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CHAPTER5 The burns management pathway I
Referring patients toa specialist
burns unit
All patients with burns injuries may be discussed with a specialist burns
team. In the UK, the National Network for Burn Care has produced guidelines for the referral of burns to specialized burn care services, which are
provided in Appendix 2.
Essential referral information toensure
safe patient transfer
Once the decision has been made to transfer the patient, this should
be undertaken promptly and safely to minimize the risk of the patient
deteriorating en route to the burns unit, on what may be a long distance or
cross- regional transfer.
The referring member of sta should ensure that:
• The transfer proforma is completed
• Any pre- transfer assessments and treatments requested by the specialist
burns team have been undertaken
• The patient is reassessed systematically to conrm that their airway
remains patent and that their physiological status has not changed since
initial presentation
• Appropriate uid resuscitation has been initiated and will continue
during the transfer
• Initial rst aid adjuncts applied to cool the patient (such as cold packs)
have been removed after the rst 30 minutes to prevent hypothermia
• The transferring ambulance crew has the appropriate equipment and
expertise, with an accompanying medical escort if indicated.
• Copies of all medical notes, drugs and uid charts, investigation results
and imaging are sent with the patient
• Priority is given to arranging a speedy transfer to a burns service with an
available bed, while maintaining the patient’s body temperature
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Chapter6
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The burns management
pathway II:receiving
and initially managing a
patient withburns
The burns multidisciplinary team 44
Receiving and accepting an acute burn referral 46
Admitting and assessing the burns patient following transfer 50
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Chapter6 The burns management pathway II
The burns multidisciplinary team
Medical
One or more specialist burns surgeons should lead the multidisciplinary
team that cares for burns patients. Junior medical sta will be actively involved in care delivery and training.
Nursing
Experienced specialist burns nurses should lead a team of dedicated nursing
and ancillary sta responsible for ward- based patient monitoring and care,
as well as outreach in some circumstances.
Intensive care and anaesthesia
One or more specialist burns anaesthetic and critical care doctors should
be an integral part of the team. Their role includes initial airway assessment
and management following transfer, providing supportive care to help prevent and treat single or multiple organ dysfunction and sepsis, and pain management. Specialist anaesthetic management during burns surgery is vital as
it presents unique challenges.
Operating theatre
Burns surgery should be undertaken in a dedicated operating theatre with a
specialist surgical, nursing, and ancillary team that regularly dresses, excises,
and grafts acute burns injuries, performs associated procedures such as
tracheostomy, and undertakes secondary burns reconstruction. Specialist
equipment including that required to warm the patient (overhead heaters,
climate controlled heating) is a prerequisite of a burns operating theatre.
Rehabilitation
Specialist rehabilitation is essential following a burns injury to minimize recovery time and optimize the functional outcomes attained. Burns physiotherapists work collaboratively with medical and nursing sta to ensure
active and passive mobilization and early and optimal functional recovery.
Occupational therapists undertake numerous activities including splinting,
pressure garment provision, and discharge planning. Play specialists may also
help to rehabilitate children.
Clinical psychology
Specialist clinical psychologists are important in helping to assess and
counsel burns patients for both pre- existing psychological conditions and de
novo problems related to their injury, its aetiology and its sequelae. Liaison
with psychiatric services is often required.
Dieticians
Nutritional support is critically important in the burn population, many of
whom require supplemental feeds. These are usually provided through gastric or jejunal feeding tubes but occasionally via a parenteral route.
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THE BURNS MULTIDISCIPLINARY TEAM
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Chapter6 The burns management pathway II
Receiving and accepting anacute burn
referral
Burns referrals are generally taken via telephone by the burns unit medical
and/ or nursing sta. As the experience of these sta members may vary, it
is helpful to use a standardized proforma to collect information about the
patient, their burns and any associated injuries, the treatments provided and
their planned transfer (Appendix 1). Written criteria for accepting a referral
should also be available to these members of sta (Appendix 2).
Essential referral information tocollect and record
• Patient name and date of birth
• Contact details of referring unit and individual
• Time of referral
• Date and time of burns injury plus uid administered so far
• Mechanism of burns injury (including any inhalational component,
associated injuries or acute medical issues)
• First aid administered at time of injury
• Estimated burn percentage (of total body surface area)
• Patient weight in kilograms
• Assessments and investigations completed and current physiological
status (eg. results of primary and secondary survey, bloods, ECG,
radiographs, scans)
• Treatments initiated and completed (eg. intubation, supplemental
oxygen, intravenous access and uid administration, analgesia, human
tetanus immunoglobulin, burns irrigation, specic antidotes, and
dressings)
• Specic concerns (eg. circumferential burns to trunk or limbs, associated
injuries requiring urgent denitive treatment)
• Remember AMPLE (allergies, medication, past medical history, last ate
and drank, events)
• Any patient with suspected inhalation injuries must be assessed by an
anaesthetist prior to arranging a transfer. This includes transfers to the
burns unit from an on- site emergency department
• The information above should be recorded by the member of sta
taking the referral; the standardized proforma in Appendix 1 may be
used for this purpose.
