Thermal Injury (02)

8/12/2019 Thermal Injury (02)

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hermal njuryPatricia M. LybargerPatrick Kadilak

ETIOLOGY OF PEDIATRIC BURN INJURIES

PATHOPHYSIOLOGY

Zones of n ju ryClassification of u rn Wounds

INJURY TYPES

Thermal InjuriesElectrical InjuriesChemical InjuriesInhalation njuryCircumferential BurnsExfoliative Disorders

CRITICAL CARE MANAGEMENT

Emergent (Shock) PhaseTransfer an d Referral PrioritiesAcute Phase

BURN OUTCOMES

SUMMARY

F re and bum injuries are second only to motor vehicleaccidents as the leading cause of death in children ofages I to 4 years in the United States. They are among the

leading causes of injury and death in children of ages I to 19years. Severe bums are considered the most catastrophicinjury a person can survive, resulting in disfigurement, pain,emotional distress, and tremendous economic costs. I

Burn care has progressed dramatically in the last 20years, in large part as the result of the establishment ofspecialized burn centers. Advances in fluid and electrolyteresuscitation, early excision and wound c1osure 2 3 andnursing care in this area have increased the probability ofsurviving massive bums.

Burn injury is divided into three phases. The emergent orshock phase begins at the time of injury and extends untilfluid resuscitation is complete. The acute phase lasts until

981

wound closure is achieved. The rehabilitative and recon-structive phase can continue for the rest of the individual'slife. Every organ system is affected by an injury to the skinthat involves 25 total body surface area (TBSA) or more.Burns affecting more than 50 TBSA have a prolongedcritical care phase that may last weeks or months.

ETIOLOGY OF PEDI TRIC URN INJURIES

Most childhood burn deaths occur as a result of house fires,in which children are unable to escape the heat and smoke.Many causes, including careless handling of smokingmaterials, unsafe cooking and heating practices, faultywiring, use of candles, and match play have been associatedwith these fatal fires. The causes of injury are varied, and

most are unintentional injuries. However, the possibility ofintentional injury is a major concern because it has beenreported that between 8 and 24 of admissions to bumunits are related to child abuse by burning. 4.5

Children at greatest risk are those who cannot protectthemselves. An infant relies totally on others for protection,whereas a preschooler can be taught to tell an adult whenmatches or lighters are found and to stop, drop, and roll.Children with neurologic disorders, disabilities, and devel-opmental delays also present a higher risk from inability toprotect themselves and have a higher incidence of prevent-able injuries, have extended hospitalizations, and bear

significantly higher mortality risks.6

Overall, burn injuries in children tend to' follow patternsrelated to both developmental level and the socioeconomicenvironment of the child. Scalds are the leading cause ofburn injury for young children and account for 58 to 67of all burn injuries. 7 8 Most scald injuries are related to thehandling and consumption of hot food and liquids. Foodprepared in microwave ovens, as well as hot coffee andsoup, are often involved. The pattern of splash and drippingis a common finding across the upper body and lap. Thesewounds are painful and may be very deep, depending on thenature of the scalding liquid and the time that the skin wasexposed to it. Grease scalds from kitchen fryers can produce


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9 Part V Multisystem Problems

Zones of Ischemia

t ermal epidermal

junction

Fig 29 Zones o ischemia.

serious injury because the hot grease cools slowly and isdifficult to remove.

Hot household tap water is an important cause o lowerbody scald injuries, especially in the bath. Because children s skin is thinner than that o a young adult, even shortexposure to water at 140 F a common setting for homewater heaters, can cause tissue destruction in fewer than 5seconds in children and in less time in small infants. 9

Children may unintentionally tum on the hot water faucetwhen left unattended in the bathtub and be unable to getaway from it Adult supervision, setting water heatersbetween 120 and 130 F and checking bath watertemperature before placing a child in the tub are key topreventing these injuries.

As children become more mobile and curious, theirexposure to household burn hazards expands. Electricalbums to the oral cavity are seen in infants and toddlers afterchewing on the connection between appliances and extension cords. Contact burns from hot irons, ovens, woodstoves, and radiators occur in all ages. Ingestion ohousehold chemicals can lead to devastating gastrointestinaldamage, and even when diluted, cutaneous contact withthese chemicals can cause full-thickness burns.

Match and fire play are a problem for the school-agepopulation but have been recognized in children as young as2 years o age. Flame burns associated with clothing ignitioncan cause serious injury from both heat and melting fabrics.Ignition of flammable liquids is seen in children old enoughto work on their bikes or mow the lawn. Flash burnsinvolving flammable liquids and explosives add a chemicalcomponent to the bum. Cigarette smoking and otherrisk-taking behaviors contribute to the burn problem foradolescents. With the increasing availability o the Internet,adolescents have found recipes for a variety o explosiveand flammable mixtures.

There are seasonal and regional differences that affect thepattern o bum injury. Summer brings fireworks, barbecues,

and sunburn. Winter brings alternative heating sources, suchas electric space heaters, kerosene heaters and wood stoves.Traditional birthday celebrations may involve lightedcandles. Cultural and socioeconomic factors, such ashousing, heating, and cooking traditions, may also influencethe risk and patterns o burn injury in any community.

Most people who die in house fires are overcome by thesmoke and are unable to escape. Those that survive are athigh risk for an inhalation injury as are those who are burnedin an enclosed space or have burned facial areas. Inhalationinjury continues to be the number-one cause o death inthermally injured patients and can occur with or withoutassociated bums. o Inhalation injury may not always beevident initially, but carbon monoxide poisoning, thermaldamage, and inhaled toxic chemical damage all affectsurvival.

P THOPHYSIOLO Y

Burn severity depends both on the intensity o the heat andthe duration of its contact with the skin. The magnitude othe physiologic response depends on the type, size, location,and depth o the burn. All body systems are potentiallyaffected as the body adapts to compensate for the alterationsin normal function.

Zones of InjuryThermal damage to tissue is described in three zones Fig.29-1). The area o superficial damage is the zone hyperemia appearing warm and red. The middle area odamage is the zone stasis where the microcirculation isdamaged and changes in capillary permeability allow fluidsto leak from the vascular system into the interstitial space.This leads to local edema and shock when extensive wounds

are present. The deepest area is the zone coagulationwherein heat-damaged cells occlude blood vessels. The


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Chapter 9 Thermallnjury 98

Burn Depth Categories

SuperficialPartial Thickness First Degree

Scald, flash, flame,contact, chemical,ultraviolet light

Dry, no blistersMinimal or no edemaErythematous

Very painfulRapid heat loss

Epidermal layers only

2 to 5 days with noscaning

May have somediscoloration

Partial Thickness Second Degree

Scald, flash, flame, contact, chemical, ultraviolet light

Moist blebs, blistersUnderlying tissue mottled pink and

whiteGood capillary refill

ery painfuI

Epidermis, papillary and reticularlayers of dermis

May include fat domes of subcutaneous layer

Superficial, 5-21 days with nografting

Deep part ia l, 21-35 days with noinfection

f infected, converts to full thickness

Full Thickness Third Degree

Scald, flash, flame, contact, chemical, electrical

Dry, leathery escharMixed white, waxy, pearlyKhaki, mahogany, soot-stained

Rapid heat lossInsensateLess rapid heat loss

Down to and may include subcutaneous tissue

May include fascia, muscle, andbone

Small areas may heal from the edgesafter weeks

Large areas require grafting

obstructed microcirculation prevents the humoral components of the immune response from reaching the burnedtissue.

Classification of Burn WoundsClassification of burn depth requires skilled clinical judgment. Surface appearance provides only a clue to the actualtissue damage below. Burns are rarely of uniform depththroughout. Appearance, pain, and tissue pliabil ity are allused to assess wound depth. The type of burning agent andthe extent of skin exposure combine to form challengingclinical presentations.

um depth is classified as partial thickness or fullthickness (Table 29-1). Superficial partial-thickness burnsinvolve only the epidermis. Deep partial-thickness burnsinvolve the epidermis and the dermis but spare epidermalappendages necessary for epidermal regeneration. Fullthickness burns involve the epidermis, dermis, epidermalappendages, and sometimes subcutaneous tissues, such asfat, muscle, and bone. Any burn wound can be converted toa deeper thickness i f infection, hypoxia, desiccation, orfurther mechanical tissue damage develops.

