Burns exact a fearful toll in death and suffering on children, especially young children. Advances in treatment have improved the outlook for victims, but prevention remains the ultimate goal.
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Burns exact a fearful toll in death and suffering on children, especially young children. Advances in treatment have improved the outlook for victims, but prevention remains the ultimate goal.
Among industrialized nations the United States has one of the highest rates of burn injury with about 1.4 million injuries each year. The peak incidence occurs among children 1 to 5 years of age. More than 20,000 children are hospitalized for the care of burns each year.1 Many more are treated in pediatricians' offices.
Tremendous mortality and morbidity are associated with burn injuries. Burns are the fourth leading cause of accidental death in the US, which has the highest annual death rate from fires of all developed countries (2.1 per 100,000 persons).2 The risk of death by fire is greatest in the elderly and children, especially those under 5 years of age, who have nearly double the risk of children over 5 years and young adults. Around 1,200 children each year die from all types of burn injuries. The disadvantaged are disproportionately affected. Persons of lower socioeconomic status and minorities have an increased risk of burn injury and death.
Children who survive severe burns have a myriad of problems arising from their injuries, including not only the physical impact of scarring but also marked psychological and developmental consequences. Efforts to reduce the terrible toll burns take on children hinge on effective treatment of even minor injuries combined with parent education and other measures to prevent burns from occurring in the first place.
Burns are classified according to the mechanism of injury as scald, contact, flame, or electrical. Table 1 lists the most likely mechanisms by age. Most children under 5 years of age are victims of scald injuries from hot liquids, burns from contact with hot surfaces, and to a lesser extent, flame burns from house fires. Most scald burns in this age group occur in the kitchen and result from the spilling of hot liquids or foods. Despite legislation to control tap water temperatures, nearly one fifth of scald injuries in small children occur in the bathroom from hot tap water.
Older children are more likely than young children to suffer flame burns from accidents with flammable liquids and house fires. Injuries of large body surface areas and inhalation injuries, such as those from explosions or housefires, are the ones most likely to be fatal.
In 1994 more than 6,000 children were treated for fireworks-related injuries.3 Most such injuries occur around the July 4th holiday, usually in older children and teenagers. They are rarely fatal but often cause scarring, damage to vision (the eyes are often involved), and finger and hand amputations. Young children also suffer fireworksrelated injuries as spectators and from handling sparklers.
Not all burns are accidental. Ten percent of all cases of physical child abuse involve burns.4 These are usually scald injuries caused by forced immersion in hot water or contact burns from a hot object, such as a cigarette.
The physician must maintain a high index of suspicion in evaluating burn injuries. A detailed history of the event must be obtained and the developmental stage of the child taken into account in the assessment. If the stated mechanism of injury is not plausible or the pattern of injuries does not fit the story, abuse must be suspected. Careful evaluation for evidence of other nonaccidental trauma, such as bruises or fractures, is also important. Children suspected of being victims of abuse should be reported to the appropriate child-protection authorities.
The first step in evaluating a child with a burn injury is to assess the severity of the injury to determine whether the child can be treated as an outpatient or should be referred to a facility with expertise in treating pediatric burn victims. Key factors in the assessment include:
The most reliable predictor of outcome is the percent TBSA burned, followed by depth of the burn. To estimate percent TBSA burned in children use either the Lund and Browder chart (Figure 1) or the size of the patient's palm, which is roughly 1% of the TBSA at any age.5,6 As shown in Table 2, depth of burn injury is determined by the extent of damage to tissue and is classified in two ways: as first-, second-, or third-degree or as partial or full thickness. Table 3 lists the indications for hospitalizing a child at a pediatric burn center.
Most burns in children are minor partial-thickness burns covering less than 10% TBSA, which can be treated in the office by the child's primary care pediatrician. Effective management of minor burns is important since inadequate care can lead to wound infection, septicemia, poor wound healing, and a poor functional or cosmetic result.
