Initial Management
Primary Assessment
- Follow the ABCDE approach: Assess Airway (with cervical spine protection), Breathing, Circulation, Disability (neurological status), and Exposure (remove clothing while preventing hypothermia).
- Inhalation injury assessment is critical in children, especially with facial burns, singed nasal hairs, carbonaceous sputum, hoarseness, or history of being in an enclosed fire.
- Monitor for signs of carbon monoxide poisoning, including headache, confusion, nausea, and bright red skin color.
Key Points
- Children have smaller airways that can swell rapidly; early intubation may be necessary with suspected inhalation injury.
- Circumferential burns on the chest can restrict breathing; escharotomy may be needed.
Fluid Resuscitation
- The Parkland Formula is commonly used: 4 mL × weight (kg) × % TBSA burn, with half given in the first 8 hours and the remainder over the next 16 hours.
- Maintenance fluids must be added to calculated resuscitation fluids for children (unlike adults) due to their limited glycogen stores and higher metabolic rates.
- Lactated Ringer's solution is typically used for initial resuscitation as it closely resembles plasma composition.
Key Points
- Children require more fluid per kilogram than adults due to higher body surface area to weight ratio.
- Urine output is the best indicator of adequate fluid resuscitation: target 1 mL/kg/hr for children <30 kg, 0.5-1 mL/kg/hr for larger children.
ALERT: Fluid overload can occur more easily in children than adults. Monitor for signs including periorbital edema, increasing respiratory rate, crackles on auscultation, and S3 heart sounds.
Burn Wound Cooling Procedure
- Remove all clothing and jewelry from the affected area
- Run cool (not cold) water over the burn for 10-20 minutes
- Never use ice water as it can worsen tissue damage
- Avoid applying any ointments, butter, or home remedies before medical evaluation
- Cover the burn with a clean, dry sheet or non-stick dressing
- Elevate burned extremities above heart level if possible
Clinical Scenario: Pediatric Scald Burn
A 2-year-old child is brought to the emergency department after pulling a pot of boiling water onto himself. He has partial-thickness burns covering his anterior chest (9%) and right arm (4.5%). He weighs 12 kg.
Assessment findings: Crying, alert, respiratory rate 32, heart rate 150, temperature 37.2°C. Burns appear red, blistered, and moist.
Priority nursing actions:
- Establish IV access and begin fluid resuscitation: 4 mL × 12 kg × 13.5% = 648 mL in first 24 hours (324 mL in first 8 hours) plus maintenance fluids
- Administer pain medication as ordered
- Apply clean, dry dressings to burns
- Monitor vital signs, urine output, and pain levels
Ongoing Management
Pain Management
- Pain assessment must be age-appropriate using tools such as FLACC scale (for infants/young children), Wong-Baker FACES scale (ages 3+), or numerical scale (older children).
- Intravenous opioids (morphine, fentanyl) are typically used for moderate to severe burn pain, with dosing carefully calculated based on weight.
- Procedural pain (during dressing changes) often requires additional pre-medication or anxiolytics.
Key Points
- Untreated pain can lead to increased metabolic demands, delayed healing, and psychological trauma.
- Children may become tolerant to opioids quickly during prolonged treatment; dosage adjustments may be necessary.
Wound Care
- Initial cleansing should be gentle using mild soap and water or saline, with debridement of loose, devitalized tissue.
- Topical antimicrobial agents commonly used include silver sulfadiazine (not for face or infants under 2 months), bacitracin, or silver-impregnated dressings.
- Dressing changes frequency depends on the agent used and wound condition, typically ranging from daily to every 3-7 days for specialized dressings.
Key Points
- Silver sulfadiazine should be avoided on facial burns (can cause hyperpigmentation) and in children under 2 months (risk of kernicterus).
- Monitor for signs of infection: increasing pain, erythema, purulent drainage, foul odor, or systemic symptoms like fever.
Nutritional Support
- Children with burns have significantly increased metabolic rates, sometimes up to 2-3 times normal, requiring proportional increases in caloric intake.
- Protein requirements increase to 2.5-4 g/kg/day (compared to normal 1-1.5 g/kg/day) to support wound healing and prevent catabolism.
- Enteral feeding is preferred when possible, with early initiation (within 24-48 hours) showing improved outcomes.
Key Points
- Regular nutritional assessment is essential; children can rapidly develop malnutrition which impairs wound healing.
- Vitamin C, zinc, and additional micronutrients are often supplemented to support collagen synthesis and immune function.
Memory Aid: Burn Assessment "DEPTH"
D - Depth (superficial, partial, full-thickness)
E - Extent (% TBSA using pediatric measurements)
P - Pain level (appropriate age-based assessment)
T - Time since injury (affects treatment approach)
H - History (mechanism, enclosed space, chemicals involved)
Complications & Special Considerations
Infection Prevention
- Burn wounds create an ideal environment for bacterial growth due to loss of skin barrier, presence of devitalized tissue, and impaired local immune response.
- Common pathogens include Pseudomonas aeruginosa, Staphylococcus aureus, and various fungi, with infection risk increasing with burn size and depth.
- Tetanus prophylaxis should be administered if immunization status is unknown or not current.
Key Points
- Prophylactic systemic antibiotics are not recommended for routine burn care unless there are signs of infection or specific indications.
- Strict aseptic technique during all wound care procedures is essential to prevent nosocomial infection.
Scarring & Rehabilitation
- Children are particularly prone to hypertrophic scarring and contracture formation due to their growing bodies and more robust healing responses.
- Early positioning, splinting, and range of motion exercises are critical to prevent contractures, especially over joints.
- Pressure garments are typically used for 12-18 months after wound closure for scars at risk of hypertrophy.
Key Points
- Rehabilitation should begin during the acute phase, not after discharge.
- Children may require frequent garment replacements due to growth, with non-compliance being a common issue.
Psychological Impact
- Children with burns may experience significant psychological trauma, including post-traumatic stress disorder, anxiety, depression, and body image issues.
- Age-appropriate interventions include play therapy, art therapy, cognitive-behavioral techniques, and family support programs.
- School reintegration programs are essential to address potential social challenges and bullying.
Key Points
- Psychological assessment should be incorporated into routine burn care from admission through long-term follow-up.
- Parents/caregivers often experience significant guilt and may require their own psychological support.
Child Abuse Considerations
- Inflicted burns account for approximately 10-20% of all pediatric burn injuries and require mandatory reporting.
- Suspicious patterns include: sharply demarcated "stocking/glove" immersion burns, symmetrical burns, burns in protected areas (buttocks, perineum), and cigarette burns.
- Inconsistent history, delayed presentation, previous injuries, and inappropriate caregiver reactions are additional warning signs.
Key Points
- All healthcare providers are mandatory reporters of suspected child abuse.
- Documentation should be thorough and objective, including photographs when possible.
ALERT: Immersion burns with clear lines of demarcation, especially in a stocking/glove distribution or on the buttocks/perineum, strongly suggest non-accidental injury and require immediate reporting to child protective services.