Major trauma – Burns

Burns are a major public health problem globally. In addition to physical damage, they can leave a long lasting psychological and social impact.^1,2

In the UK 130,000 people each year visit the Emergency Department with burn injuries.² Approximately 8% (10,000) of these patients are admitted.²

A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures.

There are various types of burns which include:

• Thermal: This is the most common type of burn and includes flame burns, scalds (from hot liquids) and contact burns (from hot objects e.g. an iron or radiator).¹
• Chemical: Acids and alkalis found in household chemical products can produce very deep burns through coagulative and liquefactive necrosis.³ They will continue to burn the skin until completely removed. It is therefore essential that the skin is thoroughly irrigated.³ Alkalis penetrate deeper than acids and those presenting with alkali burns (commonly due to cement) will require immediate attention.
• Electrical: As an electrical current travels through the body it creates an entry and exit point, damaging tissue along its path as it is converted from electrical to thermal energy. Electrical burns from domestic low voltage exposures tend to be less severe than high voltage electrical burns, which can cause extensive tissue damage and limb loss. It is still very important that domestic electrical burns are taken seriously and an ECG is performed as the alternating nature of domestic current can cause arrhythmias.
• Cold exposure (frostbite): These burns are caused by ice crystals which can form both intra and extracellularly.⁴ The subsequent fluid and electrical fluxes cause cell membrane lysis and cell death and a damaging inflammatory process is set up.⁴
• Radiation: Radio frequency energy or ionising radiation causes tissue damage. The most common type of radiation burn is sun burn.⁴ Other patients at risk of getting radiation burns are those undergoing radiation therapy for cancer treatment.

Overall, flame injuries are the most common cause of burns, followed by scalds. Electrical and chemical injuries are much less common.¹ However, the types of burn sustained are different in different groups of people; in children the most common type of burn is a scald, whereas in adults flame burns are the most common.^1,5

Figure 1 shows the causes of burns by type and figure 2 shows the incidence of burns by age.

1. The airway is at risk by three major mechanisms:
   • Generalised oedema as a systemic response from an increasing burn size and depth can cause swelling of the airway and compromise airflow.^8,9
   • Localised oedema as a result or direct thermal damage to the airway can obstruct airflow.⁸
   • Inhalation injury as a result of heat, smoke or toxic chemicals can cause damage to the airway.⁸

   Assessment

   Factors that increase the suspicion of airway obstruction or inhalation injury include⁹:

   Hoarse voice

   Respiratory distress/ stridor

   Carbonaceous sputum

   Singed nasal/facial hairs

   Inflamed oropharynx

   Burns to the face/oropharynx

   History of burns in an enclosed space

   Raised blood gas carbon monoxide (CO) level

   Airway compromise can develop over a matter of hours and may only come to light when the patient is in crisis.⁹ Figure 5 shows airway change over a period of 1 hour.

   

   Management

   1. Sit patient upright
   2. Any suspected airway injury necessitates senior anaesthetic review to identify and predict deterioration.⁸
   3. If indicated, early intubation with an uncut tube prevents the tube moving in the event of further swelling.⁹

Common pitfall:

Failure to recognise or predict the deteriorating airway.

Breathing

Gas exchange can be compromised for a number of reasons:

• Direct damage from inhalation injury to lower airways and gas exchange surfaces
• Carbon monoxide (CO) can quickly build up impairing oxygen carrying capacity.⁹
• Burnt tissues with significant loss of the elasticity in superficial fibres are known as an eschar. This creates a constricting effect and inhibits expansion (figure 11). When circumferential around the chest/torso/neck this can lead to impaired chest expansion and subsequent ventilation issues.^9-10

Assessment:

• Exposure of the chest to assess for any injuries, and adequacy of ventilation
• Prompt assessment of oxygenation with a saturation probe^9,10
• Baseline blood gas (to assess oxygenation, ventilation, and carbon monoxide^9,10

Management

• Initially high flow oxygen (bear in mind that peripheral saturation readings may be falsely elevated with raised carbon monoxide levels), which can be later titrated to target appropriate saturations⁹
• Immediate discussion with burns centre if any restriction of movement of chest⁹
• Suspected inhalation injury may warrant intubation^8,9

Common pitfalls:

• Failure to recognise rising CO level
• Failure to recognise poor ventilation and the need for escharotomy.

