In this section
are common in children. Burns range from minor wounds that can be managed in an
outpatient setting to moderate wounds,
requiring transfer to Paediatric Burns Unit and surgical management,
through to major wounds with associated traumatic injuries requiring retrieval
to Paediatric Intensive Care and Burns Unit.
Scald burns in young children are the most common type of burn. Most
burns are mild and can be managed in a community setting, however major burns
require prompt and high quality
management to optimise the cosmetic and functional outcome of potentially
devastating injuries. The psychosocial impact of a substantial burn can be
Burns in children are different to those in adults due to their
differences in their physical attributes, developmental abilities and emotional
An accurate assessment of a burn depth is difficult, especially
early post injury. All burn injuries should be considered part of a trauma assessment,
and non-accidental inflicted injury should be considered.
Burns are a significant cause of morbidity and mortality in
children, and a common cause for hospital admission.
Most burns occur in the home, predominantly in the kitchen. Most burns
are not very severe and are small; <10% total body surface area (TBSA). Most
hospitalisations are short (<1 day), though many burns require community
care and some for prolonged periods of time.
nearly 96, 000 children under the age of 20 were fatally injured as a result of
a fire-related burn in 2004[i]. Within all countries burn risk correlated with
socioeconomic status. Regional
differences in burns exist; in
2018 children under 5 years
of age in African Region have 2 times incidence of burn deaths than their
worldwide counterparts; boys under 5 years
of age from low-middle income countries of the Eastern Mediterranean Region are
nearly twice as likely to die from burns as similar boys from
the European Region; burn injuries requiring medical care is almost 20 times
higher in Western Pacific Region compares to the Region of the Americas[ii].
In the developing world open cooking fires are a major source of
burns; commonly hand burns. Burn injuries to hands are particularly disabling due
to impaired functionality and lack of adequate rehabilitation/assistance
devices in the developing world - even a small hand burn can affect an
individual’s ability to perform activities of daily living independently and
perform physical labour for a family’s livelihood.
The death rate in low-income and middle-income countries is eleven
times higher than that in high-income countries – 4.3 per 100 000 as compared
to 0.4 per 100 000[i].
The type and cause of paediatric burns are related to the age and
developmental stage of the child. Young children are most likely to incur a burn
injury: 70% paediatric burns occur in <5 year old children. Infants have the
highest death rates. The highest rates of hospital admission are of children
<4 years old which correlates with the period of
time children are starting to
walk, climb and explore. Three quarters of burns in children >9 years of age
are due to flame injuries. Scalds from hot (instant) noodles is increasing in
adolescents, and the death rate climbs again for 15 – 19 year olds when risk
taking behaviour increases and work related burns are introduced[iii].
Males are over represented in all age groups for burns and the
gender imbalance increases with age. From 10-14 years of age males have a sharp
increase in burn injuries from exposure to highly flammable liquid (eg petrol).
In Australia, burn
and scald injuries are especially high for infants and children <4 years of
age. Hot drinks, food, fats and
cooking oils cause more than half of the scalds in this group, with face,
trunk and arm burns being the most common sites of injury. Aboriginal
and Torres Strait Islander people have higher rates of burns in all ages
compared to other Australians, and whilst
all Australians have the highest rate of burns in less than 4 year olds
Aboriginal and Torres Strait Islander children of this age are more likely than
other Australians to be burned (174 cases per 100,000 compared
to 45 cases per 100,000
risk factors for paediatric burns include poverty, overcrowding, lack of
safety measures or adequate parental supervision including young girls being
given a household role of cooking. Children with some underlying medical conditions are also at
increased risk of burns such as epilepsy and physical or cognitive
are at risk of burns from neglect and inflicted burns as child abuse.
A burn is a thermal injury
resulting in a wound characterised by an inflammatory reaction leading
initially to local oedema from increased vascular permeability, vasodilation
and extravascular osmotic activity. It is caused by direct effect of the burn
agent on microvasculature and resultant chemical
A burn is an injury with both
local and systemic responses. There are three major types of burn: thermal,
electrical and chemical. Changes in tissue after the burn
trauma are very important. In large burns fluid loss from damaged tissue causes
decreased plasma and increased haematocrit with decreased cardiac output which
contributes to widespread cellular hypoperfusion resulting in multisystem
of coagulation – this is the primary site
of injury and the site of maximum damage. This zone comprises irreversible
tissue loss due to exposure to heat, electricity and/or chemicals.
of stasis – this surrounding zone has decreased
tissue perfusion and is a penumbra of potentially salvageable tissue. Good quality
first aid and burn resuscitation aims to reverse ischaemia and minimise the size
of this zone. Risks to increasing size include increased depth of burn, prolonged
hypotension, infection and oedema. This zone changes making initial burn
assessment difficult. The full extent of injury is only apparent after several
of hyperaemia – this outer zone comprises
and area with increased perfusion and will
recover unless there is an additional insult.
