Introduction of Burn Injuries PowerPoint Presentation

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Chantel R. Grubbs Robert Smith Latrice Wilson Gabrielle Paul Burn Injuries 1 Case Presentation PHA 5601 Pediatrics Ambulatory Care Dr. Angela Thornton, PharmD March 21st, 2013

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Objectives Classify the types of burns, along with defining the prevalence, causes, and pathophysiology. Explain various preventative measures, and different disabilities that may arise as a result of burn. Outline the approach to management and treatment options. Discuss and compare related clinical trials on various medication used to treat pediatric burns. 2

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Definition A burn is an injury caused by fire, heat, radiation, electricity, or flammable agent. 3

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Epidemiology 4 It is estimated that 1.2 million people in the United States require medical care for burn injuries each year, with 51,000 requiring hospitalization. About 30-40% of those patients are less than 15 years old. With the average age of the patient being only 2.5 years of age. The most common burn injuries result from exposure to heat and chemicals. It is the second leading cause of death for children under the age of 12.

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Risk Factors 5 Child negligence Child abuse Improper Adult supervision Cognitive Impairment Psychiatric illness

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Pathophysiology of Thermal Burns 6 Thermal Burn Injury Pathophysiology is based off of Jackson’s Thermal Wound Theory. The zone of coagulation is the area near the burn cell membranes rupture, clotted blood and thrombosed vessels. Zone of Stasis area surrounds the zone of coagulation inflammation, and is characterized by decreased blood flow. Zone of Hyperemia is the peripheral area of burn characterized by increased blood flow.

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Pathophysiology of Thermal Burns 7

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Pathophysiology of Electrical Burns 8 There are 3 proposed mechanisms of electrical burns: Electrical energy causing direct tissue damage, altering cell membrane resting potential. Conversion of electrical energy into thermal energy, causing massive tissue destruction and coagulation necrosis. Mechanical injury with direct trauma resulting from falls or violent muscle contraction.

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Pathophysiology of Chemical Burns 9 There are 6 proposed mechanisms by which chemicals cause burn-like injuries: Oxidation: The protein denaturation is caused by inserting an oxygen, sulphur, or halogen atom to viable body proteins. Reduction: Reducing agents act by binding free electrons in tissue proteins. Heat may also be a product of a chemical reaction, thereby causing a mixed picture Corrosion: It causes protein denaturation on contact. They tend to produce a soft, which may progress to shallow ulceration

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Pathophysiology of Chemical Burns 10 Mechanisms Continued: Protoplasmic poisons: They produce their effects by causing the formation of esters with proteins or by binding or inhibiting calcium or other organic ions necessary for tissue viability and function. Vesicants: They produce ischemia with anoxic necrosis at the site of contact. These agents are characterized to produce cutaneous blisters. Desiccants: These substances cause damage by dehydration of tissues. The damage is often exacerbated by heat production, as these reactions are usually exothermic.

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Etiology 11 Chemical Burns Radiation Burns Electrical Burns Thermal Burns

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Skin Layer Overview 12

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Types of Burns First-degree (superficial burn)burns affect only the outer layer, also known as the epidermis. Second-degree (partial thickness) burns affect both the epidermis and a variable portion of the dermal layer. Superficial partial Mid partial 13

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Types of Burns Third-degree (full thickness) burns affect the entire epidermis, dermis and subcutaneous layers. Deep partial Full thickness Fourth-degree (full thickness) burns affect the epidermis, dermis, muscle, tendon, and bone. 14

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15 Types of Burns

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Clinical Manifestations 16 First Degree Dry No blisters Edema Erythema

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Clinical Manifestations Second Degree Moist Blisters Underlying tissue is marked with pink and white spots Fair capillary refill Bleeds 17

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Clinical Manifestations 18 Superficial Partial Mid Partial

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Clinical Manifestations Third Degree No bleeding Dry Presents with white, brown and black markings Waxy 19

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Clinical Manifestations 20 Deep Partial Thickness Full Thickness

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Clinical Manifestations Fourth Degree Muscles and bone is visible Blackened and charred appearance 21

