Burns: Assessment, First Aid and Dressing

Why Burns Are Dangerous

In short: the skin is an organ. Burn it and you lose its protection, its fluid and its heat control — the burn keeps harming the casualty long after the flames are out.

What the skin does

• Protection — a barrier against germs and fluid loss.
• Thermoregulation — keeps body heat in.
• Excretion and sensation.
• Lose a large area and all four fail at once.

Complications to expect

• Infection — the burn destroys the skin barrier.
• Blisters → fluid loss. Large burns lose a lot of fluid → risk of shock and dehydration.
• Fluid loss is massive even without blisters — a 3rd-degree burn has no blisters but leaks heavily.
• Loss of skin, pain and swelling.
• Hypothermia — with no skin to hold heat, cooling a big area can chill the whole casualty. Cool extensive areas with care.
• Compartment syndrome — swelling under tight burnt skin squeezes muscles and vessels. Watch for it in burns and fractures.

Pain is a good sign: the nerves still work. A burn that does not hurt is deeper and worse.

Classifying Burn Depth

In short: the deeper the burn, the less it hurts and the longer it takes to heal. Depth decides first aid, dressing and whether the casualty needs a hospital.

The four degrees

• A typical 2nd-degree burn of the hand: red, moist, shiny surface with several blisters — and it hurts.
• A deep burn (3rd–4th degree): black, leathery tissue; the deepest parts feel nothing.

Healing times (SCMG 22nd ed.)

• Superficial 2nd degree: 7–10 days.
• Deep 2nd degree: about 3 weeks.

Estimating the Burnt Area

In short: the size of a burn is given as a percentage of body surface area (% BSA). It drives fluid replacement and the evacuation decision.

Rule of nines (adults)

• Palm method: the casualty’s own palm is about 1% of their body surface — handy for scattered or small burns.
• Count only 2nd degree or deeper (burns into the epidermis or beyond). A 1st-degree burn keeps the waterproof layers intact, so it loses very little fluid.

Children and the Lund & Browder chart

• Children have a bigger head and smaller legs than adults:
  • Infant / toddler: head 18%, each leg 13.5%.
  • Child: head 12%, each leg 16.5%.
• The Lund & Browder chart adjusts for age and is more accurate than the rule of nines. Use a burn chart if one is on board.

First Aid: Stop the Burning and Cool

In short: make the scene safe, stop the burning, then cool with running water for at least 20 min. Keep the rest of the casualty warm.

Approach

• Use the usual casualty routine: DR BBCFS → ABC → % — Danger, Response, Breathing, Bleeding/Burns, Consciousness, Fractures, Shock; then airway, breathing, circulation; then estimate the % BSA.
• Your own safety first.
• Keep assessing the casualty while the burn cools.

Clothing on fire (EFA manual V1.3)

1. A dry-powder extinguisher is by far the best way to put out burning clothing.
2. No extinguisher: lay the person down and smother the flames — wrap them in any material, or use a bucket of water or a hose.
3. Make sure all smouldering clothing is out.
4. Powder in the eyes does little or no harm — wash it out after the fire is out, while you cool the burns.

Cooling a thermal burn

1. Stop the burning process before anything else: remove the source and start cooling.
2. Cool water, about 15°C: run or pour it over the burn, or submerge the part and change the water every few minutes.
3. How long: current guidance is at least 20 min under running water. Figures you will meet: older guidance said at least 10 min; some sources say 30 min, and chemical burns need longer (see below).
4. Cooling still helps up to 3 h after the burn. Protected by a burn bag or medical cling film, cooling can go on for 30 min to 3 h — it improves healing time.
5. No suitable water? Use towels or cloths soaked in water or normal saline, changed every 2–3 min.
6. Burn-gel wraps only cool — they are not a dressing. For long soaking of a hand, put it in a plastic bag of water.

No ice, ice packs or refrigerated water — they cause more damage. Do not cool extensive burns over 15% BSA (SCMG 22nd ed.): hypothermia risk. Skin loss over 10% already carries a hypothermia risk from cooling — keep the rest of the casualty warm.

While you cool

• Remove rings, watches, belts and anything tight before the swelling starts.
• Remove clothing that is not stuck to the burn. Stuck clothing stays on — unless it is a chemical burn.
• When cooled: pat dry gently with a clean towel and cover with cling film.
• Elevate the burnt part and treat for shock.

Chemical, Electrical and Inhalation Burns

In short: each special burn has one extra rule — get the chemical off, find the exit wound, watch the airway.

Chemical burns on the skin

• Liquid chemical: remove all wet, contaminated clothing before cooling.
• Powder or solid chemical: brush it off downwind before removing clothing. Wear gloves — there is an inhalation risk.
• Wash time: alkali → 2 h (alkali soaks deeper, so about double the acid time) · acid → 1 h — or until the burning pain stops.
• Don’t wash the chemical over unaffected skin or into the other eye; don’t let water collect in the shoes.
• Look up the chemical in the MFAG and the IMDG Code, and check its MSDS. The dangerous-goods data sheet goes to hospital with the casualty.

Chemical in the eye

• Approach: DR BBCFS → ABC → TMAS.
• Spray, splashes or fumes cause redness and irritation.
• At the eye-wash station: flush with at least 1 litre of water for 20 min, burnt eye down so the water does not run into the other eye or onto the skin.
• Get medical help — some chemicals leave permanent damage. Always check the MSDS.

