Patient Presentation
A 15-month-old female was visiting her grandparents during the winter holidays. Her mother had a bucket of scalding water on the floor that she was cleaning with to get ready for a family party. The child had gotten up from her nap where she had been in an adjacent bedroom sleeping on a camping mattress placed onto the floor. The child placed her left hand into the bucket and immediately screamed. Her mother turned around and the grandmother came into the hallway at the same time. They gently wrapped her hand in some gauze and came to the emergency room at a regional children’s hospital.
The past medical history showed her to be healthy. She had received all of her health supervision visits and was current with her immunizations.
The social history revealed that the parents were married, both employed, and with an older sibling.
The grandparents had several young grandchildren who visited and so had installed stair gates, kitchen door latches, outlet covers and other safety measures in their home.
The review of systems was negative for other trauma.
The pertinent physical exam showed a scared child with normal vital signs and growth parameters. The dorsum of the left hand had a white/grey colored area that was non-blanching and non-painful of 1.5 cms that was surrounded by a white area that was painful and had also some blisters. The dorsum of the fingers also had areas that were white and other areas that were red with blisters. She also had 2 small irregular area of erythema on the palm of the hand and forearm that appeared to be consistent with splash marks.
The diagnosis of full-thickness and partial thickness burns was made and later confirmed by burn surgeons. She was admitted and patient underwent debridement and skin grafting. The surgeons discussed the case with the local child abuse expert informally and after reviewing the hospital records, the expert agreed that it was most likely an accidental burn. She was discharged 5 days after the injury and was doing well at a burn clinic visit 5 days later. Her care was transferred to another children’s hospital in her local community.
Discussion
It is estimated that 1.2 -2 million burn injuries occur in the US yearly with about 1/3 of those occurring in children. About 1000 deaths occur because yearly.
Most (80%) are because of contact with hot liquids or objects.
- Scald injuries are most common cause of burns. They are caused by hot water, particularly hot bath water, which can be prevented by turning the hot water heater to below 120° F.
Children will also pulls hot items off of a stove, or can be splattered by cooking grease. These can be prevented by cooking on back heating elements, turning pot handles to the side or back and by not having children in the kitchen if possible. - Flame injuries from candles, fireworks and house fires also are common. Prevention lies in not using candles or fireworks or in using them only with children not around. House fire burns can be prevented or decreased with working smoke detectors.
- Contact injuries with clothes irons, hair curling iron, hot glue guns, etc. also occur. Again use of the items when not around children is recommended. Adults should promptly replace the cords and put the item up out of reach of children.
- Electrical injuries from electric outlets and cords also occur. Prevention through outlet covers and minimizing the length of cord used is recommended.
- Chemical burns also occur from contact or consumption of household cleaners, bleach and lye. Keeping products out of reach and/or locked up is recommended for prevention.
Initial management of burns depends on the history, physical examination and total body surface area (TBSA). Standard burn maps and tables help to determine the TBSA which changes with age. One general rule is that the size of the palm of the hand is 1% BSA. Second and third degree burns are ONLY counted toward the TBSA. The depth of the burn is also important.
- First degree (superficial) burns – affects only the epidermis and heals in a few days without scarring. These present with redness and pain and blanch when touched. They are treated with emollients 2-3 times a day and pain relief.
- Second degree (superficial- or deep- partial thickness) burns – affects the whole epidermis and part of the dermis. These present with redness, pain and blisters.
- Superficial partial thickness burns will blanch if touched and heal in about 2 weeks with minimal scarring. Treatment is debridement, local wound care and pain relief.
Blisters should be left intake if there is clear fluid, the entire blister is intact and the blister does not impede the range of motion of a joint. Otherwise the blisters should be debrided. Local wound care includes antibiotic ointment, non-stick dressings with an overlay of gauze that are changed twice a day. Soap and water can be used during dressing changes. Silvadene is not usually recommended for superficial partial thickness burns because it may inhibit wound healing. - Deep partial thickness burns often do not blanch to touch. They may have a whiter appearance and be less painful. They take 3-8 weeks to heal with scarring.
They often require excision and skin grafting.
- Superficial partial thickness burns will blanch if touched and heal in about 2 weeks with minimal scarring. Treatment is debridement, local wound care and pain relief.
- Third degree (full thickness) burns – affect the entire epidermis and dermis. They appear grey, white, brown or black and somewhat leathery. They are non-blanching and non-painful. These require excision and skin grafting and heal with scar formation.
Silvadene is used in full thickness burns because its’ able to penetrate eschars.
Treatment for other injuries is also important such as smoke inhalation in house fires. Other specialty care may also be needed such as ophthalmological or dental care. All burn patients need fluid to maintain hydration particularly children. Child abuse and/or neglect may also be possibility with pediatric burns (~20%) particularly if there are burns in more than one location, burns are in different stages of health, or there is a particular pattern (glove and stocking submersion injury, circular burns from cigarettes). Immunization status should be discussed and tetanus toxoid given if not administered with the past 5 years.
Learning Point
An experience burn center suggests that patients should be considered for treatment at a burn center if they are or have:
- > 10% TBSA affected
- Burns to the face, hands, or perineum
- Inhalation injuries
- Electric burns
- Child abuse
- Associated trauma
Patient can be treated on an outpatient management if are or have:
- < 15% TBSA affected
- Not requiring fluid resuscitation
- Able to take oral fluids
- No serious perioral burns
- No airway involvement or aspiration of hot liquids
- No child abuse suspected
- Family is able to monitor patient properly and is able to reliably return for clinic appointments
If in doubt, evaluation by a surgeon or telephone consultation with a local or regional burn unit about the proper management should be done.
Questions for Further Discussion
1. Where are your local and regional burn consultants located?
2. What are some of the long term burn care complications that primary care physicians may be needed to assist patients and families with?
Related Cases
- Disease
Burns
Hand Injuries and Disorders
Injuries
- Symptom/Presentation
Burns
- Specialty
Emergency Medicine
Surgery
- Age
Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Burns
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Pizano LR, Corallo JP, Davies J. Nonoperative management of pediatric burn injuries. J Craniofac Surg. 2008 Jul;19(4):877-81.
Feldmann ME, Evans J, O SJ. Early management of the burned pediatric hand. J Craniofac Surg. 2008 Jul;19(4):942-50
Kassira W, Namias N. Outpatient management of pediatric burns. J Craniofac Surg. 2008 Jul;19(4):1007-9.
O’Brien SP, Billmire DA.J Craniofac Surg. Prevention and management of outpatient pediatric burns. 2008 Jul;19(4):1034-9.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 