Thanks for joining TCA today for our presentation on Pediatric Burn Care for the Non-Burn Practitioner. Please be sure you call into the conference line for sound. Go ahead and enter your toll-free number, access code, and then your PIN number. The handouts were emailed yesterday. They're also available on the webinar. All attendees are muted by default. At the very end, I will open it up for questions. If you have entered in your PIN number, please raise your hand and ask your question. Evaluations are very important to us. At the end of the presentation, I will be emailing you out the survey link. This is in order to receive your CMEs and CEs. Today we're going to be talking about describing how children are burned, describe the depth of burns and implications for each, understanding treatment options for outpatient burns, and learning to recognize possible and non-equivalent trauma. Today's presentation is provided by Dr. David Meager at Children's Medical Center in Dayton, Ohio. He has done his training throughout the country, basically. He started out in Baylor, did some training there, the university, and surgery. Then he went on to Children's in Cincinnati. Then also did some training in Children's Hospital in Denver, Colorado. His specialties and interests include pediatric surgery, trauma, and burn care. He has been in association with the ABA for over 35-plus years. I'd like to welcome Dr. Meager at this time. He'll go ahead and start the presentation. All right, Deb. Deb, I'm unable to advance the slides. Okay, first of all, I have no disclosures and I want to welcome everybody. Part of my goal since I took over as the chair of the Pediatric Committee for TCAA was to increase the amount of pediatric specific trauma and burn education for our membership. When I finished my general surgery training at Baylor College of Medicine in Houston, there were two things that I was not planning on doing in my career. One of them was burn care and one of them was hand surgery, and now I do a lot of burned hands. First, I want to go over some general epidemiology. Burns, the fifth leading cause of death in all ages in the United States, roughly 3,500 burns per year, and that data is about three to four years old. Burn injuries, fortunately, have decreased over my career over the past 30 years due to a number of factors. We have increased use of smoke detectors in our hotels, residences, etc. We have new federal regulations regarding flammability of clothing. There are government regulations that are now in place for workplace safety. There has been a significant emphasis, as led by the American Burn Association, on prevention activities and fire safety. Also, as everybody realizes that's been around as long as I have, there's a marked decrease in the number of people that are smoking. One that I'm very happy to see, because I've championed this for years, was a lower preset in newer water heaters, and there are, of course, fewer open fires. Deb, the slides are not going backwards. All right, now, this burns cause still a very significant amount of monetary loss each year. It's estimated that there are about 50,000 total years of potential life lost in the United States because of burn fatalities, and that, again, was data from 2013. However, more importantly, survivors may suffer significant disability that impacts their ability to seek employment and to perform their workplace activities, and impacts their income for many years. As far as children go, for those less than five, the mean hospital charges have been estimated to be about $43,000 for the stay in the hospital, and that is the data that's about five years old. It's estimated that skull burns actually cost less because they tend not to be as deep of an injury, do not have to stay as long, but these numbers do not include the parental loss of income, the travel costs, and the cost of supplies. Well, as necessity is the mother of invention, we as burn cleric clinicians must develop the resources that we need to meet the needs of our community, and this varies across the country from cities in the east where there are many burn centers and a number of facilities taking care of burn children to those out west where I spent most of my career where you can go 500 to 1,000 miles without a burn care facility, particularly for children. In Dayton, Ohio, just as an example, we have the opportunity here at Dayton Children's Hospital, we're a level two ACS verified pediatric trauma center, and we have mostly an outpatient burn program and are not verified by the American Burn Association at this time. We also have a level one adult trauma center with a commitment to burn care, but they will only admit patients greater than 13 years of age. So our resources in the region are Nationwide Children's Hospital, which is an ABA verified burn center, and Shriners Hospital for Children in Cincinnati. The average length of stay in our program is quite fairly short because we do not take or accept bigger burns. The mean for our admitted patients is about 3.38 days, however most of our patients are in less than two days. Their ICU number of days is skewed