Burns in pediatric patient

7/30/2019 Burns in pediatric patient

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OBJECTIVES

Describe the differences between partial

and full-thickness burns.

Describe how to estimate the size of aburn.

Describe initial care of burns.

Describe follow-up care of partial

thickness burns.


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References for photos

Advanced Burn Life Support Course,American Burn Association, 1994

Textbook of Military Medicine, Part I, Vol 5

Conventional Warfare, OTSG, 1991

Textbook of Surgery, Sabiston, editor

W. B. Saunders, 1986

SESAP VI,

American College of Surgeons, 1988Burn care product info


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Depth of burn

Partial thickness

burn =

involves epidermis

Deep partial

thickness =

involves dermis

Full thickness =

involves all of skin


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Partial thickness burns

Sunburn is a very superficial burn.

Expect blistering and peeling in a few days.Maintain hydration orally.

Heals in 3-6 days- generally no scaring

Topical creams provide relief.

No need for antibiotics


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Deeper partial thickness

Blisters are typical of partial thickness burns.

Dont be in a hurry to break the blisters.

Heals in 14-21 days

Blisters provide biologic dressing and comfort.

Once blisters break, red raw surface will be very painful.


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Full thickness burn

Yellow, leathery appearance; or charred

Often have no sensation (nerve endings destroyed) Outer edges might be partial thickness.

Initial management same as partial thickness.

Later will need skin grafts.


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Mixed partial and full thickness

Central yellow area might be full thickness.

Outer edges are probably partial thickness.

Initial management is the same.

Later will need skin grafts for the full thickness

areas.


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Zones of Burn Wounds

Zone of Coagulation

devitalized, necrotic, white, no

circulation

Zone of Stasis circulation sluggish

may covert to full thickness,

mottled red Zone of Hyperemia

outer rim, good blood flow, red


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Wound

excision until

fine punctatebleeding

occurs


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Estimate the size of the

burnThe patients own palm is about 1%

of his body surface area.

Rule of Nines


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Rule of 9s

ABA


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American Burn Assoc

says send these to a burn center Partial thickness burns >10% BSA

Burns involving the face, hands, feet, genitalia,

perineum, or major joints full thickness/3 degree burn

Electrical, Chemical, and Inhalation burns

In combat, all but the most superficialburn should be evacuated


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Burn care products

< 20% TBSA 2nd degree Silvadene (SVC)Cream BID

Any > 20% TBSA-SVC and Sulfamylon(SMC) alt BID

3rd degree burn SVC and SMC alt BID

*SMC only to the ears * Bacitracin

Opth to face


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Care of small burns

What can YOU do?


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Care of small burns

Clean entire limb withsoap and water (also under nails).

Apply antibiotic cream

(no PO or IV antibiotic).

Dress limb in position of function,and elevate it.

No hurry to remove blisters unless infection occurs.

Give pain meds as needed (PO, IM, or IV)

Rinse daily in clean water; in shower is very practical.

Gently wipe off with clean gauze.


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Blisters

In the pre-hospital setting, there is nohurry to remove blisters.

Leaving the blister intact initially is less

painful and requires fewer dressingchanges.

The blister will either break on its own,

or the fluid will be resorbed.


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Blisters break on their own

Upper arm burn day 1 day 2

Burn looks worse the next day because of

blisters breaking and oozing


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Upper arm

burn

Blisters show probable partial thickness burn.

Area without blister might be deeper partial

thickness.

121


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Debride blister using simple instruments


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Medic debriding blister


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After debridement


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Before and after debridement

Removing the blister leaves a weeping, very

tender wound, that requires much care.


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Silver sulfadiazene


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Arm burn 4 days


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Arm burn 7 days note the exudate


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Foot burn

debridement

Before debriding

and applyingcream,

clean entire foot

(including

toes and nails).


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Silver- impregnated dressings

(Silverlon)

Apply wet silver dressing

directly on the burn.

Creams or dressingsunder the silver dressing

impede the antimicrobial action.

Keep it moist!

Remove it, rinse it out, replace it on the

burn.


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Steps in using silver-impregnated

dressings

Clean the burn and surrounding area.

Soak silver-impregnated dressing and gauze in

STERILE WATER or BOTTLED DRINKINGWATER

Apply silver-impregnated dressing(over-lapping edges are best).

Wrap with the moist gauze.

