- A first-degree burn is superficial,
painful to touch, and
heals in less than 1
first-degree burn is exemplified by prolonged exposure to sunlight
- A second-degree burn is partial
thickness and pink or
possibly mottled red.
It exhibits bullae
or frank weeping on the surface. It usually is
painful unless classified as deep
and heals in 1 to 3 weeks.
Second- and third-degree burns can result from contact with hot
fluids (scald) or hot objects, such as an iron (contact burn),
flames (flame burn), high-voltage electricity (electrical burn);
various chemical agents, including acid and alkali (chemical burn);
or very cold objects or environments (frostbite).
- A third-degree burn is the most serious. It appears pearly
parchmentlike. The dead skin
white, tan, brown, black, and
occasionally red. Superficial vascular thrombosis can be
observed; there also can be focal tissue loss with prolonged
exposure and a soapy-looking
lesion that is found in
Figure. The "rule of nines" altered for the anthropomorphic
differences of infancy and childhood. Reprinted with permission from Herndon DN,
ed. Total Burn Care. 2nd ed. London, England: Saunders: 2002.
Also, palm = 1%.
Once sustained, the burn injury, especially full-thickness burns
that occupy 40% or more TBSA, give rise to many complications. The
most immediate are burn shock and burn
edema, as well as
inhalation injury, if sustained. Within a few days of the burn
injury, other responses are detected, including
systemic inflammatory response syndrome (SIRS),
Acute Changes: Burn Shock and Burn Edema
Burn injury results in loss of fluid
from the intravascular
space and excessive
fluid accumulation in the interstitial
space, resulting in
hypovolemia and swelling of the
burned skin. When burns exceed 25% TBSA,
tissues also swell. The cause of the
fluid shift is believed to be the presence of various
stimulated by the burn injury. These mediators also
impair cardiac contractility and
increase vascular resistance,
creating a scenario for
cardiovascular collapse, and
death, if aggressive resuscitation therapy is not initiated early.
Mediators of Burn Shock and Edema
||Mast cells from burned skin
||Increases capillary permeability,
arteriolar dilatation, and venular contraction
||Arachidonic acid released from
burned tissue and inflammatory cells
potent vasodilators; increase microvascular permeability
||Platelets in the burn wound
||Thromboxanes A2 and B2:
vasoconstrictors; contribute to tissue ischemia
||Increase venular permeability
||Vasoconstrictor; reduces blood
flow to burn wounds
||Vasoconstrictor; contributes to
wound ischemia, increased systemic vascular resistance
||Increase vascular permeability and burn
|Platelet aggregation factor
||Burn wound platelets
|Angiotensin II and vasopressin
||Renal juxtaglomerular cells
||Vasoconstrictors; may be responsible for
intestinal ischemia (angiotensin) and increased systemic vascular
Electrical burns cause additional complications. Cardiac
ventricular fibrillation, can
occur at the time and site of the injury, as can
myocardial damage. Tissues that
are most resistant to electric current, such as
bone, sustain the
greatest heat injury,
and soft tissue next to the bone frequently is damaged.
renal failure, and neurologic
damage, including Guillain-Barré syndrome, transverse myelitis,
amyotrophic lateral sclerosis, paresis, and paralysis, can
up to 2 years following an
electrical burn. Eye injuries complicate 5% to 20% of
electrical burns; cataracts are
the most common complications.
- Children who have large burns experience an increase in energy
expenditure and protein metabolism of approximately 50% after the
first few days following injury.
- Results in negative nitrogen balance and depletion of body
protein stores, which can last for 9 months following the burn.
- incr HR, RR, WBC, fever, decr BP, shock, and multisystem organ
- hyperactive immune response causes a
generalized inflammation that damages
tissue as well as infected burn
permeability leads to decreased tissue oxygenation, and
blood flow is reduced due to
microthrombi. During this
reaction, the intestinal and, possibly, the respiratory
barriers to infection are damaged,
allowing the entry of additional bacteria into the circulation,
known as bacterial translocation.
