Burn assessment and treatment

A burn that looks minor at the scene can deepen over the following 24–48 hours if the initial cooling is wrong or the dressing traps heat. At the other extreme, a large partial-thickness burn covering more than 20% of body surface area will drive a person into hypovolemic shock through fluid weeping alone — without any visible bleeding. The right response in the first 30 minutes determines the outcome for everything that follows.

Educational use only

This page provides general educational information for emergency preparedness scenarios when professional medical care is unavailable. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider. Use this information at your own risk.

Stopping the burn process

Burns continue to damage tissue after the heat source is removed. Residual heat in clothing, jewelry, and the skin surface itself keeps cooking the tissue unless actively removed.

Move the victim away from the heat source. If the burn is chemical, glove up before touching them.
Remove burning or smoldering clothing as quickly as possible. If clothing is melted or fused to the skin, cut around the fused area and leave the adhered material in place — tearing it free removes viable tissue.
Remove rings, watches, bracelets, and any constricting jewelry from the affected limbs immediately. Burns swell fast and a ring that slides off now will require cutting off in 30 minutes.
For chemical burns, brush off any dry chemical powder with a dry cloth before water contact — adding water to certain dry chemicals (particularly alkalis like dry lime) activates an exothermic reaction that worsens the burn. Then flush with copious running water.

Electrical burns

Electrical burns require a disconnect-first approach — do not touch the victim until the power source is off. An electrical burn that looks like a small entry wound at the hand may have caused extensive internal muscle and vessel damage along the entire current path. Treat the visible burns, treat for shock, and transport priority — internal damage is not visible at the scene.

Cooling the burn

Correct cooling reduces burn depth, reduces pain, and improves healing outcomes. Incorrect cooling — particularly ice or very cold water — causes vasoconstriction, deepens the injury, and can cause hypothermia in large burns.

Run cool water at 59–68°F (15–20°C) over the burn surface for 20 minutes. Use a gentle stream — pressure is not needed and hurts.
Start within 30 minutes of the burn. Research shows meaningful benefit when cooling begins within 30 minutes; cooling after 3 hours provides minimal tissue protection.
Do not use ice, ice water, or any liquid below 50°F (10°C). Cold water causes vasoconstriction that deepens the burn boundary and increases tissue death.
Do not apply butter, oil, toothpaste, flour, or any household remedy. These trap heat, increase infection risk, and obscure wound assessment.
Do not apply ice packs directly. Even gel packs from a cooler can be too cold if applied without a barrier.
After cooling: cover the burn loosely with clean plastic wrap, a non-adherent dressing, or clean cloth while you complete the assessment. Do not use fluffy cotton — fibers stick to moist burn surfaces.

Field note

If you are treating a burn in a cold environment, balance cooling the burn against the risk of systemic hypothermia. For burns greater than 10% body surface area in a cold environment, limit active cooling to 10 minutes and then cover the patient aggressively. Hypothermia kills faster than the extra burn depth in these situations.

Burn depth assessment

Burn depth determines dressing strategy, fluid requirements, infection risk, and whether the wound needs professional care to heal without scarring. You must classify each burn before deciding how to treat it.

Superficial (first-degree)

Tissue involved: Epidermis only
Appearance: Red, dry, no blisters, skin intact
Sensation: Painful — very sensitive to air and touch
Example: Most sunburns, brief contact with hot surface
Treatment: Cool water, light moisturizer or aloe vera, no dressing needed, heals in 3–7 days without scarring

Superficial partial thickness (second-degree, shallow)

Tissue involved: Epidermis and upper dermis
Appearance: Red, moist, blistered, blanches white when pressed and refills
Sensation: Intensely painful — nerve endings are intact and exposed
Treatment: Non-adherent dressing; keep moist; change every 24–48 hours; heals in 10–21 days with minimal scarring

Deep partial thickness (second-degree, deep)

Tissue involved: Epidermis and deep dermis
Appearance: Red to pale pink, may be moist or slightly dry, blisters present, may blanch sluggishly or not at all
Sensation: Reduced — pain present but less acute than superficial partial
Treatment: Non-adherent dressing with antimicrobial cover; heals in 21–60 days with significant scarring; often requires grafting

