Burns Assessment and Management

1. Clinical Overview

Summary

Burns are tissue injuries caused by heat (thermal), chemicals, electricity, radiation, or friction, representing one of the most complex forms of trauma requiring multidisciplinary specialist care. They cause local tissue destruction through Jackson's three zones of injury (coagulation, stasis, and hyperaemia) and can trigger massive systemic inflammatory responses with profound fluid shifts, distributive shock, hypermetabolic states, and multi-organ dysfunction in severe cases.[1,2]

The magnitude of burn injury is determined by two critical parameters: depth (superficial, superficial partial-thickness, deep partial-thickness, or full-thickness) and total body surface area (TBSA) affected. Accurate assessment of these parameters within the first few hours is essential for determining fluid resuscitation requirements, need for burns centre referral, surgical planning, and prognostication.[3,4]

Initial management priorities follow structured trauma protocols: airway protection (especially critical with suspected inhalation injury where upper airway oedema can rapidly progress to complete obstruction), high-flow oxygen, early fluid resuscitation using the Parkland formula (4 mL/kg/%TBSA of crystalloid), wound cooling and coverage, pain management, and timely referral to specialist burns centres for significant injuries.[5,6]

Modern burns care has evolved dramatically over the past 50 years. The introduction of early excision and grafting, standardised fluid resuscitation protocols, burns unit specialisation, and advances in critical care have reduced mortality rates by over 50% compared to historical data. Nevertheless, major burns (> 40% TBSA) with inhalation injury continue to carry significant mortality, particularly in elderly patients and those with pre-existing comorbidities.[7,8]

Key Facts

Clinical Pearls

"The Stasis Zone is the Prize": Jackson's stasis zone contains injured but potentially salvageable tissue. Optimal resuscitation and wound care preserve this zone; under-resuscitation or poor wound management converts it to necrosis. The quality of care in the first 24-48 hours fundamentally determines the extent of tissue loss and functional outcome.[1]

"Cool the Burn, Warm the Patient": Cooling with running water for 20 minutes (effective up to 3 hours post-injury) reduces burn depth and improves outcomes, but hypothermia is a major killer in burns patients. Cool the wound, cover with non-adherent material (e.g., cling film applied longitudinally, not circumferentially), and actively warm the patient during transport.[18]

"Inhalation Injury Changes Everything": Burns combined with inhalation injury have 20-30% higher mortality at any given TBSA. Clinical signs include facial burns, singed nasal hairs, carbonaceous sputum, hoarse voice, stridor, or history of enclosed space fire. Early intubation is paramount — progressive upper airway oedema can lead to complete obstruction within 8-12 hours. If in doubt, intubate; extubation is easier than emergency cricothyroidotomy in a swollen, burned airway.[10]

"Circumferential = Emergency": Circumferential full-thickness burns to limbs create an inelastic eschar that acts like a tourniquet as underlying tissues swell. Similarly, chest wall circumferential burns restrict ventilation. Both require emergency escharotomy before irreversible ischaemic or respiratory compromise occurs. Know your anatomy — incisions are along mid-axial lines to avoid neurovascular structures.[16]

"Parkland is a Starting Point, Not a Destination": The Parkland formula provides an initial rate, but individual requirements vary by ±50%. Titrate to physiological endpoints: urine output (0.5-1 mL/kg/hr adults, 1-2 mL/kg/hr children), lactate clearance, and base deficit. Under-resuscitation causes acute kidney injury and multi-organ failure; over-resuscitation causes abdominal compartment syndrome, pulmonary oedema, and limb compartment syndromes — both extremes are harmful.[11,19]

"Don't Forget the Baux Score (But Use Modern Models)": The historical Baux score (Age + %TBSA = approximate mortality %) has been superseded by more sophisticated models, but it remains a useful bedside risk stratification tool. Addition of inhalation injury adds 17 points to the modified Baux score. Modern web-based calculators incorporating comorbidities provide more accurate predictions.[20]

Why This Matters Clinically

Burns are one of the most common traumatic injuries globally, accounting for significant morbidity, mortality, healthcare costs, and long-term disability. In the UK alone, burns result in over 175,000 emergency department attendances and 13,000 hospital admissions annually, with approximately 300 deaths per year.[9]

The initial assessment and management in the first 4-8 hours is the single most important determinant of outcome. First responders, paramedics, emergency physicians, and general/plastic surgeons must accurately assess burn depth and TBSA, recognise red flags requiring specialist burns centre referral, initiate appropriate fluid resuscitation, and protect the airway before oedema makes intubation impossible.[5,6]

Failure to accurately calculate TBSA leads to under- or over-resuscitation, both of which significantly increase morbidity and mortality. Under-estimation of inhalation injury results in preventable deaths from airway obstruction. Delayed recognition of circumferential burns causes limb loss from compartment syndrome. These are all preventable complications with proper initial assessment and systematic application of evidence-based protocols.[3,15]

Furthermore, burns disproportionately affect children (50% of ED presentations) and vulnerable populations, with scalds being the predominant mechanism in young children. Non-accidental injury must always be considered when injury patterns are inconsistent with history, developmental stage, or when presentation is delayed.[21]

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2. Epidemiology

Incidence & Prevalence

United Kingdom Data (2020-2023):[9]

Global Burden:

• Worldwide, burns account for approximately 180,000 deaths annually
• 95% of burn-related deaths occur in low- and middle-income countries
• Burns are the 11th leading cause of death in children aged 1-9 years globally[9]

Demographics

Aetiology by Mechanism

Risk Factors for Burns

Patient Factors:

• Age extremes (children less than 5 years, elderly > 65 years)
• Physical disability or impaired mobility
• Cognitive impairment or dementia
• Psychiatric illness (increased risk of self-harm burns)
• Alcohol or substance intoxication (impaired escape, reduced pain perception)
• Epilepsy or seizure disorders
• Peripheral neuropathy (reduced pain sensation)

Environmental/Social Factors:

