Contact

• Direct contact with hot surface
• Includes ingestion of hot food e.g. microwaved
• Beware situations where child may have been held against hot object e.g. cooker, iron etc (See later)

Flame

• Bonfires, cigarettes, house fires

Electrical

• Look for entry and exit wounds
• Beware risk of compartment syndrome from deep tissue damage
• Perform ECG and admit for observation if abnormal ECG or history of arrhythmia or loss of consciousness

Chemical

• Beware alkali (including lime and cement) burns as tissue penetration occurs and admission for repeated irrigation
• Beware hydrofluoric acid burns as these cause local and systemic depletion of calcium (see Toxbase)
• Consider if child has accidentally ingested bleach, corrosives etc

Radiation

• Usually sunlight

Scald

• Commonest burn seen in A&E
• Bath immersions are less common than in recent years

Cold

• Rare

Several factors need to be considered when assessing burns:

1. Total body surface area of burn (TBSA)
2. Depth of burn
3. Site of burn
4. Complicating factors

Total body surface area (TBSA) can be difficult to assess in ED: redness and erythema make it difficult to accurately assess burns.

• Ignore redness alone (superficial burn - no blistering) and include partial and deeper burns only (See later)
• Use Lund and Browder chart to ascribe area by age by anatomical site
• A rough estimation may be obtained by using the palmar surface (including adducted fingers) of the childs’ hand:
  • Palmar area = 1% TBSA approximately

It is good practice to demonstrate the areas affected on as accurately as possible on a burns chart. This will also help with determination of TBSA.

Burn depth can be classified as follows:

It is not unusual for all or some of these to co-exist. This makes it difficult to determine exact depth on initial presentation.

Some advocate pricking areas of burn to determine if pain sensation present. It is doubtful if this is useful as most  children are either too distressed already or are so sick not to notice.

Some areas affected by a burn need special care and consideration. These include:

Complicating factors include:

• Smoke inhalation
• Hypothermia
• Suspected child abuse or neglect

It is difficult to describe the exact sequence of management of a burn. All of the following need to be done in the order described. However a team effort will ensure all actions are done. Comprehensive clinical guidelines have been
produced by COBIS ((Care of Burns in Scotland Managed Clinical Network).

1. Assess Airway and Breathing
   • Burns to face, neck, mouth etc put airway at risk from swelling
   • Sooty face, stridor or wheeze indicate airway involvement
   • If any present contact senior ED staff and anaesthetic support
2. Assess Circulation
   • Circulation usually only at risk if TBSA >10% and delay in resuscitation
   • If other injuries present e.g. trauma as well as burn occult blood loss may be an issue. Tachycardia may indicate pain or hypoxia rather than hypovolaemia
   • Capillary return may be unhelpful as hypothermia and pain can cause a mottled skin response and delay in capillary refill
   • Burns greater that 10% TBSA should receive fluid as per the Modified Parkland Formula for the first 8 hours post injury
3. Weigh child if at all possible or estimate weight if not
4. Record vital signs inc T, P, RR, BP and SaO2
   1. If hypothermia suspected ensure temperature taken using a thermometer capable of recording low temperatures
   2. Failure to pick up SaO2 may indicate poor perfusion
5. Assess TBSA involved and document on Lund and Browder chart
6. Assess pain requirements - do not be afraid to use opiate analgesia (iv or intranasal)
7. For chemical burns ensure that all chemical is washed off.
   1. Hydrofluoric acid requires special care. Litmus paper may help detect residual acid or alkali
   2. Beware contamination of staff when washing affected areas
8. Cover burns with cling film as a temporary dressing

The following burns should be considered as serious and should be referred for advice/admission:

• TBSA > 3% (for analgesia / fluids)
• Deep partial thickness or Full thickness burns of any size
• High voltage electrical burns
• Chemical burns
• Burns affecting difficult areas
• Any patient with smoke inhalation
• Any patient with hypothermia
• If there is suspected child abuse or neglect

Superficial or superficial partial thickness burns of less than 3% TBSA can usually be managed as an out-patient.

As described above ensure adequate resuscitation is commenced and appropriate senior ED staff and support specialties are involved e.g. Anaesthetics and Plastic Surgery.

