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Management of Acute Phase of Thermal Burns in Children
MANAGEMENT OF
A~UTE
PHASE OF THERMAL
BURNS IN
~HILDREN
ROBERT H. ALWAY, M.D.
Burns contribute a high percentage of the accident death toll in childhood. The mortality rate, however, inadequately depicts the physical, emotional and financial stress to a child and his family produced by a severe burn. Better application of the knowledge gained regarding fluid, electrolyte and colloid shifts and losses should permit the greatest number of seriously burned children to survive. Although successful management of the immediate postburn period is no guarantee of eventual recovery, attention to other than antishock measures should increase the number of seriously burned children in optimal condition for early skin grafting. ESTIMATION OF SEVERITY
A severe burn is one which is sufficient to produce shock or may later require grafting. The child under the age of six years with as little as 8 per cent partial thickness burn may require parenteral therapy. More than 15 per cent involvement may be equally serious in the child aged six to twelve years. These are in contrast to greater than 20 per cent area of equal seriousness in the adult. The depth of involvement is important in that a considerably smaller area of full thickness (third degree) burn may be equally serious. Flame burns are more apt to produce deep involvement than are hot liquid scalds. More anemia, both early and late, seems to follow third degree burns of any extent. Correct estimation of the extent and depth of burn injury is difficult when the patient is first seen. Usually the area is exaggerated and the depth underestimated. The extent of the burn, so far as this affects therapy, may be calculated satisfactorily from a modification of Berkow'sl and Wallace's6 suggestions. 901
902
MANAGEMENT OF ACUTE PHASE OF THERMAL BURNS IN CHILDREN
Head ................................. 9% Neck ................................. 1% Arms, each. . . . . . . . . . . . . . . . . . . . . . . . . . .. 9 % Trunk, front .......................... 18% back ........................... 18% Genitalia. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1 % Legs, each (including buttocks) .......... 18%
Allow relatively more for the head (almost two times) and less for the legs (about one half) in children under two years. Finally, in estimating severity the time elapsed from burn insult is important. NATURAL HISTORY OF SEVERE BURNS
The natural history of burns may be divided roughly into three periods: Phase
I: the first forty-eight to seventy-two hours following the burn; marked by shock and edema Phase II: third through the tenth day approximately; may be marked by water intoxication, hyponatremia Phase III: after the tenth day with slough, sepsis and starvation
Phase I
In the twenty-four to forty-eight hours after a burn there is a relentless expansion of the extracellular fluid space, in the burned area as well as the rest of the body. Without replacement measures adequate in rate, volume and composition, not only may shock develop, but also the patient's later course may be prejudiced. This "loss" into an abnormal third space (burn edema) may equal a 50 per cent increase in ex· tracellular fluid volume within a few hours. The associated decrease in effective circulating volume may be exaggerated by loss from the burn surface and further complicated by a variable degree of decreased red blood cell circulating volume. This loss is greatest in full thickness burns. This occurs early from hemolysis and stasis and later from decreased regeneration and surface loss from granulation tissue. This dislocation of extracellular fluid being most rapid in the first eight to twelve hours, early rapid replacement or maintenance of an adequate circulating volume is essential. Renal function may be altered as a result of several factors. With delayed or inadequate replacement therapy effective renal plasma flow may decrease to one tenth or less of normal within minutes to a few hours after a burn. The usual response to severe stress results in sodium and water retention and failure to conserve potassium. Finally, mor· phine or barbiturate therapy may lead to an increase in antidiuretic hormones, an inability to excrete excess water and signs and symptoms of water intoxica.tion.
