Pediatric burns seminar

1. Every year children are involved in accidents or
born with conditions that require medical care not
always available by their local provider.

2. • Shriners Hospitals for Children® – Cincinnati
has experts in the field of burn care, pediatric
plastic reconstruction and rehabilitation
• Our goal is provide comprehensive services
regardless of the patient’s ability to pay

3. There are about 486,000 burn injuries per
year in the US that require medical
attention and 3,275 deaths
ABA 2016 fact sheet

4. Burn Injuries
40,000 of 486,000 injuries are hospitalized – 30,000
of those into the 128 burn centers
The other 4500 U.S. acute care hospitals average less
than 3 burn admissions/year
Place of occurrence: 73% home, 8% job, 5% street,
5% recreational, 9% other
More males than females burned – 2.5:1
ABA 2016 fact sheet

5. Etiology of Admitted Burns
• Fire & flame 43%
• Scalds 34%
• Hot object contact 9%
• Electrical 4%
• Chemical 3%
• Other 7%
ABA 2016 fact
sheet

6. • Protection
1st line of defense against infection
• Loss of Body Fluids
After a burn, large fluid loss occurs
• Temperature Regulation
Full thickness injuries destroy sweat glands
• Sensory
Pain, pressure, temperature, and touch
Change in sensory perception
Skin is largest organ in the body

7. • Vitamin D activation
Skin + sunlight activates vitamin D
Partial thickness burns reduce this ability and full
thickness burns result in complete loss of ability to
activate Vitamin D from the area burned
• A person’s Physical identity is closely tied to how
their skin looks
Self-image issues are common after a burn injury
Skin

8. • Infants (up to age 1) & children (up to age 15) have a greater surface
area per unit of body weight than adults.
• Results in greater contact with the environment & greater evaporative
water loss per unit of body weight than adults;
• Therefore infants & children need more fluid per unit of body weight
during resuscitation than adults.
Body Surface Area

9. • 2 layers
• Epidermis
• Outer layer
• Contains no blood
vessels
• Healing occurs
from the dermal
layer underneath
the epidermis
Anatomy of Skin

10. • Thicker than the
epidermis
• Contains blood vessels,
sensory nerves, hair
follicles, and sweat
glands
• Healing can occur as
long as there is some
dermis present after the
burn injury
Dermis

11. • When the whole
dermal layer is
destroyed from
the burn, the skin
can no longer
restore itself
• Beneath the
dermis is
subcutaneous fat,
muscles, tendons,
and bones
Dermis

12. Types of Burns
• Flames
• Scalds
• Chemicals
• Electrical/Lightning

13. Flames
• House fires
• Explosions – gas
• Gasoline
• Campfires
• Fireworks

14. Firework Injuries
• Consumption of fireworks has been increasing significantly
over recent years with relaxed laws
• In 2017, there were 8 deaths from fireworks and 12,900
injuries. Two-thirds happened around the July Fourth
holiday. The large majority of the injuries were burns.
• Children under 15 years of age experienced about 36
percent of the injuries, and males of all ages were involved
in 70 percent.
• Insurance Journal: July 2018

15. Scald Injuries
• Occur when the child has a hot liquid spilled on him
• How bad the burn will be depends on what the hot
liquid is.
Example: Water boils at 100C, but soup with chicken fat
will boil at a higher temperature so soup will burn
deeper faster

16. Scald Injuries
• Most scald injuries in children occur while
bathing
• Most common burn injury in children under 4
years of age
• 95% of scalds occur in the residence

17. Scald Injuries
• Time of contact and water temperature to cause a
burn
- 120 degrees – 5 minutes
- 130 degrees - 30 seconds
- 140 degrees - 5 seconds
- 160 degrees - instantaneous
• Young children and older adult may burn deeper
faster because their skin is often thinner
• Set hot water heaters appropriately

18. Accidental Scald Burns
 Splash marks present
 Irregular pattern of burn
 Run-down pattern
 Consistent history

19. Identifying Abuse and Neglect
• Verify burn history
• Assess burn pattern
• 60% of burn histories do not match the
pattern of injury
• The child is pre verbal so they are unable to
explain the injury

20. Patterns of Injury
Classic Abuse:
• Sock-glove like distribution
• No splash marks
• Symmetrical deep second or third degree
burns of the hands or feet

21. Chemicals
Most common types
•Alkalis 
Home & work: cleaning, hobbies
•Acids 
•Organic compounds – petroleum products

22. Treatment
• Protect yourself – use PPE
• Remove saturated clothing, jewelry, contacts
• Brush off powder agents
• Continuously irrigate area with copious amounts of water
* Neutralizing chemical contraindicated
Potential for heat generation
* Continue irrigation until pain
decreases or patient is evaluated at a
burn center

23. Treatment
• Support ABC’s. Chemical agents can
impact respiratory &/or circulatory status
• Establish IV access for large
chemical injuries
• If irrigating a large burn, avoid
hypothermia
• Identify agent if possible but do not delay
therapy until agent is identified
• Contact Poison Control Center if needed

