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Burns in pediatrics
Pediatric burn injuries require specialized management due to children having limited physiologic reserves. Scald burns are most common in young children and abuse must be ruled out. Fluid resuscitation follows the Parkland formula and aims to maintain blood pressure, heart rate, and urine output. Wounds are debrided and covered to prevent infection while excision and grafting are used for deeper burns. Inhalation injuries require pulmonary support and burn patients are at high risk for infections due to immunosuppression. Hypermetabolism persists for months requiring aggressive calorie and protein supplementation.
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Burns in pediatrics
- 1. Dr Abhijeet Deshmukh DNBPediatrics Fellow in PICU & NICU
- 2. 50% ofburns - pediatric population, 17% - < 5 years Infants and children increased susceptibility to death- as they have limited physiologic reserves & the patterns of injury are very different from adults.
- 3. Types of BurnInjuries Scald Burns More likely child abuse < 5 years Thorough history should include the type and consistency of the causative liquid. oil and thick soups - higher heat capacity and more viscouscause longer contact at higher temperatures more damage water of 140° C – deep burns in 3 seconds of contact & 160° C - 1 second
- 4. Abuse -glove or stocking like, and/or symmetric burns to the buttocks, legs, or perineum. Concomitant fractures and retinal hemorrhages, delays in seeking treatment or inconsistencies in the patient history. full evaluation by social services with referral to appropriate state or government agencies regardless of the depth or extent of burn.
- 6. Thermal Burns > 5 years. ~ 50% of all burn admissions. flame or contact with hot objects 90% - minor and outpatient management with good outcomes. larger burns - mortality influenced by - size, age , +/- inhalation injury. extent of soft tissue injury duration of exposure , presence and type of clothing material
- 7. Electrical Burns Rare (2% - 3%) but devastating Mejority - electrical cords and outlets, Minority - lightening. AC > DC AC -cyclic flow of electricity tetanic contractions increased tissue damage Children propensity to chew on cords or insert objects into outlets.
- 8. Wet ormoist skin, including the mucous membranes around the mouth, has negligible resistanceconsiderable soft tissue trauma. Nerves, blood vessels, and muscles - least resistance, as compared to bone, fat, and tendons. lack of overt skin damage may mask more significant underlying soft-tissue damage.
- 9. Chemical Burns Most common - strong bases in common household products. Alkali drain cleaners (sodium hydroxide) – denature cutaneous lipids. Severity - type and concentration & duration of exposure. Initial treatment - copious irrigation with tepid water for > 15 minutes. Never neutralize the acid or base as exothermic reaction worsens tissue injury.
- 10. Depth & Extentof Burn injury Superficial Burns/First degree burns : significant pain, erythematous changes, lack of blistering. Damage to epidermis only, sparing the dermis and dermal structures. blanch on examination & heal within 2 to 3 days after the damaged epidermis desquamates. eg. - sun burns. Scarring is rare
- 11. Superficial Partial-ThicknessBurns / 2nd degree burns entire epidermis and superficial dermis. fluid-containing blisters at the dermal-epidermal junction. After debridement, the underlying dermis is erythematous, wet-appearing, painful, and blanches with pressure. deeper dermis is left undamaged - heal within 2 weeks without hypertrophic scarring. No need for skin grafting
- 13. Deep Partial-ThicknessBurns / 2nd degree burns clinically similar to third-degree burns. As blood vessels of the dermis are partially damaged blister base - mottled pink and white appearance do not easily blanch , less painful than superficial burns due to nerve injury. Treatment - excision and grafting. Need surgical intervention, May develop hypertrophic scars and/ or contractures.
- 15. Full-Thickness Burns/3rd degree burns complete involvement of all skin layers and require definitive surgical management. white, cherry red, brown, or black in color, and do not blanch with pressure. dry and often leathery typically insensate because of superficial nerve injury.
- 17. Fourth-degree burns- full-thickness + the underlying subcutaneous fat, muscle, and tendons. May need amputation and/or extensive reconstruction with grafting.
- 20. Zones of Injury Burn wounds continue to evolve for days and the inflammatory process may last for several months. Divided into : 1) zone of coagulation : necrotic tissues closest to the injury site 2) zone of stasis : area of ongoing injury, located between the zones of coagulation and hyperemia, Poor perfusion of this zone initially viable tissue in this area to further necrosis and deeper wounds. 3) zone of hyperemia : normal, uninjured skin with a physiologic increase of blood flow in response to local tissue injury.
