Burn Depth Classification
Superficial (Epidermal)
First Degree
- Appearance: Erythema, dry, no blistering
- Sensation: Painful (nerve endings intact)
- Blanching: Yes — capillaries intact
- Healing: 7–10 days, no scarring
- Grafting: Not required
- Example: Mild sunburn
Not included in %TBSA calculations for fluid resuscitation.
Superficial Partial Thickness
Second Degree — Superficial
- Appearance: Blistering, moist, pale pink/red
- Sensation: Very painful — dermis exposed
- Blanching: Yes
- Healing: 14–21 days, possible hypertrophic scar
- Grafting: Usually not required
- Example: Scalds, flash burns
Deep Partial Thickness
Second Degree — Deep
- Appearance: Wet or dry, mottled red/white, fixed staining
- Sensation: Reduced — deep dermis involved
- Blanching: Poor or absent
- Healing: >21 days — conversion risk
- Grafting: May require split-thickness skin graft
- Example: Contact burns, prolonged scalds
Full Thickness
Third / Fourth Degree
- Appearance: Leathery, white, brown, or black (charred); eschar
- Sensation: Painless — nerve endings destroyed
- Blanching: No
- Healing: Does not self-heal
- Grafting: Always required — surgical excision + STSG
- Example: Prolonged flame, electrical, chemical
Special Burn Types
⚗ Chemical Burns
Acid Burns
- Mechanism: Coagulative necrosis — protein denaturation forms eschar that limits penetration
- Appearance: Well-demarcated, coloured eschar (colour varies by acid)
- Examples: Sulphuric, hydrochloric, nitric acid
- First Aid: Copious water irrigation ≥20 min
Alkali Burns — More Dangerous
- Mechanism: Liquefactive necrosis — saponification of fat, deeper penetration, ongoing injury
- Appearance: Soft, soapy-feeling wound, deeper than visible
- Examples: Sodium hydroxide (NaOH), cement, oven cleaners
- First Aid: Prolonged irrigation, pH monitoring of wound
Warning: Do NOT neutralise chemical burns — exothermic reaction can worsen injury. Irrigation with water only.
⚡ Electrical Burns
- Entry wound: Small, well-defined at contact point
- Exit wound: Larger, "blow-out" injury where current exits
- Internal injury: Extent far exceeds visible surface — iceberg phenomenon
- Current path: Follows path of least resistance (nerves, blood vessels)
- Cardiac risk: Arrhythmias (VF, asystole) — continuous ECG monitoring mandatory
- Rhabdomyolysis: Myoglobin release from muscle necrosis — dark/tea-coloured urine, AKI risk
- Fluid target: Urine output 1–1.5 mL/kg/h (above standard) to protect kidneys
- Compartment syndrome: High risk in limbs — monitor neurovascular status hourly
Clinical Action: All significant electrical burns require 24h cardiac monitoring regardless of initial ECG findings. Obtain CK, myoglobin, and urinalysis on admission.
🌫 Inhalation Injury
Critical: Inhalation injury is a major independent predictor of mortality. The airway must be assessed and secured BEFORE oedema develops — a delay of even 30–60 minutes can make intubation impossible.
Clinical Signs
- Stridor — partial upper airway obstruction
- Carbonaceous (sooty) sputum
- Hoarseness of voice
- Singed nasal/facial hair
- Facial burns — particularly perioral/nasal
- Burns in enclosed space
- SpO2 <10% may not show on standard pulse oximetry (CO poisoning)
Three Levels of Injury
- Upper airway (supraglottic): Thermal — oedema, obstruction, requires early intubation
- Tracheobronchial: Chemical — toxic gases, sloughing of mucosa, cast formation
- Pulmonary (alveolar): Chemical — ARDS, pneumonia risk, impaired gas exchange
🔢 %TBSA Estimation Methods
Rule of Nines — Adults
| Body Region | %TBSA |
|---|---|
| Head & Neck | 9% |
| Each Upper Limb (arm) | 9% |
| Anterior Trunk (chest + abdomen) | 18% |
| Posterior Trunk | 18% |
| Each Lower Limb (leg) | 18% |
| Perineum / Genitalia | 1% |
| Total | 100% |
Other Methods
- Lund and Browder Chart: More accurate — accounts for age-related differences (paediatric head is proportionally larger). Preferred in children and burns centres.
