Burn in Children

Smriti Poudel
Lecturer
 Introduction
• Injuries that results from direct contact with
or exposure to any thermal, chemical,
electrical or radiation sources as termed as
burns.
• Burn injury usually attributes to the extreme
heat but many also results from exposure to
cold.
• Thermal injuries are 3rd most common causes
of accidental deaths in children.
• Burns are 2nd leading cause of injuries in age
between 1 to 14years and most occurs at
home.
 Patterns of burn
• Hot water scalds- most common in toddlers
• Flame related burns- older children
• 10% to 20% child abuse related to burns
• Children playing with lighter or matches
account 1 in 10 houses fires.
Burns in children have higher mortality because
they have:
• Thin and highly sensitive skin
• large body surface area
• Immature immune system
• Limited physiological reserves
• Significant metabolic and systemic disturbance
• Increased fluid requirement
 Causes
1. Thermal burn: Majority of burns results from contact
with thermal agents such as flames, hot surfaces, or hot
liquids.
• Scald burn: contact with moist heat(water or oil) and
steam. The most common hot liquids are liquid foods
such as hot water, tea, coffee, milk. Common in toddlers
because of curiosity they pull hot water, spills hot cup of
tea or may enter into a tub of hot water.
• Flame burns: This type of burn is the 2ndcommon cause
of burn and a leading cause of mortality among children.
During playing with lighter, candles, matches or open
fire in winter seasons or from fireworks during festivals.
• Contact with hot objects: direct contact with
stove, heater, cylinder of motorbike, cigarettes
smoking in bed and un-extinguished cigarettes
etc.
• Cold exposure (frostbite):  Frostbite is a
severe, localized cold-induced injury due to
freezing of tissue.
2. Electrical burns: Devastating injury caused by
high voltage electrical contact. These burn
injuries are common in toddler and
adolescent, specially associated with risk
taking behaviour of the boys,
3. Chemical burn: Most chemical burns are seen
in paediatric population and can cause
extensive injury. Because of the curious
nature, children are exposed with the different
kinds of household chemical products.
4. Radiation burn: prolonged exposure to
ultraviolet rays (UV) of the sun or to other
sources of radiation, such as x-ray or gamma
radiation therapy for cancer. Damage may
occur due to exposure to ionizing radiation.
 Classification of burn injuries
According to depth/degree of burn injury;
1. Superficial Burn Injuries (1st degree Burn)
• This usually involves epidermal layer that
followed by erythema in latent phase and
usually minor in nature.
• There is minimal tissue damage with no
blistering.
• Protective function of skin remains intact and
systemic effects are rare.
• Healing takes place after several days without
scarring.
• Pain is a predominant symptom.
• Burn injury heals within 5 to 10 days without
scarring.
• Eg Mild sunburn
2. Partial-thickness (Second degree) Burn:
• This type of injuries results involves epidermis
and varying degree of the dermis.
• Wound are painful, moist, red and blistered.
• some portion of the skin appendages remains
viable, allowing epithelial repair of the burn
wound without skin grafting.
a. Superficial partial-thickness burn involves
the epidermis and superficial (papillary)
dermis
• Wound heals within 14 to 21 days with
varying degree of scarring.
• These burns appear pink, moist, and soft.
• These wounds are very sensitive to
temperature change, exposure to air and
even to light touch.
b. Deep partial-thickness burns
• although classified as 2nd degree deep thermal burns
resemble full thickness injuries in many respects
except that sweat glands and hair follicles remains
intact
• burn may appear mottled, pink, red or waxy white
area exhibiting blisters and edema formation.
• It is less painful than superficial partial thickness
burns.
• Systemic effect may present as in full thickness burn.
• Healing- many wounds may occurs spontaneously
and may extend beyond 21 days with extensive
scarring.
3. Full-thickness (Third degree) burn
• These are serious injuries
• involve the entire epidermis and dermis and extend
into subcutaneous tissue.
• The capillary network of the dermis is completely
destroyed. The nerve endings, hair follicles and
sweat glands, are destroyed.
