What is the initial management and medication dosage for a 4-year-old pediatric burn patient in the Emergency Room (ER), including intravenous (IV) fluids?

Emergency Management of a 4-Year-Old Pediatric Burn Patient

Immediate Initial Resuscitation (First Hour)

Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) intravenously within the first hour, regardless of burn size, to address early hypovolemic shock. 1

IV Access and Fluid Choice

• Establish IV access immediately, preferably in unburned areas 1
• If IV access cannot be rapidly obtained, use intraosseous route 1
• Use Ringer's Lactate or Hartmann's solution as first-line fluid (avoid 0.9% NaCl due to risk of hyperchloremic acidosis and acute kidney injury) 1, 2

Weight-Based Calculation for 4-Year-Old

• Average 4-year-old weight: approximately 16-18 kg
• Initial bolus: 320-360 mL of Ringer's Lactate over first hour 1

Burn Assessment

Measure Total Body Surface Area (TBSA)

• Use Lund-Browder chart (pediatric version) - most accurate method for children 1
• Alternative: Serial halving method or palm method (patient's palm + fingers = 1% TBSA) 1
• Children with burns ≥10% TBSA require formal fluid resuscitation 1, 3, 2

Ongoing Fluid Resuscitation (After First Hour)

Modified Parkland Formula for Children

For burns >10% TBSA, calculate total 24-hour fluid requirement:

• 3-4 mL/kg/% TBSA 3, 2
• PLUS basal maintenance fluids using 4-2-1 rule: 1, 3
  • First 10 kg: 4 mL/kg/hour
  • Second 10 kg: 2 mL/kg/hour
  • Each additional kg: 1 mL/kg/hour
  • For 16 kg child: (10×4) + (6×2) = 52 mL/hour basal

Fluid Administration Schedule

• Give half of calculated 24-hour requirement in first 8 hours (from time of burn, not arrival) 1, 3, 2
• Give remaining half over next 16 hours 1, 3, 2
• Children typically require approximately 6 mL/kg/% TBSA total over first 48 hours 1, 3

Example Calculation for 16 kg Child with 20% TBSA Burn:

• Parkland: 3.5 mL × 16 kg × 20% = 1,120 mL over 24 hours
• First 8 hours: 560 mL (70 mL/hour)
• Next 16 hours: 560 mL (35 mL/hour)
• Add basal maintenance: 52 mL/hour to each phase

Monitoring and Adjustment

Target Urine Output

• Goal: 0.5-1 mL/kg/hour (8-18 mL/hour for 16 kg child) 3, 2
• Adjust fluid rate based on urine output - this is the simplest and most reliable parameter 3, 2

Additional Monitoring

• Arterial lactate concentration 3
• Avoid "fluid creep" (over-resuscitation) which increases morbidity 3, 2

Pain Management

Analgesia Dosing

• Morphine IV: 0.05-0.1 mg/kg every 2-4 hours (0.8-1.8 mg for 16 kg child) 4
• Fentanyl IV: 1-2 mcg/kg every 1-2 hours (16-36 mcg for 16 kg child) 4
• Consider intranasal analgesia for initial management if IV not yet established 4

Wound Care

Initial Management

• Cool burn with room temperature water for 10-20 minutes (avoid hypothermia) 4
• Cover with clean, dry dressing or sterile sheet 4
• Do NOT apply ice, butter, or topical agents in ER 4

Infection Prophylaxis

Antibiotic Considerations

• Routine prophylactic antibiotics NOT recommended for initial burn management 5
• If infection suspected or high-risk contamination:
  • Cefazolin pediatric dose: 25-50 mg/kg/day divided every 6-8 hours 5
  • For 16 kg child: 400-800 mg/day (100-200 mg every 6 hours) 5

Critical Assessments

Airway Evaluation

• Assess for inhalation injury: circumoral burns, oropharyngeal burns, carbonaceous sputum, singed nasal hairs 2
• Inhalation injury significantly increases mortality 2
• Most pediatric burns do NOT require intubation 4

Compartment Syndrome

• Monitor for circumferential burns causing circulatory compromise 1, 2
• Escharotomy should be performed at burn center if possible 1, 2
• Only urgent indication: compromised airway movement/ventilation 1

Transfer Criteria

Immediate Burn Center Consultation

• Contact burn specialist to determine need for transfer 1
• Use telemedicine for initial assessment if available 1
• Direct admission to burn center preferred over secondary transfer 1
• Burns involving face, hands, feet, genitals require specialized care 2

Common Pitfalls to Avoid

• Do NOT delay fluid resuscitation - early administration (within 2 hours) reduces morbidity and mortality 1
• Do NOT use normal saline as primary resuscitation fluid 1, 2
• Do NOT over-resuscitate - causes compartment syndrome and increased complications 3, 2
• Do NOT underestimate fluid needs - children require proportionally more fluid than adults due to higher surface area-to-weight ratio 1, 3