Pediatric Burn Case Study: Advanced Management & Recovery at Kauvery Hospital

A case report and discussion: Burns

R. Nivetha¹, C. Malathi², S.J. Sonya mercy anbu³, R. Ruby⁴

¹Staff nurse – POW, Kauvery Hospital, Maa Kauvery, Trichy, Tamil Nadu

²Superviaor – POW, Kauvery Hospital, Maa Kauvery, Trichy, Tamil Nadu

³Nurse educator – Kauvery Hospital, Maa Kauvery, Trichy, Tamil Nadu

⁴Senior DNS – Kauvery Hospital, Maa Kauvery, Trichy, Tamil Nadu

Abstract

A 4 year- old female, presented to our facility following an alleged incident of accidental hot water spillage at her residence. She was initially treated outside with intravenous antibiotics, intravenous fluids, and other supportive care was referred to Maa Kauvery for advanced care and treatment. During the course of admission, the child developed persistent low- grade fever and irritability, with symptoms progressively worsening. In the two days preceding referral, the patient exhibited marked irritability and an inability to recognize her mother.

Clinical Findings

WT: 18 kg

Child irritable but consolable

Pulse volume: Good

GRBS: 157mg/dL

Temp: 98.6 F, HR: 150/min, RR: 40/min,SPO2: 98%

Systemic Examination

Systemic examination was normal

Local Examination

Scald over bilateral lower limbs, genitalia, gluteal region and posterior trunk

Antenatal History and Birth History

Uneventful

Development History

Attained developmental milestones at appropriate age

Immunization History

Immunized till date

Diagnosis

Infected Scald Burns (25%)/Polymicrobial Sepsis/MODS

Procedure

A change of dressing was done under TIVA (Total intravenous anesthesia). During the procedure, wound wash given, swab and tissue cultures were sent, and debridement along with antibacterial dressing was performed.

Alternative days the dressing was again changed with TIVA, with saline wash, wound debridement and application of antibacterial dressing.

The wound showed signs of improvement. Baby had multiple dressing change under TIVA involved painting and draping the affected parts, followed by dressing using debridement, antibiotic topical application with wound moisturizer.

Investigation

S.no	Investigation	Patient value	Normal value
1	Haemoglobin	9.5 g/dl	11.5 – 13.5 g/dl
2	Platelet	2,68,000 /µl	1,50,000 – 4,50,000 /µl
3	WBC	2,660 cells/µl	4,500 – 11,000 cells/µl
4	Urea	31 mg/dl	20 – 40 mg/dl
5	Creatinine	0.52 mg/dl	0.7 – 1.2 mg/dl
6	Sodium	144 meq/l	135 – 145 meq/l
7	Potassium	4.02 mmol/l	3.5 – 5.0 mmol/l
8	Procalcitonin	78.84 ng/ml	0.05 – 0.25 ng/ml
9	Serum albumin	3.26 g/dl	3.5 – 5.5 g/dl
10	Total bilirubin	1.45 mg/dl	0.1 – 1.2 mg/dl
11	Direct bilirubin	1.25 mg/dl	≤ 0.3 mg/dl
12	Indirect bilirubin	1.02 mg/dl	0.2 – 0.8 mg/dl
13	SGOT (AST)	234 U/L	5 – 40 U/L
14	SGPT (ALT)	467 U/L	7 – 56 U/L

Course in the Hospital

A 4-Year-old girl with no previous illness was admitted with a history of hot water spillage at home. She sustained burns over the bilateral lower limbs, genitalia, gluteal region, and posterior trunk.
She was initially treated at a nearby hospital with fluids (parkland formula),iv antibiotics, and supportive care.
On evaluation here, she had leucopenia, elevated CRP, deranged liver function (hyperbilirubinemia, transaminitis), the coagulation profile was deranged, and serum electrolytes showed hyponatremia.
In view of coagulopathy, the child received 3 units of FFB. She had intermittent low grade fever since admission, and on day 5, her sensorium worsened. Hence she was referred for further management.
On arrival at the ER, the child had a GCS of E2V2M5, pupils 2 mm, was afebrile, hemodynamically stable, and had scald burns over bilateral lower limbs, groin, genitalia, and posterior trunk. Infected deep dermal burns (27%) and sepsis with encephalopathy were suspected.
The child was started on IV fluids, IV antibiotics, PPI, antipyretic, analgesic, and other supportive measures.
Initial blood tests showed mild anemia, leucopenia with high procalcitonin. The child had hyperammonemia; hence oral rifaximin and lactulose were given.
Due to deranged coagulation, 1 unit of FFB was transfused. On admission, pus culture grew enterococcus faecium and staphylococcus pseudo intermedius. The child was continued on Inj. Meropenem and vancomycin.
To prevent infection and multiorgan dysfunction, inj. Ulinastatin was given for one week. Serial albumin level was low; hence daily albumin was given.
Blood culture was sterile. Serial pus culture grew acinobactor, and antibiotics were changed to antifungal were added.
Tissue culture also grew acinebactor. The child had hypokalemia, which was corrected. Serial LFT showed improvement. In view of severe anemia, 2 units of LDPC were transfused and hemoglobin improved. Fever gradually reduced. On 27.02.2025, the last dressing was done. The wound appeared healthy in the lower limbs, genitalia, and gluteal region.
Throughout the hospital stay baby was nursed with complete HICC adherence.