• Color varies from red to tan, waxy white, brown, or
black and is distinguished by dry leathery
appearance.
• Full-thickness burns lack sensation in the area of
injury because of the destruction of nerve endings.
• most full-thickness burns have superficial and
partial-thickness burned areas at the
periphery of the burn where nerve endings
are intact and exposed.
• So as the peripheral fibers regenerate, painful
sensations return and children often
experience severe pain related size and depth
of the burn.
• Full thickness injuries are not capable of re-
epithelialization so requires surgical excision
and grafting to close the wound.
4. Fourth degree burn
• Fourth-degree burns cause full-thickness
destruction of the skin and subcutaneous
tissue and also involve the underlying
structures as fascia, muscle, bone.
• The wound appears dull and dry, and
ligaments, tendons, and bone may be exposed.
• These injuries require extensive debridement
and complex reconstruction of specialized
tissues and invariably result in prolonged
disability.
The American Burn Association has used these
parameters to establish guidelines for the
classification of burn severity.
Major Burn Injury:
• Major burn injury includes:
• Partial-thickness burns involving more than
25% of TBSA in adults or 20% of TBSA in
children younger than 10 years or adults older
than 50 years, or
• Full-thickness burns involving more than 10%
of TBSA, or
• all burns involving the face, eyes, ears, hands,
feet, or perineum that may result in functional
or cosmetic impairment and burns caused by
caustic chemical agents, high-voltage electrical
injury, burns complicated by inhalation injury
or major trauma; or burns sustained by high-
risk patients (those with underlying
debilitating diseases
Moderate Burn Injury:
• Moderate burn injury includes:
• Partial-thickness burns of 15-25% of TBSA in adults
or 10-20% of TBSA in children or older adults, or
• Full-thickness burns involving 2-10% of TBSA that
do not present serious threat of functional or
cosmetic impairment of the eyes, ears, face,
hands, feet, or perineum.
• This category excludes high-voltage electrical
injury, all burns complicated by inhalation injury or
other trauma
Minor Burn Injuries:
• Minor burn injury includes:
• burns involving less than 15% of TBSA in adults
or 10% of TBSA in children or older persons, and
• full-thickness burns involving less than 2% of
TBSA that do not present a serious threat of
functional or cosmetic risk to eyes, ears, face,
hands, feet, or perineum
 Signs and symptoms
• BURN SIGN AND SYMPTOMS.docx
Assessment
• The extent of burn is expressed as a
percentage of the total Body Surface Area
(TBSA).Various methods are used to estimate
the TBSA affected by burn. Among them are
– Lund and Browder
– Palm method
– Rule of nine only for older children
A. Modified Rule of Nine: The "rule of nines" is a practical
technique for estimating the extent of TBSA involved in
a burn injury of adult. This approach divides the major
anatomic areas of the body into percentages of TBSA.
• For the adult, it allots 9% of the TBSA to the head and
neck and to each upper extremity, 18% each to the
anterior and posterior portions of the trunk, 18% to
each lower extremity, and 1% to the perineum and
genitalia.
• But there is small difference between TBSA of the adult
and infant as the size of the infant's head (18%), which
is proportionally larger than that of the adult, and the
lower extremities (14%), which are proportionally
smaller than those of the adult.
B. Lund-Browder Chart: Lund-Brower charts with
age-appropriate diagrams can be used to better
estimate the area of burn injury in children.
• It gives the exact percentage at different age
groups in different parts of the body.
• It subdivides body areas into segments and
assigns a proportionate percentage of body
surface to each area based on age. Rather than
being viewed as a whole, the lower extremities
is divided as foot, leg and thigh.
• First-degree burns are not included in the
calculation of burn size.
c. Rule of hand/Palm method: Child’s own one
hand surface with closed finger, amounts to
1% (approximately) of body surface area and
this can be used for calculation the extent of
burn injury.
d. 100 minus burned area: In very extensive
burns it is sometimes easier to calculate the
unburned area & then subtract this from 100.
