Student Guide

Burns: ermal
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Student Guide
Learning Objectives NREMT Requirement
Cognitive Domain 1. Refresher
1. State major functions of the skin. a. Trauma
2. List the layers of the skin and their b. Elective
components. 2. Additional related continuing education
3. Describe the causes of burn injuries and the
emergency treatment for a patient with burns.
4. Describe the indicators for signs of airway
compromise in burn patients.
5. Describe the assessment process for a burn
patient; include determining the depth of burn
and percentage of burned area.

Psychomotor Domain
1. Demonstrate the steps in emergency care for
superficial, partial-thickness, and full-thickness
burns.
2. Demonstrate the emergency care for a respira-
tory emergency.

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Notes
Lesson Outline
I. Classification of burns by depth1
A. Superficial burns
1. Characteristics include:
a. Involvement of only the epidermis
b. Reddened skin
c. Pain at the site
d. Healing in 7 to 10 days
B. Partial-thickness burns
1. Commonly result from contact with hot liquids or flash
burns from gasoline flames
2. Characteristics include:
a. Involvement of both the epidermis and the dermis but
not the underlying tissue
b. White to red skin that is moist and mottled
c. Blisters
d. Intense pain
e. Swelling
f. Skin sensitivity to air current
g. Healing in 14 to 21 days
C. Full-thickness burns
1. Commonly caused by fire, prolonged exposure to hot liq-
uids, contact with hot objects or electricity, and requires
skin grafting
2. Characteristics include:
a. Extension through all the dermal layers; may involve
subcutaneous layers, muscle, bone, or organs
b. Dry and leathery skin2
c. White, dark brown, or charred skin2
d. Loss of sensation, i.e. little or no pain at site, hard to
the touch, intense pain at the periphery
II. Determining burn severity depends on:
A. Depth or degree of the burn3
B. Percentage of body surface area burned
1. Rule of Palm: The size of the patient’s hand is equal to 1
percent of his or her body surface area3
2. Rule of Nines—adult3
a. Head and neck: 9 percent4
b. Each upper extremity: 9 percent4
c. Anterior trunk: 18 percent4

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d. Posterior trunk: 18 percent4 Notes

e. Each lower extremity: 18 percent4
f. Genitalia: 1 percent4
3. Rule of Nines—infant/child. Discuss how chart varies,
depending on age, and to consider using Rule of Palm.4
a. Head and neck: 18 percent5
b. Each upper extremity: 9 percent
c. Anterior trunk: 18 percent
d. Posterior trunk: 18 percent
e. Each lower extremity: 14 percent
C. Location of the burn. Burns are severe if they involve:1
1. Face and upper airway burns6
2. Burns of the hands6
3. Burns of the feet6
4. Burns of the genitalia6
D. Pre-existing medical conditions
E. Age of patient. Burns are severe if they occur in patients who
are:
1. Younger than 5 years of age
2. Older than 55 years of age7
F. Infant and child considerations
1. Relative size of the infant and child compared with adults
influences the severity of burns.1
a. Children have a larger surface area in relationship to
the total body size.1
b. This larger surface area results in greater fluid and
heat loss.
2. Children are at a higher risk for shock, airway problems,
and hypothermia than adults.1
3. Consider possibility of child abuse when treating a
burned child.
4. Any full-thickness burn or partial-thickness burn greater
than 20 percent, or burn involving the hands, feet, face,
airway, or genitalia, is considered a critical burn in a child.1
5. Any partial-thickness burn of 10–20 percent is considered
a moderate burn in a child.1
6. Any partial-thickness burn of less than 10 percent is con-
sidered a minor burn in a child.1
G. Categories of burn severity
1. Critical burns include:
a. Full-thickness burns involving the hands, feet, face,
or genitalia1
b. Burns associated with respiratory injury1
c. Full-thickness burns covering more than 10 percent
of the body surface area1

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d. Partial-thickness burns covering more than 30 per- Notes

cent of the body surface area1
e. Burns complicated by a painful, swollen, deformed
extremity1
f. Moderate burns in young children or elderly patients1
g. Burns encompassing any body part1
2. Moderate burns include:
a. Full-thickness burns of 2–10 percent of the body sur-
face area excluding hands, feet, face, genitalia, and
upper airway
b. Partial-thickness burns of 15–30 percent of the body
surface area1
c. Superficial burns of greater than 50 percent of the
body surface area1
3. Minor burns include:
a. Full-thickness burns of less than 2 percent of the
body surface area1
b. Partial-thickness burns of less than 15 percent of the
body surface area1
III. Emergency medical care3
A. Ensure scene safety. Do not approach until you are sure the
scene is safe.
B. Take standard precautions.
C. Stop the burning process initially with room-temperature
water or saline.
D. Remove smoldering clothing and jewelry but do not attempt
to remove clothing stuck to patient.
E. Establish and maintain an open airway and continually moni-
tor the airway for evidence of closure.
F. Administer oxygen.
1. If breathing is adequate, apply oxygen by non-rebreather
mask 15 LPM.
2. If breathing is inadequate, provide positive-pressure ven-
tilation with 100 percent oxygen and assess adequacy of
ventilation delivered.
3. If breathing is inadequate, ALS care should include intu-
bation.
G. For respiratory distress, position the patient with the head el-
evated if a spinal injury is not suspected.
H. If ALS is available, start two large-bore IVs.
I. If ALS is available, manage pain as per protocol.
J. Determine the severity of the burn.
1. If the burn is critical, transport the patient immediately.
2. Know local protocols for transport to an appropriate local
facility.

