OVERVIEW: What every practitioner needs to know

Are you sure your patient has burns? What are the typical findings for this disease?

Burns continue to be a significant cause of injury in the pediatric population. It is the third leading cause of accidental death in the pediatric population behind motor vehicle accidents and drowning. Mortality has declined because of improvements in burn management and implementation of anticipatory guidance and prevention strategies. Nevertheless, some children with moderate to severe burns still often have to go through intensive therapy and then must deal with scarring, post-traumatic stress disorders, and social difficulties.

This chapter will deal with thermal burns and chemical burns. Although there are some differences, the management is similar. Burns are generally not difficult to diagnose, however, determining the severity of the burn can be a challenge.

The American Burn Association (ABA) has classified burns into minor, moderate and major based primarily on the depth and size of the burn. The size of the burn is typically expressed as a percentage of the total body surface area (TBSA) that is burned. Superficial burns are not usually included in this estimation. A modified Lund-Browder chart is most often used in children to estimate the burn size. Most importantly, knowing when to transfer a patient to a burn center can make a significant difference in the morbidity and mortality of the patient.

The symptoms found will depend on the severity and surface area of the burn. In general, however, pain is very common in superficial and partial thickness burns. In deep partial thickness and full thickness burns, the sensation is decreased and there is only the perception of pressure or deep pressure. Other symptoms for superficial and partial thickness burns can be erythema, blanching with pressure, and blisters. For more severe burns, there is no blanching with pressure and the skin will appear waxy, leather, or may appear black or charred.

Is there an accepted grading system for burn injury severity?

A Burn Severity Grading System was developed to help providers distinguish between minor, moderate and major burns and to provide guidance regarding disposition.

To be considered a minor burn the total burn surface area (TBSA) must be less than 10% in adults and less than 5% in children or older adults. If it's a full thickness burn, then it only requires 2% to qualify as a minor burn. Disposition for these patients is generally handled in the outpatient setting.

For moderate burns, the TBSA burn in adults is 10%-20%, 5%-10% in children or the elderly, and 2-5% if it's a full thickness burn. Additionally, special types f burns are considered moderate regardless of percentage. These include high voltage injury, suspected inhalational injury, and circumferential injuries, and burns in patients who are predisposed to infections such as in a diabetic, cancer or sickle cell patient. These patients are generally admitted to the hospital for therapy.

Finally, for major burns, TBSA greater than 20% in adults, greater than 10% in children and the elderly, high voltage burns, known inhalational injury, any significant burn to the face, eyes, ears, genitalia, or joints, and anyone with significant associated injuries such as a fracture or major trauma. These patients should be referred to a burn center.

See Table I. American Burn Association Burn Injury Severity Grading

Table I.

American Burn Association Burn Injury Severity Grading System
Burn Type Minor Moderate Major
Criteria <10% TBSA Burn in Adults<5% TBSA burn in young children or the elderly<2% full thickness burn 10-20% TBSA burn in adults5-10% TBSA in young children or the elderly2-5% full-thickness burnHigh voltage InjurySuspected inhalational injuryCircumferential burnMedical problem predisposing to infection (Diabetes Mellitus, Sickle Cell Disease) >20% TBSA in adults>10% TBSA burn in young children or the elderly>5% full thickness burnHigh voltage burnKnown inhalational injuryAny significant burn to face, eyes, ears, genitalia, or jointsSignificant associated injuries (fracture of other major trauma)
Disposition Outpatient Admit to Hospital Refer to Burn Center

Are there graphic representations to aid with determination of total body surface area burned?

Refer to Figure 1 (Infant Lund Browder chart) and Figure 2 (Rule of nines).

Figure 1

Infant Lund Browder Chart

Figure 2

Rule of Nines

What other disease/condition shares some of these symptoms?

There are some medical diseases that can mimic thermal or chemical burns. These include Steven's Johnson, Toxic epidermal necrolysis, epidermolysis bullosa, staphylococcal scalded skin syndrome, and erysipelas.

