Classification of Burns and Management of a 30-Year-Old Male with Burns on the Anterior Neck and Chest

PART 1: CLASSIFICATION OF BURNS

A. Classification by Depth

B. Classification by Extent - Rule of Nines

C. Classification by Aetiology

• Thermal - flame, scald (most common), contact
• Electrical - low-voltage (<1000V) vs high-voltage (>1000V); may cause deep tissue destruction hidden beneath superficial skin
• Chemical - acids (coagulative necrosis), alkalis (liquefactive necrosis - deeper penetration)
• Radiation - solar, nuclear, radiotherapy
• Inhalational - carbon monoxide poisoning, direct thermal injury to airway, chemical irritant injury; major independent predictor of mortality

D. Classification by Severity (ABA Criteria)

PART 2: PATIENT MANAGEMENT - 30-YEAR-OLD MALE, ANTERIOR NECK AND CHEST BURNS

PHASE 1 - IMMEDIATE (First 24-72 Hours): Emergency Management

Step 1: Primary Survey (ABCDE)

• Neck burns place the airway at immediate risk. Signs of inhalational injury include singed nasal hairs, hoarseness, stridor, carbonaceous sputum, facial burns, and enclosed-space history.
• Early intubation is mandatory if any airway compromise is suspected - delay is dangerous because progressive edema can make later intubation impossible. Fibreoptic bronchoscopy is the gold standard to assess the airway.
• Administer 100% oxygen empirically while checking arterial blood gas and carboxyhemoglobin levels (note: pulse oximetry falsely reads normal in CO poisoning).

• Chest burns may cause restricted excursion. Monitor respiratory rate, oxygen saturation, and peak airway pressures if ventilated.
• Escharotomy of the chest: If a full-thickness circumferential or near-circumferential chest burn causes rising peak airway pressures and reduced chest excursion, bilateral longitudinal escharotomy incisions along the anterior axillary lines, joined by a transverse incision across the subcostal margin (creating an "H" or "ladder" pattern), relieve the constrictive eschar.

• Two large-bore IV lines (ideally through unburned skin).
• Foley catheter to monitor urine output (target: 0.5 mL/kg/h in adults).
• Blood tests: FBC, U&E, LFTs, coagulation, blood group, cross-match, ABG, carboxyhemoglobin.

Step 2: Fluid Resuscitation

Total fluid in first 24 hours = 4 mL × body weight (kg) × % TBSA burned

• Fluid used: Lactated Ringer's (Hartmann's) solution - crystalloid only in first 24 hours; colloid is withheld until capillary permeability normalises.
• Timing: Half given in first 8 hours (from time of injury, not from time of arrival), remaining half over next 16 hours.
• Example: For a 70 kg man with 13% TBSA burns: 4 × 70 × 13 = 3,640 mL total; ~1,820 mL in first 8 hours.
• After 24 hours, albumin/colloid can be added to restore plasma oncotic pressure.
• Titrate all fluids to urine output as the primary endpoint. If UO falls below 0.5 mL/kg/h, increase rate; if persistently above 1 mL/kg/h, reduce rate (avoid "fluid creep").

Step 3: Wound Care (Acute Phase)

• Do NOT debride in the initial emergency assessment; cover with a dry sterile sheet.
• Once stabilised, wound cleaning with antiseptic soap or chlorhexidine.
• Application of topical antimicrobials - the gold standard is 1% silver sulfadiazine cream (SSD) or mafenide acetate (superior eschar penetration); silver-containing dressings (e.g., Mepilex Ag, Aquacel Ag) can be left for 3-7 days reducing painful dressing changes.
• Biological/synthetic dressings (allograft cadaver skin, xenograft pig skin, Biobrane) applied within 72 hours for second-degree wounds provide barrier protection while epithelium heals underneath.
• Tetanus prophylaxis must be ensured.
• Systemic antibiotics are NOT given prophylactically; they are reserved for clinical infection. Perioperative cover targets Staphylococcus aureus, Pseudomonas, and Klebsiella.

