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<< An Evidence-Based Approach To Pediatric Burns
ED Evaluation
The A, B, C’s Of Burn Care
As in all trauma emergencies, the primary survey is designed to be a quick evaluation and treatment of potentially life-threatening situations. Airway and breathing evaluation is especially important in burn victims with potential inhalation injury from exposure to smoke or in the presence of facial burns. Inhalation injury is a major cause of morbidity and mortality in burn victims, especially victims of house fires.32 If inhalation injury is suspected, 100% oxygen should be administered to aid in dissociating carbon monoxide from hemoglobin in order to improve oxygenation to vital tissues. Smoke inhalation can lead to both airway edema and massive pulmonary edema that may require early tracheal intubation. Facial burns, carbonaceous sputum, or singed nasal hairs may be an earlier sign that inhalation injury has occurred. (See Figure 3.) If these signs are apparent, the emergency practitioner should strongly consider tracheal intubation prior to the onset of airway obstruction, which is indicated by stridor, hoarseness, drooling, or respiratory distress.33 Other indications for early tracheal intubation include altered mental status or circumferential chest wall burns that may impede adequate chest wall movement.
Circulatory compromise is evaluated as part of the primary survey. Two large bore intravenous lines should be placed through uninjured tissue. Adequate blood flow can be compromised due to increased capillary permeability as well as constricting burn wounds. If unexplained tachycardia, decreased perfusion of the extremities, or hypotension is present, fluid resuscitation should be initiated with an isotonic crystalloid fluid such as lactated Ringer’s or normal saline solution. Detailed burn resuscitation calculations are not part of the primary survey. Specific fluid rate can be determined after the initial circulatory compromise has been corrected.34
Secondary Survey
A thorough head-to-toe examination of the patient should be performed prior to other interventions such as debridement or wound care in order to evaluate for associated injuries. Repeat vital signs including an accurate weight should be obtained. In addition to the routine trauma examination, the emergency practitioner should include the extent of burn injury in reference to depth (superficial, superficial partial-thickness, deep partial-thickness, or full thickness) as well as the TBSA involved.
Critical management decisions are based on burn size; therefore, much research has been performed trying to standardize burn measurement in reference to TBSA. There are several acceptable methods of measurement. The most commonly used methods are the Lund and Browder Chart and Wallace’s “rule of nines.”35 The Lund and Browder method was established in 1944 as a modification of the Berkow tables.36, 37 The Lund and Browder chart is based on the recognition that the relative surface area of body parts vary according to the age of the patient. Although the Lund and Browder chart is the most accurate measurement of TBSA of a burn injury, it can be time consuming and the chart may not be readily available.36 A.B. Wallace introduced the rule of nines in 1951 that divided body surface area into easily recalled ratio’s of 9%.38 However, due to the variation in relative body surface area in children, the original rule of nines is only useful in patients older than 16 years of age. Adaptations of the rule of nines have been developed for infants and children. Another method is to use the patient’s palm size to measure burn TBSA. Although the exact BSA percentage of a patient’s hand varies on sex and age, the surface area of the palmer surface of the hand including to the tips of the fingers is approximately 1% TBSA.39, 40 Using the palmer surface of the patient’s hand is a quick and easy method to determine TBSA in both small and irregular burns.41
History
In addition to the AMPLE history (allergies, medications, past medical history, last meal, events leading up to the injury) defined by the American College of Surgeons for trauma patients, certain historical questions will aid in the evaluation and management of burn victims. The history of the burned child should include a detailed mechanism of injury. Knowledge that the patient was in a confined space increases their risk of inhalation injury or carbon monoxide poisoning, as does injury from a house fire. In the case of a fire in a highly plastic environment, there is increased risk of cyanide poisoning. Blast injuries should raise concern of associated trauma, crush-like injury, or corneal abrasions. Care should be taken to correlate the patient’s injuries to the historical account of the incident. Any discordance should alarm the examiner of possible non-accidental trauma.
