Any injury to the skin or other organic tissue caused primarily by heat, radiation, radioactivity, electricity, friction, or chemical contact is called a burn.
Burns are an important issue for youPreparing for surgery. Read this post carefully to understand everything you need to know about burns.
Referral indications for a dedicated burn center
Partial combustion with >10% TBSA
- Any full-thickness burn
- Burns on the face, hands, feet, joints and genitals.
- electric combustion
- chemical combustion
- Burn by inhalation
- burn with trauma
- Comorbid burns in the elderly
- Burn-in children who need special emotional care
- ↑ radiation loss: secondary to ↑ blood flow and integumentary loss
- Heat Loss: Evaporation of water from combustion (also causes fluid loss)
- Massive release of inflammatory mediators: leads to
- ↑ Capillary permeability - liquid leakage
- edema - fluid loss in the third space - hypovolemia
- Global depression of immune function
- Release of catecholamines, glucagon, corticosteroids → hypermetabolism → fever
- wavy ulcers
- It's a stress sore that only occurs in 1/3thirdof TBSA is incinerated.
- Caused by ↓ decreased mucosal defenses due to hypovolaemia (gastric acid secretion is normal)
- Occurs due to increased acid secretion.
Skin lesions in burns
area of hyperemia
Burn classification (based on burn depth)
First degree burns
- Also known as an epidermal burn
- Only the epidermis is involved
- Painful and erythematous
- No blistering
- Healing occurs without scarring in 5 to 10 days
Second degree burns
- Also known as partial thickness firing
- It is divided into
|Superficial partial thickness burn||Deep partial burn|
|Involvement of the epidermis + papillary dermis||Involvement of epidermis + reticular dermis Burnt area mottled with whitish and pink|
|Blisters present / painful||No blisters/no pain|
|know how to play||The pinprick feeling is retained|
|Healing occurs without scarring (within 7 to 14 days)||Healing occurs with scars (3-9 weeks)|
Third degree burns
- Also known as a full fire
- Involvement of epidermis + dermis + subcutaneous fat
- Burn surface shows black leathery eschar surrounding - escharotomy performed to prevent compartment syndrome.
- No pain, no blisters, no pin prick sensation
- Healing occurs in contractures: To prevent contractures -
Excision of burned skin with skin graft after patient resuscitation.
Fourth degree burn
- Skin involvement + underlying structures (muscle, bone and brain)
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Causes of death from burns
- MC Cause of death at fire site: asphyxiation
- MC Cause of early death from burns: hypovolaemia/shock
- MC Cause of late death from burns: sepsis
- Common cause of death from CM in burns: sepsis
- MC organism responsible for burn sepsis: Pseudomonas
Danger sign of respiratory burns
Burns to head, neck and face
- Singed/burned nose hairs
- Carbonaceous deposits in sputum
- hoarse voice
- H/o burns in a closed room
Burn patient management
- Venous access in adults
- Ideal places: hand veins, crook of elbow or neck
- severed saphenous vein
- Is carried out when accessibility is difficult
- Favored over centerline insertion
IV liquid ventilation
- >10% TBSA in children Risk of hypovolemia
Requires liquid ventilation
- >15% TBSA in adults
- Your choice of liquid: Ringer's lactate
- Maintenance fluid of choice in children: Normal saline dextrose (DNA) because children have less glycogen stores
- Other liquids used are
- hypertonic saline
- normal saline solution
- fresh frozen plasma
- human albumin
- Hypertonic saline is used for patients in shock from burns because it has higher oncotic pressure and becomes trapped in the vascular compartment.
Calculation of fluid requirements
- It is based on crystalloids
- 24 hours. Fluid requirement = 4 ml × body weight (kg) × % surface area burned
- Time starts when the patient burns
- First degree burns are not included.
- Maximum fluid administered should be brought to 50% TBSA to avoid fluid overload
- Half of the calculated fluid is given in the first 8 hours and the remaining half of the fluid is given in the next 16 hours.
- 2ndthe daily fluid requirement should be 40 to 60% of the daily fluid requirement.
