1. Chapter 9 Common surgical problems Burns

2. Case study: Alisher
Alisher, a 10 months old girl was brought to the district hospital by her mother. At presentation Alisher was very anxious, crying in pain and was not able to breastfeed. On the upper half of the chest there was a large scald.

3. What are the stages in the management of Alisher?

4. 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

5. Temperature: 37.20C, pulse: 160/min, RR: 45/min
What emergency (danger) and priority (important) signs have you noticed?
Temperature: 37.20C, pulse: 160/min, RR: 45/min
Chest: burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no added sounds.

6. 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

7. History
At 6pm the previous day Alisher overturned a hot teapot and was burnt. Her mother and relatives took off her clothes and applied toothpaste and potato to the burn skin.
During the night the child was very anxious and restless, by the morning her condition had worsened and she could not feed. Her mother brought her to the hospital.

8. Examination Diagnosis:  Burns
Vital signs: temperature: 37.20C, pulse: 160/min, RR: 45/min,
Weight: 9 kg
Chest: Burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no added sounds.
Cardiovascular: both heart sounds were audible and there was no murmur
Abdominal examination: soft, bowel sound was present
Mouth: mildly dry mucus membranes
Skin: mildly decreased skin turgor
Diagnosis:  Burns

9. Two very important questions:
How much of the body is burnt?
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

10. Further examination: Estimate the total area burned
(Ref. p. 270)

11. How would you treat Alisher?

12. Treatment & burns management
Hospitalize all children with burns of the skin more than 10%.
Consider whether the child has a respiratory injury due to smoke inhalation.
Fluid resuscitation (required for >20% total body surface burn). Use Ringer’s lactate with 5% glucose, normal saline with5% glucose or half-normal saline with 5% glucose.
Calculate appropriate fluid requirements (Ref. p ) 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 ( mg/kg every 2-4 hours) if pain is severe
(Ref. p )

13. Treatment & burns management (continued)
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 antibiotics/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
Treat secondary infection if present
Check tetanus vaccination status and give tetanus immunoglobulin or toxoid booster as appropriate
(Ref. p )

14. What supportive care and monitoring are required?

15. Supportive care Nutrition
Begin feeding as soon as practical in first 24 hours
High calorie diet with adequate protein, vitamin and iron supplements (Ref. p. 272)
Children with extensive burns require about 1.5 times the normal calorie and 2-3 times the normal protein requirements
Prevention of secondary infection
Hand washing
(Ref. p )

16. Supportive care (continued)
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)

17. Monitoring Observe the child frequently
Monitor respiratory rate and look and listen for signs of airway obstruction and respiratory distress at the beginning
Monitor adequacy of circulation and hydration
Pulse
Capillary refill
Urine output
Use a Monitoring chart (Ref. p. 320, 413)
Ensure the child is calm and pain free and feeding adequately (Ref. p )

18. Follow-up
Plan discharge when there are signs of recovery of the burnt skin and the parents can care for the child at home. Notify parents on the date of follow up visit.
Administer physiotherapy to minimise contractures.
Accomplish a counseling about home safety and about first-aid management of burns (irrigate with cold water).

19. Summary
Burns and scalds are associated with a high risk of mortality in children.
It is important to avoid secondary infection
Antiseptic
Clean dressings
Hand-hygiene
Avoid unnecessary antibiotics
Effective analgesia is the second main pillar in management of burns
Initially, and for all painful procedures