BURNS

BURNS
Burns are injuries to body tissue caused by excessive heat (heat greater than 104°F/ 40°C]).

Burns are the second most common unintentional injuries seen in children 1 to 4 years of age
and the third most common cause in children 5 to 14 years of age.

Younger children are most at risk for scald burns that are caused by hot liquids or steam.

Older children are more apt to be burned from flames after they move too close to a campfire,
heater, or fireplace; touch a hot curling iron; or play with matches or lighted candles

Burn injuries tend to be more serious in children than in adults because the same size burn
covers a larger surface of a child’s body.
Many burns can be prevented with improved parent and child
education. When providing patient education, burn prevention tips for
parents include:
1. Install smoke alarms in the home, on every floor, and near all rooms in which family members
sleep.

2. Maintain smoke alarms by testing them monthly to make sure they are working properly and
by using long-life batteries.

3. Create a family fire escape plan, involve the children in the planning, and practice frequently.

4. Never leave food unattended on the stove and always supervise or restrict the use of stoves,
ovens, and microwaves with children.

5. Check the water heater temperature and make sure that the thermostat is set to 120°F or
lower. Always test the water before children enter the bathtub or shower
Assessment
Because burns are classified as to degree, when children with a burn injury are brought to
a healthcare facility, the first questions asked must be “Where is the burn?” and “What are
its extent and depth?”

Along with the size and depth, be certain to assess and document the location of the burn.

Face and throat burns, for example, 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 also 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 for secondary infection.

Genital burns are also hazardous because edema of the urinary meatus may
prevent a child from voiding.
History of burn

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

• Scald: estimated temperature and nature of the liquid

• Contact: estimated temperature and nature of the surface
• Friction
• Flame / explosion: product that burned/exploded, location (enclosed vs. open space); duration
of exposure, inhalation injury
• Electrical: voltage, type of current (AC or DC), duration of contact
• Chemical: type of product
• Cold: direct contact with cold surface or exposure (frostbite)
• Radiant: sunburn
•First aid
• Time started (was it within 3 hours and maintained)
• Agents used
• If clothes and jewelry were removed
• Decontamination method (for chemical exposure)

•Consider co-existing non-burn injuries

•Consider non-accidental injury or vulnerable child
•Tetanus status
With adults, the “rule of nines” is a quick method of estimating the extent of a burn. For
example, each upper extremity represents 9% of the total body surface; each lower extremity
represents two 9s, or 18%, and the head and neck represent 9%. Because the body
proportions of children are different from those of adults, this rule does not always apply and
is misleading in the very young child.
Depth of Burns
First degree (Superficial burns)

Involves the epidermis or outer layer of skin. Appears reddened,

dry, and feels mildly painful. Heals by simple regeneration; takes 1–
10 days to heal.

First-degree burns affect only the outer layer of skin, the

epidermis. The burn site is red, painful, dry, and with no blisters.
Long-term tissue damage is rare and often consists of an increase
or decrease in the skin color.
S/Sx
Most first degree burns involve a small surface area of the skin, but some affect
larger areas. They usually present as a dry, discolored area of skin. Burns on
light skin look red, whereas burns on dark skin appear reddish-brown. Typically,
first degree burns do not break the skin or cause blisters to form.
The best-known symptom of a first degree burn is a change in the color of the skin.

Other symptoms may include:

•pain
•soreness in the burned area, which usually lasts for 2–3 days
•skin that feels warm to the touch
•swelling
•dry skin
•peeling of the top skin layer within 1–2 days and the rest within 3 weeks
•itching
•a temporary change in skin color due to peeling
•in people with light skin, the burnt skin turning white when applying pressure to it
 Management
People can take steps to treat a first degree burn at home. These include:
• removing clothing, watches, rings, and any other jewelry near or covering the burned area
• plunging the burned area into cool (not ice cold) water right away and keeping it there for at least 5 minutes or
applying cold, wet compresses (not ice) to the area until the pain subsides
• cleaning the burned area gently with mild soap and water
• refraining from applying butter or toothpaste to a first degree burn, as this can increase the risk of infection and
prevent healing
• covering the burned area with a nonstick bandage and changing the bandage three times a week or, if there are
signs of infection, every day
• avoiding popping any blisters that may develop, as this can increase the risk of infection and scarring
• taking over-the-counter (OTC) pain relievers, such as acetaminophen or ibuprofen, to reduce pain, swelling,
and inflammation
• drinking plenty of fluids to avoid dehydration
• protecting the area from the sun by staying indoors or covering the area with sun-protective clothing
Second degree (Partial Thickness Burns)
Involves the epidermis and part of the dermis layer of skin. Appears red,
blistered, and may be swollen. Very painful. Heals by regeneration of tissue over
2–6 weeks.
Second-degree burns can be relatively minor, such as when a burn from a stove or
iron burns deeper into the skin. They can also be very serious and even life-
threatening.