- Coexisting with SIRS is another reaction termed the
response syndrome (CARS), which
limit the damage created by
inflammatory cells. However, the CARS reaction also promotes
reactions are generated by
chemokines, which are
located in the macrophages and endothelial cells, and
attract inflammatory cells to
the site of damage. The inflammatory cells
produce cytokines, which
also stimulate the inflammatory
response and tissue destruction.
Differentiating SIRS and CARS from
sepsis, which is the leading
cause of death in burns,
is extremely challenging.
- Inhalation of the toxins
associated with flame smoke accounts
for 80% of burn-related
- carbon monoxide
and hydrogen cyanide, which can
potentiate tissue hypoxia and acidosis.
- It is important to know
both the source of the fire
and the nature of the gases it
produces to treat the injury adequately.
- inhaled hot gases cause
edema in the same way
that they affect other tissues, as discussed previously.
- aldehydes, can
cause contact damage to the
trachea and bronchi, resulting in inflammation and formation of
fibrin casts that can
obstruct the lower
airway completely and lead to decreased oxygenation due to
pulmonary vascular vasoconstriction
Diagnosis and Management of the Burn Wound
- obtain a complete history of the burn injury because certain
sources, such as alkali, may require additional treatment to stop
the penetration of skin layers.
- If less than 10% TBSA: usually can be treated on an outpatient
basis unless abuse is suspected.
- apply a cotton gauze occlusive dressing to
protect the damaged skin from
eliminate air movement over the wound (thus reducing pain),
and decrease water loss.
- change dressings daily
- topical antimicrobial agent should be applied to the wound
prior to the dressing for
prophylaxis. The agent used most commonly is
silver sulfadiazine, which
has activity against Staphylococcus aureus, Escherichia coli,
Klebsiella sp, Pseudomonas aeruginosa, Proteus sp, and
Candida albicans. The primary adverse effect of silver
sulfadiazine is leukopenia,
which occurs in 5% to 15% of treated patients. However, there is
no increase in the incidence of infection.
- Daily clinical inspection and wound culture, if necessary,
should determine when the wound is healed, but
such wounds generally heal in fewer
than 2 weeks.
- Also, the application of Biobrane® by experienced
practitioners can be of value in partial-thickness burns. The
product consists of a coat of cellophane topped by a protein that
adheres to the wound and protects it while healing.
Initial Treatment of a Child Who Has Extensive Burns
- fluid resuscitation to prevent shock
- early excision and grafting of the burn wound
- early nutrition support
- identification of airway involvement due to inhalation injury
- treat sepsis.
- more specific measures can be taken to diagnose acute
complications, such as cardiac arrhythmias, or to use antidotes for
- any jewelry removed (sources of heat)
- in the case of a chemical burn, any saturated clothing removed
and skin thoroughly irrigated with water, taking care not to spread
any chemical to unburned skin.
- chest should be exposed to assess respiratory effort, and pulse
should be obtained.
- Any accompanying injuries, such as fractures, also should be
- two large-bore intravenous catheters
- past medical history, allergies, and current medications at the
scene is advisable if time permits.
- Once the nature and extent of injury are assessed, fluid resuscitation
is begun. The Galveston formula:
burned surface area per day, with an
per day of Ringer’s lactate and 5% dextrose
- The first half of the fluid load is infused over the first
8 hours postburn; the
remainder is infused over the ensuing
- adjust to maintain a urine flow of
- During the second 24 hours, fluid administration is
reduced to 3,750
area burn, with 1,500
TBSA per day as
maintenance, which almost always can be administered in the form
of enteral feeding through a feeding tube.
Early Excision and Grafting
- Early excision and grafting of the burn wound should be performed
at a burn center.
- The rationale for rapid closure of all unequivocal deep burns
is to reduce wound infection, fluid loss, and concomitant
- Most burn surgeons close deep wounds within 1 to 2 weeks of the
Early and Aggressive Nutrition Support
With early and aggressive nutrition support, burn centers have been
able to reduce the resting energy expenditure from 1.6 to 2 times
normal to less than 1.5 times normal. Because other processes beyond
hypermetabolism, such as fluid loss, sepsis, and inflammation,
contribute to energy expenditure, intensive nutrition support can
help minimize protein catabolism and weight loss.
