The one treatment that works for a burn is boring, free, and takes far longer than anybody does it for — and most of what people reach for instead makes the injury worse.

What has already been done, and what to undo

Say what caused it, how long ago, how long it has been under water, and what has gone on it. The tool gives the first action for that cause — which is different for chemicals and for electricity — then goes through what has been applied and says which of those to remove, wash off, stop adding to, or keep. Nothing is saved, nothing leaves the page, and this cannot examine anybody.

Why twenty minutes, and why cool rather than cold

• A burn goes on burning after the heat is removed. Heat stored in the tissue keeps damaging cells for a long time, and the zone around the obvious injury can either recover or die depending on what happens in the first minutes and hours. Cooling is the only thing a bystander can do that changes that.
• Twenty minutes is the number, and it is a real number. Not two minutes, not until it stops hurting. Studies of cooling time show benefit out to twenty minutes and beyond, in less deep burns, less need for grafting and better scars — and the commonest failure is stopping far too early.
• Cool tap water, not ice and not iced water. Around fifteen degrees is ideal; ordinary cold tap water is close enough. Ice and ice packs cause vasoconstriction and freezing injury on top of the burn, which makes it deeper. This is the single most common well-meant mistake.
• It still helps late. Cooling started up to about three hours afterwards is still worth doing, which matters because most people do a hurried two minutes and then stop. If you are reading this an hour later, go back to the tap.
• Cool the burn, keep the person warm. A large burn cooled for twenty minutes can drop somebody's core temperature, and small children lose heat fastest. Cover the rest of them — blanket, jumper, car heater — while the burn is under the water.
• If there is no running water use any cool clean fluid: a shower, a bath, bottled water, wet clean cloths swapped often. A hydrogel burn dressing is a reasonable substitute and is not better than water.

What not to put on it, and why

The burns that go in regardless of how small they look

• Face, neck, ears, hands, feet, genitals, or across a joint. These are referred on site rather than size, because of function and scarring: a small burn on a knuckle can cost the use of a finger, and a small one on an eyelid is a different problem entirely.
• All the way round a finger, a limb or the chest. A circumferential burn can tighten as it swells and cut off circulation or restrict breathing. It needs assessing whatever its area.
• Anything that looks white, brown, waxy or leathery, or does not hurt. Painless is not good news: it means the nerve endings have gone, which means it is deep. Deep burns do not heal without help.
• Bigger than the palm of the burnt person's hand, and any burn at all in a baby, a young child, somebody over about sixty-five, or somebody who is pregnant, diabetic, on steroids or immunosuppressed.
• Any chemical or electrical burn, and any burn with signs of breathing in heat or smoke. These are not judged by the skin at all — the skin is often the least of it.
• Anything that does not add up. A burn whose pattern does not match the story, a scald with a sharp line and no splash marks, burns on both feet or the buttocks in a child, or a delay in seeking help: these are asked about because they have to be, and the asking protects the child.

Chemicals: the order is different

1. Protect yourself first. Gloves if there are any, and do not get the substance on your own skin. Somebody who becomes a second casualty helps nobody.
2. Brush dry powder off before any water goes near it. Some powders react with water — dry lime, for instance — and irrigating them straight away can make the injury worse. Brush it away from the face, then irrigate.
3. Remove contaminated clothing, including anything soaked. Cut it away rather than pulling it over the head where you can, and keep it away from unburnt skin.
4. Then irrigate with running water for much longer than twenty minutes. For most chemicals at least twenty minutes and often far longer, until help arrives; alkalis in particular keep damaging tissue for a long time and need prolonged irrigation.
5. Do not try to neutralise it. Acid on alkali or alkali on acid generates heat and makes things worse. Water, in quantity, for a long time.
6. Take the container or a photograph of the label. The name of the substance changes the treatment and the poisons service can only help if somebody knows what it was.

