Depth
The depth of the burn is defined by the depth of skin tissue damaged. This can be classified as superficial, partial thickness or full thickness (Cook 2002); or alternatively as epidermal, superficial dermal, deep dermal and full thickness (Hettiaratchy and Papini 2004) (Table 10.1).
Table 10.1 Burn depth
Source: Herndon 2007.
| Epidermal or superficial burn | Only part of the epidermis is destroyed. The area looks red and is very painful. There is brisk capillary refill and the burn usually heals within a week. |
| Superficial dermal or superficial partial thickness burn | The epidermis is fully destroyed as is part of the papillary dermis. The area may have blisters and looks red and wet on examination. Brisk capillary refill and sensate. Usually heals within 2 weeks. |
| Deep dermal or deep partial thickness burn | All the epidermis, papillary dermis and part of the reticular dermis are destroyed. The area is paler and may be mottled in colour and often drier in appearance. Sluggish capillary refill. Sensation is reduced. Usually heals within 3 weeks, although grafting may be considered depending on size and area. |
| Full thickness burn | Both the epidermis and dermis are destroyed and sometimes underlying tissues. The area will be charred, leathery-looking or waxy white in colour and thus can be sometimes be mistaken for unburnt skin. Insensate and no capillary refill. All but very small full thickness burns usually need excision and grafting as they will take longer than 3 weeks to heal with potential complications. |
The assessment of burn depth is multifactorial and involves visual observation, clinical assessment of sensation, bleeding and blanching, the history of the thermal source, contact time and any first aid given.
The deeper the burn the less sensation – a superficial burn is very painful, whereas a full thickness burn has no sensation as all the nerve endings have been destroyed. Similarly, bleeding on a pin prick is brisk in a superficial burn but is delayed in a deep dermal burn and nonexistent in a full thickness burn. However, these can be difficult to assess and a more accurate, non-invasive method is to assess the capillary return on blanching of the burn wound with pressure. In a superficial burn the capillary return is brisk. This becomes slower as the deeper the burn until there is no blanching in deep dermal and full thickness burns.
Laser Doppler imaging can also be used to aid burn depth assessment alongside the clinical assessment (Sainsbury 2008). This uses a red laser to scan the burn wound and then produces a diagrammatic colour image of the blood flow in the wound. This can be helpful in determining borderline deep dermal/full thickness depths and whether surgery is indicated.
Management of Burns
Primary and Secondary Survey
A primary survey is required, using the ABCDE approach as for any child following trauma, but additional consideration needs to be given to particular areas specifically related to the burn injury.
Airway
The history of the injury will give vital clues as to the risk of airway involvement, for example if they were in an enclosed environment, smoke present, burns to the face, singeing of nasal hair and/or eyebrows, hoarseness, breathing difficulties and change of conscious level, this would give a high index of suspicion of airway involvement.
Anaesthetic assessment should be sought for any burns to the face and neck if there is a possibility of smoke inhalation injury or any respiratory impairment. It is recommended that if there is a threat to the airway, intubation occurs earlier rather than later due to the risk of swelling (Australia and New Zealand Burn Association 2006). An uncut ET tube should be used as the face is likely to swell considerably. Cotton tapes rather than adhesive tape should be used to secure the ET tube as these can be adjusted as required.
As with any other trauma injury the cervical spine should be protected until clinically cleared (Chapter 9).
Breathing
A full respiratory assessment is required, including arterial blood gas and carbon monoxide (CO) levels. Oxygen is required to maximise tissue oxygenation and perfusion and to combat any CO intoxication.
An escharotomy (an excision through the burnt eschar to viable tissue to relieve constriction allowing for chest expansion) may be required for circumferential full thickness burns to the chest in order to facilitate adequate ventilation.
Circulation
The child’s peripheral and central circulation needs to be assessed and any bleeding stopped. This is an important part of the initial assessment, especially if there has been a delay in treatment as there is a risk of hypovolaemia due to fluid being lost from the burn. It is also important to assess the peripheral circulation in case there are circumferential deep burns that are causing inadequate tissue perfusion which can lead to compartment syndrome and may need an escharotomy to release the pressure. Any jewellery should be removed due to risk of impairment to tissue perfusion from swelling. Good, reliable venous access (ideally in unburnt skin) should be obtained, bloods taken for urea and electrolytes, full blood count cross-match, CO levels and fluids commenced as per burn fluid regimen and any additional boluses to stabilise the child (ATLS 2008).
Disability
Assessing the child’s neurological level is required using the AVPU (alert, voice, pain, unconscious) score initially and then an age-appropriate tool. Hypoxia from smoke inhalation and/or CO intoxication will cause reduced consciousness levels. These need to be ruled out before consideration is given to other causes of altered neurological status, such as head injury or alcohol intoxication.
Exposure
Once the life-threatening issues have been assessed it is important to do a thorough examination to assess the extent of the burn and look for any other injuries. The child should be kept warm and exposure kept to a minimum.
The Secondary Survey
This includes an AMPLE (allergies, medicines, past medical history, last meal, event) history and relevant X-rays should be undertaken in line with the trauma guidelines (Australia and New Zealand Burn Association 2006). The child should be reassessed regularly to ensure any change in their condition is not missed.
