This educational activity is credited for 5 contact hours at completion of the activity.
This course is designed to offer healthcare professionals a concise overview of burn injuries, including their types, common causes, classifications by degree, fluid resuscitation strategies, key aspects of burn shock, and essential nursing considerations.
Burns are traumatic injuries that commonly affect the skin, the body’s largest organ, which averages a surface area of approximately 2 m². Damage to the skin from burns compromises its barrier function, increasing the risk of fluid loss, renal and circulatory failure, and microbial invasion that may lead to infection and sepsis. This course explores burn injuries by outlining their types, underlying pathophysiology, and immediate care. It also reviews fluid resuscitation formulas for both adult and pediatric patients, addresses fluid needs specific to electrical burns, and discusses long-term care and emergency nursing considerations.
Upon completion of this course, the learner will be able to:
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| Acid | A chemical substance that neutralizes alkalis, dissolves some metals, and turns litmus red; typically, a corrosive or sour-tasting liquid of this kind. |
| Activated Partial Thromboplastin Time (aPTT) | A screening test that helps evaluate a person’s ability to appropriately form blood clots. |
| Acute Radiation Syndrome (ARS) | Illness caused by exposure to large dose of ionizing radiation in a short duration of time. |
| Acute Respiratory Distress Syndrome | A type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. |
| Alkalinize | To make alkaline. |
| Alkali | A basic, ionic salt of an alkali metal or an alkaline earth. |
| Allograft | The transfer of tissue between genetically nonidentical members of the same species. |
| Alpha Rays | Consist of two protons and two neutrons bound together into a particle identical to a helium-4 nucleus. |
| Anasarca | A general accumulation of serous fluid in various tissues and body cavities characterized by swelling of the whole body. |
| Antidiuretic Hormone (ADH) | Helps the body regulate the water content of your blood, which impacts blood pressure and volume. |
| Anxiety | Natural response to stress that can become a disorder if it affects one’s life. |
| Autograft | Grafts that have been harvested from the patient at the time of surgery and are the “gold standard” by which the success of other grafting techniques is assessed. |
| Beta Particle | Also called beta ray or beta radiation (symbol β), is a high-energy, high-speed electron or positron emitted by the radioactive decay of an atomic nucleus during the process of beta decay. |
| Burn Shock | A unique combination of hypovolemic and distributive shock, accompanied by cardiogenic shock. |
| Burn | Tissue damage that results from heat, overexposure to the sun or other radiation, or chemical or electrical contact. |
| Capillary Leak Phase | A rare disease that involves the leaking of massive amounts of plasma and protein through capillaries, leading to hypovolemic shock, which deprives major organs of oxygen. |
| Central Venous Pressure | The blood pressure in the venae cava, near the right atrium of the heart. |
| Chemical Burn | Injuries to the eyes, mouth, skin, or internal organs caused by contact with a corrosive substance. |
| Coagulation Necrosis | A type of cell death that occurs when blood flow to cells stops or slows (ischemia). |
| Contractures | A permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult. |
| Depression | A mood disorder that causes a persistent feeling of sadness and loss of interest. |
| Dermis | The middle layer of your skin that supports your epidermis, protects your body from harm, produces sweat and hair, and feels different sensations |
| Dialysis | A blood purifying treatment given when kidney function is not optimum. |
| Disseminated Intravascular Coagulation (DIC) | A rare blood clotting disorder that can cause organ damage and uncontrollable bleeding. |
| Distributive Shock | A medical emergency where the body cannot get enough blood to the heart, brain, and kidneys. |
| Diuresis | A condition that causes increased urination because of increased fluid filtration from the kidneys. |
| Electrical Burn | A burn that results from electricity passing through the body causing rapid injury. |
| Epidermis | The top layer of the skin that protects internal organs from harm, maintains hydration, produces new skin cells, and contains melanin. |
| First-Degree Burn | A superficial burn that affects only the epidermis of the skin. |
| Full Thickness Burn | A third-degree burn that affects the epidermis and dermis of the skin. |
| Gamma Ray | A penetrating form of electromagnetic radiation arising from the radioactive decay of atomic nuclei. |
| Hyperkalemia | A condition in which potassium levels are too high in blood, which can cause muscle weakness, heart problems and other complications. |
| Hypertrophic Scar | Thick, raised scars that form when skin is injured and heals with too much collagen. |
| Hyperuricemia | When there’s too much uric acid in blood, which can cause gout, kidney stones, and other health problems. |
