Child with Trauma / Burns

Question 1

Relevant history for trauma?

Answer 1

• MIST
  
  • Mechanism
  • Injury/illness
  • Signs/symptoms
  • Treatment
• AMPLE
  
  • Allergies
  • Medications
  • Past medical history/ Pregnancy
  • Last meal
  • Events/ Environment
• Events and Environment
  
  • Timing
  • Nature of the forces involved
  • Protective and safety apparatus

Question 2

Relevant examinations and investigations?

Answer 2

• Primary survey
  
  • Airway with cervical spine control
  • Breathing and ventilation
  • Circulation with haemorrhage control
  • Disability and neurological assessment
  • Exposure with Environmental control
• Head to toe
• Fingers or instrument in every opening
• Assume injury present until excluded by clinical examination or investigation
• Bloods
• X-rays
  
  • Lateral cervical spine
  • Chest
  • Pelvis

Question 3

What are some anatomical differences between a baby/child and adult?

Answer 3

Question 4

What is available to manage the airway?

Answer 4

• Basic airway manoeuvres
  
  • Chin lift
  • Jaw thrust
• Oral and nasopharyngeal airways
• Intubation
• Surgical airway

Question 5

When being suspicious of airway injuries, what should you be looking for?

Answer 5

• Fall onto sharp object
• Running/riding into wires
• Penetrating neck injury
• Facial burns
• Burns resuscitation

Question 6

What are some signs of airway obstruction?

Answer 6

• Injury to face, neck, mandible
• Swelling of tongue, pharynx, mouth
• Restlessness
• Cyanosis
• Accessory muscles
• Wheeze, stridor, dysphonia
• Respiratory distress
• Low saturations

Question 7

How would you investigate suspected cervical spine injuries?

Answer 7

• Rare in children
  
  • Serious consequences if missed
• Assume present
  
  • Collar
  • Sandbags and tape
• Beware distracting injury
• Cervical spine series
  
  • Lateral C spine
  • AP C spine
  • Odontoid peg views
• Swimmers view
• CT
• MRI

Question 8

What are the differences when assessing breathing in children compared to adults?

Answer 8

• Anatomical differences
  
  • Horizontal ribs
  • Diaphragmatic breathers
  • Fewer Type I fibres
  • Small airways
• Respiratory rate more rapid than adult
• Tidal volume proportionally the same

Question 9

What do you check for in Breathing in the context of trauma?

Answer 9

• Airway obstruction/injury
• Chest injury
• Head injury
• Aspiration
• Burns
• Shock/acidosis

Question 10

How do you manage impaired breathing in the context of trauma?

Answer 10

• Airway secure
• If ventilated, aim:
  
  • Respiratory rate 20 to 30 breaths per minute
  • Tidal volume 7-10 mL per kg
• Treat problems as identified

Question 11

Describe management of circulation in the context of trauma

Answer 11

• Information
  
  • Circulating volume 80 mls/kg
  • Infant has small stroke volume, thus has high heart rate
  • Blood pressure varies with age
• Management
  
  • Control haemorrhage
  • Vascular access
    
    • Percutaneous
    • Cut-down
    • Intra-osseous

Question 12

How do you assess and manage Disability in the context of trauma?

Answer 12

• Assessment
  
  • More difficult to assess in children as:
    
    • May not be able to communicate
    • Behaviour may regress because of stressful situation
  • Paediatric GCS - Best verbal response
    
    • 5 Coos and babbles
    • 4 Irritable cry
    • 3 Cries to pain
    • 2 Moans to pain
    • 1 No response
• Management
  
  • Optimise ABCs
  • Discuss further investigations and management with neurosurgeon

Question 13

How do you assess and manage Exposure and Environment?