Second-degree burns are more dangerous when:

•They affect large areas of the body.
•They affect the joints, face, or hands.
•They affect the genitals or buttocks.
•They occur in someone with a weakened immune system, such as someone who is
undergoing chemotherapy for cancer.
Second-degree burns can cause serious infections, especially if they cover large
areas of the body or if a person does not receive the right treatment.
Causes
Physical sources of heat, such as the sun and stoves, can cause second-degree burns. Certain
chemicals, including bleach and other cleaning products, can also cause burns.

Some common causes of second-degree burns include:

•severe sunburn, such as when a person with very fair skin sits in the sun for an extended period
•accidents with ovens and stoves
•exposure to fire
•contact with boiling water
Accidental injuries are a common reason for second-degree burns. For example, a child might
place their hand on a hot burner.
Intentional abuse, such as during acid attacks, can also cause second-degree burns.
Some common symptoms of second-degree burns include:
•a wet-looking or seeping wound
•blisters
•a burn with an irregular pattern
•intense pain or skin sensitivity
•skin that looks white, very deep red, or very dark brown
A person who develops a fever or feels ill after sustaining a burn may have an
infection.
Third Degree Burn
Third-degree burns destroy the epidermis and dermis. They may go
into the innermost layer of skin, the subcutaneous tissue. The burn
site may look white or blackened and charred.

Involves the epidermis and full extent of the dermis. Appears white
or charred and lacks sensation as the nerve endings are destroyed.
Skin grafting is usually necessary, and healing takes months. Scar
tissue will cover the final healed site.
Causes
Third degree burns will typically result from contact or exposure to the following:
•flames
•flash from an explosive blast
•chemicals such as acids
•electricity
•scalding liquids
•contact with an extremely hot object for an extended period
Symptoms
•skin discoloration, which can include the skin becoming:
• white
• grey
• black
• brown
• yellow
•skin appearing
• dry
• leathery
• waxy
•swelling
•a lack of pain due to damage to nerve endings
Shock
Severe burns can also result in potentially fatal complications. For example, the body
may go into shock.

Normally, the body produces an inflammatory response to protect itself from injury,
infection, or other threats. However, in some cases, such as with severe burns, the
body may overreact, and the inflammatory response may cause more harm.

Shock typically causes damage because the extreme inflammatory response results
in tissues and organs not receiving enough oxygen. Several organs, such as the
lungs, heart, and brain, are particularly susceptible to damage by “burn shock.”
Infections
Infection is another major concern with third degree burns. The severe damage to
the skin makes the body more susceptible to pathogens.

Burns can also weaken the immune system, meaning the body is less capable of
fighting off infection. In particular, acquiring pneumonia and sepsis infections are
common and potentially fatal complications.
Treatment
•Surgery: Third degree burns typically require multiple surgeries to remove burned tissue from the
burn site.

•Skin graft: As third degree burns do not heal by themselves, a skin graft is often necessary. A doctor
may use a combination of natural skin grafts, artificial skin products, or laboratory-grown skin.

•Intravenous fluids: Some people may receive extra fluids to maintain their blood pressure and prevent
shock.

•Medication: A person will likely receive several different medications, such as antibiotics and pain
medication, to prevent infection and ease pain.

•Tetanus shot: As tetanus bacteria are more likely to trigger infections through burn wounds, a person
may receive a tetanus shot to prevent this.
Fourth Degree Burn
Full-thickness burn extending into muscle or bone. Skin grafting is
necessary; muscle and bone may be permanently damaged;
scarring will cover the healed site.

Fourth-degree burns go through both layers of the skin and

underlying tissue as well as deeper tissue, possibly involving
muscle and bone. There is no feeling in the area since the nerve
endings are destroyed.
 Causes
Fourth-degree burns are primarily caused by flames and chemicals. Some of the possibilities include:
•a hot stove or oven
•hot irons
•open flames, such as fireplaces or campfires
•injuries from a building fire
•Chemicals

These can also cause lesser-degree burns. What makes a burn fourth-degree, however, is the extent of
the damage to your body.

