Thermal Injuries



Thermal Injuries


Andrew Hashikawa

Marc H. Gorelick



INTRODUCTION

Thermal injury in children involves not only the skin, but also the respiratory, circulatory, immune, and central nervous systems. Successful treatment of pediatric thermal injuries requires comprehensive assessment and management. Management of burn injury is dictated by assessment of burn severity, determined by the mechanism, depth, and extent of injury.


DIFFERENTIAL DIAGNOSIS LIST



  • Thermal causes—direct flame burns, contact burns, scald burns


  • Chemical causes


  • Electrical causes


  • Radiation


DIFFERENTIAL DIAGNOSIS DISCUSSION


Thermal Burns

Thermal burns are the most common type of burns affecting children. They may result from contact with hot liquids (scalds), hot surfaces, or flames. Scald burns tend to be more extensive but more superficial than contact burns. Flame injuries are most often associated with inhalation injuries.


Chemical Burns

Chemical burns are caused by contact with corrosive substances. Contact with acids causes coagulation necrosis, whereas contact with alkali causes liquefaction necrosis. Alkali burns are typically deeper and more severe than acid burns. Chemical burns require extensive irrigation with water or saline to remove the corrosive agent and prevent further injury.


Electrical Burns

Electrical injury results from contact with a source of electrical current or from arcing of current near the body.

Electrical injury typically produces a depressed entry wound and an exit wound that appears “blown out.” With high-voltage currents (> 1,000 V), the extent of the underlying deep tissue damage is typically far in excess of that suggested
by the appearance of the cutaneous burn. Both low- and high-voltage currents can cause cardiac arrhythmias, even in the absence of visible burns.

Patients exposed to significant electrical current should have an electrocardiogram to monitor for arrhythmia.



Radiation Burns

The most common type of radiation burn in children is sunburn. It is typically first degree or, rarely, superficial second degree.


EVALUATION OF THERMAL INJURY


Patient History

The following information should be ascertained:



  • Mechanism of injury


  • Duration of exposure


  • If the cause of injury was fire, whether the fire occurred in a closed space


  • History of loss of consciousness


  • Tetanus immunization status


Physical Examination


Burns are classified according to their depth and extent (Table 76-1). Depth of injury is assessed on the basis of the clinical findings and is classified as superficial (first degree), partial thickness (superficial second degree), or full thickness (deep second degree, third degree, and fourth degree). Initially, the percentage of body surface area (BSA) involved with partial- and full-thickness burns should be estimated using the “rule of nines” (Table 76-2). After the patient is stabilized, a
more detailed assessment of the extent of burns is made using a modified Lund and Browder chart.








TABLE 76-1 Classification of Burns

































Type of Burn


Affected Skin Layer


Appearance


First degree


Epidermis


Erythema, hypersensitivity


Second degree





Superficial


Upper (papillary) dermis


Erythema, blistering intact hairs, exquisite pain



Deep


Deep (reticular) dermis


Skin may be white or mottled and nonblanching, or blistered and moist; pain may or may not be present; hairs easily pulled


Third degree


Entire dermis


Dry, white, or charred skin; leathery appearance, painless, no hair


Fourth degree


Subcutaneous tissue


Same as third degree; may have exposed muscle and bone


The patient should be assessed for signs of inhalation injury (Table 76-3). Significant inhalation injury may exist in the absence of any surface burns; therefore, a high index of suspicion should be maintained in the face of a suggestive history (e.g., fire in a closed space).

Sep 14, 2016 | Posted by in PEDIATRICS | Comments Off on Thermal Injuries

Full access? Get Clinical Tree

Get Clinical Tree app for offline access