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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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