Michaele Conchita M. Zapanta, MD,RN

8/14/2019 Michaele Conchita M. Zapanta, MD,RN

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Michaele Conchita M. Zapanta, MD,RN


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BURNS in Children


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q This baby was notthe direct victimof earthquake.He got the burnwound due tofalling into

cooking utensils.q

q Actually childrenburnt case iscommon indevelopingcountries, like

Haiti.

q This is becausemany familieswho aresuffering frompoverty have tostay in verycongested areasthat there

BURN VICTIM FROM HAITI


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BURNS1/3-1/2 - of the yearly hospitalizations

for burns occur in children youngerthan 18 years of age

At least half of these accidents children under 15 years of age

1000 deaths a year in this age group


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Occurence

Deaths from fires and burns second to motorvehicle accidents

American Academy of Pediatrics, Committee on Injury and Poison

Prevention, 2000


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FOUR TYPES

Thermal

most common

occurs fromflames, flash,

scalds, or contactwith hot objects


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THERMAL BURN

qFlame injury - ignition of combustiblematerials and contact with fire;

household and residential fires

qFlash injury explosions, such asgasoline, kerosene and charcoallighter

qScald Burns hot liquid spill / hot tapwater

q

Contact Burn exposure to hotsurfaces


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ELECTRICAL BURNS

Chewing on electric wires

Inserting objects into electric sockets


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Chemical burns

Children ingest or are exposed to causticagents such as household cleaningproducts


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radiation

Results from overexposure to theUV rays of the sun


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pathophysiology

Minor to multisystem involvement

Alterations on different body systems

body system manifestations after major burn


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body system manifestations after major burnRESPONSE TREATMENT

CARDIOVASCULAR SYSTEM

First 24-48 hours Postburn cardiac output resulting fromcapillary permeability andvasodilation metabolic acidosis hematocrit48- 72 hours PostburnCapillary permeability is restoredInterstitial fluids move back intobloodstream Hematocrit Platelet count

Adequate fluid

replacementMonitor vital signs, esp .BPAssess blood gases

Monitor vital signsMonitor urine output IV fluidsMonitor PTT

RENAL SYSTEM

Reducedblood flow to kidneys leadto urine outputPotential for acute renal failure

BUN CreatinineWith fluid mobilization, urineoutput as interstitial fluid ismobilized and eliminated

Monitor I/O

Administer IV fluids at a

rate that maintains urineoutput of 1-2 cc/kg/hrAnticipate fluidremobilizationAssess BP


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RESPONSE TREATMENT

RESPIRATORY SYSTEMUpper airway edema andobstruction from inhaling heatedgasesLower airway obstruction andpneumonia from smoke

inhalationCO poisoning and hypoxia frominhaling end products ofcombustion causes mucosalerythema and edemaAtelectasis and respiratoryfailurePulmonary edema fro toovigorous fluid replacementRestriction of chest excursion

Monitor respirationsAssess for rales ,wheezesAssessdepth of

respirations

Monitor blood gases

Assess for equal

respirations

Notify health careprovider and prepareatient for escharotom


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RESPONSE TREATMENTGASTROINTESTINAL SYSTEM

Perfusion of GI tract andliver due to blood flow Gastric acid production for48-72

hrs followed by acid

productionand risk of stress ulcers GI motility

Monitor bowel soundsAssess liver enzymesAssess NG drainage forevidence of blood

Place NG tube fordecompression of stomach

CENTRAL NERVOUSSYSTEMBurn-related encephalopathydue to hypoxemia,hypovolemia , and

septicemiaManifestations include:

Hallucinations, personalitychanges,

delirium, seizures, and

coma

Monitor fluids and bloodgasesAssess signs of infectionAssess neurologic status

frequentlyInitiate seizure precautions:


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RESPONSE TREATMENT

METABOLISM

Metabolic rate from nitrogenlosses

and stress of injury Heat losses through damagedskinRapid protein breakdown andmuscle wasting Blood glucose levels due toinsulin resistance and breakdownof glycogen storesDelayed growth and maturationfrom need to use energy to repair

burned tissues

Monitor intake of caloriesGive parenteral nutrition asneeded

Give diet high in proteins

Give multivitamins, vitaminA & C


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CLINICAL MANIFESTATIONS

Severity is determined bythe depth of the tissuedestroyed and the totalBSA involved

Current - categorized bythe depth of tissuedestruction intosuperficial, partial andfull thickness wounds.


