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Burns In The Pediatric Population

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Edmund M. Regis Jr.
Edmund M. Regis Jr.

Burns are a leading cause of accidental pediatric injuries and deaths worldwide. Scalding from hot liquids is the most common cause of burns in children, often related to cooking practices. Initial management involves fluid resuscitation, antibiotics, dressings, and nutrition to support wound healing. Complications can include disfigurement, contractures, and emotional trauma. Ultimately, decreasing the burden of pediatric burns requires prevention through education, legislation, and environmental modifications.

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Burns In The Pediatric Population Dr. E. M. Regis Jr. MD. House Officer Dept. of General Surgery
Overview Definition Incidence/ Etiology Risk/ Contributing Factors Child Abuse Pathophysiology Classification Criteria for admission Management Complications
Definition A burn is a type of injury to the flesh or skin caused by heat, electricity, chemical, friction or radiation
Incidence One of the leading causes of accidental injuries at home. 5th most common cause of accidental death in children Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
Etiology Flame 57% Scalding 32% Chemical 7% Electricity & Radiation 4%
Burns In The Pediatric Population
Contributing Factors Socio-economics - children from low income homes have 8x a risk of sustaining burns than those from higher income homes - severity of burns inversely proportional to decreasing SES - burn mortality is higher among children from lower SES
Living Conditions - children are naturally curious, impulsive and active,increases risk of burns - flammable and caustic substances stored in the home - heating with indoor fires - cooking practices; NB. 2 billion people worldwide cook with open flames or unsafe traditional stoves
- lack of adult supervision - overcrowding Medical conditions -Epilepsy * Increase risk of fall * Traditional medicine practices; eg. The deliberate burning of feet to rouse the child from convulsive state.
Child Abuse Burns account for 10% of all cases of child abuse Majority of victims are < 2 years of age Scalding is the most common cause
Suspicion of child abuse Burns to: Perineum Ankles Wrists Palms Soles Burns with clean line of demarcation Presence of older injuries Contradictory accounts of accident Delays in seeking treatment
Pathophysiology According to Jacksons Thermal wound theory, there are three zones associated with burn injuries: Zone of Coagulation - area closest to the wound - ruptured cell membranes, clotted blood & thrombosed vessels Zone of Stasis - area around zone of coagulation - inflammation & decreased blood flow Zone of Hyperemia - peripheral area of the wound - limited inflammation & increased blood flow
Classification
Burns In The Pediatric Population
Criteria for admission Greater than 10% burns in a child Any burn in the very young or the infirm Any full thickness burn Burns of special regions: face, hands, feet, perineum Circumferential burns Inhalation injury Associated trauma or significant pre-burn illness: e.g. diabetes
TBSA
Burns In The Pediatric Population
Management ABC Intubate and mechanically ventilate if you suspect inhalation injury Quickly establish IV access (ideally 2 large bore IVs) Evaluate for compartment syndrome, particularly with circumferential burns
Assessing inhalation injury Look for: Singed facial hairs Edema of nose, mouth, pharynx and larynx Carbonaceous sputum Hoarseness Stridor
Fluid Resuscitation Restoring adequate intravascular volume to prevent hypotension and shock Correcting electrolyte abnormalities Minimize renal insufficiency If burns >15% Massive fluid shifts will likely occur due to systemic inflammatory response syndrome (SIRS) Fluid needs will be greater than anticipated based on appearance of burn alone
Parkland formula: 3-4 ml x kg x % total burn surface area (TBSA) 12 in first 8 hours Remaining in next 16 hours Galveston Shriners formula 5000 mL/m2 TBSA burn + 2000 mL/m2 body surface area (BSA)
Fluid: Lactate Ringer plus 12.5 g 25% albumin per L plus D5W as needed for hypoglycemia Remember to monitor glucose levels Glycogen stores of children <5 y/o run out quickly Inhalation injury increases fluid requirements by 1.1 ml/kg/% TBSA Goal of fluid resuscitation = Adequate urine output (1-1.5ml/kg/hr)
Muir & Barclay Formula TBSA % x weight (kg) = volume (mls) fluid need per period. The volume needs to be recalculated at each change in time period: Every four hours for the first 12 hours; Every six hours between 12 and 24 hours; After 36 hours.
Dressings Topical antibiotic: Silver nitrate Cheap Does not penetrate eschar Depletes electrolytes Silver sulfadiazine Some penetration of eschar Risk of neutropenia Mafenide acetate Penetrates eschar Risk of developing acidosis
Nutrition Burns lead to increased metabolic demands and energy requirements For burns >40%, resting metabolic rate increases up to 200% Primarily protein catabolism * Protein requirement increased to 2.0 g/kg/day Without adequate nutrition wound healing will not occur
Goal: Loss of less than 10% of preinjury weight Patients should be weighed daily Enteral feeds are superior to parenteral Feed child orally if possible Otherwise place nasogastric feeding tube
Management contd. PPIs. Prophylaxis against stress ulcers Adequate analgesics Prophylaxis antibiotics Physiotherapy/ pressure garments
Complications Disfigurement Contractures Lead to severe disability in many cases Emotional damage/sequelae Delay in reaching developmental milestones and educational development Death
Summary Burns account for a significant proportion of pediatric morbidity and mortality worldwide, particularly in LSES. Majority of burns are due to fire or scalding, often related to cooking practices. Initial evaluation should always include an assessment for child abuse. Ultimately, the key to decreasing morbidity and mortality associated with burns is prevention via... Educational campaigns Legislative changes Hazard reduction and environmental modification
References Stone, Keith and Humphries, Roger; Current Diagnosis and Treatment: Emergency Medicine. McGraw- Hill New York 2008 Stead, Latha G. etal ; First Aid for the Emergency medicine Clerkship; McGraw Hill 2002 www.emedicine.com www.google.com/images Global Health Education Consortium

