TRIAGE CRITERIA AND CARE PLANS

Triage criteria Care plan

Minor burns/non-critical sites: Dress wounds; tetanus prophylaxis;

<10% TBSA for children outpatient care

<20% TBSA for adults

Minor burns/critical sites (hands, face, Admit, early operations, special wound care,

perineum) short hospital stay

20–60% TBSA burned Requires intravenous fl uids/careful monitoring;

burn unit trained personnel

Extensive burns (>60% TBSA burned); Mortality high; may be placed in expectant

inhalation injury/associated trauma; associated category; pain medication; psychological

medical illnesses support

Minor burns; inhalation injury; associated Administer oxygen; measure

injuries carboxyhemoglobin; + or − intubate;

ventilate; care of associated injuries[1]

Assessment of burn depth

Clinical observation

Burn injury may involve one or both layers of the skin, and

may extend into the subcutaneous fat, muscle, and even bony

structures.40 Burns involving only the epidermis are erythematous

and very painful but do not form blisters. Most sunburns

fi t this category of superfi cial, epidermal injury. Within 3–4

days, the dead epidermis sloughs and is replaced by regenerating

keratinocytes.

Superfi cial dermal burns extend into the papillary dermis

and characteristically form blisters. Blistering may not occur

immediately following injury and burns thought to be superfi -

cial may subsequently be diagnosed as dermal burns by day.2

Once the blister is removed from a superfi cial partial-thickness

burn, the wound is pink, wet, and hypersensitive to touch.