Apresentação em tema: "Queimaduras em Paciente Pediátricos"— Transcrição da apresentação:
1 Queimaduras em Paciente Pediátricos André Garbin
2 DefiniçãoLesão traumática da pele ou qualquer tecido orgânico causada por exposições agudas, principalmente térmicas.Ocorre quando algumas ou todas as células do tecido em questão são destruidas pelo calor, frio, eletricidade, radiação ou cáusticos— 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 .
3 Epidemiologia 4a causa mais comum de trauma 90% ocorrem em países de média e baixa renda Na população pediatrica 84% ocorre em casa sendo que em 80% dos casos estão sem supervisãoTipo mais comum é 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 .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 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 reportWorldwide, 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 . In comparison, 27 percent of patients 5 to 20 years of age had scald injuries.
4 Epidemiologia Relação com gênero Mortalidade maior em crianças (< 2 anos) para qualquer extensão de queimaduraMaior relação área/pesoMortalidade maior em sexo feminino independe da idade.Nos lactentes (2a) Mesma porcentagem de area causa dano maior pela menor massaRins e figado imaturo nao conseguem remover solutos dos tecidos lesados tampouco restaurar suporte nutricional adequadoBurn 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].Burns — Burns occur in 6 to 20 percent of physically abused children  and are considered by some authors to be more indicative of premeditated acts than are other types of injury . 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) . 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 . 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) .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 burnsBrands — In 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 burns — Cigarette 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 , 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 .Immersion burns — Immersion burns usually are seen on the buttocks or legs, or in a stocking or glove distribution on the extremities (picture 7) . 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 oven — Microwave 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 .Stun gun burns — Stun 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 skin
5 EpidemiologiaQueimaduras não acidentais correspondem a até 20% dos casos admitidos.Padrões de lesão no abuso< 10 anos
9 Patofisiologia: resposta local Necrose por coagulaçãoFormam-se 3 zonas distintasZona de coagulação: coagu vasc irreversivel, nenhum fluxo, profundidade depende da temp e duração, viscosidadeZona de estase: lesado sem coag, fluxo capilar lento, determina extensao futura dependendo dos cuidadosZona de hiperemia resposta inflamatoria habitualLocal injury — Thermal 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.
10 Patofisiologia: resposta sistêmica Lesão celularExposição do ColágenoLiberação de Substâncias VasoativasPeleCitocinasNOHistaminaCininas – Sist. CalicreínaÁc. Araquidônico - PGsSalientar que esse mecanismo ocorre localmente mas se sup maior 20% ocorre sistemicamente, embora edema generalizado deva-se mais a hipoproteinemiaSystemic response — Immediately following the burn injury, vasoactive mediators (such as cytokines, prostaglandins, and oxygen radicals) are released from damaged tissue . 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 . 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 . This reduction in oxygen carrying capacity may exacerbate burn shock.Vaso
11 Extravasamento de Plasma (Eletrólitos , Proteínas e etc) Rapida perda de vol intravasPerde liquido pela vasodilatação e perde adicional por aumento da posmotica intersticialSe maior que 20% as Sup corp há resposta sistemica (edema gener e choque hipovol)Extravasamento de Plasma(Eletrólitos , Proteínas e etc)
12 Patofisiologia: edema Perda maior nas primeiras 6-12 horasIntegridade capilar retomada em horasConsequências sistêmicas se SCQ > 20%Edema em tecidos não queimados - hipoproteinemia
13 Resposta metabólica Resposta ao trauma: hipermetabolismo acentuado Evaporação de até 300ml/m2/h (normal 15ml/m2/h)580kcal/L de água evaporadaReforçar que na queimadura o catabolismo eh bem maiorMetabolic response — Following resuscitation, children with major burns develop a hypermetabolic response that results in a dramatic increase in energy expenditure and protein metabolism . Increases in catecholamines, glucagon, and cortisol are correlated with elevation of metabolic rate and catabolism . Levels of anabolic hormones such as human growth hormone and insulin-like growth factor are decreased for several weeks following a significant burn .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].
15 Burn depth — The 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 1 and figure 1) . The term fourth degree is still used to describe the most severe burns, burns that extend into the muscle, bone, and/or joints.Superficial — Superficial 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-thickness — Partial 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-thickness — These 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 burns — Fourth degree burns are deep and potentially life-threatening injuries that extend through the skin into underlying tissues such as fascia, muscle, and/or bone.
16 • Queimaduras de espessura parcial superficial são aquelas de primeiro grau e/ou de segundograu superficial;• Queimaduras de espessura parcialprofunda são aquelas de segundo grauprofundo;• Queimaduras de espessura total sãoaquelas de terceiro grau.
25 Determinar extensão Regra da mão espalmada Regra dos 9 Tabela de Lund-BrowderLesões superficiais excluídas.Jamais considerar lesoes de primeiro grauPERCENT BODY SURFACE AREA ESTIMATES — A 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.CLASSIFICATION — The 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 1 and table 2).The system currently being used to classify burn depth is based upon the need for surgical intervention (table 3 and figure 2).
26 Regra da mão espalmada Utilidade Palma do paciente – 0.5 a 1% SCT Palm method — Small 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].
