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Pediatric Burns
Objectives
Upon completion of this article, the student should be able to achieve the following objectives:
1.
2.
3.
4.
5.

Explain the different layers of the integumentary system and how they are affected by each burn classification.
Describe the different types of burn injuries, including thermal, chemical, and electrical.
Recognize special burn patterns that may be seen in cases of abuse/neglect.
Identify the total body surface area (BSA) of the burn following the Rule of Nines and other methods.
Describe the pre-hospital practices for assessment and treatment of pediatric burns.

Case Study
It is early afternoon on a cold December day. You and your partner are dispatched to a residence in a quiet, upscale
suburban neighborhood. A woman, with limited English language skills, has called 911 to report that a 4-year-old
female has been injured, but your dispatcher cannot provide additional information due to the language barrier. Upon
arriving at the residence, you encounter a frantic and crying middle-aged woman in a housekeepers uniform. The
housekeeper leads you to the kitchen, and you see a child on the floor who is crying and is in obvious distress. There is
a large pot on the floor, which is wet. Through a series of hand gestures, the housekeepers halting English, and your
poor Spanish, you are able determine that the housekeeper had placed a pot of water on the stove to make pasta for
the evening meal. She stepped away from the stove to retrieve a load of laundry but then heard the pot crash to the
floor and the child scream. She returned to the kitchen and saw that the child was drenched with hot water and was
clearly in pain, and she immediately called 911.

Introduction
Before we begin any discussion of burns, it is imperative to understand the anatomy and physiology of the
integumentary system. The integumentary system consists of the skin and its accessory structures, with an underlying
layer of subcutaneous tissue.2 In general, the skin has a total mass of approximately 3 kg, or 16% of total body weight,
and it protects the body from heat, light, and pathogens. It also plays an important role in temperature regulation and
fluid balance.
The skin is a complex organ that consists of two layers: the epidermis (superior layer) and the dermis (middle layer).
These layers are superior to a third layer (inferior) called the subcutaneous tissue (subcutis or hypodermis) layer, which
is not considered a true layer of the skin.3 Histologically, there are distinct differences between the layers, and it is
important to be aware of their composition and functions.

Epidermis
The most superior of the layers of the skin, the epidermis is composed of epithelial tissue, specifically stratified
epithelial tissue, which is devoid of capillaries so it receives little direct blood flow. The epidermis is thickest on the soles
of the feet and the palms of the hands. The cells in this layer are organized into five layers called stratum.4 From
superior to inferior, these layers are as follows:
Stratum corneum This layer contains dead cells, the cytoplasms of which have been replaced by keratin. Keratin is a
protein that makes the epidermis impermeable and resistant to bacteria, viruses, and other pathogens. The cells from
this layer are constantly being shed and replaced with new cells formed in the inferior layers by the process of mitosis. 5
Stratum lucidum This clear layer of cells (three to five cells deep) contains a substance called keratohyalin, which is
formed in the inferior layers.6
Stratum granulosum This layer consists of three to five cellular layers that contain granules of keratohyalin. 7
Stratum spinosum This layer is composed of several distinct sublayers. The cells of this layer are characterized by
short cytoplasmic projections that meet similar projections from adjacent cells. The cells contain significant RNA, which
is associated with protein production for growth and development.8
Stratum basale (germinativum) This layer consists of a single layer of columnar cells with inferior cytoplasmic
projections that serve to anchor the epidermis to the underlying dermis.9 Cellular division occurs in this layer, with the
newer cells rising into the superior layers.
The epidermis also contains cells called melanocytes that produce a pigment called melanin. This pigment contributes to
skin color. Melanin production varies in response to exposure to external factors, such as UV radiation and X-rays.10

Also dispersed throughout the epidermis are phagocytic cells, which engulf foreign material. These cells are called
Langerhans cells and they help initiate the immune response of lymphocytes. 11

