Pediatric BurnsPediatric Burns

Carolyn O’Donnell, MDCarolyn O’Donnell, MD

EpidemiologyEpidemiology

Worldwide: Worldwide:

Young children- 60-80% scaldsYoung children- 60-80% scalds

Older children- fire injury more likelyOlder children- fire injury more likely

>/= 5 yrs: 56% with flame burns>/= 5 yrs: 56% with flame burns Inflicted burns: usually scalds (stocking Inflicted burns: usually scalds (stocking

distribution typical), < 4 yrs of agedistribution typical), < 4 yrs of age Mortality related to size, depth, and Mortality related to size, depth, and

presence of inhalational injurypresence of inhalational injury

Symmetric Stocking Symmetric Stocking DistributionDistribution

PathophysiologyPathophysiology

Thermal injury->protein denaturation Thermal injury->protein denaturation and coagulation->irreversible tissue and coagulation->irreversible tissue damagedamage

Surrounding zone of decreased Surrounding zone of decreased perfusion-perfusion-

potentially salvageablepotentially salvageable Depth determined by intensity and Depth determined by intensity and

duration of exposureduration of exposure

Deeper BurnsDeeper Burns

more common in young children with more common in young children with thinner skinthinner skin

Prolonged contactProlonged contact High heatHigh heat High viscosityHigh viscosity

Systemic ResponseSystemic Response

Damaged tissue ->vasoactive mediatorsDamaged tissue ->vasoactive mediators

(cytokines, prostaglandins, free radicals)(cytokines, prostaglandins, free radicals) Increased capillary permeability-> increased Increased capillary permeability-> increased

fluid in surrounding interstitial spacefluid in surrounding interstitial space Capillary leak: 18 to 24 hoursCapillary leak: 18 to 24 hours Large burns: can see myocardial depressionLarge burns: can see myocardial depression Major burns: hypotension, edemaMajor burns: hypotension, edema

(burn shock, burn edema)(burn shock, burn edema)

Large BurnsLarge Burns

Can see myocardial depressionCan see myocardial depression Red Blood Cell destructionRed Blood Cell destruction

Local destruction of up to 15% of RBCsLocal destruction of up to 15% of RBCs

Decreased RBC survival time- can-> Decreased RBC survival time- can-> additional 25% reductionadditional 25% reduction

Metabolic ResponseMetabolic Response

Hypermetabolic response: Hypermetabolic response: Increased catecholamines, glucagon, Increased catecholamines, glucagon,

cortisol -> increased metabolic rate, cortisol -> increased metabolic rate, catabolismcatabolism

Decreased growth hormone, insulin-Decreased growth hormone, insulin-like growth factor (anabolic like growth factor (anabolic hormones)hormones)

ClassificationClassification

Minor, moderate and major (ABA)- Minor, moderate and major (ABA)- based on depth and sizebased on depth and size

Treatment and prognosis based on Treatment and prognosis based on classificationclassification

Burn SizeBurn Size

Accuracy is important- often Accuracy is important- often underestimatedunderestimated

Often determines management Often determines management Typically expressed as percentage of Typically expressed as percentage of

total body surface area (TBSA)total body surface area (TBSA) Lund and Browder chart usefulLund and Browder chart useful Palm size- approximately 0.5% TBSAPalm size- approximately 0.5% TBSA

Burn DepthBurn Depth

Can appear more superficial initially Can appear more superficial initially and progressand progress

Superficial- involve only the Superficial- involve only the epidermal layer of skinepidermal layer of skin

Painful, dry, red, blanch with Painful, dry, red, blanch with pressurepressure

Heal in 3-6 daysHeal in 3-6 days No scarringNo scarring

SuperficialSuperficial

Superficial Partial ThicknessSuperficial Partial Thickness

Epidermis and superficial dermisEpidermis and superficial dermis Painful, red, weeping, blanch with Painful, red, weeping, blanch with

pressurepressure Usually form blistersUsually form blisters Heal in 7-21 daysHeal in 7-21 days Scarring is unusualScarring is unusual Can see pigment changesCan see pigment changes

Superficial Partial ThicknessSuperficial Partial Thickness

Deep Partial thicknessDeep Partial thickness

Extend to deeper dermis (hair Extend to deeper dermis (hair follicles/glandualr tissue)follicles/glandualr tissue)

