Why is cool running water better than ice for burns?

Cool running water at approximately 15°C cools the burn tissue without causing vasoconstriction. Burns have three injury zones — a central zone of irreversible tissue death, a surrounding zone of stasis with compromised circulation that is potentially salvageable, and an outer zone of hyperaemia that will recover. Cooling within 3 hours converts stasis-zone tissue back toward the hyperaemia zone, reducing the final depth of the burn and the eventual scar. Ice and iced water cause intense vasoconstriction that deepens the stasis zone and can cause hypothermia in extensive burns or in children. This is why the ANZBA rule is specifically cool tap water for exactly 20 minutes — not ice, not cold packs.

How do I estimate the percentage of total body surface area burned?

Never include simple erythema (superficial burns that only redden the skin) in your %TBSA estimate — only partial-thickness and full-thickness areas count. Two tools are used: Wallace's rule of nines for adults, which assigns 9% to the head, 9% to each arm, 18% to the anterior trunk, 18% to the posterior trunk, 18% to each leg, and 1% to the perineum. The Lund-Browder chart is more accurate for children because it accounts for the proportionally larger head and smaller legs at different ages. For scattered or patchy burns, the patient's palm plus fingers represents approximately 1% TBSA and is useful for estimating small or irregular burns.

What are the ANZBA criteria for specialist burns unit referral?

The Australia and New Zealand Burn Association (ANZBA) criteria for transfer to a specialist burns unit are: partial-thickness burn ≥10% TBSA in adults or ≥5% TBSA in children; any full-thickness burn; burns involving the face, hands, feet, perineum, or major joints; circumferential burns; electrical or chemical burns; inhalation injury; burns in pregnant patients; burns in patients with significant pre-existing medical conditions affecting management; burns with concomitant trauma; and any burn where non-accidental injury is suspected in a child. If in doubt, contact the receiving burns unit for triage advice — a brief phone discussion with a burns specialist can guide appropriate disposition.

What should never be applied to a burn wound?

Never apply ice or iced water — this deepens the wound through vasoconstriction and risks hypothermia. Never apply butter, cooking oil, toothpaste, egg white, aloe vera from the garden, or any folk remedy — these introduce infection, obscure wound assessment, and delay healing. Silver sulphadiazine cream, once the standard topical agent, is no longer recommended in modern burns care: it interferes with wound assessment by staining the wound, delays re-epithelialisation compared to modern silver-containing dressings, and is not superior to simpler approaches. In the acute phase before specialist assessment, cover the burn loosely with cling-wrap (or a non-stick hydrogel dressing such as Burnshield for transport) and leave it undisturbed.

Burns — acute management

Burns — acute first aid, assessment, and transfer: the Australian approach

By Dr HB Lo, FACRRM Reviewed 17 September 2026 6 min read

Burns cause ~5,500 Australian hospitalisations per year. ANZBA first-aid rule: cool with running water (~15°C, never ice) for 20 minutes within 3 hours; cling-wrap; analgesia; tetanus. Never apply ice, butter, or oils.

Assess depth (superficial, partial-thickness, full-thickness) and %TBSA — Wallace's rule of nines (adults) or Lund-Browder (children). Modified Parkland for ≥10% TBSA adult / ≥5% paediatric: 3 mL × kg × %TBSA Hartmann's over 24 h, half in first 8 hours from injury.

ANZBA referral: partial-thickness ≥10% adult / ≥5% paediatric; any full-thickness; face/hands/feet/perineum/joints; circumferential; electrical/chemical; inhalation injury; suspected non-accidental injury.

Burns are among the most time-critical presentations in Australian general practice. The depth of final injury, the degree of scarring, and the patient’s survival in major burns are all influenced by actions taken in the first minutes to hours. Australia hospitalises approximately 5,500 burn patients per year, with paediatric scalds and adult flame burns dominating the epidemiology. The ANZBA and the Australian Resuscitation Council have produced clinical guidelines that every GP needs to know — not because GPs manage major burns, but because the GP is often the first clinical contact after initial first aid, and the correct initial steps prevent a worse outcome.

A. Core clinical — the AU general-practice framework

Burn depth determines whether the wound will heal spontaneously or require surgical grafting:

Superficial (epidermal, first-degree): red, dry, intact surface, very painful, blanches with pressure. Examples: sunburn. Heals in 3–7 days without scarring.
Superficial partial-thickness (superficial second-degree): red, blistering, weeping, intensely painful, blanches. The dermis is injured but superficially. Heals in 7–14 days; minimal scarring.
Deep partial-thickness (deep second-degree): pale, mottled, less painful than expected (deeper nerve injury), slow capillary refill. Heals in 3–6 weeks with likely hypertrophic scarring; often requires grafting.
Full-thickness (third-degree): white, brown, or black; leathery; dry; painless (complete nerve destruction); no blanching. Will not heal without surgical excision and skin grafting.

