If the patient cannot tell you what happened, then the paramedics should be able to advise on whether the burn was caused by heat, chemicals, electric shock or a combination of all of these. They will also be able to warn if other trauma is involved (such as a jump from a burning building).

• If smoke was involved or if there is any sign of soot or burns around the mouth or nose, then damage to the airway from smoke inhalation must be considered. The patient must be put on 100% oxygen and a very careful watch put on their airway and their oxygen saturation. specific problems which the patient may experience are:
  
• Smoke may contain carbon monoxide.
  
• Toxic fumes in the smoke may also have caused chemical damage to the lungs. This may lead to a rapid onset of pulmonary oedema with a fall in blood gases and the need for assisted ventilation.
  
• If the patient has actually breathed in flames, damage to the lining of the upper airway will lead to swelling of the glottis. Stridor will be the first sign – followed rapidly by complete airway obstruction. It is safest to perform endotracheal intubation early, as it can be almost impossible to find the vocal cords once oedema has set in. Otherwise, an emergency tracheostomy will be needed.

Move the patient to safety, (taking care not to be injured yourself). For heat or chemical burns apply as much clean water as possible, to prevent further heat damage and to dilute chemicals so that the burning process stops as quickly as possible. Cold water will also reduce pain, and wash out any contamination which may cause infection. Cover the burn with a dressing (cling film will do well) to prevent subsequent contamination and reduce pain. Pain relief will also be needed.

Patients with burns lose large volumes of fluid by exudation and evaporation. These fluids need to be replaced if circulation is to be maintained and renal failure avoided. A cut-down may be needed to obtain good venous access, for crystalloids, colloids and even blood transfusion. In severe cases a urinary catheter and a central venous line will be needed to monitor the state of the circulation so that the appropriate volume of fluids can be given.

Exposed wounds lose fluid, cool the patient by evaporation, are very painful and are at risk of becoming infected. Any foreign material embedded in the wound will need removing, but at this stage it is only important to make sure that noxious chemicals are washed away and any smouldering material is cooled down so that the burn does not extend. The burns are best covered with cling-film or some other non-stick conforming dressing covering some kind of antiseptic cream such as silver sulfazine.

High voltage electric shocks will traverse the patient’s body leaving only a small entry and exit burn visible externally, even when there is extensive internal damage. An electrocardiograph (ECG) will be needed to exclude myocardial damage; compartment syndrome is also a risk in the limbs.

The severity of burns is determined by the area involved and the depth of the burns.

Area