Burns

Physiologic differences

• Children seem more susceptible to symptomatic bronchospasm than adults

• Young infants may have a less mature renal concentrating ability than adults

• Young children seem to handle fluid overload poorly in comparison to adults

• Children resuscitated with hypotonic fluid may develop cerebral edema and seizures

• Young children have a higher metabolic rate and energy requirements per unit body weight and will lose lean body mass more rapidly if fasted

• Young children have a higher surface area to body weight ratio which makes hypothermia more likely to occur

• Young children may form hypertrophic scar more readily than older adults

Anatomic differences

• Child’s upper airway is narrower and therefore more susceptible to occlusion by soft-tissue swelling

• Child’s trachea is shorter and therefore more susceptible to mainstem intubation

• Young children have thinner skin than older children and adults which makes burn healing and donor harvesting more problematic

• Young children have smaller blood vessels than adults which makes vascular access more challenging

• Young children grow, often outgrow, with an initially good surgical result and require revision

Psychologic differences

• Pain and anxiety assessment is more difficult in children than adults

• Family and school issues have a major impact on physical and emotional recovery in children

• Major changes in psychologic needs with developmental stage are predictable

../images/188491_2_En_29_Chapter/188491_2_En_29_Fig1_HTML.jpg — Fig. 29.1

Young children have a high surface area to mass ratio and often minimal subcutaneous fat, making them extremely prone to hypothermia

Important anatomic differences also exist. The child’s upper airway is narrow and more prone to occlusion from resuscitation-associated edema. The trachea is shorter in infants, and more susceptible to mainstem intubation. Young children have small caliber blood vessels, making vascular access more challenging. Children will often outgrow an initial good surgical result, requiring more frequent reconstructive interventions. Anecdotally, young children more vigorously form hypertrophic scar than the elderly. Young children, like the elderly, have a much thinner skin, making burn healing and donor procurement more challenging.

Important emotional and psychologic differences also exist. Pain and anxiety are more difficult to assess in young children and adults. Emotional pitfalls and needs vary with development, with the middle school years being particularly difficult. Family and school issues have a major impact on the well-being of a recovering child.

29.3 Epidemiology and Mechanism Differences

The etiology and incidence of burns varies most with socioeconomic status and age [3]. In the developing world, legislative safety mandates are less frequently enforced resulting in both a higher incidence of injury and differing mechanisms. Electrical injuries are far more common in developing countries as are related cooking injuries. In the developed world, scald injuries predominate in infants and toddlers.

Safety and prevention are laudable efforts in this age group. Safety mandates are variably enforced and include legislation regarding fire retardant sleepwear, fire safe cigarettes, and hot water heater temperature set points. Prevention efforts focused on family education have been successful [4]. Constant repetition is essential.

Importantly, abuse and neglect as a mechanism of injury are more frequent in young children [5]. Burn providers are mandated reporters to their state child protective services. When caring for such children, non-judgmental documentation, careful wound diagrams, and quality wound photography are extremely important (Fig. 29.2).

../images/188491_2_En_29_Chapter/188491_2_En_29_Fig2_HTML.jpg — Fig. 29.2

When caring for children in whom abuse or neglect is suspected, detailed and non-judgmental documentation, careful wound diagrams, and quality wound photography are extremely important

29.4 Outpatient Care Differences

Most burns in children are small and are quite competently managed in the outpatient setting by general pediatric practices [6]. Having a connection with a regional burn program is useful to such practices for the purpose of consultation and follow-up. Children selected for outpatient care should not need a fluid resuscitation, should have no airway embarrassment, should be taking adequate liquids by mouth, should have no circumferential burns, and should not have deep burns of critical areas, or deep burns clearly requiring early surgery. Very importantly, the child’s family should be capable of dealing with the child’s acute and ongoing follow-up needs [7]. Numerous topical management strategies exist that apply equally well to adults and not be repeated here, the reader referred to the outpatient burn chapter. As in adult outpatient care, membrane dressings of a variety of types have proven efficacious in extending the ability to provide comfortable outpatient burn care (Fig. 29.3).

