Question 28

You are called to the Emergency Department to assist with the management of an 8-year-old child (25kg) with severe burns.

Initial vital signs are: blood pressure 70/30 mm/Hg; respiratory rate 35 breaths per min; heart rate 136 beats per minute, sinus rhythm; peripheral oxygen saturations are 92% on 6 L/min oxygen via a Hudson mask.

On clinical examination the child is distressed, coughing and has obvious singeing to the eyebrows. Burn assessment reveals erythema and blistering across the anterior chest, abdomen and both upper limbs. The estimated burns surface area (BSA) is 40%.

Outline your approach to assessment and management of this child.
 

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College Answer

Syllabus topic/section:
2.1.17    Paediatrics – L2.
2.1.14    Environmental Injuries and Toxicology in ICU – L1.

Aim:
The allow the candidate to demonstrate management of a paediatric trauma and detail the alterations in practice required in the critically unwell child for the first 24 hours.

Discussion:

The question explores the topic of thermal injuries and shock in an 8-year-old. Most of the information required was centred around universal principles of assessment and management of thermal injuries and shock. Candidates who provided details on the management and assessment of these core conditions AND adapted them to the paediatric patient received high marks. Most candidates used an ABCDE approach for assessment and management which is perfectly acceptable.
This is a child with shock who has suffered burns, and the good candidates highlighted the potential life- threatening injuries and treated them. They also asked sensible questions about the MIST and used this to determine immediate intubation requirement versus be prepared to intubate early.
Candidates did less well if they did not recognise and manage shock as a priority. Some candidates appeared to have a superficially short answer suggesting that they might have had insufficient time allocation to the question. Please see the previous SAQs particularly SAQ 20 discussion for tips on time management strategies.

Discussion

What appears to have been expected here is "assessment and management of thermal injuries and shock" but with a paediatric flavour.  What follows is an alphabetical assessment structure ("which is perfectly acceptable")  from the burns chapter, garnished with paediatric elements that are outlined with italics

Assessment

History: MIST:

  • Mechanism:
    • How did the burns occur (maintaining suspicion: nonaccidental injury?)
    • Enclosed space, risk of smoke, steam or carbon monoxide? These change the decision to intubate now or later
    • Corrosive exposure
  • Injuries:
    • Obvious external trauma observed by the emergency responders
  • Signs and symptoms:
    • Pain severity
  • Treatment:
    • Analgesia, fluids, sedation already administered
    • Any first aid (eg. cold water)
    • Medications, allergies, and vaccination/tetanus status

Examination and imvestigations

  1.  Look for signs of airway burns (already the eyebrows are singed) - this also determines the decision to intubate earlier rather than later
  2. Assess for features of carbon monoxide or cyanide poisoning
  3.  Hypotension, hypovolemia, adequacy of fluid resuscitation;
    • Also, problems gaining vascular access (not through the burn, unless you have no choice).
    • Other important burn patterns:
      1. Presence of circumferential burns
      2. Presence of corneal, perineal or genital burns
  4. Decreased level of consciousness, head injury, eye injury; analgesia
    • CT may be required to exclude intracranial and other injury as examination will be difficult
  5. Electrolyte disturbance: hyponatremia and hyperkalemia
  6. Exposure and assessment of total burned areas
  7. Urine output (the most important parameter to guide fluid resuscitation)
  8. Haematocrit: haemoconcentration is a sign of volume depletion
  9. Temperature: likely to be hypothermic (small mass, loss of autoregulation) 

Management

  1. Recruit airway expert and prepare for intubation, on balance of things this will likely be required because:
    • the patient probably has airway burns
    • is hypoxic and distressed
    • may have extremely high analgesic requirements in the medium term
    • Most likely will require retrieval transfer
  2. Administer 100% oxygen and ventilate to aim for normocapnia
  3. Establish secure IV access (eg. femoral CVC) and resuscitate with fluid according to the Parkland formula, guided by paediatric BSA chart
    1. ​​​​​​​​​​​​​​​​​4ml/kg/% of body surface area, for first 24 hrs
    2. First half of the volume given over the first 8 hours
  4. Adequate analgesia and sedation for the assessment and early management
  5. Correct any electrolyte abnormalities; watch for hypoglycaemia
  6. Fluid should consist of isotonic saline and albumin
  7. Insert IDC to monitor urine output
  8. monitor haematocrit with serial ABGs to watch for haemoconcentration
  9. Rewarm the patient and minimise heat/moisture loss using occlusive plastic wraps / cling film. Prophylactic antibiotics are not called for in the acute setting.
  • Disposition: this child needs transfer to a burns unit, owing to the BSA affected 
  • Circumferential burns may require escharotomy prior to transfer
  • Family need to be engaged and communication with them needs to include the possibility of death and prolonged complicated recovery

References

Young, Amber Elizabeth. "The management of severe burns in children." Current Paediatrics 14.3 (2004): 202-207.

Legrand, Matthieu, et al. "Management of severe thermal burns in the acute phase in adults and children." Anaesthesia Critical Care & Pain Medicine 39.2 (2020): 253-267.1

Yarrow, J., N. Moiemen, and S. Gulhane. "Early management of burns in children." Paediatrics and Child Health 19.11 (2009): 509-516.

Meyers, Rachel S. "Pediatric fluid and electrolyte therapy." The Journal of Pediatric Pharmacology and Therapeutics 14.4 (2009): 204-211.

Wang, Jingjing, Erdi Xu, and Yanfeng Xiao. "Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis." Pediatrics (2013): peds-2013.

Neilson, Julie, et al. "Intravenous fluids in children and young people: summary of NICE guidance." BMJ: British Medical Journal (Online) 351 (2015).

Arikan, Ayse Akcan, and Agop Citak. "Pediatric shock." Signa Vitae 3.1 (2008): 13-23.