Physicians responsible for the emergency care of injured children manage pediatrie bum wounds frequently. This may involve initial evaluation and resuscitation, referral to a bum center, or supervision of follow-up, especially in communities in which specialist consultation is limited. Emergency care of pediatrie burns includes the assessment of circumstances of injury pertaining to abuse and neglect.
Recent published data reveal that 27.5% of all bum center admissions are children under age 10.
Burns belonged to one of five etiological categories:
* those who were the victims of their own actions, eg, playing with matches, * innocent bystanders, eg, victims of structure fires,
* intended victims, eg, abuse
* victims of their preexisting illnesses, eg, epilepsy with injury during a convulsion, and
* fire-rescue victims, eg, trying to save objects or other individuals from a fire.1
Data from the regional burn center at Maricopa Medical Center reveal that approximately one third of burn patients are O to 14 years old, and two thirds of these are O to 4 years old. Overall, approximately 60% are male, but in younger individuals, gender differences are slight.
Scald burns predominate in most series, constitutiang 70% of all thermal injuries in children, especially at younger ages. More than half occur in the kitchen, primarily from hot liquid spills. Most of the remainder occur in the bathroom, primarily as tub immersion scalds. Contact and flame bums cause the majority of the nonscald thermal injuries. The body surface area affected by burns in children averages <20%, regardless of age. Length of stay is influenced by mechanism of injury (Figure 1). Inhalation injury increases the risk of mortality and length of hospitalization. Sixtyfive percent of pediatrie bums require no operation and heal spontaneously. If surgical debridement is required, a mean of 2.3 operations will be needed, although the number varies with mechanism of injury.
EVALUATION AND INITIAL TREATMENT Small burns not requiring hospitalization constitute a significant segment of the emergency department practice, especially in rural hospitals. Many of these pediatrie injuries will be contact or scald burns, often involving the face or hands. Following adequate pain control and cleaning of the wounds, a nonadherent dressing (usually bacitracin and Adaptic) is applied and covered with a dry gauze dressing. This can be secured with surgical net. Daily dressing changes are generally adequate, especially if the wounds are cleaned thoroughly. Attention should be given to monitoring for cellulitis, which may require hospitalization and intravenous antibiotics.
Figure 1. Average length of stay by mechanism of burn injury, 1994-1995, at the regional burn center at the Maricopa Medical Center.
Although stressful for child and family, small scald wounds commonly heal in 7 to 10 days with little residual impairment. Management of superficial scald burns can be simplified and made much less painful by the application of Biobrane, a synthetic wound covering. Following cleansing, Biobrane is applied, secured in place with steri-strips, and covered with gauze. If adherent after 24 hours, the covering will remain in place as the only treatment until it is spontaneously separated by epithelial regeneration. Failure to adhere indicates the formation of eschar. In this case, the Biobrane is removed and the wound treated with daily silver sulfadiazine dressings. Biobrane does not adhere well to facial burns because of normal motion. Biobrane gloves, if available, can be effective for hand burns.
Larger burns can be much more serious and should be evaluated by a physician familiar with principles of burn care. The guidelines contained within the curriculum of the Advanced Burn Life Support Course state that children with burns involving more than 10% of the body surface area or with any inhalation injury should be hospitalized and undergo fluid resuscitation.2 If possible, these children should be referred to a burn center (Table 1 ). In rural areas where initial care and resuscitation must be given by the community hospital, rapid referral to a bum center would be indicated for significant burns. As in all emergency situations, attention should be given first to establishing a secure airway. Those children who have been in structure fires, are unconscious, or may have upper airway thermal injuries should be intubated. In addition to evaluation for associated blunt injuries, care should be taken to maintain normal body temperature. Wrapping of burn patients in wet sheets or in ice should be avoided since resultant hypothermia seriously compromises resuscitation. Protection of thermal wounds with clean dry sheets is preferred, although small burns such as those affecting hands can be covered with wet dressings during transportation and evaluation.
