Algorithm

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graph TD

classDef start fill:#1b5e20,color:#ffffff,stroke:#66bb6a;
classDef step fill:#0d47a1,color:#ffffff,stroke:#42a5f5;
classDef decision fill:#4a148c,color:#ffffff,stroke:#ab47bc;
classDef alert fill:#b71c1c,color:#ffffff,stroke:#ef5350;

A(<b>Pediatric Burn</b>):::start
B1[<b>Prehospital Care</b><br>Extinguish and wrap]:::step
B2[<b>Primary Survey</b><br>ABCDE assessment]:::step
B3[<b>Special Injuries</b><br>Identify mechanism]:::step

A --> B1
A --> B2
A --> B3

C1[<b>Minor Burns</b><br>Cool water under 10 TBSA]:::step
C2[<b>Major Burns</b><br>No cold water over 15 TBSA]:::alert

B1 --> C1
B1 --> C2

D1[<b>Airway Management</b><br>100 Oxygen and intubate]:::step
D2[<b>Circulation Access</b><br>IV or IO placement]:::step
D3[<b>Calculate Severity</b><br>Lund-Browder TBSA]:::step

B2 --> D1
B2 --> D2
B2 --> D3

E1{<b>Burn Center Required</b>}:::decision

D3 --> E1

F1[<b>Burn Center Transfer</b><br>Critical or large burns]:::alert
F2[<b>Standard Care</b><br>Local wound management]:::step

E1 -->|Yes| F1
E1 -->|No| F2

G1[<b>Resuscitation</b><br>4mL x kg x TBSA volume]:::step
G2[<b>Nutritional Support</b><br>Early enteral feeding]:::step

F1 --> G1
F1 --> G2

H1[<b>Topical Agents</b><br>No systemic antibiotics]:::step
H2[<b>Surgical Care</b><br>Escharotomy or grafting]:::step

F2 --> H1
F1 --> H2

I1[<b>Inhalation Injury</b><br>Hydroxycobalamin for cyanide]:::alert
I2[<b>Electrical Injury</b><br>ECG and forced diuresis]:::alert

B3 --> I1
B3 --> I2

Epidemiology And General Principles

• Unintentional fire-related injuries account for approximately 10% of unintentional injury-related pediatric deaths.
• Children face higher mortality risk compared to adults.
• Scald burns represent leading hospitalization cause in children under 4 years, comprising 65% of admissions.
• Flame burns manifest most frequently in children over 5 years.
• Child abuse contributes to approximately 18% of burn injuries.
• Abuse presents typically as glove or stocking distribution, isolated deep trunk burns, or circular cigarette burns.
• Loss of skin integrity precipitates hypothermia, massive fluid loss, and environmental microbial invasion.

Prehospital And Emergency First Aid

• Wrap victim in blanket immediately at scene.
• Extinguish flames by rolling victim on ground.
• Avoid running with burning clothes.
• Extricate safely to airy environment.
• Prevent continued inhalation of carbon monoxide and cyanide.
• Remove smoldering clothing immediately.
• Remove constricting jewelry to prevent vascular compromise during edema phase.
• Irrigate minor burns under 10% TBSA with cool tap water for 10-20 minutes.
• Cold water application strictly contraindicated for burns exceeding 15% TBSA due to severe hypothermia risk.
• Avoid home remedies including grease, soda, butter, oil, powder, or toothpaste.
• Cover wound strictly with clean dry sheeting or sterile dressing.

Primary Survey And Acute Resuscitation

Airway And Breathing Management

• Administer 100% oxygen immediately for facial burns, singed hair, carbonaceous sputum, or suspected smoke inhalation.
• Assess airway strictly for laryngeal edema, stridor, or retractions.
• Perform early elective intubation for any evidence of significant airway compromise.

Circulation And Hemodynamics

• Obtain intravenous access in non-burned areas preferably.
• Utilize burned areas for vascular access if alternative sites remain unavailable.
• Place intraosseous line if intravenous access fails emergently.
• Replace intraosseous access with central venous line subsequently.

Disability And Exposure Control

• Perform rapid neurological assessment evaluating hypoxia or carbon monoxide poisoning.
• Expose fully to calculate TBSA accurately.
• Assess concurrent injuries thoroughly.
• Cover immediately with warmed blankets preventing hypothermia.
• Maintain cervical spine precautions for explosion, fall, or high-voltage mechanisms.