ROBERT H. ALWAY
903
Phase II
The "toxic" picture frequently presented by the severely burned subject between the fourth and tenth days is poorly understood, and accordingly there has been an unsatisfactory lowering of the mortality in this phase. "Adrenal exhaustion" does not adequately explain the picture, nor has adrenal cortical replacement therapy satisfactorily handled it. Hyponatremia may be noted. Water intoxication may be suggested by salivation, vomiting, twitching and convulsions. The older child may complain of headache or blurred vision. Phase III
The third phase in the course of severe burns is marked by separation of eschars. This may be complicated by infection. Liedberg and co-workers 4 recently restressed the relative importance of group A beta-hemolytic streptococcal infections in the failure of skin grafting. In their experience staphylococci, pseudomonas, proteus and the coli-aerogenes group are not apparently of like significance. Infection may not only delay satisfactory closure of the burn wound, but may also interfere with adequate correction of hypoproteinemia and anemia. TREATMENT
A formula for therapy connotes a degree of precision which, however, is not real. A rule-of-thumb approach is as apt to mislead. Despite the diverse opinions and multiple therapeutic regimens espoused, it should be possible to proceed on some general principles concerning three major obstacles to the recovery of the severely burned patient. These obstacles are shock, sepsis, starvation. Measures taken in the first fortyeight hours are not merely to restore or maintain an adequate circulation, but equally should be designed to carry the patient into the second and third phases in optimal condition. This is to facilitate early closure of the burn wound. Electrolytes, particularly sodium, water and colloids, including whole blood, all may be essential. Emphasis on one, relatively minimizing others, may permit survival through the first postburn phase, but with an unnecessary handicap. The treatment of severely burned children based on surface area involved has not been satisfactory in our hands. We have used a modification of Cope's2 suggestions in which the upper limit of deficit therapy is based on anticipated expansion of the extracellular fluid space and modified by the hourly urine output. Fluid Therapy in Phase I
The amount of fluids required in the first forty-eight hours after a burn may be estimated as follows:
904
MANAGEMENT OF ACUTE PHASE OF THERMAL BURNS IN CHILDREN
A. To cover expanding extracellular fluid space-volume in milliliters equivalent to not over 10 per cent of the patient's admission weight in kilograms; B. To provide for surface loss from the burn-about 50 ml. per 1 per cent of burn area; C. To cover the normal daily requirements for insensible loss and urine volume-200 ml. of water per kilogram per forty-eight hours and 10 to 15 gm. of glucose solution per kilogram for the same period. This amount may be divided in four equal volumes given in each twelve hour period intravenously. The sum of quantities A and B, divided equally between colloid and electrolyte solutions, may be given intravenously, one half in the first eight hours after the burn, one fourth in the second and third eight hours, and one fourth in the second twenty-four hours. :This volume of fluid may be too much or too little. More should be given only if the hourly urine volume decreases below 10 to 20 ml. or with other manifestations of inadequate treatment: rising pulse, hematocrit over 60 per cent, hypotension, and so on. Colloid may be given as plasma, Dextran or blood. The last may be given in amounts equivalent to 2 to 4 per cent of the patient's body weight in the first twenty-four hours. Blood should be used with a known or presumed full thickness burn, as in extensive fire burns. Electrolytes should be given as balanced salt solution: two parts of 5 per cent glucose in normal saline solution to one part sixth-normal sodium lactate solution rather than "unphysiologic" saline solution containing a relative excess of chloride. As soon as the child is out of shock and not vomiting, oral intake may be encouraged. Salt solution may be tolerated if offered repeatedly in small amounts. A palatable solution may be made by adding 3 gm. (1 teaspoonful) of sodium chloride and 1.5 gm. (two-thirds teaspoonful) of sodium bicarbonate to one quart of iced water. Parenteral therapy should be curtailed proportionally to the retained oral intake. Tap water should not be offered in the first forty-eight hours unless dry oral mucosa, severe thirst or a serum sodium over 138 mEq. per liter is noted. Hourly Urine Volume
The urine output is a reasonably satisfactory measure of the adequacy of fluid therapy in the acute postburn period. An indwelling catheter will facilitate accurate urine collection. An output of 30 to 50 ml. per hour is within safe limits. Continued hourly volumes over 80 ml. imply too much fluids, while volumes under 10 to 20 ml. should be investigated. A low hourly output usually means inadequate fluids to keep up with the expanding extracellular fluid space and consequently a decreased circulating volume. It may, though, result from renal damage. The
ROBERT H. ALWAY
905
problem may be resolved by water loading. Give 25 ml. per kilogram of 5 per cent glucose in water intravenously in forty-five to sixty minutes. If no change in urine flow follows, renal tubular damage may be present. Continued increased fluid intake might then be disastrous. An increased flow subsequent to the water load is an indication for more vigorous treatment. Local Therapy
Strict aseptic technique should be maintained at all times by all personnel until the burn wound is healed. Cover the patient with a clean sheet until general supportive measures h.ave been started. After obvious dirt has been removed with a liquid detergent and the burned area flushed with warm saline solution, the less done the better. No local medication is probably the best general rule. Burned extremities should be elevated and immobilized with joints in a position of function. Open or closed handling of the burn wound will depend on the extent and location of the burn and the facilities available. Additional Orders for Acute Phase Treatment
The following should be restressed or done in addition to those points already discussed: Maintain strict isolation and aseptic technique. Type and cross match blood on admission. Record the hourly urine volume. Administer tetanus antitoxin, 1500 units, and procaine penicillin, 300,000 units daily intramuscularly, or its equivalent. Oral feeding is ill tolerated in the acute phase. Children, however, usually will accept hard candy and sweetened carbonated drinks quite early. This should be encouraged. SUMMARY
In children shock may follow considerably less extensive burns than in adults. Because of the rapidity of the development of shock, therapy should be started immediately in a child under six years of age with over 8 per cent of burned area. A plan of therapy based on the anticipated expansion of the extracellular fluid space has been satisfactory in our experience, being remarkably free of secondary complications therapeutically induced. The use of whole blood, sodium without chloride excess and little or no electrolyte-free water in the acute phase are emphasized. Rigid adherence to aseptic technique and isolation plus the prophylactic use of penicillin should facilitate early closure of the burn wound and a more rapid recovery.
