#107: Burning Up! Caring for Pediatric Burn Patients

April 10, 2024 | By Sam Masur

Audio

Summary:

Extinguish any fears you have about pediatric burns with our great guest, Dr. Tam Pham. Dr. Pham is a board-certified surgeon and Director of the University of Washington Medicine Regional Burn Center and a Professor of surgery at UW. In our episode we cover: burn classification and triage, first aid of burns, and care for burns in different clinical settings.

Pediatric Burn Care Pearls

1. Understanding the type of burn injury can inform your triage decision for patients
2. ­­­­­­­Burn depth is a function of the agent, the heat source, the duration of contact and the skin thickness.
3. Skin blanching is a sign that the dermis is alive! You push the dermal capillaries away and once you let go with your finger, you have capillary refill. This refill is a sign of dermal viability
4. Debridement can be a vague term! Initial management of the wound may involve cleansing with a washcloth and blunt instrument vs surgical debridement, which may be referred to as tangential excision 
5. Burn teams are multidisciplinary. We rely on team work to care for our patients

Pediatric Burn Notes

Burn Classification and Triage

Burns are classified according to first, second and third degrees. Knowing the type of burn can help decide the best location of care for your patient.

Physical Exam Pearl: Skin blanching is a sign that the dermis is alive! You push the dermal capillaries away and once you let go with your finger, you have capillary refill. This refill is a sign of dermal viability. Loss of this skin function might suggest that the burn may evolve into a serious problem.

Types of Burns

­­­­­­­Burn depth is a function of the agent, the heat source, the duration of contact and the skin thickness.

It only takes one second of exposure to water at 160°F to experience a full thermal burn. The boiling point of water is 212°F, so even cooling liquids (ex the coffee left on the counter) have the potential for serious burns. Soups and other liquids that have fats (ex pasta sauce) have even higher boiling temperatures and can be harder to remove.  

There are several other types of burns: flame burns (ie open cooking), electrical burns (ie electrical burns), chemical burns (ie detergents).  

First Aid for Burns

The first step is to remove exposure to the agent. If a hot liquid is on the clothes, remove the garment. The next step (depends on the amount of body surface involved) is to cool the burn with running cool tap water (avoid cold packs or the frozen bag of vegetables you forgot about in the freezer – those are too cold!). Running cool water on the burn may limit depth of injury and keep burns from evolving into more serious injury (Sutton 2019).

Care for Burns in Ambulatory Settings

If there is blistering the size of a quarter, you can use a washcloth to remove the skin. Larger blisters tend to erupt on their own. Dressings should stay on, slow the onset of infection, and provide a moist barrier for skin regeneration. Use a greasy gauze (hydrophobic barrier that traps moisture at the wound base) and a topical antibiotic ointment. Bacitracin targets more gram-positive coverage (deeper wounds may require more gram-negative coverage). Silver sulfadiazine may be used to temporize moderate to more severe wounds, but Dr. Pham does not routinely use it for superficial wounds.  

Care for Burns in the Emergency Department or Hospital Settings

Burn centers work because the team works together! Burn centers consist of a multidisciplinary and interprofessional team including pediatricians, surgeons, nursing, therapists, psychiatrists and more.

Per Dr. Pham, a good initial assessment is key to management of burns. Thinking about pain and sedation plans can help facilitate the first examination of the wound (but it should not delay assessment).

Dehydration is a major risk for burn patients. Burns have a huge capillary leak that also lowers plasma protein outside of the site and promotes edema. It is important for fluid resuscitation to happen early and be monitored in the appropriate setting.

Infection control can be maintained with topical antimicrobial agents or silver releasing products. Dr. Pham does NOT recommend systemic agents for routine care of burns.

Dr. Pham recommends shared decision making for whether a patient with an extensive burn should receive a graft.

Words Matter: Debridement is a vague term. Initial care of a burn involves cleaning of the wound with a washcloth and a blunt instrument to remove loose tissue. Surgical debridement may refer to tangential excision under either general anesthesia or nerve block. Tangential excision involves moving tissue layer by layer until wound base is reached.

Discharge planning is complex which is why patients are supported by a multidisciplinary team. 

Disparities in Burn Care 

Burns are a common injury and most burns in the world happen in developing countries and majority of those patients are children (Bresler 2022). Burns in the United States disproportionately impact racial and ethnic minorities (Won 2024).

Links

Burn Educational Videos – University of Washington

Goal

Listeners will explain burn classification and triage, first aid of burns, and care for burns in different clinical settings.

Learning Objectives

After listening to this episode listeners will…  

1. Recall the disparities seen in the incidence of burns. 
2. Be familiar with first line treatments for burns.
3. Recognize the importance of interdisciplinary teams. 
4. Describe indications for surgical intervention.

Disclosures

Dr Pham reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Nwora C, Pham T, Masur S, Chiu C, Berk J. “#107: Burning Up! Caring for Pediatric Burn Patients”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ April 10, 2024.