Initial Assessment and Management of Thermal Burn Injuries in Children

Ramin Jamshidi and Thomas T. Sato

Pediatrics in Review 2013;34;395
DOI: 10.1542/pir.34-9-395

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 Article emergency medicine

Initial Assessment and Management of

Thermal Burn Injuries in Children
Ramin Jamshidi, MD,*
Educational Gap
Thomas T. Sato, MD†
Burns are a frequent cause of injury in children and adolescents. Clinicians should be
familiar with initial assessment and management of burns and be capable of identifying
Author Disclosure burn injuries appropriate for referral to a regional burn center.
Drs Jamshidi and Sato
have disclosed no
Objectives After reading this article, readers should be able to:
financial relationships
relevant to this article. 1. List 3 types of burn injuries.
This commentary does 2. Describe the initial evaluation of a burned child in terms of burn depth, size, and
not contain discussion associated injuries or medical conditions.
of unapproved/ 3. Describe appropriate burns for outpatient management.
investigative use of 4. Estimate initial fluid resuscitation requirements for the first 24 hours in children with
a commercial product/ large (>25% total body surface area) partial-thickness burns.
device. 5. Describe 2 methods of dressing management for a 5% total body surface area partial-
thickness burn.
6. Recognize indications for transfer of a burned child to a regional burn center.

Introduction
Death from fires and burn injuries is the third leading cause of fatal home injury and the
third leading cause of unintentional death in children younger than 14 years in the United
States. (1) In 2009, the Centers for Disease Control and Prevention estimated 437 deaths
and 120,761 nonfatal burn injuries in children age 0 to 19 years. (2) Although hospital-
ization rates for children with burns appear to be decreasing in the past decade, annual cost
estimates of approximately 10,000 inpatient hospitalizations for pediatric burn care ex-
ceeded $211 million in 2000. (3) Although it is difficult to estimate the global incidence
rate, morbidity, and mortality of burn injuries, it is clear that burns are a major cause of
injury in both developed and developing countries. (4) Burns are one of the most physi-
ologically and psychologically stressful injuries that occur in children and adults. Given the
high frequency of pediatric burn injuries, physicians caring for children should be familiar
with initial burn assessment and management. It is also important to identify children with
burn injuries appropriate for referral to a regional burn center.
Children with burn injuries are evaluated in a variety of settings, including emergency
departments, urgent care centers, and primary care pediatric clinics. Although assessment of
burn injuries is relatively standardized, management strategies vary between individual
practitioners and institutions. From a public health and patient education standpoint, most
pediatric burn injuries are preventable, and conscientious efforts at risk reduction and safety
in the home should be emphasized during well-child visits.

Types of Burns
A burn is an acute injury to the skin or soft tissue due to thermal energy transfer or trauma.
Burn injuries also include skin or tissue injury due to sun exposure, radioactivity, electricity,
chemical exposure, or friction. Frostbite injuries due to cold exposure are also a type of
injury from thermal energy transfer. In practice, the mechanism of burn injury is an

*The Pediatric Surgeons of Phoenix, Phoenix, AZ.

†
Division of Pediatric Surgery, Children’s Specialty Group, Children’s Hospital of Wisconsin, and The Medical College of Wisconsin,
Milwaukee, WI.

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emergency medicine thermal burn injuries

