Elsevier

The Lancet

Volume 383, Issue 9923, 29 March–4 April 2014, Pages 1168-1178
The Lancet

Review
Burns in children: standard and new treatments

https://doi.org/10.1016/S0140-6736(13)61093-4Get rights and content

Summary

Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.

Introduction

Major burn injury is the biggest trauma and can be classified according to cause and depth of the burns. Every year, more than half a million burn injuries happen in the USA.1 These injuries are typically not severe, although about 50 000 patients with burns still need admission and treatment at a burn centre or burn hospital. Because the effects of burns are debilitating, substantial resources have been devoted to the specialty, which has greatly improved outcomes of patients with burns.2, 3, 4 Improved outcomes can be attributed to specialised burn centres, advances in resuscitation, protocolised and specialised critical care, improved coverage of wounds and treatment of infections, better treatments for inhalation injury, and the burn-induced hypermetabolic response.4, 5 Another major advance is the recent initiatives by burn care providers to hold consensus conferences and implement specific definitions of disease processes in patients who have been severely burned, which will allow appropriate multicentre trials6 and comparative studies to be done. All these changes have substantially improved morbidity and mortality after burn injury. In a recent study in The Lancet,5 we showed that the burn size associated with increased risk of mortality at a specialised centre increased from 40% total body surface area (TBSA) burned to more than 60% TBSA burned in the past decade or so.5 We would like to emphasise that the pathophysiological response to burn injury and the mortality of patients with burns are proportional to the extent of burn in a sigmoid dose-response way, and that these responses are not an all or none phenomenon beginning at 60%. The cutoff for these pathophysiological responses is around 30% TBSA burned in children (aged 0–18 years), 20% in adults (aged 18–65 years), and about 15% in elderly people (older than 65 years).

Despite advances in burn care, severe burns still damage almost every organ in the body, resulting in profound debilitating complications or even death.2, 3, 4, 5, 7 Every year, nearly 4000 cases of burns result in death from complications related to thermal injury.2, 8, 9 Deaths caused by burns generally happen either immediately after the injury or weeks later as a result of infection or sepsis, multisystem organ failure, or hypermetabolic catabolic responses.5, 10 In the past decade, the cause of death has changed profoundly.10 10 years ago, the major cause of death in patients who had been severely burned and admitted to a burn centre was anoxic brain injury, followed by sepsis and multiple organ failure. Nowadays, the major cause of death in burned paediatric patients is sepsis followed by multiple organ failure and anoxic brain injury.10 This shift in the cause of death requires a review of the basic understanding and treatment approaches to further improve post-burn morbidity and mortality. Patient outcome and survival are directly related to the quality of the complex care that burn patients receive. Three key aspects of care exist. First, initial care at the scene, pre-hospital care, and the early hospital phase: adequate and timely response, assessment of the burns, resuscitation, and admission to a burn centre, escharotomies or fasciotomies, resuscitation, and treatment of inhalation injury. Second, after hospital phase: wound care including burn surgeries, infection control, maintenance of organ function, and attenuation of hypermetabolism. Third, long-term phase: persistent hypermetabolism, reconstruction, and rehabilitation.

Four interrelated aspects seem to be crucial for survival: burn shock and resuscitation, inhalation injury, wound closure, and burn hypermetabolism. Therefore, we discuss standard and novel treatments in these specialties. Pain control is an important aspect of burn care that affects burn outcomes and quality of life at all stages, but will not be discussed in depth. Modern pain management has substantially evolved and includes multimodal treatments such as shortacting and longacting opioids, methadone, ketamine, central-acting agents (gabapentin), non-steroidal anti-inflammatory drugs, anxiolytics, and antidepressants. Tremendous improvements have been made over the past decades, but detailed discussion of these modalities is beyond the scope of this Review.

