Management of Facial Burns in a 9-Year-Old Child
Immediate cooling of the facial burn with cold running water for 20 minutes is the essential first step in management, followed by application of a thin layer of 1% silver sulfadiazine cream and non-adherent dressings for optimal healing and reduced scarring. 1
Initial Assessment and Airway Management
Airway Evaluation
- Monitor closely for signs of respiratory distress, especially if smoke inhalation is suspected
- Tracheal intubation is not recommended in the absence of respiratory distress in children with facial burns from hot fluid 2
- Intubation should be performed immediately if any of these criteria are met:
- Deep circular neck burn
- Symptoms of airway obstruction (voice modification, stridor, laryngeal dyspnea)
- Very extensive burn (TBSA ≥40%)
- Signs of smoke inhalation (fire in enclosed space, soot on face, dysphonia, wheezing, blackish sputum)
Burn Severity Assessment
- Use the Lund-Browder chart (pediatric version) for accurate TBSA measurement 1
- Facial burns require immediate medical attention regardless of TBSA percentage 1
- Evaluate depth of burn (superficial, partial-thickness, or full-thickness)
Wound Management
Immediate Care
- Cool the burn with cold running water (15-25°C) for 20 minutes to reduce burn depth and decrease need for hospitalization 1
- Gently irrigate the wound with warmed sterile water, saline, or dilute chlorhexidine (1/5000) 1
Blister Management
- Keep small blisters intact to maintain a sterile environment 1
- For large blisters, decompress by piercing while leaving the blister roof intact as a biological dressing 1
Topical Treatment
- Apply a thin layer (approximately 1/16 inch) of 1% silver sulfadiazine cream 3
- Reapply once to twice daily or whenever the cream has been removed by patient activity 3
- Use non-adherent dressings (e.g., Mepitel™ or Telfa™) for denuded areas 1
- Consider silver-containing products for sloughy areas only 1
Pain Management
Pain control is crucial in pediatric facial burns to ensure compliance with treatment and prevent prolonged healing:
- Use multimodal analgesia with titration based on validated pediatric pain scales 1
- Administer analgesics prior to any wound care procedures 1
- Consider non-pharmacological techniques such as virtual reality or hypnosis during dressing changes 1
Infection Prevention
- Monitor for signs of infection: increasing pain, redness, swelling, discharge, fever 1
- Take swabs for bacterial and candidal culture from lesional skin on alternate days 1
- Do not administer systemic antibiotics prophylactically; only use when clinical signs of infection are present 1
Specialized Care Considerations
Transfer Criteria
- Consider transfer to a specialized burn center if:
- Facial burns are deep or extensive
- Burns involve functional areas (eyes, ears, nose, mouth)
- Signs of inhalation injury are present
Surgical Management
- Early surgical excision and skin grafting should be considered for deep burns to minimize scarring and improve functional outcomes 4
- For partial-thickness burns, the goal is healing within 2-3 weeks to minimize scarring 4
Rehabilitation
- Begin early range of motion exercises to prevent contractures, especially around the mouth, eyes, and neck 1
- Consider massage therapy to soften scar tissue and improve circulation 1
Pitfalls and Caveats
- Do not apply ice directly to the burn as it can worsen tissue damage 1
- Do not delay cooling - immediate cooling significantly improves outcomes 1
- Avoid unnecessary intubation in children with facial burns without respiratory distress 2
- Do not perform bronchial fibroscopy outside of burn centers if smoke inhalation is suspected, as it may delay transfer 2
- Monitor fluid balance carefully - children with burns ≥10% TBSA require crystalloid fluid resuscitation (20 ml/kg in first hour) 1
Regular reassessment of the burn wound and the child's overall condition is essential throughout the healing process to ensure optimal outcomes and minimize scarring.