16.3 Pediatric Thermal Injuries: Burn Resuscitation, Inhalation Injury & Modified Parkland Formulation
Key Takeaways
Estimate pediatric partial- and full-thickness TBSA with the age-adjusted Lund–Browder chart. Count the foot when calculating a whole lower extremity.
Use the named burn protocol to estimate resuscitation fluid. Account for time since injury and prior fluid, add separate dextrose-containing maintenance when indicated, and titrate to perfusion and urine output.
The Galveston estimate uses both burned area and total body surface area. Its total-area term already includes maintenance.
Give 100% oxygen for suspected carbon monoxide poisoning and check blood co-oximetry. Act early on progressive airway obstruction and consider hydroxocobalamin for suspected life-threatening cyanide poisoning.
Progressive limb ischemia or impaired chest excursion from circumferential deep burns calls for urgent burn-surgical assessment for escharotomy.
Pediatric Burns, Inhalation Injury and Fluid Resuscitation
Quick Answer: Assess airway, breathing and perfusion before calculating burn size. Estimate partial- and full-thickness TBSA with an age-adjusted Lund–Browder chart. Start fluids under the pediatric burn protocol, account for elapsed time and prior fluids, and titrate by perfusion and urine output. Suspected smoke toxicity calls for immediate oxygen, while worsening airway patency, chest restriction or limb ischemia requires urgent specialist intervention.
Initial Care, Depth and Burn Size
Stop the burning process. Remove hot wet clothing and jewelry if they are not adherent. Cool the affected area promptly with cool running water while keeping the rest of the child warm. Do not delay stabilization for cooling or apply ice directly. A pediatric cohort associated 20 minutes of running water within three hours with fewer grafts. After assessment, protect the wound with a clean nonadherent cover, provide analgesia, and reassess depth because it can evolve. Review tetanus protection for a burn with devitalized tissue and give vaccine and/or immune globulin as indicated by the immunization history. Routine systemic antibiotics are not indicated for a clean burn. Treat clinical infection and consult the burn team for dressing and operative decisions. Pediatric cooling study · Pediatric acute burn guideline · CDC tetanus guidance
| Depth | Typical appearance and sensation | Count in TBSA? |
|---|---|---|
| Superficial | Dry, red and blanching. May hurt, with no blisters. | No |
| Superficial partial-thickness | Moist, red, blistered, briskly blanching and very painful. | Yes |
| Deep partial-thickness | Drier and paler, with diminished blanching or sensation. | Yes |
| Full-thickness | Dry, leathery or variably colored, with absent pinprick sensation in the deepest area. Surrounding areas can still be painful. | Yes |
Use the Lund–Browder chart for pediatric fluid and referral decisions. The head accounts for a larger share in infants and the legs account for a larger share as children grow. The chart shows the full head separately from the neck, and a whole lower extremity includes the thigh, lower leg and foot. In the Joint Trauma System (JTS) chart, both entire lower extremities account for 28% in the birth-to-one-year row (2 × [5.5 + 5 + 3.5]) 34% in the 5–9-year row (2 × [8 + 5.5 + 3.5]) and 38% in the 15-year row (2 × [9 + 6.5 + 3.5]). For small scattered burns, the child's palmar surface including fingers approximates 1%. Document which surfaces are burned and exclude simple superficial erythema. JTS burn guide, appendix C · ABA depth and referral guidance
Estimate Fluid, Then Titrate
For substantial pediatric burns, start calculated resuscitation and contact the burn team early. Thresholds and initial rates vary by protocol. The U.S. JTS pediatric guidance usually uses calculated fluid above 10% TBSA and starts with 3 mL × kg × percent TBSA of isotonic resuscitation fluid in the first 24 hours. It assigns half to the first eight hours after injury and uses a separate D5LR maintenance rate for children under 13. The traditional Parkland factor is 4 mL/kg per percentage point, so state the chosen factor in a calculation. For a young child who needs IV maintenance, estimate it separately when the selected formula excludes it. The hourly 4-2-1 estimate uses 4 mL/kg for the first 10 kg, 2 for the next 10, and 1 above 20. Check glucose and electrolytes and individualize the fluid composition and rate. JTS pediatric protocol · Vanderbilt pediatric burn protocol
Worked estimate. A 15-kg child with 30% TBSA burned has a 24-hour burn-volume estimate of 3 × 15 × 30 = 1,350 mL. The first eight-hour allocation is 675 mL. At two hours after injury, suppose 75 mL of LR has already counted toward that allocation. An estimated 600 mL remains over six hours, or 100 mL/hour. If the protocol calls for separate D5LR maintenance, its starting estimate is (10 × 4) + (5 × 2) = 50 mL/hour. This arithmetic provides a starting plan. Review previous fluids and the child's response with the burn team before escalating the rate to meet a calculated allocation.