What caused this disease to develop at this time?

Because burns are typically related to exposure, there are not lab values, epidemiologic information, nutrition or genetic information that is helpful. Certainly exposure and questions related to household chemicals, profession, home safety, and fire safety are pertinent in determining how or why the patient was burned.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

  • Although there are no laboratory studies that will help confirm a diagnosis of a burn in a patient, there are a few basic laboratory studies that may be useful as the patient is being followed.

    • Complete Blood Count (CBC) that reveals an unexpectedly low hemoglobin or hematocrit should instigate an investigation into associated injuries leading to occult blood loss, or it may be low secondary to a dilutional effect of aggressive fluid resuscitation. Maintaining adequate oxygen carrying capacity is important when treating any patient, but specifically burned patients and so knowing the hemoglobin level is imperative.

    • Basic metabolic panel which includes electrolyes, BUN and creatinine are helpful because of the significant fluid shifts and metabolic changes that occur in a burned patient.

    • Carbon monoxide level may be indicated if the patient was in a fire.

    • Total and ionized calcium are helpful in patients with chemical burns from hydrofluoric or hydrochloric acid.

    • Other laboratory studies should be done based on the pattern of injury. For example, in a crush injury, a urinalysis for myoglobin is helpful.

    • Blood, urine or cerebrospinal fluid cultures are not routinely done, especially early in diagnosis or management.

Would imaging studies be helpful? If so, which ones?

Imagine studies are indicated depending on the mechanism of injury. If the burn is fire related, then a chest x-ray and upper airway film may be indicated for suspected inhalational injury. If there is concern for other trauma, then the imaging studies should be based on the injury. Alternatively, in burns in which there is no concern for airway or breathing abnormalities then no routine imaging is necessary.

Confirming the diagnosis

The Journal of Burn Care and Rehabilitation (April 2001 pp17) published an algorithm for initial burn management that was developed through a collaborative task force supported by the ABA, the National Coalition of Burn Center Hospitals, and Paradigm Health Corporation, which reviewed the literature to develop practice guidelines. The guidelines and algorithm use Class II and Class III evidence.

See attached algorithm(Figure 3) of initial assessment of burn injury.

Figure 3.

Algorithm for initial assessment of burn injury.

If you are able to confirm that the patient has burns, what treatment should be initiated?

Initial and emergent management

The initial management of a child with either a thermal burn or a chemical burn begins with the ABC's. Airway, breathing and circulation is assessed early and immediately, and supplying supplemental oxygen, especially if the burn was the result of a fire, is important. There are other priorities in the early management of these patients that should be done whether the burn is a chemical burn or a thermal burn. First, removing the patient from the environment and removing all clothing and jewelry will help stop the burning process. In the case of a chemical burn, brushing away any dry chemical from the patient will help decrease the exposure to the patient.

In patients with thermal burns, the burn can be covered with a clean sheet and pain medication should be provided. If there is concern for upper airway involvement the patient should be intubated immediately before the airway anatomy becomes distorted. Soot in the mouth or burns on the face or nose may be a better predictor of an inhalational injury than symptoms of hoarseness or stridor.

Early intubation is also indicated if the patient has a decreased level of consciousness, possibly secondary to carbon monoxide or cyanide which can interfere with ventilation. Circumferential burns can limit chest wall compliance and may lead to respiratory compromise as well and intubation should be considered in these patients. When intubating a burn patient, rapid sequence intubation should be performed. Etomidate and succinylcholine can be used if there is no risk for hyperkalemia. Preserving the blood pressure is important as these patients have significant shifts in fluid and blood pressure.

Children may present with signs of circulatory collapse and should be assessed carefully for other injuries. If these children have no other injuries and they are tachycardic with poor peripheral perfusion and hypotension they may be experiencing "burn shock". Burn shock occurs in patients with large burns, usually >15-20% TBSA. Inflammatory mediators lead to increased capillary permeability and depressed myocardial function which can cause hypotension and shock.

