BURN INJURIES

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 Each yr more than 1500 children under the age
of 15 die, and nearly 10,000 children suffer
permanent disability from thermal injuries (US).
 Burns from scalding [when hot liquid touches
skin] are the most common thermal injury in
children <3yr of age & are also prevalent in
cases of child abuse. Flame burns are more
commonly seen in children over age 3.
 In comparison to the adult, children have a
disparity between their body surface area and
total body wt: larger body surface area relative
to total body weight and in consequence, have
greater evaporative losses than the adult.
 Children under age 2 also have very thin skin,
and, therefore, full-thickness burns may initially
appear as partial-thickness.

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 PATHOPHYSIOLOGY OF THERMAL BURNS
 The skin functions:
 regulating body temperature,
 preventing fluid loss, and
 restricting entry of microorganisms into the body.
 composed two layers: an outer epidermis and deeper
dermis.
 The epidermis contains an inner region of nucleated
cells, the stratum germinativum (SG), and an outer
layer of anucleate cells, the stratum corneum.
 The stratum corneum, (keratin and lipid content), acts
as a relatively impermeable barrier that protects
against the loss of body fluids & the inward
penetration of foreign substances. When this layer is
violated, fluid loss occurs and can be extensive.

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 When epidermal layers above the SG are
destroyed or the entire epidermis is damaged,
but the epidermal appendages are intact, the
SG may regenerate a new epidermis.
- If a burn injury extends beneath the SG &
transcends the dermis, re-epithelialization is
not likely to take place.
 Because the pain fibers lie deep in the dermis,
superficial burns can cause severe pain, but
with deeper burns that destroy the dermis, the
fibers can be injured and the burn is initially
painless.
 The severity of a cutaneous burn injury is
largely determined by the temperature to
which the tissue is exposed and the duration of
contact with the burning process.

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 Three areas of injury identified in a severe burn:
 The “zone of coagulation” contains nonviable
tissue and is located in the center of the injury.
B/c the skin in the area is coagulated  ideal
environment for the growth of microorganisms.

 The “zone of stasis” surrounds this, and in the 1st

24-48 hr after a burn, contains dilated blood
vessels and leaky capillaries become occluded
by RBCs and platelet microthrombi. Edema
develops primarily in this area, and is reversibly
damaged.

 The “zone of hyperemia” surrounds the zone of

stasis, vasculature is maintained and minimal cell
death occurs in this area.

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 Immediately after a burn, transient arterial
constriction occurs, followed by vasodilation at
the site of the burn. Opening of precapillary
sphincters occurs with a resulting increase in
hydrostatic capillary pressure and effective
transcapillary filtration.
 With fluid resuscitation, edema formation
begins and reaches a maximum at 18 to 24 hours
after the burn. The vascular damage that occurs
in the burn-injured tissue is probably secondary
to the direct heat injury and to the release of
vasoactive substances such as histamine,
serotonin, bradykinin, prostaglandin, and
leukotrienes from the burned tissue.

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 Burns are classified as first, second, or third degree (on
the depth of the injury).
- a 1st-degree burn: a sunburn/ a burn from brief contact
with a hot liquid. Clinical findings are local erythema
and pain & tissue injury is limited to the epidermis.
- 2nd-degree burns: injury of the epidermis and dermis.
Because the deeper epidermal structures (hair follicles
and sweat glands) are viable partial-thickness burns.
. erythematous, moist, & swollen skin, blisters & bullae,
. Nonviable superficial layers of the epidermis can be
easily debrided from the area. Nerve endings are
exposed and irritated, & hypersensitive.
. Causes include flash, flame, & scalding. Healing
generally occurs within 2 to 3 wks but impaired if an
infection occurs in the area.

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 3rd-degree/ full-thickness burns: total
destruction of the epidermis and dermis
including the epidermal appendages.
- Causes include electrical, chemical, scalding,
and flame injuries.
- Clinically, the injury has a charred appearance
& dry and leathery to the touch. If the burn is
over 2 cm in diameter, reepithelization is not
possible and skin replacement [graft] is
necessary for healing to occur. It is frequently
difficult to distinguish between second-degree
and third-degree burns.

