You are dispatched to Jack, a 3-year-old with a burn. When you arrive, you’re told by Jack’s frantic mother that she turned her head for a second in the kitchen and Jack pulled a pot of boiling water off the counter, spilling hot water on his left arm and upper chest. Jack is crying in pain. Jack’s mother asks what his treatment will be and whether this will leave a permanent scar. You’re not sure how to answer.
About Sirens to Scrubs
Sirens to Scrubs was created with the goal of helping to bridge the disconnect between pre-hospital and in-hospital care of emergency patients. The series offers in-hospital providers a glimpse into the challenges and scope of practice of out-of-hospital care while providing pre-hospital providers with an opportunity to learn about the diagnostic pathways and ED management of common (or not-so-common) clinical presentations. By opening this dialogue, we hope that these new perspectives will be translated into practice to create a smoother, more efficient, and overall positive transition for patients as they pass through the ED doors.
- Review the classifications of thermal burns
- Review the management of thermal burns
Why do we care about minor burns?
Apart from the fact that even minor burns are very, very painful and can leave unsightly scars, burns compromise the basic functions of skin. The three functions of skin include:
- Thermoregulation: preventing the loss of heat from the body
- Control of fluid loss: preventing dehydration and shock
- Providing a protective barrier against microbial infiltration: preventing infection
By exposing skin to excessive heat, skin cells are damaged and die, resulting in the compromise of these functions. These factors, taken together, are what necessitate the prompt and appropriate management of burns.1
There are several different types of burns, including thermal, chemical, radiation and electrical burns. This article will focus on the presentation and management of thermal burns, which are burns sustained from contact with hot objects (including things like fire and boiling water).
How (and why) do I classify my patient’s burn?
Firstly, burns can be classified based on their depth. Previously, the nomenclature was based on the “degree” of the burn, with first-degree burns being the least serious, and third-degree burns being the most serious. We are moving away from this terminology toward a more physiology-based nomenclature. The physiology-based nomenclature depends on which anatomic layer of the skin is affected.2
|Superficial thickness (previously first-degree burns)||Red, no blisters. |
Looks like a sunburn.
|Epidermis (most superficial layer of the skin, <1mm in most areas).||1 week to heal.|
Does not need grafting.
Unlikely to scar
|Superficial partial thickness (previously second-degree burns)||Red and blanchable with blisters. |
|Upper dermis.||1-2 weeks to heal.|
Does not need grafting.
|Deep partial thickness (previously second-degree burns)||Red or white without blisters.|
May or may not blanch.
|Deeper dermis.||2-3 weeks to heal.|
May require grafting.
|Full thickness (previously third-degree burns)||Leather-like, charred.|
Does not blanch with pressure.
|Subcutaneous tissue (muscles, bones, connective tissues).||More than 3 weeks to heal.|
Will need grafting.
Secondly, burns are classified based on size. Size of a burn matters because it is correlated with mortality.1 Traditionally, burns were classified using the Rule of 9s, which splits the body into segments that are 9% of the patient’s total body surface area (TBSA). Only burns that are superficial partial thickness or deeper should be included in this estimate.
This works quite well for adults with large burns. For children, we can use the modified Rule of 9s, or the more accurate Lund-Brower Chart, in which proportions change depending on age.
For smaller burns, it is more accurate to use the surface of the patient’s palm (fingers included) to estimate 1% TBSA.
Using depth and size, we can classify burns as minor, moderate or severe. Minor burns include partial-thickness burns <5% TBSA in children and elderly, and <10% TBSA in adults, and full-thickness burns <2% TBSA. Furthermore, in order to be a minor burn, the burn must be an isolated injury (i.e. no suspicion of inhalation or high-voltage injury), it mustn’t involve the face, hands, perineum or feet, it mustn’t cross major joints, and it mustn’t be circumferential (or wrap all around a part of the body).
Putting all this together: both depth and extent of the burn are important because they will determine the management, prognosis and disposition.1 As mentioned, location of the burn is important as well: a burn to the face is much more serious than, say, a burn to the leg.
How do I treat a burn in the pre-hospital setting?
Disclaimer: This section focuses around the rationale behind burn therapy rather than specifics. The numbers in this section are based on guidelines for EMS in Ontario. We always recommend following local protocols.
When assessing a burn, it is important to remember your general trauma assessment. Do not let the alarming appearance of a burn distract you from the fact that the patient may have a compromised airway, might not be breathing or have a pulse, or may have other serious injuries. Once you are confident that the patient is stable with no other injuries, you can focus on the burn.
- Start by clearing the area around the burn: remove any clothing, non-adherent debris, or anything that might be retaining heat (including jewelry).
- Next, cool the burn. Run cool tap water over the burn until pain diminishes. Evidence suggests that cool running water for 20 minutes total (including any time spent cooling prior to EMS arrival) within 3 hours of a burn is associated with decreased depth of burn and need of grafting in children.3 This provides rationale for spending some time on scene when there are no other serious injuries present. If you cannot stay on scene due to other injuries, it is appropriate to apply cold-water-soaked gauze to the site of the wound for < 30 minutes. Do not use ice, as ice can increase pain and burn depth. Ontario’s BLS Patient Care Standards recommends that burns <15% TBSA should be cooled for < 30 minutes. Any longer, or for larger burns, there is an increased risk of hypothermia. If the patient begins shivering or becomes hypotensive: stop cooling.
Given that the skin prevents heat loss and its damage compromises this function (along with the fact that you are cooling the burn), it is important to keep the patient warm to prevent hypothermia.
- Then, dress the wound with a sterile dressing to protect the open wound from bacteria.
For superficial burns: cover the burn with moist dressing.
