Surgical Treatment of Burns 

Traumatic injuries cause more deaths in childhood than all other causes combined. Although motor vehicle injuries are the foremost cause of death, each year approximately 440,000 children receive treatment for burns in the United States. More than 75,000 of these children require hospitalization, 10,000 experience severe permanent disability, and 2,500 die from thermal injury. Burn injuries represent the third leading cause of mortality in patients younger than 5 years. The overall morbidity from thermal injury has improved markedly over the years as a result of an aggressive multidisciplinary approach to care for the pediatric patient with thermal injury.

Approximately 90% of burns are caused by household accidents or child abuse. In children younger than 3 years, scalds are responsible for most burns.^[1] Scald burns may occur when a child pulls scalding liquid onto himself or may result from bathtub submersion injuries, which can often be quite severe. In older children, flame burns are more common. Space heaters, matches, and house fires are the most common etiologic factors for these burns, which are often full thickness and constitute most fatal burns.

Appreciating the major differences between burn management in children and adults is important. Children have nearly 3 times the body surface area (BSA)-to-body mass ratio of adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporative water loss than adults. The large BSA-to-body mass ratio of the child also predisposes the child to hypothermia, which must be aggressively avoided.

Children younger than 2 years have thinner layers of skin and insulating subcutaneous tissue than older children and adults. As a result, they lose more heat and water than adults do, and they lose these more rapidly than adults. In very young children, temperature regulation is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen consumption, and lactate production. In addition, because of disproportionately thin skin, a burn that may initially appear to be partial thickness in a child may instead be full thickness in depth. Thus, the child's thin skin may make initial burn depth assessment difficult.

The depth of burn is classified as follows (see the image below):

Superficial partial thickness

These burns are superficial with injury to the epidermis and superficial dermis. These are second-degree burns and are characterized by ruptured weeping blisters. They are also erythematous and painful. Superficial partial-thickness burns spontaneously heal within 1-3 weeks, usually without scarring (see the image below).

Deep partial thickness

These are deep burns with injury to the epidermis and deeper dermis, but some viable dermis remains. These are also considered second-degree burns but are whiter and less erythematous as the depth into the dermis increases. Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult. Deep partial-thickness burns heal spontaneously but often after 3-4 weeks. The degree of scarring is related to the length of time needed for reepithelialization. See the image below.

Full thickness

Injury to the epidermis and entire dermis occurs. These are the third-degree burns that typically are white, brown, or black. The eschar is leathery and insensate. These burns do not heal spontaneously (except for very small wounds that heal by contraction). See the image below.

Electrical burns

Low-voltage injuries result from sources of less than 1000 volts and include oral injuries from biting electrical cords, outlet injuries from placing objects into wall sockets, and injuries from contacting live wires or indoor appliances. High-voltage injuries are caused by sources of more than 1000 volts and result from contact with a live wire outdoors or from being struck by lightning.

Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring, serial electrocardiography, urinalysis, and determination of creatine kinase and urine myoglobin levels. Myoglobinuria and hemoglobinuria should be aggressively treated with hydration, osmotic diuretics, and alkalinization of the urine to avoid renal failure. Extremities must be carefully monitored for the development of compartment syndrome, necessitating escharotomy or fasciotomy. Appropriate radiographic examinations should be performed to exclude concomitant long bone injury.

Many children who have sustained low-voltage electrical injury can be treated as outpatients as long as (1) the patient has no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident; (2) the patient remains asymptomatic after 4 hours of observation in the emergency department; (3) the wounds are manageable in an outpatient setting; and (4) the patient can return for a wound check the following day. Parents of children with oral commissure burns must be instructed in the application of pressure to the lip in the event that the burn erodes into the labial artery, a complication that usually does not develop until several days after the injury.

Frostbite

Frostbite results from prolonged exposure to severe cold and usually affects the ears, nose, hands, and feet. Ice crystal formation in the tissues results in cellular dehydration, venous dilation and vasoconstriction causing peripheral blood pooling, and finally, tissue necrosis.

Signs and symptoms of frostbite include red, blue, or pale skin; a prickling sensation with superficial frostbite; painless rigid skin with deep frostbite; and functional impairment.

Treatment involves placing the patient in a warm environment, removing clothing from the affected region, and rewarming the affected region by immersion in water at 100-105°F for up to 30-45 minutes. Do not rewarm the frozen part with massage or dry heat.

Chemical burns

Saturated clothing should be removed, powdered chemicals should be brushed off the skin, and the contaminated area irrigated with copious amounts of water for at least 20 minutes, and until the patient experiences a decrease in pain in the wound.^[2]

Chemical injuries to the eye are treated by forcing the eyelid open and flushing the eye with water or saline.

With gasoline injuries, the petroleum products may cause severe full-thickness cutaneous tissue damage, and absorption of the hydrocarbon may cause pulmonary, hepatic, or renal failure.

Burn excision and grafting are recommended for all full-thickness burns and for deep partial-thickness burns that would appear to take more than 2-3 weeks to heal.

See Clinical for a discussion of relevant anatomy in patients with burn injuries.

Any condition that would ordinarily preclude the patient with burn injuries from having general anesthesia, otherwise no contraindications to surgery are noted.