The management of major burns – a surgical perspective

In the UK, 1000 patients per year will need resuscitation and inpatient treatment for burns. The mortality has improved significantly over the last 50 years but over three hundred people die each year. A greater understanding of the pathophysiology together with improvements in resuscitation, critical care and surgical techniques have all contributed to survival. For larger burns (greater than 25% total body surface area) there is a profound release of cytokines and chemokines. This results in a marked systemic inflammatory response syndrome, leading to edema, effects on multiple organ systems, a hypermetabolic response and suppression of the immune system. Early surgical care is based around the ABCD philosophy (as guided by Advanced Trauma Life Support and also Emergency Management of Severe Burns). An assessment system based on depth is vital for clinical decision making and prognosis. Many centers now aim for early excision and grafting of burns. Early excision modifies the host responses by removing devitalized tissue that might otherwise invoke deleterious effects, but its removal in itself may also provide a major insult. Several variations in approach are possible to modify the impact of excision and an approach tailored to the individual is appropriate. Covering the excised burn area can be achieved with wide range of materials from allograft to synthetic skin substitutes. Key to successful burn care is a directed multi-disciplinary model for providing appropriate expertise on individual sites, together with the development of burn care networks to facilitate effective delivery of burns services across an entire region.