CHANTEL R . GRUBBSROBERT SMITH

LATRICE WILSONGABRIELLE PAUL

Burn Injuries1

Case PresentationPHA 5601 Pediatrics Ambulatory

CareDr. Angela Thornton, PharmD

March 21st, 2013

Objectives

Classify the types of burns, along with defining the prevalence, causes, and pathophysiology.

Explain various preventative measures, and different disabilities that may arise as a result of burn.

Outline the approach to management and treatment options.

Discuss and compare related clinical trials on various medication used to treat pediatric burns.

2

Definition

A burn is an injury caused by fire, heat, radiation, electricity, or flammable agent.

3

Epidemiology 4

It is estimated that 1.2 million people in the United States require medical care for burn injuries each year, with 51,000 requiring hospitalization.

About 30-40% of those patients are less than 15 years old. With the average age of the patient being only 2.5 years of age.

The most common burn injuries result from exposure to heat and chemicals.

It is the second leading cause of death for children under the age of 12.

Risk Factors5

Child negligenceChild abuseImproper Adult supervisionCognitive ImpairmentPsychiatric illness

Pathophysiology of Thermal Burns6

Thermal Burn Injury Pathophysiology is based off of Jackson’s Thermal Wound Theory.

The zone of coagulation is the area near the burn cell membranes rupture, clotted blood and thrombosed vessels.

Zone of Stasis area surrounds the zone of coagulation inflammation, and is characterized by decreased blood flow.

Zone of Hyperemia is the peripheral area of burn characterized by increased blood flow.

7

Pathophysiology of Thermal Burns

Pathophysiology of Electrical Burns8

There are 3 proposed mechanisms of electrical burns: Electrical energy causing direct tissue damage,

altering cell membrane resting potential. Conversion of electrical energy into thermal

energy, causing massive tissue destruction and coagulation necrosis.

Mechanical injury with direct trauma resulting from falls or violent muscle contraction.

Pathophysiology of Chemical Burns9

There are 6 proposed mechanisms by which chemicals cause burn-like injuries: Oxidation: The protein denaturation is caused by

inserting an oxygen, sulphur, or halogen atom to viable body proteins.

Reduction: Reducing agents act by binding free electrons in tissue proteins. Heat may also be a product of a chemical reaction, thereby causing a mixed picture

Corrosion: It causes protein denaturation on contact. They tend to produce a soft, which may progress to shallow ulceration

10

Pathophysiology of Chemical Burns

Mechanisms Continued: Protoplasmic poisons: They produce their effects by

causing the formation of esters with proteins or by binding or inhibiting calcium or other organic ions necessary for tissue viability and function.

Vesicants: They produce ischemia with anoxic necrosis at the site of contact. These agents are characterized to produce cutaneous blisters.

Desiccants: These substances cause damage by dehydration of tissues. The damage is often exacerbated by heat production, as these reactions are usually exothermic.

Etiology11

Chemical Burns

Radiation Burns

Electrical Burns

Thermal Burns

12

Skin Layer Overview

Types of Burns

First-degree (superficial burn)burns affect only the outer layer, also known as the epidermis.

Second-degree (partial thickness) burns affect both the epidermis and a variable portion of the dermal layer. Superficial partial Mid partial

13

Types of Burns

Third-degree (full thickness) burns affect the entire epidermis, dermis and subcutaneous layers. Deep partial Full thickness

Fourth-degree (full thickness) burns affect the epidermis, dermis, muscle, tendon, and bone.