important consideration because other medical and sur- burn injuries in children, direct communication with a re-
gical issues may coexist or occur shortly after injury. Elec- gional burn center is imperative to facilitate safe, expedient
trical injuries are generally more common in older transfer. Clinicians performing initial assessment of a
children and adolescents and result from exposure to burned child should focus on gathering data necessary to
faulty wiring, leaking current from electrical appliances, initiate burn management. This information includes pa-
contact with high-voltage lines, or lightning. Although tient demographics and medical history, mechanism of
they may generate limited visible injury, survivors of se- injury, and estimated severity of the burn wound.
vere electrical burns may have extensive deep tissue in-
jury, with significant nerve and muscle damage that
leads to arrhythmia, unconsciousness, loss of extremity Estimating Burn Severity
function, and rhabdomyolysis. Chemical burns typically Estimating the severity of a burn requires clinical evalu-
involve topical or mucosal exposure to alkaline or acidic ation of the following: (1) the child’s age and medical his-
agents, and the management is generally specific to the tory; (2) the mechanism of injury; and (3) the surface
chemical class involved. Unintentional injury from chem- area, depth, and pattern of the burn injury. Infants and
icals has become less common since the enactment of the children younger than 2 years and children with clinically
US Poison Prevention Packaging Act in 1970. A detailed significant medical problems (eg, diabetes mellitus, sickle
evaluation and management of electrical and chemical in- cell disease, and children receiving chemotherapy) have
juries in children are beyond the scope of this review; greater risk of burn-related morbidity and mortality.
therefore, focus will be placed on the more commonly Rapid estimate of the TBSA of a burn injury in adoles-
encountered thermal injuries. cents and adults can be performed using the “rule of
Common thermal injuries observed in infants and chil- 9’s.” On the basis of this guideline, the surface area of
dren include scald and contact burns associated with ei- each arm is approximately 9% TBSA, each leg is 18%,
ther cooking or consuming food. Specifically, injuries the anterior and posterior torso (including the pelvis)
from spilled hot coffee, hot liquids, and ramen noodle are 18% each, the head is 9%, and the perineum is 1%
soup comprise most outpatient pediatric burn wounds. TBSA. Because anatomical body surface area varies with
Contact burns from hot space heaters, barbecue grills, age, a more accurate estimation of burn surface area in
fireplace grates, stoves, and ovens typically occur from infants, children, and adults is achieved with a Lund-
a child’s inadvertent hand or extremity contact with Browder chart widely available in printed and electronic
the heat source. Finally, contact burns from hot irons, formats (Figure 1). (6) The percentage of TBSA involved
curling irons, campfires, and fireworks are common with a burn wound has significant implications for the
among children. physiologic impact of the injury. Pediatric burn wounds
that involve greater than 10% TBSA will induce a more
profound systemic inflammatory response characterized
Initial Evaluation by increased microvascular capillary leak, interstitial
The initial evaluation of the burned child should take into edema formation in both injured and noninjured tissue,
account the clinician’s experience and the immediate in- and intravascular hypovolemia.
stitutional resources available for burn management. Tri- Burn depth is another important variable in assessing
age will be dictated, in part, by the clinician’s estimate of severity of injury. The depth of burn strongly influences
burn injury severity. Most children with minor burn in- the predicted degree of physiologic derangement in-
juries, for example, partial-thickness scald burns of less duced by the injury. In addition, in conjunction with
than 5% total body surface area (TSBA), may be managed the surface area involved, burn depth has direct implica-
on an outpatient basis. Children with moderate to severe tions for wound management and the likelihood of po-
burn injury require attention to the ABCDEF’s (airway, tential disfigurement. Table 1 outlines historical and
breathing, circulation, disability, exposure, and fluid re- contemporary nomenclature for describing the depth
suscitation requirements) of traumatic and thermal injury of burn injury. Accurate clinical description of burn
evaluation. Emergency assessment of the airway, ade- wound depth indicates the degree of injury to the dermis.
quacy of ventilation, oxygenation, and circulation is es- The common sunburn is a superficial burn injury in which
sential. Clothing, including diapers, should be removed the epidermis is injured, but the underlying epidermal
to prevent further smoldering or scalding injury in a cells and dermis remain intact. The injured epidermis will
temperature-controlled environment. (5) Unless the in- eventually peel after a few days, but new epidermal skin
stitution has significant experience with moderate to severe cells will be regenerated. Given their limited physiological

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 emergency medicine thermal burn injuries

Figure 1. Modified Lund Browder chart for estimating size of burn in terms of total body surface area. Partial-thickness, full-
thickness, and indeterminate-depth burns are used in the calculation. Adapted from Lund and Browder (6) and courtesy of the
Trauma Program, Division of Pediatric Surgery, Children’s Hospital of Wisconsin.