Answer 13

• Assess
  
  • Head to toe examination of whole body
  • Common sites to miss injuries:
    
    • Scalp
    • Neck
    • Hands
    • Back and perineum
  • Large surface area to body ratio
    
    • Risk of hypothermia
• Management
  
  • Warm the patient
    
    • Overhead heater
    • Warm blanket
    • Warm fluids
  • Can remove collar to examine neck with immobilisation
  • Log-roll patient
  • Analgesia
    
    • Caregiver or good nurse with an explanation
    • Local anaesthetic blocks
    • Morphine - analgesic and anxiolytic
      
      • Titrate small doses IV as a bolus
  • Multitrauma the rule
    
    • Thorough secondary survey
    • Repeat as tertiary survey the next day
  • Growing and developing
    
    • Long-term review required
    • Optimal management to avoid morbidity
  • Beware non-accidental injury
    
    • Inconsistent history which varies
    • Delayed presentation
    • Physical signs of abuse and neglect

Question 14

What are some causes of burns in children?

Answer 14

• 50% Scald
• 30% Contact/Friction
• 15% Flame
• 2% Electrical
• 2% Chemical
• 1% Sun

Question 15

How long does it take to cause full thickness burns with hot water at:

• 60C
• 55C
• 50C

Answer 15

• The average temperature of domestic hot water is 70C.
• At 60C it takes one second for hot water to cause full thickness burn
• At 55C it takes 10 seconds
• At 50C it takes five minutes.

Question 16

What is the response to burn injuries?

Answer 16

• Proportional to % TBSA Burn and Depth
• Local response (TBSA <10%)
  
  • Tissue injury and oedema
    
    • At site of burn
• Generalised systemic response (TBSA >10%)
  
  • Tissue injury Plus
  • Systemic inflammatory response (SIRS)

Question 17

In systemic inflammatory response (SIRS), what are the effects of inflammatory mediators?

Answer 17

• Inflammatory mediators are produced locally in minor burns (<10%) and act systemically in a major burns (>10%).
• Inflammatory mediators cause
  
  • Increased microvascular permeability which results in: local production of oedema at the burn site, generalised loss of intra vascular water and electrolytes development of shock
  • Increase in body temperature
  • Inhibition of immune response
  • Pulmonary oedema + ARDS
  • Paralytic ileus + gastric erosions
  • Hypermetabolism - Increase in calorie requirement - 50% increase in 25% burn,100% increase in 40% burns

Question 18

How do you prevent SIRS in burns?

Answer 18

• Stabilisation of burn wound
• Cerium Nitrate (inhibitory effect on LPC)
• Immediate Surgical excision of all burnt tissue and wound closure.

Question 19

What are the effects of SIRS on the airway?

Answer 19

• Upper Airway swelling
  
  • Direct heat- rare
  • Scalds or flame burns of the anterior neck cause secondary soft tissue swelling which compresses the airway.
  • Children are particularly vulnerable and may require intubation.
• Lower Airway
  
  • Smoke inhalation causes toxic damage to the bronchial tree chemical burn of the airway and to alveoli
  • ARDS pulmonary oedema + interstitial inflammation
• Systemic intoxication
  
  • CO
  • HCN

Question 20

What are the effects of SIRS on circulation?

Answer 20

• Loss of fluid form the circulation
  
  • Hypovolemic shock
• Circumferential burns
  
  • Limbs
    
    • cause constriction and distal ischaemia
    • Elevate
    • assess peripheral circulation
  • Torso – consider respiratory compromise from restriction of thoracic and abdominal excursion
    
    • Consider escharotomy if no improvement

Question 21

How do you treat an asymptomatic child with a scald to the anterior neck?

• (a) May develop upper airway obstruction?
• (b) May need intubation?
• (c) Requires referral to a Burns Unit?

Answer 21

• First Aid
  
  • Give at scene or after Primary Survey
  • Remove clothes - Cool the burn
  • Running water from cold tap Immerse in River/Sea/Pool
  • Avoid hypothermia
• Assessment of the burnt patient: Primary Survey
  
  • Airway (Cervical Spine control)
  • Breathing
  • Circulation
  • Disability (Neurological Assessment)
  • Environment (Expose and assess area of burn)
  • Fluid (Calculate using modified formula)
• Assessment of the burn
  
  • Body surface area of burns % TBSA (with Wallace Rule of Nines)
  • Depth exclude superficial burns (erythema) from calculation
  • Circumferential - Limbs / torso
  • Compartment syndrome (Limbs in electrical abdominal in all major burns)
• Resuscitation
  
  • Intravenous
  • Intraosseous
  • Oral
  • Begin as soon as possible and calculate amount from the time of the burn

Question 22

Describe the Wallace Rule of Nines (TBSA for burns)

Answer 22

Question 23

How do you calculate fluid resuscitation for burns?

