Burns in Children Review

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Burns in Children Review

• Tarek Hazwani, MD
• Assistant Consultant Pediatric Intensivist
• King Abdulaziz Medical City

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Burns in Children Review

• Anatomy of Skin
• Pathophysiology
• Critical Factors
• Management

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Anatomy of Skin

• Largest body organ
• More than just a passive covering

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Anatomy

• Two layers
• Epidermis
• Dermis

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Skin Functions

• Sensation
• Protection
• Temperature regulation
• Fluid retention

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Burn Pathophysiology

• Loss of fluids
• Inability to maintain body temperature
• Infection

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Burn Pathophysiology

• Patients with large burns (15 percent TBSA for
  young children and 20 percent for older children
  and adolescents) develop systemic responses to
  these mediators.
• For patients with 40 percent TBSA or more,
  myocardial depression can occur .
• As a result, patients with major burns may become
  hypotensive (burn shock) and edematous (burn
  edema).

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Burn PathophysiologyMetabolic response 

•  Following resuscitation, children with major
  burns develop a hypermetabolic response that
  results in a dramatic increase in energy
  expenditure and protein metabolism .
• Evidence suggests that modulation of the
  hypermetabolic response with therapies such as
  beta blockers and human growth hormone may
  improve outcomes for severely burned children

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Pathophysiology

• Systemic capillary leak usually persists for 18
  to 24 hours. Protein is lost from the
  intravascular space during the first 12 to 18
  hours after a burn, after which vascular
  integrity improves.

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Critical Factors

• Depth
• Extent

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Burn Depth

• First Degree (Superficial)
• Involves only epidermis
• Red
• Painful
• Tender
• Blanches under pressure
• Possible swelling, no blisters
• Heal in 7 days

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Burn Depth

• Second Degree (Partial Thickness)
• Extends through epidermis into dermis
• Salmon pink
• Moist, shiny
• Painful
• Blisters may be present
• Heal in 7 to 21 days

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Burn Depth

• Burns that blister are second degree.
• But all second degree burns dont blister.

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Burn Depth

• Third Degree (Full Thickness)
• Through epidermis, dermis into underlying
  structures
• Thick, dry
• Pearly gray or charred black
• May bleed from vessel damage
• Painless
• Require grafting

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Burn Depth

• Often cannot be accurately determined in acute
  stage
• Infection may convert to higher degree
• When in doubt, over-estimate

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Burn Extent

• Pediatric Rule of Nines

For each year over 1 year of age, subtract 1
from head, add equally to legs.
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Burn Extent

• Rule of Palm
• Patients palm equals 1 of his body surface area

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Burn Extent
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Burn Severity

• Based on
• Depth
• Extent
• Location
• Cause
• Patient Age
• Associated Factors

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Critical Burns Need Burn centre American Burn
Association

• Age lt10 years with gt10 percent TBSA burn
• Age 10 years with gt20 percent TBSA burn
• Full thickness burn gt5 percent TBSA
• Inhalational injury
• Any significant burn to face, eyes, ears,
  genitalia, or joints
• Significant associated injuries (fractures or
  major trauma)

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Associated Factors

• Patient Age
• lt 5 years old
• gt 55 years old
• Burn Location
• Circumferential burns of chest, extremities

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Burn shock

• characterized by specific hemodynamic changes
  (decreased cardiac output and plasma volume,
  increased extracellular fluid, and oliguria)

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Burn Edema

• Fluid shift intravascular to extravascular soon
  after a burnpersist for the first 24 hours
• In small burns edema peaks early, in large burns
  edema developed continue for 18-24 hours
• Unburned tissue edema occurs when burn exceeds
  35-40 TBSA
• Early increase vascular permeabilityin part
  related to histaminemechanism is likely related
  to PMN and their adhesion to the endothelium

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Burn Management
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Stop Burning Process

• Remove patient from source of injury
• Remove clothing unless stuck to burn
• Cut around clothing stuck to burn, leave in place

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Assess Airway/Breathing

• Start oxygen if
• Moderate or critical burn
• Decreased level of consciousness
• Signs of respiratory involvement
• Burn occurred in closed space
• History of CO or smoke exposure
• Assist ventilations as needed

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Assess Circulation

• Check for shock signs /symptoms

Early shock seldom results from effects of burn
itself. Early shock Another injury until proven
otherwise
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Obtain History

• How long ago?
• What has been done?
• What caused burn?
• Burned in closed space?
• Loss of consciousness?
• Allergies/medications?
• Past medical history?

