From Clinical guidelines — Diagnosis and treatment manual › Chapter 10: Medical and minor surgical procedures · Médecins Sans Frontières, Current online edition (last updated August 2022)
MSF clinical guidance on classification, evaluation, and management of minor and severe burns for clinicians in humanitarian and resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition (last updated August 2022)
- Audience
- Clinicians and healthcare workers in humanitarian, conflict, and resource-limited settings
- Evidence
- Expert consensus based on MSF field experience
- Reviewed
- 21 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline provides comprehensive management protocols for burns caused by heat, electricity, chemicals, or radiation. Burns are classified as severe if involving >10% body surface area (BSA) in children or >15% in adults, or if involving inhalation injury, major trauma, critical anatomical locations (face, hands, neck, genitalia, joints), electrical/chemical causes, or vulnerable age groups (60 years). Minor burns involve less BSA without other risk factors.
The guideline emphasises early fluid resuscitation using Ringer lactate (2 ml/kg × % BSA for first 8 hours), morphine analgesia (0.2 mg/kg SC initially), and aggressive nutritional support (25 kcal/kg + 40 kcal/% BSA daily). Infection control is paramount: strict asepsis, regular occlusive dressings with silver sulfadiazine every 48 hours, and empiric antibiotherapy (cefazolin plus ciprofloxacin) only when systemic infection is confirmed by at least 2 of 4 criteria (temperature >38.5°C or 100%).
Surgical management includes emergency escharotomy for circumferential burns causing ischaemia or respiratory compromise, and early excision-grafting of deep burns between days 5–6. Pain management is intensive, using morphine for all moderate-to-severe pain, with doses of 0.5–1 mg/kg PO or 0.2–0.5 mg/kg SC before dressing changes, adjusted according to simple verbal pain scales.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Severe burns defined as >10% BSA in children, >15% in adults, or involving inhalation, critical locations (face, hands, neck, genitalia, joints), electrical/chemical causes, or age <3 or >60 years
- Initial resuscitation: Ringer lactate 20 ml/kg in first hour, then 2 ml/kg × % BSA over 8 hours; morphine SC 0.2 mg/kg; increase fluids by 50% (to 3 ml/kg × % BSA) for inhalation injury or electrical burns
- Target urine output: 1–2 ml/kg/h in children <1 year, 1–1.5 ml/kg/h in children 1–12 years, 0.5–1 ml/kg/h in older children/adults; systolic pressure ≥60 mmHg in infants, 70–90 + (2 × age) in children 1–12 years, ≥100 mmHg in adults
- Nutritional requirements: 25 kcal/kg + 40 kcal/% BSA daily, with 1.5–2 g/kg protein; start at hour 8, use nasogastric feeding if BSA >20%
- Systemic infection defined by ≥2 of: temperature >38.5°C or <36°C, tachycardia, tachypnoea, white cell count elevation >100%; treat with cefazolin IV (children >1 month: 25 mg/kg every 8 hours; adults: 2 g every 8 hours) plus ciprofloxacin PO (children >1 month: 15 mg/kg twice daily; adults: 500 mg 3 times daily)
- Dressing changes every 48 hours with silver sulfadiazine 3–5 mm layer (not in children <2 months), applied under sterile conditions in operating room or at bedside with morphine
- Early excision-grafting of deep burns on days 5–6, involving ≤15% BSA per surgery; emergency escharotomy for circumferential burns causing ischaemia or respiratory compromise
- Pain management for dressing changes: morphine PO 0.5–1 mg/kg or SC 0.2–0.5 mg/kg given 60–90 minutes beforehand; halve dose in children <1 year, quarter in infants <3 months; increase by 25–50% if pain score ≥2
Lund-Browder table – Percentage of body surface area according to age
Table extracted from the guideline
| Location | <1 year | 1–4 years | 5–9 years | 10–15 years | Adults |
|---|---|---|---|---|---|
| Head | 19 | 17 | 13 | 10 | 7 |
| Neck | 2 | 2 | 2 | 2 | 2 |
| Anterior trunk | 13 | 13 | 13 | 13 | 13 |
| Posterior trunk | 13 | 13 | 13 | 13 | 13 |
| Right buttock | 2.5 | 2.5 | 2.5 | 2.5 | 2.5 |
| Left buttock | 2.5 | 2.5 | 2.5 | 2.5 | 2.5 |
| Perineum/genitalia | 1 | 1 | 1 | 1 | 1 |
| Right upper arm | 4 | 4 | 4 | 4 | 4 |
| Left upper arm | 4 | 4 | 4 | 4 | 4 |
| Right lower arm | 3 | 3 | 3 | 3 | 3 |
| Left lower arm | 3 | 3 | 3 | 3 | 3 |
| Right hand | 2.5 | 2.5 | 2.5 | 2.5 | 2.5 |
| Left hand | 2.5 | 2.5 | 2.5 | 2.5 | 2.5 |
| Right thigh | 5.5 | 6.5 | 8.5 | 8.5 | 9.5 |
| Left thigh | 5.5 | 6.5 | 8.5 | 8.5 | 9.5 |
| Right leg | 5 | 5 | 5.5 | 6 | 7 |
| Left leg | 5 | 5 | 5.5 | 6 | 7 |
| Right foot | 3.5 | 3.5 | 3.5 | 3.5 | 3.5 |
| Left foot | 3.5 | 3.5 | 3.5 | 3.5 | 3.5 |
Source: Médecins Sans Frontières, Burns — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“Infection is one of the most frequent and serious complications of burns: hygiene precautions, rigorous wound management, separate new patients from convalescent patients, do not administer antibiotherapy in the absence of systemic infection.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As a WHO consultant who has worked in conflict and post-disaster settings across the South Caucasus, I recognize that burns represent a significant burden in Georgia, particularly in rural areas where access to specialized care is delayed. This MSF guideline offers evidence-based protocols that district hospital clinicians can implement immediately: the Lund-Browder table for accurate BSA assessment, the 2 ml/kg × % BSA fluid resuscitation formula adjusted for age, and the clear infection criteria (≥2 of temperature extremes, tachycardia, tachypnoea, white cell elevation >100%) that prevent antibiotic overuse—critical in our region where antimicrobial resistance is rising. I would stress to Georgian colleagues the importance of adequate morphine analgesia before dressing changes (0.5–1 mg/kg PO or 0.2–0.5 mg/kg SC), a practice still under-utilized in many of our facilities due to unfounded fears of addiction in acute settings. The realistic implementation caveat is that early excision-grafting on days 5–6, limiting procedures to ≤15% BSA to control bleeding risk, requires surgical expertise and blood banking capacity available only in tertiary centres, meaning the national burn care pathway must ensure timely referral while district facilities focus on resuscitation, infection control, and pain management during the critical first 48 hours.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026
