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Chapter 10. Pediatric Burns
As discussed earlier, presence of facial burns suggests a
likelihood of inhalation injury; however, definitive diagnosis
is obtained with bronchoscopy. Ocular involvement, particularly corneal epithelial injury, is assessed with fluorescein test.
Evidence of severe retrobulbar edema in the setting of inelastic periorbital eschar should prompt swift lateral canthotomy
to avoid devastating effects of retinal ischemia due to
increased ocular pressures [22].
The possibility of non-accidental trauma must always be
considered in young children. Patterns of injury that raise
suspicion include spared upper extremities, “stocking and
glove” lower extremity symmetry, or clearly demarcated
cigarette or iron shaped wounds. Burns appearing older
than reported, wounds inconsistent with given history, or
identification of concurrent fractures are also concerning
for abuse [14, 23].
Perhaps the most important step after quantifying burn
injury is to assess whether the evaluating center has appropriate medical and surgical capabilities to fully care for the
burned pediatric patient in question. The American Burn
Association has documented well-defined criteria to warrant
transfer to a burn center—factors pertinent to pediatric
patients include partial-thickness burns greater than 10%
TBSA, burns involving face, genitalia, or perineum, inhalation injury, and burns in the setting of concomitant trauma.
239
Resuscitation
To prepare for forthcoming resuscitation, obtaining reliable
intravenous (IV) access is paramount. Bilateral large bore
peripheral IVs are preferred, even if inserted through burned
skin. Should edema preclude peripheral IV access, a central
vein can be cannulated [7, 21]. If all attempts fail, intraosseous
access can be obtained; volumes upwards of 100mL per hour
can be infused into the bone marrow. Additionally, a Foley
catheter is inserted to accurately measure urine output
throughout the resuscitative process.
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The ideal resuscitation fluid is isotonic and adequately
replaces deficient electrolytes. In all ages, lactated Ringer’s
solution is most commonly used within the first 24 h [6].
Infants are prone to hypoglycemia due to their limited glycogen stores. Thus, strict blood glucose monitoring is imperative
in children less than 1year old and dextrose-containing maintenance fluids should be added as supplementation [21].
For burns less than 15–20% TBSA, large volume
resuscitation is not indicated. Instead, maintenance fluid via
IV or oral routes will suffice, with close clinical monitoring of
volume status [24]. For larger burns, the Advanced Trauma
Life Support (ATLS) 10th edition recommends a pediatric
derivation of the Parkland formula, 3mL/kg/% burn. Other
commonly used pediatric resuscitation formulas are the
Galveston and Cincinnati formulas which are based on body
surface area (Table10.1). Compared to the Parkland formula,
the latter two include provisions for a maintenance rate as
well as administration of 25% albumin to combat loss of
oncotic gradient [11]. Colloid infusion, as early as 8–12h after
injury, has shown to decrease total crystalloid requirement
during resuscitation [25, 26].
These formulas offer guidance for resuscitation, but
require continuous adjustments as clinical and laboratory
parameters change. Patients’ hourly urine output is the most
frequently relied upon set point, aiming to achieve a goal of
1mL/kg/h in children less than 30kg and 0.5mL/kg/h in children greater than 30 kg [27]. Additional endpoints include
base deficit <3mEq/L, lactate <2mmol/L, patient arousability, and warm extremities with full pulses [24, 28].
Close bedside monitoring is pivotal, as under- and overresuscitation both pose significant morbidity. Insufficient
fluid volumes result in inadequate tissue perfusion and subsequent end-organ failure, whereas excessive volumes induce
“fluid creep” and its devastating sequelae: pulmonary edema,
pleural effusion, extremity or abdominal compartment syndromes, and acute respiratory distress syndrome [6, 27, 29].
Albumin infusion has been shown to help mitigate such complications [30].