24. Chemical Injuries to Eyes
• Alkalis are twice as common as acid injuries
• Alkalis bond to tissue protein: require prolonged irrigation
• Water or saline irrigation – begin at scene & continue until
seen by qualified professional
• Consult ophthalmologist

25. Anhydrous Ammonia
• Seen commonly in fertilizer or industrial refrigerant
• Used in the manufacture of methamphetamine
• Is a strong base with a penetrating odor – pH 12
• Skin blistering with exposure, eye irritant
• If fumes are inhaled  Increased secretions combined with
sloughed epithelium, necrotic debris, tissue edema & reactive
bronchospasm
Treat with copious irrigation to
wounds; intubate as necessary
may need

26. Tar Burns
• Tar creates a thermal injury, not a chemical one
• Bitumen compound not absorbed, not toxic
• Cool tar to stop the burning process
• Facilitate removal with use of a petroleum based ointment
or medically safe solvent to emulsify the tar

27. Electrical Injury: The Grand Masquerader
* Small surface injuries may be associated with devastating internal
injuries
* Many work related with
significant economic impact

28. Electrical Injuries
• Low-voltage <1,000 V
Localized to area surrounding
the area
•
• High-Voltage >1,000 V
Deep extension and underlying
tissue damage

29. The extent of the injury is dependent upon…
•Type of current
- Alternate Current (AC) – 120v, back & forth flow of current;
usually contact burn only
- Direct Current (DC)– flows in 1 direction; entrance and exit
points Usually high voltage
•Pathway of flow through body
•Local tissue resistance
•How long the body is in contact with the electrical source
Tissue Injury

30. • Bone & skin have high resistance
• Once through the skin, the electrical current flows through the
tissue under it, especially along bones creating more heat
• Heat damages the muscle around it
• Deep muscle injury may occur, including compartment
syndrome, even when superficial muscle appears normal
Tissue Resistance

31. Treatment
• Scene Safety
• Assess Entrance and Exit wounds
• Monitor for dysrhythmias
• May require increased fluids during
resuscitation to flush out myoglobin
• NaHCO3 may be considered if myoglobin is
present in urine

32. Lightning
• Over the last 10 yrs, caused average of 28 deaths/yr.
• The spectrum of burn injury varies widely from pt to pt.
• Many survivors suffer serious complications related to the
cardiac and neurological systems.
• Not always associated with deep burns as the current
generated from lightning often travels on the surface of the
body and not through it.
• The cutaneous burns are typically superficial presenting
what has been called a “splashed on” spidery pattern.

33. Burns From Other Sources
• Curling Iron
• Irons
• Grills
• Cigarettes
Suspect abuse if you notice several pattern burns

35. Frostbite
Injury due to intracellular water turning to ice and
extreme cold constricting, damaging, and blocking the
blood supply to exposed parts.
Treatment protocol involves re-warming and care in a
specialized treatment unit for wound care

36. •Determining the Severity of a Burn

37. • Burn severity is based on how much of the body
surface area is injured and the depth of the burn
• Skin thickness also affects burn depth
Young children and older adults tend to have
thinner skin, resulting in deeper injuries in these age
groups, even when the temperature is lower
Depth of Burn Injury

38. • Only involves the epidermis – also
called 1st degree burn
• The cells needed for re-growth
remain
• Caused by prolonged exposure to
low intensity heat or short exposure
to high intensity heat
• Flash burn
Superficial Thickness Wounds

39. • Reddened, Painful, Mild Swelling
• No Blisters
• Peeling occurs 2-3 days after the burn
• Heals Within 3-6 Days
• No Scarring
• Care: Lotion or aloe for comfort
• Acetaminophen or ibuprofen for mild pain
Superficial Thickness Wounds

40. • Involves the entire epidermis and varying depths
of the dermis – also called 2nd degree burn
• Called a superficial partial thickness or deep partial
thickness burn depending on how far down into
the dermis the injury goes
Partial Thickness Wounds

41. • Involves the upper third of the dermis
• Small vessels bringing blood to this area are damaged,
resulting in large amounts of plasma leaking, which is trapped
between the dermis and epidermis resulting in a blister
• Pink, Moist, Blisters, Swollen, Blanches
• Painful because nerve endings are exposed when the blisters
are broken
• Heals within 2-3 weeks with proper care
• No scarring, but pigmentation changes can result and be
permanent
Superficial Partial Thickness Injuries

42. 42
Deep Partial Thickness

43. • Burn injury extends in into the lower 2/3 of the dermis
• Blisters don’t usually form because the layer of dead tissue
is thick, and sticks to the dermis underneath, so does not
easily lift off the surface to make the blister
• Wound is dryer than a superficial partial thickness injury
because fewer blood vessels are left that have not been
injured
• Often looks red with patches of white
• Blanching either occurs slowly or not at all
Deep Partial Thickness Injuries

