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Volume: 3 Issue: 2 June 2023

FULL TEXT

ARTICLE
Outpatient Management of Pediatric Burns in Chile

ABSTRACT

Most burn injuries can be treated on an outpatient basis. However, data on burn injuries treated at outpatient centers are largely omitted from the burn literature. Patients suitable for pediatric outpatient burn care are mostly children younger than 5 years old at the time of the injury, with the hand as the prevalent burn location and total body surface area of <1%. The main causal agent in this population are scalds and hot objects, and patients have an average healing time of 13 days. The hospitalization rate varies from 1% to 6%. The success of ambulatory care depends on careful patient selection. The criteria for outpatient management can vary based on the center’s experience and resources and mainly involve partial thickness burns affecting <5% of the total body surface area and burns with minimal involvement of special areas. A careful review of the patient’s social and economic situation is an essential component of the assessment for successful outpatient burn care, as the child’s family should be able to support the wound care, attend to follow-up consultation, and have access to transportation for timely access to a specialized burn center. The treatment goal should be to close the burn wounds as soon as possible. The outpatient care strategy should include adequate pain management, local wound care, home instructions, and follow-up until the burn wounds are well reepithelialized. The most important potential complication is wound infection. It is relevant to know the symptoms and signs of local and systemic infection, so that infections can be treated in a timely and adequate manner. At our outpatient burn center in Chile, we can successfully manage 85% to 90% of patients with burns by making adequate patient selection, having an outpatient management strategy that includes family education, and knowing the possible complications.


KEY WORDS: Ambulatory, Burn, Children, Dressing, Wound care

INTRODUCTION
Burn injuries are a major public health problem. Each year, there are almost 9 million new burn injuries requiring medical care, with most burn injuries concentrated among the pediatric population. Most burn injuries are considered as minor injuries, and 80% to 95% can be treated on an outpatient basis.1-3 Despite most burn injuries being minor, the literature on outpatient-treated burn injuries is scarce.2 Large-scale, national databases containing information about burns, such as the National Burn Repository, National Trauma Data Bank, and the Global Burn Registry, only contain inpatient data; however, most patients seen in burn centers are treated as outpatients.4-6

Small burn injuries can pose significant challenges for clinicians. Although treatment of burns in an outpatient setting can significantly reduce the cost of burn care and improve the patient experience, suboptimal management of small burn wounds may lead to increased pain,7 delayed reepithelialization,8 and increased promotion of pathologic scarring.9 Because treatment of minor burns in pediatric patients without hospital admission has been gradually becoming the routine,10 a better understanding of burn care practices that foster the effectiveness and safety of outpatient procedures is warranted.

COANIQUEM is an outpatient acute burn and rehabilitation center based in Chile that has more than 40 years of experience delivering wound care, outpatient reconstructive surgery, and rehabilitation services for children affected by burns in Chile. With an interdisciplinary model of care, COANIQUEM aims to provide free-of-charge specialized burn care and rehabilitation services that cover all of the children’s and families’ needs. We present our experience with pediatric outpatient burn care and our patient management strategy.

In this review, we describe the profile of pediatric burn patients with minor burn injuries in Chile and aim to identify proper patient selection criteria to be used, to establish wound care strategy suitable for an outpatient setting, and to detect possible complications arising from an outpatient management strategy.

PROFILE OF THE OUTPATIENT PEDIATRIC BURN PATIENT
Scientific literature that focuses on outpatient burns is scarce; however, 2 studies have described pediatric outpatients with burn injuries in the United States. Brown and colleagues reported that, in 2014, 87% of patients admitted to their pediatric burn unit were treated with outpatient wound care.11 Similarly, in 2020, Grote and colleagues described that 86% of the patients with a mean total body surface area (TBSA) of 3% admitted in a 3-year period were offered outpatient care.12 Moreover, an assessment of all children presenting to an Australian pediatric burn unit during 2013 showed that 87% were initially treated as outpatients, representing the vast majority with small- to medium-sized burns. Patients had a median of 2 years and 3 months from when they sustained the injury, and the most frequent burn mechanisms were scalds and contact burns.13

In Chile, Rojas and colleagues14 described a pediatric group who received outpatient care in Santiago, Chile, highlighting that 66% sustained burns of 1% TBSA or less. In this cohort, 65% were younger than 4 years at admission, and hand burns were present in 40% of the cohort.

