Paediatric Burns

ASSESSMENT

• Allergies
• Medications
• Past medical history

Events:

• mechanism for other injuries
• whether appropriate first aid has been carried out (20min of cooling under running water)
• treatment instituted by ambulance staff (analgesia and fluid resuscitation)
• any other injuries sustained (unlikely)
• last meal

MANAGEMENT – ATLS/APLS approach

Call for help early – ICU, anaesthesia, surgery, radiology, blood bank, OT

Airway with C-spine protection

• examine for patency, protection and any obvious signs of airway burn
• early intubation
• RSI with inline immobilization
• ETT tube size = age/4 + 4 (-1 if cuffed)
• features of an airway burn:

-> closed space
-> cough, stridor, hoarseness of voice
-> burn to face, lips, mouth, pharynx or nasal mucosa
-> soot in sputum, nose or mouth
-> hypoxaemia
-> SOB
-> carboxyhaemoglobin levels > 2%
-> acute confusional state or depressed LOC

Breathing + O2

• rule out life threatening chest injury
• assess RR and SpO2 and apply face mask O2 if hypoxic
• examine whether chest wall has been effective by burn as may develop respiratory failure from exhaustion and extreme pain

Circulation + control of external haemorrhage

• pulse and BP
• central perfusion
• state of hydration
• rule out any external haemorrhage
• obtain IV access through intact skin and send off bloods (U+E, FBC and Group + Hold in case patient needs debridement and grafting – can develop massive blood loss)
• IV access through groin often spared in a burn
• 20mL/kg crystalloid bolus

Disability + Neurological assessment

• level of consciousness
• pain score
• titrate in IV morphine until comfortable (start with increments to 0.2mg/kg however may need more)
• causes of an altered mental state:

-> TBI
-> CO or CN poisoning
-> hypoxaemia
-> other pathology: seizure, hypoglycaemia, drug ingestion

Exposure + Keep warm

• take all clothes off
• if there are areas that are stuck to patients skin -> cut around

Head to Toe examination

• burn as a percentage of TBSA
• depth of burn (superficial, partial (superficial and deep), full thickness)
• photograph

Other important issues

1. Analgesia

• assess using behaviour observation rather than by direct questioning @ this age
• multi-modal analgesia ideal however acutely is managed with IV opioids
• cautious titration of opioids as this patient is likely to develop hypovolaemic shock
• start with increments to morphine 0.2mg IV, but may need more
• also load with IV paracetamol 20mg/kg
• apply cling film (sterile, non-adherent dressing) to burn which will aid with preventing heat loss but also helps with pain as it prevents depolarization of burnt nerve endings from air moving over burn
• post surgery; use paracetamol (15mg/kg qid), ibuprofen (10mg/kg qid), topical local anaesthesia and opioids +/- ketamine

2. Fluid resuscitation

• Parkland Formula; 3-4mL/kg/percentage burn (give half this volume over first 8 hours from time of burn, and the other half over 16 hours) + maintenance needs to be added to this
• use a balanced salt solution like Hartmans
• this will need to be titrated and adjusted to end-organ perfusion variable like urine output (1ml/kg/hr) haemodynamics, mental state and lactate.
• close monitoring of blood loss during surgery with infiltration of LA and adrenaline under GA helps limit blood loss