44. • Moderate amounts of edema
• Less pain than with superficial burns because more of the
nerve endings have been destroyed
• Can convert to full thickness wounds if there is infection,
or poor blood flow to the area because there is further
tissue damage
• Heals within 2-6 weeks
• Skin grafting can reduce healing time and often
produces a better looking scar
• These burns will scar
• Massage and pressure garments will reduce thickness
and redness of scars
Deep Partial Thickness Injuries

45. • Burn injury destroys the entire epidermis and all of the
dermis, leaving no skin cells to regenerate. Also called a 3rd
degree burn
• Will not heal without grafting
• No pain
• No blanching
• Hard, dry leathery appearance called eschar forms from the
destroyed skin
• Eschar is dead tissue and must be removed before any
healing can occur
• If the eschar is not removed, patient can become
septic and even die from toxins given off by the eschar
Full Thickness Injuries

46. • Severe edema is present under the
eschar
• Circumferential injuries:
• Because of the leathery texture of
the eschar and the severe edema,
blood flow to and movement of
the area may be reduced
• Escharotomies or fasciotomies may
be needed to relieve pressure,
allowing normal blood flow
Full Thickness Injuries

47. • May be called a 4th degree
burn
• The burn injury damages
muscle, bone, and/or
tendons
• Looks black and sunken in
• All feeling is gone
• Amputation may be
needed when an extremity
is involved
Deep Full Thickness Injuries

49. • Affects all body systems
• Vascular changes
• Circulation to the burned skin is immediately
altered
• Inflammation that develops causes the blood
vessels near the wound to dilate and have
increased capillary permeability causing fluids to
leak into the interstitial space = “3rd spacing”
Initial Clinical Manifestations of Burn Injury

50. • Continuous leak of plasma from the vascular space
into the interstitial space
• Leads to loss of plasma and proteins which decreases
blood volume and decreases blood pressure
• This leakage occurs in surrounding tissues and may
cause edema even in areas not burned
• If TBSA is >25%, capillary leak and edema occurs in
both burned and unburned areas
• This fluid shift occurs within the first 12 hours and
continues for 36 hours after burn injury
Third Spacing

51. • Fluid shifts lead to fluid/electrolyte and acid/base
changes
• Hypovolemia-3rd spacing
• Metabolic acidosis-cell destruction
• Hyperkalemia (↑K)-cell destruction releases
large amounts of potassium (K)
• Hyponatremia (↓Na) - 3rd spacing
• Sodium stays in the body but it is in the
interstitial space, not the vascular system
Third Spacing con’t …

52. • Increased hemoglobin and hematocrit
• Vascular dehydration- the volume is outside the blood
vessels in the 3rd space
• Problem as it increases blood viscosity, decreases
general blood flow throughout the body and
increases tissue hypoxia
Hemoconcentration from Fluid Shift

53. • Capillary leak stops
• Amount of edema seen on
the outside is matched in
the airway and pulmonary
system
24-36 Hours After Injury

54. • Tachycardia
• Decreased cardiac output because of fluid shifts and hypovolemia
initially
• May improve with fluid resuscitation
• Proper resuscitation and administration of oxygen helps prevent
complications
Cardiac

55. • Direct lung injury from flames rarely
occurs
• Superheated air, steam, toxic fumes, and
smoke can cause respiratory injury
• Respiratory issues are the major
cause of death in burn patients and
much more likely to happen when
the injury occurred indoors e.g.
trailers
• Difficult to have inhalation injury
with an outdoor fire
Respiratory

56. • Inhalation injuries can occur in
upper airway, major airways, and
lung tissue
• Upper airway- inhaled smoke or
irritants cause edema and blocks the
trachea
• Inflammatory response results in edema
of throat and mouth with possible
airway obstruction
• Same level of edema seen on outside is
also in the airway
• Worsens with fluid resuscitation but it is
necessary
Respiratory

57. • Toxic irritants ( chemicals & gases) can damage the lung
tissue including alveoli and capillaries
• Leaking capillaries in the lungs can cause alveolar edema
which leads to decreased oxygen exchange
• The leaking fluids contain protein which forms fibrinous
membranes and leads to respiratory distress and
pulmonary failure
• Smoke and gases also slow the ciliary activity allowing
particles to enter the bronchi
• Lining of trachea and bronchi may slough at 48-72
hours after injury and obstruct the lower airway
Respiratory

58. Effects of Edema on Airway Resistance
in the Infant versus the Adult
Infant
Adult
Normal Edema 1mm Resistance
increase
Diameter
Decrease
16x
3x
75%
44%

59. • As respiratory failure can follow, endotracheal
intubation or tracheostomy is sometimes needed
to maintain an open airway
• Chest burns with eschar can restrict chest
movement
• Carbon monoxide poisoning
Respiratory

60. • Reduced cardiac output and fluid shifts decrease
blood flow to the GI tract
• Impairs gastric motility and stress can cause a
gastro-duodenal ulcer called a Curlings ulcer
• At worst, destroys sections of the intestine
• As peristalsis decreases an ileus may develop
• Secretions and gases collect in GI tract causing
abdominal distention
GI Changes

