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What should I know about burns and scalds

What should I know about burns and scalds?

Before you look at burns and scalds you should be aware of skin structure, as explained in the module Organisation of body systems. This will help you understand the associated injuries, recognise the organs or systems that lie underneath a burn and also explain certain signs and symptoms.

For example, some superficial (partial thickness) burns tend to be more painful than full thickness burns because of the depth of the nerve endings.

So do you know what a burn is? How does it differ from a scald? See if you're right about burns and scalds in the Resource Centre. 

In Britain some 143,000 injuries a year are caused by heat and around 11,000 are admitted to a burns unit. Approximately 700 people die every year from burns, most of which are the result of house fires. Some people are more likely to suffer certain kinds of burns than others - think about the predisposing factors in the Resource Centre.



Burns shock


Shock results from the escape of plasma from the burnt tissues and from the escape of blood or plasma into the tissues causing swelling.

The greater the area that is burnt the greater the extent of the shock will be.

Always be aware that SHOCK CAN KILL!


Managerment Treatment of burns

Treatment of burns

Ensure your own safety first and that of your colleagues and bystanders. If necessary remove the patient to a place of safety, making sure that burning clothes have been extinguished.

Ensure a clear airway and that the patient is breathing and has circulation.

Cool the burn with lots of cold water if possible. This will help to reduce the extent of the burn and help to ease the pain.

Cover the burn with a large sterile pad or dressing. If this is not available then use a clean non-fluffy towel or bed linen. This will prevent the spread of infection and will also stop the patient looking at the injury and becoming anxious. Keep the patient warm to prevent hypothermia setting in. Ordinary cling-film can be a good dressing for a burn but it is very important to make sure the burn is cooled before it is applied. It should only be applied in strips and NOT as a roller bandage.

Nil by mouth
You must not give anything by mouth, but you can moisten the lips.

Constricting items
Constricting items like rings should be removed as soon as possible because swelling will occur almost immediately.

Raise and immobilise
Burnt limbs should be raised if possible and charred limbs should be immobilised as for a fracture.

Your patient is extremely frightened and is looking to you to sort out their problems. A cool calm approach is of paramount importance. The patient's psychological well-being is also very important, plenty of reassurance will go a long way to gaining the patient's confidence.

If the patient has a major burn the receiving hospital should be forewarned of the patient's condition, level of consciousness and your estimated time of arrival.

Pain relief
Pain relief can be administered as per individual service protocol, either entonox or drug-induced analgesia .

In the case of undefined industrial or chemical burns, specialist advice should be obtained and the fire brigade requested to attend


Partial thickness

Partial thickness

This involves the epidermis only. Redness and swelling of the skin occurs and can be very painful but usually heals within a week without scaring.

This involves both the epidermis and dermis layers of the skin. This type of burn has reddening and swelling of the skin but also has associated blistering and is extremely painful.


Full thickness burns

Full thickness

This type of burn involves not only the layers of skin but also underlying tissues and bones. These burns will have a whitish yellow appearance with a waxy texture.

There might be associated bleeding and some blood vessels may be visible. Charring of the surrounding tissues will also be apparent.

Although not always the case, this type of burn will seldom be very painful because the nerve endings in the skin have been destroyed


what is a burn

A burn is a breach in the continuity of tissue caused by the excessive transfer of heat energy:

  1. To the skin - flame burns and scalds
  2. From the skin - ice burns, frost bite
  3. Electricity - electrical current, lightening
  4. Chemical - strong acids or alkalis, other corrosives
  5. Radiation - from excess radiotherapy




Boiling water and fat will continue to damage the tissues until such time as they are cooled down. This may take quite some time, so cold running water must be applied if possible for at least 10 minutes, making sure that the patient does not become hypothermic in the process, then continue to treat as a burn


Predisposing factors burns

Predisposing factors

  1. Very young children, the elderly, epileptics and drug abusers are more at risk as are people under the influence of alcohol or who are confused.
  2. Scalds are particularly common in the under five range, as are burns to children playing with matches.
  3. Electrical power cables and railway lines also attract children.
  4. Suicides by burning are quite common, especially among Asian females and psychiatric patients.
  5. Industrial molten metal burns are usually full thickness and are quite serious.
  6. Fireworks injuries can be fairly horrific but are thankfully on the decline.
  7. Fires as a result of road traffic accidents are not all that common.
  8. Non-accidental injuries occur in child abuse or physical abuse between adults. These are usually caused by either hot irons or cigarettes.


burns area adult

Burn area

Burns in the region of 10% of the body's area are considered to be major burns and can produce very severe shock.

