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Queimaduras em Paciente PeditricosAndr GarbinDefinioLeso traumtica da pele ou qualquer tecido orgnico causada por exposies agudas, principalmente trmicas.

Ocorre quando algumas ou todas as clulas do tecido em questo so destruidas pelo calor, frio, eletricidade, radiao ou custicos

A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures. Burns occur when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals. Burns are acute wounds caused by an isolated, non-recurring insult and progress rapidly through an orderly series of healing steps [1].2Epidemiologia4a causa mais comum de trauma

90% ocorrem em pases de mdia e baixa renda

Na populao pediatrica 84% ocorre em casa sendo que em 80% dos casos esto sem superviso

Tipo mais comum a escaldura (60-80%) em < 5 anos. Entre 5 e 20 anos cai para 27%

Burns are the fourth most common type of trauma worldwide, following traffic accidents, falls, and interpersonal violence [3].

Approximately 90 percent of burns occur in low to middle income countries, regions that generally lack the necessary infrastructure to reduce the incidence and severity of burns [4]

Most burn injuries occur in a domestic setting, with cooking as the most common activity [6,7]. Pediatric burns occur more commonly in the home (84 percent) and while children are unsupervised (80 percent)

There are regional differences for the most frequent cause of burns in children. In the US, the number of scalds far exceeds the number of flame burns in children age 0 to 4.9 years. However, flame burns outnumber scalds in all other pediatric age groups in the US, based on the National Burn Repository report

Worldwide, scalds account for 60 to 80 percent of burn injuries for young children [3,4,7-11]. Among children in the United States less than 5 years of age with burn injuries reported to the National Burn Repository, 65 percent sustained scalds [8]. In comparison, 27 percent of patients 5 to 20 years of age had scald injuries.

3EpidemiologiaRelao com gnero

Mortalidade maior em crianas (< 2 anos) para qualquer extenso de queimadura

Maior relao rea/peso

Mortalidade maior em sexo feminino independe da idade.

Nos lactentes (2a) Mesma porcentagem de area causa dano maior pela menor massa

Rins e figado imaturo nao conseguem remover solutos dos tecidos lesados tampouco restaurar suporte nutricional adequado

Burn injuries can be a manifestation of child abuse. Non-accidental burns account for as many as 20 percent of burn unit admissions [16,17]. Inflicted burns are usually scalds and most children are less than four years of age [18,19]. A pattern of deep burns on the lower extremities in a symmetric stocking distribution is typical (picture 1). (See "Physical abuse in children: Epidemiology and clinical manifestations", section on 'Immersion burns'.) Inflicted craniofacial immersion injuries have been infrequently reported, as have accidental mechanisms for stocking distribution extremity burns [20,21].

BurnsBurns occur in 6 to 20 percent of physically abused children [56]and are considered by some authors to be more indicative of premeditated acts than are other types of injury [41]. In one study of 507 consecutive admissions to a pediatric burn unit in Australia, 8 percent of burns were caused by abuse or neglect and 6 percent were "concerning" (the family situation was thought to have contributed to the injury or made further injury more likely) [57]. Factors associated with inflicted or concerning burns included: single parent families, burns to both hands or both legs, increased frequency of necessity for skin grafting, increased need for intensive care, and prior notification for abuse or neglect [57]. The mortality rate of burns caused by abuse is greater than that of noninflicted burns (5.6 to 9.6 percent versus 2.6 to 6.0 percent) [57].

As with bruises, the pattern of injury suggests the mechanism or object used to inflict it. Burns indicative of abuse include the following:

Brands/contact burns

Cigarette burns

Immersion burns

Microwave oven burns

Stun gun burns

BrandsIn a brand or contact burn, the imprint of a hot object, such as cross-hatching from a radiator grille, imprint of a clothes iron (picture 6) or curling iron, or the flame end of a cigarette lighter, is left on the skin. The clear outlines of the object are visible, and the burn is of relatively uniform depth. In contrast, in unintentional burns, the burn typically is shallow because of the reflex to pull away, and only part of the object's outline is seen.

