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CHAPTER40

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The Ingestion of Corrosives

What should be your initial rst aid?

CASE 1

A 3-year-old girl drank from an unlabelled soft drink bottle that she found in her father’s garage. She immediately developed severe mouth, throat and epigastric pain and had difculty swallowing. The uid ingested was identied as caustic soda.

Q 1.1

What investigation should be performed in hospital, and

Q 1.2

what major complication of this injury do you wish to prevent?

In children, swallowing corrosive fluids or solids nearly always is accidental, and the exploring toddler aged between 1 and 3 years is most often the victim. Symptoms of caustic ingestion include cervical and epigastric pain, irritability, excessive drooling, dysphagia and respiratory distress. However, about 20% present with no symptoms; in some, this is despite significant oesophageal injury.

Prevention

The most effective way to prevent such accidents is to keep all chemicals used in the home and garden out of reach of small children and in their proper containers. They should not be stored under the kitchen sink or in unlabelled containers. The introduction of safety caps for all bottles containing chemical materials has significantly reduced the incidence of corrosive ingestion in children.

Pathology

The oesophagus is the most common organ seriously injured by corrosive ingestion. Extensive or circumferential oesophageal burns may lead to severe strictures, which cause dysphagia within weeks of injury.

Burns of the buccal mucosa, soft palate or tongue sug-

gest that the oesophagus has been damaged as well.

Mucosal injury and oedema of the larynx occurs in 15%, and may be life-threatening, requiring intubation or tracheostomy.

First aid

1 If ingestion has just occurred, wash off any excess

corrosive material from the lips and skin, using plenty of water.

2 Immediately dilute any corrosive in the mouth,

oesophagus or stomach by giving cold water or milk to drink. Do not attempt to use an antidote acid or alkali because the corrosive may have been identified incorrectly and the chemical antidotes themselves may cause damage. Do not promote vomiting, as the vomitus may include the corrosive material, leading to further insult to the oesophagus and oral cavity.

3 If ingestion of corrosive was not witnessed or con-

firmed by an adult, always assume it has occurred if the lips or mouth are blistered or if the toddler is drooling excessively and unable to swallow saliva.

4 Where the nature or composition of the corrosive is

uncertain, consult the Poisons Information Service by

Jones’ Clinical Paediatric Surgery, Seventh Edition. Edited by John M. Hutson, Michael O’Brien, Spencer W. Beasley, Warwick J. Teague and Sebastian K. King. © 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.

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telephone. Only induce vomiting with ipecac syrup if directed by a poisons service.

5 Send a sample of the corrosive agent with the child

when transferring to hospital if identification has not been made with certainty.

6 All children should be sent to the nearest paediatric

surgical centre as soon as possible after ingestion.

Definitive Management

Upper gastrointestinal endoscopy at about 24 h is performed to assess the severity and distribution of corrosive injury to the oesophagus and/or stomach. This will determine the need for prophylactic treatment to reduce the likelihood of subsequent oesophageal stricture formation. Where there is no damage to the oesophageal mucosa on endoscopy, no treatment is required.

Patchy oedema of the intact oesophageal mucosa is regarded as the minimal degree of burn and is not likely to cause a stricture. No treatment is required, and the patient may leave hospital as soon as normal feeding isre-established. A white mucosal slough or circumferential ulceration is more serious and may lead to subsequent stricturing (incidence varies from 5 to 50%). In these patients, antibiotics may be given to limit the effects of secondary infection. Steroids may diminish the extent of fibrosis, although their value in the early post-ingestion period is uncertain. Oesophagoscopy and dilatation of the oesophagus is performed under general anaesthesia in children with extensive and deep oesophageal burns. This procedure is usually commenced 2 weeks after the initial injury.

If the mucosa has healed and there is no evidence of narrowing, treatment is discontinued. If there are

abnormal findings at 2 weeks, treatment is continued for a further 6 weeks. Where there is worsening dysphagia and the stricture cannot be dilated effectively by bouginage or repeated radial dilatation under fluoroscopic control over many months, placement of an oesophageal stent may be advantageous. If the stent fails to provide an adequate oesophageal calibre, then segmental resection and anastomosis may be required. Occasionally, an extensive resection and replacement of the oesophagus is inescapable; but in the long term, the best oesophagus is the patient’s own, and repeated dilatations are justified to avoid an extensive oesophagectomy.

KEY POINTS

• Oesophageal injury may be minimised by rapid dilution of corrosive by drinking cold water or milk.

• Ulcers on lips or inside mouth suggest oesophageal burn – conrmed by drooling saliva.

• Upper gastrointestinal endoscopy within 24 h determines the severity of the burn and the treatment required.

Further reading

Karagiozoglou-Lampoudi T, Akakidis CH, Chryssostomidou S

etal. (2011) Conservative management of caustic substance ingestion in a pediatric department setting: short-term and long-term outcome. Dis Esophagus 24(2): 86–91.

