Burns in Children

1. Burns
• An injury occuring from destruction of the skin
by thermal forces.

2. Classification
• Burns are classified by depth, type and extent
of injury
• Every aspect of burn treatment depends on
assessment of the depth and extent

3. Classification by depth
• 1st degree(superficial)-affects the epidermis and
is reddish eg a sun burn
• 2nd degree(partial thickness)-affects dermis and
epidermis, are pink or red, blistering or weeping
and painful.
• 3rd degree(full thickness)- affects epidermis,
dermis,sq muscle or the bone. Eschar
presents(leatherly,shiny) black or white, usually
dry, have no sensation and do not blanch on
pressure.

4. Burn extent
• Burn extent is calculated only on individuals
with second and third degree burns
• Palmar method: the child’s palm is used to
estimate the burnt area which represents
approximately 1% of the total body surface
area.
• body surface area chart below according to
age

5. LUND AND BROWDER METHOD
• Front and back of the head about 20%
• Front and back of the head 2%
• Upper limbs 10% each
• Trunk 15% anterior 15% posterior
• Buttocks 3% each
• Lower limbs 15% each

6. Lab studies
Severe burns:
• Complete Blood Count
• ABG with
carboxyhemoglobin
• Coagulation profile
• U/A
• Creatinine
phosphokinase and
urine myoglobin (with
electrical injuries)
• 12 Lead EKG

7. • HEAD =18%
• ANTERIOR TRUNK-18%
• POSTERIOR TRUNK-18%
• UPPER LIMB-9%+9%=18%
• LOWER LIMB-14%+14%=28%
• PERINEUM-1%

8. Imaging studies
• CXR
• Plain Films / CT scan: Dependent upon
history and physical findings

9. Treatment
• Admit all children with burns covering > 10% of
their body surface; those involving the face,
hands, feet, perineum and joints; those that are
circumferential and those that cannot be
managed in an outpatient ward.
• Initially, burns are sterile. Focus treatment on
speedy healing and prevention of infection.

10. Cont’
• Consider whether the child has a respiratory
injury due to smoke inhalation.
– If there is evidence of respiratory distress, provide
supplementary oxygen, and ensure the airway
are safe and remain safe by regular observation.
Inform the anaesthetist if there is potential
airway obstruction
– Severe facial burns and inhalation injuries may
require early intubation or tracheostomy to
prevent or treat airway obstruction

11. • Fluid resuscitation is required for burns covering >
10% total body surface.
• Use Ringer’s lactate or normal saline with 5%
glucose; for maintenance, use Ringer’s lactate with
5% glucose or half-normal saline with 5% glucose.
• The total daily fluid requirement of a child is
calculated with the following formula: 100 ml/kg for
the first 10 kg, then 50 ml/kg for the next 10 kg,
thereafter 25 ml/kg for each subsequent kg.
• – First 24 h: Calculate fluid requirements by adding
maintenance fluid requirements to the additional
emergency fluid requirements (volume equal to 4
ml/kg for every 1% of surface burnt).

12. • 100ml×10=1000ml
• 50ml×10=500ml
• 25ml×10=250ml
• 4ml×30×30=3600ml
Total fluids=5350mls in 24hours

13. Cont’
• Administer half of total fluid in first 8 h, and remaining
fluid in next 16 h.
• Example: 20 kg child with a 25% burn:
• Total fluid in first 24 h = (100×10+ 10*50) + 4 ml x 20 kg
x 25% burn
• = 1500 ml + 2000 ml
• = 3500 ml (1750 ml over first 8 h)
• – Second 24 h: give half to three quarters of fluid
required during the first day.

14. Cont’
• Monitor the child closely while giving
emergency fluids (pulse, respiratory rate,
blood pressure and urine output), taking care
to avoid circulatory fluid overload.
• – Blood may be given to correct anaemia or
for deep burns to replace blood loss

15. Prevent infection:
• – If skin is intact, clean with antiseptic solution, gently,
without breaking the skin.
• – If skin is not intact, carefully debride the burn. Except
for very small burns, debride all bullae, and excise
adherent necrotic (dead) tissue during the first few
days.
• – Give topical antibiotics or antiseptics (the options
depend on resources;they include: silver nitrate, silver
sulfadiazine, gentian violet, betadine and even mashed
papaya). Clean and dress the wound daily.
• – Small burns and those in areas that are difficult to
cover can be managed by leaving them open to the air
and keeping them clean and dry.

