1. Paediatric Burns
2013

2. BURNS IN CHILDREN
In South Africa burns are the number one cause of unnatural death in children under the age of 4 years
The vast majority of burns occur in the home of the child
Hot water scalds are the most common cause of burns
Causes of burns: Scalds: hot water pot; flame: house fire, paraffin stove, candle falling on bed; contact: cooking appliances, heaters; electrical: open informal wires in informal dwelling or high voltage in substations; chemical: unsafe storage practices of acids and alkalis eg stove cleaner or drain cleaner
75% of burns occur at home due to poor socio-economic infrastructure, crowded living environment without fire breaks. Open fires in the house are risky for the child

3. The ABC of Burns resuscitation

4. Basic first care SAFE approach: Stop the burning Cool the burn wound
Shout for help
Advance with care
Free the person from danger
Evaluate the patient - ABCD
Stop the burning
Cool the burn wound

5. Airway History: Examination: Management: enclosed space? Smoke? Steam?
burns to face
Sputum containing soot
Change in voice or cry, brassy cough, dysphonia, stridor
Management:
Clear airway,chin lift, jaw thrust. Beware: spine
Close observation
Humified 100% oxygen for 24h in all major burns
ET tube

6. Breathing Breathing effort: Cyanosis or bright pink colour
Tachypnoea, hypopnoea
Abnormal chest movements
Cyanosis or bright pink colour
Cardiopulmonary resuscitation if not breathing, endotracheal intubation

7. Circulation Check the pulse Capillary refill time (normal < 3 sec)
Shock in burns does not occur immediately, but evolves over time. If early shock look for bleeding elsewhere

8. Circulation: Fluids
Initial 20mls/kg fluid bolus of Ringers Lactate if patient is shocked (can be repeated)
Ongoing fluid requirements need to be calculated
Resuscitation (Ringers Lactate):
Day 1: 2-3ml x kg x % burn first half given in the 8 hours from the time of injury and the second half in the subsequent 16 hours
Day 2: 1 - 2ml x kg x % burn over 24 hours
Plus: Maintenance, per day (Paediatric maintenance solution with Glucose): 100 ml/kg up to 10kg plus 50 ml/kg from 10 – 20 kg
This is only a guide. Clinical reassessment is important to adjust the fluids, for example if output is low and perfusion poor then give a fluid bolus of 10 ml/kg, if output is abundant and urine not concentrated then reduce fluids

9. Disability: Level of consciousness
Altered sensorium may be due to:
Associated head trauma
Poor oxygenation
Shock
Carbon monoxide toxicity

10. Exposure
Purpose of full exposure is to assess total burnt surface area and other injuries
Be aware that children are at risk of developing hypothermia

11. Burn wound assessment Two components:
Assessment of burn wound area: Determines fluid and metabolic needs
Estimation of depth of the wound: Determines local and surgical management

12. Estimation of total burn surface area
For every year after 1 year the head area decreases by around 1% and each leg gains 0.5%.Thus adult proportions are reached by age 10 years.
Alternative method: Open unstretched Hand represents 1% BSA

13. Estimation of burn depth

16. Analgesia
Pain management must be started from the beginning: Diminishes SIRS, diminishes long term psychological scaring
Oral:
Tilidine HCL (Valoron): 1 mg/kg 6 hourly
Paracetamol: Loading dose 20 mg/kg; maintenance 15 mg/kg/dose, can be repeated 6 hourly

17. Analgesia Parenteral analgesia:
Morphine 0.5 mg/kg in 50 ml 5% D + W. Infusion rate 1 – 4 ml/hour
Ketamine 2 mg/kg/dose: For procedures
Need to be able to ventilate child if stops breathing (resuscitation equipment must be ready)

18. Definitive management
Transfer to burns centre is indicated for the following:
Partial thickness burns greater than 10% TBSA
Burns involving face, hands, feet, genitalia, perineum, major joints
Third degree burns (any extent)
Electrical, chemical burns
Inhalation injury
Circumferential burns
Suspected child abuse
Any patient that can not be managed at the referring facility

19. Definitive management
Before transfer to the burns centre do the following:
Document history and time of the burn
Document fluids planned and received
Diagrammatic sketch of burnt area
Send signed consents for slough excision and grafting
Ensure safe transport and qualified accompanying personnel to continue resuscitation en-route (working drip essential)

20. Definitive management
Prevent limb ischemia: Escharotomies
Prevent Katabolism: Early enteral feeding
Prevent sepsis: Early sloughectomy, skin grafting. Prophylactic antibiotics do NOT work
Prevent contractures: Splinting