BURNS in CHILDREN

INRODUCTION
• Skin and underlying tissues can be destroyed by thermal, chemical, or
electrical injury. Burns are open wounds.

• As in other injuries, initial treatment is aimed at saving the patient’s

life. Then the treatment is directed toward preserving or restoring to
normal, or as nearly normal as possible, the patient’s bodily functions
and appearance as rapidly as possible.

• The pathophysiology of burn injury is caused by disruption of the

three key functions of the skin: regulation of heat loss, preservation
of body fluids, and barrier to infection.
• Burn injury releases inflammatory and vasoactive mediators resulting in
increased capillary permeability, decreased plasma volume, and decreased
cardiac output.

• The body then becomes hypermetabolic with increased resting energy

expenditure and protein catabolism. This hypermetabolic state may
continue for up to a year after injury.

• Burns usually are classified on the basis of four criteria:

• 1. Depth of injury
• 2. Percent of body surface area involved
• 3. Location of the burn
• 4. Association with other injuries
 CLASSIFICATION OF BURNS
• The severity of the injury is determined by the location and the cause of the burn.
The Abbreviated Burn Severity Index (ABSI) is a five-variable scale used to
evaluate burn injury severity and the probability of survival.

• The five variables are sex, age, presence of inhalation injury, presence of full-
thickness burn, and percentage of total body surface burned

• The depth of injury should be assessed by the clinical appearance. Categories of

first-degree, second-degree, and third-degree are commonly used;

• however, classification by depth (superficial, superficial partial-thickness, deep

partial-thickness, and full-thickness) conveys more information about the
structures injured and the likely need for surgical treatment and may be more
clinically useful.
• First-degree superficial burn: Only the outer layer of the epidermis is
involved in a first-degree burn. Superficial erythema, redness of the
skin, and tissue destruction occur, but healing takes place rapidly

• Superficial (first-degree) burns are red, painful, and dry. Commonly

seen with sun exposure or mild scald injuries, these burns involve
injury to the epidermis only.

• They heal in 2 to 5 days without scarring and are not included in burn
surface area calculations
• Superficial partial-thickness (second-degree) burns involve the entire
epidermis and superficial dermis. These burns have fluid-containing blisters.
• After debridement the underlying dermis will appear erythematous and
wet, will be painful, and will blanch under pressure.
• Healing is dependent on the uninjured dermis and usually occurs within
about 2 weeks without the need for skin grafting and without scarring.
• Deep partial-thickness (also second-degree) burns involve the entire
epidermis and deeper portions of the dermis.
• These burns may also have blistering, but the dermal base is less blanching,
mottled pink or white, and less painful than superficial partial-thickness
burns.
• They behave more like full-thickness burns and will often require excision
and grafting.
• Full-thickness (third-degree and fourth-degree) burns involve all skin
layers.
• They appear dry, white, dark red, brown, or black in color. They do
not blanch and are usually insensate. Full-thickness burns require
surgical management.
• Fourth-degree burns involve underlying fascia, muscle, or bone and
may require reconstruction in addition to grafting.

• Inhalation injuries should be suspected if there are facial burns,

singed nasal hairs, or carbonaceous sputum.
• Hoarseness on vocalization also is consistent with a supraglottic
injury. Inhalation injuries may result in bronchospasm, airway
inflammation, and impaired pulmonary function.
 BURN AREA CALCULATION
• There are multiple methods and charts available for calculating the percentage of skin surface
involved in a burn.
• 1. Small areas: The area of patient's hand (including palm and extended fingers) equals 1% of
BSA

• Rule of Nines The body surface of an adult can be divided into areas equal to multiples of 9% of
the total body surface that may be used for children of various ages is the extent of skin
involvement of older adolescent and adult patients may be estimated as follows:

• 9 % each upper extremity, 9%; each lower extremity, 18%; anterior trunk, 18%; posterior
trunk, 18%; head, 9%; and perineum, 1%.

• The location of the burn is important in assessing the risk of disability. The risk is greatest when
the face, eyes, ears, feet, perineum, or hands are involved.
• Inhalation injuries not only cause respiratory compromise but also may result in difficulty in
eating and drinking.
 LABORATORY AND IMAGING STUDIES
• Initial laboratory testing, including complete blood count, type and crossmatch
for blood, coagulation studies, basic chemistry profile, arterial blood gas, and
chest radiograph, can be helpful for patients with major burns.

