The principles of managing burns in children are similar to those for adults. The airway should be secured and circulation restored by controlling fluid loss and initiating fluid resuscitation to maintain global tissue perfusion. Assessment following the basic principles of primary and secondary survey as described previously should be followed. However, it is important to note the following differences between children and adults in regards to burns:
Children have a higher body surface area to body weight ratio, which means they have a higher metabolic rate, have greater evaporative water loss and have a greater propensity for heat loss [xxi]. It is important to monitor body temperature especially during first aid, if extensive burns are present. The younger the child, the quicker they may become hypothermic.
A child’s skin is much thinner than an adult’s. A thermal injury is much more likely to result in a deeper burn than in an adult.
Burn depth assessment in a child is often more difficult due to their thinner skin. Colour changes in burned skin are not always the same as in adults.
Children require burns resuscitation fluid at a lesser TBSA percentage than adults (10% in children as opposed to 20% in adults).
General assessment will follow the same principles of primary and secondary survey.
Airway and Breathing assessment
Airway assessment remains a vital part of the primary survey. The airway is narrower in children and therefore obstruction will occur at a lesser degree of oedema than in adults.
Repeated evaluation of airway patency is vital.
Assess for presence of stridor, black discolouration of lips/perioral area/ sooty saliva/ presence of soot in oropharynx or any signs of inhalation injury. Sputum is less evident in young children who cannot expectorate. Again, ensuring a provider who is experienced in paediatric airway management is on hand is vital. Consider early intubation when inhalation injuries exist or where there are external facial and neck burns.
Asthma is relatively common in children and inhalation of smoke will frequently lead to bronchospasm. Immobilise the spine if associated trauma.
Carbon monoxide poisoning should be considered if an inhalation injury is present, especially in an enclosed space. In such instances, high-flow O2 should be provided.
Beware of circumferential chest burns, as an escharotomy may be required to improve ventilation.
The rule of nines may be inaccurate in small children. Aside from the TBSA differences, children have proportionately smaller hips and legs and larger shoulders and heads. Accurate TBSA estimation is essential for adequate fluid resuscitation. Using the adult rule of nines charts may seriously under- or overestimate the size of the burn wound and lead to insufficient or excessive fluid administration. The paediatric Lund and Browder chart (modified rule of nines chart) should be used to enable accurate calculations. Beware overestimation occurs when simple erythema is included. See poster: Paediatric Burns Assessment Ruler See poster: Burn Depth Characteristics
Assessment of fluid status in a child must take place early. Children have good compensatory mechanisms that aid in maintaining their circulation in spite of a fluid deficit. Little warning of immediate collapse is given; hypotension is a very late sign [xxii]. More reliance must be placed therefore on the subtle signs of hypovolaemia and inadequate circulation such as:
the general appearance of the child (assess for lethargy, drowsiness, decreased conscious state etc.)
vital signs (tachycardia and prolonged central capillary refill time)
decreased urine output
skin colour and skin temperature (assess for pallor/cool peripheries, low core temperature)
Principles of management focus on securing the airway and maintaining an adequate circulation via fluid administration.
Airway: Ensure the airway is patent and secure. Have a provider experienced in paediatric airway management on hand if possible.
Breathing: Apply high flow oxygen if suspicion of an inhalation injury and consider the possible need for chest escharotomy if circumferential chest wall burns are present.
Circulation: IV cannulation is essential in burns greater than 10% TBSA management. If peripheral venous access is difficult then central or intraosseous insertion should be obtained and/or central access considered.
Fluid administration consists of three components:
Initial fluid to treat initial peripheral circulatory failure (shock) if present, plus
Fluid to replace that loss from burnt tissues (burn resuscitation), plus
Initial fluid: The presence of initial peripheral circulation failure (shock) is not expected unless presentation is delayed. See primary survey section for resuscitation of the hypovolaemic patient Fluid loss from burnt tissues: In children, fluid resuscitation should take place in burns that have a TBSA over 10 per cent. To replace fluid lost from the burnt tissues, fluid administration should follow the modified Parklands formula of
3–4 mL × TBSA% × kg= ____ mL/24 hours.
Use Hartmann’s solution where available or Normal Saline. Fifty per cent of the total is administered in the first eight hours post injury, and 50 per cent given in the following 16 hours. This is a guide only. Effect of resuscitation fluids must be assessed regularly and changes made accordingly. Particular attention should be paid to urine output maintaining >1ml/kg/hr.
Maintenance fluid: Maintenance fluid should be added over and above the Parklands formula.
The recommended maintenance fluid is 0.9 per cent Normal Saline (Note: this differs from Vic Burns recommendations of 0.45% plus 5% Dextrose, currently under review and due to align with Trauma Victoria). Potassium chloride supplements may be required.
Use the following formulae to calculate normal hourly fluid requirements in children up to 30kgs:
Up to 10kgs – 100ml/kg/day
10-20 kgs – 1000mls plus 50ml/kg/day for each kg over 10kgs
20-30 kgs – 1500mls plus 20ml/kg/day for each kg over 20kgs
Urine output: should be monitored frequently to assess the adequacy of resuscitation. Goal urine output is 1 mL/kg/hr., or as close as possible. In dwelling catheter is recommended in patients undergoing fluid resuscitation.
First Aid: Leave any clothing that is adhered to underlying skin. Immediately cooling burns with cool running tap water helps to reduce the severity of tissue damage and relieve pain. Cool wounds for 20 minutes total (with running water if possible). This can be done in increments if hypothermia is a concern (ie 5min blocks.) First aid is effective for up to 3hrs post injury. Apply saline-soaked gauze to the affected areas, changing it regularly if free-flowing water is not accessible.
Dressing: If the patient is being transferred to the burns unit within six hours, cover the wound with plastic cling film. It should be applied longitudinally (to allow for swelling) rather than circumferentially, which may have a tourniquet-like effect. If none is available and/or the patient is unlikely to be transferred to the burns unit within six hours, cover with a clean and dry non-adherent dressing such as paraffin gauze or silver dressing. Do not use hydrogels or burnaid on children – they may cause peripheral shut down due to hypothermia.
For detailed dressing instructions, refer to the Victorian state burns clinical practice guidelines.
Escharotomy: if circulation to limbs is compromised by burns, escharotomies may be required. Burns to the the chest/abdominal region may compromise chest excursion and trunk escharotomies should be considered. Early consultation is required prior to intervention.