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K. Prevent further contamination.3 Notes

1. Follow local protocol.
2. Cover the burned area with a dry, sterile dressing or ster-
ile burn sheet.
3. Do not use any type of ointment, lotion, or antiseptic on
the burn.
4. Do not break blisters.
L. Transport promptly to the appropriate facility.
IV. Chemical burns3
A. Take the necessary scene safety precautions to protect your-
self from exposure to hazardous materials.
B. Wear gloves and eye protection.
C. Emergency medical care8
1. Dry powders should be brushed off skin before flushing.
2. Immediately begin to flush the skin with large amounts of
water.
3. Continue flushing the contaminated area while en route to
the receiving facility.
4. Do not contaminate uninjured areas when flushing.
V. Electrical burns3
A. Ensure scene safety.
B. Do not attempt to remove the patient from the electrical
source.
C. If the patient is still in contact with the electrical source or you
are unsure, do not touch the patient. Call for resources.
D. Emergency medical care
1. Administer oxygen if indicated.
2. Monitor the patient closely for respiratory and cardiac ar-
rest.
3. These burns are often more severe than external indica-
tions.
4. Look for both an entrance and exit wound.

References
In addition to meeting the current national EMS Education Standards,
the information in this program is supported by the following references:
1 Bledsoe, B.E., Porter, R.S., & Cherry, R.A. (2011). Essentials of
Paramedic Care (2nd ed.). Upper Saddle River, NJ: Pearson.
2 Sanders, Mick J. “Chapter 39: Burns.” Mosby’s Paramedic Textbook,
Fourth Edition. St. Louis, MO: Mosby, Inc. (Elsevier Inc.), 2012.
1122-1145.
3 Salomone, J.P., & Pons, P.T. (2007). PHTLS (6th ed.). St. Louis, MO:
Mosby Elsevier.

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4 Barnes, Leaugeay, Joseph A. Ciotola, & Benjamin Gulli. “Chapter 24: Notes
Soft-Tissue Injuries.” Emergency Care and Transportation of the Sick
and Injured, 10th Edition. Burlington, MA: Jones & Bartlett Learning,
2011. 822-837.
5 Dieckmann, R., Brownstein, D., & Gausche-Hill, M. (2000). Pediatric
Education for Prehospital Professionals. Sudbury, MA: Jones and
Bartlett.
6 Limmer, Daniel, Michael F. O'Keefe, and Edward T. Dickinson.
"Chapter 28: Soft-Tissue Trauma." Emergency Care. 12th Edition.
Upper Saddle River, NJ: Pearson/Prentice Hall, 2005. 659-670.
7 Monafo WW. Initial management of burns. N Engl J Med. 1996;
335:1581–6.
8 Mistovich, Joseph J., and Keith J. Karren. “Chapter 29: Burns.”
Prehospital Emergency Care, 10th Edition. Pearson, 2014. 811-831.

