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CLINICAL REVIEW

Emergency and early management of

burns and scalds
Stuart Enoch,1 Amit Roshan,2 Mamta Shah3

1
University Hospital of South Burn injuries are an important global health problem. estimating small burns (<15%) or large burns (>85%).
Manchester, Manchester M23 9LT Most simple burns can be managed by general practi- In large burns, the burnt area can be quickly calculated
2
Cambridge University Hospitals, tioners in primary care, but complex burns and all by estimating the area of uninjured skin and subtract-
Addenbrooke’s Hospital, major burns warrant a specialist and skilled multidisci- ing it from 100.6 A common mistake is to include
Cambridge CB2 8QE
3
Central Manchester and
plinary approach for a successful clinical outcome. erythema—only de-epithelialised areas should be
Manchester Children’s Hospitals This article discusses the principles behind managing included in these calculations.
NHS Trust, Manchester major burns and scalds using an evidence based
Correspondence to: M Shah, approach and provides a framework for managing sim- How is the depth of a burn assessed?
Regional Paediatric Burns Unit,
Booth Hall Children’s Hospital,
ple burns in the community. Clinical estimation of burn depth (fig 1) is often subjec-
Manchester M9 7AA tive—an independent blinded comparison among
mamta.shah@cmmc.nhs.uk What is the burden of burns injuries? experienced surgeons showed only 60-80%
Cite this as: BMJ 2009;338:b1037
Annually in the United Kingdom, around 175 000 concurrence. 7 Burn wounds are dynamic and need
doi:10.1136/bmj.b1037 people attend accident and emergency departments reassessment in the first 24-72 hours, because depth
with burns from various causes (box 1).1 This repre- can increase after injury as a result of inadequate treat-
sents 1% of all emergency department attendances, ment or superadded infection. 8 Burn wounds can be
and about 10% of these patients need inpatient care in superficial in some parts but deeper in other areas
a specialist unit.2 A further 250 000 patients are mana- (fig 2). The table shows some characteristic features of
ged in the community by general practitioners and burns of varying depth.
allied professionals. Of patients referred to the hospi- A blinded rater comparison of laser Doppler imaging,
tal, some 16 000 are admitted, and about 1000 patients which assesses skin blood flow, with clinical assessment
need active fluid resuscitation. The number of burns and histopathology found that imaging was 90-100% sen-
related deaths average 300 a year.1 sitive and 92-96% specific for estimating burn depth.7
Globally, the World Health Organization estimates However, the high outlay costs for this equipment pre-
that 322 000 people die each year from fire related clude its use outside specialist burns units. Other methods
burns.3 This could be an underestimate, however, such as transcutaneous videomicroscopy (direct visualisa-
because we have no valid comprehensive statistics tion of dermal capillary integrity) and infrared thermogra-
from developing countries, where >95% of these phy (temperature gradient between burnt and intact skin)
deaths occur.3 4 High population density, illiteracy, remain largely experimental.9 10
poverty, and unsafe cooking methods contribute to The terms “partial thickness” or “full thickness”
the higher incidence in developing countries.4 burns describe the level of burn injury and indicate
Sources and selection the likelihood and estimated duration for healing to
criteria How is the area of a burn estimated? occur. Superficial burns usually heal (by epithelialisa-
We searched Medline, In adults, Wallace’s “rule of nines” is useful for estimat- tion) within two weeks without surgery, whereas dee-
Ovid, Burns, and the ing the total body surface area—18% each for chest, per burns probably need excision and closure of the
Cochrane Library until back, and legs apiece, 9% each for head and arms area, often with skin grafts. Hypertrophic scarring is
June 2008 for apiece, and 1% for the perineum. It is quick to apply more common in deeper burns treated by surgery
randomised controlled and easily remembered, although it tends to overesti- and skin grafting than in superficial burns.11
trials, systematic mate the area by about 3%.5 The Lund and Browder
reviews, evidence chart takes into account changes in body surface area What factors influence outcome?
reports, and recent with age (and growth). It is useful across all age groups Logistic regression analysis of survival data from 1665
evidence based and has good interobserver agreement.5 Another use- burns patients from the Massachusetts General Hospi-
guidelines from
ful, but rather subjective, guide is to use the surface area tal identified three risk factors for death: age over
international burn
of the patient’s palm and fingers, which is just under 1% 60 years, more than 40% of body surface area injured,
associations.
of the total body surface area. This method is useful for and inhalation injury.12 As survival outcomes have

