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Pediatric Burns: Severity, First Aid, and When to Refer · Pediatrics in Practice: A CME Podcast

• 0:03
  Mike (Host): Welcome to Pediatrics in Practice, A CME podcast.
• 0:06
  I'm your host, Dr.
• 0:07
  Mike, and joining me today is Dr.
• 0:10
  Pablo AAO from Children's Mercy, and we're gonna be discussing a crucial topic,
• 0:14
  burns in children, specifically focusing on assessment and treatment by severity.
• 0:20
  Dr.
• 0:21
  Aguire, welcome to the podcast.
• 0:23
  Let's start off right away with how Burns are classified by severity in
• 0:26
  kids, And what key features help you to distinguish, each level of severity.
• 0:34
  Pablo Aguayo, MD: Sure.
• 0:35
  Yeah, that's a great question.
• 0:36
  Thanks for having me, Dr.
• 0:37
  Mike.
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  So the, uh, most important thing about burn injuries is identifying
• 0:41
  the depth And the extent of the burns.
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  And so I think most people are familiar with first, second, third degree burns.
• 0:47
  That still holds true, but we have a little bit of a different nomenclature
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  now, which we call a superficial, which is a sunburn, which is very painful,
• 0:54
  red and no blisters at all whatsoever.
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  Again, for sunburns, a classic, And that would be what was used
• 1:01
  to be known as first-degree.
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  Then we have the second degree burns, which are separated into superficial
• 1:08
  and deep partial thickness, And the difference between these is actually
• 1:11
  you start seeing some of the blistering in the partial thickness burns.
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  When you have a superficial partial thickness burns, they're usually thin roof
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  blisters that rupture real easy, that's wet and weeping, And the wound blanches
• 1:25
  with pressure and it's intensely painful.
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  It usually heals within about 21 days.
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  The deep, however, Those are a little bit more waxy.
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  They are still wet, but they're modeled in coloring and they
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  are, not as painful, but they're.
• 1:40
  Painful to some degree because, some of the nerve fibers have actually
• 1:44
  been destroyed during the process.
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  These take a lot longer to heal and are higher risk for scarring.
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  Then we have the full thickness, which was used to be the third degree burns,
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  And this destroys all the epidermis and dermis, so the layers of the skin,
• 1:58
  and these appear leathery, dry, they're Inc sensate, And so really easy to
• 2:02
  distinguish these and all of these.
• 2:05
  Full thickness burns certainly need to be grafted or sent to somebody
• 2:08
  who specializes in burn care.
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  The final one is a fourth degree, which we don't see very often, but that extends all
• 2:14
  the way down to the muscle or the bone, and Those are obviously very, very severe.
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  the other thing is that's important is defining the extent of the.
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  So we use total body surface area to define that, which
• 2:27
  you can find on any burn.
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  Website, helps you distinguish, you know, different age groups, what parts
• 2:33
  of the body measure approximately what total body surface area burns.
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  And so defining the depth And the extent is incredibly,
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  important for diagnosis purposes.
• 2:44
  Mike (Host): In children, what are some of the more common causes of, of these birds?
• 2:49
  Pablo Aguayo, MD: Well, actually about 60 to 70% of 'em are actually
• 2:52
  scald burns, and these are scalds from coffee, hot soups, showers
• 2:57
  or baths, things like that.
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  The next common is flames, And so flames can be from anything from fires.
• 3:05
  And, we see this a lot with, people who are outside cooking there or people who
• 3:10
  are live out in farms and have, bonfires.
• 3:14
  And then the third is the friction burns and contact burns.
• 3:17
  So contact burns a little more common, and Those are just when kids touch, very
• 3:22
  hot stove or a hot fireplace glass or any, anything That is, uh, in the kitchen
• 3:29
  that could be, accessed by a child.
• 3:31
  Mike (Host): So what should pediatricians focus on during the initial exam
• 3:36
  Pablo Aguayo, MD: So This is a great question.
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  So actually it kinda depends on their setting.
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  So a lot of pediatricians just have their own private clinic or their
• 3:42
  clinic in a, in a office or a hospital, and by that, by the time they see
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  a burn patient's, it's already been maybe a day or maybe several hours.
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  I think one part that distinguishes the treatment Is where you're at.
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  So in emergency rooms or in urgent care centers, a couple of things that
• 3:58
  they need to be aware of is that if the injury occurred within the last three
• 4:04
  hours, there are several things that can be done to cool off the wound to
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  reduce the extent of the burn And the.
• 4:13
  Complications from the burn.
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  And so we recommend that they run cool water for about 20 minutes over
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  the burns, And that, actually reduces the need for subsequent grafting.
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  It helps heal the skin sooner, but this needs to be done within the three hours of
• 4:30
  the burn injury And the water temperature.
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  Again, you can just get cool running water from the faucet and it.
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  It should not be a tub.
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  In other words, it should not be standing water, but running water for 20 minutes.
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  The other thing is they just again, need to assess the
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  depth And the TPSA accurately.
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  And then really, one of the things that I think we sometimes forget is that we
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  need to screen for non-accidental injury.
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  And so by that means abuse.
