13.1 Chemical, Electrical, and Thermal Burns
Key Takeaways
- Stop the burning process, then dry the patient; never ice a burn in the field or in the cabin.
- Brush dry chemical powder first, then use copious water unless hazardous-materials guidance names a water-reactive metal; hydrofluoric acid needs calcium.
- Electrical injury is hidden deep muscle, rhabdomyolysis, hyperkalemia, continuous cardiac monitoring, and spinal packaging after a fall—not the small entrance wound.
- Closed-space soot, singed hair, and carbonaceous sputum mean early intubation on the ground; airway swelling progresses after you close the door.
- Circumferential chest or limb eschar is a recognition problem; escharotomy is a receiving or physician skill.
Burn care in flight starts by stopping the burning process, naming the agent, and deciding whether the airway will last the hop. Domain 3.G of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests burn injury as chemical, electrical, and thermal. Radiologic burns appeared on the outgoing 2021 outline; they are not a 2026 Domain 3.G lecture. Fluids, destination, and cabin packaging live in section 13.2.
Depth and adult size
Name depth before you name a formula. Superficial burns (classic first-degree) stay in the epidermis: red, painful, no blisters. Do not count them in total body surface area (TBSA) for resuscitation math. Partial-thickness burns (second-degree) enter the dermis. Superficial partial-thickness is blistered, moist, blanching, and very painful. Deep partial-thickness looks mottled, blanches slowly, and feels duller. Full-thickness burns (third-degree) destroy the dermis. The surface is leathery, white, brown, or charred and insensate. This is the depth that forms a tight eschar. Some texts add fourth-degree for muscle and bone after high-voltage contact.
Adult Rule of Nines and the palmar 1 percent
Adult teaching uses the Rule of Nines and the palmar method. A child's head is a larger fraction of body surface; pediatric sizing belongs in Chapter 18 (neonatal-pediatric-care). Do not drop adult nines onto a toddler.
| Adult region | Approximate TBSA |
|---|---|
| Head and neck | 9% |
| Each upper extremity | 9% |
| Anterior trunk | 18% |
| Posterior trunk | 18% |
| Each lower extremity | 18% |
| Perineum | 1% |
The patient's own palm including fingers is about 1 percent TBSA for patchy splatters. Count only partial- and full-thickness. A 70-kilogram adult with a sunburned back is not a fluid-formula patient.
Stop the burning process
Pull the patient out of the flame, extinguish smoldering cloth, and cut off jewelry before swelling locks a ring on. Brief cool—not ice-cold—water can stop residual heat. Then dry the patient. Do not ice. Ice vasoconstricts, deepens injury, and starts the hypothermia a winter cabin will finish.
Chemical burns
Treat chemical injury as a scene hazardous materials (HAZMAT) problem first. Protect the crew. Remove soaked clothing.
- Brush dry powder off first. Water on dry powder makes a concentrated slurry.
- Then irrigate with copious water unless HAZMAT identifies a water-reactive metal (elemental sodium, potassium, lithium, and some magnesium or phosphorus compounds). Water on those metals can ignite. Follow the HAZMAT plan.
- Do not "neutralize" an acid with a base on the ramp. The reaction is exothermic.
- Alkalis (lye, wet cement, oven cleaner) keep saponifying and need longer irrigation.
Hydrofluoric acid (HF) behaves like a metabolic poison. Fluoride binds calcium and magnesium, tracks deep, and can drop ionized calcium enough to trigger ventricular dysrhythmias. Pain is out of proportion. After irrigation, the antidote is calcium—topical calcium gluconate gel first; severe exposures follow protocol intravenous or intra-arterial calcium. Monitor the heart. Do not treat HF as ordinary battery acid.
A powder-covered patient in a closed cabin is a crew inhalation injury. Decontaminate before you load.
Electrical burns
Electrical injury is voltage, current type, path, and contact time—not the size of the hole. Entrance and exit wounds can look trivial. The real injury is cooked muscle between them: hidden deep injury.
Hunt what the skin hides:
- Rhabdomyolysis and hyperkalemia (K+): dark urine, rising potassium, a hardening compartment
- Cardiac dysrhythmia: continuous cardiac monitoring through the hop
- Spinal injury: tetany throws the worker off the pole. Package the spine even when the holes are tiny.
Do not chart this as a 2 percent thermal burn. Fluid for pigmented urine is section 13.2. After 24 hours, succinylcholine can dump potassium (Chapter 5). Lightning may flash over the skin and still leave asystole or fibrillation plus blunt trauma.
Thermal burns and inhalation
Flame, scald, contact, and tar are the thermal family. Flame in a closed space is inhalation until proven otherwise. Scalds dominate kitchens and bathrooms (Chapters 18 and 19). Contact burns come from mufflers and hot platens. Cool tar to stop heat transfer; do not peel it off the dermis on the ramp.
Inhalation injury will not wait for the burn center. Suspect it after a closed-space fire or collapse in smoke. Clues include singed nasal or facial hair, soot in the mouth, hoarseness, and carbonaceous sputum. Stridor is late. Supraglottic edema progresses. A talking patient at the landing zone can obstruct after you close the door. Intubate early on the ground. A vibrating cabin is a terrible place to lose a face. Carbon monoxide (CO) and cyanide (CN) belong in section 13.2.
Circumferential eschar
A circumferential full-thickness chest burn will not let the chest wall expand. Peak inspiratory pressure (PIP) rises and end-tidal carbon dioxide (ETCO2) falls. A circumferential limb becomes a tourniquet. Escharotomy is a receiving or physician skill. Recognize the need, loosen wraps, elevate the limb, and warn the receiving surgeon. Do not invent a field knife unless a written program protocol says otherwise.
A scene patient is covered in dry industrial powder that is still injuring the skin. The crew is about to load for a rotor hop. What is the first decontamination action?
A high-voltage lineman has a small charred palm wound, a second small wound on the heel, and was thrown from a pole. Which flight assessment is correct?
A closed-space house-fire patient has singed nasal hair and carbonaceous sputum but is still talking. You have a 40-minute rotor hop. What is the airway plan?