Secure with mesh, gauze, or tape.Keep it moist with WATER, every 12h or so

More frequent in hot arid environments


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picsSoak silver dressings and gauze

in WATER (not saline).

Apply the

silver dressing.

Wrap with moist gauze.

Secure with mesh, gauze, or tape.


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pics Moisten with WATERq12h or so.

Moisten well

to remove it each day.

Rinse it out, and put itback on the burn.


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After several days

Replace silver dressing

every 2 - 5 days

depending on amount of exudate,cellular debris

First wet the silver dressing before removingit.

Dont pull on it if its stuck moisten it more.

Apply new moist silver dressing and gauze.


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QUESTIONS ABOUT

SMALL BURNS?SUMMARY

Describe the differences between partial and

full-thickness burns.Describe how to estimate the size of a burn.

Describe initial care of small burns.

Describe follow-up and post-burn care.

NEXT TOPIC - BURNS OF SPECIAL AREAS


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Burns of special areas

of the body Face

Mouth

Neck

Hands and feet

Genitalia


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Face

Be VERY concerned for the airway!!

Eyelids, lips and ears often swell

alarmingly.

In fact, they look even worse the next day.

But they will start to improve daily afterthat.

Cleanse eyes with warm water or saline.

Apply antibiotic ointment or liquid tearsuntil lids are no longer swollen shut.

Bacitracin cream/ointment will serve

H d d f t


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Hands and feet

This is rather deep

and might requiregrafting.

But initial

management is basic.

Dressings should not impedecirculation.

Leave tips of fingers exposed.

Keep limb elevated.


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Hands and feet

Allow use of the hands in dressings by day. Splint in functional position by night.

Keep elevated to reduce swelling.


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Hands and feet

Fingers might developcontractures if active

measures are not taken

to prevent them.

G it li


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Genitalia

Shower daily, rinse off old cream, apply new cream.

Insert Foley catheter if unable to urinate due to swelling.


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Large Burns


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Causes of death in burn

patientsAirway

Facial edema, and/or airway

edema

Breathing

Toxic inhalation (CO, +/- CN)

Respiratory failure due to smoke

injury or ARDS


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Edema Formation

Amount of edema can beimmense (even withoutfacial burns)

Depression of mentalstatus can worsen problem

Edema peaks at 12 to 24hours

Pediatric patients evenmore concerning


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Causes of death in burn

patientsCirculation: failure of resuscitation

Cardiovascular collapse, or acute

MIAcute renal failure

Other end organ failure

Missed non-thermal injury


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Patients with larger burnsFirst assess

CBAs

Disability (brief neuro exam)

Expose

Later

Examine rest of patient

Calculate IV fluidsTreat burn


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Airway?

Flash burns may refer to

those that suddenly flare up,then die down quickly.

Patients may have burntfacial hair and carbon on

lips. Patients with this kind of

facial burn will probablyNOT need an artificialairway.

Give humidified oxygenwhile under closeobservation.

Ci l i


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Circulation

Record vital signs.

Check distal pulses and nail beds.

Keep him warm!

Loss of skin impairs ability to retain heat

and fluids.Being cold will cause vasoconstriction.

Monitorurine output (in larger burns, insert Foleycatheter for hourly urine output). 30/50cc/hr

Monitor at least HCT and urine specific gravity.

When available, monitor electrolytes.

N t t


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Neuro status

The burn itself does not alter the level of

consciousness. If patient is not alert, think of other causes:

hypovolemia

carbon monoxide

head injury Dont allow swollen eyelids to prevent you from

examining the pupils.

Test sensation and motion in burned extremities.

E


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Expose

Undress the patient to examine

the whole body.

But burned patients lose body

heat quickly, so keep them

warm.

To keep warm, use whatever

means available:

blankets

heating lamps

bed frame

large box covered with

blankets

H d t t


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Head to toe exam

Obtain history and examine rest of body.Ask about allergies, meds, medical

conditions.

Look for other injuries.

C l l t fl id i t


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Calculate fluid requirements

wt in kg x % burn x 2 - 4cc / kg / %

100 kg patient with 50% TBSA burn:

100 x 50 x 2 = 10,000cc = 10 liters RL

This is calculated for the first 24 hours post-burn.

Give half of this in first 8 hours.

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

C l l t fl id i t


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Calculate fluid requirements

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

How do we know if this is too much fluid, or too little?