61. • Increased metabolism
• Oxygen use and caloric needs are high
• Caloric needs may double and cause catabolic
activity
• **Can remain elevated even months after all
wounds are healed
• Increases core body temperature:
Lose heat through burned areas and the body tries to
heat the body to maintain equilibrium, often resulting in
low-grade fever
Metabolic Changes

62. • Diuretic phase- fluid goes back from the interstitial space into
the vascular space
• Blood volume increases leading to ↑ blood flow to kidneys
and diuresis occurs
• Hyponatremia continues- now because the kidneys are
excreting the sodium
• Hypokalemia- potassium moving back into cells and excreted
in urine
• Sodium & potassium will need to be replaced by IV
• Protein continues to be lost from the wounds
• Metabolic acidosis due to ↑ metabolic rate & loss of
bicarbonate in the urine
48-72 Hours After Burn Injury

63. 1. Safety
2. Stop the Burning Process
3. Primary Survey and Support
– Airway - maintain airway with cervical-spine control
– Breathing - assess and support (Oxygen)
– Circulation -assess, support, control external
hemorrhage, monitor ECG; begin fluid replacement
– Disability - evaluate neurologic status (AVPU Method-
alert, responds to verbal, pain, unresponsive)
– Exposure - Allow for detailed exam
Primary Survey of Burn Patient

64. Predisposing Factors
• Closed space
Physical Examination
• Facial burns, singed nasal hairs
• Mucosal edema of nose and mouth
• Carbonaceous (black) sputum
• Hoarseness, strider (laryngeal)
• Difficulty breathing, wheezing (small airway)
• Decreased level of consciousness
Airway & Breathing
Assessment for Inhalation Injury

65. • Non-Rebreather mask
• Bag-Valve Mask Assist – bag patient
• Intubation
Oxygen

66. • Assessment Findings
• Absent or poor respiratory effort
• Absent peripheral pulses (Central pulse is weak
or strong)
• Unconscious
• Elective vs. Emergent is preferred
Intubation

67. Carbon Monoxide
• Colorless Odorless Gas
• 200x Affinity for Hemoglobin
• Does not allow for O2 transport
Treatment for CO Poisoning is removal from source,
followed by 100% O2.

68. • Monitor Heart Rate, Pulses, Color, Capillary Refill, O2
level, bleeding
• IV’s – large bore IV (2 if a large burn) – through unburned
skin if possible but can use burned skin
• Pre-hospital amounts before TBSA is calculated:
5 yrs & younger: 125ml Lactated Ringers (LR)/hr
6-13 yrs: 250ml LR/hr
14 yrs & older: 500ml LR/hr
Circulation

69. Disability
• Level of consciousness: A burn injury, even 100%
will not render a victim unconscious
• If the patient is unconscious or incoherent, look for
a cause other than the burn.
• Heart Attack
• Anoxia
• Stroke
• Head Injury
• Pain levels
• Glascow scale; APVU to determine LOC

70. • Quick Head to Toe examination without clothes – strip
& flip
• Temperature control
• Clean dry dressings
Exposure

71. Exposure
Wet vs. Dry Dressing?
• Always place in dry clean dressings.
• Topicals antibiotics are not necessary if being
transferred to a burn facility
• Ice and cold is absolutely not applied! It causes
vasoconstriction to an area that already has poor blood
flow

72. One of the major functions of the skin is
temperature regulation. If the skin is damaged the
body cannot maintain this function.
Hypothermia can result.
Temperature Regulation

73. • Temperature Regulation in infants and children, is affected by
their relatively greater body surface area so body heat is lost
quickly. (Cover head also!)
• Heat generation by shivering is hard for children due to their
relatively small muscle mass.
• Temperature regulation in infants < 6 months old depends
less on shivering and more on the body’s metabolic processes
and the air temperature around them.
Temperature Regulation

74. • Increased fluid needs
• Clotting factors are inhibited
• End Organ Perfusion is decreased
• DEATH
Complications of Hypothermia

75. The secondary survey does not begin until the
primary survey is completed
Secondary Survey

76. • History, burning agent & location of injury, associated
trauma
• Medical history – AMPLET (allergies, medications,
previous illnesses, last meal, events related to injury,
tetanus & immunizations
• Accurate pre-burn patient weight
• Complete Head to Toe Evaluation
• Severity & depth of burn
Secondary Survey

77. • TBSA involved*
• Adjusted fluid rates after TBSA determined*
• Monitor fluid resuscitation & urine output*
• Obtain labs & x-rays as needed
• Pain & anxiety management*
• Psychosocial support
• Wound Care*
Secondary Survey

78. • Total Body Surface Area
TBSA
Size of Burn Injury

79. Rule of “Nines”
Modified for Age
5 years
1 year
9 9
36
14
16 16
36
18
9
9
14 14
9 9
18 18
1
36
9
Adult

80. • The Lund & Browder Chart takes into account the
proportional differences of a child at different ages so is
more accurate in determining the percentage of body
burned at different ages. This chart should be used in
patients <15 years.
• The Palmar Method – where the palm and fingers
represent approximately 1% of TBSA – is useful in
estimating the extent of irregularly scattered small
burns.
Calculation of
Total Burn Surface Area

