Int J Crit Illn Inj Sci. 2012 Sep-Dec; 2(3): 128–134.
PMCID: PMC3500004
doi: 10.4103/2229-5151.100889
Pediatric burn injuries
Vijay Krishnamoorthy, Ramesh Ramaiah, and Sanjay M Bhananker
Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
Address for correspondence: Dr. Vijay Krishnamoorthy, Box 359724, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104,
USA. E-mail:
[email protected]Copyright : © International Journal of Critical Illness and Injury Science
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with
causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the
total body surface area involved and the depth of injury. Large burn injuries have multisystemic
manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic
measures. Management of burn injuries requires intensive medical therapy for multi-organ
dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In
addition, pain management throughout this period is vital. Specialized burn centers, which care for these
patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries.
This review highlights the major components of burn care, stressing the pathophysiologic consequences of
burn injury, circulatory and respiratory care, surgical management, and pain management of these often
critically ill patients.
Keywords: Burns, pediatric, trauma
INTRODUCTION
Burn injury in children continues to be a major epidemiologic problem around the globe. Nearly a fourth
of all burn injuries occur in children under the age of 16, of whom the majority are under the age of five.
[1] Most burn injuries are minor and do not necessitate hospital admission.[2] A minority of burn injuries
are serious and meet criteria for transfer to a burn center; the care of these critically ill children requires a
coordinated effort and expertise in the management of the burned patient. The mortality rate following
major burns at these highly specialized centers is less than 3%.[3] This provides a team of pediatricians,
surgeons, anesthesiologists, intensivists, nurses, respiratory therapists, and other healthcare providers with
a unique opportunity to make a multidisciplinary collaborative effort to help some of the most vulnerable
patients.
The cause of burn injury varies depending on the age of the child and based on historical clues. Scald
injuries tend to be the most common type of thermal injury under the age of 5, accounting for over 65% of
the cases, while fire injury tends to occur in older children, accounting for over 56% of the cases.[4] The
identification of injury mechanism may provide clues into the other systemic manifestations, for example,
the significant component of coexisting inhalational injury after a fire. Finally, child abuse has to be on the
differential for any suspicious lesion. A typical injury of this type involves a pattern consistent with a scald
injury in a typical “stocking” distribution, although a high index of suspicion needs to be maintained in all
mechanisms of burn injury. In children under the age of 2, nearly 20% of cases of burn injury may be
reported to state social services for investigation, and a fifth of these reported patients were discharged to
foster care.[5]
The goals of initial patient management include preservation of overall homeostasis while appreciating the
physiologic challenges that the burn injury poses to the body. Major burn injury not only results in local
damage from the inciting injury, but in many cases results in multisystem injury. Initial efforts are focused
on resuscitation, maintaining hemodynamic stability, and airway management. Intermediate efforts are
focused on managing the multi-organ failure that results from systemic inflammatory mediators that result
in diffuse capillary leak and surgical therapy. Finally, efforts shift to issues with chronic wound healing,
pain management, restoration of functional capabilities, and rehabilitation.
This review will focus on the classification of burn injury, physiologic effects of the initial burn injury,
management of the primary injury, management of the primary systemic manifestations, and pain
management for the burn-injured child.
CLASSIFICATION OF BURN INJURY
Initial classification of burn injury involves both the depth of the burn and the total body surface area
(TBSA) encompassed by the burn injury, which also has implications on the aggressiveness of fluid
resuscitation. Figure 1 shows the differences in proportion of TBSA between adults and children.
The traditional classification of burns (first, second, third degree) has been replaced by a classification
system that reflects the need for surgical therapy-burns are currently grouped as superficial, superficial
partial-thickness, deep partial-thickness, full thickness, and fourth-degree burns.[6] A superficial burn is
classified as a burn that affects the epidermis, without involvement of the dermis, usually presenting with
redness with erythema. A partial thickness burn (both superficial and deep) involves the entire epidermis
and variable parts of the dermis. A superficial partial-thickness burn presents with pain, redness that
blanches, and blistering. In contrast, a deep partial-thickness burn presents with only pressure, a variable
color (white to red) that does not blanch, and blistering-these generally require surgical therapy. Full
thickness burns affect the entire epidermis and dermis, usually presenting with a particularly leathery
appearance. Lastly, fourth-degree burns are the deepest subgroup with involvement of fascia, muscle, and
bones. While deep partial-thickness burns are usually treated with surgical procedures, full thickness and
fourth-degree burns are almost always treated with surgical excision and grafting.
