A week of fireworks, and a chapter that stops being theoretical
On Thursday night, St John Ambulance and South East Coast Ambulance Service treated 52 people at the Lewes Bonfire celebrations; four were taken on to hospital [1]. In Scotland, fire crews attended more than 767 incidents on Bonfire Night [2]. Today is Diwali. The trend is going the wrong way: NHS England counted 85 firework-related hospital admissions in November 2025, up from 60 a year earlier, and 161 across the whole of 2025 against 120 in 2024 [3]. The Children's Burns Trust reports that firework burns in children needing admission to a specialist burns unit rose by 63% between 2024 and 2025 [4]. Over last year's Diwali, AIIMS New Delhi treated 190 eye injuries from firecrackers and carbide guns, nearly half of them open-globe injuries [5].
For ATLS candidates this matters for a specific reason. Thermal injury is the chapter in which well-prepared candidates most reliably drop easy marks, not because the material is hard but because many of us have learned a perfectly respectable number that is not the ATLS number. The 11th edition has now changed the arithmetic itself. What follows is a trap-by-trap guide built around this week's injuries, with practice questions at the end.
Trap one: treating a firework injury as a burn
A firework is an explosive device, and its injuries are rarely purely thermal. A ten-year review of 93 patients at a UK regional burns and plastic surgery unit found that 74% presented in October and November, with mechanisms spanning contact, flash and flame burns and blast, and with eye injuries, soft-tissue defects and fractures alongside the burns [6].
So the primary survey, not the burns chart, comes first. ATLS 11 has added an "x" to the mnemonic: exsanguinating external haemorrhage is controlled before the airway [7]. A mangled hand pumping blood after a firework detonated in it needs direct pressure or a tourniquet before anyone reaches for a Lund and Browder chart.
The second lesson is the single most examinable idea in the chapter. Early hypotension is not burn shock. Burn shock is a capillary-leak process that develops over hours; a patient who is hypotensive within the first hour is bleeding, or has another cause, until proved otherwise. The ATLS 11 compendium of changes is explicit on both halves of this: bolus fluid is avoided except temporarily while treating hypotension, and hypotension should prompt a search for a non-burn cause [8]. A stem with modest burns and a systolic pressure of 80 mmHg at 30 minutes is not a question about Parkland.
The eye deserves a mention too: the 11th edition's ocular trauma chapter now describes lateral canthotomy and cantholysis in detail and adds a time-prioritised ocular flowsheet [8]. A firework to the face is exactly the mechanism that produces a tense, proptosed orbit.
Trap two: the number
Here the UK candidate is most exposed. ATLS 11 sets the initial adult calculation for thermal burns at 2 mL/kg/%TBSA of lactated Ringer's (Hartmann's), and 4 mL/kg/%TBSA for all electrical injuries [8]. That brings the course into line with the American Burn Association's clinical practice guideline, which recommends starting resuscitation at 2 mL/kg/%TBSA specifically to reduce total resuscitation volumes [9].
Much British practice still starts higher. The Care of Burns in Scotland adult guidance uses a modified Parkland formula of 4 mL × weight × %burn, with half given in the first eight hours from the time of injury [10]. RCEM Learning teaches a range of 2 to 4 mL, with 3 mL as the usual figure [11]. A UK trainee who has internalised "Parkland, 4 mL, half in eight hours" has learned something locally defensible, and wrong for the ATLS exam.
Why the move downwards? Fluid creep, the phrase Basil Pruitt used in 2000 for the tendency of modern patients to receive far more fluid than any formula predicts. Jeffrey Saffle's 2007 review described the pattern in detail, attributing much of the excess to progressive oedema in unburned tissue after the first eight hours [12]. A quantitative review of 48 studies and 3,196 patients by Shah and colleagues found a mean 24-hour infusion of 5.2 mL/kg/%TBSA, well above Parkland's 4 mL [13]. The price of that excess is abdominal and limb compartment syndromes, respiratory failure and deepening wounds. Starting at 2 mL is a bet that it is easier to titrate up from a low opening rate than to claw back fluid already in the interstitium.
Trap three: the clock
This is the 11th-edition change most likely to catch candidates who revise from older material, including, candidly, any question bank written before the new edition arrived. The traditional rule, still reproduced in most revision sources, is that half of the 24-hour volume is given in the first eight hours from the time of the burn and the rest over the next sixteen. If the patient arrives late, that first half is squeezed into whatever remains of the eight-hour window [14].
