Burns nursing: Parkland formula, rule of nines, and NCLEX

Burns are one of the most complex injury types in acute care nursing. Managing them requires rapid depth classification, accurate total body surface area (TBSA) estimation, precise fluid resuscitation timing, and vigilant monitoring for life-threatening complications. This reference covers all of it: burn depth classification with clinical features, Rule of Nines, Parkland formula with a worked example, inhalation injury assessment, wound care principles, pain management, nursing priorities, complications, and special burn types. Bookmark it before your trauma or critical care rotation.

Burn depth classification

Burn depth determines treatment approach, healing timeline, and whether grafting is required. Classification is based on which skin layers are involved.

Key clinical point: Superficial burns (first-degree) are excluded from TBSA calculations. Only partial-thickness and full-thickness burns are counted when calculating Parkland formula fluid volumes.

Rule of Nines: TBSA estimation

Estimating how much body surface area is burned guides fluid resuscitation, hospital admission decisions, and burn center transfer criteria.

Adult Rule of Nines

Modifications for children

The Rule of Nines is not accurate for children because the head is proportionally larger and the legs proportionally smaller. The Lund-Browder chart is the standard for pediatric TBSA estimation. As a rough adjustment: in infants, the head accounts for 18% TBSA (not 9%), and each leg accounts for 14% (not 18%). The proportions shift progressively toward adult values as the child grows.

Palm method

For scattered or irregular burns that don’t map cleanly to body regions, use the patient’s own palm (fingers together) as a reference: the palm surface equals approximately 1% TBSA. This is useful for estimating small, patchy burns.

Parkland formula: fluid resuscitation

The Parkland formula determines the volume of crystalloid fluid needed in the first 24 hours after a major burn.

Formula:

Total volume (mL) = 4 mL × body weight (kg) × % TBSA burned

• Use lactated Ringer’s solution (LR) – isotonic, similar to extracellular fluid, less hyperchloremic than normal saline
• Count only partial-thickness and full-thickness burns in TBSA
• The 24-hour clock starts from the time of injury, not time of hospital arrival

Timing of infusion:

• First half (50% of total volume) – infuse over the first 8 hours from time of injury
• Second half (50% of total volume) – infuse over the next 16 hours

If the patient arrives at hospital 2 hours after injury, and the first 8-hour window is already partially elapsed, the first-half volume must be delivered in the remaining 6 hours (not re-started from scratch).

Worked example

Patient: 70 kg adult with 35% TBSA partial-thickness burn. Time of injury: 08:00.

1. Calculate total volume: 4 × 70 × 35 = 9,800 mL in 24 hours
2. First half: 9,800 ÷ 2 = 4,900 mL over the first 8 hours (08:00–16:00) = 612 mL/hr
3. Second half: 4,900 mL over the next 16 hours (16:00–08:00 next day) = 306 mL/hr

Important nuance: The Parkland formula gives a starting rate, and the patient’s response decides everything after it. Titrate the infusion to hourly urine output, which remains the standard bedside marker of adequate resuscitation. Adult targets are about 0.5 mL/kg/hr, or 30–50 mL/hr (the ABLS course and most burn center protocols), and the 2008 ABA guideline gave a range of 0.5–1 mL/kg/hr.

Current practice has moved to 2 mL/kg/%TBSA

Nursing programs and NCLEX question banks still teach the 4 mL figure, and you should know it. But the American Burn Association’s 2024 Clinical Practice Guidelines on Burn Shock Resuscitation recommend initiating resuscitation at 2 mL/kg/%TBSA in adults with burns of 20% TBSA or more, specifically to reduce the total volume infused. The same guideline recommends considering albumin, especially in larger burns, and selective monitoring of intra-abdominal and intraocular pressure. It does not set a urine output target of its own.

