| disease | Pediatric Burns |
Pediatrics refers to children under the age of 12, with burns most commonly occurring during early childhood and preschool years, particularly in children aged 1 to 4. Due to the incomplete anatomical and physiological development during a child's growth, their tolerance to illness after burns is relatively poor, making them more susceptible to shock, sepsis, and death.
bubble_chart Clinical Manifestations
1. Pediatric Burn Shock
1. Due to the immature development of various organs in children, especially the incomplete development of the nervous system, and the relatively smaller total blood volume per unit of body surface area, children's regulatory functions and tolerance to fluid loss are poorer than those of adults. The systemic disturbances caused by pain, dehydration, plasma component loss, and water-electrolyte imbalances after burns are far more severe than in adults. The incidence of burn shock is also higher in children. Generally, children with burn areas exceeding 10% are at risk of shock.
2. Head and facial burns in children are more likely to cause shock: This is because the relative surface area of a child's head is larger, the tissue is looser, and the blood supply is more abundant, leading to more exudation than in other areas. Additionally, swelling of the head and face can easily cause respiratory dysfunction and hypoxia.
3. The incidence of shock is related to age: Generally, as age increases, the body's regulatory functions and tolerance to fluid loss gradually improve. For children with burn areas exceeding 40%, the incidence of shock is very high. However, for children with burn areas below 40%, the incidence of shock shows a clear correlation with age. The incidence of shock is significantly different between children aged 4 and above and those below 4 years old, with younger children having a higher incidence of shock.
4. Clinical features and diagnosis of pediatric burn shock: Due to the anatomical and physiological characteristics of children, primary shock is more common, especially in burns involving sensitive areas such as the head, face, and perineum. This later transitions to secondary shock, often manifesting as: thirst, dysphoria, restlessness, or even delirium or convulsions; oliguria or anuria; cold extremities; pale or cyanotic complexion; delayed capillary refill; in severe cases, the skin may appear waxy yellow with mottling; rapid and weak pulse, which can increase to over 180–200 beats per minute; low and weak blood pressure that eventually becomes unmeasurable; followed by dull heart sounds, slowed heart rate, and ultimately circulatory and respiratory failure.The diagnosis of pediatric burn shock is primarily based on clinical symptoms, such as urine output, mental state, and changes in skin color, with blood pressure and pulse serving as secondary references. When observing mental state, it is important to note that manifestations vary by age. Children under 1 year old often exhibit drowsiness. Those aged 1–4 may show excitement, restlessness, or uncharacteristic quietness, later transitioning into lethargy. Children over 4 years old may display abnormal excitement, often appearing tense and talkative.
5. Pediatric hypertension: Approximately 20% of pediatric burn cases exhibit significant blood pressure elevation, the cause of which is unknown. This typically occurs 7–10 days after the injury and may gradually decrease after skin grafting. Most children show no symptoms, though some may experience headache or even confusion.
2. Pediatric Burn Infection and Pediatric Burn Sepsis
Due to insufficient immune function, thin skin, restlessness, and a higher incidence of shock, children are more prone to wound sepsis. Sepsis is the leading cause of death in pediatric burn cases, accounting for 740.6%. In 71.4% of cases, sepsis occurs within 15 days after the injury.(1) Pediatric Burn Wound Sepsis
⑴ Local changes in the wound: ① Fresh wounds may darken, partially ulcerate, or exhibit bleeding spots or ulcerated areas. ② Fresh granulation tissue may harden, turn black or purple, with pus formation at the base or sudden knife-cut-like depressions at the wound edges. ③ The surrounding normal skin may show inflammatory infiltration, such as redness, swelling, heat, and pain. ④ Small spots or patches of necrotic tissue may appear on the wound. ⑤ Tissue edema may persist or recur after subsiding.
⑵ Systemic symptoms: The systemic symptoms are generally similar to those in adults, typically including high fever, shivering, decreased or increased white blood cell count, and toxic shock in advanced stages.
(2) Pediatric Burn Sepsis
⑴Body temperature: Children's body temperature is easily affected by factors such as dressing changes and the environment, making fever alone insufficient for diagnosis. However, persistent high fever above 40°C, especially sudden spikes or drops to normal or below normal, holds diagnostic value. A persistently low body temperature often indicates severe septicemia. Older children may experience chills before or during fever, sometimes several times a day. Infants and young children may exhibit spasms.
(2) Heart rate: Children's heart rate is unstable, and any external stimulus can accelerate it. However, when the heart rate exceeds 160 beats per minute, attention should be paid. If it exceeds 200 beats per minute, especially accompanied by arrhythmia, strong heart sounds, gallop rhythm, premature contractions, or unexplained sudden acceleration, it has greater diagnostic reference value.
