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

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About This Issue

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

Table of Contents
  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.)

Table 1. Jackson's Burn Model Zones
Systemically, burns > 20% TBSA in children result in more profound pathophysiologic effects due to the release of inflammatory cytokines. Capillary leak, peripheral and central splanchnic vasoconstriction, and depressed myocardial function (linked to tumor necrosis factor-alpha) may lead to hypotension.

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

Table 1. Jackson's Burn Model Zones
Table 2. Classification of Burns by Depth

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.

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Publication Information
Authors

Hilary Fairbrother, MD, MPH, FACEP; Megan Long, MD; Elizabeth Haines, DO, MAS, FACEP

Peer Reviewed By

Melissa L. Langhan, MD, MHS, FAAP

Publication Date

June 30, 2020

CME Expiration Date

July 1, 2023

CME Credits

4 AMA PRA Category 1 Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Pub Med ID: 32530588

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