Most children survive a burn injury regardless of the size of cutaneous injury.
Sepsis, respiratory failure, and anoxic brain injury are the leading causes of death in pediatric burn victims.
The Parkland formula with modifications for size and presence of inhalational injury is the resuscitation formula of choice.
Colloid is often used to prevent crystalloid over-resuscitation despite a lack of evidence regarding outcome.
Early burn wound excision with skin coverage is the most important therapeutic maneuver with full-thickness injury to the skin.
Silver-impregnated products provide excellent wound coverage for exposed dermis present in donor sites and partial-thickness wounds and limited full-thickness burn wounds.
Dermal replacement products are valuable in extensive burn injury for wound coverage and neodermal development.
Optimal nutrition is essential in the management of moderate and large surface area burn injury.
Pharmacological therapy is helpful in optimizing nutrition and blunting the hypermetabolic response.
Burn Care in the Twenty-First Century
There have been many advances in the care of the burn victim since the middle part of the twentieth century. Current survival rates indicate how successful burn care has become. A 50% mortality rate for a 20% body surface area burn in the late 1940s can be compared to at least a 65% survival rate currently reported in 85% body surface area burn. Survival is nearly assured in a child with any size burn who arrives to a burn unit alive with published mortality rates of less than 3%. In a 20-year autopsy study of 145 children dying of burn injury, 47% died of sepsis, 29% from respiratory failure, and most of the remainder from anoxic brain injury.
The first task, when presented with a newly burned child, is to follow the ABCs of trauma. Assessment of the airway is paramount in a patient with burn injury of the face and neck or with exposure to smoke in an enclosure. Intubation may be necessary because of neurologic changes from carbon monoxide poisoning, airway obstruction, or for airway protection (Table 83-1). The edema of the burned airway will peak at 12 hours post injury, converting a routine intubation at time of arrival into a difficult one. The burned child with impending upper airway obstruction will only become symptomatic moments before disaster. “When in doubt, intubate!” Figure 83-1 is an algorithm for airway management.
Algorithm for airway management of the burned child.
Table 83-1Absolute and Relative Indications for Endotracheal Intubation of the Burned Child |Favorite Table|Download (.pdf) Table 83-1 Absolute and Relative Indications for Endotracheal Intubation of the Burned Child
|Absolute Indications for Intubation ||Relative Indications |
|Full-thickness burns to face, lips, mouth, and neck ||Soot in oropharynx |
|Smoke inhalation seen by endoscopy ||Singed nasal hairs |