The size of the area burnt is more important than the depth of the burn and the patient's age is an important consideration. On average:

A person less than 20 years old will usually survive a burn of 20% area

A person of 60 years has a 40% chance of surviving 20% burns

A person of 70 years has a 1% chance of surviving 20% burns

A person of 75 years or more will usually die from a burn greater than 18-20%

A person less than 20 years old has a 40% chance of surviving a 50% burn area

A person of 50 years or more will usually die from a burn area of 50%

Children with burns become shocked much more easily than adults because they have less body fluid but they are more resilient and can withstand the effect better.

Estimating burn area: the rule of nines
A patient's hand as a rule, is equal to approximately 1% of a person's body area. Bearing this in mind a system has been developed where:

Head and neck = 9%

Front of trunk = 18%

Back of trunk = 18%

Leg = 18%

Arm = 9%

Genitalia = 1%

There is a slight change in this method when using it to assess small children and infants:

Head and neck = 18%

Front of trunk = 18%

Back of trunk = 18%

Leg = 14%

Arm = 9%

Genitalia = 1%

A image thumb

burns area child infant

There is a slight change in this method when using it to assess small children and infants:

Head and neck = 18%

Front of trunk = 18%

Back of trunk = 18%

Leg = 14%

Arm = 9%

Genitalia = 1%

A image thumb

Chemical burns

Chemical burns

These occur when the skin comes in contact with strong acids, alkalis or other corrosives. The burn progresses as long as the chemical is in touch with the skin.

The area should be flushed with copious amounts of water to neutralise the chemical. Contaminated clothing should be removed with care, ensuring that you do not become contaminated yourself. Then treat as for any other burn.




Anxiety can result from many things, the accident itself, pain or fear. It is often incorrectly called shock.

Shock is a clear medical condition with specific signs and symptoms. A better way to describe anxiety would be to say that the patient was distressed or anxious.


Respiratory problems

Respiratory problems

Respiratory problems can occur following the inhalation of flames or hot gases. This may make the patient unconscious or even kill them before the fire consumes them. The airway becomes obstructed by swelling or pulmonary oedema.

Airway obstruction should be suspected in fires in enclosed areas, fires involving toxic chemicals or plastics, facial burns, if the patient's voice is hoarse, if there is coughing, or if redness can be seen in the upper airway.

Airway obstruction should be treated by the administration of oxygen but in the absence of this, cold compresses can be administered to the outside of the neck and throat.

Patients who die a few days after being admitted to a burns unit do so usually as a result of airway problems or infection.

Sometimes the complex changes to the body as a result of shock can also be the cause of death




Electrical burns may produce very severe internal damage with only slight external injury. Electricity takes the route of least resistance and tends to follow the path of nerves and blood vessels. It will always have an entrance and exit wound.

The entrance wound would be at the point of the body that touched the electricity. The exit wound could be anywhere on the body, but as a rule if the patient were standing up at the time of the incident the exit wound would most likely be at the feet.

About 40 people die each year from electrocution and another 2000 are injured.

Lightening bolts contain over a million volts of electrical current and may cause cardiac arrest as the electrical current passes through the chest, cause massive entrance and exit wounds and set clothing alight


 control mechanisms for maintaining body temperature

How is body temperature maintained?

Normal body temperature is in the range of 36-37ºC. In order to maintain this temperature the body has several mechanisms to accommodate any fluctuation in the norm.

These control mechanisms are:

  1. Constriction of the blood vessels on the periphery of the body to prevent blood from cooling on the surface. This keeps the inner temperature higher.
  2. Voluntary or involuntary muscle movement causing the production of heat, eg shivering.
  3. Erection of body hairs to trap a layer of warm air near the body surface. This process can also be reversed to lose heat from the body.
  4. To lose heat the body will produce sweat, which then evaporates from the skin's surface causing heat loss.
  5. Breathing rates can also change. To lose heat breathing rates increase, drawing cooler air into the inner body. To gain heat breathing rates slow down to minimise the amount of cool air entering the body.




If the body temperature rises above 36-37ºC the patient is said to be hyperthermic. This can be caused by environmental conditions like the weather and also by disease or infection.

Your prime objective after checking ABC is to reduce the patient's temperature as quickly as possible. This may be achieved by either removing clothing or soaking the patient with cold water. If the heat source is artificial, like an electric fire, then it must be removed. If the heat source happens to be the sun, then the patient must be removed to a cooler place in the shade.

