25.10.2020

Treatment of burns in children

Often, burns in children occur due to the negligence of parents when they immerse the child in a too hot bath or for a long time are left to warm themselves with heating pads. At school age, various pyrotechnic fun, kindling fires, “experiments” with combustible mixtures, etc., are a particular danger for children. Such frolics with fire usually end in disrepair, as they often lead to extensive thermal burns. Thermal burns in children usually affect integumentary tissues; however, burns of the eyes, respiratory tract and digestive tract can also occur.

Depending on the damaging agent, burns in children are divided into thermal, chemical, electrical and radiation. The occurrence of thermal burns in children in most cases is due to skin contact with boiling water, steam, open fire, melted fat, red-hot metal objects. Young children most often scald with hot liquids (water, milk, tea, soup).

Chemical burns are less common and usually occur when household chemicals are not properly stored in a place accessible to children. Small children may inadvertently spill acid or alkali on themselves, spill a powdery substance, spray an aerosol with a dangerous chemical, mistakenly drink a caustic liquid. When taking aggressive chemicals inside the burn of the esophagus in children is combined with burns of the mouth and respiratory tract.

The causes of electrical burns in young children are malfunctioning electrical appliances, their improper storage and operation, the presence in the house of electrical outlets accessible to the child, protruding bare wires. Older children usually get electric burns, playing near high-voltage lines, riding on the roofs of electric trains, hiding in transformer boxes.

Radiation burns in children are most often associated with direct sunlight on the skin over a long period of time. In general, thermal burns in children account for about 65-80% of cases, electric – 11%, and other types – 10-15%.

In the framework of this topic, the features of thermal burns in children will be considered.

Symptoms of thermal burns in children

Depending on the depth of tissue damage, thermal burns in children can be of four degrees.

  • I degree  burn (epidermal burn) is characterized by superficial skin damage due to short-term or low-intensity exposure. In children, local pain, hyperemia, edema and burning sensation are noted. A slight scaling of the epidermis may be observed at the site of the burn; Superficial burns in children heal after 3-5 days on their own completely without a trace or with the formation of a small  pigmentation .
  • The second degree  burn (surface dermal burn) proceeds with complete necrosis of the epidermis, under which accumulates a transparent liquid, forming bubbles. Swelling, pain and redness of the skin are more pronounced. After 2-3 days, the contents of the bubbles become thick and jelly-like. The healing and restoration of the skin lasts about 2 weeks. When burns II degree in children increases the risk of infection of a burn wound.
  • A third degree  burn (deep dermal burn) can be of two types: III degree – with preservation of the basal layer of the skin and IIIb degree – with necrosis of the entire thickness of the skin and partially of the subcutaneous layer. III degree burns in children occur with the formation of dry or wet necrosis. Dry necrosis is a dense brown or black scab that is insensitive to touch. Wet necrosis has the appearance of a yellowish-gray scab with a sharp swelling of fiber in the area of ​​the burn. After 7-14 days, the scab rejection begins, and the complete healing process is delayed for 1-2 months. Epithelization of the skin occurs due to the preserved germ layer. IIIb degree burns in children heal with the formation of coarse, inelastic  scars .
  • A fourth-degree  burn (subfascial burn) is characterized by damage and exposure of the tissues that lie deeper than the aponeurosis (muscles, tendons, vessels, nerves, bones, and cartilage). Visually, with IV degree burns, a dark brown or black scab is seen, through the cracks of which the affected deep tissues are visible. With such lesions, the burn process in children (cleansing the wound, the formation of granulations) is slow, often developing local, especially purulent, complications –  abscesses ,  cellulitis ,  arthritis . IV degree burns are accompanied by a rapid increase in secondary changes in the tissues, progressive thrombosis, damage to internal organs and may result in the death of a child.

Burns I, II and IIIa in children are regarded as superficial, burns IIIb and IV degree – as deep. In pediatrics, as a rule, there is a combination of burns of various degrees.

Burn disease in children

In addition to local phenomena, with burns, children often develop severe systemic reactions, which are characterized as burn disease. During a burn disease, 4 periods are distinguished – burn shock, acute burn toxemia, burn septicemia and recovery.

Burn shock lasts 1-3 days. In the first hours after receiving a burn, the children are excited, they sharply react to pain, scream (erectile phase of shock). There is chills, increased blood pressure, increased breathing, tachycardia. In severe shock, body temperature may drop. After 2–6 hours after a burn, the torpid phase of shock begins in children: the child is dynamic, slowed down, does not complain and practically does not react to the environment. The torpid phase is characterized by arterial hypotension, rapid filamentous pulse, severe pallor of the skin, severe thirst, oliguria or anuria, and in severe cases, “coffee-vomiting” vomiting due to gastrointestinal bleeding.

I degree burn shock develops in children with superficial lesions of 15–20% of body area; II degree – with burns of 20-60% of the body surface; Grade III – more than 60% of the body area. Rapidly progressive burn shock leads to the death of a child on the first day.

With further development, the period of burn shock is replaced by a phase of burn toxemia, the manifestations of which are caused by the entry of decay products from damaged tissues into the general circulation. At this time, children who have suffered burns may have fever, delirium, convulsions, tachycardia, arrhythmia; in some cases, a coma. Against toxemia, toxic myocarditis, hepatitis, acute erosive and ulcerative gastritis, secondary anemia, nephritis, and sometimes acute renal failure may develop. The duration of the period of burn toxemia is up to 10 days, after which, in deep or extensive burns in children, a septicotoxemia phase begins.

