Annals of Burns and Fire Disasters - vol. XXIX - n.

1 - March 2016

GERMAN, EUROPEAN OR AMERICAN BURN GUIDELINES –

IS ONE SUPERIOR TO ANOTHER?
RECOMMANDATIONS ALLEMANDE, EUROPÉENNE ET AMÉRICAINE DE PRISE EN
CHARGE DES BRÛLÉS. L’UNE EST-ELLE SUPÉRIEURE À L’AUTRE?

Paprottka F.J.,1* Krezdorn N.,2 Young K.,3 Ipaktchi R.,2 Hebebrand D.,1 Vogt P.M.2
1
Department of Plastic and Reconstructive Surgery, Hand Surgery, Agaplesion Diakonieklinikum Rotenburg, Germany
2
Department of Plastic and Reconstructive Surgery, Hand Surgery, Burn Center, Medizinische Hochschule Hannover, Germany
3
Department of Hand and Plastic Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom

SUMMARY. Adequate medical care of severe burn injuries requires special organizational infrastructure and high educational standards,
with an appropriate number of health care professionals. Guidelines were written by the German Society for Burn Treatment (DGV), the
European Burns Association (EBA) and the American Burn Association (ABA) to assist with the delivery of such care. Current DGV
(2010), EBA (2013) and ABA (2001/2006/2008) guidelines are compared, focusing on similarities, differences, conciseness and complete-
ness. This publication presents advantages and disadvantages of each of them. DGV guidelines outline understandable treatment recom-
mendations for first aid measures, clinical procedures and wound care. Extensive rehabilitation guidelines with clearly defined indications
and precise infrastructure requirements for a Burn Centre are stated. Negative aspects are the presence of multiple documents containing
redundant and confusing information. EBA guidelines offer the most comprehensive treatment recommendations with multidisciplinary
approaches. Overall, infrastructural requirements are weighted much higher than staff qualification demands – in contrast to ABA guidelines.
However, lack of conciseness and complicated criteria regarding transfer of patients to a Burn Center - including imprecise indications for
rehabilitation treatment - have to be mentioned as disadvantages. ABA guidelines have a clear focus on staff qualifications and easy-to-un-
derstand transfer criteria. Another focus is on detailed clinical procedures. However, these guidelines lack burn definition and precise treat-
ment recommendations for rehabilitation. The reviewed guidelines provide standardized treatment recommendations for burn patients.
Despite their usefulness, they all have weaknesses and discrepancies. Findings should be used to improve each of them.

Keywords: comparison of burn guidelines, Deutsche Gesellschaft für Verbrennungsmedizin (DGV), German burn guidelines, European
Burns Association (EBA), American Burn Association (ABA), transfer criteria

RÉSUMÉ. La prise en charge correcte des brûlés graves nécessite une organisation spécifique, une expertise adaptée et un nombre adéquat
de personnels entraînés. Des recommandations spécifiques ont été édictées par la « German Society for Burn Treatment » (DGV), l’Euro-
pean Burns Association (EBA) et l’American Burn Association (ABA) afin d’aider à cette prise en charge. Nous les avons comparées, en
nous focalisant sur les similarités, les différences, la concision et l’exhaustivité, chacune d’entre eux ayant ses points positifs et négatifs,
que nous présentons ici. Les recommandations allemandes insistent sur la prise en charge initiale et le traitement local. La rééducation et
les infrastructures nécessaires sont explicitées. Les documents sont cependant multiples et fréquemment redondants, obérant leur facilité
d’utilisation. Les recommandations européennes sont plus exhaustives et s’attachent à l’approche multidisciplinaire. Les obligations in-
frastructurelles y ont un poids supérieur à l’expertise soignante, ce qui diffère des recommandations américaines. Cependant, une concision
argumentable et des critères d’hospitalisation en CTB compliqués (ainsi que des critères de rééducation spécialisée flous) doivent être
marqués défavorablement. Les recommandations américaines ont l’avantage de la clarté en ce qui concerne le niveau d’expertise des in-
tervenants, les critères d’hospitalisation en CTB et le détail de la prise en charge. Elles pêchent cependant par le flou concernant la défi-
nition d’une brûlure et l’absence de préconisation concernant la rééducation. Globalement, ces recommandations ne présentent que des
approches incomplètes de la prise en charge des brûlés et devraient toutes être optimisées.

