Emergency Care of Pediatric Burns
Emergency Care of Pediatric Burns
Author: Charles Stewart, MD, FACEP, Emergency Physician, Colorado Springs, CO.Peer Reviewer: Perry Stafford, MD, FACS, FAAP, FCCM, Director, Trauma and Surgical Critical Care, Children’s Hospital of Philadelphia, PA.
Thermal burns are perhaps the most devastating injury suffered by an individual. The skin separates us from our environment. It provides the bulk of cooling from the stress of heat, regulates the egress of bodily fluids, and prevents outside agents and bacteria from entering the body. It is the largest organ in the body. When the skin is broached by a burn, we lose some or all of these factors to some degree, depending upon the extent of the burn.
The emergency care provider may find caring for the burned child to be stressful, frightening, and even repugnant.
This article reviews current assessment and management strategies for pediatric burns.
— The Editor
Demographics of Burns in Children
Among the environmental injuries sustained by man, by far the most common are thermal burns. The National Consumer Commission has estimated that at least 2 million people in the United States are burned each year. Of these patients, some 100,000 will require hospitalization, and about 12,000 will die.1 Burns are not only common, they also can be lethal. While a minor burn requires little treatment, a 20% full-thickness burn is an injury equivalent to having both legs crushed.
About 440,000 children will receive treatment each year for burn injuries.2 Young children and older adults have a higher fatality rate than older children and adults for the same degree and extent of burn, although survival has improved for children younger than 4 years.3,4 The reason for the higher mortality rate in young children is not clear, although it may involve less physiologic reserve, more extensive damage with thinner skin, less margin for error in fluid management, and technical difficulties with vascular access.
Indeed, children younger than 6 have more burns than any other age group. Burns ranked third as a cause of childhood injury-related mortality in both Canada and the United States.5,6 Children are most often victims of scald and contact burns, smoke inhalation, and electrical burns.7,8 Structural fires account for 45% of burn-related deaths, and burns are the leading cause of childhood injury-related death within the home.9 African American and Native American children are at higher risk of death or injury from burns compared to white children. Both low income and poor quality housing have been blamed for this. Use of alternative heating sources may contribute to the disparity.10
Survival of the burn patient is dependent upon the amount and depth of the burn, the age of the patient, and other associated injuries.11 Determining the degree of injury in a given patient helps when deciding where to transport the patient, the appropriate level of care, and immediate focus of therapy.
Age 0-2
The young child is at greatest risk to sustain a scald burn. Scald burns fall into two categories: kitchen scalds and bathroom scalds.
With scald burns, the magnitude of injury depends upon the heat transferred from the liquid. This, in turn, depends on the specific heat of the liquid (the amount of heat needed to raise a certain volume of liquid a specific number of degrees). A higher specific heat means that the liquid’s capacity to store and release heat is greater. Water has a higher specific heat than most substances found in nature. The heat stored in even small quantities of hot water is sufficient to cause thermal injuries in children. The maximum temperature that liquid water can attain at sea level is 100°C (212°F). Other liquids, such as tar, sulfur, or molten metals, can attain higher temperatures. Sulfur and tar also have higher specific heats than water; thus, the burns from these two substances can be severe.
The length of time a liquid is in contact with the skin also is important. At temperatures greater than 70°C (158°F), water can cause complete necrosis of the epidermis in less than two seconds. It is fortunate that water is not particularly viscous and flows unless impeded by clothing. With immersion scalds, the duration of contact between the hot liquid and skin is considerably longer than when water splashes onto the skin. Consequently, the resulting injury is more severe.
Kitchen scalds are the most dangerous. Grabbing a dangling cord attached to a frying pan, deep fryer, slow cooker, or electric kettle can bring extremely hot water or grease down on a toddler. Pulling a parent’s coffee or other hot beverage off the table may scald both child and parent alike.
Bathroom scalds occur from hot tap water. These may occur whenever the water temperature is greater than 128°F. Indeed, when the water temperature is 150°F or greater, a scald burn may occur in less than two seconds. On the other hand, it takes more than five minutes exposure to water of 120°F to cause a scald burn. Simply setting the hot water heater temperature at 120°F can prevent the vast majority of these burns.12
Although infrequently reported, aspiration of hot liquid can occur in conjunction with upper-body scald burns, leading to acute compromise of the small pediatric airway.13 If the early, subtle signs of airway compromise are neglected, the child may develop severe respiratory distress.
Wood- and gas-burning stoves, grills, or fireplaces also can cause burns when the toddler touches the hot metal.14 Although these burns are common, there are few long-lasting sequelae.15
Electrical cords, plugs, and sockets are attractive nuisances to the toddler, and children may suffer electrical injuries when chewing or playing with electrical outlets and cords.
Age 3-8
Children at this age continue to require both guidance and protection. These children are still developing coordination, and the body is not fully in control, so scald and contact burns persist in this age group.
Fascination with fire, matches, and lighters begins at an early age, before the motor coordination and judgment to handle dangerous items have developed. Experimentation with matches, camp fires, fireplaces, and stoves occurs in solitary or group play situations. This can lead to house fires and clothing ignition. In a Massachusetts study, flame burns ranked second after scalds in the 3- to 8-year-old age group, and the burns requiring hospital treatment often involved a single-ignition, single-victim flame injury.4
Fireworks injuries are common in this age group.16 Many of the injuries will be minor and due to sparklers, firecrackers, bottle rockets, and roman candles. Adult supervision can prevent as many as half of the injuries.
Age 9-12
Risk-taking behavior and peer pressure become driving forces. There is an increasing wish to be responsible and do adult tasks. This behavior may lead to increased use of flammable liquids such as gasoline for lawn mowers. These youngsters are often unaware of the dangers of these flammable liquids. Many of the hospitalized youngsters in this age group will have flame burns due to careless use of lighter fluids, charcoal lighter, gasoline, or even hair spray. Fireworks injuries also are common in this age group.
