Reference — Emergency Nursing
Burn Assessment & Management Reference
Burn depth classification, Rule of Nines TBSA, Parkland formula, inhalation injury signs, initial management priorities, escharotomy indications, and burn center transfer criteria — quick reference for emergency nursing.
Emergency Nursing
Educational use only. Major burn care is complex and institution-specific. Contact a burn center early for any significant burn injury. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Burn Depth Classification
| Depth | Appearance | Sensation | Healing | TBSA | Treatment |
|---|---|---|---|---|---|
| Superficial (1st degree) Epidermis only | Erythema, dry, no blisters | Painful | 3–5 days, no scar | NOT counted | Cool water, moisturizer, analgesia |
| Superficial Partial-Thickness (2nd superficial) Epidermis + superficial dermis | Moist, pink/red, blisters | Very painful | 7–21 days, minimal scarring | COUNTED | Non-adherent / silver dressings, analgesia |
| Deep Partial-Thickness (2nd deep) Epidermis + deep dermis | Pale/mottled, may blister, less moist | Reduced (pressure painful) | 21–35 days, scarring likely, may need graft | COUNTED | As above; closely monitor for conversion to full-thickness |
| Full-Thickness (3rd degree) Full dermis destroyed | Leathery, waxy, white/brown/black, dry | Painless (nerves destroyed) | Does NOT heal without grafting | COUNTED | Escharotomy if circumferential; wound grafting required |
| Deep Full-Thickness (4th degree) Muscle, bone, tendon involved | Charred, deep tissue visible | No pain | Amputation/reconstruction often required | COUNTED | Emergent surgical consultation; amputation often necessary |
Rule of Nines — TBSA Estimation
Superficial (1st degree) burns are NOT included in TBSA calculation. Only partial-thickness and full-thickness burns count.
| Body Area | Adult % TBSA | Child (proportional difference) |
|---|---|---|
| Head & Neck | 9% | 18% |
| Each Arm (entire) | 9% | 9% |
| Anterior Trunk | 18% | 18% |
| Posterior Trunk | 18% | 18% |
| Each Leg (entire) | 18% | 14% |
| Perineum / Genitalia | 1% | 1% |
| TOTAL (adult) | 100% | Lund-Browder chart more accurate for pediatric age-specific proportions |
Patient's palm (including fingers) ≈ 1% TBSA — useful for estimating irregular or scattered burns.
Parkland Formula
4 mL × Weight (kg) × %TBSA = Total LR in 24 hours
| Fluid of choice | Lactated Ringer's (LR) — NOT normal saline (NS causes hyperchloremic metabolic acidosis in large volumes) |
| First 8 hours | Give ½ (50%) of 24h total — TIME FROM INJURY, not from admission |
| Next 16 hours | Give remaining ½ (50%) |
| Titration goal | Urine output 0.5–1 mL/kg/hr adults; 1 mL/kg/hr pediatrics. Parkland = starting estimate — titrate to UO |
| Pediatrics | Add D5LR maintenance fluids separately (LR alone causes hypoglycemia in children) |
| Example | 70 kg, 40% TBSA: 4 × 70 × 40 = 11,200 mL. First 8h: 5,600 mL (700 mL/hr). Next 16h: 5,600 mL (350 mL/hr). |
Inhalation Injury — Recognition
Suspect inhalation injury with any of:
- Singed nasal hairs, eyebrows, or facial hair
- Carbonaceous (sooty, black) sputum or oropharyngeal deposits
- Hoarseness, voice change, or stridor
- Burns from enclosed-space fire
- Burns from steam or hot gas inhalation
- Decreased LOC (CO poisoning)
Action: High-flow O₂ (100% via NRB) → anticipate early intubation (airway edema peaks in hours)
CO poisoning: pulse oximetry falsely normal — use CO-oximetry. Give 100% O₂ (reduces CO half-life from 4–5h → 60–90 min)
Initial Management Priorities
| Priority | Action |
|---|---|
| Stop the burning | Remove burning clothing; brush off dry chemical; irrigate chemical burns 20–30 min. HAZMAT PPE for chemical/organophosphate exposure. |
| Airway | Inspect: singed nasal hairs, sooty sputum, hoarseness, stridor. Apply high-flow O₂ (NRB). Anticipate early intubation for inhalation injury — edema progresses. |
| IV access | Two large-bore IVs through unburned skin. Intraosseous if IV fails. Draw: CBC, BMP, coags, type & screen, lactate, carboxyhemoglobin. |
| Fluid resuscitation | Start LR per Parkland formula (4 mL × kg × %TBSA). Give ½ in first 8h from time of injury; ½ over next 16h. Titrate to UO 0.5–1 mL/kg/hr. |
| Foley catheter | Insert for burns ≥ 20% TBSA. Hourly urine output: gold standard for fluid adequacy. Goal: 0.5–1 mL/kg/hr adults; 1 mL/kg/hr pediatrics. |
| Wound care | Cover with dry sterile dressings. Do NOT apply ice, butter, or home remedies. Tetanus prophylaxis. |
| Pain management | IV opioids (partial-thickness burns are extremely painful). Procedural pain management for dressing changes. Full-thickness burns painless at burn site but perimeter painful. |
| Temperature | Keep patient warm. Loss of skin = loss of thermoregulation. Warm IV fluids, warm blankets, warm room. Hypothermia worsens coagulopathy. |
| Disposition | Minor burns: ED treatment + outpatient follow-up. Moderate-severe: admit. Major burns: burn center transfer. |
Escharotomy — Indications
When to suspect compartment syndrome / impaired perfusion in circumferential burns:
- Absent or decreasing distal pulses (check q1h with Doppler)
- Progressive pallor of extremity
- Paresthesias (numbness/tingling) distal to burn
- Paralysis or weakness distal to circumferential burn
- Chest burns: restrict chest wall expansion → decreased respiratory compliance
Escharotomy is a surgical procedure (provider performed) — full-thickness incision through eschar to release pressure. Nurse role: monitor distal circulation, communicate early, position extremity at heart level, document pulse checks.
Burn Center Transfer Criteria (ABA)
- •Partial-thickness burns > 10% TBSA
- •Any full-thickness burn
- •Burns of face, hands, feet, genitalia, perineum, or major joints
- •Circumferential limb or chest burns
- •Electrical burns (including lightning)
- •Chemical burns
- •Inhalation injury
- •Significant pre-existing medical comorbidities
- •Pediatric burns (if local facility lacks pediatric capability)
- •Burns with concomitant traumatic injury
NCLEX Pearls
Parkland fluid = LR, NOT NS. Large-volume NS causes hyperchloremic metabolic acidosis.
Time starts at injury, not admission. Adjust first 8h rate if patient arrives late.
1st degree (superficial) NOT counted in TBSA.
Full-thickness burns are painless at burn center (no nerve endings). Partial-thickness are very painful.
UO is the best fluid resuscitation monitor — titrate Parkland to 0.5–1 mL/kg/hr, not a fixed rate.
Inhalation injury = intubate early — airway edema peaks hours later. Hoarse voice or stridor is an emergency.
Do NOT apply ice to burns — causes vasoconstriction and worsens injury; also risks hypothermia.
Electrical burns: small external wound, massive internal damage. Check ECG, CK, and urine myoglobin.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →