MANAGEMENT OF BURNS IN

PAEDIATRIC PATIENTS

CHAIRPERSONS PROF. S.S.BHOJ

ASSOC. PROF. N.R MALLIK
SPEAKER DR. SUDIP HALDAR

Burns and Scalds

Mortality from burns and scalds is low but morbidity (pain and scarring) is high.
Rates of injury are highest in the 12 to 24 month age group (44/100000/year)
Around half of these are scalds, almost all of which occur in the home.
The severity of the burn is closely related to temperature of the liquid.
Electrical
Usually low voltage in children (<1000 volts),involve extension cords in young children.
Chemical
Ingested dishwasher powder (alkali) is the most common cause of chemical burns to
children.
House fire
Admission rate following injury related to house fire is relatively low (around 4/100000).
Mortality from house fire is significant - accounting for 10 to 15% of child injury mortality.
Young children have the highest mortality when involved in house fires.

Superficial Burn
Epidermis and upper part of dermal papillae
only
are involved
Burn may appear bright pink or red in
colour.
Skin blanches on pressure.
Blisters may or may not be present.
Burn is painful and sensitive.
Healing occurs in 7-10 days with no scarring

Superficial Partial Thickness Burns

Epidermis is lost with varying degrees of dermis.
The damage can range from superficial to deep
dermal.
Burn is usually coloured pink and white.
May or may not blanche on pressure.
Variable degrees of reduced sensation may be present.
Epithelial cells are present in hair follicles and sweat
glands.
Results in regeneration and spread.
Healing occurs in 14 days.
Some depigmentation of scar may occur.
May require skin grafting.

Deep Partial thickness

Extend to deeper dermis (hair follicles/glandular 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

Full Thickness Burns

Extend through dermis
Often painless
Waxy white to leathery gray to charred and
black
Skin dry and inelastic, nonblanching
Severe scarring- sometimes with contractures
Spontaneous healing is not possible.

Fourth degree Burns

Extend to underlying tissues like fascia,
muscle or bone

Major Burn Injury Criteria (American Burn Association)

Second-degree burns >10% TBSA in patients younger than 10 years of age
Third-degree burns >5% TBSA
Burns involving the face, hands, feet, genitalia, perineum, and major joints
Chemical burns
Electrical burns including lightning injury
Inhalation injury
Burns with signifiant concomitant trauma or signifiant preexisting medical
disorders

ABCs
Airway: - Look for signs of inhalation injury- soot in mouth, facial burns, Nasal
singing, stridor, hoarseness.
- Intubate early if concerned
Breathing: - The chest exposed to ensure adequate and equal chest expansion.
- 100% o2 to treat carboxyhaemoglobinaemia
- Escharectomy if circumferential burns restrict ventilation
Circulation: - Evaluate for associated injuries
- Check the pulse - is it strong or weak?
- Capillary blanch test - normal return is two seconds. Longer
indicates
hypovolaemia or need for escharotomy on that limb
- If shocked, give a bolus of 0.9% saline (20ml / kg) and look for cause
of
shock other than burn.
Titrate analgesia as per pt discomfort
Monitor saturation and blood pressure

Examination

History
Thorough general examination, obtain weight if possible
Skin exam: * Assessing extent of burn:
- Erythema should not be considered
- Lund and Browder chart: most accurate method
- For a rapid estimation of burn size, the palmar method can be used. The palmar
surface is approximately 1% of the TBSA
- TBSA-based formulas, such as the ShrinersGalveston formula - better at
estimating fluid requirements in children less than 20 kg.TBSA is assessed from
height and weight using standard nomograms or calculated using formulas Dubois or Jacobson formulas
* Assessing burn depth
- Gold standard is clinical assessment by doctor: 60-70% accuracy

Lund & Browder Chart

- Biopsy and histology : invasive, early biopsies inaccurate due to

wound progression, experienced pathologist required
- Laser Doppler techniques: ambient light problems, high cost, wound
infection and topical substances affect readings - 90-97% accuracy
- Video microscopy: skin contact-so risk for infection, Pt compliance
necessary so problematic in kids and restless pts - 90-97% accurate

