What are the indications for referral to a burn unit?

Indications for Referral to a Burn Unit

Patients with severe burns should be referred to specialized burn centers for optimal outcomes, as specialized assessment and management significantly reduces morbidity, mortality, and improves long-term functional outcomes. 1

Primary Referral Criteria

• Burn depth and extent:

  • Deep partial-thickness or deeper burns ≥ 10% total body surface area (TBSA) 2
  • Full-thickness burns ≥ 5% TBSA 2
  • Burns requiring surgical intervention (excision and grafting) 3

• Anatomical considerations:

  • Burns involving face, hands, feet, genitals, perineum 3, 1
  • Burns involving major joints or flexure lines 3
  • Circumferential burns 3

• Patient factors:

  • Age extremes (children and older adults) 2
  • Significant comorbidities that may complicate management 4
  • Patients with diabetes mellitus (increased risk of complications) 4

• Special burn types:

  • Chemical burns requiring specialized management 1, 5
  • Electrical burns 2
  • Radiation injuries 2
  • Inhalation injuries 3

Secondary Referral Criteria

• Complications requiring specialist management:

  • Compartment syndrome requiring escharotomy 3, 1
  • Signs of systemic toxicity 1
  • Concomitant trauma 4
  • Hyperalgesia requiring specialized pain management 3

• Special conditions benefiting from burn center care:

  • Frostbite 2
  • Stevens-Johnson syndrome/Toxic Epidermal Necrolysis 2
  • Necrotizing soft-tissue infections 2

Process for Referral

1. Initial assessment:

   • Accurately measure TBSA using Lund-Browder chart (most accurate method) 3
   • Determine burn depth 4
   • Assess for associated injuries 4

2. Specialist consultation:

   • Urgently seek burn specialist opinion for severity assessment 3
   • Utilize telemedicine when specialists aren't readily available 3, 1
   • Send images through secure systems for remote evaluation 3

3. Transfer considerations:

   • Direct admission to burn center is preferred when indicated 3
   • Consider transition phase at nearby facility only if patient has hemodynamic or respiratory instability and transportation time is long 3

Benefits of Specialized Burn Care

Early referral to specialized burn centers provides significant benefits:

• Decreased morbidity and mortality 3, 1
• Reduced complications 3
• Shorter hospital stays 3, 1
• Better functional outcomes 1
• Access to early surgical interventions (excision and grafting) 3
• Specialized multidisciplinary approach 3

Common Pitfalls to Avoid

• Inaccurate TBSA estimation:

  • TBSA is often overestimated (in 70-94% of cases), leading to excessive fluid resuscitation 3
  • Use appropriate measurement tools rather than estimation

• Delayed referral:

  • Attempting to manage severe burns in non-specialized settings worsens outcomes 1
  • Delayed excision increases morbidity and mortality 3

• Inappropriate triage:

  • Both overtriage (consuming unnecessary resources) and undertriage (increasing morbidity/mortality) should be avoided 3
  • Consult with burn specialists when uncertain about severity 3

• Performing escharotomy outside burn centers:

  • Escharotomies for compartment syndrome should ideally be performed by experienced providers in burn centers 3

By following these guidelines for burn unit referral, healthcare providers can ensure optimal outcomes for patients with severe burns through timely and appropriate specialized care.