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Rapid Physical Exam

• Check for other injuries
• Rapidly estimate burned, unburned areas
• Remove constricting bands

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Treat Burn Wound

• Cover with DRY, CLEAN SHEETS
• Do NOT rupture blisters
• Do NOT put goo on burn

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Special Considerations

• In Pediatrics always
• Consider possibility of abuse
• As many as 10 of abuse cases involve burns

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Burn Management

• Parkland formula, as follows
• (2-4 cm3 of crystalloid) X ( BSA burn) X (body
  weight in kg)
• The Parkland formula must be modified in
  pediatric patients by adding maintenance

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Burn Management Fluid resuscitation

• Estimating fluid requirements for the first 24
  hours following a burn injury include
• Parkland - 4 mL/kg per percent total burn surface
  area (TBSA). Add glucose maintenance fluid for
  children lt5 years of age.
• Galveston - 5000 mL/m2 per percent TBSA. Add 2000
  mL/m2 per day for maintenance requirements.
• Half of the fluid is given over the first 8
  hours. The remaining half is given over the next
  16 hours

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Burn Management Fluid resuscitation

• Choice of fluid
•  Ringers lactate (RL) is the resuscitation and
  maintenance fluid of choice for the first 24
  hours at most burn centers.
• Experts recommend adding D5 to maintenance fluid
  for children lt20 kg to prevent hypoglycemia .
• Colloid is typically added after 24 hours to
  restore oncotic pressure and preserve
  intravascular volume

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Burn Management Colloid resuscitation

• The addition of plasma or albumin to
  resuscitation fluids has been criticized on the
  assumption that the burn-induced increase in
  vascular permeability and the consequent
  extravasation of proteins persist for up to 36 h
  post injury .
• The main concern is that protein administration
  during the first 24 h increases protein
  accumulation in the interstitium and thus traps
  water .
• Using 131iodine-labeled albumin and
  autoradiographic techniques to demonstrate have
  shown that effective transcapillary sieving of
  albumin molecules into burned skin essentially
  stops at approximately 8 h post injury and that
  edema of injured tissues, maximal at 3 h post
  burn, persists beyond24 h post injury

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Burn Management Fluid resuscitation

• Monitoring fluid status
•  The volume status of burn patients must be
  carefully monitored in order to successfully
  navigate the narrow path between inadequate
  volume and fluid overload. The following
  parameters are helpful
• 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 30 kg.
• Heart rate is a better monitor of circulatory
  status in children than is blood pressure.
  Tachycardia may indicate hypovolemia, but pain
  can elevate heart rate in euvolemic patients.
• Metabolic acidosis can be a marker for inadequate
  fluid resuscitation, but also occurs with carbon
  monoxide or cyanide exposure

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Burn Management Fluid resuscitation

• Burn Children not response to large fluid volumes
  to maintain adequate perfusion
• Volume loss from occult injuries
• Neurogenic shock as the result of a spinal cord
  injury
• Myocardial depression or decreased vascular tone
  from inhaled or ingested toxins

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Burn Management Pain control

• Most burn centers use
• morphine 
• Fentanyl may be a safer choice for initial pain
  management for patients whose cardiovascular
  status may be unstable

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Burn Management Antibiotics

• Topical antibiotics have been used to dress burn
  wounds
• It is available, and reduce the risk of
  infection.
• The topical antibiotic is applied to the wound
  which is then covered with a nonadherent
  dressing.
• Specific antibiotic Silver sulfadiazine ,
  Mafenide , Bacitracin

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Burn Management Special Considerations

• Steroids have no role in treating burn wounds
• Intravenous antibiotics are not recommended in
  the initial treatment of most burn patients, as
  it may increase the chance of colonization with
  more virulent and resistant organisms. They
  should be reserved for those patients with
  secondary infections

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Burn Complications Infection

• Early Infections
• Organism GAS , S. aureus
• Specific colonization of burn wounds is somewhat
  predictable over time. Initially, gram-positive
  organisms are present
• infection that occurs in the first 48 hours after
  the burn is usually secondary to GAS.
• The incidence of GAS infections in burned
  patients has decreased, probably secondary to
  immediate use of topical antimicrobial therapy.
• Routine administration of antibiotics
  prophylaxis is not recommended ( colonization and
  potential infection with more resistant
  organisms).
• S. aureus also causes early septicemia. If there
  is concomitant inhalation injury.

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Burn Complications Bacteremia

• Bacteremia is not uncommon in the burned patient.
  
• Risk factors include wound manipulation and the
  presence of an intravascular catheter.
• infected intravascular thrombus can cause
  persistent bacteremia.
• Endocarditis must be considered in any patient
  with prolonged bacteremia.