Eye examination 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

Urine Analysis may reveal myoglobinuria if muscle injury

Carbon monoxide levels

Consider CXR, soft tissue neck films

Others based on specific presentations

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

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
- Ringers lactate often used (LR) in 1st 24 hours. D5LR often used for children <20kg
- Consider colloid/albumin after 24 hours to improve oncotic pressure

TBSA-based formulas, such as the ShrinersGalveston formula - better at estimating fluid

requirements in children less than 20 kg.TBSA is assessed from height and weight
using standard nomograms or calculated using formulas Dubois or Jacobson formulas.

Reliable IV access for fluid resuscitation peripheral/ central/ intraosseus

Consider bladder catheter to reliably measure UOP

Fluid Creep

Tendency to give more fluid than Parkland dictates

- 60% patients get more [J Burn Care Rehab 2000;21:91-5]
- 7ml/kg/%burn [ J Burn Care Rehab 2002;23:258-65]

Complications - pneumonia, bloodstream infection, acute respiratory distress

syndrome (ARDS), multiple-organ failure

Permissive hypovolemia helps avoid these complications and has been

shown to decrease multiple organ dysfunction

MONITORING

Very close Input/Output

- <30 kg or < 2yrs: Urine Output 1-2ml/kg/hr
- >30 kg or > 2yrs: 0.5-1 ml/kg/hr
- If increased Urine Output: check for glucose (osmotic diuresis)
- If decreased Urine Output: 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

PREVENTION OF HYPOTHERMIA

Cover

patients with a dry sheet

keep head covered

Pre-warm

trauma room

Administer

warmed IV solutions

Avoid

application of salinesoaked dressings

Remove

wet / bloody clothing

and sheets

Continual

monitoring of core
temperature via foley or SCG
temperature probe

Cool with water 10-20 minutes after

burn

Water temp no less than 8C. Stop

cooling if core body temperature is
<35C

No ice (ice water damages viable

tissue causes vasoconstriction )
Gel Pads (such as Hydrogel,
BurnaideTM ) can be used as an
alternative to running tap water
where water is unavailable or not
practical

Nasogastric tube - For gastric emptying/gastric feeds of >15%

TBSA

Tetanus vaccine if >5 yrs since booster

Tetanus immune globulin if incomplete primary immunization

(less than 3)

Consider surgical consultation

MEDICATION FOR PAEDIATRIC BURN PATIENTS >15% TBSA

Multivitamins - 0-3 years Pentavite infant 0.45ml daily
- Over 3 years Pentavite mixture 5 ml daily
Iron supplement - 0-30kg 2.5mg/kg (0.4ml/kg) daily
- Over 30kg 1 tablet (105mg) daily
Ascorbic Acid - <2 years 250mg daily tablet crushed
- >2 years 500mg daily 1 tablet crushed
Zinc Sulphate - 1mg/kg/day (of elemental zinc)
in 1-3 divided doses
Antibiotics
Used ONLY if positive wound culture or clinical infection is detected and
NOT used as prophylaxis.
Should be discussed with Infectious Diseases if: - recurrent
- does not resolve
- multi-organisms involved.

PAIN MANAGEMENT
Major Burns > 15%:
Short term after initial burn (first 1 to 4 days)
- Intravenous morphine infusions or

Patient Controlled
Analgesia (PCA) and regular paracetamol (15mg/kg QID)

- If standard doses of morphine do not provide adequate analgesia for pain, early
introduction of a low dose ketamine infusion
- In PICU a midazolam infusion may also be required
Transition to oral analgesia - 1) Background analgesia using continuous slow release

agents eg Morphine slow release or Tramadol Sustained Release

2) Breakthrough analgesia using an immediate acting
medication eg. Oxycodone,Tramadol

Minor burns <15%:

Short term after initial burn

- Paracetamol: 15mg/kg/dose 6 hourly regularly

Oxycodone: Ibuprofen (Cease 48 hours prior to
surgery/grafting). Do not routinely prescribe for
children <3 months
- Tramadol

Breakthrough analgesia may comprise -

Minor burn injuries - minimal debridement

- Intranasal fentanyl dose is 1.5 mcg/kg
- If requiring more debridement, administer oral morphine syrup 0.5
mg/kg on presentation

NUTRITION
High energy snacks (nourishing snacks list) to supplement intake
Regular weights twice weekly using the same scales and without wet dressings
wherever possible - essential to assess the adequacy of nutrient intake.
- If suboptimal, enteral feeding may be required.
Enteral feeding is indicated- Burns <15% TBSA with an inability to meet requirements via oral intake alone
- Burns >15% TBSA enteral feeding should be commenced as early as possible.
If enteral feeding is indicated it should be commenced within the first 24-48 hours

 Nasogastric feeds may be used in the short term. PEG feeds should be considered if
long term feeding would be required, or for severe burn injuries. Nasojejunal
feeding may be indicated if nasogastric feeding is not tolerated.
Oral intake should be encouraged even when enteral feeding is being used.
Weight loss of more than 1% of baseline wt per day should not be tolerated for
more than ~5 days before progressing to the next level of nutritional support
Curreri Formula: calories/day=(wt in kg) (25) + (40) (%BSA)
Sutherland formula : 60 kcal/kg + 35 kcal/%TBSA
Davies formula : 3g/kg + 3g/%TBSA

WOUND INFECTION
After the initial resuscitation , the major cause for mortality and morbidity is
wound infection
Without topical antimicrobial agents the wound becomes colonized with gram
positive organisms within 48hrs. Most common gram + : beta hemolytic
streptococcus and staphylococcus.
Gram negative organisms appear after 3-21days. Pseudomonas , proteus and
acinetobacter baumani are the most common organisms
Eschar will become infected unless its removed by re - epithealization process
or surgical excision
Systemic antibiotics only if systemic infection.

Clean with mild soap and water

Avoid disinfectants

Remove clothing and debris

Scalds
- Remove all soaked clothing
- A scald is deepest - Where the clothing is thicker
- Where the liquid is held in the natural creases of the body
(e.g., toddlers around their necks and folds of skin in their legs)
- Where the clothing is compressed in the natural creases of the body.
- Immediately cool the burn with cool running water.

Debridement of devitalized tissue with sterile saline soaked gauze

Showering better than bathing- less wound cross contamination

Blister removal controversial - recommendation is to aspirate blister and leave skin

intact

Wound swab useful to dx bacteria but cant differentiate between colonisation and
wound infection, tissue culture is superior (quantifies bacteria)

PCT, CRP, WCC, NEUTROPHILS ,TEMP - useful markers to monitor sepsis

PERIANAL BURNS
- After bowel actions, perineal area should be cleaned with a soapy solution.
- Soft paraffin or topical antibiotic ointment like mupirocin (Bactroban) or Silver
sulphadiazine impregnated onto Chux - applied over perineal area and
changed after every void and bowel action. - may be placed inside a nappy.
- Bathed daily in 4% chlorhexidine skin wash.

TOPICAL AGENTS

Silver sulfadiazine : effective 24hrs ,water soluble, low toxicity, commonly used.

Poviodine : short t ,inactivated by wound exudates ,did not improve healing times
Mupirocin : broad spectrum but not effective against pseudomonas
Chlorhexidine : effective against pseudomonas but difficult to apply
Mafenide : broad spectrum and good penetration. Causes electrolyte imbalance and
painful application
Acriflavin : good antiseptic. Can be cytotoxic, irritate and stain skin
Acticoat ; anti bacterial + anti fungal , 5 day application. Treatment choice with good
outcomes
Melladerm : local honey based products , antibacterial , promotes moist wound
healing ,very promising results

