Burn injuries

see also:

• Burns – Acute Management (Clinical Practice Guideline)
• Burns – Post Acute Care and Dressings (Clinical Practice Guideline)
• Burns unit – Clinical information

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 – it does not include epidermal burn
3. Optimal fluid resuscitation is crucial – inadequate resuscitation contributes to intravascular hypovolaemia and organ failure; excessive resuscitation contributes to fluid creep with extension of the burn wound and systemic oedema causing cardiorespiratory compromise, intra-abdominal and limb compartment syndrome 
4. Managing pain and preventing complications are an important part of burn assessment and patient care
5. Close supervision of children at all times will help prevent burns
6. Some minor burns will be able to be managed at non- Paediatric Burn Unit centres; some burns will require acute management then referral or retrieval to local Paediatric Burns Unit
7. Burn management requires multidisciplinary approach including psychosocial care which addresses the significant impact a burn can have on a child and their family   

Background

Burns 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 significant.

Burns in children are different to those in adults due to their differences in their physical attributes, developmental abilities and emotional maturity.

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. 

Epidemiology

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.

Globally, 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 population)^[iv].

Other 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 disabilities. Children are at risk of burns from neglect and inflicted burns as child abuse.

Pathophysiology

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 inflammatory mediators.

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 damage.

Local response

Zone 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.

Zone 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 days.

Zone 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 2 Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004;328(7453):1427–1429Ds).

Systemic response

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      

Reproduced with permission. (Figure 3 Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns British Medical Journal. 2004;328(7453):1427–1429^[v]). 

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.

How children are different to adults

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 <20kgs.

The risk of airway compromise in children following inhalation injury is greater due to a smaller airway opening and greater risk of closure from oedema.

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.

Assessment: History of burn

Time of injury

Mechanism of injury, including circumstance for specific pattern of burn

• Scald: estimate temperature and ask about the nature of the liquid 
  • Recently boiled water?: likely to be close to 100 degrees Celsius,
  • Hot drink with milk?: likely to be a cooler than recently boiled water
  • A solute in the liquid?: eg boiled rice – raises the temperature of liquid
  • Viscous liquid? more viscous fluids result in more severe burns as they remain in contact with skin for longer 
    • Common causes include scalds from hot drinks(tea/coffee), kettles, bath, noodles
• Contact: estimated temperature and nature of the surface
  • Common causes include irons, hair straighteners, exhausts, campfires, metal clips on car seats
• Radiant:
  • Common causes include sunburn - this may be associated with neglect.  Some burns sustained during house fires or bush fires can be due to radiant heat.
• Friction:
  • Common causes include falling on, or touching, moving treadmills, or road rash after a motor vehicle crash
• Flame / explosion:
  • ask about the product that burned/exploded: to predict temperature and predict secondary effects
  • ask about the location where the patient was exposed: indoor flame injuries are more likely associated with inhalation injury as compared to those in open spaces; indoor explosions may be associated with greater traumatic injuries
  • ask about the duration of exposure: to predict extent of burn
    • Common causes include flash burns after pouring accelerants (kerosene, petrol) onto BBQ's / bonfires, as well as in house fires
• Electrical:
  • Low voltage (<1000V - typically domestic), high voltage (>1000V - often industrial) and lightening have different patterns of injury and complications
  • Type of current: alternating current (AC) or direct current (DC).   DC typically provides a single convulsion or contraction usually propelling person away from source, whereas AC causes repeated convulsions and cardiac arrhythmias such as VF and is considered more dangerous; a larger magnitude of DC is required to cause injury than AC
    • Was there a flash or arcing: more likely to cover a large surface area and be more superficial, time and duration of contact: to predict severity of burn
      • Common cause include young children chewing on electrical cords
• Chemical:
  • ask about the type of product: to predict extent of burn and secondary effects (alkali vs acid burns)
  • look at clothing for stain colour 
•  Cold:
  • direct contact with cold surface or exposure (frostbite)
• Inhalation:
  • common causes include inhalation of hot gases during a house fire, or flame burns to the face.  May be of greater consequence if they have occurred in enclosed space

First aid

• Time started (was it within 3 hours)
• Agents used - cool running water vs less effective agents (standing water, cold compress, ice, home remedies)
• Duration - was it at least 20mins of cool running water?
• If clothes and jewelry were removed
• Decontamination method (for chemical exposure)
  

Any circumstances to implicate co-existing non-burn injuries

Any circumstances to implicate non-accidental injury or vulnerable child

Tetanus status

Assessment: Primary survey

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.

