burn injuries
DESCRIPTION
Burn Injuries. Chantel R. Grubbs Robert Smith Latrice Wilson Gabrielle Paul . Case Presentation PHA 5601 Pediatrics Ambulatory Care Dr. Angela Thornton, PharmD March 21 st , 2013. Objectives. Classify the types of burns, along with defining the prevalence, causes, and pathophysiology. - PowerPoint PPT PresentationTRANSCRIPT
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CHANTEL R . GRUBBSROBERT SMITH
LATRICE WILSONGABRIELLE PAUL
Burn Injuries1
Case PresentationPHA 5601 Pediatrics Ambulatory
CareDr. Angela Thornton, PharmD
March 21st, 2013
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Objectives
Classify the types of burns, along with defining the prevalence, causes, and pathophysiology.
Explain various preventative measures, and different disabilities that may arise as a result of burn.
Outline the approach to management and treatment options.
Discuss and compare related clinical trials on various medication used to treat pediatric burns.
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Definition
A burn is an injury caused by fire, heat, radiation, electricity, or flammable agent.
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Epidemiology 4
It is estimated that 1.2 million people in the United States require medical care for burn injuries each year, with 51,000 requiring hospitalization.
About 30-40% of those patients are less than 15 years old. With the average age of the patient being only 2.5 years of age.
The most common burn injuries result from exposure to heat and chemicals.
It is the second leading cause of death for children under the age of 12.
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Risk Factors5
Child negligenceChild abuseImproper Adult supervisionCognitive ImpairmentPsychiatric illness
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Pathophysiology of Thermal Burns6
Thermal Burn Injury Pathophysiology is based off of Jackson’s Thermal Wound Theory.
The zone of coagulation is the area near the burn cell membranes rupture, clotted blood and thrombosed vessels.
Zone of Stasis area surrounds the zone of coagulation inflammation, and is characterized by decreased blood flow.
Zone of Hyperemia is the peripheral area of burn characterized by increased blood flow.
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Pathophysiology of Thermal Burns
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Pathophysiology of Electrical Burns8
There are 3 proposed mechanisms of electrical burns: Electrical energy causing direct tissue damage,
altering cell membrane resting potential. Conversion of electrical energy into thermal
energy, causing massive tissue destruction and coagulation necrosis.
Mechanical injury with direct trauma resulting from falls or violent muscle contraction.
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Pathophysiology of Chemical Burns9
There are 6 proposed mechanisms by which chemicals cause burn-like injuries: Oxidation: The protein denaturation is caused by
inserting an oxygen, sulphur, or halogen atom to viable body proteins.
Reduction: Reducing agents act by binding free electrons in tissue proteins. Heat may also be a product of a chemical reaction, thereby causing a mixed picture
Corrosion: It causes protein denaturation on contact. They tend to produce a soft, which may progress to shallow ulceration
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Pathophysiology of Chemical Burns
Mechanisms Continued: Protoplasmic poisons: They produce their effects by
causing the formation of esters with proteins or by binding or inhibiting calcium or other organic ions necessary for tissue viability and function.
Vesicants: They produce ischemia with anoxic necrosis at the site of contact. These agents are characterized to produce cutaneous blisters.
Desiccants: These substances cause damage by dehydration of tissues. The damage is often exacerbated by heat production, as these reactions are usually exothermic.
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Etiology11
Chemical Burns
Radiation Burns
Electrical Burns
Thermal Burns
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Skin Layer Overview
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Types of Burns
First-degree (superficial burn)burns affect only the outer layer, also known as the epidermis.
Second-degree (partial thickness) burns affect both the epidermis and a variable portion of the dermal layer. Superficial partial Mid partial
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Types of Burns
Third-degree (full thickness) burns affect the entire epidermis, dermis and subcutaneous layers. Deep partial Full thickness
Fourth-degree (full thickness) burns affect the epidermis, dermis, muscle, tendon, and bone.
