Pediatrics FAQ 6 - Pediatrics burns: short and sweet

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Dr Shailesh Gophane

DCH from J.J. Hospital, Mumbai and DNB from Port Trust Hospital Mumbai.

"This is a series of Notes for dnb pediatrics theory exams. Definitely they are not the alternative to reading Nelson's thoroughly, but these notes will prove helpful during final days of revision and may be helpful to overcome any loopholes if you are not having enough time to cover whole system. December 2015 had 6 repeat questions from these notes".

FAQ: 6
Provide classification of burns injury. Describe the clinical manifestation of electrical burns. Outline the emergency management of a child with 20% burns.

A.Classification: Based on depth

1st-degree burns

Involves only the epidermis and are characterize by swelling, erythema, and pain (similar to mild sunburn). Tissue damage is usually minimal, and there is no blistering. Pain resolves in 48-72 hr; in a small percentage of patients, the damaged epithelium peels off, leaving no residual scars.

A 2nd-degree burn involves injury to the entire epidermis and a variable portion of the dermal layer (vesicle and blister formation are characteristic).

1. A superficial 2nd-degree burn is extremely painful because a large number of remaining viable nerve endings is exposed. Superficial 2nd-degree burns heal in 7-14 days as the epithelium regenerates in the absence of infection.

2. Midlevel to deep 2nd-degree burns also heal spontaneously if wounds are kept clean and infection-free. Pain is less than in more superficial burns because fewer nerve endings remain viable. Fluid losses and metabolic effects of deep dermal (2nd-degree) burns are essentially the same as those of 3rd-degree burns.

Full-thickness, or 3rd-degree, burns involve destruction of the entire epidermis and dermis, leaving no residual epidermal cells to repopulate the damaged area. The wound cannot epithelialize and can heal only by wound contraction or skin grafting. The absence of painful sensation and capillary filling demonstrates the loss of nerve and capillary elements.


B. CLINICAL FEATURES OF ELECTRICAL BURNS

1.Cardiac Dysrhythmias:

Asystole, ventricular fibrillation, sinus tachycardia, sinus bradycardia, premature atrial contractions (PACs),premature ventricular contractions (PVCs), conduction defects,atrial fibrillation, ST-T wave changes

2.Pulmonary

Respiratory arrest, acute respiratory distress

3.Renal:

ARF, myoglobinuria

3.Neurologic

Immediate: loss of consciousness, motor paralysis, visual disturbances, amnesia, agitation; intracranial hematoma. Secondary: pain, paraplegia, brachial plexus injury, syndrome of inappropriate antidiuretic hormone secretion (SIADH), autonomic disturbances, cerebral edema

Delayed: paralysis, seizures, headache, peripheral neuropathy CT scan of the brain if indicated
Cutaneous/oral Oral commissure burns, tongue and dental injuries; skin burns resulting from ignition of clothes, entrance and exit burns, and arc burns.

4.Abdominal Viscus

Perforation and solid organ damage; ileus; abdominal injury rare without visible abdominal burns

5.Musculoskeletal

Compartment syndrome from subcutaneous necrosis limb edemaand deep burns

6.Ocular Visual changes

Optic neuritis, cataracts, extra-ocular muscle paresis

C. Emergency management of a child with 20% burns

                       Image: Nelson Textbook of Pediatrics

Fluid based on parkland formula:

4 mL lactated Ringer solution/kg/20 %BSA. Half of the fluid is given over the 1st 8 hr, calculated from the time of onset of injury; the remaining fluid is given at an even rate over the next 16 hr. The rate of infusion is adjusted according to the patient’s response to therapy.

Pulse and blood pressure should return to normal, and an adequate urine output (>1 mL/kg/hr in children; 0.5-10 mL/kg/hr in adolescents) should be accomplished by varying the IV infusion rate.
Vital signs, acid-base balance, and mental status reflect the adequacy of resuscitation.

Ref : Nelson Textbook of Pediatrics

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