Management of 40% Total Body Surface Area Burns
Patients with 40% total body surface area (TBSA) burns require immediate intubation, aggressive fluid resuscitation with balanced crystalloids, and specialized burn center care to reduce morbidity and mortality. 1
Initial Assessment and Airway Management
Airway Management
- Immediate intubation is indicated for patients with 40% TBSA burns, as this is considered a very extensive burn 1
- Additional indications for intubation include:
- Deep circular neck burns
- Symptoms of airway obstruction (voice changes, stridor, laryngeal dyspnea)
- Severe respiratory distress, hypoxia, hypercapnia, or coma
Smoke Inhalation Assessment
- Suspect smoke inhalation with:
- Fire in enclosed space
- Soot on face
- Dysphonia, dyspnea, wheezing, blackish sputum
- Do not perform bronchial fibroscopy outside of burn centers to avoid transfer delays 1
Fluid Resuscitation
Initial Fluid Management
- Begin with 20 mL/kg balanced crystalloid solution in the first hour 2
- Use Parkland formula as starting point: 2-4 mL/kg/%TBSA for first 24 hours 2
- For 40% TBSA: approximately 80-160 mL/kg over 24 hours
- Half given in first 8 hours, remainder over next 16 hours
- Establish IV access in unburned areas when possible 2
Fluid Type
- Use balanced crystalloids (Lactated Ringer's) for initial resuscitation 2
- Avoid normal saline for large volume resuscitation to prevent hyperchloremic metabolic acidosis unless patient has traumatic brain injury 2
Monitoring and Adjustments
- Target urine output:
- Adults: 0.5-1 mL/kg/hour
- With myoglobinuria: 1-2 mL/kg/hour 2
- Adjust fluid rates based on clinical response rather than rigid formula calculations 2
- Additional monitoring may include:
- Arterial lactate concentration
- Echocardiography
- Hemodynamic parameters 2
Pitfalls in Fluid Management
- Avoid "fluid creep" (excessive fluid administration) which can lead to complications 3
- Recent evidence suggests restrictive fluid regimens may be associated with better outcomes than liberal Parkland-guided approaches 4
- Most burn patients receive more fluid than predicted by the Parkland formula in clinical practice 5, 3
Wound Management
Initial Wound Care
- Cleanse and debride burn wounds under sterile conditions 6
- Apply silver sulfadiazine cream to a thickness of approximately 1/16 inch 6
- Reapply once to twice daily and after hydrotherapy 6
- Continue treatment until satisfactory healing or until the burn site is ready for grafting 6
Pain Management
- Implement multimodal analgesia immediately
- Titrate analgesics based on validated pain assessment scales
- Consider combining intravenous ketamine with other analgesics for severe burn pain 2
Special Considerations
Escharotomy
- Rarely indicated immediately except for compromised airway/ventilation
- Consider for intra-abdominal hypertension or circulatory impairment within 48 hours
- Should be performed at a Burns Center or after specialist consultation 2
Transfer Criteria
- All patients with 40% TBSA burns should be transferred to a specialized burn center as soon as possible after initial stabilization
- Do not delay transfer for non-essential procedures 1
Ongoing Care
- Monitor for complications including compartment syndrome, respiratory issues, and infection
- Provide nutritional support to meet increased metabolic demands
- Early excision and grafting of deep burns improves outcomes 7