What is the best approach for managing burn wounds in a patient with full-thickness burns covering 45% of their Total Body Surface Area (TBSA)?

Burn Wound Management for Full-Thickness Burns Covering 45% TBSA

This patient requires immediate transfer to a specialized burn center with aggressive early surgical excision and grafting, as specialist management significantly improves survival and reduces complications in severe burns. 1

Immediate Priorities

Specialist Consultation and Transfer

• Contact a burn specialist immediately to guide initial management and arrange direct transfer to a burn center, as this patient meets mandatory referral criteria (>10% TBSA in adults and full-thickness burns >5% TBSA). 1, 2
• Direct admission to a burn center (bypassing non-specialized facilities) is associated with better survival, reduced complications, shorter hospital stays, and lower costs. 1, 2
• Use telemedicine if available to facilitate initial assessment and transfer decisions. 1

Accurate TBSA Assessment

• Use the Lund-Browder chart (not the Rule of Nines) to confirm the 45% TBSA measurement, as this is the most accurate method and prevents fluid overresuscitation that occurs in 70-94% of cases when TBSA is overestimated. 1, 2
• Repeat TBSA measurements during initial management to ensure accuracy. 1

Escharotomy Assessment

• Perform urgent escharotomy if circumferential full-thickness burns cause compartment syndrome compromising circulation, respiration, or airway patency. 1, 2
• Ideally, escharotomy should be performed in the burn center by an experienced provider, but do not delay if limb or life-threatening compromise exists. 1

Wound Care Strategy

Initial Wound Management

• Do not initiate wound care until proper resuscitation is established, as this is the priority in severe burns. 2
• Once resuscitated, clean burn wounds with tap water, isotonic saline, or antiseptic solution in a clean environment. 2, 3
• Provide adequate pain control during wound care, which will require deep analgesia or general anesthesia for burns of this magnitude—use titrated intravenous opioids and ketamine. 2

Dressing Selection

• Apply silver sulfadiazine cream to a thickness of approximately 1/16 inch once to twice daily to all burn areas, keeping wounds covered at all times. 4
• Reapply cream immediately after hydrotherapy or to any areas where patient activity has removed it. 4
• Cover with clean occlusive dressings. 2

Critical caveat: While silver sulfadiazine is FDA-approved and widely used, avoid prolonged use on any areas that prove to be superficial partial-thickness burns, as it may delay healing in these zones. 2, 5

Topical Antibiotic Use

• Do not use topical antibiotics as first-line treatment—reserve them only for confirmed infected wounds to prevent antimicrobial resistance. 2, 3
• Do not administer systemic antibiotic prophylaxis routinely; antibiotics should only be used for documented infections. 2

Surgical Management

Early Excision and Grafting

• Plan for early escharectomy starting around postburn day 3, with the first operative procedure excising as much eschar as possible—preferably 40% or more of the total burned area. 6
• The surgical strategy for this 45% TBSA full-thickness burn will require staged excision and grafting procedures over multiple operations. 6, 7

Skin Coverage Options

Given the limited donor site availability with 45% TBSA full-thickness burns, a staged approach is essential:

• Use widely meshed autografts (1:3 to 1:6 expansion ratios) or Meek micrografting technique to maximize coverage from limited donor sites. 7
• Apply allograft or xenograft as temporary coverage over excised areas where autograft is insufficient, then replace with autograft as donor sites heal and can be reharvested. 8, 6
• Consider synthetic dermal substitutes (such as NovoSorb Biodegradable Temporizing Matrix) in conjunction with autologous skin cell suspension (RECELL) to improve outcomes when autograft is scarce. 8
• Maintain exposed wound area under 5% throughout the therapeutic course to prevent burn infection. 6

Donor Site Management

• Plan for multiple donor site harvests as sites re-epithelialize (typically every 10-14 days). 6
• Use growth hormone to accelerate donor site healing and improve nutritional state. 6

Supportive Care

Nutritional Support

• Initiate enteral nutrition within 12 hours after burn injury, preferably via oral or enteral routes. 2
• Supplement with trace elements (copper, zinc, selenium) and vitamins (B, C, D, E). 2
• Use growth hormone to correct nutritional state and accelerate healing. 6

Thromboprophylaxis

• Routinely prescribe thromboprophylaxis for this severe burn in the initial phase. 2

Infection Prevention

• Control environmental humidity with dehumidifiers to reduce fungal infection risk. 6
• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge. 2, 3
• Monitor serum sulfa concentrations in extensive burns, as levels may approach therapeutic range (8-12 mg%); check urine for sulfa crystals and monitor renal function. 4

Common Pitfalls to Avoid

• Do not delay transfer to a burn center—every hour matters for survival in burns of this magnitude. 1
• Do not allow exposed wound area to exceed 5% at any point during treatment, as this dramatically increases infection risk and mortality. 6
• Do not use hydroxyethyl starches for fluid resuscitation—they are contraindicated by the European Medicines Agency in severe burns. 1
• Do not perform conservative, limited eschar excision—aggressive early excision (≥40% of burned area in first operation) improves outcomes. 6
• Do not apply ice directly to burns or use prolonged external cooling devices, as hypothermia risk is significant with this TBSA. 2, 3