Chapter 9 Common surgical problems Burns

Case study: Joshua Joshua, a 2 year, 3 month old boy was brought to the hospital from a health centre after being burned in a fire.

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage Emergency treatment History and examination Laboratory investigations, if required Main diagnosis and other diagnoses Treatment Supportive care Monitoring Discharge planning Follow-up

Triage – Emergency and Priority signs, weight Burn on side of face, neck, back and buttocks, pale skin Weight 9.2kg (check z-score) Temperature: 35.3oC, pulse: 165/min, RR: 45/min, chest indrawing, SpO2 97% on oxygen Cold feet and hands, thread radial pulse, blood pressure 82/35 Eyes closed, but moves when stimulated

Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

Emergency treatment Airway - Examine for burns to face or mouth. Is there stridor? Are the lips or tongue swollen? Airway support early if any obstructed breathing. Anaesthetist and surgeon (tracheostomy) Breathing - Give oxygen. Circulation - IV line. Start fluid replacement (Ref. p. 269-271) Glucose – check blood glucose Analgesia - IV morphine sulphate (0.05-0.1 mg/kg every 2-4 hours) Pass a nasogastric tube Urinary catheter

History At 6pm the previous day Joshua’s clothes caught fire when he got too close to a fire. His father took off his clothes and washed him in water. His mother and father brought him to a health centre, where the nurse irrigated the burns with water, and applied saline-soaked gauze, gave oxygen, and brought him in the clinic ambulance to the hospital.

History Other relevant history to burn care Did the burn occur inside or outside? Was there an explosion? Immunization status?

Burn examination How much of the body is burnt? How deep is the burn? Use a body surface area chart according to age (Ref. p. 270) Alternatively, use the child's palm to estimate the burn area. A child's palm is approximately 1% of the total body surface area How deep is the burn? Full thickness burns are black or white, usually dry, have no feeling and do not blanch on pressure. Partial thickness burns are pink or red, blistering or weeping, and painful

Examination: estimate the total area burned Back of head = 9 Back = 13 Upper thigh posterior = 3+3 Both arms posterior = 4+4 Total surface burned 36% (Ref. p. 270)

How would you treat Joshua?

Treatment and burns management Fluid resuscitation for >20% total body surface burn. Use Ringer’s lactate with 5% glucose, normal saline with 5% glucose or half-normal saline with 5% glucose. Calculate appropriate fluid requirements (Ref. p. 269-271) and administer ½ of total fluid in first 8 hours, and remaining in next 16 hours Pain control Paracetamol (10-15mg/kg every 6 hours) by mouth and / or IV morphine sulphate (0.05-0.1mg/kg every 2-4 hours) if pain is severe Debridement (cleaning) of dead skin. Escharotomy if compartment syndrome (Ref. p. 269-272)

Treatment and burns management Prevent infection If skin is intact, clean gently with antiseptic solution If skin is not intact, debride the burn (blisters should be pricked and dead skin removed) Give topical antiseptics Clean and dress the wound daily, unless the burn is small and difficult to cover, then it can be managed by leaving it open to the air Hand hygiene Treat secondary infection if present Check tetanus vaccination status and give tetanus immunoglobulin or toxoid booster as appropriate (Ref. p. 269-272)

What supportive care and monitoring are required?

Supportive care Nutrition Begin feeding as soon as possible in first 24 hours Nasogastric feeding High calorie diet with adequate protein, vitamin and iron supplements (Ref. p. 272): F100 Children with extensive burns require 1.5 times the normal calorie and 2-3 times the normal protein requirements (Ref. p. 269-272)

Supportive care Prevention of burn contractures Passive mobilization of involved areas Splinting flexor surfaces Physiotherapy Should begin early and continue throughout the course of the burn care Toys and play (Ref. p. 272)

Monitoring Use a Monitoring chart (Ref. p. 320, 413) Monitor respiratory rate, SpO2 and look and listen for signs of airway obstruction and respiratory distress at the beginning Monitor adequacy of circulation and hydration Pulse, blood pressure Capillary refill Urine output Ensure the child is calm and pain free Monitor nutritional intake (Ref. p. 269-272)

Follow-up Plan discharge when there are signs of recovery of the burnt skin and the parents can care for the child at home. Physiotherapy to minimise contractures. Counseling about home safety and about first-aid management of burns (irrigate with cold water).

Summary Burns and scalds are common injuries in children Home safety measures will prevent many injuries Emergency treatment is lifesaving Avoid secondary infection Antiseptic Clean dressings Hand-hygiene Avoid unnecessary antibiotics Effective analgesia – start early and give for all painful procedures – paracetamol, morphine, ketamine