More Related Content

Burns In The Pediatric Population

  • 1. Burns In The Pediatric Population Dr. E. M. Regis Jr. MD. House Officer Dept. of General Surgery
  • 2. Overview Definition Incidence/ Etiology Risk/ Contributing Factors Child Abuse Pathophysiology Classification Criteria for admission Management Complications
  • 3. Definition A burn is a type of injury to the flesh or skin caused by heat, electricity, chemical, friction or radiation
  • 4. Incidence One of the leading causes of accidental injuries at home. 5th most common cause of accidental death in children Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
  • 5. Etiology Flame 57% Scalding 32% Chemical 7% Electricity & Radiation 4%
  • 7. Contributing Factors Socio-economics - children from low income homes have 8x a risk of sustaining burns than those from higher income homes - severity of burns inversely proportional to decreasing SES - burn mortality is higher among children from lower SES
  • 8. Living Conditions - children are naturally curious, impulsive and active,increases risk of burns - flammable and caustic substances stored in the home - heating with indoor fires - cooking practices; NB. 2 billion people worldwide cook with open flames or unsafe traditional stoves
  • 9. - lack of adult supervision - overcrowding Medical conditions -Epilepsy * Increase risk of fall * Traditional medicine practices; eg. The deliberate burning of feet to rouse the child from convulsive state.
  • 10. Child Abuse Burns account for 10% of all cases of child abuse Majority of victims are < 2 years of age Scalding is the most common cause
  • 11. Suspicion of child abuse Burns to: Perineum Ankles Wrists Palms Soles Burns with clean line of demarcation Presence of older injuries Contradictory accounts of accident Delays in seeking treatment
  • 12. Pathophysiology According to Jacksons Thermal wound theory, there are three zones associated with burn injuries: Zone of Coagulation - area closest to the wound - ruptured cell membranes, clotted blood & thrombosed vessels Zone of Stasis - area around zone of coagulation - inflammation & decreased blood flow Zone of Hyperemia - peripheral area of the wound - limited inflammation & increased blood flow
  • 15. Criteria for admission Greater than 10% burns in a child Any burn in the very young or the infirm Any full thickness burn Burns of special regions: face, hands, feet, perineum Circumferential burns Inhalation injury Associated trauma or significant pre-burn illness: e.g. diabetes
  • 16. TBSA
  • 18. Management ABC Intubate and mechanically ventilate if you suspect inhalation injury Quickly establish IV access (ideally 2 large bore IVs) Evaluate for compartment syndrome, particularly with circumferential burns
  • 19. Assessing inhalation injury Look for: Singed facial hairs Edema of nose, mouth, pharynx and larynx Carbonaceous sputum Hoarseness Stridor
  • 20. Fluid Resuscitation Restoring adequate intravascular volume to prevent hypotension and shock Correcting electrolyte abnormalities Minimize renal insufficiency If burns >15% Massive fluid shifts will likely occur due to systemic inflammatory response syndrome (SIRS) Fluid needs will be greater than anticipated based on appearance of burn alone
  • 21. Parkland formula: 3-4 ml x kg x % total burn surface area (TBSA) 12 in first 8 hours Remaining in next 16 hours Galveston Shriners formula 5000 mL/m2 TBSA burn + 2000 mL/m2 body surface area (BSA)
  • 22. Fluid: Lactate Ringer plus 12.5 g 25% albumin per L plus D5W as needed for hypoglycemia Remember to monitor glucose levels Glycogen stores of children <5 y/o run out quickly Inhalation injury increases fluid requirements by 1.1 ml/kg/% TBSA Goal of fluid resuscitation = Adequate urine output (1-1.5ml/kg/hr)
