Surgery — Burns and Soft Tissue Injury, NMC MBBS licence examination syllabus (Nepal Medical Council).
Almost everything that matters in a burn can be reasoned out from two ideas: heat keeps working after the fire stops, and injured capillaries leak.
Burns are common, and they are a reliable source of exam questions because so little of the subject is memorisation. Depth, the airway threat, the shock, the circumferential emergency — each follows from a mechanism you can reconstruct at the bedside.
You do not assess depth by how bad it looks. You assess it by asking what the skin can still do.
A superficial burn is red, dry and painful, and it blanches on pressure then refills — the nerves and the vessels are intact, so both still respond. A partial-thickness burn blisters, is moist, and is very painful; the damage extends into the dermis but the structures that regenerate skin survive. A full-thickness burn is dry, leathery, white or charred — and painless.
That last point is the one candidates get wrong. The burn does not hurt because the nerve endings have been destroyed. Absence of pain is the worst sign, not a reassuring one. A burn that does not hurt is deeper, not better.Suspect inhalation injury from the circumstances before you look at the patient: a fire in an enclosed space is the single most important piece of history. Then look for soot around the nose or mouth, singed nasal hairs, burns to the face or neck, a hoarse voice, stridor, or carbon in the sputum.
The reason this is urgent is that the swelling is progressive. An airway that is adequate on arrival may not be adequate in two hours — and by then it will also be far harder to secure, because the anatomy has swollen and distorted.
So the airway is secured early, while it is still easy, on suspicion rather than on proof. Waiting to see whether it worsens is exactly how a manageable airway becomes an emergency at three in the morning.A large burn makes capillaries leak — and not only at the burn. Fluid moves out of the circulation into the tissues throughout the body. It has not left the patient; it has left the circulation. This is why a badly burned patient swells while their blood pressure falls.
Because that leak takes time to accumulate, burn shock develops over hours rather than minutes. A patient who looks stable in the morning can be profoundly shocked by the evening — which is the argument for starting fluids on the basis of the burn's size rather than waiting for the blood pressure to fall.
Resuscitation is guided by a formula that estimates a starting rate from the burn's size and the patient's weight, and is then adjusted against urine output. Look the formula up rather than trusting memory; what matters for the exam is knowing that it produces an estimate to be titrated, not a prescription to be followed.
Cool with running water, and keep cooling. Retained heat continues to damage tissue after the source has gone, so cooling limits how deep the burn eventually becomes — which is a real reduction in injury, not merely comfort.
But cool the burn and keep the patient warm. A wet patient with a large burn loses heat fast and becomes hypothermic, and hypothermia makes everything that follows worse.
Not ice, which causes further injury through vasoconstriction and cold damage. And not butter, oil, toothpaste or ash: they introduce infection and make the wound impossible to assess.
Full-thickness skin is rigid and does not stretch. When such a burn encircles a limb or the chest, the tissue beneath swells against an unyielding band.
Around a limb, the rising pressure cuts off the circulation. Around the chest, it restricts breathing. Both develop over hours as the swelling increases, which means a limb that was fine on admission must be rechecked repeatedly — a single normal examination proves nothing about the next few hours.
The treatment is surgical release, and it is urgent. What is expected of a candidate is to recognise the pattern and escalate.
Analgesia. Partial-thickness burns are among the most painful injuries there are, and pain relief is repeatedly under-prescribed in them. It is part of the treatment, not an optional courtesy.
Non-accidental injury. When the pattern of the burn does not fit the story given — a sharply demarcated immersion pattern, burns in a protected site, a delay in presentation, an account that changes between tellings — that discrepancy must be raised and documented, in a child or a vulnerable adult.
A patient rescued from a house fire, hoarse, with soot around the nostrils, currently breathing comfortably. Enclosed space plus soot plus hoarseness means an airway at risk. Get senior help now and secure it while it remains easy — comfortable breathing at this moment is not reassurance.
A large burn, painless and leathery over much of the area. Full thickness. The painlessness is the depth marker; it will not heal without surgery.
A burned patient hypotensive fifteen minutes after the injury. Too early for burn shock. Look for bleeding or another injury.
A circumferential forearm burn with a hand that was warm on admission and is now cool with poor capillary refill. The swelling has closed off the circulation beneath rigid burned skin. This is an urgent surgical release, not a matter for observation.
Painless and mild. Painless means the nerve endings are gone — it is the deepest kind of burn.
Cooling the burn and cooling the patient. Cool the wound with running water; keep the patient warm.
Early shock and burn shock. Burn shock takes hours. Shock in the first minutes means bleeding.
A limb that is fine now and a limb that will stay fine. Circumferential burns tighten as the swelling grows, so the examination has to be repeated.
Depth is judged by what still works — pain, blanching, moisture. Painless means full thickness.
Enclosed space, soot, hoarseness, singed hairs → secure the airway early, because the swelling is progressive.
Capillaries leak, so shock develops over hours. Early shock is bleeding.
Cool the burn with running water, keep the patient warm. No ice, nothing else applied.
Remove rings and bangles before the swelling starts.
Circumferential burn → limb circulation or chest expansion is threatened; recheck and escalate.
Analgesia, and consider non-accidental injury when the pattern does not fit the history.
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