Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
Burn injuries are a major source of morbidity 
and mortality, responsible for about 100,000 deaths 
and 9 million injuries requiring medical attention 
annually. Burns are most commonly due to open 
flame or scalds (hot liquids), with other causes being 
contact, electrical, chemical, and friction injuries. 
While the types of burns are similar across the globe, 
middle income countries have the highest incidence 
of burn related injuries. This is important to 
understand as burn related injuries account for a large 
proportion of disability-adjusted life years lost. 
Women and children contribute to most of these 
losses in regard to gender and age group respectively. 
This negatively impacts a country’s economic 
productivity now and for the future. 
The severity and treatment of a burn injury is 
dependent upon multiple factors: the size of the 
burned area, the depth of the burn, the location of the 
burn, and the resources available to treat the injury. 
Obviously, large surface area burns carry high risk 
for morbidity and mortality with high risk for 
infection and chronic pain. But even smaller burns 
can be devastating. For example, a small full-
thickness hand burn can be life altering for a patient, 
affecting activities of daily life and can causing 
occupational disability.  
Burn victims are often neglected by doctors 
and nurses who lack the experience and knowledge 
to care for them. You should take a special interest in 
the care of these patients. Think beyond the initial 
healing period and help construct a plan for long term 
care. The long term care of a severe burn victim 
should include physical and occupational therapy, 
pain management, and psychological care. Burn 
wounds can cause terrible pain and potential 
disability. You have a unique opportunity to provide 
survivors with compassionate, life-changing care.  
 
Anatomy:  
The integumentary system is the largest 
organ of the body. It serves many functions 
including: 
● Protecting deeper structures from mechanical, 
chemical, and thermal injuries 
● Preventing desiccation  
● Inhibiting invasion of microorganisms by 
releasing cytokines  
● Regulating body temperature  
● Containing sensory nerve endings to facilitate 
touch and proprioception 
● Regulating hydration by preventing fluid loss  
● Protecting against ultraviolet radiation  
● Playing a role in endocrine function by secreting 
1,25 OH Vitamin D 
● Playing a role in exocrine function by secreting 
urea, water, sebum, ammonia, sweat, and 
pheromones. 
 
The skin is composed of an outer layer, the 
epidermis, and a deeper layer, the dermis. The 
epidermis itself has up to five sublayers (depending 
on the body region) while the dermis has two 
sublayers. The thickness of these sublayers 
determines the thickness of skin. For example, the 
glabellar skin of the palm is thick due to epidermal 
redundancy. In contrast, the skin of the back is thick 
due to a thicker dermis.  
The superficial sub-layer of the dermis, the 
papillary dermis, separates during blister formation, 
while the deeper dermal layer, the reticular dermis, is 
essential to skin regeneration. Burn injuries 
involving the reticular dermis and beyond will often 
lead to prolonged healing times, scarring, loss of 
function over joints, and increased rates of infection. 
 
Layers of the skin. Generally, a superficial partial thickness 
burn is one in which there are many epidermal stem cells 
(stratum basale) remaining, while full thickness burns have no 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
remaining epidermal stem cells. Deep partial thickness burns 
are of varying depths, in between these two extremes. Note also 
that the hair follicle is surrounded by epidermal stem cells. Skin 
regeneration can be driven by these cells when more superficial 
layers are destroyed. Source: US Government, Public Domain, 
via Wikimedia Commons 
 
Superficial burns (first degree) involving the 
epidermis alone are painful and characterized by 
redness and darker pigmentation. Superficial burns 
normally heal within a week. It is possible for even 
dark-skinned people to sustain such burns with 
extensive sun exposure.  
 
Superficial (first degree) burn 
 
Partial thickness burns (second degree) are 
divided into superficial partial thickness and deep 
partial thickness injuries.  
Superficial partial thickness burns involve 
epidermolysis of the papillary dermis and are 
characterized by blistering. The wound base is pink 
and moist, wounds blanch (turn pale and then return 
to their initial color) upon pressure, and are sensate 
to pin prick. With preventative wound care, these 
burns will heal in less than 28 days. 
Deep partial thickness burns involve the 
reticular dermis and are characterized by a dry, pale 
or hemorrhagic wound base. They are often insensate 
to pin prick and do not blanch. Healing is difficult to 
predict as there is a significant risk of conversion to 
full thickness wounds, especially with delayed 
presentation, imbalanced resuscitation and wound 
infection. 
 
