Burns Management

Burns are coagulative tissue destruction caused by thermal, electrical, chemical, or radiation energy. For NEET PG, this is a perennial high-yield trauma topic: examiners love the Rule of Nines, Parkland formula, depth classification, escharotomy indications, and complications like Curling's ulcer. Master the numbers and the decision points.

Classification by Depth

Depth determines healing, scarring, and the need for grafting. The older terminology (first/second/third degree) maps onto the modern descriptive system.

Depth	Layers involved	Appearance	Sensation	Capillary refill	Healing
Superficial (1st degree)	Epidermis only	Red, dry, no blisters (e.g. sunburn)	Painful	Present	5–7 days, no scar
Superficial partial-thickness (2nd, superficial dermal)	Epidermis + papillary dermis	Pink, moist, blisters, weeping	Very painful	Brisk, blanches	2–3 weeks, minimal scar
Deep partial-thickness (2nd, deep dermal)	Into reticular dermis	Red/white mottled, less blistering	Reduced (dull)	Sluggish/absent	>3 weeks, hypertrophic scar; often grafted
Full-thickness (3rd degree)	Entire dermis ± subcutis	White/waxy/charred, leathery, dry	Painless (nerves destroyed)	Absent, no blanch	Will not heal spontaneously → graft
4th degree	Into muscle/bone/fascia	Charred, exposed deep tissue	Painless	Absent	Excision/amputation

High-yield: A burn that is painless, dry, white/leathery, and does not blanch is full-thickness. Pain and blistering imply viable nerve endings → partial-thickness.

Depth is dynamic — a partial-thickness burn can convert to full-thickness over 48–72 h ("burn wound conversion") due to the zone of stasis progressing if resuscitation is inadequate.

Jackson's burn wound zones

1. Zone of coagulation — central, irreversible necrosis.
2. Zone of stasis — surrounds it; salvageable with good perfusion, lost with hypotension/infection. Resuscitation targets this zone.
3. Zone of hyperaemia — outer, vasodilated, recovers fully.

Estimating Burn Surface Area (TBSA)

Only partial- and full-thickness burns are counted; superficial (erythema) burns are excluded from TBSA used for fluid calculation.

Wallace Rule of Nines (adult)

Quick bedside estimate in multiples of 9% (and 1%):

• Head & neck = 9%
• Each upper limb = 9% (total arms 18%)
• Anterior trunk = 18%, posterior trunk = 18%
• Each lower limb = 18% (total legs 36%)
• Perineum/genitalia = 1%

High-yield: Rule of Nines differs in children — large head, small legs. In an infant, head & neck ≈ 18% and each leg ≈ 14%. The Lund–Browder chart corrects for age and is the most accurate method, especially in children.

Other methods

• Palmar method — the patient's palm including fingers ≈ 1% TBSA; useful for small or scattered burns.
• Lund–Browder chart — most accurate; adjusts segment percentages by age.

Initial Assessment & Resuscitation

Burns are trauma — start with ATLS: Airway, Breathing, Circulation. Look for inhalation injury early.

Approach (flow): Stop the burning process & remove clothing/jewellery → Airway (assess for inhalation injury, intubate early if in doubt) → Breathing (100% O₂, exclude circumferential chest eschar) → Circulation (two large-bore IV lines through unburned skin, start fluids) → Disability/Exposure → calculate TBSA & depth → analgesia (IV opioids) → cover wounds, keep warm → catheterise → tetanus prophylaxis.

High-yield: Apply cool running water (≈ 8–25 °C) for 20 minutes within the first 3 hours. Avoid ice (causes vasoconstriction, deepens the burn and risks hypothermia).

Parkland (Baxter) formula — the most tested calculation

$$\text{Fluid (first 24 h)} = 4\ \text{mL} \times \text{body weight (kg)} \times %,\text{TBSA}$$

Fluid of choice = Ringer's lactate (isotonic crystalloid).

• Give half in the first 8 hours (counted from the time of injury, not from arrival).
• Give the remaining half over the next 16 hours.

Worked example: 70 kg adult, 40% TBSA → 4 × 70 × 40 = 11,200 mL in 24 h. First 8 h = 5,600 mL (≈ 700 mL/h); next 16 h = 5,600 mL (≈ 350 mL/h).

High-yield: Titrate fluids to urine output, the best endpoint of resuscitation: 0.5–1 mL/kg/h in adults (≈ 30–50 mL/h) and 1 mL/kg/h in children. For electrical burns / myoglobinuria, aim higher (1–1.5 mL/kg/h) to flush pigment and prevent acute kidney injury.

