BJA Education, 22(3): 94e103 (2022)

doi: 10.1016/j.bjae.2021.10.001
Advance Access Publication Date: 21 December 2021

Matrix codes: 1A01,

2A02, 3H00

Major burns: Part 1. Epidemiology, pathophysiology

and initial management
C. McCann, A. Watson* and D. Barnes
St Andrews Centre for Burns & Plastic Surgery, Broomfield Hospital, Chelmsford, UK
*Corresponding author: agnes.watson@nhs.net

Keywords: burns; epidemiology; pathophysiology; surgical management

Learning objectives Key points

By reading this article you should be able to:  An adult with a major burn, defined as >15% of
 Describe the epidemiology of major burn injuries total body surface area burned, will require
and the possible mechanisms of injury. resuscitation and care at a specialised burns
 Recall the structure and function of the skin. service.
 Use burn depth classification and surface area to  Depth of burn is assessed by the degree that the
assess a patient’s burn wound. dermis has been affected and determines subse-
 Describe the initial management of a major quent surgical management.
burn.  Major burns have local tissue and wider systemic
effects. In burns >25% total body surface area, a
systemic inflammatory response occurs.
A burn injury is the coagulative destruction of the skin and  Timely but safe transfer to a specialist centre is
its structures by thermal, chemical, electrical or mechanical often required with attention to airway, invasive
energy. A major burn is defined according to the percentage catheters, fluids and temperature maintenance.
total body surface area (%TBSA) affected by the injury. A  Early surgical management with total or near-
burn greater than 15% TBSA is considered major in an adult total burn wound excision in <48 h of injury has
aged >16 yrs. A recent update on paediatric burns is been shown to decrease blood loss, burn wound
available.1 sepsis and length of stay.

Epidemiology
Claire McCann BMedSci MRCP FRCA FFICM is a speciality registrar
in anaesthetics and clinical fellow in burns anaesthesia and intensive Fire, heat and hot substance injuries caused 8,991,468 injuries
care at St Andrew’s Centre for Burns and Plastic Surgery. and 120,632 deaths worldwide in 2017.2 Ninety percent of
these were in low- or middle-income countries.3 Compre-
Agnes Watson FRCA FFICM is a consultant in adult and paediatric hensive up-to-date statistics for the UK are not available for
burns and plastics anaesthesia and intensive care, St Andrew’s reference, but there are approximately 10,000 hospital ad-
Centre for Burns and Plastic Surgery. She is the outgoing college missions and 300 major burns in adults requiring fluid
tutor for burns and plastics anaesthesia and has a special interest in resuscitation in England and Wales per year.4,5 In Scotland
anaesthesia for cleft lip and palate surgery. there is an incidence of 500 burn injury admissions per year, of
David Barnes BMSc MSc FRCS Plast (Edin) is consultant and clinical which 5% are major burns.6
lead for adult and paediatric burns surgery, St Andrew’s Centre for The most common mechanism of injury requiring admis-
Burns and Plastic Surgery. He is a previous chair of the London South sion is scalds; however, the most common cause of major
East Burns Network and a member of the 2018 British Burn Care burns are flame injuries.7 Burn injuries have a wide aetiology
Standards panel. including thermal (scald, flame, flash, contact, irradiation),

