What is the immediate management for a patient with full-thickness burns covering 45% of their Total Body Surface Area (TBSA)?

Immediate Management of Full-Thickness Burns 45% TBSA

This patient requires immediate transfer to a specialized burn center with aggressive fluid resuscitation, airway assessment for potential intubation, and multidisciplinary burn team activation. 1, 2

Critical First Steps

Immediate Burn Center Transfer

• Direct admission to a burn center is mandatory for this patient, as burns >40% TBSA significantly increase mortality risk and require specialized multidisciplinary care 1
• Contact burn specialists immediately via telemedicine if available to guide initial resuscitation and prevent undertriage-related mortality 1
• Do not delay transfer for wound care procedures that can be performed at the burn center 1

Airway Management Decision

• Consider immediate intubation given the 45% TBSA meets the threshold (≥40% TBSA) for prophylactic airway management, even without facial burns 1, 3
• Intubate without delay if any of the following are present: 1, 3
  • Severe respiratory distress, hypoxia, or hypercapnia
  • Altered mental status or coma
  • Deep circular neck burns
  • Signs of airway obstruction (voice changes, stridor, laryngeal dyspnea)
  • Suspected smoke inhalation in enclosed space
• If intubation is performed, anticipate difficult airway and use video laryngoscopy if available 3
• Avoid succinylcholine after 24 hours post-injury due to hyperkalemia risk 3

Fluid Resuscitation Protocol

Initial Crystalloid Strategy

• Begin aggressive fluid resuscitation with lactated Ringer's solution at 4 mL/kg/% TBSA burned over the first 24 hours 4
  • For a 70 kg patient with 45% TBSA: approximately 12,600 mL over 24 hours
  • Give half in the first 8 hours, remaining half over next 16 hours
• Titrate strictly to urine output of 0.5-1.0 mL/kg/hour (adults) to avoid "fluid creep" 2
• Do not use hydroxyethyl starches - these are contraindicated by the European Medicines Agency in severe burns 1, 2

Monitoring Parameters

• Hourly urine output via Foley catheter 2
• Daily weights and strict fluid balance 2
• Serum albumin levels (maintain >30 g/L) 2
• Daily complete blood count, electrolytes, renal function, liver function 2

Wound Assessment and Management

Initial Wound Care

• Defer extensive wound care until after resuscitation and arrival at burn center 1
• If transfer will be delayed >few hours, cleanse wounds with warmed sterile water or isotonic saline 1, 2
• Apply non-adherent dressings or sterile gauze - do not use prolonged external cooling devices to prevent hypothermia 1
• Monitor for compartment syndrome requiring escharotomy, particularly with circumferential burns on limbs or trunk 1

Escharotomy Indications

• Perform emergent escharotomy if deep circumferential burns cause: 1
  • Compromised distal perfusion in extremities
  • Restricted chest wall movement impairing ventilation
• Ideally performed at burn center by experienced provider 1

Infection Prevention

Antimicrobial Strategy

• Do not administer prophylactic systemic antibiotics - reserve for documented infection only 1, 2
• Take wound swabs for bacterial and fungal cultures immediately and on alternate days 2
• Apply topical antimicrobial agents (e.g., silver sulfadiazine) only to sloughy or contaminated areas, not routinely 1, 2

Nutritional Support

Early Enteral Nutrition

• Insert nasogastric tube and initiate continuous enteral feeding immediately if oral intake inadequate 2
• Provide 20-25 kcal/kg/day during acute catabolic phase, increasing to 25-30 kcal/kg/day during recovery 2
• Supplement with copper, zinc, selenium, and vitamins B, C, D, and E 1

Additional Critical Interventions

Thromboprophylaxis

• Initiate routine thromboprophylaxis in the initial phase 1

Pain Management

• Provide aggressive analgesia with short-acting opioids and ketamine for burn-related pain 1
• Consider general anesthesia for highly painful procedures 1

Environmental Control

• Barrier-nurse in side room with controlled humidity and temperature 2
• Use pressure-relieving mattress 2

Critical Pitfalls to Avoid

• Avoid fluid overload ("fluid creep") - use conservative crystalloid approach guided strictly by urine output, not formulas alone 2
• Do not perform bronchial fibroscopy outside burn centers if smoke inhalation suspected - this delays transfer 1, 3
• Never use colloids (hydroxyethyl starch or gelatin) in acute burn resuscitation 1, 2
• Do not cool burns >20% TBSA in adults due to hypothermia risk 1
• Avoid unnecessary prehospital intubation - nearly one-third are inappropriate and increase complications 1, 3