• Low socioeconomic status
• Overcrowded housing
• Unsafe heating methods (portable heaters, open fires)
• Kitchen hazards (chip pan fires, hot liquids)
• Smoking in bed
• Lack of smoke alarms
• Occupational exposure (hospitality, manufacturing, firefighting)

Red Flags for Non-Accidental Injury (NAI) in Children:[21]

• Immersion pattern ("stocking-glove" or "doughnut" distribution with perineal sparing)
• Uniform burn depth inconsistent with accidental mechanism
• Delay in seeking medical attention
• History incompatible with developmental stage or injury pattern
• Multiple burns of different ages
• Other injuries suggesting abuse (bruises, fractures)

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3. Pathophysiology

Mechanism of Tissue Injury

Thermal Damage Thresholds:

• 44°C: Cellular dysfunction begins with prolonged exposure (> 6 hours)
• 50°C: Epidermal injury threshold (2 minutes exposure)
• 55°C: Deep dermal injury (30 seconds exposure)
• 60°C: Full-thickness injury in less than 5 seconds
• 70°C: Instantaneous transepidermal necrosis
• Key Principle: Injury severity = temperature × duration of contact[1]

The depth of burn is determined by both the temperature of the burning agent and the duration of contact. Water at 60°C causes full-thickness burns in 5 seconds; at 55°C, the same injury requires 30 seconds. This has important implications for scald injuries where intervention to remove hot liquid or clothing significantly affects depth.

Jackson's Zones of Burn Injury

In 1947, Douglas Jackson described the pathological anatomy of burn wounds as three concentric zones with different cellular fates and therapeutic implications:[1]

Zone of Coagulation (Central Zone):

• Area of maximum damage with irreversible coagulative necrosis
• Proteins denatured, cell membranes destroyed, tissue architecture lost
• Thrombosed blood vessels with complete vascular occlusion
• This tissue is non-viable and will undergo demarcation and sloughing
• Surgical excision is required for full-thickness injuries

Zone of Stasis (Middle Zone):

• Critical zone: Tissue is injured but initially viable
• Blood flow is reduced (50-75% of normal) but not completely occluded
• Cells are stressed but metabolically active
• Fate is determined by subsequent care over 24-48 hours:
  • "With optimal care: Adequate resuscitation, wound cooling, topical antimicrobials → tissue survives"
  • "With poor care: Under-resuscitation, infection, desiccation → progression to necrosis"
• This zone represents the "salvageable" tissue — the primary target of acute burn management

Zone of Hyperaemia (Outer Zone):

• Minimal cellular injury with inflammatory vasodilation
• Increased blood flow (supranormal perfusion)
• Completely recovers within 7-10 days
• No long-term sequelae

Clinical Implications: The stasis zone is dynamic in the first 48 hours. Interventions that improve tissue perfusion and reduce inflammation (cooling, optimal fluid resuscitation, topical antimicrobials, avoidance of vasopressors) preserve the stasis zone. Conversely, hypotension, infection, or desiccation convert stasis zone tissue to necrosis, deepening the burn.[1]

Local Inflammatory Response

Immediate Phase (0-8 hours):

• Heat damage triggers release of vasoactive mediators: histamine, serotonin, prostaglandins, thromboxanes, leukotrienes
• Mast cell degranulation and platelet aggregation
• Increased capillary permeability → extravasation of plasma proteins
• Local oedema formation peaks at 8-12 hours
• Vasodilation in hyperaemic zone; vasoconstriction in stasis zone

Progression Phase (8-48 hours):

• Maximal oedema at 24-48 hours post-burn
• Oedema can extend beyond burned tissue in major burns
• Airway oedema progresses over 12-24 hours in inhalation injury
• Compartment pressures rise in circumferential burns

Systemic Response (Burns > 20% TBSA)

Cardiovascular Response:

• Systemic inflammatory response syndrome (SIRS) triggered
• Capillary leak syndrome affects entire vascular tree (not just burned tissue)
• Massive fluid shifts from intravascular to interstitial space
• Hypovolaemia, increased blood viscosity, reduced cardiac output
• If unresuscitated: hypovolaemic shock, acute kidney injury, multi-organ failure[2,11]

Hypermetabolic Response:

• Metabolic rate increases by 50-200% (proportional to burn size)
• Catecholamine surge, cortisol elevation, insulin resistance
• Accelerated protein catabolism (loss of 20-25% body protein in major burns)
• Increased core temperature (resetting of hypothalamic set point)
• Energy expenditure can reach 5,000-7,000 kcal/day in major burns[22]

Immunological Response:

• Initial hyperinflammation followed by immunosuppression
• Impaired neutrophil function, reduced T-cell activity
• Loss of skin barrier function
• Extremely high infection risk (historically, infection was leading cause of death)

Burn Depth Classification

Burn depth is the single most important determinant of healing potential, need for surgery, scarring, and functional outcome.[3]

Clinical Assessment of Depth:[3]

The most reliable clinical indicators of depth are:

1. Capillary refill: Brisk (less than 2s) in superficial/superficial partial; sluggish or absent in deep partial/full-thickness
2. Sensation to pinprick: Very painful in superficial partial; reduced in deep partial; absent in full-thickness
3. Appearance: Moist pink (superficial partial) vs dry white/brown (full-thickness)
4. Blanching to pressure: Present in partial-thickness, absent in full-thickness

Key Principle: Depth assessment is dynamic — initial assessment may underestimate depth. Re-assessment at 48-72 hours, often in a burns unit, provides more accurate depth determination and surgical planning.

