The most common question around burns treatment in first aid training is “Does this need to go to hospital?” We’ve all burned ourselves at some time or other. We know how it happens and what it feels like. Most of us have a good idea of the correct treatment too (see below). So how do you decide who needs help and who can be treated at home? Your hands can help you decide, along with your common sense and something called the Rule of Nines.
Friction Burns and Other Pains
Dry heat – your radiator, heater, stove, etc. These things are common causes of burns, especially in children reaching where they shouldn’t. If clothing has melted into skin, leave it in place. Let the doctor deal with that.
Wet heat – your coffee, the kettle, etc. It’s hot liquids or steam which cause a burn. If clothing is wet and can be safely removed (don’t burn their face as you take it off!) then do so. Hot water soaked into clothing can continue to burn a person
Cold – yes that’s still a burn. Think of a burn as ‘heat transfer from the hot object to the cold one’. Normally that means from a hotter object into you. In the case of cold burns, you are the hotter object. Heat exchange still occurs, and skin/tissues still get damaged. You may need to find a way to detach the person from the metal they have frozen on to.
Radiation – unless you’re working in a speciality area, we’re probably talking about sunburn here! When it comes to assessment, remember to consider all the burned areas. (And if you ware working in a radioactive environment, this isn’t the place to pick up your specialist training.)
Electricity – remember there will be 2 burns. One burn where the electricity entered the person and one in the feet, bottom or wherever it went to earth. Yes, you will have to look and treat, but if they tell you their feet are sore, then that’s where you should be looking. There’s also a good chance of internal damage where the current passed through tissues. Remember your own safety, especially when it comes to chucking water around.
Chemical – OK, the exchange of heat is less obvious, but it’s still a burn. Be extra careful of where the chemical is and don’t get it on yourself, wash it into the drinking water supply, etc.
Friction – oh yes, this is still a burn as well! However they got it, if they’ve come to get first aid then you need to help. And no laughing (at least not until after they’ve left).
Along with the 6 causes of burn, we want to look at 3 depths of burn. They used to be called ‘1st degree, 2nd degree, etc.’ Not so much any more, although you’ll still hear them called this.
How deep the heat?
- Not very: Superficial Burns
- Deep enough to blister: Partial Thickness Burn
- Deep enough to damage (muscle/tendon/bone/etc): Full Thickness Burn
So what happened to the degrees of burning? Well first aid is moving away from that terminology because it’s too confusing and involves too many factors. If you’ve heard of them, then probably you’ve heard of the 1st, 2nd and 3rd degree burns.
Then it would surprise you to know there are at least 6 degrees, and some argue for as many as 10 degrees of burn. If you check the Wiki it lists 5 degrees of burn, and confuses you even more by calling them 1st – 4th degree, with the 2nd degree being divided in two.
In first aid situations, we need to make quick assessments to lead to quick decisions, not worry about whether it is or isn’t a 2nd degree burn. So here’s what we do:
The skin is reddened. It’s painful. Think of sunburn. Think of briefly touching the hot stove/heater. There is little damage to the body, although they can range from slightly painful to quite sore. They’re going to heal fairly well regardless of what you do. Treat them and send the person home. No worries unless the burn is very large (see the Rule of Nines).
Partial Thickness Burn.
They blister. That’s their definition. Part of the ‘thickness’ of your body is now involved. The burn has moved on from superficial and now involves underlying layers of skin. As well as a superficial redness, there will be blistering, perhaps open/broken skin and a raw looking wound. They will be painful to touch. There’s an increased risk of infection and you’re more likely to send them for medical attention.
Full Thickness Burn. The full thickness of the skin has been damaged, and underlying body structures will be burned as well. The actual area of burn may be less painful as nerves are burned away (there will also be surrounding partial & superficial burns which will still hurt!). There’s likely to be charred or blackened skin, perhaps with a ‘waxy’ appearance in some areas (as the fat has melted too). You don’t need me to tell you these people all go to hospital as quick as you can get them there. Still you need to apply the basic treatment while waiting for help/transport.
Signs and Symptoms
This should be common sense! So a quick list will be enough:
- History of contact with something hot (or see above)
- Feeling of ‘burning’
- Potentially: charring, reduced sensation, muscle and tissue damage.
Now it’s time to get your hands involved and start to look at the extent of the burn on the person’s body. The point of assessing a burn is to decide:
- Will you treat it and send them ‘home’ or wherever?
- Will you treat it and call for help/EMS?
First, we’ve already discussed the Full Thickness Burn. They need EMS/ambulance immediately. They might well need surgery too. Don’t hang around; get your local emergency services activated and get the person treated.
We’ve also talked about superficial burns. Most of them won’t need medical attention unless they’re really large (see below).
So we come to the Partial Thickness Burns – when to send them to the medic, when to send them home?
Getting ‘Hands On’
You need hands to assess the Partial Thickness Burn. Some blistering is common and many of us will have done this without going to the doctors. So how much is too much?
If the blister is bigger than the palm of the patient’s own hand, then have it checked out by a doctor. Your hand may be a good enough estimate, but of course if you’re dealing with children & babies, then a much smaller burn may still need looking at.
