If airway edema progressing then early intubation before loss of landmarks
Smaller endotracheal tube size anticipated
Significant facial or neck burns
Difficult airway preparation
Surgical airway backup readiness
Oxygen and toxins
High flow oxygen for smoke exposure
Carboxyhemoglobin elimination accelerated with oxygen
Hyperbaric discussion per local protocol when severe
Cyanide antidote consideration
Enclosed space fire with altered mental status
Markedly elevated lactate supporting suspicion
Fluid resuscitation and hemodynamic targets
Resuscitation principles
Indications
Partial thickness and deeper exceeding 15 percent TBSA
Capillary leak peak within first 24 hours
Ongoing reassessment with urine output targets
Children with lower TBSA thresholds per local burn center guidance
Maintenance fluids required in addition to resuscitation
Hypoglycemia risk in small children
Initial formula starting points
Lactated Ringer starting estimate
2 mL per kg per percent TBSA for adults as conservative start
Half in first 8 hours from time of burn
Remaining over next 16 hours
3 mL per kg per percent TBSA for children as starting estimate
Separate maintenance dextrose containing fluids if indicated
Frequent glucose monitoring in young children
4 mL per kg per percent TBSA for electrical injury consideration
Higher risk of deep tissue necrosis
Higher urine output targets often used
Titration targets
Urine output goals
Adults 0.5 mL per kg per hour
Foley catheter for major burns
Adjust fluids hourly to goal
Children 1 mL per kg per hour
Consider 2 mL per kg per hour in infants
Avoid over resuscitation with lung exam and ultrasound adjuncts
Electrical injury 1 mL per kg per hour or higher per burn center
Myoglobinuria clearance goal
Urine alkalinization per consult if severe rhabdo
Analgesia and sedation
Pain control ladder
Non opioid baseline for minor burns
Acetaminophen oral dosing per weight and age
Max daily dose per local formulary
Hepatic disease adjustment
Ibuprofen oral dosing per weight and age
Avoid in renal hypoperfusion
Avoid in bleeding risk settings
Opioid first line for moderate to severe burns
Morphine IV titration
Small incremental dosing
Monitor respiratory status
Fentanyl IV titration
Useful for short procedures
Hemodynamic stability advantage
Dissociative analgesia for severe pain or procedures
Ketamine IV
Titrated doses for analgesia versus sedation
Emergence reaction mitigation per protocol
Regional anesthesia options
Digital block for finger burns
Avoid epinephrine in end artery concerns per local protocol
Sensory exam documented before block when possible
Local wound care by burn depth
Superficial burns
Supportive care
Cool compresses after initial cooling period
Ongoing cold exposure avoided to prevent vasoconstriction injury
Hydration and sun protection advice
Moisturizer and aloe once skin intact
Avoid occlusive greasy products on acute thermal burn
Pruritus control plan
Superficial partial thickness burns
Blister and dressing approach
Non adherent dressing with topical antimicrobial when indicated
Bacitracin for small areas
Avoid routine silver sulfadiazine for minor outpatient burns due to delayed healing risk
Blister management individualized
Large tense blisters impairing motion may be de roofed in sterile fashion
Small intact blisters often left intact
Deep partial thickness burns
Early specialist involvement
Burn center consultation
High risk of conversion and scarring
Excision and grafting consideration
Elevation and splinting when over joints
Contracture prevention
Early occupational therapy planning
Full thickness burns
Definitive care pathway
Burn center management
Early excision and grafting typical
Escharotomy readiness if circumferential
Dry sterile dressings during stabilization
Avoid topical agents that obscure depth assessment during transfer
Temperature maintenance priority
Infection prevention and tetanus
Infection and immunization bundle
Wound cleansing and debridement
Gentle cleansing with soap and water
Foreign material removal
Necrotic tissue debridement as indicated
Systemic prophylactic antibiotics avoided for uncomplicated burns
Antibiotics reserved for clinical infection
Sepsis evaluation if systemic signs
Tetanus prophylaxis
Clean minor wounds guidance
Vaccine if unknown or fewer than 3 doses
Booster if 10 years or more since last dose
