Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter XXI.4. Burns
Annemarie Uliasz
July 2002

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This is a 3 year old male who is brought to the emergency room after suffering burns to the right arm when a hot cup of coffee spilled on him. His family applied gel from an Aloe plant to the burn before coming to the ER. He is otherwise healthy and his immunizations are up to date.

Exam: VS T 37.5, P120, R20, BP (unobtainable, crying), oxygen saturation 100% in room air. Weight 15 kg. He is alert and active, in moderate distress. His right forearm appears mostly red, and is painful upon palpation. Blanching is apparent on palpation. One smaller intact blister and one large ruptured blister are present on the dorsal aspect of the right forearm. The blistered surface area is estimated to be 2% and the non-blistered red area is estimated to be 2% for a total body surface area (TBSA) of 4%.

The physician recommends an IM dose of morphine, but his parents decline this, so acetaminophen with codeine is given instead. Cool, sterile, saline-soaked gauze is applied to the wound surface and the open areas are gently cleansed with saline. Tissue from the ruptured blister is removed and the intact blister is flimsy so it is drained and removed. Silver sulfadiazine cream is applied to areas of partial thickness burns and the burns are dressed. He is discharged with instructions for the parents to gently cleanse the burns with mild soap and water, reapply the antibacterial cream, and change the dressing each day. His burn healed completely without complications in five weeks.


Fires are second only to motor vehicle crashes as a leading cause of death in children. In the US, approximately 1.2 million people seek medical treatment for burns. Approximately 50,000 are hospitalized. One third to one half of these are under 18 years old. Children from birth to age 4 account for nearly 50% of all pediatric burns (1). After age 4, the incidence of burn injuries declines only to rise again in adolescence as individuals enter the work force.

Skin is the largest organ in the body. It consists of three main layers: the epidermis, the dermis, and the subcutaneous tissue. The epidermis is the outermost layer of the skin. It is composed of viable cells that mature and differentiate into cornified cells as they reach the skin surface. The superficial layer of anuclear cornified cells is called the stratum corneum. The stratum corneum prevents water and electrolyte loss, as well as acting as barrier to the entrance of microorganisms.

Deep to the epidermis is the dermis. The dermis is made up of stroma, a dense fibroelastic connective tissue containing collagen and elastic fibers, and ground substance, an extracellular gel. The dermis contains an extensive neurovascular network, special glands and appendages that communicate with overlying epidermis. The innermost layer of skin is subcutaneous tissue. It consists of fatty connective tissue, skin appendages, glands, and hair follicles.

Burns are classified according to the depth of injury. First degree burns are limited to the epidermis. A sunburn is an example of a first degree burn. These burns are red, dry and painful with no epidermal sloughing or blistering. Blanching is visible when pressure is applied to the wound. First degree burns do not lead to scarring, and require only local wound care. Second degree (partial thickness) burns extend into the dermis, with some residual dermis remaining viable. These burns are pink to pale pink, moist, and painful. They blanch on application of pressure. Epidermal sloughing and blisters are present. In third degree (full thickness) burns, the entire dermis is destroyed leaving subcutaneous tissue exposed. These burns appear white, mottled, or charred. They are dry and may be firm or leathery. Third degree burns do not blanch and are not painful. Fourth degree (transmural) burns extend through the subcutaneous tissue, exposing muscle and bone. They are usually associated with a lethal injury.

Most pediatric burn injuries occur at home and are largely preventable. In children younger than 4 years old, the most frequent burns are scalds. These injuries are the result of exposure to hot liquids (pulling pots off the stove, spilling hot beverages, or hot tap water). The second most frequent cause of burn injuries is contact with hot objects (the stovetop, a hot oven door, clothes irons, or curling irons). Furthermore, infants, toddlers, and small children may not be able to escape the burning object as well as an older child. Prolonged duration of contact may increase the severity of the injury. In older children, the majority of burns are due to fires and environmental causes such as hot barbecue grills, hot mufflers or engines.

