Michaele Conchita M.

Zapanta, MD,RN
BURNS in Children
 q This baby was not
the direct victim
of earthquake.
He got the burn
wound due to
BURN VICTIM FROM HAITI falling into
cooking utensils.
q
q Actually children
burnt case is
common in
developing
countries, like
Haiti.


q This is because
many families
who are
suffering from
poverty have to
stay in very
congested areas
that there
BURNS
1/3-1/2 - of the yearly hospitalizations
for burns occur in children younger
than 18 years of age
At least half of these accidents –
children under 15 years of age
1000 deaths a year in this age group

 Occurence




 Deaths from fires and burns – second to motor
vehicle accidents


American Academy of Pediatrics,



 Committee on Injury and Poison

 Prevention, 2000


FOUR TYPES


 Thermal


most common

occurs from
flames, flash,
scalds, or contact
with hot objects

THERMAL BURN
qFlame injury - ignition of combustible
materials and contact with fire;
household and residential fires
qFlash injury– explosions, such as
gasoline, kerosene and charcoal
lighter
qScald Burns – hot liquid spill / hot tap
water
qContact Burn – exposure to hot
surfaces
ELECTRICAL BURNS

 Chewing on electric wires



 Inserting objects into electric sockets


Chemical burns

 Children ingest or are exposed to caustic
agents such as household cleaning
products

radiation


 Results from overexposure to the

UV rays of the sun
pathophysiology


 Minor to multisystem involvement



 Alterations on different body systems



body system manifestations after major burn
RESPONSE TREATMENT
CARDIOVASCULAR SYSTEM
First 24-48 hours Postburn
↓ cardiac output resulting from Adequate fluid
↑capillary permeability and replacement
vasodilation Monitor vital signs, esp .
↓ metabolic acidosis hematocrit BP
48- 72 hours Postburn Assess blood gases
Capillary permeability is restored Monitor vital signs
Interstitial fluids move back into Monitor urine output
RENAL SYSTEM
bloodstream
Reducedblood ↓Monitor
IV fluids
I/O
↓ Hematocrit flow to kidneys lead Monitor PTT
to ↓ urinecount
↓ Platelet output
Potential for acute renal failure Administer IV fluids at a
↑ BUN rate that maintains urine
↑ Creatinine output of 1-2 cc/kg/hr
With fluid mobilization, ↑ urine Anticipate fluid
output as interstitial fluid is remobilization
mobilized and eliminated Assess BP
body system manifestations after major burn
RESPONSE TREATMENT
RESPIRATORY SYSTEM
Upper airway edema and
obstruction from inhaling heated Monitor respirations
gases Assess for rales ,
Lower airway obstruction and
wheezes
pneumonia from smoke Assessdepth of
inhalation respirations
CO poisoning and hypoxia from
Monitor blood gases
inhaling end products of
combustion causes mucosal
erythema and edema Assess for equal
Atelectasis and respiratory respirations
failure
Pulmonary edema fro too
Notify health care
vigorous fluid replacement provider and prepare
Restriction of chest excursion
patient for escharotomy
 body system manifestations after major burn
RESPONSE TREATMENT
GASTROINTESTINAL SYSTEM
↓CENTRAL
Perfusion NERVOUS
of GI tract and Monitor bowel sounds
liver
SYSTEM due to ↓ blood flow Assess
Monitor liver
fluidsenzymes
and blood
↓Burn-related
Gastric acid production for Assess
encephalopathy gases NG drainage for
48-72
due to hypoxemia, evidence
Assess signsof blood
of infection
hrs followed, and
hypovolemia by ↓ acid Assess neurologic status
production Place NG tube for
septicemia frequently
decompression of stomach
and risk of stress
Manifestations include: ulcers Initiate seizure precautions:
↓ Hallucinations,
GI motility personality
changes,
delirium, seizures, and
coma
body system manifestations after major burn
RESPONSE TREATMENT

METABOLISM
↑ Metabolic rate from nitrogen Monitor intake of calories
losses Give parenteral nutrition as
and stress of injury needed
↑ Heat losses through damaged
skin Give diet high in proteins
Rapid protein breakdown and
muscle wasting
↑ Blood glucose levels due to
insulin resistance and breakdown Give multivitamins, ↑↑ vitamin
of glycogen stores A&C
Delayed growth and maturation
from need to use energy to repair
burned tissues
CLINICAL MANIFESTATIONS
 Severity is determined by
the depth of the tissue
destroyed and the total
BSA involved

 Current - categorized by
the depth of tissue
destruction into
superficial, partial and
full thickness wounds.

