Silliman University

College of Nursing
Dumaguete City

FIRST AID FOR BURNS HANDOUT

Submitted To:
Asst. Prof. Rowena Mission Turtal, RN, MAN

Submitted By:
Francess Jade Añosa
Fiona Isobel Caballo

Teaching Date:
May 2022

Venue:
Google Meet
 Table of Contents

Learning Outcomes 3

The Skin: A brief review 4

Understanding the Skin 4
Anatomy of the Skin 4

Burn and its Pathophysiology 6

What is a Burn? 6
Pathophysiology of a Burn 6

Types of Burns according to Causes 8

Thermal burns. 8
Radiation burns. 8
Chemical burns. 8
Electrical burns. 8
Friction burns. 9

Types of Burns according to Depth 9

First-degree (superficial) burns. 9
Second-degree (partial thickness) burns. 10
Third-degree (full thickness) burns. 10
Fourth-degree burns. 11

Types of Burns according to Severity 12

Assessing the Degree of Burn using the Rule of Nines 13

First-Aid Measures According to Types 15

References 20
 First Aid for Burns

Learning Outcomes:
After the 25-minute discussion, the Level II- A4 students will:
1. Recall the anatomy and the functions of the skin;
2. Describe the pathophysiology of a burn;
3. Accurately enumerate the different types of burns according to causes, depth, and
severity;
4. Differentiate each type of burn according to causes;
5. Differentiate each type of burn according to depth;
6. Differentiate each type of burn according to severity;
7. Correctly calculate the total body surface area percentage that is burned for a
hypothetical patient who has experienced burns using the Rule of Nines; and
8. Discuss the first aid measure for burns according to types.
 First Aid for Burns

I. The Skin: A brief review

Understanding the Skin
To understand different kinds of burns, it is helpful to know about skin. The skin
is the largest organ of the body. The average adult has 18 square feet of skin, which
accounts for 16 percent of total body weight.
Your skin:
● Acts as a physical barrier for you to the outside world
● Protects you against infection and injury
● Provides a water-tight barrier
● Helps regulate body temperature
● Contains glands that lubricate and moisturize your skin
● Undergoes constant repair and regeneration
Lacerations, abrasions or burns alter the skin's ability to protect and buffer you
from your surroundings.

Anatomy of the Skin

Layers of the Skin

The three layers of the skin:

1. Epidermis (top layer)
Your epidermis is the top layer of the skin that you can see and touch.
Keratin, a protein inside skin cells, makes up the skin cells and, along with other
proteins, sticks together to form this layer. The epidermis:
 ● Acts as a protective barrier: The epidermis keeps bacteria and germs from
entering your body and bloodstream and causing infections. It also
protects against rain, sun, and other elements.
● Makes new skin: The epidermis continually makes new skin cells. These
new cells replace the approximately 40,000 old skin cells that your body
sheds every day. You have new skin every 30 days.
● Protects your body: Langerhans cells in the epidermis are part of the
body’s immune system. They help fight off germs and infections.
● Provides skin color. The epidermis contains melanin, the pigment that
gives skin its color. The amount of melanin you have determines the color
of your skin, hair, and eyes. People who make more melanin have darker
skin and may tan more quickly.

2. Dermis (middle layer)

The dermis makes up 90% of the skin’s thickness. This middle layer of
skin:
● Has collagen and elastin: Collagen is a protein that makes skin cells strong
and resilient. Another protein found in the dermis, elastin, keeps skin
flexible. It also helps stretched skin regain its shape.
● Grows hair: The roots of hair follicles attach to the dermis.
● Keeps you in touch: Nerves in the dermis tell you when something is too
hot to touch, itchy, or super soft. These nerve receptors also help you feel
pain.
● Makes oil: Oil glands in the dermis help keep the skin soft and smooth.
Oil also prevents your skin from absorbing too much water when you
swim or get caught in a rainstorm.
● Produces sweat: Sweat glands in the dermis release sweat through skin
pores. Sweat helps regulate your body temperature.
● Supplies blood: Blood vessels in the dermis provide nutrients to the
epidermis, keeping the skin layers healthy.