The ATLS 11 compendium abandons this. Its wording is that calculations are "over 16 hours, not 8"; fluid calculations are not adjusted for the time of injury or for volume given before the calculation; and rates are then adjusted hourly according to urine output [8]. The starting hourly rate is the 24-hour estimate divided by 16, the convention several US burns protocols already use [15, 16]. The pump is then titrated, not left alone.
Worked example. An 80 kg man sustains 30% TBSA partial- and full-thickness flame burns when petrol thrown on a garden bonfire flares back. He arrives two hours after injury, having received 1,000 mL of crystalloid from paramedics.
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One patient, three defensible rates, nearly threefold apart; only one is the ATLS 11 answer. The logic is that catch-up front-loads fluid into a delayed patient just as capillary leak peaks, and that under-resuscitation should be corrected from the urine bag rather than by arithmetic at the door.
Before you have a weight and a TBSA, ATLS 11 keeps age-based starting rates for a probable major burn of 20% TBSA or more: lactated Ringer's at 500 mL/h for patients aged 13 and over, 250 mL/h for ages 6 to 12, and 125 mL/h for children aged 5 and under [8]. Note the boundary. Advanced Burn Life Support draws the top band at 14 years [14]; if an ATLS question gives you a 13-year-old, the ATLS answer is 500 mL/h. These rates are a bridge; the calculated rate replaces them without subtraction.
For children, the compendium says resuscitation is age-based and follows American Burn Association recommendations [8]. ABLS-aligned paediatric protocols use 3 mL/kg/%TBSA, again divided by 16 for the starting rate, with dextrose-containing maintenance fluid for small children [16]. For urine output, the targets candidates need are 0.5 mL/kg/h in adults and 1 mL/kg/h in children under 30 kg, with higher targets when the urine is pigmented [11, 17].
Trap four: measuring the wrong thing
Only partial- and full-thickness burns count towards TBSA; simple erythema does not. Firework flash burns to the face often look dramatic in the first hour and are frequently superficial. The rule of nines works for adults, the patient's own palm with fingers approximates 1% for scattered burns, and children need a Lund and Browder chart because the proportions of head and limbs change with age.
Errors here are common, and mostly run one way. In children transferred to a US burns centre, referring institutions estimated a mean TBSA of 15.5% against the burns centre's 9.5%; nearly half were overestimated by five percentage points or more, and overestimation of that size was associated with over-resuscitation [18]. In a prospective Boston series, 59% of children received more fluid at the referring hospital than their true burn size warranted [19]. A Dutch nationwide evaluation found that referring physicians overestimated burn size in children by a factor of two [20]. Overestimation is a fluid-creep generator, because whatever error you make is multiplied by body weight and by the formula.
Size is not the whole story for referral. UK national referral guidance sets the threshold at 2% TBSA in children and 3% in adults, includes all full-thickness and circumferential burns, and asks for specialist discussion of burns to the hands, feet, face, perineum and genitalia [21, 22]. Firework injuries cluster on exactly those areas.
Trap five: the airway reflex
Singed eyebrows, soot at the nostrils and a blistered face trigger a powerful reflex to intubate. ATLS is right to treat the burned airway as time-critical: oedema progresses over hours, and a tube that is easy at 30 minutes may be impossible at three hours. Its triggers for early intubation centre on signs of obstruction such as hoarseness, stridor and accessory muscle use; extensive deep facial burns or burns inside the mouth; full-thickness circumferential neck burns; very large burns; difficulty swallowing; failing oxygenation or ventilation; reduced consciousness; and transfer without someone able to secure the airway on the way.
But markers of exposure are not indications in themselves. In a series of 416 intubated patients admitted to a US burns centre, 31% were extubated within a day and 40% within two; those short-intubation patients had much smaller burns, were more often intubated before arrival and had more often been burned outdoors, and none needed reintubation [23]. A later update from another US burns centre put the figure at 37.5% of pre-arrival intubations [24]. Outdoor flash injuries, which most firework burns are, fit that low-risk profile. For the exam: know the triggers, do not intubate for soot alone, and remember that when genuine doubt coincides with a long transfer, ATLS sides with the tube.
Cool the burn, warm the patient
Stopping the burning process is part of the primary survey, and cooling has genuine outcome data behind it. In 2,495 children at an Australian burns centre, 20 minutes of cool running water within three hours of injury was associated with lower odds of skin grafting (odds ratio 0.6) [25]. The counterweight, and the reason ATLS places temperature under E, is hypothermia. A child left under a cold shower for half an hour can arrive hypothermic. Cool the burn; warm the patient.
