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Guidelines for Burn Patient Referral

Developed to support clinical teams, these guidelines are intended to aid in referral decisions and should not be used as a substitute for professional judgment. If referencing or sharing these guidelines, please cite the American Burn Association as the original source.

If you have sustained a burn injury, please seek medical advice from a medical professional.


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Advice on Transfer and Consultation

These guidelines are designed to support healthcare professionals in making informed clinical decisions regarding burn patient referrals. They are not definitive care recommendations but may help support the development of an effective local referral network.

Local and regional infrastructure, available resources, and existing provider relationships may influence when and where referral to a burn center is appropriate.

For individuals with burn injuries, these guidelines are not intended for self-assessment. Patients should consult a qualified healthcare provider for medical advice.

 

Immediate Consultation with Consideration for Transfer Consultation Recommendation
Thermal Burns

Full thickness burns

Partial thickness ≥10% TBSA*

Any deep partial or full thickness burns involving the face, hands, genitalia, feet, perineum, or over any joints

Patients with burns and other comorbidities

Patients with concomitant traumatic injuries

Poorly controlled pain

Partial thickness burns <10% TBSA*

All potentially deep burns of any size
Inhalation Injury All patients with suspected inhalation injury Patients with signs of potential inhalation such as facial flash burns, singed facial hairs, or smoke exposure
Pediatrics (≤14 years, or <30 kg) All pediatric burns may benefit from burn center referral due to pain, dressing change needs, rehabilitation, patient/caregiver needs, or non-accidental trauma  
Chemical Injuries All chemical injuries    
Electrical Injuries

All high voltage (≥1,000V) electrical injuries

Lightning injury

 Low voltage (<1,000V) electrical injuries should receive consultation and consideration for follow-up in a burn center to screen for delayed symptom onset and vision problems

Burn Severity Determination

Superficial

  • Dry, red, easily blanching, sometimes painful

  • Example: Sunburn

  • NOT counted in calculations of total burn surface area (TBSA)

Superficial Partial Thickness

  • Moist, red, blanching, blisters, very painful

  • Counted in calculations of total burn surface area (TBSA)

Deep Partial Thickness

  • Drier, more pale, less blanching, less pain

  • Counted in calculations of total burn surface area (TBSA)

Full Thickness

  • Dry, leathery texture, variable color (white, brown, black), loss of pin prick sensation

  • Counted in calculations of total burn surface area (TBSA)

Percentage Total Body Surface Area (TBSA)

"Rule of Nines"

"Palmar Method"

Patient's entire palmar surface is approximately 1%.

What Is the Rule of Nines?

The Rule of Nines is a quick method used by healthcare professionals to estimate the total body surface area (TBSA) affected by a burn. This estimation helps guide initial fluid resuscitation, determine severity, and support decisions around referral and level of care. 

In adults, the body is divided into sections—each representing approximately 9% (or multiples of 9%) of the TBSA: 

  • Head and neck: 9% 

  • Each arm: 9% (4.5% front, 4.5% back) 

  • Each leg: 18% (9% front, 9% back) 

  • Front of torso: 18% 

  • Back of torso: 18% 

  • Perineum: 1% 

Key Notes:

  • The Rule of Nines is most accurate for adults. For children and infants, adjustments (such as the Lund and Browder chart) are recommended due to different body surface proportions. 

  • It is intended for initial assessment, not long-term care planning. 

  • Even small burns involving critical areas (face, hands, feet, genitalia) may require specialized evaluation regardless of TBSA. 

What Is the Palmar Method?

The Palmar Method is a quick way to estimate the size of small or scattered burn injuries when the total body surface area (TBSA) involved is less than 15–20%. 

This method uses the patient’s palm (excluding the fingers) as a reference. The palm is considered approximately 1% of the TBSA. 

When to Use It: 

  • For small burns or irregularly shaped injuries 

  • In pre-hospital or emergency settings where precision tools aren't available 

  • As a supplement to other TBSA estimation tools 

Key Notes:

  • The patient’s own palm is used for the most accurate estimate. 

  • Some variations include the palm and fingers together, which approximate about 0.8–1%—so it’s important to clarify what reference is being used in your setting. 

Copyright© 2025 American Burn Association.

The downloadable PDF of the ABA Guidelines for Burn Patient Referral may be distributed in its original form, in its entirety, without permission provided that attribution is given to the American Burn Association. All requests to edit, repurpose, or reprint require permission by emailing info@ameriburn.org with the details of the request.