The Rule of Nines provides a rapid adult body surface area estimation. Each region = 9% or multiple thereof.
| Body Region | TBSA % |
|---|---|
| Head & Neck | 9% |
| Each Arm (× 2) | 9% each = 18% |
| Anterior Trunk | 18% |
| Posterior Trunk | 18% |
| Each Leg (× 2) | 18% each = 36% |
| Perineum/Genitalia | 1% |
| Total | 100% |
Patient's palm (including fingers) = approximately 1% TBSA — useful for small/irregular burns estimation.
Children have proportionally larger heads and smaller legs vs adults. Lund-Browder corrects for age-related surface area differences.
| Age | Head % | Each Thigh % | Each Leg % |
|---|---|---|---|
| 0–1 yr | 19% | 3% | 3% |
| 5 yr | 15% | 4% | 3% |
| 10 yr | 12% | 4.5% | 3.5% |
| 15 yr | 9% | 4.5% | 3.5% |
| Adult | 7% | 4.75% | 3.5% |
Do NOT include superficial/epidermal (first-degree) burns in TBSA calculation — only partial and full thickness.
| Depth | Layers Involved | Colour/Appearance | Blistering | Sensation | Cap. Refill | Healing |
|---|---|---|---|---|---|---|
| Superficial Epidermal | Epidermis only | Red, dry, no blisters | None | Very painful | Brisk | 3–5 days |
| Superficial Dermal | Epidermis + superficial dermis | Pink/red, moist, weeping | Yes — thin-walled, fluid-filled | Painful (intact nerve endings) | Brisk | 7–14 days (scarring uncommon) |
| Deep Dermal | Epidermis + deep dermis | Pale/mottled/blotchy red, fixed staining | May blister — thick, may rupture | Reduced — pressure only (nerve damage) | Sluggish or absent | 21–28+ days; high scarring risk — often needs grafting |
| Full Thickness | Epidermis + full dermis | White/waxy, leather-like, charred | None (skin destroyed) | Painless (nerve endings destroyed) | Absent | Does not heal — requires surgical grafting |
| Sub-Dermal | Full depth incl. fat/muscle/bone | Black/charred, may expose structures | None | None | None | Amputation or major reconstruction required |
Flame burns from abaya ignition are a significant GCC-specific pattern, often causing circumferential burns to lower limbs and torso.
Acids cause coagulative necrosis — eschar formation limits deeper penetration. Causes: industrial acids, battery acid, drain cleaners.
Treatment: Irrigate with large volumes of water for minimum 20–30 minutes. Remove contaminated clothing. Do NOT attempt neutralisation (exothermic reaction risk).
Alkalis cause liquefactive necrosis — continue to penetrate deeply (saponification of fats). Often more severe than equivalent acid burns. Causes: cement, oven cleaner, bleach.
Treatment: Irrigate with copious water for 30–60 minutes. Check pH — continue until pH 7–8. High risk of eye involvement — urgent ophthalmology.
Antidote: Calcium Gluconate gel (topical) or IV/intra-arterial injection — fluoride ion chelation prevents hypocalcaemia and systemic toxicity.
HF penetrates deeply regardless of concentration. Fluoride ions cause severe tissue necrosis, hypocalcaemia, hypomagnesaemia, and potentially fatal cardiac arrhythmias.
Visible skin burns massively underestimate internal damage. Electrical current causes deep tissue necrosis along conduction pathways between entry and exit wounds.
Household current. Local tissue injury, arrhythmia risk lower but still present.
Industrial, power lines. Massive internal damage, arc flash burns, blast injury, entry/exit critical.
Time zero = time of burn, NOT time of admission. Calculate how much should have been given by the time the patient arrives, and adjust the rate accordingly.
Over-resuscitation beyond Parkland formula volumes — often driven by urine output anxiety. Volumes of 6–9 ml/kg/%TBSA are now commonly seen in clinical practice, exceeding the original 4 ml/kg/%TBSA guideline by 50–100%.
Intra-abdominal pressure >20 mmHg + new organ dysfunction. Signs: distended tense abdomen, oliguria, raised peak airway pressures, CVS compromise. Measure bladder pressure. May require decompressive laparotomy.
Protein-rich oedema from capillary leak. Worsens gas exchange in inhalation injury. Monitor CXR, SpO₂ trends, FiO₂ requirements. Fluid restriction may be necessary post-resuscitation.
Periorbital oedema from massive fluid loading can compress the globe. Monitor intraocular pressure, visual acuity. Lateral canthotomy may be required urgently.
Inhalation injury is a major determinant of burns mortality — it increases predicted mortality by 20% for any given TBSA burn. Early identification is critical as airway oedema progresses rapidly.