(3) Respiration: In burn sepsis, respiratory rate increases earlier in children. Sometimes there are also changes in respiratory state, such as respiratory distress or pauses. Pulmonary infections or pulmonary edema often occur concurrently.(4) Mental symptoms: For infants under 6 months, manifestations include delayed reactions, not crying, not eating, and in severe cases, unconsciousness or light unconsciousness. For children under 2 years, symptoms include listlessness, apathy, drowsiness, being easily startled, or screaming and crying during dreams. Sometimes, excitement, dysphoria, carphology (picking at bedclothes), head shaking, random limb movements, or even convulsions may occur. For children over 3 years, hallucinations, delusions, or excessive eating—similar to adult sepsis symptoms—may appear.
(5) Digestive system symptoms: Diarrhea is the earliest symptom, occurring several to dozens of times a day. Other symptoms include anorexia, vomiting, hyperactive borborygmi (loud bowel sounds), and in severe cases, intestinal paralysis, severe dehydration, and acidosis.
(6) Rash: Rashes, ecchymosis, petechiae, and urticaria are common. Staphylococcus aureus sepsis can cause scarlet fever-like rashes, especially in infants.
(7) Wound surface: Epithelial growth stagnates, the wound deepens, edges become steep, granulation tissue appears dirty, dull, or necrotic patches emerge. Focal necrosis in the wound and necrotic patches on normal skin are more common in Pseudomonas aeruginosa sepsis.
(8) Laboratory tests: A prominent feature is a sharp increase in white blood cell count, generally above 20×109/L, sometimes reaching 30–40×109/L, with toxic granules and vacuoles present.
III. Characteristics of Pediatric Inhalation Injury
For pediatric inhalation injury, if there is airway obstruction or lower airway injury, endotracheal intubation or tracheostomy should be performed immediately. During endotracheal intubation in children, the tube should be placed in the pharyngeal and tracheal edema area to prevent airway obstruction. Nasopharyngeal and tracheal intubation causes less damage. Due to the short neck in children, the tracheostomy site should be lower than in adults, preferably between the fourth and fifth tracheal cartilage rings.
1. Estimation of Burn Area in Children
Due to the continuous growth and development of children, the percentage of body surface area occupied by various body parts changes with age. The characteristics include a large head and short lower limbs. There are multiple methods for estimating body surface area in children of different ages. In China, a practical formula improved based on the commonly used "Rule of Nines" for adults is:
Head and neck: 9 + (12 - age)
Both lower limbs: 46 - (12 - age)
Additionally, the palm method is another commonly used approach. The size of a child's palm with fingers closed also represents 1% of the total body surface area. This can be used for measuring small-area burns or as a supplement to the Rule of Nines.
2. Classification of Burn Severity in Children
Due to the unique anatomical and physiological characteristics of children, their responses to stimuli such as wounds, shock, and sepsis differ from those of adults, and their resistance varies significantly. For deep burns of the same area, children have higher incidences of shock, sepsis, and mortality compared to adults. Therefore, the classification of burn severity in children differs from that in adults. Currently, the classification method adopted at the 1970 National Burn Conference is widely used in clinical practice:
Grade I burns: Second-degree burns with a total area of less than 5%.
Grade II burns: Second-degree burns with a total area of 5–15% or third-degree burns with an area of less than 5%.
Grade III burns: Second-degree burns with a total area of 15–25% or third-degree burns with an area of 5–10%.
Special Grade III burns: Second-degree burns with a total area exceeding 25% or third-degree burns exceeding 10%.
However, in 1976, the Burn Prevention and Treatment Research Institute of the Third Military Medical University summarized 724 cases of pediatric burns and found that the incidences of shock, sepsis, and mortality varied with different burn areas. They proposed a revised classification for pediatric burns:
Grade I: Second-degree burns with a total area of less than 10%.
Grade II: Second-degree burns with a total area of 10–29% or third-degree burns with an area of less than 5%.
Grade III: Second-degree burns with a total area of 30–49% or third-degree burns with an area of 5–14%.
Special Grade III: Second-degree burns with a total area exceeding 50% or third-degree burns exceeding 15%.
The following conditions are considered severe burns: ① Burns involving the head, face, or neck; ② Burns in the perineal area; ③ Inhalation injury; ④ Hand burns.
bubble_chart Treatment Measures
Due to the unique anatomical, physiological, and psychological characteristics of children, their treatment has distinct features.
I. Treatment Measures
1. Because children’s anatomical, physiological, and psychological development is immature, their tolerance to diseases is poor, and their condition can change rapidly during the course of illness. Therefore, the severity of the condition must be carefully assessed, and treatment should be given high priority, especially in pediatric burn emergencies, which require active and stable intervention.
