Burn, Pediatric



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Burn, Pediatric

Characterization of Burn: Minor, Moderate, or Major

Minor

  • <5% TBSA partial thickness

Moderate

  • 5-15% TBSA partial thickness
  • Circumferential
  • Face, head, neck, hands, feet, perineum, over joints

Major

  • >15% TBSA partial thickness
  • >5% TBSA full thickness
  • Significant electrical burns
  • Inhalation injuries

Major Burns:

  • Immediate Trauma/Surgery Consult.
  • Other Trauma: Assess and manage other injuries before addressing burns.
  • Pain: Opiates will likely be needed, but should be administered with consideration of the patient’s entire presentation, co-existing trauma, respiratory and mental status, etc.
  • Fluid: Should be discussed with Trauma/Surgery or Burn Center. Burn patients are at high risk for developing anasarca with administration of fluids. Urine output should be monitored closely (goal 1 mL/kg/hr) and fluid administration should be a dynamic process. General guidelines:
  • Children >20 kg: Lactated Ringer at 2–4 mL/kg per percentage of total body surface area (TBSA) burned per 24 hours (give first half in first 8 hours). If burn is ≥30% TBSA, use 5% albumin solution at maintenance rate and subtract that rate from lactated Ringer solution initially calculated.
  • Children <20kg: Lactated Ringer at 2–3 mL/kg per percentage of TBSA burned per 24 hours (give first half in first 8 hours). Plus lactated Ringer solution with 5% dextrose at maintenance rate. If burn is ≥30% TBSA, use 5% albumin solution at maintenance rate and subtract that rate from lactated Ringer solution initially calculated.
  • Dressing: Cover would with clean, dry sheet or dressing prior to transfer to Burn Center. Elevate burn above level of heart, if possible.
  • Tetanus Prophylaxis: Use chart to the right to determine if tetanus vaccine or immune globulin is indicated. Give as indicated:
  • <7 years old: DTaP
  • ≥7 years old: Tdap
  • Human tetanus immune globulin

Inclusion Criteria
  • Thermal burn
Exclusion Criteria
  • Inhalation injury or signs of respiratory distress
  • Loss of consciousness or altered mental status
  • Burn involving >25% of TBSA
  • Associated major trauma
  • Chest pain

Initial Assessment:

  • Vital signs including oxygen saturation
  • Inhalation injury
  • Assess burns
  • Electrical burns
  • Chemical burns

Concern for non-accidental injury or neglect?

Initiate Trauma Assessment off pathway

Obtain History:

  • Type of burn – flame, scald, chemical, electric
  • Mechanism of injury
  • Duration and timing of burn
  • Associated trauma
  • Screen for non-accidental trauma
  • Tetanus vaccination status

Burn Assessment:

  • Estimate total body surface area (TBSA) using the Lund-Browder chart.
  • Estimate depth of burn.
  • Characterize as mild, moderate, or severe burn.

Concern for non-accidental injury or neglect?

Is Tetanus Prophylaxis Needed?

Patient’s Immunization Status

Vaccine Needed?

Tetanus Immune Globulin Needed?

  • Received fewer than 3 tetanus vaccines or Unknown

Yes

Yes

  • Received 3 or more vaccines,
  • Clean and minor wounds: <10 years since most recent tetanus vaccine
  • Contaminate or large wounds: <5 years since most recent tetanus vaccine

No

No

  • Received 3 or more vaccines,
  • Clean and minor wounds: ≥10 years since most recent tetanus vaccine
  • Contaminate or large wounds: ≥5 years since most recent tetanus vaccine

Yes

No

Lund-Browder Chart for Estimating Total Body Surface Area (TBSA)

Birth - 1 yr

1 - 4 yr

5 - 9 yr

10 - 14 yr

15 yr

Head

19

17

13

11

9

Neck

2

2

2

2

2

Ant. trunk

13

13

13

13

13

Post. trunk

13

13

13

13

13

Buttock

2.5

2.5

2.5

2.5

2.5

Genitalia

1

1

1

1

1

Upper arm

4

4

4

4

4

Lower arm

3

3

3

3

3

Hand

2.5

2.5

2.5

2.5

2.5

Thigh

5.5

6.5

8

8.5

9

Leg

5

5

5.5

6

6.5

Foot

3.5

3.5

3.5

3.5

3.5

Chemical burns: remove clothing and jewelry, copious irrigation, ophthalmology consult if ocular involvement.

Depending on stability of patient, they will either require direct admission to the PICU or transfer to burn center.

Inhalation injury: consider intubation in cases of facial soot, facial burns, singed nose hairs, hoarseness, stridor, or respiratory distress. An arterial blood gas and carboxyhemoglobin level should be obtained in patients with suspected inhalation injury.

