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Course: Pediatric Nursing

Topic: Nursing Care of Child with Burn

The Nurses International Community

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Module Goals

Learners will be able to:

Identify risk factors and causes of burn injuries in children.
Discuss the pathophysiology of burn wounds.
Describe characteristics of burn wounds.
Identify signs of child abuse-induced burns.
Discuss management of burns including emergency treatment of burns in children.
Apply the nursing process to assess, diagnose, plan, intervene, and evaluate care for child with burn wounds.

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Anatomy of Skin

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Burn

An injury to the skin or other organic tissue primarily caused by heat, radiation, radioactivity, electricity, friction or contact with chemicals.

Burns injuries in children are common.

Burns are the fifth most common presentation of non-fatal childhood injuries worldwide.

WHO, 2018

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Burn in Children

Children have thinner skin than adults, predisposing them to a deeper burn for any given temperature.
The majority of burns result from scalds, followed by contact and flame burns.
Less common injuries include electrical, chemical and radiation burn.
Young children are at risk of hypothermia, especially during initial cooling of the burn.

The Royal Children’s Hospital Melbourne, 2020

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Risk Factors for Burns in Children

Poverty.
Overcrowding and lack of proper safety measures.
Lack of parental education.
Placement of young girls in household roles such as cooking and care of small children.
Underlying medical conditions, including epilepsy, peripheral neuropathy, and physical and cognitive disabilities.

WHO, 2018

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What Would the Nurse Do?

A 3 year old child was rushed to the emergency department by the child’s mother with burns.

The mother informed that the child pulled a pot of hot boiling water from the stove when she had gone to another room to get some spices.

What should the nurse identify as a risk factor for burn in this child?

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Pathophysiology of Burn

Burns cause thermal injury to the skin, which in turn compromises its protective functions.

By doing so, the effective skin barrier is lost and complications, such as hypothermia and infection, can occur.

Suman & Owen, 2020

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Classification of Burn

1st, 2nd and 3rd degrees no longer used.

Image: Burn depth and extent of dermal injury

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Classifications of Burn

Superficial

Previously called erythema.
Involve only the epidermis.
These burns are not included in estimating Total Body Surface Area (TBSA).
Characterised by redness that slowly disappears, no blistering present.

Children’s Health Queensland Hospital and Health Services, 2021

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Classification of Burn

Superficial Partial thickness:

Involve superficial part of the dermis
Characterised by blistering skin, blanches when touched
Often most painful burns

Deep Dermal Partial thickness:

Involves deep dermal layers
May often have areas of blistering with other pale areas
May often have areas that look ‘cherry red’ in color, while it may look nice and pink these areas generally will not blanch

Children’s Health Queensland Hospital and Health Services, 2021

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Classification of Burn

Full thickness:

Extends into subcutaneous fat
Burns appear white in color and can be quite thick to touch or leathery
Generally has no sensation

Fourth Degree Burn:

The deepest subgroup with involvement of fascia, muscle, and bones

Children’s Health Queensland Hospital and Health Services, 2021

Krishnamoorthy, Ramaiah & Bhananker, 2012

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Critical Thinking Question

A child was brought into the emergency room with the complaint of burn. Upon assessment, it was found that the upper right arm had a burn that was cherry read in color and painful to touch. The lower arm looked white in color and had a leathery feel with no pain sensation. Which type of burn does the child have? (Select all that apply)

Superficial
Superficial partial thickness
Deep dermal partial thickness
Full thickness
Fourth degree

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Assessment of Burn

The total body surface area (TBSA) is assessed using Lund and Browder burns chart that denotes the percentage of body surface and changes with age of the child.

An alternative rule is that the patient's palm and fingers represent 1% of the body surface.