Airway

Examination

• Signs of airway burn/inhalation injury: stridor, hoarseness, black sputum or respiratory distress, singed nasal hairs or facial swelling
• Sign of oropharyngeal burn: presence of soot in mouth, intraoral oedema and erythema
• Significant neck burn

Management

• If suspicion of airway burns apply high flow oxygen
• If above present, consider early intubation by an experienced airway specialist
• Protect the cervical spine with cervical spine motion restriction if there is associated trauma

Breathing

Examination

• Signs of inhalation injury as above
• Full thickness and/or circumferential chest burns 
• Tension pneumothorax secondary to an explosion / associated trauma

Management

• Decompress tension pneumothorax (see: Management of traumatic pneumothorax and haemothorax / Thoracostomy and chest drain insertion in paediatric trauma)
• Full thickness/circumferential chest burns may require escharotomy to permit chest expansion

Circulation

Examination

• If early shock is present, consider causes other than the burn
  
• For circumferential burns check peripheral perfusion (and need for escharotomy)

Management

• IV or IO access (preferably 2 points of access)
• Consider IV fluid resuscitation  

Resuscitative Fluid management in burns >10% TBSA

• This is required to compensate for excess fluid losses in the first 24 hours after burn
• Calculate requirements from time of the burn, not time of presentation
• Calculate fluid volume using Modified Parkland Formula (MPF) (below)
• Hartmann’s Solution is the fluid of choice - if unavailable, use 0.9% N saline
• Glucose in maintenance fluid is required for children <20kgs

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

For burns >10% TBSA

• In dwelling catheter (IDC) is recommended to monitor urine output
• Nasogastric tube (NGT) is recommended with nil by mouth state to manage an initial gastroparesis associated with burns and later to ensure adequate caloric intake in the coming days 

Fluid creep

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.

Disability

• Neurological state: GCS and pupillary response
• If suspicion of carbon monoxide poisoning apply high flow oxygen
• Neurovascular status if limb involved (asses with doppler ultrasound if necessary) – requires elevation of the effected limb and hourly neurovascular observations

Exposure

Fully expose the patient in order to assess the extent of injury in terms of:

1. the percentage of Total Body Surface Area (TBSA) that is affected by the burn and 
2. the burn depth 

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.

Assessment of TBSA

• Expose whole body - remove clothing and log roll to visualise posterior surfaces 
• Keep patient warm
• Estimate burn area with the Lund & Browder Chart
• Do NOT include area with epidermal burn (erythema only)
  
• TBSA determines need and volume of fluid resuscitation, hospital admission and transfer to Paediatric Burns Unit
   
  

Reproduced with permission.  (Appendix 1.  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^[vii]). 

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
  
• Burns are described as epidermal, dermal (superficial/mid/deep) and full thickness
• Speed of capillary refill is a good indicator of burn depth, although burn wound evolution results in increasing depth therefore examination can change over time
• Most burn wounds are not a homogenous depth 

Assessment: Other considerations

Consider co-existing injuries

Especially in motor vehicle crashes, blasts/explosions, electrical injuries or jumps/falls from significant heights.

Consider alternate diagnosis: scald burn mimics

• Staphylococcal Scalded Skin Syndrome
• Blistering distal dactylitis – caused by group A strep
• Stevens Johnson Syndrome/Toxic Epidermal Necrolysis – follows medication use
• Hair tourniquet – distal erythema and swelling can mimic a peripheral burn

Consider non-accidental injury (see below)

Burn Wound Management

Like all traumas paediatric burn injuries require recognition and management of all injuries following the primary and secondary survey.

