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Patient Evaluation and Treatment Planning
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In both outpatient and inpatient settings, a careful evaluation of the patient is essential for treatment planning. Patient evaluation is organized into a primary and a secondary survey, following the guidelines of the American College of Surgeons Committee on Trauma and the Advanced Burn Life Support Course of the American Burn Association. As in trauma, the primary survey begins with an assessment, and control if necessary, of the airway. Deeper burns of the face and neck can result in progressive airway edema. Occasionally, a child will aspirate hot liquids resulting in very severe upper airway edema mandating urgent intubation.
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A burn-specific survey evaluates the issues uniquely associated with burn injury (ch95etb1.1). This may take just a few seconds if the burn is small, but will be much more time consuming in the more seriously injured.12 In those with small injuries, essentials include a detailed determination of the mechanism of injury, a screen for associated trauma, consideration of the possibility of abuse (Fig. 95-4), and a detailed assessment of the burn wound. Delayed presentation for care, confusing stories, sharply demarcated margins, immersion patterns, and contact injuries are physical findings suggesting for abuse or neglect.13 All such children should be admitted for evaluation.
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After the patient has been evaluated, the burn wound should be examined for size, extent, depth, and circumferential components.14 Burn extent is best estimated using a chart based on the Lund–Browder diagram that compensates for the changes in body proportions with age (ch95efg4.1). An alternative is a modified “rule-of-nines,” in which the head and neck is given 18% (instead of the adult 9%), each lower extremity is given 15% (instead of the adult 18%), each upper extremity is given 10% (instead of the adult 9%), and the anterior and posterior torso are each given 16% (instead of the adult 18%). For scattered or irregular burns, the entire palmar surface of the patient's hand represents approximately 1% of the body surface over all ages.
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Burn depth is classified as first, second, third, or fourth degree (Fig. 95-1A–D). First-degree burns are red, dry and painful and are often deeper than they appear, sloughing the next day. Second-degree burns are red, wet and very painful. There is an enormous variability in their depth, ability to heal, and propensity to hypertrophic scar formation. Third-degree burns are leathery, dry, insensate, and waxy. Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone.
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Near or completely circumferential burns should be identified for special monitoring, as they may need to be decompressed in the hours following injury to avoid ischemia (extremities) or failure of ventilation (torso).
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The majority of burns can be successfully managed in the outpatient setting. However, poorly provided outpatient burn care can be frustrating and painful for patients and providers. The key is careful patient selection (ch95etb1.2) and a detailed care plan, especially an inpatient care plan (ch95etb1.3).
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Burn wounds and grafts typically develop some degree of hypertrophic scarring.15 This involves a gradual increase in vascularity and collagen deposition in the months following healing. Some wounds will demonstrate significant contracture formation, with important functional and esthetic consequences (Fig. 95-5). Many patients will have bothersome pruritus and sometimes temporary neuropathic pain if burns are deep. A long-term follow-up plan, consisting of scar management strategies, rehabilitation, reconstructive surgery, and emotional support will facilitate optimal outcomes. This care is best provided in a multidisciplinary burn clinic, ideally part of a comprehensive burn program. With such supports in place, the long-term outcome for most patients is surprisingly good. When managed in a comprehensive follow-up program, even those who have suffered devastating burns tend to become happy and productive again.16,17
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