14.1 Burns & Thermal Injury
Key Takeaways
- Pediatric burn depth and total body surface area (TBSA) drive fluid resuscitation, airway decisions, and transfer thresholds — use age-adjusted estimates, not adult Rule of Nines alone.
- Airway edema from facial, neck, or inhalational injury can progress rapidly in infants and children; early definitive airway is preferred over watching progressive stridor.
- Parkland-style resuscitation is calculated from time of injury using crystalloid (typically lactated Ringer's), with pediatric urine output goals often 1–2 mL/kg/hour rather than adult fixed volumes.
- Infection risk rises after the first 24–48 hours; strict asepsis, early wound care, nutrition, and tetanus status are core ICU nursing priorities.
- Hypothermia, hypoglycemia, and pain/anxiety amplify shock physiology in burned children — warm the environment, monitor glucose, and titrate analgesia with airway vigilance.
Why Pediatric Burns Differ from Adult Burns
Burned children are not small adults. Higher body-surface-area-to-mass ratio, thinner dermis, immature thermoregulation, and limited glycogen stores mean deeper injury for a given exposure, faster heat loss, and earlier hypoglycemia. A scald that looks limited on the trunk of a toddler can still produce significant plasma loss, capillary leak, and airway compromise when the face or neck is involved. On the CCRN Pediatric exam, stems often pair a modest-looking TBSA with progressive stridor or oliguria — the correct priority is always the earliest life threat.
Thermal injury includes flame, scald, contact, electrical, and chemical burns. In pediatrics, scalds from hot liquids are the most common mechanism in toddlers; flame and house-fire inhalation injuries dominate among older children and adolescents. Non-accidental trauma must remain on the differential when injury pattern, history, and developmental stage do not align (for example, sharply demarcated immersion burns or delayed presentation).
Assessing Depth and Extent
Depth classification
Depth guides healing potential and surgical need:
| Depth | Appearance | Sensation | Healing / management implications |
|---|---|---|---|
| Superficial (1st degree) | Erythema, dry, no blisters | Painful | Heals without scarring; supportive care |
| Partial-thickness superficial | Moist, pink, blisters | Very painful | Usually heals with wound care if protected |
| Partial-thickness deep | Mottled, less moist, pale | Decreased sensation | Often needs excision/graft consideration |
| Full-thickness (3rd degree) | Dry, leathery, white/brown/charred | Insensate | Requires excision and grafting |
Mixed-depth injury is common. Reassess over 24–72 hours because early appearance can underestimate deep dermal involvement.
TBSA estimation in children
Adult Rule of Nines overestimates head and underestimates legs in infants. Use Lund-Browder charts or pediatric-adjusted percentages. The child's palm including fingers ≈ 1% TBSA is a useful bedside check for scattered burns. Do not count superficial (first-degree) erythema in resuscitation TBSA calculations — include partial- and full-thickness injury only.
Typical transfer or burn-center criteria include partial/full-thickness burns involving a substantial TBSA (thresholds vary by guideline and age), burns of face, hands, feet, genitalia, perineum, or major joints, circumferential extremity or chest burns, inhalation injury, electrical/chemical burns, and concomitant major trauma or comorbidity. Know your region's referral thresholds, but exam logic favors early specialty consultation when airway, circumference, or large TBSA is present.
Airway Edema and Inhalation Injury
Facial burns, singed nasal hairs, carbonaceous sputum, voice change, stridor, and closed-space fire exposure signal inhalation injury. Pediatric airways are smaller; a few millimeters of edema can critically narrow the glottis. Progressive hoarseness and biphasic stridor are late warnings. Prefer early elective intubation with an appropriately sized tube over repeated nebulizers while edema worsens. Avoid cutting the tube too short; leave margin for facial swelling and secure carefully without circumferential tape that constricts venous return.
Circumferential chest burns restrict ventilation. Rising peak pressures, declining tidal volumes, and hypercarbia may indicate need for escharotomy to restore chest wall compliance. Extremity circumferential full-thickness burns threaten distal perfusion — monitor pulses, capillary refill, Doppler signals, and compartment signs; escalate promptly.
Carbon monoxide (CO) exposure accompanies many house fires. Suspect CO when neurologic depression is out of proportion to visible injury. High-flow oxygen is first-line; carboxyhemoglobin levels guide severity. Cyanide co-toxicity is possible in smoke inhalation with profound lactic acidosis — follow institutional toxicology/burn protocols.
Fluid Considerations After Burn Shock
Capillary leak peaks in the first 8–24 hours. Fluid resuscitation formulas (classically Parkland: 4 mL × kg × %TBSA of crystalloid over 24 hours from time of injury, with half in the first 8 hours) are starting points, not rigid scripts. Pediatric practice often emphasizes lactated Ringer's, weight-based rates, and titration to end-organ perfusion — especially urine output. Many pediatric burn protocols target roughly 1–2 mL/kg/hour of urine in younger children (exact targets vary by center and age; some use lower goals in adolescents approximating adult ranges). Over-resuscitation causes edema, abdominal hypertension, and worsened airway swelling; under-resuscitation worsens acute kidney injury and shock.
Remember maintenance fluids may still be required in small children in addition to burn replacement — follow unit protocol so you do not double-count or omit glucose-containing maintenance. Monitor electrolytes (especially sodium and potassium), hematocrit trends, lactate, and mental status. Insert a urinary catheter for accurate hourly output in significant TBSA burns. Warm all fluids and the environment; hypothermia worsens coagulopathy and oxygen demand.
Electrical burns may look small at entry/exit yet hide deep muscle injury, rhabdomyolysis, and arrhythmias — continuous cardiac monitoring and myoglobin/creatinine kinase surveillance matter more than the skin wound size.
Infection, Wound Care, and Supportive ICU Nursing
Early burn surfaces are relatively sterile; bacterial colonization and invasive infection rise after the first day or two. Hand hygiene, aseptic dressing technique, topical antimicrobial regimens per burn-team orders, and early recognition of fever, leukocytosis, wound discoloration, or septic shock are core nursing roles. Tetanus immunization status must be addressed. Nutrition — preferably early enteral feeding — supports healing and immune function; burned children have markedly elevated metabolic demand.
Pain and procedural anxiety are clinical priorities, not afterthoughts. Titrate opioids and adjuncts carefully while protecting the airway. Itching, sleep disruption, and parental distress affect cooperation with dressing changes. Position to minimize edema (elevate burned extremities when perfusion allows), prevent contracture with range-of-motion as ordered, and watch for compartment syndrome after fluids.
Psychosocial care includes honest updates, involvement of child life when available, and screening for non-accidental injury with mandated reporting pathways. The exam rewards the nurse who pairs physiologic vigilance with family-centered communication without delaying airway or fluid interventions.
A 3-year-old is admitted 2 hours after a kitchen scald involving the face, anterior neck, and upper chest. The child is restless with progressive hoarseness and soft inspiratory stridor. Which action is the priority?
Using a Parkland-style estimate, a 20 kg child with 25% TBSA partial- and full-thickness burns needs crystalloid resuscitation from the time of injury. Which nursing statement best reflects correct application?
On hospital day 2 after a 30% TBSA flame burn, a school-age child develops high fever, wound discoloration, and rising lactate. Which nursing focus best matches this timeline?