WHO estimates that burns cause around 180,000 deaths a year, the vast majority in low- and middle-income countries, and many more serious injuries. Children and women are at particular risk, often from open cooking fires, kerosene stoves, hot liquids and gas explosions. Good first aid and early nursing care reduce death, infection and disfiguring scars.
First aid: the first 20 minutes
- Stop the burning: remove the person from the source; “stop, drop and roll” for burning clothes; switch off electricity before touching.
- Cool the burn with cool running water for 20 minutes, as soon as possible and up to 3 hours after injury. Do not use ice, iced water, butter, oil, toothpaste, egg or traditional remedies.
- Remove clothing and jewellery near the burn, unless stuck to the skin.
- Keep the person warm: cool the burn, not the patient. Hypothermia is a risk, especially in children and large burns.
- Cover loosely with cling film (laid on, not wrapped tightly) or a clean, non-fluffy cloth.
- For chemical burns, brush off dry chemicals and irrigate with large volumes of water.
Assess: A to E first
- Airway: burns to the face, singed nasal hair, soot around the mouth, hoarse voice or stridor suggest inhalation injury. The airway can swell quickly; call for senior anaesthetic help early.
- Breathing: circumferential chest burns can restrict breathing. Consider carbon monoxide poisoning in enclosed-space fires (SpO₂ readings can be falsely normal).
- Circulation: IV access, ideally through unburnt skin.
- Disability and Exposure: look for other injuries.
Estimating burn size: total body surface area (TBSA)
- Palm method: the patient’s palm with fingers is about 1% of their body surface area. Useful for small or scattered burns.
- Rule of nines (adults): head and neck 9%; each arm 9%; front of trunk 18%; back of trunk 18%; each leg 18%; perineum 1%.
- Children have proportionally larger heads and smaller legs, so use a Lund and Browder chart.
- Do not count simple erythema (red skin without blisters, like sunburn).
Burn depth
| Depth | Appearance | Sensation | Healing |
|---|---|---|---|
| Superficial (epidermal) | Red, dry, no blisters | Painful | About 7 days |
| Superficial partial thickness | Pink, moist, blisters, blanches | Very painful | Within 2–3 weeks |
| Deep partial thickness | Blotchy red or white, may not blanch | Reduced | Often needs surgery; scarring |
| Full thickness | White, waxy, leathery or charred | Painless | Needs surgery (grafting) |
Fluid resuscitation: the Parkland formula
Burns larger than about 15% TBSA in adults or 10% in children usually need IV fluid resuscitation, because fluid leaks out of damaged blood vessels.
Parkland formula: 4 mL × body weight (kg) × %TBSA = total crystalloid (usually Hartmann’s/Ringer’s lactate) over the first 24 hours from the time of injury (not from arrival).
- Give half in the first 8 hours from injury, and the other half over the next 16 hours.
- Example: a 70 kg adult with 30% burns: 4 × 70 × 30 = 8,400 mL. 4,200 mL in the first 8 hours (525 mL/hr if started at the time of injury); 4,200 mL over the next 16 hours (about 262 mL/hr).
- Children also need maintenance fluids with glucose in addition.
- The formula is a starting point. Adjust to urine output: aim for about 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children. A urinary catheter is needed.
- Too much fluid (“fluid creep”) causes swelling, compartment syndrome and breathing problems; too little causes shock and kidney injury.
Ongoing nursing care
- Pain: burns are extremely painful, especially dressing changes. Give regular analgesia and pre-dressing doses as prescribed.
- Infection prevention: strict hand hygiene and aseptic technique; watch for wound infection and sepsis. Tetanus status.
- Wound care: as directed by the burns team; common options include silver-based dressings or other antimicrobials.
- Circulation checks for circumferential burns of limbs: escharotomy may be needed.
- Nutrition: burns greatly increase calorie and protein needs. Early feeding helps.
- Temperature control: keep the room warm.
- Psychological support and, for children, safeguarding: consider whether the injury pattern fits the story.
- Early physiotherapy and positioning to prevent contractures.
When to refer to a burns centre
Commonly: large burns, full-thickness burns, burns to the face, hands, feet, genitals or across joints, circumferential burns, inhalation injury, electrical and chemical burns, burns in very young or old patients or those with serious illnesses, and any suspected non-accidental injury. Follow your national referral criteria.
Related: IV fluids · Drug and fluid calculations · Wound dressings
Based on WHO burns fact sheets, the British Burn Association first aid guidance and Emergency Management of Severe Burns principles. Educational content: follow your local burns protocol.