Burns: Emergency Recognition, Resuscitation, Wound Care and Referral

Learning objectives

• Explain burn mechanisms, depth, extent and factors that determine severity.
• Perform scene safety, first aid and an ABCDE primary survey, including inhalation and electrical injury assessment.
• Estimate burn size and depth, start safe resuscitation and recognise when the patient needs a burns centre.
• Provide pain relief, wound protection, tetanus care, infection prevention, nutrition and nursing monitoring.
• Anticipate airway compromise, compartment effects, shock, hypothermia, renal injury and other complications.
• Plan discharge, rehabilitation, scar prevention, psychosocial support and prevention education.

Definition and mechanisms

A burn is tissue damage caused by thermal energy, chemicals, electricity, radiation or intense friction. Thermal burns may be due to flame, hot liquid (scald), steam, hot object or explosion. Chemical burns continue to damage tissue until the agent is removed or diluted. Electrical burns may have tiny skin marks but deep muscle, nerve, vessel and cardiac injury. Inhalation injury can occur from smoke, hot gases or toxic products even when the skin burn is small.

Depth of burn

Burn depth can evolve during the first 48 hours because of oedema, thrombosis, infection and inadequate perfusion. Reassess rather than relying on the first visual description.

Estimating extent and severity

• Rule of nines: a rapid adult estimate that assigns approximate percentages to body regions; use the locally taught chart.
• Lund–Browder chart: more accurate for children because body proportions change with age.
• Patient’s palm: the patient’s palm including fingers is approximately 1% TBSA and is useful for small or scattered burns.
• Count partial- and full-thickness areas; do not count simple erythema without epidermal injury in formal resuscitation estimates.
• Record depth, TBSA, location, mechanism, time, associated injuries and whether the burn is circumferential.

Scene safety and first contact

1. Ensure the scene is safe: stop flames, isolate electricity, ventilate smoke and use PPE for chemicals or contaminated clothing.
2. Stop the burning process. Remove the patient from the source; extinguish flames with stop–drop–roll, water or a suitable blanket when safe.
3. Remove hot, wet or contaminated clothing and jewellery, but do not pull off material stuck to the skin.
4. Cool thermal burns with cool running water for about 20 minutes as soon as possible; avoid ice, very cold water, butter, toothpaste, oils and powders.
5. For chemical burns, brush off dry powder first if safe, remove contaminated clothing and irrigate with copious water. Protect rescuers and bring the container or label.
6. Cover with a clean non-fluffy cloth or sterile dressing, keep the rest of the patient warm and arrange urgent transport for significant burns.

ABCDE primary survey

A — Airway and cervical spine

• Look for facial burns, soot, singed nasal hair, hoarseness, stridor, carbonaceous sputum, oral oedema, drooling or difficulty swallowing.
• Ask about enclosed-space fire and loss of consciousness; suspect inhalation injury even when the mouth appears normal.
• Give high-flow oxygen when smoke inhalation or carbon monoxide exposure is suspected and involve anaesthesia early.
• Airway oedema can worsen rapidly after fluid resuscitation; prepare for early controlled intubation if signs progress.
• Maintain cervical-spine precautions when there was a fall, explosion or trauma.

B — Breathing

• Assess respiratory rate, work, chest excursion, SpO2, wheeze, crackles and fatigue.
• Carbon monoxide can make pulse oximetry falsely reassuring; use co-oximetry where available and rely on history, mental state and clinical signs.
• Consider toxic smoke exposure, bronchospasm, pulmonary oedema and airway sloughing; prepare ventilatory support.
• A tight circumferential chest burn can restrict expansion and may need urgent surgical assessment for escharotomy.

C — Circulation

• Check pulse, blood pressure, capillary refill, skin temperature, peripheral pulses and ECG.
• Insert two large-bore IV lines through unburned skin when possible; intraosseous access may be needed in shock if IV access fails.
• Major burns cause capillary leak and hypovolaemia. Begin warmed isotonic crystalloid using the local burns formula when indicated and titrate to perfusion and urine output.
• Control associated bleeding, remove constrictive items and reassess limb perfusion in circumferential injuries.

D — Disability

• Assess GCS/AVPU, glucose, pupils, pain and evidence of head injury, hypoxia or poisoning.
• Confusion, headache, seizures or collapse after smoke exposure may indicate carbon monoxide or cyanide toxicity.

E — Exposure and environment

• Expose the whole patient to identify hidden burns and trauma, then cover promptly to prevent hypothermia.
• Inspect the back, scalp, perineum, folds and pressure points; remove wet clothing and record burn time and mechanism.

