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Burns

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Definitions

Superficial or Epidermal
Epidermis only involved
Burn appears red, no blistering, is painful
Heals quickly without cosmetic blemish 
Partial thickness
Superficial partial thickness or Superficial Dermal
Superficial part of dermis as well as epidermis involved
Burn has blisters, base of blister is pink, normal cap refill, is painful
Should heal spontaneously by epithelialisation within 14 days, colour match defect only
Mid Dermal
Extends midway into the dermis and entire epidermis
Burn has blisters, base of the blister is dark red, capillary refill is sluggish. Is painful
Should heal spontaneously but often prolonged with estimated healing time between 14-21 days
Deep partial thickness or Deep Dermal
Destruction of the dermal vascular plexus
May have some blistering, base of blisters are blotchy red, loss of capillary refill, loss of sensation
Do not heal spontaneously
Full Thickness
Destruction of epidermis and dermis
White/waxy/charred appearance, no capillary refill, no sensation
Do not heal spontaneously

Children's skin is much thinner and therefore more susceptible to deep burns.

Depth Colour Blisters Cap refill Sensation Heal with dressings
Epidermal Red No Normal Normal Yes
Superficial Dermal Pale pink Yes Normal/Sluggish Normal Yes/usually
Mid Dermal Dark pink Yes Sluggish +/- Yes/prolonged
Deep Dermal Blotchy red +/- Absent Absent No
Full thickness White No Absent Absent No

Causes

Burns and Scalds

  • Mortality from burns and scalds is low but morbidity (pain and scarring) is high
  • Rates of injury are highest in the 12 to 24 month age group (44/100000/year)
  • Around half of these are scalds, almost all of which occur in the home
  • Hot drinks, water on stoves, kettles and hot tap water are most commonly involved
  • The severity of the burn is closely related to temperature of the liquid. Liquid at 60°C will burn children in less than 5 seconds, compared with 10 minutes if the liquid is at 49°C
  • Hot object burns also typically occur in the home and typically involve heaters, irons and ovens

Electrical

  • Usually low voltage in children (<1000 volts), usually involve extension cords in young children

Chemical

  • Ingested dishwasher powder (alkali) is the most common cause of chemical burns to children

House Fire

  • Admission rate following injury related to house fire is relatively low (around 4/100000)
  • Mortality from house fire is significant - accounting for 10 to 15% of child injury mortality
  • Young children have the highest mortality when involved in house fires

Management

Initial Assessment

Primary survey

  • Airway - beware hoarse voice, stridor, cough, carbonaceous sputum. Secure airway by intubation early if burn to airway is suspected.
  • C spine
  • Breathing
    Consider Carbon monoxide (CO) poisoning:
    • CO has a much greater affinity than oxygen for haemoglobin and so displaces oxygen.
    • Assume carbon monoxide exposure in patients burned in enclosed areas.
    • Diagnosis of CO poisoning is made primarily from a history of exposure.
    • Patients with CO levels of less than 20% usually have no physical symptoms.
    • Higher CO levels may result in headache and nausea, confusion, coma and death.
    • CO dissociates very slowly but this is increased by breathing high-flow oxygen via mask.
  • Circulation
    If shock present look for an alternative cause - acute burns very rarely cause shock.
  • Disability
  • Environment - temperature (beware hypothermia), remove clothing and jewellery
  • Consider co-existing injuries especially if associated motor vehicle accident, blast or explosion, electrocution, jump or fall while escaping fire.
  • Resuscitate as abnormalities in the primary survey are detected.

Acute Treatment of Burn

 Cool the Burn

  • Apply tap water at room temperature onto burned area for at least 20 minutes (within 3 hours of burn), unless completed pre-hospital.
  • Never use ice or iced water
  • Keep the non burned area dry and warm
  • Stop cooling if core body temperature is <35°C

Analgesia

  • Opiate analgesia is often required initially (even for relatively small burns). Consider IV morphine or IN fentanyl
  • Covering the burn with an occlusive dressing (cling film) will reduce pain

Fluid resuscitation

  • Insert IV line if burn >10% BSA.
  • Take blood for Hb, U and Es, Cr, BSL. Albumin if >10% BSA.
  • Request carboxy Hb if possible inhalation injury.
  • If shocked, give a bolus of 0.9% saline (20ml / kg) and look for cause of shock other than burn.

