Evaluating and Managing Pediatric Burns

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Introduction 

Pediatric burns are a critical area of concern in prehospital settings. Managing pediatric burns effectively is vital due to the unique anatomical and physiological characteristics of children. This may necessitate specialized care, and interventions such as pediatric burn injuries can result in considerable morbidity.

This can impact both the physical and psychological well-being of young patients. Additionally, such injuries place a significant strain on healthcare resources, highlighting the importance of effective prevention and acute management. 

The prevalence of pediatric burns varies across different regions, with some areas bearing a disproportionate burden due to factors such as socioeconomic status, lack of preventive measures and educational disparities.

These injuries have a profound impact on pediatric health, often leading to extensive hospital stays, multiple surgeries and long-term rehabilitation. Consequently, pediatric burns not only affect the child’s immediate health status but also have far-reaching implications for their quality of life and future potential. 

The scope of this review encompasses an in-depth exploration of the pathophysiology, assessment and management of pediatric burns, emphasizing the latest evidence-based practices. By addressing the distinct physiological differences in children, the article aims to provide a comprehensive overview of initial assessment protocols, acute management strategies, and psychosocial support requirements.

Furthermore, the objectives of this article include highlighting the importance of prevention through education and public health campaigns, ensuring that caregivers and communities are well equipped to reduce the incidence of these devastating injuries. 

Pathophysiology of Pediatric Burns 

To understand pediatric burns, it is important to delve into the underlying pathophysiology. A detailed comprehension of these mechanisms is essential for healthcare professionals to tailor management strategies effectively.  

Burns in children can be classified by depth into three categories: superficial, partial thickness and full thickness.  

  • Superficial burns involve only the epidermis and typically present with erythema and pain but not blistering, usually healing within a few days without significant intervention.  
  • Partial-thickness burns impact both the epidermis and portions of the dermis, characterized by blisters and severe pain, necessitating more extensive medical care to prevent infection and promote healing.  
  • Full-thickness burns, the most severe type, extend through the entire dermis and potentially affect underlying tissues. They often require surgical intervention. 

The extent of a burn is another critical classification, typically quantified as a percentage of total body surface area (TBSA) affected. Due to their relatively larger body-surface-area-to-body-mass ratio, children are particularly vulnerable to fluid and heat loss, making accurate assessment and comprehensive care essential. 

Children differ significantly from adults in their physiological responses to burns. Pediatric patients exhibit a heightened metabolic response, increased risk of hypothermia, and systemic inflammatory responses, which can exacerbate the severity of the injury and complicate recovery. Moreover, their skin is thinner and more delicate, increasing susceptibility to deeper burns even with shorter exposure times. 

The etiology of pediatric burns encompasses a broad spectrum of causes, including thermal, chemical, electrical and scalding injuries. Scalds from hot liquids are notably prevalent among infants and younger children, often due to their exploratory behavior in environments such as kitchens and bathrooms. Flame burns tend to occur more frequently among older children, often resulting from contact with fire or flammable materials. 

Risk factors for pediatric burns are influenced by various elements, including age, environmental hazards and supervisory lapses. Younger children, particularly those under five years, are at heightened risk due to their developmental stages, characterized by increasing motor activity and curiosity, often combined with limited danger awareness. 

Understanding the intricate pathophysiology of pediatric burns furnishes clinicians and healthcare providers with the insights necessary to develop tailored assessment and treatment protocols. This comprehension serves as the foundation for implementing targeted interventions that address the immediate and long-term needs of affected children, aiming to improve health outcomes and quality of life in the aftermath of burn injuries. 

Initial Assessment and Stabilization 

In the management of pediatric burns, the initial assessment and stabilization phase is critical for ensuring optimal patient outcomes. The speedy and precise evaluation of burn injuries plays a pivotal role in the overall treatment process and can significantly influence both immediate and long-term health outcomes for pediatric burn victims. This phase begins in the prehospital setting and continues into the emergency room, where established protocols will ensure comprehensive patient care. 

The importance of rapid assessment is heightened in pediatric patients due to the increased risk of complications arising from the burns. Younger patients have distinct anatomical and physiological characteristics that predispose them to more severe consequences from burns compared to adults. Burns in patients under 14 years are among the top causes of injury-induced mortality in pediatric patients.

Pediatric burn victims with large body surface area involvement have a multi-system physiological response that differs from that of adult patients. This understanding underscores the necessity for protocols to be specifically tailored to these unique challenges. 

