Management Of Children With Burns And Abscesses

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Management Of Children With Burns And Abscesses

• Ramla Habib M.D.
• July 2007

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BURNS

• Classification And Management

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EPIDEMIOLOGY

• Burns are the third leading cause of accidental
  death (following motor vehicle/pedestrian and
  drowning injuries) among children in the United
  States
• Scald injuries represent 4050 of all burns with
  the highest incidence in toddlers
• 16 of all burn injuries are non-accidental and
  50 of these are a result of abuse
• Flame burns resulting from playing with matches,
  gasoline, firecrackers, flammable aerosols
  continue to occur in the 6 to 14 year old group.

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CLASSIFICATION

• First-degree
• Involve only the epidermis and are characterized
  by swelling, erythema, and pain.
• Dry, red, painful, blanches with pressure.
• Healing time 3 to 6 days.
• Example sunburn

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First-degree burns
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CLASSIFICATION

• Second-degree (Partial thickness)
• Injury to the entire epidermis and a variable
  portion of the dermal layer
• Superficial partial-thickness
• Blisters, moist, red, weeping, blanches with
  pressure, extremely painful
• Healing time 7 to 20 days
• Example Scald (spill or splash)
• Deep partial-thickness
• Blisters (easily unroofed), wet or waxy dry,
  variable color patchy to cheesy white to red),
  does not blanch with pressure
• Healing time gt 21 days
• Examples Scald (spill), flame, oil, grease

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Partial thickness (Superficial Deep) burns
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CLASSIFICATION

• Third-degree (full-thickness)
• Involve destruction of the entire epidermis and
  dermis
• Waxy white to leathery gray to charred and black.
  Dry and inelastic with no blanching with
  pressure.
• Sensation to deep pressure only
• Can heal only by wound contraction or skin
  grafting, cannot epithelialize
• Examples Scald (immersion), flame, steam, oil,
  grease, chemical, electrical

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Full Thickness (third-degree burn)
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Lund and Browder chart
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(No Transcript)
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Rule Of 9s

• Frequently used method of estimating burn size
• It is modified for use with children
• 9 is taken from the legs and added to the head
  of a child lt 1-year-old. For each subsequent
  year, 1 is returned to the legs until 9 years
  old at which time the head is in proportion to
  the adult

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INDICATIONS FOR HOSPITALIZATION

• The American Burn Association recommends
  admission to the hospital for wound care,
  intravenous fluid administration, and pain
  management in the following situations
• Age lt10 years with 5 to 10 percent TBSA burn
• Age 10 years with 10 to 20 percent TBSA burn
• Full thickness burn 2 to 5 percent TBSA
• Burns involving face, neck, hands, feet, eyes,
  ears, genitalia, or joints
• High voltage/electrical injury
• Suspected inhalational injury
• Circumferential burn
• Concern for inflicted injury

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MANAGEMENT

• ALL burn patients go to USAMC for initial
  evaluation, wound is dressed and the patient is
  transferred to USACW for further care.
• Percentage of total body surface area burn is
  also calculated during initial assessment by the
  surgery resident
• Our goals of management
• Pain control
• Maintain optimum hydration and nutrition
• Wound Care (co-ordinate with physiotherapists,
  arrange for deep sedation if needed, follow wound
  cultures)

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PAIN CONTROL

• Usual pain meds
• 1. Tylenol with codeine (as needed for
  pain and for dressing changes if patient
  ready)
• 2. Morphine IV ( for dressing changes
  and for pain if needed)
• Other meds
• 1. Benadryl (Diphenhydramine)
• 2. Colace (Docusate)
• 3. Miralax (Polyethylene glycol)
• 4. Antibiotics

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HYDRATION

• The volume status of burn patients must be
  carefully monitored
• Urine output should be maintained at 1 to 2 mL/kg
  per hour for children lt30 kg and 0.5 to 1 mL/kg
  per hour for those gt30 kg
• Parkland Formula- 4 mL/kg per percent total burn
  surface area (TBSA). Add maintenance fluid for
  children lt5 years of age. (Half of the fluid is
  given over the first 8 hours. The remaining half
  is given over the next 16 hours)
• Heart rate is a better monitor of circulatory
  status in children than is blood pressure,
  although both can be elevated secondary to pain
• It is also important to encourage PO intake of
  fluids, most patients admitted to the floor would
  not require aggressive fluid resuscitation if
  they are able to take adequate volume PO.

