AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
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INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Approximately 1.2 million people seek medical treatment for burns each year in the United States. Roughly 50,000 of these (4.2%) require hospitalization. Approximately one third of burn injuries (30-40%) are in children. Although the incidence has been decreasing, fire continues to be a major cause of fatalities in children. Fires are second only to motor vehicle accidents as the leading cause of death in children. Fires account for up to 34% of fatal injuries in children younger than 16 years.

Pathophysiology

The skin is the largest organ in the body, ranging in area from 0.25-1.8 m². It is composed of 3 main layers, as follows:

• The epidermis is the outermost layer, and itself is composed of 2 layers. In the epidermis, the outer layer of anucleated cornified cells (stratum corneum) acts as a barrier to the entrance of microorganisms and the loss of water and electrolytes. The inner layer of the epidermis is composed of viable cells (Malpighian layers) that mature and differentiate into cornified cells of the stratum corneum.
• Beneath the epidermis is the dermis (corium), which is composed of a dense fibroelastic connective tissue stroma containing collagen, elastic fibers, and an extracellular gel termed the ground substance. The dermis contains an extensive vascular and nerve network and special glands and appendages that communicate with the overlying epidermis.
• The innermost layer of the skin is the subcutaneous tissue, which is composed primarily of areolar and fatty connective tissue. This layer contains skin appendages, glands, and hair follicles.

Burns are divided into 4 categories, depending on the depth of the injury, as follows:

• First-degree burns are limited to the epidermis. A typical sunburn is a first-degree burn. It is characterized by erythema, pain, and minor microscopic changes. Pain usually lasts 48–72 hours, and the damaged epithelium peels off in 5-10 days. First-degree burns do not lead to scarring and require only local wound care.
• With second-degree burns, the point of injury extends into the dermis, with some residual dermis remaining viable. The healing is directly related to the amount of undamaged dermis. Deep dermal burns lead to severe hypertrophic scarring and may take 25–35 days to heal.
• Third-degree, or full-thickness, burns involve destruction of the entire dermis, leaving only subcutaneous tissue exposed. It is characterized by lack of sensation in the burned skin, a leathery texture, and no capillary refill.
• Fourth-degree burn is a term that is rarely seen in literature and periodicals. This type of burn is usually associated with lethal injury. Fourth-degree burns extend beyond the subcutaneous tissue, involving the muscle, fascia, and bone. Occasionally termed transmural burns, these injuries often are associated with complete transection of an extremity.

The extent of body surface area (BSA) involved in second-degree burns, at the least, has great impact on the morbidity and mortality associated with the injury. Deep burns may have a clearcut area of irreversible skin necrosis. Surrounding the area of necrosis is an area of inflammation and ischemia. The tissue in this area may survive or may die. Edema, infection, further exposure, and dehydration may contribute to an increase in the area of ischemia and further irreversible skin necrosis. Surrounding the ischemic zone is an area of hyperemia. Increased blood flow in this zone is promoted by numerous mediators that are liberated from the injured tissue.

In children, scalding, which is most common in toddlers, accounts for 85% of all injuries. Immersion in water at 52°C (126°F) takes 2 minutes to cause full-thickness burns compared to only 5 seconds of immersion in water at 60°C (140°F). Water heaters in the home should be set from 49-55°C (120-130°F). Water heaters placed in apartment houses pose a particular problem because boilers are usually set at 70°C (158°F) in order to deliver adequate amounts of hot water, which can cause full-thickness skin burns within one second.

Direct contact with flame accounts for another 13% of burns. In the United States, sleepwear is legally required to be flame retardant; this requirement has led to a dramatic decrease in the number of clothing ignition incidents. Recently, the US Consumer Product Safety Commission has voted to loosen some of the children's sleepwear flammability standards that were previously set by the Federal Flammable Fabrics Act.

Frequency

United States

The National Burn Information Exchange, a voluntary burn patient registry established in 1964, reports that children younger than 4 years have a high percentage of burn accidents and account for more than 50% of the total number of pediatric burns. Most burn injuries in children occur at home and appear to be largely preventable.