by one particular patient in 2015 and 16 that was in for quite a bit longer period of time. We had 647 children treated in our emergency department for burns over the two-year period ending December 2016. Only 76 or about 35 of these children were admitted to the inpatient areas each year. However, we have a very robust burn clinic that gets about 1,500 referrals from both our emergency department, local regional emergency departments, and private practitioners. So our first polling question, which area of the house do most burns occur? A. Bathroom, B. Garage, C. Kitchen, or Bedroom? If you would go ahead and vote. We're going to go another second or two. And we are going to close with 92% say in the kitchen and 8% say in the garage. Okay, you guys are good. You can give this talk. This is our data showing the blue is the kitchen, the orange is the bathroom, other rooms is the yellow, and outside, which would probably include the garage, is the gray. So the kitchen is the number one place where burns in children occur. Now burn care, there's a certain socioeconomic group that tends to have more frequent burn injuries. They are risk takers, they have lower socioeconomic status, and this is just looking at what our clinic payer mix is. You can see our major sources for Medicaid or Medicaid managed care organization. Medicaid insurance is the orange, and very few are self-pay, and this is again for the years 2015 to 2016. Every burn talk that I've ever probably witnessed has this diagram or one very similar. Looking at normal skin anatomy, you have the epidermis, the dermis, and the subcutaneous tissue, and you will notice that the hair shaft go well down into the dermis and actually into the subcutaneous tissue. So what is a first degree, or we prefer to call it a superficial burn? This is like a sunburn. The skin is dry, erythematous, but there are no blisters. A second degree burn, or as we determine it to be, a partial thickness, either superficial partial thickness, which involves the epidermis and the superficial dermis, versus deep partial thickness burn, which is the epidermis and deeper dermis, and deep partial thickness burns in children are typically treated more like full thickness burns in adults, and you will see in this picture a typical hand burn where the palmar surface has been injured and the blisters are present and now decompressed. A third degree, or full thickness burn, looks very similar to the picture shown here. The color can vary from pale yellow, cherry red, or black. There's a leathery appearance, and typically there is significantly decreased sensation when compared to the partial thickness burn or when compared to how the burn looks. Fourth degree burns are fortunately quite rare. This involves the entire dermis extending into the subcutaneous tissue down to the fascia, the muscle, tendon, or bones. Electrical injuries can have this type of picture. So the pathophysiology of burns, no matter what size they are, it just differs depending on what the extent of the burn is. There is a plasma loss and vascular responses resulting in increased capillary permeability, increased hemo concentration, increased blood viscosity, and increased peripheral resistance. There is also an increased metabolic rate, which is influenced by the severity of the burn, the patient's age, the ambient temperature of where the patient is, anxiety, and a late impact from infection. Signs and symptoms of infection can include tachypnea, tachycardia, and low grade to high grade temperature. Most burns of any significant size, the thermal regulatory mechanism is reset so that a normal temperature is between 38 and 39 degrees centigrade. Now this picture is also, the bullseye is also present in most burn talks. It shows a zone of coagulation, which is the central portion. This is a zone where the injury immediately is determined, and you have, as a practitioner, little ability to influence. There's a zone of stasis, where we can have some influence with good resuscitation. There's a zone of hyperemia, where hopefully that will recover. And then there's normal tissue in the black. And this is a picture of a child sort of showing these areas from around here to all the way out here. There are various sources of injury. We group these together as thermal burns, which includes flame, contact, flash, scald. Chemical burns, which fortunately we do not see very many of in children. It can be acid, alkali, petroleum-based, and the source of the chemical can either be wet or dry. Then there's electrical burns, which can involve alternating current, which can cause tetany, as well as direct current, say from lightning or batteries. There's also radiation, ultraviolet radiation, ionizing radiation, nuclear radiation, and the one that we see the most, of course, is sun exposure. In our burn clinic over the last two years, this shows the mix of burns that we see in a very typical outpatient pediatric burn population. You notice that contact burns are the biggest area, followed quickly by scald burns. This is because our patient population is quite young. The others, the friction burns, as well as flame burns, and