managing multiple pediatric burns: from the field to the ...€¦ · the statistics burns account...
TRANSCRIPT
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Managing multiple pediatric burns: From the field to the
Burn Center
Melanie Stroud, RN San Francisco, CA
Marvin Wayne, MD Bellingham WA
Chris Streck, MD Charleston, SC
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The Statistics
Burns account for >300,000 deaths yr worldwide In U.S., they are the third leading cause of fatal
home injuries Death usually results from the inhalation injury.
Of 25 developed countries US mortality is eighth
Major risk factors; extremes of age, alcohol (in 40% of deaths) and substandard housing.
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The Statistics
>60% are thermal, the majority of others being chemical and radiation
Electrical burns, infrequent but require important considerations.
Morbidity and mortality increase with both depth and extent.
Prehospital, and early hospital treatment can decrease future disability and mortality.
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January 1, 2012 4:22 hrs
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CASE SCENARIO- 2 Burn
Patients in a community hospital
Space heater house firePt 1: 11 y/o F 22% Deep 2nd and 3rd Degree Burns
to L face/ head, L chest, L arm, R arm, both hands
Respiratory distress with CO >40%
Pt. 2: 4 y/o 20% 3rd degree burns to face/head,
bilateral hands. Respiratory distress CO >30%
Transported to community hospital for
stabilization- Nearest Pediatric Level I Burn Center
is 1 ½ hours away
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Pt 1 Prehospital:
Obvious airway concerns with carbonatious
sputum CO level of >40%. Pt very somnolent.
Burned clothing quickly removed IV rapidly
established fluids started.
IV, Dilaudid, versed and pt preoxygenated,
intubated in back of EMS unit.
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Pt 2 Prehospital:
Also with airway concerns, carbonatious
sputum CO >30% Burned clothing removed
and IO line placed. Dilaudid and versed
followed by intubation in EMS Unit.
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Resuscitation
Audience Question?
What are the main considerations in Resuscitation?
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Resuscitation
Airway
Breathing
Circulation
Disability
Exposure
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Primary and Secondary Survey Airway: Early recognition of airway
compromise prompt intubation If soot in the mouth consider early intubation even if the patient appears
to be breathing normally.
Breathing: Determine if patient is moving air.
Circulation: Obtain vascular access and monitor
Disability: Detect if other injures or neurologic deficits.
Exposure: Completely exposed (while keeping warm).
Exposure: All orifices must examined
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Primary and Secondary Survey
Fluid resuscitation: A mainstay in the treatment. Discussed in third
question after the calculation %TBSA
Guidelines of Acute Trauma Life Support (ATLS) should be followed
Note child is prone to hypothermia due to high surface to volume ratio and low fat mass.
Ambient temperature should be from 28° to 32°C(82° to 90°F).
Patient’s core temperature must be kept at least above 34°C.
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Primary and Secondary Survey
Secondary survey is a burn-specific survey.
performed during admission to the burn unit.
Full history should include: Detection of the mechanism of injury.
Time of injury.
Consideration of abuse.
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Primary and Secondary Survey
Height and weight. Possibility of carbon monoxide intoxication
based on history of a closed space, presence of soot in mouth and nose.
Where there is high CO, think Hydrogen Cyanide
Facial burns. Examination of the cornea and ear in case of explosion
A systemic overview should be performed including EFAST, exam genital region, lower and upper extremities (think: X-Ray C-Spine, Thorax, and Pelvic).
Consider abuse if history unclear.
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Inhalation Injury
Signs of potential inhalation
injury include :
Facial burns
Singed nasal hairs
Carbonaceous sputum
Abnormal mental status
Respiratory distress (
dyspnea, wheezing, stridor)
Elevated carboxy-
hemoglobin levels
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Audience Question?What are the indications for intubation, acutely, and prior to transfer?
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Indications for Intubation
Pediatric Burns - Indications for Intubation
Closed space injury
Loss of consciousness
↑carboxyhemoglobin
Hypoxia, hypercapnea
Acidosis
Burns > 30% TBSA
Prolonged air transport
Carbonaceous sputum
Hoarseness
Stridor
Burns to face, head, neck
Singed hair
Tachypnea
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Transfer to a Burn Unit
Audience Question:
Does the patient meet the criteria for injuries
requiring referral to the Burn Unit?
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Transfer Guidelines
Burn injuries that should be referred to a burn center include the following:
Airway burns
Partial-thickness burns greater than 10%
Burns that involve face, hands, feet, genitalia, perineum, or major joints.
Third-degree burns in any age group.
Electrical burns, including lightning injury.
Chemical burns.
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Estimating Burns
Audience Question:
What is the best scale to use when estimating burn areas in children?
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Lund and Browder chart
Compensates for variation in
body shape, age
Gives accurate assessment of
burns in children
Expose and evaluate
sequentially
Estimating Burns in Children
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CASE SCENARIO- 2 Burn Patients in a community hospital
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Fluid Resuscitation
Audience Question:
What percent burn should receive fluid resuscitation, using what formula?
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Fluid Resuscitation
Burns greater than 20% TBSA associated with
Increased capillary permeability and intravascular volume deficits
Are most severe in the first 24hours following injury.
Optimal fluid resuscitation: Support organ and tissue perfusion at the least physiological cost (edema/capillary leak)
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Fluid Resuscitation
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Fluid Resuscitation
1.5 – 2
mL / kg
0 – 2 years
1 mL / kg
3 – 5 years
0.5 – 1 mL / kg
6 – 12 years
Larger burns often need a Foley
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Audience question:
What kind of laboratory tests should be performed?
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Labs
What kind of laboratory tests should be done?BMP
Hct
UA
ABG/CO
Albumin/pre-albumin
CXR
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How to care for the Burns?
Audience Question:
What is the best way to care for burn wounds prior to transport?
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Covering the Burn
Providers should remove clothing around the burn
Cover burns with a clean dry sheet and keep patients warm.
Kerlix is another good option
Don’t need to spend time rupturing blisters
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Audience question?
Who needs escharotomy prior to transfer?
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Audience question?
Who needs HBO2?
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Other early considerations• Debridement and coverage
• Biobrane, Xeroform, Mepitel AG, EZ Derm
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Audience question?• Colloid?
• Tetanus?
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Audience question?
•When to start enteral nutrition?
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Other early considerations
• Associated traumatic injuries
• Child abuse/neglect
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Skin Sparing“Dougnut hole”
Sparing of the creases
Uniform Burn Depth
Uniform burn line demarcation
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Thank you!
Questions?