Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine) 4th Ed.

CHAPTER

137

Pediatric Burns

Phyllis L.  Hendry

HIGH-YIELD FACTS

• Burns are the fifth leading cause of unintentional injury-related death. Children younger than 4 years tend to have scalding-related injuries, whereas older children tend to suffer from exposure to flames.

• Most physicians use the classic Lund and Brower chart to estimate %BSA burned as it adjusts for the age of the patient. Because of the possibility for error in estimations, some physicians use the child’s palm, considered approximately 1%, to measure the total %BSA burned.

• The primary survey should focus on the patency of the child’s airway as well as the severity of the burn. Any carbonaceous sputum or singed nasal hairs should alert the physician to impending airway edema.

• Of particular importance are circumferential burns, which may cause both vascular and respiratory compromise. If vascular compromise is apparent, the patient should undergo an immediate escharotomy.

• The Parkland formula is widely used to estimate fluid requirements. This formula calls for an isotonic crystalloid solution (such as Lactated Ringers) to be given at 4 mL/kg/%BSA over a 24-hour period. Half of this fluid volume is given over the first 8 hours, and the second half is given over the next 16 hours.

• Pain management is an important consideration in burn management. Opioid analgesia is often required.

• Initial wound care in the emergency department should consist of covering the burns with a dry, sterile sheet. Antiseptic solutions such as povidone–iodine and topical antibiotics should be avoided in patients who are being transferred to a burn center until the primary service has had the opportunity to evaluate the wounds.

• Topical antibiotics are routine in outpatient burn care. One percent silver sulfadiazine is most commonly used.

• All burn patients should be reevaluated at 24–48 hours to ensure proper wound healing and to examine for signs of infection.

EPIDEMIOLOGY

Burns are the fifth leading cause of unintentional injury-related death in children. Non-fatal burn injuries are the third leading cause of unintentional injury and average about 120,000 cases per year in US patients <21 years of age but declined by 30% over the past 17 years.1 Children <6 years of age sustained 58% of the injuries with approximately 60% resulting from thermal (scald) burns. The hands were most frequently burned (36%) followed by the head and face with most injuries occurring in the home.2,3 The mortality rate in pediatric burns continues to fall. Children with at least 60% total body surface area (TBSA) involved had a decrease in mortality rates from 33 to 14% over the last 20 years.4 With earlier intervention, the morbidity and mortality related to thermal burns have decreased; however, there are still significant sequelae that increase with the amount of TBSA involved. The treatment of burn injuries in the ED is usually followed by outpatient management with <10% of cases requiring hospital admission or transfer to a burn center. This chapter addresses common etiologies, clinical evaluation, management, and disposition of children who present to the emergency department with thermal injuries. Electrical burns are covered in Chapter 154.

ETIOLOGY

image THERMAL

Scald injuries are the most common cause of burns in children younger than 4 years old. These typically occur as a result of hot liquids that tip over or are accidentally spilled near a child. Infants are at risk for bath-related scalds. Contact burns from touching hair curling or clothing irons are often seen in young children accidently touching a hot surface or pulling on an electrical cord attached to a heated object. Children can sustain greater depth of injury to the skin with less contact time than adults; however, most pediatric burns are minor scalds

image FLASH

Accidental ignition of volatile substances, such as alcohol-based cleaners and liquids, can cause flash injuries to children. Because the time of exposure is so short, the result is usually a partial-thickness burn (Fig. 137-1).

image

FIGURE 137-1. Depth of burn wounds.

image FLAME

Flame injuries are the most common reason for burn-related injuries in older children. Young children can still sustain these types of burns, particularly with house fires, or even accidental ignition of clothing. Flames and burn injuries accounted for about a quarter of these deaths. Complicating this process is the inhalation of toxic gases, including carbon monoxide and cyanide. Flame injuries associated with smoke inhalation result in the majority of burn-related deaths.13

image CHILD ABUSE

Unfortunately, approximately 10–20% of burns in children are not accidental. Any child with burn injuries must have a thorough history and physical examination to rule out potential abuse. Most inflicted burns are scalds from forced submersion. The injury must match the mechanism described in the history. For example, burns in a stocking distribution on the legs are highly suspicious for intentional scalding injury. Intentional cigarette or iron burns are also seen in abuse situations. See Chapter 10 for management of child abuse. Ideally, photographs of suspicious burns should be taken before burn dressings are applied.5