Partial thickness (second degree) burn before (above) and after 
(below) initial debridement 
 
Full thickness burns (third degree) violate the 
reticular 
dermis 
and 
may 
extend 
into 
the 
hypodermis/fat, muscle, tendon, and bone. These can 
be desiccated, white or leathery brown, insensate, 
and do not blanch. If healing occurs, it does so by 
contraction from wound edges and often takes 
months to years to achieve wound closure, often 
leaving disabling or disfiguring scar contractures 
along the way.  
 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Full thickness (third degree and likely deeper) burn 
 
Burn wounds, however, often have varying 
degrees of depth. Additionally, it may not always be 
clear how deep the burn is initially, and the wound 
may undergo conversion in the first several days. It 
is easier to differentiate between superficial and deep 
wounds and more difficult to differentiate those that 
are of intermediate depth. Specifically, the question 
of whether to allow the wound to heal with time, or 
to excise and skin graft, can be difficult with 
intermediate-depth burns.  
 
Principles:  
The initial evaluation of the burned patient 
begins with the standard primary survey (ABCDE). 
Protecting the airway is of utmost importance, but 
local resources may limit what interventions are 
possible. Patients may have burns involving the face 
and upper airway and/or lower airway inhalation 
injury that compromise the patient’s airway and 
respiratory status. If resources permit, endotracheal 
intubation and mechanical ventilation may be 
needed. Obtaining reliable vascular access is 
essential and can be achieved with peripheral IV, 
central venous catheter placement, or intraosseous 
access. If necessary, these may be inserted through 
burned skin. Recall that burned patients may have 
also suffered trauma, such as a motor vehicle 
accident, assault, or explosion, prior to or while 
sustaining the burn.  
Upon completion of the primary survey and 
addressing immediately life-threatening injuries, 
complete a secondary survey with calculation of the 
percent total body surface area (TBSA) injured and 
assess the depth of each burn. 
 
TBSA is calculated for partial (second degree) and 
full thickness (third-degree) burns only. Superficial 
burns (first-degree) are not included in this 
calculation. Rapid estimation of TBSA can be 
calculated in several different ways. The Rule of 
Nines divides the body into anatomic regions that are 
9% each (i.e. multiples of 9.) It is important to 
recognize that even though each region is a multiple-
of-9%, the typical burn does not involve the entire 
anatomic region. Only the fraction of the burned 
region should be included in the estimation. 
Additionally, the rule of nines is modified for 
infants/children due to their relatively larger head 
and smaller torso and legs. Burn surface area 
diagrams differ significantly for children of different 
ages, as during growth the proportional size of the 
head decreases, as shown further below.  
The “rule of nines” for an adult. Source: Jmarchn, CC BY-SA 
3.0 via Wikimedia Commons 
 
For smaller wounds or those that span body 
regions, TBSA can also be estimated using the 
patient’s hand (palm and fingers) to equal 1% TBSA. 
This is particularly helpful with burns that are 
scattered across anatomic regions. This technique 
may overestimate the TBSA but provides a quick and 
useful metric. 
Lund-Browder (LB) charts are also effective 
methods of determining the TBSA. Regions of the 
body are assigned specific percentages. Various 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
standardized LB charts exist for victims of different 
age and gender subgroups. 
 
The Lund-Browder Chart allows you to calculate the relative 
percentage of body surface area by age. Source: Department of 
Health and Human Services - available at 
https://commons.wikimedia.org/w/index.php?curid=25740802  
 
