Burn ICU (Burn Intensive Care Unit)

A severe burn is treated in phases over weeks. Early surgery cut deaths by nearly two thirds in trials.

A burn intensive care unit looks after patients whose burns are large or deep enough to threaten the circulation, the lungs and the body's defense against infection. Treatment changed in the 1970s. Surgeons began removing burned skin within days and covering the wound with grafts, and a meta-analysis of six randomized trials later found that this early surgery lowered the risk of death to 0.36 of the risk under older treatment in patients without smoke inhalation (Ong and colleagues, Burns, 2006). This page explains how the Burn ICU at Biruni Hospital in Istanbul works, phase by phase, and when a burn patient can be moved between countries.

How the severity of a burn is judged

Two measurements decide where a burned patient is treated. One is depth. The other is the share of the body surface involved, which doctors write as percent TBSA, for total body surface area, with an adult palm and fingers counting as one percent.

A review in Nature Reviews Disease Primers classes a burn as major above 20 percent TBSA in adults, above 30 percent in children and above 10 percent in elderly patients, and notes that burns beyond 20 percent need fluids by vein (Jeschke and colleagues, 2020). Burns of the face, hands, feet, genitals and major joints, electrical and chemical burns, and any burn with smoke inhalation go to a specialist unit whatever their size.

Size and depth are reassessed on the second day, because burns deepen.

The three numbers behind the outlook

Revised Baux score equals age in years, plus percent of body surface burned, plus 17 if the patient inhaled smoke.

Surgeons in Vermont built that score from the records of 39,888 burn patients in the American national burn repository, and in their analysis age and burn size weighed almost equally, and smoke inhalation added the equivalent of 17 more years of age (Osler and colleagues, Journal of Trauma, 2010). Their paper makes a further point that families should hear. The older version of the score had become too pessimistic, because burn care had improved.

What no burn unit can promise

Survival falls as age, burn size and smoke inhalation add up. No unit changes that arithmetic. Deep burns leave scars for life, and grafted skin looks and feels different, does not sweat and needs sun protection for good. A good team says these things early, and says them again when the family is ready to hear them.

The three phases of burn intensive care

Burn treatment runs on a timetable, and each of its three phases brings its own danger and its own team effort.

Phase one, the first 48 hours

Fluids

Burned skin leaks. Fluid pours out of the circulation into the tissues, blood pressure falls, and kidneys fail unless the loss is replaced hour by hour. American Burn Association guidance quoted in the same review sets the first 24 hours at 2 to 4 milliliters of fluid per kilogram of body weight for each percent of body surface burned, so a 70 kilogram adult with a 40 percent burn receives between 5.6 and 11.2 liters on the first day. Nurses then adjust the rate against the urine output every hour, because too much fluid swells the limbs and the lungs as surely as too little starves the kidneys. Children need more for their weight, and very heavy adults less. Nothing here is left to guesswork at night, because the formula gives the starting rate, the urine bag gives the correction, and a burn unit repeats that loop every hour for two days.

Airway and smoke

Hot gas and soot injure the airway in three ways, according to the same review, namely poisoning by carbon monoxide and cyanide, heat damage to the throat, and chemical damage deep in the lungs from the substances carried in smoke. Swelling peaks over the first day. A breathing tube goes in early, before the throat closes.

Tight, leathery burns that circle a limb or the chest are cut open at the bedside to restore blood flow and breathing.

Phase two, surgery in the first days

Early excision and grafting

Dead skin feeds infection, so modern units remove it in the first days and close the wound with thin sheets of the patient's own skin taken from an unburned area. Six randomized trials pooled in the journal Burns compared this early surgery with the older practice of waiting, and mortality fell to a relative risk of 0.36 in patients without inhalation injury while hospital stay shortened by 8.9 days on average. Blood transfusion needs rose. That was the one drawback the authors recorded (Ong and colleagues, 2006). Surgeons still debate whether the first operation belongs on day one or after the 48 hours of fluid treatment. The reasoning is easy to follow at the bedside. Burned skin left in place leaks fluid, breeds bacteria and keeps the whole body inflamed, while a closed wound does none of those things, and each operation that closes another tenth of the body surface moves the patient closer to leaving intensive care.

When donor skin runs short

Above 30 to 40 percent TBSA the unburned skin cannot cover everything in one operation. Surgeons then stretch the graft through a mesh, cover the rest with donated skin or a manufactured substitute, and return to the same donor sites once they have healed, every one to two weeks, until the whole wound is closed.

Phase three, the long middle

Feeding a body in overdrive

After the first three or four days the metabolism of a severely burned patient accelerates, and the review reports that this hypermetabolic state persists for up to 36 months, so muscle wastes unless calories and protein keep pace. Feeding through a tube into the stomach starts early and runs around the clock, and the room is kept warm so that energy goes to healing.

