A burn is tissue injury from heat (thermal), chemicals, electricity, or radiation. Severity depends on depth, extent (% total body surface area, TBSA), location, age, inhalation injury, and comorbidities.

Burn depth

Burn depth can deepen over the first 48–72 hours as injured tissue becomes ischemic.

Systemic response in large burns (about 20% TBSA or more)

• Inflammatory mediators make capillaries leaky → plasma shifts from vessels into tissues (massive edema, including unburned areas)
• Result: hypovolemia, burn shock, hemoconcentration (raised hematocrit), decreased cardiac output — the greatest early threat
• Early hyperkalemia (cell destruction), hyponatremia, metabolic acidosis
• Fluid remobilization after about 48–72 hours: fluid returns to vessels → diuresis, hemodilution, risk of fluid overload and hypokalemia
• Hypermetabolism for months: high energy and protein needs, muscle wasting
• Immunosuppression and loss of the barrier → infection and sepsis (leading cause of death after the first days)
• Reduced gut perfusion → paralytic ileus, stress (Curling) ulcer

Inhalation injury

• Upper airway thermal injury → rapid edema and obstruction
• Chemical injury of lower airways from smoke → bronchospasm, ARDS, pneumonia
• Carbon monoxide (CO) poisoning — binds hemoglobin; pulse oximetry reads falsely normal
• Cyanide poisoning from burning plastics — severe lactic acidosis

Electrical burns: small entry and exit wounds may hide extensive deep muscle, nerve, and vessel damage along the current path; risks include dysrhythmias, rhabdomyolysis (myoglobinuria → acute kidney injury), compartment syndrome, and spinal injury.

Phases of care: emergent/resuscitative (injury to about 48–72 hours), acute (until wounds close), rehabilitation.

Primary survey first: airway (with cervical spine protection if trauma), breathing, circulation, disability, exposure (remove clothing and jewelry, prevent hypothermia).

Signs of inhalation injury — expect airway compromise

• Burns of the face, neck, or mouth; singed nasal hairs or eyebrows
• Soot in the mouth or nose, carbon-tinged (black) sputum
• Hoarseness, stridor, wheezing, dyspnea, drooling, difficulty swallowing
• Enclosed-space fire, confusion, headache (CO)

Estimating TBSA — Rule of Nines (adults)

• Palm method: the client's palm including fingers ≈ 1% TBSA — useful for scattered burns
• Children: larger head and smaller legs — use the Lund-Browder chart
• Do not count superficial (first-degree) burns in TBSA

Other assessments: circumferential burns (limbs — pulses, capillary refill, pain; chest — ventilation), urine color (dark red suggests myoglobin), ECG after electrical injury, pain, tetanus status, possible abuse (patterned burns, inconsistent history).

Fluid resuscitation — calculate from the time of injury, not arrival

Formal resuscitation is used for burns of about 20% TBSA or more in adults (smaller thresholds in children). Use isotonic crystalloid, usually lactated Ringer's.

• Parkland (Baxter) formula — classic teaching: 4 mL × kg × %TBSA in 24 hours; half in the first 8 hours from injury, the rest over the next 16 hours
• Current guidance (American Burn Association clinical practice guideline, 2023/2024): start at 2 mL × kg × %TBSA for adults with thermal burns to reduce over-resuscitation ("fluid creep"), then titrate the rate every hour to urine output. The formula is only a starting estimate
• Electrical injury: higher starting volume (commonly 4 mL × kg × %TBSA) and a higher urine target until urine clears
• Children: 3 mL × kg × %TBSA plus maintenance fluid containing dextrose for small children

Worked example — 70 kg adult, 40% TBSA partial and full thickness:

• Parkland: 4 × 70 × 40 = 11,200 mL/24 h → 5,600 mL in the first 8 hours = 700 mL/h
• ABA starting estimate: 2 × 70 × 40 = 5,600 mL/24 h → 2,800 mL in the first 8 hours = 350 mL/h, then adjusted hourly
• If 2 hours passed before IV access, the first-8-hour volume is given over the remaining 6 hours

Urine output targets (hourly, indwelling catheter)

• Adults: 0.5 mL/kg/h (about 30–50 mL/h)
• Children under 30 kg (66 lb): about 1 mL/kg/h
• Myoglobinuria / electrical injury: 1–1.5 mL/kg/h (about 75–100 mL/h in adults) until urine clears
• Rising output above target → decrease the rate; low output → increase the rate (do not give diuretics to raise urine output during resuscitation)
• Albumin may be added in larger burns to reduce total crystalloid volume

