|Year : 2013 | Volume
| Issue : 1 | Page : 8-13
Advanced pediatric life support in burn injuries
K Mathangi Ramakrishnan
Chief, Plastic Surgery and Burns, Chairperson, The CHILDS Trust Medical Research Foundation, Kanchi Kamakoti CHILDS Trust Hospital, Nungambakkam, Chennai, Tamil Nadu, India
|Date of Web Publication||22-Nov-2013|
K Mathangi Ramakrishnan
The CHILDS Trust Medical Research Foundation, Kanchi Kamakoti CHILDS Trust Hospital, 12-A Nageswara Road, Nungambakkam,
Source of Support: None, Conflict of Interest: None
In major burns in the pediatric age group, there is a very narrow transition between life and death. Amongst deaths due to pediatric trauma, burns rank the second highest in India. Emergency management of each pediatric burn requires knowledge of normal physiology and its changes with age as this is important in planning management for the burnt child. We have to keep in mind that children with burns have a higher morbidity and mortality. Hence, an advanced life support course must be popularized for pediatric burns.The advanced pediatric life support (APLS) in burns would be the care given over the first 24 h to the burnt child.
Keywords: Pediatric burns, Advanced life support
|How to cite this article:|
Ramakrishnan K M. Advanced pediatric life support in burn injuries. Indian J Burns 2013;21:8-13
| Introduction|| |
There are certain occasions in pediatric trauma (0-18 years), where treatment has to start from the onset of the occurrence of the injury. Major burns is one such indication. In major burns in the pediatric age group, there is a very narrow transition between life and death. Hence, life support should be started at the site of accident, in the transport ambulance or in the emergency room (ER) of a hospital. Ideally it should be done in the ER with trained staff. Towards this goal, a nationwide dedicated, structured and organized life support training is the need of the hour to save the burnt child. This discipline of advanced life support training has been established in many advanced countries and is directed towards targeting non-doctors, doctors, and paramedics especially nurses, nursing aids, and technicians.
Advanced life support is available today in the medical disciplines of pediatrics and neonatology. This advanced life support course must now be popularized for pediatric burns including the neonates.
Ideally these courses are arranged by trained teachers who are specialists in their own fields. These can be conducted during a major burn conference or largely attended medical educational programs. The course can be regionalized to suit the existing facilities. The course studies may vary slightly from country-to-country, as the depth of burns/damage to the skin will vary from race-to-race depending on the type of skin. Minor variations in the course contents should be done in booklets published in various countries.
Few facts about pediatric burns
According to World Health Organization (WHO), in India, over 10 lakh people are moderately or severely burnt every year. Along with adult women, children are particularly vulnerable to burns. Burns are the 11 th leading cause of death of children aged between 1 and 9 years and are also the fifth most common cause of nonfatal childhood injuries. While a major risk is improper adult supervision, a considerable number of burn injuries in children result from maltreatment. Scalds are more common than thermal injuries below the age of 3 years. Flame burns are more commonly seen in children over 3 years. Child abuse occurs due to scalds with hot water or chemicals or due to direct contact with electrical objects. Amongst deaths due to pediatric trauma, burns rank the 2 nd highest in India. In USA, 3 rd largest cause of death in the age group 1-9 years is due to burns.
Etiology of pediatric burn injuries
The common etiologies of pediatric burns are: Flame, scalds, chemical [Figure 1], special burns like tar burns [Figure 2], electrical [Figure 3], and child abuse [Figure 4]a, b, c, and d.
|Figure 4: (a) Deliberate hot water burns. (b) Acid thrown on perinium. (c) Hot iron burn contact. (d) Intentional caustic soda stick burn|
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| Proposed Course Details|| |
Pediatric life support is defined as the emergency treatment given to a child, who is a victim of burn trauma, in the ER of a tertiary care hospital or in the casualty department of a district peripheral hospital. The advanced pediatric life support (APLS) in burns would be the care given over the first 24 h to the burnt child.
Burn injuries are increasing in India, and the need has arisen to prevent, treat, and rehabilitate in a meaningful way. Fire accidents cannot be classified as a natural calamity like earthquake, floods, or Tsunami. Fire accidents are preventable. Human negligence, lack of proper maintenance of systems by authorities and the innate desire to abuse another human being due to various causes, result in the burn accidents. There are many protocols and advancements for prevention of burns around the world. Along with prevention, the current need of the hour is to have a comprehensive and structured Burn Care Team [Figure 5] comprising of people from various disciplines including the government, police, fire and rescue service, social workers, philanthropists, and burn surgeons to manage a fire accident.