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 CLINICAL REVIEW

Superficial Superficial Deep Full Box 1 Some important causes of burns and scalds
dermal dermal thickness
Flame burns
Epidermis Scalds (hot liquids)
Contact burns (hot solid)
Chemicals (acids or alkalis)
Dermis
Electrical burns (high and low voltage)
Flash burns (burns resulting from brief exposure to
intense radiation)
Subcutaneous
Sunburns
Friction burns
Fig 1 | Burn depth nomenclature Radiation burns
Burns from lightning strike
improved (mortality about 5-6% in resourced
centres),13 however, assessment of outcome has shifted
When is referral to a specialist burns unit needed?
from mortality to quality of life measures.14 Thus, the
current focus in burns patients is the preservation of Box 2 shows the criteria for referring a “complex” burn
function, reconstruction, and rehabilitation.13 to the specialist burns unit. Small area burns that take
more than 14 days to heal; become infected; or are
How are minor burns managed? likely to lead to considerable aesthetic, functional, or
psychological impairment (face, hands, feet, across
Flowchart 1 (web fig 1 on bmj.com) provides a guide-
flexures, genitalia) may also need to be referred.1
line for managing a “minor” burn in the community.
The European working party of burns specialists
How should major burns be managed?
recommends cleaning burns with soap and water (or
All major burns should be managed initially according
a dilute water based disinfectant) to remove loose
to trauma resuscitation guidelines.18 Box 3 shows a
skin, including open blisters.15 Although the clinical
consensus summary on first aid management (prehos-
evidence for “deroofing” of blisters is poor, without
pital care) for burns,18 and box 4 shows the principles
deroofing burn depth cannot be assessed. All blisters
for managing any large burns.
should therefore be deroofed, apart from isolated lax
Prompt irrigation with running cool tap water for
blisters <1 cm2 in area, which can be left alone.16 A
20 minutes provides optimal intradermal cooling.19
simple non-adhesive dressing, such as soft silicone
Ice and very cold water should be avoided because
(for example, Mepitel), padded by gauze is effective
they cause vasoconstriction and worsen tissue ischae-
in most superficial and superficial dermal burns. How-
mia and local oedema.20 Hypothermia should be
ever, biological dressings such as Biobrane are better,
avoided, especially in children. Patients with chemical
especially for children, because they reduce pain and
burns may need longer periods of irrigation (up to 24
the wound bed can be inspected through the translu- hours), and specific antidote information should be
cent sheet.17 New non-animal derived synthetic poly- obtained from the regional or national toxicology unit.
mers such as Suprathel look promising for treating
Prehospital consensus guidelines emphasise that dres-
partial thickness burns, but further studies are needed.
sings help relieve pain from exposed nerve endings and
Silver sulfadiazine can be used for deep dermal burns.
keep the area clean.18 Polyvinylchloride film (such as
Dressings should be examined at 48 hours to reassess
depth and the wound in general, and dressings on
superficial partial thickness burns can be changed
after three to five days in the absence of infection. If
evidence of infection exists, daily wound inspection
and dressing change is indicated. Deep dermal burns
need daily dressings until the eschar has lifted and re-
epithelialisation is under way, after which dressings
can be changed more often.

Characteristic features of burns of different depths

Feature
Burn type Appearance Blisters Capillary refill Sensation
Epidermal Red, glistening None Brisk Painful
Superficial dermal Pale pink Small Brisk Painful
Fig 2 | Tea scald over the chest and shoulder of a child
Deep dermal Dry, blotchy cherry red May be present Absent Dull or absent
showing heterogeneity of burn depth. S=superficial,
Full thickness Dry, white or black None Absent Absent I=intermediate, D=deep