Burns are also described y measuring the size of theTBSA burned. For children, this size is determined using aLund and Browder or Berkow chart, which takes intoaccount the proport ional body changes that occur dur inggrowth (Fig. 29-2). Deep partial- and full- thickness burnson body parts are charted as a percent of the whole.Superficia l par tia l- thickness injur ies are not par t of thecalculation because the integrity of the skin is not broken.

Affected areas are measured and combined to de termineTBSA burned. This percent TBSA becomes important incalculating fluid resuscitation and nutri tional needs afterburns.

A number of other methods are used for de te rmining

TBSA burned in children. The palmar method may be usedin smalle r o r more scattered burns. This method equatesthe palm of the child s hand with I of the body surfacearea. Another method is the baby rule of nines (Fig. 29-3).Thi s method is used primarily in children younger than3 years of age and allows for the relative di fference inhead size and lower extremity size in children comparedwith adults. Of all the methods, the Lund and Browderchart is preferred for children because it takes into accountthe variation in distribution of body surface area in childrenof different ages.

NJURY TYP S

Thermal InjuriesThern1al injuries include three subclassif ications: scaldinjuries, contact injuries, and flame injuries. All three typesare governed by the principles of thermodynamics; thus thedepth and severity of injury are dependent on the duration ofcontact and properties of heat or cold transference of theinjury source. This becomes particularly relevant whenexamining a scald injury because the transference of heat bya liquid results in a greater zone of stasis. This zone willevolve over the first 72 hours, resulting in a more significantinjury than on first assessment.


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1 2 3 4 5 6 7 8

A ( r\ ( \

) - -c K /

( \ ( \D ) \)

E t I \ I \

r

1/G ?

uH

r ( -

V \ I

/ fJ t ~ ~ ~ /

Newborn 3 Years 6 Years 12+ Years

Head 18 15 12 6Trunk 40 40 40 38Arms 16 16 16 18Legs 26 29 32 38

Fig. 29-2 Lund and Browder chart.

1 D2

3 Burned

Ant Post

Head

Trunk

RArm

LArm

R Leg

L Leg

Total

Electrical Injuries

Electrical injuries are caused by the conversion of electricalenergy into heat energy, which coagulates body tissues.Electrical injuries can be divided into two categories basedon th e voltage to which the tissue was exposed. Low-voltageinjuries are those sustained with contact with less than 1000volts, including house current lI S to 220 volts). Highvoltage injuries are those with contact with greater than1000 voltage lines and include high-tension wires (up to250 000 volts).

Electrical injuries in children occur most often in theinfant and toddler and adolescent age groups. Infants andtoddlers, while exploring their environment, often put

everything they find into their mouth. Saliva, which servesas an excellent conductor, creates a current pathway from

the electrical source and through the child s tissues. Thus the

majority of these injuries are low-voltage injuries fromplugs or cords and result in oral commissure burns. 12 Thestructure of extension cords, including holiday light sets, isa neglected area in legislation and federal standards forinjury prevention. Voluntary standards are maintained bymost manufacturers via independent laboratory approvaland have contributed to some solutions, such as extensioncords being manufactured with safety caps for unused plugs.However, this precaution is not universal and does notaddress cord-biting or cord-sucking injuries. 3

The adolescent usually comes in contact with electricityas an unintentional sequela of risk-taking behavior such as

climbing power poles or trees, as a result of tangled kites inhigh-tension wires, from lightening strikes, from contact


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Fig. 29-3 Baby rule of nines allows for proportionate difference in head size related to lower extremity size in childrenyounger than 3 years of age compared with adults. Note that headis 18 of the total body surface area TBSA) in children versus9 TBSA in adults. Lower extremity is then 14 , rather than 18

in adults. From Kravitz M: Thermal injuries. In Cardona V et aI,eds: Trauma nursing resuscitation through rehabilitation Philadelphia, 1994, WB Saunders, p 710.)

with transformers, or from household electrical appliances.Of the injuries seen in the adolescent group 11 to 18 yearsof age), 76 to 9 are high-voltage injuries, resulting inamputation, deep muscle involvement, fasciotomy, andsignificant morbidity. In addition, 6 to 9 of theadolescents sustaining high-voltage injuries are male. 12 13

Prevention of high-voltage injuries as a result of adolescentrisk-taking behavior remains an ongoing challenge toprevention educators.

Although most injuries occur because of direct physicalcontact with an electrical source, the child may not have toactually touch the current source to sustain injury. Electricalcurrent has been known to jump or arc from the source toelectrically conductive substances in its search for a path inwhich to g round. This holds true for current flowingthrough the body, because it may arc from one area of thebody to another e.g., across flexed joints). Additional injurycan occur by electrical contact with clothing causingignition, resulting in surface bums from burning fabrics andinhalation injury from the smoke and toxic chemicals

produced by the burning clothing.

The physiologic impact of an electrical injury on thebody is very unpredictable, causing damage by threemechanisms: I) direct injury caused by the effect of theelectricity on the body, 2) thermal damage as electricity isconverted into heat, and 3) trauma resulting from a fall orsevere muscle contraction following the electrical injury. 12.14 Direct injury caused by electrical contact includesvascular aneurysms and destruction of muscle and red bloodcells, resulting in myoglobinuria and hemoglobinuria. Inaddition, vascular thrombosis formation; cardiac arrhythmias; myocardial damage; neurologic impairment; ophthalmologic injuries; rupture of the tympanic membrane; and,with forceful tetanic contractions, fractures and tendonrupture are other sequelae of direct injury by electricalcontact. Extensive cellular destruction can also result inmassive infusion of intracellular potassium into the circulation. The resulting hyperkalemia can rapidly reach toxiclevels or produce lethal dysrhythrnias.

Thermal damage caused by the electrical injuries is oftendifficult to assess. Where the current enters the body, theremay be only a small entrance wound. The current then

follows a path of least resistance and explodes out of thebody where the body is in contact with a grounding source,resulting in one or more exit wounds. Massive tissue edemacan result in compartment syndrome with further tissuedestruction. Because the extent of tissue destruction is oftenhidden under normal-appearing skin, fluid loss into theinterstitial spaces may go undetected. This can lead toinadequate restoration of the circulat ing blood volumeduring fluid resuscitation. The sum of these effects mayresult in local tissue destruction and intravascular coagulation so severe that amputation of the necrotic tissue becomesessential.

Management of pediatric electrical injuries begins with adetailed understanding the history of the injury, includingtype and strength of voltage, duration of contact, presence orabsence of water, and associated trauma workup forsuspected fall or injury. Blood chemistry abnormalities aremonitored, including serum electrolytes, as well as skeletaland cardiac enzymes indicative of skeletal or cardiac muscledestruction. Cardiac rhythm, regardless of voltage level, ismonitored for dysrhythmias. Assessment for myoglobinuriaand compartment syndrome, including circulation sensationand movement distal to the injury, is essential.

hemical njuriesChemical injury results from the thermal energy producedwhen strong acids or alkalis come in contact with bodytissue. Strong acids and alkalis are the most common causesof chemical bums in children. In infants, injury is commonfrom household cleaning chemicals, such as lye, ammonia,sulfuric acid, and laundry detergents. Older children areinjured in school laboratory accidents or when experimenting at home. In addition, older children may be injured bygasoline-soaked clothing or by exposures related to theirfirst jobs or home activities.