14

15Types of Burns

Clinical Manifestations16

First Degree Dry No blisters Edema Erythema

Clinical Manifestations

Second Degree Moist Blisters Underlying tissue is marked with pink and

white spots Fair capillary refill Bleeds

17

Clinical Manifestations18

Superficial Partial Mid Partial

Clinical Manifestations

Third Degree No bleeding Dry Presents with white, brown and black markings Waxy

19

Clinical Manifestations20

Deep Partial Thickness

Full Thickness

Clinical Manifestations

Fourth Degree Muscles and bone is visible Blackened and charred appearance

21

Clinical Manifestations22

23

Differential Diagnosis

Steven’s Johnson’s Syndrome Anticonvulsants

Carbemazepine (Tegretol®) Valproate (Depakote®) Zonisamide (Zonegran®)

Sulfonamides Bactrim®

Antibiotics Penicillins

Toxic Epidermal Necrolysis

Burn severity is dictated by Percent total body surface area (TBSA) involvement Rule of Nines

Rule of Palm

Diagnosis

Rule of NinesAnatomic Surface % of total body surface

Head and neck 9%Anterior trunk 18%Posterior trunk 18%

Arms, including hands 9% eachLegs, including feet 18% each

Genitalia 1%

24

Rule of Nines25

26Lund-Browder Diagrams

Treatment

27

Dispelling Myths About Burn Treatment

28

ToothpasteIceButterEgg WhitesBursting Blisters

Goals of Therapy29

Prevention of infection Acute care and resuscitation Wound management Pain reliefReconstructionRehabilitation and Psychosocial adjustment

First Aid Treatment30

Extinguish the FireBring child to more ventilated areaCarefully remove smoldering clothing and jewelry

Thoroughly irrigate area with cool water to remove an access particles or debris

Cover area with a clean dry sheeting and apply cold wet compress to small injuries

Administer OTC analgesic Acetaminophen (Tylenol®)

10-15 mg/kg every 4-6 hours Ibuprofen (Advil®)

5-10 mg/kg every 6-8 hours

31

Nonpharmacological

Aloe Vera

Cool compresses

Aspects of Treatment32

Topical AgentsPain ManagementAntihistaminesFluid Resuscitation Nutritional SupportWound ClosuresRespiratory Therapy

Treatment of

Superficial 1st Degree & Superficial Dermal 2nd Degree Burns

33

Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns

34

First and second degree burns on <10% of the body may be treated with outpatient therapy

There is an increase risk of tetanus following a burn injury Be sure to administer vaccine if patient has not been

already vaccinated.

Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns

35

Blisters should be left in tact and not be popped and treated with topical agents Bacitracin (AK-Tracin®) ($8.00) -Prescription Silver Sulfadiazine Cream (Silvadene®) ($20.00)-

PrescriptionDressings should be changed daily

Wound should we washed with lukewarm water.Small 1st degree and mild 2nd degree burn on

face can be treated with Bacitracin and left open Vaseline($4.00)- OTC

Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns

36

Silver Sulfadiazine

Proper Dressing Application37

Wash handsCarefully remove old dressing and throw

awayClean burn area mild soap (ie. Hibiclens) and

lukewarm or cool waterRinse area thoroughly Pat dry with clean towel or gauzeCheck for healing Apply prescribed ointment or fresh dressingWrap sterile gauze over dressing to secure

Dressings for Ruptured Blisters38

Ruptured blisters are treated with wound dressing/wound membrane AQUACEL- Ag Biobrane Mepilex Ag Acticoat Hydrocolloid dressings Impregnated gauze

Dressing are kept on for 7-10 days and check periodically through the week

All dressings that are on the formulary are found in the burn unit supply closet.

Dressings 39

Dressings 40

Dressings 41

Dressings 42

Hydrocolloid Dressing DuoDERM Tegaderm Comfeel Nu-Derm

Impregnated Gauze Xeroform impregnated gauze Chlorhexidine impregnated gauze (Bactigras) Petrolatem/Vaseline impregnated gauze

Dressings 43

Hydrocolloid Dressings

Dressings 44

Impregnated gauze

Topical Agents 45

Topical agents for more severe burns AQUACEL Ag Available by Prescription

Sulfacetamide Acetate* Silver Sulfadiazine Mafenide Acetate - 0.5% Silver Nitrate Solution Accuzyme Ointment *

Treatment of Deep Thermal 2nd Degree Burns

&3rd Degree Burns

46

Criteria for Hospital Admission47

Burns affecting >15% of body surface areaElectrical burns caused by high-tension wires

