Pediatric burns

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burns in children and managment in PICU

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Pediatric burns

  1. 1. Sheeba Hakak Children’s university hospital, Temple street.
  2. 2.  Burns and scalds account for 6% of peadiatric injuries.  The majority involve pre-school children,burns being most common between 1-2 yrs,flame burns bet 5-18 yrs.  House fires are the cause of most fatal burns with smoke inhalation being the immediate cause of death in many cases.  Scalds are most commonly associated with hot drinks in toddlers,also occur with over heated bath water and hot cooking oil.  Consider NIA in children.
  3. 3.  Children have nearly 3 times BSA:BM ratio of adults.consequently greater fluid requirements and more evaporative water loss than adults.  children <2yr have thinner layers of skin and insulating sub cutaneous tissue than older children and adults.Burn that may appear partial thickness may instead be a full thickness burn.
  4. 4.  Severity of burn is related with 1.Temperature and 2.Duration of contact.e.g., At 44c tissue damage occurs with 6hrs of contact with heat source while At 70c epidermal injury occurs in just 1sec.
  5. 5. Wounds caused by exposure to: 1. Excessive heat 2. Chemicals 3. Fire/steam 4. Radiation 5. Electricity 4 5
  6. 6. WoundWound excision untilexcision until fine punctatefine punctate bleedingbleeding occursoccurs
  7. 7. Partial thickness burn = involves epidermis Deep partial thickness = involves dermis Full thickness = involves all of skin
  8. 8.  Involves only the epidermis  Tissue will blanch with pressure  Tissue is erythematous and often painful  Involves minimal tissue damage  Sunburn
  9. 9.  Referred to as partial- thickness burns  Involve the epidermis and portions of the dermis  Often involve other structures such as sweat glands, hair follicles, etc.  Blisters and very painful  Edema and decreased blood flow in tissue can convert to a full-thickness burn
  10. 10.  Referred to as full- thickness burns  Charred skin or translucent white color  Coagulated vessels visible  Area insensate – patient still c/o pain from surrounding second degree burn area  Complete destruction of tissue and structures
  11. 11.  Involves subcutaneous tissue, tendons and bone
  12. 12.  PT and FTB with affected BSA>10% under 10yrs age.  PT and FTB with affected BSA>20% over 10 yrs age.  FTB with affected BSA>5%.  PT or FTB involving face,hands,feet,perinium or major joints.  PT or FTB involving an inhalational burn.  PT or FTB involving an electrical or chemical burn.
  13. 13. % BSA involved morbidity Burn extent is calculated only on individuals with second and third degree burns Palmar surface = 1% of the BSA
  14. 14.  Rule of Nines: Quick estimate of percent of burn  Lund and Browder: More accurate assessment tool Useful chart for children – takes into account the head size proportion.  Rule of Palms: Good for estimating small patches of burn wound
  15. 15.  Head & Neck = 9%  Each upper extremity (Arms) = 9%  Each lower extremity (Legs) = 18%  Anterior trunk= 18%  Posterior trunk = 18%  Genitalia (perineum) = 1% 17
  16. 16. ABA
  17. 17. 19Evans, 18.1, 2007)
  18. 18.  Weigh pt or perform accurate estimate.  Assess BSA.  Establish time and mode of burn injury and note time presentation.  Resusitate according to APLS,EPLS guidelines i.e., ABCs  Establish access rapidly.  Give analgesia.  Contact burn surgeon.  Consider need to protect airway and intubate.  If housefire or possibility of inhalational give 100% o2 and measure COHb levels.
  19. 19.  As the primary survey is starting ,give high flow o2 from face mask with a reservior bag.  A cervical collar should be applied if potential injury spine from a fall or escape.  Cooling the burn wound –cold running water for 15-20 min,avoid making pt hypothermic.  Prevent hypothermia-there is disruption to thermoregulation with a significant burn.  Insert min 2 peripheral cannula in unburnt skin if possible.  Fluid resusitate according to protocol
  20. 20.  Insert urinary catheter in all pts>20% BSA.  Fast the pt and insert NG tube for all pts with>20% BSA,all intubated pts,head and neck burns,younger children >10%BSA.  Adequate analgesia-IV opoids.  Emergency wound management e.g.,cling film or clean non-adhesive dressing.  Escharotomy if indicated e.g., circumferential burns around limbs or trunk.
  21. 21.  FBC  Clotting studies.  Electrolytes,renal and liver function.  CK if suspicion of significant tissue damage.  Cross –match if early surgery anticipated.
  22. 22.  Evidence of possible airway compromise: .burn to head and neck with swelling .stridor,hoarse voice,swollen lips. .singed facial ,nasal or head hairs. .carbonaceous mat in or around mouth or nose or sputum . Unconscious . If complex/severe burns which require significant interventions.