• A carboxyhemoglobin assessment should be performed for any suspected

inhalation exposure (a house or closed-space fire or a burn victim who requires
cardiopulmonary resuscitation).

• Cyanide levels should be considered in children who sustain smoke inhalation

and have altered mental status.
• Unusual patterns of burns may increase suspicion of child abuse and result in
appropriate evaluation to assess for nonaccidental trauma to the skeleton or
central nervous system.
TREATMENT
• For severe burns, care is best managed by a multidisciplinary team in a qualified
burn center.
• The American Burn Association criteria for patients who should be transferred
to a burn center are:
• partial and full-thickness burns greater than 10% total body surface area (TBSA)
in patients less than 10 years old or more than 50 years old, or greater than 20%
TBSA in other age groups;
• partial and full-thickness burns involving the face, hands, feet, genitalia,
perineum, or major joints;
• electrical burns; chemical burns; inhalation injury;
• burn injury in patients with preexisting medical conditions that could complicate
management, prolong recovery, or increase mortality rate;
• burn injury in children admitted to hospitals without qualified personnel or
equipment for pediatric care;
• burn injury in patients requiring special social, emotional, or rehabilitative
support, including child abuse cases.
 Initial Care of the Burn Patient
• Initial treatment should follow the ABCs of resuscitation.

• 1. Stop the burning process: All clothing, jewelry, and metal and synthetic
objects in contact with the patient’s skin are removed.
• 2. Ensure a patent airway:
• Airway management should include assessment for the presence of airway
or inhalation injury, with early intubation if such an injury is suspected.
• Smoke inhalation may be associated with carbon monoxide toxicity; 100%
humidified oxygen should be given if hypoxia or inhalation is suspected.
• The systemic capillary leak that occurs after a serious burn makes initial fluid
and electrolyte support of a burned child crucial
• 3. Establish IV fluid therapy:

• The first priority is to support the circulating blood volume, which requires
the administration of intravenous fluids to provide maintenance fluid and
electrolyte requirements and to replace ongoing burn-related losses.

• Blood samples are drawn for laboratory analysis and type and
crossmatching when a venipuncture or cutdown is performed to establish
an IV route for fluid and nutritional administration.
• Fluid and electrolyte balance must be restored as quickly as possible.
• Fluid, electrolytes, and protein are lost through changes in capillary
permeability, causing intravascular volume shifts to interstitial tissues.
• Fluid shifts are directly proportional to the depth and extent of the burn.
Several formulas for determining fluid replacement have been developed
to maintain plasma volume during the first 24 hours
• Formulas exist to help guide fluid management; however, no formula
accurately predicts the fluid needs of every burn patient.
• Children with a significant burn should receive a rapid bolus of 20 mL/kg of
lactated Ringer solution. There after, the resuscitation formula for fluid
therapy is determined by the percent of body surface burned.

• The calculated fluid replacement time begins at the time of injury, not when
the patient arrives in the emergency department. A crystalloid solution of
Ringer’s lactate is infused initially because its hypertonic state decreases
fluid loss from the intravascular space. Colloid-containing fluid, fresh frozen
plasma, and other nutrients may be infused after the first 24 hours.
• (1) Consensus formula. The estimated crystalloid requirement for the
first 24 hours after injury is calculated on the basis of patient weight
and BSA burn percentage.
• Lactated Ringer solution volume in the first 24 hours = 2 to 4 mL ×
%BSA (second-, third-, and fourth-degree burns only) × body weight
(kg).
• One-half of the calculated volume is given in the first 8 hours after
injury, and the remaining volume is infused over the next 16 hours.
• Fluid resuscitation calculations are based on the time of injury, not
the time when the patient is evaluated
• Fluids should be titrated to achieve adequate perfusion, one marker of which is
urine output greater than 1 mL/kg/hour.

• Colloid therapy may be needed for patients with extensive burns.

• Because burn injury produces a hypermetabolic response, children with

significant burns require immediate nutritional support.

• Enteral feeds should be started early unless there is a specific contraindication.

• Children with critical burn injury may require parenteral nutrition if unable to
tolerate full enteral feeds.
• Consider supplementation of vitamins and trace elements.
• 4. Insert an indwelling Foley catheter: Urine specimens are sent for
analysis. Urine is checked for pH and specific gravity at frequent
intervals.
• The hourly output is recorded. Adequate fluid replacement should
maintain an output of at least 30 mL/hr.