31 PEQUENO QUEIMADO• queimaduras de primeiro grau em qualquerextensão, em qualquer idade e/ou;• queimaduras de segundo grau com áreacorporal atingida até 5% em criançasmenores de 12 anos, ou;corporal atingida até 10% em maiores de12 anos.MÉDIO QUEIMADOcorporal atingida entre 5% a 15% emcorporal atingida entre 10% a 20% emmaiores de 12 anos, ou;• qualquer queimadura de segundo grauenvolvendo mão ou pé ou face oupescoço ou axila ou grande articulação(axila ou cotovelo ou punho ou coxofemoralou joelho ou tornozelo), emqualquer idade;• queimaduras que não envolvam face ou mãoou períneo ou pé, de terceiro grau com até5% da área corporal atingida em criançasaté 12 anos, ou;ou períneo ou pé, de terceiro grau com até 10%da área corporal atingida em maiores de 12 anos.GRANDE QUEIMADOConsidera-se como queimado de grandegravidade o paciente com:corporal atingida maior do que 15% emcorporal atingida maior do que 20% em• queimaduras de terceiro grau com áreacorporal atingida maior do que 5% emcorporal atingida maior do que 10% em• queimaduras de segundo ou terceirograu atingindo o períneo, em qualqueridade, ou;• queimaduras de terceiro grau atingindo mãoou pé ou face ou pescoço ou axila, emqualquer idade, ou;• queimaduras por corrente elétrica.
32 Tratamento Inicial Mesmas prioridades de qualquer traumatizado Parar queimadura, tirar anéis, roupas não queimadas.A – vias aéreasB – ventilaçãoC – circulaçãoD – disfunção sist nervoso central (Hipóxia - Glasgow, TCE assoc.)E – exposição (SCQ)Ver a ordem de novo naas diretrizes brasileiras
33 A – Vias AéreasEntubar precocemente se houver sinais de queimaduras em vias aéreas ou se dúvida, antes da ressuscitação vol. - edemaSinais de queimadura de vias aéreasTosse com odor carbonáceoQueimadura dos vestíbulos nasais ou vibrissasAlteraçoes no timbre, rouquidão, estridorAirway — Patients 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 .
34 B - Respiração Restrição mecânica – escarotomia Intoxicação por CO - depressão respiratória e queda da oxigenação – IOT + O2 100%Breathing — Decreased 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.
35 C – Ressuscitação Volêmica Dois acesso venosos periféricos calibrososColetar: gasometria (hipóxia)Estimar SCQ (regra dos 9)Cristalóide IsotônicoParkland determina necessidade nas 24 iniciais:4mL/Kg/%SCQ – metade em 8h, metade em 16HCuidar com excesso de RL (alcalose metabolica) devido a metabolização do lactato q eh alcalinizanteFluid resuscitation — Adequate 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 requirements — Formulas 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 <5 years of age. (See "Maintenance fluid therapy in children".)Galveston mL/m2 per percent TBSA. Add 2000 mL/m2 per day for maintenance requirements.Half of the fluid is given over the first 8 hours. The remaining half is given over the next 16 hours.
36 MonitorizaçãoMonitoring fluid status — The volume status of burn patients must be carefully monitored in order to successfully navigate the narrow path between inadequate volume and fluid overload. The following parameters are helpful (table 5):Urine output should be maintained at 1 to 2 mL/kg per hour for children <30 kg and 0.5 to 1 mL/kg per hour for those ≥30 kg [25,26,33]. For outputs that exceed this rate, urine should be tested for glucose. Hyperglycemia (as the result of increased catecholamine levels) can cause an osmotic diuresis that should not be misinterpreted as a reflection adequate volume status.Heart rate is a better monitor of circulatory status in children than is blood pressure. Tachycardia may indicate hypovolemia, but pain can elevate heart rate in euvolemic patients (table 6 and table 7).Metabolic acidosis can be a marker for inadequate fluid resuscitation, but also occurs with carbon monoxide or cyanide exposure.
37 C – Ressuscitação Volêmica Se SCQ >30% - Colóides (albumina), somente após 24h0.5mL/kg/%SCQ
38 Período pós - ressuscitação Soro de reposição com estimativa de perda da seguinte forma:(25 x %SCQ) x m2 de superf. corporal total = mL/hTratamento inicial da queimaduraLavar com SF e sabãoSe queimaduras profundas pode-se usar antibiótico tópicoSulfadiazina prata
39 Período pós - ressuscitação Suporte Nutricional – Iniciar precocementeNecessidade estimadaRelação calorias não-protéicas/protéicas de 100/1Mínimo de 2g proteína/kg/diaSuport nutric mais precoce posivel para facilitar cicatrização e translocação bactPedir exames como rotina diariamente –hemograma, eletrólitos, proteinograma,coagulograma, ureia, creatinina, glicemia dejejum, urina tipo I.Laboratório diário – HMG, eletrólitos, coagulograma, uréia, creatinina.
40 Tratamento CirúrgicoEscarotomia – avaliação de extremidades – Sd compartimental.Debridamento: primeiras 48h, assim que paciente estiver estabilizado – risco de infecção.Enxerto: queimaduras de espessura totalEscaro pode se realizar na sala de admissao com sedação