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CHAPTER35 Non-accidental injury (NAI) inchildren
Introduction toNAI inchildren
Children are inquisitive and as a result, accidents may occur. Unfortunately
children are vulnerable to non- accidental burn injuries.
Prevalence
• Non- accidental burns represent between 1% and 16% of all burns in
children presenting to hospital.
• Deliberately inicted burns are seen in 10% of physically abused and 5%
of sexually abused children.
• Mortality due to non- accidental burns is higher than in accidental burns
(5.6– 9.6% vs. 2.6– 6%).
Assessment
History
Details of injury must be meticulously gathered:
• Time of injury, mode, and sequence of events plus any rst aid
procedures undertaken must be claried
• Is the history plausible? Is the history consistent?
• History should be reviewed repeatedly to check for variation, which
may indicate an attempt to conceal a NAI
• Does the distribution of the injury t in with known patterns of injury?
Examination
• ABCDs should be assessed and treatment provided according to ATLS
protocol.
• Accurate and systematic examination of the patient ’s body should be
performed in a warm and comfortable environment
• Size, site, and depth of burns should be recorded
• Photographs aid recording along with recording on burn charts
• Other injuries and bruises should be noted
• Achaperone should be present to ensure patient comfort and provide
protection for the examining health professional
The assessment of NAI is undertaken by the multidisciplinary team including
general practitioners, paediatricians, plastic surgeons, and emergency physicians, as well as nursing sta (paediatric, emergency, and school nurses)
health visitors, and social workers. The police may need to be involved also.
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PATTERNS OFNAI
Parents’ and children’s characteristics
• Parents may appear angry, abusive, or depressed and withdrawn
• They present late and may not be keen to allow their child to be
assessed or admitted for treatment
• They may discharge their children before treatment is completed
• Parents of accidentally burnt children are very keen for medical
attention. They present early to emergency services and are clearly
upset and feel guilty about the burn
• Abused children are often withdrawn, anxious, or rebellious
• Older children may avoid talking about their injuries
Patterns ofNAI
In order to detect NAI, health professionals must consider the possibility
and therefore be vigilant. There are certain patterns of injury that should
increase suspicion:
• Symmetrical ‘glove and stocking’ scalds and buttock scalds with
‘doughnut sparing’ of the perineum are characteristic of forced
immersion injuries. The doughnut sparing occurs due to the perineum
coming into contact with the base of the bath and the hot water
producing scalds to the other areas
• Non- accidental burns have uniform burn depth and well- delineated
upper margins; accidental burns are varied in depth and have irregular
upper margins
• Symmetrical scalds should be treated with great suspicion as a child
would never enter a bath with both feet simultaneously
• Branding in the shape of the hot objects pressed against the skin leave
tale tell marks. Common objects used include spoons and forks
• Cigarette burns produce a deep circular crater with or without a more
supercial tail (caused as the cigarette moves against the skin after initial
contact). They may be single or multiple
• Burns may be multiple and of varying age. This should further evoke
suspicion
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CHAPTER35 Non-accidental injury (NAI) inchildren
Dierential diagnosis
It is important to keep an open mind. Occasionally a lesion may not be due
to abuse. If there is no history of burn and the history is plausible and consistent then alternative diagnoses should be considered.
• Impetigo, epidermolysis bullosa, urticarial, contact dermatitis, and
severe nappy rash may mimic a burn injury
• Freak accidents do occur. Burns secondary to seatbelt straps on a very
hot day do occur. Likewise vinegar (acetic acid) is acidic (pH 1– 2) and so
prolonged contact could lead to a chemical burn
• If a child has a neurological decit then the normal protective
mechanisms will not prevent burn injuries. In these situations unusual
accidental burns may occur
Health professionals must not overlook neglect. Children may present with
burns as a result of neglect (negligent inability to protect a child from injury).
Although the burn injury is not deliberately inicted as in abuse, the incident
should serve a warning of potentially devastating injury. It is therefore our
duty as health professionals to report these incidents to appropriate authorities to minimize future risk.
Further reading
Andronicus M, Oates RK, Peat J, Spalding S, Martin H. Non- accidental burns in children. Burns
1998;24:552– 8.
Greenbaum A, Donne J, Wilson D, Dunn KW. Intentional burn injury:an evidence based, clinical and
forensic review. Burns 2004;30:628– 42.
Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that
indicate intentional scalds in children. Burns 2008;34:1072– 81.
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Chapter36
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Burns itch
Introduction to burns itch 316
Types of pruritus 316
Causes which increase itch 317
Epidemiology 318
Biology (neurotransmitters involved in itch) 318
Biology (itch neurological pathways) 318
Assessment 319
Therapy for itch 320
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CHAPTER36 Burns itch
Introduction toburns itch
• Post- burn pruritus is one of the most common and distressing
complications of burn injury
• Itching typically begins in the rst 2 weeks after burn injury and may last
for an extended period of time (several years)
• Post- burn pruritus may interfere with
• Sleep
• Activities of daily living
• May complicate healing when scratching damages healing or thin
epithelium and newly grafted skin
• Can cause problems with concentration and lead to depression
Denition
Itch was initially described in 1660 by Samuel Hafenreer, a German physician who dened itch as an ‘unpleasant sensation that elicits the desire or
reex to scratch.’ This denition remains the most used.
