PRINCIPLES OF MANAGEMENT

OF THERMAL, CHEMICAL AND

ELECTRICAL BURNS

Christian Dumontier, MD, PhD

Guadeloupe-FWI
With the help of Francesco Brunelli &
Marseille Burn Center
I have nothing to disclose
Presentations can be dowloaded on www.diuchirurgiemain.org
 TWO ISSUES
• Management of « large
burns » ➠ basic knowledge of
a highly specialised care

• Management of hand burns

• Common features and small

differences with larger burns

• Differences between
thermal, electrical and
chemical burns
Flame Liquid Contact
electrical Chemical

4 %
4 %
8 % 32 %

12 %
52 % 2 %
6 %

24 % 57 %
Outpatients

Hospitalised
Liu M et al. Epidemiology and Outcome Analysis of 470 Patients with Hand Burns: A Five-Year
Retrospective Study in a Major Burn Center in Southwest China. Med Sci Monit 2020;26:e918881
 GRAVITY OF BURNS (1)
Causative agent Thermal Electrical Chemical Radiation

44< T < 51°c, T> 60°c,

Time of < 44°c , no cellular lesions T > 51°c early immediate
exposure lesion double for destruction destruction of
every degree proteins

Age < 5 years > 65 years

Associated
Polytraumatism Inhalation Blast Syndrom …
injuries
 GRAVITY OF BURNS (2)
Ori ce
Functional
Localisation (mouth,
area
Hands Thorax Limbs,…
perineal,…)

Surface Rule of 9’s Lund and Browder

2nd degree 2nd degree

Deepness 1st degree
(super cial) (deep)
3rd degree Carbonisation

Rapidity and
ef cacy of Cooling and lavage Burn center availability
immediate care
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 LOCALISATION
• Mouth (beware of
inhalation) ☞ respiratory
distress

• Perineal (may require

colostomy) ☞ infection

• Functional sequelae ☞
axilla, hands, feet,…
 SURFACE
• Rule of 9’s (Wallace)

• Tables of Lund and Browder

• Unit Burn standard = % burned

surface + 3 * (Third degree burn
surface).

• Severe if over 100

• Deadly if > 150

• Baux’s Index: age + TSA (< 10%

survival if over 100, now 130)
 DEEPNESS: SKIN ANATOMY

• Epidermis (0,05-1,5 mm)

• Dermis (0.3-3,0 mm)

• Hair follicles, sebaceous and

sweat glands have their
base in the deep dermis
and have an epithelial lining
 DEEPNESS
• Clear-cut demarcation between
1st and 2nd super cial degree
(complete healing without
sequelae) and 2nd deep, 3rd
and 4th degree burns (require
surgery most often)

• Burn is an evolutive lesion

• Burn is a mosaic

• Very dif cult to assess (70%

accuracy)
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 EASY TO DIAGNOSE
• 4th degree

JOURNAL OF BURNS AND WOUNDS

• Carbonisation
VOLUME 6

• 1st degree

• Painful erythema

• Complete healing
without sequelae
within 4-5 days after
desquamation
Figure 2. Clinical case 1. (a) Burn to dorsal face of
 3RD DEGREE BURN
• Quite easy to diagnose

• Destroys the dermal appendages

• Leaves no nests of epidermal cells

• Dermal vessels and super cial

veins may be thrombosed and
visible,

• The skin is leathery, dry,

desiccated, or carbonized.

• The wounds insensate

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2ND DEGREE IS DIFFICULT TO ASSESS
• Super cial 2nd Degree: • Deep 2nd Degree:

• Blistered and moist. • Nerve endings are destroyed (insensate

to light touch)
• Nerve endings are intact (painful to light
touch) • Dermal capillary beds are absent, white,
brown or dark coloration
• Dermal capillary beds are present,
blanching on palpation.
• Firm texture or induration

• Hair are non-adherent

• Normal or Firm « texture » on palpation
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 NOT SO EASY
Super cial Deep
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TREATMENT OF (HAND) BURNS
• Immediate (pre-admission)

• In the ER: Triage (outpatient

vs hospitalisation)

• Early treatment (splint,

rehabilitation, coverage)

• Reconstructive Surgery

Kamolz LP et al. The treatment of hand burns. Burns 2009;35:327-337.