3. Hypodermis/ Subcutaneous tissue (bottom or fatty layer)

The bottom layer of skin, otherwise known as the subcutaneous fat or
subcutis, is the fatty layer. The hypodermis:
● Cushions muscles and bone: Fat in the hypodermis protects muscles and
bones from injuries when you fall or are in an accident.
● Has connective tissue: This tissue connects layers of skin to muscles and
bones.
 ● Helps the nerves and blood vessels: Nerves and blood vessels in the
dermis (middle layer) get larger in the hypodermis. These nerves and
blood vessels branch out to connect the hypodermis to the rest of the body.
● Regulates body temperature: Fat in the hypodermis keeps you from getting
too cold or hot.

II. Burn and its Pathophysiology

What is a Burn?
According to the World Health Organization, a burn is an injury to the skin or
other organic tissue caused by some type of energy source such as heat. They can be
manageable and heal with at-home treatments or can be life-threatening and require
specialized medical care.
Burns occur mainly in the home and workplace, with fire and flame injuries being
the most common causes, followed by scalds, contact with a hot object, and electrical
injuries. Children and women are usually burned in domestic kitchens, from upset
receptacles containing hot liquids or flames, or from cookstove explosions. Men are most
likely to be burned in the workplace due to fire, scalds, and chemical and electrical burns.

Pathophysiology of a Burn
Burn injuries results in both local and systemic responses.​
A. Local response
Heat from burns causes protein denaturation and thus coagulative necrosis.
Around the coagulated tissue, platelets aggregate, vessels constrict, and
marginally perfused tissue (known as the zone of stasis) can extend around the
injury. In the zone of stasis, tissue is hyperemic and inflamed.

The three zones of a burn were described by Jackson in 1947.

1. Zone of coagulation—This occurs at the point of maximum damage. In
this zone, there is irreversible tissue loss due to coagulation of the
constituent proteins.
2. Zone of stasis—The surrounding zone of stasis is characterized by
decreased tissue perfusion. The tissue in this zone is potentially
salvageable. The main aim of burns resuscitation is to increase tissue
perfusion here and prevent any damage from becoming irreversible.
Additional insults—such as prolonged hypotension, infection, or edema—
can convert this zone into an area of complete tissue loss.
3. Zone of hyperemia—In this outermost zone tissue perfusion is increased.
The tissue here will invariably recover unless there is severe sepsis or
prolonged hypoperfusion.
 Jackson's burns zones and the effects of adequate and inadequate resuscitation

These three zones of a burn are three-dimensional, and loss of tissue in the
zone of stasis will lead to the wound deepening as well as widening. Damage to
the normal epidermal barrier allows bacterial invasion, external fluid loss, and
impaired thermoregulation.
Damaged tissues often become edematous, further enhancing intravascular
volume loss. Heat loss can be significant because thermoregulation of the
damaged dermis is absent, particularly in wounds that are exposed.

B. Systemic response
The release of cytokines and other inflammatory mediators at the site of
injury has a systemic effect once the burn reaches 30% of total body surface area.
1. Cardiovascular changes—Capillary permeability is increased, leading to
loss of intravascular proteins and fluids into the interstitial compartment.
Peripheral and splanchnic vasoconstriction occurs. Myocardial
contractility is decreased, possibly due to the release of tumor necrosis
factor α. These changes, coupled with fluid loss from the burn wound,
result in systemic hypotension and end-organ hypoperfusion.
2. Respiratory changes—Inflammatory mediators cause bronchoconstriction,
and in severe burns, adult respiratory distress syndrome can occur.
3. Metabolic changes—The basal metabolic rate increases up to three times
its original rate. This, coupled with splanchnic hypoperfusion, necessitates
early and aggressive enteral feeding to decrease catabolism and maintain
gut integrity.
4. Immunological changes—Non-specific down-regulation of the immune
response occurs, affecting both cell-mediated and humoral pathways.
 Systemic changes that occur after a burn injury