As in all trauma emergencies, the primary survey is designed to be a quick evaluation and treatment of potentially life-threatening situations. Airway and breathing evaluation is especially important in burn victims with potential inhalation injury from exposure to smoke or in the presence of facial burns. Inhalation injury is a major cause of morbidity and mortality in burn victims, especially victims of house fires.32 If inhalation injury is suspected, 100% oxygen should be administered to aid in dissociating carbon monoxide from hemoglobin in order to improve oxygenation to vital tissues. Smoke inhalation can lead to both airway edema and massive pulmonary edema that may require early tracheal intubation. Facial burns, carbonaceous sputum, or singed nasal hairs may be an earlier sign that inhalation injury has occurred. (See Figure 3.) If these signs are apparent, the emergency practitioner should strongly consider tracheal intubation prior to the onset of airway obstruction, which is indicated by stridor, hoarseness, drooling, or respiratory distress.33 Other indications for early tracheal intubation include altered mental status or circumferential chest wall burns that may impede adequate chest wall movement.
Circulatory compromise is evaluated as part of the primary survey. Two large bore intravenous lines should be placed through uninjured tissue. Adequate blood flow can be compromised due to increased capillary permeability as well as constricting burn wounds. If unexplained tachycardia, decreased perfusion of the extremities, or hypotension is present, fluid resuscitation should be initiated with an isotonic crystalloid fluid such as lactated Ringer’s or normal saline solution. Detailed burn resuscitation calculations are not part of the primary survey. Specific fluid rate can be determined after the initial circulatory compromise has been corrected.34
Secondary Survey
A thorough head-to-toe examination of the patient should be performed prior to other interventions such as debridement or wound care in order to evaluate for associated injuries. Repeat vital signs including an accurate weight should be obtained. In addition to the routine trauma examination, the emergency practitioner should include the extent of burn injury in reference to depth (superficial, superficial partial-thickness, deep partial-thickness, or full thickness) as well as the TBSA involved.
Critical management decisions are based on burn size; therefore, much research has been performed trying to standardize burn measurement in reference to TBSA. There are several acceptable methods of measurement. The most commonly used methods are the Lund and Browder Chart and Wallace’s “rule of nines.”35 The Lund and Browder method was established in 1944 as a modification of the Berkow tables.36, 37 The Lund and Browder chart is based on the recognition that the relative surface area of body parts vary according to the age of the patient. Although the Lund and Browder chart is the most accurate measurement of TBSA of a burn injury, it can be time consuming and the chart may not be readily available.36 A.B. Wallace introduced the rule of nines in 1951 that divided body surface area into easily recalled ratio’s of 9%.38 However, due to the variation in relative body surface area in children, the original rule of nines is only useful in patients older than 16 years of age. Adaptations of the rule of nines have been developed for infants and children. Another method is to use the patient’s palm size to measure burn TBSA. Although the exact BSA percentage of a patient’s hand varies on sex and age, the surface area of the palmer surface of the hand including to the tips of the fingers is approximately 1% TBSA.39, 40 Using the palmer surface of the patient’s hand is a quick and easy method to determine TBSA in both small and irregular burns.41
History
In addition to the AMPLE history (allergies, medications, past medical history, last meal, events leading up to the injury) defined by the American College of Surgeons for trauma patients, certain historical questions will aid in the evaluation and management of burn victims. The history of the burned child should include a detailed mechanism of injury. Knowledge that the patient was in a confined space increases their risk of inhalation injury or carbon monoxide poisoning, as does injury from a house fire. In the case of a fire in a highly plastic environment, there is increased risk of cyanide poisoning. Blast injuries should raise concern of associated trauma, crush-like injury, or corneal abrasions. Care should be taken to correlate the patient’s injuries to the historical account of the incident. Any discordance should alarm the examiner of possible non-accidental trauma.
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