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Moderate and severe thermal burns in children: Emergency management

Moderate and severe thermal burns in children: Emergency management
Literature review current through: Sep 2023.
This topic last updated: Jul 14, 2023.

INTRODUCTION — This topic will review the emergency management of moderate to severe thermal burns in children (table 1).

The care of minor thermal burns, smoke inhalation, chemical burns to the skin and eye, electrical injuries, and ongoing burn management, are discussed separately.

(See "Treatment of minor thermal burns".)

(See "Inhalation injury from heat, smoke, or chemical irritants".)

(See "Topical chemical burns: Initial assessment and management".)

(See "Electrical injuries and lightning strikes: Evaluation and management".)

(See "Overview of the management of the severely burned patient".)

PATHOPHYSIOLOGY — Local injury, systemic response, and metabolic changes combine to determine the severity of a burn injury as follows:

Burn wound – Significant thermal energy transferred to skin denatures and coagulates protein, resulting in irreversible tissue destruction. Surrounding this zone of coagulation is an at-risk area of decreased perfusion [1]. Tissue in this zone is salvageable, provided that resuscitative efforts are successful in restoring perfusion. Perfusion is increased at the outer margins of the burn. Tissue in this zone can recover as long as the patient does not experience prolonged hypoperfusion.

The intensity and duration of thermal exposure determines the depth of a burn wound [2]. Prolonged skin contact from hot liquids with high specific heat or high viscosity can result in deeper burns. Deeper burns are more common in young infants and children because their epidermis and dermis are thinner than the skin of adults [1].

Systemic response – Immediately following the burn injury, vasoactive mediators (such as cytokines, prostaglandins, and oxygen radicals) are released from damaged tissue [3]. Increased capillary permeability results in extravasation of fluid into the interstitial space around the burn. Patients with large burns (≥15 percent TBSA for young children and ≥20 percent for older children and adolescents) often develop systemic responses to these mediators. For patients with 40 percent TBSA or more, myocardial depression and systemic capillary leak can occur [4]. As a result, patients with major burns may become hypotensive (burn shock) and edematous (burn edema).

Systemic capillary leak usually persists for 18 to 24 hours, though venular permeability to albumen may resolve as early as six hours post-burn injury [5]. Protein is lost from the intravascular space soon after a major burn, after which vascular integrity improves.

In large burns, up to 15 percent of red blood cells may be destroyed locally and an additional reduction of 25 percent of the red blood cell mass may occur due to decreased red cell survival time [3]. This reduction in oxygen carrying capacity may exacerbate burn shock.

Metabolic response – Following resuscitation, children with major burns develop a long-lasting hypermetabolic response that results in a dramatic increase in energy expenditure and proteolysis. Increases in catecholamines, glucagon, and cortisol are correlated with elevation of metabolic rate and catabolism. Levels of anabolic hormones such as human growth hormone and insulin-like growth factor are decreased for several weeks following a significant burn. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Hypermetabolic response'.)

Evidence suggests that modulation of the hypermetabolic response with a variety of therapies may improve outcomes for severely burned children. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Attenuation of the hypermetabolic response'.)

CLASSIFICATION — The American Burn Association (ABA) has provided guidance regarding the severity of burns with clinical parameters that define which patients should be referred to a burn center (ie, severe burns) (table 2). Patients who do not meet these criteria but require hospitalization are regarded as having moderate burns, and those who meet criteria for outpatient management have mild or minor burns. Thus, it is important that clinicians properly characterize the size and severity of their patients' burns. The classification of burns is discussed separately. (See "Assessment and classification of burn injury".)

Burn size is typically expressed as the percentage of total body surface area (TBSA) that is burned. Only partial (dermal) and full-thickness burns are included in this estimation (see "Assessment and classification of burn injury", section on 'Classification by depth'). A modification of the Lund and Browder chart for calculation of percent TBSA is used most often for children (figure 1 and table 3).

The system currently being used to classify burn depth is based upon the need for surgical intervention, which is required for deep partial thickness, full thickness, or deeper burns (table 1 and figure 2).

PREHOSPITAL CARE — Priorities for the prehospital care of patients with moderate or severe thermal burns include the following [6]:

Provide basic life support. Patients should usually receive supplemental oxygen. Children rarely require assisted ventilation. Patients with airway burns and longer transport times may require intubation.

Rapidly transfer the patient to a hospital. Minimize interventions that delay transport.

Stop the burning process. Burnt clothing and any jewelry should be removed (unless stuck to the patient). Chemical burns may require immediate irrigation.

Covering the burn area with a clean sheet or blanket reduces pain and keeps the child warm.

Fluid administration is not usually necessary for transport times less than one hour. Patients with larger burns and prolonged transport times may require intravenous (IV) fluid therapy.

Pain may be treated with IV, or intranasal (IN) administration of pain medications (eg, IV or IN fentanyl). Intramuscular administration of analgesia may be ineffective or unpredictable when given to patients with burn shock. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Fentanyl' and "Pain in children: Approach to pain assessment and overview of management principles", section on 'Opioids'.)

For small and moderate burns, cooling immediately after a burn injury limits the area of injury and improves wound healing [7,8]. Experts recommend that the burn area be cooled with water for at least 20 minutes immediately following the injury [6,9]. The benefit of cooling for longer than 30 minutes after injury is uncertain. Water temperature should not be lower than 8°C. Ice should never be applied to burns. The patient should be carefully monitored to prevent hypothermia.

