Pediatric emergency medicine trisk 807

responsive to fluid therapy, should have an aggressive diagnostic workup
for concurrent problems.
Antibiotics. Burn sepsis continues to be the major cause of mortality after
the period of initial resuscitation despite improvements in topical and
systemic antimicrobials. Meticulous antiseptic techniques can lessen
colonization of burns with potential pathogens. Topical antibiotics further
reduce bacterial number. Early streptococcal cellulitis is less common than
in years before the development of topical antibiotics for burns. Most burn
centers do not routinely treat patients with prophylactic systemic antibiotics
given absence of data to support this practice, and the increased likelihood
of inducing resistant organisms. Frequent examination of healing burns for
signs of infection and cultures to monitor colonization can direct specific
antibiotic therapy if documented infections were to occur.
Wound Care. Early surgical management of some partial- and most fullthickness burns with excision and grafting has been an important advance in
burn treatment. Initially, burns should be covered loosely with sterile sheets
during the resuscitation phase in severe injuries. Once the cardiorespiratory
status is stabilized, the wounds are uncovered and fully assessed for size
and depth. The goals of burn wound care are to promote rapid healing and
prevent infection. Cleansing with large volumes of lukewarm sterile saline
reduces contamination. Loose tissue can often be wiped away with sterile
gauze, simplifying and expediting burn debridement. Blisters should be left
intact whenever possible. However, large blisters or those that obscure the
assessment of the burn depth may need debridement. Smaller blisters may
be left intact to preserve the barrier to bacterial invasion. Application of
temporary skin substitutes may reduce pain, expedite healing, and reduce
length of hospitalization compared with topical antibiotics and conventional
dressings but are often not applied in the ED. It is not necessary to apply
topical antimicrobials to burns prior to transfer to a burn center or tertiary
care children’s hospital.
Escharotomy. First, all jewelry and watches should be removed because
these may restrict distal flow of the blood. For extensive and deep extremity

burns, pulses should be checked by Doppler ultrasound if they cannot be


palpated. Absence of flow or progressive diminution of the pulse are
indications for escharotomy through the depth of the eschar on the medial
and lateral aspects of the extremities, including the hands. Finger
escharotomies are seldom necessary and should be undertaken only after
consultation with a burn center surgeon. It is especially important to extend
escharotomy incisions across the joints because the skin is tightly adhered
to the underlying fascia at these locations and vascular obstruction is more
likely to occur. The procedure does not require anesthesia because fullthickness wounds are insensate. Pulses assessed by palpation or Doppler
ultrasound should immediately improve after escharotomy. If improvement
is not immediate, hypovolemia should be suspected. Reperfusion of the
extremities after escharotomy may abruptly reduce intravascular volume
and require prompt adjustment of fluid therapy.
Tetanus. Children who have received <3 doses of tetanus toxoid or whose
immunization status is unknown require tetanus toxoid-containing vaccine
and tetanus immunoglobulin. Children who have had >3 doses of the
vaccine require only the vaccine. Red Book Guidelines suggest giving Td to
those between 7 and 10 years and Tdap to those 11 years or greater (see
Chapter 110 Minor Trauma , Table 110.1 Tetanus Prophylaxis).
Pain Management. Safely reducing pain is an important consideration in the
management of children with burns of all sizes. Calm, developmentally
appropriate verbal reassurance, even to preverbal children, can reduce
anxiety and dramatically reduce the perception of pain. The exposure of
sensory nerve receptors in partial-thickness burns makes them sensitive to
environmental stimuli. Movement of cool air across burned tissue increases
pain significantly. The simple measure of covering burns with a sterile
sheet, only exposing them when necessary for burn assessment, provides
extremely effective and safe analgesia.

Many children will still have significant pain after nonpharmacologic
measures are taken. Narcotic analgesics are useful when administered
appropriately. Morphine may reduce the blood pressure, especially in
patients who are hypovolemic. Fentanyl causes less cardiovascular effect
than morphine but has a short half-life. Clinicians should be prepared to
support the circulation with intravenous fluids when using opioids.


Intranasal medications can be given during early assessment of patients
in severe pain. Ongoing analgesic medications are commonly administered
intravenously for patients with severe burns because they are effective and
predictable. Intramuscular injections or oral doses should not be given to
patients with significant burns because circulation to muscle and gut is
reduced, and absorption of medication will be delayed and unpredictable. In
children who do not respond well to the initial dose of pain medication, a
careful assessment for other causes of pain or agitation should be sought.
The possibility of compartment syndrome, hypoxemia, early shock, and
occult injuries should be assessed while simultaneously preparing repeated
doses of analgesics. Analgesic administration just before debridement of
any burn wound is recommended.
Disposition (Transfer Criteria). Guidelines for admission must be
individualized when treating children with burns. Hospitals, physicians, and
parents have varying capabilities for managing pediatric patients with
burns. If a physician suspects that the burns cannot be adequately cared for
in the home, admission to the hospital is warranted.
Children with burns <5% TBSA can be considered for outpatient
management with close follow-up. Admission criteria include 5% to 10%
TBSA burn, 2% to 5% TBSA full-thickness burn, high-voltage injury,
concern for inhalational injury, circumferential burn, significant associated
trauma, or medical comorbidity (such as diabetes or sickle cell disease).

Burns in certain locations are at higher risk for disability or poor cosmetic
outcome and should be considered for treatment in the hospital. These
include more than 1% of BSA burns of the face, perineum, hands, and feet;
or burns overlying joints. Children with any of the following should be
considered for transfer to a burn center: >10% TBSA burn, >5% TBSA
full-thickness burn, high-voltage burn, chemical burn, known inhalational
injury, burn to face, hands, feet, perineum, joints, significant comorbidities
that could affect burn treatment, or when social or emotional factors related
to the burn injuries will influence rehabilitation.

MINOR BURNS
CLINICAL PEARLS AND PITFALLS


Suspicious injuries should be reported to the appropriate
authorities and should prompt further clinical investigation.
Assess the safety of the household and provide anticipatory
guidance even in cases where there is not a suspicion of inflicted
injury.
Ensure adequate wound care and follow-up.

Goals of Treatment
A small minority of all burns in children requires therapy in the hospital.
Once a careful assessment has led to a decision to manage a burn as an
outpatient, preparations for treatment at home should begin. Parents or
guardians need to be instructed carefully regarding wound care and reasons
to return. The goal of the treatment of minor burns is to reduce pain,
decrease risk of infection, and improve functional outcome through careful
home management and close outpatient follow-up.

Clinical Considerations
It is important to consider the possibility of inflicted burns and to carefully
examine even minor burns for characteristic shapes and patterns.
Additionally, it is crucial to perform a detailed secondary survey to ensure
that no other traumatic injuries are missed.
Clinical Recognition
A child with superficial or partial-thickness burns <5% TBSA may be a
suitable candidate for outpatient burn care. There should be no concern for
inflicted burn, and appropriate parental and family resources need to be in
place to ensure careful home care and close follow-up.
Triage Considerations
See Table 104.1 for suggested triage guidelines. Most minor burns can be
triaged to the urgent or nonurgent level of care.
Clinical Assessment
Analgesia may be needed to perform a careful wound assessment. Sloughed
epidermis should be removed with sterile normal saline and gauze, allowing