Surgical Treatment of Burns in Children Treatment & Management

Updated: May 07, 2018
  • Author: Renata Fabia, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Treatment

Approach Considerations

Rapid assessment and treatment of immediate life-threatening conditions is mandatory in patients with burns. Endotracheal intubation is indicated in children with respiratory distress or airway compromise caused by airway edema. Because of the small diameter of the pediatric airway, a low threshold for intubation should be maintained. Children with burns affecting more than 10% of total body surface area (TBSA) should receive intravenous (IV) fluid resuscitation.

Burn wounds should initially be covered with dry sterile sheets, and a thorough history and physical examination should be obtained. Wet sheets or cooling packs should not be used because this contributes to hypothermia. Patients should be kept warm by infusing warm IV fluids, elevating room temperatures, and minimizing patient exposure. Tetanus immunization should be administered as indicated.

Indications and contraindications for surgery

Burn excision and grafting are recommended for all full-thickness burns and for deep partial-thickness burns that would appear to take more than 2-3 weeks to heal. Any condition that would ordinarily preclude the patient with burn injuries from having general anesthesia may be a contraindication; otherwise, no contraindications to surgery are noted.

Future and controversies

Numerous clinical and basic science burn research initiatives are undergoing active investigation. One such area of interest is the hypermetabolic response to severe burns and the association with increased energy expenditure and muscle-protein catabolism. Studies have investigated different mechanisms to attenuate the muscle-protein catabolism that occurs frequently, despite appropriate nutritional support, in children with large burns. [8] These studies are promising because attenuation of muscle-protein losses may improve strength and ability to recuperate.

A prospective randomized controlled trial of recombinant human growth hormone (HGH) in combination with propranolol demonstrated attenuated hypermetabolism and inflammatory and acute-phase responses after severe burn injury. [9] HGH improves posttraumatic hypermetabolism, but its use alone is associated with hyperglycemia and increased free fatty acids and triglycerides. Concomitant administration of propranolol improved fat metabolism and insulin sensitivity and avoided the adverse effects of recombinant HGH alone.

Oxandrolone, an anabolic steroid, has been shown to increase muscle protein net deposition and to decrease length of stay in patient with major burns. [10]  In a randomized clinial trial of long-term (up to 24 months) administration of oxandrolone to severely burned pediatric patients, Reeves et al found that at 5-year follow-up, this approach yielded significant improvements on whole-body bone mineral content (BMC), lumbar-spine BMC, lumbar-spine bone mineral density (BMD), and height velocity. [11]

The extent of initial resuscitation efforts and the subsequent care of a burn-injured patient have a significant impact on whether the patient recovers or experiences complications, including the development of multiple organ dysfunction syndrome (MODS) and death. The Burn Research Group developed standardized protocols for patient care based on management principles derived from published clinical and laboratory studies. [12] Studies continue to investigate new ways to address current fluid therapy needs, to monitor the end points of resuscitation, and to prevent the negative effects of current therapies [13]

Smoke inhalation injury, either by itself or in conjunction with a dermal burn, results in severe lung-induced morbidity and mortality. Presently, the most common cause of death in burn patients is a respiratory failure. [14] A large focus of burn-related research involves important pathophysiologic pathways and therapeutic targets for the treatment of acute inhalational injuries. [15] The mechanisms for secondary infection after burn injury, including respiratory infection, continue to be subjects of investigation. [16]

Another active area of research is in the development of cultured skin to treat very large burns. Cultured epidermal autografts (CEAs), which are grown from the patient's own uninjured epidermis, are commonly used; however, these grafts are very thin and fragile. In the future, cultured bilayered skin (epidermis and dermis) should lead to better functional and cosmetic results.

