BURNS

Hilda M Sagayaga, MD
College of Medicine
La Consolacion University Hospital
November 2019
Patient that you can send home after treating in the
emergency room
a.A 21 year old who was trapped in a burning room full of
smoke, who sustained 8% TBSA full thickness burns in both
arms
b.A 16 year old who developed 14% TBSA burns at the
anterior trunk after 10 hours under direct sun radiation
c.A 40 year old who spilled some liquid chemicals in his eye
with 2% TBSA burns at the upper and lower eyelid
d.A 34 year old who was working at an electrical line in the
highway and inadvertedly handled a live wire, sustaining 5%
TBSA burns at the right hand. arm and left foot
A 32 year old 60kg, female with scald burn injury 24%
TBSA superficial to deep partial thickness burn to the
trunk, upper and lower extremities comes to the
Emergency Room 3 hours after the accident. Using the
Consensus formula, what is the initial fluid
resuscitation you should give?
a.240 ml/hr
b.360 ml/hr
c.576 ml/hr
d. 1152 ml/hr
A 34 year old Meralco lineman sustained 65% TBSA
Electrical burns at his arms, anterior and posterior trunk,
abdomen and lower extremities. During admission, he
developed difficulty in breathing, characterized by short
breaths, with poor and restricted air entry. His burn injury
was characterized by dry, leathery, noncompliant and
painless burn all over the trunk. Next step would be:
a. Early wound excision and grafting
b. Burn wound dressing with silver containing agents
c. Nebulization with a beta agonist
d. Escharotomy
Intended Learning Outcomes
At the end of the session, the student is expected to

• Discuss the burn burden

• Discuss the skin and its function
• Discuss types of burn injuries
• Discuss first aid for burns
• Discuss hospital referral and management of burns
• Discuss medical and surgical management of burns
• Discuss the complications of burns
• https://www.youtube.com/watch?v=j4v7PFw5wA0
Burn Burden
• estimated 1.1 Million burn injuries in the US
• 50,000 require hospitalization
• 4,500 die annually from burn injuries
• 180,000 deaths every year worldwide are from burns

WHO 2018
Grabb and Smith 2007
THE SKIN

www.benjaminreece.com
FUNCTIONS OF THE SKIN
• Serve as a barrier to prevent infection and injury
• Regulates body temperature
• Water barrier to prevent loss of body fluid
• Transmit sensory feedback from the environment
• Provide a cosmetic covering for personal identity
Types of burn injuries and their causes
• Thermal burns
• Flame—Accelerants such as petroleum, ignition of clothing by
candles, or cigarettes
• Scald—Boiling water from bath, kettle, or hot drink. These are the
most common causes of thermal injury (60% of paediatric burns)
• Contact—Radiators, irons, hobs, and hair straighteners
• Flash—Ignition of a volatile substance, often after using accelerants
when burning rubbish
44/M FLAME Burn
4/F SCALD Burn
21/M CONTACT Burn
(motorcycle muffler)
4/F SCALD Burn
Types of burn injuries and their causes
• Electrical burns
• Low voltage—Domestic electrical supplies <240 V.
Electrocardiography is needed to rule out arrhythmias. May cause
cardiac arrest
• High voltage—Power cables >1000 V, industrial accidents, lightning
strikes. Injury can also occur through a high tension “flash” burn, in
which the current arc does not pass through the patient but can
cause clothing to catch fire and can cause deep burns
• Lightning—Not a common mechanism in the UK (2-5 people a year)
but important worldwide, with 10 000 deaths annually as a result of
lightning strikes
Electrical Burn

Eatonhand.com
Types of burn injuries and their causes
• Chemical burns
• Acids—Common agents are acetic, hydrochloric, sulphuric, and
hydrofluoric acid. Note that with hydrofluoric acid severe
hypocalcaemia can occur, combined with hypomagnesaemia, leading
to fatal cardiac arrhythmias. Small burns (2% total body surface area)
caused by hydrofluoric acid can be fatal. Consult burns unit promptly.
Do not contaminate yourself while washing the patient
• Alkali—Household cleaning agents such as bleach. Contact burns
from wet cement
• Organic compounds—Bitumen/tarmac or petroleum contact burns
CHEMICAL Burn
Types of burn injuries and their causes
• Radiation burns
• Ultraviolet light—Sun, tanning booths. Varies greatly with skin type
• Ionising radiation—Radiation therapy, x rays, radioactive fallout.
Severity is related to the volume of exposure
First aid
• Treatment of a burn begins at the scene of the incident.
• As with any trauma patient, a primary survey using an ABCDE (Airway,
Breathing, Circulation, Disability, Exposure) approach should be
adopted so that life threatening abnormalities can be recognized
promptly and corrected.
First aid
• Adopt a SAFE approach (Shout for help; Assess the scene; ensure it is
Free from danger; Evaluate the casualty) as you would for any pre-
hospital emergency and undertake an initial primary survey.

