{
 "topic": "Thermal Burns",
 "slug": "thermal-burns",
 "category_id": 15611,
 "summary": "Burn depth classification, the Parkland fluid resuscitation formula, burn center referral criteria, and how immersion-burn physics helps distinguish accidental from inflicted injury.",
 "written_by": "claude-sonnet",
 "references": [
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    692,
    693,
    696
   ]
  },
  {
   "title": "Caring for the Hospitalized Child",
   "author": "Section on Hospital Medicine, American Academy of Pediatrics;Jeffrey C. Gershel;Daniel A. Rauch;",
   "pages": [
    857
   ]
  },
  {
   "title": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga)",
   "author": "CamScanner",
   "pages": [
    712
   ]
  },
  {
   "title": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online",
   "author": null,
   "pages": [
    217
   ]
  },
  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
  {
   "title": "Pediatric ICD-10-CM 2023",
   "author": "American Academy of Pediatrics Committee on Coding and Nomenclature;",
   "pages": [
    417
   ]
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    8726
   ]
  },
  {
   "title": "Pediatric emergency medicine (Sean M. Fox, Dale P. Woolridge (editors))",
   "author": null,
   "pages": [
    212
   ]
  }
 ],
 "short": [
  {
   "title": "In short",
   "content": "- Burns are classified by depth: first-degree (superficial, epidermis only \u2014 erythematous, painful, dry, heals within 2 weeks, no scarring); second-degree/partial-thickness (superficial: pink, moist, painful, heals <3 weeks; deep: paler, drier, less painful from nerve destruction, often speckled from thrombosed vessels, heals >3 weeks with scarring, may need grafting); third-degree/full-thickness (destroyed dermis, insensate, yellowish/depressed appearance).\n- Mechanisms: scalds (hot liquid/steam), contact (hot objects), flame, chemical (strong acid/alkali), and electrical.\n- Water-temperature/time-to-full-thickness-burn relationship: 120\u00b0F takes about 10 minutes, 130\u00b0F about 30 seconds, 140\u00b0F about 5 seconds, 150\u00b0F about 2 seconds, 158\u00b0F about 1 second \u2014 a normal child's withdrawal reflex from water above 120\u00b0F should leave only superficial fingertip/toe burns, so a full-thickness immersion burn is rarely accidental.\n- Fluid resuscitation for significant burns uses the Parkland formula: IV fluid (mL) = weight (kg) \u00d7 %TBSA burned \u00d7 4; give half in the first 8 hours and the remaining half over the next 16 hours, in addition to maintenance fluids.\n- Burn center referral criteria: partial-thickness burns >10% TBSA, full-thickness burns >5% TBSA, any third-degree burn, electrical burns (high-tension wires or lightning), chemical burns, inhalation injury regardless of TBSA, burns of the face/hands/feet/perineum/genitals/major joints, inadequate home/social environment, suspected abuse or neglect, preexisting conditions complicating recovery, and associated injuries (e.g., fractures).\n- Prevention measures shown to help: flame-retardant clothing, smoke detectors, setting water heater thermostats to 48.9\u00b0C (120\u00b0F), and prohibiting cigarette smoking around children.\n- With dedicated burn-center care, survival of at least 80% is achievable even with burns covering 90% of total body surface area (TBSA) in children and young adults; death is more likely when irreversible anoxic brain injury occurred at the time of the burn.\n- Assess for inhalation injury with any thermal burn \u2014 exposure to toxic gases (carbon monoxide, hydrogen cyanide) and direct airway injury from high-temperature gas, steam, or hot liquid inhalation; for chemical burns, identify the causative agent and irrigate promptly, consulting ophthalmology urgently for any chemical eye burn.\n- Cigarette burns are the most common thermal injury to the cornea in childhood, typically in 2-4 year olds, usually when a toddler runs into a cigarette held at eye level by an adult; the eyelid-closure reflex and Bell phenomenon usually limit corneal damage.\n- Emergency triage stratifies by severity: critical/resuscitation-room criteria include inhalational injury, altered mental status, burns >25% TBSA, and facial burns with singed nasal hairs or hoarse voice; acute-level criteria include any full-thickness burn, partial-thickness burns >15% TBSA, and burns to the face or genitalia."
  }
 ],
 "long": [
  {
   "title": "Definition",
   "content": "Thermal burns are classified both by mechanism and by depth. By mechanism, burns may be scalds (hot liquid or steam), contact burns (hot objects), flame burns, chemical burns (strong acids or alkalis), or electrical burns. By depth: first-degree (superficial) burns are confined to the epidermis and appear erythematous, painful, and dry, healing within about 2 weeks without scarring. Second-degree (partial-thickness) burns extend into part of the dermis and are subclassified as superficial (erythematous, moist, painful, healing in under 3 weeks) or deep (paler, drier appearance, often speckled from thrombosed vessels, less painful because sensory nerve endings are damaged, healing over more than 3 weeks and typically leaving scars, sometimes requiring skin grafting). Third-degree (full-thickness) burns destroy the epidermis and dermis entirely, appear yellowish and depressed, and are insensate because the cutaneous nerves are destroyed. Burns should always be described by both estimated depth and total body surface area (TBSA) involved."