 Tetanus prophylaxis

 Further Assessment

 History

  • When did it happen?
  • How did it happen?
  • Who saw it?
  • What was done? Length of cooling?
  • Consider non-accidental injury - concerns about supervision, delay in presentation, history of burn but unexplained or inconsistent with injuries, repeated injuries, multiple burns, burns to buttocks or genitals. If in doubt discuss with senior colleague.

Complete secondary survey

Assessing the extent of the burn

See Assess the Extent and Depth of the Burn . Consider printing sheet and incorporating in your clinical record

Be aware that the extent and depth of a burn is likely to evolve

 Burns often change rapidly over the first few hours and the best definitive assessment can be made at 48 to 72 hours post burn.

Chemical burns

  • Can result from exposure to acids, alkalis, or petroleum products.
  • Alkali burns (liquefactive necrosis) tend to be deeper and more serious than acid burns (coagulative necrosis).
  • Immediately flush away the chemical with large amounts of water for at least 20 to 30 minutes (at least 1 hour for alkali burns).
  • Alkali burns to the eye may require continuous irrigation during the first 8 hours after the burn.
  • If dry powder is still present on the skin, brush it away before irrigation with water.
  • Consider the possibility of systemic effects of the chemical.
  • Ingestion of corrosive agent
    - If intra-oral burns then endoscopy is usually recommended - discuss with Paediatric Surgeon
    - Systemic steroids do not prevent stricture formation

Electrical burns

  • Usually 'low voltage' (<1000 volts) - cause local burns but not usually deep muscle damage
  • If the child meets all the following criteria;
    - Healthy child
    - Exposed to common household currents (AC ≤240V or DC), without water contact
    - Asymptomatic at ED presentation
    - No ventricular arrhythmia or cardiac arrest prior to presentation
    Then they do not need an ECG or further monitoring/observation for cardiac arrhythmia.
  • If the child does not meet these criteria then consider ECG and admission for cardiac monitoring - suggest discussing with senior doctor.
  • May be more serious than they appear on the surface if higher voltage injuries
  • May cause rhabdomyolysis which results in myoglobin release. This can cause acute renal failure. If the urine is dark, start therapy for myoglobinuria immediately:
    - Fluid administration should be increased to ensure a urinary output of at least 1 to 2 ml/kg/hour
    - Mannitol should be given if the pigment does not clear with this increase in fluid.
    - Metabolic acidosis should be corrected by maintaining adequate perfusion and adding sodium bicarbonate.

Disposition

The Paediatric Burns service is based at Middlemore Hospital.

Contacts include:
Plastics Registrar is on call for Burns advice & admission 24 hours a day - contact through the Middlemore Hospital operator 276 0000. Pictures can be emailed through to Plasticreferrals@middlemore.co.nz
Burns Clinic 276 0044 ext 8214 or 8664

Referral to the Paediatric Burns service is indicated in the following circumstances

  • Area of partial thickness burn greater than 10% of total body surface area
  • Full thickness or deep partial thickness burn
  • Partial thickness burns to face, hands, feet, genitalia, perineum, and over major joints
  • Circumferential partial thickness burns of limbs or chest

Suspected Non-accidental injury (NAI) that does not need review by the paediatric burns service should be referred to Te Puaruruhau during the day or General Paeds consultant on call after hours as per other physical non accidental injury (see Abuse & Neglect guideline).

