In the Rapid Review series, we briefly review the key points of a clinical review paper (or three). The topic this time: pediatric burns.
Arbuthnot, M. K., & Garcia, A. V. (2019). Early resuscitation and management of severe pediatric burns. Seminars in Pediatric Surgery, 28(1), 73–78. https://doi.org/10.1053/j.sempedsurg.2019.01.013
Sheridan, R. L. (2018). Burn Care for Children. Pediatrics in Review, 39(6), 273–286. https://doi.org/10.1542/pir.2016-0179
Crombie, T., Malic, C., & TREKK Network. Bottom line recommendations for the treatment and management of pediatric thermal burns – version 1.0. Published online: February 2021. https://trekk.ca/system/assets/assets/attachments/508/original/2020-11-27-Burns_v_1.0.pdf?1613062803
This is a guest post by Punithan Thiagalingam, an MD student at the University of Toronto. He has a background in biochemistry and development of novel cancer biotechnology platforms. His areas of interest include EBM, FOAMed, emergency medicine, and working to rectify health disparities impacting marginalized patient populations.
How are burns in pediatric patients different than in adults?
- Must consider the possibility of non-accidental injuries (NAI)
- Different body shapes that affect calculation of total body surface area (%TBSA)
- Greater fluid and heat loss due to larger surface area to body mass ratio
- Increased fluid loss, oxygen, and glucose demand due to higher metabolic rate
- Deeper burns due to thinner skin
- Different fluid resuscitation thresholds and considerations
- Smaller airway increases risk of obstruction
What is the initial ED management?
Although the diagnosis of burns seems pretty straight forward, it is essential to recognize that burn patients are trauma patients and perform a complete trauma assessment. Have a high degree of suspicion for inhalational injuries, carbon monoxide, and cyanide poisoning. Anticipate impending airway compromise and consider early intubation. Primary and secondary surveys should include inspection for fractures, traumatic brain injuries, thoracic, and abdominal injuries.
First aid for burns includes cool running water for 20 minutes; never use ice as it leads to vasoconstriction and secondary tissue injury. Provide tetanus booster and/or tetanus immune globulin if indicated. Analgesia should be employed early and can include acetaminophen or ibuprofen for mild pain and fentanyl IN/IV for moderate to severe pain. Warming is important to prevent hypothermia.
Who needs to be seen at a burn center?
There are multiple considerations, including:
|Burn Type and Size||Partial thickness >10% TBSA, or full thickness|
|Nature of Burn||Electrical, chemical, circumferential, inhalational Injury|
|Burned Area||Hands, face, feet, genitalia, perineum, major joints|
|Comorbidity||Presence of disorders that complicate management or prolong recovery|
What are signs of NAI?
Non-accidental injury should be considered when the history and injury pattern do not match. Consider the child’s developmental stage, delayed presentation to care, patterned bruises, and location of bruises in your assessment.
How do you estimate %TBSA?
The severity of the burns is based on depth of the burn and %TBSA. Only partial thickness and full thickness burns are used to calculate %TBSA. However, it is important to be cautious in one’s initial estimation, because the depth of a burn cannot accurately be assessed on day one.
The Lund and Browder Chart Should be used in children, as it accounts for the development of body shape with increasing age. Alternatively, (and more simply), the palm of the patient (including fingers) can be used to estimate 1% TBSA, regardless of age.
Who needs fluid resuscitation?
Plasma loss from burned tissue causes systemic inflammatory responses that cause widespread capillary leak and massive fluid shifts. The goal of resuscitation is to maintain adequate organ and tissue perfusion while minimizing edema.
Exact numbers vary between different guidelines, but fluid resuscitation should be considered for any infant or child with greater than 10-15% TBSA. (In adolescents and adults, the threshold is generally higher, at 15-20% TBSA.)
What is “fluid creep”?
A term used to describe fluid overload. Pediatric patients are especially vulnerable to fluid overload because they have smaller intravascular volume per unit burned surface area. Use a formula to guide fluid resuscitation.
What is the role of colloids in fluid resuscitation?
Guidelines differ on whether crystalloid fluids or colloids should be used in resuscitation. Some experts suggest that the early use of colloids may reduce incidence of fluid overload by increasing oncotic pressure, decreasing capillary leakage, and the amount of crystalloid fluid required. Critics are skeptical as to whether capillary integrity in burned tissue is sufficient to influence oncotic pressure. Both the Galveston and Cincinnati formulas presented below include the use of colloid.
How much fluid is needed?
In adolescents and adults, the modified Brook formula is employed: 3mL/kg/%TBSA
Children have a larger body surface area to mass ratio and require greater volume. We use the Cincinnati Formula or Galveston Formula. There have been no direct comparisons between these two formulae. Administer ½ of the fluids over the first 8 hours and ½ over the next 16 hours.
|Crystalloid||5000mL/m2 burn + 2000ml/m2 total BSA||4mL/kg/%TBSA burn + 1500ml/m2 total BSA|
|Colloid||12.5g of 25% albumin per liter of crystalloid||12.5g of 25% albumin per liter of crystalloid|
|5% Dextrose||Add if <30kg||Add if <30kg|
*For the Cincinnati formula in younger children, fluid composition changes each 8-hour period: for the 1st 8-hour period add 50meq/L sodium bicarbonate, for the 2nd 8-hour period there is no additive, for the 3rd 8-hour period add albumin.
How do I monitor my resuscitation?
As usual, circulatory endpoints to assess serially include urinary output, peripheral perfusion, vital signs, and mental status. Urinary output can be monitored hourly, and fluids titrated appropriately. The goal is 1mL/kg/hr or 0.5mL/kg/hr for children <30kg and >30kg, respectively.
What are signs of inhalational injuries?
Suspect inhalational injuries when patients are found in enclosed fires (even one minute is clinically relevant). Other clues are facial burns, singed nasal hairs, soot in/around the airway, or display the typical symptoms of airway compromise.
What toxicologic considerations need to be made for patients with inhalational injuries?
- Carbon monoxide: Give 100% oxygen to decrease the half-life of carbon monoxide and measure CO levels by ordering a carboxyhemoglobin level from a VBG; do not rely on pulse oximeter!
- Hydrogen cyanide: Cyanide levels cannot be measured in time to be clinically useful. Suspect HCN toxicity in patients with altered mental status, metabolic acidosis, and high lactate. Administer hydroxycobalamin (CYANOKIT) or sodium thiosulfate.
To debride or not to debride?
These reviews suggest debridement to remove infected or non-healing tissue for partial and full thickness burns. This is controversial. The evidence has been reviewed on First10EM previously, showing that the practice is harmful without evidence of benefit.
Topical antimicrobial ointments with a petrolatum base can be applied to a sterile non-adherent dressing and used to cover the burn areas. Silver sulfadiazine is commonly employed but should be avoided as it impairs healing, increases the risk of infection, and requires frequent dressing changes.