PATHOPHYSIOLOGY

Burn injuries can range from simple first-degree sunburns to devastating full-thickness or third-degree burns. Tissues are destroyed by coagulation necrosis and the resulting inflammatory process. Injured cells begin to release vasoactive mediators that continue to cause injury even after the inciting agent is removed. Ischemia, necrosis, and thrombosis can occur. Later, the damaged capillaries become more permeable and leakage of protein and fluid into the interstitial space results in edema. Third spacing of this fluid can result in profound intravascular hypovolemia and shock. In addition to the potential for hemodynamic instability, injured tissue can serve as a nidus for bacterial infections. Burn management is directed by determination of the location, depth of injury, and percentage of body surface area (BSA) involved.6 (Fig. 137-1)

image FIRST DEGREE

First-degree burns involve the epidermis and sensation remains intact. There are no blisters. A good example is sunburn. First-degree burns can easily be managed with pain medication and usually heal in one week (Fig. 137-2A).

image

FIGURE 137-2. A. First-degree burn. B. Second-degree burn. C & D. Third-degree burns.

image SECOND DEGREE

Second-degree burns, also known as partial-thickness burns, involve the epidermis and part of the dermis. The skin will be red or mottled, often with edema, blistering, weeping, and marked pain with air current or palpation of the area (Fig. 137-2B). Scalding injuries are the most common etiologies. Average healing time is approximately 2–3 weeks.

image THIRD DEGREE

Third-degree burns, also known as full-thickness burns, involve the entire extent of the epidermis and dermis. Nerve endings are damaged resulting in insensate skin, which can appear white, waxy, leathery, dark or black (Fig. 137-2C and D). The surface is usually painless and dry. The skin does not regenerate well and may require skin-grafting. Fluid losses can be severe with this type of injury.

image FOURTH DEGREE

Fourth-degree burns are also full-thickness burns, but extend even further than the underlying dermis involving muscles, tendons, and bone.

BSA CALCULATION

The location, percentage, and depth of burn will be necessary to calculate fluid requirements and determine need for burn center transfer or patient disposition. The BSA is generally calculated by using the “rule of nines.” This is a simple estimate, generally more useful with adults that assigns 9% BSA to the head and each upper extremity. Eighteen percent is estimated for the anterior chest and 18% to the posterior chest. Each lower extremity estimates 18% and the perineal area and genitalia are 1%. Children have different body proportions, especially the head, which can cause erroneous estimations. The head changes from a BSA of 19% in an infant to 7% in an adult size patient. Most physicians use the classic Lund and Browder chart to estimate % BSA burned as it adjusts for age of the patient (Fig. 137-3). A child’s palm including fingers can be used to estimate 1% of the TBSA.

image

FIGURE 137-3. Classic Lund and Browder chart.

CLINICAL EVALUATION

The initial evaluation begins with the ABC’s (airway, breathing, circulation) followed by history and physical examination. It is important to speak with prehospital transport personnel, the family, patient, and any witnesses to determine cause and details of the burn and to rule out possible child abuse or neglect. If the patient was a victim of fire, potential carbon monoxide or cyanide toxicity, as well as smoke inhalation injury and hypoxia must be considered. Burning clothing and all jewelry should be removed in the prehospital setting and ice or ice water should be avoided.

The primary survey should focus on patency of the child’s airway as well as severity of the burn. Victims of fires are at increased risk for airway edema. Carefully examine the face including oral mucosa and nasal hairs. Any carbonaceous sputum or singed nasal hairs should alert the physician to possible impending airway edema and inhalation injury requiring early endotracheal intubation. If intubation is not deemed necessary, but the patient has signs of bronchospasm or hypoxia, then humidified oxygen should be considered in addition to PEEP or CPAP. β-Adrenergic agonists, such as albuterol or levoalbuterol can also be used to treat bronchospasm. These patients require aggressive reassessment and monitoring with continuous cardiac, pulse oximetry, and often end tidal CO2 monitoring to rapidly detect clinical deterioration.