Mots-clés: recommandations, brûlés, DGV, EBA, ABA, transfert, milieu spécialisé

Introduction
National and international associations aim to improve and
standardize burn care by setting standards and guidelines for
treatment recommendations and operating procedures.1 For
high quality care of severely burned patients, a specific infra-
structure, high demands for medical staff and an adequate per-
sonnel count are essential.2 In view of this necessity, guidelines
have been written by the German Society for Burn Treatment
(Deutsche Gesellschaft für Verbrennungsmedizin [DGV])3 the
European Burns Association (EBA)4 and the American Burn
Association (ABA).5-7 The DGV provides burn guidelines for

*
Corresponding author: Dr. med. Felix Julian Paprottka, Klinik für Plastisch-Ästhetische und Rekonstruktive Chirurgie, Handchirurgie, Agaplesion Diakonieklinikum
Rotenburg, Elise-Averdieck-Straße 17, 27356 Rotenburg (Wümme), Germany. Tel.: +49 4261776870; fax: +49 4261776873; email: felix.paprottka@me.com
Manuscript: submitted 06/07/2015, accepted 17/07/2015.

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 Annals of Burns and Fire Disasters - vol. XXIX - n. 1 - March 2016

German-speaking countries such as Germany, Austria and
Switzerland – all of which have high medical standards. The
EBA includes many more European countries. The ABA guide-
lines, which are internationally well known and respected,
serve as a benchmark for the other mentioned guidelines.
By representing multiple European countries, the EBA set
out to create guidelines that are applicable for medical burn
treatment within all participating countries. Each country in
Europe has its own national healthcare system with variable
standards. All afore-mentioned burn associations have devel-
oped their own burn treatment recommendations. Here, the dif-
ferences, advantages and disadvantages of each are reviewed.
The aim of this publication is to improve the EBA guidelines,
due to their planned update scheduled for the end of 2015.
Material and methods
The current DGV guidelines (last revision in 2010 / 2nd
revision),3 EBA guidelines (last revision in 2013 / 2nd revi-
sion)4 and ABA “Practice guidelines for burn care” (last revi-
sion in 2001, $100 for non-ABA members),6 “Guidelines for
the Operation of Burn Centers” (last revision in 2006 / 3rd re-
vision),5 and “American Burn Association Practice Guidelines
Burn Shock Resuscitation” (minor update concerning burn re-
suscitation in 2008)7 are compared, focusing on similarities,
differences, conciseness and completeness.
The DGV guidelines are written in German and consist of
five individual documents, the EBA guidelines are published
in English in one single comprehensive document, and the
ABA guidelines are also in English and composed of two com-
prehensive documents and one minor update in 2008 concern-
ing burn resuscitation. All the guidelines were written by
experts in the field, and all reviewed guidelines also refer to
scientific publications (EBA > ABA > DGV). The ABA guide-
lines have not been updated since 2001/2006,5, 6 except for one
minor update in 2008. Compared to the other guidelines, this
is the longest period without any update/revision. The defini-
tion of burns, recommended first aid measures, criteria for
transfer to a Burn Center, clinical procedures for burn treat-
ment, infrastructural requirements for Burn Centers, personnel
count and staff qualifications, instructions for burn wound
management, wound treatment and patient follow-up including
rehabilitation recommendations are examined in detail. They
have been rated by all the authors in order to assess each set of
guidelines’ content. This kind of rating should help the reader
of the article to get a more precise overview of this complex
topic, focusing on the advantages and disadvantages of each
reviewed guideline. The following scores are applied: very de-
tailed = (++), adequate = (+), insufficient = (-), missing = (—
). If there were opposing opinions concerning the score, the
argument of the majority of experts with identical points of
view was chosen.
Results

