How Do Pediatric Burns Usually Occur?

Burns are a leading cause of in-home harm to children. Infants who are not yet walking are often burned when they are placed in contact with hot surfaces, or as a result of a hot liquid spill. Mobile toddlers are able to pull a cup containing hot liquid off a table, chew on an electrical cord, or accidentally step on a hot surface. Adolescent burns may involve gasoline and fire. Overall, 70% of pediatric burns are associated with hot liquids.

What Are the Different Classifications of Burns?

Initial classification is based on the type of burn:

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  Thermal burns: the depth of the skin injury is related to contact temperature, duration of contact, and thickness of the skin involved. There may be airway damage from hot smoke inhalation;

  
  
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  Cold exposure burns such as frostbite occur when bodily tissues are frozen;

  
  
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  Chemical burns cause caustic reactions, alteration of the pH, disruption of cell membranes, and/or toxic effects on metabolic processes. Acid burns cause tissue coagulation whereas alkali burns cause liquefaction necrosis;

  
  
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  Electric current burns are transformed into thermal injury as the current passes through poorly conducting tissues. They may cause severe fractures, hematomas, visceral injury, and skeletal and cardiac muscle injury which can lead to pain, myoglobinuria, and dysrhythmias or other ECG abnormalities;

  
  
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  Inhalation burns are typically caused by steam or fire;

  
  
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  Radiation burns result from radiofrequency energy or ionizing radiation that causes damage to skin and tissues (e.g., sunburn).

Burns are further classified based on their penetrating depth:

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  Superficial (first-degree) burns involve only the epidermal layer of the skin. These burns do not blister but are painful, dry, and blanch with pressure. These injuries are self-healing and require about one week to heal.

  
  
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  Partial thickness (second-degree) burns can be classified as either superficial or deep. Superficial partial thickness burns are painful, red, weeping and also blanch with pressure. They blister within 24 hours, and do not typically scar, although skin pigmentation may change. Deep partial thickness burns extend deeper into the dermis and include damage to the hair follicles and glandular tissues. They are painful only to pressure and almost always blister. They are wet or waxy dry and have a mottled discoloration to them. They do not blanch with pressure. Without skin graft or infection, they heal in three to nine weeks.

  
  
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  Full thickness (third-degree) burns destroy all the layers of the dermis and injure underlying subcutaneous tissue. Burn eschar typically remains intact. If the eschar is circumferential, it can compromise the area it is surrounding. These burns are usually painless. The skin appears along the spectrum of waxy white to charred black. The skin is dry, inelastic, and does not blanch with pressure. Blisters do not develop. Without surgery, these burns heal with contractures. These burns scar severely with contractures. Surgery is required for this healing process.

  
  
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  Fourth-degree burns are deep and potentially life-threatening burns that extend from the skin down to the fascia, muscle, and/or bone.

What Is the Estimated Percent Total Body Surface Area Burned on This Patient?

Burns can be classified according to the percentage body surface area (BSA) involved. The total percentage BSA derives from the “Rule of Nines,” which is different in children than in adults since the pediatric head accounts for a larger percentage of BSA (Figure 16.1).

Figure 16.1 Schematic representation of body surface area (BSA) variability between children and adults.

Reproduced with permission from: Litman RS, Basics of Pediatric Anesthesia, Philadelphia, 2014. Illustration by Rob Fedirko.

A major burn is defined as: (1) a second-degree burn with greater than 10% BSA or second-degree burn for children over 10 years old with greater than 20% BSA; (2) a third-degree burn with greater than 5% BSA; or (3) a second- or third-degree burn of the hands, feet, perineum, or major joints, electrical or chemical burns, inhalational injury, or burns in patients with preexisting medical conditions. The American Burn Association recommends that patients suffering from a major burn should be referred to a certified burn center.

Morbidity and mortality increase with increasing size and depth of the burn. Inhalational smoke injury and early shock are associated with greater mortality. The risk of mortality increases when the burn extends to greater than 60% BSA; yet there have been patients who have survived with a 90% burn. Severely burned patients may survive the initial insult, only to succumb to a secondary complication (e.g. infection). The age of the burned child is important for his or her survival, because of better prognosis with increasing age.

What Are Your Initial Anesthetic Concerns?

The initial anesthetic management of the pediatric burn patient should focus on airway evaluation and management, provision of adequate oxygenation and ventilation, as well as restoring circulatory volume. Burn patients will have difficulty regulating body temperature, so heat lamps and blankets should be used to maintain euthermia. There are pharmacokinetic implications after third-degree burns because of the up-regulation of postsynaptic receptors, which can lead to acute hyperkalemia with succinylcholine administration. Wound care is usually deferred until after the acute resuscitation phase.

IV access can be difficult in cases of severe burns covering large surface areas necessitating central access. Intraosseous access can be an important tool in these patients and should be used when appropriate to avoid delay in resuscitation.