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15Types of Burns
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Clinical Manifestations16
First Degree Dry No blisters Edema Erythema
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Clinical Manifestations
Second Degree Moist Blisters Underlying tissue is marked with pink and
white spots Fair capillary refill Bleeds
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Clinical Manifestations18
Superficial Partial Mid Partial
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Clinical Manifestations
Third Degree No bleeding Dry Presents with white, brown and black markings Waxy
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Clinical Manifestations20
Deep Partial Thickness
Full Thickness
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Clinical Manifestations
Fourth Degree Muscles and bone is visible Blackened and charred appearance
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Clinical Manifestations22
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Differential Diagnosis
Steven’s Johnson’s Syndrome Anticonvulsants
Carbemazepine (Tegretol®) Valproate (Depakote®) Zonisamide (Zonegran®)
Sulfonamides Bactrim®
Antibiotics Penicillins
Toxic Epidermal Necrolysis
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Burn severity is dictated by Percent total body surface area (TBSA) involvement Rule of Nines
Rule of Palm
Diagnosis
Rule of NinesAnatomic Surface % of total body surface
Head and neck 9%Anterior trunk 18%Posterior trunk 18%
Arms, including hands 9% eachLegs, including feet 18% each
Genitalia 1%
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Rule of Nines25
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26Lund-Browder Diagrams
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Treatment
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Dispelling Myths About Burn Treatment
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ToothpasteIceButterEgg WhitesBursting Blisters
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Goals of Therapy29
Prevention of infection Acute care and resuscitation Wound management Pain reliefReconstructionRehabilitation and Psychosocial adjustment
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First Aid Treatment30
Extinguish the FireBring child to more ventilated areaCarefully remove smoldering clothing and jewelry
Thoroughly irrigate area with cool water to remove an access particles or debris
Cover area with a clean dry sheeting and apply cold wet compress to small injuries
Administer OTC analgesic Acetaminophen (Tylenol®)
10-15 mg/kg every 4-6 hours Ibuprofen (Advil®)
5-10 mg/kg every 6-8 hours
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Nonpharmacological
Aloe Vera
Cool compresses
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Aspects of Treatment32
Topical AgentsPain ManagementAntihistaminesFluid Resuscitation Nutritional SupportWound ClosuresRespiratory Therapy
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Treatment of
Superficial 1st Degree & Superficial Dermal 2nd Degree Burns
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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns
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First and second degree burns on <10% of the body may be treated with outpatient therapy
There is an increase risk of tetanus following a burn injury Be sure to administer vaccine if patient has not been
already vaccinated.
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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns
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Blisters should be left in tact and not be popped and treated with topical agents Bacitracin (AK-Tracin®) ($8.00) -Prescription Silver Sulfadiazine Cream (Silvadene®) ($20.00)-
PrescriptionDressings should be changed daily
Wound should we washed with lukewarm water.Small 1st degree and mild 2nd degree burn on
face can be treated with Bacitracin and left open Vaseline($4.00)- OTC
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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns
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Silver Sulfadiazine
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Proper Dressing Application37
Wash handsCarefully remove old dressing and throw
awayClean burn area mild soap (ie. Hibiclens) and
lukewarm or cool waterRinse area thoroughly Pat dry with clean towel or gauzeCheck for healing Apply prescribed ointment or fresh dressingWrap sterile gauze over dressing to secure
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Dressings for Ruptured Blisters38
Ruptured blisters are treated with wound dressing/wound membrane AQUACEL- Ag Biobrane Mepilex Ag Acticoat Hydrocolloid dressings Impregnated gauze
Dressing are kept on for 7-10 days and check periodically through the week
All dressings that are on the formulary are found in the burn unit supply closet.
