Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Burns

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In one line

·Heat, electricity, chemicals, or radiation damages or kills skin cells, breaking the body's protective barrier and triggering fluid loss, swelling, and infection risk.

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Normal physiology

·Skin is the body's outermost layer, made of three main parts: the epidermis (thin top layer), the dermis (thicker middle layer with blood vessels, nerves, and sweat glands), and the subcutaneous fat underneath. It acts like a waterproof seal, keeps germs out, holds body fluids in, senses touch and temperature, and helps control body heat by sweating or holding warmth. Keep this picture in your head, because every burn finding makes sense only as a change from this normal job.

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What goes wrong

·Heat, electricity, chemicals, or radiation kills skin cells outright, breaking the protective barrier. Blood vessels underneath start leaking, fluid pours out of the bloodstream into tissue, and the body loses its seal against germs and water loss. If the burn is deep or wraps around a limb, swelling can squeeze blood vessels and nerves inside tight compartments. If smoke or heat is breathed in, the airway tissue swells and can close off hours later. That one upstream break—loss of the skin barrier—explains every strange finding you see downstream.

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Hallmark signs

·Red, warm skin that hurts when you touch it (first-degree burn)
·Blisters with clear or yellow fluid, very painful, weeping surface (second-degree / partial-thickness burn)
·White, brown, or black leathery skin that does not hurt (third-degree / full-thickness burn)
·Burned area covers a large part of the body (measured by percentage of total body surface area, or TBSA)
·Burn goes all the way around an arm, leg, chest, or neck (circumferential burn)
·Soot or burned hairs inside the nose or mouth, hoarse voice, or coughing up black mucus
·Burn on the face, hands, feet, groin, or over a joint
·Burn from electricity (entry and exit wounds, muscle pain, dark urine)

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Red flags · escalate now

·Burns covering more than 10% of the body in an adult or more than 5% in a child (high risk of shock and organ failure)
·Any burn that goes all the way around an arm, leg, chest, or neck (can cut off blood flow or breathing)
·Burn on the face, airway signs (soot in nose, hoarse voice, trouble breathing), or suspected smoke inhalation (airway can swell shut)
·Electrical or chemical burns (hidden deep-tissue damage or ongoing chemical injury)
·Burns in very young children, older adults, or people with other serious medical problems like diabetes or heart disease (higher risk of complications)

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Workup

·Arterial blood gas (ABG) with co-oximetry for carboxyhemoglobin and methemoglobin levels
·Complete blood count (CBC) with differential
·Basic metabolic panel (BMP): sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose
·Creatine kinase (CK) and urine myoglobin
·Serum lactate
·Chest X-ray
·Bronchoscopy (camera down the breathing tube into the airways)

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Treatment

·Stop the burning process immediately: put out flames by rolling on the ground or smothering with a blanket, remove all burned clothing and jewelry (metal and fabric keep burning the skin), run cool (not ice-cold) tap water over the burn for 10–20 minutes, brush off dry chemical powders before rinsing with water, flood chemical burns with copious water for at least 20 minutes
·Secure the airway early with endotracheal intubation if any of these are present: burns to the face or neck, soot in the nose or mouth, singed nasal hairs or eyebrows, hoarse or changing voice, a high-pitched noise on breathing in (stridor) (high-pitched breathing sound), respiratory distress, fire in an enclosed space, or carboxyhemoglobin > 10%
·Start large-volume IV fluid resuscitation using the Parkland formula: 4 mL of lactated Ringer's (preferred) or normal saline × patient's weight in kilograms × percent total body surface area burned; give half of the calculated volume in the first 8 hours from the time of the burn (not from arrival), and the other half over the next 16 hours. Titrate the rate up or down every hour to keep urine output at 0.5–1 mL/kg/hour in adults or 1–2 mL/kg/hour in children. If urine is dark (myoglobinuria), target 1–2 mL/kg/hour and consider adding IV sodium bicarbonate to keep urine pH > 6.5 and IV mannitol to flush the pigment out faster.
·Perform escharotomy (surgical cuts through the full thickness of burned skin) within hours if circumferential full-thickness burns on the chest restrict breathing (you see the chest barely moving or oxygen levels dropping despite the airway being open) or circumferential burns on an arm, leg, or digit show signs of poor blood flow (absent pulses by Doppler, cold skin, blue color, severe pain, or tight compartment on exam)
·Apply topical antimicrobial to partial-thickness and full-thickness burns after cleaning: silver sulfadiazine 1% cream (avoid on the face, in pregnant women, newborns, or anyone allergic to sulfa drugs) or alternatives like mafenide acetate, silver-impregnated dressings, or bacitracin. Change dressings once or twice daily. Give tetanus toxoid booster if the last dose was > 5 years ago (or tetanus immune globulin if never vaccinated). Control pain with IV opioids (morphine, fentanyl) titrated to effect; do not rely on oral or IM routes in the first 48 hours because gut absorption and muscle blood flow are unpredictable during resuscitation.
·Provide early nutrition (within 24 hours) via a feeding tube into the stomach or small intestine if the person cannot eat by mouth (intubated, nausea, vomiting, decreased consciousness). Use high-protein, high-calorie formulas because burn patients' metabolic rate can double—they burn through energy and protein to fight infection, heal wounds, and maintain body temperature. Measure and replace trace elements (zinc, selenium, copper) and vitamins (A, C, E) that are consumed rapidly during wound healing.
·Transfer to a verified burn center if any of these criteria are met (per American Burn Association): partial-thickness burns > 10% TBSA in any patient, any full-thickness burn, burns involving face/eyes/ears/hands/feet/genitals/perineum/major joints, circumferential burns, electrical or lightning burns, chemical burns, inhalation injury, burn plus serious other trauma, burns in very young children or elderly adults, burns in patients with serious pre-existing medical conditions (diabetes, heart failure, immune suppression), or burns where the local hospital does not have the staff or resources for complex long-term burn care

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NCLEX trap

·Cool the burn with cool (not cold) running water for 10–20 minutes to stop the heat from spreading deeper. Ice freezes the skin and makes the damage worse, killing even more cells.
·Leave blisters intact. The clear fluid inside cushions the raw skin underneath and acts as the body's own sterile bandage. Popping them invites infection and slows healing.
·Use the Parkland formula: 4 mL × body weight in kg × % total body surface area burned, spread over 24 hours. Give half of that total in the first 8 hours. Then adjust by watching urine output (goal 0.5–1 mL/kg/hr in adults, 1 mL/kg/hr in children). Too much fluid too fast causes dangerous swelling in the lungs and brain.
·Smoke and hot air can burn the inside of the airway even when the face looks fine. Watch for hoarse voice, soot in the mouth or nose, singed nose hairs, or a high-pitched noise on breathing in (stridor) (high-pitched breathing sound). These signs mean the airway is swelling shut. Put the breathing tube in early—once swelling closes the throat, you cannot get the tube in.
·White or leathery skin with no pain means a full-thickness (third-degree) burn. The nerves are dead, so the patient feels nothing there. This is the deepest, worst kind of burn and will need surgery to remove the dead tissue and cover with skin grafts. Pain actually means nerves are still alive—a better sign.
·Give a tetanus booster for any burn because the dead skin is a perfect place for tetanus bacteria (which live in dirt and love wounds without oxygen). If the last shot was more than 5 years ago, give the booster. Burns are considered 'dirty' wounds by CDC guidelines.

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