Children And Burns
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Introduction Burns in a child are a triple tragedy. First is the injury, which requires prolonged, painful and costly treatment. Secondly, the scars are visible and lifelong (whereas a ruptured liver or spleen will heal to become normal tissue), deep burns to the skin even with optimal treatment heal to become unsightly fibrous scars. Thirdly, are the psychological problems: there is considerable parental guilt and the child has to endure the treatment and adjust to their new physical appearance. The tragedy is all the more poignant because it is so unnecessary: burns are the most preventable of injuries. Some communities (usually affluent) have significantly decreased burns, while the problem remains entrenched in others (usually deprived). It is not unusual to have almost no burns in some areas of a city but clusters in other areas. For example in Sydney (Australia), the Eastern and Northern Suburbs have very few burns; whereas the Western and Southern Suburbs have significant bunching of burns (often in the same street). Therefore any efforts to treat the disease of burns must focus not just on the surgery but also prevention. Prevention Most burns in children are scalds from kitchen and bathroom accidents, such as spilt cups of tea or coffee and hot baths (60%). Every effort should be made to educate the public as to the hazards of these hot fluids especially near toddlers. Regulating the temperature of the hot water system (or at least the taps) in the bathroom to 42ºC can reduce bath scalds injuries. Cold water should always be run in first, and then hot water, to bring up the temperature to the desired level. Epileptics need to be supervised always during baths and showers. The other 40% of burns in children are due to flame (25%), contact (10%), and less commonly electrical, chemical and sun. Younger children are more likely to suffer scalds whereas older children suffer more flame burns. Open fires or radiators where a young child can put a piece of paper between the guards are known mechanisms that start devastating house fires. Similarly allowing children to play with matches and cigarette lighters courts disaster. Many countries now outlaw easy to use cigarette lighters. Smoke detectors have been a proven method of reducing mortality from fires and all houses should have them fitted and there should be adequate checks as to they are being maintained and working well. Contact burns from barbecues are common in Australia and usually involve the palms of the hands in toddlers who do not realize the danger. Fire related risk-taking behaviour in adolescent boys has always been a problem and they need to be forewarned as to the dangers. This traditional risky group has been further stimulated by access to the Internet where irresponsible people have put on formulas as to how make small incendiary devises from household products. As physicians treating burns there is an obligation to try and prevent further injury. Publicity of cases that do occur have a marked effect on public perception and is one of the main ways to further reduce the burden of burn injuries in your community. Particular attention needs to be paid to deprived areas, as these are difficult to get information into and the poverty associated with these communities often leads to unsafe situations and a propensity for burns. It is a problem of a trilogy of “not having”, “not knowing” and unfortunately at times “not caring”. A low rate of childhood burns is an indicator of a community’s
sophistication. The main differences between children and adults when treating the child with burns are: 1.
The difference in weight to body surface area {produces a:}
2.
Proportionately higher metabolic rate than an adult
3.
The thickness of the skin.
4.
The differences in psychological status.
Key points •
Scalds from kitchen and bathroom accidents are the most common of a number of mechanisms of burns in children.
•
For the most part, burns are preventable. Education is the key.
First aid A key aim when you are rung about a burn is to ensure that the harm is minimized. This can be achieved by ensuring that all clothing is removed immediately. When singlets are left on there is often accentuated burning where the material is thickest near pleats. The ideal treatment is to immerse the injured part in tepid water for 20-30 minutes. Temperatures of between 8oC and 25oC are satisfactory with the optimum being 15oC. This is still useful up to 3 hours after the burn. If the hand or foot is burnt this is easy and safe to immerse, but if there is a burn to the trunk one needs to be careful of not inducing hypothermia. The use of ice, or meat from the freezer is contraindicated as these can produce further burns due to the cold temperature. A good indication that the first aid is working is the diminution in the degree of pain. If the hand is removed and there is a reappearance of pain then it can be re-immersed in the tempered fluid. Such first aid can reduce the severity of pain and the degree of the burn. Primary assessment The key triage tool is the history. Major burns In cases of a house fire or where there is a risk of smoke inhalation in an enclosed area one is dealing with an emergency. In this situation the early management of severe trauma guidelines need to be evoked. Careful attention to the airway and early intubation if needed are mandatory. In these situations precisely the same sequence of treatment as in adults must be instituted as there is often more harm done to the child by hesitating and not working through a set adult regime. If a situation exists that in an adult would necessitate intubation, then almost certainly in the same situation a child would need to be intubated. A similar mental priority list applies for decisions as to introduction of intravenous fluids and need for escharotomy.