EVALUATION — The initial priorities for the management of a burn patient are similar to those for any injured child. Life-threatening conditions (such as airway compromise, respiratory insufficiency, and/or inadequate circulation) must be rapidly recognized and stabilized. Serious associated injuries must be identified and children with major burns should receive prompt fluid resuscitation.

An initial approach to the injured child, as well as the assessment of airway, ventilatory, and circulatory function in children is reviewed separately. (See "Classification of trauma in children" and "Initial assessment and stabilization of children with respiratory or circulatory compromise", section on 'Initial assessment' and "Technique of emergency endotracheal intubation in children" and "Assessment of systemic perfusion in children".)

The remainder of this discussion will focus on the evaluation specific to children with moderate and severe thermal burns (algorithm 1).

Initial rapid assessment

Airway – Patients with upper airway burns should be intubated early, before airway anatomy becomes distorted by edema. Securing the endotracheal tube is of paramount importance. Soot in the mouth, facial burns, and body burns may be more useful predictors of inhalation injury than symptoms of stridor, hoarseness, drooling, and dysphagia [10].

Breathing – Decreased level of consciousness, inhaled smoke or toxins (such as carbon monoxide or cyanide), or associated injuries can interfere with ventilation and/or oxygenation. Patients with circumferential burns to the chest or abdomen may develop respiratory compromise as the result of decreased chest wall compliance.

Circulation – Children with signs of compromised circulation at initial presentation (such as unexplained tachycardia, poor peripheral perfusion, or hypotension) should be carefully evaluated for associated injuries. (See "Thoracic trauma in children: Initial stabilization and evaluation", section on 'Initial rapid assessment' and "Pediatric blunt abdominal trauma: Initial evaluation and stabilization", section on 'Evaluation in the stable patient'.)

Children with compromised circulation who are being examined several hours after the burn injury may be experiencing burn shock, with or without associated injuries. (See 'Pathophysiology' above.)

Immediate burn care – During the initial resuscitation, burn care should be limited to preventing further injury by removing clothing that is hot, burned, or exposed to chemicals. Jewelry that may become constricting should also be removed.

History — Historical features may identify children at risk for any of the following:

Patients with flame burns who have been injured in an enclosed space may have experienced smoke inhalation.

Children with flame burns may have been exposed to carbon monoxide (as the result of carbon combustion) or cyanide (from the combustion of materials such as polyurethane, acrylonitrile, nylon, wool, or cotton).

History of a fall or explosion suggests the possibility of associated injuries.

Patients with electrical burns from exposure to high voltage (>1000 V) may have associated conditions such as cardiac arrhythmias, fractures, compartment syndromes, and myoglobinuria (table 4). (See "Electrical injuries and lightning strikes: Evaluation and management".)

Chemical burns require copious irrigation. Life-threatening hypocalcemia can develop as the result of exposure to concentrated or anhydrous hydrofluoric acid. (See "Topical chemical burns: Initial assessment and management", section on 'Hydrofluoric acid'.)

Inconsistencies in the history may indicate an inflicted injury.

Physical examination — A complete physical examination, including vital signs with pulse oximetry, should be performed. An accurate weight is essential for determining fluid requirements and should be obtained whenever possible. Capnography may be helpful for assessing ventilation and detecting metabolic acidosis. (See "Carbon dioxide monitoring (capnography)", section on 'Detecting metabolic acidosis'.)

For victims of house fires with carbon monoxide poisoning, oxygen saturation by pulse oximetry will often be normal or elevated and falsely reassuring relative to directly measured oxygen saturation. (See 'Diagnostic studies' below and "Carbon monoxide poisoning", section on 'Diagnosis'.)

General examination — Children with significant associated injuries such as inhalation, head injury, or blunt abdominal trauma can have normal or nonspecific findings on initial physical examination. The following clinical features, when present, may indicate specific conditions:

A depressed mental status may be the result of hypoxia, hypotension, toxins such as carbon monoxide and/or cyanide, head injury, or pain medication.

Children with signs of upper airway obstruction (such as drooling or stridor) may have upper airway injury. Patients with singed nasal hair, hoarseness, or carbonaceous sputum are likely to have upper airway burns. (See "Inhalation injury from heat, smoke, or chemical irritants".)

Thermal injury to the epiglottis has been reported in association with scald burns to the face [11].

Signs of respiratory distress (such as tachypnea, retractions, or grunting) or wheezing suggest an inhalation injury. (See "Inhalation injury from heat, smoke, or chemical irritants".)

Abdominal tenderness, in association with a compatible history, may indicate an intraabdominal injury.

Evaluation of burn injury — The size (percent total body surface area [TBSA]) and depth (superficial, superficial or deep partial thickness, full thickness, or deeper) of the burn injury should be determined (figure 1 and table 3 and table 1). This is an essential step in the proper care of burns in children. An application for smartphones and tablets may increase the speed and accuracy in assessment of total burn surface area (TBSA) and in calculation of fluid resuscitation protocols in burns [12]. After obtaining appropriate consent, photographic documentation of the burn wound is a valuable part of many electronic medical records. It is especially useful for injuries that may evolve over time or for patients that are transferred to other hospitals.

