Thermal burns: first aid and treatment

A thermal burn is tissue damage caused by high temperatures, such as open flames, hot liquids and steam, red-hot objects, or explosions. Severity is determined by the depth of the skin lesion and the proportion of the total body surface area. The deeper and more extensive the burn, the higher the risk of shock, infection, and scarring. Understanding the mechanisms, proper first aid, and early risk stratification directly impact the outcome. [1]

Three concentric "zones" form within the wound, according to Jackson: a central zone of coagulation (irreversible tissue death), a surrounding zone of stasis (ischemia, still reversible), and a peripheral zone of hyperemia (inflammation, recovery possible). The goal of first aid and early treatment is to "save" the stasis zone and prevent the burn from "converting" into a deeper one. [2]

Thermal trauma triggers a systemic inflammatory and stress response with pronounced catabolism and hypermetabolism; without proper nutrition, pain relief, and early surgical intervention, this leads to complications and long-term rehabilitation. [3]

Modern solutions include objective depth assessment (laser Doppler imaging, thermal imaging), revised referral criteria to burn centers, and careful fluid therapy with possible early addition of albumin to reduce “hyper-resuscitation.” [4]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, thermal burns are coded in the range T20-T32: by anatomical site (T20-T25), by eye and internal organ involvement (T26-T28), as well as by multiple/unspecified sites and by percentage of body surface area (T30-T32; T31 - "burns classified by body surface area"). Chemical burns are separately classified as "corrosions." For completeness, codes for external causes (e.g., exposure to fire, smoke, hot substances) can be added. [5]

The International Classification of Diseases, Eleventh Revision, uses the ND90-ND9Z block for burns of the external body surface by area, NE00-NE0Z for burns of the eye and internal organs, NE10-NE11 for multiple/unspecified, and NE2Z for unspecified. ICD-11 makes extensive use of "expansion codes" to detail the depth, cause, and circumstances (e.g., thermal factor as an external cause). [6]

Table 1. Correspondence of codes (ICD-10 ↔ ICD-11, aggregated)

Essence	ICD-10	ICD-11 (core code)	Note
Burns of the outer surface in areas	T20-T25	ND90-ND9Z	The depth and side are specified by "expanding codes"
Burns to the eye/internal organs	T26-T28	NE00-NE0Z	Including the respiratory tract in case of thermal inhalation injury
Multiple/unspecified burns	T30, T29	NE10-NE11, NE2Z
Classification by body surface area	T31-T32	additional signs (ICD-11)	In ICD-11, area is coded using expansion codes
External cause (heat/fire/hot substances)	X00-X19	external cause codes (chapter "External causes")	Used together

Epidemiology

According to estimates from the World Health Organization and the Global Burden of Disease Study, burns remain a significant problem: approximately 180,000 people die from burns annually, with the overwhelming majority of deaths occurring in low- and middle-income countries. Non-hospitalized burns in the general population number in the tens and hundreds of millions of cases per year; in children and adolescents, the incidence is high, although it has been declining since the 1990s. [7]

New estimates for 2021 show multi-million prevalence of “minor” burns and millions of “severe” burns, with marked regional heterogeneity: higher rates in Latin America and the Caribbean, while significant declines are observed in North America and East Asia. [8]

In some countries and at-risk groups, rising costs and treatment times continue, particularly for burns, electrical injuries and explosions, impacting families and health systems. [9]

The proportion of the inhalation component (damage to the respiratory tract and systemic toxicity from combustion products) is small in number, but significantly increases mortality and requires specialized care. [10]

Table 2. Key epidemiological figures

Indicator	Grade
Burn mortality worldwide (per year)	≈ 180,000 cases
Global "minor" burns (prevalence, 2021)	≈ 235 million cases
Global "severe" burns (prevalence, 2021)	≈ 13 million cases
Trend 1990→2021	Overall decline, but high burden in low/middle income countries

Reasons

The main causes of thermal burns are flames (fires, clothing fires), hot liquids and steam (burns from boiling water, food, fats), contact with hot surfaces, and blast injuries. The type of source influences the depth and shape of the wound: flame burns are often deeper and more extensive, while dousings with boiling water often produce areas of varying depth. [11]