Chapter 10. Pediatric Burns
½ over next
16h
½ over first 8h
½ over next
16h
½ over first 8h
½ over next
16h
5%
dextrose as
needed
5%
dextrose as
needed
241
None None ½ over first 8h
T . Pediatric formulas for burn uid resuscitation
Formula Calculation Crystalloid Colloid Glucose Administration
Parkland 3mL/kg/%TBSA Ringers
12.5g of 25% albumin
lactate
Ringers
2
Cincinnati 4mL/kg/%TBSA +
per liter of crystalloid in
last 8h of the first 24h
12.5g of 25% albumin
per liter of crystalloid
lactate
Ringers
lactate
2
BSA
total BSA
2
1500mL/m
burned+2000mL/m
total BSA
Galveston 5000mL/m
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Patients with persistent hemodynamic instability receiving
fluids at or exceeding calculated rates should prompt suspicion of other etiologies, including cardiogenic in nature.
Hemodynamic monitoring in tandem with echocardiography
may be implemented, with possible consideration of vasopressor support [10]. Real-time clinical interpretation is
essential as resuscitation is a dynamic process.
Analgesia andSedation
Pain management and sedation are important aspects of
pediatric burn care. Aside from pain caused by the acute burn
itself, the patients’ subsequent hospital course and recovery
will consist of innumerable dressing changes, operative procedures, and physical therapy. If undertreated, pain from these
interventions can lead to feelings of depression, insomnia,
fear, and helplessness even long after the injury [31]. Thus,
analgesic and anxiolytic regimens must be implemented early
and effectively.
Opioid medications are heavily utilized for pain
management following burn injury [39]. Despite the current
paradigm shift away from opioid administration in the field of
medicine, burn pain is very challenging to treat. With frequent dressing changes and procedural interventions, patients
suffer multiple bouts of acute pain superimposed with baseline pain from the initial injury. For rapid and effective
analgesia, morphine sulfate and fentanyl are most commonly
used via intermittent intravenous push [32].
Additionally, given the complex nature of burn pain,
physicians should strive to incorporate multimodal therapy
with the ultimate goal to reduce opioid requirement as time
from injury lengthens. Scheduled acetaminophen and
nonsteroidal anti-inflammatory drugs are often implemented
as background pain control [33]. Gabapentin and pregabalin
are important adjuncts known to address neuropathic pain [34,
35].
Chapter 10. Pediatric Burns
243
Sedation may be procedural or continuous. Many
medications are used for both, but with varying doses and
routes of administration depending on the indication.
Continuous sedation is generally implemented in patients
requiring intubation. Particularly in children intubated for
inhalation injury, maintenance of adequate sedation is
crucial to ensure security of the endotracheal tube.
Commonly, benzodiazepines are co-administered with
opioids due to their synergistic interaction. Dexmedetomidine
has gained increasing popularity due to its partial analgesic
effects, preservation of respiratory drive, and less hypotensive
events [32, 36, 37]. Perhaps most relevant to the pediatric
population is its ability to induce sedation that closely parallels natural sleep [31]. Propofol is another widely used
agent, generally for short- term sedation. Benefits include its
rapid clearance and recovery; conversely, it is known to
cause hypotension due to global vasodilation and cardiac
depression. Burn injury greatly impacts pharmacokinetics,
thus it is important to monitor clinical response and titrate
dosing accordingly [31, 32].
Procedural sedation must be tailored specifically to each
patient, based on extent of wounds, pain tolerance, and dressings required. Intravenous benzodiazepines, such as midazolam and lorazepam, are most commonly selected as they
produce rapid-onset effects with high potency. Particularly
important in the pediatric population, these achieve anterograde and retrograde amnesia, anxiolysis, and muscle relaxation. Midazolam has the benefit of shorter duration of
action (30–120 min) thus is the mainstay of procedural
sedatives, especially if administered via the oral route [31].
Ketamine is a dissociative agent that produces sedation, analgesia, and amnesia. Having minimal effects on cardiopulmonary function, both IV and intramuscular ketamine are
widely implemented as safe and effective therapy [38, 39].
Although not yet widely instituted, intranasal dexmedetomidine is a recently emerging agent for procedural premedication in children, demonstrating efficacy similar to that of
benzodiazepines [40].
