Pediatric Burns: Epidemiology, Etiology and Treatment. Susan Ziegfeld, MSN, PNP-BC Manager, Pediatric Trauma and Burn Program

Transcription

1 Pediatric Burns: Epidemiology, Etiology and Treatment Susan Ziegfeld, MSN, PNP-BC Manager, Pediatric Trauma and Burn Program

2 No Disclosers

3 The Problem: Statistics 486,000 - Burn Injuries Receiving Medical Treatment 40,000 - Hospitalizations Related to Burn Injury 3,275 - Deaths from Fire/Smoke Inhalation Survival Rate: 96.8% Gender: 68% Male, 32% Female Ethnicity: 59% Caucasian, 20% African-American, 14% Hispanic, 7% Other Admission Cause: 43% Fire/Flame, 34% Scald, 9% Contact, 4% Electrical, 3% Chemical, 7% Other Place of Occurrence: 73% Home, 8% Occupational, 5% Street/Highway, 5% Recreational/Sport, 9% Other 2018 ABA Burn Incidence Fact Sheet

4 Pediatric Burn Injuries Fire and burns are the leading cause of unintentional death in the home 1,000 children deaths/year 116,00 children < 14 burned seriously enough to require medical attention Scald burns most common thermal injury in children < 3 Scald burns prevalent in child abuse Flame burns more common in older children

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6 Etiology Burn injury occurs when there is contact between tissue and an energy source Thermal Chemical Radiation Electrical The younger the child the thinner the dermis = deeper injuries

7 The Real Etiology Thermal (Scald)

8 The Real Etiology Thermal (Flame) Thermal (Contact) Thermal (Flash)

9 Quiz Thermal Burns (Scalds) How long will it take for a full thickness burn to occur at 120? 5 minutes At 140? 5 seconds What is the typical temperature hot liquids are served?

10 More Trivia Cooking Method Deep frying Baking Frying Boiling Electric Crock Pot Hot Beverages Approximate Temperature 500 F (260 C) 400 F (204 C) 300 F (148 C) 212 F (100 C) 200 F (93 C) F (71-82 C) It takes less than one second for a third degree burn to occur from these cooking methods.

11 Time and Temperature The severity of injury depends on temperature and length of time of exposure

12 The Real Etiology Chemical Types: acid, alkali, organic Severity depends on agent, concentration, volume, and duration of exposure Electrical Types: Contact with high voltage or low-voltage electricity or lightning strike High-voltage contact causes underlying injury as well as obvious tissue damage Low-voltage contact causes minimal cutaneous damage plus pain and neurologic sequelae Lighting may cause cardiac arrest Radiation Types: Exposure to radioactive substances in the air or ingestion of or skin contact with such substances

13 Initial Assessment ABLS Approach Same approach as trauma!!! Airway maintenance with c-spine protection Breathing and ventilation Circulation with hemorrhage control Disability (assess neurologic deficit) Exposure (completely undress child, but maintain temperature)

14 Airway Considerations that place kids at particular risk Soft tissue in OP (tongue/tonsils) large vs. oral cavity Makes visualization of the larynx difficult Easily obstructs The narrowest portion of the airway the glottis Rapid onset of airway loss with mild edema Trachea is short (~5-7cm )... ETT easily misplaced with changes in head position

15 Inhalation Injury Present in 20-50% of flame burn patients Identified in 60-70% of patients that die in burn centers Types Injury caused by exposure to toxic gas including CO* Injury above the glottis Injury below the glottis

16 Carbon Monoxide Poisoning CO binds to hemoglobin with an affinity 200 times greater the O2 Leads to tissue hypoxia ABG and pulse-ox not affected 400 deaths from unintentional CO poisoning Cause of most fatalities at the scene COHb %: 10-20: Tension in forehead; dilatation of skin vessels 20-30%: H/A; pulsating temples 30-40%Severe H/A, N/V 40-50%Increased RR & HR; asphyxiation 50-60%Coma; seizures; cheyne-stokes respirations (cherry red lips?) > 60% Weak respirations, pulse; death Smoke inhalation is the most common cause of cyanide poisoning

17 Inhalation Injury Above the Glottis Nasopharynx, Oropharynx, Larynx Most common Typically thermal or chemical Damage to the pharynx is often severe enough to produce upper airway obstruction Early airway intervention with Intubation Trash explosion

18 Inhalation Injury Below the Glottis Can be thermal or chemical Pathophysiologic changes associated with injury below the glottis Impaired ciliary activity Inflammation Hypersecretion Edema formation Ulceration of the mucosa Increased blood flow Spasm of bronchi and bronchioles Impaired immune defense Wheezing within minutes to hours Mucosal sloughing 4-5 days post injury CXR typically normal, initially

19 Management of Inhalation Injuries 100% humidified O2 until the carboxyhemoglobin is <10% Elevate HOB Intubation if airway obstruction is imminent Hoarseness Stridor Decreased LOC Hyperbaric Chamber??

