The ABC’s Of Pediatric Burns

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The ABC’s of Pediatric BurnsThe ABC’s of Pediatric BurnsShawn D. Larson, MD, FACSDivision of Pediatric SurgeryCoding Fiesta 2019October 26, 2019Disclosures I have no relevant financial disclosures– Research Support: NIH GMS– Site PI, MediWound NexoBrid clinical trial I have no known conflicts of interest Graphic photographs of burnsObjectives1. Recognize that children require a specializedapproach and resources2. Recognize that pediatric trauma and burninjury is a significant public health issue3. Discuss pediatric burn management4. Why specialized burn management mattersCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20191

The ABC’s of Pediatric BurnsAre Children Just LittleAdults?The Myth“Our pediatric colleagues arewrong children are smalladults you just have to runthe IV slower ”‐Attributed toNorman E. McSwain Jr, MD FACS1937 – 2015William E. Ladd, MD 1906 – Graduates from Harvard (MD)– Trained in gynecology– Practices general surgery 1910 – Begins volunteering at(Boston) Children’s Hospital– “The Children’s was my very first andmost permanent love.”– Increasingly devotes more time to thestudy of pediatric diseases 1911 & 1913 – Publishes experienceswith intussusception in BostonSurgical JournalWilliam E. Ladd, MD(1880 – 1967)– Demonstrates reduction in mortality to45% (would later mortality to 5%)Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20192

The ABC’s of Pediatric BurnsIssues with Surgery in Children 1910 Dismal survival– Appendicitis 4th leading cause of death in kids 12 yrs– Colostomy 90% (or higher) mortality– Intussusception, pyloric stenosis – near 100% mortality IV fluid therapy is poorly understood Few available medicines (no antibiotics)– Anesthesia issues in children (none or too much) Adult surgical instruments Challenges with diagnosis (i.e. rare conditions) Few surgeons willing to operate on childrenThe First Rule of Pediatric Surgery“ a child was not just a diminutive man orwoman the adult may safely be treated as achild, but the converse can lead to disaster ”‐Dr. W.E. LaddBoston Surgical Society Address“Nonsense! Anyone who can work on a bunnyrabbit can operate on a child!”‐Dr. Edward Churchill*(*attributed)Summary #1 Children have unique:– Physiology and anatomical considerations– Developmental and psychological considerations Children deserve specialized, age, anddevelopmentally appropriate care Trauma care is in Pediatric Surgeon’s DNA Children are not little adults!Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20193

The ABC’s of Pediatric BurnsWhy Care About PediatricTrauma & Burns?Childhood Injuries Each year:– 225,000 hospitalizations– 9,000,000 ED visits– 11,000,000 office visits Pediatric injuries cost 87 billion annually inmedical and societal costs– Death, hospitalizations, ED visits, etc.Source: Centers for Disease Control & Prevention (www.cdc.gov/safechild)Pediatric Trauma 1 child every hour dies from an injury– 1 in 5 child deaths is due to injury Every 4 seconds – a child is treated in an EDfor injury 9000* US children died of injury in 2009– Most are preventableRemains the #1 cause of childhood death*Ages 0‐19Source: www.cdc.gov/safechild/nap/index (accessed: 8/5/2017)Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20194

The ABC’s of Pediatric Burns10 Leading Causes of Death by AgeGroup, US ‐ 2015Causes of Death: Ages 1 – 14 yearsUS enital NeoplasmAnomalyInjurySource: National Center for Injury Prevention and ControlCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20195

The ABC’s of Pediatric BurnsCauses of Death: Ages 1 – 5 yearsUS 20096005004003002001000MVCDrowningFire/burn Suffocation PedestrianSource: National Center for Injury Prevention and ControlPediatric Burns – By Numbers 100,000 children 14 years old were treated for burnsin hospital emergency rooms in 2007.– 20% were 4 years old 70% of pediatric burn injuries fire/flame, scald– Scald burns most common cause of burn injury in children 5 years old– Majority are from hot foods and liquids Burns in children are responsible for nearly 2,500deaths per year Up to 25% of burn admissions child abuse‐related– Mostly infants and toddlersCoran et al. Pediatric Surgery, 7th ed. 2012.Holcomb et al. Ashcraft’s Pediatric Surgery, 6th ed. 2014.Burn‐related Injury Rates (1990‐2006)D'Souza AL et al. Pediatrics 2009;124Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20196