- Palmar Method: Patient's own palm + fingers = approximately 1% TBSA. Useful for scattered or irregular burns.
- Paediatric Rule of Nines difference: Head = 18% (9% per year subtracted, distributed to legs), each leg = 14% at birth increasing with age.
Exclude superficial (epidermal) burns from %TBSA calculations used for fluid resuscitation.
☢ Radiation Burns
- Delayed onset: Erythema may not appear for days to weeks after exposure
- Dose-dependent: Low dose — epidermal reaction; high dose — full-thickness necrosis
- Unique feature: Progressive microvasculature damage leads to poor wound healing and endarteritis
- Sources: Radiotherapy, industrial accidents, nuclear incidents
- Management: Specialist radiobiology input; wounds are notoriously difficult to heal; hyperbaric oxygen may help
Primary Survey — ATLS / ABCDE with Burns Additions
🔴 Airway — Burns-Specific Considerations
Priority: Secure the airway EARLY. Oropharyngeal and supraglottic oedema develops rapidly in inhalation injury — intubation becomes impossible once oedema is established.
- Assess for signs of inhalation injury (stridor, hoarseness, carbonaceous sputum, singed hair, facial burns)
- If any signs present — call anaesthetics/intensivist immediately for RSI assessment
- Apply 100% O2 via non-rebreather mask (NRB) 15 L/min while preparing
- Rapid Sequence Intubation (RSI) if SpO2 <92%, worsening stridor, or altered consciousness
- Consider early intubation prophylactically for large facial/oral burns even without symptoms
- Post-intubation: confirm ETT position, note tube length at teeth
Standard pulse oximetry is UNRELIABLE in CO poisoning — SpO2 appears falsely normal. Use CO-oximetry (ABG) to assess true oxygenation.
🫁 Breathing
- Assess RR, depth, symmetry of chest expansion
- Circumferential chest burns: Eschar may restrict chest wall excursion — may require escharotomy to restore tidal volume
- Signs: rising peak airway pressures (ventilated patient), reduced tidal volumes, respiratory distress
- Auscultate for wheeze (bronchospasm from inhalation), crackles
- Maintain SpO2 >95% (use CO-oximetry in suspected CO poisoning)
🫀 Circulation
- Two large-bore IV cannulae (14–16G) — can be placed through burned skin if necessary
- Begin fluid resuscitation early (Parkland formula — see Tab 3)
- Monitoring: BP, HR, capillary refill, urine output (catheterise all significant burns)
- Limb circumferential burns — assess pulses hourly, Doppler if needed
- Intra-osseous access if IV impossible (paediatric or massive burns)
🧠 Disability (Neurological)
- GCS assessment — reduced consciousness may indicate CO poisoning, hypovolaemia, or associated head injury
- Pupils: CO poisoning may cause neurological signs
- Pain score assessment — document analgesia given
- Assess for any associated traumatic injury (RTA, explosion, fall)
📋 Exposure / Environment
- Remove all clothing and jewellery (rings, watches — constrict with oedema)
- Calculate %TBSA (Rule of Nines / Lund and Browder)
- Document burn depth, distribution, and mechanism
- Hypothermia risk: Burns patients lose heat rapidly — warm environment, warm IV fluids; target T >35°C
- Photography: document wounds before dressings
First Aid — Stop the Burning Process
💧 Cooling Protocol
Evidence-Based Guideline: Cool burns with tepid running water at 15–20°C for 20 minutes. This is the single most effective pre-hospital first aid intervention to limit burn depth and severity.
