Chapter 69: Burns and Smoke Inhalation

INTRODUCTION

This chapter will describe the acute evaluation and management of pediatric patients who experience severe burns and/or smoke inhalation.

BURNS

• Burns are a common phenomenon in the pediatric population, but when severe, can be responsible for over 2,500 deaths annually.

• The most common type of burn in children less than age 5 is scald burns, whereas older children experience flame burns more often.

INITIAL EVALUATION

• All burn patients should receive a full trauma evaluation in the emergency department.

• The patient's airway, breathing, and circulation (ABCs) should be evaluated as per normal protocol.

• The extent of burn injury should be determined. This is done by quantifying the percentage body surface area involved, as well as the depth of the burn injury.

• Total body surface area involvement:

  • See Figure 69-1 for approximations for quantifying total body surface area involved in infants and children (do not count erythema).

  • The Lund and Browder Chart or Berkow Formula are recommended resources for accurately quantifying the extent of body surface area involvement.

  • Rule of Nines is employed for adults: 9% total body surface area involved for each upper extremity, 18% for the head, and 14% for each lower extremity.

  • For smaller areas involved, may use the patient's hand size to equal approximately 1% of total body surface area.

• Depth of burn estimation:

  • First-degree burn: erythematous, painful, dry; only epidermis involved

  • Second-degree burn: erythematous, very painful, moist, blistering present; epidermis and dermis involved

  • Third-degree burn: full-thickness burn, not painful, dry; epidermis, dermis, and subcutaneous involvement

• Criteria for transfer to burn center for pediatric patients:

  • Greater than 10% total body surface area involved if second-degree burns

  • Greater than 5% total body surface area involved if third-degree burns

  • Second- or third-degree burns involving face, hands, feet, genitalia, perineum, and major joints

  • Electrical burns, including lightning injury

  • Chemical burns

  • Inhalational injury

  • Burn injury in patients with preexisting medical disorders that may complicate management, prolong recovery, or affect mortality

  • If concomitant trauma, consider transfer if burn injury reflects greatest risk of morbidity or mortality; consider initial treatment in a trauma center if the trauma represents the greatest risk of morbidity or mortality (as determined by physician judgement and hospital/local policy)

  • If the hospital lacks the necessary equipment or expertise in care of burn patients

  • Burn injury in patients with special emotional/social/rehabilitative needs (such as cases involving child abuse)

MANAGEMENT

• Initial resuscitation

  • There are local and systemic responses to burns that result in direct tissue coagulation, dermal destruction/loss of barrier integrity, and release of vasoactive and inflammatory mediators. Secondary organ injury and shock can occur from interstitial edema (from increased capillary permeability and increased hydrostatic pressure), increased systemic vascular resistance, reduced cardiac output, and hypovolemia from fluid losses. This occurs especially when >20% of total body surface area is involved.

  • Fluid resuscitation:

    • The greatest fluid losses occur within the ...