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NUTRITION

• Provision of optimum nutrition is of utmost
  importance in burn patients to promote healing
• Poor appetite due to pain and/or prolonged NPO
  periods for deep sedations are common causes of
  interference with adequate nutrition
• Check pre-albumin (ideallygt18) biweekly in
  patients with prolonged hospitalization
• Some patients may need n/g feeds to meet the
  required caloric goals
• Older kids may benefit from super shakes
  (pediasureicecream) that provide 300 calories
  per serving
• Multivitamins also are not necessary in every
  single patient

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WOUND CARE

• Daily dressing changes are done by PT
  (physiotherapists), it is a good idea for at
  least one of the team members to be present
  during the dressing change if possible (as it is
  your only chance to actually see the burn!)
• Wound cultures are done three times a week, keep
  track of those
• The burn surgeon also evaluates the burns during
  dressing changes.
• Antibiotics (systemic) are NOT indicated
  routinely for all patients, however there can be
  several indications to start antimicrobials
  either on admission or later if needed
• Fever with or without abnormal CBC
• Positive wound/blood culture
• Old burns, extensive burns

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MANAGEMENT

• CHOICE OF ANTIBIBIOTICS
• Common pathogensstrep pyogenes,
  Enterobacter sp., S. aureus, S. epi, E. faecalis,
  E.coli, P. aeruginosa
• For Gram positive coverage Clindamycin (MRSA
  remains the most common pathogen)
• For gram negative coverage Ceftazidime
  (preferred due to anti-pseudomonal activity)

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CHEAT SHEET

• Remember to use the pre-printed burn order sheet!
• Some useful drug doses
• 1. Tylenol with codeine 0.5-1mg/kg/dose
  codeine PO Q4-6 hrs.
• Elixir 12mg codeine with 120 mg
  acetaminophen in 1tsp(5ml)
• Tylenol2 15mg codeine
• Tylenol3 30mg codeine All tabs
  have 300mg
• Tylenol4 60mg codeine
  acetaminophen
• 2. Morphine (IV/IM) 0.1-0.2 mg/kg/dose every
  2-4 hrs
• 3. Benadryl 1.25mg/kg/dose PO every 6 hrs
• Calorie contents of different formulas
• - 20 kcal/oz (standard infant formulas)
  0.6 kcal in 1 cc
• - 22 kcal/oz (enfacare) 0.7 kcal in 1 cc
• - 24 kcal/oz (special formulas) 0.8 kcal
  in 1 cc
• - 30 kcal/oz (Pediasure) 1 kcal in 1 cc

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DISCHARGE CRITERIA

• Tolerating dressing changes with PO pain meds
• Afebrile and good appetite
• Cleared by social services
• Outpatient daily wound care arranged (done by
  social services/PT)

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CASE 1

• An 18m old female suffered lt1 TBSA burn to
  her left foot when she pulled on to the cord of a
  hot curling iron and it landed on her foot. Her
  wound is dressed, she is active, alert, afebrile
  and her vital signs are stable. She finished an
  8oz bottle of milk while you were examining her.
  The patient does not have any other injuries or
  any underlying medical problems.

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ABSCESSES

• Assessment And Management

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SKIN ABSCESS

• DEFINITION
• Infection characterized by formation of purulent
  material due to the localized accumulation of
  polymorphonuclear leukocytes, with tissue
  necrosis involving the dermis and subcutaneous
  tissue.
• Large numbers of microorganisms are typically
  present in the purulent material.