82. Lund Browder Charts
Courtesy of Nationwide Childrens Hospital

83. Lund Browder Chart
Courtesy of Nationwide Childrens Hospital

84. Patient’s palm including
fingers
is equal to 1% of their
Total Body Surface Area
(TBSA)
Estimation of Small Scattered Burns
Palmar Method

85. Burn Shock
Burn damage increases capillary permeability.
This increase and the inflammatory process causes
leakage into the interstitial space = edema /third
spacing
Level of edema peaks at 24-36 hours
Burns larger than 25% TBSA will have generalized
systemic edema, including areas not burned.
Adequate Fluid Resuscitation

86. Maintain vital organ function while
avoiding complications of too little or
too many fluids
Fluids: The Goal

87. • > 15% burn in adults
• > 10% burn in children
• Age >65 y/o or < 2 y/o any size burn
Indications for Fluid Resuscitation

88. • 1-2 Large Bore IV(s)
• Isotonic Crystalloid Solution
– Lactated Ringers (LR)
• Begin as soon as possible
Fluid Resuscitatiaon

89. Formula for Fluid Resuscitation
(At Treating Hospital)
Adult: (2ml x kg x % burn) = mls / first 24 hours
Child (13 years and under): (3ml x kg x % burn)
High voltage electrical: (4ml x kg x % burn)
ABLS Provider Manual 2015

90. Formula for Fluid Resuscitation
(At Treating Hospital)
• Parkland Formula
• (4ml x kg x % burn) = ml / 24 hours
(4ml may ↑ to 4.5-5 in electrical injuries)
Regardless of formula used, you should give:
• 50% in first 8 hours from the time of the burn
• 25% in second 8 hours
• 25% in third 8 hours
• Maintenance fluids also given with all formulas used

91. Resuscitation Calculations
Calculated Resuscitation requirement
• (In this example our patient is 20 kg, 60% TBSA burn.)
• (4ml x __ kg x __ % burn) = ml/24 hours
____ ml/24hrs
Resuscitation Fluid per 8 hours
• 1st 8 hours ____ ml or ___ ml/hr
• 2nd 8 hours ____ ml or ___ ml/hr
• 3rd 8 hours ____ ml or ___ ml/hr

92. Resuscitation Calculations
Calculated Resuscitation requirement
• (In this example our patient is 20 kg, 60% TBSA burn.)
• (4ml x 20 kg x 60 % burn) = ml/24 hours
4800 ml/24hrs
Resuscitation Fluid per 8 hours
• 1st 8 hours 2400 ml or 300 ml/hr
• 2nd 8 hours 1200 ml or 150 ml/hr
• 3rd 8 hours 1200 ml or 150 ml/hr

93. • In general, all patients with >20% burn should have a urinary
catheter inserted
• Children (1-14 yrs): 1 ml/kg/hr
• Adults (>14 yrs): 30 to 50 ml/hr
• Electrical: Child 1.5-2ml/kg/hr; Adult: 75-100 ml/hr
NOTE: Fluids are calculated and given using the formula but the
volume of fluid actually given is adjusted according to the patient’s
urinary output and clinical response.
Adequate Fluid Resuscitation
Urine Output

94. NO BOLUS THERAPY
NO DIURETICS
Increase total fluids by
one third /hr
(Decrease by 1/3 if too much urine/hr)
Urine Output Inadequate

95. Complications from Edema
• Burn patients will have edema. It is normal!
• Compartment Syndrome
• Assess for the need for Escharotomies /
Fasciotomies

96. • Assess for:
Pain
Coolness
Discoloration (Paleness)
Poor capillary refill
Numbness/Tingling
-Elevate the extremity
and assess pulse
hourly by palpation or doppler
Nursing Considerations in Circumferential
Injuries with Edema

97. • Physicians will check
compartment pressures
• Pressures equal to or >30
mmHg need
escharotomies or
fasciotomies
Compartment Pressures

98. • Generally not needed until several hours
into burn resuscitation
• Incision made into the eschar
to relieve pressure in compartment
• Laterally & medially - across
involved joints, from 1 unburned
area of skin to another
• Incision to depth to allow release of
pressure (30 mmHg)
Escharotomy & Fasciotomy

99. 99
Chest Escharotomy

100. Fasciotomy
• If pulses do not return after an escharotomy then a
deeper incision is made down through the fascia.
• If pulses do not return after the fasciotomy then
tissue necrosis will occur and amputation is
probable.