Accepted: 11 October 2021

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

94
 Major burns, Part 1

electrical (including lightning strikes) and chemical (acid, al- which predicted mortality is 50%) is 109.6.11 Other risk predic-
kali). Most are accidents in the home or work-related, but tion models are also in use such as the Belgian Outcome in Burn
intentional injuries from deliberate self-harm, assaults or fires Injury score and the Abbreviated Burn Severity Index.12,13 As
are more likely to result in major burns.8 increasing age is strongly associated with mortality from a burn
injury, there is a developing need to assess frailty and comor-
Risk factors bidities as part of a holistic assessment of the older burns pa-
tient, although not yet included in the current scoring
Risk factors worldwide for suffering a burn injury include: low systems.14 Clinical frailty scores are increasingly being used in
socioeconomic status; overcrowding; households where burns services, and the Rockwood clinical frailty scale is used in
young girls have domestic roles; cooking with kerosene; our unit for burn injuries in older people.15,16
generalised poor health; and poor safety practices.3 Injuries
are more common in patients with pre-existing psychiatric
diagnoses, substance use problems and those at extremes of Pathophysiology
age. Children suffer accidental and non-accidental injury. As Skin physiology
the population ages, the older and frail individuals with pre-
existing medical conditions presenting as collapse, are The skin is the largest organ system in the body. It is
increasingly represented.9 Burns are a preventable injury and composed of the five layers of the epidermis and the two
strategies to decrease the incidence focus on awareness, ed- layers of the dermis, which sit on subcutaneous fat, connec-
ucation and health and safety legislation. tive tissue and the muscle compartments. The deepest layers
of the epidermis continually divide and migrate to the surface
to regenerate every 2e3 weeks. Melanocytes responsible for
Risk prediction
the skin’s pigmentation are found in the epidermis. The
The main scoring system used to predict mortality and length dermis contains nerves, blood vessels, exocrine glands and
of hospitalisation in adult burns injury is the revised Baux hair follicles around which regenerating epidermal cells are
score, which takes into account age, %TBSA burned and the found. The epidermis cannot regenerate without the presence
presence of inhalation injury.10 The point of futility (the Baux of dermal tissue. By understanding the multiple functions of
score at which the predicted mortality approaches 100%) was the skin and its roles in homeostasis (Fig. 1), it is easy to un-
100 in Baux’s original article. The point of futility with 21st derstand the sequelae of a burns injury, which will be dis-
century burn care is now 160 and the Baux50 (the Baux score at cussed in detail in Part 2 of this series.17

Prevents fluid loss

Barrier to entry of microorganisms
Epidermis Major site of immune system activity
Neurosensory (pain, touch)
Social and psychological

Regulation of body temperature

Dermal vascular plexus
Sweating
Dermis
Piloerection
Responsible for skin
durability and flexibility

Fig 1 Functions of the skin.

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Major burns, Part 1

Classification of burn injuries model.18 The zone of coagulation contains dead tissue as a
result of direct injury. Adjacent to this area in the zone of
A burns injury is classified according to aetiology, percentage
stasis tissues suffer hypoperfusion owing to the vasocon-
total body surface area involved and depth (Fig. 2).
striction of vessels in response to the injury, and although not
Simple erythema involving damage to the epidermis only
directly damaged, these tissues are vulnerable to ischaemia,
is referred to as an epidermal or superficial burn and excluded
infection and necrosis, and initial burn wounds may expand
from the calculation of surface area involved. Clinically sig-
and deepen. Dead tissue prompts the release of inflammatory
nificant burns involve the dermis, and are termed partial
mediators, which act locally causing vasodilation, increased
thickness, either superficial or deep, and full thickness.
vascular permeability and oedema in the zone of hyperaemia.
Worldwide it is more common for burn depth to be described
In the absence of resuscitation with i.v. fluids, this vasodila-
as first degree (epidermal/superficial), second degree (partial
tion exacerbates hypovolaemia and subsequent tissue hypo-
thickness) or third degree (full thickness). The characteristics
perfusion. In burns >25% TBSA, these mediators also cause a
on examination are detailed in Figure 3.
systemic inflammatory response with the effects outlined in
The amount of tissue damage caused can be burn related
Figure 5.
or patient related. Burn-related factors include aetiology,
Early burn wound excision decreases the necrotic load,
temperature and duration of exposure. For example wet heat
infection risk and systemic inflammatory effects. Burns
(scalds) carries more energy than dry heat (flame), so greater
dressings help stabilise the wound bed, decrease fluid losses
tissue damage is caused by the same temperature. Patient-
and help prevent infection. Systemic effects consist of an
related factors include skin thickness, age and whether or
acute phase up to 48 h after injury, in which a combination of
not first aid was given. The very young and older individuals
peripheral vasodilation, hypovolaemia and myocardial
with thinner, more fragile skin will have a greater injury from
depression result in burns shock and a hypermetabolic phase
the same insult compared with an adult. A superficial partial
from approximately 48 h up to 1 yr after injury. The stress
thickness wound has a good blood supply and sufficient
response to a burn injury is via the same pro-inflammatory
regenerating epidermal cells that, with proper management,
mediators as in other causes of tissue injury, but of greater
can heal without scarring in 1e2 weeks. Deep partial thick-
severity and duration.
ness and full thickness burns have lost the dermal vascular
plexus and cells to heal. They are generally managed by
excision and skin grafting. The burn can also affect tissue Initial management
deep to the dermis, the fat and muscle. Muscle injury can lead
First aid
to compartment syndrome and rhabdomyolysis.
First aid at the scene is vitally important in burns and can
prevent more severe injury. In particular there is a strong
Local and systemic effects of major burns
evidence base that a burn should be managed under cool or
Major burn injuries have local and systemic effects (Fig. 4). tepid running water for 20 min even up to 4 h after the injury is
The local effects are divided into three zones of tissue sustained. By arresting tissue damage, wounds are not as deep
injury and blood flow described in Jackson’s burn wound as they otherwise would have been, with subsequent

