Chapter 1: Admit To

ADMIT TO:  ____ICU

                                    ____FLOOR STATUS

Most burn victims can be treated as outpatients.  Less than 20% of these patients require admission. 

Who really needs to be admitted? 

Do they need intensive care?

Both questions need to be addressed early.  Indeed, the level of care afforded to the burn patient in the first eight hours will determine life or death. 

Admit the Following:[i]

1) Patients requiring iv access- Intravenous fluid resuscitation is required for all patients with 2^nd and 3^rd degree burns grater than 10% of the total body surface area in patients under 10 or over 50 years of age, and in those burns greater than 20% of the total body surface area in other age groups.

2) Anticipated surgery- Patients with deep burns will require admission for possible excision and grafting. 

3) Respiratory problems- Patients who have been intubated at the referring facility or who require intubation and ventilatory support will require admission.  In addition, have a high index of suspicion for the presence of inhalational injury in the following situations:

·        history of fire in enclosed spaces

·        presence of stridor

·        singed nasal and/or eyebrow hairs

·        deep burns to the face

4) Special nursing issues- any patient with wounds requiring difficult and/or painful dressing changes will usually require admission.  Burns of the face, hands, feet, perineum and genitalia are included.  Likewise patients with families unable to adequately care for the burn wound should receive special training and/or home health care services. 

5) Special burn injuries

a) Chemical injury - Most chemical burns are often more severe than the initial examination would suggest.  Unlike thermal burns, tissue destruction can occur for many hours after injury.  Patients with chemical burns should be admitted if:

·        the injuries are deep and will require excision

·        systemic manifestations of chemical toxicity are present

·        the chemical responsible for injury requires a specific antidote

b) Electrical injury - The following patients require admission for 24-hour monitoring: 

·        documented cardiac arrest at the scene,

·        cardiac arrhythmia noted at any point prior to admission to burn unit,

·        abnormalities on 12-lead EKG.

c) Exfoliative skin disorders- includes toxic epidermal necrolysis syndrome (TENS) and Stevens-Johnson syndrome.  Patients with these disorders often require intensive care for the systemic manifestations of the disease as well as wound care.

6) Domestic violence - Every state requires physician to report all suspected child abuse cases.  Admission of the child to the burn unit affords protection.  The burn physician in these situations also functions as facilitator, ensuring that the full work-up for child abuse cases has been completed.  This includes confirming that the appropriate skeletal x-ray surveys, rape kit tests, head CT, etc. have been performed.  Similar attention is given elderly abused burn patients. 

Should you admit to the ICU or the ward?

There are well-defined medicine intensive care unit admission criteria.[ii]  Unfortunately none exists for burn patients.  To qualify for admission to the ICU, patients should require hourly vital signs and urine output recordings at least every two hours. 

This applies to all patients who are unstable or potentially unstable.  It includes:

·                    all burn patients requiring IV fluid

·                    inhalational injuries

·        chemical injuries with systemic manifestations of toxicity

·        electrical injuries

·        medical conditions and

·        associated trauma (bone fractures, sub- or epidural hematomas, abdominal blunt or sharp injuries

Management of the outpatient:

After burn wound assessment, it often becomes evident that the burn itself will not require inpatient admission.  If no other injuries are discovered, the patient may be sent home.             Patients sent home should be told the signs and symptoms suggestive of wound infection: 

·        swelling and erythema

·    fevers, chills, nausea, emesis

·    increased serous wound drainage

·    the presence of frankly purulent wound drainage 

If any of the above is present, the patient or family should seek medical attention. Superficial wounds that will heal spontaneously should be followed weekly in the burn clinic for at least two weeks.  Patients should be informed that there would be a difference in skin color between the healing burn and normal skin for at least 6 months to 1 year as the wound matures.  They should avoid sun exposure to the burn wound during this time and wear heavy sunscreen (i.e. SPF of 45 or greater) during the sunny months as ultraviolet light which will darken the burned area). Adequate a analgesic medication should be prescribed and for hand burns or burns over a joint surface, patient should be shown simple range-of-motion exercises