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BURNS IN PEDIATRICS Ella Dayan RN BA Shaare Zedec Medical Center Jerusalem, Israel May 2018 eladayan@013.net
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STATISTIC FACTS (ISRAEL) The Israeli Ministery of Health : 3002 total registered visits of children who suffered from burns, to ERs and different kinds of primary clinics (2015) (should be considered a large number of unreported cases). Statistics from the ERs of 10 average hospitals in Israel from 2010- 2016 show that more than 50% of the pediatric burns in patients were caused by hot liquids of different sorts.
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STATISTICS FACTS (ISRAEL) 2 80% of pediatric burn hospitalizations were caused by hot liquids. 2008 - 2016 – 47 children died in a fire. 64% of them were of Arab origin. (This is 2.4 times more tphoapnutlahteiosnhaorfeIsorfatehl)e Arab population in the general Burn victims make up 5.5% of all deaths due to traumatic injury
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GENERAL WORLDWIDE STATISTIC FACTS Children aged 0 – 4 are at the highest risk of suffering pediatric burn injuries. A significant increase of visits to ERs and primary clinics due to burns has been observed on weekends. Most burn injuries occur in the home and in the yard, and half occur in the kitchen. Most burns occur in the presence of parents, golrdaenrdbpraorethnetsrsaannddostihsteerrcsa).regivers, (like babysitters,
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GENERAL WORLDWIDE STATISTIC FACTS 2 Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids. Flame 57% • Hot fluids and 32% • Chemical 7% • Electricity & Radiation 4%
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GENERAL WORLDWIDE STATISTIC FACTS 3 Crehcieldivrienngfsroevmerleowbuinrncsomtheanhothmoesse hfraovme 8hitgimheers itnhceomrisek hoof mes . Severity of burns is inversely proportional to decreasing Socioeconomic Status; burn mortality is higher among children from lower SES
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GENERAL WORLDWIDE STATISTIC FACTS 3 Majority of burn victims are under 2 years of age Scalding by hot fluids and extreme heat sources is the most common cause The location of burns that raise suspicion of child abuse are: Perineum, Ankles, Wrists, Palms, Soles. Other suspicious factors: Burns with clean line of demarcation presence of previous medical records about injures Contradictory evidence about the “accident” Delays in seeking treatment
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GENERAL WORLDWIDE STATISTIC FACTS 4 In 2015, there were 67 million fire and heat caused injuries. This caused about 2.9 million hospitalizations and 176,000 deaths. Most deaths due to burns occur in the developing world, particularly in Southeast Asia. In the United States, 95% of patients with burn injuries that show up to the ER are immediately treated and discharged; only 5% require hospital admission
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BURNS CLASSIFICATION ABA classification based on a number of factors: Total Body Surface Area of injury Involvement of specific anatomical zones The age of the person Other associated injuries American Burn Association generally classifies the burns as: Major Moderate Minor
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Due to the differences in body proportions between BABIES, CHILDREN, and ADULTS, the Baby Burns percentage distribution is also different. It’s still close to the “nines rule”, but has some variations. Generally: 5% burn in a child is equivalent to the severity of 10% burn in an adult AREA COUNTING FOR BABIES AND YOUNG CHILREN
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THE BURNS PERCENTAGE DISTRIBUTION IN CHILDREN
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THE “LUND-BROWDER CHART”
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PATHOPHYSIOLOGY
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There are also fourth degree burns; fortunately they are very rare Burn injury in the 4th degree includes subcutaneous tissues, muscles, tendons and bones… CLASSIFICATION
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CLASSIFICATION OF BURNS:
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SEVERITY CLASSIFICATION:
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BURNS MANIFESTATION ACCORDING THE 3 DEGREE SCALE 1-st degree (superficial) Layers involved : EPIDERMIS Appearance: REDNESS (no blisters) Texture: DRY Sensation: PAINFUL Healing time: 5-10 DAYS Prognosis: HEALS WELL. NO SCARS. REPEATED SUNBURNS INCREASE THE RISC OF SKIN
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1-st degree (superficial)
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BURN MANIFESTATION ACCORDING THE 3 DEGREE SCALE 2nd degree (superficial partial thickness) Layers involved : EXTENDS TO SUPERFICIAL (PAPALLAR) DERMIS Appearance: REDNESS WITH BLISTERS (CLEAR FLUID). THE RED SURFACE BLANCHES WITH PRESSURE. POSSIBLE PRESENTATION OF SMALL YELLOW/WHITE AREAS Texture: MOIST Sensation: VERY PAINFUL Healing time: 2-3 WEEKS Prognosis: LOCAL INFECTION CELLULITIS. USUALLY NO SCARRING
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2ND DEGREE (SUPERFICIAL PARTIAL THICKNESS)
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2ND DEGREE (SUPERFICIAL/DEEP PARTIAL THICKNESS)
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BURN MANIFESTATION ACCORDING THE 3 DEGREE SCALE 2nd degree (deep partial thickness) Layers involved : EXTENDS TO DEEP (RETICULAR) DERMIS Appearance: YELLOW OR WHITE SURFACES. MAY BE BLISTERING, LESS BLANCHING. Texture: RELATIVELY DRY Sensation: LESS PAINFUL. PERCEPTION OF PRESSURE AND DISCOMFORT Healing time: 3-8 WEEKS Prognosis: SCARING CONTRACTURES MAY REQUIRE SKIN GRAFTING
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2-nd degree (deep partial thickness)
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BURNS MANIFESTATION ACCORDING THE 3 DEGREE SCALE 3-rd degree (full thickness) Layers involved : EXTENDS THROGH ENTIRE DERMIS Appearance: STIFF AND WHITE/BROWN. NO BLANCHING. Texture: TOUGH, HARD TEXTURE Sensation: PAINLESS Healing time: MONTHS Prognosis: SCARING CONTRACTURES. AMPUTATION EARLY EXCISION RECOMENDED
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3-RD DEGREE (FULL THICKNESS)
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BURN MANAGEMENT The treatment of burns is very complex and requires the use of many therapeutic resources to maintain all life- supporting systems of the body. Sometimes performance of an Escharotomy and/or Fasciotomy is needed to prevent Compartment Syndrome. Extensive, life-endangering burns are treated in special intensive care units and Burn- Centers.
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BURNS MANAGEMENT This presentation regards only the topical treatment of burns, with the curative materials and medications used in the department of pediatric surgery. The children who arrive at the Pediatric Surgery Department have generally already undergone treatment in the ER or PICU.
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THE GENERAL PRINCIPLES OF BURN MANAGEMENT IN HOSPITALISATION mGivincide gapainsnoit -reeb duof ciner gpainful tphreocteimdueroesf ,tbhey coonnsseitdoefring tsiemveeroefpmaiedicn, anationd the peak influence. sCoverinmeliret gattheire awoundsevprtosl wientht contamination. hProvidingetorp-hgi Highmni -ecalorie,tosla pprrootveidine aanudgmmeenettecdalorie mreeqtuaibreomlisemntsandof increased catabolism
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THE GENERAL PRINCIPLES OF BURN MANAGEMENT IN HOSPITALIZATION 2 Wrapping fingers and toes separately to acovonitdacttissue adherence from prolonged Any dressings that have adhered to the wwoatuenrd. Ecaasnilybdeerteamchoevdedtisbsyueapisplaylisnog tepid debrided during the cleansing process Use room temperature water. Btoefpooreurpwoaurrminganwdatpelreaosnanthtewbauternr oanrehae, astltahryt afereelains gosf athned boobdjeycttoiopn.revent negative
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THE GENERAL PRINCIPLES OF BURN MANAGEMENT IN HOSPITALIZATION 3 Caprepalimeds danirdecotliynttmo eanbtsursnhosulrdfanceo,tbbuet to daprepslsieindgtsomthaeteirniajulsr,ewd hsiictehsare then Aprpopmlyottheeobpatinmduamgeciinrcaulfaigtiuorne.-eight to Elastic bandages are recommended to prevent epithelial breakdown, decrease eanddemimapforormveamtioonb,ilsittiym. ulate circulation Nonotthneecfaecsesaarryetao. use dressings on burns Ipnhvyoslivointhgesrappeicsitalasntdafef:dnuuctartiitoionnailstt,eam, medical clowns, volunteers, etc.