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Clinical Manifestations 22

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Differential Diagnosis 23 Steven’s Johnson’s Syndrome Anticonvulsants Carbemazepine (Tegretol®) Valproate (Depakote®) Zonisamide (Zonegran®) Sulfonamides Bactrim® Antibiotics Penicillins Toxic Epidermal Necrolysis

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Burn severity is dictated by Percent total body surface area (TBSA) involvement Rule of Nines Rule of Palm Diagnosis 24

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Rule of Nines 25

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26 Lund-Browder Diagrams

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Treatment 27

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Dispelling Myths About Burn Treatment 28 Toothpaste Ice Butter Egg Whites Bursting Blisters

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Goals of Therapy 29 Prevention of infection Acute care and resuscitation Wound management Pain relief Reconstruction Rehabilitation and Psychosocial adjustment

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First Aid Treatment 30 Extinguish the Fire Bring child to more ventilated area Carefully remove smoldering clothing and jewelry Thoroughly irrigate area with cool water to remove an access particles or debris Cover area with a clean dry sheeting and apply cold wet compress to small injuries Administer OTC analgesic Acetaminophen (Tylenol®) 10-15 mg/kg every 4-6 hours Ibuprofen (Advil®) 5-10 mg/kg every 6-8 hours

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Nonpharmacological 31 Aloe Vera Cool compresses

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Aspects of Treatment 32 Topical Agents Pain Management Antihistamines Fluid Resuscitation Nutritional Support Wound Closures Respiratory Therapy

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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns 33

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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns 34 First and second degree burns on <10% of the body may be treated with outpatient therapy There is an increase risk of tetanus following a burn injury Be sure to administer vaccine if patient has not been already vaccinated.

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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns 35 Blisters should be left in tact and not be popped and treated with topical agents Bacitracin (AK-Tracin®) ($8.00) -Prescription Silver Sulfadiazine Cream (Silvadene®) ($20.00)-Prescription Dressings should be changed daily Wound should we washed with lukewarm water. Small 1st degree and mild 2nd degree burn on face can be treated with Bacitracin and left open Vaseline($4.00)- OTC

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Treatment of Superficial 1st Degree & Superficial Dermal 2nd Degree Burns 36 Silver Sulfadiazine

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Proper Dressing Application 37 Wash hands Carefully remove old dressing and throw away Clean burn area mild soap (ie. Hibiclens) and lukewarm or cool water Rinse area thoroughly Pat dry with clean towel or gauze Check for healing Apply prescribed ointment or fresh dressing Wrap sterile gauze over dressing to secure

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Dressings for Ruptured Blisters 38 Ruptured blisters are treated with wound dressing/wound membrane AQUACEL- Ag Biobrane Mepilex Ag Acticoat Hydrocolloid dressings Impregnated gauze Dressing are kept on for 7-10 days and check periodically through the week All dressings that are on the formulary are found in the burn unit supply closet.

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Dressings 39

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Dressings 40

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Dressings 41

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Dressings 42 Hydrocolloid Dressing DuoDERM Tegaderm Comfeel Nu-Derm Impregnated Gauze Xeroform impregnated gauze Chlorhexidine impregnated gauze (Bactigras) Petrolatem/Vaseline impregnated gauze

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Dressings 43 Hydrocolloid Dressings

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Dressings 44 Impregnated gauze

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Topical Agents 45 Topical agents for more severe burns AQUACEL Ag Available by Prescription Sulfacetamide Acetate* Silver Sulfadiazine Mafenide Acetate - 0.5% Silver Nitrate Solution Accuzyme Ointment *

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Treatment of Deep Thermal 2nd Degree Burns&3rd Degree Burns 46

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Criteria for Hospital Admission 47 Burns affecting >15% of body surface area Electrical burns caused by high-tension wires Inhalation injury, regardless of the amount of body surface area burned Inadequate home situation Suspected child abuse or neglect Burns to the hands, feet, or genitals

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Fluid Resuscitation 48 Lactated Ringer Solution Dose Parkerland Formula: 4 mL lactated Ringer/kg/% BSA burned Half of fluid given 1st 8hrs; Next half administered over 16hrs IV Infusion Rate Varies Monitoring Parameters Urine Output Glucose Clinical Pearls Initial fluid should be warmed Infants are at risk for hypoglycemia

