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Pediatric burn is the leading cause of death in children -
- 1. BURNS IN PAEDIATRICS By G. Lukumay
- 2. Introduction • Burns are the second leading cause of accidental deaths in childhood • The highest incidence of burns occurs in children younger than 5 years • Children at high risk are those of lower social economic status and of single parent. • However, any child, supervised or unsupervised, is at risk for a burn injury.
- 3. Definition • A burn is an acute traumatic event caused by non persisting injurious insult to the skin and tissues that cause damage at the cellular level, followed by a healing process ( Rice PL, et al 2012 ).The insult could be thermal, chemical, or electrical
- 4. Review of Anatomy and physiology of the skin • The skin is the largest organ of the body, accounting for about 15% of the total adult body weight. • It performs many vital functions, including protection against external physical, chemical, and biologic assailants, as well as prevention of excess water loss from the body. • Plays a role in thermoregulation. • The skin is continuous, with the mucous membranes lining the body’s surface (Kanitakis, 2002).
- 5. Layers of the skin
- 6. Pathophysiology of burn • The pathophysiology of the burn wound is characterized by an inflammatory reaction leading to rapid oedema formation, due to increased microvascular permeability, vasodilation and increased extravascular osmotic activity. • These reactions are due to the direct heat effect on the microvasculature and to chemical mediators of inflammation.
- 7. Pathophysiology of burn cont… • The earliest stage of vasodilatation and increased venous permeability is commonly due to histamine release. Damage to the cell membranes partly caused by oxygen-free radicals released from polymorphonuclear leucocytes would activate the enzymes catalyzing the hydrolysis of prostaglandin precursor (arachidonic acid) with rapid formation of prostaglandin as the result.
- 8. Pathophysiology of burn cont… • Prostaglandins inhibit the release of norepinephrine and may thus be of importance in modulating the adrenergic nervous system which is activated in response to thermal injury. • The morphological interpretations of the changes in the functional ultrastructure of the blood lymph barrier following thermal injury seem to be an increase in the numbers of vacuoles and many open endothelial intercellular junctions.
- 9. Pathophysiology of burn cont… • Furthermore, the burn wound provides a vast area of entry of surface infection with a high risk of septic shock. • This explains the reasons of the four main principles in the current management of patients with severe thermal injury, namely early wound closure, prevention of septic complications, adequate nutrition and control of the external environment. Arturson G,1980
- 10. Clasification of burn • Burn injuries are described according to the depth of the injury and the extent of body surface area injured. • Burn Depth • Burn depth determines whether epithelialization will occur. • Determining burn depth can be difficult even for the experienced burn care provider.
- 11. classification of burns cont… • Burns are classified according to the depth of tissue destruction as: Superficial partial-thickness injuries (first degree burn): • In a superficial partial-thickness burn, –the epidermis is destroyed or injured and –a portion of the dermis may be injured. –The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister (very minimal).
- 12. classification of burns cont… Typical Characteristics for Superficial thickness burn –Mild to severe erythema (pink to red) –NO BLISTERS –Skin blanches –Painful –Pain responds well to cooling –Lasts about 48 hours; healing in 3-7 days
- 14. Partial-thickness burn • Injury involves destruction of epidermis and dermis • The wound is painful, sensitive to temperature change and air exposure. • Typically, they blister and are moist, red, with exudes fluid • More commonly referred to as second-degree burns.
- 16. Deep partial-thickness burn • Injury involves destruction of entire epidermis and dermis, and in some cases underlying tissue as well • Blistering or easily unroofed burns which are wet or waxy dry. • The color of the wound varies from white to red, brown or black • The burned area is painless
- 17. Deep partial-thickness burn cont… • More commonly referred to as third- degree burns. • It is sometimes difficult to differentiate these burns from full-thickness burns.
- 18. Full-thickness burn • Burns which cause the skin to be waxy white to a charred black and tend to be painless. • Includes destruction of epidermis and the entire dermis as well as possible damage to the SQ tissues, muscle and bone • Healing is very slow, if at all, and may require skin grafting. • More commonly referred to as fourth-degree burns.
- 19. classification of burns cont… • The following factors are considered in determining the depth of the burn: – How the injury occurred – Causative agent, such as flame or scalding liquid – Temperature of the burning agent – Duration of contact with the agent – Thickness of the skin
- 20. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS Thermal Burns Caused by flame, flash, scald, or contact with hot objects. It is the most common type of burn Chemical Burns • Result from tissue injury and destruction from necrotizing substances (chemicals) • Most commonly caused by acids
- 21. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont… Chemical Burns cont’d –Respiratory and systemic problems –Eye injuries –Clothing containing the chemical should be removed –Tissue destruction may continue for up to 72 hours after a chemical injury
- 22. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Electrical Burns • Intense heat generated from an electrical current • May result from direct damage to nerves and vessels causing tissue anoxia and death • Severity of injury depends on the amount of voltage, tissue resistance, current pathways, surface area, and on the length of time of the flow
- 24. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Cold Thermal (Frostbite) • Usually affects fingers, toes, nose, and ears • Numbness, pallor, severe pain, swelling, edema • Blistering in a warm environment • Handle the tissue carefully
- 25. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries • Result from inhalation of hot air or noxious chemicals • Cause damage to respiratory tract • Important determinant of mortality in fire victims
- 26. Calculating area of burn injuries • Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are: – the rule of nines, –the Lund and Browder method, and –the palm method.
- 27. Calculating area of burn injuries RULE OF NINES • An estimation of the TBSA involved in a burn is simplified by using the rule of nines. • The rule of nines is a quick way to calculate the extent of burns. • The system assigns percentages in multiples of nine to major body surfaces.
