Burns are among the most excruciatingly painful physical injuries.

Even a relatively minor burn can be intensely painful. A burn occurs when the skin, and often other bodily organs, come in contact with heat, radiation, electricity or chemicals for a period long enough to cause damage. Burns can affect many body parts aside from the site of the burn. Nerves, blood vessels, bones, muscles and other areas may be involved when another part of the body is injured. For example, the respiratory system may be hampered or shut down from smoke inhalation and the kidneys and heart may be damaged from fluctuations in the balance of fluids and electrolytes following a burn. Usually infants and the elderly have more serious reactions to burns and also more extended healing processes. People with other health problems may suffer more serious damage as well, due to lowered resistance. Burns are generally put into three categories. These classes are first, second and third degree burns. The burn category indicates the severity of the burn along with the amount of body area covered by the burn injury. FIRST DEGREE BURNS The first-degree burn usually produces a pink to reddish color on the burned skin. Mild swelling, tenderness and pain are also symptoms of a first-degree burn. This is the least serious type of burn and involves only the upper layer of skin, the epidermis. For these minor burns, the victim should cool with plain water and use non-prescription antibiotic creams. These burns usually heal on their own within a few days with little or no scarring. However, if a first-degree burn is over a large area of the body, seek emergency medical attention. Also, if an infant or elderly person suffers any type of burn, even minor, obtain medical assistance promptly.

SECOND DEGREE BURNS Second-degree burns involve the epidermis and the second skin layer, the dermis. The epidermis is destroyed and burned-through in a second-degree burn. There are the same symptoms of pain and swelling but the skin color is usually a bright red and blisters are produced. Usually second-degree burns produce scarring. Second degree burns may take from one to three weeks to heal but are considered minor if they cover no more than 15% of the total body area in adults and 10% body area in children. These burns require medical attention and medication to heal properly. Call for immediate medical help as soon as the burn occurs and do not apply any type of butter or greasy substance to the burn. This can hamper cooling of the burn area and also do further damage. Consult medical personnel about whether or not to administer fluids to victim before arriving at a hospital. THIRD DEGREE BURNS The third-degree burn may appear charred or have patches which appear white, brown or black. Both the dermis and epidermis are destroyed and other organs, tissues and bones may also be involved. Third-degree burns are considered the most serious. They produce deep scars that many times require cosmetic or reconstructive surgery and skin grafts. Pain may or may not be present since usually nerve endings which transmit pain have been destroyed in this type burn. Possible complications from burns include infection, tetanus, scarring, pneumonia and shock. Shock may set in due to the fluid and electrolyte loss in a serious burn. If present when a victim suffers an electrical burn, turn off the source of power as soon as possible. Do not touch the victim with bare hands. Try to move the victim with some non-conductive material like a wooden chair or board. Check for breathing and start mouth-to-mouth resuscitation if necessary. Call for immediate emergency help. In the case of chemical burns, put the affected area under a faucet and let cool water at medium pressure rinse the wound for at least 15 minutes. While area is being rinsed, call 911 for instructions on what to do next. Never try to remove jewelry or clothing from a burn victim before reaching a hospital if those items seem stuck to the skin. If, after suffering a burn and undergoing treatment, you experience any of the following, seek medical help as soon as possible: ---chills, fever ---increased pain ---swelling ---wound suddenly starts to bleed Pediatric Burn Care Epidemiology 3rd leading cause of accidental death amongst children Mortality higher for children and the elderly