ATLS modification of the Parkland formula
- It is based on
- Type of injury
- Adults, children ≥ 14 years
- 2mL × Physical Pesos × % BSA
- Children under 14 years old, weight ≤ 30 kg
- 3ml x corporate peso x % BSA
- Electrical burns (regardless of age)
- 4 ml × Peso Corporal × % BSA
|Fluid rates for burn resuscitation and target urination by burn type and age|
|burn category||age and weight||Adjusted liquid rates||urine output|
|flame or scalding||Adults and over 14 years (>_14 years)||2 ml LR × kg × % TBSA||0,5 ml/kg/h 30-50 ml/kg/h|
|Children (<14 years)||3 ml LR × kg × % TBSA||1ml/kg/h|
|Infants and Toddlers (30 pounds)||3 mL LR × kg/% TBSAPlus to saccharified solution at maintenance rate||1ml/kg/h|
|electrical injuries||Every age||4 ml LR x kg x % TBSA until urine is clear||1-1.5 ml/kg/h until urine is clear|
|LR: Lactated Ringer's solution TBSA: Total body surface area|
- Both crystalloid and colloid based
- Fluid requirements = 1.5 ml/kg/% TBSA crystalloids + 0.5 ml/kg/% TBSA colloids + 2 liters of free water
- It's a pediatric formula
- Fluid requirement = 5000 ml/m2of the total burned surface + 1500 ml/m2the entire body surface
Volume resuscitation monitoring
- Best clinical indicator of tissue perfusion: urine output
- Minimum U.O. after sufficient tissue perfusion in adults: 1ml/min
- Minimum U.O. after sufficient tissue perfusion in children: 0.5-1.0 ml/min
- Patients with cardiac dysfunction are monitored by
- Trans-esophageal USG (or)
Estimation of the burned surface
Determining the size of the burn - Estimate the extent of the injury
- Given by Alfred Russel Wallace
- The Rule of 9 is followed for adults but is not very accurate for children.
- For children, there are 14 percent members
Lund & Broder Diagram
- More accurate for estimating burn surface area in children
- Also used to estimate burn surface area in children
- To assess small irregular burns:
Open hand area - represents 1%
- Used for
- splash burns
- Mixed distribution of burns
burn patient supplies
Cool the burns
- Provides analgesia
- Delays delayed microvascular damage
- Cooling must be done for at least 10 minutes
- The cooling is effective up to 1 hour after burns
- Best water temperature for cooling burns 15°C
- Tap water can also be used.
- Cold water or ice should not be used as they increase the risk of hypothermia
- cutaneous vasoconstriction; Prolong heat damage
- Second degree superficial burns
- Scar-free healing in 2 weeks
- Exposure method can be used - antimicrobial administration without dressing
- Carried out for circumferential scar
- The cut layers are lengthwise
- fascia superficial
- deep fascia
- No bandage is made
- Antibiotics are given 2-3 times a day
- Used for face and head burns
- Increased pain and heat loss
- Increased risk of cross contamination
- closed method
- The occlusive dressing is placed over the antimicrobial agent
- Changed twice a day
- Less pain and heat loss
- Reduced risk of cross contamination
- Increased risk of bacterial growth - if the dressing is not changed twice a day
- topical antimicrobials
- Silbersulfadiazin (1%)
- Provides broad spectrum antimicrobial prophylaxis – mainly against Pseudomonas and MRSA
- Silbernitrat (0,5 %)
- Highly effective against Pseudomonas colonization
- Causes "black spots" on furniture near patients
- Phenethacetat (5 %)
- Used in the US
- painful to use
- Its use is associated with metabolic acidosis
- silver sulfadiazine and cerium nitrate
- Used for full thickness burns
- Causes harsh effect on burned skin
- Mainly used in the elderly: Increases cell-mediated immunosuppression (CMI) – cerium nitrate
- Sterile scab form
- Increase CMI
- dressing materials
- Absorbent but non-stick
- Used for heavily exuding wounds
- Capable of handling moderate to heavy exudate
- Used for heavily exuding wounds
- Contraindicated in non-draining wounds
- Facilitate autolytic debridement - used for pressure ulcers and stasis ulcers
- Do not use on heavily exuding wounds
- Hydrates the wound bed
- Facilitates autolytic debridement
- May soften the wound from over-hydration
- transparent film
- Facilitates autolytic debridement
- Do not use on heavily exuding wounds
treatment of chemical burns
- Extensive rinsing with water or saline solution
- Ready for at least 20 minutes
- Elemental Metals: Causes an exothermic reaction with water
- Phenol: Leads to deeper tissue infiltration
- Treatment should be continued – until the pH of the skin is normal
- Remove contaminated clothing and jewelry
- Do not try to neutralize the chemical burn
- Neutralization causes an exothermic reaction - leading to more injuries
For direct current (DC)
- Is this a low voltage/electrical appliance injury?
