Pediatric Case of the Week 19: Burn

Winter has lingered far too long in your cozy little mill-town.  Children and their shortened attention spans are wreaking havoc in homes all across the land.  Parents are begging for the momentary relief that comes with a bit of green grass and a few extended beams of sunshine.

Unfortunately, the glut of indoor time has probably contributed to your next case...




A 2 year old boy presents with his parents in severe distress after a steaming pot of water (intended for yet another meal of macaroni and cheese) was pulled off the stove by his 4 year old sister and onto his torso, arms, and legs.  He is distraught, crying, and inconsolable with areas of blistering and denuding skin.  Specifically, his burn involves the left side chest, abdomen, and left lateral arm/leg.






You estimate about 20% burn involvement.  Arm and leg burns are non-circumfirential.

Vitals: HR 121 BP 75/60 RR 43 Sat 97%RA

What is your initial management?

If you elect to intubate, what agent(s) would you use?

How do you estimate burn surface area?

How do you calculate fluid replacement?

Do you want any labs?  What lab abnormalities might you find in a burn patient?

What is the most common type of pediatric burn?

If the patient presented with an isolated gluteal burn or plantar foot surface burn, what would you suspect?

What would you do about that blister?

What is this patient's disposition?


--------------WEEKEND UPDATE--------------


Burn injuries are the 3rd leading cause of unintentional injury in children age 0-18 years old.  (Behind  motor vehicle accident and drowning.

Scald injury is the most common pediatric burn accounting for 70-80% of cases.  These burns occur most commonly in age less than 4




Burns Classification:

-Superficial: only the epidermis, non-blistering

-Superficial Partial-Thickness: entire epidermis and superficial layers of the dermis, +/- blister

-Deep Partial-Thickness: entire epidermis and dermis, waxy appearance, significant scarring

-Full Thickness: entire epidermis and dermis, insensate, charred or leathery, skin graft







You may use the modified pediatric "rule of 9's" or the "Lund and Browder chart" to estimate burn surface area.  (Remember Pediatric Patients have BIG HEADS)

Burns greater than 20% total body surface area (TBSA) can have systemic effects that require aggressive fluid resuscitation.

There are several resuscitation formulas that can be used to initiate infusion:  ***  Most important that you AGGRESSIVELY HYDRATE because burns result in significant fluid loss.


Interestingly, lab studies are considered important in patients with burn injury.  Burns can lead to anemia so a CBC is recommended.  Electrolytes are important because of the potential for large fluid shifts.  Hypoglycemia can occur due to decreased glycogen stores.  Also, muscle injury associated with electrical, thermal, crush, or blast burns can easily lead to Rhabdomyolysis.  Also, if fire related, consider checking carbon monoxide levels.

Don't forget about other injuries.  Blast victims may also have associated traumatic injuries.

Burns should be cleansed with mild soap and water, derided, and treated with topical antimicrobial dressings or occlusive dressings.  Blisters should remain intact (this remains controversial...but let someone else do it.)  During the initial resuscitation you can simply cover large burn areas with cool wet gauze. There is little evidence that silver sulfadiazine reduces infection and it may actually increase the risk of allergic reaction.   If you're really concerned about infection, I'd recommend bacitracin over silver.

Always, Always, Always consider child abuse.  Sadly, approximately 6% of burned children under the age of 12 years old are victims of abuse.

GIVE ANALGESIA.  Oligoanalgesia is far too common among pediatric burn patients.  GIVE them meds. Morphine, Fentanyl, or dilauded...treat the pain.

"Ay is fah' Ayaway!!!"  if there are any signs of inhalation injuries or burns near the mouth/nose, carbonaceous sputum, singed nasal hair, CONSIDER EARLY INTUBATION.  Airway edema can evolve, so remember that just because the airway is patent NOW might not mean that it will be patent over time.  Err on the side of caution and have LOW THRESHOLD TO  intubate.


Don't forget to check the patient's tetanus status.

Disposition:

Indications to transfer child to a burn center (Developed by the American Burn Association)

-Partial thickness burns greater than 10% total body surface area
-Burns involving face, hands, perineum, genitalia, or major joints
-Full thickness burn in any age group
-Electrical burns, including lightning
-Chemical burns
-Inhalation injury
-Pre-existing conditions that complicate management, recovery, or mortality
-Burn injury with Trauma
-Injury that will require special social, emotional, or rehab intervention