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Pediatric Burns

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Title: Care of Moderate and Severe Burns- pediatric Author: ummhc Last modified by: ummhc Created Date: 1/15/2010 6:33:28 PM Document presentation format – PowerPoint PPT presentation

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Learn more at: http://www.umassmed.edu
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Tags: burns | pediatric | shock

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Title: Pediatric Burns


1
Pediatric Burns
  • Carolyn ODonnell, MD

2
Epidemiology
  • Worldwide
  • Young children- 60-80 scalds
  • Older children- fire injury more likely
  • gt/ 5 yrs 56 with flame burns
  • Inflicted burns usually scalds (stocking
    distribution typical), lt 4 yrs of age
  • Mortality related to size, depth, and presence of
    inhalational injury

3
Symmetric Stocking Distribution
4
Pathophysiology
  • Thermal injury-gtprotein denaturation and
    coagulation-gtirreversible tissue damage
  • Surrounding zone of decreased perfusion-
  • potentially salvageable
  • Depth determined by intensity and duration of
    exposure

5
Deeper Burns
  • more common in young children with thinner skin
  • Prolonged contact
  • High heat
  • High viscosity

6
Systemic Response
  • Damaged tissue -gtvasoactive mediators
  • (cytokines, prostaglandins, free radicals)
  • Increased capillary permeability-gt increased
    fluid in surrounding interstitial space
  • Capillary leak 18 to 24 hours
  • Large burns can see myocardial depression
  • Major burns hypotension, edema
  • (burn shock, burn edema)

7
Large Burns
  • Can see myocardial depression
  • Red Blood Cell destruction
  • Local destruction of up to 15 of RBCs
  • Decreased RBC survival time- can-gt additional 25
    reduction

8
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9
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10
Metabolic Response
  • Hypermetabolic response
  • Increased catecholamines, glucagon, cortisol -gt
    increased metabolic rate, catabolism
  • Decreased growth hormone, insulin-like growth
    factor (anabolic hormones)

11
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12
Classification
  • Minor, moderate and major (ABA)- based on depth
    and size
  • Treatment and prognosis based on classification

13
Burn Size
  • Accuracy is important- often underestimated
  • Often determines management
  • Typically expressed as percentage of total body
    surface area (TBSA)
  • Lund and Browder chart useful
  • Palm size- approximately 0.5 TBSA

14
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15
Burn Depth
  • Can appear more superficial initially and
    progress
  • Superficial- involve only the epidermal layer of
    skin
  • Painful, dry, red, blanch with pressure
  • Heal in 3-6 days
  • No scarring

16
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17
Superficial
18
Superficial Partial Thickness
  • Epidermis and superficial dermis
  • Painful, red, weeping, blanch with pressure
  • Usually form blisters
  • Heal in 7-21 days
  • Scarring is unusual
  • Can see pigment changes

19
Superficial Partial Thickness
20
Deep Partial thickness
  • Extend to deeper dermis (hair follicles/glandualr
    tissue)
  • Less painful than superficial partial
  • Usually blister, wet or waxy dry
  • Nonblanching
  • Color variable- red to cheesy white
  • gt21 days to heal, scarring can be severe
  • Can be hard to distinguish from full-thickness

21
Deep Partial Thickness
22
Full Thickness
  • Extend through dermis
  • Often painless
  • Waxy white to leathery gray to charred and black
  • Skin dry and inelastic, nonblanching
  • Severe scarring- sometimes with contractures

23
Full thickness
24
Fourth degree
  • Extend to underlying tissues like fascia, muscle

25
Grading System
  • Minor lt10 TBSA in adults, lt5 in kids or older
    adults, lt2 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

26
Major
  • gt20 TBSA in adults, gt10 young or old
  • gt5 full thickness
  • High voltage burn
  • Known inhalation injury
  • Significant burn to face, eyes, ears, genitalia,
    or joints
  • Significant associated injuries- fall, etc

27
Pre-Hospital care
  • ABCs, supplemental oxygen
  • Intubation if airway burn/inhalation
  • Remove burned clothing and jewelry
  • Cover area with clean sheet (warmth)
  • Establish vascular access if possible- IV fluids,
    pain medications

28
Cooling
  • Immediate cooling can be beneficial
  • Cool with water 10-20 minutes after burn
  • Water temp no less than 8 Celsius
  • No ice, no butter
  • Watch for and take measures to prevent hypothermia

29
ABCs
  • 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)
  • Circulation evaluate for associated injuries if
    VS changes, poor perfusion

30
Examination
  • Thorough general examination, obtain weight if
    possible
  • Skin exam
  • Size and depth of burn
  • Early eye exam including fluorescein stain to
    look for corneal burns
  • Note external ear burns risk for suppurative
    chondritis
  • Circumferential burns- very close monitoring of
    distal perfusion/capillary refill (compartment
    syndrome), and respiratory status

31
Diagnostic Studies
  • Baseline CBC, electrolytes
  • UA may reveal myoglobinuria if muscle injury
  • Carbon monoxide levels
  • Consider CXR, soft tissue neck films
  • Others based on presentation

32
Management
  • Airway
  • Anticipate difficult airway
  • Rapid sequence intubation avoid BP lowering
    sedatives (etomidate okay), avoid succinylcholine
    if gt48 hrs due to increased risk of hyperkalemia
  • Monitor ETT closely- avoid accidental extubation

33
Management
  • Reliable IV access for fluid resuscitation
  • Consider bladder catheter to reliably measure UOP
  • Tetanus vaccine if gt5 yrs since booster
  • Tetanus immune globulin if incomplete primary
    immunization (less than 3)
  • Consider surgical consultation

34
IV Fluids
  • Parkland formula 4 ml/kg per TBSA in 24 hours
    in addition to maintenance fluids
  • Half of fluid given over 1st 8 hours, 2nd 50
    given over the next 16 hours
  • 421 for maintenance fluids/hour
  • Ringers lactate often used (LR) in 1st 24 hours.
    D5LR often used for children lt20kg
  • Consider colloid/albumin after 24 hours to
    improve oncotic pressure

35
Monitoring
  • Very close Is/Os
  • lt30 kg UOP 1-2ml/kg/hr
  • gt30 kg 0.5-1 ml/kg/hr
  • If increased UOP check for glucose (osmotic
    diuresis)
  • If decreased UOP increase fluid, evaluate renal
    function
  • Monitor HR and BP (pain may factor in)
  • Can see metabolic acidosis w/ inadequate fluid
    resuscitation (also w/ CO, cyanide exposure)
  • Pain control- morphine, fentanyl

36
Wound Management
  • Clean with mild soap and water
  • Avoid disinfectants
  • Remove clothing and debris
  • Debridement of devitalized tissue with sterile
    saline soaked gauze
  • Large, painful blisters and those likely to
    rupture should be removed

37
Wound Dressing
  • Topical antibiotic covered with nonadherent
    dressing, then covered with tubular net or gauze
    bandage
  • Ideally biologic dressing for deeper burns
  • Topical Abx
  • Silver sulfadiazine 1- broad antimicrobial,
    decreases pain, delayed healing
  • Mafenide- penetrates well, broad spectrum,
    painful on application. Limited to cartilage,
    established infections- can -gt metabolic acidosis
    in large amount
  • Bacitracin- often used on face- painless, doesnt
    bleach pigment from skin
  • Dressings should be changed frequently- 1-2x/day

38
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39
Escharotomy
  • 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
  • Can relieve restriction (chest burns) and reduce
    pressure (compartment syndrome)

40
Escharotomy
41
References
  • Up to Date online
  • Google images
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