• When dealing with burns patients and assessing ABCDE it is

important to consider inhalation injuries, which might not be
immediately apparent but can cause rapid airway obstruction, as well
as trauma, carbon monoxide exposure, and inhalation of hydrogen
cyanide gas.
First aid
• The importance of assessing for inhalation burns cannot be
overstated because such injuries can be rapidly fatal.

• Look for facial, mouth, nose, and pharynx burns; singeing of nasal
hairs and eyebrows; soot in sputum; or signs of respiratory distress.

• Inhalation injury often presents with increasing edema of the airways,

progressing to obstruction over hours, so it is essential to reassess
patients often.
First aid
• Definitive airway management may be needed in patients with an
inhalation injury or those with a decreased level of consciousness
who might not be able to maintain a patent airway.
First aid
• Appropriate first aid has a measurable effect on outcomes, preventing
further tissue damage and reducing associated morbidity.

• Stop the burning process by removing the patient from the source of
burning.

• Remove clothing and jewelery unless they are melted or adherent to

the wound, in which case they should be left in place.
Management of a burn
• Management of the burn wound itself is best remembered by the
three Cs: Cool, Call, and Cover

• Cool by irrigating with cool running tap water (around 15ºC) for 20
minutes.

• It is important to keep the patient, especially children, as warm as

possible while cooling the burn wound to prevent hypothermia—
“cool the burn, but warm the patient.”
Management of a burn
• Call for an ambulance
HOSPITAL ADMISSION AND
BURN CENTER REFERRAL
 BURN UNITS IN THE PHILIPPINES
• EAST AVENUE MEDICAL CENTER
• JOSE REYES MEMORIAL MEDIAL CENTER
• PHILIPPINE GENERAL HOSPITAL
• QUIRINO MEMORIAL MEDICAL CENTER
• SOUTHERN PHILIPPINES MEDICAL CENTER
REFERRAL TO BURN CENTER
• burns more than 5 to 10% (in general)
• Partial thickness (PT) and full thickness (FT) burns > 10% TBSA in
patients under 10 but over 50 years of age
• PT and FT burns totaling > 20% TBSA in other age groups
• PT and FT burns involving the face, hands, feet, genitalia, perineum or
major joints
• FT burns > 5% TBSA in any age group
• Electrical burns, including lightning injury
REFERRAL TO BURN CENTER
• Chemical burns
• Inhalational injury
• Burn injury in patients with preexisting medical disorders that could
complicate management, prolong the recovery period, or affect
mortality
• Any burn with concomittant trauma (e.g. fractures) in which burn
injury poses the greatest risk of morbidity or mortality
• Burn injury in children admitted to a hospital without qualified
personnel or equipment for pediatric care
REFERRAL TO BURN CENTER
• Burn injury in patients requiring special social, emotional and/or long-
term rehabilitative support, including cases involving suspected child
abuse
EMERGENCY ROOM CARE
• Advanced Cardiac Life Support (ACLS)
• Lactated Ringers solution
• Constricting clothing and jewelry should be removed from burn parts
prior to transport
• Iced water should not be used even on the smallest of burns
• Hoarseness and expiratory wheezes = airway edema
• Copious mucus production and carbonaceous sputum
• Carboxyhemoglobin
EMERGENCY ROOM CARE
• Fluid resuscitation starts with LR at 1000ml/hr in adults and 20ml/kg
per hour in young children
• Hourly urine output of 30ml/hr in adults and 1.0-1.5ml/kg / hr in
young children
• Tetanus prophylaxis
CLASSIFICATION OF BURN
LAYERS OF SKIN CLINICAL OUTCOME
MANIFESTATION
FIRST DEGREE
Superficial thickness Epidermis only red heals in <7-10 days
painful no scarring
SECOND DEGREE
Superficial partial Epidermis and red heals in 2 weeks
thickness superficial dermis painful minimal scarring
blister
Deep partial Epidermis and mottled heals in 3-6 weeks
thickness deep dermis white hypertrophic
painful scarring
CLASSIFICATION OF BURN
LAYERS OF SKIN CLINICAL OUTCOME
MANIFESTATION
THIRD DEGREE
Full thickness Epidermis and white and leathery will not heal
dermis no pain spontaneously
only through TE +
STSG
Burn Shock
• Histamine
• Serotonin
• Prostaglandin, PGE2,
• Prostacyclin, PGI2
• Kinins, Bradykinins
• PAF
Metabolic Response
• increased REE
• glucose metabolism
• gluconeogenesis and glycogenolysis
• plasma insulin levels
• basal rate of glucose production increased despite hyperinsulinemic
state
• lipolysis
• proteolysis
Inhalational Injury
• flame burn in an enclosed place
• singed nasal hair
• burn injury around airway
• hyperemic mucosa
• hoarseness, stridor
• carbonaceous expectorated sputum

