Pediatric emergency medicine trisk 806

importance not to neglect the possibility of other injuries from the burn mechanism, or associated injuries, which may also require emergent treatment and stabilization Finally, patients with ocular area burns will need specialized ophthalmology consultation for evaluation of corneal involvement Management Airway The inhalation of hot gases can burn the upper airway, leading to progressive edema and airway obstruction Children with burns of the face, singed facial hairs, or hoarseness are at high risk, but airway burns can also occur in the absence of these signs Edema of the burned airway will worsen over the first 24 to 48 hours Knowledge of the time course of airway swelling justifies endotracheal intubation for subtle signs of airway compromise that occur shortly after the injury Early intubation may circumvent a difficult intubation later in the course of a child with severe pharyngeal and airway edema Endotracheal tubes of smaller diameter than expected for age should be available in anticipation of a narrowed airway Cuffed tubes are preferred to accommodate the potential for changing airway edema over the course of the recovery Children who have jumped or fallen in house fires, been burned in motor vehicle accidents, or been burned by explosions are at risk for other traumatic injuries, and cervical spine precautions should be maintained during management of their airways Furthermore, children with severe burns may have depressed levels of consciousness for many reasons and airway obstruction from the loss of pharyngeal tone is not uncommon Breathing A rapid assessment of ventilation includes respiratory effort, chest expansion, breath sounds, and color Pulse oximetry is useful, but patients with significant levels of carboxyhemoglobin will look pink and have “normal” oxygen saturation as measured by a pulse oximeter Children with severe burn injury should receive 100% supplemental oxygen Blood gases with co-oximetry should be obtained promptly Venous or arterial gases can be used, although arterial samples are preferred for hemodynamically unstable patients and to best assess degree of acidosis Inhalational injury can also cause damage to the lower airway Chest radiographs may be normal initially, even if pulmonary injury has occurred Mild inhalational injury can be treated with supplemental oxygen, and consideration of albuterol or racemic epinephrine nebulizer treatment when wheezing or stridor are present, respectively Steroids are generally not recommended for treatment of burn patients with airway injury, although a single-center study showed no increased risk with a single dose Patients should continue to be monitored closely for any deterioration in their clinical status Significant inhalational injury will require endotracheal intubation and ventilatory support Extensive full-thickness burns of the thorax may restrict expansion of the chest and impair ventilation Respiratory insufficiency in this setting is an indication for escharotomy of the chest Incision through the depth of the eschar should be performed along the anterior axillary lines to allow adequate chest expansion If the deep burns extend to the abdomen, the escharotomies should be extended downward and connected by incision along the costal margin Circulation The rapid assessment of circulation includes skin color, capillary refill time, temperature of the peripheral extremities, heart rate, and mental status Blood pressure is often maintained until late in the course of shock, making it an unreliable early measure Hypertension from increased systemic vascular resistance has been reported immediately after severe burns, particularly in pediatric patients, and should not be taken as an indication to discontinue proper fluid therapy Vascular access should be obtained soon after the arrival of the child with severe burn injury Peripheral, large-bore intravenous catheters are favored because they have the lowest resistance Catheters placed in the upper extremity through intact skin are preferred because they are easier to secure, but access through burned areas may be necessary Anticipating the need for hyperalimentation, sites for central catheter placement should be saved, if possible Attention to aseptic technique when starting intravenous catheters in the emergency department (ED) can prevent infectious complications during subsequent care Circumferential taping is dangerous because the swelling that occurs during the first 24 hours can cause circulatory insufficiency distal to the constriction Urine output is the most important means of monitoring fluid status, but in patients with severe burns with associated inhalational injury, central venous pressure monitoring may be useful in the first few hours Major burns cause decreased splanchnic blood flow and ileus After ensuring intact airway reflexes or that the airway is protected by placement of an endotracheal tube, the clinician should consider placing a nasogastric tube Hypothermia can occur rapidly in small children, especially in those whose skin injury impairs normal thermoregulation Core temperature should be monitored and the child kept covered, except as necessary for examination and burn assessment Fluid Resuscitation An initial bolus of 20 mL/kg of normal saline or Ringer lactate solution is recommended while assessment of the extent of the burns takes place Fluid volume from all initial boluses including prehospital care should be counted when calculating fluid volumes during the first 24 hours of treatment A urinary catheter should be placed early in the management because there may be several hours of monitoring during transport or in the ED during which urine production can provide clinicians with information about fluid status Rapid treatment of the hypovolemia that occurs early in children with severe thermal injuries is of prime importance The fluid status of children with burn injury is a dynamic process that requires careful reevaluation and therapeutic adjustments Extravasation of water, sodium, and protein through abnormally permeable capillaries continues for about 24 hours after injury Capillary integrity then improves and intravascular volume stabilizes Isotonic crystalloid solutions are recommended in the resuscitation phase Potassium is released from damaged cells and measured serum levels may be elevated shortly after injury; therefore, potassium replacement is not recommended during the early phase of fluid therapy Several formulas for the calculation of initial fluid therapy exist ( Table 104.2 ) The Parkland formula recommends mL/kg/% of BSA of crystalloid over the first 24 hours, half during the first hours from the time of injury and half during the next 16 hours This formula often underestimates the fluid needs of young children, who are also at greater risk for hypoglycemia Maintenance requirements using isotonic solutions with 5% dextrose are added for patients with burns who are younger than years The Galveston Shriners formula uses BSA rather than weight to calculate fluid therapy Galveston Shriners recommends 5,000 mL/m2/% of BSA, half during the first hours from the time of injury and half during the next 16 hours, plus 2,000 mL/m2/day as maintenance TABLE 104.2 FLUID RESUSCITATION FORMULAS Parkland: mL/kg/% of BSA second- and third-degree burns, half in the first hrs following injury, half in the next 16 hrs Add maintenance with 5% dextrose containing fluid in children