101. ABA Burn Center Referral Criteria
• Partial thickness - 2nd degree burn > 10% TBSA
• Burns involving face, hands, feet, genitalia,
perineum, or major joints
• 3rd degree burns any age group

102. ABA Burn Center Referral Criteria
• Electrical burns including lightning
• Chemical burns
• Inhalation Injuries
• Burns with pre-existing medical conditions that
could complicate management, prolong recovery, or
affect mortality

103. ABA Burn Center Referral Criteria
• Burns with concomitant trauma in which the burn
poses the greatest risk of morbidity or mortality
• Hospitals without qualified personnel or
equipment for the care of children
• Burn injury in patients who will require special
social, emotional, or long term rehabilitative
intervention

104. Wound Care

105. Management of Burn Wounds
• Starts with debridement- removal
of cellular debris and eschar
• Wounds cleaned 1-2 times per
day
• Dead tissue is removed
• Burn areas are washed with
soap and water

106. Dressing change – partial thickness
Dressing change 1-2 times daily
• Remove old dressing, soak off with soapy water as needed so
healing skin is not traumatized.
• Wash with a clean wash cloth and mild
non-perfumed soap and water removing any
old medicine and drainage.
• The wound may bleed (and bleed more if the child is crying), so
apply firm pressure with washcloth.
• Rinse the area and pat or air dry.
• Provide distraction for child during dressing change

107. Dressing Change con’t
• Apply a thin layer of an OTC antibiotic ointment - e.g.
Bacitracin, Polysporin, Neosporin - to a non-adherent
dressing (such as Adaptic)
• NO Silver Sulfadiazine (Silvadene) on small partial thickness
• Place dressing on open areas only – do not overlap onto
unburned or healed areas – irritating.
• Secure the non-adherent dressing with a gauze dressing or
similar device.
• When healed (dry & shiny) stop the OTC ointment and
massage with a non-alcohol, non-perfumed moisturizing
cream.

108. Dressing Types
• Standard Dressings
• Application of topical antibiotics to prevent
infection
• Silvadene, sulfamylon cream, bacitracin
• Multiple layers of gauze to contain drainage
• Rolled gauze or ace wrap applied in distal to
proximal direction
• Silver impregnated dressings
• Acticoat, Aquacel Ag, Mepilex Ag
• Releases silver ions when moistened
with water or exudate from the wound
• Use on partial thickness wounds
and donor site
• Can stay on for 7 days

109. Biologic Dressings
• Used for temporary wound coverage
• Promotes healing or prepares the wound for
autografting
• Allograft
• Human skin obtained from a cadaver
• Cost is high and there is a risk of transmitting a
bloodborne infection
• Xenograft
• Skin obtained from an animal; Pigskin is most common

110. Integra
• Two layered substance
• Silastic (plastic) epidermis and a
porous dermis made from beef
collagen and shark cartilage
• Over time, the artificial
dermis slowly dissolves,
leaving blood vessels and
connective tissue that
supports an autograft
after the silastic portion is
removed

111. Surgical Management
• Autografting is used when:
• Full thickness injuries
• Natural wound healing would result in loss of joint function
• Natural wound healing would result in an unacceptable cosmetic
appearance

112. Excision
• Surgical excision of the wound is performed early in
the postburn period
• Leaving dead tissue on the wound for too long
causes sepsis
• Removal of very thin layers of necrotic burn tissue
until bleeding tissue is encountered

113. Autografting
Permanent skin coverage for full thickness
burns
• Epidermis and part of the dermis is taken om from an
unburned area of the patient’s body (donor site) and
transplanted to cover the burn wound (graft site).
Graft secured in place with staples
• Leaves a partial thickness injury at the donor site
• Patient with large full thickness wounds will require
repeated removal of skin from the same donor site or
meshing of the grafts prior to application

114. Sheet Autograft
• Ideal permanent wound coverage
• Better cosmetic appearance
• Used for hands and face
114

115. Mesh Autograft
• Split thickness autograft
• Sheet graft passed through
a mesher to expand and
cover a larger area
115

116. Mesh Autograft cont…
• The graft retains the meshed pattern
• Fades slightly over time with pressure garments
116

117. Graft Care
• After initial application the graft, sites are
immobilized for 3-5 days to allow
vascularization of the grafted skin
• Allows blood vessels in the tissue to
connect with the newly transplanted
graft
• Any activity that might cause separation
of the graft from the tissue is prohibited
• Often requires increased sedation

118. Itching
• As healing occurs, skin is often dry and itchy due to
damage to the sweat & oil glands.
• Massaging healed areas 3-4x a day with an alcohol-
free, non-perfumed moisturizing cream / lotion can
help relieve this. Massage until lotion disappears.
• For overnight itching, moisturize before bedtime.

119. Itching
• If moisturizing is not helping or the child is waking
up from sleep due to itching, an antihistamine like
Benadryl (Diphenhydramine) may be used.
• Use as instructed on package directions
• Remind pt/family that Benadryl can also cause
drowsiness in some children or hyperactivity in
others.