Epidermis

Dermis

Subcutaneous
tissue

Superficial partial thickness Deep partial thickness burn – Full thickness burn – has
burn – the upper dermis is extends into the deep dermis extended through the entire
damaged but the vascular affecting the vascular plexus but not thickness of the dermis and
plexus and most adnexal all of the dermis is destroyed. Only no dermal tissue remains
structures remain intact deep adnexal structures are intact

Fig 2 Depth of burn injuries are described by how much of the dermis has been destroyed. Adapted with permission from the Nederlandse Brandwonden
Stichting, Dutch Burns Foundation.

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 Major burns, Part 1

Fig 3 Clinical characteristics of burn injuries (written consent obtained from patient to publish images). (A) Superficial partial thickness burns are pale, pink and
moist. Blisters form from fluid leak because of blood vessel damage. They are very painful because the nerve endings are exposed. (B) Deep partial thickness burns
are drier, red and non-blanching as the dermal plexus is coagulated by heat. They are less sensate. (C) Full-thickness burns are waxy and white; they may look
charred and are not painful.

improvement in healing and decreased scar formation.19 The All major burns are traumatic injuries and should be
general principles for thermal injuries are to use the SAFE treated according to the principles of Advanced Trauma Life
approach (Shout/call for help, Assess the scene, Free from Support (ATLS).24 The treatment recommendations that
danger, Evaluate the casualty), stop the burning process, cool follow can be learnt on the Emergency Management of Severe
the burn and then cover in a non-adherent dressing (e.g. cling Burns (EMSB) course run by the British Burn Association.25
film).20,21 Although the burn must be cooled, the rest of the
patient must be warmed to prevent hypothermia. For chem-
ical burns the patient should be removed from the area of
Airway and breathing
exposure and all contaminated clothing removed. Chemical The airway can be threatened via several mechanisms in a
burns should be irrigated with running water or sterile fluids patient with major burns. Indications for intubation are:
taking care not to wash chemicals into the eyes. Irrigation is reduced conscious level requiring airway protection (e.g.
key in such burns as removing the chemicals stops the because of head trauma during escape from a fire also requiring
burning process. It is recommended that acid burns be irri- c-spine immobilisation, systemic toxicity from inhalation
gated for 45 min and alkali burns for 1 h.21 Agent-specific injury, medical or substance use causing collapse); actual or
treatments should be given if available according to National impending upper airway obstruction owing to deep neck, per-
Poisons Information Service advice.22 Electrical injuries may ioral or intra-oral burns and oedema; respiratory distress from
be accompanied by a burn, a useful comprehensive review of inhalation injury requiring ventilatory support; or to facilitate
presentation and specific management is available.23 safe transfer to a burns centre. However, the requirement for

Burn >25% systemic effects Release of histamine, prostagladins, leukotrienes

- Systemic inflammatory response thromboxanes, kinins, reactive oxygen species,
- Whole body is zone of hyperaemia interleukins, IL-6, IL-1E, TNF-D and IL-8

LOCAL
Zone of coagulation
TISSUE
EFFECTS
and cell death
Epidermis (direct tissue injury)

Zone of stasis
Dermis (cells viable but vulnerable)

Zone of hyperaemia
and vasodilation
Subcutaneous (tissue recovery expected)
tissue

Fig 4 Pathophysiology of burns. IL, interleukin; TNF-a, tumour necrosis factor-alpha.

