BURNS IN PAEDIATRICS

By G. Lukumay
 Introduction
• Burns are the second leading cause of
accidental deaths in childhood
• The highest incidence of burns occurs in
children younger than 5 years
• Children at high risk are those of lower
social economic status and of single
parent.
• However, any child, supervised or
unsupervised, is at risk for a burn injury.
 Definition
• A burn is an acute traumatic event caused by
non persisting injurious insult to the skin and
tissues that cause damage at the cellular level,
followed by a healing process ( Rice PL, et al
2012 ).The insult could be thermal, chemical,
or electrical
 Review of Anatomy and physiology of
the skin
• The skin is the largest organ of the body,
accounting for about 15% of the total adult body
weight.
• It performs many vital functions, including
protection against external physical, chemical,
and biologic assailants, as well as prevention of
excess water loss from the body.
• Plays a role in thermoregulation.
• The skin is continuous, with the mucous
membranes lining the body’s surface (Kanitakis,
2002).
Layers of the skin
 Pathophysiology of burn
• The pathophysiology of the burn wound is
characterized by an inflammatory reaction leading
to rapid oedema formation, due to increased
microvascular permeability, vasodilation and
increased extravascular osmotic activity.

• These reactions are due to the direct heat effect

on the microvasculature and to chemical mediators
of inflammation.
 Pathophysiology of burn cont…
• The earliest stage of vasodilatation and
increased venous permeability is commonly
due to histamine release. Damage to the cell
membranes partly caused by oxygen-free
radicals released from polymorphonuclear
leucocytes would activate the enzymes
catalyzing the hydrolysis of prostaglandin
precursor (arachidonic acid) with rapid
formation of prostaglandin as the result.
 Pathophysiology of burn cont…
• Prostaglandins inhibit the release of
norepinephrine and may thus be of importance in
modulating the adrenergic nervous system which
is activated in response to thermal injury.
• The morphological interpretations of the
changes in the functional ultrastructure of the
blood lymph barrier following thermal injury
seem to be an increase in the numbers of
vacuoles and many open endothelial intercellular
junctions.
 Pathophysiology of burn cont…
• Furthermore, the burn wound provides a vast
area of entry of surface infection with a high
risk of septic shock.
• This explains the reasons of the four main
principles in the current management of
patients with severe thermal injury, namely
early wound closure, prevention of septic
complications, adequate nutrition and control
of the external environment. Arturson G,1980
 Clasification of burn
• Burn injuries are described according to the
depth of the injury and the extent of body
surface area injured.
• Burn Depth
• Burn depth determines whether
epithelialization will occur.
• Determining burn depth can be difficult even
for the experienced burn care provider.
 classification of burns cont…
• Burns are classified according to the depth of
tissue destruction as:
Superficial partial-thickness injuries (first
degree burn):
• In a superficial partial-thickness burn,
– the epidermis is destroyed or injured and
– a portion of the dermis may be injured.
– The damaged skin may be painful and
appear red and dry, as in sunburn, or it may
blister (very minimal).
 classification of burns cont…
Typical Characteristics for Superficial thickness
burn
– Mild to severe erythema (pink to red)
– NO BLISTERS
– Skin blanches
– Painful
– Pain responds well to cooling
– Lasts about 48 hours; healing in 3-7 days
Superficial burn cont…
 Partial-thickness burn
• Injury involves destruction of
epidermis and dermis
• The wound is painful, sensitive to
temperature change and air exposure.
• Typically, they blister and are moist,
red, with exudes fluid
• More commonly referred to as second-
degree burns.
Partial-thickness burn cont…
 Deep partial-thickness burn
• Injury involves destruction of entire
epidermis and dermis, and in some cases
underlying tissue as well
• Blistering or easily unroofed burns which
are wet or waxy dry.
• The color of the wound varies from white
to red, brown or black
• The burned area is painless
Deep partial-thickness burn cont…
• More commonly referred to as third-
degree burns.
• It is sometimes difficult to differentiate
these burns from full-thickness burns.
 Full-thickness burn
• Burns which cause the skin to be waxy
white to a charred black and tend to be
painless.
• Includes destruction of epidermis and the
entire dermis as well as possible damage to
the SQ tissues, muscle and bone
• Healing is very slow, if at all, and may
require skin grafting.
• More commonly referred to as fourth-
degree burns.
 classification of burns cont…
• The following factors are considered in
determining the depth of the burn:
– How the injury occurred
– Causative agent, such as flame or scalding
liquid
– Temperature of the burning agent
– Duration of contact with the agent
– Thickness of the skin
 CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS
Thermal Burns
Caused by flame, flash, scald, or contact with
hot objects. It is the most common type of
burn
Chemical Burns
• Result from tissue injury and destruction
from necrotizing substances (chemicals)
• Most commonly caused by acids
 CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS cont…
Chemical Burns cont’d
– Respiratory and systemic problems
– Eye injuries
– Clothing containing the chemical should be
removed
– Tissue destruction may continue for up to
72 hours after a chemical injury
 CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS cont’d
Electrical Burns
• Intense heat generated from an electrical
current
• May result from direct damage to nerves and
vessels causing tissue anoxia and death
• Severity of injury depends on the amount of
voltage, tissue resistance, current pathways,
surface area, and on the length of time of the
flow
Electrical Burn- Hand
 CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS cont’d
Cold Thermal (Frostbite)
• Usually affects fingers, toes, nose, and ears
• Numbness, pallor, severe pain, swelling,
edema
• Blistering in a warm environment
• Handle the tissue carefully
 CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS cont’d
Smoke Inhalation Injuries
• Result from inhalation of hot air or
noxious chemicals
• Cause damage to respiratory tract
• Important determinant of mortality
in fire victims
 Calculating area of burn
injuries
• Various methods are used to estimate the
TBSA (total body surface area) affected by
burns; among them are:
– the rule of nines,
– the Lund and Browder method, and
– the palm method.
 Calculating area of burn
injuries
RULE OF NINES
• An estimation of the TBSA involved in a burn is
simplified by using the rule of nines.
• The rule of nines is a quick way to calculate
the extent of burns.
• The system assigns percentages in multiples of
nine to major body surfaces.
Rule of 9
 Calculating area of burn
injuries
LUND AND BROWDER METHOD
• A more precise method of estimating the extent
of a burn is the Lund and Browder method,
• It recognizes that the percentage of TBSA of
various anatomic parts, especially the head and
legs, and changes with growth.
• By dividing the body into very small areas and
providing an estimate of the proportion of TBSA
accounted for by such body parts, one can obtain
a reliable estimate of the TBSA burned.
• The initial evaluation is made on the patient’s
arrival at the hospital and is revised on the
second and third post-burn days because the
demarcation usually is not clear until then.
Calculating area of burn
injuries
 Calculating area of burn
injuries
PALM METHOD
• In patients with scattered burns, a method to
estimate the percentage of burn is the palm
method.
• The size of the patient’s palm is approximately
1% of TBSA.
 Management of the Patient With a
Burn Injury
• Emergency Procedures at the Burn Scene
– Extinguish the flames
– Cool the burn
– Remove restrictive objectives
– Cover the wound
– Irrigate chemical burns
Emergent/resuscitative phase mgt
• Emergency Medical Management
• The patient is transported to the nearest
emergency department.
• The hospital nurses (staff) and physician are
alerted that the patient is in route to the
emergency department so that life-saving
measures can be initiated immediately by a
trained team.
• Initial priorities in the emergency department
remain airway, breathing, and circulation.
Emergent/resuscitative phase mgt
Emergency Medical Management cont’d
• For mild pulmonary injury, inspired air is
humidified and the secretions can be removed by
suctioning
• For more severe situations, it is necessary to
remove secretions by bronchial suctioning and to
administer bronchodilators and mucolytic agents.
• If edema of the airway develops, endotracheal
intubation may be necessary.
Emergent/resuscitative phase mgt
Emergency Medical Management cont’d
• Continuous positive airway pressure and
mechanical ventilation may also be required
to achieve adequate oxygenation.
• A large-bore (16- or 18-gauge) intravenous
cannular should be inserted in a non-burned
area (if not inserted earlier).
Emergent/resuscitative phase mgt
Emergency Medical Management cont’d
• Assessment of both the TBSA burned and the
depth of the burn is completed after soot and
debris have been gently cleansed from the
burn wound.
• An indwelling urinary catheter is inserted to
permit more accurate monitoring of urine
output and renal function for patients with
moderate to severe burns.
 Management of fluid loss and shock
Fluid Replacement Therapy:
• The total volume and rate of intravenous fluid
replacement are gauged by the patient’s
response.
• The adequacy of fluid resuscitation is determined
by:
– Output totals of 30 to 50 mL/hour
– systolic blood pressure exceeding 100 mm Hg
and/or
– pulse rate less than 110/minute.
Conditions Leading to Burn Shock
 Management of fluid loss and shock
wt in kg x % burn x 2 - 4cc / kg / %

100 kg patient with 50% TBSA burn:

100 x 50 x 2 = 10,000cc = 10 liters RL

This is calculated for the first 24 hours post-burn.

Give half of this in first 8 hours.