Full thickness (third-degree)

Tissue involved: All skin layers destroyed, into subcutaneous fat
Appearance: White, brown, tan, or black; leathery or waxy texture; does not blanch
Sensation: Painless — nerve endings destroyed. Surrounding partial-thickness tissue will be painful.
Treatment: Cover to prevent infection and fluid loss; do not debride in the field; requires surgical grafting; transport priority

Fourth-degree

Tissue involved: Extends to muscle, tendon, or bone
Appearance: Charred, black; may expose underlying structures
Treatment: Field stabilization only. Cover. Prevent hypothermia. Transport as quickly as possible.

Depth decision grid

Depth	Color	Surface	Pain
Superficial	Red	Dry	Intense
Superficial partial	Red/pink	Moist	Intense
Deep partial	Pale pink/red	Dry-moist	Reduced
Full thickness	White/brown/black	Leathery	None
Fourth degree	Black/charred	May expose tissue	None

Depth	Blisters	Field prognosis
Superficial	None	Heals without care
Superficial partial	Yes, intact	Heals with dressing
Deep partial	Yes, may rupture	Needs antimicrobial cover; often scars
Full thickness	None	Requires grafting; transport
Fourth degree	None	Field stabilization only

Body surface area — Rule of Nines

Estimating the total body surface area (TBSA) burned is critical for two decisions: whether to initiate fluid resuscitation and when to transport.

For adults:

Body segment	%BSA
Head and neck	9%
Each arm (entire)	9%
Chest (anterior)	9%
Abdomen (anterior)	9%
Upper back	9%
Lower back and buttocks	9%
Each thigh (anterior + posterior)	9%
Each lower leg and foot	9%
Genitalia	1%

Palm rule: The patient's palm — not including fingers — represents approximately 1% BSA. Use this for irregular, scattered burns that don't map cleanly to body regions.

Pediatric adjustment: Children have proportionally larger heads and smaller legs. A child's head can represent up to 18% BSA; each leg as little as 13%. Use the Lund and Browder chart if available, or apply palm-rule estimation. Do not apply adult Rule of Nines to children under 10 — it will underestimate head burns and overestimate leg burns.

Major burn thresholds (transport priority)

A burn is classified as major — requiring the highest urgency of care — when any of these apply:

Partial-thickness burn > 20% BSA in adults (> 10% BSA in children under 10 or adults over 50)
Any full-thickness burn > 5% BSA
Burns involving face, hands, feet, genitalia, perineum, or major joints
Circumferential burns of limbs or chest (can restrict circulation or breathing)
Burns associated with inhalation injury
Electrical or chemical burns
Burns with concurrent significant trauma

Wound care by burn depth

Superficial burns

Superficial burns do not require dressings. Cool water, aloe vera gel or a fragrance-free moisturizer, and protection from sun exposure for 2 weeks. If blisters develop later, do not break them deliberately.

Partial-thickness burns

Glove up. Do not break intact blisters — the blister wall is a sterile barrier protecting the raw dermis underneath. A ruptured blister exposed to bacteria becomes an infected wound.
If a blister has already ruptured, trim the loose deflated blister skin with clean scissors — it has no remaining protective value and becomes a bacterial harbor.
Gently clean the wound surface with clean water or saline solution. Do not scrub.
Apply a non-adherent contact layer directly over the burn surface — Adaptic, Mepitel, or Telfa (not plain gauze, which sticks to moist burns and tears healing tissue on removal).
Add an absorbent secondary layer of gauze pads over the contact layer.
Wrap with a conforming bandage. Do not wrap too tightly — burns swell for 24–48 hours after injury.
Change the dressing every 24–48 hours. Each dressing change is an opportunity to reassess for infection.
If available, silver-containing dressings (Mepilex Ag, Aquacel Ag) reduce infection risk and cause less pain on removal than older silver sulfadiazine cream. Note: current evidence suggests modern moist wound dressings outperform silver sulfadiazine (SSD) for partial-thickness burns — SSD delays re-epithelialization and requires more frequent changes. If SSD is your only option, apply a thin layer with a gloved hand; do not use on the face.