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SKIN ABSCESS

• Can develop at any site on the body
• Insect bites, abrasions/lacerations, diaper
  rashes are the most common precursors
• Nasal or skin carriage of S.aureus predisposes to
  the formation of skin abscess
• Patients can have single or multiple skin
  abscesses
• Risk factors include diabetes, immunocompromise
  (HIV, transplant etc)
• They are usually painful, tender, and fluctuant
  red nodules, often surmounted by a pustule and
  surrounded by a rim of erythematous swelling

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MICROBIOLOGY

• The most common pathogen is S. aureus (MSSA or
  MRSA)
• There has been a substantial increase in the rate
  of community-associated methicillin-resistant S.
  aureus (CA-MRSA) infections
• Other organisms include Strep pyogenes, GBS and
  E.coli (in neonates)
• Clostridium perfringens, Psuedomonas aeruginosa,
  Vibrio vulnificus may cause necrotizing
  fasciitis

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Assessment

• Clinical assessment of the severity of infection
  is crucial, it is important to know
• When to admit for IV antibiotics
• When to incise and drain yourself
• When to arrange surgical drainage
• When to treat as an outpatient

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Management As Outpatient

• Treating as an outpatient is appropriate when
• The abscess is small
• Patient is afebrile and non toxic
• Spontaneously draining or incision drainage
  done in the clinic/Emergency dept.
• Antimicrobial therapy covers MRSA
• Abscess fluid sent for culture and in vitro
  susceptibility testing (if IDed)

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Indications For Hospitalization

• Presence of fever, constitutional signs,
  lymphadenopathy, extensive cellulitis
• Large abscess requiring ID in OR
• Abscess in certain areas (perianal, vulvovaginal)
• High CRP (gt 13) and WBC count
• THE CHILD LOOKS SICK! (poor appetite, decrease
  activity, difficult to arouse)
• It is the recommendation of IDSA that
  patients with soft-tissue infection accompanied
  by signs and symptoms of systemic toxicity (eg,
  fever or hypothermia, tachycardia, and
  hypotension have blood drawn for CBC with diff,
  CRP, culture, CPK, creatinine and bicarb

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Incision And Drainage

• Should be performed if the abscess feels
  fluctuant or has "pointed."
• Warm compresses may be tried prior to ID to
  promote spontaneous drainage
• Surgery consult is appropriate for any large/deep
  abscess or an abscess not spontaneously draining
• Send abscess fluid for culture and in vitro
  susceptibility testing.
• Treat all patients with empiric antibiotic
  therapy

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Antimicrobial Therapy

• CA-MRSA now accounts for the majority of
  community-acquired skin and soft tissue
  infections in both adults and children in many
  communities
• Empiric antibiotic therapy for uncomplicated skin
  abscess should cover CA-MRSA.
• Oral/IV clindamycin is a reasonable choice since
  local CA-MRSA resistance patterns indicate
  clindamycin susceptibility

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Antimicrobial Therapy

• For patients who have either cellulitis extending
  well beyond the rim of an abscess or signs of
  systemic toxicity or a positive blood culture,
  intravenous vancomycin therapy is suggested
• Therapy may be changed or modified later in light
  of culture and sensitivity results
• 1st generation cephalosporins or TMP/SMP can be
  used for most MSSA infections

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Antimicrobial Therapy

• Broad-spectrum coverage is given to patients with
  complicated oral, perianal, and vulvovaginal
  abscesses, because antibiotic therapy must be
  directed against "mixed" infection due to
  gram-positive, gram-negative, and anaerobic
  organisms.
• Preferred regimens in children are clindamycin
  and an aminoglycoside, such as gentamicin, or
  vancomycin, gentamicin, and metronidazole.

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Complications

• Most feared complication is disseminated
  infection with an invasive strain of MRSA
• Organisms can localize at any site
• Can lead to endocarditis, septic arthritis,
  osteomyelitis, empyema
• Persistent fever, positive blood cultures,
  elevated CRP should raise red flags

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Prevention

• http//www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMt
  gStrategies.pdf
• Table 3.56, RED BOOK 2006 (page 604)