Kochhar R, Poornachandra KS (2010) Intralesional steroid

injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc 2(2): 61–68.

Millar AJW, Namanoglu A (2012) Caustic strictures of the

esophagus. In: Coran AG, Adzick NS, Krummel TM, Laberge J-M, Shamberger RC, Caldamone AA (eds) Pediatric Surgery, 7th Edn. Elsevier Saunders, Philadelphia, pp. 919–926.

CHAPTER41

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Burns

CASE 1

At 5 P.M., an 18-month-old boy is rushed into the emergency department of a country hospital after tipping hot tea on to himself 10

min earlier. The tea was just boiled and no milk had been added.

The area of scald estimated with a Lund–Browder chart is 15%.

What rst aid and primary management should be initiated

Q 1.1

in the country hospital?

Q 1.2

Does this child warrant referral to the regional specialist

Burns Centre?

CASE 2

A 6-month-old infant brought to your clinic with red, weeping lower legs and feet after being scalded by a hot bath.

Q 2.1

What is the likely mechanism of injury?

A burn may be caused by extremes of temperature, friction, radiation (e.g. sunburn), electricity or chemical agents. In children, more than half of all burns are scald injuries, caused by exposure to hot liquids. Other common mechanisms of burn injury in children are contact with hot surfaces (~20%) and flame burns (~15%). Severity of a burn injury depends on the size and depth of burn, and its anatomical site. Depth of a burn is proportional to both the strength of the injurious agent (e.g. temperature, concentration of acid) and the duration of time the agent remains in contact with the tissues. Burn wound depth may be classified according to the skin layers involved:

1 Superficial: epidermal burns, superficial dermal

burns, mid-dermal burns

2 Deep: deep dermal burns, full-thickness burns

CASE 3

Will and Ali are brought to the emergency department after they poured petrol on a campre. Their faces are blackened and their hair and eyebrows are singed. Q 3.1 What injury is likely to pose the most immediate threat to

health and life?

Most burns are heterogenous with varying depths in the same burn. Epidermal burns are not included when estimating the percentage of total body surface area burned.

First aid and early primary management of even severe burns can be effectively delivered in the prehospital and non-specialist hospital setting. The ongoing care of a child with severe burns requires the services of a multidisciplinary specialist Burns Unit and may extend over many years. Alongside the sometimes more obvious need to manage a child’s burn wound and associated systemic response to the burn insult, the psychological and social needs of a child (and family) with burns are significant. Therefore, health and allied health professionals (e.g. physiotherapy, occupational therapy, play therapy, dietician, psychologist, social

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worker) must work together as a team in the short- and long-term management of paediatric burns.

Prevention

Most burns in children

1 Occur at home (~90%), mostly in the kitchen or

bathroom

2 Are ‘self-inflicted’ despite being in the care or super-

vision of an adult

3 Occur due to exposure to heat (temperatures >50 °C

will produce necrosis) The classic and commonest example of these observations is the toddler at home in the kitchen under parental supervision, who pulls a newly prepared hot beverage onto themselves, sustaining a scald. In older children, flame burns are more common than scalds and are most often the result of playing with matches and flammable fluids.

Prevention of burns rests on three main approaches:

1 Education: of both children and adults, concerning

potential dangers, and the need for continual

vigilance. Government-sponsored prevention pro-

grammes have stressed to the public that burns in

children can be prevented by (i) supervising them, (ii)

separating them from the hazard, (iii) reducing the

hazard or access to it and (iv) removing the hazard. It

is hoped that such messages will achieve a further

reduction in the incidence of burn injuries in chil-

dren: in the last 25 years, the frequency of paediatric

burns has declined by more than 50% in the state of

Victoria, Australia.

2 Design: for example, improvements in clothes, heating

appliances, guards on stoves, temperature regulators

in hot water systems.

3 Legislation: for example, government (legal) control of

fireworks, nightwear materials and design regulations.

Treatment

Early, competent assessment and treatment of a burn is essential for good short- and long-term outcomes. The key phases of burns treatment are summarised in Table 41.1, with a multidisciplinary team approach being central to the success of each phase.

Table 41.1 Management of burns in children

1. First aid

2. Emergency management and assessment

3. Fluid resuscitation

4. Referral and transfer

5. Burn wound care

6. Early excision of devitalised tissue with grafting

7. Prevention and control of infection

8. Adequate nutrition

9. Psychological support and rehabilitation Minimisation of scars and contractures (e.g. pressure

10. garments)

11. Reconstructive surgery, if necessary

First aid

First aid aims to limit the extent and severity of the burn. The child must be removed quickly from the source of injury to stop the burning process, and the wound cooled. For example, any flames are extinguished, and clothing removed immediately as they may contain or concentrate latent heat. The burned area, or if necessary the whole body, should be cooled for 20 min, ideally with cool running water (15

°C). Ice or iced water is dangerous and should never be used to cool a burn wound. Ice may paradoxically increase the depth and extent of a burn by causing local ischaemia, as well increasing the likelihood of hypothermia.

