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Rule of Nines (Wallace): Used for estimating total body surface area (TBSA) burned in adults. Head = 9%, each arm = 9%, each leg = 18%, trunk front = 18%, trunk back = 18%, perineum = 1%. Lund-Browder chart is more accurate for children (head proportionally larger).
Burn Depth Classification
| Depth | Appearance | Sensation | Healing Time | Management |
|---|
| Superficial | Erythema, dry, no blisters | Painful | 3–5 days | Simple analgesia, moisturiser |
| Superficial Partial | Blisters, moist, red/pink | Very painful | 14–21 days | Non-adherent dressings |
| Deep Partial | Pale/white, may blister | Reduced sensation | >21 days | Often needs skin grafting |
| Full Thickness | Leathery, white/brown/black | Painless (nerve destruction) | Cannot heal alone | Always requires skin grafting |
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Inhalation Injury — Early Intubation: Signs: singed eyebrows or nasal hairs, hoarse voice, carbonaceous (sooty) sputum, stridor, facial burns, oropharyngeal oedema. Airway oedema can progress rapidly — EARLY intubation before loss of airway. Do NOT delay.
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Primary Survey (ABCDE)
- A — Airway: assess for inhalation injury; early intubation if indicated
- B — Breathing: respiratory rate, SpO₂; high-flow O₂ for CO poisoning (100%)
- C — Circulation: IV access ×2 (avoid burnt skin if possible); start Parkland formula
- D — Disability: GCS (CO poisoning?), pain assessment
- E — Exposure: full body assessment; remove jewellery, clothing; maintain warmth
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Circumferential Burns & Escharotomy
- Circumferential full-thickness burns → tight eschar → compartment syndrome
- Limbs: reduced pulse, paraesthesia, pain on passive stretch, pallor
- Chest: restricted chest expansion → respiratory failure
- Escharotomy: incision through eschar (not fascia) to release pressure
- Performed at bedside or theatre; no anaesthesia required (painless in full-thickness burn)
- Monitor hourly: distal pulses, capillary refill, compartment pressures
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Burn Referral Criteria (Major Burns)
- TBSA >10% in children / >15% in adults
- Full-thickness burns any size
- Burns involving face, hands, feet, genitalia, perineum, major joints
- Circumferential burns
- Inhalation injury
- Chemical or electrical burns
- Burns in extremes of age
- Burns with significant co-morbidities
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Infection & Sepsis
- Burns destroy skin barrier → highest infection risk
- Most common organisms: Pseudomonas aeruginosa, S. aureus (MRSA), Candida
- Signs: wound colour change, increased exudate, wound breakdown, systemic sepsis
- Burn wound biopsy (not swab) for quantitative culture (>10⁵ organisms = infected)
- IV antibiotics guided by cultures
- Strict infection control: isolation rooms, gowns, gloves, masks
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Contracture
- Most common rehabilitation complication
- Risk: deep partial or full-thickness burns crossing joints
- Prevention: early mobilisation, splinting, pressure garments
- Established contracture: physiotherapy, serial casting, surgical release (Z-plasty, skin grafting)
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Hypertrophic Scarring
- Raised, red, itchy scars confined to wound boundary
- Risk factors: deep burns, delayed healing (>21 days), dark skin, young patients
- Management: pressure garments, silicone, steroid injections, laser therapy
- Distinguish from keloid (extends beyond wound boundary)
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Curling's Ulcer: Stress ulcer occurring in major burns patients (particularly >35% TBSA). Caused by reduced mucosal perfusion + stress response. All major burns patients should receive proton pump inhibitor (PPI) prophylaxis. Enteral feeding also protects mucosa.
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High-Yield Exam Points
- Parkland: 4 mL × kg × %TBSA = 24h RL; HALF in first 8h from time of burn
- Monitor UO: 0.5-1 mL/kg/h adults; 1 mL/kg/h children
- Full thickness = painless (nerve destruction)
- Inhalation injury = singed nasal hairs + hoarse voice → early intubation
- Circumferential full-thickness burn → escharotomy
- Pressure garments: 6-24 months; 24h/day wear
- Splint in position of function (not comfort)
- Protein requirement: ≥2g/kg/day (hypermetabolic)
- Lund-Browder: more accurate than Rule of Nines in children
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Common Exam Traps
- Parkland timing = from TIME OF BURN (not hospital arrival)
- Do NOT use ice for first aid — use cool running water
- Full-thickness burn = painless (not more painful)
- Ringer's Lactate (NOT normal saline) for Parkland formula
- Escharotomy = through eschar only; fasciotomy = through fascia (compartment syndrome trauma)
- Deep partial thickness = reduced (not absent) sensation
Practice MCQs — Burns Rehabilitation
Q1. A 70 kg patient sustains 30% TBSA burns at 14:00. Using the Parkland formula, how much Ringer's Lactate should be infused by 22:00 (first 8 hours from burn time)?
A. 2,100 mL
B. 4,200 mL
C. 8,400 mL
D. 1,050 mL
Correct: B. Parkland formula: 4 × 70 × 30 = 8,400 mL total over 24 hours. Half (4,200 mL) is given in the first 8 hours from TIME OF BURN (14:00 to 22:00). The remaining 4,200 mL is given over the subsequent 16 hours.
Q2. A patient with circumferential full-thickness burns to the right forearm develops absence of radial pulse and paraesthesia. The burn is 12 hours old. What is the priority intervention?
A. Increase IV fluid rate to improve circulation
B. Apply a pressure bandage to control oedema
C. Urgent escharotomy to release compartment pressure
D. Elevate limb above heart level and observe for 2 hours
Correct: C. Absence of distal pulse plus paraesthesia following circumferential full-thickness burns indicates compartment syndrome secondary to circumferential eschar. Urgent escharotomy (incision through the eschar to release pressure) is required. Increasing fluids or elevation will not reverse established compartment syndrome.
Q3. A patient is 3 weeks post-major burn involving both hands. The physiotherapist recommends custom pressure garments. How long should the patient expect to wear these garments?
A. 2-4 weeks
B. 2-4 months only
C. 6-24 months, 23 hours per day
D. Permanently for life
Correct: C. Pressure garments are worn for 6-24 months (until scar maturation is complete), worn 23 hours per day (removed only for bathing and exercises). They provide approximately 24-25 mmHg pressure to reduce hypertrophic scar formation. Premature discontinuation leads to scar recurrence.
Q4. A burns nurse is assessing a new admission. The wound appears white and leathery with no sensation to sharp touch. What burn depth does this describe?
A. Superficial partial-thickness burn
B. Deep partial-thickness burn with reduced sensation
C. Full-thickness burn — will always require skin grafting
D. Superficial burn that will heal in 5 days
Correct: C. A leathery, white appearance with complete painlessness (absent sensation) is characteristic of full-thickness (third-degree) burn. All skin layers including nerve endings are destroyed. Full-thickness burns cannot heal spontaneously and always require surgical debridement and skin grafting.