AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Traumatic injuries cause more deaths in childhood than all other causes combined. Although motor vehicle injuries are the foremost cause of death, each year approximately 440,000 children receive treatment for burns in the United States. More than 75,000 of these children require hospitalization, 10,000 experience severe permanent disability, and 2,500 die from thermal injury. Burn injuries represent the third leading cause of mortality in patients younger than 5 years. The overall morbidity from thermal injury has improved markedly over the years, with an aggressive multidisciplinary approach to care for the pediatric patient with burn injury.

Etiology

Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years, scalds are responsible for most burns. Scald burns may occur when a child pulls scalding liquid onto himself or may result from bathtub submersion injuries, which can often be quite severe. In older children, flame burns are more common. Space heaters, matches, and house fires are the most common etiologic factors for these burns, which are often full thickness and constitute most fatal burns.

Pathophysiology

Appreciating the major differences between burn management in children and adults is important. Children have nearly 3 times the body surface area (BSA)–to–body mass ratio compared to adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporative water loss than adults.

Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children and adults. As a result, they lose more heat and water than adults do, and they lose these more rapidly than adults. In very young children, temperature regulation is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen consumption, and lactate production. In addition, because of disproportionately thin skin, a burn that may initially appear to be partial thickness in a child may instead be full thickness in depth. Thus, the child's thin skin may make initial burn depth assessment difficult.

Clinical

• The depth of burn is classified as follows (see Image 1):
• • Superficial partial thickness: These burns are superficial with injury to the epidermis and superficial dermis. These are second-degree burns and are characterized by ruptured weeping blisters. They are also erythematous and painful. Superficial partial-thickness burns heal spontaneously within 1-3 weeks, usually without scarring (see Image 2).
  • Deep partial thickness: These are deep burns with injury to the epidermis and deeper dermis, but some viable dermis remains. These are also considered second-degree burns but are whiter and less erythematous as the depth into the dermis increases (see Image 3). Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult. Deep partial-thickness burns heal spontaneously but often after 3-4 weeks. The degree of scarring is related to the length of time needed for reepithelialization.
  • Full thickness: Injury to the epidermis and entire dermis occurs. These are the third-degree burns that typically are white, brown, or black (see Image 4). The eschar is leathery and insensate. These burns do not heal spontaneously (except for very small wounds that heal by contraction).
• Electrical burns require special consideration.
• • Low-voltage injuries result from sources of less than 1000 volts and include oral injuries from biting electrical cords, outlet injuries from placing objects into wall sockets, and injuries from contacting live wires or indoor appliances. High-voltage injuries are caused by sources of more than 1000 volts and result from contact with a live wire outdoors or from being struck by lightning.
  • Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring, serial electrocardiography, urinalysis, and determination of creatine kinase and urine myoglobin levels. Myoglobinuria and hemoglobinuria should be treated aggressively with hydration, osmotic diuretics, and alkalinization of the urine to avoid renal failure. Extremities must be monitored carefully for the development of compartment syndrome necessitating escharotomy or fasciotomy. Appropriate radiographic examinations should be performed to exclude concomitant long bone injury.
  • Many children who have sustained low-voltage electrical injury can be treated as outpatients as long as (1) the patient has no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident; (2) the patient remains asymptomatic after 4 hours of observation in the emergency department; (3) the wounds are manageable in an outpatient setting; and (4) the patient can return for a wound check the following day. Parents of children with oral commissure burns must be instructed in the application of pressure to the lip in the event that the burn erodes into the labial artery, a complication that usually does not develop until several days after the injury.
• Frostbite requires special consideration. Frostbite results from prolonged exposure to severe cold and usually affects the ears, nose, hands, and feet. Ice crystal formation in the tissues results in cellular dehydration, venous dilation and vasoconstriction causing peripheral blood pooling, and finally, tissue necrosis. Signs and symptoms of frostbite include red, blue, or pale skin; a prickling sensation with superficial frostbite; painless rigid skin with deep frostbite; and functional impairment. Treatment involves placing the patient in a warm environment, removing clothing from the affected region, and rewarming the affected region by immersion in water at 100-105°F for up to 30-45 minutes. Do not rewarm the frozen part with massage or dry heat.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Burn excision and grafting are recommended for all full-thickness and deep partial-thickness burns.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