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 Indications for Hospitalization for Burns
 Burns greater than 15% body surface area

 High-tension wire electrical burns

 Inhalation injury regardless of the size of body

surface area burn

 Inadequate home situation

 Suspected child abuse or neglect

 Burns to hands, feet, genitals

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 ESTIMATION OF BODY SURFACE AREA OF BURN.
 Appropriate burn charts for different childhood age
groups should be used to accurately estimate the extent
of BSA burned.
- The volume of fluid needed in resuscitation is
calculated from the estimation of the extent & depth of
burn surface.
- The variable growth rate of the head and extremities
throughout childhood makes it necessary to use
surface area charts. The “rule of nines” used in adults
may be used only in children > 14 yr or as a very rough
estimate to institute therapy before transfer to a burn
center. In small burns under 10% of BSA, the “rule of
palm” may be used. The area from the wrist crease to
finger crease (the palm) in the child equals 1% of the
child's BSA.

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 Life support measures should include the
following:
1. Rapidly review the cardiovascular and
pulmonary status and document pre-existing
conditions (e.g., asthma, congenital heart
disease, renal or hepatic disease).
2. Ensure & maintain an adequate airway,
provide humidified oxygen by mask/
endotracheal intubation. The latter in children
with facial burns or burn sustained in an
enclosed space, before facial/ laryngeal edema
becomes evident. If hypoxia or carbon
monoxide poisoning is suspected, 100% oxygen
should be used.

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3. Children with burns greater than 15% of BSA
require intravenous fluid resuscitation to
maintain adequate perfusion.
4. All inhalation injuries, regardless of the extent of
BSA burn, require venous access to control fluid
intake.
5. All high-tension and electrical injuries require
venous access to ensure forced alkaline diuresis in
case of muscle injury to avoid myoglobinuric
renal damage.

 Lactated Ringer solution, 10–20mL/kg/hr

(normal saline may be used if lactated Ringer is
not available), is infused until proper fluid
replacement can be calculated.
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5. Evaluate for associated injuries, (common in
patients with a history of high-tension electrical
burn, especially if there has been a fall from a
height). Injuries to spine, bones, & thoracic or
intra-abdominal organs may occur. The child
should be placed on CERVICAL SPINE
PRECAUTION until this injury is ruled out.
- very high risk of cardiac abnormalities, e.g.
ventricular tachycardia or ventricular
fibrillation, resulting from conductivity of the
high electric voltage. Cardiopulmonary
resuscitation should be instituted promptly at
the scene.

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 Children with burns greater than 15% BSA
should not receive oral fluids (initially),
because they may develop ileus.
- insertion of a nasogastric tube in the emergency
department to prevent aspiration.
6. A Foley catheter should be inserted to monitor
urine output in all children who require
intravenous fluid resuscitation.
7. All wounds should be wrapped with sterile
towels.

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 . Acute Treatment of Burns
 First aid
 Fluid resuscitation
 Supply energy requirements
 Pain control
 Prevention of infection –early excision and
grafting
 Control of bacterial wound flora
 Biologic and synthetic dressings to close
wound

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MANAGEMENT:
A. Outpatient Mx of minor burns-
 1st & 2nd degree burns <10% BSA,

- update immunization of the child, if not

current,
- leave blisters intact, dress with bacitracin /
silver sulfadiazine cream; daily wound care,
- debridement of devitalized skin,
- pain control with acetaminophen / codeine
1hr before dressing changes,
- heal in 10-20 days.

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 B. Fluid Resuscitation-
 Parkland formula can be used as starting
guideline, i.e. 4ml/kg/% of BSA burned, RL,
deficit replacement:
- one half given over the 1st 8hr calculated from
time of onset of injury,
- the remaining half is given over next 16hr at
even rate (may be adjusted by patient response)
- monitor response: pulse & BP, urine output
(1ml/kg/hr), mental status, & acid-base balance,
- burns of ≥30% BSA require large venous access
(central venous line).

