Sixteen patients with massive burns (exceeding 50% of total body surface) were treated at the University of California--Davis Burn Center in the period of 1980 and 1981. Fifteen had flame burns, and eight had inhalation injuries. Mean burn size was 72% total body surface (range, 51-94) with 20-81% full thickness. Mean age was 27 years. Survival results were compared with a similar group of 13 patients treated in 1978 and 1979, mean age 25, and burn size 65% total body surface. Fifteen of the 16 survived, compared with six of 13 in the early group. Substantial changes in therapy between the time periods resulted in the improvements. These include: 1) early endotracheal intubation with application of PEEP before evidence of pulmonary dysfunction; 2) elimination of Swan-Ganz and central venous lines for early volume resuscitation unless absolutely necessary; 3) the addition of hypertonic saline and protein infusions during the first 24 hours of resuscitation along with Ringer's lactate alone resulting in 30% decrease in fluid requirements; 4) rapid institution of nutritional support beginning by day three using a combination of peripheral hyperalimentation and tube feeding; 5) early eschar excision and grafting beginning in the first week rather than the second or third week as previously practiced. Septic complications and hospital stay were also decreased. Cadaver skin or artificial skin were unavailable. A significant improvement in survival rate was noted after a more aggressive treatment protocol was instituted.