Initial assessment and management of burns
How to examine, treat, and refer severe burns injuries
Burns represent a substantial healthcare burden, accounting for more than 300 000 global deaths annually. In the United Kingdom, an estimated 250 000 patients present to primary care with a burns injury every year and 175 000 attend emergency departments,  so medical students are highly likely to encounter such patients during rotations. Most burns occur at home, and children are more likely than adults to be scalded.
Many burns can be adequately managed with appropriate first aid treatment at home or in primary care. In more severe cases, however, prompt recognition, assessment, and appropriate management can be life saving.
The initial management has an important effect on the patient’s long term outcome, so your interventions can have a positive impact. Initial management consists of following a structured plan and frequently reassessing the patient’s condition and response to what you are doing. This article aims to provide you with a basic understanding of the pathology of burns, a safe and effective system for assessing patients with burns, and guidance on appropriate initial management strategies.
What is a burn?
According to the Oxford English Dictionary, a burn is “an injury caused by exposure to heat or flame.” Most burns occur as a result of thermal injury—the largest proportion of these are scalds, especially in the paediatric population. Burns can also be caused by several other mechanisms including electricity, chemicals, or radiation (box 1). Burns are often considered as injuries of the skin only, but this is not the case—any tissue can be burnt, including cornea and lung. This is important to remember—inhalation injuries must never be overlooked.
Box 1: Types of burn injuries and their causes
- 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
- 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
- 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
- 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
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. Courses such as advanced trauma life support (ATLS) teach a systematic approach to treatment and links are provided in the further reading section to refresh your knowledge of this approach. This article assumes knowledge of this and will focus on burns management.
If you are first on the scene do not rush in immediately. 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.
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. 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.
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 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
- 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.
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.
Alternatively, Lund and Browder charts (fig 2 2 ) are often available in emergency departments and account for age related differences in body surface area, making them a more appropriate tool for evaluating TBSA in the paediatric population. Children have relatively large heads in proportion to their body size, so it is important to use an appropriate paediatric chart for your calculations.
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
- 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.
|Burn depth||Appearance||Capillary refill||Sensation||Notes|
|Epidermal||Erythematous; no blistering; dry||Present||Painful||Area will heal so not include in % TBSA calculation|
|Superficial dermal||Erythematous with small blisters; moist||Brisk capillary refill||Usually painful||Will heal within 14 days|
|Mid dermal||Dark pink; blistered||Sluggish||Dull/absent||Usually heal|
|Deep dermal||Blotchy red; may be blistered||No refill||Insensate||Do not heal|
|Full thickness||Stiff; white or black; eschar may be present; leathery appearance||No refill||Insensate||Do not heal|
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.
When assessing a burn you should:
- 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
- Recognise 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.
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 should be started in all burns estimated at greater than 10% TBSA in children and greater than 15% TBSA in adults. Use the modified Parkland formula to calculate fluid requirements (box 2).
Box 2: Modified Parkland formula
- 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
- Also give maintenance fluid—for example, 0.45% saline + 5% dextrose—according to weight and local policy
- 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.
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.
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.
- 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
- 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
- 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.
The National Network for Burn Care has produced referral guidelines that are endorsed by the British Burn Association. If a specialist burns team is within one hour’s journey, patients should be transported there in the first instance. The exception to this advice is where immediate intervention is needed to preserve life, such as endotracheal intubation for inhalation injuries.
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.
All patients who meet the criteria in box 3 should be referred. If you are unsure, it is better to discuss the patient with your nearest burns team. Similarly, if there are concerns regarding healing of the burn, infection, or suspected toxic shock syndrome, the burns team should be consulted for advice.
Box 3: 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
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.
Outcomes for patients with burns injuries
You may have been taught that the sum of the patient’s age and the % TBSA give an indication of the mortality rate for that patient (Baux score). However, as survival rates after burn injury continue to improve, this score now tends to overestimate mortality rates. Twenty five years ago, a young adult with a 50% total body surface area burn had a 50% mortality rate; this has now been reduced to 10%. Improvements in our understanding of resuscitation, nutritional support, and the prevention and management of infection, as well as developments in surgical techniques, have all combined to improve the outlook for patients.
The care provided by the multidisciplinary burns team is essential for patients with severe burns. The initial aim is to save life and allow people to get back to their home. Rehabilitation can be prolonged and patients may be left with restricting or visible scarring. Scar revision surgery is possible over time, and it is helpful for patients to feel that they are supported by the burns team, acutely and in the longer term.
This 40 year old woman has a history of epilepsy. She was sitting down to drink a cup of freshly made tea, when she had a seizure. She spilt tea over her right thigh and perineum. This happened about 30 minutes ago, and a relative brought the patient straight to hospital. 3
Describe what you see in the photograph of the patient’s right thigh.
The patient has burnt about 1.5% TBSA on the anteromedial aspect of her right thigh. The area has been blistered, but these have burst, showing an area of erythema, which is painful and has brisk capillary refill—consistent with an area of superficial dermal burn.
The patient has an additional area of similar burn (1% TBSA) on the perineal area. There are no other injuries. How will you manage this patient?
This patient has 2.5% TBSA superficial dermal burns, and therefore does not require resuscitation fluids. The area has not been cooled, and the burn was less than three hours ago, and so the area should be cooled for 20 minutes with tepid running water. Showering the area can be a convenient way to cool the burn. As the burn involves the perineum, it is appropriate to discuss the injury with a specialist burns unit. The burn can be covered with clingfilm until a decision has been made about further care.