Pathophysiology of Thermal Burns
Burns are caused by the transfer of energy to the skin at a faster rate than the body or skin can dissipate it. The depth of a burn depends upon the temperature and duration of the heat applied, and the ability of the tissues to dissipate the transferred energy. The rate of heat transfer is more critical than the total amount of heat transferred.
Vascular Changes in Burned Skin. Almost immediately after the burn, the vessels in the adjacent area are altered. At first, an intense vasoconstriction is caused by the release of numerous vasoactive substances from the injured cells.
After a few hours, the vessels dilate as kinins are released from the damaged mast cells. During the vasodilatation, the capillaries become more permeable, allowing extravasation of plasma into the burned wound.
Ischemia from the initial vasoconstriction and subsequent microthrombus formation may extend the area of the injury. The ischemia may be present to a depth of as much as 3-7 times greater than the area of the cells directly damaged by the heat. Because of this ischemia, final determination of the depth of the burn may be delayed as long as five days.
Many authorities recognize three concentric layers of vascular changes due to the effects of the burn and subsequent ischemia. The center of the burn is often called the zone of coagulation and represents the area of direct cellular destruction by the heat. Within this region, all blood vessels are thrombosed. As the intensity of the heat or the length of the exposure increases, this zone of coagulation will become deeper and wider.
Surrounding the zone of coagulation is a zone of stasis. In this area, there is vasoconstriction and some microvascular thrombosis. Some blood vessels will remain patent, even though blood flow is reduced overall. If circulation is promptly restored, some of the injured cells in this region will survive. However, a delay in treatment can cause more irreversible damage.
Surrounding the area of vascular stasis is an area of minimal damage, the zone of hyperemia. The bright red color that blanches on pressure is noted at the margin of all burn wounds, and, in the most minimal cases, may comprise the entire wound.
Water and Heat Losses. In addition to the direct reactions to a thermal burn, burns that destroy the epidermis will allow increased insensible water losses of up to 15 times normal. As the water evaporates, body heat is lost, which can lead to the development of hypothermia. Caloric requirements increase enormously as the body tries to adjust to this increase in metabolic rate. Major thermal injury is also associated with extreme hypermetabolism and catabolism.
Infection Potential. Following a severe skin burn from any source, the skin undergoes coagulation necrosis and becomes an excellent growth medium for bacteria. Because the local blood supply is also compromised, the local defense mechanisms may be inadequate. The degree and consequences of the resultant bacterial invasion will vary directly with the severity of the wound. Bacterial invasion is one of the most frequent, fatal complications of a serious burn.
Initially, the microflora is gram positive like the normal skin flora. After the fifth day, the wound is colonized with gram-negative organisms. Less severe burns may evolve into deeper burns as tissue is destroyed by infection.
Assessment of the Burn. The assessment of thermal burn injury involves three major factors: the location, depth, and extent of the damage. These three factors help determine the capacity for regeneration and the potential for bacterial invasion. Included in the initial assessment of the burn should be the evaluation of potentially exacerbating factors such as age, prior medical history, allergies, and current medications.
Initial History. Obtain the history of the injury from the patient, parents, relatives, or emergency response crew. Remember that although the burn may ultimately be fatal, if the patient has survived the initial insult, the burn wound itself is not likely to be the immediate threat to life. Gas explosions, propane explosions, or other explosive injuries may cause substantial associated injuries. Confinement in an enclosed car or a room may be associated with pulmonary injuries from inhalation of toxic gases. The child may have been involved in an accident that preceded the burn, or may have leapt to escape being more severely burned. These potentially life-threatening injuries may take precedence over the burn wound management and should be dealt with as necessary.
The history should include any associated illnesses such as diabetes, hypertension, metabolic disorders, or cardiac and pulmonary diseases. It is important to find out if there are any allergies and current drug therapies. The patient’s age should be noted at this time. Remember that burns occurring to those at the extremes of age will be associated with the highest morbidity and mortality.
The Skin
The epidermis is the outer layer of the skin and is made up of four layers:
1. Stratum corneum. This water-retaining layer consists of dead, dried out (keratinized) cells that are constantly being shed.
2. Stratum lucidum. This is a clear cell layer in which cells are becoming keratinized.
3. Stratum granulosum. In this layer, the epidermal cells gradually die and start to keratinize.
4. Stratum germinativum. This is the layer in which new skin cells are produced. Injury to this layer may result in vitiligo, a mottled coloring of the skin. This is the layer that is destroyed in a third-degree burn.
The true skin, dermis, or corium is the inner layer of the skin, and is composed of connective tissues and the pressure sensors, nerves, pain sensors, hair follicles, and sweat glands. This layer also controls heat balance. The germinal layer, stratum germinativum, extends into the dermis where the skin’s hair follicles, sweat glands, and other appendages are produced.
Depth of the Burn
The depth of a burn provides the initial clue to the severity of the injury, but it may not be possible to accurately determine the depth of a burn until debridement has been performed. What initially appears to be a second-degree burn may evolve into a third-degree burn by infection or vascular changes from the original burn injuries. Burns may be classified based on depth and percentage of body surface involved. (See Table 1.)
| Table 1. Burn Classification Scheme |
| Major Burn Injuries |
| • Second-degree burn greater than 25% TBSA in adults |
| • Second-degree burn greater than 20% TBSA in children |
| • Third-degree burns greater than 10% TBSA |
| • Burns of hands, face, eyes, ears, feet, or perineum |
| • All inhalation injuries |
| • Electrical burns |
| • Burns complicated by fractures or other trauma |
| • Burns in poor risk patients |
| Moderate Uncomplicated Burn Injuries |
| • Second-degree burns greater than 15% TBSA in adults |
| • Second-degree burns greater than 10% TBSA in children |
| • Third-degree burns greater than 2% TBSA that do not involve ears, eyes, face, hands, feet, or perineum |
| Minor Burn Injuries |
| • Second-degree burns less than 15% TBSA in adults |
| • Second-degree burns less than 10% TBSA in children |
| • Third-degree burns that are less than 2% and do not involve any of the critical areas |
| TBSA = Total body surface area |
First-Degree Burns. A first-degree burn affects only the superficial epidermis. It results in vasodilatation and congestion of the dermal vessels. The resultant erythema will blanch upon pressure. There is no bullae formation, and the wound is painful. Premature cell death often results in desquamation or peeling a few days after the burn.
