Burns

Description 

General and supportive measures

Medicine treatment 

Referral 

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ICD-10 code: T30.0

DESCRIPTION

Burns lead to skin and soft tissue injury and may be caused by:

• heat, e.g. open flame, hot liquids, hot steam;
• chemical compounds;
• physical agents, e.g. electrical/lightning;
• radiation.

GENERAL AND SUPPORTIVE MEASURES

Emergency treatment

• Remove smouldering or hot clothing.
• Remove constrictive clothing/rings.
• To limit the extent of the burn, soak the affected area generously in cold water for not more than 20 minutes.
• In all burns > 10% or where carbon monoxide poisoning is possible (enclosed fire, decreased level of consciousness, disorientation) administer high flow oxygen (15 L/minute).
• Examine carefully to determine the extent and depth of the burn wounds.
• Respiratory obstruction due to thermal injury or soot inhalation, production of black coloured sputum, shortness of breath, hoarse voice and stridor are serious signals and may rapidly proceed to respiratory compromise. Consider early endotracheal airway placement.

Further assessment and care

The extent and depth may vary from superficial (epidermis) to full-thickness burns of the skin and underlying tissues. 
Since burns are usually sterile, empiric antibiotics are not initially indicated.

Assessment:

Depth of burn wound	Surface/Colour	Pain sensation/Healing
Superficial or epidermal	Dry, minor blisters, erythema	- Painful - Heals within 7 days
Superficial partial thickness or superficial dermal	Blisters, moist	- Painful - Heals within 10-14 days
Deep partial thickness or deep dermal	Moist white or yellow slough, red mottled	- Less painful - Heals within a month or more - Generally needs surgical debridement and skin graft
Full thickness (complete loss of dermis)	Dry, charred whitish, brown or black	- Painless, firm to touch - Healing by contraction of the margins (generally needs surgical debridement and skin graft)

Burns are classified as minor or major burns.

Major burns:

• Partial thickness burns of > 10% body surface area.
• Full thickness burn of > 3% body surface area.
• Any burn involving the head and face, hands, feet and perineum.
• Inhalation injuries.
• Circumferential burns.
• Electrical burn injuries.
• Burns in neonates.
• Burns in patients with serious pre-existing or concomitant injuries.

Minor burns:

• Partial thickness burns of < 10% body surface area in a child > 1 year of age.
  Estimation of total body surface area (TBSA) involved in burn injury:
  
  

Click on the image to enlarge

The figure above is used to calculate body surface area %, and indicates percentages for the whole leg/arm/head (and neck in adults) not the front or back.

• In children, the palm of the hand is 1%.
• The following adjustments are made in children up to the age of 8 years old after which adult percentages are used for the head, neck and each lower limb.
• Less than 1 year:
  • Head and neck are 18% of TBSA.
  • Each leg is 14% of TBSA.
• After 1 year:
  For each year of life:
  • Head and neck decrease by 1% of TBSA until 9% (adult value).
  • Leg gains 1/2% of TBSA until 18% (adult value).

Age (Years)	Head + neck Front + back	Torso Front	Torso Back	Lower limb Front + back	Upper limb Front + back
< 1 year	18%	18%	18%	14%	9%
1 to < 2 years	17%	18%	18%	14.5%	9%
2 to < 3 years	16%	18%	18%	15%	9%
3 to < 4 years	15%	18%	18%	15.5%	9%
4 to < 5 years	14%	18%	18%	16%	9%
5 to < 6 years	13%	18%	18%	16.5%	9%
6 to < 7 years	12%	18%	18%	17%	9%
7 to < 8 years	11%	18%	18%	17.5%	9%
8 to < 9 years	10%	18%	18%	18%	9%
≥ 9 years (plus 1% perineum)	9%	18%	18%	18%	9%

Care
Inhalation injury

In addition to other treatment, the degree of inhalation injury may warrant:

• monitoring of blood gases,
• warm humidified oxygen and/or intubation,
• positive pressure ventilation.

Ensure adequate airway in the presence of inhalational burns.
Children with burns may present with delayed onset of airway obstruction. Consider early intubation.

Suspect carbon monoxide poisoning in all fire victims.

• Obtain carboxyhaemoglobin level.
• Treat by administering 100% oxygen (15 L/min by facemask with reservoir bag).

Prevent heat loss

Nurse all major burns in a warm room (26°C).