Patients with moderate to severe burns with or without circulatory compromise require aggressive fluid resuscitation. If possible, a central venous catheter should be placed. If no other access is available, an intraosseous line is indicated.

The Parkland formula for fluid resuscitation is favored over other methods because of its simplicity. 4ml/kg per percent TBSA burned of resuscitation fluid is used for initial fluid management. Ringers lactate is used rather than normal saline. In patients younger than 5 years old, maintenance fluid is added to the resuscitation fluid and 5% dextrose is recommended to be added in these patients to prevent hypoglycemia. Half of the resuscitation fluid is given in the first 8 hours and the rest is given over the ensuing 16 hours.

It's important to recognize that these fluid formulas provide only an estimated amount of fluid necessary. Following urine output and clinical status is essential. A urine output of 1-2ml/kg/hour is appropriate for children under 30 kilograms and 0.5-1ml/kg/hour is adequate for patients over 30 kg. An unusually high urine output can be deceiving and can indicate hyperglycemia which is common in burn patients and can provoke an osmotic diuresis. Checking the urine for glucose can help determine whether hyperglycemia is contributing to the urine output.

Early pain control is also important. Most burn centers use morphine, however fentanyl can be used in patients with unstable blood pressure.

Early wound management is limited to cleaning with a mild soap and warm water. Any debris in the wound bed should be removed. Debridement of the necrotic tissue can help decrease the risk of infection and can help determine the true depth of the burn. This early debridement can be done with sterile saline soaked gauze.

There is some controversy related to unroofing blisters. A large painful blister or one that is likely to rupture is generally removed. Smaller blisters that are not painful may be left alone. If the patient is to be transferred to a burn center quickly, simply cover the burn with a dry sterile dressing. No ointments should be applied because they can interfere with burn assessment at the burn center.

For any patient not being immediately transferred to a burn center, partial and full thickness burns should be dressed. The dressing should be moist and provide a barrier that reduces the risk for infection. The dressing should not adhere to the wound and topical antibiotics can be used to reduce the risk of infection. The dressing can be held in place by gauze wrap or a net tubular wrap. In partial thickness burns treated in an outpatient environment, topical antibiotic creams are not necessary.

If the patient has a partial or full thickness burn and has not been immunized to tetanus or the immunization status is unknown, tetanus immunoglobulin should be given. If the patient has not received a tetanus booster within 5 years then a tetanus booster should be administered.

For chemical burns, the initial management is the same. Remove the patient from the environment, remove clothing and jewelry to stop the burning process. Brush away any dry chemical from the patient to help decrease exposure. The use of copious irrigation is often important. There are some chemical exposures that can cause worsening of the burn if exposed to water. These will be discussed later.

Using warm water in high volumes but low pressure decreases the risk of hypothermia and scattering of the chemical. Irrigation should begin at the site of contamination and the eyes and face. Irrigation of the face prevents further inhalation or ingestion of the chemical. Guidelines for irrigation of chemical burns are not supported by good evidence.

For any chemical burn, continuous irrigation until the pH of the skin returns to normal is necessary. Re-checking the pH of the skin 15-20 minutes after irrigation is stopped can help determine whether there is any residual chemical. For eye exposures, irrigation for 15 minutes is typically sufficient for the eye pH to return to normal. Additionally, penetration into the cornea is unusual. Early ophthalmologic evaluation is recommended in these cases.

The treatment of burn wounds can be complex. Burn wound healing is a complicated process with three phases: inflammation, proliferation and tissue formation, and tissue remodeling. The tissue remodeling can take several weeks to months and the fibroblast is an important component to this remodeling.

Often, in partial and full thickness burns, the wound bed can become colonized with bacteria. This can delay the wound healing process. Several topical options have been used to decrease the bacterial load and promote healing. Silver sulfadiazine is one of the most common and most well known topical agents. The sulfadiazine has a bacteriostatic effect on the bacteria while the silver disrupts the endocellular structures of the bacteria.