Learning bites

• Escharotomy can be a lifesaving procedure that relieves restriction of movement and allows chest expansion. This is an emergency situation.
• Cyanide poisoning is common in patients that have been exposed to inhalation of burnt household items. In profound hypoxia consider early administration of cyanokit .⁹

Circulation

• Burns >20% total body surface area (TBSA) can cause profound circulatory shock that can occur from both large fluid losses through tissue damage and from a systemic inflammatory response.⁶
• Haemodynamic instability is rarely due to the burn alone and should prompt us to look for other causes
• Circumferential limb burns can compromise blood supply distally.

Assessment

• A thorough assessment of the extent of a burn is paramount.
• Capillary refill time (CRT), blood pressure and mucous membrane assessment are important indicators of hydration status but may be hard to measure due to location of the burn.⁹
• Though rarely immediately helpful in the Emergency Department setting, early catheterisation is important as urine output is a reliable sign that can demonstrate poor perfusion and serve as a guide to ongoing resuscitation.^9,11
• In a significant burn there can be an increased metabolic demand on the patient which can cause organ dysfunction. Therefore, important baseline tests to consider are full blood count, urea and electrolytes, coagulation profile, liver function tests, amylase, C-reactive protein and capillary blood glucose. This also helps to identify any other issues impacting on the patient. If the patient is likely to go to theatre a serum group and save is warranted.
• In circumferential limb burns, blood supply to the extremities should be checked regularly. If unable to do this clinically, a Doppler ultrasound can be used.^9-11

Management

1. Immediate intravenous (IV) access and, if required, fluid resuscitation are critical steps in initial care.^9-11
2. Blood tests
3. Evaluate any areas of circumferential burns in limbs and constantly reassess perfusion.

Any deterioration in the circulation to a limb could indicate ischaemia or a compartment syndrome. This warrants immediate discussion with a burns centre and may require urgent intervention such as escharotomy or fasciotomy.⁹

Learning bites

• IV access is paramount. If it is not possible to get IV or IO access through unburnt skin, access is mandated through burnt tissue.
• Creatine kinase is a useful test to perform to assess muscle breakdown.

Disability and exposure

Like any trauma patient disability and exposure cannot be ignored.

Appropriate exposure is fundamental for the assessment of patients with burns. A thorough assessment of size and depth of burns is impossible without full exposure and a good secondary survey.^8-10 However patients with burns are physiologically vulnerable to getting cold so it is critical to keep them warm and minimise fluid loss.^8,9

Management

1. Consideration should be made to maintain body temperature by both active and passive warming.^8,9 This is balanced with the need to adequately expose the burn in order to assess, photograph and clean.⁹
2. Clean the burn with normal saline and cover with strips of cling film. Do not use cling film on the face.
3. Consider imaging e.g. X-ray, CT etc. based on findings of the secondary survey.

Common pitfalls

• Missing other injuries not related to burns g. traumatic head injury or long bone fractures in a blast injury
• Failure to give adequate analgesia

Learning bites

• Have all members of the team present during exposure of an area to simultaneously evaluate and photograph the areas to avoid repeated unnecessary exposure and heat loss.

The burning process is exceptionally painful and analgesia should be given early. Both pharmacological and non-pharmacological methods should be used to control pain.

• Non-pharmacological methods include cooling the burn under cold running water and covering with cling film. Cling film also helps to reduce heat loss and the risk of infection.
• Pharmacological treatment includes simple analgesia such as paracetamol and NSAIDs, as well as stronger analgesia like opioids and ketamine.

To guide management goals, it is important to assess both extent and depth of the burn.

To assess the extent of a burn it is vital to expose all areas of the body to accurately estimate percentage TBSA affected. This is essential to:

• Decide whether the patient requires fluid resuscitation (>10% TBSA in children or >15% TBSA in adults)
• Calculate the fluid requirement during the initial resuscitation period if needed

Common ways to estimate %TBSA are

• Lund and Browder charts (fig 7a)
• Using the patient’s palm (including finger and thumb surfaces) as an estimate of 1% TBSA
• Rule of 9s (fig 7b)
• Mersey Burns App (fig 7c) which enables the user to highlight areas of burn tissue on a model to accurately estimate %TBSA affected.

adapted from: https://rphcm.allette.com.au/publication/cpm/Burns.html

Figure 7c

Not all of the burn area would necessarily be included in the %TBSA calculation. The depth of burn needs to be considered.

Learning bite

• Epidermal burns are not included when calculating the burn %TBSA.

To make an accurate assessment of the depth of a burn, skin needs to be cleaned, blisters removed (except for small non-tense blisters [<6mm]) and capillary refill time tested.

Guidance on which blisters to de-roof and how to do it by the London and South East of England Burn Network (LSEBN) can be found here.

