What is the best next step in care for a 15-month-old boy with an oral burn and eschar formation after biting an electric cord, with no brisk bleeding or loss of consciousness?

Management of Pediatric Oral Electrical Burn

Discharge the patient after securing specialty follow-up with plastic surgery or a burn specialist. This 15-month-old with an isolated oral commissure burn from biting an electric cord, who is hemodynamically stable without loss of consciousness, does not require hospital admission or cardiac monitoring.

Rationale for Outpatient Management

Low-voltage household electrical injuries in children rarely require admission and can be safely managed as outpatients. A comprehensive 25-year retrospective review of 127 pediatric electrical injuries found that the vast majority of patients with low-voltage electrical injuries (including oral burns from biting cords) did not need hospital admission and could have been safely cared for on an outpatient basis 1. This represents the standard approach for isolated oral commissure burns without systemic complications.

Key Clinical Decision Points

Cardiac monitoring is not indicated for this patient because:

• No loss of consciousness occurred, indicating no transthoracic current passage 1
• The injury is isolated to the oral commissure without evidence of systemic electrical injury 2
• Cardiac arrhythmias from electrical injury occur primarily with high-voltage injuries or when current passes through the thorax 3
• The mechanism (biting a cord) produces localized tissue damage without significant current flow through vital organs 1

Conservative Wound Management Approach

Early surgical intervention is contraindicated; conservative management is the standard of care for oral commissure burns 2. A long-term study (5-17 years follow-up) of 24 patients with oral commissure burns demonstrated that:

• Conservative treatment without splinting or early surgery is safe and effective 2
• No patients suffered significant hemorrhage at eschar separation when managed conservatively 2
• Reconstructive surgery should be delayed until after scar maturation and functional/aesthetic impairment is established 2
• Early intervention does not improve outcomes and may complicate healing 2, 4

Specific Wound Care Instructions

The eschar should be left undisturbed and allowed to separate naturally 2. Parents must be counseled about:

• The risk of delayed hemorrhage (typically 5-14 days post-injury when the eschar separates from the labial artery) 2
• Instructions to apply direct pressure if bleeding occurs and seek immediate medical attention 2
• The need for close outpatient follow-up to monitor healing 4

Mandatory Specialty Referral

Immediate referral to a burn specialist or plastic surgeon is required to establish a treatment plan and monitor for complications 3. The American College of Surgeons recommends referral to a burn specialist immediately to determine appropriate ongoing management 3. This multidisciplinary approach should include:

• Plastic surgery or burn surgery for wound assessment and long-term reconstruction planning 4
• Pediatric dentistry for evaluation of potential dental and orthodontic complications 4
• Oral and maxillofacial surgery consultation if significant tissue loss is present 4

Long-term Considerations

Younger children with more severe burns have less favorable outcomes, making close follow-up essential 2. Reconstructive procedures (commissuroplasty and/or lip surgery) may be necessary months to years after injury once scar maturation is complete 2. The use of microstomia prevention devices during healing may improve functional and aesthetic outcomes 4.

Common Pitfalls to Avoid

Do not perform escharotomy or primary closure on oral commissure burns, as these interventions are not indicated and may worsen outcomes 2. Escharotomy is reserved for circumferential burns causing compartment syndrome, not for localized oral burns 3.

Do not admit for cardiac monitoring based solely on the mechanism of electrical injury without clinical indicators of systemic involvement 1. This represents unnecessary resource utilization and does not improve patient outcomes for low-voltage household injuries 1.

Do not underestimate the potential for delayed complications, particularly labial artery hemorrhage at eschar separation 2. Parents must receive explicit instructions about this risk and emergency management 2.