906
MANAGEMENT OF ACUTE "HASE OF THERMAL BURNS IN CHILDREN
REFERENCES
1. Berkow, S. G.: A Method of Estimating the Extensiveness of Lesions (Burns and Scalds) Based on Surface Area Proportions. Arch. Surg., 8:138, 1924. 2. Cope, 0., and Moore, F. D.: The Redistribution of Body Water and the Fluid Therapy of the Burned Patient. Ann. Surg., 126:1010, 1947. 3. Liedberg, N. C-F., Kuhn, L. R., Barnes, B. A., Reiss, K, and Amspacher, W. H.: Infection in Burns. 1. The Problem and Evaluation of Therapy. Surg., Obst. & Gynec., 98:535, 1954_ 4_ Liedberg, N. C-F., Kuhn, L. R., Barnes, B. A., Reiss, K, and Amspacher, W. H.: Infection in Burns. II. The Pathogenicity of Streptococci. Surg.,Obst., & Gynec., 98:693, 1954. 5. Moyer, C. A.: Recent Advances in Chemical Supportive Therapy of Thermal Injury. Texas State J. Med., 45:635,1949. 6. Wallace, A. B.: The Exposure Treatment of Bums. Lancet, 1:501, 1951. 4200 East 9th Avenue Denver 20, Colorado
A~UTE
PHASE OF THERMAL
BURNS IN
~HILDREN
ROBERT H. ALWAY, M.D.
Burns contribute a high percentage of the accident death toll in childhood. The mortality rate, however, inadequately depicts the physical, emotional and financial stress to a child and his family produced by a severe burn. Better application of the knowledge gained regarding fluid, electrolyte and colloid shifts and losses should permit the greatest number of seriously burned children to survive. Although successful management of the immediate postburn period is no guarantee of eventual recovery, attention to other than antishock measures should increase the number of seriously burned children in optimal condition for early skin grafting. ESTIMATION OF SEVERITY
A severe burn is one which is sufficient to produce shock or may later require grafting. The child under the age of six years with as little as 8 per cent partial thickness burn may require parenteral therapy. More than 15 per cent involvement may be equally serious in the child aged six to twelve years. These are in contrast to greater than 20 per cent area of equal seriousness in the adult. The depth of involvement is important in that a considerably smaller area of full thickness (third degree) burn may be equally serious. Flame burns are more apt to produce deep involvement than are hot liquid scalds. More anemia, both early and late, seems to follow third degree burns of any extent. Correct estimation of the extent and depth of burn injury is difficult when the patient is first seen. Usually the area is exaggerated and the depth underestimated. The extent of the burn, so far as this affects therapy, may be calculated satisfactorily from a modification of Berkow'sl and Wallace's6 suggestions. 901
902
MANAGEMENT OF ACUTE PHASE OF THERMAL BURNS IN CHILDREN
Head ................................. 9% Neck ................................. 1% Arms, each. . . . . . . . . . . . . . . . . . . . . . . . . . .. 9 % Trunk, front .......................... 18% back ........................... 18% Genitalia. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1 % Legs, each (including buttocks) .......... 18%
Allow relatively more for the head (almost two times) and less for the legs (about one half) in children under two years. Finally, in estimating severity the time elapsed from burn insult is important. NATURAL HISTORY OF SEVERE BURNS
The natural history of burns may be divided roughly into three periods: Phase
I: the first forty-eight to seventy-two hours following the burn; marked by shock and edema Phase II: third through the tenth day approximately; may be marked by water intoxication, hyponatremia Phase III: after the tenth day with slough, sepsis and starvation
Phase I
In the twenty-four to forty-eight hours after a burn there is a relentless expansion of the extracellular fluid space, in the burned area as well as the rest of the body. Without replacement measures adequate in rate, volume and composition, not only may shock develop, but also the patient's later course may be prejudiced. This "loss" into an abnormal third space (burn edema) may equal a 50 per cent increase in ex· tracellular fluid volume within a few hours. The associated decrease in effective circulating volume may be exaggerated by loss from the burn surface and further complicated by a variable degree of decreased red blood cell circulating volume. This loss is greatest in full thickness burns. This occurs early from hemolysis and stasis and later from decreased regeneration and surface loss from granulation tissue. This dislocation of extracellular fluid being most rapid in the first eight to twelve hours, early rapid replacement or maintenance of an adequate circulating volume is essential. Renal function may be altered as a result of several factors. With delayed or inadequate replacement therapy effective renal plasma flow may decrease to one tenth or less of normal within minutes to a few hours after a burn. The usual response to severe stress results in sodium and water retention and failure to conserve potassium. Finally, mor· phine or barbiturate therapy may lead to an increase in antidiuretic hormones, an inability to excrete excess water and signs and symptoms of water intoxica.tion.
