Total Burn Care

Total Burn Care
Copyright Page
Preface
In Memorium of Ted Huang, MD
List of Contributors
Video Table of Contents
List of Video Contributors
1 A Brief History of Acute Burn Care Management
	Early Excision
	Skin Grafting
	Topical Control of Infection
	Nutritional Support
	Fluid Resuscitation
	Inhalation Injury
	Hypermetabolic Response to Trauma
	Conclusion
	Further Reading
	References
2 Teamwork for Total Burn Care
	Introduction
	Members of a Burn Team
		Burn Surgeons
		Plastic Surgeons
		Anesthesiologists
		Nurses
		Physical and Occupational Therapists
		Respiratory Therapists
		Exercise Physiologist
		Nutritionists
		Psychosocial Experts
		Spiritual Therapists
		Music Therapists
		Students, Residents, and Fellows
	Dynamics and Functioning of the Burn Team
	Summary
	References
3 Epidemiological, Demographic and Outcome Characteristics of Burns
	Introduction
	Demography
	High-Risk Populations
		Children
		Elderly
		Disabled
		Military Personnel
	Burn Etiologies
		Fire/Flame
		Scald
		Contact
		Work-Related Burns
		Chemical Burns
		Electrical Current Injury
		Lightning Burns
		Fireworks
		Intentional Burns
		Hospital Burns
	Burn Patient Transport and Transfer
	Mass Casualties
	Outcome Analysis in Burns
	Conclusion
	References
4 Prevention of Burn Injuries
	Introduction
	Injury Prevention Models
	Burn Intervention Strategy
	Epidemiology
		Overview of Burn Injuries in the United States
		Common Mechanisms of Injury
		High-Risk Populations
	Engineering and Enforcement
		Smoke Alarms
		Fire Sprinklers
		Fabric Flammability
		Fire-Safe Cigarettes
		Water Temperature Regulations
		Fireworks Regulation
	Education
	Evaluation
	Global Burn Prevention
	Future
	References
5 Burn Management in Disasters and Humanitarian Crises
	Introduction
	Definitions
	The Historical Record
		Terrorist Attacks
			New York City—September 11, 2001
			Kuta, Bali, Indonesia—October 12, 2002
			Madrid, Spain—March 11, 2004
			London, England—July 7, 2005
		Indoor Fires
			Gothenburg, Sweden—October 30, 1998
			Volendam, the Netherlands—January 1, 2001
			Warwick, Rhode Island—February 20, 2003
			Buenos Aires, Argentina—December 30, 2004
			Kiss Nightclub Fire, Santa Maria, Rio Grande do Sul, Brazil—January 27, 2013
			Colectiv Nightclub Fire, Bucharest, Romania— October 30, 2015
		Transportation Crashes
			Alcanar, Spain—July 11, 1978
			Lyce Diyarbakir, Turkey—July 21, 2014
			Ramstein, West Germany—August 28, 1988
			Pope Air Force Base, North Carolina—March 23, 1994
		Explosions
			San Juanico, Mexico—November 19, 1984
			Piper Alpha, North Sea—July 6, 1988
			Bashkir Autonomous Soviet Socialist Republic— June 4, 1989
	Phases of Mass Casualty Events
		Chaos and Alarm
		Organization
		Search and Rescue
		Triage and First Aid
		Initial Transport
		Burn Center Referral
		Evacuation to Other Burn Centers
		Secondary Transport
		Transport Home
		Long-Term Follow-Up and Rehabilitation
		Debriefing
	Emergency Care: Special Considerations in Disasters
		First Aid
		Fluid Resuscitation
		Oral Resuscitation
		Airway Management
		Oxygen
		Anesthesia
		Blood
		Wound Care and Escharotomies
	Communication
		Means of Communication
			Cellular Telephone
			Conventional Telephone
			Voice over Internet Protocol
			Two-Way Radio
			Trunked Radio System
			Satellite Telephone
			Internet
			Electronic News Media
		Communication With News Media
		Communication With Relatives and Friends
	Strategies for Distribution of Patients and Resources
		The Role of Burn Centers
		The Role of Trauma Centers
		The Role of Burn-Bed Databases
		The Role of International Cooperation
	Humanitarian Crises
	Conclusions
	References
6 Care of Outpatient Burns
	Introduction
	Who Can Be Managed as an Outpatient?
		Percent of the Burn
		Depth of the Burn
		Distribution of the Burn
		Injuring Agent
			Electricity
			Chemicals
		Respiratory Complications
		Associated Trauma
		Comorbid Disorders
		Social Circumstances
		Hospital Resources
	Management of Minor Burns
		Cooling the Burn
		Pain Control
		Blisters
		Cleansing the Wound
		Topical Agents
		Dressing the Wound
		Synthetic Wound Dressings
			Mepitel
			Mepilex AG
			Acticoat
			TheraBond 3D
			Silverlon
			Suprathel
			Hydrocolloid Dressings
		Synthetic Tissue-Engineered Wound Dressings
			Biobrane
		Biologic Wound Dressings
			Allogenic Amnion
			Xenograft
			Allograft
		Elevation of the Burned Part
		Infection and Use of Systemic Antibiotics
		Vaccinations
		Instructions and Follow-Up Care
		Definitive Wound Closure
		Pruritus
		Traumatic Blisters in Reepithelialized Wounds
		Rehabilitative Physical Care
	Outpatient Treatment of Moderate and Major Burns
	Conclusion
	References
7 Prehospital Management, Transportation, and Emergency Care
	Introduction
	Prehospital Care
	Onsite Assessment of a Burned Patient
		Primary Assessment
		Secondary Assessment
	Transport to Hospital Emergency Department
		Keeping the Patient Warm and Dry
		Pain Control
	Transferring a Burn Patient
	Privacy and Security Issues
	Transportation Guidelines
		Transport Team Composition
		Training and Selection
		Modes of Transportation
			Ground Transport
			Air Transport
				Helicopters and Fixed-Wing Aircraft.