Full-thickness burns

Cover with a dry, non-adherent dressing. Do not attempt to debride eschar (the dead leathery tissue) in the field — it is a barrier against bacterial invasion until surgical care is available.
Keep covered to minimize evaporative fluid loss.
Manage for hypovolemic shock — these wounds weep fluid continuously.
Do not apply topical antimicrobials directly to full-thickness burns in the field. The benefit is minimal and the risk of introducing contamination exceeds the benefit.

Circumferential burns — escharotomy

A circumferential full-thickness burn of a limb creates a rigid, non-elastic ring of eschar that can compress underlying vessels and nerves as swelling progresses — the equivalent of a tourniquet that tightens itself. Signs: pain on passive stretch of distal digits (early), loss of capillary refill, pallor, loss of pulse (late). An escharotomy — a surgical incision through the eschar to release the compression — is required. This is a trained provider procedure, but the recognition is not. If a circumferential limb burn is worsening despite correct management and distal signs are deteriorating, this is the cause and escalation is urgent.

Infection prevention and recognition

Burns are sterile at the time of injury. Bacterial colonization begins within 24–48 hours of the burn and progresses rapidly through the damaged tissue. The burn wound is a nutritious, moist, warm environment — ideal for bacterial growth.

Prevention steps

Change dressings every 24–48 hours using clean technique (gloves, clean work surface).
Do not use hydrogen peroxide or povidone-iodine directly on the wound surface — both are cytotoxic (they damage healing cells) at wound concentrations. Use saline or clean water for cleaning.
Keep the wound covered at all times between dressing changes.
For partial-thickness burns, silver-containing dressings provide sustained antimicrobial cover without the cytotoxicity of antiseptics.

Signs of infection

Sign	What it means
Wound color changes from pink/red to gray or green	Pseudomonas or Klebsiella infection — high-risk pathogens in burns
Increasing pain in a previously less-painful partial-thickness wound	Re-innervation (normal healing) OR — more importantly if sudden — infection
Expanding redness beyond the wound margin	Spreading cellulitis
Purulent discharge with odor	Bacterial colonization progressing to infection
Fever above 101°F (38.3°C)	Systemic infection response
Wound breakdown — previously closed areas reopening	Deep infection undermining wound bed

Antibiotics for burn infections

Oral antibiotics are not routinely indicated for burns without clinical signs of infection. When infection signs appear, amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 7 days is a reasonable first choice for outpatient management of an infected partial-thickness burn without systemic signs. For systemic infection signs (fever, confusion, spreading cellulitis), this exceeds field treatment capacity — transport priority.

Fluid resuscitation

Burns destroy the skin barrier that prevents fluid from evaporating and weeping from blood vessels. Large burns cause rapid fluid loss that drives hypovolemic shock — not from bleeding, but from plasma leaking into the burn and surrounding tissue.

When to initiate fluid resuscitation

Start aggressive oral or IV fluid replacement when any of the following apply: - Partial-thickness burns ≥ 15% BSA in adults - Partial-thickness burns ≥ 10% BSA in children - Any significant full-thickness burn

The Parkland formula (guidance for IV resuscitation)

The traditional Parkland formula provides a starting point for IV fluid volume:

4 mL × patient weight in kg × %BSA burned = total fluid (mL) for first 24 hours

Half of this volume is given in the first 8 hours from the time of the burn (not from when treatment started — if the burn happened 3 hours ago, the remaining first-8-hour volume compresses into 5 hours). The second half is given over the following 16 hours.

Current practice trends toward using the Parkland formula as a ceiling rather than a target, as aggressive resuscitation has caused abdominal compartment syndrome and orbital complications. Titrate to response: target urine output of 0.5 mL/kg/hr in adults (1.0–1.5 mL/kg/hr in children).

Example: An 80 kg (176 lb) adult with a 25% BSA partial-thickness burn needs approximately 4 × 80 × 25 = 8,000 mL (8 liters) over 24 hours — 4 liters in the first 8 hours, 4 liters over the next 16 hours.

