Dr Abhijeet Deshmukh

DNB Pediatrics
Fellow in PICU &
NICU
 50% of burns - pediatric population,
 17%- < 5 years
 Infants and children increased susceptibility to death-
as they have limited physiologic reserves & the
patterns of injury are very different from adults.
Types of Burn Injuries
 Scald Burns
 More likely child abuse
 < 5 years
 Thorough history should include the type and
consistency of the causative liquid.
 oil and thick soups - higher heat capacity and more
viscouscause longer contact at higher
temperatures more damage
 water of 140° C – deep burns in 3 seconds of contact &
160° C - 1 second
 Abuse - glove or stocking like, and/or symmetric
burns to the buttocks, legs, or perineum.
 Concomitant fractures and retinal hemorrhages,
delays in seeking treatment or inconsistencies in
the patient history.
 full evaluation by social services with referral to
appropriate state or government agencies regardless
of the depth or extent of burn.
 Thermal Burns
 > 5 years.
 ~ 50% of all burn admissions.
 flame or contact with hot objects
 90% - minor and outpatient management with good
outcomes.
 larger burns - mortality influenced by - size, age , +/-
inhalation injury.
 extent of soft tissue injury duration of exposure ,
presence and type of clothing material
 Electrical Burns
 Rare (2% - 3%) but devastating
 Mejority - electrical cords and outlets,
 Minority - lightening.
 AC > DC
 AC -cyclic flow of electricity  tetanic contractions
increased tissue damage
 Children  propensity to chew on cords or
insert objects into outlets.
 Wet or moist skin, including the mucous
membranes around the mouth, has negligible
resistanceconsiderable soft tissue trauma.
 Nerves, blood vessels, and muscles - least resistance,
as compared to bone, fat, and tendons.
 lack of overt skin damage may mask more significant
underlying soft-tissue damage.
 Chemical Burns
 Most common - strong bases in common household
products.
 Alkali drain cleaners (sodium hydroxide) –
denature cutaneous lipids.
 Severity - type and concentration & duration of
exposure.
 Initial treatment - copious irrigation with tepid water
for > 15 minutes.
 Never neutralize the acid or base as exothermic reaction
worsens tissue injury.
Depth & Extent of Burn injury
 Superficial Burns/First degree burns :
 significant pain, erythematous changes, lack of
blistering.
 Damage to epidermis only, sparing the dermis and
dermal structures.
 blanch on examination & heal within 2 to 3 days after
the damaged epidermis desquamates.
 eg. - sun burns.
 Scarring is rare
 Superficial Partial-Thickness Burns / 2nd degree burns
 entire epidermis and superficial dermis.
 fluid-containing blisters at the dermal-epidermal junction.
 After debridement, the underlying dermis is erythematous,
wet-appearing, painful, and blanches with pressure.
 deeper dermis is left undamaged - heal within 2 weeks
without hypertrophic scarring.
 No need for skin grafting
 Deep Partial-Thickness Burns / 2 nd degree burns
 clinically similar to third-degree burns.
 As blood vessels of the dermis are partially damaged
blister base - mottled pink and white appearance
 do not easily blanch ,
 less painful than superficial burns due to nerve
injury.
 Treatment - excision and grafting.
 Need surgical intervention,
 May develop hypertrophic scars and/ or contractures.
 Full-Thickness Burns /3 rd degree burns
 complete involvement of all skin layers and require
definitive surgical management.
 white, cherry red, brown, or black in color, and do not
blanch with pressure.
 dry and often leathery
 typically insensate because of superficial nerve
injury.
 Fourth-degree burns - full-thickness + the
underlying subcutaneous fat, muscle,
and tendons.
May need amputationand/or extensive
reconstruction with grafting.
Zones of Injury