		Equipment
			Portable Monitor
			Infusion Pump
			Ventilator
	Stabilization
	Patient Assessment Prior to Transport to a Specialized Burn Care Unit From a Referring Hospital
	Summary
	Further Reading
	References
8 Pathophysiology of Burn Shock and Burn Edema
	Introduction and Historical Notes
	Hypovolemia and Rapid Edema Formation
	Normal Microcirculatory Fluid Exchange
	Mechanisms of Burn Edema
		Capillary Filtration Coefficient (Kf)
		Capillary Pressure (Pc)
		Interstitial Hydrostatic Pressure (Pif)
		Osmotic Reflection Coefficient (σ)
		Plasma Colloid Osmotic Pressure (πp)
		Interstitial Colloid Osmotic Pressure (πif)
		Endothelial Dysfunction and the Glycocalyx
	Unburned Tissue
	Altered Cellular Membranes and Cellular Edema
	Inflammatory Mediators of Burn Injury
		Histamine
		Prostaglandins
		Thromboxane
		Kinins
		Serotonin
		Catecholamines
		Reactive Oxygen Species
		Nitric Oxide
		Platelet Aggregation Factor
		Angiotensin II and Vasopressin
		Other Mediators
	Hemodynamic Consequences
		Myocardial Dysfunction
			Increased Systemic Vascular Resistance and Organ Ischemia
		Pulmonary Circulation and Lung Edema
		Fluid Overload and Abdominal Compartment Syndrome
	Conclusion
	Further Reading
	References
9 Burn Resuscitation
	Introduction
	Early Approaches to Fluid Resuscitation
		Brooke and Parkland Formulas
	Children
	Choice of Fluid
	Route of Administration
	Patients at Increased Risk During Resuscitation
	Monitoring Resuscitation
	Fluid Creep and Edema Management
	Pharmacologic and Extracorporeal Adjuncts
	Protocol-Driven and Computerized Resuscitation
	Conclusion
	References
10 Evaluation of the Burn Wound
	Introduction
	Pathophysiology of the Burn Wound
		Skin Biology
	Pathophysiological Changes of Thermal Injury
	Assessment of Burn Depth
		Clinical Observation
		Adjuncts to Clinical Evaluation
	Mechanisms of Thermal Injury
		Flash and Flame Burns
		Scalds
		Contact Burns
		Chemical Burns
		Electrical Burns
	Further Reading
	References
11 Treatment of Infection in Burn Patients
	Introduction
	Prevention of Infection
	Diagnosis of Burn Wound Infection
	Treatment of Burn Wound Infections
		Topical Antimicrobial Compounds
		Systemic Antimicrobials in Burn Patients
	Specific Pathogens in Burn Wounds
	Infections From Sources Other Than Wounds in the Burn Patient
	Conclusion
	References
12 Operative Wound Management
	Introduction
	Advantages of Operative Wound Management
	Techniques of Burn Wound Excision
		Excision of a Small Burn
		Tangential Excision
		Fascial Excision
		Controlling Blood Loss During Burn Excision
		Techniques of Wound Closure
	Advances in Wound Closure
		Dermal Replacement
		Cultured Epidermal Autografts
		Skin Procurement
		Management of Donor Site
		Dressings
		Temporary Skin Substitutes
	Management of Specific Types of Burns
		Scald Burns
		Extensive Burns
			The Operating Room
			The Operation
	Operative Management of Burns Involving Special Areas
		The Hand
			Escharotomy and Fasciotomy
			Techniques of Excision and Grafting
			Techniques to Salvage Length in Fourth-Degree Hand Burns
		The Scalp
		The Face
		Eyelids
		Genital Burns
		The Breast
	Conclusion
	Further Reading
	References
13 Anesthesia for Burned Patients
	Introduction
	Preoperative Evaluation
		Initial Evaluation of Burn Injury
		Airway and Pulmonary Function
		Effect of Burn Injury on Circulation
		Effect of Burn Injury on Renal Function
		Metabolic Changes Associated With Burn Injury
		Thermoregulation in Burn Patients
	Pharmacological Considerations
	Airway Management
	Monitors
	Vascular Access
	Patient Transport
	Selection of Anesthetic Agents
	Fluid Management
		Blood Transfusion
		Blood Components
			Whole Blood
			Packed Red Blood Cells
			Fresh Frozen Plasma
			Platelets
			Cryoprecipitate
		Complications of Massive Blood Transfusion
			Coagulopathy
			Citrate Toxicity
			Potassium Abnormalities
			Acid–Base Abnormalities
			Altered Oxygen Transport
			Hypothermia
			Pulmonary Complications
			Transfusion Reactions
			Infection
	Postoperative Care
	Conclusion
	References
14 The Skin Bank
	History
	The Growth of Skin Banking
	Role of the American Association of Tissue Banks
	Clinical Uses of Allograft Skin
		Coverage of Extensive Full-Thickness Wounds
		Coverage of Widely Meshed zSkin Autografts and Partial- Thickness Wounds
		Template for Delayed Application of Keratinocytes
		Acellular Dermal Matrix
	Potential Disadvantages of Allograft Use
		Infection
		Rejection
	Technical Aspects of Skin Banking
		Donor Screening
		Skin Recovery
		Skin Processing
			Processing Environment
			Microbiologic Testing
			Maintenance of Viability
		Refrigeration
		Cryopreservation
		Lyophilization
		Irradiation
	Transport
	Rewarming
	FDA Regulation of Human Skin Banking
		Amnion Processing
	The Future of Skin Banking
	References
15 Skin Substitutes and ‘the next level’
	Introduction
		Structure and Function of the Skin
		Consequences of Loss of Barrier Function
	Temporary Skin Substitutes and Dressings
		Biological Tissues
			Allograft
			Human Amnion
			Xenograft
		Synthetic Materials
	Permanent Skin Substitutes
		Epidermal Cells and Constructs
		Dermal Constructs
			Tissues
			Dermal Scaffolds
		Cellular Dermal Substitutes
		Subcutaneous Fat
	Full Skin Substitutes
	Regulatory Issues
	Conclusion
	References
16 The Pathophysiology of Inhalation Injury
	Introduction and Epidemiology
	Pathophysiology
		Injury to the Oropharynx
		Injury to the Tracheobronchial Area
		Injury to the Lung Parenchyma
		Long-Term Effects of Inhalation Injury
	The Fire Environment and Toxic Smoke Compounds
		Carbon Monoxide
			Symptoms and Diagnosis of Carbon Monoxide Poisoning
		Hydrogen Cyanide
			Symptoms and Diagnosis of Cyanide Poisoning
		Other Toxic Chemicals
	References
17 Diagnosis and Treatment of Inhalation Injury
	Introduction
	Diagnosis
	Pathophysiology of Pulmonary Insufficiency with Inhalation Injury
	Treatment
	Potential Future Therapeutic Strategies
	Long-Term Changes in Pulmonary Function
	References
18 Respiratory Care
	Introduction
	Bronchial Hygiene Therapy
		Therapeutic Coughing
			Series of Three Coughs
			Tracheal Tickle
			Cough Stimulation
		Chest Physiotherapy
			Bronchial Drainage/Positioning
			Percussion
			Vibration/Shaking
		Early Ambulation
		Airway Suctioning