Optimum healing of a burn wound requires well-coordinated integration of the complex biologic and molecular events of cell migration and proliferation, as well as of extracellular matrix deposition and remodeling. Future treatment options could include stem cell therapy, which has been shown to improve the quality of burn wound healing, reduce the formation of scars, and reestablish the normal function of the skin and its appendages. Although treatment of burn wounds with adult stem cells is improving, issues remain to be addressed before stem cell therapy can be widely used clinically. [17, 18]

Another important area of research aimed at ensuring improved outcomes in children with burn injuries focuses on achieving a better understanding of the posttraumatic stress induced by burns. [19, 20]

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Medical Therapy

Criteria for hospitalization

Hospital admission criteria for patients with thermal injury include the following:

  • Partial-thickness burns larger than 10% of TBSA
  • Full-thickness burns larger than 2% of TBSA
  • Burns involving the face, hands, genitalia, perineum, or major joints
  • Circumferential extremity burns
  • All high-voltage electrical burns, including lightning injury
  • Admission of low-voltage electrical burns is selective
  • Chemical burns
  • Inhalation injury
  • Burn injuries in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality (eg, diabetes, immunosuppression)
  • Suspected child abuse
  • Cases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for the burn)

Inhalation injury

Clues to inhalation injury include the following:

  • Increased respiratory rate
  • Hoarseness
  • Being burned in an enclosed space
  • Altered mental status
  • Head and neck burns
  • Singed nasal hairs
  • Inflamed oral mucosa
  • Carbonaceous sputum

Indications for intubation include the following:

  • Compromised upper airway patency
  • Need for ventilatory support as manifested by poor gas exchange or increased work of breathing
  • Compromised mental status

Correlation of the history and the clinical findings is the most practical approach to determining the need for intubation.

Important considerations with regard to the pediatric airway include the following:

  • The larynx is more cephalad in children
  • Children deteriorate faster than adults in terms of upper-airway edema and alveolar-capillary block
  • Repeated intubation attempts may cause edema and obstruction

For these important reasons, experience in pediatric intubation is needed. Once an airway is established, securing the airway well is important, especially in patients with facial burns, to avoid accidental extubation. A multitude of approaches have been developed to ensure better stabilization of endotracheal tubes, such as anchoring the tube to the teeth with a dental device (see the images below).

Endotracheal tube immobilization in children. The Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
Dental device to anchor the endotracheal tube. Dental device to anchor the endotracheal tube.

Carbon monoxide (CO) toxicity is the leading cause of death in patients with inhalation injury. CO is a byproduct of combustion that displaces oxygen from the hemoglobin molecule. It has 250 times the affinity for hemoglobin that oxygen does, thus causing a left shift in the hemoglobin-oxygen disassociation curve. This impairs oxygen unloading at the tissue level and causes a switch to anaerobic metabolism with severe metabolic acidosis. CO toxicity should be suspected when metabolic acidosis persists despite adequate volume resuscitation.

It must be kept in mind that arterial oxygen tension (PaO2) will be normal because the amount of oxygen dissolved in arterial plasma is normal. In addition, arterial oxygen saturation (SaO2) will be normal on a standard pulse oximeter in the presence of CO toxicity because the oximeter cannot differentiate between hemoglobin saturated with oxygen and hemoglobin saturated with CO.

To treat CO toxicity, all patients with inhalation injury should be treated with 100% oxygen. This lowers the half-time (t1/2) of CO to 30-90 minutes, as opposed to 4-5 hours in room air. Therefore, all major burns should be treated with 100% oxygen until CO toxicity is ruled out or the CO level returns to normal. Hyperbaric oxygen (HBO) therapy (3 atm) leads to even more rapid displacement of CO (≤20 min). Its use should be considered for CO greater than 50%, severe neurologic compromise, and nonresponsiveness to 100% oxygen.

Cyanide toxicity results from the burning of natural (wool, silk, cotton, paper) or synthetic (polyurethane, plastic, nylon, acrylic) products, which leads to the production of toxic hydrocyanide gas. Cyanide binds to the cytochrome oxidase system, inhibiting cellular metabolism and adenosine triphosphate (ATP) production. It causes a shift to anaerobic metabolism with profound metabolic acidosis and obtundation. Treatment of cyanide toxicity involves administration of the cyanide antidote sodium thiosulfate (250 mg/kg IV, not to exceed 12.5 g; if symptoms persist, this may be repeated at 30 min at 50% of the original dose, not to exceed 6.25 g). The antidote converts cyanide to nontoxic, excretable thiocyanate.

