Burns

A burn is tissue damaged by heat, chemicals, electricity or radiation. Size (% total body surface area, TBSA), depth, location and inhalation exposure decide how sick the patient is and where they go.

• Thermal: flame, scald, contact or hot-liquid injury
• Chemical: corrosive agents. Strip the contaminated clothing and irrigate. Hydrofluoric acid needs its own antidote pathway (see ALS)
• Electrical: at any size, it is a referral trigger under the ABA criteria
• Large burns: adults at 20% TBSA or more need a formal resuscitation plan (ABA 2024 shock guideline). Fluids and urine output drive it from the start

Burn Center Referral (ABA Criteria)

Any one of these is a reason to refer to a burn center (ABA Burn Center Referral Guidelines):

• Location: deep partial-thickness or full-thickness burns of the face, hands, feet, genitalia, perineum or over a joint, at any size
• Depth and size: full-thickness burns at any age; partial-thickness burns of 10% TBSA or more. Superficial (first-degree) burns such as sunburn are not counted in TBSA
• Mechanism: any chemical burn; electrical injury (high voltage of 1,000 V or more, or lightning, needs immediate consultation; low voltage needs consultation); suspected inhalation injury
• Patient factors: concurrent trauma; burns with other comorbidities; poorly controlled pain; need for special social, emotional or rehabilitative support
• Children: the ABA recommends burn center consultation for children 14 years or younger or under 30 kg; children treated in a facility without staff or equipment trained for children also meet referral criteria

Red Flags

• Hoarseness, stridor, soot in the airway or smoke exposure in an enclosed fire: inhalation injury
• Circumferential burn or a burn over a joint: burn center to assess for escharotomy
• Adult burn of 20% TBSA or more: start the shock pathway
• Chemical exposure of any size; electrical injury, which needs cardiac and muscle-injury assessment

Estimate the TBSA and the depth, then run the referral criteria above. Don't hold the transfer for labs.

Estimating TBSA and Depth

• Adult Rule of Nines: head 9%; each arm 9%; anterior trunk 18%; posterior trunk 18%; each leg 18%; genitalia and perineum 1% (WikEM)
• Patient's palm (without fingers): about 0.5% TBSA. In large burns, the palm method can overestimate (AAFP 2020)
• Children: reach for an age-based Lund-Browder chart. The adult Rule of Nines is inaccurate in children
• Superficial (erythema only) burns are not counted in TBSA. Blistered, moist, painful skin does count, along with anything deeper

1. Scene safety and source: stop the burning, remove the patient from smoke or the source, and disconnect power before touching an electrical injury (per local protocol).
2. Thermal burns, cool with running water: 20 minutes of cool running tap water (8–25 °C, 46–77 °F). Cooling should start within 30 minutes of injury; benefit may still be possible up to about 3 hours after injury. Do not use ice. For a large burn, shorten cooling per protocol if the patient becomes cold; never cool a patient who is cold or hypothermic.
3. Chemical burns, remove and irrigate: remove contaminated clothing, brush off dry chemical before irrigating, and irrigate with copious water until the agent is removed, with duration set by poison center guidance. Protect responders and call poison control. Do not use the thermal cooling step for chemical burns.
4. Cover and keep warm: a clean, dry dressing over the burn; dry sheets or blankets over the rest of the body. Burn patients have impaired thermoregulation, so keep the patient and the environment warm.
5. Oxygen: 100% oxygen by non-rebreather mask with any suspected inhalation or carbon monoxide exposure. Pulse oximetry is unreliable in carbon monoxide poisoning and can read normal. See Oxygen.
6. Notify and transport: call ALS and the receiving burn center early. Do not delay transport to finish cooling if the patient meets referral criteria.

Doses vary by protocol; follow local protocols and medical direction.

