3. Definition
• A burn is a type of injury to the flesh or skin
caused by heat, electricity, chemical, friction
or radiation.
4/23/2023 3
4. Incidence
• One of the leading
causes of accidental
injuries at home.
• 5th most common
cause of accidental
death in children.
• Children from 0-4
years are high risk of
burn.
4/23/2023 4
6. Contributing Factors
• Socio-economics
- children from low income homes have 8x a risk
of sustaining burns and higher mortality.
- heating with indoor fires.
- cooking practices.
4/23/2023 6
7. • AGE
- children are naturally curious, impulsive and
active
• HARMFUL PRACTICES
- flammable and caustic substances stored in the
home.
- lack of adult supervision
- overcrowding
4/23/2023 7
8. •Medical conditions
-Epilepsy
* Increase risk of fall
*Traditional medicine practices; eg. The
deliberate burning of feet to “rouse the child
from convulsive state”.
4/23/2023 8
9. Child Abuse
• Burns account for 10% of all cases of child
abuse
• Majority of victims are < 2 years of age
• Scalding is the most common cause.
4/23/2023 9
10. Pathophysiology
According to Jackson’s Thermal wound theory,
there are three zones associated with burn injuries:
Zone of Coagulation
- area closest to the wound
- ruptured cell membranes, clotted blood & thrombosed
vessels
Zone of Stasis
- area around zone of coagulation
- inflammation & decreased blood flow
Zone of Hyperemia
- peripheral area of the wound
- limited inflammation & increased blood flow
4/23/2023 10
24. Management
• TABC
Intubate and mechanically ventilate if you
suspect inhalation injury
Quickly establish IV access (ideally 2 large bore IVs)
Evaluate for compartment syndrome, particularly
with circumferential burns.
4/23/2023 24
26. Fluid Resuscitation
• Restoring adequate intravascular volume to
prevent hypotension and shock.
• Correcting electrolyte abnormalities
• Minimize renal insufficiency.
• If burns >15%
– Massive fluid shifts will likely occur due to
systemic inflammatory response syndrome (SIRS).
– Fluid needs will be greater than anticipated
based on appearance of burn alone.
4/23/2023 26
27. • Parkland formula:
4 ml x kg x % total burn surface area (TBSA)
1⁄2 fluid in first 8 hours
Remaining in next 16 hours
4/23/2023 27
Fluid calculation
28. • Fluid: Lactate Ringer
– plus 12.5 g 25% albumin per L
– plus D5W as needed for hypoglycemia
• Maintenance fluid in addition, at an hourly
rate of:
4ml/kg for the first 10kg of body weight plus;
2ml/kg for the second 10kg of body weight
plus;
4/23/2023 28
Fluid resuscitation
29. Glucose maintenance
Remember to monitor glucose levels
• Glycogen stores of children <5 years old run out
quickly
• Inhalation injury increases fluid requirements by 1.1
ml/kg/% TBSA
• Goal of fluid resuscitation = Adequate urine output
(1-1.5ml/kg/hr)
Note: Tetanus toxoid should be given if patient is not
currently covered.
4/23/2023 29
30. Dressings
Topical antibiotic:
– Silver nitrate
• Cheap
• Does not penetrate eschar
• Depletes electrolytes
– Silver sulfadiazine
• Some penetration of eschar
• Risk of neutropenia
– Mafenide acetate
• Penetrates eschar
• Risk of developing acidosis
4/23/2023 30
Following resuscitation,
more than 75% of
deaths of burn patients
result from infection.
31. Nutrition
• Burns lead to increased metabolic demands and
energy requirements
– For burns >40%, resting metabolic rate increases
up to 200%
* Protein requirement increased to 2.0
g/kg/day
4/23/2023 31
32. • Goal: Loss of less than 10% of preinjury weight
– Patients should be weighed daily
• Enteral feeds are superior to parenteral
– Feed child orally if possible
– Otherwise place nasogastric feeding tube
4/23/2023 32
Nutrition
39. Debridement
Mechanical debridement:
- frequent moist to dry dressing changes
- placing a moist dressing over the affected area
and then removing the dressing when it is dry.
Under general anesthesia or deep
sedation.
4/23/2023 39
40. GRAFTING
• Early excision and grafting are directly related to
improved survival rates.
• One study demonstrated a difference in mortality from
45% to 9% when full-thickness burns were excised
and grafted within three days of injury compared to
delayed grafting after 21 to 24 days.
4/23/2023 40
42. Escharotomy
• Circumferential burn (compartment
syndrome).
• It releases the constricting tissue
allowing the body tissues and organs
to maintain their normal perfusion
and function.
• single incision is inadequate
• Incision site: torso or the medial
and lateral sides of each affected
4/23/2023 42
45. Amputation
• Amputation is the removal of the whole or part
of a limb or digit by cutting through bone or joint.
• The highest prevalence of amputation
corresponded to be the right upper limb
(76.2%).
• All the patients that required amputation of any
structure had contact with high voltage energy.
4/23/2023 45
48. Reconstruction
• Silicone is commonly used in skin substitutes to create
a protective layer that acts as the new epidermis.
• Corticosteroid injection has been a mainstay in the
treatment of hypertrophic scars and has been proven
to reduce pain, pruritis, and prevent scar contractures.