ROBERT H. ALWAY
903
Phase II
The "toxic" picture frequently presented by the severely burned subject between the fourth and tenth days is poorly understood, and accordingly there has been an unsatisfactory lowering of the mortality in this phase. "Adrenal exhaustion" does not adequately explain the picture, nor has adrenal cortical replacement therapy satisfactorily handled it. Hyponatremia may be noted. Water intoxication may be suggested by salivation, vomiting, twitching and convulsions. The older child may complain of headache or blurred vision. Phase III
The third phase in the course of severe burns is marked by separation of eschars. This may be complicated by infection. Liedberg and co-workers 4 recently restressed the relative importance of group A beta-hemolytic streptococcal infections in the failure of skin grafting. In their experience staphylococci, pseudomonas, proteus and the coli-aerogenes group are not apparently of like significance. Infection may not only delay satisfactory closure of the burn wound, but may also interfere with adequate correction of hypoproteinemia and anemia. TREATMENT
A formula for therapy connotes a degree of precision which, however, is not real. A rule-of-thumb approach is as apt to mislead. Despite the diverse opinions and multiple therapeutic regimens espoused, it should be possible to proceed on some general principles concerning three major obstacles to the recovery of the severely burned patient. These obstacles are shock, sepsis, starvation. Measures taken in the first fortyeight hours are not merely to restore or maintain an adequate circulation, but equally should be designed to carry the patient into the second and third phases in optimal condition. This is to facilitate early closure of the burn wound. Electrolytes, particularly sodium, water and colloids, including whole blood, all may be essential. Emphasis on one, relatively minimizing others, may permit survival through the first postburn phase, but with an unnecessary handicap. The treatment of severely burned children based on surface area involved has not been satisfactory in our hands. We have used a modification of Cope's2 suggestions in which the upper limit of deficit therapy is based on anticipated expansion of the extracellular fluid space and modified by the hourly urine output. Fluid Therapy in Phase I
The amount of fluids required in the first forty-eight hours after a burn may be estimated as follows:
904
MANAGEMENT OF ACUTE PHASE OF THERMAL BURNS IN CHILDREN
A. To cover expanding extracellular fluid space-volume in milliliters equivalent to not over 10 per cent of the patient's admission weight in kilograms; B. To provide for surface loss from the burn-about 50 ml. per 1 per cent of burn area; C. To cover the normal daily requirements for insensible loss and urine volume-200 ml. of water per kilogram per forty-eight hours and 10 to 15 gm. of glucose solution per kilogram for the same period. This amount may be divided in four equal volumes given in each twelve hour period intravenously. The sum of quantities A and B, divided equally between colloid and electrolyte solutions, may be given intravenously, one half in the first eight hours after the burn, one fourth in the second and third eight hours, and one fourth in the second twenty-four hours. :This volume of fluid may be too much or too little. More should be given only if the hourly urine volume decreases below 10 to 20 ml. or with other manifestations of inadequate treatment: rising pulse, hematocrit over 60 per cent, hypotension, and so on. Colloid may be given as plasma, Dextran or blood. The last may be given in amounts equivalent to 2 to 4 per cent of the patient's body weight in the first twenty-four hours. Blood should be used with a known or presumed full thickness burn, as in extensive fire burns. Electrolytes should be given as balanced salt solution: two parts of 5 per cent glucose in normal saline solution to one part sixth-normal sodium lactate solution rather than "unphysiologic" saline solution containing a relative excess of chloride. As soon as the child is out of shock and not vomiting, oral intake may be encouraged. Salt solution may be tolerated if offered repeatedly in small amounts. A palatable solution may be made by adding 3 gm. (1 teaspoonful) of sodium chloride and 1.5 gm. (two-thirds teaspoonful) of sodium bicarbonate to one quart of iced water. Parenteral therapy should be curtailed proportionally to the retained oral intake. Tap water should not be offered in the first forty-eight hours unless dry oral mucosa, severe thirst or a serum sodium over 138 mEq. per liter is noted. Hourly Urine Volume
