Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.
com/ on January 21, 2022 at Universidad El Bosque.
1
Paediatric Emergency
Department, Royal Belfast
Hospital for Sick Children,
Belfast, UK
2
Paediatric Emergency
Department, Royal Belfast
Children’s Hospital, Belfast, UK
3 principles of burns management, we aim to
Faculty of Medicine, Health
and Life Sciences, Queen’s
University, Belfast, UK
Correspondence to
Dr Stephen Mullen, Paediatric
Emergency Department,
Royal Belfast Hospital for
Sick Children, Belfast, UK;
drsmullen@gmail.com
Received 30 September 2021
Accepted 15 December 2021
© Author(s) (or their
employer(s)) 2022. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: McAlister P,
Hagan G, Lowry C, et al.
Arch Dis Child Educ Pract Ed
Epub ahead of print: [please
include Day Month Year].
doi:10.1136/archdischild-
2021-323229
McAlister P, et al. Arch Dis Child Educ Pract Ed 2022;0:1–6. doi:10.1136/archdischild-2021-323229
Fifteen-minute consultation:
Management of paediatric
minor burns
Peter McAlister ,1 Gary Hagan,1 Christopher Lowry
1,3
Stephen Mullen
ABSTRACT
Burn injuries are a common presentation to
the paediatric emergency department (PED)
and are painful, distressing and may have
long-term sequelae. In adhering to the first aid
alleviate pain, prevent bacterial contamination
and minimise the extent of injury. First aid
involves cooling the burn and covering with
an appropriate material while simultaneously
providing analgesia. Assessing the severity (depth
and total body surface area) of the burn are
important for prognostication with implications
for management. It is imperative to consider
non-accidental injury in burns, which be present
in 10% of cases .
INTRODUCTION
Burn injuries are a common presentation
to the emergency department (ED). In
the acute situation, the primary aims are
to alleviate pain, minimise the extent of
injury and prevent bacterial colonisation.
Adherence to first aid principles reduces
the long-term disability that are a sequelae
of a burn injury. This article will focus on
minor burns,
Case
Jason is a 2-year-old boy presenting to ED
with a burn to his chest and arm. Jason
sustained the burn after pulling a cup of
tea from the kitchen worktop. As you read
the chart, you wonder if this is a common
injury in this age?
Epidemiology
Approximately 64 000 paediatric patients
seek medical attention in the UK each
year as a consequence of a burn, of which
75% are under the age of 5 years.1 Scalds
are the most common injury, often the
result of pulling down a hot beverage
(tea/coffee) followed by contact burns (eg,
Best practice
,2
irons, hair straighteners).2–4 Other types
of burn injuries include chemical, flame,
radiation (sun) and electrical. Figure 1
shows the relationship between increasing
age and causes of burns. Burns are more
common in males, in those from a lower
socioeconomic background and in single
parent families.3
Jason’s parents cooled the burn for 5
min under running water and adminis-
tered paracetamol before bringing him to
ED.
What does your initial management
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entail?
FIRST AID
The first aid principles in the manage-
ment of burns are the same at home as
they are in hospital: analgesia, cooling
and covering.
Analgesia
Burns are incredibly painful and unfortu-
nately, analgesia can be overlooked. Anal-
gesia should be given as soon as possible,
aiming to decrease pain, improve compli-
ance and help alleviate parental anxiety.
Over the counter medication such as
paracetamol and ibuprofen can be admin-
istered at home and in the pediatric emer-
gency department (PED). In hospital,
agents such as fentanyl, diamorphine,
morphine and ketamine may be consid-
ered and administered orally, intrave-
nously, intramuscularly or intranasally
(IN).5 IN administration of fentanyl
and diamorphine has been shown to be
effective and safe. Non-pharmacological
methods such as distraction techniques
should also be used in a multifaceted
approach. Cooling and covering the
burn appropriately provides an analgesic
effect.
1

