Paediatric Burns

2013

BURNS IN CHILDREN• In South Africa burns are the

number one cause of unnatural death in children under the age of 4 years

• The vast majority of burns occur in the home of the child

• Hot water scalds are the most common cause of burns

The ABC of Burns resuscitation

Basic first care• SAFE approach:

– Shout for help– Advance with care– Free the person from danger– Evaluate the patient - ABCD

• Stop the burning• Cool the burn wound

Airway• History:

– enclosed space? Smoke? Steam? • Examination:

– burns to face– Sputum containing soot – Change in voice or cry, brassy cough,

dysphonia, stridor• Management:

– Clear airway,chin lift, jaw thrust. Beware: spine– Close observation– Humified 100% oxygen for 24h in all major

burns– ET tube

Breathing• Breathing effort:

– Tachypnoea, hypopnoea– Abnormal chest movements

• Cyanosis or bright pink colour• Cardiopulmonary resuscitation if not

breathing, endotracheal intubation

Circulation• Check the pulse• Capillary refill time (normal < 3

sec)• Shock in burns does not occur

immediately, but evolves over time. If early shock look for bleeding elsewhere

Circulation: Fluids– Initial 20mls/kg fluid bolus of Ringers

Lactate if patient is shocked (can be repeated)

– Ongoing fluid requirements need to be calculated • Resuscitation (Ringers Lactate):

– Day 1: 2-3ml x kg x % burn first half given in the 8 hours from the time of injury and the second half in the subsequent 16 hours

– Day 2: 1 - 2ml x kg x % burn over 24 hours•Plus: Maintenance, per day (Paediatric

maintenance solution with Glucose): 100 ml/kg up to 10kg plus 50 ml/kg from 10 – 20 kg

Disability: Level of consciousness

• Altered sensorium may be due to:– Associated head trauma– Poor oxygenation– Shock– Carbon monoxide toxicity

Exposure• Purpose of full exposure is to

assess total burnt surface area and other injuries

• Be aware that children are at risk of developing hypothermia

Burn wound assessment• Two components:

– Assessment of burn wound area: Determines fluid and metabolic needs

– Estimation of depth of the wound: Determines local and surgical management

Estimation of total burn surface area

Estimation of burn depth

Analgesia• Pain management must be started

from the beginning: Diminishes SIRS, diminishes long term psychological scaring

• Oral:– Tilidine HCL (Valoron): 1 mg/kg 6 hourly– Paracetamol: Loading dose 20 mg/kg;

maintenance 15 mg/kg/dose, can be repeated 6 hourly

Analgesia• Parenteral analgesia:

– Morphine 0.5 mg/kg in 50 ml 5% D + W. Infusion rate 1 – 4 ml/hour

– Ketamine 2 mg/kg/dose: For procedures• Need to be able to ventilate child if stops

breathing (resuscitation equipment must be ready)

Definitive management• Transfer to burns centre is indicated for

the following:– Partial thickness burns greater than 10%

TBSA– Burns involving face, hands, feet, genitalia,

perineum, major joints– Third degree burns (any extent)– Electrical, chemical burns– Inhalation injury– Circumferential burns– Suspected child abuse– Any patient that can not be managed at the

referring facility

Definitive managementBefore transfer to the burns centre do

the following:– Document history and time of the burn– Document fluids planned and received– Diagrammatic sketch of burnt area– Send signed consents for slough

excision and grafting– Ensure safe transport and qualified

accompanying personnel to continue resuscitation en-route (working drip essential)

Definitive management

• Prevent limb ischemia: Escharotomies• Prevent Katabolism: Early enteral

feeding• Prevent sepsis: Early sloughectomy,

skin grafting. Prophylactic antibiotics do NOT work

• Prevent contractures: Splinting