A 35-year-old man presents to the emergency department 6 hours after sustaining a scald injury from boiling water to his right arm and anterior chest. On examination, the skin is red, blistered, and painful to light touch. The estimated TBSA is 12%. Vital signs are stable. After initial assessment and pain relief, what is the most appropriate next step in management?

Explanation

## Management of Partial-Thickness (Second-Degree) Scalds **Key Point:** A 12% TBSA partial-thickness (second-degree) burn in a haemodynamically stable patient does NOT meet criteria for fluid resuscitation (threshold is ≥15–20% TBSA in adults). Local wound care and outpatient follow-up are appropriate. ### Classification of Thermal Injuries by Depth | Degree | Depth | Appearance | Pain | Healing | Management | |--------|-------|------------|------|---------|-------------| | **First** | Epidermis only | Red, dry | Yes | 3–7 days | Topical analgesia, moisturizer | | **Second (Partial-thickness)** | Dermis (superficial or deep) | Blistered, red, weeping | Very painful | 2–3 weeks | Cleanse, topical antibiotics, dressing | | **Third (Full-thickness)** | All skin layers | White/charred, leathery | No pain | Requires grafting | Escharotomy, grafting, burn centre | | **Fourth** | Subcutaneous/muscle | Charred, contracted | No pain | Amputation/grafting | Burn centre, surgical intervention | ### Criteria for Fluid Resuscitation **High-Yield:** Parkland formula resuscitation is indicated for: - **≥20% TBSA** in adults (≥15% in children <10 years or >60 years) - **≥10% TBSA** if inhalation injury suspected - **Circumferential burns** of limbs or chest This patient has 12% TBSA—**below the threshold**—so IV resuscitation is not needed. ### Local Wound Care for Partial-Thickness Burns 1. **Cleansing:** Gentle washing with mild soap and water or saline 2. **Debridement:** Remove loose, non-adherent skin and blisters 3. **Topical antibiotics:** Silver sulfadiazine (SSD) is the gold standard - Broad-spectrum coverage (Gram-positive, Gram-negative, fungi) - Applied 1–2 mm thick, 1–2 times daily - Penetrates eschar well 4. **Dressing:** Non-adherent gauze or specialized burn dressings 5. **Analgesia:** Paracetamol, NSAIDs, or weak opioids as needed 6. **Tetanus prophylaxis:** If status unknown or >5 years since last dose **Clinical Pearl:** Partial-thickness burns typically heal within 2–3 weeks with minimal scarring if infection is prevented. Early outpatient follow-up (48 hours) allows assessment of wound healing and infection signs. ### Decision Tree for Burn Management ```mermaid flowchart TD A[Thermal injury]:::outcome --> B{TBSA and depth?}:::decision B -->|<15% TBSA, partial-thickness| C[Outpatient management]:::action B -->|≥15-20% TBSA or full-thickness| D[Admit, IV resuscitation]:::action C --> E[Cleanse, topical SSD]:::action C --> F[Dressing, analgesia, tetanus]:::action C --> G[Follow-up in 48 hours]:::action D --> H[Parkland formula, 2 large-bore IVs]:::action D --> I[Urinary catheter, monitor UOP]:::action D --> J[Burn centre referral if deep/extensive]:::action ``` **Mnemonic:** **SCALD** for partial-thickness burn management: - **S**ilver sulfadiazine (topical antibiotic) - **C**leanse and debride gently - **A**nalgesia (paracetamol, NSAIDs) - **L**ocal wound care (dressing, tetanus) - **D**aily follow-up (outpatient in 48 hours) [cite:Park 26e Ch 9]