The reason is decades of evidence on “fluid creep.” Patients started on Parkland often received far more than the calculated volume once the rate was titrated upward, and the resulting edema drove abdominal compartment syndrome, extremity compartment syndrome, pulmonary edema, and prolonged ventilation. In the studies the 2024 panel reviewed, starting at 2 mL lowered total resuscitation volumes. The panel graded that evidence as limited and did not assess mortality.

What this means at the bedside: the formula sets the opening rate, and hourly urine output sets everything after that. A patient started at 2 mL/kg/%TBSA who is not making urine gets the rate increased; the guideline changes where you begin and leaves the ceiling to titration. Expect exam questions to use 4 mL; expect the burn unit to start at 2 mL and titrate.

Starting rates for children and electrical injury

The ABLS course uses different starting points for two groups. Children (protocols draw the line at roughly 13–14 years or 30 kg) start at 3 mL/kg/%TBSA, and young children also need a separate dextrose-containing maintenance infusion (D5LR) because their glycogen stores are small. High-voltage electrical injuries start at 4 mL/kg/%TBSA, because the surface burn underestimates the muscle damage underneath. In both cases half the 24-hour estimate is given over the first 8 hours from injury, and the rate is then titrated to urine output.

Burn assessment and triage

When does a burn need a burn center?

The American Burn Association (ABA) publishes burn center referral criteria, which are a lower threshold than the older “major burn” severity grading many textbooks still reprint. The long-standing (2006) criteria, still reprinted in many nursing texts, list:

• Partial-thickness burns covering >10% TBSA
• Burns involving face, hands, feet, genitalia, perineum, or major joints
• Third-degree (full-thickness) burns in any age group
• Electrical burns (including lightning) and chemical burns
• Inhalation injury
• Burns in patients with pre-existing medical disorders that could complicate care or recovery
• Burns with concomitant trauma
• Burned children in hospitals without qualified pediatric personnel or equipment
• Patients who will need special social, emotional, or rehabilitative support

Circumferential burns and age are not separate items on that list. A circumferential full-thickness burn already qualifies as third-degree, and it is an escharotomy concern in its own right.

Know the current version for practice. The 2018 eDelphi consensus study, published in the Journal of Burn Care & Research in 2020, renamed the criteria “Recommended Guidelines for Transfer and Consultation” and organized them into three tiers: transfer potentially indicated, telemedicine consultation, and outpatient burn center referral (within 7 days of injury for children). In the transfer tier for thermal burns it lists full-thickness burns >5% TBSA, partial-thickness burns >10% TBSA, and any deep partial- or full-thickness burn of the face, hands, genitalia, feet, perineum, or over a joint. The panel states the tiers are not prescriptive and are meant to prompt a provider-to-provider conversation. It defines older adults as 55 and over (older sources use >50), applies the same %TBSA thresholds to children and older adults, and adds non-burn conditions that benefit from burn center care: Stevens-Johnson syndrome / toxic epidermal necrolysis with epidermal slough, necrotizing soft-tissue infections, and grade II–IV frostbite.

The ABA’s current referral page (Guidelines for Burn Patient Referral) uses two columns. Immediate consultation with consideration for transfer covers full-thickness burns, partial-thickness burns ≥10% TBSA, deep burns of the special areas above, burns with comorbidities or concomitant trauma, poorly controlled pain, suspected inhalation injury, all chemical injuries, and high-voltage (≥1,000 V) electrical and lightning injuries. Consultation is recommended for partial-thickness burns <10% TBSA, potentially deep burns of any size, signs of possible inhalation exposure (facial flash burns, singed facial hair, smoke exposure), and low-voltage electrical injuries. For children (≤14 years or <30 kg), the page notes that any pediatric burn may benefit from burn center referral because of pain, dressing needs, rehabilitation, caregiver needs, or possible non-accidental trauma.

A common exam trap: the numbers “>20% TBSA in adults, >15% in children or patients over 50” describe the retired ABA burn severity classification, not the referral criteria. If a question asks when to transfer, the threshold is lower than the severity grading suggests.

