Burn injury centres: When and why to refer patients

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Managing and controlling these principles significantly decrease inflammation. Inflammation enhances hyper metabolism and muscle catabolism (Urden, Stacey & Louw 2018:841), that will ultimately decrease morbidity and mortality.  

Burn injuries mostly occur in the workplace, home and outdoors. Injuries could be accidental, due to self-harm or because of abuse or assault (Angelo, van Aswegen, Wilson, Grobler, 2022).  

Thermal burn injury often needs admission to a hospital due to a higher level of severity [Gauglitz & Williams. 2020]. A person who sustained a burn injury of 30% TBSA or more undergoes systemic changes that results in the development of complications (Anagelo et al 2022). 

Burn injuries are often not taken as seriously as other traumatic injuries. According to WHO, 11 million burn injuries occur internationally of which 180 000 result in death.  Men have a higher chance of sustaining burn injuries compared to women, but women have a higher chance of dying because of sustained burn injuries. It is there for imperative that burn injury patients are referred to hospital as soon as possible, to receive specialised care which will include early rehabilitation.  


Not all burn injuries warrant specialised care. Most minor burn injuries can be managed by the patient under the guidance of a physician or wound clinic registered nurse. The burn injuries that need specialised care is classified as major burn injuries. These are burn injuries of more than 20% of the total body surface area (TBSA). The following criteria should be considered for a burn injury as described by Kruger, Kowal, Bilir, Han, Foster (2020) and Gauglits & Williams (2020) and Urden et al (2018:842), to warrant admission to a specialised unit: 

  • Partial thickness burns injury
  • Full thickness burn injury
  • Burn injuries to the face, hands, feet, genitalia, perineum or major joints
  • Electrical burn injuries, including lightning
  • Inhalation injury
  • Chemical burn injuries
  • Any patient with pre-existing medical disorders that could prolong recovery
  • Burn injuries in children
  • Burn injuries to vulnerable people.


Inhalation injuries are acute injuries to the respiratory system as well as the lungs. Mucosal Injuries to the airways occur due to direct exposure to heat, harmful particles, or poisonous gases. These injuries lead to an inflammatory response resulting in vascular leakage and pulmonary oedema (American Burn Association, Burn incidence and treatment in the United States, 2016). 

Possible sign of inhalation burn injury will include: 

  • Burnt eyebrows and eyelashes
  • Singed nasal hairs
  • Hoarseness of voice
  • Stridor will be audible
  • Bronchospasm.

In the presence of any of the above signs and symptoms, inspect the airways and commence artificial oxygenation, anticipate possible loss of a functional airway, be prepared to place an artificial airway.   


Burn injuries are characterised by Australia and New Zealand Burn Association (ANZBA, 2021) under the following headings: epidermal; dermal and full thickness. Dermal burn injury can further be characterised as either superficial, mid or deep dermal injury. Burn injury is usually made up of a mixture of areas of different depths.  

Epidermal burn injury: Epidermal burn injury involves the outer layer of the epidermis. These burn injuries are red and painful but do not develop into blisters. When using the Nikolsky sign (a sign when rubbing the skin the top layer of the skin slips away from the lower layer of the skin), if the dermis shears, this is suggestive of a dermal burn (ANZBA, 2021). Healing of this burn injury occurs within three-seven days and no scar formation is visible. Healing occurs through regeneration from the epidermal layer. Epidermal burn injury is not included when calculation for fluid resuscitation is estimated. These types of burn injury do not usually require specialised hospital care. 

Dermal burn injury: Involves the epidermis and layers of the dermis. This is further sub divided into superficial, mid and deep dermal burn injury. 

Superficial dermal burn injury: This burn injury includes the epidermis and the superficial layer of the dermis (the papillary dermis). Blisters will form although not immediately after the injury. The epidermal layer covering the blisters is nonviable. Blister fluid results from the outpouring of inflammatory oedema from the viable base. The wound bed is pink and moist as there is adequate capillary refill present. These wounds are very pain full due to exposure of superficial nerves. They usually heal spontaneously due to epithelisation within 10-14 days. Permanent scarring may occur.  

