Avoid complications with pediatric burn injuries
(Editor's note: This month's issue of ED Nursing features a special pediatric package. We cover burn injuries, treatments for cellulitis, interventions to speed care of asthma patients, and overdoses of cold and cough medications.)
Increased respiratory rates, causing greater fluid loss and more inhalation of toxic gases. Smaller airways causing airway edema. Larger body surface area in proportion to body weight, which calls for intravenous maintenance fluids. Increased risk of deeper burns due to thinner skin.
Those are some of the physiological features of infants and toddlers that increase risk of complications from burn injuries, says Mary Frey, RN, P-SANE, CPN, ED nurse at Cincinnati Children's Hospital Medical Center. Of 269 pediatric upper extremity burns treated at an urban ED, complications occurred in five patients, including hypertrophic scarring, flexor contractures, compartment syndrome requiring fasciotomy, and infection.1
8 steps to better burn care
To avoid complications in children with acute burn wounds, do the following:
• Don't wrap or position any burned extremity so a contracture or position deformity may occur.
Always wrap fingers and toes separately and never mitten them, and use a splint to help maintain normal position, says Paula Miller, RN, CCRN, an ED educator at Lucile Packard Children's Hospital in Palo Alto, CA.
• Elevate extremities.
"This will prevent dependent edema, which will slow down healing," says Miller. "Position the head carefully to prevent pressure on burned ears. Cartilage has a poor blood supply and heals slowly."
• Place a Foley catheter early for perineal burns.
"The area will swell, especially the scrotum in boys, and it will become impossible to catheterize the child if we wait," says Miller. "The child will need to remain catheterized until the swelling subsides."
• Perform frequent neurovascular checks for extremity burns, especially circumferential burns.
Signs of impending vascular compromise include tense swelling, extreme pain with minimal movement, numbness, coolness, and loss of pulses, says Ember Lee Ewings, MD, the above study's author and a resident in the Division of Plastic Surgery at Saint Louis University Hospital.
"ED nurses who are able to recognize these signs and act quickly will have done much to prevent this potentially devastating complication," says Ewings. "A child's small arms and fingers are at higher risk for swelling and ischemia."
• Control the pain.
"Burns are some of the most painful injuries that a child can suffer," says Michael Vicioso, RN, CCRN, ED pediatric nurse manager at Children's Hospital of Orange County (CA). However, ED nurses may be reluctant to give appropriate doses of pain medication, either because they underestimate the child's pain or wrongly think that kids can't tolerate pain medications, he says.
Morphine is the pain medication of choice for ED treatment of pediatric burn patients, says Vicioso. "I interviewed my staff and asked if they ever encountered respiratory depression or arrest from administration of morphine in a child. None had," he says. "Medicate these children until the pain goes away."
However, be cautious giving morphine with another opioid or a benzodiazepene, because respiratory depression and respiratory arrest is possible, says Vicioso.
• Don't automatically apply ointment.
"It is difficult to examine a burn if it is buried under a layer of ointment," says Miller. "Also, if ointment is applied at the receiving ED, it will have to be removed before the burn can be assessed by the surgeon when the child arrives at the burn unit. This is a painful process," she says.
• Remember that there is a high potential for airway obstruction, especially if the child has facial burns, singed nasal hair, carbonaceous sputum, a hoarse voice, or stridorous respirations.
"It is essential to open and clear the airway, administer high-flow oxygen, suction the oral-nasal pharynx as needed, and consider intubation in a timely manner," Frey says. "Airway edema can occur rapidly in infants and children with burn injuries."
• Prevent hypothermia.
"Because kids have a large surface area-to-volume ratio, they can lose a great deal of heat to the environment," says Miller. "The smaller the child, the more important it is to maintain normothermia."
In infants, especially unstable ones, hypothermia produces cold stress, resulting in further deterioration, says Miller. "Also, there is no clinical reason to keep the burn moist after the burning has been stopped," she says. "However, if the burned area is less than 10% of the child's total body surface area, cool wet dressings may be applied to help control pain."
To prevent hypothermia, ED nurses at Lucile Packard Children's do these interventions:
Keep the room at 85°F with use of warming lights.
Close the doors, and use curtains or screens to avoid drafts.
Cover the child with a sterile, dry sheet and blankets.
Cover the child's head to prevent heat loss.
"This is the largest part of a child's body and the greatest area of heat loss. An infant's head and neck equal 21% of their total body surface area," says Miller.
Remove any wet bedding.
Use a fluid warmer for intravenous fluids.
Monitor the child's core body temperature by using a rectal probe, says Vicioso. "Cover burns with wet to dry dressing and frequently change them. Use water at room temperature or warmer to cool the burn. Never use cold water. You will risk hypothermia with cold water."
Pediatric patients don't tolerate heat loss well, warns Vicioso. "A drop in temperature to below normal can cause bradycardia and respiratory depression in the very young," he says. "This is commonly missed in an all-age ED."
Reference
- Ewings EL, Pollack J. Pediatric upper extremity burns: Outcomes of emergency department triage and outpatient management. J Burn Care Res 2008; 29:77-81.
Sources
For more information on caring for pediatric burn injuries, contact:
- Ember Lee Ewings, MD, Department of Surgery, Saint Louis University Hospital, St. Louis. E-mail: [email protected].
- Mary Frey, RN, P-SANE, CPN, Emergency Department, Cincinnati Children's Hospital Medical Center. E-mail: [email protected].
- Paula Miller, RN, CCRN, Educator, Emergency Department, Lucile Packard Children's Hospital, Palo Alto, CA. Phone: (650) 725-8211. E-mail: [email protected].
- Michael Vicioso, RN, CCRN, Pediatric Nurse Manager, Emergency Department, Children's Hospital of Orange County (CA). E-mail: [email protected].
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