Burns

Any person, 16 years and over, presenting with burns to any part of the body.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
All burn injuries	Position of comfort Patients with head and neck burn injuries should be nursed head-up, to reduce swelling
Suspected C-spine injury	Stabilise the C-spine with in-line immobilisation or foam collar (appendix)

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning
Evidence of airway burn: Stridor Singed facial hair Hoarse voice Black or sooty sputum Burn to face, mouth or neck Neck or facial swelling Intraoral oedema or erythema	Escalate as per local CERS protocol immediately Give humidified oxygen via a non-rebreather mask Airway injury may worsen over time Continual observation is required for any face or neck burn Consider and prepare for early intubation

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation if required Expose the chest to ensure adequate chest expansion If the respiratory rate is less than 10 BPM or more than 20 BPM, consider severe injury and escalate as per local CERS protocol Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%
Carbon monoxide inhalation	Pulse oximetry may not reflect actual oxygen saturations in carbon monoxide poisoning Apply 100% oxygen Ventilation support may be required Check blood gas
All severe burns	Apply oxygen via a non-rebreather
Circumferential chest or abdominal burns	Apply oxygen via a non-rebreather Expose the chest to ensure adequate chest expansion

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or for electrical, hydrofluoric acid and severe burns
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved If early shock is present, consider causes other than burn
Total body surface area (TBSA) %	Calculate the TBSA % using the rule of nines, see burns focused assessment If burns over 20% TBSA: give 1000 mL compound sodium lactate (Hartmann’s solution) over two hours, once only, if fluids not already given for signs of shock escalate as per local CERS protocol second cannula may be required see pathology section

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength If restless and/or reduced level of consciousness, consider hypoxaemia, carbon monoxide intoxication, shock, alcohol or drug
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment Analgesics should be withheld in patients with hydrofluoric acid burns until decontamination has occurred. Reduction in pain will indicate the effectiveness of treatment, see specific treatment section

Exposure

Assessment	Intervention
Temperature	Aim for normothermia Remove wet clothing, towels, and blankets If hypothermic, less than 35.5°C, initiate slow re-warming using blankets, air warming device and warmed room Measure core temperature if actively warming
Skin inspection, including posterior surfaces	Identify all burn distribution areas, including posterior surfaces and scalp Confirm adequate cooling has been initiated Remove all non-adhered clothes and jewellery Keep the rest of the body warm to prevent hypothermia Apply non-circumferential cling wrap to burn, if the appropriate dressing is delayed See specific treatment section for wound management following A to G assessment

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
Nausea and/or vomiting	If present, see nausea and/or vomiting section
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete burns focused assessment.

Consider secondary survey in trauma patients.

Precautions and notes

• Do not use ice or iced water to cool a burn.
• Burns products do not replace initial first aid of running water.
• When using oxygen masks for patients with facial burns ensure affected surfaces are protected with a barrier dressing, e.g. soft white paraffin (Bactigras) or impregnated gauze (Jelonet gauze).
• Recommended: download the NSW trauma app for interactive burns calculator.

Carboxyhaemoglobin

• Pulse oximetry cannot differentiate between haemoglobin and carboxyhaemoglobin, so will not read low, even when a patient is hypoxic.
• Blood gas will show metabolic acidosis and raised carboxyhaemoglobin.

Frostbite

• Frostbite, also known as reverse-thermal, is a type of burn injury to the skin and underlying tissues caused by freezing. It most commonly affects the extremities, occurring through exposure to cold-weather conditions or direct contact with ice, metals, liquids, such as LPG or aerosols sprayed directly onto the skin.
• Minor frostbite injuries can be managed with simple first aid involving analgesia and rewarming, followed by simple wound care. More serious injuries may require review with a burns service, for more intensive wound care management.

Interventions and diagnostics

Specific treatment

First aid

• Ensure adequate analgesia has been administered and ensure adequate time has lapsed post-analgesia administration before cleansing or dressing the burn.
• Remove jewellery and any clothing in direct contact with the burn.
• Do not remove bitumen or anything adhered to the skin. This requires removal in theatre, or in consultation with a burn specialist.
• Prevent hypothermia by cooling the burn not the patient.

Clean

• Limit debridement to wiping away clearly loose and blistered skin.
• De-roof blister, with a moist gauze or forceps and scissors, if over 5 mm or over joints.
• Clean burn wound and surrounding skin with sodium chloride 0.9%.

Cover

• Consider taking photos with consent before covering.
• For severe burns cover with plastic cling film lengthways along the burn:
  • Do not wrap circumferentially.
  • Do not apply plastic cling film to the face, use paraffin ointment.
  • Do not apply plastic cling film to a chemical burn.
• Paraffin gauze or silver dressing can be applied, if patient transfer is delayed for more than 8 hours.
• For all other burns, apply an occlusive non-adherent dressing.

Limb burn

• Elevate limb by positioning and adjuncts, e.g. pillows, towels or slings.
• Assess for circumferential burns.
• Do not apply dressings circumferentially.
• Ensure all digits are dressed individually.
• Check peripheral pulses.
• Provide hourly neurovascular observations.

First aid management for specific burn types

• If any uncertainty, contact Poisons Information Centre 13 11 26 and/or 000, Fire and Rescue NSW.

Chemical burns

• Contact Poisons Information Centre.
• Apply full PPE.
• Consider hazmat requirements for the place of treatment.
• If dry or powder chemical burn, remove or brush off before applying water.
• Irrigate with copious amounts of water (consider shower).
• Chemical burns should be cooled for 1–2 hours.

Electrical burns

• Complete 12 lead ECG.
• Assess for entry and exit wounds.

Hydrofluoric acid burns

• Escalate as per local CERS protocol immediately.
• Analgesics should be withheld in patients with hydrofluoric acid burns until decontamination has occurred. Reduction in pain will indicate the effectiveness of treatment.
• Decontamination:
  • Irrigate with copious amounts of water (consider shower) for a minimum of 30 minutes. Tap water is safe to use.
  • After irrigating, apply calcium gluconate 2.5% gel into the affected area and massage into skin for 15–30 minutes. Reapply gel every 10–15 minutes until pain subsides.
• Hydrofluoric acid burns cause significant complications including metabolic imbalances and cardiac arrhythmia. Apply cardiac monitoring and complete 12 lead ECG.

Ocular burn

• Instil one drop of oxybuprocaine 0.4% or tetracaine (amethocaine) hydrochloride 0.5% or 1% to the affected eye. Block lacrimal sac at medial canthus during and for one minute after drop.
• Drops may need to be re-instilled every 10 minutes during irrigation, maximum 3 doses.
• Irrigate the eye with sodium chloride 0.9% attached to giving set.
• Irrigate until pH is neutral by using appropriate pH indicator paper.
• Severe burns may require over 30 minutes of irrigation.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Tetanus

If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.

• Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
• If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
• If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
• If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually required for minor burns.

• Total body surface area (TBSA) over 20% or requiring surgery: FBC, UEC, BSL, group and hold, VBG
• Inhalation injuries and/or concerns for smoke inhalation: ABG (if trained) or VBG to assess for carboxyhaemoglobin (COHb) and lactate.
• Electrical burn with entry/exit points: CK, urinalysis – collect and check for blood which may indicate myoglobinuria or haemoglobinuria

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au