DO — Correct Actions
- Tepid running water 15–20°C
- Cool for full 20 minutes
- Remove clothing/jewellery during cooling
- Cover with cling film (non-adhesive) after cooling
- Maintain patient warmth (blankets to rest of body)
DO NOT — Common Errors
- Ice or iced water — causes vasoconstriction and deepens injury
- Butter, cooking oil — trap heat, promote infection
- Toothpaste — common cultural remedy in GCC — harmful, obstructs wound assessment
- Raw egg — infection risk, hinders assessment
- Flour, henna, or traditional pastes — common regional home remedies — all harmful
In the GCC context, healthcare professionals must actively educate patients and families about the dangers of traditional home remedies applied to burns. These practices are widespread and delay appropriate treatment.
🩹 Temporary Wound Coverage
- Cling film (PVC wrap): First-line temporary dressing — non-adherent, preserves moist environment, allows wound inspection, reduces pain, prevents heat/fluid loss
- Apply in layers (not circumferentially around limbs)
- Do NOT use cotton wool, fluffy gauze, or dry bandages directly on wound
- For facial burns: cling film or saline-soaked gauze (cannot wrap face)
Transfer Criteria to Burns Centre
🏥 Referral / Transfer Criteria (ABA / ISBI Guidelines)
Mandatory Transfer
- Partial thickness burns >10% TBSA (adult) or >5% TBSA (child)
- Any full-thickness burn
- Burns involving face, hands, feet, genitalia, perineum, or major joints
- Circumferential limb or chest burns
- Suspected inhalation injury
- Chemical or electrical burns (including lightning)
Consider Transfer
- Extremes of age: children <5 years, elderly >60 years
- Significant co-morbidities (diabetes, immunosuppression, cardiac disease)
- Burns with associated trauma
- Suspected non-accidental injury (safeguarding concern)
- Circumferential burns of any region
- Social or psychological concerns
💉 Tetanus Prophylaxis
- All burns are tetanus-prone wounds — prophylaxis is mandatory
- Immunised patient: Tetanus toxoid booster if >5 years since last dose
- Unknown/unimmunised: Tetanus immunoglobulin (TIG) + tetanus toxoid (start primary course)
- Document tetanus status on admission to burns unit
Fluid Resuscitation
🧮 Parkland Formula
Total 24h fluid = 4 mL × Weight (kg) × %TBSA
Fluid: Lactated Ringer's (Hartmann's solution) — crystalloid of choice
First 8 hours: ½ of total volume
Time from time of burn — NOT from time of hospital admission
Next 16 hours: ½ of total volume
If patient arrives late, recalculate back from time of burn
Important: The Parkland formula is a starting guide only. Actual fluid rates must be titrated to clinical response — urine output is the most reliable guide to adequacy.
Urine Output Targets
| Patient | Target UO |
|---|---|
| Adults | 0.5–1 mL/kg/hour |
| Children (<30kg) | 1 mL/kg/hour |
| Electrical burns | 1–1.5 mL/kg/hour |
Monitoring Parameters
- Hourly catheter urine output
- Capillary refill time (<2 sec)
- Mental status (agitation = under-resuscitated)
- Base deficit on ABG
- Serum lactate
- Avoid over-resuscitation — Abdominal Compartment Syndrome risk
Inhalation Injury — Specific Management
🌬 Inhalation Injury Protocol
- 100% O2: Non-rebreather mask 15 L/min — reduces CO half-life from 4–5h (room air) to ~60–90 min
- Nebulised heparin (5000 units q4h): Reduces fibrinous cast formation in airways
- Nebulised N-acetylcysteine (20% solution): Mucolytic, reduces airway casts, antioxidant
- Alternating heparin/NAC protocol: Evidence-based in major inhalation injury
- Fibreoptic bronchoscopy: Gold standard for diagnosis — visualises soot, mucosal erythema, ulceration; used for lavage of casts
- Chest physiotherapy: Frequent positioning, percussion, suction
- Ventilator strategy: Lung-protective (low tidal volume 6 mL/kg), PEEP, consider prone positioning in ARDS
- Avoid steroids: No evidence of benefit, increases infection risk
🟤 Carbon Monoxide (CO) Poisoning
Danger: Pulse oximetry reads COHb as oxyhaemoglobin — SpO2 appears falsely normal. Must use ABG with CO-oximetry to detect CO poisoning.
