Minor Burns in Children

Burns in children are really common, and half of the reason I love doing PEM. In many departments you only ever see minors in the Paediatric department, and I think it is in minors that you make the biggest difference. Burns are painful, and can cause life long psychological, cosmetic, and physical problems if they are not well treated- and it is the basics that really make a difference. We've recently printed a poster (see below, or here for pdf copy) for our waiting room about burn prevention and treatment, as so much burn treatment can be done at home.When we put the poster up we also sent out a burns briefing sheet to all our Doctors and Nurses as a reminder of the basic treatment.

The "STOP"  idea on the poster comes from a 2012 article from "Burns". We modified it slightly - we don't want all burns arriving in the ED by ambulance, but we thought it was a very good idea.

There are excellent resources for Burns from the London and South East of England Burn Network. They’ve got referral guidelines, direct dial numbers, body maps, and everything you could possibly want. 


There is a good summary of minor burns (in adults) on Life in the Fast Lane. The BMJ wrote a good overview in 2004, but I suspect that burn treatment has moved on since then - we don't tend to use flamazine any more. Their more recent overview (2009) doesn't touch much on dressings.
There is an indepth summary on 'crashing patient', including procedural advice. There is a really useful series of case reports on burns here.

Prevention of Burns
There’s some good fire safety leaflets online here (and there’s a QR code on the poster for patients to scan). ROSPA have some good safety tips.

Physiology of Burns
There's an excellent summary here, including lots of information on burn shock.We'll cover the physiology of burns in more detail in the next blog post - major burns in children.

Immediate Treatment of Burns
Evidence to suggest cooling within three hours of the burn has beneficial effect
    - So if the burn was less than three hours ago, cool it.
    - We should be cooling for around 20 minutes - until the burn has cooled down completely.
    - Burn Gel and burn dressings are  generally good in the back of an ambulance, but not as good as cool water. If you do use cooling dressings, they seem to work best if they are left uncovered.
Don’t forget to check tetanus status like you would in other wounds.

Analgesia
    - Remember cooling provides pain relief
    - Ibuprofen is a good pain killer for burns
    - Children may need intra-nasal diamorphine to settle them
    - Analgesic gas (entonox) may be needed whilst waiting for other analgesia to work.
    - Never underestimate the power of suggestion and hypnosis.Asking someone to imagine cooling particles flowing towards the burnt area of skin can't do any harm - and might do some good.

Evaluation of Burns
As always, remember to start with an ABC approach. Once you are happy with thatI was always taught to strip children under five off completely to check for burns or injuries elsewhere, and anything that might make you worried about safeguarding issues.

Depth of burns:
Superficial burns (1st degree)
- Erythematous, painful
- Only involve outer layer of epidermis (fluid loss not an issue)
- Heal without scarring in 4-5 days

Partial thickness burns (2nd degree)
- Superficial partial thickness: red and painful with blister formation
- Partial destruction of dermis
- Weeping/moist appearance
- Healing in 7-10 days with minimal scarring

Deep partial thickness: greater than 50% of dermis
- 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
- No bleeding, painless
- high risk for infection and fluid loss

Estimation of Burn Area - (do not include superficial burns):
Rule of 9s

Lund and Brower chart

Baby

2 year old

5 year old

10 year old

Adult

Burn Blisters
    - Current advice is to de-roof blisters if over the size of the patient’s little fingernail
    - Consideration should be given to:
       -  The risk/ benefit of ‘deroofing’ small, non-tense blisters
       - The risk/benefit of ‘deroofing’ blisters on the palmar surface of the hand and the plantar aspect of the  foot
        -   Patient compliance with the procedure and on-going care when considering the management of small, non-tense blisters i.e. patients with dementia, learning difficulties, and toddlers

Dressings
    - Mesitran (honey dressing) is a good dressing that helps cool the burn, reduce infection and reduce burn erythema.
    -  Practice Nurse should be able to change these in 48hours time.

Burn Follow Up and Advice
Prophylactic antibiotics have no proven beneficial effect.  
Increase oral fluids and protein in the diet.
Return if any sign of systemic illness developing.
The burnt area will be sensitive to the sun, and need sunscreen on it.