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Fluid Resuscitation 49 Albumin (Albuked 25 ®, Flexbumin 25%®, Human Albumin Grifols 25%®, Kedbumin®, Plasbumin2-25®, Plasbumin-5®) Use 5% albumin solution 30–50% of total BSA, 0.3 mL /kg/% BSA 50–70% of total BSA, 0.4 mL/kg/% BSA 70–100% of total BSA, 0.5 mL/kg/% BSA burn Monitoring Parameter: Albumin≥2g/dl Clinical Pearls Concurrent use for burn >85% of BSA Administered 8-24hr after injury

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Qualifications for Albumin Treatment 50 It is not usually screened for infections. Albumin is synthesized exclusively in the liver. The normal rate of albumin synthesis is 0.2g/kg body weight per day. Controversy exists as to whether colloid should be provided in the early period of burn resuscitation. One preference is to use colloid replacement concurrently if the burn is >85% of total BSA. Colloid treatment is usually instituted 8–24 hr after the burn injury. For burns of 30–50% of total BSA, 0.3 mL of 5% albumin/kg/% BSA burn is infused over a 24-hr period For burns of 50–70% of total BSA, 0.4 mL/kg/% BSA burn is infused over 24 hr For burns of 70–100% of total BSA, 0.5 mL/kg/% BSA burn is infused over 24 hr

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Fluid Resuscitation 51 Packed Red Blood Cells Hematocrit falls to <24% (hemoglobin = 8 g/dL) Fresh frozen plasma: Prothrombin level of >1.5 times control Monitoring Parameters: Hematocrit & PT Clinical Pearls Use in patients with repeated excision and grafting w/<30% hemoglobin Prescription NaCL Burns >20% of BSA Dosed:4 g/m2 burn area/24 hr divided into 4–6 equal doses Monitoring Parameters: Serum [Na+] >130 mEq/L Urinary [Na+] >30 mEq/L Serum [K+] >3 mEq/dL Clinical Pearls Silver nitrate increases Na+ and K+ loss Prescription

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Nutritional Support 52 Calories are provided at approximately 1½ times the basal metabolic rate Macronutrients Protein: 3–4 g/kg of protein/day Carbohydyrates: 5-7mg/kg/hr Fats: 1-1.5g/kg/day Micronutrients Copper: 2.5mg/day Vitamin C: 200mg/day Vitamin A:10,000IU /day Zinc Sulfate: 25mg/day Selenium:50-70mg/day Anabolic Agents Growth hormone Oxandrolone Low-dose insulin Catabolic Agents Propanolol

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Respiratory Therapy 53 Beta Agonist Aerosols Albuterol Nebulizer (AccuNeb®)- Patients >2 years of age 1.25mg or 0.63mg by inhalation over 5-15 minutes 3-4 times daily times a day Prescription Inhaled Corticosteroids Fluticasone (Flovent®) Patients 4-11 years of age 88mcg Prescription only Administer 100% Oxygen

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Fluid Maintenance & Infection Prevention 54 Diuretic Furosemide (Lasix®) Dosed: 0.5-2mg/kg/IM/IV q8-24h Max 6mg/kg/dose Antibiotic Empiric Treatment Sulfamethoxazole/Trimethoprim (Bactrim DS®): 10-12mg/kg/day PO or IV q12h + Rifampin (Rifadin®): 20mg/kg PO or IV q24h for 4 days Vancomycin (Vancoled®) : 40–60 mg/kg/day q6–8h for 7-10 days

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Common Organisms in Burn Patients 55 Gram positive Staphylococcus aureus = Penicillin G, Erythromicin, Azithromycin Methicillin resistant S. aureus = Bactrim, Erythromycin Enterococcus spp. = Augmentin, clindamycin+ciprofloxacin Gram Negative Pseudomonas aeruginosa = gentamicin, ciprofloxacin, cefepime Escherichia coli = Gentamicin, ciprofloxacin Klebsiella pneumonia = Parental cefepime, ciprofloxacin Serratia marcescens = Parental cefepime, aztreonam, gentamicin Fungi Candida spp. = Amphotericin B, Fluconazole Aspergillus spp. = Amphotericin B, Intraconazole Viruses Herpes simplex virus = Acyclovir, Famciclovir,