Sheridan RL, et al. The acutely burned hand: management and outcome based on a ten-year experience
with 1047 acute hand burns. J Trauma 1995;38(3):406–411.
Soni A et al. Acute management of hand burns. Hand Clin 2017; 33:229-236
 IMMEDIATE TREATMENT
• Remove from injury source

• AcBC (airway, Breathing,

Circulation) assessment

• Refresh under water (15 mn under

water at 15°C)

• Remove clothes (if not adherent)

• Remove jewels, rings,…

• Cover burned area (“Cool the burn

wound but warm the patient”)

Singer AJ. What is the safety, ef cacy, and feasibility of cooling in the rst aid management of a thermal cutaneous burn? 2005 International
Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science with Treatment Recommendations:
Section 2: Stroke and First Aid Circulation, 2005:
Allison K et al. Consensus On The Pre-hospital Approach To Burns Patient Management. J R Army Med Corps 2004; 150: 10-13
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 TRIAGE

• Criteria for hospitalisation

• Age

• Localisation

• TSA

• mechanism, associated
injuries
 KEY AIMS FOR HAND BURNS

After admission, the burn wounds should be cleaned and debrided

(remove foreign bodies; unroof large blisters, evaluation of lesion…)
Swain AH, Azadian BS, Wakeley CJ, Shakespeare PG. Management of blisters in minor burns. British Medical Journal 1987;295(6591):181.
 •
•
•
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( 7,1 vs 20,8%)
Deep dermal AND
ACUTE SURGICAL MANAGEMENT OF HAND BURNS 2077
circumferential burns

21/02/09 23:33
Decrease by 4 nger necrosis
Maintenance of perfusion +++

eep second-degree burns. A A step-off is present between the wound bed and the unburned skin. B, C A thick
cover a pale wound bed with hemorrhage in the dermis.
ESCHAROTOMY
Surgical Technique
 DRESSING AND SPLINTINGFigure 61-7 Ideal splinting position for the hand. 21/02/09 23:36

• Do not wait

• Early splinting in good position

(open 1st web, …)
Figure 61-7 Ideal splinting position for the hand.

• Dressings changed at least daily

before nal decision for coverage

• Immediate rehabilitation
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SUPERFICIAL LOCALIZED BURNS

• Lipid regulating ointments

(Bepanthen®) or Dressings

• Early motion

• Splinting at night if needed

 Dressings

A number of dressings are available for the treatment of clean partial-thickness burns. Porcine heterograft (pigskin)
is inexpensive, but becomes inelastic once applied, hindering hand and finger motion. Allograft (human cadaver
skin) provides an excellent temporary dressing but is too expensive for routine use. Biobrane® biosynthetic wound
dressing (Bertek Pharmaceuticals, Morgantown, West Virginia) is a bilayer semisynthetic dressing consisting of an
elastic nylon fabric bonded to a semi-permeable silastic membrane and coated with collagen polypeptides. Gloves

SUPERFICIAL LARGE BURNS

manufactured from this material are available in a variety of sizes and are ideal dressings for clean partial-
thickness burns of the hands (Figure 1). The gloves can be applied in the emergency department and then
monitored daily on an outpatient basis. Nonadherence of the dressing indicates the possibility of infection or that
the burn is full thickness. In the case of infection, the dressing should be removed, and topical antimicrobials
placed. The gloves are flexible, facilitating hand therapy, and are less painful than daily washing and application of
topical creams. The dressing material lifts off the burn wound, as epithelialization proceeds, and is trimmed with
scissors.

• Large dressing are

cumbersome and will
prevent early motion
Figure 1. Pictured here are biosynthetic wound dressing gloves.

• Use gloves to cover the hand Positioning

A burned hand that is not properly positioned, splinted, or ranged will develop contractures. These represent major
disabilities that are not easily corrected by later reconstructive surgery (Figures 2A and B). The typical contracture