16. Cont’
• closed treatment for burns of the hand and feet
with a vaseline gauze and bandage
Treat secondary infection if present.
• – If there is evidence of local infection (pus, foul
odour or presence of cellulitis), treat with
amoxicillin (15 mg/kg orally three times a day) plus
cloxacillin (25 mg/kg orally four times a day). If
septicaemia is suspected,use gentamicin (7.5
mg/kg IM or IV once a day) plus cloxacillin (25–
50mg/kg IM or IV four times a day). If infection is
suspected beneath an eschar, remove the eschar

17. Cont’
Pain control
• Make sure that pain control is adequate, including before
procedures such as changing dressings.
• – Give paracetamol (10–15 mg/kg every 6 h) by mouth, or
give IV narcotic analgesics (IM injections are painful), such
as morphine sulfate(0.05–0.1 mg/kg IV every 4 h or prn)or
pethidine 1mg/kg prn if pain is severe.
Check tetanus vaccination status.
• In all cases, administer tetanus prophylaxis
• – If not immunized, give tetanus immune globulin.
• – If immunized, give tetanus toxoid booster, 0.5ml stat if
this is due.

18. Nutrition
• – Begin feeding as soon as practical in the first 24
h.
• – Children should receive a high-calorie diet
containing adequate protein, and vitamin and
iron supplements. (Omit the iron initially in
severe malnutrition.)
• – Children with extensive burns require about 1.5
times the normal calorie and two to three times
the normal protein requirements.

19. anaemia
• Check the hb and if less than 7g/dl transfuse
.give ferrous sulphate for less severe anemia.

20. • Burn contractures: burn scars across fl exor
surfaces contract. This happens even with the
best treatment (and nearly always happens
with poor treatment).
• – Prevent contractures by passive mobilization
of the involved areas and
• by splinting fl exor surfaces to keep them
extended. Splints can be made of plaster of
Paris. Splints should be worn only at night.

21. Physiotherapy and rehabilitation
• Should begin early and continue throughout the
course of burn care
• If the child is admitted for a prolonged period,
ensure that she or he has access to toys and is
encouraged to play.

22. Complications of burns
Hypothermia
Renal failure
Infection
Anemia
Contractures

23. Exercise
• Master X one and a half years old and 11kgs has
been admitted in your ward with 30% burns.
– Calculate the total amount of ringers lactate you will
administer in the first 2 days (4mks)
– Other than the surface area burnt, explain two (2)
other factors of determining the Severity of burnt
wounds. (2 marks)
– State three acute complications of burns.(3mks)
– Discuss the specific nursing management of Master X.
In the first 24hrs (11mks)

24. GASTROENTERITIS :
Acute Gastroenteritis (AGE): diarrheal disease of rapid
onset, with or without accompanying symptoms,
signs, such as nausea, vomiting, fever, or abdominal
pain
Diarrhea: the frequent passage of unformed liquid
stools (3 or more loose, watery stool per day)
Dysentery: blood or mucus in stools

25. Diarrhea
Acute diarrhea:
Short in duration (less than 2 weeks).
Chronic diarrhea:
6 weeks or more

26. Etiologies:
Viral
70-85% of AGE in developed countries
• Rotavirus-50%
• Caliciviruses, astroviruses, and enteric
adenoviruses,Norwalk virus
Presentaion:
• Low-grade fever
• Vomiting followed by copious watery diarrhea (up to 10-
20 bowel movements per day)
• Symptoms persisting for 3-8 days

27. Etiologies:
Bacterial
Salmonella, Shigella, E. coli,
Campylobacter, Yersinia, Clostridium
difficile
Presentation:
High fevers
Shaking chills
Bloody bowel movements (dysentery)
Abdominal cramping & fecal leukocytes

28. Etiologies:
Parasitic
Giardia and Cryptosporidium
<10% of cases
Presentation:
• Watery stools
• Low-grade fever
• differentiated from viral gastroenteritis by a
protracted course or history of travel to
endemic areas

29. Other causes
• Emotional stress- increases motility
• Intenstinal infection- inflamaation of mucosa,
increased mucus secretion in colon
• Food sensitivity- decreased digestion of food
• Food intolerance(lactose or introduction of
new foods, overffeding)
• Medications(iron, antibiotics)-irritation
• Colon disease-(colitis, enterocolitis,
necrotizing enterocolitis)-inflammation