Children with burns are admitted to RHCYP but should be referred to the plastics team on call here at SJH for assessment and advice. In collaboration with the ED team, the on-site plastic surgery junior doctor will help ensure that
the patient has a satisfactory airway, satisfactory resuscitation regime, adequate iv access, adequate pain relief and suitable wound cover and will liaise with the on-call registrar and/or consultant.

NB Children with burns >10% TBSA are usually admitted to ITU at RHSC. These children should be discussed with the PICU consultant on call who will help decide if the retrieval team should undertake the transfer.

If transferring to RHSC, please ensure that the RHSC Clinical coordinator is informed (bleep 9278 through RHSC switchboard 0131 536 0000). They will ensure that an appropriate bed is available.

By definition these burns require little in the way of resuscitation and can usually be managed as outpatients. Burns suitable for outpatient management include:

• TBSA < 3%
• Superficial or partial thickness only
• Does not involve dangerous area
• Does not have any complicating factors

COBIS provide guidance on the appropriate management / dressings for burns depending on depth and site. For small (<3%) burns being managed as an out-patient:

• Deroof blisters and debride loose skin
• Cleanse with warmed normal saline or tap water
• Obtain wound swabs
• Apply a secondary dressing of gauze/burns swabs and crepe bandage if required
• Apply a non-adherent dressing (Mepitel). Use an antimicrobial dressing if required
• Reassess wounds after 24-48 hours (ED Review clinic or practice nurse)

Parents should be aware of the ongoing need for analgesia. Paracetamol 15mgs/kg qds with Ibuprofen 5-10 mg/kg tds is usually adequate. If pain persists or increases after discharge the child should be brought back for review.

Don’t forget to give advice about the signs and symptoms of Toxic Shock Syndrome – there is an advice leaflet that contains this information.

It is usual for these burns to be followed up in the ED review clinic after 24-48 hours. For children who live a distance away it may be appropriate to have a review at the GP surgery.

In all cases parents should be aware that we can be contacted at any time for advice.

There should be a low threshold for asking parents to bring children back for review if they are concerned. In general reviews should be seen by or discussed with senior staff.

Smoke inhalation commonly accompanies house fires. It should be suspected if any child presents with soot on the face, hoarse voice, stridor or wheeze.

Components:

1. Soot acts as a foreign body giving rise to foreign body type inflammation
2. Heat to upper airway gives burn to pharynx. The extent of this will be determined by the protection offered by the moisture etc in the nasopharynx and pharynx. It does not take too much for these natural moisturising and heat exchange mechanisms to be overwhelmed.
3. Carbon monoxide inhalation
4. Cyanide inhalation (from burning plastics)

These children can deteriorate rapidly so early recognition is paramount. If suspected, immediately notify senior ED staff and consider early anaesthetic support.

Initial management will involve:

1. Secure airway as appropriate -this should only be done by a member of staff competent in burns airway management
2. Provide high-flow oxygen. It may help to moisturise this by using oxygen delivered through saline in a nebuliser chamber.
3. Establish IV access
   1. Take venous blood for FBC, U&E, Carboxyhaemaglobin
   2. Send a sample for capillary/venous blood gas analysis
4. Resuscitate with fluid as directed by Parkland formula
5. CO poisoning should be treated with high-flow oxygen until senior staff can decide on further treatment
6. Cyanide poisoning can be difficult to detect biochemically. If suspected discuss with PICU at RHSC to consider use of antidotes
7. Monitor urine output

This is defined as a core temperature below 35.5oC. Young children can lose heat rapidly. Burns increase heat loss by removing a degree of thermoregulation. In some cases aggressive cooling of the burn in the prehospital phase can lead to quite profound hypothermia.

Children with hypothermia appear mottled, tachycardic and often lethargic. The only reliable way to determine hypothermia is to use a low-reading thermometer. The rectal route is more reliable than axillary/tympanic.

Treatment:

1. Rewarm using blankets. Consider using a Bair-Hugger.
2. These children may benefit from a period of observation either on the paediatric ward here or plastics ward at RHSC.

SCAN is thankfully rare, but unfortunately does exist. Burns feature prominently in descriptions of children who have been abused so it is important to detect and act early.