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Aside from the aforementioned medications, many nonpharmacologic interventions can help diminish fear and anxiety. These include maintaining a sleep-wake cycle, intrusive
noise reduction, ensuring comfortable positioning, and maximizing the presence of family members at the bedside [41].
Play therapy is an essential component of daily stress relief
and social development; incorporating child life specialists
into the care plan has shown to further alleviate periprocedural anxiety [32]. Fostering a sense of familiarity and
normalcy for pediatric patients is crucial to facilitate
convalescence.
Wound Management
Burn wound management principles are covered elsewhere
in this textbook, however there are some important points to
emphasize when managing pediatric burn patients. The current burn center protocol is to debride partial-thickness
burns and apply a durable burn dressing, which has been
shown to reduce pain [42, 43]. Nonetheless, the optimal dressing selection should provide a moist, protective wound healing environment.
Topical antimicrobials such as bacitracin, polymyxin, or
silver sulfadiazine can be used on burns of limited extent to
help minimize the risk of infection. Silver sulfadiazine
(Silvadene), while bactericidal and relatively painless upon
application, can promote accumulation of proteinaceous exudate on the wound surface and retard epithelialization.
Prolonged use of silver sulfadiazine uncommonly causes a
reversible leukopenia, thus monitoring may be indicated.
Mafenide acetate (Sulfamylon) offers gram negative coverage, including Pseudomonas and has excellent penetration
into eschar and cartilage. Thus it remains the drug of choice
for extensive full-thickness burns involving the ear and nose,
as exposed cartilage increases the risk of developing chondritis. Disadvantages include pain on application, lack of antifungal activity, and development of metabolic acidosis if
Chapter 10. Pediatric Burns
applied to large surface areas due to inhibition of renal carbonic anhydrase after systemic absorption. Due to these
potential adverse effects, its use should be limited to burns
less than 20% TBSA.
Silver-impregnated fabric and foam dressings have largely
replaced silver sulfadiazine and mafenide acetate. They contain biologically active silver ions, which provide antibacterial
properties as well as facilitate absorption of excess wound
exudate. These dressings can be changed every 7days or until
reepithelialization of the burn occurs with the additional benefit of less pain with less frequent dressing change, thus mitigating parental concern about dressing changes at home [44].
Other biologic options include allografts, xenograft, and
amniotic membrane. Dermal substitutes such as acellular
human dermal substitute, bovine collagen and shark cartilage
glycosaminoglycan, and biodegradable temporizing matrix
may also be utilized as a temporary wound covering to prepare a wound bed prior to grafting. These latter products may
be best suited for use at burn centers with more extensive
experience and training.
245
Surgical Treatment
It is widely recognized that early surgical excision and skin
grafting have decreased morbidity and improved survival and
cosmesis following burn injury in the pediatric population [27,
45]. Early excision decreases progression of the hypermeta-
bolic burn state and reduces risk of subsequent wound
infection [46]. As previously discussed, it is imperative for the
evaluating physician to determine whether the center has
appropriate medical and surgical capabilities to fully care for
the burned pediatric patient.
Partial-thickness burns often present with loose, sloughing
tissue and blisters that can be adequately managed in an outpatient setting or by an emergency physician. Management of
blisters is a source of controversy in the burn community;
however, the collective goals remain constant: preventing
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infection, reducing time to epithelialization, improving functional and aesthetic outcome, and optimization of patient
comfort [47]. Sloughed tissue and broken blisters can be
debrided with coarse gauze, soap, and warm water. Intact
blisters may be broken to promote patient comfort or left in
place to act as a biological dressing against infection. Some
authors recommend blister debridement for lesions greater
than 2cm [43].
For large surface area partial- or full-thickness burns,
surgical treatment is best undertaken at a burn center. Initial
surgical management involves cleaning the wound and
debridement of necrotic tissue. Typically, tangential excision
of full-thickness burns is performed using Weck blade, or
dermatome until healthy, viable tissue is encountered.