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 The daily maintenance fluid should also be
included in the 1st 24hr fluid calculation.
 During the 2nd 24 hr after the burn,
reabsorbtion of edema fluid & diuresis begin,
- half of the 1st day’s fluid requirement is infused
as RL in 5% dextrose,
 Use of colloid in the early period of burn
resuscitation is controversial, ? Concurrently if
>85% of BSA; usu instituted 8-24hr after burn.
 Oral supplementation may start as early as
48hr post burn; as oral fluids are tolerated, IV
fluid is ↓ proportionately so as total intake
remains constant.

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 C. Packed red cells infusion recommended if the
Hct <24%.
 Electrolyte abnormalities (Na & K) should be

looked for & treated accordingly.

D. Prevention of infection done using
prophylactic penicillin therapy.
E. Nutritional support: burn injury has hyper
metabolic response xized by both protein & fat
catabolism.
- maintain body wt & meet metabolic demands,
1 ½ times the basal metabolic rate (3-4g/kg of
protein per day).

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 Acute care should include the following:
1. Extinguish flames by rolling on the ground;
cover the child with a blanket, coat, or carpet.
2. Determine that the airway is patent, remove
smoldering clothing or clothing saturated with
hot liquid.
- Jewelry, particularly rings and bracelets,
should be removed/ cut away to prevent
constriction and vascular compromise during
the edema phase in the first 24–72hr post burn.
3. In chemical injury, brush off any remaining
chemical if powdered or solid; then use
copious irrigation or wash the affected area
with water.

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4. Cover with clean, dry sheeting & apply cold
(not iced) wet compresses to small injuries.
 Significant large burn surface area injury (>15–

20% BSA) decreases body temperature control

& contraindicates the use of cold compress
dressings.
5. If the burn is caused by hot tar, use mineral oil
to remove the tar.

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High-tension electrical wire burn, for which children be
admitted for observation regardless of the BSA burned,
- Deep muscle injury is usual & cannot be readily
assessed initially. These injuries result from
high voltage (>1,000V). Points of entry of
current through the skin and the exit site show
characteristic features consistent with current
density and heat.
- The majority of entrance wounds involve the
upper extremity, with small exit wounds in the
lower extremity.
- The electrical path from entrance to exit takes the
shortest distance b/n the two points and may produce
injury in any organ or tissue in the path of the current.

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 - Multiple exit wounds attest to the possibility of
several electrical pathways in the body, placing
virtually any structure in the body at risk.
 Cardiac abnormalities manifested by
ventricular fibrillation/ cardiac arrest are
common; patients with high-tension electrical
injury need cardiac monitoring until they are
stable & have been fully assessed.
 Renal damage from deep muscle necrosis &
subsequent myoglobinuria is another
complication; such patients need a forced
alkaline diuresis to minimize renal damage.
 Aggressive removal of all dead and devitalized
tissue is important in effective management of
the electrically damaged extremity.

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 INHALATIONAL INJURY.
 Serious in the infant & child, particularly if pre-existing
pulmonary conditions are present.
 MR are 45–60% in adults; no exact figures in children.
 Evaluation aims at early identification of inhalational airway
injuries which may occur from:
(1) direct heat (greater problems with steam burns),
(2) acute asphyxia,
(3) carbon monoxide poisoning, and
(4) toxic fumes, including cyanides from combustible plastics.
Sulfur, nitrogen oxides, & alkalis (the combustion of
synthetic fabrics) produce corrosive chemicals, erode mucosa
and cause significant tissue sloughing.
 Exposure to smoke degradation of surfactant & decrease
its production, resulting in atelectasis.

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 Pulmonary complications of burns & inhalation can be
divided into three syndromes with distinct clinical
manifestations and temporal patterns:
1. Early carbon monoxide poisoning, airway obstruction,
and pulmonary edema are major concerns.
2. Acute respiratory distress syndrome usu at 24–48hr,
although it can occur even later.
3. Late complications (days- wks) include pneumonia and
pulmonary emboli.
 Inhalation injury should be assessed by evidence of
obvious injury (swelling or carbonaceous material in
nasal passages), wheezing, crackles or poor air entry,
and
 laboratory determination of carboxyhemoglobin
(HbCO) and arterial blood gases.

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