III. Types of Burns according to Causes

Burns can either be caused by thermal, radiation, chemical, electrical contact, or
friction. The following are the types of burns according to their causes:
A. Thermal burns.
Thermal burns refer to burns due to external heat sources that raise the
temperature of the skin and tissues. These burns also cause tissue cell death or
black charring. Hot metals, scalding liquids, steam, and flames, when coming in
contact with the skin, can cause thermal burns.
B. Radiation burns.
Radiation burns are caused by prolonged exposure to ultraviolet rays of the sun.
Also caused by exposure to other sources of radiation such as therapeutic cancer
treatments or nuclear power plant leaks.
C. Chemical burns.
Chemical burns refer to burn injuries caused by strong acids, alkalis, detergents,
or solvents coming into contact with the skin or eyes.
D. Electrical burns.
Electrical burns are from electrical current, either alternating current (AC) or
direct current (DC).
 E. Friction burns.
Friction burns are from direct damage to the cells and from the heat generated by
friction. Examples include children falling on or touching a treadmill in motion.
Or a rope burn from a rope sliding through the hands.

IV. Types of Burns according to Depth

Traditionally the terms first, second, third, and fourth-degree have been used
to describe the depth of tissue injury.

Degrees of Burns

A. First-degree (superficial) burns.

First-degree burns affect only the outer layer of skin, the epidermis. The
burn site is red, painful, dry, and with no blisters. Long-term tissue damage is rare
and often consists of an increase or decrease in skin color. Mild sunburn is an
example.

First-Degree Sunburn
B. Second-degree (partial thickness) burns.
Second-degree burns involve the epidermis and part of the lower layer of
skin, the dermis. The burn site looks red, blistered, and may be swollen and
painful. Blisters are the most common sign of a second-degree burn. The skin
under the blisters is wet, weepy, pink, and painful. This type of burn may occur
from a scald, hot grease, or contact with a hot surface, such as a curling iron.

Second-degree burns are divided into two categories based on the depth of the
burn:
1. Superficial second-degree burns typically heal with conservative care (no
surgery required) in one to three weeks. Topical medications are placed on
the burn wound. Daily wound bandage changes are the norm. New
epidermis grows in one to three weeks with proper wound care.
2. Deep second-degree burns appear more pale than pink. The skin is drier
and the sensation of that skin can be diminished. Sometimes, these burns
will need surgery for skin grafting. This decision cannot be made in the
first few days, and a short course of conservative treatment (topical
medications) will be tried to allow wounds to heal, if possible.

Second-Degree Steam Iron Burn

C. Third-degree (full thickness) burns.

Third-degree burns destroy the epidermis and dermis. They may go into
the innermost layer of skin, the subcutaneous tissue. The burn site may look white
or blackened and charred. Typically, these burns have very diminished pain due to
damage to the sensory receptors. If a burn DOES NOT hurt, it may be a third-
degree burn. These burns usually require surgery for skin grafting.
 Third-Degree Burn on Foot caused by a hot motorcycle muffler

D. Fourth-degree burns.
Fourth-degree burns go through both layers of the skin and underlying
tissue as well as deeper tissue, possibly involving muscle and bone. There is no
feeling in the area since the nerve endings are destroyed. Appears black, charred
with eschar, takes months to heal and needs skin grafting.

A patient with fourth-degree burns to her face. The burn was caused by burning
her hair extensions, which ignited and the patient was unable to extinguish the
flames.
 V. Types of Burns according to Severity
The severity of a burn is classified into three – minor burns, moderate burns, and major
burns. This is affected by the following factors: the extent and depth of the burn, the causative
agent and the duration of contact with the burning agent, the body area involved, the patient’s
age, and concomitant injuries and illnesses.

The table below by Boyd (2016) illustrates the determinants of each of the three
classifications.