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Depth of tissuedestruction

First Degree- superficialthickness

Second Degree partialthickness

Third and Fourth Degrees-full thickness


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Superficial Burns

Epidermal layer of skin

Painful, dry, red, andblanch with pressure.Injuries

Approximately heal in 5-10days without scarring

s


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sunb

u rn

Systemiceffectsuncommon

Example :sunburn


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Superficial partial-thickness burn

Involve epidermis andsuperficial and deepdermal layers

Painful to temperature andcold air

Moist red and weeping,usually form blisters, andblanch with pressure.

Heal in 14 to 21 days Scarring may result

Pigment changes mayoccur.


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Superficial partial-thickness burn


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Partial thickness

Partial-thickness burns to both feetimmediately after debridement ofblisters.

I


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INDET

ERM

IN ATEPARTIA

LTHICKNE

SS


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full thickness burns

Deeper dermis, damaging hair

follicles and glandular tissue,extend to SC Painful to pressure only. Always blister (easily unroofed),

are wet or waxy dry, and havevariable color from patchy

cheesy white to red Form eschar Do not blanch with pressure. They require over 21 days to

heal Scarring may be severe.

Differentiation from full-thicknessburns is often difficult.


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Full thickness Extend to tendon, muscles andbones

Painless Whitish, leathery ,dry and

inelastic appearance Skin appearance can vary from

waxy white to leathery gray tocharred and black

Decreased sensation to pain Result to scarring and

contractures Require skin grafting , skin

flaps, or possible amputation

to fully heal Not blanch with pressure


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Burn with an area ofNecrosis

Minor burns Out Patient basis

Moderate Burns andSevere Burn requireshospitalization

Burns involving hands,feet, face, eyes, earsand genitalia pediatricburn unit, PICU orpediatric burn carecenter


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diagnosis

Clinical manifestations

History

Physical Examination

R


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RULE

OFNINES


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Rule of ninesqDivides the surface area of the body into areas of

9% or multiples of 9% equal to 18%qWhen all body areas of 9% are summed, 1%

remains, which is assigned to the genitalia andperineum.

qConvenient and rapid method of estimating theextent of body surface area burned.

qIt is less than accurate, however, for children.

qFor patients younger than 15, a more precise

method of burn size estimation must be used.


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Lund and Browder Chart

qSecond, more accurate, method of measuringthe extent of total body burn

q

qSubdivides body areas into segments and

assigns a proportionate percentage of bodysurface to each area based on age

q Rather than being viewed as a whole, the lower

extremity is divided into foot, leg, and thighareas.


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Palmar surfaceThe third method of estimating burn injury extent

uses the size of the patient's hand, assumingthe palmar surface of the hand is roughly 1% ofthe total body surface.

Visualizing the patient's hand covering the burn

wound approximates the amount of bodysurface involved, especially if the burn areasare scattered.

In actuality, the palm alone more accuratelyrepresents 0.5% of the body's total surfacearea.


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treatment

Respiratory managementFluid Resuscitation

Pain Management

Wound carePrevention of Impaired Mobility

Nutritional Support

Psychological support


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Respiratory management

Assessing patency of the airway Establishing and/ or maintaining

Pulmonary complications leading cause of death inthermal burns

Anticipate respiratory involvement burn occurred in an enclosed space or found unconsciousIf with hypoxia - Oxygen administered

vAssess childs ability to expand the chest

vFull thickness that extend trunk may interfere with

breathing-


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Respiratory management

When there is potential for airwaycomplications, a difficult airway cartcontaining a range of various sizeendotracheal tubes, Eschmann stylet,

laryngeal mask airways (LMA), FastrachLMA, fiberoptic bronchoscope, fiberopticstylets should be available.


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escharotomyAn incision made into constricting eschar to

restore peripheral blood circulation, may berequired to release the chest restrictionArterial blood gases- provide evidence of smoke

inhalation and the adequacy of gas exchange

E.g: Child with burn on upper body burns, facialburns or smoke inhalation airway obstructionfrom edema Intubation done exhibits face and neck

edema, soot in the nose or mouth, or singednose hairs


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Fluid resuscitation

Large bore central venouscatheter to administermassive fluid loads

Fluid formularequirements: 2-4ml/kgof body weight X TBSA

Urine output reflects theadequacy ofresuscitation on UO of 1-2 ml/kg/hr, stable vitalsigns, and alert and

oriented mental status

Foley catheter to facilitateurine outputmeasurement

Type and amount of fluidused will be based on theresults of blood

electrolyte tests

Parkland formula for fluid resuscitation


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Parkland formula for fluid resuscitation

4 ml Lactated Ringers solution X kg of bodyweight X % TBSA

One half of total is given in the first 8 hourspostburn

One- fourth of total is given in the second 8hours postburn

One- fourth of total is given in the third 8hours postburn

Note : Time is calculated from the time of theinjury,not the time of admission to thehospital.