Less painful than superficial partialLess painful than superficial partial Usually blister, wet or waxy dryUsually blister, wet or waxy dry NonblanchingNonblanching Color variable- red to cheesy whiteColor 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-Can be hard to distinguish from full-

thicknessthickness

Deep Partial ThicknessDeep Partial Thickness

Full ThicknessFull Thickness

Extend through dermisExtend through dermis Often painlessOften painless Waxy white to leathery gray to Waxy white to leathery gray to

charred and blackcharred and black Skin dry and inelastic, nonblanchingSkin dry and inelastic, nonblanching Severe scarring- sometimes with Severe scarring- sometimes with

contracturescontractures

Full thicknessFull thickness

Fourth degreeFourth degree

Extend to underlying tissues like Extend to underlying tissues like fascia, musclefascia, muscle

Grading SystemGrading System

Minor: <10% TBSA in adults, <5% in Minor: <10% TBSA in adults, <5% in kids or older adults, <2% full kids or older adults, <2% full thicknessthickness

Moderate: 10-20% in adults, 5-10% Moderate: 10-20% in adults, 5-10% young or old, 2-5% full thickness, young or old, 2-5% full thickness, high voltage injury, suspected high voltage injury, suspected inhalation injury, circumferential inhalation injury, circumferential burn, underlying medical condition burn, underlying medical condition predisposing to infectionpredisposing to infection

MajorMajor

>20% TBSA in adults, >10% young or >20% TBSA in adults, >10% young or oldold

>5% full thickness>5% full thickness High voltage burnHigh voltage burn Known inhalation injuryKnown inhalation injury Significant burn to face, eyes, ears, Significant burn to face, eyes, ears,

genitalia, or jointsgenitalia, or joints Significant associated injuries- fall, etcSignificant associated injuries- fall, etc

Pre-Hospital carePre-Hospital care

ABC’s, supplemental oxygenABC’s, supplemental oxygen Intubation if airway burn/inhalationIntubation if airway burn/inhalation Remove burned clothing and jewelryRemove burned clothing and jewelry Cover area with clean sheet Cover area with clean sheet

(warmth)(warmth) Establish vascular access if possible- Establish vascular access if possible-

IV fluids, pain medicationsIV fluids, pain medications

CoolingCooling

Immediate cooling can be beneficialImmediate cooling can be beneficial Cool with water 10-20 minutes after Cool with water 10-20 minutes after

burnburn Water temp no less than 8 CelsiusWater temp no less than 8 Celsius No ice, no butterNo ice, no butter Watch for and take measures to Watch for and take measures to

prevent hypothermiaprevent hypothermia

ABC’sABC’s

Airway: Look for signs of inhalation Airway: Look for signs of inhalation injury- soot in mouth, facial burns, injury- soot in mouth, facial burns, stridor, hoarseness. Intubate early if stridor, hoarseness. Intubate early if concernedconcerned

Breathing: Ventilation/oxygenation can Breathing: Ventilation/oxygenation can be affected by toxins (CO), associated be affected by toxins (CO), associated injuries, decreased level of injuries, decreased level of consciousness, circumferential burns consciousness, circumferential burns (chest/abdomen)(chest/abdomen)

Circulation: evaluate for associated Circulation: evaluate for associated injuries if VS changes, poor perfusioninjuries if VS changes, poor perfusion

ExaminationExamination Thorough general examination, obtain Thorough general examination, obtain

weight if possibleweight if possible Skin exam: Skin exam: Size and depth of burnSize and depth of burn Early eye exam including fluorescein stain Early eye exam including fluorescein stain

to look for corneal burnsto look for corneal burns Note external ear burns: risk for Note external ear burns: risk for

suppurative chondritissuppurative chondritis Circumferential burns- very close Circumferential burns- very close

monitoring of distal perfusion/capillary monitoring of distal perfusion/capillary refill (compartment syndrome), and refill (compartment syndrome), and respiratory statusrespiratory status

Diagnostic StudiesDiagnostic Studies

Baseline CBC, electrolytesBaseline CBC, electrolytes UA may reveal myoglobinuria if UA may reveal myoglobinuria if

muscle injurymuscle injury Carbon monoxide levelsCarbon monoxide levels Consider CXR, soft tissue neck filmsConsider CXR, soft tissue neck films Others based on presentationOthers based on presentation

