Burns
Each year, approximately 250,000 children in the United States are burned seriously enough to require medical attention, and burns are the third-most frequent cause of pediatric injury-related mortality.
Common types of burn injuries are thermal (scald and flame), chemical (acids and alkalis), electrical, and radiation (sunburn). Scald burns are the most frequent type in children under five years of age, while flame burns are most common in those 5–13 years of age. In teenagers, burn injury most often results from accidents involving flammable liquids.
Up to one-third of child abuse cases involve burns, accounting for 10–25% of all childhood burns. The most common mechanism is scalding. Other causes include burns from appliances, matches, and tobacco products.
Clinical Presentation
The presentation and severity of a thermal injury is determined by the type and temperature of the agent causing the burn and the duration of exposure to the agent.
Determining the surface area and depth of tissue involved are priorities in evaluating the extent of a burn injury. The “rule of nines” used in older children and adolescents requires modification for infants and young children, because the percentage of the total body surface area (BSA) represented by the various body parts changes with age. To estimate the BSA involved, use the patient’s own hand, which, including the fingers, is approximately 0.8–1% of the BSA. Depth can be difficult to estimate, since the injury is usually not uniform in all affected areas, and the depth may progress over time. Scald burns, other than those caused by immersion, tend to be superficial, while chemical burns are typically deeper. Electrical burns (pp. 214–217) can cause tissue damage that is much deeper than suspected during the initial examination.
First-Degree Burns
First-degree burns involve only the superficial epidermis. Sunburn is the most common example of a first-degree burn. The area appears pink or light red and blanches with pressure. The burn is dry, without blister formation and is hypersensitive. Healing generally takes place within seven days, without scarring.
Second-Degree Burns
Second-degree burns are also known as partial-thickness burns. They are subdivided into superficial and deep partial-thickness burns. Superficial partial-thickness burns involve the epidermis and the papillary layer of the dermis. They present with blisters and bullae and are typically bright red or mottled in color. They have a moist surface, and the superficial skin can be wiped away. These burns are extremely painful. With proper care, they heal within 14–21 days with a small risk of hypertrophic scarring.
Deep partial-thickness burns involve the epidermis and both the papillary and reticular layers of the dermis. Most are caused by flame, oil grease, and very hot liquids. The skin may appear yellow-white or dark red (nonblanching), with a dry or mildly moist surface. There is sensation to pressure only, secondary to nerve destruction. These injuries may be difficult to distinguish from third-degree burns and may require >21 days (up to two months) for healing with residual scar formation.
Third-Degree Burns
Third-degree, or full-thickness, burns are usually caused by flame, hot grease or oil, chemicals, or prolonged immersion. All skin elements are lost, with coagulation of blood vessels. The skin is dry or leathery, grayish-white, and waxy. Thrombosed superficial veins may be visible. The patient has sensation to deep pressure only. Wound closure requires resurfacing and grafting, because the burned surface will not support the migration of normal epithelium from the unburned periphery.
Diagnosis
The evaluation of any burn injury includes determination of the cause, location, and depth of the burn. Look for evidence of inhalation injury or other associated injuries, and note any preexisting illness. Always consider child abuse when the patient presents with burns to the buttocks or burns with a sharp delineation from immersion or the application of a hot object to the skin.
Burns can be classified as minor, moderate, or major, based on the severity of the burn and the involved BSA. Minor burns are first-degree, as well as second-degree injuries encompassing <10% total BSA. Moderate burns include partial-thickness burns that cover 10–20% total BSA. Full-thickness injuries covering <10% total BSA are also considered moderate. Major burns include partial-thickness burns >20% BSA and third-degree burns >10% BSA, as well as burns of the hands, face, eyes, ears, feet, and perineum.
