Eur J Plast Surg (1996) 19:207-212

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© Springer-Verlag 1996

Management of burn injuries in children R. Slator, J.D. Frame North East Thames Regional Plastic Surgery and Burns Unit, St. Andrews Hospital, Billericay, Essex, UK

Abstract. 120000 patients are seen with burns in emergency departments in the U.K. each year, Of these, 50% will be children. The average age of the children admitted to the North East Thames Regional Burns Unit (NETRBU) will be 4 years, and the size of the burn 10% body surface area. Some of the children admitted will be severely ill requiring intensive treatment. Many will be scarred, and have long-term morbidity. This paper offers a treatment protocol for burned children from first aid to management in the emergency department, and describes the regimen for treatment then followed in the NETRBU.

Key words: Burns - Children - Toxic shock syndrome, management of

It is estimated that in a year, 120000 patients with burns will be seen in casualty departments in the UK. Of these, 50% will require admission to hospital, and 50% will be children. At the North East Thames Regional Burns Unit (NETRBU) approximately 15 children are referred each month with burn injuries. Of these, ten will be admitted to the burns department, the rest being treated as outpatients or in a general plastic surgery floor. Of those admitted, the average size burn will be 10% body surface area, and the average length of stay in the burns department is ten days. The average age of the children will be four years. Some of these children will be severely ill, requiring intensive treatment of their condition. Many will be scarred and have long-term morbidity. The major causes of thermal injury in children are domestic accidents, most commonly scalds (Fig. 1), for example from spilled tea or coffee, saucepans pulled over, and bath water run too hot. Contact burns (Fig. 2) from radiators, fires, and irons are also seen regularly. Other Correspondence to: J.D. Frame, Consultant Plastic Surgeon, North East Thames Regional Plastic Surgery and Burns Unit, St. Andrews Hospital, Billericay, Essex CMI20BH, UK

injuries include flame burns (Fig. 3), electrical (Fig. 4), and chemical (Fig. 5) injuries. Inhalational and respiratory burns may also occur.

First aid At the scene of the injury the most important initial action is limitation of the damage done. The source of the burn, including clothing, should be removed and the thermal injury reduced by cooling the environment by immersion in cold water for 10 to 15 minutes. However, care should be taken to prevent a small child from becoming hypothermic. The child should then be transferred to the local emergency department as quickly as possible.

Management of the emergency department In the emergency room, management of the burned child will depend on the severity of the injury. Burns have been categorized by the American Burns Association into major, moderate and minor, according to the size of the burn, the depth of the burn, the site of the burn, and the presence or absence of other medical conditions or associated injuries (Table 1). In general, prognosis deteriorates with increasing size and depth, and in the presence of other medical conditions or associated injuries. Inhalational injury greatly increases the risk of death. The patient is assessed by a careful history including the time the burn occurred. The nature of the injury and the first aid carried out may give useful clues as to the severity of the injury. For example, information as to how recently the kettle had boiled, what clothes were being worn, whether they were removed, and whether the burned area was cooled immediately should be obtained. The likelihood of inhalational or respiratory damage as a result of the nature of the injury is also considered. The general medical condition of the patient must also be established, and the possibility of other injuries excluded.

208

Fig. 1. Typical superficial burn from scald injury Fig. 2. Contact burn from electric bar fire Fig. 3. Flame burn from house fire Fig. 4. Typical electrical injury to hand Fig. 5. Acid burn to face Fig. 6. Non accidental injury: loss of toes following immersion of foot in hot water Fig. 8. Desquamation of rash approximately two weeks after burn associated toxic shock syndrome

209

Name. Age

Ward Admission weight

Number

Date

Lund and Browder charts

ignore simpleerythema

~ ~

Partial thickness loss (PTL) ~UlFTL~hicknessloss

Region Head Neck Ant. trunk Post. trunk Right arm Left arm Buttocks Genitalia Right leg Left leg Total burn