2005: >120,000 children <15 years of age received care in ED for burns Children <5 years old: 65% scald injuries o 5-20 years old: 27% scald injuries Non-accidental burns: estimated as high as 20% of burn admissions Inhalational injury increases mortality significantly Pathophysiology: 1. Local injury: heat denatures and coagulates protein => irreversible tissue destruction o Surrounding this => zone of decreased tissue perfusion (salvageable tissue) o Young children have thinner skin => deeper burns o Increased capillary leak around burn 2. Systemic response: release of vasoactive mediators from tissue: cytokines, prostaglandins, O2 radicals o >15% burn in young children, >20% burn in older children: systemic response to mediators o Systemic capillary leak lasts 18-24 hours => burn shock/SIRS o Immunosppuression o Local destruction of RBC s o Myocardial depression o Hypermetabolic response: catecholamine release, glucagon, cortisol elevation 3. Advocacy: with140-150 degree water (normal for home water heater): 3rd degree burn in approximately 2 seconds o Reset water heaters to 120 degrees Classification of Burns: Depth of burns: based on intensity and duration of thermal exposure Superficial burns (1st degree): erythematous, painful o Only involve outer layer of epidermis (fluid loss not an issue) o Heal without scarring in 4-5 days Partial thickness burns (2nd degree) o Superficial partial thickness: red and painful with blister formation _ Partial destruction of dermis _ Weeping/moist appearance _ Healing in 7-10 days with minimal scarring o Deep partial thickness: greater than 50% of dermis lost _ White, pale, less painful (nerve fibers destroyed) _ 2-3 weeks to heal, severe scarring can occur, contractures _ May requires skin grafting Full thickness burns (3rd degree): white, waxy, leathery o No bleeding, painless o High risk for infection and fluid loss Fourth degree burn: destruction of underlying structures tendons, nerves, muscle, bone, deep fascia Pediatric Burn Care 2 Peoples, J Estimation of Burn Area (do not include superficial burns): Adolescents/adults: rule of 9 s o Head/Arm: 9% each o Leg, anterior trunk, posterior trunk: 18% o Neck and groin: 1% each Children: surface of child s palm = 0.5% TBSA o Modified Lund and Brower chart (see image) Initial Assessment/Evaluation ABC s Inhalational injury o Upper airway edema o Bronchospasm o Small airway occlusion from debris, endobronchial sloughing o Circumferential burn on chest limits chest wall compliance o Susepect: history of closed space exposure, facial burns, singed nasal hairs, carbonaceous debris in the mouth o Secure the airway if suspected (cuffed tube) Insert 2 large bore IV s for fluid management (okay to insert IV s through burn) Pediatric Burn Care 3 Peoples, J Remove burnt clothing/jewelry Cover burn with clean sheet/blanket: reduces pain, decreases fluid/heat loss

Eye examination o Evaluate for corneal burns with fluorescein before edema of eyelids develops Flame burns consider CO poisoning o Dx with carboxyhemoglobin level o Administer 100% O2, consider hyperbaric O2 for level >30% o 100% O2 decreases half life of CO from 250 minutes at room air to 40-50 minutes Note any circumferential burns on the body Labs: CBC, lytes, UA (myoglobin), carboxyhemoglobin Criteria for admission to burn unit (American Burn Association) 1. Partial-thickness burns of greater than 10% of the total body surface area 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third-degree burns in any age group 4. Electrical burns, including lightning injury , chemical burns 5. Inhalation injury 6. Burn injury in patients with preexisting medical disorders that could complicate management 7. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality 8. Burned children in hospitals without qualified personnel or equipment for the care of children 9. Burn injury in patients who will require special social, emotional, or rehabilitative intervention Fluid Management Aggressive management required for patients with >15% of TBSA burned o Parkland: 4ml/kg/%TBSA _ Children<5 y/o: add maintenance fluids _ Give half in the 1st 8 hours _ Give the other half in the next 16 hours o Fluid: LR, add dextrose for children <20kg Add colloid after 24 hours to help restore oncotic pressure Monitor: goal uop: 1-2ml/kg/hr, acidosis Not improving with initial resuscitation? o Consider continued volume loss, myocardial depression, neurogenic shock Nutrition: Higher caloric needs due to hypermetabolic state Begin enteral nutrition as soon as possible o Demonstrated better outcomes with enteral feeding vs TPN Can feed duodenum if concerned for risk of aspiration GI prophylaxis Curling s Ulcers: Zantac or Prilsoec Other Considerations 1. Infection o Decreased rates of wound infection, but patients live longer => _ Increased rates of central catheter infection and ventilator associated PNA o Global decrease in immune function: neutropenia, t-cell dysfunction, increased gut permeability, many blood transfusions Pediatric Burn Care 4 Peoples, J o Wound sepsis: staph/pseudomonas most common _ No ppx abx _ Rates have improved significantly with prompt wound closure o ENT: ear poorly vascularized _ Sinusitis/OM: indwelling tubes o Optho: corneal ulcer infection o Pulmonary: inhalational injury => pneumonia v. tracheobronchitis (35%) _ Ventilator associated PNA o Central venous catheter infections/UTI o Intraabdominal infection o Musculoskeletal: compartment syndrome, suppurative costal chondritis, abscess o Viral (immunosuppression): HSV, CMV, varicella reactivation o Fungal infection due to prlonged abx (candida, aspergllus) o Prevention: catheter care, early wound closure, culture/abx with fever/hypotension (be judicious!), topical abx o Tetanus o Infection control programs 2. Abdominal compartment syndrome o After large fluid resuscitation with capillary leak