As the area was very painful, and the perineum was involved, the patient was transferred to the regional burns unit for analgesia and wound care. A urinary catheter was inserted, and the area was dressed with simple, non-adherent dressings. The burn healed after around two weeks of conservative care, and the patient was discharged home.
You receive a telephone call from the emergency department in your hospital. A 49 year old woman has just been brought in by ambulance. She was cleaning a portable bio-oil heater, and was relighting it to burn off some residue, when it exploded. She has burns to her right arm and both legs.
What do you ask next?
Be systematic—remember ABCDEF. Ask about the details of the burn—was the patient inside or outside? Does she have any symptoms or signs suggesting an inhalation injury? Did her clothing catch fire? Has the burn been cooled? Has she any other injuries?
The burn happened in the garden, and she has no obvious signs of inhalation injury. The patient’s clothing caught fire, and she rolled on the ground and then got into a cool shower, before being brought to hospital. There are no other injuries. You go to the emergency department, and examine the patient. 4 5
Figure 5 shows the anterior aspect of the right arm. There is a mixed depth burnt area, most of which is insensate with delayed capillary refill time, in keeping with deep dermal or full thickness burn. The burn is circumferential. There is a small (0.5% TBSA) deep dermal burn on the left knee. You estimate a total of 10.5% TBSA burn, and so the patient does not require resuscitation fluids.
What specific examination would you now perform?
As there is a circumferential burn of the right arm, the next step is to assess the circulation in the limb. On examination, the limb feels swollen and firm, and the capillary refill time in nailbeds of the fingers on the right hand is greater than 4 seconds. You can palpate a radial pulse.
What do you do now?
The presence of a palpable pulse does not mean that perfusion of the limb is adequate—and remember that the limb will swell over the next 24-72 hours. You should prepare to perform escharotomies of the limb, to release the pressure on the limb.
Escharotomies were performed (fig 6), and the capillary refill time returned to normal. Note the midaxial incision, avoiding the ulnar nerve at the medial epicondyle; you will also see the gap between the skin edges after release of the constricting eschar. The patient was managed conservatively for one week, until the mixed depth areas had fully delineated. She then required excision of 5% TBSA burn from the right arm, and 2% TBSA from the right leg. The excised areas were reconstructed with split skin grafts. These healed well, and the patient has been discharged home. 6
It is natural to feel overwhelmed when faced with a patient with a burn injury. Taking a calm, systematic approach to assessment and initial management will give the patient the best possible chance of a good outcome. Once you have completed your initial management, consider whether the patient needs to be referred for specialist treatment. If you are not sure, discuss the case with the regional burns service. You might also consider attending an emergency management of severe burns course—this one day, multidisciplinary course covers the immediate management of burns in more detail than this article.
- Emergency Management of Severe Burns: In the UK, this course is arranged by the British Burn Association—www.britishburnassociation.org/emsb
- Resuscitation Council (UK). A systematic approach to the acutely ill patient, ABCDE—www.resus.org.uk/resuscitation-guidelines/a-systematic-approach-to-the-acutely-ill-patient-abcde
- Royal College of Surgeons. Advanced Trauma Life Support (ATLS) Provider Programme—www.rcseng.ac.uk/courses/course-search/atls.html
1Queen’s University Belfast, Northern Ireland, 2Centre for Experimental Medicine, Queen’s University Belfast, Northern Ireland
Correspondence to: email@example.com
SMA initiated the article, revised the draft article, and is guarantor. PMC performed the literature search, wrote the draft article, and produced the final version.
Competing interests: None declared.
Patient consent obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
- Mock C, Peck M, Peden M, Krug E, eds. A WHO plan for burn prevention and care. 2008. http://apps.who.int/iris/bitstream/10665/97852/1/9789241596299_eng.pdf.
- National Burn Care Review. National burn injury referral guidelines. In: Standards and strategy for burn care. NBCR, 2001:68-9.
- Wilkinson E. The epidemiology of burns in secondary care, in a population of 2.6 million people. Burns 1998;24:139-43.
- British Burn Association. Emergency management of severe burns (EMSB) course manual. 15th ed. 2012. www.britishburnassociation.org/emsb.
- Skinner A, Peat B. Burns treatment for children and adults: a study of initial burns first aid and hospital care. N Z Med J 2002;115:1-9.
- British Burn Association. First aid position statement, 2014. www.britishburnassociation.org/downloads/BBA_First_Aid_Position_Statement_-_8.10.14.pdf.
- Wachtel TL, Berry CC, Wachtel EE, et al. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns 2000;26:156-70.
- Van Hasselt EJ. 2008. Burns manual. 2nd ed. Nederlandse Brandwonden Stichting.
- Lund C, Browder N. The estimation of areas of burns. Surg Gynecol Obstet 1944;79:352-8.
- Nichter LS, Williams J, Bryant CA, et al. Improving the accuracy of burn-surface estimation. Plast Reconstr Surg 1985;76:428-33.
- Miller SF, Finley RK, Waltman M, et al. Burn size estimate reliability: a study. J Burn Care Rehabil 1991;12:546-5.
- National Network for Burn Care. Burn care referral guidance. Version 1. 2012. www.britishburnassociation.org/downloads/National_Burn_Care_Referral_Guidance_-_5.2.12.pdf.
- Jackson PC, Hardwicke J, Bamford A, et al. Revised estimates of mortality from the Birmingham Burn Centre, 2001-2010. Ann Surg 2014;259:979-84.
- Richards A, Dafydd H. Key notes on plastic surgery. 2nd ed. Wiley Blackwell, 2015.
Cite this as: Student BMJ 2015;23:h5583