Pediatric Burns By Bradley J. Phillips

injuries.¹¹ Due to the highly variable body proportions in the pediatric population, the commonly used “rule of nines” in adult burn management is not applicable without significant modification. An alternative method to estimate the area involved, referred to as the “rule of palms,” uses the patient’s hand as an internal control. The surface area of one side of the patient’s hand, including the fingers, is equal to 1% of the TBSA. This palm estimate is particularly useful with injuries that present with a splattered or blotchy distribution. A more precise calculation of the TBSA involves the use of an age-appropriate Lund-Browder chart (Table 1).¹ In particular, emergency medical services and the emergency department may find the modified “rule of nines” and the palm estimate very helpful. In these circumstances, the TBSA is used for triage purposes and serves only as a marker of the extent of injury. Upon admission to a burn center or intensive care setting, the TBSA will influence initial resuscitation and management until the Lund-Browder chart is utilized for a more accurate assessment.⁸

Burn Management

History should be obtained from the patient, the patient’s caregivers, and the responding emergency medical services, if applicable. The mechanism of injury as well as the temperature of the agent and duration of contact should be determined. The surrounding circumstances should be documented very carefully, as up to 20% of pediatric burns are a result of negligence or abuse.¹² Health care providers should be alert and aware of the warning signs of abuse, such as an inconsistent or changing history, an unexplained delay in seeking medical attention, and treatment being sought by an unrelated adult (Table 2).⁸

Triage

Outpatient Care

Outpatient care of a pediatric burn is preferable whenever possible. Management of smaller burns (TBSA less than 10%) in the normal home environment provides a less traumatic as well as a more cost-effective means of providing care, to the benefit of both the patient and society. In order to permit outpatient care, the patient must be able to maintain oral nutrition and hydration, and the family must be able to manage appropriate wound care.¹ The caregiver should be reliable and should demonstrate wound care competence prior to discharge.⁹ Daily care involves washing the wound with a mild detergent in warm water and providing gentle debridement with a wet washcloth. A thin layer of topical antimicrobials, such as silvadene or bacitracin, should be applied to the affected area in order to maintain a moist environment conducive to wound healing and to help with pain control. The wound can then be covered with a nonadherent dry dressing. The patient’s pain should be sufficiently controlled with oral medications to permit dressing changes and regular use of the affected areas. In addition to patient education, physical therapy should be considered, particularly if the injury crosses a joint.²

Inpatient Care

The American Burn Association has recommended guidelines for admission or transfer to a burn center. All children with a burn greater than 10% TBSA or with involvement of an area of functional importance should be immediately admitted for care.¹¹ Other cutaneous injuries requiring admission, which may be more significant than initially appreciated, are chemical and electrical burns and the presence of inhalation injury. Pediatric patients initially treated in a facility without qualified caregivers should be transferred to a burn center specializing in pediatric care. The child may require intubation prior to transportation and should be covered in dry, sterile sheets to maintain body temperature.¹²

Pre-hospital Preparation

In preparing for the patient’s arrival, the room should be warmed to 31.5°C ± 0.7°C and equipped with warming blankets.¹² The materials necessary for airway management and intravenous access should be readily available, as well as large volumes of warm intravenous fluids. All personnel should be gowned, gloved, and masked to protect themselves and the patient.⁸

Burn management can be divided into 3 phases (Figure 1): (1) emergent, (2) acute, and (3) rehabilitation and reintegration.

Emergent

The goal of the emergent phase in pediatric burn management is to stop the injury process and stabilize the patient. Health care providers should follow the pediatric advanced life support and advanced trauma life support protocols, attending to the patient’s airway, breathing, and circulation. Adequate fluid resuscitation and maintenance of core body temperature are also very important throughout the management of a pediatric burn.

Airway—Upper Airway Injury

Airway obstruction occurs with injury to the soft tissues of the head, face, and neck, including the upper airway. The upper airway is defined as the oropharynx above the glottis