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Pediatric Burns

Pediatric Burns. Carolyn O’Donnell, MD. Epidemiology. Worldwide: Young children- 60-80% scalds Older children- fire injury more likely >/= 5 yrs: 56% with flame burns Inflicted burns: usually scalds (stocking distribution typical), < 4 yrs of age

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Pediatric Burns

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  1. Pediatric Burns Carolyn O’Donnell, MD

  2. Epidemiology • Worldwide: Young children- 60-80% scalds Older children- fire injury more likely >/= 5 yrs: 56% with flame burns • Inflicted burns: usually scalds (stocking distribution typical), < 4 yrs of age • Mortality related to size, depth, and presence of inhalational injury

  3. Symmetric Stocking Distribution

  4. Pathophysiology • Thermal injury->protein denaturation and coagulation->irreversible tissue damage • Surrounding zone of decreased perfusion- potentially salvageable • Depth determined by intensity and duration of exposure

  5. Deeper Burns • more common in young children with thinner skin • Prolonged contact • High heat • High viscosity

  6. Systemic Response • Damaged tissue ->vasoactive mediators (cytokines, prostaglandins, free radicals) • Increased capillary permeability-> increased fluid in surrounding interstitial space • Capillary leak: 18 to 24 hours • Large burns: can see myocardial depression • Major burns: hypotension, edema (burn shock, burn edema)

  7. Large Burns • Can see myocardial depression • Red Blood Cell destruction Local destruction of up to 15% of RBCs Decreased RBC survival time- can-> additional 25% reduction

  8. Metabolic Response • Hypermetabolic response: • Increased catecholamines, glucagon, cortisol -> increased metabolic rate, catabolism • Decreased growth hormone, insulin-like growth factor (anabolic hormones)

  9. Classification • Minor, moderate and major (ABA)- based on depth and size • Treatment and prognosis based on classification

  10. Burn Size • Accuracy is important- often underestimated • Often determines management • Typically expressed as percentage of total body surface area (TBSA) • Lund and Browder chart useful • Palm size- approximately 0.5% TBSA

  11. Burn Depth • Can appear more superficial initially and progress • Superficial- involve only the epidermal layer of skin • Painful, dry, red, blanch with pressure • Heal in 3-6 days • No scarring

  12. Superficial

  13. Superficial Partial Thickness • Epidermis and superficial dermis • Painful, red, weeping, blanch with pressure • Usually form blisters • Heal in 7-21 days • Scarring is unusual • Can see pigment changes

  14. Superficial Partial Thickness

  15. Deep Partial thickness • Extend to deeper dermis (hair follicles/glandualr tissue) • Less painful than superficial partial • Usually blister, wet or waxy dry • Nonblanching • Color variable- red to cheesy white • >21 days to heal, scarring can be severe • Can be hard to distinguish from full-thickness

  16. Deep Partial Thickness

  17. Full Thickness • Extend through dermis • Often painless • Waxy white to leathery gray to charred and black • Skin dry and inelastic, nonblanching • Severe scarring- sometimes with contractures

  18. Full thickness

  19. Fourth degree • Extend to underlying tissues like fascia, muscle

  20. Grading System • Minor: <10% TBSA in adults, <5% in kids or older adults, <2% full thickness • Moderate: 10-20% in adults, 5-10% young or old, 2-5% full thickness, high voltage injury, suspected inhalation injury, circumferential burn, underlying medical condition predisposing to infection

  21. Major • >20% TBSA in adults, >10% young or old • >5% full thickness • High voltage burn • Known inhalation injury • Significant burn to face, eyes, ears, genitalia, or joints • Significant associated injuries- fall, etc

  22. Pre-Hospital care • ABC’s, supplemental oxygen • Intubation if airway burn/inhalation • Remove burned clothing and jewelry • Cover area with clean sheet (warmth) • Establish vascular access if possible- IV fluids, pain medications

  23. Cooling • Immediate cooling can be beneficial • Cool with water 10-20 minutes after burn • Water temp no less than 8 Celsius • No ice, no butter • Watch for and take measures to prevent hypothermia

  24. ABC’s • Airway: Look for signs of inhalation injury- soot in mouth, facial burns, stridor, hoarseness. Intubate early if concerned • Breathing: Ventilation/oxygenation can be affected by toxins (CO), associated injuries, decreased level of consciousness, circumferential burns (chest/abdomen) • Circulation: evaluate for associated injuries if VS changes, poor perfusion

  25. Examination • Thorough general examination, obtain weight if possible • Skin exam: • Size and depth of burn • Early eye exam including fluorescein stain to look for corneal burns • Note external ear burns: risk for suppurative chondritis • Circumferential burns- very close monitoring of distal perfusion/capillary refill (compartment syndrome), and respiratory status

  26. Diagnostic Studies • Baseline CBC, electrolytes • UA may reveal myoglobinuria if muscle injury • Carbon monoxide levels • Consider CXR, soft tissue neck films • Others based on presentation

  27. Management • Airway: • Anticipate difficult airway • Rapid sequence intubation: avoid BP lowering sedatives (etomidate okay), avoid succinylcholine if >48 hrs due to increased risk of hyperkalemia • Monitor ETT closely- avoid accidental extubation

  28. Management • Reliable IV access for fluid resuscitation • Consider bladder catheter to reliably measure UOP • Tetanus vaccine if >5 yrs since booster • Tetanus immune globulin if incomplete primary immunization (less than 3) • Consider surgical consultation

  29. IV Fluids • Parkland formula: 4 ml/kg per %TBSA in 24 hours in addition to maintenance fluids • Half of fluid given over 1st 8 hours, 2nd 50% given over the next 16 hours • 4:2:1 for maintenance fluids/hour • Ringer’s lactate often used (LR) in 1st 24 hours. D5LR often used for children <20kg • Consider colloid/albumin after 24 hours to improve oncotic pressure

  30. Monitoring • Very close Is/Os • <30 kg: UOP 1-2ml/kg/hr • >30 kg: 0.5-1 ml/kg/hr • If increased UOP: check for glucose (osmotic diuresis) • If decreased UOP: increase fluid, evaluate renal function • Monitor HR and BP (pain may factor in) • Can see metabolic acidosis w/ inadequate fluid resuscitation (also w/ CO, cyanide exposure) • Pain control- morphine, fentanyl

  31. Wound Management • Clean with mild soap and water • Avoid disinfectants • Remove clothing and debris • Debridement of devitalized tissue with sterile saline soaked gauze • Large, painful blisters and those likely to rupture should be removed

  32. Wound Dressing • Topical antibiotic covered with nonadherent dressing, then covered with tubular net or gauze bandage • Ideally: biologic dressing for deeper burns • Topical Abx: • Silver sulfadiazine 1%- broad antimicrobial, decreases pain, delayed healing • Mafenide- penetrates well, broad spectrum, painful on application. Limited to cartilage, established infections- can -> metabolic acidosis in large amount • Bacitracin- often used on face- painless, doesn’t bleach pigment from skin • Dressings should be changed frequently- 1-2x/day

  33. Escharotomy • A consideration in partial and full thickness burns which can lead to functional impairment (often seen as edema increases) • Involves incision completely through the depth of the burn eschar • Can relieve restriction (chest burns) and reduce pressure (compartment syndrome)

  34. Escharotomy

  35. References • Up to Date online • Google images

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