Surgical Treatment of Burns in Children Workup

Updated: May 18, 2022
  • Author: Renata Fabia, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Laboratory Studies

Monitoring of electrolytes and blood counts is often helpful, especially with large burns requiring aggressive fluid resuscitation. Obtaining the carboxyhemoglobin level can be important in patients with inhalation injury, especially in those burned in enclosed spaces. Lactate levels correlate with burn severity and cyanide poisoning, and serial levels could be used to define the endpoint of burn shock resuscitation. Prealbumin levels should be monitored weekly in patients with burns involving more than 20% of total body surface area (TBSA) as a measure of nutritional repletion.

A fever workup (including a complete blood count [CBC]; urinalysis, and blood, urine, sputum, and wound cultures) should be performed as clinically indicated.

If invasive burn wound sepsis is suspected (eg, on the basis of clinical deterioration, a change in the appearance of the burn, or an odor to the burn) definitive diagnosis can be obtained with quantitative burn wound cultures (requiring removal of at least 1 g of burned tissue at the bedside) with the microbiology laboratory alerted that quantitative wound cultures are being sent. Invasive burn wound sepsis is defined as more than 105 organisms/g tissue.

An alternative method of diagnosing invasive burn wound sepsis is by burn wound biopsy with histologic examination showing bacteria invading viable tissue.


Imaging Studies

Chest radiography can be helpful in patients who are intubated and in patients who have a suspected inhalation injury. Chest radiography is also required as part of a complete fever workup, as indicated.

Thermal imaging may prove useful in determining the depth of acute burns in children. A study by Ganon et al found the FLIR One Thermal Imager (FLIR Systems, Arlington, VA)—an inexpensive, noninvasive, and easy-to-use device—to have excellent specificity for measuring dermis perfusion as a reflection of burn depth in children; however, the sensitivity of the device was relatively low. [9]



Calculation of the percentage of TBSA burned can be performed by means of various approaches. The fastest initial estimate of percent BSA burned can be made by employing the pediatric rule of nines (see the image below). This is an adaptation of the adult rule of nines, which takes into consideration the observation that in children, the relative size of the head is larger and the relative size of the lower extremities is smaller.

Pediatric Rule of Nines. Pediatric Rule of Nines.

Next, Lund and Browder charts can be used to more precisely calculate the percentage of TBSA burned by mapping the injured areas of the body on charts detailing age-appropriate measurements (see the image below).

Lund and Browder Chart. Lund and Browder Chart.

Finally, burn involvement can also be calculated by using the patient's palm. This approach is particularly helpful for small scattered burns and is based on the estimate that the patient's palm (excluding the fingers) represents approximately 0.5% of TBSA.

Note that these are estimates and should be revised by burn care providers in order to achieve more precise calculation when necessary.