Optimizing Emergency Management to Reduce Morbidity and Mortality in Pediatric Burn Patients (Trauma CME)

Table of Contents

 

Burn injuries in children are a frequent cause of ED visits. Although the majority of pediatric burn injuries are minor, the relative risk of morbidity for pediatric patients with burn injuries is higher than for adult burn patients. When pediatric patients present with serious burn injury, appropriate airway management, fluid resuscitation, and disposition can reduce morbidity and mortality. Minor burn injuries require wound care, pain management, and assessment for antibiotics and tetanus prophylaxis. This supplement provides evidence-based recommendations for the evaluation and management of pediatric patients with burn injuries of all types and severity. You will learn:

The methods for classification of burn injuries, including by depth, severity, and total body surface area affected, and how classification informs management decisions

Why the accurate calculation of total body surface area is important, and how to make the calculation for children using the Lund-Browder chart

The benefit of treating burns with cool running tap water

When to consider intubation for patients with suspected inhalation injury

Commonly used formulas for calculating resuscitative fluid requirements

Wound care techniques for superficial and partial-thickness burns, including blister aspiration, topical therapies, and wound dressings

How to assess pain in pediatric burn patients and choose appropriate medication for pain control

The special management considerations for circumferential burns, chemical injuries, and electrical injuries

How to recognize burn injuries that suggest nonaccidental trauma

The indications for transfer of pediatric burn patients to an accredited burn center

The current evidence for burn treatment using Vitamin C, vasopressors, and steroids

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Pathophysiology
6. Prehospital Care
7. Emergency Department Evaluation
   1. Initial Management
   2. Burn History and Examination
8. Classification of Burns
   1. Classification of Burns by Depth
   2. Classification of Burns by Severity
   3. Classification of Burns by Percentage of Total Body Surface Area Affected
9. Diagnostic Studies
   1. Laboratory Studies
   2. Diagnostic Imaging
10. Treatment
    1. Cooling
    2. Airway Management
    3. Fluid Resuscitation
       1. Establishing Vascular Access
       2. Appropriate Fluid Choice
       3. Monitoring Fluid Resuscitation and Assessing Endpoints
    4. Wound Care
       1. Superficial Burns
       2. Partial-Thickness Burns
          • Wound Cleansing
          • Skin Examination and Blister Aspiration
          • Choosing Topical Therapies and Wound Dressings
       3. Full-Thickness Burns
    5. Antibiotics and Tetanus Prophylaxis
       1. Antibiotics
       2. Prophylaxis
    6. Pain Management
       1. Topical Analgesics
       2. Opioids and Adrenergic Antagonists
       3. Pruritus
11. Disposition
12. Prevention and Advocacy
13. Special Circumstances
    1. Circumferential Burns
    2. Chemical Injuries
       1. Hydrofluoric Acid
       2. Anhydrous Ammonia
    3. Electrical Injuries
    4. Nonaccidental Trauma
14. Controversies and Cutting Edge
    1. Technology to Estimate Total Body Surface Area of Burns
    2. Decreasing the Number of Early Intubations
    3. Vitamin C
    4. Vasopressors and Steroids
    5. Ongoing Controversies in Management
15. Cost-Effective Strategies
16. Summary
17. Risk Management Pitfalls in Management of Pediatric Burns
18. Key Points in Management of Pediatric Burn Injuries
19. Case Conclusions
20. Clinical Pathway For Management Of Burns In Pediatric Patients
21. Tables and Figures
    1. Table 1. Jackson's Burn Model Zones
    2. Table 2. Classification of Burns by Depth
    3. Table 3. American College of Surgeons Burn Severity Assessment in Children
    4. Table 4. Laboratory Studies for Assessment of Pediatric Burn Patients
    5. Table 5. Formulas for Fluid Resuscitation in Pediatric Burn Patients
    6. Table 6. Topical Therapies: Advantages, Disadvantages, and Associated Costs
    7. Table 7. Occlusive Dressings: Advantages, Disadvantages, and Associated Costs
    8. Table 8. Recommended Tetanus Prophylaxis in Burn Wound Management
    9. Table 9. Indications for Transfer to a Burn Center
    10. Figure 1. Anatomy of a Burn
    11. Figure 2. Superficial Partial-Thickness Burn
    12. Figure 3. Deep Partial-Thickness Burn
    13. Figure 4. Full-Thickness Burn
    14. Figure 5. Lund-Browder Chart for Total Body Surface Area Calculation in Children
    15. Figure 6. Full-Thickness Burn Requiring Escharotomy
    16. Figure 7. Comparison of Accidental Iron Burn Versus Nonaccidental Space Heater Burn
22. Refences

Abstract

Burns are a significant cause of injury-induced morbidity and mortality in pediatric patients. The spectrum of management for pediatric burn victims is vast and relies heavily on both the classification of the burn and the body systems involved. The immediate focus of management includes resuscitation and stabilization, fluid management, and pain control. Additional focus includes decreasing the risk of infection as well as improving healing and cosmetic outcomes. Discharge care and appropriate follow-up instructions need to be communicated carefully in order to avoid long-standing complications. This supplement reviews methods for accurate classification and management of the full range of burns seen in pediatric patients.

