Severe burns: what really changes

Coverage of the Crans-Montana fire has brought renewed attention to one of the most complex clinical conditions to manage in emergency medicine: severe burns. When burns involve 70% of the body, survival is no longer just a matter of luck. It is the result of surgical, resuscitative, and psychological strategies orchestrated with precision.
Professor Roberto D’Alessio, for 22 years Director of the Division of Plastic Surgery and the Major Burns Centre at Cardarelli Hospital in Naples, recounts an experience in which patients’ survival depends on a complex combination of expertise and protocols.

At the Neapolitan centre, a reference point for Campania and neighbouring regions such as Calabria, Basilicata, Puglia, and Abruzzo, patients have been admitted with burns affecting up to 70–80% of total body surface area.
«When a burn exceeds 30–40–50% of the body surface, it becomes complicated to manage, both clinically and surgically. The two aspects must be combined,” the professor explains. “We have treated patients with burns involving even 70–80% who managed to survive thanks to combined strategies that addressed resuscitation, because, obviously, such patients must be supported in their vital functions, through a whole series of resuscitation procedures, intensive care, and surgical interventions that gradually led them to progressive recovery».

Burns and early mistakes

A frequent problem concerns the patient’s initial management. «Very often, patients are first admitted to hospitals that lack adequate expertise, so the extent of the burned body surface is incorrectly assessed. This results in improper therapeutic planning from the outset – explains Professor D’Alessio – The truth is that, unfortunately, burn patients require extremely specialised care. Moreover, the condition is not very common. The biggest issue is that when a patient arrives at a first-level facility without adequate expertise, they do not receive appropriate treatment. When they are eventually transferred to a major burns centre, incorrect initial care can compromise, or at least alter, the therapeutic process».

An incorrect assessment can compromise early treatment and influence the entire course of care, even after transfer to a specialised centre.

How modern therapies have transformed prognosis

In recent years, the prognosis for patients with severe burns has improved significantly.
«There has been an incredible improvement in burn patient survival. Advances, particularly in resuscitation and intensive care therapies, as well as surgical techniques, have led to a gradual increase in survival rates for patients with severe burns».

It is not only about saving lives: new procedures, from regenerative medicine devices to the use of artificial dermis, have transformed and reduced the invasiveness of interventions, promoting more effective healing.
«When I was appointed in 2000/2003 to direct the centre at Cardarelli Hospital in Naples, I worked to introduce some improvements and innovations in the management of these patients. I remember being invited to France to acquire skills in the use of so-called synthetic or artificial dermis in burn care, which I then introduced as standard practice in our department».

Also significant was the introduction of a cream that performs selective escharolysis, which «removes dead tissue while sparing healthy tissue, thereby reducing the surgical burden. This means that demolitive surgical procedures are no longer necessary for the patient, with a major impact in terms of tolerability. It ensures re-epithelialisation, therefore spontaneous healing, in areas where the burn was evidently not excessively deep».

Care and the return to daily life

The recovery journey of burn patients is not limited to physical healing. Extensive and disabling scars have significant functional and aesthetic consequences, and the psychological impact can be profound. For this reason, it would be essential for all major burn centres to provide multidisciplinary teams capable of supporting patients with physiotherapists and psychologists, accompanying them through both physical rehabilitation and social reintegration.

«The most important thing for a young doctor who wants to begin or approach this branch of plastic surgery is to understand that it requires great dedication, great patience, and great endurance, because burn patients require a great deal of time».

The journey involves successive surgical procedures, frequent, sometimes painful, dressings, and continuous care that combines general medical expertise with specialized surgical skills.

«Burn surgery is complex, long, and demanding. It must be performed properly. This branch of surgery must be given the importance it deserves, also within plastic and reconstructive surgery training programs in Italy, so that universities can work alongside burn centre departments, which are almost all hospital-based units».