The Burned or Scalded Child

Question 1

What is the most common cause of death in burning/ scalding?

Answer 1

• Smoke inhalation
  
  • from house fires
  • Most common cause of death in the 1st hour following burn injuries
  • 15% higher mortality rate when there is inhalational injury
• Smoke filled rooms
  
  • Cardiac arrest from breathing in:
    
    • soot particles
    • hot gases
    • noxious substances
  • Depleted of oxygen

Question 2

What substances are associated with scalds?

Answer 2

SCALDS

• hot drinks
• contact burns
• bath water
• cooking oil

Question 3

When should NAI be considered in scalds and burns?

Answer 3

SCALDS AND BURNS

CONSIDER NAI if:

• inconsistencies in the history (when & how)
• history incompatible with pattern of burn (size, shape, location) or mechanism of burn (age)
• certain patterns of burn including consistent with forced immersion
• delay in seeking medical attention

Question 4

Describe the pathophysiology of burns and scalds.

Answer 4

BURNS AND SCALDS

PATHOPHYSIOLOGY

• Factors determining severity
  
  • temperature (time to cellular destruction decreases exponentially with higher temp)
  • duration of contact
• Scalds
  
  • usually water below boiling point, contact for < 4 secs
  • more serious injuries occur when temp higher (hot fat / steam) or duration of contact longer (infants, handicapped)
• Burns
  
  • flame burns - higher temp
  • => most serious injuries

Question 5

Describe the primary survey and resuscitation of burns and scalds.

Answer 5

BURNS AND SCALDS

PRIMARY SURVEY AND RESUS

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• Airway and C-spine
  
  • Immobilise C-spine as appropriate
  • Airway compromise due to:
    
    • inhalational injury (high index of suspicion - not always obvious)
    • oral scalds (“)
    • severe burns to the face
  • Indicators of inhalational injury - SMOKE DEATHS SUCK
    
    • Smoke exposure in a confined space (history)
    • Deposits around mouth and nose
    • Sputum is carbonaceous
  • Early Intubation
    
    • thermal injury –> oedema
    • airway can deteriorate rapidly
    • more difficult as oedema progresses
• B
  
  • High flow oxygen
  • Consider I+V for increased WOB
  • Assess breathing adequacy
    
    • RR
    • Chest movements (NB circumferential burns to the abdomen in infants or to chest can mechanically restrict chest movement)
    • Cyanosis (late sign)
• C
  
  • Hypovolaemic shock in the first few hrs after injury
    
    • = rarely due to burns!
    • find the source of bleeding
  • IV X 2 / IO
    
    • ideally in unburnt areas
    • through eschar if necessary
  • Fluids
  • Ix
    
    • baseline - FBC, U+E,
    • Cross match
    • GLUCOSE
    • CARBOXYHAEMOGLOBIN LVL
• D
  
  • Pupil reactivity
  • AVPU
  • –> GCS - reduced may be due to:
    
    • hypoxia (smoke filled rooms contain little O2)
    • hypovolaemia
    • HI
• E
  
  • warm environment & cover with blankets (lose heat rapidly)
  • remove jewellery and piercings (digit and limb swelling may occur)

Question 6

Describe the secondary survey of scalds and burns.

Answer 6

SCALDS AND BURNS

SECONDARY SURVEY

• Secondary survey
  
  • head to toe
  • may suffer other injuries
    
    • effects of blast
    • falling objects
    • fall whilst trying to escape
• BURN assessment (severity)
  
  • SURFACE AREA
    
    • age specific burns chart / Mersey burns app
    • pt’s palm + adducted fingers = 1% body surface
    • > 14 yo –> rule of 9’s
  • DEPTH
    
    • superficial epidermal
    • superficial dermal = pale pink skin + blisters
    • mid-dermal = dark pink + sluggish CRT +/- reduced touch sensation
    • deep dermal = red, blotchy +/- blisters + LOSS of CAPILLARY BLUSH
    • partial thickness = pink/ mottled +/- blistering, some damage to dermis
    • full thickness = white/ charred, painless, leathery to touch (both epidermis + dermis damage +/- deeper structures)
  • SPECIAL AREAS
    
    • Face (see primary survey)
    • Mouth (“)
    • Hands & feet (scarring causes severe functional loss)
    • Perineum (high risk of infection)
    • Circumferential burns (parial or full thickness) –> ESCHAROTOMY = urgent INCISION
      
      • Limbs & neck - distal ischaemia
      • Torso - restricts breathing

Question 7

Describe the Rule of 9’s to estimate body surface area percentage in children of 14 years or more.