SYSTEMIC EFFECTS OF BURN INJURY
The physiologic manifestations of burn injury span every organ system [Table 1] and can result in
profound morbidity and mortality. There is a hormonal and metabolic response to the initial burn injury
and, depending on the severity, can cause both local and systemic manifestations. Immediately after the
injury is sustained, a variety of vasoactive mediators, catecholamines, and inflammatory markers are
released,[7] resulting in a local and systemic capillary leak phenomenon, thus promoting a loss of protein
and the development of interstitial edema. This development is a manifestation of the systemic
inflammatory release syndrome (SIRS) and carries a high degree of morbidity and mortality.[8] In very
large burns (>40% TBSA), significant myocardial depression and hypotension may ensue,[9] thus making
hemodynamic management challenging.
In addition to the development of SIRS, a hypermetabolic state ensues as well. The inflammatory
mediators and loss of protein result in a significant increase in energy expenditure and a catabolic state,
[10] while the level of anabolic hormones is markedly decreased[11] causing an imbalance of energy use
and availability. This contributes to a loss of muscle protein, bone mineral density, and overall bone
mineral content.[1] In addition, thermoregulatory responses are impaired, with resetting of the patient's
core temperature in proportion to the total burn area.[12] Burned skin is unable to retain heat and water,
with the potential consequence of massive evaporative fluid losses and metabolic responses much more
severe than thought previously.[13]
From a respiratory standpoint, burn injury results in a complicated picture, with initial management
focused on securing a potentially edematous airway, and further management involving management of
the consequences of inhalational injury, poisoning with carbon monoxide and cyanide, and the
management of the potential development of the acute respiratory distress syndrome (ARDS). It has been
demonstrated that both larger burn size and younger age are independent predictors for the need for
intubation,[14] and that morbidity and mortality are high in burn patients with respiratory problems or
inhalational injury.[15]
Gastrointestinal system dysfunction with bacterial translocation across the gut is a common complication
of major burn injury and an independent cause of septic shock in the post-burn patient.[16] Bleeding from
acute ulceration of the gastric mucosa may contribute to hypotension, anemia, and possible perforation,
peritonitis, and septic shock.[17] Finally, the acute decrease in gastric emptying may put the burn patient at
risk for aspiration during periods of sedation, airway instrumentation, or changes in mental status.[18]
Renal and hepatic dysfunction is primarily a result of decreased perfusion secondary to multifactorial
causes of hypotension including significant evaporative fluid loss, protein loss, and decreased effective
circulating volume, SIRS, and the development of septic shock in the setting of decreased barrier function.
[19] Increased levels of catecholamines and inflammatory mediators result in vasoconstriction of the renal
vasculature, which can be further aggravated by myoglobinuria, especially in children with electric burns.
A secondary effect of hepatic and renal dysfunction is altered metabolism and elimination of several drugs
used routinely in the care of the burn patient.
The propensity to develop infectious complications in burn children is secondary to disruption of barrier
function of skin and gut mucosa, coupled with the immunosuppressive effects of burn injury. In addition to
the wound as an obvious source of infection, other sites which demand vigilance and consideration in the
burn patient include bacterial translocation from the gut, intravenous catheter-related bloodstream
infection, urinary catheters, and ventilator-associated pneumonia.[20] Fever, tachycardia, and leukocytosis
(three classic SIRS symptoms) are almost universal in burn patients and do not necessarily indicate sepsis.
Pharmacologic changes and altered binding and clearance of drugs occur almost immediately after burn
injury, altering the pharmacodynamic and pharmacokinetic properties of many drugs. In the initial state of
hypotension and organ injury, renal clearance is impaired, while later hyperdynamic and hypermetabolic
states (>48 h after burn injury) lead to increased clearance.
Decreased levels of serum albumin, occurring almost immediately, leads to increased free fraction of
acidic drugs, while increased levels of a acid glycoprotein results in decreased free fraction of basic drugs.
[21] A systemic upregulation of acetylcholine receptors and their proliferation to extra-junctional locations
has been noted over time during the acute course of burn illness,[22] making succinylcholine
administration to patients >24 h after burn injury an unsafe practice, potentially leading to life-threatening
hyperkalemia and cardiac arrest. From a pain management standpoint, the elimination of morphine is
unchanged after burn injury.[23]
MANAGEMENT OF INHALATIONAL INJURY AND RESPIRATORY FAILURE
Initial management of the pediatric burn patient requires evaluation of potential airway compromise,
oxygenation, and ventilation. Predictors of significant inhalation injury and impending respiratory failure
including stridor, wheezing, drooling, and hoarseness are indicative of airway swelling and compromise.
The presence of soot in the mouth, facial burns, and history of entrapment in closed spaces such as house
fires may be even more useful predictors of significant injury.[24] Circumferential burns to the neck can
result in tight eschar formation that can exacerbate upper airway compromise. The key to airway
management is to rapidly secure the airway prior to overt airway closure. The advent of fiberoptic
intubation, video laryngoscopes, and laryngeal mask airway (LMA)-guided intubation has aided in the
management of the difficult airway, although the route of tracheal intubation should be individualized and
planned ahead of time.[25]
The source of burn injury to the lung involves a combination of both direct lung injury and systemic
toxicity.
