Transcript Care of Moderate and Severe 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
 Mortality related to size, depth, and
presence of inhalational injury
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Symmetric Stocking Distribution
Pathophysiology
Thermal injury->protein denaturation and
coagulation->irreversible tissue damage
 Surrounding zone of decreased perfusionpotentially salvageable
 Depth determined by intensity and
duration of exposure
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Deeper Burns
more common in young children with
thinner skin
 Prolonged contact
 High heat
 High viscosity
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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)
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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
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Metabolic Response
Hypermetabolic response:
 Increased catecholamines, glucagon,
cortisol -> increased metabolic rate,
catabolism
 Decreased growth hormone, insulin-like
growth factor (anabolic hormones)
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Classification
Minor, moderate and major (ABA)- based
on depth and size
 Treatment and prognosis based on
classification
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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
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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
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Superficial
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
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Superficial Partial Thickness
Deep Partial thickness
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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
Deep Partial Thickness
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
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Full thickness
Fourth degree
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Extend to underlying tissues like fascia,
muscle
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
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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
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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
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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
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ABC’s
Airway: Look for signs of inhalation injurysoot 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
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Examination
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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
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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
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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
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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
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Monitoring
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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
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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 infectionscan -> 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
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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)
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Escharotomy
References
Up to Date online
 Google images
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