Although the majority of pediatric burns are accidental, approximately 20% of burn injuries occur as a result of child abuse (2). If a non-accidental burn is suspected, the family should be questioned carefully. Any inconsistencies in the history of the injury suggest the possibility of child abuse and should be reported to the child protective authorities as required by law. Chronically abused children may have a depressed affect. Furthermore, the pattern of the burn may be suspicious of intentional injury. Scalding burns of the extremities in which the entire foot or hand is burned, with a glove or stocking pattern and lack of splash marks, suggest forced immersion into hot water. Additionally, burns on the back, buttock, or both soles of the feet are highly suspicious for child abuse. The depth of the burn is another factor to keep in mind when abuse is being considered. Partial thickness burns commonly result from accidental scalding. Full thickness burns caused by scalding suggest sustained contact with hot water. Small area, full thickness burns suggest injury from a cigarette. Evidence of other trauma, such as bruising or numerous healed wounds, should be documented.

The first step in management of a burn injury is assessment of life-threatening conditions. The airway must be evaluated immediately for compromise in the case of burns caused by flame or history of smoke exposure. Smoke inhalation can result in severe inflammation of the airways and lungs. Classic signs associated with significant smoke inhalation are burns to the face or nasal hairs and/or carbonaceous sputum. Because the airway can swell rapidly, this condition must be treated aggressively and quickly to prevent airway obstruction. Immediate tracheal intubation is indicated if the patient shows signs of laryngeal edema, such as hoarseness, stridor, or a brassy cough. Endotracheal intubation and mechanical ventilation are required in the case of respiratory failure. Signs of respiratory failure include the development of tachypnea, use of accessory respiratory muscles, and hypoxemia (3).

All patients exposed to smoke in an enclosed space should be screened for carbon monoxide poisoning by measuring a CO level or co-oximetry since an arterial blood gas and pulse oximetry will not adequately identify CO poisoning.

To accurately estimate the depth of skin injury, devitalized tissue must be debrided, and large blisters must be removed. This procedure is usually painful and requires potent analgesics. Burn depth is estimated by careful observation of the wound surface.

The extent of total body surface area (TBSA) covered by second or third degree burns has a great impact on the morbidity and mortality, and must be estimated. Areas of first degree burns are associated with negligible mortality, so the important components of the TBSA are the areas of second and third degree burns. Although time-consuming, the Lund and Browder chart is the most accurate method of determining TBSA. It consists of an anterior and posterior diagram of a patient that is divided into sections which can be colored in according to the distribution of the patient's burns. The TBSA of burn is the sum of the colored areas. Different charts are available for different age groups. An alternative to the Lund and Browder chart is the rule of nines. In this method, the body is divided into eleven areas of nine percent each. Each upper extremity is 9%, the anterior and posterior portions of each lower extremity are 9%, the anterior upper and lower portions of torso are 9% each, the posterior upper and lower portions of the torso are 9% each, and the neck and head together is 9% to give a total of 99%. The perineum makes up the remaining 1%. However, it must be taken into account that the head is relatively larger and the legs relatively smaller in surface area for children compared with adults. A palm of the hand on one side including the area of the digits, is approximately 1% of the body surface area and can be used to estimate the TBSA of burn.

A burn covering 10% or more of the TBSA of a child is considered a serious burn and should be managed as an inpatient, preferably in a burn unit where specialized expertise is available. Significant burns of face, hands, genitalia, feet, or across the joints are categorized as serious. Transfer to or consultation with a burn center should be considered for these patients.

Management: Any clothing and jewelry should be removed from the area of the burn. If clothing has adhered to the skin, it should be left for removal during the cleansing of the wound (4). Non-adherent material may be cut away. To decrease pain, the burn may be cooled with the application of cooled, sterile, saline-soaked gauze.

Prior to cleaning the burn, analgesia is desirable (4). Burns should be cleansed to remove contaminating debris. Tar or asphalt may be removed with a mixture of cool water and mineral oil (4). Embedded clothing and debris can be removed by irrigation.

