Burn Assessment — TBSA, Depth & Airway

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Target exams

Red flags

• Count ONLY partial-thickness (2nd degree) and full-thickness (3rd degree) burns in %TBSA. Superficial (1st degree / erythema / sunburn) is EXCLUDED. Counting it inflates the formula and causes fluid overload (fluid creep).
• Inhalation injury (soot in mouth/nose, singed nasal hairs, carbonaceous sputum, hoarse voice, stridor, enclosed-space fire) demands EARLY intubation — secure the airway before oedema closes it. It carries roughly three-fold higher odds of in-hospital mortality.
• The first half of the Parkland volume goes in the FIRST 8 hours; the remainder follows over the subsequent 16 hours. Deliver by titration to urine output, not as a fixed volume.
• Use an age-adjusted chart (LUND-BROWDER) for children — fixed adult percentages (Rule of Nines) misestimate TBSA in the small child because the head is proportionally much larger and the legs smaller; estimation errors are greatest in injured children.
• The palm method = the PATIENT'S OWN palm (palm + digits, not palm alone). It is ~0.8-1% TBSA. Using the rescuer's palm or the palm-only (0.5%) is a common error.
• Enclosed-space fire = carbon monoxide + cyanide. Check carboxyhaemoglobin (pulse oximetry is falsely normal). Give 100% oxygen; hydroxocobalamin for cyanide. See the CO/cyanide topic.
• Circumferential full-thickness burn of the chest or a limb = prophylactic escharotomy. The rigid eschar plus sub-eschar oedema causes ventilatory failure (chest) or limb ischaemia (limb).
• Electrical burns grossly under-estimate true tissue injury — surface TBSA misses deep muscle damage. Expect much higher fluid requirements, watch for myoglobinuria and compartment syndrome in unburned limbs.
• A major burn in a child, or any non-accidental injury pattern (stocking/glove distribution, sharply demarcated 'dunk' lines, unrelated delays in presentation) = safeguarding referral.
• Depth is DYNAMIC. A superficial partial burn can convert to deep partial or full thickness over 48-72 h (especially with inadequate perfusion or infection). Re-assess.