2. Pediatric resuscitation and fluid replacement have specific characteristics in terms of quality and quantity: ① Compared to adults, children lose relatively more fluids after burns, so the volume of fluid replacement should be larger, particularly in the first 8 hours post-injury. Close attention must be paid to the infusion rate during early resuscitation to ensure adequate fluid replenishment without overburdening the heart, lungs, brain, or other organs, thereby avoiding complications such as cardiac insufficiency, pulmonary or cerebral edema. ② Children are prone to electrolyte imbalances after burns. Their kidneys’ ability to concentrate, dilute, and excrete potassium is not yet fully developed. Thus, the tonicity of the replacement fluids must be carefully monitored and adjusted based on the patient’s specific condition to maintain water and electrolyte balance, preventing alkalosis or water intoxication. ③ Due to poor appetite, reduced food intake, and significant exudation from burn wounds, children may still develop low blood electrolyte and protein levels despite early high-tonicity fluid replacement. Therefore, continued fluid correction, appetite improvement, and enhanced nutritional support for the digestive system are essential to fundamentally resolve electrolyte disturbances.
3. Wound management is critical in pediatric burns. The process must be gentle, efficient, and thorough to avoid adverse stimulation or re-injury. A compassionate attitude and meticulous technique will help the child feel at ease, laying the foundation for subsequent treatment.
4. Nutritional support is a key issue during pediatric burn recovery, influencing the entire course of the disease and treatment outcomes. The treatment plan should carefully account for the child’s nutritional status, eating and digestion capacity, dietary preferences, and age. Nutrient-rich, varied, and palatable foods should be provided to encourage eating. For those unable to eat or with severe malnutrition, intravenous hyperalimentation, or small, frequent transfusions of fresh blood or albumin may be necessary.
5. Children’s nervous systems are underdeveloped, making them prone to high fever and convulsions. Preventive measures or control strategies should be strengthened.
6. Children are in a phase of growth and development. Deep burns, scalds, or electrical injuries in functional areas must be managed properly to prevent scarring, functional impairment, developmental hindrance, or deformities, which could cause lifelong suffering.
7. Children’s psychological development is immature. During treatment, psychological issues should be identified and addressed promptly to alleviate mental burdens and trauma. Efforts should be made to foster and build the child’s self-esteem and confidence, especially for those who have suffered disfigurement or disability due to deep burns.
8. Late-stage (third-stage) rehabilitation exercises are crucial. Post-discharge care is an extension of hospitalization and is vital for functional recovery. Under medical guidance, active exercise should be encouraged after wound healing. Children may resist exercise due to pain or other reasons, so doctors and parents must persuade and guide them. Otherwise, lack of exercise may lead to deformities and functional impairments in certain areas due to prolonged disuse.
9. Children’s immune systems are underdeveloped, making them more susceptible to wound infections and sepsis than adults. Therefore, wound care and rational antibiotic use are essential to prevent infections.
10. Children’s organs and tissues are immature, so medication must account for drug side effects and the organs’ tolerance. Dosages should be precisely calculated before administration.
II. Wound Management
The principles of pediatric burn wound management are largely similar to those for adults, but the following points should be noted:
1. Children's skin is delicate and thin, with fewer appendages, making wounds prone to deeper infection once contaminated. However, children have vigorous growth capabilities. With proper treatment and effective infection prevention, wound healing is faster than in adults. For example, deep second-degree wounds in children can heal within about 2 weeks if uninfected, whereas adults typically require around 3 weeks.
2. Children's body temperature is easily influenced by the environment. When the ambient temperature is high, excessive bandaging can lead to high fever or even spasms. Therefore, exposure therapy is often preferred. However, children are generally less cooperative. For smaller burn areas, especially on the limbs, bandaging may be used to facilitate care and protect the wound. For those undergoing exposure therapy, appropriate restraint and immobilization should be applied.
3. Children have thin skin, and the thickness of autologous skin grafts should not exceed 0.3mm. When harvesting autologous skin, the graft should be as thin as possible. The grafted area must be properly immobilized and restrained to ensure secure fixation and optimal growth.
4. Special considerations for topical medications on wounds: ① Due to the higher ratio of body surface area to weight in children compared to adults, drug concentrations should not be too high, and the application area should be limited to avoid excessive absorption and toxicity. ② Because children's skin is delicate, extra care must be taken to protect it, especially when using high-concentration or highly irritating medications, to prevent dermatitis, eczema, erosion, or even pyoderma, which could complicate wound management.
5. During the wound healing process, cutaneous pruritus is prominent. During this period, measures should be taken to immobilize the child and protect the newly healed wound to prevent scratching, which could lead to infection or scarring.
6. For deep burns on the face, hands, or other functional areas, early escharectomy and skin grafting should be performed as soon as possible after the shock phase has passed and the child's condition is stable. Children with extensive third-degree burns should receive early escharectomy and skin grafting. During surgery, respiratory and circulatory stability must be maintained, excessive bleeding should be minimized, surgical time should be shortened, and adequate fluid and blood transfusion must be ensured.
