Key Facts

Burns management requires systematic assessment of depth, area, and associated injuries. Appropriate fluid resuscitation and timely referral to specialist services are critical.

Epidemiology

~175,000 burn injuries/year in UK (most minor). ~13,000 ED attendances for burns. ~4,500 hospital admissions. ~300 deaths annually. Peak populations: Children <5 (scalds) and young adult males (flame burns).

Aetiology

• Thermal: Flame (~35%), scald (~30%), contact (~10%)
• Chemical: Acid, alkali (alkali typically causes deeper injury — liquefactive necrosis)
• Electrical: Low voltage (household), high voltage (>1000V — deep tissue injury, cardiac arrest risk)
• Radiation: Sunburn, industrial
• Non-accidental injury: Consider in children — symmetrical burns, clear demarcation, inconsistent history

Pathophysiology

Jackson's burn model (zones of injury):

• Zone of coagulation: Central; irreversible tissue necrosis
• Zone of stasis: Surrounding; potentially salvageable tissue (at risk of ischaemia in first 48 hours)
• Zone of hyperaemia: Peripheral; will recover

Adequate resuscitation protects the zone of stasis from converting to necrosis.

Burn Depth Assessment

Red Flags

• Airway: Stridor, hoarseness, carbonaceous sputum, facial burns, singed nasal hairs → EARLY intubation (airway oedema progresses rapidly)
• Circumferential burns: Limb — vascular compromise; chest — respiratory compromise → escharotomy
• Electrical burns: May have minimal skin injury but deep tissue/organ damage; risk of cardiac arrhythmias, compartment syndrome, rhabdomyolysis
• Non-accidental injury: Child with glove/stocking pattern burn, clear tide marks, inconsistent history

Bedside

• TBSA assessment: Rule of Nines (adults) or Lund and Browder chart (more accurate, especially children)
• Patient's palm: ~1% TBSA (useful for small or scattered burns)
• Airway assessment: Flexible nasendoscopy if inhalation injury suspected
• ECG: Electrical burns (arrhythmia risk)

Bloods

• FBC, U&Es, LFTs: Baseline
• CK: Rhabdomyolysis (electrical burns, major burns)
• ABG/VBG: CO level (carboxyhaemoglobin) if inhalation injury — co-oximetry
• Lactate: Perfusion marker
• G&S/crossmatch: Major burns
• Clotting: DIC in severe burns

Imaging

• CXR: Inhalation injury, ARDS
• CT: If associated trauma

Immediate (Pre-Hospital and ED)

1. Safety: Remove from source of burn; stop the burning process
2. Cool: Running tepid water for 20 minutes (effective up to 3 hours post-injury); avoid ice (causes vasoconstriction)
3. Cover: Cling film (single layer, loosely) — reduces pain, prevents contamination
4. ABCDE: Especially airway — intubate early if inhalation injury suspected
5. 100% O₂: If CO poisoning suspected (SpO₂ unreliable — CO gives falsely normal SpO₂)

Fluid Resuscitation (Burns >15% TBSA adults, >10% children)

• Parkland formula: 4mL × weight (kg) × %TBSA burns
• Give 50% in first 8 hours from time of burn (NOT from time of arrival), remaining 50% over next 16 hours
• Use Hartmann's solution (Ringer's lactate)
• Titrate to urine output: Adults 0.5-1 mL/kg/hr; children 1 mL/kg/hr

Wound Management

• Superficial: Simple dressings, analgesia
• Partial thickness: Non-adherent dressings (e.g., Mepitel), silver-based antimicrobials if needed
• Full thickness: Will require surgical debridement and skin grafting
• Escharotomy: Circumferential full-thickness burns causing vascular/respiratory compromise

Referral to Burns Centre

• 10% TBSA (adults), >5% (children), >5% (elderly >60)

• Full-thickness burns >5%
• Circumferential burns
• Face, hands, feet, genitalia, perineum, major joints
• Inhalation injury
• Chemical or electrical burns
• Non-accidental injury
• Pre-existing medical conditions complicating management

Surgical

• Debridement and grafting: Full-thickness and deep partial-thickness burns
• Split-thickness skin graft (SSG): Most common; donor site (thigh) heals spontaneously
• Negative pressure wound therapy: Aids graft take

• Baux score: Mortality estimate = Age + %TBSA (modified Baux adds 17 for inhalation injury)
• Minor burns (<10% TBSA, partial thickness): Excellent prognosis
• Major burns (>40% TBSA): Significant mortality; modern burn centres have improved survival
• Inhalation injury: Doubles mortality for any given TBSA
• Hypertrophic scarring: Common in deep partial and full-thickness burns; managed with pressure garments, silicone, physiotherapy
• Psychological morbidity: PTSD, depression, body image issues — psychological support essential

Rule of Nines (Adults)

Parkland Formula