Dermis
The dermis is the thickest layer of the skin, ranging from 0.5 mm to 3.0 mm or more in thickness.12 It is composed of
irregular, dense connective tissue divided into two distinct sublayers, the papillary layer superiorly and the reticular
layer inferiorly. The papillary layer has ridges and protrusions that extend into the epidermis, while the reticular layer
contains dense, irregular connective tissue and thick collagen fibers. The majority of the accessory structures of the skin
reside within this layer, including hair follicles, sensory cells (receptors), glands (sebaceous and sudoriferous), muscle
fibers, and blood vessels.13
Hair follicles This structure, composed of epidermal cells that penetrate deep into the dermis, is responsible for the
production of hair. 14 It receives its blood supply directly from the underlying blood vessels that enter the follicle at its
base. The hair root, located at the base of the hair follicle, is the site of mitosis. The cells produce keratin and receive
their pigmentation from melanin. As they die, they become part of the hair shaft that protrudes through the skin. A
small smooth muscle called the arrector pili muscle lies at the base of the hair follicle. This muscle, when stimulated,
contracts and pulls the hair follicle upright, causing goose bumps. The hair on the body has various functions; for
example, it helps the body to stay warm and it keeps foreign objects from entering the eyes.15
Receptors These structures provide four skin senses: thermal, pressure, touch, and pain. These receptors are
composed of nervous tissue and are thus connected to the central nervous system (CNS). For example, the sensory
receptors for pain are free nerve endings, while the receptors for touch and pressure are encapsulated nerve
endings.16
Glands There are several different types of exocrine glands. These glands produce a secretory product that is
transported through ducts to its final location, where it is dispersed throughout the dermis. Glands are composed of
epithelial tissue and produce different substances in response to physiological conditions and external factors. 17
Sudoriferous glands There are two types of sudoriferous (sweat) glands, apocrine sudoriferous glands and eccrine
sudoriferous glands.18
Apocrine sudoriferous glands are concentrated in the axilla and the genital region, and they are stimulated by emotions
and stress. The secretions produced by these glands are inodorous; however, if allowed to accumulate on the skin,
dermal bacteria will metabolize the secretions and produce an odor commonly referred to as body odor.
Eccrine sudoriferous glands are found throughout the body. They are most numerous on the palms of the hands and the
soles of the feet, but they can also be found in great numbers on the forehead and the upper lip. These sweat-producing
glands are extremely important for homeostasis and temperature regulation. These glands increase their production of
sweat in response to external and internal stimuli, and as the sweat evaporates from the skins surface, it takes with it
heat, thus cooling the body.
Sebaceous glands These are holocrine glands, meaning their secretions are produced in the cellular cytoplasm and
are released as a result of cellular destruction. These glands produce a lipid-based secretion and are usually connected
to the hair follicles. Several of these glands will drain into the follicle together, although they can drain directly to the
skins surface.
Sebaceous glands are found throughout the body, with the greatest concentrations found around the nose and mouth,
but they are completely absent from the soles of the feet and the palms of the hands. These glands produce sebum,
which has a mildly antimicrobial effect, and this substance serves as a lubricant and moisturizer.19 If insufficient
quantities of sebum are produced, the skin will dry out and crack. These cracks produce a solution of continuity that will
permit pathogens to enter the subjacent structures, potentially causing infection and illness. If an excessive amount of
sebum is secreted, bacteria may become trapped in the hair follicle, causing a small, localized infection and pustule
commonly called a pimple.20
Ceremonious glands These glands are modified sebaceous glands that produce cerumen, and they are found in the
dermis of the auditory canal. The primary function of cerumen is to moisturize the external surface of the tympanic
membrane, thus keeping it pliable and moving freely. 21 Excessive production of cerumen can become impacted in the
auditory canal, thus decreasing auditory acuity, and it may lead to infections.
Nails These hard plates are formed at the tips of the phalanges. 22 They are composed of hard keratin, a more
persistent form of keratin than is found in the epidermis.23 Their functions are to protect the tips of the fingers and toes
and to assist in picking up small objects. Production occurs in the nail root, the site of mitosis, which is found on the
proximal end of the nail. The nail is superior to the nail bed (living tissue), and growth is constant, although it does slow
with age. 24

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Blood vessels Capillaries can be found throughout the dermis. These originate in larger, deeper blood vessels called
arterioles, which are small arteries that contain smooth muscle tissue in their walls, allowing vasodilation and
vasoconstriction. The best example of this process is blushing, a mechanism of the homeostatic properties of the skin
that is regulated by hypothalamic temperature receptors in the brain.25 The process of arteriolar vasoconstriction can
also occur in response to the fight or flight response; since dermal blood flow is secondary in times of fight or flight,
blood flow is redirected to the vital organs and muscles to prepare the body to stand and fight or run away.
Lymphatic tissues In the form of lymph capillaries, lymphatic tissues are found in varying concentrations throughout
the dermis. These capillaries are continuous with the lymphatic vessels found in the subcutaneous tissue. They function
to absorb excess fluids, large molecules, and other items, passing them onto the lymph nodes and then ultimately to
the cardiovascular system for distribution or excretion. 26
It is important to note that the skin is also an organ of excretion, albeit minimally. Urea, which is a byproduct of protein
metabolism, and sodium chloride are excreted in small quantities through the skin as sweat.27 The skin is also
responsible for the production of vitamin D. This occurs in response to exposure to the ultraviolet light found in sunlight.
In colder climates, due to limited skin exposure to the sun, it is important to enrich certain food items with vitamin D to
help ensure the recommended daily dose of this vitamin is achieved. Vitamin D is vital in the absorption, through the
small intestine, of calcium and phosphorus from our diet. Calcium is important in osteogenesis, or bone formation.28

