109 Lec

• Burns


  Injuries to body tissue caused by excessive heat (heat greater than 104°F [40°C])
• Burns are the second greatest cause of unintentional injury in children 1 to 4 years of age and the third greatest cause in children age 5 to 14 years

  
• How older children are often burned


  • Moving too close to a campfire, heater, or fireplace
  • Touching a hot curling iron
  • Playing with matches or lighted candles
• Some burns (particularly scalding) can also be caused by child maltreatment
• Burn injuries tend to be more serious in children than in adults, because the same size burn covers a larger surface of a child's body

  
• Many burns can be prevented with improved parent and child education
• Assessment of extent of burns in children

  Determining where the burn is and what are its extent and depth

  
• Assessing burns


  • Face and throat burns are particularly hazardous because there may be accompanying but unseen burns in the respiratory tract that could lead to respiratory tract obstruction
  • Hand burns are hazardous because, if the fingers and thumb are not positioned properly during healing, adhesions will inhibit full range of motion in the future
  • Burns of the feet carry a high risk for secondary infection
  • Genital burns are hazardous because edema of the urinary meatus may prevent a child from voiding

  
• The "rule of nines" for estimating the extent of a burn does not always apply and is misleading in the very young child

  
• Determining burn depth


  • Use the appearance of the burn and the sensitivity of the area to pain as criteria
  • Many burns are compound, involving first-, second-, and third-degree burns, or there may be a central white area insensitive to pain (third degree), surrounded by an area of erythematous blisters (second degree), surrounded by another area that is erythematous only (first degree)

  
• Therapeutic Management of Minor Burns

  1. Immediately apply cool water to cool the skin and prevent further burning

  2. Apply an analgesic–antibiotic ointment and a gauze bandage to prevent infection

  3. Follow up in about 2 days to have the dressing changed and the area inspected for a secondary infection

  4. Caution parents to keep the dressing dry
• Therapeutic Management of Moderate Burns

  1. Do not rupture blisters

  2. Cover the burn with a topical antibiotic such as silver sulfadiazine and a bulky dressing

  3. Follow up in 24 hours to assess pain control and check for signs of infection

  4. Broken blisters may be debrided to remove possible necrotic tissue
• Therapeutic Management of Severe Burns

  Provide fluid therapy, systemic antibiotic therapy, pain management, and physical therapy
• Electrical Burns of the Mouth

  The mouth can be burned severely as electrical current from the plug is conducted for a distance through the skin and underlying tissue
• Therapy for Burns


  1. Second- and third-degree burns may receive open treatment or closed treatment

  2. Do not allow two burned body surfaces to touch

  3. Do not use adhesive tape to anchor dressings to the skin

  
• Topical Therapy


  • Silver sulfadiazine (Silvadene) is the drug of choice for burn therapy to limit infection
  • If Pseudomonas is detected, nitrofurazone (Furacin) cream may be applied
  • If a topical cream is not effective, daily injections of specific antibiotics into the deeper layers of the burned area may be necessary
• Escharotomy


  1. Fluid accumulates rapidly under an eschar, putting pressure on underlying blood vessels and nerves

  2. To alleviate this, an escharotomy (cut into the eschar) may need to be performed
• Grafting


  1. Allografting is the placement of skin (sterilized and frozen) from cadavers or a donor on the cleaned burn site

  2. Autografting is a process in which a layer of skin is removed from a distal, unburned portion of the child's body and placed over the prepared burn site

  3. Mesh grafts can be used to cover large burn areas

  
• Poisoning occurs in all socioeconomic groups and is entirely preventable
• The age group in which poisoning occurs most commonly is children between the ages of 2 and 3 years
• When poisoning occurs in a child over about 7 years of age, it may not be poisoning but a self-injury attempt
• Information parents need to provide in an emergency

  • What was swallowed
  • The child's weight and age and how long ago the poisoning occurred
  • The route of poisoning
  • An estimation of how much of the poison the child took
  • The child's present condition
• Acetaminophen Poisoning


  • Acetaminophen in large doses can cause extreme permanent liver destruction
  • Immediately after ingestion, the child develops symptoms of anorexia, nausea, and usually vomiting
  • Serum aspartate transaminase (AST [SGOT]) and serum alanine transaminase (ALT [SGPT]), liver enzymes, rise
  • The liver may feel tender on palpation as liver toxicity occurs
• Emergency Management of Poisoning at the Health Care Facility

  1. Activated charcoal is administered to halt the action of the poison

  2. Acetylcysteine, a mucolytic agent and also the specific antidote for acetaminophen poisoning, will be administered
• Caustic Poisoning


  • Ingestion of a strong alkali, such as lye, causes burns and tissue necrosis in the mouth, esophagus, and stomach
  • Parents should not try to make a child vomit after ingestion of these substances, because they can cause additional burning as they are vomited
• Assessment of Caustic Poisoning