Acute management of superficial burns with erythema only

• Can be treated without dressing
• Infants who show a tendency to blister or scratch, a protective, low-adherent dressing with crepe bandage may be helpful.

Acute management of minor burns (isolated, <10% TBSA)

• Analgesia may be required for assessment and initial dressings
• Consider sling and splinting for more extensive upper limb burns
• Dressings that can remain in situ for 3-7 days are recommended for partial thickness burns
• The depth of a partial thickness burn may only be declared after 7-10 days
• De-roof/debride if blister is large or overlying a joint

Acute Management of major burns (>10% TBSA) or complex burns

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

First aid

• Remove jewelry and clothing in contact with burn source
• Do not remove bitumen stuck to a burn
• Cool affected area as soon as possible (within 3 hours from time of burn) for a total of 20 minutes with cool running water
  • If cool running water is unavailable, other options include: frequently changed cold water compresses/towels, immersion in a basin, irrigation via an open giving set
  • Never apply ice and avoid use of hydrogel burn products
  • Do not use butter, sugar, oil, toothpaste, potato, egg white or other traditional remedies
• Prevent hypothermia: cool the burn not the child
  • Remove wet clothes/dressings after initial cooling
  • Try to keep child otherwise warm
  • Cover the wound and the child after assessment
  • When possible, warm the intravenous fluids and the room
• Cover burn with plastic cling film lengthways along the burn (do not wrap circumferentially) - this helps maintain burn wound moisture and protect exposed nerve endings which contributes to pain management
  • 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 should accompany a referral if possible

Analgesia

• Burns are painful and often require strong analgesia: appropriate initial choices include intranasal fentanyl or IV morphine
• Utilise multimodal analgesia including cooling, cling film, parental presence/support to alleviate anxiety and distraction
• Analgesia is required especially during cooling, dressing and mobilisation

Clean

• Limit debridement to wiping away clearly loose/blistered skin
• De-roof blister (with moist gauze or forceps and scissors) if >5mm or crossing joints
• Clean burn wound and surrounding surface with saline or water or 0.1% Aqueous Chlorhexidine on gauze (flannel if no gauze)
• Pat dry

Assess

• Assessment of burn injury TBSA and depth as above  
• Take photos with appropriate consent

Dress

• 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 non-adhesive paraffin antiseptic dressing.

Elevate

• Elevate burn by positioning and adjuncts (pillows, towels, slings)
• Elevation aids management of oedema to minimise poor tissue perfusion and improve wound healing
• Do not apply tight circumferential bandages
• Elastic compression is helpful (Tubigrip)
• Encourage functional activity of effected body part

Operative management

Superficial 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.

Deep 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

1. The removal of injured tissue
2. Selection of a donor site, an area from which healthy skin is removed and used as cover for the cleaned burned area
3. Harvesting, where the graft is removed from the donor site
4. Placing and securing the skin graft over the surgically-cleaned wound so it can heal

For large burns multiple operations may be required to complete the grafting process.

 Investigations 

Special considerations

Circumferential deep burn (deep dermal or full thickness)

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 required.

Limb burns

Elevate the limb and monitor perfusion distal to burn.

Hand 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 Rehabilitation below.

Treadmill injury

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 rehabilitation.

Head and neck burns

Nurse head up to reduce swelling and oedema.

Ocular burns

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.

• Irrigate until all chemical/alkali washed out (test with pH strip prior and post)
• Up to 1 hour with acidic contamination
• Up to 2 hours with alkaline contamination

Use topical Chloramphenicol to prevent secondary infection.

Urgent paediatric ophthalmology review is required to for:

• All ocular burns
• Full thickness eye lid burns
• Facial burns with inability to close eyelids

Electrical injuries

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 compartment syndrome. 

Reproduced 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]

Electrical 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 significant haemorrhage.

Chemical burns

Chemical burns are caused by caustic agents:

• Acids cause coagulative necrosis of the superficial tissue eg toilet cleaner
• Bases cause liquefactive necrosis and have a higher capacity for injury, including deep to the initial wound and ongoing injury process despite removal of base eg laundry detergent
• Organic solutions cause injury by dissolving the lipid membrane
• Inorganic solutions cause injury by tissue denaturation

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.

