Major Burns in Children

Major burns don't happen very often but sometimes clothing gets set alight (whether deliberately or accidentally) and patients suffer significant burns. A major burn is classed as anything greater than 10% body surface area in a child (or 15% in an adult), or an airway burn.

There are some excellent summaries on major burns including: 

• The BMJ ABC   
• BMJ Burn Circulation Review (including worked examples) 
• LITFL 
• Burn Journal  
• Anaesthetic Update

First aid management is pretty much the same as in minor burns but severe burns can have some serious affects on the rest of the body, so there are few things that need to be looked at more closely.

Pathophysiology of Burns
The first thing that happens is the burn makes capilliaries become leaky. Plasma is lost and water is drawn out with it causing a hypovolaemic distributive shock. This lasts for 3- 36 hours.
Because water is drawn out of the tissue, the patient becomes very oedematous.

Burns damage the red blood cells, and make them fragile, so anaemia can result

Jackson's Burn Model is used to understand burn pathophysiology. There are three main areas in a burn:

• Zone of hyperaemia: this is the outer ring of erythema. The tissue here is unaffected, and viable.
• The zone of vascular stasis is the next ring in. This tissue has been affected by the burn and may recover, but may not. Making sure the patient is adequately hydrated will affect this zone of stasis.
• The central zone of necrosis is irreversibly damaged. This thermally coagulated tissue behaves like cutaneous gangrene. It has no blood supply - so if it remains dry, it is inhospitable to bacterial growth. If it remains moist, bacteria resistent to antibiotics will proliferate. These micro-organisms can release exotoxins, leading to deepening of the burn wound, local cellulitis and sepsis.
  This damaged tissue also has an inflammatory response, releasing leukotrienes, prostaglandins, oxygen free radicles and histamine into the circulation. This leads to increased capillary permeability. The effects are very similar to the effects seen in sepsis.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC421790/

Airway
Stridor, hoarse voice, singed nasal hairs are all listed as "red flags" when assessing the airway in a burns patient. There are no studies looking at the predictive value of these signs in airway injury, but as a small amount of swelling can significantly affect the airway diameter, especially in children, it pays to be vigilant. I have been told by a burns anaesthetists that the only way to reliably assess the degree of airway swelling is to have a look - either when you intubate, or with a bronchoscope / naso-endoscope. Accessing these tools can be tricky so I suspect most places will err on the side of caution.

In any patients with features suggestive of inhalational injury we should measure carboxyhaemoglobin values. 

 

C-Spine

Remember that many people with burns may have been involved with explosions or other traumas. 

 

Breathing

Circumferential chest burns can cause problems with ventilation, and may require urgent treatment. 

Circulation

Managing circulation can be difficult in burns. Initial fluid requirements can be very high due to burn shock and altered vascular permeability. Later, fluid causes massive oedema and further management difficulties. 

 

Assessing burn depth and area covered is the first step to calculating fluid requirements. 

 

 Assessing Burn Depth 

As much as we all like a fancy test or gadget to help us, clinical assessment is the only way of assessing burn depth.

There are four things we can assess to help us gauge the depth of the burn - which nearly fit an ABBC approach! 

Appearance - this can be difficult as burns are often covered with soot or dirt, and blisters obscure the burn base. 

Blanching - capillary refill can be assessed - preferably by pressing on the burn with a sterile cotton bud (or wound swab).

Bleeding - I have never seen bleeding assessed before, but it is suggested that you can test bleeding with a 21 gauge needle. Brisk bleeding on superficial pricking indicates the burn is superficial or superficial dermal. Delayed bleeding on a deeper prick suggests a deep dermal burn, while no bleeding suggests a full thickness burn.

Sensation - You should test sensation with a needle. Painful burns are superficial or superficial dermal burns.  Non-painful burns indicate a deep dermal injury, while full thickness injuries are insensate. However oedema can blunt sensation.

 

Assessing Burn Percentage 

Lund and Browder charts are better and more accurate than Wallace's rule of nines (covered in minor burns). Remember not to include simple erythema in your calculations!

Fluid Resuscitation

• The Parkland formula is as good as any other methods at calculating fluid requirements, and I find it easier to remember than the others.
  The Parkland formula is for crystalloid only. Children require maintenance fluid in addition.
• High tension electrical injuries require more fluid (up to 9 mlx(burn area)x(body weight) in the first 24 hours).
•  Inhalation injuries may  increase fluid requirements by 50%.

