PassFinals
Plastic Surgery

Burns

Heat, chemicals or electricity destroy skin and drive an inflammatory capillary leak, so a burn threatens the airway, the circulating volume and, when circumferential, ventilation and limb perfusion.

In a nutshell

Burns are graded by depth and by total body surface area (TBSA), and TBSA decides the fluid. Cool with running water for 20 minutes, then give warmed Hartmann's by the Parkland formula, 2 to 4 mL x kg x %TBSA, usually 3.

Classic presentation

A man pulled from a house fire has a hoarse voice, soot around his mouth and singed nasal hairs, with deep circumferential burns to both forearms.

Key points

  • The rule of palm uses the patient's whole palm including fingers and thumb as 1% TBSA. It is the patient's hand, not yours.
  • Lund and Browder is the most accurate chart because it re-weights the head and legs by age. The adult rule of nines does not.
  • Human tetanus immunoglobulin is 250 units intramuscularly, but 500 units after a burn, after 24 hours, or with heavy contamination.
  • High-tension electrical injury may need far more fluid, up to 9 mL x kg x %TBSA, with a urine output of 1.5 to 2 mL/kg/hour.
  • If venous or intraosseous access cannot be obtained through unburned skin, place it through burned tissue rather than delay.
  • Escharotomy divides burnt skin down to fat to release a circumferential burn. Fasciotomy opens muscle compartments and is a different operation.
  • Cyanide toxicity follows inhaling burning household materials. Suspect it if lactate stays high despite resuscitation, and ask a senior about hydroxocobalamin.

First-line investigation

Expose fully and chart depth and TBSA on a Lund and Browder chart, excluding erythema, plus a blood gas with co-oximetry after smoke or an enclosed-space fire.

Management

Stop the burn, then secure the airway

  • Stop the burning process, remove burned or constricting clothing and jewellery, and cool with cool running tap water for 20 minutes, within 3 hours of injury.3
  • Cool the burn but warm the patient: cover unburned skin, warm actively, use warmed fluid. Never ice. Cover with longitudinal cling film strips, not circumferentially, not on the face.3
  • Hoarse voice, stridor, carbonaceous sputum, singed nasal hairs, inflamed oropharynx, facial burns or an enclosed-space fire: sit upright, call a senior anaesthetist, intubate with an uncut tube.1,4

Calculate, then titrate, the fluid

  • Resuscitate adults above 20% TBSA and children above 10%. Warmed Hartmann's (compound sodium lactate), Parkland 2 to 4 mL x kg x %TBSA over 24 hours, usually 3.1,5
  • Half in the first 8 hours from the time of the burn, the remainder over the next 16 hours. Resuscitation fluid sits on top of maintenance.2,1
  • Catheterise. Aim above 0.5 mL/kg/hour of urine in adults and above 1 mL/kg/hour in children under 30 kg, doubled if urine is pigmented or rhabdomyolysis is suspected.1
  • Paracetamol 1 g IV every 4 to 6 hours (maximum 4 g daily), and morphine 5 mg by slow IV injection every 4 hours, titrated. Not intramuscular.8,9

Wound, tetanus and mechanism

  • Codeine 30 to 60 mg orally every 6 hours, maximum 3 days, for moderate pain. Cooling and cling film are analgesia too, and cling film cuts heat loss and infection.10,1
  • A burn is tetanus-prone only with systemic sepsis. Reinforcing vaccine if the last dose was over 10 years ago, plus immunoglobulin if high risk or not adequately primed.11
  • Chemical: brush off powder, irrigate at least 20 minutes, never neutralise, phone NPIS. Electrical: ECG on arrival, creatine kinase, and check the urine for pigment.3,1

Refer, and catch the mechanical emergencies

  • Refer all burns 2% TBSA or more in children, 3% or more in adults, all full-thickness, all circumferential, unhealed at 2 weeks, or suspected non-accidental injury within 24 hours.6,1,5
  • Discuss hands, feet, face, perineum, genitalia, chemical, electrical, friction or cold injury, an unwell febrile child, and comorbidity affecting healing. Regional networks add further criteria.6,7
  • Circumferential full-thickness burn restricting chest movement or limb perfusion: elevate, reassess, and call the burn service before the pulses go. Expect escharotomy.1,5
  • Any size of burn with pyrexia, rash, vomiting, diarrhoea, hypotension or falling urine output: suspect toxic shock syndrome and refer early.1