C l l i i i fl id i 4 2 1


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Calculating maintenance iv fluid rate using 4:2:1rule

to calculate the hourly IV rate, first determine the childs dailymaintenance fluid requirement, then divide that number by 24. inpractice, this process can be simplified by using 4:2:1 rule withoutsacrificing accuracy. Try it out:

IV rate = 4 ml/kg each kg of weight up to 10 kg + 2 ml/kg/hr for each kg of weight between 10-20 kg + 1 ml/kg/hr for each kg over 20 kg

Example: Daily IV fluid rate for a 45-kg childwho is NPO would be :

40ml 20 ml 25 ml 85ml/hr

E l f fl id t


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Example of fluid management

70kg patient with 50% body surface area burn wouldrequire:

4 x 50 x 70 = 14000mls of Hartmanns solution over 24hours. Therefore 7 litres should be given in the first 8hours and 7 over the following 16 hours

(Calculated with the Parklands formula)

Regular reassessment of the adequacy of resuscitationshould be performed. Blood products and colloid mayalso be given in addition to these requirements


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Preventing hypothermic shock

Do not apply ice or cold water to any burn

Cause hypothermia

May intensify a shock condition furtherischemic injury to the burned area


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PAIN MANAGEMENT


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Pain management

Pain from injury, reduce when child is t rest Fear and anxiety contribute to the childs perception of

pain

Major burns IV narcotics : morphine sulfate

Minor burn - acetaminophen

Fluid shift limits absorption from the SC and IM areas,pain will not be relieved


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DEBRIDEMENT


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DEBRIDEMENTqRemoval of dead tissue from the burn site,

associated with severe pain

qSoaking the wound for about 10 minutes tosoften tissue

q

qWashed from the inner to outer edges usinga firm, circular motion

qLoose or dead tissue is removed by gentlylifting it up with forceps and cutting it

away


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DEBRIDEMENT

Surrounding areas are cleaned, an antimicrobialcream, such as silver sulfadiazine (Silvadene),(Flammazine)

To minimize bacterial proliferation andprevent infection


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Wound care

Initial wound care given after child has beenstabilized

Use aseptic technique

Medicate the child prior to the procedure

Wounds gently cleaned and debrided.


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hydrotherapy

To soften dead tissue to help in the debridementprocess

To improve circulation to the wound

Experience is painful and scary for all burn

patientsMedicated prior to hydrotherapy and dressing

changes

Caregivers to be present to comfort and distract

the child


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Skin grafting


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Burn dressings Changed once or twice a day Once the wound have been debrided and beginning to

heal temporary skin grafts used to facilitatehealing process

Homograft (cadaver skin) Begin to slough off around 14 days

Heterographs (pig skin) Replaced daily or every other day Used in children with scald burns of hands and face Temporary grafts accelerate wound healing by creatignan

environment that promotes epithelial growth in the form ofgranulation tissue`


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A new medical adhesive - a fibrin sealant - called Artiss for usein attaching skin grafts onto burn patients, has just beenapproved by the US FDA.Fibrin sealants are tissue adhesives that contain the proteinsfibrinogen and thrombin, which are essential in the clotting ofblood. Artiss (Fibrin Sealant, VH S/D 4) differs from other fibrinsealants in that it contains a lower concentration of thrombin. This

lower concentration allows surgeons more time to position skingrafts over burns before the graft begins to adhere to the skin.Artiss also contains aprotinin, a synthetic protein that delays thebreak down of blood clots.
http://www.fda.gov/http://www.fda.gov/


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Skin grafting

Extensive full thickness require permanent skingraft- an autograft to fully healTaken from an unburned area of the childs own

skinOnce place, area must be immobilized

Cultured epithelial autograft used in childrenwith burns covering more than or equal to 80%TBSASheets of skin grown in the lab from a small kin

biopsy of the child.

vLONG TERM FOLLOW UP studies pending


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Skin grafting

After grafts heal, pressure dressings applied toprevent formation of contracture and minimizescarring.