Burns from hot metals and molds can create distinct geometric contours, and after flashovers, combined damage with inhalation injury. Hot oils and sugar-containing syrups retain heat longer than water, increasing the risk of deep injuries. [12]

Fires in enclosed spaces are dangerous due to the combination of temperature, toxic gases (carbon monoxide, cyanides) and oxygen deficiency, which requires a special algorithm for providing assistance. [13]

Household factors (insufficient fire safety, lack of thermostats on taps, overload of electrical networks) and industrial risks (working with melts, steam, furnaces) determine the injury scenario. [14]

Risk factors

Risk factors for severe outcomes include older age, childhood, large area and depth of injury, inhalation injury, comorbidities, delay in first aid, and late evacuation. [15]

Social and environmental factors (overcrowding, use of open fires for cooking/heating, lack of fire alarms) increase the frequency and severity of burns. [16]

Alcohol intoxication, impaired mobility, sedative use, and limited skin sensation (diabetic neuropathy) increase the risk of deep burns and delayed recognition.[17]

In indoor fires, there are added risks of hypoxia, carbon monoxide poisoning, and cyanide poisoning, which worsens the prognosis even with moderate-sized skin burns. [18]

Pathogenesis

Locally, a burn wound consists of three zones according to Jackson; "conversion" of the stasis zone to necrosis occurs with persistent ischemia, edema, and infection. Adequate cooling, removal of the heat source, and early stabilization of microcirculation reduce the depth of damage. [19]

A systemic inflammatory cascade develops: cytokines (interleukin-6, interleukin-8, tumor necrosis factor-alpha, etc.) are released, the sympathoadrenal system is activated, and capillary leakage and hypovolemia develop. This leads to burn shock, requiring careful fluid management based on diuresis and clinical parameters. [20]

Over days and weeks, hypermetabolism and catabolism predominate: energy expenditure increases, proteolysis and insulin resistance intensify, anemia develops, and weight loss progresses. Treatment includes high-protein nutrition, early mobilization, and pain, itching, and sleep control. [21]

Skin regeneration occurs through the coordination of inflammation, granulation and epithelialization; in deep defects, surgical excision and skin grafting are necessary, otherwise the risk of infection and pathological scarring increases. [22]

Symptoms

Skin signs vary with depth, ranging from redness and tenderness in superficial lesions to pallor/waxiness, numbness, and a hard scab in full-thickness skin damage. Blisters are typical of superficial-to-medium-thickness injuries and should not be ruptured unless medically indicated. [23]

Systemic manifestations include thirst, cold, clammy sweat, and weakness; in cases of inhalation injury, hoarseness, cough, soot around the mouth/nose, and shortness of breath. Any sign of respiratory failure requires immediate medical attention. [24]

Burn pain is a complex mix of nociceptive and neuropathic pain and is often difficult to control with standard opioids, especially during dressing changes, which justifies multimodal regimens with ketamine and adjuvants. [25]

As healing progresses, itching, paresthesia, and sleep disturbances are common; antihistamines are of limited benefit, with gabapentinoids appearing to be more effective based on current evidence. [26]

Classification, forms and stages

Clinically, the following are distinguished: superficial burns (epidermis), superficial partial lesions (upper layers of the dermis), deep partial (deep layers of the dermis), and complete (the entire thickness of the skin, possibly involving subcutaneous tissue and muscles). The "degree" system (I-III) is now being superseded by "by thickness", since it more accurately determines tactics. [27]

In adults, the area of damage is often assessed using the “rule of nines”; in children, using the Lund-Browder table; for small burns, the “palm of the victim” is used as a guide, ≈ 1% of the body surface. [28]

Inhalation burns are distinguished as a separate clinical and pathological form: thermal damage to the supraglottic structures, chemical irritation of the respiratory tract and systemic toxicity (carbon monoxide, cyanides). [29]

The burn center referral criteria used for routing are: any full-thickness burns, partial ≥ 10% of the area in adults, facial/hand/feet/genital/perineal/large joint injuries, electrical injuries, chemical burns and inhalation injuries, as well as pediatric cases and combined injuries. [30]