 Management
Emergency management of Burn Injury
• The initial management of the burn patient begins at the
scene of injury.
• In case of flame burns the first priority is to stop the burning
process
– Place the child in the horizontal position and roll in a blanket, rug or
similar article, with care taken not to cover the head and face
because of danger of inhalation of toxic fumes.
– If nothing is available the victim should lie down and roll over slowly
to extinguish the flames. Remaining in the vertical position may
cause the hair to ignite or the inhalation of flames, heat or smoke.
• Major burn with large amounts of denuded skin should not
be cooled. Heat is rapidly lost from burned areas, and
additional cooling leads to drop in core body temperature
and potential circulatory collapse.
• Assess the victim condition
– As soon as the fire is extinguished the victim should be
assessed. Airway, breathing and circulation are the
primary concern.
– Cardiopulmonary complications may results from the
exposure to the electric current, inhalation of the toxic
fumes and smoke, hypovolemia and shock.
• Cover the burn
– The burned wound should be covered with a clean cloth
to prevent contamination, decrease pain by eliminating
air contact, and prevent hypothermia.
– No attempts should be made to treat the burn.
Application of topical ointments, oils, or other home
remedies is contraindicated.
• Transport the child to the medical aid
– The child with extensive burn should not be given
anything by mouth to avoid aspiration in the
presence of paralytic ileus and upper airway edema
– The child should be transported to the nearest
medical facility
– If this cannot be accomplished within a relatively
short period, IV access should be established, if
possible, with a large-bore catheter.
– Oxygen should be administered if available, at 100%.
• Provide reassurance to the child and the family.
• Chemical burns require continuous flushing with large
amounts of water before transport to a medical facilities.
The use of neutralizing agents is contraindicated because
of risk of initiation of chemical reaction that may further
damage the injury.
• If the chemical is in the powder form, the addition of
water may spread the caustic agent. So the powder
should be brushed off if possible.
• The burned clothes should be removed to prevent
further damage from the smoldering fabric and hot
beads of melted synthetic materials.
• Jewelry should also be removed to eliminate the transfer
of heat from the metal ad constriction resulting from
edema formation.
 Therapeutic Management of Burn Injury

Assess:
• A: Airway
• B: Breathing: beware of inhalation and rapid
airway compromise
• C: Circulation: fluid replacement
• D: Disability: compartment syndrome (edema
pressure, tissue damage, loss of body function).
• E: Exposure: percentage area of burn
a. Management of Minor Burn
• First- and second-degree burns less than 10% TBSA may be
treated on an outpatient basis.
• These outpatients do not require a tetanus booster or
prophylactic penicillin therapy.
• Children who are not current with immunizations should
have their immunizations updated.
• The wound should be cleansed with a mild soap and tepid
water. Debridement of the wound includes removal of any
embedded debris, chemicals and devitalized tissue.
• Removal of intact blisters remains controversial. Some
authorities argue that blisters provide a barrier against
infection; others maintain that blister fluid is effective
medium for the growth of micro-organisms. However,
blisters should be broken if the injury is due to chemical
agent to control absorption.
• The wound should be covered with an anti-microbial
ointments to reduce the risk of infection and to
provide some form of pain relief.
• The dressing should consist a non-adherent fine
mesh-gauze placed over the ointment and a light
wrap of gauze dressing that avoids interference with
movement.
• Dressings should be changed once daily, after the
wound is washed with lukewarm water to remove
any cream left from the previous application.
• Very small wounds, especially those on the face, may
be treated with bacitracin ointment and left open.
• Debridement of the devitalized skin is
indicated when the blisters rupture..
• Pain control should be accomplished by using
acetaminophen with codeine 1 hour before
dressing changes.
• Systemic antibiotics should be used only when
there is signs of infection.
• Wounds that appear deeper than at initial
assessment or that have not healed by 21 days
may require a short hospital admission for
grafting.
 Management of major burn
Establishment of adequate airway :
• The first priority of care is airway maintenance.
