Treating burns as an EMT starts with scene safety, then follows a systematic approach: stop the burning process, assess burn depth and size, manage the airway, cool the wound appropriately, cover it with sterile dressings, manage pain, and transport to the right facility. The specifics change depending on whether you’re dealing with thermal, chemical, or electrical burns, and getting the assessment right drives every decision that follows.
Assessing Burn Depth
Four things tell you how deep a burn goes: appearance, whether it blanches under pressure, how much pain the patient reports, and whether they can feel sensation in the burned area. These findings guide your treatment priorities and transport decisions.
Superficial (first-degree) burns affect only the outermost skin layer. They look pink to red, are dry with no blisters, and are moderately painful. Think sunburn. These rarely need much prehospital intervention beyond cooling and comfort.
Partial-thickness (second-degree) burns come in two varieties, and the distinction matters. Superficial partial-thickness burns blister, and when you see the wound bed underneath, it’s uniformly pink or red and blanches when you press it. These are painful. Deep partial-thickness burns also blister, but the wound bed underneath looks mottled and blanches slowly. Pain is minimal and only present with deep pressure, which tells you the nerve endings in the deeper skin layers are damaged.
Full-thickness (third-degree) burns look leathery, stiff, and dry. The burned area won’t blanch at all because the blood supply is destroyed. The patient feels no pain or sensation in the burned area because the nerves are gone too. Paradoxically, the worst-looking burns often hurt the least.
Calculating Burn Size With the Rule of Nines
Total body surface area, or TBSA, is the universal language for communicating burn severity. In adults, the Rule of Nines breaks the body into predictable segments. The entire head is 9%. The front of the torso is 18%, the back is 18%. Each entire arm is 9%. Each entire leg is 18%. The groin accounts for the remaining 1%.
Children have proportionally larger heads, so these numbers shift. For infants and small children under about 10 kg, a modified system assigns roughly 20% to the head, 32% to the trunk, 16% to each leg, and 8% to each arm. The patient’s palm (including fingers) represents roughly 1% of their body surface area and works well for estimating scattered or irregular burns. Only count partial-thickness and full-thickness burns toward your TBSA estimate; superficial burns don’t factor in.
Checking for Inhalation Injury
Airway compromise can kill a burn patient faster than the burn itself, and swelling can close an airway rapidly. Look for facial burns, burns around the mouth, singed nasal hairs, and soot in the mouth or nostrils. Hoarseness, stridor, and drooling suggest the airway is already swelling. Any patient with these findings or a history of being in an enclosed space with smoke needs high-flow oxygen and close monitoring during transport. If you’re at the EMT-Basic level, early recognition and rapid transport are your tools. Paramedics may need to consider advanced airway management before edema makes it impossible.
Cooling Thermal Burns
For thermal burns, cool the affected area with cool (not cold) running water. The commonly cited recommendation is 20 minutes, though the exact optimal duration isn’t firmly established. What is clear: cooling reduces pain, can limit how deep the burn progresses, and improves outcomes when started quickly.
Use room-temperature or cool tap water. Ice, ice water, and freezing cold water are harmful because they cause vasoconstriction and can deepen tissue injury. For burns covering a large TBSA, be cautious with prolonged cooling. Hypothermia is a real risk, especially in children and the elderly. Cover areas you’re not actively cooling, monitor the patient’s temperature, and stop cooling if the patient starts shivering or their core temperature drops.
Treating Chemical Burns
Chemical burns require a different first step: protect yourself. Don gloves, eye protection, and any other PPE appropriate for the substance. Remove the patient from the exposure, then remove all clothing, shoes, and jewelry from the affected area.
For dry powder chemicals, brush off as much powder as possible with a dry towel or brush before adding any water. This is critical for substances like dry lime (calcium oxide), which reacts with small amounts of water to generate heat and form a strong alkali, making the burn worse. Once the dry chemical is brushed away, begin copious water irrigation. For liquid chemical exposures, skip the brushing step and go straight to flushing with large volumes of water. A few specific chemicals, including elemental sodium, elemental potassium, and phenol, react dangerously with water. If you know the substance and it’s one of these, follow your local protocol for alternative decontamination. When in doubt, copious water irrigation is the safest default.