Chemicals destroy skin by coagulation necrosis, which

may progress over time. The severity of the injury is


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Headache, dyspnea, confusion,lapse o attention, loss o peripheral vision

Irritability, faulty judgment, dimvision, nausea, vomiting, easilyfatigued

Tachycardia, tachypnea, confusion,hallucinations, ataxia, syncope,convulsions, coma

Often fatal

Physiologic Effects

>60

ted from Cohen MA, GuzzardiW:

Inhalationo

productso

mbuslion. n n merg Med 12:628-632, 1983.

extensive head or neck bums is treated by protecting theairway with an endotracheal tube (ETT) until the edemaresolves. Because o the small comparative size o children s airways, intervention in the form o endotrachealintubation is often required. 15

Another aspect o inhalation injury occurs when carbonmonoxide (CO) combines with the hemoglobin molecule toreduce the oxygen-carrying capacity o red blood cells. COis a clear, colorless, odorless gas produced by the incomplete combustion o organic materials, such as wood, paper,cotton, gasoline, and others. Incomplete combustion occursbecause insufficient oxygen is available in fire conditions.Depending on the carboxyhemoglobin levels, the child mayexperience symptoms ranging from mild intellectual dysfunction to apnea and cardiac arrest (Table 29-2). Thebinding o CO to hemoglobin can be reversed by theadministration o 100 oxygen. Experiments attempting toquantify the elimination half-life o CO by nonrebreathingface mask or by ETT intubation demonstrate a range o 26to 146 minutes. 16

Hyperbaric oxygen (HEO) therapy may also be indicatedfor the child with CO poisoning, al though its use remainscontroversial. A child undergoing HBO treatment is put intoa hyperbaric chamber and is exposed to 100 oxygen at apressure higher than atmospheric pressure. This method hasshown to aid in displacing CO from the hemoglobinmolecule, thus providing increased amounts o availableoxygen and reversing the toxic effects o CO. 17

Another sequela o inhalation injury is hypoxia caused byexposure to fire conditions wherein environmental oxygen israpidly consumed by combustion. This results in environmental oxygen concentrations that reduce the FT 2 , so Pa0 2levels o 50 to 60 mmHg are commonplace. Combined with

CO exposure, the reduced FI 2 worsens the tissue hypoxiaand its consequences.

The inhalation o toxic gases from the fire may producea chemical pneumonitis. The combustion o commonlyfound materials liberates toxic gases, which can include

T LE 9 Physiologic Effects o CarbonMonoxide Exposure

~ p r b o x y h e m o g l o b i n

~ i L ~ v e l J

Inhalation Injury

dependent on the chemical properties, the concentration othe chemical, and the duration o contact with skin ormucous membranes. Care for children with chemicalinjuries includes obtaining a thorough history o theaccident with the type and duration o contact and rinsingthe affected area with copious amounts o water until a bumcenter consult can be obtained, as well as frequent assessment o the affected area.

Inhalation injury, often called smoke inhalation, is acondition associated with exposure to the heat and toxicfumes produced by fire conditions in a closed space.Complete and incomplete combustion o materials commonly found in the everyday environment produces extremeheat, toxic fumes, and a reduction in the environmentaloxygen concentration, often reducing it to 16 or less.

The identification o a person who has sustained aninhalation injury is often difficult. Clinically, a person whois at risk has the following characteristics:

Burned in a closed space or standing upright as theirclothing burned

Burns o the face or neck Singed eyebrows, nasal hairs, and hairline or facial hair Carbon particles in the mouth or nose or carbonaceous

sputum Brassy cough, hoarseness, or stridor Significant serum carboxyhemoglobin level (greater

than 15 )9

These children warrant close observation and immediateintervention respiratory distress develops. Early or

prophylactic intervention, particularly in young children, isessential for survival.

The inhalation injury produced by fire conditions hasfour components. First, thermal injury occurs in the upperairways because o exposure to high environmental temperatures and superheated gases. Direct heat damage isusually limited to the upper airway because the moistmucous membranes act as a heat exchanger, lowering thetemperature o the inhaled gases before they cross the vocalcords. In fire conditions, the upper airway extracts excessheat from inhaled gases. This protects the lower airway(below the vocal cords) from thermal damage. The sole

exception to this is the inhalationo

steam. Steam has aheat-carrying capacity that is approximately 400 times thecapacity o ambient air This allows the steam to passthrough the vocal cords with little heat loss in the upperairway, thus creating thermal burns below the vocal cords.The exposure to hot gases produces diffuse edema throughout the upper airway, resulting in airway obstruction. Theedema rapidly advances and peaks at about 6 to 12 hoursafter injury.

Extensive burns o the head and neck or hot liquidaspiration can produce such massive edema in local tissuesthat the airway is compromised. Although not a trueinhalation injury, these injuries may present with similarclinical signs and symptoms. Suspicion o aspiration or


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hydrogen sulfide, hydrogen cyanide, hydrogen chloride,acrolein, mustard gas, nerve gas, and many others. Whenthese gases come in contact with the epithelium lining thetracheobronchial tree, they form corrosi ve acids that destroythe cilia and underlying tissue. Toxic materials also adhereto soot particles that are inhaled, providing an additionalsource toxic exposure and debris that must be cleared.Toxins are absorbed into the general circulation, where theycan have systemic effects (e.g., production hydrogencyanide, which causes immediate respiratory dysfunction).The initial response the lung is bronchorrhea followed bya sloughing of necrotic tissues. The increased debrisformation plus the loss the cilia results in atelectasis. Theclinical symptoms may present hours to 7 days later.

There are three time periods following injury when thedamage caused by these toxic agents occur. Immediatelyafter the exposure to fire conditions, hypoxia associated withdecreased environmental oxygen concentrations, CO poisoning, and airway edema from exposure to hot gasesdevelops. During the 24 to 48 hours following injury,pulmonary edema is associated with the toxicity inhaled

gases and fluid resuscitation. After 48 hours, the effects atelectasis and pneumonia become evident as a clinicalpicture similar to acute respiratory distress syndrome(ARDS) develops.

The presence skin involvement further complicates themanagement inhalation injury. Skin damage that involvesmore than 25 TBSA results in diffuse capillary leakthroughout the body, including the lung. The increase ininterstitial water surrounding the alveoli reduces effectivegas exchange and increases the patient s volume requirements. Inhalation injury can increase the body s fluidrequirement up to 37 over calculated fluid resuscitationneeds. The assessment of fluid balance becomes increasingly complicated, and pulmonary edema is a commoncomplication. The treatment pulmonary edema is usuallyreduction the infused fluid volume in increments untilsymptoms disappear. 18

Full-thickness, circumferential surface burns the neckand chest wall can compromise pulmonary function evenfurther. When inelastic eschar surrounds the chest, acorsetlike effect is created. Edema continues to occur in theburn wound, compressing the tissues the chest wallinward and compromising the vital capacity. Relief isprovided by escharotomies (incisions through the eschar)that allow the chest wall to expand. Escharotomies to relieve

chest compression are usually performed within the first 24hours after injury, but extensions the escharotomies mayneed to be done as the edema continues through theemergent phase.

Surviving the initial inhalation injury is not the end thechild s pulmonary problems. The child may develop ARDSfollowing hypoxic or hypovolemic insult or as a componentof septic shock associated with bacteremia from wounddebridement, intravascular lines, urinary tract infections, orpneumonia.

The long-term sequelae inhalation injury includebronchiolitis obliterans, cylindrical bronchiectasia, and tra

cheal stenosis associated with prolonged intubation or


tracheostomy. Children whose respiratory units are destroyed at a young age have a better prognosis for long-termrespiratory function than do school-age children or adolescents. As the young child grows after the injury, theremaining respiratory units can increase in surface areamore than would normally be expected to compensate forthe units that were destroyed.

Circumferential BurnsFull-thickness circumferential burns the torso or extremity present a special problem for the child. As mentionedearlier, circumferential burns to the torso may impede achild s ability to ventilate. Similarly, circumferential areas full-thickness bums to extremities are nonelastic andproduce a tourniquet effect that diminishes blood flow to theaffected area. As edema occurs in the affected area and thetissue cannot stretch, the child experiences numbness andtingling distal to the injured area, loss of motor function andsensation, and severe pain. Release pressure must occurand requires surgical intervention by escharotomy or

fasciotomy (Fig. 29-4). An escharotomy involves an incision through the burned tissue down to the subcutaneous fatlayers to restore blood supply. A fasciotomy is necessarywhen the escharotomy has not restored adequate perfusionand the injury has extended into the muscle. This procedureinvolves a deeper incision through the fascia covering themuscle compartments and allows the expansion compressed or edematous areas muscle.

Fig 9 4 Diagram shows preferred sile of escharo tomyincisions. From Finkelstein JL, Schwartz SB, Madden MR et al:Pediatric bums: an overview, Pediarr lin orth 39: 1145-1163, 1992.