Clean the wound thoroughly with povidone iodine or sterile saline and carefully remove dead tissue. Small blisters may be left intact. The fate of larger blisters and bullae is controversial. Some advocate opening them while others believe that this increases the risk of infection. In our experience, most large blisters, especially those that cross joints, should be opened. After cleaning and debridement, apply a gauze dressing impregnated with a broad-spectrum topical antibiotic such as silver sulfadiazine or bacitracin.
Instruct the child's parent or guardian about expected wound appearance and proper management, which usually includes dressing changes once or twice a day and analgesia, usually with acetaminophen and codeine. A follow-up appointment should be made before the patient leaves the office.
The physician should reassess the wound in 24 to 48 hours to make sure it is healing properly. Itching is a common symptom of the healing process. Once epithelialization has occurred, moisturizing creams can be applied to relieve residual dryness and itching. Antipruritic agents such as diphenhydramine and hydroxyzine also have been used successfully. Warn parents that the healed burn will be sensitive to sunlight for months and that the child should use sunscreen.
Problems the pediatrician may encounter include fever, change in wound appearance that may suggest infection, and failure to heal. Although the incidence of fever in children treated as outpatients has not been rigorously studied, fever is the rule in hospitalized burn patients, even those with small (1% to 10% of TBSA), partial-thickness burns. Many hospitalized patients have temperatures over 40° C without evidence of infection. Fever should keep us vigilant for infection of the burn wound since infection rarely occurs in the absence of fever. Fever alone is not synonymous with infection, however, and should not be considered a reason to empirically prescribe systemic antibiotics.
Wound infection, failure to heal, and delayed therapy should prompt consultation with a surgeon or burn center. Burn wounds are subject to infection for a variety of reasons. Loss of skin removes not only a protective barrier but also normal protective skin flora. The wound is a protein-rich medium ideal for microbial growth. Its avascularity makes it inaccessible to components of the immune system and systemic antibiotics.
Infection is rare in small burns but should be suspected if the wound margins appear cellulitic or there is purulent drainage. Focal areas of necrosis, edema, erythema or discoloration of the wound margin, hemorrhage within the subcutaneous tissue, and conversion from partial thickness to full thickness are other indications of wound infection. Although routine surface cultures of burn areas are not indicated, cultures may be useful if the wound appears to be infected, as discussed below.
Local infection is a serious complication that can lead to systemic infection, scar formation with deformity, and loss of function. The most effective treatment includes systemic and topical antibiotic therapy directed against Staphylococcus aureus, the most common pathogen, pending results of cultures. Antibiotic treatment is usually combined with wound debridement.
Speed of healing varies from patient to patient, but most small burns heal completely in two weeks. If the wound fails to heal within this period, referral for debridement and grafting may be necessary. Occasionally a patient may seek treatment belatedly for a burn injury, only after an infection develops or the wound does not heal. Such patients should be referred to a surgeon or burn center.
Unfortunately, a large number of pediatric burn victims have severe injuries requiring care in a burn center (Figure 2). The percent of TBSA involved and the depth of the burn predicts mortality risk for children with severe burns, just as it does the success of outpatient management of small burns. The larger the percent of TBSA involved and the deeper the burn, the higher the mortality, both immediately following the injury (from shock or associated injuries) and later on in patients who have been successfully resuscitated (from respiratory or infectious complications).
In adults, three factors predict burn mortality: age over 60 years, involvement of more than 40% TBSA, and inhalation injury. The mortality formula predicts 0.3%, 3%, 33%, or 90% mortality, depending on whether zero, one, two, or three risk factors are present.7 Although this formula obviously is not completely applicable to children, the same trend of increasing mortality with greater TBSA involvement and inhalation injury is seen, especially in children younger than 5 years.
Enormous progress in burn therapy has occurred in recent decades. One of the most important advances has been referral of pediatric burn victims to centers that specialize in treating burns. Such centers are staffed by multidisciplinary teamsincluding plastic surgeons, pediatric intensivists, infectious disease specialists, specialized nurses, occupational and physical therapists, nutritionists, psychologists, social workers, and play therapiststhat can meet the many needs of the pediatric burn patient.