Assessment Of Burn Severity

Classification Of Burn Depth

• Accurate classification guides treatment and predicts scarring.

Estimation Of Total Body Surface Area

• Rule of nines remains inaccurate for children under 15 years.
• Larger head-to-body mass ratio dictates specialized assessment.
• Variable extremity growth requires age-specific evaluation tools.
• Utilize Lund and Browder chart for accurate pediatric estimation.
• Utilize child's palmar surface including fingers for rapid 1% TBSA estimation.

Indications For Burn Center Admission

• Appropriate triage minimizes pediatric morbidity and mortality.

Fluid Resuscitation And Hemodynamic Monitoring

• Replenish massive fluid losses aggressively.
• Maintain adequate end-organ perfusion.
• Protect ischemic zone without overloading pediatric circulation.
• Initiate rigorous intravenous resuscitation for burns exceeding 10-15% TBSA.
• Institute strict urinary catheterization for continuous output monitoring.

Resuscitation Formulas And Administration

Hemodynamic Adjustment Protocols

• Increase fluid infusion rate by 10% if urine output falls below target.
• Decrease infusion rate by 10% if urine output exceeds target.
• Recognize tachycardia as unreliable resuscitation marker due to profound hypermetabolism.
• Insert central venous lines for reliable volume delivery in burns over 20% TBSA.
• Adjust second 24-hour fluids accounting for insensible losses and wound exudation as capillary leak seals.

Analgesia, Sedation, And Nutrition

Pain And Anxiety Management

• Implement multimodal pain approach addressing wide intensity fluctuations.
• Administer scheduled long-acting opioids for background pain.
• Utilize potent short-acting intravenous opioids for procedural pain.
• Administer midazolam for procedural anxiolysis.
• Schedule gabapentin targeting neuropathic pain.

Metabolic And Nutritional Support

• Anticipate severe hypermetabolic and catabolic state.
• Target massive protein intake reaching 2-4 g/kg/day for survival.
• Initiate enteral feeding via nasogastric or nasojejunal tube on admission day.
• Preserve gastrointestinal mucosal integrity through early enteral feeding.
• Calculate infant caloric requirements: 2100 Cal/m2 plus 1000 Cal/m2 burn surface area.
• Calculate child caloric requirements: 1800 Cal/m2 plus 1300 Cal/m2 burn surface area.

Wound Care And Topical Antimicrobial Therapy

General Wound Management

• Avoid prophylactic systemic antibiotics strictly.
• Systemic antibiotics promote resistant pathogens without preventing sepsis.
• Rely entirely on local topical antimicrobial agents.
• Leave minor burn blisters intact.
• Debride ruptured blisters removing devitalized tissue.

Specific Topical Agents

Surgical Intervention

• Perform prompt decompressive escharotomy for circumferential extremity or truncal burns.
• Prevent compartment syndrome and respiratory restriction aggressively.
• Execute early surgical excision of eschar for deep burns exceeding 10% TBSA.
• Perform autologous skin grafting rapidly to prevent systemic sepsis and optimize functional outcomes.

Management Of Special Burn Injuries

Inhalational Injuries

• Suspect inhalation injury in closed-space fires.
• Identify singed facial hair, carbonaceous sputum, hoarseness, or altered sensorium.
• Confirm carbon monoxide poisoning via elevated carboxyhemoglobin levels.
• Administer 100% oxygen immediately.
• Oxygen dramatically reduces carbon monoxide elimination half-life from 4 hours to 40 minutes.
• Suspect cyanide toxicity with synthetic material combustion.
• Administer intravenous hydroxycobalamin 70 mg/kg addressing cyanide toxicity.
• Hydroxycobalamin binds cyanide forming stable cyanocobalamin for urinary excretion.
• Avoid amyl nitrite and sodium nitrite strictly due to severe methemoglobinemia induction risk.

Electrical Injuries

• Anticipate direct contact or arcing mechanisms.
• Characterized distinctly by specific entry and exit wounds.
• Recognize surface burns severely underestimate deep tissue destruction.
• Disconnect patient immediately from power source utilizing non-conductive materials.
• Initiate continuous cardiac monitoring due to fatal arrhythmia risk.
• Anticipate massive muscle necrosis precipitating myoglobinuria.
• Mitigate acute renal failure risk via aggressive fluid resuscitation and forced alkaline diuresis.
• Monitor closely for deep compartment syndrome.
• Perform urgent fasciotomies and aggressive surgical debridement for necrotic muscle.