Burns
Cool with running water for 20 minutes, size it with the patient's palm, judge the depth, and refer the burns that need a burns unit.
A 4-year-old (16 kg) pulled a pan of boiling water used for tea onto herself 40 minutes ago. Her grandmother put toothpaste on the burns. The front of her chest and both forearms are pink, wet and blistered; a patch on the left forearm is white and doesn't blanch. She is crying, pulse 150, capillary refill 2 seconds.
How big is the burn, does she need IV fluids, and does she need a burns unit?
- Airway firstBurns in a closed room, soot in the nose or mouth, singed nasal hairs, hoarse voice, stridor: anaesthetist early.
- Stop the burning and coolCool running water for 20 minutes, useful up to 3 hours after the burn. Keep the patient warm.
- Wash off home remedies gentlyToothpaste, ghee, eggs, ice, ash.
- Estimate size and depthPalm with fingers is about 1%. Don't count simple redness.
- AnalgesiaCooling and cling film help pain. IV or intranasal opioid for larger burns.
- Fluids if largeAdults 15% or more, children 10% or more: Parkland formula.
- CoverCling film in strips, not wrapped around.
- ReferBy size, depth, site, mechanism and safeguarding concerns.
- Inhalation injury or hoarse voice
- Burns 15% or more (adult) or 10% or more (child)
- Full-thickness burns
- Face, hands, feet, genitals, perineum or major joints
- Circumferential burns
- Electrical, chemical or acid burns
- Concern about abuse
- Inhalation injury and airway swelling
- Carbon monoxide or cyanide poisoning
- Circumferential burns needing escharotomy
- Deep injury from electrical burns
- Child abuse
- Toxic shock syndrome in children
| First aid cooling | 20 minutes of cool running water (not ice), within 3 hours |
| Palm with fingers | About 1% TBSA |
| Parkland | 4 mL × weight (kg) × %TBSA of Ringer's lactate over 24 hours, half in the first 8 hours from the time of burn |
| Children | Add maintenance fluid with glucose to Parkland |
| Urine output target | Adults 0.5 mL/kg/hour, children 1 mL/kg/hour |
| Refer to burns unit | Partial thickness over 3% (adult) or 2% (child), any full thickness, special areas, circumferential, inhalation, electrical, chemical |
Check every dose against a current drug reference and your hospital protocol.
On this page
First aid
- Stop the burningRemove from the source. Stop, drop and roll for flames.
- CoolCool running tap water for 20 minutes. Not ice, not iced water.
- RemoveClothing and jewellery, unless stuck to the skin.
- Warm the patientCool the burn, not the child. Hypothermia is a real risk in small children.
- CoverCling film in strips laid on (not wrapped), or a clean non-fluffy dressing.
- AnalgesiaParacetamol, ibuprofen, opioid if needed.
Families often apply toothpaste, ghee, eggs, ice or ash. Wash it off gently and cool with running water. Explain kindly that cool running water is the right first aid, and tell them for next time.
How deep?
| Depth | Appearance | Blanching | Pain | Heals |
|---|---|---|---|---|
| Superficial (epidermal) | Red, dry, no blisters | Yes | Painful | 3–7 days; not counted in %TBSA |
| Superficial partial thickness | Pink, wet, blisters | Yes, quickly | Very painful | Around 2 weeks, little scarring |
| Deep partial thickness | Blotchy red and white, drier | Slow or no | Less painful | 3 weeks or more, often needs grafting |
| Full thickness | White, leathery, brown or charred | No | Painless | Needs grafting |
Depth can progress over 48 hours. Reassess, especially scalds in children.
How big?
Palm with fingers ≈ 1% TBSA
Rule of nines: head 9, each arm 9, front of trunk 18, back 18, each leg 18, perineum 1
Lund and Browder chart: head is bigger, legs smaller (a baby's head is about 18–19%)
Use the Parkland calculator. Count only partial and full thickness, never simple redness.
Fluid resuscitation
- Two large cannulasThrough unburned skin if possible; intraosseous if needed.
- Parkland4 mL × kg × %TBSA of Ringer's lactate over 24 hours.
- Time from the burnHalf in the first 8 hours from the time of the burn (not from arrival), the rest over the next 16 hours.