Dressings

  1. Initially consider covering burns with temporary covering of plasticized polyvinyl chloride film or cling film prior to initial assessment of wound occurring.
    1. The film should never constrict movement or be applied to the face or head area.
  2. Ensure adequate analgesia.
  3. Clean and debride the wound.
    1. Clean wound with warmed 0.9%NaCl.
    2. Remove devitalised tissue (loose nonviable skin)
    3. Tense large blisters should be drained by popping with a sterile needle and may need debriding, small blisters can be left alone
    4. Blisters over digits should not be debrided
  4. Definitive dressing
    1. The preferred acute burns dressing in CED is a Hydrofibre ionic silver dressing called Aquacel Ag.
    2. Releases ionic silver in a controlled manner as wound exudate is absorbed into the dressing.
    3. Maintains the moist environment optimal for wound healing.
    4. To apply:
      The Aquacel Ag should overlap 5cm (2 inches)  onto the skin surrounding the burn. Consider a bigger overlap for larger burns.
      Do not moisten.
      Apply a sterile second dressing (eg Telfa) to cover the Aquacel Ag.
      Place low allergy dressing retention sheet (Hypafix) over the top - ensure plenty of overlap in order to secure this dressing onto normal skin.
    5. Handout given to parents explaining dressing and burn care requirements
  5. Burns to the face
    1. Most burns to the face are superficial dermal and can be managed with the use of liquid paraffin.
    2. Small mid dermal burns can be managed with Aquacel Ag and GP review
    3. Larger mid dermal - deep dermal burns will require discussion with plastics at MMH.
  6. Follow-up
    1. GP review at Day 10.
    2. Review in CED at Day 10 only if there were concerns with depth of the burn at time of initial presentation.
    3. At Day 10 most superficial - mid dermal burns have re epithelialised
    4. If any section of the primary dressing remains adhered to the burn wound then trim the remainder and leave in place. Do not forcibly remove the dressing as it is designed to adhere until full epithelialisation has occurred. Cover with Telfa and Hypafix. Review as required.
    5. For fully epithelialised burn wounds, discharge with script for moisturiser. Advise to apply 2-3 times per day for 2 weeks.
  7. If ongoing concerns review again as required:
    1. If there is a large amount of ooze and the dressing appears wet then the family should be advised to return to CED. Usually only the Telfa and Hypafix will need replacing.
  8. Removal of dressing
    1. Care must be taken when removing the low allergy dressing retention sheet.
    2. Caregivers should be asked to apply olive oil to the edges of the cover dressing prior to seeing their GP or coming to CED
    3. When olive oil has not been applied or the glue in the cover dressing is still sticky, an adhesive 'remove' wipe may be used to loosen the dressing.
    4. Ensure none of the solvent from the adhesive removal wipe comes in contact with the wound surface.
  9. Concerns with depth and site of burn
    1. Patient referred to Plastics at MMH and will be discharged home prior to review in clinic.
    2. In this situation the preferred acute burns dressing in CED is a nanocrystalline silver dressing (eg Acticoat) as it can be removed easily for review.
    3. This dressing consists of three layers: an absorbent inner core sandwiched between outer layers of silver coated, low adherent polyethylene net. Supersonic welds hold these layers in place.
    4. To apply:
      Trimmed to fit burn (but does not need to be a perfect fit and if in doubt extend onto area of simply erythema)
      Moisten the Acticoat with warm water (Not with normal saline - it will deactivate the silver)
      Manufacturer recommendations state to place the darker blue surface in direct contact with the skin
      Place low allergy dressing retention sheet (Hypafix) over the top - it is required to overlap the nanocrystalline silver dressing onto normal skin.
    5. Parents educated about moistening
    6. Handout given to parents explaining dressing and burn care requirement

Prevention

Burns and Scalds

  • Reducing the temperature of tap water reduces the severity of scalds.
  • Secondary prevention by cooling the burn for 20 mins reduces burn severity.

Advice for parents

  • Install child safety gates to Keep Kids Clear of the Kitchen
  • Place guards or barriers around fires and heaters
  • Take care with microwaved food and fluid
    - Allow microwaved food or fluid to stand
    - Stir the food thoroughly to disperse any hot spots before feeding child
    - Test the temperature before serving
  • Reduce the hot water temperature to less than 50ºC (120ºF) at all outlets in the house, by using a tempering valve or reducing the preset temperature at the hot water heater.
  • Ensuring hot drinks, kettle cords and pots are placed out of reach
  • Avoid the use of table cloths (as children pull on them)
  • Don't drink hot drinks while holding or feeding infants
  • Bath water temperature should always be checked before putting children in.