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Dressings 39
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Dressings 40
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Dressings 41
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Dressings 42
Hydrocolloid Dressing DuoDERM Tegaderm Comfeel Nu-Derm
Impregnated Gauze Xeroform impregnated gauze Chlorhexidine impregnated gauze (Bactigras) Petrolatem/Vaseline impregnated gauze
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Dressings 43
Hydrocolloid Dressings
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Dressings 44
Impregnated gauze
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Topical Agents 45
Topical agents for more severe burns AQUACEL Ag Available by Prescription
Sulfacetamide Acetate* Silver Sulfadiazine Mafenide Acetate - 0.5% Silver Nitrate Solution Accuzyme Ointment *
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Treatment of Deep Thermal 2nd Degree Burns
&3rd Degree Burns
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Criteria for Hospital Admission47
Burns affecting >15% of body surface areaElectrical burns caused by high-tension wires
Inhalation injury, regardless of the amount of body surface area burned
Inadequate home situationSuspected child abuse or neglectBurns to the hands, feet, or genitals
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Fluid Resuscitation48
Lactated Ringer Solution Dose
Parkerland Formula: 4 mL lactated Ringer/kg/% BSA burned Half of fluid given 1st 8hrs; Next half administered over
16hrs IV Infusion Rate Varies
Monitoring Parameters Urine Output Glucose
Clinical Pearls Initial fluid should be warmed Infants are at risk for hypoglycemia
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Fluid Resuscitation
Albumin (Albuked 25 ®, Flexbumin 25%®, Human Albumin Grifols 25%®, Kedbumin®, Plasbumin2-25®, Plasbumin-5®) Use 5% albumin solution
30–50% of total BSA, 0.3 mL /kg/% BSA 50–70% of total BSA, 0.4 mL/kg/% BSA 70–100% of total BSA, 0.5 mL/kg/% BSA burn
Monitoring Parameter: Albumin≥2g/dl Clinical Pearls
Concurrent use for burn >85% of BSA Administered 8-24hr after injury
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Qualifications for Albumin Treatment
It is not usually screened for infections. Albumin is synthesized exclusively in the liver. The normal rate of albumin synthesis is 0.2g/kg body weight per day.
Controversy exists as to whether colloid should be provided in the early period of burn resuscitation. One preference is to use colloid replacement concurrently if the burn is >85% of total BSA. Colloid treatment is usually instituted 8–24 hr after the burn injury.
For burns of 30–50% of total BSA, 0.3 mL of 5% albumin/kg/% BSA burn is infused over a 24-hr period
For burns of 50–70% of total BSA, 0.4 mL/kg/% BSA burn is infused over 24 hr
For burns of 70–100% of total BSA, 0.5 mL/kg/% BSA burn is infused over 24 hr
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Fluid Resuscitation51
Packed Red Blood Cells Hematocrit falls to <24%
(hemoglobin = 8 g/dL) Fresh frozen plasma:
Prothrombin level of >1.5 times control
Monitoring Parameters: Hematocrit & PT
Clinical Pearls Use in patients with
repeated excision and grafting w/<30% hemoglobin
Prescription
NaCL Burns >20% of BSA Dosed:4 g/m2 burn area/24
hr divided into 4–6 equal doses
Monitoring Parameters: Serum [Na+] >130
mEq/L Urinary [Na+] >30 mEq/L Serum [K+] >3 mEq/dL
Clinical Pearls Silver nitrate increases
Na+ and K+ loss Prescription
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Nutritional Support52
Calories are provided at approximately 1½ times the basal metabolic rate
Macronutrients Protein: 3–4 g/kg of
protein/day Carbohydyrates:
5-7mg/kg/hr Fats: 1-1.5g/kg/day
Micronutrients Copper: 2.5mg/day Vitamin C: 200mg/day Vitamin A:10,000IU /day Zinc Sulfate: 25mg/day Selenium:50-70mg/day
Anabolic Agents Growth hormone Oxandrolone Low-dose insulin
Catabolic Agents Propanolol
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Respiratory Therapy53
Beta Agonist Aerosols Albuterol Nebulizer (AccuNeb®)-
Patients >2 years of age 1.25mg or 0.63mg by inhalation over 5-15 minutes 3-4 times daily times a day
PrescriptionInhaled Corticosteroids
Fluticasone (Flovent®) Patients 4-11 years of age 88mcg Prescription only
Administer 100% Oxygen
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Fluid Maintenance & Infection Prevention