Case Presentations

A 3-month-old girl is brought to the ED by her mother with a burn to the right buttock. The burn occurred the day before and was caused by a hot curling iron. On examination, you see a 6-inch linear burn with draining. What other historical data should you obtain in this burn patient? Should other services be consulted for management of this infant?

A 6-year-old boy is brought to the ED because he had touched an area of exposed metal on a cord when he was plugging in holiday lights. On presentation, it had been approximately 1 hour since the injury. On examination, he has a 2-cm nonpainful white annular wound with blackened edges on the distal aspect of the right thumb. You wonder if this patient meets the criteria to be discharged home to follow up on an outpatient basis.

Just then, a 10-year-old girl is brought in via ambulance from a local house fire. She presents with deep partial-thickness burns to her entire back, the posterior of her right leg, and her entire right arm. There are some superficial burns on her posterior neck and left upper arm. As you consider your management options, you wonder whether you should transfer this patient to an accredited burn center...

Introduction

Thermal burns in pediatric patients are frequently seen in the practice of the emergency clinician. Approximately 1% of all annual United States ED visits are due to burns,¹ and burns in patients aged < 14 years are consistently among the top causes of injury-induced mortality.² When compared to outcomes in adult burn patients, burns in pediatric patients carry a disproportionately higher morbidity. The majority of burns occur in children aged < 5 years, with a peak incidence at 1 year of age.³

Most pediatric burns occur as a result of accidents in the home.⁴ The majority of pediatric burns are due to scald injuries, a burn caused by hot liquids spilling onto the skin. Scalds and contact burns from sources such as stoves and hot irons together account for 85% of burns seen by emergency clinicians.⁵

The vast majority of all pediatric burns are minor, and > 90% of burns can be managed safely in the outpatient setting.⁶ For patients with serious injury, appropriate disposition, care environment, resuscitation, and wound care impact morbidity and mortality greatly. Approximately 5% of pediatric patients with burns benefit from admission to a burn center.⁷ Improvements in care and infection control have decreased mortality in patients treated in burn specialty centers to 3%.⁸

The LD50 (the dose that is lethal to 50% of the population) of burns in the 1950s was 51% of total body surface area (TBSA). The same statistic was calculated from data collected between 1992 and 2002, and the more recent LD50 is 71% TBSA.⁹ Although the United States has seen an overall decline in burn incidence and mortality, prevention strategies deserve further attention.

Critical Appraisal of the Literature

A literature search was conducted using the following databases: Ovid MEDLINE^®, PubMed, Cochrane Database of Systematic Reviews, and Web of Science™. Search terms included pediatric burn, pediatric burn care, burn wound care, and burn treatment. Randomized controlled trials (RCTs), systematic reviews, and professional guidelines were sought. Recent publications yielded information on changes in the use of biomarkers, updated analysis on the cost of burn care, evidence supporting immune-modulated interventions, new wound care options, and a revised classification system of burns. Additionally, the American College of Emergency Physicians (ACEP) and the American Academy of Pediatrics (AAP) websites were reviewed for professional guidelines. Neither group has published consensus guidelines for clinical practice management of burns. However, prevention strategies have been published by the AAP. The American Burn Association (ABA) in conjunction with the American College of Surgeons (ACS) has published professional guidelines.

Pathophysiology

There are 6 types of thermal burns: scald, flame, contact, electrical, sun, and friction burns. A thermal injury occurs when tissue contacts a heat source such as liquid, flames, hot solids, steam, or electrical current. The duration of contact, the type of tissue involved, and the height of the temperature directly correlate with the amount of tissue destruction and injury. As temperature rises to > 44°C (111.2°F), protein structure is compromised.

The body mounts both local and systemic responses to burns. Systemic response occurs in superficial partial-thickness burns or more severe burns affecting > 15% to 20% of the TBSA. Originally described by Jackson in 1959, the local injury and anatomy of the burn includes 3 zones: centrally, the zone of coagulation; intermediately, the zone of stasis; and exteriorly, the zone of hyperemia.¹⁰ (See Table 1 and Figure 1.)