- Doesn't have enough energy to cause extensive tissue destruction
Due to the increased resistance – Causes minor deep burns at the site of entry and exit → fingers and toes
- Damage to tendons and nerves can occur
For alternating current (AC)
- Produces tetany in muscle: Patient cannot disconnect from device until mains power is turned off
- Main danger: AC disrupts the normal heart rhythm without significantly damaging the myocardium, ECG is performed
Q. All of the following statements regarding the management of burns and complications are true except
- M/C cause of death is sepsis
- The exposure method is used for the face and hand
- Silver sulfadiazine is effective against Pseudomonas and MRSA
- The Galveston formula is based on colloid
Q. Which of the following patients should be referred to the designated burn center for treatment?
- Burns to the face, hands, feet, genitals, perineum, or large joints
- Any full-thickness burn
- Electrical injuries, including lightning injuries
- all of the above
F. Combine the following
- YES; 2-A; C:3- B, D
- I WALKED; AND; 2-A; C:3-B
- I WALKED; AND; 2A; 3- B, C
- YES; 2-A; D:3- B, C
F. Combine the following
- I-A, F; 2-A, C, F; 3-B; 4-D, E; 5-B,G
- I-A, 2-A, C, F; 3-B; 4-B, D, E; 5-B,G
- I-A, F; 2- C, F; 3-B; 4-B, D, E, 5-B, G
- I-A, F; 2-A, C, F; 3-B; 4-B, D, E; 5-B,G
Q. A 50-year-old woman weighing 50 kg suffered burns after a pressure cooker exploded, affecting 60% of her total body surface. How much fluid should be given in the first 8 hours?
Q. In the above question. Calculate the fluid requirement on the second day?
Q. All of the following statements regarding burn size estimation are correct except
- On the infant's head and neck equals 21% and on each leg equals 13%
- The Lund and Browder plot is preferred over the Berkow formula for accurately determining burn size in children
- The open hand range is helpful in evaluating splash burns and burns with mixed distribution
- The open hand area includes the area under the palm of approximately 1% of the TBSA.
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What is the rule of 10 for burns? ›
Burns Rule of TENS:
Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg). 3. For every 10 kg above 80 kg add 100 mL/hr to the rate.
The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight. The Parkland formula is 4mls x body surface areas burned (BSAB) x weight. Both formulas estimate the first 24 hour fluid requirements from the time of the burn, with half the amount given in the first 8 hours.How do you calculate burn fluid resuscitation? ›
Charles Baxter, is perhaps the most widely recognized fluid replacement formula for burn injuries. It stipulates that 2 to 4 ml of Ringer's Lactate per kilogram of weight per percentage of body surface area burned, with the first half given over the first 8 hours and the remainder given over the next 16 hours.What are the 4 types of burn? ›
- First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. ...
- Second-degree (partial thickness) burns. ...
- Third-degree (full thickness) burns. ...
- Fourth-degree burns.