• Examination of an oral and nasal membranes that reveals
edema, hyperemia and blister or evidence of trauma to the
upper respiratory passages all suggest inhalation of noxious
agents or respiratory burns, if there is evidence of
respiratory involvement , 100% Oxygen should be
administered and blood gas values including carbon
monoxide( toxic) levels, are determined.
• If the child exhibits sign of respiratory distress, an ET tube is
inserted to maintain the airway.
• When severe edema of the face and neck is
anticipated, intubation is performed before
swelling make tube placement difficult or
impossible.
Fluid resuscitation:
• The objectives of fluid therapy are to:
• Compensate for water and sodium losses to
traumatized area and the interstitial space,
• Re-establish sodium balance,
• Re-store circulating volume,
• Provide adequate perfusion,
• Correct acidosis, and
• Improve renal function.
• Fluid replacement is required during the first 24
hours because of fluid shifts that occurs after the
injury.
• Various formulas are used to calculate fluid needs.
Parameters such as vital signs (especially heart rate),
urine output, capillary filling and state of sensorium
determine the adequacy of fluid resuscitation.
• Crystalloid Solutions are used during initial phase (1 st
24 hour) of fluid resuscitation therapy.
Parkland formula is commonly used to
determine the fluid needed for resuscitation
of burns greater than 15-20% TBSA.
• In 1st 24 hour:-The total amount of calculated
fluid requirement is- 4ml of RL/Kg of body
weight/% of TBSA burned.
– One half amount of the calculated fluid is given
over the first 8 hours, calculated from the time of
injury.
– The remaining half is given at an even rate over
the next 16 hours.
• In next 24 hour: - The fluid requirement is calculated
as: 2ml of RL per kg of body weight per % of TBSA
burned.
• Pulse and blood pressure should return to normal, and
an adequate urine output (1 mL/kg/hr) should be
accomplished by varying the intravenous infusion rate.
• Patients with burns of 30% BSA require a large venous
access (central venous line) to deliver the fluid
required over the critical first 24 hr.
• Patients with burns greater than 60% BSA may require
a multi-lumen central venous catheter; these patients
are best cared for in a specialized burn unit.
• Adequacy of resuscitation should be constantly
assessed using vital signs, blood gases,
hematocrit, and protein levels.
• Some patients require arterial and central
venous lines, particularly if undergoing
multiple excisions and grafting procedures as
needed, for monitoring and replacement
purposes.
• Femoral vein cannulation is a safe access for
fluid resuscitation especially in infants
andchildren.
• Packed red cell infusion is recommended if the
hematocrit falls below 24% (hemoglobin ≤8 g/dL).
• Sodium supplementation may be required for
children having burns greater than 20% BSA
• Oral supplementation may start as early as 48
hour post burn. Milk formula, artificial feedings,
given by bolus or constant infusion through a
nasogastric or small bowel feeding tube.
• As oral fluids are tolerated, intravenous fluids are
decreased proportionately in an effort to keep the
total fluid intake constant.
 Medication
• Antibiotics are usually not administered prophylactically. The
administration of systemic antibiotics to control wound
colonization is not indicated, because decreased circulation to
the injured area prevents delivery of the medication to the areas
of the deepest injury.
• Surveillance culture and monitoring of the clinical course provide
the most reliable indicators of developing infection. Appropriate
antibiotics can then be instituted to treat the identified organism.
• Some form of sedation and analgesia is required for the care of
children.
– Morphine Sulphate the drug of choice for severe burn injuries.
Continuesinfusion and frequent administration of morphine is needed
for pain management in burn.
– When combined, midazolam and fentanyl also provides excellent IV
sedation and analgesia to control procedural pain in children with burn.
– Dosage monitoring is essential because tolerance
to opioids may develop.
– IV analgesics are most effective when they are
administered just before the onset of procedural
pain.
– The short acting anesthetic agents, such as
Propofol, Nitrous Oxide and ketamine also are
used to control procedural pain.
