From the Guidelines
Management of a 22% body surface area (BSA) burn requires immediate and comprehensive care, with a strong emphasis on fluid resuscitation, pain management, wound care, and nutritional support to mitigate morbidity, mortality, and improve quality of life. The initial treatment should focus on fluid resuscitation using the Parkland formula (4mL × kg body weight × %BSA burned) with half given in the first 8 hours and the remainder over the next 16 hours, as suggested by 1. Intravenous access should be established with two large-bore catheters. Pain management is essential, typically using morphine (0.1-0.2 mg/kg IV every 2-4 hours) or fentanyl (1-2 mcg/kg IV). Wound care involves gentle cleansing with mild soap and water, application of topical antimicrobials such as silver sulfadiazine cream or silver-impregnated dressings, and regular dressing changes every 12-24 hours. Tetanus prophylaxis should be administered if needed.
Nutritional support is critical, with increased caloric needs and protein requirements, as highlighted by 1. The patient may require up to 35-40 kcal/kg/day and 1.5-2 g/kg/day of protein to support healing and mitigate muscle catabolism. It is also important to monitor for complications including infection, respiratory issues, and compartment syndrome. With 22% BSA involvement, hospitalization is necessary, and early consultation with a burn specialist or consideration of transfer to a burn center is recommended, as this extent of burn carries significant risk for systemic complications and may require specialized wound management or surgical intervention including debridement and possible skin grafting, as noted by 1.
Key considerations in the management of a 22% BSA burn include:
- Fluid resuscitation using the Parkland formula
- Pain management with morphine or fentanyl
- Wound care with gentle cleansing and topical antimicrobials
- Nutritional support with increased caloric and protein intake
- Monitoring for complications such as infection and respiratory issues
- Early consultation with a burn specialist or consideration of transfer to a burn center, as emphasized by 1 and 1.
From the FDA Drug Label
The burn areas should be covered with silver sulfadiazine cream, USP 1% at all times The cream should be applied once to twice daily to a thickness of approximately one sixteenth of an inch. There is no information about 22% BSA management in the provided drug label. The FDA drug label does not answer the question.
From the Research
Burn Management
- The management of burns, particularly those covering a significant percentage of the body surface area (BSA), is crucial for patient outcomes 2, 3, 4.
- For adults with burns ≥20% of the total body surface area (%TBSA), the American Burn Association recommends considering the use of human albumin solution to lower resuscitation volumes and improve urine output 4.
- Initiating resuscitation based on providing 2 mL/kg/% TBSA burn is recommended to reduce resuscitation fluid volumes 4.
- Selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation is also recommended 4.
Fluid Resuscitation
- Fluid resuscitation following burn injury must support organ perfusion with the least amount of fluid necessary and the least physiological cost 2.
- The use of a simplified fluid resuscitation formula, such as the one recommended by the World Health Organization Technical Working Group on Burns, may be beneficial in mass casualty scenarios with resource-limited situations 5.
- This formula estimates an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned 5.
Treatment Options
- Silver sulfadiazine (SSD) therapy is an effective and safe option for managing moderate and severe burns, often requiring additional treatments to maximize its benefits 6.
- SSD therapy is effective for second- and third-degree burns, with positive outcomes including enhanced healing, granulation tissue formation, and infection control 6.
- However, complementary treatments may be necessary to optimize results, and ongoing research and clinician training are essential in refining best practices and ensuring the most effective use of SSD therapy 6.