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Education Newsletter

Offered by the PTS Education Committee

Journal Scan:
Burn injuries

Prepared by: Mark Johnston, RN, Manager Burn Program, Regions Hospital, St. Paul, MN.

Regions Hospital Burn Center

Why this topic is relevant:
Burn injuries represent the 4th most common cause of unintentional injury and death in children and adolescents accounting for 400 deaths per year in the United States. Children sustaining moderate to severe burns may undergo initial treatment in the PICU, however, little data are available regarding the epidemiology, management or outcomes of such patients.

Article #1:

Age-Based Characteristics of Pediatric Burn Injuries From Outdoor Recreational Fires
Zola Trotter, MD, Kevin Foster, MD, Shailesh Khetarpal, MD, Madhumita Sinha, MD
Journal of Burn Care & Research, iraa064, https://doi.org/10.1093/jbcr/iraa064
Published:
04 May 2020

Abstract
Accidental burns from outdoor recreational activities, such as campfires, bonfires, ceremonial fires, and firepits, are not uncommon; however, few studies describe the nature of such injuries in children. The objective of this study was to examine the age-based pattern of pediatric burn injuries from outdoor fires. Children and adolescents 0 to 18 years, admitted to the Burn Center between 2008 and 2018 with acute burn injuries from outdoor fires, were included in the current study. Demographic and clinical data were obtained from the burn injury database. Patients were categorized into three age groups: 0 to 5 years, 5 to 10 years, and 10 to 18 years. One hundred and sixty-seven children were included in the data analysis, the mean age of the cohort was 6.4 (SD ¡À 4.9) years, and the majority (66.5%) were males. More than half (52.1%) were less than 5 years of age, they commonly sustained hand burns and frequently required inpatient burn management. Burn severity varied between age groups, and the mean total burn surface area (TBSA) was significantly higher in adolescents (10.9%). Almost half the injuries (49.7%) resulted from a fall onto a campfire, bonfire, or a firepit. In this study, we found age-specific variation in the mechanism and pattern of burn injuries. Children at least 5 years and adolescents were least common victims of burns due to outdoor fires but suffered from more serious injuries with significantly higher TBSA involvement, longer intensive care unit, and ventilator days. Raising awareness among parents, caregivers, and children about outdoor fire safety is important for the prevention of such injuries.

Article #2:

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?
Niti Shahi, MD, Maxene Meier, MS, Ryan Phillips, MD, Gabrielle Shirek, BA, Adam Goldsmith, BA, John Recicar, RN, Jeannie Zuk, PhD, Alan Bielsky, MD, Myron Yaster, MD, Steven Moulton, MD
Journal of Burn Care & Research, iraa049, https://doi.org/10.1093/jbcr/iraa049
Published:
18 April 2020

Abstract
Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child¡¯s care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child¡¯s pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ¡İ12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child¡¯s opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ¡Ü 12 years old with burns that cover ¡İ3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Article #3:

Beyond the Burn Center: Creating Nursing Clinical Guidelines for Pediatric Burn Patients That Present to Community Emergency Departments
Jillian Nickerson, MSN, RN, CPEN, TCRN, Paul C Decerbo, MSEM, NRP, EMS-IC
Journal of Burn Care & Research, Volume 41, Issue Supplement_1, March 2020, Pages S226-CS227, https://doi.org/10.1093/jbcr/iraa024.362

Abstract
The goal of this project was to improve the initial care of pediatric burn patients that present to community hospital emergency departments before transfer to a burn center. The pediatric burn center received a transfer of a burn patient from a community emergency department that showed there was room for improvement on the initial care before transfer to the burn center.

Results
This project resulted in a multi-site collaborative effort which produced a thorough and easy to follow algorithm which takes the care provider through each step of the initial resuscitation of a pediatric burn patient. The algorithm initiates with the primary survey and moves through to the secondary survey with individual color coded categories for each thickness of burn. These categories run through the treatment recommendations while adhering to burn center¡¯s treatment recommendations. This all terminates into a disposition determination for both minor and major burns. The major burn category runs through the transport criteria set forth by The American Burn Association.

Conclusions
Phase one of this project concluded with a collaborative effort between a Community Hospital ED and a Level 1 Burn Center ED. This coordination established an evidence based practice guideline allowing two completely separate departments within the state to provide synergistic and coordinated care to one of the most vulnerable populations.


CME Opportunitues

This is a no cost 58 minute podcast where Dr. Rajan Thakkar, Member of the Pediatric Trauma Society and Pediatric Burn Surgeon from Nationwide Children¡¯s, stops by the studio and discusses pediatric burns and their care. Burn classification is reviewed as well as initial and ongoing management, surveillance for complications and anticipatory guidance for families referred to a comprehensive burn center.

CME/CNE Link

This is a no cost 1 hour video based lecture that describes the incidence of common burn injuries, risk factors and injury prevention strategies as they apply to patients in the pediatric age group. It discusses how to correctly identify appropriate assessment, principles of initial resuscitation, diagnostic/imaging studies, and principles of injury specific continued care in the injured child. Finally a discussion will help to identify appropriate priorities in the evaluation, initial management, and continuing care of the injured child with emphasis on current evidence-based practice recommendations and guidelines.

CME/CNE Link