| Hypocalcemia | A condition when the level of calcium in your blood is too low. |
| Hypothermia | A condition of having a lower body temperature than normal body temperature. |
| Immunosuppression | The partial or complete suppression of the immune response of an individual, either naturally because of disease or another condition or artificially induced to help the survival of an organ after a transplant operation. |
| Infection | The invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins that they produce. |
| Inflammatory Mediators | Substances produced by cells in response to injury or infection. |
| Keratin Layer | Fibrous structural protein of hair, nails, horn, hoofs, wool, feathers, and of the epithelial cells in the outermost layers of the skin. |
| Liquefaction Necrosis | Occurs when affected cells are completely digested by hydrolytic enzymes, resulting in a soft, circumscribed lesion consisting of pus and the fluid remains of necrotic tissue. |
| Lund-Browder Chart | A tool useful in the management of burns for estimating the total body surface area affected. |
| Mean Arterial Pressure | The average arterial pressure throughout one cardiac cycle, systole, and diastole. MAP = DP + 1/3(SP – DP). |
| Microthrombi | A microscopic clump of fibrin, platelets, and red blood cells. |
| Modified Brooke | Recommended as a starting point for fluid resuscitation for burns >15% BSA in children and >20% BSA in adults. 2mls x body surface areas burned (BSAB) x weight. |
| Modified Parkland Formula | A reasonable starting point for determining fluid requirements in adult patients. -> Adults – 4ml/kg/% -> Children – 3-4ml/kg/%. |
| Myoglobinuria | A condition where urine turns dark red or brown due to excess myoglobin, a protein that carries oxygen in muscles. |
| Oliguria | Low urine output of less than 400ml a day. |
| Parkland Formula | An essential tool for calculating fluid resuscitation in patients with critical burns. Total crystalloid fluid 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) |
| Partial-Thickness Burn | Also known as a second degree burn) is a burn that affects the top two layers of skin, called the epidermis and hypodermis. |
| Post-Traumatic Stress Disorder (PTSD) | A mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations. |
| Prothrombin Time (PT) | A test to evaluate blood clotting. |
| Radiation Burn | A damage to the skin or other biological tissue and organs as an effect of radiation. |
| Renin-Angiotensin-Aldosterone System (RAAS) | A system of hormones, proteins, enzymes, and reactions that regulate r blood pressure and blood volume on a long-term basis. |
| Rhabdomyolysis | A serious condition where damaged muscle fibers leak into the blood, causing kidney and heart problems, or even death. |
| Rule of Nines | A tool to estimate the burn percentage of total skin. It divides the body into sections by multiples of 9% each. |
| Second-Degree Burn | A mild to moderate burn that damages the top layer of skin (epidermis) and the second layer of skin (dermis). |
| Sepsis | An infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever. |
| Solvents | Liquids that can dissolve, suspend, or extract other substances without changing them chemically. |
| Stratum Spinosum | A layer of the epidermis found between the stratum granulosum and stratum basale. |
| Thermal Burn | Skin injuries caused by excessive heat, typically from contact with hot surfaces, hot liquids, steam, or flame. |
| Third-Degree Burn | A severe burn that destroys all the tissue of the epidermis and dermis and extends into the fatty tissue below the dermis. |
| Thromboprophylaxis | A medical treatment to prevent the development of blood clots inside blood vessels in those considered at risk for developing thrombosis. |
| Total Body Surface Area (TBSA) | An effortless way to get a rough burn size estimate that can be used when calculating a patient’s fluid resuscitation needs. |
| Venous Thromboembolism (VTE) | A condition that occurs when a blood clot forms in a vein. |
Burns are traumatic injuries that typically affect the skin, the body’s largest organ, which covers an average surface area of approximately 2 m². This essential barrier comprises the epidermis and dermis, serving to protect underlying tissues and aid in wound healing. When the skin sustains a burn, it compromises this protective function, leading to risks such as fluid loss, renal and circulatory failure, and susceptibility to microbial invasion, which may result in infection and, in severe cases, sepsis.¹
Burns represent a common injury globally, with over one million incidents occurring annually in the United States alone.² Even burns classified as minor can lead to lasting functional and cosmetic consequences. Due to the high potential for complications, immediate and appropriate medical intervention is critical. The first 24 hours post-injury are especially pivotal in determining outcomes and minimizing recovery time. This course explores the classification, pathophysiology, and initial management of burn injuries. It also covers fluid resuscitation strategies for both adults and children, special considerations for electrical burns, and the long-term and emergency nursing care necessary for optimal recovery.
