eMedicine Specialties > Pediatrics: Surgery > General Surgery

Burns: Surgical Perspective: Treatment

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

Treatment

Medical Therapy

Rapid assessment and treatment of immediate life-threatening conditions is mandatory in patients with burns. Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway edema. Because of the small diameter of the pediatric airway, a low threshold for intubation should be maintained. Children with burns affecting more than 10% of the body surface area (BSA) should receive intravenous fluid resuscitation. Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physical examination should be obtained. Wet sheets or cooling packs should not be used because this contributes to hypothermia. Patients should be kept warm by infusing warm intravenous fluids, elevating room temperatures, and minimizing patient exposure. Tetanus immunization should be administered as indicated.

Admission criteria

Hospital admission criteria for patients with thermal injury include the following:

• Partial-thickness burns greater than 10% total BSA (TBSA)
• Full-thickness burns greater than 2% TBSA
• Burns involving the face, hands, genitalia, perineum, or major joints
• Circumferential extremity burns
• All high-voltage electrical burns, including lightning injury
• Admission of low-voltage electrical burns is selective
• Chemical burns
• Inhalation injury
• Burn injuries in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality (eg, diabetes, immunosuppression)
• Suspected child abuse
• Cases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for the burn)

Inhalation injury

Clues to inhalation injury include increased respiratory rate, hoarseness, being burned in an enclosed space, altered mental status, head and neck burns, singed nasal hairs, inflamed oral mucosa, and carbonaceous sputum. Indications for intubation include compromised upper airway patency, the need for ventilatory support as manifested by poor gas exchange or increased work of breathing, or compromised mental status. Correlation of the history and clinical findings comprise the most practical approach to determining the need for intubation.

Important considerations regarding the pediatric airway include the fact that the larynx is more cephalad in children, that children deteriorate faster than adults in terms of upper airway edema and alveolar-capillary block, and that repeated intubation attempts may cause edema and obstruction. For these important reasons, experience in pediatric intubation is needed. Once an airway is established, securing the airway well is important, especially in patients with facial burns, to avoid accidental extubation (see Media file 7).

Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct of combustion that displaces O₂ from the hemoglobin (Hgb) molecule. It has 250X the affinity of O₂ for Hgb, therefore shifting the Hgb-O₂ disassociation curve to the left. This impairs O₂ unloading at the tissue level and causes a switch to anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected with persistent metabolic acidosis despite adequate volume resuscitation. Remember that the PaO₂ in an arterial blood gas will be normal since the amount of O₂ dissolved in arterial plasma is normal. In addition, the O₂ sat (measured O₂ saturation of Hgb) will be normal on a standard pulse oximeter in the presence of CO toxicity since the oximeter cannot differentiate between Hgb saturated with O₂ and Hgb saturated with CO.

To treat CO toxicity, all patients with inhalation injury should be treated with 100% O₂. This lowers the T½ of CO to 30-90 minutes whereas it would be 4-5 hours in room air. Therefore, all major burns should be treated with 100% O₂ until CO toxicity is ruled out or the CO level returns to normal. Hyperbaric oxygen (HBO) therapy (3 atm) leads to even more rapid displacement of CO within 20 minutes. Its use should be considered for CO greater than 50%, severe neurologic compromise, and nonresponsiveness to 100% O₂.

Cyanide toxicity results from the burning of natural (wool, silk, cotton, paper) or synthetic (polyurethane, plastic, nylon, acrylic) products, which leads to the production of toxic hydrocyanide gas. Cyanide binds to the cytochrome oxidase system, inhibiting cellular metabolism and ATP production. It causes a shift to anaerobic metabolism with profound metabolic acidosis and obtundation. The treatment of cyanide toxicity involves administration of the cyanide antidote sodium thiosulfate (8 g intravenously if <12 y; 12.5 g intravenously if ³ 12 y). The antidote converts cyanide to nontoxic, excretable thiocyanate.

Intravenous access may be obtained percutaneously or by cutdown, either peripherally or centrally. Peripheral access in an unburned area is preferred. Intraosseous (IO) infusion may be lifesaving in the severely burned patient if necessary.

Several burn resuscitation formulas can be used in pediatric burn care; the modified Parkland formula is most commonly used. Ringer lactate solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each percent of BSA burned for the first 24 hours. One half of the calculated fluid needs are administered in the first 8 hours after the burn occurs, and the remaining half are administered over the following 16 hours. Maintenance fluids should be administered concomitantly (this represents the modification to the Parkland formula for pediatric patients).