Skin loss decreases the
body’s ability to preserve heat and water and act as a barrier to prevent
infection. Resuscitation and treatment aim to correct these consequences.
Figure 1: Jackson's Burn Wound Model, 1947. (Reproduced
with permission: Figure
S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical
Once TBSA >30% a systemic
inflammatory response will occur.
The renal and hepatic systems are susceptible to dysfunction due to
resultant fluid and protein loss and a decreased blood volume. In
major burns the fluid state of the patient must be carefully managed. Adequate
and timely fluid resuscitation due to excess losses from the burn are crucial
in curbing the extent of systemic dysfunction from this mechanism. Similarly,
over resuscitation with excess fluid can have detrimental effects on
cardiorespiratory function and contribute to compartment syndrome in the limbs
and abdominal cavity.
A widespread inflammatory response also occurs as the result of a burn injury
with release of catecholamines, vasoactive mediators and inflammatory markers
which can trigger a systemic inflammatory response syndrome (SIRS) resulting in
multiple organ dysfunction syndrome (MODS).
Figure 2: Systemic response to burns
permission. (Figure 3 Hettiaratchy S, Dziewulski P. ABC of burns:
pathophysiology and types of burns British Medical Journal.
SIRS also contributes to
immunosuppression rendering a patient more susceptible to bacterial infection
and sepsis. The systemic
response worsens initial organ damage caused by shock and reduces the body’s
ability to fight infection; this leads to an increased risk of sepsis which
further triggers inflammation, immunoparesis and infection.
Following a burn injury, a hypermetabolic state ensues where catabolism
increases and anabolism decreases resulting in loss of muscle and bone mineral
density. Wound healing may also be affected. This hypermetabolic state is
sustained despite wound closure. Protein breakdown continues 6 – 9 months after
the initial burn making nutritional support to sustain lean body mass and
promote wound healing of crucial import. Bone growth can be delayed for 2 years
after a burn injury in children.
Children have thinner skin
than adults, therefore the time to burn, or the
energy required to cause a burn is less. This means that a
burn agent at any given temperature, will
cause a deeper burn, at a faster rate,
in a child compared to an adult.
Young children are at risk of hypothermia, especially during
initial cooling of the burn and from increased evaporative loss due to their
larger surface area to body mass ratio.
Children have an increased blood volume relative to their mass
therefore fluid resuscitation needs to accommodate for this: large volumes per
unit body weight are required compared to adults. Small children are more
likely to become hypoglycaemic and maintenance
fluids should incorporate glucose replacement in children
The risk of airway compromise in children following inhalation
injury is greater due to a smaller airway opening and greater risk of closure
The systemic inflammatory response in children tends to be
stronger with more vulnerability to their effects, including am increased
susceptibility to the resultant hypermetabolic state.
As children are still growing their need for skin growth and
elasticity to accommodate this growth complicate wound and scar management.
Mechanism of injury,
including circumstance for specific pattern of burn
circumstances to implicate co-existing non-burn injuries
circumstances to implicate non-accidental injury or vulnerable child
Like all traumas,
paediatric burn assessments require an initial
primary survey with the aim of identifying and managing immediate life threats:
do not be distracted by the burn injury until all
immediate life threats have been addressed. The list below indicates some of the key examination findings to look for during the primary survey. These findings may signal the presence of an immediate life threat requiring management during the primary survey. Do not neglect to apply personal protective equipment (PPE) which is especially
important to protect health care workers where the patient
has a chemical burn.