Subcutaneous Tissue (Subcutis/Hypodermis)

This layer is composed mostly of adipose tissue and loose connective tissue, although in certain areas, such as the
skin of the scrotum, the penis, and the eyelids, adipose tissue is not present. The thickness of the adipose tissue is
dependent on a persons general state of health and dietary intake. The hypodermis also contains some blood vessels
and nerves. In addition, it functions as an insulator, it protects internal organs and structures, and it plays an important
role in skin mobility.29

Burns
Burns cause local and systemic effects ranging from instant cellular death to nonspecific systemic reactions. At the site
of the burn, cells that are not destroyed immediately undergo severe metabolic changes that can eventually leads to
tissue necrosis. 30
Damage to the skin destroys the normal epidermal barrier, allowing microbial invasion and extensive fluid loss. The
damaged tissues can become edematous, causing further intravascular fluid loss. In severe cases, this fluid loss can
lead to hypovolemic shock, which requires rapid fluid replacement therapy to maintain blood pressure.
Heat loss is also seen in patients with larger body surface area (BSA) burns because the thermoregulative properties of
the skin are lost. [31] It is also important to note that burns are often accompanied by significant injury to other body
systems.

Localized Response to Burns

The extent of tissue damage associated with
burns is dependent on the amount of heat
generated by the causative agent, the length of
exposure, and the concentration of the heat.
Thermal burn tissue damage is assessed
according to Jacksons Thermal Wound Theory,
the model of which is shown in Figure 2. This
theory is also known as the bulls eye theory
and is considered the gold standard when
assessing tissue viability secondary to thermal
burn damage.31, 32 The zones are as follows:
Zone of hyperemia This is the outermost
zone of a burn. It is characterized by
increased blood flow in response to the
injury. This increased blood flow improves
the likelihood of recovery of the tissue in
this zone, unless there is a subsequent
infection.34
Zone of stasis This is the middle zone,
where there is markedly decreased blood

Jacksons Burn Model37

flow. The tissue in this zone can be saved,

but blood flow must be restored or
increased for recovery to occur.35
Zone of coagulation This is the innermost
zone, where complete coagulation necrosis
of the tissue occurs, caused by
denaturation. Cellular death is complete.
Depending on the depth of the injury, this
area will most likely be replaced by scar
tissue. 36
The body responds to a burn injury by initiating
the inflammatory response mechanism.
Inflammation is defined as the response of
vascularized living tissue to a local injury.38
Inflammation serves to destroy, dilute, or isolate
the causative agent, as well as initiate a complex
series of events that will help heal and repair
damaged tissue.39 The inflammatory response
can be further classified as acute inflammation
and chronic inflammation.
Acute inflammation is a short-lived event, typically lasting no more than a few days. It is characterized by the
chemotaxis-regulated migration of leukocytes and fluid exudation. Chemotaxis is a response by cells based on the
presence of certain chemicals within their environment. An exudate is a protein-rich fluid that enters the tissues due to
the increased vascular permeability caused by inflammation.40
The intensity and duration of the acute inflammatory response is dependent on the severity of, and the individuals
capacity to respond to, the injury. In patients who are in good general health, the response is considered more efficient
than the response seen in patients in poor health. The inflammatory response may remain localized or it may become
systemic, depending on the same parameters mentioned above. 41
Although the inflammatory response is progressive, it should be noted that numerous stages might co-exist
simultaneously. Clinically, localized changes in inflamed tissue include hyperthermia, erythema, edema, pain, and loss
of function, although this last sign might not be assessed visually.42 Localized hyperthermia and erythema are a result
of the increased blood flow to the area; this carries more warm blood and thus increases the temperature and color.
Edema is the result of the accumulation of fluid and the increase in blood flow to the tissues. This results in an increase
in pressure in the tissue, which, in conjunction with the presence of toxins, cellular enzymes, and acids, stimulates the
nerve endings found in the dermis, causing pain.43
Chronic inflammation s also occurs in burns, and is typically longer in duration, although variable in nature. It is
characterized by the presence of macrophages, lymphocytes, and a proliferation of blood vessels and connective
tissues. 44 Chronic inflammation may appear following acute inflammation due to the continued presence of an antigen
or an injury. It may also be secondary to repeat episodes of acute inflammation of different origins. In this case, there
will be signs of acute inflammation along with signs of healing.45
Chronic inflammation may also arise as an insidious and insipid response that is devoid of the classic signs of
inflammation. This is seen in cases of autoimmune diseases, such as rheumatoid arthritis, and the presence of a chronic
infection, such as tuberculosis.46 Chronic granulomatous inflammation is a type of chronic inflammation seen in such
diseases as leprosy and schistosomiasis.47
Inflammation, however, is also a beneficial process that helps in tissue repair. Specifically, exudates that enter the
tissue carry molecules (e.g., antibodies that block the action of pathogens) and complement proteins that regulate the
inflammatory response. Exudates also have clotting factors that stop bleeding and attract phagocytic cells that help
control the number of pathogens and cellular debris that invade the area. In addition, exudates contain nutrients that
provide the food needed by the cells of the inflamed tissue. 48