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 CLINICAL REVIEW

for early intubation ascertained before transfer to a spe-

Box 2 National burn injury guidelines for referral to a burns unit cialist unit. In full thickness circumferential burns—
All complex injuries should be referred. Such injuries are likely to be associated with: especially to the neck, chest, abdomen, or limbs—
Extremes of age (<5 or >60 years) escharotomy may be needed to avert respiratory dis-
Site of injury tress or vascular compromise of the limbs from con-
striction. Flowcharts 2 and 3 (web figs 2 and 3 on
 Face, hands, or perineum
bmj.com) show the management of patients in the
 Any flexure including neck or axilla emergency department or the specialist burns unit.
Circumferential dermal burns or full thickness burn of the limb, torso, or neck
Inhalation injury (excluding pure carbon monoxide poisoning) What is the role of fluid resuscitation?
Mechanism of injury Effective fluid resuscitation remains the cornerstone of
management in major burns. If more than 25% of the
 Chemical burns >5% total body surface area (except for hydrofluoric acid when >1%
body is burnt, intravenous fluids should be given “on
area needs referral)
scene,” although transfer should not be delayed by
 Exposure to ionising radiation
more than two attempts at cannulation.18 The aims
 High pressure steam injury are to maintain vital organ perfusion and tissue perfu-
 High tension electrical injury sion to the zone of stasis (around the burn) to prevent
 Hydrofluoric acid burns >1% extension of the thermal necrosis. In the UK, expert
Suspected non-accidental injury in a child (if delayed presentation, unusual pattern consensus recommends that fluid resuscitation be
of injury, inconsistent history, discrepancy between history and clinical findings, initiated in all children with 10% burns and adults
multiple injuries, or old scars in unusual anatomical locations) with 15% burns; children who had early (within two
Large size hours) fluid resuscitation had a lower incidence of sep-
sis, renal failure, and overall mortality.8 21
 Child (<16 years old) >5% total body surface area
Adult (≥16 years) >10% total body surface area How much fluid?
Coexisting conditions Several formulae, based on body weight and area
 Serious medical conditions (such as immunosuppression) burnt, estimate volume requirements for the first 24
 Pregnancy hours. Although none is ideal, the Parkland formula
 Associated injuries (fractures, head injury, or crush injuries) (3-4 ml/kg/% burn of crystalloid solution in the first
24 hours, with half given in the first eight hours) and
its variations are the most commonly used. Resuscita-
tion starts from the time of injury, and thus any delays
clingfilm) is useful, but remember that circumferential in presentation or transfer to the hospital or specialist
wrapping can cause constriction. Cellophane films can unit should be taken into account and fluid require-
worsen chemical burns, so the area should be irrigated ment calculated accordingly. Resuscitation formulae
thoroughly until pain has decreased and only wet dres- are only guidelines, and the volume must be adjusted
sings should be applied. Intravenous opiates or intra- against monitored physiological parameters.
nasal diamorphine should be used for analgesia.
All patients with facial burns or burns in an enclosed Which fluid?
area should be assessed by an anaesthetist and the need The preferred resuscitation fluid varies greatly. Cur-
rently, the most popular one is crystalloid Hartmann’s
solution, which effectively treats hypovolaemia and
Box 3 Consensus guidelines for prehospital management of burns18 extracellular sodium deficits. Sodium chloride solution
Approach with care and call for help (0.9%) should be avoided because it causes hyperchlor-
aemic metabolic acidosis. A recent Cochrane meta-
Stop the burning process
analysis of 67 randomised controlled trials (RCTs) of
Help the person to “drop and roll” if the clothing is alight trauma, burns, and post-surgery patients found no evi-
Turn the power off if electricity is involved dence that colloid resuscitation reduces mortality more
Assess patient as per guidelines for emergency management of severe burns (see box 4) effectively than crystalloids.23 Although the addition of
and manage appropriately colloids in burn resuscitation may decrease total
Cool the area but prevent hypothermia volume requirements, RCTs are needed to evaluate
Assess burn severity its other benefits.24 Many burns units add a colloid
after the first 12 hours for large area burns.22
Cover or dress the area with clingfilm or cellophane
Suspect inhalation injury in burns sustained in an enclosed area, facial burns, or when How is resuscitation monitored?
nasal hair has been singed The use of urine output to assess adequate fluid resusci-
Early intubation may be needed if there is evidence of inhalation injury tation in burns has been challenged.5w1 Invasive haemo-
Cannulate and administer fluids (Hartmann’s solution or Ringer’s lactate) dynamic monitoring with central venous pressure or
Provide adequate analgesia pulmonary artery catheters are not recommended for
routine monitoring of fluid replacement in burns
Transfer to appropriate hospital or burns care centre
because of the risk of infection. Less invasive monitoring

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CLINICAL REVIEW

Skin biopsy
Skin specimen Isolated keratinocytes

Single or composite
layered substitute Injured
Temporary or area Grafting
permanent coverage

