**7. Treatment of burns**

were more common; these patients were more likely to require skin grafting and treatment in the intensive care unit [12]. Moreover the abused/neglected children were more likely to come

The appropriate first aid after burn injury is very important in reduction of burn depth, which means that it influences the requirement for surgical treatment, can shorten the hospitaliza-

According to WHO, the person who gives the first aid to the burned child should stop the burning process by removing clothing and irrigating the burns; extinguishing flames by allowing the patient to roll on the ground, or by applying a blanket, or by using water or other fire-extinguishing liquids; use cool running water to reduce the temperature of the burn; in chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water; and wrap the patient in a clean cloth or sheet and transport to the nearest appropri-

WHO also pays attention on the actions that the person who gives the first aid to the burned child should not do; for example, do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals, etc.); do not apply paste, oil, haldi (turmeric), or raw cotton to the burn; do not apply ice because it deepens the injury; avoid prolonged cooling with water because it will lead to hypothermia; do not open blisters until topical antimicrobials can be applied, such as by a health-care provider; do not apply any material directly to the wound as it might become infected; and avoid application of topical medica-

The person who gives first aid to the child after the burn injury is usually the person that was present during the accident—in most of cases—the parent. Unfortunately, the own results indicate that parents do not provide first aid to burned children correctly. The most common

The aim of prehospital care is stabilizing ABCDEs (airway, breathing, circulation, disabilities, and environment control), preventing ongoing burn injury and provision of analgesia, cover-

It is worth to underline that also first aid provided by medical stuff in the place of the injury is not correct. The situation seems surprising, because in Poland young doctors are trained in

Nessler et al. conducted the pilot study (the anonymous questionnaire) among young doctors in Malopolska region (Poland) to evaluate the knowledge of burn first aid, because many patients admitted to burn centers in Poland receive inadequate treatment just after burn injury. The questionnaire verified the respondents' knowledge about appropriate first aid provided several minutes after burn trauma and included questions about possibilities of actions after

tion until the patient has been placed under appropriate medical care [2].

mistakes were no cooling the burn wound and no analgesics used [13].

ing area involved, and rapid transfer to emergency department [9].

first aid (including first aid in burns) during studies.

from single parent families [12].

282 Essentials of Accident and Emergency Medicine

ate facility for medical care [2].

tion time, and results in better esthetic scar.

**6. First aid in burns**

Care for burned pediatric patient is a challenge for medical and paramedical staff. Treatment of burns is multidisciplinary. According to Juan P. Barret and David N. Herndon, in the burn team, apart from surgeons who specialize in the treatment of burns (general, pediatric, and plastic surgeons), should work also nurses (experienced with care for burned patients), intensive care professionals, scrub and anesthesia nurses, case managers (acute and reconstructive), anesthesiologists, respiratory therapists, rehabilitation therapists, dietitians, psychosocial experts, social workers, volunteers, microbiologists, research personnel, quality control personnel, and workers of support services [1].

The triage decision is based on the extent of burn, body surface area involved, type of burn, associated injuries, any complicating medical or social problems, and availability of ambulatory management [4].

In addition to what has been mentioned above, the criteria that are taken into account to decide if the patient requires hospitalization or referral to the center of burns are anatomic location of the injury and age of the patient.

The most important aspect in pediatric population is age—all the children younger than 1 year old should be hospitalized. Moreover all patients with third-degree burns should be treated in the hospital. Apart from depth of the injury, also extension of burn is taken into account. Hospitalization should be considered in children from families with lower socioeconomic status. Pediatric patients with burns on the face, hands, feet, genitalia, perineum, and joints; all patients with inhalation injuries and electrical or chemical burns; and also patients with associated injury should be hospitalized. Moreover, each patient with suspected nonaccidental injury should be admitted to the hospital. In Poland children with burns are hospitalized in departments of pediatric surgery (with personnel educated about care of burnt patients) or burn centers (children with major burns).

It is possible to classify burn injury according to the severity into minor, moderate, and major [1]. Patients with moderate and major burns require hospital treatment. Minor burns are burns covering less than 15% total body surface area in adults and less than 10% total body surface area in children; less than 3% total body surface area is full-thickness burn; they do not involve the head, feet, hands, or perineum [1]. Moderate burns are burns covering 15–25% total body surface area in adults and 10–15% total body surface area in children, full-thickness burns 3–10% total body surface area, and superficial partial-thickness burns of the head, hands, feet, or perineum [1]. Each case of suspected child abuse is classified as moderate burn [1]. Moreover, in this group, all patients have burn injury and concomitant trauma, significant preexisting disease, and extreme age (neonate and infants). Major burns cover more than 25% total body surface area in adults and more than 15% total body surface area in children [1]. In this group are full-thickness burns of more than 10% total body surface area, deep burns of the head, hands, feet, and perineum, inhalation injuries, chemical burns, and electrical burns [1].