Table I - Burn definitions: listing of burn definitions provided by German The content of each set of guidelines was analyzed. The
Society for Burn Treatment (DGV)3, European Burns Association (EBA)4 authors determined the guidelines’ definitions of a burn: the
and American Burn Association (ABA) guidelines (GL).5-7 Rating by the au- DGV definition was thought to be satisfactory, the EBA de-
thors: very detailed = (++), adequate = (+), insufficient = (-), missing = (–) tailed and the ABA definition was absent (Table I). Only the
DGV GL EBA GL ABA GL DGV guidelines list basic instructions and ABA guidelines
Burn The affected A burn is a complex minor instructions for first aid measures for burn treatment
definition skin is damaged trauma needing (Table II). Criteria for patient transfer to a Burn Center vary
by thermal or multidisciplinary and
within the presented guidelines (Table III). The DGV transfer
chemical impact continuous therapy.
at different burn Burns occur through criteria are not as strict as the EBA or ABA ones, e.g. a patient
depths, which intensive heat contact with third degree burns should only be transferred to a Burn
leads to partial or to the body, which - Center if at least 10% of total body surface area (TBSA) is af-
complete necrosis destroys and/or fected. In contrast, EBA transfer criteria are made more com-
of the skin. damages human skin
(thermal burns). plex by setting the TBSA in correlation to the patient’s age.
In addition to thermal Apart from that, all patients with 2nd - 3rd degree burns should
burns, there are be transferred to a Burn Center for further treatment. The ABA
electric, chemical, transfer criteria are made simpler and easier to understand by
radiation and
stating that all patients with second degree burns and a TBSA
inhalation burns.
Frostbite also comes >10% and all third degree burned patients in any age group
under this category. should be treated in a Burn Center. Also, the DGV guidelines
Rating Satisfactory Detailed None imply that all patients with inhalation injury and electrical
definition (+) definition (++) (–) burns should be treated in a Burn Center. The ABA guidelines

Table II - First aid: listing of first aid measures provided by German Society for Burn Treatment (DGV)3, European Burns Association (EBA)4 and
American Burn Association (ABA) guidelines (GL).5-7 Rating by the authors: very detailed = (++), adequate = (+), insufficient = (-), missing = (—)
DGV GL EBA GL ABA GL

First aid Eliminating heat source, stop effect of vicious agent, removal of
hot clothes, turn off electricity, self-protection
Check vital signs
For smaller burn injuries  cooling with tap water; careful with
extensive burns and cooling  CAVE: no hypothermia
Chemical injuries  rinsing with water, identifying chemical agent
Assessment of TBSA in % & depth in degrees
Cooling effects (application of ice contraindicated) 
CAVE: frostbite; cold treatment must be applied and
- continued through first 30 minutes post-burn (not
longer!)
Percentage of TBSA using Lund-Browder chart, depth
of burn wound estimation by experienced clinicians

Rating First aid instructions available (++) None (--) First aid instructions available (no separate
section) (+)

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Annals of Burns and Fire Disasters - vol. XXIX - n. 1 - March 2016