 Management of wound
• The objective of wound management include
prevention of infection, removal of devitalized
tissue, and closure of the wound
i. Primary excision-
– In children with large, full-thickness burn wounds,
excision is performed as soon as patient is
hemodynamically stable after initial resuscitation.
– Early wound excision has significantly decreased
the incidence of infection, and threat of sepsis.
ii. Debridement-
– Partial thickness of wound require debridement of
devitalized tissue to promote healing.
– Debridement is very painful and require analgesia
before the procedures.
– Hydrotherapy is used to cleanse the wound and
involves soaking in a tub or showering once or twice a
day, for no more than 20 minutes. (The water acts to
loosen and remove sloughing tissue, exudate and
topical medications.)
– Any loose tissue is carefully trimmed away before the
wound is redressed.
– Daily dressing changes of the burn wound are
recommended to allow for inspection.
• Topical antibiotics:
• Topical antibiotics do not eliminate organism
from the wound but can effectively inhibit
bacterial growth.
• The commonly used topical antibiotics are:
– Silver nitrate 0.5%
– Silver sulfadiazine1%
– Mafenide acetate 10%
– Bacitracin
• Some topical agents are packaged and
prepared on fine mesh gauze, which allows
ease of application.
Skin Graft
– Permanent coverage of deep partial-thickness and
full-thickness burns is usually accomplished with a
split thickness skin graft.
– This graft consist of epidermis and a portion of
dermis removed from an intact area of skin by
special instrument- dermatome.
– The donor site is dressed with synthetic wound
coverings or fine-mesh gauze until the dressing
separates at 10-14 days when the wound is healed.
– Dressing are not changed on donor site to avoid
damage to newly healed, delicate epithelium.
 Nursing Management
Assessment
• Airway
– Assess for airway patency.
• Breathing
– Look-respiratory movement, respiratory rate, presence
of cyanosis.
– Feel-Perform palpation and percussion
– Listen-Auscultation for normal air entry and breathing
sounds equal bilaterally, absence or addition of noises.
• Circulation
– Look-Inspect for pallor and capillary refill time
– Feel
• Palpate pulse presence.
• Palpate pulse rate
• Palpate peripheral temperature
– Check-Blood pressure
• Disability
– Determine level of patient’s consciousness using AVPU assessment.
• A-Alert (confused/disoriented)
• V-Response to vocal stimuli
• P-Responds to painful stimuli
• U-Unresponsive
• Exposure:
- Percentage area of burn /depth of burn should be
estimated.
Nursing diagnosis
• Impaired gas exchange related to inhalation injury, pain
and immobility.
• Pain related to burn wound and associated treatments.
• Impaired tissue perfusion related to arrested blood
circulation secondary to decreased intravascular fluid
volume
• Fluid volume deficit related to shift of fluid from
intravascular to interstitial tissues.
• Impaired skin integrity related to thermal injury.
• Altered nutrition: less than body requirements related
to hypermetabolic state and loss of appetite.
• Impaired physical mobility related to pain; impaired
joint movement.
• Body image disturbance related to cosmetics and
functional sequelae of burn wound
• Fear and anxiety related to pain, treatments,
procedure and hospitalization.
• Risk of infection related to loss of integrity of
skin/injured skin and decreased immunity
• Risk of development of contractures related to scarring
of tissue, pain and immobility
Management
• Achieving adequate oxygenation and
respiratory function
• Managing pain
• Maintaining Fluid and Electrolyte balance
• Provide wound care
• Preventing Infection
• Prevent Contracture
• Provide adequate nutrition
• Preserving Positive Body Image
• Reducing fear and anxiety
Discharge Teaching
• The home care needs of the family should be
addressed long before the child is ready for
discharge. Discharge teaching focus on;
– Nutrition and diet requirements.
– Daily dressing changes and skin care
– Application of splint.
– Daily range of motion exercises to prevent from
contractures.
– Prevention of exposure from sun.
– Protection of the burned area from further injury.
– Signs of infection and action to be taken.
Prevention