Acute management of burns in Pediatrics

Pediatric burns are a significant cause of morbidity and mortality. They require specialized management due to physiological differences between children and adults, such as larger relative body surface area, thinner skin, and increased risk of hypothermia and hemodynamic instability.

Prevention is key, but adequate acute management is essential to improve prognosis and reduce long-term sequelae.

2.1. Depth Determination

• First Degree (Superficial): Only epidermis, erythema, pain, no blisters.
• Second Degree (Partial Thickness):
  • Superficial: Papillary dermis, blisters, pink, painful, filled with capillaries.
  • Deep: Reticular dermis, broken blisters, whitish, less pain, slow capillary refill.
• Third Degree (Total Thickness): All layers, pearlescent/charred color, painless, leather texture.

2.2. Estimation of Burned Body Surface Area (%SCQ)

The "Rule of Nines" is not accurate in children. Use the Lund-Browder table or the "Palm Rule" (the patient's palm, including fingers, represents approximately 1% of his SCQ).

Important: Only second and third degree burns are included in the %SCQ calculation for liquid resuscitation.

23. Airway Assessment and Inhalation Injury

Look for signs such as facial burns, charred nasal vibrissae, carbonaceous sputum, dysphonia, stridor, and a history of closed-space burns.

3.1. Stopping the Burning Process

Remove burned clothing, jewelry. Cool with warm water (15-25°C) for 10-20 minutes. Avoid ice water to prevent hypothermia.

3.2. Airway, Breathing and Circulation (ABC)

• Airway: Ensure permeability. Early intubation if there are signs of inhalation injury or impending compromise.
• Breathing: Assess breathing. Supplemental oxygen.
• Circulation: Establish vascular access (2 routes if >10% SCQ).

3.3. Water Resuscitation (Modified Parkland Formula)

Fluid resuscitation is crucial in second and third degree burns with %SCQ > 10% in children. Lactated Ringer's solution is used.

Modified Parkland Formula (Burns):
For second and third degree burns:
3 mL x Weight (kg) x %SCQ (in the first 24 hours)
Administer 50% of this volume in the first 8 hours from the burn, and the remaining 50% in the following 16 hours.

Holliday-Segar formula (basal maintenance):

• First 10 kg: 100 mL/kg/day
• Next 10 kg (11-20 kg): 50 mL/kg/day
• Each additional kg (>20 kg): 20 mL/kg/day

The intravenous fluid calculator in the “Liquid Calculator” tab now considers both requirements.

Hospitalization or referral to a pediatric burn center should be considered in the following cases:

• Second degree burns > 10% SCQ.
• Any third degree burn.
• Burns affecting the face, hands, feet, genitals, perineum or major joints.
• Circumferential burns.
• Inhalation injury.
• Electrical or chemical burns.
• Burns in children with pre-existing comorbidities.
• Signs of child abuse.
• Any burn where there is doubt about the ability to care for it at home.

Pain is a prominent feature of burns and must be managed aggressively. Use a pain scale appropriate for the child's age (e.g. FLACC, Wong-Baker, VAS).

• Oral pain relievers: Paracetamol, NSAIDs (for mild to moderate pain).
• Opioids: Morphine, fentanyl (for moderate to severe pain). Administer safely and titrate the dose.
• Non-pharmacological considerations: Distraction, music therapy, parental presence.

The goal is to prevent infection, promote healing, and minimize scarring. Daily cleaning is essential.

• Cleaning: With mild soap and water or sterile saline solution.
• Debridement: Remove non-viable tissue and broken blisters. Small intact blisters may be left.
• Dressings: Variety of options depending on depth and extension (silver sulfadiazine, hydrogels, silver dressings, etc.). Regular dressing changes.
• Tetanus prophylaxis: Assess vaccination status.

7.1. Infection

Frequent complication. Monitor for signs of local and systemic infection. Cultures if there is suspicion. Antibiotics according to antibiogram.

7.2. Hypothermia

Children lose heat quickly. Maintain warm environment, warm liquids.

7.3. Compartment Syndrome

In deep circumferential burns. Requires escharotomy or fasciotomy.

7.4. Metabolic Alterations

Hypoglycemia, electrolyte imbalance. Frequent monitoring.

Burned children have a significant hypermetabolic state. Proper nutrition is vital for healing and recovery.

• Early start: As soon as possible, preferably enterally.
• High calories and protein: Calculate requirements individually.
• Supplements: Vitamins (A, C, E), zinc.

Burns are traumatic experiences for children and families. Psychological support is crucial.

• Family support.
• Evaluation of post-traumatic stress, anxiety, depression.
• Early intervention by child psychologists.
• Promote social and school reintegration.