recommend that as well as inhalation injuries and electrical
burns, also chemical burns should be treated there. On the other
hand, the EBA guidelines state that all burns with a suspicion
of an inhalation injury should be transferred, whereas only
major electrical or chemical burns should be treated in a Burn
Center. Additionally, the DGV has established a nationwide
hotline to coordinate ICU-burn-bed-availability, making the
transfer of a severely burned patient to a receptive Burn Center
easier for the primary care physician. The EBA guidelines rec-
ommend that treatment of burn-like diseases, such as toxic epi-
dermal necrolysis (TEN), necrotising fasciitis or
staphylococcal scalded skin syndrome (SSSS), take place in a
Burn Center (Table III).
Clinical procedures after burn patient admission are listed
by the DGV guidelines with general instructions including
cooling. EBA guidelines focus on fluid substitution and anal-
gesia, whereas ABA guidelines offer the most comprehensive
instructions for clinical procedures, focusing on outpatient
management of burn patients, initial management of carbon
monoxide and cyanide exposure, diagnosis and initial manage-
ment of inhalation injury, initial management and overview of
burn shock resuscitation, hypertonic fluid resuscitation, colloid
fluid resuscitation, pediatric resuscitation, monitoring of fluid
resuscitation, escharotomy, initial nutritional support of burn
patients and deep venous thrombosis prophylaxis in burns
(Table IV).6,7
Examining personnel count and staff qualifications, the
DGV states that the physician to patient ratio should be one to
two and that nursing care in relation to patient should be one
to one. The EBA requires at least one physician looking after
two patients and one highly skilled nurse being responsible for
one patient (EBA has therefore higher demands than DGV),
whereas the ABA does not state a physician- or nurse-patient
ratio (Table V). The ABA guidelines have a clear focus on staff
qualifications, whereas the DVG and EBA guidelines lack this
precision.
DGV and EBA guidelines focus on infrastructure require-
ments for Burn Centers (DGV < EBA), while the ABA guide-
lines refer to staff qualifications instead of infrastructural
demands (Table VI). For a Burn Center, the DGV and ABA

Table III - Transfer criteria to Burn Center: listing of criteria for burn patient transfer to a Burn Center defined by German Society for Burn Treatment
(DGV)3, European Burns Association (EBA)4 and American Burn Association (ABA) guidelines (GL).5-7 Rating by the authors: very detailed = (++),
adequate = (+), insufficient = (-), missing = (—)

DGV GL EBA GL ABA GL

Transfer Adults with ≥15% 2° TBSA
criteria Children with ≥10% 2° TBSA
to Burn Adults with ≥10% 3° TBSA
Center (not as strict as EBA/ABA GL)
Children with ≥5% 3° TBSA
(not as strict as EBA/ABA GL)
Pat. having preexisting sicknesses or age
<8 or >60 years
1° and 2a° burns 
5% of TBSA in children <2 years
10% of TBSA in children 3-10 years
15% of TBSA in children 10-15 years
20% of TBSA in adults
10% of TBSA in seniors >65years (TBSA
in relation to age  complicated!)
2b°and 3° burns in any age group and any
extent (all 2b°+ 3° burns!)
Any type of burns if there is doubt about
the treatment
2° burns >10% TBSA (no determination
of age + TBSA concerning 2° burns as
in DGV/EBA)
3° burns in any age group (all 3° burns
like EBA, but 2b° burns are excluded)
Burned children in hospitals without
qualified personnel or equipment for
specialized burn care
(minor age pat. transferral when missing
infrastructure)

Burn patients who require special social, Burn patients who require special social,
- emotional or longterm rehabilitation support emotional, rehab-intervention

Hotline for ICU-burn-bed-availability in - -

burn centers

All pat. with burns on the face/ neck, Pat. with burns on face, hands, genitalia or Burns involving face, hands, feet, genitalia,
hands, feet, ano-genital-region, axillae, major joints (more imprecise than DGV – perineum or major joints (more imprecise
major joints or other complex burned no feet!) than DGV)
regions

- Circumferential burns in all ages -

All pat. with inhalation injury Burns with a suspicion of inhalation injury Inhalation injury

All pat. with electrical burns Major electrical burns (only major traumas) Electrical burns, including lightning injury

- Major chemical burns (only major traumas) Chemical burns (all traumas!)