To summarize, patients treated on an outpatient basis are characterized by being usually younger than 5 years old at the time of the injury, the most frequent location is the hand, and most have a burn extension smaller than 1% TBSA. Scalds and hot objects are the main causal agent, the average healing time is 13 days, and hospitalization rates vary from 1% to 6%.

PATIENT SELECTION CRITERIA
The success of ambulatory care depends on careful patient selection.15 The criteria for outpatient management relies on factors such as the size, depth, and location of the burn; patient age, comorbidities, and functional state; no concern for abuse or neglect; and home support, including assistance in wound care and transportation; these factors can vary based on the center’s experience and resources (Table 1).2

In Chile, and especially at our center, outpatient management for pediatric patients is considered if the patient presents with the following: (1) partial thickness burns affecting less than 5% TBSA located in neutral areas3,16,17,18 (Figure 1); (2) no requirement for fluid resuscitation or surgical procedures; and (3) burn has no or minimal involvement of special areas, in terms of extension and depth (Figure 2).

We consider that hospital admission is necessary for the following cases: (1) children with deeper or larger burns on special areas, such as face, hands, feet, neck, and genitals, until burn depth is clearly established, pain is well controlled, and the follow-up and wound care strategy is created15; (2) patients with full-thickness burns that require surgical repair. Even small deep wounds that need grafting must be surgically addressed early, avoiding any delay on the access to such procedures for the child and families.3,15,16 (3) Patients who have circumferential partial-thickness or full-thickness burns on the limbs or chest should require hospital admission. Circumferential burns can compromise the compliance of the trunk and the perfusion on the limbs. In case of impairment of ventilation or circulation or abdominal compartment syndrome due to circumferential burns, the need for escharotomy should be carefully evaluated by experienced clinicians.3,17-19 Hospitalization is also necessary for (4) burns with associated inhalation injuries,16,18 (5) electrical or chemical burns,16,18 and (6) burns associated with trauma or comorbidities that might complicate patient care, delay recovery, or increase the risk of mortality.3,18 In addition, hospitalization is necessary for (7) patients with suspected nonaccidental injury or social support issues that may require specialist evaluation. Special consideration should be given to any pediatric patient presenting with burns in which the history is inconsistent with the clinical presentation.18 Finally, hospitalization should be necessary for (8) children with burns who are admitted to a health care center lacking the qualified personnel or equipment for appropriate care.3

A careful review of the patient’s social and economic situation is an essential component of the assessment for outpatient burn care, as the child’s family should be able to support the wound care, follow-up, and transportation needs.2,15 Table 2 provides a summary of the patient selection criteria for outpatient management.

OUTPATIENT CARE STRATEGY
In the initial management of burns that are suitable for pediatric outpatient management, it is essential to prevent poor outcomes in relation to scarring.20 There is a well-established link between healing time and the risk of developing hypertrophic scars, especially in pediatric patients.8,19 Thus, the treatment goals should be oriented to close the burn wounds as soon as possible, minimizing the need for repeated dressing changes and limiting pain and psychological distress. Pain control, return of full function, and good aesthetic results are all main objectives of this strategy.3

Before admission to a healthcare facility, adequate first aid helps to stop the burning process and cool the burned wound. Clothing must be removed, and applying cool running water to the burn wound for 20 minutes has been shown to be effective in reducing the burn depth and decreasing the need for grafting, hospitalization, and surgical interventions. Caution should be applied to avoid hypothermia, especially in children.18,19,21

With regard to wound care in an outpatient burn center, recommendations for patients are to treat in a suitable environment, with controlled temperature, comfort, and analgesia. Clinical photography of the wound site should be encouraged to allow the wound to be evaluated by other clinicians without the need to remove dressings19 (Figure 3).