30. • Inflammation and ulceration of intenstinal
walls, reduced absorption of fluids, increased
intenstinal motilitity
• Surgical alterations- short bowel syndrome-
reduced size of colon, decreased absorption
surface)

31. Pathophysiology
The primary mechanisms
(1) Osmotic diarrhea; Osmotic diarrhea results from the presence
of osmotically active, poorly absorbed solutes in the bowel
lumen that inhibit normal water and electrolyte absorption.
Certain laxatives such as lactulose and citrate of magnesia or
maldigestion of certain food substances such as milk are
common causes of osmotic diarrhea eg Mg So4 and Na So4
(2) Secretory diarrhea: occurs when the small and large
intestines secrete rather than absorb electrolytes and
water ie there is reduced absorption and increased
secretion.
(3) Increased bowel motility diarrhea;due to reduced transit
time when food passes the bowel too quickly could be due
to infection.

32. Sign & Symptoms
• Nausea & Vomiting
• Diarrhea
• Loss of appetite
• Fever
• Headaches
• Abdominal pain
• Abdominal cramps
• Bloody stools
• Fainting and Weakness
• Heartburn
• Dehydration
• Lethargy

33. • Goals:
• Prevent dehydration
• Replacement of electrolytes maintaenance of
hydration
• Proper feeding
• Treat the cause if identified

34. plan A-Diarrhea with no
dehydration
• Done according to severity of dehydration
• Give extra fluid ie breastfeed more,ors and
clean water
• Children up to 2 years give 50mls-100 after
each loose stool
• >2yrs 100-200mls after each loose stool given
as small frequent sips if vomits wait for 10 min
then continue slowly.

35. Plan B-some dehydration
• Give ors 75ml/kg plus 100-200mls of clean
water during the first 4 hours then reassess
and classify for dehydration. Then treat
appropriately
• Give extra fluid
• Continue feeding
• Give ors to use at home

36. Plan c-severe dehydration
• Give iv ringers Lactate 100ml/kg if unavailable
give nomal saline if the child can drink give ors
5ml/kg/hr. reassess every 1-2hrsif hydration
status not improving give fluids more rapidly.
Reassess the child after 3 hrs and an infant
after 6 hours. Then give appropriate plan ie A B
or C
• Can use ngt if iv access not possible with ORS
120ml/kg for 6hrs reassess after 1-2 hrs if
hydration status not improving refer for iv
therapy. After 6hrs and choose appropriate

37. Dehydration with severe
malnutrition
• Use rehydration solution for
malnutrition(resomal) contain40mmol Na,
40mmol K and 3mmol/litre. Give orally or by
ngt 5ml/kg q 30 min for the first 2 hours then
5-10ml/kg for the next 10 hrs. if rehydration is
still occuring at 6 and 10 hrs give starter F- 75
instead of resomol the same volume.
• *do not use iv route except in cases of shock
don’t use ors as it has high levels of sodium and
low of K

38. management
• Give a combination of ORS and Znso4
• Vitamin A
• intravenous therapy ringers lactate if not
available use normal saline
• Dehydration with severe malnutrition use
rehydration solution for malnutrtion(resomal)

39. cont
• Breastfeeding
• Ors if not available give uji or rice
water,yoghurt
• High caloric diet eg with cereals .dairy
products and eggs, fresh fruit juices and
bananas
• Thick soup
• Avoid a lot of sugar

40. • Drugs should be given ONLY when absolutely
necessary. Do not use antidiarrheal and anti
emetic.
• Use antibiotics for proven dysentry with
ciprofloxacin and cholera cases with
erythromycin 15mg/kg orally or iv 6hrly as 1 st
line and chloramphenical 50mg/kg as 2nd line
• Antiprotozoal ie metronidazole 15-50mg/kg od
in case of amoebiasis

41. Complication
• Dehydration
Excessive loss of fluids and minerals (electrolytes)
from the body
Common in infants and young children with viral
gastroenteritis or bacterial infection
Kidney failure, eg in infection by E.coli
• Electrolyte deficiency

42. prevention
.Early and exclusive breast feeding
• Rota virus and measles vaccination
• Vit A supplimentation
• Hand washing with running soapy water(5
instances)
• Proper disposal of feaces
• Improved water supply quantity and quality