Nasogastric drainage

Use a nasogastric tube on free drainage in all burns > 10% (especially during transfer). Within the 1st 24 hours, commence nasogastric feeds in children with > 15% TBSA where ileus is not suspected.

Nutritional support

Consult a dietician as children with burns require a higher than usual intake of nutrients (due to a hypermetabolic state). Start enteral feeds within 6 hours in all children unless there are contraindications.

Estimate daily energy and protein needs using the formulae:

Energy (kJ):	250 kJ/kg mass body + (150 kJ X % burned TBSA)
Protein (g):	3 g/kg body mass + (1 g x % burned TBSA)
Maximum % burn area used for calculation should not exceed 50%

Give iron and vitamins routinely until burn wounds are healed and/or skin grafting has successfully been completed.

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Note: Do not supplement iron during sepsis or infection.

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In addition, provide:

• psychological support,
• physiotherapy,
• occupational therapy,
• waterbeds and cradles.
• distraction therapy: music, video games, etc. for dressing changes.

MEDICINE TREATMENT

Fluid replacement

Burns < 10% of total body surface area:

• Oral fluids.

Burns > 10% of total body surface area:

• IV fluid for resuscitation.

If in shock first treat shock. See: Shock.

As in all fluid administration in sick children, volumes are estimates and response must be constantly re-evaluated and rates adjusted appropriately.

Calculation Of Initial Fluid Replacement (after Shock Has Been Treated)

First 24 hours:
Replacement fluids for burns

• Sodium chloride 0.9%, IV OR Modified Ringers lactate.
  • Calculate total fluid requirement in 24 hours:

[Total % burn ____ x weight (kg) ____x 4 mL] as sodium chloride 0.9%. 

Give half of this volume in the 1st 8 hours from the time of the burn.
Administer remaining fluid volume in next 16 hours.

LoEI¹

Note: If urine output not adequate (adequate urine output = 1–2 mL/kg/hour), increase fluids for the next hour by 50% (continue at higher rate until urine output is adequate then resume normal calculated rate).

PLUS 

Maintenance fluids in children

 In children, give oral or intravenous maintenance fluid in addition to the above calculated volume.

Child maintenance fluid requirement volumes
≤ 1 year	120 mL/kg/24 hours
All children > 1 year – the sum of the following:
- For each kg of body weight up to 10 kg	100 mL/kg/24 hours
- For each additional kg of body weight more than 10 kg	50 mL/kg/24 hours
- For each additional kg of body weight more than 20 kg	20 mL/kg/24 hours

 

Example: 24 kg child with 10% burns
1st 24 hours:
Replacement for expected losses: 4 mL/kg x 24 kg x 10%	= 960 mL
Maintenance: First 10 kg = 10 kg x 100 mL/kg/24 hours Second 10 kg = 10 kg x 50 mL/kg/24 hours Remaining 4 kg = 4 kg x 20 mL/kg/24 hours Total maintenance:	= 1000 mL + =500 mL + = 80 mL = 1580 mL
Thus
1st 8 hours: = ½ resuscitation fluids + ⅓ maintenance fluids	480 mL sodium chloride 0.9% + 527 mL sodium chloride 0.9%/dextrose 5%
Next 16 hours: = ½ resuscitation fluids + ⅔ maintenance fluids	480 mL sodium chloride 0.9% + 1053 mL sodium chloride 0.9%/dextrose 5%

The above are guidelines. Regular review is needed to maintain urine output 1– 2 mL/kg/hour.

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Avoid circumferential taping when securing infusion lines as oedema under the eschar may decrease the venous return.

If urine output > 1–2 mL/kg/hour or base excess (BE) better than minus 4, stop resuscitation fluids. Too much fluid is almost as harmful as too little fluid.

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Second 24 hours:
If urine output is adequate, continue resuscitation:

• Sodium chloride 0.9%, IV, 1.5 mL/kg/% burn/ 24 hours.

PLUS

Maintenance:

• Sodium chloride 0.9%/dextrose 5% (dextrose saline), as per maintenance requirement above.

Part of this volume may be replaced by enteral feeds.

Thereafter, progressively decrease IV fluids and increase enteral fluids according to response over time. Aim for full enteral feeds as soon as possible.

Anaemia
If haemoglobin < 7 g/dL:

• Packed red cells, 10 mL/kg over 3 hours.

Hypoalbuminaemia
If indicated by symptomatic hypoalbuminaemia:

• Albumin 20%, IV, 2 g/kg/day. (20 g = 100 mL).

