African Journal of Emergency Medicine (2013) 3, 2229

African Federation for Emergency Medicine

African Journal of Emergency Medicine

www.afjem.com
www.sciencedirect.com

An overview of acute burn management in the Emergency

Centre
Un apercu de la gestion des brulures aigues dans les centres
durgence
Adaira Landry a, Heike Geduld b, Alex Koyfman c,*
, Mark Foran a

a
Department of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center, New York, NY, USA
b
Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
c
Division of Emergency Medicine, University of Illinois College of Medicine at Peoria, OSF Saint Francis Medical Center, Peoria,
IL, USA

Received 25 June 2012; revised 3 August 2012; accepted 5 August 2012

Available online 14 September 2012

KEYWORDS Abstract Despite the frequency and severity of burns in Low Income Countries, including many in
Africa; Africa, there is a paucity of research and funding for these populations to aid in prevention, treat-
Emergency Medicine; ment and recovery of burn patients. The objectives of this paper are four-fold. First, by addressing
Emergency centre; the pathophysiology of burns the reader may strengthen understanding of the clinical progression
Burns; of burns. Second, through describing proper assessment of burn patients one will learn how to
Burn management decide if patients can be discharged, admitted or transferred to burn centre. Third, the inclusion
of treatments solidies the steps necessary to manage a patient in a hospital setting. Lastly, the over-
all goal of the paper, is to raise awareness that more research, publication and funding is required to
create a better understanding of burns in Africa and why they continue to be devastating social and
economic burdens.
2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights
reserved.

* Corresponding author.
E-mail address: akoyfman8@gmail.com (A. Koyfman).
Peer review under responsibility of African Federation for Emergency Medicine.

Production and hosting by Elsevier

2211-419X 2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.afjem.2012.08.004
An overview of acute burn management in the Emergency Centre 23

KEYWORDS Abstract Malgre la frequence et la gravite des brulures dans les pays a` faible revenu, dont bon
Africa; nombre en Afrique, il existe tre`s peu detudes et de fonds destines a` ces populations pour aider a`
Emergency Medicine; la prevention, au traitement et au retablissement des patients victimes de brulures. Les objectifs
Emergency centre; de cet article sont au nombre de quatre. Premie`rement, en abordant la physiopathologie des bru-
Burns; lures, le lecteur aura la possibilite de renforcer sa comprehension de la progression clinique des bru-
Burn management lures. Deuxie`mement, a` travers une evaluation pertinente des patients brules, on apprendra
comment decider si un patient peut quitter lhopital, etre admis ou transferre dans un centre de
brules. Troisie`mement, le fait dinclure des traitement renforce les etapes necessaires pour prendre
en charge un patient en milieu hospitalier. Finalement, lobjectif global de cet article est de faire
prendre conscience que plus de recherche, de publications et de fonds sont necessaires pour favor-
iser une meilleure comprehension des brulures en Aque et pourquoi elles continuent detre des far-
deaux economique et social catastrophiques.
2012 African Federation for Emergency Medicine. Production and hosting by Elsevier B.V. All rights
reserved.

