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Pediatric Considerations
Consider child abuse or neglect when dealing with hot water burns in children; abuse accounts for 15% of pediatric burns. Special concerns are sharply demarcated wounds, immersion injuries, and suspect stories. Involve child welfare services early.
EPIDEMIOLOGY
- Predominant age: 30 years; 13% infants; 11% >60 years of age
- Predominant gender: males account for 70%
Incidence
Per year in the United States
- 1.2 to 2 million burns; 700,000 emergency room visits; 45,000 to 50,000 hospitalizations; 3,900 deaths owing to burn-related complications
- In children: 250,000 burns; 15,000 hospitalizations; 1,100 deaths
- Estimated total cost of $2 billion annually for burn care
- House fires cause 75% of deaths.
- Burn deaths decreasing nationally due to improved prevention and treatment
- Increase in burns from the illegal production of methamphetamines. Patients can present with a combination of chemical burn, thermal burn, and explosion injury.
ETIOLOGY AND PATHOPHYSIOLOGY
- Open flame and hot liquid are the most common causes of burns (heat usually ≥45 °C): flame burns more common in adults; scald burns are more common in children.
- Caustic chemicals or acids (may show little signs or symptoms for the first few days)
- Electricity (may have significant injury with very little damage to overlying skin)
- Excess sun exposure
RISK FACTORS
- Water heaters set too high
- Workplace exposure to chemicals, electricity, or irradiation
- Young children and older adults with thin skin are more susceptible to injury.
- Carelessness with burning cigarettes: related to 18% of fatal fires in 2006
- Inadequate or faulty electrical wiring
- Lack of smoke detectors: Lacking or nonfunctioning smoke alarms are implicated in 63% of residential fires.
- Arson: cause of 12.4% of fires that resulted in fatalities in 2012
GENERAL PREVENTION
Home safety education should be a key mechanism for injury prevention.
- Families educated on home safety were more likely to have safe hot water temperatures.
- Safety education results in more families having functioning smoke alarms and increased use of fireguards.
COMMONLY ASSOCIATED CONDITIONS
Smoke inhalation syndrome
- May involve thermal burn to respiratory mucosa (e.g., trachea, bronchi) as well as carbon monoxide inhalation
- Occurs within 72 hours of burn
- Should be suspected in all burns occurring in an enclosed space or exposure to explosions
DIAGNOSIS
HISTORY
- History of source of burn
- In children or elderly: Check for consistency between the history and the burn's physical characteristics.
PHYSICAL EXAM
- 1st degree: Erythema of involved tissue, skin blanches with pressure, skin may be tender.
- 2nd degree: Skin is red and blistered, skin is very tender.
- 3rd degree: Burned skin is tough and leathery; skin is nontender.
- Rule of 9s (1)[C]
- Each upper extremity: adult and child 9%
- Each lower extremity: adult 18%; child 14%
- Anterior trunk: adult and child 18%
- Posterior trunk: adult and child 18%
- Head and neck: adult 10%; child 18%
- Quick estimate: The surface area of the patient's hand (palmar surface plus fingers) is 1% of the body surface area (BSA).
- Careful documentation of extent of burn and the estimated depth of burn
- Check for any signs suggestive of potential airway involvement: singed nasal hair, facial burns, carbonaceous sputum, progressive hoarseness, inflamed oropharynx, circumferential burns around the neck, tachypnea
DIAGNOSTIC TESTS & INTERPRETATION
- Children: glucose (hypoglycemia may occur in children because of limited glycogen storage)
- Smoke inhalation: arterial blood gas, carboxyhemoglobin
- Electrical burns: ECG, urine myoglobin, creatine kinase isoenzymes
Initial Tests (lab, imaging)
- Labs: hematocrit; type and crossmatching; electrolytes, including BUN and creatinine; urinalysis
- Imaging: Chest radiograph; Xenon scan is useful in suspected smoke inhalation.
Diagnostic Procedures/Other
Bronchoscopy may be necessary in smoke inhalation to evaluate lower respiratory tract (2)[A].
TREATMENT
- Prehospital care (1)[C]
- Remove the patient from the source of burn.
- Extinguish and remove all burning clothing.
- Room-temperature water may be poured onto burn but only in the first 15 minutes following burn exposure.
- Wrap patient to prevent hypothermia.