effect, superficial burn injuries are not used to calculate to the dermis and the skin’s epithelial elements. Full-
TBSA involvement. Scald burns that cause blisters to thickness burns will not regenerate epithelium; therefore,
form are prototypical partial-thickness injuries. The skin injuries of this depth uniformly require surgical manage-
is partially injured, and if the blister is ruptured, the un- ment (Figure 2). Infants and younger children have
derlying wound will appear pink and moist. A limited, much thinner dermis than in adolescents and adults,
correctly managed partial-thickness burn wound should and it can be difficult to determine the complete extent of
be expected to epithelialize in approximately 7 to 14 days. skin injury either initially or during the first few days of care.
Full-thickness burns are characterized by irreversible injury Equivocal partial-thickness injuries are best characterized

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emergency medicine thermal burn injuries

Table 1. Nomenclature for Depth of Burn Injury

Depth of Burn Injury Extent of Injury
First degree Superficial Epidermis injured; dermis intact
Second degree Partial thickness Dermis partially injured but skin remains viable
Third degree Full thickness Dermis completely injured and skin nonviable
Indeterminate Dermis partially injured; cannot determine skin
viability

as indeterminate depth wounds. Partial-thickness, full- or distribution of a burn injury, communication with
thickness, and indeterminate-depth burn wounds are child protective services and referral to a pediatric burn
used to calculate estimated percentage of TBSA burn in- center are necessary. Table 2 lists a burn severity grading
volvement. Characterizing burn wounds based on the system from the American Burn Association as a guideline
depth of injury allows for determination of treatment for treatment.
based on their expected evolution.
The mechanism of burn injury is often helpful in esti- Treatment
mating severity and identifying associated potential prob- Treatment of infants and children with burn injuries
lems. Burns to the face, head and neck, hands, feet, and should follow recommendations for the treatment of
genitalia are generally considered injuries that may re- any pediatric trauma patient, with initial attention di-
quire specialized, multidisciplinary evaluation and care. rected at identifying adequate airway, breathing, and cir-
Children with facial burns that involve the orbit should culation. For minor partial-thickness burns less than 5%
have their corneas assessed for injury by an ophthalmol- TBSA, treatment is aimed at provision of analgesia and
ogist. Full-thickness burn injuries that involve the entire wound care. Preemptive analgesia and sedation may be
torso can cause restriction of breathing due to inadequate required to perform initial wound assessment to avoid es-
chest wall excursion; similarly, full-thickness burns that calating or repetitive psychological trauma associated
involve an entire extremity can cause venous and/or ar- with wound care. Initial care of a minor partial-thickness
terial insufficiency of the extremity. Escharotomies, or in- burn is straightforward and involves debridement, or re-
cisions in the full-thickness burn (eschar), may be moval, of any sloughing epidermis using sterile normal
necessary to prevent the tourniquet effect of the eschar. saline and gauze. The exposed wound will be moist
Burn injuries that involve closed-space structural fires cre- and painful, and prompt placement of a burn dressing will
ate high risk for associated inhalational injury, including help to reduce pain associated with convection of air on
carbon monoxide poisoning and combustion byproduct the wound. Most minor burns can be effectively managed
inhalation. Burns that occur in motor vehicle crashes and on an outpatient basis with a low-cost, relatively easy-to-
explosions can be accompanied by significant brain, tho- use dressing using a topical antimicrobial agent that
racic, and abdominal injury that requires emergency in- prevents wound desiccation and inhibits bacterial coloni-
tervention. Finally, infants and children are at risk for zation or invasion. Typical burn antimicrobial agents
intentional burn injuries; these children are also at risk include silver sulfadiazine or bacitracin ointment. (7) Be-
for other injuries that require emergency management. tween dressing changes, the wound may become covered
Pediatric burn injuries in which there is delay in seeking with exudative drainage. The exudate should be gently
treatment or isolated scald or contact burns to the hands, wiped off daily with a clean cloth or gauze in the shower
feet, genitalia, or buttocks without a clearly defined or bathtub and dressed with a topical antimicrobial agent
mechanism should prompt further investigation. Unusual and gauze. Minor partial-thickness burn injuries can be
patterns of burn injuries occur with intentional immer- expected to epithelialize in 7 to 14 days.
sion of hands or feet into scalding water, causing glove- An alternative management strategy for minor and
like or socklike injuries that lack surrounding splash moderate (5%-10% TBSA) partial-thickness burn injuries
burns. Suspicious patterns of contact burns with hot is wound coverage with a biological dressing, such as pig-
clothing irons, heaters, or cooking pans that do not cor- skin, or a biocomposite temporary dressing. Biocompo-
relate with the reported history should be thoroughly in- site dressings are composed of semipermeable silicone
vestigated. If there is any concern regarding the mechanism and nylon mesh coated with porcine collagen