• lsebn.nhs.uk Burns Blister Management
• lsebn.nhs.uk Deroofing Guideline

The depth of the burn can be classified into 1 of 4 types. The British Burn Association (BBA) accepted definition has replaced the older 1^st, 2^nd and 3^rd degree classification.¹²

Figure 8^12,13

• In clinical practice burn wounds are not homogenous but often are of mixed depths, as shown in Figure 9.

Figure 9 – Property of Burns unit, Chelsea & Westminster Hospital
The white areas are Full Thickness burns (FT), with the deeper red and paler pink areas showing Deep Partial Thickness (DPT) and Superficial Partial thickness (SPT) burns respectively.

In summary, assessing the depth of a burn is necessary to determine what the patient needs immediately, and what they may require going forwards in their management.

The distinction between epidermal burns (erythema) and those that are deeper is necessary as epidermal burns are excluded from the %TBSA calculation when deciding on the need for resuscitation and fluid management.

The distinction between full thickness burns and anything more superficial is necessary as those with full thickness burns, depending on location, are at risk of ventilatory problems or limb ischaemia and may require urgent surgical intervention.

Learning bite

The distinction between different types of partial thickness burns is not clinically relevant to the emergency practitioner. Only the inclusion of full thickness, and exclusion of epidermal burns aids in management.

Adults with burns >20% TBSA and children with burns >10% TBSA (>20% on some guidelines)¹⁴ require fluid resuscitation. There are a number of methods to calculate appropriate fluid requirements. The most frequently used is the Parkland formula¹⁵:

2-4ml x weight in kg x %TBSA

• This estimates the total resuscitation fluid required over 24 hours from the time of the burn
• This is in addition to the usual maintenance fluid requirement
• Usually 3ml is used for the calculation
• 2ml might be considered in children or those at risk of complication from fluid overload
• 4ml might be considered in inhalational injuries where fluid losses are likely to be greater
• Half of the calculated volume should be administered within the first 8 hours from the time of the burn
• The remaining half should be administered over the subsequent 16 hours
• The optimal fluid choice is warmed balanced crystalloid, such as Hartmann’s Solution or Plasmalyte
• Urine output should be monitored closely and input titrate to achieve an output of >0.5mg/kg/hr in adults and >1ml/kg/hr in children <30kg
• Urine output targets should be doubled if rhabdomyolysis is suspected

1. REMOVE

Remove loose clothing and all jewellery. Do not remove anything that is adherent or melted

2. COOL

Irrigate and cool thermal burns with cool (15°C) running tap water for 20 minutes. This can be beneficial up to three hours post-burn injury and should be done in the emergency department if not carried out in full prehospitally.

Irrigate chemicals from skin/eyes immediately with warm running water for at least 15 minutes (though irrigation periods longer than this are usually required).

Do not use ice/iced water/ice packs/gel based cooling products for this purpose.

3. COVER

Clean the wound with normal saline and cover any areas of skin loss with cling film.

Do not use cling film on the face.

Do not wrap cling film circumferentially around a limb (this creates a constrictive eschar).

Cover chemical burns with a non-adherent dressing.

Tetanus status should be considered though latest guidelines would only consider a burn to be tetanus-prone in conjunction with signs of systemic sepsis.^8,9,16

Management of the burn wound – electrical

The initial management of patients presenting with electrical burns is unchanged from that already described, however there are key differences to bear in mind.

In contrast to thermal burns, deeper tissue damage may be far more extensive than any superficial wounds may suggest and may involve whole compartments of the limbs. In patients with electrical burns to a limb, a high level of suspicion of compartment syndrome should be maintained.

Tissue damage from electrical burns may also lead to renal failure due to the release of haemochromogens into the circulation. For this reason, if the urine is pigmented, urine output targets should be doubled (to 1ml/kg/hr in adults or 2ml/kg/hr in children).

An ECG should be obtained on admission for every patient presenting with an electrical burn. However, if the patient is asymptomatic and the ECG is normal, then there is no need for further cardiac monitoring or admission.¹⁷

In certain circumstances, patients should be referred to specialist burn services.¹⁸

The minimum threshold for referral suggested by the British Burn Association can be summarised as:

• All burns ≥2% TBSA in children or ≥3% TBSA in adults
• All full thickness burns
• All circumferential burns
• Any burn not healed in 2 weeks
• Any burn with suspicion of non-accidental injury should be referred to a burn unit/centre for expert assessment within 24 hours.

In addition, the following factors should prompt a discussion with a consultant in a specialised burn care service and consideration given to referral:

• All burns to hands, feet, face, perineum, or genitalia
• Any chemical, electrical or friction burn
• Any cold injury
• Any unwell/febrile child with a burn
• Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn.