Smoke inhalation can also cause a chemically induced inflammatory reaction in the airways, leading to microbial colonization and pneumonia. Affected patients may need ventilatory support. In severe cases, oscillating ventilators and extracorporeal membrane oxygenation (ECMO) have been successfully used in these patients.

Fluid resuscitation

IV access may be obtained percutaneously or by cutdown, either peripherally or centrally. Peripheral access in an unburned area is preferred. Intraosseous (IO) infusion may be lifesaving in the severely burned patient if necessary.

Several burn resuscitation formulas can be used in pediatric burn care; the modified Parkland formula is most commonly used. Lactated Ringer solution is initially used in pediatric patients of all ages at 3-4 mL/kg for each 1% of TBSA burned for the first 24 hours. One half of the calculated amount of fluid needed is administered in the first 8 hours after the burn occurs, and the remaining half is administered over the following 16 hours. Maintenance fluids should be administered concomitantly (this represents the modification to the Parkland formula for pediatric patients).

Representative fluid resuscitation guidelines for pediatric burn patients with burns larger than 15% TBSA are as follows:

  • Modified Parkland formula (Parkland formula plus maintenance fluids, used in patients who weigh less than 20 kg)
  • Resuscitation fluids - 3-4 mL lacted Ringer solution × weight (kg) × %TBSA burned (second-degree and third-degree), with half administered over the first 8 hours (from the time of injury) and the remaining half administered over the next 16 hours
  • Maintenance fluids - Lacted Ringer solution with 5% dextrose at 4 mL/kg/hr for patients weighing 0-10 kg, plus 2 mL/kg/hr for those weighing 10-20 kg, plus 1 mL/kg/hr for each 1 kg above 20 kg

Prehospital fluids must also be considered. If prehospital fluid resuscitation is inadequate, the fluid deficit must be added to the fluid rate calculated for the first 8 hours of resuscitation.

For patients with burns involving 15% of TBSA or less, the following are indicated:

  • Patients with burns to 5-10% of TBSA who are taking oral fluids well - Oral fluids only
  • Patients with burns to 5-10% of TBSA who are not taking oral fluids well - Maintenance fluids
  • Patients with burns to 10-15% of TBSA - 150% maintenance fluids

The above recommendations are guidelines only. Patients with burns larger than 15% of TBSA should have a urinary catheter placed. Desired urine output is 1 mL/kg/hr for patients who weigh less than 30 kg and 30-50 mL/hr for those who weigh more than 30 kg. For major burns, fluid resuscitation must be reassessed hourly on the basis of the patient's urine output.

Rates of fluid administration should be altered in accordance with the patient's response. If a patient presents after some delay and has not been resuscitated properly before presentation, the calculated fluid requirements should be adjusted so as to take these factors into account. Infants are at risk for hypoglycemia because of their limited glycogen stores; therefore, glucose levels should be monitored, and lactated Ringer solution with 5% dextrose should be used for maintenance fluids. Evaluate the response to fluid administration by measuring urine output via an indwelling urinary catheter. Monitoring the sensorium, peripheral circulation, and blood pH is also helpful in assessing the adequacy of resuscitation.

Temperature regulation

As previously mentioned, children younger than 2 years lose heat and water more rapidly than older children and adults because of their thinner layers of skin and insulating subcutaneous tissue; temperature regulation in these very young children is partially based on nonshivering thermogenesis, which further increases metabolic rate, oxygen consumption, and lactate production. Therefore, hypothermia in the pediatric burn patients should be avoided by paying careful attention to increasing the room temperature, minimizing exposure time, and using radiant warmers, fluid warmers, and other tools.