Electrical burns

• Current passes through the body: always look for both an entry and an exit wound (e.g. entry on the hand, exit on the foot).
• The damage along the internal path can be much worse than the skin suggests.
• Adapted routine:
  • Danger — is it safe? Is the power off?
  • Response — radio medical advice, casualty, AVPU.
  • Breathing — be ready for cardiac arrest.
  • Bleeding / Burns — treat.
  • Consciousness — AVPU.
  • Fractures — treat.
  • Shock — W.A.T.E.R.

The on-board rule given for electrical burns: do not cool or apply water.

Inhalation injury

• Burns to the airway cause swelling that can block the air flowing into the lungs.
• Suspect it after a fire in an enclosed space, with soot round the nose or mouth, singed nasal hairs or a hoarse voice.

Circumferential burns

• A burn that goes all the way round a limb, the chest or the neck.
• The burnt tissue tightens like a tourniquet: it can cut off circulation below (limb) or restrict breathing (chest).
• Monitor pulse, colour and sensation below the burn.
• Chest → escharotomy: surgical cuts through the rigid burnt tissue to let the chest move — a hospital procedure.

Dressing Burns on Board

In short: pain relief first, then a light, sterile, non-stick dressing agreed with TMAS. Protect the airway and genitals first and keep fingers apart.

Burns dressing kit

• Gloves (non-sterile nitrile) · sterile dressings · paraffin gauze (non-adherent) · burn gel · Biafine emulsion · saline for irrigation · bandages or net.
• Paraffin gauze brands: Paranet (10 × 10 cm, sterile, petroleum-jelly gauze) · Jelonet · Bactigras (antiseptic). Store flat below 25°C; external use only.
• Large burn → have an IV giving set ready for fluid replacement.

Never use Inadine (povidone-iodine non-adherent dressing) on burns. Prefer a dressing with diluted real honey or Vaseline.

Step by step

1. Pain relief before cleaning or dressing — tramadol or low-dose morphine, on radio medical advice.
2. Grease burns: clean first with mild soap and warm water.
3. Choose the dressing with TMAS: medical cling film, or honey, or petroleum (paraffin) gauze in strips + a sterile non-adherent pad.
4. Add absorbent padding and bandage lightly. The dressing must be light, sterile and non-fluffy — non-stick (silver-based types exist).
5. Priority, even in total-body burns: face (airway) and genitals first, then fingers and toes separately — burnt fingers and toes fuse together.
6. Dress large areas in small strips, or dressings cut in half side by side: each piece comes off on its own, with less pain.
7. Superficial burns can be left uncovered.
8. Elevate the part. Swelling rises for days — re-check the tightness of every dressing.

Products and when to change

• Alginate dressing with active honey (e.g. Algivon) — a honey option.
• Hydrocolloid dressings for closed 1st/2nd-degree burns: waterproof, stay on up to 7 days, never on an infected wound.
• Silver sulfadiazine cream for 2nd–3rd-degree burns — keep it in the fridge.
• Changing: sources differ. SCMG 22nd ed.: leave dressings undisturbed for 1 week. On-board practice: change daily for the first 2 days if the pads are soaked. Wash honey off with warm sterile water.
• At a change, dead tissue can be removed with tweezers until it bleeds slightly; salt-water baths of 2–3 min help.

Blisters

• Leave them intact. Remove only if:
  • the blister is over a joint;
  • the casualty cannot avoid lying on it;
  • the fluid is cloudy or bloody.
• Use sterile scissors.

Fluid Replacement: the Parkland Formula

In short: a big burn leaks fluid fast. Work out the 24-hour need with Parkland, give half in the first 8 h, and agree the route with TMAS.

The formula

Fluid in the first 24 h = 4 ml × % BSA burnt × weight (kg)

• Give half in the first 8 h (counted from the time of the burn), the rest over the next 16 h.
• Start it when the burn is 2nd degree or deeper AND over 20% BSA.
• Count only 2nd-degree or deeper burns in the % BSA.

Which fluid, which route

• Oral fluids are acceptable if the casualty can drink — keep a strict fluid in/out chart.
• Never plain water. Use water + salt + sugar, or oral rehydration salts, with whatever is on board.
• Polase (potassium + magnesium) is a useful add-on but has no sodium — don’t use it alone.
• IV: the clinical standard is Ringer’s lactate / Hartmann’s.
• Large area → IV or rectal infusion may be needed. IV access impossible (burnt skin, collapsed veins) → intraosseous (IO) route: a needle into the bone marrow, usually the upper tibia or the humerus; it delivers fluids and drugs like an IV.
• Whatever the route: treat for shock and give analgesics.

Infection and Evacuation

In short: serious burns need a hospital within hours; every burn needs watching for infection for days.

Hospital within 6 hours (SCMG 22nd ed.)

• 3rd-degree burns — especially those encircling the chest or a limb.
• Burns to the face, genitals or joints.
• Burns over 18% BSA in an adult or 10% in a child.
• Any burn to a risk area of the body → seek medical help at once.

Recognising an infected burn

• Fever · more pain · redness · swelling · enlarged lymph nodes · bad smell.
• Never ignore it: high risk of septicaemia → radio medical advice immediately.
• Treatment: antibiotics by mouth or injection (systemic), remove dead tissue, clean dressing changed every 2 days.