Initial Assessment and Management

of burn injury in Children

Irene Yuniar
Pediatric Intensive Care Unit
Child Health Department FKUI-RSCM Jakarta
Objective

1. Describe the initial evaluation of a burned

in children in terms of burn depth, size
and associated injuries or medical
condition
2. Estimate initial fluid resuscitation
requirement for the first 24 hours
3. Recognize indication for transfer of a
burned injury child to burn center
 Introduction
Burn injuries is the third leading cause of unintentional death in
children < 14 years (USA)
CDC (2009) : 437 deaths and 120,761 nonfatal burn injuries
(0 - 19 y.o)
Difficult to estimate the global incidence rate, morbidity, and
mortality of burn injuries
Burns are a major cause of injury in both developed and
developing countries.
Physicians initial burn assessment and management, and
identify children with burn injuries appropriate for referral to a
regional burn center.
Burn aetiology

Gandhi M et all. Int J Pediatr.

2010;1-9
Scope of the Problems

Anatomy

Narrow Burn
spectrum TBW
child

Immunity
Scope of problem
Initial Evaluation
Triage estimate of burn injury severity
Severity :
- minor burn injuries : < 5% total BSA outpatient
- moderate to severe burn injury : ABCDEFs
(airway, breathing, circulation, disability, exposure, and fluid
resuscitation)
Emergency assessment, clothing (temperature-controlled
environment)
Estimating burn severity
Age and medical history :
- Infants and children < 2 years old anatomical BSA varies
with age : Lund-Browder chart
- DM, sickle cell disease, and children receiving chemotherapy
Surface area, depth, and pattern of the burn injury
The mechanism of injury
Surface area, depth, and
pattern of the burn injury
Surface are :
- Rapid estimate of the TBSA of a burn injury in adolescents
and adults rule of 9s.
- Burn wounds >10% TBSA SIRS
Depth :
- influences the predicted degree of physiologic derangement
- direct implications for wound management
Schematic representation of Jacksons
burn model

Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns.

BMJ. 2004;328:1427-9.
The depth of burn

Dermis

Source:
Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns.
BMJ. 2004;328:1427-9.
Depth of burn injury

partial-thickness
scald burn

full-thickness
flame burn
Pathophysiology
Basic principles:
Degree of tissue injury: length of exposure,
temperature, age
Skin can tolerate temperature up to 40oC
Imflammatory mediators are released: edema,
fluid loss, circulatory stasis, protein and muscle
breakdown, coagulopaties, impaired immunity
Significant metabolic response: insulin
resistance, impaired GI barrier function
Treatment
Initial assessment : ABC
Minor partial-thickness burns (<5%) TBSA :
analgesia and wound care (debridement/ removal)
Burn dressing reduce pain
Minor burns
- outpatient basis with a low-cost
- topical antimicrobial agent prevents wound desiccation
inhibits bacterial colonization / invasion.
- Burn antimicrobial agents silver sulfadiazine or bacitracin ointment
- Epithelialize in 7 to 14 days
Minor- moderate (5-10% TBSA) partial-thickness burn injuries :
- wound coverage with a biological dressing (pigskin) or a biocomposite
temporary dressing (semipermeable silicone)
Severe burn injuries pediatric burn center
Treatment
Stigmata of inhalational injury high probability of requiring
mechanical ventilation
- history of closed-space structural fire
- soot in the nose or mouth
- elevated carboxyhemoglobin > 10%, PaO2 to FiO2 ratio < 200.
Inhalational injury and/or carbon monoxide poisoning intubation
(ventilation with 100% O2)
Prevent hypothermia.
Moderate or severe burn injuries (> 10% TBSA) IV fluid
resuscitation
The goal of fluid resuscitation : maintenance of end-organ perfusion
through preservation of intravascular volume
The most commonly used resuscitation formula : Parkland or Baxter
Monitoring
Airway and Ventilation
Circulation iv volume (urine output : 2
ml/kg/hour)
SIRS sepsis
Environment
Antibiotics therapy based on colonization
pattern
Nutrition
Family education
Nutritional support

Age Daily caloric requirement

(yr)
0-1 2100 kcal/m2BSA + 1000 kcal/m2 burned
surface area
1-11 1800 kcal/m2BSA + 1300 kcal/m2 burned
surface area
12-18 1500 kcal/m2BSA + 1500 kcal/m2 burned
surface area
Summary
Burns are still the potential cause of injury-related death in
children
The challenges to the burn team are magnified, when the
burned patient happens to a child.
Multidiciplinary approach are needed for best outcome
Prevention remains the best and most effective treatment
method
Thank You