**8. Consequences of burns**

barrier to infective organisms [9].

increased evaporative water loss [10].

result in difficulties in eating and drinking [4].

impact of disfiguring burns [4].

The consequences of burns are mostly related with the loss of skin functions. The skin is the largest organ in the body and plays a crucial role in regulating body's temperature by preventing heat loss to the environment. It also prevents water loss from the body and acts as a

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It is important to underline the fact that children have a greater ratio of surface area to volume of the body, increased metabolic rate, increased heat loss (less fat and shivering), and

Possible complications of burns include variety of problems, for example, sepsis, hypovolemia, hypothermia, carbon monoxide poisoning, cyanide poisoning, gastric ulcers, cardiac dysfunction, hypermetabolic state, renal failure, transient antidiuresis, and anemia [4]. Another possible complication is laryngeal edema that can be treated with endotracheal intubation and tracheostomy [4]. Moreover, due to edema, compartment syndrome can develop, which means that the patient requires escharotomy [4]. Escharotomy technique involves making longitudinal incisions in segments with inelastic circumferential burns, usually of full thickness [1]. Possible contractures should be treated with physical therapy. Due to the risk of psychological trauma, it is important to provide to burn patients psychological rehabilitation [4]. The possible complications from respiratory system include pulmonary infiltrates, pulmonary edema, pneumonia, and bronchospasm [4]. Inhalation injuries may result in bronchospasm, airway inflammation, and impaired pulmonary function [4]. Moreover, they can

Among long-term consequences of burns in children are physical scarring and emotional

The risk of burn is the highest in children under 2 years old and in boys [5, 6]. Most of burns occur at home, when the child is under the supervision of parent. Appropriate supervision seems even more important than safe environment in prevention of burns in children [16].

Most of burns in children less than 2 years old occur when their mother or father is in the same room. The researchers found that family characteristics play a crucial role in increasing the likelihood of the injury. Lower maternal education, young age of mother and unemployment,

It is worth to underline that economic situation of the family is also important, because differences in the income result in differences in living conditions. The home environment plays an

Among effective strategies that reduce number of flame burns in pediatric population are

**9. Risk factors of burns in children: social, economic, and** 

and lone parenthood are identified risk factors of burns in children [17].

important role in the risk of burn injury among children.

installation of smoke alarms and smoke detectors [16].

**environmental issues related with burns in children**

Initial treatment follows the ABCDEs of resuscitation. The aim is to stabilize the airway, breathing, and circulation [9].

Airway management should also include assessment for the presence of airway or inhalation injury [4]. In the cases of suspected airway burns, early intubation can be considered [9]. Children with stridor due to upper airway compromise also require urgent intubation [9]. Potential indications for ventilation are excessive burns that cover over 60–70% of total body surface area, full-thickness circumferential chest burns, and severe inhalation lung injury causing pulmonary edema and hypoxemia [9].

All children with burns over 20% of total body surface area should have intravenous access (peripheral access through non-burnt skin is preferred) [9]. Fluid resuscitation rates should be calculated using the time of burn, patient's body mass, and the surface of burn with the use, for example, of Parkland formula [9]. To determine the adequacy of fluid replacement, monitoring of urinary output is useful [9]. Some patients require nasogastric tube. Important issue in care of burned patient is analgesia.

The treatment of burns can be conservative and operative. Fortunately, most of children do not require surgical treatment, which is reserved for patients with deep (third degree) burns. Conservative treatment is indicated in children with superficial, partial-thickness burns.

Among the most often realized surgical procedures are escharotomy (rare), excision of the dead tissue, and skin grafting [1]. Escharotomy is indicated in patients with circumferential burns on the chest or limbs. The aim of escharotomy is to release the constrictive eschar. The burned skin should be released by incisions with electrocautery within the lines of escharotomy. Early excision of necrotic tissues and grafting is indicated in patients with full-thickness burns. In Poland burn wounds are covered with autografts (donor site is usually tight, less often scalp or back). Skin grafts can be split-skin grafts and full-thickness skin grafts. Most pediatric patients require split-skin grafts. Full-thickness skin grafts can be necessary in specific areas, such as the face (lips, eyelids, nose), hand/fingers, toes, and genitalia. In cases of extensive burns, it is possible to use meshed skin grafts.

Burn wound dressings play crucial role in the care for patient with burns. Burn dressing should protect the burn wound from further harm, such as desiccation, mechanical trauma, and infection. Moreover, they can facilitate the process of healing and relief pain [10]. The current literature is still inconclusive with regard to the gold standard burn dressing for the pediatric population [15]. In Poland burn wound is usually treated with silver sulfadiazine. However, it is commonly known that the ideal dressing for children should alleviate pain, decrease length of hospital stay, and minimize the risk of complications [15].
