Burns and soft-tissue emergencies

Burns — initial assessment

Overview and approach

Burn assessment covers depth, total area, site, mechanism and inhalational injury.

  • Learning objectives: burn depth, severity and extent (TBSA%); surgical and non-surgical management; severe burns (respiratory care, fluid therapy, wound management, pain, nutrition, sepsis, rehabilitation); write preliminary fluid orders (Parkland); assess percentage burned in adults and children. Special burns (electrical, respiratory, chemical) are on the next page.
  • Australian and New Zealand Burn Association (ANZBA) guidance, RCH and NSW ACI guidance underpin Australian practice (1)(2)(3)(5).
Assessment and clinical features

ABCDE, exposure time, cooling, circumferential burns, face/hands/genital/joints and comorbidities; avoid hypothermia.

  • Primary survey first (airway with inhalation risk, cervical spine if trauma), then burn assessment: mechanism, time of injury, first aid given, depth, TBSA, special sites, circumferential burns, comorbidities, tetanus status and possibility of non-accidental injury (1)(3).
  • Depth: superficial (red, dry, painful), partial thickness (blisters, moist, painful; superficial vs deep dermal), full thickness (white/leathery, painless).
Differentials and investigations

Estimate TBSA with an appropriate age-adjusted method, excluding simple erythema; fluid/lab needs depend on severity.

  • TBSA: Rule of Nines in adults; Lund and Browder chart for children; the patient's palm with fingers is about 1% for small burns. Exclude simple erythema (1)(2).
  • Severe burns: bloods (FBC, U&E, CK, lactate, COHb if inhalation), ECG for electrical injury. Differentials: scalds vs contact vs flame vs chemical vs electrical; toxic epidermal necrolysis, staphylococcal scalded skin.
Management and follow-up

For thermal burns, cool with running cool water for a total of 20 minutes within 3 hours when possible, while preventing hypothermia; cover, provide analgesia, review tetanus and apply burns-service referral criteria.

  • First aid: cool running tap water for 20 minutes within 3 hours of injury; no ice or hydrogels; keep the patient warm (1)(2).
  • Cover with non-adherent cling film or dressing; analgesia; tetanus review; remove jewellery; elevate limbs.
  • Fluids (Parkland, modified): for adults over 20% or children over 10% TBSA, 3 mL Hartmann's x kg x %TBSA, half in the first 8 hours from injury and the rest over 16 hours, titrated to urine output (1)(2). Children also need maintenance fluids; follow the local burns-service protocol.
  • Refer to a burns service: adult over 10% or child over 5% TBSA, full-thickness over 5%, hands/face/feet/perineum/major joints, circumferential burns, inhalation, chemical or electrical, major trauma, pregnancy, extremes of age, suspected non-accidental injury (3)(4).
  • Surgical management: excision and grafting for deep burns; wound care, nutrition, infection surveillance, rehabilitation and scar management.
Red flags and clinical pearls

Airway signs, major/deep burns, circumferential compromise, chemical/electrical injuries and vulnerable patients need specialist assessment. Do not use ice.

  • Circumferential limb or chest burns may need escharotomy.
  • Burns inconsistent with the history or pattern: consider non-accidental injury.
  • Over-resuscitation ('fluid creep') is also harmful.
References
  1. NSW ACI: Burn patient management guidelines
  2. RCH: Burns - acute management
  3. ANZBA: Management of burns
  4. Queensland Trauma Education: Burns resources
  5. ANZBA: Initial management of severe burns (Primary Health Tasmania)

Last updated from Sen’s notes on 9 October 2026.