		Therapeutic Bronchoscopy
		Pharmacologic Adjuncts
	Mechanical Ventilation
		Modes of Ventilation
			Control Mode
			Assist-Control Mode
			Synchronized Intermittent Mandatory Ventilation
			Pressure Control Mode
			Pressure Support Ventilation
		Alternate Modes of Ventilation
			High-Frequency Ventilation
			Airway Pressure Release Ventilation
		Volumetric Diffusive Ventilation
		Ventilator Settings
			Tidal Volumes
			Respiratory Rate
			Flow Rates
			Inspiratory/Expiratory (I:E) Ratio
			Inspired Oxygen Concentration
			Positive End-Expiratory Pressure
		Extubation Criteria
	Infection Control of Respiratory Equipment
		Handwashing
		Chemical Agents for Sterilization/Disinfection
			Aldehydes
			Alcohols
	Late Complications of Inhalation Injury
		Tracheal Stenosis
		Obstructive/Restrictive Disease
	Summary
	Further Reading
	References
19 The Systemic Inflammatory Response Syndrome
	Introduction
	Definition of SIRS
	The Initiating Event
	SIRS and Immunological Perturbations
	The Two-Hit Hypothesis
	Cytokine and Noncytokine Mediators of SIRS
	Circulating Cytokines as Markers of SIRS and Predictors of Outcome
	Anti-Inflammatory Therapy for SIRS
		Activation of the Coagulation Cascade During Inflammation
		The Hemodynamic Response
	Changes in Endothelial Permeability
		Increased Epithelial Permeability
	The Hyperdynamic State
	Conclusion
	Further Reading
	References
20 Host Defense Antibacterial Effector Cells Influenced by Massive Burns
	Introduction
	Neutrophils
		Impaired Neutrophil Recruitment
		Impaired Neutrophil Killing
		Pro- and Antiinflammatory Neutrophils
		Role of Damage-Associated Molecular Patterns in Inducing Antiinflammatory Neutrophils Postburn Injury
		Suppressing Adaptive Immunity
	Macrophages
		Tissue Macrophages and Infiltrating Monocyte-Derived Macrophages
		M1 Macrophages as an Antibacterial Effector Cell
		M2 Macrophages as Inhibitors for Macrophage Polarization From Quiescence to the M1 Phenotype
		Plasticity of Various Phenotypes of Macrophages
	Innate Lymphoid Cells
		Impaired ILC1 Generation Due to Impaired IL-12 Production After Burn Injury
		Type 2 Immune Responses Induced by Activated ILC2s
		Intestinal ILC3s
	Dendritic Cells
	Summary
	References
21 Biomarkers in Burn Patient Care
	Introduction
	Prediction of Sepsis and Infection
		TNF-α
		IL-8
		IL-6
		C-Reactive Protein
		Procalcitonin
		Leptin
		Combined Panels
	Prediction of Patient Survival with Clinical Characteristics
	Inhalation Injury and Mechanical Ventilation
	Resuscitation and Kidney Function
	Wound Healing
	Conclusion
	Further Reading
	References
22 Hematology, Hemostasis, Thromboprophylaxis, and Transfusion Medicine in Burn Patients
	Introduction
	Etiology of Anemia in Burn Patients
	Hemostasis in Burn Patients
	Coagulopathy in Burn Patients
	Transfusion of Blood Cells
	Venothromboembolic Prophylaxis
	Hematopoiesis
		Myeloid Growth Factors
			Granulocyte Colony-Stimulating Factor
			CSF-1
			GM-CSF
		Lymphoid Growth Factors
		Megakaryocyte Growth Factors
		Transcription Factors
	Conclusion
	References
23 Significance of the Hormonal, Adrenal, and Sympathetic Responses to Burn Injury
	Introduction
	Normal Hypothalamic- Pituitary-Adrenal Axis
	Strong Sympathetic Activation Following Burn Trauma
		Cardiovascular Response
		Catecholamine Resistance
		Catecholamines and Hypermetabolism
		β-Blockade
		Sympathetic Influences on Immune Function
		Sympathetic Response to Sepsis
	Role of Thyroid Function
		Sex Steroids Following Burn Trauma
			Androgens
				Release of C19 Steroids.
			Estrogens
		Adrenal Cortical Steroids Following Burn Trauma
			Free versus Total Cortisol
		Substrate Cycling
			Influence on Metabolic Pathways
			Hormonal Determinants of Glucose Utilization
		Glucocorticoids Following Burn Injury
			Glucocorticoids and Carbohydrate Metabolism
			Glucocorticoids and Protein Metabolism
			Glucocorticoids on Bone Metabolism
			Glucocorticoids on Immune Suppression
	Further Reading
	References
24 The Hepatic Response to Thermal Injury
	Introduction
	Anatomy and Physiology of the Liver
		Anatomy
		Physiology
	The Hepatic Response to a Severe Thermal Injury
		Liver Damage and Morphological Changes
			Underlying Molecular Mechanisms
		Effects on the Biliary System
		Mononuclear Phagocyte System (MPS)
			Glucose, Protein, and Lipid Metabolism
			Acute-Phase Response
			Vitamin Metabolism
			Coagulation and Clotting Factors
			Hormones
	Importance of the Liver for Postburn Outcomes
	Conclusion
	Acknowledgments
	Further Reading
	References
25 Importance of Mineral and Bone Metabolism after Burn
	Metabolic Actions of Calcium, Phosphate, and Magnesium
		Calcium
		Phosphate
		Magnesium
	Homeostasis of Calcium, Phosphate, and Magnesium
		Calcium
		Phosphate
		Magnesium
	Effect of Burn Injury on Calcium, Phosphate, and Magnesium Homeostasis
	Rationale for Therapy
	Treatments for Maintaining Mineral Homeostasis
	Hypercalcemia and Impaired Renal Function After Burns
	Bone
	Treatment of Bone Catabolism After Severe Burn
	Heterotopic Ossification After Burn Injury
	Acknowledgement
	Further Reading
	References
26 Micronutrient Homeostasis
	Importance of Vitamins and Trace Elements
	Vitamins
		Vitamin C
		Vitamin D
		Vitamin E
		Vitamin K
	Trace Elements
		Blood Concentrations
		Exudative and Urinary Losses
		Role of Trace Elements in Inflammation and Antioxidant Defenses
		Trace Element Therapy
	Conclusion
	Further Reading
	References
27 Hypophosphatemia
	Etiology of Postburn Hypophosphatemia
		Stress Response
		Resuscitation and Topical Therapy
		Ulcer Prophylaxis
		Hyperventilation
		Metabolic Support
		Burn Wound Physiology
		Acute-Phase Response and Sepsis
		Other Electrolytes
		Summary
	Consequences of Hypophosphatemia
		Cardiac Dysfunction
		Neuromuscular Dysfunction
		Hematologic Dysfunction
		Summary
	Prevention and Treatment of Hypophosphatemia
		Summary
	Further Reading
	References
28 Nutritional Needs and Support for the Burned Patient
	Introduction
	Metabolic Pathology Associated With Burn Injury
	Nutritional Demand and Substrate Metabolism in Burn Patients
		Increased Total Caloric Demand
		Substrate-Specific Requirements
			Carbohydrates
			Fats
			Protein
	Nutritional Support
		Enteral Nutrition
			Benefits of Enteral Nutrition
			Initiation of Feeds
				Early Initiation.
