Epidemiology

• Burns are common injuries caused by a variety of etiologic mechanisms. Both incidence
and mechanism vary with age and socioeconomic status.

• In developed countries, infants and toddlers are particularly vulnerable, most

commonly injured by scalding in bath and kitchen incidents.
•
• In low-income countries, incidence and severity tend to be higher because of fewer
mandated electrical safety precautions and more primitive living and cooking conditions.

Incidence:
• Over ½ of all burns and 80% of contact burns occur in the home
• Higher incidence in disabled children
• Higher incidence in minorities
• Boys : Girls - 1.27:1 in 2012
Risk factor for Mortality:

• Inhalation injury – can increase risk up to 21 times

• Young age
• Burn size – starting at > 40% TBSA from 0-15.9 and 50% from 16-19.9 years old
• Sepsis or multi-organ failure

Etiology:

• From birth to 19.9 years old (2003-2012):

• Scald injury (44.9%): most common for children less than 5 years old
• Fire/flame (25.4%): most common in the adolescent age group
• Hot object contact (13.5%)
• Electrical (1.7%)
• Chemical (1.2%)
• For children less than 5 years old, 74% of burns are from scald or contact with hot objects.
 Normal pediatric skin physiology

Purpose:
• Regulates temperature
• Protects against infection
• Fluid retention

Thinner epidermal layer than adults, less keratinized

• Results in quicker absorption
• More sensitive to temperatures (e.g. bathtub water)
• 5 seconds at 60° C (140° F) will cause full thickness burn (<6 yo)

Body Surface Area: larger in children

• The smaller the child, the larger the difference

• Can result in more rapid fluid/heat loss than in adult
 Types of Burn Injuries

Scald Burns Thermal Burns Electrical Burns Chemical Burns

• More likely child abuse • > 5 years. • Rare (2% - 3%) but • Most common - strong bases in
devastating common household products.
• < 5 years • ~ 50% of all burn
• Majority - electrical cords and
• Thorough history should admissions. outlets,
• Alkali drain cleaners (sodium
• Flame or contact with hot hydroxide) – denature cutaneous lipids.
include the type and • Minority - lightening.
consistency of the objects • AC > DC • Severity - type and concentration &
causative liquid. • 90% - minor and • AC -cyclic flow of electricity duration of exposure.
• Oil and thick soups - outpatient management tetanic contractions -
• Initial treatment - copious irrigation with
higher heat capacity and with good outcomes. increased tissue damage
tepid water for > 15 minutes.
more viscous • Larger burns - mortality • Children-propensity to chew
• Cause longer contact at influenced by - size, on cords or insert objects into • Never neutralize the acid or base as
outlets exothermic reaction worsens tissue
higher temperatures age , +/- inhalation injury. • Wet or moist skin, including injury.
• More damage • Extent of soft tissue the mucous membranes
• Water of 140° C – deep injury depend on around the mouth, has • In severe burn shock or trauma , there
burns in 3 seconds of duration of exposure , negligible resistance - may be loss of airway due to
considerable soft tissue supraglottic obstruction from edema
contact & 160° C - 1 presence and type of formation
second clothing material trauma.
• Nerves, blood vessels, and • Facial burns, singed nasal hairs,
muscles - least resistance, as carbonaceous sputum, hypoxia, and
compared to bone, fat, and history of entrapment in an enclosed
tendons. space are sign of inhalational injury

• If there is a suspicion for inhalation

injury, inpatient treatment with
intravenous resuscitation and potential
transfer to a burn center should be
considered
 Pathophysiology of burn

Thermal:
• Healthy skin is disrupted, leading to water permeability, capillary leakage, and significant fluid loss
• With fluid and protein shifts, edema develops
• Massive cell destruction leads to shock and a hypermetabolic state, with TBSA > 40%.
• Given the large surface area to mass ratio, children are also at risk for hypothermia
Electrical:
• Current is conducted greater in high-water content tissues (blood vessels, nerves, muscles) and
generates heat, which is retained in deep tissue and can lead to further injuries (ie, compartment
syndrome)
• Can also cause cardiac arrhythmias Classification According to depth
 Depth & Extent of Burn injury

1-Superficial Burns/First degree burns : 3-Deep Partial-Thickness Burns / 2nd degree

2-Superficial Partial-Thickness Burns / 2nd degree burns burns
ºSignificant pain, erythematous changes, lack of
blistering. Clinically similar to third-degree burns.
Entire epidermis and superficial dermis.
Damage to epidermis only, sparing the dermis and Do not easily blanch
Fluid-containing blisters at the dermal-epidermal junction.
dermal structures. Less painful than superficial burns due to nerve
After debridement, the underlying dermis is erythematous,
wet-appearing, painful, and blanches with pressure.
injury.
Blanch on examination & heal within 2 to 3 days Treatment - excision and grafting.
after the damaged epidermis desquamates. eg. - sun Deeper dermis is left undamaged - heal within 2 weeks
without hypertrophic scarring. Need surgical intervention,
burns. May develop hypertrophic scars and/ or
No need for skin grafting
Scarring is rare contractures.