Answer 23

• 2 large bore cannulae non burnt skin
• Modified Parkland Formula
• 3mL x kg x % burn in the first 24 hours calculated from the time of the burn (Hartman’s solution or Normal Saline)
  
  • 1/2 in first 8hrs, next 1/2 in 16 hrs (+ maintenance)
  • Adjust volume to maintain urine output of 1 mls / kg / hr
• • Maintenance in Children (N Saline + 5% dextrose)
    
    • 100 mls/kg up to 10kg.
    • 50 mls/kg up to 20 kg
    • 20 mls/kg >20 kg

Question 24

What causes haemochromogenuria and how do you manage?

Answer 24

• Haemochromogenuria - dark red, black urine. Caused by
  
  • High Voltage electrical Injury
  • Extensive deep burn
  • Crush injury
• Myoglobinuria
  
  • Haemoglobin and myoglobin are excreted into the urine
• Management
  
  • Increase fluid volume to double urine output
  • If necessary add Mannitol

Question 25

Describe the depth of burn classification

Answer 25

• Erythema: Epidermis intact no blisters
• Superficial Dermal: Regeneration from intact basal epidermal layer
• Mid Dermal: Regeneration from epidermal appendages hair follicles sebaceous and sweat glands
• Deep Dermal: Destruction of dermal capillary plexus
• Deep: White/ charred/ waxy.

Question 26

What factors do you consider when assessing the depth of burns?

Answer 26

• Mechanism of injury
• Length of exposure
• Temperature of heat source
• Colour
• Pain
• Blistering
• Capillary return, hair follicles
• Appearance changes with progression from superficial to deep
  
  • Erythema
  • Blistering may be delayed look- for Nikolski’s sign
  • Pink, blanching
  • Red, non-blanching
  • Leathery or charred.
• Early appearances are deceptive

Question 27

Describe erythema burn

Answer 27

• Surface of skin red but not broken
• Caused by flash flame injury, sunburn, or scald injury
• No intervention required
• Apply moisturiser regularly.

Question 28

Describe superficial dermal burns

Answer 28

• Blister, Redness, Moist, Painful, Oedema
• Re-epithelialisation within 14 days with minimal to no scarring

Question 29

Describe the treatment for different depths of burns

Answer 29

• Superficial: Moisturise
• Superficial dermal: Burns dressing, Expect healing <10 days
• Mid dermal: Burns dressing, Expect healing 14-21 days
• Deep dermal: Skin graft
• Full thickness: Immediate Skin graft

Question 30

What are the principles of burns dressings?

Answer 30

• Provide an optimal environment for wound healing and reepithelialisation
• Provide an antimicrobial environment
  
  • Silver dressings
• Minimise frequency of dressings changes
  
  • Long acting silver dressings ( Acticoat.Mepilex Ag)
• Early determination of depth
  
  • Laser Doppler
• Minimise pain
  
  • Prepare -Use Distraction therapy
  • Analgesia- Opiates /N20/ Intra nasal fentanyl
  • Presence of an Anaesthetist useful

Question 31

What are the principles of wound closure?

Answer 31

• Autografts
  
  • When donor sites are available try to graft early if burns are not healing <14 days
  • Grafts may be meshed if donor skin is limited.
• Lack of donor sites in a major burn may require :
  
  • Temporary skin substitutes
  • 1 Bioengineered dressings
    
    • Biobrane/ BTM ( Biodegradable Temporising Maitrix)
  • 2 Allograft
    
    • Cadaveric skin
    • Fresh in nutrient media (1 week)
    • Cryopreserved –196 degrees C (1 year)
  • Cultured epithelial autografts (CEA)
    
    • Suspension (10^6 cells/sq. cm.-1 week)
    • Sheets (10/10 cm. 3weeks)
  • Bioengineered Dermal templates
    
    • Integra

Question 32

List multidisciplinary management for burns

Answer 32