o Pressure > 25-30cm H2O o Decreased renal perfusion, cardiovascular output, pulmonary compliance 3. Pain control + anxiolysis Wound Care Initial care never put ice! o Cover with sterile sheet o Cool with water 10-20 minutes after burn Topical abx: decrease both risk of infection, fluid loss from burn o Silver sulfadiazine: painless, poor eschar penetration, broad antibacterial spectrum, no metabolic side effects. o Mafenide: Penetrates tissue well, broad abx spectrum, painful on application. Application to >20% tbsa may lead to metabolic acidosis o Bacitracin: often used for burns of face, painless, no pigment bleaching (can be seen with silver sulfadiazine) o Aqueous silver nitrate 0.5%: painless application, poor eschar formation, leeches electrolytes Elevate burned extremity to minimize edema Decompressive escharotomy essential with compartment syndrome, circumferential scar Sources: 4. Reed, JL and WJ Pomerantz. Emergency management of pediatric burns. Pediatric Emergency Care. 21 (2): Feb, 2005: 118-129. 5. Sheridan, RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005: S112-S119. 6. Andel, H et al. Nutrition and anabolic agents in burned patients. Burns. 29. 2003: 592-595. 7. Uptodate.com: Joffe, MD. Emergency care of moderate and severe thermal burns in children 8. Uptodate.com: Mandel, J and CA Hales. Smoke inhalation. 9. Bressack, M. Inpatient management of pediatric burns. Santa Clara Valley Medical Center. 10. American Burn Association website

Pediatric burn services, a collaboration of MassGeneral Hospital for Children and the Shriners Hospitals for Children Boston, specializes in burn and wound care treatment of children with burns and related injuries, including:

y y y y y y y y

Acute child burns Smoke inhalation injury Reconstructive or restorative surgery as a result of healed burns Scarring resulting in contractures or interfering with mobility of the limbs Scarring and deformity of the face and hands Caustic injuries of the esophagus Frostbite

Non-burn conditions requiring pediatric wound care including toxic epidermal necrolysis (TEN), staphylococcal scalded skin syndrome, abrasion/friction injuries, traumatic degloving, purpura fulminans, epidermolysis bullosa, congenital hairy nevi and pemphigus vulgaris Pediatric burn patients are treated by MassGeneral Hospital for Children surgeons at the adjoining Shriners Hospitals for Children - Boston, the only pediatric hospital in New England verified as a Level I (highest level) burn center by the American College of Surgeons Committee on Trauma and the American Burn Association. Shriners Hospitals for Children Boston is a 30-bed pediatric burn hospital, research and teaching center. The Boston hospital is one of three burn hospitals operated by Shriners Hospitals for Children, an international health care system of 22 hospitals dedicated to providing pediatric specialty care, innovative research and outstanding teaching programs. Children up to age 18 with orthopaedic conditions, burns of all degrees, spinal cord injuries, and cleft lip and palate are eligible for care and receive all services in a familycentered environment at no charge regardless of financial need. Shriners Hospitals for Children Boston s mission is to excel as the premier pediatric burn service in the world, providing comprehensive, high-quality care to children with burn injuries. Medical Staff The burn care team includes burn surgeons, plastic surgeons, anesthesiologists, subspecialty pediatricians, psychiatrists, orthopaedists and other subspecialists. The surgeons and physicians are active staff of MassGeneral Hospital for Children and active faculty of Harvard Medical School. The acute and reconstructive surgical services work closely together to provide seamless pediatric burn and wound care from initial resuscitation through long-term rehabilitation. Nursing Staff Shriners Hospitals for Children - Boston nurses are burn-care experts. The nurses are highly trained to provide care that results in optimal outcomes for our pediatric burn patients. An individualized competency-based orientation is provided to all new employees, including classroom time and one-to-one hands-on training with an experienced preceptor. The collaboration and expertise of the medical staff and nursing staff with patients and families enables our team to devise a burn care treatment plan that will provide optimal outcome and healing for the patient. Health Care Team At Shriners, Family Services and Care Coordination serve children and their families during and after hospitalization. Family Services includes licensed clinicians who assist with the adjustments families may face during a child s burn care treatment. Social workers provide individual and family counseling during inpatient and clinic visits. They help families understand and develop coping strategies to deal with the social, emotional and psychological impact of illness. The team also includes a care coordinator who is either a registered nurse or licensed social worker. Psychiatrists and psychologists provide counseling to burn patients when it is needed. These experts help patients on the road to emotional recovery and healing. Rehabilitation therapists include both physical and occupational therapists. Patients are assigned a primary therapist upon admission who provides exercise, splinting and positioning to optimize full movement. As the child heals, the therapist sets up an exercise program to strengthen and stretch muscles and joints. The therapist continues to treat the child through rehabilitation and return to home and/or school. Therapists also follow the child in clinic to provide additional exercises and scar control measures such as massage, pressure garments, silicone gel and custom face masks. Other members of the team include child life, recreation and music therapists who provide procedural support, diversion activities, return-tocommunity outings, medical play, operating room tours and coping