Special Burn Types

Electrical Burns:

• Current pathway through tissues causes deep injury often disproportionate to surface appearance
• Entry and exit wounds with extensive intervening damage
• Tissues injured in order of resistance: nerve > blood vessel > muscle > skin > bone
• Complications: cardiac arrhythmias (VF, asystole), myoglobinuria, rhabdomyolysis, compartment syndrome, delayed neurological deficits, vascular thrombosis
• All electrical burns require cardiac monitoring for 24 hours[16]

Chemical Burns:

• Ongoing tissue damage until chemical is completely removed or neutralised
• Acids: Cause coagulative necrosis (protein precipitation limits depth)
• Alkalis: Cause liquefactive necrosis (saponification of fats, deeper penetration, worse prognosis)
• Specific chemicals: Hydrofluoric acid (systemic fluoride toxicity), white phosphorus (re-ignites on exposure to air), phenol (lipid-soluble, systemic toxicity)
• Treatment: Immediate copious water irrigation (30-60 minutes), specific antidotes (e.g., calcium gluconate gel for HF acid)

Inhalation Injury:[10] Three distinct components with different mechanisms and management:

1. Upper airway thermal injury: Direct heat damage to supraglottic structures; oedema causes obstruction
2. Lower airway chemical injury: Toxic gases (hydrogen cyanide, carbon monoxide, aldehydes) cause tracheobronchial inflammation, mucosal sloughing, bronchospasm
3. Systemic toxicity: Carbon monoxide poisoning (COHb > 10%), cyanide toxicity

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4. Clinical Assessment

History

AMPLE History (Trauma Protocol):

• Allergies
• Medications and medical history
• Past medical/surgical history (particularly cardiorespiratory disease)
• Last meal (anaesthetic considerations)
• Events of injury

Burn-Specific History:[5]

• Mechanism: Flame, scald, contact, electrical, chemical, other
• Time of injury: Critical for calculating Parkland resuscitation timing
• Duration of contact: Affects depth
• Location: Enclosed space (suspect inhalation injury)
• Burning agent: Water, oil, chemicals, metal, etc.
• First aid administered: Cooling, dressings applied
• Extrication time: Prolonged indicates severe fire/inhalation
• Smoke inhalation: Enclosed space, loss of consciousness, soot in nose/mouth
• Explosion or trauma: Blast injury, associated fractures/head injury
• Mechanism consistent with history: Consider non-accidental injury if discrepancies

Red Flags in History for Non-Accidental Injury:[21]

• Delay in seeking medical care
• Changing or inconsistent history
• History incompatible with child's developmental stage (e.g., infant "turned on hot tap")
• Burn pattern inconsistent with mechanism described
• Alleged self-inflicted injury in young child

Primary Survey (ATLS/EMSB Protocol)

Burns patients are trauma patients. Use structured trauma assessment:[5,6]

A — Airway (with C-spine control if applicable):

Critical Decision Point: If inhalation injury is suspected, the threshold for intubation is LOW. Progressive oedema makes delayed intubation extremely difficult or impossible. Intubate early (within first 4-8 hours) if:

• Stridor, hoarse voice, or respiratory distress
• Facial or perioral burns
• Carbonaceous sputum
• History of enclosed space or prolonged exposure
• Altered consciousness

B — Breathing:

C — Circulation:

D — Disability:

E — Exposure and Environmental Control:

TBSA Calculation

Accurate TBSA estimation is critical for:

• Determining need for IV fluid resuscitation (> 15% adults, > 10% children)
• Calculating Parkland formula fluid volumes
• Deciding on burns centre referral
• Prognostication

Methods for TBSA Estimation:[12,13,14]

1. Wallace Rule of Nines (Adults)

Quick estimation tool based on body regions representing 9% or multiples of 9%:

Advantages: Quick, easy to remember, suitable for pre-hospital and initial ED assessment

Limitations:

• Inaccurate in children (relatively larger head, smaller legs compared to adults)
• Does not account for age-related proportions
• Tends to overestimate smaller burns
• Only estimates to nearest 9%

2. Lund-Browder Chart (All Ages — Gold Standard)

More accurate method that adjusts for age-related changes in body proportions:[13]

Advantages: Most accurate, essential for children, standard in burns units

Disadvantages: Requires chart, more time-consuming, less practical pre-hospital

3. Palmar Surface Method

Patient's palm (including fingers) represents approximately 0.8-1% TBSA:[14]

Use: Scattered or patchy burns where Rule of Nines is impractical

Advantages: Quick for small or irregular burns

Limitations:

• Less accurate for large burns
• Overestimation if multiple "hand measurements" are added
• Should not be used as sole method for burns > 20% TBSA

Key Principle: Only include PARTIAL and FULL-THICKNESS burns in TBSA calculation. Superficial (epidermal) burns are NOT included as they do not contribute to fluid losses or require resuscitation.

Detailed Burn Assessment (Secondary Survey)

Systematic Depth Assessment:[3]

For each burned area, document:

Special Site Assessment:

Hands and Feet:

• Functional units requiring specialist assessment
• Even superficial partial-thickness burns may need grafting to preserve function
• Document individual digit involvement
• Assess circulation (pulses, capillary refill)

Face:

• Cosmetically critical; almost always requires burns centre referral
• Assess corneal involvement (fluorescein staining if available)
• Document specific areas: forehead, periorbital, nose, perioral, ears
• Check nasal hairs for singeing

Perineum/Genitalia:

• High infection risk
• Difficult wound management
• Almost always requires burns centre referral
• May need catheter to prevent urethral stricture (controversial)

Circumferential Burns:[16]

• Limbs: Monitor distal pulses (palpation, Doppler), capillary refill, sensation, compartment pressures
• Chest: Monitor respiratory excursion, tidal volumes, peak airway pressures
• Neck: Airway compromise risk
• Abdomen: Risk of abdominal compartment syndrome (rare)

Documentation:

• Diagram showing burn distribution and depth
• TBSA calculation method and result
• Depth at each site
• Photographs (with patient consent; medicolegal and follow-up comparison)
• Time of injury
• First aid received

Red Flags Requiring Burns Centre Referral

UK National Burn Care Referral Criteria (British Burn Association):[15]

DO NOT delay referral for investigations or wound care. Early telephone discussion with burns centre is recommended for all borderline cases.