Third-degree burns can affect deep layers of your skin, including fatty tissues. Fourth-degree burns
also go much deeper, affecting your muscle tissues, tendons, and nerves
Symptoms
With a fourth-degree burn, you’ll first notice that the affected area has a charred-
looking appearance. It may even be white in color. You might see exposed bone
and muscle tissue.

Unlike first- or second-degree burns, fourth-degree burns aren’t painful. This is

because the damage extends to the nerves, which are responsible for sending
pain signals to your brain.

Such nerve damage makes this burn level even more dangerous — just because
you can’t feel the pain doesn’t mean that the burn isn’t serious.
Treatment
The precise treatment for your fourth-degree burn will depend on
the extent of the damage to your body, as well as your overall
health. While waiting for an ambulance to arrive, you can help a burn
victim by:

•raising the injured body part above the heart, if possible

•covering the affected area with a loose bandage or cloth
•placing a light sheet or blanket over them, especially if they appear
cold from reduced blood pressure
•flushing the area with water (for chemical burns only)
The actions you don’t take are perhaps just as important as the ones you do take. As
you wait for emergency medical attention, make sure you:

•don’t apply ice

•don’t apply creams or ointments to the burns
•don’t remove clothing that may be stuck to the burn
•don’t pick at skin or peel away any blisters
Emergency Management for Minor Burns
All burns, including minor burns, need immediate care because of the potential
pain involved (Mandt & Grubenhoff, 2012). Although minor burns (typically first-
degree partial-thickness burns) are the simplest type of burn, they involve pain
and death of skin cells and therefore must be treated seriously. Immediately
apply cool water to cool the skin and prevent further burning. Application of an
analgesic–antibiotic ointment and a gauze bandage to prevent infection is usually
the only additional treatment required. Be certain that parents have a follow-up
appointment in about 2 days to have the dressing changed and the area
inspected for a secondary infection. Caution parents to keep the dressing dry (no
swimming or getting the area wet while bathing until the burn is healed—about 1
week).
Emergency Management for Moderate Burns
Moderate or second-degree burns typically are blistered. Do not
rupture these blisters because doing so denudes the site and
invites infection. The burn should be covered with a topical
antibiotic such as silver sulfadiazine and a bulky dressing to
prevent damage to the burned site and promote healing. The child
usually is asked to return in 24 hours to assess that pain control is
adequate and there are no signs and symptoms of infection. Broken
blisters may be debrided (cut away) to remove possible necrotic
tissue as the burn heals.
Emergency Management for Severe Burns
The child with a third-degree or fourth-degree burn is critically
injured and requires immediate care. Sure care, including fluid
therapy, systemic antibiotic therapy, pain management, and
physical therapy. The goal is to prevent disability caused by
scarring, infection, or contracture.
Emergency Management for Electrical Burns of the Mouth
If a child puts the prongs of a plugged-in extension cord into the mouth or chews
on an electric cord, the mouth can be burned severely. When electrical current
from a plug is conducted for a distance through the skin and underlying tissue it
can cause an ulcer. If blood vessels were burned, active bleeding from the lesion
will be present.
The immediate treatment for electrical burns of the mouth is to unplug the electric cord and
control bleeding if present. This can be done by pressing a towel against the burn site. In the
emergency room, pain management and wound care are essential. Clean the wound with an
antiseptic solution, such as half-strength hydrogen peroxide, or as otherwise prescribed to
reduce the possibility of infection (a real danger in this area due to the amount of bacteria
present in the mouth).

Most children with electric burns are admitted to an observation unit for at least 24 hours
because edema in the mouth could lead to airway obstruction. Eating will be a challenge for
the next week because the child’s mouth is so sore. Soft foods and fluids may be easiest to
swallow.

Electrical burns of the mouth turn black as local tissue necrosis begins. They heal with white,
fibrous scar tissue, possibly leaving a deformity of the lips or cheeks and difficulty speaking
clearly afterward. This can be minimized by using a mouth appliance, which helps maintain lip
contour. Many children need follow-up care by a plastic surgeon to restore the lip contour.
Therapy for Burns
Silver Sulfadiazine (Silvadene)

Topical Therapy
Silver sulfadiazine (Silvadene) is the drug of choice for burn therapy to limit infection at the
burn site in children. It is applied as a paste to the burn, and the area is then covered with a
few layers of mesh gauze. Because silver sulfadiazine has a sulfa base, it is an effective agent
against both gram-negative and gram-positive organisms and even against secondary
infectious agents, such as Candida. It is soothing when applied and tends to keep the burn
eschar soft, making debridement easier. It does not penetrate the eschar (the tough, leathery
scab that forms over moderately or severely burned areas) well, however, which is its one
drawback.
Debridement
Debridement is the removal of necrotic tissue on which
microorganisms could thrive from a burned area to reduce the
possibility of infection.