Cell membrane alterations lead to potassium leak and compensatory sodium and fluid shifts, creating considerable burn edema.¹¹ An increased metabolic rate secondary to protein catabolism after a major burn also complicates the physiologic environment, changing a patient's nutrition requirements. The capillary leak and hypermetabolic state seen in patients with burns > 40% to 60% TBSA result in myocardial depression, decreased cardiac output, and decreased tissue perfusion.¹² An increase in cortisol, catecholamine, and glucagon levels in circulation lead to anaerobic metabolism. Concomitant glucose elevation results in lactate production.

In the pulmonary system, acute respiratory distress syndrome (ARDS) and inflammatory-mediated bronchoconstriction are seen. Finally, erythrocyte progenitor cells decline approximately 1 week after a large burn occurs. This anemia is unresponsive to erythropoietin, and transfusion remains the only viable treatment option.¹³

Risk Management Pitfalls in Management of Pediatric Burns

1. “I saw a patient who was in a house fire, and he was breathing fine when I first examined him. I don’t know why he suddenly got worse.”

Patients presenting from fires that have occurred in closed spaces are at higher risk for inhalation injury. Early normal voice and oxygen saturation levels may not adequately predict a patient’s true airway status. In fact, oxygen saturation may be spuriously high from concomitant carbon monoxide poisoning. While there is currently a move toward avoidance of unnecessary pediatric intubations, any suspicion of airway involvement should prompt careful evaluation. Clinicians should look for carbonaceous sputum, soot in the nares, or damage to the oropharynx. Patients with signs of inhalation injury should be considered for early intubation due to potential respiratory failure from airway edema and obstruction.

6. “I have a severely burned patient who is in shock, and I gave her fluids at 3 mL/kg/%TBSA, but she is still hypotensive. Now the intensivist is saying that the patient needed fluid much faster and possibly a blood transfusion.”

The ATLS^® recommendations and other formulas calculate 24-hour fluid needs in burn victims, but patients presenting in shock require trauma management, including fluid boluses up to 60 mL/kg (in 20-mL/kg aliquots), consideration of blood transfusion, and consideration of vasopressor support for fluid-resistant shock. Using the ATLS^® or other formulas for hourly fluid calculation for a patient in shock will typically not provide adequate fluid resuscitation.

10. “I have a patient who has 10% TBSA superficial burns, 7% TBSA partial-thickness burns, and 4% TBSA full-thickness burns, totaling 21% TBSA burned. I called the burn center to transfer the patient, and I calculated the fluids for resuscitation. They accepted the transfer, but told me to recalculate the TBSA affected.”