Burns can also be classified as minor, moderate, and major based upon the severity of the burn as well as risk group. Minor burns include partial- or full-thickness burns <5% BSA in a child under ten years of age, partial- or full-thickness burns <10% BSA in a child ten years of age or older, and full-thickness burns <2% BSA. Moderate burns include partial- or full-thickness burn involving 5–10% BSA in a child younger than ten years of age, partial- or full-thickness burns involving 10–20% BSA in a child ten years of age or older, full-thickness burns involving 2–5% BSA, suspected inhalation injury, and circumferential burns. Major burns include any burn in an infant, any burn involving the face, eyes, ears, genitalia, or joints, burns complicated by fractures or other trauma, high-voltage burns, burns complicated by inhalation injury, partial- or full-thickness burns of >10% BSA in a child under ten years of age, partial- or full-thickness burns >20% BSA in a child ten years of age or older, and full-thickness burn >5% BSA.
ED Management
First-Degree Burns
Treat pain with acetaminophen (10–15 mg/kg q 4h) or ibuprofen (10 mg/kg q 6h). Hydrocortisone ointment (1%) may help reduce the pain and swelling of severe sunburn, especially if the eyelids and face are involved, but do not apply steroids to higher-degree burns. Cool showers and oatmeal baths are also helpful. Severe itching can occur after a few days and persist for more than one week; treat with hydroxyzine (2 mg/kg/day div tid, 50 mg/dose maximum) or diphenhydramine (5 mg/kg/day div qid, 50 mg/dose maximum).
Second-Degree Burns
Immediately remove any clothing that is hot or soaked with chemical. Use mineral oil mixed with cool water to remove substances like tar. Decrease the burning process by applying sterile gauze pads soaked with slightly cooled (12 °C; 53.6 °F) or room-temperature saline. To be effective in preventing microvascular changes, the cooling must occur within 30 minutes after the burn occurred.
Before the burn is cleaned, parenteral analgesia, such as IM or IV morphine sulfate (0.05–0.15 mg/kg q 4–6h, as needed), may be required. Do not attempt IV access in a burned area. Gently clean the burned surface with chlorhexidine solution and rinse thoroughly. Debride devitalized tissues using aseptic technique.
To promote restoration of mobility, open and debride blisters over joints. Also open and debride large blisters over immobile areas, but leave small blisters on immobile areas intact. If there is a concern about follow-up, debride all blisters as intact or spontaneously collapsed blisters can serve as a focus for wound infection.
Silver sulfadiazine has both Gram-positive and Gram-negative activity and provides good prophylactic antibiotic coverage. It also facilitates debridement. However, do not use silver sulfadiazine on the face, for children with hypersensitivity to sulfonamides, or for infants under two months of age (bacitracin ointment is an acceptable alternative). Use a sterile tongue depressor to apply a 2 mm layer, and cover with either a nonadherent or petrolatum-impregnated dressing, then wrap with gauze.
If the hand and fingers are involved, dress each finger individually and splint the hand with the wrist extended to 15–30 degrees, metacarpophalangeal joints at 60–90 degrees of flexion, the interphalangeal joints fully extended, and the thumb fully abducted. Use a sling to elevate the extremity above the level of the heart.
Clean and dress the burn daily. At each dressing change, remove the silver sulfadiazine completely, as it loses its antibacterial activity.
Biobrane (Woodruff Laboratories, Santa Ana, CA), a biosynthetic dressing coated with collagen peptides, is indicated for superficial second-degree burns (those with no chance of becoming third-degree burns). Apply it directly to a cleaned burn area, then cover with an absorbent dressing that should be changed every 24 hours. The Biobrane will separate on its own in 1–2 weeks. Apply it to flat surfaces only.
General Approach to the Burned Child
1. Stop the burning process by removing burned clothing and copiously lavage all chemical burns. Apply cool or room-temperature soaks to reverse the thermal gradient and relieve pain (second-degree burns), but avoid hypothermia.
2. Assess and maintain ventilation. Check for signs of inhalation injury (pp. 226–229); if any are present, measure the oxygen saturation and immediately perform fiberoptic laryngoscopy to rule-out involvement of the upper airway. Obtain a carboxyhemoglobin level if the patient was in a closed-space fire. If there is a marked metabolic acidosis or hyperlactatemia, treat the patient for possible cyanide toxicity (see p. 229).
