burns in pediatrics: statistics, classification, topical treatment

1. BURNS IN PEDIATRICS
Ella Dayan
RN BA
Shaare Zedec Medical Center
Jerusalem,
Israel
May 2018
eladayan@013.net

2. STATISTIC FACTS (ISRAEL)
The Israeli Ministery of Health :
 3002 total registered visits of children who suffered from burns, to
ERs and different kinds of primary clinics (2015)
(should be considered a large number of unreported cases).
 Statistics from the ERs of 10 average hospitals in Israel from 2010-
2016 show that more than 50% of the pediatric burns in patients
were caused by hot liquids of different sorts.

3. STATISTICS FACTS (ISRAEL) 2
80% of pediatric burn hospitalizations were caused by
hot liquids.
2008 - 2016 – 47 children died in a fire.
 64% of them were of Arab origin. (This is 2.4 times more
than the share of the Arab population in the general
population of Israel)
Burn victims make up 5.5% of all deaths due to traumatic
injury

4. GENERAL WORLDWIDE STATISTIC
FACTS
Children aged 0 – 4 are at the highest risk of
suffering pediatric burn injuries.
 A significant increase of visits to ERs and primary
clinics due to burns has been observed on weekends.
 Most burn injuries occur in the home and in the
yard, and half occur in the kitchen.
Most burns occur in the presence of parents,
grandparents and other caregivers, (like babysitters,
older brothers and sisters).

5. GENERAL WORLDWIDE STATISTIC FACTS
2
 Hot tap water burns cause
more deaths and
hospitalizations than burns from
any other hot liquids.
 Flame 57% • Hot fluids and
32% • Chemical 7% • Electricity
& Radiation 4%

6. GENERAL WORLDWIDE STATISTIC FACTS 3
Children from low income homes have 8 times the risk of
receiving severe burns than those from higher income homes
.
Severity of burns is inversely proportional to decreasing
Socioeconomic Status; burn mortality is higher among
children from lower SES

7. GENERAL WORLDWIDE STATISTIC
FACTS 3
 Majority of burn victims are under 2 years of age
 Scalding by hot fluids and extreme heat sources is the most
common cause
 The location of burns that raise suspicion of child abuse
are: Perineum, Ankles, Wrists, Palms, Soles.
 Other suspicious factors:
 Burns with clean line of demarcation
 presence of previous medical records about injures
 Contradictory evidence about the “accident”
 Delays in seeking treatment

8. GENERAL WORLDWIDE STATISTIC
FACTS 4
In 2015, there were 67 million fire and heat caused
injuries. This caused about 2.9 million hospitalizations
and 176,000 deaths.
Most deaths due to burns occur in the developing
world, particularly in Southeast Asia.
 In the United States, 95% of patients with burn
injuries that show up to the ER are immediately
treated and discharged; only 5% require hospital
admission

9. BURNS CLASSIFICATION
ABA classification based on a
number of factors:
 Total Body Surface Area of injury
Involvement of specific anatomical
zones
 The age of the person
 Other associated injuries
American Burn Association
generally classifies the burns as:
 Major
 Moderate
Minor

10.  Due to the differences in body proportions
between BABIES, CHILDREN, and ADULTS, the
Baby Burns percentage distribution is also
different.
 It’s still close to the “nines rule”, but has some
variations.
 Generally: 5% burn in a child is equivalent to
the severity of 10% burn in an adult
AREA COUNTING FOR BABIES AND YOUNG CHILREN

11. THE BURNS PERCENTAGE DISTRIBUTION IN CHILDREN

12. THE “LUND-BROWDER CHART”

13. PATHOPHYSIOLOGY

14.  There are also fourth degree burns;
fortunately they are very rare
 Burn injury in the 4th degree
includes subcutaneous tissues,
muscles, tendons and bones…
CLASSIFICATION

15. CLASSIFICATION OF BURNS:

16. SEVERITY CLASSIFICATION:

17. BURNS MANIFESTATION ACCORDING
THE 3 DEGREE SCALE
1-st degree (superficial)
Layers involved : EPIDERMIS
Appearance: REDNESS (no blisters)
Texture: DRY
Sensation: PAINFUL
Healing time: 5-10 DAYS
Prognosis:
o HEALS WELL.
o NO SCARS.
o REPEATED SUNBURNS INCREASE THE RISC OF
SKIN

18. 1-st degree (superficial)

19. BURN MANIFESTATION ACCORDING THE
3 DEGREE SCALE
2nd degree (superficial partial thickness)
Layers involved : EXTENDS TO SUPERFICIAL
(PAPALLAR) DERMIS
Appearance: REDNESS WITH BLISTERS (CLEAR FLUID).
THE RED SURFACE BLANCHES WITH PRESSURE.
POSSIBLE PRESENTATION OF SMALL YELLOW/WHITE AREAS
Texture: MOIST
Sensation: VERY PAINFUL
Healing time: 2-3 WEEKS
Prognosis:
o LOCAL INFECTION
o CELLULITIS.
o USUALLY NO SCARRING