Depth assessment can be difficult in the first 24–48 hours as burns “declare” over time; the initial assessment should be conservative (assume deeper than apparent) for planning.

%TBSA estimation (ANZBA EMSB): never include simple erythema. For adults, use Wallace’s rule of nines: head and neck 9%; each arm 9%; anterior trunk 18%; posterior trunk 18%; each leg 18%; perineum 1%. For children, use the Lund-Browder chart to account for the proportionally larger head and smaller legs at different ages. For scattered burns, the patient’s palm plus fingers represents approximately 1% TBSA.

B. First aid — the ANZBA 20-minute rule

The foundation of burn first aid is ARC Guideline 9.1.3 and ANZBA guidance:

Stop the burning process — remove the patient from the heat source; smother flames; remove burning or chemical-soaked clothing if not adhered to skin (do not pull off melted synthetic fabric). For chemical burns, brush off dry chemical first, then begin continuous water irrigation for at least 30 minutes (alkali burns may need longer).
Cool the burn with running cool water at approximately 15°C for 20 minutes — ideally within 3 hours of injury. This is the single most important modifiable intervention affecting burn depth and outcome (Bartlett 2020). For facial burns, use a wet facecloth in a continuously replenished bowl.
Avoid ice and iced water — causes vasoconstriction that deepens the stasis zone and risks systemic hypothermia in children or extensive burns. Avoid butter, toothpaste, oils, plant remedies, and egg white — these introduce infection and impede assessment.
Cover loosely with cling-wrap after cooling — single layer, not wrapped tightly around a limb. Cling-wrap is non-adherent, preserves wound assessment, and protects from contamination during transfer. Alternatively, hydrogel dressings (Burnshield, Waterjel) are acceptable and may provide additional symptomatic relief.
Do not rupture intact blisters before specialist review — the blister roof provides a biological dressing and reduces infection risk.
Analgesia: paracetamol for mild burns; titrate IV morphine 2.5–5 mg (adult) or weight-based IV opioid for moderate to severe burns; add ondansetron for nausea.
Check tetanus status per ATAGI guidelines — burns are tetanus-prone wounds.

C. Fluid resuscitation — the modified Parkland formula

Fluid resuscitation is indicated for partial-thickness or full-thickness burns of 10% TBSA or more in adults or 5% TBSA or more in children.

Modified Parkland formula (ANZBA EMSB): 3 mL × body weight (kg) × %TBSA of Hartmann’s (lactated Ringer’s) solution over 24 hours. Half the total volume is given in the first 8 hours from the time of injury — not from the time of presentation or IV access. The remaining half is given over the following 16 hours.

Titrate to urine output: target 0.5 mL/kg/h in adults, 1.0 mL/kg/h in children, via urinary catheter. In children, add 4-2-1 maintenance fluid (D5W/normal saline) in addition to the Parkland resuscitation volume.

Avoid colloids in the first 24 hours (current evidence does not support early colloid use). Avoid over-resuscitation — “fluid creep” beyond what is needed to maintain urine output increases oedema, abdominal compartment syndrome, and pulmonary complications.

D. ANZBA referral criteria

Transfer urgently to an ANZBA-accredited specialist burns unit for any of the following:

Criterion	Adult	Paediatric
Partial-thickness %TBSA	≥10%	≥5%
Full-thickness burn	Any	Any
Burns of face, hands, feet, perineum, major joints	All	All
Circumferential burn	Yes	Yes
Electrical or chemical burn	All	All
Inhalation injury	All	All
Pre-existing illness affecting management	Yes	Yes
Pregnancy	Yes	—
Suspected non-accidental injury	Yes	Yes

Australian ANZBA-accredited specialist burns units: Royal Adelaide Hospital; Royal Brisbane and Women’s Hospital; Concord Repatriation General Hospital (NSW); Royal North Shore Hospital (Sydney); The Alfred (Melbourne); Royal Perth Hospital; Royal Hobart Hospital. Paediatric units: Children’s Hospital at Westmead; Royal Children’s Hospital Melbourne; Queensland Children’s Hospital; Perth Children’s Hospital; Women’s and Children’s Hospital Adelaide.

E. Special populations

Children: Scalds from hot beverages and cooking liquids are the most common mechanism in toddlers. Paediatric burns have higher mortality per %TBSA than adults at the extremes of age. Non-accidental injury (NAI) accounts for approximately 10% of paediatric burn admissions; features include inconsistent history, delay in presentation, burn patterns inconsistent with the stated mechanism (glove-and-stocking distribution, cigarette burns, forced immersion pattern), or prior child protection concerns. Mandatory reporting obligations apply per state child protection legislation.

Elderly patients: Mortality rises sharply with age — a 30% TBSA burn in a patient over 70 carries approximately 50% mortality. Low threshold for early specialist referral.