When a blister is that big, there’s a good chance of infection getting in. There will also be some fluid loss and the risk of shock (depending on how much bigger than ‘a hand’ the burn is).
People with blisters of ‘a hand’ size which are not burst and which you have treated effectively could reasonably be referred to their own family doctor or whoever they normally would see. Bigger blisters, uncontrolled pain despite treatment, or burst blisters would be an indicator to send them to the local clinic/hospital straight away. Not necessarily by ambulance, but they need seeing today, not when the next appointment becomes available. Of course, burns that are ‘really big’ may need you to call EMS anyway. Sometimes, you’ll need to use….
The ‘Rule of Nines’
So you can see that if both arms are burned, then that’s 9% of the body. Front of the chest is another 9% All of the upper body (neck to hips, front and back) would be 36% and so on.
Any burn (even a superficial one) greater than 9% of the body surface area should have medical assessment. Again, some common sense can be used. By this definition, technically a sun-burned back should go to the doctors. The reason is that a burn this size has a very good chance of infection.
Any burn over 9% that isn’t just superficial will need EMS and hospital attention. That much blistering leads to a lot of fluid loss and the risk of shock as well as infection.
As for the 1% well we’d suggest any burn there is going to be painful. Send them to hospital to be checked out.
Wherever and whatever the burn, it will still need the basic First Aid treatment, even if it’s just while you’re waiting for the ambulance to arrive.
Treatment of Burns
Cool them and cover them. It’s as simple as that.
Ideally under running cold water until the burning sensation has stopped. This is likely to be at least 10 minutes. If the person is not going for further assessment, then re-assess after 10 minutes. You may need another 10 minutes or even more. If there is still the feeling of burning after 30 minutes under cold running water, get more advanced help.
If cold running water isn’t available, use what you have. It may be to put a hand or foot in a bucket of water and change this occasionally. It may be something other than water (try to keep it as clean as you can!). Do what you can with what you have.
Once the burn is completely cooled, cover it with something clean/sterile to keep out any infection. You may also want to consider some sort of padding to cushion the area or protect any blisters. Tell the person to try and keep the area clean until it has healed. This should be 7-10 days for a superficial burn and up to 21 days for a partial thickness burn.
There are lots of ‘special situations’ for burn injuries, when you need to think about things other than just the burn itself. Here are the commonest ones.
If something is stuck to/in the burn, the doc will need to deal with that – you cool whatever is stuck as well as the person.
If they are wearing a ring, watch, belt, etc. in the area of the burn, have them remove it. There is a good risk of swelling and then the circulation gets cut off. If they can’t remove it, then EMS or the hospital will – and they have a good idea of how much pain they’re willing to go through to save the ring Granny passed down to them for their 21st birthday!
When chemicals are involved, wash the area with clean running water for at least 20 minutes. In industrial settings (where some chemicals explode or react on contact with water) make sure you have the correct training before the problem occurs.
If a person has a burn to the eye – get help (and keep cooling it)
If a person has a circumferential burn (it goes all the way round the limb/body eg: round the wrist like a bracelet) – get help. The risk is that swelling all the way round cuts of circulation or sensation.
If electricity is involved, be aware of your own safety when using water. Make sure the power is off. If a person is still attached to a high power source, it may be that all you can do is call EMS and the power company.
If the burn is large, you may need to cool them with a hose/shower. Be careful not to cause hypothermia, but don’t be afraid of cooling them in this way.
If there is a burn to the airway (eg: breathing in hot gas/fumes) then you may need to be ready to do CPR. Get help and keep checking that the person is still breathing. There isn’t much you can do to cool this one.
When to send for help, when to get help
OK, so there’s been a lot of information in this post! Time to summarise the point of it all – How your hands help you decide if a burn needs medical attention.
Call for EMS in these cases:
- All Full Thickness Burns
- Partial Thickness Burns of 9% or more
- All burns to the eye
- All burns to the ‘1%’ on the picture
- All circumferential burns
- Any time you’re unsure
Send to the doctor/clinic/hospital in these cases
- Partial Thickness Burns greater than 1% (‘a hand’)
- Small Partial Thickness Burns which continue to be painful despite treatment
- Superficial burns greater than 9% – consider sending
Finally there may be something you’ve heard said about a burn that hasn’t been covered – so here are a few things not to do!
What not to do
No fats. Do not put butter on it. It might briefly feel cooling, but fat is used to fry stuff. It’s good at keeping in the heat and making the burn worse.
No Bicarb of Soda. I’m not even sure why granny used to do this, but it doesn’t help and shouldn’t be needed.
No anaesthetic creams. The point is to treat the burn (by cooling) until there is no more pain. If you block the pain with something you got at the pharmacy, you won’t know if the cooling is working. Remember that pain lasting more than 30 minutes was one reason to send for help.
Leave the blisters alone. They are your body’s own method of protection. Don’t burst them, and try to persuade kids to do the same.
We’d love to hear any other comments on this topic. It’s a big area and we’ve covered it in some detail, but let us know if there’s something we missed, some treatment you once heard someone did and want to know more about, or just any comments on burns in general.