Secondary survey in children
When you have excluded or addressed life-threatening conditions in the primary survey of your pediatric patient, continue with a secondary survey. This involves taking the patient’s history and assessing the wound.
Full step-by-step instructions for the secondary survey in adults are available at Secondary survey: assessing a patient with burn wounds. Follow those instructions with the adjustments outlined on this page if your patient is a child.
Take a history
Check the patient’s identity, then take a history using the AMPLE approach, then take a burn-specific history according to the following five points:
- Etiology – the cause of the burn (e.g. flame, hot water, acid)
- Intensity – temperature and viscosity of the drink/food or concentration of the chemical agent
- Quantity – volume (e.g. pot versus cup of tea or splash versus immersion)
- Duration – amount of time the patient was exposed (also consider the condition of the skin)
- First aid – actions taken at the accident site
If the child is too young to ask, or if there is any information missing, ask family members or people who witnessed the event.
Non-accidental burns: how to spot them and what to do
Children are particularly vulnerable to non-accidental burns, so always be aware of signs of non-accidental injury. Evaluate any prior history or indications of other types of abuse or neglect when taking the history.
During the survey, you should look out for signs of neglect or mistreatment. If you suspect a child’s burn is non-accidental, always refer them to a burn center.
Raise suspicions when:
- History of the event does not match the pattern of the injury
- History is not clear, contradictory or changing
- Presentation is delayed
- The injury is not compatible with the level of development of the child
- There are other signs of trauma or previous injury
- Parents were not present at the time of the accident or during admission to hospital
Spot the patterns of non-accidental injury:
- Sock or glove pattern indicates immersion
- Cigarette marks
- Donut sign
Traditional healing
In low and middle-income countries, patients may have been treated by traditional healers before being admitted to your healthcare facility. This may have been decided due to traditional beliefs and/or access and affordability of healthcare.
Traditional treatment may include application of herbal products, eggs and ashes. It can result in late presentations with severe complications, including sepsis.
Physical examination
Follow the instructions for secondary survey outlined for adults when conducting a physical examination. Remember to remove all clothing to reveal hidden burns. For example, a diaper on an infant that has sustained a scald may hide a deep burn.
Assessing a child’s burn wound
There are adjustments to make when assessing the burn wound in children.
Estimating the extent of the burn wound
You can use the palm method to estimate the extent of the burn wound. Be sure to use the child’s palm as a reference, not your own.
Compared to adults, children have an increased body surface area to weight ratio. Therefore, the Rule of Nines used in adults must be modified for use in children:
| Age of patient | Head %TBSA | Each arm %TBSA | Each leg %TBSA | Anterior trunk %TBSA | Posterior trunk %TBSA |
|---|---|---|---|---|---|
| 0-1 years | 18 | 9 | 14 | 18 | 18 |
| 1-10 years | Subtract 1% per year (to 9%) above age 1 | 9 | Add 0.5% per year above age 1 | 18 | 18 |
Depth of the burn wound
Perform a full-body physical examination following the instructions for secondary survey outlined for adults.
When focusing on the burn injury, be aware that a child’s skin is much thinner than an adult’s. For this reason, a scald caused by water of 70˚C results in a much deeper burn wound in children than in adults.
A pediatric burn is more difficult to assess than an adult burn, especially when dealing with a scald. Color changes of the burned skin may differ from adults. These burns are often mixed depth, and they may further deepen over 48 hours.
Referring a child to a burn center
The requirements to transfer pediatric burn patients to a burn center are different from referral requirements for adults.
When non-accidental injury is suspected, transfer the child to a burn center immediately.
Children with burns exceeding 5% TBSA should be considered for transfer.
Transfer may also be needed if adequate pain relief, for example opioid continuous rate infusion, is unavailable or insufficient.
Recommendations on referral depend on local circumstances; check local protocols if available.