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Burn Complications Renal failure

• ARF in burn patients is not common. Two distinct
  pictures
• of ARF can be observed early ARF, occurring
• either few hours after injury or in the first few
  days,
• and late ARF developing approximately 1 or more
• weeks after burn injury. Early ARF may be due to
• hypovolemia and hypoperfusion of the kidneys,
• whereas late ARF is a consequence of infection,
  endotoxemia,
• and MODS

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Burn Complications Renal failure

• Renal damage can arise even from hemoglobinuria
• in burn patients with associated hemolysis, the
  administration of haptoglobin may prevent
  hemoglobinuria-nduced renal failure

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Inhalation Injury
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Inhalation Injury

• 10-20 hospitalized burn patients sustained
  inhalation injury.
• Increased mortality
• History (closed space)
• P.E. (facial burn, singed nasal hairs, erythema,
  carbonaceous material in back of the troat)
• laboratory tests (carboxyhemoglobingt15) and
  bronchoscopy (erythema and sooty deposite in the
  airway)
• Treatment supportive. Nasotracheal or
  endotracheal intubation preferable to early
  tracheostomy. Prophylactic antibiotics and
  steroids not indicated.

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Inhalation Injury Problems

• Hypoxia
• Carbon monoxide toxicity
• Upper airway burn
• Lower airway burn

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Inhalation Injury Carbon Monoxide

• Product of incomplete combustion
• Colorless, odorless, tasteless
• Binds to hemoglobin 200x stronger than oxygen
• Headache, nausea, vomiting, roaring in ears

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Inhalation Injury Carbon Monoxide
Exposure makes pulse oximeter data meaningless!
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Inhalation Injury Carbon Monoxide Measurement

• Carbon monoxide has various effects depending
  upon levels
• Must check levels on Blood Gas analysis
• ???? 0-10 can be seen in smokers can be
  seen in smokers
• ???? 10-20 patients can have headache
• ???? 20-30 patients develop severe
  headache, nausea, vomiting, CNS collapse
• ???? 30-40 patients present with
  syncope, convulsions, depressed cardiac activity
  and respiratory function
• ???? 40 and greater death may ensue
  within hours

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Inhalation Injury Upper Airway Burn

• True Thermal Burn
• Danger Signs
• Neck, face burns
• Singing of nasal hairs, eyebrows
• Tachypnea, hoarseness, drooling
• Red, dry oral/nasal mucosa

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Inhalation Injury Lower Airway Burn

• Danger Signs
• Loss of consciousness
• Burned in a closed space
• Tachypnea (/-)
• Cough
• Rales, wheezes, rhonchi
• Carbonaceous sputim

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Electrical Burns
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Electrical Burns Considerations

• Intensity of current
• Duration of contact
• Kind of current (AC or DC)
• Width of current path
• Types of tissues exposed (resistance)

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Electrical Burns Considerations

• Conductive injuries
• Tip of Iceberg
• Entrance/exit wounds may be small
• Massive tissue damage between entrance/exit

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Electrical Burns Management

• Make sure current is off!
• Check ABCs
• Assess carefully for other injuries
• Patient needs hospital evaluation, observation

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Electrical Injury Complications

• If gross urinary pigment is present sodium
  bicarbonate and mannitol are initially given in
  addition to Ringers lactate.
• Diuretics in contraindicated.
• Urine output maintained 100-125 ml/h until it is
  seen to clear
• Precipitate cardiac arrhythmia,routine cardiac
  monitoring not necessary, unless cardiac arrest
  at accident, abnormal EKG, arrhythmia during
  transport

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Electrical InjuryOther Complications

• Respiratory arrest
• Spinal fractures
• Long bone fractures

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Chemical Burns
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Chemical Burns

• Alkaline substances such as sodium and potassium
  hydroxides and cements are most common cause of
  chemical burn
• Direct chemical reaction instead of heat
  production
• Often underestimated. Immediate treatmentcopious
  tap water lavaging

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Chemical Burns Concerns

• Damage to skin
• Absorption of chemical systemic toxic effects
• Avoiding EMS personnel exposure

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Chemical Burns Management

• Remove chemical from skin
• Liquids
• Flush with water
• Dry chemicals
• Brush away
• Flush what remains with water

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Chemical BurnsInjuries require special care

• Hydrofluoric acid treated with a paste
• made of 35 ml of 10 calcium gluconate
• in 150 gm of K-Y jelly. Applied to the
• affected area and changed every hour if
• needed. More severe case require
• subcutaneous injection of calcium
  gluconate into the painful area

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Chemical BurnsInjuries require special care

• Phenol not soluble in water. Absorbed
  through intact skin. Topical application of
  polyethylene glycol or vegetable oil
• Phosphorus keep the areas copiously irrigated
  and continuously wet with water, early
  debridement of extraneous particles

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Chemical BurnsInjuries require special care

• Cement rinsed with water until the soapy feeling
  disappear, then dried thoroughly
• Tar respond well to application of bacitracin or
  neomycin ointment for 12 hours, then washed off
  and silver sulfadiazine applied

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• Thank You