Burns to Children
There have been many advances in pediatric burn care over the last few decades so that about half of all children survive even with a 98 percent total body surface area burn. Mortality is greatest in the child less than two years of age and those that have burns over 95 percent total body surface area.
Initial Care of the Child Burn Victim
Initial care of the child burn victim is no different than with adults in many instances. The child must be removed from the burning area and the burns must be cooled, taking care not to induce hypothermia. The child must have an established airway and, if there is evidence of smoke inhalation, a ventilation tube might be necessary. If the wound is around the entire chest, careful observation of the ability to expand the chest must be done continuously and measures taken to improve chest expansion performed if necessary.
Remember that the child’s circulatory system will be abnormal after a burn, with a lot of leakage of fluids out of the vascular system and into the tissues. The child can easily go into shock if they don’t receive IV fluids, either through a regular peripheral IV or other IV access, such as a central venous catheter or an intraosseous line.
An intraosseous line is one in which the IV catheter is placed into the bone of the anterior tibial plateau, the medial malleolus or the anterior iliac crest of the child’s lower extremities. These methods can offset the large amount of fluid being lost from the area of the burn. Fluid losses tend to be greater in children because they have a small ratio of body weight to total body surface area.
Children are resuscitated from burns using special formulas that allow for their body weight and their percentage of burned body surface.
When a child is becoming dehydrated, signs such as low urine output and low blood pressure don’t show up until the child has lost at least 25 percent of their total fluid volume. Rapid heartbeat may be the only sign of impending serious dehydration. Even so, the child should have a catheter placed so that urine volume can be measured.
Fluid must be given carefully as there are as many problems with giving too much fluid as there are too little fluids given. Children can get fluid on the lungs and respiratory distress from too much fluid and they can develop compartment syndrome, which involves swelling around the chest, abdomen or extremities, limiting blood flow to crucial areas. They can even get excess fluid on the brain, leading to cerebral edema.
Management of the Airway
Children are more prone to upper airway obstruction after an inhalation injury because they have narrowed airways compared to adults to begin with. They can develop airway swelling due to the excess volumes of fluid necessary to resuscitate them or from injury to the tracheal lining from smoke inhalation. Early intubation with a ventilator tube is advised if it seems as though the airway is likely to be compromised.
Inhalation injuries are dangerous to children. The mortality rate of a child with an ordinary burn is about 1-2 percent but with an inhalation injury, the death rate rises dramatically to 40 percent. Using a hundred percent oxygen in cases of suspected inhalation injury is strongly advised.
Burn injuries raise the metabolic rate of children dramatically. They can lose body mass from soft tissue and muscles at a high rate after a burn because the body needs those sources to burn calories for fuel. The greater the area of burn, the higher is the degree of hypermetabolism. Oxygen is rapidly used up in the body and there is loss of protein, fat and sugar stores. It can take up to six months to restore normal metabolism after a severe burn.
In order to stop the loss of lean body mass, things such as growth hormone, insulin, insulin-like growth factor and anabolic steroids are given to counteract what’s going on in the burn process.
Children can lose body temperature faster than adults and care must be taken to reduce the amount of body heat lost during resuscitation. In addition, they need nutritional support through enteral feedings primarily. Enteral feedings are given using a tube that is passed from the nose through the esophagus and into the stomach. This can feed the patient as he or she heals from the burn. Care must be taken not to overfeed as things like abdominal pain and diarrhea can develop.
A Child’s growth pattern can be delayed after a serious burn; they can have delay of bone growth that lasts up to two years after the burn injury.
Treatment of Burns in Children
Like adults, the fastest way to heal from a burn is to excise the burn and cover it with an autograft (skin from elsewhere on the patient’s body) or an allograft (skin from a cadaver donor). Doctors found that it is safe and effective to use this technique even within 24 hours of sustaining the burn. Topical antimicrobial agents are also used to prevent infection.
Pain must be managed in the pediatric burn patient. Children show pain differently from adults at times so it is important to recognize when pain is occurring in order to fight off the psychological effects of having to suffer from excessive pain during the hospitalization. Morphine and fentanyl are common medications used to handle burns in children.
Eventually, children heal to the point of needing rehabilitation. They need physical and occupational therapy to regain those developmental milestones lost from prolonged immobility and they need psychological care to manage the intensity of the injury.
A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.