When to Refer a Burn Patient to a Burn Center
A burn patient should be referred to a burn center based on specific criteria related to burn size, depth, location, patient age, and special circumstances—with immediate specialist consultation strongly recommended for any deep partial-thickness or full-thickness burns ≥10% TBSA, deep burns ≥5% TBSA, burns to functional areas (hands, feet, face, perineum), or any burns in high-risk patients. 1, 2
Adult Burn Center Referral Criteria
Immediate Referral Required (Any Single Criterion):
- Total body surface area (TBSA) burned >20% 1
- Deep burns >5% TBSA 1
- Presence of smoke inhalation (known or suspected) 1
- Deep burns in function-sensitive areas: face, hands, feet, perineum, regardless of size 1, 3
- High-voltage electrical burns 1
Referral Required with TBSA <20% Plus Any of These:
- Age >75 years 1
- Severe comorbidities (including diabetes mellitus, which increases infection risk and complications) 1, 4
- Deep circular burns (risk of compartment syndrome requiring escharotomy) 1, 3
- Superficial burns in function-sensitive areas (face, hands, feet, perineum, skin folds) 1
- TBSA >10% 1
- Deep burns 3-5% TBSA 1
- Low-voltage electrical burns 1
- Chemical burns (e.g., hydrofluoric acid) 1
Pediatric Burn Center Referral Criteria (Any Single Criterion):
- TBSA >10% 1, 2
- Deep burns >5% TBSA 1
- Infants <1 year of age 1
- Severe comorbidities 1
- Smoke inhalation injuries 1
- Deep burns in function-sensitive areas (face, hands, feet, perineum, flexure lines) 1
- Circular burns (any location) 1
- Any electrical or chemical burn 1
Additional Conditions Requiring Burn Center Consultation:
- Frostbite 2
- Stevens-Johnson syndrome/TENS 2
- Necrotizing soft-tissue infections 2
- Full-thickness (third-degree) burns ≥5% TBSA should automatically trigger burn center referral 2, 4
Critical Implementation Points
Use Telemedicine When Specialists Are Not Immediately Available:
Telemedicine consultation should be utilized if immediate burn specialist access is unavailable to guide initial management, improve TBSA assessment accuracy, determine transfer urgency, and prevent undertriage, which directly increases mortality. 3, 5, 2
Accurate TBSA Assessment Is Essential:
Use the standardized Lund and Browder chart (suitable for both adults and children) rather than the rule of nines, which tends to overestimate TBSA and lead to inappropriate fluid resuscitation. 1, 6 Prehospital providers consistently overestimate burn size compared to burn specialists, with agreement decreasing as TBSA increases, making specialist consultation critical. 7
Direct Transfer Is Superior:
Direct admission to a burn center improves survival and functional outcomes compared to sequential transfers through multiple facilities. 3, 5 Specialized burn centers provide concentrated expertise, multidisciplinary teams, and higher patient volumes that directly correlate with better outcomes, reduced hospital length of stay, and lower costs. 3, 5
Common Pitfalls to Avoid
- Do not delay specialist consultation for any partial-thickness or full-thickness hand burn, as undertriage leads to permanent functional impairment and increased mortality 3, 2
- Do not rely solely on initial burn appearance, as depth may evolve over the first 48-72 hours; reconsult if uncertain 6
- Do not undertriage smaller burns in high-risk patients (elderly, very young, comorbidities), as these patients benefit from early burn center outpatient follow-up 2
- Smaller burns ideally should be followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more 2