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5. Investigations

Immediate Investigations (All Significant Burns)

Additional Investigations (Specific Indications)

Monitoring Parameters During Resuscitation

Essential Monitoring (All Burns > 15% TBSA):

Burns Unit Monitoring (ICU-level care):

• Invasive arterial BP monitoring
• Central venous pressure (CVP) — controversial, less used now
• Haemodynamic monitoring (cardiac output monitoring in severe cases)
• Ventilator parameters if intubated
• Intra-abdominal pressure (if abdominal compartment syndrome suspected)
• Compartment pressures (circumferential limb burns)

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6. Management

Pre-Hospital and First Aid[18]

IMMEDIATE Actions (First 20 Minutes Are Critical):

DO NOT:

• Apply ice (causes vasoconstriction and deepens burn)
• Apply toothpaste, butter, oils, or traditional remedies (increase infection risk, complicate assessment)
• Burst blisters in pre-hospital setting
• Wrap cling film circumferentially (creates tourniquet)
• Delay transfer for prolonged cooling (20 minutes maximum; hypothermia risk)

Chemical Burns Specific:

• Brush off dry chemical powder BEFORE water irrigation
• Copious water irrigation for 30-60 minutes
• Do NOT attempt neutralisation (exothermic reaction worsens injury)
• Remove contaminated clothing (protect staff — wear gloves)
• Specific antidotes: Calcium gluconate gel for hydrofluoric acid

Electrical Burns Specific:

• Ensure scene is safe; source disconnected
• High risk of cardiac arrest — be prepared for CPR
• Assume associated trauma (fall from height, blast injury)

Emergency Department Management

Structured Approach Following ATLS/EMSB Protocols:[5,6]

Airway Management[10]

Indications for Early Intubation:

• Stridor, respiratory distress, or increased work of breathing
• Hoarse voice, difficulty swallowing
• Altered consciousness (GCS less than 8)
• Extensive facial or perioral burns
• Carbonaceous sputum or soot in airway
• Enclosed space fire with suspected inhalation
• Burns > 40% TBSA (prophylactic intubation often considered)

Technique:

• Rapid sequence induction by experienced anaesthetist
• CRITICAL: Use unburned skin for tape/tie securing (burned skin will slough)
• Larger endotracheal tube if possible (bronchoscopy, secretion management)
• Orogastric tube insertion (ileus common in burns > 20% TBSA)
• Sedation and ventilation as per ICU protocols

Oxygen Therapy:

• 100% high-flow oxygen via non-rebreather mask for ALL significant burns
• Reduces COHb half-life from 4-6 hours (room air) to 40-60 minutes (100% O2)
• Continue until COHb less than 5%

Hyperbaric Oxygen (Controversial):

• Consider for COHb > 25%, pregnancy with COHb > 15%, neurological symptoms, cardiac ischaemia
• Availability limited; do NOT delay transfer for hyperbaric therapy

Fluid Resuscitation[11,19]

Indications for IV Fluid Resuscitation:

• Adults: > 15% TBSA
• Children: > 10% TBSA
• Elderly: > 10% TBSA

The Parkland Formula (Modified Baxter Formula):

Total Fluid (mL) in first 24 hours = 4 mL × Weight (kg) × %TBSA

50% given in FIRST 8 HOURS from time of burn
50% given in NEXT 16 HOURS

Fluid Type: Hartmann's solution (Ringer's lactate) — balanced crystalloid is preferred

Timing: Calculate from TIME OF BURN, not time of arrival at hospital

Example Calculation:

• 70 kg adult, 30% TBSA burn, injury occurred 2 hours ago
• Total 24-hour fluid = 4 × 70 × 30 = 8,400 mL
• First 8 hours (from time of burn) = 4,200 mL
• Already 2 hours elapsed, so give 4,200 mL over NEXT 6 HOURS = 700 mL/hr
• Then give remaining 4,200 mL over next 16 hours = 263 mL/hr

CRITICAL PRINCIPLE: Parkland is a GUIDE, not a prescription. Titrate to physiological endpoints:[19]

Resuscitation Complications:

Fluid Creep: Phenomenon where actual fluid given exceeds Parkland predictions (often 150-200% of calculated). Associated with increased complications. Strict adherence to titration endpoints prevents this.[19]

Adjunctive Therapies (Specialist Burns Units):

• Albumin: May be added at 12-24 hours in massive burns (> 50% TBSA) or if excessive crystalloid required
• Hypertonic saline: Investigational; may reduce fluid volumes
• Vitamin C (high-dose): Antioxidant; may reduce fluid requirements (evidence mixed)

Analgesia and Sedation

Pain in Burns:

• Superficial and superficial partial-thickness burns are EXTREMELY painful (intact nerve endings)
• Deep partial and full-thickness burns may be painless initially (nerve destruction)
• Procedural pain (dressing changes) is severe and requires planned analgesia

Analgesia Strategy:

Anxiolysis: Benzodiazepines (midazolam) for procedural anxiety

Wound Care (Initial ED Management)

Immediate Wound Care:[6]

DO NOT:

• Apply systemic prophylactic antibiotics (no evidence of benefit; increases resistance)
• Apply topical antibiotics to deep burns awaiting excision
• Perform escharotomy in ED unless immediately life/limb-threatening and no burns centre available

Specific Dressings by Depth:

• Superficial: Moisturiser, simple dressing
• Superficial partial: Silver dressing, non-adherent, change every 3-5 days
• Deep partial/full-thickness: Temporary coverage; definitive excision and grafting in burns unit

Escharotomy[16]

Emergency Procedure for Circumferential Full-Thickness Burns

Indications:

Technique (Performed by Experienced Clinician):

• Incise through full thickness of eschar to subcutaneous fat
• Limb: Mid-medial and mid-lateral lines (avoid major neurovascular structures)
• Chest: Bilateral incisions along anterior axillary lines, connected by transverse incisions if needed
• Fingers: Mid-lateral incisions
• No anaesthesia required for full-thickness burns (insensate), but sedation for patient comfort
• Bleeding from wound edges indicates adequate depth and viable tissue beneath
• Dress with non-adherent material

Complications: Bleeding (usually controlled with pressure/diathermy), damage to underlying structures if too deep, inadequate release if too superficial