Mechanical cleansing by irrigation is the factor that has been significantly correlated with decreasing the bacterial count in the wound.19 The irrigation cleansing can be applied in several ways, depending on the resources available at the setting with any sterile or decontaminated cleansing solution being suitable for use.19,22 There is great debate about the clinical decision regarding burn blisters. Our recommendation is to de-roof the blister, which can increase patient comfort, prevent infection, limit the burn wound deepening, and allow an easier assessment of the underlying wound.3,18,19,22

Dressing choices should be individual and based on patient and wound-related factors, as well as availability. Temporary biosynthetic skin substitutes are generally recommended, as definitive management for partial thickness burns and antimicrobial dressings are considered for burn wounds at risk of colonization and infection.19,23,24

Burn-related procedures can be painful, and it is important to minimize pain. Explaining the procedure to the patient and parents, using preventive and combined analgesia, using nonpharmacologic interventions, and of most importance, using strategies shown to be effective to control pain during procedures are important. Nonpharmacological interventions, such as hypnosis, virtual reality, music therapy, and others, can also reduce children’s pain and anxiety during medical treatment.25

Patients and caregivers should be provided clear instructions, including written information about resting, care of bandages, and administration of analgesics (detailing dosage and frequency). Instructions must also include attention to signs and symptoms, such as increased pain, localized heat, foul-smelling exudate, past dressings, and appearance of symptoms and signs of systemic infection, such as fever, general condition decline, diarrhea, vomiting, and skin spots. Caregivers must be aware that burns are dynamic and may evolve after the initial assessment. It is important to ensure that burn wounds are reassessed 2 to 3 days after the first visit, so that the wound remains appropriate for outpatient care management.15

With optimal care, the wound site should improve within 14 days, thus also reducing the risk of hypertrophic scarring. Deep burns or burns that have not healed within 7 to 10 days and burns with signs of infection should be referred to a specialized burns unit, as they probably require surgical treatment.18

COMPLICATIONS
Outpatient care can be complicated by multiple factors, such as poor pain control, poor oral fluid intake, and wound infections.2,11,12 Among the complications, the most important one is infection. It is recommended that prophylactic antibiotics are not routinely given for acute burn injuries.19

Having proper surveillance and a protocol for signs of local and systemic infection, for timely and adequate treatment, are important. Burn wounds needs constant monitoring, and the main method of detecting infection is to observe changes in wound appearance. Changes in the wound color, increased pain, and increased exudate that cannot be contained by the dressing are all signs that indicate infection. Patients may also present with systemic symptoms of infection, such as pyrexia, tachycardia, and hypotension.19,26 Colonization may be demonstrated by qualitative or quantitative microbiological analysis, and a positive result in combination with clinical features of infection should prompt consideration of antibiotic use plus antimicrobial dressings and possibly surgical management.19

CONCLUSIONS
Most burns are successfully managed on an outpatient basis. Excellent results can be achieved with the knowledge of basic concepts of burn care and having adequate patient selection for outpatient care. Having an outpatient management strategy that includes family education, close monitoring of the burn wound, and scheduling of follow-up visits are important parts of the strategy, given the dynamic and fragile progression of burn injuries and the risk of complications.

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Volume : 3
Issue : 2
Pages : 33 - 38


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From the 1Surgery Department, Corporación de Ayuda al Niño Quemado, COANIQUEM, Santiago, Chile; the 2Pediatric Plastic Surgery and Pediatric Burns Team, Clínica Alemana, Santiago, Chile; and the 3Research Department, Corporación de Ayuda al Niño Quemado, COANIQUEM, Santiago, Chile
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: María Dora Espinosa González, 8586, San Francisco Av, Pudahuel 9020070, Santiago, Chile
PHONE: +56 9 9224 0132
E-MAIL: mariadorae@yahoo.com