Electrical

  • Electrical safety switches (Ground Fault Circuit Interrupters) have been shown to prevent electrocution fatalities in the home.

Advice for parents

  • Electrical safety switches should be installed and be tested every 3 months.
  • Electrical safety
    - Install power point covers
    - Avoid the use of electrical appliances near water
    - Ensure extension cords are not accessible and any frayed or damaged cords are replaced.

Chemical

  • Dishwasher powder ingestion injuries can be reduced by using products of lower alkalinity

Advice for parents

  • Store chemicals in their original containers, in cupboards with child resistant latches or locks
  • Ensure children cannot access dishwasher powder, including left over powder in the dishwasher itself.

House Fire

  • Smoke alarms work
    - Giveaway programs reduce the incidence of fire-related injuries
    - Door-to-door canvassing is an effective method for distribution of smoke alarms to communities
    - Maintenance programs are required as battery loss/failure is a common problem
  • School education programs improve knowledge
  • Fire department involvement in programs is helpful
  • It is likely that Reduced Ignition Propensity (RIP or "fire safe") cigarettes will reduce the incidence of house fire (they have become mandatory in Canada and some states in the USA).

Advice for parents

  • Smoke alarms should be installed and be regularly tested
  • Homes should have a fire extinguisher, placed at the entrance to the kitchen.
  • Care should be taken with cigarette stubs
  • Cooking shouldn't be left unattended,
  • Avoid placing items on heaters.
  • Electric blankets should be turned off before going to sleep.
  • Educate children about
    - Which things in the home are hot
    - That hot things are painful
    - Not to play with fire.
  • Children and their families can develop, learn and practice a fire escape plan for the household including "stop, drop and roll".

Burn Management Summary

Management Summary

Assess the Extent and Depth of the Burn

(click on the image below to print a pdf for notes)

Assessment

Information for families

Download a printable copy of the information sheet  'What is an AquacelAg Burns Dressing' from Children's Emergency Department at Starship.

References

Paediatric Burns Management Recommended Best Practice

Aquacel Ag advice sheet

Acticoat Patient Handout

Australian and New Zealand Burn Association. Emergency Management of Severe Burns Course Manual 10th edition March 2006. (see website http://www.anzba.org.au/)

Hettiaratchy S, Papini R; Initial management of a major burn. BMJ 2004;328:1555-1557.

Hudspith J, Rayatt S; First aid and treatment of minor burns. BMJ 2004;328:1487-1489

Reed JL, Pomerantz WJ. Emergency Management of Pediatric Burns. Ped Em Care 2005;21;118-129.

Papini R; Management of burn injuries of various depths. BMJ 2004;329:158-160.

Chen EH. Sareen A. Do children require ECG evaluation and inpatient telemetry after household electrical exposures? Annals of Emergency Medicine 2007. 49(1):64-7.

Burns Charts:
The Lund and Browder charts originate from the 1944 edition of Surgery, Gynaecology and Obstetrics edited by CC Lund (American surgeon) and NC Browder (American paediatrician).
The Rule of Nines appeared in AB Wallace: The exposure treatment of burns. Lancet 1951;1(9):501-4.

Dunn K. Edwards-Jones V. The role of Acticoat with nanocrystalline silver in the management of burns. Burns 2004;30 Suppl 1:S1-9.

Health Canada. Reducing the fire-risk of cigarettes. April 2004. http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/2004/2004_19bk1_e.html (accessed 15/06/2007).

Ta V, Frattaroli S, Bergen G, Gielen A. Evaluated community fire safety interventions in the Unites States: A review of current literature. J Com Health 2006;31:176-197.

Erdmann TC, Feldman KW, Rivara FP Heimbach DM, Wall HA. Tap water burn prevention: the effect of legislation. Pediatrics 1991;88:572-7.

Turner C, Spinks A, McClure R, Nixon J. Community-based interventions for the prevention of burns and scalds in children (review) The Cochrane Database of Systematic Reviews 2004, Issue 2 Art. No.CD004335.

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Document Control

  • Date last published: 18 January 2016
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Mike Shepherd
  • Editor: Greg Williams
  • Review frequency: 2 years

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