Burns in children

4. 50% of burns - pediatric population,
17% - <5years
Infants and children increased susceptibility to death-
as they have limited physiologic reserves & the
patterns of injury are very different fromadults.

5. Types of Burn Injuries
Scald Burns
More likely child abuse
<5years
Thorough history should include the type and
consistency of the causativeliquid.
oil and thick soups - higher heat capacity and more
viscouscause longer contact at higher
temperatures more damage
water of 140°C –deep burns in 3seconds of contact &
160°C - 1second

6. Abuse- glove or stocking like, and/or symmetric burns
to the buttocks, legs, orperineum.
Concomitant fractures and retinal hemorrhages,
delays in seeking treatment or inconsistencies inthe
patient history.
full evaluation by social services with referral to
appropriate state or government agencies regardlessof
the depth or extent ofburn.

8. Thermal Burns
>5years.
~50% of all burn admissions.
flame or contact with hot objects
90% - minor and outpatient management with good
outcomes.
larger burns - mortality influenced by - size, age , +/-
inhalation injury.
extent of soft tissue injury duration of exposure ,
presence and type of clothing material

9. Electrical Burns
Rare (2% - 3%) but devastating
Mejority - electrical cords and outlets,
Minority - lightening.
AC > DC
AC -cyclic flow of electricity  tetanic contractions
increased tissue damage
Children  propensity to chew on cords or insert
objects into outlets.

10. Wet or moist skin, including the mucousmembranes
around the mouth, has negligible
resistanceconsiderable soft tissuetrauma.
Nerves, blood vessels, and muscles - least resistance,
as compared to bone, fat, and tendons.
lack of overt skin damage may mask more significant
underlying soft-tissue damage.

11. Chemical Burns
Most common - strong bases in common household
products.
Alkali drain cleaners (sodium hydroxide) –denature
cutaneous lipids.
Severity - type and concentration & duration of exposure.
Initial treatment - copious irrigation with tepid water for>
15minutes.
Never neutralize the acid or base as exothermic reaction
worsens tissue injury.

12. Depth & Extent of Burn injury
Superficial Burns/First degree burns :
significant pain, erythematous changes, lack of
blistering.
Damage to epidermis only, sparing the dermis and
dermal structures.
blanch on examination & heal within 2to 3days after
the damaged epidermisdesquamates.
eg. - sun burns.
Scarring is rare

13. Superficial Partial-Thickness Burns / 2nd degree burns
entire epidermis and superficialdermis.
fluid-containing blisters at the dermal-epidermal junction.
After debridement, the underlying dermis iserythematous,
wet-appearing, painful, and blanches with pressure.
deeper dermis is left undamaged - heal within 2weeks
without hypertrophic scarring.
No need for skin grafting

16. Deep Partial-Thickness Burns / 2nd degree burns
clinically similar to third-degreeburns.
As blood vessels of the dermis are partiallydamaged
blister base - mottled pink and white appearance
do not easily blanch ,
less painful than superficial burns due to nerveinjury.
Treatment - excision and grafting.
Need surgical intervention,
May develop hypertrophic scars and/ orcontractures.

19. Full-Thickness Burns /3rd degreeburns
complete involvement of all skin layers and require
definitive surgical management.
white, cherry red, brown, or black in color, and do not
blanch with pressure.
dry and often leathery
typically insensate because of superficial nerve injury.

21. Fourth-degree burns - full-thickness + the
underlying subcutaneous fat, muscle, and
tendons.
May need amputation and/or extensive
reconstruction with grafting.

24. Zones of Injury
Burn wounds continue to evolve for days andthe
inflammatory process may last for several months.
Divided into :
1) zone of coagulation : necrotic tissues closest to the
injury site
2) zone of stasis : area of ongoing injury, located between
the zones of coagulation and hyperemia, Poor perfusion of
this zone initially viable tissue in this area to further
necrosis and deeper wounds.
3) zone of hyperemia : normal, uninjured skin with a
physiologic increase of blood flow in response to local
tissue injury.

26. Management
Estimating the Extent of the Burn
An accurate assessment & Total body surface area
(TBSA) of burn minimize morbidity and mortality.
Overestimation cause over resuscitation with resultant
complications, inappropriate transfer to burn centers,
Newer methods for (TBSA) are being researched -
computerized imaging, two- and three-dimensional
graphics, and body contour reproductions.

