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A major burn can defined as any burn that requires intravenous fluid resuscitation (10% Body Surface  Area (BSA. in a child, 15% in an adult) and / or a burn to the airway.
  1. Beyond simple erythema, burns are either partial or full thickness depending on whether the basement membrane has been lost.
  2. On examination a full thickness (3rd degree) burn is usually pale, bloodless and insensitive to the firm touch of a sterile needle.
  3. Partial thickness burns can be further divided into superficial (1st degree) and deep (2nd degree), which refers to the depth at which the dermal layer is injured. Sensation is preserved and healing of the skin more likely. 
  4. The mechanism of the burn can be classified into six categories
    1. Contact - direct contact with a hot surface.
    2. Scald - hot fluid/gas usually causing a superficial burn.



1. Splash type injury

2. Immersion injury



  1. Flash - a brief burn, usually partial thickness.
  2. Flame - usually full thickness.
  3. Chemical
  4. Electrical

Grades of Burns


First degree—injury localized to the epidermis


Superficial second degree—injury to the epidermis and superficial dermis


Deep second degree—injury through the epidermis and deep into the dermis


Third degree—full-thickness injury through the epidermis and dermis into subcutaneous fat


Fourth degree—injury through the skin and subcutaneous fat into underlying muscle or bone

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For adults and children, the American Burn Association grades the level of care required for burns as follows:

Minor burns -- these can be managed on an outpatient basis:

1. <10% total body surface area (TBSA) in an adult

2. <5% TBSA in young or elderly

3. <2% full thickness burn

Moderate burns -- these should be managed on an inpatient basis:

1. 10-20% TBSA burn in an adult

2. 5-10% TBSA in young or elderly

3. 2-5% full thickness burn

4. Suspected inhalation injury

5. Circumferential burn

6. Associated medical problem, e.g., diabetes

Major burns -- these require transfer to a specialized burn center:

1. >20% TBSA burns in adult

2. >10% TBSA burns in young or elderly

3. >5% full thickness burn

4. inhalation injury

5. Significant burn to face, eyes, genitalia or joints

6. Significant associated traumatic injury

  1. Superficial burns, those without blistering or evidence of deeper skin damage, are best managed simply with a lotion and antibiotics.
  2. Burns which have blistered (second-degree burns) should have large blisters, or blisters which have burst, débrided.
  3. An antibiotic ointment is then applied. Traditionally, this has been silver sulfadiazine.
  4. This agent should be avoided on the face (ophthalmic bacitracin is a better choice), if there is a history of sulfa drug allergy, and in the very young, when there is a danger of kernicterus.
  5. The ointment is applied twice a day and covered with a gauze dressing.
  6. Sometimes, patients with even superficial burns will develop infection in the burn.
  7. The typical organism is Streptococcus pyogenes Qand it is often highly sensitive to penicillin.
  8. Recently, however, Staphylococcus aureus has emerged as a common organism.
  9. The first few hours after a major burn are associated with massive fluid shifts, resulting in profound shock if not corrected.
  10. Later, there is a hyperdynamic phase, as the body meets the increased metabolic demands placed upon it.
  11. Initially, the patient should be assessed in the usual fashion with attention paid to the airway, breathing and circulation.
  12. In cases of burns, breathing may be compromised by the presence of circumferential burns around the chest wall.
  13. These burns result in restriction of chest expansion and thus respiratory compromise. If this is the case, then an escharotomy should be considered.
  14. Escharotomy is the procedure of incising through the burnt tissue until healthy tissue is reachedQ
  15. Escharotomies may also be limb saving procedures when there are circumferential burns around arms, legs or digits, compromising the circulation, unless the pressure is released.
  16. In general, escharotomies should be performed on the midlateral or medial aspects of limbs or digits in order to prevent joint exposure. 'rule of nines' refers to a mechanism to evaluate the extent of the burns.
  17. Rule of 9’s: The major body areas are divided such that each area is a multiple of nine. The head represents 9% of the body surface, and each arm is 9%. The front of each leg (to the groin) is 9%, and the back 9%.
  18. The front of the torso is 18%, and the back is 18%.
    The remaining 1.0% of the body surface area is allocated to the perineum. Another rule of thumb is that the palm of the hand represents 0.5% of the body surface area.
  19. In children, the preferred method of assessment of the extent of the burn area is through the use of the Lund-Browder chart.