As one of the important steps is to provide APLS as soon as a victim is brought to the ER, all the members who would be involved in care should undergo training. Hence, this training does not address the doctors alone, but is for the nurses, paramedics, nursing aids, and technicians. Irrespective of the specialty, all doctors also should get trained. The trained people can teach new entrants and these trainees will become trainers subsequently. Preferably this course can be conducted along with Burn conferences and workshops, so that there will be a large number of people attending. Where intensive care unit (ICU) specialists are available they will give the life support in the ER and train others.
Objectives (Differences between child and adult)
The objective is to first understand the following
- Compare adult and the child (0-18 years - WHO)
- Body surface area to body weight of the child
- Temperature regulation in the child
- Skin thickness of the child
Depth and total body surface area (TBSA); some facts to be kept in mind for child
The infant and young child presents a disparity between the large surface area and the total body weight. It has been identified that a 7 kg child is one-tenth the weight of his 70 kg adult counterpart, but the adult maintains only a 3:1 ratio of body surface area to the child. As a consequence of this relatively large body surface area, the child has greater evaporative water loss relative to weight than the adult. This ratio ultimately equalizes when the age of puberty is reached.
Children under age 2 also have disproportionally thin skin (because of thinner dermal layer) that results in full-thickness, third degree burns that initially appear to be partial-thickness burns.
Body surface area calculation
Though Wallace's rule of nine is rapid and easy to use, it is not accurate in children as it tends to overestimate area in the lower limb and underestimate in the head neck region. Hence, it is best to use the Lund and Browder Chart which will give a fairly accurate calculation according to the age of the child.
Temperature regulation in the infant and child is influenced by the child's relatively greater body surface area which compromises conservation of body heat and a lesser ability to shiver because of a relatively small muscle mass.
Temperature regulation in infants less than 6 months depends less on shivering and more on the intrinsic metabolic processes and environmental temperature. Although in the infant of more than 6 months and the young child shivering is more effective in controlling body temperature; nonetheless, a relatively lesser body muscle mass limits the amount of heat generated. It is therefore a good idea to maintain an environmental temperature slightly warmer than the body temperature.
Exposure at or below 111 degrees F (44°C) can be tolerated for extended periods of time by infants and adults. Above this temperature, the tissue destruction increases in a logarithmic fashion causing full thickness burns. A temperature of 130°F will cause a full thickness burn in an adult in 30 s, but take just 10 s to cause full thickness burns in children.
On arrival at the ER
Questions which are to be asked to the onlookers or transport staff that have seen the incident:
- Nature of house fire, blast, flame?
- Was there an explosion?
- How long was the exposure?
- Time elapsed from injury to arrival to the ER
- ABCDEF (airway, breathing, circulation, disability, exposure, fluid)
- Depth of burn
- TBSA burnt
- Body parts involved
- Circumferential burns
A-Airway: Assess the airway in the ER. Look out for signs of respiratory tract injury in the form of altered consciousness, direct facial/oropharyngeal burns, hoarseness/stridor, soot in nostrils/sputum, expiratory rhonchi, and dysphagia. We must remember that laryngeal edema can develop rapidly; hence, one should keep a low threshold for prophylactic intubation by an experienced operator [Figure 6].
B-Breathing: Give 100% oxygen to all the patients. We have to keep in mind that the mechanisms of respiratory compromise could be circumferential burns to chest, blast injury, smoke inhalation, or the presence of carboxyhemoglobin.
C-Circulation: Intravenous (IV) access should be taken preferably via unburned skin. At the same time obtain initial investigations (group/matching, packed cell volume (PCV), urea, electrolytes, arterial blood gas (ABG) with carboxyhemoglobin (COHb)). Also check extremity perfusion. Keep in mind that edema can have a tourniquet effect.
D-Disability: Assess neurological disability by the GCS (Glasgow Coma Scale). The child may be confused due to hypoxia or hypovolemia. If it is an old burn, the child may be septic [Figure 7].
E-Exposure: Examine the entire patient (including the back) and assess the burn area. At this time identify all other associated injuries. One can take photographs at this time. As we are exposing the child to do this examination, keep in mind that the child can develop hypothermia, hence one may have to use a warm blanket [Figure 8].
F-Fluid: To be calculated according to the TBSA burnt.
Parkland's formula is used. The guidelines for fluid resuscitation in the infant and child are 3-4 ml per kg per percent TBSA burn during the first 24 h. As this does not include fluids for insensible losses or other maintenance fluid, the requirement for maintenance fluid is to be calculated and added to the above resuscitative fluid. This maintenance fluid is to be given in the form of 0.9 Glucose Normal Saline.
The maintenance requirements are according to the weight of the child. For children ≤ 10 kg give at rate of 4 ml/kg/h. For children 10-20 kg give 4 ml/kg/h for the first 10 kg and add 2 ml/kg for each kg over 10.