Airway and inhalation injury

• 100% oxygen by non-rebreather mask for suspected CO poisoning; hyperbaric oxygen in selected cases
• Early intubation when upper airway burns, stridor, hoarseness, or extensive facial burns are present — edema worsens over hours
• Suspected cyanide toxicity: hydroxocobalamin IV
• Escharotomy for circumferential chest burns restricting breathing or limb burns threatening circulation

Wound management

• Initial first aid: cool running water for about 20 minutes (useful up to 3 hours after injury); no ice, butter, or toothpaste; then cover with clean dry dressing; keep the client warm
• Chemical burns: brush off dry powder, then irrigate with large volumes of water
• Cleansing and debridement of devitalized tissue
• Blisters: small intact blisters are usually left intact; large, tense, or joint-limiting blisters may be aspirated or debrided per burn center protocol
• Topical antimicrobials or silver-containing dressings; moist wound healing
• Early excision and grafting (autograft; temporary allografts or skin substitutes)
• Tetanus prophylaxis

Other: IV opioids for pain (not IM — erratic absorption), stress ulcer prophylaxis, early enteral nutrition (within 24 hours) with high protein, DVT prophylaxis, glucose control.

Drug safety

Listed in priority order.

1. Airway and breathing — assess for inhalation injury first even when the burn looks limited; high-flow oxygen; prepare for intubation with hoarseness or stridor; elevate head of bed
2. Circulation and fluids — two large-bore IVs (through unburned skin if possible); titrate fluids hourly to urine output; monitor vital signs, mental status, urine color
3. Perfusion of circumferential burns — hourly pulses, capillary refill, sensation; elevate limbs; report signs of compartment syndrome
4. Cardiac monitoring for electrical burns and electrolyte shifts
5. Temperature control — warm room, warm fluids, cover wounds; the barrier to heat loss is gone
6. Infection prevention — strict aseptic technique during wound care, hand hygiene, protective barriers, clean environment; monitor for wound infection signs: discoloration, new purulent drainage (green suggests Pseudomonas), conversion to deeper injury, sudden eschar separation; prophylactic systemic antibiotics are not routinely used
7. Pain management — IV opioids before procedures; non-drug measures: deep breathing, relaxation, distraction, virtual reality, music
8. Nutrition — early enteral feeding; high-protein, high-calorie diet; weigh daily; monitor albumin trends and wound healing
9. Graft care — immobilize grafted areas for the prescribed period; watch for fluid or blood under the graft
10. Mobility and contracture prevention — positioning in anti-contracture positions (neck extended — no pillow under the head for neck burns; arms abducted; hips and knees extended), splints, range of motion, early ambulation
11. Psychosocial care — anxiety, acute stress, body image; support family

• First aid at home: stop the burning, cool with running water about 20 minutes, remove jewelry, cover with a clean cloth; no ice or home remedies
• Wound and graft care at home; signs of infection to report
• Pressure garments worn nearly all day (commonly about 23 hours/day) for many months to reduce hypertrophic scars
• Continue stretching and splint use; physical and occupational therapy
• Protect healed skin from sun; use moisturizer for itching and dryness; healed areas may not sweat normally
• High-protein diet during healing
• Prevention: smoke alarms, water heater at or below 49 °C (120 °F), test bath water, keep children away from stoves and hot liquids, safe handling of chemicals and electricity, no fireworks for children

• Airway first — hoarseness, stridor, singed nasal hair, soot, black sputum → prepare for intubation
• CO poisoning: SpO₂ falsely normal; give 100% oxygen; check COHb
• Rule of Nines: head 9, each arm 9, front trunk 18, back trunk 18, each leg 18, perineum 1; palm ≈ 1%
• Full-thickness burns are painless, white or leathery; superficial partial-thickness burns are blistered and very painful
• Parkland: 4 mL × kg × %TBSA, half in first 8 hours from injury
• Current ABA guidance: start at 2 mL × kg × %TBSA and titrate hourly to urine output 0.5 mL/kg/h (30–50 mL/h) in adults
• Electrical: urine target 1–1.5 mL/kg/h (75–100 mL/h); cardiac monitoring; small skin wounds hide deep damage
• Emergent phase: hypovolemic shock, hyperkalemia, high hematocrit; later fluid remobilization → overload, hypokalemia
• Strict asepsis; no routine prophylactic systemic antibiotics
• High-protein, high-calorie early enteral feeding
• Pain: IV opioids, not IM; plus relaxation and distraction
• Rehab goal: prevent contractures — positioning, splints, ROM, pressure garments