| COHb Level | Clinical Features |
|---|---|
| <10% | Headache, nausea — often subclinical |
| 10–25% | Severe headache, dizziness, impaired judgement |
| 25–40% | Confusion, visual disturbance, tachycardia |
| 40–60% | Seizures, coma, cardiovascular collapse |
| >60% | Death |
- Treatment: High-flow 100% O2 via NRB or ETT until COHb <5%
- Hyperbaric oxygen (HBO) indications: COHb >25%, loss of consciousness, neurological signs, pregnancy, cardiac involvement
Analgesia
💊 Pain Management in Burns
| Agent | Route | Use | Notes |
|---|---|---|---|
| Morphine | IV | Background/procedural pain | Titrate to effect; NCA/PCA in adults; caution respiratory depression |
| Ketamine | IV/IN | Dressing changes (sub-dissociative 0.5 mg/kg) | Maintains airway reflexes; analgesic + dissociative; useful in resource-limited settings |
| Entonox (50% O2/N2O) | Inhaled | Procedural analgesia | Patient-controlled; short-acting; useful for dressing changes |
| Paracetamol | PO/IV | Regular background analgesia | Regular dosing; adjunct; reduces opioid requirements |
| NSAIDs | PO | Adjunct (caution) | Avoid if haemodynamically unstable or renal impairment |
| Gabapentin/Pregabalin | PO | Neuropathic/procedural pain | Long-term neuropathic pain; acute procedural anxiety |
Nutritional Support
🍽 Burns Hypermetabolism & Nutrition
Principle: Burns cause profound hypermetabolism — up to 200% above baseline metabolic rate in major burns. Early aggressive nutritional support is essential to prevent catabolism, support wound healing, and reduce infection risk.
- Timing: Commence enteral nutrition within 6 hours of burn injury
- Route: Nasogastric (NG) tube — preferred; nasoduodenal if gastric motility impaired
- Curreri formula: Adults: (25 kcal × kg) + (40 kcal × %TBSA) per day
- Protein: High requirements — 1.5–2 g/kg/day; supports wound healing and immune function
- Vitamins/Micronutrients: Vitamin C (high dose — antioxidant), Zinc (wound healing), Vitamin A, B vitamins
- Monitoring: Daily weights, albumin/pre-albumin, nitrogen balance, blood glucose (insulin resistance common)
- Anabolic agents: Oxandrolone — reduces muscle catabolism in major burns; used in specialist centres
- PN: Only if enteral route not feasible; associated with higher infection risk
Burn Wound Dressings
🩹 Dressing Comparison
| Dressing | Composition | Indications | Change Frequency | Key Points |
|---|---|---|---|---|
| Silver Sulfadiazine (SSD) | 1% silver in water-soluble cream | Partial thickness burns; widely available | Daily or BD | Broad-spectrum antimicrobial; can be painful on application; leukopenia with extensive use; not recommended on face |
| Mepitel | Silicone mesh (non-adherent) | Superficial/partial thickness; donor sites | Every 3–7 days | Atraumatic removal; preserves fragile new epithelium; no active antimicrobial |
| Mepilex Ag | Silver-containing foam | Partial thickness; infected/at-risk wounds | Every 2–5 days | Antimicrobial silver + absorbent foam; less-frequent changes reduce pain/trauma; good for outpatient management |
| Biobrane | Biosynthetic — nylon mesh + porcine collagen | Clean superficial partial thickness | Leave until epithelialised | Adherent to wound base if wound clean; reduces fluid/protein loss; contraindicated if wound infected |
| Acticoat | Nanocrystalline silver | Partial/deep partial thickness; infected burns | Every 3–7 days | Sustained silver release; moisten with water (NOT saline); highly effective antimicrobial |
🔄 Dressing Change Technique
- Pre-medication: Administer analgesia 30–45 minutes before procedure (oral morphine/opioid). Document pain score before and after.