- All patients to receive 100% oxygen via face mask
- Hospitalization for all serious burns
- 2nd-degree burns >10% of BSA
- Any 3rd-degree burn
- Burns of hands, feet, face, or perineum
- Electrical or lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
- Transfer to burn center for (3)[C]
- 2nd- and 3rd-degree burns >10% of BSA in patients <10 years and >50 years of age
- 2nd-degree burns >20% of BSA and full-thickness burns >5% BSA in any age range
- 3rd-degree burns in any age group
- Burns of hands, feet, face, or perineum
- Electrical or lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
- Burns in patients with additional trauma (fractures, etc.) in which the burn is the more severe injury; otherwise, send to trauma center for stabilization.
- Burn injuries in patients with preexisting medical conditions that could affect management, mortality, or recovery
GENERAL MEASURES
- Based on depth of burns and accurate estimate of total BSA involved (rule of 9s)
- Tetanus prophylaxis (if not current)
- Remove all rings, watches, and other items from injured extremities to avoid tourniquet effect.
- Remove clothing and cover all burned areas with dry sheets.
- Flush area of chemical burn (for ~2 hours).
- For all major burns, use 100% oxygen administration; consider early intubation.
- Do not apply ice to burn site.
- Nasogastric tube (high risk of paralytic ileus)
- Foley catheter
- Analgesia
- ECG monitoring in first 24 hours following electrical burn
- Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
- Daily or BID cleansing with dressing changes
- Burn fluid resuscitation (1)[C]
- Calculate fluid resuscitation from time of burn, not from time treatment begins.
- 2 to 4 mL lactated Ringer — body weight (kg) — % BSA burn (1/2 given in first 8 hours, in second 8 hours, and in third 8 hours); in children, this is given in addition to maintenance fluids and is adjusted according to urine output and vital signs. Protocol-based resuscitation leads to superior outcomes.
- Colloid solutions are not recommended during the first 12 to 24 hours of resuscitation (1)[C],(4)[A].
- Other: Use of biologic membranes or skin substitutes may be indicated for burn coverage.
- Inhalation injury
- Intubation, ventilation with positive end-expiratory pressure assistance
- Hyperbaric oxygen treatment may be useful in patients with carbon monoxide levels >25%, patients with coma, focal neurologic deficit, ischemic ECG changes, and pregnant patients (1)[C].
MEDICATION
First Line
- IV morphine or hydromorphone (Dilaudid) for severe pain
- Oral analgesics, such as acetaminophen (Tylenol) with codeine, acetaminophen with oxycodone (Percocet), or acetaminophen with hydrocodone (Lortab) for moderate pain
- Silver sulfadiazine (Silvadene): Apply topically to burn site (can cause leukopenia). Do not use in sulfa-allergic patients, women who are pregnant/breastfeeding, or infants < 2 months)
- Neosporin or bacitracin ointment: Apply to facial burns.
- Mupirocin: has potent inhibitory activity against methicillin-resistant Staphylococcus aureus (MRSA) (5)[B]
- Acticoat A.B. (a dressing consisting of 2 sheets of high-density polyethylene mesh coated with nanocrystalline silver) has a more controlled, prolonged release of silver, allowing less frequent dressing changes (5)[B].
- Electrical burn with myoglobinuria will require alkalinization of urine and mannitol.
- Consider H2 blockers (e.g., famotidine) or proton pump inhibitors (e.g., lansoprazole, pantoprazole) for stress ulcer prophylaxis in severely burned patients.
- Tetanus toxoid/tetanus immunoglobulin
- There is no clear indication for prophylactic systemic antibiotics (5)[B].
- Use of negative pressure wound therapy may result in a low-protease environment with higher levels of angiogenic factor (vascular endothelial growth factor [VEGF]) during wound healing, leading to more chaotic, hyperkeratinized, thickened epidermis when compared with a standard hydrocolloid dressing (6)[C].
Second Line
- Mafenide (Sulfamylon) for full-thickness burn, best against Pseudomonas (Caution: metabolic acidosis, painful)
- Silver nitrate 0.5% (messy, leeches electrolytes from burn, causes water toxicity)
- Povidone-iodine (Betadine) may result in iodine absorption from burn and "tan eschar,"ť makes d ©bridement more difficult.
- Travase (enzymatic debridement)
SURGERY/OTHER PROCEDURES
- Escharotomy may be necessary in constricting circumferential burns of extremities or chest due to compartment syndrome.
- Tangential excision with split-thickness skin grafts: Early excision of burns results in a significant reduction in mortality (excluding patients with inhalational injury) and a significant decrease in hospital length of stay (7)[B].
- Various dressings (e.g., biosynthetic, biologic) are available to help reduce the number of dressing changes and promote healing.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Early mobilization is the goal.