International

Countries without strict manufacturing laws regarding children's clothing (in particular sleepwear) have a much higher incidence of clothing ignition incidence. Garments that are not flame retardant can ignite spontaneously when introduced to a significantly high temperature (eg, a splash of hot oil from a stove).

Mortality/Morbidity

Over 5000 burn-related deaths occur each year in the United States.

Sex

Most burn injuries in older children are related to fires. In these injuries, boys are involved much more frequently than girls.

Age

Children younger than 4 years account for more than 50% of the total number of pediatric burns.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

A careful history is extremely important. For example, a person who is trapped in a smoke-filled space for even a few moments can inhale toxic amounts of smoke without incurring any burn to the skin. Inquire about the etiology of the burn, duration of exposure, age, and associated medical conditions.

Physical

As with all trauma patients, physical examination of patients with burns should take place in the prehospital care area, in the primary survey of the emergency department (ED), as well as in the secondary survey and subsequent evaluations.

• Calculation of the total BSA burned is important. In the prehospital setting, the evaluation method must be quick and accurate.
• • Most prehospital care providers use the rule of nines. Essentially, the rule of nines divides the body into 11 areas of 9% each. Each arm is 9% (2), the anterior and posterior portions of each leg are each 9% (4), the anterior upper and lower portions of the thorax are 9% each (2), the posterior upper and lower portions of the thorax are 9% each (2), and the area including the neck and head is 9% (1). The total is 9% times 11, or 99%. The perineum comprises the remaining 1%.
  • The BSA burned is based on the percent of second- and third-degree burns. This rule is acceptable for adults and is less accurate for children who tend to have proportionally larger heads and smaller legs. Burn calculations with the rule of nines tend to overestimate the size of the burn. This overestimation is advantageous, especially for prehospital care providers who need to start the triage process at a high level.
  • A quicker, but less accurate, method for determining burn size is to use the palm of the patient's hand, which is roughly equivalent to 1% of the patient's BSA. The palm-of-the-hand approach is most convenient for splash-type nonconfluent burns and should never be used for significant burns (>10% BSA).
  • The most accurate yet time-consuming method of determining skin involvement is with the Lund and Browder chart. Essentially, the health care provider has an anterior and a posterior diagram of the patient, which is divided into sections. When calculating the percentage of skin involvement, the clinician colors in the areas on the chart for both the anterior and posterior regions of the patient. The sum of the colored areas is the BSA involved. Different charts are available for different age groups.
• Acute upper gastrointestinal tract erosions and ulcers may occur in patients with severe burn injuries. The lesions are termed stress or Curling ulcers. Painless gastrointestinal tract bleeding is the most common clinical finding. Blood loss usually is minimal and can be prevented with prophylactic administration of H2 blockers.
• Thermal burns to the respiratory tract, oral cavity, pharynx, larynx, or lung parenchyma are rare. Dry heat from a flame cannot deliver sufficient kilojoules to the tissue to sustain tissue damage.
• • These types of injuries, which can develop into extremely difficult acute airway problems, usually are secondary to steam or other hot vaporized liquids. The water molecules in steam (aerosolized) can deliver very high amounts of kilojoules capable of causing upper respiratory and lung parenchymal injury.
  • Smoke inhalation also can result in inflammation of airways and lungs that is significant enough to cause clinical implications. Classic signs associated with significant smoke inhalation are burns to the face or nasal hairs, carbonaceous sputum, or both.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Glomerulonephritis

Associated conditions

Metabolic acidosis
Respiratory acidosis
Acute tubular necrosis
Asthma
Bacteremia
Diabetic ketoacidosis
Epiglottitis
Esophageal foreign bodies
Gastroenteritis
Head trauma
Hemolytic-uremic syndrome
Hypercalcemia
Hyperkalemia
Hypermagnesemia
Hyponatremia
Hypophosphatemia
Impetigo
Bacterial meningitis
Mood disorder (ie, depression)
Nephritis
Pneumonia
Respiratory distress syndrome
Rhabdomyolysis
Shock
Sudden infant death syndrome
Syncope
Toxic shock syndrome
Carbon monoxide toxicity
Ethanol toxicity
Organophosphates toxicity