4-Full-Thickness Burns /3rd degree burns

5-Fourth-degree burns - full-thickness
Complete involvement of all skin layers and + the underlying subcutaneous fat,
require definitive surgical management. muscle, and tendons
White, cherry red, brown, or black in color, and do
not blanch with pressure.
Dry and often leathery May need amputation and/or extensive
Typically insensate because of superficial nerve reconstruction with grafting.
injury.
 The body’s response to a burn
Burn injuries result in both local and systemic responses
• Local response:
The three zones of a burn were described by Jackson in 1947.
• Zone of coagulation
• This occurs at the point of maximum damage.
• In this zone there is irreversible tissue loss due to coagulation of the constituent proteins.
• Zone of stasis:
• characterized by decreased tissue perfusion.
• The tissue in this zone is potentially salvageable.
• The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage
becoming irreversible.
• Additional insults—such as prolonged hypotension, infection, or oedema—can convert this zone into
an area of complete tissue loss.
• Zone of hyperaemia
• In this outermost zone tissue perfusion is increased.
• The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.
• These three zones of a burn are three dimensional, and loss of tissue in the zone of
Burn Edema:
• Local swelling is often extensive due to thermal injury involving less than 25%
TBSA, the loss of capillary integrity and shift of fluid are localized to the burn
itself, resulting in blister formation and edema only in the area of injury.
• Unnecessary over-resuscitation will in-crease edema formation in both burn
tissue and non-burn tissue, resulting in compartment syndrome
 • Systemic response:
• The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once
the burn reaches 30% of total body surface area.

1-Cardiovascular changes
• Capillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial
compartment.
• Peripheral and splanchnic vasoconstriction occurs.
• Myocardial contractility is decreased, possibly due to release of tumour necrosis factor .
• These changes, coupled with fluid loss from the burn wound, result in systemic hypotension and end organ
hypoperfusion.

2-Respiratory changes:
• Inflammatory mediators cause bronchoconstriction, and in severe burns adult respiratory distress
syndrome can occur.

3-Metabolic changes:
• The basal metabolic rate increases up to three times its original rate.
• This, coupled with splanchnic hypoperfusion, necessitates early and aggressive enteral feeding to decrease
4-Immunological changes:
• Non-specific down regulation of the immune response occurs, affecting both cell
mediated and humoral pathways.
• The loss of skin integrity is compounded by the release of abnormal inflammatory
factors, altered levels of immunoglobulins and serum complement, impaired
neutrophil function, and a reduction in lymphocytes (lymphocytopenia)

5-Other systemic responses:

• Renal function may be altered as a result of decreased blood volume.
• Destruction of red blood cells at the injury site results in free hemoglobin in the
urine. If muscle damage occurs (eg, from electrical burns), myoglobin is released
from the muscle cells and excreted by the kidney.
• If there is inadequate blood flow through the kidneys, the hemoglobin and myoglobin
occlude the renal tubules, resulting in acute tubular necrosis and renal failure
Estimating the Extent of the Burn

Management
• An accurate assessment & Total body surface
area (TBSA) of burn minimize morbidity and
mortality.
• Overestimation cause over resuscitation with
resultant complications, inappropriate transfer to
burn centers,
• Newer methods for (TBSA) are being researched -
computerized imaging, two- and three-dimensional
graphics, and body contour reproductions.

Current methods for (TBSA)

