Pediatric Burns Carolyn O’Donnell, MD

Epidemiology Worldwide: Worldwide: Young children % scalds Older children- fire injury more likely >/= 5 yrs: 56% with flame burns Inflicted burns: usually scalds (stocking distribution typical), < 4 yrs of age Inflicted burns: usually scalds (stocking distribution typical), < 4 yrs of age Mortality related to size, depth, and presence of inhalational injury Mortality related to size, depth, and presence of inhalational injury

Symmetric Stocking Distribution

Pathophysiology Thermal injury->protein denaturation and coagulation->irreversible tissue damage Thermal injury->protein denaturation and coagulation->irreversible tissue damage Surrounding zone of decreased perfusion- Surrounding zone of decreased perfusion- potentially salvageable Depth determined by intensity and duration of exposure Depth determined by intensity and duration of exposure

Deeper Burns more common in young children with thinner skin more common in young children with thinner skin Prolonged contact Prolonged contact High heat High heat High viscosity High viscosity

Systemic Response Damaged tissue ->vasoactive mediators Damaged tissue ->vasoactive mediators (cytokines, prostaglandins, free radicals) Increased capillary permeability-> increased fluid in surrounding interstitial space Increased capillary permeability-> increased fluid in surrounding interstitial space Capillary leak: 18 to 24 hours Capillary leak: 18 to 24 hours Large burns: can see myocardial depression Large burns: can see myocardial depression Major burns: hypotension, edema Major burns: hypotension, edema (burn shock, burn edema)

Large Burns Can see myocardial depression Can see myocardial depression Red Blood Cell destruction Red Blood Cell destruction Local destruction of up to 15% of RBCs Decreased RBC survival time- can-> additional 25% reduction

Metabolic Response Hypermetabolic response: Hypermetabolic response: Increased catecholamines, glucagon, cortisol -> increased metabolic rate, catabolism Increased catecholamines, glucagon, cortisol -> increased metabolic rate, catabolism Decreased growth hormone, insulin-like growth factor (anabolic hormones) Decreased growth hormone, insulin-like growth factor (anabolic hormones)

Classification Minor, moderate and major (ABA)- based on depth and size Minor, moderate and major (ABA)- based on depth and size Treatment and prognosis based on classification Treatment and prognosis based on classification

Burn Size Accuracy is important- often underestimated Accuracy is important- often underestimated Often determines management Often determines management Typically expressed as percentage of total body surface area (TBSA) Typically expressed as percentage of total body surface area (TBSA) Lund and Browder chart useful Lund and Browder chart useful Palm size- approximately 0.5% TBSA Palm size- approximately 0.5% TBSA

Burn Depth Can appear more superficial initially and progress Can appear more superficial initially and progress Superficial- involve only the epidermal layer of skin Superficial- involve only the epidermal layer of skin Painful, dry, red, blanch with pressure Painful, dry, red, blanch with pressure Heal in 3-6 days Heal in 3-6 days No scarring No scarring

Superficial

Superficial Partial Thickness Epidermis and superficial dermis Epidermis and superficial dermis Painful, red, weeping, blanch with pressure Painful, red, weeping, blanch with pressure Usually form blisters Usually form blisters Heal in 7-21 days Heal in 7-21 days Scarring is unusual Scarring is unusual Can see pigment changes Can see pigment changes

Superficial Partial Thickness

Deep Partial thickness Extend to deeper dermis (hair follicles/glandualr tissue) Extend to deeper dermis (hair follicles/glandualr tissue) Less painful than superficial partial Less painful than superficial partial Usually blister, wet or waxy dry Usually blister, wet or waxy dry Nonblanching Nonblanching Color variable- red to cheesy white Color variable- red to cheesy white >21 days to heal, scarring can be severe >21 days to heal, scarring can be severe Can be hard to distinguish from full-thickness Can be hard to distinguish from full-thickness