Resuscitative Fluid management in burns >10% TBSA
Patients with delayed fluid resuscitation, electrical conduction
injury and inhalation injury have higher fluid requirements. Discuss with
For burns >10% TBSA
Fluid creep refers to excessive fluid administration to
patients with burns. Adequate fluid resuscitation is a crucial part of managing
children with major burns; if provided early it restores intravascular volume
and maintains tissue perfusion both to the burn wound which avoids extension of
the injury into the zone of stasis, and to the body which evades more
widespread complications such as renal failure and reduces mortality[iv].
The Modified Parkland formula above should be used as an
initial guide to fluid resuscitation but the ongoing fluid replacement in a
child with a major burn must include regular and in-depth fluid assessment
beyond the urine output alone. If a child with a major burn is overhydrated it
can lead to the development of systemic interstitial oedema which independently
cause complications such as limb ischaemia from increased limb compartment
pressures, renal failure from intra-abdominal compartment syndrome and
respiratory failure from airway swelling and trauma.
To avoid fluid creep, avoid over estimation of TBSA,
include all resuscitation fluids received by patient when calculating the
appropriate resuscitation volume. If the fluid volumes appear greater than the
predicted requirements from the modified Parkland formula alternative causes
should be sought and managed. A fluid assessment of a patient with major burns
includes not only the urine output but clinical fluid examination, biochemical
markers, ventilatory parameters and end organ perfusion markers.
Fully expose the patient in order to assess the extent of injury in terms of:
Check the patient's temperature (it is easy for small children to become hypothermic after cooling). The principle is to keep the patient warm, but the burn cool. The 20 mins of cool running water during first aid can be split into shorter sessions, with warming of the patient in between, as long as all the cooling occurs within the first 3 hours.
with permission. (Appendix
– Management of a paediatric burn patient within the Pegg Leditschke Children’s
Burns Centre. Children’s
Health Queensland Hospital and Health Service[vii]).
Especially in motor vehicle crashes, blasts/explosions, electrical
injuries or jumps/falls from significant heights.
alternate diagnosis: scald burn mimics
Consider non-accidental injury (see
Like all traumas paediatric burn injuries require recognition
and management of all injuries following the primary and secondary survey.
First aid, Analgesia, Clean, Assess, Dress, Elevate
there is anticipated delay or time until definitive care, consider use of
multiple layer non-adhesive paraffin antiseptic dressing.
white soft paraffin twice daily after cleaning face
ointment to eye and ear burns
burns are at risk of contamination – after bowel action, area should be
cleaned with soapy solution; consider catheterisation; 4% chlorhexidine skin
not require dressing
covering with protective, low-adherent dressing for comfort
Dressing product used depends on the expected
duration required before removal or wound review
- for small, superficial partial thickness burn
wounds use a low adherent dressing then crepe bandage/tape
- for more extensive or deeper partial thickness
burn wounds use a low adherent silver dressing then crepe bandage.
wounds should heal by regeneration within 2 weeks and need only cleaning,
dressing and review to optimise healing. If a burn has not healed within 2
weeks it should be referred for assessment and may require surgery.
partial thickness or full thickness burns are likely to require operative
management which includes excision of the deep burn and skin grafting within
5-10 days to expedite healing and minimise scarring. Sometimes artificial
dermis is used as a bridge to skin grafting. Skin grafts can be autografts or allografts.
Grafting consists of 4 steps
For large burns multiple operations may be
required to complete the grafting process.
Elevate part of limb distal to
burn to minimise swelling and oedema. Assess and monitor for neurovascular compromise of tissue distal
to the burn; escharotomy may be
Elevate the limb and monitor perfusion distal to burn.
Hand burns in children are common
due to the inquisitive nature of children and their developing motor skills.
Assessment and management of hand burns in children are as above. Special priority
must be given to early active rehabilitation to optimise hand function. See
Exercise equipment is becoming commonplace in homes. Children
should not have access to treadmills at any time: switch off power at wall and
unplug, keep behind closed toddler gate or locked door. A friction injury
caused by a treadmill is a type of burn, which should be assessed and treated
as a burn. Friction injuries from treadmills are commonly on children’s hands
and cause serious burns often requiring surgical intervention and lengthy
Nurse head up to reduce swelling and oedema.
Signs of ocular burns include
blepharospasm, tearing and conjunctivitis. All facial burns should have
ophthalmological assessment including visual acuity, external ocular exam and Fluorescein
2% eye drops to assess for corneal damage. Full thickness facial burns propose
high risk of ocular damage.