../images/188491_2_En_29_Chapter/188491_2_En_29_Fig3_HTML.jpg — Fig. 29.3

As in adult outpatient care, membrane dressings of a variety of types have proven efficacious in extending the ability to provide comfortable outpatient burn care. This membrane dressing absorbs moisture while releasing silver ion. Many partial thickness wounds will epithelialize under such membranes, but monitoring for submembrane infection is important

29.5 Inpatient Care Differences

The general management strategy for children with large burns based on the early excision paradigm is not conceptually different than that for adult patients [8]. These principles are well outlined elsewhere in this book. However, some subtle but important differences in execution do exist. Engaging the family throughout the care process is important. Time should be budgeted in the busy provider’s day to review progress and plans with the family frequently. Having the family as an ally is extremely helpful both short and long term.

Some critical care differences are of practical importance. Endotracheal tube security is a particularly important issue in mobile young children with facial edema. Reintubating children after unplanned extubation can be quite challenging and is best avoided through adequate sedation and mechanical tube security, one of which is a tube–tie harness system (Fig. 29.4). Uncuffed tubes are ideally avoided in all age groups [9]. Tracheostomy is needed in some children with injuries requiring long-term mechanical ventilation [10], but fairly long-term trans-laryngeal intubation is also associated with good outcomes [11]. Assessing and controlling pain and anxiety in young children with deep burns is very difficult, but should be done on a regular basis [12]. Children will predictably develop rapid tolerance to standard doses of opiates and benzodiazepines, and humane escalation is advised. Early use of a “third drug” is useful in blunting dose escalation. Dexmedetomidine is an excellent choice. Procedural interventions often generate additional sedation needs, which can generally be addressed with additional opiates and benzodiazepines or ketamine [13]. Good control of pain and anxiety may require high-dose pharmacotherapy but it has enduring positive psychologic benefit [14].

../images/188491_2_En_29_Chapter/188491_2_En_29_Fig4_HTML.jpg — Fig. 29.4

Reintubating children after unplanned extubation can be quite challenging and is best avoided through adequate sedation and mechanical tube security, one of which is a tube–tie harness system as illustrated here

The hypermetabolic catabolic state is poorly tolerated by young children. Early tube feedings are advocated, generally beginning during resuscitation. Short-term parenteral nutrition is well tolerated and can be useful during periods of sepsis or hemodynamic instability [15]. Nutritional targets should include 2–2.5 g per kilogram of ideal body weight per day of protein and a caloric target of 1.5–1.7 times a basal metabolic rate [16]. The use of anabolic agents remains an area of some controversy in the field with good outcomes documented on both sides [17, 18].

Differentiating benign fever from sepsis in children can be challenging. Many young children have a propensity to manifest high fever in the absence of infection. In the current era of antibiotic stewardship, if a child looks toxic with a fever, drawing blood cultures and starting antibiotics with a plan to stop them if the blood cultures are negative at 72 h is reasonable [19]. Children with inhalation injury and respiratory failure are ideally managed with lung protective strategies of mechanical ventilation, pulmonary toilet, and focused treatment for infection [20]. It was not that long ago that young age was an independent predictor of mortality in burns. However, that is no longer the case largely secondary to the evolution of pediatric critical care techniques with early wound excision, accurate individualized fluid resuscitation, lung protective strategies of ventilation, and focused treatment of infection [21].

29.6 Fluid Resuscitation Differences

Basic principles of burn resuscitation are similar in adults and children. Here again, this section will only present differences that have practical clinical consequences. Children with burns less than about 15% of the body surface generally need no formal resuscitation. Providing them fluid at about 150% of a maintenance rate via combined oral and intravenous route is generally sufficient. Adequacy of hydration can be monitored by urine output (weighing diapers and physical exam looking at mucous membranes and peripheral pulse quality).

As burns become larger, a calculated resuscitation is advisable. It has been the authors experience that over-resuscitation is quite common in young children which exacerbates the complications associated with anasarca. Resuscitation-associated anasarca can be minimized by refining resuscitation endpoints (Table 29.2) and by more liberal use of colloid early in resuscitation [22]. Extreme anasarca is associated with morbidity related to retrobulbar edema, compartment pressure elevations, impaired gas exchange, and abdominal visceral edema (Fig. 29.5). While acknowledging the success of crystalloid-only resuscitation, the author’s personal practice has included early colloid for many years, and is detailed in Table 29.3 [23].

Table 29.2

Suggested resuscitation endpoints in children

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