Inhalation injury, regardless of the amount of body surface area burned

Inadequate home situationSuspected child abuse or neglectBurns to the hands, feet, or genitals

Fluid Resuscitation48

Lactated Ringer Solution Dose

Parkerland Formula: 4 mL lactated Ringer/kg/% BSA burned Half of fluid given 1st 8hrs; Next half administered over

16hrs IV Infusion Rate Varies

Monitoring Parameters Urine Output Glucose

Clinical Pearls Initial fluid should be warmed Infants are at risk for hypoglycemia

49

Fluid Resuscitation

Albumin (Albuked 25 ®, Flexbumin 25%®, Human Albumin Grifols 25%®, Kedbumin®, Plasbumin2-25®, Plasbumin-5®) Use 5% albumin solution

30–50% of total BSA, 0.3 mL /kg/% BSA 50–70% of total BSA, 0.4 mL/kg/% BSA 70–100% of total BSA, 0.5 mL/kg/% BSA burn

Monitoring Parameter: Albumin≥2g/dl Clinical Pearls

Concurrent use for burn >85% of BSA Administered 8-24hr after injury

50

Qualifications for Albumin Treatment

It is not usually screened for infections. Albumin is synthesized exclusively in the liver. The normal rate of albumin synthesis is 0.2g/kg body weight per day.

Controversy exists as to whether colloid should be provided in the early period of burn resuscitation. One preference is to use colloid replacement concurrently if the burn is >85% of total BSA. Colloid treatment is usually instituted 8–24 hr after the burn injury.

For burns of 30–50% of total BSA, 0.3 mL of 5% albumin/kg/% BSA burn is infused over a 24-hr period

For burns of 50–70% of total BSA, 0.4 mL/kg/% BSA burn is infused over 24 hr

For burns of 70–100% of total BSA, 0.5 mL/kg/% BSA burn is infused over 24 hr

Fluid Resuscitation51

Packed Red Blood Cells Hematocrit falls to <24%

(hemoglobin = 8 g/dL) Fresh frozen plasma:

Prothrombin level of >1.5 times control

Monitoring Parameters: Hematocrit & PT

Clinical Pearls Use in patients with

repeated excision and grafting w/<30% hemoglobin

Prescription

NaCL Burns >20% of BSA Dosed:4 g/m2 burn area/24

hr divided into 4–6 equal doses

Monitoring Parameters: Serum [Na+] >130

mEq/L Urinary [Na+] >30 mEq/L Serum [K+] >3 mEq/dL

Clinical Pearls Silver nitrate increases

Na+ and K+ loss Prescription

Nutritional Support52

Calories are provided at approximately 1½ times the basal metabolic rate

Macronutrients Protein: 3–4 g/kg of

protein/day Carbohydyrates:

5-7mg/kg/hr Fats: 1-1.5g/kg/day

Micronutrients Copper: 2.5mg/day Vitamin C: 200mg/day Vitamin A:10,000IU /day Zinc Sulfate: 25mg/day Selenium:50-70mg/day

Anabolic Agents Growth hormone Oxandrolone Low-dose insulin

Catabolic Agents Propanolol

Respiratory Therapy53

Beta Agonist Aerosols Albuterol Nebulizer (AccuNeb®)-

Patients >2 years of age 1.25mg or 0.63mg by inhalation over 5-15 minutes 3-4 times daily times a day

PrescriptionInhaled Corticosteroids

Fluticasone (Flovent®) Patients 4-11 years of age 88mcg Prescription only

Administer 100% Oxygen

Fluid Maintenance & Infection Prevention

54

Diuretic Furosemide (Lasix®)

Dosed: 0.5-2mg/kg/IM/IV q8-24h Max 6mg/kg/dose

Antibiotic Empiric Treatment

Sulfamethoxazole/Trimethoprim (Bactrim DS®): 10-12mg/kg/day PO or IV q12h + Rifampin (Rifadin®): 20mg/kg PO or IV q24h for 4 days