Physiological Systemic Responses to Burns

The emergent phase of a burn injury is associated with, depending on the extent of the burn, localized general pain.
Additionally, there is a marked increase in heart rate, increased respiratory rate, and mild to moderate hypotension.
This phase is also associated with varying degrees of anxiety and emotional distress. In addition, there are other
specific systemic responses, such as the following:

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Respiratory system responses Bronchoconstriction is common in burn victims. This is due to the
mediators of inflammation that are released as a result of the injury. In severe burn cases, the victim may
develop respiratory distress syndrome (RDS).49
Cardiovascular system responses Vascular permeability is increased at the burn site. This causes a loss
of intravascular fluid and proteins, which decreases osmotic pressure and leads to the acceleration of fluid
loss. This fluid is shunted into the interstitial compartment and ultimately contributes to systemic
hypotension. This, along with vasoconstriction, results in decreased blood flow to the vital organs.50
Other systemic responses There are other systemic responses to burns. These, however, are not readily
apparent to the pre-hospital rescuer, and they are usually not part of the emergency care protocol, but it
is important to be aware of their existence. The two most important systemic responses are the
immunological response and the metabolic response.
Burn victims often suffer from a decrease in immunological response secondary to burns. This response is a result of
the down regulation, or the decreased response of both cell-mediated and humoral-immunological response
pathways. The cause of this down regulation is not completely understood, but it causes increased susceptibility to
secondary infections and can contribute to the victims death.
The systemic metabolic response is characterized by a threefold increase in the victims metabolism. Quick and
intensive intervention and nutritional support by the attending physician is essential to prevent body catabolism and to
ensure intestinal functioning.51

Causes of Burns
Thermal Burns
Thermal burns are the most common type of burns in the pediatric population. 52 Thermal burns occur when the skin of
the patient is exposed to hot objects, such as metals, boiling liquids, steam, or flames. Thermal burns can be caused by
both dry heat (flames)53 and wet heat (boiling liquids and/or steam). Seventy percent of all burns to children are
caused by wet heat. [54] Common causes of burns include fires, motor vehicle accidents, portable heaters, and
fireworks; however, the most common causes of burns by far are from accidents in the kitchen or elsewhere in the
household.55
In pediatric patients with BSA burns of as little as 10 percent, hypovolemic shock may be present, which results in an
inadequate intravascular volume. The decreased volume decreases ventricular filling in the heart and causes reduced
stroke volume. The body tries to compensate for this by increasing the heart rate to prevent the decrease in cardiac
output. However, this compensatory mechanism will soon fail if the fluid loss is not treated rapidly and aggressively. 56
Clinically, the patient presents with a rapid, weak pulse associated with a decrease in blood pressure. Tachypnea is also
present, but these signs are often not correlated with hypovolemic shock because the pain felt by the patient from the
burn injury can induce similar signs.57, 58 One or two large bore intravenous lines should be placed and fluid
administered according to local protocol.
It is important to note that burns caused by the cold are also classified as thermal burns. These are commonly
associated with prolonged exposure to cold, wet, and windy conditions. 59 It is therefore imperative to monitor children
in colder climates and limit their exposure to these types of conditions. It should also be noted that sunburns, although
technically radiological burns, are treated as thermal burns.