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Diuretic Furosemide (Lasix®)
Dosed: 0.5-2mg/kg/IM/IV q8-24h Max 6mg/kg/dose
Antibiotic Empiric Treatment
Sulfamethoxazole/Trimethoprim (Bactrim DS®): 10-12mg/kg/day PO or IV q12h + Rifampin (Rifadin®): 20mg/kg PO or IV q24h for 4 days
Vancomycin (Vancoled®) : 40–60 mg/kg/day q6–8h for 7-10 days
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Common Organisms in Burn Patients
Gram positive Staphylococcus aureus = Penicillin G, Erythromicin, Azithromycin Methicillin resistant S. aureus = Bactrim, Erythromycin Enterococcus spp. = Augmentin, clindamycin+ciprofloxacin
Gram Negative Pseudomonas aeruginosa = gentamicin, ciprofloxacin, cefepime Escherichia coli = Gentamicin, ciprofloxacin Klebsiella pneumonia = Parental cefepime, ciprofloxacin Serratia marcescens = Parental cefepime, aztreonam, gentamicin
Fungi Candida spp. = Amphotericin B, Fluconazole Aspergillus spp. = Amphotericin B, Intraconazole
VirusesHerpes simplex virus = Acyclovir, Famciclovir,
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Treatment of Infections
Methicillin Resistant S. Aureus Sulfamethoxazole/Trimethoprim (Bactrim®)
8mg/kg/day (for children older than 2 months) Prescription
Doxycycline (Doryx®) 4mg/kg/day (for children older than 8 years) Prescription
Vancomycin (Vancocin®) 10-15mg/kg every 6 hours Prescription
Linezolid (Zyvox®) 10mg/kg every 8-12 hours Prescripton
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Pain & Anxiety Management57
Morphine Sulfate (NSIR®, MSContin®) Dosed 0.3–0.6 mg/kg every 4–6 hr PO initially and until wound
cover is accomplished Dosed 0.3–0.6 mg/kg is given 1–2 hr before the procedure +
IV bolus 0.05–0.1 mg/kg given immediately before the procedure Prescription
Lorazepam (Ativan®) Dosed of 0.04 mg/kg PO or IV for before the procedure Prescription
Midazolam (Versed®) Dosed 0.05–0.1 mg/kg/hr IV infusion or IV bolus;
May be repeated in 10 min, Max dose of 0.2 mg/kg Prescription
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Potential Drug Interactions with Treatment
Beta Agonists In combination with Beta Blockers may lead to a
decreased efficacy of either drugs due to antagonismCorticosteroids
In combination with Azole Antifungals may increase corticosteroid plasma concentrations
Furosemide In combination with Aminoglycosides may increase
aminoglycoside concentration resulting in an increased risk of ototoxicity and nephrotoxicity
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Potential Drug Interactions with Treatment
Bactrim In combination with Warfarin, there is an increased the risk of
bleeding and bruising In combination with Antipsychotics or Tricyclic Antidepressant,
Bactrim increases the risk of QT prolongation and torsade de pointesRifampin
In combination with Birth control pills, there is an decreased efficacy of birth control pills
In combination with Morphine, there is a decreased efficacy of morphine
In combination with corticosteroids, there is a decreased efficacy of corticosteroids
Vancomycin In combination with Aminoglycosides, there is an increased additive
risk of ototoxicity and nephrotoxicity.
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Wound Closures60
GraftsSkin grafts:
Pinch: Quarter inch pieces of skin Split-thickness: Superficial and some deep
layers of skin Full-thickness: For weight-bearing portions of
the body and friction prone areas such as, feet and joints
Pedicle grafts: Skin used from the donor site will remain attached to the donor area and the remainder is attached to the recipient site
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Wound Closures
GraftsExcisions
TagenitalPros: Improved function and cosmetic outcomeCons: Increased bleeding, takes longer, more
skin Fascial
Pros:Rapid, Use with skin subsitutesCons: Risk of nerve injury and joint exposure,
decreased cosmetic outcome
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TANGENTIAL EXCISON62
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FASCIAL EXCISION63
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Skin Graft Video64
http://www.youtube.com/watch?v=bn9uMVxk8wI
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Clinical Trials
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Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients
Objective To study the efficacy of growth hormone given to
severely burned children from discharge to 12 months after burn and for 12 months after the drug was discontinued.
