What is the appropriate management plan for a patient with superficial partial-thickness burns covering 28% TBSA, with a history of hypertension, currently on Losartan, and initially treated with Ketorolac and Silver sulfadiazine 1% cream?

Management of Superficial Partial-Thickness Burns (28% TBSA)

Immediate Priorities

This patient requires admission to a burn center with immediate fluid resuscitation, transition away from silver sulfadiazine to superior dressings, multimodal analgesia, and careful monitoring of his hypertension during the acute phase. 1

Fluid Resuscitation (Critical First Step)

• Initiate immediate intravenous fluid resuscitation with Ringer's Lactate at 20 mL/kg within the first hour, as this patient has 28% TBSA burns (exceeding the 20% threshold for adults) 1
• Calculate total 24-hour fluid requirements using the Parkland formula: approximately 2-4 mL/kg/%TBSA = 5,880-11,760 mL over 24 hours for this 105 kg patient 1
• Ringer's Lactate is superior to 0.9% NaCl as it reduces hyperchloremia, metabolic acidosis, and acute kidney injury 1
• Obtain IV access in unburned areas; use intraosseous route if IV access cannot be rapidly obtained 1
• Titrate fluids based on urine output (goal 0.5-1 mL/kg/hr) and hemodynamic parameters 1

Pain Management

• Discontinue Ketorolac (NSAIDs can worsen renal perfusion during the hypovolemic phase and interfere with fluid resuscitation) 2
• Implement multimodal analgesia with titrated intravenous ketamine combined with short-acting opioids as these are the most effective agents for burn-induced pain 2, 1
• Ketamine limits morphine consumption and is particularly effective for severe burn pain 2, 1
• Consider general anesthesia for highly painful dressing changes given the extensive TBSA involved 2, 1
• Use validated pain assessment scales to guide titration 1

Wound Care Management

Critical change needed: Silver sulfadiazine should be discontinued and replaced with superior alternatives, as prolonged use on superficial burns is associated with delayed healing 2, 1, 3, 4

Why Discontinue Silver Sulfadiazine:

• Evidence demonstrates that silver sulfadiazine increases burn wound infection rates (OR = 1.87; 95% CI: 1.09-3.19) and prolongs hospital stays by an average of 2.11 days compared to alternative dressings 3
• Multiple studies show that newer dressings achieve faster wound healing than SSD 4
• The lipid base makes removal painful and wound assessment difficult 5

Recommended Alternative Dressings:

• Medical-grade honey dressings show superior outcomes with healing 7.80 days faster than SSD (95% CI: -8.78 to -6.63) and significantly lower complication rates (RR 0.13; 95% CI: 0.03-0.52) 6, 3
• Petrolatum-based antibiotic ointment with non-adherent dressing is appropriate for partial-thickness burns 1, 6
• Moist dressings significantly reduce hypertrophic scarring compared to dry SSD dressings (RR 0.13; 95% CI: 0.03-0.52) 6
• Choose dressing based on TBSA, wound appearance, and patient condition 2, 1

Wound Care Protocol:

• Perform wound care only after adequate resuscitation is established—this is not an immediate priority 2, 1
• Clean wounds with tap water, isotonic saline, or antiseptic solution in a clean environment 2, 1, 6
• Require deep analgesia or general anesthesia for dressing changes given the extensive TBSA 2, 1
• Do not use topical antibiotics as first-line treatment; reserve for infected wounds only 2, 1, 6
• Re-evaluate dressings daily 2, 3
• Monitor for infection signs: increasing pain, redness, swelling, purulent discharge 6, 3

Hypertension Management Considerations

• Continue Losartan but monitor closely during fluid resuscitation as hemodynamic instability may occur 2
• Burns trigger capillary leakage and hypovolaemia, which may alter drug effects 2
• Titrate antihypertensive therapy based on blood pressure response during the acute phase 2
• Current BP of 165/81 is acceptable during acute resuscitation; avoid aggressive BP lowering that could compromise perfusion 2

Additional Critical Interventions

• Initiate nutritional support within 12 hours after burn injury, preferably via oral or enteral routes 6
• Prescribe thromboprophylaxis routinely for severe burns patients 6
• Consider supplementation with trace elements (copper, zinc, selenium) and vitamins (B, C, D, E) 6
• No routine antibiotic prophylaxis—reserve antibiotics for documented infections 6, 3
• Tetanus prophylaxis already appropriately administered 1

Burn Center Admission Criteria Met

This patient meets multiple criteria requiring burn center care: 1, 6

• TBSA >10% in adults (this patient has 28%)
• Burns involving anterior neck (potential airway compromise)
• Burns involving anterior chest (potential respiratory compromise)
• Extensive TBSA requiring specialized multidisciplinary care

Specialist burn center care is associated with better survival, reduced complications, shorter hospital stays, and lower costs 1

Common Pitfalls to Avoid

• Do not continue silver sulfadiazine beyond the initial emergency department application 2, 1, 3, 4
• Do not delay fluid resuscitation for wound care—resuscitation takes absolute priority 2, 1
• Do not use external cooling devices for prolonged periods due to hypothermia risk 2, 1, 6
• Do not apply ice directly to burns as this causes tissue ischemia 1, 6
• Avoid NSAIDs during acute resuscitation phase due to renal perfusion concerns 2
• Do not break intact blisters as this increases infection risk 1