The ABCs of Burn Care for School Age Children - A Resource for School Nurses

Whether a student is opening a thermos at lunch, performing a lab experiment or playing on hot playground equipment, there are burn risks for children of all ages during the school day. As students head back to school this fall, it is important for school nurses to be aware of the common sources of burn injuries, the diagnosis and classification of burns, how to assess and manage burns, and when to seek care from a physician.

What is a burn?

A burn is an injury to the skin caused by heat, flames, chemicals or electricity. Scald burns caused by hot liquids are the most common cause of burn injury in young, school-age children. At 155^oF, it takes just one second for a deep burn injury to occur. At 120^oF, it takes five minutes of contact.

How should I initially manage a burn?

• The first steps are to stop the burning process! If emergency assistance is required, call 9-1-1.
• For all burns caused by heat, remove any affected clothing and cool the area with cool running water for at least two minutes. Avoid applying ice packs — ice will cause vasoconstriction, decreasing the blood flow to the wound, potentially worsening the injury.
• Chemical burns require irrigation with water to remove wet chemicals from the skin. Dry chemicals should be brushed off first, before starting irrigation. Eyes injured by the chemical agent should be flushed with either water or saline for at least 20 minutes and then sent for evaluation by a medical provider.

How do I assess the degree of a burn?

The degree (or depth) of a burn is dependent on how many layers of skin the burn penetrates. It is important to keep in mind that a burn will continue to progress in depth for the first 48-72 hours, so follow-up assessment of the injury is mandatory to accurately determine depth. ­­­

A first-degree burn affects only the epidermis, which is the outermost layer of skin. The skin remains intact but is reddened. These burns are painful initially. Fortunately, the redness and the pain will subside in three to five days and usually no scarring occurs.

A second-degree burn penetrates through the epidermis and affects the dermis, which is the deeper layer of skin. Blistering occurs because of this skin damage. The exposed dermis is pink and can vary from moist to dry depending on the depth of the injury.

• Superficial second-degree burn wounds can take from 7-21 days to form the first layer of fragile new skin after the injury. This new skin can then take another one to two months to mature back to usual thickness. The color will often take several months and sometimes up to a year to return to the usual pigmentation. Usually, superficial second-degree burns do not form raised scars.
• Deep second-degree burn wounds can take four to six weeks for the wound to heal These wounds are at increased risk of forming raised scars and may require skin grafting procedures.

A third-degree burn goes through all the layers of the skin down to the subcutaneous tissue or even deeper. These burns can be deceptively painless because the skin nerves have been destroyed. A third-degree burn will appear leathery and have no appreciable blanching. These wounds require surgical skin grafting for treatment.

How do I assess the size of the burn?

For small burns (smaller than a handprint), a ruler can be used to measure in centimeters. For burns larger than a handprint, you can obtain a quick estimate by using the child’s hand. The area of the hand (palm + fingers) is approximately equal to 1% of the total body surface area (TBSA). Burn specialists prefer to describe burns with regards to percentage of TBSA.

In general, burn injuries larger than 5 cm (or 2 inches) in diameter should be seen as soon as possible by a medical provider.

When may a student require transfer to a burn center? (This may be facilitated by a pediatrician or local emergency department depending on the extent of the injury.)

The American Burn Association suggests the following criteria for urgent evaluation of a burn injury:

• Second-degree burn injury greater than 10% TBSA (which is approximately an entire arm from hand to shoulder)
• Any third-degree burn injury
• Burn injuries to sensitive areas (eyes, face, hands, feet, major joints, genital region)
• Patients who may have inhalation injury
• Patients with chronic disease
• Any suspicion of child abuse

What should I do about any blisters?

For patients going to see a medical provider, the blisters should be left intact. Pain from a burn wound can increase significantly once the wound bed is open to air. It is highly recommended to give the patient pain medication prior to unroofing of blisters.

How should I cover the burned areas after cooling and/or irrigation?

If the patient is being sent to a medical provider immediately, cover the burn wound with a clean, dry dressing.

Otherwise, if the student is going home after school, a dressing of bacitracin ointment with gauze bandage should be applied to the burned area. Bacitracin ointment will cover the most common bacteria on the skin. Triple antibiotic ointment can also be used if bacitracin is not available.

If I have any questions or am uncertain about the burn injury, who can I contact?

Your closest burn center will always welcome inquiries and questions. Shriners Children’s operates verified burn centers in Massachusetts, Texas and California, and also provides specialized burn care in Ohio and Mexico. For more information and educational resources, visit our School Nurse Resources page.