		Delivering Enteral Feeds
			PO Feeding
			Enteral Access for Feeding
		Diet Composition and Enteral Feed Formulas
			Immunonutrition
		Parenteral Nutrition
		Meeting Prescribed Feeding Goals
		Complications of Nutritional Support
	Nutritional Assessment and Monitoring
		Total Caloric Requirements
		Body Composition
			Total Body Weight
			Muscle and Lean Body Mass
			Obesity
			Ideal Body Weight
			Clinical Imaging
				Dual-Energy X-Ray Absorptiometry.
				Computed Tomography and Ultrasound.
			Albumin and Serum Markers for Nutrition
	Conclusion
	Further Reading
	References
29 Modulation of the Hypermetabolic Response after Burn Injury
	Introduction
	Cardiovascular Dysfunction
	Skeletal Muscle Catabolism and Regeneration
	Insulin Resistance and Hyperglycemia
	Alterations in Lipid Metabolism and Fat Composition
	Nonpharmacological Modulation of the Hypermetabolic Response
		Environmental Support
		Early Wound Excision and Closure
		Nutritional Support
		Exercise
	Pharmacological Modulation of the Hypermetabolic Response
		Recombinant Human Growth Hormone (rhGH)
		Insulin-Like Growth Factor-1
		Oxandrolone
		Propranolol
		Insulin
		Metformin
	Alternative Therapeutic Options
	Conclusion
	References
30 Etiology and Prevention of Multisystem Organ Failure
	Introduction
	Etiology and Cellular Response
		Common Ground: Humoral Mediators
	Organ-Specific Failure and Prevention
		Hypermetabolism
		Cardiovascular
		Lungs
		Gastrointestinal Dysfunction
		Renal
	Prevention of Sepsis
	Ensuring Adequate Oxygen Delivery
	The Potential Role of Nutritional and Specific Immunomodulators
		Nutritional Immunomodulation
		Nonspecific and Specific Immunomodulation
	References
31 Acute Renal Failure in Association with Thermal Injury
	Introduction
	Definition
	Etiology
		Early
			Hypovolemia
			Overresuscitation and Abdominal Compartment Syndrome
			Rhabdomyolysis
			Cardiac Dysfunction
		Late
			Sepsis
		Toxins
			Antibiotics
	Diagnosis
		Urine Volume
		Urinalysis
			Creatinine Clearance
			FeNa
			Microscopy
		Serum Biomarkers
			Creatinine
			NGAL
			Others
	Treatment
		Renal Protection in the Early Phase of Acute Burn Care
			Resuscitation
			Other Acute Issues
				Heart.
				Remove Nephrotoxins.
			Late
				Workup.
				Sepsis Treatment.
				Medical Therapy: Fenoldopam.
			Renal Replacement Therapy
				Modalities.
	Conclusion
	References
32 Critical Care in the Severely Burned
	Introduction
	Burn Intensive Care Unit Organization
		Physical Plant
		Personnel
		Equipment
	Hemodynamic Monitoring in the Burn Intensive Care Unit
		Cardiovascular Monitoring
			Arterial Lines
			Cardiac Output Measurement
			Arterial Waveform Analysis
			Echocardiography
			Laboratory Estimates of Perfusion
	Multisystem Organ Failure
		Humoral Mediators
		Course of Organ Failure
	Critical Care Interventions
		Toxicological Burn Critical Care
		Neurological Burn Critical Care
		Cardiovascular Burn Critical Care
			Preload
			Cardiac Contractility
			Afterload
			Heart Rate and Rhythm
			Effects of Burn on Cardiac Performance
				Hemodynamic Therapy: Preload Augmentation.
				Hemodynamic Therapy: Inotropes and Vasopressors.
			Effects of β-Blockade on Cardiac Performance After Severe Burn
		Pulmonary Burn Critical Care
			Indications for Intubation
			Pulmonary Physiology
				Ventilation.
				Oxygenation.
				Expectoration.
			Mechanical Ventilation
				Ventilator Modes.
				Weaning From Mechanical Ventilation.
				Monitoring of Mechanical Ventilation.
					limiting ventilator-induced lung injury.
				Epidemiology, Pathophysiology, and Treatment of ARDS.
				Treatment of ARDS.