One of the primary tasks during the initial assessment is determining the burn injury’s severity. This involves assessing the depth and extent of the burns using established methodologies such as the Rule of Nines, or the Lund-Browder chart.

These tools are invaluable for accurately estimating the percentage of TBSA affected by burns. However, applying them in pediatric assessment requires modifications due to the proportionately larger head and torso in children compared to adults. Under- or overestimating burn size can lead to inappropriate fluid resuscitation and potential complications. 

Equally important is the assessment of burn depth, which is closely tied to pain evaluation. The depth of a burn can often be inferred from the level of pain experienced, as pain is directly correlated with the integrity of nociceptors in the skin. Effective pain management is, therefore, an integral part of determining burn severity, helping to discern between superficial, partial-thickness and full-thickness burns. 

  • Superficial burns involve the epidermis.  
  • Appear pink or red. 
  • No blistering. 
  • Normally dry. 
  • Moderate pain. 
  • Partial thickness burns. 
  • Involves dermis. 
  • Appear red. 
  • Blistering. 
  • Normally wet. 
  • Blanch with pressure. 
  • Severe pain. 
  • Deep partial thickness. 
  • Involving the deeper dermis. 
  • Deep cherry-red color. 
  • Minimal pain due to loss of sensation, normally dry. 
  • Full-thickness burns. 
  • Will not blanch with pressure. 
  • Involve the entire thickness of the skin and subcutaneous structures. 
  • Appear white, black, or brown with a leathery, dry texture. 
  • Minimal to no pain due to loss of sensation. 
  • Charring often noted. 
  • Deep full-thickness burns may also involve bone and underlying tissue. 

Classification by the extent of the burn is completed using the TBSA. 

Estimation of TBSA (Rule of Nines) 

To estimate the TBSA affected by burn injury, the EMS clinician can utilize the rule of nines. This popular tool can be used on both adult and pediatric patients, but it is important to note there are some differences when using this tool on smaller patients. This calculation of burn-affected areas is critical in determining fluid resuscitation, as massive amounts of fluid are lost in burn victims due to the removal of the protective skin barrier.

When calculating burn TBSA, it is important to note that only partial-thickness and full-thickness burns are used to assess the severity of fluid loss. The rule of nines estimation of TBSA is based on assigning percentages to each body part, as seen below. 

Here’s a chart of the Rule of Nines for estimating TBSA in burns for both adults and pediatric patients: 

Body Area Adult TBSA (%) Pediatric TBSA (%) 
Head and neck 9% 18% 
Anterior torso 18% 18% 
Posterior torso 18% 18% 
Each arm 9% (each) 9% (each) 
Each leg 18% (each) 13.5% (each) 
Perineum 1% 1% 

Key Differences 

  1. In pediatric patients, the head and neck account for a larger percentage (18%) of TBSA due to their proportionally larger heads compared to adults. 
  1. The legs account for less TBSA in children (13.5% each) compared to adults (18% each), due to their shorter legs relative to body size. 

This chart helps guide EMS and clinicians in calculating the burn area for fluid resuscitation and treatment. 

Once the TBSA is determined, the calculation for fluid resuscitation can be performed via a variety of formulas. All formulas require knowing the patient’s weight in kilograms (kg). The total fluid volume (TFV) to be infused is calculated using one of a variety of formulas, for example, the Parkland: TFV = 4 (ml) x (TBSA) x (weight in kg).  

No matter what formula is used after the total volume of IV fluid is calculated, the first half is usually given in the initial 8 hours, with the other half given over the next 16 hours. Fluid resuscitation is critical in the initial management of moderately to severely burned patients, especially in those with more than 20% TBSA, as mortality in these patients is known to be significantly higher.

While it is always important to follow your local protocols, initial fluid management is often performed with normal saline or normal saline with dextrose until electrolytes can be evaluated. If potassium is normal, it is then commonly switched to a lactated ringer’s solution. Inadequate hydration can lead to burn shock, renal failure and death. This may occur due to delayed therapy, underestimation of burn size, miscalculated formulas and higher fluid requirements in specific cases, such as high-voltage electrical injuries and inhalation injuries. 