- ChildrenAdd maintenance fluid with glucose; check sugar.
- CatheterTitrate to urine output: adults 0.5 mL/kg/hour, children 1 mL/kg/hour.
- AdjustThe formula is a starting point. Too much fluid causes swelling, compartment syndromes and lung problems.
Worked example: a 70 kg adult with 30% partial and full thickness burns. 4 × 70 × 30 = 8,400 mL in 24 hours. Half (4,200 mL) in the first 8 hours from the time of burn. If he arrives 2 hours after the burn, that 4,200 mL goes in over the next 6 hours.
Special burns
| Burn | Concerns | What to do |
|---|---|---|
| Inhalation (closed room, soot, hoarse voice) | Airway swells fast; CO and cyanide poisoning | 100% oxygen, anaesthetist early, carboxyhaemoglobin, lactate |
| Circumferential (limb or chest) | Limb ischaemia, breathing restriction | Elevate, monitor pulses and ventilation; escharotomy by burns team |
| Electrical | Small skin wounds, deep muscle damage | ECG and monitoring, CK, urine for myoglobin, admit |
| Chemical and acid | Ongoing burning | Irrigate with large volumes of water for at least 30–60 minutes; eyes immediately |
| Acid attack | Face and eyes, scarring | Irrigate, eye team, burns unit; medicolegal case |
| Lightning | Cardiac arrest, ear and eye injury | ECG, full trauma assessment |
Burns common in Pakistan
- Tea and hot water scalds in toddlers.
- Gas cylinder and heater explosions, kerosene stoves, especially in winter.
- Electrical burns from illegal connections and high-tension lines.
- Acid attacks (medicolegal; protect the patient's dignity and safety).
- Burns from firecrackers around celebrations.
Safeguarding in children
Think of non-accidental injury when:
- The story doesn't fit the injury, or keeps changing.
- There is delay in bringing the child.
- Glove or stocking scald patterns with clear edges (forced immersion), symmetrical burns, burns on the buttocks or soles.
- Round cigarette burns, iron or other object-shaped burns.
- Other injuries, poor hygiene, or previous visits.
Involve your senior and follow the hospital child protection process.
Small burns that can go home
- Superficial partial thickness under 3% (adult) or 2% (child), not in a special area, no safeguarding concern.
- Clean with saline, leave small blisters intact, deroof large or tense blisters per local policy.
- Non-adherent dressing (paraffin gauze or silicone), review in 48 hours.
- Paracetamol and ibuprofen regularly. Tetanus if not up to date.
- Return if fever, increasing pain, smell, or redness spreading (infection, toxic shock in children).
Treatment doses
Common mistakes
- Using ice or iced water (deepens the burn and causes hypothermia).
- Counting simple redness in %TBSA (leads to too much fluid).
- Starting the Parkland clock from arrival instead of from the burn.
- Missing an inhalation injury until the airway swells.
- Wrapping cling film round a limb.
- Treating an electrical burn as a small skin wound.
- Ignoring a story that doesn't fit in a child.
Frequently asked questions
What is the first aid for a burn?
Stop the burning, cool the burn under cool running water for 20 minutes (useful up to 3 hours after), remove clothing and jewellery unless stuck, keep the patient warm, and cover with cling film or a clean dressing.
What is the Parkland formula?
4 mL × body weight (kg) × %TBSA burned, of Ringer's lactate over 24 hours, with half given in the first 8 hours from the time of the burn and half over the next 16 hours. Children also need maintenance fluid.
How do you estimate the size of a burn?
The patient's palm with fingers is about 1% of body surface. For larger burns use the rule of nines in adults and the Lund and Browder chart in children. Don't count simple redness.
Which burns need a burns unit?
Partial thickness over 3% in adults (2% in children), any full thickness burn, burns to the face, hands, feet, genitals, perineum or major joints, circumferential burns, inhalation, electrical and chemical burns, and any concern about abuse.
Should burn blisters be popped?
Small blisters are usually left intact. Large or tense blisters may be deroofed under clean conditions, following local burns unit policy.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 70 kg adult has 30% TBSA burns. Using Parkland, how much fluid in the first 8 hours?