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Major burns, Part 1

Cardiovascular effects: Systemic inflammatory respone to injury

Hypovolaemia HPA axis activation
Myocardial depression ↑ ADH
↓ Cardiac output Sympathetic NS activation
Burns shock up to 48h ↑ RAA
Hypercoagulability
Vascular effects:
Hypoalbuminaemia
↑ Capillary permeability
Na+ and proteins leak into interstitium
Tissue oedema Hypermetabolic phase from 48h up to 1 year
↑ Catecholamines, cortisol, glucagon
Respiratory effects:
Bronchoconstriction ↓ Insulin

ARDS ↑ Hepatic gluconeogenesis,

glycogenolysis, lipolysis, proteolysis
Peripheral and splanchnic vasoconstriction: Hyperdynamic circulation
AKI Hyperthermia
Ileus Increased O2 consumption
GI stress ulceration Weight loss
Fluid resuscitation Muscle weakness
Tissue oedema Immunosupression
Pulmonary oedema Impaired wound healing
Abdominal compartment syndrome

Fig 5 Systemic effects of major burns. ADH, anti-diuretic hormone; AKI, acute kidney injury; ARDS acute respiratory distress syndrome; GI, gastrointestinal; HPA,
hypothalamicepituitaryeadrenal; NS, nervous system; RAA, renineangiotensinealdosterone.

intubation is not always clear-cut, and the main concern is that can be used safely up to 48 h after burn injury.27 A video-
a burned patient may have an associated inhalation injury that laryngoscope should be used if available and an uncut
will subsequently cause airway oedema and an airway emer- tracheal tube is vital to allow for further soft tissue swelling
gency in the hours that follow fluid resuscitation. that might otherwise make a cut tube recede into the mouth.
A larger-diameter tracheal tube is preferable to facilitate
bronchoscopy and respiratory toilet.
Inhalation injury
The hot gaseous products of combustion are inhaled partic-
ularly when a patient is trapped in an enclosed space with a Ventilation
fire. Hot gas causes direct burn injury to the upper airway, In full thickness burns the dead tissue or ‘eschar’ is non-
particulate matter and chemicals enter the lower airways compliant and may prevent adequate ventilation and
causing acute lung injury and carbon monoxide and adversely affect cardiac pre-load, necessitating escharotomies
hydrogen cyanide cause systemic toxicity. Inhalation injury to the chest before transfer (Fig. 6). Impaired gas exchange may
is more common if facial burns are present, but not all pa- also be the result of inhalation injury and associated carbon
tients with facial burns have an inhalation injury. Signs and monoxide poisoning. Hypoxaemia will persist despite adequate
symptoms include cough, soot in the nose, mouth and oxygen saturation by pulse oximetry, so it is important to check
sputum and singed eyebrows and nasal hair, but in the the co-oximetry results on an arterial blood gas. The time to
absence of a facial burn these are unlikely to signal an airway carbon monoxide washout is reduced by ventilation in 100%
emergency. Voice changes, hoarseness and stridor, however, oxygen, but hyperbaric oxygen therapy is not currently rec-
are particularly concerning as these signs may not develop ommended.22 Patients’ lungs should be ventilated with 100%
until swelling is already obstructing the airway.26 If there is oxygen until the carboxyhaemoglobin level is <3%, taking care
doubt about whether tracheal intubation is needed, discus- to reduce the FIO2 as soon as possible to avoid further lung
sion with the receiving burns service is advised. When damage.27 Hydrogen cyanide poisoning should be considered in
securing the airway, it is vital to plan for a difficult intubation patients with inhalation injury, cardiovascular instability and
including a surgical airway as the tissues may be erythem- increasing blood lactate levels not responding to treatment,
atous, ulcerated and distorted by oedema. Suxamethonium and the specific antidote e hydroxycobalamin e should be