Electrical Burns
In this type of burn, the tissue damage is a result of the heat that is generated by the passing of the electrical current,
with temperatures reaching as high as 5000 F, or 2760 C. 59 The joule effect is the passage of an electrical current
through a solid conductor that results in the conversion of the electrical energy into heat.61 The current passing through
the body can damage internal organs while leaving relatively small entry and exit burns. If exposed to sufficient
voltage, the patient may suffer from cardiac arrhythmias, as well as respiratory issues, including paralysis of the
respiratory muscles.62
Childhood electrical burns are most often caused by exposure to low voltages in the household (120 V to 240 V),
although high-voltage injuries can also be seen, although less often.63 Recent studies have shown that the incidences of
low-voltage burns are decreasing, while the incidence of high-voltage burns has remained constant. Some authors have
inferred that this may be a result of the increase in the use of ground fault circuit interrupters (GFCIs) in modern
homes. 64

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The type of electrical current also plays an important role in determining the extent of injury. Electricity flows in one of
two ways: alternating current (AC) and direct current (DC). Comparing similar voltage of electrical discharges in each
flow type, AC is significantly more dangerous. This is because contact with an alternating current causes sustained
muscular contraction without intervals of relaxation. This causes prolonged exposure time, which allows for greater
amounts of heat to be generated and leads to a greater extent of tissue damage.65
Ohms Law states that V (voltage) = I (current) x R (resistance). Current represents the volume of electrons that flow
across a potential gradient; it is measured in amperes and is a measure of the total energy that flows through a body.
Resistance is an impedance force, as it slows the speed at which electrical energy can pass through the body. The
amount of resistance in the human body varies depending on an individuals hydration status and electrolyte levels.
Tissues with high water content and electrolyte concentrations, such as nervous tissue, cardiovascular structures, blood,
and muscles, have a low resistance, whereas bones and adipose tissue have a high resistance.
In addition to Ohms Law, there is Joules Law, which states the following:
J = I2 R T
J = Heat Production
I = Current
R = Resistance
T = Time
From this formula, one can see that the heat generated by the electrical current will increase if any one of the
contributing factors is increased. Therefore, the greater the current, resistance, or time of exposure, the greater the
potential for injury. This explains the differences seen in low- versus high-voltage burns. In low-voltage burns, the
wounds are small but deep and are often limited to the integumentary system. Although the current passes through the
body in the same way as in low-voltage burns, high-voltage burns (greater than 500 V) can cause extensive tissue
damage and necrosis, affecting underlying muscles and bones, which may result in the loss of an extremity or death.66
The phenomenon known as flash burns occurs when the current passes near, but not through, the patient, such as in
lightning strikes and electrical arches. In this situation, the heat produced by the passing of the current causes thermal
burns to the skin facing the event. If sufficient heat is generated by the event, it may ignite the patients clothing,
resulting in injuries that are more extensive in nature. 67 Burns caused by electricity undergo progressive necrosis that
may exceed the size of the original injury.68

Chemical Burns
Chemical burns are caused by direct contact or exposure to chemicals, such as strong acids and bases. The extent of
the burn injury caused by these chemicals is directly related to their pH level, the length of exposure, the concentration
of the substance, the volume, and the form of the agent. 69 The more extreme pH values (acids 1 to 3 and bases 10 to
14) are associated with increased corrosive properties and thus more damage.
Acids that contact tissue produce coagulation necrosis, in which the affected tissue becomes dry and opaque from the
resulting protein denaturation. Bases produce liquefaction necrosis that causes a softening of the affected tissue. 70
Necrosis is defined as the sum total of changes that occurs after cellular death.71 This tissue necrosis can extend slowly
from the initial site of contact for several hours or days and can be associated with systemic diseases.72 As in all burns,
the long-term effect is scarring, which can be quite significant and associated with strictures. In addition, long-term
psychological effects are
In children, this type of burn is usually associated with exposure to household cleaning products.73 Children are
naturally attracted to scented and brightly colored fluids, which can be found under the kitchen sink in most homes.
These household products are sometimes swallowed and can cause burns of the mouth, the throat, and the
esophagus. 74
In the American Association of Poison Control Centers 2010 report, U.S. poison centers answered more than 3.9 million
calls, including nearly 2.4 million calls concerning human exposures to poisons. In children, about 40 percent of
poisonings involved medications. The other 60 percent of child poisonings involved products such as plants, cleaning
supplies, pesticides, paints, and solvents.
Poisoning is the fourth leading cause of death among children, with peak incidences occurring between the ages of 1 and
3 years old.75 Children younger than 6 years old were involved in the majority of chemical poisoning exposures, and
they comprised 3.2 percent of total fatalities. Of these pediatric fatalities, 81.3 percent were reported as unintentional
and 6.3 percent were coded as resulting from malicious intent.

