1. BURNS IN CHILDREN A Lecture by Dr. B. O. Edelu Department of Paediatrics

2. 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.

3. Classification of Burns  Can be classified in various ways:  Cause of burn  Depth of burn  Surface area  Severity* (Combination of factors)

4. Cause of injury  Heat  Electrical  Chemical  Fire  Radiation  Friction  Lightning

5. Class Layer involved AppearanceTextureSensation Healing time First degree Epidermis Redness (erythema) DryPainful1wk or less Second degree (Partial thickness) Extends into the dermis, but spares appendages Superficial - Clear blisters, Deep - Red or white with bloody blisters. MoistPainful Weeks - 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.

6. Based on surface area

7. Surface area cont’d

8. 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

9. 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

10. 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.

11. Pathophysiology Cont’d  This excessive fluid loss usually occur in the 1 st 24 hrs before normalizing.  Therefore, under-resuscitation in the 1 st 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.

12. 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.

13. 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.

14. Management of Burns Emergency 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% O 2 mandatory for severe burns

15. 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.

16. 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

17. Further Management Inpatient management  All major burns must be managed in the hospital  Fluid Therapy Parkland’s formula  1 st 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 1 st 24hrs in younger children

18.  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.

19.  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

20.  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

21. Other management considerations  Tetanus toxoid boster  ATS for the unimmunized  Temperature regulation  Blood glucose monitoring

22. Prevention of Burns See Lecture on accidents and poisoning