burns in children and managment in PICU

1. Sheeba Hakak
Children’s university hospital,
Temple street.

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.  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.  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. Wounds caused by exposure to:
1. Excessive heat
2. Chemicals
3. Fire/steam
4. Radiation
5. Electricity
4 5

7. WoundWound
excision untilexcision until
fine punctatefine punctate
bleedingbleeding
occursoccurs

9. Partial thickness burn
=
involves epidermis
Deep partial thickness
=
involves dermis
Full thickness =
involves all of skin

10.  Involves only the
epidermis
 Tissue will blanch with
pressure
 Tissue is erythematous
and often painful
 Involves minimal tissue
damage
 Sunburn

11.  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

12.  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

13.  Involves
subcutaneous
tissue, tendons and
bone

14.  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.

15. % BSA involved morbidity
Burn extent is calculated only on individuals with second
and third degree burns
Palmar surface = 1% of the BSA

16.  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

17.  Head & Neck = 9%
 Each upper extremity (Arms) = 9%
 Each lower extremity (Legs) = 18%
 Anterior trunk= 18%
 Posterior trunk = 18%
 Genitalia (perineum) = 1%
17

18. ABA

19. 19Evans, 18.1, 2007)

20.  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.

21.  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

22.  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.

23.  FBC
 Clotting studies.
 Electrolytes,renal and liver function.
 CK if suspicion of significant tissue damage.
 Cross –match if early surgery anticipated.

24.  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.

25.  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

27.  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.

28.  Surgery and dressings
 Airway/ventilation
 Nutrition
 Antibiotics
 Miscllaneous

29.  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.

30.  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.

31.  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.

32.  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.

33.  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

34.  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.

35.  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.

36.  CO is a colourless and odourless gas caused by
incomplete combustion of organic matter including
fossil fuels.

38.  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.

39.  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.

40.  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.

41. 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

42.  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.

43.  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.