Burns and scalds
Exam Tips
- In OSCEs, start with first aid and ABCDE before describing burn depth/TBSA.
- State UK complex burn triggers clearly: all chemical/electrical burns, critical areas, circumferential or joint-crossing burns, and larger TBSA thresholds.
- Do not count simple erythema in TBSA calculation; use Lund and Browder in children (see standard chart figure used in burn teaching).
- Reassessment at 24-72 hours is high yield: burn depth can worsen due to evolving zone of stasis injury.
- Always mention safeguarding when burn pattern or history is inconsistent with accidental injury.
Definition
Burns are tissue injuries caused by thermal, electrical, chemical, or radiation energy; scalds are thermal burns from hot liquids or steam. Injury may involve not only skin but also deeper structures (airway, muscle, or bone), with severity determined by depth, total body surface area (TBSA), and whether critical areas (face, hands, feet, perineum, genitalia, circumferential or joint-crossing burns) are involved.
Pathophysiology
Thermal or chemical/electrical energy causes protein denaturation, cell membrane disruption, microvascular thrombosis, and an inflammatory capillary-leak response. Classically, tissue forms zones of coagulation (irreversible necrosis), stasis (potentially salvageable with good perfusion), and hyperaemia (usually recovers). Larger burns trigger systemic inflammatory response with fluid shifts, hypovolaemia, and risk of burn shock; inhalational injury adds airway oedema and bronchospasm, while electrical injuries can cause occult deep muscle necrosis, rhabdomyolysis, arrhythmia, and myoglobinuric AKI. See Figure reference: Lund and Browder TBSA chart used in UK burn assessment teaching.
Risk Factors
- Age extremes (children, especially under 5 years, and older adults)
- Reduced mobility or sensory impairment
- Cognitive impairment, dementia, learning disability, or reduced hazard awareness
- Epilepsy, syncope, alcohol/drug misuse leading to accidental exposure
- Occupational exposure to heat, electricity, chemicals, or steam
- Comorbidity impairing healing (diabetes, chronic cardiac/respiratory/hepatic disease, malnutrition, immunosuppression)
- Unsafe home environment (hot water scald risk, poor supervision of vulnerable people)
Clinical Features
Symptoms
- Pain severity often correlates with depth (deep full-thickness areas may be relatively painless)
- History of heat/flame/contact/electrical/chemical exposure
- Dyspnoea, throat pain, hoarseness, cough, or chest tightness after smoke exposure
- Systemic symptoms in severe burns: dizziness, thirst, weakness, reduced urine output
- Itch and neuropathic pain during healing phase
Signs
- Burn depth signs: erythema/blistering/moist pink dermis (superficial-partial) versus pale/mottled, dry, non-blanching, leathery eschar (deep/full-thickness)
- TBSA estimate (exclude simple erythema) using Lund and Browder chart; Rule of Nines in adults
- Critical-site involvement: face, hands, feet, perineum/genitalia, circumferential burns, burns crossing joints
- Inhalation red flags: singed nasal hairs/eyebrows, soot in mouth/sputum, stridor, wheeze, carbonaceous sputum
- Shock physiology in major burns: tachycardia, hypotension, cool peripheries
- Neurovascular compromise distal to circumferential limb burn (pain, pallor, pulselessness, paraesthesia, paralysis)
- Safeguarding red flags: sharply demarcated immersion pattern, glove/stocking distribution, implement-shaped burns, inconsistent history
Investigations
Management
Lifestyle Modifications
- Immediate first aid: stop burning process, remove heat source and non-adherent clothing/jewellery, cool with cool running water for 20 minutes (ideally within 3 hours), avoid ice
- Cover with clean non-fluffy dressing or cling film layer (not circumferentially wrapped); keep patient warm to prevent hypothermia
- Early specialist referral for complex burns (all chemical/electrical burns; critical areas; large TBSA; circumferential burns; inhalation injury; safeguarding concern)
- Reassess burn depth and neurovascular status at 24-72 hours; provide clear safety-net advice for infection, increasing pain, fever, or reduced urine output
Pharmacological Treatment
Analgesia
- Paracetamol 1 g orally every 4-6 hours (max 4 g/day in adults)
- Ibuprofen 400 mg orally three times daily with food (max 2.4 g/day)
- Morphine sulfate IV titrated in small boluses (e. g, 1-2 mg every 5 minutes) for severe acute pain in monitored settings
Avoid NSAIDs in AKI risk, active GI ulceration, severe dehydration, or NSAID hypersensitivity/asthma sensitivity. Titrate opioids carefully; monitor sedation and respiratory rate, and prescribe antiemetic/laxative if ongoing opioid use.