Features associated with (but not diagnostic of) SCAN:

• Delay in presentation
• Features of examination not consistent with history
• Burns to the following areas are less likely to be accidental:
  • Back of hand
  • Buttocks/perineum/genitalia
  • Feet
  • Multiple cigarette burns
• Situations where child unsupervised e.g. playing with matches, electrical burn from uncovered plug

If suspicious ensure senior member of ED staff involved early and follow SCAN guidelines. Document everything accurately.

BEWARE: Skin lesions mimicking burns eg Staphylococcal infection

Toxic Shock Syndrome (TSS) is an under diagnosed complication of burns and scalds in children. It can follow minor burns including those treated as outpatients. Mortality of the full-blown syndrome can reach 11%. This is a disease that can progress to death within a few hours if untreated so a high index of suspicion and prompt treatment are life saving.

Diagnosis of TSS

Strong grounds for suspicion of TSS if the child has three or more of the following:

• Pyrexia of 39ºC or above
• Irritability
• Diffuse macular rash which can progress to redness all over the body. Blanches on pressure.
• Occlusive Dressings
• Diarrhoea or vomiting
• WCC < 4.0
• Urine output less than 1ml/kg/hr
• An excess IV fluid requirement which may be over and above burn resuscitation fluid
• Inflamed mucous membranes
• Staph. Aureus on wound swabs but can be caused by Streptococci
• Mean occurrence is 2 to 3 days post burn but can occur earlier or later
• Hypotension. This is a late and very serious sign.

Treatment of TSS

This is directed to assume Staph. Aureus or Streptococci on the Burn Wound:

• Inform Plastic Surgery Registrar (at SJH) who will involve Plastic Consultant on call for RHSC – may need transfer by PICU retrieval team
• Immediate IV Access (there is no time to wait for EMLA or Ametop)
• Bloods for FBC, Coagulation, Biochemistry Full ITU Screen, Blood Culture, Cross Match
• Bolus of fluids PPS, Saline or Hartmanns at 10 to 20mls/kg, repeated if required.
• IV fluids 0.45% Saline / 5% Dextrose at maintenance rate.
• Antibiotics:
  • Flucloxacillin 50 mg/kg/dose IV immediately and prescribed IV 4 times daily
  • Benzylpenicillin 50 mg/kg/dose IV immediately and prescribed IV 4 times daily
• These patients need careful monitoring and a comprehensive policy guiding this exists on the plastics unit at RHSC.
• Ibuprofen 5 mg/kg may help reduce the temperature acutely but ensure urine output greater than 1 ml/kg/hr. Avoid Diclofenac as this may contribute to renal failure in sepsis.
• If Clinically Unstable or failing to improve refer to PICU immediately

This formula should be used for all burns greater than 10% as a starting point. Remember it is a guideline and requires frequent observation of the patients’ clinical parameters to allow adjustment of the resuscitation fluid rate. Urea and electrolytes and acid base need monitoring up to 6 hourly in larger burns (these will be looked after in ITU).

Resuscitation Fluid

• Fluid type: Hartmann’s solution
• Calculate 2mls × Weight in kg × % Burn Surface Area
  • This gives the extra fluid needed to resuscitate the child in the first 8 hours post burn.
  • Calculate hourly rate of to ensure that this amount is given in the 8 hours from the time of the burn. (e.g. if started 2 hrs post burn, the hourly rate should ensure that the volume calculated is given over the next 6 hrs)
• This fluid is given over and above the maintenance fluid and the rate can be increased or decreased as the clinical conditions dictate.

Maintenance IV Fluid

• Fluid type: 0.45% Saline / 5% Dextrose
• This is calculated in the usual way:
  • 4mls/kg/hr for up to 10kg
  • Plus 2mls/kg/hr for 10 to 20kg
  • Plus 1 mls/kg/hr for each kg more than 20kg

Common Reasons for Increased Fluid Requirements

• Concurrent smoke inhalation
• Muscle damage with rhabdomyolysis (this produces red urine due to myoglobinuria which can cause renal failure)
• Pyrexia (may need an extra 10% fluid per degree rise in temperature)
• Toxic Shock Syndrome

(To be completed)