22 HOW TO TREAT : PAEDIATRIC BURNS ausdoc . com . au
4 AUGUST 2023
22 HOW TO TREAT : PAEDIATRIC BURNS ausdoc . com . au
Figure 3 . Flame burn of the dorsum of the right hand , 48 hours post-injury . Note that the wound has been debrided , with removal of necrotic epidermis . The paler central aspect of the burn indicates at least a deep partial-thickness burn that will require grafting .
Box 1 . Standard trauma sequence
• Airway with cervical spine control .
• Breathing and ventilation .
• Circulation with haemorrhage control .
• Disability assessment ( with at least AVPU [ Alert , Verbal response , Pain response or Unresponsive ] or ideally Glasgow Coma Score determined ).
• Exposure with environmental control to facilitate accurate diagnosis but minimise risks of contamination and hypothermia .
PAGE 20 with a major burn — defined as greater than 10 % TBSA . Use warmed normal saline or Hartmann ’ s solution as the resuscitation fluid , with the rate determined by the modified Parkland formula ( 3-4mL / kg /% TBSA burn in the first 24 hours ). Most importantly , 50 % of this calculated volume is given within the first eight hours of the occurrence of the burn injury and the remainder within the next 16 hours . Monitor the child ’ s response closely — including pulse rate , respiratory rate , blood pressure and urine output ( aiming for 0.5-1.0mL / kg / hr ) — to help determine the need to vary the quantity of fluid needed .
In children , maintenance fluids are required and must contain glucose . In the primary care setting , if IV fluids are not available for resuscitation , oral fluids can be given ( ideally , using commercially prepared rehydration salts : one sachet per 250mL of water ).
Remove burnt or wet clothing to allow adequate exposure to determine accurately the extent of the burn and help prevent further thermal injury from retained heat . Take care to avoid hypothermia ; this can be achieved by covering unburnt
Figure 4 . Electrical burns of the hand , 72 hours post-injury . The pallor and surrounding blackened areas indicate deep full-thickness burns . Most electrical burns in children will be deep at the entry and exit points because of exposure to lowvoltage domestic electrical current .
areas and sequentially covering burnt areas once examined with a warm blanket or towel . Remove any jewellery to prevent distal ischaemia that might result from subsequent swelling ; metal can also retain heat and cause ongoing thermal injury . Examine the eyes , ears and mouth to exclude any unexpected thermal injury . Airway compromise can occur in the form of an inhalational burn — for example , a child trapped in a house fire or with a hot water scald burn that involves the face and neck . Remove underwear and / or nappies as part of the examination to avoid missing significant injuries to the external genitalia , perineum and anus that will impact how the patient is managed .
Carefully assess any circumferential burns for any evidence of peripheral oedema and potential for ischaemia . The capillary refill time should be less than two seconds , but this can be difficult to assess in burnt skin . Doppler ultrasound remains the most accurate assessment tool but is unlikely to be available in a primary care setting . In the case of limb burns , elevate the affected limb as much as possible , either with a rolled towel or pillow . Treat patients with circumferential head , neck and upper torso circumferential burns sitting up as much as possible , rather than supine , as this will help to reduce the risk of cerebral oedema complicating fluid resuscitation . In ED , in patients with established oedema , consider performing an escharotomy before transfer . Discuss this with the receiving burns unit , which can advise on both the need for and how to safely perform this procedure .
Fortunately , most burn injuries
Deroofing blisters versus leaving them intact is highly controversial .
will not be associated with major trauma .
Once other injuries have been excluded , move the focus to determining the extent and depth of the burn injury while ensuring that the correct BFAT has been applied . In the rare setting of a chemical burn in a child , having donned the correct PPE , ongoing irrigation with cold running water should , in general , neutralise most agents . Hydrofluoric acid burns uniquely require treatment with 2.5 % calcium gluconate gel but fortunately remain extremely rare in children .
In those children thought to require specialist care , apply a readily available temporary dressing in the expectation that this will need to be removed once the child arrives in ED . This reduces the risk of infection , prevents drying of the wound and helps alleviate pain . If the transfer time is likely to be short ( less than four hours ), a simple , loosely applied plastic wrap can be used or a clean , dry sheet . For those likely to experience longer transfer times , use a dressing with antimicrobial properties , such as paraffin-infused tulle gauze with chlorhexidine . Review the immunisation status of the child to ensure their tetanus cover is up to date , and for those requiring IV fluids , insert a nasogastric tube to allow supplementary feeding .
Burns are usually extremely painful . Early use of analgesics will provide appropriate relief for the patient and will also facilitate examination and assessment of the burn . Cool running water , as well as cooling the burn and potentially reducing the depth of any burn , will also provide excellent analgesia , as will covering the burn after examination . Oral analgesia in the form of