Answer: 4.2 litres. 4 × 70 × 30 = 8,400 mL over 24 hours; half in the first 8 hours.
- 12 litres: Too much.
- 8.4 litres: That's the 24-hour total.
- 1 litre: Too little.
- 2.1 litres: Too little.
2. What is the first aid for a scald?
Answer: Cool running water for 20 minutes. Cool within 3 hours, cover loosely, keep the patient warm.
- Ice: Causes further damage.
- Toothpaste or butter: Harmful.
- Burst blisters: No.
- Dry dressing immediately: Cool first.
3. A burn is white, leathery and painless. What is its depth?
Answer: Full thickness. Full-thickness burns destroy nerve endings and need grafting.
- Epidermal: Red.
- Superficial partial: Blistered, painful.
- Deep partial: Some sensation.
- Superficial: Red and painful.
4. A man has a full-thickness circumferential burn of the chest and is struggling to breathe with high ventilation pressures. What procedure is needed?
Answer: Chest escharotomy. Full-thickness burns form a rigid, inelastic eschar. Circumferential chest burns restrict chest expansion (ventilatory failure); circumferential limb burns cause compartment-like ischaemia. Escharotomy — incision through the eschar (painless, as nerve endings are destroyed) — releases the constriction. It is done early, often in the emergency setting. Fasciotomy may be needed in electrical burns with deep muscle damage.
- Immediate skin graft: Grafting comes later; the immediate problem is that the rigid eschar restricts chest movement.
- Tracheostomy: A tracheostomy does not relieve chest wall restriction caused by a circumferential burn.
- Fasciotomy: Fasciotomy is for compartment syndrome in limbs; the chest needs escharotomy through the eschar.
5. A man with full-thickness circumferential burns to the chest has rising airway pressures and difficulty ventilating. What is needed?
Answer: Escharotomy. Circumferential full-thickness burns form an inelastic eschar that restricts chest expansion (or limb perfusion). Escharotomy — incising the eschar through to fat along defined lines — restores ventilation/perfusion. Fasciotomy is for compartment syndrome deep to fascia (electrical burns, crush). Other burn emergencies: inhalation injury (early intubation), carbon monoxide/cyanide poisoning.
- Fasciotomy of the limbs: Limb fasciotomy does not help chest restriction.
- Higher tidal volumes: Higher tidal volumes do not relieve the restriction.
- Skin graft today: Skin grafting is not acute treatment.
6. Using the rule of nines, what percentage of body surface area is burnt in an adult with burns covering the whole front of the trunk and the whole of one arm?
Answer: 27%. Rule of nines (adult): head 9%, each arm 9%, front of trunk 18%, back of trunk 18%, each leg 18%, perineum 1%. Front of trunk (18) + one arm (9) = 27%. Children have relatively larger heads (Lund and Browder chart). The patient's palm (with fingers) is about 1% for small burns.
- 18%: Only the front of the trunk.
- 36%: Front and back of trunk.
- 45%: Not correct.
- 9%: Only one arm.
7. After a superficial skin injury, which epidermal layer regenerates the epidermis?
Answer: Stratum basale. The stratum basale contains stem cells that divide to replace keratinocytes, which mature upward through spinosum, granulosum, lucidum (thick skin) and corneum over about 4 weeks. In partial-thickness burns, re-epithelialisation comes from basal cells in surviving hair follicles and sweat glands; full-thickness burns lose these and need grafting.
- Stratum corneum: Dead keratinised cells.
- Stratum lucidum: Only in thick skin; no division.
- Stratum granulosum: Keratohyalin granules; no division.
- Papillary dermis: Dermis, not epidermis.
References and dose sources
- NICE CKS — Burns and scalds
- British Burn Association — First aid & referral
- Ringer's lactate (Hartmann's solution) dosing: Drugs.com: Lactated Ringer's dosage (see also our ringer's lactate (hartmann's solution) dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Ibuprofen dosing: Drugs.com: Ibuprofen dosage (see also our ibuprofen dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Tetanus toxoid and immunoglobulin dosing: Drugs.com: Tetanus toxoid dosage (see also our tetanus toxoid and immunoglobulin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.