Healing of the first-degree burn is not normally accompanied by scarring or discoloration, and there is no substantial clinical significance to this injury in the otherwise healthy child. Most first-degree burns take 3-5 days to heal.
Typical etiologies may include thermal and thermal exposure (particularly scalding injuries in children), ultraviolet exposure, and occasionally ionizing radiation exposure.
Second-Degree Burns. A second-degree burn involves a portion of the dermis and produces an epidermolysis. The resultant edema and fluid exudate leads to bullae formation, a hallmark of the second-degree injury. There is a varying depth of destruction, with sparing of dermal appendages such as sweat glands, hair follicles, and sebaceous glands. There is erythema that blanches with pressure. The epidermis is easily separated from the skin.
By definition, the full-thickness dermis is not destroyed in a second-degree burn, and the epidermis can regenerate over a period of time without significant scarring or contracture formation. Since nerve fibers in the skin are often spared, these burns are exquisitely painful. This is the typical scalding injury in children.
The intact blisters provide a sterile water-proof covering for the wound and healing occurs by continued growth of the remaining basal cells. Underlying the blister formation may be an erythematous or waxy base, depending upon the depth of the burn. If the blister is broken, a weeping wound will result. There is then concomitant increase in evaporative water and heat losses, and exposure of naked nerve fibers.
The typical second-degree burn heals in about 14-21 days. There is minimal scar formation with a second-degree burn. Dark-complected children may lose melanin in the burned tissues and develop vitiligo.
Deep second-degree burns occur when the damage is extensive, but the deeper structures retain viable skin elements. This is most often true in deep burns of the back, palms, and soles. At times, the only remaining elements may be very deep in the dermis, such as sweat glands and hair follicles. This burn may develop the same eschar as the third-degree burn. It is important to recognize these deeper second-degree burns in extensively burned patients because the skin may regenerate without skin grafting. This differentiation may become obsolete as more experience is developed with culturing human epithelium from the victim.17-20
Although bullae are classically found with second-degree burns, they may be also caused by infection or by superheated steam. Bullae due to second-degree burns develop relatively promptly after the injury. Those bullae noted with infection present later, usually 24 or more hours after the insult. The provider should be suspicious of blisters appearing more than 16 hours after a burn injury. Superheated steam also may cause bullae because the high temperature causes water in the skin to boil and then vaporize, separating the dermis from the epidermis. The burns from superheated steam should be considered third-degree at all times. Note that superheated steam is used only in commercial and marine boilers and is not a common source of injury in children.
When the burn is greater than 10% of the body surface in children, and particularly in infants, the child should generally be admitted to the hospital and therapy started there.
Third-Degree Burns. As the depth of injury increases in more severe burns, all epidermal and supporting structures are destroyed. The surface of a third-degree burn is dry, leathery, and inelastic. The burned skin surface may appear white to gray, waxy, and translucent. Mottling and superficial coagulated vessels may be seen through the surface of the resultant eschar. The leathery eschar permits water losses to an excessive degree and there is no functional barrier to bacterial invasion. These burns are often painless, due to the destruction of the nerve fibers.
By definition, the third-degree burn will not regenerate except from the unburned edges of the skin or from a skin graft. For this reason, surgical intervention will usually be needed. New research with skin cell cloning may help some of these victims.
Only very small third-degree burns in children should be treated in the outpatient setting. Consultation with a plastic surgeon or a surgeon skilled in the treatment of the hand burn is mandatory.
Fourth-Degree Burns. Though not used by all authorities, the classification of fourth-degree burn is applied to burns that extend beyond the depth of the skin to involve underlying fascia, muscle, tendons, nerves, periosteum, and vessels. Occasionally even bone may be involved. This burn classification is most often used with electrical injuries, but severe charring of extremities also may be termed fourth-degree lesions. The natural history of this wound is the same as a third-degree burn, but there is deeper destruction and more dysfunction. There is no difference in the initial treatment of a third-degree burn and a fourth-degree burn.
Fourth-degree burns in children should be treated by hospitalization in all cases. This is beyond the scope of this article.
Extent of the Burn Surface
A variety of methods have been developed to estimate the amount of involved body surface area.
Lund and Browder Chart. Since the proportions of surface areas of the younger patients will vary with age, schemes to approximate the burn surface area will fail unless these variations are taken into account. The most accurate method for determining the extent of the burn is the Lund and Browder Chart, which accounts for changes in the sizes of the body parts that occur during growth.21 (See Table 2.) These calculations can be quite time consuming, and the rule of nines is more frequently used in field emergency services, though it is less accurate for the pediatric population.
| Table 2. Lund and Browder Chart | ||||||
| Age vs. Body Surface Area Proportions (Percentage) | ||||||
| Area | Up to 1 Year | 1-4 Years | 5-9 Years | 10-14 Years | 15 Years | Adult |
| Head | 19% | 17% | 13% | 11% | 9% | 7% |
| Neck | 2% | 2% | 2% | 2% | 2% | 2% |
| Ant. Trunk | 13% | 13% | 13% | 13% | 13% | 13% |
| Post. Trunk | 13% | 13% | 13% | 13% | 13% | 13 % |
| Buttock | 2.5% | 2.5% | 2.5% | 2.5% | 2.5% | 2.5 % |
| Upper Arm | 4% | 4% | 4% | 4% | 4% | 4% |
| Lower Arm | 3% | 3% | 3% | 3% | 3% | 3% |
| Hand | 2.5% | 2.5% | 2.5 % | 2.5% | 2.5% | 2.5% |
| Thigh | 5.5% | 6.5% | 8% | 8.5% | 9% | 9.5% |
| Leg | 5% | 5% | 5.5% | 6% | 6.5% | 7% |
| Foot | 3.5% | 3.5% | 3.5% | 3.5% | 3.5% | 3.5% |
| Genitalia | 1% | 1% | 1% | 1% | 1% | 1% |
| Adapted from: Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944;79:352-358. | ||||||
Rule of Nines. The rule of nines apportions a 9% segment to each of 11 major body surfaces, and the remaining 1% is apportioned to the groin. This scheme is for the adult human. For children, a greater percentage is assigned to the head and a lesser percentage to the lower extremities.