Necrotic tissue must be debrided to minimize infection. Removal of necrotic tissue can be accelerated with the use of enzymatic debriding preparations such as collagenase and papain-urea preparations. These preparations may be less painful and may hasten epithelialization. Blisters which have already lysed should be debrided so that the excess skin does not harbor infection. Flimsy intact large blisters are likely to lyse on their own soon, so these can be debrided as well. Small firm blisters can be left alone. The appearance of the burn on the second day almost always looks worse with enlarging blisters. This should be anticipated in counseling.

Patients suffering wounds deeper than a superficial partial-thickness burn should have their tetanus immunization updated. Bacitracin ointment or silver sulfadiazine cream are not necessary in the treatment of superficial burns, but should be used to prevent infection in all other burns.

Once cleansed, the wound should be dressed daily until epithelialization occurs. This will provide some pain relief, protect the wound from infection, and absorb drainage from the wound.

Superficial partial thickness burns heal in approximately 1-3 weeks. Most deep partial-thickness burns eventually heal by epithelialization in 3-9 weeks. Epithelialization begins in the dermis in the remaining hair follicles. As buds of epithelium grow, they eventually merge to close the wound. Hair follicles are destroyed in full-thickness wounds preventing epithelialization. Full thickness burns require surgical treatment consisting of eschar excision and skin grafting.

Severely injured patients are better served at a designated burn center specifically trained in analgesia and wound care for patients with burns. Transfer to a burn center should be considered in more severe burns, major burns to the hands, face, feet, perineum, or complex electrical burns.

If an extremity is involved, immobilization and elevation may be helpful to reduce edema. Edema may increase ischemia and tissue necrosis. Furthermore, compartment syndrome may develop in an extremity that has sustained a circumferential burn. Patients with circumferential burns of an extremity should be admitted to the hospital for observation of the development of this potentially limb and life threatening condition.

Patients with burns covering 10-15% of the TBSA or more, usually require parenteral fluids. Ingestion of fluids may be inadequate in children due to pain, anxiety, and the effects of narcotics. Extravasation of fluid into unburned tissue as well as increased evaporation from the surface of the wound results in hypovolemia. Fluids must be administered to prevent hypovolemia-induced ischemia, lactic acidosis, and shock. Fluid resuscitation with Ringer's lactate or normal saline solution should be administered according to the Parkland formula (7). This formula estimates the fluid requirements of the pediatric patient for the first 24 hours (4 cc/kg for each TBSA percentage point infused over 24 hours in addition to the maintenance calculation), but urinary output is the best indicator of satisfactory hydration. Although adequate fluid administration is essential, it is important to avoid over-hydration. Increased hydrostatic pressure and decreased oncotic pressure from protein loss contributes to the fluid shift, and over-hydration may result in increased wound and whole-body edema (including pulmonary edema and respiratory compromise).

When administering fluid to infants, it is important to appreciate the lack of maturity of their kidneys. Adult glomerular filtration rate levels are not achieved until age 9-12 months. The infant handles fluid overload very inefficiently. Because of an imbalance of maturation of tubular and glomerular functions, the osmolar concentrating ability is estimated to be one half of that seen in adults (6).

Loss of water by evaporation leads to heat loss. Small pediatric burn patients are especially at risk for hypothermia. In order to minimize radiant and evaporative heat loss, the ambient temperature should be kept sufficiently high. IV fluids should be warmed during large fluid infusions. Special care should be taken in patients younger than 6 months old. Children in this age group do not have the ability to shiver. Thermiogenesis is accomplished by catabolism of fat stores requiring large amounts of oxygen. Excessive lactate production and metabolic acidosis may result from prolonged thermiogenesis.

The basal metabolic rate may double after a major burn injury. The increase in metabolic expenditure is roughly proportionate to the surface area burned. For example, a child with a burn covering 50% TBSA requires an increase in the basal level of calories of at least 50%. To decrease the loss of muscle mass, about 20% of the calories administered should be from protein.