Adults or children with burns ≥ 15-20% 
TBSA, depending on the depth of injury need fluid 
resuscitation due to increased capillary permeability. 
The impaired systemic perfusion due to loss of 
intravascular volume is known as “burn shock.” The 
goal of resuscitation is to maintain critical organ 
perfusion 
while 
minimizing 
excess 
fluid 
resuscitation, as both under and over-resuscitation 
are harmful. 
Fluid resuscitation can be given orally or 
intravenously depending on what local resources 
allow. Patients with burns <30% TBSA who are not 
requiring medications to augment their blood 
pressure may be candidates for oral resuscitation, 
however, IV fluid resuscitation is preferred as 
balanced IV solutions such as Lactated Ringers can 
minimize adverse electrolyte shifts from the 
resuscitation fluids. Burns <40% TBSA can be 
managed with one peripheral IV, while those >40% 
would benefit from two or more. The internationally 
accepted Consensus Formula recommends 2-4 
mL/kg/TBSA with crystalloid fluids over 24 hrs 
which is used to guide initial fluid resuscitation. For 
adults providers should use 2 mL, pediatrics 3 mL 
and electrical injuries 4 mL. Fluid administration is 
titrated based on the physiologic status of the patient. 
A urine output of 0.5 mL/kg/hr, or approximately 30 
mL/hr, for the average adult or 1 mL/kg/hr in 
infants/toddlers is a surrogate for adequate organ 
perfusion. Resuscitation of children is specific to 
their weight and should be calculated based on 0.5 
mL/kg/hr. This metric can also be used to ensure 
proper fluid intake after initial fluid resuscitation is 
complete.  
In addition to fluids, tube feeds via a 
nasogastric or orogastric tube should be initiated on 
admission if resources allow. Early (within 24-48 
hours) passive gut feeding has decreased burn 
mortality rates in children and adults.  
After the initial evaluation and stabilization 
of the patient, the wounds need to be cleaned and 
dressed. Wound care is painful, and if the patient is 
not experiencing much pain, it suggests that the 
wounds may be full thickness and the cutaneous 
nerve endings may be compromised. Ensure that 
adequate analgesia is administered prior to beginning 
wound care (e.g. fentanyl, morphine, ketamine) and 
adjuvant medications are scheduled throughout 
wound 
care 
period 
(e.g. 
muscle 
relaxants, 
gabapentin, 
non-steroidal 
anti-inflammatories, 
paracetamol, etc) 
Studies have investigated leaving blisters 
intact versus unroofing them. Unless the blisters are 
small and intact, they are normally unroofed and 
dressed due to the increased risk of wound infection 
from delayed violation of blisters as well as wound 
conversion that can occur under a blister. If supplies 
are limited, an alternative to partial thickness wounds 
is to open the blister and allow the fluid to escape, 
permitting the wall of the blister to serve as a 
dressing. A drawback to this approach is that the 
wound bed cannot be seen and a deep partial 
thickness injury or even progression to full thickness 
injury may occur unseen. 
The wounds are cleansed with gentle 
washing. Soap and water is generally effective and 
the use of saline or antiseptics is not necessary. Once 
the wounds are cleaned and non-viable tissue is 
debrided, the wounds should be dressed with a moist 
cytoprotective dressing. Commonly, this includes a 
thick layer of an antibiotic ointment (neomycin or 
bacitracin), or moistened gauze with saline or 
Dakin’s solution, followed by dry dressings to hold 
them in place. Silver sulfadiazine (“SSD”) is also 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
available in many settings. These dressings should be 
changed one-two times daily or more frequently if 
they become soiled, to decrease the bacterial burden 
at the base of the wound. If the burn requires surgical 
excision, the dressings post-operatively can be 
similar or are determined by the skin substitute or 
graft used. The burn wound will need dressings until 
re-epithelialization occurs. Bear in mind that topical 
antibiotics such as neomycin applied to a large 
wound may be systemically absorbed, leading to 
toxicity.  
 
Before and after initial debridement. This patient received a 
Cyanokit 
(hydroxocobalamin) 
which 
has 
altered 
the 
appearance of the wound bed. 
 
Circumferential or near circumferential full-
thickness burns of the extremities, with eschar that 
compromise the underlying tissue or circulation, 
require escharotomy. Similarly, circumferential or 
near circumferential eschar to the neck and torso will 
need escharotomy if ventilation is compromised. 
Escharotomy to an extremity should be done within 
eight hours of injury and ideally well before evidence 
of impaired perfusion develops. It is rarely needed 
after resuscitation has been completed, i.e. after 48-
72 hrs. Escharotomy is incision of the burn, down to 
the subcutaneous fat, parallel to the limb, torso, or 
neck, in such a way that the circumferential nature of 
the burn does not constrict the tissue underneath.  
 
