What is the management approach for a pediatric burn in the emergency department in Australia?

Management of Pediatric Burns in Australian Emergency Departments

Pediatric burn management in Australian emergency departments should follow a structured approach that includes accurate assessment, early specialist consultation, appropriate wound care, pain management, and consideration for transfer to specialized burn centers to reduce morbidity and mortality.

Initial Assessment and Triage

Burn Surface Area Assessment

• Use the Lund-Browder chart (pediatric version) as the reference method for accurate TBSA measurement in children 1, 2
• Alternative methods for quick estimation in prehospital settings:
  • Serial halving method
  • Palm method (palm and fingers = approximately 1% TBSA) 1
• Avoid using the Wallace rule of nines as it significantly overestimates TBSA in children 1, 2
• Consider using burn assessment smartphone applications (e.g., E-Burn, Mersey Burns) to improve accuracy 1, 3

Criteria for Specialist Consultation

Seek burn specialist consultation for:

• Burns involving face, hands, feet, genitalia, or perineum
• Full-thickness burns
• TBSA >10% in children
• Cases with hyperalgesia or need for special medico-social care 1, 2

Caution: Research shows referring hospitals often overestimate TBSA by up to 40% compared to specialized burn centers, potentially leading to unnecessary transfers and overtreatment 4, 5. Using standardized assessment tools can reduce these discrepancies.

Immediate Management

Wound Care

1. Cleanse wounds by gently irrigating with warmed sterile water, saline, or dilute chlorhexidine (1/5000) 2
2. Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over intact epidermis 2
3. For blisters:
   • Keep intact to maintain sterile environment and reduce infection risk
   • If necessary, decompress by piercing while leaving the blister roof intact to act as a biological dressing 2
4. Apply appropriate dressings:
   • Non-adherent dressings for denuded areas (e.g., Mepitel™ or Telfa™)
   • Consider silver-containing products for sloughy areas
   • Apply a thin layer (approximately 1/16 inch) of 1% silver sulfadiazine cream to second and third-degree burns 2

Pain Management

• Implement multimodal analgesia using validated pediatric pain assessment tools 2
• Medication options:
  • Acetaminophen (paracetamol)
  • NSAIDs (if not contraindicated)
  • Opioids for moderate to severe pain
  • Consider ketamine as an adjunct for severe burn-induced pain 2
• Provide analgesia prior to any wound care procedures 2
• Consider non-pharmacological techniques (virtual reality, distraction) when appropriate 2

Fluid Resuscitation

For children with burns ≥10% TBSA:

• Administer 20 ml/kg of balanced crystalloid solution in the first hour 2
• Use balanced crystalloid solutions such as Ringer's lactate for initial resuscitation 2
• Monitor fluid balance carefully and catheterize if necessary 2
• Begin nutritional support within 12 hours after burn injury, preferring oral or enteral routes 2, 6

Infection Prevention and Management

• Take swabs for bacterial and candidal culture from lesional skin on alternate days 2
• Do not administer systemic antibiotics prophylactically - only use when there are clinical signs of infection 2, 7
• Monitor for signs of infection: increasing pain, redness, swelling, discharge, fever or systemic symptoms 2, 7
• Employ strict barrier nursing to reduce nosocomial infections 2

Transfer and Specialist Care Considerations

Telemedicine Consultation

• When burn specialists are not readily available, use telemedicine to improve assessment accuracy and determine appropriate management 1
• This can help prevent both overtriage (unnecessary hospitalizations) and undertriage (increased risk of morbidity and mortality) 1

Transfer Criteria

Consider transfer to a specialized burn center for:

• Burns involving face, hands, feet, genitalia, or perineum
• Full-thickness burns
• TBSA >10% in children 1, 2

Important: If transfer to a burn center is indicated, the patient should be admitted directly to the center rather than being admitted elsewhere first 1

Special Considerations

• Maintain ambient temperature between 25°C and 28°C to prevent hypothermia 2
• Begin early range of motion exercises to prevent contractures 2
• Consider escharotomy if a deep burn induces compartment syndrome that compromises airways, respiration, or circulation (ideally performed at a burn center by an experienced provider) 1

Rehabilitation Planning

• Begin planning for rehabilitation early in the care process
• Consider massage therapy to soften scar tissue and improve circulation 2
• Use pressure-relieving mattress for patients with extensive burns 2