A 4-year-old is carried out of a second-story bedroom after firefighters extinguish her burning clothes. Her back and torso are involved. Her face is burned. There is soot at the nares. Her arms and legs are hot and red – but not blistered.
The burn is obvious. The most dangerous questions are not.
How much of this skin actually counts toward TBSA? Does the soot mean she needs a tube now? Does she need a 20 mL/kg bolus, a burn formula, both, or neither? What belongs on the wound before transfer?
In the first hour, pediatric burn care comes down to five decisions.
1. Stop the burn – and stop the child from getting cold
Start by stopping the burning process. Remove hot or smoldering clothing and jewelry unless material is adherent to the skin. For a thermal burn, cool the injured area with cool running water; do not use ice. And please, no butter, grease, toothpaste, or other kitchen-counter burn remedies. They retain heat, contaminate the wound, and make the next clinician’s job harder.
Typically, it is recommended to run the burn under cool water for up to 10 minutes – a longer duration of rinsing can cause maceration of the tissue. In a small child with a large burn, the caveat is just as important as the treatment: cool the burn, not the child. Expose enough to assess, monitor temperature, use a warm room and warmed blankets, and cover the child with a clean, dry sheet once cooling is complete.
2. Count the burn – not every patch of erythema
The answer to “What is the TBSA?” is not “all the red skin.” Superficial burns are excluded. Partial- and full-thickness burns are counted. Current American Burn Association descriptions are a useful bedside reset:
- Superficial: Dry, red, blanching, painful, and without blisters. Think sunburn. Do not count it.
- Superficial partial thickness: Moist, pink or red, blanching, blistered, and very painful. Count it.
- Deep partial thickness: Drier, pale or mottled, less blanching, and often less painful. Count it – and expect a higher risk of scarring or grafting.
- Full thickness: Dry or leathery, variable in color, and with reduced sensation. Count it. These burns generally need burn-surgical management.
For children, use a Lund–Browder chart because the head and legs change proportionally with age. The Rule of Nines is a fast adult estimate, not the best pediatric tool. For small, scattered burns, the patient’s palmar surface is a useful bedside ruler – typically, the patient’s palm is equal to ~0.5% TBSA, and the palm + fingers is ~1% TBSA.
Back to the case: the red, non-blistered arms and legs may be superficial and therefore excluded. If the anterior trunk, posterior trunk, and part of the head are partial- or full-thickness, the child has a burn of roughly one-third TBSA and needs formal burn resuscitation and immediate burn-center involvement. The exact percentage should be recalculated with the specific age-adjusted chart being used.
3. Treat the patient – not the soot
Burn patients still get an ABCDE assessment. A child found in a house fire may also have fallen, jumped, been struck by debris, or sustained a blast injury. Do not let the skin distract you from trauma, glucose, or neurologic assessment.
Facial burns, soot, singed hairs, carbonaceous sputum, hoarseness, and an enclosed-space exposure should raise concern for inhalation injury. They are warning signs – not automatic intubation criteria.
Escalating work of breathing, stridor, progressive edema, hypoxemia or hypercarbia, inability to protect the airway, or a deteriorating examination are far more compelling reasons to secure the airway. In a concerning child, involve anesthesia, ENT, respiratory therapy, and the burn team early rather than waiting until edema turns a controlled airway into a rescue airway.
Give 100% oxygen when carbon monoxide exposure is possible. Conventional pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin; obtain venous or arterial co-oximetry. Just as importantly, the carboxyhemoglobin number does not correlate well with illness severity or outcome and should not decide whether the child is intubated. Hyperbaric oxygen decisions should be individualized with toxicology and hyperbaric consultation.
Consider cyanide when an enclosed-space fire is paired with soot exposure and altered mental status, cardiovascular collapse, or severe unexplained lactic acidosis. There is no rapid confirmatory blood test. If clinical suspicion is high, treatment should not be delayed for a cyanide level.
Hydroxocobalamin is commonly used because it does not intentionally induce methemoglobinemia – an important advantage when carbon monoxide exposure may coexist.
4. Use the fluid formula as a starting line, not the finish line
Burn-center consultation thresholds and formal IV resuscitation thresholds are not the same.