• 5. Cleanse the wound: All burns are treated aseptically. A mild

cleansing agent, such warm water or saline solution are used to
gently remove debris and loose, devitalized tissue.

• Copious amounts of water, along with appropriate neutralizing

agents, are used to cleanse and irrigate chemical burns. After
cleansing, wet sheets under and around the patient must be removed
and dry, and sterile ones applied.
• 6. Assess the patient’s preexisting medical history and other injuries: The
patient may have a chronic illness, such as diabetes or heart disease, that
must be stabilized as part of the treatment regimen.
• The patient may have suffered other injuries in the accident causing the
burn. Abuse may be suspected, particularly in a child or older person.
• Appropriate interventions must be taken. The burn may not be the first
priority if, for example, the patient has a head injury, ruptured internal
organs, or fractures.
• 7. Prepare the patient for transport: The patient may go from the
emergency department directly to a burn unit, the OR, or some other care
area.
• The attending physician may initiate therapy before referral to a plastic
surgeon.
• If available, hyperbaric oxygen (HBO) therapy may be used. HBO produces
marked vasoconstriction, decreasing the loss of serum through the burn
surface. This may reduce the need for fluid replacement.
• Dressing changes Occlusive dressings, if used, must be changed frequently
to control infection harboring under them. An antimicrobial or
chemotherapeutic agent may be applied as an integral part of the dressing.
The following considerations apply:
• 1. Silver sulfadiazine (Silvadene 1%) cream applied directly to the burned
area makes removal of a dressing less painful and does not disturb the
healing process as it is removed.
• It is an effective topical antimicrobial and produces no metabolic side
effects; some patients have developed neutropenia and delayed wound
healing after its use.
• A layer of fine mesh gauze is laid over it (unless the open-exposure method
will be used for further healing).

• Then soft, absorbent material, such as fluffed gauze, and a preformed

splint may be used. These are held in place by a cotton elastic bandage.
• Mafenide acetate (Sulfamylon 5%) cream penetrates intact eschar
rapidly and is quite successful in reducing bacterial counts to optimal
levels for skin grafting.
• Application directly on the burned area is painful for the patient after
cleansing and debridement.
• Absorption may result in metabolic acidosis; thus the acid-base
balance must be closely monitored. Prolonged use may lead to renal
or pulmonary complications.
• Sulfamylon is available in a topical solution form. It is supplied in a 50-
g package that can be added to a 1000-mL bottle of sterile saline or
water for irrigation.
• Once prepared, the solution should be discarded after 48 hours. The
solution is used to keep grafted skin dressings moist.
• Silver nitrate solution 0.5% in sterile distilled water is used
infrequently. After cleansing and debridement, multiple-thickness
dressings are applied to the area.

• These are kept saturated with 0.5% silver nitrate solution and
changed every 12 hours. For debridement, sterile distilled water is
used for irrigation because saline may cause the precipitation of silver
salts.

• Care is taken to avoid splashing silver nitrate solution onto walls and
floors because staining can occur.

• If disposable drapes and gowns are not used, stained linen must be
laundered separately from other linen
• Wound care starts with cleaning and debriding the wound. Effective pain
control is important to allow for complete debridement.

• Topical agents and dressings are then applied to control bacterial

colonization, decrease evaporative losses, and aid in pain control.

• Commonly used topical agents include silver sulfadiazine or, if the burn is
shallow, polymyxin B/bacitracin/neomycin (Neosporin) ointment.

• Silver nitrate and mafenide acetate (Sulfamylon) are alternative

antimicrobial agents. Sulfamylon has the benefit of penetrating eschar, but it
is painful and can cause metabolic acidosis. Silver nitrate is used less
commonly because of poor tissue penetration and potential for electrolyte
abnormalities.
 COMPLICATIONS
• Sepsis Monitor for infection,
• Hypovolemia Fluid replacement
• Hypothermia Adjust ambient temperature: dry blankets in field
• Laryngeal edema Endotracheal intubation, tracheostomy
• Carbon monoxide poisoning 100% oxygen, hyperbaric oxygen
• Cardiac dysfunction Inotropic agents, diuretics
• Gastric ulcers H2-receptor antagonist, antacids
• Hypermetabolic state Enteral and parenteral nutritional support
• Renal failure Supportive care, dialysis
• Anemia Transfusions as indicated
• Pulmonary infiltrates ventilation, oxygen
Pulmonary edema Avoid overhydration, give diuretics
Pneumonia Antibiotics
Bronchospasm β-Agonist aerosols
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