African relevance
 Lower Income Countries in Africa, despite frequency and
severity of burn injuries, lack research and funding to aid
in prevention, treatment, and recovery.
 In rural clinics and hospitals without invasive monitoring
an understanding of local and systemic responses to burns
may help physicians gauge the severity of injury.
 In regions where resources may be scarce it is important to
know who deserves further treatment and who is safe for
discharge.
Whats new?
 Lower Income Countries in Africa, despite frequency and
severity of burn injuries, lack research and funding to aid
in prevention, treatment, and recovery.
 Review of risk factors for burns in Africa and preventative
measures needed to decrease injury.
 Local and systemic physiologic responses to burns.
 Approach to primary and secondary survey with initial
evaluation of patient.
Introduction
The World Health Organisation (WHO) showed in 2004 that
over 90% of the total fatal re-related burns occur in develop-
ing or low income countries (LIC).1 In LIC the rate of death
and disability from injuries (including burns) is increasing.1,2
As a global concern, preventing res (i.e. smoke detectors),
responding to res (i.e. re department personnel) as well as
individual consequences (i.e. healthcare costs) all combine to
create economic burden.3 This burden is greatest among
poorer countries that have incomplete regulation to prevent
res, limited access to emergency responders and few options
for insurance and disability coverage.
In comparison, in the United States between the years 2001
and 2010 there was a 96% survival rate of all patients admitted
to one of the 125 burn centres. Seventy-ve percent of deaths
related to re and burn injuries occurred at the scene or during
initial transport.4 Preventing the 75% out-of-hospital deaths
are as important as assuring the remaining 25% get appropri-
ate medical attention. In high income countries (HIC) the inci-
dence of injuries as well as morbidity and mortality from burns
is decreasing.57 The improvement is attributed to increasing
prevention as well as improving medical therapy.1,8,9
Optimization of burn care in low income settings is a prior-
ity.10 Development of an effective national burn care model is
dependent on money, materials and knowledge.11 For the indi-
vidual patient, treatment should begin with adequate rst aid
to limit tissue damage, morbidity and need for surgery. In
many parts of Africa, homemade remedies such as urine and
mud, cow dung, beaten eggs or mud and leaves are the primary
treatments.10 Combining traditional and western knowledge at
the lay-person level may be the rst step in developing a burn
care model.
Fire-related burns are one of the major causes of disability-
adjusted life years (loss of the equivalent of one year of good
health) in low income countries.12 Because of the large burden
on society there is signicant interest, such as in the World
Burn Foundation, in returning survivors to their baseline level
of function.13 Burns have physical and psychological effects on
survivors and require comprehensive rehabilitation. Even in
HIC there is a 90% dropout rate in the rst year for those
who do attempt rehabilitation.13 Despite national professional
societies such as, South Africa Burn Society, Trauma Society
of South Africa, National Burn Association of South Africa
and social support societies such as Childsafe, Southern Africa
Burn Foundation, and Children of Fire, much work is yet to
be done to improve patient outcomes.
Epidemiology and risk factors
In Africa, there are 6.1 burn related deaths per 100,000 popu-
lation per year compared to 1.0 burn related deaths per
100,000 population per year in high income countries.14 Eigh-
teen percent of hospital admissions in Africa are due to burns;
of those admitted there is a mortality rate of 610%.13 Vitality
statistics in the United States have been widely available with it
known that deaths from res and burns are the third leading
cause of fatal home injury.15,16 However in Africa, few coun-
tries have even partially completed vitality statistics.17
24
The United States Fire Administration recommends private
homes to have at least one working smoke alarm. Of surveyed
US households 9697% have at least one smoke alarm.5
Unsurprisingly, there is no available data on the usage of
smoke alarms in private homes in Africa and most countries
have no legislation enforcing its use. While there is limited
published data on burns in Africa, a survey in Ethiopia showed
over 80% of the populations burns occurred at home.18
There have been attempts to explain why burn mortality and
morbidity is so high in Africa. WHO states that common risk fac-
tors include alcohol and smoking use, open res near homes,
ground level stoves for cooking, high set temperature in hot water
heaters, and sub-standard electrical wiring.4 Rode et al. add that