Gas phase constituents of smoke including carbon monoxide (CO), cyanide, acidic and aldehyde gases,
and oxidants can directly impair ciliary function, increase bronchial vessel permeability, and lead to
alveolar destruction. In addition, the release of inflammatory mediators such as tumor necrosis factor, and
neutrophil infiltration alter microvascular barrier function, leading to the development of pulmonary
edema.[26] The direct alveolar injury, along with airway and bronchial edema, sloughing of necrotic
epithelial mucosa producing thick secretions, and resultant ventilation−perfusion mismatch, ultimately
lead to hypoxia.
The inhaled byproducts of burning wood, plastic, and other materials can lead to carbon monoxide (CO)
and cyanide (CN) poisoning. CO has a 250-fold affinity for hemoglobin as compared to oxygen, and shifts
the oxy-hemoglobin dissociation curve to the left, ultimately resulting in the impairment of oxygen
delivery to tissues. The treatment of CO poisoning relies on administration of 100% oxygen, with
hyperbaric oxygen therapy reserved for refractory toxicity, as it is fraught with practical difficulties of
transporting critically ill patients into hyperbaric chambers. Cyanide is released when natural and synthetic
polymers are burned, and causes tissue hypoxia by uncoupling oxidative phosphorylation in mitochondria.
Treatment should be considered for patients with unexplained severe lactic acidosis, despite normal
oxygen saturation and low carboxyhemoglobin levels.[27]
Ventilator strategies to manage hypoxia and ARDS in the pediatric burn patient can be challenging. While
a lung-protective ventilation strategy using low-tidal volumes, positive end-expiratory pressure, and
permissive hypercarbia have clearly shown a benefit in adult patients with ARDS,[28] this strategy seems
reasonable in pediatric patients as well, as it minimizes the effect of ventilator-induced lung injury.[29]
Refractory hypoxia in pediatric burn patients has been managed by a variety of methods, including the use
of high-frequency percussive ventilation (HFPV) and high-frequency oscillatory ventilation (HFOV).[30]
In addition, small studies have shown a survival benefit to the use of extracorporeal membrane
oxygenation (ECMO) in these patients if they have failed maximal ventilator therapy.[31] Despite the
progress in using advanced ventilator strategies for managing refractory hypoxia in these patients, there is
unfortunately a lack of consensus amongst major burn centers as to which therapy is the best, with wide
variability in practice being noted.[32]
FLUID MANAGEMENT
Fluid resuscitation is of paramount importance during the initial care of the burned child. During the initial
phase of resuscitation, adequate vascular access must be obtained. While preferable to not use a site that is
burned, sometimes very large burn areas preclude this, and observational evidence shows that intravenous
catheters may be placed through burned skin.[33] Central venous access may be necessary in select cases
and does appear to be safe in children with burn injury.[34] The overall objective of resuscitation is to
replace fluid losses and restore euvolemia, while avoiding the detrimental effects of fluid overload.
The fluid requirements may be calculated using several different formulae, all of which achieve good
results. The Parkland formula provides a simple and easily remembered basis for resuscitation (4 mL
Ringer's lactate (RL)/kg/percent BSA burned; one-half to be given during the first 8 h after injury and the
rest in the next 16 h). The type of fluid administered is generally an isotonic crystalloid, with the
recommendation for the addition of dextrose to children under 20 kg to prevent the development of
hypoglycemia.[35] While some experts have recommended the use of colloid early in resuscitation,[36]
large reviews have not demonstrated a survival benefit.[37] The Parkland formula has been observed to
underestimate resuscitation volumes in children,[38] especially in the presence of inhalational injury.[39]
Thus, it is critical to monitor the endpoints of fluid resuscitation including hemodynamics, urine output-
with a goal of maintenance of 1–2 mL/kg/h for children <30 kg and 0.5–1 mL/kg/h for those ≥30 kg,[40]
mental status, lactate levels, and base deficit.