Escharotomy involves incision through burned tissue down to 
subcutaneous fat, in areas where the burn is circumferential 
and inhibits circulation (in the extremities) or ventilation in the 
trunk, as shown here.) Source: Greenwood JE 
https://doi.org/10.1177/0310057X19895523  
 
Capillary refill of the nail beds, pulses, 
doppler signals of the arteries, temperature, 
compartment 
pressures, 
and 
whether 
the 
compartment “feels” full and tight are used to assess 
if escharotomy is needed. However, if you are 
uncertain whether or not to perform escharotomy, the 
recommendation is to perform it. The risk of 
complications 
of 
performing 
an 
unnecessary 
escharotomy are much lower than the potential loss 
of limb that may result from failure to perform or 
performing a delayed escharotomy. 
 
Decision Making: 
Burn care is resource intense, requiring a 
team approach to provide care that can last months 
or even longer. In the evaluation of these patients, it 
is important to know if the hospital has the needed 
resources, and if it is possible and better to refer these 
patients to another hospital. In many resource-
limited settings, an entire country may be served by 
a single burn center, which may be hundreds of 
kilometers away. An understanding of your 
country’s resources can help tremendously in a 
discussion with the patient and the family.  
Goals of burn care are multifaceted and 
patient autonomy should be respected throughout 
their care. In general, the goal is to get the burn 
wounds to heal as quickly as possible, prevent 
infection, and minimize the complications associated 
with hypertrophic scar formation. Achieving these 
goals can be an extensive undertaking, requiring 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
critical care support, wound care, operative 
intervention, nutritional support, treatment of 
infections, and rehabilitation. There are times when 
a large TBSA burn may not be survivable, especially 
in a resource limited setting, and an approach 
focusing on patient comfort and support may be the 
appropriate option. Keeping wounds covered with 
dressings can help control pain and keep the patient 
comfortable. The decision to palliate rather than treat 
an extensive burn can be very difficult, and should 
be made in consultation with experienced clinicians 
who know what is possible in your setting.  
If resources permit, patients with deep partial 
and full thickness burns will best be treated by early 
excision and grafting (within 2-5 days of injury). A 
plan should be devised for each major burn patient, 
and is dependent upon the extent of burn, its location 
and depth, and resources available. This approach 
makes intensive use of operating theater time, blood 
products, and other resources, though it ultimately 
results in faster healing and a shorter hospital stay. 
See Tangential Excision of Burns. 
In resource limited settings, a longer wound-
care focused approach may be more realistic. 
Dressing changes are performed until the eschar has 
sloughed off and granulation tissue has established 
on the wound bed. At this point the wound bed is 
prepared and skin grafted where needed. If this 
approach is taken, it is important that the patient 
receives attentive care, and undergoes ongoing 
physical therapy, splinting, nutritional support, and 
regular 
revaluation 
for 
wound 
infection 
development. The eschar will slough by bacterial 
activity. As this method involves leaving a wound 
open for some time, it is prone to invasive infection. 
Close monitoring and frequent wound care is crucial.  
Bear in mind also that this approach is painful 
for the patient. We have seen, in extreme 
circumstances, 
patients 
develop 
tolerance 
to 
anesthetic 
medications 
because 
of 
frequent 
debridements.  
 
Initial appearance of a burn caused by exposure to a “space 
heater” while unconscious. It is impossible to tell how much of 
this wound is full thickness at this time. It is reasonable to defer 
judgment until after the initial debridement. 
 
 
The same burn, after debridement and serial dressing changes 
for a few days. It is now quite clear that the brown and white 
areas in the center of the wound are full thickness and must be 
excised. The surrounding pink area may or may not contain 
viable epidermal cells. It would be reasonable to debride this 
area gently with a scalpel and if it bleeds, apply a meshed split 
thickness skin graft to the whole area.  
 