The case for the old arithmetic
The 11th edition is not simply progress, and the counter-argument is strong. The Parkland formula exists because, before it, burn patients died early of shock and renal failure, and under-resuscitation kills faster and less reversibly than over-resuscitation. Requirements are not uniform: in Shah's review, patients with inhalation injury received significantly more fluid than those without, 5.0 against 3.9 mL/kg/%TBSA [13]. In a multicentre analysis of patients resuscitated with Burn Navigator decision support, starting at 2 mL/kg/%TBSA did not increase mortality or complications, but it did not abolish shock either: 12% of the lowest-start group developed it, against none of the highest-start group, although the intermediate arms fared worse [26]. And the evidence behind the ABA recommendation is thin. The guideline panel found only 24 studies that met its criteria, and could not make recommendations about survival because the literature lacked studies of adequate size and quality [9].
Abandoning catch-up has its own risk. A patient who arrives four hours late having received nothing is already behind, and a starting rate that ignores the lost hours depends entirely on the team noticing a falling urine output and acting promptly.
The fair synthesis is that the formula only sets the opening bid. What determines outcome is whether someone measures urine output every hour and changes the rate in response; on that, both camps agree. ATLS has chosen the lower opening bid and the simpler clock because, in the hands of non-specialists at three in the morning, conservative and simple errors are easier to correct than generous and complicated ones. That is a defensible choice. It is not yet a proven one.
What this means for your ATLS exam
xABCDE first. Control catastrophic haemorrhage from blast-injured hands before anything else. Early hypotension in a burn patient means another cause; boluses are only a temporary measure for hypotension.
Before TBSA is known (probable burn of 20% or more): 500 mL/h at age 13 and over, 250 mL/h at 6 to 12 years, 125 mL/h at 5 years and under.
Adult thermal burns: 2 mL × kg × %TBSA. Electrical injury, any age: 4 mL × kg × %TBSA.
The clock: starting hourly rate is the 24-hour estimate divided by 16, with no adjustment for time since injury or fluid already given. Then titrate hourly to urine output.
TBSA: partial and full thickness only; erythema is excluded.
- Airway: intubate for the airway you predict, not for soot alone.
References
1. ITV News Meridian. Fifty two people injured and eleven arrested during Lewes Bonfire celebrations. 6 November 2026. https://www.itv.com/news/meridian/2026-11-06/fifty-two-people-injured-and-eleven-arrested-during-lewes-bonfire-celebrations
2. STV News. Seven people arrested across Scotland amid Bonfire Night disorder. 6 November 2026. https://news.stv.tv/scotland/seven-people-arrested-as-fireworks-thrown-at-emergency-services-and-police-car-set-alight-on-bonfire-night
3. Kirby J (PA Media). Firework warning as data shows rise in number of people admitted to hospital. ITV News, 31 October 2026. https://www.itv.com/news/2026-10-30/firework-warning-as-data-shows-rise-in-number-of-people-admitted-to-hospital
4. Kenny S. Are your children safe around fireworks? The Bonfire Night safety tips every parent needs to know. MadeForMums, 3 November 2026 (reporting Children's Burns Trust data). https://madeformums.com/news/family-news/bonfire-night-safety-tips-for-parents-families
5. IANS. 190 suffer firecracker, carbide gun-based eye injuries during Diwali: AIIMS Delhi. 29 October 2025. https://ianslive.in/190-suffer-firecracker-carbide-gun-based-eye-injuries-during-diwali-aiims-delhi--20251029145219
6. Nizamoglu M, Frew Q, Tan A, Band H, Band B, Barnes D, El-Muttardi N, Dziewulski P. The ten-year experience of firework injuries treated at a UK regional burns & plastic surgery unit. Ann Burns Fire Disasters. 2018;31(1):13–16. https://researchexperts.utmb.edu/en/publications/%C3%A9tude-sur-10-ans-des-br%C3%BBlures-par-feu-dartifice-trait%C3%A9es-dans-un-/
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8. ATLS 11 Overview and Compendium of Changes (20 pp., undated; publicly hosted copy, accessed 8 November 2026). Chapters 8 (Exposure and Environmental Threats), 9 (Thermal Injuries) and 23 (Ocular Trauma). https://machaonas.org/app/uploads/2026/10/ATLS-11-Compendium-of-Changes.pdf
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