Burns: Assessment, Classification, and Management

Burns: Assessment, Classification, and Management

Burns are among the most complex traumatic injuries encountered in pre-hospital care. A systematic approach to burn assessment, depth classification, and immediate management significantly improves patient outcomes and prepares you to give accurate reports to receiving facilities.

Burn Depth Classification

Burns are classified by the depth of tissue injury.

Superficial (first-degree) burns involve only the epidermis. The skin appears red and dry, is painful to touch, and does not blister. Sunburn is a common example. These burns are generally not counted when calculating total body surface area (TBSA) burned for resuscitation purposes.

Superficial partial-thickness (second-degree) burns extend into the superficial dermis. They produce blisters, a moist or weeping surface, intense pain, and blanch with pressure. These are included in TBSA calculations.

Deep partial-thickness (second-degree) burns reach the deep dermis. The wound may appear pale, mottled, or red, is less painful because nerve endings are damaged, and does not blanch reliably. Included in TBSA calculations.

Full-thickness (third-degree) burns destroy the entire dermis and may involve subcutaneous tissue, muscle, or bone. The wound appears white, brown, or charred, is leathery or waxy, and is typically painless at the burn site because nerve endings are destroyed. Always included in TBSA.

Fourth-degree burns extend through all skin layers into muscle and bone. These are life-threatening and require aggressive management and immediate transport.

Calculating TBSA: The Rule of Nines

The Rule of Nines divides the adult body into regions, each representing approximately 9% (or a multiple of 9%) of total body surface area:

• Head and neck: 9%
• Each upper extremity: 9% (18% total)
• Anterior trunk: 18%
• Posterior trunk: 18%
• Each lower extremity: 18% (36% total)
• Perineum/genitalia: 1%

Total: 100%

For children, the Rule of Nines is modified because the head is proportionally larger and the legs proportionally smaller. The Lund-Browder chart provides age-adjusted percentages and is more accurate for pediatric patients. As a quick field guide, a child's head accounts for about 18% and each leg for about 13% at age one, with adjustments as age increases.

A practical tip: the patient's palm and fingers together represent approximately 1% of that patient's TBSA. This is useful for estimating small or irregular burns.

Only partial-thickness and full-thickness burns are counted in TBSA for treatment decisions. Do not include superficial (first-degree) burns.

Burn Severity

Burn severity is determined by depth, TBSA, location, patient age, and associated injuries.

• Minor burns: Small TBSA, superficial or partial-thickness, not involving critical areas.
• Moderate burns: Larger TBSA partial-thickness, or full-thickness burns of limited area.
• Major/critical burns: Burns greater than approximately 25% TBSA in adults; any full-thickness burn of significant size; burns involving the face, hands, feet, genitalia, or major joints; circumferential burns; inhalation injury; electrical or chemical burns; burns in very young, elderly, or patients with significant comorbidities. These patients require transport to a burn center when available.

Pre-Hospital Burn Wound Care

Safety and speed are priorities. Always ensure scene safety before approaching a burn patient.

1. Stop the burning process: Remove the patient from the source. Remove burning or smoldering clothing and jewelry unless adherent to the skin. Do not pull off adherent clothing.

2. Cool the burn: Flush with cool (not cold) running water for approximately 10–20 minutes for small burns. Never apply ice, butter, toothpaste, or other home remedies — ice causes vasoconstriction and worsens tissue damage. Do not cool large burns extensively in the field as this risks systemic hypothermia.

3. Cover the wound: Apply dry sterile dressings. Do not break blisters; intact blisters protect against infection. Do not apply creams, ointments, or wet dressings in the pre-hospital setting unless directed by medical direction.

4. Assess and manage the airway: Signs of inhalation injury include facial burns, singed nasal or facial hair, carbonaceous (sooty) sputum, hoarseness, stridor, and exposure to smoke in an enclosed space. Airway edema can develop rapidly — early airway management, including advanced airway intervention at the paramedic level, may be necessary.

5. Prevent hypothermia: Cover the patient with a clean sheet and blanket. Burn patients lose heat rapidly.

6. IV access and fluid resuscitation: Establish large-bore IV access. Initiate fluid resuscitation per local protocol and medical direction using the formula provided on your reference card. Lactated Ringer's solution is the standard fluid for burn resuscitation.

Fluid Resuscitation

Pre-hospital fluid resuscitation for significant burns is guided by established formulas. The Parkland formula is widely referenced:

4 mL × patient weight (kg) × TBSA (%) = total fluid (mL) for the first 24 hours

Half of this volume is given in the first 8 hours from the time of burn (not from arrival), and the remaining half over the next 16 hours. In the pre-hospital setting, you calculate the estimated rate and initiate infusion; the hospital team manages ongoing resuscitation. Always follow your local protocol and contact medical direction for guidance.

Safety Reminders

• Never apply ice to burns.
• Never break blisters.
• Always assess for inhalation injury — this is a life threat.
• Burns involving the airway, face, or large TBSA require rapid transport.
• Maintain scene safety; do not become a victim.