Burn 1. Emergency Department Management, Initial Resuscitation and Transfer of Burn Trauma Patients
All other
burn patients should receive Alert Activation at the discretion of the ED
attending.
Transfer
Process/Responsibility:
·
Tier 1 (Trauma Alert RED) burn patient
transfers should be handled by TRAUMA.
·
Tier 2 (Trauma ALERT) and
NON-ACTIVATED burn patient transfers should be handled by EM.
·
Decision to transfer should be made
within 30 minutes of arrival.
·
All transfers should occur (departed the ED) within
120 minutes of initial arrival.
Consideration for Transfer vs Admission with consultation to PLASTICS:
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PLASTICS consultation:
If a burn patient did not
require critical care from the Blue Surgery Service and has no other traumatic
injuries, the plastic surgery consult resident should be notified to evaluate
the patient prior to discharge/transfer.
If, however, the burns are
very minor and the ED attending feels the injuries can be treated as an
outpatient without a plastic surgery consultation, clear wound care
instructions, plastic surgery contact information, and follow-up appointments
should be made prior to discharge.
Patient Care:
Evaluate the Airway &
Breathing: All patients receive 100% FIO2. If the patient
has singed nasal hairs, suspect an inhalational injury and consider intubation
vs close observation. Document the ETT size.
Evaluate the Circulation: Obtain
a manual blood pressure and place monitors as able to the skin. The
monitors may be stapled to the skin if necessary.
Evaluate the Burn Size: Notate
the degree and location of all burn area preferably with a burn
diagram. Turn the patient to evaluate the back and
perineum. Look for areas of circumferential burn and assess distal
pulses. Calculate the TBSA%; obtain the patient’s weight in kilograms, and the
time of injury.
Wound Care: Cover
the burns with sterile sheets and ensure that the burns are evaluated by the
plastic surgery team. Do not cover the wound with any topical agents
until ordered by the plastic surgery team.
Fluid Resuscitation: If
>20% TBSA burn, recommendations from the American Burn Association are that
referring facilities and EMS no longer need to calculate the Parkland
Formula. The current guideline is to run LR at 500ml/hr for people over
14 yrs, 6-13 years of age 250 ml/hr, and under 5 years of age 125 ml/hr.
Pain Control: If
intubated and normotensive, consider fentanyl and propofol gtts. If
intubated and hypotensive, consider fentanyl and versed or ketamine gtts.
Intubation RSI: Consider
etomidate and rocuronium. Succinylcholine is acceptable if the burn
is within 12 hrs.
Procedures: The
following procedures should be performed by a resident or attending in the ED
as part of the initial resuscitation if the patient is a red alert and
intubated:
1. CVL
in nonburn area (mandatory only if 20% TBSA or greater)
2. Arterial
Line
3. NGT
4. Bronchoscopy
to evaluate degree of inhalational injury if consideration of admission
6. CO
level should be ordered on all burn patients.
Escharotomies: If
the patient has circumferential extremity burns especially with diminished
distal pulses, notify the plastics or critical care teams to consider
escharotomies. If the patient has circumferential torso burns
especially with difficult ventilation, notify the plastics or critical care
teams to consider escharotomies.
Imaging: Burn
patients should be evaluated for other traumatic injuries especially if
involved in an explosion mechanism, MVC with fire or leapt from
height. These patients should be given consideration for pan-scan.
Disposition:
The intubated and
critically ill severely burned patient should be transferred.
If not severely burned but
critically ill from polytrauma or inhalation injury, the patient may be
admitted by Blue Surgery with Plastic Surgery consultation for wound
management.
Otherwise, the patient
will be admitted to Plastic Surgery.
For more
on standard burn care, see this web-based tutorial: http://www.basicburnsmanagement.com/
Transfer Facilities:
1. University
of Louisville (First Call)
2. University
of Cincinnati Burn Center, Cincinnati, OH
3. Vanderbilt
University Burn Center, Nashville, TN
Facility Contact
Information
First Call: University of Louisville Access Center 502-562-8008
Michelle.broers@uoflhealth.org
C. John Luttrell, BSN, RN
charles.luttrell@uoflhealth.org
Haily Smith BSN, RN, CCRN
Burn Educator and Resource Nurse Burn Program
Medical Director
Matthew Bozeman, MD
matthew.bozeman@louisville.edu
University of Cincinnati Transfer Center 513-584-2337
University Hospital Burn Center
Medical Director
Julia Slater, MD
For patients up to 18
years of age:
Shriners Children’s of
Ohio Burn Referrals 866-947-7840
One Children’s Plaza
2 West
Dayton, Ohio 45404
Vanderbilt University Transfer Center 615-875-4000
Vanderbilt Burn Center
1211 Medical Center Drive, Suite 11234
Nashville, TN 37232
For outpatient clinic visits: 615-936-2876.
Vanderbilt Outpatient Burn Clinic
1211 Medical Center Drive, Suite 11201
Nashville, TN 37232
Medical Director
Anne L. Wagner, MD
Transfer Facility
Communication: The responsibility of the transfer of critically
ill burn patients rests with the Trauma or EM Junior, Chief, Fellow or
Attending who will speak with an accepting physician at the receiving facility
to relay pertinent clinical data and arrange transfer logistics.
Transportation: Arrangements
should occur simultaneously with patient acceptance. The responsible provider
must determine the appropriate mode of transport (ground or air) and contact
Dispatch at 36215 to request transport.
Transfer Patient Care:
The patient will remain in the UK Emergency Department until transport facility
arrives with continued fluid resuscitation and patient care as recommended by
the receiving facility but directed by the Trauma & Critical Care Attending
along with the Plastic Surgery physicians.
If arrival of transport team is
greater than 1 hour, consider admission to the ICU for continued resuscitation
and monitoring until transfer can be completed.
Drafted December 22, 2011; Revised February 2024; Revised April 12, 2025 for Time to Transfer
Revised October 16, 2025 (C Reynolds) for Burn transfer PI process.
