Pediatric emergency medicine trisk 803

Consider early intubation in patients with suspected pharyngeal or
airway swelling
Inquire about the circumstances of the burn and determine the
potential for associated injuries
Remember to remove sources contributing to ongoing thermal
damage

Current Evidence
Globally, burns are the 11th leading cause of death in children aged 1 to 9
and the fifth most common cause of nonlethal injury. A recent study
examining data on pediatric burns from the Nationwide Emergency
Department Sample (NEDS) found that the majority were burns to the
wrists/hands, followed by the lower limbs, with the most common causes
being electric appliances and hot liquids/vapors. Data from the National
Burn Repository suggest that burn injuries are more prevalent in minority
children than would be expected based on demographics alone. Scald and
contact burns are more common in the younger ages, with fire/flame more
common in adolescent and adult patients.
Recent data suggest significantly improved survival for children with
careful attention to burn care. In one study, half of children with burn
injuries up to 90% TBSA survived their injuries, and research is ongoing
into new methods for surgical management and pharmacologic treatment of
burn wounds. Burn size and inhalational injury are two key predictors of
survival in children.
Major systemic pathophysiologic effects are seen in children with burns
of more than 20% of body surface area (BSA). Burn injury causes increased
capillary permeability and the release of osmotically active molecules to the
interstitial space resulting in extravasation of fluid. Protein is lost from the
vascular space to the interstitium during the first 24 hours. In patients with
large burns, vasoactive mediators are released to the circulation and result
in systemic capillary leakage. Edema develops in both burned and

noninjured tissues. Circulating factors that depress myocardial function
decrease cardiac output. Acute hemolysis of up to 15% of red blood cells
may occur both from direct heat damage and from a microangiopathic


hemolytic process. The profound circulatory effects of severe burns can
result in life-threatening shock early after injury.

Goals of Treatment
High-quality care is key for functional outcome and survival from burn
injuries. Emergency management begins with prehospital care, assessment,
resuscitation, treatment of potential inhalational injury, wound care,
infection control, and appropriate admission. The continuum of care
extends through hospitalization, potential surgical management, and
rehabilitation. The unifying goals of these treatment modalities are to
compensate for the physiologic effects of the burn and promote healing.

Clinical Considerations
Clinical Recognition
Immediately after arrival, the physician must determine if a patient with
burn injury requires aggressive therapy for major burns. In children with
severe injuries, the evaluation and initial management take place
simultaneously. Smoldering clothing or other sources of continued burning
must be removed. Information about the circumstances of the burn and the
potential for associated injuries should be sought from prehospital care
providers, police, or family members, but this should not delay the initial
treatment.
It is crucial to recognize inhalational injury as a cause of impending
airway obstruction and respiratory failure. A history of smoke exposure is a
risk factor. Clinical signs of potential inhalational injury include burns on

the face, singed nasal hairs, soot in the sputum or soot visible in the upper
airway.
Triage Considerations
All children with nontrivial burns should be rapidly transported to a hospital
setting. Once in the hospital, the triage process should take into account the
child’s age and medical history, the injury mechanism, and the surface area
and depth of the burn. Children <2 years of age and those with significant
comorbidities have a higher risk of burn-related complications. The
physical response to burn injury and mortality prognosis appears to worsen


significantly when 30% of TBSA is burned, and so those children should be
triaged to receive care more rapidly.
One possible triage guideline based on a five-level emergency severity
index (ESI) scale is shown in Table 104.1 .
Clinical Assessment
Percentages. After the primary survey and initial stabilization, a systematic
evaluation of the surface area and depth of burns follows. The rule of nines
is used to estimate burn surface area in adolescents and adults. Each arm is
approximately 9% TBSA, each leg is 18%, the anterior and posterior torsi
are each 18%, the head is 9%, and the perineum is 1%.
This rule cannot be applied to children because they have different body
proportions. In particular, young children have relatively larger heads and
smaller extremities. Therefore, age-adjusted methods of estimating burn
surface have been developed ( Fig. 104.1 ). Alternatively, a child’s palm
including the fingers is approximately 1% of BSA and this can be used to
estimate the extent of scattered, smaller burns.


TABLE 104.1

BURN TRIAGE GUIDELINES
Triage level

Characteristics

Resuscitation
room
1—Critical

Inhalational injury, altered mental status/LOC, chest
pain, arrhythmias, associated major trauma
Facial burns with: singed nasal hairs, hoarse breath
sounds, oropharyngeal edema, dysphagia
Burns >25% TBSA
Electrical burns with history of either altered mental
status or seizure
Any full-thickness burn
Partial thickness >15% TBSA
Burns to face, genitalia
Caustic chemicals to eyes
Circumferential burns
Significant burns of hands, feet
Any burn with significant pain
Caustic skin burns
Electrical burns with any of the following:
Loss of consciousness
Thrown from source or frozen to source
Entrance and exit wounds
Concern for abuse
Partial thickness >5% TBSA

Infected burn
Burns requiring debridement
<5% partial-thickness burn
Burn redress
Superficial burn

2—Acute

3—Urgent

4—Urgent
5—Nonurgent

Abbreviations: TBSA, total-body surface area; LOC, loss of consciousness.