See page 1184 for characteristics of superficial, partial-thickness, and full-thickness burns.

Electrical burns:

Rapid pulse, low blood pressure.

Subnormal temperature.

Pallor, cyanosis, prostration.

Failure to recognize parents or other familiar people.

Poor muscle tone; flaccid extremities.

Prostration, fever, rapid pulse.

Glucosuria, decreased urine output.

Vomiting, edema.

These symptoms may progress to coma or death.

Dyspnea, tachypnea, hoarseness.

Stridor, substernal and intercostal retractions, nasal flaring.

Restlessness, drooling, cough, increasing hoarseness.

Carbonaceous sputum.

Facial burns and/or edematous lips.

Black nasal or oral secretions.

Hypoxemia.

History of burn within a closed space.

Bronchiolitis.

Pulmonary edema (acute respiratory distress syndrome)—of noncardiac origin.

Severe airway obstruction.

Delayed damage: up to 7 days after the burn injury.

Burns in a pattern.

History and physical findings inconsistent with the burn injury.

Burn injuries incompatible with child’s developmental level.

Burn to buttocks, perineum, or genitals.

Burns involving immersion into hot water. Typical findings reveal the back of the knees will be spared of burn injury, with entire feet and lower legs burned.

Multiple and new and old burns in different stages of healing.

Burns that are circular in nature, likely due to cigarette burns.

Presence of other nonburn injuries such as bruises, scrapes, or previous fractures.

Rule of Nines (used in assessment of extent of burns in adults) has not proven to be exact when applied to young children; it may be acceptable to use in child older than age 10. It is not recommended for hospital use; the Lund and Browder chart is recommended. Total body surface area (TBSA) is based on age, thus compensating for changes in body surface area that change during growth (see Figure 55-1).

A rough estimate can be obtained by using the child’s hand (palm, with fingers extended), which is equal to 1%.

Total area injured, depth of injury, location of injury.

Age of child.

Condition of patient (ie, level of consciousness). Confusion is the hallmark of an anoxic brain.

Medical history (ie, comorbidities, chronic disease).

Additional injuries.

Minor burn—10% TBSA or less; first- and second-degree burn

Moderate burn:

Major burn:

Fluid loss from transcapillary leakage is greatest during the first 12 hours after injury and diminishes to almost zero 12 to 24 hours after injury. Fluid loss after 48 hours is due to vaporization of water from the wound.

Replacement usually consists of lactated Ringer’s solution, an isotonic electrolyte solution. Lactated Ringer’s solution has a much lower sodium content than 0.9% saline (130 mEq/L vs. 154 mEq/L), has a much higher pH (6.5 vs. 6.0), and has 28 mmol/L of lactate, which is used as a buffering agent.

The Consensus formula is commonly used to determine the fluid needed for resuscitation for burns greater than 15% TBSA (see page 1185). Children age 6 months to 5 years should receive a maintenance containing formula with dextrose to prevent hypoglycemia (5% dextrose or D5LR).

Burns are most commonly treated by the closed method. However, dependent on the location of the burn a combination technique using both open and closed methods may be necessary.

Using the closed method is preferred as it allows children to be more mobile when a burn injury is covered and because they experience less pain.

Hydrotherapy is the treatment of choice for cleaning wounds. Isotonic saline rather than water may be needed for large wounds and small children. A large stainless steel tub, commonly with a one-use-only tub liner, is used to ensure a clean environment during the treatment. During a tub treatment, children should be encouraged to participate with washing off cream whenever possible. A gentle soap or shampoo can be used to wash the burned and nonburned parts of the body and hair. Tub or shower treatments are usually done daily unless a longer-acting dressing is in place between hydrotherapy sessions.

The use of a hand-held shower to facilitate the loosening and removal of sloughing tissue, eschar, exudate, and topical medications is gaining popularity. The shower—water about 90° F (32.2° C)—flows over the child; debridement is then performed.

Use pharmaceutical and psychological interventions, unique to each child and appropriate for their developmental stage and comfort needs, to ensure appropriate pain and anxiety management.

See page 1184 for wound cleaning and debridement, hydrotherapy, topical antimicrobials, surgical management, and burn wound grafting. It is important to use bacitracin ophthalmic ointment on a child’s face because touching or rubbing the face may get ointment into the eyes. Topical bacitracin will cause conjunctivitis if it gets into the eyes.

Be alert to the symptoms of shock that occur shortly after a severe burn—tachycardia, hypothermia, hypotension, pallor, prostration, shallow respirations, anuria.

Monitor the administration of IV fluids because major burns are followed by a reduction in blood volume due to outflow of plasma into the tissues.

Maintain and record intake and output to provide an accurate measure of volume.

With severe burn injuries, insert an indwelling catheter.

Weigh patient daily to help evaluate fluid balance.

Monitor sensorium, pulse, pulse pressure, capillary refill, and blood gas values.

Provide a rich oxygen environment to combat hypoxia, as necessary.

Monitor electrolyte and hematocrit results as a guide to fluid replacement.

Maintain a warm, humidified ambient environment (especially with burns of 20% TBSA) to maintain body temperature and decrease fluid needs.

Wash hands with antibacterial cleansing agent before and after all patient contact and use appropriate precautions.

Be alert for reservoirs of infection and sources of cross-contamination in equipment, assignment of personnel.

Observe burn wounds with each dressing change: assess drainage for color, odor, and amount; necrosis; increase in pain; and surrounding erythema, warmth, swelling, and tenderness, which may indicate infection.