Superficial burns are not included in calculation of the percentage of TBSA affected by burns; only partial-thickness and full-thickness burns are included. This estimate should be calculated as accurately as possible, as it will determine fluid volume for resuscitation and will help determine a patient’s appropriate disposition for definitive care.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. United States Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. 2011; Accessed June 1, 2020. (Government report)
2. United States Centers for Disease Control and Prevention. Ten Leading Causes of Injury Death by Age Group. 2019; Accessed June 1, 2020. (Government report)
3. Kemp AM, Jones S, Lawson Z, et al. Patterns of burns and scalds in children. Arch Dis Child. 2014;99(4):316-321. (Prospective multicenter cross-sectional study; 1215 patients)
4. Simons M, Kimble R. Pediatric Burns. In: International Encyclopedia of Rehabilitation. Buffalo, NY: Center for International Rehabilitation Research Information and Exchange; 2010. (Research resource)
5. Shields BJ, Comstock RD, Fernandez SA, et al. Healthcare resource utilization and epidemiology of pediatric burn-associated hospitalizations, United States, 2000. J Burn Care Res. 2007;28(6):811-826. (Retrospective review; 10,000 patients)
6. Warner PM, Coffee TL, Yowler CJ. Outpatient burn management. Surg Clin North Am. 2014;94(4):879-892. (Review)
7. Demling RH, DeSanti L. Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes). Burns. 1999;25(3):256-261. (Prospective randomized controlled trial; 21 patients)
8. Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or = 70% full-thickness). Ann Surg. 1997;225(5):554-565. (Prospective cohort study; 103 subjects)
9. Pruitt BA, Jr. Combat casualty care and surgical progress. Ann Surg. 2006;243(6):715-729. (Review)
10. Jackson D. Diagnosis in the management of burns. BMJ. 1959;1(5132):1266. (Review)
11. Klein GL, Herndon DN. Burns. Pediatr Rev. 2004;25(12):411-417. (Review)
12. Jeschke MG, Pinto R, Herndon DN, et al. Hypoglycemia is associated with increased postburn morbidity and mortality in pediatric patients. Crit Care Med. 2014;42(5):1221-1231. (Prospective cohort analysis; 760 subjects)
13. Williams KN, Szilagyi A, Conrad P, et al. Peripheral blood mononuclear cell-derived erythroid progenitors and erythroblasts are decreased in burn patients. J Burn Care Res. 2013;34(1):133-141. (Prospective observational study; 10 patients, 4 controls)
14. Liao CC, Rossignol AM. Landmarks in burn prevention. Burns. 2000;26(5):422-434. (Review)
15. Raine TJ, Heggers JP, Robson MC, et al. Cooling the burn wound to maintain microcirculation. J Trauma. 1981;21(5):394-397. (Prospective controlled trial)
16. Benson A, Dickson WA, Boyce DE. Burns. BMJ. 2006;332(7542):649-652. (Review)
17. Hettiaratchy S, Papini R. Initial management of a major burn: II--assessment and resuscitation. BMJ. 2004;329(7457):101-103. (Clinical review)
18. Madnani DD, Steele NP, de Vries E. Factors that predict the need for intubation in patients with smoke inhalation injury. Ear Nose Throat J. 2006;85(4):278-280. (Retrospective review; 41 patients)
19. Enoch S, Roshan A, Shah M. Emergency and early management of burns and scalds. BMJ. 2009;338:b1037. (Review)
20. Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29(1):257-266. (Practice guideline review)
21. Koumbourlis AC. Electrical injuries. Crit Care Med. 2002;30(11 Suppl):S424-S430. (Review)
22. Bentrem DJ, Bill TJ, Himel HN, et al. Chondritis of the ear: a late sequela of deep partial thickness burns of the face. J Emerg Med. 1996;14(4):469-471. (Case review)
23. Kagan RJ, Peck MD, Ahrenholz DH, et al. Surgical Management of the Burn Wound and Use of Skin Substitutes. Chicago, IL: American Burn Association; 2009. (White paper)
24. Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin North Am. 1997;32(2):343-364. (Review)
25. Joffe M. Burns. In: Fleisher GR, Ludwig L, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1282-1283. (Textbook chapter)
26. Wachtel TL, Berry CC, Wachtel EE, et al. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. 2000;26(2):156-170. (Prospective observational study; 24 subjects)
27. Hammond JS, Ward CG. Transfers from emergency room to burn center: errors in burn size estimate. J Trauma. 1987;27(10):1161-1165. (Prospective oberservational study; 132 cases)
28. Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care. 1997;13(4):254-255. (Prospective observational study; 91 subjects)
29. Reed JL, Pomerantz WJ. Emergency management of pediatric burns. Pediatr Emerg Care. 2005;21(2):118-129. (Review)
30. Husain FA, Martin MJ, Mullenix PS, et al. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg. 2003;185(5):485-491. (Prospective observational study; 137 patients)
