What are the criteria for admitting a patient with alkali burns less than 10% to a burn unit?

Admission Criteria for Alkali Burns <10% TBSA

Alkali burns less than 10% TBSA should be admitted to a burn center if they involve critical anatomical areas (face, hands, feet, genitals, perineum, or flexure lines), are full-thickness, occur in high-risk patients (children, elderly >75 years, or those with severe comorbidities), or are chemical burns requiring specialized management. 1, 2

Critical Anatomical Location Overrides TBSA Threshold

• Burns involving the face, hands, feet, genitals, perineum, or flexure lines require burn center admission regardless of TBSA because these areas may require surgical intervention to prevent permanent disability and functional impairment. 2, 1
• Deep burns in function-sensitive areas warrant burn center evaluation even when TBSA is <10%. 2

Burn Depth Determines Admission Need

• Full-thickness alkali burns ≥5% TBSA require burn center transfer, even though total TBSA is below 10%. 1
• Deep partial-thickness burns ≥10% TBSA (or full-thickness ≥5%) meet transfer criteria. 1
• Alkali agents have deep and long-lasting penetrating power, causing burns that evolve over several days, making initial depth assessment challenging. 3, 4

Patient-Specific Risk Factors

• Children with any alkali burn should have a lower threshold for admission, as pediatric patients with TBSA ≥5% require formal resuscitation and burn center care. 1
• Patients >75 years with severe comorbidities warrant burn center evaluation even with TBSA <20%. 1
• Infants (<1 year of age) with any significant alkali burn should be admitted to a burn center. 2

Chemical Burn-Specific Considerations

• All chemical burns, including alkali burns, are considered severe and warrant burn center consultation regardless of TBSA when they meet other criteria (electrical or chemical burn designation). 2
• Alkali burns require specialized wound management with potential two-step surgical strategy (early excision followed by delayed skin grafting 2-3 days later) to reduce graft failure and improve healing time. 3
• Chemical burns may require specialized treatments not available at non-burn centers, including specific debridement techniques and wound coverage strategies. 4

Additional Admission Triggers

• Circular burns on extremities require burn center admission due to risk of compartment syndrome, even if <10% TBSA. 2, 1
• Suspected or confirmed smoke inhalation injury (though less common with isolated alkali burns). 1
• Low-voltage electrical burns combined with alkali exposure. 2

Common Pitfalls to Avoid

• Do not underestimate alkali burn depth based on initial appearance, as these burns continue to evolve and deepen over several days due to the prolonged penetrating action of alkaline agents. 3, 4
• Avoid delaying specialist consultation, as early telemedicine consultation should be used immediately to accurately measure TBSA, determine burn depth and severity, and make appropriate transfer decisions. 1
• Do not use the rule of nines for TBSA measurement; instead use the Lund-Browder chart to prevent overestimation that occurs in 70-94% of cases. 1
• Failure to recognize that alkali burns may require excision to fascia or intradermal debridement, unlike thermal burns, necessitating specialized surgical expertise. 4

Pre-Transfer Management

• Initiate immediate cooling with clean running water for 5-20 minutes if the patient presents acutely. 2
• Administer 20 mL/kg balanced crystalloid in the first hour for adults with burns >15% TBSA or children >10% TBSA before transfer. 1
• Remove jewelry before swelling occurs to prevent vascular compromise. 2
• Establish early specialist consultation, preferably via telemedicine, to guide initial management and transfer decisions. 1