For Referring Physicians and Hospitals

Urgent Referrals:
The Mass General Burn Center has a "no-refusal" policy. To speak directly with an attending physician 24 hours a day for a referral or consultation, call 1-800-678-BURN. We can arrange for transportation from any location within the US and abroad.

Ambulatory Referrals:
To schedule an outpatient appointment with our burn team, call (617) 726-3712.

Referring Physicians and primary care providers receive a fax or call summarizing the patient's injury within 24-72 hours of admission. Every effort is made to contact the patient's primary care provider.

Emergency Treatment of Burn Patients

1. Immediate Emergency Burn Care

• Stop the burning process
• Maintain airway
• Use airway and C-spine precautions
• ABC’s

2. Emergency Burn Management

• Airway Management
  1. Administer highflow 100% oxygen to all burn patients; be prepared to suction and support ventilation if necessary
  2. Keep head of bed elevated if no contraindications
  3. If an inhalation injury is suspected, assess for the following:
     
     
     • Burned in an enclosed space
     • Darkened or reddened oral and/or nasal mucosa
     • Burns to the face, lips, nares, singed eyebrows, singed nasal hairs, carbon or soot on teeth, tongue or throat
     • Raspy, hoarse voice or cough
     • Stridor or inability to clear secretions may indicate impending airway occlusion;
     • Circumferential burns to neck
       
       
  4. Intubation may be necessary
     
     
• Insert Two Large Bore IV Catheters (in non-burned area if possible), if unable to get peripheral access and the patient must travel by air, place only femoral central line
• Insert Foley Catheter

3. Fluid Resuscitation & Percent of Burn

• Fluid Resuscitation: IV fluid required for fluid resuscitation is determined by size of burn and weight of patient in Kg’s
• Determine the percentage of burn using this table:
  • 4.5% face/neck 4.5% back of head
  • 9% left arm 9% right arm
  • 18% left leg 18% right leg
  • 18% anterior trunk 18% posterior trunk
  • 1% perineum 1% spotty areas*
    (*estimate the spotty areas by using the size of the patient’s palm as 1%)
• TBSA is different for children
• Calculate the fluid rate using this formula
  • Adults: 4 ml ringers lactate x Kg body weight x Percentage Burn equal amount of fluids to be infused in first 24 hours post burn injury; give the first half over the first eight hours, and the remainder over the next sixteen hours
  • Additional fluid is necessary for patients who were dehydrated before burns
  • Children over 10 years old:
    Use the same formula as above
  • Children under 10 years old:
    Formula used in pediatric patients calls for the administration of 5000 ml/m2 body surface area burn = 2000 ml/m2 BSA given over the first 24 hours after burn, with half the volume administered during the first 8 hours

4. Treat Concurrent Injuries

• Treat burn patient as trauma patient, check for:
  Head injury (Note: burns do not alter consciousness; if patient has limited response to stimuli, look for another cause, e.g. head injury, anoxia, intoxication or mental retardation)
  Fractures
  Spinal injuries
  Soft tissue damage
  Foreign bodies (especially in explosion)
• Proceed with emergency treatment of any concurrent injuries and prevent further injuries

5. Estimate Depth of Burn Injury

• Determine the probably depth of the burn injury using these guidelines:
  1st Degree (Partial Thickness) Reddened, painful, warm to touch, e.g. sunburn
  2nd Degree (Partial Thickness) Reddened, blistered, painful to touch, blanches to touch; when blisters debrided, weeps fluid from wound
  3rd Degree (Full Thickness) Black, brown, white or red leathery wound, firm in appearance; does not blanch and is not painful to touch
  4th Degree (Full Thickness) Charred appearance; burns that extend below the dermis and subcutaneous fat, muscle, bone or nerve

6. Obtain Patient History
Record the following information:

• How the victim was burned, was it an enclosed space
• Chemical burns – What was the agent
• How long ago did it happen
• What was the first aid given
• Concomitant injuries
• Allergies
• Medical/surgical history
• Current medications
• Drug and/or alcohol history

7. Determine Referral to Burn Center

• See American Burn Association referral criteria below; if any criteria met patient should be transferred to burn center as soon as possible

8. Pain Relief Measures

• Give all medication via IV route; give Morphine Sulfate (if not contraindicated) in the following proportions:
  Adults: 3-5 mg IV Q 10 minutes or prn
  Children: Titrate IV Morphine Sulfate by body weight (0.1 mg/Kg/dose) or consult burn care pediatrician
  Do not use ice/iced saline to comfort

9. Wound Care Measures

• Remove burned clothing or foreign debris
• Wound debridement not usually necessary at referring facility; discuss with local surgeon/burn center surgeon need for escharotomies in circumferential burns
• Wrap burned areas with clean/sterile gauze or sheets
• Elevate HOB and burned extremities to decrease swelling
• Do not apply ice, ointments, or creams
• Maintain body heat – wrap in blankets if necessary, prevent unnecessary exposure of the body

10. Other Interventions

• Labs: CBC, SMA18, ABG, Carboxy hemoglobin
• X-ray: CXR and any areas of suspected trauma
• Insert NG tube and decompress stomach if nausea and vomiting are present; if TBSA greater than 20% or if patient is to be transported by air, keep patient NPO
• Medications: Tetanus Toxoid/antotoxin as history indicates; Mannitol: if black, brown or absent urine, give Mannitol 25 gms IV STAT followed by NaBicarb 2amps (or appropriate dosage for age, size and electrolyte studies) to flush renal tubules and prevent renal failure; increase rate of IV fluids when Mannitol given; Antibiotics usually not given prophylactically
• Monitor patient’s blood pressure, breath sounds, apical and peripheral pulses every 15 minutes

American Burn Association Criteria for Injuries Requiring Referral to a Burn Center

The American Burn Association has identified the following injuries as requiring referral to a burn center after initial assessment and treatment at an emergency department:

1. Partial thickness burn > 10% total body surface area (TBSA)

2. Burns that involve the face, hands, feet, genitalia, perineum or major joints.

3. Third-degree burns in any age group.

4. Electrical burns, including lightning injury.

5. Chemical burns.

6. Inhalation injury.

7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery or affect mortality.

8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.

9. Burned children in hospitals without qualified personnel or equipment for the care of children.

10. Burn injury in patients who will require special social, emotional or long-term rehabilitative interventions.

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