WORKUP

Section 5 of 11  

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• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Screen all patients with closed-space smoke exposure (indoor) for carbon monoxide poisoning. In patients with minor burns and in patients in whom arterial puncture is not otherwise indicated, venous carboxyhemoglobin levels are as accurate as arterial levels. The pulse oximeter is not accurate in patients with carbon monoxide poisoning, and chest radiography is not sensitive enough to detect inhalation injury. In patients exposed to fires occurring outside (where smoke can escape easily into the environment), the likelihood of carbon monoxide poisoning is low.
• In patients with significant burns, recommended laboratory evaluations include CBC, typing and crossmatching blood, carboxyhemoglobin levels, coagulation studies, basic chemistry panel, arterial blood gas, and chest radiograph. Other studies that may be ordered include measurement of the urine myoglobin, serum protein, and ethanol levels; urinalysis; and toxicology screen. Patients with heart disease or with cardiac risk factors need a baseline ECG.
• Cyanide poisoning is a consideration if the patient has had significant inhalation exposure because cyanide is released in the combustion of certain hydrocarbons. No laboratory test can measure cyanide levels immediately in the acutely ill patient. Cyanide toxicity is strongly suggested in patients burned by fire who have persistent metabolic acidosis and exhibit cellular hypoxia.

Imaging Studies

• An initial chest radiograph is essential. Although normal radiograph findings may not exclude parenchymal lung damage, the initial chest radiograph demonstrates life-threatening injuries, such as rib fractures, hemothorax, or pneumothorax.
• Parenchymal lung damage, such as that seen in pulmonary contusions, may not become apparent on images until 6-18 hours after the initial injury.
• In a severely injured patient, obtain radiographs as needed. However, even in seemingly stable patients, repeating the chest radiograph after several hours may reveal previously undiagnosed lung injury.
• Order other radiographs as basic trauma protocol dictates.

Other Tests

• Evaluate patients using a cardiac monitor and pulse oximeter until they are proven to have no significant inhalation injury or burns.
• • Pulse oximeter readings may appear normal even in the presence of significant carbon monoxide exposure, which is important to remember.
  • Pulse oximeter readings cannot differentiate oxyhemoglobin from carboxyhemoglobin.
  • Obtain an arterial or venous carboxyhemoglobin level to exclude carbon monoxide poisoning.
  • Tachypnea may be the earliest indication of pulmonary injury in the patient who first presented without tachypnea.

TREATMENT

Section 6 of 11  

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Medical Care

Burn patients are trauma patients. During evaluation, advanced trauma life support (ATLS) protocols should be followed. Patients with burns may have inhalation injury as well as other types of blunt or penetrating injuries. Initially, treat hypotension or signs of shock with crystalloid boluses of isotonic sodium chloride solution or lactated Ringer solution at 20 mL/kg. Assess the patient's cardiovascular status before initiating fluid resuscitation.