A high-carbohydrate diet is needed
because of the relative
inability of the burn
victim to use fat, as discussed previously. If indirect
calorimetry is not available, use of the Galveston formula is
- Infants: 0 to 1 y: 2,100 kcal/m2 plus 1,000 kcal/m2
- 1 to 11 y: 1,800 kcal/m2 plus 1,300 kcal/m2 burn
- 12 years and older: 1,500 kcal/m2 plus 1,500 kcal/m2
Vitamins, minerals, and trace elements are provided according to
the recommended daily intakes. However, severe burn injury may
produce additional requirements, which have not been investigated
completely, including calcium, magnesium, and vitamin D as well as
zinc and, possibly, other micronutrients.
injury, patients experience
and magnesium depletion,
despite receiving large
quantities of enteral
calcium and magnesium. This
is believed to be due to an
of the parathyroid gland calcium-sensing
receptor (the body senses more calcium than it has - JS),
is limited to providing the minerals in
quantities to cause
serum levels to return to normal.
Recognition of Airway Involvement
- A history of
closed-space exposure to smoke
should raise suspicion of inhalation injury.
- Physical signs
- Patients who are
obtunded or comatose may have
been exposed to carbon monoxide,
- diagnosed by measurement of
- However, the
inhalation injury and
symptoms and signs often is
poor, which necessitates
during evaluation at the burn center.
Intravenous radionuclide scans using xenon133 can
identify small airways that are
affected by inhalation injury. Areas retaining xenon for more than 90
seconds are assumed to be obstructed.
- Treatment of inhalation injury is supportive.
With combined burn and inhalation
injury, fluid requirements are increased by 40% to 75% in the first 24
- For carbon monoxide exposure, patients should
receive 100% oxygen until the blood
carboxyhemoglobin levels are less than 10%.
- Patients who have hypoxia require supplemental oxygen.
- Chest physiotherapy and spirometry generally are used to treat
- Wheezing is an indication for
to determine whether there is plugging of the airway or
bronchospasm and edema.
- If there is plugging,
aerosolized heparin and humidification
- For bronchospasm, treatment initially is with nebulized beta2
agonists and, if needed, intravenous aminophylline.
- If respiratory failure ensues, the treatments of choice are
intubation, mechanical ventilation, and tracheostomy.
- If ventilation remains inadequate, permissive hypercapnia may
stimulate respiratory effort.
Burn wound sepsis is defined as
the site showing proliferating microorganisms that exceed 105/g
tissue and invasion of underlying unburned tissue.
is indicated by the transient presence of microorganisms in
the blood; sepsis is defined as
invasion of the blood by pathogenic bacteria from local foci of
infection, such as the burn wound. Sepsis frequently is accompanied
by hyperthermia, hypothermia, and prostration.
Some of the more common infections seen with severe burn injury
subacute bacterial endocarditis,
infections, cholecystitis, and
Antibiotic therapy should be based on sensitivity of the organism(s)
Table 2. Features of Bacterial Sepsis Following Large Burns
to 12 h onset
||Temperature increased or normal, followed
||White blood cell count either
low or high; blood cultures may
develop focal gangrene
||Burn wound biopsy with >105
organisms per gram of tissue
||Ileus, decreased blood pressure and urine
usually 104°F (40°C) or
White blood cell count
blood cultures may be
||Burn wound biopsy with >105
organisms per gram of tissue
||Ileus, decreased blood pressure
and urine output, anorexia, irrationality
Despite the seriousness of large burn injury in children, the
prognosis for survival is good and improving steadily. Recent data
analyzed at the United States Army Institute for Surgical Research
showed that adults older than 50 years of age who had burns of less
than 50% TBSA accounted for 19% of the admissions to burn units, but
greater than 50% of the deaths. In contrast, children younger than 4
years of age who were similarly burned accounted for 19% of
admissions but only 12.5% of the deaths. Other challenges remain,
including physical and emotional rehabilitation, reconstructive
surgery, treatment of the hypermetabolic state with anabolic agents
such as growth hormone, and reintegration of children into their
communities. Work is ongoing in these and other areas.
Pediatrics in Review.
Burns. Gordon L.
Klein, MD, MPH*. David N. Herndon, MD