Paediatric Burn Injuries: Assessment And Treatment

Severity of Burn Injuries in Children

Zaynab is a kid and is vulnerable to slips, falls and burns. They have sensitive skin and can be life threatening, depending upon the severity of the burn (de Jong et al.2014). It is evident form the case study that Zaynab was having second degree burn that involves deep layers beneath the skin, dermis. These burns are painful as they form blisters and the healing time can take more than three weeks. Pain occurs due to the release of the inflammatory mediators like prostaglandins and bradykinin triggering the pain receptors present in the skin. (McBride and Holland  2015). Young children are physically unstable and are mentally inquisitive, hence burn can bring physical as well as emotional trauma in the patient. (Bittner et al. 2015). The health care professionals in charge of the paediatric units should be able to act promptly against any kind of emergency situations. In order to do this, communication among the multidisciplinary team is very crucial in order to manage the perioperative care in a manner that is in compliance with treatment goals of the clinical setting (Krishnamoorthy et al. 2012). 

Zaynab is an emergency case; he will not be prepared for any kind of surgical procedures and hence will require an operating department practitioner (ODP). I order to apply the anaesthesia it is essential to detect if Zaynab had any histories of allergies. Pain and trauma can bring about gastric emptying; hence it is necessary to address the concerns of the child by assessing her facial expression or her voice. 

The preliminary assessment of a burn includes the Clearance of the airways, breathing, and stabilization of the circulation followed by homeostasis. One of the major parts of the treatment is the pain management (Snell et al. 2013). Regardless of the aetiology of the burn, there should be a check up of any signs of hypovolemis, decreased blood pressure and the output of urine (Bittner et al. 2015).

Early excision of the dead tissues with permanent or temporary coverage of the open areas reduces the chance of colonization of the wound and sepsis (Brown et al. 2012). A deep second degree burn may require surgery for removing the burnt tissue. A healthy skin from another part of the body is generally used as a skin graft. After a skin graft the dressings has to be changed regularly ensuring no infection (Snell et al. 2013). Less serious second degree burn would simply require topical antibiotic creams. The burnt site has to be regularly monitored for ensuring proper healing (Brown et al. 2012).

Pain Management in Paediatric Burn Injuries

A child with burns should be treated as a multiple trauma patient at first and assessment of the airway should be the first priority during the initial assessment (Krishnamoorthy et al. 2012). As Zaynab has had some injury over her chest hence, the presence of any airways injury and airway obstruction should be identified. Airway injuries might go unnoticed in the beginning but airway oedema may be formed due to heavy fluid resuscitation (Bittner et al. 2015). Hence it is safer to provide intubation to the patient early, as it might become difficult to intubate after the swelling of the airways. As per the Royal college of Anaesthesia, when there are limited resources, basic airway manoeuvres can be followed such as Zaynab’s head and chin can be tilted, Jaw thrust can be provided to clear the airways (Royal collage of Anesthesia, 2018)

As per the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the airway management should include the equipments involving airway management included endotracheal tubes and face masks and before commencing any intervention it is necessary to assess the anatomical variation in each child (AAGBI, 2013). Zaynab did not suffer from excessive burns as face burns can be a warning sign for the upper airways injury, hence intubation may disrupt the clinical evolution. Intubation in paediatric patients can be difficult due the variation in the anatomical structure of the airway (Krishnamoorthy et al. 2012). This is due to the fact as the epiglottis of some of the children might be large or floppy hence the intubation tool, miller blade can be used in order to get a clear view of the epiglottis (Belanger et al. 2014). Oral intubation can be performed by direct laryngoscopy (Haberal et al. 2010). In case of facial burns the tube can be fixed by encircling the front maxillary incisors and the tracheal tube with heavy braided silk sutures or dental wires.  Mask ventilation can be given to Zaynab, as she was not having any facial or neck burns (Krishnamoorthy et al. 2012).

Rapid sequence induction (RSI) can be given for reducing the risks of aspiration of the intestinal contents and regurgitation (Barnard et al.2012). Just before the placement of an endotracheal tube, intravenous induction of the anaesthesia along with the application of cricoid pressure, because the upper oesophagus is occluded by being compacted between the cervical vertebrae and the trachea preventing the passive reflux of the gastric content (Barnard et al.2012). Since Zaynab is over two years, endotrachaeal tube of size 4mm can be given.  

Airway Management in Paediatric Burn Injuries

Severe fluid loss is one of the greatest problems faced in burn injuries. Heat injury releases sets of inflammatory and vasoactive mediators that are responsible for the systemic vasodilatation, local vasoconstriction and increased transcapillary permeability (Bittner et al. 2015). This leads to the rapid transfer of water and inorganic solutes between the interstitial spaces there is an intravascular fluid loss due to these events, requires replacement of the intravascular volume for preventing end organ hypoperfusion (Haberal et al. 2010). Current recommendations include intravascular fluid resuscitation (Apagbi.org.uk, 2018). Enteral resuscitaion can be given with balanced salt solution. Isotonic crystalloids, hypertonic colloids can be given to restore the plasma volume (Haberal et al. 2010). The parkland formula is the popular guide used in the UK, which recommends that isotonic crystalloid can be given initially followed by colloids 24 hours after the injury (Arya 2012). As per the parkland’s formula, Ringer’s lactate solution 3ml/kg/% burn can be given to children. 4ml/kg/hour can be given to children of 5 years of age in the initial 24 hours (Haberal et al. 2010). One should be aware of the risks, while application of the anaesthesia, after a full stomach, as there is a risk of aspiration. Hence it is important to determine the time of the last meal (RCN. 2005). 

