Case Study 7

The Answer


  • Patient has 5% superficial burns to the back of the left lower leg and a 2” x3” partial thickness burn to the heel of the left foot.

The Plan

  • We will dress the partial thickness injury with the burn cream in our kit and clean gauze.
  • The patient is uncomfortable. It will be difficult to keep the wound clean. The patient cannot wear their boots. We are concerned with the location of the partial thickness burn on the heel. We will evacuate the patient.
  • The patient is able to walk with his running shoes with the heel folded down. We will hike to the trailhead, which we should reach tomorrow, and have this burn seen by a physician.

Anticipated Problems

  •  Wound infection.
  • Inability to walk.


Other than a sunburn the most common cause of a burn on a NOLS course, and on many wilderness trips, is a scald from spilled hot water. The pot of hot water is a concentrated source of energy, which if applied to skin, can burn. Stoves, lanterns, and fires are also sources of burns.

Minor burns may be no more than a trivial nuisance, yet they represent a potential site of infection. A large burn may rapidly cause shock.

The treatment principles begin, of course, with safety. Ensure the scene is safe. Remove the patient from immediate danger. Put out the fire and heat. Cool water may reduce the extent of the injury and help with pain management, but use common sense and be careful of hypothermia, especially with burns greater than 20% total body surface area (TBSA). Remove clothing and constricting objects such as jewelry, watches, and belts.

Assess the ABCs, being suspicious of burns on the face/neck, soot in the mouth/nose, singed hair, and a dry cough as indicating an airway burn. Assess, monitor, and treat for shock.

Estimate the depth of the burns.

  • Superficial: Red, painful, swollen.
  • Partial thickness: Red, painful, swollen, and blistered.
  • Full Thickness: Painless, without blisters, can be pale or charred.

Estimate the extent of the burns; use the rule of nines or the rule of palmar surfaces. The patient’s palm and fingers are roughly 1% of the patient’s TBSA. You’ll see this “rule” described as palm only, or palm and fingers. Consensus on this seems elusive in medical texts. Regardless, it’s a ballpark estimate for us. A physician will use a much more detailed body surface area map.  

Assess the location of the burns. Face, neck, hands, feet, armpits, groin, and circumferential burns are particularly dangerous.

Clean the burn with gentle irrigation. Cover the burns with the cleanest available dressings, burn gel or sheets, or products such as 2nd Skin®. In extended care situations clean the wound daily, debride dead skin around blisters that have self-drained (but don’t drain intact blisters). Give pain medications as needed (NSAID's often recommended) and keep the patient hydrated.

Non-adherent dressings are easier to change than coarse gauze. If you only have course gauze, consider smearing your water soluble antibiotic cream or Silvadene onto the gauze. Spenco 2nd Skin is a hydro-gel that absorbs fluids, wicks serum and secretions from wounds, and helps healing. NU-GEL and Hydrogel are examples of other burn dressings in this class. Aquaphor gauze is a petrolatum-impregnated gauze dressing.

Wet versus dry dressing is an area of controversy. In general, moist dressings feel better, but can be a source of hypothermia in extensive (>20%) burns. In this case use dry dressings.

NOLS Wilderness Medicine recommends evacuating all full thickness burns. Consider, as in this case, evacuating partial thickness burns, especially to the hands, feet, face, armpits, or groin for pain management and wound care. Rapidly evacuate any patient with partial and/or full thickness burns covering more than 10% TBSA, any patient with partial or full thickness circumferential burns, and any patient with signs and symptoms of airway burns.

End of the Tale

The student was able to walk slowly to the trailhead with the help of trekking poles and some creative bridge-building to get him over small streams. The wound healed well and in a few weeks he was back hiking.