• For treatment purposes, burns can be divided into 2 categories, eg, minor and major burns.
• • Infants with burns over less than 10% BSA and children with burns over less than 15% BSA without significant inhalation injury or preexisting medical conditions can be considered to have minor burns and can be treated initially without IV access.
  • Infants with burns over greater than 10% BSA, children with burns over greater than 15% BSA, or individuals with significant inhalation injury are considered to have major burns and should be treated with IV access and fluid resuscitation.
• Compared to adults, children have a larger BSA relative to their weight. BSA is a major determinant of evaporative water loss in burn patients. As a result, children with burns have more evaporative water loss compared by weight than do adults. Therefore, children usually have somewhat greater fluid needs during resuscitation. The greater amount of evaporative water loss also leads to greater heat loss. The infant or child with burns is especially prone to hypothermia; therefore, the ambient temperature should be kept high to minimize radiant and evaporative heat losses.
• Infants younger than 6 months present a special challenge.
• • Temperature is largely regulated by nonshivering thermogenesis in this age group. This metabolic process involves catabolism of fat stores under the influence of norepinephrine, which requires large amounts of oxygen. Prolonged periods of thermogenesis in the hypothermic infant can lead to excessive amounts of lactate production and metabolic acidosis. Infants and children older than 6 months have the ability to shiver and are not as likely to develop lactic acidosis.
  • Another problem unique to resuscitation of an infant with burns is immaturity of the kidneys and inefficiency in handling fluid overload. The glomerular filtration rate in infants does not reach adult levels until age 9-12 months due to an imbalance in maturation in tubular and glomerular functions. During the first year of life, the infant has approximately 50% the osmolar concentrating capacity of an adult, and water load is handled inefficiently. The younger the infant, the more exaggerated is the imbalance. During the first few weeks of life, infants are likely to retain a larger portion of the water load administered as part of burn resuscitation. Most experts feel that the hyposmolarity of lactated Ringer solution, when used in accordance with the Parkland formula, already accounts for the free water needs of infants during the first 24 hours of resuscitation. Additional hydration of young infants may result in fluid overload.
  • Infants are at increased risk for developing infection because their immune system is not completely developed.
• Treatment of minor burns can be summarized by the following steps:
• • Debride devitalized tissue.
  • Evaluate the wound for surface area and depth of injury.
  • Develop a wound care plan.
  • Management of intact blisters has been controversial. Most experts advise leaving intact blisters alone. Blister fluid contains vasoactive mediators such as thromboxane, which can cause vasoconstriction, promote ischemia, cause progression of the ischemic zone, and inhibit healing. The intact blister also serves as a physiologic dressing against infection, and unless the blister is overlying a large joint, there is little debate that the blister should be left intact. Blisters larger than several inches in diameter are most likely to rupture and should be removed.
• Superficial or partial-thickness burns that are limited in size (£3%) can be treated with a semiocclusive dressing, such as Xeroform gauze. The wound should be pink and moist and exhibit good blanching.
  • Place gauze dressings on a clean wound devoid of devitalized tissue. Apply multiple layers of gauze dressing because the impregnated gauze offers little barrier to moisture evaporation and wound dehydration.
  • Covering wounds reduces pain considerably.
  • When an extremity is involved, instruct the patient and family regarding immobility and as much elevation as possible. Edema, which is exacerbated when the extremity is held in the natural position, can worsen the ischemic zone and tissue loss.
  • Observe patients who have circumferential burns closely; they may require admission to the hospital. Patients with circumferential burns are at risk for development of compartment syndrome, which can compromise circulation to the entire extremity. Incision of the burned skin (escharotomy) is the treatment for compartment syndrome.
• Patients with major burns usually benefit from placement of a nasogastric (NG) tube and a Foley catheter.
  • Patients with burns often develop an adynamic ileus and bowel obstruction. Decompression of the stomach and removal of its contents via the NG tube decreases the likelihood of significant aspiration, which could contribute to an already tenuous respiratory status.
  • A Foley catheter is important to closely follow urinary output, which is the best means to monitor an adequate hydration status.
• Treat patients with major burns who require fluid resuscitation according to the Parkland formula. The Parkland formula is a starting point for fluid resuscitation.
  • In patients who have sustained significant injury, urinary output is the best indicator of appropriate hydration status.
  • Maintain urine output (as measured with a Foley catheter) at 1.0 mL/kg/h. In younger children ( <30 kg), maintain a urine output of 1.0-1.5 mL/kg/h.
  • The Parkland formula is used during the first 24 hours of fluid resuscitation and is as follows: Amount of IV fluid in first 24 hours = weight in kg X 4 mL X % BSA burned

  Administer one half of the calculated fluid during the first 8 hours and one half of the calculated fluid in the subsequent 16 hours. The starting time is considered to be the time at which the burn occurred and not the time at which medical care is initiated. Children aged 6 months to 5 years should receive the fluid recommended by calculations using the Parkland formula plus maintenance during the first 24 hours.

• Urine output is the criterion standard for gauging appropriate intravascular volume and hydration status.

• All burn patients should receive supplementary oxygen at the highest concentration allowed by patient comfort. Maintain a high flow of oxygen until a negative carboxyhemoglobin level result has been returned from the laboratory. Once carbon monoxide poisoning has been excluded, supplemental oxygen can be given to maintain appropriate oxygenation.
• Verify tetanus immunization and administer tetanus toxoid (0.5 mL) if indicated. Patients with more than 50% of the body surface burned should receive tetanus immune globulin.

