Management ofSmall Burns

B I E N N O V A T I O N , 1 4 . S e p t e m b e r 2 0 1 8

D r . m e d . K a t h r i n N e u h a u s , U n i v e r s i t y C h i l d r e n ` s H o s p i t a l Z u r i c h , P e d i a t r i c B u r nU n i t , D i v i s i o n o f P l a s t i c a n d R e c o n s t r u c t i v e S u r g e r y

Main Topics

• Pre-hospital care for thermal injuries

• Repetition of basic (burn) wound assessment

• Conservative management: options for dressings

• Decision making conservative vs operative treatment

• Surgical treatment of small burns

• Principles of rehabilitation and after care

Epidemiology of Burns

Type of Injury Temperature Frequency in Children

Scald burn 60 - 100 º C 65%

Flame burn 1000 º C 25%

Contact burn 250 - 500 º C 8%

Electrical burn/electric arc

1000 º C 1%

Chemical burn 0.5%

First Aid

• Disruption of heat contact + cooling

• Scald burns may be cooled with clothing on

• Do not cool the entire body, only body parts

• Cool first, then warm up/wrap, and then call for help!!!!

Tap water 20-25 degree Celsius for 10 (-15) min.

Transfer to the Hospital

• rough estimation of BSA (in steps of 10%)

• rough estimation of burn depth (1st/2nd/3rd degree)

• keep the patient warm and monitor body temperature

• analgesia (opioids, ketamin), keep NPO

• dressings: isolating rescue blankets, simple petroleum gauzedressing, leave blisters intact no wet gauzes!!

Transfer to the Hospital

• Peripheral iv line:

≥ 10% BSA or ≥ 5-10% BSA + expected transfer time ≥ 60min:

formula based fluid rescuscitation only for burns >20% BSA AND transfer time ≥ 2-3h (contact pediatric burn center)

• difficult venous access consider intraosseous access

cristalloides (e.g. lactated ringer` s solution): 10 ml/kg (bolus) + 10 (-15) ml/kg/h continously

Transfer Criteria to Pediatric Burn Centers

• 2nd degree burns > 10-15 % BSA

• 3rd degree burns

• Face, hand, feet, genitalia burns, burns crossing large joints

• Electrical injuries

• Chemical burns

• Inhalation trauma

• Children with significant comorbidities

Assessment of BSA Involved

14 months

14 years

Assessment of BSA involved

14 Monate

Assessment of BSA Involved

Rule of nine by Wallace for the age of 14 or older!

Assessment of BSA Involved

1 %

Burn Case 3D

Skin Anatomy and Burn Depth

Skin Anatomy and Burn Depth

1st degree = sun burnOnly epidermis involved erythema, no blistering, swelling and pain

Heals within a few days, no scars

Skin Anatomy and Burn Depth2a = superficial partial thicknessepidermis and papillary dermis involved, but basal cell membrane partially intact blisters, wound pink and blanching, moist, moderate pain

Heals within 5-14 days, no scars, possiblepermanent changes in pigmentation

Skin Anatomy and Burn depth2b = (deep) partial thicknessComplete involvement of basal layer ofepidermis and main parts of dermis (reticulardermis)± blisters, wound white/pinkish withhemorrhagic staining, minimal to no blanching, dry, minimal pain

Heals within 3-5 weeks, usually with severescar formation, usually requires grafting

Skin Anatomy and Burn Depth

3rd degree = full thicknessComplete epidermis and dermis involvedincluding skin appendagesand sometimes subcutanous fat

wound white, dry, eschar formation, insensate, no blanching, hair can be pulled out

Heals from the edges only, over weeks andmonths with scar formation, requires grafting

Skin Anatomy and Burn Depth

4th degreeComplete epidermis, dermis and subcutanousfat, muscle, tendons and bones may beinvolved

Black eschar, insensate, no pain

No healing potential, may require flap

Wound Assessment

Wound Assessment

Wound Assessment

Wound Assessment

Wound Assessment

„Restrain yourself to give any earlyprognosis“

„Restrain yourself to give any earlyprognosis“

Day 3 Day 8

Assessment of microvascular dermal perfusionin the wound – allows non invasive objectiveburn depth assessment

- Window of assessment: 48h to 5d post burn- accuracy 90 - 98%- pos. predictive value for deep dermal to full

thickness burns (HP >21 Tage) 85-98%Moor LDI

Laser Doppler Imaging

Moor LDI

Laser Doppler Imaging

Zurich Management of Small Burns (< 15-20% BSA)

Zurich Management of Small Burns (< 15-20% BSA)

The care of a burned child and his family should be done from the day of injury till transition to adult medicine by one team

at one single location.