20 Breathing Ventilation requires adequate functioning of the lungs, chest wall and diaphragm 100% O2 Early intubation Circumferential full thickness burns of the trunk may impair ventilation

21 Circulation IV access for fluid resuscitation Greater BSA/kg (Size of burn) results in larger evaporative surface and ability to conserve heat Less metabolic reserve Higher fluid needs Hypoglycemia Assess circulatory status of circumferentially burned extremity

22 Burn Shock November 28, 1942,Cocoanut Grove in Boston, Massachusetts, the deadliest nightclub fire in United States history claimed the lives of 492 people and injured hundreds more 132 patients treated by Dr. Charles Boston City Hospital 39 patients treated by Dr. Oliver Massachusetts General Both noted that patients with burns & inhalation injury required more fluid during resuscitation - raising concern for inducing pulmonary edema Cope decided to decrease the amount of fluid given to these patients; Lund treated them with the volumes they were requiring No detrimental effects were reported from administering increased (needed) fluid volumes This fire led to a reform of all buildings fire codes and safety standards The club s owner, mafia linked Barney Welansky, was eventually convicted of involuntary manslaughter

23 Fluid Resuscitation Initial phase of burn injury: capillary permeability, PVR, blood viscosity, plasma volume, CO Resembles hypovolemic shock Lasts 24 hours Diuresis phase of burn injury: Occurs hours after injury Shock is resolved, capillary integrity is re-established, fluids are mobilized Characterized by hypermetabolic state and CO

24 Fluid Resuscitation Protocol Burns > 20% TBSA Calculated by L & B by a JH provider Patients < 40kg: ((( 3cc/kg/TBSA)/2)-pre-admission fluid)/(8-time from injury)= starting RF Start maintenance IVF with D5LR Do Not Titrate Blood Glucose <70mg/dL change to D10NS Blood Glucose >180ml/dL change to LR Patients > 40kg: (((2cc/kg/TBSA)/2)-pre-admission fluids)/(8-time from injury)= starting RF No maintenance IVF required RF is titrated according to UO q hour Difficult to resuscitate pathway Albumin/Epi/Dobutamine

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28 Escharotomies May be required to permit normal ventilation and peripheral perfusion, particularly with deep circumferential limb or trunk burns Assess circumferential wounds for circulation: color, temperature, pulses, increased pain (use doppler if needed to assess arterial flow)

29 Escharotomies Remove constricting objects Immediate elevation of burned extremities Early escharotomies on circumferential third or fourth degree burn Escharotomy must extend completely through the burned tissue Hemostasis is obtained with pressure, electrocautery

30 Disability Obtain History Need to consider Associated injuries? CO poisoning? Substance abuse? Hypoxia? Pre-existing medical conditions?

31 Exposure Universal precautions Remove all clothes and jewelry Keep patient warm STOP THE BURNING PROCESS!! The severity of injury depends on temperature and length of time of exposure

32 History A M P L E T Allergies Medications Past medical history Last meal Events leading up to injury/circumstances of injury Tetanus and immunizations Flame: Inside or outside, clothes, time burning, any fuel involved, how did child escape, MVC, other injuries? Scald: How did burn occur, temperature of the liquid, what was the liquid, how quickly were the clothes removed, how quickly was care sought, consistent story? Chemical/Radiation: What was the agent, how did the exposure occur, duration of contact, decontamination, explosion? Electric: What kind of electricity, did the child fall, estimated voltage, any LOC, CPR administered?

33 Classification Classification of burn injuries has implications for the kinds of treatment choices that are made Total Body Surface Area (TBSA) affected, location and type of burn, depth of burn all impact the overall management of these patients Burn injuries can be classified in terms of: % of TBSA (Extent) Zone of injury Depth

34 Classification Extent Refers to the percentage of TBSA that has been affected by a burn injury. Only 2 nd and 3 rd degree burns are included when tabulating the TBSA. Rule of Nines Lund and Browder Diagram Palm Method

35 Rule of Nines (classic) Body divided into 11 regions, each of which is assigned a 9% value; + genitals=1% Most appropriately used in field for adults

36 Palm Method Palm plus fingers = 1% TBSA Based on size of patient s palm Can be used for small or patchy burns over multiple surfaces Less refined estimation technique

37 Lund Browder Diagram Can be used for any age patient Appropriate for patients <10 years of age Burn distribution (% TBSA affected) is adjusted for age Preferred for pediatric patients; yields a more accurate value