PTL FTL

Relative p e r c e n t a g e of body surface area affected by growth area A--1/2 of head B=1/2 of one thigh C=1/2 of one leg

age 0 91/2 23/4 21/2

Fig. 7. Chart for estimating severity of burn wound

1 81/2 31/4 21/2

5 61/2 4 2a/4

10 51/2 41/2 3

15 41/2 41/2 31/4

adult 31~ 43/4 31/2

210 Table 1. Categorisation of burn injuries in children

Partial thickness Full thickness Specialised areas involved Inhalational injury Associated injuries Other medical problems Miscellaneous

Table 2. Symptoms and signs indicative of inhalational or respiratory injury

Major

Moderate

Minor

>20% >10% Yes

10-20% 2-10% -

< 10% <2% -

Yes Yes Poor risk patients Electrical injury

Relatively good risk patients -

None

Table 3. The Muir and Barclay 2 formula

Weight (kg) x %BSA burned History Examination

Fire in an enclosed space, unconsciousness Facial burns Singed nasal hair Perioral full thickness burns Posterior pharyngeal swelling Cough +/- bronchorrhoea Sooty sputum Stridor Dyspnoea and tachypnoea Tachycardia Sweating and exhausting

In children, non-accidental injury must also be considered (Fig. 6). This may be indicated by inconsistent or vague recall of what happened, and by the pattern of injury. Examination establishes the location and size of the injury, and the percentage body surface areas (BSA) burned is recorded. This is best done using a Lurid and Browder chart (Fig. 7). An estimation of the depth of the burn is also made, although this is notoriously difficult to do accurately. Where there are circumferential fullthickness burns of the digits, limbs, chest or neck, escharotomy must be considered, and carried out immediately when there is vascular or ventilatory compromise. The child is weighed. Evidence of inhalational or respiratory injury is also considered (Table 2), and the opinion of an anesthetist is required if there is any suggestion of impending or actual airway obstruction, or of respiratory failure. Early intubation is the rule if there is evidence of ventilatory or respiratory compromise; rapidly developing-edema of damaged airways may make intubation difficult.

Treatment

Very minor burns (<5% BSA, superficial) can often be treated conservatively with dressings on an outpatient basis. The burned area should be gently cleaned with saline, and any punctured or fragile blisters deroofed. The wounds can then be dressed with Jelonet (paraffin gauze dressing BP) or Mepitel (non-adherent silicone dress-

-

Burn periods (post burn) 1st 0-4 h 4th 2nd 4-8 h 5th 3rd 8-12 h 6th

Volume of plasma (ml) required/ per burn period 12-18 h 18-24 h 24-36 h

ing), and an absorbent dressing. The wounds need to be reviewed every two to five days, depending on how much ooze there is through the dressing, and how well they remain in place. Dressings continue until the wounds are healed. Small areas on the face can be exposed with application of liquid paraffin, or silicone, to prevent drying. Any areas unhealed after three weeks need referral to a specialist unit. When treating small children (<10 years), it must be recalled that even superficial injuries of <5% BSA can give rise to toxic shock syndrome (TSS) and be life-threatening in such young children [1]. Moderate or major burns in children require admission to a specialist centre. Burns of >10% BSA require formal fluid resuscitation, and this should be started in the emergency department. In the UK this is usually carried out following the Muir and Barclay [2] formula (Table 3). This formula divides the resuscitation into six time periods from the time of the injury, and requires knowledge of the size of the burn and the weight of the patient. It was originally calculated for the use of plasma, but is usually now used with human albumin solution. If required, fluid resuscitation should be started as soon as possible after the burn injury, and blood should also be taken for full blood count and packed cell volume. In a major burn (>30% BSA), monitoring of fluid balance will also require accurate hourly measurement of urine output, and a urinary catheter should be passed. Blood should also be grouped and saved for cross matching, as blood transfusions may be necessary in the resuscitation period as a result of destruction of red cells by the burn injury. If needed, analgesia should be given as soon as possible after the injury. A burn is a traumatic and painful event, and adequate analgesia may well require repeated

211 doses of intravenous opiates. Intramuscular analgesia should not be given because of the potential for poor absorption. The burn wound itself, after assessment, should be wrapped in cling film or clean towels, before transfer to a specialist unit. The patient must be kept warm.