Chemical burn: oesophageal injury

Many harmful 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.

Tetanus prone wounds

Consider if prophylaxis with vaccination or tetanus immunoglobulin is required.

Inhalation injury

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 toileting.

Carbon monoxide and cyanide poisoning

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].

Symptoms include:

• Gastrointestinal: nausea,
• Respiratory: dyspnoea, respiratory failure
• Cardiac: syncope, cardiovascular compromise with myocardial ischaemia
• Neurological: dizziness, vertigo, ataxia, visual disturbances, headache, confusion and decreased conscious, seizures

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.

Cyanide 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:

• Gastrointestinal: nausea, vomiting
• Respiratory: tachypnoea, dyspnoea
• Cardiac: tachycardia, hypertension
• Neurological: headache, decreased conscious state, seizures

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

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 management.

Non-Accidental Injury

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].

Concerning features on history

• Inadequate supervision
• Delayed presentation
• Changing mechanism
• History that is incompatible with age/development of child and injury
• Mechanism that is incompatible with injury

Scalds are the most commonly inflicted burn injury. Certain locations or patterns of burn are more suspicious for an abusive cause:

• Hands
• Feet
• Genitals
• Buttocks 

Burns concerning for inflicted injury

Submersion burns

• Circumferential
• Symmetrical
• Uniform depth
• No splash marks/satellite burns
• Buttocks, perineum, extremities
• Sparing on buttock cheeks “donut sign” (held down on bath), in flexures (groin, knees) and abdominal creases (as trunk is flexed forward when child tries to protect them self)
• Glove and stocking distribution for limb submersion

Contact burn

• Very young child
• Patterned burn >1 lesion
  • Cigarette burn: clustered, sharply demarcated, ~1cm punched out, deep, circular, hands and feet
  • Iron
  • Lighter – classic “smiley face” patterned burn
• Trunk or buttock
• Bilateral foot sole burns from being held on hot pavement

What to do if you are concerned a burn injury was caused by neglect or abuse

• Take clear photographs with consent for the patient’s medical record ensuring you capture the edges of all burns and presence/absence satellite lesions, clearly document age of the burn as child protection can use burn healing to help ascertain the cause and timing of the injury (consider image with tape measure if available for sizing)
• Report suspected abuse to Department of Health and Human Services
• Consider a “scene investigation” – a formal assessment of the scene of injury performed by Police or Child Protection to provide valuable information regarding the environment where the injury occurred
• Carefully assess the child for other evidence of inflicted injury (bruising, fractures, abusive head trauma, injuries from shaking/impact)
• Consider referral to local paediatric forensic service

Consider consultation with local paediatric team when

• Suspected non accidental injury, self-inflicted burns or assault
• Multiple co-morbidities
• Concern regarding social situation or dressing compliance

Consider transfer to a Paediatric Burn Unit when

Child requiring care beyond the comfort level of the hospital

Following burns:

• >10% TBSA
• All full thickness burns
• 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

Discharging a patient with a burn wound

Minor burns may be discharged at initial presentation and referred to outpatient burns follow up of local service with 1-2 visits per week initially.

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.

Follow up

Burns can 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:

• Depth is unclear after 3 - 5 days
• Slow to heal – poor progression at 5-7 days

Post Acute Care of Burns

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.

Burn Dressings

The burn wound dressing will depend on the type and severity of the burn wound. 

Principles of burn wound management

• Relieve pain
• Maintain a moist wound environment
• Keep wound clean
• Prevent/minimise infection

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).

Secondary Dressing/Fixation

Provides a final layer to absorb exudate and secure primary dressing/contact layer in place (Melolin, Hyperfix).

Analgesia

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.

Preventing Infection

Standard infection control measures apply to children with burn injuries

• Staff and visitors must perform hand hygiene
• Staff must wear gloves for dressing changes
• Visitors who are unwell should not visit the patient

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 precautions.

Nutrition

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 nutrition.

In burns >15% TBSA NGT feeds should be commenced within 6 hours of the burn.

Positioning

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.