A burn is a traumatic injury affecting the skin or other tissues caused by exposure to thermal, chemical, electrical, or radiation sources. Burns are categorized based on the source of injury and the depth of tissue involvement.
Thermal burns occur due to exposure to heat sources such as flames, hot surfaces, steam, or scalding liquids. These burns may range from superficial, affecting only the epidermis, to deeper injuries involving the dermis or underlying tissues. Thermal burns represent approximately 90% of all burn injuries and are further subdivided into scalds, dry heat burns, and contact burns. Scalds, caused by hot liquids, are the most frequent, especially in children—accounting for roughly 70% of pediatric burns—and are generally classified as partial-thickness burns. Dry heat burns result from exposure to radiant heat or flame, commonly in adults, and often present with complications like smoke inhalation. These burns may be partial- or full-thickness and often require surgical treatment. Contact burns arise from prolonged contact with a hot object and are frequently associated with deeper tissue damage, particularly in cases involving unconsciousness, often necessitating surgical repair.¹⁻⁴
Chemical burns stem from exposure to corrosive agents such as acids, alkalis, or solvents, comprising about 3% of all burns. These burns denature proteins and inflict immediate tissue injury upon contact. The burn’s severity depends on the chemical’s type, concentration, and contact duration. Alkali burns tend to be more severe due to liquefaction necrosis, which allows deeper tissue penetration. In contrast, acid burns typically cause coagulation necrosis, limiting penetration but still causing significant injury.¹⁻⁵
Electrical burns occur when the body comes into contact with an electrical current, causing damage along the current’s path. Though they account for less than 5% of burn injuries, they frequently result in extensive internal damage to muscles, nerves, and organs. Burn severity is influenced by voltage, current type and duration, and current path. Low-voltage burns (<1000 V) may leave small but deep entry and exit wounds, while high-voltage burns (>1000 V) can result in severe complications such as limb loss, rhabdomyolysis, cardiac arrhythmias, asystole, and kidney failure. Electrical burns can be deceptive, with minimal external signs masking serious internal injury, and are associated with a higher mortality rate than other burn types.¹⁻⁵
Radiation burns arise from exposure to harmful radiation such as alpha, beta, and gamma rays. Alpha particles are heavy, positively charged helium nuclei that travel short distances and cannot penetrate intact skin but can cause severe damage if inhaled or ingested. Beta particles are high-speed electrons that penetrate a few millimeters into the skin, leading to superficial injuries resembling sunburn. Gamma rays, which originate from radioactive decay or X-ray exposure, penetrate deeply into tissues, potentially harming internal organs, bone marrow, and DNA. Deep gamma-ray exposure can result in systemic effects collectively known as Acute Radiation Syndrome (ARS).¹⁻⁴⁻⁶
Burns are classified into three primary degrees based on the depth and severity of tissue damage, each presenting with specific characteristics and clinical implications: first-degree, second-degree, and third-degree burns.