  },
  {
   "title": "Clinical features",
   "content": "Edema of underlying tissue can make a full-thickness injury deceptively appear more superficial on initial exam, and a wound that looks partial-thickness at first evaluation can evolve into a full-thickness injury over time, especially with secondary infection, trauma, or hypoperfusion \u2014 so serial reassessment matters. Deep partial-thickness burns are notable for reduced pain sensation (from damaged sensory nerve endings) despite retained overall pain sensation, which can be misleading. Significant burns frequently coexist with other injuries requiring emergent evaluation: inhalation injury (from toxic gases such as carbon monoxide and hydrogen cyanide, or direct thermal airway injury from high-temperature gas, steam, or hot liquid), ocular injury, or associated trauma (e.g., fractures). Certain burn patterns raise suspicion for abuse: immersion burns with a sharply demarcated line and no splash pattern are rarely accidental, since a child's normal withdrawal reflex from water hotter than 120\u00b0F (48.9\u00b0C) would produce only superficial fingertip or toe burns rather than a uniform full-thickness burn \u2014 full-thickness immersion injury implies the limb was held in place."
  },
  {
   "title": "Diagnostics",
   "content": "Assessment centers on estimating burn depth and TBSA, since these drive triage, fluid resuscitation, and referral decisions. For thermal burns, actively assess for inhalation injury (toxic gas exposure, airway injury from inhaled heat) rather than relying on visible skin findings alone. For chemical burns or IV extravasation injuries, identify the specific causative agent, since this affects irrigation and treatment; chemical burns warrant burn specialist consultation and admission at a lower TBSA threshold than thermal burns, and any chemical burn to the eye requires immediate irrigation and prompt ophthalmology consultation because it can threaten vision."
  },
  {
   "title": "Treatment",
   "content": "Severe burns require intravenous fluid resuscitation, commonly calculated with the Parkland formula: total fluid volume (mL) = body weight (kg) \u00d7 %TBSA burned \u00d7 4, with half given over the first 8 hours (counted from the time of injury) and the remaining half over the following 16 hours, on top of ongoing maintenance fluid needs. Emergency department triage stratifies burns by severity: resuscitation-room-level criteria include inhalational injury, altered mental status, chest pain/arrhythmias, or associated major trauma; critical-level criteria include facial burns with singed nasal hairs, hoarse voice, oropharyngeal edema, or dysphagia, burns exceeding 25% TBSA, and electrical burns with altered mental status or seizure; acute-level criteria include any full-thickness burn, partial-thickness burns exceeding 15% TBSA, burns to the face or genitalia, caustic chemical eye burns, circumferential burns, and significant hand or foot burns. Care in a dedicated burn center improves survival meaningfully \u2014 at least 80% survival is achievable even with burns covering 90% of TBSA in children and young adults \u2014 and death in survivable-TBSA burns is more likely when irreversible anoxic brain injury occurred at the time of the burn."
  },
  {
   "title": "Prevention",
   "content": "Reducing serious burn injury relies on layered measures: flame-retardant clothing, functioning smoke detectors, setting building water heater thermostats to 48.9\u00b0C (120\u00b0F) or lower, and prohibiting cigarette smoking around children. Effective first aid and rapid triage can reduce both the extent and depth of an injury once it occurs. For young children specifically, keeping cigarettes away from eye level (a common mechanism of corneal thermal injury in 2-4 year olds) and close supervision around hot liquids and surfaces reduce the most common accidental exposures."
  }
 ],
 "clinical": [
  {
   "title": "Initial management",
   "content": "Estimate burn depth and TBSA immediately, and assess for inhalation injury (toxic gas exposure \u2014 carbon monoxide, hydrogen cyanide \u2014 and direct thermal airway injury) with any significant thermal burn, since this can dictate airway management ahead of the skin injury itself. For chemical burns or IV extravasation, identify the causative agent and irrigate promptly; involve ophthalmology emergently for any chemical or thermal burn to the eye.\n\nCalculate IV fluid resuscitation using the Parkland formula for significant burns: fluid volume (mL) = weight (kg) \u00d7 %TBSA burned \u00d7 4, giving half over the first 8 hours post-injury and the remainder over the next 16 hours, in addition to maintenance fluids. Triage by severity: send to the resuscitation room for inhalational injury, altered mental status, chest pain/arrhythmia, or major associated trauma; treat as critical for facial burns with singed nasal hairs or hoarse voice, burns over 25% TBSA, or electrical burns with loss of consciousness or seizure; treat as acute for any full-thickness burn, partial-thickness burns over 15% TBSA, or burns involving the face or genitalia.\n\nRefer to a dedicated burn center for partial-thickness burns over 10% TBSA, full-thickness burns over 5% TBSA, any third-degree burn, electrical burns from high-tension wires or lightning, chemical burns, any inhalation injury regardless of TBSA, burns involving the face, hands, feet, perineum, genitals, or major joints, burns in a child with a preexisting condition that could complicate recovery, associated injuries such as fractures, an inadequate home or social environment, or any suspicion of abuse or neglect \u2014 including immersion burns with a sharp demarcation line inconsistent with a normal withdrawal reflex. Reassess burns serially, since apparent depth can worsen with secondary infection, trauma, or hypoperfusion, and edema can initially mask a full-thickness injury as superficial."
  }
 ]
}