Gold standard : bronchoscopy

Carbon Monoxide Poisoning
• Majority of house fire deaths are due to MO poisoning
• CO affinity 200x that of oxygen
• CO binds to Hb to form carboxyhemoglobin
• Half life of COHb is ~ 4 hours
• on 100% oxygen - 45 to 60 mins
• in hyperbaric oxygen chamber at 2 atm ~ 30min
Electrical Burn Injury
• low or high voltage
• myoglobinuria
• mandatory ECG
• cardiac enzyme analysis
• cataracts in 5 to 7% of high voltage electrical injury
Chemical Burn Injury
• copious irrigation with tepid water at accident scene around 15
minutes
Patient that you can send home after treating in the
emergency room
• a.A 21 year old who was trapped in a burning room full of
smoke, who sustained 8% TBSA full thickness burns in
both arms
• b.A 16 year old who developed 14% TBSA burns at the
anterior trunk after 10 hours under direct sun radiation
• c.A 40 year old who spilled some liquid chemicals in his
eye with 2% TBSA burns at the upper and lower eyelid
• d.A 34 year old who was working at an electrical line in
the highway and inadvertedly handled a live wire,
sustaining 5% TBSA burns at the right hand. arm and left
foot
Burn Management
• Primary Survey - ABCs
• Secondary Survey - Fluids / IV access
Wounds
Pain control
FLUID RESUCITATION
• Crystalloid
• Colloid
• formal fluid resuscitation is usually reserved for patients with burns >
15-20% TBSA
• Parkland formula
• 4cc/kg/%TBSA - total fluid in 24 hours
• 50% in first 8 hours
• 50% in next 16 hours
Fluid Resuscitation
• adults : target UO > 30cc/hr
• children 1cc/kg/hour
• fluid boluses for hypotension (not to improve UO)
• colloid typically not used until 12 to 24 hours following burn injury
RULE OF NINES
A 32 year old 60kg, female with scald burn injury 24%
TBSA superficial to deep partial thickness burn to the
trunk, upper and lower extremities comes to the
Emergency Room 3 hours after the accident. Using
the Consensus formula, what is the initial fluid
resuscitation you should give?
a. 240 ml/hr
b. 360 ml/hr
c. 576 ml/hr
d. 1152 ml/hr
LUND AND BROWDER
 TREATMENT
• SILVER SULFADIAZINE DRESSING
Mafenide
• antimicrobial agent
• cream, 5% solution
• broad spectrum
• penetrates eschar well
• carbonic anhydrase inhibitor -
can cause metabolic acidosis
• can be painful

https://www.drugs.com
https://www.doctoralerts.com
Silver Nitrate
• broad spectrum
• applied every 4 hours to
keep the dressings moist
• stains everything black
• prepared in water =
hypotonic (0.5%) = osmolar
dilution
• methemoglobinemia
Bacitracin, neomycin, polymyxinn B
• usually for superficial wounds
• with or without petrolatum gauze
NUTRITIONAL SUPPORT
• Curreri Formula
Adult: 25 kcal x weight (kg) + 40 kcal x %TBSA
Children: 65 kcal x weight (kg) + 35kcal x % TBSA60