Some services use an area-based Galveston estimate. Its 24-hour calculation includes 5,000 mL per square meter burned plus 2,000 mL per square meter of total body surface area. For total BSA 0.70 m² and 30% burned, the terms are 5,000 × 0.21 = 1,050 mL and 2,000 × 0.70 = 1,400 mL, yielding 2,450 mL. The second term already represents maintenance. Confirm fluid composition and timing with the treating service. Carvajal pediatric approach · JSBI guideline on pediatric starting rates
Reassess hourly early in major burns. JTS uses a pediatric urine-output goal of 0.5–1 mL/kg/hour, with perfusion, mental status, blood pressure and labs also informing titration. Other pediatric protocols use targets such as 1 mL/kg/hour. For oliguria, check catheter patency, perfusion and renal function and consider compartment physiology when fluid requirements rise. An enlarging tense abdomen, worsening ventilation or oliguria despite resuscitation warrants assessment for intra-abdominal hypertension using the pediatric technique where indicated. Electrical injury with pigmenturia requires burn-team guidance, cardiac and electrolyte assessment and individualized fluid and urine-output goals. JTS burn guide · Pediatric WSACS consensus
Airway and Smoke Toxicity
Enclosed-space exposure, facial burns, hoarseness, soot or carbonaceous sputum increase concern for inhalation injury. Assess for progressive voice change, stridor, increased work of breathing and visible airway swelling. Provide oxygen, call an experienced airway team early and secure the airway before worsening obstruction when compromise is present or developing. Isolated singed hairs or a reassuring initial saturation cannot determine the need for intubation. Also evaluate lower-airway injury and associated trauma. Pediatric burn airway guideline
- Carbon monoxide: A conventional two-wavelength pulse oximeter cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. Give 100% oxygen immediately for suspected poisoning. Obtain venous or arterial blood co-oximetry without delaying treatment. Levels fall after removal from exposure or oxygen treatment and correlate poorly with clinical severity. Oxygen speeds clearance. Use serial clinical and neurologic assessment and seek hyperbaric input for significant poisoning, such as levels in the 25%–30% range or above, cardiac involvement, severe acidosis, unconsciousness or neurologic impairment. Pregnancy warrants early specialist consultation even at lower levels. CDC CO guidance
- Cyanide: Suspect life-threatening toxicity after an enclosed fire with collapse, altered consciousness or otherwise unexplained severe lactic acidosis. The U.S. Cyanokit label identifies lactate at least 10 mmol/L as a clue in smoke inhalation. Treat strong clinical suspicion without waiting for a cyanide result. AHA recommends hydroxocobalamin for life-threatening pediatric cyanide poisoning, mainly extrapolating from adult evidence. A pediatric starting regimen used in toxicology protocols is 70 mg/kg IV, max 5 g, over 15 minutes. The U.S. label cites 70 mg/kg from non-U.S. use and states pediatric safety and effectiveness have not been established. Notify the lab and dialysis team about assay and blood-leak detector interference. Red urine and skin discoloration are expected, and renal injury and hypertension are possible. AHA 2025 cyanide guidance · U.S. Cyanokit label · Pediatric toxicology dosing
Circumferential Burns and Referral
Reassess distal temperature, capillary refill, sensation and Doppler signals when a deep circumferential limb burn swells. Remove constricting dressings or jewelry. Worsening perfusion needs immediate burn-surgical assessment for escharotomy. For chest burns, check tube position, patency, circuit and other reversible causes of poor ventilation. Restriction of chest excursion from a rigid eschar can require chest escharotomy. Assess the pattern and progression rather than waiting for a single pressure cutoff. Escharotomy releases the constricting skin. Persisting deep compartment syndrome after release may need fasciotomy. Escharotomy practice guideline · JTS burn guide
The American Burn Association recommends immediate consultation with consideration for transfer for full-thickness burns, partial-thickness burns of at least 10% TBSA, deep burns involving critical sites such as face, hands, feet, genitalia, perineum or joints, and suspected inhalation injury. Pain, concomitant trauma, dressing needs, caregiver capacity and suspected abuse also affect disposition. Even smaller pediatric burns may benefit from burn-center input and planned reassessment. ABA referral guidance
A 15-kg 3-year-old arrives two hours after a scald. The Lund–Browder assessment finds 30% partial-thickness TBSA. The burn team uses the JTS pediatric starting formula of 3 mL × kg × %TBSA, allocates half over the first eight hours from injury and counts 75 mL of prearrival LR toward that allocation. The team plans separate D5LR maintenance using 4-2-1. What are the 24-hour burn estimate and the calculated starting rates for the six hours remaining?
1,800 mL of burn fluid over 24 hours, with 137.5 mL/hour for the remaining six hours and 50 mL/hour of maintenance.
1,350 mL of burn fluid over 24 hours, with 112.5 mL/hour for the remaining six hours and 50 mL/hour of maintenance.
1,350 mL of burn fluid over 24 hours, with 100 mL/hour for the remaining six hours and 50 mL/hour of maintenance.
1,350 mL of burn fluid over 24 hours, with 75 mL/hour for the remaining six hours and 50 mL/hour of maintenance.
A 12-year-old is rescued from an enclosed house fire. Hoarseness progresses to stridor and retractions. SpO2 is 99% on room air and blood co-oximetry shows carboxyhemoglobin of 28%. Which action best addresses the immediate threats?
Observe on room air and repeat pulse oximetry to document carbon monoxide clearance.
Use low-flow oxygen and defer airway preparation until the saturation falls.
Transfer directly for hyperbaric treatment before stabilizing the airway.
Give 100% oxygen immediately and have an experienced airway team secure the airway. Seek hyperbaric input after initial stabilization.
An intubated 8-year-old has circumferential deep burns of the right arm and chest. The right hand is cold and cyanotic, and the radial Doppler signal disappears despite removing constricting dressings. On pressure-controlled ventilation, tidal volume falls at the same inspiratory pressure, chest excursion is markedly restricted and PaCO2 rises. The tube and circuit are patent and tension pneumothorax has been excluded. What is the most appropriate urgent intervention?
Arrange urgent burn-surgical escharotomy of the chest and right arm to release the external restriction.
Increase ventilator pressure and observe the limb until the next scheduled neurovascular check.
Proceed directly to limb fasciotomy as the first release and defer treatment of the chest restriction.
Defer release until both limb compartment pressure and peak inspiratory pressure exceed fixed thresholds.
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