Formula	Crystalloid	mL per kg per %TBSA
Parkland (Baxter)	Ringer's lactate	4 mL
Modified Brooke	Ringer's lactate	2 mL
Galveston (paediatric)	RL + dextrose + albumin, by BSA (m²)	5000 mL/m² burn + 2000 mL/m² total

Children additionally need maintenance fluid with dextrose because of limited glycogen stores. Colloid (albumin) is usually withheld in the first 8–24 h because of capillary leak.

When to start IV resuscitation?

• Adults: burns > 15–20% TBSA.
• Children: burns > 10% TBSA. Smaller burns can often be managed with oral rehydration.

Inhalation Injury

The leading cause of early death in burns. Suspect with fire in an enclosed space.

Clues: facial/neck burns, singed nasal hairs, carbonaceous sputum, soot in oropharynx, hoarseness/stridor, brassy cough.

• Diagnosis of choice / gold standard: fibreoptic bronchoscopy (also allows lavage). Carboxyhaemoglobin level confirms CO exposure.
• Three components: (1) supraglottic thermal injury (oedema → airway obstruction), (2) subglottic chemical injury from smoke, (3) systemic toxicity (CO, cyanide).

High-yield: Intubate early — laryngeal oedema worsens over hours and makes later intubation impossible. Do not wait for overt obstruction.

Carbon monoxide poisoning

• CO binds Hb with ~240× the affinity of O₂ → falsely normal pulse oximetry (SpO₂ reads oxy- + carboxy-Hb).
• Cherry-red skin, headache, confusion. Diagnose with co-oximetry (COHb level).
• Treatment = 100% oxygen (reduces CO half-life from ~4 h to ~40–60 min); hyperbaric O₂ for severe cases/pregnancy.
• Cyanide (from burning plastics) → high anion-gap lactic acidosis; treat with hydroxocobalamin.

Escharotomy vs Fasciotomy

A circumferential full-thickness burn forms a rigid, non-elastic eschar. As oedema builds, it acts like a tourniquet.

	Escharotomy	Fasciotomy
Indication	Circumferential full-thickness limb/chest eschar causing vascular or respiratory compromise	True compartment syndrome (e.g. electrical burns, crush)
Depth of incision	Through eschar into subcutaneous fat	Through deep fascia
Signs prompting it	Loss of distal pulses/Doppler, ↑ compartment pressure, ↓ chest expansion	Pain, ↑ pressure (>30 mmHg), neuro deficit

High-yield: Chest escharotomy is needed when circumferential torso burns restrict ventilation. Electrical burns classically need fasciotomy because deep muscle damage exceeds the visible skin injury (iceberg phenomenon).

Wound Care & Surgical Management

• Topical antimicrobials: silver sulfadiazine (broad, but penetrates eschar poorly and can cause leucopenia; avoid in sulfa allergy, pregnancy/neonates, G6PD). Mafenide acetate penetrates eschar/cartilage best (use for ear/nose burns) but causes pain and metabolic acidosis (carbonic anhydrase inhibitor). Silver nitrate causes hyponatraemia and black staining.
• Early tangential excision and grafting (within first few days) of deep partial- and full-thickness burns reduces infection, sepsis, and mortality.
• Skin grafts: split-thickness skin graft (STSG) is the workhorse for burns; can be meshed to expand coverage. Full-thickness grafts give better cosmesis for face/hands but need a well-vascularised bed.
• Temporary cover when donor sites are scarce: allograft (cadaveric), xenograft, biosynthetic dressings, cultured epithelial autografts (CEA), and dermal substitutes (e.g. Integra).
• Nutrition: burns are hypermetabolic — early enteral high-protein, high-calorie feeding; Curreri formula estimates needs. Glutamine and adequate vitamins/trace elements support healing.

High-yield: Curling's ulcer = acute stress gastroduodenal ulcer in burns. Cushing's ulcer = stress ulcer with raised intracranial pressure (head injury/CNS). Give PPI/H₂-blocker prophylaxis to all major burns.

Mnemonic: "Curling = Combustion (burns); Cushing = Cranium (brain)."

Criteria for Referral to a Burns Centre

High-yield (American Burn Association): Refer if — partial-thickness > 10% TBSA; any full-thickness burn; burns of face, hands, feet, genitalia, perineum, or major joints; electrical (including lightning) burns; chemical burns; inhalation injury; burns at extremes of age/with comorbidities; circumferential burns; and burns with associated trauma.

Special Burns

• Electrical burns: small entry/exit wounds hide massive deep muscle necrosis → rhabdomyolysis, myoglobinuria, AKI, compartment syndrome, cardiac arrhythmias (get an ECG, monitor). High-voltage (>1000 V) is most dangerous. Maintain high urine output; alkalinise urine for myoglobinuria.
• Chemical burns: copious water irrigation (do NOT neutralise — exothermic reaction worsens injury). Alkali burns cause deeper liquefactive necrosis and are worse than acids (coagulative). Hydrofluoric acid → hypocalcaemia/hypomagnesaemia, life-threatening arrhythmias; treat with calcium gluconate (topical gel ± IV/intra-arterial).
• Cold/frostbite: rapid rewarming in 37–39 °C water.