Evidence suggests that burn size is frequently overestimated in children [13]. As an example, in a retrospective observational study of 201 children referred to a burn center for treatment, almost 50 percent of patients had the burn size overestimated by 5 percent or greater TBSA [14]. Burns with TBSA of 10 to 20 percent were overestimated most often and by the largest amounts in this study. Burn size overestimation may result in excessive fluid administration [15]. To accurately estimate TBSA, clinicians should use standard charts to calculate and document the extent of burns during the physical examination.

Additional findings with important implications for management include:

A careful eye examination, including fluorescein staining to identify corneal burns, should be performed before edema of the eyelids develops.

Burns of the external ear should be noted because of the risk for suppurative chondritis.

Patients with circumferential burns must be carefully monitored.

Constriction of an extremity from circumferential burns may compromise distal perfusion or cause compartment syndrome. The quality of distal pulses and capillary refill should be assessed frequently.

Circumferential burns of the chest can interfere with the mechanics of respiration. Chest wall excursion, oxygen saturation, and exhaled carbon dioxide (if capnography is available) should be monitored.

Circumferential burns to the abdominal wall and back can lead to an abdominal compartment syndrome, especially if administration of excessive volume leads to intra-abdominal fluid accumulation. (See "Abdominal compartment syndrome in adults".)

Treatment with escharotomy may be necessary during early resuscitation as indicated by changes in distal pulse, bladder pressure, and peak airway pressure. (See "Treatment of deep burns", section on 'Escharotomy'.)

Specific patterns (such as a symmetric stocking distribution (picture 1), buttock burns or pattern burns/branding) may suggest an inflicted burn injury. (See "Physical child abuse: Recognition", section on 'Intentional burns'.)

Diagnostic studies — The following laboratory studies should be obtained for children who have significant burns:

Complete blood count.

Electrolytes with blood urea nitrogen and creatinine levels should be obtained as a baseline, in anticipation of major fluid shifts and metabolic changes associated with serious burns.

Creatine kinase, urinalysis, and urine for myoglobin to evaluate for rhabdomyolysis.

Arterial or venous blood gas, carboxyhemoglobin, and serum lactate levels to assess for carbon monoxide and cyanide poisoning in patients burned in fires.

Imaging studies should be obtained as indicated by the mechanism of injury and physical examination:

Cervical spine radiography, computed tomography of the head, chest, and/or abdomen to identify associated injuries should be performed as indicated based upon mechanism of injury (eg, blast injury) and/or physical examination.

Children with respiratory symptoms should generally receive plain chest radiographs, although initial imaging may be normal for patients with smoke inhalation. (See "Inhalation injury from heat, smoke, or chemical irritants" and "Inhalation injury from heat, smoke, or chemical irritants", section on 'Chest imaging' and "Inhalation injury from heat, smoke, or chemical irritants", section on 'Management overview'.)

Soft tissue neck radiographs at the bedside may be useful for children with equivocal signs of upper airway obstruction but should never delay definitive airway management. (See 'Initial management decisions' below.)

MANAGEMENT

Initial management decisions — Conditions identified in the initial rapid assessment (such as evidence of airway injury or respiratory distress) must be aggressively managed. Children with major burns must also receive prompt fluid resuscitation and treatment for pain.

Children with fire-related burns should receive supplemental oxygen.

Patients with signs of airway injury should be intubated early, with the following considerations:

A difficult airway should be anticipated. (See "The difficult pediatric airway for emergency medicine", section on 'Acquired conditions'.)

Rapid sequence intubation should be performed for patients who require advanced airway management. A sedative agent that protects blood pressure (such as etomidate or ketamine) is recommended. Succinylcholine may be used (unless otherwise contraindicated) for patients whose burns are less than 48 hours old, when the risk for hyperkalemia has not yet developed. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach", section on 'Sedation (induction) with paralysis'.)

The endotracheal tube must be fastidiously secured to prevent accidental extubation. For patients with extensive facial burns in whom tape or ties are not effective or appropriate, several approaches have been used with a focus on orthodontic appliances [16].

Reliable vascular access should be obtained, preferably at a site that is not burned. However, observational evidence indicates that catheters may be safely placed through burned skin [17]. In addition, central catheters appear to be safe for children with burn injury [18]. Bladder catheterization should be performed when timely and accurate measurement of urine output is necessary to monitor fluid status. (See 'Monitoring fluid status' below.)

Patients burned by fires in enclosed spaces should undergo evaluation for carbon monoxide; if altered mental status or metabolic acidosis is present, evaluation for cyanide poisoning is also indicated. If confirmed, treatment should begin promptly. (See "Carbon monoxide poisoning" and "Cyanide poisoning".)

Tetanus immunization should be administered to children with partial or full-thickness burns who have not received booster immunizations within five years. Tetanus immune globulin should be given to patients who have not completed primary immunization (table 5). (See "Tetanus" and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on 'Wound management' and "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules'.)

Surgical consultation should generally be obtained for children with moderate and severe burns (table 2).

Fluid resuscitation — Adequate fluid resuscitation is an essential component of the initial management of children with major burns and requires an accurate assessment of the total body surface area (TBSA) that is burned. Observational evidence and clinical experience suggest that adequate initial fluid resuscitation improves outcomes for these patients [19,20].