Dermal cellular substitutes Sheet autograft Culture Feeder cells

(human fibroblasts) Cultured epidermal autograft
Allogenic composite
cultured skin
Step 1: Step 2: Autologous
Dermal cover skin graft

+
Integra or Alloderm Skin graft 3-4 weeks later
Dermal acellular matrix (bovine or human)

Fig 3 | Newer tissue engineering directions in burns management. Cultured epidermal autografts (right), staged dermal acellular
substitutes (bottom), single application dermal cellular substitutes or allogenic composites (left)

using thermodilution methods to measure intrathoracic disease modulation.w6 Nutritional requirements are
blood volume, cardiac output, and cardiac index have dynamic, and early debridement and skin cover result
recently received attention. Although preliminary stu- in a 50-75% increase in energy expenditure. Thus, a
dies have suggested that this may aid resuscitation, one nutritional plan—that takes account of factors such as
RCT failed to support these findings in burns.w5 the extent and depth of the burn, the need for repeated
surgical interventions, the appropriateness of the
What is the role of nutrition? enteral or parenteral route, and the pre-injury health
The role of nutritional support in major burns has status of the patient—should be implemented within
shifted from one of preventing malnutrition to one of 12 hours.

Psychosocial aspects
Box 4 Emergency management of severe burns approach (adapted from the Australian
The psychological requirements of patients and their
and New Zealand Burns Association)
carers change over the early resuscitative phase, acute
Order of management priority in patients with severe burns phase, and rehabilitation phase. The prevalence of
A. Airway with cervical spine control depression is estimated to be high (up to 60%) in
B. Breathing and ventilation burns inpatients, and up to 30% have some degree of
C. Circulation with haemorrhage control post-traumatic stress disorder.w7 All burns centres offer
specialist advice on long term psychosocial adjustment
D. Disability—neurological status
in burns patients. Changing faces in the UK and the
E. Exposure preventing hypothermia
Phoenix society in the United States provide excellent
F. Fluid resuscitation support for burns survivors.
Adults
Resuscitation fluid alone (first 24 hours): How are scar and burn areas managed after healing?
 Give 3-4 ml (3 ml in superficial or partial thickness burns, 4 ml in full thickness burns A retrospective cohort study of 337 children with up to
or those with associated inhalation injury) Hartmann’s solution/kg body weight/% a five year follow-up found hypertrophic scarring in
total body surface area. Half of this calculated volume is given in the first eight hours less than 20% of superficial scalds that healed within
after injury. The remaining half is given in the second 16 hour period 21 days but in up to 90% of burns that took 30 days
Children or more to heal.11 Appropriate treatment must there-
Resuscitation fluid as above plus maintenance (0.45% saline with 5% dextrose, the
fore be instituted early and infection prevented to
volume should be titrated against nasogastric feeds or oral intake): encourage rapid healing. Healed burns do not have
adnexal structures, and are therefore dry, sensitive,
 Give 100 ml/kg for first 10 kg body weight plus 50 ml/kg for the next 10 kg body
and irregularly pigmented. Hence the area should be
weight plus 20 ml/kg for each extra kg
moisturised and massaged to reduce dryness and to

940 BMJ | 18 APRIL 2009 | VOLUME 338

 CLINICAL REVIEW

equivalent) and fibroblasts (dermal equivalent) are

SUMMARY POINTS
also available.w9
Most minor burns can be managed in primary care Although a recent meta-analysis of 20 RCTs has
Appropriate first aid limits progression of burn depth and influences outcome shown these substitutes to be safe, their efficacy could
not be determined on the basis of current evidence.w9
Assessment of area and depth is crucial to formulating a management plan
Contributors: SE and AR designed the paper, carried out the literature
Burn depth may progress with time, so re-evaluation is essential search, collated the up to date evidence, and prepared the manuscript. SE
All major burns require fluid resuscitation, which should be guided by monitoring of the created the flow charts and AR created fig 3. Both authors contributed
physiological parameters equally in the development and completion of this article. MS is the senior
author who proofread the article, provided invaluable suggestions, did
A multidisciplinary approach is crucial for a successful clinical outcome the necessary corrections and amendments, and provided the expert
advice. SE is guarantor.
Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
keep the healed area supple. A sun cream, with a sun
protection factor of 30, is advised to prevent further
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burns_factsheet.pdf.
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