Burn septicotoxemia is characterized by the addition of a secondary infection and suppuration of a burn wound. The general condition of children with burns remains severe; There may be complications in the form of otitis, ulcerative stomatitis, lymphadenitis, pneumonia, bacteremia, burn sepsis, and burn exhaustion. In the recovery phase, recovery of all vital functions and scarring of the burn surface prevail.

Diagnosis of burns in children

Diagnosis of burns in children is made on the basis of history and visual examination. To determine the area of ​​burns in younger children, Lund-Browder tables are used, taking into account the change in the area of ​​various parts of the body with age. In children older than 15 years, they use the rule of “nine”, and with limited burns, the rule of the palm.

Children with burns should examine hemoglobin and hematocrit, urinalysis, biochemical analysis of blood (electrolytes, total protein, albumin, urea, creatinine, etc.). In case of suppuration of a burn wound, a fence is taken and bacteriological sowing of wound discharge is carried out on the microflora.

Be sure to (especially when electric shock in children) is performed and repeated in the dynamics of the ECG. In case of chemical burns of the esophagus in children, esophagoscopy (FGDS) is necessary. With the defeat of the respiratory tract requires bronchoscopy, radiography of the lungs.

Treatment of burns in children

First aid for burns in children involves the termination of the thermal agent, the release of the affected skin from clothing and its cooling (by washing with water, an ice bubble). For the prevention of shock at the prehospital stage, the child can be given analgesics.

In a medical institution, primary treatment of the burn surface, removal of foreign bodies of epidermis fragments is carried out. Anti-shock measures for burns in children include adequate anesthesia and sedation, conducting infusion therapy, antibiotic therapy, oxygen therapy. Children who do not receive the appropriate prophylactic vaccinations are given emergency immunization against tetanus.

Local treatment of burns in children is carried out closed, open, mixed or surgically. With the closed method, the burn wound is closed with an aseptic bandage. For dressings, antiseptics (chlorhexidine, furatsilin), film-forming aerosols, ointments (ofloxacin + lidocaine, chloramphenicol + methyluracil, etc.), enzyme preparations (chymotrypsin, streptokinase) are used. An open method for the treatment of burns in children involves the abandonment of the application of bandages and the management of the patient under strict asepsis. It is possible to move from a closed method to an open one to speed up the recovery process, or from open to closed – with the development of infection.

During the rehabilitation period, exercise therapy, physiotherapy (ultraviolet irradiation therapy, laser therapy, magnetic laser therapy, ultrasound), and hyperbaric oxygen therapy are prescribed to children with burns.

With deep, but small in area burns in children, excision of necrotic tissue is performed, followed by autodermoplasty. In the case of scarring, a scar is excised with a cosmetic suture overlaid. The method of treating burns in children is determined by a combustiologist or a children’s traumatologist.

When burns I-II degree is almost always the outcome is favorable. With extensive and deep burns in children, the prognosis is always serious. For young children, burns of more than 30% of the body surface are critical; for older children – 40% of body area and more. The cause of death of children in most cases is a secondary infection.

Prevention of burns in children, first of all, requires increased responsibility on the part of adults. The child should not be allowed to come into contact with fire, hot liquids, chemicals, electricity, etc. For this, in the house where there are small children, safety measures must be provided (storage of household chemicals in an inaccessible place, special plugs in sockets, hidden electrical wiring, etc.). etc.). Constant supervision of children is necessary, the imposition of a strict prohibition on touching dangerous objects.

Burns in children are a type of injury that occurs when tissue is damaged by physical and chemical factors (thermal energy, electricity, ionizing radiation, chemicals, etc.). The clinic of burns in children depends on the influencing factor, localization, depth, extent of tissue damage and includes local (pain, hyperemia, edema, blistering) and general manifestations (shock). The main tasks of diagnosing burns in children are to determine the nature of the burn injury, the depth and area of ​​damage, for which infrared thermography and measuring techniques are used. Treatment of burns in children requires anti-shock therapy, a toilet of the burn surface, and dressing.

Burns in children – thermal, chemical, electrical, radiation damage to the skin, mucous membranes and underlying tissues. Children account for 20–30% of the total number of persons with burn injuries; moreover, almost half of them are children under 3 years of age. The mortality rate due to burns among children reaches 2-4%, in addition, about 35% of children are disabled annually.

The high prevalence of burns in the pediatric population, the tendency to develop burn disease and severe post-burn disorders make the prevention and treatment of burn injury in children a priority in pediatric surgery and traumatology.

The peculiarities of children’s anatomy and physiology are such that the skin of children is thinner and more delicate than that of adults, has a developed circulatory and lymphatic network and, therefore, has a higher thermal conductivity. This feature contributes to the fact that exposure to a chemical or physical agent, which in an adult causes only superficial skin damage, leads to a deep burn in a child.

The helplessness of children at the time of injury causes a longer exposure of the damaging factor, which also contributes to the depth of tissue damage. In addition, the imperfection of compensatory and regulatory mechanisms in children can lead to the development of burn disease even with a lesion of 5-10%, and in infancy or with a deep burn – only 3-5% of the body surface. Thus, any burns in children are more severe than in adults, since in childhood disorders of blood circulation, metabolism, functioning of vital organs and systems occur faster.

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