Table 3. Burn depth - clinical signs

Depth	Color/humidity	Pain/tenderness	Capillary reaction	Healing prognosis
Superficial (epidermis)	Erythema, dry	Expressed	Fast	3-6 days, no scars
Partial superficial	Pink, wet, bubbly	Strong	Fast	1-2 weeks, minimal scarring
Partial deep	Pale pink/marble	Less pain	Slow/spotty	2-3 weeks, risk of scarring
Full thickness	White/brown, dry scab	Little pain	Absent	Requires excision/plastic surgery

Table 4. Area assessment - adults and children

Method	Adults	Children	Comments
The Rule of Nines	Head 9%, arm 9%, leg 18%, front chest 18%, back 18%, crotch 1%	Other percentages (head bigger, legs smaller)	For children, the Lund-Browder table is more accurate.
"Palm"	Palm of the victim ≈ 1%	Same	Convenient for minor burns

Table 5. Criteria for referral to a burn center (briefly)

Criterion	Not really
Any full thickness burns
Partial thickness ≥ 10% of area in adults
Face, hands, feet, genitals, perineum, large joints
Electrical injuries (including lightning), chemical burns
Inhalation injury
Children, severe comorbidities, combined injuries, intractable pain

Complications and consequences

Early complications include burn shock, respiratory failure (including inhalation injury and poisoning), wound infection, and sepsis—the leading cause of death in large burns. The likelihood of sepsis with burns affecting more than 20% of the body surface reaches 3-30%. [31]

Thromboembolic complications are more common than previously thought: when more than 10% of the body surface is affected, the risk of deep vein thrombosis and pulmonary embolism increases significantly, which justifies pharmacological prophylaxis with low molecular weight heparins with monitoring of anti-Xa activity. [32]

Late consequences: hypertrophic scars and contractures, chronic pain and itching, anxiety and post-traumatic stress disorder (according to various estimates, up to 20-40% in the first 6-12 months). Long-term rehabilitation and psychological support programs are required. [33]

Burn wound infections are often associated with gram-negative pathogens, particularly Pseudomonas aeruginosa, including multidrug-resistant ones, which dictates strict antisepsis, early wound closure, and an antibacterial policy based on indications rather than prophylaxis. [34]

When to see a doctor

Immediately - in case of burns to the face, hands, feet, genitals, large joints; in case of any surface complete damage; in case of partial burns in adults ≥ 10% or in case of signs of inhalation injury (hoarseness, soot, shortness of breath). [35]

Urgently - if blisters are present over a large area, pain/swelling/odor from the wound increases, temperature rises, signs of dehydration appear, or adequate pain relief cannot be achieved at home. [36]

In case of indoor fires - even without visible skin burns - an assessment for carbon monoxide poisoning is required (measurement of carboxyhemoglobin, supply of 100% oxygen; the decision on hyperbaric therapy is individual). [37]

Children, the elderly, and pregnant women are advised to seek help even for minor burns: the risk of dehydration, infection, and scarring is higher. [38]

Diagnostics

Step 1. First aid and assessment of vital signs. Stop exposure to heat; cool with running cool water for exactly 20 minutes if less than 3 hours have passed; remove rings/watches/tight clothing; do not use ice/oil/home remedy ointments. Assess the airway, breathing, and circulation. [39]

Step 2. Assessment of area and depth. Clinical examination, the "rule of nines"/Lund-Browder; if there is any doubt about the depth, dynamic observation for 24-72 hours, if possible, objectification: laser Doppler visualization, thermal imaging; in specialized centers - fluorescein angiography with indocyanine. [40]

Step 3. Laboratory assessment and inhalation injury. Complete blood count, electrolytes, creatinine, lactate; blood gas analysis. In case of fire - carboxyhemoglobin; if cyanide is suspected - lactate > 10 mmol/L as an indirect sign, the decision on antidote (hydroxocobalamin) - strictly according to indications. [41]

Step 4. Visualization and endoscopy as indicated. Bronchoscopy is the "gold standard" in the early hours to confirm inhalation injury, assess its extent, and perform debridement. X-ray/CT scan - in case of complications; photographic documentation of wounds for follow-up. [42]