 Burn wounds continue to evolve for days and the

inflammatory process may last for several months.
Divided into :
 1) zone of coagulation : necrotic tissues closest to
the injury site
 2) zone of stasis : area of ongoing injury, located
between the zones of coagulation and hyperemia, Poor
perfusion of this zone initially viable tissue in this area
to further necrosis and deeper wounds.
 3) zone of hyperemia : normal, uninjured skin with
a physiologic increase of blood flow in response to
local tissue injury.
Management
 Estimating the Extent of the Burn
 An accurate assessment & Total body surface
area (TBSA) of burn minimize morbidity
and mortality.
 Overestimation cause over resuscitation with
resultant complications, inappropriate transfer to
burn centers,
 Newer methods for (TBSA) are being researched -
computerized imaging, two- and three-dimensional
graphics, and body contour reproductions.
Current methods for (TBSA)
1) Adults : “rule of nines,” by Palaski and Tennison
(palm and fingers of one hand account for 1% of the
normal body surface area).
 This calculation often overestimates, especially
in children.
 BSA is distributed differently in children and infants
due to proportionally larger heads and smaller
extremities.
2) Infants & Children : Lund Browder
diagram
 Early Management of Burn Injuries
 After removing or extinguishing the source  washed with
tepid water.
 Chemical burns - flushed copiously to remove the
inciting agent and prevent further tissue damage.
 Ice or iced water- increase tissue damage ,
hypothermia & mortality, in patients with more extensive
burns.
 Approximately 10% of all burn patients present with
additional traumatic injuries
 severe burn shock or trauma loss of airway due to altered
mental status or supraglottic obstruction from edema
formation.
 Signs of inhalation injury : facial burns, singed nasal hairs,
carbonaceous sputum, hypoxia, and history of entrapment
in an enclosed space.
 Evaluation of circulation  and resuscitation in greater
than 10% TBSA because these injuries are characterized
by a systemic inflammatory response that may lead to
hemodynamic lability.
 Electrical injuries compartment syndromes , multiorgan
system involvement, Cardiac dysrhythmias , direct muscle
necrosis , Seizures and spinal cord transections &
respiratory arrest secondary to injury of the brainstem or
tetany of the respiratory musculature.
 The majority of these burns can safely be treated with
minor debridement, oral hydration, topical wound
care, and outpatient follow-up.
 Those patients requiring supplemental nutrition or
hydration, or who fail outpatient treatment, may
need continued care in an inpatient setting
 if there is a suspicion for inhalation injury, inpatient
treatment with intravenous resuscitation and
potential transfer to a burn center should be
considered.
 Before transfer : -
 wounds covered with clean, dry material or
nonadherent gauze.
 wet dressings - avoided to prevent hypothermia and
subsequent complications in patients with large
burn wounds.
 Tetanus prophylaxis with appropriate pain
control before transport.
 In extensive burns, a Foley catheter should be inserted
to help guide fluid management.
Resuscitatio
n
 General Principles
>10% total BSA - IV fluid resuscitation & urinary
catheter.
 In major injury - nasogastric tube to decompress the
stomach.
 During transport - maintain body temperature.
 Fluid Resuscitation
 Burn leads to intravascular volume depletion
 Major losses occur during the first 24 hrs – crystalloids used.
 Myocardial depression - 24-“36 hrs after injury.
 The goal of resuscitation is to maintain adequate intravascular
volume to support tissue perfusion and thereby preserve
organ function.
 The adequacy of resuscitation - based on observation of blood
pressure, heart rate, and urine output.
 Fluid to maintain normal blood pressure, heart rate, and hourly
urine output of 1 mL/kg/hr in the infant and young child and
0.5 mL/kg/hr in the child >12 years of age or >50 kg in weight.
 Parkland formula - crystalloid-based formula - with
RL - based on the BSA of burn and the patient's
body weight. Maintenance fluids (5% dextrose in
lactated Ringer solution)
= (4ml/kg+ BSA of burn) + Maintainance fluids
 (For adults and children who weigh >40 kg,
maintenance fluids are not included in the estimate
of fluid requirements.)
 Half of this - in the first 8 hrs after injury, and
other half is given in the following 16 hrs.
 After the first 24 hrs, - maintenance requirements + to
replace ongoing losses.
 The hourly evaporative fluid loss from wounds can be
estimated as:
= ( 25 + Burn surface area) x total BSA
 The evaporative losses are primarily free water.
 However, to avoid rapid changes in sodium concentration
in children, this loss is replaced with - 5% dextrose in 0.2%
normal saline.
 loss of serum protein occurs in > 40% BSA burns.
 When the injury is larger, the loss is replaced in the second
24 hrs after injury with 5% albumin.
ultimate goal – to maintain normal blood pressure,
heart rate, urine output, and serum sodium
 Hypoalbuminemia- Causes :
 Increased losses of albumin : d/t drainage from burn
wounds, and inflammatory mediators triggered
capillary leakage
 Reduced Albumin production in critical illness due to an
increase in the production of acute phase proteins.
 Dilutional hypoalbuminemia in the immediate
postresuscitation phase d/t increased intravascular
vol.
 Albumin is given - to avoid exacerbating acute lung injury,
diarrhea, feeding intolerance, impaired wound healing,
and the resultant complications.
in critically ill patients- 25% albumin should be added
if the serum level is below 3 mg/dL.
 Management of Inhalation Injury :
 aggressive pulmonary toilet, mucolytics,
early identification and treatment of
infection and supportive care.
 nebulized heparin to reduce atelectasis and improved
pulmonary function,
 Prophylactic antibiotics & corticosteroids are not
used
 supplemental oxygen & advanced modes of
assisted ventilation and hyperbaric oxygen therapy.
 Stridor - racemic epinephrine neb
 12% - require intubation
70% of those intubated have sustained inhalation
injury .
Wound Care