There is no data, however, to support that silver sulfadiazine decreases bacterial wound infections despite it's bacteriostatic activity. It has been combined with other agents to promote improved wound healing. The chart below shows some of the common agents used in the topical treatment of burns and includes the clinical indications and contraindications of each.

Longer term management and treatment

Further treatment depends upon the severity, size, and location of the burn. In circumferential partial or full thickness burns an escharotomy may be indicated if respiratory compromise or compartment syndrome is a problem. An escharotomy is done by making an incision through the depth of the burn eschar. This is done by a surgeon familiar with the care of burn patients, typically in a burn center.

Additionally, patients with severe burns are at high risk from infection. Careful monitoring of their temperature, vital signs, and clinical status is critical for early identification of a potentially deadly infection. Central lines must also be fastidiously attended to in order to prevent a deep vein thrombosis or line infection.

Burn patients are also susceptible to hyperglycemia. Tight glucose control has been linked with better outcomes in children with severe burns. Furthermore, aggressive nutritional support and dealing with the systemic inflammatory response help to improve outcomes in children with severe burns.

Physical therapy, occupational therapy and speech therapy may play a role in both the long term and short term treatment of patients with moderate to severe burns.

Skin grafting is also a potential long term treatment that any patient with moderate to severe burns may have to discuss with their doctor.

What are the adverse effects associated with each treatment option?

In the early treatment of a burned patient, fluid resuscitation is a major component of treatment. As with any aggressive fluid resuscitation effort, there is the potential to overload the patient with fluid that exceeds the ability of the heart to manage. This may lead to pulmonary edema. Careful clinical observation for signs of fluid overload or myocardial depression can help prevent this from occurring.

In chemical burns, aggressive irrigation may cause splaying of the chemical to other parts of the body. Therefore, careful, low pressure, but copious irrigation is the appropriate management of most chemical burns to prevent this from occurring.

Early wound debridement can cause bleeding and pain. Having the patient under good pain control is absolutely essential. Also, ensuring that the appropriate surgical subspecialist is available for debridement will decrease the risk of bleeding and infection during and after wound debridement.

The topical options for treatment all have some contraindications. They are listed In Table II. The adverse effects are primarily related to allergic type reactions the patient may develop from the topical treatment.

Table II.

Topical Burn Treatment
Antimicrobial Agents Clinical Indications Contraindications
Silver sulfadiazine Small, medium or large surface area burns Burns near the eyesPregnant WomenBreastfeeding womenBabies under 2 months of ageAllergy to sulfa drugsSigns of re-epithelialization
Silver sulfadiazine plus cerium Small, medium and large surface area burns Burns near the eyesPregnant womenBreastfeeding womenBabies under 2 months of ageAllergy to sulfa drugsSigns of re-epithelialization
Topical antibiotic ointments Face, ears, perineum, allergies to sulfa drugs Bacterial resistanceAllergySigns of re-epithelialization
Providone-iodine Not used unless no other agent is available Children under 2 years of agePregnant womenBreastfeeding womenThyroid disordersMay inhibit fibroblast activity

What are the possible outcomes of burns?

The prognosis and the outcome are dependent upon the nature of the burn (chemical, fire, electrical, etc.), depth, and the TBSA burned. Often, scarring is inevitable for anything deeper than a superficial burn regardless of treatment. For full thickness burns, grafting is often necessary. If the patient had a severe inhalational injury, there may be long term lung complications. If there was a caustic ingestion and the oral cavity or esophagus was affected, a g-tube for feeding may be necessary for the short, and sometimes, the long term.

The mortality rate for children receiving burn care in a burn center is about 3%. This has decreased over the years. Infection continues to be a source of morbidity and mortality in the burn population. In addition to the short term morbidities and risk of mortality, there may be long term disabilities that a patient with severe burns faces. Long term physical and occupational therapy may be needed to keep the patient from developing contractures and to learn how to use their affected limbs. Psychological counseling might be necessary to deal with post-traumatic stress disorders which are commonly seen in burn patients.

