What is the initial management of pediatric burns in the emergency department?

Initial Management of Pediatric Burns in the Emergency Department

The initial management of pediatric burns in the emergency department should include immediate cooling with cold running water for 20 minutes, accurate assessment of burn severity using the Lund-Browder chart, appropriate pain management, and early consultation with a burn specialist for burns involving critical areas or exceeding 10% total body surface area (TBSA) in children. 1

Assessment and Triage

Burn Severity Assessment

• Use the Lund-Browder chart (pediatric version) for accurate TBSA measurement 2
• The Wallace rule of nines significantly overestimates TBSA and is not suitable for children 2
• Alternative methods in prehospital settings:
  • Serial halving method for mass casualty situations 2
  • Palm method (palm and fingers = 1% TBSA) for quick estimation 2

Criteria for Specialist Referral

Seek burn specialist consultation for:

• Burns involving face, hands, feet, genitalia, or perineum
• Full-thickness burns

• 10% TBSA in children (compared to >20% TBSA in adults)

• Suspected non-accidental injury (present in up to 10% of cases) 3
• Hyperalgesia or need for special medico-social care 2

Immediate Interventions

Cooling and Wound Care

1. Apply cold running water for 20 minutes to the burned area 1

   • This reduces burn depth and decreases the percentage of burns requiring hospital admission
   • Avoid ice or very cold water which can worsen tissue damage

2. Cleanse wounds gently:

   • Use warmed sterile water, saline, or dilute chlorhexidine (1/5000) 1
   • Apply greasy emollient over intact epidermis 1

3. Blister management:

   • Keep blisters intact to maintain a sterile environment
   • If necessary, decompress by piercing while leaving the blister roof intact 1

Dressing Application

• Use non-adherent dressings for denuded areas (e.g., Mepitel™ or Telfa™) 1
• For second and third-degree burns, apply a thin layer (1/16 inch) of 1% silver sulfadiazine cream 4
• Consider silver-containing products for sloughy areas only 1
• Reapply dressings once to twice daily or whenever removed by patient activity 4

Pain Management

Multimodal Approach

• Use validated age-appropriate pain assessment tools at least once daily 1
• Provide analgesia prior to any procedures 1
• Implement a multimodal approach:
  • Acetaminophen
  • NSAIDs (if not contraindicated)
  • Opioids as needed for moderate to severe pain
  • Consider ketamine as an adjunct for severe burn-induced pain 1

Fluid Resuscitation

Indications and Protocol

• Initiate IV fluid resuscitation for burns ≥15% TBSA in children (compared to ≥20% TBSA in adults) 5
• Use balanced crystalloid solutions (e.g., Ringer's lactate) 1
• Initial dose: 20 ml/kg of balanced crystalloid solution in the first hour for children with ≥10% TBSA burns 1
• Monitor fluid balance carefully and catheterize if necessary 1

Infection Prevention

Monitoring and Management

• Take swabs for bacterial and fungal culture from lesional skin on alternate days 1
• Do not administer systemic antibiotics prophylactically 1
• Only use antibiotics when there are clinical signs of infection 1
• Monitor for signs of infection:
  • Increasing pain, redness, swelling
  • Discharge, fever, or systemic symptoms 1

Special Considerations

Escharotomy

• Consider escharotomy if a deep burn induces compartment syndrome that compromises:
  • Airways and respiration
  • Circulation to limbs
• Ideally performed in a burns center by an experienced provider 2

Telemedicine

• When burn specialists are not readily available, use telemedicine to improve initial assessment 2
• This helps prevent overtriage (unnecessary hospitalization) and undertriage (increased risk of morbidity and mortality) 2

Common Pitfalls to Avoid

1. Inaccurate TBSA assessment: TBSA is often overestimated in 70-94% of cases, leading to excessive fluid administration 2
2. Delayed specialist consultation: Early consultation improves outcomes and ensures appropriate triage 2
3. Inadequate cooling: Failure to cool burns immediately and adequately can lead to progression of burn depth 1
4. Missing non-accidental injury: Always consider child abuse in pediatric burns with suspicious patterns or inconsistent history 3
5. Inappropriate fluid resuscitation: Children require fluid resuscitation at lower TBSA thresholds (15%) than adults (20%) 5