- Pat. requiring burn shock resuscitation -

Pat. with concomitant trauma
Burns of any size with concomitant trauma or
diseases, which might complicate
treatment, prolong recovery or affect mortality
Patients with burns and concomitant trauma
or burn injury poses greatest risk of
morbidity  stabilization in trauma center
 transfer to burn center
(U.S. medical infrastructure different to
German medical system)

- TEN, necrotising fasciitis, SSSS etc.; TBSA -

≥10% for children/elderly and
≥15% TBSA for adults or if any doubt

Rating Precise/concise transfer criteria, partly Very detailed GL with occasionally Mostly detailed but easy to understand
uncertain (+)  complicated transfer criteria (TBSA vs. age) transfer criteria (++);
multiple documents with slightly (+); burn-associated diseases should be ABA GL not completely applicable to
opposing content treated in Burn Center German medical infrastructure

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 Annals of Burns and Fire Disasters - vol. XXIX - n. 1 - March 2016

Table IV - Clinical procedures: listing of clinical procedures recommended by German Society for Burn Treatment (DGV),3 European Burns Association
(EBA)4 and American Burn Association (ABA) guidelines (GL)5-7 to treat burned patients. Rating by the authors: very detailed = (++), adequate = (+),
insufficient = (-), missing= (—)

DGV GL EBA GL ABA GL

Clinical Topic wound treatment  dry
procedures Shock resuscitation therapy: ≥15% in
adults and ≥8% in children
Electrolyte and fluid substitution 
Baxter formula
Intubation of unstable pat. recommended
Adequate analgesia (cold water
application)
Minor burns  self-treatment / general
practitioner; any larger burns  hospital
Separately listed recommendation for
burn treatment concerning child burn
care
Rating General instructions including cooling
(++)
Fluid therapy
Fluid resuscitation - in relation to burn
and body size
Effects of fluid resuscitation on
hemodynamic status of pat. should
consistently be assessed
Monitoring of urine output
No colloids for first 8 hours after burns
Pain management  multi-disciplinary
approach
Individualized for each patient
Constant monitoring of pain
Patients should be awake and alert but
comfortable
Fluid substitution and analgesia
mentioned (+)
Trauma check-up using ATLS (Advanced
Trauma Live Support Program)
Diagnosis of inhalation injury
Tetanus immunization
Furthermore: special focus on outpatient
management of burn patients, initial
management of carbon monoxide and cyanide
exposure, diagnosis and initial management of
inhalation injury, initial management and
overview of burn shock resuscitation, hypertonic
fluid resuscitation, colloid fluid resuscitation,
pediatric resuscitation, monitoring of fluid
resuscitation, escharotomy, initial nutritional
support of burn patients and deep venous
thrombosis prophylaxis in burns
Widespread GL for clinical procedures (++)

Table V - Personnel count and staff qualifications: personnel count and staff qualifications demanded by German Society for Burn Treatment (DGV),3
European Burns Association (EBA)4 and American Burn Association (ABA) guidelines (GL)5-7 in order to offer adequate burn treatment. Rating by the
authors: very detailed = (++), adequate = (+), insufficient = (-), missing = (—)

DGV GL EBA GL ABA GL

Personnel 1 physician / 2 patients ≥1 physician / 2 patients No fixed physician-patient-ratio
count and There should be 1 nurse per patient and shift 1 highly skilled nurse per patient No fixed nurse-patient-ratio
staff Other disciplines: Other disciplines: Other disciplines:
qualification physiotherapy, occupational therapy, continuous rehabilitation personnel, psychosocial physical/occupational therapists,
bacteriological monitoring, work, nutritional services, physician extenders, social workers,
availability of skin bank, psychological services, microbiologist, social workers, physio- nutritional services personnel, pharmacy
social service /ergo-therapists, dietitians, speech personnel, respiratory care services
therapist, pain managers, skin bank, personnel, clinical psychiatry/psychology
other disciplines of maximum care personnel
Rating Precise but less detailed requirements Detailed description of personnel Very detailed! But no
concerning personnel needs/qualifications (+) qualifications, higher demands than physician/nursing per patient ratio,
DGV (+) staff qualifications > infrastructure
demands (++)

Table VI - Infrastructure requirements for Burn Centers: listing of infrastructure requirements for a Burn Center stated by German Society for Burn
Treatment (DGV),3 European Burns Association (EBA)4 and American Burn Association (ABA) guidelines (GL).5-7 Rating by the authors: very detailed
= (++), adequate = (+), insufficient = (-), missing = (—)