		Gastrointestinal System Burn Critical Care
			Pathophysiologic Changes in the Gut After Burn
			Clinical Changes in the Gut After Burn
		Renal Burn Critical Care
			Pathophysiology
		Hematologic Burn Critical Care
		Endocrine Burn Critical Care
		Infectious Disease Burn Critical Care
	Prevention of Organ Failure
	Conclusion
	Further Reading
	References
33 Burn Nursing
	Introduction
	Emergency Needs: Resuscitation and Pulmonary Priorities
	Acute Care of the Burn Wound
	Surgical Care
	Nutrition and Metabolic Changes
	Pain and Anxiety Assessment and Management
	Patient and Family Education
	Rehabilitation of the Burn Patient
		Work-Hardening Programs for Adults
			Assessment
			Planning
			Implementation
			Evaluation
		Extensive Exercise in Children
			Assessment
			Planning
			Implementation
			Evaluation
	Reconstructive Care
		Assessment
		Planning
		Implementation
		Evaluation
	Recovery and Social Reintegration
	Conclusion
	Further Reading
	References
34 Care of the Burned Pregnant Patient
	Introduction
	Mortality Factors
	Fetal Viability
		Practical Management Algorithm
	Treatment
	Additional Considerations
		Hematology and Coagulopathy
		Psychological Issues
		Nonsevere Burns
	Conclusion
	Further Readings
	References
35 Special Considerations of Age
	Introduction
	Initial Evaluation
	Resuscitation
	Assessment of Resuscitation
	Evaluation and Management of Airways
	Inhalation Injury
	Hypermetabolism
		Thermoregulation
		Nutritional Support
	Growth Delay
	Management of Burn Wound
	Pain Management
	Rehabilitation
	Prevention
	Further Reading
	References
36 Care of Geriatric Patients
	Introduction
	Epidemiology
	Outcome
	Risk Factors
		Decreased Cardiopulmonary Reserve
		Infections
		Malnutrition and Decreased Lean Body Mass
		Aging Skin and Wound Healing
		Immune Response
	Treatment
		Initial Resuscitation
		Wound Management
		Metabolic and Nutritional Support
	Pain, Sedation, and Comfort Care
	Perioperative Optimization
	Rehabilitation
	Intentional Burns in Older Adults
	Conclusion
	Further Reading
	References
37 Surgical Management of Complications of Burn Injury
	Introduction
	Burns and Trauma
		Primary Assessment
		Associated Injuries
	Gastrointestinal Tract Complications
		Paralytic Ileus
		Ogilvie’s Syndrome
		Abdominal Compartment Syndrome
			Complications Associated With Feeding Tubes
		Stress Gastritis
		Acalculous Cholecystitis
		Pancreatitis
		Superior Mesenteric Artery Syndrome
		Necrotizing Enterocolitis
		Clostridium difficile Infection
	Vascular Complications
		Suppurative Thrombophlebitis
		Complications Related to Central Venous Access
		Distal Limb Ischemia
	Thoracic Complications
		Pneumothorax
		Empyema
	Urologic Complications
	Conclusion
	Further Reading
	References
38 Electrical Injuries
	Introduction
	Pathophysiology
	Acute Care
	Electrocardiographic Monitoring
	Myoglobinuria
	Compartment Syndrome and Initial Operative Intervention
	Further Surgical and Wound Considerations
	Problem Areas
	Lightning Injury
	Low-Voltage Injuries
	Complications
	References
39 Cold-Induced Injury
	History of Frostbite
	Pathophysiology and Classification of Frostbite
	Clinical Findings and Classification of Frostbite Injury
	Initial Management of Freezing Cold Injury
	Post-Thaw Evaluation and Management
		Nonsurgical Therapies
		Imaging and Surgical Management
	Conclusion
	Further Reading
	References
40 Chemical Burns
	Introduction
	Pathophysiology
	General Principles of Management
	Specific Agents
		Acids
			Acetic Acid
			Carbolic Acid (Phenol)
			Chromic Acid
			Epichlorohydrin Acid
			Formic Acid
			Hydrochloric Acid, Muriatic Acid, and Sulfuric Acid
			Hydrofluoric Acid
			Nitric Acid
			Oxalic Acid
			Phosphoric Acid
		Alkalis
		Cement
		Metals
		Hydrocarbons
		Hypochlorite Solutions
		Alkyl Mercuric Compounds
		Tar
		Vesicant Chemical Warfare Agents (Mustard, Lewisite, Nitrogen)
	Conclusion
	Further Reading
	References
41 Radiation Injuries and Vesicant Burns
	Radiation Injury: Introduction
	Terminology
	Incidence
	Pathophysiology
		Thermal Effects
		Radiation Effect
		Localized Injury
		The Acute Radiation Syndrome
			Hematopoietic Syndrome
			Gastrointestinal Syndrome
			Neurovascular Syndrome
		Triage
	Treatment
		First Aid
		Assessment
		General Care of Irradiated Patients
			Oral Resuscitation
		Care of Burn Wounds
		Treatment of Complications
			Hematologic
			Infection
		Summary
	Vesicant Burns
		Introduction
		Mechanisms of Action
		Clinical Features
		Acute Treatment for Exposure to a Vesicant Agent
		Long-Term Effects of Acute Exposure
		Summary
	Further Reading
	References
42 Exfoliative Diseases of the Integument and Soft Tissue Necrotizing Infections
	Introduction
	Severe Exfoliative Disorders
	Toxic Epidermal Necrolysis
		Epidemiology
			Prognosis, Morbidity, Mortality
		Etiology
			Triggers and Risk Factors
			Genetics
			Immunopathology
		Clinical Presentation
		Diagnosis and Prognostic Evaluation
			Histopathology
		Complications
			Systemic and Other Nonmucocutaneous Complications
		Management
			General Management and Resuscitation
			Immunomodulation Therapy
				Corticosteroid Therapy.
				Cyclosporine A.
				Intravenous Immunoglobulin.
				TNF-α Inhibitors, Thalidomide.
				Surgical Approach.
				Topical Therapy.
