Burns

Any person, 4 weeks to 15 years, 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
General appearance/first impressions	Position of comfort Patients with head and neck burn injuries should be nursed head-up, to reduce swelling
Suspected cervical 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 or cry 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 Airway injury may worsen over time Continual observation is required for any face or neck burn Consider and prepare for early endotracheal intubation

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%
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 and back and assess for circumferential burns

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor: for all electrical and severe burns or if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Complete 12 lead ECG for electrical 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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL 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 10% TBSA: escalate as per local CERS protocol second cannula may be required see pathology section

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess 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

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/or warmed room Measure core temperature if actively warming
Head-to-toe 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	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
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, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

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 the 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: for easy to use TBSA calculator, download the NSW trauma app.

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.

Non-accidental burn injuries

Concerning features on history:

• Inadequate supervision
• Delayed presentation
• Changing mechanism of burn story
• History that is incompatible with the age or development of the child and injury
• Mechanism that is incompatible with injury.

Burns raising concern for non-accidental injury:

• Scalds
• Location, e.g. hands, feet, genitals and buttocks
• Pattern
  • Circumferential
  • Symmetrical
  • Uniform depth
  • No splash marks
  • Sparing on buttock cheeks “doughnut sign” (held down in bath), in flexures (groin, knees) and abdominal creases (as the trunk is flexed forward when the child tries to protect themselves)
  • Glove and stocking from limb submersion
  • Patterned burn over 1 lesion: cigarette burns; iron; lighter; classic “smiley face”
• Submersion burns
• Very young child
• Bilateral foot sole burns from being held on hot pavement.

Interventions and diagnostics

Specific treatment

First aid

• Give analgesia and wait for it to take effect 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 burns 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 transfer is delayed for more than 8 hours.
• For all other burns, apply an occlusive non-adherent dressing.

Limb burns

• 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.

Specific burn first aid management

• 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.

Ocular burns

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Analgesia

Select pain score:

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

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Tetanus

All patients must be considered for a tetanus booster if they have a tetanus-prone wound. Refer to medical or nurse practitioner or nurse immuniser to consider tetanus immunisation requirements.

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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.

• TBSA over 10% or requiring surgery: FBC, UEC, BSL, VBG, group and hold
• Inhalation injuries and/or concerns for smoke inhalation: 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 patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

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