the child with burns or scalds

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