Vancomycin (Vancoled®) : 40–60 mg/kg/day q6–8h for 7-10 days

55

Common Organisms in Burn Patients

Gram positive Staphylococcus aureus = Penicillin G, Erythromicin, Azithromycin Methicillin resistant S. aureus = Bactrim, Erythromycin Enterococcus spp. = Augmentin, clindamycin+ciprofloxacin

Gram Negative Pseudomonas aeruginosa = gentamicin, ciprofloxacin, cefepime Escherichia coli = Gentamicin, ciprofloxacin Klebsiella pneumonia = Parental cefepime, ciprofloxacin Serratia marcescens = Parental cefepime, aztreonam, gentamicin

Fungi Candida spp. = Amphotericin B, Fluconazole Aspergillus spp. = Amphotericin B, Intraconazole

VirusesHerpes simplex virus = Acyclovir, Famciclovir,

56

Treatment of Infections

Methicillin Resistant S. Aureus Sulfamethoxazole/Trimethoprim (Bactrim®)

8mg/kg/day (for children older than 2 months) Prescription

Doxycycline (Doryx®) 4mg/kg/day (for children older than 8 years) Prescription

Vancomycin (Vancocin®) 10-15mg/kg every 6 hours Prescription

Linezolid (Zyvox®) 10mg/kg every 8-12 hours Prescripton

Pain & Anxiety Management57

Morphine Sulfate (NSIR®, MSContin®) Dosed 0.3–0.6 mg/kg every 4–6 hr PO initially and until wound

cover is accomplished Dosed 0.3–0.6 mg/kg is given 1–2 hr before the procedure +

IV bolus 0.05–0.1 mg/kg given immediately before the procedure Prescription

Lorazepam (Ativan®) Dosed of 0.04 mg/kg PO or IV for before the procedure Prescription

Midazolam (Versed®) Dosed 0.05–0.1 mg/kg/hr IV infusion or IV bolus;

May be repeated in 10 min, Max dose of 0.2 mg/kg Prescription

58

Potential Drug Interactions with Treatment

Beta Agonists In combination with Beta Blockers may lead to a

decreased efficacy of either drugs due to antagonismCorticosteroids

In combination with Azole Antifungals may increase corticosteroid plasma concentrations

Furosemide In combination with Aminoglycosides may increase

aminoglycoside concentration resulting in an increased risk of ototoxicity and nephrotoxicity

59

Potential Drug Interactions with Treatment

Bactrim In combination with Warfarin, there is an increased the risk of

bleeding and bruising In combination with Antipsychotics or Tricyclic Antidepressant,

Bactrim increases the risk of QT prolongation and torsade de pointesRifampin

In combination with Birth control pills, there is an decreased efficacy of birth control pills

In combination with Morphine, there is a decreased efficacy of morphine

In combination with corticosteroids, there is a decreased efficacy of corticosteroids

Vancomycin In combination with Aminoglycosides, there is an increased additive

risk of ototoxicity and nephrotoxicity.

Wound Closures60

GraftsSkin grafts:

Pinch: Quarter inch pieces of skin Split-thickness: Superficial and some deep

layers of skin Full-thickness: For weight-bearing portions of

the body and friction prone areas such as, feet and joints

Pedicle grafts: Skin used from the donor site will remain attached to the donor area and the remainder is attached to the recipient site

61

Wound Closures

GraftsExcisions

TagenitalPros: Improved function and cosmetic outcomeCons: Increased bleeding, takes longer, more

skin Fascial

Pros:Rapid, Use with skin subsitutesCons: Risk of nerve injury and joint exposure,

decreased cosmetic outcome

TANGENTIAL EXCISON62

FASCIAL EXCISION63

Skin Graft Video64

http://www.youtube.com/watch?v=bn9uMVxk8wI

Clinical Trials

65

Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients

Objective To study the efficacy of growth hormone given to

severely burned children from discharge to 12 months after burn and for 12 months after the drug was discontinued.

