Australian Doctor 4th August 2023 AD 4th Aug Issue | Page 25

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at home in the family room at about 11.30am when he pulled a hot cup of black coffee , which his mother had just made , over himself . His mother heard him cry out and found Mohammed sitting on the lounge floor crying , with the cup and its contents on the floor . She quickly applied a cold tea towel to the lower face , neck and chest areas . After trying to soothe Mohammed , she removed his clothing and noted that the burnt areas were erythematous . When Mohammed ’ s father returned home , they applied egg white to the burnt skin . Mohammed was very unsettled that night , was not interested in feeding in the morning and appeared to be in pain , which did not settle with paracetamol . Mohammed is normally well but has not had his 12-month vaccinations .

On examination , Mohammed has a pulse rate of 132bpm and a temperature of 37.6 ° C . The GP estimates that he has an 11 % TBSA mixed-depth burn involving the chin , neck , right shoulder and chest . There is evidence of blistering in several areas , with a patch of decreased capillary refill approximately 4cm in diameter on the upper chest . There is no evidence of intraoral burns , and the remainder of his examination is unremarkable .

The GP diagnoses a mixed-depth burn that , considering the TBSA , warrants admission to a burns unit . Optimal burns first aid was not given at the time of injury , but as it is now more than three hours since the injury , this is unlikely to confer additional benefit .

The GP cleans the burn wounds with warm normal saline to remove

1 . Which THREE are the most common mechanisms for burn injuries in children ? a Scalds . b Contact burns . c Electrical burns . d Flame burns .

2 . Which TWO statements regarding burns are correct ? a Burns that do not heal within 14 days or that require grafting have an increased risk of hypertrophic scarring . b Any burn greater than 10 % of the TBSA is considered serious and requires admission to a burns unit . c Major burns may have longterm physical , social and mental health effects . d Minor burns never have important consequences .

3 . Which THREE statements regarding the aetiology of paediatric burns are correct ? a Flame burns are generally shallower . b Scalds are generally from hot water in the bathroom or kitchen or from knocking over a hot drink . c Scalds are typically mixed depth , with epidermal , superficial and deep dermal elements . the egg and applies a paraffin gauze dressing impregnated with chlorhexidine .

On admission to the burns unit , Mohammed has IV access established and is started on resuscitation fluids ( warm normal saline ) and maintenance fluids , including dextrose . A nasogastric tube is inserted and feeding started , as well as a urinary catheter to monitor urine output . Analgesia is supplied with IV morphine . The burn wounds are debrided under general anaesthesia that afternoon .

Laser doppler imaging suggests a deeper burn involving the upper chest that will likely require grafting . A nanocrystalline dressing is applied and the patient returned to the ward . The parents receive support from the

burns unit social worker , with temporary arrangements made to care for Mohammed ’ s four siblings .

The following day , Mohammed has maintained a good urine output but remains febrile at 37.9 ° C . He is now comfortable with paracetamol only and tolerating oral feeds . His resuscitation fluids are ceased . The fever settles over the next 24 hours , and arrangements are made for his burn to be reviewed in the burns unit on day five after his injury .

At that dressing change , Mohammed is found to have a deep burn involving the upper chest and lower

d Electrical burns in children are generally less serious than those seen in adults as domestic low-voltage injuries predominate .

4 . Which ONE is optimal BFAT ? a A damp cloth or towel on top of the clothing over the burn . b The application of cold running water to the burnt area for at least 20 minutes . c Ice , preferably wrapped in a towel , applied to the burn . d Apply a product that contains fat , such as butter or oil .

5 . Which TWO are crucial in determining the appropriate treatment in a paediatric burn ? a How long ago the burn occurred . b The depth of the burn . c How much of the patient has been burnt ( percentage TBSA ). d What first aid was administered . neck , with approximately 6 % TBSA , requiring grafting . Following detailed explanation of the need for surgery and postoperative care , the deeper burns are debrided and grafted the next day , with the right buttock as the donor site . The grafts take , but Mohammed requires a pressure garment and neck splint for the next 18 months to ameliorate hypertrophic scarring and neck contractures .

