What is the initial management for pediatric patients presenting with first or second-degree burns in the emergency department?

From the Guidelines

The initial management of pediatric patients with first or second-degree burns in the emergency department should focus on stopping the burning process, assessing the burn severity, and providing appropriate pain control, with the most recent guidelines from 2024 recommending covering the burn with a nonadherent bandage or clean cloth to protect the wound and reduce pain 1.

Key Steps in Management

• Remove all clothing and jewelry from the affected area and irrigate the burn with cool (not cold) water for about 20 minutes to halt the burning process and reduce pain.
• For pain management, administer acetaminophen (15 mg/kg/dose) or ibuprofen (10 mg/kg/dose) for mild pain, while moderate to severe pain may require opioid analgesics such as morphine (0.1 mg/kg IV) or fentanyl (1-2 mcg/kg IV).
• Clean the wound gently with mild soap and water, then apply a thin layer of petroleum-based ointment or silver sulfadiazine cream (for second-degree burns) and cover with a non-adherent dressing.
• Assess the burn's depth, size (using age-appropriate charts like the Lund-Browder chart), and location to determine if transfer to a burn center is needed, with the Lund-Browder chart being the most accurate method for total body surface area (TBSA) quantification 1.

Special Considerations

• Burns involving the face, hands, feet, genitalia, or major joints require special attention.
• Tetanus prophylaxis should be administered if the child's immunization status is not up to date.
• Maintain the child's body temperature and provide appropriate fluid resuscitation for larger burns using the Parkland formula if the burn exceeds 10% of total body surface area.

Avoiding Harmful Practices

• Avoid using ice, butter, or home remedies as these can worsen tissue damage.
• Be cautious of overestimating TBSA, as this can lead to overtriage and consumption of inappropriate resources, and undertriage can lead to increased morbidity and mortality 1.

From the FDA Drug Label

Prompt institution of appropriate regimens for care of the burned patient is of prime importance and includes the control of shock and pain. The burn wounds are then cleansed and debrided; silver sulfadiazine cream, USP 1% is then applied under sterile conditions. Silver sulfadiazine cream, USP 1% is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second and third degree burns.

For initial management of pediatric patients presenting with first or second-degree burns in the emergency department, the following steps should be taken:

• Control of shock and pain should be prioritized.
• The burn wounds should be cleansed and debrided.
• Silver sulfadiazine cream, USP 1% can be applied to second-degree burns as an adjunct for the prevention and treatment of wound sepsis. However, for first-degree burns, there is no direct information in the provided drug labels to support a specific treatment recommendation. 2 2

From the Research

Initial Management of Pediatric Burns

The initial management of pediatric patients presenting with first or second-degree burns in the emergency department involves several key steps:

• Assessment of burn depth and total body surface area (TBSA) affected 3
• Calculation of percent of TBSA affected to determine the necessity for hospitalization versus outpatient management 3
• Evaluation of the need for fluid resuscitation, airway involvement, and oral fluid intake 3

Topical Treatment and Pain Management

For pediatric patients with first or second-degree burns:

• Topical antimicrobial agents such as bacitracin, neomycin, silver sulfadiazine, and mafenide can be used to control microbial colonization and prevent invasive infections 4
• Pain management is an integral component of burn care, and a multidisciplinary approach may be necessary to achieve adequate pain relief 5
• Both pharmacological and nonpharmacological treatment options can be considered for pain management 5

Special Considerations in Pediatric Burn Patients

Pediatric burn patients require special consideration due to their unique physiology and energy requirements 6

• Fluid and electrolyte handling, as well as energy requirements, must be carefully managed in pediatric burn patients 6
• The goal of initial management is not only to ensure survival but also to minimize morbidity and complications, allowing for effective integration into society 6

Outpatient Management and Referral Criteria

Outpatient management of pediatric burns may be appropriate for patients with burns affecting less than 15% TBSA, who do not require fluid resuscitation, and have a dependable family able to transport the patient for clinic appointments 3

• Referral to a specialist burn service may be necessary for patients who do not meet outpatient management criteria or require ongoing care and support 7