Severe burn injuries are rare and represent less than 1% of all medical emergencies. At the scene of the accident self-protection is important. The progress of thermal injury should be stopped, while cold water therapy is usually not indicated as the resulting hypothermia severely reduces the prognosis. A thorough body check reveals the burn size, depth and presence of co-injuries. Volume depletion is the main pathophysiological reason for burn shock. Early infusion therapy is of prognostic significance. Sufficient analgesia has to be established. Intubation is not generally indicated even with extensive burns, whereas early intubation can be life-saving in the case of circular thoracic burns, face burns and inhalation trauma. Local or systemic administration of corticosteroids is not indicated. Transfer to a specialized burn unit depends on burn size and depth. Emergency room management includes stabilization of vital functions, evaluation of co-injuries and initiation of the specific surgical and intensive care therapy.