Example:
23 year old male, 70kg, partial thickness scald burns on whole anterior
trunk and anterior bilateral lower extremities
• 23 year old male, 70kg, partial thickness scald burns on whole
anterior trunk and anterior bilateral lower extremities

Adult: 25 kcal x weight (kg) + 40 kcal x %TBSA

25 kcal x 70kg + 40kcal x 36% TBSA
1750 + 1440
3190 kcal / day
Nutritional Support
• Harris-Benedict Formula (BEE)
Men: 66.5 + 13.8 x weight (kg) + 5 x height (cm) -6.76 x
age (yrs)
Women: 65.5 + 9.6 x weight (kg) + 1.85 x height (cm) -
4.68 x age (years)

BEE x 1.5 to 2 for px with large burns = caloric

requirements

2 g / kg protein per day

• 23 year old male, 70kg, 162.56 cm tall partial thickness scald burns on
whole anterior trunk and anterior bilateral lower extremities
• 66.5 + 13.8 x weight (kg) + 5 x height (cm) -6.76 x age (yrs)

• 66.5 + 13.8 x 70kg + 5 x 162.56 - 6.76 x 23

• 66.5 + 966 + 812.8 -155.48
• 1689.82 kcal / day x 1.5 = 2534.73
Curreri + HB
• (3190 + 2534.73)/2
• 2862.36 kcal / day
Surgical Management
• Debridement every 2-3 days
• Early Tangential Excision and Grafting
Tangential Excision
Curling Ulcers
• best protection is to feed early
• PPIs
Deep Venous Thrombosis
Risks
• prolonged bedrest
• indwelling catheters
• Deep venous thrombosis prophylaxis may be indicated
Infection
• nearly all patients with > 15% TBSA are febrile within 72 hours
following burn injury
• routine culture not necessary
• infection management should be culture driven
CONTRACTURE
CONTRACTURE
CONTRACTURE
CONTRACTURE
CONTRACTURE
CANCER
A 34 year old Meralco lineman sustained 65% TBSA
Electrical burns at his arms, anterior and posterior trunk,
abdomen and lower extremities. During admission, he
developed difficulty in breathing, characterized by short
breaths, with poor and restricted air entry. His burn injury
was characterized by dry, leathery, noncompliant and
painless burn all over the trunk. Next step would be:
• a.Early wound excision and grafting
• b.Burn wound dressing with silver containing agents
• c.Nebulization with a beta agonist
• d.Escharotomy
FASCIOTOMY
SKIN GRAFTING
SKIN GRAFTING
SKIN GRAFTING
SKIN GRAFTING
SKIN GRAFTING
 POSTOP: RELEASE OF CONTRACTURES WITH
PREOPERATIVE PICTURES DOUBLE Z PLASTY AXILLA AND SPLIT THICKNESS
SKIN GRAFTING NECK AND LOWER LIP
1 MONTH POSTOP
Patient that you can send home after treating in the
emergency room
• a.A 21 year old who was trapped in a burning room full of
smoke, who sustained 8% TBSA full thickness burns in
both arms
• b.A 16 year old who developed 14% TBSA burns at the
anterior trunk after 10 hours under direct sun radiation
• c.A 40 year old who spilled some liquid chemicals in his
eye with 2% TBSA burns at the upper and lower eyelid
• d.A 34 year old who was working at an electrical line in
the highway and inadvertedly handled a live wire,
sustaining 5% TBSA burns at the right hand. arm and left
foot
A 32 year old 60kg, female with scald burn injury 24%
TBSA superficial to deep partial thickness burn to the
trunk, upper and lower extremities comes to the
Emergency Room 3 hours after the accident. Using the
Consensus formula, what is the initial fluid
resuscitation you should give?
• a.240 ml/hr
• b.360 ml/hr
• c.576 ml/hr
• 1152 ml/h
A 34 year old Meralco lineman sustained 65% TBSA
Electrical burns at his arms, anterior and posterior trunk,
abdomen and lower extremities. During admission, he
developed difficulty in breathing, characterized by short
breaths, with poor and restricted air entry. His burn injury
was characterized by dry, leathery, noncompliant and
painless burn all over the trunk. Next step would be:
• a.Early wound excision and grafting
• b.Burn wound dressing with silver containing agents
• c.Nebulization with a beta agonist
• d.Escharotomy
THANK YOU
References
• World Health Organization. 2018. http://www.who.int/news-