Scalds Most burns are minor and involve burns to the hands, feet, head or trunk area. A common problem is to decide as whether the child needs to be admitted, whether fluids should be introduced, and whether grafting is needed. In general burns to the hands, feet, face and genital areas always require admission. Often a history is helpful in that if the child had a simple splash injury and there is only erythema than the child can be managed as an outpatient. Alternatively a child who has grabbed a hot iron and burns to the flexor creases of the hand should be admitted and early grafting considered. Fluid resuscitation A child under 1 year of age has a head and neck surface area equal to 18% of total body surface area with each lower limb being 14%. Each year after this the head proportionally looses 1% and the lower limbs gain 0.5% each. Therefore adult proportions are reached at around 10 years of age. The estimation of the surface area and depth of burn is always difficult and more important than precise calculations, is to start the appropriate fluids, insert a urinary catheter and review the child regularly. The aim in children is to produce 1mL per kilogram per hour of urine. A starting resuscitation infusion is 4ml of Ringer’s lactate per kilogram body weight, for each percent of burns over the first 24 hours. Once the 24 hours fluid is worked out one half of the fluid is administered in the first 8 hours and the remaining half in the next 16 hours. It is important to remember that the above fluid requirement is for resuscitation and maintenance fluids must be added. In young children glucose needs to be added to the solutions to maintain their blood sugar levels. It must be stressed that the early calculations are only an approximation and the most important feature in the resuscitation of burns is frequent reassessment and adjustments of fluids depending on the urine output. Key points •
Estimation of body surface area in children may be difficult
•
It is important to start fluid resuscitation early.
Burns care The management of paediatric burns is a specialized area. As early as possible the child should be transferred to a burns unit for assessment by a Paediatric Burns Surgeons. The reason for this is not so much the expertise in treating the burn per se, but rather the large team effort, which involves complex pain relief, specialist nurses, social workers, physiotherapists, nutritionists, and family therapists. Burns often occur in families where there has recently been some social disruption and this together with the guilt felt by the parents greatly aggregates the difficulty in treating the burns. Contractures can occur quickly
and early movement with appropriate pain relief is essential. Wound assessment (classification) (see also Chapter 11) The initial assessment of wounds can be difficult in both estimating the fluid requirements and in assessing the ultimate need for grating. Superficial These appear reddened and blistered. Partial thickness These are often mottled with red and white patches interspersed and these do not blanch on pressure. There are also areas of petechial haemorrhage. Full thickness These burns appear much whiter and quickly go to a brown dry colour and are leathery on palpation. In the base there may be thrombus veins visible. In full thickness burns there is a loss of pain sensation. Wound management Pain relief Morphine is the best agent for pain relief. The initial dose is 0.1mg/kg but this may be increased to 0.2 to 0.3mg/kg if necessary. The drug is given intravenously as a continuous infusion but necessitates meticulous respiratory monitoring in children. This will allow the initial cleaning of the wound, which is allows more precise assessment. The initial washing of the burn should be with tempered normal saline and performed in a warm environment. Any soot or other material should be gently removed. Blisters are best left intact. Wound surgery There are differences in opinion as to whether early grafting or observation with later grafting is preferable. There are also differences of opinion as to the precise technique of grafting. These differences of opinion demonstrate that we as yet have not reached an optimal way of removing dead tissue and encouraging the regrowth of new skin. In many ways the techniques are the same as in the adults with refinements as to the depth of taking skin grafts. It is likely that in the future that new technology of growing the patient’s own skin will be a major contribution to the better care of paediatric burns. Unusual burns Electrical Most injuries to children are a result of exposure to electricity in the home. Prevention is easy by the use of small plugs to cover electrical outlets and the installation of circuit breakers into the main switchboard.