31. Kamolz LP, Andel H, Schramm W, et al. Lactate: early predictor of morbidity and mortality in patients with severe burns. Burns. 2005;31(8):986-990. (Prospective observational study; 166 patients)
32. Matuszczak E, Tylicka M, Debek W, et al. Correlation between circulating proteasome activity, total protein and C-reactive protein levels following burn in children. Burns. 2014;40(5):842-847. (Prospective observational study; 50 consecutively enrolled patients)
33. Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. 1991;325(25):1761-1766. (Case-controlled series)
34. Alexander G, Saldanha J, Ebrahim MK, et al. Is routine admission chest radiograph of any clinical value in non-intensive care burn patients without inhalation injury? Burns. 2003;29(5):499-500. (Retrospective review; 166 patients)
35. Blinn DL, Slater H, Goldfarb IW. Inhalation injury with burns: a lethal combination. J Emerg Med. 1988;6(6):471-473. (Retrospective review; 86 patients)
36. Griffin BR, Frear CC, Babl F, et al. Cool running water first aid decreases skin grafting requirements in pediatric burns: a cohort study of two thousand four hundred ninety-five children. Ann Emerg Med. 2020;75(1):75-85. (Prospective cohort; 2495 patients)
37. Nguyen NL, Gun RT, Sparnon AL, et al. The importance of initial management: a case series of childhood burns in Vietnam. Burns. 2002;28(2):167-172. (Retrospective case series; 695 patients)
38. Jandera V, Hudson DA, de Wet PM, et al. Cooling the burn wound: evaluation of different modalites. Burns. 2000;26(3):265-270. (Prospective controlled trial; 10 animal subjects)
39. Altintas B, Altintas AA, Kraemer R, et al. Acute effects of local cold therapy in superficial burns on pain, in vivo microcirculation, edema formation and histomorphology. Burns. 2014;40(5):915-921. (Prospective controlled trial; 12 subjects)
40. Singer AJ, Taira BR, Thode HC, Jr., et al. The association between hypothermia, prehospital cooling, and mortality in burn victims. Acad Emerg Med. 2010;17(4):456-459. (Retrospective review; 1215 patients)
41. Zhao R, Di LN, Zhao XZ, et al. Measuring surface temperature and grading pathological changes of airway tissue in a canine model of inhalational thermal injury. Burns. 2013;39(4):767-775. (Prospective randomized controlled study; 20 animal subjects)
42. Rong YH, Liu W, Wang C, et al. Temperature distribution in the upper airway after inhalation injury. Burns. 2011;37(7):1187-1191. (Prospective observational study; 18 animal subjects)
43. Moylan JA, Chan CK. Inhalation injury--an increasing problem. Ann Surg. 1978; 188(1):34-37. (Review)
44. Thompson PB, Herndon DN, Traber DL, et al. Effect on mortality of inhalation injury. J Trauma. 1986;26(2):163-165. (Retropective review; 1018 consecutive patients)
45. Shirani KZ, Pruitt BA, Jr., Mason AD, Jr. The influence of inhalation injury and pneumonia on burn mortality. Ann Surg. 1987;205(1):82-87. (Retrospective review; 373 patients)
46. Sen S, Palmieri T, Greenhalgh D. Review of burn research for the year 2013. J Burn Care Res. 2014;35(5):362-368. (Review)
47. Ikonomidis C, Lang F, Radu A, et al. Standardizing the diagnosis of inhalation injury using a descriptive score based on mucosal injury criteria. Burns. 2012;38(4):513-519. (Prospective observational study; 100 patients)
48. Herndon DN. Total Burn Care. Philadelphia, PA: Saunders-Elsevier; 2007. (Textbook)
49. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018. (Manual)
50. Puffinbarger NK, Tuggle DW, Smith EI. Rapid isotonic fluid resuscitation in pediatric thermal injury. J Pediatr Surg. 1994;29(2):339-341. (Retrospective review; 44 patients)
51. Ansermino JM, Vandebeek CA, Myers D. An allometric model to estimate fluid requirements in children following burn injury. Paediatr Anaesth. 2010;20(4):305-312. (Descriptive research study)
52. Romanowski KS, Palmieri TL. Pediatric burn resuscitation: past, present, and future. Burns Trauma. 2017;5:26. (Review)
53. Parvizi D, Kamolz LP, Giretzlehner M, et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns. 2014;40(2):241-245. (Prospective observational study; 80 clinicians)
54. Ciofi Silva CL, Rossi LA, Canini SR, et al. Site of catheter insertion in burn patients and infection: a systematic review. Burns. 2014;40(3):365-373. (Systematic review)
55. Carcillo JA. Intravenous fluid choices in critically ill children. Curr Opin Crit Care. 2014;20(4):396-401. (Review)
56. Cartotto R, Callum J. A review of the use of human albumin in burn patients. J Burn Care Res. 2012;33(6):702-717. (Review)
57. Saffle JI. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res. 2007;28(3):382-395. (Review)
