Pediatric Burns

Hi, I'm Doctor Pramod Pulliantla, pediatric surgeon and pediatric intensivist at the Montreal Children's Hospital. Today, we're gonna talk about the essentials of pediatric burns. Burns, one of the most common causes of pediatric injury, resulting in over 300 visits and 2 deaths per day. The mechanism, hot liquids or steam in younger children, and fire in older children. But as you're well aware, management of these patients is complex. Let's start like we typically do with a clinical scenario. An 8 year old male is found at a nearby campsite and brought to your ER where he's found to have a 25% total body surface area burn. What are your criteria for transferring him to a burn center? So, certainly the patient that you described in the scenario needs to be transferred. But in general, we accept patients who have burns of more than 5% of their total body surface area, particularly if they involve the face, the hands, feet, genitalia, perineum, or major joints. Electrical burns, chemical burns, and inhalational injury, those definitely should be transferred. And certainly, those patients who have significant circumferential burns should also be. Sometimes, depending on the level of care that is available, those patients with complex medical histories or pre-existing medical disorders may also need to be transferred. And I think most importantly, that if you suspect in any way, shape or form that this is part of, uh, non-accidental trauma, then that patient should definitely be transferred to a tertiary care center where they can provide the appropriate care to that patient. And if you work at a burn center, what are your criteria for admitting a patient? Yeah, so we're a little more, I guess, conservative or liberal, but perhaps that's maybe the better way to say it. Any infant under the age of 1 or a total body surface area burn of greater than 8%. Any 2nd degree burn greater than 10% or any 3rd degree burn greater than 5% would be indications for admission. Certainly burns to the face, eyes, ears, hands, genitalia, as I mentioned previously, would be important, as well as in the context of poly trauma, an electrical or a chemical burn, or significant comorbidities or inhalational injury. So there is quite a bit of overlap, but certainly the very small infants, uh, we tend to admit them. OK, so assume you don't work at a burn center. What are you going to do for this patient before you transfer them? The first thing is certainly to provide the patient with some adequate pain control cause this can be a significant source of pain, uh, for the patient. And then I would generally just apply some silver sulfadiazine and wrap the wounds, uh, lightly with gauze. Sometimes I might add a little bit of Bact degras so that the gauze does not stick to the wound. And I just may also make sure that when I'm transferring patients that I can rapidly and repeatedly assess for distal profusion of the feet and the toes and the hands and the fingers because this is really important. We don't want to have a very tight bandage that is compromising an already compromised limb. When you first start taking care of a burn patient, you always have to keep in mind fluid resuscitation. How would you go about determining what fluids or what rate to give? It's important to state that those patients who have smaller burns can actually be treated with oral rehydration therapy. They don't necessarily have to receive intravenous fluids. In our center, patients with greater than 10% total body surface area burns or teenagers with greater than 15% total body surface area burns are those that we do initiate in resuscitation. With respect to the type of formula that you use, it's all predicated on the accurate determination or estimation of the burned surface area. And in this context, the London Browder chart is probably the best chart to use because it takes into account the body shape variations in children, and it actually provides a much more accurate estimation of the, of the body surface area. If you don't have access to that or not familiar with it, you can always use the palm of the patient as an estimate of 1% body surface area burn. With respect to the Parkland formula, if you were to use that, it should be Ringer's lactate solution at 3 ccs per kilo per percentage body surface area burn. But I tend to use either the Cincinnati formula or the Galveston formula. Because these are much more uh pediatric specific. The big question is, well, when do I add dextrose containing solutions? We tend to add dextrose for any patient who is under 30 kg, and we provide that as maintenance fluids. So the resuscitation is above that. I think the other reason why I really like the Cincinnati and Galveston formulas is because within that protocol, you actually have recommendations or provisos for the use of colloids. Now, colloid. Uh, use has been very controversial in the past, but now I think it's becoming more accepted. Giving colloid has been in a, actually, uh, a prospective study by Dietrich to show that there is statistically less fluid use overall, shorter lengths of stay, and a reduced incidence of fluid creep. What is fluid creep and how do you treat it? So fluid creep is basically the general phenomenon of giving too much fluid and not taking into account the fluid that has been given, such as previous boluss or miscalculating the total volume. The other issues with fluid creep are not just related to the uh local wound issues, but But certainly, fluid overload can lead to respiratory compromise, making this patient very difficult to ventilate and all of the other morbidities that are associated with that. So, I think that if you've adequately fluid resuscitated the patient, then you can proceed with diuresis in a controlled fashion and potentially add some colloid as well in order to get rid of excess fluid. When do you place a foley in a burn patient? Yeah, I think a Foley is a clinical decision. Certainly for those patients with extensive burns or in the context of multiple trauma or in those patients who have electrical burns where they may have uh rhabdomyolysis, I certainly put in a Foley catheter. If they are small burns just