room/fact-sheets/detail/burns
• Schwartz's Principles of Surgery.
• Grabb and Smith Plastic Surgery. 6th ed. 2007
• WHO. Burn prevention and care. 2008
First aid
• Treatment of a burn begins at the scene of the incident. As with any
trauma patient, a primary survey using an ABCDE (Airway, Breathing,
Circulation, Disability, Exposure) approach should be adopted so that
life threatening abnormalities can be recognised promptly and
corrected.
• Adopt a SAFE approach (Shout for help; Assess the scene; ensure it is
Free from danger; Evaluate the casualty) as you would for any pre-
hospital emergency and undertake an initial primary survey. When
dealing with burns patients and assessing ABCDE it is important to
consider inhalation injuries, which might not be immediately
apparent but can cause rapid airway obstruction, as well as trauma,
carbon monoxide exposure, and inhalation of hydrogen cyanide gas.
First aid
• The importance of assessing for inhalation burns cannot be
overstated because such injuries can be rapidly fatal. Look for facial,
mouth, nose, and pharynx burns; singeing of nasal hairs and
eyebrows; soot in sputum; or signs of respiratory distress. Inhalation
injury often presents with increasing oedema of the airways,
progressing to obstruction over hours, so it is essential to reassess
patients often.
First aid
• Definitive airway management may be needed in patients with an
inhalation injury or those with a decreased level of consciousness
who might not be able to maintain a patent airway. Involve the
anaesthetic team promptly, because early intubation to protect the
airway is better than trying to intubate a patient whose airway has
become occluded.
First aid
• Appropriate first aid has a measurable effect on
outcomes,[5] preventing further tissue damage and reducing
associated morbidity. Stop the burning process by removing the
patient from the source of burning. Remove clothing and jewellery
unless they are melted or adherent to the wound, in which case they
should be left in place.
Management of a burn
• Management of the burn wound itself is best remembered by the
three Cs: Cool, Call, and Cover
• Cool by irrigating with cool running tap water (around 15ºC) for 20
minutes. Cooling is beneficial for up to three hours after injury. Do not
apply butter or oils. It is important to keep the patient, especially
children, as warm as possible while cooling the burn wound to
prevent hypothermia—“cool the burn, but warm the patient.” Keep
unburned areas wrapped up (warming blankets) while running water
over burned areas
Management of a burn
• Call for an ambulance
• Cover the cooled burn loosely with clingfilm, omitting the face. If
clingfilm is not available, cover with a clean cloth or non-adherent
dressing. Facial burns can be covered with wet gauze or hydrogel
dressings for transfer. Burn gel wraps can be used for their analgesic
properties, but only after the burn has been sufficiently cooled. Do
not wrap limbs too tightly. Swelling can occur rapidly after burns
injury, and the dressing can then act as a tourniquet, restricting blood
flow. Remember that wet or gel dressings will cool the patient, so
wrap the patient in blankets to prevent hypothermia.
How to examine a burn
• The severity of a burns injury is related to the proportion of the body
surface area that has been burnt and the depth (thickness) of the
burn. Accurate estimation of the size of the burn, given as a
percentage of total body surface area (% TBSA) is the main factor in
deciding whether patients need active resuscitation. As part of this
assessment, do not count areas of erythema—reddening of the skin
without blistering or loss of the epidermis. These areas will heal
spontaneously and are not included in the estimated % TBSA of the
burn.
How to examine a burn
