What is the best course of treatment for a 57-year-old male patient with 22% total body surface area (TBSA) scald burns, including full thickness burns on the buttocks, thighs, and legs, who was initially treated with first aid and Paracetamol (acetaminophen) on board a ship?

Management of 22% TBSA Full-Thickness Scald Burns in a 57-Year-Old Male

This patient requires immediate specialist burn center consultation and should ideally be transferred directly to a specialized burn center, as the current management plan with scheduled debridement and NPWT is appropriate, but specialist oversight is essential for optimizing outcomes in burns of this magnitude. 1, 2

Critical Initial Assessment

Burn Severity Classification

• 22% TBSA with full-thickness burns involving buttocks, thighs, and legs represents a severe burn injury requiring specialized multidisciplinary care. 1, 3
• The patient's burns involve critical anatomic areas (lower extremities with circumferential risk) that automatically elevate severity regardless of TBSA percentage. 2, 3
• Age (57 years) and TBSA (22%) are two of the three major mortality risk factors in severe burns (the third being smoke inhalation, which is absent here). 1, 3

Immediate Specialist Consultation

• Burn specialist consultation should have been obtained immediately upon hospital arrival to guide admission decisions and initial management. 1, 2
• Telemedicine consultation with a burn center should be utilized if direct specialist access is unavailable to determine whether transfer is indicated. 1, 2
• Direct admission to a burn center (rather than sequential transfers) improves survival and functional outcomes through concentrated expertise and specialized techniques. 1, 2, 3

Fluid Resuscitation Strategy

Current Plan Assessment

• The current order of PLR 1L at 100cc/hr is inadequate for a 22% TBSA burn in a 70kg patient. 3
• For adults with TBSA ≥15%, the initial resuscitation should be 20 mL/kg of crystalloid in the first hour, which would be 1,400 mL for this 70kg patient. 3
• Balanced crystalloid solutions (Ringer's lactate) are preferred over normal saline as they reduce risk of hyperchloremic acidosis, metabolic acidosis, and acute kidney injury. 3

Colloid Considerations

• Human albumin may be considered if crystalloid requirements become excessive, as it can increase oncotic pressure and reduce fluid overload complications (ARDS, acute kidney injury, abdominal compartment syndrome). 1
• Hydroxyethyl starches are absolutely contraindicated in severe burns per European Medicines Agency and French drug safety authorities. 1

Airway Management

No Intubation Required

• This patient does NOT require intubation as he has no face/neck burns, no smoke inhalation, no respiratory distress, and TBSA <40%. 1
• Routine intubation is not indicated for lower extremity burns without respiratory compromise. 1
• The patient should be monitored continuously for any signs of respiratory distress, but prophylactic intubation would be inappropriate and associated with unnecessary complications. 1

Compartment Syndrome Monitoring

Critical Warning Signs

• Monitor closely for compartment syndrome given the circumferential nature of some burns (bilateral buttocks, thighs, legs). 2, 4
• Assess for: tightness of compartments, blue/purple/pale extremities, progressive pain out of proportion (currently 8-9/10), distal neurovascular compromise, and decreased pulses. 2, 4
• Escharotomy should be performed only at a burn center due to high complication risks including hemorrhage and infection. 4, 3
• If compartment syndrome develops and transfer is impossible, obtain specialist telemedicine consultation before attempting escharotomy. 4

Antibiotic Strategy

Current Piperacillin-Tazobactam Plan

• Prophylactic systemic antibiotics (PipTazo) should be reserved for clinically evident infections, not given routinely. 2, 4
• The current plan to start broad-spectrum antibiotics prophylactically is not supported by guidelines and may promote resistance. 2, 4
• Antibiotics should be initiated only if signs of infection develop: increased pain, erythema extending beyond burn margins, purulent discharge, fever, or positive cultures. 2

Topical Antimicrobial Approach

• Topical antimicrobial agents should be used from the outset in patients at significant risk from sepsis due to wound severity. 5
• Avoid prolonged use of silver sulfadiazine on any superficial components as it may delay healing. 2

Pain Management

Current Anesthesia Consultation

• The plan for pain management consultation with anesthesia is appropriate. 2
• Titrated intravenous opioids or ketamine should be used for severe burn pain, as burn pain is often intense and difficult to control with oral agents alone. 2
• The patient's current pain score of 8-9/10 indicates inadequate analgesia that requires immediate escalation beyond what was given in the ER. 2

Nutritional Support

Protein Requirements

• The addition of 6 egg whites (2 per meal) provides approximately 21g of protein daily, which is grossly inadequate for a 22% TBSA burn. 1
• Severe burn patients require aggressive nutritional support with high protein intake to support wound healing and prevent catabolism. 1
• Consider formal nutrition consultation to calculate specific caloric and protein requirements based on burn size and metabolic demands. 1

Surgical Planning

Scheduled Debridement and NPWT

• Early surgical excision and skin grafting, performed routinely at burn centers, significantly reduce morbidity, mortality, and hospital length of stay. 3
• The scheduled debridement with NPWT application is appropriate, but this should ideally occur at a specialized burn center. 3
• Full-thickness burns require specialized surgical techniques beyond simple debridement to prevent permanent functional disability. 2, 3

Critical Pitfalls to Avoid

• Do not delay specialist burn center consultation or transfer - undertriage increases morbidity and mortality. 1, 2, 3
• Do not continue prophylactic broad-spectrum antibiotics without clinical evidence of infection. 2, 4
• Do not underestimate fluid requirements - use proper resuscitation formulas for TBSA ≥15%. 3
• Do not delay compartment syndrome recognition - irreversible damage can occur within 6-8 hours. 4
• Do not perform escharotomy outside a burn center unless absolutely unavoidable with specialist guidance. 4, 3

Laboratory Monitoring

The ordered labs (CBC, renal function, electrolytes, albumin, coagulation studies, urinalysis, wound/blood cultures) are comprehensive and appropriate for baseline assessment and ongoing monitoring. 1