- 21. Management Estimating theExtent of the Burn An accurate assessment & Total body surface area (TBSA) of burn minimize morbidity and mortality. Overestimation cause over resuscitation with resultant complications, inappropriate transfer to burn centers, Newer methods for (TBSA) are being researched - computerized imaging, two- and three-dimensional graphics, and body contour reproductions.
- 22. Current methodsfor (TBSA) 1) Adults : “rule of nines,” by Palaski and Tennison (palm and fingers of one hand account for 1% of the normal body surface area). This calculation often overestimates, especially in children. BSA is distributed differently in children and infants due to proportionally larger heads and smaller extremities.
- 23. 2) Infants &Children : Lund Browder diagram
- 25. Early Managementof Burn Injuries After removing or extinguishing the source washed with tepid water. Chemical burns - flushed copiously to remove the inciting agent and prevent further tissue damage. Ice or iced water- increase tissue damage , hypothermia & mortality, in patients with more extensive burns. Approximately 10% of all burn patients present with additional traumatic injuries severe burn shock or trauma loss of airway due to altered mental status or supraglottic obstruction from edema formation.
- 26. Signs ofinhalation injury : facial burns, singed nasal hairs, carbonaceous sputum, hypoxia, and history of entrapment in an enclosed space. Evaluation of circulation and resuscitation in greater than 10% TBSA because these injuries are characterized by a systemic inflammatory response that may lead to hemodynamic lability. Electrical injuries compartment syndromes , multiorgan system involvement, Cardiac dysrhythmias , direct muscle necrosis , Seizures and spinal cord transections & respiratory arrest secondary to injury of the brainstem or tetany of the respiratory musculature.
- 27. The majorityof these burns can safely be treated with minor debridement, oral hydration, topical wound care, and outpatient follow-up. Those patients requiring supplemental nutrition or hydration, or who fail outpatient treatment, may need continued care in an inpatient setting if there is a suspicion for inhalation injury, inpatient treatment with intravenous resuscitation and potential transfer to a burn center should be considered.
- 29. Before transfer: - wounds covered with clean, dry material or nonadherent gauze. wet dressings - avoided to prevent hypothermia and subsequent complications in patients with large burn wounds. Tetanus prophylaxis with appropriate pain control before transport. In extensive burns, a Foley catheter should be inserted to help guide fluid management.
- 30. Resuscitation General Principles >10% total BSA - IV fluid resuscitation & urinary catheter. In major injury - nasogastric tube to decompress the stomach. During transport - maintain body temperature.
- 31. Fluid Resuscitation Burn leads to intravascular volume depletion Major losses occur during the first 24 hrs – crystalloids used. Myocardial depression - 24-“36 hrs after injury. The goal of resuscitation is to maintain adequate intravascular volume to support tissue perfusion and thereby preserve organ function. The adequacy of resuscitation - based on observation of blood pressure, heart rate, and urine output. Fluid to maintain normal blood pressure, heart rate, and hourly urine output of 1 mL/kg/hr in the infant and young child and 0.5 mL/kg/hr in the child >12 years of age or >50 kg in weight.
- 32. Parkland formula- crystalloid-based formula - with RL - based on the BSA of burn and the patient's body weight. Maintenance fluids (5% dextrose in lactated Ringer solution) = (4ml/kg+ BSA of burn) + Maintainance fluids (For adults and children who weigh >40 kg, maintenance fluids are not included in the estimate of fluid requirements.) Half of this - in the first 8 hrs after injury, and other half is given in the following 16 hrs.
- 33. After thefirst 24 hrs, - maintenance requirements + to replace ongoing losses. The hourly evaporative fluid loss from wounds can be estimated as: = ( 25 + Burn surface area) x total BSA The evaporative losses are primarily free water. However, to avoid rapid changes in sodium concentration in children, this loss is replaced with - 5% dextrose in 0.2% normal saline. loss of serum protein occurs in > 40% BSA burns. When the injury is larger, the loss is replaced in the second 24 hrs after injury with 5% albumin.