we have very few radiation burns or electrical burns. Now, inhalation injury is something that is very, very important. We need to know if the victim was in an enclosed space, whether they have carbonaceous or black sputum, and do they have a hoarse voice. Just a couple of pictures to suggest this. Inhalation injury is a very, very important component to burn mortality and is beyond really the scope of this presentation, since we're focusing on outpatient burns. Now, chemical burns. The idea is quickly to decrease the exposure to the chemical. Remember, don't become a victim yourself as part of the care provider team. You need to remove the clothes from the patient and flush the skin with water. The injury and importance of the injury is influenced by the length of contact with the chemical, as well as the chemical concentration. The signs and symptoms include erythema, edema, blister formation, necrosis, and significant pain, sometimes out of proportion to the extent of the contact. The treatment is, after flushing with water, is to neutralize with soap, which is a mild base, or water, which is actually a mild acid, and you do not want to administer strong acids or alkalis, because then you'll get a thermal reaction. Electrical burns. It's important to know what the entrance and the exit. You can see in these pictures examples of this. Entrance burn is where the patient came in contact with the current, and the exit wound is where the current exited from the patient. Electrical burns, one of the most important facts, is that you do not know what the total body surface area involved is, but you know what it is, but you don't know how that represents the severity of the injury, since many of the injuries are beneath the skin and not demonstrated by looking at the skin. You need to be sure to monitor for cardiac dysrhythmia, because the current may disrupt the heart's intrinsic pacemaker. You need to look for pigment in the urine, which may represent myoglobinuria, hemoglobinuria. You need to increase the administration of IV fluids in order to avoid acute renal injury. Now, unfortunately, one of the things that we have to talk a lot about in the pediatric burn world is non-accidental trauma, and I like to say N-A capital T, because it is trauma. It has social implications, but trauma is the major thing. Look for N-A-T when the story doesn't match the injury that you see. Consider that as a possibility. Many cases of N-A-T are abusive skull burns. This typically occurs with water and not very often with food or drink. You need to look for areas that are spared. You need to look for the fact that the presentation for treatment may be delayed, even by days. Here are some more examples of abuse. Abusive burns occur in children typically under 10 years of age, with the vast majority being under 2 years of age. Burns account for 10% of all child abuse in some series. They also are associated with other acute injuries about 20% of the time. Looking at this patient, you want to look for lines, and you can bet that this child has sparing in the popliteal fossa. Other areas to look for, you look for circumferential injuries, usually up to a strict line around the patient. Unfortunately, many, many, many of these abusive skull burns are associated with toilet training. How long does it take to get a third-degree skull burn? This is a chart from the American Burn Association a number of years ago. It shows the temperature and the duration of exposure needed for a third-degree burn in a child. It will vary somewhat on the area involved versus, say, the palm versus the face, and it will vary somewhat by the age of the patient because of the thickness of the skin. But it used to be that water heaters came from the factory set at 155 degrees Fahrenheit, and this shows you only have to have a one-second exposure to get a third-degree burn. We, as burn prevention experts, like to teach parents to make sure that the water heaters set 120 degrees Fahrenheit or below because you have plenty of time to get the patient out of the water to prevent a third-degree burn. Now, the amount of burn surface area, or TBSA or TBSAB, is important to know. The rule of nines works in adults, but it doesn't work in children. Anybody who's ever carefully looked at a child realizes that they have relatively shorter extremities, lower extremities, and a larger head. This is a modified Lund-Browder diagram, and it is important to estimate the size of the burn not using the rule of nines. This helps you determine what is the best fluid resuscitation if it is needed. Another rule of thumb is that one percent of the patient's body surface area is equaled by the patient's, not the care provider's, but the patient's palm. So since burns tend to be somewhat irregular, use their palm to estimate what the size of the burn is. Fluid resuscitation is very important. Probably the fluid resuscitation formula that most people know the best is called the Parkland formula from the burn center in Dallas, Texas. Calculation is based on, again, second and third degree areas, partial and full thickness, and it's four milliliters per kilogram per