Cigarette burnsCigarette burns are circular, 8 to 10 mm in diameter, and of uniform depth, with an indurated heaped-up margin. These burns may be difficult to distinguish from impetigo, but the latter involves superficial skin layers and occurs in crops, whereas cigarette burns usually are third-degree, deep, and relatively painless [41], and occur on the face or on the dorsa of the hands or feet. In addition, impetigo heals cleanly with antibiotic therapy, whereas cigarette burns heal slowly and leave scars [58].

Immersion burnsImmersion burns usually are seen on the buttocks or legs, or in a stocking or glove distribution on the extremities (picture 7)[59]. They are of uniform depth, with a sharp line of demarcation between burned and normal skin. Drip or splash marks, which would be seen when hot liquid is spilled, are absent. Sparing of the thicker skin of palms or soles, and of skin folds where knees and hips are flexed, is a common finding.

Microwave ovenMicrowave oven burns occur when a child (usually an infant) is placed in an operating microwave oven. Partial- or full-thickness burns occur on the skin surfaces closest to the microwave-emitting device. On pathologic tissue examination, subcutaneous fat is characteristically undamaged and may lie between significantly burned layers of skin and muscle. Charring and nuclear streaming, seen with electrical burns, are absent [60].

Stun gun burnsStun guns were developed in the United States in 1979 and are available to the public without license in most states [61,62]. A stun gun produces a peak voltage of up to 50,000 volts in a series of short-duration pulses, resulting in repetitive muscle contraction, numbness, confusion, and incapacitation for up to 15 minutes, as well as partial-thickness electrical burns at the site of contact. Abusive stun gun injuries usually are multiple and appear as paired lesions approximately 0.5 cm in diameter and 5 cm apart [61,62].

Child abuse Burns account for 10 percent of all cases of child abuse [64,65]. The child burn victim is almost always under age 10 years and the majority are less than two years old. Scalds from immersion into hot baths or splashes are the most frequent burn injury. Contact with heated objects including cigarettes, iron, curling iron, hair dryer and heated kitchen utensils are commonly used in abuse cases.

The medical evaluation of children who sustain burns includes seeking evidence of:

Healed burns from subsequent injuries

Multiple simultaneous burns

Bruises shaped like hands, fingers or objects that suggest burns, hits, or bite marks

Sexual abuse

Inconsistent history from parents or guardians and physical examination

Doughnut shaped burn pattern on the buttocks

Sparing of the soles of the feet

Pattern of burn similar to a cigarette or other heated object

Stocking or glove pattern burn

Waterlines on skin4EpidemiologiaQueimaduras no acidentais correspondem a at 20% dos casos admitidos.

Padres de leso no abuso< 10 anos

Padroes simtrico em bota luva 6

Patofisiologia: resposta localNecrose por coagulaoFormam-se 3 zonas distintas

Zona de coagulao: coagu vasc irreversivel, nenhum fluxo, profundidade depende da temp e durao, viscosidadeZona de estase: lesado sem coag, fluxo capilar lento, determina extensao futura dependendo dos cuidadosZona de hiperemia resposta inflamatoria habitual

Local injuryThermal energy denatures and coagulates protein, resulting in irreversible tissue destruction. Surrounding this zone of coagulation is an area of decreased tissue perfusion. Tissue in this zone is potentially salvageable, provided that resuscitative efforts are successful in restoring perfusion to the area. Perfusion is increased at the outer margins of the burn. Tissue in this zone will recover as long as the patient does not experience prolonged hypoperfusion.