A child with greater than 20% BSA burned will need further management with two large-bore intravenous lines. In addition to routine laboratory studies, the patient will need a chest X-ray, ABG to assess acid/base status, oxygenation, and carbon monoxide level, and type/cross-match if surgery or skin grafting will become necessary. A myoglobin level may be useful, as severely injured patients can have significant muscle injury and rhabdomyolysis.

The secondary survey should include a thorough physical examination. Examination of the eye using fluorescein stain should be considered to evaluate for corneal burns. The location and depth of burns should be recorded on a standardized form. Of particular importance are circumferential burns, which may cause both vascular and respiratory compromise. Vascular perfusion should be carefully monitored using capillary refill and distal pulses, employing a Doppler evaluation if necessary. Signs of impending ischemia or compartment syndrome include pulselessness, paresthesias, and severe pain. If vascular compromise is apparent, the patient should undergo an immediate escharotomy, wherein a lateral incision is made through the depth of the eschar to relieve pressure. Escharotomy may also be indicated in circumferential burns of the thorax, which can mechanically impair chest wall expansion, leading to respiratory compromise.6

LABORATORY STUDIES

Key laboratory studies include a complete blood count, basic metabolic panel, myoglobin level, urinalysis, arterial blood gas, and coagulation studies along with type and cross-match if surgical repair becomes necessary. The white blood cell count in a burn victim will often be elevated initially because of acute demargination in response to injury, but can also be elevated because of infection. Burn patients can have a falsely elevated hemoglobin and hematocrit because of hemoconcentration from significant fluid loss, or can be low because of blood loss. It is important to assess the renal function in a burn patient in order to follow not only potential acidosis from volume loss, but also to see signs of acute tubular necrosis from myoglobinuria caused by muscle breakdown. The urine will show large blood without evidence of red cells on microscopic analysis. Hyperkalemia can also develop from cell breakdown and a potential metabolic acidosis from hypovolemia, and hypoperfusion can cause an extracellular shift of potassium. Aggressive hydration is necessary to avoid these potential complications.

MANAGEMENT

After airway management has been addressed, the priority in burn patients is fluid resuscitation. Although there is controversy on the subject of resuscitation formulas, the Parkland formula is widely used. This formula calls for an isotonic crystalloid solution (such as Lactated Ringers) to be given at 4 mL/kg/% BSA over a 24-hour period. Half of this fluid volume is given over the first 8 hours, and the second half is given over the next 16 hours. BSA can be calculated using the Lund and Browder diagram (Fig. 137-3), with only second- and third-degree burns factoring into fluid resuscitation. Pediatric patients should be started on maintenance IV fluids in addition to resuscitation fluids and adjustments made to fluid rates in order to maintain urine output of 1–2 mL/kg/h for children and 0.5–1 mL/kg/h for adolescents and adults.

Tetanus immunization should be administered to all patients without a complete immunizations series or who have not had a tetanus booster within 5 years.

Pain management is an important consideration in burn management. Burns, especially partial-thickness burns, can be extremely painful. Opioid analgesia is often required, preferably given intravenously because of fluid shifts and absorption irregularities from the oral and intramuscular routes. Morphine is the most commonly used analgesic, with a starting dose of 0.1 mg/kg IV.7

Initial wound care in the emergency department should consist of covering the burns with a dry, sterile sheet. The burn surface can be cleaned with a sterile saline solution, and debridement may be performed on devitalized tissue. Sterile saline-soaked dressings may be applied to small burns, but should be avoided in large burns because of the risk of developing hypothermia. Antiseptic solutions such as povidone–iodine and topical antibiotics should be avoided in patients who are being transferred to a burn center until the primary service has had the opportunity to evaluate the wounds.

Minor burns can be managed on an outpatient basis. These burns should be cleaned with sterile saline solution. Ruptured blisters and devitalized tissue should be debrided. The management of intact blisters remains controversial; large, painful, or hemorrhagic blisters should be debrided but smaller blisters can be left intact.8 Topical antibiotics are routine in outpatient burn care. One percent silver sulfadiazine cream is most commonly used, although it should be avoided in facial burns due to the risk of tissue hypopigmentation. Bacitracin ointment is an alternative agent for the face or small burns. Do not apply topical antibiotics if transferring to a burn center or another hospital pending discussion with accepting pediatric or burn surgeon due to need for visualization of the burn, varying opinions on topical treatment choices, or possibility of skin grafts. Sterile gauze dressings should be applied over topical antibiotic ointment or cream and changed once or twice daily.