7. Children's skin is thin and sensitive, with poor tolerance to pain stimuli. Debridement should be performed gently and patiently to minimize wound irritation.
1. Preoperative Medication for Pediatric Burns
The purpose of preoperative medication is to calm the child; inhibit respiratory secretions and saliva production; counteract adverse reactions caused by anesthesia and surgery; increase the pain threshold; and reduce metabolism and oxygen consumption. Commonly used preoperative medications include atropine, scopolamine, meperidine, and phenobarbital. The dose varies with age, as shown in Table 1.
Table 1 Preoperative Medication Dose Table (Intramuscular Injection)
| Age | Weight (kg) | Analgesic (mg) | Anticholinergic (mg) | Phenobarbital (mg) | Diazepam (mg) | ||
| Meperidine | Morphine | Atropine | Scopolamine | ||||
| Newborn | 3 | 0.1 | 0.1 | ||||
| 6 months | 6 | 0.2 | 0.2 | 30 | 3 | ||
| 1 year | 9 | 10 | 1 | 0.2 | 0.2 | 40 | 4 |
| 2 years | 11 | 15 | 1.5 | 0.25 | 0.2 | 50 | 5 |
| 4 years | 15 | 20 | 2.0 | 0.3 | 0.25 | 60 | 6 |
| 6 years | 19 | 25 | 2.5 | 0.35 | 0.3 | 70 | 7 |
| 8 years | 23 | 30 | 3.0 | 0.4 | 0.3 | 80 | 89 |
| 10 years | 27 | 35 | 3.5～4.0 | 0.4 | 0.3 | 90 | 9 |
| 12 years | 31 | 40 | 4～5 | 0.5 | 0.3 | 100 | 10 |
| 14 years | 35 | 45 | 5 | 0.5 | 0.35 | 100 | 10 |
2. Commonly Used Antibiotics for Children
(1) Select antibiotics based on bacterial sensitivity, as shown in Table 2. The blood concentration of the antibiotic should be 5 to 10 times higher than the bacterial sensitivity to the drug.
Table 2 Common Doses and Side Effects of Various Antibiotics (Intravenous or Intramuscular Injection)
| Antibiotics | Dose (mg/kg·d) | Usage | Side Effect | |
| Divided Doses | Interval (h) | |||
| Cefazolin Sodium | 20～100 | 2～4 | 6 | Allergic rash, drug fever, nausea, diarrhea |
| Carbenicillin | 200～100 | 4 | 6 | Thrombocytopenia, interference with platelet function |
| New Penicillin II | 50～100 | 4 | 6 | Rash |
| Kanamycin | 40～50 | 4 | 6 | Kidney damage |
| Gentamicin | 6 | 4 | 6 | Kidney damage |
| Amikacin | 15～22 | 3 | 8 | Kidney damage, ototoxicity |
| Polymyxin B | 25,000μ | 3 | 8 | Kidney damage |
| Penicillin | 50,000～250,000μ/kg | 6 | 6 | Rash, anaphylactic shock |
| Ticarcillin | 200～300 | 4 | 4 | Hyponatremia, hypokalemia |
| Cefoperazone | 50～200 | 2 | 6 | Allergic reactions |
| Ceftriaxone | 50mg/kg/12h | 1～2 | 6 | Diarrhea, rash, drug fever, cutaneous pruritus |
Cefotaxime | 100～150 | 3～4 | 6 | |
| Erythromycin | 20～30 | 2～3 | 8 | Gastrointestinal reactions, allergic reactions, liver damage |
| Chloramphenicol | 23～50 | 2 | 8 | Bone marrow suppression |
| Lincomycin | 10～20 | 2 | 6 | Gastrointestinal reactions |
⑵ Understand the absorption, distribution, and excretion of antibiotics. Some can cross the blood-brain barrier (e.g., chloramphenicol), while penicillin, kanamycin, cephalosporins, and erythromycin cross the blood-brain barrier less frequently. Polymyxin does not cross the blood-brain barrier. Antibiotics are primarily excreted by the kidneys, resulting in high concentrations in urine.
⑶ For patients with renal insufficiency, use antibiotics cautiously, preferably avoiding polymyxin or gentamicin. Choose other antibiotics or appropriately extend the interval between doses based on the degree of renal impairment.
3. Antipyretic and Analgesic Drugs
⑴ Aminopyrine: Infants 0.015～0.06/dose, toddlers double the dose. Children: 1/2～1/3 of the adult dose, intramuscular injection.
⑵ Pediatric APC: 1 Tab /dose, 3 times/day, orally.