Case study two

Jasmine , a 14-year-old girl , presents to her GP with a burn on the medial aspect of her right ankle that was sustained five days earlier . She was riding pillion while her 16-year-old brother was driving his 125cc dirt bike on the family farm . Her brother

Burns often require collaborative care with a burns unit to enable an optimal long-term outcome . lost control , and the bike rolled over , trapping Jasmine ’ s foot against the exhaust for several minutes . Her brother poured water from a drink bottle onto the burn , but they did not reach the homestead until two hours had passed . Her mother applied butter and then a gauze bandage secured with crepe . Jasmine is otherwise well and fully vaccinated . She did experience asthma when she was younger but has not required any treatment for several years .

On examination , she has a fever of 37.9 ° C and a pulse rate of 105bpm . There is a full-thickness

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6 . Which THREE are part of the initial medical treatment of burns ? a Keep the patient as cold as possible to prevent the burn progression . b Administer resuscitation fluids in all children with a burn greater than 10 % TBSA . c Remove burnt or wet clothing and jewellery . d Examine the eyes , ears and mouth to exclude any unexpected thermal injury .

7 . Which TWO statements regarding burn dressings are correct ? a There are limited objective data to clearly demonstrate the superior efficacy of one contemporary dressing type over another . b One dressing will generally suit all burn wounds . c Antimicrobial nanocrystalline silver-containing dressings can be applied and left for up to seven days . d Wrap burns in plastic wrap if transfer time to ED is more than four hours .

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PAEDIATRIC BURNS

burn that is 4cm in diameter involving the medial aspect of the ankle ( see figure 9 ). There is marked surrounding erythema and a purulent exudate with mild inguinal lymphadenopathy .

8 . Which ONE is not a feature of the ideal burn dressing ? a Antimicrobial . b Tightly adherent to the wound even if removal causes minor pain . c Contours easily and retains contact with wound . d Maximises healing potential of burn wound .

9 . Which THREE presentations may flag non-accidental injury ? a Burns that present late . b Those with an unusual history . c Burns not consistent with the reported mechanism . d Burns where unusual dressings have been applied , such as toothpaste or butter .

10 . Which THREE statements regarding follow-up and scar management are correct ? a Burns that heal within 1-2 weeks are much less likely to scar . b Exposing a healed burn to sunlight early aids in restoring normal pigmentation . c Those who develop hypertrophic scars require an extended period of scar management . d Contractures may occur much later in patients with growth spurts , such as during puberty .

Figure 9 . A motorbike exhaust contact burn , day five post-injury . Pallor indicates a deep full-thickness burn that will require grafting . The absence of pain initially , because of destruction of nerve endings , may cause the patient to present late .

The GP takes a wound swab , irrigates the wound and applies a sterile nanocrystalline silver dressing . Jasmine is seen in ED , where IV access is obtained and antibiotics started . She is transferred to the state burns unit , where the burn is debrided under a general anaesthetic and a negative-pressure dressing applied . The swab reveals a heavy growth of Staphylococcus aureus .

Three days later , the wound bed appears clean and is grafted , with the donor site the right inner thigh . The graft takes , but because of its location , Jasmine requires several months of splinting and 12 months of treatment with a pressure garment sock to reduce scarring .

CONCLUSION

BURNS in children remain very common , with scald and contact burns causing more than 85 % of all burn injuries . The most important initial treatment remains prompt and effective first aid with cold running water for at least 20 minutes within the first three hours of the injury .

Many burns will be minor , involving less than 5 % TBSA and likely to heal within 10-14 days , providing infection can be prevented . Burns that do not heal within 14 days or those that require surgical closure will have a much greater risk of hypertrophic scarring .

Burns are painful and will often require collaborative care with a burns unit to enable an optimal longterm outcome .

RESOURCES

• Australian and New Zealand Burn Association bit . ly / 3nOi7hm

• Australian and New Zealand Burn Association : burns units bit . ly / 3HVcftm

References Available on request from howtotreat @ adg . com . au