• A straightforward assessment tool for estimating % TBSA is Wallace’s
“rule of nines,” in which the head and arms are each calculated as
occupying 9% TBSA, the anterior and posterior surfaces of the lower
limbs are each 9% (18% in total for each lower limb), the chest and
back are 18% each, and the perineum is 1% (fig 1 1 ). 1 This approach
cannot be used for patients under 16 years and slightly overestimates
body surface area.[7]
WALLACE RULE OF 9
LUND AND BROWDER
• Another simple yet subjective method is to equate the area of the
patient’s hand, inclusive of palm and fingers, to 1% of TBSA. Although
each method has its advantages, all are subject to varying degrees of
inter-rater variability, and several studies have highlighted the need
for more reliable methods of estimating TBSA.
• Burns are classified according to depth and may be described as:
• Superficial dermal
• Mid-dermal
• Deep dermal
• Full thickness.
• These would previously have been described as first, second, or third
degree burns (superficial partial and deep partial would formerly have
been classified as second degree burns). You are quite likely to hear
this terminology used, but it has been superseded by depth, rather
than degree. The table describes the features of these burns.
• The skin loses its elasticity as the depth of the burn increases. Deep
dermal and full thickness burns, particularly those that extend all the
way around a limb (known as circumferential) can act as a tourniquet
when swelling inevitably develops. This can lead to complete
ischaemia of the limbs or respiratory compromise if the chest wall is
involved. In both scenarios, rapid recognition of the potential for
problems is essential. Burnt skin may have to be incised, in a
procedure known as escharotomy, to allow lung ventilation or to
restore or maintain limb circulation.
Burn assessment
• Follow a systematic ABCDE approach, be alert to the possibility of
inhalation injury, and call for help early
• Estimate the area that has been burnt because this indicates the need
for fluid resuscitation and is important for deciding whether the
patient needs to be referred to the burns team
• Recognize areas of erythema and exclude them from your calculations
• Try to gauge the burn depth—it will usually be a mixture, such as 25%
partial thickness and 20% full thickness. Check for circumferential
burns
• Consider the possibility of carbon monoxide or cyanide poisoning.
Fluid resuscitation
• Burns cause enormous systemic insult, with huge volumes of fluid shifting
into the injured area in response to direct damage to the microcirculation
and the production of inflammatory mediators at the site of the burn. Fluid
resuscitation aims to deal with the systemic insult promptly. When the
burn is greater than 20-30% TBSA, overwhelming production of
inflammatory mediators can trigger an increase in vascular permeability,
leading to generalised oedema. When combined with evaporative loss
from the surface of the burns, this can cause hypovolaemia, which can
cause failure of other organs, especially the kidney, if left untreated. Burns
cause a central area of tissue destruction, with a surrounding area of stasis
(critically reduced blood flow). Persistent hypotension increases the
likelihood of injury to this zone, so the restoration of circulation volume
with prompt fluid resuscitation can help minimise progression of the burn
injury.
Fluid resuscitation
• Fluid resuscitation should be started in all burns estimated at greater
than 10% TBSA in children and greater than 15% TBSA in
adults.[4] Use the modified Parkland formula to calculate fluid
requirements
Modified Parkland formula
• All patients
• Give 3-4 mL Hartmann’s solution per kg body weight per % TBSA over 24 hours: Give half
calculated volume over first 8 hours Give second half over next 16 hours