Thermal injury — direct heat. Oropharyngeal oedema, stridor, hoarseness. Rapidly life-threatening — early intubation essential. Endoscopy confirms supraglottic burns.
Chemical/toxic — steam/smoke toxins. Tracheobronchitis, mucosal sloughing, bronchospasm, impaired mucociliary clearance. Presents over hours to days. Diagnosed by bronchoscopy.
Pulse oximetry (SpO₂) is falsely normal in CO poisoning — CO-Hb is read as Oxy-Hb. Use co-oximetry (co-oximeter or ABG) to measure COHb directly.
Classic teaching — cherry-red skin/lips from COHb. Rarely seen clinically — more often pallor or cyanosis. Do not exclude CO poisoning if absent.
100% high-flow oxygen via non-rebreather mask — reduces CO half-life from 4–5h (room air) to 60–90 minutes. Consider hyperbaric oxygen (HBO) if available for severe poisoning (>25%), pregnancy, neurological symptoms.
Suspect in any victim of enclosed-space fire, especially with rapid cardiovascular collapse disproportionate to COHb level. Combination CO + cyanide poisoning is common and synergistically lethal.
Combustion of synthetic materials (polyurethane foam, nylon, wool, silk, plastics) — all found in domestic and commercial fires in GCC.
Anticipate difficult airway — experienced anaesthetist should perform. Video laryngoscopy recommended. Have surgical airway kit available.
Flexible bronchoscopy is gold standard for diagnosing inhalation injury (mucosal erythema, carbonaceous deposits, sloughing) and for therapeutic airway clearance of casts.
Circumferential full-thickness burns create a rigid, inelastic eschar. As underlying oedema builds, compartment pressure rises — compromising perfusion and ventilation.
The 5 Ps of compartment syndrome in burns:
Additional indicators: rising compartment pressures (>30 mmHg or within 30 mmHg of diastolic BP), loss of Doppler signals, progressive numbness.
Medial and lateral longitudinal incisions through the eschar from proximal to distal. Extend from mid-humerus to wrist across the elbow. For hand involvement — incisions between metacarpals (dorsal surface) and mid-lateral fingers.
Medial and lateral incisions from groin to ankle. Avoid medial aspect of knee (saphenous nerve/vein). Foot — dorsal web-space incisions between metatarsals. Check foot pulses with Doppler before and after.
Bilateral anterior axillary line incisions connected by a transverse subcostal incision — creating a rectangular eschar window. Releases chest wall restriction. Immediate improvement in peak airway pressures confirms success.
| Product | Indication / Burns Depth | Key Properties | Evidence / Notes |
|---|---|---|---|
| Mepitel One | Superficial dermal, deep dermal | Silicone contact layer, non-adherent, atraumatic removal, preserves regenerating epithelium | Current evidence supports over silver sulfadiazine for partial-thickness burns — faster healing, less pain, lower infection rates |
| Silver Sulfadiazine (Flamazine) | Partial/full thickness, infected wounds | Broad-spectrum antimicrobial (silver), 1% cream in water-soluble base. Daily or BD change. | Evidence now superseded by silicone dressings for partial thickness — but remains useful for infected wounds, large areas, resource-limited settings |
| Allograft (Cadaveric Skin) | Temporary cover for large burns awaiting definitive grafting | Biological barrier; reduces fluid/protein loss, prevents infection, pain relief | Temporary biological dressing — eventually rejected. Used as bridge to autograft when donor sites limited |
| Porcine Xenograft | Superficial partial thickness, donor site cover | Similar to allograft; biological wound cover, promotes re-epithelialisation | Halal considerations relevant in GCC context — confirm institutional policy. Porcine-derived products require specific consent. |
| Mepilex Ag | Infected/high-risk partial thickness burns | Silver-impregnated foam, sustained antimicrobial release, absorbent | Less frequent dressing changes (every 3–7 days), reduces patient distress and nursing time |
GCC Note: Porcine-derived biological dressings require specific informed consent in Muslim and Jewish patients. Discuss alternatives (bovine, synthetic) where required. Document discussion in notes.
Ensure adequate analgesia before any donor or recipient site dressing change — include anxiolytic pre-medication (oral midazolam/intranasal dexmedetomidine in paediatrics).
Major burns (≥20% TBSA) cause a profound hypermetabolic response — 2× basal metabolic rate — driven by catecholamine surge, cytokine release, and elevated cortisol. Persists for months post-injury.