The risks and benefits of each treatment option should be discussed with the family. It is important to make sure the family understands that any early decision about morbidity and mortality must be reserved until the full extent of the burn can be established. Therefore, the benefit of early interventions such as intubation, fluid resuscitation, central access placement, and transfer to a burn center outweigh the risks of these procedures. The later treatment options such as escharotomy, skin grafting, types of topical agents should be discussed as they come up. Certainly a discussion about escharotomy and skin grafting should be reserved for the surgeons who specialize in severe burn care.

What causes this disease and how frequent is it?

  • Detailed epidemiology:

    • Incidence, seasonal variation, age distribution

      • In the United States about 120,000 children receive care in the emergency department for fire or burn related injuries. Many burns are minor and the patients do not receive care, so in all likelihood, the true incidence is under represented. The most common causes of burns are scalding injuries in the less than 5 year old age group. In older children, flame burns are common, and they are more common in males than females. Fireworks can be a seasonal cause of burns. Otherwise, there is no true evidence of seasonal variation.

    • Predisposing exposures (zoonoses, environmental, toxin, activities)

      • Certainly not following safety guidelines for fireworks, lighters and chemicals and other objects or substances that have a high risk of causing a burn is the most common reason for an injury resulting from their use. Otherwise, there are no predisposing exposures.

How do these pathogens/genes/exposures cause the disease?

When a patient experiences a thermal burn, the thermal energy causes denaturation and coagulation of proteins. This results in irreversible tissue destruction. Surrounding this area of tissue destruction is an area of decreased tissue perfusion. In some cases, this zone may be salvageable if the initial resuscitation efforts are successful in restoring perfusion to that area.

In children, burns are often deeper despite a similar insult than in adults because their skin is thinner. The intensity and duration of the exposure determines the depth of the burn.

There is also a systemic response when a patient has a moderate to severe burn. Vasoactive mediators are released from the tissue that has been damaged and there is increased capillary permeability. This causes intravascular fluid to extravasate into the extravascular space around the burn. If the TBSA is greater than 15% for young children and 20% for adults, this release of vasoactive mediators can cause a systemic response. Depressed myocardial activity, hypotension, and edema can result. Additionally, hemolysis may occur at the site of the burn. The decrease in oxygen deliver that results from hemolysis and anemia can lead to worsening of burn shock.

There may also be an exacerbated metabolic response after a severe burn. Increased catecholamine, glucagon, and cortisol release can increase catabolism in these patients. The metabolic demands may be difficult to meet in these patients for several days.

Other clinical manifestations that might help with diagnosis and management

The basic management of a chemical burn is similar to that of a thermal burn. The earliest intervention is almost always copious irrigation. There are a couple of chemical burns for which water is contraindicated or used with caution. The concentration and potency of the chemical as well as the duration of contact will determine the degree of tissue destruction.

The following chemicals are not treated with immediate water irrigation because it can cause a harmful exothermic reaction or it can release hazardous by products. Some of these chemicals include dry lime, phenol, muriatic acid, concentrated sulfuric acid, elemental potassium, and sodium. Antidotes do not play a big role in the treatment of chemical burns. The most common exception is hydrofluoric acid.

  • Dry Lime: This should be brushed off the skin prior to irrigation. When combined with water it can form calcium hydroxide which is a very strong alkali.

  • Muriatic acid: Often used in residential swimming pool. It is an impure form of hydrochloric acid.

  • Sulfuric acid and muriatic acid produce extreme heat when combined with water. If possible, these agents should be treated with soap prior to irrigation.

  • Burn Assessment: Chemical burns can be difficult to assess because burns that appear superficial may really be quite deep. Frequent re-examination is necessary to observe for on-going tissue damage.

  • There is also the possibility of systemic toxicity in chemical burns. Inhaled vapors can cause both inhalational injuries, as well as systemic toxicity. Chemicals absorbed through the skin can also cause systemic toxicity. Consulting with poison control is very important in making sure that patients exposed to chemical burns are treated appropriately.