First-degree burns, or superficial burns, affect only the epidermis, the skin’s outermost layer, without involvement of the underlying structures. These burns typically cause redness, mild swelling, and pain. A common example is mild sunburn. First-degree burns generally heal within ten days and are not associated with permanent scarring or significant complications.¹⁻⁴
Second-degree burns, also known as partial-thickness burns, penetrate deeper into the dermis—the layer beneath the epidermis that houses blood vessels, nerve endings, and hair follicles. These burns are more painful and carry a greater risk of scarring and complications than first-degree burns. They may result from exposure to hot liquids, flames, or chemicals. Clinical features include redness, edema, and blister formation due to the accumulation of ultrafiltrate plasma in the stratum spinosum. Healing time ranges from 10 to 14 days, although it can be prolonged depending on burn severity and depth.¹⁻⁷
Third-degree burns, or full-thickness burns, extend through all layers of the skin and may involve subcutaneous tissues, muscle, or even bone. The affected area may appear white, leathery, brown, or charred. Nerve destruction can lead to a lack of pain in the injured area despite the severity of the damage. These burns do not heal spontaneously and typically require more than six weeks of recovery, often necessitating surgical intervention such as skin grafting. There is also an increased risk of complications, including substantial fluid loss and infection. Prompt emergency treatment is essential to minimize systemic effects and long-term disability.¹⁻⁵
During the initial management of burn injuries, prompt and systematic interventions are essential to prevent complications and support recovery. The first priority is a comprehensive airway assessment, particularly in cases of thermal burns involving enclosed fires or explosions, where inhalation injury is a concern. Clinical indicators of inhalation injury include facial burns, singed nasal hairs, hoarseness, carbonaceous sputum, and signs of respiratory distress. If airway compromise is suspected, immediate administration of supplemental oxygen is warranted, and early endotracheal intubation may be necessary to secure the airway and ensure adequate ventilation.¹²⁴⁸
Simultaneously, all clothing should be carefully removed to allow for a complete evaluation of the burn’s extent. This is essential for calculating the total body surface area (TBSA) affected, a critical factor in planning treatment and initiating fluid resuscitation protocols. Accurate TBSA estimation guides the volume of fluids required and helps prioritize care.¹²⁴⁸
Application of wet sterile dressings over the burn site provides both cooling and analgesia. Prompt cooling has been shown to improve cellular outcomes and relieve pain. However, cooling must be performed cautiously to avoid further injury. Applying ice or very cold substances can exacerbate tissue damage by causing vasoconstriction and reducing perfusion, potentially leading to frostbite or hypothermia, particularly in extensive burns. The ideal temperature range for cooling burned tissue is 10–20°C, applied for a limited duration.¹²⁴⁸
For moderate to severe burns, fluid resuscitation is initiated early due to significant fluid and electrolyte losses associated with increased capillary permeability and evaporative water loss. Intravenous fluids are administered to restore circulatory volume, maintain organ perfusion, and prevent hypovolemic shock. Various evidence-based formulae, such as the Parkland formula, are used to calculate fluid requirements and guide resuscitation strategies.¹²⁴⁸
Estimating Total Body Surface Area (TBSA%) burned is essential for evaluating the severity of burn injuries and plays a pivotal role in clinical decision-making, especially in fluid resuscitation. Two primary methods used to determine TBSA% are the Rule of Nines and the Lund-Browder Chart.
The Rule of Nines is a rapid assessment tool commonly used for adults with second- and third-degree burns. This method divides the body into anatomical regions, each assigned a multiple of 9% of the total body surface area. The assigned values are: head and neck (4.5% front, 4.5% back – totaling 9%), each arm (9%), anterior trunk (18%), posterior trunk (18%), perineum (1%), and each leg (18%). While quick and practical in emergency settings, this method may yield less accurate estimates for pediatric or obese patients due to variations in body proportions.⁹¹⁰
The Lund-Browder Chart offers a more detailed and individualized approach. It accounts for age-specific anatomical differences, making it the preferred method for children. This chart breaks the body into smaller regions, each with percentage values that adjust based on the patient’s age. This allows for more precise estimation of burn size and guides accurate fluid and nutritional management. By reflecting developmental variations in body surface distribution, the Lund-Browder Chart ensures better accuracy across diverse patient populations.⁹⁻¹¹
Burn shock is a form of distributive shock characterized by insufficient tissue perfusion and oxygen delivery despite normal or elevated cardiac output. The initial response to severe burns involves a short phase of vasoconstriction triggered by sympathetic nervous system activation, accompanied by tachycardia to maintain cardiac output. Simultaneously, a systemic inflammatory response is initiated, releasing mediators that increase capillary permeability. This process, known as the capillary leak phase, allows plasma and proteins to shift from the intravascular space into the interstitial compartment, leading to intravascular volume depletion.¹²
As a result, hypovolemia develops, reducing cardiac output despite ongoing tachycardia. Endothelial dysfunction impairs microcirculation, and the formation of microthrombi along with red blood cell aggregation leads to decreased tissue perfusion and cellular hypoxia. These disruptions further compromise organ function. The inflammatory cascade also stimulates the coagulation pathway, potentially resulting in disseminated intravascular coagulation (DIC) in severe cases.