120. Face Grafts
• Vascularize quickly
• Bleeding is often an issue; roll graft with sterile Q-tip
hourly until signs of graft healing are noted
• No dressing, only topical e.g. bacitracin
POD 0 POD 2
120

121. Epicel (Cultured Epidermal Autograft)
• CEA is pure epithelium, also called Keratinocytes
• 2 full thickness postage stamp size biopsies taken from
undamaged skin then live skin cells are extracted to get a
cell yield. Grafts grown in petri dishes.
• Pt has a dermal regeneration template (e.g. Integra)
placed on the wound to help prepare the bed for grafting
• Skin graft will be ready for use approximately 21 days
after skin biopsy is received.
• Initially, the skin grafts are very thin and immature, only
2-8 cell layers thick. Placed on a piece of Vaseline gauze
for transfer

122. Epicel (CEA)• During the first post-op week, the skin grafts will migrate to
the wound bed.
• During dressing change, area left open to air 2 hrs, 2x/day
• POD 7-10 – layer of Vaseline gauze slowly peeled back and
areas covered with adaptic & topical antibiotic (based on
cultures) during twice daily dressing change
• POD 21 – daily dressings with 2-4 hr air outs followed by
adaptic & topical antibiotic
• After POD 21 – not a sterile dressing, limited exposure to
water; grafts susceptible to maceration & blistering
• If no skin is seen by POD 21, it is unlikely to re-epithelialize

123. Pain Management – Severe Injury
“Burns hurt and patients should not have to demonstrate
their pain tolerance”.
Richard Kagan, MD
Retired Chief of Staff
SHC-C

124. Children who are in pain will:
Cry / Scream
Kick / Bite
Try to escape
Throw up
Spit / Punch / Curse
Patients will also have changes in their HR, RR, BP, and
oxygen saturation.

125. Children who are not in pain will:
Suck their thumb
Sleep
Play
Cooperate
Laugh

126. • With the numerous advances in burn care, many
seriously injured patients will survive their injury, thus
making adequate pain management throughout all
phases of care paramount for successful physical and
psychological recovery.

127. Factors which may Influence Pediatric
Burn Patients’ Pain
• Patients have developed a physical tolerance
• Prior hospitalization
• Presence/absence of parent
• Traumatic experience of the burn injury (abuse,
death of loved one, etc.)
• Anticipatory fear
• Separation / Stranger anxiety

128. Pediatric Pain Scales

129. FLACC Scale
• The Face, Legs, Activity, Cry, Consolability scale or FLACC scale is a
measurement used to assess pain for children between the ages of 2
months and 7 years or individuals who are unable to tell you about
their pain.
• The scale is scored in a range of 0–10 with 0 representing no pain.
• The scale has five criteria, which are each assigned a score of 0, 1 or
2.

130. Criteria[ Score 0 Score 1 Score 2
Face
No particular
expression or smile
Occasional grimace or
frown, withdrawn,
uninterested
Frequent to
constant
quivering chin,
clenched jaw
Legs
Normal position or
relaxed
Uneasy, restless,
tense
Kicking, or legs
drawn up
Activity
Lying quietly,
normal position,
moves easily
Squirming, shifting,
back and forth, tense
Arched, rigid or
jerking
Cry
No cry (awake or
asleep)
Moans or whimpers;
occasional complaint
Crying steadily,
screams or sobs,
frequent
complaints
Able to be
consoled
Content, relaxed
Reassured by
occasional touching,
hugging or being
talked to, distractible
Difficult to
console or
comfort

131. Pain Rating Scale
• Designed for children aged 3 years and older.
• It gives a visual description for those who don't have
the verbal skills to explain how they feel.
• To use this scale, you should explain that each face
shows how a person in pain is feeling. The patient
chooses the face that best fits how they feel.
From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301.
Copyrighted by Mosby, Inc.

132. Numerical Pain Scales
• For the older child, a numerical pain scale allows
the child to describe the intensity of his
discomfort in numbers ranging from 0 (no pain) to
10 (worst possible pain).
• Numerical pain scales may include words or
descriptions to better explain symptoms, from
feeling no pain to experiencing excruciating pain.

133. Non-Pharmacological Interventions
• Frequent pain assessment
• Distraction, music
• Giving the patient choices when able
• Reduction of waiting time as much as possible
• Honesty / development of a trust relationship
• Maintaining calm environment when able

134. Non-Pharmacological Interventions
• Use of blankets or other comfort items (pacifier,
favorite toy)
• Guided Imagery
• Healing touch
• Relaxation
• Avoidance of “over-stimulation”
• Massage
• Parental involvement

135. Pharmacological Pain Interventions
• Administration of opioid analgesics
• Morphine, Fentanyl, Dilaudid
• Given IV in the resuscitation phase
• IM or SC meds remain in the tissue spaces and don’t
relieve the pain d/t edema
• Once the fluid shift occurs and edema decreases, all
of the medication is absorbed at once resulting in
lethal blood levels of opioids
• Assess for respiratory depression
• After that, oxycodone/APAP, regular Tylenol, or similar
analgesics, are usually effective.