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 emergency medicine thermal burn injuries

(8) There are several emerging silver-impregnated, flex-

ible, and self-adhesive synthetic burn wound dressings
that also provide similar wound management function
as well. The addition of silver ions into the dressing
provides broad-spectrum antimicrobial function. The
advantages of biological and biocomposite wound dress-
ings include dressing flexibility, durability, less frequent
dressing changes, and reduced exposure of the healing
skin to mechanical shear. However, these dressings
may not be readily available outside regional burn
centers.
Severe burn injuries require specialized management
and are best cared for in a regional pediatric burn center.
Indications for referring an infant or child to a regional
burn center are listed in Table 3. A description of the
child’s history, mechanism of injury, estimated percent-
age of TBSA burn, and associated issues should be as-
sessed and provided. For moderate or major burns,
control of the airway and assisted ventilation may be re-
quired. Infants and children with stigmata of inhalational
injury, including a history of closed-space structural fire,
soot in the nose or mouth, elevated carboxyhemoglobin
level greater than 10%, and a PaO2 to FiO2 ratio less than
200 have a high probability of requiring mechanical ven-
tilation. Infants and children with suspected inhalational
injury and/or carbon monoxide poisoning who require
intubation should initially receive ventilation with 100%
oxygen. Wounds may be covered with a clean, dry sheet;
wet dressings should be avoided to prevent hypothermia.
Infants and children with moderate or severe burn inju-
ries greater than 10% TBSA should undergo intravenous
Figure 2. Estimating depth of burn injury. A. A partial-
(IV) fluid resuscitation. Before transfer, IV access should
thickness scald burn to the hand has caused epithelial
be established and fluid resuscitation initiated. The resus-
sloughing; the underlying epidermis and dermis are injured
but will regenerate skin. This burn has a glovelike distribution citative phase of burn injury includes consideration of the
suggestive of intentional immersion injury. Note the acute adequacy of the airway, establishment of effective gas ex-
soft tissue edema from the burn. B. A full-thickness flame change, and maintenance of circulating intravascular vol-
burn to the torso has completely injured the epidermis and ume. For severe burn injuries, the latter requires clinically
dermis. This burn wound will require excision and grafting. significant IV fluid volume resuscitation because the burn
injury creates a systemic inflammatory response that af-
fects both injured and noninjured tissues. As a result,
(BiobraneÒ; UDL Laboratories, Sugar Land, TX) or marked intravascular fluid loss and extravascular fluid se-
semipermeable silicone with a hyaluronic acid pad questration lead to hypovolemia in the first 24 hours after
(HyalomatrixÒ; Anika Therapeutics, Padova, Italy). Af- injury. The goal of fluid resuscitation is maintenance of
ter wound assessment and nonexcisional debridement, end-organ perfusion through preservation of intravascu-
the burn wound is covered with the dressing, and once lar volume. The most commonly used resuscitation for-
adherent, the dressing is allowed to remain in place until mula used to estimate IV fluid requirements after burn
new epithelium grows underneath it. The dressings are injury is the Parkland, or Baxter, formula. (9) This calcu-
typically kept dry for 1 week. The dressing will begin lift- lation is based on estimated percentage of TBSA burn
ing off in 7 to 14 days as the new epithelium becomes and the child’s weight in kilograms. The IV fluid require-
confluent. In addition, there is generally less pain and ment for the first 24 hours after burn injury is calculated
analgesic requirement once these dressings are adherent. as follows:

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emergency medicine thermal burn injuries

American Burn Association Burn Injury Severity Grading System

Table 2.