Burn injuries also create an immunosuppressive state, heightening vulnerability to infections. To counteract fluid loss, the body activates the renin-angiotensin-aldosterone system (RAAS), which promotes sodium and water retention, and releases antidiuretic hormone (ADH) to enhance water reabsorption in the kidneys. Clinically, burn shock presents with hypotension, sustained tachycardia, cool and clammy extremities due to peripheral vasoconstriction, and oliguria caused by decreased renal perfusion.¹³
In cases of large deep partial-thickness or full-thickness burns—specifically those covering more than 20% of the Total Body Surface Area (TBSA) in adults or over 10% in children—fluid resuscitation becomes essential. This involves the intravenous administration of crystalloid fluids to counteract the substantial hypovolemia that arises during the early stages of severe burns, primarily due to the capillary leak phenomenon. Multiple fluid replacement formulas exist to guide care, including the Parkland, Modified Parkland, Brooke, Modified Brooke, Evans, and Monafo formulas. Each method factors in patient weight and burn area to tailor fluid therapy within the first 24 hours following injury. Selection depends on clinical judgment, institutional protocols, and individual patient factors, with frequent reassessment required to match evolving fluid needs.¹²
Parkland Formula
Developed by Dr. Charles Baxter at Parkland Hospital, this is the most widely used method in U.S. burn centers. The Parkland Formula recommends administering 4 mL/kg/%TBSA burned of Lactated Ringer’s (LR) solution over the first 24 hours post-injury for adults, and 3 mL/kg/% for children. In pediatric maintenance, rates are weight-dependent:
During the first 24 hours, no colloids are used. In the second 24 hours, colloids make up 20–60% of the calculated plasma volume while crystalloids are discontinued. Dextrose in water is also introduced to maintain a urine output of 0.5–1 mL/kg/hour in adults and 1 mL/kg/hour in children.¹³ ¹⁴
Modified Parkland Formula
This version adjusts fluid distribution: half is given in the first 8 hours, and the remaining half over the next 16 hours. In the second 24-hour phase, 5% albumin is administered at a dose of 0.3–1 mL/kg/%TBSA over 16 hours, with LR used during the initial phase.¹⁴
Brooke Formula
Created at Brooke Army Medical Center, this formula suggests in the first 24 hours:
In the next 24 hours:
Modified Brooke Formula
This removes colloids from the first 24 hours and increases LR volume to:
During the second 24 hours, crystalloids are stopped and colloids are started at 0.3–0.5 mL/kg/% burn, with glucose solutions added as needed to support urine output.¹⁴
Evans Formula
Developed in the 1950s by Dr. Everett Evans, this formula prescribes:
First 24 hours:
Second 24 hours:
Monafo Formula
Introduced in the 1980s, this method uses hypertonic saline containing:
The solution is administered during the first 24 hours and adjusted according to urine output. In the second 24 hours, titration continues with one-third normal saline.¹⁴ ¹⁵
Pediatric-Specific Formulas
Because children have a higher BSA-to-mass ratio, adult-based formulas often underestimate fluid needs. Pediatric-specific strategies include the Shriner’s Cincinnati and Galveston Formulas.¹⁶
Shriner’s Cincinnati Formula
This is based on Parkland but adds a BSA-based maintenance fluid component.
