1 How common are burns and fire-related deaths among children?

Injury-related deaths are the leading cause of death in children ages 1–14 years. Centers for Disease Control and Prevention statistics from 2002 rate fire- or burn-related injuries as the third leading cause of injury-related deaths in this age group, behind motor vehicle–related deaths and drowning. Burns and fire-related injuries were responsible for 480 childhood deaths in the United States in 2002 and more than 1600 hospitalizations.

National Center for Injury Prevention and Control: www.cdc.gov/ncipc

2 What functions of the skin do burns affect?

3 How are different depths of burns classified?

See Table 51-1.

4 What are the common sources of burns in children?

The cause of burns in children varies with the setting in which they are evaluated and the age of the child (Table 51-2). Common burns treated in an emergency department (ED) differ from those requiring hospitalization. Contact and scald burns make up a higher proportion of burns treated on an outpatient basis. The true pattern of burn injuries in children, including those not seeking medical care, may be substantially different. Scald burns predominate in the younger age group. Most of these occur when the child pulls over a hot liquid from the surface of a table or stove. Burns due to flames account for most hospital admissions in older children.

Banco L, Lapidus G, Zavoski, et al: Burn injuries among children in an urban emergency department. Pediatr Emerg Care 10:98–101, 1994.

Morrow SE, Smith DL, Cairns BA: Etiology and outcome of pediatric burns. J Pediatr Surg 31:329–333, 1996.

5 How long must the skin be in contact with hot water to cause a burn?

The actual duration of contact and water temperature required to cause a partial-thickness burn depend on the location and thickness of the skin. Partial-thickness burns on the soles of the feet require a longer period of contact with the water because of the thick layer of skin. Scald burns occur more rapidly in the skin of young children than in adults, and partial- or full-thickness burns can occur in less time than listed below:

Tepas JJ III, Fallat ME, Moriarty TM: Trauma. In Gausche-Hill M, Fuchs S, Yamamoto L (eds): The Pediatric Emergency Medicine Resource, 4th ed. Boston, Jones and Bartlett, 2004, pp 268–323.

6 Why is it important to interview the paramedics who arrive with fire victims?

Paramedics can provide the answers to questions that influence therapy as well as prognosis. Important questions include the following:

7 Name the methods commonly used to estimate the percentage of body surface area (BSA) damaged by burns in a child

The distribution of BSA is different in children and adults. The standard “rule of nines” used in adults is not as accurate in children. The young child has a greater proportion of the BSA in the head and less in the lower extremities. Nagel and Schunk demonstrated that the entire palmar surface of a child’s hand (including the fingers) is approximately 1% of BSA. The Lund and Browder chart (Fig. 51-1) provides useful estimates of larger contiguous burn areas in children younger than 10 years of age. First-degree burns are not generally included in the calculation of total BSA burned.

Figure 51-1 Lund and Bowder charts are somewhat more accurate to estimate the percentage of body surface burn than the rule of nines. Compared with adults, children have larger heads and smaller legs. Other areas are relatively stable through life.

From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, 2nd ed. Philadelphia, W.B. Saunders, 1991, pp 614–615.

Lund C, Browder N: The estimation of areas of burns. Surg Gynecol Obstet 79:352–358, 1944.

Nagel TR, Schunk JE: Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care 13:254–255, 1997.

8 What is the initial treatment of major burns in a child?

Tepas JJ III, Fallat ME, Moriarty TM: Trauma. In Gausche-Hill M, Fuchs S, Yamamoto L (eds): The Pediatric Emergency Medicine Resource, 4th ed. Boston, Jones and Bartlett Publishers, 2004, pp 268–323.

9 Name some recommended topical therapies for burns

Multiple creams and ointments are appropriate for the treatment of burns. They should perform several functions, including minimizing bacterial colonization, preventing desiccation, and reducing pain. Superficial burns require only a moisturizer. Commonly used topical therapies include:

Monafo WW: Current concepts: Initial management of burns. N Engl J Med 335:1581–1586, 1996.

10 How should blisters be treated?

Intact blisters maintain a sterile environment below the surface, while unroofing the blisters allows for easier cleaning. Nonviable skin from a ruptured blister that is allowed to remain in the burn provides a medium for bacterial growth. Blisters should never be aspirated as this predisposes to infection by disrupting the sterile environment and can introduce bacteria into the wound. The treatment is controversial, but in general, small blisters should be allowed to remain intact. Open blisters, large blisters likely to rupture, and those crossing joints should be unroofed and debrided. The burn is then cleaned with mild soap and water.

Reed JL, Pomerantz WJ: Emergency management of pediatric burns. Pediatr Emerg Care 21:118–129, 2005.