Types ofpruritis
• Itch is arbitrarily divided into acute and chronic with the transition
occurring at 6months following onset of symptoms. The other
categorization is based on location of the origin of the itch experience
• Pruritogenic:localized to the skin and associated with dryness,
inammation or other cutaneous injury (the type most associated
with burn injuries)
• Neuropathic:due to dysfunction along the peripheral nerve pathway
• Neurogenic:itch arising due to central nervous system dysfunction
without evidence of peripheral pathology
• Psychogenic:the experience of itch in the absence of any organic
pathology
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CAUSES WHICH INCREASE ITCH
Causes which increase itch
Injury type
• All mechanisms of burn injury can lead to itch; however, scald injury is
most common followed by ame or contact injuries
Location
• Legs are most commonly aected by itch followed by the arms and then
the face
Surgical Intervention
• Grafted burns are at greater risk of developing itch than non- grafted
burns. This may be a function of time to healing and burn depth.
• The presence of itch correlates positively with number of surgical
procedures
• Wounds requiring more than 3 weeks to heal
Burn Surface area involved
• > 40% TBSA is associated with increased itching
Itch also correlates positively with PTSD symptoms and poor coping
strategies
Environmental
• High ambient temperature (70%) and/ or sweating (61%)
• Skin dryness (83%)
• Stress and fatigue (57%) increase itch
• Movement (52%) can increase itch
• Particular fabrics (48%)
• For some subjects, cold temperatures (30%), cold water (26%), and rest
(22%) helped combat itch symptoms
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CHAPTER36 Burns itch
Epidemiology
• 87– 100% incidence following burn injury
• Onset at 1month with peak symptoms at 6months
• One study reported 87% incidence at 3months, 70% at 12, and 67%
at 24months. In another study, at 4years post injury, 79% of patients
reported some problems with itch and in 29% this was persistent. At
12years this gure reduced to 44% and 5%, respectively
• Gender distribution is female > male
Biology (neurotransmitters involved
initch)
• Histamine from mast cells and keratinocytes bind a variety of histamine
receptors
• H1 neuroreceptors are most associated with itch these are located on
the unmyelinated C bre peripheral nerves
• H2 (peripheral nerves), H3 (central), and H4 (mast cells) may
have a role
• Acetylcholine from skin cells and autonomic synapses and binds
cutaneous muscarinic receptors
• Kinins including neurokinin Aand bradykinin bind vanilloid receptors
(VR- 1) on the C bres. Vanilloid receptors are likely to be antagonistic
to itch mediators
• Substance P binds the neurokinin- 1 receptor (NK- 1) on C bres
• Proteinases; tryptase and mast cell chymase bind proteinase activation
receptor (PAR- 1) on the C bre
• Following burn injury there is an initial depletion of cutaneous mast
cells, substance P positive nerve bres, proteinases, and inammatory
mediators; at 2 weeks the levels are increased signicantly over
pre- injury levels
Biology
Itch neurological pathways
• Specic unmyelinated C bres synapse in the dorsal horn signals travel
orthodromically in the spino- thalamic tract to the thalamus then on to
the somatosensory cortex (areas in the cingulate gyrus and prefrontal
cortex connections are also activated explaining the emotional
response)
• There is evidence for localized antidromic signally leading to a histamine
releasing positive feedback loop
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Assessment
Objective assessment of itch is dicult and uses experimental techniques
like perceptual matching, MRI/ PET, microneurography and accelerometers to measure itch while asleep. Itch is a subjective experience; however, many factors inuence the intensity of itch at the point of observation.
Commonly used and accepted techniques include:
• Visual analogue scale with a range 0– 10 anchored between no itch and
worst possible itch
• The ‘Itch Man Scale’ copyrighted by the Shriners Hospitals based on the
Likert 5- point scale
• Itch Severity Scale developed by Yosipovitch based on the Modied
McGill Pain Scale
• The itch component of the Abbreviated Burns Specic Health Scale
ASSESSMENT
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CHAPTER36 Burns itch
Therapy foritch
Adults and children can use the same interventions for the management of
itch with adjusted dosing for weight and age and observing for unwanted
side eects.
• Simple interventions which compliment the pharmacological
interventions include
• Moisturisers:simple (E45/ Nivea), Aloe- Vera
• Cooling, rest, the provision of appropriate environment (place,
lighting, noise, temperature, décor, etc.), reassurance, distraction,
imagery and relaxation techniques
• Non- irritant garments
• Silicone scar therapy
• First- line pharmacological therapy involves antihistamines
• First generation:chlorpheniramine, diphenhydramine, hydroxyzine,
cyproheptadine bind histamine, muscarinic, alpha- adrenergic, and
serotonergic receptors and are sedative
• Second generation:cetirazine, loratidine bind histamine receptors and
inhibit leukotriene release
• Second- line pharmacological therapy involves
• Gabapentin/ pregabalin increasing dose until therapeutic eect
achieved
• Topical antihistamines; mepyramine, chlorpheniramine, hydroxyzine
• Histamine H2 antagonist cimetidine
• Capsaicin cream 0.025% (which works through neuropeptide
depletion)
• Topical dothiepin cream (5%) (Doxepin) some sedative eect but
50– 800 better histamine binding that rst- generation antihistamines.
• Adjuncts include
• Massage
• Psychological support
• Transcutaneous nerve stimulation (TENS)
• Emerging or third- line techniques
• Topical dapsone
• Naltrexone (signicant side eects)
• Laser
• Topical EMLA on small areas
• Topical nano- crystalline silver
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Chapter37
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Nutritional requirements
inthe burn patients
Increased nutritional requirements after burns 322
Route and timing of feeding 322
Energy requirements 323
Food types 324
Vitamins and trace elements 325
Monitoring 325
Further reading 326
Reference 326
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