Rule of Palms. The rule of palms is convenient for measuring small burn surfaces. The patient’s hand is roughly 1% of the patient’s total body surface area (TBSA). Estimation of the number of hand spans for a small burn will give a rough approximation of the burned surface area. This method is not accurate for large burned surfaces. (Note: Although the Advanced Trauma Life Support course teaches that the patient’s palm is 1% of the total surface area, the better approximation is that the patient’s hand, including the fingers, is 0.8%.)22-23
Location of the Burn
The location of a burn is critical in planning care of the patient’s burn. Most facial burns, groin burns, hand burns, and foot burns require inpatient care.
Facial burns should be carefully assessed for associated airway involvement. In general, all but the most superficial facial burns should be admitted. If there is any question of ocular injury, then admission is essential. Burns of the neck can rapidly become macerated and may require in-hospital treatment. Up to 48 hours of observation is wise for any patient with significant facial burns, especially if there is any question of inhalation injury.
Patients with deep or extensive burns of the hands should receive a surgical consultation. These burns are very difficult to manage at home because they often are treated with topical agents, no dressings, and may require debridement. Early evaluation and participation in physical therapy is a major advantage of inpatient care. Deep second-degree, as well as third-degree, burns of the hand may benefit from early excision of the burn eschar.
One of the more trying injuries to treat at home is a foot burn. The necessary elevation and pain on walking make home management very difficult, even in children. If the patient tries to care for himself, severe edema, pain, excessive exudation, and early superficial infection often occur. Burns of the feet are initially best treated in the hospital.
The final critical area is the groin, including both the perineum and the genitalia. Even second-degree burns in this area should be treated with open management. This requires expert nursing care. If these burns macerate, they rapidly develop infection and severe scarring. With good hospital care and treatment, however, these wounds heal extremely well.
The pattern of the burn also should be carefully examined to detect elements of abuse. A child who accidentally pulls a container with hot liquid from a stove will usually have a scalding burn of the anterior head/face, anterior neck, palmar surfaces of the hands and fingers, extended arm or arms, anterior shoulder, axilla, and anterior chest. A scald due to immersion usually involves the lower trunk, buttocks, perineum, and legs. Abusive burns tend to be deeper and larger than accidental burns.
Burns that are seldom accidental include: stocking or glove burns; mirror image burns; burns that spare flexor surfaces; and burns located on the buttocks, perineum, external genitalia, dorsal hands, fingers and feet, and posterior head, neck, shoulders, torso, and extremities. Contact burns are the most common pattern of abuse. Multiple cigarette burns or contact burns, particularly of varying ages, should be considered abuse until proven otherwise.
Finally, very young children or those with pre-existing disease will have more mortality or morbidity as a result of the complications from a burn injury. Those pre-existing diseases that increase the risk of a major burn include (but are not limited to) major cardiovascular or respiratory diseases, hepatic and renal diseases, insulin dependent diabetes, alcoholism, severe psychiatric illness, and head injuries with unconsciousness. Patients with sickle cell disease also should be considered to be in this category because they will frequently develop a sickle cell crisis in response to major burns.
Care of the Burn Patient
Upon arrival at the ED, therapy begins with any chemically contaminated garments being removed and the victim washed with copious amounts of water (with only a few exceptions).
Burns may be inflicted in children as a form of abuse. Contact burns with matches, cigarettes, irons, or hot metal appliances, and scald burns are common forms of this type of child abuse. If the history seems inconsistent with the trauma noted, or if the parent’s concern seems inconsistent with the seriousness of the injuries of a child, the physician should be alerted to the possibility of child abuse. Frequent locations of non-accidental burn trauma include burns of the backs of the hands, and legs, buttocks, and feet.
Moist soaks or ice applications are often recommended to relieve the pain of a superficial burn. If the patient has more than a single extremity burned, the patient should not be wrapped in cold compresses or have ice applied.24 If the burn is third degree, the child also does not need treatment with ice or cold water. With an immersion of this sort in an infant, it is easy to imagine the rapid development of hypothermia. The child with a burn does not need the additional stress of hypothermia and its associated problems.
IV access should not be placed in any burned area, if possible. If IV fluids are not available for any reason, oral fluid replacements may be required. The decision to give oral fluids in this situation should not be made lightly, as about 30% of patients with a burn of 20% or more of the body surface area will develop an adynamic ileus. The complications of an adynamic ileus and administration of oral fluids are obvious. If contraindications to the administration of oral fluids exist, such as abdominal trauma, facial trauma, or unconsciousness are present, oral fluids should not be given.
Care should be taken to keep burned extremities elevated when possible so that excessive edema formation does not occur. Circumferential extremity burns should be treated as outlined below to prevent limb ischemia. Circumferential chest injuries may also necessitate an escharotomy to prevent respiratory embarrassment.
It should be remembered that for the patient with an extensive burn, this is only the beginning of a treatment program that may last for years. The emergency physician’s goal is to enhance the maximum chance for survival of both body and burned surfaces for the patient. This may mean that the emergency physician’s appropriate role is that of stabilization and referral rather than definitive therapy. Burn care has advanced tremendously during the past 20 years through the joint efforts of cognizant emergency providers and burn researchers in specialized burn units. The average hospital quite simply does not have the resources or training for management of the severely burned patient.
Appraisal of the Burn
Upon arrival of the patient, the physician needs to assess the basics of airway, breathing, and circulation. Airway swelling, respiratory distress, and signs of potential inhalation injury should be sought and corrected immediately.
