Examining the Wound Clinic’s Role in Pre- & Post-Hospitalized Pediatric Burn Care Patients

Burn injuries in the pediatric population present major challenges to patients and the medical community. Pediatric burns may have high mortality rates and can cause significant long-term disabilities lasting years past the initial recovery period. Thus, a standard of care for burn patients is essential and starts with accurate collection of data. The National Burn Repository and the National Burn Data Standards compile demographic and outcome data among burn centers.  The database is managed by the American Burn Association and is focused on providing accurate and up-to-date information from which standards of care can be developed.¹ According to the Center for Research Injury and Policy, there are more than 120,000 pediatric burn injuries each year in the United States, accounting for more than 100,000 emergency department (ED) visits and 2,500 pediatric deaths annually.² The goal in burn care remains to achieve rapid healing, adequate pain control, retention of function, and a pleasing aesthetic outcome.  

This article will focus on care in the outpatient setting, both prior to and following hospital treatment.

Prehospital Treatment 

It is essential to accurately calculate fluid resuscitation in the ED or prior to transferring a patient to a tertiary care unit. The Lund and Browder Chart, “rule of palm” and “rule of nines” serve as estimates for calculating volume resuscitation.^3-6 Excess resuscitation can be as harmful as under resuscitation and should be adjusted according to the patient’s physiologic response. The major criteria for referral to a burn center includes: second- and third-degree burns > 10% of total body surface area (TBSA) in patients younger than 10 years; second- and third-degree burns > 20%; third-degree burns > 5%; burns to the face, hands, feet, genitalia, perineum, and major joints; electrical or chemical burns; inhalation injury; patients living with preexisting conditions; circumferential third-degree burns to an extremity or the chest; and burns involving concomitant trauma with risk of morbidity and mortality.¹ Fortunately, the majority of pediatric burns are superficial or partial-thickness injuries. These types of burns can be treated in the outpatient setting when they comprise < 15% of the TBSA and do not require fluid resuscitation or treatment of inhalation injuries.⁷ 

Post-Hospital Treatment

Follow up care: Patients who’ve experienced severe burns requiring surgical intervention should have close follow up with burn specialists. Burns that are less severe are treated in the outpatient setting, often following an initial visit to the ED. As with other types of outpatient wound care, a patient’s family members/caregivers are important team members and require detailed instructions. A follow-up visit should be planned with a primary care provider within 24 hours of discharge to aid with assessment of the social and economic challenges the family may face. Early assessment of needed resources, such as dressings, and frequent follow up reduce the risk of complications such as infection, contractures, and prolonged open wounds. Additionally, there are often times when the depth and extent of a burn does not become clear until 24-48 hours after initial injury. The secondary survey can help initiate a higher level of care. 

Oral antibiotics: The use of antibiotics is rarely needed, especially with outpatient burn care.  Prophylactic antibiotics have not proven to reduce the incidence of infection in healthy individuals with clean wounds. Topical antibiotic ointment can reduce the risk of infection in minimally contaminated wounds. The tetanus immunization status should be reviewed as soon as possible and updated, if necessary. Tetanus toxoid should be administered for patients who have no tetanus immunization history, have not completed a primary series, or are older than 10 years from the last tetanus booster.⁸ If a patient has a puncture or contaminated wound and has never received a tetanus immunization, the tetanus immunoglobulin should be administered.⁹ 

Topical antibiotics: Topical antibiotics such as bacitracin, mupirocin, or triple antibiotic ointment can be applied to the face twice daily and can reduce the rate of infections.¹⁰ Side effects such as rash, erythema, and itching are associated with prolonged topical antibiotic use and may be confused with a true wound infection. In these instances, petroleum jelly may be substituted. Silver sulfadiazine can be used on all other skin areas, but is avoided on the face to prevent discoloration. Silver sulfadiazine should also not be used in patients with sulfa allergy and should be avoided with newborns.¹¹ In order to obtain the antimicrobial effect of silver sulfadiazine, it should be applied twice daily with washing of the wound and complete removal of prior applications prior to reapplication.

Treatment and dressing care: Dressing care for burns serves multiple purposes. The dressing can reduce risk of infection, aid wound healing, minimize pain, improve aesthetic appearance, and preserve function. A moist environment will help promote epithelialization and prevent dehydration of the wound bed. Cleaning the wound daily reduces the risk of infection significantly. Warm water or saline with antibacterial soap can be used in the home setting.

• First-degree burns involve the epidermis and are often described as a “sunburn.”  The skin is erythematous, painful, and dry. A common mechanism of injury is excess sun exposure or thermal injury. They usually heal in 5-10 days and without a long-term scar.¹² Pain control with anti-inflammatory medication and topical care with fragrance-free lotion, aloe vera, or triple antibiotic ointment can be helpful.^13,14 These agents can reduce the drying and cracking of skin, which causes discomfort.
• Second-degree burns are partial thickness involving the epidermis and a portion of the dermis with damage to the upper papillary dermis layers. This will result in erythematous skin that blanches with pressure, blisters, and is painful to the touch. The literature is full of discussion around blisters and whether to remove the blister or leave it in place. As a general guideline, if a blister is restricting movement, is excessively large, or is inhibiting proper dressing placement it should be debrided. If it is < 6 mm it can remain intact.¹⁵ This degree of burn will generally heal in two weeks without significant scar formation, though darker-skinned patients often experience hyperpigmentation for several months.  Topical care is needed and is similar to first-degree burn care with the addition of silver sulfadiazine. Occlusive dressings can limit fluid loss, improve pain control, promote healing, and decrease infection risk. Dressings can be a challenge in the pediatric population and often require larger, bulkier garments than would be used on a similar area in an adult. 
• Deep second-degree burns involve the reticular dermis and present with white-looking skin that does not blanch with pressure. These injuries will take three or more weeks to heal and often heal with a scar. The burn may not have appeared this way during the first few hours after injury, and burn-specialist referral is necessary to assess for surgical intervention.  
• Third-degree burns are often called “full-thickness burns” and involve the epidermis, dermis, and subcutaneous fat layer that result in a dark discoloration of the skin with a thick, leathery feel and little to no sensation. Mafenide acetate can penetrate an eschar and is useful on ear burns, however there is an increased risk of metabolic acidosis with this agent. Third-degree burns should be treated by experienced burn surgeons and require surgical debridement and skin grafting.  