For partial thickness burns: if <15% TBSA: use moist dressing, if ≥15% TBSA: use dry sterile dressing.
For any full thickness burns: use dry dressing.
If the burn involves the hands be sure to dress the digits separately to prevent them from adhering to each other.
- Treat your patient’s pain in a relatively aggressive manner. Why? Burns hurt. There is direct stimulation of nociceptors (pain receptors) in skin. Treating pain early and aggressively is associated with improved psychological outcomes, and (for reasons that are not entirely clear) improved healing.4,5 Options include acetaminophen, NSAIDs, opiates, or any other analgesia available in your region. It’s reasonable to have a pretty low threshold for use of opiates in burns. These can be titrated to match the patient’s pain.1
- Finally, prepare for fluid replacement, a key aspect of burn management. Burns result in large losses of fluid because of fluid loss through the disrupted epidermal barrier, and fluid shifts out of capillaries due to increased permeability.1 Thus, fluid replacement is essential to prevent hypovolemic shock. IV fluid through 2 large bore IVs is recommended for patients with large burns (>20% TBSA in adults or >10% TBSA in children) – i.e. this won’t apply for mild burns but is important to think about.
Fluid replacement over the first 24 hours post-burn is often estimated using the Parkland formula. Remember that TBSA doesn’t include superficial thickness burns.1
Fluids in first 24 h = (4mL Lactated Ringer) x (body weight in kg) x (%TBSA)
½ of the fluid will be given over the first 8 hours, and the other ½ over the following 16 hours.
Onto the hospital: will my patient be transferred to a burn centre?
Consideration for transfer to a burn centre generally depends on the province. In Ontario, the following factors are considered when deciding whether to send a patient to a burn centre:6
- ≥20% TBSA partial and/or full thickness at any age
- ≥10% TBSA partial and/or full thickness for ages ≤10 and ≥50
- Full thickness burns ≥5% TBSA at any age
- Inhalation + partial and/or full thickness burns ≥5% TBSA
- Children with burn injury presenting to a hospital that does not have appropriate equipment or qualified personnel to provide care for children
- All electrical and chemical burns
- Burns to hands, face, feet, joints, genitalia, perineum
- Burns with comorbidity
- Burns with patients who require special social, emotional or rehabilitation care.
Will my patient need antibiotics?
Prophylactic systemic antibiotics are not indicated in acute burns! Topical antibiotics can be used in partial- or full-thickness burns. Tetanus, on the other hand, must be up to date in any patient with a burn.7
What are some other things to consider on this type of call?
It’s prudent to always consider physical abuse and non-accidental injuries, especially in vulnerable populations like children or elderly. Things that might suggest a non-accidental injury include: scald burns with sharply demarcated edges, burns in the shape of an object, small circular burns matching a cigarette tip, and burns in the perineal area matching a “dip in” pattern (such as a child dipped into scalding water).7 Although the nature of the burn will generally not affect your immediate management, it is important to keep in mind when considering the safety of your patient and follow local child- or elder-protection protocols. A high degree of suspicion would be important to pass along to the next care provider.
Circumferential burns (especially if full-thickness) are concerning. The thick, leathery burned tissue (in combination with increased swelling of underlying tissue), if wrapped around a limb, can cause compression of the tissues and lead to a compartment syndrome. Compartment syndrome occurs when there is decreased blood flow and ischemia to tissues due to increased pressure in the tissues. This can result in limb loss. It is corrected with escharotomy, in which the tough, leathery burned tissue is cut open to relieve pressure in the compartment, allowing for blood flow.1,7
Always consider inhalation injuries in burns – either burns to the upper airway structures or inhalation of toxic chemicals, such as carbon monoxide or cyanide – especially if sustained due to a fire in an enclosed space. Be liberal with giving high-flow oxygen in these scenarios.
You rinse Jack’s burn with cool tap water for 20 minutes, at which point the pain seemed to improve. The burn is red and you notice some areas of blistering, so you classify the burn as superficial partial thickness. Using Jack’s palm size as an estimate, you classify the burn as 3% TBSA. Based on this, you correctly identify this as a minor burn. You dress his wound with moist dressing and provide acetaminophen to manage the pain. At the hospital, his tetanus status was confirmed, and he was not given any antibiotics. His burn will likely heal with minimal long-term scarring.
This post was copyedited by @SneathPaula
- 1.Singer AJ, Lee CC. Thermal Burns. In: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:715-723.
- 2.Helman A, Fish J, Ivankovich M, Kovacs G. Burn and Inhalation Injuries: ED Wound Care, Resuscitation and Airway Management. Emergency Medicine Cases. Published online May 21, 2020.
- 3.Griffin B, Frear C, Babl F, Oakley E, Kimble R. Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children. Ann Emerg Med. 2020;75(1):75-85. doi:10.1016/j.annemergmed.2019.06.028
- 4.Griggs C, Goverman J, Bittner E, Levi B. Sedation and Pain Management in Burn Patients. Clin Plast Surg. 2017;44(3):535-540. doi:10.1016/j.cps.2017.02.026
- 5.Christian L, Graham J, Padgett D, Glaser R, Kiecolt-Glaser J. Stress and wound healing. Neuroimmunomodulation. 2006;13(5-6):337-346. doi:10.1159/000104862
- 6.Burns Centre Consultation Guidelines. Critical Care Services Ontario. Published 2019. Accessed March 20, 2020. https://www.criticalcareontario.ca/EN/Documents/BurnCentreConsultationGuidelines_2019-EN.pdf
- 7.Wiktor A, Richards D. Treatment of Minor Thermal Burns. UpToDate. Published December 9, 2019. Accessed March 8, 2020. https://www.uptodate.com/contents/treatment-of-minor-thermal-burns?