BURN WOUND MANAGEMENT
After stabilization of the critical care issues in the burn-injured child, attention is directed toward burn
wound management. The key elements of conservative burn wound management include cleansing,
debridement, topical antimicrobial agents, and dressing changes of the burned areas. Superficial burns with
an intact epidermis do not require specific treatment with antimicrobial agents or dressing changes.[41]
For patients with deeper burns, there is no consensus on which combination of topical agents and dressings
provides the best wound coverage and infection control.[42]
Cleansing allows better inspection of the wound surface, and debridement removes devitalized and
necrotic tissue from the burn wound. Burn wounds are initially gently cleansed mild soap and water, and
debridement is performed using gentle mechanical techniques, such as brushing or scraping. In addition, a
number of proteolytic enzymes have been used to aid debridement,[43] although they should not be used if
infection is suspected. The use of topical antimicrobial agents has reduced the incidence of invasive wound
infections,[44] although a specific agent has not been shown to be superior.[42] Lastly, regular dressing
changes and aggressive wound care are instrumental toward recovery, as it protects the wound from further
infection, provides comfort, and promotes healing, although no trial has been performed to address the
optimal frequency of dressing changes. It should be noted that a variety of dressings exist including
standard fine mesh gauze, hydrocolloid, silver-containing dressings, biosynthetic, and biologic dressings.
While each has particular theoretical advantages,[45] there is no clear evidence on which dressing provides
the best coverage; thus, the choice can be made based on cost, availability, frequency of dressing changes
(i.e. dressing which minimizes amount of changes may be more suitable for children), and institutional
familiarity.
Definitive surgical management of the wound includes excision, grafting, and reconstruction. Burn
reconstruction procedures have the ultimate goal of covering wounds, restoring function, and preserving
esthetics.[46] In addition, the reconstruction is often completed in separate phases, depending on severity
of burn and donor tissue availability. The use of early excision and skin grafting allows initial acute
coverage of burns; also, early excision and skin grafting reduce necrotic and infected tissue.[47] In
addition, early excision and skin grafting leads to decreased hospital lengths of stay, a reduced cost of
hospital care,[48] and a significant reduction in mortality.[49]
Free skin grafts with either full or split thickness are the conventional options for burn wound coverage
after excision. Split thickness grafts allow the advantage of covering large surface areas with less donor
skin, while full thick grafts allow the advantage of improved skin texture and esthetics.[46] In addition to
free skin grafts, a variety of biosynthetic skin substitutes (i.e. Integra, Matriderm) have increased the
number of reconstructive options. These biosynthetic substitutes attempt to replicate the properties of
normal skin, which is then supplemented with a thin split thickness free skin graft. Unfortunately, data
derived from large prospective trials of skin substitutes are currently lacking.
PAIN MANAGEMENT
Pain management is a critical piece in the overall care of the burned child. Severe pain is a major
consequence of burn injury, and it has been demonstrated that it is often inadequately treated.[50] Anxiety
and depression are confounding components in a major burn and can further decrease the pain threshold.
The different types of pain must be taken into account (acute, procedure-related pain versus background,
or baseline pain) in the development of an effective pain regimen. High-dose opioids are commonly used
to manage acute breakthrough pain and pain associated with burn procedures, and morphine is currently
the most widely used drug at burn centers in North America.[51] As alterations in morphine clearance do
not seem to be an effect of burn injury and most burned patients will develop tolerance to its effects,
titration to the appropriate level of pain control and frequent reassessment are important. In addition, the
combination of opioids and benzodiazepines (with appropriate monitoring) can be used successfully for
procedural sedation, as daily wound care and dressing changes are commonplace and can be associated
with significant pain. Table 2 shows a protocol for pain management in burn children from our institution,
which is a burn center for the northwest United States.
Due to the concerns of tolerance, withdrawal, and opioid-induced hyperalgesia,[52] the use of a
multimodal pain management regimen has been advocated. For background analgesia, analgesics such as
acetaminophen can be used for their opioid-sparing effect. Ketamine, an N-methyl-D-aspartic acid
(NMDA) antagonist has been used with increased frequency for procedural sedation. Advantages for its
use include preserved muscle tone and protective airway reflexes, reduced risk of respiratory depression,
and reduced hemodynamic effects.[53] Regional anesthetic techniques may also serve as a useful opioid-
sparing adjunct for burn injuries limited to an extremity. Lastly, a variety of other techniques including
music therapy, hypnotherapy, massage, behavioral techniques, and even virtual reality techniques have
been successfully used to reduce pain during wound care.[54] Table 3 lists some of these techniques, their
advantages, and disadvantages.
CONCLUSION
Burn injury in children continues to be a major epidemiologic problem. Care for these particularly
vulnerable patients requires a sound understanding of the multisystemic pathophysiological effects of burn
injury on virtually every organ system. In addition, close attention must be paid to initial evaluation and
management, resuscitation, and pain control. Through the use of multidisciplinary teams, burn centers, and
advancement of knowledge through sustained research efforts, we can continue to offer these patients an
excellent chance for recovery.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
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Figures and Tables
Figure 1
Comparative proportions of total body surface area distribution between adults and children
Table 1
Pathophysiologic manifestations of burn injury
Table 2
Harborview Medical Center (WA, USA) for pain management of a pediatric (<40 kg) burn patient
Table 3
Nonpharmacologic strategies for pediatric burn pain
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