If the above criterie not met, continue with local care and dressings as required

If the burn wound changes in appearance or there are signs of infection or concerns regarding healing, then discuss with a specialised burn service

If there is any suspicion of toxic shock syndrome (TSS) then refer early. Consider this in any patient with any size burn, presenting with:

• Pyrexia
• Rash
• Diarrhoea/vomiting
• General malaise
• Anorexia
• Tachycardia/tachypnoea/hypotension
• Reduced urine output

Local referral policy may differ and should be followed. Local centres may also have an online referral method with the capability to send photographs of burns in a secure way, which can be extremely useful.

With full thickness and deep partial thickness burns, the dermis can become very stiff. If this occurs circumferentially over the chest it can restrict chest wall movement and lead to mechanical respiratory failure. Equally if there are circumferential burns to the limbs this can cause limb ischaemia. In these cases an emergency escharotomy needs to be undertaken to release the rigid skin to allow: adequate ventilation (if the chest is involved) or circulation (in the limb).¹⁹

The process of the dermis stiffening takes time and the majority of patients requiring escharotomies often go to theatre for this at a later stage. However, knowledge of the procedure can be life and limb saving in the emergency setting.

Procedure:

• The limb should be kept in the anatomical position.
• The area is cleaned and incised along the anatomical lines (see figure 10) with a scalpel down to the fat
• The incision should not go down to the muscle or fascia
• For the limbs the incisions need to release both medial and lateral aspects
• For the chest the incision needs to release the whole breast plate.

1. Stewart BT. Epidemiology, risk factors, and prevention of burn injuries. UpToDate, updated in 2025.
2. NHS commissioning board: Specialised Burn Care (All Ages), Service specification D06/S/a, 2013
3. Hettiaratchy S, Dziewulski P. Pathophysiology and types of burns. BMJ 2004; 328 :1427.
4. Orgill DP. Assessment and classification of burn injury, UpToDate, Updated in 2024.
5. Hettiaratchy S, Dziewulski P. ABC of burns. Introduction. BMJ. 2004 Jun 5;328(7452):1366-8.
6. Sheridan R. Cutaneous burns – Symptoms, diagnosis and treatment. In: BMJ Best Practice. 15 Apr 2025 [cited 2026 Jan 12].  
7. Battaloglu E, Greasley L, Leon‑Villapalos J, Young A, Porter K. Management of Burns in Pre‑Hospital Trauma Care. Faculty of Pre‑Hospital Care & British Burn Association. 2019.
8. Lee JH, et al. Airway Obstruction after Laryngeal Burn Induced by Swallowing Hot Food. Korean J Otorhinolaryngol-Head Neck Surg. 2015 Sep;58(9):634-636.
9. London and South East Burns Network. Initial Management of Severe Burns, 2020. London (UK): London and South East Burn Network; 10 Feb 2025 [cited 2026 Jan 12].
10. Stander et al The emergency management and treatment of Severe burns Emergency medicine International 2011; 2011: 161375. 
11. Hettiarachy et al Initial management of burns II – assessment and resuscitation BMJ 2004 Jul 10; 329(7457): 101–103.
12. British Burn Association: European practice guidelines for Burn Care Based by the Copenhagen EBA meeting, September 2002.
13. National Institute for Health and Care Excellence (NICE). Burns and scalds. Clinical Knowledge Summaries, NICE, 2023.
14. Borrows E, Randle E, Chigaru L. Burns Management. Clinical guidelines. Children’s Acute Transport Service (CATS). NHS; 2022.
15. National Institute for Health and Care Excellence (NICE). Mersey Burns for calculating fluid resuscitation volume when managing burns. [MIB58] NICE, 2016.
16. Public Health England. Tetanus: the green book, chapter 30, 2013. Last updated 2025.
17. Dollery W. Cardiac monitoring not needed in household electrical injury if the patient is asymptomatic and has a normal ECG. BestBETs, 2003.
18. London and South East Burn Network. Making a Burns Referral. London (UK): London and South East Burn Network; 10 Feb 2025 [cited 2026 Jan 12].
19. Health New Zealand. Escharotomy Guidelines. National Burn Service Resources. [cited 2026 Jan 12].
20. Riphagen S, et al. Paediatric Critical Care: Early management of burns. Version 5.0. South Thames Retrieval Service (STRS) at Evelina London.14 May 2025.
21. Dien S, et al. The evidence – based topical therapies for management of minor burns in outpatient clinic. Journal of General-Procedural Dermatology & Venereology Indonesia. 2015;1(1):9-19.