Indications for Hospital Admissions of Pediatric Burns
Topical Bum Dressings* for Burns of Various Depths
Volume sequestration into a temporarily nonfunctional fluid compartment is a well-known sequela of burn wounds and leads to massive edema in some cases.5 This is mediated primarily by wound-stimulated histamine release from mast cells. These early fluid losses, if not replaced, compromise organ and tissue circulation. A variety of fluid resuscitation formulas have been advocated. The most prevalent was developed by Baxter and Shires more than 20 years ago and is referred to as the Parkland Formula.4·5 This states that 4 mL of lactated Ringer's solution per percent surface area burn per kilogram body weight should be given during the initial 24 hours following a bum. Half is given in the first 8 hours since fluid loss into the interstitial space is maximal because capillaries are at their lowest functional integrity. Additional fluid will be necessary to resuscitate especially young children, partly because renal immaturity limits their ability to conserve water and sodium. Whereas the experimentally derived fluid constant for adults is 4.2 mL/kg/% burn, this number is 5.8 mL/kg/% bum in children.6
In some burn centers, this increased requirement is managed by giving volumes derived from standard Parkland calculations plus maintenance fluids. In other centers, the fluid appropriate for the body surface area of the patient plus an additional increment for the burn surface area is provided as initial resuscitation. Amounts depend on age from the published data by Carvajal et al.7,8 On the first day, 5000 mL/mp 2 burned area plus maintenance 2000 mL/m2 is administered, and on the second day, 3750 mL/mp 2 burned area plus maintenance 1500 mL/mp 2 is administered. Protein in the form of 12.5 g human albumin per liter of crystalloid is given after the first 8 hours to limit edema. Normalized vital signs and urine output of 1 mL/kg/hour are accepted measures of adequate circulatory support.
While pulmonary artery catheters may be desirable in patients with large or complicated burns, normal children have such effective myocardial function that standard vital signs, urine output, and central venous pressure determinations are often sufficient to guide resuscitation. Oral fluid and nutritional intake are started following completion of resuscitation.
Initial evaluation of the wound includes estimation of bum extent and depth with the burn diagram. The bum surface area is factored into the fluid resuscitation formula. The "rule of nines" is easily remembered: each arm represents 9% of the body surface; head and neck, 9%; anterior torso, 18%; posterior torso, 18%; each leg, 18%; and perineum 1%.2 Unfortunately, this rule may not be the best guide for small children. Toddlers and younger children have relatively larger heads and smaller legs compared with adults. Therefore, although this guideline may suffice to begin resuscitation, an alternative method is preferred and the 1944 Lund and Broder modification of the Berkow body surface area chart is used in most burn centers.9 It divides the body into small enough portions so that accuracy is maximized. It also takes into account childhood differences in body proportions. A recent study in our bum center indicates that both prehospital personnel and the bum team may significantly misjudge the extent of pediatrie bums when compared with an actual measurement (D. Slattery, C. Pollack, and W.R. Schiller, unpublished data, 1996).
Clinical appraisal of circumferential wounds should include a decision as to the necessity for decompressive escharotomy. Although clinical signs of limb ischemia have been used, these may appear after a significant period of poor perfusion. Delays in dealing with limb compartment syndrome may compromise function in the convalescent phase. Earlier assessment using compartment pressures is the preferred technique. Pressures in excess of 25 mm Hg generally should prompt an escharotomy.10
Figure 2. Superficial scald burn with raw areas of denuded blistered skin surrounded by red, painful first-degree burn.
Figure 3. This spilled grease burn demonstrates white burn eschar indicating a deep, possibly third-degree burn. Although the periphery of this burn will heal spontaneously, surgical debridement and skin grafting may be necessary for appropriate wound closure.
