Management of paediatric burns
- A W N Reid, core trainee year 2, plastic surgery,
- J Akhtar, foundation year 2, plastic surgery,
- O P Shelley, consultant plastic surgeon
- Correspondence to: A W N Reid awnr2@cam.ac.uk
An 11 year old girl presented to an accident and emergency department with an injury to her right foot. She had splashed hot oil from a pan on to her socks while preparing food in the kitchen. Her mother had immediately placed the affected foot in cold water for 15 minutes and dressed the injury with cling film. Her mother had then taken her without delay to the hospital. The girl had no other injuries and non-accidental injury was not suspected. She was otherwise fit and well, she was not taking any regular drugs, and she had no allergies.
On arrival, she was given oral paracetamol and intranasal diamorphine analgesia. On initial examination, the affected area on the right foot measured 4×5 cm; some of the area appeared pink, the rest of the area was covered with blisters. After deroofing of the blisters using plastic forceps (figure⇓), all the affected skin was moist, blanched on gentle pressure, and was sensate. Routine general examination was otherwise unremarkable.
Questions
- 1 What is the per cent total body surface area of the burn and how is this determined?
- 2 What is the probable depth of this burn?
- 3 Would you use intravenous fluids to resuscitate this child?
- 4 Would you discuss this burn with the specialist burn centre? Justify your decision
- 5 What are the potential complications of this particular burn?
Answers
1 What is the per cent total body surface area of the burn? How is this determined?
Short answer
Long answer
Burn surface areas are usually estimated using Wallace’s rule of nines for adults: head and neck is 9%, each upper limb is 9%, trunk front is 18%, trunk back is 18%, each lower limb is 18%, and the perineum is 1%.2 Lund and Browder charts show the changes in total body surface area of these regions with age and should be used to calculate the per cent of total body surface area burnt in children.2
Another useful method for adults and children (particularly with smaller burns such as this) is that the palm (together with fingers) corresponds to about 0.8% of the total body surface area: 0.78% total body surface area (standard deviation 0.08%) in adults and up to 0.87% (0.06%) in young children.1
Only include de-epithelialised areas (only dermal or full thickness burns) when calculating per cent total body surface area. A common mistake is to include areas of erythema confined to the epidermis.2
2 What is the probable depth of this burn?
Short answer
Superficial dermal. Although the burn appears lighter than the patient’s normal skin tone, the examination findings (moist, blanched on gentle pressure, and sensate) are clinical features of this depth of burn (table⇓). Blistering denotes a dermal burn but does not help determine whether it is superficial or deep dermal.
View this table:
Characteristics of burns of different depths2 3
Long answer
The depth of some burns (particularly contact burns from flames or immersion) may be underestimated unless the wound is gently washed and any blisters deroofed.
Burn wounds are dynamic and need re-assessment over the next 24-72 hours because they may progress during this time.2
3 Would you use intravenous fluids to resuscitate this child?
Short answer
No, the burn is less than 10% of the total body surface area, which is the threshold for defining a major burn that requires intravenous fluids in children.
Long answer
This child does not require intravenous fluid resuscitation because the burn is less than the 10% total body surface area threshold for children.2
Major burns (>15% total body surface area in adults and >10% total body surface area in children) require resuscitation with intravenous Hartmann’s solution (adults) or 0.18% NaCl/4% dextrose solution (children). The Parkland formula is used to calculate the volume needed as follows: 3-4 ml × (% total body surface area) × (weight in kg). Half of this volume should be given in the first eight hours after the burn and the remainder in the next 16 hours.4
Over-resuscitation after burns is a contentious area, and the American Burn Association has recently suggested a resuscitation threshold of 20% total body surface area in adults and children, using a formula of 2-4 ml/kg/% total body surface area.5
The aims of intravenous fluid resuscitation in major burns are to maintain vital organ perfusion and tissue perfusion to the zone of stasis around the burn and thereby prevent extension of thermal necrosis.2 In major burns in children, a maintenance regimen of 0.18% NaCl/4% dextrose solution should be given in addition to the resuscitation volume.
However, formulae are only a guide and infusions should be tailored to urine output. For major burns, an indwelling urethral catheter should be inserted to monitor hourly urine output.
4 Would you discuss this burn with the specialist burn centre? Justify your decision
Short answer
Yes. The location of this burn is on a “critical site”—the feet.
Long answer
The National Burn Care Review issued guidelines for referring burns cases to a specialist centre. You should discuss any complex burn6 including:
- Burns over a certain size (>5% total body surface area in children, >10% total body surface area in adults)
- Burns in patients under 5 years or over 60 years
- Burns caused by high pressure steam, high tension electricity, chemicals (>5% total body surface area or >1% for hydrofluoric acid)
- Burns on the face, hands, feet, perineum, flexures (including neck or axilla); also circumferential burns of a limb, the torso, or neck
- Inhalation injuries
- Burns in patients with serious comorbidity (or immunosuppression, pregnancy, associated injuries)
- When non-accidental injury is suspected.
Such burns should be referred because the clinical course may be complex and require the experience and resources of a specialist centre.
5 What are the potential complications of this particular burn?
Short answer
- Infection
- Toxic shock syndrome, which is often missed. It is a rare but serious complication and the most common cause of unexpected death in children with small burns.9
Long answer
Complications include infection, scarring, and the rare—but serious—complication of toxic shock syndrome.
Scar hypertrophy is more common in certain areas of the body, such as the feet. Problems of hypopigmentation and hyperpigmentation are more common in people with dark skin.7 8 Permanent scarring is more likely to occur in burns that take longer than 30 days to heal10 and deeper burns treated with skin grafting.2
Toxic shock syndrome is a rare but serious complication that must not be missed because children with even small burns can die from it.9 The incidence of toxic shock syndrome has been estimated at 2.5% of children admitted to burns centres.11 The condition is mediated by endotoxins from Staphylococcus aureus or group A Streptococcus, which are both part of the normal skin flora. Systemic signs include temperature over 38.9°C, erythematous rash, gastrointestinal disturbance, and lethargy or irritability within a few days of burn injury.9 Treatment includes fluid resuscitation, anti-staphylococcal antibiotics, and fresh frozen plasma or intravenous immunoglobulin.9
Outcome
This girl came back to the burns centre outpatient clinic two days after initial presentation for routine wound review. She was followed up every two to three days thereafter and discharged after two weeks, by which time the burn injury had healed with minimal scarring.
Footnotes
- Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
- Provenance and peer review: Commissioned; externally peer reviewed.
- Parental consent obtained.
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