A key message in electrical burns is that the degree of tissue injury is often much extensive than would be initially expected on the initial examination. Quite often vessels are thrombosed, muscles are hypoxic and fractures may have occurred. Face Facial burns can lead to marked swelling that causes more alarm than is warranted by the end outcome. Although very swollen and blistered the skin often does recover well although there is a tendency in many patients to keloid formation. When skin grating is needed it is important to colour match the area and to take thicker than normal grafts. Eyes When the eyelid is damaged there is often concern about direct damage to the cornea. However this is very unlikely as the lids are often closed shut and there is relative protection of the eye. Early treatment should involve the use of Chloromycetin eye ointment. Hands This can be very difficult to manage as the ideal situation would be for the child to start early movement. Techniques such as putting the whole hand in a glove smeared with SSD sometimes work but on occasions the child is not cooperative and in that instance regular dressings are required. In general early excision and grafting in used in the hand areas as it is important to get early mobility. Feet These can be deceptive. Splashes of hot liquid onto the feet may result in blistering and a very mild burn. However in other instances with the shoes on or if fat falls on to socks there can often be quite extensive localized burning. Very careful assessment and if necessary early excision and grafting is warranted. Keloid scars in this area are very difficult to treat as the children remain very active and resist pressure garments. Perineum These are difficult in that urine and faeces will interfere with the healing process. Therefore a urinary catheter is inserted and constipation induced by the use of codeine phosphate. This will allow up to 10 days of non-passage of faeces. If healing has not occurred in that stage or the burn is more extensive and will not heal by that time the colostomy is warranted. Infection At the time of the burn all wounds will be sterile but within 24 to 48 hours a flora partly from the patient and partly from the environment will cover the wound area. The key aim of treatment is not necessarily to pursue the impossible task of producing sterility but rather preventing sepsis. Opinions continue to differ as to the value of various antiseptic agents and the place of antibiotics. For simple burns no treatment would be the best form of management and for more extensive burns the use of SSD is practiced in most
institutions. Antibiotics are reserved for episodes of sepsis or sometimes given prophylactically at the time of major grafting episodes. Septicaemia when it occurs in children can be rapid and profound. Therefore constant vigilance is required and early aggressive treatment by both fluids and antibiotics is required once burns are suspected.
sophistication. The main differences between children and adults when treating the child with burns are: 1.
The difference in weight to body surface area {produces a:}
2.
Proportionately higher metabolic rate than an adult
3.
The thickness of the skin.
4.
The differences in psychological status.
Key points •
Scalds from kitchen and bathroom accidents are the most common of a number of mechanisms of burns in children.
•
For the most part, burns are preventable. Education is the key.
First aid A key aim when you are rung about a burn is to ensure that the harm is minimized. This can be achieved by ensuring that all clothing is removed immediately. When singlets are left on there is often accentuated burning where the material is thickest near pleats. The ideal treatment is to immerse the injured part in tepid water for 20-30 minutes. Temperatures of between 8oC and 25oC are satisfactory with the optimum being 15oC. This is still useful up to 3 hours after the burn. If the hand or foot is burnt this is easy and safe to immerse, but if there is a burn to the trunk one needs to be careful of not inducing hypothermia. The use of ice, or meat from the freezer is contraindicated as these can produce further burns due to the cold temperature. A good indication that the first aid is working is the diminution in the degree of pain. If the hand is removed and there is a reappearance of pain then it can be re-immersed in the tempered fluid. Such first aid can reduce the severity of pain and the degree of the burn. Primary assessment The key triage tool is the history. Major burns In cases of a house fire or where there is a risk of smoke inhalation in an enclosed area one is dealing with an emergency. In this situation the early management of severe trauma guidelines need to be evoked. Careful attention to the airway and early intubation if needed are mandatory. In these situations precisely the same sequence of treatment as in adults must be instituted as there is often more harm done to the child by hesitating and not working through a set adult regime. If a situation exists that in an adult would necessitate intubation, then almost certainly in the same situation a child would need to be intubated. A similar mental priority list applies for decisions as to introduction of intravenous fluids and need for escharotomy.
Scalds Most burns are minor and involve burns to the hands, feet, head or trunk area. A common problem is to decide as whether the child needs to be admitted, whether fluids should be introduced, and whether grafting is needed. In general burns to the hands, feet, face and genital areas always require admission. Often a history is helpful in that if the child had a simple splash injury and there is only erythema than the child can be managed as an outpatient. Alternatively a child who has grabbed a hot iron and burns to the flexor creases of the hand should be admitted and early grafting considered. Fluid resuscitation A child under 1 year of age has a head and neck surface area equal to 18% of total body surface area with each lower limb being 14%. Each year after this the head proportionally looses 1% and the lower limbs gain 0.5% each. Therefore adult proportions are reached at around 10 years of age. The estimation of the surface area and depth of burn is always difficult and more important than precise calculations, is to start the appropriate fluids, insert a urinary catheter and review the child regularly. The aim in children is to produce 1mL per kilogram per hour of urine. A starting resuscitation infusion is 4ml of Ringer’s lactate per kilogram body weight, for each percent of burns over the first 24 hours. Once the 24 hours fluid is worked out one half of the fluid is administered in the first 8 hours and the remaining half in the next 16 hours. It is important to remember that the above fluid requirement is for resuscitation and maintenance fluids must be added. In young children glucose needs to be added to the solutions to maintain their blood sugar levels. It must be stressed that the early calculations are only an approximation and the most important feature in the resuscitation of burns is frequent reassessment and adjustments of fluids depending on the urine output. Key points •
Estimation of body surface area in children may be difficult
•
It is important to start fluid resuscitation early.
