Burns & Thermal Care

Burn Injuries

Burns and Thermal Injuries

Burn injuries may result from many different sources, and their appearance, severity, and effect on the body depend on the type of burn, temperature involved, duration of exposure, and amount of tissue affected.

Young children and older adults are at greater risk of serious complications from burns. Factors such as age, existing medical conditions, skin thickness, protective clothing, and the length of exposure can influence the severity of the injury.

Burn patients should also be evaluated carefully for airway injury, breathing problems, and hypoxia, especially when the burn occurred in an enclosed space where smoke or toxic gases may have accumulated.

Unusual burn patterns may raise concern for possible abuse, particularly in children, older adults, or dependent individuals. Suspicious findings may include patterned contact burns, unusual scald distributions, or burns involving protected areas such as the genitals, buttocks, or thighs.

Structure and Function of the Skin

The skin is the body’s largest external protective barrier. Burn injuries may damage one or more layers of the skin and interfere with several important functions.

The skin helps:

Layers of the Skin

Epidermis

The epidermis is the outermost layer of the skin. It acts as the body’s first barrier against the external environment.

Important characteristics include:

Dermis

The dermis lies beneath the epidermis and is stronger and more elastic.

It contains:

Because the dermis contains sensory nerves and blood vessels, burns extending into this layer may cause significant pain and fluid loss.

Subcutaneous Tissue

The subcutaneous layer, also called the hypodermis, lies beneath the dermis.

It mainly contains fatty tissue that:

Major Types of Burns

Thermal Burns

A thermal burn occurs when tissue is exposed to excessive heat. Tissue damage develops when the heat absorbed by the body exceeds the tissue’s ability to dissipate it.

The severity of a thermal burn depends on:

Flame Burns

Flame burns result from direct exposure to fire.

These injuries may:

Any patient burned in an enclosed space should be carefully evaluated for inhalation injury.

Scald Burns

Scald burns result from exposure to hot liquids. They are especially common in young children but can occur at any age.

Scald injuries may:

Hot liquid should be removed from contact with the skin as soon as safely possible.

Hot Oil and Grease Burns

Hot oils and grease may produce particularly deep thermal injuries because they:

Because of prolonged contact, these burns may be deeper than ordinary hot-water scalds.

Contact Burns

A contact burn occurs when the skin directly touches a hot object.

Examples include hot metal, cookware, heating equipment, or other heated surfaces.

Brief contact may result in a small localized burn, while prolonged contact can produce deeper tissue destruction. Patients who cannot quickly move away from the heat source may sustain more severe injuries.

Steam Burns

Steam may cause thermal injury when hot vapor contacts the skin or respiratory tract.

Steam burns can:

Flash Burns

Flash burns occur after brief exposure to an intense source of heat.

They are commonly associated with:

Although exposure may be brief, flash burns can affect large exposed areas of skin and may be associated with airway, eye, or blast injuries.

Chemical Burns

Chemical burns occur when tissue is exposed to a harmful chemical substance. The severity of the injury depends on the type and concentration of the chemical, its physical state and temperature, duration of exposure, and how deeply it penetrates the tissues.

Different chemicals damage tissue in different ways:

Chemical exposure should be stopped as quickly and safely as possible while preventing contamination of rescuers.

Airway and Inhalation Burns

Inhalation injury can rapidly become life-threatening because swelling or tissue damage may compromise the patient’s airway.

Heat, smoke, steam, and toxic chemicals can injure different areas of the respiratory system. Superheated gases usually affect the upper airway, while steam and inhaled chemicals may penetrate farther into the lower respiratory tract.

Possible findings include:

Airway swelling may worsen over time, so patients with suspected inhalation injury require frequent reassessment.

Smoke Inhalation

Smoke inhalation can cause injury through several mechanisms at the same time. A patient may experience:

Enclosed-space fires are especially concerning because concentrations of smoke and toxic gases can become very high.

Carbon Monoxide Exposure

Carbon monoxide (CO) is a colorless and odorless gas produced by incomplete combustion. It binds strongly to hemoglobin and interferes with the blood’s ability to transport oxygen effectively.

CO exposure may produce:

A standard pulse oximeter may show an apparently normal oxygen saturation even when significant carbon monoxide poisoning is present because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin.

Some specialized devices can estimate carboxyhemoglobin levels, but clinical assessment and definitive testing remain important when CO exposure is suspected.

Chemical Inhalation Injuries

The effects of inhaled chemicals partly depend on how easily the substance dissolves in water and therefore where it reacts within the respiratory tract.

