What is the initial management of pediatric burns?

Initial Management of Pediatric Burns

Pediatric burn patients with total burned body surface area (TBSA) of 10% or greater should receive 20 mL/kg of balanced crystalloid solution within the first hour of management, followed by ongoing fluid resuscitation guided by hourly urine output. 1

Initial Assessment and Resuscitation

Fluid Resuscitation

• For burns ≥10% TBSA in children:

  • Administer 20 mL/kg of balanced crystalloid solution (preferably Ringer's Lactate) in the first hour 1
  • Establish IV access in unburned areas when possible
  • Use intraosseous access if IV cannot be rapidly obtained 1
  • Avoid central femoral venous access except as last resort

• After initial bolus, calculate ongoing fluid requirements:

  • Children require higher fluid volumes (approximately 6 mL/kg/%TBSA) due to higher body surface area/weight ratio 2
  • Consider adding basal fluid requirements using Holliday-Segar formula (4-2-1 rule) to the burn formula 1
  • Adjust fluid rates based on urine output (target 0.5-1 mL/kg/hr) 2

Pain Management

• Implement multimodal analgesia immediately:
  • Titrate all analgesics based on validated pain assessment scales 1
  • Intravenous ketamine can be effectively combined with other analgesics for severe burn pain 1
  • For stable patients, incorporate non-pharmacological techniques during dressing changes 1

Wound Care

Immediate Wound Management

• Clean and debride burn wounds under sterile conditions 3
• Apply silver sulfadiazine cream to a thickness of approximately 1/16 inch 3
• Reapply silver sulfadiazine once to twice daily and after hydrotherapy 3
• Continue treatment until satisfactory healing occurs or until the burn site is ready for grafting 3

Special Considerations

• Escharotomy:

  • Rarely indicated immediately except for compromised airway/ventilation
  • Consider for intra-abdominal hypertension or circulatory impairment within 48 hours 1
  • Should be performed at a Burns Center or after specialist consultation 1

• Carbon Monoxide Poisoning:

  • All children with suspected CO poisoning should immediately receive 100% oxygen 1
  • Consider hyperbaric oxygen therapy for children with impaired consciousness or neurological symptoms 1

Monitoring and Ongoing Management

• Hourly urine output monitoring is the most reliable parameter for assessing fluid resuscitation adequacy 2
• Watch for signs of:
  • Under-resuscitation: persistent oliguria, hypotension, rising lactate
  • Over-resuscitation ("fluid creep"): excessive edema, respiratory compromise
• Adjust fluid rates promptly based on clinical response 1, 2
• For burns >30% TBSA, consider advanced hemodynamic monitoring 2

Common Pitfalls to Avoid

• Delayed fluid resuscitation: Early fluid resuscitation (within 2 hours) reduces morbidity and mortality in children 1
• Inaccurate TBSA calculation: Children have different body proportions than adults; use age-appropriate charts
• Fluid overload: Children with 10-20% TBSA burns may benefit from more conservative fluid management 1
• Inadequate pain control: Uncontrolled pain can lead to increased anxiety, delayed wound healing, and long-term psychological consequences 4
• Failure to adjust fluid rates: Formulas provide initial estimates but must be adjusted based on clinical response 1, 2