There are several popular commercially available products for treatment of burns including silver-containing antimicrobial dressings made of carboxymethylcellulose fibers. These newer synthetic alternatives are often used for outpatient burn management in children. Designed to act as a “second skin,” these dressings do not require frequent changes and have been associated with improved patient compliance and outcomes.9,10

All burn patients should be reevaluated at 24–48 hours to ensure proper wound healing and to examine for signs of infection. Oral pain medication may be required before dressing changes.

DISPOSITION

Indications for outpatient management, admission, and transfer to burn center are given in Table 137-1.

Table 137-1

Burn Center Referral Criteria

Partial-thickness and full-thickness burns >10% TBSA in patients <10 years or >50 years of age or >20% TBSA in other age groups.

Partial-thickness and full-thickness burns involving face, eyes, ears, hands, feet, genitalia, perineum, or major joints.

Full-thickness burns >5%TBSA in any age group.

Significant electrical burns, including lightning injury.

Significant chemical burns.

Inhalation injury.

Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

Patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. If the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.

Burned children in hospitals without qualified personnel or equipment for the care of children.

Burn injury in patients who will require special social, emotional, or rehabilitative intervention including suspected child abuse and neglect.

All transfers should be evaluated on an individual case basis including consideration of physician judgment and regional medical control, disaster, and triage protocols.

Source: Data from American Burn Association. http://www.ameriburn.org/BurnCenterReferralCriteria.pdf?PHPSESSID=6a506bc17284a5d434d023412cc6be630 and Advanced Trauma Life Support for Doctors Student Course Manual. 8th ed.; 2008,(6) p. 219.6

PREVENTION

Most pediatric burns are unintentional and preventable. Prevention techniques include: keeping pot handles turned inside away from reach, keeping irons and heated hair appliances unplugged when not in use or associated electrical cords out of reach, and maintaining bath water less than 120ºF by setting water heater thermostats. Home fire prevention methods include smoke-detector programs, school fire prevention programs, planned escape routes, and cigarette lighter safety design. Many pediatricians, family physicians, and emergency care providers are involved in community outreach programs promoting burn safety.

ACKNOWLEDGEMENTS

The author would like to recognize Kavitha Reddy and Lisa Parke Maier for their contributions to this chapter in previous editions.

REFERENCES

1. Vital Signs. Unintentional Injury Deaths Among Persons Aged 0–19 Years — United States, 2000-2009. MMWR. Early release April 16, 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0416a1.htm?s_cid=mm61e0416a1_w

2. CDC Fire Deaths and Injuries Fact Sheet. http://www.cdc.gov/homeandrecreationalsafety/fire-prevention/fires-factsheet.html. Accessed December 12, 2012.

3. D’Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990 and 2006. Pediatrics. 2009;124:1424–1430.

4. Sheridan RL, Remensnyder JP, Schnitzer JJ, Schulz JT, Ryan CM, Tompkins RG. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med. 2000;154:245–249.

5. Peck MD, Priolo-Kapel D. Child abuse by burning: a review of the literature and an algorithm for medical investigations. J Trauma-Inj Infect Critic Care.2002;53:1013–1022.

6. American College of Surgeons. Committee on Trauma. Advanced Trauma Life Support for Doctors. 8th ed. Chicago, IL: American College of Surgeons; 2008.

7. Gandhi M, Thomson C, Lord D, Enoch S. Management of pain in children with burns. Int J Pediatr. 2010; Article ID 825657, 9 pp. doi:10.1155/2010/825657.

8. Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res. 2006;27:66.

9. Caruso DM, Foster KN, Blome-Eberwein SA, et al. Randomized clinical study of Hydrofiber dressing with silver or silver sulfa-diazine in the management of partial-thickness burns. J Burn Care Res.

10. Hindy A. Comparative study between sodium carboxymethyl-cellulose silver, moist exposed burn ointment, and saline-soaked dressing for treatment of facial burns. Ann Burns Fire Disasters. 2009;22:131–137.