20. 2ND DEGREE (SUPERFICIAL PARTIAL THICKNESS)

21. 2ND DEGREE
(SUPERFICIAL/DEEP PARTIAL THICKNESS)

22. BURN MANIFESTATION ACCORDING THE
3 DEGREE SCALE
2nd degree (deep partial thickness)
Layers involved : EXTENDS TO DEEP (RETICULAR)
DERMIS
Appearance: YELLOW OR WHITE SURFACES. MAY BE
BLISTERING, LESS BLANCHING.
Texture: RELATIVELY DRY
Sensation: LESS PAINFUL.
PERCEPTION OF PRESSURE AND DISCOMFORT
Healing time: 3-8 WEEKS
Prognosis:
o SCARING
o CONTRACTURES
o MAY REQUIRE SKIN GRAFTING

23. 2-nd degree (deep partial thickness)

24. BURNS MANIFESTATION ACCORDING
THE 3 DEGREE SCALE
3-rd degree (full thickness)
Layers involved : EXTENDS THROGH ENTIRE
DERMIS
Appearance: STIFF AND WHITE/BROWN. NO BLANCHING.
Texture: TOUGH, HARD TEXTURE
Sensation: PAINLESS
Healing time: MONTHS
Prognosis:
o SCARING
o CONTRACTURES.
o AMPUTATION
o EARLY EXCISION RECOMENDED

25. 3-RD DEGREE (FULL THICKNESS)

26. BURN MANAGEMENT
The treatment of burns is very complex and
requires the use of many therapeutic
resources to maintain all life- supporting
systems of the body.
Sometimes performance of an Escharotomy
and/or Fasciotomy is needed to prevent
Compartment Syndrome.
Extensive, life-endangering burns are treated
in special intensive care units and Burn-
Centers.

27. BURNS MANAGEMENT
This presentation regards
only the topical treatment of
burns, with the curative
materials and medications
used in the department of
pediatric surgery. The children
who arrive at the Pediatric
Surgery Department have
generally already undergone
treatment in the ER or PICU.

28. THE GENERAL PRINCIPLES OF BURN
MANAGEMENT IN HOSPITALISATION
Giving pain-reducing
medications before painful
procedures, by considering
the time of the onset of
severe pain, and the peak
time of medication
influence.
Covering the wounds with
sterile materials to prevent
contamination.
Providing High-calorie,
high-protein meals to
provide augmented
protein and meet calorie
requirements of increased
metabolism and
catabolism

29. THE GENERAL PRINCIPLES OF BURN
MANAGEMENT IN HOSPITALIZATION 2
Wrapping fingers and toes separately to
avoid tissue adherence from prolonged
contact
Any dressings that have adhered to the
wound can be removed by applying tepid
water. Easily detached tissue is also
debrided during the cleansing process
Use room temperature water.
Before pouring water on the burn area, start
to pour warm and pleasant water on healthy
areas of the body to prevent negative
feelings and objection.

30. THE GENERAL PRINCIPLES OF BURN
MANAGEMENT IN HOSPITALIZATION 3
 Creams and ointments should not be
applied directly to a burn surface, but to
dressings materials, which are then
applied to the injured sites
 Apply the bandage in a figure-eight to
promote optimum circulation.
 Elastic bandages are recommended to
prevent epithelial breakdown, decrease
edema formation, stimulate circulation
and improve mobility.
 Not necessary to use dressings on burns
on the face area.
 Involving special staff: nutritionist,
physiotherapist and educational team,
medical clowns, volunteers, etc.

31. THE TREATMENT OF BURNS
BURN SHIELD
 It is a remarkable Sterile, Hydrogel (wet) product
 Provides the essential physical protection urgently
needed when someone is accidentally burnt.
 Safe for use on children
 Highly effective within the first 24 hour period.
THE DRESSING MATERIALS AND MEDICATIONS
• Burnshield provides constant relief in terms
of cooling.
• Burnshield provides the ability to transport
the patient to nearest facility.
• Burnshield provides covering for the burn.
• For use within the first 24hr period

32. THE TREATMENT OF BURNS
Silver Sulfadiazine
 topical antibiotic used in partial thickness and full thickness burns
to prevent infection.
Silver sulfadiazine was discovered in the 1960s as an effective and
safe medicine for burn-care
Silver sulfadiazine must not be used on premature babies or on
newborns during the first 2 months of life because of the risk of
serious side effects.
THE DRESSING MATERIALS AND MEDICATIONS
Silver Sulfadiazine
 Once or twice daily dressing
 Clean the damaged area before every application, to remove
dead tissues and wound secretions.
 Significant side effects are:
 Leucopenia
 Thrombocytopenia
 Haemolysis (G6PD defficiancy)
 Transfered by breast milk

