Burns: Degrees, First Aid and Treatment Methods

What Is a Burn?

Hello, I am Dr. Emre Geçer. A burn is damage to the skin and underlying tissues caused by heat, chemical agents, electric current, radiation or friction. Burns are one of the most common types of injury worldwide and affect millions of people every year. In Turkey, home accidents (scalding water, hot oil, open flames) are the most frequent causes of burns.

The severity of a burn depends on its depth, the body surface area affected, its location, the patient's age and any accompanying injuries. Correct and rapid first aid can limit the progression of the burn and significantly improve recovery.

Burn Pathophysiology: Jackson's Burn Zones

A burn wound contains three concentric zones described by Jackson:

• Zone of coagulation (center): The area of most intense burn injury, where cells have suffered irreversible damage (necrosis). Tissue loss here is permanent.
• Zone of stasis: The surrounding area where blood flow is reduced but cells are still alive. It can be salvaged with proper treatment; however, inadequate intervention, infection or hypoperfusion can convert it to necrosis.
• Zone of hyperemia (outermost): An area of increased blood flow with minimal damage; it usually heals on its own.

The fundamental goal of burn first aid is to save the tissue in the zone of stasis and prevent the burn from deepening.

Burn Classification

Superficial (First-Degree) Burn

Only the epidermis (outer skin) is affected.

• Appearance: Redness, dry surface, no blistering.
• Pain: Present (nerve endings are intact).
• Example: Mild sunburn.
• Healing: 3–7 days, leaves no scar.
• Not included in TBSA calculations.

Superficial Partial-Thickness (Superficial Second-Degree) Burn

The epidermis and the papillary layer of the dermis are affected.

• Appearance: Red, moist, blisters filled with clear fluid.
• Pain: Severe (nerve endings are exposed).
• Capillary refill: Brisk (blanches with pressure and rapidly refills).
• Healing: 7–21 days, usually with minimal scarring.

Deep Partial-Thickness (Deep Second-Degree) Burn

The epidermis and the reticular layer of the dermis are affected.

• Appearance: Pale or mottled red, moist or dry; blisters may be present.
• Pain: Reduced (deep nerve endings are damaged).
• Capillary refill: Slow or absent.
• Healing: 3–8 weeks, high risk of noticeable scarring; grafting may be required.

Full-Thickness (Third-Degree) Burn

The entire epidermis and dermis are destroyed; the burn may extend into subcutaneous fat.

• Appearance: White, waxy, brown or black; dry and leathery (eschar).
• Pain: Painless (nerve endings completely destroyed) — this illusion may mislead patients about the severity.
• Capillary refill: Absent.
• Healing: Does not heal on its own; surgical debridement and grafting are required.

Fourth-Degree Burn

Extends beyond skin and subcutaneous tissue to involve muscle, tendon, bone or joint structures. Usually seen with electrical burns or prolonged flame exposure. Amputation may be required.

Burn Surface Area Calculation

Rule of Nines — Adults

Used for a rapid estimation of total body surface area (TBSA):

• Head and neck: 9%
• Each arm: 9%
• Chest (anterior): 18%
• Back (posterior): 18%
• Each leg: 18%
• Perineum: 1%

Lund–Browder Chart

Because children's body proportions differ from those of adults (proportionally larger head, smaller legs), the Lund–Browder chart provides age-adjusted TBSA calculation and is the gold standard in children.

Palm Method

For small or irregular burns, the patient's palm (including fingers) corresponds to approximately 1% of the total body surface area and is useful for quick estimation.

First Aid: Do It Right, Save a Life

Step 1: Safety and Removing the Source

• Make sure your own safety is secured first.
• Remove the patient from the burn source.
• Extinguish burning clothing ("stop, drop and roll" technique).
• Remove clothing that is not stuck to the skin; do not forcibly pull off items that have stuck.
• Immediately remove jewelry such as rings, watches and bracelets (before swelling sets in).

Step 2: Cooling with Water

This is the most critical step of burn first aid.

• Cool the burn under cool running water (15–20 °C) for 20 minutes.
• This is effective within the first 3 hours after the burn.
• It limits tissue damage in the zone of stasis and reduces pain.

DO NOT:

• Do not apply ice: Vasoconstriction increases tissue damage and can cause hypothermia.
• Do not apply butter, toothpaste, yogurt or egg: They increase infection risk, trap heat, and make medical assessment difficult.
• Do not apply cotton wool or any fluffy material: It sticks to the wound.
• Do not burst blisters: This breaches the infection barrier.