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A 5 years old child with burn of size of palm has what % of burns of total body surface area? (AIPG 2011)
A 1%               
B 5%               
C 10%             
D 15%


Ans. A. 1%.


Aides memoire for calculation of burn size include:

  1. Wallace's rule of nines ( which is not applicable to children under the age of 14 years),
  2. use of patient's hand ( = 1 per cent TBSA) and
  3. Lund and Browder pictorial charts.  
  1. Burn Assessment.
    After completion of the primary survey, a secondary survey should assess the depth and total body surface area (TBSA) burned.


  1. Superficial partial thickness/
  2. Deep partial thickness burns/
  3. Full thickness burns
  4. Depth of burns depends on-  Temperature of source and duration of contact.
  5. Hot water 65*C- 7 seconds-   superficial partial thickness burns
  6. Hot water 65*C- 15 seconds-  deep partial thickness burns
  7. Hot water 65*C- 45 seconds-  full thickness burns
Hot water at 70*C- 1 second-   epidermal destruction
  1. First-degree burns involve the epidermis layer of the skin, but not the dermal layer. These injuries are characterized by pain, erythema, and lack of blisters. These burns heal without scar formation.
  2. Second-degree burns are subdivided into superficial and deep partial-thickness burns.
  3. Superficial partial-thickness burn injury
    1. Involves the papillary dermis, containing pain-sensitive nerve endings.
    2. Burn management, burns, burn Blisters or bullae may be present, and the burns usually appear pink and moist.
    3. These burn injuries heal with little or no scarring. 
  4. Deep partial-thickness burn injury
    1. Damages both the papillary and reticular dermis.
    2. These injuries are painful and often appear white or mottled pink.
    3. Deep partial-thickness burns can produce significant scarring. 
  5. Full-thickness or third-degree burns
    1. Involve all layers of the epidermis and dermis and may destroy subcutaneous structures.
    2. They appear white or charred.
    3. These burns are usually insensate because of destruction of nerve endings, but the surrounding areas are extremely painful.
    4. Third-degree burns are best treated with skin grafting to limit scarring.


Superficial partial

Deep partial

Full thickness

Capillary Filling














Pink to White

Leathery Black or Leathery White


Heal without scarring in 2 weeks

3 or more weeks (30 days) to heal without surgery, hypertrophic scarring is usual

Require surgical intervention

Fourth-degree burns
involve structures beneath the subcutaneous fat, including muscle and bone. 

  1. Primary management
      1. Stop, Drop, Roll, and Cool.
      2. Cool the burn wound (minimum 10 minutes and effective up to an hour) with a water having room temperature to decrease the depth of wound. (Ideal temp to cool the burn wound is 15*c)
      3. Ice cooled water should not be used because of the risk of infection and hypothermia
      4. In temperate climates cooling should be done at 15*C and hypothermia should be avoided.
      5. In Burns heat loss is due to evaporation from the exposed area.
    2. Hospital Management


Partial-thickness burns greater than 10% TBSA

Burns involving the face, hands, feet, genitalia, perineum, or major joints

Third-degree burns in any age group

Electrical burns, including lightning injury

Chemical burns

Inhalation injury

Burn injury in patients with complicated pre-existing medical disorders

Patients with burns and concomitant trauma in which the burn is the greatest risk. If the trauma is the greater immediate risk, the patient may be stabilized in a trauma center before transfer to a burn center.

Burned children in hospitals without qualified personnel for the care of children

Burn injury in patients who will require special social, emotional, or rehabilitative intervention

