Superficial

Superficial burns generally involve only the epidermal layer. These are commonly seen resulting from sunburn or minor scalds. Blistering does not occur immediately but may over the next few days. The pain and swelling generally last only a few days. The skin is erythematous and blanches normally. The epidermis will often peel within 3–7 days and is completely healed by 7–10 days, without scarring.

Partial thickness

Partial-thickness burns occur when the whole epidermis is involved and part of the dermis. The more of the dermis that is involved, the increased scarring potential.

Full thickness

Full-thickness burns generally occur after flame burns or after prolonged contact with a hot surface. Other causes include hot oil, prolonged immersion, or chemical burns. They involve the epidermis and all the dermis, including epidermal appendages. They have either a dry, hard, white, leathery appearance or may be black in colour. They usually have no sensation because the nerve endings have been destroyed, and pain is due to more superficial burns on the edge of the full-thickness burn. Full-thickness burns are able to heal only from skin regrowth from the edge of the burn, which causes scarring. Therefore most will require skin grafting.

All significant burns will become colonised with bacteria. Heat causes coagulation of tissue, which leads to oedema and non-viable skin. This will potentially become a rich source of nourishment for bacteria. Adequate debridement is required to reduce the risk of infection. Infection will increase the depth of skin damage and thus the degree of scarring.

The location of the burn is also important regarding potential scarring, contracture, and caring for the acute burn. Facial, hand, foot, and perineal burns may be difficult to dress. Hence the part of the body involved by the burn will influence whether inpatient or specialist care is required.

Primary survey

The initial assessment of the child should be directed to the presence of any features that suggest potential airway involvement. These include singed nasal hairs or eyebrow hairs, oral or facial burns, coughing up carbonaceous sputum, barking cough, altered voice, stridor, wheeze, or respiratory distress. Airway compromise (upper or lower) may have an insidious onset, so frequent re-examination of the child is vital during the first 12–24 hours. If stridor or hoarse voice is present, this indicates upper airway involvement, and early intubation is required prior to evolving oedema causing total airway obstruction. Delayed intubation in this setting can be increasingly hazardous due to distortion of the normal laryngeal anatomy. Scalds to the face rarely cause airway compromise, unless the child has ingested hot liquids.

The circulation status should be assessed next. Hypovolaemia resulting from third-space fluid loss will not occur for a few hours after a severe burn. Therefore, if early-onset cardiovascular instability is present, then an alternative explanation, such as bleeding, should be sought. The peripheral perfusion of limbs should be assessed where circumferential burns are apparent. Comparing the pulse wave forms of various digits on the limb using a saturation oximeter may assist this in questionable instances.

Evaluation of burn area

The extent and depth of the burn should be assessed after the patient has been stabilised. This is usually done from a body chart (Fig. 3.5.1), which can be useful to aid documentation of the burn. This chart is used because the surface area involved will alter depending on the age of the child and the parts of the body where the burn is located. A simple method, using the palmar surface of the child’s hand and fingers, can also be used to estimate the area of burn. This correlates to approximately 1% of the child’s total surface area. The adult formula using the ‘rule of nines’ can be used in adolescents older than 15 years.

Fig. 3.5.1 Lund Browder chart for estimation of percentage size of burn.

Prehospital

The main aims of prehospital care are stabilising ABCs, preventing ongoing burn injury, provision of analgesia, covering the area involved, and rapid transfer to an emergency department.

The first priority in any burn is to assess and stabilise the airway and breathing. Oxygen should be administered where there is suspected carbon monoxide poisoning with inhalation burns. Circulation is generally not a problem in the first hour after a major burn, and rapid transport to hospital should occur. If transfer time is greater than 1 hour, and the burn is greater than 20%, then intravenous fluid replacement should begin en route where possible.

The burns should be covered with water-soaked sterile cloth or the newer tea tree oil soaked pads. Excessive cooling of major burns causes hypothermia and worsens the patient’s outcome. Recently sustained minor burns should be cooled under running water for at least 20 minutes. This acts to minimise the extent of the burn and also affords some pain relief.

Analgesia is generally required early, and a single dose of a narcotic (e.g. fentanyl 1.5–2 mcg kg^–1 intranasally) is a good choice in burns less than 20%. Greater than 20%, then intravenous access should be obtained and analgesia titrated to responses as well as administering intravenous fluids.

If electrical injury has been sustained, then cardiac monitoring should occur during transfer. Patients with chemical burns should undergo extensive washing of the affected area before transport.

Emergency department

The initial priority should focus on stabilisation of airway, breathing, and circulation, with concurrent provision of analgesia. If airway burns are suspected, then early intubation should be considered. Patients with obvious stridor due to upper airway compromise require urgent intubation. Supplemental oxygen should be instituted and oxygen saturation monitored.

Other potential indications for ventilation in major burns include:

The fluid losses due to the burn itself do not cause early circulatory failure, and other contributing injuries should be sought in the patient with early shock. It is also important to note the time the patient is evaluated, relative to the time of the burn. Children who have delay (e.g. a few hours) in presentation may arrive with circulatory compromise from skin fluid losses.