Initial survey priorities

Burn resuscitation follows the ATLS primary survey. The 11th edition of ATLS, launched in 2025, changed the sequence from ABCDE to xABCDE, moving control of exsanguinating external hemorrhage ahead of airway. For an isolated thermal burn there is rarely exsanguinating hemorrhage, so airway remains the practical first action – but burns are frequently accompanied by blast, blunt, or penetrating trauma, and in those patients catastrophic bleeding is addressed first.

1. x – Exsanguinating hemorrhage – control catastrophic external bleeding (direct pressure, tourniquet) before moving on. New to ATLS 11.
2. Airway – in an isolated burn, the highest priority. Inhalation injury can close the airway within hours of injury. Assess immediately.
3. Breathing – assess chest wall movement; circumferential thoracic burns restrict expansion
4. Circulation – IV access, initiate fluid resuscitation
5. Disability – GCS, neurological status; carbon monoxide poisoning can cause altered mental status
6. Exposure/Environment – remove all clothing and jewelry; prevent hypothermia

Remove all clothing and jewelry immediately – retained items trap heat and conduct electricity in electrical burns.

Inhalation injury

Inhalation injury is a burn center referral criterion regardless of how much skin is burned, and it is one of the strongest predictors of death after a burn. In the revised Baux score, built from almost 40,000 patients in the National Burn Repository, inhalation injury adds the mortality equivalent of 17 years of age or 17% TBSA (Osler 2010).

Mechanisms of injury

Smoke inhalation injures the patient in four ways: heat above the vocal cords, chemical injury below them, and two systemic poisons (carbon monoxide and cyanide).

Upper airway thermal injury: Direct heat causes edema of the supraglottic airway (pharynx, larynx). Edema can progress rapidly and completely obstruct the airway within hours. This is why early intubation – before edema is visible – is often the correct decision.

Tracheobronchial chemical injury: Incomplete combustion products (aldehydes, acids, sulfur dioxide) damage mucosal surfaces below the vocal cords, causing chemical tracheobronchitis and impaired mucociliary clearance.

Carbon monoxide (CO) poisoning: CO binds hemoglobin with 200× the affinity of oxygen, forming carboxyhemoglobin (COHb). Standard pulse oximetry gives falsely normal SpO2 readings – it cannot distinguish oxyhemoglobin from carboxyhemoglobin. Diagnosis requires co-oximetry (ABG with CO-oximeter).

Cyanide toxicity: Cyanide is released by the combustion of synthetic materials – plastics, polyurethane foam, wool, and nylon – commonly found in enclosed-space fires. Cyanide inhibits cytochrome c oxidase (complex IV of the mitochondrial electron transport chain), blocking cellular respiration regardless of oxygen delivery. The result is histotoxic hypoxia: cells cannot use available oxygen, producing severe lactic acidosis. Cyanide toxicity may co-exist with CO poisoning in smoke inhalation patients and should be considered in any patient with an enclosed-space burn who has altered mental status, cardiovascular instability, or a markedly elevated lactate out of proportion to apparent clinical severity.

Signs and symptoms of cyanide toxicity:

• Headache, dizziness, and confusion (early neurological involvement)
• Agitation progressing to loss of consciousness and seizures
• Cherry-red skin or mucous membranes (rare; due to elevated venous oxygen from failure of peripheral oxygen extraction)
• Severe lactic acidosis. In fire victims without severe burns, a plasma lactate above 10 mmol/L on admission was a sensitive marker of a toxic blood cyanide level (Baud 1991)
• Cardiovascular collapse: bradycardia, hypotension, refractory dysrhythmias
• The hallmark: metabolic acidosis that persists or worsens despite 100% oxygen therapy

Treatment of cyanide toxicity:

• Hydroxocobalamin (Cyanokit) is the first-line antidote in the United States. A cobalt-containing compound, it binds cyanide in the bloodstream to form cyanocobalamin (vitamin B12), which is renally excreted. Label dosing: 5 g IV over 15 minutes in adults, with a second 5 g dose (10 g total) depending on severity and response, infused over 15 minutes in a patient in extremis or up to 2 hours otherwise. The label notes 70 mg/kg has been used in children outside the US.
• Hydroxocobalamin is preferred over the older sodium nitrite + sodium thiosulfate regimen, particularly in patients with suspected concurrent CO poisoning, because sodium nitrite induces methemoglobin – a hemoglobin state that cannot carry oxygen – which compounds hypoxia already caused by CO.
• Sodium thiosulfate (alone, without sodium nitrite) is sometimes used as an adjunct – it provides sulfur substrate for rhodanese enzyme, which converts cyanide to thiocyanate for renal excretion.

Nursing considerations for cyanide toxicity:

• Administer hydroxocobalamin immediately when cyanide toxicity is clinically suspected – do not wait for confirmatory testing. No reliable bedside test exists; diagnosis is clinical.
• Maintain 100% oxygen via non-rebreather mask (or the ventilator) at the same time; it treats any concurrent CO poisoning.
• Give hydroxocobalamin through its own IV line. The label lists it as chemically incompatible with sodium thiosulfate and sodium nitrite, among other resuscitation drugs.
• Warn staff that hydroxocobalamin turns the skin and urine red. Per the label, skin redness can last up to 2 weeks and urine color up to 5 weeks. The color interferes with colorimetric lab tests and can make hemodialysis machines alarm for a false “blood leak”, so draw baseline labs before the infusion when that causes no delay.
• Monitor renal function and blood pressure. The label warns of acute kidney injury with oxalate crystals (check BUN and creatinine for 7 days) and of transient blood pressure rises.
• Monitor arterial blood gas and serum lactate serially. Falling lactate and improving mental status are the primary markers of treatment response.
• Continuous cardiac monitoring is essential – cyanide toxicity can cause any dysrhythmia and progression to cardiac arrest.

Signs and symptoms of inhalation injury

• Facial burns, singed nasal hair, or singed eyebrows
• Carbonaceous (sooty) sputum
• Hoarse voice, stridor, or altered phonation
• Burns in an enclosed space
• Altered mental status, confusion, or headache (CO poisoning)
• Elevated COHb on co-oximetry. Nonsmokers normally run below about 3%, and smokers can run higher. The level confirms exposure but correlates poorly with symptoms and outcome, so treat the patient’s condition rather than the number (Hampson 2012)

Nursing management for inhalation injury

• Place patient on 100% non-rebreather mask immediately – even if SpO2 appears normal
• Prepare for early endotracheal intubation when there is stridor, hoarseness, deep facial or neck burns, or a rapidly swelling airway – waiting for complete obstruction makes intubation far harder. Facial flash burns alone, without signs of airway involvement, do not automatically require intubation
• Obtain ABG with co-oximetry (not standard pulse oximetry)
• Continuous cardiac monitoring – CO causes dysrhythmias
• Anticipate ICU admission
• Hyperbaric oxygen may be considered for selected patients with CO poisoning. ACEP’s 2017 clinical policy supports either hyperbaric or high-flow normobaric oxygen (Level C) and notes it is unclear whether hyperbaric therapy is superior; in a patient with a major burn, resuscitation and airway control come first

Fluid resuscitation: nursing management

Fluid resuscitation is time-critical and requires active nursing management throughout the first 24–48 hours.

IV access

Establish two large-bore peripheral IV lines (18-gauge or larger), ideally through unburned skin. If unburned sites are unavailable, IVs may be inserted through burned tissue. Central venous access (for monitoring and drug infusion) and an arterial line (for continuous blood pressure and frequent ABGs) are common in major burns.

Monitoring resuscitation adequacy

Urine output is the primary guide. Insert a Foley catheter immediately and measure output hourly.