Inhalation injury and toxic exposure

• Upper-airway injury: progressive oedema, hoarse voice, stridor, drooling and difficulty swallowing. Early anaesthetic airway planning is safer than late rescue intubation.
• Lower-airway injury: cough, wheeze, soot, bronchospasm, hypoxia and respiratory failure may evolve over hours.
• Carbon monoxide: headache, dizziness, confusion, syncope, myocardial ischaemia or unexplained acidosis. Give high-concentration oxygen and consult toxicology/critical care.
• Cyanide: consider in enclosed-space fire with severe lactic acidosis, cardiovascular collapse or altered mental state; seek urgent antidote advice under local protocol.
• Do not use a normal SpO2 alone to exclude smoke toxicity.

Fluid resuscitation

Formal IV resuscitation is generally required for larger burns, commonly around 20% TBSA in adults and lower thresholds in children or vulnerable patients, according to local protocol. A commonly taught Parkland-style estimate is 4 mL of balanced crystalloid × body weight (kg) × %TBSA, with half in the first eight hours from the time of burn and the remainder over the next 16 hours. This is only a starting estimate—not a prescription. Children also need maintenance fluid, and all patients require titration to clinical response.

• Calculate from the time of injury, subtract fluid already given and record the calculation clearly.
• Use warmed balanced crystalloid where recommended; avoid hypothermia.
• Monitor urine output hourly, mental state, pulse, blood pressure, capillary refill, lactate, electrolytes, pulmonary signs and limb perfusion.
• Too little fluid causes shock and kidney injury; too much causes pulmonary oedema, abdominal compartment effects and worsening limb/chest pressure.
• Escalate to a burns/critical-care team when targets are not achieved or large volumes are required.

Pain and anxiety management

• Assess pain before and after cooling, dressing changes, transfer and procedures.
• Use titrated IV or oral analgesia appropriate to severity, with respiratory and sedation monitoring.
• Consider procedural analgesia or sedation for debridement and dressing changes only with trained staff and full monitoring.
• Explain each procedure, involve a support person when appropriate and address fear, guilt and distress.
• Do not inject into burned tissue, and do not allow pain relief to replace repeated neurovascular and respiratory assessment.

Wound care in the emergency department

1. After cooling and stabilisation, gently remove loose contaminants and cover with a clean, non-adherent dressing.
2. Do not break intact blisters routinely outside a specialist plan; remove devitalised tissue when indicated by trained clinicians.
3. Use sterile saline or an approved cleaning solution; avoid harsh scrubbing and household remedies.
4. Elevate burned limbs and protect exposed tendons, digits and pressure points.
5. Apply topical antimicrobial or advanced dressings only according to local burns protocol and allergy check.
6. Give tetanus vaccination or immunoglobulin according to wound status and immunisation history.
7. Systemic antibiotics are not used routinely as prophylaxis; use them for documented infection, sepsis or specialist-directed indications.

Special burn mechanisms

Chemical burns

• Protect staff, remove contaminated clothing and brush off dry powder before irrigation.
• Irrigate copiously with water; continue until pain and tissue pH improve according to local protocol. Do not attempt neutralisation with another chemical.
• Ocular chemical injury is an emergency: irrigate immediately, check pH repeatedly and obtain ophthalmology review.
• Hydrofluoric acid requires urgent calcium therapy advice because systemic hypocalcaemia and dysrhythmia can occur even with a small surface burn.

Electrical burns

• Do not touch the patient until the power source is isolated.
• Perform ECG and monitor for dysrhythmia; assess entry and exit wounds, tetany, falls, spinal injury and deep muscle damage.
• Check urine colour and renal function for rhabdomyolysis; dark urine, severe swelling or rising potassium requires urgent escalation.

Radiation and friction

• Remove the source, follow radiation-safety procedures and seek specialist advice.
• Friction burns may conceal contamination and deeper tissue injury; clean carefully and assess for associated trauma.

Circumferential burns and escharotomy

A non-elastic full-thickness eschar can act like a tourniquet. Circumferential limb burns may compromise pulses and nerves; circumferential chest burns may restrict ventilation. Check pulses, Doppler signals, capillary refill, sensation, motor function and ventilatory pressures repeatedly. Urgent specialist assessment is required; escharotomy is a surgical procedure and should not be attempted by untrained staff.

Investigations

• Serial full blood count, electrolytes, urea/creatinine, glucose, lactate and blood gas in significant burns.
• Carboxyhaemoglobin/co-oximetry when carbon monoxide is suspected; do not rely on standard pulse oximetry.
• ECG and cardiac monitoring for electrical injury, chest symptoms, syncope or significant systemic illness.
• Chest imaging and bronchoscopy based on inhalation symptoms and specialist assessment.
• Creatine kinase, urine myoglobin and potassium when electrical injury, crush injury or rhabdomyolysis is suspected.
• Pregnancy test when relevant; imaging and analgesia should be planned safely.
• Photographs, TBSA charting and serial measurements support referral and reassessment.

