Pediatric Burns By Bradley J. Phillips

Head and Neurological—A change in mental status or loss of consciousness is an indication for a head CT scan in order to evaluate for accompanying intracranial trauma. Other causes to be considered include intoxication, hypoxia, hypotension, and inhalation injury.

Eyes and Ears—In the event of facial involvement, an ophthalmology consultation should be obtained early, as a delayed evaluation will be difficult with advancing facial edema. A fluorescein exam to evaluate the cornea is helpful to evaluate for subtle eye injuries. External ear burns should be debrided and treated with mafenide acetate to prevent suppurative chondritis.

Chest—The patient’s ability to ventilate should be reevaluated during the secondary survey, particularly with a deep, circumferential injury. Full-thickness burns will result in an inelastic eschar which restricts the chest wall’s ability to rise with inspiration. Signs of respiratory distress and elevated peak airway pressures will be seen with decreased chest compliance. An escharotomy, in which incisions through the eschar to healthy tissue are made along the flanks and below the costal margins, allows the anterior chest wall to dissociate from the posterior chest wall and abdomen.¹⁹ This results in relieving the constriction and improving the patient’s respiratory status.

Extremities—Deep circumferential burns to the limbs may cause a complication similar to that described above. The leathery eschar constricts the underlying soft tissue as subcutaneous structures proceed to swell with aggressive fluid resuscitation and systemic inflammation. This constriction results in an increase in compartment pressure. When the pressure exceeds 25 mmHg to 30 mmHg, capillary filling pressure is overcome and tissue becomes hypoperfused. This hypoperfusion can lead to limb ischemia, functional disability, and amputation.³ The injured limb should be kept at the level of the heart to maintain optimal mean arterial pressure while limiting dependent pooling.¹² Early findings of compartment syndrome include pain on stretching, a tense limb, palpable pulses, brisk capillary refill, and paresthesia.¹⁹ Once the syndrome develops, treatment via escharotomy to release constriction is indicated.³ Warm ischemia leads to soft tissue death within 2 to 3 hours, allowing escharotomies to be performed in the controlled environment of an operating room. The incision should be performed with electrocautery to minimize blood loss and should follow the proceeding guidelines: avoid named nerves, preserve longitudinal veins, and avoid crossing joints in straight lines to minimize future contractures.¹⁹

Abdomen—The patient should be evaluated for associated injuries, particularly in the setting of excess fluid requirements and rapidly decreasing hematocrit levels. Abdominal fluid and pressure should be monitored in efforts to avoid massive overresuscitation. With sympathetic activity decreasing splanchnic flow, the patient should be initiated on H2 antagonist prophylaxis to prevent Curling’s ulcers of the gastroduodenum. Since burn patients are also prone to swallowing air and gastric dilation, a nasogastric tube should be placed to decompress the stomach during the emergent phase.¹²

Tetanus

As open wounds, burn injuries are vulnerable to tetanus infection.⁸ If the patient’s immune status is unknown, he or she should receive active immunization with injection of tetanus toxoid. If the patient is not immunized, passive immunization in the form of antitetanus immunoglobulin should be administered in addition to tetanus toxoid.²⁰

Acute Phase

The goal of the acute phase is to cover the wound in order to decrease water vapor loss, prevent desiccation, and aid in pain control and bacterial inhibition.²⁰ Complications seen during this period include wound infection, sepsis, pulmonary insufficiency, and multisystem organ failure.²

Pain control throughout this phase is very important in order to minimize trauma and additional stress. Dose-appropriate intravenous morphine, oral acetaminophen, and acetaminophen with codeine are commonly used in pediatric burn management. Similar to other pediatric medications, these analgesics should be dosed by weight.²¹

Extended-release oxycodone can help with pain control in older children. Conscious sedation with the use of ketamine is helpful during procedures such as extensive dressing changes.⁹

Intact blisters of partial-thickness wounds are managed by using firm, sweeping motions with warm saline-soaked gauze to unroof and debride them. The wounds are then treated with topical antimicrobials and covered with dry, nonadherent dressings. Bacitracin is commonly used and has coverage against some gram-positive bacteria. Its primary function is to maintain a moist environment conducive to healing. Silvadene is an agent which has a broader spectrum of antimicrobial coverage, including gram-positive and gram-negative bacteria and fungi. However, as an opaque white