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  So about 10% of the burns we see And we see across the nation are due
• 5:03
  to non-accidental burns or abuse.
• 5:06
  Mike (Host): You know, initial cooling of the burn.
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  That's pretty good advice for parents too,
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  right?
• 5:12
  Pablo Aguayo, MD: Absolutely.
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  And you know, we, well, pediatricians as primary care providers really have
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  enough o opportunity to teach this to a lot of the families, even if
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  they've already suffered a burn or if they're there for a burn, teaching
• 5:26
  them these sorts of, treatment options for home or fantastic Because they may
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  have all the other kids, or they may have, family members who have kids.
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  But there are always, uh, great opportunities to, help in prevention
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  of burns by, disseminating the word that This is extremely helpful.
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  It's been proven in multiple studies all across the world.
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  So, it, it helps.
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  Mike (Host): Now when we look at the different severities again, you know,
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  you had, your one through four basically, first-degree through fourth degree.
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  How does treatment differ for each one of those?
• 5:59
  Pablo Aguayo, MD: Right.
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  So anything that's third degree or fourth degree should definitely
• 6:03
  be seen by a burn specialist, and they should be seen fairly quickly.
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  Some of them are really small burns and may not require urgent admission
• 6:10
  to the hospital, or if there is no.
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  Pediatric burn center in the surrounding area.
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  They don't need to be transported to one, but, they definitely need to be evaluated
• 6:20
  at a clinic or a local hospital to see.
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  We have pretty clear guidelines in terms of the American Burn Association
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  has pretty clear guidelines on, when one should consult the burn
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  center and you can find those online, as a BA referral criteria.
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  So Those are pretty specific.
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  The thing we have to remember is that about 85% of all pediatric
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  burns have a very small TBSA or total body surface area.
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  They're about 3%.
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  So a lot of those can be managed as outpatients.
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  With only about 4% requiring subsequent admissions.
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  So that's important information to keep in mind that they don't all
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  need to be shipped immediately.
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  That consultation with the burn center can be helpful from a pediatrician
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  standpoint or from a primary care physician standpoint to just call
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  and give them some information.
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  Describe the burns And then.
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  Have them help you decide who can be treated as an outpatient and who should
• 7:17
  be seen at a hospital either that night or that day or within the subsequent week.
• 7:23
  Mike (Host): in adults often, You know, with, especially with third
• 7:25
  degree, fourth degree burns, there's hemodynamic instability and, And that's.
• 7:30
  a big cause of, of, problems.
• 7:33
  Is that the same for kids or do you, do you have to manage,
• 7:37
  that as well as the burn?
• 7:40
  Pablo Aguayo, MD: Yes, and that's a great point.
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  So actually when it becomes important is once they get bigger than 15% total
• 7:47
  body surface area burn, that's when we start our resuscitation protocols.
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  And those definitely need to be seen in an ICU setting, or at least in
• 7:55
  a facility that has ICU after 15%.
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  We found that those burns, can cause significant inflammation.
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  Systemic inflammatory response syndrome, which will cause their
• 8:07
  bodies to lose fluids through those burns, which subsequently can
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  lead to hemodynamic instability.
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  So 15% is what most people use as their cutoff.
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  Here at Children's Mercy, for example, we use 20%, but, anything,
• 8:21
  certainly over 10 to 15% usually gets admitted to the hospital for
• 8:25
  observation, And then we manage their fluid status while they're here.
• 8:29
  But it's almost the same thing as it is with adults.
• 8:32
  Mike (Host): Are all burns regardless of the severity susceptible to infection.
• 8:37
  Pablo Aguayo, MD: Yes, and that's a great question.
• 8:39
  So two points to make about that, even though they are susceptible to
• 8:43
  infections, antibiotics for burns are not recommended prophylactically.
• 8:48
  So we should never give antibiotics to burns that come
• 8:51
  in without evidence of infection.
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  Usually, if an infection occurs, it's gonna occur
• 8:55
  within the first 10 to 14 days.
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  And they could be pretty minor to pretty major, depending on the
• 9:01
  extent of the burn, but we only use antibiotics at that time.
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  The whole point of taking care of these burns really is to take care of the
• 9:08
  surface of that burn to make sure it's as clean as we can possibly make it while the
• 9:12
  body regenerates the epithelium so that it can cover those up and minimize that risk.
• 9:18
  So I think that's important to remember that the body will heal itself.
• 9:21
  Our job is to just kind of keep it clean and try to keep it as
• 9:25
  free from infection as possible.
• 9:27
  Mike (Host): that's a little different approach from, from a while ago.
• 9:30
  I remember training, at least in adults, we, antibiotics were used pretty quickly.
• 9:35
  Pablo Aguayo, MD: Correct So, It is a, it is a change and we've been doing this
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  for, I don't know, probably a decade or a little more than a decade, but we've found
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  that, most of the time, particularly in kids, the incidence of infection in kids,
• 9:48
  even in larger burns is extremely low.
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  Those infections, meaning related to the actual burn tissue they do.
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  Kids who are have bigger burns and are in the ICU have risks of line sepsis
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  or, ventilatory associated infections.
