Toxic Shock Syndrome in Paediatric Burns
Flowcharts
Introduction, Scope & Purpose
Toxic Shock Syndrome (TSS) is a rare but potentially fatal illness caused by a bacterial toxin. The most common causative organisms are Staphylococcus Aureus and Streptococcus Pyogenes[PS1]  (Group A streptococcus).
 
Toxic shock syndrome is most commonly seen in young children aged 1 to 5 years, 2 to 5 days after a burn injury. The burns are most often small (<10% TBSA) and often appear clean.
 
TSS is thought to be more common in children due to their immature immune system, with less than 30% of under 5 years olds having antibody protection to the specific exotoxins compared to 70-95% of adults. The higher incidence of TSS in smaller burns is thought to be due to their less aggressive management. Large surface area burns in children are often managed quite aggressively with surgical debridement, specialist dressings and regular reviews.
 
The clinical course is precipitous and shock and multi-organ failure occur early in the course of the disease, with a mortality rate of up to 50% if untreated. Early recognition, management and escalation is therefore essential.
 
This guideline aims to help to identify toxic shock syndrome in children with burns as well as to consolidate and clarify the management of toxic shock syndrome in these patients. It also provides details of appropriate escalation of care for these children, including details of how to refer to the regional burns unit in Salisbury District Hospital.
 
It should be noted that, although burns are the most common cause of toxic shock syndrome in children, toxic shock syndrome can have other precipitating causes including: other disruptions to the skin barrier (wounds, abscesses); infections (cellulitis, tonsillitis, influenza, chickenpox, osteomyelitis, septic arthritis; retained products of conception or retained tampons. Although this guideline focuses primarily on burns, the clinical management is the same for all suspected cases of toxic shock syndrome (although escalation pathways will differ).

 Symptoms and Signs of TSS
 
It can be difficult to diagnose TSS as the signs may be non-specific and mimic other conditions. Any child with a recent burn (between 1 to 7 days) and fever >38°C should be reviewed by the paediatric +/- burns teams for signs of toxic shock. [PS1] 
 
Abbreviated criteria for TSS:
  • Pyrexia >38.9
  • Rash (any)
  • Vomiting +/- diarrhoea
  • Irritability/ drowsiness
  • Lymphopenia
  • Hyponatraemia
Plus signs of shock: tachycardia, tachypnoea, hypotension, poor perfusion, coagulopathy (although these are late signs)
Children with burns may also develop sepsis without TSS so any change in clinical condition that could indicate infection should be carefully considered.
 
Management of TSS
 
Please see flow chart for full guidance.
 
The guidelines focus on early recognition, escalation and management of TSS.
 
Key management points include:
  • Early intravenous access
  • Blood and microbiology samples (FBC, U&E, clotting screen, blood cultures, wound swap)
  • Treat shock with IV fluid boluses
  • Early intravenous antibiotics
  • Provide passive immunity with FFP and/or IVIG
  • Manage as HDU patient
  • Escalate early to critical care if not showing signs of improvement
 
There are no studies comparing the use of FFP and IVIG in the management of toxic shock syndrome. This guideline has suggested the use of virally- inactivated FFP (in most trusts locally this is Octaplas) first line due to comparative ease of access, however it would not be inappropriate to use IVIG first line if this can be accessed quickly.

Scope and purpose

This guideline is for use in all regional emergency departments and general paediatric departments within Wessex.
 
The patient group is all children presenting within region with burns and suspected toxic shock syndrome or sepsis.
 
The aim is to provide a standardised approach to the management of toxic shock syndrome and burn related sepsis in children, and to ensure appropriate escalation and referral of these patients to appropriate regional burns centres where plastic surgery input can be provided alongside Paediatric care

Definitions​
  • TSS= Toxic Shock Syndrome
  • TBSA= Total body surface area
  • FFP= Fresh frozen plasma
  • IVIG= Intravenous immunoglobulin
  • IV= Intravenous
  • FBC= Full blood count
  • U&Es= Urea and electrolytes
  • CRP= C reactive protein
  • HDU= High dependency unit
  • SORT= Southampton Oxford Retrieval Team
  • MDSAS= An online referral system for various NHS specialities 
Details of Policy/Procedure to be followed
See flow charts for full details.
 
  • Urgent review by senior member of paediatric team
  • Regular observations
  • Examine for other signs of infection
  • Burns dressings removed to examine, photograph and swab wound
  • Full septic screen and antibiotics (ceftriaxone and clindamycin) started promptly along with intravenous fluids, fresh frozen plasma (FFP) and/or intravenous immunoglobulin (IVIG)
  • Paediatric consultant to be informed urgently
  • Complete MDSAS referral (nww.mdsas.nhs.uk/burns/) and contact Salisbury Paediatric Burns Unit via Sarum ward on 01722 336262 (ext 2561/2560) if clinically stable
​
Consider escalating to local intensive care team and discussing with SORT (023 8077 5502) and Bristol Burns Centre (01173 403444 / 01179 753995) if unstable and not responding to initial management
Communications and Training plans
This guideline will be made available regionally on the PIER website. Local PIER network leads within General Paediatrics will disseminate the guideline and raise awareness locally.
Process for Monitoring Compliance
The PIER network will review problems associated with this guideline through it’s governance process. 
Document Review
Guideline to be reviewed after three years or sooner as a results of audit findings or as any changes to practice occur.
References​
  1. Adalat S, Dawson T, Hackett SJ, Clark JE; In association with the British Paediatric Surveillance Unit. Toxic shock syndrome surveillance in UK children. Arch Dis Child. 2014;99(12):1078-1082.
  2. Cole R.P. and Shakespeare P.G. 1990. Toxic shock syndrome in scalded children. Burns. 16, pp. 221-4
    Department of Health, 2011. Clinical Guidelines for Immunoglobulin use. Available from: http://igd.mdsas.com/wp-content/uploads/2016/04/dh_129666.pdf
  3. Leicester Royal Infirmary Emergency Department and Children's Hospital. Recognition, Diagnosis and Management of Toxic Shock Syndrome in Children Including those with Burns. June 2022. Available at: https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Toxic%20Shock%20Syndrome%20UHL%20Childrens%20Guideline.pdf
  4. Michelle C. White, Katharine Thornton, Amber E.R. Young. (2005) Early diagnosis and treatment of toxic shock syndrome in paediatric burns. Burns. Volume 31, Issue 2. Pages 193-197. https://doi.org/10.1016/j.burns.2004.09.017.
  5. Owen Hibberd,  Costas Kanaris  . Toxic shock syndrome, Don't Forget the Bubbles, 2023. Available at: https://doi.org/10.31440/DFTB.53918
  6. Salisbury District Hospital. Management of Toxic Shock Syndrome and Sepsis in Paediatric Burns.
  7. University Hospitals Bristol. Burns (Paediatric): Toxic Shock Syndrome and Sepsis. 2018.
  8. Young AE, Thornton KL. (2007) Toxic shock syndrome in burns: Diagnosis and management. Archives of Disease in Childhood Education and Practice 92(4):97-100​
Document Version: 
1.1

Lead Authors: 
Tamali Oxford, Paediatric ST7 Trainee, 
Seb Gray, Paediatric Consultant, SDH
Louise Pitman, Lead Paediatric Pharmacist, SDH
Jim Baird Paediatric Consultant, SDH
Approving Network:
General Paediatric PIER Network

Date of Approval: 
October 2023

Review Due:
October 2026