to perhaps a hand and you're just admitting them because you're worried about the functionality of that hand, they don't probably don't need a Foley catheter, and you can accurately assess urine output based on just collecting urine or weighing diapers or, or, or whatever. Do antibiotics or tetanus play a role in the initial resuscitation of a burn patient? Certainly, all patients should get at least a tetanus booster if their vaccination card is not available. Um, there's no harm in that. It's probably a very, very good idea. I personally do not give antibiotics until I have a proven infection. I think, in fact, leads to the, uh, development of resistant or uh infection with resistant organisms. So I do not give antibiotics at the outset. When should we be checking carbon monoxide levels? All right. So, carbon monoxide, I think in any patient where you suspect that there was a closed space fire or an inhalational injury, these are the patients that need to be checked. And it's easy enough to check this on a blood gas, uh, with cooximetry where you actually can measure the oxyhemoglobin. The classic presentation of the patient with carbon monoxide poisoning is not intuitive because you have to actually look at the blood gas in order to determine that because their saturation on your transcutaneous monitor, uh, will be normal because all of their hemoglobin is saturated with oxygen. But these patients will present with a low PAO2, and therefore, that's how you will make that clinical connection. But again, any patient who is in a closed space or, or a fire, they should be treated as if they have carbon dioxide poisoning. How should you manage suspected inhalation injury? I think the attention to inhalational injury is critical, and that if you believe that the patient has had incurred an inhalational injury, these patients need to be intubated very quickly because once the edema sets in, it's extremely difficult to intubate these patients sometimes. Second of all, once you've intubated these patients with inhalational injury, they very likely require a bronchoscopy. The bronchoscopy is useful because it allows you to assess the extent of the airway injury, but it can also be very valuable for pulmonary toilet, because often these patients will shed mucosa and have casts in their airways that could then lead to further ventilatory issues. And the last thing as well is that in the trauma bay, We talked about the clinical scenario of carbon monoxide where you have a normal saturation, but your PAO2 is low. But the other thing that you have to be acutely aware of is that if a patient is desaturating and you don't have good chest rise, and they do have chest burns, you need to be very vigilant with respect to whether or not you need to do an esterotomy. A chest escheotomy, which would be incisions in the anterior axillary lines bilaterally and then with a sort of an oblique, sort of chevron type of incision that meets those two lateral incisions down to good tissue so that you are actually able to get good chest rise. How often do you reassess the burn for progression? So I think what's the most important aspect here is that burns do evolve over time and therefore, what may look initially as a superficial burn may actually turn into something that is 2 degree or, or, or partial second degree, which would then require more therapy or definitive surgical debridement and grafting. So my, my personal take on this is that wounds uh Should be dressed at least daily. So I actually will reassess wounds every 24 hours for the 1st 48 hours. Usually during this period of time, we have continued with resuscitation, the patient is a bit more stable, and then I have a much better idea of what would be my initial uh targets in terms of debridement and what areas would need to be grafted. I think this is generally a pretty safe way to go. How long do you wait before taking the patient to the operating room for debridement? I think that if you wanted to, and if it was fairly superficial burns, you could do a very quick debridement right away because these patients are unlikely to require a tremendous amount of resuscitation. And those patients can be even treated as a, on an outpatient basis with a longer-acting uh dressing that contains silver that could perhaps be changed in a week's time in the outpatient clinic. Uh, one of the things that's most important, however, is that you have to make sure that you've reached your resuscitation endpoints before you consider doing a surgical procedure. The endpoints that should be used is generally urine output, and that's where the Foley catheter comes into play. So, in young children who are less than 30 kg, it should be 1 cc per kilo per hour of urine output as a clinical goal. And if they're over 30 kg, then you could accept 0.5 cc's per kilo per hour for urine output. So if you are in that stable period, and again, just to reiterate that you've given half of the fluid that you've calculated using your Galveston or Cincinnati formula in the 1st 8 hours and the next amount in 16 hours, and you're hemodynamically stable, that is when I would often take the patient uh to the operating room for initial evaluation and debridement of the wounds. And then we can decide what the extent of the wounds are and then plan likely for grafting at that point. Now that we've talked about the essentials of burns, what do you think are the key clinical points in pediatric burn management? Here are the highlights we hope you just thought of or wrote down. Get an accurate assessment of the extent of the burn. Use an appropriate resuscitation algorithm. Remember the need for dextrose containing maintenance fluids in children less than 30 kg. Don't give too much fluid as it will set back your ability to definitively treat the wounds. Use clear clinical endpoints to guide resuscitation, debride and graft early, once the patient is hemodynamically stable. And that's our summary of Burn. Let us know what you thought, what you liked, what you didn't, what worked for you, and what you'd like to see in the future. This video cast was created by Ray Hinkey, Zach Korb, Todd Ponsky, and the rest of the state current crew.