⑶ Indomethacin: 0.5mg/kg/dose, orally.
⑷ Luminal: Oral dose 2～3mg/kg/dose, injection dose 5～8mg/kg/dose.
⑸ Diazepam: 0.2～0.3mg/kg/dose, intramuscular injection.
⑹ Meperidine: 1.0～1.5mg/kg, intramuscular or intravenous injection.
1. Indigestion
Indigestion or digestive dysfunction is relatively common in pediatric burn cases, with an incidence rate of approximately 20%±. It mostly occurs in infants and young children.
1. Causes
⑴ Internal factors: The digestive system of children is underdeveloped, with low gastric acidity and weak resistance to infection. Due to insufficient secretion and low activity of digestive enzymes, their tolerance to food is poor. Additionally, children grow rapidly and require more nutrients, placing a heavier burden on their digestive tract. Moreover, their immature nervous system results in poor regulation of gastrointestinal function, making them prone to digestive disorders. The levels of immunoglobulins in children's blood are lower than in adults (especially IgM and IgA), and secretory IgA in the gastrointestinal tract is also reduced, weakening their defense against infections.
⑵ External factors: ① After burns, a large amount of fluid leaks from the wound, reducing blood volume and stimulating the nervous and endocrine systems. This leads to a redistribution of blood supply to organs, reducing gastrointestinal blood flow and impairing normal digestive function. Additionally, severe local pain and psychological trauma after burns also affect gastrointestinal function. ② Dietary factors. After burns, children often experience reduced appetite and digestive function, especially infants who may need to switch to artificial feeding, which they may not adapt to immediately. Sometimes, to compensate for the reduced digestive capacity post-burn, caregivers may overfeed, improperly prepare food, or schedule meals too tightly, overburdening the gastrointestinal tract and impairing digestion and absorption, leading to diarrhea and/or vomiting. ③ External intestinal infections. Infections such as sepsis, severe wound infections, and severe toxemia often cause digestive dysfunction. Secondary infections like upper respiratory infections, pneumonia, and otitis media can also contribute. This is mainly due to toxins disrupting the body's regulatory functions, reducing digestive enzyme activity, and causing gastrointestinal motility disorders. ④ Internal intestinal infections. Similar to general intestinal infections, these are primarily caused by contaminated food or utensils and reduced immunity. However, in pediatric burns, pathogens may sometimes originate from wound bacteria, such as Staphylococcus aureus, Escherichia coli, or Proteus. Other times, they result from dysbiosis due to prolonged antibiotic use. ⑤ Other factors, such as medication effects or metabolic disorders, can also cause indigestion.
2. Clinical Manifestations
Mild cases mainly present with digestive symptoms, such as reduced appetite, nausea, vomiting, and increased bowel movements (several to over ten times a day). Stools may appear "egg-drop-like" or loose, with a sour odor and small amounts of mucus but no pus or blood. Microscopic examination reveals large amounts of fat globules, undigested food residues, and a few blood cells. Severe cases may involve dozens of watery stools daily, frequent vomiting, or even intestinal paralysis, accompanied by dehydration, acidosis, hypokalemia, and other electrolyte imbalances. Due to the absorption of intestinal toxins, children may exhibit toxic symptoms such as lethargy, drowsiness, restlessness, or even convulsions and unconsciousness.
3. Prevention and Treatment
⑴ Focus on prevention. Actively control wound infections and promote early wound healing to prevent sepsis and other complications. Pediatric feeding should be prioritized as a key aspect of post-burn care, managed by dedicated personnel. In addition to maintaining dietary hygiene, gradually and maximally increase the child's food intake as tolerated by their gastrointestinal tract.
⑵ Carefully analyze the causes and address them accordingly. For intestinal infections, administer sensitive antibiotics; for dysbiosis, adjust antibiotics; for improper feeding, correct the feeding practices, etc.
(3) Reasonable dietary adjustment during convalescence: Regardless of the cause of digestive dysfunction, dietary regulation should be emphasized. ① Grade I cases: Appropriately reduce food intake and choose easily digestible foods. Milk can be diluted to a ratio of 1:1 or 1:2. Closely observe stool characteristics; if digestion improves, gradually increase food quantity or milk concentration. If no improvement is observed, consider short-term fasting and intravenous fluid therapy. ② Grade III cases: Fasting should be implemented with intravenous fluid therapy, typically for 12-24 hours. Then, depending on the condition, start with liquid diets and gradually increase food intake. For infants, rice water and diluted milk can be given first, with milk quantity reduced by 1/2-2% of normal amounts. Feed every 4-6 hours, supplementing insufficient fluids between feedings. Skimmed milk is preferable, with 1-2% sugar added. As the condition improves, gradually increase food intake, avoiding sudden large increases. If the condition doesn't improve and prolonged fasting is required, consider intravenous hyperalimentation for nutritional supplementation.