Estimation of burn depth is performed on admission and reevaluated during the initial days of treatment. First -degree and superficial second-degree bums usually heal spontaneously and are characterized by pain and redness, with blisters being the hallmark of second'degree wounds (Figure 2). Deep second-degree and third-degree burns may look leathery or white and are less painful (Figure 3). These wounds involve most or all of the depth of skin and generally require surgical debridement and skin grafting. Areas that initially may not appear deep may "convert" over 2 or 3 days, thereby necessitating surgical intervention.
Prophylactic antibiotics have not been shown to decrease burn wound infections since topical antibiotics suppress bacterial growth in burn eschar.11 Superficial bums affecting small areas of skin may be protected adequately using topical ointments such as bacitracin and changing the dressings once or twice daily. More serious burns require broad'Spectrum topical coverage such as silver sulfadiazine cream. In patients with sulfonamide allergy, 0.5% stiver nitrate solution offers an effective alternative. It should be remembered that silver nitrate dressings must be kept wet to prevent wound desiccation. In addition, silver nitrate produces a dark discoloration of all surfaces it comes in contact with. Mafenide cream may be used for infected burns and to protect the auricular cartilage of burned ears, but this is painful. It also produces mild metabolic acidosis, due to its activity as a carbonic anhydrase inhibitor (Table 2 ) . Regardless of which topical preparation is used, early eschar excision and biological wound coverage with autografi, homograft, or heterograft offers the best strategy for preventing colonization and infection. Furthermore, eschar removal ameliorates catabolic stress (including fever) and decreases the inflammatory reaction.12 Fever occurs frequently in burned children and stimulates a predictable response to identify the pyrogenic source. However, in the majority of the patients, fever is not from the wound but rather from common pediatrie diseases such as otitis media, pharyngitis, urinary tract infections, or pulmonary infections.
Recent improvement in patient survival following severe bums is largely attributed to early excision of burn eschar. Some centers perform surgical removal within the first 24 hours following admission.13 We schedule the patient for eschar excision when resuscitation is complete, usually within 3 days. Large burns may require multiple procedures to remove eschar, establish wound coverage, and gradually convert all nonautologous dressings to autografts. This may necessitate repetitive harvesting and reharvesting of skin donor sites every 7 to 10 days. Hemdon and coworkers14 used growth hormone to accelerate healing of donor sites and thereby facilitate wound closure. When the burn is large and minimal graft donor sites are available, tissue culture to provide sheets of autologous keratinocytes may greatly aid wound coverage. In some cases, this seems to be life-saving.15 While most burn centers have had positive experiences with cultured keratinocytes, the question of whether this technique decreases mortality or improves outcome remains to be confirmed.16
ANCILLARY SUPPORT ISSUES
Pain control in pediatrie burns can be a challenge. Small children are nonverbal in their expression of pain so as-needed pain medications often produce less than optimal relief. Interpretation of pain severity by nursing and surgical staff is highly variable. Thus, analgesia for pediatrie burn victims should assure medication on a regular basis to provide adequate and continuous pain relief. For small burns, elixir of acetaminophen with codeine may be sufficient, especially if supplemented for the first few days with patenterai narcotics. More potent medication is necessary for large burns. Recently, it has been recognized that methadone for 24-hour analgesia is both safe and effective for children. ' 7 Morphine and fentanyl remain reliable parenteral analgesic agents for dressing changes and difficult physical therapy, but ketamine may be preferred as it produces dissociative anesthesia with low risk of hypoxia. Propofol also has been used for painful procedures, although the patient should be monitored carefully during its use.
Burn wounds produce metabolic changes by a variety of stimuli including hormone secretion, activation of cytokines, and blood-borne products of bacterial proliferation. These effects are exaggerated by hypothermia. Thus, warming of treatment rooms, intravenous fluids, and respirator gases is protective. These metabolic variances cause significant increases in caloric expenditure, breakdown of lean body mass, and massive cycling of metabolites in proportion to the severity of the wounds. They persist until the wounds are biologically closed. These alterations may be quantified by monitoring oxygen consumption, carbon dioxide production, 24-hour urinary nitrogen, 3-methylhistidine and creatinine excretion; tracking body weight; and measuring acute reactants such as prealbumin and transferrin levels.