The ABC’s of Pediatric BurnsRates of Burn Injuries by Type for Children 6 Years of AgeD'Souza AL et al. Pediatrics 2009;124Inpatient Burn Care Costs Billing at US hospitals for pediatric acuteburn injury (2001‐2009)– Mean of 1.9 hospitalizations over 3‐4 years– Mean total cost of hospitalization perpatient: 83,535– Median total cost of hospitalization perpatient: 16,331Carey et al. J Trauma Acute Care Surg 2012Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20197

The ABC’s of Pediatric BurnsIf Children Are Different,Then How Do WeApproach the Burn?Approaching the Burn Stop the burn process Primary Survey– ACS ATLS & ABA ABLS Protocols (ABC’s)– Priorities remain the same as adult Special considerations for anatomy, physiology, anddevelopmental stage Initial ResuscitationSecondary SurveyInitial Debridement and Wound CareSkin Coverage &/or graftingStop the BurnCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20198

The ABC’s of Pediatric BurnsPrimary Survey (ABC’s) Airway– Pediatric airway considerations– Inhalation injury airway edema Breathing– Ventilation Circulation– Shock, vascular compromise– IV access Disability/Neuro Environment/Exposure– Prevent hypothermiaPediatric Airways Narrow, funnel‐shaped– Usually anterior– Smaller children prone tobronchospasm Emergent intubation rarelyindicated for burn injuries– STOP & Think– Back up plan– “Don’t take away a child’s airwayunless you have to”Inhalation injury Breathing super heated air smokeBurns to the airwayDebris in distal airway (‘soot’)Carbon Monoxide (indoor burn) other gasesBronchoscopy and washouts– Bronchodilators– Aerosolized heparinCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 20199

The ABC’s of Pediatric BurnsTime to Rethink Intubation? Retrospective study n 51 patients (2013 – 2017)- Flash burns(51%)(98%)& flamemanagedburns (35%)without50/51patients- 50% occurred in closed space- All patients had intubation“traditional” symptoms ofinhalation injury- Use of flexible fiberoptic laryngoscopyMoshrefi et al JBC&R 2019; 40(3)Initial Resuscitation IV access– 2 large bore IV’s– Early interosseous access– Avoid burned extremity IV Fluids– Maintenance for 15% TBSA– Fluid boluses (20 ml/kg) 15% TBSA Delay in treatment– Significant fluid demands Consider Foley for 15% TBSA Pain medication!Resuscitation Resuscitation Formulas– Traditional Parkland 15% TBSA 4ml/kg/%TBSA e.g. 60kg * 45% burns * 4ml/kg/%TBSA 10,800 mL ½ in first 8h; remainder over 16h– Judicious IV Fluid resuscitation is key! Prevent fluid overload (edema) Transition or transfer to definitive care Nutrition– Early enteral access & feedsCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201910

The ABC’s of Pediatric BurnsFluid Resuscitation Matters Authors noted significant differences in TBSAestimates and fluid resuscitation calculations– TBSA often overestimated– 60% of referred children received significantlymore fluid than necessaryGoverman et al. JBC&R 2014: 36(5)Secondary Survey Systematic head‐to‐toe Formal evaluation of burn extent– Total Body Surface Area percentage (TBSA%)– “Rule of 9’s”– Lund & Browder Chart– Using patient’s palm of hand (smaller children) Labs, Imaging, etc.TBSA % ‐ “Rule of Nines”Klein GL & Herndon DN Pediatrics in Review 2004;25Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201911

The ABC’s of Pediatric BurnsLund‐Browder Chart TBSA%Accurate Estimation of TBSAInitial estimate 15% TBSAFinal estimate 6% TBSABurn DepthCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201912

The ABC’s of Pediatric BurnsSuperficial (1st Degree)Superficial Partial‐thickness(2nd Degree)Deep Partial‐thickness (2nd Degree)Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201913

The ABC’s of Pediatric BurnsFull Thickness (3rd Degree)4th Degree (bone & tendon)Initial Debridement & Wound Care Cleansing & debridement Topical antimicrobial agents Dressings– Compresses– Biosynthetics– Biologics Appropriate analgesia– First experience is criticalCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201914

The ABC’s of Pediatric BurnsAntibiotic Ointment vs.Silver Sulfadiazine Use of antibiotic ointment was superior tosilver sulfadizine in regards to time to healing– Associated with less pain– Silver sulfadiazine has specific uses in childrenRaymond SL et al. Am Surg 2018; 84(6)Excision & Grafting Follows fluid resuscitation Excision– Sharp / Hydrosurgery – to healthy bleeding tissue– Conservative excision in childrenExcision & GraftingTOOLS OF THE TRADECoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201915