Step 4: Burn Centre Transfer Criteria

• Burns involve the face/neck (criterion 2 of ABA)
• Partial-thickness burns >10% TBSA (criterion 1)
• Risk of inhalational injury (criterion 6)

PHASE 2 - ACUTE SURGICAL MANAGEMENT (Days 1-7)

Early Excision and Grafting (EEG)

• Tangential excision: Sequential shaving of burn eschar with a Watson or Humby knife until viable bleeding tissue is reached. Used for partial-thickness burns.
• Fascial excision: Full excision to fascia for extensive full-thickness burns; causes significant contour deformity but minimises blood loss.

• Split-thickness skin graft (STSG): Harvested with a dermatome from donor sites (thighs, back). Can be meshed (1:1.5 to 1:6 ratio) to cover larger areas. The gold standard for most burn wounds.
• Full-thickness skin graft (FTSG): Better cosmesis and less contracture; preferred for face and neck reconstruction when possible as it gives superior aesthetic and functional outcomes.
• Biological/dermal substitutes: Integra (dermal regeneration template) provides a dermal scaffold; a thin STSG is applied 2-3 weeks later. Particularly useful for neck burns where contracture prevention is paramount.

PHASE 3 - SUBACUTE MANAGEMENT (Days 3-21)

Wound Monitoring

• First dressing change of grafted site at day 3-5; under anaesthesia for extensive burns.
• Graft checks for hematoma or seroma which can prevent take.
• Daily dressing changes for non-excised areas.
• Donor site heals spontaneously in 15-21 days with non-adherent dressings left in place.

Nutritional Support

Infection Control

• Daily wound assessment for signs of infection: increased erythema, purulence, odour, pyrexia >38.5°C.
• Regular wound swabs + blood cultures if systemic sepsis suspected.
• Topical antimicrobials continued until wound closure.

Pain Management

• Multimodal analgesia: opioids (morphine/oxycodone) for procedural and background pain, paracetamol, NSAIDs (with caution), ketamine (useful as procedural agent with amnestic properties), pregabalin/gabapentin for neuropathic/itch symptoms.
• Itch (pruritus) is common during the proliferative phase - treat with antihistamines (cetirizine, hydroxyzine), gabapentin, and moisturisers.

Psychological Support

• Early psychological assessment; burns to the face and neck cause significant body image disruption and depression.
• CBT-based psychological therapy, peer support programmes.

PART 3: REHABILITATION OF ANTERIOR NECK AND CHEST BURNS

A. Acute Phase Rehabilitation (Days 1-14)

• Avoid neck flexion at ALL times - even during sleep.
• The patient should be nursed without a pillow initially; instead, a cervical extension roll or specialised burn neck orthosis maintains neck extension.

• Deep breathing exercises (diaphragmatic + lateral costal expansion) from day 1.
• Incentive spirometry - hourly when awake.
• Humidified oxygen if airway involved.
• Positioning: upright (30-45°) to optimise lung compliance.
• Early mobilisation and ambulation.
• If escharotomy was performed, chest physiotherapy is even more critical as compliance should now be restored.

• Elevation of upper extremities (if also involved).
• Gentle manual lymphatic drainage once wound is stable.

B. Intermediate Phase Rehabilitation (Weeks 2-12)

• Active ROM exercises of the neck (flexion, extension, rotation, lateral flexion) begin as soon as the graft adheres (around day 5-7 post-grafting).
• Start gently and progressively increase intensity.
• Passive ROM and manual stretching by a physiotherapist for tight/stiff areas.
• Exercises should be performed 3-4 times daily.
• For the chest: thoracic extension exercises, shoulder girdle exercises (shoulder flexion, abduction, external rotation) to prevent pectoral tightening.
• Active scar stretching - patient instructed to actively push into the direction of tightness (cervical extension, rotation) several times a day.
• Strengthening exercises for neck and upper limb girdle muscles to counteract deconditioning.

• Cervical extension orthosis (neck conformer/splint): Custom-made thermoplastic collar that maintains the neck in neutral to slight extension with the chin elevated. Essential for anterior neck burns - worn continuously except during exercises and hygiene.
• Serial static splinting: Worn at night; progressively adjusted as ROM improves.
• Dynamic splinting: Provides controlled tension to stretch contractures while allowing movement.
• Chest/thoracic splint or garment: If chest involvement is significant.

