Case 7

The 20-month-old toddler in the photograph below was well until the day of admission. His mother reports that she put Ramen noodles in the microwave, turned the microwave on and momentarily left the room. She returned when she heard the child crying. She saw that he had pushed a toy chest in front of the microwave and had hot noodles on his chest and abdomen. He was wearing a one-piece pajama outfit that she quickly removed.

Image description below
Source: A. S. Botash, MD, used with permission

Accessible Version

3 photos: Photo 1: An injury to the skin on a toddler’s chest that is inflamed and irregular, extending to under the axillae on the left, with surrounding redness and a central area of yellowed granulation tissue. Photo 2: Red, blistered injuries to the left hand and anterior distal arm, and on the child’s thumb, thenar eminence, and distal anterior wrist. There is black discoloration on the tip of the 2nd digit, and on the dorsal distal interphalangeal joint (back) of the 3rd digit. Photo 3: An injury to the anterior left thigh with irregular red borders and a central area of yellowed granulation tissue.

Which of the following most accurately reflects the situation?

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A. The pattern of the injury is not consistent with a hot liquid scald over pajamas.

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B. The timing of the injury is not consistent with the finding of granulation tissue.

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C. Approximately 15% of the body surface area is burned.

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D. The black discoloration of the fingers indicates superficial partial thickness burns.

Which of the following most accurately reflects the situation?

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A. The pattern of the injury is not consistent with a hot liquid scald over pajamas.

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B. The timing of the injury is not consistent with the finding of granulation tissue.

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C. Approximately 15% of the body surface area is burned.

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D. The black discoloration of the fingers indicates superficial partial thickness burns.

The best answer is B

A burn in the kitchen is likely to be accidental and likely to be a scald burn. However, the term accidental does not rule out the possibility of neglect. Approximately half of all scald burns in the kitchen involve children pulling a pot of hot liquids onto themselves. Accidental burn margins are likely to be irregular and asymmetrical, as in this case. This case demonstrates a classic pattern for hot scald with a common culprit, Ramen noodles. Having the pajamas on may have been a little protection but may have actually resulted in worse burns due to the hot clothing continuing to be in contact with the skin.

Granulation tissue invades a wound at about 4 days. This burn is already on its way to healing well. There are no longer any blisters, seen the first day or two, and there is evidence of yellow granulation tissue.

Using the rule of eights, much less than 15% of the body surface area is burned. Less than half of the anterior chest is burned (6.5% at the most), and less than half of one anterior portion of the thigh (less than 4%), and approximately 1% of the hand. This is a maximum total of 11.5%. The rule of eights is generally calculated as follows for infants weighing less than 10kg: 8% for each arm, 8 x 2 or 16% for each leg, 8 x 4 or 32% for the trunk, and 20% for the head.

The rule of nines may be used to provide estimates of body surface area for patients weighing 10 to 80 kg. If you use the rule of nines, it is closer to a maximum total of 13%, but still not 15%. Note that in obese patients the percentages are further modified.*

Black or white discoloration usually indicates full thickness burns. In this case, it is probably a thermal burn from picking up the cup, but could be a scald burn.

The patient in this case was brought in 4-5 days after the accident. His mother was treating him at home and initially gave a false history regarding the timing of the event. A scene investigation showed that he could move the toy chest and reach the microwave. However, the delay in seeking healthcare prompted a neglect investigation.

Case 7

Accessible Version

Which of the following most accurately reflects the situation?

Which of the following most accurately reflects the situation?

The best answer is B

Further Reading