Best practice
Figure 1 Age breakdown according to burn type.2
Cooling
Cooling a burn reduces pain and the temperature of
the wound. While there are many modalities to cool
a burn, cool running water at around 15°C remains
the gold standard (ie, tap water). The burn can be
cooled up to 3 hours postinjury, preferably within the
first hour, for a duration of 20 min.6 7 Where possible,
clothing adjacent to the burn should be removed.
Decreasing the temperature of the burn injury is a
key component of first aid and is based on the Jackson
burn wound model (figure 2). The zone of stasis has
potentially salvageable tissue and improving tissue
perfusion can reduce the severity of the injury in terms
of the total body surface area (TBSA) and depth of
the injury.8 There is good evidence to support cooling
with a recent study by Griffin et al, demonstrated that
correct use of cool running water significantly reduced
the odds of skin grafting (OR 0.6), full thickness burns
Figure 2 Jackson Burn model. Figure drawn by Mrs Stephane
McAlister, used with permission.
2 McAlister P, et al. Arch Dis Child Educ Pract Ed 2022;0:1–6. doi:10.1136/archdischild-2021-323229
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.com/ on January 21, 2022 at Universidad El Bosque.
(OR 0.4) and operative intervention OR (0.7) in
comparison to inadequate first aid.6
Prolonged cooling of the burn (>20 min) may lead
to hypothermia and increase in burn depth due to
prolonged vasoconstriction.7 Ice or very cold-water
should be avoided. Other methods include cool water
sprays and regularly replaced soaked swabs; however,
these are inferior to cool running water.
Covering
Once a burn has been cooled effectively, the area
should be covered loosely with a non-adhesive
dressing or wrap such as cling film.7 This prevents
bacterial colonisation of the wound, reduces stimula-
tion of exposed nerve fibres and consequently pain,
while also allowing visualisation of the injury without
the frequent removal of other dressings that may cause
further tissue damage. In cases of limb injury, ensure
the dressing is applied loosely to prevent a tourniquet
effect which may impend blood flow.
Facial wounds can be covered using a petroleum or
paraffin wax based ointment, and topical antibiotics
such as chloramphenicol should also be considered.
Case continued
Jason has received IN diamorphine and completed a
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total of 20 min of cooling while in ED thanks to the
departments excellent triage nurses. The play therapist
is distracting him, and he has cling film applied to his
chest wounds.
Before you go in, you review the key components of
the assessment.
ASSESSMENT
General principles
Burns are a trauma, and the patient should be
approached in the standard c-ABC trauma algo-
rithm. This is particularly important for major burns
(ie, >10% TBSA, burns to airway, respiratory or circu-
latory compromise, polytrauma, enclosed space and so
on). All patients require a full head to toe examination
and a full set of observations.
Burn depth
The depth of a burn is multifactorial, relating to the
source, duration of contact, temperature and skin
thickness. Children have thinner skin than adults
predisposing them to deeper burns for any given
temperature. Clinical examination of a burn to assess
depth should include appearance, capillary refill, pres-
ence of blisters and sensation.
Burns are described as superficial (epidermal), super-
ficial partial thickness (partial dermal), deep partial
thickness (all of dermis) and full thickness (epidermis,
dermis and subcutaneous tissues) (table 1).9 An alter-
native classification for burns is first to fourth degree
burns where first degree burns equates to superficial
burns. This is not widely used within the UK.9 The
 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.com/ on January 21, 2022 at Universidad El Bosque.
Best practice

Table 1 Classification of burns injuries (images courtesy of BAPRAS, used with permission)
Classification of burn Dermal layers Wound appearance Capillary refill Blisters Sensation Picture
Superficial Epidermis only Red and dry Present No Painful

Superficial partial Epidermis Pale pink Present Present Painful

thickness Upper 1/3 dermis
(papillary layer)

Deep partial thickness Epidermis Blotchy cherry red and Significantly Absent Absent
All dermis white, mottled delayed or
absent

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Full thickness Epidermis White, brown, black Absent Absent Absent
Dermis
Subcutaneous
tissue

assessment of burn depth can be difficult, especially
in the first 48–72 hours. As well as being dynamic
wounds that evolve, burns can be heterogeneous
and have mixed depth. It is important that burns are
assessed 2–3 days later to ensure they remain appro-
priate for ambulatory management.
may be less accurate than newer techniques such as the
Mersey Burns and E-burns applications (figure 3).10 11
These smartphone applications are available to help
facilitate an efficient estimation of the extent of
burns.11

Burn size/TBSA Special areas

The assessment of a burn size as a percentage of TBSA
is of upmost importance as it influences fluid resusci-
tation, patient disposition and need for specialist inter-
vention (paediatric intensive care unit (PICU)/plastics
or burns team).
Epidermal burns (erythema only) are not included
in TBSA calculations. There are many methods to help
gain an accurate estimation. The palmar surface of the
patient’s hand, including palm and fingers, represents
approximately 1% TBSA. The Lund and Browder chart
can help identify the extent of the burn; however, it
Burns to the palmar aspect of the hand are common
and although relatively small in terms of TBSA, can
prove problematic due to the functional deficit.12 The
majority heal without surgical intervention, yet some
do require grafting. The aim of treatment is to preserve
fine and gross motor function with prevention of
contractures. Burns to feet carry similar concerns
regarding the impact on motor function. Burns in the
‘glove and stocking distribution’ are strongly asso-
ciated with immersion injuries in keeping with non-
accidental injury (NAI).