			Nutritional Support
	Soft-Tissue Infections and Other Acute Skin Disorders
		Staphylococcal Scalded Skin Syndrome
			Pathology
			Presentation
			Diagnosis
			Management
		Necrotizing Fasciitis and Bacterial Myonecrosis
			Diagnosis
			Management
		Purpura Fulminans
		Calciphylaxis
	Conclusion
	Further Reading
	References
43 Burn Injuries of the Eye
	Introduction
	Selected Anatomy
	Examination
	Applied Pathology
		Electrical Injury
		Exposure Keratitis and Eyelid Burns
		Epithelial Defects
		Corneal Ulcer
		Bacterial Keratitis
		Fungal Keratitis
		Viral (Herpetic) Keratitis
		Orbital Compartment Syndrome
		Amblyopia
		Descemetocele, Corneal Perforation, and Open Globe
	Interventions
		Bandage Contact Lens
		Lateral Canthotomy
		Eyelid Closure and Reconstruction
		Conjunctival (Gundersen) Flaps
		Reconstruction of the Lacrimal Apparatus
		Corneal Transplantation
	References
44 The Burn Problem
	Introduction
	Systemic Reactions to Burns
		Hypoxia and Ischemia
		Infection
		Coagulopathy
	Review of Organ Systems Affected by Burns
		Integumentary System
		Respiratory System
		Cardiovascular System
		Urinary System
		Digestive System and Hepatobiliary Tract
		Lymphoid System
		Endocrine System
		Musculoskeletal System
		Central Nervous System
	The Burn Autopsy
	Further Reading
	References
45 Molecular and Cellular Basis of Hypertrophic Scarring
	Introduction
	Extracellular Matrix
		Collagen
		Proteoglycans and Glycoproteins
	Cellular Contributions to Hypertrophic Scar
		Hypertrophic Scar Fibroblasts
		Role of Myofibroblasts in Normal and Pathological Situations
		Role of Mechanical Stress and Myofibroblasts
		Pathological Repair (Hypertrophic Scars and Keloids)
		Origin of (Myo)Fibroblasts
		The Role of Fibrocytes in Hypertrophic Scar
		Hypertrophic Scar Keratinocytes
	The Role of Cytokines in Hypertrophic Scar
		TGF-β
		CTGF/CCN2
		Platelet-Derived Growth Factor
		Insulin-Like Growth Factor 1
		Interferons
	The Immune System Regulates Wound Healing
	Conclusion
	Further Reading
	References
46 Pathophysiology of the Burn Scar
	Introduction
		Prehistoric and Historic Perspectives
		Incisional Wounds With Primary Closure
		Delayed Wound Closure “by Second Intention” and Wound Contraction
		First-Degree or Superficial Injury of Skin
		Second-Degree or Partial- Thickness Injury
		Third-Degree or Full-Thickness Injury
	Biology of Wound Healing
		Changes in Vascular Permeability
		Granulation Tissue and the Proliferative Phase of Wound Healing
		Influx of Circulating Cells
		Migration of Keratinocytes to Cover the Wound (Epiboly)
		Collagen Matrix Formation and Maturation
		Cytokines and Growth Factors
		Biophysics of Thermal Injury
	Factors That Alter Wound Healing
		Changes in Blood Supply and Perfusion
		Compromised Wound Healing: Requirements for Optimal Wound Healing
		Biologic Responses to Wound Excision and Grafting
		Wound Infection
	Hypertrophic Wound Healing
		Histologic Features of Hypertrophic Scars
		Experimental Models of Hypertrophic Healing
		Phenotypic Abnormalities of Hypertrophic Scar Fibroblasts
		Gene Expression in Hypertrophic Scars
		Interplay of Systemic and Local Inflammatory Responses
		Pathogenic Concepts
	Conclusion
	Further Reading
	References
47 Burn Rehabilitation Along the Continuum of Care
	Introduction
	Evaluation of the Burn Patient
	Positioning and Splinting of the Burn Patient
		Head
		Neck
		Spine
		Shoulder Girdle/Axilla
		Elbow/Forearm
		Wrist/Hand
		Hip
		Knee
		Foot/Ankle
			Orthotic Treatment of the Lower Extremity
		Serial Casting
	Prosthetic Interventions
	Burn Scar Management
		Historical Review
		The Scar
		Scar Assessment
		Treatment of Hypertrophic Scars
		Pressure Therapy
		Inserts
		Burn Scar Massage
		Therapeutic Exercise
			Exercise During the Acute Rehabilitation Phase
			Exercise During the Intermediate Rehabilitation Phase
			Long-Term Rehabilitation Phase
	The Role of Exercise Physiology in Burn Rehabilitation
		Exercise for the Outpatient
		Exercise Evaluation
			Subjective Data
			Objective Data
		Exercise Testing
			Three-Repetition Maximum Test (3RM)
			Body Composition Measurement
	When to Implement an Exercise Program
		Components of an Exercise Program
			Warm-Up Stage
			Endurance Stage
			Recreational Activities
			Cool-Down Stage
	Exercise Prescription
		Aerobic Training
			Intensity
			Duration
			Frequency
			Mode
			Progression of Exercise
				Initial Conditioning Stage.
				Improvement Stage.
				Maintenance Stage.
		Resistive Training
			Exercise Type
			Training Frequency
			Type of Contraction
			Amount of Load Lifted
			Number of Repetitions
			Number of Sets
			Exercise Order
			Rest Periods
			Progressive Overload
	Example of an Exercise Program
		Important Considerations
	Patient and Caregiver Education
	Conclusion
	Further Reading
	References
48 Musculoskeletal Changes Secondary to Thermal Burns
	Acknowledgment
	Introduction
	Changes Confined to Bone
		Osteoporosis
		Osteomyelitis
		Fractures
	Changes Involving Pericapsular Structures
		Heterotopic Ossification
		Pathogenesis of Heterotopic Ossification
			Percentage of Burn Effect on Heterotopic Ossification
			Location of Burn Effect on Heterotopic Ossification
			Period of Confinement Effect on Heterotopic Ossification
			Osteoporosis and Heterotopic Ossification
			Superimposed Trauma on Heterotopic Ossification
			Genetic Predisposition to Heterotopic Bone
		Characteristics and Behavior of Heterotopic Bone
		Prevention and Treatment of Heterotopic Bone
	Changes Involving the Joints
		Dislocation
		Septic Arthritis
		Amputations
	Alterations in Growth
	Further Reading
	References
49 Reconstruction of Bodily Deformities in Burn Patients
	Reconstruction of Burn Deformities
		General Principles
		Early Treatment of Deformity and Timing of Surgical Intervention
		The Techniques of Reconstruction
			Primary Wound Closure Technique
			Skin Grafting Technique
				Free Skin Graft Without Incorporating a Dermal Template.
				Free Skin Graft With Prior Incorporation of a Dermal Regenerative Template.
			Skin Flap Technique
				The Axial Skin Flap.
				The Z-Plasty Technique.
				The Modified Z-Plasty Technique; Alias Three-Quarters Z-Plasty Technique.
			Musculocutaneous or Fasciocutaneous Flap Technique
				Musculocutaneous Z-Plasty Technique.
				Fasciocutaneous Z-Plasty Technique.
				Three-Quarter Fasciocutaneous Z-Plasty Technique.
				Paratenon Cutaneous Z-Plasty and Three-Quarter Paratenon Cutaneous Z-Plasty Techniques.