• Adult target: about 0.5 mL/kg/hr, commonly written as 30–50 mL/hr (ABLS and burn center protocols). The 2008 ABA guideline gave 0.5–1 mL/kg/hr. The 2024 ABA guideline sets no target of its own.
• Pediatric target: about 1 mL/kg/hr in children under 30 kg (the 2008 guideline gave 1–1.5 mL/kg/hr)
• High-voltage electrical injury with dark (pigmented) urine: 75–100 mL/hr in adults until the urine clears
• Urine below target: increase the infusion rate. Protocols adjust in steps (10–20%, or up to one-third of the current rate) each hour rather than giving repeated boluses
• Urine well above target (for example >1 mL/kg/hr in an adult): decrease the rate. Failing to turn the rate down is a major driver of fluid creep

Signs of adequate vs. inadequate resuscitation

Over-resuscitation (“fluid creep”) leads to abdominal compartment syndrome, pulmonary edema, and extremity compartment syndrome. Match infusion rate to urine output and these trends rather than running a fixed rate. Hypotension during burn shock is treated by increasing the infusion rate (with a bolus if needed); burn center protocols discourage vasopressors in this phase because skin vasoconstriction can deepen the burn, and the 2024 ABA guideline found too little evidence to make any recommendation on them.

Abdominal compartment syndrome is defined by the World Society of the Abdominal Compartment Syndrome as a sustained intra-abdominal pressure above 20 mmHg with new organ dysfunction. Bladder pressure is the standard bedside measurement, and the 2024 ABA guideline recommends selective intra-abdominal pressure monitoring during resuscitation.

Additional monitoring

• Weigh patient daily (edema accumulation)
• Monitor electrolytes, creatinine, and BUN – acute kidney injury (AKI) is a major complication. For more detail, see AKI nursing reference.
• Monitor for sepsis markers (rising WBC, fever, tachycardia, rising lactate). See sepsis nursing for assessment criteria.
• Vital signs at minimum every hour in the acute phase – see vital signs by age for pediatric baselines.

Wound care

Principles

Burns are contaminated wounds. Goals of wound care are infection prevention, moisture maintenance, protection of healing tissue, and preparation for grafting where needed.

Clean technique (not sterile) is standard for wound dressing changes in most burn units. Wash hands, use clean gloves, and clean the wound gently with chlorhexidine or mild soap and water.

Debridement

• Remove loose, devitalized tissue to reduce infection risk and promote healing
• Enzymatic debriding agents (e.g., collagenase) are used for selective debridement in less critical wounds
• Sharp debridement and surgical excision are performed in the operating room for deep partial-thickness and full-thickness wounds

Topical antimicrobials

Escharotomy

Full-thickness circumferential burns create a rigid, non-compliant eschar. As edema accumulates under the eschar, compartment pressures rise, compromising circulation and (in thoracic burns) ventilation.

Escharotomy – incision through the eschar to release pressure – is performed when:

• Circumferential full-thickness burn of extremities with diminished distal pulses, increasing pain, or paresthesias
• Circumferential thoracic burns with impaired chest wall excursion (rising peak airway pressures in ventilated patients)

Nurses monitor for escharotomy need by checking hourly distal pulses (Doppler if palpation is unreliable due to edema), capillary refill, sensation, and pain levels in burned extremities.

Pain management

Burns cause severe and continuous pain from two sources: background pain from exposed nerve endings in partial-thickness wounds, and procedural pain from dressing changes and debridement.

Background pain

• IV opioids (morphine, hydromorphone, fentanyl) are first-line for major burns in the acute phase
• Titrate to pain score; under-treatment is a documented problem in burn care
• Adjuncts: IV ketamine at subanesthetic doses, IV or oral acetaminophen, gabapentin (for the neuropathic component)
• Watch sedation closely: high opioid doses during resuscitation are linked to larger fluid requirements, and burn center protocols warn against oversedation

Procedural pain management

Dressing changes produce the most intense, predictable pain events. Pre-medicate 20–30 minutes before the procedure:

• IV opioid bolus
• IV ketamine. Subanesthetic analgesic boluses should not exceed 0.35 mg/kg, and analgesic infusions generally stay at or below 1 mg/kg/hr outside intensive monitoring (ASRA/AAPM/ASA 2018 consensus). Larger dissociative doses for procedural sedation require a provider credentialed in sedation and full monitoring
• Anxiolytics (benzodiazepines) for anxiety and procedural distress
• Nitrous oxide in some settings

Non-pharmacological approaches

Music therapy, virtual reality distraction, and guided imagery have evidence for reducing procedural pain perception in burns. They work as adjuncts alongside adequate analgesia.

