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Case # 2 CC: Burn HPI: 8 year old female presents with a skin burn from an accident with hot liquid. The patient was reaching in the microwave for Ramen noodle soup and accidentally spilled it on the upper chest and few fingers. This occurred 40 minutes ago. Patient had pain and 2 large blisters that formed on the chest and smaller blisters are seen on few fingers. One of the blisters on the chest ruptured. Associated symptoms are pain. PMH: no chronic illness PSHX:none Social HX: lives with mother. parent`s are divorced. Accident happened at father`s house. Father`s friend was present. Allergies: NKDA Medications: none VS: 117/84, 120, 98.7 Physical exam: General: no distress HEENT: NC/AT, PERLA, EOMI, no neck mass cardiac : RRR, s1 s2, no murmur Respiratory: CTA Abdomen: + BS, non-tender Integumentary: 2 % BSA second degree superficial partial thickness burn. 5 % first degree burn on anterior chest. One intact blister and one ruptured blister on the anterior chest, Mild tenderness to palpation. No necrotic tissue visualized. Few small blisters on the 2nd and 3rd digit on the right hand have small blisters and erythema. Tender to palpation. Intact capillary refill. On exam: Treatment: clean with soap and water Bacitracin ointment apply BID cover with sterile dressing and wrapped in elastic gauze Motrin for pain p.r.n f/u with PCP in 24-48 hrs Burn wounds covered with gauze dressing Burns Burns by BSA Classification of burns: Superficial burn: 1st degree .Erythema without blisters. Epidermis damaged. Superficial partial thickness: 2nd degree. Erythema with blisters. Epidermis and papillary dermis damaged Deep partial thickness: 2nd degree, white appearance of skin , blisters. Absent capillary refill. Epidermis, reticular dermis, sweat glands, hair follicles, nerve fibers damaged. Full thickness: 3rd degree, pale , charred, leathery, painless. No blisters. Absent capillary refill. Epidermis, entire dermis and may extend to subcutaneous tissue. First degree burn Second degree burns: Third degree burns: Burns seen in child abuse: Seen in 10 % of child abuse cases Make up to 10 % of burns admitted to Burn Center Most common in children < 2 years old , can be up to 10 years old. Very common are from contact with hot water Types: Scalding burns (most common) immersion burns burns from contact with hot objects (often leave patterns) Common locations: chest, buttocks, perineum, genitalia, hands, feet Patterns of burns seen in abuse cases: Lack of splash marks “mirror image” of burn on both feet or hands (stocking, glove pattern) Sharp line of demarcation between burned and unburned areas Sparing of flexion creases Immersion burn “doughnut” pattern burn child abuse burns: Obtain a good history: Look for contradictory stories or variation in story Is the parent angry or resentful towards child Look for other injuries (bruises,fractures) Presence of other multiple simultaneous burns that may have healed Evidence of sexual abuse Delay in seeking care Developmental status of child Other medical conditions that child has Minor burns that can be treated as outpatient: Partial thickness < 5% BSA ,in age less than 10 yo or over 50 yo Partial thickness < 10 % BSA, in age 10-50 yo Full thickness < 2 % BSA , any age -not on face , hands, feet, perineum -not involving joints -not circumferential -no inhalation injury -not an electric burn Minor burns that can be treated as outpatient: Partial thickness < 5% BSA ,in age less than 10 yo or over 50 yo Partial thickness < 10 % BSA, in age 10-50 yo Full thickness < 2 % BSA , any age -not on face , hands, feet, perineum -not involving joints -not circumferential -no inhalation injury -not an electric burn Treatment of burns: Remove clothing Use cool tap water or saline soaked gauze Do not apply ice directly on the burn, this causes more damage Clean with soap and water. Do not use (providone iodine) or other skin disinfectants Debride necrotic tissue, ruptured blisters Do not rupture blisters , or aspirate blisters NSAIDS, opioids for pain Topical antibiotic to prevent infection for non-superficial burns (burns with damaged epidermis) -Silver sulfadiazine or Bacitracin -Silver sulfadiazine believed to slow wound healing -Aloe vera , honey -Tetanus immunization for burns that are more than superficial -Dressing : nonadherent gauze (Adaptic) placed over the burn, then a dry gauze placed on top and an outer layer of elastic gauze (Kerlix). Superficial burns do not need dressing. Partial and full thickness do Dressing to be changed 1-2 times per day. Change when dressing soaked with exudate, fluid. No clear established guidelines. -Follow up with PCP in 24-48 hrs and then weekly intervals till epithelialization -Refer to surgeon specializing in burn care if : If > 2 % full thickness wound infection Epithelialization of wound does not occur within 2 weeks necrotic tissue hypertrophic scar -Most wounds should heal completely in 7-10 days Healing of Burns Day 1 day 6 day 16 American Burn Association recommends inpatient admitting for observation, IV fluids, pain management for the following pediatric cases: 5-10 % BSA burn for age < 10 yo 10-20 % BSA burn for age >10 yo 2-5 % Full thickness (3rd degree) burn Circumferential burn Infection Comorbid illness that may cause complications American Burn Association recommends the patient should be referred to a Burn Center for the following conditions: Third degree burn Significant burn on face, hand, feet, perineum, over joints Second degree > 10 % BSA burns Circumferential burns Lightning or electrical burn Chemical burn Inhalational injury Burn associated with trauma Non accidental burns Poor social support Patient with preexisting illness that may cause complications Thank You