Estimating fluid requirements — Formulas for estimating fluid requirements for children for the first 24 hours following a burn injury include:

Parkland (modified) – 4 mL/kg per percent total burn surface area (TBSA, counting moderate (partial thickness) and severe (full thickness) burn area only) plus normal 24 hour maintenance fluid requirements. Add maintenance fluid with glucose for children <5 years of age. (See "Maintenance intravenous fluid therapy in children".) A Parkland nomogram to calculate fluid therapy in children with significant burns may be easier to use and more accurate than pen and paper or electronic calculator [21].

Galveston – 5000 mL/m² per percent TBSA. Add 2000 mL/m² per day for maintenance requirements.

Half of the fluid is given over the first eight hours starting from the time of injury. The remaining half is given over the next 16 hours.

Formulas that are used to determine fluid rates provide an estimate of the initial requirements. Observational evidence indicates that they may underestimate the volume of fluid required for adequate resuscitation [19,22-24], especially if an inhalation injury has occurred [25]. Conversely, fluids administered for medications and other treatments may result in volumes that exceed the formula, so called "fluid creep". Consequently, volume status must be carefully monitored, and fluid therapy adjusted accordingly. (See 'Monitoring fluid status' below.)

Choice of fluid — We suggest that isotonic crystalloid fluids be used for the first 24 hours of fluid resuscitation when systemic capillary leak may be significant. Ringer's lactate (RL) is the resuscitation and maintenance fluid of choice during this time period at most burn centers to avoid the development of a hyperchloremic metabolic acidosis [26]. For children <20 kg, we suggest that maintenance fluid contain 5% dextrose to prevent hypoglycemia [27].

Several alternatives have been proposed for patients with severe burns with the goal of reducing the total volume of fluid resuscitation:

Colloid – When considering the use of colloid for fluid resuscitation in children with severe burns, we advise discussion with the burn surgeon who will manage the patient. Patient selection for and the role and timing of colloid fluid administration to restore oncotic pressure and preserve intravascular volume is unclear. Some centers, in an attempt to minimize burn-wound edema, anasarca, and possibly abdominal compartment pressure, administer colloid earlier (eg, starting at 6 to 12 hours of fluid resuscitation), particularly in patients with inadequate urine output or elevated serum lactate [28,29]. The use of colloid for fluid resuscitation in adults with burns is discussed separately. (See "Anesthesia for patients with burn injuries", section on 'Fluid administration'.)

Hypertonic saline – Evidence for the use of hypertonic saline rather than balanced crystalloid for fluid resuscitation in burn victims is limited, and evidence for improved outcome is lacking [30]. Thus, further study is needed before its use for fluid resuscitation in burn patients is routine.

Vitamin C – Although evidence is lacking for children, some experts use high-dose vitamin C for pediatric patients with severe burns [27,31]. If used, it should be under the direction of a pediatric burn surgeon.

In animal studies, vitamin C decreases burn wound edema, produces an osmotic diuresis, and reduces markers of lipid peroxidation [32]. Studies in adults have suggested that high-dose vitamin C early in the treatment of major burns may reduce fluid requirements and improve outcomes [32,33]. For example, in a randomized trial of 37 adults with severe burns (mean burn size >50 percent of body surface area), individuals assigned to a high-dose infusion of vitamin C added to standard fluid resuscitation with lactated Ringer had significantly lower 24-hour total infusion volumes and fluid retention in the second 24 hours of fluid resuscitation. Potential adverse effects of high doses of vitamin C include exacerbation of hypovolemia if osmotic diuresis is misinterpreted as reflecting adequate urine output and worsening of acute kidney injury [32]. Vitamin C also falsely elevates the blood glucose in some point-of-care devices. Thus, if used, glucose management must be guided by standard laboratory measurement of serum glucose.

Monitoring fluid status — The volume status of burn patients must be carefully monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload. However, advanced invasive cardiovascular monitoring has not been shown to reduce morbidity and mortality in burn victims when compared to patients treated according to the Parkland formula [34]. The following parameters are helpful (table 6):

Urine output should be maintained at 1 to 2 mL/kg per hour for children <30 kg and 0.5 to 1 mL/kg per hour for those ≥30 kg [35-37]. The assumption that urine output is an accurate proxy measure for renal blood flow may not be reliable when antidiuretic hormone (ADH) levels are high in the acute phase of a burn injury [38]. Assessment of intravascular volume should consider additional parameters, including ultrasound [39], to avoid excessive fluid administration [40]. For urine outputs that exceed the desired rate, urine should be tested for glucose. Hyperglycemia (as the result of increased catecholamine levels) can cause an osmotic diuresis that should not be misinterpreted as a reflection of adequate volume status.

During the early phase of burn resuscitation and before the onset of a hypermetabolic response, heart rate is a better monitor of circulatory status in children than is blood pressure. Tachycardia may indicate hypovolemia, but pain can elevate heart rate in euvolemic patients (table 7 and table 8).

Metabolic acidosis can be a marker for inadequate fluid resuscitation, but also occurs with carbon monoxide or cyanide exposure.

Children who require large fluid volumes to maintain adequate perfusion or who do not improve with vigorous fluid resuscitation should be carefully evaluated for other conditions that can cause cardiovascular compromise including:

Volume loss from occult injuries

Neurogenic shock as the result of a spinal cord injury

Myocardial depression or decreased vascular tone from inhaled or ingested toxins

Central venous pressure or pulmonary arterial pressure monitoring may be helpful for some patients. Meticulous care of central venous catheters is required to avoid complications such as infection and deep vein thrombosis [18].