Systemic antibiotics

Systemic antibiotic prophylaxis is not used in the treatment of burn patients, because it increases the risk of infection with resistant organisms. Instead, the use of systemic antibiotics is reserved for the treatment of specific infections, with the agents administered at the first sign of clinical infection. Antibiotic regimens are then modified as culture results and antimicrobial sensitivity results become available.

Burn wound cellulitis refers to infection spreading in dermal lymphatics in the nonburned skin surrounding a burn, usually occurring in the first few days after burn injury. Burn cellulitis is commonly caused by Streptococcus pyogenes. Invasive burn wound sepsis leads to systemic toxicity with high fever, bacteremia, and a hyperdynamic circulatory state with hypotension and cardiovascular collapse. Large burns are prone to fungal infections as well. The diagnosis can be made on the basis of clinical examination, quantitative burn wound cultures, or burn wound histology.

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Surgical Therapy

Topical treatment

Devitalized skin and ruptured blisters should be debrided. Topical antibiotic therapy should be used to delay bacterial colonization. Silver sulfadiazine cream is a commonly used broad-spectrum topical antimicrobial cream. It is applied as a thin layer with gauze dressings twice daily. It does cause transient neutropenia, which resolves even with continued use of the agent. [21]

Facial burns are usually treated with a combination antimicrobial product containing polymyxin B, neomycin, and bacitracin or an immunomodulating cream such as beta-Glucan (a cream that contains complex carbohydrate isolated from the cell wall of oats). The use of silver sulfadiazine cream is avoided on the central face because it may cause severe ocular irritation. Significant ear burns should be treated with mafenide cream because the thin subcutaneous tissue in the ears predisposes to the development of chondritis.

Hydrotherapy provides wound and body cleansing with gentle removal of loose eschar and topical ointments. [22] If used, hydrotherapy sessions are limited to 10-15 minutes once a day to decrease promotion of infection. Topical enzyme preparations such as Santyl (a collagenase-containing debriding ointment) can be applied to the burn surface to chemically debride devitalized tissue without injuring viable tissue. This allows earlier assessment of the wound bed, with fewer days to a clean wound bed and reepithelialization.

To avoid the need for frequent painful dressing changes, sustained-release (continuous topical antimicrobial) silver-impregnated dressings, which can be left in place for several days, may be used for the treatment of partial-thickness burns. Many such dressing are currently available in various forms (eg, foam, hydrofiber, hydrocellular dressing, synthetic mesh or gel) and silver concentrations. Examples include the following:

  • Foam - Mepilex Ag (a silver-impregnated foam that can be easily applied and removed and can be left in place for 7 days; see the first image below)
  • Hydrofiber - Aquacel Ag (creates a viscous gel upon contact with burn surface, which prevents fluid loss and traps bacteria; can be left in place for 2 wk; see the second image below)
  • Hydrocellular dressing - Allevyn (a highly absorbant dressing with a high concentration of ionic sustained-release silver that is active up to 7 days)
  • Synthetic mesh - Acticoat Ag (a low-adherent silver-coated polyethylene net used as an antimicrobial barrier for up to 3 days; Acticoat 7 can be used for up to 7 days; Acticoat-Flex has increased flexibility)
  • Gel - Nanoparticle silver gel with a lower concentration of silver, therefore potentially avoiding adverse effects of long-term silver use such as argyria and delayed wound healing
  • Combination foam - Acticoat Moisture Control (polyurethane foam layer and a nanocrystalline silver-coated polyurethane layer, which is active up to 7 days)
Application of Mepilex Ag foam dressing. Application of Mepilex Ag foam dressing.
Aquacel Ag adherent to burn wounds. Aquacel Ag adherent to burn wounds.

If reepithelialization is not complete by the time the product must be removed, the product can be reapplied.

In a prospective randomized controlled trial that included both pediatric and adult patients with partial-thickness burns, Hundeshagen et al compared Mepilex Ag with the polylactic acid–based polymer Suprathel. [23] Both dressings were found to be feasible and efficacious. Suprathel was associated with significantly reduced pain during the first 5 days and with better overall scar quality; Mepilex Ag was associated with elevated viscoelasticity of burned skin compared with unburned skin at 1 month and with lower treatment cost per square centimeter.