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Radiation Burns
Radiation burns are caused by the exposure to, or contact with, ionizing radiation, x-rays, and/or excessive sunlight.76
The most common type of radiation burns in children is sunburns caused by prolonged exposure to UV radiation found in
sunlight. Typically, visual assessment reveals erythema in the exposed area, as well as blistering in extreme cases.
Radiation burns have been associated with secondary cases of cancer because it causes damage to cellular DNA. This
may lead to cellular dysplasia/anaplasia.77
Radiation burns can also occur with high-power radio waves, since the body absorbs the energy from radio frequencies
and converts them into heat. According to the U.S. Federal Communications Commission, 50 watts is the maximum
power authorized; radio stations must evaluate emission safety before transmitting radio waves higher than this limit.

Abuse Burns
Non-accidental burns in the pediatric population are, unfortunately, prevalent. It is important for the medical rescuer to
understand this type of burn injury and be able to identify suspected cases. It has been estimated that between 3 and
10 percent of all pediatric burns are the result of abuse. 78 Burn injuries can be seen in victims of physical or sexual
abuse, most frequently in children under the age of 3 years old.79
The first responder should be aware of the characteristics of an abuse burn. These include the outline of a cigarette, a
cigar, lighters, or irons, which are usually seen on the extremities or the hands.80 Burns located in areas not usually
exposed to burn hazards (e.g., genitalia and gluteal regions), the absence of splash burns that are commonly seen in
accidental immersion injury, and circumferential burns should also increase your index of suspicion. Burns may also be
seen around the mouth, such as when such as when hot food has been forced into the childs mouth.81, 82
Often, the history given for the event is inconsistent with the injury encountered. The perpetrator may deny that the
injury is a burn, or may blame the child or the childs sibling for the injury.83 If the childs hand has been immersed in
hot fluid, the natural reaction is to make a fist. This will spare the palmar surface of the hand from injury and that
pattern can be seen upon evaluation.84 If the feet are immersed in hot fluid, the toes tend to curl, and that usually
spares the tissue between the toes and sometimes a portion of the sole.85 In the case of contact burns, a clear outline
or pattern of the object is often seen.86
The patients medical history, scene notes, and EMS medical records may all become evidence in a criminal case.
Therefore, the importance of documentation cannot be overstated.
To help put this topic into perspective, Table 1 below displays the statistics on burns, according to burn admissions to
burn centers between 2001 and 2010:
Table 1. Burn Statistics87
Burn Admissions to Burn Centers: 20012010
Survival
Rate

Gender

Ethnicity

Admission Cause

Place of Occurrence

96.1%

Male (70%)

Caucasian (60%)

Fire/flame (44%)

Home (68%)

Female (30%)

African-American
(19%)

Scald (33%)

Occupational (10%)

Hispanic (15%)

Contact (9%)

Street/highway (7%)

Other (6%)

Electrical (4%)

Other (15%)

Chemical (3%)
Other (7%)

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Physiological Repair Mechanisms

The body attempts to heal from the damage induced by an injury almost immediately after the insult occurs.88
Ultimately, this effort results in the repair or replacing of necrotic or damaged cells with healthy cells. Of the two
processes involved regeneration and replacement in regeneration, the damaged tissue is replaced by cells of the
same type. This will leave little or no visible evidence of the original injury.
The cells of the body can be classified based on their ability to regenerate. Labile cells are those that retain the ability
to proliferate throughout life. Stable cells are those that retain the ability to proliferate, but do not normally do so.
Permanent cells are those that cannot reproduce themselves at all.89 The majority of cells that make up the tissue of
the skin are labile cells. 90 Therefore, depending on the extent of the injury, these cells can regenerate and replace the
damaged or dead cells, leaving few or no residual effects.
In cases where the damage is too extensive and the labile cells are destroyed, the body will utilize the replacement
mechanism. This mechanism replaces the damaged tissues with tough, fibrous connective tissue, leaving a visible
scar.91