Older children:
Younger children:
Galveston Formula
Developed at Shriners Hospitals for Children in Galveston:
For effective fluid resuscitation in burn injuries, the ideal solution should restore circulating plasma volume while minimizing potential side effects. The three primary types of fluids used include isotonic crystalloids, hypertonic solutions, and colloids. Crystalloids, such as Lactated Ringer’s (LR), Hartmann’s solution, and normal saline, are typically used in the early stages post-burn. LR is a balanced solution containing electrolytes like sodium, potassium, calcium, and lactate. Although widely used, large volumes of normal saline may lead to hyperchloremic acidosis, while LR has been associated with increased neutrophil activation and reactive oxygen species (ROS) production, contributing to oxidative stress and potential tissue injury. All crystalloids can impact coagulation pathways, raising the risk of thromboembolic complications.¹⁵
Hypertonic solutions are characterized by their higher osmolarity compared to body fluids. These solutions help counteract sodium imbalances seen in burn shock by drawing intracellular fluid into the vascular space, thereby expanding plasma volume and reducing cellular swelling. For example, rapid administration of 250 mEq/L saline can effectively increase vascular volume. However, studies have shown that total fluid requirements after 48 hours are similar to those with LR use, and hypertonic solutions are linked to increased rates of renal failure and mortality.¹⁵
Colloids, including albumin and glucose-based solutions, are hyperosmotic fluids that support plasma volume by increasing oncotic pressure and preventing fluid leakage from vessels. Although colloids are known to be beneficial, the timing of their use is debated. Some studies suggest minimal benefit and potential respiratory complications if used in the first 24 hours post-burn. However, when introduced early, colloids may reduce overall fluid requirements, improve hemodynamic stability, and decrease mortality rates compared to crystalloids alone.¹⁵ ¹⁸
High-voltage electrical burns (>1,000 V) present unique challenges in fluid resuscitation. These burns often cause both visible surface injuries and deeper, less apparent tissue damage from resistive heating of internal structures like muscle and bone. Surface burns caused by electrical arcs and ignited clothing are accounted for in standard fluid resuscitation formulas. However, deep injuries can result in complications like compartment syndrome and rhabdomyolysis, leading to myoglobinuria, renal dysfunction, and ultimately acute kidney injury. Electrical burn patients are at high risk of chronic kidney disease and increased mortality.¹⁹
Standard resuscitation formulas, such as the Parkland formula, are typically used as a baseline, but electrical burn patients often require greater fluid volumes. Children especially need proportionally more fluids due to their higher surface area-to-mass ratios. Nevertheless, over-resuscitation must be avoided, as it can lead to compartment syndrome, pulmonary and cerebral edema, infection, acute respiratory distress syndrome (ARDS), and generalized edema (anasarca). Inadequate or excessive fluid can also worsen burn severity and delay healing.
The current standard for monitoring resuscitation adequacy is urine output, targeted at 75–100 mL/hour (or 1 mL/kg/hour). If urine output is insufficient, clinicians should monitor other parameters, including serum lactate, base deficit, hemoglobin, and hemodynamic metrics such as mean arterial pressure (MAP) and central venous pressure (CVP) to guide fluid therapy.¹⁹
Severe burns can impair renal function, leading to acute kidney injury (AKI) that may require dialysis. Burn-induced complications like rhabdomyolysis result in the release of myoglobin into circulation, which can overwhelm renal filtration, especially at serum levels above 1.5–3 µg/mL or urine levels of 0.02 µg/mL. This condition is indicated by dark or tea-colored urine and, if untreated, may progress to renal failure. In such cases, dialysis is considered to correct fluid and electrolyte imbalances, eliminate toxins, and support renal recovery. Unfortunately, burn patients who require dialysis face a high mortality rate of up to 80%, and some may need long-term renal replacement therapy.¹ ¹³ ¹⁹
In cases of rhabdomyolysis where urine output does not improve early during resuscitation, 25 g of mannitol every 6 hours may be administered, along with continuous infusion of 5% sodium bicarbonate to alkalinize urine and enhance myoglobin solubility. However, bicarbonate use can falsely elevate base deficit values, necessitating close monitoring of serum lactate to assess metabolic trends. Electrolyte levels—including calcium, potassium, and urine pH—should also be tracked to avoid hypocalcemia, hyperkalemia, and hyperuricemia. If urine pH remains low or if electrolyte complications arise, bicarbonate therapy should be discontinued. Hyperkalemia may be managed through diuretics or dialysis as needed.¹ ¹³ ¹⁹
The American Burn Association (ABA) provides comprehensive practice guidelines for fluid resuscitation in burn shock, emphasizing individualized care based on patient size, burn extent, and injury severity. In adults and children with burns exceeding 20% of total body surface area (TBSA), formal fluid resuscitation should be initiated. Most formulas recommend administering 2–4 mL/kg/% TBSA burned of crystalloid solution within the first 24 hours post-injury. Regardless of the formula or fluid used, urine output should be closely monitored, with a goal of 0.5–1.0 mL/kg/hour in adults and 1.0–1.5 mL/kg/hour in children. Maintenance fluids should be provided in addition to resuscitation fluids in pediatric patients. Individuals with full-thickness burns, inhalation injuries, or delays in initiating resuscitation may require greater fluid volumes. Several additional supportive strategies are available to optimize outcomes.²⁰
Colloid-containing fluids may be introduced after 12–24 hours to help reduce total fluid volume requirements. For alert patients with moderate burn injuries, oral fluid resuscitation may be appropriate. The use of hypertonic saline should be limited to experienced providers due to the risk of excessive hypernatremia. High-dose ascorbic acid has been explored as a way to reduce overall fluid needs, though more research is necessary to confirm its efficacy. ABA guidelines also recommend referring patients to a burn center if they present with partial-thickness burns covering more than 10% TBSA, full-thickness burns, burns involving the face, hands, feet, genitalia, or major joints, chemical or electrical burns, significant inhalation injuries, coexisting medical conditions, or traumatic injuries.²⁰
Burn patients often require a multidisciplinary approach beyond fluid resuscitation, including infection prevention, nutritional support, metabolic management, pain control, and clotting risk assessment.
