burns in the pediatric population
TRANSCRIPT
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Burns In The Pediatric Population
Dr. E. M. Regis Jr. MD.House Officer
Dept. of General Surgery
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Overview
• Definition• Incidence/ Etiology• Risk/ Contributing Factors• Child Abuse• Pathophysiology • Classification• Criteria for admission • Management • Complications
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Definition
• A burn is a type of injury to the flesh or skin caused by heat, electricity, chemical, friction or radiation
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Incidence
• One of the leading causes of accidental injuries at home.
• 5th most common cause of accidental death in children
• Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids.
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Etiology
• Flame 57%• Scalding 32%• Chemical 7%• Electricity & Radiation 4%
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Contributing Factors• Socio-economics
- children from low income homes have 8x a risk of sustaining burns than those from higher income homes
- severity of burns inversely proportional to decreasing SES
- burn mortality is higher among children from lower SES
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• Living Conditions- children are naturally curious, impulsive and
active,…increases risk of burns
- flammable and caustic substances stored in the home
- heating with indoor fires
- cooking practices; NB. 2 billion people worldwide cook with open flames or unsafe traditional
stoves
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- lack of adult supervision
- overcrowding
•Medical conditions-Epilepsy* Increase risk of fall* Traditional medicine practices; eg. The deliberate burning of feet to “rouse the child from convulsive state”.
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Child Abuse
• Burns account for 10% of all cases of child abuse
• Majority of victims are < 2 years of age
• Scalding is the most common cause
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Suspicion of child abuse
Burns to:– Perineum – Ankles – Wrists – Palms – Soles
•Burns with clean line of demarcation
•Presence of older injuries
•Contradictory accounts of “accident”
•Delays in seeking treatment
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PathophysiologyAccording to Jackson’s Thermal wound theory, there
are three zones associated with burn injuries:
Zone of Coagulation - area closest to the wound - ruptured cell membranes, clotted blood &
thrombosed vessels
Zone of Stasis - area around zone of coagulation - inflammation & decreased blood flow
Zone of Hyperemia - peripheral area of the wound - limited inflammation & increased blood flow
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Classification
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Criteria for admission• Greater than 10% burns in a child
• Any burn in the very young or the infirm
• Any full thickness burn
• Burns of special regions: face, hands, feet, perineum
• Circumferential burns
• Inhalation injury
• Associated trauma or significant pre-burn illness: e.g. diabetes
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TBSA
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Management
• ABC
Intubate and mechanically ventilate if you suspect inhalation injury
Quickly establish IV access (ideally 2 large bore IVs)
Evaluate for compartment syndrome, particularly with circumferential burns
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Assessing inhalation injury
• Look for: – – Singed facial hairs – – Edema of nose, mouth, pharynx and larynx– – Carbonaceous sputum – – Hoarseness – – Stridor
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Fluid Resuscitation– – Restoring adequate intravascular volume to
prevent hypotension and shock – – Correcting electrolyte abnormalities – – Minimize renal insufficiency
• If burns >15% – – Massive fluid shifts will likely occur due to
systemic inflammatory response syndrome (SIRS) – – Fluid needs will be greater than anticipated
based on appearance of burn alone
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• Parkland formula:– 3-4 ml x kg x % total burn surface area (TBSA)
1⁄2 in first 8 hours Remaining in next 16 hours
• Galveston Shriner’s formula – 5000 mL/m2 TBSA burn + 2000 mL/m2 body
surface area (BSA)
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• Fluid: Lactate Ringer – plus 12.5 g 25% albumin per L – plus D5W as needed for hypoglycemia
Remember to monitor glucose levels • Glycogen stores of children <5 y/o run out
quickly
• Inhalation injury increases fluid requirements by 1.1 ml/kg/% TBSA
• Goal of fluid resuscitation = Adequate urine output (1-1.5ml/kg/hr)
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Muir & Barclay Formula • TBSA % x weight (kg) = volume (mls) fluid need per period.
•The volume needs to be recalculated at each change in time period:• Every four hours for the first 12 hours;• Every six hours between 12 and 24 hours;• After 36 hours.
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DressingsTopical antibiotic: – Silver nitrate • Cheap• Does not penetrate eschar • Depletes electrolytes
– Silver sulfadiazine• Some penetration of eschar • Risk of neutropenia
– Mafenide acetate• Penetrates eschar• Risk of developing acidosis
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Nutrition• Burns lead to increased metabolic demands and
energy requirements – For burns >40%, resting metabolic rate increases
up to 200% – Primarily protein catabolism
* Protein requirement increased to 2.0 g/kg/day • Without adequate nutrition wound healing will
not occur
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• Goal: Loss of less than 10% of preinjury weight – Patients should be weighed daily
• Enteral feeds are superior to parenteral– Feed child orally if possible– Otherwise place nasogastric feeding tube
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Management cont’d.
• PPIs…. Prophylaxis against stress ulcers
• Adequate analgesics
• Prophylaxis antibiotics
• Physiotherapy/ pressure garments
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Complications• Disfigurement
• Contractures – Lead to severe disability in many cases
• Emotional damage/sequelae
• Delay in reaching developmental milestones and educational development
• Death
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Summary• Burns account for a significant proportion of pediatric
morbidity and mortality worldwide, particularly in LSES. • Majority of burns are due to fire or scalding, often related
to cooking practices.
• Initial evaluation should always include an assessment for child abuse.
• Ultimately, the key to decreasing morbidity and mortality associated with burns is prevention via...
– Educational campaigns– Legislative changes– Hazard reduction and environmental modification
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References Stone, Keith and Humphries, Roger; Current Diagnosis
and Treatment: Emergency Medicine. McGraw- Hill New York 2008
Stead, Latha G. etal ; First Aid for the Emergency medicine Clerkship; McGraw Hill 2002
www.emedicine.com
www.google.com/images
Global Health Education Consortium