Burns Assessment

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Last updated: January 13, 2022

Revisions: 7

Introduction
Burn injuries can have wide-ranging physical and psychological sequelae, with many patients requiring treatment in specialised centres. In the UK,
130,000 patients present to Emergency Departments with a burn each year.

Whilst most burns are minor, major burns will require close monitoring and management, especially to those of increasing age or with extensive co-
morbidities.

Aetiology

Type Description

Scald Injury caused by hot liquids and steam, common in children and elderly

Thermal Flame Direct exposure to fire, can be associated with concomitant inhalation injury

Flash Indirect exposure to flame

Exposure to a very hot stimulus for short amount of time (e.g. industrial accidents) or exposure to a
Contact  
hot surface for an abnormally long amount of time (e.g. radiator)

Acid Results in coagulation necrosis to affected tissues

Chemical
Alkali Results in liquefaction necrosis to affected tissues*

Current from an electrical source passes directly through the body†, resulting in an entry and exit
Direct contact
wound and can cause significant internal damage
Electrical

Electrical arc A flash thermal burn occurs due to an electrical arc coming briefly into contact with skin

Table 1 – Classification of burns injury; *Alkaline buns often result in deeper and more severe burns, due to protein denaturation and fat saponification;
†Complications of electrical burns include cardiac arrhythmias and rhabdomyolysis

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Inhalation Injury
An inhalation injury is damage to the airway, secondary to the inhalation of hot air. Inhalation injury should be suspected whenever an injury is
from a flame or smoke exposure in enclosed environment. Mortality in burns increases by 20% when associated with an inhalation injury.

Anyone with features of airway compromise, such as stridor, hoarse voice, or respiratory compromise, post-injury will likely need a definitive
airway placed (i.e. intubation). More subtle features to suggest a potential airway injury include singed nasal hairs, facial burns, or soot deposits
around the nose.

Nasoendoscopy in suspected cases may show erythema or oedema of airway on direct visualisation, however in those with red flag symptoms,
early involvement of anaesthetics for potential intubation should be the priority.

Burn Initial Management

When assessing a patient with burns injury, a thorough A to E assessment is vital. Once performed and the patient stable, try to elicit details regarding
the mechanism of the burn, as it can provide clues to the likely depth, associated inhalation injury, and concomitant traumatic injuries

A major burn is any burn with >20% TBSA (>10% in children) of partial or full-thickness burns (i.e. not including superficial burns). Major burns can
result in profound inflammatory responses and large fluid shifts occurring, and aggressive fluid resuscitation is often required to mitigate burn shock.

Ensure any source of burning is removed as a priority, as is any non-adherent clothing.

Initial Assessment
The initial assessment of a patient with a burns injury requires an A to E assessment (discussed more here), however there are a few specific points to
be aware of for burns patients:

Airway
Evaluate for signs of inhalation injury; pre-emptive intubation may be required if suspected or high-risk. Remember to protect cervical spine until
clinically cleared

Breathing
Administer 100% oxygen via non-rebreather reservoir mask. In more extensive burns, evaluate the need for escharotomy, especially if
circumferential chest burns are present. Obtain an ABG and check carboxyhaemoglobin levels (for carbon monoxide poisoning)

Circulation
Site two wide bore intravenous cannula (avoiding insertion through burned tissue, if possible) and take routine bloods, including group and
screen, clotting, and creatinine kinase. Aggressive intravenous fluid therapy is indicated (discussed later); insertion of a urinary catheter is
essential for fluid balance monitoring

Disability
Evaluate neurological status using the Glasgow Coma Scale and remember to check the temperature, as there is a increased risk of hypothermia

Exposure
The patient should be fully exposed to get an accurate estimation of the percentage of total body surface area (%TBSA) burned and to check for
any concomitant injuries*. Ensure the patient is given a tetanus booster if their status is uncertain.

*Remember that electrical burns may show only a small area of external injury, but have caused significant visceral injury

Intravenous morphine should be used where required for analgesia. Ensure an ECG and CXR are performed, and start a strict fluid balance chart.

Wound dressing protocols vary, however in general, if the patient is to be transferred to higher-level burn care, initially dress the wound with Clingfilm
to allow full evaluation of burn depth, whilst minimising fluid losses from the affected wounds.

Hypothermia is a severe risk following burns injury, due to the extensive heat and fluid loss that can occur from the burns sites. As such, assessment
in a warmed room, giving warmed fluids if possible, and reducing wound exposure time can all help in limiting hypothermia.

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Minor Burns
Rapid and thorough first aid should be performed for all minor burns. General management principles for the management of minor burns starts
with removing the source of the burn.

Any non-adherent clothing should be removed, before the wound is cooled under running water for twenty minutes as soon as possible, as this
promotes re-epithelialisation.

Assessing Burn Severity

The severity of a burn is generally defined by the percentage total body surface area (%TBSA) burned and burn depth.

Accurate estimation of %TBSA burned is a critical step in guiding appropriate burns management as it determines the initial fluid volume
requirements for resuscitation, and whether or not the patient should be considered for transfer to specialist care.