Most children sustain electrical burns by the insertion of a metal object into a wall outlet or by exposure to frayed electric cords. Intense heat and deep injuries are produced when the current passes through the tissues. If a child puts a live electric cord into the oral cavity, the lips may be burned. Additionally, the burn may extend completely through the lips and oral mucosa to the labial artery. This can be potentially catastrophic if this artery erodes due to sloughing of necrotic tissue. Sudden hemorrhage can occur as late as one week after injury (1).

Burn injuries may result in scarring and contracture. There is a high risk of scar formation associated with burn wounds that take more than 3 weeks to heal. Furthermore, scars may develop in wounds that heal spontaneously without skin grafting. Children tend to scar worse than adults, and patients with dark skin color, scar worse than patients with light skin. Pressure garments worn 24 hours a day, continuously for one year after healing, may limit the progression of scarring. Joint contractures are characteristic of scarring.

Physical and occupational therapy should begin on the day of admission in order to maximize the cosmetic and functional outcome. If necessary, therapy may continue after discharge for several months as the scar tissue forms and contractures develop. Rehabilitation involves joint positioning, active and passive range of motion exercises, limitation of pressure necrosis, ambulation, and assistance in daily activity. Rehabilitation programs for burn patients consist not only of physical support, but emotional support as well. As the pediatric burn patient matures and enters into new social situations, psychological support may be beneficial.


Questions

1. When is antibacterial ointment indicated?

2. When treating an infant, what are some special considerations that must be acknowledged?

3. When should a patient be sent to a burn unit?

4. How is the %TBSA calculated?

5. What formula is used to determine the amount of fluid administered to the pediatric burn patient within the first 24 hrs?

6. Despite following the above fluid formula, a burn patient has a continuous urine output via urinary catheter of only 0.2 cc/kg/hr (ideally, this should be about 1 cc/kg/hr). The child appears to be moderately edematous. Should the fluid rate be increased or continued at the same rate?


References

1. Hansbrough JF, Hansbrough W. Pediatric Burns. Pediatr Rev 1999;20(4):117-123.

2. Smith ML. Pediatric burns: management of thermal, electrical, and chemical burns and burn-like dermatologic conditions. Pediatr Ann 2000;29(6):367-378.

3. Monafo WW. Initial management of burns. N Engl J Med 1996;335(21):1581-1586.

4. Morgan ED, Bledsoe SC, et al. Ambulatory Management of Burns. AAFP 2000;62(9):2015-26, 2029-30, 2032.

5. Henry DB. Burn pain management in children. Pediatr Clin North Am 2000;47(3):681-698.

6. Lucchesi M. "Thermal Burns." eMedicine Journal. January 3, 2002, volume 3, number 1.

7. Battan FK, Dart RC. Chapter 11 - Emergencies, Injuries, and Poisoning. In: Hay WW, Hayward AR, et al (eds). Current Pediatric Diagnosis and Treatment, fifteenth edition. 2001, New York: McGraw-Hill, pp. 289-291.


Answers to questions

1. Antibiotic ointments such as silver sulfadiazine and bacitracin are indicated for all burns except superficial burns.

2. Infants 6 months old or younger are more prone to fluid overload because of their reduced glomerular filtration rates. Additionally, they are more susceptible to hypothermia because they are unable to generate heat by shivering.

3. A patient should be sent to a burn unit if they have serious burns that are beyond the scope of care in the local institution. Examples of this include, second degree burns of 20% TBSA, third-degree burns of 5% TBSA, major burns to the hands, face, feet, perineum, or electrical burns.

4. % TBSA can be estimated by using the rule of nines, the Lund and Browder chart, or by designating the child's palm as 1% of the TBSA. The most accurate method is the Lund and Browder chart.

5. The Parkland formula is used to estimate the amount of fluid appropriate for administration in the first 24 hours.

6. The slow urine output indicates hypovolemia. The fluid infusion rate should be increased to improve the urine output.


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