BURNS IN CHILDREN A Lecture by Dr. B. O. Edelu Department of Paediatrics.
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Transcript of BURNS IN CHILDREN A Lecture by Dr. B. O. Edelu Department of Paediatrics.
BURNS IN CHILDREN
A Lecture by Dr. B. O. EdeluDepartment of Paediatrics
Introduction
Burn is a type of injury to the flesh caused by heat, electricity, chemicals, fire, radiation or friction.
A common cause of preventable injury, especially in children
Most affect only the skin, but sometimes deeper structures are affected.
Children ≤ 2yrs more affected Boys more affected than girls Highly under reported because most minor burns
will not present to the health facility Scalds are burns caused hot liquids.
Classification of Burns
Can be classified in various ways: Cause of burn Depth of burn Surface area Severity* (Combination of factors)
Cause of injury
Heat Electrical Chemical Fire Radiation Friction Lightning
Class Layer involved
Appearance Texture Sensation Healing time
First degree Epidermis Redness
(erythema) Dry Painful 1wk or less
Second degree (Partial thickness)
Extends into the dermis, but spares appendages
Superficial - Clear blisters, Deep - Red or white with bloody blisters.
Moist PainfulWeeks - may progress to third degree
Third degree (Full thickness)
Involves all layers, including appendages
Leathery and white/brown
Dry, leathery Painless
Requires excision and grafting
Classification by Depth
Some include a fourth degree - Extends beyond the skin to the muscles and bone. Appears black and charred.
Based on surface area
Surface area cont’d
Based on Severity
Based on a number of factors, including total body surface area burnt, the involvement of specific anatomical zones, age of the person and associated injuries.
Minor burn (Can be managed as out patient) First degree burn Partial thickness burn involving <10% of
total body surface area
Severity Cont’d Major Burn (Requires hospital admission)
Partial thickness burn involving >10% of total body surface area
Any full thickness burn Burns involving the hands, face, feet, or perineum Burns that cross joints Circumferential burns Electrical burns Burns associated with inhalational injury, fractures
or other trauma Burns in infants Burns in persons at high-risk of developing
complications
Pathophysiology of burns
Extent of damage depends on surface temperature and contact duration
Thermal burns cause coagulation of tissues by denaturing their proteins
As areas become reperfused, there is release of vasoactive substances ,causing formation of reactive oxygen species which leads to ↑sed capillary permeability.
Result is Pathophysiology fluid loss leading to ↑sed plasma viscosity which can cause microthrombi formation.
Pathophysiology Cont’d
This excessive fluid loss usually occur in the 1st 24 hrs before normalizing.
Therefore, under-resuscitation in the 1st 24 hrs will lead to hypovolaemia and shock.
Burns also result in hypermetabolic state leading to fever, ↑sed metabolic rate, ↑sed ventilation, ↑sed gluconeogenesis resistant to glucose infusion.
Chemical Burn
Severity of injury depends on PH of chemical, conc. of reagent , volume and contact time.
Acids mainly cause coagulation necrosis, forming a coagulum that limits further tissue penetration of the acid.
Bases on the other hand cause liquefaction necrosis which does not limit penetration, thus result in more severe injury.
Neutralization will cause release of heat and thus more burn injury.
Electrical Burn Usually from contact with low voltage alternating
current High voltage burns more in adolescent males Thermal energy is released in proportion to the
amount of electrical current passing through the tissue
Low electrical resistance tissues like blood vessels, nerves and muscles are more affected.
Internal injury may be more significant than external injury.
This includes: ventricular fibrillation, cardiac arrest, muscle tetany, asphyxia from resp muscle involvement, myoglobinuria with resultant renal failure
Other assoc. injurie include fracture, dislocation from assoc. fall and visceral injury.
Management of BurnsEmergency management
Follows standard protocol: ABC of life First, remove cause of burn if still present Airway
Facial burns with upper airway involvement require early intubation b/c it usually worsens over time
Breathing Rapid assessment of respiratory effort, chest
expansion, breath sound Pulse oximetry, Arterial blood gases 100% O2 mandatory for severe burns
Emergency management Cont’d Circulation
Quick assessment of circulation- pulses, extremities, CRT, heart rate, mental status,
Initial fluid resuscitation for all severe burns (see below)
Secondary survey Look for associated injury
Investigation FBC, Group and xmatch, coagulation profile,
CXR (may be delayed), SEUCr, ECG etc.
Further Management Outpatient management
Minor burns can be managed as an outpatient Clean with warm saline or soap water Leave blisters intact Apply topical antibacterial agent eg. Silver
sulfadiazine, bacitracin, mafenide, aqueous silver nitrate
Light dressing Twice daily dressing Analgesic (NSAID) Daily follow up
Further Management Inpatient management
All major burns must be managed in the hospital Fluid Therapy
Parkland’s formula 1st 24hrs: crystalloids(Ringer’s lactate) at 4ml/kg /%
burn surface area ½ given over 8 hrs and ½ over remaining 16hrs Calculation of time starts from time of burn After 24hrs, fluid requirement drops to about ½ of day 1
because of reabsorption of oedema fluids. Colloids(albumin, plasma) may be introduced at this
point Dextrose may be added in the 1st 24hrs in younger
children
Fluid Therapy Cont’d Monitor Urine output closely and adjust fluid
as indicated. 1ml/kg body weight/hr is adequate urine
output Oral fluid supplementation may start as early
as 48hrs after burn Also, monitor electrolyte closely. Sodium and potassium supplementation may
be needed in children with burns >20% BSA if 0.5% silver nitrate is used for dressing.
Antibiotic therapy Sepsis is a major complication of burn and
must be anticipated. Meticulous asepsis in all procedures Early debridement of dead tissues and
escharotomy Topical and systemic antibiotics Frequent examination of injury for signs of
infection Regular culture of wound swabs
Pain management Reduction of pain is very important to make
child calm Cover with clean sheet as even cool air
movement increases pain. Adequate anlgesia IV analgesic more effective than IM and oral Anxiolytic may be added to the analgesic Emotional therapy (TLC) is an important
component that helps relieve pain
Other management considerations
Tetanus toxoid boster ATS for the unimmunized Temperature regulation Blood glucose monitoring
Prevention of Burns
See Lecture on accidents and poisoning