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 Major burns, Part 1

major burns patients become hypothermic. Erythema alone is

not counted in the estimation of burn surface area. All areas of
superficial partial thickness burn or deeper are included.
Many management decisions including transfer decisions and
prognosis are based on %TBSA burned, and overestimation of
burned surface area leads to fluid overload. Traditional
methods include the Lund and Browder chart or the Wallace
Rule of Nines, but more recently the Mersey Burns app has
gained popularity for ease of use and accuracy.28 Example
output from the app can be seen in the recent BJA Education
article on burns in paediatrics.1

Indications for escharotomy

Initial surgical management at the referring centre should be
either life or limb saving. Escharotomies are surgical incisions
through non-compliant full thickness burn, which restricts
ventilation on the chest and abdomen or causes significantly
Fig 6 Example of escharotomies performed to facilitate ventilation in a reduced perfusion in circumferential burns to the limbs.
major chest burn (published with written consent from the patient).
Escharotomies to produce decompression should be per-
formed as soon as they are required for ventilation or perfu-
sion; the incision is longitudinal from unburned skin to
unburned skin if possible, and deep enough to reach subcu-
given. A recent detailed review of inhalation injury is available taneous fat and release the eschar.29 Anaesthesia will be
from BJA Education.26 required, diathermy is usually used so blood loss should be
minimal and prophylactic antibiotics should be given. Fas-
ciotomy incisions are deeper than for escharotomies, through
Circulation the subcutaneous tissue and the fascial layers surrounding
Burns and burn shock are not an immediate cause of hypo- the muscle compartments. They are most commonly indi-
volaemia. Any haemodynamic instability must be assessed as cated in high-voltage electrical burns where tissue necrosis of
possible bleeding in the first instance. Peripheral i.v. access muscle causes compartment syndrome.
may be difficult with limited sites available. Two large bore
cannulas are necessary. Ideally, access is not placed through Secondary survey
burned tissue but this may be unavoidable and if unable,
Other common areas of injury in major burns include corneal
intraosseous access must be gained before proceeding to
damage and examination with fluorescein stain is required.
definitive central venous access. The Parkland formula guides
Electrical burns are at risk of rhabdomyolysis, and a creatine
resuscitation fluids in the first 24 h for burns of >15% TBSA.
kinase level should be measured. All major burn injuries
The principles are as follows:
should receive tetanus toxoid treatment. Pain relief using
intravenous opioid titrated to effect should be given (if the
Parkland formula: 2e4 ml  actual body weight (kg)  %TBSA
patient is not already anaesthetised). Gastric decompression
burned
with a nasogastric tube should occur. Routine use of antibi-
otics is not required.
e From the time burn sustained
e ½ in first 8 h, ½ in subsequent 16 h
e Subtract any fluid already given Criteria for referral to a specialist unit and
e Use warm, isotonic balanced crystalloid initial management
The modified Parkland formula of 3 ml  actual body The referral criteria to specialist burns services are available.30
weight (kg)  %TBSA burns is advocated to limit excessive All major burns will need referral and transfer to specialist
fluids being given. The amount of fluid actually given will need services. Severe burns thought to be non-survivable should
adjustment according to the evolving clinical picture as also be discussed as accurate estimation of burn size, site of
covered in Part 2 of this series. donor areas, age and comorbidities are essential in making
this decision, which is best done using the expertise of the
burns centre.
Disability
Reduced Glasgow Coma Scale at presentation in major burns
Goals of transfer
is not caused by the burn itself and must lead to a search for
the cause and appropriate management. As described previ- Patients should be transferred as soon as they are resuscitated
ously, these include poisoning by inhaled toxins (carbon and stable, and with a secure airway noting that fluid resus-
monoxide and hydrogen cyanide); overdose; trauma including citation will cause burn oedema, which may worsen en route. If
head injury and medical comorbidities leading to collapse. the patient’s trachea is intubated, a nasogastric tube should
also be inserted to decompress the stomach.27 If tracheal
intubation is not indicated, the patient should be sat up as
Exposure and estimation of % TBSA burned
much as possible to offset the effects of developing oedema.
All clothing and jewellery must be removed; however, expo- Invasive monitoring is usually required, and lines must be
sure of the patient must be kept to a minimum as almost all secured with stitches. Provision for continuation of possible