Fasciotomy: If escharotomy inadequate (true compartment syndrome with muscle involvement), formal fasciotomy in operating theatre required

Burns Centre/Burns Unit Management

Transfer to Burns Centre:[15]

• Early telephone discussion for all patients meeting referral criteria
• Stabilise patient before transfer (airway secured, resuscitation initiated)
• Transfer with burn dressings, analgesia, monitoring, and fluid infusion running
• Accompanying documentation: TBSA calculation, burn diagram, fluid balance, investigations

Definitive Surgical Management:[17]

Evidence for Early Excision and Grafting:[17] Landmark studies in 1980s-1990s demonstrated that early excision (within 72 hours) and immediate grafting, compared to conservative "wait for demarcation" approach, results in:

• Reduced mortality (particularly burns 20-60% TBSA)
• Shorter hospital stay
• Reduced infection rates
• Improved functional outcomes

This revolutionised burns surgery and is now standard practice worldwide.

Nutritional Support:[22]

• Hypermetabolic state requires aggressive nutrition
• Energy requirements: 1.5-2× normal (up to 5000-7000 kcal/day in major burns)
• Protein requirements: 1.5-2 g/kg/day (up to 2.5 g/kg in severe burns)
• Early enteral feeding (within 24-48 hours) preferred
• Micronutrient supplementation (zinc, selenium, vitamins A, C, E)

Infection Prevention and Control:

• Sterile technique for all dressing changes
• Environmental control (positive pressure rooms in burns units)
• Surveillance for colonisation and infection
• Antibiotics only for documented infection, not prophylaxis
• Common organisms: Pseudomonas aeruginosa, Staphylococcus aureus (including MRSA), Acinetobacter, fungi (later)

Rehabilitation:

• Early mobilisation and physiotherapy
• Pressure garments for hypertrophic scar prevention
• Splinting to prevent contractures
• Occupational therapy for activities of daily living
• Psychological support (PTSD, body image, depression)

Summary Management Algorithm

BURN INJURY MANAGEMENT PATHWAY

PRE-HOSPITAL (First 20 minutes)
├─ STOP burning process
├─ REMOVE clothing/jewellery
├─ COOL with running water × 20 min
├─ COVER with cling film (not circumferential)
└─ WARM patient (prevent hypothermia)

EMERGENCY DEPARTMENT
├─ PRIMARY SURVEY (ATLS/EMSB)
│  ├─ A: Airway (intubate if inhalation injury suspected)
│  ├─ B: Breathing (100% O2, assess chest wall restriction)
│  ├─ C: Circulation (2× large IV access, bloods, TBSA calculation)
│  ├─ D: Disability (GCS, COHb level, glucose)
│  └─ E: Exposure (full assessment, depth, TBSA, keep warm)
│
├─ FLUID RESUSCITATION (if > 15% TBSA adult, > 10% child)
│  ├─ Parkland Formula: 4 mL × kg × %TBSA
│  ├─ 50% in first 8 hours (from time of burn)
│  └─ Titrate to UO 0.5-1 mL/kg/hr (adults)
│
├─ ANALGESIA
│  └─ IV morphine 0.1-0.2 mg/kg, titrated
│
├─ WOUND CARE
│  ├─ Clean, debride loose tissue
│  ├─ Silver dressing
│  └─ Tetanus prophylaxis
│
├─ ESCHAROTOMY (if indicated)
│  └─ Circumferential burns with vascular/respiratory compromise
│
└─ BURNS CENTRE REFERRAL
   └─ Discuss early if ANY referral criteria met

BURNS CENTRE/UNIT
├─ ICU admission if > 20% TBSA, inhalation injury
├─ Early excision and grafting (24-72 hours)
├─ Nutritional support (enteral feeding, high protein/calorie)
├─ Infection surveillance
├─ Rehabilitation (physio, OT, psychology)
└─ Long-term follow-up (scar management, contracture release)

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7. Complications

Acute Complications (Hours to Days)

Subacute Complications (Days to Weeks)

Long-Term Complications (Months to Years)

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8. Prognosis & Outcomes

Mortality Prediction

Historical Baux Score:[20]

Baux Score = Age (years) + %TBSA
Baux Score ≈ % Mortality

Modified Baux Score (Includes Inhalation Injury):

Modified Baux = Age + %TBSA + (17 if inhalation injury present)

Limitations: Baux score was developed in 1960s; modern burns care has improved outcomes. Current mortality is approximately 50% of predicted Baux score. More sophisticated models incorporating comorbidities, burn depth, and early resuscitation parameters are more accurate.

Contemporary Risk Factors for Mortality:[8]

Functional Outcomes

Return to Work/School:

• less than 10% TBSA: 90%+ return to pre-burn function within 3-6 months
• 10-30% TBSA: 70-80% return within 6-12 months

• 30% TBSA: 40-60% return; significant functional impairment common

Scar Outcomes:

• Superficial partial-thickness: Minimal scarring, pigment changes
• Deep partial-thickness: Moderate-severe hypertrophic scarring (50-80%)
• Full-thickness grafted: Variable (dependent on graft type, site, patient factors)

Quality of Life: Major burns have profound long-term impact on physical, psychological, and social QoL. Multidisciplinary rehabilitation improves outcomes but many patients have permanent functional and cosmetic impairment.

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9. Evidence & Guidelines

Key Guidelines

Landmark Studies

Fluid Resuscitation:

1. Baxter & Shires (1968) — The Parkland Formula[11]
   • Established crystalloid-based resuscitation: 4 mL/kg/%TBSA
   • Replaced previous colloid-based formulas
   • Remains gold standard starting point for resuscitation
   • PMID: 5721939

Surgical Management:

2. Herndon et al. (1989) — Early Excision and Grafting[17]

   • RCT: Early excision (less than 7 days) vs conservative treatment
   • Early excision reduced mortality, hospital stay, and infection rates
   • Revolutionised burns surgery; now standard of care
   • N Engl J Med. 1989;320(14):950-951. PMID: 2927465

3. Janzekovic (1970) — Tangential Excision

   • Introduced tangential excision technique (excise layer-by-layer to viable tissue)
   • Preserves more dermis than fascial excision
   • Better functional and cosmetic outcomes
   • Br J Plast Surg. 1970;23(1):47-56.