First aid cooling

Cooling belongs to first aid. The ABA advises cooling a minor burn under cool (not cold or icy) running water for at least 5 minutes. Australian and New Zealand guidance goes further, at 20 minutes of cool running water within 3 hours of injury, based on outcome data. Never apply ice, which worsens tissue damage. Avoid prolonged cooling of large burns, because it risks hypothermia.

Nursing priorities

The following priorities apply to major burn care. The sequence reflects urgency – airway failure kills faster than infection.

1. Airway patency and breathing – assess for inhalation injury; apply 100% O2; prepare for intubation; monitor for CO poisoning. This is always first.
2. Hemodynamic stability and fluid resuscitation – establish large-bore IV access; start LR at the formula rate ordered (2 mL/kg/%TBSA in current ABA practice, 4 mL in the classic Parkland formula); insert Foley; begin hourly urine output monitoring.
3. Wound covering – cover burns with clean, dry dressings or sheets to reduce heat loss and contamination while assessment and resuscitation proceed. Formal wound care follows stabilization.
4. Pain management – administer IV opioids; assess pain at every assessment. Untreated pain causes catecholamine surge, increasing metabolic demand.
5. Hypothermia prevention – burn patients lose thermoregulation rapidly. Remove wet dressings, keep the room warm (burn units run near thermoneutral temperatures, which ESPEN also lists as a way to blunt hypermetabolism), use warmed IV fluids, and apply warming blankets. Hypothermia worsens coagulopathy and acidosis.
6. Infection prevention – clean or sterile technique per unit protocol for wound care; topical antimicrobials as prescribed; surveillance for wound infection, bacteremia, and sepsis. Check tetanus status on arrival: the CDC lists burns among wounds with devitalized tissue, which count as dirty or major wounds. Give a tetanus toxoid-containing vaccine if the last dose was 5 or more years ago or the history is unknown or incomplete, and add tetanus immune globulin (250 units IM) if the primary series is incomplete or unknown, or the patient has HIV or severe immunodeficiency.
7. Nutritional support – burns cause extreme hypermetabolism. ESPEN-endorsed recommendations make early enteral feeding a strong recommendation, with protein at 1.5–2 g/kg/day in adults and 3 g/kg/day in children and limits on glucose delivery. Energy needs are best measured by indirect calorimetry; where it is unavailable, ESPEN suggests the Toronto equation (Schofield in children). The older Curreri formula tends to overestimate needs and risks overfeeding.
8. Psychological and emotional support – burns produce disfigurement, loss of function, and profound psychological trauma. Assess for acute stress reaction; involve social work and psychology early. Family support and communication are part of nursing care.

Complications to monitor

For more on ARDS assessment, see ARDS nursing. For AKI management detail, see AKI nursing reference.

Special burn types

Chemical burns

Chemical burns continue to injure tissue as long as the chemical remains in contact with skin. Removing the chemical comes first, ahead of identifying or neutralizing it.