3. Initiate IV fluid therapy for patients with >20% partial- or full-thickness burns. Immediately place a large-bore IV catheter in either a central or peripheral vein found in an unburned area. Treat signs of hypovolemia with a 20 mL/kg bolus of normal saline or lactated Ringer’s solution. Use dopamine (5–20 mcg/kg/min) if poor perfusion persists. For patients not in shock, administer 2–4 mL/kg/%BSA burned of normal saline or lactated Ringer’s solution over the first 24 hours. Give one-half of the calculated total over the first 8 hours (starting from the time of the burn incident) and the remainder over the next 16 hours. For a child weighing <30 kg add the estimated daily maintenance fluid requirement. A larger patient >30 kg does not need the maintenance fluids added as part of the fluid replacement. The goal is a urine output from 1 mL/kg/h in a young child to 0.5 mL/kg/h in an adolescent.
Insert an indwelling urinary catheter using aseptic technique in any burn victim needing IV fluids. Discard any urine obtained when the catheter is inserted, as this may have been in the bladder before the burn injury. Check the urine (with a dipstick) for hemoglobin or myoglobin; if positive, obtain a microscopic urinalysis to differentiate hematuria from rhabdomyolysis. If myoglobin is present, increase the fluid rate to maintain a brisk urine output (2 mL/kg/h).
4. Take a careful history. Inquire about the cause of the burn, preexisting illnesses, chronic medications, and allergies. Suspect child abuse (pp. 604–608) if the accident occurred when the child was reportedly alone, the injury is attributed to a sibling, the history varies from one interview to another, there is a previous history of accidental trauma, the history is incompatible with the observed injury, or there is delay in seeking medical attention.
5. Check the tetanus immunization status and give 0.5 mL of tetanus toxoid booster (Tdap) if the last immunization was more than five years ago. If the patient has received fewer than three tetanus toxoid boosters, give 0.5 mL of tetanus immune globulin as well as 0.5 mL of tetanus toxoid booster.
6. Perform a careful physical examination. Check for corneal injury with fluorescein staining if the lids are burned, the eyelashes have been singed, or eye damage is suspected. Evaluate the patient for associated injuries, especially fractures and head trauma, and signs of child abuse. Non-accidental burn injuries include pattern burns, sharply demarcated burns of the hands, feet, buttocks, and perineum, and stocking-glove burn injuries.
7. Insert a nasogastric tube and attach it to suction if the burn exceeds 20% of total BSA or if there is nausea, vomiting, or abdominal distention. An ileus is common as a result of splanchnic vasoconstriction.
8. Give pain medication as needed (IV morphine sulfate, 0.1–0.15 mg/kg q 15–60 min).
9. Perform the initial burn wound care as described above.
10. Examine the patient for circumferential injuries. Remove all rings, bracelets, and restrictive clothing. Look carefully for signs of impaired circulation, including cyanosis, impaired capillary refill, changes in sensation, deep tissue pain, or paresthesias. If circulatory impairment is a possibility, call a burn surgeon or a plastic surgeon as an escharotomy may be necessary.
Follow-up (Minor Burns)
First-degree burns: return at once if blisters form.
Second- and third-degree burns: return at once if there are any signs or symptoms of impaired circulation (numbness, tingling, or color change distal to the bandage) or infection (fever, vomiting, poor feeding, or change in mental status). Otherwise, follow-up with a primary care provider in 3–4 days
Indications for Admission
Guidelines for Transferring the Burn Victim
In addition to the usual considerations when transferring any patient to another institution, there are several special concerns when transferring a burn victim:
1. The patient’s airway must be securely protected. An accidental extubation in a burn victim with a swollen airway can prove fatal. A physician who is able to perform an emergency intubation and/or emergency cricothyroidotomy must accompany the patient.
