The burn patient may need to be referred to a burn center, depending on the injury, the patient’s age or situation, the capacity of the healthcare facility and other factors. Referral criteria differ by location, and the patient will need to be prepared for transfer if referral is indicated.

After stabilizing the burn patient, decide if the current facility is the best place for them to receive further burn care.

Referral can only take place if a burn center is available. If the option is available, it is advisable to refer the patient to a well-equipped (burn) center immediately. You can always reconsider the option of referral if required in the later stages of treatment.

Severe burns in neonates and pregnant women require individualized management, preferably by a specialized team, so referral is recommended in those cases.

Referral indications may differ by country. If the patient meets one of the referral criteria, consult with the burn center as early as possible.

To refer a patient, you will need to provide accurate documentation.

Burn center referral criteria

There are many criteria for referral to a burn center. Please adhere to local protocols if available.

Preparing the patient for transfer to a burn center

The patient must be stabilized before transfer and can only be transferred once stable.

Respiratory system

For all patients with major injuries, stabilize the respiratory system by supplying oxygen at a rate of 15L/min through a non-rebreathing mask. Before transfer, assess the need for endotracheal intubation, as upper airway obstruction can progress rapidly.

Circulatory system

Commence fluid resuscitation according to the Modified Parkland formula. To administer this, ideally obtain IV access through two large bore cannulas. If this is not possible, consider other routes of access – for example, using a peripheral venous cutdown (ankle or elbow), percutaneous central venous line (femoral, subclavian or internal jugular) or an intra-osseous needle. It is also important to prevent hypothermia.

Management of the burn wound

First evaluate the adequacy of any first aid treatment provided, then move onto administering early burn wound treatment. To do this, wash the burn with either 0.1% chlorhexidine solution or 0.9% saline, then cover the wound with a sterile, non-adhesive bandage or clean cloth. Do not use topical agents if the referral center can be reached within an acceptable time frame (1-2 hours).

Specific considerations

Head and neck burns can progress rapidly, causing upper airway obstruction, therefore these patients should be in a seated position during transfer.

Burns of the perineum require early urinary catheterization.

When there is burn injury to the extremities, these should be elevated to prevent edema.

If essential functions such as ventilation or circulation are compromised by eschar formation, or they risk becoming compromised during transport, this is an indication for an early escharotomy before transfer.

Analgesia

Given that most burn injuries are extremely painful, opioid analgesia should be provided intravenously, if available. For example, morphine at a starting dose of 0.05-0.1mg/kg of bodyweight can be used. Subsequently, titrate the dose, dosing every 3-5 minutes. The final dose is determined by the patient’s response.

Gastrointestinal system

Patients with major burns are also at a high risk of gastroparesis. Therefore, insert a nasogastric tube for adults with burns >20% TBSA and for children with burns >10% TBSA. This prevents gastric dilatation, vomiting and subsequent aspiration.

Tetanus

Tetanus prophylaxis must be administered at the first point of medical contact. This should be checked when the patient arrives at the referral center.