Paediatric Burns 2013

BURNS IN CHILDREN In South Africa burns are the number one cause of unnatural death in children under the age of 4 years The vast majority of burns occur in the home of the child Hot water scalds are the most common cause of burns Causes of burns: Scalds: hot water pot; flame: house fire, paraffin stove, candle falling on bed; contact: cooking appliances, heaters; electrical: open informal wires in informal dwelling or high voltage in substations; chemical: unsafe storage practices of acids and alkalis eg stove cleaner or drain cleaner 75% of burns occur at home due to poor socio-economic infrastructure, crowded living environment without fire breaks. Open fires in the house are risky for the child

The ABC of Burns resuscitation

Basic first care SAFE approach: Stop the burning Cool the burn wound Shout for help Advance with care Free the person from danger Evaluate the patient - ABCD Stop the burning Cool the burn wound

Airway History: Examination: Management: enclosed space? Smoke? Steam? burns to face Sputum containing soot Change in voice or cry, brassy cough, dysphonia, stridor Management: Clear airway,chin lift, jaw thrust. Beware: spine Close observation Humified 100% oxygen for 24h in all major burns ET tube

Breathing Breathing effort: Cyanosis or bright pink colour Tachypnoea, hypopnoea Abnormal chest movements Cyanosis or bright pink colour Cardiopulmonary resuscitation if not breathing, endotracheal intubation

Circulation Check the pulse Capillary refill time (normal < 3 sec) Shock in burns does not occur immediately, but evolves over time. If early shock look for bleeding elsewhere

Circulation: Fluids Initial 20mls/kg fluid bolus of Ringers Lactate if patient is shocked (can be repeated) Ongoing fluid requirements need to be calculated Resuscitation (Ringers Lactate): Day 1: 2-3ml x kg x % burn first half given in the 8 hours from the time of injury and the second half in the subsequent 16 hours Day 2: 1 - 2ml x kg x % burn over 24 hours Plus: Maintenance, per day (Paediatric maintenance solution with Glucose): 100 ml/kg up to 10kg plus 50 ml/kg from 10 – 20 kg This is only a guide. Clinical reassessment is important to adjust the fluids, for example if output is low and perfusion poor then give a fluid bolus of 10 ml/kg, if output is abundant and urine not concentrated then reduce fluids

Disability: Level of consciousness Altered sensorium may be due to: Associated head trauma Poor oxygenation Shock Carbon monoxide toxicity

Exposure Purpose of full exposure is to assess total burnt surface area and other injuries Be aware that children are at risk of developing hypothermia

Burn wound assessment Two components: Assessment of burn wound area: Determines fluid and metabolic needs Estimation of depth of the wound: Determines local and surgical management

Estimation of total burn surface area For every year after 1 year the head area decreases by around 1% and each leg gains 0.5%.Thus adult proportions are reached by age 10 years. Alternative method: Open unstretched Hand represents 1% BSA

Estimation of burn depth

Analgesia Pain management must be started from the beginning: Diminishes SIRS, diminishes long term psychological scaring Oral: Tilidine HCL (Valoron): 1 mg/kg 6 hourly Paracetamol: Loading dose 20 mg/kg; maintenance 15 mg/kg/dose, can be repeated 6 hourly

Analgesia Parenteral analgesia: Morphine 0.5 mg/kg in 50 ml 5% D + W. Infusion rate 1 – 4 ml/hour Ketamine 2 mg/kg/dose: For procedures Need to be able to ventilate child if stops breathing (resuscitation equipment must be ready)

Definitive management Transfer to burns centre is indicated for the following: Partial thickness burns greater than 10% TBSA Burns involving face, hands, feet, genitalia, perineum, major joints Third degree burns (any extent) Electrical, chemical burns Inhalation injury Circumferential burns Suspected child abuse Any patient that can not be managed at the referring facility

Definitive management Before transfer to the burns centre do the following: Document history and time of the burn Document fluids planned and received Diagrammatic sketch of burnt area Send signed consents for slough excision and grafting Ensure safe transport and qualified accompanying personnel to continue resuscitation en-route (working drip essential)

Definitive management Prevent limb ischemia: Escharotomies Prevent Katabolism: Early enteral feeding Prevent sepsis: Early sloughectomy, skin grafting. Prophylactic antibiotics do NOT work Prevent contractures: Splinting