Management in the burns centre

The principles followed when treating a burned child are the same for any burned patient, namely to replace fluid losses, prevent infection, maintain nutrition, close the burn wound, and restore function and appearance. Fluid replacement is monitored closely for 36 h, with checks of packed cell volume at the end of each burn period and daily full blood count, urea and electrolytes, and blood glucose. Core (rectal) and peripheral (great toe) temperatures, blood pressure, pulse and respiration rates, and urine output are monitored hourly. In a child urinary catheterization should not be undertaken lightly since problems of infection and urethral stricture may occur, but will be necessary in a major burn. In moderate burns nappies can be weight where appropriate. Fluid replacement should be varied to maintain urine output at 0.5 ml/kg body weight/h. The fluid resuscitation formula does not take into account normal daily fluid requirements and the child should be encouraged to eat and drink. Where this does not occur because of distress or discomfort, supplementation of normal daily requirements is carried out, either with intravenous crystalloid solution, or preferably nasogastric feeding. The burn wounds are cultured on admission to the burn unit, as are axillae, groins, nose, throat and rectum of the patient. Wound cultures are repeated at dressing changes, and nose, throat and rectal cultures weekly. Infection may increase the depth of the burn, and cause systemic illness. Patients with major burns are known to be immunocompromised and are therefore at great risk for systemic infection, which remains the main cause of death among burn victims. The infectious agent usually arises from the patient themself. If bacteriology has been obtained prior to infection, appropriate antibiotic therapy can be started at the first sign of systemic illness. Prophylactic antibiotics are not usually given. To help prevent infection the patient is isolated in a single room with visitors being limited to two. Cultures of nose and throat are also taken from these visitors. Gloves and gowns are required for all those interacting with the patient. Children under the age of 10 are thought to be particularly susceptible to infection following burn injuries, and in particular to the effects of exotoxin producing staphylococci because of a lack of staphylococcal antitoxins [3]. Such antitoxins are present in 95% of adults [4]. As a result of their lack of antitoxins it appears that children may develop staphylococcal toxemia or toxic shock syndrome even with small burns. Children suffering from toxemia or developing TSS after burn injuries become rapidly unwell one to four days after their injury, suffering a marked rise in temperature, pulse and respi-

ratory rates. They are likely to vomit and have diarrhea, and may develop a rash which sometimes desquamates after two weeks (Fig. 8). The hemoglobin and white cell counts of these children fall. Most marked is the general condition of the children which deteriorates rapidly. Treatment with intravenous antistaphylococcal agents, fluid resuscitation and fresh frozen plasma to provide immunoglobulins results in a rapid response [4]. Staphylococcal exotoxins also increase susceptibility to gram negative endotoxins, and antibiotic cover against gramnegative bacteria is also recommended [5]. The diagnosis of developing toxic shock is clinical, and early treatment is recommended. A scoring system 1 has therefore been developed at the NETRBU to aid decision-making as to when to treat such patients. Maintenance of nutrition is important for the outcome of the burn injury. For burns > 20% BSA, nasogastric feeding is used to supplement the patients diet and caloric intake. Metabolic rate increases with the size of burn up to a maximum at 40% BSA. A dietitian should be involved in the care of all patients with moderate or major burns to monitor their caloric intake and modify their diet where necessary to meet the increased metabolism demands. In general, patient should be encouraged to eat whatever they like to maintain their intake, but not forced to eat more than they want to. There is some evidence that some patients on high calorie diets as inpatients continue to consume large quantities of calories after discharge and consequently become overweight in the long term. Supplementary nasogastric feeding should be used only to top up their requirements, and should preferably be given at night. If patients find eating difficult, nutritious liquid supplements may be of value. Closure of the burn wound is the ultimate aim of treatment. Obviously superficial partial thickness burns are treated with dressings. These may be simple Jelonet or Mepitel or have Flamazine (silver sulfadiazine (1%) added as a bacteriostatic agent. Flamazine, however makes the burn depth difficult to assess after its application and requires daily dressings. A superficial burn will heal within three weeks. The more quickly the wound heals the less severe is the resultant scarfing. Dressings without Flamazine need only be changed if they become offensive, wet from oozing, or splip off. Repeated removal of dressings will slow re-epithelialization and healing. The more slowly the wounds heal the more likely is hypertrophic scarring. A full thickness burn needs excision, and the resulting defect reconstruction, usually with skin grafts. This can be carried out at any time once the patient is stable, and is best done early within the first three days after the burn. In major burns, the area excised may be limited by blood loss to 20%. Limitations in the amount of skin for grafting may also occur. In very small children, parents may provide allogenic graft material to cover the burn wound. Alternatives include cadaveric skin and synthetic 1Khan JI, Iwuagwu F, Frame JD: The MARSBAR scoring system for assessment of prodromal paediatric toxic shock syndrome. Presented at the International Society of Burn Injuries, Paris, June 1994