The 4/2/1 rule: 4 ml/kg for first 10kg, 2ml/kg for the next 10kg, 1 ml/kg for every 1kg over 20. For example, for a 70kg person: 4×10=40; 2×10=20; 1×50=50. Total=110 ml/hr.What is Rule 9 of burn? ›
The size of a burn can be quickly estimated by using the "rule of nines." This method divides the body's surface area into percentages. The front and back of the head and neck equal 9% of the body's surface area. The front and back of each arm and hand equal 9% of the body's surface area.What is the Muir and Barclay formula for burns? ›
The Muir and Barclay formula is as follows: % x kg = volume needed. Total % of burn surface area x body weight in kilograms = volume in millilitres of fluid to be given in each period.What is the formula for burn in ACLS? ›
It is calculated as 4ml x %TBSA x kg. The first half is given in the first 8 hours, the second half is given in the next 16 hours. First 24 hours after burn: 4ml x %TBSA x kg in the first 24 hours.What is Baxter burns formula? ›
The widely quoted Baxter (Parkland) formula for initial fluid resuscitation of burn victims is 4 mL of Ringer's lactate per kilogram of body weight per %TBSA burned, one half to be given during the first 8 hours after injury and the rest in the next 16 hours.What is the rule of 9 fluid resuscitation? ›
The "Wallace Rule of Nines" is the most common method of determining BSA. In the adult formulation, the head is 9%, each circumferential upper extremity is 9%, each circumferential lower extremity is 18%, the anterior trunk is 18%, the posterior trunk is 18%, and the perineum is 1%.
Which IV fluid is best for burns? ›
The recommended IV fluid per the Advanced Burn Life Support course of the American Burn Association is Lactated Ringers, but Isolyte/Plasmalyte may be used instead.Why use Ringer's lactate for burns? ›
Hartmann's (or Lactated Ringer's) solution is the preferred first-line fluid recommended by the British Burns Association. Its composition and osmolality closely resemble normal bodily physiological fluids and it also contains lactate which may buffer metabolic acidosis in the early post- burn phase.What are the 4 C's for burns? ›
The four Cs are cool it, clean it, cover it, and call for help.What is the rule of 5 in burns? ›
For obese patients weighing more than 80 kg a rule of fives is proposed: 5% body surface area for each arm, 5 x 4 or 20% for each leg, 10 x 5 or 50% for the trunk, and 2% for the head.What is a 7th degree burn? ›
This is the deepest and most severe of burns. They're potentially life-threatening. These burns destroy all layers of your skin, as well as your bones, muscles, and tendons. Sometimes, the degree of burn you have will change. This can happen if your damaged skin keeps spreading and the injury becomes deeper.What is the ABCD burn rule? ›
A-B-C-D-E can be used as to recall that the initial assessment includes examining the airway, breathing, circulation and disability, and that the patient should be exposed and examined. The second caregiver should assess the mechanism of injury to determine the cause of the burn.What are the 6 types of burn? ›
- Thermal Burns. Thermal burns occur when you come in contact with something hot. ...
- Chemical Burns. ...
- Electrical Burns. ...
- Friction Burns. ...
- Radiation Burns. ...
- First-Degree Burns. ...
- Second-Degree Burns. ...
- Third-Degree Burns.
Hold the burned area under cool (not cold) running water or apply a cool, wet compress until the pain eases. Don't use ice. Putting ice directly on a burn can cause further damage to the tissue. Remove rings or other tight items.What is a TBSA burn? ›
The extent of the burn injury is expressed as a percentage of the patient's total body surface area (TBSA).What is the Lund and Browder rule? ›
For children and infants, the Lund-Browder chart is used to assess the burned body surface area. Different percentages are used because the ratio of the combined surface area of the head and neck to the surface area of the limbs is typically larger in children than that of an adult.