(Children)
Minor (Outpatient) Moderate (Admit to Hospital) Severe (Refer to Burn Center)
<5% TBSA burn 5%-10% TBSA burn >10% TBSA burn
<2% TBSA full-thickness burn 2-5% TBSA full-thickness burn >5% TBSA full-thickness burn
High-voltage injury High-voltage burn; chemical burn
Suspected inhalational injury Known inhalational injury
Circumferential burn Burn to face, eyes, ears, genitalia, joints
Associated medical problems (diabetes, Associated medical problems; intentional burns
sickle cell disease)
Significant associated injuries (major trauma)
TBSA¼total body surface area.
Adapted from Guidelines for the Operation of Burn Centers, Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American
College of Surgeons.

Intravenous Fluid Volume (in Milliliters) [ IV fluid that contains dextrose should be provided in ad-
Body Weight (in Kilograms) 3 Percentage of dition to burn resuscitation fluid. Controversy exists over
TBSA Burn 3 3 to 4 mL of Lactated Ringer the administration of colloid solutions during burn resus-
Solution citation, but in most burn centers that practice albumin
Therefore, a 20-kg child with a 20% TBSA burn requires administration, it is generally started after initial resusci-
an estimated 1,200 to 1,600 mL of lactated Ringer solu- tation. Adequacy of resuscitation is initially best assessed
tion in the first 24 hours after burn injury for IV fluid re- by hourly urinary output; therefore, with moderate to se-
suscitation. Half of the total fluid volume is given in the vere burn injuries, a urinary catheter should be placed. IV
first 8 hours, and half is given in the next 16 hours after fluid resuscitation should be adjusted to prevent persis-
burn injury. For children younger than 2 years, maintenance tent hypovolemia or unnecessary fluid overload. Early es-
tablishment of enteral feeding is recommended in all
severely burned children because caloric needs will be
substantial. Burn wounds that involve more than 40%
American Burn
Table 3.
TBSA induce a profound hypermetabolic inflammatory
Association Criteria for response. Currently, b-blockade using propranolol has
been demonstrated through randomized clinical trials
Referral to a Burn Center to be one of the most efficacious methods of significantly
Partial-thickness burns >10% TBSA reducing the catabolism in severe pediatric burn injuries.
Burns to the face, hands, feet, genitalia, perineum, or (10)(11)
major joints Full-thickness burns and deep dermal burns in which
Full-thickness burns (any) spontaneous healing would lead to significant functional
Electrical or chemical burns
Burns associated with inhalational injury loss require specialized surgical management. (12) A
Presence of comorbid conditions that may affect common surgical principle for full-thickness burn injuries
resuscitation and treatment includes early excision of the eschar and wound coverage
Significant associated injuries (major trauma, such as typically using skin grafts (Figure 3). Early excision and
motor vehicle crashes and explosions) grafting lead to more prompt resolution of the inflamma-
Burn injuries that exceed specialist or institutional
capacity tory response, better functional outcome, and reduced
Burn injuries with special long-term social, emotional, or hospital length of stay. The use of split-thickness skin
rehabilitative needs grafts allows harvest of the graft from a nonburned area
Suspected intentional injury of the body. Split-thickness skin grafts are generally taken
TBSA¼total body surface area. as thin grafts that measure 8/1,000-in thickness that in-
Adapted from Guidelines for the Operation of Burn Centers, clude the epidermis and a thin layer of dermis. For larger
Resources for Optimal Care of the Injured Patient 2006, Committee
on Trauma, American College of Surgeons. burn wounds with limited donor sites, the skin graft may
be meshed to provide greater coverage of the burn

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 emergency medicine thermal burn injuries

wound closure or placement of a full-thickness skin graft

typically harvested from the groin.