Advances in intensive care also have had a positive impact on burn victims. Increasing knowledge of the pathophysiology of shock has led to aggressive treatment of patients with fluid resuscitation and other adjunctive therapies, and caregivers now recognize the importance of caloric intake in wound healing and infection prevention. In addition, much progress has been made in the care of burn wounds, especially early debridement and excision of dead tissue, use of topical antimicrobial agents, improved grafting techniques, and new biologic and synthetic wound coverings.
Because of these advances, the extent of burn injury associated with 50% survival in pediatric patients has increased from 55%TBSA to 80% TBSA.7 Unfortunately, infants under 1 year of age have not shared in the increase and have a higher mortality than older children for the same percent TBSA burned. A couple of factors are thought to contribute to this disadvantage. Infants have a larger surface area relative to weight than older children and thus greater metabolic demands, which their bodies may not be able to meet when the demands of burn injury are added. Their immature immune systems may contribute to infectious complications as well.
Emergency management of the severely burned child always starts with the ABCs: evaluation of the airway, breathing, and circulation. Securing the airway and establishing adequate ventilation are the first priorities. Smoke inhalation injury, resulting from breathing heated air and gases, is the leading cause of death in patients who initially survive burn injuries. Inhalation injuries are most common with flame burns but can also occur with scald burns, perhaps from steam, although the cause is not certain.
Clues to inhalation injury are singed nasal and facial hair, soot around the nose and mouth, burns on the face and neck, erythema of the buccal mucosa and pharynx, and respiratory distress. Arterial blood gases, carboxyhemoglobin level, a chest radiograph, and direct laryngoscopy and bronchoscopy can help make the diagnosis.
Treating inhalation injury requires administering 100% oxygen and often endotracheal intubation. Hyperbaric oxygen and other measures such as surfactant administration are controversial. Corticosteroid therapy and prophylactic antibiotics are contraindicated because corticosteroids may predispose the patient to infection and antibiotic prophylaxis may lead to colonization and infection with resistant organisms.
Assessing circulation is the next step in emergency management. Fluid replacement is required in any child with burns over more than 10% TBSA or smaller burns accompanied by smoke inhalation. Since younger children have more surface area relative to weight than adults or older children they have greater fluid requirements, and fluid replacement formulas used for adult burn victims may not be adequate in determining their needs.
A good starting point for the first 24 hours is to give four times the patient's weight in kilograms multiplied by the total surface area burned for replacement and add maintenance fluids. Give half the amount in the first eight hours and the rest in the remaining 16 hours. A 10 kg child who sustains a 30% TBSA burn, for example, would require fluid replacement as follows: 4 x 10 x 30 + maintenance = 40 x 30 + 1,000 mL = 2,200 mL of fluid, half in the first eight hours (1,100 mL divided by 8 = about 140 [137.5] mL/h) and half in the subsequent 16 hours (1,100 mL divided by 16 = about 70 [68.75] mL/h). Lactated Ringer's solution is most often used for fluid replacement.
The patient's fluid status must be reassessed continuously and the regimen changed accordingly. The best way to monitor fluid status is by precise measurement of urine output using either a urinary catheter or accurate diaper weights. Frequent monitoring of vital signs and mental status are other important ways to assess the adequacy of fluid replacement. Measurement of central venous pressure may be necessary in the critically burned patient.
Emergency evaluation must also include assessment of associated injuries and determination of the patient's immunization status. Tetanus prophylaxis should be given if incomplete or if six years have elapsed since the last dose. Pain management is of utmost importance and usually requires narcotics.
Major burns must be assessed for percent of TBSA affected and depth, then cleaned of debris with either sterile saline or sterile water and covered until surgical evaluation. To prevent hypothermia, especially in small infants, burns should not be left uncovered. Some patients need heating lamps to maintain adequate body temperature.
Severe burn wounds require management under surgical care in a pediatric burn unit. Early wound debridement, surgical excision and grafting, and routine use of topical antimicrobial agents contribute immensely to preventing and controlling infections following burns.
Pediatricians are often asked to help in the care of children hospitalized with burns, most commonly in evaluating the patient for a possible infectious complication. Burn victims are susceptible to a wide range of infections because of loss of the protective skin barrier, immunosuppression that accompanies all burns over more than 30% TBSA, and the need for intensive supportive care (intravenous or urinary catheters can lead to catheter-associated sepsis or urinary tract infections, for example; intubation for smoke inhalation may predispose the patient to nosocomial pneumonia). Table 4 lists possible infectious complications in pediatric burn patients.