•  Muir and Barclay is sometimes used, although colloids are not ideal. 
• Colloid resuscitation with plasma
• The first 36 hours are divided into time periods of 4,4,4,6,6,12 hour intervals
• Each interval = 0.5 x %BSA x Wt (Kg)
• This gives us 3 x %BSA x Wt over 36 hours - so a lot less fluid than the Parkland formula

Disability
Infection is common, but the role of prophylactic antibiotics is unclear.
Tetanus cover should be provided.
 
Escharotomies
Deep dermal or full thickness burns are inelastic, and will not stretch. Oedema and swelling beneath this tissue increases tissue pressures. To allow adequate skin perfusion and ventilation, division of the burn may be needed. In an escharotomy only the burnt tissue is divided - not any fascia. In a fasciotomy underlying fascia is divided too.
Escharotomies should be performed with cautery (as they tend to bleed), ideally in aseptic conditions in theatre. 

And all of this is summarised beautifully on Academic Life in EM. And not so beautifully below.

Minor Burns in Children

Burns in children are really common, and half of the reason I love doing PEM. In many departments you only ever see minors in the Paediatric department, and I think it is in minors that you make the biggest difference. Burns are painful, and can cause life long psychological, cosmetic, and physical problems if they are not well treated- and it is the basics that really make a difference. We've recently printed a poster (see below, or here for pdf copy) for our waiting room about burn prevention and treatment, as so much burn treatment can be done at home.When we put the poster up we also sent out a burns briefing sheet to all our Doctors and Nurses as a reminder of the basic treatment.

The "STOP"  idea on the poster comes from a 2012 article from "Burns". We modified it slightly - we don't want all burns arriving in the ED by ambulance, but we thought it was a very good idea.

There are excellent resources for Burns from the London and South East of England Burn Network. They’ve got referral guidelines, direct dial numbers, body maps, and everything you could possibly want. 


There is a good summary of minor burns (in adults) on Life in the Fast Lane. The BMJ wrote a good overview in 2004, but I suspect that burn treatment has moved on since then - we don't tend to use flamazine any more. Their more recent overview (2009) doesn't touch much on dressings.
There is an indepth summary on 'crashing patient', including procedural advice. There is a really useful series of case reports on burns here.

Prevention of Burns
There’s some good fire safety leaflets online here (and there’s a QR code on the poster for patients to scan). ROSPA have some good safety tips.

Physiology of Burns
There's an excellent summary here, including lots of information on burn shock.We'll cover the physiology of burns in more detail in the next blog post - major burns in children.

Immediate Treatment of Burns
Evidence to suggest cooling within three hours of the burn has beneficial effect
    - So if the burn was less than three hours ago, cool it.
    - We should be cooling for around 20 minutes - until the burn has cooled down completely.
    - Burn Gel and burn dressings are  generally good in the back of an ambulance, but not as good as cool water. If you do use cooling dressings, they seem to work best if they are left uncovered.
Don’t forget to check tetanus status like you would in other wounds.

Analgesia
    - Remember cooling provides pain relief
    - Ibuprofen is a good pain killer for burns
    - Children may need intra-nasal diamorphine to settle them
    - Analgesic gas (entonox) may be needed whilst waiting for other analgesia to work.
    - Never underestimate the power of suggestion and hypnosis.Asking someone to imagine cooling particles flowing towards the burnt area of skin can't do any harm - and might do some good.

Evaluation of Burns
As always, remember to start with an ABC approach. Once you are happy with thatI was always taught to strip children under five off completely to check for burns or injuries elsewhere, and anything that might make you worried about safeguarding issues.

Depth of burns:
Superficial burns (1st degree)
- Erythematous, painful
- Only involve outer layer of epidermis (fluid loss not an issue)
- Heal without scarring in 4-5 days

Partial thickness burns (2nd degree)
- Superficial partial thickness: red and painful with blister formation
- Partial destruction of dermis
- Weeping/moist appearance
- Healing in 7-10 days with minimal scarring

Deep partial thickness: greater than 50% of dermis
- White, pale, less painful (nerve fibers destroyed)
- 2-3 weeks to heal, severe scarring can occur, contractures
- May requires skin grafting

Full thickness burns (3rd degree):
- white, waxy, leathery
- No bleeding, painless
- high risk for infection and fluid loss