strategies. A therapeutic playroom is staffed daily and children on isolation are visited regularly. School teachers provide individual and group instruction both in a classroom and at the bedside. They also coordinate a school re-entry program for children returning to school for the first time after an injury and for those changing schools. Corrective make-up is offered weekly during the reconstructive clinic to help soften the appearance of any scars. Related Pediatric Burn Research Two floors of Shriners Hospitals for Children - Boston are dedicated to research. Pediatric burn and wound care projects currently underway include, among others, skin replacement technology, metabolic responses to burn injuries, and the development of novel therapies, diagnostics and devices through bioengineering. Family-Centered Care At MassGeneral Hospital for Children and Shriners, we know that the time of your child s treatment is a very stressful one and we strive to provide an open, welcoming environment. We believe that no one knows a child as well as the parent does: parents, along with primary care providers, become our partners in a child's care and have an active voice in all treatment plans. Study Shows Pediatric Burns Heal With Fewer Treatments Finding could improve recovery experience for pediatric patients KANSAS CITY, Mo., Oct. 17, 2011 /PRNewswire/ -- According to a new study from researchers at Children's Mercy Hospitals and Clinics in Kansas City, Mo., fewer treatments are just as effective as standard of care for children suffering from burns. The research was presented at the American Academy of Pediatrics National Conference and Exhibition in Boston. "Given the risk of infection, dressings for burn patients need to be changed once or twice a day. The experience can be traumatic, especially for a young child," said Daniel Ostlie, M.D., director, Surgical Critical Care at Children's Mercy and lead investigator of the study. "If we can reduce this trauma just the slightest bit by eliminating one of the topical applications with no major implications for outcome we can make a significant improvement in the patient recovery experience." In the prospective randomized study, researchers compared the effectiveness of two burn therapies commonly used to facilitate the healing process: topical silver sulfadiazine, an antimicrobial treatment, and collagenase ointment, an enzyme therapy. While silver sulfadiazine is frequently used for its anti-bacterial properties, collagenase ointment is believed to shorten the healing time of burn wounds. "For all of our burn patients, we want to avoid more invasive treatment, such as skin grafting, because they add another layer of distress for the patient and the family," said Janine Pettiford, M.D., surgical scholar in the Department of Surgery at Children's Mercy and an author of the study. "Noninvasive topical therapies have proven effectiveness but no studies have demonstrated if one treatment is more effective than another in reducing the odds that the patient would need a skin graft." Using a consistent intervention approach for both therapies, researchers found there was no difference in the need for skin grafting between the two therapies. Additionally, the cost differential associated with both therapies was insignificant. About Children's Mercy Hospitals and Clinics Children's Mercy Hospitals and Clinics, located in Kansas City, Mo., is one of the nation's top pediatric medical centers. The 314-bed hospital provides care for children from birth through the age of 18, and has been recognized by the American Nurses Credentialing Center with Magnet designation for excellence in nursing services, and ranked by U.S. News & World Report as one of "America's Best Children's Hospitals" in all 10 specialties they rank. Our faculty of 600 pediatricians and researchers across more than 40 subspecialties are actively involved in clinical care, pediatric research and educating the next generation of pediatric subspecialists. For more information about Children's Mercy and its research, visit childrensmercy.org or download our mobile phone app CMH4YOU for all phone types. For breaking news and videos, follow us on Twitter, YouTube and Facebook.