(4) Antibiotic treatment: Emergency enteritis caused by non-invasive bacteria is mostly a self-limiting disease, especially in mild cases, which can often be cured with supportive therapy alone. It is generally believed that the appropriate use of antibiotics can reduce the amount of diarrhea and shorten the duration of bacterial excretion in stools. Invasive enteritis usually requires antibiotic treatment. Viral enteritis lacks specific treatment and relies mainly on dietary therapeutics and supportive therapy, with no need for antibiotics.
(5) Pay attention to correcting water and electrolyte imbalances. Based on the degree and nature of the child's dehydration, select the type and tonicity of fluid replacement, and adjust the infusion speed during the expansion phase, the phase mainly replenishing cumulative losses, and the maintenance phase. Also, correct acidosis and appropriately supplement potassium, calcium, and magnesium.
(6) For grade I diarrhea that is definitely not caused by intestinal infection or dietary disorders, small amounts of antidiarrheal agents may be considered, such as compound formula camphor tincture, aluminum hydroxide, and other astringents. These should not be used in other cases.
(7) Medications that regulate the spleen and stomach and clear dampness-heat can be applied. Acupuncture therapy or a combination of acupuncture and moxibustion may also be used.
II. Scarlet Fever-like Staphylococcus Aureus Infection
1. Clinical Manifestations
(1) Body temperature: Sudden high fever, generally above 39–40°C.
(2) Rash: Appears 1–3 days after fever, initially around healthy skin near the wound, then rapidly spreads throughout the body. The rash consists of diffuse small papules, about 1 mm in size. Initially flat, they later become slightly raised and feel rough to the touch. The rash is very dense and generally red, temporarily blanching under pressure and returning to its original color after a few seconds. Sometimes, the face and entire body become flushed, with "circumoral pallor." The rash fades after a few days, followed by desquamation (peeling or large-scale shedding). In severe cases, the rash is dense and numerous, even hemorrhagic, and does not blanch under pressure. Some small red spots gradually merge, closely resembling urticaria. The rash usually lasts 1–2 days, up to 4–5 days at most. A few cases may experience recurrent rashes until the wound fully heals. "Strawberry tongue" is less common, with most cases only showing enlarged taste buds, which differs somewhat from typical scarlet fever.
(3) Toxic symptoms: Apart from high fever, the child may appear lethargic or drowsy. In severe cases, unconsciousness or convulsions may occur, with more pronounced toxic symptoms than typical scarlet fever.
(4) Throat symptoms: Generally mild, without respiratory symptoms.
(5) Wound changes: When the rash appears, wound infection may worsen, with stalled epithelial growth or erosive infection, presenting a "moth-eaten" appearance.
(6) Laboratory tests: Elevated white blood cell count, exceeding 10,000–20,000. No beta-hemolytic streptococci are found in the throat, but Staphylococcus aureus grows in the wound.
2. Treatment
(1) General supportive therapy: Transfusion of fresh blood, which has a toxin-neutralizing effect.
(2) Systemic administration of effective antibiotics: Generally selected based on the sensitivity of Staphylococcus aureus in the wound.
3. Wound Management
Eliminating the source of infection is fundamental, such as enhancing wound drainage and cleaning, and promptly eradicating the wound.
III. High Fever
Fever of varying degrees is common after burns. In burned children, temperatures exceeding 39°C are also very common and generally do not require special treatment. However, if the temperature persists above 39.5°C, the cause of the fever should be actively investigated for emergency management to avoid delaying treatment of complications or causing other serious consequences.
1. Causes of Fever
Due to the immature thermoregulatory center in children, high fever can easily occur in response to various stimuli. Common causes include the following.
(1) Wound infection: Often manifests as local moisture, pus accumulation, or foul odor. Early signs include obvious cellulitis around the wound edges, with severe cases presenting as wound sepsis.
(2) Septicemia: Sudden spikes or persistent high fever are often early symptoms of septicemia and should be noted. In addition to high fever, other symptoms of septicemia are usually present.
(3) Excessive and overly thick dressing of the wound can lead to poor heat dissipation, especially in summer. Body temperature usually drops rapidly after switching to exposure therapy.
(4) Dressing change fever: Often caused by excessive dressing change area, leading to increased toxin absorption. This type of high fever is usually one-time and has a clear causal relationship with dressing changes.
(5) High environmental temperature: Commonly seen in summer or when winter insulation temperatures are too high. It mostly occurs in younger children but can sometimes also affect older children.
(6) Concurrent lung infection: Often accompanied by respiratory symptoms such as cough, shortness of breath, and wet rales in the lungs. X-ray examination can usually confirm the diagnosis.