Suman & Owen, 2020

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Rule of Nine for Adult and Children

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The Mersey Burns App

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Assessment of Depth of Burn

The Royal Children’s Hospital Melbourne, 2020

Classification	Depth	Colour	Blisters	Capillary Refill	Sensation
SUPERFICIAL	Epidermal	Red	No	Brisk	Present
	Superficial Dermal	Pale Pink	Present	Brisk	Painful
	Mid Dermal	Dark Pink	Present	Sluggish	+/-
DEEP	Deep Dermal	Blotchy Red	+/-	Absent	Absent
DEEP	Full Thickness	White	No	Absent	Absent

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Signs of Child Abuse-Induced Burns

Contact burns in clear shape of hot object (eg, fork, clothing iron).
Classic forced immersion burn pattern with sharp stocking-and-glove demarcation.
Splash/spill burn patterns not consistent with history or developmental level.
Cigarette burns.
Bilateral or mirror image burns.
Localized burns to genitals, buttocks, and perineum (at toilet-training stage).
Excessive delay in seeking treatment and presence of other forms of injury.

Giardino, 2017

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Critical Thinking Question

A 6 year old child was brought to the emergency department with burns. Upon assessment the child had burns at the anterior part of left lower arm as well as anterior part of the left thigh and leg.

What percentage of total body surface area burn does this child have based on Lund and Browder chart?

5 %
8.25%
10%
9.3%

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Management (First Aid)

Remove all heat source including clothes, nappies, jewellery.
Cool the burn with cool running water for 20 minutes.
Do not use ice for cooling.
Keep the child normothermic 36-37°C.
If outside hospital, do not apply any burns gels - burns can be covered with Acticoat for transfer. Do not use Fixomull.

Children’s Health Queensland Hospital and Health Services, 2021

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Criteria for Transferring to Specialist Burn Unit

Burn >5% body surface area
Any burn involving the face, hands, feet, perineum, or over a joint
Circumferential burns
Burn associated with another injury or with inhalational injury
Suspected non-accidental injury
Electrical burns
Chemical burns

Suman & Owen, 2020

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Assessment

History of burn

Time of injury
Mechanism of injury, including circumstance for specific pattern of burn

Scald, Contact, Flame / explosion
Electrical: voltage, type of current (AC or DC)
Chemical: type of product
Cold: direct contact with cold surface or exposure (frostbite)
Radiant: sunburn

First aid measures

The Royal Children’s Hospital Melbourne, 2020

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Assessment (Continued)

Airway

Signs of airway burn/inhalation injury:

Stridor, hoarseness, black sputum, respiratory distress, singed nasal hairs or facial swelling

Sign of oropharyngeal burn:

Soot in mouth, intraoral edema and erythema

If Significant neck burn:

Consider early intubation
Apply high flow oxygen
Protect the cervical spine with immobilisation if there is associated trauma

Children’s Health Queensland Hospital and Health Services, 2021

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Assessment (Continued)

Breathing:

Full thickness/ circumferential chest burns may require escharotomy to permit chest expansion

Circulation: If shock is present

IV fluid resuscitation as required
IV or IO access (preferably 2 points of access)
For circumferential burns check peripheral perfusion and need for escharotomy

Disability: If altered conscious state, consider airway support

Exposure - burn assessment

Children’s Health Queensland Hospital and Health Services, 2021

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Fluid Management

For minor burns, oral hydration may be acceptable.
Any pediatric burn with greater than 10% TBSA requires Intravenous fluid replacement.
The most commonly used formula is the Parkland formula:

3–4 ml kg−1×TBSA % burns over a 24 h period
Half the total is given over the first 8 h from the time of burn, and half over the following 16 h
The modified Brooke formula

2 ml kg−1×TBSA % burns over the same time period as the Parkland formula.

Suman, & Owen, 2020

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Intraoperative Management

Common procedures include:

Wound cleaning and debridement.
Dressing changes.
Skin grafting.
In circumferential burns: Escharotomies may be required to avoid neurovascular compromise and compartment syndrome.

Suman, & Owen, 2020

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What Would the Nurse Do?