38 Lund Browder Diagram Different percentage for Different ages

39 Classification Zone This looks at the pathophysiology of a thermal burn (flame, scald, contact, flash). The degree of tissue destruction is dependent on: Temperature (of source of injury) Duration of exposure The physiologic impact varies, depending on depth of burn and TBSA affected

40 Zones of Thermal Injury The burn wound is a 3-dimensional mass of damaged tissue. Zone of Coagulation Zone of Stasis Zone of Hyperemia

41 Zone of Coagulation Center of the burn Had most contact with heat source Tissue is non-viable and there is no chance of cellular repair

42 Zone of Stasis Extends peripherally from zone of coagulation Extent of the zone of stasis is minimized by adequate resuscitation The inflammatory response in the zone of stasis is responsible for burn edema and shock

43 Zone of Hyperemia Extends even more peripherally from zone of stasis Minimal tissue damage Cells should recover within 1-10 days with minimal treatment

44 Depth Refers to the layers of the skin that have been affected In the past, the depth of a burn injury has been classified as: 1 st degree 2 nd degree 3 rd degree 4 th degree (involves muscle and maybe bone)

45 Burn Depth A more meaningful way to classify the depth of burn injuries is to consider 4 primary categories: Superficial (1 st ) Superficial Partial Thickness (2 nd ) Deep Partial Thickness (2 nd ) Full Thickness (3 rd )

46 Superficial (1st degree) Injury involving only outer dermis (epidermis) Sunburn or minor scalds Characterized by erythema, pain

47 Superficial (1st degree) Patients with superficial burns (only) generally do not require IV fluid replacement Not included in the estimation of burn wound injury Will generally heal on its own without scarring in 3 5 days

48 Initial Burn Wound Care Thermal Burns No Old wives tale remedies Pain control Cool water Stop the burning process Cover with clean, dry cloth, keep warm!

49 Superficial Partial Thickness (2 nd degree) Damages but does not destroy the first and second layers of skin Characterized by intense pain, blisters, skins is bright pink to cherry red, moist and weepy 1st and 2nd layers

50 Superficial Partial Thickness Nails, hair, oil and sweat glands, and nerves are left intact and function without disruption Spontaneous re-epithelialization in 10 days 2 weeks

51 Deep Partial Thickness (2 nd degree) Injury involving first and second layers of skin Can result in disruption of nails, hair, sebaceous glands Characterized by intense pain; dry, white in color May cause scarring; may need grafting 1st and 2nd layers (but more of the 2nd layers)

52 Deep Partial Thickness May require excision of burn eschar and grafting Eschar Post Graft

53 Full Thickness (3 rd degree) Injury involving all layers of skin Characterized by charred black color (perhaps with areas of dry, white), pain may be absent or intense (depending on nerve ending involvement) Cause scarring; skin grafting required all layers of skin

54 Full Thickness Burn

55 Full Thickness Burns Treatment Gold Standard: Early excision and grafting Should be considered the treatment of choice for all burns that will not heal spontaneously in two weeks

56 Other Considerations Pain Management Background, Breakthrough and Procedural Pain team and child life Wound Care Daily dressing changes Patients should be turned PT/OT Abide by splinting guidelines Allow daily therapy Psychosocial support

57 Nutrition: A key component for recovery after burn injury The greater the burn size the greater the in metabolism Early Enteral feeds- ND feeds through OR Increased protein 20% of Kcals for burned children Healthy children require 8-12 % Oxandrolone- Burns ~ > 30% Anabolic hormone (testosterone derivative) used to halt catabolic state Reduces protein loss and improves muscle mass, bone density and wound healing Vitamins A Zinc C

58 The OR Avoid hypothermia keep room 75-85ºF prevent coagulopathy Estimated 0.5cc blood loss per 1cm 2 burn excised Limit OR time to 3 hours Attention to hemostasis Limit blood loss to <60% total blood volume

59 Timing of Excision Excision is carried out as soon after the injury as possible when the patient is stable and it is safe to move back and forth from the operating room A few hours to a few days Excision and grafting is safe during the resuscitation if patient is stable Goulian Dermatome (Weck Knife) Humby Dermatome

60 Autograft vs Allograft Autograft: Tissue transplanted from one part of the body to another in the same individual Partial thickness skin graft - Contains epidermis and superficial part of dermis Full thickness skin graft - Contains epidermis and all of dermis Re-vasculization typically occurs within 2-3 days post graft with full circulation to the graft within 6-7 days Allograft: The transplant of an organ or tissue from one individual to another of the same species Pooled donor skin, donors are screened Temporary biologic dressing, usually removed before rejection at 7-10 days

61 A Practical Approach to Excision Burns up to 30% TBSA Excision and autografting Meshed 1.5 : 1 or sheet grafts Punctate bleeding Sheet graft