  • 23. Muir & Barclay Formula TBSA % x weight (kg) = volume (mls) fluid need per period. The volume needs to be recalculated at each change in time period: Every four hours for the first 12 hours; Every six hours between 12 and 24 hours; After 36 hours.
  • 24. Dressings Topical antibiotic: Silver nitrate Cheap Does not penetrate eschar Depletes electrolytes Silver sulfadiazine Some penetration of eschar Risk of neutropenia Mafenide acetate Penetrates eschar Risk of developing acidosis
  • 25. Nutrition Burns lead to increased metabolic demands and energy requirements For burns >40%, resting metabolic rate increases up to 200% Primarily protein catabolism * Protein requirement increased to 2.0 g/kg/day Without adequate nutrition wound healing will not occur
  • 26. Goal: Loss of less than 10% of preinjury weight Patients should be weighed daily Enteral feeds are superior to parenteral Feed child orally if possible Otherwise place nasogastric feeding tube
  • 27. Management contd. PPIs. Prophylaxis against stress ulcers Adequate analgesics Prophylaxis antibiotics Physiotherapy/ pressure garments
  • 28. Complications Disfigurement Contractures Lead to severe disability in many cases Emotional damage/sequelae Delay in reaching developmental milestones and educational development Death
  • 29. Summary Burns account for a significant proportion of pediatric morbidity and mortality worldwide, particularly in LSES. Majority of burns are due to fire or scalding, often related to cooking practices. Initial evaluation should always include an assessment for child abuse. Ultimately, the key to decreasing morbidity and mortality associated with burns is prevention via... Educational campaigns Legislative changes Hazard reduction and environmental modification
  • 30. References Stone, Keith and Humphries, Roger; Current Diagnosis and Treatment: Emergency Medicine. McGraw- Hill New York 2008 Stead, Latha G. etal ; First Aid for the Emergency medicine Clerkship; McGraw Hill 2002 www.emedicine.com www.google.com/images Global Health Education Consortium

Editor's Notes

  • #20: Can occur without skin burns Carbonaceous sputum burned saliva
  • #21: Fluid is key for:
  • #22: Plus maintenance fluid
  • #24: this uses a colloid resuscitation with plasma and runs over 36 hours. As the fluid lost from the circulation is plasma, it seems logical to replace it with plasma. With colloid resuscitation, less volume is required and the blood pressure is better supported. However, both colloid and plasma are expensive. They may also leak out of the circulation and may result in oedema of the lungs. The 36 hours are divided into six periods of varying length, and an equal volume of plasma is administered in each period. The volume to be transfused in each period is calculated via the formula. This volume is given in each successive period of four, four, four, six, six and 12 hours. At the end of a period, if the assessment shows that the patients clinical condition is stable, the transfusion is continued according to the formula. If there is any clinical evidence of under- or overtransfusion then the plasma rations for the next and following periods are altered accordingly.
  • #25: Silver sulph ( broad spec prophylaxis against pseudomonas and methicillin resistant stap aureus) Silver nitrate ( not active against some gram ve aerobes and need to be reapplied ever 2-4hrs) Mafenide cream ( painful to apply, associated with metabolic acidosis)
  • #29: +/- social worker and counselling