1. Chapter 9 Common surgical problems Burns

2. 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.

3. 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

4. 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

5. 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

6. 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 )
Glucose – check blood glucose
Analgesia - IV morphine sulphate ( mg/kg every 2-4 hours)
Pass a nasogastric tube
Urinary catheter

7. 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.

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

9. 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

10. 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)

11. How would you treat Joshua?

12. 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 ) 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
Debridement (cleaning) of dead skin.
Escharotomy if compartment syndrome
(Ref. p )

13. 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 )

14. What supportive care and monitoring are required?

15. 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 )

16. 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)

17. 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 )

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.
Physiotherapy to minimise contractures.
Counseling about home safety and about first-aid management of burns (irrigate with cold water).

19. 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