			Tissue Expansion Technique
			Free Composite Tissue Transfer via Microsurgical Technique
			Fat Grafting Technique
	Allotransplantation: Facial Transplantation
	Comments
	Further Reading
	References
50 Reconstruction of the Head and Neck after Burns
	Introduction
	Acute Management
	Pathogenesis
	Evaluation of Facial Burn Deformities
	Fundamental Principles and Techniques
		Contractures
		Aesthetic Units
		Z-plasty
		Laser Therapy
		Grafts
		Flaps
		Tissue Expansion
	Timing of Reconstructive Surgery
		Acute-Phase Reconstruction
			Eyelids
			Perioral Deformities
			Cervical Deformities
		Intermediate-Phase Reconstruction
		Late-Phase Reconstruction
	Reconstruction of Specific Areas of the Head and Neck
		Scalp
		Eyebrows
		Eyelids
		Lower Lip and Chin
		Upper Lip Deformities
		Electrical Burns of the Oral Commissure
		Nasal Deformities
		Ear Deformities
	Burn Neck Contractures
		Prevention
		Release and Grafting
		Local Flap Reconstruction
		Distant Flap Reconstruction
	Further Reading
	References
51 Management of Postburn Alopecia
	Introduction
	Spectrum of Postburn Alopecia
		Classification of Scalp Burns
	Surgical Correction of Alopecia
		Serial Excision
		Bipedicle Flaps
		Local Flaps and the Rotation Flap Template
		Tissue Expansion
		Hair Follicle Grafting
	Conflict of Interest
	References
52 Trunk Deformity Reconstruction
	Introduction
	Reconstruction of the Trunk Soft Tissue Layers
		Acute Reconstructive Management of the Trunk Soft Tissue Layers
		Late Reconstructive Management of the Trunk Soft Tissue Layers
	Reconstruction of the Trunk Boundaries
	Reconstruction of the Breast
		Principles of Breast Reconstruction
		Release and Scar Resurfacing
		Replacement of Missing Parts: Breast Mound Reconstruction
		Nipple-Areola Complex Reconstruction
		Asymmetry
	Conclusion
	References
53 Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients
	Introduction
	Contractural Deformities of the Shoulder (Axilla), Elbow, Hip, and Knee Observed in a Burned Patient
		The Factors Leading to Formation of Contractural Deformities
		Incidence of Burn Contracture Involving the Shoulder (Axilla), Elbow, and Knee Joints
		Efficacy of Splinting in Controlling Burn Contractures of Shoulder (Axilla), Elbow, and Knee Joints
	Management During the Acute Phase of Recovery
		Body Positioning and Joint Splinting
			Body Position
				Shoulder (Axillary) Joint.
				Elbow Joint.
				Wrist Joint.
				Hip Joint.
				Knee Joint.
		Exercise
	Management During the Intermediate Phase of Recovery
		Body Positioning and Joint Splinting
		Pressure Dressing
	Management of Established Contractural Deformities
		Patient Evaluation
		Nonoperative or Minimally Invasive Approach to Correct a Contracted and/or Stiff Joint
			Shoulder (Axillary) Contracture
				Figure-of-Eight Compression Dressing.
				Airplane Splint.
			Elbow and Knee Contracture
				Three-Point Extension Splint.
				Skeletal Traction Technique.
		Surgical Treatment of a Contracted Joint
			Presurgical Evaluation
			Techniques of Joint Contracture Release
				Release of Joint Contracture by Incising the Scarred Tissue.
				Z-Plasty Technique.
			Wound Coverage
				Primary Closure of the Wound.
				Skin Grafting Technique.
					operative technique.
					after-care.
				Interposition Flap Technique.
					operative technique.
					after-care.
				Muscle Flap or Skin-Muscle Flap Technique.
				Use of a Free Flap or Muscle Flap.
	Conclusion
	Further Reading
	References
54 Acute and Reconstructive Care of the Burned Hand
	Introduction
	Initial Assessment and First Aid
	Acute Care of the Burned Hand
	Occupational Therapy of the Burned Hand
	Management of Established Burned Hand Deformities
		Reconstructive Methods
	Reconstruction of Phalangeal Deformities
		Flexion Contracture Deformities
		Extension Contracture Deformities
		Web Space Contracture
			First Web Space Contracture
		Reconstruction of a Deformed Thumb
		Reconstruction of a Claw Hand
	Electrical Injuries Involving the Upper Limb
		Decompressive Escharotomy and Fasciotomy
		Early Débridement
		Wound Management
		Functional Reconstruction of Limb Deformities
	Conclusion
	Further Reading
	References
55 Management of Burn Injuries of the Perineum
	Introduction
	Management During the Acute Phase of Injury
		Burns of the Penis
		Skin Loss Over the Penile Shaft and Scrotum
		Burns of Labia Majora
		Perineal Wound Coverage
		Anal Burns
		Rectal Prolapse
	Reconstruction of Established Deformities of the Perineum and Perineal Structures
		Reconstruction of Penile Deformity
		Reconstruction of Scrotal Deformities
		Reconstruction of Labial Deformity
		Reconstruction of Band Deformity Around the Perineum
			The Technique of Multiple Z-Plasties
		Reconstruction of Anal Strictures
		Reconstruction of Rectal Prolapse
	Conclusion
	Further Reading
	References
56 Reconstruction of Burn Deformities of the Lower Extremity
	Assessment of Salvage Potential
	Amputations
	Early Reconstruction
	Late Reconstruction
	Grafts and Flaps
	Conclusion
	References
57 Electrical Injury
	Introduction
	Physiological Basis of Tissue Destruction
	Diagnosis and Acute Treatment
	Assessment of Tissue Damage
	Rhabdomyolysis and Myoglobinuria
	Renal Failure
	Cardiac Monitoring
	Surgical Debridement
	Compartment Syndrome
	Head: Scalp, Skull, and Mouth
	Thorax and Abdomen
	Extremities
	Amputations
	Peripheral Nerve Injury
	Complications
		Central Nervous System
		Ocular Manifestations of Electrical Injury
	Skeletal Injury
	Conclusion
	Further Reading
	References
58 The Role of Alternative Wound Substitutes in Major Burn Wounds and Burn Scar Resurfacing
	Introduction
	Classification of Alternative Wound Substitutes
	Clinical Applications of Alternative Wound Substitutes in Major Burn Wounds
	Clinical Applications of Alternative Wound Substitutes in Burn Scar Resurfacing
	Future Directions
	References
59 Aesthetic Reconstruction in Burn Patients
	Introduction
	Timing of Reconstruction
	Patient–Surgeon Relationship
	Pre- and Postoperative Care in Burn Reconstruction
	Surgical Approach to the Burn Reconstructive Patient: The Role of the Reconstructive Ladder
	Aesthetic Reconstruction of Burned Patients
		Head and Neck
		Burn Alopecia
		Upper Extremity
		Breasts
		Lower Extremity
	References
60 Laser for Burn Scar Treatment
	History of Laser and Intense Pulse Light
	Physics of Laser
	Overview of Lasers in Hypertrophic Burn Scar
		General Considerations
		Pulsed Dye Laser Therapy
		Ablative/Nonablative Fractional Lasers
		Erbium-YAG Laser
		CO2 Laser
		Lasers to Target Pigment
		Intense Pulsed Light
	Treatment of Specific Post Burn Scar Conditions
		Four-Year Review
		Vascular and Hypertrophic Scars
			Folliculitis
		Scar Contracture
		Hyperpigmentation
	Laser Complications and Laser Safety
		Laser Complications
		Laser Safety
	Logistical and Financial Considerations
	Future Investigations
	Conclusion
	References
61 The Ethical Dimension of Burn Care
	Introduction
	What Is an Ethical Problem?
