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.
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...
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.
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.
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
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.
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.
Why To Use
The Parkland formula has been endorsed by the American Burn Association. It has been shown to appropriately restore intravascular volume and limit the development of hypovolemic shock.
When To Use
Resuscitation endpoints and monitoring:
David Zodda, MD
Critically ill burn patients are best cared for at a dedicated burn center, particularly those who have any of the following:
It is important to remember that all resuscitation formulas should only be used as guides. Patients should be assessed frequently, with individual adjustments made to maintain adequate organ perfusion.
Blumetti et al (2008) conducted a retrospective study of patients resuscitated with the Parkland formula at a single institution over 15 years to determine the accuracy of the formula in guiding resuscitation. Using urine output as a guideline for adequate resuscitation, they found that patients commonly received fluid volumes higher than predicted by the Parkland formula, and concluded that the formula should represent a resuscitation “starting point,” but urine output is the most important parameter to control resuscitation volume.
Cartotto et al (2002) performed a retrospective study, and also found that the Parkland formula underestimated the volume requirements in most adults with burns, especially in those with large full-thickness burns. Thus, the Parkland formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient (Baxter 1974, Cartotto 2002, Blumetti 2008).
Charles Baxter, MD
Hilary Fairbrother, MD, MPH, FACEP; Megan Long, MD; Elizabeth Haines, DO, MAS, FACEP
Melissa L. Langhan, MD, MHS, FAAP
June 30, 2020
July 31, 2023
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.
Date of Original Release: June 30, 2020. Date of most recent review: May 31, 2020. Termination date: June 30, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; thorough review of current literature on the topic and practice gap assessment; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
CME Objectives: Upon completion of this activity, you should be able to: (1) clinically examine and categorize burns; (2) manage pain and fluid resuscitation in the burn patient; (3) appropriately disposition burn patients based on guidelines and follow criteria for transfer to a burn center; and (4) recognize patterns of injury consistent with nonaccidental trauma.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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Commercial Support: This supplement to Pediatric Emergency Medicine Practice did not receive any commercial support.
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