27. Current methods for (TBSA)
1) Adults : “rule of nines,” by Palaski and Tennison (palm
and fingers of one hand account for 1%of the normal
body surfacearea).
This calculation often overestimates, especiallyin
children.
BSA is distributed differently in children and infants
due to proportionally larger heads and smaller
extremities.

28. 2) Infants & Children :Lund Browder diagram

30. Early Management of Burn Injuries
After removing or extinguishing the source  washed with
tepid water.
Chemical burns - flushed copiously to remove the inciting
agent and prevent further tissuedamage.
Ice or iced water- increase tissue damage , hypothermia &
mortality, in patients with more extensiveburns.
Approximately 10%of all burn patients present with
additional traumatic injuries
severe burn shock or trauma loss of airway due to altered
mental status or supraglottic obstruction from edema
formation.

31. Signs of inhalation injury : facial burns, singed nasal hairs,
carbonaceous sputum, hypoxia, and history of entrapment
in an enclosed space.
Evaluation of circulation  and resuscitation in greater
than 10%TBSA because these injuries are characterized by
a systemic inflammatory response that may lead to
hemodynamic lability.
Electrical injuries compartment syndromes , multiorgan
system involvement, Cardiac dysrhythmias , direct muscle
necrosis , Seizures and spinal cord transections &
respiratory arrest secondary to injury of the brainstem or
tetany of the respiratory musculature.

32. The majority of these burns can safely be treated with
minor debridement, oral hydration, topical wound
care, and outpatient follow-up.
Those patients requiring supplemental nutrition or
hydration, or who fail outpatient treatment, mayneed
continued care in an inpatient setting
if there is a suspicion for inhalation injury, inpatient
treatment with intravenous resuscitation andpotential
transfer to a burn center should beconsidered.

34. Before transfer : -
wounds covered with clean, dry material or
nonadherent gauze.
wet dressings - avoided to prevent hypothermia and
subsequent complications in patients with largeburn
wounds.
Tetanus prophylaxis with appropriate paincontrol
before transport.
In extensive burns, a Foley catheter should be inserted
to help guide fluid management.

35. Resuscitation
General Principles
>10%total BSA - IV fluid resuscitation & urinary
catheter.
In major injury - nasogastric tube to decompress the
stomach.
During transport - maintain body temperature.

36. Fluid Resuscitation
Burn leads to intravascular volumedepletion
Major losses occur during the first 24hrs –crystalloidsused.
The goal of resuscitation is to maintain adequate intravascular
volume to support tissue perfusion and thereby preserve organ
function.
The adequacy of resuscitation - based on observation of blood
pressure, heart rate, and urine output.
Fluid to maintain normal blood pressure, heart rate, and hourly
urine output of 1mL/kg/hr in the infant and young child and 0.5
mL/kg/hr in the child >12years of age or >50kg in weight.

37. Parkland formula - crystalloid-based formula - with
RL- based on the BSA of burn and the patient's body
weight. Maintenance fluids (5% dextrose in lactated
Ringer solution)
= (4ml/kg+ BSAof burn) + Maintainance fluids
(For adults and children who weigh >40kg,
maintenance fluids are not included in the estimateof
fluid requirements.)
Half of this - in the first 8hrs after injury, and other
half is given in the following 16 hrs.

38. After the first 24hrs, - maintenance requirements +to
replace ongoing losses.
The hourly evaporative fluid loss from wounds can be
estimated as:
= ( 25 + Burn surface area) x total BSA
The evaporative losses are primarily freewater.
However, to avoid rapid changes in sodium concentration
in children, this loss is replaced with - 5% dextrose in 0.2%
normal saline.
loss of serum protein occurs in >40% BSA burns.
When the injury is larger, the loss is replaced in the second
24hrs after injury with 5% albumin.

39. ultimate goal –to maintain normal blood pressure,
heart rate, urine output, and serumsodium

40. Hypoalbuminemia- Causes :
Increased losses of albumin : d/t drainage from burn
wounds, and inflammatory mediators triggered capillary
leakage
Reduced Albumin production in critical illness due toan
increase in the production of acute phaseproteins.
Dilutional hypoalbuminemia in the immediate
postresuscitation phase d/t increased intravascular vol.
Albumin is given - to avoid exacerbating acute lung injury,
diarrhea, feeding intolerance, impaired wound healing,
and the resultant complications.