See Clinical for a discussion of relevant anatomy.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

No contraindications to surgery exist.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Electrolytes and complete blood cell count: Monitoring of electrolytes and blood counts is often helpful, especially with large burns requiring aggressive fluid resuscitation.
• Carboxyhemoglobin level: Obtaining the carboxyhemoglobin level can be important in patients with inhalation injury, especially in those burned in enclosed spaces.

Imaging Studies

• Chest radiography: A chest radiograph can be helpful in patients who are intubated and in patients who have a suspected inhalation injury.

Other Tests

• Calculation of percent BSA burned
• • Several ways exist to calculate the percentage of BSA burned. The most useful initial estimate of percentage of BSA burned is the pediatric rule of nines (see Image 5). This is an adaptation of the adult rule of nines, which takes into consideration that, in children, the relative size of the head is larger and the relative size of the lower extremities is smaller.
  • Burn involvement can also be calculated based on the patient's palm. This is particularly useful for small scattered burns and is based on the estimate that the patient's palm (excluding the fingers) represents approximately 0.5% BSA burned.
  • Finally, Lund and Browder charts can be used to precisely calculate the percent BSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements (see Image 6).

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

Rapid assessment and treatment of immediate life-threatening conditions is mandatory. Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway edema. Because of the small diameter of the pediatric airway, a low threshold for intubation should be maintained. Children with burns affecting more than 10% BSA should receive intravenous fluid resuscitation. Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physical examination should be obtained. Wet sheets or cooling packs should not be used because this contributes to hypothermia. Patients should be kept warm by infusing warm intravenous fluids, elevating room temperatures, and minimizing patient exposure.

Admission criteria

Hospital admission criteria for patients with thermal injury include the following:

• Partial-thickness burns greater than 10% total body surface area (TBSA)
• Full-thickness burns greater than 2% TBSA
• Burns involving the face, hands, genitalia, perineum, or major joints
• Circumferential extremity burns
• All high-voltage electrical burns, including lightning injury
• Admission of low-voltage electrical burns is selective
• Chemical burns
• Inhalation injury
• Burn injuries in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. Such conditions might include, but are not limited to, diabetes, immunosuppression, etc.
• Suspected child abuse
• Cases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for the burn)

Inhalation injury

Clues to inhalation injury include increased respiratory rate, hoarseness, being burned in an enclosed space, altered mental status, head and neck burns, singed nasal hairs, inflamed oral mucosa, and carbonaceous sputum. Indications for intubation include compromised upper airway patency, the need for ventilatory support as manifested by poor gas exchange or increased work of breathing, or compromised mental status. Correlation of the history and clinical findings comprise the most practical approach to determining the need for intubation.

Important considerations regarding the pediatric airway include the fact that the larynx is more cephalad in children, that children deteriorate faster than adults in terms of upper airway edema and alveolar-capillary block, and that repeated intubation attempts may cause edema and obstruction. For these important reasons, experience in pediatric intubation is needed. Once an airway is established, it is critically important to secure the airway well, especially in patients with facial burns, to avoid accidental extubation (see Image 7).

Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct of combustion that displaces O₂ from the hemoglobin (Hgb) molecule. It has 250X the affinity of O₂ for Hgb, therefore shifting the Hgb-O₂ disassociation curve to the left. This impairs O₂ unloading at the tissue level and causes a switch to anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected with persistent metabolic acidosis despite adequate volume resuscitation. Remember that the PaO₂ in an arterial blood gas will be normal since the amount of O₂ dissolved in arterial plasma is normal. In addition, the O₂ sat (measured O₂ saturation of Hgb) will be normal on a standard pulse oximeter in the presence of CO toxicity since the oximeter cannot differentiate between Hgb saturated with O₂ and Hgb saturated with CO.

