BURNS AND SCALDS
Burns are common household accidents in children, including flame-burns, wet-burns (scalds) due to hot liquids and fume-burns, e.g. carbon monoxide (CO) poisoning. Most cases are accidental, though intentional burns (child abuse, Branding) are not uncommon.
Classification: Burns are classified according to the depth and extent of lesions, to assess their severity, need for hospitalization, fluid requirements and prognosis.
Depth-wise, burns are classified as:
• First-degree burns, limited to epidermis only. These burns present with local pain, erythema and swelling, without blisters and usually heal within 7 days without scarring.
• Second-degree burns involve entire epidermis and part of dermis. These burns are extremely painful due to exposure of viable nerve endings and heal in 1-2 weeks with scarring, unless infected.
• Third degree (full thickness) burns denote destruction of entire epidermis and dermis. Pain is minimum in these cases due to destruction of nerve endings. The wounds cannot epithelialize spontaneously and heal only by contraction scar or after skin grafting.
Extent-wise, burns are denoted in terms of percentage of body surface area (Table 27.22). Conventional rule of 9 in adults, is not applicable in children below 12 years. Management: of burns include on-site management and hospital therapy.
TABLE 27.22: Calculation of % burn in children
| Burnt part | 0-3 years | 3-6 years | 6-12 years |
| Head | 18% | 15% | 12% |
| Trunk | 40% | 40% | 40% |
| Arms | 16% | 16% | 16% |
| Legs | 26% | 29% | 32% |
On-site first-aid includes—(a) extinguish the fire by rolling-over the patient or covering with a blanket,
(b) ensure airway patency, (c) remove non-adherent clothing, (d) irrigate affected parts with cold, clean water,
(e) cover the affected parts with a dry-clean sheet, and
(f) transfer to the nearest hospital.
Hospitalization is indicated in all cases with: (a) burns gt;10-15%, (b) burns involving face, neck, perineum, joints and hand/feet, (c) electrical/lightening burns,
(d) suspected smoke inhalation, and (e) child abuse. Remaining cases can be managed on outdoor basis with local cleaning/dressing and mild analgesics, e.g. paracetamol or codeine. Intact blisters should not be punctured.
Management of severe cases include:
• Cardiopulmonary resuscitation, ensuring airway patency, ventilatory and circulatory support.
• IV Fluid therapy in all cases with gt;15% burns, to replenish fluid losses due to interstitial edema, tissue injury and plasma loss. As the amount of fluid loss depends on the severity of burn, first-day fluid requirement is calculated as 4 ml/kg/percentage of burn- half of which is to be given in first 8 hours and rest in next 16 hours (Parkland formula).
By second day, reabsorption of interstitial edema starts and only half of the first-day fluid amount is necessary, unless indicated otherwise on clinical or biochemical monitoring. Colloids, e.g. blood plasma, albumin, etc. may be used for volume replacement on 2nd day in cases with gt;85% burns.
• Electrolyte correction is required for hyponatremia (due to extracellular fluid loss) and hyperkalemia (due to extracellular movement of K+ from injured tissues) - two most common electrolyte disturbances in burns.
• Prevention of infection is essential with—(a) barrier nursing, (b) topical dressings, (c) excision of dead tissue, (d) prophylactic antibiotics, and (e) early tissue grafting. Nosocomial infections, specially due to Psuedomonas, are leading cause of late morbidity and mortality in burns.
• Enteral feeding may be started orally or via nasogastric tube after 48 hours in most cases. Due to higher requirement for tissue regeneration, ~150% of normal caloric requirement and 3-4 gm/kg of proteins per day is recommended.
• Inhalation injury due to hot/toxic fumes, asphyxia and CO poisoning, presents with pulmonary edema within few hours and ARDS after 24-48 hours. Symptoms of CO poisoning correlate well with HbCO levels, ranging from mild dyspnea and cloudy sensorium (HbCOlt;20%), to confusion and diminished vision (20-40%) and coma (gt; 40%).
• Pain-relief is usually provided with benzodiazepines, though morphine may be needed in severe cases.
• Topical therapy includes local application of bacitracin or silver sulfadiazine cream or ointment without dressing in mild cases. Blisters should not be punctured. Second-degree or deeper burns often need debridement of overlying dead skin, followed by silver-impregnated wound dressings.
• Reconstructive surgery and rehabilitation is essential part of late management in severe burns to improve the quality of life.
Outcome of burns depend on their severity, co-existing inhalation injury, appropriate early therapy and nosocomial infections.
27.5.3