For pain

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Pain associated with burn injury is often severe and requires active and continuous management. Procedural pain management measures need to be taken during dressing changes.

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See: Management of pain.

For pruritus
Antihistamines

• Chlorphenamine, oral, 0.1 mg/kg/dose as a single dose at night.
  • Maximum: 4 mg.

For children 2 years and older, second-generation antihistamines can be considered:

• Cetirizine, oral, as a single dose.
  • Children 2–6 years: 5 mg.
  • Children 6–12 years: 10 mg.

Topical

• Aqueous cream.

If not controlled:

• Ondansetron, oral, 0.1–0.2 mg/kg 12 hourly.

If oral route cannot be used:

• Ondansetron, IV, 0.1 mg/kg immediately.
  • Maximum: 4 mg/day.

Refractory pruritus: Refer for consideration of gabapentinoids.

Change of dressing

Provide analgesic cover at each dressing change (See Pain Control). In major burns, change dressings under procedural sedation or general anaesthesia.

Gastric erosions

Preventative medication treatment is not given. Effective early resuscitation and early feeding decrease the incidence of gastric erosion.

If gastric erosion is suspected due to haematemesis or brownish gastric aspirates.

Proton pump inhibitor, e.g.

• Omeprazole, oral, 0.4–0.8 mg/kg/dose 12 hourly. Specialist initiated.
  • Maximum dose: 20–40 mg/dose.
  • If 1 month–2 years: 2.5 mg 12 hourly.
  • If > 2–6 years: 5 mg 12 hourly.
  • If > 7–12 years: 10 mg 12 hourly.

If unable to take orally:

• Proton pump inhibitor, e.g.
  • Pantoprazole, IV, 0.5 mg/kg/dose 12 hourly.

OR

• Ranitidine, IV, 1 mg/kg 6 hourly. (Click here for circular 2024/01/25/EDP/01 on the therapeutic alternative for Ranitidine 25mg/ml injection; 1 injection)

Local treatment of burns
Gently clean the wounds with running water, utilising appropriate pain and sedation, see Management of pain. Remove loose skin and debride dead tissue and dress with topical antiseptic cream and non-adherent dressing. Thereafter, daily rinse with running water and dress with topical antiseptic cream and non-adherent dressing.

In < 20% body surface area burns:

• Povidone-iodine 0.5% with occlusive dressings.

In > 20% body surface area burns:

• Silver-sulphadiazine 1%, on non-adhesive dressings.
  • Cover with paraffin gauze and crepe bandages.
  • Change dressings daily.

Excise and graft all full thickness or deep dermal burns as soon as the patient is stable.

Consider skin grafting in wounds not healed in three weeks.

Antibiotics
Consider if signs of infection are present as these may be subtle:

• pyrexia/hypothermia,
• shock (compensated or not compensated),
• rising pulse or respiratory rate,
• petechiae,
• leucocytosis/thrombocytopenia,
• looks ill/toxic/altered level of consciousness,
• local inflammatory changes,
• vomiting.

The choice of antibiotics is based on the culture and sensitivity results of wound, urine and blood cultures once available.
Positive wound cultures alone do not indicate systemic infections requiring antibiotic treatment.

• Start empiric antibiotics early.
• Aim to get source control: all pus should be drained; all necrotic tissue should be removed/debrided.

Before initiating antibiotic therapy, take blood and urine specimens, if appropriate, for culture and sensitivity testing.

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Consider whether community or hospital acquired and treat based on anticipated susceptibility. Ensure immediate administration.

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Reconsider antibiotic and/or antifungal therapy when culture and sensitivity results become available.

Tetanus prevention

Patients with no previous immunisation in the last 5 years:

• Tetanus toxoid, IM, 0.5 mL.
  • Complete course in previously unvaccinated patients.

Where deep necrotic lesions are part of the burn and if the immunisation status is not known:

• Tetanus immunoglobulin, IM, 500 IU.

Prior to transport/referral

• Commence resuscitative measures, if necessary.
• Administer 100% humidified oxygen by facemask for inhalation injuries, if necessary
• Cover wounds with clean dressings after hot or smouldering clothing have been removed.

REFERRAL

• Major burn injuries.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition, Updated according to Erratum 2025/02/EDP/01

Chapter 1: Emergencies and Trauma, 1.1 Paediatric Emergencies,  1.2.1  Burns