Antimicrobial Therapy:
Burn wounds are highly susceptible to infection and sepsis due to compromised skin integrity. Management strategies include early excision and grafting, along with topical antimicrobial dressings. Although prompt treatment is essential, initiating broad-spectrum antibiotics prophylactically is not generally recommended without clear evidence of infection. In cases involving immunocompromised patients or heavily contaminated wounds, bacterial cultures should guide the use of antibiotics and antifungal agents.¹ ² ⁴ ²⁰
Hypermetabolism Management:
Severe burns induce a hypermetabolic state marked by increased catabolism, stress hormone release, and energy demands. For TBSA <10%, resting energy expenditure remains normal, but with TBSA >40%, energy needs may double. Managing this metabolic response is critical to prevent muscle loss, delayed healing, and organ dysfunction. Environmental adjustments like increasing room temperature can reduce energy demands. Pharmacological agents with anabolic or anti-catabolic properties may also be necessary.¹ ² ⁴ ²⁰
Nutritional Support:
Adequate nutrition is essential for wound healing and modulating hypermetabolism. Early enteral feeding within the first 24 hours is preferred over oral intake alone, as it preserves gastrointestinal function and reduces the risk of infection. Initial feeds should start at low volume and progress gradually. High-protein, high-carbohydrate diets help maintain lean mass and stimulate insulin production. Supplements including zinc, iron, copper, and vitamins A, C, and D should be administered intravenously early in the treatment course due to rapid depletion during fluid loss. Nutritional plans must be tailored to individual needs based on metabolic rate, burn severity, and clinical status.¹ ² ⁴ ²⁰
Pain Management:
Effective pain control is vital for patient comfort, wound care tolerance, and recovery. A multimodal approach using both opioid and non-opioid analgesics is often most effective. Regional anesthesia methods, such as epidural analgesia, can provide targeted relief. Ongoing assessment of pain and side effects is essential to guide medication adjustments.¹ ² ⁴ ²⁰
Coagulation Monitoring and Thromboprophylaxis:
Burn patients are at risk of coagulopathy due to inflammation, tissue injury, and extensive fluid therapy. Regular monitoring of PT, aPTT, and platelet counts is necessary to detect coagulation abnormalities early. Interventions may include clotting factor or blood product administration. Immobility and endothelial damage also raise the risk of venous thromboembolism (VTE). Preventive strategies include mechanical interventions like intermittent pneumatic compression and, when indicated, pharmacologic anticoagulation. The choice and timing of these treatments should be guided by individual bleeding risk and wound status.¹ ² ⁴ ²⁰
Long-term management of burn injuries involves a holistic approach that addresses not only the physical aspects of healing but also the emotional and psychological challenges that may arise. Individualized care plans, continuous evaluation, and collaboration among multidisciplinary teams are essential components of effective long-term treatment. One of the most impactful outcomes for burn survivors is the change in physical appearance. Burns can lead to permanent scarring and alterations in skin pigmentation and texture, significantly affecting a patient’s self-image and quality of life. In many cases, surgical grafting procedures—such as autografts using the patient’s own skin or allografts using donor tissue—are required to support wound closure and function. These grafts demand extensive long-term care to maintain viability and reduce complications, but they may still result in hypertrophic scarring. Scar management strategies like compression garments, silicone-based treatments, and topical agents may be used to minimize these effects, though results vary. In certain cases, surgical scar revision offers a more effective solution for improving the appearance and function of the affected area. Emotional and psychological support is a critical aspect of care during this phase, helping patients cope with body image concerns and fostering acceptance.²¹