Electrical burns: obtain EKG, urinalysis, and CK.

Urinalysis with micro, Urine
Creatine Phosphokinase (CPK), Serum
ECG

Burn Center Referral Criteria:

  • Partial thickness burns greater than 10% total body surface area (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 disorders that could complicate management, prolong recovery, or affect mortality.
  • Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, 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 will be necessary in such situations 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 special social, emotional, or rehabilitative intervention.

Taken from The American Burn Association: http://ameriburn.org/wp-content/uploads/2017/05/burncenterreferralcriteria.pdf.

Depth Classifications:

Classification

Depth

Description

Healing Time

Superficial

Epidermis

Erythematous, no blister, painful

4-5 days

Superficial partial-thickness

Epidermis and dermis

Pink, moist, blanching with intact capillary refill; blister; painful when blister deroofed and open to air

7-10 days

Deep partial-thickness

Deeper dermis

Erythematous or yellow, nonblanching; dry to waxy; blister easily unroofs; possibly not painful if nerve fibers involved; presence of hair follicles; capillary burs when red punctum

2-3 weeks

Full thickness

Dermis

White, waxy, and leathery; lack hair follicles; insensate

Weeks

Moderate Burns:

  • Pain control: Oral ibuprofen and acetaminophen ATC. IV or intranasal fentanyl or oral oxycodone 30 minutes prior to debridement and dressing may be required.
  • Fluids: Fluid resuscitation is generally not required when burn is <15% TBSA. IV + PO total fluid goal of 150% of maintenance with close monitoring of I/Os.
  • Debridement and Dressing: Consult Trauma/Surgery prior to debridement and dressing to evaluate burn. General principles of debridement and dressing similar to “Minor Burn” management.
  • Tetanus Prophylaxis: Use chart to the right to determine if tetanus vaccine or immune globulin is indicated. Give as indicated:
  • <7 years old: DTaP
  • ≥7 years old: Tdap
  • Human tetanus immune globulin
  • Hospitalization: May require hospital admission for close monitoring and management of pain and initial healing. Discuss with Trauma/Surgery.
  • Follow up: Burns to the face, hands, feet, genitalia, perineum, or major joints should be referred to follow up at a Burn Center. Otherwise, follow up will be determined by Trauma/Surgery service.
  • Seek care for:
  • Fevers.
  • Signs of infection: erythema, swelling, drainage.

Acetaminophen suspension
Ibuprofen suspension
Fentanyl Intranasal
Oxycodone

The decision for admission or discharge home should be made in conjunction with the consulting Trauma/Surgery service, taking into account:

  • Concern for inhalation or airway involvement.
  • Pain control.
  • Wound dressing changes and management.
  • Ability for family to care for burns at home.
  • Transportation and follow up availability.

Concerning for Non-Accidental Burn Trauma:

  • Delayed presentation to care.
  • Sharply demarcated margins.
  • Immersion patterns.
  • Confusing or conflicting stories.
  • Burns of different ages.
  • Signs of neglect.
  • History inconsistent with child’s developmental stage.
  • History of previous Child Protective Services involvement.

Minor Burns:

  • Pain control: Oral ibuprofen and acetaminophen ATC. IV or intranasal fentanyl or oral oxycodone 30 minutes prior to debridement and dressing may be required.
  • Debridement: Gently cleanse of debris and loose skin with lukewarm tap water and mild soap. Do not drain closed blisters.
  • Dressing: [Note: superficial burns (i.e., sunburns) do not require dressings]
  • Silver-based antimicrobial dressing (e.g., Mepilex, Acticoat, Aquacel, and Glucan Silver Matrix) followed by elastic gauze (e.g., Kerlix). Dressing changes with soap and water wash when soiled or every 3-5 days.
  • OR Bacitracin ointment followed by a non-adherent dressing (e.g., Adaptic or Zeroform) followed by elastic gauze (e.g., Kerlix). Dressing changes with soap and water wash and removal of previous ointment twice daily.
  • Tetanus Prophylaxis: Use chart to the right to determine if tetanus vaccine or immune globulin is indicated. Give as indicated:
    • <7 years old: DTaP
    • ≥7 years old: Tdap
    • Human tetanus immune globulin
  • Follow up: 24-72 hours.
  • Seek care for:
  • Fevers.
  • Signs of infection: erythema, swelling, drainage.

Acetaminophen suspension
Ibuprofen suspension
Fentanyl Intranasal
Oxycodone

Discharge home if meets the following discharge criteria:

  • No inhalation or airway concerns.
  • No full-thickness burns.
  • Must be able to hydrate by mouth.
  • Adult who can care for burns at home.
  • Reliable follow up and access to transportation.
  • No concern for abuse or neglect.

Admit to the hospital for full NAT work up.