Mid -dermal burn injury: This burn injury is a combination of superficial dermal burn and a deep dermal burn. At this level of the skin there are fewer surviving epithelial cells therefore epithelialisation is much slower. Capillary refill is delayed, and blisters may still be present. The burn is darker pink in appearance when compared to superficial dermal burn. When touching the burn area, pain will be experienced. Healing usually occurs within three weeks. Permanent scarring may occur.  

Deep dermal burn injury: This involves destruction of almost all essential structures of the skin that is needed for spontaneous healing. Wounds are dark red and blotchy in appearance because of haemoglobin leaking from red blood cells from damaged blood vessels. Capillary refill is absent. No spontaneous healing occurs. 

Full thickness burn injury: Both the epidermal and dermal layer of the skin is destroyed. These wounds appear white, dry, leathery or black. There is no capillary refill and no sensation. These injuries do not heal spontaneously. Deeper structures may be involved in this type of burn injury eg fat, muscle and bone. 


TBSA is the calculated value used internationally to estimate the extend of the burn injuries over the surface of the skin. The rule of nine is used to estimate a percentage of TBSA of an adult body (ANZBA, 2021).  

The following estimated divisions, in percentages, can be used, see figure 1. 

  • Head = anterior 4½% and 4½% posterior
  • Trunk anterior 18% and posterior 18%
  • Each arm = 4½% anterior and 4½% posterior
  • Perineum = 1%
  • Each leg [anterior 9% and posterior 9%] = 18%.

The pathophysiology of burns is characterised by Urden et al (2018) an inflammatory reaction leading to rapid oedema formation due to increased microvascular permeability, vasodilation and increased extravascular osmotic activity. These reactions are due to the direct heat effect on the microvasculature and to chemical mediators of inflammation. 

Systemic response 

Systemic response is described as the release of cytokines and other inflammatory mediators at the site of the injury and has a systemic effect once the burn injury reaches 30% of the total body surface area. 

Cardiovascular changes 

Cardiovascular changes are described as an increase in capillary permeability, resulting in loss of intravascular proteins and fluids into the interstitial compartment. Splanchnic and peripheral vasoconstriction occurs. A decrease in myocardial contractility occurs. These changes together with fluid loss from the burn wound results in systemic hypotension and end organ hypo perfusion. 

Respiratory changes 

 As a result of continuous inflammatory cytokine release, bronchoconstriction occurs with severe burn injury and can lead to adult respiratory distress syndrome. 

Metabolic changes 

The basal rate increases three-fold. This together with splanchnic hypo perfusion early and aggressive enteral feeding is indicated, to decrease catabolism as well as to maintain gut integrity. 

Immunological changes 

Non- specific down regulation of the immune response occurs disturbing both cell mediated and humoral pathways. 


Pathophysiological changes that occur in the burn wound is described by Urden et al (2018:841). During the first day after burn injury, three concentric zones of tissue injury characterised a full thickness burn: zones of coagulation; stasis and hyperaemia, see figure 2.  

Zone of coagulation occurs at the point of extreme damage. There is irreversible tissue loss due to coagulation of the essential proteins. 

Zone of stasis is characterised by decreased tissue perfusion. Tissue is possibly salvageable. The main aim of burn injury resuscitation is aimed at increased tissue perfusion to prevent irreversible damage from occurring, 

Zone of hyperaemia: tissue perfusion is increased in this most outer layer. The tissue will recover unless in the presence of severe sepsis or an extended period of hypo perfusion. These three zones of burn injury wound are three dimensional, and a loss of tissue in the zone of stasis will result in the wound deepening as well as broadening. 


Urden et al (2018:495) further state that burns injury patients may present with burns of different depth, size and mechanisms of injury. Other underlying factors could also be present that have an impact on top of the obvious burn injury. 

All patients with these injuries as well as co-morbidities should be seen early and referred to a burn specialised unit. 

  • ≥10 TBSA in adult patients
  • ≥5 TBSA in a child
  • ≥5% TBSA full thickness 
  • Burn injury to face, hands, feet, genitalia, perineum and major joints
  • Electrical burn injury (including lightning injury)
  • Chemical burn injury/inhalation injury
  • Circumferential burn injury to chest or limbs
  • Major trauma 
  • Inhalation injury
  • The elderly 
  • Non accidental injuries
  • Pregnancy
  • Pre-existing illness.