McAlister P, et al. Arch Dis Child Educ Pract Ed 2022;0:1–6. doi:10.1136/archdischild-2021-323229 3


Best practice
Figure 3 Lund and Browder chart. Image courtesy of NHS Clinical
Knowledge Summary, used with permission.
Burns to the genitalia and perineum should raise
significant concerns regarding the cause as they are
strongly linked to NAI.13 Scalds are the most common
cause of burns to genitalia, especially in younger chil-
dren and often present in combination with more
widespread burn injuries. They may require earlier
surgical input from plastic surgery and urology.13
Case continued
Jason has 4% burns to his chest and neck that are a
mixture of superficial and deep partial thickness with
blistering. His c-ABC assessment is otherwise unre-
markable as are his observations. You discuss the
case with your senior wondering about deroofing the
blisters. The consultant takes the opportunity to probe
you about intravenous fluids, antibiotics/tetanus, the
need for plastics review and safeguarding.
Deroofing blisters
Blisters are most commonly associated with partial
thickness burns, where the dermis separates from
the epidermis. The British Burns Association recom-
mends that small (<0.6 cm) non-tense blister should
be left alone but other blisters should be deroofed.14
In deroofing the blister, you can assess the burn depth
with direct visualisation of the underlying skin and
relieve any potential pressure that may impede blood
4 McAlister P, et al. Arch Dis Child Educ Pract Ed 2022;0:1–6. doi:10.1136/archdischild-2021-323229
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.com/ on January 21, 2022 at Universidad El Bosque.
Figure 4 Parkland formula. Images created by Mrs Stephanie
McAlister, used with permission. BSA, body surface area.
flow to the zone of stasis. To deroof a blister, the area
should be cleaned with sterile water and all non-viable
tissue should then be removed using damp gauze or
scissors and forceps. The margins should include the
non-viable tissue only.14
Intravenous fluids
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The outcome of your initial assessment will dictate
the need for further treatment, including the use of
intravenous fluids. If Jason was clinically shocked,
he would require an fluid bolus and if he had >10%
TBSA the Parkland formula (figure 4) would be used
to guide fluid replacement.15 As Jason was not shocked
and has a 4% burn, he does not require intravenous
access, bloods or intravenous fluids.
When to involve burns specialists
Referral criteria differ depending on geographical
location and it is imperative that you familiarise your-
self with local protocols. The British Burns Association
published guidelines in 2012 which form the backbone
of most local protocols (table 2).
Plastic surgery plays an important role in the surgical
management of burns, both in the acute scenarios and
reconstructive surgery. Acute surgical options include
excision of burns as well as techniques such as skin
grafting, skin flaps and more novel options such as
synthetic and biosynthetic membranes.15 Intensive
care specialists may be involved in more significant
burn injuries.
Antibiotics and tetanus
Superficial burns generally have no associated
infective sequelae; however, the deeper the burn,
the higher the risk for associated infection. Histor-
ically, prophylactic antibiotics, especially Ceph-
alosporins and Penicillins, have been used to
prevent infective complications such as toxic shock
syndrome; however, there is no strong evidence that
 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.com/ on January 21, 2022 at Universidad El Bosque.
Best practice

Table 2 National Burns Referral Guidelines, British Burns Association 2012 (https://www.britishburnassociation.org/wp-content/
uploads/2018/02/National-Burn-Care-Referral-Guidance-2012.pdf) (images used with permission)
Criteria Facility threshold Unit threshold Centre threshold Note
TBSA Refer ≥2% ≥5% ≥30%
<5% <30% ≥15% if under 1 year
≥5% old
<15% if under 1 year old
Discuss ≥20%
≥10% if less than 1
Year Old
Depth Refer All full thickness burns ≥2% full thickness if under ≥20% TBSA if full All burns that are not
10 years old thickness blanching should be
≥1% full thickness if under referred to a specialised
6 months old burn service
Site Refer Any significant burn to ‘Significant’ can mean any
special areas injuries where the referrer
(hands, feet, face perineum feels that greater MDT
or genitalia) expertise is required
Any circumferential burn
Discuss Any burn to special
areas (hands, feet, face,
perineum, genitalia)
Mechanism Discuss Any chemical, electrical,
friction burn
Any cold injury
Other factors Refer Any burn not healed in Any predicted or actual All those predicted Any child requiring assisted
2 weeks need for HDU/PICU to require assisted ventilation for >24 hours
(including those predicted ventilation specifically must be within a paediatric
to require support for for their burn injury for intensive care unit.