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THE TREATMENT OF BURNS Provides the essential physical protection urgently needed when someone is accidentally burnt. Safe for use on children Highly effective within the first 24 hour period. THE DRESSING MATERIALS AND MEDICATIONS BURN SHIELD It is a remarkable Sterile, Hydrogel (wet) product Burnshield provides constant relief in terms of cooling. Burnshield provides the ability to transport the patient to nearest facility. Burnshield provides covering for the burn. For use within the first 24hr period
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THE TREATMENT OF BURNS THE DRESSING MATERIALS AND MEDICATIONS Silver Sulfadiazine topical antibiotic used in partial thickness and full thickness burns to prevent infection. Silver sulfadiazine was discovered in the 1960s as an effective and safe medicine for burn-care Silver sulfadiazine must not be used on premature babies or on newborns during the first 2 months of life because of the risk of serious side effects. Silver Sulfadiazine Once or twice daily dressing dCelaedantitshseuedsaamnadgwedouanredasbecerfeotrieonesv.ery application, to remove Significant side effects are: Leucopenia Thrombocytopenia Haemolysis (G6PD defficiancy) Transfered by breast milk
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THE TREATMENT OF BURNS THE DRESSING MATERIALS AND MEDICATIONS StoUpLiFcAalMsuYlLfOanNil®am(imdeasfegnrioduepacmeetadtiec)inise.an antimicrobial Hgraasmb-apcotesirtiiovsetaatnicdagcrtaiomn-nagegaiantsivtebarogaedntsspectrum of Safe for pediatric usage after the age of 3 months Pmraofveindieddeiancpeatactkeeto cboenrteacinoinsgti5tu0tgedoifnst1e0r0il0e mL of Sterile Water USP or 0.9% Sodium Chloride . Amfatefernmidixeinagce, tahtees. olution contains 5% w/v of Tdhaeysreacftoenrsptirteupteardatsioolnutiifosntomready ibneuunsoepdefnoerdup to 28 cUoNnUtaSiEnDersP.OORNTCIOENASCHOONUTLADINBEERDIISSCOAPRENDED,AAFNTYER 4 285°HCOURS. Store the reconstituted solution at 20° to thhoeugrsauorzeasdrneescseinssgamryatyo bkeempowisette.ned every 6-8 SULFAMYLON
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THE TREATMENT OF BURNS THE DRESSING MATERIALS AND MEDICATIONS Despite being a medication with great potential, and the ability to penetrate through the thick, contaminated injured tissues, this drug is not widely used because of: PAIN!!! Metabolic acidosis. The caregivers should pay attention when the following symptoms appear: Rush, difficulty breathing; swelling of face, lips, tongue, or throat. Pale or yellowed skin, dark colored urine, fever, confusion or weakness Chest pain, fast or pounding heartbeat, headache Nausea, vomiting, stomach pain, appetite changes, muscle weakness, bone pain, and weight loss
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THE TREATMENT OF BURNS THE DRESSING MATERIALS AND MEDICATIONS AQUACEL The AQUACEL Burn is a Hydrofiber essing reinforc d with nylon, and is an absorbent, sterile, non-woven hydroentangled dressing. Tcrheias tceosnafosromftagbelel wdhreicshsinmgaiisnthaiginhslya ambosoisrtbeennvtiroofnwmoeunntd fluid and Suunpnpecoertsssatrhyemboatdeyr’isalnfarotumratlhheeawlionugnpdr,owciethssouant daamidasginingthneerwemlyofovarml oefd tissue Rtheadtukcillses arisbkrooaf dinsfepcetciotrnumduoeftpoaitohnoicgesnilvser – a proven antimicrobial – Tlahregedrrerescstinagngisulcaursstiozmesizaanbdlevatoriopuastiegnlotvneeseidzes sbecause it is available in AQUACELL Dserceosnsidnagrymdaryesbseinlegftminorpelafrceequupenttoly1i4f sdaatyusra. teCdhange Tooil mreamyobvee,ussoeadktion rweamteorv/esasltinubeb3o0rnmdinruestesisn.gMpiineecreasl . Pwaatrimenwt mataeyr taolsroelbeeasinesdtrruecssteindgto shower to allow AcoQnUtiAnCueEsL,®anAdgfudrlleyssdientgacbheegsinas twooduentdachhealss.healing
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THE TREATMENT OF BURNS FLAMINAL Flaminal is a gel enriched by unique enzyme system, and is highly absorbent Was created as a universal, reliable dressing that simplifies care of the wound. provides many clinical advantages in one powerful product. maintains a moist wound environment provides continuous purification of wound antibacterial protection safe for skin cells and hypoallergenic THE DRESSING MATERIALS AND MEDICATIONS FLAMINAL Flaminal Hydro for wounds that are dry or have mild to moderate amounts of exudate. The dressing may stay 3-4 days. Flaminal Forte for wounds that have moderate to heavy amounts of exudate. The dressings generally should be changed every 1-2 days.
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FLAMINAL Clean and rinse the wound, and make it dry Apply a thick layer (5mm) of either Flaminal Hydro or Flaminal Forte to the wound in a sterile manner. Flaminal does not need to spill over the wound edge. THE TREATMENT OF BURNS  nonadhesive bandage   THE DRESSING MATERIALS AND MEDICATIONS In Dry wound: use Flaminal Hydro and paraffin gauze fixed by a non-adhesive bandage Slightly exuding: non-adherent dressing fixed by a Moderately exuding: absorbent, non-adherent compress fixed by a non-adhesive bandage Very heavily exuding: absorbent non-adherent compress fixed by a non-adhesive bandage Change from Flaminal Forte to Flaminal Hydro as exudate reduces.
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REFERENCES: American Burn Association's practice guidelines, 2012 INTERNET – charts and pictures, and drug and medications information Stone, Keith and Humphries, Roger; Current Diagnosis and Treatment: Emergency Medicine. McGraw- Hill New York 2008 Whaley & Wong’s Nursing care of Infants and Children, sixth edition