- Environment: Warm room (prevent hypothermia). Prepare all equipment before starting to minimise procedure time.
- Anxiety management: Explain procedure to patient. Consider anxiolytic (midazolam) for highly anxious patients. Music therapy/distraction.
- Aseptic technique: Full ANTT (Aseptic Non-Touch Technique). Sterile gloves, sterile field. Clean inner-to-outer or least-to-most contaminated.
- Wound assessment: Inspect for signs of infection (increasing erythema, purulence, odour, increased pain). Reassess depth — wounds evolve in first 48–72h.
- Photography: Photograph wound at each change (with ruler/scale). Document in notes. Enables depth tracking and legal documentation.
- Wound swabs: Swab if signs of infection. Quantitative swabs preferred (>10⁵ organisms/g tissue = infection threshold).
- Apply dressing: Appropriate choice for depth/exudate level. Secure with tubular bandage or crepe (non-circumferential in limbs).
Surgical Management
🔪 Escharotomy
Emergency Procedure: Escharotomy must not be delayed. Full-thickness eschar is inelastic and will restrict circulation/breathing as oedema develops. Timely escharotomy prevents limb loss and respiratory failure.
Limb Escharotomy
- Indication: Circumferential full-thickness limb burn with impaired distal circulation
- Signs of need: Absent/diminished Doppler signals, compartment pressure >30 mmHg, pain on passive stretch, paresthesia, pallor, paralysis
- Technique: Medial and lateral longitudinal incisions through eschar to bleeding subcutaneous tissue
- Post-op: Reassess Doppler signals immediately after
Chest Escharotomy
- Indication: Circumferential chest/torso burn restricting ventilation
- Signs of need: Rising peak airway pressures, reduced tidal volumes, SpO2 drop in ventilated patient
- Technique: Bilateral anterior axillary line incisions + transverse subcostal (creates "H" or "brace" pattern)
- Nursing: Observe for immediate improvement in ventilation; manage bleeding from incision sites
🏗 Debridement Techniques
Tangential Excision
- Sequential thin layers of eschar removed with Watson/Humby knife until bleeding dermis reached
- Preserves maximum viable tissue
- Preferred for partial and mixed-depth burns
- Higher blood loss — tourniquet, epinephrine, tumescence
Fascial Excision
- All tissue down to fascia removed
- Used for very deep/electrical burns, extensive full thickness
- Less blood loss than tangential but poor cosmetic outcome
- Permanent contour deformity, loss of subdermal fat
🧬 Skin Grafting
Split-Thickness Skin Graft (STSG)
- Definition: Epidermis + partial dermis harvested from donor site (thigh most common)
- Sheet graft: Better cosmesis — used on face, hands
- Meshed graft: Expanded (1:1.5 to 1:6 ratio) — covers larger areas; interstices heal by secondary intention
- Graft take assessment: Day 5 — pink, adherent = good take; pale, lifting = poor take (haematoma, infection, shear)
- Post-graft care: Immobilise graft site for 5 days; elevate limb; minimise shear
Donor Site Care
- Most painful area: Exposed nerve endings — donor site often more painful than burn wound
- Dressings: Mepitel One (silicone non-adherent) or alginate (e.g., Kaltostat) — leave until healed
- Healing: 10–14 days for thin harvest; can re-harvest same site after healing
- Patient education: Explain donor site pain; important for patient satisfaction
Advanced Options
- CEA (Cultured Epithelial Autograft): Patient's own keratinocytes cultured in laboratory (3 weeks); for massive burns where donor sites insufficient; fragile
- Integra (Dermal Regeneration Template): Bovine collagen + chondroitin sulphate bilayer; neodermis forms over 3 weeks; then STSG applied