If the hyperthermia is caused by disease or infection, cooling must still take precedence but the patient is in definite need of medical attention, so hospitalisation must be sought immediately. Monitoring of the patient's vital signs in this situation is of paramount importance



Signs and symptoms are:

Treatment includes:


When the body temperature falls below 35ºC, the patient is said to be hypothermic, that is to say that the body is too cold to function properly. The elderly are extremely susceptible to this condition for many reasons including poor housing and heating, a lack of nourishment and poor general health.

Signs and symptoms are:

  1. Lack of concentration
  2. Continuous shivering (early signs)
  3. Lack of interest in their surroundings
  4. Pale dry skin, cold to touch
  5. Slow shallow breathing
  6. Slow weak pulse
  7. Falling level of consciousness
  8. Cardiac arrest in severe cases

Treatment includes:

Check your own safety, do not give up your own clothing. If the patient is outside get them into shelter as soon as possible

Check the patient's ABC (airways, breathing and circulation), resuscitate if need be

Warm the patient up as quickly as possible - avoid using hot water bottles and the like. If the patient is conscious give them warm, sweet drinks

Monitor your patient at all times - rewarming can cause cardiac problems

If need be, use your own body heat to warm up the patient

Keep your patient warm and reassured, get them to hospital as soon as possible


What do I need to know about infectious diseases?

What do I need to know about infectious diseases?

Infection can find its way into the body by four major routes; inhalation, ingestion, inoculation (absorption) or sexual transmission . Once a patient has become infected, they can then spread the disease to others in two ways:


1. Direct Contact
A second person actually touches the contaminated person. The infection is contained in tiny drops of perspiration which are then absorbed through the skin of the second person. Contamination of the skin by an infected patient's blood can also spread an infection.
2. Indirect Contact
The most common indirect method is airborne infection, where infection spreads in droplets of moisture expelled from the patient's nose and mouth, either by ordinary breathing, sneezing or coughing. It is also possible to spread infection via contact with articles of clothing etc that an infected patient has handled, or via contact with their faeces or urine


Infectious diseases are categorised into three groups

Category I

Category I are those every day run of the mill type diseases. Very little or no precaution is required when transporting this type of patient.

Diseases include:

  1. Leprosy
  2. Influenza
  3. Whooping cough
  4. Legionaires disease
  5. Glandular fever
  6. Malaria
  7. Tetanus
  8. Scabies
  9. Erysipelas
  10. Leptospirosis
  11. Ophthalmia neonatorum


Category II diseases

Category II

Category II are those diseases that, on the whole can only be transmitted via direct contact, either with the patient themselves or their excreta.

Obviously a little more precaution has to be paid in the transportation of these patients, but if no contact with the patient occurs, then there is no risk.

Diseases include:

  1. Anthrax
  2. Measles
  3. Cholera
  4. Rubella
  5. Meningitis
  6. Hepatitis B
  7. Food poisoning
  8. Gastroenteritis
  9. Tuberculosis
  10. Infestations
  11. Chickenpox
  12. Diphtheria
  13. Dysentery
  14. Typhus
  15. Shingles
  16. Mumps
  17. Encephalitis
  18. Poliomyelitis


Category III diseases

Category III

Category III are those diseases that are considered highly contagious and require special precaution and treatment in their transportation.

These include:




Lassa Fever


Viral haemorrhagic fevers (VHF)


Once an outbreak has occurred, it can be contained by four methods


Some people are naturally immune to some diseases, others have to be inoculated.

This is the means by which a person is exposed to a small amount of the disease in the form of a vaccine.

The body then fights the reduced infection and builds up its own immunity


Disinfection does not necessarily mean the application of artificial cleaning agents, although this is highly effective.

Disinfection can also happen naturally by the action of the sun or wind


This method speaks for itself. Infected or suspected infected patients are kept isolated until the outbreak is cleared up


The law demands that certain infectious diseases are notified to the medical officer for environmental health.

The patient's doctor usually does this.

Environmental health can then monitor the outbreak and trace its origin if need be


There are certain safety guidelines set out for the use of medical gas cylinders

What medical gases should I be aware of?

Medical gases are stored in standard size cylinders. Those in usual service are supplied by BOC and are either D or F size. Although the amount of gas stored in the cylinder may vary according to the gas in question it will always be charged to 2000psi.