Deep Partial Thickness

Full Thickness Extend through dermis Extend through dermis Often painless Often painless Waxy white to leathery gray to charred and black Waxy white to leathery gray to charred and black Skin dry and inelastic, nonblanching Skin dry and inelastic, nonblanching Severe scarring- sometimes with contractures Severe scarring- sometimes with contractures

Full thickness

Fourth degree Extend to underlying tissues like fascia, muscle Extend to underlying tissues like fascia, muscle

Grading System Minor: <10% TBSA in adults, <5% in kids or older adults, <2% full thickness Minor: <10% TBSA in adults, <5% in kids or older adults, <2% full thickness Moderate: 10-20% in adults, 5-10% young or old, 2-5% full thickness, high voltage injury, suspected inhalation injury, circumferential burn, underlying medical condition predisposing to infection Moderate: 10-20% in adults, 5-10% young or old, 2-5% full thickness, high voltage injury, suspected inhalation injury, circumferential burn, underlying medical condition predisposing to infection

Major >20% TBSA in adults, >10% young or old >20% TBSA in adults, >10% young or old >5% full thickness >5% full thickness High voltage burn High voltage burn Known inhalation injury Known inhalation injury Significant burn to face, eyes, ears, genitalia, or joints Significant burn to face, eyes, ears, genitalia, or joints Significant associated injuries- fall, etc Significant associated injuries- fall, etc

Pre-Hospital care ABC’s, supplemental oxygen ABC’s, supplemental oxygen Intubation if airway burn/inhalation Intubation if airway burn/inhalation Remove burned clothing and jewelry Remove burned clothing and jewelry Cover area with clean sheet (warmth) Cover area with clean sheet (warmth) Establish vascular access if possible- IV fluids, pain medications Establish vascular access if possible- IV fluids, pain medications

Cooling Immediate cooling can be beneficial Immediate cooling can be beneficial Cool with water minutes after burn Cool with water minutes after burn Water temp no less than 8 Celsius Water temp no less than 8 Celsius No ice, no butter No ice, no butter Watch for and take measures to prevent hypothermia Watch for and take measures to prevent hypothermia

ABC’s Airway: Look for signs of inhalation injury- soot in mouth, facial burns, stridor, hoarseness. Intubate early if concerned Airway: Look for signs of inhalation injury- soot in mouth, facial burns, stridor, hoarseness. Intubate early if concerned Breathing: Ventilation/oxygenation can be affected by toxins (CO), associated injuries, decreased level of consciousness, circumferential burns (chest/abdomen) Breathing: Ventilation/oxygenation can be affected by toxins (CO), associated injuries, decreased level of consciousness, circumferential burns (chest/abdomen) Circulation: evaluate for associated injuries if VS changes, poor perfusion Circulation: evaluate for associated injuries if VS changes, poor perfusion

Examination Thorough general examination, obtain weight if possible Thorough general examination, obtain weight if possible Skin exam: Skin exam: Size and depth of burn Size and depth of burn Early eye exam including fluorescein stain to look for corneal burns Early eye exam including fluorescein stain to look for corneal burns Note external ear burns: risk for suppurative chondritis Note external ear burns: risk for suppurative chondritis Circumferential burns- very close monitoring of distal perfusion/capillary refill (compartment syndrome), and respiratory status Circumferential burns- very close monitoring of distal perfusion/capillary refill (compartment syndrome), and respiratory status

Diagnostic Studies Baseline CBC, electrolytes Baseline CBC, electrolytes UA may reveal myoglobinuria if muscle injury UA may reveal myoglobinuria if muscle injury Carbon monoxide levels Carbon monoxide levels Consider CXR, soft tissue neck films Consider CXR, soft tissue neck films Others based on presentation Others based on presentation

Management Airway: Airway: Anticipate difficult airway Anticipate difficult airway Rapid sequence intubation: avoid BP lowering sedatives (etomidate okay), avoid succinylcholine if >48 hrs due to increased risk of hyperkalemia Rapid sequence intubation: avoid BP lowering sedatives (etomidate okay), avoid succinylcholine if >48 hrs due to increased risk of hyperkalemia Monitor ETT closely- avoid accidental extubation Monitor ETT closely- avoid accidental extubation

