Features of Complex Burns (that require referral to an appropriate service)

These diagrams and illustrations have been designed to help you learn, memorise and recall key information.

Following the recommendations of the National Burn Care Review 2001, Specialised Burn Services were strati ed into three levels of service:

 

Burn Centres (C) – This level of in-patient burn care is for the highest level of injury complexity and offers a separately staffed, geographically discrete ward. The service is skilled to the highest level of critical care and has immediate operating theatre access.

 

Burn Units (U)– This level of in-patient care is for the moderate level of injury complexity and offers a separately staffed, discrete ward.

Burn Facilities (F) – This level of in-patient care equates to a standard plastic surgical ward for the care of non- complex burn injuries 

Specific Advice to Emergency Departments, General Practitioners and other non-specialised providers: -

  • The suggested minimum threshold for referral into specialised burn care services can be summarised as: All burns ≥2% TBSA in children or ≥3% in adults.
    - All full thickness burns.
    - All circumferential burns.

    - Any burn not healed in 2 weeks.

    - Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours.

  • In addition, the following factors should prompt a discussion with a Consultant in a specialised burn care service and consideration given to referral:

    - All burns to hands, feet, face, perineum or genitalia Any chemical, electrical or friction burn.
    - Any cold injury.
    - Any unwell/febrile child with a burn.

    - Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn.

  • If the above criteria/threshold is not met then continue with local care and dressings as required.

  • If burn wound changes in appearance / signs of infection or there are concerns regarding healing then discuss with a specialised burn service.

  • If there is any suspicion of Toxic shock syndrome (TSS) then refer early. 

Thresholds for Referral to Adult Burn Services: - 

TBSA

(F) Refer ≥3%<10% (including those with inhalation injury)

(U) Refer ≥10%<40% ≥10%<25% with inhalation injury

(C) Refer ≥40% ≥25% with inhalation injury

(C) Discuss ≥25%

The minimum indication for Inhalation Injury is defined as – Visual evidence of suspected upper airway smoke inhalation, laryngoscopic and/or bronchscopic evidence of tracheal or more distal contamination/injury or unconscious at scene with suspicion of inhalation or raised COHb. If there are any concerns regarding inhalation injury with a patient with any size burn then it should be discussed with a Burn Care Centre. Special Consideration should be given to referring patients >65 yrs with ≥25% TBSA (especially where there are co-morbidities) to the Burn Care Centre

DEPTH

(F) Refer Any full thickness burns

(U) Refer ≥5%<40% if non- blanching

All burns that are not blanching should be referred to a specialised burn service

 

SITE

(F) Discuss Any burn to special areas (hands, feet, face, perineum, genitalia)

(U) Refer Any significant burn to special areas (hands, feet, face, perineum, genitalia) or any non-blanching circumferential burn. “Significant” can mean any injuries where the referrer feels that greater MDT expertise is required.

 

MECHANISM

(F) Discuss Any chemical, electrical, friction burn. Any cold injury

 

OTHER FACTORS 

(F) Refer Any burn not healed in 2 weeks.

(F) Discuss Any concern regarding burn injury and co-morbidities including any co-morbidities that may affect treatment or healing of the burn.

(U) Refer Any predicted or actual need for HDU or ITU level care or any burn with suspicion of non-accidental injury should be referred to
a Burn Unit / Centre for expert assessment within 24 hours

(U) Discuss Patients who are pregnant and all patients with Major Trauma + Burn Injury (post treatment within Major Trauma Centre) where the burn injury meets unit level thresholds.

(C) Discuss All patients with Major Trauma + Burn Injury (post treatment within Major Trauma Centre) where the burn injury meets centre level thresholds. Patients assessed as requiring end of life care should be discussed with a Consultant Burn Specialist at a Burn Centre (to discuss the appropriateness of local palliative care versus transfer to a centre).

The treatment of patients with Major Trauma + Burn Injury should be agreed between the Trauma service and the appropriate specialised burn service (in accordance with the TBSA,Depth, Site and Mechanism criteria listed above)

Thresholds for Referral to Paediatric Burn Services: - 

TBSA 

(F) Refer ≥2%-5%

(U) Refer ≥5%-30%
(U) Refer ≥5%-15% if under 1 year old

(C) Refer ≥30%
(C) Refer ≥15% if under 1 year old

(C) Discuss ≥ 20%
(C) Discuss ≥ 10% if less than 1 Year Old

DEPTH

(F) Refer All full thickness burns.

(U) Refer ≥2% full thickness if under 10 yrs old

(U) Refer ≥1% full thickness if under 6 months old

(C) Refer ≥ 20% TBSA if Full Thickness

NOTE: - All burns that are not blanching should be referred to a specialised burn service

SITE

(F) Discuss Any burn to special areas (hands, feet, face, perineum, genitalia)

(U) Refer Any significant burn to special areas (hands, feet, face perineum or genitalia) and any circumferential burn. “Significant” can mean any injuries where the referrer feels that greater MDT expertise is required

 

MECHANISM

(F) Discuss Any chemical, electrical, friction burn. Any cold injury.

 

OTHER FACTORS

(F) Refer Any burn not healed in 2 weeks.

(F) Discuss Unwell/febrile child with a burn.

(F) Discuss Any concern regarding burn injury any co-morbidities that may affect treatment or healing of the burn.

(U) Refer Any predicted or actual need for HDU / PICU (including those predicted to require support for reasons other than the burn injury – e.g. smoke inhalation)

(U) Refer Any significant deterioration in physiology. Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours

(U) Discuss All children with Major Trauma + Burn Injury (post treatment within Major Trauma Centre) where the burn injury meets unit level thresholds

(U) Discuss Any burn injury in a neonate.

(C) Refer All those predicted to require assisted ventilation specifically for their burn injury for more than 24 Hours. Any child requiring assisted ventilation for >24 Hours must be within a Paediatric Intensive Care Unit. It is recommended that all children with smoke inhalation (irrespective of the presence of burn injury) are referred to a PICU with a specialised burn care service on site.

(C) Refer Any child who is physiologically unstable as a result of burn injury

Suggested parameters for physiologically unstable are:

- Requirement for Inotropic support

- Requirement for renal support or with deteriorating renal function

- A base deficit >5 and deteriorating

- An oxygen requirement >Fi02 of 50% and increasing, especially with abnormal C02 / respiratory rate

(C) Discuss All children requiring respiratory support

(C) Discuss All children with Major Trauma + Burn Injury (post treatment within Major Trauma Centres) where the burn injury meets centre level thresholds

(C) Discuss Any burn injury in a neonate.

The treatment of children with Major Trauma + Burn Injury should be agreed between the Trauma service and the appropriate specialised burn service

Neonates should only be admitted to burn services with an onsite NICU.

 

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© TIPS in Plastic Surgery 2016

John K Dickson