	How Should Clinical Ethics Problems Be Managed?
		The Role of the Care-Provider in Ethical Dialogue
		The Role of the Patient or Surrogate in Ethical Dialogue
		How Should Persistent Ethical Conflict Be Managed?
	The Patient Without Decision-Making Capacity, Surrogate, or Advance Directive
	How Should Organizational Ethics Problems Be Managed?
	Conclusion
	Further Reading
	References
62 Intentional Burn Injuries
	Introduction
	Prevalence Rates of Intentional Burn Injuries
		Prevalence of Childhood Burns
		Prevalence in Elderly
	Distinctive Characteristics of Perpetrators and Families
	Indicators of Intentional Injuries
	Self-Inflicted Burn Injuries
	Clinical Evaluation of Suspicious Injury With Pediatric Patient and Family
		Physician Assessment
	Types of Burn
		Scald
		Contact
		Chemical Burns
	Psychosocial Assessment
	Reporting Suspected Intentional Burn Injury
	Clinical Interviewing With Other Vulnerable Populations
	Maintaining Professional Relationships With Patient and Family
	Future Burn Prevention and Child Safety
	Further Reading
	References
63 Functional Sequelae and Disability Assessment
	Introduction
	Postburn System-Based Disability Assessment
		Constitutional
		Skin/Integument
		Facial Injuries, Scars, and Ear/Nose/Throat Problems
		Musculoskeletal
		Hand Function
		Neurological
		Cardiovascular/Metabolic
		Respiratory
		Eyes/Vision
		Renal/Genitourinary
		Gastrointestinal
		Endocrine
		Hematological and Lymphatic
		Psychological
		Overall Quality of Life
	References
64 Management of Pain and Other Discomforts in Burned Patients
	Introduction
	Pathology of a Burn Injury Pain and Pain-Generating Mechanisms
	Additional Factors Contributing to Pain Generation
	Pain as a Function of the Healing Process
	Tolerance to Opiates and Opiate-Induced Hyperalgesia
	Measurement of Pain in Burned Patients
		Pain Measurement Techniques for Adult Burned Patients
		Pain Measurement Techniques for Pediatric Burned Patients
	Measurement of Anxiety
	Measurement of Itching
	Treatment Considerations
		Surgical Treatment of Pain
		Topical Agents
		Pharmacological Treatment of Burn Pain
		Opioids
			Morphine
			Fentanyl
			Remifentanil
			Alfentanil
			Methadone
		Benzodiazepines
		Nonopiate Analgesics
		Anticonvulsants
		Ketamine
		α2 Agonists
		Propofol
		Nitrous Oxide
	Initial Injury
	Background and Breakthrough Pain
	Analgesia for Procedures
	Itch Medications
	Development of Protocols for Comfort
		Nonpharmacologic Therapies in Burned Patients
	Classical Conditioning
	Operant Conditioning
	Cognitive Interventions
	Augmented Reality
	Hypnosis
		Virtual Reality Hypnosis
		Other Approaches
		Empirical Support
	Conclusion
	References
65 Psychiatric Disorders Associated With Burn Injury
	Introduction
	Preexisting Factors
	Disorders in Children and Adolescents
	Social Considerations in Pediatric Burns
	Self-Inflicted Burns and Suicide Attempts
	In-Hospital Contributing Factors and Disorders
		In-Hospital Disorders
		Delirium
	Acute Stress Disorder and Posttraumatic Stress Disorder
	Long-Term Postburn Disorders
	General Anxiety Disorder
	Major Depressive Disorder
	Persistent Depressive Disorder
	Substance-Related and Addictive Disorders
	Comorbidity and Problems Beyond Psychiatric Illness
	Adjustment in Children After Burns
	Diagnosis (Screening Instruments, SCID)
	Treatment
		Delirium and Agitation
		ASD and PTSD
		Other Anxiety Disorders
		Major Depression
		Sleep Disturbances
		Special Aspects in Pediatric Treatment
		Nonpharmacological Prevention of PTSD
	Resilience, Posttraumatic Growth
		Interventions to Foster PTG
	Conclusion
	References
66 Psychosocial Recovery and Reintegration of Patients With Burn Injuries
	Introduction
	Integrating Psychological Treatment With Physical Treatment
		Preinjury Adjustment
		Admission Crisis
		Critical Care Phase
		In-Hospital Recuperation Phase
		Reintegration Phase
		Rehabilitation Phase, Postdischarge
	Assisting With Grief Following Trauma
	Cultural Sensitivity
	Postburn Psychological Distress and Long-Term Outcome
		Acute and Posttrauma Distress
	Chronicity of Postburn Psychological Distress: From In-Hospital Through Long-Term Follow-Up
	Theory-Guided Research as the Next Step in Enhancing Psychological and Social Adjustment
	Formulating Psychological Distress Following Burn Injury: Using Posttrauma Distress as an Illustration
		Resilience and Recovery
		Body Image, Stigmatization, and Social Integration
		Social Belongingness as Core Survival Need
		Appearance, Social Stigmatization, and Social Exclusion
		Factors Affecting Body Image Dissatisfaction and Social Discomfort
		Distress of Families of Burn Survivors
		Long-Term Outcome: Quality of Life
		Interventions for Burn Survivors Beyond Acute Care
	Summary
	Acknowldgments
	References