Highly Water-Soluble Chemicals

These substances tend to react quickly with the moist surfaces of the upper airway and may cause:

Moderately Water-Soluble Chemicals

These agents may affect both upper and lower respiratory structures. Symptoms can develop progressively depending on the concentration and duration of exposure.

Poorly Water-Soluble Chemicals

These substances may travel deeper into the lungs before causing significant irritation.

Because of this, patients may initially appear relatively well but later develop:

Anyone with significant chemical inhalation should be monitored carefully for delayed respiratory deterioration.

Electrical Injuries

Electrical burns can cause extensive internal damage even when the external wounds appear small. The severity depends on several factors, including the strength and type of current, duration of contact, resistance of the tissues, and pathway of the electricity through the body.

Electric current tends to travel through tissues that conduct electricity effectively, including blood vessels, nerves, and muscles. This can produce injury well below the skin surface.

Possible complications include:

External electrical injuries may include contact wounds where the current entered or exited the body, although obvious entrance and exit wounds are not always present.

Because severe internal damage may be hidden, electrical injuries should be treated as potentially serious even when the skin findings appear minor.

Types of Electrical Burn Injury

Electrical Conduction Injury

A conduction injury occurs when electrical current travels directly through the body.

Damage may be concentrated at contact points but can also extend along the current’s path through deeper tissues. The visible surface burn may underestimate the degree of underlying injury.

Electrical Arc or Flash Injury

An arc-flash injury occurs when electricity travels through the air between an electrical source and another conductive surface.

The resulting heat can be extremely intense and may cause:

Direct passage of current through the body may or may not occur.

Electrical Flame Burn

A flame burn occurs when an electrical source ignites the patient’s clothing or nearby combustible materials.

In this situation, the resulting injury is primarily a thermal flame burn, although electrical injury may also be present depending on the circumstances.

Important Assessment Considerations

Patients with significant electrical injury require evaluation beyond the visible skin damage. Important concerns include:

The external appearance of an electrical burn should never be used alone to estimate the severity of internal injury.

Lightning Injuries

Lightning strikes are uncommon electrical events, but they can produce severe or immediately life-threatening injuries because of the extremely high amount of energy involved. Although contact with lightning usually lasts only milliseconds, significant cardiac, respiratory, neurologic, and tissue injury may occur.

Possible complications include:

In some patients, normal cardiac activity may return before spontaneous breathing does. Because of this, respiratory support may remain necessary even when circulation has been restored.

Lightning Safety

Prevention is the most effective way to reduce lightning-related injury. During a thunderstorm, people should seek shelter inside a substantial building or enclosed vehicle and avoid open areas, isolated tall objects, trees, metal structures, and other good electrical conductors.

Radiation-Related Injuries

Radiation injuries are uncommon but may occur in industrial facilities, medical environments, transportation incidents involving radioactive materials, or other hazardous-material events.

The severity of injury depends on factors such as the type of radiation, dose received, distance from the source, and duration of exposure.

Different forms of radiation penetrate tissue to different degrees:

Scene safety is especially important whenever radioactive material may be present. EMS personnel should avoid unnecessary exposure and use appropriate protective procedures and specialized hazardous-material resources when indicated.

Acute Radiation Syndrome

Acute radiation syndrome (ARS) may develop after a significant whole-body or large-area exposure to penetrating radiation over a short period.

It can affect several body systems, particularly:

Early symptoms may include nausea, vomiting, weakness, and fatigue. The time between exposure and the onset of symptoms can help indicate the severity of exposure.

Vomiting that develops very soon after a known major radiation exposure may suggest a higher absorbed dose and should increase concern for serious radiation injury.

Because some effects may not become obvious immediately, patients with significant suspected exposure require specialized evaluation and continued monitoring.

Localized Radiation Skin Injury

Radiation exposure may also cause localized damage to the skin and underlying tissues.

Early changes may resemble:

More severe exposure may later produce blistering, tissue breakdown, or necrosis. Skin findings may be delayed for hours, days, or even longer, depending on the radiation dose and type of exposure.

Burn Depth Classification

Burn injuries are commonly classified according to how deeply tissue has been damaged.

Superficial Burns

A superficial burn, historically called a first-degree burn, affects only the epidermis.

Typical characteristics include:

Because the deeper skin structures remain intact, these burns generally heal without major scarring.

A common example is a mild sunburn.

Partial-Thickness Burns

A partial-thickness burn, traditionally called a second-degree burn, involves the epidermis and part of the dermis.

