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Managing Inflammation and Infection in Children Post Burn Injury

Explore the study on inflammatory response post burn injury in preschool children, identifying factors associated with infection and fever. Results indicate inflammatory response varies with burn size, influencing clinical outcomes and re-presentation rates.

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Managing Inflammation and Infection in Children Post Burn Injury

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  1. Recognising and managing inflammation and infection following burn injury in children - the results from Julia Sarginson – March 2016 With thanks to: Dr A Young, Prof A Emond and Mr I Mackie

  2. Introduction Burns in Pre-school Children: • Peak age is between 9and 24 months. • 3rd most common injury type in children under five(following soft tissue injuries and head injuries). • 4th most common mechanism of accidental injury requiring hospitalisation (following falls, struck by object, foreign body or poisoning). • Over 5,200 children under the age of five were admitted to burns services in the UK in 2014. • 104 per 100,000 children in this age group.

  3. 9% TBSA Kettle or shower scald Introduction Most of these injuries are ‘small’. Children under 5 years with <10% TBSA burns ≈ 70% workload paediatric burn services in the UK 0.5% TBSA Contact burn to hand or foot 4% TBSA Hot drink scald

  4. Introduction Burn wound infection, sepsis or Toxic Shock Syndrome Community acquired bacterial or viral illness Febrile Illness

  5. Introduction Studies looking at the Inflammatory Response in Paediatric Burns Mean age (years) ? Mean burn size (% TBSA) Circle size = population in study

  6. Introduction Aims: • To describe the typical inflammatory response to small burn injury in pre-school children, • To identify patient and injury characteristics associated with re-presentation and post-burn febrile illness.

  7. Method Morbidity In Small Thermal Injury in Children • Prospective Observational Cohort Study • 3 Paediatric burns services in England • 18 months (January 2014 to July 2015)

  8. Method Eligibility criteria: • < 5 years of age, • Presenting within 48 hours of injury, • Burn less than 10% TBSA, • Any mechanism (including friction injury), and any depth. Birmingham Chelmsford Bristol

  9. Method Prospective Data collection: Medical notes; • Clinical details – pre-injury, assessment and management, post-injury events, • ALL physical observations for injury episode, • ALL blood test results for injury episode.

  10. Method Prospective Data collection: Parental questionnaires & temperature diaries

  11. Method Clinical Governance: • Ethics approval obtained, • Local R&D approvals obtained. Data management and analysis: • Standardised CRFs, • Database storage - , • Statistical Analysis - .

  12. Results • 676 included in final analysis • - 625 with burns • - 51 comparison group (finger-tip injuries) 95 %

  13. Results Recruited: 625 children Median Age: 1y 7m [IQR: 1.15 to 2.45] Median % TBSA: 1.00 [IQR: 0.30 to 2.50] Follow-up: Medical notes data 100% Post-injury follow-up 76% Temperature diaries 46% Other 3 % Contact 42 % Scald 55 % Burn Type:

  14. Results Aim 1: To describe the typical inflammatory response to small burn injury in pre-school children

  15. Results Temperature change: Scalds Temp change over 7 days (p<0.001) 4345 recordings from 237 patients

  16. Results Temperature change: Scalds Temp variation by burn size (p<0.001) 4345 recordings from 237 patients

  17. Results Temperature change: Contact burns Temp change over 7 days (p=0.363) 1269 recordings from 137 patients

  18. Results Temperature change: Contact burns Temp variation by burn size (p<0.001) 1269 recordings from 137 patients

  19. Results Heart rate: Scalds

  20. Results CRP: Scalds

  21. Results Temperature

  22. Results Aim 2: To identify patient and injury characteristics associated with re-presentation and post-burn febrile illness.

  23. Results Full post-injury follow-up: 476/625 (76%) • Unexpected re-presentation to medical care (burns service, ED or GP): 103/476 (22%) • Unplanned re-admission: 46/476 (10%)

  24. Results Diagnoses given: Toxic Shock Like Illness – 14 Burn wound infection – 5 Sepsis – 1 Deep burn – 4 Nonspecific viral illness – 10 URTI – 14 LRTI – 6 Gastroenteritis – 2 Chickenpox – 2 Cough/cold – 7 Teething – 2 Skin reaction – 5 Pyrexia ?cause – 3 Other – 8 None given – 20 23% ?

  25. Results Factors associated with re-presentation: Scalds: • TBSA • OR 1.27 [95% CI: 1.09 to 1.47] (p=0.002) • Burn site head and neck • OR 2.07 [95% CI: 1.12 to 3.81] (p=0.019) • Weak associations: Deep/FT component, burn site torso, lack of cool water first aid

  26. Conclusions A systemic inflammatory response to injury can be identified in burns over 2% TBSA. This is likely to be a cause of some cases of post-burn pyrexia. Some of the ‘pathological’ diagnoses given for re-presentations may be an inflammatory response in the absence of infection. Both the inflammatory response and re-presentations with post-burn illness increase with increasing burn size.

  27. Take home messages • A systemic inflammatory response to burn injury can be seen in young children with relatively small sized burns. • One in five children re-present to medical care with a systemic illness after a small burn. • Clinicians should be aware that some of these presentations will be infections, and some will be a SIRS response in the absence of infection.

  28. Next steps • Derive normal reference ranges and symptom profiles for the inflammatory response. • Identify signs and symptoms profiles that distinguish between inflammation and infection. • Identify high-risk group for re-presentation who may benefit form enhanced follow-up.

  29. Outcomes and Impact • Prognostic score for children at risk of re-presentation post-burn. • Diagnostic criteria to differentiate normal inflammatory response from infection. • New treatment pathways. • Reduce and target antibiotic use in burns in children.

  30. Acknowledgements

  31. Acknowledgements Bristol Research Centre Staff : Lauren Bratby(Research centre administrator) Paula Brock, Rose Hawkins & Julie Veale (research nurses) Karen Coy (lead research nurse) Linda Hollen(statistician) Academic and Clinical Supervisors: Prof Alan Emond Dr Amber Young Mr Ian Mackie • Bristol Clinical Team: • Mr Tim Burge • Mr Jon Pleat • Miss Catalina Estela • Mr Tom Cobley • Mr SānkhyaSen • Ms Shirin Pomeroy (specialist nurse) • - and all the outpatient department, ward and outreach nursing Staff at the South West Children’s Burns Centre The St Andrew’s Centre for Plastic Surgery and Burns, Chelmsford: Prof Peter Dziewulski Helen Gerrish& Natalie Whybro(research nurses) Alethea Tan (Fellow) Birmingham Children’s Hospital: Miss Yvonne Wilson Mr David Wilson Sarah Payne (research nurse) Federica d’Asta(research fellow) Clare Thomas (specialist nurse) Our thanks also go to all the parents and children who have contributed to this important research

  32. Thank-you for listening! Any questions?

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