Fluid resuscitation for major burns
- Hartmann's solution IV using Parkland approach: 4 mL x body weight (kg) x %TBSA over first 24 hours (give half in first 8 hours from time of burn)
Used for significant burns (commonly >15% TBSA adults, lower thresholds in children). End points include urine output and haemodynamic response; avoid under-resuscitation (shock/AKI) and over-resuscitation (oedema/compartment risk).
Tetanus prophylaxis
- Td/IPV vaccine booster 0.5 mL IM when indicated by immunisation status and wound risk
- Human tetanus immunoglobulin 250 IU IM (or 500 IU IM if heavily contaminated/high-risk delay) for selected tetanus-prone wounds
Check vaccine history in all burn patients. Follow UK tetanus-prone wound guidance; do not delay urgent burn care while arranging prophylaxis.
Antimicrobials (if infection present, not routine prophylaxis)
- Flucloxacillin 500 mg-1 g orally four times daily (adult) for surrounding cellulitis if clinically appropriate
Routine systemic prophylactic antibiotics are not recommended for uncomplicated acute burns. Use local microbiology guidance and escalate to IV therapy for sepsis. If topical silver sulfadiazine is considered in specialist care, avoid in sulfonamide allergy, near-term pregnancy, and neonates.
Surgical / Interventional
- Burn wound cleansing and debridement (including blister management according to local protocol)
- Escharotomy for circumferential full-thickness burns with vascular or ventilatory compromise
- Fasciotomy if compartment syndrome develops
- Early excision of non-viable tissue and split-thickness skin grafting for deep dermal/full-thickness burns
- Reconstructive scar/contracture surgery in late phase when function is limited
Complications
- Airway oedema and respiratory failure from inhalation injury
- Carbon monoxide or cyanide toxicity in enclosed-fire exposure
- Hypovolaemic shock and hypothermia in major burns
- Wound infection, cellulitis, sepsis, and toxic shock syndrome (especially children, 2-4 days post-burn)
- Cardiac arrhythmias after electrical injury
- Distal ischaemia/compartment syndrome in circumferential burns
- AKI (early from hypoperfusion/rhabdomyolysis; later from sepsis/nephrotoxins)
- Hypertrophic scarring, contractures, chronic neuropathic pain/itch
- Psychological sequelae: anxiety, depression, PTSD, body-image and sleep disturbance
Prognosis
Outcome depends on burn depth, TBSA, anatomical site, age, comorbidity, and speed/quality of first aid and resuscitation. Superficial epidermal burns usually heal within about 7 days and superficial dermal burns within about 14 days, generally without scarring; deeper dermal and full-thickness burns often require surgery and carry higher risks of contracture and hypertrophic scar formation, particularly if healing exceeds 2-3 weeks.
Sources & References
💊BNF Drug References(6)
- Atracurium besilate[cautions]
- Cisatracurium[cautions]
- Pancuronium bromide[cautions]
- Rocuronium bromide[cautions]
- Suxamethonium chloride[contraindications]
- Vecuronium bromide[cautions]
✅NICE Guidelines(1)
- Burns and scalds[overview]
📖Textbook References(6)
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 225, 226)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 304)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 413, 414)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 413)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 413, 414)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 303, 304)[context]