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  But in terms of the wounds, it's very, very rare that
• 10:06
  they actually get infections.
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  So we found that it was, we were just using them too much and creating sort
• 10:12
  of super species of bugs, because of it.
• 10:15
  Mike (Host): Yeah, no doubt.
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  We have to worry about that resistance.
• 10:17
  Right.
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  So that makes a lot of sense to me.
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  I know you've already touched on this a little bit, but I, I think,
• 10:23
  you know, This is very important.
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  I want to go back and talk about when a general pediatrician should refer the
• 10:31
  patient to the specialist like yourself.
• 10:34
  Pablo Aguayo, MD: Sure.
• 10:35
  Large burns for sure.
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  So anything over 15% should definitely be referred to a specialist.
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  If you look at, third degree burns anywhere, Those are, should be referred.
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  But then also burns that are across major joints, burns that
• 10:50
  are on the face or the genitalia.
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  burns that are on the feet or the hands should all be referred.
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  Any inhalation injuries or electrical injuries should be referred as well.
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  And I'll point out that when we say refer, it doesn't mean transfer
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  because I think a lot of us used to confuse that list with, okay, you've
• 11:09
  gotta transfer to a burn center.
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  Most of the time it really just involves a phone call to your.
• 11:15
  Regional or local burn center or specialists to give them information
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  And then they can refer you to the appropriate clinical setting at that time.
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  Again, the majority of the time, over 85% of the time, they don't need to be at a
• 11:31
  burn center that day, And so we're able to accommodate them during clinic hours
• 11:37
  or follow-up with them on subsequent days in our er if, those were available.
• 11:41
  Mike (Host): What kind of follow-up care, occurs with,
• 11:44
  the severe burns en large burns.
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  Sure.
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  Pablo Aguayo, MD: Well, with kids, we follow them for many, many years,
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  And the reason is the larger burns, they usually cross major joints.
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  They're on the hands or on the face, And so we really have
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  to monitor for contractures.
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  Scarring that will affect their function.
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  Our goal for every patient is to return them to appropriate
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  function, And so as they grow, those scars won't grow with them.
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  So we have to really keep close tabs on where they're at with their
• 12:12
  scarring so that we can intervene at the appropriate time before they
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  lose some of that muscle function.
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  Or before some of their attendance actually become frozen
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  because they've been held in that position for a long time.
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  So the bigger burns we follow pretty frequently.
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  We usually follow till they're late teenage years if they're large
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  burns, just to make sure that they're not developing any problems that
• 12:33
  we need to address at that time.
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  Mike (Host): focusing just for a brief moment on, let's say, you know, not, not
• 12:40
  a severe burn, not, not a large burn, maybe the parent feels like they can take
• 12:44
  care of this at the house, at the home.
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  what are some of the tips you would give for that?
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  Pablo Aguayo, MD: Sure.
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  of course do what we talked about earlier, which is the cooling.
• 12:54
  So 20 minutes of cooling under some, tap water.
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  And then that's, uh, the most important factor when you do it.
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  The second one is just keeping it clean and dry.
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  So that means, gently cleaning those wounds every day, applying
• 13:07
  some, ointment on there.
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  You could use some bass trace, an ointment, just topical and
• 13:13
  regular dressings that will, just hold in place to wherever it's at.
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  So, and you do that every day and until the wound heals, the
• 13:22
  majority of these wounds are gonna be closed by about day 10.
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  If they're not closed by about day 10, it's probably a good time to get
• 13:29
  a second opinion from a physician.
• 13:31
  But, any sort of, again, just dressing on there and keeping it
• 13:35
  clean with, some gentle soap and some water every day is going to most of
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  these injuries are going to heal.
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  Pretty well without any other intervention.
• 13:45
  Mike (Host): Dr.
• 13:45
  Aguire, this has been fantastic information.
• 13:47
  I really appreciate you coming on.
• 13:48
  Any last words for the listening audience?
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  Pablo Aguayo, MD: Yeah.
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  I think the last thing I'd want to talk about is just briefly,
• 13:55
  prevention is the best thing.
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  So talk to your patient's about how to take care of a child in the
• 14:00
  kitchen, in particular, what you need to watch out for in the kitchen, and
• 14:05
  who should be allowed in the kitchen and who should be allowed to cook.
• 14:08
  We see a lot of.
• 14:09
  Ramen soup skulls and burns of little kids and coffee, spilling over the kids.
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  So, be very cognizant of that.
• 14:16
  And we focus on prevention is the best thing that we can do.
• 14:20
  Mention that to all the parents who have younger kids, particularly those
• 14:24
  that are just learning to walk in their, exploring their surrounding.
• 14:29
  Mike (Host): Perfect summary.
• 14:30
  Perfect way to end this podcast.
• 14:31
  Again, thank you so much for coming on the show today.
• 14:34
  For more information, you can visit c MKC link slash CME podcast.
• 14:41
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• 14:45
  library of topics of interest to you.
• 14:48
  This is Pediatrics in Practice, A CME podcast.
• 14:51
  I'm Dr.
• 14:52
  Mike.
• 14:52
  Thanks for listening.