ManagementManagement

Airway: Airway: Anticipate difficult airwayAnticipate difficult airway Rapid sequence intubation: avoid BP Rapid sequence intubation: avoid BP

lowering sedatives (etomidate okay), lowering sedatives (etomidate okay), avoid succinylcholine if >48 hrs due avoid succinylcholine if >48 hrs due to increased risk of hyperkalemiato increased risk of hyperkalemia

Monitor ETT closely- avoid accidental Monitor ETT closely- avoid accidental extubationextubation

ManagementManagement

Reliable IV access for fluid resuscitationReliable IV access for fluid resuscitation Consider bladder catheter to reliably Consider bladder catheter to reliably

measure UOPmeasure UOP Tetanus vaccine if >5 yrs since boosterTetanus vaccine if >5 yrs since booster Tetanus immune globulin if incomplete Tetanus immune globulin if incomplete

primary immunization (less than 3)primary immunization (less than 3) Consider surgical consultationConsider surgical consultation

IV FluidsIV Fluids

Parkland formula: 4 ml/kg per %TBSA in Parkland formula: 4 ml/kg per %TBSA in 24 hours in addition to maintenance fluids24 hours in addition to maintenance fluids

Half of fluid given over 1Half of fluid given over 1stst 8 hours, 2 8 hours, 2ndnd 50% given over the next 16 hours50% given over the next 16 hours

4:2:1 for maintenance fluids/hour4:2:1 for maintenance fluids/hour Ringer’s lactate often used (LR) in 1Ringer’s lactate often used (LR) in 1stst 24 24

hours. D5LR often used for children hours. D5LR often used for children <20kg<20kg

Consider colloid/albumin after 24 hours to Consider colloid/albumin after 24 hours to improve oncotic pressureimprove oncotic pressure

MonitoringMonitoring Very close Is/OsVery close Is/Os <30 kg: UOP 1-2ml/kg/hr<30 kg: UOP 1-2ml/kg/hr >30 kg: 0.5-1 ml/kg/hr>30 kg: 0.5-1 ml/kg/hr If increased UOP: check for glucose (osmotic If increased UOP: check for glucose (osmotic

diuresis)diuresis) If decreased UOP: increase fluid, evaluate If decreased UOP: increase fluid, evaluate

renal functionrenal function Monitor HR and BP (pain may factor in)Monitor HR and BP (pain may factor in) Can see metabolic acidosis w/ inadequate Can see metabolic acidosis w/ inadequate

fluid resuscitation (also w/ CO, cyanide fluid resuscitation (also w/ CO, cyanide exposure)exposure)

Pain control- morphine, fentanylPain control- morphine, fentanyl

Wound ManagementWound Management

Clean with mild soap and waterClean with mild soap and water Avoid disinfectantsAvoid disinfectants Remove clothing and debrisRemove clothing and debris Debridement of devitalized tissue Debridement of devitalized tissue

with sterile saline soaked gauzewith sterile saline soaked gauze Large, painful blisters and those Large, painful blisters and those

likely to rupture should be removedlikely to rupture should be removed

Wound DressingWound Dressing Topical antibiotic covered with nonadherent dressing, Topical antibiotic covered with nonadherent dressing,

then covered with tubular net or gauze bandagethen covered with tubular net or gauze bandage Ideally: biologic dressing for deeper burnsIdeally: biologic dressing for deeper burns Topical Abx:Topical Abx: Silver sulfadiazine 1%- broad antimicrobial, decreases Silver sulfadiazine 1%- broad antimicrobial, decreases

pain, delayed healingpain, delayed healing Mafenide- penetrates well, broad spectrum, painful on Mafenide- penetrates well, broad spectrum, painful on

application. Limited to cartilage, established infections- application. Limited to cartilage, established infections- can -> metabolic acidosis in large amountcan -> metabolic acidosis in large amount

Bacitracin- often used on face- painless, doesn’t bleach Bacitracin- often used on face- painless, doesn’t bleach pigment from skinpigment from skin

Dressings should be changed frequently- 1-2x/dayDressings should be changed frequently- 1-2x/day

EscharotomyEscharotomy

A consideration in partial and full A consideration in partial and full thickness burns which can lead to thickness burns which can lead to functional impairment (often seen as functional impairment (often seen as edema increases)edema increases)

Involves incision completely through Involves incision completely through the depth of the burn escharthe depth of the burn eschar

Can relieve restriction (chest burns) Can relieve restriction (chest burns) and reduce pressure (compartment and reduce pressure (compartment syndrome)syndrome)

EscharotomyEscharotomy

ReferencesReferences

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