Post Acute Care Complications

Itch

Healing wounds are often itchy. Non sedating antihistamines are a safe option for symptomatic management.

Oedema

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 neurovascular compromise.

Fever

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.

Signs/symptoms TSS

• Shock (tachycardia, hypotension)
• Fever >38.9 degrees
• Erythematous rash
• Diarrhoea and vomiting
• Lethargy
• Irritability

Treatment includes active resuscitation with IV fluids, IV antibiotics and urgent paediatric and burns specialty care.

Psychosocial 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.

Rehabilitation

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:

• Hand burns
• Deep dermal or full thickness burns crossing flexor surface of a joint (risk of contracture)
• Significant oedema limiting limb function or vascular integrity (poor capillary return, cool to touch distal to burn)
• Immobilisation by use of splint may be required to ensure safe position or integrity of underlying body structures

Ongoing OT requirement may be necessary to optimise patient function and minimise risk of irreversible complication such as contracture and deformity

Rehabilitation is a long and intensive process 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 rehabilitation.

Scar management

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.

Burn reconstruction

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.

Paediatric Home Safety Tips to Prevent Burns

• Ensure cups of hot liquid are always out of reach of children
• Thick soup is more viscous and remains on a child continuing to burn them – wash soup or hot food off with cool running water and continue first aid for 20 minutes
• Avoid table clothes as children can pull hot food/drinks down
• Always ensure handles of pots on the stove are angled in and out of reach of children
• Ensure cords in kitchen not long or hanging down into child’s reach (eg kettle/toaster able to be pulled down by loose cord)
• Install a guard around hot plates on stove
• Ensure deep fryers are OUT of reach of children
• Block off entry to kitchen with childproof gate
  
• Always check bathwater before putting child in bath
• Put in cold water first, then add hot water, temperature should not exceed 50 degrees
• Do not leave children unattended in bath
  • can turn on hot tap directly causing burn
  • can electrocute self in bath with bathroom electronic equipment (hairdryer, shaver etc)
  • Always run some cold water through the tap last so faucet is not hot
• Ensure smoke alarms installed and functioning to the Australian Standard, replace batteries each year with daylight savings
• Always supervise children around any naked flame (candle, fireplace, BBQ)
• Ensure children cannot access matches/lighters
• Do not use accelerants on an open fire (eg petrol, grappa, methylated spirits)
• Ensure secure storage of flammable material within the home
• Do not set off fireworks/flares
• Do not smoke around children, do not smoke whilst carrying child in baby carrier (ash and cigarette can burn child’s face)
• Place guards around heaters and teach children not to touch or stand too close
• Do not leave power cords plugged in and accessible to children
• Place safety blocks into unused power points
• Do not use electric blankets in children’s bed (risk of overheating, risk of electrocution if wet bed)
• Replace any electrical cords that are frayed/broken down
• Lock up all cleaning materials and ensure children have no access
• Do not store cleaning materials or other home maintenance materials in old food containers (eg coolant in soft drink bottle, snail bait or rat poison in ice-cream container) 
• Ensure batteries are stored away from access to children
• Limit use of toys/devices requiring button batteries and if used ensure safety cap over battery compartment are always securely screwed in
• Ensure running treadmills are inaccessible to children
  • Electricity switched off at power and unplugged
  • In separate room child cannot get into
  • Walled off with child’s playpen

[i] World Health Organisation, Children and Burns, 2004.

https://www.who.int/violence_injury_prevention/child/injury/world_report/Burns_english.pdf

[ii] World Health Organisation, Burns, 2018.

https://www.who.int/en/news-room/fact-sheets/detail/burns

[iii] Australian Institute of Health and Welfare, Burns and Scalds.

https://www.aihw.gov.au/reports/injury/burns-scalds/contents/table-of-contents

[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 13^th 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 13^th May 2020.  https://litfl.com/cyanide-poisoning-ccc/

 [xi] Victorian Forensic Paediatric Medicine Service.  Burns Including Scald Burns [online]. Viewed 20^th April 2020.  https://www.rch.org.au/vfpms/guidelines/Burns_including_scald_burns/