percent body surface area burned, given over 24 hours from the time of the burn, not from when you first saw the patient. You have the first half of the fluid calculation in the first eight hours, and the second half over the next 16 hours. So if you get a patient four to five hours after the burn has occurred, then you're behind, or the patient is behind, the eight ball, and you have to really hurry those fluids in. You want to adjust the fluids up or down, not based on a single one-hour urinary output, but an average urinary output, and a good rule of thumb is a half milliliter to one milliliter per kilo in children, up to 30 kilograms, and in adults, 30 mls or greater. Sometimes if you calculate the amount of fluid in the Parkland formula, you will find that the Parkland formula is less than the maintenance fluid calculation. So obviously, it makes no sense to give a child less than maintenance fluids. And just remember, burn formulas do not apply to electrical burns because of the unknown extent of injury underneath the normal skin. Now the American Burn Association, in their course, Advanced Burn Life Support, has come up with a consensus fluid resuscitation formula for pediatric patients defined as less than 14 years of age or less than 40 kilograms. It is 3 mL of Ringer's Lactate per kilo per percent total body surface area burned in those patients, and for patients older than 14 or greater than 40 kilograms, it is 2 mL per kilogram per percent body surface area burned, again, the first half of the volume given eight hours post-injury and the second half over the next 16 hours. Recent research indicates that resuscitation at the original Parkland formula commonly results in excessive edema and over-resuscitation, and this was brought into the Advanced Burn Life Support in 2011. The ABA has also come up with burn transfer criteria, and these are the typical ones for a non-burn facility. If the child has a partial thickness burn greater than 10 percent total body surface area, burns that involve face, hands, feet, genitalia, perineum, or major joints, or any significant third-degree burn should be considered for transfer. Also clearly, electrical burns, including lightning, chemical burns, and any child with an inhalation injury should be transferred. There can be burn injury with pre-existing medical comorbidities in many of our patients. Patients that have burns and trauma, where the burn injury is the greatest risk of morbidity and mortality, should be transferred to a burn center. If the trauma is the major factor, then they need to go to a trauma center, though many places in this country, the burn center and the trauma center are at the same place. Non-burn children should be transferred when qualified personnel or the appropriate size equipment are not available. Some burn patients have special social, emotional, and rehabilitative needs, and those should be also transferred. Here is our second polling question. What guidelines do you have in place at your institution for addressing a burn less than 30 percent for transfer to a burn center? I'm just quite interested to see whether silvadene and dressings, moist dressings, vasitracin or adiosporin, petroleum-based antimicrobials, and adaptic, open-to-air, or other. So if you'd respond to that. Okay, we're going to go ahead and close the poll with 17% saying sylvidine, 22% moist dressing, 22% vasitracin, 4% open to air, and 35% other. My my, that is quite a range. Well, I do not have my anti-sylvidine button on today, but we had many people in the burn world for outpatient burns, particularly those in children, have gotten away from silver sulfadiazine for obvious reasons. If you've ever used it, you have to scrub it off to see the burn. It exposes them to an allergy, to potential allergy to sulfur, and it's just not needed for outpatient burns. So when I came here now nine years ago, there was a variety of care provided in our very busy emergency department to burn patients. So we decided to work with the ED team to standardize at least the management of burns here in this institution. We have an Alpha Bravo Charlie system of activations for our trauma program. Burns greater than 14% total by surface area is often a Bravo trauma activation. I will caution you that in the burn world, it's known that the estimates by non-burn practitioners usually is about twice as big as the actual size of the burn injury. For example, if I'm told there's a 40% burn coming in, it's probably more likely 20%. The ED care for children not requiring admission consists of pain medications. We use ibuprofen and acetaminophen. We believe in de-roofing all blisters, mainly because that allows the antimicrobial to get to the burn bed. It also removes the fluid, blister fluid contains significant chemicals that can result in a deepening of the burn injury. Also in the emergency department, they have access to narcotics which can be used to help the patient's discomfort during their acute management. We use a lot of Bacitracin or Neosporin ointment. We put that on a non-stick adaptic type dressing and refer the patient to the burn clinic as needed. That's what