58. Gibran NS, Wiechman S, Meyer W, et al. Summary of the 2012 ABA Burn Quality Consensus conference. J Burn Care Res. 2013;34(4):361-385. (Conference summary)
59. Todd SR, Malinoski D, Muller PJ, et al. Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007;62(3):636-639. (Review)
60. Shah N. Burn, Thermal. In: Hoffman R, Wang V, Scarfone R, eds. Fleisher and Ludwig’s 5-Minute Pediatric Emergency Medicine Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:130-131. (Textbook chapter)
61. Faraklas I, Lam U, Cochran A, et al. Colloid normalizes resuscitation ratio in pediatric burns. J Burn Care Res. 2011;32(1):91-97. (Retrospective review; 53 patients)
62. Cochran A, Morris SE, Edelman LS, et al. Burn patient characteristics and outcomes following resuscitation with albumin. Burns. 2007;33(1):25-30. (Case-controlled study)
63. Oda J, Ueyama M, Yamashita K, et al. Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients. J Trauma. 2006;60(1):64-71. (Prospective observational study; 36 patients )
64. Cancio LC, Reifenberg L, Barillo DJ, et al. Standard variables fail to identify patients who will not respond to fluid resuscitation following thermal injury: brief report. Burns. 2005;31(3):358-365. (Retrospective review; 3807 patients)
65. Sheridan RL. Management of burns. Surg Clin North Am. 2014;94(4):xv-xvi. (Review)
66. Paratz JD, Stockton K, Paratz ED, et al. Burn resuscitation-hourly urine output versus alternative endpoints: a systematic review. Shock. 2014;42(4):295-306. (Systematic review)
67. Fabia R, Groner JI. Advances in the care of children with burns. Adv Pediatr. 2009;56:219-248. (Review)
68. Holm C, Mayr M, Tegeler J, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns. 2004;30(8):798-807. (Randomized controlled trial; 50 consecutive patients)
69. Wasiak J, Cleland H, Campbell F, et al. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013;3:CD002106. (Systematic review; 30 randomized controlled trials)
70. Jamshidi R, Sato TT. Initial assessment and management of thermal burn injuries in children. Pediatr Rev. 2013;34(9):395-404. (Review)
71. Vermeulen H, Westerbos SJ, Ubbink DT. Benefit and harm of iodine in wound care: a systematic review. J Hosp Infect. 2010;76(3):191-199. (Systematic review; 27 randomized controlled trials)
72. Hudspith J, Rayatt S. First aid and treatment of minor burns. BMJ. 2004;328(7454):1487-1489. (Review)
73. Garner WL, Zuccaro C, Marcelo C, et al. The effects of burn blister fluid on keratinocyte replication and differentiation. J Burn Care Rehabil. 1993;14(2 Pt 1):127-131. (Prospective controlled trial)
74. Pan SC, Wu LW, Chen CL, et al. Angiogenin expression in burn blister fluid: implications for its role in burn wound neovascularization. Wound Repair Regen. 2012;20(5):731-739. (Laboratory study)
75. Gimbel NS, Kapetansky DI, Weissman F, et al. A study of epithelization in blistered burns. AMA Arch Surg. 1957;74(5):800-803. (Observational study)
76. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-294. (Prospective observational study)
77. Murphy F, Amblum J. Treatment for burn blisters: debride or leave intact? Emerg Nurse. 2014;22(2):24-27. (Systematic review)
78. Shaw J, Dibble C. Best evidence topic report. Management of burns blisters. Emerg Med J. 2006;23(8):648-649. (Review)
79. Rowley-Conwy G. Management of minor burns in the emergency department. Nurs Stand. 2012;26(24):60, 62, 64-67. (Review)
80. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am. 2008;26(1):125-136. (Review)
81. Vloemans AF, Hermans MH, van der Wal MB, et al. Optimal treatment of partial thickness burns in children: a systematic review. Burns. 2014;40(2):177-190. (Systematic review; 51 studies)
82. Genuino GA, Baluyut-Angeles KV, Espiritu AP, et al. Topical petrolatum gel alone versus topical silver sulfadiazine with standard gauze dressings for the treatment of superficial partial thickness burns in adults: a randomized controlled trial. Burns. 2014;40(7):1267-1273. (Randomized controlled trial; 50 patients)
83. Singer AJ, Brebbia J, Soroff HH. Management of local burn wounds in the ED. Am J Emerg Med. 2007;25(6):666-671. (Review)
84. Vandamme L, Heyneman A, Hoeksema H, et al. Honey in modern wound care: a systematic review. Burns. 2013;39(8):1514-1525. (Systematic review; 55 studies)
85. Majtan J. Honey: an immunomodulator in wound healing. Wound Repair Regen. 2014;22(2):187-192. (Review)
86. Weinbren MJ. Pharmacokinetics of antibiotics in burn patients. J Antimicrob Chemother. 1999;44(3):319-327. (Review)
87. Vella D, Walker SA, Walker SE, et al. Determination of tobramycin pharmacokinetics in burn patients to evaluate the potential utility of once-daily dosing in this population. J Burn Care Res. 2014;35(4):e240-e249. (Retrospective review; 58 patients)