The ABC’s of Pediatric BurnsGrafting Allograft Xenograft Autograft– Split thickness– Full thickness– Sheet graft Cultured Epithelial Autograft(CEA)– Compassionate use only (FDA)– “Experimental” Use a conservative approachSummary #2 Pediatric trauma remains the #1 cause of death inchildren– Most trauma deaths are preventable– Burns remain a significant cause of death While the assessment priorities do not change, mustconsider:– Special anatomical considerations– Age‐specific physiology– Developmental age & needs Accurate assessment of size & depth of burn wound isessential Early but conservative excision “Phone a friend” – transfer to centers of expertiseCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201916

The ABC’s of Pediatric BurnsWhat Makes the UFPediatric Burn ProgramDifferent?Answer: The TeamUF Pediatric Burn Care Overview Provide comprehensive burn care to pediatric patients and families witha multidisciplinary team– 24/7 Pediatric Surgical coverage– Care for burn wounds up to 50% TBSA– Specialized resources for children 24/7 PICU with CCM and sedationPediatric Anesthesia & Pediatric Specialist Surgeons (Hand, Plastic, Ortho)Pediatric PT & OTSocial Work & Child Life SpecialistSpecialized Burn NursesChild Psychiatry & Pain management– Use cutting edge technology Cultured Epithelial Autograft PTSD screening Virtual Reality– Research and Quality Improvement Initiatives– Work closely with law enforcement, Child Protective Services and DCF toprotect children that have suffered intentional burn injuriesCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201917

The ABC’s of Pediatric BurnsUF Pediatric Burn Care Average 188 pts/yearTotal Admissions– High volume center Performed 506 IP dressingchanges FY‐18250– 450 Floor– 56 PICU w/ sedation200 528 Outpatients appointments150– Weekly clinic w/open access Outpatients evaluated by:––––100Pediatric ARNP & SurgeonPediatric Burn RNPediatric OTChild Life/Social Work500 Burn Clinic provides the abilityto follow long term outcomesand functionFYFYFYFY2014 ‐ 2015 ‐ 2016 ‐ 2017 ‐15161718FY2018 ‐19Previous Pediatric Burn Care ‐ SilosPediatricBurnPatientPediatric SW &Child LifePediatricCCMPediatricSurgeryPCP orPediatric EDPediatric Pediatric OPRehabClinicAdult BurnTeamPediatricSurgeryCurrent Patient Centered CarePediatricSurgerySpecializedPediatric BurnClinicPediatricBurnPatientPeds SocialWork & ChildLifePedsPT/OT/RehabCoding Fiesta 2019Pediatric CCMSpecialistBurn Nurses &Burn CntrExpertiseResearch & QIShawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201918

The ABC’s of Pediatric BurnsThe Team in ActionPatient T 14 yo male, unrestrained backseat passengerin single vehicle crash– Patient came into contact with high voltage livewire during escape– No LOC / other significant injuries– Initially estimated burn 25% TSBA Following Burn ICU debridement 45% TSBA Burns to:––––Bilateral UETorso / groins / genitalsBilateral LE (with circumferential burns to LLEFull thickness burns (3rd & 4th degree [foot])Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201919

The ABC’s of Pediatric BurnsHospital Course (briefly) 4 month hospitalization Rehab 2 weeks Underwent 10 operations– Debridement & allografting– Left below knee amputation (BKA)– Additional debridement & grafting– Cultured Epithelial Autograft (CEA) placement 48 sheets (2880cm2 or 9 ft2)– Final operation (EUA, staple removal)Coding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201920

The ABC’s of Pediatric BurnsCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201921

The ABC’s of Pediatric BurnsBurn SurvivorFinal Summary UF Health Shands Children’s Hospitalprovides comprehensive burn care tochildren and families High volume centers improve outcomes The “Team” matters Children require and deserve specializedattention and treatmentAnd Finally Trauma & Burn care is the chance tosave a life Pediatric Trauma & Burn care is thechance to save a lifetimeCoding Fiesta 2019Shawn D. Larson, MD, FACSUF Division of Pediatric SurgeryOctober 26, 201922

The ABC’s of Pediatric BurnsQuestions Email:– [email protected] (