 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-NBRFigures from Bi-NBR Figures by courtesy of Bi-NBR 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 Injury  Temperature  Duration of contact  % of Body Surface Area burnt

irway nd C spine control reathing irculation A B C

Airway management must 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  Stridor SMOKE IS HOT Watch for progressivesigns 45% of patients with flame burns with flame burns above the clavicles have inhalation injury have inhalation injury

Early intervention Suspicion

 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

CRYSTALLOID 20 ml / kg CRYSTALLOID SURGERY BLOOD 10 ml/kg Assess Response

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  ml / kg / hr ◦ Ideally ml/kg/hr ◦ Avoid overhydration  >2 ml/kg/hr if haemochromogenuria Formulae are only guides

BURNT CHILDREN LOSE HEAT VERY RAPIDLY

 Blast  Falls  MVAs  Falling objects  Escape Any injury can occur Associated 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 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 In adult 1 x 9 for h & n, each arm 2 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 Scalds

Treat airway compromise early Treat shock and resuscitate Look for associated injuries Use IV analgesia as appropriate Care for wounds Refer appropriately Quality transfer

 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

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

 Active core re-warming vital  No initial medications until core >30 o C  Initial defibrillating shocks, but no repeat till core >30 o 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

Drowning

Good BLS Remember cervical spine injury Protect the airway from aspiration Remember hypothermia