Overview
Definition:
Burns in children are injuries to the skin or deeper tissues caused by heat, electricity, chemicals, radiation, or friction
Estimating the Total Body Surface Area (TBSA) involved and initiating appropriate fluid resuscitation are critical initial steps in management.
Epidemiology:
Burns are a significant cause of morbidity and mortality in children
Scalds from hot liquids and contact burns are most common etiologies
Accidental burns are prevalent, with specific age groups having higher risks (e.g., toddlers for scalds, older children for flame burns)
Indian data shows high incidence of domestic burns.
Clinical Significance:
Accurate TBSA estimation guides fluid resuscitation, which is crucial in preventing hypovolemic shock in pediatric burn patients
Inadequate or excessive fluid administration can lead to significant complications, impacting patient outcomes and survival rates
This topic is a cornerstone of pediatric emergency and critical care.
Clinical Presentation
Symptoms:
Pain at the burn site
Redness and inflammation
Blistering of the skin
Swelling of the affected area
In severe cases, loss of sensation or signs of shock.
Signs:
Erythema, edema, and blistering for superficial and partial-thickness burns
Charring or leathery appearance for full-thickness burns
Vital sign abnormalities: Tachycardia, hypotension (indicating shock), tachypnea
Signs of airway compromise if inhalation injury is suspected.
Diagnostic Criteria:
No formal diagnostic criteria for burns
diagnosis is based on clinical assessment of the injury
TBSA estimation using age-appropriate charts (e.g., Lund-Browder chart) and degree of burn are the key components for management planning.
Diagnostic Approach
History Taking:
Mechanism of injury (scald, flame, chemical, electrical, contact)
Time of injury
Circumstances of injury (accidental vs
non-accidental)
Pre-existing medical conditions
Medications
Allergies
Last oral intake
Vaccination status (especially tetanus).
Physical Examination:
Assess airway patency, breathing, and circulation (ABCs)
Inspect the burn wound: depth (superficial, partial-thickness, full-thickness), extent (TBSA estimation), and distribution
Assess for associated injuries
Perform a complete systemic examination to rule out other issues
Assess for signs of inhalation injury (sooty nostrils, facial burns, hoarseness, stridor).
Investigations:
Complete Blood Count (CBC) to assess for anemia or infection
Electrolytes (Sodium, Potassium, Chloride) and Renal function tests (BUN, Creatinine) to monitor fluid and electrolyte balance
Glucose levels
Blood gas analysis (ABG) for acid-base status and oxygenation
Coagulation profile if indicated
Chest X-ray if inhalation injury is suspected
Burn wound culture if infection is suspected.
Differential Diagnosis:
Non-accidental injury (child abuse) should be considered, especially with burns inconsistent with history or presentation
Other skin conditions mimicking burns (e.g., cellulitis, allergic reactions, bullous disorders) but are usually distinguishable by history and examination.
Management
Initial Management:
Stop the burning process
Remove smoldering clothing and jewelry
Cool the burn with clean, cool (not cold) water for 10-20 minutes
Cover the burn loosely with a clean, dry dressing or cling film
Assess and secure airway
administer oxygen
Establish intravenous access (large bore cannula) in a non-burned area if TBSA > 10%.
Fluid Resuscitation:
The Parkland formula is used for initial resuscitation of burn patients
Formula: 4 mL x weight (kg) x TBSA (%) = Total 24-hour fluid requirement
Half of the total fluid should be administered in the first 8 hours from the time of injury, and the remaining half over the next 16 hours
For children, Lactated Ringer's solution is preferred
Use age-appropriate formulas for younger children with smaller TBSA burns
Monitor urine output (target 1 mL/kg/hr) closely.
Medical Management:
Analgesia: IV opioids (morphine, fentanyl) for pain control
Tetanus prophylaxis: Tetanus toxoid and immunoglobulin if indicated based on immunization history
Antibiotics: Prophylactic antibiotics are generally not recommended unless there is suspicion of severe contamination or inhalation injury
Topical antimicrobials (e.g., silver sulfadiazine, mafenide acetate) are applied to burn wounds once debrided and cleaned.
Supportive Care:
Wound care: Daily wound cleaning and dressing
Escharotomy or fasciotomy for circumferential burns if compromising circulation or ventilation
Nutritional support: Early initiation of enteral feeding is crucial for wound healing
High-protein, high-calorie diet
Monitoring: Close monitoring of vital signs, urine output, fluid balance, electrolytes, and signs of infection
Pain management should be ongoing
Respiratory support may be required if inhalation injury is present.
Complications
Early Complications:
Hypovolemic shock
Hypothermia
Airway obstruction
Acute renal failure
Electrolyte imbalances (hyponatremia, hyperkalemia)
Sepsis.
Late Complications:
Scarring and contractures
Chronic pain
Nutritional deficiencies
Psychological sequelae (PTSD, depression)
Infection and osteomyelitis
Growth and developmental delays.
Prevention Strategies:
Prompt and adequate fluid resuscitation
Strict aseptic techniques for wound care
Early mobilization and physiotherapy
Adequate pain control
Nutritional support
Psychological support
Prevent non-accidental injuries through vigilant assessment.
Prognosis
Factors Affecting Prognosis:
Depth and extent of burn (TBSA)
Age of the child (very young and elderly are at higher risk)
Presence of inhalation injury
Associated comorbidities
Quality of initial management and subsequent care
Development of complications (sepsis, organ failure).
Outcomes:
Survival rates have improved significantly with modern burn care
Outcomes depend heavily on the severity of the burn and the promptness and efficacy of treatment
Children generally have better healing potential than adults but are more susceptible to long-term consequences of scarring and growth disturbances.
Follow Up:
Long-term follow-up is essential
This includes monitoring for scar maturation, contracture development, and functional limitations
Regular physiotherapy and occupational therapy may be needed
Psychological support for the child and family should be provided
Regular checks for growth and development are important.
Key Points
Exam Focus:
Remember the Parkland formula (4mL x Wt x %TBSA) and its application in pediatric burns
Know the fluid distribution (1/2 in first 8 hrs, 1/2 in next 16 hrs)
Differentiate burn depths clinically
Recognize signs of inhalation injury and hypovolemic shock
Tetanus prophylaxis is crucial
Consider non-accidental injury.
Clinical Pearls:
Use age-specific TBSA charts for accurate estimation in children
For infants and toddlers, the rule of nines is less accurate
use Lund-Browder or similar charts
Urine output is the most reliable indicator of adequate resuscitation
Aim for 1 mL/kg/hr of urine output
Avoid hypothermia – keep the child warm
Early enteral nutrition is vital for recovery.
Common Mistakes:
Underestimating TBSA, leading to inadequate fluid resuscitation and shock
Overestimating TBSA, leading to fluid overload and pulmonary edema
Delayed initiation of fluid resuscitation
Using ice-cold water for cooling burns, which can cause hypothermia
Inadequate pain management
Neglecting to consider non-accidental injury.