Dressing may be elastic wraps, pressure splints,or pressurized garments that providecontinuous and uniform pressure over theburned areas.

Prevention of impaired mobility


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p y(preventing Contractures)

Develop due to prolonged bed restMuscular atrophy and shortening

Stiffening of burned tissues

Important to implement appropriate positioning

strategies to prevent deformities and anexercise program to maintain muscle strengthand joint mobility

Prevention of impaired mobility


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p y(preventing Contractures)

When muscles not exercised maintained in maximalextension using splints

Early exercise is encouraged

ROM performed actively at least 3X a day


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Nutritional support

Diet high in protein (23% of total calories) to maintainweight and muscle function

Increase vitamins A & C to help replace losses from the

changes in metabolism and losses from the open burnwounds

Use enteral feedings

Psy

Play therapy help to deal withthe frustrationsof burn therapy


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ycho

logica

l

suppo

rt

of burn therapy

Encouragechild to moveand activelyparticipate inactivities withother children

Counseling -as recoverycontinues , withvarious supportservices tofoster childsself- esteem

Caregiversneed to besupported andencouraged toparticipate inthe care of the

F il t hi


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Family teachingsHome care need

discussed andaddressed long beforechild is discharge

Includes nutrition, dietrequirements, daily

dressing changes andskin care, applicationof elasticized garments(Jobst jacket or pants)

Application of splints

Daily ROM exercises

Caregivers need supportand encouragement

Home tutors necessary tohelp child keep up withschool

Encourage all involved to

explore their feelings andbe supportive of childsreturn to the community


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COMPLICATIONS


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SMOKE INHALATION The ensuing release of inflammatory mediators, oxygen

derived free radicals, nitric oxide causes a largeincrease in the vascular permeability of the pulmonarycirculation.

The resultant airway edema, when combined withsloughing of necrotic epithelial mucosa and thick, viscidsecretions, produces airway obstruction at variouslevels of the bronchial tree.

SMOKE INHALATION


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SMOKE INHALATION A combination:

direct pulmonary injury

systemic

metabolic toxicity.

The severity of smoke lung injury depends on fuels, intensity,

duration, and confinement.

Gas phase constituents of smoke include carbon monoxide(CO), cyanide, acid and aldehyde gases and, oxidants.

S O O


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SMOKE INHALATION

These can cause direct damage to muco-ciliary function,bronchial vessel permeability, alveolar destruction andsecondary edema. Smoke exposure causes inactivationof surfactant and immediate atelectasis.

Bronchial blood flow increases manifold and lungmacrophages and neutrophils are activated.

SMOKE INHALATION


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SMOKE INHALATION Concomitant cutaneous burn injury aggravates the lung

damage by releasing pro-inflammatory mediators andcausing hydrostatic pulmonary edema.

The end result is a mismatched V/Q ratio and hypoxemia.

Mechanical ventilation can cause or worsen lungdamage

PAIN

D


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DISTRA

CTION


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shows a patient using U.W. HITLab/Harborvviews SnowWorld paindistraction at Shriners Childrens Burn Center Galvestondesigner/researcher

SNOW WORLD PAIN DISTRACTION


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SNOW WORLD PAIN DISTRACTION

Hunter Hoffmanslatest version ofSnowWorld wascreated for the UW

by giftedworldbuilders atwww.firsthand.com: using

www.Virtools.com

Virtual World Development Software.
http://www.firsthand.com/http://www.virtools.com/http://www.virtools.com/http://www.firsthand.com/


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The University of Washington Harborview Burn Center,directed byDr. Nicole Gibran, is a regional burn center.

Patients with severe burns from 5 surrounding states aresent to Harborview for special care. Harborview haspioneered a number of advanced treatments (e.g., earlyskin grafting).

As a result of advances here and elsewhere, the chances

of surviving a bad burn, and quality of living for survivorshas improved dramatically over the past 20 years.

Unfortunately, the amount of pain and suffering experiencedby patients during wound care remains a worldwideproblem for burn victims as well as a number of otherpatient populations
http://www.uwmedicine.org/Facilities/Harborview/CentersOfEmphasis/Burn/http://depts.washington.edu/surgery/faculty/gibran.htmlhttp://depts.washington.edu/surgery/faculty/gibran.htmlhttp://www.uwmedicine.org/Facilities/Harborview/CentersOfEmphasis/Burn/


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hank you for!!!istening

Bye have a nice day !!!


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y y


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Documents

Michaele Conchita M. Zapanta, MD,RN