Burns
Burns are injuries caused by exposure to thermal, electrical, chemical, or radiation energy.
This updated UKMLA guide to burns is based on NICE CKS and RCEM Learning, which covers causes, classification, assessment, referral criteria, and management
Types of Burn (By Underlying Cause)
| Type | Cause / description |
|---|---|
| Thermal burn | Thermal burns include:
|
| Electrical burn | Occur when electricity flows through the body from an entry point to an exit point. Heat energy from the electric current damages tissue along its path of flow |
| Chemical burn | Results from contact with corrosive agents
|
Classification of Burns by Depth
| Depth of burn | Affected skin | Skin appearance | Blisters | Sensation | Capillary refill |
|---|---|---|---|---|---|
| Superficial epidermal | Epidermis (no dermis involvement) | Red | No | Painful (normal) | Blanches then refill rapidly |
| Superficial dermal | Epidermis + superficial dermis (no deep dermis involvement) | Red / pale pink (moist) | Yes | Blanches then refill slowly | |
| Deep dermal | Epidermis + entire dermis (no subcutaneous involvement) | Blotchy / mottled / red (dry) | Painful (less intense) | Does not blanch | |
| Full thickness | Epidermis + dermis + subcutaneous tissue +/- muscle and bone | White / brown / black (charred)
Dry / leathery / waxy |
No | Painless |
One may still come across the traditional burn classification system (1st, 2nd, 3rd degree burns) in some textbooks or older resources. This is how the latest classification (shown above) corresponds to the old classification:
- Superficial epidermal = 1st degree burn
- Superficial dermal + deep dermal = 2nd degree burn
- Full thickness = 3rd degree burn
Quantifying Burn Extent
There are 3 main ways to estimate the burn extent, measured by TBSA – the % of the body surface area that is burnt / affected.
Wallace’s Rule of 9s
The rule of 9s estimates the body surface area using multiples of 9, representing different areas of the body:
- Head + neck = 9%
- Each upper limb = 9%
- Anterior torso = 18%
- Posterior torso = 18%
- Each lower limb = 18%
- Perineum and genitalia = 1%
It is possible for exam questions to ask one to estimate the TBSA by providing a written description of what parts of the body are affected / burn (e.g. this patient comes in with his entire left arm and leg burnt, what is the estimated burnt surface area?).
Rule of Palm
The rule of palm is a simple method to estimate the TBSA by using the patient’s palm as a reference:
- The entire palmar surface of the patient’s hand (including the fingers) represents ~1% of body surface area
The rule of palm is mainly useful for irregular burn patterns or small burnt areas.
Lund and Browder Chart
The Lund and Browder chart is the gold standard and most accurate method to estimate TBSA across all age groups (adults, children and babies)
- The chart divides the body into multiple regions, each assigned a specific percentage that represents its contribution to body surface area
- It accounts for changes in body proportions with age, especially important in children (e.g., a larger head relative to body).
Complications
| General complications |
|
| Circumferential burn |
|
| Electrical burn |
|
| Chronic complications |
|
Assessment and Management
Approach (in order):
- Immediate first aid (pre-hospital)
- Assess burn severity and complexity to decide the need for referral
- Definitive management
Step 1 – Immediate First Aid
Assess the patient’s ABC (airway, breathing, and circulation) and assess for any potentially life-threatening injuries or trauma (e.g. head injuries, crush injuries, penetrating injuries).
If there are no other more worrying / serious injuries, provide the following first aid measures:
| Burn type | First aid measures |
|---|---|
| Thermal burns |
See below for the indications for A&E referral in patients with thermal burns. Do NOT apply topical creams at this stage, as this will affect assessment of the wound |
| Electrical burns |
ALL electrical burns require immediate admission to A&E |
| Chemical burns |
Do not attempt to neutralise chemicals (e.g. using alkali to neutralise an acidic chemical burn) as it risks generating additional heat, which may increase tissue damage. ALL chemical burns require immediate admission to A&E |
Step 2 – A&E Referral Indications
Information regarding burn depth and extent classification is outlined above.