These injuries are often very painful because many nerve endings remain functional.

Partial-thickness burns can be divided into two general categories.

Superficial Partial-Thickness Burns

These burns extend into the upper dermis but preserve much of the deeper skin structure.

Common findings include:

Healing often occurs within a few weeks when complications such as infection do not develop.

Deep Partial-Thickness Burns

Deep partial-thickness burns extend farther into the dermis and damage more of the skin’s underlying structures.

They may involve:

The skin may appear pale, mottled, red, or waxy. Sensation may be decreased in deeper areas because nerve endings have been damaged.

Deep partial-thickness burns may result from hot liquids, steam, grease, prolonged contact with heat, or other intense thermal exposures. They can sometimes be difficult to distinguish from full-thickness burns based only on appearance.

Full-Thickness Burns

A full-thickness burn, historically called a third-degree burn, destroys the entire epidermis and dermis and may extend into the subcutaneous tissue.

The skin’s ability to regenerate is greatly reduced because important structures within the dermis have been destroyed.

Possible appearances include:

The center of a full-thickness burn may have little or no pain because sensory nerves have been destroyed. However, surrounding areas with partial-thickness injury may remain extremely painful.

Full-thickness burns are serious injuries that usually require specialized burn care and may require surgical treatment such as excision and skin grafting.

Circumferential Burn Injuries

A circumferential burn completely surrounds an area of the body, such as the neck, chest, abdomen, arm, or leg. These injuries are especially concerning because progressive swelling beneath stiff burned tissue can interfere with breathing or circulation.

Important complications include:

Patients with significant circumferential burns require prompt transport for definitive burn evaluation and treatment.

Determining Burn Severity

Burn severity depends on more than the depth of the injury. Providers should also consider the total body surface area (TBSA), location of the burn, age of the patient, mechanism of injury, associated trauma, and underlying medical conditions.

Burns involving the face, hands, feet, genitalia, major joints, or airway are particularly concerning because even relatively small burns in these locations may cause serious functional complications.

More Serious Adult Burns

Burns should receive a higher level of concern when they involve:

Large or complex burns generally require consultation with or transport to a burn center or other appropriate specialty facility according to local protocols.

Pediatric Burn Severity

Children have different body proportions and less physiologic reserve than adults, so burns can become serious with a smaller absolute area of injury.

Important pediatric concerns include:

Young children can lose heat and fluid rapidly and should be monitored closely for hypothermia and shock.

Burn Shock

Extensive burns can produce systemic effects far beyond the injured skin. Damage to the capillaries causes fluid and proteins to shift from the bloodstream into surrounding tissues, leading to substantial edema and reduced circulating blood volume.

This process may affect multiple systems, including the:

As circulating volume decreases, the body attempts to compensate through tachycardia and peripheral vasoconstriction. If fluid losses continue, tissue perfusion worsens and burn shock may develop.

Other effects may include:

Patients may also experience pain, chills, nausea, weakness, or altered mental status as the burn injury becomes more severe.

Estimating Total Body Surface Area

The total body surface area (TBSA) estimate describes the percentage of the body affected by significant burns. In most burn calculations, superficial burns are not included; partial-thickness and full-thickness burns are used when estimating TBSA.

Rule of Nines for Adults

For adults, the body can be divided into areas that represent approximately multiples of nine:

For example, a burn involving the entire right arm and the entire anterior trunk would involve approximately 27% TBSA.

Children and Infants

Children have proportionally larger heads and smaller legs than adults, so the adult Rule of Nines is less accurate.

Approximate age-based values may be used for a quick estimate, but the Lund-Browder chart is more accurate because it adjusts percentages according to the patient’s age.

In general:

Palm Method

For scattered or irregular burns, the patient’s hand can provide a quick estimate.

The patient’s entire hand, including the fingers, is approximately 1% of TBSA. This technique can be useful when the burned areas are small or distributed unevenly.

Initial Management of Burn Patients

Scene Safety

Responder safety comes first. Before approaching the patient:

Major burn patients should not remain on scene longer than necessary when rapid transport is indicated.

Airway and Breathing

Airway injury can worsen rapidly as swelling develops. Burns involving the face, neck, mouth, or enclosed-space smoke exposure should increase concern for inhalation injury.

Assess for:

Provide oxygen and ventilatory support when indicated. Early advanced airway management may be necessary when progressive airway swelling is suspected, because later intubation can become extremely difficult.

Circulation

Assess circulation and look for signs of shock.

