Which burn patient can be safely managed outside a level I trauma center, such as a patient with 30% first-degree burns?

Which Burn Patient Can Be Safely Managed Outside a Level I Trauma Center?

The patient with 30% first-degree burns (Option D) can be safely managed outside a level I trauma center, as first-degree burns are superficial injuries involving only the epidermis that do not meet criteria for specialized burn center referral. 1

Analysis of Each Patient

Option D: 30% First-Degree Burns (CORRECT ANSWER)

• First-degree burns are superficial injuries involving only the epidermal layer and require only simple first-aid techniques with over-the-counter pain relievers. 2
• Despite the large total body surface area (30%), first-degree burns do not penetrate beyond the epidermis and do not trigger burn center referral criteria based on depth or severity. 2
• These patients can be managed with outpatient care including cooling, pain control with acetaminophen or NSAIDs, and simple wound coverage. 3, 2
• The field triage guidelines do not mandate burn center transfer for superficial burns without other trauma mechanisms or complicating factors. 1

Option A: Diabetic Patient with Second-Degree Burn to Leg (REQUIRES REFERRAL)

• Patients with diabetes mellitus are at significantly increased risk of complications and infection from burn injuries, and early referral to a burn center should be considered. 2
• The presence of diabetes as a comorbidity combined with a partial-thickness burn creates special patient considerations that trigger Step Four of the field triage decision scheme, warranting contact with medical control and consideration for burn center transport. 1
• Burns involving certain anatomical areas and special patient populations (including those with diabetes) require specialist consultation regardless of extent. 1, 4

Option B: Inhalation Injury (REQUIRES REFERRAL)

• Inhalation injury is a major risk factor for mortality in burn patients and requires immediate specialized burn center care. 4
• Smoke inhalation increases mortality risk and requires close monitoring for glottic edema and respiratory distress. 1
• These patients need access to bronchial fibroscopy (the gold standard for diagnosis), specialized airway management, and intensive monitoring capabilities only available at burn centers. 1
• The negative impact of inhalation injuries on mortality increases with transfer delays, making direct admission to a burn center critical. 1

Option C: 15% Third-Degree Burns (REQUIRES REFERRAL)

• Full-thickness (third-degree) burns involve the entire dermal layer, and patients with these burns should automatically be referred to a burn center. 2
• Third-degree burns require early surgical excision and skin grafting, which are routinely performed at burn centers and significantly reduce morbidity, mortality, and hospital length of stay. 1, 4
• Circumferential third-degree burns can induce compartment syndrome requiring emergency escharotomy, a specialized procedure best performed at burn centers. 1, 4
• The 15% total body surface area combined with full-thickness depth meets multiple criteria for mandatory burn center referral. 4, 2

Key Burn Center Referral Criteria

According to national field triage guidelines, burns requiring specialized center care include: 1

• Partial-thickness burns (second-degree) with complicating factors (diabetes, anticoagulation, extremes of age)
• Full-thickness burns (third-degree) of any significant extent
• Burns with inhalation injury
• Burns to critical anatomical areas (face, hands, feet, genitals, perineum, major joints)
• Circumferential burns of extremities or chest

Direct admission to burn centers improves survival and reduces morbidity through concentrated expertise, specialized surgical techniques, and multidisciplinary care. 1, 4, 3