Nutrition and metabolic support

• Large burns produce a hypermetabolic, catabolic response and increased protein loss.
• Start oral or enteral nutrition early when safe; involve dietetics for high-calorie, high-protein planning.
• Monitor glucose, electrolytes, weight, bowel function, wound healing and micronutrient needs.
• Prevent nausea, constipation and aspiration; assess swallowing when facial or airway injury is present.

Referral and admission criteria

When transferring, send the TBSA/depth estimate, photographs if policy permits, mechanism, time of injury, cooling duration, airway findings, fluids given, urine output, analgesia, tetanus status and all investigations.

Nursing interventions and monitoring

• Record observations at the acuity-appropriate frequency and trend rather than relying on one set of vital signs.
• Maintain strict input/output, hourly urine output in major burns and accurate fluid-balance charts.
• Inspect dressings, drainage, colour, odour, pain, temperature and signs of infection.
• Check peripheral pulses, sensation, movement and capillary refill in circumferential or limb burns.
• Maintain warmth while avoiding overheating, pressure injury and dehydration.
• Administer analgesia and antiemetics safely; pre-medicate for dressing care.
• Use aseptic line and wound care, hand hygiene and safe disposal of contaminated material.
• Support nutrition, sleep, communication, mobility and psychological wellbeing.
• Document depth, TBSA, photographs/measurements, dressings, response and every escalation.

Complications

• Airway obstruction, inhalation pneumonitis, carbon monoxide or cyanide poisoning and respiratory failure.
• Burn shock, hypothermia, electrolyte abnormalities, acute kidney injury and rhabdomyolysis.
• Infection, sepsis, pneumonia, wound conversion and delayed healing.
• Compartment effects, limb ischaemia, contractures and functional loss.
• Hypertrophic scars, keloids, itch, chronic pain, pigment change and psychological trauma.
• Malnutrition, anaemia, venous thromboembolism and pressure injuries during prolonged admission.

Discharge and rehabilitation

• Give written wound-care instructions, dressing schedule, analgesia plan and clear return precautions.
• Arrange review of burns that are deep, not healing as expected, infected, painful or functionally important.
• Teach range-of-motion exercises and refer for physiotherapy/occupational therapy early when joints are involved.
• Use pressure garments, silicone, moisturisers and sun protection only as prescribed by the burns team.
• Address body image, sleep, trauma, school/work disruption and family support.
• Ensure tetanus, nutrition, diabetes and smoking cessation needs are addressed.

Prevention

• Keep hot liquids away from children, turn saucepan handles inward and test bath water.
• Install safe cooking and electrical practices, maintain fire extinguishers and plan escape routes.
• Store chemicals in labelled containers, never in drink bottles, and use gloves and eye protection.
• Teach stop–drop–roll, smoke alarm response and safe handling of paraffin, gas and generators.
• Use workplace PPE and lockout procedures for electrical, chemical and thermal hazards.

Scenario-based application

Common errors to avoid

• Cooling with ice or very cold water and causing hypothermia or further tissue injury.
• Applying butter, toothpaste, oils, powders or unknown herbal preparations.
• Pulling away clothing stuck to the wound or using adhesive dressings on burned skin.
• Underestimating TBSA, inhalation injury, electrical depth or chemical continuation.
• Giving large unmonitored fluid volumes or failing to calculate from time of injury.
• Using prophylactic antibiotics for every burn or ignoring infection and tetanus assessment.
• Missing circumferential chest/limb compromise and declining perfusion.
• Discharging a high-risk burn without specialist review and follow-up.

Documentation checklist

• Mechanism, time, enclosed-space exposure, chemical/electrical source and first aid performed.
• ABCDE findings, airway risk, oxygen therapy, ECG, pain and mental status.
• Depth, TBSA method, location, circumferential involvement, neurovascular status and photographs if permitted.
• IV access, fluid calculation/rate, urine output, analgesia, tetanus and dressings.
• Investigations, specialist calls, referral destination, handover and patient education.

Quick revision questions

1. What are the first five actions for a fresh thermal burn?
2. How do superficial, partial-thickness and full-thickness burns differ?
3. Which methods estimate TBSA, and why is Lund–Browder preferred in children?
4. What signs suggest inhalation injury and impending airway compromise?
5. When is formal IV fluid resuscitation required, and what clinical endpoints guide titration?
6. Why are electrical burns dangerous despite small skin wounds?
7. What burns require urgent specialist referral?
8. Which household remedies should never be applied to a burn?

Key takeaways

Further reading

• WHO: Burns and first aid
• American Burn Association: Burn first aid
• NHS: Burns and scalds
• NICE CKS: Initial burn management