Inflicted burns and scalds — formative SAQs

SAQ 1 (10 marks)

An eighteen-month-old boy is brought to the emergency department with a scald to both feet and lower legs. The burn stops at a sharp, clear line just above both ankles. His mother says he pulled a cup of hot tea over himself while standing at the coffee table. He is otherwise stable. On examination there are no splash marks and the depth is uniform across the affected area. [1] [2]

1. Give the most likely interpretation of this injury with the features that support it, and contrast it with the pattern expected from the stated history. (3) [1]
2. Outline your immediate clinical and safeguarding assessment, including the decision tool you would use and the investigations you would request. (4) [2] [3]
3. Describe the stepped management plan, naming the mandatory safeguarding steps and the parallel burn-care track. (3) [6]

Model answer — SAQ 1

(1) Interpretation and pattern contrast (3). The pattern is most consistent with an inflicted immersion scald: symmetrical stocking-glove distribution on both feet and lower legs with a sharp upper margin at a consistent height (the fluid level), uniform depth, and no splash marks. This does not fit the stated history of pulling a cup of tea, which produces an irregular splash pattern with tapering, dripping edges, variable depth, and visible splash marks on nearby skin or clothing. The uniform depth implies sustained contact (the limb held still in hot water), whereas a brief spill produces variable depth. [1]

(2) Assessment and investigation (4). Clinically, estimate the %TBSA with an age-appropriate Lund-Browder chart, assess depth at each site, provide analgesia, and cool with running water if within three hours. Apply the BuRN-Tool (Kemp 2018) to objectify and defend the suspicion of maltreatment. Perform a full top-to-toe examination looking for co-existing injuries — bruises, fractures, older scars — because Pawlik 2016 showed co-existent injury is common in referred children. Document the history verbatim from each informant, photograph the burn with consent and a ruler, and record discrepancies. Request a skeletal survey (the child is under two) to look for occult fractures, baseline bloods including coagulation, and convene a strategy discussion with social care and police. [2] [3]

(3) Stepped management (3). Run the burn-care and safeguarding tracks in parallel. Resuscitate and treat the burn (analgesia, fluids if large, dressing, burns-centre referral if criteria met). On the safeguarding track, the inflicted nature triggers mandatory notification to child protection or social care — the duty is statutory and overrides confidentiality. Convene a strategy discussion the same day; admit the child to a place of safety (the paediatric ward) and do not discharge home pending assessment. Follow up with a multi-agency case conference and a child-protection plan, plus prevention counselling. [6]