Following hospital care, many patients may not be able to complete follow up at burn centers, meaning primary care and wound care specialists are important in the patient’s continued care. The wound site should be examined for signs of infection or contracture. The common organisms involved in burn infections are Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, Acinetobacter, and Klebsiella species.¹⁶ The signs of infection can be difficult to determine since the area is expected to be red, painful, and swollen from surgery. Excessive or increased pain, edema, erythema, excessive malodor, or purulent drainage should prompt wound culture to tailor antibiotic treatment to the specific organism or organisms involved. 

There are many types of dressings available in burn care with an associated range of cost and availability. Nonadherent gauze decreases adherence of bandages, but does not provide beneficial healing properties. Absorptive dressings such as silver alginate, BIOBRANE (Smith & Nephew, Fort Worth, TX), or hydrocolloids are helpful for wounds that are wet and improve healing time. 

ACTICOAT (Smith & Nephew) is a silver-impregnated dressing frequently used at burn centers that can improve pain control and reduce frequency of dressing changes. MatriStem^® (ACell, Columbia, MD) is regenerated cells from porcine bladder and stimulates wound healing. It is common for the patient to mount a histamine response that can lead to excessive pruritus. An antihistamine such as cetirizine or topical doxepin can be used safely to calm the itching.¹⁷ 

Deep burns can lead to excess scarring and contractures that impair movement and can deform structures of the face, neck, and joints. Wound care clinicians should maintain a high index of suspicion and long-term follow up of these patients. Massage, silicone sheets, compressive dressings, and steroid injections can improve or prevent excess scar formation. Patients who show signs of contracture or displacement of normal structures (eg, eyelid malposition) should be referred early to a specialist for evaluation. Prolonged contracture can inhibit proper growth in the pediatric population.

Physical Therapy

Physical therapy is essential for maintaining or regaining function in the cases of full-thickness burns and after surgery. Burns that cross a joint have an increased risk of contracture. Patients will guard the injured area and restrict activity if the area is painful. This can lead to stiffness and weakness. Therapy can help encourage motion and strength-building.¹⁸

Conclusion

Primary care and outpatient wound care providers are central to the care of pediatric burn victims. Early identification of patients who require burn center referral prevents mortality and morbidity. The majority of pediatric burns will require some type of outpatient care. Therapy is based on depth of injury. Occlusive dressings reduce desiccation of the tissue, which aids in pain management, improves healing time, and reduces the risk of infection. Topical antibiotic ointments are easy to apply and can be utilized on the face. Silver sulfadiazine can be utilized on all other areas, is inexpensive, and is widely available. However, it requires frequent dressing changes and may be difficult to remove. Deeper injuries mandate specialist referral. Close follow up in the outpatient setting prevents complications associated with excess scarring. 

Claire Sanger and Brinda Thimmappa are assistant professors in the plastic and reconstructive surgery department at Wake Forest University Baptist Medical Center, Winston-Salem, NC.

References 

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2. New National Study Finds Decrease in Rate of Pediatric Burns. Center for Injury Research and Policy. 2009. Accessed online: www.nationwidechildrens.org/news-room-articles/new-national-studyfinds-decrease-in-rate-of-pediatricburns?contentid=49195

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8. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine From the Advisory Committee on Immunization Practices, 2010. CDC. Accessed online: www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm

9. Ask the Experts: Diseases & Vaccines: Diphtheria, Tetanus, Pertussis. Immunization Action Coalition. Accessed online: www.immunize.org/askexperts/experts_tet.asp

10. Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med. 1995;2(1):4-10.

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12. Grunwald TB, Garner WL. Acute burns. Plast Reconstr Surg. 2008;121(5):311e-319e.

13. Proksch E, Jensen JM, Crichton-Smith A, Fowler A, Clitherow J. [Rational treatment of first-degree burns]. [Article in German] Hautarzt. 2007;58(7):604-10.

14. Maenthaisong R, Chaiyakunapruk N, Niruntraporn S, Kongkaew C. The efficacy of aloe vera used for burn wound healing: a systematic review. Burns. 2007;33(6):713-8.

15. Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res. 2006;27(1):66-81.

16. Rezaei E, Safari H, Naderinasab M, Aliakbarian H. Common pathogens in burn wound and changes in their drug sensitivity. Burns. 2011;37(5):805-7.

17. Demling R, DeSanti L. Topical doxepin cream is effective in relieving severe pruritus caused by burn injury: a preliminary study. Wounds. 2001;13(6):210-15.

18. O’Brien SP, Billmire DA. Prevention and management of outpatient pediatric burns. J Craniofac Surg. 2008;19(4):1034-9.