Airway Management and Inhalation Injury
The majority of children admitted to the PICU with a thermal injury have been intubated and require assistance with their respiratory system. This is due to the extent of the injury or the suspicion that the child has had an inhalation injury (Chapter 4).
The most common signs and symptoms associated with an inhalation injury are discussed in the primary survey section and, as stated, it is better to intubate earlier rather than later as the intubation will be more difficult if facial, tongue and upper airway swelling has occurred. Bronchoscopy is often used to confirm an inhalation injury along with clinical signs and symptoms.
Classification of inhalation injury can be divided into upper airway and lower airway injury, where the tissue is damaged by heat and inhaled chemicals, and systemic toxicity which occurs when the absorption of toxic substances occurs through the alveoli (Australia and New Zealand Burn Association 2006). Studies have shown that the addition of an inhalation injury along with a thermal injury increases mortality risk (Lafferty 2010).
Most inhalation injuries are caused if the child has been involved in a house fire or in an enclosed space where they have inhaled heat and toxic smoke particles and fumes causing irritation, which can lead to airway and gas-exchange complications. Many household materials produce toxic gases when ignited (Traber et al. 2007), including CO and hydrogen cyanide. Inhalation injury can also be caused by steam, which tends to stay hotter for longer and thus causes a lower airway thermal injury.
CO poisoning occurs because of its higher affinity than oxygen to haemoglobin, forming carboxyhaemoglobin. It is important to realise that CO poisoning can give a false high pulse oximetry reading. Treatment is the administration of 100% oxygen until the CO levels are <10%.
The treatment for smoke inhalation includes toileting of the bronchial tree with regular lavage and suction until the particles are no longer visible, regular chest physiotherapy and regular repositioning of the patient with the aim to remove any foreign particles as quickly as possible to reduce complications. In recent years there has been much debate on the use of drug adjuncts to treat an inhalation injury. This includes the use of nebulised heparin, acetylcysteine, salbutamol (Palmieri 2009) or sodium bicarbonate (Prior et al. 2009).
The ventilation of the child follows the same principles as for all ventilation, using the least possible level of oxygen and pressure to get an acceptable level of gas exchange (O’Ceallaigh and Shah 2008). It is beyond the scope of this chapter to cover the many strategies for pulmonary ventilation in children with burns with or without inhalation injuries. However, the principles of lung protective ventilation strategies are now widely used and include high-frequency flow ventilation, positive end expiratory pressure and low tidal volumes. There have been some reported cases of using extracorporeal membrane oxygenation (ECMO) on patients with smoke inhalation injury (Niederbichler et al. 2009). However, performing surgery on children with a large cutaneous burn while on ECMO would put them at risk.
Securing the endotracheal tube can be difficult in children who have burns to the face. Whatever method is used, the nurse must ensure it is secure, checked regularly, the area kept clean and that the mechanics of ventilation do not cause more damage to the face by the action of pressure.
In some cases a child requires a prolonged period of ventilation and a tracheostomy may be performed. Although there are complications with tracheostomies some studies support this early intervention (O’Ceallaigh and Shah 2008). Consequently, in many cases if the patient has had a deep thermal injury to the face and neck, the neck area where the tracheostomy will be sited will be grafted as a priority to allow the site to heal and stabilise prior to cannulation.
Fluid Resuscitation and Patient Monitoring
Children with burns >10% TBSA will need fluid resuscitation to ensure adequate tissue perfusion due to the amount of fluid lost through capillary permeability from the circulation. This is particularly relevant in the first 8 hours following burn injury, but in the more severely burnt child may be prolonged.
There are many burn fluid resuscitation formulas and all take into consideration the size of burn and weight of the child. In the United Kingdom, the Parkland formula (Table 10.2) is commonly used (Baker et al. 2007), as it is a relatively simple and easy to use crystalloid-based regime. The Cochrane Review (Schierhout and Roberts 1998) on the use and risks of albumin in fluid resuscitation caused considerable debate about whether it should be used. More recently it has been suggested that the advantage of using crystalloids is that they have smaller molecules than albumin so do not get trapped in the extravascular space when capillary permeability is reduced, leading to third spacing. However, crystalloids are more easily lost from the circulation, leading to oedema, whereas the larger molecules of albumin stay in the circulation longer (Duncan and Dunn 2008). Albumin is also more expensive and carries a great risk of an adverse reaction, which has caused Perel and Roberts (2007) to question the use of colloids. Their review showed no evidence that the use of colloids compared to crystalloids in resuscitation reduced mortality. Some burn services, although using crystalloids initially, will introduce albumin after about 8 hours when the capillary permeability leak begins to decline. This is more to replace the oncotic protein loss than increase the circulatory volume (Hettiaratchy and Papini 2004). Further research is currently being undertaken in burn fluid management using other types of fluid, such as starches.
Table 10.2 The Parkland formula
Adapted from Australia and New Zealand Burn Association (2006).
| Requirement | |
| Resuscitation fluid | |
| The amount of fluid to be given in the first 24 hours from the time of injury | 4 ml Hartmann solution × Wt (kg) × TBSA Half of the calculated volume is given in the first 8 hours post injury and the remaining half of the volume given over the following 16 hours |
| Maintenance fluid | |