 Depth of tissue
destruction
 First Degree- superficial
thickness

 Second Degree – partial
thickness

 Third and Fourth Degrees-
full thickness
Superficial Burns
 Epidermal layer of skin

 Painful, dry, red, and
blanch with pressure.
Injuries

 Approximately heal in 5-10
days without scarring

sunburn


Systemic


effects
uncommon


Example :


sunburn

Superficial partial-thickness burn
 Involve epidermis and
superficial and deep
dermal layers
 Painful to temperature and
cold air
 Moist red and weeping,
usually form blisters, and
blanch with pressure.
 Heal in 14 to 21 days
 Scarring may result
 Pigment changes may
occur.
Superficial partial-thickness burn
 Partial thickness

Partial-thickness burns to both feet

immediately after debridement of
blisters.
INDETERMINATE PARTIAL THICKNESS
full thickness burns
 Deeper dermis, damaging hair
follicles and glandular tissue,
extend to SC
 Painful to pressure only.
 Always blister (easily unroofed),
are wet or waxy dry, and have
variable color from patchy
cheesy white to red
 Form eschar
 Do not blanch with pressure.
 They require over 21 days to
heal
 Scarring may be severe.
 Differentiation from full-thickness
burns is often difficult.
Full thickness  Extend to tendon, muscles and
bones
 Painless
 Whitish, leathery ,dry and
inelastic appearance
 Skin appearance can vary from
waxy white to leathery gray to
charred and black
 Decreased sensation to pain
 Result to scarring and
contractures
 Require skin grafting , skin
flaps, or possible amputation
to fully heal
 Not blanch with pressure

Burn with an area of 

Necrosis 

 Minor burns – Out –

Patient basis
 Moderate Burns and
Severe Burn – requires
hospitalization
 Burns involving hands,
feet, face, eyes, ears
and genitalia – pediatric
burn unit, PICU or
pediatric burn care
center
diagnosis


 Clinical manifestations
History
Physical Examination

RULE OF NINES
Rule of nines
qDivides the surface area of the body into areas of
9% or multiples of 9% equal to 18%
qWhen all body areas of 9% are summed, 1%
remains, which is assigned to the genitalia and
perineum.
qConvenient and rapid method of estimating the
extent of body surface area burned.
qIt is less than accurate, however, for children.
qFor patients younger than 15, a more precise
method of burn size estimation must be used.
Lund and Browder Chart


qSecond, more accurate, method of measuring

the extent of total body burn
q
qSubdivides body areas into segments and
assigns a proportionate percentage of body
surface to each area based on age


q Rather than being viewed as a whole, the lower

extremity is divided into foot, leg, and thigh
areas.

Palmar surface
 The third method of estimating burn injury extent
uses the size of the patient's hand, assuming
the palmar surface of the hand is roughly 1% of
the total body surface.
 Visualizing the patient's hand covering the burn
wound approximates the amount of body
surface involved, especially if the burn areas
are scattered.
 In actuality, the palm alone more accurately
represents 0.5% of the body's total surface
area.
treatment
 Respiratory management
 Fluid Resuscitation
 Pain Management
 Wound care
 Prevention of Impaired Mobility
 Nutritional Support
 Psychological support

Respiratory management
 Assessing patency of the airway
 Establishing and/ or maintaining
 Pulmonary complications – leading cause of death in
thermal burns
 Anticipate respiratory involvement – burn occurred in an
 enclosed space or found unconscious
If with hypoxia - Oxygen administered

vAssess child’s ability to expand the chest

vFull thickness that extend trunk – may interfere with
breathing
-
Respiratory management
 When there is potential for airway
complications, a difficult airway cart
containing a range of various size
endotracheal tubes, Eschmann stylet,
laryngeal mask airways (LMA), Fastrach
LMA, fiberoptic bronchoscope, fiberoptic
stylets should be available.
escharotomy
 An incision made into constricting eschar to
restore peripheral blood circulation, may be
required to release the chest restriction
 Arterial blood gases- provide evidence of smoke
inhalation and the adequacy of gas exchange


