Pediatric Burns - Work-up and Management

Epidemiology
- 3rd most common cause of death by injury in children
- 60% of all pediatric burns are scalds
- In 160F water, burns start after 1 sec exposure
What percentage of peds burns result from abuse?
- 14% are nonaccidental in children <1y
- Almost all NAT burns are in kids under 10yrs, majority under 2yrs
- 10% of child abuse cases are burns
- 10% of peds burn admissions are abuse
- Suspicious features: immersion burns; donut burns (sparing of central buttocks due to
contact with the cooler porcelain surface of a bathtub, with surrounding burns)
- Burns involving genitals, buttocks, or perineum
- Burns on dorsum of hand
- Burn markings that look like objects (cigarettes, irons)
Assessment
Body surface area calculation
- Rule of 9s applies if child is >15y
- Modified rule of 9s for younger children:
- Head & neck 18%
- Each lower ext 15%
- Each upper ext 9.5%
- Ant torso 9.5%
- Post torso 16%
- Quick-and-dirty estimate: palmar surface of childs hand = 1% BSA
Management
- Immediate: ABCs
- Be sure to assess airway for heat / smoke damage - directly visualize!
- Ensure full exposure - particularly for clothing soaked with chemicals
- Avoid topical Abx until pt stabilized
- When to admit to burn unit (per American Burn Assoc guidelines):
- Partial thickness burns > 10%TBSA
- Burns to face, hands, feet, genitals, perineum, major joints
- Presence of any third-degree burns
- Any electrical burns
- Any chemical burns
- Inhalation injury present
- Pre-existing medical condition that could complicated mgmt
- Burns + trauma andburns are the more life-threatening injury
- If trauma is more life-threatening, stabilize at trauma ctr before
sending to burn ctr
- Social, emotional, long-term rehab needs
- Fluid resuscitation
- PO resuscitation for burns < 15% TBSA; else: IV

Inhalation injury
- 20-30% of major burns
- 40% higher mortality vs non-injured airways
- High-freq percussive ventilation can help in kids more than adults
- Aerosolized heparin/N-AC helps break down mucus (in PICU)

Fluid resuscitation for burns in pediatric patients:

Demographic group

Burn protocol

Older children; or >

20kg

Parkland (4mL/kg/%TBSA burned for first 24h)

- Give 50% of total vol in first 8h post burn
- Target UOP 50mL/hr

Kids < 20kg

Galveston Shriners formula:

- Based on BSA [height (cm)^0.725] x [weight (kg) ^
0.425] x [0.007184]
- 1st 24h after injury:
- 5L/m2 TBSA burned PLUS 2L/m2
TBSA maintenance
- Half total vol given in first 8h
- >24h after injury:
- 3750mL/m2 TBSA burned or open
PLUS 1500mL/m2 TBSA
- Target UOP:
- Infants 2mL/kg/hr
- Children 1mL/kg/hr

For kids < 2yrs

Add 5% dextrose - hypermetabolic state following burns can last

up to 12 mos
- 25kcal/kg/day Plus 40kcal/%TBSA burned

For standard dehydration, trauma, shock:

- Initial resuscitation: 20mL/kg bolus wide-open/push-pull, re-assess BP after bolus in
- Maintenance fluids: 4-2-1 rule
- 4mL/kg/hr for first 10kg
- 2mL/kg/hr for next 10kg
- 1mL/kg/hr for each kg above 20kg