Care of Moderate and Severe Burns
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Transcript Care of Moderate and Severe Burns
Pediatric Burns
Carolyn O’Donnell, MD
Epidemiology
Worldwide:
Young children- 60-80% scalds
Older children- fire injury more likely
>/= 5 yrs: 56% with flame burns
Inflicted burns: usually scalds (stocking
distribution typical), < 4 yrs of age
Mortality related to size, depth, and
presence of inhalational injury
Symmetric Stocking Distribution
Pathophysiology
Thermal injury->protein denaturation and
coagulation->irreversible tissue damage
Surrounding zone of decreased perfusionpotentially salvageable
Depth determined by intensity and
duration of exposure
Deeper Burns
more common in young children with
thinner skin
Prolonged contact
High heat
High viscosity
Systemic Response
Damaged tissue ->vasoactive mediators
(cytokines, prostaglandins, free radicals)
Increased capillary permeability-> increased
fluid in surrounding interstitial space
Capillary leak: 18 to 24 hours
Large burns: can see myocardial depression
Major burns: hypotension, edema
(burn shock, burn edema)
Large Burns
Can see myocardial depression
Red Blood Cell destruction
Local destruction of up to 15% of RBCs
Decreased RBC survival time- can->
additional 25% reduction
Metabolic Response
Hypermetabolic response:
Increased catecholamines, glucagon,
cortisol -> increased metabolic rate,
catabolism
Decreased growth hormone, insulin-like
growth factor (anabolic hormones)
Classification
Minor, moderate and major (ABA)- based
on depth and size
Treatment and prognosis based on
classification
Burn Size
Accuracy is important- often
underestimated
Often determines management
Typically expressed as percentage of total
body surface area (TBSA)
Lund and Browder chart useful
Palm size- approximately 0.5% TBSA
Burn Depth
Can appear more superficial initially and
progress
Superficial- involve only the epidermal
layer of skin
Painful, dry, red, blanch with pressure
Heal in 3-6 days
No scarring
Superficial
Superficial Partial Thickness
Epidermis and superficial dermis
Painful, red, weeping, blanch with
pressure
Usually form blisters
Heal in 7-21 days
Scarring is unusual
Can see pigment changes
Superficial Partial Thickness
Deep Partial thickness
Extend to deeper dermis (hair follicles/glandualr
tissue)
Less painful than superficial partial
Usually blister, wet or waxy dry
Nonblanching
Color variable- red to cheesy white
>21 days to heal, scarring can be severe
Can be hard to distinguish from full-thickness
Deep Partial Thickness
Full Thickness
Extend through dermis
Often painless
Waxy white to leathery gray to charred
and black
Skin dry and inelastic, nonblanching
Severe scarring- sometimes with
contractures
Full thickness
Fourth degree
Extend to underlying tissues like fascia,
muscle
Grading System
Minor: <10% TBSA in adults, <5% in kids
or older adults, <2% full thickness
Moderate: 10-20% in adults, 5-10%
young or old, 2-5% full thickness, high
voltage injury, suspected inhalation injury,
circumferential burn, underlying medical
condition predisposing to infection
Major
>20% TBSA in adults, >10% young or old
>5% full thickness
High voltage burn
Known inhalation injury
Significant burn to face, eyes, ears,
genitalia, or joints
Significant associated injuries- fall, etc
Pre-Hospital care
ABC’s, supplemental oxygen
Intubation if airway burn/inhalation
Remove burned clothing and jewelry
Cover area with clean sheet (warmth)
Establish vascular access if possible- IV
fluids, pain medications
Cooling
Immediate cooling can be beneficial
Cool with water 10-20 minutes after burn
Water temp no less than 8 Celsius
No ice, no butter
Watch for and take measures to prevent
hypothermia
ABC’s
Airway: Look for signs of inhalation injurysoot in mouth, facial burns, stridor,
hoarseness. Intubate early if concerned
Breathing: Ventilation/oxygenation can be
affected by toxins (CO), associated
injuries, decreased level of consciousness,
circumferential burns (chest/abdomen)
Circulation: evaluate for associated injuries
if VS changes, poor perfusion
Examination
Thorough general examination, obtain weight if
possible
Skin exam:
Size and depth of burn
Early eye exam including fluorescein stain to
look for corneal burns
Note external ear burns: risk for suppurative
chondritis
Circumferential burns- very close monitoring of
distal perfusion/capillary refill (compartment
syndrome), and respiratory status
Diagnostic Studies
Baseline CBC, electrolytes
UA may reveal myoglobinuria if muscle
injury
Carbon monoxide levels
Consider CXR, soft tissue neck films
Others based on presentation
Management
Airway:
Anticipate difficult airway
Rapid sequence intubation: avoid BP
lowering sedatives (etomidate okay),
avoid succinylcholine if >48 hrs due to
increased risk of hyperkalemia
Monitor ETT closely- avoid accidental
extubation
Management
Reliable IV access for fluid resuscitation
Consider bladder catheter to reliably
measure UOP
Tetanus vaccine if >5 yrs since booster
Tetanus immune globulin if incomplete
primary immunization (less than 3)
Consider surgical consultation
IV Fluids
Parkland formula: 4 ml/kg per %TBSA in
24 hours in addition to maintenance fluids
Half of fluid given over 1st 8 hours, 2nd
50% given over the next 16 hours
4:2:1 for maintenance fluids/hour
Ringer’s lactate often used (LR) in 1st 24
hours. D5LR often used for children <20kg
Consider colloid/albumin after 24 hours to
improve oncotic pressure
Monitoring
Very close Is/Os
<30 kg: UOP 1-2ml/kg/hr
>30 kg: 0.5-1 ml/kg/hr
If increased UOP: check for glucose (osmotic
diuresis)
If decreased UOP: increase fluid, evaluate renal
function
Monitor HR and BP (pain may factor in)
Can see metabolic acidosis w/ inadequate fluid
resuscitation (also w/ CO, cyanide exposure)
Pain control- morphine, fentanyl
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 Dressing
Topical antibiotic covered with nonadherent dressing,
then covered with tubular net or gauze bandage
Ideally: biologic dressing for deeper burns
Topical Abx:
Silver sulfadiazine 1%- broad antimicrobial, decreases
pain, delayed healing
Mafenide- penetrates well, broad spectrum, painful on
application. Limited to cartilage, established infectionscan -> metabolic acidosis in large amount
Bacitracin- often used on face- painless, doesn’t bleach
pigment from skin
Dressings should be changed frequently- 1-2x/day
Escharotomy
A consideration in partial and full thickness
burns which can lead to functional
impairment (often seen as edema
increases)
Involves incision completely through the
depth of the burn eschar
Can relieve restriction (chest burns) and
reduce pressure (compartment syndrome)
Escharotomy
References
Up to Date online
Google images