inux of people to urban areas, poor urban development and elec-
trication of homes, kerosene (also called parafn) as an energy
source and lack of preventative programs all contribute.13
In the literature kerosene use is a large negative risk factor
for re occurrence.2,3,7,13 Maritz et al. found that 28% of all
mortalities in Africa were due to shack res and fuel stoves.
71% of the stove injuries were from kerosene stoves. Stove
injuries and the resulting shack res are noted to have high
mortality.19 Godwin et al. showed that out of 99 patients in-
jured by shack res, 39 patients died.20.
A new type of parafn stove, the Parasafe Stove, is being
developed with the aims to signicantly reduce kerosene-re-
lated domestic burn injuries.13,21
Histology and pathophysiology
Histology
The skin is composed of two layers. Fig. 1 shows the basic
depiction of epidermis and dermis.22 The function of the epi-
dermis is to protect skin from pathogens, heat, UV radiation
and dehydration. The dermis consists of structural proteins
and cells which give strength to the skin. In the dermis are
blood vessels, hair follicles, sweat glands, and nerves.
Fig. 1 MacNeil S. Progress and opportunities for tissue-engineered skin. Nature Feb2007;445:874880.
A. Landry et al.
Burns severity changes over the rst 23 days and the
depth of injury can vary on the same patient. Therapy in the
emergency room is usually based on initial burn characteristics
as the evolution of burns usually occurs after patient has left
the department. Fig. 2 shows the burn wound is an arrange-
ment of three zones radiating outwards from the centrally
burned tissue.23 These three zones describe the local response
to burns.
The Zone of Coagulation is the point of maximum dam-
age. The severity depends on exposure time, the vascular sup-
ply and thickness of skin as well as the temperature or
concentration of insult. The Zone of Stasis has decreased tis-
sue perfusion but potentially reversible with restored perfu-
sion. Delay in uids, infection or oedema can cause this
area to have complete tissue loss. The Zone of Hyperaemia
is the outermost region which appears erythematous since tis-
sue perfusion is increased secondary to release of vasoactive
substances.23.
Pathophysiology
Cardiovascular changes occur when the oedema is at its peak
and red blood cells leak through capillaries. As the burn ap-
proaches 1520% TBSA, large uid shifts can force the patient
into shock 612 h after injury. Heat causes denaturation of
proteins and expansion of potential third space in the interstit-
ium. Damage to cellular membranes can allow for accumula-
tion of sodium and water which causes cellular swelling.
Myocardial contractility is decreased, peripheral and splanch-
nic vasoconstriction occurs which in combination with uid
shifts can cause end organ hypoperfusion. Respiratory distress
may occur if inammatory mediators cause bronchoconstric-
tion or an ARDS type picture. Metabolic rate can increase
up to 300%, which in combination with splanchnic hypoperfu-
sion requires early enteral feeding to maintain gut integrity.
Immunological changes occur from down regulation of the im-
mune system.24
An overview of acute burn management in the Emergency Centre
Fig. 2 Hettiaratchy S, Dzieulski P. Pathophysiology and types of burns. BMJ 2004;328:1427.
Burn classication
Burn depth
Supercial burns or First degree burns involve supercial epi-
dermis and are erythematous, at, and painful. These typically
heal within 23 days by sloughing of skin. Scarring is rare.
These burns are often found at the borders of second degree
burns or develop after intense sun exposure.25.
Partial thickness or Second degree burns involve all of the
epidermis and part of the dermis. These have large variabil-
ity in depth, ability to heal and likelihood of hypertrophic
scarring.25 They are further classied according to the depth
of the dermis affected. Supercial dermal burns involve the
entire epidermis and part of the dermis, appear erythematous
with clear blisters, are painful, blanch, and heal within
2 weeks.25 Deep dermal burns involve entire epidermis and
deep dermis with blistering, appear mottled pink and white
colour, less painful (due to nerve injury) and do not blanch.
These wounds are closer to Full thickness or Third degree
burns and may require skin grafting or intervention to
heal.26.
Full thickness or Third degree burns have complete involve-
ment of both the epidermis and the dermis, appear white, cher-
ry red, black or brown in colour, haemorrhagic blisters,
insensate, and non-blanching. These burns require surgery
and often lead to hypertrophic scarring, amputation and
contractures.25,26.
Circumferential burns (burns that encircle a limb, neck, or
torso) can limit vascular perfusion and may require escharot-
omy (an incision through the eschar to the depth of the subcu-
taneous fat permitting expansion of subcutaneous tissue and