Products for wound closure

Temporary wound closure for major burns can be obtained by using allograft (cadaveric human skin). Additionally, developments in tissue bioengineering have provided temporary skin substitutes that avoid the need for allograft use. A number of products are commercially available, and many others are in development.

Epidermal products include the following:

  • Epicel (cultured autologous epidermal autograft cultivated by the patient's own skin)
  • Cultured allogeneic epidermal cells

Dermal products include the following:

  • AlloDerm (allogeneic acellular dermal matrix with an intact basement membrane complex obtained from human skin that prepares the wound bed for grafting)
  • Integra (extracellular matrix composed of bovine collagen and other wound-healing promoting substances that generate new dermis)
  • TransCyte (extracellular matrix generated by allogeneic neonatal foreskin fibroblasts with nonporous silicone layer)
  • EZ-Derm (porcine-derived biosynthetic xenograft, which may substitute for allograft by providing an environment that promotes the migration and proliferation of epithelial cells)
  • ACell, an extracellular matrix (epithelial basement membrane layer harvested from pig bladders that promotes repair and remodeling of damaged tissue)

Combined epidermal and dermal products include the following:

  • Apligraf (a living allogeneic bovine product containing keratinocytes, fibroblasts, and bovine type I collagen)
  • OrCel (known as composite cultured skin; a bilayered cellular matrix composed of epidermal keratinocytes and dermal fibroblasts cultured in two separate layers into a type I bovine collagen sponge)

Preparation for surgery

Successful burn wound management in children demands conversion of open wounds to closed wounds as soon as possible. The concept of early removal of burn eschar and immediate wound closure has gained widespread acceptance. Evidence suggests that early eschar removal is effective in decreasing morbidity and improving mortality.

Full-thickness burns (with the exception of very small injuries that are allowed to heal by contraction) should be grafted. The goal is to excise the wound within the first week of the injury. Additionally, deep partial-thickness burns that take longer than 3 weeks to heal usually benefit from grafting, with less hypertrophic scarring and better cosmetic results.

Preoperatively, patients must be hemodynamically sound and have optimal acid-base, fluid, and electrolyte balance. Adequate blood must be available before considering excision and grafting. Preoperative antibiotics are not required unless patients have other compromising systemic diseases or invasive burn sepsis; however, a prophylactic dose of a first-generation cephalosporin antibiotic may be used.

Operative details

Attention to maintenance of body temperature at all times is extremely important.

Burn excision involves tangential removal of thin slices of eschar until profuse pinpoint bleeding from a moist, viable, deep dermal surface or subcutaneous fat is observed. Meticulous hemostasis is then obtained using epinephrine-soaked (1:100,000) sponges, topical spray thrombin, and electrocautery, followed by immediate grafting with thin sheets of autograft. A newer technique of burn wound debridement is Versajet hydrosurgery, which allows more precise debridement and reduced blood loss. [24, 25]

Skin grafting involves harvesting partial-thickness pieces of skin from donor sites on unburned areas using a dermatome. The thickness of the harvested skin commonly is 0.008-0.012 in. (0.2-0.3 mm), depending on the age and skin thickness of the patient. The grafts are then applied to the wound bed and secured.

Autograft skin is obviously preferred whenever possible. Unfortunately, patients with large burns may not have enough autologous skin available for complete coverage. In such patients, burns can be excised and temporarily covered with numerous biologic dressings (eg, cadaveric skin, pigskin) or skin substitutes. As more donor sites become available, the temporary wound covers are removed and the wounds are grafted. Studies have shown that human growth hormone (HGH; 0.15-0.2 mg/kg/day intramuscularly [IM]) can speed donor-site healing, allowing more rapid reharvesting of healed donor sites. [9, 26, 27, 28]

Meshed autografts are harvested from donor sites and passed through a meshing machine that cuts a series of parallel offset slits in the grafts at various expansion ratios (eg, 1.5:1, 2:1). This technique allows expansion of the graft to cover a larger surface area. In addition, the interstices in the graft allow for drainage of fluids under the graft so that the grafts do not lift off their beds. Unfortunately, the meshed patterns of the grafts persist after healing and often lead to suboptimal cosmetic results.

