Children’s university hospital,
Burns and scalds account for 6% of peadiatric injuries.
The majority involve pre-school children,burns being
most common between 1-2 yrs,flame burns bet 5-18
House fires are the cause of most fatal burns with
smoke inhalation being the immediate cause of death
in many cases.
Scalds are most commonly associated with hot drinks
in toddlers,also occur with over heated bath water and
hot cooking oil.
Consider NIA in children.
Children have nearly 3 times BSA:BM ratio of
adults.consequently greater fluid requirements
and more evaporative water loss than adults.
children <2yr have thinner layers of skin and
insulating sub cutaneous tissue than older
children and adults.Burn that may appear partial
thickness may instead be a full thickness burn.
Severity of burn is related with
2.Duration of contact.e.g.,
At 44c tissue damage occurs with 6hrs of contact
with heat source while
At 70c epidermal injury occurs in just 1sec.
Wounds caused by exposure to:
1. Excessive heat
excision untilexcision until
fine punctatefine punctate
Partial thickness burn
Deep partial thickness
Full thickness =
involves all of skin
Involves only the
Tissue will blanch with
Tissue is erythematous
and often painful
Involves minimal tissue
Referred to as partial-
Involve the epidermis and
portions of the dermis
Often involve other
structures such as sweat
glands, hair follicles, etc.
Blisters and very painful
Edema and decreased
blood flow in tissue can
convert to a full-thickness
Referred to as full-
Charred skin or
translucent white color
Area insensate – patient
still c/o pain from
degree burn area
Complete destruction of
tissue and structures
tissue, tendons and
PT and FTB with affected BSA>10% under 10yrs
PT and FTB with affected BSA>20% over 10 yrs
FTB with affected BSA>5%.
PT or FTB involving face,hands,feet,perinium or
PT or FTB involving an inhalational burn.
PT or FTB involving an electrical or chemical burn.
% BSA involved morbidity
Burn extent is calculated only on individuals with second
and third degree burns
Palmar surface = 1% of the BSA
Rule of Nines:
Quick estimate of percent of burn
Lund and Browder:
More accurate assessment tool
Useful chart for children – takes into
account the head size proportion.
Rule of Palms:
Good for estimating small patches of burn
Weigh pt or perform accurate estimate.
Establish time and mode of burn injury and note time
Resusitate according to APLS,EPLS guidelines i.e.,
Establish access rapidly.
Contact burn surgeon.
Consider need to protect airway and intubate.
If housefire or possibility of inhalational give 100% o2
and measure COHb levels.
As the primary survey is starting ,give high flow o2
from face mask with a reservior bag.
A cervical collar should be applied if potential injury
spine from a fall or escape.
Cooling the burn wound –cold running water for 15-20
min,avoid making pt hypothermic.
Prevent hypothermia-there is disruption to
thermoregulation with a significant burn.
Insert min 2 peripheral cannula in unburnt skin if
Fluid resusitate according to protocol
Insert urinary catheter in all pts>20% BSA.
Fast the pt and insert NG tube for all pts with>20%
BSA,all intubated pts,head and neck
burns,younger children >10%BSA.
Adequate analgesia-IV opoids.
Emergency wound management e.g.,cling film or
clean non-adhesive dressing.
Escharotomy if indicated e.g., circumferential
burns around limbs or trunk.
Electrolytes,renal and liver function.
CK if suspicion of significant tissue damage.
Cross –match if early surgery anticipated.
Evidence of possible airway compromise:
.burn to head and neck with swelling
.stridor,hoarse voice,swollen lips.
.singed facial ,nasal or head hairs.
.carbonaceous mat in or around mouth
or nose or sputum
. If complex/severe burns which require significant
Cuffed ETT used,as chest
wall compliance may be
reduced resulting in sig
Intubation should be
performed by experienced
individual – failed attempts
can create edema and
further obstruct the airway
4 ml R/L x % burn x body wt.
½ of calculated fluid is
administered in the first 8
Balance is given over the
remaining 16 hours.
Maintain urine output at 0.5
If evidence of extensive
tissue damage then aim for
a higher UO 1-2 ml/kg/hr.
Monitor sr electrolytes esp
In younger children
calculate the maintenance
fluids and add this to the
Surgery and dressings
Escharotomy may be needed for circumferential
burns to limbs,neck or trunk.
Early surgical debridement of nectrotic tissue is
preferred as early grafting is associated with
Scrubbing of affected skin is also frequently
Blood loss during operative sessions can be large.
Circulation to distal limb is in danger due to swelling.
Progressive loss of sensation / motion in hand / foot.
Progressive loss of pulses in the distal extremity by
palpation or doppler.
In circumferential chest burn, patient might not be able to
expand his chest enough to ventilate, and
might need escharotomy of the skin of the chest.
Early enteral nutrition ideally post pyloric.
Aim for a high calorie,high protein intake.
Supplement with parenteral if enteral feeding is
not well tolerated.
Add trace element supplements.
If severe burns to perineum consider creation of
an abdominal stoma to prevent faecal
Prophylactic antibiotics are avoided.
Fever is universal after a severe burn and doesn’t
Monitor wbc count,check frequent cultures.
There is no evidence to support routine line
changes unless there is clear suspicion of line-
Acute ulcerative gastro duodenal disease
Occur within 24 hours after burn
Due to reduced GI blood flow and mucosal
Treat pts with H2 blockers, mucoprotectants,
and early enteral nutrition
Watch for sudden drop in hemoglobin
Minor changes of dressings are often performed on ward
with sedation and analgesia.
ICU pts are transferred to theater with sedative and
analgesic infusions continuing.
If iv ascess is present,iv induction is appropriate otherwise
Suxamethonium is best avoided from 5-150 days post burn
because of risk of severe hyperkalemia.
Application of ECG dots,oximeter probes,NIBP cuffs may
Dressing around the trunk may restrict ventilation and
make airway management difficult.
Burn >10% TBSA adult,>5% TBSA child.
Electrical and chemical burns.
Circumferential burn to the limbs or chest.
Patients at the extremes of age.
Pts with poor medical condition,which may
CO is a colourless and odourless gas caused by
incomplete combustion of organic matter including
.CO decreases the o2
carrying capacity of Hb.
.CO shifts the Hb
dissociation curve to left.
.CO binds to
cytochromes , decreases
ATP and increases free
.free radicles activate
.releases reactive 02
species that cause brain
History to note:
.h/o exposure especially fire.
.duration of exposure.
breath,loss of muscle control.nausea,amnesia.
.signs of smoke inhalation.
.resp:tachypnoea,hypoxia,crackels,abnormaly high pulse
oximetry in face of hypoxia.
hypertension,dysrhythmia,myocardial depression and
.Neurological:reduced conscious level,rigidity,brisk
reflexes,hearing and visual loss,seizures.
.opthalmology:retinal discoloration,flame shaped
COHb [%] Symptoms
0-15 None [smokers]
15-20 Head ache,mild confusion.
20-40 Nausea and
40-60 Hallucinatios ,ataxia,fits,coma.
ABG with co-oximetry.
Lactate and acid base status.
CK-rules out rhabdomyolysis.
Head CT-If evidence of cerebral damage.
All pts with expected HbCO should receive 100% o2.
Half life of HbCO decreases from 320min to 30 -90 min
in 100% o2.
Treat burns if indicated.
Treat brain injury if indicated.
Consider HBO therapy if HbCO>25% and if evidence of
cerebral injury or myocardial dysfunction.