Representative fluid resuscitation guidelines for pediatric burn patients with burns more than 15% TBSA are as follows:

• Modified Parkland formula (Parkland formula plus maintenance fluids, used in patients who weigh less than 20 kg)
  • Resuscitation fluids - 3-4 mL Ringer lactate X weight (kg) X %TBSA burned (second-degree and third degree); half administered over the first 8 hours (from time of injury), remaining half administered over the next 16 hours
  • Maintenance fluids - Ringer lactate solution with 5% dextrose at 4 mL/kg/h for 0-10 kg, plus 2 mL/kg/h for 10-20 kg, plus 1 mL/kg/h for each kg more than 20 kg

• Patients with burns 5-10% TBSA who are taking oral fluids well - Oral fluids only
• Patients with burns 5-10% TBSA who are not taking oral fluids well - Maintenance fluids
• Patients with burns 10-15% TBSA - 150% maintenance fluids

The above recommendations are guidelines only. Patients with burns of more than 15% TBSA should have a urinary catheter placed. Desired urine output is 1 mL/kg/h for patients who weigh less than 30 kg and 30-50 mL/h for patients who weigh more than 30 kg. For major burns, fluid resuscitation needs to be reassessed hourly based on the patient's urine output.

Rates of fluid administration should be altered based on the patient's response. If a patient presents after some period of delay and has not been resuscitated properly during that time, adjustments should be made in the calculated fluid requirements to take these factors into account. Infants are at risk of developing hypoglycemia because of limited glycogen stores; therefore, glucose levels should be monitored, and Ringer lactate solution with 5% dextrose should be used for maintenance fluids. Assess response to fluid administration by measuring urine output via an indwelling urinary catheter. Monitoring sensorium, peripheral circulation, and blood pH is also helpful to assess the adequacy of resuscitation.

Systemic antibiotics                 

Prophylactic systemic antibiotics are not used in the treatment of burn patients because this increases the risk of infection with resistant organisms. Instead, the use of systemic antibiotics is reserved for the treatment of specific infections, with antibiotics administered at the first sign of clinical infection. Antibiotic regimens are then modified as culture results and antimicrobial sensitivity results become available.

Burn wound cellulitis refers to infection spreading in dermal lymphatics in the nonburned skin surrounding a burn, usually occurring in the first few days after burn injury. Burn cellulitis is commonly caused by Streptococcus pyogenes. Invasive burn wound sepsis leads to systemic toxicity with high fever, bacteremia, and a hyperdynamic circulatory state with hypotension and cardiovascular collapse. Diagnosis can be made by either clinical examination, or by quantitative burn wound cultures or burn wound histology.

Surgical Therapy

Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterial colonization. Silver sulfadiazine cream (Silvadene) is a commonly used broad-spectrum topical antimicrobial cream. It is applied as a thin layer with gauze dressings twice daily. It does cause transient neutropenia, which resolves even with continued use of the agent. Facial burns are usually treated with a combination antimicrobial product containing polymyxin B, neomycin, and bacitracin (eg, Neosporin ointment) or an immunomodulating cream such as beta-Glucan (a cream that contains complex carbohydrate isolated from the cell wall of oats). The use of silver sulfadiazine cream is avoided on the central face because it may cause severe ocular irritation. Ear burns should be treated with mafenide cream (Sulfamylon) because the thin subcutaneous tissue in the ears predisposes to the development of chondritis.

Hydrotherapy provides wound and body cleansing with gentle removal of loose eschar and topical ointments. If used, hydrotherapy sessions are limited to 10-15 minutes once a day to decrease promotion of infection. Topical enzyme preparations such as Santyl (a collagenase-containing debriding ointment) can be applied to the burn surface to chemically debride devitalized tissue without injuring viable tissue. This allows earlier assessment of the wound bed, with fewer days to a clean wound bed and reepithelialization.

To avoid the need for painful dressing changes, artificial skin substitutes, such as Aquacel Ag and Acticoat, may be used for the treatment of partial-thickness burns. Aquacel Ag is a hydrofiber dressing in which antibacterial silver (Ag+) ions are incorporated into the dressing and released in a continuous sustained-release fashion for continuous topical antimicrobial effects. The fibers in the dressing hydrate upon contact with the burn surface creating a viscous gel that prevents fluid loss and traps bacteria. Once adherent to the burn surface, usually within 24-48 hours, the dressing can be left in place for as long as 2 weeks, during which time reepithelialization is usually complete. If reepithelialization is not complete by that time, the Aquacel Ag can be reapplied (see Media file 8).