Although impairment of circulation is not usually a problem in the early management phase of an uncomplicated burned patient, burned patients have frequently sustained additional trauma in the process of exiting the burning area or as a consequence of the burn. The patient should be examined thoroughly for signs of additional trauma. As the formation of local edema in the burn progresses, hypovolemia (burn shock) becomes likely and must be corrected. Locally, circulation to the extremities may be impaired by circumferential burns. This must be promptly treated.
Inhalation Injuries. Postburn lung dysfunction is a major cause of mortality in the burned pediatric patient. Increasing use of plastics and other materials that liberate noxious fumes when ignited has increased the potential for such injuries. Objective criteria for diagnosis of inhalation injuries such as fiberoptic bronchoscopy and Xenon lung scans have demonstrated the presence of pulmonary insult in up to one-third of all burn victims. These problems should not be underestimated. Patients of any age with a burn and inhalation injury have twice the mortality of patients with only a burn.
The presence of a pulmonary or respiratory injury due to the inhalation of products of combustion should be anticipated. Suspect carbon monoxide poisoning in all burned patients and obtain CO levels.
In cases with upper airway damage, rapid intubation may be life-saving. Stridor is an ominous finding and implies that at least 20% of the airway is occluded in the adult patient. In the young child, small amounts of edema can result in severe occlusions because of the small diameter of a pediatric airway. Ensure that the patient is intubated with an endotracheal tube. Administer 100% humidified oxygen to prevent mucous membrane drying and ensure oxygenation of the patient.
Do not rely on pulse oximeters in burn victims. Because they measure reflectance of bound hemoglobin, they are notoriously inaccurate in the presence of CO-bound and HS-bound hemoglobin.
Burn Shock. Following a severe burn, adult patients may lose up to 10-15 liters of fluid due to increased capillary permeability throughout the body. This isotonic fluid and protein leak from the intravascular compartment to the cellular interstitium has its greatest losses during the first 8-12 hours. If untreated, this transfer of fluid may cause hypovolemic shock.
Fluid resuscitation "budgets" developed over the past two decades have virtually eliminated death due to burn shock. In fact, burn edema due to increased capillary permeability and simultaneous over zealous fluid administration is now the most common complication of a burn.
Fluid resuscitation becomes critical in children who have sustained burns of more than 10% of their body surfaces. The goals of fluid resuscitation are to maintain cardiovascular hemodynamics, prevent renal and pulmonary complications, and to correct acid/base abnormalities.
Calculating Fluid Replacements. In 1952, Evans and associates devised a formula for calculating the fluid and electrolyte requirements of severely burned patients. Our concepts of the fluid and electrolyte replacements called for in the burned patient have been derived from suggestions by many investigators since that time. (See Table 3.)
| Table 3. Burn Resuscitation Formulas in the First 24 Hours | |||
| Investigator | Electrolyte | Colloid | Water |
| Evans | 1 cc/kg/% burn | 1 cc/kg/% burn | D5W 2000 cc |
| Brooke Burn Unit | 1.5 cc/kg/% burn | 0.5 cc/kg/% burn | D5W 2000 cc |
| Brooke (Rev. 1979) | 2-3 cc/kg/% burn LR | none | none |
| Baxter (Parkland) | 4 cc/kg/% burn LR | none | none |
| Slater | Lactated Ringers 2L/24 hours |
Fresh frozen plasma 75 cc/kg/24 hours |
|
| Monafo | Hypertonic lactated saline. Fluid contains 250 mEq Na+/L. To maintain urine at 30 cc/hr (About 2 cc/kg/% burn). |
||
| (Warden) Hypertonic Sodium Solution |
Volume to maintain urine output at 30-50 cc/hr. Fluid is lactated Ringer's plus 50 mEq NaHCO3 (180 mEq Na/L), Lactated Ringer's to maintain urine at 30- 50 cc/hr beginning 8 hours postburn. |
||
| Dextran formula | Lactated Ringer's—volume to maintain urine at 30 cc/hr. | ||
| (Demling) | Dextran 40 in saline 2 cc/kg/hr for 8 hours. Fresh frozen plasma 0.5 cc/kg/hr for 18 hours, 8 hours after the burn. |
||
There are several components to the burn budgets listed above. Crystalloid, particularly Ringer’s lactate, is the most popular resuscitation fluid used today. Proponents of Ringer’s lactate feel that other solutions are no better and are substantially more expensive than Ringer’s. In major burns, severe hypoproteinemia may result with these crystalloid resuscitation formulas. The hypoproteinemia may result in more edema formation.
These fluid budgets were designed for adult patients with adult burns. In a child with 10-20% burn, the Parkland formula alone would be insufficient for maintenance, much less for burn resuscitation.25 A child’s maintenance fluid requirements can be calculated through a number of different techniques relying on surface area or weight. A useful method of calculating the child’s maintenance fluid requirements is:
Maintenance fluid = (100 cc/kg/day for first 10 kg)
+ (50 cc/kg/day for second 10 kg)
+ (20 cc/kg/day for weight in excess of 20 kg)
In the child, burn resuscitation should be the maintenance fluids plus additional fluids to compensate for losses (2-3 cc/kg x % burn surface area). As with the Parkland fluid formula, half should be given during the first eight hours and half during the next 16 hours.
The Caravajal formula uses body surface area instead of weight to estimate the fluid requirements.26 Although this formula is technically more accurate than adding maintenance fluids to the Parkland formula, it is more difficult in most EDs to calculate the child’s body surface area. Caravajal recommends 5000 mL/m2 per percentage of burned surface area and then adding 2000 mL/m2 for maintenance fluids. He also recommends giving half of the calculated amount in the first eight hours and half in the ensuing 16 hours.
The physician should administer all fluids to children as normal saline or lactated Ringer’s. If the fluid given is hypotonic, there is a distinct risk of iatrogenic hyponatremia with subsequent cerebral edema and seizures. This is particularly true in the patient who is getting large amounts of fluids for extensive burns.