To treat CO toxicity, all patients with inhalation injury should be treated with 100% O₂. This lowers the T½ of CO to 30 minutes whereas it would be 2-3 hours in room air. Therefore, all major burns should be treated with 100% O₂ until CO toxicity is ruled out or the CO level returns to normal. Hyperbaric oxygen (HBO) therapy (2-3 atm) leads to even more rapid displacement of CO, and its use should be considered for CO greater than 50%, severe neurologic compromise, and nonresponsiveness to 100% O₂.

Cyanide toxicity results from the burning of synthetics (eg, polyurethane), which leads to the production of hydrocyanide gas. Cyanide binds to the cytochrome oxidase system, inhibiting cellular metabolism and ATP production. It causes a shift to anaerobic metabolism with profound metabolic acidosis and obtundation. The treatment of cyanide toxicity involves administration of the cyanide antidote sodium thiosulfate (8 g IV if <12 y; 12.5 g IV if >12 y). The antidote converts cyanide to nontoxic, excretable thiocyanate.

Fluid resuscitation

Several burn resuscitation formulas exist that can be used in pediatric burn care, with the modified Parkland formula commonly used. Ringer lactate solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each percent BSA burned for the first 24 hours. One half of the calculated fluid needs are administered in the first 8 hours after the burn occurs, and the remaining half are administered over the following 16 hours. Maintenance fluids should be administered concomitantly (this represents the modification to the Parkland formula for pediatric patients). Representative fluid resuscitation guidelines for pediatric burn patients are as follows:

Table 1. For Burns >15% TBSA

Table 2. For Burns £15% TBSA

Rates of fluid administration should be altered based on the patient's response. If a patient presents after some period of delay and has not been resuscitated properly during that time, adjustments should be made in the calculated fluid requirements to take these factors into account. Infants are at risk of developing hypoglycemia because of limited glycogen stores; therefore, glucose levels should be monitored, and Ringer lactate solution with 5% dextrose should be used for maintenance fluids. Assess response to fluid administration by measuring urine output via an indwelling urinary catheter. Monitoring sensorium, peripheral circulation, and blood pH also is helpful to assess the adequacy of resuscitation.

Nutrition

No formula to estimate caloric needs of patients with burn injury has been universally agreed on. The Curreri formula (see below) is a formula initially devised for adult patients with burn injury but was modified to meet the needs of pediatric patients. Nutritional support should be started as soon as possible after injury, preferably with enteral feedings. A high-calorie high-protein diet should be ordered, and calorie counts should be recorded by a dietitian. If patients cannot ingest adequate calories, a feeding tube should be placed and feedings should be initiated. Feedings do not need to be interrupted by multiple operative procedures. Calorie and protein requirements of patients with electrical burns are calculated as those for patients with thermal burns.

The daily requirements of pediatric burn patients according to the Curreri formula are as follows:

• Age 0-1 years - Basic metabolic requirements + 15 kcal/%BSA burn
• Age 1-3 years - Basic metabolic requirements + 25 kcal/%BSA burn
• Age 4-15 years - Basic metabolic requirements + 40 kcal/%BSA burn

Surgical therapy

Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterial colonization. Silver sulfadiazine cream (Silvadene) is a commonly used broad-spectrum topical antimicrobial cream. It is applied as a thin layer with gauze dressings twice daily. It does cause transient neutropenia, which resolves even with continued use of the agent. Facial burns are usually treated with a combination antimicrobial product containing polymyxin B, neomycin, and bacitracin (eg, Neosporin ointment) because silver sulfadiazine cream on the central face may cause severe ocular irritation. Ear burns should be treated with mafenide cream (Sulfamylon) because the thin subcutaneous tissue in the ears predisposes to the development of chondritis.