Electrical burns: High-voltage (>1,000 V) electrical injury causes internal tissue injury along the current path, cardiac arrhythmia (monitor for at least 24 hours; ECG on presentation and serially), and rhabdomyolysis (measure CK and target urine output 1 mL/kg/h until CK normalising). Entry and exit wounds may appear deceptively small. Low-voltage (≤1,000 V) injury carries lower systemic risk but still warrants hospital assessment for hand or deep tissue involvement.

Chemical burns: Duration of irrigation matters — alkali burns penetrate more deeply by liquefactive necrosis and may need irrigation for 60 minutes or more. Identify the chemical when possible (Safety Data Sheet); avoid chemical-specific antidotes in the field.

When to escalate

Call 000 for any burn with suspected inhalation injury (hoarseness, stridor, soot in nostrils, singed nasal hairs, enclosed-space fire), haemodynamic instability, or a burn meeting ANZBA referral criteria. Inhalation injury can produce progressive upper airway oedema — intubation is far safer before oedema develops than after. Contact the receiving burns unit before transfer for advice on fluid resuscitation, wound coverage, and timing.

For wound care follow-up of minor burns managed in general practice: review at 48 hours to check for signs of infection (increasing pain, erythema, purulent discharge, fever); modern silver-based dressings (e.g. Mepilex Ag, Aquacel Ag) are preferred over silver sulphadiazine for outpatient management of superficial partial-thickness burns.

What this article is and is not

This article reflects current guidance from ANZBA, the Australian Resuscitation Council, eTG, and the Royal Children’s Hospital Melbourne applicable to Australian general practice. It is educational material for adults and is not a substitute for clinical assessment by a qualified health professional. Burns are complex time-sensitive injuries; if there is any doubt about severity or the need for specialist assessment, early contact with a burns unit is always appropriate. In an emergency, call 000.

Sources cited

Frequently asked questions

Why is cool running water better than ice for burns?

Cool running water at approximately 15°C cools the burn tissue without causing vasoconstriction. Burns have three injury zones — a central zone of irreversible tissue death, a surrounding zone of stasis with compromised circulation that is potentially salvageable, and an outer zone of hyperaemia that will recover. Cooling within 3 hours converts stasis-zone tissue back toward the hyperaemia zone, reducing the final depth of the burn and the eventual scar. Ice and iced water cause intense vasoconstriction that deepens the stasis zone and can cause hypothermia in extensive burns or in children. This is why the ANZBA rule is specifically cool tap water for exactly 20 minutes — not ice, not cold packs.
How do I estimate the percentage of total body surface area burned?

Never include simple erythema (superficial burns that only redden the skin) in your %TBSA estimate — only partial-thickness and full-thickness areas count. Two tools are used: Wallace's rule of nines for adults, which assigns 9% to the head, 9% to each arm, 18% to the anterior trunk, 18% to the posterior trunk, 18% to each leg, and 1% to the perineum. The Lund-Browder chart is more accurate for children because it accounts for the proportionally larger head and smaller legs at different ages. For scattered or patchy burns, the patient's palm plus fingers represents approximately 1% TBSA and is useful for estimating small or irregular burns.
What is the modified Parkland formula and how is it applied?

The modified Parkland formula calculates intravenous fluid resuscitation volume for major burns: 3 mL × body weight in kilograms × %TBSA burned, of Hartmann's (lactated Ringer's) solution, given over 24 hours. Half the calculated volume is given in the first 8 hours — importantly, this 8 hours is measured from the time of injury, not from the time of presentation or IV insertion. The remaining half is given over the subsequent 16 hours. Fluid rate is titrated to urine output: target 0.5 mL/kg/h in adults and 1 mL/kg/h in children. In children, add maintenance fluid separately (4-2-1 rule). Avoid over-resuscitation — fluid creep increases oedema and complications.
What are the ANZBA criteria for specialist burns unit referral?

The Australia and New Zealand Burn Association (ANZBA) criteria for transfer to a specialist burns unit are: partial-thickness burn ≥10% TBSA in adults or ≥5% TBSA in children; any full-thickness burn; burns involving the face, hands, feet, perineum, or major joints; circumferential burns; electrical or chemical burns; inhalation injury; burns in pregnant patients; burns in patients with significant pre-existing medical conditions affecting management; burns with concomitant trauma; and any burn where non-accidental injury is suspected in a child. If in doubt, contact the receiving burns unit for triage advice — a brief phone discussion with a burns specialist can guide appropriate disposition.
What should never be applied to a burn wound?

Never apply ice or iced water — this deepens the wound through vasoconstriction and risks hypothermia. Never apply butter, cooking oil, toothpaste, egg white, aloe vera from the garden, or any folk remedy — these introduce infection, obscure wound assessment, and delay healing. Silver sulphadiazine cream, once the standard topical agent, is no longer recommended in modern burns care: it interferes with wound assessment by staining the wound, delays re-epithelialisation compared to modern silver-containing dressings, and is not superior to simpler approaches. In the acute phase before specialist assessment, cover the burn loosely with cling-wrap (or a non-stick hydrogel dressing such as Burnshield for transport) and leave it undisturbed.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.