Surgical Care

• Clean burned areas using isotonic sodium chloride solution or mild soap and water, taking care to maintain thermal homeostasis.
• Remove ruptured blisters and devitalized epidermis with forceps and scissors or, more efficiently, by rubbing with gauze soaked in isotonic sodium chloride solution after an adequate level of analgesia is obtained.
• Leave intact blisters alone.
• Apply a topical antimicrobial (silver sulfadiazine, bacitracin) followed by a sterile dressing after the burn has been cleaned and debrided.
• Dressings should be changed and wounds cleaned daily in outpatients.
• Incision of burned skin (escharotomy) is the treatment for compartment syndrome.

Consultations

Children with major burns may benefit from transfer to a regional burn center.

Diet

Nutritional support is important for patients who have major burns in order to minimize protein catabolism, total body weight loss and glucose intolerance. The catabolic response after a burn injury may be severe, and the basal metabolic rate may increase to more than twice the baseline. As a rough rule, metabolic expenditures increase in proportion to the burn injury. A child with burns over 50% of the BSA requires at least a 50% increase in the basal level of energy ingestion. Aggressive nutritional support, control of pain, stress, and sepsis, as well as rapid wound closure, help to control the hypermetabolic rate. The use of beta blockers, insulin, growth hormones and testosterone analogues has been shown decrease catabolism. According to some studies, intensive insulin therapy seems to improve survival and lower infection rates in children with severe burn injuries.

MEDICATION

Section 7 of 11  

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Apply silver sulfadiazine to the wound for the first 48 hours after initial treatment. Dressing changes cause further debridement and aid epithelialization. Silver sulfadiazine is most effective against gram-positive organisms and is relatively ineffective against pseudomonads. If the wound develops a greenish drainage or a sweet smell, consider Pseudomonas aeruginosa colonization or infection. Other gram-negative pathogens are found commonly in burn wounds.

Many authors also advocate bacitracin ointment for small- and moderate-sized burns. Bacitracin is as effective as silver sulfadiazine and is somewhat easier to apply. Bacitracin should always be used for burns located above the clavicles because silver sulfadiazine occasionally causes cosmetic complications (eg, skin pigmentation changes).

Mafenide acetate cream provides more complete coverage against Pseudomonas and other gram-negative species. Unlike silver sulfadiazine, mafenide acetate cream is painful on application because it is hyperosmolar. Extensive wounds covered with mafenide acetate may develop metabolic acidosis.

Some researchers report shorter healing time (4.5 d difference) for burns treated with silver sulfadiazine and hyaluronic acid versus silver sulfadiazine alone.

Enzymatic debriding preparations are expensive and controversial in the treatment of burns.

Drug Category: Analgesic agents

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or have extensive injuries.

Drug Name	Fentanyl (Sublimaze)
Description	The shortest acting opioid, fentanyl has a minimal effect on histamine release. Of all opioids, fentanyl releases histamine the least and is the safest in patients with hyperactive airway disease. Consider continuous infusion because of the short half-life of fentanyl.
Adult Dose	1-2 mcg/kg/dose IV q30-60min
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; hypotension; potentially compromised airway in patients in whom establishing rapid airway control would be difficult
Interactions	Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Use extreme caution in patients who are hemodynamically unstable or who have tenuous respiratory status; caution in patients with history of hyperactive airway disease or who are actively wheezing because histamine is released

Drug Category: Vaccines

Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Drug Category: Topical burn agents

These agents elicit antimicrobial activity, preventing wound infection.