DIET
- High-protein, high-calorie diet when bowel function resumes
- Nasogastric tube feedings may be required in early postburn period.
- Total parenteral nutrition if NPO is expected for >5 days
- Early initiation of enteral nutrition in the first 24 hours of admission results in shorter intensive care unit (ICU) stay and lower wound infection rates
PATIENT EDUCATION
- Use of sunscreen: Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes.
- Prevent access to electrical cords/outlets.
- Isolate household chemicals.
- Use low-temperature setting for water heater (<54 °C).
- Household smoke detectors with special emphasis on maintenance
- Family/household evacuation plan
- Proper storage and use of flammable substances
- Burn management: http://www.aafp.org/afp/2000/1101/p2029.html
- Burn prevention: http://www.aafp.org/afp/2000/1101/p2032.html
PROGNOSIS
- 1st-degree burn: complete resolution
- 2nd-degree burn: epithelialization in 10 to 14 days (deep 2nd-degree burns probably will require skin graft)
- 3rd-degree burn: no potential for reepithelialization; skin graft is required.
- Baux score (sum of age and TBSA burned) and Denver 2 score (pulmonary score ranging 0 to 3, using PaO2/FiO2 cutoffs of 100, 175, and 250), renal score (0 to 3, using creatinine cutoffs of 1.8, 2.5, and 5.0 mg/dL), hepatic score (0 to 3, using bilirubin cutoffs of 2, 4, and 8 mg/dL), and cardiac score (0 to 3, based on number and dosage of inotropes) can be used to estimate mortality (8)[B].
- Length of hospital stay and need for ICU care depend on extent of burn, smoke inhalation, comorbidities, and age.
- Burn size is correlated to complications; >60% TBSA burned in children and >40% in adults are at increased risk for mortality and morbidity (8)[B].
- A 50% survival rate can be expected with a 62% burn in patients aged 0 to 14 years, 63% burn in patients aged 15 to 40 years, 38% burn in patients aged 40 to 65 years, and 25% burn in patients >65 years of age (1)[C].
- 90% of survivors can be expected to return to an occupation comparable to their preburn employment.
COMPLICATIONS
- Gastroduodenal ulceration (Curling ulcer)
- Marjolin ulcer: malignant squamous cell carcinoma developing in old burn site
- Signs of infection: discoloration, green fat, edema, eschar separation, and conversion of 2nd-degree to 3rd-degree wound
- Biopsy is the best way to diagnose wound infection.
- Burn wound sepsis: most commonly S. aureus (including MRSA), vancomycin-resistant enterococci, and gram-negative organisms (5)[B].
- Pneumonia
- Decreased mobility with possibility of future flexion contractures
- Hypertrophic scarring common with burns.
REFERENCES
11 Teague H, Swencki SA, Tang A. The burned patient: assessment, diagnosis, and management in the ED. Trauma Reports. 2005;6(2):1-12.22 Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med. 2013;21:31.33 Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349e-358e.44 Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.55 Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev. 2006;19(2):403-434.-66 Caulfield RH, Tyler MP, Austyn JM, et al. The relationship between protease/anti-protease profile, angiogenesis and re-epithelialisation in acute burn wounds. Burns. 2008;34(4):474-486.77 Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(2):145-150.88 Jeschke MG, Pinto R, Kraft R, et al. Morbidity and survival probability in burn patients in modern burn care. Crit Care Med. 2015;43(4):808-815.
CODES
ICD10
- T30.0 Burn of unspecified body region, unspecified degree
- T30.4 Corrosion of unspecified body region, unspecified degree
ICD9
- 949.0 Burn of unspecified site, unspecified degree
- 949.1 Erythema [first degree], unspecified site
- 949.2 Blisters, epidermal loss [second degree], unspecified site
- 949.3 Full-thickness skin loss [third degree nos]
- 949.5 Deep necrosis of underlying tissues [deep third degree] with loss of a body part, unspecified
- 949.4 Deep necrosis of underlying tissue [deep third degree] without mention of loss of a body part, unspecified
SNOMED
- 125666000 Burn (disorder)
- 403190006 First degree burn (disorder)
- 403191005 Second degree burn (disorder)
- 403192003 Third degree burn (disorder)
- 284196006 burn of skin (disorder)
CLINICAL PEARLS
- 1st degree: erythema of involved tissue; skin blanches with pressure. Skin may be tender.
- 2nd degree: Skin is red and blistered. Skin is very tender.
- 3rd degree: Burned skin is tough and leathery. Skin is not tender.