Current American Burn Association referral guidance recommends immediate consultation with consideration for transfer for partial-thickness burns of at least 10% TBSA, any full-thickness burn, suspected inhalation injury, and deep burns involving critical areas. It also notes that all pediatric burns may benefit from burn-center referral. Many pediatric burn protocols begin formal resuscitation around 10% to 15% TBSA. Call early and follow the receiving center’s protocol.
For a child with a roughly one-third TBSA burn, obtain IV or intraosseous access – through burned skin if necessary – start balanced crystalloid, and calculate a formal resuscitation.
A commonly used pediatric starting estimate is:
3 mL × weight in kilograms × %TBSA over the first 24 hours
(Half given in first 8 hours, rest over 16 hours)
Age-appropriate maintenance fluid is added for younger children according to the local protocol. The clock starts at the time of injury – not ED arrival – and prehospital fluid counts.
Then stop worshiping the formula.
Place a urinary catheter in a child with a large burn, trend perfusion and mental status, and titrate the resuscitation to clinical endpoints. Common urine-output targets are about 1 mL/kg/hour for children under 30 kg and 0.5 mL/kg/hour for larger children, but the receiving burn center should set the target.
More fluid is not automatically better. “Fluid creep” can increase edema, pulmonary complications, and compartment syndromes.
5. Dress the wound, preserve motion, and make the right disposition
Burns hurt. Address pain early and anticipate procedural analgesia, anxiolysis, child-life support, or sedation for cleansing and debridement. Clean with mild soap and water, remove clearly loose or nonviable tissue, and avoid aggressive sharp debridement outside the appropriate surgical setting.
Blister management is still not a one-size-fits-all answer. Small, non-tense blisters can often remain intact. Large, thin-walled, ruptured, contaminated, or joint-limiting blisters are commonly deroofed so the wound can be assessed and movement preserved.
For a small outpatient burn, a nonadherent dressing with an appropriate topical agent is typically appropriate. The CHOP Burn Pathway recommends either playing Bacitracin-polymyxin B ointment for most locations or placing Mepilex Ag (which stays on for 1 week).
On hands and across joints, avoid a dressing so bulky that the child stops moving.
Routine systemic prophylactic antibiotics are not indicated for an uncomplicated burn; treat infection when it is present. Review tetanus status. CDC classifies burns as dirty or major wounds: a patient with a complete primary series generally needs a booster when at least five years have elapsed, while incomplete or unknown immunization can also trigger tetanus immune globulin depending on the wound and host.
Finally, disposition is not only about TBSA. Depth, location, pain, caregiver capacity, dressing needs, rehabilitation, electrical or chemical mechanism, inhalation concern, comorbidities, and possible non-accidental trauma all matter.
Clear immersion lines, uniform depth, patterned injury, concerning sparing, an implausible history, or delayed presentation should trigger a careful child-protection evaluation – but no single pattern is pathognomonic.
The child in our case needs immediate burn-center consultation and transfer planning. The combination of a large partial- or full-thickness burn, facial involvement, and possible inhalation injury makes that decision easy.
What changes on my next shift?
- Cool the burn, not the child. Use cool running water; never ice, butter, or grease.
- Count partial- and full-thickness burns. Superficial erythema does not belong in TBSA.
- Soot is a clue, not a tube. Repeated airway assessment and clinical progression matter.
- A resuscitation formula starts the conversation. Urine output and perfusion steer it.
- Call the burn center early, especially for children, large or deep burns, critical locations, inhalation concern, or difficult pain and dressing needs.
References and further reading
1. American Burn Association. Guidelines for Burn Patient Referral.
3. Centers for Disease Control and Prevention. Clinical Guidance for Carbon Monoxide Poisoning.
4. U.S. Food and Drug Administration. CYANOKIT—hydroxocobalamin prescribing information.
9. British Burn Association. Clinical Practice Guideline for Management of Burn Blisters. 2018.
Dr. Ellen Szydlowski, MD, is a Pediatric Emergency Medicine physician and Director of Procedural Education at the Children’s Hospital of Philadelphia. She can be reached at SZYDLOWSKE@chop.edu.
