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Burns — Thermal and Chemical

Category: Trauma Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

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

Sources

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