(7) Concurrent craniocerebral injury: Refers to central hyperthermia caused by damage to the thermoregulatory center.
(8) Transfusion or blood transfusion reaction: Mostly transient, lasting 4–6 hours. If caused by severe blood contamination, persistent high fever may occur.
(9) Allergic reaction: Caused by drug allergies.
(10) Drug fever: Especially common after prolonged use of large amounts of antibiotics.
(11) Dehydration fever: Mainly hypertonic dehydration caused by cerebral dehydration. In addition to high fever, convulsions or unconsciousness may sometimes occur. Symptoms can be relieved after correcting dehydration, and body temperature will drop.
2. Prevention and Treatment
(1) The focus of high fever in children lies in prevention. Take active measures to address the various causes of high fever and avoid its occurrence. If a child already has a high fever, carefully investigate the cause and take appropriate measures accordingly. Avoid blindly relying on antibiotic treatment.
(2) Fever reduction: Before identifying the cause of high fever or if the fever persists despite identifying the cause, fever reduction measures should be taken to prevent serious consequences such as convulsions. Common fever reduction methods fall into two categories: ① Physical cooling methods: a. Warm water sponge bath: Often used in the initial stage of high fever accompanied by shivering. Since ice water cooling is not suitable at this stage, warm towel wiping is used instead. b. Cold compress or alcohol sponge bath: After shivering subsides, cold compresses, ice packs (placed over major blood vessels), or alcohol sponge baths can be applied until the skin turns red. c. Cold saline enema: 50–100 ml for 1-year-olds, 300–600 ml for 3-year-olds. Chloral hydrate or aspirin can be added to the saline, with doses equivalent to oral administration. d. Acupuncture or acupoint (Quchi) block. ② Due to the weak constitution of burned children, antipyretics should be used with extreme caution to avoid excessive sweating leading to collapse. If physical cooling is ineffective, reduced doses of antipyretics such as aspirin or antondine may be used. ③ Sedatives and anticonvulsants: High fever in children, especially sudden high fever, can easily lead to convulsions. Therefore, sedatives and anticonvulsants such as phenobarbital sodium or chloral hydrate should be used concurrently to prevent convulsions. In severe cases, lytic cocktail may also be used. If convulsions have already occurred, rapid measures must be taken, including anticonvulsant drugs and immediate fever reduction.
(3) Traditional Chinese medicine: Applied based on pattern identification according to the condition.
IV. Convulsions
Convulsions are temporary disturbances in brain function, more common in infants and young children, with younger age correlating to higher incidence. Prolonged convulsions can cause cerebral hypoxia, leading to brain damage, or even asphyxia-induced respiratory and cardiac arrest, endangering life. Therefore, active and timely emergency treatment is essential.
1. Disease causes
The common causes of convulsions in burned children include the following: ①High fever: More common in children aged 6/12 to 3 years. It often occurs at the onset of fever, with episodes generally not exceeding 2-3 times, and no neurological symptoms or signs. The convulsions cease once the fever subsides. ②Toxic encephalopathy and central nervous system lesions: Convulsions caused by pediatric sepsis are mostly due to toxic encephalopathy, often lasting for an extended period, up to several days. They are accompanied by other toxic manifestations of sepsis, such as unconsciousness, delirium, dysphoria, and restlessness. ③Cerebral hypoxia and cerebral edema. ④Water and electrolyte imbalance: More commonly seen in severe hypertonic dehydration, hypocalcemia, and water intoxication. Sometimes hypoglycemia, acidosis, or ketosis can also trigger convulsions. Malnourished children are more susceptible. ⑤Uremia. ⑥Drug allergies or side effects: Such as antibiotic allergies or poisoning. ⑦Epilepsy. ⑧Tetanus. ⑨Central nervous system diseases: Such as multiple brain abscesses, cerebral hemorrhage and necrosis, meningoencephalitis, intracranial hemorrhage, or fluid accumulation.
The most common causes among the aforementioned are: high fever, sepsis, cerebral hypoxia and cerebral edema, as well as disturbances in water and electrolyte balance.
2. Diagnosis
Diagnosis primarily relies on clinical manifestations. If typical symptoms are present, diagnosis is generally straightforward. However, at times, especially in the early stages, symptoms may vary. For instance, convulsions may occur in only one limb, or shift from one limb to another. Sometimes, brief twitching may appear at the corner of the mouth or eye, along with neck stiffness, opisthotonos, and other manifestations. Therefore, early detection, timely diagnosis, and prompt intervention are crucial. Do not wait until a major seizure occurs to make a diagnosis, as this not only complicates management but also delays critical timing. A distinctive aspect of diagnosis is identifying the underlying disease cause.