Problems with fluids
Parkland formula sometimes results in over resuscitation. There is also the risk of compartment syndrome due to this over resuscitation. Hence, it is essential to catheterize and actively titrate the fluid therapy. One should target for a urine output of 1 ml/kg/h in children. The fluids should be reduced when urine output increases.
Extent of injury
The extent of injury depends on age, body surface involvement, and the depth of burn. Measurement of body surface using the Rule of Nine can be done even in children - at the age of one the head and neck represent 18% of body surface rather than 9% and this 9% can be decreased equally from each lower extremity (minus 4.5 from each lower extremity) which will now represent 14.5% body surface area as compared to the adult's 18%. With each year of increasing age minus 1% from the head face neck (HFN) and add 0.5% each to each lower limb till age of 10.
Look out for circumferential full thickness burns of the limbs as escharotomy becomes as emergency procedure in these patients. The same is true for circumferential burns of the chest and abdomen or even burns of chest involving only anterior chest but crossing anterior axillary fold bilaterally. Escharotomy is required in all these instances [Figure 9].
Initial wound therapy
Wash wound with soap and clean water. Remove the dead skin, debride the bullae/blisters, and cover with cling film or dress with sterile gauze.
Check the tetanus toxoid status.
Antibiotics: Initially the wound is sterile; hence, there is no need for systemic antibiotics (unless it is an old, infected wound). Topical antibiotics can be used as per the burn surgeon's instructions
Analgesia: First and second degree burns are extremely painful. IV or oral analgesia is essentially required. Third degree burns are not painful, but must be sedated well.
| Specific Principles of Management of Special Types of Burns|| |
Scalds and flame burns
- Remove burn clothing and tags of skin.
- Place on a clean sheet and cover with another sheet after wet sponging.
- Prevention of further damage by causing cooling by pouring cool water, but do not put water on the face, as the child may aspirate. Use warm water judiciously.
- Be careful about hypothermia in children.
- Apply closed or open dressing with topical antimicrobial cream as directed by the surgeon.
- Use of biological dressing is again the choice of the surgeon.
- Pain management is important.
- Bulky dressings are applied over circumferential burns.
Electrical burns presents unique challenges. One needs to understand:
- How to differentiate from thermal injuries?
- Which injury requires electrocardiogram (ECG) monitoring?
- Which patients are at acute risk of compartment syndrome?
- Fluid Resuscitation - must maintain urinary output, double the goal rate, if myohemoglobinuria is suspected.
- Wound care - liberal excision of necrotic tissue.
- Occurs due to acid, alkali, organic substances, and/or pesticides
- Damage depends on the concentration of the offending agent and duration of contact
- No neutralizers to be used for fear of direct tissue destruction
- Liberal irrigation with water
- Not to dip in bath tub
- Early excision of dead tissue and grafting.
When to suspect abuse
- Absence of splash marks
- Stocking glove distribution
- Sharply demarcated burns
- Burns on soles, palms, and cigarette ash burns
- Frequently changing history
- Stated mechanism inconsistent with developmental age.
| Some Questions|| |
What are the criteria for Admission?
- Burns > 10% TBSA in a child
- Any burn in the very young
- Any full thickness burn
- Burns of hands, feet, face, and perineum
- Circumferential burns
- Inhalation injury
- Suspicion of abuse.
When to transfer the patient to a burn center?
- All children with inhalation
- Burns over 10% deep partial thickness or deep burn
- Facial burns.
How to prepare the child for transfer to burn center?
- Two good secure IV lines
- Urinary catheter
- Nasogastric tube
- Resuscitation fluid to be started
- In extensive burns, if expert is available central line must be placed.
[Table 1] shows the 10 year data of pediatric burn admissions at Kanchi Kamakoti CHILDS Trust Hospital at Chennai from 1992 to 2012 and their details with respect to age, sex, and cause of burn. Of the total of 911 pediatric burns, 25 expired.
|Table 1: Incidence of pediatric burns at Kanchi Kamakoti CHILDS Trust Hospital 1992-2012|
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| Summary|| |
Emergency management of each pediatric burn requires an individual plan of care. Consideration must be given to the disparity between TBSA and body weight when calculating fluid replacement. Knowledge of normal physiology and its changes with age is important in planning therapy for the burnt child. It is extremely important to be aware of certain special considerations necessary to be implemented when caring for the burned pediatric patient.
| Conclusion|| |
Burns are seen often in the ER. We have to keep in mind that children with burns have a higher morbidity and mortality. It is important to provide adequate analgesia to these children as also, keep a high index of suspicion for abuse.
| Acknowledgements|| |
I'd like to acknowledge Prof. Hanumadass, Chicago; Dr. Bala Ramachandran, PICU, KKCTH, Chennai; Dr. Mary Babu, M.D., Phd.; and Dr. Mathivanan, M.S., M.Ch. for their valuable inputs.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]