Pediatric burn injury
- Burns and scalds account for 6% of peadiatric injuries.
- The majority involve pre-school children,burns being most common between 1-2 yrs,flame burns bet 5-18 yrs.
- Children have nearly 3 times BSA:BM ratio of adults.
- Consequently greater fluid requirements and more evaporative water loss than adults.
- Burn that may appear partial thickness may instead be a full thickness burn.
Wounds caused by exposure to:
- Excessive heat
DEPTH OF BURN:
- Partial thickness burn = involves epidermis
- Deep partial thickness = involves dermis
- Full thickness = involves all of skin
DEGREE OF BURN:
1st DEGREE BURN:
- Involves only epidermis
- Tissue will blanch with pressure
- Tissue is erythematous and often painful
- Involves minimal tissue damage
2nd DEGREE BURN:
- Partial thickness burns
- Involve the epidermis and portions of the dermis
- Often involve other structures such as sweat glands, hair follicles, etc.
- Blisters and very painful
- Edema and decreased blood flow in tissue can convert to a full-thickness burn
3rd DEGREE BURN:
- Referred to as fullthickness burns
- Charred skin or translucent white color
- Coagulated vessels visible
- Area insensate – patient still c/o pain from surrounding second degree burn area
- Complete destruction of tissue and structures
4th DEGREE BURN:
- Involves subcutaneous tissue, tendons and bone
- PT and FTB with affected BSA>10% under 10yrs age.
- PT and FTB with affected BSA>20% over 10 yrs age.
- FTB with affected BSA>5%.
- PT or FTB involving face,hands,feet,perinium or major joints.
- PT or FTB involving an inhalational burn.
- PT or FTB involving an electrical or chemical burn.
- Burn extent is calculated only on individuals with second and third degree burns
- Palmar surface = 1% of the BSA
- Rule of Nines: Quick estimate of percent of burn
- Lund and Browder:
- More accurate assessment tool
- Useful chart for children – takes into account the head size proportion.
- Rule of Palms: Good for estimating small patches of burn wound
RULES OF NINES:
- Head & Neck = 9%
- Each upper extremity (Arms) = 9%
- Each lower extremity (Legs) = 18%
- Anterior trunk= 18%
- Posterior trunk = 18%
- Genitalia (perineum) = 1%
- High flow o2 face mask with reservior bag.
- Cervical collar (injury spine )
- Cooling burn wound –cold running water for 15-20 min,avoid making pt hypothermic.
- Prevent hypothermia
- Insert min 2 peripheral cannula in unburnt skin
- Fluid resusitatation
- Insert urinary catheter in all pts>20% BSA.
- Fast the pt and insert NG tube for all pts with>20% BSA,all intubated pts,head and neck burns,younger children >10%BSA.
- Adequate analgesia-IV opoids.
- Emergency wound management e.g.,cling film or clean non-adhesive dressing.
- Escharotomy if indicated e.g., circumferential burns around limbs or trunk.
- 4 ml R/L x % burn x body wt. In kg.
- ½ of calculated fluid is administered in the first 8 hours
- Balance is given over the remaining 16 hours.
- Maintain urine output at 0.5 ml/kg/hr.
- If evidence of extensive tissue damage then aim for a higher UO 1-2 ml/kg/hr.
- Monitor sr electrolytes esp for hyponatremia.
- In younger children calculate the maintenance fluids and add this to the resusitation fluids
Surgeries and Dressings:
- Escharotomy may be needed for circumferential burns to limbs,neck or trunk.
- Early surgical debridement of nectrotic tissue is preferred as early grafting is associated with improved outcome.
- Scrubbing of affected skin is also frequently undertaken.
- Blood loss during operative sessions can be large.
- Circulation to distal limb is in danger due to swelling.
- Progressive loss of sensation / motion in hand / foot.
- Progressive loss of pulses in the distal extremity by palpation or doppler.
- In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.
- According to Parkland formula, the initial orders for choice of fluid and rate of infusion should be Ringer’s lactate, 1250 ml/h for 71/2h
- Burn injury with the body parts involved: face including scalp, both buttocks and circumferentially around both thighs TBSA 0.35
- Burns in children assessed by Lund and Browder
- Head and neck burns in infant constitute 18 of burns
- Parkland formula for burns is for Ringer lactate
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