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Treatment of Infections 56 Methicillin Resistant S. Aureus Sulfamethoxazole/Trimethoprim (Bactrim®) 8mg/kg/day (for children older than 2 months) Prescription Doxycycline (Doryx®) 4mg/kg/day (for children older than 8 years) Prescription Vancomycin (Vancocin®) 10-15mg/kg every 6 hours Prescription Linezolid (Zyvox®) 10mg/kg every 8-12 hours Prescripton

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Pain & Anxiety Management 57 Morphine Sulfate (NSIR®, MSContin®) Dosed 0.3–0.6 mg/kg every 4–6 hr PO initially and until wound cover is accomplished Dosed 0.3–0.6 mg/kg is given 1–2 hr before the procedure + IV bolus 0.05–0.1 mg/kg given immediately before the procedure Prescription Lorazepam (Ativan®) Dosed of 0.04 mg/kg PO or IV for before the procedure Prescription Midazolam (Versed®) Dosed 0.05–0.1 mg/kg/hr IV infusion or IV bolus; May be repeated in 10 min, Max dose of 0.2 mg/kg Prescription

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Potential Drug Interactions with Treatment 58 Beta Agonists In combination with Beta Blockers may lead to a decreased efficacy of either drugs due to antagonism Corticosteroids In combination with Azole Antifungals may increase corticosteroid plasma concentrations Furosemide In combination with Aminoglycosides may increase aminoglycoside concentration resulting in an increased risk of ototoxicity and nephrotoxicity

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Potential Drug Interactions with Treatment 59 Bactrim In combination with Warfarin, there is an increased the risk of bleeding and bruising In combination with Antipsychotics or Tricyclic Antidepressant, Bactrim increases the risk of QT prolongation and torsade de pointes Rifampin In combination with Birth control pills, there is an decreased efficacy of birth control pills In combination with Morphine, there is a decreased efficacy of morphine In combination with corticosteroids, there is a decreased efficacy of corticosteroids Vancomycin In combination with Aminoglycosides, there is an increased additive risk of ototoxicity and nephrotoxicity.

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Wound Closures 60 Grafts Skin grafts: Pinch: Quarter inch pieces of skin Split-thickness: Superficial and some deep layers of skin Full-thickness: For weight-bearing portions of the body and friction prone areas such as, feet and joints Pedicle grafts: Skin used from the donor site will remain attached to the donor area and the remainder is attached to the recipient site

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Wound Closures 61 Grafts Excisions Tagenital Pros: Improved function and cosmetic outcome Cons: Increased bleeding, takes longer, more skin Fascial Pros:Rapid, Use with skin subsitutes Cons: Risk of nerve injury and joint exposure, decreased cosmetic outcome

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TANGENTIAL EXCISON 62

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FASCIAL EXCISION 63

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Skin Graft Video 64 http://www.youtube.com/watch?v=bn9uMVxk8wI

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Clinical Trials 65

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Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients Objective To study the efficacy of growth hormone given to severely burned children from discharge to 12 months after burn and for 12 months after the drug was discontinued. Design Single-site, double-blinded, randomized, placebo controlled study Methods Forty-four pediatric patients with over 40% total body surface area burns were studied for 24 months after burn. Patients were randomized to receive either rhGH (0.05 mg/kg body weight) or placebo. 66 Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802

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Results Recombinant human growth hormone administration increased serum GH and decreased cortisol concentrations when compared with placebo (P < 0.05). Beneficial Effects of Extended Growth Hormone TreatmentAfter Hospital Discharge in Pediatric Burn Patients 67 Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802

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Intensive Insulin Therapy in Severely Burned Pediatric Patients Objective To determine whether intensive insulin therapy is associated with improved post-burn morbidity Design Single-site, prospective randomized trial Methods A total of 239 severely burned pediatric patients with burns over greater than 30% of their total body surface area were randomized to intensive insulin treatment (n = 60) or control (n = 179) 68 Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359

