Paediatric Burns- fluids and the airway

Dr FA Potter
Alder Hey Hospital

 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

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

Burn Shock - local

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

Burn Shock systemic 1

TNFalpha, interleukin-1,2,5,8 interferon gamma

SIRS
Increased microvascular permeability
Vasodilatation
Decreased cardiac contractility
Intravascular fluid, electrolytes,proteininterstitial
Lymph vessel obstruction (platelets, leukocytes)
Generalised oedema 24-48hr

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

What Fluid ?
Eggnog (& enemas) Fauntleroy 1919
Plasma Harkins 1942 (fluid relate to area of burn)
Albumin

Evans formula 1952

1ml/kg/%burn NS +1ml/kg/%burn albumin +2000ml

glucose. Second 24hr: half the saline +albumin +glucose

Crystalloid

Baxter & Shires 1968

Estimation of
Burn Area
Burn extent
Rule of Nines
Lund and Browder
charts

Patient weight
Calculation using
formula

Lund & Browder Chart

How Much?
Parkland

Mount Vernon

4ml/kg/%burn
Hartmanns solution
Half over 8hr
Half over 16hr
+
maintenance

O.5ml/kg/%burn
Plasma
6 periods
4hr 8hr 12hr 18hr
24hr 36hr post burn
+
maintenance

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

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 Hartmanns
10% use albumin, 15% both
50% do not change fluid after 24 hr

Fluid Creep
Tendency to give more fluid than Parkland dictates
60% patients get more [J Burn Care Rehab 2000;21:915]
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

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;58:131322

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

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

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

Inhalational injury
Oedema of
tracheobronchial mucosa
Separation of epithelium
Bronchial casts

Bronchoscopy- diagnosis
removal casts

Parenchyma-congestion,
oedema ,neutrophil
Infiltration, hyaline
membranes

CXR infiltrates over 510days

Xenon scanning

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 survivors
TBSA burn 45%

Cause of death

140 non-survivors
TBSA burn 70%
50 pulmonary, 31 sepsis, 15MOF 8burn shock

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

Intubation
Window
Drugs
Devices
Fixation
Definitive

Drugs
Intravenous Induction
Suxamethonium
Rapid sequence
Inhalational Induction
Sevoflurane in oxygen

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

ET Tube wired

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

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;1333:53740

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