Overview: Two Fluid & Perfusion Emergencies
Why burns and shock belong together.
Burns and shock are grouped because both come down to fluid and tissue perfusion. A major burn destroys the skin barrier and drives fluid out of the blood vessels into the tissues, which can drop the circulating volume enough to cause hypovolemic shock — the leading early threat after a large burn. Once you understand the fluid shifts of a burn and the stages of shock, both topics become much easier to reason through.
Shock = inadequate tissue perfusion, so cells don't get enough oxygen. Whether the cause is a burn, bleeding, a failing heart, or a severe infection, the body's response and the nurse's priorities (airway, oxygen, fluids, and finding the cause) follow the same logic.
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Burn Depth (Classification)
How deep the burn goes determines how it looks, how it feels, and how it heals.
- Superficial1st degree
- Epidermis only. Red, dry, no blisters, painful (like sunburn); heals in days.
- Partial-thickness2nd degree
- Epidermis + part of dermis. Moist, blisters, red/pink, very painful.
- Full-thickness3rd degree
- Entire epidermis + dermis. Dry, leathery, white/brown/black eschar; little or no pain in the center (nerves destroyed); needs grafting.
It seems backwards, but a full-thickness burn is often not painful in its center because the nerve endings have been destroyed. Don't be reassured by a lack of pain — assess depth by appearance, and remember these deep burns need grafting and carry the highest infection risk.
Burn Extent: The Rule of Nines
Estimating the percent of body surface burned (TBSA).
The rule of nines quickly estimates the percent of total body surface area (TBSA) burned in an adult, which guides fluid resuscitation:
- Head & neck
- 9%
- Each arm
- 9%
- Front of trunk
- 18%
- Back of trunk
- 18%
- Each leg
- 18%
- Perineum
- 1%
The rule of nines is for adults. Children have proportionally larger heads and smaller legs, so a pediatric (Lund-Browder) chart is used instead. Only partial- and full-thickness burns are counted toward TBSA for fluid calculations.
Burn Phases & Fluid Resuscitation
Fluid shifts OUT, then back IN — and the labs flip with them.
Emergent (Resuscitative) Phase — onset to ~24–48 hours
- Fluid shifts out of the vessels into the tissues (third-spacing) → hypovolemia, edema, and risk of hypovolemic shock
- Hyperkalemia — potassium is released from damaged cells
- Hemoconcentration (high hematocrit) as plasma is lost; risk of acute kidney injury
- Fluid resuscitation happens here
Acute Phase — until wounds heal
- Fluid shifts back into the vessels → diuresis and risk of fluid overload
- Hypokalemia — potassium moves back into cells and is lost in urine
- Infection becomes the leading threat; high-calorie, high-protein nutrition is essential
4 mL of lactated Ringer's × weight (kg) × %TBSA. Give half in the first 8 hours from the time of the burn (not from arrival), and the rest over the next 16 hours. Titrate to a urine output of about 30 mL/hr in adults — the best indicator that resuscitation is working.
? The Parkland formula gives half the fluid in the first 8 hours — from what time does the clock start?
Burn Nursing Priorities
Airway first — then fluids, infection, pain, and nutrition.
With facial or chest burns, suspect inhalation injury and watch for hoarseness, stridor, and a brassy cough. Carbon monoxide poisoning can also occur — give 100% oxygen. The window to secure the airway closes quickly as edema develops, so airway always comes first.
Shock & Its Stages
When perfusion fails, the body compensates — until it can't.
Shock is inadequate tissue perfusion, so cells become starved of oxygen. It progresses through stages:
- Compensatoryearly
- Body compensates: ↑HR, ↑RR, cool clammy skin, restlessness, ↓urine output — BP still near normal.
- Progressive
- Compensation failing: BP drops, rapid weak pulse, ↓level of consciousness, organ ischemia, acidosis.
- Irreversiblerefractory
- Profound organ failure; does not respond to treatment.
The classic mistake is waiting for the blood pressure to drop. In early shock the BP is maintained — the warning signs are tachycardia, restlessness, cool clammy skin, and falling urine output. Acting on these early signs is what saves the client.
Types of Shock
Same end result, different causes and treatments.
- Hypovolemic
- Low volume — bleeding, burns, dehydration, vomiting/diarrhea. Replace volume (IV fluids, blood).
- Cardiogenic
- The heart can't pump (often after an MI). Improve the pump; give fluids cautiously (can overload).
- Septicdistributive
- Severe infection → vasodilation. Antibiotics, fluids, vasopressors; warm/flushed early.
- Anaphylacticdistributive
- Severe allergic reaction. Epinephrine first; protect the airway.
- Neurogenicdistributive
- Loss of sympathetic tone (spinal cord injury). Unique: bradycardia + warm, dry skin.
- Obstructive
- Physical block to flow (PE, cardiac tamponade, tension pneumothorax). Relieve the obstruction.
Most shock causes a fast heart rate and cool, clammy skin. Neurogenic shock is the exception — loss of sympathetic tone causes bradycardia and warm, dry skin. If a question pairs hypotension with a slow heart rate after a spinal cord injury, think neurogenic.
Shock Nursing Care
Recognize early, support perfusion, treat the cause.
- Recognize early — tachycardia, restlessness, cool clammy skin, falling urine output (hypotension is late).
- Oxygen — apply supplemental oxygen to support tissue perfusion.
- IV fluids — large-bore IV access; isotonic crystalloids (normal saline, lactated Ringer's) for most shock; blood for hemorrhage. Give fluids cautiously in cardiogenic shock.
- Positioning — for hypovolemic/distributive shock, supine with legs elevated improves venous return; a client in cardiogenic shock or respiratory distress is usually placed in semi-Fowler's.
- Monitor — vital signs, urine output, and level of consciousness closely; treat the underlying cause.
The kidneys need good perfusion to make urine, so urine output is one of the best bedside signs of whether shock treatment is working. A falling output (under 30 mL/hr in an adult) is an early warning; a recovering output is reassuring.
? In hypovolemic shock, how should the client be positioned — and does this change for cardiogenic shock?
Key Medications
The drugs most associated with burns and shock.
- Lactated Ringer's / Normal saline
- Isotonic IV fluids — first-line volume replacement in burns and most shock.
- Blood products
- For hemorrhagic (hypovolemic) shock.
- Norepinephrine, dopamine
- Vasopressors — raise BP when fluids aren't enough (e.g., septic shock).
- Epinephrine
- First-line for anaphylactic shock.
- Opioids (IV)
- Burn pain control — IV route (IM absorption is unreliable with fluid shifts).
- Silver sulfadiazine
- Topical antimicrobial for burn wounds.
You don't need to memorize every detail — anchor on the logic: burns shift fluid out of the vessels (watch the airway and replace fluid), shock means poor perfusion (recognize it early and support oxygen, fluids, and the cause), and each type of shock has one or two signature clues. The cheatsheet below condenses it all onto one page.
Frequently Asked Questions
Common student questions on this topic.
What is the priority assessment for a client with burns?
How is the size of a burn estimated?
What is the Parkland formula?
What are the main types of shock?
What is an early sign of shock?
Why are burns and shock taught together?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Burns & Shock Cheatsheet
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