Because the most drastic fluid shifts occur in the first 8-12 hours after the burn, most formulas advocate replacement of half of the calculated fluid requirements for the first 24 hours be given during the first 8-12 hours. When calculating the replacement, be certain to consider the time of the burn, not the time of arrival of the patient in the ED. On the other hand, care must be taken not to overwhelm the patient’s cardiovascular system with massive fluid administration rates if the patient arrives late in the course of the burn. Judgment becomes critical when the patient arrives 4-6 hours after a severe burn and has not had adequate fluid resuscitation.
In general, use the formula recommended by the local burn center. Although good results have been obtained with all formulas and "budgets," the local burn team may be more familiar with a different formula. Since they are going to be responsible for the care of this patient for an extended time, it is thoughtful to find out, in advance, the burn center’s preferences and make their task easier.
Monitoring the State of Hydration. All of the burn formulas and budgets are merely guidelines, and a rigid application of formulas will ignore the variability of both burn and patient. The burn fluid replacement formulas frequently result in over- or under-hydration at the extremes of weight and burn size. Do not rely on a single parameter to judge the efficacy of fluid replacement. Look for a combination of the following factors:
• Clear sensorium;
• Extremity capillary filling and warmth of extremities;
• Vital signs normal or near normal;
• Decreasing hematocrit; and
• Adequate urine output (30-50 cc/hr in children older than 12 years or 0.5-1 cc/kilogram/hr in younger children).
If more than 1 cc/kg/hr is given, even in a child, there is a risk of iatrogenic pulmonary edema.
Hematocrit, blood pressure, and pulse have significant limitations as indicators of shock in the burned child. As always, obtaining a blood pressure reading in a toddler may be difficult. Even in an older child, it is often quite difficult to obtain an accurate pulse or blood pressure through the thick, tough eschar of a severe burn. Arterial lines may be needed for accurate monitoring of blood pressure. The blood pressure in children and young adults is often stable until late in the clinical picture of shock. Hypertension frequently may be found in severely burned children. With the increased metabolic rates associated with thermal trauma, a pulse in excess of 100 is often found and is compatible with adequate fluid resuscitation.
Hematocrit of 55-60% are common in the first 24 hours after serious burn injuries, even with adequate fluid administration. Decreasing hematocrit is to be expected with adequate fluid resuscitation, but may also be a hallmark of occult bleeding. If the patient apparently requires fluid far in excess of the burn budget, a vigorous search for occult bleeding is indicated.
Circumferential Burns. In severe burns of the extremities, especially those with circumferential or total involvement, it is imperative to establish the adequacy of perfusion. Marked edema from a deep dermal and third-degree burn within the confines of inelastic eschar or the rigid fascial compartments of the extremity can limit the arterial supply and the venous outflow. The resultant tissue hypoxia can cause muscle necrosis that results in further swelling and further decrease in blood supply.
The appropriate preventative measures include early removal of rings and jewelry and elevation of the limbs. If the extremity appears cyanotic distal to the injury, or capillary filling time is increased despite these measures escharotomy should be considered. Doppler flow detectors also may be used to assess small vessel blood flow. If the patient develops weak or absent distal peripheral pulses, progressive neurological signs such as paresthesias, or deep tissue pain, escharotomy is indicated. When in doubt, perform a fasciotomy or escharotomy rather than risk a subsequent amputation. A tissue pressure of greater than 30 mm of mercury, obtained by inserting a needle into the tissues and attempting to infuse saline or by attaching a manometer is indicative of impending vascular compromise.
The escharotomy should be made in both the mid-medial and the mid-lateral line of the limb and carried down to the ends of the fingers or to unburned skin. The incisions should be carried across involved joints and should be incised only to the depth which allows the cut edges of the eschar to separate.
Thoracic escharotomy may be required to prevent respiratory decompensation in the child with a severe chest burn.
Care of the Burn Wound
Care of the burn wound should be directed toward four principles:
• Preventing infection;
• Decreasing of burn fluid losses;
• Relieving of pain; and
• Salvaging of all viable burn tissue.
It should be emphasized that the best coverage for tissue is skin. Although acceptable artificial substitutes are now available, there is still nothing better than the "real thing."27-29
Cleansing the Wound. Before cleansing the burn, soak off charred clothing with sterile saline, and clip any hair within about two inches of the burn. Gently cleanse the burn with mild soap and water, debriding it of all foreign particulate matter and charred tissue. The process is easier if the affected area is immersed in warm saline or water. The use of a Hubbard or similar immersion tank is ideal for treatment of larger burns, but washing under running tap water will suffice for smaller burns. Enzymatic debriding preparation may prove useful in the treatment of burns. These agents may help in the removal of necrotic tissue. Debriding also may be less painful.
Once cleansing has taken place, the next step is debridement. Obviously necrotic and partially sloughed epidermis and dermis is removed by using forceps and tissue scissors. This skin is dead, and therefore, insensitive. Local anesthetics are not required.
The question of whether to debride intact bullae has been controversial for more than 20 years.30-32 Proponents of leaving blisters note that the blister provides a sterile biologic dressing and should be left intact unless it is extremely large or inhibits motion. Adherents to blister removal point out that the fluid within the blister is an ideal culture media for bacteria.
A rational compromise between the two opposing camps is proposed. Intact bullae less than 2 cm in diameter should probably be left intact. Alternately, these may be aspirated using aseptic technique. Intact bullae more than 2 cm in diameter should be debrided because they are easily ruptured and, once violated, the fluid within provides an excellent culture medium for inoculating bacteria. If the blisters are ruptured, hemorrhagic, or purulent, they should be debrided.
Burn Excision
The concept of excising and promptly closing a burn wound is appealing for several reasons. First, when the wound is closed, the risks of fluid losses and infection are markedly decreased. Second, wound closure will allow decrease in pain medications, more effective physical therapy, and potentially faster recovery. There does not appear to be any significant decrease in either hospital stay or mortality.33
Obviously, third-degree and some deep second-degree burns are the only candidates for excision of the burn wound. Superficial partial thickness wounds will not require removal of the eschar and will re-epithelialize within three weeks. Following the excision of burned tissue, the wound is covered with either an artificial membrane, autologous donor graft, allograft, or xenografts. Burn excision should be performed by a plastic or general surgeon who will manage the ongoing care of the patient.