Burns care The management of paediatric burns is a specialized area. As early as possible the child should be transferred to a burns unit for assessment by a Paediatric Burns Surgeons. The reason for this is not so much the expertise in treating the burn per se, but rather the large team effort, which involves complex pain relief, specialist nurses, social workers, physiotherapists, nutritionists, and family therapists. Burns often occur in families where there has recently been some social disruption and this together with the guilt felt by the parents greatly aggregates the difficulty in treating the burns. Contractures can occur quickly
and early movement with appropriate pain relief is essential. Wound assessment (classification) (see also Chapter 11) The initial assessment of wounds can be difficult in both estimating the fluid requirements and in assessing the ultimate need for grating. Superficial These appear reddened and blistered. Partial thickness These are often mottled with red and white patches interspersed and these do not blanch on pressure. There are also areas of petechial haemorrhage. Full thickness These burns appear much whiter and quickly go to a brown dry colour and are leathery on palpation. In the base there may be thrombus veins visible. In full thickness burns there is a loss of pain sensation. Wound management Pain relief Morphine is the best agent for pain relief. The initial dose is 0.1mg/kg but this may be increased to 0.2 to 0.3mg/kg if necessary. The drug is given intravenously as a continuous infusion but necessitates meticulous respiratory monitoring in children. This will allow the initial cleaning of the wound, which is allows more precise assessment. The initial washing of the burn should be with tempered normal saline and performed in a warm environment. Any soot or other material should be gently removed. Blisters are best left intact. Wound surgery There are differences in opinion as to whether early grafting or observation with later grafting is preferable. There are also differences of opinion as to the precise technique of grafting. These differences of opinion demonstrate that we as yet have not reached an optimal way of removing dead tissue and encouraging the regrowth of new skin. In many ways the techniques are the same as in the adults with refinements as to the depth of taking skin grafts. It is likely that in the future that new technology of growing the patient’s own skin will be a major contribution to the better care of paediatric burns. Unusual burns Electrical Most injuries to children are a result of exposure to electricity in the home. Prevention is easy by the use of small plugs to cover electrical outlets and the installation of circuit breakers into the main switchboard.
A key message in electrical burns is that the degree of tissue injury is often much extensive than would be initially expected on the initial examination. Quite often vessels are thrombosed, muscles are hypoxic and fractures may have occurred. Face Facial burns can lead to marked swelling that causes more alarm than is warranted by the end outcome. Although very swollen and blistered the skin often does recover well although there is a tendency in many patients to keloid formation. When skin grating is needed it is important to colour match the area and to take thicker than normal grafts. Eyes When the eyelid is damaged there is often concern about direct damage to the cornea. However this is very unlikely as the lids are often closed shut and there is relative protection of the eye. Early treatment should involve the use of Chloromycetin eye ointment. Hands This can be very difficult to manage as the ideal situation would be for the child to start early movement. Techniques such as putting the whole hand in a glove smeared with SSD sometimes work but on occasions the child is not cooperative and in that instance regular dressings are required. In general early excision and grafting in used in the hand areas as it is important to get early mobility. Feet These can be deceptive. Splashes of hot liquid onto the feet may result in blistering and a very mild burn. However in other instances with the shoes on or if fat falls on to socks there can often be quite extensive localized burning. Very careful assessment and if necessary early excision and grafting is warranted. Keloid scars in this area are very difficult to treat as the children remain very active and resist pressure garments. Perineum These are difficult in that urine and faeces will interfere with the healing process. Therefore a urinary catheter is inserted and constipation induced by the use of codeine phosphate. This will allow up to 10 days of non-passage of faeces. If healing has not occurred in that stage or the burn is more extensive and will not heal by that time the colostomy is warranted. Infection At the time of the burn all wounds will be sterile but within 24 to 48 hours a flora partly from the patient and partly from the environment will cover the wound area. The key aim of treatment is not necessarily to pursue the impossible task of producing sterility but rather preventing sepsis. Opinions continue to differ as to the value of various antiseptic agents and the place of antibiotics. For simple burns no treatment would be the best form of management and for more extensive burns the use of SSD is practiced in most
institutions. Antibiotics are reserved for episodes of sepsis or sometimes given prophylactically at the time of major grafting episodes. Septicaemia when it occurs in children can be rapid and profound. Therefore constant vigilance is required and early aggressive treatment by both fluids and antibiotics is required once burns are suspected.
