Common surgical problems Burns

Chapter 9

Case study: Alisher

Alisher, a 10 months old girl was brought to the district hospital by her mother. At presentation Alisher was very anxious, crying in pain and was not able to breastfeed. On the upper half of the chest there was a large scald.

What are the stages in the management of Alisher?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency (danger) and priority (important) signs have you noticed?

Temperature: 37.20C, pulse: 160/min, RR: 45/min Chest: burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no added sounds.

Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

History
At 6pm the previous day Alisher overturned a hot teapot and was burnt. Her mother and relatives took off her clothes and applied toothpaste and potato to the burn skin. During the night the child was very anxious and restless, by the morning her condition had worsened and she could not feed. Her mother brought her to the hospital.

Examination
Vital signs: temperature: 37.20C, pulse: 160/min, RR: 45/min, Weight: 9 kg Chest: Burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no added sounds. Cardiovascular: both heart sounds were audible and there was no murmur Abdominal examination: soft, bowel sound was present Mouth: mildly dry mucus membranes Skin: mildly decreased skin turgor

Diagnosis: Burns

Two very important questions:

How much of the How deep is the burn? body is burnt? Full thickness burns are black or white, usually Use a body surface area chart according to age dry, have no feeling and (Ref. p. 270) do not blanch on Alternatively, use the pressure. child's palm to estimate Partial thickness burns the burn area. A child's are pink or red, palm is approximately blistering or weeping, 1% of the total body and painful surface area

Further examination: Estimate the total area burned

(Ref. p. 270)

How would you treat Alisher?

Treatment & burns management

Hospitalize all children with burns of the skin more than 10%. Consider whether the child has a respiratory injury due to smoke inhalation.

Fluid resuscitation (required for >20% total body surface burn). Use Ringers lactate with 5% glucose, normal saline with5% glucose or half-normal saline with 5% glucose.
Calculate appropriate fluid requirements (Ref. p. 269-271) and administer of total fluid in first 8 hours, and remaining in next 16 hours

Pain control
Paracetamol (10-15mg/kg every 6 hours) by mouth and / or IV morphine sulphate (0.05-0.1mg/kg every 2-4 hours) if pain is severe (Ref. p. 269-272)

Treatment & burns management (continued)

Prevent infection If skin is intact, clean gently with antiseptic solution

If skin is not intact, debride the burn (blisters should be pricked and dead skin removed)
Give topical antibiotics/antiseptics Clean and dress the wound daily, unless the burn is small and difficult to cover, then it can be managed by leaving it open to the air Treat secondary infection if present

Check tetanus vaccination status and give tetanus immunoglobulin or toxoid booster as appropriate
(Ref. p. 269-272)

What supportive care and monitoring are required?

Supportive care
Nutrition Begin feeding as soon as practical in first 24 hours

High calorie diet with adequate protein, vitamin and iron supplements (Ref. p. 272)
Children with extensive burns require about 1.5 times the normal calorie and 2-3 times the normal protein requirements Prevention of secondary infection
Hand washing (Ref. p. 269-272)

Supportive care (continued)

Prevention of burn contractures
Passive mobilization of involved areas Splinting flexor surfaces

Physiotherapy
Should begin early and continue throughout the course of the burn care

Toys and play

(Ref. p. 272)

Monitoring
Observe the child frequently

Monitor respiratory rate and look and listen for signs of airway obstruction and respiratory distress at the beginning
Monitor adequacy of circulation and hydration Pulse Capillary refill

Urine output

Use a Monitoring chart (Ref. p. 320, 413) Ensure the child is calm and pain free and feeding adequately (Ref. p. 269-272)

Follow-up
Plan discharge when there are signs of recovery of the burnt skin and the parents can care for the child at home. Notify parents on the date of follow up visit.

Administer physiotherapy to minimise contractures.

Accomplish a counseling about home safety and about first-aid management of burns (irrigate with cold water).

Summary
Burns and scalds are associated with a high risk of mortality in children. It is important to avoid secondary infection Antiseptic Clean dressings Hand-hygiene Avoid unnecessary antibiotics Effective analgesia is the second main pillar in management of burns Initially, and for all painful procedures