Partial control of these processes by performing early wound excision and skin grafting, protecting body core temperature, and providing exogenous nutrients are now a standard of care. Adult nutritional formulas are not well-suited in children. Caloric requirements of burned children are probably best estimated by the formula used at the Shriners Bum Center in Galveston, Texas18:
* infants - 2100 cal/m2 surface area plus 1000 cal/m2 of burn surface area,
* older children - 1800 cal/m; surface area plus 1300 cal/m2 of burn surface area, and
* adolescents - 1500 cal/m2 daily for both body surface area and bum surface area.
In addition, administration of" 1 to 2 g protein per kilogram body weight plus supplementation of vitamins and trace minerals are common practice. Although some patients require total parenteral nutrition, we and many other centers prefer to start tube feedings during the first day of admission with rapid advancement to intake goals.
Figure 4, This composite photograph demonstrates a deep burn of the buttocks, which by itself may not indicate that the burn was intentionally inflicted. However, the associated photo panel confirms intent, ie, typical cigarette burns on the soles of the child's foot.
Seriously burned children should undergo aggressive physical therapy and psychological support. Many burn centers do routine psychological evaluations and support of severely burned victims to help them adapt to burn care and rehabilitation. Psychological adaptive maladjustments vary depending on the age. Agitation, withdrawal, and extreme fright are common. Regression to immature behavior is a response seen in most burned children. Jorgenson and Brophy19 have described three phases of psychological responses to burns. First is the survival phase in which physical needs are of paramount importance. Confusion, hyperactivity, and sleep disorders are common. An intermediate adaptive phase follows, wherein the patient begins to understand and cope with the burn and treatments. In the recuperative phase, the patient learns to cope with rehabilitation, physical impairment, and pain. Restoring family dynamics toward normal, longterm emotional support and return to school must be managed.
Evaluation of the child's social environment and family dynamics is performed as soon as practical. Many pediatrie burns occur in the setting of poverty and family dysfunction. The identification of these issues can help us provide temporary community resources to support the stressed family. In some cases, neglect and abuse will become apparent, signaling the need for more active intervention Figure 4 ) · Protection of the child may become as important as medical care for the burn. Pediatricians responsible for general care of the patient may be called on to follow-up on such problems after discharge.
Early in the treatment of a burn, affected areas should be splinted appropriately, elevated to minimize edema, and encouraged to heal in the shortest possible time to limit ongoing inflammation at the wound. As soon as possible, passive, followed by active, range of motion exercises are begun. Splinting of hands in children may differ from adults due to their tendency to respond by making a fist. Splinting hands and wrists in extension will maximize return to function and prevent flexion contractures. Dynamic splinting and casting can be useful depending on the child's ability to cooperate. Use of mouth splints to prevent or treat microstomia in facial burns is desirable.
As the wounds are covered and some of the critical concerns such as infection and withdrawal from mechanical ventilation are resolved, physical therapy and focused rehabilitation become prime concerns. Compression garments, splints, and intense programs to restore function comprise the last of the hospital stay and the postdischarge transitional period, and continue through follow-up visits to the burn clinic. Control of itching, residual pain, sun avoidance, and proper use of splints and compression garments are common problems addressed in the clinic. Although increased survival of large burns has become common, restoration to a normal lifestyle can be accomplished only by a proper program of postsurvival treatment by all disciplines of the burn team.
Pediatric burn care consists of a coordinated program to provide acute physiological support during the shock phase, prompt wound closure, aggressive ancillary care, and appropriate postdischarge management. Adherence to predetermined burn care guidelines will produce the most optimal results in survival and return to function.
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Indications for Hospital Admissions of Pediatric Burns
Topical Bum Dressings* for Burns of Various Depths