Applicability
Georgia and the South Caucasus
This guideline is highly relevant for Georgia and the South Caucasus, where burns from household accidents, workplace injuries, and conflict-related incidents occur regularly but specialized burn care is limited to tertiary centres in Tbilisi and regional capitals. Georgian clinicians in district hospitals must manage initial resuscitation and stabilization before referral, making the clear fluid resuscitation protocols (Ringer lactate 2 ml/kg × % BSA), infection control measures (silver sulfadiazine dressings every 48 hours, empiric cefazolin plus ciprofloxacin only when infection criteria met), and pain management algorithms (morphine 0.2–0.5 mg/kg SC) immediately applicable. National burn programmes would need to ensure availability of silver sulfadiazine (currently not consistently stocked in all facilities), morphine for procedural pain (often under-prescribed due to opioid-phobia), high-energy nutritional supplements for burns >20% BSA, and training in Lund-Browder assessment for accurate BSA calculation. The emphasis on early excision-grafting (days 5–6) and limiting surgical procedures to ≤15% BSA per operation requires surgical capacity that may necessitate regionalization of burn care beyond initial stabilization.
Questions this guideline answers
Quick answers
How do I calculate body surface area involved in a child with burns?
Use the Lund-Browder table, which adjusts for age. For example, in a 2-year-old child, the head represents 17% BSA (not 7% as in adults), while each thigh is 6.5%. Add percentages for all burned areas. For burns >50% BSA, limit your fluid calculations to 50% to avoid over-resuscitation.
When should I start antibiotics in a burn patient?
Do not give antibiotics prophylactically. Start empiric antibiotics (cefazolin IV 25 mg/kg every 8 hours in children, 2 g every 8 hours in adults, plus ciprofloxacin PO 15 mg/kg twice daily in children, 500 mg 3 times daily in adults) only when systemic infection is present, defined as ≥2 of: temperature >38.5°C or <36°C, tachycardia, tachypnoea, or white cell count elevation >100%.
How much fluid should I give in the first 24 hours to a 30 kg child with 20% BSA burns?
First 8 hours: 2 ml/kg × 20% = 1,200 ml Ringer lactate, plus maintenance fluid (4 ml/kg/h for first 10 kg = 40 ml/h, plus 2 ml/kg/h for next 10 kg = 20 ml/h, plus 1 ml/kg/h for remaining 10 kg = 10 ml/h, total 70 ml/h × 8 = 560 ml) = 1,760 ml total. Hours 8–24: another 1,200 ml Ringer lactate plus 1,120 ml maintenance (70 ml/h × 16 hours) = 2,320 ml. Adjust based on urine output target of 1–1.5 ml/kg/h.
What morphine dose should I give before changing dressings in a 6-year-old child?
Start with morphine 0.5–1 mg/kg PO or 0.2–0.5 mg/kg SC given 60–90 minutes before the procedure. The effective dose is usually around 1 mg/kg PO or 0.5 mg/kg SC, with no maximum dose. If the pain score is ≥2 during the procedure, increase the dose by 25–50% for the next dressing change. If pain remains inadequate, perform dressing changes under general anaesthesia in the operating room.
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- Treatment of a simple wound — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Dressings — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Abnormal uterine bleeding (in the absence of pregnancy) — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Major genital infections (summary) — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Venereal warts — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Upper genital tract infections (UGTI) — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Other guidelines on this topic
- Treatment of a simple wound — MSF Clinical guidelines
- Dressings — MSF Clinical guidelines
- Abnormal uterine bleeding (in the absence of pregnancy) — MSF Clinical guidelines
- Disseminated or miliary tuberculosis — MSF Tuberculosis
- Essential Medicines List for Management of Patients Admitted to Intensive Care Units with Suspected or Confirmed COVID-19 Diagnosis
- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 10: Medical and minor surgical procedures
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition (last updated August 2022)
- Status
- Current
- Published
- 2026-10-14
- Languages
- English
- Scope
- Clinical management of minor and severe burns from initial evaluation through rehabilitation
- Audience
- Clinicians and healthcare workers in humanitarian, conflict, and resource-limited settings
- Evidence
- Expert consensus based on MSF field experience
- Record history
- Created 21 Oct 2026 · updated 21 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Burns. In: Clinical guidelines — Diagnosis and treatment manual [Internet]. Paris: MSF; 2022 Aug [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/en/viewport/CG/english/chapter-10-medical-and-minor-surgical-procedures-burns-23537071.htmlGMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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