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Burns — Thermal and Chemical

Category: Trauma Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06

Overview

Burns are tissue injuries from thermal (heat, flame, steam, hot liquids), chemical (acids, alkalis, industrial chemicals), electrical, or radiation sources. Severity is determined by depth (superficial/partial/full thickness), total body surface area (TBSA), location (face/airway, hands, feet, genitalia, circumferential), and patient age/comorbidities. Airway burns and large TBSA burns are immediate life threats.

Key Points

Burn depth: - Superficial (1st degree): Epidermal only; red, painful, no blisters (sunburn). Not included in TBSA calculation. - Partial thickness (2nd degree): Epidermis + dermis; red, moist, blisters, painful — indicates nerve endings intact - Full thickness (3rd degree): All skin layers + may involve subcutaneous tissue, muscle, bone; leathery, dry, waxy or charred black/gray; may be painless (nerve endings destroyed)

TBSA estimation (see rule-of-nines for full reference including pediatric modifications and Lund-Browder): - Rule of Nines (adults): Head 9%, each arm 9%, chest 9%, abdomen 9%, each upper leg 9%, each lower leg 9%, back 18%, perineum 1% - Palmar method: Patient's palm (fingers together) = approximately 1% TBSA — useful for irregular burns - Children have proportionally larger head/smaller legs than adults

Critical burns (require burn center transport): - >20% TBSA partial thickness - Any full thickness burn - Facial/airway burns (singed nasal hair, soot in nares, stridor, hoarseness) - Burns to hands, feet, genitalia, circumferential extremity - Chemical or electrical burns - Burns in patients with significant comorbidities or extremes of age - Burns + concurrent trauma

Airway burns are time-critical — upper airway edema develops rapidly; early airway management is essential if facial burns or inhalation injury are present.

Assessment Relevance

History (history-taking): - MOI: source of burn, duration of exposure, enclosed space (CO/cyanide inhalation risk), explosive force (blast injury) - Time of burn - Clothing removed? Partial or full? - Prior treatments applied (ice, butter — do NOT use; cool water yes, cold/ice no)

Physical exam (secondary-assessment): - Airway: singed nasal hair, soot in mouth/nares, facial burns, hoarseness, stridor, drooling — all indicate inhalation injury → early airway management - Breathing: SpO2 (may be falsely normal in CO poisoning), respiratory rate and effort - Circulation: IV access needed for fluid resuscitation in burns >20% TBSA - Skin: document burn depth and estimate TBSA; location - Associated injuries: electrical burns may have internal injuries from the current path; blast burns may have concurrent trauma

Procedures

All burns: 1. Stop the burning process — remove patient from source 2. Remove jewelry and clothing unless adhered to skin (do NOT forcibly remove adhered material) 3. Cool the burn: cool (not cold) water for partial thickness burns; do NOT use ice, ice water, or butter 4. Dry sterile dressings — no two burned surfaces touching 5. Prevent hypothermia — maintain body temperature; burn patients lose heat rapidly 6. Primary assessment (primary-assessment): airway (inhalation injury?), breathing, circulation 7. Transport to burn center when appropriate; consider air evacuation for critical burns 8. ALS intercept for IV fluid resuscitation (burns >20% TBSA)

Airway burns: - Anticipate airway compromise with: singed nasal hair, soot in nares/mouth, facial burns, stridor - Early invasive airway management — do NOT wait for overt obstruction - See bvm-ventilation and Respiratory Arrest Guidelines

Fluid resuscitation (Parkland Formula — ALS scope): - 4 mL/kg/% TBSA = total mL for first 24 hours (Lactated Ringer preferred) - ½ given in first 8 hours; ½ over next 16 hours - Quick calculation: body weight (kg) × TBSA = mL of fluid for first 2 hours - Large bore IV/IO; second IV in unburned area; for >20% TBSA burns

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

Thermal Burns — EMT-B scope: - Stop burning process; remove from source - Primary assessment; history and vital signs - Estimate % BSA affected; estimate partial vs. full thickness - Remove jewelry and clothing unless adhered to skin - Dry sterile dressings over burns; no two burned surfaces touching - Maintain body temperature to prevent hypothermia - Transport to appropriate facility; consider air evacuation; contact Medical Control for destination decisions - Large bore IV/IO isotonic fluid (titrate to adequate vital signs) — en route - Second IV in unburned area if >20% BSA: Parkland Formula - 4 mL/kg/TBSA = mL for first 24 hours - ½ in first 8 hours; ½ over next 16 hours - Quick field calc: weight (kg) × TBSA = mL in first 2 hours - LR preferred - Pain management (ALS scope): - Morphine: Adult 4–10 mg slow IV/IO; Pediatric (2–12 yrs) 0.05 mg/kg IV/IO or IM - Fentanyl: Adult 25–100 mcg slow IV/IO; Pediatric 0.5–1 mcg/kg IV/IO or IM (max 2 mcg/kg) - Anti-emetics if nausea/vomiting: Ondansetron (Zofran) 4 mg IV/IO/PO/IM adult; Pediatric 0.05–0.1 mg/kg (max 4 mg) - Facial/airway involvement (singed nasal hair, soot in nares, stridor): early invasive airway management - Note: Do NOT apply electrodes to burned areas - TBSA quick method: patient's hand = 1% TBSA