Drug Name	Mafenide acetate (Sulfamylon)
Description	Mechanism of action is unknown but is different from that of the sulfonamides. No correlation exists between bacterial sensitivities to mafenide and sulfonamides. Activity of the drug is not altered by acidity of the environment. The osmolality of 5% topical solution is approximately 340 mOsm/kg. Applied topically, mafenide acetate diffuses through devascularized areas. Following application of mafenide acetate, peak concentration in burned human skin occurs at 2 h for the cream and 4 h for the solution. Mafenide acetate exerts broad bacteriostatic action against many gram-negative and gram-positive organisms, including P aeruginosa and certain strains of anaerobes. Mafenide acetate (5% topical solution) is supplied as a powder and is reconstituted with sterile water or 9% sodium chloride solution. Observe aseptic technique during preparation of the solution. After reconstitution, filter the resulting mafenide acetate 5% solution through a 0.22-µm sterilized grade filter prior to use. Store at room temperature, and use within 48 h after preparation. Also supplied as an 8.5% cream.
Adult Dose	Apply topically generously (thickness of approximately 1/16 in), completely covering involved skin; apply sterile dressing
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Mafenide acetate and its metabolite, p-carboxybenzenesulfonamide, inhibit carbonic anhydrase, which may result in metabolic acidosis (acidosis usually is mild and compensated by hyperventilation); in presence of impaired renal function, high blood levels of mafenide acetate and its metabolite may exaggerate carbonic anhydrase inhibition (close monitoring of acid-base balance is necessary, particularly in patients with extensive burns and in patients with pulmonary or renal dysfunction)

FOLLOW-UP

Section 8 of 11  

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• Follow-up
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Further Inpatient Care

• Consider inpatient therapy in patients with the following burns:
• • Major burns
  • Electrical or chemical burns
  • Burns of the face, hands, feet, perineum, or major overlying joints
  • Burns that appear to be the result of abuse
• Admit patients with significant carbon monoxide or cyanide poisoning or with preexisting chronic illnesses for inpatient therapy.
• To facilitate the maximum in cosmetic and functional outcome, occupational and physical therapy must begin on the day of admission. In some patients, therapy should continue after discharge.
• Rehabilitation involves maximizing positioning, range of motion of all joints, limitation of pressure necrosis, exercise, ambulation, and assistance in daily activity.
• • Pressure therapy is important and should be implemented as part of the rehabilitation program. Pressure therapy can reduce hypertrophic scar formation. Garments used in pressure therapy can be custom made and are available for different body parts and in varying sizes.
  • Pressure therapy is used to deliver consistent pressure on scarred areas, thus shortening the time of scar maturation and thickness and the total affected area.

Further Outpatient Care

• Patients with minor burns (burns over <10% BSA in infants, burns over <15% BSA in children, and patients without carbon monoxide poisoning, other serious injuries, or preexisting comorbidities) can be treated on an outpatient basis. Continued evaluation, adjustment to scarred areas, and minor surgical procedures may be necessary to optimize cosmetic outcome and long-term function.

Transfer

• Severely injured patients are better served at a designated burn center with patient care units and personnel who are specifically trained in analgesia and wound care for patients with burns.
• • Consider transfer for patients who sustain second-degree burns of BSA greater than 20%, third-degree burns of BSA greater than 5%, or major burns to the hands, face, feet, or perineum or in patients with electrical burns.
  • Consider transfer for patients with significant burns associated with potentially life-threatening injuries.

Deterrence/Prevention

• In the last decade, the incidence of pediatric burns has decreased significantly. The decrease is due (in large part) to education regarding prevention, regulation of consumer products, availability of regional treatment centers, increased prevalence of smoke detectors, and social changes (eg, decline in smoking).
• Measures should be taken to childproof the home and turn down home hot water heaters to 49-52°C.