 General Principles
 Objective - to avoid infection and protect the wound from
further injury.
 Small (<2 cm) blisters - left intact, larger blisters and full-
thickness wounds should be debrided and covered with a
topical agent.
 Debridement - under general anesthesia or deep
sedation.
 Ketamine - profound cutaneous analgesia.
 Even in the absence of debridement, burns are painful, and
patients usually require opioid analgesia.
 Agents that may cause additional tissue damage
are avoided,
 circulation of the wound is protected by avoiding
hypotension, hypoxemia, and hypothermia and by
excluding the use of adrenergic agents.
 Maintain sterile precautions & environment.
 Surgical Care
 Excision and closure – reduce the extent of injury & risk of
wound infection.
 Tangential excision until viable tissue is identified
Advantage - best cosmetic and functional result,
Disadvantage- bleeding
 Deep excision of the wound to the level of the fascia -
minimal blood loss and is used when wounds are deep,
full thickness, and infected, or when large areas are
excised.
The cosmetic results are poor, and lymphatic drainage
is impaired after this type of excision.
 usual approach- first 3-4 days after injury .
 Autografts & Allografts
 Integra Life Sciences Corporation provides a
temporary epidermis as an outer layer of silastic and
an inner layer matrix for the growth of a neodermis.
 This non antigenic matrix provides a scaffold for a new
dermis upon which a thin epidermal graft may be
placed
 Invasive infection:
 The criteria for diagnosis by American Burn
Association guidelines,
1 )Inflammation of the surrounding uninjured skin
2 )Histologic examination that shows invasion by the
infectious organism into adjacent viable tissue
3 )Isolation of an organism from the blood in the absence
of other infection
4 ) Signs of the systemic inflammatory response syndrome
(such as hyperthermia, hypothermia, leukocytosis,
tachypnea, hypotension, oliguria, or hyperglycemia at a
previously tolerated level of carbohydrate intake) and
mental status changes
 Other Infections
 the associated immunocompromise status may set
the stage for infection at any site.
 high incidence of urinary tract infections and
pneumonia, appendicitis, but often do not present
with classic features due to a suppressed
inflammatory response.
 A high index of suspicion is necessary to detect these
infections.
 Sinusitis
 d/t nasogastric feeding tubes and nasotracheal intubation,
especially in patients with inhalation injury.
 Treatment - removal of all tubes and catheters, initiation of
appropriate antibiotic therapy, and drainage.

 Bacterial Endocarditis :
 Immune compromise, recurrent bacteremia, and the
frequent use of central venous catheters in the patient
with burn injury are risk factors
. Antibiotic therapy is based upon blood culture
results and should continue for 4 - 6 weeks
Hypermetabolism
Key Points

 Initial evaluation of the patient includes

determination of depth of injury and extent of surface
area involved. These are trauma patients and may
have other injuries in addition to the burn.
 Fluid resuscitation in the first 24 hrs is based on a
formula to calculate the amount of lactated Ringer
solution to infuse. The formula is only a guide;
adjustments are made based on vital signs and
urine output.
 Silver sulfadiazine is the topical agent most commonly
used for burn wounds.
 Early excision of the wound is now standard of care
in the burn-injured patient
 Hypermetabolism is very prominent- Proteins
and calories must be provided to address these
needs, beginning on the day of injury.
Hypermetabolism persists for 9- 12 months post-
injury.
Reference
s
 Zimmerman –Pediatric critical care (4 ed)
th

Rogers Textbook of pediatric critical care.