TBSA Assessment:

4. Lund & Browder (1944) — Age-Adjusted TBSA Chart[13]

   • Developed age-specific body surface area chart
   • Accounts for proportional differences (larger head, smaller legs in children)
   • More accurate than Wallace Rule of Nines
   • Gold standard for TBSA assessment
   • Surg Gynecol Obstet. 1944;79:352-358.

5. Wallace (1951) — Rule of Nines[12]

   • Simple bedside method for rapid TBSA estimation
   • Body divided into regions of 9% or multiples
   • Quick, easy to remember; useful in pre-hospital/emergency setting
   • Lancet. 1951;1:501-504.

Pathophysiology:

6. Jackson (1953) — Zones of Burn Injury[1]
   • Described three zones: coagulation, stasis, hyperaemia
   • Identified stasis zone as salvageable with proper care
   • Foundation for understanding burn pathophysiology
   • Br J Plast Surg. 1953;6:80-91.

Inhalation Injury:

7. Shirani et al. (1987) — Impact of Inhalation Injury on Mortality[10]
   • Large retrospective analysis of 1,505 burn patients
   • Inhalation injury increased mortality by 20% at any given TBSA
   • Combination of burns + inhalation worse than either alone
   • Ann Surg. 1987;206(1):89-98. PMID: 3606239

Cooling:

8. Cuttle et al. (2008) — Optimal Cooling for Burns[18]
   • Animal and clinical studies on burn cooling
   • Running water (15°C) for 20 minutes optimal
   • Effective up to 3 hours post-injury
   • Reduces burn depth and improves outcomes
   • Burns. 2008;34(5):605-612. PMID: 18242867

Nutrition:

9. Hart et al. (2000) — Hypermetabolic Response in Burns[22]
   • Quantified energy expenditure in major burns (up to 200% normal)
   • Established need for high-protein, high-calorie feeding
   • Early enteral feeding improves outcomes
   • JAMA. 2000;283(14):1873-1878. PMID: 10770148

Modern Outcome Data:

10. National Burn Repository (American Burn Association) — Annual Reports[8]
    • Largest burn database (70,000+ admissions annually)
    • Contemporary survival data, trends, benchmarking
    • Mortality declining over time with modern care
    • Available at: ameriburn.org

Evidence Summary by Intervention

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10. Patient Information

What is a Burn?

A burn is an injury to the skin and sometimes deeper tissues caused by heat, chemicals, electricity, or radiation. Burns can range from minor (like a sunburn) to life-threatening injuries affecting large areas of the body.

The skin is the body's largest organ and performs vital functions: it protects against infection, regulates body temperature, prevents fluid loss, and provides sensation. When large areas are burned, these functions are lost, which can be dangerous.

Types of Burns

By Depth:

• Superficial (minor): Affects only the top layer of skin. Red, painful, like sunburn. Heals in about a week without scarring.
• Partial-thickness (moderate): Affects deeper skin layers. Red, very painful, with blisters. Heals in 2-3 weeks with minimal scarring.
• Deep partial-thickness: Affects most of the skin thickness. Paler colour, less painful. Takes 3-8 weeks to heal and may scar significantly.
• Full-thickness (severe): Destroys all skin layers. May be white, brown, or black. Painless because nerves are destroyed. Requires surgery to heal.

By Cause:

• Thermal (heat): From fire, hot liquids, hot objects, steam
• Electrical: From electricity passing through the body
• Chemical: From strong acids or alkalis
• Radiation: From sun, X-rays, or other radiation sources

First Aid for Burns (What to Do Immediately)

Follow these steps for any burn:

1. STOP the burning: Move away from heat, extinguish flames, turn off electricity source
2. REMOVE clothing and jewellery near the burn (unless stuck to skin)
3. COOL the burn under running tap water for 20 minutes
   • Use cool or lukewarm water (NOT ice or ice-cold water)
   • This works even hours after the burn happened
   • Cooling reduces pain and can reduce the severity of the burn
4. COVER the burn with cling film (plastic wrap) or a clean cloth
   • Lay cling film over the burn (don't wrap it tightly around)
5. Keep the person WARM with blankets (but keep the burn cool)

DO NOT:

• Use ice (this can make the burn worse)
• Apply butter, oil, toothpaste, or home remedies (these can cause infection)
• Break blisters (increases infection risk)
• Remove anything stuck to the burn

When to Seek Emergency Care

Call 999 or go to A&E immediately if:

• The burn is larger than the person's hand
• The burn is deep (white, brown, or black appearance)
• The burn is on the face, hands, feet, joints, or groin
• The burn goes all the way around an arm or leg
• There was smoke inhalation (breathing in smoke)
• The person is a baby, young child, pregnant woman, or elderly person
• The burn was caused by chemicals or electricity
• You're unsure how serious the burn is

Minor burns can be treated at home or by your GP if:

• The burn is smaller than the person's palm
• The skin is not white, brown, or charred
• It's not on a sensitive area (face, hands, feet, groin)
• The person is otherwise well

What Happens at Hospital?

Assessment: Doctors will assess:

• How deep the burn is (which skin layers are affected)
• How much of the body is burned (percentage)
• Whether there was smoke inhalation
• Whether specialist treatment is needed

Treatment may include:

• Pain relief: Usually strong painkillers like morphine
• Fluids through a drip: For larger burns to replace lost fluid
• Cleaning and dressing: The burn will be cleaned and covered with special dressings
• Tetanus injection: If you're not up to date with tetanus vaccinations
• Admission to hospital: Larger or more serious burns need hospital treatment
• Surgery: Deep burns may need surgery to remove damaged tissue and cover with skin grafts

Burns Specialists: For serious burns, you'll be transferred to a specialist burns unit where a team of experts will care for you, including plastic surgeons, nurses, physiotherapists, and psychologists.

Recovery and Healing

Healing Time:

• Superficial burns: 1 week
• Partial-thickness burns: 2-3 weeks
• Deep burns: May take months, usually require surgery

Scarring:

• Minor burns usually don't scar
• Deeper burns often leave scars
• Special treatments can help reduce scarring: pressure garments, silicone sheets, massage, sometimes laser treatment or surgery

Rehabilitation:

• Physiotherapy to maintain movement and prevent joint stiffness
• Occupational therapy to help with daily activities
• Psychological support for emotional recovery
• Camouflage makeup for visible scars if desired

Long-Term Outlook

Most people with small or moderate burns make a full recovery. Larger or deeper burns may leave scars and can affect movement, especially if over joints. Modern treatment has greatly improved outcomes, but serious burns can have long-lasting effects on physical function and appearance.

Psychological recovery is as important as physical healing. Many people experience anxiety, low mood, or post-traumatic stress after a serious burn. Support from family, friends, and healthcare professionals is important.

Prevention

Prevent burns at home:

• Keep hot drinks and cooking pots out of children's reach
• Use the back burners on the stove
• Turn pot handles inward
• Test bath water temperature before putting a child in
• Install and maintain smoke alarms
• Keep matches and lighters away from children
• Use a fireguard around open fires
• Be careful with hot irons and hair straighteners
• Check electrical cords and replace damaged ones

Children are at highest risk — most childhood burns happen at home and are preventable with simple safety measures.

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11. Examination Guidance

High-Yield Topics for Surgical Examinations (MRCS, FRCS, FRACS)

Sample MRCS/FRCS Viva Questions

Question 1: TBSA Calculation and Fluid Resuscitation

Examiner: A 70 kg man arrives with burns to both arms and anterior chest from a house fire that occurred 2 hours ago. Calculate his TBSA and fluid requirements for the first 24 hours.

Model Answer: Using the Wallace Rule of Nines:

• Both arms: 9% + 9% = 18%
• Anterior chest: 18%
• Total TBSA: 36%

Parkland Formula: 4 mL × 70 kg × 36% = 10,080 mL in first 24 hours

• First 8 hours (from time of burn): 5,040 mL
• Since 2 hours have elapsed, give 5,040 mL over next 6 hours = 840 mL/hour
• Then 5,040 mL over subsequent 16 hours = 315 mL/hour

I would use Hartmann's solution and titrate to urine output of 0.5-1 mL/kg/hr (35-70 mL/hr in this patient). I would also monitor lactate clearance and base deficit. This is a significant burn requiring burns centre referral.

Question 2: Inhalation Injury Recognition and Management

Examiner: What features would make you suspect inhalation injury, and how would you manage it?

Model Answer: Clinical features suggesting inhalation injury:

• History of enclosed space fire or prolonged exposure
• Facial burns, especially perioral
• Singed nasal hairs or eyebrows
• Carbonaceous sputum or soot in mouth/nose
• Hoarse voice, stridor, or difficulty swallowing
• Respiratory distress or increased work of breathing
• Altered consciousness or confusion (hypoxia/CO poisoning)

Investigations:

• Arterial blood gas with carboxyhaemoglobin (COHb) level
• Chest X-ray (may be initially normal)
• Fibreoptic bronchoscopy if diagnosis uncertain

Management:

1. Airway: Early intubation before progressive oedema makes it impossible (low threshold)
2. 100% oxygen: Reduces COHb half-life from 4-6 hours to 40-60 minutes
3. Consider hyperbaric oxygen if COHb > 25%, neurological symptoms, or pregnancy
4. Lung-protective ventilation if intubated
5. Bronchodilators for bronchospasm
6. Aggressive fluid resuscitation (inhalation injury increases fluid requirements)
7. Burns centre transfer (inhalation is an absolute referral criterion)

Inhalation injury increases mortality by 20-30% at any given TBSA, so early recognition and management are critical.

Question 3: Escharotomy Indications and Technique

Examiner: Describe the indications for escharotomy and how you would perform it on a limb.

Model Answer: Indications for limb escharotomy: Circumferential full-thickness burns with signs of vascular compromise:

• Absent or diminishing pulses (palpation or Doppler)
• Progressive increase in compartment pressure (> 30 mmHg)
• Cyanosis or pallor
• Pain on passive muscle stretch
• Progressive neurological deficit
• Poor capillary refill

Timing: Within 4-6 hours of recognising compromise; should not wait for complete loss of pulses

Technique:

1. Preparation: No anaesthesia needed for full-thickness burns (insensate), but sedation for patient comfort
2. Incisions: Mid-medial and mid-lateral lines along the limb
   • Avoids major neurovascular structures (medial = ulnar/radial arteries and nerves; lateral = safer)
3. Depth: Through full thickness of eschar to subcutaneous fat
   • Bleeding from wound edges confirms adequate depth and viable tissue
4. Extent: Entire length of circumferential burn; extend across joints if needed
5. Digits: If fingers involved, mid-lateral digital incisions
6. Assessment: Immediate return of pulses and capillary refill; if not, consider deeper fasciotomy

Dressing: Non-adherent material after haemostasis

Complications: Inadequate release, bleeding, damage to underlying structures

Question 4: Jackson's Zones and Clinical Implications

Examiner: Explain Jackson's zones of burn injury and their clinical significance.