Complications

• Fever occurs frequently in children and adults with burns. The burned skin is a potent source of mediators (eg, interleukin 1) that produce fevers. Every fever spike in a patient with burns does not require an extensive evaluation with blood cultures and other diagnostic modalities. Careful studies in both children and adults have shown that fevers do not correlate well with infection after burn injury.
• Closely observe burn wounds because, most frequently, they are the source of an infection. Risk of infection in burn wounds depends on the extent of the burn, depth of the burn, age of the patient, and flora of the wound. Wound infections are classified as cellulitis, invasive infections, and impetigo.
• • Cellulitis and coexistent inflammation appear to be related to the liberation of cytokines, since organisms rarely can be cultured from the areas of involvement. Cellulitis usually begins on the second or third day after the burn injury occurs. If the cellulitis does not resolve and continues to expand, treat it first topically with the appropriate antibiotic, warm soaks, and mafenide acetate cream until the infection is controlled.
  • Invasive infections can be caused by bacterial, fungal, or viral pathogens. The infections may be difficult to diagnose but may be characterized by focal, multifocal, or generalized dark or violaceous discoloration that can mimic hemorrhage. The most reliable sign for invasive infection is conversion of a partial-thickness injury to full-thickness necrosis. Daily examination of the entire wound is necessary to check for signs of infection. In difficult cases, perform biopsy on suspected lesions and submit specimens for culture and microscopic evaluation. Treatment with topical antimicrobial drugs or early excision is important for infection control.
  • Evidence of cellulitis, increased drainage, or discoloration of the wounds suggests the need for systemic antibiotics. Bacteremias are uncommon in small burns.
  • Patients with burns to the face or head may be at increased risk for developing gram-positive infections, including toxic shock syndrome.

Prognosis

• Hypertrophic scarring refers to the development of thickened raised skin. Scarring may be characterized by contractures of joints.
• In general, children scar more than adults. Patients with pigmented skin tend to scar more than patients with lighter skin.
• Continuous wearing of pressure garments for up to 1 year after healing has been shown to help limit the progression of hypertrophic scarring. The garments must be worn nearly 24 hours per day to be effective.

Patient Education

• A return to the normal routine should be accomplished as soon as possible. School reentry is an important part of the long-term rehabilitation process; early return to school is important in overall recovery. Occasionally, a relationship must be developed between the hospital, rehabilitation personnel, and the staff at the child's school. Patients with burns are often withdrawn and can scare their schoolmates. These fears can be exacerbated with an apprehensive and self-conscious patient.
• A well thought-out school reentry program is essential for the recovery of patients with significant cosmetic injury.
• In a study investigating the cause, classification, prognosis, and expense of firework-related injuries, the primary injury was burn in 72% of cases. The study cited 360 children over a 20-year period and demonstrated that the peak incidence of injury was a 3-week period from June 22nd to July 14th. Of patients, 71% were male, and the average age was 8.5 years, with a range of 1 month to 17 years. The child was a bystander in 26% of cases, and adult supervision was present in 54% of cases. Permanent sequelae followed the injuries in 10% of patients. Firecrackers were associated with 42% of the injuries, followed by bottle rockets (12%), other types of rockets (7%), and fountains (5%). The authors concluded that children and their families should be encouraged to enjoy fireworks at public fireworks displays conducted by professionals. They felt that fireworks for individual private use should be banned.
• For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal (Heat or Fire) Burns.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Failure to consider the possibility of abuse in pediatric patients with burns
• Silver sulfadiazine has occasionally been associated with skin pigmentation changes, a cosmetic complication. Bacitracin is recommended for burns located above the clavicles.

Special Concerns

• Approximately 20% of burn injuries occur as a result of child abuse. Always consider the possibility of abuse and learn to recognize some of the telltale signs. It is important to elicit a very thorough history of the event from caregivers, witnesses, and the child. Always compare the pattern of injury to the history obtained.
• • Scalds typically occur when a child pulls a hot pot from a stove and usually affect the side of the face, neck, chest, or arms. The hot liquid cools and narrows as it runs down the body, producing an arrowhead-shaped pattern.
  • Splash burns can occur in any exposed or lightly clothed area and result in speckled involvement.
  • Burns on the fingertips or palm of the dominant hand are consistent with a child touching a hot stove or flame.
  • Significant burns from a liquid without surrounding splash injury; burns on the back, buttocks, or both soles of the feet; or burns in a glove or stocking distribution are highly suggestive of child abuse.
  • Complete circumferential burns of the hand or foot, extending to the wrist and ankle, are rarely accidental.
  • Small-area full-thickness burns (as from a cigarette) should raise the question of abuse.

MULTIMEDIA

Section 10 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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Media file 1:  59-year-old physician with deep-seated bulla on middle finger after burning himself taking a hot bun out of oven.
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Media type:  Photo

REFERENCES

Section 11 of 11

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• Medication
• Follow-up
• Miscellaneous
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Article Last Updated: Aug 29, 2006