Scar Management
📊 Burn Scar Assessment
- Proliferative phase: Scar maturation takes up to 2 years; hypertrophic scars form when healing exceeds 21 days
- Vancouver Scar Scale (VSS): Validated tool — scores vascularity, pigmentation, pliability, height; range 0–13
- Patient and Observer Scar Assessment Scale (POSAS): Incorporates patient-reported outcomes
- Signs of active scar: Red/pink colour, raised (hypertrophic), pruritic, stiff
Scar Management Interventions
- Compression garments: Custom-fitted, worn 23 h/day for 12–18 months; apply once wounds >90% healed; pressure 25–30 mmHg
- Silicone sheets/gel: Worn over scar 12–24h/day; flatten, soften, reduce pruritus; mechanism unclear (hydration/pressure)
- Steroid injections (triamcinolone): Intralesional; reduces hypertrophy; monthly injections
- Laser therapy: Pulsed dye laser; fractional CO2; evidence for scar remodelling
Physiotherapy & Splinting
🤸 Anti-Deformity Positioning
Principle: Scars contract in the position of comfort — which is flexion. Burns rehabilitation must maintain the position of maximum function through splinting and active exercise.
| Body Region | Anti-Deformity Position | Rationale |
|---|---|---|
| Neck | Extension, slight lateral — NO flexion | Prevents anterior neck contracture, chin-to-chest deformity |
| Axilla / Shoulder | Shoulder abduction 90°, slight forward flexion | Prevents axillary contracture and shoulder adduction |
| Elbow | Extension | Prevents flexion contracture of antecubital fossa |
| Wrist / Hand | Wrist neutral/slight extension, MCP 70–90° flexion, IP extension, thumb abduction (intrinsic plus position) | Prevents claw hand deformity |
| Hip | Extension, neutral rotation, slight abduction | Prevents hip flexion/adduction contracture |
| Knee | Extension | Prevents posterior knee contracture |
| Ankle / Foot | Neutral (90°), slight dorsiflexion | Prevents equinus deformity (foot drop) |
Splints are removed for exercises and wound care. Document splint wear times. Reassess splint fit regularly as oedema reduces.
💪 Exercise Programme
- Early mobilisation: Begin passive and active ROM exercises from day 1 where clinically safe
- Post-graft: Immobilise graft site for 5 days, then resume gentle ROM
- Strengthening: Progressive resistance exercises once wounds closed
- Ambulation: Elevation stockings/compression for lower limb burns; elevate legs during rest; gradual progressive weight-bearing
- Hydrotherapy: Aquatic physiotherapy — buoyancy reduces weight-bearing pain; also used for wound cleansing
Psychological Care
🧠 Psychological Impact of Burns
- PTSD: High incidence (30–45% of major burns patients); flashbacks, nightmares, avoidance, hyperarousal
- Depression: Common — grief response for altered body image and function
- Anxiety: Procedural anxiety (dressing changes), social anxiety, agoraphobia
- Body image disturbance: Scarring, disfigurement, amputation — profound impact on self-concept
- Survivor guilt: Especially in mass casualty incidents (fires, explosions)
- Screening: Use validated tools — IES-R (Impact of Events Scale), PHQ-9 (depression), GAD-7 (anxiety)
- Early psychological input: Burns psychologist/psychiatrist — begin during acute admission
- CBT: Cognitive Behavioural Therapy — first-line for PTSD and anxiety
- Peer support: Burns survivor networks; burn camps for children (e.g., regional GCC burn camps)
- Family support: Families of burn survivors also at risk of PTSD and carer burnout
Long-Term Issues
🩺 Pruritus (Itch) Management
- Pruritus is nearly universal in healing burns — affects sleep, quality of life, and compliance with dressings
