Burn Injuries

Indications for Admission

Burns covering >10% of total body surface area (BSA), burns associated with smoke inhalation, burns resulting from high-tension (voltage) electrical injuries, and burns associated with suspected child abuse or neglect should be treated as emergencies and the child hospitalized ( Table 92.2 ). Small 1st- and 2nd-degree burns of the hands, feet, face, perineum, and joint surfaces also require admission if close follow-up care is difficult to provide. Children who have been in enclosed-space fires and those who have face and neck burns should be hospitalized for at least 24 hr for observation for signs of central nervous system (CNS) effects of anoxia from carbon monoxide (CO) poisoning and pulmonary effects from smoke inhalation.

First Aid Measures

Acute care should include the following measures:

• 1

  Extinguish flames by rolling the child on the ground; cover the child with a blanket, coat, or carpet.

• 2

  After determining that the airway is patent, remove smoldering clothing or clothing saturated with hot liquid. Jewelry, particularly rings and bracelets, should be removed or cut away to prevent constriction and vascular compromise during the edema phase in the first 24-72 hr after burn injury.

• 3

  In cases of chemical injury , brush off any remaining chemical, if powdered or solid; then use copious irrigation or wash the affected area with water. Call the local poison control center for the neutralizing agent to treat a chemical ingestion.

• 4

  Cover the burned area with clean, dry sheeting and apply cold (not iced) wet compresses to small injuries. Significant large-burn injury (>15% of BSA) decreases body temperature control and contraindicates the use of cold compresses.

• 5

  If the burn is caused by hot tar , use mineral oil to remove the tar.

• 6

  Administer analgesic medications.

Emergency Care

Supportive measures are as follows ( Table 92.3 and Table 92.4 )

• 1

  Rapidly review the cardiovascular and pulmonary status and document preexisting or physiologic lesions (asthma, congenital heart disease, renal or hepatic disease).

• 2

  Ensure and maintain an adequate airway, and provide humidified oxygen by mask or endotracheal intubation ( Fig. 92.1 ). The latter may be needed in children who have facial burns or a burn sustained in an enclosed space, before facial or laryngeal edema becomes evident. If hypoxia or CO poisoning is suspected, 100% oxygen should be used (see Chapters 81 and 89 ).

  

• 3

  Children with burns >15% of BSA require intravenous (IV) fluid resuscitation to maintain adequate perfusion. In an emergency situation if IV access is unattainable, an intraosseous line should be placed. When inserting central lines to provide high-volume fluid, special attention should be paid to use a very-small-caliber catheter in small children to avoid injury to the vascular lining, which may predispose to formation of clots. All inhalation injuries, regardless of the extent of BSA burn, require venous access to control fluid intake. All high-tension and electrical injuries require venous access to ensure forced alkaline diuresis in case of muscle injury to avoid myoglobinuric renal damage. Lactated Ringer solution, 10-20 mL/kg/hr (normal saline may be used if lactated Ringer solution is not available), is initially infused until proper fluid replacement can be calculated. Consultation with a specialized burn unit should be made to coordinate fluid therapy, the type of fluid, the preferred formula for calculation, and preferences for the use of colloid agents, particularly if transfer to a burn center is anticipated.

• 4

  Evaluate the child for associated injuries, which are common in patients with a history of high-tension electrical burn, especially if there has also been a fall from a height. Injuries to the spine, bones, and thoracic or intraabdominal organs may occur (see Chapter 82 ). Cervical spine precautions should be observed until this injury is ruled out. There is a very high risk of cardiac abnormalities, including ventricular tachycardia and ventricular fibrillation, resulting from conductivity of the high electric voltage. Cardiopulmonary resuscitation (CPR) should be instituted promptly at the scene and cardiac monitoring started on the patient's arrival at the emergency department (ED) (see Chapter 81 ).

• 5

  Children with burns of >15% of BSA should not receive oral fluids (initially) because gastric distention may develop. These children require insertion of a nasogastric tube in the ED to prevent aspiration.

• 6

  A Foley catheter should be inserted into the bladder to monitor urine output in all children who require IV fluid resuscitation.

• 7

  All wounds should be wrapped with sterile dressings until it is decided whether to treat the patient on an outpatient basis or refer to an appropriate facility.

• 8

  A CO measurement (carboxyhemoglobin [HbCO]) should be obtained for fire victims and 100% oxygen administered until the result is known.

• 9

  Review child immunization. Burns <10% BSA do not require tetanus prevention, whereas burns >10% need tetanus immunization. Use diphtheria, tetanus toxoids, and acellular pertussis (DTaP) for tetanus prophylaxis for children <11 yr old, and use tetanus, diphtheria, and pertussis (TdaP) for children >11 yr old (see Chapter 238 ).

Classification of Burns

Proper triage and treatment of burn injury require assessment of the extent and depth of the injury ( Table 92.5 and Fig. 92.2 ). 1st-degree burns involve only the epidermis and are characterized by swelling, erythema, and pain (similar to mild sunburn). Tissue damage is usually minimal, and there is no blistering. Pain resolves in 48-72 hr; in a small percentage of patients, the damaged epithelium peels off, leaving no residual scars.

A 2nd-degree burn involves injury to the entire epidermis and a variable portion of the dermal layer (vesicle and blister formation are characteristic). A superficial 2nd-degree burn is extremely painful because many remaining viable nerve endings are exposed. Superficial 2nd-degree burns heal in 7-14 days as the epithelium regenerates in the absence of infection. Mid-level to deep 2nd-degree burns also heal spontaneously if wounds are kept clean and infection free. Pain is less with these burns than in more superficial burns because fewer nerve endings remain viable. Fluid losses and metabolic effects of deep dermal (2nd-degree) burns are essentially the same as those of 3rd-degree burns.

Full-thickness, or 3rd-degree, burns involve destruction of the entire epidermis and dermis, leaving no residual epidermal cells to repopulate the damaged area. The wound cannot epithelialize and can heal only by wound contraction or skin grafting. The absence of painful sensation and capillary filling demonstrates the loss of nerve and capillary elements.

Technologies are being used to help accurately determine the depth of burns. Laser Doppler imaging can be used from 48 hr to 5 days after the burn. It produces a color map of the affected tissue; yellow indicates second-degree burns, reflecting the presence of capillaries, arterioles, and venules, and blue reflects very low or absence of blood flow, which indicates third-degree burns. Its accuracy is up to 95%, and with accurate assessment, the proper treatment can be applied without delay. Doppler imaging can be used in both outpatients and inpatients.

Another technology called reflectance confocal microscopy (RCM), can be combined with optical coherence tomography (OCT) to visualize tissue morphology at the subcellular level. It determines if the cells are damaged and enables detection of skin morphologic changes up to 1 mm in depth. It provides accurate determination of the depth of the burn, allowing for the appropriate treatment.