There are certain safety guidelines set out for the use of medical gas cylinders:

  1. No smoking
  2. Check cylinder head for damage
  3. Equipment must fit and seal to cylinder tightly
  4. Do not use excessive force on cylinder valves
  5. There is a risk of explosion if equipment or cylinders come into contact with grease or oil
  6. Change cylinder when it is ¼ full - do not allow to run dry
  7. Cylinders should be stored in a well ventilated situation
  8. Separate full and empty cylinders
  9. Cylinder should be carried not rolled during transit



what gases

what colour bottle

side effects

contra indications


Entonox is an analgesic gas made up of 50% oxygen (O2) and 50% nitrous oOxide (N2O). Different services will have different manufacturers equipment, but they will all function from a D-size cylinder which holds 500 litres of gas charged to a pressure of 2000psi. The cylinder is blue in colour and has a white segmented neck. The pin index on the neck will comprise one locating hole, so it can be told apart from D-size cylinders containing other gases. The male part of the pin index will be found on the connecting yoke of the equipment.

The gases may separate if the cylinder is left in freezing temperatures, but this can be remedied by warming the cylinder in tepid water for a few minutes and turning it upside down several times, to remix the gases.

All equipment will result in the gas being self-administered. If the patient becomes drowsy the face mask or mouthpiece will fall away and administration will cease, making it impossible for the patient to overdose.

The patient must:

  1. Self-administer the gas
  2. Be fully conscious
  3. Be capable of understanding what is being offered
  4. Be instructed in its use
  5. Be warned of the side effects

There are certain patient conditions that are contraindicated in the administration of entonox. This means that the gas should not be administered to those patients with:

  1. Severe head injuries
  2. Maxillo-facial injuries
  3. Severe chest injuries
  4. Drink or drug abuse
  5. Mentally ill patients
  6. Decompression sickness

Side effects of entonox include dry mouth, dysphagia, mild nausea, drowsiness, and light-headedness



bottle colour




Oxygen is a colourless, odourless gas that exists naturally - 20-21% of atmospheric air is oxygen. Oxygen for medical use is stored in a black cylinder with a white neck. There are two most common sizes of cylinder in use in the Ambulance Service:

D size - 340 litres of oxygen charged to 2000psi

F size - 1360 litres of oxygen charged to 2000psi

The D-size cylinder has a pin index on the collar made up of two locating holes that correspond to two locating lugs on the regulator. The regulator is fitted to the cylinder and acts as a pressure-reducing valve, which reduces the cylinder pressure of 2000psi down to a more useable value of 60psi.

The F-size cylinder has a bullnose connection, a threaded affair, which screws into the valve on the cylinder. The regulator usually connects direct to the cylinder and again reduces the pressure to 60psi. The regulator is then connected to another valve mechanism, usually a flow meter in the case of piped oxygen, but can also be any type of resuscitator that will deliver a preset amount of gas. Some flow meters have variable settings calibrated in litres per minute flow rate, whereas others are calibrated to deliver preset amounts.

Face masks vary tremendously from service to service, but as a rule the percentage of oxygen delivered by the mask will be written on the packaging, and this will usually depend on flow rate and the type of mask being used.

It must be remembered that oxygen is a prescription only medicine (POM) and as such must be administered with great care.

Oxygen direct from a cylinder is a dry compound and can cause discomfort or damage to the membranes lining the respiratory tract. This can be remedied by either a humidifier (not usually carried on an ambulance) or by ceasing the administration after 20 minutes and giving the patient sips of water, just to moisten the membranes.

It is difficult to give exact oxygen percentages to correspond with each individual patient condition. As a rule any cardiovascular complaint such as heart disease or severe blood loss, will require a high percentage oxygen therapy, and any chronic respiratory conditions such as bronchitis or emphysema will require a low percentage oxygen therapy, probably 25-28%.

Other conditions that may require varying percentages of oxygen therapy are as follows,

  1. Head injury
  2. Chest injury
  3. Shock
  4. Hypoxia
  5. Internal haemorrhage
  6. Carbon monoxide poisoning
  7. Acute asthma
  8. Major fractures
  9. Hyperthermia
  10. Hypothermia
  11. Burns
  12. CPR
  13. CVA

Patients that should not be given oxygen (contraindications)

  1. Prolonged administration to a premature neonate can cause blindness, so administer with great care. 
  2. Patients suffering PARAQUAT POISONING must NOT be given oxygen therapy


A burn is defined as a breach in the continuity of a tissue caused by excessive heat energy.

Yes   No

A burn is defined as a breach in the continuity of a tissue caused by excessive heat energy.



 A person less than 20 years of age will usually survive a 20% burn.

Yes   No



Using the rule of nines for an adult, one whole leg represents 9% body area.

Yes   No



Using the rule of nines for a child, one whole arm represents 18% body area.

Yes   No



Normal body temperature is within the range of 36-37oC. 

Yes   No