Pediatric burn injury

Pediatric burn injury


INTRODUCTION:

  • 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.
  • Children
  • Burn that may appear partial thickness may instead be a full thickness burn.
BURNS:
Wounds caused by exposure to:
  • Excessive heat
  • Chemicals
  • Fire/steam
  • Radiation
  • Electricity
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
  • Sunburn

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
MAJOR BURNS:
  • 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.
BURNS EXTENT:
  • Burn extent is calculated only on individuals with second and third degree burns
  • Palmar surface = 1% of the BSA
MEASUREMENT CHARTS:
  • 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%
MANAGEMENT:

URGENT:

  • 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.

PARKLAND FORMULA:

  • 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.

Escharotomy:

  • 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.

Exam Important

  • 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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