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The best time to perform an escharotomy varies and isbased on frequent assessment of the affected area, distalcirculation, sensory motor function, and pulses, as well asrespiratory effort and peak inspiratory pressures with torsobums. If an escharotomy is performed, blood loss may be aproblem as circulation is restored and is monitored. theescharotomy is performed too late, necrosis of the entireextremity distal to the injury site, compartment syndrome,

and gangrene can develop.

Exfoliative DisordersAlthough not considered thermal injuries, several diseasesincluding toxic epidermal necrolysis (TEN), epidermolysisbullosa, and purpura fulminans are increasingly beingtreated in bum units. Bum units have been demonstrated tocoordinate resources to manage these large complex woundsand reduce mortalityl9.21

TEN is a rare, severe form of epidermal sloughing occurring most often as a result of a severe drug-induced reaction.In addition to epidermal sloughing, the epithelial linings ofthe gastrointestinal tract and respiratory tract and the mucous membranes of the eye and oropharynx may alsoslough. TEN is manifested by fever (all cases), conjunctivitis (32 of cases), sore throat (25 of cases), pruritus (28of cases), malaise, and a rash with a positive Nikolsky s sign(a sloughing of sheets of epidermis in response to lighttouch)?2 Drugs that often trigger TEN include sulfonamides, nonsteroidal antiinflammatory drugs, anticonvulsants, penicillins, and allopurinol. Milder forms of the samedisease process include erythema multiforme and an intermediate form known as Stevens-Johnson syndrome.

Staphylococcal scalded skin syndrome (SSSS), a syn

drome clinically similar to TEN, is caused by a staphylococcal skin infection usually occurring in children youngerthan 5 years of age. Some strains of staphylococci producean epidermolyric toxin that causes the epidermis to cleave atthe upper malpighian and granular layers. The presentationof SSSS is very similar to TEN, also presenting with apositive Nikolsky s sign. Differentiation between these twodiseases is generally done by histologic examination of askin biopsy or sample.

RITI L RE M N GEMENT

Emergent Shock Phase s with any other trauma, initial management pnonlIesfocus on support o f airway, breathing, and circulation(ABCs). For the burned patient, the first priority is to stopthe burning process, then proceed with the ABCs.

Thorough and ongoing assessment of the airway is key inthe initial nursing care. Immediate intubation is consideredif a facial burn, upper airway edema, or an inhalation injuryis present. Ensuring an adequate airway is crucial becausedelay may make intubation difficult or impossible as a resultof massive swelling.

Maintenance of a stable airway may require creativity,including the use of tracheal ties or other nonadhesive

stabilization techniques because traditional adhesives do notstick to slippery, wet, edematous skin. With oral intubation,care is taken to protect the commissures of the mouth fromerosion by the ties used to hold the E T I in place. Creativityand nursing vigilance to ensure the protection of these areascan significantly reduce the need for difficult oral or lipreconstruction. This may include the use of elastomer oralcommissure pads; the use of double tracheostomy ties to

secure the tube; or additional padding with dressings or4 x s under the ties, above the ears, or at the back of thehead (Fig. 29-5).

Ventilatory support is provided as needed. Oxygen at100 is continued for any child with CO poisoninguntil carboxyhemoglobin levels are below 15 . In casesof inhalation injury, conventional mechanical ventilationmodes may not provide sufficient ventilatory support andnecessitate the use alternative ventilatory therapies?3.25

Maintenance of fluid balance is an important component of the emergent phase. Establishment of intravenous access with a large-caliber catheter is essentialbecause fluid resuscitation is vital to the initial management

Fig. 9 5 Securing oral endotracheal tubes requires creativityand attention to prevent oral commissure erosion, as well aspossible accidental extubation. Pictured here, elastomer oralcommissure pads are used to prevent injury, with two tracheostomycotton twill ties providing stability and ensuring tube security.(Photo courtesy Topliffe L and Lopez 1999.)


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TABLE 9 3 Fluid Resuscitation Formulas

Type and Volume of Fluid

First 4 Hours

Colloid: 0.5 mllkg/ burnCrystalloid: Lactated Ringer s

1.5 mllkg/ burn

D5W: 2000 mllm2

Urine: 30-50 mllhr (adult); 1-2 ml/kg/hr (child)Rate: 2 in first 8 hr

I in next 8 hr I in last 8 hr

Calculation of volume: use bum area up to 50 TBSA,>50 TBSA calculate at 50 TBSA

Colloid: noneCrystalloid: lactated Ringers

4 mllkg/ bumD5W: none

Urine: 50-70 mllhr (adult); 1-2 mllkg/hr (child)Rate: 2 in first 8 hr

/4 in next 8 hr 4 in last 8 hr

Calculation of volume; use total bum area for all size burns

Colloid: noneCrystalloid: Na 250 mEq/L

l 150 mEqlLlactate 100 mEqlL

D5W: liberal free water by mouthUrine: 3040 mllhr (adult); 1-2 ml/kg/hr (child)Rate; average 30 mI/hrCalculation of volume; ti trate to urine output not burn size

Second 4 Hours

0.25 ml/kg/Lactated Ringer s 0.75 ml/kg/ bum1500-2000 ml

Same /2 of first 24 hour s colloids

crystalloids

700-2000 ml (adul t) as needed tomaintain urine output

NoneSufficient to maintain urine outputSame 2 of first day s lactated Ringer s

NoneD5W

Ij5W 5 dextrose in water; TBS lotal body surface area.

mVkg/hr in the child and 30 to 50 ml/kg/hr in patientsgreater than 50 kg.

A mild metabolic acidosis occurs with bum shock butusually resolves within 18 to 24 hours of injury. Childrenyounger than 2 years of age, because of their inadequatelydeveloped buffer system, are especially prone to thedevelopment of metabolic acidosis Serum pH is monitored closely, and bicarbonate is given if the acidosisbecomes severe or if circulating blood volume is restoredwithout resolution of acidosis.

Mental status is a critical guide to evaluate the adequacyof fluid resuscitation. A child in an obtunded state requiresa thorough assessment because the burn injury itself doesnot directly affect mental status. If obtunded because ofshock, fluid resuscitation should restore the child s normalsensorium. If this is not the case, other causes of alteredlevel of consciousness are considered, including concurrenttrauma issues that might have occurred during the accident,as well as hypoglycemia.

Pediatric burn patients are particularly affected byalteration in temperature because of their greater BSA. Inaddition, they are less able to shiver because of relativelysmall muscle mass, which limits their ability to generate

heat. 9 Patients with large burns are at risk for hypothermia

until skin coverage is achieved. Exposure during proceduresand dressing changes may produce rapid hypothemnia.Efforts by patients to maintain temperature increase oxygenconsumption and energy expenditure and add to the stress ofthe burn injury.

The environment is kept free of drafts and warmer thannormal to allow a normal temperature (37 to 37.5 C) to bemaintained. Use of warm blankets, head covering, reflectiveblankets, and warming shields are nursing measures thateffectively raise the body temperature. Increasing environmental humidity can decrease evaporative losses from wetdressings and exposed body surfaces. Continuous monitoring with a rectal probe may be appropriate initially. Warmedintravenous and irrigation solutions and a warming blanketmay be considered if profound hypothermia develops.

Wound Care As the child s respiratory and cardiovascular status is stabilized, attention can be directed towardthe management of the burn wounds. Immediately followinginjury, clothing is removed, and a total survey of the body isperformed in a clean, warm environment. In children withlarge bums, assessing only a portion of the body at a timemay be necessary to maintain the child s temperature. Thisapproach becomes increasingly important in the infant and

young child because heat loss is rapid and physiologic


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consequences are significant. Classification of depth anddetermination of TBSA inv olvement a re verified. Lessobvious areas of injury, such as the sca lp and oropharynx,are examined for evidence of thermal injury. Regularassessment of periphera l pulses is performed on involvedextremities.