Pain control — For optimum effect and comfort, children with moderate to severe burns typically require opioid analgesics for pain relief. Most burn centers use morphine for wound care pain [41]. Intravenous (IV) or intranasal (IN) fentanyl may be a safer choice for initial pain management for patients whose cardiovascular status may be unstable.

Management of burn pain is discussed in greater detail separately. (See "Management of burn wound pain and itching", section on 'Pharmacologic treatment options'.)

Initial burn wound management — Burn wounds should initially be cleaned with mild soap and water. Disinfectants are typically avoided because they may inhibit wound healing. Clothing and debris that are embedded in the wounds should be removed. Administer tetanus prophylaxis as needed (table 5) to children with burns deeper than superficial-thickness.

Debridement — Debridement of devitalized tissue (including ruptured blisters) decreases the risk of infections. In addition, the depth of burn wounds can be determined with better accuracy when the wound bed is inspected directly. Initial debridement can usually be accomplished with sterile saline-soaked gauze.

Although the approach to intact blisters is controversial, experts generally recommend that large blisters, those that are likely to rupture, and those that are painful (regardless of size) be removed. The management of burn blisters is covered in greater detail separately. (See "Treatment of superficial burns requiring hospital admission", section on 'Burn blisters'.)

Wound dressing — For patients who are being rapidly transferred to a burn unit, burns should be covered with dry sterile dressings. Ointments or creams should not be applied because they can hinder initial wound assessment at the burn center.

Superficial burns (epidermal and superficial partial thickness burns) are generally managed with topical antimicrobial agents with an overlying dressing. Factors to consider include:

A moist wound environment should be maintained for optimal healing.

The dressing should provide a barrier that reduces the risk of infection.

For optimum effect and pain relief, the dressing should maintain maximum contact with the wound without adhering to it. It should also be easy to apply and remove. Specific types of burn dressings are discussed in greater detail separately. (See "Topical agents and dressings for local burn wound care", section on 'Dressings'.)

Topical antimicrobial agents have been used extensively to dress superficial burn wounds. They are readily available, generally inexpensive, and reduce the risk of infection. Patients with extensive burns should have burn dressings applied by the clinician who will be providing ongoing management. The topical agent is applied to the wound, which is then covered with a nonadherent dressing. A layer of dry, absorbent gauze can be used early after burn injury when significant drainage is expected. The dressing is held in place using either a tubular net bandage or gauze wraps. Dressings must be changed frequently (eg, twice daily). While silver-containing topical antimicrobial creams have not been shown to be superior to other antimicrobial agents, there is some evidence that wound healing and infection rates are better when sustained-release silver foam dressings are applied. These products do not require frequent dressing changes but are associated with greater cost.(See "Topical agents and dressings for local burn wound care", section on 'Antimicrobial agents'.)

The potential indications and adverse effects of specific antibiotic preparations are presented in the table (table 9) and discussed in greater detail separately. (See "Topical agents and dressings for local burn wound care", section on 'Antimicrobial agents' and "Treatment of minor thermal burns", section on 'Dressings' and "Treatment of superficial burns requiring hospital admission", section on 'Local burn care'.)

Escharotomy — Circumferential partial and full thickness burns may lead to functional impairment (such as restriction of chest wall movement for chest burns or development of a compartment syndrome for extremity burns) as edema increases over the first 24 hours following a burn injury. An emergency escharotomy (which involves making an incision completely through the depth of the burn eschar) may be required to relieve restriction (as with chest burns) or reduce pressure (as with a compartment syndrome). (See "Emergency care of moderate and severe thermal burns in adults", section on 'Escharotomy'.)

Additional management considerations — Children whose transfers to burn centers are delayed may need to be managed in the emergency department for extended periods of time. They should be carefully monitored in order to detect and treat conditions that develop in response to initial injuries, such as burn shock and worsening respiratory status for those with inhalational injury.

Glycemic control — Tight glycemic control appears to improve outcomes for children with severe burn injuries. Consequently, children who develop hyperglycemia should be treated carefully with insulin to maintain blood glucose levels within the normal range (eg, 80 to 110 mg/dL [4.4 to 6.1 mmol/L]). (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Glycemic control' and "Overview of nutrition support in burn patients", section on 'Glycemic control'.)

Other therapies that appear to improve outcomes (such as early burn wound excision, aggressive nutritional support, and modulating the hypermetabolic response to burn injury) are typically initiated on admission to a burn center. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Attenuation of the hypermetabolic response'.)

Eyelid and ocular burns — The clinician must do a careful assessment of eyelid burns to identify the likelihood of scarring and subsequent lid retraction, and the possibility of direct thermal injury of the globe [42]. Key interventions include [42,43]:

Contact lenses should be removed.

Topical anesthesia (eg, one drop of proparacaine 0.5 percent in each eye) may be used initially but should not be applied long-term.

Debris should be irrigated from the eye and conjunctiva.

Scorched eye lashes should be trimmed so that char does not cause ongoing irritation of the eye surface and conjunctiva. This procedure should be performed with fine scissors that have ophthalmic ointment applied to the blades so that the trimmed lashes do not fall into the eye.

Burns near the eye require treatment with ophthalmic preparations of topical antibiotic ointment (eg, erythromycin 0.5 percent ointment) because application of topical antimicrobial preparations (eg, silver sulfadiazine) close to the lid margins may result in eye exposure and excessive absorption of toxic components.

