Burns

Abstract

Thermal injuries are a cause of significant morbidity and mortality in the pediatric population. Each year, approximately 440,000 children receive medical treatment for burns in the United States, among whom over 75,000 require hospitalization, 10,000 suffer severe permanent disability, and 2,500 eventually die. Recent advances in the care of the critically burned patient and the use of an aggressive multidisciplinary approach have led to significantly improved outcomes.

Appendices

Summary Points

Inhalation injury is the leading cause of death in pediatric burn patients.

Child abuse comprises up to 10–20% of pediatric thermal injuries and must be ruled out.

Due to the larger body surface area to mass ratio of children compared to adults, the modified Parkland formula, which adds maintenance fluids to resuscitation fluids, is used in the resuscitation of smaller children.

Fluid resuscitation should be guided by the patient’s response (urine output).

Extremity escharotomy may be needed to prevent compartment syndrome, and chest escharotomy may be needed to prevent respiratory compromise.

Recent developments of silver-impregnated sustained release dressings (e.g., Aquacel^® Ag) have allowed for the treatment of partial-thickness burns in a nearly painless fashion.

Recent advances in the care of the critically burned patient with use of an aggressive multidisciplinary approach have led to significantly improved outcomes in children.

A multidisciplinary approach to burn care including participation of surgeons, nurses, occupational therapists, physical therapists, dieticians, play therapists, social workers, psychologists, and discharge planners, leads to the best outcome.

Editor’s Comment

In addition to management of the physical injury and the ABCs of trauma care, care of the burned child demands careful consideration of many simultaneous and sometimes competing issues: social and legal concerns, the psychological and emotional care of the child, alleviating pain and anxiety, and, of course, ruling out other injuries. Making matters more difficult is the fact that for severely injured children, the care provided in our trauma bay is likely to be transitional as they need to be accepted from the first responders and safely prepared for transfer to a pediatric burn center. Transfers of care increase the risk of medical errors, increasing the importance that we maintain attention to detail and anticipate potential snags. One should never assume that the care provided at another institution or in the field was adequate: always check endotracheal tube position by auscultation and a chest X-ray, be sure that the cervical spine is properly immobilized, and perform a careful physical assessment yourself. Likewise, if the patient is being transferred, it is important to think ahead as to what will be needed on the receiving end: rather than applying cream or ointment, cover the burns with dry sterile dressings that can be easily removed for a proper assessment of the depth and extent of the injury; secure adequate intravenous access and hydrate the patient well; avoid long-acting muscle relaxants to allow an accurate assessment of neurologic status after transfer; be sure that copies of all films and medical records accompany the patient; and so on.

Silvadene has been the therapy of choice for many years, though many prefer to use patrolatum-based antibiotic ointments, which are transparent, keep the wounds moist, and do not need to be removed or washed off before every application. The antibiotic concentration in most topical antibiotic preparations is too high for use in the eye, so in little children, it is best to use ophthalmic-strength ointment for burns on the face or hands.

Diagnostic Studies

• Chest X-ray if inhalation injury is suspected

• Carboxyhemoglobin levels for suspected inhalation injury

• CBC, chemistry studies if significant fluid resuscitation required

• Fever workup (CBC; U/A; blood, urine, sputum, wound cultures) as clinically indicated

• Quantitative wound cultures or wound histology for suspected invasive burn wound sepsis

Parental Preparation

• Explanation of grafting procedure, location of donor sites, expected cosmetic result

• Possibility of complications including graft failure, infection, progression of partial-thickness burns to full-thickness burns

• Possibility of psychological sequelae related to scarring and post-traumatic stress

Preoperative Preparation

• Fluid resuscitation

• Prophylactic antibiotics

• Type and crossmatch

• Informed consent

Technical Points

Always have sufficient blood available for intra-operative transfusion.

Pay careful attention to preserving body temperature and avoiding hypothermia.

Utilize measures to minimize blood loss (tourniquets, epinephrine solution, topical thrombin)

Use sheet graphs when possible, especially on cosmetically and functionally sensitive areas such as the face, hands, and over joints.

Pay careful attention to securing of grafts, preventing sheer stress on grafts, and avoiding build up of fluid or blood under grafts.