2. Just prior to transport, remove all saline-soaked dressing and replace them with sterile dry gauze dressings to prevent hypothermia.
3. Treat the patient with adequate sedation and analgesia to minimize pain and agitation.
Bibliography
Drowning
Drowning is a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium. This results in a liquid–air interface in the child’s airway. Therefore, do not use the terms wet drowning, dry drowning, secondary drowning, and near-drowning. Approximately one-third of deaths from unintentional drowning occur in patients <19 years of age, while drowning is the second most common cause of injury and death in children aged 1 month to 14 years of age. Among toddlers, most incidents occur in bathtubs and swimming pools. Risk factors include inadequate supervision, developmental disorders, use of alcohol and/or illicit drugs, and associated trauma.
Death may be caused directly by laryngospasm, or by cerebral hypoxia, carbon dioxide narcosis, or cardiac arrest.
Aspiration of either saltwater or freshwater results in hypoxemia. There is no longer a distinction made between the two. As little as 1–3 mL/kg of water can cause pulmonary vasoconstriction and impaired gas exchange, as surfactant is either destroyed or washed out. Compliance is reduced and ventilation/perfusion mismatch develops. These pulmonary complications can develop slowly or rapidly.
Hypothermia is the double-edged sword of drowning. Cold water (< 20 °C; 68 °F) decreases metabolic demands and shunting blood from nonvital to vital organs, but adverse effects such as dysrhythmias (sinus bradycardia, atrial and ventricular fibrillation, asystole) often occur.
Clinical Presentation and Diagnosis
Inquire about the site and duration of submersion, water temperature, possibility of trauma or physical abuse, drug or alcohol use, and past medical history.
A drowning victim’s mental status may range from fully alert to comatose. The patient may have no signs of respiratory distress or may present with tachypnea, nasal flaring, and/or retractions. Auscultation of the lungs may reveal adventitious sounds (crackles and/or wheezes), and any type of dysrhythmia may be seen on ECG. Among adolescents, inquire about drinking or drug use prior to the event. The chest radiograph can be normal or show evidence of air space disease either localized or diffuse.
Trauma is often involved in near-drowning. Pay particular attention to the possibility of head or cervical spine injuries. Consider internal injuries to the chest or abdomen, especially if the patient does not respond appropriately to resuscitation interventions. Arterial blood gases may show a metabolic and/or respiratory acidosis.
ED Management
Handle the patient carefully because of the possibility of cervical spine injury (pp. 741–743). Place a rectal temperature probe to confirm the core temperature, rapidly assess the airway and breathing, and provide 100% oxygen. Consult with a pediatric pulmonologist about the possibility of noninvasive ventilation (NIV) for a patient who is alert and maintaining their airway, but remains hypoxic. Indications for assisted ventilation via bag-mask apparatus and endotracheal intubation are apnea, an oxygen saturation <85% while inspiring 100% oxygen, or signs of neurologic deterioration. If intubation is needed, place an orogastric tube to relieve gastric distention. The patient may require positive end expiratory pressure (PEEP) if there is an inadequate response to the initial ventilator settings. Treat bronchospasm with nebulized albuterol (0.03 mL/kg in 3 mL of normal saline) and repeat as needed. There is no evidence that steroids are beneficial in aspiration-induced bronchospasm.
Assess the cardiac status and continuously monitor the ECG. If the patient is pulseless, start basic life support, then advanced life support as warranted by the ECG rhythm and the clinical status. However, most resuscitation drugs are not effective in a severely hypothermic patient and are therefore contraindicated during rewarming (see Hypothermia, pp. 224–226). One exception is glucose. Give 0.5–1 g/kg (1–2 mL/kg D50; 0.25–0.5 mL/kg D25) to any patient with altered mental status. Also give naloxone (0.4–2.0 mg IV or 4.0 mg ET) to an adolescent if the history suggests a narcotic overdose.