Debridement is the removal of dead (necrotic) or infected skin

tissue to help a wound heal.
Grafting
Skin grafting is a surgical procedure that involves removing skin from one area of
the body and moving it to a different area of the body. This surgery may be done
if a part of your body has lost its protective covering of skin due to burns, injury,
or illness.

Allografting is the placement of skin (sterilized and frozen) from cadavers or a

donor on the cleaned burn site.
POISONING
Poisoning is injury or death due to swallowing, inhaling, touching or
injecting various drugs, chemicals, venoms or gases. Many
substances — such as drugs and carbon monoxide — are
poisonous only in higher concentrations or dosages. And others —
such as cleaners — are dangerous only if ingested. Children are
particularly sensitive to even small amounts of certain drugs and
chemicals.
How you treat someone who may have been poisoned depends on:

•The person's symptoms

•The person's age
•Whether you know the type and amount of the substance that caused poisoning
When providing patient education, poison prevention tips for parents should include

1. Keep medicines and toxic products locked and away from children.
2. Add the poison control number (1-800-222-1222) in your cell phone and make sure
all caretakers do the same.
3. Call the poison control center if you think your child has ingested anything that may
be poisonous. Keep in mind that the child may be awake and alert and acting
normally.
4. If your child has ingested a poisonous product and collapses or stops breathing,
call 911.
5. When administering medications, be sure to read labels carefully and to administer
the appropriate amount.
6. Safely dispose unused, unneeded, or expired medications and vitamins
(CDC,2015).
SYMPTOMS
•Nausea and/or vomiting
•Diarrhea
•Rash
•Redness or sores around the mouth
•Dry mouth
•Drooling or foaming at the mouth
•Trouble breathing
•Dilated pupils (bigger than normal) or constricted pupils (smaller than normal)
•Confusion
•Fainting
•Shaking or seizures
 CAUSES
• Household products and personal care products, like nail polish remover and mouthwash, which is harmful to children

• Cleaning products and detergents

• Paint thinner

• Pesticides and bug spray

• Lawn chemicals, such as herbicides, fertilizers, and fungicides

• Metals, such as lead

• Mercury, which can be found in old thermometers and batteries

• Prescription and over-the-counter medicines when combined or taken the wrong way

• Illegal drugs

• Carbon monoxide gas

• Spoiled food

• Plants, such as poison ivy and poison oak

• Venom from certain snakes and insects

EMERGENCY MANAGEMENT OF POISONING AT HOME
Instructions are specific to what the child ingested. The parent should be prepared to
provide the following information to the poison control center:

• What was swallowed; if the name of a medicine is not known, what it was prescribed for
and a description of it (color, size, shape of pills)
• The child’s weight and age and how long ago the poisoning occurred
• The route of poisoning (oral, inhaled, sprayed on skin)
• An estimation of how much of the poison the child took (a bottle of cleaner or medicine
should say how many pills or how much liquid it originally contained)
• The child’s present condition (sleepy, hyperactive, comatose)
EMERGENCY MANAGEMENT OF POISONING AT THE
HEALTHCARE FACILITY
In the emergency department, the best method to deactivate a swallowed poison is the
administration of activated charcoal either orally or by way of an NG tube to halt the
action of the poison.

Activated charcoal is supplied as a fine black powder that is mixed with water for
administration. Adding a sweet syrup to the mixture can make it more palatable. Caution
parents that, as the charcoal is excreted through the bowel over the next 3 days, stools
will appear black so they do not mistake the color for blood
ACETAMINOPHEN POISONING
Acetaminophen (Tylenol) is an over-the-counter medication that is
frequently involved in childhood poisoning today because parents
use acetaminophen to treat childhood fevers and have it readily
available in the home. They may delay bringing the child for
emergency care, thinking it is a harmless drug. Acetaminophen in
large doses, however, is not innocent; it can cause extreme
permanent liver destruction
CAUSTIC POISONING
Ingestion of a strong alkali, such as lye, which is contained in
certain toilet bowl cleaners or hair care products, causes burns
and tissue necrosis in the mouth, esophagus, and stomach. It’s very
important that parents do not try to make a child vomit after
ingestion of these substances because they can cause additional
burning as they are vomited