Surgical escharotomies may be required during theresuscitation phase to restore effecti ve circulation to extremities and digits. After the escharotomy has been performed,the neurologic status of the affected limb is assessedfrequently b ecause peak edema fo nn atio n does not o ccuruntil 24 hours afte r the bum

Wounds are cleansed with antibacterial soap and steri lewater or normal saline. Loose tissue is mechanicallydebrided, and the prescribed topical agent is applied. Topicalagents are not applied if the child is to be t ransferred to aburn center; instead the wo unds are wrapped in clean drydressings. Th e initial dressings are wrapped loosely, particu larly in the hands and feet, to a llow ant ic ipated swel ling.The head an d ex tremities are elevated for co mfo rt and tominimize fluid accumulation. Access to peripheral pulses isanticipated, so dressings are wrapped to allow periodicassessment of circulation. Wound management varies withphysician preference, but current therapy generally involvestotal removal of all dev ita lized ti ssue as soon as feasible.

Comfort anagement Most extensive burn in juries have components o f superficial and partial- andfull-thickness injuries. Superficial and partial-thicknessinjuries are very painful. Full-thickness injuries initially areanesthetic, but as the wounds are debrided, the nerveendings in the deeper layers of t issue become exposed,resulting in very painful lesions. In addi tion , woundcontraction inhibits j oi nt mobility, so ran ge-of-motion

exercises, activities of daily living, and dressing changes arepainfu l and anxie ty producing. Int ravenous narcot ics areind icated for the pain associa ted with burns. The medications of choice are morphine sulfate and fentanyl. Anxiolyticmedications such as midazolam or lorazepam are especiallyimportant for comfo rt man ag emen t and when prov idingventi latory support. Medicat ions are g iven in small dosesand titrated to rel ieve distress without complicat ing ventilation. Th e recommended approach is that all medicat ionsbe given intravenously during the emergent phase becauseof unre liable uptake from edematous t issues when givensubcutaneously or intramuscularly.

In addition to pharmacologic management of pain,interventions such as relaxation techniques and distractionmay be appropriate. These approaches also provide a meansfor family members to be involved in the care of the child.Every effort is mad e to meet the pa tient s n eed for comfor tand psychologic support . Consideration is given to associated injuries, past medical history, and the developmentalneeds of the child.

Psychologic Support During the resuscitative phaseof care, pat ients may be awake and alert. Survival. loss ofcontrol, and adaptation to an unfamiliar environment are thefocus of psychosocial support systems. Th e ability tocommunica te needs is impaired as a resu lt o f the treatmento f pain, anxiety, and respiratory function.

Chapter hermal njury 99

Box 29

American Burn Association Criteriafor Patient Transfer to a Burn Center

I Partial-thickness burns greater than 10 total bodysurface area TBSA)

2. Burns that involve face. hands feet genitalia, perineum,and major joints

3. Full-thickness burns in any age group4. Electrical bums, induding lightning injury5. Chemical bums6. Inhalation injury7. Burn injury in patients with preexisting medical disor

ders that could complicate management Burn patients with concomitant trauma in which the bum

injury poses the greatest risk of morbidity or mortality9. Burned children in hospitals without qualified personnel

or equipment for the care of cbildren10. Bum injury in patients who will require special social,

emotional, or long-term rehabilitative intervention

The child and family should be informed of theprocedures taking place and included in the overall plan ofcare. Efforts to reassure and calm the family are importantcomponents. Social services, psychiatry, chaplaincy, andother hospital resources can be involved as needed.

Transfer and Referral PrioritiesThe American Bu m Association has identified the type ofinjuries that req ui re referral to a specialized bu m center Box 29-1). Th e patient with electric, chemical, or thermal

injury requires immediate assessment and stabilization atthe closest appropriate hospital. There, hospital personnelcomplete a primary and secondary assessment and evaluatethe patien t for potential transfer. Clear documenta tion ofprocedures and care provided accompany the patient to thereceiving hospital. Th e use of transfer agreements betweenregionalized bu m centers and outlying community hospitalsa re con sid ered to facilitate orderly transfers and to meetcontinuing education needs. 9 Some su ggest that the earlytransfer of the child with acute bums may shorten the lengthof hospitalization and reduce complications 3

Acute PhaseWound Care and Coverage After stabilization has

been achieved in the emergent phase, a tten tion is d irec tedtoward closing the burn wound. The first step in this processis the assessmen t of wound depth and the surface areainvolved. Th e depth and exten t are variab le, depending onthe intensity of the source and the durat ion o f contact withthe source of injury. Over the first 48 to 72 hours after injury,the wounds continue to evolve. Th e ultimate depth of theinjury, especially in scald and chemical injuries, may not beevident until this evolution is complete.

Th e goals o f wound care become the preservation of asmuch viable tissue as possible, removal of all necrotic


12/17

Part V ultisystem roblems

tissue, control of the growth of microorganisms on thewound, and creation of an environment that is conducive towound healing. Where extensive full -thickness skin lossoccurs, the deficit must be replaced by some form ofautograft or permanent skin substitute. These goals areachieved in a myriad of ways, but the ultimate outcome isthe same-wound closure with intact, durable skin.

The first s tep in the preservation of viable tissue is therecognition of that which is viable . Viable tissue is pink,moist, warm, and sensate depending on the depth of thewound). Viability is a reflection of the degree of perfusion ofthe tissue, the availability of adequate substrates for tissuerepair, and the degree of exposure to such noxious agents asbacteria and fungus, some topical agents, and cleansingsolutions. Debriding dressings, mechanical trauma, shearingforces caused by movement, and desiccation drying) of thewound bed contribute to loss of viable tissue. Episodes ofhypotension, hypoxia, and poor perfusion of the wound bedcan also reduce tissue viability.

The activities of the burn care team are directed towardthe preservation of viable tissue. Specifically, the focus of

care is to maintain adequate tissue perfusion, provideadequate nutritional resources, prevent desiccation, reduceshear and mechanical trauma, and critically evaluate dressing materia ls that are being used on a part icular wound. Inaddition, keeping the wound free of debr is and necrot ictissue, reducing the exposure of the wound to toxic topicalagents and cleansing solutions, and providing permanentwound closure by early excision of eschar and graf ting assoon as possible are the tenets of the burn care team.

Controlling all of the variables that influence tissueviabi lity is not possible, but care should be taken to reduceknown risks to tissue survival while considering therequirements of the whole child. When the viability of aspecific tissue is uncertain, it is often best to allow the bodyto demarcate the line between viable and nonviable . Thisdilemma often occurs when the viability of fingers or toes isin question.

Debridement of necrotic tissue is the second componentin wound care. It can be achieved in a number of ways,including dressings, blunt and sharp debridement withhydrotherapy or showers, and primary excision underanesthesia. Regardless of the methods selected by the burnteam for the individual patient, providing adequate pain andanxiety relief is essential. Intravenous or oral narcotics andanxiolyt ic agents must be given in adequate doses dur ingthese procedures. Assessment of the child s pain and anxietyis performed throughout the procedure, and additionalmedication is administered, as needed.

Many dressing materials are on the market, with newones being int roduced often. The specific propert ies andrecommended uses for a product must be understood bycaregivers. Inappropriate use of a product can actually bedetrimental to the wound. The choice of material isgenerally directed by the goal of the therapy. If debridementofthe wound is the goal, one of the least expensive and mostcommonly available materials is wide mesh gauze WMG).WMG is laid in a single layer ove r the wound. may be

impregnated with a cream topical agent before application

or soaked with a liquid topical agent after a bulky outerdressing has been applied.

Many biologic dressings are available. These materialsinclude human cadaver allografts, porcine xenografts andseveral biosynthetic materials manufactured materials impregnated with collagen). The biologic dressings must beapplied to clean wound beds because they decrease evaporative wate r loss from the wound and create a warm moistenvironment. Biologic dressings placed over contaminatedwounds facilitate the growth of microorganisms and resultin deepening of the wound. At the first sign of purulentdrainage, increasing local inflammation, or systemic signsof sepsis, the biologic dressing tha t is not adherent to thewound bed is removed, and the wound is inspected andcultured.

The ideal coverage of the debrided full-thickness burnwound is skin grafts from the child s own body. Autologousskin grafts, the patient s own skin, remains the onlypermanent, durable closure for the burn wound. Autograftsmay be harvested from unburned areas of the body.Split-thickness autografts include both epidermal and der

mal elements and vary in thickness from 0.015 to 0.04 em.Epidermal appendages are spared so that the donor site willheal in to 4 days. The donor site is then available forreharvesti ng.

