What is the treatment approach for a patient with a full body second-degree burn?

Treatment of Full Body Second-Degree Burns

Patients with extensive second-degree burns require immediate transfer to a specialized burn center, aggressive fluid resuscitation with Ringer's Lactate solution, early surgical excision and skin grafting, and meticulous wound management to reduce mortality and long-term morbidity. 1

Immediate Prehospital Management

Initial Cooling and Stabilization

• Cool the burn with clean running water for 5-20 minutes to limit tissue damage and reduce pain, but monitor closely for hypothermia in extensive burns 2, 3
• Remove all jewelry and constrictive items before swelling occurs to prevent vascular compromise 2, 4
• Administer analgesics (acetaminophen or NSAIDs) for pain control 2, 4

Critical Early Actions

• Immediately contact a burn specialist to determine severity, calculate total body surface area (TBSA), and arrange transfer 1
• Use telemedicine when specialists are not readily available to improve TBSA assessment and prevent undertriage, which increases mortality 1
• Assess for inhalation injury (soot around nose/mouth, difficulty breathing) which significantly increases mortality 2

Fluid Resuscitation (Life-Saving Priority)

Immediate IV Access and Fluid Administration

• Administer 20 mL/kg of crystalloid solution intravenously within the first hour for burns covering ≥20% TBSA in adults or ≥10% TBSA in children 2
• Use Ringer's Lactate solution as first-line fluid rather than 0.9% NaCl, as balanced solutions reduce the risk of hyperchloremia, metabolic acidosis, and acute kidney injury 1
• Continue aggressive fluid resuscitation following established burn formulas (typically Parkland formula: 4 mL/kg × %TBSA over 24 hours, with half given in first 8 hours) 1

Transfer to Specialized Burn Center

Indications for Burn Center Admission

• Direct admission to a burn center is mandatory for full body second-degree burns, as specialized centers significantly improve survival, reduce morbidity, decrease hospital stay, and enable earlier surgical intervention 1
• Burns centers provide multidisciplinary teams, specialized techniques, and higher patient volumes that directly correlate with better outcomes 1
• Delayed transfer increases time to surgical excision, duration of mechanical ventilation, and overall mortality 1

Exception for Unstable Patients

• Consider brief stabilization at a nearby facility only if the patient exhibits severe hemodynamic or respiratory instability AND transportation time is prolonged 1

Wound Management

Initial Wound Care

• Cleanse wounds with tap water, isotonic saline, or antiseptic solution before applying dressings 2, 3
• Preserve intact blisters as biological dressings to reduce pain, promote healing, and decrease infection risk 4
• For ruptured blisters, gently debride loose epidermis while leaving adherent tissue in place 1

Topical Antimicrobial Selection

• Apply petrolatum-based triple-antibiotic ointment (bacitracin, neomycin, polymyxin B) as first-line topical therapy, as it enhances reepithelialization and reduces scarring compared to silver-based dressings 2, 5
• Avoid prolonged use of silver sulfadiazine on superficial second-degree burns, as it may delay healing 3, 4
• Silver sulfadiazine (1% cream applied 1-2 times daily) should be reserved for deeper burns or those with significant contamination 6
• Apply topical antimicrobials only to areas with necrotic tissue, not the entire burn surface 2

Dressing Application

• Cover with clean, non-adherent dressings (paraffin gauze is effective) 3
• Change dressings daily to monitor healing and assess for infection 1, 3
• Reapply topical agents after each dressing change and hydrotherapy 6

Surgical Management

Early Excision and Grafting

• Perform early surgical excision and skin grafting as this approach significantly reduces morbidity, mortality, and hospital length of stay in severely burned patients 1
• Prospective randomized trials demonstrate that early excision (within 48-72 hours) improves outcomes compared to delayed surgery 1
• Continue wound treatment until satisfactory healing occurs or the burn site is ready for grafting 6

Escharotomy Considerations

• Perform escharotomy within 48 hours if circumferential deep second-degree burns cause compartment syndrome affecting limbs, trunk, or compromising respiration/circulation 1
• Escharotomy should ideally be performed at a burn center by experienced providers due to risks of hemorrhage and infection 1

Infection Prevention and Monitoring

Surveillance

• Monitor daily for signs of infection: increased pain, erythema extending beyond burn margins, swelling, or purulent discharge 2, 3
• Fungal colonization may occur with bacterial reduction but systemic fungal infection through burn wounds is rare 7

Antibiotic Use

• Do not use systemic antibiotics prophylactically; reserve for clinically evident infections 3
• For infected wounds requiring additional antimicrobial coverage, mafenide acetate may be considered, though it inhibits carbonic anhydrase and requires close acid-base monitoring 7

Critical Pitfalls to Avoid

• Never apply ice directly to burns, as this causes additional tissue damage 2, 3, 4
• Never apply butter, oils, or home remedies to burn wounds 2
• Never delay transfer to a burn center for extensive burns, as this increases mortality 1
• Never withdraw antimicrobial therapy prematurely while infection risk remains, unless significant adverse reactions occur 6

Special Monitoring Requirements

Metabolic Considerations

• Monitor acid-base balance closely, particularly with extensive burns and when using mafenide acetate, which can cause metabolic acidosis 7
• Watch for unexplained hyperventilation with respiratory alkalosis in burn patients 7
• Monitor renal function closely, as impaired renal function with high drug levels can exaggerate carbonic anhydrase inhibition 7