- 28. Rule of 9
- 29. Calculating area of burn injuries LUND AND BROWDER METHOD • A more precise method of estimating the extent of a burn is the Lund and Browder method, • It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. • By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. • The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then.
- 30. Calculating area of burn injuries
- 31. Calculating area of burn injuries PALM METHOD • In patients with scattered burns, a method to estimate the percentage of burn is the palm method. • The size of the patient’s palm is approximately 1% of TBSA.
- 34. Management of the Patient With a Burn Injury • Emergency Procedures at the Burn Scene –Extinguish the flames –Cool the burn –Remove restrictive objectives –Cover the wound –Irrigate chemical burns
- 35. Emergent/resuscitative phase mgt • Emergency Medical Management • The patient is transported to the nearest emergency department. • The hospital nurses (staff) and physician are alerted that the patient is in route to the emergency department so that life-saving measures can be initiated immediately by a trained team. • Initial priorities in the emergency department remain airway, breathing, and circulation.
- 36. Emergent/resuscitative phase mgt Emergency Medical Management cont’d • For mild pulmonary injury, inspired air is humidified and the secretions can be removed by suctioning • For more severe situations, it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. • If edema of the airway develops, endotracheal intubation may be necessary.
- 37. Emergent/resuscitative phase mgt Emergency Medical Management cont’d • Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation. • A large-bore (16- or 18-gauge) intravenous cannular should be inserted in a non-burned area (if not inserted earlier).
- 38. Emergent/resuscitative phase mgt Emergency Medical Management cont’d • Assessment of both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound. • An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns.
- 39. Management of fluid loss and shock Fluid Replacement Therapy: • The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. • The adequacy of fluid resuscitation is determined by: – Output totals of 30 to 50 mL/hour – systolic blood pressure exceeding 100 mm Hg and/or – pulse rate less than 110/minute.
- 40. Conditions Leading to Burn Shock
- 41. Management of fluid loss and shock 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
- 42. Management of fluid loss and shock 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.
- 43. Fluid requirements in children • Use same formula for fluids to replace loss from burns. • 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
- 44. Fluid 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
- 45. Fluid requirements in children • Be sure the patient’s 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.
- 46. 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
- 47. Wound Management • administering topical antibacterial drugs like: – Silver sulfadiazine 1% (Silvadene) – watersoluble cream, – Silver nitrate 0.5% aqueous solution, – Mafenide acetate 5% to 10% (Sulfamylon) hydrophilic-based cream, – Acticoat, etc
- 48. Pain Management • Opioid every 1 to 3 hours for pain • Several drugs in combination • Morphine • Non pharmacologic strategies • Relaxation tapes • Visualization, guided imagery
- 49. Complication of Burn Skin and joint contractures Hypertrophic scarring
- 50. Contracture of the Axilla
- 52. Nursing care plans nursing diagnosis Impaired gaseous exchange related to upper air way obstruction, carbon monoxide, poisoing or smoking inhalation as evidenced by difficulty in breathing, desaturation, respiratory acidosis. Expected Patient out come • The patient would demonstrate adequate respiratory function and maintain adequate oxygenation and slight respiratory alkalosis, as evidenced by normal arterial blood gas analysis
- 53. Nursing diagnosis cont… Intervention • Elevate head of the bed to semi-foul’s position at all times to decrease risk of pneumonia or risk of ventilator pneumonia, risk of aspiration, and air way edema. Also to facilitate optimal breathing parttence. • Increase activity as tolerated, in order to facilitate diaphragmatic excursion and support respiratory muscle function • Suctioning • Administer oxygen as required • Broncho dilators
- 54. Nursing diagnosis cont… • Nursing Diagnosis • Risk for Fluid volume deficit related to burn injury as evidenced by decreased cardiac output, urinary output, temperature, bowel sound, BP, increased pulse,
- 55. Nursing diagnosis cont… • Expected outcome • The patient would maintain normal hemodynamic, adequate urine output not less than 1mls/kg/hour, • Patients electrolyte status should be maintained within normal range.
- 56. Nursing diagnosis cont… Intervention • Administer R/L solution 2-4mls/kg/TBSA burned for 1st 24hour, ½ of the total amount should be given within the first 8 hours of injury, 1/4th should be given in 2nd 8hours and the1/4th should be given in the 3rd 8hours. Then reassess after every 30-60 min. for the signs of adequate resuscitation. • Patient’s fluids and electrolyte status should be maintained within normal range, in 2nd 24hours administer 5% dextrose as ordered,
- 57. Nursing diagnosis cont… • Pain related to burn injury as evidenced by raised pulse rate, blood pressure, restlessness, alterations in sleep pattern, complaints of pain, irritability, and crying
- 58. Nursing diagnosis cont… • Expected patient out come • Patient should not suffer unnecessary pain
- 59. Nursing diagnosis cont… Intervention • Assess factors that may contribute to an increased perception of pain eg anxiety, fear. • Be gently and efficient as well as though in performing all nursing care procedures.
- 60. Nursing diagnosis cont… • Wound should be covered with topical agents and dressing • Offer analgesic and sedatives routine to enhance patient active cooperation and decrease anxiety • Morphine is the drug of choice. • Non pharmacological method
- 61. Nursing diagnosis cont… • Use environmental comfort measures to relief pain(alleviate all unnecessary stressors or discomfort sources) eg calm speaking voice and plan nursing care to facilitate periods of rest and sleep. • Assess vital sign, because increase pain can cause transient increase in respiratory and cardiac rates and BP
- 62. Refferences • Pattern of burns identifi ed in the Pediatrics E mergency Department at King Abdul-Aziz Med ical City: Riyadh • Down loaded article http://www.jsn brn.org retrived on Monday June 2016 • Mariane et al (2005) Manual of Critical Care Nursing fifth edition, USA