Ref: Schwartz's Principles of Surgery 9th Edition Ch 8
  1. Airway - check the airway is clear.
  2. Endotracheal intubation is necessary if there are deep burns to the face and neck, soot in the nostrils, burns of the tongue and pharynx, stridor or hoarseness.
  3. History including time and nature of the incident (Wet or dry burn/chemical/electrical/inside or outside).
  4. Weigh the patient.
  5. Examine the burn and assess the size with the 'rule of nines' to give a %BSA.
  6. Intravenous access - obtain large bore venous access, even through burnt tissue.
  7. Blood sampling -samples for haematocrit, electrolytes, crossmatch, arterial blood gases and carboxyhaemoglobin levels.
  8. Analgesia - intravenous morphine, ketamine, or Entonox.
  9. Catheterise - assess urine output as a gauge of tissue perfusion and adequate resuscitation.
  10. Reassess the patient thoroughly at regular intervals and also the burn. 
  1. Fluid resuscitation
    1. This should be instituted as soon as possible.
    2. There are two simple protocols that both depend upon the %BSA, time passed since injury and patients weight
    3. The rule of nines may over-estimate the BSA, but the
    4. Lund and Browder chart gives a more accurate assessment.
    5. Fluid requirements may be greater than the protocols suggest. 

ParklandsQ: Crystalloid resuscitation with Hartmanns


24 hour fluid requirement = 4 x %BSA x Wt (Kg)


Give half over the first 8 hours, and the remainder over the next 16 hours


Although there may be pronounced generalised oedema initially, as large volumes are required, it is cheap and produces less respiratory problems later on.


Muir and Barclay: Colloid resuscitation with plasma


The first 36 hours are divided into time periods of 4,4,4,6,6,12 hour intervals


Each interval = 0.5 x %BSA x Wt (Kg)      

  1. With colloid resuscitation, less volume is required and the blood pressure is better supported.
  2. However they are expensive, often unavailable and tend to leak out of the circulation and may result in later oedema especially in the lungs.
  3. In inhalation injury may increase fluid requirements by 50%.
  4. Adequacy of resuscitation is assessed by blood pressure, pulse, capillary return, urine output, level of consciousness and haematocrit.
  5. Additional fluid should be given if resuscitation is inadequate.
  6. Water loss is related to evaporative and other extrarenal losses and may lead to a hypernatraemia.
  7. Salt intake should be balanced against the plasma sodium concentration, but is usually about 0.5mmol/kg/%BSA.
  8. If the burn is left exposed in an hot environment, sodium free water intake must be increased, but only to achieve a moderate hypernatraemia.
  9. Aggressive water load may lead to a low plasma sodium and result in 'burn encephalopathy'.
  10. Hyperkalaemia usually associated with severe muscle damage may require correction with insulin and dextrose. 
  1. Airway management
    1. Laryngeal oedema develops from direct thermal injury leading to early loss of the airway.
    2. With signs of an airway burn (soot in the nostrils/stridor/hoarse voice) consider early intubation of the patient.
    3. If in doubt it is better to protect the airway (and be able to provide tracheo-bronchial toileting) than to risk losing the airway altogether.
    4. A tracheostomy may be necessary if there is any delay in securing the 'at risk' airway.
    5. The airway is further endangered by an associated loss of respiratory drive due to a depressed level of consciousness (eg head injury or carbon monoxide poisoning). Again intubation may be required. 
  2. Burn management
    1. Burn wound will inevitably be colonised with micro-organism within 24-48 hours.
    2. Pseudomonas is the most common infection in dry wound.
    3. Systemic antibiotics are not used prophylactically in a burn patient and are required in case of documented infection only.
    4. Hyperglycemia is seen in early burns.
    5. Superficial Partial thickness wounds & mixed depth wounds-
    6. Heal almost irrespective of dressing. Simplest method of Rx is exposure.
    7. Hydrocolloid dressings (Duoderm)- changed every 3-5 days.
    8. Biological synthetic (Biobrane) and Natural (Amniotic membranes)- for superficial burns only, need not be changed. Not for mixed depth wounds.
    9. Full thickness and deep partial thickness burns-
    10. Need to be dressed with antibacterial dressings to delay the onset of contamination of wound.
    11. Silver sulphadiazine cream (1%)-
      1. Most commonly used. Broad spectrum prophylaxis. Effective against pseudomonas and MRSASilver nitrate solution (0.5%)-
      2. Highly effective against pseudomonas, needs to be changed every 2-4 hrs as it causes black staining of dressing. Mafenide acetate cream (5%)- Painful Causes metabolic acidosis
      3. Can penetrate the eschar and it is the only agent which can suppress the subeschar bacterial proliferation. Serum nitrate- for full thickness burns, reduces cell mediated immunosuppression.

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