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Sunday, 22 June 2014


·       3rd leading cause of accidental death amongst children
·       Mortality – higher for children and the elderly
·       2005: >120,000 children <15 years of age received care in ED for burns / COMBUSTIO
·       Children <5 years old: 65% scald injuries
·       5-20 years old: 27% scald injuries
·       Non-accidental burns: estimated as high as 20% of burn admissions
·       Inhalational injury increases mortality significantly

1.     Local injury: heat denatures and coagulates protein => irreversible tissue destruction
o   Surrounding this => zone of decreased tissue perfusion (salvageable tissue)
o   Young children have thinner skin => deeper burns
o   Increased capillary leak around burn
2.     Systemic response: release of vasoactive mediators from tissue: cytokines, prostaglandins, O2 radicals
o   >15% burn in young children, >20% burn in older children: systemic response to mediators
o   Systemic capillary leak lasts 18-24 hours => burn shock/SIRS
o   Immunosppuression
o   Local destruction of RBC’s
o   Myocardial depression
o   Hypermetabolic response: catecholamine release, glucagon, cortisol elevation
3.     Advocacy: with140-150 degree water (normal for home water heater): 3rd degree burn in approximately 2 seconds
o   Reset water heaters to 120 degrees
Classification of Burns:
·       Depth of burns                                   : based on intensity and duration of thermal exposure
·       Superficial burns (1st degree)           : erythematous, painful
o   Only involve outer layer of epidermis (fluid loss not an issue)
o   Heal without scarring in 4-5 days
·       Partial thickness burns (2nd degree)
o   Superficial partial thickness: red and painful with blister formation
Partial destruction of dermis
Weeping/moist appearance
Healing in 7-10 days with minimal scarring
o   Deep partial thickness: greater than 50% of dermis lost
White, pale, less painful (nerve fibers destroyed)
2-3 weeks to heal, severe scarring can occur, contractures
May requires skin grafting
·       Full thickness burns (3rd degree): white, waxy, leathery
o   No bleeding, painless
o   High risk for infection and fluid loss
·       Fourth degree burn    : destruction of underlying structures – tendons, nerves, muscle, bone, deep fascia

Estimation of Burn Area (do not include superficial burns)            :
·       Adolescents/adults: rule of 9’s
o Head/Arm: 9% each
o Leg, anterior trunk, posterior trunk: 18%
o Neck and groin: 1% each
·       Children: surface of child’s palm = 0.5% TBSA
o Modified Lund and Brower chart (see image)

Initial Assessment/Evaluation
·       ABC’s
·       Inhalational injury
o   Upper airway edema
o   Bronchospasm
o   Small airway occlusion from debris, endobronchial sloughing
o   Circumferential burn on chest – limits chest wall compliance
o   Susepect: history of closed space exposure, facial burns, singed nasal hairs, carbonaceous debris in the mouth
o   Secure the airway if suspected (cuffed tube)
·       Insert 2 large bore IV’s for fluid management (okay to insert IV’s through burn)
·       Remove burnt clothing/jewelry
·       Cover burn with clean sheet/blanket: reduces pain, decreases fluid/heat loss
·       Eye examination
o   Evaluate for corneal burns with fluorescein – before edema of eyelids develops
·       Flame burns – consider CO poisoning
o   Dx with carboxyhemoglobin level
o   Administer 100% O2, consider hyperbaric O2 for level >30%
o   100% O2 decreases half life of CO from 250 minutes at room air to 40-50 minutes
·       Note any circumferential burns on the body
·       Labs: CBC, lytes, UA (myoglobin), carboxyhemoglobin
Criteria for admission to burn unit (American Burn Association)
1.     Partial-thickness burns of greater than 10% of the total body surface area
2.     Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3.     Third-degree burns in any age group
4.     Electrical burns, including lightning injury , chemical burns
5.     Inhalation injury
6.     Burn injury in patients with preexisting medical disorders that could complicate management
7.     Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality
8.     Burned children in hospitals without qualified personnel or equipment for the care of children
9.     Burn injury in patients who will require special social, emotional, or rehabilitative intervention
Fluid Management
·       Aggressive management required for patients with >15% of TBSA burned
o   Parkland: 4ml/kg/%TBSA
Children<5 y/o: add maintenance fluids
Give half in the 1st 8 hours
Give the other half in the next 16 hours
o   Fluid: LR, add dextrose for children <20kg
·       Add colloid after 24 hours to help restore oncotic pressure
·       Monitor: goal uop: 1-2ml/kg/hr, acidosis
·       Not improving with initial resuscitation?
o   Consider continued volume loss, myocardial depression, neurogenic shock
Nutrition         :
·       Higher caloric needs due to hypermetabolic state
·       Begin enteral nutrition as soon as possible
o   Demonstrated better outcomes with enteral feeding vs TPN
·       Can feed duodenum if concerned for risk of aspiration
·       GI prophylaxis – Curling’s Ulcers: Zantac or Prilsoec
Other Considerations
1.     Infection
o   Decreased rates of wound infection, but patients live longer => Increased rates of central catheter infection and ventilator associated PNA
o   Global decrease in immune function: neutropenia, t-cell dysfunction, increased gut permeability, many blood transfusions
o   Wound sepsis: staph/pseudomonas most common
No ppx abx
Rates have improved significantly with prompt wound closure
o   ENT: ear poorly vascularized
Sinusitis/OM: indwelling tubes
o   Optho: corneal ulcer infection
o   Pulmonary: inhalational injury => pneumonia v. tracheobronchitis (35%)
Ventilator associated PNA
o   Central venous catheter infections/UTI
o   Intraabdominal infection
o   Musculoskeletal: compartment syndrome, suppurative costal chondritis, abscess
o   Viral (immunosuppression): HSV, CMV, varicella reactivation
o   Fungal infection due to prlonged abx (candida, aspergllus)
o   Prevention: catheter care, early wound closure, culture/abx with fever/hypotension (be judicious!), topical abx
o   Tetanus
o    Infection control programs
2.     Abdominal compartment syndrome
o   After large fluid resuscitation with capillary leak
o   Pressure > 25-30cm H2O
o   Decreased renal perfusion, cardiovascular output, pulmonary compliance
3.     Pain control + anxiolysis
Wound Care
·       Initial care – never put ice!
o   Cover with sterile sheet
o   Cool with water 10-20 minutes after burn
·       Topical abx: decrease both risk of infection, fluid loss from burn
o   Silver sulfadiazine: painless, poor eschar penetration, broad antibacterial spectrum, no metabolic side effects.
o    Mafenide: Penetrates tissue well, broad abx spectrum, painful on application. Application to >20% tbsa may lead to metabolic acidosis
o   Bacitracin: often used for burns of face, painless, no pigment bleaching (can be seen with silver sulfadiazine)
o   Aqueous silver nitrate 0.5%: painless application, poor eschar formation, leeches electrolytes
·       Elevate burned extremity to minimize edema
·       Decompressive escharotomy essential with compartment syndrome, circumferential scar


1.     Reed, JL and WJ Pomerantz. Emergency management of pediatric burns. Pediatric Emergency Care. 21 (2): Feb, 2005: 118-129.
2.     Sheridan, RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005: S112-S119.
3.     Andel, H et al. Nutrition and anabolic agents in burned patients. Burns. 29. 2003: 592-595.
4.     Uptodate.com: Joffe, MD. Emergency care of moderate and severe thermal burns in children
5.     Uptodate.com: Mandel, J and CA Hales. Smoke inhalation.
6.     Bressack, M. Inpatient management of pediatric burns. Santa Clara Valley Medical Center.
7.      American Burn Association website

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