The Pediatric Burn Patient: A Simplified Approach

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Burns are a fairly common occurrence among the pediatric population. While most burns are limited and require only localized wound care and outpatient follow up, severe burns can be quite a challenge to care for and treat. Of the three types of burns – thermal, electrical, and chemical – the most common by far is thermal, which includes direct exposure to fire or flame, scalding injury, and contact burns.1 Emergency physicians at both tertiary centers and community EDs should feel confident and prepared to perform the initial assessment of burns, initiate fluid resuscitation, provide adequate analgesia, and arrange for the next level of care. Although burn patients can provoke anxiety, even for experienced practitioners, don’t get rattled. Use the ATLS™ Primary Survey to guide your initial management.

A. Look for signs of airway compromise – facial burn, singed brows or eye lashes, soot in the nose or mouth, a hoarse or absent cry or voice, low oxygen saturation with no visible outer injury, or, in the case of chemical burn due to ingestion with aspiration, there may be residual toxin on lips or tongue.2 If the airway is compromised or the child is unable to protect their airway, intubation should not be delayed. If your department is equipped, having fiber optic bronchoscopy at the bedside is recommended as airway inflammation and edema can obscure direct laryngoscopy and complicate intubation. Some of these patients may require a surgical airway.3 Along with managing the airway, there should be no delay in providing pain relief, and if IV access becomes a challenge, intranasal fentanyl (3 mcg/kg) and midazolam (0.2 – 0.3 mg/kg) can be given.4,5 When IV access is established, you may choose to continue with procedural sedation (if not already intubated and sedated) for further debridement with any number of sedating agents, including fentanyl and midazolam, ketofol, or ketamine. As an outpatient, pediatric analgesia can often be achieved with acetaminophen or ibuprofen.6

B. The primary cause of burn injuries in patients under five years of age is scalding. Inhalation is less prevalent than in adults, but in the setting of structure fires children are less capable of escaping from confined spaces, and therefore are more susceptible to inhalation injury.1 When there is concern for inhalational injury, a carboxyhemoglobin level should be measured, and an assessment for concomitant cyanide toxicity performed. Carboxyhemoglobin elevations should at least prompt consideration for hyperbaric oxygen therapy at the nearest facility with such capabilities. Patients should be maintained on 100% FiO2 by non-rebreather. Monitor for airway edema during fluid resuscitation, as the large volumes these patients need for repletion may precipitate swelling. There is also the risk of pneumonitis with chemical aspiration or inhalation burns, which often declare themselves later in the course of illness.

C. The assessment of circulation starts with the external exam, looking for circumferential limb burns that may threaten perfusion to the distal limb. With contraction, a circumferential burn can cause ischemic injury that may precipitate irreversible nerve and muscle damage. Perform frequent neurovascular exams, and be prepared for emergency escharotomy. It is crucial to determine the percentage of total body surface area (%TBSA) of second and third degree burns to plan appropriate fluid resuscitation. Several techniques can assist in this estimation, including the hand technique (1%TBSA per patient palm size), Lund Browder chart, or the free online tool found at www.SageDiagram.com. In any pediatric patient with >10% TBSA, the classic teaching includes using the Parkland formula. This involves administration of 4 mL/kg x %TBSA burned, with 50% given in the first eight hours from the time of injury, and the second half given over the next 16 hours.7 The %TBSA is frequently overestimated outside of certified burn centers.8 Of late, there has also been concern that the Parkland formula may not provide a correct estimation. Under-resuscitation can lead to organ failure, but over-resuscitation can lead to “fluid creep,” which leads to airway edema/ARDS, pleural or pericardial effusions, deep conversions of burns, and limb or abdominal compartment syndromes.9 During the resuscitation, titrate fluid according to the patient’s urine output, with a goal of 1-2mL/kg/hr. Crystalloids are the most frequent choice in the acute setting. Lactated Ringer’s is cited as a preferable fluid option, however head-to-head crystalloid fluid efficacy studies are lacking in pediatric burn patients.10,11 Early initiation of enteral nutrition has shown improved outcomes in pediatric burn patients, so be proactive and place the NG tube to feed the gut.12,13

D. Don’t forget to look for other injuries sustained at the time of the burn or during escape from the burning environment. Non-accidental trauma should be considered, with special attention paid to the mechanism of injury and the stage of child development. Clues such as delay in seeking care, unwitnessed injury, and suspicious burn patterns (i.e., submersion scalds, irons, or punctate cigarette burns) should prompt further evaluation and a child protective services referral.10

E. Exposure, in the case of burns, includes complete disrobement and express transfer to the pediatric regional burn center. The American Burn Association has burn center referral criteria.1,7 There are eight states in the country without a regional burn center, so no matter where you practice, it is important to be familiar with your facility’s resources and the nearest next level care. If the child can be discharged, outpatient follow up should be arranged with return instructions for fever >38.5C° after 72 hours from the time of injury, inability to take good PO, or abnormal behavior between pain control. Parents should be educated about dressing changes and keeping the area clean and dry. Children with a concurrent viral or bacterial illness will often have their illness exacerbated with the SIRS response from the burn. Lastly, take a minute to provide anticipatory guidance on burn prevention, because the best burn is the one that never happens.

References

  1. American Burn Association National Burn Repository 2014 Version 10.0
  2. Cowan D, Ho B, Sykes KJ, et al: Pediatric oral burns: A ten-year review of patient characteristics, etiologies and treatment outcomes. International Journal of Pediatric Otorhinolaryngology 77:1325-28, 2013.
  3. Sen S, Heather J, Palmieri T, et al: Tracheostomy in pediatric burn patients. Burns 41:248-251, 2015.
  4. Goodwin SA, Burton JH, Gerardo CJ, et al: Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Annals of Emergency Medicine 63(2): 247-258, 2014.
  5. Pacheco GS, Ferayorni A: Pediatric Procedural Sedation and Analgesia. Emergency Medicine Clinics of North America 31:831-852, 2013.
  6. Cowan D, Ho B, Sykes KJ, et al: Pediatric oral burns: A ten-year review of patient characteristics, etiologies and treatment outcomes. International Journal of Pediatric Otorhinolaryngology 77:1325-28, 2013.
  7. Goutos I, Tyler M: Early management of paediatric burn injuries. Paediatrics and Child Health 23(9): 391-39,2013.
  8. Swords DS, Hadley ED, Swett KR, et al: Total body surface area overestimation at referring institutions in children transferred to a burn center. The American Surgeon 81(1):56-63, 2015.
  9. Jeschke MG, Herndon DN. Burns in children: standard and new treatments. Lancet 383: 1168-78, 2014.
  10. Gonzalez R, Shanti CM: Overview of current pediatric burn care. Seminars in Pediatric Surgery 24(1):47-49.2015
  11. Kraft R, Herndon DN, Branski LK, et al: Optimized fluid management improves outcomes of pediatric burn patients. Journal of Surgical Research 181:121-128, 2013.
  12. Khorasani EN, Mansouri F: Effect of early enteral nutrition on morbidity and mortality in children with burns. Burns 36(7): 1067-71, 2010.
  13. Mosier MJ, Pham TN, Klein MB, et al: Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study. Journal of Burn Care Resuscitation 32(1): 104-9, 2011.
Megan Cobb, MD, DPT

Megan Cobb, MD, DPT

Pediatrics & Emergency Medicine Residency, University of Maryland Medical Center, Baltimore, MD
Megan Cobb, MD, DPT

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