1. Pediatric Scald and Inhalation Burns in the Emergency Department A Nursing Perspective Elizabeth Waibel, MSN, CPNP Department of Trauma and Burn Surgery Children’s National Medical Center

2. Objectives Describe epidemiology of burn wounds Review concepts of burn assessment, fluid resuscitation and initial emergency treatment of burns Review priorities of inhalation injury management Discuss pediatric burn management and guidelines for care

3. Epidemiology According to 2014 american burn repository (compilation of data 2004-2013) Estimated 450,000 injuries/year Scald most common in children <5, fire/flame in adolescent/young adulthood Overrepresentation of minorities-disappears in young adulthood

4. A look at our numbers…. Burn Visits by Etiology of Injury from 2012 to 2013 Etiology of Injury20122013 Scald 11441165 Contact with hot object466493 Fire/Flame 69112 Electrical 837 Other 7740 Non Burn Conditions 2063 Chemical 1419 Radiation48 Total18021937

5. How does it happen? Most Cooking Activity: Deep fry 500 o Baking 400 o Frying 300 o Crock Pot 200 o Boiling Begins 170 o Taken from www.grossburncenter.org

6. Priorities in Burn Care Evaluate airway, ventilation Depth/injury pattern/neurovascular concerns Calculate TBSA Determine if transfer indicated Fluid Resuscitation Pain Control Wound treatment/dressings Treat associated medical issues/determine need for opthamology, social work, child life, PT/OT, etc

7. Airway/inhalation injury Priorities: Securing potentially edematous airway - look for wheezing/drooling, soot in airway - high clinical suspicion if injury occurred in enclosed space - circumferential burns of neck - evaluate airway/oxygenation/ventilation Management of CO/Cyanide poisoning Management of ARDS *

8. CO/Cyanide Poisoning Carbon Monoxide Odorless, colorless 250 fold affinity for hemoglobin Treatment: 100% FiO2 until carboxy <10% If obtunded, intubate Cyanide Assume cyanide poisoning with smoke inhalation Send cyanide level Treatment: cyanokit

9. Burn Depth Classification Superficial (1º) Partial thickness (2º) Superficial Deep Full thickness (3º) Full thickness (4°)

10. “Sunburn” Damage to epidermis only No blistering Heal spontaneously Superficial Burns

11. Partial Thickness Burn Wounds

13. Partial Thickness Burns involve epidermis damage to upper dermis pink, red blisters intense pain heal within 3 weeks-6 weeks minimal scarring, hypopigmentation

14. Deep Partial Thickness damage to deep dermis red, white, yellow less pain

15. Full Thickness destruction of dermis ivory, brown, black (dry eschar) minimal to no pain require skin grafting or excision/revision

18. Circumferential Burns Potential for neurovascular compromise - Admit to PICU - STRICT elevation - Q 1 hr neurovascular checks

19. Non-Accidental Trauma Injury pattern inconsistent with burn Characteristics include: -line of demarcation -no splash marks -sparing of flexor creases -may be circumferential

21. If NAT is suspected… Admit to trauma/burn CAPC consult Social work/CPS consult NAT workup: -head CT if <2 yrs old -skeletal survey -labs (r/o abdominal trauma)

22. Debridement BeforeAfter

23. www.sagediagram.com

25. Minor Burns <1% or superficial Surgery consult only if needed Tx: aquaphor/bacitracin No social work issues d/c from ED with PMD f/u Tylenol/motrin prn

26. Moderate Burns (2-9%) Consult trauma/burn If d/c’d home, needs bedside debridement, application of silver foam dressing and follow up in burn clinic in 1-3 days If admitting for OR debridement, cover wound with xeroform - MIVF -Pain mgmt -Nutrition consult/high calorie and high protein diet

27. Moderate Burns (10-14%) Admit to floor for IVF, pain control, debridement and nutrition Admit to PICU if airway compromise Place NG tube for nutrition Xeroform to wounds