33. THE TREATMENT OF BURNS
THE DRESSING MATERIALS AND MEDICATIONS
SULFAMYLON® (mafenide acetate) is an antimicrobial
topical sulfanilamides group medicine.
Has bacteriostatic action against broad spectrum of
gram-positive and gram-negative agents
Safe for pediatric usage after the age of 3 months
Provided in packets containing 50 g of sterile
mafenide acetate to be reconstituted in 1000 mL of
Sterile Water USP or 0.9% Sodium Chloride .
After mixing, the solution contains 5% w/v of
mafenide acetate.
The reconstituted solution may be used for up to 28
days after preparation if stored in unopened
containers. ONCE A CONTAINER IS OPENED, ANY
UNUSED PORTION SHOULD BE DISCARDED AFTER
48 HOURS. Store the reconstituted solution at 20° to
25°C
the gauze dressing may be moistened every 6-8
hours or as necessary to keep wet.
SULFAMYLON

34. THE TREATMENT OF BURNS
THE DRESSING MATERIALS AND MEDICATIONS
Despite being a medication with great potential,
and the ability to penetrate through the thick,
contaminated injured tissues, this drug is not
widely used because of:
PAIN!!!
Metabolic acidosis.
The caregivers should pay attention when the
following symptoms appear:
Rush, difficulty breathing; swelling of face, lips,
tongue, or throat.
Pale or yellowed skin, dark colored urine, fever,
confusion or weakness
Chest pain, fast or pounding heartbeat, headache
Nausea, vomiting, stomach pain, appetite
changes, muscle weakness, bone pain, and weight
loss

35. THE TREATMENT OF BURNS
AQUACELL
 Dressing may be left in place up to 14 days . Change
secondary dressing more frequently if saturated
 To remove, soak in water/saline 30 minutes . Mineral
oil may be used to remove stubborn dressing pieces .
 Patient may also be instructed to shower to allow
warm water to release dressing
 AQUACEL® Ag dressing begins to detach as healing
continues, and fully detaches as wound heals.
THE DRESSING MATERIALS AND MEDICATIONS
AQUACEL
 The AQUACEL Burn is a Hydrofiber dressing reinforced with nylon, and is
an absorbent, sterile, non-woven hydroentangled dressing.
 This conformable dressing is highly absorbent of wound fluid and
creates a soft gel which maintains a moist environment
 Supports the body’s natural healing process and aids in the removal of
unnecessary material from the wound, without damaging newly formed
tissue
 Reduces risk of infection due to ionic silver – a proven antimicrobial –
that kills a broad spectrum of pathogens
 The dressing is customizable to patient needs because it is available in
larger rectangular sizes and various glove sizes

36. THE TREATMENT OF BURNS
FLAMINAL
 Flaminal is a gel enriched by unique
enzyme system, and is highly absorbent
Was created as a universal, reliable
dressing that simplifies care of the wound.
provides many clinical advantages in one
powerful product.
maintains a moist wound environment
provides continuous purification of
wound
antibacterial protection
safe for skin cells and hypoallergenic
THE DRESSING MATERIALS AND MEDICATIONS
FLAMINAL
Flaminal Hydro for wounds that are dry or have
mild to moderate amounts of exudate. The
dressing may stay 3-4 days.
Flaminal Forte for wounds that have moderate
to heavy amounts of exudate. The dressings
generally should be changed every 1-2 days.

37. FLAMINAL
Clean and rinse the wound, and make
it dry
Apply a thick layer (5mm) of either
Flaminal Hydro or Flaminal Forte to
the wound in a sterile manner.
Flaminal does not need to spill over
the wound edge.
THE TREATMENT OF BURNS
THE DRESSING MATERIALS AND MEDICATIONS
In Dry wound: use Flaminal Hydro and paraffin gauze
fixed by a non-adhesive bandage

Slightly exuding: non-adherent dressing fixed by a
nonadhesive bandage

Moderately exuding: absorbent, non-adherent
compress fixed by a non-adhesive bandage

Very heavily exuding: absorbent non-adherent compress
fixed by a non-adhesive bandage
Change from Flaminal Forte to Flaminal
Hydro as exudate reduces.

38. REFERENCES:
• American Burn Association's practice guidelines, 2012
• INTERNET – charts and pictures, and drug and medications information
• Stone, Keith and Humphries, Roger; Current Diagnosis and
Treatment: Emergency Medicine. McGraw- Hill New York 2008
• Whaley & Wong’s Nursing care of Infants and Children, sixth edition