Both thermal and
chemical corneal burns threaten vision; alkalis penetrate deeper and have greater
potential for serious and delayed burns.
Treat all ocular chemical burns with
copious irrigation using 0.9% NaCl as soon as possible. Ensure the
unaffected eye is uppermost during irrigation of effected eye to avoid further
contamination. Use topical anaesthetic on effected eye for
analgesia and to aid tolerance of irrigation.
Use topical Chloramphenicol to prevent
Urgent paediatric ophthalmology review is
required to for:
Degree of injury is related to the voltage of the electrical
source. Electrical injuries can be associated with other injuries: consider
spinal precautions. Electrical injuries can also cause cardiac dysrhythmias -
consider 24 hours ECG monitoring. Monitor and manage elevated CK, urine haemoglobin/myoglobin
and haemochromogen. Monitor for
with permission. Clinical Guideline, Statewide
Burn Injury Service – NSW Burns transfer guidelines (4th edition) Page 12
Electrical burns: table Overview of electrical injuries © Copyright -
Agency for Clinical Innovation 2020[viii]
injury: labial artery erosion
Children can suck on or chew through power cords, or can chew on
damaged/frayed power cords, resulting in an electrical burn. Even low voltage
electrical burns can be serious causing deep injury with muscle tendon and
vessel involvement. Electrical burns occurring at the edge of the mouth can be
associated with acute or delayed (up to 21 days) labial artery involvement and
Chemical burns are
caused by caustic agents:
First aid of chemical burns with
irrigation of cool running water is extremely important and is often forgotten. Personal
protective equipment for first aid givers should be worn (gloves, mask, gown,
eye protection. Ensure contaminated clothing is removed and brush any powdered
agent off skin onto a collection sheet to be disposed of appropriately.
Irrigate from the top of the wound down to the floor with
appropriate drainage so contaminated water does not cause further injury.
Consider systemic symptoms from metabolic and electrolyte
disturbance from absorbed agent.
agents are found in everyday households eg toilet cleaner, bathroom cleaner,
hair products, laundry and dishwasher detergents, batteries, drain and oven
cleaners. Ingestion of caustic agents can lead to oesophageal burns, strictures
and perforation. Children with significant injury may have no-mild symptoms
only. Symptoms include dysphagia, drooling, chest/abdominal pain, refusal to
eat, respiratory compromise. The injury tends to worsen over time.
Consider if prophylaxis with vaccination or tetanus immunoglobulin
These occur with flame burns in
enclosed spaces. Direct inspection of the oropharynx should be performed on
arrival and consideration of early intubation by an experienced airway specialist.
Inhaled smoke is cool upon
reaching the lungs but products of combustion are irritating leading to
bronchospasm, inflammation and swelling. This predisposes an individual to
atelectasis and pneumonia, and can be worse in asthmatics. Patients may require
non-invasive positive pressure ventilation or invasive ventilation and airway
If suspicion of associated Carbon
monoxide (CO) poisoning or cyanide poisoning liaise early with Paediatric Burn
Unit, Critical Care and Poisons Information (Tel: 131126).
Carbon monoxide is a toxic gas
inhaled during a fire, such as a patient enclosed in a house fire. Carbon
monoxide binds very strongly to haemoglobin and intracellular proteins
contributing to intracellular and extracellular hypoxia. Toxicity is dose
dependant involving no or few symptoms through to cardiovascular compromise
with seizures and death[ix].
Pulse oximetry cannot differentiate between haemoglobin and
carboxyhaemaglobin so will not read low even when a patient is hypoxic. Blood
gas will show metabolic acidosis and raised carboxyhaemaglobin. These patients
require 100% oxygen and may require ventilation. Unborn foetus can be affected
by toxicity: specifically discuss care of pregnant women with specialist teams.
is a potentially lethal toxic poison that is produced in gaseous form from burning natural and synthetic fibres such as plastics and
wools such as occurs in in domestic/industrial fires. Cyanide poisoning occurs
from inhalation of this gas and often occurs with carbon monoxide poisoning. Toxicity
is dose dependant and incudes multisystem involvement[ii].
Initial symptoms include:
More severe symptoms include end organ damage
form anaerobic metabolism with associated hypotension, bradycardia and
cardiovascular collapse, respiratory depression and reduced GCS.
Blood gas will show metabolic
acidosis with high lactate, serum level cyanide should be taken.
