eMedicine Specialties > Pediatrics: Surgery > General Surgery

Burns: Surgical Perspective: Workup

Author: Gail E Besner, MD, John E Wilson Endowed Professor of Neonatal Research, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine; Director, Pediatric Surgical Research, Department of Surgery, Nationwide Children's Hospital
Coauthor(s): Iyore Amy Otabor, MD, Clinical Instructor House Staff, Department of General Surgery, The Ohio State University College of Medicine
Contributor Information and Disclosures

Updated: Mar 10, 2009

Workup

Laboratory Studies

  • Electrolytes and CBC count: Monitoring of electrolytes and blood counts is often helpful, especially with large burns requiring aggressive fluid resuscitation.
  • Carboxyhemoglobin level: Obtaining the carboxyhemoglobin level can be important in patients with inhalation injury, especially in those burned in enclosed spaces.
  • Prealbumin levels: These should be monitored weekly in patients with burns exceeding more than 20% of the total body surface area (BSA).
  • Fever workup (CBC count, urinalysis, and blood, urine, sputum, and wound cultures): This should be performed as clinically indicated.
    • If invasive burn wound sepsis is suspected (clinical deterioration, a change in the appearance of the burn, an odor to the burn) definitive diagnosis can be obtained with quantitative burn wound cultures (requiring removal of at least 1 g of burned tissue at the bedside) and the microbiology laboratory is alerted that quantitative wound cultures are required. Invasive burn wound sepsis is defined as more than 105 organisms/g tissue.
    • An alternative method of diagnosing invasive burn wound sepsis is by burn wound biopsy with histologic examination showing bacteria invading viable tissue.

Imaging Studies

  • Chest radiography can be helpful in patients who are intubated and in patients who have a suspected inhalation injury.
  • Chest radiography is also required as part of a complete fever workup, as indicated.

Diagnostic Procedures

  • Calculation of the percent BSA burned can be performed using various approaches. The fastest initial estimate of percent BSA burned can be made using the pediatric rule of nines (see Media file 5).

    Pediatric Rule of Nines.

    Pediatric Rule of Nines.

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    Pediatric Rule of Nines.

    Pediatric Rule of Nines.


    This is an adaptation of the adult rule of nines, which takes into consideration that, in children, the relative size of the head is larger and the relative size of the lower extremities is smaller.
  • Next, Lund and Browder charts can be used to more precisely calculate the percent BSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements (see Media file 6).

    Lund and Browder Chart.

    Lund and Browder Chart.

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    Lund and Browder Chart.

    Lund and Browder Chart.

  • Lastly, burn involvement can also be calculated based on the patient's palm. This is particularly useful for small scattered burns and is based on the estimate that the patient's palm (excluding the fingers) represents approximately 0.5% BSA. 

More on Burns: Surgical Perspective

Overview: Burns: Surgical Perspective
Workup: Burns: Surgical Perspective
Treatment: Burns: Surgical Perspective
Follow-up: Burns: Surgical Perspective
Multimedia: Burns: Surgical Perspective
References
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References

  1. Lowell G, Quinlan K, Gottlieb LJ. Preventing unintentional scald burns: moving beyond tap water. Pediatrics. Oct 2008;122(4):799-804. [Medline].

  2. Jeschke MG, Finnerty CC, Kulp GA, Przkora R, Micak RP, Herndon DN. Combination of recombinant human growth hormone and propanol decreases hypermetabolism and inflammation in severely burned children. Pediatr Crit Care Med. Mar 2008;9:209-216. [Medline].

  3. Chan MM, Chan GM. Nutritional therapy for burns in children and adults. Nutrition. Mar 2009;25(3):261-9. [Medline].

  4. Besner GE. Burns. In: Glick PL, Pearl RH, Irish MS, et al, eds. Pediatric Surgery Secrets. ed. Philadelphia, PA: Hanley & Belfus; 2000:246-52.

  5. Heimbach D. What's new in general surgery: burns and metabolism. J Am Coll Surg. Feb 2002;194(2):156-64. [Medline].

  6. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. Oct 25 2001;345(17):1223-9. [Medline].

  7. Hildreth M, Gottschlich M. Nutritional support of the burned patient. In: Herndon D, ed. Total Burn Care. Philadelphia, PA: WB Saunders Co; 1996:237-45.

  8. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner G. A Silver Impregnated Antimicrobial Dressing Reduces Hospital Length of Stay for Pediatric Burn Patients. J Burn Care Research. May-Jun 2007;28:409-411. [Medline].

  9. Peters DA, Verchere C. Healing at Home: Comparing Cohorts of Children with Medium-Sized Burns Treated as Outpatients With In-Hospital Applied Acticoat (TM) to those Children Treated as Inpatients with Silver Sulfadiazine. J Burn Care Research. Mar-Apr 2006;27:198-201. [Medline].

  10. Sheridan RL, Weber JM, Schnitzer JJ, et al. Young age is not a predictor of mortality in burns. Pediatr Crit Care Med. Jul 2001;2(3):223-224. [Medline].

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Further Reading

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Keywords

burns, skin grafting, burn excision, partial-thickness burn, superficial partial-thickness burn, deep partial-thickness burn, full-thickness burn, electrical burn, frostbite, body surface area, BSA, thermal injury, child abuse, scald burn, scalding injury, flame burns, hypothermia, weeping blisters, frostbite, chemical burns, pulmonary failure, renal failure, hepatic failure

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Contributor Information and Disclosures

Author

Gail E Besner, MD, John E Wilson Endowed Professor of Neonatal Research, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine; Director, Pediatric Surgical Research, Department of Surgery, Nationwide Children's Hospital
Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons
Disclosure: Trillium Therapeutics, Inc. Consulting fee Consulting; Trillium Therapeutics, Inc. Grant/research funds Other

Coauthor(s)

Iyore Amy Otabor, MD, Clinical Instructor House Staff, Department of General Surgery, The Ohio State University College of Medicine
Iyore Amy Otabor, MD is a member of the following medical societies: American College of Surgeons, American Medical Student Association/Foundation, and Student National Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Denis Bensard, MD, Director, Pediatric Trauma, Division of Pediatric Surgery, Children's Hospital of Denver; Associate Professor, University of Colorado Health Sciences Center
Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Michael G Caty, MD, Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo
Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Physician Executives, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, and Association for Surgical Education
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP, Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University School of Medicine
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

 
 
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