Prior to accepting any burn for admission, the accepting clinician should
liaise with the burn unit and/ or the intensive care unit (ICU) to ensure that
there are available beds. Auseful algorithm for this process is provided in
Fig. 6.1.
If an appropriate bed is not available at the closest burns unit, the burn
clinician should suggest that the referrer contact the National Burns Bed
Bureau (if in the UK) or the equivalent national or regional coordinating
body to nd the nearest available specialist burns unit bed.
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RECEIVING AND ACCEPTING ANACUTE BURN REFERRAL
Referral received
Meets criteria (appendix 1)
for complex burn?
Yes
Any suspected
inhalation injury?
Yes
Ensure anaesthetic review
completed at referring unit
Liaise with ward/ICU sta: is
there a bed available?
Document time patient
accepted for transfer
Exchange patient details &
contact details
Does the patient still need to be
transferred?
Ensure follow-up plans
NoYes
Advise to contact national
burns bed bureau
Fig.6.1 Accepting a burns patient for admission.
Ensuring safe patient transfer
Once the decision has been made to accept the patient by a burns unit, care
should be taken that the transfer is undertaken promptly and safely.
The receiving member of sta should ensure that the transfer proforma
is completed, and that any pre- transfer assessments and treatments requested by them have been undertaken by the referring team (Appendix 1).
They should conrm that the patient’s airway remains patent and that
their physiological status has not changed since the initial referral.
Care should be taken to ensure that appropriate uid resuscitation has
been initiated and will continue at the correct rate during the transfer, and
that the transferring ambulance crew has the appropriate equipment and
expertise, with accompanying medical escort if indicated.
The referring team should be reminded to send copies of all medical
notes, investigation results and imaging to the receiving burns unit with the
patient.
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No
NoNo Yes
are made
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Chapter6 The burns management pathway II
The aim is to minimize the risk of the patient deteriorating en route to
the burns unit, on what may be a long distance or cross- regional transfer.
Over- resuscitation is common due to over- estimation of the burn surface area.
Monitor urine output during a long transfer and alter the rate of uid administration as required.
The priority is to get the patient to the burns unit as quickly and safely
as possible, while minimizing delays and preventing cooling of the patient
during the transfer.
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RECEIVING AND ACCEPTING ANACUTE BURN REFERRAL
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Chapter6 The burns management pathway II
Admitting and assessing theburns
patient following transfer
Upon arriving at the burns unit, the patient should be assessed through a
formal and systematic process that includes
• Aspecialist medical assessment (to include a complete ATLS primary
and secondary survey and formal anaesthetic review of the airway and
ventilation if indicated)
• Re- assessment of the burns depth and extent (including any
circumferential injuries). Exposure and rolling is essential to ensure
accurate TBSA
• Any routine investigations not already undertaken
• Cleaning, photography, microbiology swabs and denitive dressing of
the burns wounds
• Warming of the patient if required
• Re- calculation and implementation of uid resuscitation if required
• Treatment of any associated injuries or comorbidities
• Initiating prophylaxis for deep vein thrombosis
• Administering appropriate analgesia
• Prescribing the patient’s regular medication
• Nutritional assessment and supplementation if required
• Initiating prophylaxis for stress ulceration if required
• Assessment and treatment of any drug or alcohol withdrawal needs
• Tetanus prophylaxis
Admission proforma
With frequent changeover of junior sta and cross- cover arrangements out
of hours, burns units are often faced with medical sta members who may
be inexperienced and unfamiliar with the unit’s protocols.
Burns units should therefore consider using a proforma to help ensure
that any required information is collected and that all components of the
standard management plan are instituted.
A suggested admission proforma based on existing versions currently in
use in the United Kingdom is available in Appendix 3.
Routine blood tests
The blood tests in Table 6.1 are recommended when a burns patient arrives
on the specialist burns unit.
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ASSESSING THE BURNS PATIENT FOLLOWING TRANSFER
Table6.1 Routine blood tests
Haematological Biochemical
Full blood count
Ferritin
Folate
Vitamin B12
Coagulation screen
Group and save
Cross- match as indicated
Urea and electrolytes
Estimated glomerular ltration rate
Bicarbonate
Magnesium
Calcium
Zinc
Phosphate
Glucose
Liver function tests, including:
Albumin
Protein
Globulin
Enzymes
Arterial blood gases if inhalation injury, and a
carboxyhaemaglobin level
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