for a detailed examination of the size and depth of the wound A burn dressing should be placed immediately after wound assessment Management Blisters For minor burns, blisters provide a biologic dressing and intact blisters should not be ruptured, unless they are large, crossing joints or limiting activity, or those obscuring the assessment of the degree of overall injury Once the blister has ruptured spontaneously, it will likely need debridement to improve healing and prevent infection For these less extensive debridements, a single dose of intranasal or intramuscular opioids can be effective and avoid the need for placement of an intravenous catheter Ruptured blisters should be unroofed using gauze and sterile saline to remove devitalized tissue, and antimicrobial ointment should be placed on the exposed wound surface Dressings A superficial burn does not require dressing, and pain control with ibuprofen or acetaminophen can be given as needed Following cleaning, a topical dressing is applied directly to the wound surface We recommend bacitracin for the face, head, and perineum as well as the fingers and toes if there is a risk of ingestion, Polysporin Ophthalmic for periorbital burns, and silver sulfadiazine (Silvadine) or triple antibiotic ointment for all other burns Of note, Silvadine cannot be used in patients with a sulfa allergy Silver-impregnated dressings have also shown promising results Work to identify the best dressing to encourage healing and reduce infection risk is ongoing, and practice may vary based on provider or institutional preference Following the selected topical treatment, a nonadherent dressing is placed on the burn, which can then be wrapped with gauze Dressings should be changed twice each day The parent should rinse off residual antibacterial ointment with warm water and inspect the wound Signs of infection, such as redness and tenderness around the margin of the burn, warrant immediate evaluation by a physician A gray-greenish material formed by serous drainage from the burn mixing with the silver sulfadiazine cream is often mistaken for purulence If the burn is healing well, the parent should reapply the antibiotic ointment and dress the wound as demonstrated by the physician or nurse in the ED Burns should be examined by a physician every or days until healing is well underway Large burns or burns of the hands, feet, perineum, or overlying joints that are managed as an outpatient should be referred to a burn specialist and evaluated in follow-up more frequently Prophylactic antibiotics are not recommended Minor partial-thickness burns can be expected to have epithelial healing in to 14 days SPECIAL CIRCUMSTANCES Goals of Treatment Certain types of burns require special attention Clinicians should remain alert to historical and/or physical examination findings which suggest inflicted burn injuries, electrical injuries, and/or chemical burns Each of these burns warrants additional workup and specific treatment Inflicted Burns Child abuse must be considered in patients with specific patterns of burn injury Between 10% and 20% of burns in children are inflicted, accounting for 10% of child abuse cases Most inflicted burns are scalds Forced submersion of the hands or feet often causes burns that are deep, have a clear line of immersion, and are symmetric Scald burns of the buttocks and thighs in toddlers are frequently the result of forcible submersion in a tub of hot water Scald burns usually have scattered splash lesions In burns from spilled hot beverages, there is often a pattern of injury spreading downward from the falling liquid Inflicted contact burns also have characteristic patterns Small, round, deep burns result from cigarettes intentionally applied to the skin A deep wound with a geometric pattern and sharply demarcated borders suggests a contact burn Deep injuries with distinctive patterns may also be noted in children held against portable heaters or burned with irons In many children with inflicted burns, the pattern of injury is nonspecific and a history of abuse is not offered Physicians should make a judgment whether the characteristics of a burn correspond with the reported mechanism in a plausible way Identifying suspicious injuries and consulting with child abuse specialists can prevent subsequent injuries Electrical Burns Burns that result when electrical current passes through the body have unique characteristics Each year, there are more than 4,000 ED visits caused by electrical injuries, mostly in children Electrical burns account for 3% of burn center admissions and are increasing in number Most injuries occur in young children from contact with low-voltage (less than 120 V) alternating household current, often from mouthing plugs or extension cords Severe high-voltage (more than 500 V) injuries are also seen, often in adolescent boys as a consequence of risk-taking behaviors Thermal energy is released in proportion to the amount and duration of electrical current that passes through tissue Current flows preferentially through tissues of low electrical resistance, such as blood vessels, nerves, and muscles Moisture on the skin decreases resistance, accounting for the greater severity of electrical burn injury in the antecubital, axillary, popliteal, and inguinal areas Current arcing through the skin can ignite clothing and cause severe thermal burns in addition to the electrical injury In some direct current electrical burns, a depressed entrance wound and a blown out exit wound can be identified If the current traverses the heart, which occurs more often when the flow is arm to arm, a myocardial injury may occur Current through the heart at certain points of the cardiac cycle can induce ventricular fibrillation or asystole Electrical injury, especially by alternating current, can cause tetany of the musculature that may prolong the contact with the high-voltage source Tetany of the respiratory muscles can lead to suffocation The initial approach to patients of electrical burns is similar to that in other children with severe burns Electrical burns are usually more severe than they appear Significant deep and internal injuries may occur in patients with relatively small external burns Fluid requirements are higher than those predicted by formulas based on percentage of BSA because a larger portion of the injury is internal Destruction of muscle often causes myoglobinuria, so serum creatine kinase and urine for myoglobin should be tested Renal failure can usually be prevented with forced diuresis and alkalinization Electrical injury and edema within fascial compartments can cause a compartment syndrome requiring fasciotomy Patients with a normal electrocardiogram (rate and rhythm) in the ED not appear to be at significant risk for later development of arrhythmias Severe electrical injuries require extensive evaluation for internal injuries, which should be done at a pediatric tertiary care or regional burn center A common electrical injury occurs to the lips and mouth of toddlers who suck on plugs or extension cords Deep burns at the corner of the mouth require specialized attention to prevent severe scarring and contracture (see Chapter 105 Dental Trauma ) Bleeding from the labial artery to weeks after injury, when the eschar separates, can result in significant blood loss In previous years, children with electrical injuries were hospitalized for weeks, but most burn specialists now manage these children as outpatients after giving careful instructions to caregivers Chemical Burns More than 25,000 different caustic products are in use in the United States Most are either acidic or alkaline Acids cause coagulation of tissue proteins, which limit the depth of penetration Alkali results in liquefaction and deeper injury Some organic compounds, including petroleum products, damage tissue by dissolving the fats in cell membranes Caustic chemicals on the skin cause a prolonged period of burning compared with most thermal burns The patient may arrive in the ED with the chemical still present, and so careful attention to decontamination and avoiding staff exposure is crucial The chemical exposure should be removed as quickly as possible, most often using irrigation Close consultation with a toxicologist or poison control center is recommended as water irrigation can worsen some chemical burns, and specific antidotes are indicated for specific exposures (see Chapter 102 Toxicologic Emergencies for further details) Edema of the underlying tissue can make full-thickness injuries appear deceptively superficial A thorough examination is necessary to identify other areas of skin exposed from splashes or contact that also require irrigation Chemical burns to the eye can threaten vision and, after starting irrigation, require prompt consultation with an ophthalmologist Consultation with a burn specialist and admission are recommended at smaller percentages of BSA with chemical burns than with thermal injuries  ... electrical injuries require extensive evaluation for internal injuries, which should be done at a pediatric tertiary care or regional burn center A common electrical injury occurs to the lips and