decompression of underlying structures).27.
Surface area of burns
The extent of burns can also be classied as the percentage of
the Total Body Surface Area (TBSA), calculated most com-
25
monly with the Lund and Browder chart or Rule of Nines.28
Estimating size is not difcult if a standard system is used. It
is important to have accurate calculation of the percentage
of surface area affected as it may inuence transfer to a burn
centre and amount of uid resuscitation required. More
importantly, mortality and morbidity from burn injury in-
creases with larger burn sizes.29 There is research showing poor
reliability of these methods between different physicians.29
While the Rule of Nines takes less time to complete, and is
helpful for patchy burns or in addition of Rule of nines, it of-
ten leads to a 3% larger burn estimate. The Lund and Browder
chart is regarded as the most accurate but it is also more com-
plex.2931 However, it was shown that despite the differences in
TSBA measured by these tools, there was no statistically sig-
nicant difference in complications and death when comparing
the two methods.29
Transfer decisions, resuscitation and prognosis all are inu-
enced by the initial burn surface area. Therefore use of some
method is important. Fig. 3 is one of the many adaptions of
Lund and Browder diagram available.28
Patient evaluation
Primary survey
A direct assessment of the airway is critical and begins by
evaluating for injury to the face and neck.32 Injury can result
in signicant airway oedema, especially if the mechanism was
from grease or ame, which can cause deeper tissue involve-
ment.24 Oedema usually worsens with uid resuscitation so
re-evaluation for airway compromise is necessary. Early intu-
bation is required in those who are unconscious, hypoxic, or
present with signs and symptoms of severe smoke inhalation
or burns to the face and neck. Breathing assessment should
begin with every patient with moderate to severe burns
receiving supplementary high ow oxygen. For carbon mon-
oxide poisoning, place patient on 100% O2 non-rebreather
face mask.25,26,33 There may be mechanical resistance
26
Fig. 3 Hettiaratchy S, Papini R. Initial management of a major burn: IIassessment and resuscitation. BMJ 2004;329:7457.
limiting chest wall expansion from circumferential brea-
things. Patients with blast injuries may experience tension
pneumothoraces, lung contusions or alveolar haemorrhage
leading to adult respiratory distress syndrome. Smoke inhala-
tion may cause pulmonary injury such as bronchospasm,
inammation, and damage to ciliary function that can cause
atelectasis and pneumonia.33 Mainstay treatment is mechan-
ical ventilation, humidication and airway toilet.34 Circula-
tion may be protected by two large bore cannulas placed
preferably through unaffected and cleaned tissue. Large bore
intravenous access will provide resuscitation with uids and
blood products. Circumferential burns may decrease distal
tissue perfusion and often require escharotomy. Hypovol-
emia shock is not a normal initial response to a burn, if
found on arrival consider causes such as cardiogenic shock,
tension pneumothorax, bleeding, or delayed presentation.
A. Landry et al.
Secondary survey
A careful physical examination should look for other associ-
ated injury. Remove clothing and jewellery that are burned,
constricting or covered in chemicals. Cool and clean burns that
are less than 3 h old with owing tap water (1525 C) for at
least 30 min.26 Avoid ice since it may increase tissue injury.35,36
Cooling and cleaning often will require local or regional anaes-
thetic. Cleaning with povidone/iodine (Betadine) or chlorhexi-
dine is contraindicated since they often delay tissue healing.36
Cover the patient with a blanket to help prevent hypothermia.
A history should be taken from the patient, witnesses, family
or emergency response personnel. History should include
cause, time and duration of burn (including temperature of
water, names of chemicals or solutions), comorbid illnesses,
tetanus status, and other associated injuries.37
An overview of acute burn management in the Emergency Centre
Patient management
Fluid resuscitation
Patients with burns <10% TBSA can be hydrated orally, un-
less there is trauma or burns to mouth or airway. Burns >10%
TBSA require 12 large bore IV lines (or intra-osseous lines)
for uid resuscitation. The Parkland formula (4 ml isotonic
crystalloid solution kg of body weight (%BSA) = total
ml in the rst 24 h) may be used to initiate uids for on-going
resuscitation and uid losses.26 Half of this total is given dur-
ing the rst 8 h post injury and the remaining given during the
next 16 h. Every patient has different systemic responses to
burns with uid loss and shifts so it must be kept in mind that
crystalloid demands are not equivalent to all patients.38
A Foley catheter for patients with burns >15% TBSA is