the ED typically does. We do not send patients home with materials for dressing changes. Many years ago, I found out that parents make very, very poor burn care providers. It takes 6-8 months to train one of our nurses or one of our nurse practitioners on the appropriate management of burn injury. I tend to like scheduled ibuprofen around the clock for 3-4 days as long as the patient is older than 6 months of age. The reason for this is in laboratory animals, there is evidence that this anti-inflammatory drug or other NSAIDs may well decrease the depth of the burn. We give narcotic, but we steadfastly avoid codeine as many of you might know. Codeine has now been associated with more and more deaths in this country, particularly codeine involved in cough medicine. In a number of children's hospitals, codeine is being outlawed. Once again, I prefer to avoid silver sulfadiazine for outpatient burns. We will use silver sulfadiazine for some of our inpatient burns. When they come to our burn clinic, we fill out the modified Lund-Browder diagram since it's unlikely that the ED filled it out. We do a complete history and physical. I may be the one seeing the patient first or my two burn nurse practitioners who assist with running our burn program. The remaining blisters or loose tissue is debrided. Photos are used to be taken all the time. We found this to be really a waste most of the time, and we tend to do dressing changes only twice weekly, again, asking the parents not to do these at home unless the burns are nearly healed. If the patient comes from a long distance, like they would when I was in Colorado, we would sometimes have local nursing agencies help with the dressing changes. Pain medication management. Once again, ibuprofen, 10 milligrams per kilogram, every six hours for the first three to four days, and then PRN is the usual rule. We avoid codeine products for the reasons I've mentioned. We do use some hydrocodone prior to dressing changes, particularly in certain patients. We have found that intranasal Versed is excellent for anxiolysis and works in a lot of children. It does make their visit longer, since it takes about 20 to 25 minutes to work. We also strongly urge, as well as the American Burn Association urges, that antibiotic therapy is not indicated in routine management of the non-infected burn. Anticipated recovery. The burn depth is not always apparent at presentation. This is particularly true in scald burns. Healing less than 12 to 14 days, in my experience, I determine this to be a superficial partial thickness burn. Healing typically does not result in scarring unless the patient is a scar former. That is the superficial partial thickness patient. The deep partial thickness patient typically heals between 14 and 20 days. Children actually are better scar formers as far as surgical incisions, but they're much worse scar formers as far as burn wounds. And there's an increased risk of scarring in a child with a deep partial thickness injury. Split thickness skin grafting is usually indicated for those patients where their burns do not heal by 14 days. The big exception is the face, since skin grafts on the face do not look good in any situation, so we will allow the face to an additional week to heal. Adolescents and adults typically can also have an additional week to heal. If there is a healing in greater than three weeks, that indicates that this was a full thickness burn and grafting is indicated. The actual grafting is beyond the scope of this webinar, but just know that that's what the criteria is for us to use. Burns of the face, ears, are managed more conservatively, as I mentioned, with delayed grafting even up to or beyond one month. Burns around joints, hands, the dorsum of the feet in children are managed more aggressively to an increased risk of contracture development. Now some burns are treated by open technique. We prefer closed technique for the majority of our burns. Burns of the face, neck, ears, scalp, and genitalia are typically washed with our new solution that we're using called Bosch. There are several brands, it's a hypochlorous acid solution. We wash and apply on gauze to remove the remaining debris and drainage. We do not try to strip the eschar any further. We apply a thin layer of neosporin, polysporin, or vasotracin, and we ask the family to wash the burn each day with either soap or water or the hypochlorous acid solution, reapplying neosporin or the topical antimicrobial of choice four times daily and as necessary to keep the burn moist. Burns love moisture for their healing. I learned long ago that when I practiced in Central California and in Colorado, there was a difference between Dayton, Ohio and Houston, Texas. The humidity, the average humidity is quite varied and it's important to keep the burns moist though in Houston many times it was sort of the opposite problem. So what we do using closed technique again is the same. We wash with the hypochlorous acid, we debride as needed, but we don't stress that as much as we used to. It used to, we would take something called a Norsen debrider and scrape the burn. Obviously this is very, very