Pediatric emergency medicine trisk 807

responsive to fluid therapy, should have an aggressive diagnostic workup for concurrent problems Antibiotics Burn sepsis continues to be the major cause of mortality after the period of initial resuscitation despite improvements in topical and systemic antimicrobials Meticulous antiseptic techniques can lessen colonization of burns with potential pathogens Topical antibiotics further reduce bacterial number Early streptococcal cellulitis is less common than in years before the development of topical antibiotics for burns Most burn centers not routinely treat patients with prophylactic systemic antibiotics given absence of data to support this practice, and the increased likelihood of inducing resistant organisms Frequent examination of healing burns for signs of infection and cultures to monitor colonization can direct specific antibiotic therapy if documented infections were to occur Wound Care Early surgical management of some partial- and most fullthickness burns with excision and grafting has been an important advance in burn treatment Initially, burns should be covered loosely with sterile sheets during the resuscitation phase in severe injuries Once the cardiorespiratory status is stabilized, the wounds are uncovered and fully assessed for size and depth The goals of burn wound care are to promote rapid healing and prevent infection Cleansing with large volumes of lukewarm sterile saline reduces contamination Loose tissue can often be wiped away with sterile gauze, simplifying and expediting burn debridement Blisters should be left intact whenever possible However, large blisters or those that obscure the assessment of the burn depth may need debridement Smaller blisters may be left intact to preserve the barrier to bacterial invasion Application of temporary skin substitutes may reduce pain, expedite healing, and reduce length of hospitalization compared with topical antibiotics and conventional dressings but are often not applied in the ED It is not necessary to apply topical antimicrobials to burns prior to transfer to a burn center or tertiary care children’s hospital Escharotomy First, all jewelry and watches should be removed because these may restrict distal flow of the blood For extensive and deep extremity burns, pulses should be checked by Doppler ultrasound if they cannot be palpated Absence of flow or progressive diminution of the pulse are indications for escharotomy through the depth of the eschar on the medial and lateral aspects of the extremities, including the hands Finger escharotomies are seldom necessary and should be undertaken only after consultation with a burn center surgeon It is especially important to extend escharotomy incisions across the joints because the skin is tightly adhered to the underlying fascia at these locations and vascular obstruction is more likely to occur The procedure does not require anesthesia because fullthickness wounds are insensate Pulses assessed by palpation or Doppler ultrasound should immediately improve after escharotomy If improvement is not immediate, hypovolemia should be suspected Reperfusion of the extremities after escharotomy may abruptly reduce intravascular volume and require prompt adjustment of fluid therapy Tetanus Children who have received 3 doses of the vaccine require only the vaccine Red Book Guidelines suggest giving Td to those between and 10 years and Tdap to those 11 years or greater (see Chapter 110 Minor Trauma , Table 110.1 Tetanus Prophylaxis) Pain Management Safely reducing pain is an important consideration in the management of children with burns of all sizes Calm, developmentally appropriate verbal reassurance, even to preverbal children, can reduce anxiety and dramatically reduce the perception of pain The exposure of sensory nerve receptors in partial-thickness burns makes them sensitive to environmental stimuli Movement of cool air across burned tissue increases pain significantly The simple measure of covering burns with a sterile sheet, only exposing them when necessary for burn assessment, provides extremely effective and safe analgesia Many children will still have significant pain after nonpharmacologic measures are taken Narcotic analgesics are useful when administered appropriately Morphine may reduce the blood pressure, especially in patients who are hypovolemic Fentanyl causes less cardiovascular effect than morphine but has a short half-life Clinicians should be prepared to support the circulation with intravenous fluids when using opioids Intranasal medications can be given during early assessment of patients in severe pain Ongoing analgesic medications are commonly administered intravenously for patients with severe burns because they are effective and predictable Intramuscular injections or oral doses should not be given to patients with significant burns because circulation to muscle and gut is reduced, and absorption of medication will be delayed and unpredictable In children who not respond well to the initial dose of pain medication, a careful assessment for other causes of pain or agitation should be sought The possibility of compartment syndrome, hypoxemia, early shock, and occult injuries should be assessed while simultaneously preparing repeated doses of analgesics Analgesic administration just before debridement of any burn wound is recommended Disposition (Transfer Criteria) Guidelines for admission must be individualized when treating children with burns Hospitals, physicians, and parents have varying capabilities for managing pediatric patients with burns If a physician suspects that the burns cannot be adequately cared for in the home, admission to the hospital is warranted Children with burns 10% TBSA burn, >5% TBSA full-thickness burn, high-voltage burn, chemical burn, known inhalational injury, burn to face, hands, feet, perineum, joints, significant comorbidities that could affect burn treatment, or when social or emotional factors related to the burn injuries will influence rehabilitation MINOR BURNS CLINICAL PEARLS AND PITFALLS Suspicious injuries should be reported to the appropriate authorities and should prompt further clinical investigation Assess the safety of the household and provide anticipatory guidance even in cases where there is not a suspicion of inflicted injury Ensure adequate wound care and follow-up Goals of Treatment A small minority of all burns in children requires therapy in the hospital Once a careful assessment has led to a decision to manage a burn as an outpatient, preparations for treatment at home should begin Parents or guardians need to be instructed carefully regarding wound care and reasons to return The goal of the treatment of minor burns is to reduce pain, decrease risk of infection, and improve functional outcome through careful home management and close outpatient follow-up Clinical Considerations It is important to consider the possibility of inflicted burns and to carefully examine even minor burns for characteristic shapes and patterns Additionally, it is crucial to perform a detailed secondary survey to ensure that no other traumatic injuries are missed Clinical Recognition A child with superficial or partial-thickness burns