Due to the resource requirements and the intricacy in the management of severe burn injury it has led to the development of regional burn injury centres. These centres are equipped in dealing with minor as well as major burns and the team consists of the following members. 

Burn surgeons: The overall control and care of a severely burned patient lies with the admitting burn injury surgeon. These surgeons have experience in plastic surgery as well as general surgery. They have additional experience of burn injury surgery and critical care nursing. 

Nurses: Nursing staff accounts for the largest section of the burn injury multidisciplinary team. They are responsible for executing the daily care of burn injury patients. Burn injury nurses require a vast range of skills from the management of critically ill patients that are being ventilated in an ICU setting. Patients with renal support, advanced wound dressing techniques. Emotional support for patients as well as their families.  

Anaesthesiologist: The treatment of major burn injury present with a wide range of challenges from airway management, ventilation, heat and fluid loss, electrolyte imbalances and circulatory imbalances. 

The anaesthesiologist must have the knowledge to deal with any challenges relating to the pathophysiological changes related to burn injuries.  

Respiratory therapist: severe pulmonary injury due to inhalation injury, impaired ventilator mechanics as well as sepsis and the systemic inflammatory response is present post burn injuries. Through protocols the respiratory therapist can provide a range of skills to evaluate pulmonary mechanics, enhance ventilation and reduce complications. In the burn injury unit they are involved with airway management and diagnostic bronchoscopies in cases where inhalation injury is present, arterial blood gas assessment and optimising ventilation. 

Dietician: Due to elevated energy and protein demands, patients with major burn injuries require intensive nutritional support. Due to hyper metabolism and muscle protein catabolism that occurs in major burn injury, the proteolysis is increased by up to 50% and results in devastating losses in lean body mass. The dietician assesses each patient’s dietary needs and provides the nutritional recommendations and feeding regime to meet changing demands. All pre-existing medical conditions which may have an impact on the nutritional status of the patient is considered. Implementation of early feeding improve outcomes. 

Psychosocial support: Burn injury have a devastating impact on the emotional and psychological well-being of patients and their families. Psychologists, psychiatrists and social workers form part of the multidisciplinary team and they provide expertise in assisting patients and their families to cope with the effect of injuries as well as to manage the transition to come to terms with the grief and consequences of the injury. Disfigurement with the loss of facial and body image also needs to be addressed in early stages and continues long term. Nursing staff also require support from psychosocial experts whilst dealing with burn injury victims and their families. 

Physiotherapist and occupational therapist: Physiotherapy commences on day one with positioning and education to achieve the best outcomes. The occupational therapist suggests specific exercises to encourage motion of injured areas, the application of splints to stretch joints and limit contractures, massaging of scars, provide compression garments to flatten raised scarring.  


It is widely recognised that burn injury patients who are seen, assessed and treated in the appropriate facility will heal quicker than those patients where treatment was delayed. Early treatment does not only save lives but also improves patient outcome.  

With the increased understanding of the extent, severity and lengthy needs of burn injury patients, it is evident that specialised burn injury units are required to effectively address the needs of these patients. As the ‘golden hour’ exists for trauma patients whereby the urgent need for care at a preferred service centre needs to take place within the first hour post injury to prevent morbidity and mortality – the same applies to persons with burn injuries. Every delayed referral result in a delay in optimal care.   


Angelou, I.K., van Aswegen, H., Wilson, M. and Grobler, R. A profile of adult patients with major burns admitted to a Level 1 Trauma Centre and their functional outcomes at discharge: A retrospective review. South African Journal of Physiotherapy 2022:78:1543. 

Gauglitz, G.G. and Williams, F.N. Overview of complications of severe burn injury. UpToDate. 2020. Published March, 5. 

Kruger, E., Kowal, S., Bilir, S.P., Han, E. and Foster, K. Relationship between patient characteristics and number of procedures as well as length of stay for patients surviving severe burn injuries: analysis of the American Burn Association National Burn Repository. Journal of Burn Care & Research 2020:41;1037-1044. 

Emergency Management of Severe Burn. 2021: EMSB. Course Manual.19th edition. The Australian and New Zealand Burn Association Limited (ANZBA). 

Urden, L.D., Stacy, K.M. and Lough, M.E. Critical care nursing-e-book: diagnosis and management. Elsevier Health Sciences. 2018. 

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