When to refer a patient to a specialist for normal burn healing?

When to Refer a Patient to a Specialist for Burn Healing

Patients with second- or third-degree burns involving the face, hands, feet, genitals, or burns involving >10% total body surface area (TBSA) in adults or >5% TBSA in children should be referred to a specialized burn center for treatment. 1

Criteria for Burn Specialist Referral

Immediate Referral Required

• Burns with the following characteristics require immediate referral to a burn center:
  • Second or third-degree burns involving:
    • Face, hands, feet, genitals, or perineum 1, 2
    • Major joints or flexure lines 2

    • 10% TBSA in adults 1

    • 5% TBSA in children 1

  • Full-thickness (third-degree) burns ≥5% TBSA 2
  • Circumferential burns 1, 2
  • Inhalation injuries (facial burns, difficulty breathing, singed nasal hairs, soot around nose/mouth) 1, 2
  • Electrical burns (especially high-voltage) 1
  • Chemical burns 1
  • Burns with signs of compartment syndrome requiring escharotomy 2

Additional Referral Considerations

• Age-related factors:
  • Children <1 year of age 1
  • Adults >75 years 1
• Patients with severe comorbidities 1
• Deep partial-thickness burns that may require surgical intervention 3

Initial Management Before Referral

1. Immediate cooling: Cool burns with clean running water for 5-20 minutes 1, 2
2. Pain management: Administer over-the-counter analgesics like acetaminophen or NSAIDs 1
3. Wound coverage: Cover with non-adherent dressing or clean cloth 1
4. Remove jewelry: Before swelling develops 1
5. Accurate TBSA assessment: Use the Lund-Browder chart for most accurate measurement 1, 2

Telemedicine Consultation

When direct transfer to a burn center isn't immediately possible, telemedicine consultation should be utilized to improve initial assessment and management decisions 1, 2, 4. This approach can:

• Reduce unnecessary transfers (overtriage) 4
• Ensure appropriate triage of serious burns
• Provide expert guidance for initial management

Pitfalls to Avoid

• Inaccurate TBSA estimation: Often leads to overestimation and excessive fluid resuscitation 1, 2
• Delayed referral: Increases morbidity and mortality 2
• Inappropriate triage: Both overtriage and undertriage should be avoided 2
• Performing escharotomies without experience: Ideally should be performed by experienced providers in burn centers 1, 2
• Treating severe chemical burns in primary care: These should be referred to specialized centers 2

Outpatient Management Criteria

Burns that can typically be managed as outpatients without specialist referral include:

• Superficial (first-degree) burns of any size 3
• Superficial partial-thickness burns <10% TBSA in adults or <5% TBSA in children without involvement of critical areas 1, 3
• Burns that do not involve face, hands, feet, genitals, or major joints 1

For outpatient management, silver sulfadiazine cream may be applied once to twice daily to a thickness of approximately 1/16 inch for burns with limited infection 5, 6.

Regular follow-up is essential for all burn patients managed as outpatients to monitor for complications and ensure proper healing 6.