All other wounds guidance
Vaccine if 5 years or more since last dose
Tetanus immune globulin if unknown or fewer than 3 doses
Escharotomy and surgical escalation
Limb and chest decompression
Indications
Circumferential full thickness with distal ischemia
Absent Doppler signals
Worsening pain and paresthesia
Circumferential chest with ventilatory compromise
Rising airway pressures on ventilation
Limited chest wall expansion
Consultation triggers
Immediate burn surgery or trauma surgery involvement
Transfer if capability not available
Special Populations
Pregnancy
Pregnancy specific considerations
Maternal first approach
Standard resuscitation priorities
Left lateral uterine displacement in late pregnancy if hypotensive
Fetal considerations
Viable gestation fetal monitoring after stabilization
Rh status and trauma overlap evaluation if indicated
Medication considerations
Opioids short term acceptable with monitoring
NSAID avoidance in later pregnancy per obstetric guidance
Geriatric
Older adult risk profile
Higher mortality for same TBSA
Lower physiologic reserve
Higher comorbidity burden
Resuscitation caution
Heart failure risk with over resuscitation
Early invasive monitoring consideration
Social and function context
Home support reliability
Delirium risk with opioids
Pediatrics
Pediatric specific elements
TBSA estimation
Lund and Browder mandatory for accuracy
Larger head and smaller legs proportions
Fluids and glucose
Maintenance fluids required in addition to resuscitation
Dextrose containing fluids in young children as indicated
Non accidental trauma consideration
Pattern burns
Inconsistent history
Delay in seeking care
Background
Epidemiology
Population level context
Burn mechanisms distribution varies by age
Scalds predominant in young children
Flame burns more common in adolescents and adults
Outcome drivers
TBSA and depth as primary predictors
Inhalation injury as major mortality multiplier
Pathophysiology
Burn physiology fundamentals
Local tissue injury
Coagulation zone necrosis
Stasis zone with conversion risk
Hyperemia zone recovery potential
Systemic response in major burns
Capillary leak and third spacing
Inflammatory mediator surge
Hypovolemia and burn shock
Inhalation injury mechanisms
Upper airway edema
Lower airway chemical pneumonitis
Carbon monoxide impaired oxygen delivery
Therapeutic Considerations
Why treatments work
Cooling rationale
Heat removal limits depth progression
Early cooling associated with improved healing
Fluid titration rationale
Under resuscitation increases organ failure risk
Over resuscitation increases edema and compartment syndromes
Early excision and grafting rationale
Reduced infection risk and hospital length of stay
Improved functional outcomes in deep burns
Patient Discharge Instructions
copy discharge instructions
Home care plan
Dressing care
Keep dressing clean and dry
Change dressing as instructed
Pain control
Acetaminophen or ibuprofen as directed if safe
Avoid exceeding labeled daily maximums
Wound protection
Sun protection over healing skin
Avoid popping blisters
Return to emergency care now
Trouble breathing
Burn on face eyes hands feet genitals or across a joint
Increasing redness warmth swelling or pus
Fever or chills
Worsening pain not controlled
Numbness or blue fingers or toes distal to burn
Large burn area or spreading blistering
Follow up
Recheck within 24 to 72 hours for partial thickness burns
Burn clinic follow up if referred
Safety
Keep water heater temperature safe
Smoke detector and fire escape plan
References
Guidelines and high quality sources
Core references
American Burn Association guidelines for burn patient referral
Partial thickness 10 percent TBSA or more referral criterion
Any full thickness burn referral criterion
CDC clinical guidance for tetanus wound management
Antibiotics not recommended solely to prevent tetanus
Wound cleaning and necrotic tissue removal emphasized
NHS guidance for burns and scalds treatment
Cool or lukewarm running water for 20 minutes
Ice and greasy substances avoided
ACEP thermal blast injuries fact sheet
Fluid resuscitation required when burns exceed 15 percent TBSA
Early initiation emphasized
HHS CHEMM burn triage and treatment resource
Burn center referral criteria summary
Chemical and inhalation injury considerations
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.