Start at least one large-bore IV with normal saline or lactated Ringer’s solution. However, give fluids cautiously since these patients are at risk for pulmonary and cerebral edema, and warm the fluids if the patient is hypothermic. Initial laboratory studies include CBC, electrolytes, BUN, creatinine, glucose, CPK, ABG, serum pregnancy test (for a female of childbearing age), serum osmolality, and type and cross (if there is any suspicion of trauma). If the history or physical examination suggests an intoxication, obtain a blood alcohol level and urine for toxicology. Also obtain an ECG and a chest radiograph. The need for other tests, such as additional x-rays or CT scans, are determined by the history of the event and serial assessments.
An initially well-appearing child may rapidly develop both pulmonary and neurologic complications any time within the first 24 hours. However, most asymptomatic children may be discharged after eight hours’ observation if the physical examination, the initial chest x-ray, and all tests are normal; the physician is assured that the family is reliable; and adequate follow-up is arranged. Poor prognostic signs include a submersion duration of >9 minutes, prolonged apnea, or coma.
Follow-up
Indications for Admission
History of prolonged submersion
Respiratory or neurologic symptoms
A patient with an abnormal chest x-ray, for at least 24 hours
Bibliography
Electrical Injuries
Small children, especially toddlers, frequently sustain low-voltage electrical injuries when they insert objects (pins, keys, etc.) into household sockets or chew on electrical cords. Older children are more likely to sustain high-voltage electrical injuries by contacting live third rails or power lines when climbing.
Most of the harmful effects from electrical injuries are due to the heat generated, which is directly related to current strength, tissue resistance, pathway, type of current (i.e., direct or alternating), and duration of contact. Serious electrical injuries are uncommon, but carry a mortality risk of approximately 40%.
Electrical injuries are usually categorized in terms of high (>1000 V) or low (<500–1000 V) voltage. In the United States, household current is low-voltage (110 V). Because voltage is directly related to current, high-voltage injuries are usually more serious than low-voltage, although a low-voltage contact applied to areas of low resistance can also cause serious injury. Exposure to an electrical socket with a wet hand can result in a current of 50–100 mA, which is enough to cause ventricular fibrillation. Low-voltage injuries account for more than one-half of all deaths from electrical injuries.
Clinical Presentation and Diagnosis
Electrical injuries can cause multiorgan dysfunction and a variety of burns and traumatic injuries. A child who has had contact with electric current can present with first-, second-, or third-degree burns of the skin, as well as entrance and exit burns (which are usually third-degree burns). There may also be burns at flexor creases and at the oral commissure, which may be associated with delayed labial artery bleeding of 2–21 days after the burn.
If the electrical current takes a vertical path, or if there is extensive skin damage, cardiac involvement is more likely. Cardiac complications include all forms of dysrhythmias, ranging from occasional ectopic atrial and/or ventricular premature contractions (VPCs), supraventricular tachycardia, first-, second-, and third-degree AV blocks, ventricular tachycardia, and ventricular fibrillation. ECG abnormalities are usually evident upon initial ED evaluation and commonly include accelerated sinus rhythm and nonspecific ST–T-wave changes, although damage to the myocardium is uncommon. Pulmonary involvement can include pulmonary contusion, hemothorax, pneumothorax, and/or ventilatory arrest.
Central nervous system involvement may be due to the electrical injury itself or the subsequent fall after the event. The patient can present with any type of mental status change. Other neurologic symptoms, such as paralysis, can occur immediately or can be delayed for up to several days. Electric current can cause tetany of skeletal muscle and both upper and lower motor neuron findings may be noted. This can lead to all types of musculoskeletal injury, from strains to fractures and/or dislocations.
Vascular injuries directly from the electric current can include hemorrhage, either immediate or delayed, in addition to thrombosis. Renal complications can include renal failure, which may be due to either third-spacing of fluid or rhabdomyolysis.
Gastrointestinal injuries can occur in up to 25% of high-voltage injuries. The most common complication is adynamic ileus. Other conditions that may be seen include hepatic, gallbladder, and pancreatic necrosis as well as stress ulcers.