Field fluid management without IV access

When IV access is unavailable: 1. If the patient is conscious and without abdominal injury, push oral fluids aggressively — electrolyte solution (oral rehydration solution, sports drink diluted to half-strength), not plain water. Plain water dilutes sodium and can trigger hyponatremia. 2. Monitor mental status, skin color, and capillary refill as indicators of volume status. 3. Signs of inadequate resuscitation: worsening tachycardia, confusion, pale or mottled skin, urine output dropping. 4. For burns over 20% BSA without IV access, oral resuscitation buys time but is not adequate definitive treatment — transport remains the priority.

Inhalation injury

Inhalation injury is present in approximately 20–35% of patients admitted to burn centers and significantly increases mortality. The airway can swell shut within hours of injury — faster than any burn wound can become life-threatening.

Recognizing inhalation injury

Suspect inhalation injury when ANY of these are present: - Burned in an enclosed space (building fire, car fire, tent fire) - Singed eyebrows or nasal hair - Sooty or carbonaceous (black-flecked) sputum - Hoarse voice or stridor (high-pitched wheeze on inhalation) - Facial burns involving the mouth, nose, or throat - Altered mental status at the scene (may indicate carbon monoxide poisoning) - Coughing up soot-stained material

Singed nasal hair alone is not sufficient for a definitive inhalation injury diagnosis, but combined with any other sign, it is an indicator of significant airway heat exposure.

Inhalation injury management

Position upright — sitting forward reduces dependent airway swelling. Do not lay a suspected inhalation injury patient flat unless unconscious or in spinal precautions.
Administer supplemental oxygen if available — high-flow oxygen at 15 L/min via non-rebreather mask. This also treats carbon monoxide poisoning by accelerating CO elimination.
Do not leave the patient unattended — airway changes can be rapid. What is a hoarse voice at the scene can become stridor within an hour and aphonia (inability to make any voice) within two hours.
Do not attempt field intubation without training — blind attempts in a thermally injured, edematous airway can complete an obstruction that was previously partial.
Inhalation injury is a transport emergency, not a field manageable condition.

Carbon monoxide poisoning

Carbon monoxide (CO) poisoning accompanies many building and vehicle fires. CO has an affinity for hemoglobin 200 times higher than oxygen — it displaces oxygen from red blood cells without visible signs in the blood.

Signs of CO poisoning: headache, confusion, weakness, nausea, bright cherry-red lips or skin (unreliable sign — often absent), unconsciousness. A patient who was confused at the fire scene and is now alert may have had significant CO exposure that has partly resolved — watch them closely.

Field treatment: remove from exposure, give high-flow oxygen, transport.

Escalation criteria — when to transport

Transport immediately (do not attempt field management beyond stabilization) when: - Any full-thickness burn is present - Partial-thickness burns > 20% BSA in adults, > 10% in children or adults over 50 - Burns to face, hands, feet, genitalia, major joints - Circumferential burns (any body part) - Suspected inhalation injury - Chemical or electrical burns - Patient showing signs of shock (tachycardia, confusion, pale/clammy skin) - Burns complicated by trauma (fractures, major wounds)

Burn kit contents

Item	Use
Non-adherent dressings (Telfa, Adaptic, Mepitel)	Contact layer for partial-thickness burns
Silver-containing dressings (Mepilex Ag, Aquacel Ag)	Antimicrobial cover, moist healing
Conforming gauze rolls (Kerlix)	Secondary absorbent and wrap layer
Sterile gauze pads 4"×4" (10×10 cm)	Absorptive layer
Medical tape	Securing dressings
Nitrile gloves	Universal precautions
Clean plastic wrap (cling film)	Emergency sterile cover, transport
Oral rehydration salts (ORS)	Fluid resuscitation without IV access
Ibuprofen 200 mg tablets	Pain management
Acetaminophen 500 mg tablets	Pain management (stagger with ibuprofen)

Burn care checklist

Burn care does not end after the first dressing. The daily inspection and clean dressing change is where infections are caught, fluid management is adjusted, and healing is monitored. For managing infection that develops from a burned wound, the infection page covers the escalation protocol, and for managing the shock state that large burns can trigger, see shock. When triaging multiple casualties, use the triage Simple Triage and Rapid Treatment (START) system to prioritize burns — RED if airway involvement or greater than 25% BSA, YELLOW for significant but stable partial-thickness burns without airway or systemic signs.