To understand the structured approach to the child with burns
To learn how to identify the severity of burns in a child
To introduce the skills and equipment used for the resuscitation of a child with severe burns
755 pts. ≤15 yoa in 14/17 Burns Units in A & NZ
Figures from Bi-NBR
Figures by courtesy of Bi-NBR 2010-2011 year
Causes of Burns
•Overall •55% are scalds•21% are contact•14% are flame
•Scalds are commonest cause up to 11 yoa
•78% of scalds occur in the usual place of residence
•>10 yoa flame burns are commonest cause
Severity of InjurySeverity of Injury Temperature
Duration of contact
% of Body Surface Area burnt
irway nd C spine control
reathing
irculation
ABC
Airway managementmust not be delayed
Systemic poisoning
◦ CO & HCN: usual cause of death at the scene
Supraglottic injury
◦ Swelling within hours causing obstruction
Infraglottic injury
◦ Smoke particles cause chemical response >1-3 days
SMOKE IS HOT
History of exposure
Soot in mouth
Carbonaceous sputum
Singed facial hair
Hoarseness or cough
StridorSMOKE IS HOT
Watch for Watch for progressive progressive
signssigns
45% of patients45% of patients with flame burnswith flame burns
above the claviclesabove the clavicles have inhalation injuryhave inhalation injury
Associated chest injuries
Circumferential burns
Small children use the diaphragm
so a burn of the front & sides
of the trunk can impair
ventilation.
Fluid loss is obligatory, max. 8 hrs, continues 48 hrs
Hypovolaemia from burns occurs relatively late
If shocked early, look elsewhere for a cause
Resuscitation Burn (%) x Weight (kg) x 4 ml per day
Calculated from the time of the burn
Half in first 8 hours
Hartmann’s
Maintenance – as usual over 24 hours
Assess fluid requirements by urine output
0.5 - 2 ml / kg / hr
◦ Ideally 0.5-1 ml/kg/hr
◦ Avoid overhydration
>2 ml/kg/hr if haemochromogenuria
Formulae are only Formulae are only guidesguides
BURNT CHILDREN LOSE HEATBURNT CHILDREN LOSE HEAT
VERY RAPIDLYVERY RAPIDLY
Blast
Falls
MVAs
Falling objects
Escape
Associated injuries may be obvious or hiddenAssociated injuries may be obvious or hidden
Surface area
◦ % of Body Surface Area (%BSA)
Depth
◦ Describe anatomically
Site
◦ Involves “special” areas?
Paediatric BSA chart
Child’s hand(palm and adducted
fingers)is 1% BSA
For simplicity use “Rule of 9s”
In Infant1 X 9 for each
arm.2 X 9 for head 14% each lower
limb4 X 9 for trunk
Take 1% off head Take 1% off head & add to legs for & add to legs for each year of life each year of life
>1>1
In adult1 x 9 for h & n, each arm2 x 9 for each lower limb
4 x 9 for trunk
Superficial- Pink- Blistered
◦ Base blanches on pressure◦ Refills on release
Mid dermal – dark, mottled red, non-blanching
Deep - White/charred - Leathery
Early depth assessment is inaccurate
Remove FBs and wash
Cling film loosely applied
Elevate
Ointments, creams or dressings ONLY as part of
definitive care or transfer delayed (discuss).
Opiates IV
Opiates IM
Flowing water 8-25°C
Most effective for partial thickness
Continue 20 minutes
Excellent pain relief
AVOID HYPOTHERMIA
“Glove and stocking” scalds Artefact shape of burn Absence of splash marks Inconsistency of history and
examination Delay in presentation Signs of other injuries Repeated presentation Witness to event not at ED
Adult – total > 10 % or full thickness >5% Child - total > 5 % Special areas: Face, hands, feet, perineum and major joints Circumferential burns Inhalational injury Chemical, radiation or electrical burns Suspicion of non accidental injury Patient with pre-existing medical disorders which may
complicate management, prolong recovery or affect mortality
Associated significant trauma
The Child with Burns or ScaldsThe Child with Burns or Scalds
Treat airway compromise earlyTreat shock and resuscitateLook for associated injuries
Use IV analgesia as appropriateCare for wounds
Refer appropriatelyQuality transfer
The leading cause for accidental death of children worldwide
NZ 18 deaths per year28 if include up to 19 yrcf Eng & Wales 34 in 1998
62 admissions per year > 24 h
Prevention Effective, early basic life support Assume cervical spine injury Handle gently if hypothermic
Intubate to prevent aspiration Gastric drainage to remove
swallowed water Measure core temperature
and treat hypothermia Full trauma assessment for other injuries
External RewarmingExternal Rewarming Remove wet clothing Wrap warmly Radiant heat Warm air system Direct heat
Core RewarmingCore Rewarming IV fluids to 39oC Ventilator gases to
42oC Gastric/bladder/
peritoneal/pleurallavage at 42o C
Extra-corporeal rewarming with
by-pass
Active core re-warming vital No initial medications until core >30o C Initial defibrillating shocks, but no repeat till core >30o C Volume expansion may be needed Continue to resuscitate until expert advice obtained
No single factor reliably predicts outcome Immersion time Time to first respiratory effort Core temperature Persisting coma The clinical course is determined by
hypoxic-ischaemic injury and adequate CPR
DrowningDrowning
Good BLSRemember cervical spine injury
Protect the airway from aspiration
Remember hypothermia