Deep burns of the lids that scar can result in retraction and corneal exposure. These injuries need to be followed very closely by an ophthalmologist. If there is incomplete lid closure, tissue loss, or ectropion (outward turning of lid margins), frequent lubrication (eg, minimum four times daily application of carboxymethyl cellulose sodium 1% [Celluvisc] and white petrolatum ointment [Lacri-Lube] at night) should be initiated. Combination antibiotic and steroid preparations (eg, tobramycin/dexamethasone ointment), temporary tarsorrhaphy (suturing together of the eyelids) and/or other surgical interventions, including early skin grafting, may be necessary to prevent corneal ulceration, opacification, and visual loss.

In cases where the ocular surface itself is burned and corneal edema is evident, reduction of surface inflammation with topical steroids, in addition to topical lubrication and antibiotic therapy may be initiated by an ophthalmologist [44]. These patients warrant close observation for signs of infection until the corneal epithelium is healed. Patients with severe surface burns may still have vision restored through amniotic membrane transplantation, autologous limbal stem cell transplantation, or keratoprosthesis.

Chemical burns to the eye are discussed separately. (See "Topical chemical burns: Initial assessment and management".)

DISPOSITION — Observational evidence and extensive clinical experience suggest that the complex initial and long-term medical and surgical needs of children with severe burns can be best managed at burn centers [20,45-47]. Burn centers can provide the surgical, critical care, medical, nutritional, nursing, and rehabilitation expertise that is not cost-effective to maintain at local hospitals [48].

Compliance with the American Burn Association guidelines for transfer to a burn center is low [49]. The ABA criteria for referring a child to a burn center are (table 2) [50]:

Partial thickness or moderate (second degree) burns >10 percent total body surface area (TBSA) burn

Any significant burn to the face, hands, feet, genitalia, perineum, or major joints

Full thickness (third degree) burns

Electrical burns, including lightening injury

Chemical burns

Inhalational injury

Burns in children with pre-existing conditions that could complicate management, prolong recovery, or affect mortality

Any child with burns and traumatic injury (eg, fractures) in which the burn injury poses the greatest risk of morbidity or mortality. If, in the physician's judgement, the greater immediate risk is due to trauma, the patient may be stabilized at the trauma center prior to transfer to a burn unit.

Children requiring social, emotional or rehabilitative factors

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

Observational evidence suggests that, within organized regional systems, patients with serious burn injuries can be safely transferred over long distances as long as they are accompanied by a transport team with pediatric expertise [51]. Problems that develop commonly include:

Inability to intubate the patient during transport

Difficulty maintaining or achieving vascular access

Hypothermia, particularly for patients with large burns

Criteria for admission to a local hospital for observation, intravenous fluid administration, and pain management include:

Children with 5 to 10 percent TBSA burn (depending upon parental capability and social circumstances)

Full-thickness burn 2 to 5 percent TBSA, if local pediatric surgical expertise is available

Circumferential burn

Medical problem predisposing to infection (such as diabetes or sickle cell disease)

Concern for inflicted injury

PROGNOSIS — Regardless of burn severity, age, and associated injuries, resuscitation should be attempted for all children after thermal injury. Children with extensive burn injuries who are unlikely to survive cannot be reliably identified at initial evaluation [52,53]. Rates of survival well above 90 percent can be anticipated for children with total body surface area burns less than 60 percent [51]. Even those patients with the most extensive and severe burns have almost 50 percent survival with timely and aggressive management in a modern burn center. In addition, aggressive physical and psychological rehabilitation provided at burn centers has improved the quality of life for severely burned children.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

Classification – Burns are classified by size (table 3 and figure 1) and depth (table 1). Severe burns meet criteria for burn center referral (table 2); moderate burns warrant hospitalization but do not meet burn center criteria. (See 'Classification' above.)

Prehospital care – Important actions include (see 'Prehospital care' above):

Unless stuck to the patient, remove burnt clothing and any jewelry.

Immediately irrigate chemical burns.

For patients with minor to moderate burns, cool the involved area with cold water for 10 to 20 minutes immediately after the burn; do not use ice.

Rapidly transport burn victims to the hospital; provide other basic life support, as needed.

Evaluation – Important findings during rapid assessment include (see 'Initial rapid assessment' above):

Airway – Soot in the mouth, facial burns, hoarseness, drooling, or dysphagia suggesting upper airway burn

Breathing – Respiratory distress that may arise from smoke inhalation or circumferential burns to the chest or abdomen that may impede lung expansion

Circulation – Tachycardia, prolonged capillary refill time, and/or hypotension at initial evaluation that suggests an associated traumatic injury

Certain types of burn have specific associated risks and need for additional treatment (see 'History' above):

Flame burn – Carbon monoxide and cyanide poisoning (see "Carbon monoxide poisoning" and "Cyanide poisoning")

Chemical burn – Copious irrigation (see "Topical chemical burns: Initial assessment and management")

High voltage electrical burn – Cardiac arrhythmias, fractures, compartment syndrome, and myoglobinuria (table 4) (see "Electrical injuries and lightning strikes: Evaluation and management")

Inflicted burn – No or implausible history and specific burn patterns (such as a symmetric stocking distribution (picture 1), buttock burns or pattern burns/branding) suggest an inflicted burn that warrants evaluation for other injuries, reporting to Child Protective Services, and involvement of a multidisciplinary child abuse team. (See "Physical child abuse: Recognition", section on 'Intentional burns'.)

