Burn Assessment
Burn injuries require systematic assessment of depth, extent, and location to determine severity and guide treatment decisions. The NREMT tests your ability to classify burns, estimate body surface area involvement, and provide appropriate field management.
Burn Depth Classification
Superficial (First Degree)
Affects only the epidermis. Red, dry, painful skin without blisters. Example: sunburn. Heals in 3-5 days without scarring. Not counted in burn severity calculations.
Partial Thickness (Second Degree)
Affects the epidermis and part of the dermis. Red, moist, blistered, very painful skin. May appear weeping or shiny. Heals in 2-4 weeks, may scar. Counted in burn severity calculations.
Full Thickness (Third Degree)
Destroys the entire epidermis and dermis. White, waxy, leathery, or charred appearance. Painless in the center (nerve endings destroyed) but painful at the edges where it transitions to partial thickness. Requires skin grafting. Always counted in burn severity.
Rule of Nines
The Rule of Nines estimates the percentage of total body surface area (TBSA) burned in adults:
- Head and neck: 9%
- Each upper extremity: 9%
- Anterior trunk: 18%
- Posterior trunk: 18%
- Each lower extremity: 18%
- Perineum/genitalia: 1%
For children, the head is proportionally larger (18%) and the legs are smaller (14% each). Use pediatric burn charts for accurate pediatric TBSA estimation.
The patient's palm (including fingers) represents approximately 1% TBSA, useful for estimating irregular or scattered burns.
Burn Severity Criteria
Critical burns requiring burn center transport:
- Partial thickness burns greater than 20% TBSA in adults (10% in children or elderly)
- Full thickness burns greater than 5% TBSA
- Burns involving the face, hands, feet, genitalia, or major joints
- Circumferential burns (completely encircling an extremity or the chest)
- Electrical or lightning burns
- Chemical burns with systemic effects
- Inhalation injury
- Burns with associated trauma
Field Management
- Stop the burning process: Remove the patient from the source. Remove clothing and jewelry (unless stuck to the burn). Do not break blisters.
- Cool the burn: Apply cool (not cold) water for small burns (less than 10% TBSA) for 10-20 minutes. Do NOT apply ice. For large burns, do not cool with water as this risks hypothermia.
- Cover: Apply dry, sterile dressings. Do not apply ointments, butter, or other home remedies.
- Prevent hypothermia: Burned patients lose heat rapidly. Keep warm with blankets.
- Pain management: Burns are extremely painful. Position of comfort and gentle handling.
- Monitor for shock: Large burns cause significant fluid loss. Assess and treat for hypovolemic shock.
Special Burn Types
Chemical burns: Brush off dry chemicals first, then irrigate with copious water for at least 20 minutes. Remove contaminated clothing. Do not try to neutralize the chemical.
Electrical burns: Ensure the power source is disconnected before approaching. External burns may appear minor while internal injuries (cardiac dysrhythmias, rhabdomyolysis, compartment syndrome) can be severe. Monitor cardiac rhythm. Look for entrance and exit wounds.
Inhalation injury: Suspect in any patient with facial burns, singed nasal hair, soot in the mouth or nose, hoarseness, or stridor. This patient needs early airway management as swelling can progress rapidly.