88. Gomez DS, Campos EV, de Azevedo RP, et al. Individualised vancomycin doses for paediatric burn patients to achieve PK/PD targets. Burns. 2013;39(3):445-450. (Prospective observational study; 13 patients)
89. Akers KS, Cota JM, Chung KK, et al. Serum vancomycin levels resulting from continuous or intermittent infusion in critically ill burn patients with or without continuous renal replacement therapy. J Burn Care Res. 2012;33(6):e254-e262. (Retrospective review; 171 patients)
90. Grunau BE, Olson J. An interesting presentation of pediatric tetanus. CJEM. 2010;12(1):69-72. (Case report)
91. United States Centers for Disease Control and Prevention. Recommended Immunization Schedule for Persons Age 0 Through 18 Years. 2020; Accessed June 1, 2020. (Government report)
92. Hill AG, Hill GL. Metabolic response to severe injury. Br J Surg. 1998;85(7):884-890. (Review)
93. Greisen J, Juhl CB, Grofte T, et al. Acute pain induces insulin resistance in humans. Anesthesiology. 2001;95(3):578-584. (Prospective observational study; 10 patients)
94. Gandhi M, Thomson C, Lord D, et al. Management of pain in children with burns. Int J Pediatr. 2010;2010:825657. (Review)
95. Singer AJ, Thode HC, Jr. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23(6):361-365. (Retrospective review; 138 patients)
96. Singer AJ, Gulla J, Thode HC, Jr. Parents and practitioners are poor judges of young children’s pain severity. Acad Emerg Med. 2002;9(6):609-612. (Prospective descriptive study; 63 patients)
97. Brofeldt BT, Cornwell P, Doherty D, et al. Topical lidocaine in the treatment of partial-thickness burns. J Burn Care Rehabil. 1989;10(1):63-68. (Prospective trial; 24 patients)
98. Adriani J. Reactions to local anesthetics. JAMA. 1966;196(5):405-408. (Review)
99. Bryant JS, Busbee BG, Reichel E. Overview of ocular anesthesia: past and present. Curr Opin Ophthalmol. 2011;22(3):180-184. (Review)
100. Borland ML, Bergesio R, Pascoe EM, et al. Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study. Burns. 2005;31(7):831-837. (Randomized double-blind trial; 24 patients)
101. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med. 2011;12(10):1551-1558. (Systematic review; 4 studies)
102. Jones GM, Porter K, Coffey R, et al. Impact of early methadone initiation in critically injured burn patients: a pilot study. J Burn Care Res. 2013;34(3):342-348. (Retrospective case-controlled study)
103. Wibbenmeyer L, Sevier A, Liao J, et al. The impact of opioid administration on resuscitation volumes in thermally injured patients. J Burn Care Res. 2010;31(1):48-56. (Retrospective review; 154 patients)
104. Schneider JC, Nadler DL, Herndon DN, et al. Pruritus in pediatric burn survivors: defining the clinical course. J Burn Care Res. 2015;36(1):151-158. (Retrospective review; 430 patients)
105. Mendham JE. Gabapentin for the treatment of itching produced by burns and wound healing in children: a pilot study. Burns. 2004;30(8):851-853. (Prospective observational study; 35 patients)
106. Goutos I. Neuropathic mechanisms in the pathophysiology of burns pruritus: redefining directions for therapy and research. J Burn Care Res. 2013;34(1):82-93. (Review)
107. Kopecky EA, Jacobson S, Bch MB, et al. Safety and pharmacokinetics of EMLA in the treatment of postburn pruritus in pediatric patients: a pilot study. J Burn Care Rehabil. 2001;22(3):235-242. (Prospective observational trial; patients)
108. Sheridan RL, Remensnyder JP, Schnitzer JJ, et al. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med. 2000;154(3):245-249. (Retrospective review; 1828 patients)
109. Weber JM, Sheridan RL, Fagan S, et al. Incidence of catheter-associated bloodstream infection after introduction of minocycline and rifampin antimicrobial-coated catheters in a pediatric burn population. J Burn Care Res. 2012;33(4):539-543. (Case-controlled study; 141 patients)
110. American Burn Association. Burn Center Referral Criteria. Accessed June 1, 2020. (Website)
111. Hop MJ, Polinder S, van der Vlies CH, et al. Cost of burn care: a systematic review. Wound Repair Regen. 2014;22(4):436-450. (Systematic review; 156 studies)
112. Streeton C, Nolan T. Reduction in paediatric burn admissions over 25 years, 1970-94. Inj Prev. 1997;3(2):104-109. (Retrospective review; 4992 subjects)
113. Cheatham ML, Safcsak K. Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? Crit Care Med. 2010;38(2):402-407. (Prospective observational study; 478 consecutive patients)
114. Salzman M, O’Malley RN. Updates on the evaluation and management of caustic exposures. Emerg Med Clin North Am. 2007;25(2):459-476. (Review)