needed to monitor urine output. According to the Advanced
Paediatric Life Support manual, urine output should be kept
at 1 ml/kg/h for children, and 0.51 ml/kg/hr in adults.39
Diuretics are contraindicated to improve output, instead uid
rates and volume can be adjusted. Dark or red urine requires
consult to a burn centre for renal failure.25
One concern with uid resuscitation is that excessive uid
resuscitation can lead to uid creep, described as pulmonary burns so the role of the care giver is usually supportive. In
oedema, acute respiratory distress syndrome, cerebral oedema
and abdominal or limb compartment syndrome.40 Excessive
resuscitation can often occur when patients have strict hydra-
tion and urinary output goals. While there are suggestions to
decrease the Parkland formula to 3 ml/kg/%TBSA, measure
intravesical and abdominal perfusion pressures and use col-
loids after 8 h of crystalloids, the most important approach
is to constantly monitor patients vitals, exam, laboratories,
and urine output.41
Medication
Tetanus immunisation and pain medications IV or oral (not
IM) are often required.24 Mild pain in those not at risk for re-
nal injury can be treated with non-steroidal anti-inammatory
agents or acetaminophen. Moderate to severe pain will likely
require opioids.42
Supercial burns do not require antibiotics or wound dress-
ings. They may be treated with any high lipid containing prod-
uct such as aloe vera, lotion or honey.4345 Topical steroids do
not reduce inammation and should be avoided in supercial
burns.46 All deeper burns require topical antimicrobial or an
absorptive occlusive dressing (such as Aquacel, Duoderm,
Xeroform). In HIC, topical silver sulphadiazine is the standard
treatment with contraindications to those with sulpha allergy,
pregnant or newborns.47 While there are studies comparing
occlusive dressing to silver sulphadiazine there is a paucity of
data to guide physicians.48 A 2008 Cochrane review states that
overall data are limited in guiding treatments but, occlusive
dressings should be used instead that may result in faster heal-
ing, decreased pain and fewer dressing changes.49 In South
Africa, a new topical therapy, nanocrystalline silver-coated
NS dressing (Acticoat) is growing in favour since it has showed
a decreased number of dressings and shorter hospital stay.50
Studies in the United States have shown also that Acticoat
has a long wear time and less painful application and removal,
fewer adverse effects and shorter healing times.51,52
27
Surgical debridement may be required for deep partial
thickness and full thickness wounds. In the acute phase these
wounds need simple cover. Saline bandages or Cling wrap is
often all that is needed to keep patients warm and dry with
wounds covered.53
Chemical burns
Patients should be fully exposed with powdered chemicals
brushed off and skin ushed for a minimum of 30 min using
copious volumes of running water. An acid burn should not
be neutralised with a base, and vice versa.24.
Electrical injuries
Differentiate between low-voltage (<1000 V) and high-voltage
(>1000 V) injuries. Immediate death usually occurs from ven-
tricular brillation or asystole induced by current or respira-
tory arrest from paralysis. For those who survive, they will
need cardiac monitoring and treatment of life-threatening
arrhythmias. Patients with low voltage burns who are asymp-
tomatic and stable may be discharged home from the emer-
gency centre.54 There is no specic therapy for electrical
some cases, compartment syndrome in high voltage limb burns
might require fasciotomy.55
Discharge
Transfer to a specialist burn centre if available and indicated.
Table 137 is a modied South African Burn Society Referral
Criteria.
Table 225 lists criteria for safe discharge of burn patients.
Particular attention should be paid to patient and family
understanding of follow-up, wound care, outpatient analgesia
and return precautions.
Conclusion
Most research geared towards burns in Africa is centred on
prevention. Yet with poor government funding and initiative,
most low-income countries lack effective preventive pro-
grammes.56 The need for patient and caregiver education is
crucial and while there are campaigns to change risk factors,
such as kerosene lamps or delay in seeking treatment, there
is still room for improvement.57 Effective burn care and the
reduction of the associated morbidity and mortality is a chal-
lenge that cannot be avoided.
Appendix A. Short answer questions
1. Which of the following are appropriate approaches to ini-
tial survey and treatment of any burn patient?
a. Remove all clothing and jewellery that are burnt, con-
stricting, or covered in chemicals. Be sure to clean
wounds with cool water, while avoiding patient expo-
sure to ice.
b. Due to high volume uid loss in burn victims, any
assessment of a patient begins rst with evaluating
blood pressure and uid status.
28 A. Landry et al.