The intensity and duration of thermal exposure determines the depth of a burn wound. Prolonged skin contact from hot liquids with high specific heat or high viscosity can result in deeper burns. Deeper burns are more common in young children because their skin is thinner than skin of adults.9Patofisiologia: resposta sistmicaCitocinasNOHistaminaCininas Sist. Calicrenac. Araquidnico - PGsVasoPele

Exposio do ColgenoLiberao de Substncias VasoativasLeso celularSalientar que esse mecanismo ocorre localmente mas se sup maior 20% ocorre sistemicamente, embora edema generalizado deva-se mais a hipoproteinemia

Systemic responseImmediately following the burn injury, vasoactive mediators (such as cytokines, prostaglandins, and oxygen radicals) are released from damaged tissue [26]. Increased capillary permeability results in extravasation of fluid into the interstitial space around the burn. Patients with large burns (15 percent TBSA for young children and 20 percent for older children and adolescents) develop systemic responses to these mediators. For patients with 40 percent TBSA or more, myocardial depression can occur [27]. As a result, patients with major burns may become hypotensive (burn shock) and edematous (burn edema).

Systemic capillary leak usually persists for 18 to 24 hours. Protein is lost from the intravascular space during the first 12 to 18 hours after a burn, after which vascular integrity improves.

In large burns, up to 15 percent of red blood cells may be destroyed locally and an additional reduction of 25 percent of the red blood cell mass may occur due to decreased red cell survival time [28]. This reduction in oxygen carrying capacity may exacerbate burn shock.

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Extravasamento de Plasma(Eletrlitos , Protenas e etc)Rapida perda de vol intravas

Perde liquido pela vasodilatao e perde adicional por aumento da posmotica intersticial

Se maior que 20% as Sup corp h resposta sistemica (edema gener e choque hipovol) 11Patofisiologia: edemaPerda maior nas primeiras 6-12 horas

Integridade capilar retomada em 36-48 horas

Consequncias sistmicas se SCQ > 20%

Edema em tecidos no queimados - hipoproteinemiaResposta metablicaResposta ao trauma: hipermetabolismo acentuado

Evaporao de at 300ml/m2/h (normal 15ml/m2/h)

580kcal/L de gua evaporadaReforar que na queimadura o catabolismo eh bem maior

Metabolic responseFollowing resuscitation, children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism [26]. Increases in catecholamines, glucagon, and cortisol are correlated with elevation of metabolic rate and catabolism [29]. Levels of anabolic hormones such as human growth hormone and insulin-like growth factor are decreased for several weeks following a significant burn [30].

Evidence suggests that modulation of the hypermetabolic response with therapies such as beta blockers and human growth hormone may improve outcomes for severely burned children [31-34].13ClassificaoAgente causal

Extenso/gravidade

Profundidade

Burn depthThe traditional classification of burns as first, second, third, or fourth degree is being replaced by a system reflecting the need for surgical intervention. Current designations of burn depth are superficial, superficial partial-thickness, deep partial-thickness, and full-thickness (table 1and figure 1)[2]. The term fourth degree is still used to describe the most severe burns, burns that extend into the muscle, bone, and/or joints.

SuperficialSuperficial or epidermal burns involve only the epidermal layer of skin. They do not blister but are painful, dry, red, and blanch with pressure (picture 1). Over the next two to three days the pain and erythema subside, and by about day four, the injured epithelium peels away from the newly healed epidermis. Such injuries are generally healed in six days without scarring. This process is commonly seen with sunburns.

Partial-thicknessPartial thickness burns involve the epidermis and portions of the dermis. They are characterized as either superficial or deep.

Superficial - These burns characteristically form blisters within 24 hours between the epidermis and dermis. They are painful, red, and weeping, and blanch with pressure (picture 2). Burns that initially appear to be only epidermal in depth may be determined to be partial-thickness 12 to 24 hours later. These burns generally heal in 7 to 21 days; scarring is unusual, although pigment changes may occur.

A layer of fibrinous exudates and necrotic debris may accumulate on the surface, which may predispose the burn wound to heavy bacterial colonization and delayed healing. These burns typically heal without functional impairment or hypertrophic scarring.

Deep - These burns extend into the deeper dermis and are characteristically different from superficial partial-thickness burns. Deep burns damage hair follicles and glandular tissue. They are painful to pressure only, almost always blister (easily unroofed), are wet or waxy dry, and have variable mottled colorization from patchy cheesy white to red (picture 3). They do not blanch with pressure.