What is the Parkland burn formula? ›
The Parkland formula is as follows: total crystalloid fluid (i.e., a solution with small molecules that can move into cells) over the first 24 hours = 4 milliliters x % TBSA (total body surface area burned) x body weight (kg). In children, the formula is edited to 3 ml x % TBSA x weight (kg).What is the ABC assessment of burns? ›
Burn assessment. Assess airway, breathing, circulation, disability, exposure (prevent hypothermia) and the need for fluid resuscitation. Also, assess severity of burns and conscious level [4, 5]. Establish the cause: consider non-accidental injury.What is Palmers rule for burns? ›
The "rule of palm" is another way to estimate the size of a burn. The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person's palm to measure the body surface area burned. It can be hard to estimate the size of a burn.What is Palmer burns method? ›
The Palmer Method of estimating total body surface area (TBSA) is an easy way to get a rough burn size estimate that can be used when calculating a patient's fluid resuscitation needs. The patient's palmer surface including their fingers = 1% TBSA.What is burn 6 criteria? ›
The team introduced the BURN-6 criteria as significantly predicting presence of sepsis (temperature < 36°C, mean arterial pressure (MAP) < 60 mmHg, HR > 130 bpm, base deficit < −6 mEq/l, presence of vasoactive medications, and serum glucose > 150 mg/dl).What is fluid creep? ›
Fluid creep occurs when a patient requires more resuscitation fluid than is predicted by standard formulas. Fluid creep is reported in 30% to 90% of patients with major burns; the incidence in- creases with burn size. Excessive fluid given in the initial hours after injury predisposes to fluid creep.What is Currie burn formula? ›
Daily caloric requirements in patients with major burns are frequently estimated using the Curreri formula (25 X body weight (kg) + 40 X % BSA burned).What is the Brooks formula? ›
The guidelines instruct the providers to calculate predicted 24-hour fluid requirements and initial fluid rate based on the American Burn Association Consensus recommendation of 2 (modified Brooke) mL x kg(-1) x % total body surface area (TBSA)(-1) to 4 (Parkland) mL x kg(-1) x %TBSA(-1) burn.What are the 4 D's of fluid resuscitation? ›
In practice, we should consider the “four D's” of fluid therapy: drug, dosing, duration and de-escalation (Table 1) .What is the 3 to 1 rule resuscitation? ›
ATLS continues to support the use of a 3-for-1 rule (3 mL of crystalloid should be used as replacement for every 1 mL of blood loss), but also encourages frequent reassessments if large amounts of crystalloid are not providing adequate resuscitation. ATLS also dictates treatment based on the class of hypovolemic shock.
What is the 2 1 rule for fluid resuscitation? ›
maintenance fluid requirements are calculated using the 4,2,1 rule (4ml/kg/hr for the first 10kg, 2ml/kg/hr for the second 10kg, and 1ml/kg/hr after that, with a maximum of 100ml/hr maintenance).Why can't you give water to a burn victim? ›
Paracelsus (1493-1541) noted that severe burn injury was accompanied by fever and a 'drying out of the blood', resulting in thirst. However, he recommended that if a patient drinks, death will follow. Drinking Na+ free fluids can cause severe hyponatremia and cerebral edema.Is normal saline or LR better for burns? ›
Fluid resuscitation is best accomplished using lactated Ringer's (LR), which is the intravenous fluid that most closely mimics the fluid lost in a burn injury. If LR is not available, 0.9% sodium chloride (saline) solution is sufficient. Nevertheless, as soon as LR is available, it should replace the saline solution.Is lactated Ringers or NS better for burns? ›
Ringer's lactate is largely used in aggressive volume resuscitation from blood loss or burn injuries; however, Ringer's lactate is a great fluid for aggressive fluid replacement in many clinical situations, including sepsis and acute pancreatitis.Why do burn patients need electrolytes? ›
Abstract. Burn injury involves a large amount of water, electrolytes and proteins loss trough the burn wound. For this reason, to avoid shock, a wide infusion of fluid is necessary in the first hours after trauma.Why is RL not given to burn patients? ›
Thus, there was significant difference in levels of sodium and RBS in patients receiving DNS as maintenance fluid in addition to RL in acute phase. Conclusion: RL is not an ideal fluid for maintenance as it is low in sodium (130mEq/L) as well as potassium (4mEq/L) in view of daily electrolyte requirement.What are the 3 main types of IV fluids? ›
- Isotonic Solutions. Isotonic solutions are IV fluids that have a similar concentration of dissolved particles as blood. ...
- Hypotonic Solutions. Hypotonic solutions have a lower concentration of dissolved solutes than blood. ...
- Hypertonic Solutions.
The main priorities in burn emergency care are as follows: blood circulation, respiration and airway management. After a primary stabilization in respiration and blood circulation, it is important to examine and classify the injuries in terms of the burn percentage.What is the rule of 10 in IV fluids? ›
Trick of the Trade
Estimate burn size to the nearest 10%. Multiply %TBSAx10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg). For every 10 kg above 80 kg, increase the rate by 100 mL/hr.
Burns are considered open wounds. You should cover a burn to keep the wound bed sterile and free of harmful bacteria.