Treatment includes ABC resuscitation, high
flow oxygen and administration of antidote hydroxocobalamin then sodium thiosulfate.
Frostbite is a type of burn
injury to the skin and underlying tissues by freezing. It most commonly effects
the extremities and can be divided into superficial or deep. It can occur
through exposure to cold-weather conditions or direct contact with cold ice,
liquid or metal. Minor frostbite injuries can be managed with simple first aid
involving analgesia and rewarming followed by simple wound care. More serious
injuries may require review with a burns service for more intensive wound care
Non-accidental burn injuries can occur in the setting of neglect
or physical abuse. Inflicted burn injuries are under recognised; it is
difficult to estimate the incidence. They effect children of all ages and incur
significant mortality and morbidity[iii].
features on history
Scalds are the most commonly inflicted burn injury. Certain
locations or patterns of burn are more suspicious for an abusive cause:
concerning for inflicted injury
to do if you are concerned a burn injury was caused by neglect or abuse
Consider consultation with local paediatric team when
Child requiring care beyond
the comfort level of the hospital
Minor burns may be discharged at initial presentation and referred
to outpatient burns follow up of local service with 1-2 visits per week
Moderate or large burns or patients with multiple injuries will
have required in patient admission or transfer to a Paediatric Burns Unit and
may require Paediatric Intensive Care. As part of acute care – once discharged
will require multiple follow up appointments as an outpatient.
The ability of a family to provide adequate care for a child with
a burn and attend appointments should be taken into account when deciding the
child’s disposition. These include geographical isolation and concern for
social welfare of child; delayed presentation, suspicion of non-accidental
injury or concern family will not care for wound or attend appointments.
evolve over time. Consider a follow up within 3 days of initial presentation to
reassess depth, monitor healing and determine ongoing management. On
reassessment referral to Paediatric Burn Unit is necessary:
The type of care a child requires depends on the type, depth and
extent of burn, involvement of burn in special areas premorbid health,
additional injuries and psychosocial situation (eg concern of neglect or non-accidental
injury). A multidisciplinary team is required.
The burn wound dressing will depend on the type and severity of
the burn wound.
Principles of burn wound management
Daily dressing change is not advised. Timing of dressing changes
depends on the product used. Dressing advice can be obtained from your local
Paediatric Burns Unit.
Many burn dressings are available. Dressing choice will depend on
what is stocked at your local service. Below is an example of a safe and
effective initial dressing.
Primary Dressing/Contact Layer
Application of silver dressing as per local methods. A typical
burn dressing may include 7 day Acticoat (alternatives include 3 day Acticoat,
Mepliex Ag, Aquacell Ag).
Provides a final layer to absorb exudate and secure primary
dressing/contact layer in place (Melolin, Hyperfix).
Pain management is an important part of paediatric burn care –
uncontrolled stress and pain contribute to poor healing. All procedures should
be performed with adequate sedation and analgesia. Multimodal analgesia is
often necessary to achieve adequate analgesia. Consult local pain service for
advice or opioid infusions/patient controlled analgesia as required for in
patients with severe burns. For minor burns including those managed in the
community consider nitrous oxide or intranasal fentanyl during burn review and
dressing changes. Consider additional analgesia requirements for children who
have had previous distress during dressing changes or ongoing anxiety.
Utilisation of child life therapy, music therapy teams and non-pharmaceutical
distractions (eg iPad, breast feeding, reading, limiting child’s ability to
watch wound care) should complement chemical analgesia and sedation.
Standard infection control measures apply to children with burn
Burns >10% TBSA require additional infection control measures
which aim to limit child’s exposure to bacteria via isolation and limiting
transmission via contact – follow local Paediatric Burns Unit infection
Nutrition is an important part of burns care. Children have an
increased metabolic requirement, and increased nutritional requirement for
growth, limited energy reserve and an increased body surface area to mass ratio
compared to adults.
Children who are unable to drink due to facial burns or other
injuries or medical issues should have a nasogastric tube inserted and commence
enteral feeds. A dietician should be involved to ensure adequate nutrition is
met including an assessment of increased macronutrient and micronutrient
requirement (consider supplementation vitamin A, vitamin C and zinc to promote
wound healing). Regular weight measurements aid assessment of adequate
In burns >15% TBSA NGT feeds should be commenced within 6 hours
of the burn.