High-Voltage Injuries
The patient may present with a variety of complications involving a number of organ systems. Asystole, respiratory arrest, and hypoxia-induced ventricular fibrillation are the most common causes of immediate death. Other complications include hemolysis, rhabdomyolysis, direct burns of the lung or viscera, neurologic injuries, renal failure, and musculoskeletal injuries such as fractures and dislocations. Burns are usually characteristic of high-voltage injuries. The types of burns that may be seen include the following.
Flash Burns
Flash burns are caused by electrical arcs on the skin. They resemble thermal burns and require the same treatment.
Arc Burns
The temperature of an electrical arc can reach 2500–5000 °C. These high-voltage burns have a dry center (up to 3 cm) with a surrounding area of congestion. There may be internal injury along the arc pathway.
Contact Burns
These may look like flash burns early in the course of care and may also suggest internal injury.
Low-Voltage Injuries
Most low-voltage injuries initially present with a small, localized, painless, white parchment-like patch of skin. However, if a child has bitten on an electrical wire, there can be considerable edema of the lips, tongue, and gums. Rarely, severe intraoral edema may result in airway obstruction. If the child conducts electricity, muscle paralysis and ventricular dysrhythmias may occur. Fortunately, conduction with low voltage is rare, so these are usually limited injuries.
ED Management
High-Voltage Injuries
Rapidly assess the adequacy of the airway. Use the chin-lift maneuver without hyperextension to maintain patency if there is the possibility of a cervical spine injury, either directly from the electrical injury or from resulting trauma (e.g., fall from a tree or ladder). If the patient is not breathing, ventilate with a bag-mask resuscitator and prepare for intubation. If respirations are adequate, administer 100% oxygen via a nonrebreather mask.
Assess the cardiovascular status, obtain an ECG, and secure a large-bore IV. If the patient is pulseless and the ECG monitor reveals ventricular fibrillation or pulseless ventricular tachycardia, defibrillate with an energy level of 2 J/kg (monophasic or biphasic; see Ventricular Fibrillation, pp. 58–64).
If the patient presents with signs of inadequate tissue perfusion, give an IV fluid bolus of 20 mL/kg of NS and repeat as needed. If the patient remains hemodynamically unstable, continue rapid IV hydration and start a dopamine drip at 5–20 mcg/kg/min (see Shock, pp. 28–36). However, inadequate tissue perfusion may be due to an associated thoracic, abdominal, or long-bone injury sustained after the electrical insult. Always consider major trauma in patients presenting in shock after an electrical injury.
If the patient has a normal pulse rate and blood pressure, give IV hydration with D5 ½ NS at a rate of 1.5–2 times maintenance. Aim for a urine output of at least 2–3 mL/kg/h, but do not add potassium for the first 24 hours (unless the patient has documented hypokalemia). The presence of rhabdomyolysis (hemoglobin or myoglobin on urine dipstick and/or an elevated creatine phosphokinase [CPK]) indicates significant deep tissue injury and predicts renal failure unless a brisk urine output is quickly established.
Initial laboratory tests include blood for an ABG, CBC, electrolytes, glucose, BUN, creatinine, PT and PTT, serum osmolality, pregnancy test (for adolescent females of childbearing age), a urinalysis, and a 12-lead ECG. Obtain radiographic studies of any region you suspect may have been injured. Do rely on CPK-MB as a single criterion for myocardial infarction as an elevation in the absence of other evidence of myocardial injury (chest pain and/or EKG changes) is not specific for myocardial damage. The role of troponin in electrical injuries has not been studied extensively.
Perform a secondary survey to check for surface thermal burns, orthopedic injuries, or evidence of compartment syndrome. If the patient presents with an altered mental status, evidence or suspicion of an intoxicant, or a distracting injury, clear the cervical spine radiographically. However, a head CT is also indicated for continued altered mental status after electrical injury.
Categorize and treat surface thermal burns in the usual fashion (see Burns, pp. 207–211).
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