You have been asked to review  a three year old child who was trapped  in a house fire and is now in the Paediatric  Emergency  Department.  There is no history  available  from  the  child’s  carer  and  you  observe  that  the  child  is drowsy and confused and has a persistent cough. His heart rate is 140 beats per minute,  blood  pressure  70/40  mmHg.  Respiratory  rate is 54 breaths  per minute and oxygen saturations are 94 % on high flow oxygen via a non re- breather mask.

a.   Briefly outline the initial priorities in management.

b.  List the features from the history and your examination of this child which would suggest a significant airway injury.

c.   List 4 likely causes for his altered conscious state.

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College Answer

a.   Briefly outline the initial priorities in management.

•    Resuscitation including primary and secondary survey
•    Assessment and management of potential airway burn injury – mention consideration of early intubation,
•    Obtain large bore iv access and administration of fluid bolus (20mls/kg) for probable hypovolaemic shock- mention that groins are usually spared in burns and are a good site for clean skin vas cath access.
•    Look for signs of traumatic injury and assess extent of body surface area and depth of burn
•    Awareness of risk of hypothermia
•    Seek collateral history for past medical history and medication history and history of acute events

b.  List the features from the history and your examination of this child which would suggest a significant airway injury.

•    Burns occurring in a closed space
•    Cough, stridor, hoarseness of voice
•    Burns to face, lips, mouth, pharynx or nasal mucosa
•    Soot in sputum, nose or mouth
•    Hypoxaemia or
•    Dyspnoea
•    Carboxyhaemoglobin  levels > 2%
•    Acute confusional state or depressed level of consciousness

c.   List 4 likely causes for his altered conscious state.

•    Traumatic brain injury
•    Carbon monoxide / CN – poisoning
•    Hypoxic insult
•    Other     pathology     precipitating     loss     of     consciousness     eg     seizure-related, hypoglycaemia, drug ingestion

Discussion

This question - though posing as a question about a paediatric patient - closely resembles Question 11 from the first paper of 2013, where the candidates were asked exactly the same series of questions about a slightly singed 64 year old male.

References

References