Complications

• Early: hypovolaemic ("burn") shock, airway obstruction, AKI, hypothermia, compartment syndrome, electrolyte shifts (early hyperkalaemia from cell lysis, later hypokalaemia/hyponatraemia).
• Infective: burn wound sepsis — leading cause of late death. Classic organism Pseudomonas aeruginosa; also Staph aureus, fungi. Toxic shock syndrome can occur even with small burns in children.
• GI: Curling's ulcer, ileus, acalculous cholecystitis.
• Late: hypertrophic scars and keloids, contractures (across joints), Marjolin's ulcer — aggressive squamous cell carcinoma arising in a chronic burn scar/unstable scar years later. Heterotopic ossification, anaemia of chronic illness, psychological sequelae.

High-yield: A non-healing ulcer or new growth in an old burn scar = Marjolin's ulcer (SCC) until proven otherwise — biopsy it.

Burn Shock & Pathophysiology

Major burns release inflammatory mediators (histamine, bradykinin, prostaglandins, TXA₂, cytokines) → systemic capillary leak. Fluid shifts into the interstitium causing massive oedema and hypovolaemia despite total-body fluid overload. There is an early ebb phase (hypometabolic, low cardiac output) followed by a flow/hypermetabolic phase (high output, catabolism, increased resting energy expenditure that can double). This drives the nutritional and resuscitation strategies above.

Key Differentials & Look-alikes

• Scalds vs flame burns — scalds (hot liquids) are usually partial-thickness; immersion scalds with sharp margins/glove-stocking pattern suggest non-accidental injury (child abuse) — examiners flag this.
• Toxic epidermal necrolysis (TEN)/SJS — drug-induced full-thickness epidermal loss mimicking burns; managed in burn units (Nikolsky sign positive, mucosal involvement).
• Staphylococcal scalded skin syndrome (SSSS) — toxin-mediated, superficial cleavage, in young children.
• Necrotising fasciitis — for deep "burn-like" infected wounds.

Recently asked / exam angle

• Parkland formula numerical — calculate total fluid and the rate for the first 8 hours; remember the clock starts at injury time. Repeatedly tested.
• Fluid of choice = Ringer's lactate; resuscitation endpoint = urine output.
• Rule of Nines percentages, and the palm = 1% rule; Lund–Browder = most accurate, especially in children.
• Curling's vs Cushing's ulcer matching question.
• Inhalation injury — best investigation (fibreoptic bronchoscopy); CO poisoning gives normal SpO₂; treat with 100% O₂.
• Escharotomy indications (circumferential full-thickness, chest/limb) vs fasciotomy in electrical burns.
• Marjolin's ulcer = SCC in chronic burn scar.
• Topical agents: mafenide → metabolic acidosis and best eschar penetration; silver sulfadiazine → leucopenia, avoid in G6PD/sulfa allergy.
• Hydrofluoric acid burn → calcium gluconate; alkali worse than acid (liquefactive necrosis).
• Criteria for burn-centre referral (TBSA cut-offs, special sites).

Rapid revision

1. Full-thickness burn = painless, dry, white/leathery, non-blanching; partial-thickness = painful + blisters.
2. Rule of Nines: head 9, each arm 9, each leg 18, front trunk 18, back trunk 18, perineum 1.
3. Patient's palm (with fingers) = 1% TBSA; Lund–Browder = most accurate, vital in children.
4. Parkland: 4 mL × kg × %TBSA Ringer's lactate; half in first 8 h from time of burn.
5. Resuscitation endpoint = urine output 0.5–1 mL/kg/h (adult), 1 mL/kg/h (child).
6. Resuscitate adults >15–20% TBSA, children >10% TBSA.
7. Cool with running water 20 min; never use ice.
8. Fibreoptic bronchoscopy = best test for inhalation injury; CO poisoning → normal SpO₂, treat with 100% O₂.
9. Escharotomy for circumferential full-thickness eschar; fasciotomy for electrical/compartment syndrome.
10. Curling's ulcer = burns; Cushing's ulcer = brain (raised ICP) — give PPI prophylaxis.
11. Marjolin's ulcer = SCC in a chronic burn scar; Pseudomonas = classic burn-wound sepsis organism.
12. Hydrofluoric acid burn → calcium gluconate; alkali (liquefactive) burns deeper than acid (coagulative); never neutralise — irrigate with water.