The Child with Burns or Scalds

1. The Child withBurns or Scalds

2. Objectives • 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

3. Epidemiology 755 pts. ≤15 yoa in 14/17 Burns Units in A & NZ Figures by courtesy of Bi-NBR 2010-2011 year Figures from Bi-NBR

4. Epidemiology • 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

7. Pathophysiology Severity of Injury • Temperature • Duration of contact • % of Body Surface Area burnt

8. Immediate Priorities A irway nd C spine control B reathing C irculation

9. Airway management must not be delayed Airway Compromise

10. Inhalational Injury • 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

11. Inhalational Injury 45% of patients with flame burns above the clavicles have inhalation injury Watch for progressive signs SMOKE IS HOT History of exposure Soot in mouth Carbonaceous sputum Singed facial hair Hoarseness or cough Stridor

12. Suspicion Early intervention Airway Management

13. Breathing • Associated chest injuries • Circumferential burns Small children use the diaphragm so a burn of the front & sides of the trunk can impair ventilation.

14. Circulation • Fluid loss is obligatory, max. 8 hrs, continues 48 hrs • Hypovolaemia from burns occurs relatively late • If shocked early, look elsewhere for a cause

15. Additional fluid 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

16. Circulation • 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 guides

17. Exposure BURNT CHILDREN LOSE HEAT VERY RAPIDLY

18. Any injury can occur Secondary Survey • Blast • Falls • MVAs • Falling objects • Escape Associated injuries may be obvious or hidden

19. Burn Assessment • Surface area • % of Body Surface Area (%BSA) • Depth • Describe anatomically • Site • Involves “special” areas?

20. Surface Area Assessment Paediatric BSA chart Child’s hand (palm and adducted fingers) is 1% BSA

21. Surface Area Assessment For simplicity use “Rule of 9s” In adult 1 x 9 for h & n, each arm 2 x 9 for each lower limb 4 x 9 for trunk In Infant 1 X 9 for each arm. 2 X 9 for head 14% each lower limb 4 X 9 for trunk Take 1% off head & add to legs for each year of life >1

22. Depth • Superficial - Pink - Blistered • Base blanches on pressure • Refills on release

23. Depth • Mid dermal – dark, mottled red, non-blanching • Deep - White/charred - Leathery Early depth assessment is inaccurate

24. Wound Care • Remove FBs and wash • Cling film loosely applied • Elevate • Ointments, creams or dressings ONLY as part of definitive care or transfer delayed (discuss).

25. OpiatesIV Opiates IM Analgesia

26. AVOID HYPOTHERMIA Cooling Therapy Flowing water 8-25°C Most effective for partial thickness Continue 20 minutes Excellent pain relief

27. Non Accidental Injury? • “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

28. Transfer criteria (adapted from EMSB) • 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

29. Advanced Paediatric Life Support The Child with Burns or Scalds

30. Burns and scaldsSummary A Treat airway compromise earlyTreat shock and resuscitateLook for associated injuriesUse IV analgesia as appropriate Care for woundsRefer appropriatelyQuality transfer C B

31. The Child with Drowning

32. Epidemiology • The leading cause for accidental death of children worldwide • NZ 18 deaths per year 28 if include up to 19 yr cf Eng & Wales 34 in 1998 • 62 admissions per year > 24 h

33. Management • Prevention • Effective, early basic life support • Assume cervical spine injury • Handle gently if hypothermic

34. Management • Intubate to prevent aspiration • Gastric drainage to remove swallowed water • Measure core temperature and treat hypothermia • Full trauma assessment for other injuries

35. HypothermiaManagement External Rewarming • Remove wet clothing • Wrap warmly • Radiant heat • Warm air system • Direct heat Core Rewarming • IV fluids to 39oC • Ventilator gases to 42oC • Gastric/bladder/ peritoneal/pleural lavage at 42o C • Extra-corporeal rewarming with by-pass

36. HypothermiaManagement of cardiac arrest • 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

37. DrowningPrognostic indicators 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

38. Advanced Paediatric Life Support Drowning

39. DrowningSummary A Good BLSRemember cervical spine injuryProtect the airway from aspirationRemember hypothermia C B