See also

Burns - Post Acute Care and Dressings

Key Points

1. Burn injuries should be managed as a Trauma case requiring primary and secondary survey
2. Accurate Total Body Surface Area (TBSA) estimation is essential for fluid resuscitation decision making. TBSA does not include epidermal burns
3. Ensure adequate analgesia to facilitate assessment and patient comfort
4. Appropriately consented photographs of the burn are very helpful for assessment and monitoring

Background

Specific features in children with burns

• Children have thinner skin than adults, predisposing them to a deeper burn for any given temperature
• Assessment of burn depth is difficult, especially early post injury
• Young children are at risk of hypothermia, especially during initial cooling of the burn

Burns are described as epidermal, dermal (superficial/mid/deep) and full thickness

Assessment

History of burn

• Time of injury
• Mechanism of injury, including circumstance for specific pattern of burn
• Scald: estimated temperature and nature of the liquid
• Contact: estimated temperature and nature of the surface
• Friction
• Flame / explosion: product that burned/exploded, location (enclosed vs. open space); duration of exposure, inhalation injury
• Electrical: voltage, type of current (AC or DC), duration of contact
• Chemical: type of product
• Cold: direct contact with cold surface or exposure (frostbite)
• Radiant: sunburn
• First aid
• Time started (was it within 3 hours and maintained)
• Agents used
• If clothes and jewellery were removed
• Decontamination method (for chemical exposure)
• Consider co-existing non-burn injuries
• Consider non-accidental injury or vulnerable child
• Tetanus status

Examination and initial management

Like all traumas paediatric burn assessments require a primary and secondary survey with the initial aim of identifying and managing immediate life threats: do not get distracted by the burn injury.

Airway

• Signs of airway burn/inhalation injury: stridor, hoarseness, black sputum, respiratory distress, singed nasal hairs or facial swelling
• Sign of oropharyngeal burn: soot in mouth, intraoral oedema and erythema
• Significant neck burn
• If above present, consider early intubation
• If suspicion of airway burns or carbon monoxide intoxication apply high flow oxygen
• Protect the cervical spine with immobilisation if there is associated trauma

Breathing

• Full thickness and/or circumferential chest burns may require escharotomy to permit chest expansion

Circulation

• If early shock is present, consider causes other than the burn
• IV fluid resuscitation as required
• IV or IO access (preferably 2 points of access)
• For circumferential burns check peripheral perfusion and need for escharotomy

Disability

• If altered conscious state, consider airway support
• Assess neurovascular status if limb involved

Exposure - burn assessment and initial management

• Assessment of burn depth
• Burns are dynamic wounds, it is difficult to accurately estimate the true depth and extent of the wound in the first 48-72 hours
• Do NOT include area with epidermal burn (erythema only)

• Assessment of TBSA
• Expose whole body - remove clothing and log roll to visualise posterior surfaces
• Use Lund & Browder Chart

 

• The palmar surface of the child’s hand (including fingers) represents approximately 1% TBSA and can be used to approximate TBSA

 

• First aid
• Remove jewellery and clothing in contact with burn source
• Cool affected area as soon as possible (within 3 hours from time of burn) for 20 minutes with cool running water
• If unavailable, other options include: frequently changed cold water compresses, immersion in a basin, irrigation via an open giving set
• Never apply ice and avoid use of hydrogel burn products
• Cover burn with plastic cling film lengthways along the burn (do not wrap circumferentially)
• Do not apply plastic cling film to face (use paraffin ointment)
• Do not apply plastic cling film to a chemical burn
• Discuss chemical burn decontamination with Poisons Information (Tel: 131126)
• Appropriately consented photos of burns prior to dressings are useful for ongoing management
• Prevent hypothermia
• Remove wet clothes/dressings after initial cooling
• Try to keep child otherwise warm
• Cover the wound and the child after assessment
• When possible, warm intravenous fluids and the room

Fluid management in burns ≥10% TBSA

The goal is management of burns shock, through optimal replacement of fluid losses to maximise wound and body perfusion, and minimise wound and body oedema and associated adverse effects 

• Calculate requirements from time of the burn, not time of presentation
• Calculate fluid volume using Modified Parkland Formula (see below)
• Hartmann’s Solution is the fluid of choice - if unavailable, use 0.9% sodium chloride
• Insert urinary catheter for strict fluid balance
• Keep nil by mouth and consider nasogastric tube - gastric ileus is a potential complication  

Modified Parkland Formula

Patients with delayed fluid resuscitation, electrical conduction injury and inhalation injury have higher fluid requirements. Discuss with specialist team

Analgesia

• Especially during cooling, dressing and mobilisation. See Acute Pain Management
• Appropriate initial choices include intranasal fentanyl or IV morphine

Initial investigations

Burn wound management

FACADE = First aid, Analgesia, Clean, Assess, Dress, Elevate

General burn management             

• Limit debridement to wiping away clearly loose/blistered skin
• De-roof blisters with moist gauze or forceps and scissors if >5mm or crossing joints. See blister management
• Clean burn wound and surrounding surface with saline or water
• Reassess burn, take photos with appropriate consent
• Apply appropriate occlusive non-adherent dressing. If these products are not available, refer to local Burns service for alternative options
• If there is anticipated delay or time until definitive care, consider use of multiple layer Bactigras^TM

 Consider consultation with local paediatric team when

• Suspected non-accidental injury, self-inflicted burns or assault
• Multiple co-morbidities
• Concern regarding ability to care for burns at home

Consider transfer when

Child requiring care beyond the comfort level of the hospital
Following burns:

• >10% TBSA
• All full thickness
• Special areas: face, ears, eyes, neck, hands, feet, genitalia, perineum or a major joint, even if <10%
• Circumferential
• Chemical
• Electrical
• Associated with trauma and/or spinal cord injury
• All inhalation/airway
• Children <12 months

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Special considerations

Chemical burns

• Personal protective equipment for first aid givers should be worn (gloves, mask, gown, eye protection)
• Remove contaminated clothing
• Brush powdered agent off skin
• Areas in contact with chemical should be irrigated with cool water
• Irrigate to floor with appropriate drainage so contaminated water does not cause further injury

Tetanus prone wounds

• see Management of tetanus-prone wounds

Parent information

Burns – medical treatment
Burns – prevention and first aid
Burns – rehabilitation

Additional notes

See individual State Burns and Trauma clinical information and mobile phone applications

Last updated June 2020