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Intensive Insulin Therapy in Severely Burned Pediatric Patients Results Intensive insulin treatment had a significant improvement in bone mineral density, body fat, lean body mass, and body mass  (P < 0.05) 69 Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359

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Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children 70 Objective To determine the long term effects of Oxandrolone in pediatric burned patients Study Design Single-center, prospective, randomized, controlled trial Methods Patients 0 to 18 years old with burns covering >30% of the total body surface area were randomized to receive placebo or oxandrolone (0.1 mg/kg PO twice daily for 12 months) At hospital discharge, patients were randomized to a 12-week exercise program or to standard of care Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502

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Five-Year Outcomes after Oxandrolone Administration in Severely Burned Children 71 Results Increased protein synthesis, bone density mass, decreased resting energy expenditure, and improved height (p < 0.001). Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502

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Prevention Strategies 72 Improve awareness among parents/caregivers Develop and enforce effective policy for dealing with burns Be informed about the burden that comes along with caring for a child with a burn Participate in burn prevention programs Install home smoke detectors and sprinkler systems. Take bath water temperature before bath Don’t leave candles and potential meals unattended.

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Role of the Pharmacist 73 Identify the severity of a burn Recommend appropriate therapy Recognizing when to refer the patient to the physician Educate patients on proper applications of creams and dressings Monitor for signs of infection

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References 74 American Burn Association. Burn Center Referral Criteria. Availableat:www.ameriburn.org/BurnCenterReferralCriteria.pdf?PHPSESSID=09036810feb72a69a1acdee9209e235b. Accessed on March 10, 2013 A.D.A.M. Medical Encyclopedia. Burns. Available at:www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001097/. Accessed on March 10, 2013 University of Maryland Medical Center. Burns- Overview. Available at:www.umm.edu/ency/article/000030.htm. Accessed on March 10, 2013 Sheridan R., Schnitzer J., Management of the High-Risk Pediatric Burn Patient. Journal of Pediatric Surgery. August 2001 ;vol 36(8):1308-1312 Jorge A., Buck M., Hubbard A., et al. Pediatric Nutrition Support Handbook. University of Virginia Children's Hospital. 2012: 1-103 Connolly S. , Clinical Practice Guidelines: Burn Patient Management . NSW Agency for Clinical Innovation. August 2011; Version 1.5:1-45 Women’s and Children’s Hospital. Guidelines for the Management of Pediatric Burns . May 2010; 1-43 Sheridan, RL. Sepsis in pediatric burn patients. Pediatric Critical Care. 6(3), 2005: S112-S119 Gandhi M., Thomson C., Lord D. , et al. Management of Pain in Children with Burns. International Journal of Pediatrics . 2010; vol(2010):1-9 Jeschke M. , Kulp G., Kraft R., et al. Intensive Insulin Therapy in Severely Burned Pediatric Patients . American Journal of Respiratory and Clinical Care Medicine . August 2010; vol .182 no. 3 :351-359 Borrillo C. Nelson Textbook of Pediatrics. 18thed. Philadelphia: Saunders Elsevier; c 2007. Chapter 74 Burn Injuries Porro L., Herndon D., Rodriguez N., et al. Five – Year Outcomes after Oxandrolone Administration in Severely Burned Children: Randomized Clinical Trial of Safety and Efficacy. Journal of the America College of Surgeon. April 2012; vol 214(4): 489-502 Przkora R., Herndon D., Suman O., et al. Beneficial Effects of Extended Growth Hormone Treatment After Hospital Discharge in Pediatric Burn Patients. Annals of Surgery. June 2006; vol 243(6):796-802 Igneri P., Gratton J. FAHC Burn Care Manual. Fletcher Allen Health Care: The University of Vermont College of Medicine. 2008; 1-69 Mock C, Peck M, Peden M, Krug E, eds. A WHO plan for burn prevention and care. Geneva, World Health Organization, 2008. Boldt,J. British Journal of Anaesthesia.Use of albumin: an update (2010) 104 (3): 276-284.