WOUND DRESSING

Topical antibiotic covered with nonadherent dressing, then covered

Ideally : biologic dressing for deeper burns

Dressings should be changed frequently- 1-2x/day

Early excision and grafting associated with better outcomes

with tubular net or gauze bandage

- Grafting should be done within 1st week

- Humby knife or dermatome with mesher
- Versa jet technology : good outcomes. useful in paediatrics and difficult access areas. Hydro
surgery using pressurised saline
- Donor sites used 3x with 10day intervals. Graft maximum 20% at a time.
- Narrow meshed autografts (1 : 1 or 1 : 2) - advantages of limiting donor
harvest area and
allowing better drainage of fluid.
- In larger burns ( >2030%), coverage may require meshed autografts (4 : 1to 6 : 1) covered with
meshed allograft (2 : 1) overlays.

SKIN SUBSTITUTES
1. BIOLOGICAL DRESSINGS
o
o
o

Allograft : cadaver skin for temporary cover. Tissue lasts 3 weeks before rejection. Expensive
needs special preservation , disease transfer
Xenografts (pig skin) : temporary coverage, less expensive than allograft, more readily
available, sloughs easily
Human amnion : for temporary wound closure, superficial wounds and excised wounds, poor
screening for viruses so not recommended.

2. SYNTHETIC DRESSINGS

Opsite : provides moisture barrier, accumulation of exudates.

Biobrane :2layer membrane with outer silicone membrane to prevent bacterial invasion coated
with a monomolecular layer of type I collagen of porcine origin.
- provides a hydrophilic coating for fibrin ingrowth.Accumalation of exudates but otherwise
good product. Inexpensive long shelve life
Transcyte: similar to biobrane, can stimulate wound healing

 Nanocrystalline silver dressing (eg Acticoat):

- Nanocrystalline silver protects the wound site from bacterial contamination while
the inner core helps maintain the moist environment optimal for wound healing.
- This dressing consists of three layers: an absorbent inner core sandwiched between
outer layers of silver coated, low adherent polyethylene net.
- To apply
Trimmed to fit burn (but does not need to be a perfect fit and if in doubt extend onto
area of simple erythema)
Moisten the Acticoat with warm water (Not with normal saline it will deactivate
the silver)
Place low allergy dressing retention sheet (Hypafix) over the top it is required to
overlap the nanocrystalline silver dressing onto normal skin.

3. COMBINED SYNTHETIC AND BIOLOGIC DRESSINGS.

Integra - an inner layer composed of a porous matrix of bovine collagen and the
glycosaminoglycan chrondroitin-6-sulfate which facilitates fibrovascular ingrowth.
- The outer layer is a polysiloxane polymer with vapor transmission
characteristics similar to normal epithelium.
- Integra acts as a dermal replacement - provides a matrix for the infitration of
fibroblasts, macrophages, lymphocytes, and capillaries from the wound bed, and promotes
rapid neo-dermis formation.
- Approximately two weeks after engraftment, the outer silicone layer is removed
and is replaced with an epidermal split thickness autograft.

Wound management

Superficial and small burns heal within 2 weeks

Large deep dermal burns heal within 2-3 weeks
Any burn not healed after 3weeks needs grafting
Open dressings: inexpensive but increased heat and fluid loss , though decrease
incidence of pseudomonas
Closed dressings :reduce heat and moisture loss, less painful, but higher
incidence of pseudomonas
Wound surface drying impedes ability of epithelial cells to migrate across the
wound
Moist wound healing:
Increased activity of growth factors
Increased activity of surface proteolytic enzymes
Improved oxygen and nutrient delivery

Burn Injury: Wound Sepsis

Characterized by gray or dark appearance, purulent discharge,

systemic signs of sepsis

If true burn wound sepsis, wound culture should yield >105

organisms/gram of tissue

Gram negative bacteremia/sepsis

- think wound, lungs

Gram positive bacteremia/sepsis

- think indwelling lines, wound

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

Incisions can be carried onto the hypothenar and thenar

eminences and dorsolateral aspects of the digits if the
hands or figers are involved

Performed with a scalpel or electrocautery along the

lateral and medial aspects of the affected extremity

Can relieve restriction (chest burns) and reduce pressure

(compartment syndrome)