An option for large areas of burns is to 
perform staged excisions to limit blood loss during 
each operation. For patients undergoing excision and 
grafting, there are several questions to think about 
prior to going to the operating room.  
1. Will the burns be excised in a single stage or 
would the patient be better served by sequential 
excisions every few days until the burn is 
completely excised? Often, this is dependent 
upon the TBSA and resources available, 
including donor skin. It may also depend on 
whether the donor site will be re-harvested for 
multiple grafts in a patient with a high TBSA 
burn. It is necessary to plan for ample healing of 
donor site in between harvests. 
2. Will the patient be immediately grafted or is a 
skin substitute needed and available for 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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placement? This depends on the physiologic 
status of the patient, the quality of the wound bed, 
the resources available, and what percentage of 
graft loss may be acceptable. 
3. Are the wounds appropriate for tangential 
excision or is fascial excision needed? Ideally, 
wounds are treated with tangential excision 
which preserves viable dermis and/or fat, 
improving functional and cosmetic outcomes. 
However, burns extending into the subcutaneous 
tissue and beyond will best be treated by fascial 
excision. Massive burns will often need full 
fascial excision because the hemodynamic insult 
of tangential excision may be beyond the 
physiologic reserve of the patient.  
4. How will blood loss be reduced during the 
operation, and is blood available if a transfusion 
is needed? A major limitation of burn wound 
excision is blood loss. However, this can be 
limited through various techniques. We describe 
these techniques in the chapter, Tangential 
Excision of Burns. 
5. Are materials in place for post-operative 
splinting and rehabilitation? Will a limb be 
splinted or do fingers need to be immobilized 
with K-wires? Ensuring that you have a plan for 
post-operative rehabilitation and mobilization 
will serve the patient well. 
6. Would the patient be better served by an 
amputation? 
Although 
many 
patients 
are 
reluctant at first, a prolonged treatment course 
that bankrupts the extended family and takes 
months or years may not be the best course of 
action.  
7. What social factors will affect this patient’s 
ability to follow the post-treatment plan? Two 
specific considerations are adequate nutrition, 
and ability to access wound care near their home.  
 
Case Study #1: 
 
A 14-month-old girl was brought to the clinic 
after putting her hand into hot tea. A dressing 
consisting of toothpaste, maize flour and cooking oil 
had already been applied by the family. With the 
home remedy applied, the depth of the burn could not 
be assessed.  
 
 
 
The wound was cleaned gently and found to 
be erythematous and sensate throughout. Thick 
adherent skin on the palm of the hand was not 
debrided. A moist, petroleum jelly (“Vaseline”) 
based ointment, covered by a protective dressing was 
applied. The mother was instructed to leave the 
dressing in place and to return to the clinic every 
other day, except weekends, for continued care.  
 
 
 
 
 
 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Two days later, the patient was seen again. 
The dressing was dirty on the outside but the wound 
was still clean and moist. The dressing was changed 
and the wound was gently cleaned. The wound 
appeared clean and healthy. No new sites of apparent 
necrosis were seen. 
 
 
 
 
 
Three days later the patient was seen again. 
The wound was progressing nicely and beginning to 
heal.  
 
 
 
 
 
 
After another three days, the wound was 
clearly progressing well. It was less “wet” in 
appearance. The patient was treated and bandaged 
again in the clinic, but areas of the healed upper arm 
were left open, and the mother was instructed to 
apply Vaseline at home. 
 
 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
The patient returned 2 days later. The wound was 
clearly all dry, and the thick skin on the palm had 
completely fallen off. Function and range of motion 
were completely normal.  
 
 
 
The final photos, shown below, were taken 11 
months after the initial injury. The hand was 
completely functional. The discoloration on the volar 
surface of the hand had also resolved completely.  
 
 
 
 
Wound care by E. Meyerhoff, RAE Clinic, Baringo, Kenya 
 
Comment: This is a very common presentation in 
low-resource settings. The history and initial 
examination suggest a benign course with proper 
wound care. Immersion in hot cooking oil or 
exposure to flames would be more likely to result in 
a full thickness burn. Frequent clinician review of the 
wound, careful mobilization of the fingers, and 
maintenance of a moist healing environment are all 
key to assuring a good outcome. It is important to 
assess the conditions at home: a single parent caring 
for multiple children will not be able to apply 
dressings themselves: the child will need to be 
brought to the clinic for review at least every 2 days, 
or admitted if this is difficult.  
 