Emergency management and assessment

Emergency management adheres to the priorities and principles of trauma patient management with primary (ABCDE) and secondary surveys, together with adjuncts such as intravenous fluid resuscitation, analgesia, as well as select insertion of gastric tubes and urethral catheters.

A central and unique aspect of the emergency management of burns is the accurate assessment of the extent and depth(s) of burned tissue. In addition, the distribution of the burn or specific anatomical sites that have particular implications for management should be noted, for example, any circumferential burns and/or burns to the face, hands, feet or perineum.

Extent

The ‘Rule of Nines’ (modified for use in children) is a widely available tool for rapid and sufficiently accurate estimation of the percentage of total body surface area

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Chapter41: Burns 251

1 2

(a) (b)

Figure 41.1 Figure 41.1 (a) Method of estimating the extent of burned surfaces, allowing for differences according to age

(Source: Adapted from Lund and Browder (1944)). A is 10% at birth, decreasing to 4% at 15 years. B and C are 2.5% in babies, increasing to 5% and 3.5%, respectively, in adolescents. (b) A typical distribution of a scald in a toddler.

involved. Alternatively, a Lund–Browder figure chart [Fig. 41.1] allows a more accurate and age-specific estimation of area burned, as well as denotes burns of differing depth. Unless this estimate is charted carefully, the area of the burn may be overestimated leading to excessive and even unnecessary fluid resuscitation

to whole body changes in tissue and capillary permeability and depressed cardiac function. The pathophysiology of burns shock changes with time, particularly during the first 24

h after injury.

Resuscitation fluids. Fluid resuscitation is indicated for all children with burns greater than 10% of total body surface area, most commonly intravenous crystalloid

Depth

A full-thickness skin burn (white, charred and painless) is usually obvious early. The exact depth of dermal burns may not be evident for 3 or more days, high-

Hartmann’s solution. The volume and rate of fluid resuscitation is guided by the modified Parkland formula, which calculates the volume of fluid required in the first 24

h from the time of injury: lighting theneed for reassessment of the burn over this period. Adermal burn which appears superficial at the

34– mL weight kg total body surface area burned××()%

time of injury (erythematous, blistering and painful white slough) may evolve to become deep (mottled, red and painless) – sometimes as a result of suboptimal management.

Half this volume is to be given over the first 8 h from the time of injury, and the half over the remaining 16

The modified Parkland formula guides but does not

blindly dictate the ongoing rate of fluid administration.

Fluid resuscitation

Major burns (>10% of total body surface area in children, >20% in adults) are associated with hypovolaemic shock. Causes of ‘burn shock’ include primary injury to the tissues and capillaries, as well as secondary to inflammatory mediators released due to the burn. The systemic effects of inflammatory mediators give rise to oedema, hypovolaemia and reduced cardiac output due

Rather, the rate of resuscitation fluids is titrated to achieve an optimal urine output of 0.5–1

mL/kg/h, obtained accurately with a urinary catheter and recorded. If the urine output is less than this, blood volume (and so perfusion) is likely reduced. Urine output exceeding 1

mL/kg/h may indicate excessive resuscitation, with resultant worsening of both oedema and, in turn, the burn wound.

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Maintenance fluids. In addition to fluid resuscitation, children will also require maintenance fluids calculatedin the usual fashion according to weight. The rate and type of these maintenance fluids is independent of resuscitation formulae. Initially, maintenance fluid therapy may be intravenous using 0.45% NaCl with 5% dextrose, but enteral maintenance fluids are favoured as soon as intake is tolerated. If oral intake is not possible or inadequate, early consideration should be given to insertion of a nasogastric (or other enteral feeding) tube.

Blood transfusion rarely is required in the first few days after the burn, but may be necessary to treat anaemia secondary to staged surgical excisions and skin grafting.

Referral and transfer

Once emergency primary care has been provided, children may require transfer to the regional specialist Burns Unit. The threshold for transfer is lower in children than adults. The Australian and New Zealand Burn Association criteria for referral for transfer to the Burns Unit include

1 Greater than 10% of the total body surface has been

burned

2 Greater than 5% of the total body surface has

sustained a full-thickness burn

3 Burns with an associated (or suspected) inhalation

injury

4 Chemical or electrical burns 5 Burns of special areas: face, hands, buttocks and

genitalia

6 Burns of the very young 7 Burns in which non-accidental injury is suspected

In major burns, transport is arranged to a hospital and intravenous fluids commenced in accordance with the principles of fluid resuscitation outlined earlier. Analgesia is provided by intravenous morphine given in titrated doses, and tetanus prophylaxis is ensured. The child is covered with a blanket or similar to prevent hypothermia.

