What is the management for a patient with a detached or miscalculated Body Surface Area (BSA) burn?

Management of BSA Detachment in Burn Patients

When BSA detachment is identified or miscalculated, immediately reassess the extent of epidermal detachment using the Lund and Browder chart, documenting detached and detachable (Nikolsky-positive) epidermis separately from erythema, as the detachment percentage—not erythema—determines prognosis and guides transfer decisions. 1

Immediate Assessment and Documentation

Accurate BSA calculation is critical for fluid resuscitation, transfer decisions, and prognostic scoring:

• Record extent of epidermal detachment separately from erythema on a body map using the Lund and Browder chart 1
• Include both detached epidermis AND detachable epidermis (Nikolsky-positive areas) in your BSA calculation—this combined figure has prognostic value 1
• Calculate SCORTEN within the first 24 hours using the accurate BSA detachment percentage 1
• Obtain baseline body weight and vital signs including oxygen saturation 1

Common pitfall: The extent of erythema does not equal extent of detachment. Many clinicians mistakenly use erythema percentage for fluid calculations and transfer criteria, leading to under-resuscitation or delayed transfer. 1

Fluid Resuscitation Based on Corrected BSA

Once accurate BSA detachment is determined, adjust fluid management immediately:

• Use the Parkland formula: 4 mL/kg/% TBSA over first 24 hours, with half in first 8 hours 2
• Target urine output of 0.5-1 mL/kg/hour as primary endpoint 2
• Adjust infusion rates based on clinical response rather than rigidly following formulas 2
• Insert urinary catheter for accurate output monitoring 1
• Site IV access through non-lesional skin when possible; change peripheral lines every 48 hours 1

Monitor for both under-resuscitation and over-resuscitation as both increase morbidity. 2 Research shows the Parkland formula may lead to significant hypovolemia despite appearing adequate, 3 while other studies demonstrate formula-based resuscitation can result in unnecessarily large fluid loads. 4

Transfer Criteria Based on BSA Detachment

Transfer decisions depend on the corrected BSA detachment percentage:

• >10% BSA epidermal detachment: Admit without delay to burn center or ICU with experience treating extensive skin loss 1
• >30% BSA detachment (TEN): Consider transfer to specialist burn center, especially with clinical deterioration, extension of detachment, or delayed healing 1
• Convene multidisciplinary team coordinated by specialist in skin failure (dermatology/plastic surgery), including intensive care, ophthalmology, and specialized nursing 1

Special Considerations for Obese Patients

The traditional "Rule of Nines" significantly overestimates head/arm BSA and underestimates trunk/leg BSA in obese patients:

• For morbidly obese patients, use modified percentages: head 5%, arms 15%, trunk 45-52%, legs 35-40% 5, 6
• Standard Lund-Browder charts may require adjustment based on BMI 6
• These errors are magnified as BMI increases and can lead to substantial miscalculation of fluid requirements 6

Skin Management for Detached Areas

Conservative approach for all patients with BSA detachment:

• Leave detached epidermis in situ to act as biological dressing 1
• Decompress blisters by piercing and expressing fluid 1
• Cleanse wounds gently with warmed sterile water, saline, or chlorhexidine (1:5000) 1
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over entire epidermis including denuded areas 1
• Apply non-adherent dressings (Mepitel or Telfa) to denuded dermis with secondary foam dressing for exudate 1
• Barrier nurse in side room with humidity control, pressure-relieving mattress, ambient temperature 25-28°C 1

Surgical approach may be considered in burn centers for patients with clinical deterioration, wound conversion, or delayed healing—involving debridement under general anesthesia and physiological closure with Biobrane/allograft/xenograft. 1

Monitoring Strategy

Establish comprehensive monitoring based on corrected BSA:

• Hourly urine output targeting 0.5-1 mL/kg/hour 2
• Serial arterial lactate concentrations 2
• Daily weight measurements and strict intake/output documentation 2
• Consider invasive hemodynamic monitoring (central/arterial line) for severe cases with hemodynamic instability 1, 2
• Take bacterial/candidal swabs from three lesional areas on alternate days 1