Use of Antibiotic Creams, Lotions, and Ointments. There are a number of ways to manage a burn once it has been cleansed. For the early care of a burn, little wound coverage is needed. Dry sheets (sterile if at all possible) will prevent air exposure to the burned tissues and will decrease pain. If something must be applied to the wound, a water-soluble base is mandatory. For long-term therapy, treatment may be open with or without topical agents, or closed with application of a topical agent followed by a dressing. The dressing protects the wound and keeps the topical agent in contact with the wound.
Open Method. The open method with topical creams cannot bc used for a child who must attend school or go to work. In these situations, an occlusive dressing is obviously the only acceptable solution. The purpose of the open method is defeated when clothing is placed over the wound. Burns on the trunk, buttocks, and thighs cannot be treated by the open method.
Facial burns should be treated without dressings or burn creams. No topical agents are usually needed for burns on the face, since the facial vascularity protects against most infections. The face is difficult to dress due to the facial angles and curves. Children may be quite agitated if the eyes are continuously covered. If the face is simply cleansed with mild soap and water twice daily, healing usually proceeds without problems.
Likewise, burns of the perineum are very difficult to dress. In children, frequent soiling is quite common. Open therapy of these burns is essential and hospitalization is usually necessary.
First-degree burns can be dressed with a lubricating lotion. Aloe also has been shown to be of benefit by inhibiting thromboxane A2 and prostaglandins. Pruritus may develop as the first-degree burn heals due to histamine release from mast cells. This can be especially troublesome to small children; diphenhydramine hydrochloride in appropriate doses can be effective in relieving this symptom.
Topical Agents. For smaller burns, treated on an outpatient basis, studies show that any of a variety of medications are appropriate. These medications include povidone-iodine, mafenide, and silver sulfadiazine. There are many opinions, but little concrete data that support one topical agent over another. Likewise, there are few data about using these agents under dressings in closed therapy. Data during development of the agents were obtained from patients with open treatment in burn units, not as outpatient therapy using dressings.
An appropriate first choice for topical therapy is silver sulfadiazine. This drug is readily available in most EDs. It should be avoided in the child who is allergic to sulfa. Silver sulfadiazine is easy to apply and is quite comfortable for the patient. It has been used for years with good effect in both open and closed treatment of burns. Silver sulfadiazine dressings should be changed at least daily. When used in open treatment, silver sulfadiazine should be reapplied at least three times daily. Silver sulfadiazine also softens tissue, thereby maintaining joint movement and facilitating eschar debridement.
Because of its relatively low toxicity and ease of use, silver sulfadiazine is the most widely used topical antimicrobial agent.34 However, silver sulfadiazine should not be used around the eyes and mouth, in children with hypersensitivity to sulfonamides, or in pregnant women, nursing mothers, and infants younger than 2 months of age (because of the risk of sulfonamide kernicterus). Potential side effects include thrombocytopenia, leukopenia, and a rash.
Mafenide acetate (Sulfamylon) is thought to have better tissue penetration. It may be superior for treatment of electrical and deeply penetrating burns. Mafenide acetate may be appropriate for the patient who is going to have excision of a small third-degree burn followed by grafting or suture repair of the defect. Mafenide penetrates deeply into the eschar and decreases the chance of infection when the wound is subsequently closed.
Unfortunately, it causes pain, dries the wound out, and can cause metabolic acidosis. The metabolic acidosis occurs because of its action as a carbonic anhydrase inhibitor, resulting in excretion of bicarbonate and retention of chloride. Mafenide acetate should never be used under a dressing because it causes severe maceration with tissue breakdown and a contact dermatitis.
Povidone iodine penetrates wounds better than silver sulfadiazine. However, povidone iodine is less well tolerated because it causes pain. Furthermore, iodine toughens and dries the eschar and diminishes joint mobility.
Do not use petroleum-based ointments, unless the burn is caused by sulfur or tar. Polymixin B sulfate and neomycin (Bacitracin and Neosporin) are petroleum based. These agents are hard to clean off and do not penetrate as well as silver sulfadiazine. Bacitracin requires fewer changes than silver sulfadiazine and is a little less expensive, but the difficulty in cleaning it off is not worth the cost benefit.
Gentamycin burn creams should be avoided. Use of gentamycin tends to select for gentamycin resistant Pseudomonas species.
Silver nitrate 0.5% is still used in some burn units but is generally unsuitable for outpatient use. It has a very good antimicrobial spectrum against most gram-positive bacteria and many gram-negative bacteria and is cheap to use. It has many disadvantages: It is messy, fails to penetrate eschar well, and can cause hyponatremia, hypochloremia, and methemoglobinemia.
If the child is going to be transferred, please check with the local burn center for their preferences. Some authorities do not wish to have any topical medications applied until they have evaluated the patient themselves.
The Dressing. Since the wound may weep copiously during the exudative phase of the burn, a sufficiently bulky dressing should be used to prevent wicking of bacteria because of a wet dressing. Plain, fine-mesh gauze placed against the burn surface allows the exudate to permeate the bulky dressing. Petrolatum-impregnated gauze often causes maceration of the wound and should not be used. Over the fine-mesh gauze, fluffs of absorbent gauze material should be used. Four or five layers are usually sufficient if the dressing is to be left in place for 24 hours. One or two layers of bias-cut stockinette or Kerlix will provide an external barrier to prevent contamination as well as secure the dressing in place. The dressing should be changed once or twice a day and inspected by a physician every second or third day.
In very young patients, it may be necessary to trim fingernails to prevent scratching of the healing wounds. Occasionally, the child’s hands must be wrapped in mitten fashion to prevent digging at the wounds.
