Pediatric Burns - Handout


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2-page summary of Initial Pediatric Burn Management

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Pediatric Burns - Handout

  1. 1. Pediatric Critical Care Simulation Day Farooq Khan MD CM June 2012 PGY3 FRCP-EM Preparatory Handout McGill University Sources: Besner, Gail. Surgical Treatment of Burns. Medscape 2012. PALS guidelines, AHA 2010, Marx: Rosen’s Emergency Medicine 7 th Ed. 2009 Key points in the Initial Management of Burns in Pediatric Critical Care Airway Pediatric airway differences Consider inhalational injury by smoke/steam which can cause rapidly progressive upper airway edema. Early techniques to buy time in supporting the airway include  Positioning  Racemic Epinephrine  Heliox Consider early intubation and anticipate difficulties. Take into account hemodynamic status when choosing RSI medications. The following may be required:  Smaller ETT size  Bougie  Video laryngoscopy  Fiberoptic  Surgical airway Breathing Oxygenation: Burned patients may be exposed to asphyxiants from smoke, as well as CN and in particular CO depending on the nature of the combustion. Appropriate therapy includes 100% O2 and measurement of CO levels to anticipate need for hyperbaric O2. Ventilation: Chest wall compliance may be compromised by burns particularly circumferential ones. Definitive treatment of a circumferential burn is surgical escharotomy. Reflex bronchoconstriction, air trapping and surfactant denaturation can also occur due to the smoke inhalation leading to worsening lung compliance. Inhaled bronchodilators can be useful in this case but mechanical ventilation may be required alleviate the demand of the increased work of breathing and avoid hypercapnic respiratory failure. Oxygenation and Ventilation: Inhalational injury may cause ARDS-like picture through direct exposure to toxic inhalants and particulate matter, leading to cellular necrosis, inflammatory exudates, leaky capillaries and alveolar edema. This coupled with the ventilatory difficulties mentioned above leads to profound V/Q mismatch and hypoxic respiratory failure. Mechanical ventilation may be required using lower volumes (4-6 cc/kg tidal volumes) and higher respiratory rates to minimize barotrauma. Signs of inhalational injury Upper respiratory tract: facial burns, carbonaceous sputum, soot marks, singed eyebrows or facial hair, hoarseness, stridor, oropharyngeal edema Lower respiratory tract: tachypnea, dyspnea, cough, decreased breath sounds, wheezing, rales, rhonchi, and retractions
  2. 2. Pediatric Critical Care Simulation Day Farooq Khan MD CM June 2012 PGY3 FRCP-EM Preparatory Handout McGill University Sources: Besner, Gail. Surgical Treatment of Burns. Medscape 2012. PALS guidelines, AHA 2010, Marx: Rosen’s Emergency Medicine 7 th Ed. 2009 Circulation Compensated shock Decompensated shock Tachycardia Pallor, diaphoresis, cold skin Delayed cap refill Weak distal pulses, narrow pulse pressure Oliguria, vomiting, ileus Deteriorating mental status Loss of peripheral pulses, weak central pulses Bradycardia Hypotension IV access can be challenging in children, particularly when there are burns. Consider the placement of an IO early so as not to delay fluid administration. Burn victims can have massive insensible losses of fluid due to compromise of the skin barrier and need aggressive fluid resuscitation. Burned children in decompensated shock need repeat boluses of NS at 20cc/kg to avoid impending cardiac arrest. For compensated burned patients, a useful guideline to achieve adequate perfusion is the modified Parkland formula: Total Fluid Requirements = TBSA burned(%) x Wt (kg) x 4mL  Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours.  For patients less than 20 kg, Maintenance fluids are administered concomitantly using the "4-2-1" Rule:  For 0-10kg: 4 mL/kg/hr  For 10-20kg: + 2 mL/kg/hr  For >20kg: + 1 mL/kg/hr Remember that the modified Parkland applies from time of burn onset and needs to be adjusted to vitals, urine output, and other parameters of perfusion. Estimate the TBSA burned using the Rule of 9’s Supportive care Remember to provide appropriate analgesia: Morphine 0.1mg/kg/dose to start and consider infusions of morphine/ ketamine/fentanyl Removal of burned clothing and appropriate dressings to burned skin Monitor temperature as children with burns have impaired temperature regulation. Provide appropriate surgical consultation for escharotomies/skin grafting Admission to Burn unit using the following criteria:  Partial-thickness burns greater than 10% total BSA (TBSA)  Full-thickness burns greater than 2% TBSA  Burns involving the face, hands, genitalia, perineum, or major joints  Circumferential extremity burns  All high-voltage electrical burns, including lightning injury, admission of low-voltage electrical burns is selective  Chemical burns  Inhalation injury  Patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality (eg, diabetes, immunosuppression)  Suspected child abuse  Cases in which it is determined that it is in the best interest to admit the child (ie, parental inability to care for the burn)