BURNS
Reconstructive surgery.
The numbers are overwhelming: domestic accidents account for 70% of burns in children.
Prevention is possible, however, and even more necessary considering domestic accidents because the social, educational, medical and professional problems faced by the severe burned.
Most of the time, it is the very evolution of the pathology that can definitively differentiate between intermediate burns and severe burns. However, pending the actions of the specialists, some beneficial actions may be performed at the scene of the accident, even in the office, if the injury allows it. The pharmacist, who is familiar with compression therapy for scars, should be able to help those around the victim to ensure the continuation of treatment at home.
BURNS IN CHILDREN
The burning of the child is not a disease but the consequence of a lack of vigilance, according to Dr. D.B.S., of the Department of General Plastic, Reconstructive and Aesthetic Surgery, attached to the intensive care unit of burned children at Trousseau Hospital in Paris. Indeed, domestic accidents cause 70% burns in children. Often caused by "scalding," they affect especially to children under the age of 5 years. Mortality from burns is 1%, mainly due to infections and secondary metabolic complications, according to statistics from the Institute Mother and Child of the University Hospital of Rennes.
M.G.: Which agents cause the most common burns in children?
Dr: The spillage of hot liquids (water, milk) and a rush to reach the mouth cause the majority of burns in children. More generally, the burn is a progressive necrosis created by the heat, electricity or chemicals.
M.G.: How do you determine the severity of a burn?
Dr: A deep burn is recognized primarily by the absence of pain and sensibility. However, superficial and intermediate burns trigger severe pain, sensibility being preserved, and the rapid appearance of blisters. It is impossible to know immediately if a burn is superficial of intermediate. So I redoubled caution in certain locations such as nostrils, eyelids, ears (that is to say, the thin-skinned organs) and scalp because the hair holds the liquid longer. Mostly it is the evolution of the pathology that can determine definitively between superficial burns, that heal after 2l days, intermediate burns that suppurate until the first day and did not heal before the 21st day. In summary, we believe that the burn is mild when the area is small (less than 5% of body surface area) and shallow (second degree, superficial). Beyond, we believe that the accident was serious.
M.G.: In what part of the body are located mostly the burns?
Dr: The body regions most frequently affected are the uncovered areas: the palm of the hand, face and limbs.
M.G.: When you perform the clinical assessment, what factors come into play?
Dr: Several parameters must be considered: surface, depth and location of the lesion, on the one hand, and secondly, the patient's age and the ground. The surface is related to the percentage using Lund and Browder charts, more accurate than the conventional rule 9 of Wallace.
As for depth, there are three degrees of involvement.
The first degree is characterized by painful erythema of the skin without blistering. Only the epidermis is affected, the healing occurs in a few days without consequences. The second degree is identified by the appearance of blisters due to the separation of tissues.
The superficial second degree burn, in the well vascularized red basement, generates intense pain. However, it can heal without scarring in one to two weeks. The deep second-degree burn is marked by a surface of white skin, dotted with red. This burn heals after several weeks and causes scarring. It is moderately sensible. In fact, the less it hurts, the more severe is the lesion.
The third degree burn causes necrosis that destroys the epidermis. The skin is white or brown, dry, without blistering. The injured area has lost its sensibility because of the destruction of nerve fibres. The subcutaneous venous network is apparent.
| CONSEILS AUX PARENTS |
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The burn is a very serious problem: no spontaneous healing can occur, we must resort to surgery to perform a skin graft. I am vigilant about the age of the child on one hand because, because in younger than two years, the prognosis is catastrophic; and secondly, his general condition: when there are associated diseases, the prognosis is worse. Finally, I particularly stress the location. When burns occur in the perineum, the risk of early and intense bacterial contamination increases. Similarly in the case of lesions on the face, respiratory complications by pharyngo-laryngeal and glottic swelling may occur.
M.G.: What beneficial actions can be made in the accident site pending the arrival of the emergency services?
Dr: In all cases, remove contaminated clothing. When the burn is on an area of the body not covered with clothes, the affected area should be washed thoroughly for 10-15 minutes, including the case of the eye (ocular burns are almost always chemical), to cool the burn.
You can use tap water or the shower; it must be cold but not chilled. This slows the spread of heat deep into and reduces the severity of the lesions. If the burn is superficial (first degree), apply Biafine. Cover the burn with a clean damp non-fluffy lint. If the burn is a little deeper (second degree), we can cut the possible blisters with clean scissors. Tullegras and compress are recommended. Pain can be soothed with Doliprane.
These tips are suitable for burns of first and second degree. However, even in cases of minor burns, the pharmacist may recommend a visit to the doctor, especially if the child is very young. The most serious burns require the use of the emergency services and emergency hospitalization in a specialized service. In this case, do not give anything to eat or drink. Vaccination against tetanus is routinely checked.
M.G.: What complications can occur as a result of severe burns?
Dr: In the case of severe burns treated at the hospital, we may be faced with early and late complications.
At the beginning of the burn, the superficial infection is inevitable. However, it must be minimized by the very strict application of rules of asepsis. The generalized infection (bacterial, sepsis) may compromise the vital prognosis. The occurrence of fluid and electrolyte disturbances should be particularly monitored, as the loss of plasma and the local edema will cause a state of shock. If it is not stopped, it can lead to renal failure. Vomiting, digestive atony (ileus) and cold will increase these disorders, and in the long term, can cause weight loss, malnutrition and stress ulcers.
| DO NOT WORSEN THE LESIONS |
The pharmacist must educate young parents to avoid some errors that may aggravate the consequences of burns. Thus it is strongly discouraged to apply:
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In the long term, the burn scar exposes to itching. Treated with antihistamines, they improve with time. Disturbances of skin pigmentation (hyper or hypo-pigmentation) appear and persist. The scar can be hypertrophic around the graft and areas of spontaneous healing.