11 What is the approach to fluid management of a child with severe burn injuries?

Fluid resuscitation is typically required in children with partial- or full-thickness burns covering 15% or more of the total BSA. Fluid administration initially consists of lactated Ringer’s solution or normal saline as needed for shock. Early fluid replacement can be estimated by following one of two formulas. The Parkland formula dictates that 4 mL/kg/% BSA burned should be administered over the first 24 hours. Half of the total volume is infused over the first 8 hours and half over the next 16 hours. Maintenance requirements should be added for children younger than 5 years of age. The Carvajal formula recommends 5000 mL/m²/% BSA burned. Half is given in the first 8 hours and the other half in the next 16 hours. Maintenance fluids of 2000 mL/m²/d are added to the total. Initial resuscitation is followed by an infusion of 5% dextrose in one-fourth normal saline solution titrated to maintain urine output at 0.5–1 mL/kg/hr. Overhydration is poorly tolerated and may contribute to development of acute pulmonary edema. Placement of a central venous pressure monitor or Swan-Ganz catheter should be considered in severe cases.

Joffe MD: Burns. In Fleisher GR, Ludwig S, Henretig FM (eds): Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1521–1522.

12 What are the indications for referral to a regional burn center?

Committee on Trauma, American College of Surgeons: Resources for optimal care of the injured patient: 1999. Chicago, American College of Surgeons, 1999, p 55.

13 A 15-year-old male presents with circumoral burns consistent with frostbite injury. What should you suspect?

This boy has burns that are suspicious for inhalant abuse. Other cutaneous findings may include a rash or paint stains around the mouth and nose. Inhalation of fluorinated hydrocarbons can cause local burns to the face and upper airways. General toxicity of inhalants involves the pulmonary, central nervous, cardiac, and renal systems. Abusers are at risk for dysrhythmias and seizures. Inhalant abuse is often associated with alcohol and other drugs of abuse. Standard urine toxicology screens do not detect inhalants. Gas chromatography can occasionally be useful, but is not routinely available.

Lorenc JD: Inhalant abuse in the pediatric population: A persistent challenge. Curr Opin Pediatr 15:204–209, 2003.

14 Describe the patterns of burns commonly associated with child abuse

In addition, burns that are inconsistent with the history or are attained in a manner beyond the developmental capacities of the child deserve further investigation.

15 Name three potential causes of loss of consciousness in a fire victim

16 What are the indications for intubation of the trachea of a fire victim?

The presence of soot in the nares or carbonaceous sputum in isolation is not an indication for intubation.

17 What acute findings are common on the chest radiograph of a child with smoke inhalation?

Initial chest radiographs are usually normal. Radiographic findings lag behind physical symptoms. Chest radiographs are thus an insensitive means of determining lung injury and rarely dictate ED management. A normal chest radiograph does not exclude the presence of significant pulmonary injuries. Early findings are suggestive of severe injury. Diffuse interstitial infiltrates are consistent with significant smoke inhalation. Focal infiltrates in the first 24 hours indicate atelectasis. Bronchopneumonia as the result of smoke inhalation does not typically occur until 3–5 days after injury. Pulmonary edema typically follows aggressive fluid resuscitation and does not appear until 6–72 hours after exposure. Pneumothorax is often the result of barotrauma after intubation and positive-pressure ventilation.

Clark WR, Bonaventura M, Myers W: Smoke inhalation and airway management at a regional burn unit: 1974 to 1983. Part I. Diagnosis and consequences of smoke inhalation. J Burn Care Rehabil 10:52–62, 1989.

18 What precautions must be taken when interpreting an arterial blood gas sample from a victim of smoke inhalation?

Partial pressure of oxygen in arterial blood (PaO₂) measures only dissolved oxygen in the blood. It is unaffected by the presence of carbon monoxide. PaO₂, therefore, provides a falsely reassuring measure of oxygenation. In addition, it is important to know whether the blood gas report includes a measured or calculated oxygen saturation. A calculated oxygen saturation does not take into account the presence of carboxyhemoglobin, whereas a measured oxygen saturation does. A calculated oxygen saturation registers falsely elevated readings in the setting of carbon monoxide poisoning.

19 Describe the pathophysiologic effects of carbon monoxide toxicity

Carbon monoxide binds hemoglobin with 230 times the affinity of oxygen. The production of carboxyhemoglobin significantly reduces the oxygen-carrying capacity of blood. The binding of carbon monoxide to the hemoglobin molecule shifts the oxygen dissociation curve to the left. This shift inhibits the release of oxygen at the tissue level. Carbon monoxide also has toxic effects on the cellular level. Carbon monoxide binds cytochrome oxidase and effectively blocks cellular respiration. This blockade facilitates free radical production and disrupts mitochondrial function. The results are tissue hypoxia and metabolic acidosis.