Long-Term Management and Expected

Outcome
A goal of contemporary burn management is to provide
a burned child adequate function, range of motion, and
acceptable cosmesis while addressing psychological and
emotional needs. Most minor burn injuries managed on
an outpatient basis will heal without functional impairment.
However, virtually all partial-thickness and full-thickness
burn wounds will heal with scarring. Hypertrophic scar
formation after burn injury is common in infants and
children, and a multidisciplinary approach is used in scar
management. For both minor and severe burn injuries,
the liberal use of lotion and massaging or rubbing the
scar may help to reduce the inflammatory response
and itching associated with healing burn wounds. Re-
duction or avoidance of sun exposure and the use of
sunscreen are essential to prevent injury to the healing
burn scar. There is an array of silicon-based scar dress-
ings and custom-fit pressure garments that assist with
maintaining skin moisture and direct pressure on scars
to reduce hypertrophy. Compression dressings and gar-
ments help to reduce scar hypertrophy during the in-
flammatory and remodeling phases wound healing.
Some burn scars will require reconstructive surgery to
maintain or increase function, range of motion, or com-
esis. Occupational and physical therapy are essential for
successful rehabilitation and preservation of the child’s
ability to perform activities of daily living. Self-image issues
Figure 3. Severe full-thickness burn injury. A. The eschar and psychosocial concerns are common in children and
has been completely removed using tangential excision. B. should be addressed prospectively, particularly in school-
Appearance of split-thickness skin grafts on postoperative aged children. Regional burn centers have dedicated phy-
day 5; the grafts were meshed to provide greater surface area sicians, psychologists, nurses, and social workers who
coverage from the donor skin. coordinate the return of a child recovering from a severe
burn injury to home and school. Many children with mod-
erate to severe burn injuries will need multidisciplinary,
wound. The donor site is generally treated as a uniform, long-term follow-up for several years after the injury.
partial-thickness wound; it will heal within 7 to 14 days of
harvest, and the donor site may be used for graft harvest
more than once. In some instances of full-thickness der- Frequently Asked Questions
mal burn, after eschar excision a dermal template com- Should Blisters Be Left Intact or “Popped”?
posed of either collagen and chondroitin sulfate or For minor burn wounds, intact blisters provide a protec-
acellular cadaveric dermis may be deployed. Once the tive environment in the form of a biological dressing. In-
dermal template has undergone neovascularization, tact blisters may be left intact as long as they are not
a split-thickness skin graft can be placed on the implant. crossing joints or otherwise limiting activity. There is
The use of dermal templates may allow for improved no benefit of placing antimicrobial ointment on intact
functional and cosmetic outcome, particularly around blisters. Once blisters rupture, they generally require de-
joints and extremities. Smaller full-thickness burn bridement to promote wound healing and prevent infec-
wounds may be managed with excision and primary tion underneath the sloughing epithelium. The ruptured

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emergency medicine thermal burn injuries