SIRS criteria are unreliable in burns — tachycardia, tachypnoea, leukocytosis, and fever are normal responses to the burn injury itself. American Burns Association (ABA) criteria set higher thresholds.
| Parameter | Threshold for Burns Sepsis |
|---|---|
| Temperature | >39°C or <36.5°C |
| Heart Rate | >110 bpm |
| Respiratory Rate | >25 breaths/min (or vent requiring) |
| Thrombocytopenia | <100,000/µL (3 days post-resus) |
| Hyperglycaemia | >200 mg/dL (non-diabetic) |
| Enteral Feeding Intolerance | >3 days failure to feed |
Plus: documented or suspected infection source. ABA requires ≥1 criterion PLUS infection source suspicion.
Sub-dissociative IV ketamine 0.3–0.5 mg/kg is gold standard for procedural analgesia in burns. Maintains airway reflexes and haemodynamic stability. Administer with midazolam to reduce emergence phenomena. Intranasal ketamine used in some paediatric protocols.
Inhaled analgesia for brief procedural pain. Entonox (50:50 N₂O/O₂) provides rapid onset/offset. Methoxyflurane (Penthrox) — available in some GCC centres — self-administered inhaler.
Regional anaesthesia (femoral, brachial plexus, paravertebral blocks) under ultrasound guidance. Reduces opioid requirements. TIVA (Total IV Anaesthesia) for major dressing changes in theatre.
Custom-fitted pressure garments worn 23h/day for 12–24 months. Reduce hypertrophic scarring and contracture formation. Fitted once wounds fully healed (no open areas). Silicone gel sheets used under garments for added effect.
Burns team nursing roles in GCC: clinical nurse specialists in wound care, burns rehab nurses coordinating physiotherapy/occupational therapy, community nurses for outpatient dressing programs.
70kg adult, 30% TBSA deep dermal burns, presenting 2 hours post burn.
20kg child, 15% TBSA scald, presenting immediately post burn.
| Depth | Colour | Pain? | Blisters? | Cap. Refill | Heals Itself? | Include in TBSA? |
|---|---|---|---|---|---|---|
| Epidermal | Red | Yes — very | No | Brisk | Yes (3–5d) | No |
| Superficial Dermal | Pink/red, moist | Yes — painful | Yes (thin) | Brisk | Yes (7–14d) | Yes |
| Deep Dermal | Pale/mottled | Reduced | Yes (thick) | Sluggish | Delayed / needs graft | Yes |
| Full Thickness | White/leather/charred | None | No | Absent | No — needs graft | Yes |
| Sub-Dermal | Black/charred | None | No | None | No — reconstruction | Yes |
4 ml × weight (kg) × %TBSA of Hartmann's solution in first 24h from time of burn. Half given in first 8h, half in next 16h. Time of burn is time zero — not admission time.
Standard pulse oximetry cannot distinguish COHb from OxyHb — both absorb light at the same wavelength. SpO₂ appears falsely normal. Use co-oximetry (ABG with co-oximeter) to measure actual COHb level.
Calcium gluconate — topical gel (2.5%) applied to burn, or IV/intra-arterial injection. Chelates the fluoride ions which cause systemic toxicity (hypocalcaemia, cardiac arrhythmias). Monitor ECG and serial calcium levels.
Circumferential full-thickness burns causing compartment syndrome (5 Ps: pain, pallor, paraesthesia, pulselessness, paralysis) or chest burns causing ventilatory compromise (rising peak airway pressures, inability to ventilate).
Burns cause significant hyperglycaemia from the stress response (catecholamines, cortisol). Adding dextrose worsens hyperglycaemia, increasing infection risk, wound healing impairment, and cerebral oedema risk in children. Use Hartmann's (LR) for first 24h.
Acid = coagulative necrosis — eschar limits penetration. Alkali = liquefactive necrosis — continues to penetrate deeply (saponification). Alkali burns are often more severe despite similar initial appearance. Both: irrigate copiously with water — do NOT neutralise.
Hydroxocobalamin (Cyanokit) 5g IV over 15 minutes — binds cyanide to form cyanocobalamin. Suspect in enclosed-space fire + profound lactic acidosis (lactate >10). Do not use sodium thiosulphate as first-line (causes methaemoglobinaemia which worsens CO poisoning).
Adult: >20% TBSA partial thickness, or >5% full thickness, or special areas. Child: >10% TBSA partial thickness. Note: superficial/epidermal burns are NOT included in TBSA calculation.
Key exam memory: Parkland = 4-half-half. Brooke = 2-half-half. First 24h = Hartmann's only. UO adult = 0.5, child = 1. Escharotomy = circumferential FT burns. CO antidote = 100% O₂. Cyanide antidote = Hydroxocobalamin. HF antidote = Calcium gluconate.