Healing time < 4 weeks

http://www.medscape.com/viewarticle/448393_print Page 2 sur 8

• 96% regain full range of

motion, 99% returned to
work
Alexander MJ. Surgical glove treatment for hand burns. JACEP. 1977, 6: 69.
Vyrva O et al. Outcomes of the glove-gauze regimen for managing burn injuries of the hand. JHSE 2020;45(7):737-741.
 LOCALISED DEEP BURN
• Excision under a tourniquet
• (K-wiring if needed)
JBUR-2897; No of Pages 11
• Coverage (skin graft or ap) burns xxx (2008) xxx–xxx
Splinting
•
• Early rehabilitation
Fig. 2 – Custom made compression glove with an additional
compression topcoat for the web spaces (by courtesy of
ThuasneW).
the donor site. A newer technique is described by Donelan and
Garcia [80].
15. Rehabilitation
The best treatment of burn scars is their prevention, an
appropriate timing and burn depth specific surgery, and well-
fitting pressure garments worn as soon as the skin grafts are
stable. Silicone sheets [81,82] have been useful on the dorsum of
fingers and web spaces, placed under the pressure garment
glove. Pressure garments [83] (Fig. 2) are worn 24 h a day at least
for an initial period of approximately 6 months in burns with
prolonged healing time or burns that have required skin
grafting. Subsequent pressure garment use is individualized
depending on scar quality and response. The exact mechanism
by which pressure garments alter scar formation is not clear
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tion of the active and passive motion of the hand as well as on
9
an early splinting and functional rehabilitation. The inter-
disciplinary teamwork of surgeons, physio- and occupational
therapists, psychologists, motivated health care personnel
and consequent treatment strategies can contribute to regai-
ning normal hand function.
Conflict of interest
There is no conflict of interest.
references
[1] Luce EA. The acute and subacute management of the
burned hand. Clin Plast Surg 2000;27:49–63.
[2] Harvey KD, Barillo DJ, Hobbs CL, Mozingo DW, Fitzpatrick
JC, Cioffi WG, et al. Computer-assisted evaluation of hand
and arm function after thermal injury. J Burn Care Rehabil
1996;17(2):176–80.
[3] Braithwaite F, Watson J. Some observations on the
treatment of the dorsal burn of the hand. Br J Plast Surg
1949;2:21–31.
[4] Peacock EE. Management of conditions of the hand
requiring immobilization. Surg Clin North Am 1953;1297–
309.
[5] Sheridan RL, Hurley J, Smith MA, Ryan CM, Bondoc CC,
Quinby Jr WC, et al. The acutely burned hand: management
and outcome based on a ten-year experience with 1047
acute hand burns. J Trauma 1995;38(3):406–11.
[6] Morel Fatio D. Surgery of the skin. In: Tubiana R, editor.
The hand. Philadelphia: WB Saunders; 1961. p. 224–5.
[7] Schmidt H-M, Lanz U. Chirurgische Anatomie der Hand. 2.,
überarb. und aktualisierte Aufl. ed. Stuttgart: G. Thieme;
2003.
[8] Deb R, Giessler GA, Przybilski M, Erdmann D, Germann G.
Die plastisch-chirurgische Sekundärrekonstruktion von
Schwerstbrandverletzten. Chirurg 2004;75:588–98.
[9] Hentz VR. Burns of the hand. Thermal, chemical, and
electrical. Emerg Med Clin North Am 1985;3:391–403.
 LARGE DEEP BURN
• Conservative treatment ?

• Early tangential excision ?

• YES: 3rd-4th degree

• NO: 2nd super cial

• YES: 2nd deep - Early is within 2-3

weeks
Hundeshagen G et al. Concepts in Early Reconstruction of the Burned Hand. Ann Plast Surg 2020 Mar;84(3):276-282.
Goodwin CW, Maguire MS, McManus WF, Pruitt Jr BA. Prospective study of burn wound excision of the hands. J Trauma 1983;23:510–7.
Richards WT et al. Acute Surgical Management of Hand Burns. J Hand Surg Am. 2014;39(10):2075-2085.
Van der Vlies CH et al. Indications and Predictors for Reconstructive Surgery After Hand Burns. J Hand Surg Am. 2017;42(5):351-358.
Omar MT, Hassan AA. Evaluation of hand function after early excision and skin grafting of burns versus delayed skin grafting: a randomized
clinical trial. Burns. 2011;37(4):707e713.
Mohammadi AA, Bakhshaeekia AR, Marzban S, et al. Early excision and skin grafting versus delayed skin grafting in deep hand burns (a
randomized clinical controlled trial). Burns. 2011;37(1):36e41.
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 CONSERVATIVE TREATMENT
burns 35 (2009) 70–74 71

of the evident lack of controlled studies of silicone gel

efficiency and the high incidence of symptomatic hyper-
trophic scars in our practice, we conducted a randomised,
double-blind, placebo-controlled trial to evaluate silicone gel
treatment of burn-induced hypertrophic scarring.