- 34. ultimate goal– to maintain normal blood pressure, heart rate, urine output, and serum sodium
- 35. Hypoalbuminemia- Causes: Increased losses of albumin : d/t drainage from burn wounds, and inflammatory mediators triggered capillary leakage Reduced Albumin production in critical illness due to an increase in the production of acute phase proteins. Dilutional hypoalbuminemia in the immediate postresuscitation phase d/t increased intravascular vol. Albumin is given - to avoid exacerbating acute lung injury, diarrhea, feeding intolerance, impaired wound healing, and the resultant complications.
- 36. in criticallyill patients- 25% albumin should be added if the serum level is below 3 mg/dL.
- 37. Management ofInhalation Injury : aggressive pulmonary toilet, mucolytics, early identification and treatment of infection and supportive care. nebulized heparin to reduce atelectasis and improved pulmonary function, Prophylactic antibiotics & corticosteroids are not used supplemental oxygen & advanced modes of assisted ventilation and hyperbaric oxygen therapy. Stridor - racemic epinephrine neb
- 38. 12% -require intubation 70% of those intubated have sustained inhalation injury .
- 39. Wound Care GeneralPrinciples Objective - to avoid infection and protect the wound from further injury. Small (<2 cm) blisters - left intact, larger blisters and full- thickness wounds should be debrided and covered with a topical agent. Debridement - under general anesthesia or deep sedation. Ketamine - profound cutaneous analgesia. Even in the absence of debridement, burns are painful, and patients usually require opioid analgesia.
- 40. Agents thatmay cause additional tissue damage are avoided, circulation of the wound is protected by avoiding hypotension, hypoxemia, and hypothermia and by excluding the use of adrenergic agents. Maintain sterile precautions & environment.
- 44. Surgical Care Excision and closure – reduce the extent of injury & risk of wound infection. Tangential excision until viable tissue is identified Advantage - best cosmetic and functional result, Disadvantage- bleeding Deep excision of the wound to the level of the fascia - minimal blood loss and is used when wounds are deep, full thickness, and infected, or when large areas are excised. The cosmetic results are poor, and lymphatic drainage is impaired after this type of excision.
- 45. usual approach-first 3-4 days after injury . Autografts & Allografts Integra Life Sciences Corporation provides a temporary epidermis as an outer layer of silastic and an inner layer matrix for the growth of a neodermis. This non antigenic matrix provides a scaffold for a new dermis upon which a thin epidermal graft may be placed
- 47. Invasive infection: The criteria for diagnosis by American Burn Association guidelines, 1 )Inflammation of the surrounding uninjured skin 2 )Histologic examination that shows invasion by the infectious organism into adjacent viable tissue 3 )Isolation of an organism from the blood in the absence of other infection 4 ) Signs of the systemic inflammatory response syndrome (such as hyperthermia, hypothermia, leukocytosis, tachypnea, hypotension, oliguria, or hyperglycemia at a previously tolerated level of carbohydrate intake) and mental status changes
- 48. Other Infections the associated immunocompromise status may set the stage for infection at any site. high incidence of urinary tract infections and pneumonia, appendicitis, but often do not present with classic features due to a suppressed inflammatory response. A high index of suspicion is necessary to detect these infections.
- 49. Sinusitis d/tnasogastric feeding tubes and nasotracheal intubation, especially in patients with inhalation injury. Treatment - removal of all tubes and catheters, initiation of appropriate antibiotic therapy, and drainage. Bacterial Endocarditis : Immune compromise, recurrent bacteremia, and the frequent use of central venous catheters in the patient with burn injury are risk factors
- 50. . Antibiotictherapy is based upon blood culture results and should continue for 4 - 6 weeks
- 51.
- 52. Key Points Initialevaluation of the patient includes determination of depth of injury and extent of surface area involved. These are trauma patients and may have other injuries in addition to the burn. Fluid resuscitation in the first 24 hrs is based on a formula to calculate the amount of lactated Ringer solution to infuse. The formula is only a guide; adjustments are made based on vital signs and urine output.
- 53. Silver sulfadiazineis the topical agent most commonly used for burn wounds. Early excision of the wound is now standard of care in the burn-injured patient Hypermetabolism is very prominent- Proteins and calories must be provided to address these needs, beginning on the day of injury. Hypermetabolism persists for 9- 12 months post-injury.
- 54. References Zimmerman –Pediatriccritical care (4th ed) Rogers Textbook of pediatric critical care.