The Triage, Treatment & Transfer of Burn Patients

Original Date: 05/2011 | Supersedes: 09/2013, 10/2017, 10/2020 | Last Review Date: 03/2024
Purpose: To provide a guideline for burn patient age

Guidelines:

Children (15 y.o. and younger)

Minor Burns- considered to be second-degree burns < 5% TBSA, which can possibly be managed as an outpatient. However, if there is any concern about the need for inpatient care or about appropriate outpatient care, the ER physician at the outside hospital where the patient was seen should call the MHH-TMC transfer center and speak to the Pediatric ER physician regarding follow-up versus transfer before discharging the patient home. If the patient is going to be discharged home, recommend that the patient’s burn wound are debrided as best as possible since this has been requested by the Pediatric Burn Surgeons.
Moderate burns- considered to be second-degree burns >5 % TBSA, but less than 10% TBSA, which may likely require transfer to a burn center for evaluation and possible admission. The ER physician at the outside hospital where the patient was seen should call the MHH-TMC transfer center and speak to the Pediatric ER physician regarding transfer.
Major Burns- considered to be second-degree burns >10% TBSA, have any component of third-degree burns, hand, perineum, face, electrical burns, inhalation injury, or any other burn that meets ABA criteria for transfer to a burn center. The ER physician at the outside hospital where the patient was seen should call the MHH-TMC transfer center and speak to the Pediatric ER physician regarding immediate transfer to the Pediatric ER at Children’s Memorial Hermann Hospital.
Burns >30% TBSA- All pediatric burns (<16 years old) should be directly transferred to Shriner’s Children’s Hospital in Galveston after calling their transfer center and discussing the case with the Pediatric ER physician. It is not necessary to contact the transfer center at MHH-TMC for these patients since it will delay appropriate transfer and care.

*** Patients with poly-trauma and major burn that would require transfer should have the trauma evaluation and management completed here. Once any emergency condition is managed, then transfer for definitive burn care can occur. Do not transfer a patient with major burns and a concomitant trauma emergency. An example would be an EDH and major burn. The EDH should undergo evacuation and ICU management here, followed by transfer when stabilized. Burn excision and wound coverage can be initiated here

Wound Care:

Wounds should be evaluated prior to consultation with the CMHH Pediatric ER physician so that an accurate assessment and triage may be made when discussing the patient.

If the Pediatric ER physician deems the patient appropriate for outpatient clinic follow up, the recommended wound care is:
- Clean wound daily with soap and water.
- Apply Polysporin and Xeroform.
- Wrap the dressing with dry gauze and secure.
If the Pediatric ER physician determines that the patient should be transferred to CMHH, the wounds should be covered with clean linen or sterile gauze so as to keep the patient warm.
- No topical antimicrobials or other dressings should be applied as the CMHH team will need to evaluate the wound.

Fluid Management:

Only patients with ≥20% TBSA burns need a formal fluid resuscitation. Patients with smaller burns may need fluid resuscitation based upon physician evaluation of volume status.

For ≥20% TBSA burns and prior to transfer to CMHH or Pediatric Surgery evaluation:

Age 5 years or younger: Isolyte or LR at 125 mL/hour
Age 6-13: Isolyte or LR at 250 mL/hour
Ages 14-15: Isolyte or LR at 500 mL/hour

*These volumes are not titrated and given until an accurate %TBSA can be calculated at CMHH*

For ≥20% TBSA burns and when at CMHH, once Pediatric Surgery has evaluated, debrided wounds, and accurately assessed TBSA, the starting fluid rate is calculated using the following formulas:

Children <30 kg: 3 mL/kg/%TBSA and maintenance fluid (D5 LR using the 4-2-1 formula)
Age <14: 3 mL/kg/%TBSA
Ages 14-15: 2 mL/kg/%TBSA

To calculate the starting fluid rate:

Multiply: appropriate formula multiplier (3 or 2 mL/kg/% TBSA x weight (kg) x %TBSA)
This volume is then divided by half.
This half is then divided by 8, giving the starting fluid rate in mL/hour.
Example: A 10-year-old child who weighs 40 kg suffers a 20% TBSA burn.
- 3 mL/kg/hour x 40 kg x 20% TBSA = 2,400 mL
- 2,400 mL divided by 2 = 1,200 mL
- 1,200 mL divide by 8 = 300 mL/hour starting rate
Example: A 6-year-old child who weighs 25 kg suffers a 20% TBSA burn.
- Resuscitative fluid:
  - 3 mL/kg/hour x 25 kg x 20% TBSA = 1,500 mL
  - 1,500 mL divided by 2 = 750 mL
  - 750 mL divide by 8 = 94 mL/hour starting rate
- Maintenance fluids
  - 40 mL/hour + 20 mL/hour + 5 mL/hour = 65 mL/hour of D5 LR

Fluid rate adjustment:

The starting rate of resuscitative fluids are then titrated hourly based upon urine output.

Goal urine output:

Weight ≤30 kg: 1 mL/kg/hour
Weight >30 kg: 0.5 mL/kg/hour

Maintenance fluids in children ≤30 kg are not titrated.

Do not bolus burn patients for any reason, including hypotension, early on in resuscitation. Hypotension can be managed with low dose vasopressors.