Approach to Children with Burns 🔥

Epidemiology and General Principles

• Unintentional injuries due to fire-related burns account for approximately 10% of all unintentional injury-related deaths, with children facing a higher risk of death compared to adults.
• Scald burns are the leading cause of burn-related hospitalizations in children $\le$ 4 years of age, representing 65% of admissions in this age group.
• Flame burns are the most common etiology in children $\ge$ 5 years of age.
• Child abuse accounts for approximately 18% of burn injuries, presenting typically as glove or stocking burns of the hands and feet, single-area deep burns on the trunk or buttocks, or small, full-thickness cigarette burns.
• Loss of skin integrity exposes the pediatric patient to hypothermia, massive body fluid loss, and invasion by environmental microorganisms.

Prehospital and Emergency First Aid

• At the scene, the child should be wrapped in a blanket or coat, and flames must be extinguished by rolling the victim on the ground; running with burning clothes should be avoided.
• The child must be safely extricated to an airy place to prevent the continued inhalation of toxic gases like carbon monoxide and cyanide.
• Smoldering clothing, clothing saturated with hot liquids, and constricting jewelry (which can cause vascular compromise during the edema phase) must be removed immediately.
• For minor burns covering less than 10% of the total body surface area (TBSA), the wound should be irrigated with cool tap water for 10 to 20 minutes.
• Cold water application is strictly contraindicated for burns exceeding 15% TBSA due to the severe risk of inducing hypothermia, as large burn injuries significantly impair body temperature regulation.
• The application of home remedies such as grease, soda, oil, butter, powder, or toothpaste is contraindicated; the wound should instead be covered with clean, dry sheeting or a sterile dressing.

Primary Survey and Acute Resuscitation

• The initial evaluation of a severely burned child follows the structured Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.
• Airway and Breathing: Children with facial burns, singed facial hair, carbonaceous sputum, or suspected smoke inhalation require immediate administration of 100% oxygen.
• The airway must be assessed for laryngeal edema, stridor, or retractions; early elective intubation is indicated for any evidence of significant airway compromise.
• Circulation: Intravenous (IV) access is preferably obtained in a non-burned area, but if unavailable, the initial line may be placed through a burn.
• If IV access cannot be secured emergently, an intraosseous (IO) line must be placed and subsequently replaced with a central venous line.
• Disability: A rapid neurological assessment should evaluate for hypoxia or carbon monoxide poisoning.
• Exposure: The child must be fully exposed to calculate the TBSA affected by the burn and assess for concurrent injuries, followed by immediate covering with warmed blankets to prevent hypothermia.
• Cervical spine precautions must be maintained if the burn was associated with an explosion, fall, or high-voltage electrical injury.

Classification of Burn Depth

• Accurate classification of burn depth is crucial for guiding treatment and predicting scarring or the need for surgical grafting.

Estimation of Total Body Surface Area (TBSA)

• The traditional "rule of nines" is inaccurate and not applicable to children under 15 years of age due to their larger head-to-body mass ratio and variable growth rates of extremities.
• The Lund and Browder chart must be utilized to accurately estimate the percentage of TBSA affected by burns in pediatric patients.
• For a rapid, practical estimation, the palmar surface of the child's hand (including fingers) represents exactly 1% of their TBSA.
  

Indications for Burn Center Admission

• Appropriate triage and referral to a specialized pediatric burn unit are vital for minimizing morbidity and mortality.

Fluid Resuscitation and Hemodynamic Monitoring

• The primary goal of fluid resuscitation is to replenish massive fluid losses, maintain end-organ perfusion, and protect the zone of ischemia without overloading the pediatric circulation.
• Children with >10% to 15% TBSA burns require rigorous intravenous fluid resuscitation and strict urinary catheterization to monitor output.
• The Parkland formula is used to estimate the fluid deficit to be replaced over the first 24 hours.

• If urine output falls below the target, the fluid infusion rate should be increased by 10%; if it exceeds the target, it should be decreased by 10%.
• Tachycardia is an unreliable marker of adequate resuscitation in major burns due to the profound hypermetabolic response.
• Patients with burns >20% TBSA often require central venous lines to deliver the necessary fluid volumes reliably.
• During the second 24 hours, as capillary leak seals and diuresis begins, IV fluids should account for insensible losses and ongoing burn wound exudation.