BJA Education - Volume 22, Number 3, 2022 99

Major burns, Part 1

BURNS ADMISSION FLOW CHART

REFERRAL RECEIVED

TRIAGE BY EMSB-TRAINED NURSE

Discussion with on-call anaesthetist

REFERRAL

REFERRAL
and burns surgeon (HEMS can be
immediately accepted if bed)

No PATIENT DEFERRED
Appropriately
PATIENT REFUSED resourced bed
available?
Reason must be recorded and on-call
team must follow the
Yes
Standard Operating Procedure for
Burns Surge and Escalation Patient needs medical
Safe to transfer No
patient optimisation or other
immediately? care priorities

Reason for deferral must be clearly

Yes recorded and the patient discussed
at each ward round

PATIENT ACCEPTED

Is this a HEMS
Inform ED and helipad referral for immediate
Yes transfer?

No

PRE-BRIEFING
PREPARATION

PREPARATION
PLACE PEOPLE PROPOSED PLAN

All burn team members Burn team members

• Admission room
must be informed in a should be involved in the
• Burns theatre
timely manner including discussion to ensure
• Burns ICU room
ODA and theatre staff shared vision

• Prepare space for admission

• Equipment / monitoring / anaesthetic machine checks
• Warming of room or theatre
• Drugs and fluid (warmed)
• Dressings
• Theatre equipment and diathermy if anticipated
• Appropriate PPE

Fig 7 Example admission room protocol in use at our institution. ED, emergency department; EMSB, emergency management of severe burns course; HEMS,
helicopter emergency medical service; MRSA, methicillin-resistant Staphylococcus aureus; ODA, operating department assitant; PPE, personal protective equipment.

100 BJA Education - Volume 22, Number 3, 2022

 Major burns, Part 1

Trauma screen must be completed in

ED before transferring
Yes
Patient transferred
TRAUMA SCREEN by helicopter?

No
ADMISSION SPACE
TRANSFER

TRANSFER
DESIGNATE TEAM LEADER

• All burn team members to be informed of arrival

• Introductions to transfer team
• Confirm patient weight
• Move to Admission Room warming area and begin active
warming
• Exchange monitoring and infusions
• Confirm patient is stable
• Formal hand over from the transfer team
• Questions from receiving team to complete handover

PRIMARY SURVEY by surgical team

Emergency resuscitation/ interventions if required by all

SECONDARY SURVEY AND INTERVENTIONS

ANAESTHETIC SURGICAL BICU NURSING

• Ensure airway secure • Complete secondary survey • Obtain Hospital ID number
• Ensure monitoring attached • Confirm %TBSA and depth • Admit on Lorenzo/MetaVision
• Ensure vascular access • Confirm surgical plan with all • Confirm height
devices are adequate members of the burn team • Print name bands
• Confirm plan for (ongoing) • Consent • Bloods incl. labels and track
anaesthesia or sedation • Examine eyes • Wound/MRSA/CoVID swabs
ADMISSION

ADMISSION
• Ensure warming measures • Photographs • Check infusions
• Check infusions with nurses • Place urinary catheter • Consider blood alcohol level,
• Prepare for bronchoscopy • Shave patient (if required) paracetamol and salicylate
• Prepare feeding tubes • Escharotomies (if required) level, urine toxicology,
• Cyanokit (if required) • Dressings as appropriate pregnancy test
• Dressings as appropriate
• Obtain GP summary

ALL TEAM
• Confirm resuscitation plan
• Confirm surgical plan
• Complete WHO Checklist prior to a general
anaesthetic or any surgical intervention

TEAM HUDDLE AND PATIENT TRANSFER TO ROOM

• Confirm ongoing burn and critical care needs with all members of the burn care team and destination
• Complete WHO Sign Out
• Prepare for transfer (anaesthetist/ODA/nurses)
• Prepare room to receive patient
• Complete admission note on MetaVision for anaesthetic, surgical and nursing aspects
• Request appropriate radiology and further investigations
• Update relatives or appropriate persons of interest

Fig 7 (continued).