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Patient Scenarios
Overview
Burns are more than simple injuries to the skin; they
are very complex emergencies that require special-
ized knowledge and unique interventions. In addi-
tion to damaging the structure of the skin and its
functions, burn injuries can dramatically affect other
body systems. Temperature regulation, fluid and
chemical balance, and circulatory and respiratory
functions are all at risk. Burns also cause emotional
and psychological problems that could last a life-
time.
Prepare
Consider the following as you integrate the video
and lesson into your training:
• Classroom lecture and discussion alone are
not adequate to train.
• Proper management of burn patients can
make all the difference in preventing mortality
and morbidity for these patients.
• Airway care needs to be emphasized!
Psychomotor Domain
• Demonstrate the steps in emergency care for
superficial, partial-, and full-thickness burns.
• Demonstrate the emergency care for a respira-
tory emergency.
Patient Scenarios 90 Minutes
Scenario 1:
You are dispatched to a house fire. You arrive on the
scene just as a fire crew is removing a person from
the building. Patient appears limp with agonal respi-
rations. Patient still has a pulse, but it is very weak.
Patient has first- and second-degree burns on his
hands and arms. There is a moderate amount of
soot on the patient’s face. Patient was found in the
living room.
Instructor note:
• Participants should do a patient assessment,
including the ABCs. Patient’s airway needs to
be protected. If patient’s airway is not immedi-
ately corrected, patient goes into cardiac ar-
rest. If patient’s airway is immediately handled
properly, patient improves to breathe on own
but does not regain consciousness. Patient’s
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Burns: ermal
burns should also be treated with dry, sterile
dressings. This is a critical burn patient and
should be transported to appropriate facility.
Scenario 2:
You arrive on the scene of a pool chemical manu-
facturing plant. Your patient has liquid chlorine on
his legs. The skin is very red and appears to be blis-
tering in areas. Vital signs are stable.
Instructor note:
• Participants should do their assessment after
taking appropriate personal protection meas-
ures. Provide oxygen and flush skin of chemi-
cal burn with copious amounts of water. Then
cover with dry, sterile dressings. Remind par-
ticipants that they must stop burning first:
Chemicals will continue to burn until flushed.
Scenario 3:
You arrive on the scene to find a young child who
was playing near a fire when a can of gasoline was
thrown on it. The child has burns of various depths
on the entire front of his body.
Instructor note:
• Participants should do their assessment, mak-
ing sure of scene safety. Provide appropriate
care for a patient with these types of burns.
They need to provide good airway protection.
Using the “Rule of Nines” chart, discuss how
pediatric burns are classified differently from
adult burns.
Scenario 4:
You arrive on the scene of a patient who had sus-
tained an electrical shock to his left arm. There is an
entrance wound. There appears to be an exit wound
to the right foot. Patient is unresponsive, apneic,
and pulseless. Patient is not in contact with electri-
cal source; scene is safe.
Instructor note:
• General care for a patient in cardiac arrest. De-
fibrillation is typically indicated in these patients.
Scenario 5:
Patient was cooking when she spilled a kettle of boil-
ing water on her groin area and upper thighs. There is
a combination of first- and second-degree burns.
Instructor note:
• Remove clothing, cool area, apply dry, sterile
dressings. Provide oxygen and pain
management.
Student Guide 8

Self-Study Tips
• Select a comfortable, quiet space with good
lighting.
• Allow enough time to complete the lesson
without interruption.
• Have available a working TV and DVD player,
or computer.
• Review the Learning Objectives.
• Take the Pre-Test.
• Review Discussion Points.
• Complete the lesson.
• Complete the Self-Study Practices and Exer-
cises.
• Review the recommended websites and re-
lated reading.
• Take the Post-Test.
Self-Study Exercises
Overview
Burns are more than simple injuries to the skin; they
are very complex emergencies that require special
knowledge and unique interventions. In addition to
damaging the structure of the skin, burn injuries can
dramatically affect other body systems. Tempera-
ture regulation, fluid and chemical balance, and cir-
culatory and respiratory functions are all at risk.
Exercise 1: Review the following scenario and dis-
cuss with another EMS professional the potential
outcomes and hidden problems. Be prepared to an-
swer the following questions.
You and your partner respond to a fire at a local
motel. When you approach the scene, you find a
man and a woman with severe burns to their faces,
arms, and upper chest. The patients are in signifi-
cant pain, but are conscious and do not appear to
be in shock. You discover that the fire originated in
their hotel room but note that they are reluctant to
explain the circumstances surrounding the source of
the blaze. The fire has been extinguished, and you
are able to observe the interior of the room, where
you find various 2-liter bottles containing remnants
of a muddy brown substance, 1-quart bottles of liq-
uid fuels, and aluminum foil.
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Burns: ermal
Based on this information, consider the following
questions:
• What kind of personal protective measures
might you need to take prior to making any fur-
ther assessment of the patients?
• How might the circumstances of this scene af-
fect the administration of Oxygen?
• What type or types of burns would you expect
to encounter in this scenario?
• What treatment would you initiate and what
other considerations may be necessary in this
scenario?
Exercise 2: Review the article listed below. Read
article:
Based on this article, consider the following
points:
• Consider how the information in this article re-
lates to information learned in previous educa-
tional opportunities.
• Review how the local information supports
your organizational, local, and regional proto-
cols.
• Develop an educational program and deliver
the program to other EMS providers or stu-
dents.
Exercise 3: Review the regional and local protocols
and organizational procedures for burn response.
These protocols should include how to identify the
severity of a burn, techniques for identifying and
handling other injuries associated with burns, and
methods for mitigating psychological and emotional
distress that may present in a burn victim. Deter-
mine whether the current policies in your locale ef-
fectively guide crew decision-making as it relates to
treatment and scene transportation.
Based on this information, complete the following
exercise:
• Create an educational program for your service
based on the results of your research.
Student Guide 9