Blood Transfusion

4 Unit FFB totally transfused.
2 units LDPC transfused.

Present Medication

S. No	Drug	Dosage	Route	Frequency	Action
1	Inj. Colistin	5,00,000 lakhs	IV	TDS	Polymyxin Antibiotic
2	Inj. Vancomycin	360 mg	IV	TDS	glycopeptide antibiotic
3	Inj. Meropenam	700 mg	IV	TDS	Antibiotc
4	Inj. Vit k	5 mg	IV	OD	Fat-soluble vitamin
5	Inj. Paracetomol	250 mg	IV	TDS	Antipyretic/Analgesic
6	Inj. Pantocid	20 mg	IV	OD	Proton Pump Inhibitors
7	Tab. Rifakimin	200 mg	P/O	BD	Antibiotic
8	Syp. Lactulose	10 ml	P/O	TDS	Laxatives
9	Inj. Fentanyl	360 mcq	IV	ONFLOW	Narcotic analgesic

Nutritional Management

Baby fed through nasogastric tube with high protein supplementary feeding and medium chain triglycerides (MCT oil) which acts as quick source of energy and well hydrated with plenty of water. Then bay was switched over to oral diet with high calorie, high protein.

Medication on Discharge

S. No	Drug Name	Frequency			Route of administration	Days
		M	A	N
1	Tab. Vitamin C	1/2	1/2	1/2	Oral	2 week
2	Tab. Zincovit	1	0	0	Oral	2 week
3	Syp. Hydroxyline	5ML	5ML	5ML	Oral	1 week
4	Syp. Hemfer	5ML	5ML	5ML	Oral	2 week
5	Cap. Doxycycline	1/2	0	1/2	Oral	7 Days
6	Tab. Clonazepam	1	0	1	Oral	5 Days
7	Syp. Brufen	8 ML	8 ML	8 ML	Oral	2 Days f/b SOS
8	Yaskin G	1	1	1	Local Application	To Continue

Dietary advice – High calorie / high protein diet.

During discharge baby’s general condition and vital signs were stable.

Advised the parents to report immediately to the hospital if baby has excessive dullness, continuous cough, cold, high grade fever, fast breathing, difficulty in breathing, excessive diarrhea, vomiting, reduced urine output.

Definition

A burn is an injury to the skin or underlying tissues caused by heat, chemicals, radiation, friction.

Causes of Burns

Thermal – Flame, hot liquids (scalds), hot objects.
Chemical – Strong acids, alkalis.
Electrical – Current, lightning.
Radiation – Sunburn, radiotherapy.
Friction – Rubbing against rough surfaces.

Classification (Degrees of Burns)

First Degree (Superficial)

Only epidermis affected.
Redness, pain, no blisters.
Example: mild sunburn

Second Degree (Partial Thickness)

Involves epidermis + part of dermis
Redness, pain, blisters, swelling.

Third Degree (Full Thickness)

Involves epidermis + part of dermis.
Skin white, charred, painless (due to nerve damage).

Fourth Degree (Severe)

Extends into muscle, bone, or deeper tissues.

Pathophysiology

Heat causes coagulation necrosis of skin and subcutaneous tissue
Release of vasoactive peptides
Altered capillary permeability
Loss of fluid to severe hypovolemia
Decreased cardiac output to decreased myocardial function
Decreased renal blood flow to oliguria
Altered pulmonary resistance causing pulmonary edema
Infection systemic inflammatory response syndrome
Multiorgan dysfunction syndrome

Medical management

These are three phases of treatment in care of the burns patient

Emergency resuscitation phase

This phase lasts for 36-48 hr from the onset of injury

Medical management

Assess the burns severity
Assess the burns depth
Assess the burns extent using rules of nine
Identity the mechanism of injury

Minor Burns

Wound evaluation and initial care
Tetanus toxoid immunization
Pain Management

Major Burns

Saving life
Maintaining and protecting airway
Restoring hemodynamic stability
Replacement of missing skin
Promoting healing
Assessing and correcting complication

Formula for calculating the fluid consciences formula

RL 2-4ml / kg %TBSA

In 1^st 8hr – First half of the amount
In Next 8hr – 1/4 of total amount
In next 8hr – ¼ of the total

2* 18*50 – 1800ml

In 1^st 8hr – 1000ml
In next 8hr – 400ml
In next 8hr – 400ml

Evan’s Formula

Electrolytes or saline = 1ml/kg /% TBSA
Colloids = 1ml/kg %TBSA +2000ml dextrose in H2O

Day 1 – Half of the amount to be given in hrs

Remaining half over next 16hrs

Day 2 – half of the colloids and electrolytes like INJ.Fentanyl may be used in procedure pain

Wound Care

Immediate care
Cover the wound with sterile towel and place on clean dry sheet
Cleansing
Debridement
Application of topical agents
Dressing

Rehabilitation Phase

Rehabilitation should begin immediately after the burn has occurred.
Wound healing, psychological support and restoration of maximal functional activity remain priorities so that the patient can have the best quality of life both personally and socially.
Reconstructive surgery may be done to improve body appearance and function.
Psychology counseling may be done to promote recovery and quality of life.

Complication

Infection
Fluid loss
Breathing process
Shock
Organ failure
Death
Psychological complication
Skin cancer

Conclusion

In this case study, the patient sustained partial-thickness burns due to accidental scalding. Timely wound care, pain management, fluid replacement, and infection control were key in promoting healing. The patient showed gradual improvement with reduction in wound size and better functional mobility. This case highlights the importance of a multidisciplinary approach in burn management, addressing not only physical injuries but also psychological and social impact. Overall, comprehensive nursing care and patient education played a vital role in the patients recovery and prevention of complications.

A case report and discussion: Burns

A case report and discussion: Burns

R. Nivetha1, C. Malathi2, S.J. Sonya mercy anbu3, R. Ruby4

Nightingale Journals

R. Nivetha¹, C. Malathi², S.J. Sonya mercy anbu³, R. Ruby⁴