Burns are the fifth leading cause of unintentional injury–related death in US children, with approximately 2500 deaths annually.^1,2 Non-fatal burn injuries are the third leading cause of unintentional injury, with approximately one million annual pediatric cases.² Male children consistently represent two-thirds of patients.^3,4 Children <6 years of age sustain 58% of burn injuries, approximately 60% of which are thermal (scald) burns.^3–5 The most frequently affected body parts are the hands (36%), followed by the head and face (21%), with most burns occurring at home.^5–7 Pediatric burn incidence, size, and mortality have decreased over the past three decades.^4,8 Despite those improvements, the potential for other significant sequelae (i.e., infection, respiratory failure, and sepsis) increases with the percent of BSA involved.³ ED burn treatment is usually followed by outpatient management, with less than 10% of cases requiring hospital admission or transfer to a burn center.² This chapter addresses common etiologies, pathophysiology, BSA calculation, clinical evaluation, management, and disposition of children presenting to the ED with thermal injuries. Electrical burns are covered in Chapter 139.

THERMAL

Scald injuries are the most common cause of burns in children younger than 4 years old.^3,4 Scalds typically occur when hot liquids tip over or accidentally spill near a child. Microwave-related burns are an important source of pediatric scald injuries, accounting for more than 600 ED visits per year in the United States. The majority occur as a result of the child accessing the microwave and removing the contents.⁹ Infants are at risk for bath-related scalds. Contact burns are often seen in young children who accidentally touch a hot surface (such as a hair curling device, clothing iron, grill surface, or hot coals), or pull on a heated object’s electrical cord. Children can sustain a greater depth of skin injury with less contact time than adults; however, most pediatric burns are minor scalds.³

FLASH

Accidental ignition of volatile substances, such as alcohol-based cleaners and liquids, can cause flash injuries. Because the exposure time is so brief, the result is usually a partial-thickness burn (Fig. 138-1).

FLAME

Flame injuries are the most common reason for burn-related injuries in older children.^2–4 Young children can also sustain flame burns, particularly from house fires or accidental ignition of clothing. Complicating flame burns from house fires is toxic gas inhalation, including carbon monoxide and cyanide. Flame injuries associated with smoke inhalation account for the majority of burn-related deaths.^1,5,6

CHILD ABUSE

Unfortunately, approximately 10% to 20% of pediatric burns are not accidental.^2,10 Any child with burn injuries must have a thorough history and physical examination to rule out potential abuse. The injury should match the mechanism described in the history. Most inflicted burns are scalds from forced submersion.¹⁰ Burns to buttocks, perineum, bilateral hands/feet, the dorsum of the hands, and burns in a “stocking” distribution are suspicious for abuse.^2,10 Intentional cigarette or iron burns and delays in seeking medical care are also seen in child abuse.² Ideally, photographs of suspicious burns should be taken before dressings are applied.¹¹ Burns from child abuse are associated with a higher mortality rate.¹⁰

Burn injuries range from simple first-degree sunburns to devastating full-thickness/third-degree burns. Burns destroy tissues via coagulation necrosis and the resulting inflammatory cascade. Injured cells release vasoactive mediators that continue to damage tissue even after the inciting agent is removed. Ischemia, necrosis, and thrombosis can occur. Later, damaged capillaries become more permeable, causing edema by leaking protein and fluid into the interstitial space. This third-spacing of fluid can result in profound intravascular hypovolemia and shock. Compounding hemodynamic instability, injured tissue can serve as a nidus for bacterial infection. Burn management is directed by location, depth, and percent of total body surface area (TBSA) involved¹² (Fig. 138-1).

FIRST DEGREE

First-degree burns involve the epidermis; sensation remains intact and there are no blisters. A common example is a mild sunburn. First-degree burns can be managed with oral pain medication and usually heal within 1 week (Fig. 138-2A).