20 How is the half-life of carboxyhemoglobin affected at different oxygen concentrations?

21 How is a pulse oximeter reading affected by the presence of carboxyhemoglobin?

The pulse oximeter essentially measures the absorption of two separate wavelengths of light. These wavelengths correspond to the peak absorption spectra of oxygenated and deoxygenated hemoglobin. Carboxyhemoglobin absorbs light at a wavelength similar to oxygenated hemoglobin and therefore does not affect the overall reading. The result is a falsely high oxygen saturation reading. Pulse oximeter readings are unreliable measures of true oxygen saturation in patients with smoke inhalation.

Bozeman WP, Myers RM, Barish RA: Confirmation of the pulse oximetry gap in carbon monoxide poisoning. Ann Emerg Med 30:608–611, 1997.

22 What are the indications for hyperbaric oxygen therapy?

The use of hyperbaric oxygen in the setting of smoke inhalation is highly controversial. Although no randomized, controlled, prospective trials in humans demonstrate reduced mortality with hyperbaric oxygen therapy, animal studies have shown improved survival with treatment after smoke inhalation. When indications for a particular patient remain unclear, further consultation should be sought from hyperbaric experts. To be considered a candidate for hyperbaric oxygen therapy, the patient must be deemed stable enough for transport. The potential benefits should outweigh the risks of transferring the patient to the chamber, especially when long distances are involved.

Juurlink DN, Buckley NA, Stanbrook MB, et al: Hyperbaric oxygen for carbon monoxide poisoning. The Cochrane Database of Systematic Reviews. CD002041, 2005.

23 What are the criteria for hyperbaric oxygen therapy?

Generally Accepted Criteria

Criteria for Consideration

Liebelt EL: Hyperbaric oxygen therapy in childhood carbon monoxide poisoning. Curr Opin Pediatr 11:259–264, 1999.

24 List the major therapeutic actions of hyperbaric oxygen

25 What is the evidence for cyanide toxicity in relation to house fires?

A study performed in France measured cyanide concentrations in blood samples obtained from fire victims by ambulance physicians at the scene. Cyanide levels were found to be significantly higher than those in one control group of patients with no fire exposure and a second control group with isolated carbon monoxide poisoning. Mean cyanide levels in fire victims declared dead at the scene were over 110 μmol/L. Mean cyanide levels in survivors were 21.6 μmol/L. Lethal cyanide levels are generally considered those exceeding 40 μmol/L.

Baud FJ, Barriot P, Toffis V, et al: Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 325:1761–1766, 1991.

26 How are cyanide levels assessed for treatment?

Treatment for cyanide poisoning is indicated in fire victims with evidence of significant smoke inhalation. Elevated lactate levels correlate with the presence of cyanide and are typically available sooner than a cyanide level.

27 What treatments are available for cyanide poisoning?

Kulig K: Cyanide antidotes and fire toxicology. N Engl J Med 325:1801–1802, 1991.

28 What is the role of steroids in the setting of smoke inhalation?

Steroids may benefit patients with acute bronchospasm due to smoke inhalation. No evidence indicates that steroids are beneficial in the acute treatment of airway edema or inflammatory processes due to smoke inhalation. Randomized trials have demonstrated an association of steroid use with worse outcomes in terms of infection and mortality.

Ruddy RM: Smoke inhalation injury. Pediatr Clin North Am 41:317–336, 1994.

29 Where do most pediatric deaths from house fires occur?

Most children (82%) die at the scene of the fire. About 7% die at a local hospital, and 11% die at a burn center.

Parker DJ, Sklar DP, Tandber D, et al: Fire fatalities among New Mexico children. Ann Emerg Med 22:517–522, 1993.

30 What is the most effective measure in reducing mortality from burns and smoke inhalation?

Anticipatory guidance and preventive care have the greatest potential to reduce deaths from burns and house fires. It is estimated that over 50% of fire-related deaths could be avoided with the proper use of smoke detectors. Over 90% of childhood deaths from fires occur in homes without properly functioning smoke detectors, and most children in house fires die from smoke inhalation rather than burns. Smoke detectors should be installed on every level of the house and tested regularly. Batteries should be replaced twice a year. Families should be educated about the planning of escape routes, evaluating fire risks in the house and in the use and storage of fire extinguishers. Careless (or any) cigarette use should be avoided. Lowering the setting on the water heater to deliver water at a maximum temperature of 120°F (48.8° C) substantially increases the time it takes for direct exposure to induce a full-thickness burn (see question 5). Boiling liquids should be placed on the back burners of the stove where they are out of the reach of young children. Children should be dressed in flame-retardant sleepwear.

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