Various techniques can be used to estimate %TBSA, such as Wallace’s Rule of Nines (Fig. 1A), the “Rule of Palm” where the patients palm area
represents 1% of their TBSA, or a Lund & Browder Chart (Fig. 1B) which are most used in paediatric cases.
 © Adapted from U.S. Department of Health and Human Services [Public domain]

Figure 1 – (A) Wallace’s Rule of Nines (B) Lund & Browder Chart

Assessing Burn Depth

Burn depth approximation is important as it guides therapy (Table 2). More superficial burns may heal spontaneously (albeit are often more painful),
while deeper burns may require further intervention (Fig. 2); deeper burns also carry an increased risk of complications.

Burn depth does not, however, guide initial resuscitative efforts and so administration of adequate fluid resuscitation should not be delayed in favour of
accurate burn depth evaluation.

Burn Thickness Deepest Layer Involved Appearance Pain Prognosis

Heals without scarring,

Superficial (first degree) Epidermis Dry, blanching, erythema Painful
5-10days

Superficial partial-
Blisters, wet, blanching, Heals without scarring,
thickness (second Upper dermis Painful
erythema <3 weeks
degree)

Heals in 3-8 weeks, likely

Deep partial-thickness Yellow or white, dry, non-
Lower dermis Decreased sensation to scar if healing >3
(second degree) blanching
weeks

Full thickness (third Leathery or waxy white, Heals by contracture >8

Subcutaneous tissue Painless
degree) non-blanching, dry weeks, will scar

Table 2 – Classification of Burns by Depth

Fluid Resuscitation
Fluid resuscitation following burn injury allows for adequate intravascular volume to limit hypovolaemia, maintain organ perfusion, and minimise tissue
ischaemia in the immediate post-burn period.

Fluids are calculated from the time of the burn, not the patient’s hospital arrival time. If the patient is clinically shocked on arrival, this should be
corrected prior to calculating any burn fluid requirements.

The modified Parkland formula is the one most commonly used for directing initial fluid requirements. This purely acts as a guide, as every patient
should be monitored closely and reassessed regularly to gauge their response to the administered fluid.

The modified Parkland formula* describes the volume of crystalloid fluid (ideally Hartmanns solution) to be administered in the first 24 hours post-
burn:

Initial 24hrs (Adults): 4mL (Hartmann’s) x Weight (kg) x %TBSA burned

Initial 24hrs (Children): 3mL (Hartmann’s) x Weight (kg) x %TBSA burned

50% of the calculated volume is given within the first 8 hours post-burn, and the remaining 50% is given in the remaining 16 hours.

*The modified Parkland formula has been shown to underestimate fluid requirements in patients with large full thickness burns, inhalation injury, or
electrical burns
 © Adapted from Kronoman [CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)], Westchaser [Public domain], and Produnis [CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)],

Figure 2 – Types of Burn (A) Superficial (B) Partial (C) Deep

Goal-Directed Therapy
The goal of fluid resuscitation is achieving adequate end-organ perfusion. Due to the systemic inflammation seen in burns patients, conventional
markers of fluid balance are not always feasible.

Urine output can be monitored closely as the main marker of fluid balance status, which should be maintained (in adults) at >0.5mL/kg/hr. Other
measures include use of mean arterial pressures (MAPs) and blood gas measurements.

Ongoing Care
Depending on the injuries involved, patients with burns may require transfer to either a burns unit or a burns centre (see Appendix):

Burn Units are facilities that have a specialised burns ward staffed by skilled burns professionals, capable of caring for moderate level of injury
complexity.

Burn Centres represent the highest level of inpatient burn care, with immediate operating theatre access and highly-skilled critical care staff, for the
management of highly complex burn injuries.

Complications of burns injuries include airway compromise and respiratory failure, fluid loss and electrolyte imbalance, hypothermia, and
compartment syndrome.

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Key Points
As with all unwell patients, ensure a rapid and thorough physiological assessment and management using a structured A to E approach

Ensure adequate warming and fluid resuscitation is provided, due to extensive fluid and heat losses that can occur

Calculate the degree and extent of the burns, as this will influence need for clinical transfer

Complications of burns injuries include airway compromise and respiratory failure, fluid loss and electrolyte imbalances, hypothermia, and
compartment syndrome

Appendix
Criteria Burns Unit Burns Centre

%TBSA 10-39% ≥40%, or ≥25% with inhalation injury

Depth Deep partial or full-thickness

Specialised areas (hands, feet, face, perineum, genitals,

over major joint)
Site

Non-blanching circumferential burns

Any chemical, electrical, friction, or cold injury require

Aetiology
discussion with burns specialists.
 Concomitant major trauma with burn injury meeting centre
Suspected non-accidental injury (NAI)
threshold

Other Concomitant severe co-morbidities and patients >65yrs

Pregnant patients
with ≥25% TBSA burns

Concomitant trauma with burn injury

Table 3 – Suggested Criteria for Determining the Transfer to Burns Unit versus Transfer to Burns Centre