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reasons other than the more than 24 hours. It is recommended that
burn injury—eg, smoke all children with smoke
inhalation) inhalation (irrespective of
the presence of burn injury)
are referred to a
PICU with a specialised
burn care service on site.
HDU, high dependency unit; MDT, multi-disciplinary team; PICU, paediatric intensive care unit; TBSA, total body surface area.

this is effective. A recent meta- analysis16 reported
that prophylactic antibiotics have no benefit in the
prevention of infection. Some departments may
recommend the use of prophylactic antibiotics and
local guidelines should be followed in relation to
this.
Tetanus vaccination is another necessary consid-
eration in those patients with burn injuries.
Patients with up-to-date tetanus vaccination history
(primary vaccination and subsequent boosters) do
not require further tetanus vaccination. 17 Patients
who have an uncertain vaccination history or are
not up to date with boosters should receive a tetanus
vaccine.17 There are other specific circumstances
where human tetanus immunoglobulin should be
considered in the context of burn injuries which
include delay >6 hours in surgical intervention,
associated puncture injury with high- risk mate-
rial, associated sepsis and compound fractures. 18
Further information is available in the Green Book.
Neglect/inflicted burns
When assessing any paediatric patient with
any injury, it is pertinent to always consider the
possibility of NAI. This remains true for burns
injuries, with an estimated 10% as a consequence
of NAI with the ratio of physical abuse to neglect
1:9.19 Your assessment must include a detailed
history of the injury including any supervision
concern, developmental stage, social services input
or child protection history. You should inquire
about delay in presentation and clarifying if there is
a history of repeated burns or other injuries. Using
a standardised proforma such as the BASAT (Burns
and Scalds Assessment Template) may help ensure
all of the relevant information is gathered. 20 Clin-
ical decision tools such as the BuRN-Tool may help
your decision making.21 If you have any concerns,
it is imperative to discuss with a senior colleague.
Case continued
You discuss the case with plastics who will review in
2 days in outpatient and advised against prophylactic
antibiotics. Before the patient leaves, the nursing staff
want to know what type of dressing to discharge
him with and if he requires any specific discharge
instructions.

McAlister P, et al. Arch Dis Child Educ Pract Ed 2022;0:1–6. doi:10.1136/archdischild-2021-323229 5


Best practice
Dressings
Dressings play a key role in the management of burns
acting as a protective barrier to prevent bacterial colo-
nisation and to promote healing. There are a wide
variety of dressings used, depending on burn depth.
Deep partial thickness burns are often managed with
silver containing dressings due to their antiseptic qual-
ities (eg, UrgoTul silver, Aquacel AG).22 Hydrocol-
loid and silicone based dressings are widely used for
superficial partial thickness burns and are associated
with good healing outcomes (eg, Mepitel, Jelonet).22
The use of dressings should be guided by your local
hospital policies.
Discharge advice
Parents should be reassured that superficial and partial
thickness burns often heal well without sequelae.
Deep partial and full thickness often require closer
follow-up. Burns that are dressed should be followed
up on a regular basis to ensure healing and to assess
for complications such as infection. This can be done
in the community, local hospital or specialist burns
centre depending on the severity of the burn. Parents
should be advised to monitor for increasing pain or
erythema surrounding the area of the burn that may
indicate a superimposed bacterial infection. Parents
should also be advised to monitor for signs of toxic
shock syndrome, a rare but severe complication of
burns. Symptoms vary and can often be non-specific
including fever, vomiting, rash and sudden deterio-
ration in clinical condition. Urgent medical attention
should be sought. We would recommend written
discharge instructions to be given to carers.
Twitter Christopher Lowry @chrislowry55 and Stephen Mullen @smullen001
Contributors SM developed the concept for the article and contributed to
writing and review. PM contributed to writing, added case discussion and
adding tables and figures. GH contributed to writing. CL contributed to review
of article.
Funding The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval This study does not involve human participants.
Provenance and peer review Commissioned; externally peer reviewed.
ORCID iDs
Peter McAlister http://orcid.org/0000-0002-9640-7408
Christopher Lowry http://orcid.org/0000-0002-3418-3795
Stephen Mullen http://orcid.org/0000-0001-7115-980X
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Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2021-323229 on 21 January 2022. Downloaded from http://ep.bmj.com/ on January 21, 2022 at Universidad El Bosque.
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