41. in critically ill patients- 25%albumin should be added
if the serum level is below 3 mg/dL.

42. Management of Inhalation Injury :
aggressive pulmonary toilet, mucolytics, early
identification and treatment of infection and
supportive care.
nebulized heparin to reduce atelectasis and improved
pulmonary function,
Prophylactic antibiotics & corticosteroids are not used
supplemental oxygen & advanced modes of assisted
ventilation and hyperbaric oxygen therapy.
Stridor - racemic epinephrine neb

43. 12%- requireintubation
70% of those intubated have sustained inhalation
injury .

44. Wound
Care
General Principles
Objective - to avoid infection and protect the wound from
further injury.
Small (<2 cm) blisters - left intact, larger blisters and full-
thickness wounds should be debrided and covered with a
topical agent.
Debridement - under general anesthesia or deepsedation.
Ketamine - profound cutaneous analgesia.
Even in the absence of debridement, burns are painful, and
patients usually require opioidanalgesia.

45. Agents that may cause additional tissue damage are
avoided,
circulation of the wound is protected by avoiding
hypotension, hypoxemia, and hypothermia and by
excluding the use of adrenergicagents.
Maintain sterile precautions &environment.

49. Surgical Care
Excision and closure –reduce the extent of injury & risk of
wound infection.
Tangential excision until viable tissue is identified
Advantage - best cosmetic and functional result,
Disadvantage- bleeding
Deep excision of the wound to the level of the fascia -
minimal blood loss and is used when wounds are deep, full
thickness, and infected, or when large areas areexcised.
The cosmetic results are poor, and lymphatic drainage is
impaired after this type of excision.

50. usual approach- first 3-4 days after injury .
Autografts & Allografts
Integra Life Sciences Corporation provides a
temporary epidermis as an outer layer of silasticand an
inner layer matrix for the growth of aneodermis.
This non antigenic matrix provides a scaffold for a new
dermis upon which a thin epidermal graft may be
placed

52. Invasive infection:
The criteria fordiagnosis by American Burn Association
guidelines,
1)Inflammation of the surrounding uninjured skin
2 )Histologic examination that shows invasion bythe
infectious organism into adjacent viabletissue
3 )Isolation of an organism from the blood in the absence of
other infection
4 ) Signs of the systemic inflammatory response syndrome
(such as hyperthermia, hypothermia, leukocytosis,
tachypnea, hypotension, oliguria, or hyperglycemia at a
previously tolerated level of carbohydrate intake) and
mental status changes

53. Other Infections
the associated immunocompromise status may setthe
stage for infection at anysite.
high incidence of urinary tract infections and
pneumonia, appendicitis, but often do not present
with classic features due to a suppressedinflammatory
response.
A high index of suspicion is necessary to detect these
infections.

54. Sinusitis
d/t nasogastric feeding tubes and nasotracheal intubation,
especially in patients with inhalationinjury.
Treatment - removal of all tubes and catheters, initiation of
appropriate antibiotic therapy, and drainage.
Bacterial Endocarditis :
Immune compromise, recurrent bacteremia, and the
frequent use of central venous catheters in the patientwith
burn injury are risk factors

55. . Antibiotic therapy is based upon blood culture
results and should continue for 4 - 6 weeks

56. Hypermetabolis
m

57. Key
Points
Initial evaluation of the patient includes
determination of depth of injury and extent of surface
area involved. These are trauma patients and mayhave
other injuries in addition to theburn.
Fluid resuscitation in the first 24hrs is based on a
formula to calculate the amount of lactated Ringer
solution to infuse. The formula is only a guide;
adjustments are made based on vital signs andurine
output.

58. Silver sulfadiazine is the topical agent most commonly
used for burn wounds.
Early excision of the wound is now standard of care in
the burn-injured patient
Hypermetabolism is very prominent- Proteinsand
calories must be provided to address these needs,
beginning on the day of injury. Hypermetabolism
persists for 9- 12months post-injury.

59. References
Zimmerman –Pediatric critical care (4th ed)
Rogers Textbook of pediatric critical care.