DGV GL EBA GL ABA GL

Infrastructure ≥4 beds - single rooms and possibility of
requirements maximal intensive care therapy
for Burn Heated emergency room and additional
Center hydrotherapy
Daily option for performing surgery
Continuous bacteriological monitoring,
dialysis, photo documentation
Personnel lock
Supply- and bed transfer lock
Rating Concisely formulated requirements (+)
≥5 acute beds for care of major burn
patients
Access to operating room always
available
Another theatre: devoted to secondary
burn reconstruction
Germ surveillance program and skin bank
Maximum care
All kinds and extents of burns must be
treated in adults and children
≥75 acute burn patients annually
1 Burn Center for 3-10 million inhabitants
Very detailed and specifically
formulated requirements (++)
≥4 ICU-beds
Access to operating room always
available
Dialysis, radiologic services
Maximum Care
Burn center must admit average of ≥100
burn pat. annually
Burn center must maintain average daily
census of ≥3 pat. with acute burn injuries
Focus: staff qualification <
infrastructure requirements (-)

guidelines demand at least four intensive care (ICU) beds,
while the EBA guidelines request at least five ICU beds and a
minimum of 75 acute burn patients annually (Table VI).
Regarding wound management, the DGV states detailed
wound and follow-up-care recommendations in relation to burn
depth, the EBA guidelines offer extensive but vague treatment
recommendations for wound care and the ABA guidelines pro-
vide basic wound-care instructions (Table VII). At present, rec-
ommendations for the use of alloplastic materials concerning
burn wound treatment in relation to certain burn depth are lack-
ing in all.
Regarding rehabilitation of burn patients, the DGV guide-
lines give a very detailed listing of rehabilitation needs and
clearly state indications for rehabilitation treatment, the EBA

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Annals of Burns and Fire Disasters - vol. XXIX - n. 1 - March 2016

Table VII - Wound management: listing of wound management recommendations provided by German Society for Burn Treatment (DGV),3 European
Burns Association (EBA)4 and American Burn Association (ABA) guidelines (GL).5-7 Rating by the authors: very detailed = (++), adequate = (+), in-
sufficient = (-), missing = (—)

DGV GL EBA GL ABA GL

1°-2a° burns  conservative treatment
Wound
management
2b -3°  early surgical intervention
Follow-up treatment:
daily skin care, avoiding sun exposure,
compression garments, physiotherapy,
occupational therapy, exercise/
positioning splint, contact to self-help
groups, psychological therapy,
long-term follow-up
Rating Detailed wound and follow-up-care
treatment-recommendations in
relation to burn depth (++)
No clinical evidence to support choice
of one dressing over another
Topical creams
Blisters – either remove them (maybe
an infect focus) or preserve them
(biologic protection)
Avoid stress due to delayed wound
healing
Wound-tissue temperature  >33°C.
Scar management
Extensive but vague treatment-
recommendations for wound care (+)
General statement: Burn center policies about
use of allograft tissues must be in compliance
with current standards
Initial wound care: direct mechanical cleansing
Blisters: either excision or retention of blisters
Wound dressings: should mimic barrier
function of epithelium, simple in application
Topical antimicrobial and prophylactic
antibiotic therapy not useful
Basic wound-care instructions listed (+)

Table VIII - Rehabilitation: listing of wound management recommendations provided by German Society for Burn Treatment (DGV),3 European Burns
Association (EBA)4 and American Burn Association (ABA) guidelines (GL).5-7 Rating by the authors: very detailed = (++), adequate = (+), insufficient
= (-), missing = (—)