Administer topical antimicrobials and systemic antibiotics, as ordered.

Provide meticulous skin care to prevent infection and promote healing.

Be alert for early signs of septicemia, including changes in mentation, tachypnea, and decreased peristalsis as well as later signs, such as increased pulse, decreased blood pressure (BP), increased or decreased urine output, facial flushing, increased and later decreased temperatures, increasing hyperglycemia, and malaise. Report to health care provider promptly.

Obtain serial cultures, as ordered.

Promote optimal personal hygiene for the patient, including daily cleansing of unburned areas, meticulous care of teeth and mouth, shampooing of hair every other day, and meticulous care of IV and urinary catheter sites.

Prevent the child from scratching by administering antipruritics and applying protective devices to his or her hands.

Be alert for the development of pneumonia or UTI related to immobility and invasive procedures. Encourage coughing, turning, deep breathing, ambulation, and early discontinuation of indwelling catheter to minimize complications.

Ensure that appropriate nutrition and enteral feeding are in place within 6 to 8 hours of injury to prevent translocation of bacteria in the gut.

Administer tetanus prophylaxis based on immunization history.

Be alert for and report symptoms of respiratory distress— dyspnea, stridor, tachypnea, restlessness, cyanosis, coughing, increasing hoarseness, drooling.

Administer supplemental humidified oxygen.

Monitor arterial blood gas (ABG) levels as necessary.

Evaluate the carboxyhemoglobin on ABG results (due to inhalation of carbon monoxide, a product of combustion) and be prepared to support ventilation if signs of hypoxemia and respiratory failure develop.

Assist with pulmonary function and bronchoscopy, as indicated.

Have intubation supplies readily available. If unable to intubate the child, then tracheostomy may be necessary. If unable to extubate in 14 to 21 days, then may be converted to tracheostomy for continuous pulmonary management. The current trend is to use the earlier time frame.

Prevent atelectasis and pneumonia through chest physical therapy, postural drainage, meticulous pulmonary technique, and, if indicated, tracheostomy care.

Be aware that hypernutrition is important because of the extreme hypermetabolism related to large burn injuries.

Maintain ambient temperature at 82.4° F to 90° F (28° C to 32.2° C) to minimize metabolic expenditure by maintaining core temperature.

Minimize anorexia to increase caloric intake.

Monitor dietary compliance with dietary goals and adjust, as needed.

Administer total parenteral nutrition, if necessary.

Administer serum albumin or fresh frozen plasma to combat hypoalbuminemia when burn area exceeds 20% TBSA.

Monitor nutritional status through weight gain, wound healing, serum transferrin, and serum albumin.

Be alert for the development of gastric distention, especially with burns greater than 20% TBSA, associated injury, or tachypnea.

Maintain nothing-by-mouth status if distention or decreased bowel sounds develop.

Insert NG tube, as indicated, to prevent vomiting, aspiration, and paralytic ileus.

Monitor the return of bowel sounds after NG extubation and before reinstituting oral feeding.

Administer H₂-blockers such as cimetidine to prevent Curling’s ulcer development.

Remove all jewelry and clothing.

Elevate extremities.

Monitor peripheral pulses hourly. Use Doppler, as necessary.

Prepare the patient for escharotomy if circulation is impaired.

Avoid tight constrictive dressings.

Observe for and report signs of thrombophlebitis or catheterinduced infections.

Titrate fluid intake as tolerated. The initial resuscitation formula is only a guide.

Maintain accurate intake and output records.

Weigh the patient daily.

Monitor results of serum potassium and other electrolytes.

Be alert to signs of fluid overload, especially during initial fluid resuscitation and immediately afterward, when fluid mobilization is occurring.

Administer diuretics, as ordered.

Cleanse wounds and change dressings twice daily. Use an antimicrobial solution or mild soap and water. Dry gently. This may be done in the hydrotherapy tank, bathtub, shower, or at the bedside.

Perform debridement of dead tissue at this time. May use gauze, scissors, or forceps, as appropriate. Try to limit time to 20 to 30 minutes depending on the patient’s tolerance. Additional analgesia may be necessary.

Apply topical bacteriostatic agents, as directed. Cream or ointment is applied 1 1/8-inch (3-mm) thick.

Dress wounds, as appropriate, using conventional burn pads, gauze rolls, or any combination. Dressings may be held in place, as necessary, with gauze rolls or netting.

For grafted areas, use extreme caution in removing dressings; observe for and report serous or sanguineous blebs or purulent drainage. Redress grafted areas according to facility protocol.

Observe all wounds daily and document wound status on the patient’s record.

Promote healing of donor sites by:

Inspect unburned skin carefully for signs of pressure and breakdown.

Maintain closed urinary drainage system and ensure patency. Use a catheter impregnated with an antimicrobial agent whenever possible.

Frequently observe color, clarity, and amount of urine.

Empty drainage bag per facility protocol.

Provide catheter care per facility protocol.

Encourage removal of catheter and use of urinal, bedpan, or commode as soon as frequent urine output determinations are not required.

Be efficient in care; do not expose wounds unnecessarily.

Maintain warm ambient temperatures.

Use radiant warmers, warming blankets, or adjustment of the bed temperature to keep the patient warm.

Obtain urine, sputum, and blood cultures for temperatures above 102° F (38.9° C) rectal or core temperature or if chills are present.