Function, scars and safeguarding

  • Reassess any burn not healed at 2 weeks. Arrange scar and contracture management, physiotherapy, occupational therapy and psychological support; small burns can still be very painful.5,13
  • Suspect maltreatment if the explanation is absent or unsuitable, the child is not independently mobile, the burn is implement-shaped, or the pattern suggests forced immersion.12

Exam traps

  • The Parkland clock starts at the burn, not at arrival. Arriving 3 hours late means the first half goes in over 5 hours, not 8.
  • Erythema is excluded from the TBSA. Counting it inflates both the burn size and the fluid.
  • Facial burns alone do not mandate intubation. Progressive voice change, stridor and enclosed-space exposure do.
  • Pulse oximetry cannot distinguish carboxyhaemoglobin from oxyhaemoglobin, so saturations read normally in carbon monoxide poisoning. Use co-oximetry, and see that chapter.
  • Do not irrigate dry lime, phenols, concentrated sulphuric acid or elemental metals with water, and never try to neutralise a chemical burn.
  • Do not wrap cling film circumferentially: it acts as a constricting eschar. Longitudinal strips only, and never on the face.
  • The doubled urine-output target is a burn-resuscitation target. No UK guideline sets a urine-output target for rhabdomyolysis itself.
  • The national referral threshold is 2% in children and 3% in adults, but some networks refer children above 1%. Use your network's table.

Illustrations

Full-thickness burn with escharA clinical photograph of a full-thickness contact burn showing dry adherent eschar and loss of viable surface tissue; clinical images must be accompanied by depth and safety context.Craig0927, Wikimedia Commons · Public domain