The following patients would require immediate admission to A&E:
| Category / type | Exact indications |
|---|---|
| By type of burn |
|
| By burn extent |
|
| By burn depth |
|
| By location | Burns affecting any of the critical areas:
|
All burns associated with suspected NAI should also be referred, regardless of the complexity of the burn. Suspected NAI with ANY of the following:
- Injury cannot be explained or is not logical
- The person is not independently mobile
- Injury on skin that is not expected to come into contact with a hot object (e.g. back, buttocks, soles of feet)
- Suspected burn from a cigarette or iron (based on the shape)
- Injury indicating forced immersion
Step 3 – Definitive Management
Primary Care Management
Superficial Epidermal Burns
Superficial epidermal burns usually do not require specific burn wound treatment after initial first aid measures.
Management is usually supportive and safety-netting:
| Symptomatic relief measures |
|
| General advice |
|
| Safety netting | Advise on:
|
| Wound infection |
DO NOT routinely prescribe antibiotics to prevent a wound infection if there are NO features of infection If the patient develops signs and symptoms of infection (e.g. fever, increase in pain, new odour, pus formation, redness):
|
Superficial Dermal Burns
Provide the following burn wound treatment, after initial first aid measures:
| Component | Treatment |
|---|---|
| Blister management | Blister de-roofing is indicated in ANY of the following:
Click to view rationale for deroofing Method of de-roofing:
|
| Wound care | Clean the wound and apply an appropriate non-adherent dressing (usually by practice nurse / district nurse / tissue viability nurse)
Arrange wound re-assessment and dressing change after 48 hours, then every 3-5 days until the wound is healed |
| Patient education | Advise:
Provide safety netting on:
|
| Tetanus prophylaxis | Assess the patient for the need for tetanus prophylaxis, in line with those outlined in the Tetanus Prophylaxis article |
| Wound infection |
DO NOT routinely prescribe antibiotics to prevent a wound infection if there are NO features of infection If the patient develops signs and symptoms of infection (e.g. fever, increase in pain, new odour, pus formation, redness):
|
Secondary Care Management
Disclaimer:
This section summarises key secondary care management principles at a non-specialist level. It does not represent the full comprehensive management of burns, which is highly individualised based on factors such as burn type, location, depth, extent, and associated complications.
Referral to Specialist Burn Services
The minimum threshold for referral: [Ref]
- All burns ≥2% TBSA in children or ≥3% TBSA in adults
- All full-thickness burns
- All circumferential burns
- Any burn not healed in 2 weeks
Fluid Resuscitation
Fluid resuscitation is indicated in: [Ref]
- Adults with >20% TBSA
- Children with >10% TBSA
Rationale: larger burns cause major intravascular fluid loss, leading to risk of hypovolaemic shock and organ hypoperfusion
The Parkland formula is most frequently used to calculate the resuscitation fluid required over 24 hours (from the time of the burn): [Ref]
- Amount of fluid over 24 hours (in mLs) = 2-4 mL x weight (in kg) x TBSA (in %)
- 3mL is usually used for the calculation
- 2mL might be considered in children or those at risk of fluid overload (e.g. renal impairment, heart failure)
- 4 mL might be considered in inhalational injuries where fluid losses are likely to be greater
- Choice of fluid: warmed balanced crystalloid (e.g. Hartmann’s solution)
- Fluid administration
- 50% of the calculated volume should be given in the first 8 hours
- The remaining 50% to be given over the subsequent 16 hours
Monitor urine output – aiming for an output of >0.5 mL/kg/hour in adults and >1 mL/kg/hour in children <30 kg
Worked example of the Parkland formula:
Case: A 75 kg patient presented with a burn affecting 30% of his TBSA
Parkland formula: 3 x 75 x 30 = 6750 mL
- 6750 mL of Hartmann’s to be given over 24 hours
- 3375 mL (50% of 6750) to be given over the first 8 hours
- 3375 mL to be given over the subsequent 16 hours
Escharotomy
Circumferential deep dermal or full-thickness burns can form a rigid, non-expansile eschar. As burn-related oedema develops, this can impair:
- Ventilation (if affecting the chest)
- Distal circulation (if affecting a limb)
An escharotomy is an emergency surgical procedure used to release the constricting eschar and restore adequate ventilation or perfusion.
An eschar is a piece of dead, leathery tissue that forms over a severe burn wound, typically in deep dermal or full-thickness burns.