Summary

Burns are tissue injuries caused by heat (thermal), chemicals, electricity, radiation, or friction. They represent a complex trauma requiring systematic assessment of burn depth, total body surface area (TBSA), and associated injuries. Burns cause local tissue destruction through Jackson's three zones (coagulation, stasis, hyperaemia) and can trigger massive systemic inflammatory responses with fluid shifts, shock, and multi-organ dysfunction in severe cases. Initial management priorities include airway protection (especially if inhalation injury), fluid resuscitation using the Parkland formula, wound care, and early referral to burns centres for significant injuries. Burn depth determines healing potential: superficial burns heal spontaneously, while full thickness burns require surgical excision and grafting.

Key Facts

• Incidence: ~175,000 ED presentations annually in UK; ~13,000 require hospitalisation
• Mortality: Major burns (>40% TBSA) carry significant mortality, especially with inhalation injury
• Critical TBSA thresholds: >15% adults, >10% children/elderly require IV fluid resuscitation
• Resuscitation formula: Parkland formula: 4 mL × kg × %TBSA in first 24 hours
• Jackson's zones: Coagulation (necrotic), Stasis (salvageable, at-risk), Hyperaemia (will recover)
• Depth assessment: Superficial (epidermal) → Superficial partial → Deep partial → Full thickness
• Rule of Nines: Quick TBSA estimation in adults; palm = 1% BSA
• Lund and Browder chart: More accurate, accounts for age differences in body proportions
• Burns centre referral criteria: >10% TBSA, full thickness >1%, face/hands/feet/perineum, inhalation, electrical, chemical
• Escharotomy: Emergency procedure for circumferential full thickness burns threatening perfusion

Clinical Pearls

"The Stasis Zone is the Prize": Jackson's stasis zone contains injured but salvageable tissue. Good resuscitation and wound care preserve it; poor management converts it to necrosis. Your first 24-48 hours of care determines outcomes.

"Cool the Burn, Warm the Patient": Cool running water for 20 minutes is first aid, but hypothermia kills burn patients. Cover with cling film (not wrapped circumferentially) and keep patient warm during transport.

"Inhalation Injury Changes Everything": Burns with inhalation injury have dramatically worse prognosis. Look for facial burns, singed nasal hairs, carbonaceous sputum, hoarse voice, or stridor. Intubate early if concerned — airway oedema can be rapid and fatal.

"Circumferential = Emergency": Circumferential full thickness burns to limbs or chest are emergencies. Inelastic eschar plus oedema causes compartment syndrome or respiratory failure. Know how to do an emergency escharotomy.

"Parkland is a Guide, Not Gospel": Start with Parkland formula but titrate to urine output (0.5-1 mL/kg/hr adults, 1-2 mL/kg/hr children). Under-resuscitation causes shock; over-resuscitation causes oedema and compartment syndrome.

Why This Matters Clinically

Burns are common injuries with significant morbidity and mortality if mismanaged. Accurate initial assessment determines appropriate triage, resuscitation, and referral decisions. First responders and emergency physicians must recognise red flags (inhalation injury, large TBSA, circumferential burns) that require burns centre input. Proper first aid and early resuscitation are life-saving interventions.[1,2]

Primary Survey (ATLS/EMSB Approach)

A — Airway (with C-spine if trauma):

• Signs of inhalation injury: facial burns, singed nasal hairs, carbonaceous sputum
• Stridor, hoarse voice indicate impending obstruction
• INTUBATE EARLY if concerned — oedema worsens rapidly

B — Breathing:

• Chest wall burns may restrict expansion
• Circumferential chest burns → escharotomy may be needed
• Assess for associated thoracic trauma

C — Circulation:

• IV access (through burned skin if necessary)
• Assess for shock (tachycardia, hypotension, delayed cap refill)
• Calculate TBSA and initiate Parkland resuscitation if indicated

D — Disability:

• GCS assessment
• Carbon monoxide or cyanide poisoning if house fire

E — Exposure:

• Remove all clothing and jewellery
• Full skin examination to assess extent
• Keep patient warm (burns patients lose heat rapidly)

Secondary Survey

Detailed Burn Assessment:

• Burn mechanism (thermal, chemical, electrical)
• Time of injury (for fluid resuscitation timing)
• First aid given
• Depth assessment (colour, blistering, sensation, cap refill)
• TBSA calculation (Rule of Nines or Lund and Browder)
• Circumferential injuries identified
• Associated injuries

Documentation:

• Diagram of burns
• Calculate TBSA
• Document depth at each site
• Photograph (with consent)

Special Assessments

Survival Prediction

Baux Score (historical, now outdated):

• Mortality % ≈ Age + %TBSA
• Modified Baux adds 17 points for inhalation injury

Modern Prediction: Computerised models using age, %TBSA, inhalation injury, and comorbidities

Prognostic Factors

Outcomes by TBSA

Key Guidelines

Landmark Studies

Parkland Formula (Baxter 1968)

• Established crystalloid-based resuscitation formula
• 4 mL/kg/%TBSA in first 24 hours
• Remains standard starting point
• PMID: 5665858

Herndon et al. — Early Excision (1989)

• Early surgical excision improved survival in major burns
• Foundation for modern burn surgery
• PMID: 2913217

ISBI Practice Guidelines (2016)

• Comprehensive evidence-based guidelines
• Covers acute management to rehabilitation
• PMID: 27613323

Evidence Strength

What is a burn?

A burn is an injury to the skin (and sometimes deeper tissues) caused by heat, chemicals, electricity, or radiation. Burns range from mild (like sunburn) to severe and life-threatening.

First aid for burns

If you or someone is burned:

1. Cool the burn under running tap water for 20 minutes (this is still effective up to 3 hours after injury)
2. Remove clothing and jewellery near the burn, unless stuck
3. Cover with cling film (lay it on; don't wrap around)
4. Keep warm — cool the burn, not the person
5. Do NOT use ice, butter, toothpaste, or any creams

When to seek help

Go to A&E or call 999 if:

• The burn is larger than the person's hand
• It's a deep burn (white or charred skin, not painful)
• The burn is on the face, hands, feet, or groin
• There was smoke inhalation
• The person is a child or elderly
• You're not sure how serious it is

What happens at hospital?

Doctors will:

• Assess how deep and how large the burn is
• Give pain relief
• Give fluids through a drip for large burns
• Clean and dress the wound
• Refer to a specialist burns centre if needed

Recovery

Small burns heal in 1-3 weeks. Larger or deeper burns may need skin grafts (surgery to cover the wound with healthy skin). Scarring is possible, and follow-up with a burns team helps with healing and rehabilitation.

High-Yield Exam Topics

Sample Viva Questions

Q1: A 40-year-old man with 40% TBSA burns arrives 2 hours after injury. Calculate his fluid requirements.

Model Answer: Using the Parkland formula: Volume = 4 mL × 80 kg (estimated) × 40% = 12,800 mL in 24 hours. Half (6,400 mL) should be given in the first 8 hours from time of burn. Since 2 hours have passed, 6,400 mL should be given over the remaining 6 hours = ~1,067 mL/hour. The second half (6,400 mL) is given over the next 16 hours = 400 mL/hour. I would use Hartmann's solution and titrate to urine output of 0.5-1 mL/kg/hr (40-80 mL/hr for an 80 kg man).

Q2: What are the indications for escharotomy?

Model Answer: Escharotomy is indicated for circumferential full thickness burns when the inelastic eschar causes compartment syndrome or restricts vital functions:

1. Limb burns: Absent pulses, pain on passive stretch, increasing compartment pressure
2. Chest burns: Inadequate chest expansion, rising airway pressures
3. Abdominal burns: Abdominal compartment syndrome (rare)

The procedure involves full-thickness incision through eschar to subcutaneous fat, along mid-axial lines to avoid major neurovascular structures.

Q3: What are Jackson's zones of burn injury?

Model Answer: Jackson described three concentric zones:

1. Coagulation: The central zone of irreversible cell death due to protein coagulation
2. Stasis: Surrounding zone with reduced perfusion; cells are viable but at risk of necrosis without adequate resuscitation
3. Hyperaemia: The outer zone with vasodilation; will recover spontaneously

The stasis zone is the therapeutic target — good first aid, resuscitation, and wound care preserve this zone; poor management causes it to convert to necrosis, deepening the burn.

Common Exam Errors

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.