• Children
• Also give maintenance fluid—for example, 0.45% saline + 5% dextrose—according to weight and
local policy

• Example
• For a 70 kg adult with 15% full thickness burns: 4 mL×70 kg × 15% TBSA=4200 mL in total Give
2100 mL during the first 8 hours after the burn and then 2100 mL during the next 16 hours

• The resuscitation clock begins at the time of the burn, not the time when the patient arrives in
your department.
Assessing the adequacy of resuscitation
• The most sensitive way to assess the adequacy of resuscitation is to
monitor the patient’s urine output. This can be done by inserting a
urinary catheter and taking hourly readings, aiming for a urinary
output of 0.5 mL per kg body weight per hour in adults and 1 mL per
kg body weight per hour in children.
• Under-resuscitation may occur if the patient’s arrival at hospital has
been delayed or if you have underestimated the extent of the burn
(or missed additional injuries or inhalation burns). Remember that
you cannot see the extent of an inhalation burn and that these burns
also lead to fluid losses. If under-resuscitation has occurred, increase
the infusion rate and reassess.
Assessing the adequacy of resuscitation
• If the urinary output is much higher than expected—for example, 2-3
mL per kg per hour—the patient may be over-resuscitated and you
should consider reducing the infusion volumes. This can also occur if
you have overestimated the extent of the burn. As at all stages in the
process reassess the patient and adjust infusion rates accordingly.
• Monitor vital signs and check serum electrolytes regularly. Dilutional
hyponatraemia is common and hyperkalaemia is often seen in
patients with extensive muscle damage—for example, after
electrocution or escharotomy.
Assessing the adequacy of resuscitation
• Dark (coffee coloured) urine can be caused by myoglobin that is
released from necrotic muscle and excreted by the kidneys. This can
be seen when external compression from full thickness burns has
resulted in muscle ischaemia, when electrocution has caused
rhabdomyolysis, or when the patient has been lying in one position
for a prolonged period. Myoglobin will rapidly block the renal
filtration system, leading to acute tubular necrosis. The first line of
management is to increase fluid resuscitation to achieve twice the
suggested hourly output of urine—1 mg per kg body weight per hour
in adults, and 2 mg per kg body weight per hour in children. Discuss
the patient’s condition with the burns team at an early stage.
Additional considerations
• Patients are often in pain and emotional distress. Give analgesia
intravenously because when it is given intramuscularly absorption will
vary according to the systemic insult. Give aliquots of morphine (0.05-
0.1 mg/kg), titrated to effect
• Perform imaging as indicated by the primary survey
• Gastroparesis often occurs in patients with a large burn: consider
inserting a nasogastric tube
Additional considerations
• Consider the possibility of non-accidental injury, especially in
vulnerable adults or children. It may be a case of deliberate injury,
such as the child who is plunged into a hot bath, or burned with an
iron. Injury may also occur as a consequence of inadequate
supervision—the older person who has fallen out of bed in a care
facility or the child who has gained access to caustic household
chemicals. Ask yourself if the pattern of injury fits the explanation. If
you are worried, seek senior advice then follow your hospital’s policy
for involving social services. The diagnosis of non-accidental injury is
not one to make in haste, but it is better to have a fairly low threshold
for referring patients according to your clinical suspicion, rather than
to miss the opportunity to intervene on behalf of a vulnerable person
Additional considerations
• Ensure a secondary survey, including a full history and head to toe
examination, is undertaken after the patient has been stabilised. Use
the AMPLE acronym when taking a history (Allergies, Medications,
Past medical history, Last ate (time), Events, and Environment relating
to injury).
• Dress burns with a non-adherent dressing, cover with gauze, and
bandage—not tightly because the area will swell. Consider whether
the patient needs to be transferred to a specialist unit. If so, clingfilm
may be used to cover burns.
Referral and transfer
• Knowing when to refer is an important part of your assessment.
Multidisciplinary, definitive care is essential for the patient with a
burns injury. Burns teams include plastic surgeons, anaesthetists,
nursing staff, occupational therapists, physiotherapists, speech and
language therapists, dietitians, psychologists, and social workers who
are all experienced in burns care.
Referral and transfer
• Ensure a secondary survey, including a full history and head to toe
examination, is undertaken after the patient has been stabilised. Use
the AMPLE acronym when taking a history (Allergies, Medications,
Past medical history, Last ate (time), Events, and Environment relating
to injury).
• Dress burns with a non-adherent dressing, cover with gauze, and
bandage—not tightly because the area will swell. Consider whether
the patient needs to be transferred to a specialist unit. If so, clingfilm
may be used to cover burns.
Referral and transfer
• Patients who have been assessed and stabilised at a hospital without
specialist burns services may need to be transferred to the regional
burns service. If patients have additional injuries, the local trauma
team should reach an agreement with the burns team about the
severity of the injuries. Patients may need to be treated in the trauma
unit, with advice from the burns team, until they are fit for transfer.
Criteria for referral to a specialist burns team

• Refer all patients in the following groups to a specialist burns team:

• Total body surface area—≥2% in children, ≥3% in adults
• Depth—All full thickness burns
• Distribution—All circumferential burns
• Duration—Any burn that has not healed within two weeks
• Non-accidental injury—Refer any patient in whom non-accidental
injury is suspected within 24 hours
Criteria for referral to a specialist burns team

• Patients with the following features should be discussed with a burns

consultant, and referral should be considered:
• Location—All burns to hands, feet, face, perineum, or genitalia
• Any chemical, friction, or electrical burn; any cold injury
• Other considerations—Unwell or febrile child with a burn, any
comorbid conditions or concerns regarding burn injuries that may
affect management or healing of the burn.