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Chapter 10
Pediatric Burns
EricS.Ruff, NikhilR.Shah, RamonL.Zapata-Sirvent,
andJongO.Lee
Introduction
Pediatric burns are a leading cause of injury and mortality both
in the United States and abroad. Each day, over 300 children
ages 0–19 are treated in emergency departments for burn-
E. S. Ruff (*)
Department of Plastic and Reconstructive Surgery, University
of Texas Medical Branch, Galveston, TX, USA
e-mail: esruff@utmb.edu; razapata@utmb.edu
N. R. Shah
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
e-mail: nikshah@utmb.edu
R. L. Zapata-Sirvent
Department of Plastic and Reconstructive Surgery, University
of Texas Medical Branch, Galveston, TX, USA
Shriners Children’s Texas, Galveston, TX, USA
e-mail: esruff@utmb.edu; razapata@utmb.edu
J. O. Lee
Department of Surgery, University of Texas Medical Branch,
Galveston, TX, USA
Shriners Children’s Texas, Galveston, TX, USA
e-mail: jolee@utmb.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_10
233
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E. S. Ruff et al.
related injuries [1]. Recent studies, however, have shown that
ED visits for pediatric burns have been decreasing, suggesting
that care for less severe burns may be taking place in outpatient settings such as urgent care or primary care offices [2].
The type of burn injury is often related to the child’s age
and developmental stage. In the toddler age group, scald
burns from hot liquids or grease predominate, as well as contact burns from stoves or grills. Younger children tend to suffer thermal burns from lighters or matches, while older
children and teens are more likely to sustain flame burns
from risk-taking activities such as use of flammable substances or fireworks [3]. Chemical burns and high-voltage
(>1000 volts) electrical injuries may also be encountered in
the pediatric population. Fire and flame-induced burns
account for the majority of fatalities, whereas death due to
scald burns are exceedingly rare. Risk factors for mortality in
burned children are larger total body surface area (TBSA)
burn, inhalation injury, multiorgan failure, age less than
4years old, and non-accidental burn [4].
Notably, 16–20% of children admitted with burns are
victims of abuse, which significantly increases mortality, though
possibly due to concomitant injuries [3]. This should be considered when there is a delay in presentation or the history of the
burn does not match the pattern of the injury. Anatomic location of the burn is an unreliable factor in differentiating nonaccidental and accidental burns, however burns on both lower
extremities convey a three times greater likelihood of being an
abusive injury [5]. There are also patient- and parent- specific
risk factors one should consider when there is suspicion of
child abuse. Patient-specific risk factors include children with
behavioral problems, chronic conditions, and disabilities.
Parent-specific risk factors include unplanned pregnancies,
single-parent household, mental illness, partner violence, and
substance abuse. Obtaining collateral information from social
workers can be beneficial; however, physicians do not need to
definitively diagnose abuse but rather have reasonable cause
to suspect it in order to report it to child protective services.
Emergency care of each pediatric burn patient requires an
individualized care plan. Consideration must be given to the
mechanism and size of the burn, age-specific relationship
Chapter 10. Pediatric Burns
between body surface area and body weight when calculating
fluid replacement, and physiological differences between
children and adults. A critical understanding of these variables is essential to improving both short- and long-term
outcomes in this population.
235
Pathophysiology
Patients suffering less than 15% TBSA burns generally have
minimal systemic manifestations. Larger burns have the
potential to cause overwhelming inflammatory states, especially in the pediatric patient [6]. Pathogenesis has been
found to be largely multifactorial.
Breakdown of the integumentary barrier leads to large
evaporative losses. This, in tandem with intravascular depletion from impaired function of capillary tight junctions, leads
to devastating hypovolemic shock [4, 7]. The pediatric population has lower circulating volumes and can decompensate
rapidly after such insults [8]. Burn injury also induces an
overwhelming vasoplegic state. This is attributed to an array
of endogenous substances, including nitric oxide, histamine,
and reactive oxygen species [9]. The resulting distributive
shock further reduces tissue perfusion.
Finally, the notion of post-burn cardiomyopathy has become
increasingly prevalent, particularly in the initial 24–48h period
[10]. This is believed to be cytokine-mediated; interleukin-6,
interleukin-8, and monocyte chemoattractant protein-1 have
been found to be markedly elevated in children following thermal injury [11, 12]. Although reportedly reversible, cardiac
depression poses diagnostic and resuscitative challenges [13].