Electricity: the burn is the smallest part

• Switch it off before touching them. Isolate at the fuse box or unplug it; do not touch somebody who may still be in contact with a live source. With overhead lines or anything industrial, stay well back and let the emergency services isolate it.
• The visible burns can be tiny and the injury large. Current travels through tissue between an entry and an exit point, damaging muscle, nerves and blood vessels on the way, so two small marks can sit either side of a serious injury.
• The heart is the real concern. Electrical injury can cause arrhythmias, sometimes not immediately, which is why assessment is recommended even when somebody feels fine — and why anybody who was thrown, lost consciousness, or has chest pain or palpitations needs an ambulance.
• Any electrical burn is a referral, including from a domestic socket, and children who bite through cables need looking at even when the mouth appears barely marked.
• Lightning and high voltage are a different scale. Cardiac arrest is the immediate risk, resuscitation works, and the ground around a live source can be dangerous for anybody approaching.

Breathing in heat or smoke

• This is a time-critical airway problem, not a skin one. Hot gases and smoke cause swelling inside the throat that can close it over hours, and the treatment is a hospital that can secure an airway before that happens.
• The signs to act on: soot around the nose or mouth, singed nose or facial hair, a hoarse or croaky voice, a harsh cough, black sputum, burns around the face and neck, or having been in a fire in an enclosed space.
• Breathlessness, confusion, headache or drowsiness after a fire also raise carbon monoxide and cyanide poisoning, which are invisible and which oxygen treats. Say there was smoke: it changes what is given.
• Somebody who looks fine can deteriorate. Airway swelling develops over hours, which is exactly why this is one of the situations where "wait and see at home" is the wrong plan.
• Get them into fresh air and ring for help. Do not go back into smoke for belongings, and do not assume a working smoke alarm means the air is safe.

Afterwards: dressings, blisters, pain and infection

• Cling film is a good first cover, laid on lengthways rather than wrapped. It is clean, it does not stick, it takes pain away and the burn can still be seen through it. Never wrap it tightly around a limb, and do not use it on the face or on a chemical burn before irrigation.
• Leave blisters alone. Intact blister skin is a sterile dressing that nothing else matches. Large or awkward ones are sometimes dealt with by a clinician, with clean equipment and a plan; a needle at the kitchen table is how burns get infected.
• Ordinary painkillers, taken properly and early. Paracetamol and ibuprofen at full dose for the person's age and weight, rather than a token amount hours later. Burn pain is worst in the first day or two and pain relief is part of the treatment, not a comfort.
• The infection signs to watch for over the following days: increasing pain rather than settling, spreading redness, swelling, smell, pus, fever or feeling unwell. Burns are wounds and they do get infected, and children with an infected burn can become ill quickly.
• Ask about tetanus. A burn is a tetanus-prone wound and the question is whether the vaccinations are up to date, which is a two-second check and easily forgotten in the moment.
• Sun protection on healing skin, for a year. New skin over a burn pigments unevenly and permanently if it is sunburnt, and this is the part of aftercare nobody is warned about.

Children: where the scalds actually come from

• Hot drinks are the commonest cause, by a long way. A cup of tea can scald a toddler badly for fifteen minutes after it is made, and most of these happen from a mug on a work surface, a table edge or a lap. Pushing mugs to the back of the counter prevents more burns than any first-aid skill.
• Bath water, and the tap at the end. Run cold first and last, mix it, and test with an elbow or the back of the wrist rather than a hand. A child can be scalded in seconds at a temperature an adult tolerates.
• Hair straighteners, oven doors, kettle cords, radiators and barbecues. Straighteners stay dangerous for a long time after they are switched off and are usually left on the floor.
• The palm rule works on children too, and their skin is thinner, so the same water at the same temperature burns them deeper and faster. Any burn in a baby, and anything bigger than a coin, is worth having looked at.
• Cool the burn and keep the child warm. Twenty minutes of cool water on a small child means a real risk of hypothermia, so keep the rest of them wrapped and keep talking to them.
• Nappy-area and both-feet burns get asked about. Not because anybody is presumed guilty, but because those patterns are the ones that occasionally are not accidents, and the question is what protects children who cannot ask for help.

The drill: 16 decisions

Sixteen ordinary moments — a mug of tea pulled onto a toddler, butter reached for out of habit, a hand held under the tap for ninety seconds, a socket that sparked. Most have an instinctive answer that sounds sensible and is wrong. Pick your move; every answer explains why.

The card

Print it and put it inside a kitchen cupboard door, where a burn actually happens.

🖨️ Print the card