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Paediatric Burns series: #4

3/2/2017

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Fluids

Fluid losses are slow and predictable. In the early phase of injury, shock is due to another cause.

All fluid formulae

take no account of other injuries
are a starting point only
increase oedema in injured and uninjured tissues

Baxter (parkland) formula: 2-4ml/kg x body weight x %burn

From time of burn: Half in first 8 hours, remainder in 16 hours. If you are ‘playing catch up’ spread this over 8 hours rather than giving a bolus.
Note: you may well have estimated the body weight and the %burn, therefore potentially compounding your error

Flame burn patients are likely to be sicker and require more fluids than scald burns.

Timing of resuscitation fluid in children: if started within 1hour better survival in major burns (>20%).
Urine output targets: adult 0.5-1ml/kg, children 2ml/kg. May also use lactate to track response. Be prepared to cut back. Beware… children may develop SIADH picture post burn (some opinion that 0.5-1ml/kg/hr if Na/renal function + haemodynamics stable is OK).

Beware fluid creep: just because fluids are good in burns, does not necessarily mean more fluids are better. Consider starting at lower end of 2-4 ml/kg

Excess fluids cause: burn progression, non-wound oedema, compartment syndromes, impaired gas exchange, cerebral oedema

Remember that fluids are COLD, warm them before infusing.

Clare Bosanko, Febr 2017

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Paediatric Burns Series: #3

1/2/2017

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Airway

Predicting presence of airway burn:

Mechanism: entrapment, explosion, altered level of conscious (at any time). Few facial scalds require intubation.
Symptoms: voice change, retrosternal burning sensation, sensation of difficult breathing

Signs: reduced level of consciousness, voice change, perioral or perinasal burns (not just facial burns), soot in the oropharynx (not just nose), erythema or oedema of tongue, stridor

Undertaking intubation:

Techniques: RSI, inhalation induction (good body of evidence), awake fibreoptic (probably not available everywhere)

Requirement: Experienced staff, full range of equipment, ED or operating theatre, oral/nasal tube (uncut), document airway findings (if normal at the time consider discontinuing intubation, but certainly will help with planning onward care)
Be prepared for hypotension (consider preparing phenylephidrine to counteract)
Tracheal tube fixation, as appropriate to patient and institution: sticking plaster, ribbon tape ties, post-nasal sling, suture/wire to nasal septum or maxilla (may need maxfax assistance)

Pitfalls:

Facial burn does not equate to airway burn
No airway injury found at laryngoscopy (may choose to discontinue intubation attempts)
Late intervention in airway injury: be prepared with senior staff and helpers
Cutting tube (DON’T)
If in doubt intubate BUT consider
- More patients are intubated now than 15 years ago
- Incidence of confirmed inhalation injury is the same or falling
- Rate and severity of intubation/ventilation complications is significant (safety, transfer logistics, ventilator related problems)
- Ventilation of patients without inhalation injury associated with increased sepsis, ionotrope usage, mortality

Clare Bosanko, Febr 2017

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Paediatric Burns series: #4

Fluids

Paediatric Burns Series: #3

Airway

Predicting presence of airway burn:

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Paediatric Burns series: #4

Fluids

Paediatric Burns Series: #3

Airway

Predicting presence of airway burn:

Categories

The Derrifoam Blog

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