blister should be completely unroofed to prevent debris with excision and grafting should be expected to heal
and bacterial trapping and antimicrobial ointment placed with scar formation. In general, partial-thickness burns
on the exposed wound. that require longer to epithelialize will heal with greater
scarring. Protecting a healing partial-thickness burn
How Should a Facial Burn Be Managed? wound from mechanical disruption of the healing epithe-
Children who present with acute thermal facial burns lium may help to reduce scarring.
should be assessed for airway patency, associated inhala-
tional injury, and eye involvement. Burn wounds that in-
volve airway issues, inhalational injury, eyes, ears, or
significant mouth involvement should be referred to Summary
a burn center. Minor partial-thickness burns of the face
• Burn injuries include skin or tissue injury due to sun
can be managed with facial soaks using normal saline exposure, radioactivity, electricity, chemical exposure,
or water several times a day, followed by application of friction, heat, or cold. The mechanism of burn injury
bacitracin ointment or other topical antimicrobial agent. remains important because there may be other
Many burn centers will deploy either a biological or bio- medical and surgical issues associated with the type of
composite dressing for larger partial-thickness facial injury.
• On the basis of strong research evidence and
burns to reduce wound care issues. Protection of the consensus (8,12), burn severity should be described by
head and face burn from sunburn is important during estimated depth (superficial, partial thickness, or full
the short-term and long-term phases of wound healing. thickness), total body surface area (TBSA) involved
with partial- or full-thickness burn (size), and
Should an IV Catheter Be Placed Through identification of associated problems, for example,
airway control, breathing, circulation, eye
Burned Skin? involvement, and/or inhalational injury.
It is preferable to place IV catheters through intact skin, • Primarily on the basis of consensus due to lack of
but in infants and children with severe, large burns, this relevant clinical studies, pediatric burns appropriate
may not be a reasonable option. IV catheters or an inter- for outpatient management may include partial-
osseous catheter may be placed through burned skin thickness burns that involve less than 5% TBSA or
full-thickness burns that involve less than 2% TBSA. A
when necessary for transport or short-term resuscitation. clinician must use discretion and judgment and have
This is preferable to central venous catheter placement planned follow-up for all outpatient burns.
unless otherwise indicated for hemodynamic monitoring. • On the basis of strong research evidence (9) and
consensus, severe burn injury requires significant
Do All Burn Injuries Require Systemic intravenous (IV) fluid volume resuscitation because
the burn injury creates a systemic inflammatory
Antibiotics? response that affects both injured and noninjured
The acute systemic inflammatory response elicited by tissues. Fluid resuscitation is used to restore
moderate to severe burn injuries includes fever, tachycar- intravascular volume and maintain perfusion.
dia, and interstitial fluid sequestration that may mimic Estimation of initial fluid resuscitation requirements
systemic infection. However, there is no role for empiric in the first 24 hours after burn injury can be calculated
by the following equation:
systemic antibiotic administration with minor, moderate,
or severe burn injury. Systemic antibiotic administration IV Fluid Volume ðin MillilitersÞ
should be reserved for clear evidence of infection by ex- ¼ Body Weight ðin KilogramsÞ
amination of the burn wound or quantitative cultures.  Percentage of TBSA Burn
Given the loss of epidermal protection and consequent
 3 to 4 mL of Lactated Ringer Solution
dermal exposure to bacteria in partial- and full-thickness
burns, topical antimicrobial dressings and early excision
of full-thickness burns are the most useful methods to Half of the estimated IV fluid volume is given in the
prevent invasive infection. first 8 hours and the remaining half during 16 hours.
• On the basis of some research evidence (7)(8) and
Will the Burn Leave a Scar? consensus, contemporary wound care management for
The degree of scar formation is related to the depth of the a 5% TBSA partial-thickness burn includes
antimicrobial ointments, such as silver sulfadiazine,
burn wound, host wound healing capacity, and environ- biocomposite temporary skin substitutes, and silver
mental factors. Despite the fact that skin regenerates it- ion-impregnated, flexible, self-adhesive dressings.
self, partial- and full-thickness burn wounds treated

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 emergency medicine thermal burn injuries

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9. Pham TN, Cancio LC, Gibran NS; American Burn Association.
American Burn Association practice guidelines burn shock re-
suscitation. J Burn Care Res. 2008;29(1):257–266
References 10. Herndon DN, Hart DW, Wolf SE, Chinkes DL, Wolfe RR.
1. Runyan SW, Casteel C, eds. The State of Home Safety in Reversal of catabolism by beta-blockade after severe burns. N Engl J
America: Facts About Unintentional Injuries in the Home. 2nd Med. 2001;345(17):1223–1229
ed. Washington, DC: Home Safety Council; 2004 11. Gauglitz GG, Williams FN, Herndon DN, Jeschke MG. Burns:
2. Web-based Inquiry Statistic Query and Reporting System. where are we standing with propranolol, oxandrolone, recombinant
National Center for Injury Prevention and Control. http://www. human growth hormone, and the new incretin analogs? Curr Opin
cdc.gov/injury/wisqars/index.html. Accessed February 21, 2013 Clin Nutr Metab Care. 2011;14(2):176–181
3. Shields BJ, Comstock RD, Fernandez SA, Xiang H, Smith GA. 12. Engrav LH, Heimbach DM, Reus JL, Harnar TJ, Marvin JA.
Healthcare resource utilization and epidemiology of pediatric burn- Early excision and grafting vs. nonoperative treatment of burns of
associated hospitalizations, United States, 2000. J Burn Care Res. indeterminant depth: a randomized prospective study. J Trauma.
2007;28(6):811–826 1983;23(11):1001–1004