Starting irrigation in the field rather than waiting for the hospital reduces burn severity and shortens hospital stays. Time matters because chemical burns keep destroying tissue as long as the agent stays in contact with skin.
Electrical Burn Considerations
Electrical burns are deceptive. The surface wounds at the entry and exit points often look small, but the current travels through the body along the path of least resistance, damaging muscle, nerves, blood vessels, and organs along the way. You cannot judge the severity of an electrical burn by looking at the skin. Treat every significant electrical injury as potentially having major internal damage.
Cardiac rhythm disturbances are a primary concern. Any patient with a significant electrical injury needs cardiac monitoring during transport. Be prepared to manage arrhythmias. Also assess for associated traumatic injuries, since electrical contact can cause violent muscle contractions or falls.
Dressings and Wound Care
After cooling, cover the burn with a clean, dry sterile dressing. For smaller burns, sterile gauze works well. For larger burns, a sterile burn sheet is more practical. The goal in the field is simple: protect the wound from contamination, reduce air movement over exposed nerve endings (which reduces pain), and prevent heat loss.
Don’t apply creams, ointments, butter, or any home remedies to the burn. Don’t pop intact blisters. If rings, watches, or tight clothing are near the burn, remove them early. Burned tissue swells rapidly, and what fits now may become a tourniquet in 20 minutes. Separate burned fingers and toes with dry gauze to prevent them from sticking together.
Pain Management
Burns are among the most painful injuries you’ll encounter, and adequate pain control matters for both patient comfort and your ability to assess and treat them. At the EMT-Basic level, your options are limited to cooling, positioning, and covering the wound. Paramedics can administer IV pain medications, with common protocols using either morphine or fentanyl. Typical adult fentanyl dosing starts at 50 micrograms IV, with additional doses every 3 to 5 minutes as needed. Morphine protocols generally start at 2 to 5 mg IV.
Monitor closely after giving opioids. Watch for a respiratory rate dropping below 12, oxygen saturation falling below 92%, or blood pressure dropping below 90 systolic. These are manageable with supplemental oxygen and, rarely, a reversal agent, but they require vigilance. In one large study of prehospital opioid use, only one patient out of hundreds required reversal, and no patients needed intubation from the medication alone.
Fluid Resuscitation for Major Burns
Patients with significant burns lose large amounts of fluid through damaged skin. For burns over 20% TBSA in adults (or lower thresholds in children), IV fluid replacement becomes essential. The Parkland formula is the most widely used guide: 4 mL of lactated Ringer’s solution per kilogram of body weight per percent TBSA burned, delivered over the first 24 hours from the time of injury. For children, the formula uses 3 mL per kilogram. Half of the calculated volume goes in during the first 8 hours, the second half over the remaining 16.
In the prehospital setting, your role is to establish IV access (two large-bore IVs for major burns) and begin fluid administration. It’s acceptable to place the IV through burned skin if no unburned sites are available. Don’t try to push the entire 24-hour volume in the field. Start the fluids, document the time of injury and your fluid totals, and communicate this clearly at handoff.
When to Transport to a Burn Center
The American Burn Association’s referral guidelines identify specific injuries that benefit from specialized burn center care. Transport directly to a burn center, or arrange transfer after initial stabilization, for any of the following:
- Partial-thickness burns 10% TBSA or greater
- Any full-thickness burn
- Burns to the face, hands, feet, genitalia, perineum, or over major joints
- All suspected inhalation injuries
- All chemical burns
- High-voltage electrical injuries (1,000 volts or more) and lightning strikes
- Burns with associated trauma
- Burns in patients with significant medical conditions that could complicate recovery
- All pediatric burns (14 years and under) may benefit from burn center referral due to pain management, dressing needs, and the need to screen for non-accidental trauma
Even low-voltage electrical injuries warrant burn center follow-up to screen for delayed symptoms and vision problems. When in doubt about whether a patient meets criteria, contact your local burn center for consultation during transport.