Early burn wound care

Epidermal burns (e.g. sunburn without blisters) may need little more wound care than moisturising and simple analgesia. These burns will heal without scarring.

The aim of early wound care for dermal and full-thickness burns is to clean and cover the burn wound. Effective procedural analgesia and Play Specialist involvement is

an essential adjunct to this care. After cleaning the wound with an antiseptic, loose or devitalised blistered skin is removed. The burn should then be covered, which significantly improves wound pain of dermal burns (full-thickness burns are insensate), and elevated. If transfer to the regional Burns Unit is imminent and the wound will be re-assessed on arrival, simple coverage by plastic film (e.g. Clingwrap®) is an ideal temporary dressing.

Various dressings can be used to definitively dress dermal and full-thickness burns. Nanocrystalline silver dressings such as Acticoat® are often favoured for their ability to prevent infection, and possibly thereby promote wound healing, in superficial and mid-dermal burns. These dressings can be left in place until review in 3–7 days.

Failure to recognise the need for escharotomies in circumferential burns may cost a burn patient their life or limb. Sometimes, escharotomies may need to be conducted prior to transfer to the regional Burns Unit by staff inexperienced with the procedure. Therefore, early consultation for advice from the specialist Burns Team is essential.

Surgical treatment

With competent burn wound dressing and care, most superficial dermal and mid-dermal burns will heal satisfactorily by re-epithelisation, and require no surgery. This healing is documented at dressing changes every 3–7 days, and if complete within 14–21 days is likely to be without significant scar formation. Deep burns, and those in whom healing is delayed or impaired, will benefit for operative burn wound care to reduce the risk of unsatisfactory scarring.

The aim of burns surgery is to excise dead skin and cover the burn wound with split-skin grafts as early as possible. Early skin coverage reduces the risk of many burn complications including infec-

prolonged hospitalisation, scar formation and

tion, psychological disturbances. The trend in burns surgery is towards earlier primary debridement of even major burns; but care must be exercised when considering surgery in the patient with established ‘burns shock’.

When the area burned is so large that coverage with split skin grafts is limited by access to unburned donor skin sites, staged excision and grafting is required (e.g. twice a week until coverage is complete). Various options are available for interim coverage of a debrided burn

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wound, including synthetic substitutes (e.g. Biobrane®) and biological dressings (e.g. cadoveric skin allograft from the Skin Bank).

Prevention of infection

Infection is the major cause of death following theinitial burn injury. Empirical antibiotics are not effective in preventing infection – and may promote

infection or colonisation by antibiotic resistant organisms. Burn wounds considered infected (or at risk of infection) are swabbed and targeted antimicrobial treatment commenced as required. Early enteral nutrition to prevent translocation of gastrointestinal tract flora into the bloodstream, early excision of devitalised burned tissue and the use of silver-based dressings have all reduced burn wound infection and systemic sepsis.

Nutrition

Good nutritional support of the severely burned patient is necessary to ensure an optimal outcome. Initiation of early enteral feeding (e.g. within 8 h of injury) improves nitrogen balance, reduces the hypermetabolic response and also reduces immunological complications. Hyperalimentation of calories, protein, trace elements and vitamins facilitates healing of the burn, as well as graft and donor wounds – despite the hypermetabolic response associated with major burns. Oral intake alone is seldom sufficient for this, particularly in young children, and a nasogastric (or other enteral) feeding tube is commonly required in these patients.

As with all severely injured children, children with major burns are at increased risk of stress peptic ulcers. Therefore, proton pump inhibitors (or other antacid therapies) are also indicated for children with burns exceeding 15% of total body surface area.

burn are at increased risk of depression and suicide in later life. This is explained only in part by burns in children with pre-existing mental illness and/or significant social stressors.

Scars and contractures

Burn injuries, particularly deep burns, are notorious for healing with hypertrophic and functionally impairing scars. Hypertrophic scars require coordinated long-term care, with strategies including long-term pressure (e.g. silicon gels, taping, garments), splints and intralesional steroid injection. Active physiotherapy is an integral component of all scar management, to maintain and improve the range of movement at those joints and muscles implicated by scar formation. Such scar management is likely to extend for years, and in some cases may require specialist scar release surgery.

Reconstructive surgery

Contractures and scars can lead to functional disabilities and leave cosmetic blemishes. Surgical excision, inlay grafts and corticosteroid injections may be required until adolescence is reached and active growth has ceased.

KEY POINTS

• Burn severity depends on its size, depth and site.

• Early assessment, rst aid and resuscitation is essential.

• Transfer to the regional burns unit all patients with

full-thickness burn greater than 5%; total burn greater than10%; inhalation burn; face, hand or buttock burns; non-accidental burn.