Minor Burns Moderate Burns Major Burns

Children

Partial thickness < 10% BSA 10-20% BSA > 20% BSA
burn

Full thickness burn < 2% BSA 2-10% BSA > 10% BSA

Adults

Partial thickness < 15% BSA 15-25% BSA > 25% BSA
burn

Full thickness burn < 2% BSA 2-10% BSA > 10% BSA

Age Patients < 2 yrs. with Patients < 10 yrs.

minor injury with major injury

Involvement of (-) (-) Moderate injury

Hands, Face, Feet, involvement
Perineum

Electrical Injury (-) (-) (+)

Chemical Injury (-) (-) (+)

Inhalational Injury Not suspected Not suspected (+)

Major associated (-) (-) (+)

medical illness

Associated (-) (-) (+)

fractures, multiple
trauma

Disposition Outpatient Hospital admission Referral to burn

management center

*BSA – body surface area.

VI. Assessing the Degree of Burn using the Rule of Nines

The Rule of Nines – also known as the Wallace Rule of Nines – is a useful
method in assessing burns by determining the estimated percentage of your skin affected
by the burn. This divides the body’s surface area into sections by multiples of 9% each,
hence the name Rule of Nines.

In the use of this method, percentages are assigned to the different body areas.
The following are the parameters of the Rule of Nines according to Blahd, Husney, et. al.
(2021):
● The front and back of each arm and hand equal 9% of the body's surface area.
● The chest equals 9% and the stomach equals 9% of the body's surface area.
● The upper back equals 9% and the lower back equals 9% of the body's surface
area.
● The front and back of each leg and foot equal 18% of the body's surface area.
● The genital area equals 1% of the body's surface area.
 The percentages, however, may vary due to varying body types caused by different BMI,
body size, age, and other factors among patients. The Rule of Nines is mostly used by emergency
medical responders in quickly and efficiently estimating the area affected by the burn in order to
determine the severity and the corresponding treatments needed upon arrival at the hospital.

❖ Supplementary Video:
● Rule of Nines: Burns | NCLEX RN Review

Sample Scenarios with use of Rule of Nines (RegisteredNurseRN.com, n.d.):

● A 25-year-old female patient has sustained burns to the back of the right arm, posterior
trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines,
calculate the total body surface area percentage that is burned?
- ANSWER: Using the Rule of Nines, it can be determined that the TBSA (total
body surface area) affected by the burns is 37%. The back of the right arm (4.5%),
posterior trunk (18%), the front of the left leg (9%), the anterior head and neck
(4.5%), and perineum (1%) make up the 37% TBSA.

(To be answered by students:)

● A 68-year-old male patient has partial-thickness burns to the front and back of the right
and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the
total body surface area percentage that is burned?
 - ANSWER: Using the Rule of Nines, it can be determined that the TBSA affected
by the burns is 58.5%. The front and back of the right and left legs (36%), the
front of the right arm (4.5%), and the anterior trunk (18%) make up the 58.5%
TBSA.
● A 35-year-old male patient has full-thickness burns to the anterior and posterior head and
neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body
surface area percentage that is burned?
- ANSWER: Using the Rule of Nines, it can be determined that the TBSA affected
by the burns is 19%. The anterior and posterior head and neck (9%), the front of
the left leg (9%), and the perineum (1%) make up the 19% TBSA.

VII. First-Aid Measures According to Types

Type of Burn First Aid Measures Rationale

Thermal In mild cases:

Burn ● Remove the heat source
from the patient, or the
patient from the heat
source, whichever is
easiest and safest.
● Immerse affected area in
cool, clean water for at
least 15 minutes.
● Do not break blisters or
rub skin.
● A first aid burn gel may
be applied, but this should
be after cooling with
water, provided water is
available.
● Place a dry, sterile
dressing over the burn
area to keep clean.
● Remove any tight
clothing, watches, rings
● To reduce the severity of
the injury as well as to
prevent further damage.
● To cool the burned area
and provide relief.
● To prevent infection and
slowing of the healing
process.
● To provide additional
temporary relief from
minor burns.
● To prevent infection,
promote moist wound
healing, and prevent
conversion to a deeper
burn.
● To prevent compression
and further injuries due to
 or jewellery from the
injured area, if possible.
In severe cases — if the patient is
badly injured, in significant pain,
affected in the eye area, or has a
burn larger than his/her arm:
● Remove the heat source
from the patient, or the
patient from the heat
source, whichever is
easiest and safest.
● Call an ambulance or
EMS if the burn is severe.
● Immerse affected area in
cool, clean water for at
least 15 minutes.
● A first aid burn gel may
be applied, but this should
be after cooling with
water, provided water is
available.
● Apply a clean, sterile
dressing over the burned
area(s).
● Keep the casualty calm
and still while you wait
for EMS to arrive.
● If possible, elevate the
burned area but only do
so if it does not cause
further discomfort to the
casualty.
● Remove any tight
clothing, watches, rings
or jewellery from the
injured area, if possible.
risk of swelling.
● To reduce the severity of
the injury as well as to
prevent further damage.
● To receive appropriate
medical treatment.
● To cool the burned area
and provide relief.
● To provide additional
temporary relief from
minor burns.
● To prevent infection,
promote moist wound
healing, and prevent
conversion to a deeper
burn.
● To prevent stress and
regulate breathing and
heart rate.
● To help prevent swelling
and pain.
● To prevent compression
and further injuries due to
risk of swelling.
Radiation Burn ● Immediately remove
source of burns from the
patient or remove patient
from the source.
● Run clean, cool water
over the affected areas or
apply a towel damp with
cool water.
● Apply a soothing gel or
lotion to the burns as
necessary after cleansing
with water.
● Take sips of cold water.
● Call EMS or go the
emergency room of your
nearest hospital if
significant pain persists or
signs of infection are
present.
Chemical ● Remove dry chemicals.
Burn Put on gloves and brush
off any remaining
material.
● Remove contaminated
clothing or jewelry. Rinse
chemicals off for at least
20 minutes, in a shower if
available. Protect your
eyes from chemical
contamination.
● Cover the burn with
sterile dressing or a clean
bandage. Wrap loosely to
avoid putting pressure on
burned skin.
● Rinse again as needed. If
you feel more burning,
rinse the area again for
● To lessen exposure and
prevent further damage.
● To cool the burned area
and provide relief.
● To provide moisture and
to soothe irritation and
pain.
● To rehydrate the body and
make up for fluid loss.
● To receive appropriate
medical treatment.
● To prevent further
damage caused by
residual chemicals.
● To protect unaffected
areas from damage.
Chemicals may cause
significant harm to the
eyes.
● To prevent infection,
promote moist wound
healing, and prevent
conversion to a deeper
burn.
● To ensure the affected
area is free of residual
chemicals/harmful
 several more minutes.
● Call for an ambulance or
EMS for major chemical
burns.
Electrical Burn ● If possible, safely and
carefully remove the
patient from the source of
electricity. Do not directly
touch the patient if he/she
is still in contact with the
electrical current. Shut off
the power source.
● Remove the patient’s
clothing, especially any
metal that is in contact
with the body (jewelry or
equipment).
● Begin CPR immediately
if the patient shows no
signs of circulation or has
no pulse.
● Try to prevent the patient
from becoming chilled.
● Apply a clean, sterile
dressing or bandage over
the burned area(s). Avoid
using blankets or towels.
Friction Burn ● Rinse the affected area
and clean it with a gentle
soap and water. There is
no need to run water over
the injury for several
minutes as the injury does
substances.
● To receive appropriate
medical treatment.
● To prevent the transfer of
the electrical current to
surrounding people. To
keep others safe.
● To prevent further
damage and to lessen
injuries.
● To keep oxygen flowing
in and out of the lungs
and to keep oxygenated
blood flowing through the
body.
● To prevent shock by
calming the patient down
and promoting adequate
circulation. To provide
comfort.
● To prevent infection.
Blankets, towels, and
similar cloth may have
fibers that will stick to the
wounds.
● To clean the wound,
provide temporary relief,
and prevent infection.
 not progress after the
friction stops unlike in
thermal burns.
● A first aid burn gel may
be applied after cleaning
the wound with soap and
water.
● Cover the burn with
sterile dressing or a clean
bandage.
● Over-the-counter pain
medications may be taken
if the patient is
experiencing significant
pain.
● Monitor the wound and
watch for signs of
infection.
● Call EMS if such
symptoms are observed.
● To provide additional
temporary relief from
minor burns.
● To prevent infection,
promote moist wound
healing, and prevent
conversion to a deeper
burn.
● To provide pain relief.
● To detect early signs of
infection in order to be
ready with preventive
measures.
● To receive appropriate
medical treatment.