2. Materials and methods

• Hand therapy
From November 2005 to November 2006, 38 people with no
history of keloid formation and with a healed, fully epithe-
lialised, hypertrophic, homogenous burn scar of at least
5 cm ! 5 cm in area, were selected. The exclusion criteria
were wound infection, open wound or sensitivity to silicone
gel. The study was approved by our university’s ethics council,
all participants having filled out informed consent forms.

• Splinting The silicone gel (Cica-Care, Smith and Nephew, Hull, UK)
comprised semi-occlusive self-adhesive sheeting made from
medical-grade silicone reinforced with silicone membrane
backing. The placebo comprised self-adhesive propylene
Fig. 2 – Application of silicone sheet and placebo.

glycol and hydroxyethyl cellulose sheeting. Both silicone

and placebo sheets were applied for 4 h/day with a 4-h daily

Daily dressings (twice a day)

increment to 24 h/day. Overlay taping was used when needed. Previous reports recommended using the silicone sheet for

• A random number table was used for the coding and

randomisation of the gel and placebo samples. Silicone gels
were applied to one segment of a single burn scar, such as the
12–24 h daily, which requires washing the scar and reapplying
the silicone sheet. Side effects include pruritis, rash, macera-
tion and foul smells; if side effects develop, therapy is

( ammazin®)
upper or lower part of the left forearm, and the other segment
was covered with placebo (Figs. 1 and 2). Treatment was
started 2–4 months after injury. Participants were followed up
at 1 and 4 months after starting treatment. The gel and placebo
sheets were removed for each examination, and each
participant was sent to another plastic surgeon for the wound
to be evaluated blindly. A digital camera recorded the serial
changes in the wounds, taking front and profile views during
each follow-up visit. An information protocol form was used to
collect the participant’s data and wound characteristics
(pigmentation, vascularity, pliability, pain and itchiness)
according to a modified version of the Vancouver scar scale,
excluding height [5].
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immediately discontinued [6,7].
SPSS software version 14 was used for analysis of the
results. Significant differences in various scar parameters
between the two groups were detected by the Wilcoxon
signed ranks test. A p-value <0.05 was considered signifi-
cant.
3. Results
Four participants were lost to follow-up (two because of
distance and two because of failure respond). The median age
of the remaining 34 participants was 22 years (1.5–60 years); 16
were male and 18 were female. The burns were distributed as
follows: 4 on the hand, 8 on the upper arm, 2 on the forearm, 7
on the thigh, 1 on the lower leg, 9 on the face and 3 on the
trunk.
The results of treatment are shown in Table 1, scored
 TANGENTIAL EXCISION

• Tourniquet ?

• Multiples passes of the

knife to reach healthy
tissues
 FIGURE 11: Example of the use of a dermal substitute. A At this stage, the Integra (Integra
on the wound bed as evidenced by the red color of the material. B After removing the silicon
we applied an STSG.

WOUND COVERAGE
TABLE 1. Dermal Substitutes and Burn-Specific Wound Dressings With a
Primary Uses, and Company Information
Skin
Substitute Components Primary Use

Xenograft Porcine Skin Superficial second-degree burns Bre

temporary covering R
Biobrane Nylon mesh, silicone, and Superficial second-degree burns Smi
type 1 porcine collagen temporary covering P
• Skin grafting (autograft) Allograft Full-thickness Deep second- and third-degree burns
H
Allo
cadaver skin temporary covering C
AlloDerm Cadaver dermis Third-degree burns combined with Life

• Prefer STSG to FTSG if Integra Silicone, collagen,

thin STSG. Wound closure
Third-degree burns combined with
B
Inte

possible (but
chondroitin-6-sulfate thin STSG. Wound closure. P
Two-stage procedure
Matriderm Collagen, elastin Third-degree burns combined with Dr.
contractures) thin STSG. Wound closure C
B
Oasis Porcine small intestinal Second degree burns as a dressing. Smi
submucosa Wound closure 3

• Avoid meshed graft Primatrix Fetal bovine dermis Second- and third-degree burns,
may be combined
with STSG. Wound closure
TEI
M

• Allograft or xenograft, skin Xenograft (pigskin) (Brennen Medical, LLC, St.