Rehabilitation through physical and occupational therapy is also crucial to preserving functional mobility and preventing contractures—tightening of skin and soft tissues that can restrict movement, particularly around joints. A regimen of range-of-motion exercises, splinting, and other therapeutic modalities should begin early and continue throughout recovery to support flexibility and joint function. Surgical intervention may be necessary in severe contractures to restore mobility. Ongoing therapy and regular follow-ups are typically required to prevent long-term disability. Additionally, the psychological impact of burn trauma can be profound. Survivors are at increased risk for mental health conditions such as anxiety, depression, and post-traumatic stress disorder (PTSD), which can disrupt relationships, daily activities, and overall emotional well-being. Routine psychological evaluations and access to counseling or psychotherapy provide essential support, helping individuals develop effective coping strategies and adjust to post-injury life.²¹
Nurses play an essential role in the comprehensive management of burn patients, encompassing both clinical and psychological care. They must be knowledgeable in medical protocols, trauma response, and emotional support for both the patient and their family. Accurate documentation and effective communication of all nursing interventions are vital to ensure continuity of care, particularly during transfers to specialized burn centers. Prior to initiating extensive local treatment, it is important to notify the burn center. Patients referred to these centers typically do not require aggressive wound debridement or topical antibiotics before arrival. Nursing teams should support procedures such as the placement of Foley and peripheral intravenous catheters, while specialized clinicians handle central and arterial line placement when necessary. Two large-bore peripheral IVs should be inserted promptly, preferably in unburned areas; however, placement through burned tissue is acceptable if no alternative exists. Peripheral IV access is the preferred initial route for fluid resuscitation in the emergency department. If peripheral access is not feasible, central venous or intraosseous access should be considered.²² ²³
It is also critical to recognize that burn patients are trauma patients and may present with additional injuries. A thorough initial evaluation must be performed, focusing on airway integrity, body temperature, and pain assessment. Hypotension, if present, is often a late indicator of burn shock and should prompt clinicians to evaluate for other traumatic causes such as hemothorax, cardiac tamponade, neurogenic shock, or intra-abdominal hemorrhage.
Burn nurses are central to coordinating care and must have expertise in multisystem organ failure, critical care practices, diagnostic assessments, and both rehabilitative and psychosocial support. Additionally, they must be highly skilled in wound care. Whether a wound heals spontaneously or through surgical grafting, it is the nurse’s responsibility to monitor for subtle changes, prevent infection, and ensure adequate pain management throughout the healing process.²² ²³
The effective management of burn injuries, especially within the critical first 24 hours, requires a detailed understanding of burn classifications, degrees of tissue damage, and the underlying mechanisms of burn shock. Fluid resuscitation—guided by established formulas—must be customized based on a patient’s weight, age, and percentage of total body surface area affected. The selection and administration of various fluid types emphasize the delicate balance needed to maintain fluid and electrolyte stability. In addition to early interventions and adherence to American Burn Association guidelines, comprehensive burn care includes antimicrobial strategies, measures to reduce hypermetabolism, nutritional support, pain control, and careful monitoring for coagulopathy and thrombotic events.
Long-term care extends beyond wound healing to address psychosocial challenges, scarring, and functional recovery. Rehabilitation efforts, including physical and occupational therapy, are essential in preventing contractures and preserving mobility. Emotional and psychological support plays a crucial role in helping patients cope with changes in appearance and quality of life. Throughout this process, nurses serve as critical advocates and caregivers, providing coordinated, compassionate, and evidence-based care at every stage.
Ultimately, managing burn injuries requires a multidisciplinary, patient-centered approach that spans acute treatment to rehabilitation. Integrating medical, surgical, and nursing expertise is essential not only for patient survival but also for promoting long-term recovery and reintegration into daily life.
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