• 1) Adults : “rule of nines,” by Palaski and Tennison
(palm and fingers of one hand account for 1% of
the normal body surface area).
• This calculation often overestimates, especially in
children.
• TBSA is distributed differently in children and
infants due to proportionally larger heads and
 Treatment
1-Superficial: 3-Deep partial or Full Thickness:
• Acute: • Subacute:
• Resuscitation mediates fluid losses, • Nutrition (nasogastric, oral)
• Moisturizing cream
shock, and potential organ damage. • Cardiopulmonary support is
• Antibiotic ointments not generally weaned as able.
needed, due to intact dermis
• Early escharotomy/debridement helps
• Autograft is performed as
prevent infection.
able.
• The use of skin substitutes (allografts, • Begin compression garments
2-Superficial Partial xenografts, synthetic grafts) can • After removing or extinguishing
Thickness: decrease healing time and pain. the source, washed with tepid
• Topical antibiotics/creams (ie, silver water.
• Pain control sulfadiazine) are used to facilitate • Chemical burns - flushed
• Debridement if necessary healing. copiously to remove the inciting
• Non-adhesive dressing • Additional antibiotics are reserved for agent and prevent further
those with evidence of systemic tissue damage.
• Daily or twice daily dressing
infection. • Ice or iced water- increase
changes, depending on depth
• No standardized pain control tissue damage , hypothermia &
• Can also use silver nitrate dressings guidelines mortality, in patients with more
if concern for infection extensive burns.
• Polymixin/bacitracin antibiotic
ointment 1-2x daily
• Continue analgesia, particularly
Aims of Rehabilitation
• Maintaining range of movement
• Minimizing development of contracture and the impact of scarring
• Prevention of deformity
• Maximising psychological well-being
• Maximising social integration
• Maximising functional ability and recovery
• Enhancing quality of life
 Stages of Rehabilitation

1-Early Stage

Respiratory care:
• Chest clearance can be achieved by raising the head and chest region.
Physiotherapy techniques such as deep breathing exercises, vibrations, percussion,
postural drainage, coughing and suctioning can be employed to clear excess
secretions.
• Consider triflow, PEP, bubble PEP.
• Patients with an inhalation injury or large burns on a fluid resuscitation regime
should be closely monitored

Positioning:
• Burn areas should be elevated to assist in the reduction of oedema. This should be
modified if peripheral circulation is compromised.
• When a burn crosses a joint, the joint should be positioned to maintain an optimal
functional ROM, ensuring that peripheral nerves are not compromised.
 Positioning UL

Head N Neck
Elevate head of bed to 45°.
No pillows beneath the head – a bolster can be placed under the
shoulders to – maximise air entry – extend the neck.
Avoid pressure on the ears – foam doughnut ring can be used.

Axillae
Shoulder abducted to 80° with 10°–30° of horizontal adduction (i.e.
arm is slightly elevated from the bed.)
Young children – may use wrist ties attached to the cot with arms
rested on foam wedges.
Older children use arm extensions attached to the bed with the
addition of foam blocks

Arm
Elbow extended and supinated.
Elbow splints may be required if maintaining extension is difficult.

Wrist/Hand
Wrist: 30–45° extension.Hand: In functional position – i.e. MCP
F=70° with IP extension – thumb in palmar abduction.
 Positioning LL

Lower Limb
Elevate end of bed 30–40°.
Alternatively elevate the legs on baffling or pillows.

Hips
Each hip in approximately 30° of abduction with neutral
rotation/extension.
Prone lying for part of the day if possible.

Knees
Extended and in neutral rotation. Splints may be required.

Ankles
Plantar grade.
May be maintained with foam-lined splints with relief for
the heels.
 Range of movement

Prior to Grafting Post Grafting

Mainly indicated for large deep burns over • Full range of movement as soon as
joints. possible after graft take.
• Normal functional use of the affected part
Aims as soon as possible.
• Maintain full range of movement. • Keep elevated when rested until good
• Stretch multijoint muscles. function is achieved.
• Assist in reducing oedema. • Restore strength
• Pain control is obtainable by performing
Management therapies during wound dressing and
• Passive range of movement/stretches. debridement, if possible\
• Active/assisted exercises. • Prevention of deep vein thrombosis can
• Positioning/Splinting. be achieved by encouraging early
• Constructive play. ambulation.
• Assist with daily living activities as • Prevention of pressure sores.
appropriate
 Exercise Notes

• Start physical therapy program immediately

• Avoid using very intense or maximal resistance training or testing

• Gradual progression is of utmost importance to avoid injury and to promote exercise

adherence

• Post-op exercises involving autografted skin over joints:

• Stop for 4–5 days

• Escharotomies, fasciotomies, heterografts, and synthetic dressings:

• Not contraindications for exercise

• Early mobilization to decrease edema, proper exercise techniques, and accurate

documentation of function are more important than the type of wound closure

• Should participate in a post-discharge, structured and supervised exercise program

 Post Burn Consequences:

1-Contracture: 2-Hetrotrophic Ossification:

Contractures of the fingers and hands can cause
significant functional impairment Most common site is the elbow

Treatment:
Common causes: • Active ROM and AAROM
• Pain • No stretching – can precipitate HO
• Immobility • Alternate splinting
• Poor positioning • Surgical removal
• Damaged structures

• The position of comfort is the position of

contracture!

Treatment:
• Use custom-molded orthoses
• Adapt orthosis to fluid/edema