Which of the following information is appropriate for the nurse to teach the parents regarding initial management of a burn? (Select all that apply)

Remove all heat source including clothes, nappies,
Cool the burn with cool running water for 20 minutes
Apply ice pack on the burn area while transporting to the hosiptal
Keep the child warm

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Prevent Hypothermia

Remove wet clothes/dressings after initial cooling.
Try to keep child otherwise warm.
Cover the wound and the child after assessment.
When possible, warm intravenous fluids.
Temperature control is vital in pediatric patients with burns.
Constant measurement of core temperature is essential in the operating room.
Commonly rectal, oesophageal or bladder temperature probes are used.

Children’s Health Queensland Hospital and Health Services, 2021

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Pain Management

Review analgesia given prior to arrival.
Intranasal fentanyl should be the 1st line analgesia.
If IV cannula already in situ, IV morphine can be given.
Oral analgesia: paracetamol, ibuprofen, oxycodone.
Be aware NSAID use in burns may be associated with risk of necrotising fasciitis.

Government of Western Australia; Child and Adolescent Health Services, 2021

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Other Management

Wound Care
Infection prevention
Nutrition
Psychological support

Government of Western Australia

Child and Adolescent Health Services, 2021

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Monitoring

In major cases:

An arterial catheter for both BP monitoring and arterial gas sampling
A urinary catheter and hourly measurement
Cardiac output monitoring

A number of cardiac output monitors are licensed (esophageal Doppler and LiDCO)

Suman & Owen, 2020

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Nursing Management

History:

Time of injury
Mechanism of injury
First Aid
Tetanus status

Assessment

Airway, Breathing, Circulation, Deformity (ABCD)
Total Body Surface Area (TBSA) burnt, (the Lund Browder chart)
Depth of burn injury
Pain Assessment

The Royal Children’s Hospital Melbourne, 2018

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Nursing Management

First Aid
Maintenance of ABC
Oxygen Administration
Fluids management
Maintain normal temperature
Pain Management
Preparation of burn dressing
Strict infections control measures
Wound care
Nutrition Management

The Royal Children’s Hospital Melbourne, 2018

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What Would the Nurse Do?

Which of the following complications should the nurse know is directly associated with burn greater than 10% of total body surface area (TBSA)? (Select all that apply)

Severe dehydration
Infection
Hypothermia
Weight gain
Hyperglycemia

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Red Flags

Burn >5% body surface area
Any burn involving the face, hands, feet, perineum
Circumferential burns
Burn associated with inhalation injury
Electrical burns
Chemical burns
Observe for burns related to abuse

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

Children’s Health Queensland Hospital and Health Services.(2021). Guidelines: Management of a paediatric burn patient. https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/guidelines/gdl-paediatric-burns.pdf

Giardino, A. P. (2017 April 24). Which burn patterns are characteristic of physical child abuse?. https://www.medscape.com/answers/915664-188842/which-burn-patterns-are-characteristic-of-physical-child-abuse?reg=1

Government of Western Australia; Child and Adolescent Health Services.(2021). Burns. https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Burns

Krishnamoorthy, V., Ramaiah, R., & Bhananker, S. M. (2012). Pediatric burn injuries. International journal of critical illness and injury science, 2(3), 128–134. https://doi.org/10.4103/2229-5151.100889

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References:

The Royal Children’s Hospital Melbourne. (2018). Nursing Management of Burn Injuries. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_management_of_burn_injuries/

The Royal Children’s Hospital Melbourne. (2020). Burns: Acute Management. https://www.rch.org.au/clinicalguide/guideline_index/Burns/

Suman, A., & Owen, J. (2020). Update on the management of burns in paediatrics. BJA education, 20(3), 103–110. https://doi.org/10.1016/j.bjae.2019.12.002

WHO. ( 2018 March 6). Burns. https://www.who.int/news-room/fact-sheets/detail/burns

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