Burn areas should be elevated to limit oedema (monitor for
compromise of peripheral circulation). When a burn crosses a joint, joint
should be positioned to maintain optimal functional range of movement with
consultation with occupational therapy and physiotherapy team.
Healing wounds are often itchy. Non sedating antihistamines are a
safe option for symptomatic management.
Circumferential burns inhibit lymphatic drainage and venous return
resulting in oedema which may take 1-2 weeks to resolve. Elevation of the area
will limit amount of oedema and accelerate resolution of oedema and minimise
Fever is a common reaction to hypermetabolic state and immune
response following a burn injury however the child must be assessed for other
causes. Prophylactic antibiotics are not recommended in burns.
If there is concern the burn wound is infected send a swab for MCS
and treat with empiric antibiotics as per local guidelines.
Toxic shock syndrome (TSS) is a rare complication of an infected
burn and can be life threatening.
Treatment includes active resuscitation with IV fluids, IV antibiotics
and urgent paediatric and burns specialty care.
The consequences of a child sustaining a burn can be profound on
the child and their family’s psychological,
emotional, social and financial wellbeing. Children have evolving development
with different physical, cognitive and emotional abilities. Children are
dependent on carers and of children presenting with burn injuries a significant
portion are vulnerable children. Treating a child with a significant burn
injury can involve multiple invasive frightening procedures, protracted
treatments and regular engagement with a health facility. Treatment compliance
is important to achieve the best outcome possible. Caring for the child includes support for
family members which includes multidisciplinary team approach noting a family’s
needs may change from acute care to rehabilitation and the child’s transition
back to community and school.
Depending on the size and site burn injuries can be associated
with a significant risk of limited functioning. Appropriate burn care includes
optimising function after a burn to achieve the best possible outcome.
Some burns may require review by occupational therapy or
physiotherapy team, including:
Ongoing OT requirement may be
necessary to optimise patient function and minimise risk of irreversible complication such as contracture and
Rehabilitation is a long and
and will commence as early as possible (often in hospital) and continue at home
with community supports. Therapy may involve a comprehensive plan including
passive and active exercises as well as resting splints. Patients and their family
are required to take on responsibility for and play an active part in ongoing
Pressure dressings are utilised to minimise scarring post burn.
Therapists may tailor pressure garments unique to the patient’s requirements and provide exercises to
optimise a patient’s functional outcome.
Skin is altered after a burn and
requires regular moisturising to prevent cracking and breaking down which can
lead to secondary infection.
Most burns managed well initially will not require reconstruction.
Sometimes burn reconstruction will be recommended to optimise comfort, function
and appearance. This occurs many months
after the initial burn.
[i] World Health
and Burns, 2004.
[ii] World Health
Organisation, Burns, 2018.
Institute of Health and Welfare, Burns and Scalds.
[iv] AIHW: Pointer S
& Tovell A 2016. Hospitalised burn injuries, Australia, 2013–14. Injury research
and statistics series no. 102. Cat. no. INJCAT 178. Canberra: AIHW.
[v] Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004; 328(7453): 1427–1429.
[iv] Rogers AD, Karpelowsky K, Millar AJW, Argent A, Rode H. Fluid Creep in Major Pediatric Burns European Journal of Pediatric Surgery 2010; 20(2): 133-138.
[vii] CHQ-GDL-06003 – Management of a paediatric burn patient within the Pegg Leditschke Children’s Burns Centre. Children’s Health Queensland Hospital and Health Service.
[viii] Clinical Guideline, Statewide Burn Injury Service – NSW Burns transfer guidelines (4th edition). Page 12 Electrical burns: table Overview of electrical injuries
[ix] Life in the Fast Lane. Carbon Monoxide Inhalation [online]. Dr Neil Long, last update August 25, 2019. Viewed 13th May 2020. https://litfl.com/carbon-monoxide-inhalation/
[x] Life in the Fast Lane. Cyanide Poisoning [online]. Dr Chris Nickson, last update April 2, 2019. Viewed 13th May 2020. https://litfl.com/cyanide-poisoning-ccc/
[xi] Victorian Forensic Paediatric Medicine Service. Burns Including Scald Burns [online]. Viewed 20th April 2020. https://www.rch.org.au/vfpms/guidelines/Burns_including_scald_burns/