Infection

Before early surgery, burn patients frequently died of sepsis while their wounds stayed open. It remains the chief threat. Single rooms, gowns and gloves for every entry, cultures of the wound several times a week, and antibiotics aimed at the organism found all belong to the routine.

Visitors are part of that routine too.

Pain and dressing changes

Dressing changes hurt more than the burn itself. Units plan them. Strong pain relief and a sedative come beforehand, and large changes are done under a short anesthetic. Tell the nurses when the plan falls short.

Moving a burn patient between countries

Fresh major burns are resuscitated where they happen. No patient should fly during the first day of fluid treatment unless no local unit can provide it. The International Society for Burn Injuries wrote its practice guidelines for hospitals at every level of resources, so sound first treatment is possible far from a burn center (ISBI Practice Guidelines Committee, Burns, 2016).

Medical transport companies working to and from Turkey describe aircraft fitted as flying intensive care beds, with a doctor and nurse on board and a cabin that can hold sea-level pressure. Two details matter more for burns than for other patients. Anyone with facial burns or smoke inhalation has the breathing tube placed before take-off, since a swollen airway cannot be managed safely in a small cabin, and the cabin is heated well above normal because burned skin loses heat fast.

Many international patients arrive later, with healed wounds, for scar and contracture surgery. That journey is an ordinary scheduled flight.

What relatives can do

Expect strict rules at the door.

• Hand washing, then a gown, gloves and a mask for every visit
• One or two people at a time
• No flowers and no food from outside
• Anyone with a cold or a fever stays away

Biruni Hospital assigns a coordinator from the first message, and that person remains the family's contact until discharge and afterward on the same WhatsApp number. The international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreters for other languages, which families need most when a surgeon explains the next operation and asks for consent. Weeks in hospital are normal after a major burn, so practical support counts. Its office arranges accommodation near the hospital, airport transfers, daily transport and the invitation letter that consulates request with a visa application, and the hospital kitchen provides halal, vegetarian and diabetic meals. A prayer room is on site. A request for a female surgeon or physician goes to the department and is met wherever the rota allows. When the patient moves from intensive care to a ward room, one relative stays overnight on the companion bed in that room for the remainder of the admission.

Your voice helps. So do photographs from home, a familiar blanket once the nurses allow it, and patience with a mood that swings.

Life after a major burn

Closing the wound ends the first half of treatment.

Scars, itch and stiffness

Why scars form

A burn that takes longer than three weeks to heal is likely to form a raised, red, itchy scar, the review notes, which explains the push for early grafting. Scars mature over one to two years. Pressure garments worn day and night, silicone sheets, massage, moisturizer and daily stretching keep them flat and keep joints moving, and a scar that pulls a joint tight can be released by surgery later. Itch responds to antihistamines, cool dressings and, when severe, to drugs that calm the nerves.

Mind and work

Mood after a burn

Nightmares, low mood and fear of being seen are common after burns and treatable, and the same review lists depression and post-traumatic stress among the strongest predictors of a poor quality of life years later.

Two systematic reviews cited in the same paper found that 66 to 74 percent of burn survivors returned to some form of work between 1 and 24 months after the injury.

Flying home and staying in touch

The flight

Most patients fly home on a scheduled flight once the wounds are closed, the pain is controlled with tablets and the surgeon has cleared them in writing. Wear the pressure garments on the plane, walk the aisle and drink water. Once you are back home, send photographs of the scars to your coordinator at the intervals the surgeon sets, and see a local doctor the same day for fever, a wound that opens, spreading redness or a graft that turns dark.

What drives the cost of burn care

Burn size drives everything else, because it sets the days in intensive care, the number of operations, the volume of blood and dressings, and the weeks of rehabilitation. Depth matters next, since deep burns need grafts, smoke inhalation adds ventilator days, and a skin substitute, when donor skin runs short, adds a large item of its own for every operation in which it is used. Age, diabetes and kidney disease lengthen every stage.

Hospitals in this market quote burn care as a daily intensive care rate plus a price per operation, since nobody can fix a package for an injury of unknown course, and dressings, blood products, skin substitutes, dialysis and rehabilitation appear as separate lines in nearly all published terms.

Put three questions in writing. How many operations does the estimate assume. Which dressings and substitutes are inside the daily rate. Who updates the estimate each week, and in which language.

Insurers and assistance companies settle many emergency burn admissions directly against a guarantee of payment, while a figure worth having comes only after the burn team has seen the photographs and the chart, and that review is free.

Burn ICU FAQ