136. Pain Interventions
• Ketamine and nitrous oxide can also
be used for painful procedures
• There are often strict guidelines
involving the use of these
medications
• Assess the effectiveness of pain
medication

137. Nutritional Support
• Nutritional Support is of primary importance following thermal injury
• Hypermetabolic state induced by the injury
• Adequate nutrition is necessary to promote healing and survival

138. • The patient will maintain adequate nutrition for
meeting caloric needs
• Stable weight will be maintained.
• Caloric intake will meet metabolic demand.
Nutrition

139. Nutrition
• Nutrition is started within first 6-12 hrs via a
nasoduodenal feeding tube inserted under
fluoroscopy
• Monitored by direct calorimetry (measurement of
energy expenditure)
• Administer nasoduodenal feedings until patient is able
to eat on his/her own
• Early enteral feeding helps to reduce weight loss,
atrophy of the stomach and intestines, and
prevent sepsis

140. • Document strict intake and output
• Coordinate care with the nutritionist to meet caloric
and protein needs
• Meet with the interdisciplinary team and patient
to identify food preferences and for each team
member to understand the importance of
nutrition
Nutrition

141. Scar Management & Rehabilitation
Long term rehabilitation is
critical to achieving the
best outcome and quality
of life.

142. Complications
• 12-18 months for scar tissue to mature
• Immature scar: red, raised and rigid.
• Hypertrophic scar: overgrowth of dermal
components that remain within the boundary of
the wound.
• Hypertrophic scarring can hinder the mobility of
the area/joint

143. Treatment
OT/PT
•Every burned joint must be exercised at least
2x/day – lotion and stretching exercises
•Done by patient &/or family members at home
daily for 12-18 months

144. Pressure Garments & Effects of Pressure
• Pressure decreases inflammation - so there is not
excess blood flowing to the healed area and there
is a decreased rate of collagen synthesis
(hypertrophic scarring)
• Realignment of collagen bundles in a parallel
pattern
• Flattening of the scar
• Increased pliability
•Should be worn 22-23 hours per day, every day until
scar tissue is mature (12-18 months)
Treatment

145. Non-Compliance
• Scars are red, raised and firm.
• Scars are usually sensitive to touch and itchy
because patient or caregiver has not massaged
them with lotion
• Mobility is typically limited

146. • School re-entry
• Discharge outings
• Burn camps
• Phoenix Society
Psychological Support & Support Services for
Burn Survivors

147. • Topics to discuss:
-what happens when you get a burn
-certain details about the hospitalization
-exercises & appliances
-functional abilities
Faculty/staff meetings are suggested so more
detailed questions can be answered.
School Re-entry

148. • A photo of the patient ends the talk
• Establish empathy.
• Have children practice what they want to say to their burned
classmate.
• The burned child does not usually attend the re-entry because
classmates may not ask questions or pay close attention.
School re-entry continued...

149. • To reintegrate the burn survivor into the community.
• An outing can tell the patient and healthcare team what psychosocial
or physical tasks need to be improved upon.
Discharge Outings

150. • The patient should be able to:
• Establish eye contact and speak to others
• Practice how to handle someone who stares or asks
questions.
• Physically be able to handle various situations such as
stairs, paying for food etc.
Discharge Outings continued...

151. STEPS: Self talk: what we say & believe
Tone of voice: friendly &
enthusiastic
Eye Contact
Posture: up/shoulders back
Smile: warm & kind
Beyond Surviving: Tools for Thriving

152. RYR: Rehearse Your Response
Write and memorize a 3 sentence response that works
for you.
1. How you were burned
2. How you are doing now
3. Ending the conversation.
If person keep asking more than you want to talk
about: “That’s all I care to discuss today. I’m sure you
understand.” Smile and walk away.
Beyond Surviving: Tools for Thriving

153. Staring is a fact of life for many burn survivors.
It produces uncomfortable moments for both people.
Stand up straight, look the person in the eye, smile and confidently say any
friendly small talk that feels natural: “Hi, nice day isn’t it?”
This can change the energy of the moment and the person sees the survivor
as a person, rather than focusing on the burn injury.
Beyond Surviving: Tools for Thriving

154. The Art of Changing the Subject removes the
attention away from the burn injury to another
subject.
“That is a really nice _____. Did you buy it around
here?
Prepare and Practice how to handle the situations
Beyond Surviving: Tools for Thriving

155. • Goals:
-to adapt physically challenging activities
to the individual needs of the child.
-to improve self-confidence by successfully
completing new activities.
-to share common experiences and problems with
other burn survivors.
Burn Camps

156. “When you look at us you may see something
that’s backwards and different, but when we
look in the mirror we see our strength and
ABILITY!”
Camp Ytiliba…a reflection of strength

157. • International support group for burn survivors of all ages.
• Website: www.phoenix-society.org
• Excellent resource for reading materials, on-line chat groups, peer
support (SOAR), Beyond Surviving Tools
• and up-to-date information on burns and burn technology.
• Phoenix SOAR® (Survivors Offering Assistance in Recovery®) programs
provide peer support to burn survivors. The purpose of the program is to
make sure no one recovers from a burn injury alone.
• Annual national conference – Phoenix World Burn Conference
Phoenix Society for Burn Survivors

158. I’M O.K.
Treat me like a kid
Just ‘cause I got burned
Doesn’t mean I’m Something Else.
A Creature - A Monster - Poor Thing.
It doesn’t mean I need protection.
It doesn’t mean I should be hid.
It doesn’t mean you need to pity me,
Doesn’t mean I’m not a kid.
If you can’t see what’s inside
I might as well have died.