Pediatric Thermal Injury



Pediatric Thermal Injury


Laura Snell MD

Howard Clarke MD, PhD, FRCS, FAAP, FACS



EPIDEMIOLOGY



  • 50% of all burns are in the pediatric population.


  • 70% of pediatric burns are caused by hot liquid.1



    • Flame burns make up the majority of the remaining 30%.


  • Younger children are at higher risk of burn injury.


  • Up to 20% of burn injuries in younger children are the result of abuse or neglect.2


PATHOPHYSIOLOGY



  • Many systemic derangements caused by burn injury contribute to fluid shifts.



    • Significant fluid shifts result in burn wound edema and systemic hypovolemia.


  • Loss of cutaneous barrier function.



    • Insensible losses.


  • Increased capillary permeability.



    • Local in all burn wounds, systemic if >25% TBSA (total body surface area).


    • Hypoproteinemia.


    • Increased fluid shift from vessels to interstitial tissues.


  • Release of arachidonic acid cascade metabolites including prostaglandins, histamine, serotonin.


  • Hormonal derangements (increase in ADH and aldosterone).


BURN CLASSIFICATION



  • Early assessment and documentation of burn depth, extent, and involvement of hands/face/perineum is very important for treatment planning and must be done.


Depth



  • First degree/superficial:



    • Red, dry, painful.


    • Will heal after several days, no scar.


  • Second degree/partial thickness:



    • Red, wet, very painful.


    • May be superficial or deep partial thickness.


    • Will likely heal after days to weeks of adequate wound care including debridement, daily wound check and dressing changes.


    • May require skin grafting and may scar.


  • Third degree/full thickness:



    • Leathery, dry, insensate, waxy.


    • Will not heal without excision and grafting.


  • Fourth degree:



    • Involves underlying subcutaneous tissue, tendon, bone.



Total Burn Surface Area (TBSA) (Fig. 14-1)



  • Lund—Browder chart.



    • Age-specific.


  • Rule of nines (Fig. 14-1).



    • Assuming adult body proportions—appropriate for use in teenagers.


    • Larger head and neck in proportion for younger children and infants.


  • Exclude first-degree burns when calculating TBSA.


PEDIATRIC BURNS: INITIAL MANAGEMENT


Primary Survey


Airway Management



  • Airway is first priority during primary survey.


  • Must be secured prior to transport.


  • Suspect inhalation injury if:



    • The fire occurred in an enclosed space.


    • Patient has:



      • Carbonaceous sputum.


      • Singed nasal hairs or eyebrows.


      • Hoarseness or stridor.


      • Elevated carboxyhemoglobin level (>10%).


  • Confirm airway injury with bronchoscopy at the bedside.


  • Hot liquid aspiration can also cause airway compromise.3


  • Indications for intubation:



    • Inhalation injury



      • Stridor.


      • Respiratory distress.


      • PaO2 < 60 mmHg, PaCO2 > 55 mmHg.


    • Need for transport to another facility.


    • Significant facial ± neck burns.


    • Anticipated aggressive fluid resuscitation.


  • Important to secure the endotracheal tube (ETT) at the time of intubation.



    • Do not cut the ETT shorter as facial edema will likely progress.


    • Ensure the ETT is secured properly.


    • Consider use of reinforced ETT.


    • 24-gauge wire around the molars and then around the tube.


    • Do not use suture material (not strong enough).


    • See Chapter 3 on Airway Management for details.






FIGURE 14-1 • Total body surface area (TBSA) estimation.



Fluid Resuscitation



  • Important to establish early secure venous access.



    • Can be difficult in the hypovolemic patient.


    • May require intraosseous access to begin resuscitation.


    • See the “Definitive Management” section later in this chapter for details.


  • Aggressive fluid resuscitation with normal saline required for burns >15%.


  • Burns <15% are generally not associated with extensive capillary leak.



    • Encourage PO fluid intake.


    • Closely monitor urine output. Goal = 1-2 mL/kg/hr.


  • Parkland resuscitation formula (Ringer lactate): 4 mL/kg/%TBSA.



    • Note: Time zero for fluid resuscitation = time of burn injury.


    • An estimation of fluid requirements for the initial 24 hours following a significant burn injury ABOVE normal maintenance requirements.


    • Give first half of calculated volume over 8 hours from time of injury.


    • Give the remaining half of calculated volume over the following 16 hours.


    • Remember to consider other ongoing losses as well (e.g., vomiting).


    • Monitor urine output closely and adjust rate of fluid infusion as needed for target urine output of 1-2 mL/kg/hr.


EVALUATION


History



  • Details of the events surrounding the injury.



    • Where did it occur? When did it occur? How did it occur?


    • Was anyone else injured?


    • What was the fluid involved—grease versus water/steam?


  • Symptoms:



    • Pain related to burns.


    • Chest pain, shortness of breath, coughing.


    • Vomiting or abdominal pain.


    • Dizziness or lightheadedness, syncope, headache, visual changes.


    • Extremity pain, numbness, tingling.


  • Past medical history:



    • Underlying cardiac, respiratory, or neurological disease.


    • Tetanus status.


    • NPO status.


Physical Examination/Burn-Specific Secondary Survey

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Pediatric Thermal Injury

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