Burns/Submersion/hypo and hyperthermia

Question 1

What is the most common cause of paediatric deaths in children aged 1- 4 years?

a) Congenital heart disease
b) Trauma
c) Submersion injury
d) Sepsis

Answer 1

Trauma first then submersion

Question 2

Submersion is the most common cause of preventable death, it affects (Males/females) 5:1
Children < X years of age are at greatest risk

Answer 2

• Most common cause preventable cause of death
• Males > Females (5x)
• Children < 5 years at greatest risk

Question 3

What is the most effective strategy to prevent submersion injuries in children?

a) Personal flotation device in children > 12 months
b) 4 sided fence with self-locking, self-closing gates
c) Swimming instruction to bronze level
d) Parent/caregiver CPR instruction

Answer 3

b) 4 sided fence with self-locking, self-closing gates

Question 4

Toddlers should always be within X distance of an adult, even in a bathtub
X is recommended number of adults per baby or 2 young children
Swimming programs for children < 4 years (do/do not) decrease rates of drowning

Answer 4

arm’s length
1 adult per baby and 1 adult per 2 young children
Swimming programs for children < 4 years DO NOT decrease rates of drowning

Question 5

T/F a PFD will flip someone supine

A lifejacket or PFD should be worn by all infants at least X kg

Answer 5

Life jacket can flip someone to supine, PFD will not
9kg
- Babies who cannot sit unsupported are too young to wear PFDs
- Water wings, inflatable undies, pool noodles are not safety devices

Question 6

Risk factors for drowning

Answer 6

• Leaving children unattended
• Alcohol or drug abuse (50% of adult drownings)
• Limited swimming ability
• Underlying medical conditions: Seizure disorder, toxin, prolonged QT, syncope

Question 7

T/F - Always delay removal from water until c spine precautions in place

Answer 7

Cervical Spine Immobilization
o Should not delay removal from water
o Only indicated under certain circumstances: Diving, alcohol or other substances, trauma

Question 8

ABCs - submersion specific interventions

Answer 8

o Use an AED if possible but dry victim first
o Discontinue resuscitative efforts only after temp 35C
Avoid abdominal thrusts if possible

Question 9

Investigations for submersion injuries

Answer 9

• Early arterial blood gas to assess degree of hypoxemia
• Electrolytes, urea, creatinine
• CXR to look for signs of ARDs
• ECG
• Ethanol level
• Core temperature

Question 10

A 14-year-old male is pulled from an icy lake after being found face down. What is the most important strategy influencing survival?

a) Immediate c-spine immobilization
b) Immediate CPR by rescuers
c) Passive external rewarming, EMS activation, and transport to health care facility for core rewarming
d) Early placement of a definitive airway

Answer 10

b) Immediate CPR by rescuers

Question 11

Prognostic Factors in Submersion

Answer 11

• Immediate bystander CPR is most important factor influencing survival
o Return of spontaneous circulation in < 10 min
o Submersion < 5 min
o Pupils equal and reactive at scene
o Normal sinus rhythm at scene

• What are poor prognostic indicators?
o Delayed CPR
o Return of spontaneous circulation > 25 min
o Submersion > 10 min

Question 12

Complications in Submersion

Answer 12

Complications
•	ARDS
•	Pulmonary edema
•	Pneumonia
•	Cerebral edema leading to increased ICP
•	Trauma
•	Hypothermia

Question 13

• Defined as core temp < X
• Can occur in water as warm as X
• Shivering stops at core temp < X

Answer 13

• Defined as core temp < 35C
• Can occur in water as warm as 21C
• Shivering stops at core temp < 32C

Question 14

Complications

Answer 14

Hypoglycemia, hypocalcemia, hypokalemia, metabolic acidosis

Associated with pancreatitis

Question 15

Findings:
o 31-32 C
o 28-31 C
o < 28 C

Answer 15

o 31-32 C - Normal ECG, ↑ HR, ↑ BP, loss of shivering
o 28-31 C - ↓ HR, ↓ BP, flipped T, atrial fibrillation, sluggish, dilated pupils
o < 28 C - absent pulse and BP, VF, coma, fixed dilated pupils

Question 16

ECG findings in hypothermia:

Answer 16

•	Marked sinus bradycardia
•	First degree AV block
•	Osborn or J waves
•	Associated with prolonged QT and bradycardia
Seen in core T < 32

Question 17

Principles of Rewarming

Answer 17

• Correct hypoglycemia. Tolerate hyperglycemia
• Acidosis is corrected as patient is rewarmed
• Watch for coagulopathy → Fresh frozen plasma
• IVF warmed to 43C
• Expect hypovolemia with rewarming (peripheral vasodilation)
• Avoid CPR in T < 28 and good pulse
• If pulseless → CPR
• If VF → defibrillation x 3 but no more until T > 30
• Drugs rarely effective until T > 30
• Can trigger dysrhythmia if T < 30 just by bumping bed!

Question 18

Rewarming with a Pulse
• If 34-36C
• If 30-34C
• If <30C

Answer 18

Rewarming with a Pulse
• If 34-36C: Passive rewarming – remove wet clothes, dry
• If 30-34C: Passive and active external warming of truncal areas only - electric blanket, overhead warmer, hot water bottles, heating pads; Minimizes “after-drop” or shock associated with peripheral vasodilation
• If <30C: Active external and internal rewarming
o Warmed IV or intraosseous (IO) fluid (without K+) at 43 C
o Warm humidified oxygen at 42-46 C
o Peritoneal lavage, ECMO, esophageal warming tubes
o Do not delay advanced airway placement

Question 19

Rewarming without a Pulse

• T ≥ 30C
• T < 30C

Answer 19

Rewarming without a Pulse
• CPR and warming with cardiopulmonary bypass
• Defibrillate all cases of pulseless VT or VF to max of 3 shocks if T < 30C
• Gentle endotracheal intubation
• Warm, humidified O2, warm IVF
• T ≥ 30C: Continue CPR, IV meds as needed, defibrillation as needed
• T < 30C: Continue CPR but no IV meds, limit defibrillation to 3 shocks

Question 20

A 5-year-old male is pulled from a lake and presents to the ED apneic and pulseless in PEA. His core temp is 29C. The most reasonable course of action is?

a) BVM, CPR and IV epinephrine 1:10 000
b) BVM, CPR and IV bretylium
c) RSI, CPR and active external and internal rewarming
d) RSI, CPR and defibrillation to a maximum of 3 shocks

Answer 20

c) RSI, CPR and active external and internal rewarming

Question 21

ED treatment of frostbite

Answer 21

• En route avoid warming if significant time to ER

* In ER, 42C water bath, do not rub, keep rewarmed areas open, dry, and sterile