Management Reliable IV access for fluid resuscitation Reliable IV access for fluid resuscitation Consider bladder catheter to reliably measure UOP Consider bladder catheter to reliably measure UOP Tetanus vaccine if >5 yrs since booster Tetanus vaccine if >5 yrs since booster Tetanus immune globulin if incomplete primary immunization (less than 3) Tetanus immune globulin if incomplete primary immunization (less than 3) Consider surgical consultation Consider surgical consultation

IV Fluids Parkland formula: 4 ml/kg per %TBSA in 24 hours in addition to maintenance fluids Parkland formula: 4 ml/kg per %TBSA in 24 hours in addition to maintenance fluids Half of fluid given over 1 st 8 hours, 2 nd 50% given over the next 16 hours Half of fluid given over 1 st 8 hours, 2 nd 50% given over the next 16 hours 4:2:1 for maintenance fluids/hour 4:2:1 for maintenance fluids/hour Ringer’s lactate often used (LR) in 1 st 24 hours. D5LR often used for children <20kg Ringer’s lactate often used (LR) in 1 st 24 hours. D5LR often used for children <20kg Consider colloid/albumin after 24 hours to improve oncotic pressure Consider colloid/albumin after 24 hours to improve oncotic pressure

Monitoring Very close Is/Os Very close Is/Os <30 kg: UOP 1-2ml/kg/hr <30 kg: UOP 1-2ml/kg/hr >30 kg: ml/kg/hr >30 kg: ml/kg/hr If increased UOP: check for glucose (osmotic diuresis) If increased UOP: check for glucose (osmotic diuresis) If decreased UOP: increase fluid, evaluate renal function If decreased UOP: increase fluid, evaluate renal function Monitor HR and BP (pain may factor in) Monitor HR and BP (pain may factor in) Can see metabolic acidosis w/ inadequate fluid resuscitation (also w/ CO, cyanide exposure) Can see metabolic acidosis w/ inadequate fluid resuscitation (also w/ CO, cyanide exposure) Pain control- morphine, fentanyl Pain control- morphine, fentanyl

Wound Management Clean with mild soap and water Clean with mild soap and water Avoid disinfectants Avoid disinfectants Remove clothing and debris Remove clothing and debris Debridement of devitalized tissue with sterile saline soaked gauze Debridement of devitalized tissue with sterile saline soaked gauze Large, painful blisters and those likely to rupture should be removed Large, painful blisters and those likely to rupture should be removed

Wound Dressing Topical antibiotic covered with nonadherent dressing, then covered with tubular net or gauze bandage Topical antibiotic covered with nonadherent dressing, then covered with tubular net or gauze bandage Ideally: biologic dressing for deeper burns Ideally: biologic dressing for deeper burns Topical Abx: Topical Abx: Silver sulfadiazine 1%- broad antimicrobial, decreases pain, delayed healing Silver sulfadiazine 1%- broad antimicrobial, decreases pain, delayed healing Mafenide- penetrates well, broad spectrum, painful on application. Limited to cartilage, established infections- can -> metabolic acidosis in large amount Mafenide- penetrates well, broad spectrum, painful on application. Limited to cartilage, established infections- can -> metabolic acidosis in large amount Bacitracin- often used on face- painless, doesn’t bleach pigment from skin Bacitracin- often used on face- painless, doesn’t bleach pigment from skin Dressings should be changed frequently- 1-2x/day Dressings should be changed frequently- 1-2x/day

Escharotomy A consideration in partial and full thickness burns which can lead to functional impairment (often seen as edema increases) A consideration in partial and full thickness burns which can lead to functional impairment (often seen as edema increases) Involves incision completely through the depth of the burn eschar Involves incision completely through the depth of the burn eschar Can relieve restriction (chest burns) and reduce pressure (compartment syndrome) Can relieve restriction (chest burns) and reduce pressure (compartment syndrome)

Escharotomy

References Up to Date online Up to Date online Google images Google images