Table 1 Criteria for transfer to burn centre. (Modied from the South African Burn Society Burn Stabilization Protocol).
 Patients <1 year old
 Patients 12 years old with burns >5% TBSA
 Full thickness burns
 >2 years old with partial thickness burns >10% TBSA
 Burns to face, hands, feet, genitalia, perineum or major joints
 Electrical, lightning, chemical burns
 Patients with inhalation injury from re or scald burns
 Patients with circumferential burns of limbs or chest
 Patients with pre-existing medical disorders that could complicate management, prolong recovery or aect mortality
 Any patient with burns and concomitant trauma
 Cases where child abuse is suspected
 Burns with treatment requirements exceeding the capabilities of the referring centre
 Septic burn wound cases

Table 2 Criteria for outpatient burn care. (Modied from Sheridan, R. article pertaining to paediatric patients).
 No question of airway compromise
 Wound should be generally < 10% so that uid resuscitation is unnecessary
 Patient must be able to take in food by mouth
 No serious burns of the face, ears, hands, genitals, feet
 Family and friends must have resources to support an outpatient care plan
 An adult caregiver should be able to stay with a child who may not be able to attend school.
 Patient or another adult must be able to properly perform wound cleaning, inspection and dressing changes.
 Patient must have transportation to health care provider or emergency services
 No suspicion of abuse
 Wounds do not warrant surgical evaluation

