General Surgery
Burns
MBBS surgery notes on burns: depth classification, rule of nines, Parkland fluid resuscitation, airway and complications, mapped to NMC codes SU4.1 to SU4.4.
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Burns
MBBS surgery notes on burns: depth classification, rule of nines, Parkland fluid resuscitation, airway and complications, mapped to NMC codes SU4.1 to SU4.4.
This chapter deals with the assessment and management of burns, from estimating depth and surface area to fluid resuscitation, airway protection and definitive wound care. It stresses the systemic effects of major burns and the indications for specialist referral.
High-yield: Burns
- Burn depth is classed as superficial, superficial partial thickness, deep partial thickness and full thickness, guiding whether it heals or needs grafting.
- Superficial partial thickness burns are painful, pink, blistered and blanch, while full thickness burns are painless, leathery and do not blanch.
- The burn surface area in adults is estimated by the Wallace rule of nines, with the palm and fingers of the patient being about 1%.
- The rule of nines overestimates burn size in children because their head is proportionally larger, so a Lund and Browder chart is preferred in paediatrics.
- The Parkland formula gives 4 mL of Ringer lactate per kg per percent burn in the first 24 hours, half in the first 8 hours from the time of the burn.
- Fluid resuscitation is titrated to a urine output of about 0.5 mL/kg/hour in adults and higher in children.
- Airway burns are suspected with facial burns, singed nasal hair, soot in the mouth, hoarseness or stridor and warrant early intubation before oedema closes the airway.
- Carbon monoxide poisoning gives a falsely normal pulse oximetry reading and is treated with 100% oxygen.
- Circumferential full thickness burns of a limb or chest can cause compartment syndrome or restrict breathing and need escharotomy.
- The commonest cause of death later in the burn course is infection and sepsis, often from Pseudomonas or Staphylococcus.
- Early excision of dead tissue and skin grafting reduce infection, shorten stay and improve outcome in deep burns.
- Burns cause a hypermetabolic state, so early enteral nutrition with high protein and calories is essential.
- Curling ulcer is a stress ulcer of the stomach or duodenum seen after major burns, prevented with acid suppression.
- Referral to a burns unit is warranted for large burns, full thickness burns, and burns of the face, hands, feet, perineum or across joints.
- Electrical burns can cause deep tissue and muscle damage with myoglobinuria despite small skin wounds, risking acute kidney injury.
Burn depth at a glance
- **Superficial:** Epidermis only; red, dry, painful, blanches. Heals in days without scarring.
- **Superficial partial thickness:** Into upper dermis; blistered, pink, moist, very painful, blanches. Heals in 2 to 3 weeks.
- **Deep partial thickness:** Into deep dermis; mottled, less painful, sluggish blanching. May need grafting.
- **Full thickness:** Whole dermis; white or leathery, painless, no blanching. Needs excision and grafting.
NMC competencies in this chapter
- **SU4.1:** Classification and assessment of burn depth and area
- **SU4.2:** Fluid resuscitation and early management of burns
- **SU4.3:** Definitive wound management and complications of burns
- **SU4.4:** Rehabilitation and referral criteria in burns
Frequently Asked Questions
How is burn surface area estimated?
In adults the Wallace rule of nines is used, and the patient palm plus fingers is about 1%. In children a Lund and Browder chart is more accurate because the head is proportionally larger.
How is the Parkland formula applied?
Give 4 mL of Ringer lactate per kilogram per percent burn over 24 hours from the time of the burn, half in the first 8 hours, then titrate to a urine output of about 0.5 mL/kg/hour.
When should you worry about the airway in burns?
Facial burns, singed nasal hairs, soot in the mouth, hoarseness or stridor suggest an inhalational injury, and early intubation is safer before airway oedema develops.
Why do circumferential burns need escharotomy?
A rigid full thickness eschar around a limb can cause compartment syndrome and around the chest can restrict breathing, so an escharotomy releases the constriction.
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