- Antihistamines: Cetirizine (non-sedating), chlorphenamine (sedating — useful at night)
- Moisturisers: Regular application to healed skin and scars — reduces dryness-related itch
- Massage: Scar massage with emollient — desensitises hypersensitive nerves
- Gabapentin/Pregabalin: For neuropathic component of pruritus
- Naltrexone (low dose): Emerging evidence for burns pruritus; central opioid mechanism
- Doxepin: TCA with antihistamine properties; topical preparations available
🏫 Occupational Therapy & Return to Life
- ADL retraining: Personal hygiene, dressing, feeding — adapted equipment if needed
- Return to school: Graded reintegration; educating peers/teachers; school liaison nurse
- Return to work: Vocational rehabilitation; modified duties; exposure to workplace triggers
- Driving: Assessment for functional ability, medication side effects
- Nutritional follow-up: Weight restoration monitoring; micronutrient supplementation (Vitamin C, zinc) long-term; dietitian input
Burns in the GCC Context
🌍 GCC Burns Epidemiology
Common Causes in GCC
- Domestic cooking burns: Open gas flame cooking, pressure cooker explosions, deep-fat frying — major cause of paediatric scalds
- Scalds: Hot liquids (tea, coffee, soup) — children and elderly most affected
- Chemical burns: Industrial workers (petrochemical industry, construction) — acids, alkalis, solvents
- Electrical burns: Construction workers — live wire contact; GCC has large construction workforce
- Road traffic accidents (RTA): Fuel fires post-collision — high-speed motorway accidents
- Fireworks: Eid and National Day celebrations — face/hand burns in children
Traditional Remedy Misuse
- Toothpaste: Most commonly applied — cools initially but traps heat, obscures wound, infection risk
- Raw egg: Applied for "cooling effect" — Salmonella infection risk, masks wound depth
- Cooking oil/ghee/butter: Traps heat, worsens injury, heavy contamination
- Henna paste: Regional remedy — can cause allergic reactions on damaged skin
- Turmeric paste / flour: Heavy contamination, interferes with wound assessment
Nursing Action: Cultural sensitivity is essential when educating families about harmful practices. Frame as wanting the best outcome for the patient, not criticism of cultural practices.
🏥 Regional Burns Centres
| Facility | Location | Key Points |
|---|---|---|
| Mafraq Hospital — Burns Unit | Abu Dhabi, UAE | Major burns referral centre for Abu Dhabi; DOH-regulated; manages mass casualty burns incidents |
| King Fahad Specialist Hospital (KFSH) — Burns Unit | Dammam, KSA | Tertiary burns centre; SCFHS affiliated; research centre |
| Dubai Hospital Burns Unit | Dubai, UAE | DHA facility; major burns referral in Dubai Emirate |
| Riyadh Military Hospital | Riyadh, KSA | Military and civilian burns care |
| Hamad Medical Corporation | Doha, Qatar | Qatar's main tertiary burns referral |
| Salmaniya Medical Complex | Manama, Bahrain | Main burns unit in Bahrain |
Burns Area & Fluid Calculator
Parkland Fluid Calculator & Burns Assessment Tool
Enter patient weight and select burned body areas (partial thickness and full thickness only — exclude superficial/epidermal burns from TBSA)
Select Burned Areas (Rule of Nines — Adults)
9%
9%
9%
18%
18%
9%
9%
9%
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1%
Results
Total %TBSA
—
%
Total 24h Fluid
—
mL Hartmann's
First 8 Hours
—
mL (from time of burn)
Next 16 Hours
—
mL
Min Urine Output
—
mL/hour (0.5 mL/kg/h)
DHA / DOH / SCFHS Exam Preparation — MCQ Practice
Q1. A patient with 30% TBSA burns weighing 70 kg. Using the Parkland formula, how much fluid should be given in the FIRST 8 hours?