Intravenous access should be placed in all children with burns body surface area (BSA) of >20%. Fluid resuscitation rates should be calculated using the time of the burn, not the time of presenting to the emergency department (see Fluid resuscitation, below). Peripheral venous access, preferably through non-burnt skin, is preferred over central venous access for the initial resuscitation. Monitoring of urinary output (via urinary catheter, weighing nappies) is important in determining the adequacy of fluid replacement. A nasogastric tube should also be inserted in children with severe burns, as gastric dilatation can occur, leading to respiratory compromise.

Analgesia should be given early, during the stabilisation of the A, B and C. Intranasal fentanyl (1.5–2 mcg kg^–1) is a good first up treatment. In severe burns, a morphine infusion should be started after adequate initial intravenous or intranasal analgesia has been given. Large doses of narcotics are sometimes needed in severe burns to control the pain. Intramuscular morphine is now obsolete given the use of intranasal fentanyl.

A careful secondary survey should then be undertaken, looking at the extent, depth, and anatomical relevance of the burns. It is important to determine if there are any circumferential burns to limbs and chest. In superficial or partial thickness burns, careful monitoring of circulation or ventilatory compromise is required. In full-thickness circumferential burns, an urgent escharotomy may be required to restore circulation to the limb or allow for adequate ventilation. A paediatric burn specialist should be consulted in this situation.

The secondary survey should also include careful examination for any other injuries requiring attention (e.g. head, neck, chest, limbs, pelvis, intra-abdominal). Burns to the face should also include fluorescein staining of the eyes to check for corneal involvement.

Fluid resuscitation

Fluid resuscitation should be calculated based on the weight of the child and the total surface area of the burn. Several formulas are used to calculate the resuscitation fluid requirement in the first 24 hours. The Parkland formula (BSA affected % × weight (kg) × 4) gives the number of millilitres of resuscitation fluid to be given over the first 24 hours. Half the fluid is given in the first 8 hours and the remainder in the subsequent 16 hours. The 24-hour period should begin from the time of the injury. Thus if a patient has received very little fluid in transfer, and it is 4 hours since initial burn, then the fluid calculated should be given over the next 20 hours, and half the calculated fluid given in the first 4 hours.

In addition, maintenance fluid for the 24-hour period should also be given. This is calculated as 100 mL kg^–1 for 0–10 kg, 50 mL kg^–1 for 11–20 kg, and 25 mL kg^–1 for >20 kg. Thus a 30-kg child’s maintenance = 1000 + 500 + 250 = 1750 mL over 24 hours. It is also important to monitor ongoing losses (urinary output, respiratory loss, etc.).

The calculated amount of fluid (burn deficient plus maintenance) to be replaced in 24 hours is only a guide and should be adjusted according to the haemodynamic response. Patients need to be maintained in a positive fluid balance for the first 24–48 hours. The adequacy of fluid replacement is monitored by urine output and clinical parameters of perfusion. In children, 0.5–1 mL kg^–1 per hour is the recommended urine output and should be monitored by a urinary catheter in severe burns. A central venous catheter is generally not required in the emergency department phase of management.

The type of fluid used varies between burn specialists, and it is best to be familiar with the preference of the local paediatric burns unit. In the shocked child, a 20 mL kg^–1 bolus of normal saline should be given. This can be repeated if necessary to restore peripheral circulation. Ongoing replacement is generally with crystalloid in the first 24 hours, as colloid may leak through the burnt capillaries, causing worsening oedema. After 24 hours, colloid is used as part of the replacement fluids in the intensive care setting. When calculating the initial fluid requirements, it is important to subtract the bolus fluids given from this amount.

Additional fluids may be required in severe electrical burns causing muscle damage, as myoglobin may cause renal failure secondary to renal tubular deposition, and therefore maintaining adequate glomerular filtration is very important.

Major burns

These patients should be treated in a specialised burns unit. Covering the burn with a sterile dressing is required prior to transfer. Specific dressing type is best decided after discussion with the receiving unit. Within the burn centre, patients are generally dressed with topical silver sulfadiazine (SSD) cream that should be changed each day. At each change, the wound should be cleaned with warm water and debrided to remove any avascular tissue (which may lead to infection). The burns are covered with a non-stick dressing over the SSD cream (e.g. Melolin), and then wrapped in crepe bandages to prevent contamination of the burn. The face and perineum are generally left open and covered with a water-based gel. SSD should not be used on the face, as the patient may spread it into the eyes. SSD is currently only recommended for inpatient care of patients with significant burns.

Small superficial burns

With these small burns, a clear plastic dressing (e.g. Tegaderm) can be placed over the burn to provide protection and be left on until it also falls off. The disadvantage of this type of dressing is that fluid from the burn tends to collect under the dressing, is a rich source of ‘food’ for bacteria, and can lead to infection. Tegaderm is better applied after a few days, when the exudate from the burn has ceased. A more porous adherent dressing, such as Fixomul or Hyperfix is better when exudate is going to occur, as it allows some egress of fluid to occur. A covering dressing of gauze and crepe is needed for the first few days. Removal of this type of dressing is problematic. Olive oil must be applied to the Fixomul several hours before the dressing can be removed, otherwise pulling the dressing off leads to removal of the new granulation tissue.

