BURNS

• Burns


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


  Burns caused by hot liquids or steam, most common in younger children
• Flame burns


  Burns caused by flames after moving too close to a campfire, heater, or fireplace; touching a hot curling iron; or playing with matches or lighted candles, more common in older children
• Burn assessment


  Determine where the burn is and what are its extent and depth
• 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 of secondary infection
• Genital burns are hazardous because edema of the urinary meatus may prevent a child from voiding
• Rule of nines


  A quick method of estimating the extent of a burn in adults
• The rule of nines does not always apply and is misleading in the very young child
• Depth of burn

  Determined by the appearance of the burn and the sensitivity of the area to pain
• Depths of burns


  • First-degree, second-degree, third-degree, fourth-degree
• Emergency management for minor burns


  Apply cool water, apply analgesic-antibiotic ointment and gauze bandage, follow up in 2 days
• Emergency management for moderate burns


  Cover with topical antibiotic and burn dressing, debride blisters as burn heals
• Emergency management for severe burns


  Fluid therapy, systemic antibiotic therapy, pain management, physical therapy
• Emergency management for electrical burns of the mouth


  Unplug electric cord, control bleeding, clean wound with antiseptic, admit for observation, provide soft foods and fluids
• Electrical burns of the mouth turn black as local tissue necrosis begins and heal with white, fibrous scar tissue, possibly leaving a malformation of the lips or cheeks and difficulty speaking clearly afterward
• Fluid management for severe burns

  Formula: 3 ml x % TBSA x weight (kg), use lactated ringers, then maintenance fluids with normal saline and 5% dextrose
• Burn prevention information for parents/caregivers

  • Install smoke alarms, test smoke alarms monthly, create a family fire escape plan, never leave food unattended on the stove, check water heater temperature
• Children may be required to remain in awkward positions to keep joints overextended to prevent contractures
• Children with burns over extremity joints may have splints applied to maintain the joints in extension to help decrease contractures
• After the first week following a major burn, some children develop symptoms of delirium, seizures, and coma that result from toxic breakdown of damaged cells, sensory deprivation, isolation, and lack of sleep
• Bronchodilators and antibiotics


  May be prescribed as a prophylactic measure
• ECMO support


  Needed because smoke inhalation has compromised lung function
• Because the child's blood volume can decrease immediately after a burn, renal function can be altered when adequate function is needed to excrete the breakdown products from burned cells
• Monitor

  1. Blood volume to detect whether hypovolemia is occurring

  2. Maintain IV fluid administration to maintain urinary output at about 1 mL/kg of body weight per hour

  3. Specific gravity of urine to determine if the kidneys have the ability to concentrate urine to conserve body fluid

  4. Urinary output
• If free hemoglobin from destroyed red blood cells plugs kidney tubules (acute tubular necrosis), the urine color will turn red or black because of the hemoglobin present
• Nursing Intervention

  1. Insert an indwelling urinary (Foley) catheter

  2. Administer a diuretic if hemoglobin in tubules develops to maintain kidney function
• After a severe burn, some children feel nauseated because bowel peristalsis halts (paralytic ileus) from the systemic shock
• Symptoms of intestinal obstruction, such as vomiting, abdominal distention, and colicky pain, follow within hours of the burn
• Fluid suctioned from an NG tube may appear blood-tinged (coffee-ground fluid) because of bleeding caused by stomach vessel congestion
• Closely observe this drainage for a change to fresh bleeding, which can be caused by the development of a stress ulcer (Curling ulcer) from the overall trauma of the burn
• Stress ulcer (Curling ulcer)


  Can be prevented by administering a histamine-2 receptor antagonist, such as cimetidine (Tagamet) or a proton pump inhibitor such as omeprazole (Prilosec), which reduces gastric acidity
• Nursing Intervention

  1. Insert an NG tube and attach to low, intermittent suction to prevent aspiration of vomitus

  2. Perform gastric lavage with iced saline if a bleeding ulcer occurs

  3. Ensure blood for transfusion is readily available
• Children are kept nothing by mouth (NPO) for 24 hours
• Children may also need supplemental vitamins (particularly B and C), iron supplements, and high-protein drinks between meals to ensure an adequate protein intake
• It may be necessary to supplement the child's diet with IV parenteral nutrition solutions or gastrostomy tube feedings
• Nursing Intervention

  Encourage school-aged children to help calculate their intake and output columns, help the dietitian add a calorie-count list, or keep track of their own daily weight
• Children are usually prescribed an antibiotic to prevent infections and tetanus toxoid vaccine to prevent tetanus