Pediatricians also are consulted about fever in the hospitalized burned child. As stated earlier, fever is an unreliable predictor of infectious complications, since it is a universal early response to thermal injury in children, regardless of type, depth, or extent of the burn, and, by itself, is not a reason to start empiric systemic antibiotic therapy. At our hospital, we have documented fever in 96% of pediatric burn patients within the first 72 hours of hospitalization. We could not correlate fever with any patient characteristic (age, percent TBSA burned, type or depth of burn), and no patient characteristic or fever pattern correlated with infectious complications. Leukocytosis, often with bandemia, is also common in burned children and represents a response to thermal injury, not necessarily an ongoing infectious process.
In assessing patients for possible infections, look for indications of the most common infectious complications: bacteremias related to indwelling catheters, respiratory infections resulting from inhalation injury, and infection of the burn wound. Intravenous catheters should always be placed away from the injured site, but this may not be possible in children with extensive burns. Controversy surrounds the risk of infection from catheters placed through the burn wound, with some data suggesting increased colonization and risk.8 If placing a catheter through a burn wound is unavoidable, the site should be inspected daily and the catheter replaced every five to seven days.9
Pneumonia is the most common infectious cause of death in burn victims. In patients with inhalation injury, it usually develops in the first week after injury. Damage to the respiratory tract epithelium impairs surfactant production, mucociliary transport, and macrophage function.
As noted above, management of an infected burn wound consists of early debridement and excision of dead tissue in conjunction with topical antimicrobial therapy. Topical antimicrobials do not sterilize the burn. They limit wound infection by decreasing the density of microorganisms on the burn surface. Since infection is defined as invasion of microorganisms into underlying, unburned tissue, decreasing the surface microorganism density limits the likelihood of invasion (which usually requires more than 105 organisms per gram of tissue).10
Many topical agents are available, which differ in their spectrum of activity and adverse effects (Table 5).11 Initially, a broad-spectrum agent is used. The most common one is silver sulfadiazine (Silvadene). If it is applied to large surface areas, neutropenia will probably occur; it reverses rapidly when the agent is discontinued. Subsequent antimicrobial choices are generally based on known colonization of the burn wound.
Enzymatic debriding agents, such as collagenase, can be used on partial thickness injuries to avoid the need for surgical debridement. These agents should be used with caution by experienced physicians since they have been associated with a higher risk of septicemia.
Many synthetic coverings (Integra, Biobrane, Alloderm, Dermagraft-TC), some incorporating antimicrobial agents, have been developed in hopes of avoiding the problems associated with existing agents. They have been found to be as effective as silver sulfadiazine.
Much controversy surrounds the utility of performing surveillance cultures of burn wounds. Evidence on the correlation between surface cultures and biopsy cultures is conflicting. More important, positive cultures are often misinterpreted as indicating infection when they merely reflect colonization. Since all burn wounds have colonizing organisms and the vast majority do not become infected, routine surveillance cultures are not indicated. They may have a role in managing patients at highest risk for infection (those with large full-thickness burns), since cultures enable empiric therapy to be directed against the known colonizing organisms when infection occurs.
Systemic antimicrobial therapy is used as an adjunct to treatment but does not eliminate the need for surgical debridement and topical antimicrobial therapy. In patients with sepsis and organ dysfunction caused by wound infection it is essential to remove the infected burned tissue, regardless of how unstable the patient's condition is. Giving antibiotics alone without removing the infected tissue will not cure the infection.
Systemic antimicrobial therapy is indicated only when the burn patient shows signs of infection such as hypotension unresponsive to fluid administration, organ dysfunction, or hypothermia not associated with prolonged exposure during dressing changes. Antibiotics should not be given prophylactically because they do not readily penetrate the avascular burn eschar and they predispose the wound to colonization with resistant organisms, thus making it more difficult to treat infection if it occurs.