The major sequelae of wound healing: the skin retraction and scar bands that block mobility. They require surgical treatment. Finally, psychological and aesthetic difficulties occur very often. Patients must learn to live with their new image and accept outside scrutiny.
M.G.: The burns are part of serious accidents and have serious consequences that most of the time, could be avoided. What do you recommend as a preventive measure?
Dr: In talking to the parents of the child victim, I see that they are responsible too often. Through carelessness, lack of supervision or just ignorance, they did not see the danger. In the most disadvantaged communities, many families lack space and comfort: they are more vulnerable to accidents. I do not insist on the problems of abuse that unfortunately we are facing. I think it is a real public health problem that only prevention and education at home will stop.
Interview by M.G.
| CURRENT CARE PROTOCOL - TROUSSEAU HOSPITAL (Paris) |
In case of superficial burns of first or second degree, local care are made:
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EMPOWERING PARENTS
In case of serious burns, the child, after his/her hospitalization, should continue to receive special care, inseparable from the treatment. Then are the parents who take over at home.
The child that has suffered a severe burn is hospitalized for curing the burn and / or skin grafting. Then he/she will be followed as an outpatient for guided healing by regular change of dressings. Parents must continue to repair the accident and ensure the continuation of treatment at home. Some information is essential to not raise concern.
Avoid sun exposure
Healing is obtained and, at this stage, the evolution looks favourable, but the risks of sequelae are still significant.
The burned areas are scar areas. This is a very sensitive and fragile skin that the slightest injury can damage. We must therefore avoid aggression from the sun and it is inadvisable to expose a burn scar in the sun for a year. It is normal that exposure to different temperatures (hot or cold) causes a red or purple coloration. It fades with time. A more or less intense itching is common in healing areas. It can expose to scratching. We then prescribe syrup to relieve the child. This itching diminishes over time.
It is not uncommon to observe disorders of pigmentation (hyper-or hypopigmentation). Unfortunately, these disorders are definitive. The scar of a burn often evolves spontaneously towards hypertrophy (thickened and swollen) and retraction, more commonly in children with black or brown skin. Hypertrophic scars usually occur around the grafts. The hypertrophic scars appear preferentially on areas of spontaneous healing.
Pressure garments
The most frequent major sequelae thus result from retraction of the skin. Only massage and continuous compression with pressure garments help prevent such complications and improve the aesthetic appearance of scars.
The continuous compression is achieved using custom-made pressure garments.
| The scarred areas are very fragile. The pharmacist should advise parents and guide them in follow-up care. |
To be renewed every three months, depending on the child's growth, the garment is worn at all times, night and day for a period of at least one year. It will be removed only for bathing and massage.
In certain circumstances, special care is required. Especially in case of severe scarring, filiform or jet showers can be effective.
Then, the doctor will propose thermal treatments at a rate of twice a year for some years. Moreover, when the burns affect the joints, physical therapy may be beneficial to mobilize the joints more or less blocked.
Finally, if despite massage and wearing compression garment, hypertrophic scars remain or develop a linear scar or band causing functional impairment, surgery can be indicated. The surgeon will propose and explain the intervention to parents during the consultation process in place to ensure regular monitoring.
INFORMATION FOR PARENTS
Your child has been burned,
He/she was hospitalized for curing and / or grafting of the burn.
He/she was followed in outpatient clinic for a guided healing by regular dressings.
Healing is achieved and at this stage the evolution appears to be favourable but beware! sequelae are frequent.
The burned areas are scar areas. These are very sensitive and fragile skin that the slightest injury can damage. That is why we must avoid the aggression of the sun. Therefore, do not expose the burn scar in the sun for a year. It is normal that exposure to different temperatures (hot or cold) causes the scars to become red or purplish. It fades with time.
Pruritus (itching) is more or less intense in the areas of healing. It can expose to scratching. Syrup will be prescribed to relieve your child. This itching diminishes over time.
It is not uncommon that disorders of pigmentation (hyper or hypopigmentation) be present. They are definitive.
You should know that the burn scar evolves spontaneously, often to hypertrophy (thick and puffy appearance) and retraction, more commonly in black and brown skins.
The most frequent major sequelae thus are the result of a retraction of the skin.
Hypertrophic scars usually occur around the grafts while the fibrous plates are possible on fibrous areas of spontaneous healing.
| MASSAGES AND HEALING |
| Massage must be performed with an oily moisturizing cream (like Biafine, Jonctum or calendula). We must press the scar with the thumbs using circular movements, four times a day, regularly for one year. |
Only massages and continuous compression with pressure garments help prevent such complications and improve the appearance of scars.
- The massages. They must be:
- made with an oily moisturizing cream. Like biafine, calendula or jonctum.
- reinforced with circular movements and a sufficient pressure using the thumbs.
- frequently, 4 times a day.
- regularly, for at least one year.
- Continuous compression: a custom-made compression garment is fashioned.
It must be:- renewed every 3 months, depending on the growth of the child.
- worn continuously, day and night.
- removed only for bathing and massage.
- worn for a period of at least one year.
Special cases:
- In the case of severe scarring, filiform or jet showers can be effective.
Thermal treatment will be proposed by the doctor. They must be repeated two times per year for a few years. - In the cases of burns in joint areas, the doctor may prescribe physical therapy for the mobilization of the joints that are more or less blocked.
- If despite massage and wearing pressure garments, hypertrophic scars remain or a lineal scar that causes functional impairment, a surgical procedure may then be indicated.
It will be proposed and explained by the surgeon during the many control visits instituted for routine monitoring.