AKT · Dermatology/Wounds, ulcers & burns

Burns

Thermal/chemical/electrical tissue injury

Overview

Tissue injury from heat, chemicals, electricity or radiation. The acute management (fluid resuscitation by the Parkland formula, airway, analgesia) is covered on the Acute Care page; this card is the DERMATOLOGICAL view — assessing depth and surface area, and knowing the referral thresholds.

Recognise

Depth: superficial (epidermis — red, painful, no blisters, e.g. sunburn); superficial partial-thickness (blisters, very painful, blanches); deep partial-thickness (less blanching/sensation); full-thickness (white/leathery/charred, PAINLESS, no blanching)
Total body surface area estimated by the Wallace "rule of nines" or the patient palm (~1%) — do NOT count simple erythema
Look for airway/inhalation injury (facial burns, soot, singed nasal hairs, hoarseness) and circumferential burns

Red flags

Inhalation injury, circumferential limb/chest burns, large %TBSA, electrical/chemical burns, or burns to face/hands/feet/perineum/joints → burns-unit referral
Non-accidental injury patterns in children (immersion/scald distribution)

Differentials & how to tell them apart

Superficial vs partial vs full thicknessblanching + pain + blisters present in partial-thickness; full-thickness is leathery, white and PAINLESS (nerves destroyed)

Staphylococcal scalded skin syndromea child with diffuse peeling and a Staph source — not a thermal injury

Toxic epidermal necrolysisdrug-induced sheet detachment with mucosal involvement, mimics a scald

Non-accidental injuryglove-and-stocking/immersion scald, clear demarcation, inconsistent history — safeguard

Clinical image

We can't host this one — the image is DermNet's and their licence doesn't cover us republishing it. Their page for it is free to view.

Burns — clinical imagesDermNet

Investigations

Assess depth and %TBSA (rule of nines/palm); fluid needs by the Parkland formula (4 mL × kg × %TBSA, half in the first 8h from the time of injury) — see Acute Care; bloods/carboxyhaemoglobin for inhalation; tetanus status.

Management

Cool + cover + analgesia; assess depth/%TBSA → Parkland fluids and burns-unit referral if indicated

1First aid: cool with running water for ~20 minutes (within 3h), remove constricting items, cover with cling film; analgesia and tetanus prophylaxis. Assess depth and %TBSA.Gate: Estimate %TBSA from the rule of nines/palm and EXCLUDE simple erythema from the count — then calculate Parkland fluids (4 mL × weight kg × %TBSA, half in the first 8 hours FROM THE TIME OF INJURY); under- or over-counting the area mis-doses the resuscitation
2Refer to a burns unit for: large %TBSA, full-thickness, inhalation injury, circumferential, electrical/chemical, or special sites (face/hands/feet/perineum/joints); deep burns → debridement and skin grafting.

Cool the burn (running water 20 min) + cover (cling film) — first aid; do not use ice

Fluid resuscitation (Parkland formula) — for significant %TBSA — see Acute Care

Analgesia + tetanus prophylaxis — supportive

Topical antimicrobial dressings (e.g. silver) — wound care; debridement/grafting for deep burns

Key points

Depth determines management: full-thickness is painless and leathery and needs grafting. Parkland fluids run from the TIME OF THE BURN, not the time of presentation. Always assess for inhalation injury and safeguard children.

Monitor & prognosis

Fluid balance/urine output, wound healing, infection, function.

Superficial burns heal without scarring; deep/full-thickness need grafting and may scar/contract.

Source: NICE CKS Burns and scalds; British Burn Association (see Acute Care for Parkland)