu N, Ogilvie MP, Panthaki ZJ: Microbiology of burn wound infections. J Craniofac Surg 2008; 19: 899–902. MEDLINE
8. Theodorou P, Maurer CA, Spanholtz TA, et al.: Acalculous cholecystitis in severely burned patients: Incidence and predisposing factors. Burns 2009; 35: 405–11. MEDLINE
9. Sheridan RL, Ryan CM, Yin LM, Hurley J, Tompkins RG: Death in the burn unit: sterile multiple organ failure. Burns 1998; 24: 307–11. MEDLINE
10. Chen Z, Wang S, Yu B, Li A: A comparison study between early enteral nutrition and parenteral nutrition in severe burn patients. Burns 2007; 33: 708–12. MEDLINE
11. Dorai AA, Lim CK, Fareha AC, Halim AS: Cultured epidermal autografts in combination with MEEK micrografting technique in the treatment of major burn injuries. Med J Malaysia 2008; 63 Suppl A: 44.
12. Spilker G, Reifenrath MW, Kaiser HW: Skin cultivation in treatment of severely burned patients. Langenbecks Arch Chir Suppl Kongressbd 1996; 113: 1149–55. MEDLINE
13. Horch RE, Jeschke MG, Spilker G, Herndon DN, Kopp J: Treatment of second degree facial burns with allografts—preliminary results. Burns 2005; 31: 597–602. MEDLINE
14. Atiyeh BS, Gunn SW, Hayek SN: State of the art in burn treatment. World J Surg 2005; 29: 131–48. MEDLINE
15. Ramakrishnan MK, Sankar J, Venkatraman J, Ramesh J: Infections in burn patients—experience in a tertiary care hospital. Burns 2006; 32: 594–6. MEDLINE
16. Leseva M, Khadzhiiski O, Grigorov G, Dimitrova A: The basic principles of the antibiotic therapy of burn patients. Khirurgiia (Sofiia) 1995; 48: 8–11.
17. Edgar D, Brereton M: Rehabilitation after burn injury. BMJ 2004; 329: 343–5. MEDLINE
18. Kamolz LP, Kitzinger HB, Karle B, Frey M: The treatment of hand burns. Burns 2009; 35: 327–37. MEDLINE
19. Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA: Burn rehabilitation: state of the science. Am J Phys Med Rehabil 2006; 85: 383–413. MEDLINE
20. Kim GH, Oh KH, Yoon JW, et al.: Impact of burn size and initial serum albumin level on acute renal failure occurring in major burn. Am J Nephrol 2003; 23: 55–60. MEDLINE
21. Oudemans-van Straaten HM: Circulating pro-apoptotic mediators in burn septic acute renal failure. Crit Care 2008; 12: 126. MEDLINE
22. Berman B, Viera MH, Amini S, Huo R, Jones IS: Prevention and management of hypertrophic scars and keloids after burns in children. J Craniofac Surg 2008; 19: 989–1006. MEDLINE
e1. Grunwald TB, Garner WL: Acute burns. Plast Reconstr Surg 2008; 121: 311e–9e. MEDLINE
e2. Guidelines for the operation of burn centers. American Burn Association and American College of Surgeons. Bull Am Coll Surg 1995; 80: 34–41. MEDLINE
e3. Mustonen KM, Vuola J: Acute renal failure in intensive care burn patients (ARF in burn patients). J Burn Care Res 2008; 29: 227–37. MEDLINE
e4. Gore DC, Chinkes DL, Wolf SE, Sanford AP, Herndon DN, Wolfe RR: Quantification of protein metabolism in vivo for skin, wound, and muscle in severe burn patients. JPEN 2006; 30: 331–8. MEDLINE
e5. Ishihara H, Otomo N, Suzuki A, Takamura K, Tsubo T, Matsuki A: Detection of capillary protein leakage by glucose and indocyanine green dilutions during the early post-burn period. Burns 1998; 24: 525–31. MEDLINE
e6. Machens HG, Berger AC, Mailaender P: Bioartificial skin. Cells Tissues Organs 2000; 167: 88–94. MEDLINE
e7. Iglesias M, Butron P, Chavez-Munoz C, Ramos-Sanchez I, Barajas-Olivas A: Arterialized venous free flap for reconstruction of burned face. Microsurgery 2008; 28: 546–50. MEDLINE
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e9. Dyster-Aas J, Willebrand M, Wikehult B, Gerdin B, Ekselius L: Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma 2008; 64: 1349–56. MEDLINE
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