painful and is not indicated as far as I'm concerned in the outpatient management. We apply a thick coating since we're only changing the dressing twice weekly of deosporin to the adaptic and just place this on the burn using clean technique. Burns are not sterile, so just as long as we have clean technique. We wrap this circumferentially with multiple layers of absorbent gauze and then we either use burn netting to hold the gauze in place or coban. We have the parents keep the dressings dry and intact until the follow-up visit. Usually the child, particularly if they've been on some ibuprofen, they do not hurt with the dressings in place. Now hand burns are a different area. It's important that you debride and clean the burns as we've mentioned. Use the same adaptic and neosporin, but you want to dress the hand in a position of function. You want to put a wad of gauze in the palm. You want to make a nice boxing glove-like dressing that's shown here in this picture because you want to maintain a position of function. Now we are not currently, for cost reasons, using a lot of biosynthetics. When I was in Colorado, I used an extensive amount of biosynthetic, but it tends to be very expensive, but I wanted to include a few slides to show this. These are some various burned hands, and there's a glove that's been placed over this. This is very important. It protects the burns. The therapist can do their range of motion exercises, and it also provides an excellent barrier and results in very little pain. This just shows a hand 16 days post-application, and the burn was one of those you saw on the previous slide. So you need to breathe and clean, as we already described. Biosynthetics can be used on clean, superficial partial thickness burn. The first time I ever used a piece of BioBrain, many years ago in Denver, one of my associates placed it over a burn that still had eschar in place. When that child came back seven days later for the dressing change, the biosynthetic was dripping with pus. Do not put a biosynthetic of any type on a deep partial thickness or full thickness burn or burn that is infected. And you want to put the biosynthetic on several centimeters beyond the size of the burn. You can gently stretch it, and you can apply Steristrips or Mastisol, and you can dress it with absorbent gauze, and families should avoid getting the dressing wet. Initial dressing changes are usually done in two to three days to evaluate for adherence. You want to drain any fluid accumulations if they're present. Beyond that, the biosynthetic dressing, if intact, can result in only weekly follow-up. If you have non-adherent biosynthetic, it is good to apply a new piece if there's no eschar or infection as the cause of the non-adherence. Alternatively, you can place an antimicrobial ointment over the open area. And these just show some of the nice things that we've used in the past. Various types of biosynthetic products can be used as socks or as feet. When the biosynthetic is dry, and usually typically eight to 12 or 14 days, the biosynthetic can be gently removed using moisturizing cream or petroleum jelly. If it fails to heal by 14 days, then we usually typically remove it in the operating room and proceed with split thickness skin grafting. Post-healing care. This is where many of our patients suffer more than you would think. Itching is excessive. And you can treat this with a moisturizer. Recently we used to use cocoa butter cream. Now there's another product that just changed its name from Eltolite to Restolite. It provides a lot of moisturization. You want to avoid lotions. Go mostly with creams because lotions typically have alcohol or can have perfume. So some of the other treatments for itching are Benadryl or Atarax, but tachyphylaxis or tolerance usually develops fairly quickly. One percent hydrocortisone cream will also work. One thing the patient and parents need to be warned about is excessive sun exposure post-healing. We recommend the use of a sunscreen with an SPF 30 or greater for about one to two years. This will partially be determined by the patient's skin characteristic, though we've seen a number of our black children suffer a sunburn for the first time in their life. Long-term follow-up is determined by what has happened with this burn. If they are grafted, I tend to follow them for a number of years because if you consider what the burned hand is in your hand versus a burned hand in a child, you see that the child's hand has to grow and the child can have an excellent result but then hit a growth spurt resulting in contracture development. Prevention is very important. Once again, we urge that hot water heaters be set at less than 120 degrees Fahrenheit. This also results in decreased energy uses. Home fire drills are very important. Your smoke detectors need to be working. Once again, the garage is not a play area. There are a lot of noxious agents in the garages. Proper storage of chemicals. The one that I typically mention is the killer soup, ramen noodles. We see an excessive amount of scald burns from this agent because it is warmed in a microwave. Also be alert to the