To avoid the need for painful dressing changes, artificial skin substitutes, such as Aquacel Ag, may be used for the treatment of partial-thickness burns. Aquacel Ag is a hydrofiber dressing in which antibacterial silver (Ag+) ions are incorporated into the dressing and released in a continuous sustained-release fashion for continuous topical antimicrobial effects. The fibers in the dressing hydrate upon contact with the burn surface creating a viscous gel that prevents fluid loss and traps bacteria. Once adherent to the burn surface, usually within 24-48 hours, the dressing can be left in place for up to 2 weeks, during which time reepithelialization is usually complete (see Image 8). If reepithelialization is not complete by that time, the Aquacel Ag can be reapplied. Its use eliminates the painful twice-daily dressing changes associated with standard dressing changes, and once the dressing adheres to the burn, pain is virtually eliminated.

Escharotomy is indicated to relieve vascular compromise or ventilatory impairment. Vascular compromise to an extremity results from circumferential, full-thickness, inelastic eschar. Although vascular compromise usually occurs in extremities affected by full-thickness burns, it can occur in areas of partial-thickness burns and even in nonburned extremities. Underlying tissue edema results in impaired venous outflow, followed by impaired arterial inflow if not treated. All extremity burns at risk should be monitored with at least hourly vascular checks of pulse or Doppler signal. Decreased pulses, direct measurement of compartment pressures with pressures greater than 40 mm Hg, or clinical symptoms (severe pain, paresthesias, decreased motor function) necessitate extremity escharotomy.

The chest wall and lungs are more compliant in children than in adults. Therefore, children may rapidly become exhausted by the edema and restriction of a circumferential chest wall burn. Impaired ventilation, with progressive increase in ventilatory requirements, may indicate the need for chest wall escharotomy.

Escharotomy is performed in areas of full-thickness injury; therefore, analgesics are not needed. Escharotomy (with a scalpel or preferably using an electrocautery device to minimize bleeding) is performed longitudinally at the medial and/or lateral aspect of the extremity, beginning above the burn and extending to below the inferior aspect of the burn (see Image 11). The incision is carried down to the subcutaneous fat, which bulges into the wound when adequately incised. Return of arterial pulse should be immediate. Chest wall escharotomy is performed with incisions along the anterior axillary lines bilaterally, extending onto the abdomen, with transverse bridging incisions across the chest (see Image 13). Adequate chest wall escharotomy improves compliance and ventilation.

Preoperative details

Successful burn wound management in children demands conversion of open wounds to closed wounds as soon as possible. The concept of early removal of burn eschar and immediate wound closure has gained widespread acceptance. Evidence suggests that early eschar removal is effective in decreasing morbidity and improving the mortality rate. Full-thickness burns (with the exception of very small injuries that are allowed to heal by contraction) should be grafted. The goal is to excise the wound within the first week of the injury. Additionally, deep partial-thickness burns that take longer than 3 weeks to heal usually benefit from grafting, with less hypertrophic scarring and better cosmetic results.

Intraoperative details

Preoperatively, patients must be hemodynamically sound and have optimal acid-base, fluid, and electrolyte balance. Adequate blood must be available before considering excision and grafting. Preoperative antibiotics are not required unless patients have other compromising systemic diseases or invasive burn sepsis; however, a prophylactic dose of a first-generation cephalosporin antibiotic may be used.

Attention to maintenance of body temperature at all times is extremely important. Burn excision involves tangential removal of thin slices of eschar until profuse pinpoint bleeding from a moist, viable, deep dermal surface or subcutaneous fat is observed. Meticulous hemostasis then is obtained using epinephrine-soaked (1:100,000) sponges, topical spray thrombin, and electrocautery, followed by immediate grafting with thin sheets of autograft. Skin grafting involves harvesting partial-thickness pieces of skin from donor sites on unburned areas using a dermatome. The thickness of the harvested skin commonly is 8-12 thousandths of an inch, depending on the age and skin thickness of the patient. The grafts are then applied to the wound bed and secured.

Autograft skin obviously is preferred whenever possible. Unfortunately, patients with large burns may not have enough autologous skin available for complete coverage. In such patients, burns can be excised and temporarily covered with a number of biologic dressings (eg, cadaveric skin, pigskin) or skin substitutes. As more donor sites become available, the temporary wound covers are removed and the wounds are grafted. Studies have shown that growth hormone (0.15-0.2 mg/kg/d IM) administration can speed donor site healing, allowing more rapid reharvesting of healed donor sites.