Monitor at least:

urine output - in adults, around 50 cc / hr

Decreasing urine output = need for more fluids.

B i i ll hild


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Burn size in small children

The head accounts for about 18% (instead of 9%).

The legs account for about 13% (instead of 18%).

Fl id i t i hild


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Fluid requirements in children

Use same formula for fluids to replace loss fromburns.

In children, add this amount to normal maintenance

rate:

10 kg - about 40 cc / hr maintenance fluids

20 kg - about 60 cc / hr

30 kg - about 70 cc / hr

Expected urine output for child: 1 cc / kg /hr

for infant: 2 cc/ kg / hr


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Fluids requirements in children

20 kg child with 30% burn:20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr

Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially

75 cc / hr for burn loss + normal 60 cc / hr maintenance =

135 cc / hr initially

How do you know if the patient is getting too much fluid,

or too little?

Check urine output, urine specific gravity, HCT


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Be sure the patients airway, breathing and

circulation are secure. Then treat the burn wound itself.

In patients with large burns, do not initially

spend much time carefully calculating fluids.

Instead, start an IV and start giving fluids

rather rapidly while exam is being performed.

DO NOT BOLUS! 500cc/hr is a good rule.

Later do the calculations.


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Special types of burn

Circumferential burn

Burn requiring escharotomy

Electrical burn Chemical burn


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Circumferential burn

Limb is burned all the way around.

Soft tissues under the skin always swell withburns

(due to capillary leak of fluids in first day or so). There is a loss of skin expansion due to the loss

of turgor/elasticity in burned tissue

Pressure inside limb gradually increases.

Eventually, pressure inside limb exceeds arterialpressure.

This requires escharotomy to relieve thepressure.

E h t i di ti


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Escharotomy - indications

Circulation to distal limb is in danger due toswelling.

Progressive loss of sensation / motion in hand /foot.

Progressive loss of pulses in the distal extremityby palpation or doppler.

In circumferential chest burn, patient might not beable to expand his chest enough to ventilate,and might need escharotomy of the skin of the

chest.

Escharotom complications


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Escharotomy - complications

COMPLICATIONS

Bleeding: might require ligation of superficialveins

Injury to other structures: arteries, nerves,tendons

NOT every circumferential burn requiresescharotomy.

In fact, most DO NOT need escharotomy.

Repeatedly assess neuro-vascular status of thelimb.

Those that lose circulation and sensation needescharotomy.

Escharotomy


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Escharotomy

Eschar = burned skin Escharotomy = cut burned skin to

relieve underlying pressure

Similar to bivalving a tight cast.

Cut along inside and outside oflimb from good skin to good skin

Knife can be used, or cautery.

Use local or no anesthesia.

(Full-thickness burn should haveno sensation, but underlyingtissues do!)

Escharotomy of forearm


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Escharotomy of forearm

Incise along medial

and/or lateral

surfaces.

Avoid bonyprominences.

Avoid tendons,

nerves, majorvessels.

Escharotomy


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Escharotomy

Patient had escharotomy of

both legs.

Incisions will heal.

They will not be closed by

DPC. These large burns are often

treated by the open

technique,that is, without dressings.

Electrical burn


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Electrical burn

Outer skin might

not appear too bad.

But heat was conducted

along the bone.

Causes the most damage.

Burns from inside out.

Usually requires fasciotomy

Fasciotomy


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Fasciotomy

Fascia = thick white covering of muscles.

Fasciotomy = fascia is incised (and often overlying skin)

Skin and fascia split open due to underlying swelling.

Blood flow to distal limb is improved.

Muscle can be inspected for viability.

Phosphorus


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Phosphorus

Particles ofphosphorus must beremoved from underthe skin.

Pick them off withforceps.

Must apply wet

dressing to prevent re-igniting.


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QUESTIONS?SUMMARY

Describe how to estimate the bodysurface area of burn.

Describe how to calculate initial fluidrequirements in a patient with a largeburn.

Describe intial management of a patient

with a large burn.Discuss indications and complications

of escharotomy.


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BURN DOWN & DIRTY

Educate your Task Force!

proper technique for burning waste,

wear of clothingDo not hesitate to evacuate.

Burns other than inhalation generallydont kill at point of injury- Bleeding andbreathing injuries do!

Oral Abx if managing burn at BAS ?

Burns in pediatric patient

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