Pediatric Thermal Injury

Laura Snell MD

Howard Clarke MD, PhD, FRCS, FAAP, FACS

EPIDEMIOLOGY

50% of all burns are in the pediatric population.
70% of pediatric burns are caused by hot liquid.¹
- Flame burns make up the majority of the remaining 30%.
Younger children are at higher risk of burn injury.
Up to 20% of burn injuries in younger children are the result of abuse or neglect.²

PATHOPHYSIOLOGY

Many systemic derangements caused by burn injury contribute to fluid shifts.
- Significant fluid shifts result in burn wound edema and systemic hypovolemia.
Loss of cutaneous barrier function.
- Insensible losses.
Increased capillary permeability.
- Local in all burn wounds, systemic if >25% TBSA (total body surface area).
- Hypoproteinemia.
- Increased fluid shift from vessels to interstitial tissues.
Release of arachidonic acid cascade metabolites including prostaglandins, histamine, serotonin.
Hormonal derangements (increase in ADH and aldosterone).

BURN CLASSIFICATION

Early assessment and documentation of burn depth, extent, and involvement of hands/face/perineum is very important for treatment planning and must be done.

Depth

First degree/superficial:
- Red, dry, painful.
- Will heal after several days, no scar.
Second degree/partial thickness:
- Red, wet, very painful.
- May be superficial or deep partial thickness.
- Will likely heal after days to weeks of adequate wound care including debridement, daily wound check and dressing changes.
- May require skin grafting and may scar.
Third degree/full thickness:
- Leathery, dry, insensate, waxy.
- Will not heal without excision and grafting.
Fourth degree:
- Involves underlying subcutaneous tissue, tendon, bone.

Total Burn Surface Area (TBSA) (Fig. 14-1)

Lund—Browder chart.
- Age-specific.
Rule of nines (Fig. 14-1).
- Assuming adult body proportions—appropriate for use in teenagers.
- Larger head and neck in proportion for younger children and infants.
Exclude first-degree burns when calculating TBSA.

PEDIATRIC BURNS: INITIAL MANAGEMENT

Primary Survey

Airway Management

FIGURE 14-1 • Total body surface area (TBSA) estimation.

Fluid Resuscitation

Important to establish early secure venous access.
- Can be difficult in the hypovolemic patient.
- May require intraosseous access to begin resuscitation.
- See the “Definitive Management” section later in this chapter for details.
Aggressive fluid resuscitation with normal saline required for burns >15%.
Burns <15% are generally not associated with extensive capillary leak.
- Encourage PO fluid intake.
- Closely monitor urine output. Goal = 1-2 mL/kg/hr.
Parkland resuscitation formula (Ringer lactate): 4 mL/kg/%TBSA.
- Note: Time zero for fluid resuscitation = time of burn injury.
- An estimation of fluid requirements for the initial 24 hours following a significant burn injury ABOVE normal maintenance requirements.
- Give first half of calculated volume over 8 hours from time of injury.
- Give the remaining half of calculated volume over the following 16 hours.
- Remember to consider other ongoing losses as well (e.g., vomiting).
- Monitor urine output closely and adjust rate of fluid infusion as needed for target urine output of 1-2 mL/kg/hr.

EVALUATION

History

Details of the events surrounding the injury.
- Where did it occur? When did it occur? How did it occur?
- Was anyone else injured?
- What was the fluid involved—grease versus water/steam?
Symptoms:
- Pain related to burns.
- Chest pain, shortness of breath, coughing.
- Vomiting or abdominal pain.
- Dizziness or lightheadedness, syncope, headache, visual changes.
- Extremity pain, numbness, tingling.
Past medical history:
- Underlying cardiac, respiratory, or neurological disease.
- Tetanus status.
- NPO status.