  1. The child has immediate pain in the mouth and throat and drools saliva

  2. The mouth turns white immediately from the burn and the child may vomit blood, mucus, and necrotic tissue

  3. The loss of blood from the denuded, burned surface may lead to systemic signs of tachycardia, tachypnea, pallor, and hypotension

  4. Tissue in the mouth turns brown as edema and ulceration develop
• Assessment after caustic ingestion

  • The child has immediate pain in the mouth and throat and drools saliva because of oral edema and an inability to swallow
  • The mouth turns white immediately from the burn and the child may vomit blood, mucus, and necrotic tissue
  • The loss of blood from the denuded, burned surface may lead to systemic signs of tachycardia, tachypnea, pallor, and hypotension
  • Tissue in the mouth turns brown as edema and ulceration develop, although there may be such marked edema of the tongue that it is difficult to examine past the lips
• Therapeutic management of caustic poisoning

  1. Immediately take the child to a health care facility for treatment because there is a high possibility that pharyngeal edema will become severe enough to obstruct the child's airway by even 20 minutes after the burn

  2. Relieve the child's pain as a first step, advocate for a strong analgesic such as IV morphine

  3. Prescribe a chest X-ray to determine whether the aspirated poison has caused an esophageal perforation

  4. Perform a laryngoscopy and esophagoscopy under conscious sedation or general anesthesia to assess the lungs and esophagus, although these must be done cautiously

  5. Assess vital signs, especially the respiratory rate, and attach a pulse oximeter to establish a baseline and for continued monitoring to help detect if edema of the pharynx is obscuring the child's airway

  6. In infants, increasing restlessness is an important accompanying sign of oxygen deprivation

  7. Intubation or a tracheotomy may be necessary to provide a patent airway, although any intubation must be done cautiously

  8. Prescribe a proton pump inhibitor intravenously to protect against stomach reflux against the burned esophageal area

  9. Prophylactic antibiotic therapy is not usually necessary
• Child abuse and neglect are serious public health problems and adverse childhood experiences (ACEs). They can have long-term impacts on health, opportunity, and wellbeing
• Physical abuse


  The intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child
• Sexual abuse


  Pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities
• Emotional abuse


  Behaviors that harm a child's self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening
• Neglect


  The failure to meet a child's basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to
• Signs that there may be something concerning happening in a child's life

  • Unexplained changes in behaviour or personality
  • Becoming withdrawn
  • Seeming anxious
  • Becoming uncharacteristically aggressive
  • Lacks social skills and has few friends, if any
  • Poor bond or relationship with a parent
  • Knowledge of adult issues inappropriate for their age
  • Running away or going missing
  • Always choosing to wear clothes which cover their body
• Assessment of potential child abuse

  • When history taking, always ask caregivers to account for any injury to a child's body
  • An important mark of maltreatment in contrast to an unintentional injury is that the injury is out of proportion to the history given by the parent or caregiver
  • The parent or caregiver may report an implausible explanation for the injury, give conflicting stories, or provide no reason for the injury
• Physical examination for potential child abuse

  • Children should be fully undressed (including removing all bandages and Band-Aids) so entire body can be observed
  • Burns or scalds are frequent injuries in maltreated children, and the pattern of burns can indicate maltreatment vs. accidental injury
  • Scalding with hot water can occur from a child pulling a hot cup of coffee or a coffee maker off a table, but this can also be child maltreatment (an adult deliberately scalded the child)
• Cerebral palsy is a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction
• Cerebral palsy


  • Affected children also may have speech or ocular difficulties, seizures, cognitive challenges, or hyperactivity
  • Muscle spasticity can lead to orthopedic or gait difficulties
  • The exact cause is unknown, but it is associated with low birth weight, preterm birth, or birth injury
  • Apparently is caused by brain anoxia leading to cell destruction of the motor tracts possibly occurring during intrauterine life
  • Nutritional deficiencies, drug use, maternal infections, and direct birth injury may also contribute
  • CP occurs in approximately 2 of every 1,000 births, most frequently in very-low-birth-weight infants and those who are small for gestational age
• Types of cerebral palsy

  • Spastic type (approximately 40% of affected children)
  • Extrapyramidal (dyskinetic) type, which is further subdivided into ataxic (approximately 10%), athetoid (approximately 30%), and mixed (approximately 10%)
• Spastic type of cerebral palsy

  • Spasticity is excessive tone in the voluntary muscles that results from loss of upper motor neurons
  • A child with spastic CP has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes, and continuation of neonatal reflexes past the usual age
  • Spastic involvement may affect both extremities on one side (hemiplegia), all four extremities (quadriplegia), or primarily the lower extremities (diplegia or paraplegia)
  • Children with hemiplegia usually have greater involvement in the arm than the leg, and may have astereognosis
  • In quadriplegia, the child invariably has impaired speech and may have difficulty swallowing saliva