c. Avoid cleaning wounds with Betadine or chlorhexidine.
d. Keep patients uncovered to prevent hyperthermia.
e. All of the above.
2. Regarding electrical burns, which of the following are true
a. Low voltage burn is often described as <1000 V and
high voltage as >1000 V.
b. Death after electrical injury is usually caused by rapid
atrial brillation or asystole.
c. Patients with either low or high voltage burns present-
ing in normal sinus rhythm and are otherwise stable for
discharge can be sent home from the ED without need
for further cardiac monitoring.
d. There is no standard of care for electrical burns and
usually involves monitoring and supportive treatment.
e. All of the above.
3. According to the modied South African Burn Society
Referral Criteria the following patients should be referred
to a burn centre EXCEPT
a. Patients <1 year old.
b. Patients >2 years old with partial thickness burns
>10% TBSA.
c. Burns to face, hands, feet, or genitals.
d. Only patients with burns and no concomitant trauma.
e. Septic burn wounds.
References
1. Mathers C, Fat DM, World Health Organization, Boerma JT. The
global burden of disease 2004 update. World Health Organization;
2008.
2. Pa B, E M. Burn incidence and medical care use in the United
States: estimates, trends, and data sources. J Burn Care Rehabil
1996;17(2):95.
3. Taira BR, Singer AJ, Thode HC, Lee C. Burns in the
emergency department: a national perspective. J Emerg Med
2010;39(1):15.
4. Forjuoh SN. Burns in low- and middle-income countries: a review
of available literature on descriptive epidemiology, risk factors,
treatment, and prevention. Burns 2006;32(5):52937.
5. Ahrens M. Smoke Alarms in US Home Fires. Quincy (MA):
National Fire Protection Association; 2009.
6. Peck MD. Structure res, smoke production, and smoke alarms. J
Burn Care Res 2011;32(5):5118.
7. Anon. National burn repository 2011 report. <http://www.amer-
iburn.org/2011NBRAnnualReport.pdf>; 2011.
8. D Government for C and L. The economic cost of re: estimates for
2004. <http://www.communities.gov.uk/publications/re/eco-
nomiccost>; 2006 accessed May 25, 2012.
9. Anon. WHO mortality database 2009. Available at: World Health
Organization. WHO mortality database 2009. <www.who.int/
healthinfo/morttables/en/index.html>.
10. Atiyeh B, Masellis A, Conte F. Optimizing burn treatment in
developing low- and middle-income countries with limited health
care resources (Part 3). Ann Burns Fire Disasters 2010;23(1):138.
11. Hodges SC, Mijumbi C, Okello M, et al. Anaesthesia services in
developing countries: dening the problems. Anaesthesia
2007;62(1):411.
12. Bradshaw D, Groenewald P, Laubscher R, et al. Initial burden of
disease estimates for South Africa, 2000. S Afr Med J
2003;93(9):6828.
13. Rode H, Berg AM, Rogers A. Burn care in South Africa. Ann
Burns Fire Disasters 2011;24(1):78.
14. Anon. A WHO plan for burn prevention and care, 2008. Available
at: <http://whqlibdoc.who.int/publications/2008/9789241596299_
eng.pdf>.
An overview of acute burn management in the Emergency Centre
15. Runyan S. The state of home safety in America: facts about
unintentional injuries in the home. 2nd ed. Home Safety Council;
2004.
16. Anon. CDC re deaths and injuries: fact sheet. Available at:
<http://www.cdc.gov/HomeandRecreationalSafety/Fire-Preven-
tion/res-factsheet.html>. Accessed May 26, 2012.
17. Anon. Causes of death disease and mortality in Sub-Saharan
Africa NCBI Bookshelf. Available at: <http://www.ncbi.nlm.-
nih.gov/books/NBK2298/>. Accessed May 26, 2012.
18. Nega KE, Lindtjrn B. Epidemiology of burn injuries in Mekele
Town, Northern Ethiopia: a community based study. Ethiop J
Health Dev 2004;16(1):17.
19. DavidMaritz LW. The aetiology of adult burns in the Western
Cape, South Africa. Burns 2011;38(1):1207.
20. Godwin Y, Hudson DA, Bloch CE. Shack res: a consequence of
urban migration. Burns 1997;23(2):1513.
21. Schwebel DC, Swart D, Azor Hui S, Simpson J, Hobe P. Parafn-
related injury in low-income South African communities: knowl-
edge, practice and perceived risk. Bull World Health Organ
2009;87(9):7006.
22. MacNeil S. Progress and opportunities for tissue-engineered skin.
Nature 2007;445(7130):87480.
23. Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and
types of burns. BMJ 2004;328(7453):14279.
24. Singer AJ, Brebbia J, Soroff HH. Management of local burn
wounds in the ED. Am J Emerg Med 2007;25(6):66671.
25. Sheridan R. Outpatient burn care in the emergency department.
Pediatr Emerg Care 2005;21(7):44956 quiz 457459.
26. Singer AJ, Dagum AB. Current management of acute cutaneous