Section snippets

Burn shock and resuscitation

According to guidelines from the American Burn Association, the management of a patient with burns starts after emergency medical response teams are called and the patient is assessed and transported to a burn centre. A crucial part of this phase is establishing whether a patient's injury is survivable or futile. Futility in adults or elderly patients with burns is usually determined by the sum of age (years), burn size (%), and the presence or absence of inhalation injury (±17), with values of

Inhalation injury

Another key component of early burn care is maintenance of adequate oxygenation and treatment of inhalation injury. A marked proportion of fire-related deaths are not attributable to burn injury, but to the toxic effects of airborne combustion byproducts.15, 25, 26, 27 Many of these compounds can act together to increase mortality. Recent studies suggest that between 20% and 30% of all severe burns are associated with inhalation injury and that between 25% and 50% of patients die if they need

Wound closure

Closure of the burn wounds establishes length of hospital stay, risk of infection, and ultimately survival, whereas failure to get the wounds closed results in death. Treatment strategies for superficial wounds must be differentiated from treatment plans for deeper wounds. The most important factor in the improvement of patient outcome has been the implementation of early excision and grafting of burn wounds, which was first described by Janzekovic30 in the 1970s. Findings from subsequent

Facial transplantation

Serious facial burns leave victims with substantial deformities that are difficult to treat. No evidence exists to suggest that standard treatment modalities for severe facial burns offer substantial improvements in function or scar outcome. These patients frequently become socially and personally isolated, and many suffer from psychological disorders and phobias.58, 59 These patients also tend to need multiple reconstructive procedures under conditions in which minimal normal tissue (secondary

Hypermetabolism

A key cause of poor outcomes after burn injury is the hypermetabolic response, which is associated with severe alterations in glucose, lipid, and aminoacid metabolism.3, 7, 64, 65 Hypermetabolism leads to severe catabolism, which is associated with protein breakdown in muscle and in organs, leading to multiple organ dysfunction. Therefore, hypermetabolism, organ function, and consequently survival, seem to be closely linked. The burn-induced hypermetabolic response that occurs in the ebb phase

Treatment of the hypermetabolic response

Various data suggest that hypermetabolism is a major contributor to poor outcome after burn and that treatment or alleviation of the hypermetabolic response is beneficial for patient outcomes. Treatment options include pharmacological and non-pharmacological strategies.3

The main goal of nutritional support is to provide an adequate energy supply and the nutrients necessary to maintain organ function and survival. Early adequate enteral nutrition alleviates catabolism and improves outcomes;93

Other non-pharmacological strategies

Early wound excision and closure have been the biggest advances in burn care in the past few decades (figure). Early excision and grafting has substantially reduced basal energy expenditure, mortality, and costs.2, 31, 32, 33, 111 The early excision of burn wounds and coverage of the excised areas with temporary cover materials or autologous skin is imperative. This process diminishes burn-induced inflammatory and stress responses, and in turn decreases hypermetabolism.

The hypermetabolic

Drugs

Drugs are used as an adjunct for the treatment of various aspects of the hypermetabolic response. In the past two decades, several agents have been tested; some are more effective and promising than others. Almost all drugs are associated with beneficial effects but also side-effects, some of them severe. The table shows drugs currently in use.

Outcome measures

The ultimate goal of intensive burn care is to keep the patient alive, an outcome that is dependent on coverage of burn wounds, maintenance of organ function, control of infection and sepsis, and alleviation of hypermetabolism. The ability to predict patient outcomes, identify patients at risk, or even individualise patient care is highly desirable. However, no predictors exist that would allow for any such identification. In a recent study145 of children with more than 30% TBSA burned, our

Conclusions

Burn injury triggers a plethora of pathophysiological responses associated with detrimental outcomes. Novel treatment strategies such as early excision and grafting, early and adequate nutrition, alleviation of the hypermetabolic response, treatment of hyperglycaemia, and the catecholamine surge with use of β blockers, improved ventilation strategies, and exercise improve survival and outcomes in patients with severe burns. Large multicentre trials with protocolised care will improve morbidity

Search strategy and selection criteria

We searched PubMed for papers published in any language between Jan 1, 2008, and Dec 18, 2012, with the following search terms: “large clinical trials in burns”, “resuscitation, inhalation injury”, “wound care”, “burn wounds”, “infection”, “organ function”, “hypermetabolism”, and “predictors of mortality”.

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