Meshed autografts are harvested from donor sites and passed through a meshing machine that cuts a series of parallel offset slits in the grafts at various expansion ratios (eg, 1.5:1, 2:1) This technique allows expansion of the graft to cover a larger surface area. In addition, the interstices in the graft allow for drainage of fluids under the graft so that the grafts do not lift off their beds. Unfortunately, the meshed patterns of the grafts persist after healing and often lead to suboptimal cosmetic results.

Nonmeshed or sheet grafts are harvested the same way but are not passed through the meshing machine. The use of sheet grafts leads to a better cosmetic result. Because the grafts do not expand, covering major areas with sheet grafts alone is difficult. Nonetheless, sheet grafts should be used whenever possible, especially in highly visible and functional areas, such as the face, neck, hands, and joints. Sheet grafts should be inspected after approximately 48 hours so that any underlying fluid can be aspirated to avoid loss of the graft. Dressings can be left in place for up to 5 days if desired on meshed grafts, as long as no suspicion of infection exists.

Follow-up

Avoidance of scarring and contracture is the best treatment. Burns that take more than 2 weeks to heal and all grafted burns should be treated with compression garments that apply approximately 30 mm Hg of pressure to the wounds, which has been found to decrease hypertrophic scar formation. Burns over joints must be treated with stretching and range-of-motion exercises during the healing process. A splinting regimen is important to minimize contractures. Aggressive attention to occupational and physical therapy, with appropriate consultation with an occupational/physical therapist, is necessary to ensure optimal results.

Patient Education: For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal (Heat or Fire) Burns.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Complications to surgery include bleeding, infection, or graft loss.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

With the exception of infants, the prognosis for survival in children and adolescents is quite good. In the past decade, the size of a survivable injury has increased from 70% BSA burned to more than 95% BSA burned in children younger than 15 years.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

A number of areas in both the clinical and basic sciences are undergoing active research. One such area of interest is the hypermetabolic response to severe burns and the association with increased energy expenditure and muscle-protein catabolism. Recent studies have investigated different mechanisms to attenuate the muscle-protein catabolism that occurs frequently, despite appropriate nutritional support, in children with large burns. These studies are promising because attenuation of muscle-protein losses may improve strength and ability to recuperate.

Another active area of research is in the development of cultured skin to treat very large burns. At present, cultured epidermal autografts (CEAs), which are grown from the patient's own uninjured epidermis, are commonly used. However, these grafts are very thin and fragile. In the future, cultured bilayered skin (epidermis and dermis) should lead to better functional and cosmetic results.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Skin histology diagram.
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Media file 2:  Superficial partial-thickness burn.
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Media file 3:  Deep partial-thickness burn.
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Media file 4:  Full-thickness burn.
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Media file 5:  Pediatric rule of nines.
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Media file 6:  Lund and Browder chart.
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Media file 7:  Securing the ETT in patients with facial burns.
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Media file 8:  Use of Aquacel Ag. Initial scald burn.
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Media file 9:  Aquacel Ag adherent to burn wounds.
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Media file 10:  Use of Aquacel Ag. Appearance of healed burns 10 days later.
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Media file 11:  Escharotomy sites.
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Media file 12:  Left, Arm escharotomy. Right, Leg escharotomy.
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Media file 13:  Chest wall escharotomy.
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

• Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. 1st ed. Philadelphia, Pa:. Hanley & Belfus;2000:246-252.
• Heimbach D. What''s new in general surgery: burns and metabolism. J Am Coll Surg. Feb 2002;194(2):156-64. [Medline].
• Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. Oct 25 2001;345(17):1223-9. [Medline].
• Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D. Total Burn Care. Philadelphia, Pa:. WB Saunders Co;1996:237-245.
• Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit Care Med. Jul 2001;2(3):223-224. [Medline].

Article Last Updated: Aug 30, 2006