Hydrogel-Based Dressings and Multidisciplinary Care in Severe Pediatric Burns: A Case Report of Successful Healing and Hypertrophic Scar Prevention

Introduction

Burn injuries among children require immediate attention and intervention. The incidence varies depending on region and population. Additionally, children are especially susceptibility to burns. Mortality rates among children under 5 years of age in Africa are 2 times higher than in children of the same age worldwide [1].

Burn injuries are a significant cause of morbidity and mortality in pediatric patients worldwide – 180 000 patients under the age of 15 years die each year due to burn injuries according to the World Health Organization (WHO). In the United States, 120 000 children receive medical treatment for burn injuries, and 30 000 of them sustain moderate to severe injuries. Mortalities were higher in infants and toddlers because of their high surface area due to increased water content caused by accidental injuries [1–3].

Most children are susceptible to minor burn injuries, and severe burn injuries have higher mortality rates than among adults with similar injuries [4]. Furthermore, length of hospital and ICU stay and operative interventions, including autografting, allografting, occupational therapy, and physical therapy, were found to be crucial for achieving good treatment outcomes [3]. This report discusses other treatment options for non-surgical interventions in pediatric patients with burn injuries.

Case Report

A 16-month-old boy with an unremarkable medical history and up-to-date vaccinations presented to the Emergency Department of Doctor Soliman Fakeeh Hospital on the 26 August 2023, after sustaining a scaled burn injury due to an accidental spill of boiling water on his chest, right arm, right thigh, and upper right leg. The estimated involved surface area was 30% using the Lund and Browder burn scale. Initial measures included dressing and analgesia. Upon further examination, he was admitted to the Intensive Burn Unit with a diagnosis of 30% mixed second-degree-partial and third-degree burns. Hydration was initiated using the Parkland formula (weight in Kg×TBSA×4), and wound care dressings were applied.

The treatment plan, led by the Plastic Surgery team, involved burn care dressings in the operating room under general anesthesia. During his stay in the burn unit, the patient received intravenous fluids with dextrose 5% in half normal saline (D5 ½ NS) at 100 ml/h. He experienced generalized tonic-clonic convulsions, spontaneously resolving after 2 min, attributed to electrolyte imbalance; specifically, hyponatremia (Na: 123). Subsequently, the patient was transferred to the Pediatric Intensive Care Unit (PICU) for a 10-day admission to rule out sepsis and correct the electrolyte imbalance. Upon arrival at the PICU, the patient experienced another episode of tonic-clonic convulsions, receiving 2 doses of diazepam and 20 mg/kg of levetiracetam with central line insertion. Necessary laboratory tests and septic work-up were performed. Additionally, the child developed a prolonged coagulation profile with no active bleeding (indicative of disseminated intravascular coagulopathy), which was promptly addressed and corrected by the PICU team. Following oxygenation support, the management plan included dextrose 5% in half normal saline (D5 ½ NS) at a rate of 90 ml/h, checking serum electrolytes every 6 h, an urgent dose of 2 mg vitamin K followed by repeated serum potassium after 2 h, fresh frozen plasma 15 ml/kg twice a day (BID), 200 mg of acetaminophen, ceftriaxone 690 mg, and vancomycin 260 mg, nutritional supplements (pediatrics normal formula), and levetiracetam 20 mg/kg/day twice daily. Subsequent assessments, including CT and MRI scans of the brain, revealed normal findings.

Following successful management in the PICU, the patient underwent surgery under general anesthesia (Figure 1). The treatment included the application of hyaluronic acid plus silver sulfadiazine, 0.5% chlorhexidine acetate, and white soft paraffin to the affected areas. Specifically, these were applied to the right side of the chest, extending toward the median site, as well as the full circumference of the right arm, thigh, and leg. Bulky dressings were applied for wound coverage with fixation, and the patient was subsequently transferred to the PICU for further monitoring.

During the patient’s stay in the PICU, occupational therapy was administered to prevent future scarring and contracture. Two days later, the patient was returned to the burn unit for regular dressing changes. Additionally, glycerin-based wound dressings (Elasto-Gel) were initiated from the third to the fifth day (Figure 2). The patient underwent 5 dressing changes and was discharged home on 10 September with scheduled follow-up appointments at the plastic surgery outpatient clinic (Figure 3). Follow-up appointments were conducted from 13 to 30 September.

To prevent further contracture of the elbow joint, split skin grafting was performed on the patient’s right thigh under general anesthesia on 1 October. Curettage of the hyper-granulation skin over the volar aspect of the right arm was performed (Figure 4). Hemostasis was achieved by soaking in adrenaline, and skin graft fixation was performed using a tie-over and a volar slab. The donor site was covered with a pressure dressing. The patient exhibited favorable wound healing thereafter (Figure 5). Skin gel, skin moisture, pressure garments, and silicone gel sheets were used to prevent the formation of hypertrophic scars.

Discussion

A 16-month-old boy presented with a 30% mixed second-degree partial-thickness and third-degree burn due to a scalded injury. These observations shed light on the prevalence of burn injuries in this age group. Factors contributing to the susceptibility of the pediatric population include a lack of awareness about hazards, curiosity, and engagement in outdoor activities. Scalds and contact burns are particularly common in children aged 0–4 years. Previous studies have indicated that male pediatric patients with burn injuries are more likely to have been involved in risky activities or had greater exposure to burn risk factors than their female counterparts [5–8].

