BURNS IN CHILDREN

A Lecture by Dr. B. O. EdeluDepartment of Paediatrics

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.

Classification of Burns

Can be classified in various ways: Cause of burn Depth of burn Surface area Severity* (Combination of factors)

Cause of injury

Heat Electrical Chemical Fire Radiation Friction Lightning

Class Layer involved

Appearance Texture Sensation Healing time

First degree Epidermis Redness

(erythema) Dry Painful 1wk or less

Second degree (Partial thickness)

Extends into the dermis, but spares appendages

Superficial - Clear blisters, Deep - Red or white with bloody blisters.

Moist PainfulWeeks - 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.

Based on surface area

Surface area cont’d

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

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

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.

Pathophysiology Cont’d

This excessive fluid loss usually occur in the 1st 24 hrs before normalizing.

Therefore, under-resuscitation in the 1st 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.

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.

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.

Management of BurnsEmergency 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% O2 mandatory for severe burns

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.

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

Further Management Inpatient management

All major burns must be managed in the hospital Fluid Therapy

Parkland’s formula 1st 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 1st 24hrs in younger

children

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.

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

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

Other management considerations

Tetanus toxoid boster ATS for the unimmunized Temperature regulation Blood glucose monitoring

Prevention of Burns

See Lecture on accidents and poisoning