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

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Presentation on theme: "Paediatric Burns- fluids and the airway Dr FA Potter Alder Hey Hospital."— Presentation transcript:

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 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 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 Burn extent –Rule of Nines –Lund and Browder charts Patient weight Calculation using formula

10 Lund & Browder Chart

11 How Much? Parkland 4ml/kg/%burn Hartmann’s solution Half over 8hr Half over 16hr + 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 1998-2004 ‘ 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 Where are we now? RHJ Baker MA Akhavani,N Jallali. Journal of Plastic & Reconstructive Surgery 2007;60:682-685 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 0.3-0.5 ml plasma over 8hr + dextrose / water to maintain urine output 98% of 516 children successfully resuscitated CR Baxter. Surgical Clinics of North America 1978;58:1313-22

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.2009 30;1:206-208 850 children 4 tertiary US centres over 10yr 603 bronchoscopic findings 216 clinical findings 31 CO elevation 710 survivors140 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 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 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 (20-31-18-7) 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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