The maintenance of body temperature in burnt patients is challenging, especially when the patient is a child (Marino et al. 2015). The inflammatory response due to burns can elevate the hypothalamic core temperature and the rate of the metabolism is increased for maintaining the elevated temperature (Bittner et al. 2015). Various strategies are taken up for maintaining the body temperature, including the use of radiant warmers, warm blankets, blood warmers, minimizing the chance of skin exposure (Brown et al. 2012).
In the case study, it seems that Zaynab has suffered from a second degree burn and is otherwise healthy.

Pain is the main problem just after the burn. The inadequate pain control measures results in adverse physical and psychological outcomes (de Jong et al. 2012). Zaynab was a kid; hence it is quite easy to assess the intensity of her pain by assessing her facial grimacing and her crying (de Jong et al. 2012). Pain management tools such as FLACC tool (Face, legs, Activity, Cry and Consolability) can be used. (Gandhi et al. 2010). The background pain that Zaynab is suffering from can be managed pharmacologically such as application of acetaminophen and the NSAIDs, opoids or morphine. Acitaminophen exhibits an antipyretic activity and analgesic effects that do not posses any inflammatory activity (Marino et al. 2015). It is the IV route that helps in the rapid circulation leading to higher plasma concentration compared to other rectal or anal route (Krishnamoorthy et al. 2012).  Oxycodone can be used instead of morphine that has a better availability than morphine (Gandhi et al. 2010). Non steroidal anti-inflammatory drugs help in managing pain by non selective inhibition of the thromoxane and the prostaglandins, thus reducing the pain (de Jong et al. 2013). Since Zaynab is just 5 years old and hence care should be taken while applying NSAIDs, as they show lethal side effects (Krishnamoorthy et al. 2012). Opoids provide anaesthesia by central and the peripheral opoid receptors (Royal collage of Anaesthesia .2018). Opoid induced respiratory depression can be caused in paediatrics due to the presence of opoid receptors in the respiratory control centres (Krishnamoorthy et al. 2012). If Zaynab has been suffering from mental trauma then few antidepressants can be recommended to improve the sleep patterns such as Amitriptyline, which acts by increasing the inhibitory pain pathways in the spinal cord. It can also be used in managing neuropathic pain (Gandhi et al. 2010). 

Fluid Resuscitation in Paediatric Burn Injuries

The case study reveals that Zaynab has received a second degree burn and apart from few bruises she is otherwise healthy. Hence it can be said that if the clinical setting is provided with the basic equipments of burn injuries then no intrahospital patient transport is required in this case. However, critically burnt paediatric patients may require mechanical ventilation at the time of the transport and at least an anaesthesia personnel and a respiratory therapist (Lloyd et al. 2012). According to Krishnamoorthy et al. (2012) patient extubation and agitation can be dangerous during the transfer, adequate sedatives and analgesia should be provided while moving the patient.

Injury due to burn and the painful treatment regimen can be traumatizing to children. The psychological response to burns can be very complex and includes cognitive difficulties such as inability to concentrate, forgetfulness, physical difficulties such as restlessness, trembling, pain, heart rate, and muscle tension, behavioural difficulties such as irritability, helplessness, tantrums, nightmares, difficulty in falling asleep and emotional difficulties such as feelings of anxiety or worrying (Bakker et al. 2016). Due to the exposure to the trauma Zaynab may avoid any kind of stimuli that reminds them of the burnout. The symptoms can ultimately lead to psychiatric mood disorders (Toon et al. 2011). One of the most common disorders faced by such trauma is the acute stress disorders and post traumatic disorders (Krishnamoorthy et al. 2012). In order to reduce the anxiety of the child it is necessary for the parents to accompany the child in all conditions. Paediatrics burn units should need a child psychiatrist in order to treat depression, anxiety, oppositional behaviour in the child (Toon et al. 2011). The most significant psychological approach is the family support (Bakker et al. 2016). Zaynab’s father and the mother should play the critical role in dealing out with the emotional distress, grief and the pain coping strategies and other mental health issues of the kid. 

The case study reveals the fact that Zaynab had spilled a hot soup over her body while playing near the dining table at the time of lunch. In this context it can be said that her parents would have been more careful as Zaynab is just a small kid. It can also be found that when Zaynab was taken in the anaesthetic room, her mother did not offer much help even after seeing her child crying out of pain. Any kinds of maltreatment or negligence of care can pose a detrimental effect in the physical and the mental well being of a child that can affect Zaynab’s recovery. The Child abuse Prevention and the Treatment act mandates the reporting of any suspected or confirmed abuse (Department of Health. 2018).

Transporting Critically Burnt Paediatric Patients

Consent is the legal expression of the ethical principles of autonomy (Attard-Montalto 2001). Zaynab cannot be considered as Gillick competent for giving consent to any kind of medical examination and treatment and hence it is the mother that has to take the initiative (Griffith 2016).  Some of the key ethical general principles that the anaesthetist or the health care professionals should keep in mind while providing care to the child is respect to the individual’s autonomy, respect to the competence of individuals (Attard-Montalto 2001). Any treatment regimen that should be taken should do any harm to her health, especially with regards to the interventional procedures and the administration of the medications (Toon et al.2011). In general a child having maturity can be involved in the decision making process, but Zaynab is too young to take any such decisions hence in such a case the caregivers advocate on behalf of the child and help her parents to take decisions. 

Burn injury is a major epidemiologic problem in children. Care for these vulnerable patients requires a sound understanding of the pathophysiologic effects of the burn injuries on almost every organ (McBride and Holland,  2015). Careful and close attention should be paid for the initial management of the burns, resuscitation and pain management. Use of multidisciplinary approaches, advanced knowledge by research efforts can provide excellent chance of recovery to Zaynab. 

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