Preoperative Details

Successful burn wound management in children demands conversion of open wounds to closed wounds as soon as possible. The concept of early removal of burn eschar and immediate wound closure has gained widespread acceptance. Evidence suggests that early eschar removal is effective in decreasing morbidity and improving the mortality rate. Full-thickness burns (with the exception of very small injuries that are allowed to heal by contraction) should be grafted. The goal is to excise the wound within the first week of the injury. Additionally, deep partial-thickness burns that take longer than 3 weeks to heal usually benefit from grafting, with less hypertrophic scarring and better cosmetic results.

Intraoperative Details

Preoperatively, patients must be hemodynamically sound and have optimal acid-base, fluid, and electrolyte balance. Adequate blood must be available before considering excision and grafting. Preoperative antibiotics are not required unless patients have other compromising systemic diseases or invasive burn sepsis; however, a prophylactic dose of a first-generation cephalosporin antibiotic may be used.

Attention to maintenance of body temperature at all times is extremely important. Burn excision involves tangential removal of thin slices of eschar until profuse pinpoint bleeding from a moist, viable, deep dermal surface or subcutaneous fat is observed. Meticulous hemostasis is then obtained using epinephrine-soaked (1:100,000) sponges, topical spray thrombin, and electrocautery, followed by immediate grafting with thin sheets of autograft. Skin grafting involves harvesting partial-thickness pieces of skin from donor sites on unburned areas using a dermatome. The thickness of the harvested skin commonly is 8-12 thousandths of an inch, depending on the age and skin thickness of the patient. The grafts are then applied to the wound bed and secured.

Autograft skin is obviously preferred whenever possible. Unfortunately, patients with large burns may not have enough autologous skin available for complete coverage. In such patients, burns can be excised and temporarily covered with numerous biologic dressings (eg, cadaveric skin, pigskin) or skin substitutes. As more donor sites become available, the temporary wound covers are removed and the wounds are grafted. Studies have shown that growth hormone (0.15-0.2 mg/kg/d intramuscularly) can speed donor site healing, allowing more rapid reharvesting of healed donor sites.²

Meshed autografts are harvested from donor sites and passed through a meshing machine that cuts a series of parallel offset slits in the grafts at various expansion ratios (eg, 1.5:1, 2:1). This technique allows expansion of the graft to cover a larger surface area. In addition, the interstices in the graft allow for drainage of fluids under the graft so that the grafts do not lift off their beds. Unfortunately, the meshed patterns of the grafts persist after healing and often lead to suboptimal cosmetic results.

Nonmeshed or sheet grafts are harvested the same way but are not passed through the meshing machine. The use of sheet grafts leads to a better cosmetic result. Because the grafts do not expand, covering major areas with sheet grafts alone is difficult. Nonetheless, sheet grafts should be used whenever possible, especially in highly visible and functional areas, such as the face, neck, hands, and joints. Sheet grafts should be inspected after approximately 48 hours so that any underlying fluid can be aspirated to avoid loss of the graft. Dressings can be left in place for as long as 5 days if desired on meshed grafts, as long as no suspicion of infection is noted.

Follow-up

Avoidance of scarring and contracture is the best treatment.

Scar prevention

For burns that take longer than 3 weeks to heal, or for wounds that have been grafted, hypertrophic scarring can be minimized with the use of compression therapy with custom-made garments that apply 25-30 mm Hg pressure to all wounds. Gel pads can be added underneath or sewn into the garments to apply extra compression. Compression therapy is continued throughout the wound healing process (approximately 12-18 months). Lotion application with massage therapy is used to keep the healed or grafted areas soft and supple. 

Contracture prevention

Contractures refer to hypertrophic scar formation over joints that result in decreased range of motion. Aggressive attention to occupational and physical therapy, with appropriate consultation, is necessary to ensure optimal results. Active and passive range of motion exercises are instituted and splints are worn at night and between exercise periods. Patients with burns are at risk for contractures are followed for years to monitor for the development of these complications.

Psychological sequelae

Burn scarring can lead to significant psychological sequelae and the assistance of a trained psychologist or psychiatrist can be an important addition to the overall care of these patients. 

Patient education

For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal (Heat or Fire) Burns.

Complications

Complications to surgery in patients with burns include bleeding, infection, or graft loss. If infection is suspected, dressings can be changed to include broad spectrum aqueous Sulfamylon solution.

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