• Remove all contaminated clothing immediately (protect self with gloves)
• Brush off dry powders (such as dry lime) before irrigating
• Irrigate with copious running water for a prolonged period, commonly at least 20–30 minutes and often an hour or more for alkali burns, which penetrate deeper. Many units check the skin or eye surface with pH paper to judge when to stop
• Do not attempt to neutralize the chemical (acid + base reactions generate heat, worsening injury)
• Alkali burns (lye, concrete, cleaning agents) are typically more severe than acid burns because they cause liquefactive necrosis and penetrate more deeply
• Eye involvement: irrigate immediately and continuously; ophthalmology consult
• Systemic absorption of some chemicals (hydrofluoric acid, phenol) causes life-threatening toxicity – contact Poison Control

Electrical burns

Electrical burns are deceptive – the surface wound is often small, but internal injury can be massive as current travels through tissue.

• Entry and exit wounds – identify both; the exit wound is often larger and on a grounded extremity
• Cardiac monitoring – obtain a 12-lead ECG on every patient. The ABA’s electrical injury guideline (Arnoldo 2006) calls for telemetry when there was loss of consciousness, a documented dysrhythmia, or ECG evidence of ischemia. A low-voltage patient with a normal ECG, no loss of consciousness, and no other reason for admission can be discharged. High-voltage injuries are generally admitted and monitored. CK and CK-MB are not reliable markers of cardiac injury after electrical burns
• Rhabdomyolysis – muscle destruction releases myoglobin; causes acute tubular necrosis and AKI. Look for dark (“cola”) urine; urine myoglobin/CK elevated. Start resuscitation at the higher electrical rate (4 mL/kg/%TBSA in ABLS) and target a higher urine output, 75–100 mL/hr in adults (roughly 1–1.5 mL/kg/hr), until the urine clears. Some centers add sodium bicarbonate to alkalinize the urine, though evidence that it adds benefit is limited.
• Compartment syndrome risk is high in electrical burns – monitor extremities carefully
• Spinal precautions – electrical injury can cause tetanic muscle contractions strong enough to fracture vertebrae; consider C-spine precautions after high-voltage exposure
• High-voltage (>1,000 V) carries the highest risk of internal injury and cardiac arrest

Circumferential burns

Burns that encircle an entire extremity or the trunk create a rigid eschar that does not expand with underlying edema.

• Extremity circumferential burns: Rising compartment pressure compresses vessels and nerves. Monitor hourly: distal pulses (by Doppler), capillary refill, sensation, and pain. Escharotomy is required if perfusion is compromised.
• Thoracic circumferential burns: The rigid eschar restricts chest wall movement, leading to progressively worsening respiratory failure (rising airway pressures in ventilated patients, declining tidal volumes, hypoxia). Bilateral thoracic escharotomies restore chest compliance.
• Abdominal compartment syndrome: Large-volume resuscitation combined with abdominal burns or intra-abdominal injury can elevate intra-abdominal pressure. Monitor bladder pressure if suspected.

Related pages

For assessment and clinical context related to burns:

• Head-to-toe assessment – systematic assessment approach applicable to the burn survey
• Wound assessment – wound classification, staging, and documentation
• Vital signs by age – pediatric normal ranges for triage and monitoring
• Sepsis nursing – sepsis recognition and management (a primary complication of major burns)
• AKI nursing reference – acute kidney injury assessment and management
• ARDS nursing – respiratory failure assessment and ventilator management

Nurses who specialize in burn care work within dedicated burn centers and trauma units. The burn nurse career guide covers the specialty’s certification pathway (CBRN), practice settings, and scope. Hyperbaric oxygen therapy is used for selected cases of carbon monoxide poisoning, and its role in acute thermal burns is unproven; the hyperbaric nurse career guide covers this related specialty. Salary data for both roles is available at burn nurse salary and hyperbaric nurse salary.

Clinical content checked on October 18, 2026 against the American Burn Association’s 2024 Clinical Practice Guidelines on Burn Shock Resuscitation, the 2018 eDelphi transfer and consultation consensus and the ABA’s current referral guidelines, the ABLS course, ATLS 11th edition (2025), the Cyanokit label, CDC tetanus wound guidance, and Herndon and Sood’s Total Burn Care (6th ed., 2026). All content is intended for educational purposes for nursing students; clinical decisions require individualized assessment by a licensed provider.

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