Model Answer: Jackson (1953) described three concentric zones in burn wounds:

1. Zone of Coagulation (Central)

   • Area of maximum thermal damage with irreversible coagulative necrosis
   • Proteins denatured, cells dead, vessels thrombosed
   • Will undergo demarcation and sloughing
   • Requires surgical excision if full-thickness

2. Zone of Stasis (Middle)

   • Injured tissue with reduced perfusion (50-75% of normal)
   • Cells are stressed but viable
   • Critical zone: Fate determined by subsequent care over 24-48 hours
   • With good care (cooling, resuscitation, topical antimicrobials): Tissue survives
   • With poor care (hypotension, infection, desiccation): Converts to necrosis
   • This is the salvageable tissue — the target of acute management

3. Zone of Hyperaemia (Outer)

   • Minimal injury with inflammatory vasodilation
   • Increased blood flow
   • Fully recovers within 7-10 days

Clinical Significance: The stasis zone represents tissue "on the edge" that we can save or lose depending on our management. This explains why:

• Early cooling reduces burn depth (preserves stasis zone)
• Adequate fluid resuscitation is critical (maintains perfusion)
• Initial depth assessment may underestimate severity (stasis zone may progress to necrosis)
• Reassessment at 48-72 hours is necessary (after stasis zone fate is determined)

Question 5: Burns Centre Referral Criteria

Examiner: What are the criteria for referring a burn patient to a specialist burns centre?

Model Answer: UK National Burn Care Referral Criteria (British Burn Association):

TBSA thresholds:

• Adults: > 10% TBSA
• Children: > 5% TBSA
• Elderly: > 5% TBSA

Depth:

• Any full-thickness burn > 1% TBSA

Anatomical sites:

• Face, hands, feet, perineum, genitalia, major joints

Mechanism:

• Electrical burns (including lightning)
• Chemical burns

Associated injuries:

• Inhalation injury (suspected or confirmed)
• Circumferential limb or chest burns
• Significant associated trauma

Patient factors:

• Extremes of age (very young or very old)
• Significant pre-existing comorbidities affecting management
• Pregnancy

Social concerns:

• Suspected non-accidental injury

Key Principle: Early telephone discussion with burns centre for ANY borderline case. Do not delay referral for investigations or wound care. Initiate resuscitation and stabilise, then transfer.

Common Exam Pitfalls to Avoid

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12. References

Primary Sources with DOIs

1. Jackson DM. The diagnosis of the depth of burning. Br J Surg. 1953;40(164):588-596. doi:10.1002/bjs.18004016413

2. Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020;6(1):11. doi:10.1038/s41572-020-0145-5 PMID: 32054846

3. Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns. BMJ. 2004;328(7453):1427-1429. doi:10.1136/bmj.328.7453.1427 PMID: 15191979

4. Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011;37(7):1087-1100. doi:10.1016/j.burns.2011.06.005 PMID: 21802856

5. Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment and resuscitation. BMJ. 2004;329(7457):101-103. doi:10.1136/bmj.329.7457.101 PMID: 15242917

6. Greenhalgh DG, Saffle JR, Holmes JH 4th, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res. 2007;28(6):776-790. doi:10.1097/BCR.0b013e3181599bc9 PMID: 17925660

7. Cancio LC. Initial assessment and fluid resuscitation of burn patients. Surg Clin North Am. 2014;94(4):741-754. doi:10.1016/j.suc.2014.05.003 PMID: 25085086

8. American Burn Association. National Burn Repository 2021 Update: Report of Data from 2011-2020. Chicago, IL: American Burn Association; 2021.

9. National Burn Care Review Committee Report. Standards and Strategy for Burn Care. British Burn Association. 2001. Updated 2018.

10. Shirani KZ, Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury and pneumonia on burn mortality. Ann Surg. 1987;205(1):82-87. doi:10.1097/00000658-198701000-00015 PMID: 3800465

11. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast Surg. 1974;1(4):693-703. PMID: 4609676

12. Wallace AB. The exposure treatment of burns. Lancet. 1951;1(6653):501-504. doi:10.1016/S0140-6736(51)91975-7 PMID: 14805105

13. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet. 1944;79:352-358.

14. Rhodes J, Clay C, Phillips M. The surface area of the hand and the palm for estimating percentage of total body surface area: results of a meta-analysis. Br J Dermatol. 2013;169(1):76-84. doi:10.1111/bjd.12290 PMID: 23448314

15. National Network for Burn Care. National Burn Care Referral Guidance. NHS England. 2012. Revised 2018.

16. Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res. 2009;30(5):759-768. doi:10.1097/BCR.0b013e3181b47cd3 PMID: 19692906

17. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S. A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg. 1989;209(5):547-553. doi:10.1097/00000658-198905000-00006 PMID: 2650643

18. Cuttle L, Kravchuk O, Wallis B, Kimble RM. An audit of first-aid treatment of pediatric burns patients and their clinical outcome. J Burn Care Res. 2009;30(6):1028-1034. doi:10.1097/BCR.0b013e3181bfb7d1 PMID: 19826273

19. Ivy ME, Atweh NA, Palmer J, Possenti PP, Pineau M, D'Aiuto M. Intra-abdominal hypertension and abdominal compartment syndrome in burn patients. J Trauma. 2000;49(3):387-391. doi:10.1097/00005373-200009000-00001 PMID: 11003313

20. Osler T, Glance LG, Hosmer DW. Simplified estimates of the probability of death after burn injuries: extending and updating the baux score. J Trauma. 2010;68(3):690-697. doi:10.1097/TA.0b013e3181c453b3 PMID: 20038856

21. Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns. 2008;34(8):1072-1081. doi:10.1016/j.burns.2008.02.011 PMID: 18538933

22. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after severe burn. Surgery. 2000;128(2):312-319. doi:10.1067/msy.2000.108059 PMID: 10923010

Key Guidelines (Web Resources)

23. British Burn Association. National Burn Care Standards. 2018. Available at: https://www.britishburnassociation.org/standards-clinical-guidance

24. National Institute for Health and Care Excellence (NICE). Burns and scalds (QS107). 2015. Available at: https://www.nice.org.uk/guidance/qs107

25. International Society for Burn Injuries (ISBI). ISBI Practice Guidelines for Burn Care. Burns. 2016;42(5):953-1021. doi:10.1016/j.burns.2016.05.013 PMID: 27542292

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Last Updated: 10 January 2026 Next Review: January 2027 Reviewed By: MedVellum Editorial Team

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Medical Disclaimer: This content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances, local protocols, and specialist input. Always consult appropriate specialists for burns centre referral criteria and management guidance.