28. Major Burns (>15%) Trauma STAT activation Admit to PICU Can start d5LR at 1.5x maintenance (while calculating TBSA/Parkland) Pain managemnt Requires NG feeds Debridement likely to take place in PICU (place xeroform in ED) >25% TBSA may be considered for transfer at discretion of Director of Trauma and Burn Surgery

29. Fluid Resuscitation Minor: no IV fluid resuscitation needed Moderate II: Maintenance IV Fluids with Dextrose

30. Complications of over resuscitation Potential for compartment syndrome (extremity, orbital, & abdominal) Acute respiratory distress syndrome (ARDS) Prolonged periods of ventilator dependence Increased mortality

31. Complications of Underrescuscitation Hypovolemic shock Renal failure Potential for wound progression (related to inadequate perfusion) Increased mortality

32. Parkland Formula PARKLAND FORMULA = 4cc X Wt (kg) X % burned surface area (FROM TIME OF INJURY) – first half over initial 8 hours (from time of burn) – second half over remaining 16 hours DEDUCT PREHOSPITAL FLUID FROM TOTAL VOLUME MONITOR URINE OUTPUT HOURLY AND ADJUST TO GOAL:<30 KG 1cc/kg/hr >30 KG 0.5cc/kg/hr

33. Fluid Resuscitation in Major Burns <30 kg: D5LR at MIVF plus Parkland Formula (LR) >30 kg: Parkland Formula (LR) PLACE FOLEY TO MONITOR URINE OUTPUT HOURLY AND ADJUST TO GOAL: <30 KG 1cc/kg/hr >30 KG 0.5cc/kg/hr IF URINARY OUTPUT IS GREATER THAN GOAL TITRATE LR BY 1/3, IF LESS THAN GOAL INCREASE LR BY 1/3

34. Let’s Try It…. 15kg child with 20% TBSA burns 10kg infant with 15% TBSA burns 20 kg child with 5% TBSA burns

35. Pain Management Mild: Tylenol or Motrin prn Moderate I & Moderate II: – IN fentanyl/IV analgesia/conscious sedation for debridement – Potentially admit for NORA Major: – Same as above – Consider intubation if sedation needs are great; debridement likely to occur in PICU

36. Treatment Options Aquaphor Bacitracin Erythromycin Xeroform Mepilex Mepitel/Acticoat Silvadene Biobrane

37. Minor Burn Treatment Aquaphor for facial burns Erythromycin to eyes/eyelids Bacitracin to burns of the genitalia Xeroform

38. Silver Impregnated Dressings Mepilex AG Mepitel/Acticoat

39. Silvadene Consider for deep partial thickness wounds and -road rash -treadmill injury Consider if concerns for infection

40. Biobrane

41. Why might a burn pt bounce back to the ED? Fevers, dehydration, decreased PO intake -kids have risk of infection d/t immunosuppresive effects of burn injury Dermatitis Staph Pustulosis

42. CNMC Burn Clinic Monday, Wednesday, Friday 8am-12pm (M,W,F) 1-4pm (W)

43. Review Airway/ventilation Depth/injury pattern/?neurovascular concerns Calculate TBSA Is referral warranted? Fluid resuscitation Pain control Wound treatment Associated medical concerns/consults (optho, CAPC, SW, etc)

44. Burn Center Referral Criteria 1. Partial thickness burns greater than 10% total body surface area (TBSA). 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 3. Third degree burns in any age group. 4. Electrical burns, including lightning injury. 5. Chemical burns. 6. Inhalation injury. 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. 8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. 9. Burned children in hospitals without qualified personnel or equipment for the care of children. 10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention. Excerpted from Guidelines for the Operation of Burn Centers (pp. 79-86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons

45. References American Burn Association, National Burn Repository® 2014. Version 10.0. Krishnamoorthy, V., Ramaiah, R., Bhanaker, S. (2012). Pediatric Burn Injuries. International Journal of Critical Illness and Injury Science, 2(3), 128-134.

46. Questions