Key sources

  1. Royal College of Emergency Medicine, RCEM Learning, Major trauma - Burns (College learning resource, not a guideline. Published 11 February 2021, reviewed 15 January 2026. Sections used: Initial Assessment and Resuscitation (airway red-flag table, circumferential limb reassessment, creatine kinase, access through burnt skin), Analgesia, Assessing the extent of a burn (rule of palm, Lund and Browder, rule of nines, Mersey Burns), Assessing the depth of a burn (de-roofing, blisters under 6 mm, four depths), Fluids (2 to 4 mL x kg x %TBSA, usually 3, threshold, Hartmann's, urine output), Management of the burn wound (cooling at 15 degrees C for 20 minutes, cling film, tetanus, electrical), Referral to specialist burn services (British Burn Association thresholds, toxic shock syndrome), Escharotomy. The individual module lesson pages are member-only and redirect to the site homepage; this public reference page carries the same text and is the address every locator here was read at)Published 11 Feb 2021 | Updated 15 Jan 2026
  2. NICE MIB58, Mersey Burns for calculating fluid resuscitation volume when managing burns (Medtech innovation briefing, Introduction. States the three total body surface area methods and that all are reported to be inaccurate, that the Lund and Browder chart is age-adjusted, that the Parkland formula is the one most commonly used in the UK, that half the fluid is given over the first 8 hours after the burn injury and half over the next 16, that children may need additional maintenance fluid, and the harms of over- and under-resuscitation. It states no millilitre figure. NICE states that medtech innovation briefings are not NICE guidance and do not constitute a guidance recommendation)Published 15 Mar 2016
  3. British Burn Association, First Aid Clinical Practice Guidelines (Compiled April 2018 by the British Burn Association Pre-Hospital Special Interest Group, issued 24 September 2018. Cool with cool running tap water for 20 minutes and within 3 hours of injury; aim to complete 20 minutes because further cooling may induce hypothermia, especially in children, older people and large burns; do not use ice or iced water; cool the burn but warm the patient; cover with loose longitudinal strips of cling film, not circumferentially and not on facial burns; chemical burns irrigated for at least 20 minutes with an isotonic solution, amphoteric solution or room-temperature running water, never neutralised, and dry lime, phenols, muriatic acid, concentrated sulphuric acid and elemental metals not irrigated with water; access the National Poisons Information Service and TOXBASE for agent-specific advice)Updated 24 Sept 2018
  4. NHS Greater Glasgow and Clyde, Airway Burns and Inhalation Injury Management, Paediatric Intensive Care Unit guideline 044 (Single health-board paediatric intensive care guideline. Last reviewed 1 June 2015 with a next review date of 10 December 2022 that has passed, and the document states it was devised for COBIS before the PICU guideline group existed and has not been through the AGREE process. Used here only for the inhalation-injury suspicion list, the statement that no factor accurately predicts the need for intubation, and the instruction not to cut the endotracheal tube. Prefer the RCEM Learning reference where both cover a point)Updated 1 Jun 2015
  5. Northern Burn Care Network, Guidelines for referral to specialised burn care services (referral pack) (Regional operational delivery network document hosted by Sheffield Children's NHS Foundation Trust. Reproduces the national minimum referral threshold, the modified Parkland formula as 3 mL x %TBSA x body weight in 24 hours, Hartmann's solution as the standard resuscitation fluid, paediatric maintenance and urine-output targets, up to 9 mL x %TBSA x body weight with a urine output of 1.5 to 2 mL/kg/hour for high-tension electrical injury and 2 mL/kg/hour for haemochromogenuria, the palmar-surface method as 1% and accurate to about 7%, the five depth descriptors with their colour, capillary refill, pain, sensation and blister findings, and escharotomy technique including the statement that only burnt tissue is divided, not underlying fascia, which differentiates it from a fasciotomy)
  6. National Network for Burn Care and British Burn Association, National Burn Care Referral Guidance (Version 1, approved February 2012, and still the current national referral document; no version 2 exists. The PDF returned empty content to automated retrieval on 7 August 2026, so the criteria printed in this chapter were read from RCEM Learning and from the Northern Burn Care Network referral pack, both of which reproduce them and both of which open)Published 1 Feb 2012
  7. South West Burns Clinical Network, Referral Criteria (Network referral table, page reviewed 8 January 2024, sourced from the London and South East Burn Network. Gives above 1% total body surface area in children and above 3% in adults, and adds neonates under 28 days, infected wounds, mental-health history or self-harm, progressive non-burn skin loss including toxic epidermal necrolysis, Stevens-Johnson syndrome and necrotising fasciitis, and people aged 60 and over)Updated 8 Jan 2024
  8. BNF, Paracetamol (Mild to moderate pain and pyrexia, by intravenous infusion, adult body-weight 51 kg and above: 1 g every 4 to 6 hours over 15 minutes, maximum 4 g per day. Reduce the daily maximum to 3 g where there are risk factors for hepatotoxicity. Taken from the verbatim extract in reports/textbook-source-packs/batch02/paracetamol.md)
  9. BNF, Morphine (Acute pain, by slow intravenous injection, adult: initially 5 mg every 4 hours, reduced dose in frail and elderly patients, adjusted to response and adjustable more frequently during titration. The monograph also notes that subcutaneous injection is not suitable for oedematous patients. Taken from the verbatim extract in reports/textbook-source-packs/batch02/morphine.md)
  10. BNF, Codeine phosphate (Short-term treatment of acute moderate pain, by mouth, adult and child 12 to 17 years: 30 to 60 mg every 6 hours as required for a maximum of 3 days. Contra-indicated in children under 12 years and in known CYP2D6 ultra-rapid metabolisers of any age. Taken from the verbatim extract in reports/textbook-source-packs/batch03/codeine-phosphate.md)
  11. UK Health Security Agency, Tetanus: the green book, chapter 30 (Chapter dated 2 June 2025, publication last updated 3 June 2025. Section Management of patients with tetanus-prone wounds lists wounds or burns with systemic sepsis as tetanus-prone, and wounds or burns with extensive devitalised tissue, heavy contamination, or surgery delayed more than six hours as high risk. Table 30.1 gives the immunisation-status grid. Section Dosage of human tetanus immunoglobulin gives 250 units by intramuscular injection, or 500 units if more than 24 hours have elapsed since injury, if there is a risk of heavy contamination, or following burns)Updated 3 Jun 2025
  12. NICE CG89, Child maltreatment: when to suspect maltreatment in under 18s (Published 22 July 2009, last updated 3 December 2025. Recommendation 1.1.6, under the heading Thermal injuries, gives the burn and scald features that should raise suspicion of maltreatment, including an absent or unsuitable explanation, a child who is not independently mobile, sites that would not contact a hot object accidentally, implement-shaped burns and forced-immersion patterns. Recommendation 1.3.7 covers a burn suggesting a lack of appropriate supervision. The lower-case URL /guidance/cg89/chapter/recommendations returned empty; the capitalised form printed here resolves)Published 22 Jul 2009 | Updated 3 Dec 2025
  13. NHS, Burns and scalds (Public-facing page, last reviewed 31 March 2026. Used for aftercare only: small burns take around 2 weeks to heal, do not burst blisters, do not apply creams, oils or butter, and do not use plasters or sticky dressings. Its first-aid section gives 15 to 30 minutes of cool running water, which differs from the British Burn Association's 20 minutes; this chapter follows the British Burn Association)Updated 31 Mar 2026

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.