Burn Types
Since the extent of damage is a rate-limiting step in the process of repair, it is necessary to understand the different
classifications of burns. In the modern literature, burns are categorized based on the depth of the injury.
Superficial burns These are also called first-degree burns. These affect the epidermal layer only. This type of burn is
commonly seen in cases of overexposure to the sun, such as sunburn. The patient will present with erythema and
blanching of the skin. Blisters are not present.
Partial-thickness superficial burns These are also called second-degree burns. These burns affect the epidermis and
extend into the dermal layer. They usually do not penetrate all the way through the dermal layer, and they can be
difficult to differentiate from superficial burns.
Partial-thickness deep burns These burns are also second-degree burns. However, the penetration from these burns
into the dermal layer is extensive. Erythema and blistering of the skin is common. The skin heals spontaneously,
although scarring and hypopigmentation of the affected area is often seen.
Full-thickness burns These are also called third-degree burns. Here, the injury extends completely through all the
layers of the skin and into the subcutaneous tissue. The skin is stiff and leathery. Scarring is common.
Deep full-thickness burns These are called fourth-degree burns by some. This is a complete penetration of the burn
through the subcutaneous tissue into underlying structures. 92 Brown or black coloration, known as eschar, is seen.
There is little or no pain associated directly with the burn area due to the destruction of nervous tissue. These burns do
not heal spontaneously and they require extensive surgical intervention to repair.

Assessing the Extent of the Burn Injury

It is insufficient to determine the depth of the burn injury only; the extent must also be determined. This can be
accomplished using the following methods:
Wallaces Rule of Nines Chart This is the most commonly used method, although it is not considered accurate
for pediatric burn assessment.93
Lund and Browder Burn Chart This is the most accurate method because it takes into account variations in body
shape with age.94
Palmar Surface Area This method uses the surface area of the patients palm to help determine the area of
burn. It is the least accurate method and is used most commonly in relatively small (<15%) BSA burns or larger
(>85%) BSA burns.95

Rule of Nines96

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Lund Browder Burn Chart97

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Management of Burn Injuries

Burn victims should be approached just as any other victim of a major trauma, and a thorough and complete history
should be taken. This should include a description of the circumstances surrounding the injury and an assessment to
determine the likelihood of associated secondary injuries. Assessment (listed in alphabetical order, not in order of
importance) should include all of the following:98
Airway Airway involvement is common in burn victims. Assess the airway, and if evidence of inhalation injury is
present, intubation is indicated. Intubation may be difficult in patients who have swallowed chemicals. Since there may
be extensive edema associated with burn damage to the respiratory system, first responders may have only one
opportunity to intubate the patient. It is recommended that the most experienced member of the team perform the
intubation.
Analgesia Morphine should be considered. Pediatric dosage is dependent on weight and can be modified as needed
once the pain has been controlled. Full-thickness burns are not associated with pain since the nerves are usually
destroyed. The surrounding areas, however, may have varying degrees of damage, and therefore pain management is
usually indicated. If IV access cannot be obtained, intramuscular (IM) administration is an acceptable alternative.
Breathing Burn victims, regardless of the cause, should receive 100% oxygen. The delivery method is dependent on
the location and extent of the burn injury. A mask is preferred, although a nasal cannula can be used. Breath sounds
should be continually assessed. Any adventitious breath sounds should be treated accordingly.