Full-thickness grafts include epidermis, dermis, andsometimes fat and muscle tissue. Because no epidermalappendages remain, the donor site must be either primarilyc losed or grafted with a split-thickness skin graft. Fullthickness grafts in large surface area bums are a very limitedresource. They are therefore reserved for hand and facialreconstruction and for coverage of open joints.

Several artificial skin replacement products are in the

research and development phases or newly available on themarket. These products, in whole or part, remain integratedwith the patient s body or are gradually replaced by thebody s own tissue?1 One such artificial skin, Integra,developed by Burke and Yannis, provides a dermal templatewith a temporary epidermal membrane. The artificial skinconsists of a collagen mat with a Silastic membrane temporary epidermis) on one side. The full-thickness burnwound is excised and Integra is sutured in place with thecollagen side down. Over about 4 weeks the collagen mat isreplaced by the body s own collagen. The Silastic membrane, which until this t ime has reduced evaporative waterlosses from the wound, is removed at 3 weeks. A very thinsplit-thickness skin graft or epithelial cell cultures are thenapplied to the neodermis. The neodermis and split-thicknessgraft form a durable skin replacement with a cosmeticallyacceptable appearance.

Epi thelia l cell cultures e.g., Genzyme) are addi tionalcommercially available products that can be used as part ofthe coverage plan for the extensively burned child. Apostage stamp-sized skin biopsy of normal skin is obtainedand sent to specific tissue culture laboratories. In thelaboratory, the epidermis is mechanically separated from thedermis. Enzymes are then added to the epidermal ti ssue toproduce a single-cell suspension. Th e single-cell suspension

is then inoculated into special tissue culture media. In about


13/17

1 days, the epidermal cells have grown into confluentsheets. These sheets are treated with an enzyme, Dispase, torelease them from their attachments to the plastic flasks. Atthis time they can be transferred to the patient s tissue;however, in most instances, the surface that they wouldcover would be insufficient to meet the patient s needs.These primary cultures are then treated with enzymes toproduce a single-cell suspension that is again inoculated intotissue culture media and incubated for another 1 days. Thecultured epithelial sheets are then Dispase-released from theflasks, clipped to Vaseline gauze carriers with surgical clips,and transported to the operating room for application to thepatient.

This process requires approximately 21 days. At thistime, the equivalent of 2 m 2 of epithelial cell culturesbecome available to the patient. During this waiting period,the wounds are excised and covered with some form ofbiologic or temporary dressing.

The epithelial cell cultures are applied to the excisedwound beds and are secured in place with either sutures orsurgical staples. Care is taken to handle the cultures as little

as possible because even minor mechanical trauma results inthe death of the epithelial cells involved. Postoperatively,the wounds are dressed with dry dressings, and the areas areimmobilized. In approximately 7 days, the Vaseline gauzebackings are gently removed. Thin glistening sheets ofepithelial cells can be seen as the backings are very gentlyremoved from the tissue. The coverage remains very fragilefor several weeks, requiring nonadherent dressings and greatcare in handling.

The durability of epithelial cell cultures is never the sameas normal skin but rather is like that of thin split-thicknessgrafts. They can, however, provide lifesaving coverage forthe child with extensive full-thickness bums. With anymethod of wound coverage selected by the bum team,coverage must be pursued aggressively if the child is tosurvive and avoid systemic sepsis and shock.

Regardless of the type of wound covering, it is criticalthat the child s wound be assessed at least daily for signs ofdeterioration. Signs of wound infection must be identifiedearly before systemic infection develops. Clinical manifestations include discoloration of eschar dark red, brown, orblack), conversion of a split-thickness injury to a fullthickness one, rapid acceleration of the eschar, reddenednecrotic lesions in unburned skin, discoloration of unburnedskin at the wound edge, and accelerated circular subcutane

ous edema with central necrosis.Infection Control The goals for the burned child

related to infection control include the following:

Prevent the transmission of microorganisms from thechild to the environment and other patients.

Prevent the transmission of microorganisms from theenvironment and other patients to the child.

Control or eradicate microorganisms that are not partof the child s normal flora.

Creating physical barriers between the burned child and theenvironment helps to prevent the transmission of microor

ganisms from the child to the environment and other patients

Chapter 9 Thermal n ury

and from the environment and other patients to the child.These barriers can be created in a number of ways,depending on the architecture and resources of the individual unit. The child can be cared for in a single room or in alaminar flow unit on an open ward. Barriers can includeplastic aprons, gauntlets, gloves, hats, and masks orisolation gowns, gloves, hats and masks. Standard precautions require the addition of goggles or face shields if areasonable risk exists for splash and splatter of body fluidsor tissues.

An environment that is conducive to wound healing iswarm and moist and has sufficient substrates for cell maturation and division. 3 Unfortunately, this environment is alsoconducive to the growth of microorganisms. These organisms compete with the body s cells for available substrateand produce toxins that inhibit the repair of the damagedtissue. The wound, therefore, is kept warm, moist, and asclean as possible, if wound healing is to be facilitated 3

Topical agents are applied to the wounds to control thegrowth of microorganisms on the wound until permanentcoverage is achieved. The appropriateness of a specific

agent for a specific wound depends on the characteristics ofthe topical agent, the wound, and the clinical experience orpreference of the bum team. Table 29-4 lists the propertiesof the various agents and their limitations.

Nutritional Management The burned child hasincreased nutritional requirements related to the hypermetabolic state and the energy needed to heal wounds. Calculated nutritional needs are based on basal metabolic rate,physical activity, and stress-induced energy needs Table29-5). Caloric requirements are estimated based on the BSAinvolved in a burn injury, as well as the child s dailyrequirements based on growth needs, and may range from1 2 to 1 5 times their basal metabolic rate. 33 34 A nutritionalconsult is planned on admission to determine caloric,carbohydrate, and protein goals with a systematic plan tomeet these goals. Formulas vary for determining the exactnutritional needs, and some may calculate as much as twicethe normal caloric and protein requirements. Adequacy ofnutritional support can be evaluated from calorie counts;laboratory values, including prealbumin and albumin levels;metabolic cart measurements; biweekly weights; and thestatus of wound healing.

Oral nutrition is the preferred method of feeding;however, oral intake is often insufficient because ofanorexia, intubation, and an inability to voluntarily take in

all the calories required. Providing supplemental enteralfeedings via flexible feeding tubes is often indicated in thesesituations to achieving calorie and protein goals. Feedingtubes can be placed into the small bowel via the gastricpylorus to minimize issues with decreased gastric motilityor high gastric residuals. Some bum centers continue enteralpostpyloric feedings during surgical procedures to make itpossible to achieve nutritional goals. 34 Other centers successfully use a program of intragastric feedings, sometimescombined with a limited intravenous hyperalimentationprogram 2 .35

The use of a limited intravenous hyperalimentation

program may be required in patients with prolonged


14/17

ffectiveness

Part V Multisystem ro lems

l T LE 9 Topical Agents~ J o p i c a lAgentI Lp

Side ffects ase of Use Pain ost

~ S i l v e rsulfadiazineI (Silvadene,~ Flamazine) 1i ~ , in water-misciblei ;.: cream base~ ~ .

~ ~

I ~i i1ver nitrate solu-

I tion 0.5 inIi~ .