  23. 23.  RSI  Cuffed ETT used,as chest wall compliance may be reduced resulting in sig leak.  Intubation should be performed by experienced individual – failed attempts can create edema and further obstruct the airway
  24. 24.  4 ml R/L x % burn x body wt. In kg.  ½ of calculated fluid is administered in the first 8 hours  Balance is given over the remaining 16 hours.  Maintain urine output at 0.5 ml/kg/hr.  If evidence of extensive tissue damage then aim for a higher UO 1-2 ml/kg/hr.  Monitor sr electrolytes esp for hyponatremia.  In younger children calculate the maintenance fluids and add this to the resusitation fluids.
  25. 25.  Surgery and dressings  Airway/ventilation  Nutrition  Antibiotics  Miscllaneous
  26. 26.  Escharotomy may be needed for circumferential burns to limbs,neck or trunk.  Early surgical debridement of nectrotic tissue is preferred as early grafting is associated with improved outcome.  Scrubbing of affected skin is also frequently undertaken.  Blood loss during operative sessions can be large.
  27. 27.  Circulation to distal limb is in danger due to swelling. Progressive loss of sensation / motion in hand / foot. Progressive loss of pulses in the distal extremity by palpation or doppler.  In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.
  28. 28.  Early enteral nutrition ideally post pyloric.  Aim for a high calorie,high protein intake.  Supplement with parenteral if enteral feeding is not well tolerated.  Add trace element supplements.  If severe burns to perineum consider creation of an abdominal stoma to prevent faecal contamination.
  29. 29.  Prophylactic antibiotics are avoided.  Fever is universal after a severe burn and doesn’t mean infection.  Monitor wbc count,check frequent cultures.  There is no evidence to support routine line changes unless there is clear suspicion of line- related sepsis.
  30. 30.  Acute ulcerative gastro duodenal disease  Occur within 24 hours after burn  Due to reduced GI blood flow and mucosal damage  Treat pts with H2 blockers, mucoprotectants, and early enteral nutrition  Watch for sudden drop in hemoglobin 1 33
  31. 31.  Minor changes of dressings are often performed on ward with sedation and analgesia.  ICU pts are transferred to theater with sedative and analgesic infusions continuing.  If iv ascess is present,iv induction is appropriate otherwise inhalational induction.  Suxamethonium is best avoided from 5-150 days post burn because of risk of severe hyperkalemia.  Application of ECG dots,oximeter probes,NIBP cuffs may be difficult.  Dressing around the trunk may restrict ventilation and make airway management difficult.
  32. 32.  Burn >10% TBSA adult,>5% TBSA child.  Burn to:face,hands,feet,genitalia,perinium,or major joints.  Electrical and chemical burns.  Inhalational injury.  Circumferential burn to the limbs or chest.  Patients at the extremes of age.  Pts with poor medical condition,which may complicate treatment.
  33. 33.  CO is a colourless and odourless gas caused by incomplete combustion of organic matter including fossil fuels.
  34. 34.  Tissue asphyxia .CO decreases the o2 carrying capacity of Hb. .CO shifts the Hb dissociation curve to left. .CO binds to mitochondrial cytochromes , decreases ATP and increases free oxygen radicle production  Inflammatory activation. .free radicles activate inflammatory response. .perivascular changes cause neutrophil sequestration and activation. .releases reactive 02 species that cause brain lipid peroxidation.
  35. 35.  History to note: .h/o exposure especially fire. .duration of exposure. .neurological symptoms: headache,dizziness,loc,shortness of breath,loss of muscle control.nausea,amnesia.
  36. 36.  Examination: .signs of smoke inhalation. .cherry-red skin .hyperthermia. .resp:tachypnoea,hypoxia,crackels,abnormaly high pulse oximetry in face of hypoxia. .CVS:tachycardia,hypo or hypertension,dysrhythmia,myocardial depression and vasodialation. .Neurological:reduced conscious level,rigidity,brisk reflexes,hearing and visual loss,seizures. .opthalmology:retinal discoloration,flame shaped haemo,papllioedema.
  37. 37. COHb [%] Symptoms COHb[%] Symptoms 0-15 None [smokers] 15-20 Head ache,mild confusion. 20-40 Nausea and vomiting,disorientation,fatigue. 40-60 Hallucinatios ,ataxia,fits,coma. >60 Death
  38. 38.  ABG with co-oximetry.  HbCO% level  FBC-Hb  Lactate and acid base status.  CK-rules out rhabdomyolysis.  CXR  Head CT-If evidence of cerebral damage.
  39. 39.  Manage ABC  All pts with expected HbCO should receive 100% o2.  Half life of HbCO decreases from 320min to 30 -90 min in 100% o2.  Treat burns if indicated.  Treat brain injury if indicated.  Consider HBO therapy if HbCO>25% and if evidence of cerebral injury or myocardial dysfunction.

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