Table 6. What and why to prescribe

Study	For what
Complete blood count, electrolytes	Evaluation of hemoconcentration and electrolyte shifts
Creatinine, urine (diuresis)	Monitoring perfusion and renal function
Gas composition, lactate	Severity of shock/hypoxia, indirectly cyanide toxicity
Carboxyhemoglobin	Diagnosis of carbon monoxide poisoning
Laser Doppler imaging/thermal imaging	Objectification of the depth and prognosis of healing
Bronchoscopy	Confirmation and extent of inhalation injury

Differential diagnosis

Chemical burns (corrosives): require prolonged irrigation and specific antidotes; clinically, "clean" edges and deep lesions with little pain are possible. For thermal burns, emphasis is placed on cooling and aseptic dressings. [43]

Electrical trauma and lightning: often small input-output "markers" with deep muscle necrosis and arrhythmias; mandatory cardiac monitoring and creatine kinase/myoglobin control. [44]

Stevens-Johnson syndrome/toxic epidermal necrolysis: drug-induced etiology, mucous membranes, positive Nikolsky sign; requires dermatologic burn management. [45]

Frostbite and radiation dermatitis: different chronic changes, different trigger; treated with different protocols, although dressings and infection control are similar. [46]

Treatment

First aid determines the depth. Remove the heat source and cool with cool running water for exactly 20 minutes within the first 3 hours after the injury; the water should be cool, not freezing. Do not apply ice, oil, paste, iodine, or "folk" remedies, as this will worsen the injury. After cooling, cover the burn with clean film/polyethylene or a sterile dry bandage and remove jewelry. Administer an analgesic and assess the indications for a tetanus vaccination. [47]

In adults with burns covering more than 20% of the burn surface, fluid therapy begins with crystalloids (lactated Ringer's solution or balanced analogs) with a target urine output (approximately 0.5-1.0 mL/kg/hour in adults). Current guidelines suggest starting with 2 mL × weight × percentage of the burn surface over the first 24 hours as a starting point and then titrating according to the response to avoid overflow. In severe burns, early addition of albumin during the first 24 hours is acceptable to reduce the total infusion volume. [48]

Pain relief is multimodal: paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) unless contraindicated, regional techniques as indicated, and, during dressing changes, low subdissociative doses of ketamine, which reduces opioid use and stabilizes hemodynamics. For procedural pain, ketamine has demonstrated comparable, and sometimes even superior, predictability of effect compared to morphine. [49]

Local wound care includes gentle cleansing, removal of exfoliated epidermis in large blisters, and the selection of modern dressings that maintain a moist environment: hydrofibers, silicone mesh, and modern silver-containing dressings, as indicated. Silver sulfadiazine is no longer considered a universal treatment for outpatient superficial burns, as it can slow epithelialization; its place is reserved for large or infected wounds in the hospital, as indicated. Prophylactic systemic antibiotics are not prescribed. [50]

Determining the depth helps to choose the tactics: superficial and superficial-partial burns usually heal on their own in 1-2 weeks under dressings; deep partial burns require early surgical evaluation; full-thickness burns require planned excision and skin grafting (autodermoplasty, mesh grafts, dermal matrices). Early excision and closure are associated with lower infection and better functional outcomes. [51]

Inhalation trauma is treated with airway management, early bronchoscopy, and oxygen therapy; carbon monoxide poisoning - 100% oxygen, consideration of hyperbaric oxygenation in symptomatic cases; suspected cyanide - consideration of hydroxocobalamin under strict indications, taking into account possible risks to the kidneys. [52]

Rehabilitation begins early: elevating the limbs, splinting in a functional position, breathing exercises, contracture prevention, selection of compression garments and silicone gels/sheets for those prone to hypertrophic scarring. Medication-induced pruritus is treated with moisturizing, antihistamines as adjuvant agents, and gabapentinoids, which have been shown to be superior to cetirizine in clinical trials. [53]

Nutrition and metabolic support - high-protein diets, adequate calories, vitamins and micronutrients; aggressive "megadoses" of vitamin C to reduce infusions have not yet had convincing clinical benefit and are not routinely recommended. [54]

New and additional techniques include negative pressure on the wound for large areas and donor sites, bromelain-based enzyme debriders in specialized centers (reduce the volume of surgery in a number of cases), and objective methods of perfusion assessment (laser Doppler imaging, indocyanine fluorescence angiography) for making decisions about necrectomy. [55]

