Burns Management Guide

Related Subjects: |Cellulitis |Pyoderma gangrenosum |Pemphigus Vulgaris |Toxic Epidermal Necrolysis |Stevens-Johnson Syndrome |Necrotising fasciitis |Gas Gangrene (Clostridium perfringens) |Purpura Fulminans |Severe burns |Anatomy of Skin

🔥 Anyone with burns should also be presumed to have smoke inhalation injury - consider the ABCs and watch for stridor, hoarseness, or drooling. 😮‍💨 These patients are at risk for ARDS and airway compromise, which may require early intubation. 📞 Referral: Transfer to a burns centre if:

• 👶 >10% TBSA in children
• 🧑 >15% TBSA in adults
• 🩹 Any full-thickness burns
• 😷 Burns to face, hands, perineum, feet, flexures, or joints
• ⚡ Chemical, electrical, lightning injuries
• 🔥 Circumferential limb or chest burns
• 🚨 Suspected inhalation injury

🔥 Types of Burns

• ☀️ First Degree / Superficial: Epidermis only. Red, painful, no blisters. Heal without scarring.
• 💧 Second Degree / Partial Thickness: Epidermis + dermis. Red, blistered, very painful, moist. Heal with minimal scarring.
• 🪵 Third Degree / Full Thickness: All layers destroyed. White/charred/leathery. Painless (nerve damage). Needs grafting → scarring.

😷 Signs of Inhalational Injury

• Facial/neck/chest burns
• Singed nasal hair/eyebrows
• Soot in sputum/oropharynx
• Hoarseness, stridor, dyspnoea
• Oropharyngeal swelling/erythema

⚠️ Complications of Burns

• Compartment syndrome
• Hypovolaemia, electrolyte imbalance
• Infection, sepsis
• Hypothermia
• Neuropathic pain, pruritus
• Hypertrophic scars, contractures
• Psychological trauma: depression, anxiety, PTSD

📍 Special Areas of Concern

• Face, hands, perineum, genitalia, feet, flexures, joints → functional & cosmetic impact.

🧪 Investigations

• Bloods: FBC, U&E, glucose, clotting, CK, cross-match
• ABG: lactate, HbCO
• CXR if inhalation suspected

🧾 Management Overview

• ABCDE approach 🔄
• High-flow O₂ 💨
• Fluid resuscitation 💧 (Parkland + urine monitoring)
• Early intubation if airway risk 🫁
• Wound care: cling film, sterile dressings 🩹
• IV analgesia 💊
• Nutritional support 🍲 (↑ metabolic demand, dietician input)
• Escharotomy if needed ✂️
• Tetanus prophylaxis 💉
• Early burns unit referral 📞

📚 Teaching Commentary

Burns are a multisystem insult - airway, circulation, and metabolism all collapse if not managed promptly. The first 24h = airway + fluids, not definitive surgery. Always check for “hidden killers”: inhalational injury, CO or cyanide, associated trauma. UK practice: 🔗 burns care is regionalised → early referral is life-saving. Remember: 🧪 resuscitation is a balance - underdo it and they die of shock, overdo it and you worsen oedema, including airway swelling. And never forget the patient’s psychological and safeguarding needs - scarring and trauma can last far beyond the acute injury.

🔖 References

• ABC of Burns: Pathophysiology and Types of Burns
• Clinical Guideline: Burns Injury
• Management of Major Burns: A Review

Case 1 – Adult flame burn with inhalation risk

A 38-year-old rescued from a house fire has facial burns, singed nasal hairs, hoarse voice, and cough with soot; mixed-depth burns to the anterior trunk and both upper limbs (~28% TBSA, Rule of Nines). Priorities: ABCDE with high-flow O₂ (100% non-rebreathe), early airway protection if progressive oedema/stridor, and blood gases including carboxyhaemoglobin (pulse oximetry unreliable). Start warmed IV fluids using the Parkland formula (4 mL/kg/%TBSA of lactated Ringer’s; give half in 8 h from time of burn), titrating to urine ≥0.5 mL/kg/h; insert urinary catheter and consider analgesia, tetanus, and escharotomy if circumferential chest/limb burns impair ventilation/flow. Cool the burn (20 min tepid water if <3 h from injury), cover with cling film, avoid ice. Refer to a UK burns centre (e.g., >10% TBSA, face/airway, hands/perineum, electrical/chemical, or inhalation injury) for debridement and definitive dressings/grafting.

Case 2 – Paediatric scald; safeguarding considerations

A 2-year-old pulls a kettle lead causing hot-water scald to the anterior chest and left arm; blistered, painful partial-thickness burns covering ~8% TBSA (use Lund–Browder chart). Manage with ABCDE, prompt analgesia (oral morphine/IN fentanyl as appropriate), tepid cooling for up to 20 min, non-adherent dressing (paraffin gauze) and cling film, elevation of the limb, and oral fluids ± IV if not tolerating; consider fluid resuscitation if >10% TBSA (many UK centres use 2–3 mL/kg/%TBSA in children) and maintain euglycaemia. Assess tetanus status. Document a careful history and injury pattern; involve senior review and safeguarding if concerns (e.g., clear immersion lines, inconsistent story). Arrange burns clinic follow-up within 24–48 h to monitor pain, infection, and function; early physiotherapy/splinting if joints are involved.