DGV GL EBA GL ABA GL

Rehabilitation Definition of certain stages of rehabilitation process Rehabilitation is ongoing process – starts Only statement: “There must
at Intensive Care Unit be rehabilitation program
designed for burned patients”
Indication for rehabilitation-treatment Mobilize as soon as possible
Definition of needed medical condition for Restore or maintain range of motion
participating in rehabilitation
Listed responsibilities/tasks of superior rehabilitation Restore pre-injury mobility
physician
Rehabilitation goals for burn victims Multi-disciplinary approach
Priorities of rehabilitation Pain management, fighting depression and
anxiety
Structural requirements: accommodation, general conditions, Return to work / return to school program
diagnostics, exercising facilities, treatment rooms
Rating Very detailed listing of rehabilitation needs, No direct rehabilitation guidelines like Only modest hints for
personnel qualification requirements only listed for DGV, only some minor aspects are achieving successful
head of rehabilitation unit, indication for highlighted (+) rehabilitation (-)
rehabilitation-treatment clearly stated (++)

guidelines highlight only some minor aspects of rehabilitation,
whereas the ABA guidelines simply state that each Burn Center
must have a rehabilitation program for burn patients available
(Table VIII).
Discussion
All the presented guidelines have clinical applicability but
lack concordance between them. This publication highlights
these differences and weaknesses in the following text and in
Table IX. The DGV guidelines state clearly understandable
treatment recommendations for first aid measures, clinical pro-
cedures and wound care. Besides that, extensive rehabilitation
guidelines with defined indications for rehabilitation treatment
and concisely formulated infrastructure requirements of a Burn
Center are set out. A precise definition of burns is given in the
DGV and EBA but not in the ABA guidelines. Redundant and
at times confusing information due to the presence of multiple
documents and a missing English translation are disadvantages
of the DGV guidelines (e.g. variable transfer criteria to a Burn
Center, partly varying first aid instructions et cetera). Due to
the fact that DGV guidelines are only available in the German
language, they are only widely read in German-speaking coun-
tries. Furthermore, exact definition of required recommenda-
tions for non-medical and/or nursing staff is lacking. In
Germany, medical care of severely burned patients is primarily
determined by the employers’ liability insurance association
named “Berufsgenossenschaften”, which creates treatment
standards by demanding high infrastructural settings.8 The
“Berufsgenossenschaften” are unique institutions that take care
of patients involved in accidents while carrying out their work.8
Their aim is to offer all insured workers high standards of med-
ical care to get them back to work in a good medical condition
as soon as possible.8 The “Berufsgenossenschaften” have in-
fluenced burn care treatment in Germany to a great extent.
Overall, the DGV guidelines are precisely formulated but
would benefit from a general revision. The several individual
documents that make up the DGV guidelines should be evalu-
ated for redundancies and assembled into one document in
order to resolve ambiguity.

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Table IX - Conclusion: demonstrating advantages and disadvantages of German Society for Burn Treatment (DGV),3 European Burns Association
(EBA)4 and American Burn Association (ABA) guidelines (GL)5-7 in a conclusive manner
DGV GL
Advantages Clearly understandable treatment
recommendations for first aid, clinical
procedures, wound treatment, extensive
rehabilitation-GL with stated
rehabilitation-indications
Concisely formulated infrastructure
demands for burn center
Disadvantages Redundance and confusion caused by
multiple documents – sometimes with
opposing contents
No exact work field definition of non-
medical/nursing staff
Missing English guideline version -
usefulness only for German-speaking
countries
EBA GL
Most comprehensive document with
multidisciplinary approaches (“manifesto”)
Infrastructure requirements > staff
qualification requirements
Special focus: Clinical GL for non-
medical disciplines (PAM)
Missing conciseness
Complex but complicated transfer
criteria of burn patients (TBSA in
correlation to burn degrees)
Imprecise rehabilitation recommendations
ABA GL
Detailed definition of personnel
qualifications
Staff qualification requirements >
infrastructure requirements
Detailed listing of clinical procedures
No burn definition and treatment
recommendation for rehabilitation
measures
Partly ABA-GL not free of charge
Last revision 2001/2006 + minor update
2008 – GL-update needed!