3. Emergency Management
(1) Controlling Convulsions: ① Acupuncture stimulation: Needle points such as Renzhong (GV26), Baihui (GV20), Yongquan (KI1), Shixuan (EX-UE11), Hegu (LI4), and Neiguan (PC6). If convulsions are not controlled within 2–3 minutes, rapidly administer one of the following medications. This method is suitable when medications are temporarily unavailable. ② Anticonvulsant drugs: a. Diazepam: 0.2–0.3 mg/kg/dose (or 1 mg/year of age), with a maximum single dose not exceeding 10 mg, administered intravenously at a rate of 1 mg/minute. For neonatal tetanus, the dose may be increased to 1–2 mg/dose, given by slow IV injection. This drug acts quickly, taking effect within 1–3 minutes, but its duration is short. If necessary, it may be repeated after 20 minutes. Diazepam has three drawbacks: respiratory depression, cardiac suppression, and hypotension. Caution is especially needed in patients who have previously received barbiturates, and resuscitation measures should be prepared. b. Paraldehyde: 5% solution, 0.1–0.2 mL/kg/dose intramuscularly, with a maximum dose not exceeding 5 mL. Alternatively, 0.3–0.4 mL/kg/dose mixed with an equal volume of mineral oil for retention enema. This drug is safe and fast-acting but can depress respiration and is contraindicated in patients with respiratory conditions. c. Chloral hydrate (10%): 50–60 mg/kg/dose mixed with an equal volume of normal saline for retention enema. d. Phenobarbital sodium: 8–10 mg/kg/dose intramuscularly. This drug is a fundamental anticonvulsant and also inhibits heat production. However, its onset is slow, taking 20–60 minutes after intramuscular injection to reach effective levels in the brain. It can be used for maintenance therapy to consolidate effects. e. Sodium amobarbital (Amytal sodium) or sodium thiopental: These drugs may be used when the aforementioned four types of medications are ineffective. Amytal sodium: 5 mg/kg/dose; sodium thiopental: 10–20 mg/dose, diluted to a 1% solution with 10% glucose and administered intravenously at 1 mL/minute. Stop injection immediately once convulsions cease. The maximum dose of sodium thiopental should not exceed 300 mg. Avoid moving the head during IV administration to prevent laryngospasm. If laryngospasm occurs, immediately tilt the head back and lift the jaw to prevent tongue obstruction, and administer atropine intramuscularly to relieve spasm. When using anticonvulsants, avoid administering multiple drugs in rapid succession. Allow sufficient time between doses to prevent synergistic respiratory depression. ③ For neonatal convulsions, first identify the cause and provide disease-specific treatment. If the cause cannot be immediately determined, emergency measures should be taken based on common causes of neonatal convulsions. The three most common causes are: ① Hypoglycemia, ② Hypocalcemia, ③ Vitamin B 6 deficiency or dependency.
(2) General Management: Place the patient in a lateral position, loosen clothing and collar, and clear secretions and vomitus from the mouth, nose, and throat to prevent aspiration and maintain airway patency. Place a bite block between the molars to prevent tongue biting, but do not force the jaws open if they are clenched, to avoid dental injury. Provide oxygen in severe cases. For high fever, use physical or pharmacological cooling. Protect any wounds to prevent abrasion or worsening.
(3) Infection Control: For infectious convulsions, administer appropriate antibiotics or sulfonamides.
⑷ Disease cause treatment: such as strengthening wound management, timely drainage to eliminate the wound; active treatment of sepsis, timely correction of typical edema and electrolyte imbalance as well as acid-base imbalance. If it is calcium deficiency, 10% calcium gluconate should be injected immediately. For hypoglycemia, 50% glucose can be administered intravenously, and the cause of calcium deficiency or hypoglycemia should be further investigated and addressed. If drug allergy or poisoning symptoms occur, the medication should be discontinued promptly. For children with epilepsy, the underlying cause should be thoroughly investigated. Cases of brain edema or tetanus should be treated according to the respective treatment methods for brain edema and tetanus.
V. Pyoderma
Children, especially newborns, have low skin resistance and are prone to infections by pyogenic bacteria such as staphylococci under normal circumstances. After burns, newly healed wounds or epithelial layers following skin grafting are extremely thin and even more vulnerable. If the surrounding areas of these wounds are not kept clean, they can easily become infected through scratching or friction from bedding or clothing, leading to widespread pyoderma.
For such cases, systemic antibiotics are often ineffective, and topical medications generally yield limited results. The focus should be on maintaining regular skin cleanliness and protection to avoid breaks or abrasions, thereby preventing the onset of the condition. If pyoderma has already developed, prompt treatment is essential to prevent its spread. In addition to selecting appropriate topical antibacterial agents based on bacterial sensitivity, the most crucial measure remains local cleansing to reduce bacterial load and accelerate healing. Furthermore, enhancing systemic supportive therapy is also a vital approach.