Diagnostic studies – Children with moderate or severe burns should undergo (see 'Diagnostic studies' above):

Complete blood count with differential

Serum electrolytes, creatinine, and blood urea nitrogen

In patients with concern for carbon monoxide or cyanide exposure, arterial or venous blood gas, carboxyhemoglobin, cyanide level, and serum lactate

Patients with respiratory distress, chest radiograph

Patients with associated traumatic injuries, require additional laboratory studies and imaging (eg, e-Fast, screening radiographs, and CT) as discussed separately (see "Trauma management: Approach to the unstable child")

Initial resuscitation – Initial resuscitation of children with moderate and severe burns includes securing the airway in children with signs of upper airway burns, oxygenation, ventilation, fluid resuscitation, and short-acting opioid pain control (eg, IV or intranasal fentanyl) (algorithm 1). (See 'Management' above.)

Fluid resuscitation – For children with moderate or severe burns, we suggest that isotonic crystalloid fluids (eg, Ringer's lactate) be used for the first 24 hours of after burn injury (Grade 2C). During the initial resuscitation of children, the Parkland formula (which uses weight) may be easier to use than the Galveston formula (which uses surface area). For children <20 kg, we suggest that maintenance fluid contain 5% dextrose to prevent hypoglycemia (Grade 2C). Carefully monitor response to fluid resuscitation (table 6). (See 'Estimating fluid requirements' above and 'Choice of fluid' above.)

Treat hyperglycemia to maintain blood glucose levels within the normal range (eg, 80 to 110 mg/dL [4.4 to 6.1 mmol/L]). (See 'Glycemic control' above.)

Burn care – During the initial resuscitation, remove clothing that is hot, burned, or exposed to chemicals, and all jewelry. Identify eyelid or ocular injury before lid edema hinders eye examination. After stabilization and pain control, burn care consists of (see 'Initial burn wound management' above):

Severe burns – For patients who are being rapidly transferred to a burn unit, cover the burns with dry sterile dressings. Do not apply topical agents. (See 'Wound dressing' above.)

Moderate burns – Gently clean the burns with mild soap and water. Debride devitalized tissues including ruptured blisters using sterile, saline-soaked gauze. Although controversial, large blisters, those that are likely to rupture, and those that are painful (regardless of size) may be opened and removed. (See 'Debridement' above.)

Dress the burn with topical antimicrobial agent as discussed separately. (See "Topical agents and dressings for local burn wound care".)

Tetanus – Administer tetanus prophylaxis as needed (table 5) to children with burns deeper than superficial-thickness.