115. Mowry JB, Spyker DA, Cantilena LR, Jr., et al. 2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila). 2013;51(10):949-1229. (Retrospective review)
116. Kearns RD, Cairns CB, Holmes JH, et al. Chemical burn care: a review of best practices. EMS World. 2014;43(5):40-45. (Review)
117. McKee D, Thoma A, Bailey K, et al. A review of hydrofluoric acid burn management. Can J Plast Surg. 2014;22(2):95-98. (Review)
118. Glatstein MM, Ayalon I, Miller E, et al. Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury. Pediatr Emerg Care. 2013;29(6):737-740. (Retrospective review; 36 patients)
119. Cooper M, Price T. University of Illinois at Chicago Labs: Electrical and Lightning Injuries. Accessed June 1, 2020. (Review)
120. Alemayehu H, Tarkowski A, Dehmer JJ, et al. Management of electrical and chemical burns in children. J Surg Res. 2014;190(1):210-213. (Retrospective review; 50 cases)
121. Roberts S, Meltzer JA. An evidence-based approach to electrical injuries in children. Pediatr Emerg Med Pract. 2013;10(9):1-16. (Review)
122. Leetch AN, Woolridge D. Emergency department evaluation of child abuse. Emerg Med Clin North Am. 2013;31(3):853-873. (Review)
123. Thombs BD. Patient and injury characteristics, mortality risk, and length of stay related to child abuse by burning: evidence from a national sample of 15,802 pediatric admissions. Ann Surg. 2008;247(3):519-523. (Retrospective review; 909 cases)
124. Wibbenmeyer L, Liao J, Heard J, et al. Factors related to child maltreatment in children presenting with burn injuries. J Burn Care Res. 2014;35(5):374-381. (Prospective observational study; 16 patients)
125. Sheng WB, Zeng D, Wan Y, et al. BurnCalc assessment study of computer-aided individual three-dimensional burn area calculation. J Transl Med. 2014;12(1):242. (Prospective observational study)
126. Oscier C, Emerson B, Handy JM. New perspectives on airway management in acutely burned patients. Anaesthesia. 2014;69(2):105-110. (Review)
127. Kameda T, Fujita M. Point-of-care ultrasound detection of tracheal wall thickening caused by smoke inhalation. Crit Ultrasound J. 2014;6(1):11. (Case review)
128. Horton JW, Burton KP, White DJ. The role of toxic oxygen metabolites in a young model of thermal injury. J Trauma. 1995;39(3):563-569. (Animal study)
129. Kuck JL, Bastarache JA, Shaver CM, et al. Ascorbic acid attenuates endothelial permeability triggered by cell-free hemoglobin. Biochem Biophys Res Commun. 2018;495(1):433-437. (Basic science research on Vitamin C)
130. Marik PE. Vitamin C for the treatment of sepsis: the scientific rationale. Pharmacol Ther. 2018;189:63-70. (Review)
131. Dennis JM, Witting PK. Protective role for antioxidants in acute kidney disease. Nutrients. 2017;9(7):718. (Review)
132. Martineau L, Racine V, Benichou SA, et al. Lymphoblastoids cell lines - Derived iPSC line from a 26-year-old myotonic dystrophy type 1 patient carrying (CTG)200 expansion in the DMPK gene: CHUQi001-A. Stem Cell Res. 2018;26:103-106. (Human stem cell research)
133. Kahn SA, Beers RJ, Lentz CW. Resuscitation after severe burn injury using high-dose ascorbic acid: a retrospective review. J Burn Care Res. 2011;32(1):110-117. (Retrospective review; 40 patients)
134. Rizzo JA, Rowan MP, Driscoll IR, et al. Vitamin C in burn resuscitation. Crit Care Clin. 2016;32(4):539-546. (Review)
135. Lin J, Falwell S, Greenhalgh D, et al. High-dose ascorbic acid for burn shock resuscitation may not improve outcomes. J Burn Care Res. 2018;39(5):708-712. (Retrospective case-controlled study; 38 patients)
136. Hoesel LM, Niederbichler AD, Schaefer J, et al. C5a-blockade improves burn-induced cardiac dysfunction. J Immunol. 2007;178(12):7902-7910. (Animal study)
137. Bernard F, Gueugniaud PY, Bertin-Maghit M, et al. Prognostic significance of early cardiac index measurements in severely burned patients. Burns. 1994;20(6):529-531. (Retrospective review; 38 patients)
138. Venet F, Plassais J, Textoris J, et al. Low-dose hydrocortisone reduces norepinephrine duration in severe burn patients: a randomized clinical trial. Crit Care. 2015;19(1):21. (Placebo-controlled, double-blind, randomized clinical trial; 27 patients)
139. Müller Dittrich MH, Brunow de Carvalho W, Lopes Lavado E. Evaluation of the “early” use of albumin in children with extensive burns: a randomized controlled trial. Pediatr Crit Care Med. 2016;17(6):e280-e286. (Randomized controlled trial; 46 patients)
140. Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey. Burns. 2010;36(2):176-182. (Survey)
141. Ahn CS, Maitz PK. The true cost of burn. Burns. 2012;38(7):967-974. (Retrospective review; 20 cases)
142. Bharat R. Value engineering-a new concept in reducing the cost of burn care. Indian Journal of Plastic Surgery. 1994;27(2):86-89. (Prospective observational study)