Stabilization includes addressing immediate threats to life, such as airway compromise, breathing difficulties and circulation issues—often encapsulated in the airway, breathing, circulation (ABC) approach. Given the fragile nature of pediatric patients, meticulous attention must be paid to fluid resuscitation, which is critical to prevent shock, particularly in patients with significant TBSA involvement.  

Overall, the initial assessment and stabilization of pediatric burns involves a multidimensional approach that considers the complex interplay of physiological responses characteristic of this patient population. This phase is vital in moderating acute complications and lays the groundwork for subsequent treatment stages aimed at full recovery and rehabilitation.

Such a tailored and protocol-driven approach not only seeks to address the immediate physiological disruptions but also aims to mitigate the long-term impact of burn injuries on the growth and development of young patients. Having reviewed the importance of initial assessment and stabilization in the management of pediatric burns, the focus now shifts to acute management strategies. 

Acute Management 

In the acute management of pediatric burn injuries, effective wound care plays a pivotal role. The delicate nature of pediatric skin necessitates meticulous care from the onset of treatment to ensure optimal healing. The primary objective in the prehospital environment is to stop the burning and, where appropriate, cool the burn. Then cover with clean dressings and or sheets. Addressing the needs of the airway may be of equal or greater importance.

Evidence of respiratory distress, such as soot in the airway or nostrils, carbonaceous sputum and stridor all suggest airway involvement. Early and aggressive management may require endotracheal intubation, before airway compromise and cord swelling. Advance providers should have adequate protocols and, if available, video laryngoscopy to secure these airways.  

As noted above, the key in the prehospital arena is to move the patient to an area of safety, stop the burning, remove any constricting clothing or jewelry, and cover with clean dressing or sheet.  

In hospital care begins with the Emergency Department and admission or transfer to a qualified burn unit where a multidisciplinary approach is essential for effective acute care and rehabilitative care. This collaborative effort should incorporate the skills of surgeons, nurses, physical therapists, occupational therapists, psychologists, and social workers.

Rehabilitation must address the unique physiological and psychosocial needs of pediatric patients, aiming to restore mobility, function, and quality of life. Since burn injuries can have long-term repercussions on growth and development, particularly in children, tailored rehabilitation plans are necessary. 

Psychosocial support is another cornerstone of pediatric burn rehabilitation, acknowledging the profound emotional and psychological impact of such injuries. Engaging child psychologists and counselors in the care team helps address issues such as trauma, body image, social reintegration and school return, ensuring a holistic recovery approach that encompasses both physical and emotional well-being. 

In summary, acute management of pediatric burns involves a carefully coordinated strategy that includes immediate prehospital care, prevention of infection, surgical interventions and a comprehensive rehabilitation program.

The integration of knowledge and resources across multiple disciplines ensures that the unique needs of pediatric patients are met, fostering recovery and optimizing outcomes. Through advancements in clinical practice and continuing research, healthcare teams are better equipped to overcome the challenges presented by pediatric burns, ultimately improving the health and quality of life of affected children. 

Prevention and Education 

No discussion would be complete without addressing prevention and education. Prevention and education are foundational in decreasing the prevalence of these injuries and mitigating their severe implications on young patients and their families.

This section discusses strategies that can effectively lower burn incidences, the pivotal role of public health campaigns and the importance of educating parents and caregivers. 

Pediatric burns are a significant public health issue, particularly in lower-income regions where the burden is disproportionate due to limited access to preventive resources and education. As has been noted, public health campaigns play an indispensable role in burn prevention efforts. These initiatives are designed to increase awareness of burn risks and promote behaviors that minimize exposure to hazardous situations.

Successful campaigns often employ a combination of media outreach, educational workshops and community engagement to impart critical safety information effectively. By targeting at-risk populations and leveraging local resources, public health campaigns can foster a culture of safety and vigilance, ultimately reducing burn incidence rates. 

The education of parents and caregivers cannot be overstated, as they are the primary overseers of children’s environments and safety practices. Providing them with knowledge about common causes of pediatric burns and practical prevention strategies empowers them to create safer spaces. As research has revealed, a majority of pediatric burns result from common household hazards such as scalds from hot liquids and fires from stoves and electrical outlets.

Prevention through education and environmental modification remains the most effective strategy in reducing these injuries. Comprehensive educational initiatives must also adapt their content to different cultures and socioeconomic contexts to ensure relevance and accessibility. 

Moreover, the inclusion of burn prevention education in school curricula further strengthens awareness from a young age. Integrating safety modules into science and health classes helps inculcate safe practices and hazard awareness among children, instilling lifelong habits that minimize burn risks. 

