BURNS IN CHILDREN FOR 5 SEM BSC NURSING .pptx

STUDY MATERIAL FOR STUDENTS

1. BURNS IN CHILDREN

2. BURNS - INCIDENCE Burns are the tissue injury caused by contact with heat,flame,chemicals,electricity and radiation 80% of burns occurs in children from home Burns are the third leading cause of death in children More common between the age group 1& 4 years Common and serious childhood injury Higher risk with children than adults Over 65% of burns in age below 5 yrs and 25% below 10 years of age

3. Definition Burns are wounds produced by various kinds of agents that cause coetaneous injury and destruction of underlying tissue.

4. TYPES OF BURNS IN CHILDREN Wounds caused by exposure to: 1. Thermal injury or Excessive heat 2. Chemicals 3. Fire/steam 4. Radiation 5. Electricity 6. Iatrogenic injury-

5. 1.Thermal injury Heat injury due to hot liquids hot surfaces,flame ..heat maybe either dry or moist Scald injury –spillage of hot liquids–most common Eg.pulling hot coffee from the table or hot water Flame injury –second most cause of burns-occurs due to faulty electrical wiring , stove,heaters .. Flash burns- due to exposure of natural gas,alcohol,combustible liquids Contact burns – contact with hot metals or objects or materials

6. 2. Cold injury- frost bite 3. Chemicals – due to ingestion of strong acid and alkali 4. Electrical – due to high voltage electrical contact 5. Radiation –over exposure to ultraviolet rays 6. Iatrogenic injury- careless use of warmers, hot applicants ,cauterization

7. Pathophysiology Heat causes coagulation necrosis of skin and subcutaneous tissue ↓ Release of vasoactive peptides ↓ Altered capillary permeability ↓ Loss of fluid → Severe hypovolemia ↓

8. Decreased cardiac Decreased myocardial ↓ output function Decreased renal blood → Oliguria flow (Renal failure) Altered pulmonary resistance causing pulmonary edema ↓ Infection ↓ Systemic inflammatory response syndrome (SIRS) ↓ Multiorgan dysfunction syndrome (MODS)

9. Classification of burns in children 1 . Depending on the thickness of skin involved First degree Superficial burns; epidermis is pink to red and painful. Heals rapidly in 5-7days No blisters By epithelisation without scarring B. Second degree: Mottled, red, painful, with blisters, Heals in 14-21 days. Superficial burn heals, causing pigmentation. Deep burn heals, causing scarring, and pigmentation.

10. C. Third degree: Charred, painless and insensitive, Thrombosis of superficial vessels. It requires grafting. Escher Charred, denatured, insensitive, contracted full thickness burn. These wound must heal by re- epithelialisation from wound edge. D. Fourth degree: Involves the underlying tissues—muscles, bones. First degree second degree burns are included in partial thickness and third degree burns is considered as full thickness burns

11. II. Depending on the depth of burn injury Partial thickness burns: It is either first or second degree burn which is red and painful, often with blisters. Epidermis, superficial layers of dermis involved b. Full thickness burns: It is third degree burns which is charred, insensitive, deep involving all layers of the skin. The wound does not heal normally and needs skin grafting

12. 111. Depending on the severity /percentage of Burns a. Mild (Minor): Partial thickness burns < 15% in adult or 10% TBSA in children. First and second degree burns Full thickness burns less than 2%. Moderate : Second degree burns 10-20% in children. Third degree between 2-5% burns. Burns which are not involving eyes, ears, face, hand, feet,perineum .

13. c. Major (severe): Second degree burns in children more than 20%. All third degree burns of 10% or more. Burns involving eyes, ears, feet, hands, perineum. All inhalation and electrical burns. Complicated Burns with Trauma, fractures or major mechanical trauma like head injury,DM,pulmonary diseases,cancer , and all at- riskpatients

14. ASSESMENT OF BURNS/ ESTIMATION OF BURNS SURFACE AREA 1,Rule of hand ( Palmar method) The child’s one hand with closed fingers is considered as 1% of BSA The percentage is calculated comparing with the hand 2.Rule of five (Lynch and Blocker method) Body parts are approximated in multiplies of five 3.Rule of nines Used in an emergency situation which is adjusted for the child’s age. For children above 10 years, rule of nines can be applied just like in adults For children below 10 years it can be adjusted

