Category: Paediatric

Paediatric Burns series: #4

3/2/2017

6 Comments

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: #2

27/1/2017

3 Comments

ED Approach to a major paediatric burn

Initial process

ATMIST
Primary & secondary survey
Safeguarding
Stabilisation

Assessment

Mechanism: scald, flame, chemical (what, acid/alkali), electrical (high/low voltage)
Time of injury
Estimated burn area and which parts of body (Mersey Burns app)
Airway compromise
First aid measures
Other injuries

Management (consultant led care)

Airway (all above + work of breathing, may need suction/nebs in inhalation injury) – see Blog post 3
Consider c-spine
100% O2
CO level, cyanide level (if required: hydroxycobalin 70mg/kg)
IV/IO access
Fluids – see Blog post 4
Catheterise if >20% TBSA

Record body surface area, using appropriate chart (Mersey Burn app). Exclude erythema (sunburn type), use Lund & Browder. Note palm surface area is 0.8%. Rule of 9’s not accurate in children, and not really in adults either.

Consider need for escarotomy prior to leaving peripheral hospital
Clingfilm
Analgesia
KEEP warm
Monitoring is an issue: may need invasive, consider ear probe on lip, may have to stitch lines through burn,

The suggested minimum threshold for referral into specialised burn care services can be summarised as:

All burns ≥2% TBSA in children or ≥3% in adults
All full thickness burns
All circumferential burns
Any burn not healed in 2 weeks
Any burn with suspicion of non-accidental injury should be referred to a Burn Unit/Centre for expert assessment within 24 hours

In addition, the following factors should prompt a discussion with a Consultant in a specialised burn care service and consideration given to referral:

All burns to hands, feet, face, perineum or genitalia
Any chemical, electrical or friction burn
Any cold injury
Any unwell/febrile child with a burn
Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn

If the above criteria/threshold is not met then continue with local care and dressings as required.
If burn wound changes in appearance / signs of infection or there are concerns regarding healing then discuss with a specialised burn service.
If there is any suspicion of Toxic shock syndrome (TSS) then refer early.

Click here for full guideline: http://www.britishburnassociation.org/

Clare Bosanko, Jan 2017

Link to previous learning blog: http://derriforded.weebly.com/derrifoam-blog/gems-wdwlt

3 Comments

Paediatric Burns series: #1

25/1/2017

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An introduction + first aid

Epidemiology
Predominantly scalds and contact burns in children.
Cups of tea and coffee.
Think about primary prevention.

First aid
Stop the burning process: remove clothing, don’t remove if adherent
Cool with running water, for 20 minutes
Temporary dressing: cling film
Elevate limbs

Basic principles

IGNORE the burn in the primary survey
Call for help! Ideally a senior (paediatric) anaesthetist. Roles: airway management, vascular access, analgesia, transfer, to bring calm where there is panic
Consider the mechanism (are there any non-burn injuries?)
Keep the patient warm (EDs are cold)

How are hospitals that look after burned patients organised?
Facility > unit > centre (National Burn Care Referral Guidance)

Facilities: less complex burns, part of a plastic surgery service
Units: moderate size or moderate severity burns, include providing treatment for those requiring critical care
Centres: highest level of care with most severe injuries and highest level of critical care

In the South West:
Derriford is a burns facility.
Bristol Southmead is a burns unit for adults
Morriston, Swansea is a burns centre for adults
Bristol Children’s Hospital is burns centre for children

C Bosanko; Jan 2017

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A little cough

10/1/2015

by Adam Herbstritt

6 year old presents unwell, febrile, viral, coryzal with some focal chest signs.
This Xray was performed in ED - what do you see?

Paediatric Burns series: #4

Fluids

Paediatric Burns Series: #3

Airway

Predicting presence of airway burn:

Paediatric Burns series: #2

ED Approach to a major paediatric burn

Paediatric Burns series: #1

An introduction + first aid

A little cough

by Adam Herbstritt

Categories

The Derrifoam Blog

Archives

Paediatric Burns series: #4

Fluids

Paediatric Burns Series: #3

Airway

Predicting presence of airway burn:

Paediatric Burns series: #2

ED Approach to a major paediatric burn

Paediatric Burns series: #1

​An introduction + first aid

A little cough

by Adam Herbstritt

Categories

The Derrifoam Blog

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An introduction + first aid