• Reducing blood flow to the scar
• Increasing collagen breakdown (collagenase activity)
• Aligning collagen fibres
• Reducing fibroblast proliferation
• Custom-made pressure garments (e.g., Jobst, Barton Carey) are measured and fitted once wounds have healed (epithelialised) - typically 3-6 weeks post-injury or post-grafting.
• Pressure must be >25 mmHg to be effective.
• Worn 23 hours/day (removed only for hygiene and physiotherapy).
• Continued for 12-24 months until scar maturation (scar is considered mature when it is pale, soft, and flat).
• For the neck, a custom neck conformer combined with a pressure garment insert maintains contact and pressure over the contoured neck area.

• Silicone gel sheets or silicone gel (Dermatix, Kelo-cote) applied to healed wounds under the pressure garment.
• Mechanism: hydration of the stratum corneum, local pressure, reduced cytokine activity.
• Worn 12-24 hours/day for 6-12 months.
• Evidence supports combined silicone + pressure > either alone.

• Begin once the wound is fully epithelialised and there are no open areas.
• Deep transverse friction massage, circular massage with a moisturising cream (aqueous cream, Vaseline) for 10-15 minutes, 3-4× daily.
• Reduces scar thickness, improves pliability, desensitises hypersensitive nerve endings.

C. Long-Term Rehabilitation (Months 3-24)

• Warm hydrotherapy facilitates ROM exercises with reduced gravity and pain.
• Suitable once all wounds are closed.

• Fractional CO2 or Erbium laser (ablative fractionated photothermolysis): The laser vaporises micro-columns of scar tissue; surrounding zones of coagulated collagen then undergo remodelling. Results in improved scar thickness, pliability, and tightness, and reduces neuropathic pain and pruritus.
• Treatments typically 3-6 sessions at 2-3 month intervals.

• Scar release + FTSG or local flap reconstruction (Z-plasty, W-plasty, local transposition flaps).
• Z-plasty: Lengthens scar along the axis of contracture by transposing triangular flaps; ideal for linear neck contractures.
• Tissue expansion: Serial expansion of adjacent normal skin to provide donor tissue for larger reconstructions.
• Reconstruction is generally deferred until the scar is mature (no longer inflammatory/active) - usually 12-18 months post-injury, unless functional deficit is severe.

• Neck burn patients may have difficulty with tasks requiring neck mobility: driving, working at a desk, overhead activities.
• OT for adaptive equipment and strategies, vocational rehabilitation.

• Burns to the visible face/neck region cause profound psychosocial impact: depression, PTSD, body dysmorphia, social isolation.
• Regular psychological assessment throughout recovery.
• CBT, burn survivor support groups, reconstructive surgery referral for severe cosmetic deformity.
• Burn-specific QoL tools (BSHS-B, SF-36) are used to track outcomes.

• Early liaison with employer if possible.
• Graded return to work starting at 3-6 months.
• Driving restrictions if neck ROM is limited.

Summary Table: Rehabilitation Milestones

Key Special Considerations for Anterior Neck Burns

1. The neck is the highest-risk site for contracture of any burn location. Even partial-thickness burns can produce chin-chest band deformity if rehabilitation is suboptimal.
2. Neck extension splinting and positioning must begin on day one and continue for the entire rehabilitation period.
3. Pressure garments over the neck must be custom-contoured as the neck anatomy does not conform to flat garment surfaces - insert pads or a neck conformer are needed to maintain adequate >25 mmHg contact pressure.
4. Anterior chest burns additionally risk restricted ventilatory function - respiratory physiotherapy is mandatory.
5. Grafted neck skin tends to contract more than other sites; FTSG or dermal substitutes (Integra) are preferred over STSG for functional zones.
6. All decisions require a multidisciplinary burn team: burn surgeon, physiotherapist, occupational therapist, clinical psychologist, dietitian, nursing team, and social worker.

• ROSEN's Emergency Medicine, block 9 (Classification and Diagnosis of Burns)
• Fischer's Mastery of Surgery 8e, block 28 (Burn Wound Evaluation, Postoperative Care)
• Sabiston Textbook of Surgery, block 10 (Resuscitation, Wound Care)
• Current Surgical Therapy 14e, block 15 (Reconstruction Philosophy, Laser Therapy)
• Bailey and Love's Short Practice of Surgery 28e, block 6 (Assessment of Burn Wound)
• NSW ACI Burn Physiotherapy and OT Clinical Practice Guide, January 2025