15. Contined .. 4. Use of Lund and Browder charts This method gives accurate percentage of burnt surface area Percentage of BSA of various anatomic parts, dividing the body in to very small area especially the head and legs that change with growth Time consuming

16. Wallace`s rules of nine It is used for early assessment

17. The Lund and Browder chart Better method for assessing the burns wound. Here each part of the body is individually assessed

18. Rule of five

19. Investigation Clotting studies LFT RFT Electrolytes Cross matching- for surgery

20. Management First aid management Management in the hospital Fluid management 4. Pain management 5. Wound management and healing of wound Debridement Hydrotherapy Grafts 6. Drug therapy 7. Nutritional support 8 .Nursing management 9.Rehabilitation Refer text books and focus on these points in detail. Wongs 923-930 Parul Datta 377-380 Sharma 727-736(first edition)

21. EMERGENCY TREATMENT Minor burns: Stop burning process: apply cool water/ hold burned area under cool running water Don’t use ice Don’t disturb any blisters Don’t apply anything to wound Remove burned clothing and jewelry

22. Emergency management.. Major burns Stop burning process Flames burns- smoother the fire Place victim in horizontal position Roll victim in a blanket Avoid covering head Cover with a clean cloth Transport to hospital

23. Conti.. General Principles >10% total BSA - IV fluid resuscitation & urinary catheter. In major injury - nasogastric tube to decompress the stomach. During transport - maintain body temperature.

24. MEDICATIONS Antibiotics – are usually not administered prophylactically because decreased circulation to the injured area prevents delivery of the medication to areas of deepest injury. Tetanus toxoid prophylaxis Analgesics- Morphine sulphate – for severe burns Midazolam and fentanyl – excellent iv sedation and analgesia Propofol and nitrous oxide – for procedural pain

25. Topical therapy : 0.5% Silver nitrate dressing Mafenide acetate or Sulfacetamide acetate cream Silver sulfadiazine cream Povidone -iodine ointment Gentamicin cream or ointment Fluid Resuscitation Burn leads to intravascular volume depletion Major losses occur during the first 24 hrs – crystalloids used. Myocardial depression - 24-“36 hrs after injury. The goal of resuscitation _ to maintain adequate intravascular volume to support tissue perfusion and thereby preserve organ function.

26. The adequacy of resuscitation based on observation of blood pressure, heart rate, and urine output. Focus to maintain normal blood pressure, heart rate, and hourly urine output of 1 mL /kg/hr in the infant and young child and 0.5 mL /kg/hr in the child >12 years of age or >50 kg in weight

27. Parkland formula - crystalloid-based formula with RL - based on the BSA of burn and the patient's body weight. Maintenance fluids (5% dextrose in lactated Ringer solution) = (4ml/kg+ BSA of burn) + Maintainance fluids (For adults and children who weigh >40 kg, maintenance fluids are not included in the estimate of fluid requirements.) Half of this - in the first 8 hrs after injury, and other half is given in the following 16 hrs

28. After the first 24 hrs, maintenance requirements + to replace ongoing losses. The hourly evaporative fluid loss from wounds can be estimated as: = ( 25 + Burn surface area) x total BSA The evaporative losses are primarily free water, to avoid rapid changes in sodium concentration in children, this loss is replaced with - 5% dextrose in 0.2% normal saline, loss of serum protein occurs in > 40% BSA burns.

29. Brooke’s formula First 24 hours – Colloids 0.5ml/kg/BSA -Saline 1.5ml/kg/TBSA -D5 as maintenance fluid Next 24 hours – colloids 0.25ml/kg/TBSA NS-0.75 ml/kg/TBSA D5 as maintenance fluid

30. When the injury is larger, the loss is replaced in the second 24 hrs after injury with 5% albumin URINE OUTPUT Best guide to tissue perfusion Adequate renal perfusion = 0.5mL/kg/hr

31. Complications Hypovolaemia (refractory and uncontrolled) and shock Renal failure Pulmonary oedema and ARDS Septicaemia Multiorgan failure Acute airway block in head and neck burns Septicemia ,cardiac and GI complications Post burn seizures ,depression ,carcinoma in burn scar