Case Study #2:  
 
A 12-month-old girl was brought to the clinic 
after sustaining burns, possibly with hot porridge. 
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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She was left alone near a metal pot of porridge 
cooking over an open fire. A neighbor heard her 
crying and found her covered in hot porridge, lying 
next to the overturned pot. On referral to the clinic, a 
home dressing consisting of raw egg had already 
been applied.  
 
 
 
 
 
All wounds appeared sensate except the 
center of the left flank burn. This area appeared pale 
and did not blanch when gentle finger pressure was 
applied. The wounds were cleaned and gently 
irrigated. A moist Vaseline-based treatment was 
applied, and bandaged with a non-stick dressing for 
protection. 
 
 
The patient was treated at the clinic every 
other day three times a week. Eight days later most 
of the wound was clearly sensate, healthy, and 
starting to dry. The area in the center of the flank 
burn remained concerning, as it appeared white, firm, 
and “leathery” in appearance, in contrast with the 
pink healing tissue surrounding it.  
 
 
 
  
The same wound care regimen was continued 
and no determination about the suspected full-
thickness portion of the burn was made at that time.  
 
Three weeks later it was clear that there were 
no living epidermal cells within the center of the 
wound. Whereas the rest of the wound was dry and 
even returning to its normal skin color, the center of 
the flank wound had only granulation tissue.  
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
 
The family was unable to access a higher 
level of care due to financial concerns. The 
granulation tissue was kept moist, with the patient 
treated at the clinic 2 or 3 times a week, whenever 
the parents could bring her. 
 
 
During the next several weeks and months 
the non-healing portion of the wound was kept moist, 
and dressed at the clinic. The following two photos 
were taken 10 weeks apart: 
 
 
 
 
 
At this time the family’s national health 
insurance was mature enough and the clinic was able 
to arrange a skin graft. The final result was complete 
healing of the wound:  
 
Wound care by E. Meyerhoff, RAE Clinic, Baringo, Kenya 
 
Comment: Unfortunately, the un-witnessed 
child burn with a somewhat vague history is also 
very common in low-resource settings. In this case, 
it was not known how long the child was unattended 
for, or how much oil was in the porridge, which 
would have raised its temperature significantly. 
Similarly, the child may have come in contact with 
the cooking pot, hot coals or flames. A full-thickness 
wound was suspected as described. In any case, it is 
almost always impossible to unravel what truly 
happened in our setting.  
Initial Management of Acute Burns 
Cassidy A. Muir, Peter Stafford, Deepak K. Ozhathil 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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When the central part of the wound failed to 
heal with supportive care, it quickly became 
apparent that there were no living epidermal cells 
within it. It got smaller in the only way that such 
wounds can: by the contraction of myofibroblasts 
pulling the wound edges together.  
If this wound had been in the axilla or across 
another joint, it would have led to contracture, a 
much harder problem to treat. Wounds in areas that 
can not completely heal by contraction remain as 
they are, granulation tissue. Eventually they may be 
at risk for malignant transformation, also known as 
Marjolin’s ulcer.  
 
 
There were no viable epidermal cells in this child’s antecubital 
fossa after he sustained a burn: the only way the wound could 
heal was by contraction of the wound edges, leading to a 
contracture deformity.  
 
 
A wound that is not able to heal by contraction of its edges, as 
here on the lateral scalp, will remain unhealed. (Note that as it 
attempted to contract, the wound pulled on the upper eyelid and 
exposed and desiccated the eye.) Over time, usually years, that 
chronic wound may undergo malignant transformation into an 
aggressive form of Squamous Cell carcinoma known as 
Marjolin’s ulcer.  
 
Cassidy A. Muir, MD 
Medical University of South Carolina 
South Carolina, USA 
 
Peter Stafford MD 
Centre Médical Evangélique 
Democratic Republic of Congo 
 
Deepak K. Ozhathil, MD 
Medical University of South Carolina 
South Carolina, USA 
 
July 2023 
 
 
 
 
Resource-Rich Settings 
For massive burns, wound coverage is often 
achieved with Cultured Epidermal Autograft, in which 
two cm full thickness skin biopsies are taken and sheets 
of skin are cultured in the lab. For patients without 
adequate donor sites, this allows the wound to be 
covered. Newer technology like cell suspension (ReCell) 
is improving the cosmetic appearance of wounds after 
care. 
