Patients with severe thermal burns are at significant risk of death and major morbidity. Look for evidence of respiratory distress and smoke inhalation injury a common cause of death in the acute burn victim. Laryngeal edema can develop suddenly and unexpectedly. Burn depth and size determine fluid resuscitation and the need for transfer. Vascular collapse from burn shock is a critical component. Rapid aggressive fluid resuscitation to reconstitute intravascular volume and maintain end organ perfusion is crucial. The fluid requirement during the initial 24 hours of treatment is 4 mL kg of body weight for each percent of total body surface area burned given IV. Superficial burns are excluded from this calculation. One half of the calculated fluid need is given in the first 8 hours the remaining half is given over the subsequent 16 hours. It is important to monitor urine output. Hourly urine output should be maintained at 0.5 mL kg in adults. Burn patients may be exposed to carbon monoxide and require immediate treatment with high flow oxygen. Cool and clean wounds but avoid inducing hypothermia. Remove any jewelry and any hot or burned clothing and obvious debris not densely adherent to the skin. Irrigation with cool water may be used. Topical antibiotics are applied to all non superficial burns. Give opioids morphine to treat pain and give tetanus prophylaxis.