More extensive superficial burns

Most extensive superficial burns should be covered with Mepitel, Melolin and crepe bandage securing this with Hyperfix. Mepitel is a low adherent wound contact dressing made of silicone gel bound to a flexible polyamide net. The dressing is left intact until the patient is reviewed after 5–7 days. Repeat dressing may be required or the healing burn can be covered with Tegaderm or Hyperfix and be left on until it falls off.

Partial thickness/small full thickness burns

Use Acticoat, a silver impregnated barrier dressing, moistened with sterile water, covered with IntraSite Conformable, gladwrap, ± crepe bandage. Secure with Hyperfix. The exudate from the wound determines the number of dressing changes required. IntraSite Conformable is a soft hydrogel dressing that combines the advantage of IntraSite gel with a non-woven dressing. It creates a moist wound environment for the continued release of silver from the Acticoat. Patients should be reviewed between 3 and 7 days for a change of dressing and to assess if skin grafting is needed.

Superficial burns on the face should be managed non-dressed, and cleaned two or three times a day with warm water. Solugel or vaseline can be applied to the face or it can be left completely non-dressed. As a burn on the face starts to dry up, application of mild lanolin ointment/cream can be used to aid in healing by softening the skin. The burn should also be protected from the sun, as sunburn of an already burnt area causes increased pigmentation to the skin.

Superficial burns rarely become infected, but infection should be suspected if the patient: has unexplained fever, or has evolving pain, redness, and tenderness. Foul discharge from the burn does not always indicate that infection is present. In this case, the dressing should be changed earlier and the burn inspected, as antibiotics may not be indicated. As the skin heals under a dressing, it becomes pruritic, which may require an antihistamine or cooling of the dressing (particularly in hot weather).

Tetanus prophylaxis is important in major burns or minor burns (which are contaminated). Antibiotics should be used only when a definite infection is present. Prophylactic use of antibiotics is not recommended.

Pain management for minor burns is generally achieved by the dressing itself. Covering the burn decreases the pain substantially. Generally, paracetamol with or without codeine should be sufficient during the first 24 hours.

Patients with burns involving hands, feet, or face should be referred to a burn specialist for ongoing management.

Introduction

These are infrequent presentations to emergency departments but have unique problems. Electrical injuries are more commonly seen in two age groups: toddlers within the home setting and male adolescents involved in risk-taking behaviour.

Young children generally sustain electrical burns from low-voltage (<1000 V) or household currents (240 V). These may be due to frayed electrical cords or children inserting metal objects into power sockets. Mouth burns may occur when small children chew on power cords. In most states in Australia, safety switches are installed in all new houses, cutting the current when overloaded, thus preventing many severe electrical burns. These low-voltage exposures rarely result in significant internal injury, and most children are asymptomatic apart from distress from the cutaneous burn.

High-voltage (>1000 V) injuries are seen most often in adolescent males as a consequence of risk-taking behaviour (e.g. climbing electrical poles, train surfing). These high-voltage exposures have a more serious outcome, as they are more likely to be associated with injury to internal structures.

Clinical effects

Electrical currents preferentially flow along low-resistance tissues such as blood vessels, nerves, and muscles, rather than the skin, causing internal injury particularly if extremities are involved. There is generally an entrance and exit burn in non-water-related current injuries, with increased tissue damage at these sites. Wet or moist skin increases current flow dramatically by decreasing the tissue resistance.

Clinical manifestations vary according to the voltage exposure and may range from trivial to cardiac arrest, as follows.

Management

Assessment of the child’s A, B and C is the initial priority with electrical exposure, followed by examining for skin burns and potential internal injuries. A baseline 12-lead ECG should be done (unless a trivial exposure), and cardiac monitoring only continued if the initial ECG is abnormal or the child is symptomatic (e.g. chest pain or impaired conscious state). A search for an entrance and exit wound should occur to determine the potential for deeper burns. Analgesia should be provided for the burn or muscle pain. Potential complications and associated injuries are treated on their merit.

Specific issues

Disposition

The following are general guidelines for admission and discharge after burns.

Treatment

Copious irrigation of the burn is the mainstay of treatment. Sufficient analgesia and topical anaesthesia is required to achieve this in a child. This can be done simply with water. Flushing of the burn should continue for at least 10–15 minutes and sometimes longer. Determination of wound pH via litmus paper may guide the duration of irrigation. If chemicals are introduced into the eye, then irrigation should continue until pH is neutral. This usually requires topical anaesthetic to the eye prior to flushing with saline. A Morgan lens is a good method of flushing eyes, as this requires less co-operation from the patient. Fluorescein staining of the eye should then determine the extent of the burn. Chemical burns to the eye require urgent ophthalmological referral. The treatment of a dermal chemical burn after decontamination should be the same as for any other burn.

Some chemicals may cause systemic toxicity from absorption through the burned skin, and these should be managed accordingly.