Design Single-site, double-blinded, randomized, placebo

controlled studyMethods

Forty-four pediatric patients with over 40% total body surface area burns were studied for 24 months after burn. Patients were randomized to receive either rhGH (0.05 mg/kg body weight) or placebo.

66

Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802

Results Recombinant human growth hormone

administration increased serum GH and decreased cortisol concentrations when compared with placebo (P < 0.05).

Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients

67

Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802

Intensive Insulin Therapy in Severely Burned Pediatric Patients

Objective To determine whether intensive insulin therapy is

associated with improved post-burn morbidityDesign

Single-site, prospective randomized trialMethods

A total of 239 severely burned pediatric patients with burns over greater than 30% of their total body surface area were randomized to intensive insulin treatment (n = 60) or control (n = 179)

68

Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359

Intensive Insulin Therapy in Severely Burned Pediatric Patients

Results Intensive insulin treatment had a significant

improvement in bone mineral density, body fat, lean body mass, and body mass  (P < 0.05)

69

Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359

Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children

70

Objective To determine the long term effects of Oxandrolone in pediatric

burned patients

Study Design Single-center, prospective, randomized, controlled trial

Methods Patients 0 to 18 years old with burns covering >30% of the total

body surface area were randomized to receive placebo or oxandrolone (0.1 mg/kg PO twice daily for 12 months)

At hospital discharge, patients were randomized to a 12-week exercise program or to standard of care

Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502

Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children

71

Results Increased protein synthesis, bone density mass,

decreased resting energy expenditure, and improved height (p < 0.001).

Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502

Prevention Strategies72

Improve awareness among parents/caregivers

Develop and enforce effective policy for dealing with burns

Be informed about the burden that comes along with caring for a child with a burn

Participate in burn prevention programsInstall home smoke detectors and sprinkler

systems.Take bath water temperature before bathDon’t leave candles and potential meals

unattended.

73

Role of the Pharmacist

Identify the severity of a burnRecommend appropriate therapyRecognizing when to refer the patient to the

physicianEducate patients on proper applications of

creams and dressingsMonitor for signs of infection

References74

1. American Burn Association. Burn Center Referral Criteria. Availableat:www.ameriburn.org/BurnCenterReferralCriteria.pdf?PHPSESSID=09036810feb72a69a1acdee9209e235b. Accessed on March 10, 2013

2. A.D.A.M. Medical Encyclopedia. Burns. Available at:www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001097/. Accessed on March 10, 2013

3. University of Maryland Medical Center. Burns- Overview. Available at:www.umm.edu/ency/article/000030.htm. Accessed on March 10, 2013

4. Sheridan R., Schnitzer J., Management of the High-Risk Pediatric Burn Patient. Journal of Pediatric Surgery. August 2001 ;vol 36(8):1308-1312

5. Jorge A., Buck M., Hubbard A., et al. Pediatric Nutrition Support Handbook. University of Virginia Children's Hospital. 2012: 1-103

6. Connolly S. , Clinical Practice Guidelines: Burn Patient Management . NSW Agency for Clinical Innovation. August 2011; Version 1.5:1-45

7. Women’s and Children’s Hospital. Guidelines for the Management of Pediatric Burns . May 2010; 1-438. Sheridan, RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005: S112-S1199. Gandhi M., Thomson C., Lord D. , et al. Management of Pain in Children with Burns. International Journal of Pediatrics . 2010;

vol(2010):1-910. Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of

Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-35911. Borrillo C. Nelson Textbook of Pediatrics. 18thed. Philadelphia: Saunders Elsevier; c 2007. Chapter 74 Burn Injuries12. Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children:

Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-50213. Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in

Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-80214. Igneri P., Gratton J. FAHC Burn Care Manual. Fletcher Allen Health Care: The University of Vermont College of Medicine. 2008;

1-6915. Mock C, Peck M, Peden M, Krug E, eds. A WHO plan for burn prevention and care. Geneva, World Health Organization, 2008.16. Boldt,J. British Journal of Anaesthesia.Use of albumin: an update (2010) 104 (3): 276-284.