II '; if:F~ ;~ j : i.X~ i : ;

jlMafenide acetate:It (Sulfamylon)rc 10 in water-j ~ m i s c i b l ecream

I,t base {( ~ ,

I~ o v i d o n eiodineI: (Betadlne) 1

1- ~ ~ Y P O C h l o r i t eIPakin'S

i fuso,

~ i C

~~ ;..:,;

~l l ~ o l l a g e n a s e

Ii;(Santyl) ~ n d~ 1 polysponn .., powderIf .t;Normal salineiii':;. 0.45 or 0.9

I-I:r ifCiL

Broad-spectrumMinimal eschar

penetration

Broad-spectrumOnly penetrates

2-4 mm intobum wound

Broad-spectrumincludingPseudomo las

Rapid and deepwound penetration

Broad-spectrum,including fungi

Broad-spectrum inconcentrations of0.025 -0.125

Safe for use as awet dressing overtendons and openjoints (used rarelyin United States)

Broad-spectrumbut no fungicoverage

No antimicrobialproperties

Keeps wound moist

Dose-relatedneutropenia

Sulfa allergiesDo lot use in

patients withtoxic epidermalnecrolysis

Development ofpseudoeschar

HypoallergenicLeaches electrolytes

from wound,especiallysodium andpotassium

Methemoglobinemia

Environmentalstaining

Inhibits spontaneous epithelialregeneration

Carbonic anhydraseinhibitor causingmetabolic acidosis as a result ofHCO) wasting

Sensitivity rash

Iodine absorptionthrough woundincreasing serumiodine levels

Iodine allergiesEnvironmental

staining

Can maceratenormal tissue

Unstable, use freshKeep in a dark

placeDrying to tissue

Sensitivity rash tosulfa drugs

Can macerate tissue

Semicloseddressings

Changed bid-qidResidue must be

washed off witheach dressingchange

Bulky ('/2-inch thick),wet dressings

Changed bid-qidMust be soaked

q2h to maintainwetness

Stains skin and environment black

Surrounding normalskin must beprotected fromstaining withpetrolatum-basedgauze

Semicloseddressings

Changed bid-qidResidue must be

washed off witheach dressingchange

Semiclosed or wetdressings

Changed bid-qid

Wet-wet dressingsWet -dry dressings

(debriding)Changed bid-qidSoak q2h

Dressing can beremoved moistor dry

Changed qd

Wet -wet dressingsWet-dry dressings

(debriding)Changed bid-qidSoak q2h

Cooling; leastpainful

Stings briefly onapplication orsoaking

Burning feeling for15-20 min

Stinging pain

Stings

None

Stings

34.35(400 g

9.75(liter)

126.00(453 g)

3.86(480 ml)

< 1.00(gal)

Collagenase: 29.95 (15 g)

Polysporin: 10.00 (10 g)

A few cents

iEJ)ata from Medical Economics Company: The red book Montvale, NJ, 1999, Medical Economics.1 :::


15/17

Chapter 29 Thermal Injury

Nutritional Support for Pediatric Burns

Basal Metabolic Rates: Infants and Children

Age to 36 mo Age 3 to 1 6 y r

Metabolic Rate Metabolic Rate kcallhr kcallhr

Weight kgMale

Female Weight kgMale

Female9.0 22.0 21.2 5 35.8 33.39.5 22.8 22.0 20 39.7 37.4

10.0 23.6 22.8 25 43.6 41.510.5 24.4 23.6 30 47.5 45.511.0 25.2 24.4 35 51.3 49.6 5 26.0 25.2 55.2 53.712.0 26.8 26.0 45 59 57.812.5 27.6 26.9 50 63.0 61.913.0 28.4 27.7 55 66.9 66.013.5 29.2 28.5 60 70.8 70.014.0 30.0 29.3 65 74.7 74.014.5 30.8 30.1 70 78.6 78.115.0 31.6 30.9 75 82.5 82.215.5 32.4 31.716.0 33.2 32.616.5 34.0 33.4

8.49.5

10.511.612.713.814.916.0 718.219.320.421.422.523.624.7

Metabolic Rate kcal/hr

Male orFemale

3.54.04.55.05.56.06.57.07.58.08.59.09.5

10.010.511.0

t A_g_e_ _W_k_to_ _m_o _

48-Thii

~ t~ ~ i g h t

kgk

j ~ o mAllman PL. Dillner OS. eds: etabolism Bethesda. Md. 1968. Federation of American Socielies for Experimental Biology.ini -yo calculate basal metabolic rate BMR). determine the age and weight of the patient. read across to appropriate sex. identify metabolic rate kcaVhr).~ i i nmultiply metabolic rate by 24 hours. For burn patients. multiply BMR by 2 to 5 to account for hypcrmetabolic state of burn injury.:ill:

paralytic ileus, an inability to meet caloric needs by otherroutes, or other gastrointestinal abnormalities making the

enteral route impractical. Consideration is given to providing necessary proteins, vitamins, trace elements. and lipidsnecessary for wound healing and growth.

Comfort Management. Comfort management is anessential issue in the acute phase, as it was in the emergentphase. Comfort management for the acutely ill child with alarge surface area burn is complicated by many factors. Thehypermetabolic state of the patient accelerates use ofnarcotic and anxiolytic medications Assessing the severity of the child s pain and fear is often difficult because ofthe child s growth and developmental level, level ofconsciousness, and ability to communicate. All of thesefactors influence the nurse s ability to assess the level ofdiscomfort and the child s responses to interventions. Painassessment tools are useful in helping the alert child toexpress pain.

Often the child is too il l to express discomfort, and thenurse can only rely on physiologic parameters. This isparticularly true if the child has been chemically paralyzedto facilitate mechanical ventilation. Liberal amounts ofanalgesics and anxiolytic medications are provided. A childwith planned interventions including dressing changes,positioning, physical therapy, and chest physiotherapyreceives appropriate premedication based on the response toprevious interventions.

Intravenous narcotics, particularly morphine sulfate andfentanyl, have become the standard for pain management.

Severe pain requires continuous infusions of intravenousnarcotics. For very painful procedures, such as dressing

changes, when premedication may not provide adequatecomfort or analgesia, bolus doses of narcotics and anxiolyticdrugs are used. For the alert school-age child and adolescent, patient-controlled analgesia is effective. Nonpharmacologic pain management strategies, such as distraction,guided imagery, hypnosis, music, and providing the childwith opportunities to exercise control, can be effective in theacute phase, as well as in the resuscitative phase. These havebeen found to be successful adjuncts to the traditionalpharmacologic management of pain and anxi ety Theirapplication for a specific child should address the child sgrowth and developmental level, level of consciousness, andwillingness to participate in these strategies, as well as theskill of the nurse or caregi ver

Mobility. Patients with burns are often immobilizedfor periods of time, placing them at risk for associatedcomplications. Movement is restricted initially by pain,bulky dressings, and splints. Bed rest and sedation also placethe burned child at risk for the hazards of immobility. Later,scar contractures, discomfort of healed wounds, musclewasting from disuse, and loss of stamina affect the ability tomove about comfortably. To maintain optimal physicalfunctioning, the patient s mobility is considered fromadmission. Active and passive range-of-motion ROM)exercises are done with every dressing change and through

out rehabilitation and recreational therapy activities. Nursing care involves routine position changes for the patient on


16/17

Part V Multisystem Problems

bed rest, comfort and protection from nerve damage, andmaintenance of joints in extended functional positions.

Physical and occupational therapy consultation andparticipation in their own daily care can maximize burnedchildren s functioning through the hospital stay and beyond.Involvement in exercise and self-care activities has important short- and long-term benefits for the child. Patientsbenefit from being out of bed as soon feasible. Pressurewraps or garments must be applied to grafted legs to helpcompensate for vascular instability in the newly grafted skinwhen the child is out of bed or ambulating. Many problemsof wound contracture, hypertrophic scarring, and impairedmobility can be limited when these issues are addressedearly.

Psychosocial Issues Emotional support for the family and patient is critical throughout this prolonged criticalillness. Nurses are instrumental in providing this supportand in coordinating support from others. The early involvement of social service and mental health professionals isessential in supporting the child and family. Maintainingcontact with the child s peers, school teachers, and othermembers of the community ultimately eases the childsreturn to a normal life. 2

As the child begins to recover and passes through criticalillness toward rehabilitation, the concerns of the child andfamily shift toward the child s ability to physically functionand the child s ultimate appearance. Children with facial andhand scars have the most difficult time dealing with theirchanged appearance. The child s body image changes withgrowth and development, producing new challenges tocoping through the different developmental stages. Parentsand siblings share these struggles.

For the child who is unable to survive the injury, support

for the family becomes the focus of resources. The team sgoals are to help them grieve for their lost child and beginto rebuild their lives as they heal their own emotionalscars. 37

Nursing staff and other caregivers need to supportthemselves and each other through this emotionally drainingexperience, Establishment of clear boundaries and involvement with patients and families may aid to prevent vicarioustrauma and maintain objectivity. Support groups, workshops, and individual discussions help professionals to

support the family and care for themselves. Open discussions surrounding the ethical issues that often surround thecare of these children are an invaluable resource to the staffwho participate.