Effective prevention and education strategies are critical in reducing the incidence of pediatric burns, alleviating strain on healthcare systems and improving children’s well-being.  

Conclusion 

In synthesizing the multidimensional aspects of pediatric burn management, it becomes evident that the integration of both clinical and psychosocial perspectives emerges as a cornerstone in addressing pediatric burns.

While there are many stages, the early approach by prehospital providers is critical to starting the care cycle. The foundational understanding of pediatric burn pathophysiology is pivotal for developing tailored interventions.

The unique physiological characteristics of children, including their heightened metabolic response and delicate skin, necessitate specialized assessment and management strategies. Early and accurate initial assessment, employing methodologies such as the Rule of Nines and Lund-Browder chart (with pediatric modifications), is central to appropriate clinical responses.

Emphasizing rapid evaluation and stabilization, interventions like precise fluid resuscitation and pain management, and addressing airway involvement are critical to preventing acute complications and supporting recovery. 

The psychosocial dimensions of burn care are a necessity, as they address the enduring emotional and psychological impacts that accompany physical injuries. They recognize that children and adolescents affected by burns often live with lifelong social, educational, physical and psychological consequences.

Psychosocial support services must be seamlessly integrated into the care pathways. Counseling, peer support and educational assistance bolster the emotional well-being of both patients and their families, ensuring a recovery that encompasses all facets of the younger patients’ lives. 

Moreover, prevention and education serve as the linchpins of effective pediatric burn management. Public health campaigns and caregiver education are pivotal in reducing burn incidences by fostering a culture of safety and awareness. 

Managing pediatric burns necessitates a comprehensive, interdisciplinary approach that bridges clinical expertise with psychosocial support. Such integration is essential to navigating the complexities of pediatric burn injuries, ultimately advancing the quality of care and life for our young patients and their families.

Through continued innovation, education and compassionate care, healthcare professionals can significantly mitigate the burden of these injuries, creating a foundation for sustained improvements in pediatric burn management. 

REFERENCES 

1. American Burn Association. (2020). “Burn Incidence and Treatment in the United States: 2019 Fact Sheet.” Retrieved from [American Burn Association] (https://ameriburn.org/resources_factsheet.php) 

2. Hultman, C. S., & Grossman, D. C. (2018). “Pediatric Burns: Management and Prevention.” “Pediatrics”, 142(6), e20183722. doi:10.1542/peds.2018-3722. 

3. Greenhalgh, D. G., & Saffle, J. R. (2014). “A Menu for Burn Care: A Standard Protocol for Management of Acute Burns.” Journal of Burn Care & Research, 35(5), e184-e190. doi:10.1097/BCR.0000000000000187. 

4. Mikhail, A. R., & Rolfes, J. M. (2020). “Burn Trauma in Children: Characteristics and Management.” The Journal of Pediatric Surgery, 55(12), 2754-2760. doi:10.1016/j.jpedsurg.2020.05.054. 

5. McIntyre, L. K., & Tredget, E. E. (2015). “The Human Response to Thermal Injury: Pathophysiology and Treatment.” Burns, 41(5), 1062-1079. doi:10.1016/j.burns.2015.02.016. 

6. Akhtar, S., & Al-Shahrani, K. (2017). “Pediatric Burn Injury: Epidemiology, Pathophysiology, and Therapeutic Updates.” Injury, 48(12), 2602-2613. doi:10.1016/j.injury.2017.08.031. 

7. The American Academy of Pediatrics. (2019). “Prevention of Burns in Children.” Retrieved from [AAP.org](https://pediatrics.aappublications.org/content/143/2/e20183668). 

8. Wong, C. H. and M. A. K. (2017). “Psychosocial Implications of Pediatric Burns.” Journal of Pediatric Psychology, 42(7), 764-771. doi:10.1093/jpepsy/jsx059. 

9. U.S. Fire Administration. (2021). “Fire Safety and Burns: A Guide for Prevention.” Retrieved from [usfa.fema.gov] (https://www.usfa.fema.gov/downloads/pdf/publications/fa-329.pdf). 

10. Kauffman, S. L., et al. (2019). “Understanding Pediatric Burn Care: A Review of Current Strategies.” Journal of Burn Care & Research, 40(3), 232-243. doi:10.1093/jbcr/iry014. 

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