The causative pathogens of burn wound infection vary from center to center. Recently, S aureus and yeasts have become more prevalent and gram-negative bacilli have decreased, although several centers continue to experience problems with Pseudomonas aeruginosa. Empiric therapy should be based upon the predominant flora of the center.
The true tragedy of burn injuries in children is that they are preventable. Table 6 lists some common preventive measures for different types of burns, which pediatricians can share with parents in their practices.
Two measures that would greatly reduce deaths caused by house fires are smoke detectors and sprinkler systems. Functional smoke detectors in all homes would save the lives of more than 500 children annually.12 The majority of fatal fires occur in houses without smoke detectors or houses in which smoke detectors are not functioning. It is imperative to check smoke detectors and replace batteries every year. Installing residential sprinkler systems would prevent nearly all pediatric fire deaths and serious injuries. Home sprinkler systems, estimated to cost around $1,000 to $2,000 in 1978, have become more affordable since 1980, when changes in the National Fire Protection's sprinkler code allowed connecting sprinkler piping to other domestic plumbing and using plastic instead of metal pipe.13
Cigarettes are the leading cause of residential fires. Convincing smokers not to go to bed with a lit cigarette and developing a self-extinguishing cigarette would greatly reduce burn-related deaths.14 Another preventable cause of house fires is by children playing with cigarette lighters.15 Such fires have decreased since 1994 when the Consumer Product Safety Commission issued a mandatory safety standard requiring child-resistant lighters, but they still account for approximately 70 deaths annually. Fires caused by portable heaters can be prevented by never leaving heaters unattended and keeping them at least three feet from upholstery or drapes. Injuries resulting from burning clothing and bedding have decreased since the 1973 Flammable Fabric Act required that sleepwear and mattresses be flame-resistant.
Fireworks are another source of flame burns for which more preventive measures are needed. Fireworks are best left to professionals and enjoyed at a safe distance.
Although much less likely than flame burns to be fatal, scalds can cause severe burns and are the most common type of burn injury in young children. Decreasing tap water temperature from 140° F to 120° F raises the time it takes to cause a serious scald burn in an adult from five seconds to 10 minutes.16 Emphasizing the importance of reducing tap water temperature, especially implementation of standards that require water heaters to be factory-set to 120° C, has greatly reduced scald burns, but a substantial number still occur. Antiscald devices are available that interrupt the flow of water above a predetermined temperature. Although these devices work well to prevent scalds, one study found that most are removed because of sediment buildup that interferes with water flow.17 Better devices are needed.
Heating foods and liquids in microwave ovens is another important cause of scald injuries. Some substances, particularly infant formula, may heat unevenly so that the container and the liquid near the top may be cool or lukewarm while the remaining contents are scalding. Parents should be warned to check the temperature of foods heated in the microwave carefully before giving them to a child. Many scald burns are caused by spills of hot foods or liquids, and more research is needed to design containers such as cups and pans that will be less likely to topple over.
Contact burns can be prevented by not allowing children to come near hot surfaces such as stove burners, ovens, and irons and by keeping beds a safe distance from radiators.
Electrical burns in young children have decreased with the advent of covers for electrical outlets, but appliance cords and extension cords are still a major electrocution hazard in small children.18 No federal standards exist for the manufacture of electrical cords. High-voltage exposures account for most electrical injuries in children older than 12 years of age.17 Many of these exposures result from risk-taking behavior, such as touching live wires or flying kites near electrical wires, but some occur when youths unknowingly climb trees through which power lines pass. Regulating the location of power lines and identifying trees through which they pass would have an impact on high-voltage electrical injuries.
Prevention is undoubtedly the best treatment for burn injuries in children. The most effective and easiest measures to implement are passive ones, such as factory setting of hot water heater temperatures. Active measures to achieve the same goal, such as parental supervision during all childhood bathing and testing of water before bathing, while important, are less effective.
Many excellent preventive measures already exist and must be put into practice by means of education and legislation. More study is needed to determine the best way of implementing known prevention strategies and to devise new ones.
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Gail Rodgers. Reducing the toll of childhood burns. Contemporary Pediatrics 2000;4:152.