If infection is prevented and wounds are allowed to heal spontaneously without grafting, they will heal in three to nine weeks. These burns invariably cause hypertrophic scarring. If they involve a joint, joint dysfunction is expected even with aggressive physical therapy. A deep partial-thickness burn that fails to heal in three weeks is functionally and cosmetically equivalent to a full thickness burn. Differentiation from full-thickness burns is often difficult.

Full-thicknessThese burns extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. Burn eschar, the dead and denatured dermis, is usually intact. The eschar can compromise the viability of a limb or torso if circumferential.

Full thickness burns are usually anesthetic or hypoesthetic. Skin appearance can vary from waxy white to leathery gray to charred and black. The skin is dry and inelastic and does not blanch with pressure (picture 4). Hairs can easily be pulled from hair follicles. Vesicles and blisters do not develop.

Pale full-thickness burns may simulate normal skin except that the skin does not blanch with pressure. Features that differentiate partial-thickness from full-thickness burns may take some time to develop.

The eschar eventually separates from the underlying tissue and reveals an unhealed bed of granulation tissue. Without surgery, these wounds heal by wound contracture with epithelialization around the wound edges. Scarring is severe with contractures; complete spontaneous healing is not possible.

Fourth degree burnsFourth degree burns are deep and potentially life-threatening injuries that extend through the skin into underlying tissues such as fascia, muscle, and/or bone.

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Queimaduras de espessura parcial superficialso aquelas de primeiro grau e/ou de segundograu superficial; Queimaduras de espessura parcialprofunda so aquelas de segundo grauprofundo; Queimaduras de espessura total soaquelas de terceiro grau.16

ClassificaoAgente causal

Extenso/GravidadeProfundidade

Determinar extensoRegra da mo espalmada

Regra dos 9

Tabela de Lund-Browder

Leses superficiais excludas.Jamais considerar lesoes de primeiro grau

PERCENT BODY SURFACE AREA ESTIMATESA thorough and accurate estimation of burn size is essential to guide therapy and to determine when to transfer a patient to a burn center.

In several observational reports comparing the estimation of burn size at the referring hospital with the estimation at the receiving burn center, the size of larger burns was underestimated. This resulted in underresuscitation at the referring hospital [5-7]. Early transfer to a burn center should be arranged when injuries meet the criteria for major burns (table 2). (See "Emergency care of moderate and severe thermal burns in adults", section on 'Initial approach'.)

The extent of burns is expressed as the total percentage of body surface area (TBSA). Superficial burns are not included in the TBSA burn assessment. The location of partial-thickness and full-thickness burned areas are recorded on a burn diagram (figure 2). Burns with an appearance compatible with either deep partial-thickness or full-thickness are presumed to be full-thickness until accurate differentiation is possible.

The two commonly used methods of assessing TBSA in adults are the Lund-Browder chart and "Rule of Nines," whereas in children, the Lund-Browder chart is the recommended method because it takes into account the relative percentage of body surface area affected by growth.

When the burn is irregular and/or patchy, the palm method may be useful.

CLASSIFICATIONThe American Burn Association (ABA) has classified burns into minor, moderate, and major, based primarily upon burn depth and size (table 1). The treatment and prognosis of burn victims correlates with this classification. Thus, it is important that clinicians properly characterize the size and severity of their patients' burns. The classification of burns is discussed separately. (See "Classification of burns".)

Burn size is typically expressed as the percentage of total body surface area (TBSA) that is burned. Superficial burns are not included in this estimation. (See "Classification of burns", section on 'Burn depth'.) A modification of the Lund and Browder chart is used most often for children (figure 1and table 2).

The system currently being used to classify burn depth is based upon the need for surgical intervention (table 3and figure 2).25Regra da mo espalmadaUtilidade

Palma do paciente 0.5 a 1% SCT

Palm methodSmall or patchy burns can be approximated by using the surface area of the patient's palm. The palm of the patient's hand, excluding the fingers, is approximately 0.5 to 1 percent of total body surface area [12-14].