Biosynthetic dressings such as DuoDerm, Epigard, Biobrane, Opsite, and others can be used for superficial partial-thickness burns in both children and adults.35-39 One biosynthetic dressing that has been extensively studied is Biobrane (Woodruff Laboratories, Santa Ana, CA), a knitted nylon fabric bonded to a silicone membrane and coated with covalently bonded collagen peptides. The biosynthetic dressings should be applied directly to the clean burn and will spontaneously separate in 7-14 days. Once adhered to a fresh, partial-thickness wound or donor site, the Biobrane is left in place until epithelialization occurs. The biosynthetic dressings must be applied to a flat surface and can cover only a 1-2% TBSA burn. The biosynthetic dressing should be covered by an absorbent dressing that is changed daily.
As a dressing that remains in place until wound healing occurs, nursing time is minimized, and the cost of multiple dressing changes is saved. These dressings may be better tolerated, are less painful, maintain wound moisture, and reduce the local trauma from frequent dressing changes.
These dressings are costly, and have not been shown to decrease healing time in partial-thickness wounds.40 Newer dressing materials are constantly being evaluated and may provide good effect for less money.34 The main disadvantages of these dressings are leakage of wound fluid, premature separation of the dressing, and cost.
Adjunctive Therapies
Nasogastric Suction. Nasogastric suction using a Salem sump or similar tube should be initiated early in the ED. Many patients with a burn of greater than 25% TBSA will develop an ileus in the first 24-48 hours that will often last for several days. If the child has nausea, distention, or vomiting with lesser burns, a nasogastric tube often will make the child more comfortable.
Curling’s ulcer (burn stress ulcers) often will be prevented by the use of cimetidine (Tagamet) or other H2 blockers or antacids instilled into the nasogastric tube or given intravenously.
Pain Medication. Patients with extensive severe burns often experience little pain. More minor burns, paradoxically are much more painful, as the cutaneous nerve endings are damaged but not destroyed. The second-degree burn is perhaps the most painful injury a child can sustain. Deep burns have destroyed the pain fibers, so these burns are not particularly painful.
Burn patients with partial thickness injuries will experience environmental aggravation of the injury and will benefit by simply covering the burn with a sheet.
The emergency physician should routinely ensure that pain and suffering are considered in the child’s management. Pain should be controlled with incremental intravenous doses of morphine sulphate or similar agents. There are no contraindications to the intravenous route, and it provides rapid action, assured uptake, and easy control. If using morphine sulphate in the child, a dose of 0.1-0.2 mg/kg intravenously IV every 15-30 minutes may be sufficient: in the older child or adolescent, 3 mg increments are often useful.
Intramuscular and subcutaneous routes are not appropriate for the patient with cardiovascular compromise. Absorption of medications given by these routes are notoriously unpredictable. If the patient becomes hypovolemic for any reason, narcotics injected intramuscularly or subcutaneously will not be absorbed until the circulatory status is restored.
If the burn patient becomes restless or agitated, first check the oxygenation, then check the fluid replacement status. Often, anxiety and agitation are early signs of hypoxia or hypovolemia. Since both conditions are commonly found in association with severe burns, the child must be evaluated for hypoxemia and hypovolemia before each dose of pain medication.
Acetaminophen may be useful for pain control later in the child’s course (15 mg/kg/dose). Acetaminophen with codeine is useful before dressing changes (codeine dose is 0.5-1.0 mg/kg) In the pediatric patient with extensive burns, ketamine is commonly used in burn units as a sedation agent for dressing changes, grafts, and similar episodic painful therapies. The child will be completely sedated and will not lose respiratory reflexes.
Blood. Erythrocyte hemolysis may occur after a major burn. The etiology of this hemolysis is not known, but between 3% and 15% of red blood cells may be lost in the first week or two after a patient’s burn. A victim of a major burn will very likely need a transfusion for these red cell losses. Ensure that adequate blood is obtained for a cross match in preparation for transfusion.
Antibiotics. In the early post-burn period, antibiotics are rarely indicated. The single exception to this is the patient who has been on antibiotics for an antecedent illness. These patients should be continued on their antibiotics.
During the first week, the wound should be carefully observed for cellulitis. Early stages of infection include the edges of the wound becoming reddened and tender and the patient complaining of increasing pain. The most common causative organism of cellulitis is beta-hemolytic Streptococcus. Penicillin, therefore, should be the antibiotic of choice in initial treatment of a mild burn wound cellulitis. If oral antibiotics are not promptly effective, the child should be hospitalized for intravenous antibiotics.
Sunscreen. Healing burn wounds are quite sensitive to sun exposure. An effective sun block (with a sun protection factor of 15 or greater) should be applied to the area of the burn for 6-12 months following treatment. This can help prevent some of the hyperpigmentation seen following burn healing.
Tetanus Immunization. A burn injury is considered a high risk wound for tetanus. If the patient has had a tetanus immunization within five years, no further therapy is needed. If the patient’s last tetanus immunization is greater than five years ago, then a tetanus booster of 0.5 cc of age-appropriate toxoid should be given. If the patient has never had a full series of tetanus immunizations, then the patient should receive hyperimmune tetanus anti-toxin and the tetanus immunization series initiated.
Conclusion
Of course, the best way to treat any illness is to prevent it from occurring. In most cases, burns are preventable.
Emergency physicians may have an opportunity to intervene before these tragic accidents occur. When a child is seen in the ED for other illnesses, simply telling the parents about recommended preventive measures may save a child at essentially no cost to the parent, physician, or society. Ideas that should be recommended to parents include: 1) ensuring that electrical cords of appliances are beyond the reach of toddlers; 2) placing cups of hot beverages out of the reach of children; 3) placing pots and pans on the stove so that the handles face away from the child; 4) turning the thermostat on the water heater to about 120°F; 5) discussing the "Stop, Drop, and Roll" protocol with the child; and 6) using smoke detectors and recommending that family members for evacuation in the event of a house fire.
The child who is burned by abuse remains at risk for abuse and neglect after discharge. These children should have a safe environment. The perpetrator, if identified, should be dealt with in a way that ensures the child remains safe.41
If the child sustains a severe burn, rapid stabilization and appropriate therapy are mandatory. For minor burns, careful selection of dressings and careful monitoring for infection are usually all that is necessary.
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