62 A Practical Approach to Excision Burns 30-40% Sufficient donor sites are usually available to graft the excised bed despite the fact that about 20-30% TBSA is unavailable for donation (face, neck, hands, feet) Grafts should be meshed 1.5:1 or 2:1 or temporary allografts should be used while donor sites are healing

63 A Practical Approach to Excision Burns > 40% TBSA Donor sites are limited and it is impossible to cover all the excised wounds with autograft. Excise 20-30% TBSA per day Autograft 1.5:1, or 2:1 3:1 for large burns Cultured epidermis The patients own epithelial cells grown in the lab Expensive Takes several weeks

64 Autograft 3:1 (due to large TBSA) Autograft 3:1 healed

65 Sheet Graft Can improve the cosmetic appearance face Good for areas that needs full ROM hands, neck and joints

66 Graft Loss Infection Most common pseudomonas aeruginosa Improperly prepared bed Most critical component of successful skin grafting Seroma or hematoma Prevents graft adherence Full thickness or sheet grafts may require pie crusting or mattress sutures

67 Donor Site: Procurement and Care Procurement Preferred donor sites are the legs, buttock, back, lower abdomen 20-30% of the TBSA is unavailable Donor skin should be inches in thickness Donor site care Achieve hemostasis, epi Silver dressing Zimmer Mesher

68 Electrical Burns Electricity passes through the body causing cutaneous burns as well as internal damage Record the voltage and duration of contact with the source High-voltage, (>1000 volts) cause significant soft tissue damage Low voltage, (<1000volts) cause less soft tissue damage but are noted to more commonly cause cardiac fibrillation Labial artery bleeds Rhabdomyolysis Urine output, hyperkalemia, alkanalize

69 Chemical Burns Occurs when living tissue is exposed to a corrosive substance The severity of a chemical burn is related to ph of the agent (acid or base)--- bring container with you Concentration of the agent Length of the contact time Volume of offending agent Treatment Protect yourself Brush powdered chemicals Remove contaminated cloths Flush immediately with copious amounts of water Identify the chemical for specific therapy Monitor for systematic toxicity Monitor body Temperature

70 Acid Burns Acids cause protein coagulation, limiting further penetration Lowers the ph producing a coagulation necrosis by denaturing proteins Sulfuric Acid (used in car batteries)

71 Alkali (Base) burns Alkali burns combine with cutaneous lipids causing tissue saponification, which continues to injure the skin Proton acceptors (OH-) the strength of a base is determined by how avidly it binds the proton. Produces a more severe injury known as liquefaction necrosis Bind with the proteins to form alkaline proteinates. ammonia

72 7 2 Mepilex AG Medical wound management Molnlycke Antimicrobial foam dressing Safetec technology proven to minimize pain and skin dressing changes Minimizes pain and trauma Treats gram and + Kills a broad spectrum of wound pathogens, through the power of ionic silver in the dressing (including Staphylococcus aureus, MRSA, VRE) Bacitracin Topical Inexpensive Prevents bacterial infections Mafenide acetate (Sulfamylon) Topical Adjunctive to control bacterial infection Good penetration of cartledge Antimicrobial

73 Wound Care Products Silver Sulfadiazine 1% cream: Gold standard for many years Used for partial thickness and full thickness burns Bactericidal for gram -/+ and yeast BID dressing changes Pain with removal Fair eschar penetration Should not be used with history of sulfa allergy

74 ED treatment of minor burns Stop the burning process Pain medicine Fluid bolus only if hemodynamically unstable Good history Cleaning / Debridement if necessary and comfortable Unroof blisters > 2cm Bacitracin, non-adherent dressing and wrap Burn clinic follow up

75 Follow up care Burn Clinic Weekly til healed then monthly Skin care for an entire year Moisturizer Scar Massage Sunscreen Compression Garments Psychosocial Support Reconstructive Surgery Laser surgery Burn Camp

76 Fractionated CO2/Pulse Dye Laser Efficacy is well-documented PDL improves the inflammatory component of scars CO2 fractionated laser improves remodeling of dermal collagen 6 Treatments every other month, using a combination of these two lasers Improvement is documented objectively with the Vancouver Scar Score (height, erythema, pliability), and subjectively with the 4P Scar Score (pruritus, paresthesia, pliability, and pain)

77 Referral Criteria Partial thickness burns > 10% Burns of face, hands, feet, genitalia, perineum or major joints 3 rd degree burns in any age Electrical burns Chemical burns Inhalation injury Burns with pre-existing medical problems Burned children in hospitals w/o qualified personal or equipment Burn injury in patients who will require special, emotional or rehabilitative interventions

78 Physical Abuse Any non-accidental physical injury to the child including striking, kicking, burning, or biting, or any action that results in a physical impairment of the child

79 Inflicted burns

80 Thank You!! Susan Ziegfeld KID BURN