  1. Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns. BMJ 2004; 328:1427.
  2. Gómez R, Cancio LC. Management of burn wounds in the emergency department. Emerg Med Clin North Am 2007; 25:135.
  3. Paro JA, Gurtner GC. Pathophysiology and assessment of burns. In: Oxford Textbook of Critical Care, 2nd, Webb A, Angus D, Finfer S, Gattinoni L, Singer M (Eds), Oxford University Press, Oxford 2016.
  4. Reynolds EM, Ryan DP, Sheridan RL, Doody DP. Left ventricular failure complicating severe pediatric burn injuries. J Pediatr Surg 1995; 30:264.
  5. Huang Q, Zhao M, Zhao K. Alteration of vascular permeability in burn injury. 1(2):62–76. MedicalExpress 2014.
  6. Allison K, Porter K. Consensus on the prehospital approach to burns patient management. Emerg Med J 2004; 21:112.
  7. Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of immediate cooling--a case series of childhood burns in Vietnam. Burns 2002; 28:173.
  8. Jandera V, Hudson DA, de Wet PM, et al. Cooling the burn wound: evaluation of different modalites. Burns 2000; 26:265.
  9. Griffin BR, Frear CC, Babl F, et al. Cool Running Water First Aid Decreases Skin Grafting Requirements in Pediatric Burns: A Cohort Study of Two Thousand Four Hundred Ninety-five Children. Ann Emerg Med 2020; 75:75.
  10. Madnani DD, Steele NP, de Vries E. Factors that predict the need for intubation in patients with smoke inhalation injury. Ear Nose Throat J 2006; 85:278.
  11. Watts AM, McCallum MI. Acute airway obstruction following facial scalding: differential diagnosis between a thermal and infective cause. Burns 1996; 22:570.
  12. Barnes J, Duffy A, Hamnett N, et al. The Mersey Burns App: evolving a model of validation. Emerg Med J 2015; 32:637.
  13. Goverman J, Bittner EA, Friedstat JS, et al. Discrepancy in Initial Pediatric Burn Estimates and Its Impact on Fluid Resuscitation. J Burn Care Res 2015; 36:574.
  14. Swords DS, Hadley ED, Swett KR, Pranikoff T. Total body surface area overestimation at referring institutions in children transferred to a burn center. Am Surg 2015; 81:56.
  15. Sadideen H, D'Asta F, Moiemen N, Wilson Y. Does Overestimation of Burn Size in Children Requiring Fluid Resuscitation Cause Any Harm? J Burn Care Res 2017; 38:e546.
  16. Sakata S, Hallett KB, Brandon MS, McBride CA. Easy come, easy go: a simple and effective orthodontic enamel anchor for endotracheal tube stabilization in a child with extensive facial burns. Burns 2009; 35:983.
  17. Goldstein AM, Weber JM, Sheridan RL. Femoral venous access is safe in burned children: an analysis of 224 catheters. J Pediatr 1997; 130:442.
  18. Sheridan RL, Weber JM. Mechanical and infectious complications of central venous cannulation in children: lessons learned from a 10-year experience placing more than 1000 catheters. J Burn Care Res 2006; 27:713.
  19. Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation improves outcomes in severely burned children. Resuscitation 2000; 45:91.
  20. Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of initial management: a case series of childhood burns in Vietnam. Burns 2002; 28:167.
  21. Bodger O, Theron A, Williams D. Comparison of three techniques for calculation of the Parkland formula to aid fluid resuscitation in paediatric burns. Eur J Anaesthesiol 2013; 30:483.
  22. Graves TA, Cioffi WG, McManus WF, et al. Fluid resuscitation of infants and children with massive thermal injury. J Trauma 1988; 28:1656.
  23. Cartotto RC, Innes M, Musgrave MA, et al. How well does the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care Rehabil 2002; 23:258.
  24. Mitra B, Fitzgerald M, Cameron P, Cleland H. Fluid resuscitation in major burns. ANZ J Surg 2006; 76:35.
  25. Fabia R, Groner JI. Advances in the care of children with burns. Adv Pediatr 2009; 56:219.
  26. Faraklas I, Lam U, Cochran A, et al. Colloid normalizes resuscitation ratio in pediatric burns. J Burn Care Res 2011; 32:91.
  27. Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present, and future. Burns Trauma 2017; 5:26.
  28. Müller Dittrich MH, Brunow de Carvalho W, Lopes Lavado E. Evaluation of the "Early" Use of Albumin in Children with Extensive Burns: A Randomized Controlled Trial. Pediatr Crit Care Med 2016; 17:e280.
  29. Fodor L, Fodor A, Ramon Y, et al. Controversies in fluid resuscitation for burn management: literature review and our experience. Injury 2006; 37:374.
  30. Bunn F, Roberts I, Tasker R, Akpa E. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2004; :CD002045.
  31. Nakajima M, Kojiro M, Aso S, et al. Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study. Crit Care 2019; 23:407.
  32. Rizzo JA, Rowan MP, Driscoll IR, et al. Vitamin C in Burn Resuscitation. Crit Care Clin 2016; 32:539.
  33. Tanaka H, Matsuda T, Miyagantani Y, et al. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Arch Surg 2000; 135:326.
  34. Holm C, Mayr M, Tegeler J, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns 2004; 30:798.
  35. Sheridan RL. Burns. Crit Care Med 2002; 30:S500.
  36. Klein GL, Herndon DN. Burns. Pediatr Rev 2004; 25:411.
  37. Ashcraft KW, Murphy JD, Sharp RL, et al. Pediatric Surgery, 3rd ed, WB Saunders, Philadelphia 2000.
  38. Dries DJ, Waxman K. Adequate resuscitation of burn patients may not be measured by urine output and vital signs. Crit Care Med 1991; 19:327.
  39. Kuwa T, Jordan BS, Cancio LC. Use of power Doppler ultrasound to monitor renal perfusion during burn shock. Burns 2006; 32:706.
  40. Satahoo SS, Palmieri TL. Fluid resuscitation in burns: 2 cc, 3 cc, or 4 cc? Curr Trauma Rep 2019; 5:99.
  41. Martin-Herz SP, Patterson DR, Honari S, et al. Pediatric pain control practices of North American Burn Centers. J Burn Care Rehabil 2003; 24:26.
  42. Malhotra R, Sheikh I, Dheansa B. The management of eyelid burns. Surv Ophthalmol 2009; 54:356.
  43. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am 2008; 26:125.
  44. Fish R, Davidson RS. Management of ocular thermal and chemical injuries, including amniotic membrane therapy. Curr Opin Ophthalmol 2010; 21:317.
  45. Barrow RE, Spies M, Barrow LN, Herndon DN. Influence of demographics and inhalation injury on burn mortality in children. Burns 2004; 30:72.
  46. Sheridan RL, Remensnyder JP, Schnitzer JJ, et al. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med 2000; 154:245.
  47. Gibran NS, Klein MB, Engrav LH, Heimbach DM. UW Burn Center. A model for regional delivery of burn care. Burns 2005; 31 Suppl 1:S36.
  48. Ashcraft KW, Murphy JD, Sharp RL, et al. Pediatric Surgery, 3rd ed, WB Saunders, Philadelphia 2000.
  49. Johnson SA, Shi J, Groner JI, et al. Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments. Burns 2016; 42:1413.
  50. Burn Center Referral Criteria. American Burn Association. http://www.ameriburn.org/BurnCenterReferralCriteria.pdf (Accessed on July 30, 2013).
  51. Kraft R, Herndon DN, Al-Mousawi AM, et al. Burn size and survival probability in paediatric patients in modern burn care: a prospective observational cohort study. Lancet 2012; 379:1013.
  52. Spies M, Herndon DN, Rosenblatt JI, et al. Prediction of mortality from catastrophic burns in children. Lancet 2003; 361:989.
  53. Cancio LC, Reifenberg L, Barillo DJ, et al. Standard variables fail to identify patients who will not respond to fluid resuscitation following thermal injury: brief report. Burns 2005; 31:358.
Topic 6567 Version 25.0

References

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