3.5 Burns & Environmental Trauma

Burns are among the most painful and disabling injuries EMTs encounter. Accurate classification, a reliable estimate of burned surface area, and prompt, correct initial care meaningfully change outcomes - and burns are a reliable NREMT topic.

Burn Classification by Depth

Superficial (first-degree): involves only the epidermis. It is red, dry, painful, and has no blisters (classic sunburn), heals in 3-5 days, and is not counted when calculating burned surface area.

Partial-thickness (second-degree): extends into the dermis. It is red, moist, blistered, and very painful because nerve endings are exposed (scalds, brief flame or hot-surface contact). Healing takes 2-4 weeks; deep partial-thickness burns may scar.

Full-thickness (third-degree): destroys the entire dermis and may reach fat, muscle, or bone. It appears white, brown, or charred, with a dry, leathery eschar, and is painless in the center because nerve endings are destroyed (though painful partial-thickness burns surround it). It requires skin grafting. A fourth-degree burn extends into muscle and bone.

Rule of Nines: Body Surface Area Estimation

Children and infants carry a proportionally larger head (18%) and smaller legs (14% each), reflecting their different body proportions. Quick tip: the patient's own palm including the fingers equals about 1% of body surface area and is handy for estimating scattered or irregular burns.

Critical Burns and Burn-Center Referral

The current American Burn Association (ABA) referral criteria treat a burn as critical when any of the following are present:

• Partial-thickness burns greater than 10% of total body surface area (older EMT texts cited 20-25%; the ABA threshold is now 10%).
• Any full-thickness (third-degree) burn.
• Burns to the face, hands, feet, genitalia, perineum, or major joints, regardless of size.
• Circumferential burns of an extremity or the chest - they can act like a tourniquet or restrict breathing.
• Inhalation injury, suspected or confirmed.
• Electrical burns, including lightning, and chemical burns.
• Burns with associated trauma, or in patients with significant pre-existing illness, or at the extremes of age.

Burn Treatment

1. Stop the burning process - remove the patient from the source; for flames, stop, drop, and roll or smother.
2. Remove clothing and jewelry from the burned area unless material is adhered to the skin.
3. Cool thermal burns with room-temperature or cool water. Do not apply ice (vasoconstriction worsens the injury and risks hypothermia) and do not apply butter, ointments, or home remedies.
4. Cover with dry, sterile, non-adherent dressings (a dry sheet for large burns); do not use moist dressings on large burns, which accelerate heat loss.
5. Prevent hypothermia - burned skin cannot regulate temperature, so keep the patient warm after cooling.
6. Provide pain control and monitor for shock, since large burns leak plasma and cause major fluid loss.

Electrical Burns

Electrical injury is deceptive: internal damage along the current's path (through vessels, nerves, and muscle) is usually far worse than the small entry and exit wounds suggest. Always look for both an entry and an exit wound. Cardiac monitoring is essential, because current can trigger lethal dysrhythmias such as ventricular fibrillation and asystole, even when surface burns look minor. Suspect associated injuries - muscle breakdown (rhabdomyolysis), fractures from violent contractions, and spinal injury from falls. Scene safety is paramount: confirm the source is de-energized before approaching.

Chemical Burns

For dry chemicals, brush off the powder first with a gloved hand, then irrigate (adding water to some dry chemicals activates them). For liquid chemicals, begin immediate, copious irrigation with water for at least 20 minutes and remove contaminated clothing during irrigation. Do not try to neutralize the chemical - the reaction releases heat and worsens the burn. Protect yourself with PPE and bring the product's safety data sheet (SDS) when possible.

Inhalation Injury

Suspect inhalation injury with singed nasal hairs or eyebrows, facial burns, carbonaceous (sooty) sputum, hoarseness or stridor (signaling laryngeal swelling), soot around the nose and mouth, or a history of fire in an enclosed space. This is an airway emergency: give high-flow oxygen at 15 L/min via non-rebreather, anticipate rapid upper-airway swelling that makes airway control progressively harder, and transport early to a burn center. Also consider carbon monoxide and cyanide poisoning in any enclosed-space fire, since pulse oximetry can read falsely normal in CO exposure.

Carbon Monoxide and Cyanide in Fire Victims

Closed-space fire victims face two invisible poisons in addition to skin and airway burns. Carbon monoxide (CO) binds hemoglobin roughly 200-250 times more tightly than oxygen, so the blood cannot carry oxygen even though the pulse oximeter may read 98-100% - the device cannot tell carboxyhemoglobin from oxyhemoglobin. Treat suspected CO exposure with high-flow oxygen via non-rebreather, which speeds CO elimination, and consider transport to a facility with hyperbaric capability for severe cases.

Cyanide, released when synthetic materials burn, blocks cellular oxygen use and presents with altered mental status and refractory shock; it is an ALS/hospital treatment, but the EMT's job is high-flow oxygen and rapid transport.

Cold and Heat Trauma in the Field

Environmental trauma extends beyond burns. Frostbite is local tissue freezing; rewarm only when there is no risk of refreezing, never rub the area (ice crystals shear tissue), and protect it with loose, dry dressings. Generalized hypothermia is covered in the environmental-emergencies section, but burn patients deserve special mention: because burned skin cannot conserve heat, large-burn patients become hypothermic quickly, which worsens shock and clotting, so warming is a treatment priority, not an afterthought.

Pediatric and Geriatric Burn Considerations

Children and older adults tolerate burns poorly. A given percentage of body surface area is more dangerous in a child because of thinner skin, a larger surface-area-to-mass ratio, and faster heat and fluid loss. Always consider non-accidental trauma when a child's burn pattern does not match the history - stocking-glove scald distributions, symmetric immersion lines, or cigarette-tip burns warrant documentation and mandatory reporting. In older adults, thin skin and slow healing make even modest burns significant, and pre-existing heart, lung, or kidney disease lowers the threshold for burn-center referral.