Answer 7

RULE OF 9’S

BODY SURFACE AREA

(SEE IMAGE)

Question 8

Describe the emergency management of scalds and burns.

Answer 8

SCALDS AND BURNS

EMERGENCY Mx

FIRE WILL CAUSE PAIN

1. PAIN! - ANALGESIA
2. FLUIDS
3. WOUND CARE
4. CARBON MONOXIDE POISONING

——————————————————————————–

1. ANALGESIA
   
   • ​​entonox (older children)
   • intranasal diamorphine (anything more than minor burn)
   • IV morphine 100 mcg/ kg (<1 yo 80 mcg/ kg)- NB titrate against pain & sedation
2. FLUIDS
   
   • ​​2 x IV cannulae
   • FLUIDS
     
     • SHOCK 10 + 10 ml/ kg
     • MAINTENANCE
     • • BURN CARE (additional)
         
         • modified Parkland formula
         • crystalloid
         • Total fluid replacement for burn in 24hrs (in addition to maintenance)
         • = % burn x WT (kg) x 3
         • give 1/2 in the 1st 8 hrs after burn
         • aim UO
           
           • =/ > 1 ml/ kg/ hr
           • =/ > 2 ml/ kg/ hr in 15% burn
           • consider catheterisation
3. WOUND CARE
   
   • ​​Purpose
     
     • ​reduce risk of infection
     • reduce pain from air passing over burned areas
     • reduce heat loss
   • Mx
     
     • COOLING
       
       • for 20 mins
       • old compresses, irrigation w/ cold water
       • do not transfer with cold soaks - lose heat rapidly
     • DRESSINGS:
       
       • PHOTOS FIRST
       • non-adhesive sterile towels OR cling film
       • apply loosely
       • no ointment or cream
       • leave blisters intact
     • TETANUS prophylaxis
4. CARBON MONOXIDE POISONING
   
   • ​​Pathophysiology
     
     • ​House fire
     • low oxygen environment
     • organic compounds burn in this env
     • carbon monoxide produced
     • inhalation
     • binds to Hb
     • carboxyhaemoglobin
     • 200 x affinity for O2
     • O2 not given up to cells
     • cellular hypoxia
     • NB sats can be NORMAL as amount of O2 in blood is normal, but not given to cells!!!
   • Mx
     
     • 5-20% carboxyhaemoglobin
       
       • O2 Tx
       • speeds up removeal of CO
     • > 20%
       
       • hyperbaric oxygen chamber Tx
       • D/W PAEDS BURNS UNIT
   • CYANIDE POISONING
     
     • burning of plastics, wool, silk
     • coma + severe metabolic acidosis without apparent cause
     • > 3 mg/ l –> ANTIDOTE
     • BEWARE - some antidotes C/I if carbon monoxide poisoning
     • D/W POISONS CENTRE - urgent

Question 9

What are the indications for referral to a specialist burns service?

Answer 9

INDICATIONS FOR REFERRAL TO

SPECIALIST BURNS SERVICE

1. PARTIAL THICKNESS + > 2% TBSA (total body surface area)
2. Discuss if any of the following: The Fire Is Just So Close - Call Emergency Centre Now!!!
   
   • Trauma (major) + burns
   • Full thickness > 1% TBSA
   • Inhalational injury
     
     • visual evidence of upper airway smoke inhalation
     • laryngoscopic +/- bronchoscopic evidence of tracheal/ bronchial contamination / injury
     • suspicion of inhalation of products of incomplete combustion
   • Joint involvement - may affect mobility and function
   • Special areas (face, neck, hands & feet, perineum)
   • Cicurmferential (trunk or limbs)
   • Chemical burn
   • Electrical burn
   • Co-morbidities
   • NAI suspected (refer w/i 24 hrs for expert assessment)

Question 10

What is TSS (Toxic Shock Syndrome)? Describe the presentation.

Answer 10

TOXIC SHOCK SYNDROME

=TSS

• toxin mediated disease
• can occur after relatively small burns
• significant mortality
• give written info on TSS to any child D/C home w/ small burn
• Presentation:
  
  • few days after burn
  • Sx
    
    • fever
    • rash or –
    • D&V

Question 11

With what percentage of burns do children need extra fluid resuscitation (in addition to maintenance fluids)?

Answer 11

Burns of 10% BSA or more