Paediatric Burns

Introduction

• Prevention better than cure
  • Hot water maximum 50 degrees
  • Flame-resistant clothing
  • Spill-proof cups
  • Child-resistant taps
  • Smoke detectors
• Differences to adults
  • Consider NAI, thinner skin (so deeper burn for given contact), greater surface area to mass ratio (so increased risk of hypothermia)
  • Burn depth estimation more difficult due to thinner skin
  • Require burns fluid resuscitation at 10% BSA (vs. 20% in adults) – RCH

Classification

• Evolves over 24-48 hours
• Superficial
  • Only epidermal layer involved
  • Blistering may occur over days
  • Epidermis often peels within 3-7 days and completely healed by 7-10 days

• Partial thickness
  • Whole epidermis and part of dermis
  • Superficial
    • Papillary layer of dermis
    • Erythema with blistering
    • Skin under blister is pink/red and moist
    • Extemely painful as nerve endings exposed
    • Heal in 2-3 weeks
    • Brisk capillary return
  • Deep
    • Reticular layer of dermis
    • May be less painful due to oedema lessing nerve exposure
    • Paler in colour with speckled thrombosed superficial vessels
    • Non-blanching or sluggish capillary return
    • Heal over 3-6 weeks
    • Skin grafting is sometimes necessary
    • Scarring is common

• Full thickness
  • Epidermis, papillary and reticular dermis + all dermal appendages
  • Dry, hard, white, leathery or black
  • No sensation and pain due to peripheral partial thickness burns
  • Non-blanching

Location

• Facial, hand, foot and perineal burns difficult to dress AND scarring is a much bigger deal

History

• Heat and contact time
• Clothing
• Enclosed space
• Any loss of consciousness
• Potential toxic exposure
• NAI
• PMHx
• Immunisation

Examination

• Primary survey
• Analgesia ++
• Check circulatory status of limbs in circumferential burns and ELEVATE no matter what
• Burn area
  • Lund-Brower chart (not including superficial)
  • Palmar surface of hand and fingers = 1% BSA
  • Rule of 9’s if over 10yo
• Secondary survey
  • Mainly looking for other injuries including eyes (fluorescein)

Investigations

• CO levels if indicated
• >15% on arrival indicates significant smoke inhalation
• CXR if inhalation suspected

Management

• Pre-hospital/first-aid
  • If transfer time >1 hour and >20% BSA, IV fluid replacement should begin
  • 20 minutes under running water first aid
  • Cover burns with cling wrap (RCH), water-soaked sterile cloth or newer tea trea oil soaked pads
  • Analgesia (IN fentanyl +- IV morphine)
  • Cardiac monitoring if electrical injury
  • Extensive washing if chemical burn

• ED
  • Early intubation if indicated
    • Suspected airway burn
    • Suspected inhalational lung injury
    • BSA >60% (to reduce WOB)
    • Full thickness circumferential chest burns
  • IV access if >20% BSA
  • Fluid resuscitation based on time of burn NOT arrival
  • IDC for urine output monitoring if >10% BSA or perineal burns
  • NG/OG for children with >10% burns due to aerophagia
  • Analgesia – Morphine infusion titrated to response in severe burns
  • Escharotomy if indicated

Fluid resuscitation

• Modified Parkland (Hartmann’s)+ Maintenance crystalloid (N/saline + 5% dextrose)
  • BSA x weight x 4 = mL over 24 hours
  • Half in first 8 hours then next 50% over 16 hours
  • Titrate to urine output and cardiovascular status
  • Colloid is not used in first 24 hours as leaks through capillaries, worsening oedema
  • Aim for 1mL/kg/hr urine output
• In electrical burns, rhabdomyolysis may warrant higher fluid resuscitation and urine output target

Disposition

• Discuss all burns with Burns Registrar LCCH
• Admission
  • Partial thickness >20% BSA
  • Full-thickness >5-10% BSA
  • Smoke inhalation or airway burn suspected
  • Child abuse suspected
• Consider admission
  • Hands, feet, face, perineum and joints
  • Burns <20% BSA but age <12mo, parents not coping, poor social situation.etc.
  • Comorbidity
  • Other significant injury
• If discharged
  • Review in 3 days to reassess depth, monitor healing
  • If burn depth is unclear for 3-5 days, refer to burns unit

Major burn management

• Anything >10% TBSA
• Cover burn with sterile dressing and t/f to paediatric burns centre
• Dressings changed daily with debridement
• Face and perineum left open with water-based gel
• SSD cream usually used

Minor burn management

• Defined as <10% TBSA
• Intact blisters should be left intact unless over a joint or extremely large
• After  7-10 days, intact blisters can be deroofed and need for grafting assessed
• If unclear, redress and review in another 7 days

Superficial burns

• Can be treated without dressings (RCH)
• Mepitel + Melolin with crepe bandage if tendency to scratch
• Leave intact for 3-7 days before review

Partial thickness/small full-thickness

• Acticoat moistened with sterile water, covered with IntraSite conformable (soft hydrogel to keep it moist) + crepe bandage and secured with Hyperfix
• Can use Acticoat 7 for review at 7 days vs. 3 days
• Review at 3-7 days
• Superficial burns of face
  • Cleaned 2-3 times per day with warm water
  • Vaseline over burn
  • When starts to dry, can apply Lanolin ointment
  • Should protect from sun to prevent pigmentation changes
• Hand, foot and face burns need referral for ongoing management

Electrical burns

• Safety switches prevent most serious internal injury from electrical burns at household voltage
• High-voltage (>1000V) are at huge risk of internal injuries
• Skin
  • Entry/exit wounds, arc burns, flame burns due to clothing ignition
• Cardiac
  • Low-voltage: Sinus tachy, AF, VF, myocardial injury uncommon
  • High-voltage can cause asystole
• Muscular
  • Tetany – Apnoea, fractures, dislocations
  • Muscle necrosis and rhabdomyolysis
• Neurological
  • Acute: ALOC, seizures, headache, speech, motor, sensory disturbances
  • Delayed: Spinal cord injury, memory and mood disturbance
• Renal
  • Myoglobinuria and renal failure
• Eyes
  • Cataracts
• GI
  • Ulceration/perforation
• Trauma from associated falls
• Management
  • ECG monitoring
  • Higher fluids due to rhabdo
  • Urinary alkalinisation may be required
  • Compartment syndrome due to oedema of muscles may require fasciotomy
  • Admission
    • Any high-voltage injury
    • Any cardiac or neurological abnormality
  • Discharge
    • Asymptomatic child with low-voltage injury and normal ECG

Chemical burns

• Alkali liquefaction the worst
• Oedema occurs more quickly and deeper burns may appear superficial
• Treatment
  • Analgesia and copious irrigation
  • Wound pH may guide if acid/alkali substance
  • Fluorescein for eyes
  • Treat skin as for any other burn

Last Updated on October 27, 2021 by Andrew Crofton