Only burnt tissue is divided, not underlying fascia

differentiating from fasciotomy

FACIAL AND NECK BURNS

Face: Severe oedema occurs very quickly consider early intubation
- Rinse thoroughly with normal saline to prevent corneal irritation.
- T.D.S eye toilets with antibiotic ointment applied whilst eyes are closed.
- Clean face and neck B.D. with saline and gauze. Apply White Soft Paraffin
ointment T.D.S. and PRN to keep moist
- Apply a thin layer of white soft paraffin or lanolin to burnt lips.
- Wash hair daily
- Observe for signs of airway involvement due to smoke/steam inhalation or
swallowing of hot fluids
- Do not use SSD as it can cause corneal ulceration
Neck: Extend the neck with a bolster under the shoulders to maximise air entry.
Ears: Avoid pressure on the ears by putting a foam doughnut under the head.

INHALATIONAL INJURY
Airway injury above the larynx
- Caused by inhalation of steam or hot gases.Soft tissue oedema results in airway
obstruction.
- In children this type of injury is usually associated with a scald injury.
Airway injury below the larynx
- Resulting from inhalation of:
Combustible products - carbon, nitrogen, sulphur and phosphorous.
Chemical compounds - carbon monoxide, ammonia, caustic cleaning products.
Systemic Intoxication Injuries
- Follows absorption of carbon monoxide, hydrogen cyanide, ammonia, hydrofluoric
acid and phosgene

EFFECTS - Oedema of tracheobronchial mucosa

- Separation of epithelium with Bronchial casts
- Parenchyma-congestion, oedema ,neutrophil infiltration, hyaline membranes
DIAGNOSIS - Bronchoscopy- removal casts
- Xenon scanning
- CXR infiltrates over 5-10days
- ABG and CarboxyHb level
MANAGEMENT - O2 maintain SpO2 >90%
- Artificial cough 2hrly
- Chest physiotherapy 4hrly
- Nebulised N-Acetyl cysteine 3 mL 4 hourly
- Nebulised heparin 500010,000 units/3 mL of NS 5 hourly
- Sputum culture 3x week
- Bronchodilators and racemic epinephrine
- TV 6ml/kg, PIP<35, permissive hypercapnoea

CHEMICAL INJURY
For most chemicals found in the home:
o remove clothing
o powdered agents should be brushed from the skin
o wash the burn with copious amounts of water, preferably
within 10 minutes of the burn injury
o chemical eye injuries require continuous irrigation until
ophthalmologic review. Always ensure that the
unaffected eye is uppermost when irrigating to avoid
contamination.
o Neutralization of chemicals not required
- Acid: irrigate* with water for up to 1 hour or until
the pain stops
- Alkali: irrigate* with water for up to 2 hours or
until pain stops

HCl Burn

NaOH Burn

ELECTRICAL BURNS
Usually low voltage (<1000 volts) - cause local burns
but not usually deep muscle damage
Turn off mains/ switch off source (power point)
Remove patient from electricity source remembering
your own safety
Spine Protection
Cervical Spine Protection
ECG - any abnormal findings require continued
monitoring for 48 hours and appropriate
management of dysrhythmias if detected

 Requires diligent fluid resuscitation. Urine output maintained at 2ml/kg/hour in

children
If the urine is dark, start therapy for myoglobinuria immediately to minimise the risk
of acute renal failure :
- Fluid administration should be increased to ensure a urinary output of at least 1 to 2
ml/kg/hour
- Mannitol should be given if the pigment does not clear with this increase in fluid.
- Metabolic acidosis should be corrected by maintaining adequate perfusion and adding
sodium bicarbonate.

Carbon Monoxide

CO affinity for Hb 200x that of

oxygen

Moves oxyhaemoglobin
dissociation curve to left

10-30% headache

50% coma

70% fatal

Half-life 4hr (air)

30-60min (high O2)

Low CO often
underestimates degree of
injury

THANK YOU