Prophylaxis against venous thrombosis is indicated for large burn areas and low mobility; low-molecular-weight heparins are preferred, with dose adjustment based on anti-Xa activity in the intensive care unit. Psychological support, screening for anxiety, and post-traumatic stress disorder improve long-term outcomes. [56]

Table 7. First aid - "do" and "don't do"

Do	Do not do
Cool with running cool water for 20 minutes during the first 3 hours.	No ice, oil, toothpaste, iodine, or alcohol.
Remove hot clothing/jewelry and cover with clean film.	You cannot open the blisters yourself.
Give an analgesic, evaluate the tetanus vaccination	Do not bandage/tie too tightly
Look for signs of inhalation/extension and decide on hospitalization	You cannot delay your appeal if the referral criteria are met.

Table 8. Dressings and topical agents - what to choose

Product/bandage	Pros	Cons/Notes	Where appropriate
Modern hydrofibers/hydrogels/silicone meshes	Moist environment, fewer dressing changes	Cost, equipment needed	Superficial/moderate burns
Silver-containing coatings	Antimicrobial effect	Delayed epithelialization is possible with superficial burns.	Large/infected wounds
Silver sulfadiazine cream	Available	Risk of delayed healing; not "universal"	Inpatient, according to indications
Medicinal honey, alternatives	Antimicrobial activity in studies	The quality of evidence varies	Protocol Supplement

Table 9. Infusion therapy - guidelines

Parameter	Recommendations
Starting volume in adults with an area of > 20%	2 ml x kg x % area over 24 h as a starter, then titrate
Solutions	Ringer's lactate or balanced
Targeted diuresis	About 0.5-1.0 ml/kg/hour in adults
Albumen	Consider within the first 24 hours if there is an increasing need for crystalloids

Prevention

Home safety: smoke detectors, fire-resistant clothing, thermostats on faucets (tap water temperature no higher than 49°C), screens on stoves, training children and caring for the elderly. In the kitchen, place long pan handles backwards, and be careful with hot oils and syrups. [57]

Manufacturing: Personal protective equipment, screens, training in handling molten metals and steam, electrical monitoring, evacuation plans and drills. [58]

Community interventions: fire safety infrastructure, education programs, and access to specialized care, which statistically reduce the burn burden in regions with implemented policies.[59]

Personal prevention: avoid alcohol/sedatives when handling fire/hot liquids, be careful when using household chemicals and flammable materials. [60]

Forecast

Prognosis depends on the depth, extent, age, presence of inhalation injury, and the speed of initiation of adequate treatment. Early cooling, proper fluid management, and early wound closure improve survival and functional outcomes. [61]

Superficial and superficial partial burns usually heal completely without significant scarring; deep partial and full-thickness burns require surgery and carry a risk of hypertrophic scarring and contractures requiring compression and physical therapy. [62]

Psychological sequelae are common and require early identification; inclusion of psychotherapy and social services improves the quality of life of survivors. [63]

Comprehensive rehabilitation (mobility, pain management, sleep and itching, nutrition, scar management) is the key to restoring function and returning to daily activities. [64]

FAQ

Can I apply butter/sour cream/toothpaste to a burn? No. This traps heat and increases the risk of infection. The best first aid is 20 minutes of cool running water for the first 3 hours, then apply a clean bandage. [65]

Are antibiotics necessary "just in case"? No. Prophylactic systemic antibiotics do not reduce the risk of infection and increase the risk of resistance. Antibiotics are prescribed for proven infection or sepsis. [66]

Is silver sulfadiazine always a good idea? Not always. It can slow healing in superficial burns, so it is not routinely used in outpatient settings. It is appropriate for inpatient use for large/infected wounds, as indicated. [67]

What to do with blisters? Small ones should be left under a protective dressing; large and tense ones can be removed by a doctor, preserving the blister cap as a biological dressing. Do not open them yourself. [68]

When should I get a tetanus shot? For any wound injury, the vaccination status is checked; if it's overdue, anatoxin is administered; if there's a high risk, immunoglobulin is administered as indicated (at the doctor's discretion). [69]