Important measures include:

Burn Wound Care

After the burning process has stopped:

Rapid transport to the appropriate trauma or burn facility is important for patients with extensive, deep, airway-related, electrical, chemical, circumferential, or otherwise complicated burns.

Airway Considerations

Airway problems can progress quickly after major burns, particularly when the face, neck, or respiratory tract is involved. Patients who require an endotracheal tube (ETT) need frequent reassessment because swelling and secretions can interfere with ventilation.

Important concerns include:

Early recognition of a threatened airway is important because advanced airway placement becomes more difficult as swelling increases.

Fluid Replacement After Major Burns

Large burns produce significant movement of fluid from the bloodstream into damaged tissues. This can lead to hypovolemia, edema, and burn shock.

Patients with extensive burns may require IV fluid replacement, particularly during the first 24–48 hours after injury.

Prehospital priorities include:

Parkland Formula

The Parkland formula is one method used to estimate the amount of crystalloid fluid required during the first 24 hours following a major burn.

Formula:

4 mL × body weight in kilograms × %TBSA burned

Only partial-thickness and full-thickness burns are normally included in the TBSA calculation.

Half of the calculated fluid is given during the first 8 hours from the time of the burn, not from the time treatment begins. The remaining half is generally administered during the following 16 hours.

Example

For a patient weighing 86 kg with burns covering 49% TBSA:

4 mL × 86 × 49 = 16,856 mL

Estimated fluid for the first 24 hours:

The formula is only a starting estimate. Actual fluid administration is adjusted according to the patient’s response and local burn-management protocols.

Pain Control

Burns can cause severe pain, especially partial-thickness injuries where sensory nerves remain intact.

Pain management should include:

Opioid medications such as fentanyl or morphine may be used when indicated and permitted by protocol.

When Specialized Burn Care Is Needed

Criteria for transfer to a burn center vary by system, so local protocols should always be followed.

Situations commonly requiring burn-center consultation or transfer include:

Care Based on Burn Type and Depth

Thermal Burns

The first priority is to stop the burning process and remove the patient from the heat source.

Afterward:

Large burns should not be continuously soaked or covered with excessively wet dressings because this can contribute to hypothermia.

Superficial Burns

For small superficial thermal burns, gentle cooling soon after injury may reduce pain and limit further heat injury.

Care may include:

Avoid extremely cold water or ice directly on burned tissue.

Partial-Thickness Burns

Partial-thickness burns are often very painful and may form blisters.

Management includes:

Full-Thickness Burns

Full-thickness burns destroy the entire epidermis and dermis. The center of the injury may be painless because nerve endings have been destroyed, while surrounding areas may remain extremely painful.

Prehospital care includes:

Thermal Inhalation Injury

Heat and smoke can injure the airway even when external burns appear limited.

Patients should be assessed for:

Early advanced airway management may be necessary if progressive swelling threatens airway patency.

Chemical Burns of the Skin

Chemical burns continue until the substance has been removed or neutralized through appropriate decontamination.

Important steps include:

Chemical-specific instructions take priority because certain substances react dangerously with water.

Chemical Inhalation Injury

Inhaled chemicals may irritate or burn the respiratory tract and can produce delayed swelling or pulmonary edema.

Care focuses on:

Significant inhalation exposures require prompt medical evaluation even if symptoms initially appear mild.

Chemical Burns to the Eyes

Chemical eye exposure requires immediate irrigation.

Care includes:

Do not delay irrigation while searching for a specific neutralizing solution.

Electrical Burns

Electrical injury may cause severe internal damage despite minor skin findings.

Assessment should focus on:

Patients with significant electrical exposure may require cardiac monitoring and rapid transport.

Lightning Injury

Lightning can cause immediate cardiac and respiratory arrest. If cardiac activity returns, respiratory paralysis may sometimes persist, making continued ventilatory support essential.

Associated trauma and spinal injuries should also be considered.

Radiation-Related Injury

Radiation incidents require careful attention to scene safety and contamination control.

Prehospital priorities include:

External contamination and radiation exposure are not the same; a patient who has been exposed to radiation is not necessarily radioactive.

Hospital-Based Burn Care

Definitive burn treatment begins with stabilization and continues throughout hospitalization and rehabilitation.

Initial hospital management may include:

Wound Management

Severe burns may require removal of damaged tissue and surgical wound coverage.

Depending on the injury, treatment may include:

Rehabilitation

Burn recovery often continues long after the wound itself has healed.

Rehabilitation may include:

The long-term goal is to preserve function, mobility, independence, and quality of life while helping the patient return as fully as possible to normal daily activities.