  • Hydrofluoric Acid - this will denature the skins proteins and cause coagulation necrosis. It penetrates quickly through the epidermal layer and dermal layer. The fluoride ions will complex with calcium and magnesium which can lead to hypocalcemia and hypomagnesemia. This can have a cardiotoxic effect and can lead to arrhythmias. This is the primary cause of death in patients exposed to hydrofluoric acid.

  • Treatment:

    • Hydrofluoric Acid - treatment of this is with copious irrigation and intravenous calcium. The calcium ions complex the free fluoride ions to correct cellular and systemic hypocalcemia. IV calcium gluconate can be given as 1000 mg slowly over 2-3 minutes if there are cardiac arrhythmias, prolonged QTc or obvious systemic illness. It can also be given as a nebulized solution in the event of an inhalational injury. Calcium gluoconate gel is also applied to the burned areas. The pain is caused by free fluoride ions. As the calcium becomes complexed to the fluoride, the pain will be relieved. Injection of calcium into the digits is not recommended.

    • Muriatic or Sulfuric acid - use a mild soap on these burns before copious irrigation begins.

    • Call Poison Control 1-800-222-1222 for questions related to other chemical exposures not listed here.

What complications might you expect from the disease or treatment of the disease?

The long term complications of a patient who has sustained a moderate to severe burn, whether it is chemical or thermal, depends on the degree and severity of the burn. Burns over joints can limit movement in the short and long term for patients which may affect their activities of daily living. Aggressive physical therapy and occupational therapy are helpful in managing these complications.

If there was an inhalational injury, the patient may experience long term effects of lung damage. If there was an upper airway or esophageal injury, long term feeding through a g-tube may be necessary.

Skin grafting and escharotomy have their own inherent risks and long term complications that should be discussed with the family by the surgeon performing the surgery. Most burns that are moderate or severe in nature will result in a scar regardless of whether the patient had grafting or not.

How can burns be prevented?

Thermal burns can be prevented in most circumstances. Home safety counseling during pediatric well visits can decrease the risk of burn related injuries. Ensuring that parents know how to turn down the temperature on the water heater can help prevent scalding injuries. Keeping the stove knobs and oven door child proofed, and keeping lighters, lighter fluid, matches, and other flames away from children is important. Additionally, having a fire escape plan in place in the event of a house fire has been shown to decrease mortality related to house fires.

Chemical burns are often caused by household cleaning agents. Exposure to these in the form of fumes, contact, or ingestion can seriously injure or cause the death of a child. Anticipatory guidance about keeping all household chemicals in a locked cabinet, as well as what to do in the event of an exposure is really important. All families should be given the Poison Control number so they can begin management of any exposure while awaiting EMS.

What is the evidence?

D'Souza, AL, Nelson, NG, McKenzie, LB. "Pediatric Burn Injuries Treated in US Emergency Departments between 1990-2006". Pediatrics. vol. 124. 2009. pp. 1414-30.

Costagliola, M, Agrosi, M. "Second-degree burns: a comparative, multicenter, randomized trial of hyaluronic acid plus silver sulfadiazine vs". silver sulfadiazine alone. Current medical Research and Opinion. vol. 21. 2005. pp. 1235-40.

Schulman, CI, King, DR. "Pediatric Fluid Resuscitation After Thermal Injury". The Journal of Craniofacial Surgery. vol. 19. 2008. pp. 910-2.

Saffle, J. "Practice Guidelines for Burn Care: Chapter 13". Journal of Burn Care and Rehabilitation. April 2001. pp. 1-80.

Hartford, CE. "American Burn Association, Journal of Burn Care and Rehabilitation". vol. 11. WB Saunders. 1996. pp. 98.

Lyons, JM, Davis, C, Rieman, MT, Kopcha, R, Phan, H, Grennhalgh, D. "Prophylactic Intravenous Immune Globulin and polymixin B decrease the incidence of septic episodes and hospital length of stay in severely burned children". Journal of Burn Care and Research. vol. 26. 200. pp. 813-8.

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