Determining the burn depth poses challenges and is often subjectively assessed by professionals. Standard local care for burns involves rapid debridement and dressing [9,10]. Furthermore, owing to the enormous number of burn patients, particularly in developing countries, comprehensive and affordable treatments should be made accessible [11,12]. Burn care aims to minimize pain, prevent infection, and facilitate rapid healing, ultimately restoring full function and aesthetics to the affected area [13]. However, scarring formation in second-degree deep partial-thickness burns may include hypertrophic and keloid scars with or without skin contracture [14]. Dressing choices depend on factors such as depth, exudate volume, cost, physician knowledge, and patient comfort [15].

Before initiating the treatment in the operating room, the patient experienced several burn-related complications. Additionally, surgical intervention may entail certain risks, such as excessive removal of healthy tissue and the requirement for blood transfusion [16,17]. Furthermore, patient refusal may play a critical role [18].

Patients with long-term burns face an increased risk of infection with multidrug-resistant pathogens, increasing overall patient risk. However, a fixed stay provides a more controlled therapeutic environment, facilitating effective immobilization to minimize dressing dislocation [10]. Zinc hyaluronic acid has been shown to enhance cell regeneration and aid rapid wound healing [19], and a combination of hyaluronic acid and silver sulfadiazine can prevent wound colonization [20]. Antimicrobial-containing gauze dressings are cost-effective and widely available, effectively preventing local bacterial infections [13]. Wound dressings can fulfill the key requirements for wound care, such as debridement, prevention of infections, and provision of a moist healing environment. Additionally, wound dressings have been shown to be effective in healing superficial skin lesions. This can be achieved by reducing fibrin levels, thus promoting wound healing [21,22].

Zinc hyaluronic acid with silver sulfadiazine, Bactigrass dressing, and Elasto-Gel were applied to our patient over the most damaged areas (chest, arms, and thighs) with regular checks within the burn unit. Despite advancements in burn wound care, infection remains the primary cause of morbidity in burn patients, leading to sepsis, organ failure, and other consequences induced by substantial inflammatory and immunological reactions. Moreover, infection restricts healing by promoting tissue damage and triggering excessive inflammation [23–25]. Elasto-gel and bactigrass dressings aim to prevent acquired infections and inflammation. Bactigrass, in particular, demonstrated efficacy in preventing clinical sepsis and lowering the morbidity and mortality rates of infection with pseudomonal species in an experimental study [26].

Although silver sulfadiazine has been considered the mainstay of conservative treatment for burn patients for over 40 years, a systematic review of randomized clinical trials has shown that there are better alternatives. Some of these alternatives were solids, while others were biological, and they exhibited features such as fewer dressing changes, reduced pain, and higher satisfaction rates. The only difference was that silver sulfadiazine has antibacterial properties [27]. Elasto-gel, which is a hydrogel-based dressing, is an occlusive dressing which is a soft and flexible patch that stretches with motion, absorbs secretions, diminishes odor, and does not liquefy into the wound. It also has anti-inflammatory properties and minimizes scars in porcine models [28,29]. The outer surface is resistant to pathogens and water, but the transparent structure allows for wound visualization without dressing removal. It is also flexible and simple to detach, and supports autolytic debridement [14]. Additionally, the hydrogels demonstrated adequate gelation time, mechanical stability, high water absorbency, and hemostatic characteristics, and their antibacterial properties are continuously released against methicillin-resistant Staphylococcus aureus (MRSA). The enhancement of wound closure in full-thickness burns was achieved, in addition to the deposition of collagen, formation of granulation tissue, neovascularization, and anti-inflammatory activity, making it favorable for patients with full-thickness burns [30]. Our method showed minimization of physical limitations and stress in the patient, similar to the study by Jozsa et al [19]. Furthermore, conservative treatment may take a longer time to heal, especially in patients with full-thickness injuries. A single case report from Japan discussed use of an advanced moist dressing in a single region of full-thickness burn injury, resulting in successful healing without serious complications. In our patient multiple regions were affected, but no pseudomonal infection occurred [18].

Despite successful conservative management, our patient had a third-degree injury around the arm, necessitating a graft from the right thigh to prevent functional disabilities. Patients with burns may experience functional impairment due to scar contractures [31]. Musculoskeletal alterations are another consequence of burn injuries that need attention due to their frequency. These include contracture, bone loss, scoliosis, kyphosis, and septic arthritis. They are either direct or indirect consequences of burn damage and impact bones, muscles, and tendons [32]. Our patient underwent occupational therapy, but surgery for post-burn scar contractures should not be performed during the active phase of wound healing and scarring. The donor site normally heals within a period of 10 days to 2 weeks, depending on the thickness of the graft [33,34].

Overall, we found that Elasto-Gel, a hydrogel-based dressing, was effective in promoting wound healing and preventing consequent complications in pediatric burns. The multidisciplinary approach used in the current case, involving plastic surgery, pediatric physicians, and occupational therapists, highlights the importance of complete patient care for dealing with burn injuries. Moreover, the challenges in this case underscore the need for specialized and prompt care for children with burn injuries, including hydration and electrolyte correction, which may differ from adult care. The patient’s late presentation to the hospital escalated the situation, leading to admission to the Pediatric Intensive Care Unit (PICU) with limited capacity due to the crowded nature of tertiary hospitals. It is essential to acknowledge the limitations of this study, focusing on a single case, which poses challenges in group comparisons and introduces the possibility of bias.

Conclusions

The presented non-surgical approach, incorporating hyaluronic acid, Bactigras, Elasto-Gel, and a multidisciplinary team, proved efficacious in treating mixed partial-thickness and full-thickness burn injuries this young child. Split-thickness grafts may be necessary in the functional areas. Therefore, a comprehensive management strategy that considers tissue damage, electrolyte balance, and infection is crucial. This report underscores the importance of meticulous assessment and correction of overall patient conditions, especially in pediatric patients prone to electrolyte imbalance. The limitation lies in its focus on a single case, necessitating caution when generalizing the findings.