Chapter 9Common surgical problems

Burns

Case study: Alisher

Alisher, a 10 months old girl was brought to the district hospital by her mother. At presentation Alisher was very anxious, crying in pain and was not able to breastfeed. On the upper half of the chest there was a large scald.

What are the stages in the management of Alisher?

Stages in the management of a sick child (Ref. Chart 1, p. xxii)

1. Triage

2. Emergency treatment

3. History and examination

4. Laboratory investigations, if required

5. Main diagnosis and other diagnoses

6. Treatment

7. Supportive care

8. Monitoring

9. Discharge planning

10. Follow-up

What emergency (danger) and priority (important) signs have you

noticed?

Temperature: 37.20C, pulse: 160/min, RR: 45/min

Chest: burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no

added sounds.

Triage

Emergency signs (Ref. p. 2, 6)

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Severe dehydration

Priority signs (Ref. p. 6)• Tiny baby• Temperature• Trauma• Pallor• Poisoning• Pain (severe)• Respiratory distress• Restless, irritable, lethargic • Referral• Malnutrition• Oedema of both feet• Burns

History

At 6pm the previous day Alisher overturned a hot teapot and was burnt. Her mother and relatives took off her clothes and applied toothpaste and potato to the burn skin.

During the night the child was very anxious and restless, by the morning her condition had worsened and she could not feed. Her mother brought her to the hospital.

Examination

Vital signs: temperature: 37.20C, pulse: 160/min, RR: 45/min,

Weight: 9 kg

Chest: Burn on chest and upper abdomen (as shown). Air entry was good bilaterally and there were no added sounds.

Cardiovascular: both heart sounds were audible and there was no murmur

Abdominal examination: soft, bowel sound was present

Mouth: mildly dry mucus membranes

Skin: mildly decreased skin turgor

Diagnosis: Burns

Two very important questions:

How deep is the burn?

• Full thickness burns are black or white, usually dry, have no feeling and do not blanch on pressure.

• Partial thickness burns are pink or red, blistering or weeping, and painful

How much of the body is burnt?

• Use a body surface area chart according to age (Ref. p. 270)

• Alternatively, use the child's palm to estimate the burn area. A child's palm is approximately 1% of the total body surface area

Further examination: Estimate the total area burned

(Ref. p. 270)

How would you treat Alisher?

Treatment & burns management

(Ref. p. 269-272)

• Hospitalize all children with burns of the skin more than 10%.

• Consider whether the child has a respiratory injury due to smoke inhalation.

• Fluid resuscitation (required for >20% total body surface burn). Use Ringer’s lactate with 5% glucose, normal saline with5% glucose or half-normal saline with 5% glucose.

– Calculate appropriate fluid requirements (Ref. p. 269-271) and administer ½ of total fluid in first 8 hours, and remaining in next 16 hours

• Pain control

– Paracetamol (10-15mg/kg every 6 hours) by mouth and / or IV morphine sulphate (0.05-0.1mg/kg every 2-4 hours) if pain is severe

Treatment & burns management (continued)

(Ref. p. 269-272)

• Prevent infection

– If skin is intact, clean gently with antiseptic solution

– If skin is not intact, debride the burn (blisters should be pricked and dead skin removed)

– Give topical antibiotics/antiseptics

– Clean and dress the wound daily, unless the burn is small and difficult to cover, then it can be managed by leaving it open to the air

• Treat secondary infection if present

• Check tetanus vaccination status and give tetanus immunoglobulin or toxoid booster as appropriate

What supportive care and monitoring are required?

Supportive care

(Ref. p. 269-272)

• Nutrition

– Begin feeding as soon as practical in first 24 hours

– High calorie diet with adequate protein, vitamin and iron supplements (Ref. p. 272)

– Children with extensive burns require about 1.5 times the normal calorie and 2-3 times the normal protein requirements

• Prevention of secondary infection

– Hand washing

Supportive care (continued)

(Ref. p. 272)

• Prevention of burn contractures

– Passive mobilization of involved areas

– Splinting flexor surfaces

– Physiotherapy

• Should begin early and continue throughout the course of the burn care

– Toys and play

Monitoring

• Observe the child frequently

• Monitor respiratory rate and look and listen for signs of airway obstruction and respiratory distress at the beginning

• Monitor adequacy of circulation and hydration

– Pulse

– Capillary refill

– Urine output

• Use a Monitoring chart (Ref. p. 320, 413)

• Ensure the child is calm and pain free and feeding adequately (Ref. p. 269-272)

Follow-up

• Plan discharge when there are signs of recovery of the burnt skin and the parents can care for the child at home. Notify parents on the date of follow up visit.

• Administer physiotherapy to minimise contractures.

• Accomplish a counseling about home safety and about first-aid management of burns (irrigate with cold water).

Summary• Burns and scalds are associated with a high risk

of mortality in children.

• It is important to avoid secondary infection

– Antiseptic

– Clean dressings

– Hand-hygiene

– Avoid unnecessary antibiotics

• Effective analgesia is the second main pillar in management of burns

– Initially, and for all painful procedures