PIR Quiz
This quiz is available online at http://www.pedsinreview.aappublications.org. NOTE: Learners can take Pediatrics in Review quizzes and claim credit
online only. No paper answer form will be printed in the journal.

New Minimum Performance Level Requirements

Per the 2010 revision of the American Medical Association (AMA) Physician’s Recognition Award (PRA) and credit system, a minimum performance
level must be established on enduring material and journal-based CME activities that are certified for AMA PRA Category 1 CreditTM. In order to
successfully complete 2013 Pediatrics in Review articles for AMA PRA Category 1 CreditTM, learners must demonstrate a minimum performance level
of 60% or higher on this assessment, which measures achievement of the educational purpose and/or objectives of this activity.
In Pediatrics in Review, AMA PRA Category 1 CreditTM may be claimed only if 60% or more of the questions are answered correctly. If you score less
than 60% on the assessment, you will be given additional opportunities to answer questions until an overall 60% or greater score is achieved.

1. A 14-year-old girl is seen in the emergency department after she spilled hot liquids from a large pot filled with
beef stew that she was preparing for her family. She has reddened skin and blisters over the right arm, anterior
chest, abdomen/pelvis, and right thigh. Which of the following estimates of total body surface area
involvement is most accurate?
A. 9%.
B. 18%.
C. 27%.
D. 36%.
E. 45%.

Pediatrics in Review Vol.34 No.9 September 2013 403

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emergency medicine thermal burn injuries

2. For the girl in question 1, who has reddened skin and blister burns, after how many days should one expect the
wound to epithelialize?
A. 3 to 5.
B. 5 to 7.
C. 7 to 14.
D. 14 to 21.
E. 21 to 28.

3. A 3-year-old child who is rescued from a house fire and has soot in the nose and mouth is suspected of having
an inhalational injury. Which of the following carboxyhemoglobin levels puts him at high risk for requiring
mechanical ventilation?
A. 2%.
B. 4%.
C. 6%.
D. 8%.
E. 10%.

4. A 6-year-old girl has partial-thickness burns after a space-heater contact injury. The emergency department
physician and primary care physician confer to determine management. How extensive should this type of burn
be regarding total body surface area to mandate intravenous fluid resuscitation?
A. >3%.
B. >5%.
C. >7%.
D. >10%.
E. All partial-thickness burns.

5. A 5-year-old boy has a partial-thickness burn with multiple blisters. Which of the following management
plans regarding blisters is most appropriate?
A. Intact blisters should be left intact regardless of location.
B. Intact blisters should be dressed with antimicrobial ointment.
C. Ruptured blisters should be left without debridement.
D. Ruptured blisters should be unroofed to prevent bacterial trapping.
E. Ruptured blisters should air dry without antimicrobial entrapment.

Parent Resources From the AAP at HealthyChildren.org

The reader is likely to find material relevant to this article to share with parents by visiting these links:
• English: http://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Treating-and-Preventing-
Burns.aspx
• Spanish: http://www.healthychildren.org/spanish/health-issues/injuries-emergencies/paginas/treating-and-preventing-
burns.aspx
• English only: http://www.healthychildren.org/English/safety-prevention/all-around/Pages/First-Aid-For-Burns.aspx

404 Pediatrics in Review Vol.34 No.9 September 2013

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 Initial Assessment and Management of Thermal Burn Injuries in Children
Ramin Jamshidi and Thomas T. Sato
Pediatrics in Review 2013;34;395
DOI: 10.1542/pir.34-9-395

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/34/9/395
References This article cites 9 articles, 1 of which you can access for free at:

http://pedsinreview.aappublications.org/content/34/9/395#BIBL
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