The EBA guidelines have the most comprehensive treat-
ment recommendations, with many multidisciplinary ap-
proaches. The infrastructural requirements are weighted much
higher than requirements for staff qualifications. In this aspect,
the EBA guidelines differ significantly from the ABA guide-
lines. The EBA guidelines have a special focus on clinical treat-
ment recommendations for non-medical disciplines –
incorporating “Professions Allied to Medicine” (PAM). This
covers a wide group of non-medical professions, including
nurses, physiotherapists, occupational therapists, social work-
ers, psychologists, dieticians and other professionals, all of
whom have an essential role in the management of patients
with severe burns.9,10 The EBA does not only represent the doc-
tor’s point of view: due to the complexity of burn care, the
other non-medical disciplines are able to contribute their ex-
perience as well. A lack of conciseness, complicated criteria
for patient transfer to a Burn Center (TBSA in correlation to
age), imprecise indications for rehabilitation treatment and un-
structured rehabilitation guidelines in comparison to the DGV
guidelines have to be mentioned as negative aspects. This lack
of concordance could create confusion amongst referring units
and affect patient care and survival outcomes. The EBA referral
guidelines are very detailed and would benefit from being sim-
plified.
The ABA guidelines express a need for a high level of per-
sonnel qualifications. In contrast to that, the infrastructural re-
quirements are regarded as rather secondary. A missing burn
definition or imprecise recommendations for rehabilitation of
burn patients have to be mentioned as disadvantages. The U.S.
medical system differs from the one in Germany, so that trans-
fer criteria by the ABA cannot be precisely applied to the Ger-
man medical system.
Literature references as valid scientific proofs - in addition
to expert opinions - are listed within all the guidelines (EBA >
ABA > DGV). In comparison with DGV and EBA guidelines,
ABA guidelines mostly do not refer to the latest scientific pub-
lications due to their last update being applied in 2001/20065,6
and minor update concerning burn shock resuscitation in 2008.7
Furthermore, the ABA guidelines would benefit from more de-
tailed infrastructure requirements concerning Burn Centers.
Recommendations for the use of alloplastic materials in
burn wound treatment in relation to certain burn depth are
missing in all the reviewed guidelines. In the current literature
and clinical practice, the benefits of using alloplastic materials
have been proven various times.11-13 However, so far there is
no skin substitute available that can be used for all extents of
burn wounds.14 Maybe, due to the variety of medical products
available on the market, it is difficult for the reviewed burn as-
sociations to make a clear statement for certain products – and
risk losing their neutral point of view.
In the interest of better patient care, the stated indications
for patient transfer to a Burn Center should be mandatory for
the primary care physician. Achieving a transfer obligation of
burned patients to a Burn Center would help to improve overall
standards of burn care. Immediate transfer of a severely burned
patient into a facility with high expertise in burn treatment will
provide a better patient outcome.15 In addition, similar national
standards for burn patients would be desirable in order to pro-
mote unity in European healthcare systems. As part of the 2015
revision of the EBA guidelines, a more precise and universal
view of all European member countries is sought. Guidelines
based on the best available evidence, which are applicable to
all European countries, are required.
Conclusion
The DGV, EBA and ABA guidelines provide standardized
treatment recommendations for burn patients. In comparison
to the ABA guidelines, which primarily focus on criteria for
patient transfer to Burn Centers and qualification of medical
staff, the DGV and EBA guidelines have a greater focus on the
infrastructure and equipment needed for a Burn Center. The
several individual documents that make up the DGV guidelines
should be revised with regard to redundant and partly contra-
dictory treatment recommendations. Also, an English version
of the DGV guidelines would be desirable. The very detailed
EBA guidelines need further improvement in terms of a sim-
plified, more clearly defined content. The ABA guidelines
would benefit from more detailed infrastructural and specific
treatment requirements for Burn Centers. Also, a new revision
of the ABA guidelines is overdue, in order to implement the
latest scientific developments in the field of burn care. Stan-

35
Annals of Burns and Fire Disasters - vol. XXIX - n. 1 - March 2016
dardized treatment recommendations concerning the use of
dermal substitutes are lacking. The gathered information
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Funding: None
Conflicts of interest: None
Ethical approval: Not required