Burns are a common cause of injury in children and the fourth leading cause of accidental death in the United States. Depending on the mechanism of injury, burns can range from superficial to life-threatening. The National Burn Repository reports that just over half of burns in children younger than 5 years are scald burns, while older children typically are injured by flame burns from residential fires or ignition of flammable substances.
Mortality in burned children is directly proportional to the size of the burn. Accurate estimate of burn size is crucial to the care of the burned pediatric patient. The following tables estimate burn depth and the percentage of total body surface area (TBSA) of burns.
Assessment of Burn Depth
|Blanches red, pink,
|± 7 days
||Exposure of limited
duration to lower
|Dull or hyperactive
pain, sensitive to
||Long duration of
exposure to high
|Painless to touch
and pinprick, may
hurt at deep
|No blanching, pale
white, tan charred,
hard, dry, leathery,
|Prolonged duration of
exposure to extreme
Modified Lund and Browder Chart for Estimating Percentage of
Total Body Surface Area of Burns by Age
Airway, breathing, and circulation (ABCs): As always, careful attention to the airway, breathing, and circulation is crucial for initial assessment and stabilization of the patient. ABC assessment is as important on arrival to the PICU, regardless of where initial triage and management occurred.
Inhalation injury: The airway should be carefully examined for signs of inhalation injury. Clues to injury of the upper and lower airway include burns to the face, singed nasal hairs, soot in the oropharynx, and carbonaceous sputum. Respiratory distress may be present, including tachypnea, use of accessory muscles of breathing, and stridor. If inhalation injury is suspected, difficult intubation should be anticipated and the airway should be secured by the most experienced physician available. The following is an algorithm for the management of suspected inhalation injury:
An Algorithm for Early Management of Fire-Related Inhalation Injury
Vascular access: Obtain reliable vascular access; this may require central venous cannulation.
Fluid resuscitation: In general, burns >20% TBSA are associated with large fluid shifts and require careful management of volume status.
- The Parkland formula is an appropriate starting guideline for fluid resuscitation for most children. Half the fluid is given during the first 8 hours from the time of onset of injury; the remaining fluid is given at an even rate during the next 16 hours. The rate of infusion is adjusted according to the patient’s response to therapy. Heart rate and blood pressure should return to normal for age, and an adequate urine output (1–2 mL/kg/hour in children; 0.5–1.0 mL/kg/hour in adolescents) should be accomplished by varying the IV infusion rate. Vital signs, acid–base balance, and mental status reflect the adequacy of resuscitation.
Volume of lactated Ringer solution = 4 mL x kg x % TBSA burned
- Whether colloid (albumin) should be provided in the early period of burn resuscitation is controversial. If utilized, one approach is to administer colloid replacement concurrently with crystalloid therapy if the burn is >85% of TBSA (e.g., 50% albumin infusion, 50% crystalloid infusion). Colloid is usually administered 12 to 24 hours after the burn injury.
Wound care: Debridement of dead tissue reduces the risk of infection, and early debridement of deeper burns has been associated with better outcomes. Application of topical antibiotics to partial-thickness burns with dry sterile dressings should be done in collaboration with a burn surgery team.
Nutrition: Nutritional support is extremely important to the healing of wounds, preferably with early enteral nutrition whenever possible.
Hypermetabolic response: Burns are associated with a hypermetabolic state, and attenuation of this response with beta-blockers and medications (e.g., oxandrolone) should be considered.
Infection: Prophylactic antimicrobial therapy is recommended only for coverage of the immediate perioperative period surrounding excision or grafting of the burn wounds to cover the documented increase in risk of transient bacteremia. Surveillance cultures of the wounds, especially if the patient arrived from another unit or location, are standard of care in most burn units and essential for guiding empiric antimicrobial therapy if infection is suspected.
Pain management: Burns can be extremely painful, as are debridement and dressing changes, especially in children. Management of pain and anxiolysis is paramount to the care of the burned child in the ICU. Common medications include morphine and fentanyl infusions and bolus doses for breakthrough pain or wound manipulation. Midazolam and lorazepam are commonly used for anxiolysis. Ketamine can be used for procedural sedation and analgesia. Itch can also be managed with diphenhydramine, hydroxyzine, and gabapentin.
Understanding the mechanism of the burn is important for ruling out other traumatic injuries and comorbidities. Trauma consults should be obtained on all burned children if suggested by history or if the patient was found unconscious with an unknown history. House fires should prompt suspicion for cyanide and carbon monoxide toxicity that should be treated promptly.
American Burn Association Burn Center Referral Criteria
Burn injuries that should be referred to a burn center include:
- partial thickness burns >10% TBSA
- burns that involve the face, hands, feet, genitalia, perineum, or major joints
- third-degree burns in any age group
- electrical burns, including lightning injury
- chemical burns
- inhalation injury
- burn injury in patients with preexisting medical conditions that could complicate management, prolong recovery, or affect mortality
- burn injury with concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of morbidity or mortality; if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit; physician judgment is necessary and should be in concert with the regional medical control plan and triage protocols
- burned children in hospitals without qualified personnel or equipment for the care of children
- burn injury in patients who will require specialized social, emotional, or rehabilitative intervention