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Circulation In cases of severe burns, IV access should be initiated with a minimum of two large bore catheters placed
in unburnt areas. If authorized to do so, a central line may be placed. All peripheral pulses should be assessed because
deep full-thickness or full-thickness burns may cause damage to the blood vessels, thus compromising circulation and
leading to further damage of the affected area. Hypovolemia can also cause a weakening of the peripheral pulses.
Cardiac monitoring should be initiated and any findings treated as appropriate. Lead placement is often complicated by
the location of the burn injury, but every effort should be made to ensure cardiac coverage.
Environmental exposure control Hypothermia is common in burn victims. This can further compromise perfusion and
contribute to further tissue damage. Burn victims should be covered to prevent hypothermia. Sterile burn sheets and
disposable space blankets are commonly used.
Fluid management The greatest amount of fluid loss in burn injuries occurs in the first 24 hours. In order to maintain
homeostasis, it is necessary to start fluid replacement for burn victims as soon as possible. The amount of fluid given to
the patient is dependent on the total BSA burned, but the patients response to treatment will help fine tune the fluid
requirements. Ringers lactate and normal saline are common fluids used in the field. The type of fluid given will vary
by protocol; therefore, pre-hospital providers should follow local protocols when initiating fluid management. There are
many formulas used to calculate the appropriate fluid replacement. However, the Parkland Fluid Replacement Formula
below is the most commonly used:
Parkland Fluid Replacement Formula99
Total Fluids/24 hrs. = 4 cc X (Wt. (kg.)) X (% burned surface area)
50% of the fluid is given in the first 8 hours
Remaining 50% is given in the following 16 hours
Additionally, in children, an hourly maintenance fluid dose is given [100]
4 cc/kg for the first 10 kg of weight + 2 cc/kg for the next 10 kg of weight + 1 cc/kg for the remaining kgs
of weight
Ultimately, the final calculation of fluids is usually determined by the receiving hospital staff, but as pre-hospital
personnel, it is your responsibility to calculate and start fluid replacement in the field. Document all intake totals and
provide them to the hospital staff.
Neurological disability assessment The Glasgow Coma Scale should be used to assess responsiveness. Burn victims
may present obtunded or confused as a result of hypoxia, hypovolemia, or the inhalation of noxious fumes.
Stop the burn process Remove the patient from any hazards in the immediate area. Ensure that all non-adhered
clothing, jewelry, and other materials, which can contribute to the continuation of the burn process, are also removed.
Be mindful of potential contamination hazards in the case of chemical burns.101
Wound dressing Cover the wounds with dry sterile gauze. The use of moist gauze on patients with large BSA burns
can further exacerbate hypothermia. Every effort should be made to avoid bursting the blisters present, as this may
contribute to possible infection. 102
According to the American Burn Association, the following are the criteria for referring a patient to a specialized burn
center. Please note that these are general guidelines; they are not designed to replace any previously established
criteria in your area.103
Burn injuries that should be referred to a burn center include the following:
Partial-thickness burns greater than 10% total body surface area
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightning injury
Chemical burns
Inhalation injury
Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery,
or affect mortality
Any patient with burns and concomitant trauma, such as fractures, where the burn injury poses the greatest risk
of morbidity or mortality; in these cases, if the trauma poses the greater immediate risk, the patient may be
initially stabilized in a trauma center before being transferred to a burn unit.
Burned children in hospitals without qualified personnel or equipment specialized for the care of children
Burn injuries in patients who will require special social, emotional, or rehabilitative intervention

Case Resolution
Initial assessment reveals erythema and blisters on the childs face and right arm. The childs clothing is wet, and you
must cut it away to assess her fully. Upon cutting away her clothes, you notice the erythema and blisters extend down

her chest, abdomen, genitalia, and right leg to the knee.

Your partner begins taking vital signs and reports the following: BP 118/78 mm Hg, respirations 32, pulse 120,
temperature 37.5 C, pupils equal and reactive, and weight approximately 20 kilograms. Although in pain, the child is
responsive and follows your commands.
Using your pocket guide, you determine the child has received significant deep partial-thickness burns to 43% of her
body. You cover the burned area with dry sterile gauze and wrap the child in a burn sheet. A large bore IV is started
and, using the Parkland Fluid Replacement Formula, you begin fluid and pain management as indicated by protocol.
Fortunately, there is a pediatric hospital with a burn unit in your area. The patients parents are informed of the childs
status and transport destination, and the patient is transported to the appropriate facility in the company of the
housekeeper at the parents request.
Author Dr. Luis A. Royer, M.D, Copyright CE Solutions. All Rights Reserved.

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[42] Ibid.
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[46] Ibid. (Robbins, 1984)
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[62] Herndon. Op.cit. (herndon, 2002)

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[66] Ibid.
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[70] Ibid.
[71] Robbins, Cotran, and Kumar. Op. cit. (Robbins, 1984)
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[86] Ibid.
[87] American Burn Association National Burn Repository (2011 Report).
[88] Robbins, Cotran, and Kumar. Op. cit. (Robbins, 1984)
[89] Ibid. (Robbins, 1984)
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[91] Robbins, Cotran, and Kumar. Op. cit. (Robbins, 1984)
[92] Singer, Taira, Lee, and Soroff. Op. cit. (Singer AJ, 2009)

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[93] Herndon. Op.cit. (herndon, 2002)

[94] Ibid. (herndon, 2002)
[95] Hettiaratchy. Op. cit. (Hettiaratchy, 2004)
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