BJA Education - Volume 22, Number 3, 2022 101

Major burns, Part 1

large volume fluid resuscitation during transfer together with 2. James SL, Lucchesi LR, Bisignano C et al. Epidemiology of
consideration of vasopressor support is necessary. Active injuries from fire, heat and hot substances: global,
warming is required as patients will continue to lose heat and regional and national morbidity and mortality estimates
may become severely hypothermic and acidotic. Delaying from the Global Burden of Disease 2017 study. Inj Prev
transfer to try to warm an already hypothermic patient is 2020; 26: i36e45
often not effective, but decisions should be made on a case- 3. World Health Organisation. Burns factsheets. Available
by-case basis in conjunction with the specialist centre. Burn from: https://www.who.int/news-room/fact-sheets/detail/
wounds should be dressed with cling film for transfer taking burns. [Accessed 14 November 2020]
care to avoid circumferential application that might impair 4. National Health Service. Hospital episode statistics 2004
blood flow.27 to 2009. England and Wales.
The admission protocol for major burns on arrival in our 5. British Burn Association. Standards and strategy for burn
unit is outlined in Figure 7. care: a review of burn care in the British isles. National Burn
Care Review Committee Report; 2001
6. Gilhooly CJ, Kinsella J. Care of burns in Scotland: 3-year
Early surgical management data from the managed clinical Network national regis-
Burns are a surgical disease; the wound must be debrided and try. Crit Care 2014; 18: 76
deep partial thickness and full thickness burns require tissue 7. International Burn Injury Database. Adult resuscitation
excision and wound closure with skin grafts. Guidance sug- burns 2019/20 and causation covering 2019 to 2020 inclusive.
gests surgical removal of full thickness burns within 5 days.31 England: Ad hoc report request; 2020
However the preferred practice at our institution is to perform 8. Peck MD. Epidemiology of burns throughout the World:
total or near-total early burn wound excision in <48 h of injury Part II. Intentional burns in adults. Burns 2012; 38: 630e7
with the aim of reducing the necrotic load of the burn wound 9. Brusselaers N, Juha  sz I, Erdei I et al. Evaluation of mor-
that drives the systemic inflammatory response. Early wound tality following severe burns injury in Hungary: external
excision has been shown to decrease blood loss, burn wound validation of a prediction model developed on Belgian
sepsis and length of stay. There is also a positive association burn data. Burns 2009; 35: 1009e14
with aesthetic and functional outcomes compared with the 10. Osler T, Glance LG, Hosmer DW. Simplified estimates of
alternative treatment of serial excision or conservative man- the probability of death after burn injuries: extending and
agement; however, available evidence is not yet conclusive on updating the Baux score. J Trauma 2010; 68: 690e7
whether this technique offers improved survival out- 11. Roberts G, Lloyd M, Parker M et al. The Baux score is dead.
comes.32e34 Once the burned tissue is excised, wound closure Long live the Baux score: a 27-year retrospective cohort
must be achieved to decrease fluid loss, prevent further study of mortality at a regional burns service. J Trauma
wound desiccation and infection and reduce hypermetabo- Acute Care Surg 2012; 72: 251e6
lism. This can be either temporary covering with allograft 12. Belgian Outcome in Burn Injury Study Group. Develop-
(skin from organ donors) or synthetic skin substitutes, or ment and validation of a model for prediction of mortality
permanent, with autologous split skin grafts. In general, in patients with acute burn injury. Br J Surg 2009; 96:
autologous split skin grafts are the gold standard for treating 111e7
burn wounds. The ability to cover all wounds permanently 13. Tobiasen J, Hiebert JM, Edlich RF. The abbreviated burn
depends on the size of area requiring grafting and the avail- severity index. Ann Emerg Med 1982; 11: 260e2
ability of donor sites. Patients with a major burn undergo 14. Bloemsma GC, Dokter J, Boxma H et al. Mortality and
repeated operations and dressing changes and require causes of death in a burn centre. Burns 2008; 34: 1103e7
multidisciplinary specialist care in ICU, which will be dis- 15. Rockwood K, Theou O. Using the Clinical Frailty Scale in
cussed in detail in a forthcoming article in this journal.17 allocating scarce health care resources. Can Geriatr J 2020;
23: 210e5
16. Masud D, Norton S, Smailes S et al. The use of a frailty scoring
Declaration of interests system for burns in the elderly. Burns 2013; 39: 30e6
The authors declare that they have no conflicts of interest. 17. McGovern C, Puxty K, Paton L. Major burns: Part 2.
Anaesthesia, intensive care and pain management. BJA
Educ 2022. https://doi.org/10.1016/j.bjae.2022.01.001
Acknowledgements 18. Jackson DM. The diagnosis of the depth of burning. Br J
The authors thank the London and South East Burn Network Surg 1953; 40: 588e96
and the Dutch Burns Foundation for their kind permission in 19. Cuttle L, Kempf M, Liu PY et al. The optimal duration and
allowing the adaptation of illustrations for Fig. 2, Nederlandse delay of first aid treatment for deep partial thickness burn
Brandwonden Stichting. injuries. Burns 2010; 36: 673e9
20. Greaves I, Porter KM. Pre-hospital medicine: the principles and
practice of immediate care. Boca Raton, FL: CRC Press; 1999
MCQs 21. British Burn Association. First aid clinical practice guidelines.
The associated MCQs (to support CME/CPD activity) will be 2018. Available from: https://www.britishburnassociation.
accessible at www.bjaed.org/cme/home by subscribers to BJA org/wp-content/uploads/2017/06/BBA-First-Aid-Guideline-
Education. 24.7.18.pdf. [Accessed 21 November 2020]
22. TOXBASE. The primary clinical toxicology database of the
National Poisons Information Service. Available from: https://
References
www.toxbase.org/. [Accessed 3 January 2021]
1. Suman A, Owen J. Update on the management of burns in 23. Waldmann V, Narayanan K, Combes N et al. Electrical
paediatrics. BJA Educ 2020; 20: 103e10 injury. Br Med J 2017; 357: j1418