Answer: B. Parkland = 4 × 70 × 30 = 8,400 mL total. Half (4,200 mL) in first 8 hours from time of burn. Note: The distractors A and B are identical in value — in an exam, B correctly contextualises the answer. Total = 8,400 mL; First 8h = 4,200 mL; Next 16h = 4,200 mL.
Q2. A nurse is assessing a burn patient and notes stridor, hoarseness, and carbonaceous sputum. What is the PRIORITY nursing action?
Answer: B. Stridor + hoarseness + carbonaceous sputum = inhalation injury with impending airway obstruction. The priority is immediate physician notification for early intubation before oedema renders airway management impossible. Oxygen is important but does not address the priority of securing the airway.
Q3. Which burn dressing characteristic makes ALKALI burns MORE dangerous than acid burns?
Answer: C. Alkali burns cause liquefactive necrosis — saponification of fat and protein denaturation without the protective eschar formed by acid burns. This allows the alkali to penetrate continuously deeper into tissue. Acid burns cause coagulative necrosis, forming an eschar that limits further penetration.
Q4. Which first aid measure is CORRECT for a thermal burn?
Answer: C. Tepid water (15–20°C) for 20 minutes is the evidence-based standard. Ice causes vasoconstriction and deepens the injury. Toothpaste, butter, and oil trap heat, promote infection, and are culturally common harmful remedies in the GCC region.
Q5. A patient presents with a burn that is leathery, white/brown, and completely painless. What depth is this burn and what does the absence of pain indicate?
Answer: C. Full thickness burns destroy all layers of the skin including the sensory nerve endings in the dermis, making the wound painless. The leathery, white/brown, or charred appearance is characteristic eschar. These wounds always require surgical excision and skin grafting.
Q6. When should fluid resuscitation timing be calculated from when using the Parkland formula?
Answer: B. The Parkland formula timing begins from the TIME OF BURN INJURY, not from admission. This is a critical exam point. If a patient arrives 2 hours after the burn, the first 8-hour half must be infused in the remaining 6 hours. The total volume does not change — only the rate adjusts.
Q7. Which of the following is the MOST ACCURATE method for estimating %TBSA in a 3-year-old child with burns?
Answer: C. The Lund and Browder Chart is the most accurate method for children as it accounts for age-related differences in body proportions (particularly the head and legs). A child's head represents a larger proportion of TBSA than in adults. The adult Rule of Nines would underestimate head burns and overestimate leg burns in children.
Q8. A patient with electrical burns has tea-coloured urine. What is the MOST LIKELY cause and what is the priority nursing action?
Answer: B. Tea/dark-coloured urine in electrical burns indicates myoglobinuria from rhabdomyolysis (muscle destruction by electrical current). Myoglobin precipitates in renal tubules causing acute kidney injury. The priority is aggressive IV hydration to flush myoglobin — target UO 1–1.5 mL/kg/h (above standard). Obtain CK, myoglobin, and renal function tests.
Q9. Which anti-deformity splinting position is CORRECT for burns of the anterior neck?
Answer: C. Anterior neck burns scar and contract in flexion (chin-to-chest deformity). The anti-deformity position is neck extension to prevent this contracture. A neck conformer splint or positioning collar is used to maintain extension. Flexion (position of comfort) must be actively avoided, especially during sleep.
Q10. A patient post-split-thickness skin graft to the right thigh is on day 3 post-operative. The nurse notes the graft appears pale and is beginning to lift at the edges. What does this indicate and what should the nurse do?
Answer: C. A good graft take at day 5 is pink, flat, and adherent. Pale, lifting graft on day 3 suggests poor take — likely causes include haematoma under the graft (preventing vascularisation), shear movement, or infection. The surgical team must be notified urgently as early intervention (evacuation of haematoma, re-adherence) may salvage the graft. After day 5, a failed graft typically requires repeat grafting.