Eur. Burn J., Volume 6, Issue 4 (December 2025) – 6 articles

Background: Enzymatic debridement with Nexobrid (NXB) is established for burn care, but specific outcomes in the elderly remain poorly characterized. This study evaluates the safety, efficacy, and clinical outcomes of NXB in patients aged ≥65 years. Methods: A retrospective case-series of 43 consecutive elderly patients (mean age 74.5 years) with deep partial- to full-thickness burns treated with NXB at a single burn center. Data on demographics, burn characteristics, treatment chronology, and complications were analyzed. Results: The median total burn surface area (TBSA) was 11%. NXB was applied selectively, with a mean debrided area of 7.41% TBSA, primarily on limbs and hands. While 76.7% of patients ultimately required surgical autografting, no patient required an escharotomy in NXB-treated areas. The mortality rate was 25.6%, which was lower than expected for a median revised Baux score of 90, which is expected to be more than 50%. Hypertrophic scarring occurred in 28.1% of survivors, associated with a prolonged median healing time of 63 days. Conclusions: In elderly burn patients, NXB facilitates precise eschar removal and reliably prevents compartment syndrome, demonstrating a strong safety profile even in high-risk individuals. Its primary benefit shifts from reducing surgical incidence to optimizing the wound bed for grafting. These findings support the use of NXB in the elderly, with the understanding that subsequent grafting is often still required due to age-related delayed healing. Full article

Background: Critical care for patients with severe burn injuries is challenging, particularly in the first 24–48 h. Multiple guidelines exist but their recommendations vary in content and in the level of detail. Methods: This narrative review analyzed recent (last 10 years) adult burn guidelines in English, Dutch and German, sourced from PubMed, Medline and official burn society publications. The review focused on airway management, mechanical ventilation, fluid resuscitation, pain management and procedural sedation. Results: All guidelines emphasize early airway assessment and timely intubation in patients at risk for loss of airway patency; however, a strategy for analyzing patients at risk is lacking. Lung-protective ventilation strategy is generally recommended. Fluid resuscitation is the cornerstone during the first phase, though recommendations for thresholds, volume and adjuncts differ. (Chronic) pain management should be multimodal, combining pharmacologic and non-pharmacologic approaches, but specifics on choice of modality are limited, also, there is no uniform strategy for procedural sedation management. Conclusion: Current guidelines offer broadly consistent recommendations for initial burn care but differ in specifics, reflecting evidence gaps. Future guidelines should address advances in airway management, fluid resuscitation endpoints, volume and adjuncts, and give a more detailed (chronic) pain strategy to improve standardization and outcomes. Full article

Introduction: Massive burns, particularly those exceeding 90% total body surface area (TBSA), represent one of the most demanding challenges in critical care and reconstructive surgery. Advances in resuscitation, early excision, and wound coverage techniques have improved survival rates, but despite these advances, mortality remains high, and standardized treatment protocols are lacking. Case Report: We report a case which demonstrates survival and meaningful recovery in an extreme case of massive burns. A 57-year-old woman sustained 92% TBSA burns following a gas explosion at her home. She developed burn shock requiring aggressive fluid resuscitation and vasopressor support. Due to extensive burns and limited donor sites, staged debridement with temporary allograft coverage was performed, followed by Meek micrografting for definitive wound closure. After 197 days in the Burn Unit and an additional three months of rehabilitation, she regained functional independence. Conclusions: While historically considered non-survivable, burns exceeding 90% TBSA are increasingly being successfully treated with multimodal strategies. This case highlights the importance of multidisciplinary care in redefining survival expectations for massive burn patients. As burn care continues to evolve, further research is needed to refine treatment strategies, enhance long-term functional outcomes and standardize protocols for these complex cases. Full article

Background: Routine early surgery for all deep burns in low-resource settings is not currently achievable. We designed and implemented a simple triage strategy that selected patients to be prioritised for early surgery based on a more urgent need and greater potential benefit. The primary outcome was the ability to perform surgery in the priority group within three days of the decision. Methods: This was a prospective, descriptive study undertaken at a tertiary hospital in Pietermaritzburg, South Africa. All patients referred to the Grey’s Hospital Burn Service were triaged into either priority or non-priority groups. Priority designation was based on total burn surface area (TBSA) > 15%, the presence of sepsis, or limb-threatening injury. Data related to demographic information, injury, and outcomes were collected and managed using REDCap electronic data capture tools. Results: There were 191 admissions with 42 (22%) meeting priority criteria. The priority group had larger burns (TBSA 25 [Interquartile range 15–30] vs. 8 [3–15]%) and included all septic injuries. We provided early surgery within a median of 1.4 (interquartile range 0.5–3.3) days of the decision for surgery being made. A total of 75% of patients were operated within 72 h of the decision, and 43% within 10 days of injury. The system identified a sicker cohort, as evidenced by high mortality, ICU admission, and acute kidney injury rates. In the non-priority group, reported outcomes were more positive, but with a high injury-to-discharge days per percentage TBSA. Conclusions: This simple triage strategy represents a novel approach for prioritising access to burn surgery in a setting where global surgery standards are desirable but not always possible. We were able to identify the high-risk groups and provide surgery within acceptable time frames. Future research should be aimed at refining this triage system and improving outcomes in the priority group. Full article

Background: Optical Coherence Tomography (OCT) is a high-resolution imaging technique capable of quantifying Blood Flow at Depth (BD) and the Attenuation Coefficient (AC). However, the clinical relevance of these parameters in burn assessment remains unclear. This study investigated whether OCT-derived metrics can differentiate between superficial and deep pediatric hand burns. Method: This prospective, single-center study analyzed 73 OCT scans from 37 children with thermal hand injuries. A structured algorithm was used to evaluate AC and BD. Results: The mean AC was 1.61 mm⁻¹ (SD ± 0.48), with significantly higher values in deep burns (2.11 mm⁻¹ ± 0.53) compared to superficial burns (1.49 mm⁻¹ ± 0.38; p < 0.001), reflecting increased optical density in more severe burns. BD did not differ significantly between burn depths, although superficial burns more often showed visible capillary networks. Conclusions: This is the first study to assess both AC and BD using OCT in pediatric hand burns. AC demonstrated potential as a diagnostic marker for burn depth, whereas BD had limited utility. Image quality limitations highlight the need for technical improvements to enhance OCT’s clinical application. Full article

Burn injuries are a major cause of morbidity and mortality, largely due to complications such as infection. Impairment of the immune system following burns increases susceptibility to both internal and external infections, underscoring the need for effective infection control strategies in burn care. In addition, burn patients frequently exhibit profound alterations in drug pharmacokinetics and pharmacodynamics (PK/PD), particularly during the resuscitation and hypermetabolic phases. In the resuscitation phase, increased capillary permeability and reduced cardiac output can prolong drug distribution, delay therapeutic response, lower peak plasma concentrations, and slow elimination. In contrast, the hypermetabolic phase is characterized by elevated catecholamine levels and enhanced tissue perfusion, which accelerate drug distribution and clearance. These physiological changes often necessitate antimicrobial dose adjustments to maintain therapeutic efficacy. This review emphasizes the critical importance of infection prevention and management in burn patients, with a focus on optimizing antimicrobial dosing and therapeutic monitoring in the context of PK/PD alterations. Full article