• IV or IO access (Paramedic/RN/CCT): place access through unburned skin where possible. See IV Insertion and IO Access.
• Adult resuscitation (20% TBSA or more): the ABA 2024 guideline starts resuscitation at 2 mL/kg per % TBSA. This is a total calculated volume for the initial resuscitation, not a bolus or an hourly rate, titrated to urine output. The ABA guideline's scope is fluid resuscitation during the first 48 hours after injury; the duration of the volume, the hourly rate and any split across periods come from the burn center protocol. If no burn center protocol is available, confirm the rate with the burn center by phone before starting. Count from the time of injury and subtract fluid already given. Worked example: 80 kg with 40% TBSA = 2 × 80 × 40 = 6,400 mL total calculated volume; the schedule for giving it comes from protocol. Use a stated dosing weight; for patients with obesity, use the dosing weight the protocol specifies. Lactated Ringer's is the usual crystalloid; see Lactated Ringer's.
• Airway (Paramedic/RN/CCT): inhalation swelling progresses. Plan an early definitive airway for stridor, hoarseness, deep facial burns or soot in the airway (see RSI). Succinylcholine: use great caution in the acute phase of burn injury; it is contraindicated after the acute phase, because hyperkalemia risk rises over days and peaks at 7 to 10 days (prescribing information). Use a non-depolarizing agent per protocol when needed.
• Pain, opioid-naive adult: morphine 0.1 mg/kg IV (max 10 mg initial dose), reassess at the peak, then titrate. Monitor SpO2, respiratory rate and blood pressure, and keep naloxone available. See Morphine. Fentanyl is an alternative per protocol: see Fentanyl.
• Suspected cyanide with smoke inhalation: hydroxocobalamin 5 g IV over 15 minutes; a second 5 g dose per protocol (max 10 g). Draw labs before giving it: hydroxocobalamin interferes with colorimetric laboratory determinations, which may include some co-oximetry methods. It needs a dedicated IV line (the label requires a separate line and it is chemically incompatible with sodium thiosulfate and sodium nitrite). It turns the skin red and the urine colored for days to weeks. Give it when cyanide is suspected, not for every smoke victim. See Hydroxocobalamin.
• Hydrofluoric acid: topical calcium gluconate gel first. See Calcium Gluconate.
• Tetanus (hospital care): per the CDC rules in Assessment; TIG 250 units IM when indicated.

• Burn center consult and transfer: confirm the referral criteria and the transfer plan with the burn center.
• Fluid titration: let urine output steer the resuscitation. The target in the reviewed trials was 0.5 mL/kg/hr. Watch for overload.
• Albumin: consider it, especially in larger burns. The goal is less total crystalloid and better urine output (ABA 2024 shock guideline).
• Monitoring: measure intra-abdominal and intraocular pressure selectively during resuscitation. The guideline does not recommend transpulmonary thermodilution to guide it (ABA 2024 shock guideline).
• Potassium: check it during resuscitation. Burn injury and tissue necrosis can push it up. See Potassium.
• Electrical injury: monitor the heart continuously and get a 12-lead ECG for dysrhythmia. Check CK and urine for myoglobin. Screen for compartment syndrome. The surface burn understates the deep injury. With myoglobinuria, the urine target may need to be higher, per the burn center.
• Circumferential burns: burn center assessment for escharotomy.
• Escalation: the ABA guideline makes no recommendation on high-dose vitamin C, fresh frozen plasma, early CRRT or adjunct vasopressors. Those follow local protocol.

• Destination: the burn center, once the ABA referral criteria are met. Write down the time of injury. The ABA guideline's scope is fluid resuscitation in the first 48 hours after injury. The burn center protocol gives the volume schedule.
• Keep running: the resuscitation infusion. Document the volume given and the urine output on the handoff.
• Keep warm: burn patients regulate temperature poorly. Cover the patient, keep the cabin warm, and don't let cooling carry on into hypothermia.
• Handoff: time of injury, agent, TBSA and depth estimate, inhalation exposure, cooling time, drugs and total volume given.

• Pediatrics: dose by weight. Use weight-based dosing and vital signs. The ABA recommends burn center consultation for children 14 years or younger or under 30 kg. Estimate TBSA with the age-based Lund-Browder chart. Children are at higher risk of hypothermia, so keep them warm and limit the cooling. Hydroxocobalamin: the label notes a 70 mg/kg dose used outside the US. Safety in children is not established. Dose it with the poison center. Scald injuries in young children call for a non-accidental injury assessment per local protocol. This page has no pediatric fluid volumes. Use the burn center's pediatric protocol.
• Pregnancy: pregnancy-specific burn care is outside this page. Talk it through with the burn center and the obstetric team. In late pregnancy, left uterine displacement and obstetric consultation per protocol.
• Older Adults: age and comorbidity are separate ABA referral considerations. Burns with other comorbidities meet an immediate-consultation criterion. Titrate fluids to urine output.

• Error: reaching for ice. Ice is not recommended. Cool a thermal burn with 20 minutes of cool running water instead.
• Error: cooling a large burn, or a cold patient, until hypothermia sets in. Keep the patient warm and shorten the cooling per protocol.
• Error: judging referral by TBSA alone. That misses chemical, suspected inhalation and high-voltage electrical injuries, which refer at any size.
• Error: counting superficial (erythema-only) burns toward TBSA. The 10% and 20% thresholds count partial-thickness and deeper burns only.
• Error: missing an inhalation injury or cyanide exposure in a smoke victim with a small burn.
• Error: giving a fixed volume with no reassessment. The 2 mL/kg per % TBSA figure is a calculated total for the initial resuscitation. It is not a rate, and it is not a fixed schedule. The burn center protocol sets the schedule. Titrate to urine output and watch for overload.
• Error: treating hydrofluoric acid like a simple burn. The 2023 individual-patient meta-analysis documents systemic toxicity after skin exposure. Use calcium gluconate and check calcium.
• Error: using adult fluid targets on a child. Go by weight, and follow the burn center's pediatric protocol.