E.g: Child with burn on upper body burns, facial

burns or smoke inhalation – airway obstruction
from edema
 Intubation done – exhibits face and neck
edema, soot in the nose or mouth, or singed
nose hairs
 Fluid resuscitation
 Allburn injuries alter  Example of fluid management
capillary permeability  A 70kg patient with 50% body
surface area burn would
 Severe –Fluid require:
Replacement – to  4 x 50 x 70 = 14000mls of
prevent hypovolemic Hartmanns solution over 24
shock hours. Therefore 7 litres should
be given in the first 8 hours and
 Lactated Ringer’s solution
7 over the following 16 hours
– compensate for (Calculated with the Parklands
capillary permeability formula
and loss of intravascular  Regular reassessment of the
fluids adequacy of resuscitation
should be performed. Blood
products and colloid may also
be given in addition to these
requirements
Fluid resuscitation
 Large bore central venous  Foley catheter – to facilitate
catheter – to administer urine output
massive fluid loads measurement
 Fluid formula  Type and amount of fluid
requirements: 2-4ml/kg used will be based on the
of body weight X TBSA results of blood
 Urine output reflects the electrolyte tests
adequacy of
resuscitation on UO of 1-
2 ml/kg/hr, stable vital
signs, and alert and
oriented mental status


Parkland formula for fluid resuscitation
4 ml Lactated Ringer’s solution X kg of body
weight X % TBSA
One half of total is given in the first 8 hours
postburn
One- fourth of total is given in the second 8
hours postburn
One- fourth of total is given in the third 8
hours postburn

 Note : Time is calculated from the time of the
injury,not the time of admission to the
hospital.

Calculating maintenance iv fluid rate using 4:2:1
rule
 to calculate the hourly IV rate, first determine the child’s daily
maintenance fluid requirement, then divide that number by 24. in
practice, this process can be simplified by using 4:2:1 rule without
sacrificing accuracy. Try it out:
 IV rate = 4 ml/kg each kg of weight up to 10 kg
 + 2 ml/kg/hr for each kg of weight
 between 10-20 kg
 + 1 ml/kg/hr for each kg over 20 kg


 Example: Daily IV fluid rate for a 45-kg child

who is NPO would be :
 40ml
 20 ml
 25 ml
 85ml/hr



Example of fluid management
 70kg patient with 50% body surface area burn would
require:
 4 x 50 x 70 = 14000mls of Hartmanns solution over 24
hours. Therefore 7 litres should be given in the first 8
hours and 7 over the following 16 hours
(Calculated with the Parklands formula)

 Regular reassessment of the adequacy of resuscitation

should be performed. Blood products and colloid may
also be given in addition to these requirements
Preventing hypothermic shock

 Do not apply ice or cold water to any burn

 Cause hypothermia

 May intensify a shock condition→→ further
ischemic injury to the burned area

PAIN MANAGEMENT
Pain management
 Pain from injury, reduce when child is t rest
 Fear and anxiety contribute to the child’s perception of
pain
 Major burns – IV narcotics : morphine sulfate
 Minor burn - acetaminophen
 Fluid shift limits absorption from the SC and IM areas,
pain will not be relieved



DEBRIDEMENT
qRemoval of dead tissue from the burn site,
associated with severe pain


qSoaking the wound for about 10 minutes to

soften tissue
q
qWashed from the inner to outer edges using
a firm, circular motion


qLoose or dead tissue is removed by gently

lifting it up with forceps and cutting it
away

DEBRIDEMENT
 Surroundingareas are cleaned, an antimicrobial
cream, such as silver sulfadiazine (Silvadene),
(Flammazine)
To minimize bacterial proliferation and
prevent infection
Wound care

 Initial
wound care given after child has been
stabilized

 Use aseptic technique

 Medicate the child prior to the procedure

 Wounds gently cleaned and debrided.
hydrotherapy
 To soften dead tissue to help in the debridement
process
 To improve circulation to the wound
 Experience is painful and scary for all burn
patients
 Medicated prior to hydrotherapy and dressing
changes
 Caregivers to be present to comfort and distract
the child
Skin grafting
Burn dressings
 Changed once or twice a day
 Once the wound have been debrided and beginning to
heal →→ temporary skin grafts used to facilitate
healing process
 Homograft (cadaver skin)
 Begin to slough off around 14 days


 Heterographs (pig skin)

 Replaced daily or every other day
 Used in children with scald burns of hands and face
 Temporary grafts accelerate wound healing by creatignan
environment that promotes epithelial growth in the form of
granulation tissue`
A new medical adhesive - a fibrin sealant - called Artiss for use
in attaching skin grafts onto burn patients, has just been
approved by the US FDA.
Fibrin sealants are tissue adhesives that contain the proteins
fibrinogen and thrombin, which are essential in the clotting of
blood. Artiss (Fibrin Sealant, VH S/D 4) differs from other fibrin
sealants in that it contains a lower concentration of thrombin. This
lower concentration allows surgeons more time to position skin
grafts over burns before the graft begins to adhere to the skin.
Artiss also contains aprotinin, a synthetic protein that delays the
break down of blood clots.
Skin grafting
 Extensive full thickness – require permanent skin
graft- an autograft to fully heal
 Taken from an unburned area of the child’s own
skin
 Once place, area must be immobilized
 Cultured epithelial autograft – used in children
with burns covering more than or equal to 80%
TBSA
 Sheets of skin grown in the lab from a small kin
biopsy of the child.


vLONG TERM FOLLOW UP studies pending


Skin grafting

 Aftergrafts heal, pressure dressings applied to
prevent formation of contracture and minimize
scarring.