Estimation of Burn Area - (do not include superficial burns):
Rule of 9s

Lund and Brower chart

Baby

2 year old

5 year old

10 year old

Adult

Burn Blisters
    - Current advice is to de-roof blisters if over the size of the patient’s little fingernail
    - Consideration should be given to:
       -  The risk/ benefit of ‘deroofing’ small, non-tense blisters
       - The risk/benefit of ‘deroofing’ blisters on the palmar surface of the hand and the plantar aspect of the  foot
        -   Patient compliance with the procedure and on-going care when considering the management of small, non-tense blisters i.e. patients with dementia, learning difficulties, and toddlers

Dressings
    - Mesitran (honey dressing) is a good dressing that helps cool the burn, reduce infection and reduce burn erythema.
    -  Practice Nurse should be able to change these in 48hours time.

Burn Follow Up and Advice
Prophylactic antibiotics have no proven beneficial effect.  
Increase oral fluids and protein in the diet.
Return if any sign of systemic illness developing.
The burnt area will be sensitive to the sun, and need sunscreen on it.

Trauma in Children

There are specific body systems affected in trauma. But what about trauma in general? Do we treat it exactly the same as we would in adults?

• Tranexamic Acid
  There is a statement here from the Royal College of Paediatrics and Child Health. They acknowledge the lack of trial data, and suggest a pragmatic dosage of 15mg/kg loading dose (max 1g) over 10minutes, followed by 2mg/kg per hour.
• FAST Scan
  This study suggests we shouldn't use FAST in children with abdominal trauma. This one says it has low sensitivity but high specificity. This one agrees. This blog makes it even more complicated - fluid in the pelvis can be normal in children!
• Urinary catheters
  Inserting a catheter in a child is the same principal as in adults. There is a guide to paediatric catheter sizing here. Hopefully the paediatricians will help if a catheter is needed.
  
  
• Courses
  There is a Children's Advanced Trauma Course. It seems to be run solely in Sheffield.

Please leave comments about what you think are important differences between paediatric and adult trauma. 

Abdominal Trauma

The abdomen is the third most injured body part in children, after the head and the chest.

There is a medscape e-learning module here, and a good pdf overview here, here, and another overview here with a summary on page 13. There is some discussion around a case here and some good CT images here. There is an excellent summary about abdominal trauma in children here, which introduces us to some guidelines for careful imaging in children.The anaesthetists at Lewisham wrote a very thorough overview here. There's a good summary of common injuries and their management here.

There is a good CT scan with some SAQs from the PMJ here.

Anatomical differences in children:
- The abdomen is square and becomes more rectangular as the child matures.
- Muscles are thinner, so there is less protection for underlying structures.
- Ribs are more flexible so they are less effective at energy dissipation, so less effective at protecting the upper abdominal structures.
- Solid organs are comparatively larger so are at more risk for injury.
- Attachments are more elastic.
- The intestine is not fully attached within the peritoneal cavity so is more vulnerable to injury due to sudden deceleration and/or abdominal compression.
- The bladder is more exposed.
- Children's spines are exposed to chance fractures, especially if they are restrained with a lap belt only.
- Abdominal distension from aerophagia is common
- Hypothermia is more likely

Clinical Features
The Seatbelt Sign
The seat belt sign is a good indicator of serious injury. In one review, 78% of patients with a seat belt contusion had intra-abdominal injuries, although all children with injuries also had abdominal pain - not just a seat belt sign.
Lap belts are designed to be worn at or below the anterior superior iliac spine level. In smaller children the belts are in the wrong place, and children can move out of them very easily. The introduction of booster seats has helped to improve this. You are up to 3 times more likely to be injured if you are not properly restrained.

Haematuria
The most common indication for abdominal imaging after trauma in children is reported to be haematuria. Non–urinary tract injury is observed more frequently than urinary tract injury in children with haematuria and asymptomatic hematuria is a low-risk indicator for abdominal injury.

80% of injuries are from blunt mechanism.

Holmes 2012 - decision Rules
Holmes looked at children with blunt torso trauma, and suggested some decision rules for when we should be CTing these patients. The paper has been reviewed on PEMLit. He has listed seven factors that make the injury low risk:

Most patients I've seen with trauma do complain of some abdominal pain -so maybe one or two CTs might be saved! This has a 99.9% negative predictive value.

If we do CT it's pretty good at picking up pathology.  If the patient is stable, ultrasound and serial observation is probably sufficient. There's a suggestion of an algorithm here. In a verbal patient, normal obs, normal examination and no abdominal pain is a pretty good indicator of no abdominal injury.