Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android



  • Successful management of a patient with a major burn requires a high-functioning multidisciplinary team.

  • Burn shock is observed when approximately 30% total body surface area is injured and is characterized by increased capillary permeability, dramatic fluid shifts, and cardiovascular effects. A profound and sustained hypermetabolic response develops in these patients, affecting nearly all organ systems.

  • The stabilization of a major burn involves a primary survey to rule out immediately life-threatening conditions, followed by a secondary survey where other injuries, including the burn wound itself, are assessed.

  • Formal fluid resuscitation should be performed for burns ≥20% total body surface area. The updated “consensus formula” is recommended to determine a starting rate for intravenous fluids.

  • The American Burn Association referral criteria should be utilized to guide the triage of patients with burn injuries.

  • Inhalation injury is confirmed using bronchoscopy, and its treatment is largely supportive.

  • Critical care of a major burn has significant differences from other patient populations in terms of analgesia/sedation, nutritional supplementation, recognition of sepsis, and perioperative care.


The management of burn injuries developed significantly over the latter half of the 20th century. Following World War II, the LD50 (the burn surface area resulting in 50% mortality) for a burn in a healthy adult was 40% total body surface area (TBSA), and by the 1990s this same figure had increased to 80% TBSA.1 This incredible shift was achieved through the introduction of topical antimicrobials, the acceptance of early surgical excision and skin grafting, the creation of burn centers, better understanding of fluid resuscitation, the adoption of nutritional support, and general advances in critical care. Many challenges remain, with ongoing work in basic science and clinical research, as well as quality improvement.

Burn care is unique among critical care and surgical disciplines. The extreme physiologic derangements (discussed later) observed in burn patients can complicate the ongoing physiologic assessment and supportive management of the cardiovascular, pulmonary, renal and immune systems. Most burn survivors will require a relatively lengthy initial hospitalization, approximately one day per %TBSA burned,2 and their care is longitudinal through the burn intensive care unit (BICU), acute surgeries, rehabilitation, reconstructive surgeries, and psychosocial support. Burn care is truly multidisciplinary, with daily collaboration between surgeons, anesthesiologists, nurses, physical therapists, occupational therapists, dieticians, respiratory therapists, social workers, and psychologists. This team approach is exemplified by the success of burn centers in improving patient outcomes.3 Lastly, burn care is a relatively niche field and relatively less evidence-based in comparison to other critical care disciplines, as burn patients are often excluded from major critical care trials.4–9

The purpose of this chapter is to introduce concepts relevant to burn pathophysiology, outline the initial assessment and stabilization of patient with a major burn injury, and highlight unique aspects of management in the BICU.


Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.