In some cases, serial debridements may be required as
the wounds continue to declare their true depth during
24–48 h after burn, especially in cases of electrical injury.
Skin grafting can often be performed at the time of excision,
however in patients with massive (>40% TBSA) burns, the
pace of definitive wound closure is limited by the availability of viable donor skin sites and hemodynamic status of the
patient. In these situations, excision and grafting have to be
completed in stages over a period of weeks. If there is concern regarding quality of the wound bed, final extent of
burn depth or a patient’s physiologic status, temporizing
measures such as allografts, dermal substitutes, or negative
pressure wound therapy devices may be utilized for shortterm wound coverage [8]. These alternatives are left in
place, for a period of days to weeks, to provide wound coverage, promote early mobilization, and minimize risk of
infection [48–50].
Chapter 10. Pediatric Burns
247
Reconstruction
With improved resuscitative and surgical techniques, large
burns in children once thought to be fatal are now successfully managed [6, 12, 51]. Due to improved survival rates, burn
reconstruction has emerged as a major aspect of long-term
pediatric burn care. While the technical components are
beyond the scope of this text, knowledge of available
resources and options for reconstruction allows the non-burn
specialist to communicate effectively with reconstructive colleagues and provide appropriate counseling to patients and
their families.
The basic concerns in pediatric burn reconstruction are
function, comfort, and appearance. In addition to the physical
wound or tissue defect, surgical planning should also account
for overall social, emotional, and neurocognitive development
of the child. Hypertrophic scarring, scar contractures, loss of
form and function, and changes in color and texture of injured
skin are common concerns among pediatric burn patients and
their caretakers. To address these problems, understanding the
principle of the reconstructive ladder is paramount. In short,
one should employ the most simple technique if possible and
progress to more complex techniques when necessary.
If there is minimal deficiency and surrounding tissues are
easily mobilized, direct closure or local tissue rearrangement
with Z-plasties can be performed to address hypertrophic
scars or contractures. For larger or more complex defects,
reconstruction with split or full-thickness skin grafts or
locoregional flaps may be required. For select anatomic
regions with a paucity of soft tissue, advancements in tissue
expansion and free tissue transfer utilizing microsurgical
techniques have made coverage of large wounds possible
even in very young infants and children [52–54].
Finally, laser scar modulation has revolutionized burn
reconstructive algorithms for children, often preceding other
reconstructive efforts regardless of anatomic location [55,
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56]. It is important to note that children may outgrow an
initial adequate result and could require multiple reconstructive operations as they continue to grow and develop.
Physicians should manage both patient and family expectations appropriately while providing them with the necessary
tools for long-term follow-up, thus ensuring optimal reconstructive results.
Conclusion
Pediatric burn care has evolved substantially in recent
decades, largely due to implementation of a holistic approach
with collaboration from community physicians, nurses, dietitians, therapists, and surgeons [57]. The challenge remains in
ensuring that providers account for anatomic and physiologic
differences in children throughout the initial evaluation,
acute resuscitation, and surgical management. Prompt referral to a multidisciplinary burn center is of utmost importance
for major pediatric burns. Fortunately in this population,
most burns are minor and can often be managed in the primary care setting with excellent long-term outcomes by utilizing the strategies presented in this chapter.
References
1. Burn Prevention. Centers for disease control and prevention.
Centers for Disease Control and Prevention; 2019 [cited
2021Feb21]. https://www.cdc.gov/safechild/burns/index.html
2. Armstrong M, Wheeler KK, Shi J, etal. Epidemiology and trend
of US pediatric burn hospitalizations, 2003-2016. Burns. 2020;
https://doi.org/10.1016/j.burns.2020.05.021.
3. Reed JL, Pomerantz WJ. Emergency management of pediatric
burns. Pediatr Emerg Care. 2005;21(2):118–29.
4. Strobel AM, Fey R.Emergency care of pediatric burns. Emerg
Med Clin North Am. 2018;36(2):441–58. https://doi.org/10.1016/j.
emc.2017.12.011.
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