Expeditious patient evaluation and intervention are crucial to
systematically address all etiologies of burn shock.
Initial Evaluation
If feasible, a targeted history from a parent, caretaker, or
witness should be taken to ascertain details about the burn
occurrence, environment, and inciting events. Etiology of
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E. S. Ruff et al.
accidental versus non-accidental trauma should be further
investigated as well. The time of presentation may be distant
from the time of injury which should warrant alteration of
resuscitation strategies. Patients presenting more than four
hours after injury without appropriate explanation should
raise concern for possible child abuse [14]. Nonetheless, all
major burn patients are assumed to be trauma patients and
must be evaluated in the same systematic approach.
As such, the airway and breathing take precedence.
Supplemental oxygen should be applied if there is suspicion
for inhalation injury, particularly after a house or building
fire, during which prolonged smoke exposure is common.
Physical examination may demonstrate significant facial
burns, singed nasal hair or eyebrows, or carbonaceous soot in
the oropharynx. Arterial blood gas and carboxyhemoglobin
levels may assist in decision-making as pulse oximetry readings are typically normal in patients with carbon monoxide
poisoning [15]. Warning signs that may indicate impending
respiratory failure include tachypnea, stridor, and hoarseness,
and should prompt emergent intubation [4].
Children with burns involving a large TBSA (>20%) or
younger than two years old also necessitate a low threshold
for intubation [3, 4, 16]. Younger children have considerably
smaller airway diameters, thus even minimal edema from
large volume fluid resuscitation may induce life-threatening
obstruction. If ventilation becomes difficult or airway pressures increase in the setting of circumferential thorax burns,
escharotomies may be indicated to restore adequate chest
expansion.
Circulation is often challenging to assess in a severely
burned patient. Palpation of distal pulses, assessment of capillary refill, and blood pressure monitoring should be attempted
if possible; however, invasive monitoring may be necessary. In
the infantile and younger pediatric population, a femoral
arterial line is likely easier to secure. Of note, inability to
appreciate extremity pulses in the setting of circumferential
eschar may also indicate need for escharotomy.
Chapter 10. Pediatric Burns
Following evaluation of the trauma “ABCs,” the secondary
survey should ensue. Efficient “head to toe” evaluation is
performed to identify additional traumatic injury. Those
involved in explosive or electrical burns are at high risk for
associated intracranial, intraabdominal, or orthopedic injuries. However, the inability of the neonatal or infant patient
to convey and localize pain greatly limits early identification
of these injuries. Thus it may be necessary to obtain full
body radiographic and tomographic imaging following
stabilization.
Clothing and coverings should be removed to expose all
burn wounds. This step often occurs earlier during initial
evaluation if the patient suffered chemical burns, as any residue retained on clothing could inflict further caustic injury
[4]. The reflexive tendency to apply ice should be avoided.
Clean sheets and blankets should be applied in order to
maintain normothermia. External warming devices and room
temperature manipulation may be required in the pediatric
population, as they inherently have lower muscle and soft tissue mass. Desired ambient and core body temperatures range
from 30 to 35°C and 36 to 38°C, respectively [17].
237
Extent ofInjury
Only wounds that are partial- and full-thickness are accounted
for when assessing extent of injury, especially if planning for
surface area-based resuscitation. Clinical evaluation of wound
depth is estimated to be accurate 60–75% of the time in the
general population, however this may be even lower in
children. Having thinner dermis, children’s burn injury often
requires 24–48h to evolve; serial wound examinations may
help delineate true depth [18, 19]. It is important to note that
burns may often be mixed-thickness, however the deepest
component is generally identified at the center. This is due to
vessel thrombosis at the periphery, causing a centripetal pattern of injury.
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E. S. Ruff et al.
F . Lund and Browder chart for estimation of burn size in
pediatric patient
The standard “Rule of Nines” cannot be readily applied to
patients younger than 15years of age due to a significantly
higher surface area to body weight ratio. This skewed ratio
manifests because of children’s large cranial surface area
compared to extremities [18, 19]. As such, Lund and Browder
chart can be used, in order to rapidly assess extent of injury
[20] (Fig.10.1). For non-confluent regions, the patient’s palmar surface with fingers adducted may approximate 1% of
body surface area [21].
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