• Botulinum toxin A is a neurotoxin derived from
bacteria allows for relaxation of muscle and reduces
wound tension, allowing the wound to heal and
minimize scar formation
4/23/2023 48
49. Reconstruction
• Laser therapy is an advantageous technique to
improve cosmetic outcomes before and after burn
injuries. When used before burn surgery, it allows the
scars to be more pliable and improve overall cosmesis
of the wound.
4/23/2023 49
50. Post burn rehabilitation
The aims of rehabilitation may include:
•Maintaining range of movement
•Minimizing development of contracture and the
impact of scarring
•Prevention of deformity
•Maximizing psychological well-being
•Maximizing social integration
•Maximizing functional ability and recovery.
•Enhancing quality of life
4/23/2023 50
51. Nursing Diagnosis
1.Ineffective Airway Clearance
2.Acute Pain
3.Deficient Fluid Volume
4.Ineffective Tissue Perfusion
5.Imbalanced Nutrition: Less Than Body
Requirements
6.Impaired Skin Integrity
7.Impaired Physical Mobility
8.Disturbed Body Image
9.Fear/Anxiety
10.Risk for Infection
11.Deficient Knowledge
4/23/2023 51
52. Complications
• Disfigurement
• Contractures
– Lead to severe disability in many cases
• Emotional damage/sequelae
• Delay in reaching developmental milestones and
educational development
• Death
4/23/2023 52
53. Summary
• Burns account for a significant proportion of pediatric
morbidity and mortality worldwide, particularly in LSES.
• Majority of burns are due to fire or scalding, often related
to cooking practices.
• Initial evaluation should always include an assessment for
child abuse.
• Ultimately, the key to decreasing morbidity and mortality
associated with burns is prevention via...
– Educational campaigns
– Legislative changes
– Hazard reduction and environmental modification
4/23/2023 53
54. References
1. Stone, Keith and Humphries, Roger; Current Diagnosis and Treatment: Emergency
Medicine. McGraw- Hill New York 2008
2. Stead, Latha G. etal ; First Aid for the Emergency medicine Clerkship; McGraw
Hill 2002
3. Engrav L, Heimbach D, Rivara F, Moore M, Wang J, Carrougher G et al.
12-Year within-wound study of the effectiveness of custom pressure garment
therapy. Burns. 2010;36(7):975-983.
4. Topical Burn Wound Management [Internet]. Wounds Research. 2021
[cited 12 April 2021]. Available from:
https://www.woundsresearch.com/article/topical-burn-wound-management
4/23/2023 54
Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
Scald: hot fluid
NB. 2 billion people worldwide cook with open flames or unsafe traditional stoves
Charred: burnt and blackened.
Leathery : having a tough, hard texture like leather.
lacking physical sensation.
Blanching: removed outer skin layer
Mason-Walker Burn Model
:It was reported that 10 seconds exposure produced a full-thickness burn, and 3 seconds a partial-thickness burn.
In cases where a full thickness burn affects the entire circumference of a digit, extremity, or even the torso, this is called a circumferential burn.
Carbonaceous sputum
The periods of time are calculated from the time of the burn injury.
One liter of Ringer's lactate solution contains:
130–131 mEq of sodium ion = 130 mmol L−1
109–111 mEq of chloride ion = 109 mmol L−1
28–29 mEq of lactate ion = 28 mmol L−1
4–5 mEq of potassium ion = 4 mmol L−1
2–3 mEq of calcium ion = 1.5 mmol L−1
Without adequate nutrition wound healing will not occur
Initial morphine: Prepare a syringe with 10mg of morphine to a total of 10mls = 1mg/ml.
<12 months 40kg use 2ml bolus, 0–30kg use 1ml 30–40kg use 1.5ml >40kg use 2ml bolus
Special garments were used that applied pressure (17–24mmHg) for half of the garment, whereas the other half had minimal compression (<5mmHg)
Low-energy ESWT along with traditional physiotherapy has been shown to relieve burn scar pain, pruritus and improve health-related quality of life. It can also be used to improve scar appearance and functional mobility in patients with severe burns.
Autolytic/Enzymatic debridement involves the use of proteolytic enzymes and agents that digest the burned and dead tissue. This process is limited in its use because it has a slower healing time and results in significant pain with dressing changes that require appropriate analgesia.
Autolytic/Enzymatic debridement involves the use of proteolytic enzymes and agents that digest the burned and dead tissue. This process is limited in its use because it has a slower healing time and results in significant pain with dressing changes that require appropriate analgesia.
Skin grafting is done in a surgical procedure that consists of:
The removal of injured tissue
Selection of a donor site, an area from which healthy skin is removed and used as cover for the cleaned burned area
Harvesting, where the graft is removed from the donor site
Placing and securing the skin graft over the surgically-cleaned wound so it can heal
Five days after grafting, exercise therapy programs, tub baths and other normal daily activities resume.
the tissues within are subject to increasing interstitial pressures exacerbated by tissue edema developed during the acute phase of burn resuscitation in the first 48h after injury.
For the abdomen and chest, transverse incisions are often required to permit restoration of respiratory movement. Delayed primary closure of escharotomy incisions may produce better functional and cosmetic results than those achieved if the escharotomies are allowed to close by secondary intention.5
Silicone is commonly used in skin substitutes to create a protective layer that acts as the new epidermis.[5] Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritis, and scar thickness six months after burn injury.
Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritis, and scar thickness six months after burn injury.
