Download Case # 2

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