PAEDIATRIC BURNS

By SowmeyaNageshwararao
Introduction to Burns
Burn injuries are a major cause of morbidity and mortality in
children. In India, the figure constitutes about one-fourth of
the total burn accidents .
There has been a decline in the incidence has coincided with
a stronger focus on :
Burn treatment and prevention,
Educating people on fire and burn prevention
Greater availability of regional treatment centers,
Widespread use of smoke detectors,
Greater regulation of Consumer products and Occupational
safety,
Societal changes such as reductions in smoking and alcohol
abuse.
Etiology
Hot tap water burns cause scald injuries.
Flammability of consumer products, such as toys and
pajamas
Playing with matches, cigarette lighters, Smoking.
Burns occurring in the kitchen
Fireworks or activities involving Gasoline.
Electric Burns occur due to activities such as climbing
utility poles or antennae. In rural areas, burns may
be caused by moving irrigation pipes that touch an
electrical source.
Types
Heat burns (thermal burns) are caused by fire, steam, hot objects, or hot liquids.
Scald burns from hot liquids are the most common burns to children and older
adults.
Cold temperature burns are caused by skin exposure to wet, cold conditions.
Electrical burns are caused by contact with electrical sources or by lightning.
Chemical burns are caused by contact with household or industrial chemicals in a
liquid, solid, or gas form. Natural foods such as Chilli Pepper, which contain a
substance irritating to the skin, can cause a burning sensation.
Radiation burns are caused by the sun, tanning booths, sunlamps, X-rays,
or Radiation Therapy for Cancer Treatment.
Inhalation injury to the lungs and airways from smoke inhalation are often less
apparent than visible burns
Friction burns are caused by contact with any hard surface such as roads ,carpets,
or gym floor surfaces. They are usually both a scrape (abrasion) and a heat burn.
Athletes who fall on floors, courts, or tracks may get friction burns to the skin.
Motorcycle or bicycle riders who have road accidents
 Classification of Burns
1st-degree burns
/ superficial burns
2nd-degree burns /
Partial-thickness burns
Deep
Superficial
3rd-degree burns / Full
Thickness burns
4th degree burns
Classification of Burns st
[1 ]
1st-degree burns involve only the
epidermis and are characterized
by Dry swelling, erythema, and pain
(similar to mild sunburn)., no blisters
, Minimal/no edema , Blanches,
bleeds
Histologic depth : Epidermal layers
only
Very Painful
Healing time 2-5 days
with no scarring
 Classification of Burns nd
[2 ]
2nd-degree burns involve only the epidermis and are
characterized by Moist blebs, blisters Underlying tissue is
mottled pink and white, with fair capillary refill. Bleeds
Histological depth :A 2nd-degree burn involves injury to
the entire Epidermis, papillary, and reticular layers of
dermis, May include domes of subcutaneous layers (vesicle
and blister formation are characteristic)..
A superficial 2nd-degree burn is extremely painful
because a large number of remaining viable nerve endings
is exposed . Relatively les painful in deep dermal burns
because fewer nerve endings remain viable
Healing time : Superficial: 5-21 days with no grafting
Deep partial:21-35 days with no infection; if
infected, converts to full-thickness burn
Fluid losses and metabolic effects of deep dermal (2nd-
degree) burns are essentially the same as those of 3rd-
degree burns.
Classification of Burns rd
[3 ]
3rd-degree burns are
characterized by Dry, leathery
eschar Mixed white, waxy, khaki,
mahogany, soot-stained. No
blanching or bleeding.
Histological depth : Down to and
may include fat, subcutaneous
tissue, fascia, muscle, and bone
Painless with No sensation
Healing time : Large areas
require grafting, but small areas
may heal from the edges after
wks
Fourth degree Burns th
[4 ]
Extend to underlying tissues like fascia, muscle
Estimation Of Body Surface Area
Accuracy is important- often Underestimated
Often determines management
Typically expressed as percentage of total body
surface area (TBSA)
Unlike the wallace rules of nine, the Lund and Browder
chart takes into consideration of age of the person, with
decreasing percentage BSA for the head and
increasing percentage BSA for the legs as the child
ages, making it more useful in pediatric burns.
Palm size- approximately 0.5% TBSA
Estimation Of Body Surface Area
INDICATIONS FOR
HOSPITALIZATION FOR BURNS
Burns affecting > 15% of body surface area
3rd-degree burns
Electrical burns caused by high-tension wires or lightening
Chemical burns
Inhalation injury, regardless of the amount of body surface area
burned
Suspected child abuse or neglect
Burns to the face, hands, feet, perineum, genitals, or major joints
Burns in patients with preexisting medical conditions that may
complicate the
acute recovery phase
Associated injuries (fractures)
Pregnancy
Pre-Hospital care
ABCs, 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
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
ABCs
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
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
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
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
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
IV Fluids
Parkland formula: 4 ml/kg per %TBSA in 24 hours
in addition to maintenance fluids
[Volume of ringer Lactate=4mlxWeightx%TBSA burn]
Half of fluid given over 1st 8 hours, 2nd 50% given
over the next 16 hours
4:2:1 for maintenance fluids/hour
Ringers lactate often used (LR) in 1st 24 hours. D5LR
often used for children <20kg
Consider colloid/albumin after 24 hours to improve
oncotic pressure
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
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
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, doesnt bleach
pigment from skin
Dressings should be changed frequently- 1-2x/day
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)
Prevention
Pediatricians can play a major role in preventing the most common
burns by educating parents and health care providers.
Simple, effective, efficient, and cost-effective preventive measures
include :
Use of appropriate clothing (polyester)
Use caution when cooking, especially with oil
Using Smoke detectors
Keep fire, matches, and lighters out of the reach of children
Do not leave lit candles unattended
planning of routes for emergency exit from the home.
Child neglect and abuse must be seriously considered when the
history of the injury and the distribution of the burn do not match.
Prognosis
Survival of at least 80% of patients with burns of
90% of the body surface area (BSA) is possible; the
overall survival rate of children with burns of all
sizes is 99%. Death is more likely in children with
irreversible anoxic brain injury sustained at the time
of the burn.