Step 3: Airway Assessment

Inhalation injury should be strongly suspected in enclosed-space fires and facial burns. Warning signs include:

• Burns on the face, nasal hairs or eyebrows
• Hoarseness, stridor
• Sooty sputum
• Edema or soot in the oropharynx
• Respiratory distress

When inhalation injury is suspected, early intubation can be life-saving; airway edema progresses rapidly.

Step 4: Covering the Burn and Preventing Heat Loss

• Cover the burn area with a clean, non-stick dressing or cling film.
• Prevent heat loss in the patient — the risk of hypothermia is high, especially with large burns.
• Paracetamol or ibuprofen can be given for pain control.

Hospital Treatment

Fluid Resuscitation: The Parkland Formula

Aggressive intravenous fluid replacement is essential in burns covering more than 20% of TBSA. Because capillary permeability is increased in burns, there is massive intravascular fluid loss (third-space loss).

Parkland formula: The amount of crystalloid (Ringer's lactate) to give in the first 24 hours:

4 mL × body weight (kg) × burn TBSA (%)

• Half of the calculated amount is given in the first 8 hours, the other half over the next 16 hours.
• The clock starts at the time of injury (not at arrival at hospital).
• Urine output (0.5–1 mL/kg/hour in adults) is monitored to adjust the fluid rate.

Wound Care

• Debridement: removing necrotic tissue.
• Topical antimicrobial agents: silver sulfadiazine, mafenide acetate, nanocrystalline silver dressings.
• Modern wound dressings: biosynthetic dressings, hydrogel, alginate.
• Regular dressing changes and monitoring for infection.

Surgical Treatment

• Escharotomy: Longitudinal incision of eschar in full-thickness circumferential burns to prevent compartment syndrome.
• Excision and grafting: Surgical removal of necrotic tissue in deep partial- and full-thickness burns and application of skin grafts.
• Skin graft types: autograft (from the patient's own skin), allograft (from a cadaver), xenograft (from animal skin), artificial skin substitutes.

When Should You Go to Hospital?

Hospital evaluation is required in the following situations:

• Burns covering more than 10% of TBSA (5% in children)
• Full-thickness (third-degree) burns — regardless of size
• Burns on the face, hands, feet, genitalia, major joints or perineum
• Circumferential burns
• Suspected inhalation injury
• Chemical or electrical burns
• Associated trauma or fracture
• Patients under 5 or over 60
• Patients with chronic illness (diabetes, immunosuppression)
• Burns where neglect or abuse is suspected

Complications

• Infection: The most serious complication of burn wounds; Pseudomonas aeruginosa and MRSA are the most frequent organisms. Sepsis can develop.
• Hypertrophic scar and keloid: Excessive scar tissue formation; managed with pressure therapy, silicone gel and steroid injection.
• Contracture: Limitation of joint movement from contracting scar tissue; managed with physiotherapy and, if needed, surgical release.
• Hypothermia: Heat loss due to disrupted skin barrier.
• Hypovolemia and shock: Massive fluid loss in large burns.

Special Types of Burns

Chemical Burns

Chemical burns result from contact with acids, alkalis or organic compounds. Alkali burns are more dangerous than acid burns — they penetrate the tissue more deeply (liquefactive necrosis).

• If the chemical is a dry powder, brush it off first.
• Irrigate with copious water for at least 20–30 minutes (longer for alkalis).
• Do not use neutralizing agents — the resulting exothermic reaction increases tissue damage.

Electrical Burns

Electrical burns are often much more serious than they appear. Current travels through low-resistance tissues (nerves, blood vessels, muscle) and causes deep tissue damage; even if the surface burn looks limited, the underlying muscle, tendon and vascular damage can be extensive.

• Risk of cardiac arrhythmia: ECG monitoring is required.
• Rhabdomyolysis: myoglobin release from muscle breakdown → acute kidney injury.
• Risk of compartment syndrome: fasciotomy may be required.
• Before approaching the patient, make sure the electrical source has been switched off.

Conclusion

Burns are injuries whose outcomes can be significantly improved with correct first aid and appropriate medical care. The most critical first-aid step is cooling the burn under cool running water for 20 minutes. Avoid wrong applications such as ice, toothpaste or butter. Hospital evaluation is required for large or deep burns, burns of the face, hands or genital area, and chemical or electrical burns. Burn prevention — kitchen safety, childproofing and fire safety — is always more valuable than treatment.

Wishing you healthy days.
Dr. Emre Geçer

References

• Sabiston Textbook of Surgery, 21st Edition — Chapter: Burns
• Tintinalli's Emergency Medicine, 9th Edition — Chapter: Thermal Burns
• American Burn Association — Burn Center Referral Criteria
• Wasiak J, et al. Water cooling for the initial treatment of burns. Cochrane Database Syst Rev. 2013