Paediatric Burns
Additional measures when treating burns in children should be considered since their anatomy and physiology is different compared to adults. In addition, children may have special psychososcial and educational needs when it comes to burns. Majority of burns in children are scalds. Scalds are generally harder to assess compared to flame burns, and the child can often be uncooperative and difficult to understand. Always consider non-accidental burns in children. It is crucial to perform the initial dressing with analgesia or anaesthesia in children since this will allow you to clean the child and wound under aseptic conditions and give the best conditions for healing. A relatively painless first encounter will also encourage future dressing changes and wound cleaning.
Key anatomical differences between adults and children
| Difference | Consequence |
|---|---|
| Thinner skin | The same temperature will cause a deeper burn in children |
| Increased surface area to volume ratio | Children cool faster than adults |
| Shorter neck and smaller tracheal diameter | Increased risk of airway obstruction |
| Smaller blood vessels | Increased difficulty gaining venous access |
- Physiological differences between children and adults
- Rapid growth
- HIgher BMR
- Increased respiratory rate
- Smaller blood volume
- Poorer rental tubular concentrating capacity
- Unable to handle fluid excess
- Immature blood brain barrier
- Immature liver funciton
Special considerations when treating burns in children
| Component | Considerations |
|---|---|
| Airway and C-spine control | Airway obstruction can develop rapidly, even without facial burns. Generalized oedema can lead to obstruction |
| Breathing and ventilation | Children can de-saturate quickly. Cirvumferential burns to the trunk, and even anterior abdominal burns can restrict ventilation |
| Circulation | Children have approximately 80 ml/kg of blood. They can compensate well initially after loosing blood but may suddenly deteriorate |
| Fluids | Resuscitation fluid is given when burns are > 15 % (compared to 20% in adults). Children also need a glucose containing maintenance fluid due to the risk of hypoglycemia. Urine output should be maintained at 1 – 2 ml/kg/h |
| Wound | Children are often covered in dirt from being outside. The burn should be cleaned thoroughly and tetanus booster given if indicated |
Critical care
Chemical burns
Chemical burns evolve over time. They need to be kept under review. The amount of tissue damage is related to the type of chemical used. Chemical burns are often scattered so its best to use the rule of palms to assess them.
Acid Vs. Alkaline burns
| Acidic burns | Alkaline burns | |
|---|---|---|
| Mechanism | Protein injury by hydrolysis, thermal burn on skin contact | Saponification of fat→ hygroscopic effect (dehydrates cells), dissolves proteins by creation of alkaline proteinates; Massive extraction of water from cells |
| Type of necrosis | Coagulative necrosis | Liquefactive necrosis |
| Depth | Shallower burns than alkaline burns | Deeper burns than acidic burns |
| Examples | Bleaches, sulphuric acid, hydrocholidc acid, hydrofluoric acid (etching glass | Washing powder, drain cleaners, pain removers etc. |
Classification
| Depth | Description |
|---|---|
| Superficial dermal acid burn | Light brown which peels off and becomes mostly pink with light brown areas. Do not produce blisters and the texture is similar to unburned skin |
| Mid dermal acid burns | Less intense brown or black, do not develop blister and are less elastic than normal skin |
| Full thickness acid burns | Pale yellow or can remain dark brown, inelastic eschar |
- What is an important concern in patients with phosphorus burns (”white phosphorus munition”)?
- Phosphorus can be absorbed leading to hypocalcemia and arrhythmias
- Treatment of Chemical burns
- Copious irrigation with tap water ASAP for up to 2 hours (DO NOT play chemist and try to neutralize the burn. This can generate heat and worsen the injury)
- Brush off chemical powder
- Remove constricting articles (belts, rings) and contact lenses
- Phenol burn – can use PEG (polyethylglutamate)
- Hydrochloric acid or Hydrofluoric acid burn – can use calcium gluconate
Electrical burns
The severity of electrical burns is determined by the voltage and ambient conditions (wet vs. dry conditions). Muscles and nerves are most at risk as they offer most resistance.
Classification of electrical burns
| Voltage | Description |
|---|---|
| Low voltage (< 1000 V) | Standard household electric supply in the form of AC (120 – 240 V). Widespread damage is unusual but muscle spasm may prevent the victim from releasing the electrical source. Usually small TBSA. Local damage may be severe. |
| High voltage (> 1000 V) | Inter city high tension tranmission. Can cause extensive deep tissue destruction and lead to death at the scene or respiratory arrest. Can cause rhabdomyolysis, myoglobinuria, and compartment syndrome. Frequently results in amputation. |
| Lightning | Extreme high voltage of ultra-short duration. Can be in the form of a side flash (more common) or direct lightning strikes. Causes dermal burns and significant burns to the feet, with ear and corneal injury. Cardio-respiratory arrest is common |
- Investigations
- EKG monitoring: mandatory (due to arrhythmogenic complications of electrical exposure)
- Urine output monitoring: keep urine output > 2ml/kg/h
- Treatment
- High volumes of resuscitation fluid
- Diuresis with manitol
- Anti-arrhythmics
- Fasciotomy (compartment syndrome can rapidly develop)
Complications of electrical injury
| System/Organ | Complications |
|---|---|
| Cardiovascular | Arrhythmia |
| Muskuloskeletal | Rhabdomyolysis, Compartment syndrome |
| Renal | Myoglobinuria |
| Nervous system | Nerve and tendon damage |
| Eye | Cataracts, macular holes, retinal artery occlusion |
| Gastrointestinal | Intestinal perforation and peritonitis |
| Bone | Heterotopic ossification, bone cysts |