102 BJA Education - Volume 22, Number 3, 2022

 Major burns, Part 1

24. American College of Surgeons. Advanced trauma life sup- 30. British Burn Association. National burn care referral guid-
port student course manual. 10th edition 2018 Available ance. 2012. Available from: https://www.
from: https://viaaerearcp.files.wordpress.com/2018/02/ britishburnassociation.org/wp-content/uploads/2018/02/
atls-2018.pdf. [Accessed 3 January 2021] National-Burn-Care-Referral-Guidance-2012.pdf.
25. British Burn Association. Emergency Management of the [Accessed 14 November 2020]
Severe Burn Course. Available from: https://www. 31. British Burn Association. National standards for provision
britishburnassociation.org/emsb-courses/ (accessed 3 and outcomes in adult and paediatric burn care. 1st edition.
January 2021). London: Burn Standards Review Group; 2018
26. Gill P, Martin RV. Smoke inhalation injury. BJA Educ 2015; 32. Herndon DN, Parks DH. Comparison of serial debride-
15: 143e8 ment and autografting and early massive excision with
27. Care of Burns in Scotland. Management of adult major cadaver skin overlay in the treatment of large burns in
burns: initial burns management standard operating children. J Trauma 1986; 26: 149e52
procedure 2021. Available from: https://www.cobis.scot. 33. Herndon DN, Barrow RE, Rutan RL et al. A comparison of
nhs.uk/wp-content/uploads/2021/01/Initial-Burns- conservative versus early excision. Therapies in severely
Management-SOP-1.png (7 accessed May 2021). burned patients. Ann Surg 1989; 209: 547e53
28. Barnes J, Duffy A, Hamnett N et al. The Mersey Burns App: 34. Dziewulski P. Total burn wound excision in major burn
evolving a model of validation. Emerg Med J 2015; 32: 637e41 injury; two decades experience at St Andrew’s. In: Annual
29. Butts CC, Holmes IV JH, Carter JE. Surgical escharotomy scientific meeting Australian & New Zealand burn association;
and decompressive therapies in burns. J Burn Care Res Perth; 2017
2019; 41: 263e9

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