Design Single-site, double-blinded, randomized, placebo
controlled studyMethods
Forty-four pediatric patients with over 40% total body surface area burns were studied for 24 months after burn. Patients were randomized to receive either rhGH (0.05 mg/kg body weight) or placebo.
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Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802
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Results Recombinant human growth hormone
administration increased serum GH and decreased cortisol concentrations when compared with placebo (P < 0.05).
Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients
67
Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802
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Intensive Insulin Therapy in Severely Burned Pediatric Patients
Objective To determine whether intensive insulin therapy is
associated with improved post-burn morbidityDesign
Single-site, prospective randomized trialMethods
A total of 239 severely burned pediatric patients with burns over greater than 30% of their total body surface area were randomized to intensive insulin treatment (n = 60) or control (n = 179)
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Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359
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Intensive Insulin Therapy in Severely Burned Pediatric Patients
Results Intensive insulin treatment had a significant
improvement in bone mineral density, body fat, lean body mass, and body mass (P < 0.05)
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Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359
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Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children
70
Objective To determine the long term effects of Oxandrolone in pediatric
burned patients
Study Design Single-center, prospective, randomized, controlled trial
Methods Patients 0 to 18 years old with burns covering >30% of the total
body surface area were randomized to receive placebo or oxandrolone (0.1 mg/kg PO twice daily for 12 months)
At hospital discharge, patients were randomized to a 12-week exercise program or to standard of care
Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502
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Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children
71
Results Increased protein synthesis, bone density mass,
decreased resting energy expenditure, and improved height (p < 0.001).
Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502
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Prevention Strategies72
Improve awareness among parents/caregivers
Develop and enforce effective policy for dealing with burns
Be informed about the burden that comes along with caring for a child with a burn
Participate in burn prevention programsInstall home smoke detectors and sprinkler
systems.Take bath water temperature before bathDon’t leave candles and potential meals
unattended.
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73
Role of the Pharmacist
Identify the severity of a burnRecommend appropriate therapyRecognizing when to refer the patient to the
physicianEducate patients on proper applications of
creams and dressingsMonitor for signs of infection
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References74
1. American Burn Association. Burn Center Referral Criteria. Availableat:www.ameriburn.org/BurnCenterReferralCriteria.pdf?PHPSESSID=09036810feb72a69a1acdee9209e235b. Accessed on March 10, 2013
2. A.D.A.M. Medical Encyclopedia. Burns. Available at:www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001097/. Accessed on March 10, 2013
3. University of Maryland Medical Center. Burns- Overview. Available at:www.umm.edu/ency/article/000030.htm. Accessed on March 10, 2013
4. Sheridan R., Schnitzer J., Management of the High-Risk Pediatric Burn Patient. Journal of Pediatric Surgery. August 2001 ;vol 36(8):1308-1312
5. Jorge A., Buck M., Hubbard A., et al. Pediatric Nutrition Support Handbook. University of Virginia Children's Hospital. 2012: 1-103
6. Connolly S. , Clinical Practice Guidelines: Burn Patient Management . NSW Agency for Clinical Innovation. August 2011; Version 1.5:1-45
7. Women’s and Children’s Hospital. Guidelines for the Management of Pediatric Burns . May 2010; 1-438. Sheridan, RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005: S112-S1199. Gandhi M., Thomson C., Lord D. , et al. Management of Pain in Children with Burns. International Journal of Pediatrics . 2010;
vol(2010):1-910. Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of
Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-35911. Borrillo C. Nelson Textbook of Pediatrics. 18thed. Philadelphia: Saunders Elsevier; c 2007. Chapter 74 Burn Injuries12. Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children:
Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-50213. Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in
Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-80214. Igneri P., Gratton J. FAHC Burn Care Manual. Fletcher Allen Health Care: The University of Vermont College of Medicine. 2008;
1-6915. Mock C, Peck M, Peden M, Krug E, eds. A WHO plan for burn prevention and care. Geneva, World Health Organization, 2008.16. Boldt,J. British Journal of Anaesthesia.Use of albumin: an update (2010) 104 (3): 276-284.