Key Facts

Burns are a common emergency presentation requiring rapid assessment of airway safety, burn depth and area, fluid resuscitation, and pain management. UK burns services are regionalised with specialist burns centres for complex injuries.

Epidemiology

Approximately 175,000 people attend UK EDs with burns annually. ~13,000 require hospital admission. ~300 deaths/year from burns and fires. Scalds are the most common mechanism in children; flame burns in adults. House fires account for the majority of deaths.

Aetiology

• Thermal: Scalds (hot liquid/steam), flame, contact (radiator, iron)
• Chemical: Acids, alkalis (alkali burns penetrate deeper)
• Electrical: Low voltage (<1000V) and high voltage (>1000V) — cardiac arrest risk
• Radiation: Sunburn, radiotherapy
• Inhalational: Thermal injury to upper airway, chemical injury to lower airway (CO, cyanide)

Pathophysiology

Burns cause tissue destruction through protein denaturation. Jackson's burn wound model describes three zones: zone of coagulation (irreversible necrosis at centre), zone of stasis (potentially salvageable — goal of resuscitation), and zone of hyperaemia (will recover). Systemic inflammatory response occurs with burns >20% TBSA causing capillary leak, hypovolaemia, and distributive shock.

Burn Depth Assessment

• Superficial (epidermal): Red, painful, no blisters, blanches — heals in 7 days without scarring
• Superficial partial thickness: Blistering, moist, painful, blanches — heals in 14-21 days with minimal scarring
• Deep partial thickness: Mottled pink/white, reduced sensation, sluggish blanching — requires surgery, >3 weeks
• Full thickness: White/waxy/leathery, painless, no blanching, no capillary refill — requires surgery/grafting

TBSA Assessment

• Wallace Rule of Nines (adults)
• Lund and Browder chart (most accurate, especially children)
• Palm method: Patient's palm (including fingers) = ~1% TBSA

Red Flags

• Stridor, hoarseness, soot in sputum — inhalational injury, may need immediate intubation
• Circumferential burns — risk of compartment syndrome (limb), respiratory compromise (chest/abdomen)
• Burns >20% TBSA — systemic response, need aggressive fluid resuscitation
• Electrical burns — cardiac arrhythmias; visible burn may underestimate deep tissue injury
• Non-accidental injury (especially children) — glove/stocking pattern, clear tide marks, delay in presentation

Bedside

• Primary survey (ABCDE): Airway is priority — assess for inhalation injury
• TBSA estimation: Wallace Rule of Nines or Lund and Browder chart
• Depth assessment: Clinical — erythema, blistering, capillary refill, sensation
• Weight: Essential for Parkland formula calculation
• SpO2 and CO-oximetry: Standard pulse oximetry may be falsely normal in CO poisoning

Bloods

• FBC, U&Es: Baseline; haemoconcentration from fluid shifts
• ABG with carboxyhaemoglobin (COHb): If inhalational injury — COHb >10% significant, >25% severe
• Lactate/cyanide level: If smoke inhalation
• CK: Electrical burns — rhabdomyolysis risk
• Group and save: If burns requiring surgery
• Coagulation: DIC risk in extensive burns

Imaging

• CXR: Baseline and for inhalational injury
• ECG: Electrical burns — arrhythmia monitoring for 24h

Special Tests

• Bronchoscopy: Confirm inhalational injury — mucosal oedema, soot, erythema
• Laser Doppler imaging: Objective burn depth assessment (used in burns centres)

Non-pharmacological

• Cooling: Cool running water 20 min within 3h; remove clothing/jewellery; cover with cling film (loosely)
• Airway: Early intubation if suspected inhalational injury — airway oedema can progress rapidly
• Fluid resuscitation (Parkland formula): 4mL × %TBSA × weight (kg) in first 24h; half in first 8h from time of burn, half in next 16h; use Hartmann's solution
• Wound care: Clean, debride loose tissue, apply antimicrobial dressings (e.g., Jelonet, Mepitel, silver-based dressings)
• Temperature: Keep warm — major burns patients lose heat rapidly

Pharmacological

• Analgesia: Paracetamol 1g QDS + opioid (morphine 0.1-0.2mg/kg IV titrated); intranasal diamorphine in children
• Tetanus prophylaxis: Update if required
• Antibiotics: NOT routine prophylaxis — only for confirmed infection
• CO poisoning: High-flow O2 100% via non-rebreather (half-life of COHb drops from 4-6h to 60-90 min)
• Cyanide poisoning: Hydroxocobalamin 5g IV (Cyanokit) if suspected
• VTE prophylaxis: LMWH for immobilised patients with significant burns

Surgical/Interventional

• Escharotomy: For circumferential full-thickness burns — decompress limb or chest
• Fasciotomy: For compartment syndrome (especially electrical burns)
• Surgical debridement and skin grafting: For deep partial and full-thickness burns
• Reconstructive surgery: Long-term management of contractures and scarring

Referral Criteria

• Burns centre referral (UK Burns Network): >10% TBSA adult, >5% child/elderly, full thickness >1%, face/hands/feet/genitalia/perineum, inhalational, circumferential, chemical, electrical, associated major trauma

• Baux score: Age + %TBSA = predicted mortality (revised Baux includes inhalation injury)
• Superficial burns: Complete healing without scarring
• Partial thickness: Healing in 2-3 weeks; risk of hypertrophic scarring
• Full thickness: Requires grafting; significant scarring risk
• Inhalational injury: Doubles mortality for any given %TBSA burn
• Electrical burns: Mortality depends on voltage; cardiac arrest and rhabdomyolysis are key risks
• Long-term: Psychological morbidity common — PTSD, depression, anxiety; burns rehabilitation is prolonged

Wallace Rule of Nines (Adult)

Parkland Formula Example

Burns Centre Referral Criteria (UK)