26Regra dos 9

Lund browner

Sempre preencher tabela na admissao

As areas so de metade da regiao (metade da cabea, face anterior, etc28

ClassificaoAgente causal

Extenso/GravidadeProfundidade

PEQUENO QUEIMADO queimaduras de primeiro grau em qualquerextenso, em qualquer idade e/ou; queimaduras de segundo grau com reacorporal atingida at 5% em crianasmenores de 12 anos, ou; queimaduras de segundo grau com reacorporal atingida at 10% em maiores de12 anos.

MDIO QUEIMADO queimaduras de segundo grau com reacorporal atingida entre 5% a 15% emmenores de 12 anos, ou; queimaduras de segundo grau com reacorporal atingida entre 10% a 20% emmaiores de 12 anos, ou; qualquer queimadura de segundo grauenvolvendo mo ou p ou face oupescoo ou axila ou grande articulao(axila ou cotovelo ou punho ou coxofemoralou joelho ou tornozelo), emqualquer idade; queimaduras que no envolvam face ou moou perneo ou p, de terceiro grau com at5% da rea corporal atingida em crianasat 12 anos, ou; queimaduras que no envolvam face ou moou perneo ou p, de terceiro grau com at 10%da rea corporal atingida em maiores de 12 anos.

GRANDE QUEIMADOConsidera-se como queimado de grandegravidade o paciente com: queimaduras de segundo grau com reacorporal atingida maior do que 15% emmenores de 12 anos, ou; queimaduras de segundo grau com reacorporal atingida maior do que 20% emmaiores de 12 anos, ou; queimaduras de terceiro grau com reacorporal atingida maior do que 5% emmenores de 12 anos, ou; queimaduras de terceiro grau com reacorporal atingida maior do que 10% emmaiores de 12 anos, ou; queimaduras de segundo ou terceirograu atingindo o perneo, em qualqueridade, ou; queimaduras de terceiro grau atingindo moou p ou face ou pescoo ou axila, emqualquer idade, ou; queimaduras por corrente eltrica.31Tratamento InicialMesmas prioridades de qualquer traumatizado

Parar queimadura, tirar anis, roupas no queimadas.

A vias areas

B ventilao

C circulao

D disfuno sist nervoso central (Hipxia - Glasgow, TCE assoc.)

E exposio (SCQ) Ver a ordem de novo naas diretrizes brasileiras32A Vias AreasEntubar precocemente se houver sinais de queimaduras em vias areas ou se dvida, antes da ressuscitao vol. - edema

Sinais de queimadura de vias areasTosse com odor carbonceoQueimadura dos vestbulos nasais ou vibrissasAlteraoes no timbre, rouquido, estridor

AirwayPatients with upper airway burns should be intubated early, before airway anatomy becomes distorted by edema. Soot in the mouth, facial burns, and body burns may be more useful predictors of inhalation injury than symptoms of stridor, hoarseness, drooling, and dysphagia [38].

33B - RespiraoRestrio mecnica escarotomia

Intoxicao por CO - depresso respiratria e queda da oxigenao IOT + O2 100%

BreathingDecreased level of consciousness, toxins (such as carbon monoxide or cyanide), or associated injuries can interfere with ventilation and/or oxygenation. Patients with circumferential burns to the chest or abdomen may develop respiratory compromise as the result of decreased chest wall compliance.

34C Ressuscitao VolmicaDois acesso venosos perifricos calibrososColetar: gasometria (hipxia) Estimar SCQ (regra dos 9)

Cristalide IsotnicoParkland determina necessidade nas 24 iniciais:

4mL/Kg/%SCQ metade em 8h, metade em 16H

Cuidar com excesso de RL (alcalose metabolica) devido a metabolizao do lactato q eh alcalinizante

Fluid resuscitationAdequate fluid resuscitation is an essential component of the initial management of children with major burns. Observational evidence and clinical experience suggest that adequate initial fluid resuscitation improves outcomes for these patients [42,43].

Estimating fluid requirementsFormulas for estimating fluid requirements for children for the first 24 hours following a burn injury include:

Parkland - 4 mL/kg per percent total burn surface area (TBSA). Add maintenance fluid for children