Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke


Pediatr Health. 2008;2(6):761-775. 

In This Article

Initial Assessment and Emergency Treatment of the Pediatric Burn Patient

In general, the initial management of the burn patient should be the same as for any other trauma patient, with special attention directed to the airway, breathing, circulation (ABC) and cervical spine immobilization according to the guidelines of the American College of Surgeons Committee on Trauma and the Advanced Trauma Live Support Center.[8] The algorithms for trauma evaluation should be diligently applied to the burn patient and the primary survey begins with the ABCs and the establishment of an adequate airway.[9] However, prior to any specific treatment, the patient must be removed from the source of injury and the burning process stopped. Always suspect an inhalation injury and administer 100% oxygen by face mask. As the patient is removed from the source of injury, care must be taken that the rescuer does not become another victim.[6] All care givers should be aware of the possibility that they may be injured by contact with the patient or the patient's clothing. Universal precautions, including wearing gloves, gowns, mask and protective eyewear, should be used whenever there is likely to be contact with blood or body fluids. Burning clothing should be removed as soon as possible to prevent further injury to the patient.[10] Removing all rings, watches, jewelry and belts is critical as they retain heat and can produce a tourniquet-like effect causing vascular ischemia.[11] If water is readily available, it should be poured directly on the burned area, since early cooling can reduce the depth of the burn and reduce pain. However, cooling measures must be used with caution to avoid hypothermia with its clinical sequelae. Ice or ice packs should never be used since they may cause further injury to the skin and induce hypothermia. Initial management of chemical burns consist of removing the saturated clothing, brushing the skin if the agent is a powder and irrigation with copious amounts of water.[11] Irrigation with water should continue from the scene of the accident through the emergency evaluation in the hospital. Efforts to neutralize the chemicals are contraindicated owing to the additional generation of heat, which can contribute to further tissue damage. In addition, the rescuer must be careful not to come into contact with the chemical. Removal of the victim from contact with an electrical current is best accomplished by turning off the current and by utilizing a nonconducting device to separate the victim from the source.[11] The possibility of a spinal cord injury needs to be anticipated in patients who have been involved in an explosion or deceleration accident. Appropriate cervical and thoracolumbal spine stabilization must be accomplished by whatever means necessary, including cervical collars to keep the head immobilized until the condition can be evaluated.

Exposure to heated gases and smoke resulting from the combustion of a variety of materials results in damage to the respiratory tract. Direct heat to the upper airways results in edema formation, which may obstruct the airway. Any stridor, wheezing, hoarseness and/or tachypnea may be a sign of airway compromise. Tracheal tugging, carbonaceous sputum, soot around the patient's airway passages and singed facial or nasal hair may suggest an impending problem and requires immediate attention. As in any trauma, progression to the next step in the primary survey is delayed until a proper airway is established and maintained. Objective measurements of breathing include respiratory rate, respiratory effort, breath sounds and skin color reflect oxygenation.[9,12] A respiratory rate of less than 10 or greater than 60 is a sign of impending respiratory failure.[12] Use of accessory muscles, manifested by supraclavicular, intercostal, subcostal or sternal retractions, as well as the presence of grunting or nasal flaring, indicate increased work of breathing.[9] Auscultation of breath sounds provides a clinical determination of tidal volume. Skin color deteriorates from pink, to pale, to mottled, to blue as hypoxemia progresses.[12] These signs need to be followed throughout the primary survey to avoid respiratory failure. Impaired ventilation and poor oxygenation may be due to smoke inhalation or carbon monoxide intoxication. A total of 100% humidified oxygen administered using a face mask should be given initially to all patients; even no obvious signs of respiratory distress are present. Children with probable respiratory failure should receive aggressive, rapid and definitive airway management. Oral intubation with the largest appropriate endotracheal tube and nasal intubation represent the preferred method for obtaining airway access and should be accomplished early and by the most experienced clinician if impending respiratory failure or ventilatory obstruction is anticipated.[9]

Cardiac assessment in the burned child begins with the assessment of peripheral, followed by the central pulses. Vital signs may be difficult to obtain in the burned victim, especially since burned extremities may impede the ability to obtain a blood pressure reading by a sphygmomanometer (blood pressure cuff). In these situations arterial lines, particularly femoral lines, can be placed to monitor continuous blood pressure readings. To assess for adequate perfusion, the color of skin and capillary refill in nonburned sites can be utilized.

While cardiac dysfunction after severe thermal injury is a well-documented complication, persistent tachycardia postinjury, despite resuscitation efforts, should alert the medical staff to a missed injury. Intravenous access should be established using two large-bore peripheral intravenous catheters, preferably through nonburned viable tissue. If there is no nonburned tissue, then placement of intravenous catheters through burned skin is justified early postburn, when the eschar is still sterile, since delays in resuscitation carry a high mortality.[13] Peripheral, large caliber intravenous catheters provide excellent access and can actually administer greater volumes of fluid owing to a diminished resistance of the catheter secondary to a shorter length. Central venous access may be difficult to establish with the crowding of people around the torso of a newly arrived trauma victim, and also carrys a risk of pneumothorax or an inability to control bleeding from inappropriate placement. In children, it can be particularly difficult to establish intravenous access and the intraosseous route can be used emergently for fluids and medicines. An intraosseous intramedullary catheter can be placed a few fingerbreadths below the tibial tubercle and is highly effective for delivering 180-200 cm3/h of fluid, whereby establishing long-term access. The most serious complication after intraosseous catheterization represents the inadvertent administration of fluid into the muscle compartments, leading to dangerously high pressures. In older children, intraosseous catheterization is more difficult to accomplish and infusion rates are inadequate. Therefore, if required, a saphenous vein cutdown is the right approach.[14]

Since burn injury may distract the healthcare provider from recognizing a potentially lethal neurologic injury, a rapid neurological survey should be completed. The burn patient should be asked to move their extremities and a Glasgow Coma Score should be assessed to document the patient's level of consciousness. Finally, a nasogastric tube, or an orogastric tube in the intubated patient, should be inserted in all patients with major burns in order to decompress the stomach.[15] Decompression immediately following any major burn is essential to help treat the paralytic ileus often observed postburn,[16] and the trauma patient will often swallow considerable amounts of air to further distend the stomach. In addition, decompression is particularly important for patients who may be transported at high altitudes to a specialized burn center.[15] A urinary catheter should also be placed, not only to decompress the bladder, but also in order to fully evaluate the patient's response to resuscitation.

One of the most important steps is to provide adequate pain control and relieve the patient from pain and stress. Pain medications should be carefully administered to not overdose and induce adverse side effects. In addition, the amount of pain medication should be reasonable and be based on the burn size and subjective pain of the patient.[17] The dosing of pain medication should be according to pediatric guidelines.


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