❖ Supplementary Videos:
● Thermal, Chemical and Electrical Burns
● How to Treat a Sunburn - First Aid Training - St. John Ambulance
● FAS Road rash and friction burns
References:

● Blahd, W., Husney, A., et. al. (2021). Rule of nines for burns. Retrieved from
https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=hw262650#:~:text=The%
20size%20of%20a%20burn,of%20the%20body's%20surface%20area
● Boyd, C. (2016). The burn manual. Retrieved from
https://slideplayer.com/slide/5919633/
● Brennan, D. (2021). What is the rule of nines. Retrieved from
https://www.webmd.com/skin-problems-and-treatments/what-is-the-rule-of-nines
● Brouhard, R. (2019, November 13). Burn pictures: A close look at first, second and third
degree. Verywell Health. Retrieved May 2, 2022, from
https://www.verywellhealth.com/burn-pictures-4020409
● Brouhard, R. (2022, March 2). Photo Gallery of second-degree burns. Verywell Health.
Retrieved May 2, 2022, from https://www.verywellhealth.com/examples-of-second-
degree-burns-1298346
● Burns Nclex review. Registered Nurse RN. (2019, August 21). Retrieved May 2, 2022,
from https://www.registerednursern.com/burns-nclex-review/
● Burns Overview. Burns Overview - Health Encyclopedia - University of Rochester
Medical Center. (n.d.). Retrieved May 1, 2022, from
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&Content
ID=P01737
● Burns: Types, symptoms & treatment. Cleveland Clinic. (n.d.). Retrieved May 2, 2022,
from https://my.clevelandclinic.org/health/diseases/12063-burns
● Carter, D. W. (2022, April 18). Burns - injuries; poisoning. MSD Manual Professional
Edition. Retrieved May 2, 2022, from
https://www.msdmanuals.com/professional/injuries-poisoning/burns/burns
● Chemical burns: first aid. (2022). MayoClinic.org. Retrieved from
https://www.mayoclinic.org/first-aid/first-aid-chemical-burns/basics/art-20056667
● Electrical burns: first aid. (2020). MayoClinic.org. Retrieved from
https://www.mayoclinic.org/first-aid/first-aid-electrical-burns/basics/art-20056687
● Greenhalgh, D. (2020, July). A series of pictures of a patient with fourth-degree burns to
her face ... ResearchGate. Retrieved May 2, 2022, from
https://www.researchgate.net/figure/A-series-of-pictures-of-a-patient-with-fourth-degree-
burns-to-her-face-The-burn-was_fig2_342988866
● Hettiaratchy, S., & Dziewulski, P. (2004). ABC of burns: pathophysiology and types of
burns. BMJ (Clinical research ed.), 328(7453), 1427–1429.
https://doi.org/10.1136/bmj.328.7453.1427
● Hypodermis (subcutaneous tissue): Function & Structure. Cleveland Clinic. (n.d.).
Retrieved May 2, 2022, from https://my.clevelandclinic.org/health/body/21902-
hypodermis-subcutaneous-tissue
● RegisteredNurseRN.com. (n.d.). Rule of nines for burns NCLEX questions. Retrieved
from https://www.registerednursern.com/rule-nines-nclex-quiz-questions/
● Skin: Layers, structure and function. Cleveland Clinic. (n.d.). Retrieved May 2, 2022,
from https://my.clevelandclinic.org/health/articles/10978-skin
● UC San Diego Health. UC Health - UC San Diego. (n.d.). Retrieved May 2, 2022, from
https://health.ucsd.edu/specialties/burn-center/pages/about-burns.aspx
● Ward, R. S. (2007). Friction burn. Retrieved from
https://www.sciencedirect.com/topics/medicine-and-dentistry/friction-burn
● World Health Organization. (2018, March 6). Burns. World Health Organization.
Retrieved May 1, 2022, from https://www.who.int/news-room/fact-sheets/detail/burns