The urine output is a reasonably satisfactory measure of the adequacy of fluid therapy in the acute postburn period. An indwelling catheter will facilitate accurate urine collection. An output of 30 to 50 ml. per hour is within safe limits. Continued hourly volumes over 80 ml. imply too much fluids, while volumes under 10 to 20 ml. should be investigated. A low hourly output usually means inadequate fluids to keep up with the expanding extracellular fluid space and consequently a decreased circulating volume. It may, though, result from renal damage. The
ROBERT H. ALWAY
905
problem may be resolved by water loading. Give 25 ml. per kilogram of 5 per cent glucose in water intravenously in forty-five to sixty minutes. If no change in urine flow follows, renal tubular damage may be present. Continued increased fluid intake might then be disastrous. An increased flow subsequent to the water load is an indication for more vigorous treatment. Local Therapy
Strict aseptic technique should be maintained at all times by all personnel until the burn wound is healed. Cover the patient with a clean sheet until general supportive measures h.ave been started. After obvious dirt has been removed with a liquid detergent and the burned area flushed with warm saline solution, the less done the better. No local medication is probably the best general rule. Burned extremities should be elevated and immobilized with joints in a position of function. Open or closed handling of the burn wound will depend on the extent and location of the burn and the facilities available. Additional Orders for Acute Phase Treatment
The following should be restressed or done in addition to those points already discussed: Maintain strict isolation and aseptic technique. Type and cross match blood on admission. Record the hourly urine volume. Administer tetanus antitoxin, 1500 units, and procaine penicillin, 300,000 units daily intramuscularly, or its equivalent. Oral feeding is ill tolerated in the acute phase. Children, however, usually will accept hard candy and sweetened carbonated drinks quite early. This should be encouraged. SUMMARY
In children shock may follow considerably less extensive burns than in adults. Because of the rapidity of the development of shock, therapy should be started immediately in a child under six years of age with over 8 per cent of burned area. A plan of therapy based on the anticipated expansion of the extracellular fluid space has been satisfactory in our experience, being remarkably free of secondary complications therapeutically induced. The use of whole blood, sodium without chloride excess and little or no electrolyte-free water in the acute phase are emphasized. Rigid adherence to aseptic technique and isolation plus the prophylactic use of penicillin should facilitate early closure of the burn wound and a more rapid recovery.
906
MANAGEMENT OF ACUTE "HASE OF THERMAL BURNS IN CHILDREN
REFERENCES
1. Berkow, S. G.: A Method of Estimating the Extensiveness of Lesions (Burns and Scalds) Based on Surface Area Proportions. Arch. Surg., 8:138, 1924. 2. Cope, 0., and Moore, F. D.: The Redistribution of Body Water and the Fluid Therapy of the Burned Patient. Ann. Surg., 126:1010, 1947. 3. Liedberg, N. C-F., Kuhn, L. R., Barnes, B. A., Reiss, K, and Amspacher, W. H.: Infection in Burns. 1. The Problem and Evaluation of Therapy. Surg., Obst. & Gynec., 98:535, 1954_ 4_ Liedberg, N. C-F., Kuhn, L. R., Barnes, B. A., Reiss, K, and Amspacher, W. H.: Infection in Burns. II. The Pathogenicity of Streptococci. Surg.,Obst., & Gynec., 98:693, 1954. 5. Moyer, C. A.: Recent Advances in Chemical Supportive Therapy of Thermal Injury. Texas State J. Med., 45:635,1949. 6. Wallace, A. B.: The Exposure Treatment of Bums. Lancet, 1:501, 1951. 4200 East 9th Avenue Denver 20, Colorado