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr

initially
 Management of fluid loss and shock
Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr
initially

How do we know if this is too much fluid, or too

little?
Monitor at least:
urine output - in adults, around 50 cc / hr

Decreasing urine output = need for more

fluids.
 Fluid requirements in children
• Use same formula for fluids to replace loss from
burns.
• In children, add this amount to normal
maintenance rate:
10 kg - about 40 cc / hr maintenance fluids
20 kg - about 60 cc / hr
• 30 kg - about 70 cc / hr
• Expected urine output for child: 1 cc / kg /hr
for infant: 2 cc/ kg / hr
 Fluid requirements in children
20 kg child with 30% burn:
20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr
Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr
initially
75 cc / hr for burn loss + normal 60 cc / hr
maintenance =135 cc / hr initially

• How do you know if the patient is getting too

much fluid,
or too little?
Check urine output, urine specific gravity, HCT
 Fluid requirements in children
• Be sure the patient’s airway, breathing and
circulation are secure.
• Then treat the burn wound itself.
• In patients with large burns, do not initially
spend much time carefully calculating fluids.
• Instead, start an IV and start giving fluids
rather rapidly while exam is being performed.
DO NOT BOLUS! 500cc/hr is a good rule.
• Later do the calculations.
 Wound Management
• Clean with mild soap and water
• Avoid disinfectants
• Remove clothing and debris
• Debridement of devitalized tissue with sterile
saline soaked gauze
• Large, painful blisters and those likely to
rupture should be removed
 Wound Management

• administering topical antibacterial drugs like:

– Silver sulfadiazine 1% (Silvadene)
– watersoluble cream,
– Silver nitrate 0.5% aqueous solution,
– Mafenide acetate 5% to 10% (Sulfamylon)
hydrophilic-based cream,
– Acticoat, etc
 Pain Management
• Opioid every 1 to 3 hours for pain
• Several drugs in combination
• Morphine
• Non pharmacologic strategies
• Relaxation tapes
• Visualization, guided imagery
 Complication of Burn

 Skin and joint contractures

 Hypertrophic scarring
Contracture of the Axilla
Hypertrophic scarring
 Nursing care plans
nursing diagnosis
Impaired gaseous exchange related to upper air
way obstruction, carbon monoxide, poisoing or
smoking inhalation as evidenced by difficulty in
breathing, desaturation, respiratory acidosis.
Expected Patient out come
• The patient would demonstrate adequate
respiratory function and maintain adequate
oxygenation and slight respiratory alkalosis, as
evidenced by normal arterial blood gas analysis
 Nursing diagnosis cont…
Intervention
• Elevate head of the bed to semi-foul’s position at all
times to decrease risk of pneumonia or risk of
ventilator pneumonia, risk of aspiration, and air way
edema. Also to facilitate optimal breathing parttence.
• Increase activity as tolerated, in order to facilitate
diaphragmatic excursion and support respiratory
muscle function
• Suctioning
• Administer oxygen as required
• Broncho dilators
 Nursing diagnosis cont…
• Nursing Diagnosis
• Risk for Fluid volume deficit related to burn
injury as evidenced by decreased cardiac
output, urinary output, temperature, bowel
sound, BP, increased pulse,
 Nursing diagnosis cont…
• Expected outcome
• The patient would maintain normal
hemodynamic, adequate urine output not less
than 1mls/kg/hour,
• Patients electrolyte status should be
maintained within normal range.
 Nursing diagnosis cont…
Intervention
• Administer R/L solution 2-4mls/kg/TBSA burned
for 1st 24hour, ½ of the total amount should be
given within the first 8 hours of injury, 1/4th
should be given in 2nd 8hours and the1/4th should
be given in the 3rd 8hours. Then reassess after
every 30-60 min. for the signs of adequate
resuscitation.
• Patient’s fluids and electrolyte status should be
maintained within normal range, in 2nd 24hours
administer 5% dextrose as ordered,
 Nursing diagnosis cont…
• Pain related to burn injury as evidenced by
raised pulse rate, blood pressure, restlessness,
alterations in sleep pattern, complaints of
pain, irritability, and crying
 Nursing diagnosis cont…
• Expected patient out come
• Patient should not suffer unnecessary pain
 Nursing diagnosis cont…
Intervention
• Assess factors that may contribute to an
increased perception of pain eg anxiety, fear.
• Be gently and efficient as well as though in
performing all nursing care procedures.
 Nursing diagnosis cont…
• Wound should be covered with topical agents
and dressing
• Offer analgesic and sedatives routine to
enhance patient active cooperation and
decrease anxiety
• Morphine is the drug of choice.
• Non pharmacological method
 Nursing diagnosis cont…
• Use environmental comfort measures to relief
pain(alleviate all unnecessary stressors or
discomfort sources) eg calm speaking voice
and plan nursing care to facilitate periods of
rest and sleep.
• Assess vital sign, because increase pain can
cause transient increase in respiratory and
cardiac rates and BP
 Refferences
• Pattern of burns identifi ed in the Pediatrics
Emergency Department at King Abdul-Aziz
Medical City: Riyadh
• Down loaded article http://www.jsn brn.org
retrived on Monday June 2016

• Mariane et al (2005) Manual of Critical Care

Nursing fifth edition, USA