wounds. N Eng J Med 2008;359(10):103746.
27. Kupas DF, Miller DD. Out-of-hospital chest escharotomy: a case
series and procedure review. Prehosp Emerg Care 2010;14(3):
34954.
28. Hettiaratchy S, Papini R. Initial management of a major burn: II
assessment and resuscitation. BMJ 2004;329(7457):1013.
29. Hammond JS, Ward CG. Transfers from emergency room to
burn centre: errors in burn size estimate. J Trauma
1987;27(10):11615.
30. Wachtel TL, Berry CC, Wachtel EE, Frank HA. The inter-rater
reliability of estimating the size of burns from various burn area
chart drawings. Burns 2000;26(2):15670.
31. Freiburg C, Igneri P, Sartorelli K, Rogers F. Effects of differences
in percent total body surface area estimation on uid resuscitation
of transferred burn patients. J Burn Care Res 2007;28(1):428.
32. Silver GM, Freiburg C, Halerz M, et al. A survey of airway and
ventilator management strategies in North American pediatric
burn units. J Burn Care Rehabil 2004;25(5):43540.
33. Hettiaratchy S, Papini R. Initial management of a major burn: I
overview. BMJ 2004;328(7455):15557.
34. Toon MH, Maybauer MO, Greenwood JE, Maybauer DM,
Fraser JF. Management of acute smoke inhalation injury. Crit
Care Resusc 2010;12(1):53.
35. Purdue GF, Layton TR, Copeland CE. Cold injury complicating
burn therapy. J Trauma 1985;25(2):1678.
36. Roberts J. Minor burns: initial therapy. Emerg Med News
2003;3:2831.
37. Karpelowsky JS, Wallis L, Madaree A, Rode H. South African
Burn Society burn stabilisation protocol. S Afr Med J
2007;97(8):5747.
29
38. Milner SM, Hodgetts TJ, Rylah LT. The Burns Calculator: a
simple proposed guide for uid resuscitation. Lancet
1993;342(8879):108991.
39. Anon., Fildes J, Meredith W, Kortbeek J, Chapleau W, Merrik C,
et al. Advanced trauma life support for doctors, ATLS, student
course manual. 8th ed. Glem Rock, PA: American College of
Surgeons, Hearthside Publishing Services; 2008, 3132.
40. Pruitt Jr BA. Protection from excessive resuscitation: pushing the
pendulum back. J Trauma 2000;49(3):5678.
41. Rogers AD, Karpelowsky JS, Argent A, Millar AJW, Rode H.
Resuscitation in major burns: the problem of uid creep. S Afr
Med J 2009;99(7):5123.
42. Stoddard FJ, Sheridan RL, Saxe GN, et al. Treatment of pain in
acutely burned children. J Burn Care Rehabil 2002;23(2):13556.
43. Jull AB, Rodgers A, Walker N. Honey as a topical treatment for
wounds. Cochrane Database Syst Rev 2008;4. Available at: <http:
//info.onlinelibrary.wiley.com/userles/ccoch/le/CD005083.pdf>.
Accessed June 17, 2012.
44. Molan PC. Potential of honey in the treatment of wounds and
burns. Am J Clin Dermatol 2001;2(1):139.
45. Molan PC. The role of honey in the management of wounds. J
Wound Care 1999;8(8):4158.
46. Faurschou A, Wulf HC. Topical corticosteroids in the treatment
of acute sunburn: a randomized, double-blind clinical trial. Arch
Dermatol 2008;144(5):620.
47. Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res
2009;30(3):464.
48. Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical
silver for preventing wound infection. Cochrane Database Syst Rev
2010;3. Available at: <http://onlinelibrary.wiley.com/doi/
10.1002/14651858.CD006478.pub2/pdf/standard>. Accessed June
17, 2012.
49. Wasiak J, Cleland H, Campbell F. Dressings for supercial and
partial thickness burns. Cochrane Database Syst Rev 2008;4.
Available at: <http://onlinelibrary.wiley.com/doi/10.1002/
14651858.
CD002106.pub3/pdf/standard>. Accessed June 17, 2012.
50. Cox SG, Cullingworth L, Rode H. Treatment of paediatric burns
with a nanocrystalline silver dressing compared with standard
wound care in a burns unit: a cost analysis. S Afr Med J
2011;101(10):72831.
51. Muangman P, Chuntrasakul C, Silthram S, et al. Comparison of
efcacy of 1% silver sulfadiazine and Acticoat for treatment of
partial-thickness burn wounds. J Med Assoc Thai
2006;89(7):9538.
52. Khundkar R, Malic C, Burge T. Use of Acticoat dressings in
burns: what is the evidence? Burns 2010;36(6):7518.
53. Choices NHS. Burns and scalds treatment NHS choices 2012.
Available at: http://www.nhs.uk/Conditions/Burns-and-scalds/
Pages/Treatment.aspx. Accessed May 27, 2012.
54. Gomez R, Cancio LC. Management of burn wounds in the
emergency department. Emerg Med Clin North Am 2007;25(1):
13546.
55. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30(Sup-
pl. 11):S42430.
56. Lau YS. An insight into burns in a developing country: a Sri
Lankan experience. Public Health 2006;120(10):95865.
57. Masellis M. Fire disaster and burn disaster: planning and
management. Ann Burns Fire Disasters 1999;12(2):6776.