Integumentary Emergencies and Wound Care
Skin findings in children are common, but the emergency nurse must separate benign rashes from life-threatening eruptions and from injury patterns that suggest abuse. In burn care, estimate total body surface area using pediatric proportions: the infant head is roughly 18% and each leg about 14%, unlike adults. The palmar surface of the child's hand approximates 1%, which is useful for small or irregular burns. Arrange transfer to a burn center for burns over 10% TBSA, full-thickness burns, burns involving the face, hands, feet, perineum, or circumferential burns, and inhalation or electrical injury.
Assessment and stabilization
Stop the burning process, remove clothing and jewelry, and cover with clean dry dressings. Do not apply ice. Establish IV access through unburned skin when possible, and calculate fluid needs for larger burns while remembering added maintenance requirements in children. Assess the airway early for singed nares, soot, hoarseness, or stridor - these signal inhalation injury.
Infection and mucosal emergencies
Cellulitis requires marking the border and reassessment; a rapidly spreading, tender, ill-appearing child needs IV antibiotics. Impetigo is honey-crusted and contagious. Abscesses need incision and drainage. Watch for toxic shock (fever, rash, hypotension, multi-organ involvement) and for Stevens-Johnson syndrome/toxic epidermal necrolysis, where mucosal involvement, blistering, and a positive Nikolsky sign mean stopping the offending drug and managing as a burn patient.
Trap: symmetric, well-demarcated burns of the buttocks or feet, or burns sparing flexural creases, are classic for inflicted injury. Document objectively, photograph per policy, and report.
Rule of thumb: any burn in a preambulatory infant, or a "stocking" burn, is abuse until investigated.