Chemical Burns — EMT-B scope: - Scene safety — do NOT enter until confirmed safe; appropriate PPE - Decontaminate small areas: irrigate with water; remove contaminated clothing; brush away dry chemical BEFORE irrigating; irrigate minimum 20 minutes - Contact HazMat team for full body contamination - Remove jewelry and all clothing prior to transport - Transport; contact Medical Control for destination decisions - IV/IO access; maintain vital signs; prevent hypothermia - Pain management same as thermal burns

Hydrofluoric acid burns (special): - Vigorously irrigate with water/NS - Cardiac monitor for significant exposures (hypocalcemia risk) - Apply calcium gluconate gel to affected skin (calcium prevents tissue damage from HF acid) - If commercial calcium gluconate gel unavailable: combine 25 mL calcium gluconate 10% in 75–150 mL sterile water-soluble gel - For fingers: apply calcium gel to hand, squirt into surgical glove, insert affected hand - For significant HF exposure with clinical hypocalcemia signs: calcium chloride 10% IV (ALS)

NREMT Relevance

High-yield NREMT topic: - Rule of Nines: know adult percentages for each body region - Palmar method: patient's palm = 1% TBSA - Critical burn indicators: >20% TBSA, full thickness, airway burns, face/hands/feet/genitalia - Do NOT use ice, ice water, or butter — use cool water only - Remove clothing and jewelry UNLESS adhered to skin - Prevent hypothermia in burn patients - Airway burns: early airway management before edema develops - Parkland Formula (know the concept): 4 mL/kg/% TBSA; half in first 8 hours

NREMT Differentiators

Rule of Nines — Adult TBSA

Body Region % TBSA
Head and neck 9%
Each arm (entire) 9%
Chest (anterior trunk) 9%
Abdomen (anterior trunk) 9%
Upper back 9%
Lower back / buttocks 9%
Each thigh (upper leg) 9%
Each lower leg + foot 9%
Perineum / genitalia 1%
Total 100%

NREMT TIP — Palmar Method: For irregular or small burns, the patient's own palm (fingers together) ≈ 1% TBSA. Use for scattered burns that don't fit the Rule of Nines neatly.

NREMT TIP — Pediatric Rule of Nines: Children have proportionally larger heads (18%) and smaller legs (each leg = 13.5%). Use the Lund-Browder chart for pediatric TBSA; the Rule of Nines underestimates pediatric head burns.

Burn Depth Classification

Degree Layers Appearance Pain Blisters Include in TBSA?
Superficial (1st) Epidermis only Red, dry (sunburn) Yes No NO
Partial thickness (2nd) Epidermis + dermis Moist, red, blistered Yes (nerves intact) Yes YES
Full thickness (3rd) All skin layers Leathery, dry, waxy, charred No (nerves destroyed) No YES

KEY DIFFERENTIATOR — Full Thickness Burns: No pain = nerve endings destroyed. This sounds like good news but means deep tissue damage. Full thickness burns ALWAYS require burn center transport regardless of TBSA.

Critical Burns — Transport to Burn Center

Any of the following = burn center: - TBSA >20% partial thickness - Any full thickness burn - Airway burns (singed nasal hair, soot in nares, hoarseness, stridor) - Burns to hands, feet, genitalia, major joints, or circumferential - Chemical or electrical burns - Burns with concurrent trauma - Burns in very young, very old, or significant comorbidity

KEY DIFFERENTIATOR — Airway Burns: Singed nasal hair + soot in nares + facial burns = airway burn until proven otherwise. Edema develops fast — manage the airway EARLY before obstruction develops. Do not wait for stridor to act.

Chemical Burns

Step Action
1 Scene safety — PPE, confirm HazMat safe before entry
2 Brush off dry chemical FIRST (before water — water activates some dry chemicals)
3 Irrigate with large amounts of water for minimum 20 minutes
4 Remove all clothing and jewelry
5 Continue irrigation during transport if feasible

NREMT RULE: Dry chemical burns — brush first, THEN irrigate. Wet the powder first and you may worsen the reaction. This sequence is the exam trap.

Electrical Burns

  • External burns underestimate internal injury — current follows path of least resistance through internal tissues
  • Entry wound + exit wound — both must be identified
  • Cardiac dysrhythmias common — monitor ECG
  • Rhabdomyolysis — muscle breakdown products damage kidneys; aggressive fluid resuscitation needed (ALS)
  • C-spine precautions if fall or thrown from electrocution

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Burns Thermal (p. 64–65); Burns Chemical (p. 66–67)