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High-Yield Facts

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  • Burns are the fifth leading cause of unintentional injury-related death. Children younger than 4 years tend to have scalding-related injuries, whereas older children tend to suffer from exposure to flames.

  • Most physicians use the classic Lund and Brower chart to estimate %BSA burned as it adjusts for the age of the patient. Because of the possibility for error in estimations, some physicians use the child's palm, considered approximately 1%, to measure the total %BSA burned.

  • The primary survey should focus on the patency of the child's airway as well as the severity of the burn. Any carbonaceous sputum or singed nasal hairs should alert the physician to impending airway edema.

  • Of particular importance are circumferential burns, which may cause both vascular and respiratory compromise. If vascular compromise is apparent, the patient should undergo an immediate escharotomy.

  • The Parkland formula is widely used to estimate fluid requirements. This formula calls for an isotonic crystalloid solution (such as Lactated Ringers) to be given at 4 mL/kg/%BSA over a 24-hour period. Half of this fluid volume is given over the first 8 hours, and the second half is given over the next 16 hours.

  • Pain management is an important consideration in burn management. Opioid analgesia is often required.

  • Initial wound care in the emergency department should consist of covering the burns with a dry, sterile sheet. Antiseptic solutions such as povidone–iodine and topical antibiotics should be avoided in patients who are being transferred to a burn center until the primary service has had the opportunity to evaluate the wounds.

  • Topical antibiotics are routine in outpatient burn care. One percent silver sulfadiazine is most commonly used.

  • All burn patients should be reevaluated at 24–48 hours to ensure proper wound healing and to examine for signs of infection.

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Epidemiology

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Burns are the fifth leading cause of unintentional injury-related death in children. Non-fatal burn injuries are the third leading cause of unintentional injury and average about 120,000 cases per year in US patients <21 years of age but declined by 30% over the past 17 years.1 Children <6 years of age sustained 58% of the injuries with approximately 60% resulting from thermal (scald) burns. The hands were most frequently burned (36%) followed by the head and face with most injuries occurring in the home.2,3 The mortality rate in pediatric burns continues to fall. Children with at least 60% total body surface area (TBSA) involved had a decrease in mortality rates from 33 to 14% over the last 20 years.4 With earlier intervention, the morbidity and mortality related to thermal burns have decreased; however, there are still significant sequelae that increase with the amount of TBSA involved. The treatment of burn injuries in the ED is usually followed by outpatient management with <10% of cases requiring hospital admission or transfer to a burn center. This chapter addresses common etiologies, clinical evaluation, management, and disposition of children who present to the emergency department with thermal injuries. Electrical burns are covered in Chapter 154.

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Etiology

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Thermal
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Scald injuries are the most common cause of burns in children younger than 4 years old. These typically occur as a result of hot liquids that tip over or are accidentally spilled near a child. Infants are at risk for bath-related scalds. Contact burns from touching hair curling or clothing irons are often seen in young children accidently ...

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