from Julia Sarginson March 2016 With thanks to Dr A Young Prof A Emond and Mr I Mackie Introduction Burns in Preschool Children Peak age is between 9 and 24 months ID: 558659
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Slide1
Recognising and managing inflammation and infection following burn injury in children - the results from
Julia Sarginson – March 2016With thanks to: Dr A Young, Prof A Emond and Mr I MackieSlide2
Introduction
Burns in Pre-school Children:Peak age is between 9 and 24 months
.
3rd
most common
injury
type
in children under
five
(following
soft tissue injuries and head
injuries).
4
th
most common
mechanism
of accidental injury
requiring hospitalisation
(following falls, struck by object, foreign body or poisoning).
Over
5,200
children under the age of five were admitted to burns services in the UK in
2014.
104
per 100,000
children in this age
group.Slide3
Introduction
Most of these injuries are ‘small’.Children under 5 years with <10% TBSA burns ≈ 70% workload paediatric burn services in the UK
9% TBSA
Kettle or shower scald
4
%
TBSA
Hot drink scald
0.5%
TBSA
Contact burn to hand or footSlide4
Introduction
Febrile Illness
Community acquired bacterial or viral illness
Burn wound infection, sepsis or Toxic Shock SyndromeSlide5
Introduction
Mean age (years)Mean burn size (% TBSA)
Circle size = population in study
Studies looking at the Inflammatory Response in Paediatric Burns
?Slide6
Introduction
Aims:To describe the typical inflammatory response to small burn injury in pre-school children,To identify patient and injury characteristics associated with re-presentation and post-burn febrile illness.Slide7
Method
Morbidity
I
n
S
mall
T
hermal
Injury in
Children
Prospective Observational Cohort Study3 Paediatric burns services in England18 months (January 2014 to July 2015)Slide8
Bristol
Chelmsford
Method
Eligibility criteria:
< 5 years of age,
Presenting within 48 hours of
injury,
Burn less than 10% TBSA,
Any mechanism
(including friction injury),
and any depth.
BirminghamSlide9
Method
Prospective Data collection: Medical notes;Clinical details – pre-injury, assessment and management, post-injury events,
ALL physical observations for injury episode,
ALL blood test results for injury episode.Slide10
Method
Prospective Data collection: Parental questionnaires & temperature diariesSlide11
Method
Clinical Governance:Ethics approval obtained,Local R&D approvals obtained.
Data management and analysis:
Standardised CRFs,
Database storage - ,
Statistical Analysis - .Slide12
Results
676
included in final analysis
- 625 with burns
- 51 comparison group (finger-tip injuries)
95 %Slide13
Results
Recruited: 625 childrenMedian Age: 1y 7m [IQR: 1.15 to 2.45]
Median % TBSA:
1.00 [
IQR: 0.30 to 2.50
]
Follow
-up:
Medical notes data
100%Post-injury follow-up 76%Temperature diaries 46%Scald 55 %Contact42 %Other 3 %Burn Type:
Slide14
Aim 1: To describe the typical inflammatory response to small burn injury in pre-school
childrenResultsSlide15
Results
Temperature change: ScaldsTemp change
over
7 days
(
p<0.001)
4345 recordings from 237 patientsSlide16
Results
Temperature change: Scalds
Temp variation
by burn size
(p<0.001)
4345 recordings from 237 patientsSlide17
Results
Temperature change: Contact burns
Temp change
o
ver 7 days
(p=0.363)
1269 recordings from 137 patientsSlide18
Results
Temperature change: Contact burns
Temp variation
by burn size
(p<0.001)
1269 recordings from 137 patientsSlide19
Heart rate:
Scalds
ResultsSlide20
CRP:
Scalds
ResultsSlide21
Results
TemperatureSlide22
Aim 2: To identify patient and injury characteristics associated with re-presentation and post-burn febrile illness.
ResultsSlide23
Results
Full post-injury follow-up: 476/625 (76%)Unexpected re-presentation to medical care (burns service, ED or GP): 103/476 (22%)Unplanned re-admission: 46/476 (10%)Slide24
Results
Diagnoses given:Toxic Shock Like Illness – 14Burn wound infection – 5Sepsis – 1
Deep burn –
4
Nonspecific viral illness – 10
URTI – 14
LRTI – 6
Gastroenteritis – 2
Chickenpox –
2
Cough/cold – 7Teething – 2Skin reaction – 5 Pyrexia ?cause – 3Other – 8None given – 20 23%
?Slide25
Results
Factors associated with re-presentation:Scalds: TBSA OR 1.27 [95% CI: 1.09 to 1.47] (p=0.002)Burn site head and neck OR 2.07 [95% CI: 1.12 to 3.81] (p=0.019)Weak associations: Deep/FT component, burn site torso, lack of cool water first aidSlide26
Conclusions
A systemic inflammatory response to injury can be identified in burns over 2% TBSA.This is likely to be a cause of some cases of post-burn pyrexia. Some of the ‘pathological’ diagnoses
given for re-presentations may
be an inflammatory response in the absence of infection
.
Both the inflammatory response and re-presentations with post-burn illness increase with increasing burn size.Slide27
Take home messages
A systemic inflammatory response to burn injury can be seen in young children with relatively small sized burns.One in five children re-present to medical care with a systemic illness after a small burn.Clinicians should be aware that some of these presentations will be infections, and some will be a SIRS response in the absence of infection.Slide28
Next steps
Derive normal reference ranges and symptom profiles for the inflammatory response.Identify signs and symptoms profiles that distinguish between inflammation and infection.Identify high-risk group for re-presentation who may benefit form enhanced follow-up.Slide29
Outcomes and Impact
Prognostic score for children at risk of re-presentation post-burn.Diagnostic criteria to differentiate normal inflammatory response from infection.New treatment pathways.
Reduce and target
antibiotic use
in burns in children.Slide30
AcknowledgementsSlide31
Birmingham Children’s Hospital:
Miss Yvonne WilsonMr David WilsonSarah Payne (research nurse)Federica d’Asta (research fellow)Clare Thomas (specialist nurse)
Acknowledgements
Our thanks also go to all the parents and children who have contributed to this important research
Bristol Clinical
Team:
Mr Tim
Burge
Mr
Jon
Pleat
Miss
Catalina EstelaMr Tom CobleyMr Sānkhya SenMs Shirin Pomeroy
(specialist nurse)- and all the outpatient department, ward and outreach nursing Staff at the South West Children’s Burns CentreBristol Research Centre Staff :Lauren Bratby (Research centre administrator)
Paula Brock, Rose Hawkins & Julie Veale (research n
urses)Karen Coy (lead research nurse)Linda Hollen (statistician)
The St Andrew’s Centre for Plastic Surgery and Burns, Chelmsford:Prof Peter DziewulskiHelen Gerrish & Natalie Whybro (research nurses)Alethea Tan (Fellow)
Academic and Clinical Supervisors:Prof Alan EmondDr Amber YoungMr Ian MackieSlide32
Thank-you for listening!
Any questions?