212 Table 4. MARSBAR - a scoring system for the assessment of burned children and the need for treatment of toxic shock** Score M

Mental state

Irritable/drowsy Hypertonic/floppy

2 2

A

Alimentary system

R S

Respiratory system Skin

5 2 2 1 5 3 3

B

Blood results

Diarrhoea Vomiting Abdominal distension Tachypnoea Rash and temp. >40 Core temp. >40 Rash alone Falling white cell Count <6 Hb <9 gin/1 Tacbycardia > 140/rain Failing platelet count Hypocalcaemia Unwell

A

appearance

R

renal system

Total score

0-9 10-15 16-25+

Urine output <0.5 ml/kg/h

5 3 1 1 1 5 1

no action suspect treat

skin, and skin m a y also be cultured, although the results from using cultured skin for grafting have not been encouraging. Mixed depth, and deep dermal burns provide a more difficult management problem. It m a y be a problem even for an experienced surgeon to judge whether or not a burn will heal spontaneously. Particularly over the first 72 h the burn may extend and become more clearly in need of surgery. During this time the wounds may therefore require repeated assessment. Those areas that do heal within a reasonable length of time will give better scars than a skin graft. Furthermore, where a donor site can be avoided it should be, particularly, in patients with darker skin where donor site morbidity from changes in pigmentation or keloid scarring can be graft. However, areas that heal only very slowly may result in very poor scarring, or eventually be grafted anyway, the patient

having endured weeks of dressing changes. Leaving the burned tissue in situ also increases the risk of infection, and a patient with a mixed depth burn who becomes systemically unwell should be treated rapidly by tangential excision and grafting. Where possible, grafts should be laid as fenestrated sheets, these will give a better cosmetic result than meshed graft. During the healing period it is imperative that joints are kept mobile. This is particularly true for hand burns, which are usually treated in plastic bags with silicone of Flamazine to allow a full range of motion of the hands. Intensive and specialized physiotherapy and occupational therapy are required, both during this time and after the burns are healed. Once the burn wound is healed the patient needs follow-up while the scars mature. Skin grafted areas, or areas that have taken more than a week to heal will require pressure garments to keep the scars soft and supple, and help prevent hypertrophy. Joint contractures may need splinting or surgical release, and such treatment m a y require follow-up over many years. The whole family, patient, parents and siblings, may require and should have easy access to psychological support. In order to obtain the best results from burn injuries in children, a coordinated team approach is required often over many years. This may involve surgeon, intensivist, physiotherapist, occupational therapist, dietician, social worker, and clinical psychologist, all of w h o m need a particular interest in and specialized knowledge of the burn injury.

References 1. Frame JD, Eve MD, Hackett MEJ et al (1985) The toxic shock syndrome in burned children. Burns 11:234-241 2. Muir IFK, Barclay TL (1962) Burns and their treatment, 2nd edn. Lloyd-Luke, London 3. Frame JD, Bird D, Eve MD, Webster ABD (1987) IgG subclass levels in thermally injured children. Scand J Plast Surg 21:323-326 4. Frame JD, Everitt AS, Gordon PWN, Hackett ME (1990) IgG subclass response to gamma globulin administration in burned children. Burns 16:437-440 5. Schlievert PM (1982) Enhancement of host susceptibility to lethal endotoxin shock by staphylococcal pyrogenic exotoxin type C. Infect Immun 36:123