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Paediatric Burns- fluids and the airway

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1 Paediatric Burns- fluids and the airway
Dr FA Potter Alder Hey Hospital

2 About 6000 children admitted to hospital with thermal injuries each year
120 major burns each year A real problem but not common occurrence for any one hospital

3 Loss of Control through decreased level of consciousness
The Airway Loss of Control through decreased level of consciousness Impending closure of the airway from burn associated swelling Treatment of respiratory failure Inhalational injury ARDS Fluid resuscitation Humanitarian/Practical Considerations

4 Burn Shock - local Dead tissue Ischaemic zone
Inflammation-histamine, prostaglandin,thromboxane,NO local oedema Reactive Oxygen Species further local damage;further inflammation

5 Burn Shock –systemic 1 TNFalpha, interleukin-1,2,5,8 interferon gamma
SIRS Increased microvascular permeability Vasodilatation Decreased cardiac contractility Intravascular fluid, electrolytes,proteininterstitial Lymph vessel obstruction (platelets, leukocytes) Generalised oedema 24-48hr

6 Burn Shock –systemic 2 Loss of intravascular volume to interstitium
Increased evaporative loss through burn wound Decreased preload Decreased cardiac contractility Decreased cardiac output Decreased end organ perfusion MULTIPLE ORGAN FAILURE FLUID RESUSCITATION

7 Eggnog (& enemas) Fauntleroy 1919
What Fluid ? Eggnog (& enemas) Fauntleroy 1919 Plasma Harkins 1942 (fluid relate to area of burn) Albumin Evan’s formula 1952 1ml/kg/%burn NS +1ml/kg/%burn albumin +2000ml glucose. Second 24hr: half the saline +albumin +glucose Crystalloid Baxter & Shires 1968

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9 Estimation of Burn Area
Emergency Examination Estimation of Burn Area Burn extent Rule of Nines Lund and Browder charts Patient weight Calculation using formula EMSB (UK) 9

10 Lund & Browder Chart

11 How Much? Parkland 4ml/kg/%burn Hartmann’s solution Half over 8hr
+ maintenance Mount Vernon O.5ml/kg/%burn Plasma 6 periods 4hr 8hr 12hr 18hr 24hr 36hr post burn + maintenance

12 Albumin Meta-analysis questioning use of albumin in critically ill patients ‘ If I survived, I would attempt to sue anyone who had given me an infusion of albumin, and I would not give my informed consent to take part in a randomised trial’ Burns +others

13 75% paeds units Hartmann’s 10% use albumin, 15% both
Where are we now? RHJ Baker MA Akhavani,N Jallali. Journal of Plastic & Reconstructive Surgery 2007;60: 78% UK units use Parkland 11% Mount Vernon 11% both 75% paeds units Hartmann’s 10% use albumin, 15% both 50% do not change fluid after 24 hr

14 ‘Fluid Creep’ Tendency to give more fluid than Parkland dictates
60% patients get more [J Burn Care Rehab 2000;21:91-5] 7ml/kg/%burn [ J Burn Care Rehab 2002;23:258-65] Surviving Sepsis Campaign 2004 – Lactate, BE, central venous saturations. Pulmonary Oedema, Abdominal Compartment Syndrome

15 Back to the future? First 24 hrs 4ml LR/kg/%burn + maintenance
Second 24hrs ml plasma over 8hr + dextrose / water to maintain urine output 98% of 516 children successfully resuscitated CR Baxter. Surgical Clinics of North America 1978;58:

16 Where might we go? Haifa Formula 1.5ml/kg/%burn FFP + 1ml/kg/%burn RL
+ more RL if urine <0.5ml/kg/hr 8%mortality (80% >80%burn) Starches – if problems of coagulation solved

17 Inhalational Injury Direct Burn – actual thermal injury supraglottic ;unless steam involved Inhaled Gases- aldehydes,NO, NO2, SO2, PVC, CO Inhaled Particulates ALI From SIRS From Fluid Overload

18 Carbon Monoxide CO affinity for Hb 200x that of oxygen
Moves oxyhaemoglobin dissociation curve to left 10-30% headache 50% coma 70% fatal Half-life 4hr (air) 30-60min (high O2) Low CO often underestimates degree of injury

19 Inhalational injury Oedema of tracheobronchial mucosa
Separation of epithelium Bronchial casts Parenchyma-congestion, oedema ,neutrophil Infiltration, hyaline membranes Bronchoscopy- diagnosis removal casts Xenon scanning CXR infiltrates over 5-10days

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22 TL Palmieri, P Warner et al. Journal of Burn Care & Research
850 children 4 tertiary US centres over 10yr 603 bronchoscopic findings 216 clinical findings 31 CO elevation 710 survivors 140 non-survivors TBSA burn 45% TBSA burn 70% Cause of death 50 pulmonary, 31 sepsis, 15MOF 8burn shock

23 Management Shriners Hospital, Galveston TX
O2 maintain SpO2 >90% Artificial cough 2hrly Chest physio 4hrly Nebulised N-Acetyl cysteine 4hrly Nebulised heparin 4hrly Sputum culture 3x week TV 6ml/kg, PIP<35, permissive hypercapnoea

24 Intubation Window Drugs Devices Fixation Definitive

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27 Intravenous Induction Suxamethonium Rapid sequence
Drugs Intravenous Induction Suxamethonium Rapid sequence Inhalational Induction Sevoflurane in oxygen

28 Fixation Difficult Oedema  displacement of tube
Tying, stapling, wiring to teeth

29 ET Tube wired

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37 Tracheostomy

38 16 patients more than 55% burn vs 9 patients with tracheostomy
Tracheostomy -anti 16 patients more than 55% burn vs 9 patients with tracheostomy Pulmonary sepsis 78% trache group Pulmonary culture=burn wound culture Avoid if at all possible FE Eckhauser J Billotte JF Burke WC Quimby American Journal of Surgery 1974; 127:418-23

39 Tracheostomy-pro 1549 pediatric burn patients <4yrs old
180 intubated 76 tracheostomy ( ) 20 tracheostomies done through eschar No loss of airway 7 children had problems decannulating (3 had severe inhalational injury) 45/76 pneumonia vs 28/104 But no patient deteriorated because of tracheostomy CE Coln, GF Purdue,JL Hunt. Archives of Surgery 1998;1333:537-40

40 Conclusions Early management of the airway is crucial Early Fluid resuscitation should follow a formula Later fluid management is more controversial Centralisation may give more answers


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