BURN OUTCOMESSuccessive improvements in burn care, technology, regionalization of burn centers, and improved fluid and electrolyteresuscitation have substantially increased survivability ofmajor burn injuries, especially in children. The costs of thisimproved treatment, in terms of allocation of scarceresources, economic, as well as ethical, have called intoquestion the wisdom of providing maximum care instead ofcomfort care in patients with massive bum injuries.

Outcomes research, a strategy to provide benchmarks tocompare future results with care provided, has recentlybegun to exanline this question. Physical appearance andfunctional outcomes examined in patients with greater than80 TBSA burns found that over 80 were independent inbasic activities of daily living, indicating that most pediatricbum survivors satisfactorily adapt to their functional limitations even after severe injuries.3 8 In addition, the massively burned patients have a quality of life comparable withthe age-matched population. This finding also suggests thatalthough the cosmetic and functional impairments may beirreparable and life-lasting, high-quality acute care, skillfulmultidisciplinary aftercare, and family support can yieldpositive long-term outcomes for these children

SUMMARYThe child who sustains a major burn injury faces and

overcomes multisystem assault with the help of an interdisciplinary team. A vast array of professionals participates inthe effort to restore the child s physiologic and emotionalintegrity. An essential part of this team is the child s parents,who must help the child with integration into the communityand development into a productive member of society.Today, physical survival from devastating burn injury canalmost be ensured. The challenge for professionals in thefuture is to ensure that survival is meaningful for the child,family, and the community.

REFERENCES Herndon DN: Tota/ hurn care London. 1996.

WB Saunders.2 Sheridan R Prelack K Kadilak P et al:

Supplemental parenteral nutrition does notincrease mortality in children J Burn CareRehahil 21 :S234, 2000.

3 Tompkins RG Remensnydcr JP Burke JFet al: Significant reductions in mortality forchildren wilh bum injuries through the use ofprompt eschar excision. Ann Surg 208:577-585, 1988.

4. Bennell B Gamelli R: Profile of an abusedburned child, Bllrn Care Rehabil 19:88 941998.

5 Hultman CS, Prio lo D Cairns BA et al:Return to jeopardy: the fate of pediatric bumpatients who are victims of abuse and neglect

Burn Care Rehabi/ 19:367-376. 19886 Ramirez RJ, Behrends LG, Blakeney Pe t al:

Children with sensorimotor deficits: a specialrisk group. u Care Rehabi/ 19:124 1271998

7 Forjuoh SN: The mechanisms, intensity oflfeatment and outcomes hospitalizedbums: issues for prevention J ur CareRehabil 19:456-460, 1998.

8 Sheridan RL, Ryan CM, Petras L el aJ: Burnsin children younger than two years of age an

experience with 200 consecutive admissionsPediatrics 100:721-723, 1997.

American Bum Association: The advQncedhurn life suppor t course Chicago. 2000.The Association

10 Nguyen IT Gilpin DA. Meyer NA el al:Current treatment severely burned patientsA li I Surg 223: 14-25. 1996.

I I. Rieg LS Jenkins M: Burn injuries in children,Crir Care Nurs Clill North Am 3:457 470.1991.

12 Rai J Jeschke M Barrow RE el al: Electricalinjuries: a 30 year review Trauma 6:9 -936. 1999.


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13. Rabban n Blair J. R os en CL: Mechanismsof ped ia tr ic e lect rica l injury: new implica -tions for product safety an d injury prevention.Arch Pediatr Adolesc Med 151 :696 7001997.

14. Zubair M Besner GE: Ped ia tr ic e lect rica lbums: management strategies Bums 23:413-420, 1997.

15. Sheridan RL: Recogni tion an d managementof h ot l iq ui d a sp ir at io n in children l l

Emerg Med 27:89 91 1996.16. Weaver LK: C arbo n m on ox id e poisoning.

Crit Care Clin /5:297-317, 1999.17. Thorp JW: H ype rb ar ic o xyg en therapy. In

Holbrook PR ed: Textbook of pediatric crit-ical care Philadelphia 1993 WB Saunders.

18 O em li ng R H, laLonde C: Bu m traumaNew York 1989 Thieme Medical Publishers.

19. McGee T Munster A: Toxic e pide rmalnecrolysis syndrome: mortality rate reducedwith early referral to regional bum center.Plastic Reconstr Surg 102:1018 1022 1998.

2 0. B row n DL , Greenhalgh DG , War de n G O:Purpura fulminans: a disease best managed ina bum center Bu m Care Rehabil 19: 119-123 1998.

21. Sheridan RL Briggs SE R em en sn yd er J Pet al: The burn unit as a resource for themanagement of acute ncnburn conditions inchildren Bl lm Care Rehabil 16:62 641995.

22. Becker DS: Toxic epidermal necrolysis Lan-

eel 351: 1417 1420 1998.23. O Toole G Peek W Jaffe 0 et al: Extracor-

poreal membrane oxygenation in .he lreat

ment of inhalation injuries Bums 24:562-565, 1998.

24. Reper P Dankaert R van Hille P et al: Th eusefulness of combined high frequency per-cussive ventilation during acute respiratoryfailure after smoke inhalation Bllms 24:34-38, 1997.

25. Sheridan RL Huford WE , Kacmarek Ret aI:Inhaled nitric oxide in bum pat ients w ithrespiratory failure Trauma 42:629 6341997.

26. Aikawa N Martyn JAJ Burke JF: Pulmonaryartery catheterization and thermodilution car-diac output determination in the managementof cri tica lly burned pat ients Am SlIrg135:811 817 1978.

27. G or nn M I Broemeling L Herndon ON et al:Estimating energy requirements in burnedc hi ld re n: a n ew a pp ro ac h d er iv ed fr om m ea -surements of resting energy expenditure. Am Clin Nw r 54:35-40, 1991.

28. K ra vitz M: Thermal injuries. In Cardona VHu m P. Baslnagel Mason Pe t ai cds: Traumanursing: from resuscitation through rehabili-tation ed 2 Philadelphia 1994 WBSaunders.

29. Helvig E: Pediatric burn injuries AACN ClinIsslles Crit Care Nlln 4:433-442, 1993.

30. S he ri da n R We be r J Prelack K et al: Earlybu m center transfer shortens th e length ofhospitalization and reduces complications inc hi ld re n w it h s er io us bu rn i nj ur ie s. J BurnCare Rehabil 20:347 350 1999.

30a. Sheridan R L H in so n M N ac ke l A et al:Development of a pediatric burn pain and

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anxiety management program J u areRehabilI8:455 459 1997.

31. Monafo WW: Current concepts: initial management of bums, N Engl Med 335:1581-1586 1996.

32. David JA: Wound managemenr: a com-prehensive guide dressing alld heal-ing Springhouse Pa 1986 SpringhouseCorporation.

33. Pre lack K Cunningham J J Sh er id an R Let al: Energy an d protcln provisions for ther-mally injured children revisited: an outcomebased approach for determining requirements. m Care Rehabil 18:177 181 1997.

34. R odr igue z D: N ut ri tion in pat ients with se-vere bums: state of me art j Burn CareRehabil 17:62 70. 1996.

35. Hansbrough WB, Hansbrough JF: Success ofimmedia te int ragast ric feeding of patientswith bums, Bllm Care RehabilI4:512 5151995.

36. Osgood PF Szyfelbein SK: Management ofburn pain in chi ld ren Pediatr Clin North Am36:1001-1013,1989.

37. Arnold JH Gemma PB: A child dies: aportrait offamily grief. Rockville Md 1983Aspen Publications.

38 . M ey er s Pa al R Blakeney P R ob er t R et al:Physical and psychologic rehabilitation out-comes for pediatric patients wh o suffer 80or more TBSA, 70 or more third degreeburns. Bu m Care Rehabil 21 :43 9 2000.

3 9. S he ri dan R L. Hi nson M I. L ia ng M H et al:Long-lenn outcomes of children survivingma Sive burns lAMA 283:69 73 2000.

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