What is the Wallace's Rule of Nines? ›
Wallace's Rule of Nines estimates the affected body surface area of an adult using multiples of 9 representing different areas of the body. Different calculations are used for children and infants. The Rule of Palm assumes that the palm (including the fingers) of the person who is burned is about 1% of the body.What burns are considered critical? ›
- Burns that cover the hands, feet, face, groin, buttocks, a major joint or a large area of the body.
- Deep burns, which means burns affecting all layers of the skin or even deeper tissues.
- Burns that cause the skin to look leathery.
- Never leave your stove unattended while cooking. ...
- Create a kid-free zone. ...
- Keep your cooking area free of flammable materials. ...
- Turn pot handles toward the back of the stove. ...
- Keep a fire extinguisher nearby. ...
- Keep cooking equipment clean.
first-degree burns: red, nonblistered skin. second-degree burns: blisters and some thickening of the skin. third-degree burns: widespread thickness with a white, leathery appearance.Has anyone survived a 6th degree burn? ›
Sixth-degree burns are not survivable. This degree of burn destroys all levels of the body and leads to a charred appearance.What is 4 5 6 degree burns? ›
Third-degree burns damage or completely destroy both layers of skin including hair follicles and sweat glands and damage underlying tissues. These burns always require skin grafts. Fourth degree burns extend into fat, fifth degree burns into muscle, and sixth degree burns to bone.What is the rule of 10s? ›
Historically, studies have recommended initiating surgical repair by the “Rule of 10s.” This states that a baby should be at least 10 weeks of age or older, achieve a weight of 10 pounds, have a hemoglobin exceeding 10 g/dL, and have a white blood cell count <10,000/mm 3 before undergoing surgery.What does 10% burns mean? ›
Moderate: Second-degree burns that cover about 10% of the body are classified as moderate. Burns on the hands, feet, face or genitals can range from moderate to severe. Severe: Third-degree burns that cover more than 1% of the body are considered severe.What is the code for burns less than 10%? ›
ICD-10 code: T31. 0 Burns involving less than 10% of body surface.What is the Rule of 10 in Six Sigma? ›
The Rule of Tens says that the resolution of your measurement system should fit at least ten times into the process variation that you are measuring, as shown on the right.
What is the Rule of 2 in surgery? ›
It is often referred to by the rule of 2's; 2% of the population, within 2 feet of the ileocecal valve, 2 inches in length, tow types of heterotopic Mucosa, and presentation before the age of two.What is the 10 10 and 10 Rule? ›
To help us deal with these particularly tough decisions, Suzy Welch created a framework called the 10/10/10 rule. This rule is, in essence, asking yourself “What will be the consequence(s) of my action/decision in 10 minutes, 10 months, 10 years”.What are the three C's for burns? ›
A systematic approach to burn care focuses on the six “Cs”: clothing, cooling, cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief).What are the first 3 steps for treating burns? ›
- Stop the burning process as soon as possible. ...
- Remove any clothing or jewellery near the burnt area of skin, including babies' nappies. ...
- Cool the burn with cool or lukewarm running water for 20 minutes as soon as possible after the injury. ...
- Keep yourself or the person warm.
Code Using the Rule of Nines
To code burn cases correctly, specify the site, severity, extent, and external cause. You need at least three codes to properly report burn diagnoses: First-listed code(s): Site and severity (from categories T20-T25)
The "rule of palm" is another way to estimate the size of a burn. The palm of the person who is burned (not fingers or wrist area) is about 1% of the body. Use the person's palm to measure the body surface area burned.What is the rule of 5 burns? ›
For obese patients weighing more than 80 kg a rule of fives is proposed: 5% body surface area for each arm, 5 x 4 or 20% for each leg, 10 x 5 or 50% for the trunk, and 2% for the head.What is burn 80% ICD-10? ›
Burns involving 80-89% of body surface with 50-59% third degree burns. T31. 85 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2023 edition of ICD-10-CM T31.What is the lowest severity of burn? ›
First Degree Burns
The least severe burns are those that affect only the outermost layers of the skin (epidermis). After the initial shock, a first degree burn is the equivalent of a minor sunburn. Signs of a first-degree burn include: Red skin that is painful to the touch.
First-degree (superficial) burns
First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color.