Appendix 8
Specialist Trauma Transfer Guidelines - 8.6 Burns

Indications for Transfer to Burns Service

• Full thickness burns greater than 5 per cent of the body surface area in any age group.

• Partial thickness burns involving more than 20 per cent of the total body surface in adults.

• Partial thickness burns involving more than 10 per cent of the total body surface area in ages under 10 and over 50 years.

• Inhalation injury indicated by:
  • facial burns
  • singeing of the eyebrows, eyelashes and nasal hair
  • carbon deposits and acute inflammatory changes in the oropharynx
  • history of impaired mentation and/or confinement in a burning environment
  • history of explosion.

• Partial thickness and full thickness burns involving face, eyes, ears, hands, feet, genitalia, perineum or skin over major joints.

• Electrical burns including lightning injury.

• Significant chemical burns.

• Lesser burns in patients with significant pre-existing disease that could complicate management*.

• Burn injury with special social requirements including suspected child abuse.
  

Primary Hospital Management

Assessment

• History.
• Body surface area-'Rule of Nines'-each anatomical body region represents 9 per cent of the total body surface area.
• Depth of burn-superficial, partial thickness, deep partial thickness, full thickness.

Airway Management

• Signs of impending airway obstruction may not be immediately obvious.
• Assume carbon monoxide (CO) poisoning in patients sustaining burns in enclosed areas. Such patients should initially receive high flow oxygen via a non-rebreathing bag.
• If there is any doubt about damage to the respiratory tract, it is important that the patient be intubated early as the evolution of pharyngeal and laryngeal oedema in the ensuing 3-4 hours may make intubation impossible, and emergency cricothyroidotomy or tracheostomy may become necessary in difficult circumstances.

Stop the Burning Process

• All burning clothing should be removed, taking special care in removal of chemically affected clothing. Dry chemicals should be rinsed off the body with copious amounts of water.

Intravenous Lines

• Any patient with burns over 20 per cent of the body surface area needs immediate intravenous fluids via a large calibre line (16g). Upper extremities, even if burned, are preferable. Presence of overlying burnt skin should not deter placement of a catheter in an accessible vein, including central veins.
• Circulating blood volume should be assessed according to hourly urine output via IDC.
  • Children: 30kg or less, 0.7-1.0 ml of urine/kg body weight/hour
  • Adults: 30-50 ml/hour.
• Infusion of balanced salt solution at 2-4ml solution/kg body weight/per cent body surface burn in the first 24 hours from time of injury.

Proportions: one half of the estimated fluid provided over the first 8 hours post burn, and the remaining half over the next 16 hours.

(This resuscitation is only an estimate and should be adjusted according to haemodynamic and urinary responses.)

Circumferential Extremity Burns-Maintenance of Peripheral Circulation

• Remove all jewellery.
• Assess status of distal circulation: cyanosis, neurological signs, absence of Doppler pulse.
• Relieve embarrassment of distal circulation in a circumferentially burned limb by escharotomy. Incision must be entire length of the eschar in medial or lateral line of the limb. Escharotomy of fingers is rarely indicated and should be done only in consultation with an appropriate specialist.

Other

• Insert a nasogastric tube if >20 per cent burns.
• Wound care-gently cover with clean linen, do not break blisters, do not apply cold water to a patient with extensive burns.
• Avoid hypothermia.