Nonmeshed or sheet grafts are harvested the same way but are not passed through the meshing machine. The use of sheet grafts leads to a better cosmetic result. Because the grafts do not expand, covering major areas with sheet grafts alone is difficult. Nonetheless, sheet grafts should be used whenever possible, especially in highly visible and functional areas, such as the face, neck, hands, and joints. Sheet grafts should be inspected after approximately 48 hours so that any underlying fluid can be aspirated to avoid loss of the graft. Dressings can be left in place for as long as 5 days if desired on meshed grafts, as long as no suspicion of infection is noted.

A full-thickness skin graft consists of both epidermal and complete dermal skin layers. It can offer a better cosmetic outcome and a smaller chance of contraction or trauma to the tissue, but it carries an increased risk of graft loss. It is used for cosmetically and functionally critical areas, such as the face, hands, and joints. [29]

In the case of burns affecting more than 50% of TBSA, the patient has insufficient areas of unaffected skin from which split-thickness skin grafts can be harvested. Cultured epidermal autografts produced from a small skin biopsy can provide permanent coverage of large areas. [30] However, a period of 3 weeks is needed for graft cultivation, and the take rate of cultured epidermal autografts may be poor, especially in chronically infected areas. Providing temporary coverage with allograft skin or application of the acellular dermal matrices may increase the chances for graft take. [31]

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Complications

Complications of surgery in patients with burns include the following:

  • Bleeding
  • Infection
  • Graft loss

Bleeding can be limited by means of various techniques, including subcutaneous infiltration of donor sites with adrenaline solution, the use of topical thrombin spray when excising, or the application of VersaJet techniques for excision of burns when possible. If infection is suspected, dressings can be changed to include a broad-spectrum antimicrobial agent along with systemic antibiotic treatment.

Complications of nonsurgical treatment include the following:

  • Infection
  • Compartment syndrome
  • Metabolic disorders
  • Feeding difficulties
  • Narcotic withdrawal

Abdominal compartment syndrome can result from aggressive fluid resuscitation and can be treated by using a percutaneous peritoneal drain. If this is not effective, laparotomy for decompression may sometimes be needed.

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Long-Term Monitoring

Scar prevention

For burns that take longer than 3 weeks to heal or for wounds that have been grafted, hypertrophic scarring can be minimized by employing compression therapy with custom-made garments that apply 25-30 mm Hg pressure to all wounds. Gel pads can be added underneath or sewn into the garments to apply extra compression. Compression therapy is continued throughout the wound healing process (~12-18 months). Lotion application with massage therapy is used to keep the healed or grafted areas soft and supple.

If scars develop despite the application of preventive methods, various techniques are available for treatment, including surgical excision or dermabrasion, ultrasound therapy, and fractional carbon dioxide laser therapy.

Contracture prevention

Contractures refer to hypertrophic scar formation over joints that results in decreased range of motion (ROM). Aggressive attention to occupational and physical therapy, with appropriate consultation, is necessary to ensure optimal results. Active and passive ROM exercises are instituted, and splints are worn at night and between exercise periods. Patients with burns are at risk for contractures are followed for years to monitor for the development of these complications.

Treatments for contractures include various surgical techniques, such as Z-plasty and excisions with full-thickness skin grafts.

Psychological sequelae

Burn scarring can lead to significant psychological sequelae. The assistance of a trained psychologist or psychiatrist is an important addition to the overall care of these patients. Acute propranolol therapy has been suggested as a potential treatment for posttraumatic stress in children with large burns, but in a study by Rosenberg et al, this approach was not shown to be clearly effective. [20]

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