Paul, MN) covers superficial second-degree burns. It
burn injuries. W
possible and use
substitutes may also be seals the wound from the environment, allowing it to
epithelialize. Allograft, cadaver skin (AlloSource,
dressing. Allogra
fashion similar to

used Centennial, CO), is useful in the management of large the cadaver skin

J Hand Surg Am. r Vol. 39, October 2014

Chandrasegaram MD, Harvey J. Full-thickness vs split-skin grafting in pediatric hand burns – a 10- year review of 174 cases. J Burn Care Res
2009; 30(5):867–71.
 DRESSING
• Very important

• Secure the graft and protect it

• Fibrin glue

• Speci c tapes

• VAC

• Allows for early therapy

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 OUTCOMES

• Normal hand function in

97% of super cial burns and
81% for deeper burns.
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 ELECTRICAL BURNS
• More subdermal damages,
highest rate of amputation for
burn.

• 4th cause of WRI deaths (1st

reported death was in 1879)

• 99% resistance to current ow is

at the epidermis

• 3 types

• Thermal contact burns.

Lee DH, Desai, MJ, Gauger EM. Electrical Injuries of the Hand and Upper Extremity. J Am Acad Orthop Surg 2019;27: e1-e8
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 ELECTRICAL BURNS
• Ohm’s law: I = V / R

• Joule’s Law: Power (heat) = I2 * R

• Low voltage (< 500 V)

• High Voltage

• An entry and an exit point

• Current goes through least

7200 V
resistant tissues: Blood vessels,
nerves, muscles…
 ELECTRICAL BURNS
• Arc burns [High-amperage
currents arc through the air]

• Thermal radiation and

intense light (up to 4000°C)

• Pressure wave blast [throw

away the victim, concussion,
ear loss,…]

• Projection of copper and

aluminum droplets
 IMMEDIATE TREATMENT
• Power shut off ! (no-let-go
phenomenon)

• ACL Support

• Beware associated injuries

(15%)

• Particularities in resuscitation
protocoles (increase volume
of uids, myoglobinuria,
cardiac enzymes,…)
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IMMEDIATE TREATMENT (HAND)

• Fasciotomies may be necessary

• 4 compartments at the forearm

(2 incisions)

• 10 compartments at the hand (4

incisions)

• Control and serial debridement

every 48 hours

Sassoon A, Riehl J, Rich A, et al: Muscle viability revisited: Are we removing normal muscle? A critical
evaluation of dogmatic debridement. J Orthop Trauma 2016;30: 17-21
 SURGICAL TREATMENT

• Localised injuries are

treated with excision and
coverage ( aps)

• Beware of progressive
necrosis (VAC useful)
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 CHEMICAL BURNS
Xylene-containing paint remover

• Rare (3 % of burn centers

admissions) up to 30% of burn-
related deaths

• Heal more slowly and require more

surgery

• 0,6% of industrial injuries

• Mostly hands

• Damage continues until

complete removal of the
chemical ++
 DO
• Get information on the product
(acid, base,…) and ask advice
from the toxicological center

• Remove clothes, jewels,

watches and any left product
(use gloves, glasses,…)

• Wash with water (rules of 15)

do not forget to wash face and
eyes)

• Unroof blisters

Robinson EP, Chhabra AB. Hand chemical burns. J Hand Surg Am. 2015;40(3):605-612.
 GRAVITY DEPENDS
OF
• Responsible substance;

• Burn percentage: The risk of systemic toxicity

increases with total body surface area (TBSA)
affected

• Chemical concentration: Higher concentration

leads to more rapid and extensive damage.

• Time of exposure: The extent of damage is

correlated with time of exposure. Early lavage is
the most important means of limiting damage.

• Skin properties: The palmar skin has thick

stratum corneum, which is more impermeable
and therefore resistant to chemical insult than
the dorsum.
 DON’T
• Immerse the limb (not so ef cient for dilution and may
diffuse the chemical)

• Use high-pressure lavage

• Use of neutralizing compounds (concentration unknown,

are mostly detrimental)

• Forget the rules of resuscitation and survey of electrolytes

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 HOWEVER
• Some chemicals are insoluble in water (Phenol,…)

• Elemental metals (sodium, potassium, and lithium)

combust when exposed to water; Burns from these
metals should be immersed in mineral oil, Sulfuric acid
• Dry lime becomes caustic only when dissolved, so it
should be thoroughly dusted off.

• Hydro uoric acid may need topical or injectable

calcium gluconate

• Impermeable nail plate may prevent decontamination

efforts. Removal of the nail should be considered in
situations like HF exposure,

• Compartment swelling may occur after chemical

injury, and the need for fasciotomy should always be
considered.
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 CONCLUSIONS
Beware