 Dressing may be elastic wraps, pressure splints,
or pressurized garments that provide
continuous and uniform pressure over the
burned areas.

Prevention of impaired mobility
(preventing Contractures)
 Develop due to prolonged bed rest
 Muscular atrophy and shortening
 Stiffening of burned tissues
 Important to implement appropriate positioning
strategies to prevent deformities and an
exercise program to maintain muscle strength
and joint mobility
Prevention of impaired mobility
(preventing Contractures)


 When muscles not exercised – maintained in maximal

extension using splints

 Early exercise is encouraged

 ROM performed actively at least 3X a day
Nutritional support

 Diet high in protein (23% of total calories) to maintain
weight and muscle function

 Increase vitamins A & C – to help replace losses from the
changes in metabolism and losses from the open burn
wounds

 Use enteral feedings

Psychological support
Play therapy –
help to deal with
the frustrations
of burn therapy


Encourage


child to move
and actively
participate in
activities with
other children


Counseling -
as recovery
continues , with
various support
services – to
foster child’s
self- esteem


Caregivers
need to be
supported and
encouraged to
participate in
the care of the
 Family teachings
 Daily ROM exercises
 Home care need  Caregivers need support
discussed and
addressed long before  and encouragement
child is discharge Home tutors – necessary to
help child keep up with
 Includes nutrition, diet school
requirements, daily  Encourage all involved to
dressing changes and explore their feelings and
skin care, application be supportive of child’s
of elasticized garments return to the community
(Jobst jacket or pants)

 Application of splints
∗COMPLICATIONS
SMOKE INHALATION
 The ensuing release of inflammatory mediators, oxygen
derived free radicals, nitric oxide causes a large
increase in the vascular permeability of the pulmonary
circulation.

 The resultant airway edema, when combined with
sloughing of necrotic epithelial mucosa and thick, viscid
secretions, produces airway obstruction at various
levels of the bronchial tree.
SMOKE INHALATION


 A combination:
 direct pulmonary injury
 systemic
 metabolic toxicity.


 The severity of smoke lung injury depends on fuels, intensity,

duration, and confinement.


 Gas phase constituents of smoke include carbon monoxide

(CO), cyanide, acid and aldehyde gases and, oxidants.
SMOKE INHALATION

 These can cause direct damage to muco-ciliary function,
bronchial vessel permeability, alveolar destruction and
secondary edema. Smoke exposure causes inactivation
of surfactant and immediate atelectasis.

 Bronchial blood flow increases manifold and lung
macrophages and neutrophils are activated.

SMOKE INHALATION
 Concomitant cutaneous burn injury aggravates the lung
damage by releasing pro-inflammatory mediators and
causing hydrostatic pulmonary edema.

 The end result is a mismatched V/Q ratio and hypoxemia.
Mechanical ventilation can cause or worsen lung
damage

PAIN DISTRACTION
shows a patient using U.W. HITLab/Harborvview’s SnowWorld pain
distraction at Shriners Children’s Burn Center Galveston
designer/researcher
SNOW WORLD PAIN DISTRACTION

 Hunter Hoffman’s
latest version of
SnowWorld was
created for the UW
by gifted
worldbuilders at
www.firsthand.com
: using
www.Virtools.com
 Virtual World Development Software.

 The University of Washington Harborview Burn Center,
directed by Dr. Nicole Gibran, is a regional burn center.
Patients with severe burns from 5 surrounding states are
sent to Harborview for special care. Harborview has
pioneered a number of advanced treatments (e.g., early
skin grafting).
 As a result of advances here and elsewhere, the chances
of surviving a bad burn, and quality of living for survivors
has improved dramatically over the past 20 years.
 Unfortunately, the amount of pain and suffering experienced
by patients during wound care remains a worldwide
problem for burn victims as well as a number of other
patient populations
Thank you for
listening !!!
Bye have a nice day !!!