Chapter 9 Common surgical problems Burns

1
Chapter 9Common surgical problemsBurns
2
Case study Alisher
Alisher, a 10 months old girl was brought to
the district hospital by her mother. At
presentation Alisher was very anxious, crying in
pain and was not able to breastfeed. On the upper
half of the chest there was a large scald.
3
What are the stages in the management of Alisher?
4
Stages in the management of a sick child (Ref.
Chart 1, p. xxii)

• Triage
• Emergency treatment
• History and examination
• Laboratory investigations, if required
• Main diagnosis and other diagnoses
• Treatment
• Supportive care
• Monitoring
• Discharge planning
• Follow-up

5
What emergency (danger) and priority (important)
signs have you noticed?
Temperature 37.20C, pulse 160/min, RR
45/min Chest burn on chest and upper abdomen (as
shown). Air entry was good bilaterally and there
were no added sounds.
6
Triage

• Emergency signs (Ref. p. 2, 6)
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
• Coma
• Convulsions
• Severe dehydration

• Priority signs (Ref. p. 6)
• Tiny baby
• Temperature
• Trauma
• Pallor
• Poisoning
• Pain (severe)
• Respiratory distress
• Restless, irritable,
• lethargic
• Referral
• Malnutrition
• Oedema of both feet
• Burns

7
History
At 6pm the previous day Alisher overturned a hot
teapot and was burnt. Her mother and relatives
took off her clothes and applied toothpaste and
potato to the burn skin. During the night the
child was very anxious and restless, by the
morning her condition had worsened and she could
not feed. Her mother brought her to the hospital.
8
Examination
Vital signs temperature 37.20C, pulse 160/min,
RR 45/min, Weight 9 kg Chest Burn on chest and
upper abdomen (as shown). Air entry was good
bilaterally and there were no added
sounds. Cardiovascular both heart sounds were
audible and there was no murmur Abdominal
examination soft, bowel sound was present Mouth
mildly dry mucus membranes Skin mildly decreased
skin turgor Diagnosis ? Burns
9
Two very important questions

• How much of the body is burnt?
• Use a body surface area chart according to age
  (Ref. p. 270)
• Alternatively, use the child's palm to estimate
  the burn area. A child's palm is approximately 1
  of the total body surface area

• How deep is the burn?
• Full thickness burns are black or white, usually
  dry, have no feeling and do not blanch on
  pressure.
• Partial thickness burns are pink or red,
  blistering or weeping, and painful

10
Further examination Estimate the total area
burned

• (Ref. p. 270)

11
How would you treat Alisher?
12
Treatment burns management

• Hospitalize all children with burns of the skin
  more than 10.
• Consider whether the child has a respiratory
  injury due to smoke inhalation.
• Fluid resuscitation (required for gt20 total body
  surface burn). Use Ringers lactate with 5
  glucose, normal saline with5 glucose or
  half-normal saline with 5 glucose.
• Calculate appropriate fluid requirements (Ref. p.
  269-271) and administer ½ of total fluid in first
  8 hours, and remaining in next 16 hours
• Pain control
• Paracetamol (10-15mg/kg every 6 hours) by mouth
  and / or IV morphine sulphate (0.05-0.1mg/kg
  every 2-4 hours) if pain is severe

• (Ref. p. 269-272)

13
Treatment burns management (continued)

• Prevent infection
• If skin is intact, clean gently with antiseptic
  solution
• If skin is not intact, debride the burn (blisters
  should be pricked and dead skin removed)
• Give topical antibiotics/antiseptics
• Clean and dress the wound daily, unless the burn
  is small and difficult to cover, then it can be
  managed by leaving it open to the air
• Treat secondary infection if present
• Check tetanus vaccination status and give tetanus
  immunoglobulin or toxoid booster as appropriate

• (Ref. p. 269-272)

14
What supportive care and monitoring are required?
15
Supportive care

• Nutrition
• Begin feeding as soon as practical in first 24
  hours
• High calorie diet with adequate protein, vitamin
  and iron supplements (Ref. p. 272)
• Children with extensive burns require about 1.5
  times the normal calorie and 2-3 times the normal
  protein requirements
• Prevention of secondary infection
• Hand washing

• (Ref. p. 269-272)

16
Supportive care (continued)

• Prevention of burn contractures
• Passive mobilization of involved areas
• Splinting flexor surfaces
• Physiotherapy
• Should begin early and continue throughout the
  course of the burn care
• Toys and play

• (Ref. p. 272)

17
Monitoring

• Observe the child frequently
• Monitor respiratory rate and look and listen for
  signs of airway obstruction and respiratory
  distress at the beginning
• Monitor adequacy of circulation and hydration
• Pulse
• Capillary refill
• Urine output
• Use a Monitoring chart (Ref. p. 320, 413)
• Ensure the child is calm and pain free and
  feeding adequately (Ref. p. 269-272)

18
Follow-up

• Plan discharge when there are signs of recovery
  of the burnt skin and the parents can care for
  the child at home. Notify parents on the date of
  follow up visit.
• Administer physiotherapy to minimise
  contractures.
• Accomplish a counseling about home safety and
  about first-aid management of burns (irrigate
  with cold water).

19
Summary

• Burns and scalds are associated with a high risk
  of mortality in children.
• It is important to avoid secondary infection
• Antiseptic
• Clean dressings
• Hand-hygiene
• Avoid unnecessary antibiotics
• Effective analgesia is the second main pillar in
  management of burns
• Initially, and for all painful procedures