Analgesia, Sedation, and Nutrition

• Burn injuries produce wide fluctuations in pain intensity, necessitating a multimodal approach encompassing background, acute, procedural, and neuropathic pain.
• Background pain requires scheduled long-acting opioids (e.g., methadone), while procedural pain during dressing changes necessitates potent, short-acting IV opioids like fentanyl, morphine, or hydromorphone.
• Anxiolysis using midazolam is critical for reducing procedural anxiety, and scheduled gabapentin addresses neuropathic pain.
• Children with burns enter a severe hypermetabolic and catabolic state, requiring massive caloric and protein intake (2-4 g/kg/day) for survival and wound healing.
• Enteral feeding via a nasogastric or nasojejunal tube must be initiated on the first day of admission to preserve gastrointestinal mucosal integrity.
• Caloric requirements are estimated as follows: Infants require $2100{\text{ Cal/m}}^2\text{ + }1000{\text{ Cal/m}}^2\text{ burn surface area}$; Children require $1800{\text{ Cal/m}}^2\text{ + }1300{\text{ Cal/m}}^2\text{ burn surface area}$.

Wound Care and Topical Antimicrobial Therapy

• Prophylactic systemic antibiotics are contraindicated as they promote resistant pathogens; local infection control relies on topical antimicrobial agents.
• Blisters in minor burns can be left intact, but ruptured blisters require debridement of devitalized tissue.
• 0.5% Silver Sulfadiazine: Painless application with a soothing effect; limits fluid loss. Adverse effects include transient leukopenia, skin rash, and thrombocytopenia.
• Mafenide Acetate: Excellent penetration through thick burn eschar, making it the agent of choice for deep burns and cartilaginous surfaces (e.g., ears). Adverse effects include severe pain upon application and metabolic acidosis due to carbonic anhydrase inhibition.
• 0.5% Silver Nitrate: Broad-spectrum coverage suitable for sulfa-allergic patients; however, it causes gray staining of the wound and can induce severe electrolyte derangements (hyponatremia, hypokalemia, hypocalcemia, and hypochloremia).
• Circumferential burns of the extremities, chest, or abdomen require prompt decompressive escharotomy to prevent compartment syndrome and respiratory restriction.
• Deep second-degree and third-degree burns >10% TBSA require early surgical excision of the eschar followed by autologous skin grafting to prevent systemic sepsis and improve functional outcomes.

Management of Special Burn Injuries

Inhalational Injuries

• Inhalation injury should be suspected in children confined in closed-space fires, presenting with singed facial hair, carbonaceous sputum, hoarseness, or altered sensorium.
• High blood levels of carboxyhemoglobin confirm carbon monoxide (CO) poisoning.
• Administration of 100% oxygen is the primary treatment, which drastically reduces the elimination half-life of carbon monoxide from 4 hours to approximately 40 minutes.
• Cyanide poisoning must be suspected when significant quantities of plastics or synthetic materials are burned.
• The antidote for cyanide toxicity is hydroxycobalamin, administered at a dose of 70 mg/kg IV, which binds to cyanide to form stable cyanocobalamin that is excreted in the urine.
• Amyl nitrite and sodium nitrite are strictly not recommended for pediatric cyanide toxicity associated with smoke inhalation, as they induce methemoglobinemia.

Electrical Injuries

• Electrical injuries occur via direct contact or arcing (e.g., lightning strikes) and are characterized by specific entry and exit wounds.
• Surface burns often severely underestimate the extent of deep tissue destruction and muscle necrosis.
• The patient must be immediately disconnected from the power source using non-conductive materials.
• Continuous cardiac monitoring is mandatory due to the high risk of fatal arrhythmias (e.g., ventricular fibrillation).
• Massive muscle necrosis frequently leads to myoglobinuria, which can precipitate acute renal failure; this necessitates aggressive fluid resuscitation and forced alkaline diuresis.
• Electrical burns carry a high risk of deep compartment syndrome, often requiring urgent fasciotomies and aggressive surgical debridement of necrotic muscle