Critical Burns

Burns are among the most common causes of injury and unintentional death in children and adolescents in the United States. Depending on the mechanism of injury, burns can range from superficial to life-threatening. The National Burn Repository reports that just over half of burns in children younger than 5 years are scald burns, while older children typically are injured by flame burns from residential fires or ignition of flammable substances.

Assessment

Mortality in burned children is directly proportional to the size of the burn. Accurate estimate of burn size is crucial to the care of the burned pediatric patient. The following tables estimate burn depth and the percentage of total body surface area (TBSA) of burns.

Assessment of Burn Depth

DEGREE	DEPTH	HISTORY	SENSATION	APPEARANCE	HEALING
1st degree	Superficial	Momentary exposure	Sharp, uniform pain	Blanches red, pink, edematous, soft, flaking, peeling	± 7 days
2nd degree	Partial thickness	Exposure of limited duration to lower temperature (40-55°C)	Dull or hyperactive pain, sensitive to air/temperature changes	Mottled red, blanches red/pink, blisters, edema, serous exudate, moist	14-21 days
3rd degree	Full thickness	Long duration of exposure to high temperature	Painless to touch and pinprick, may hurt at deep pressure	No blanching, pale white, tan charred, hard, dry, leathery, hair absent	Granulates, requires grafting
4th degree	Underlying structures	Prolonged duration of exposure to extreme heat	Usually painless	Charred, “skeletonized” with possible exposed bone	Amputation, fasciectomy

[Image] — **Modified Lund and Browder Chart for Estimating Percentage of Total Body Surface Area of Burns by Age**

Management

Airway, breathing, and circulation (ABCs): As always, careful attention to the airway, breathing, and circulation is crucial for initial assessment and stabilization of the patient. ABC assessment is as important on arrival to the PICU, regardless of where initial triage and management occurred.

Inhalation injury: The airway should be carefully examined for signs of inhalation injury. Clues to injury of the upper and lower airway include burns to the face, singed nasal hairs, soot in the oropharynx, and carbonaceous sputum. Respiratory distress may be present, including tachypnea, use of accessory muscles of breathing, and stridor. If inhalation injury is suspected, difficult intubation should be anticipated, and the airway should be secured by the most experienced physician available. The following is an algorithm for the management of suspected inhalation injury:

Vascular access: Obtain reliable vascular access; this may require central venous cannulation.

Fluid resuscitation: In general, burns >20% TBSA are associated with large fluid shifts and require careful management of volume status.

The Parkland formula is an appropriate starting guideline for fluid resuscitation for most children. Half the fluid is given during the first 8 hours from the time of onset of injury; the remaining fluid is given at an even rate during the next 16 hours. The rate of infusion is adjusted according to the patient’s response to therapy. Heart rate and blood pressure should return to normal for age, and an adequate urine output (1-2 mL/kg/hour in children; 0.5-1.0 mL/kg/hour in adolescents) should be accomplished by varying the IV infusion rate. Vital signs, acid-base balance, and mental status reflect the adequacy of resuscitation.

Parkland Formula

Volume of lactated Ringer solution = 4 mL x kg x % TBSA burned

Whether colloid (albumin) should be provided in the early period of burn resuscitation is controversial. If utilized, one approach is to administer colloid replacement concurrently with crystalloid therapy if the burn is >85% of TBSA (e.g., 50% albumin infusion, 50% crystalloid infusion). Colloid is usually administered 12 to 24 hours after the burn injury.

Wound care: Debridement of dead tissue reduces the risk of infection, and early debridement of deeper burns has been associated with better outcomes. Application of topical antibiotics to partial-thickness burns with dry sterile dressings should be done in collaboration with a burn surgery team.

Nutrition: Nutritional support is extremely important to the healing of wounds, preferably with early enteral nutrition whenever possible.

Hypermetabolic response: Burns are associated with a hypermetabolic state, and attenuation of this response with beta-blockers and medications (e.g., oxandrolone) should be considered.

Infection: Prophylactic antimicrobial therapy is recommended only for coverage of the immediate perioperative period surrounding excision or grafting of the burn wounds to cover the documented increased risk of transient bacteremia. Surveillance cultures of the wounds, especially if the patient arrived from another unit or location, are standard of care in most burn units and essential for guiding empiric antimicrobial therapy if infection is suspected.

Pain management: Burns can be extremely painful, as are debridement and dressing changes, especially in children. Management of pain and anxiolysis is paramount to the care of the burned child in the ICU. Common medications include morphine and fentanyl infusions and bolus doses for breakthrough pain or wound manipulation. Midazolam and lorazepam are commonly used for anxiolysis. Ketamine can be used for procedural sedation and analgesia. Pruritus can also be managed with diphenhydramine, hydroxyzine, and gabapentin.

Other Injuries

An understanding of the mechanism of the burn is important for evaluation of other traumatic injuries and comorbidities. Trauma consults should be obtained for all burned children if suggested by history or if the patient was found unconscious with an unknown history. House fires should prompt suspicion for cyanide and carbon monoxide toxicity that should be treated promptly.

American Burn Association Burn Center Referral Criteria

Burn injuries that should be referred to a burn center include:
• partial thickness burns ≥10% TBSA
• burns that involve the face, hands, feet, genitalia, perineum, or major joints
• full thickness burns in any age group
• electrical burns, including lightning injury
• chemical burns
• inhalation injury
• burn injury in patients with preexisting medical conditions that could complicate management, prolong recovery, or affect mortality
• burn injury with concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of morbidity or mortality; if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit; physician judgment is necessary and should be in concert with the regional medical control plan and triage protocols
• burn injury with poorly controlled pain
• burn injury in children at hospitals without qualified personnel or equipment for the care of children
• burn injury in patients who will require specialized social, emotional, or rehabilitative intervention

Research

Landmark clinical trials and other important studies

Research

Antiseptics for Burns

Norman G et al. Cochrane Database Syst Rev 2017.

In this Cochrane Review of 56 randomized-controlled trials, the evidence was unclear whether antiseptics were associated with any difference in healing, infections, or other outcomes.

Antibiotic Prophylaxis for Preventing Burn Wound Infection

Barajas-Nava LA et al. Cochrane Database Syst Rev 2013.

In this Cochrane Review of 36 randomized, controlled trials, the evidence was unclear about the effects of antibiotic prophylaxis In burn patients.

Colloid Normalizes Resuscitation Ratio in Pediatric Burns

Faraklas I et al. J Burn Care Res 2011.

This small study demonstrated that the addition of colloid to burn resuscitation of pediatric patients may help improve overall fluid balance.

Fluid Resuscitation in Major Burns

Mitra B et al. ANZ J Surg 2006.

This retrospective review of children at one major burn center found that fluid-resuscitation volumes higher than estimated by traditional formulas were administered without complications.