Main Patient Population < 4yScald Burns

• map like pattern of variable depth within one anatomic region

• ”deepen” within 24-48h

• 2a/2b (3), some require grafting

Contact Burns• mainly palm burns• 2b/3, frequently require

grafting• difficult to rehabilitate

Key Points of Management

1. Minimal and “atraumatic” dressing changes: every 5-7 days, under analgosedation

2. Precise assessment of burn depth: clinical experience : + Laser-Doppler-Imaging

3. Specific dressing concept for different burn depths

4. Decision conservative vs surgical management not later than day 9-12 for scald burns and day 14-21 for palm burns

The Ideal Wound Dressing ?

maximum support of wound healing

maximum protection against infection

long acting low frequency of dressing changes

minimum pain during dressing changes

minimum costs

The Ideal Wound Dressing ?

Dressing Algorithm

Dressing AlgorithmDay of injury Day 2-5 Day 8-12

Dressing Algorithm

Woundcleaning anddebridment

undersedation in

the EDMepilexAg®

Day of injury Day 2-5 Day 8-12

Dressing Algorithm

Woundcleaning anddebridment

undersedation in

the EDMepilexAg®

Day of injury Day 2-5 Day 8-12

Dressing Algorithm

Woundcleaning anddebridment

undersedation in

the EDMepilexAg®

2a: Suprathel®

Dressing changeunder

sedation + Laser

Doppler-Imaging

Outpatient, dressingchange without sedation

Day of injury Day 2-5 Day 8-12

Dressing Algorithm

Woundcleaning anddebridment(sedation) in

the EDMepilexAg®

2a: Suprathel®

Dressing changeunder

sedation + Laser

Doppler-Imaging

2a/2b:Polymem Ag®

outpatient dressingchange without sedation

Inpatient or outpatient, w/o sedation, definitive decision cons vs surgical

Day of injury Day 2-5 Day 8-12

Dressing Algorithm

Woundcleaning anddebridment(sedation) in

the EDMepilexAg®

2a: Suprathel®

Dressing change

(sedation) + Laser

Doppler-Imaging

2a/2b:Polymem Ag®

2b/3: Acticoat®

Outpatient, dressingchange without sedation

Inpatient or outpatient, definitive decision cons

vs surgical

inpatient or outpatient, sedation, definitive

decision cons vs surgical

Day of injury Day 2-5 day 8-12

Dressing Algorithm

Woundcleaning anddebridment(sedation) in

the EDMepilexAg®

2a: Suprathel®

Dressing change

(sedation) + Laser

Doppler-Imaging

2a/2b:Polymem Ag®

2b/3: Acticoat®

outpatient dressingchange without sedation

Inpatient or outpatient, w/o sedation, definitive decision cons vs surgical

inpatient or outpatient, dressing change under

sedation, definitive decision cons vs surgical

Day of injury Day 2-5 Day 8-12

…if Surgery is Needed: STSG

5 important rules

1. Prevent any unnecessary blood loss!

2. Do not sacrifice vital dermis

3. Go for the scalp!

4. Do not mesh, use sheet grafts!

5. Invest time and passion into your dressings!

Tangential Necrosectomy

Tangential Necrosectomy1. thoroughly mark the area that requires excision

2. inject the area with epinephrine (or use a tourniquet)

3. wait prepare the next step , chat with your colleagues

4. score the edge of the area with a scalpel

5. excise tangentially using a weck (goulian) or watson knife until woundbed is vital

6. achieve hemostasis (epinephrine soaked telpha non adhesive pads, electrocautery)

7. prepare and harvest your donor site

Harvesting the Scalp

Harvesting the Scalp

• Favourable size relation in children

Up to 350cm2 per harvest

Lower rate of complication (CAVE dark skin types)

• ”hidden donor site”

Harvesting the Scalp

Harvesting the Scalp

Do not mesh!

Sheet Grafting

Outcome

Post STSG• POD 5-7: graft take down removal of suture material under sedation simple, thin

dressing

Measurements for pressure garments

Physiotherapy/occupational therapy

• POD 6-10: no more dressing mobilisation

daily baths and moisturizing (Bepanthen/Dexeryl)instruction of parents

garment fit test

• POD 9-12: discharge home

...When Things Go Wrong

Wound Bed Related

• Wound bed not vital, insufficientnecrosectomy

• Wound bed infection

Graft Related

• Mechanical forces (insufficient dressingan/or incompliant patient/parents

• STSG too thin

• STSG applied upside down

5 Reasons for Graft Loss

Rehabilitation

Rehabilitation/Follow up

Multidisciplinary outpatient burn clinic every 3 months (6 weeks) in thefirst year:

assessment of scar quality/hypertrophic scarring siliconesheets/gel?

assessment of pruritus

ROM need for pyhsiotherapy/occupational therapy?

need for splints

fit of garments and need for further garments (± 12 months)

Keep pressure garments as long as needed and as short as possible!

Rehabilitation

• Early surgery: rarely needed, usually no reconstructive surgerywithin first 12 months of the injury, await scar maturization

• New option: Laser therapy: pulse dye and fractional CO2 Laser

• Reconstructive Surgery during growth: Local flaps, Scar Incision andrelease

Questions????