dangling cords such as on a slow cooker. Curling irons, clothing irons, hair straighteners all cause very deep burns, many of which can result in the need for grafting or operative intervention. The one that shows a lot about our society is we are seeing more and more treadmill-related friction burns where the child's hand can get caught under the belt, under the device or whatever. When should you refer a child to a burn professional? Well, obviously if we like to have them healed by 12 to 14 days, I like to see them by 5 to 7 days so that I can assess what I call the velocity of healing. Any deep partial or full thickness burns should obviously be referred. Any burns to special areas and any burns with complications. Each area of the country has their own professionals. At this point, I'd like to open this and give it back over to Deb so we can open this up for questions. I think we have a good amount of time for that. Go ahead and raise your hand or ask your question. The first one, does that include sunburns, de-roofing? Yes, a sunburn that has blisters is typically a superficial partial thickness burn and so if we treat it like a burn, we take off the blisters. We do see that a fair amount of time, but most sunburns are only first degree and obviously don't have blisters. The second question is, we use dry sterile now. What are the participants who indicated other using? I'm not sure what they are using. We do not, in transfer of patients, it is important to consider evaporative heat loss. So a clean dry sheet is what the American Burn Association recommends. Many times we get children transferred in and they've had these nice elaborate dressings done. Unfortunately, sometimes with silver sulfodiazine and they come to us and then one hour later I have to take off those dressings, take off the ointment so I can see the burn because I'm obligated to know what type of burn I'm dealing with. So if you're not going to be the one that's a burned professional, then do not put a lot of ointments on them until after they arrive at the ultimate care facility. Next question, do you set up the ED resuscitation room with sterile sheets on the bed prior to patient arriving and what about tetanus shots? Well tetanus is very important because burns are tetanus prone injury, particularly those that occur outdoors and are typically the more older children with flame burns. But it is important to assess the tetanus status of the patient and yes, if we know that we're receiving a burn victim in, we will tend to use sterile dry sheets on our trauma resuscitation table. Open the line to Felisa, had a question. Ms. Powell, go ahead with your question. Yes, how long do you recommend for electrical burns, how long should kids be monitored for cardiac dysrhythmia? That's an excellent question and the data is actually not available. What I typically do is for at least 24 hours. If it's a real big electrical burn, then of course they're going to be in the hospital in the burn unit longer than that and we monitor them as long as they stay. But I would watch a more superficial electrical burn for at least 24 hours of monitoring, particularly if it's an alternating current type injury. Now one electrical burn that I did not mention, and I should have put a slide in, is the most common electrical burn in a pediatric patient. And that is a burn to the angle of the mouth. Children like to put things in their mouth, as you know, particularly young children. And they will bite down on a cord, an electrical cord, and they'll get a significant full thickness injury to the corner of the mouth. Now the management of these has evolved over the years. Some people believe in early operative intervention. Some believe in letting the wound scar in, and I mean literally scar in. Some people put mouth gags in these poor children and try to keep it open by that technique. But these are fairly, used to be very common injuries, now less common. But it's one that you will see in a child. Are there any other questions? Go ahead and raise your hand or type it in, please. Okay, I see no other questions. At this time I'd like to thank Dr. Meeger for a great presentation and wealth of information provided today. As you digest this information, if you have any questions, please email or call the office and we will forward this on to Dr. Meeger. Please don't forget to complete the evaluation following the program so we may continue to improve our offerings. Thank you again for participating in the webinar. Deb? Deb? Yes, Dr. Meeger? When is our next presentation and what's the subject? The next one is... Do we know it yet? The PEDS one is in August with open fractures and pain control. Excellent. We urge you all to attend that too. And for further webinars, we do have them on our website, but I can tell you April's will be trauma care burnout or trauma team burnout is scheduled for April. At this point, I'd like to thank everybody and have a great day.

pediatric burn care

treatment options

non-accidental trauma

fluid resuscitation

pain management

post-healing care

referring a child

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