Polly put the kettle on… and poured a cup of tea

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Jack, a 2 year old boy, is rushed into the Emergency Department by his distraught mother, Polly. She had just poured a cup of tea and prior to adding milk, Jack reached up to the kitchen table, pulling the tea toward himself and sustaining a burn to his neck and chest. You recall an article that was presented at Journal Club recently – ‘Airway compromise in children with anterior neck burns: Beware the scalded child’, and you wonder what to do next….

What are the basic principles of burns management?

Simultaneous assessment and management:

Management of a burn injury is time critical – prompt assessment and timely intervention is required to decrease morbidity and mortality. If there is associated trauma follow an ‘Airway, Breathing, Circulation’ approach and manage life threatening injuries systematically.

Analgesia:

Burns are PAINFUL! Administer opioid analgesia (for example, 1.5mcg/kg intranasal fentanyl) plus oxycodone 0.1mg/kg. Don’t forget non-pharmacological adjuncts to analgesia – including cooling the burn and distraction therapy like bubbles or music.

First aid:

Application of cool or tepid water for twenty minutes within the first three hours of sustaining the burn decreases the ‘zone of stasis’ and minimises the size of the burn. Remove wet, non-adherent clothing, rings, jewellery or other items which may cause constriction of affected limbs. Monitor temperature – be mindful of hypothermia secondary to exposure and first aid.

Airway:

Recognise that upper airway oedema caused by inhalational injuries may progress rapidly – careful timing of intervention is required to secure the airway. Assess for signs suggestive of an inhalational injury including burns to the face and oropharynx, presence of carbonaceous material in the upper airway, changes in voice or stridor.

Breathing:

If there are signs of inhalational injury, burns with large TBSA (total body surface area), neurological signs, or exposure to carbon monoxide or cyanide administer oxygen via a non-rebreather mask. Escharotomy may be required if there is compromise of ventilation due to circumferential chest burns.

Circulation:

Burns cause an intense inflammatory response and fluid sequestration. For those with >10%TBSA full thickness burn, the estimated fluid requirement is calculated according to the modified Parkland Formula.

3-4mls x body weight (kg) x body surface area affected by burn of Hartmann’s solution

50% is administered over the first 8 hours and 50% over the next 16 hours from the time that the burn was sustained. Maintenance fluid are administered in addition to this volume. Strict fluid balance including measurement of urine output is required.  

Specific Considerations:

Consider the circumstances in which the child sustained the burn – think about non accidental injury

Check tetanus status

Refer to a Specialised Burns Centre for Ongoing Care:

  • Criteria for medical retrieval

    • Intubated children or those with inhalational injuries and cutaneous burns
    • Head and neck burns
    • >Mid-dermal, deep dermal or full thickness burns >10% in children
    • Circumferential burn to limbs or chest that compromises circulation or respiration
    • Electrical conduction injury with cutaneous burns
    • Chemical injury with cutaneous burns
    • Burns with associated trauma or significant co morbidities
  • Mid- dermal, deep dermal or full thickness burn in children >5% TBSA
  • Burns to the face, hands, feet genitalia, perineum and major joints
  • Circumferential burns of the limbs or chest
  • Suspected NAI or patient with other medical problems that could complicate the burn injury

What are the traditional clinical indicators for airway intervention following a burn?

Signs suggesting airway burn:

  • Facial burns
  • Singed nasal hair
  • Carbonaceous sputum
  • Presence of soot in the mouth or nose
  • Hoarseness of voice
  • Stridor or expiratory wheeze

Signs that the airway may be threatened due to systemic effect:

  • Decreased level of consciousness
  • Acute respiratory distress or wheeze
  • Circumferential neck burns
  • Supraglottic oedema or inflammation on bronchoscopy

What about that article - ‘Airway compromise in children with anterior neck burns: Beware the scalded child’ ?

Children’s airways are more narrow compared to adults and are vulnerable to small changes in diameter – Pousielle’s law states that the airway resistance will increase by a power of four for any decrease in the radius of the airway. The direct effect of burns causing oedema is well known and if a patient has sustained an inhalational injury there should be prompt intervention to secure the airway. But the effect of progressive oedema in the subcutaneous and soft tissue structures in the anterior neck, and the potential to compromise the airway due to extrinsic compression or intrinsic oedema is unclear.  This retrospective review aimed to analyse the clinical features of children admitted to PICU following an anterior neck burn and the characteristics which contributed to a requirement for intubation.

The review included children requiring admission to PICU in a Paediatric Hospital over ten years (January 2004- December 2013). 466 children with anterior neck burns were admitted to the Burns Unit over the study time. 52 children (11%) were admitted to PICU and 47 of those required intubation.  Children admitted to PICU were analysed in two subgroups – those who had sustained anterior neck burns due to scalds and those who had a flame/explosion injury. The group that had sustained scalds were unlikely to have an inhalational component to their injury, and the subgroup analysis was performed to identify if there was an association between airway compromise due to oedema from an anterior neck burn.

What were the results of the subgroup analysis?

Age and gender: Those who sustained scalds were significantly younger at 2.3 years compared with the flame/explosion group who were average 9.7 years (p<0.0001). The majority were male in both groups – 82% in the scald group and 77% in the flame/explosion group.

Time prior to intubation: In the scald group, intubation occurred on average 9.3 hours following injury, whereas those requiring intubation in the flame/explosion group occurred on average 3.3 hours after injury (p = 0.002). The majority of those intubated in the scald group occurred after transfer to the Burn Unit (63%), whereas 68% of those requiring intubation in the flame/explosion group had their airway secured prior to transfer.

Overzealous fluid administration: Those in the scaled group received on average 479% the recommenced amount of IV fluid, and those in the scalded group received a significantly higher amount (0.8ml/kg/%TBSA/hour prior to intubation) compared to those in the flame/explosion group (0.3ml/kg/%TBSA/hour) (p= 0.003).

Requirement for intubation: 54% of the flame/explosion group required intubation for decreased level of conscious, having sustained an airway or inhalational injury, or having had a large TBSA burn. 74% of the scaled group were intubated due to complications associated with subcutaneous/soft tissue oedema of the anterior neck. The difference was not statistically significant. There was a higher rate of airway oedema observed in children in the scald group on laryngoscopy (32% v 21%; p=0.5), and a higher rate of difficult intubations (11% v 7%; p=1), though these differences were not statistically significant. There were more children requiring intubation who had an upper respiratory tract infection (37% v 29%; p=0.29), though this difference was also not statistically significant.

How does the article contribute to our clinical awareness of potential airway deterioration?

This article draws our attention to the potential that anterior neck burns caused by scalds can be associated with progressive oedema and the need for intubation. It highlights the need for judicious fluid management, as those receiving larger amounts of fluid were more likely to require airway intervention. Monitor for signs of evolving oedema, repeat your clinical assessment and avoid over resuscitation of patients. Be aware of other influences that may contribute to airway narrowing, such as the presence of upper respiratory tract infection, when assessing the airway.

References:

‘ABC of burns – pathophysiology and types of burns’ Hettiaratchy and Dziewulski, BMJ, Volume 328, 12 June 2004.

‘Airway compromise in children with anterior neck burns: Beware the scalded child’ Hyland EJ, et al, J Paediatr Child Health. 2015 Oct; 51 (10): 976-81. http://www.ncbi.nlm.nih.gov/m/pubmed/25939573/

Australian Resuscitation Council Guidelines – found at http://resus.org.au/guidelines/

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th edition. Tintinalli et al. 2011.

Minor Burns on Don’t Forget The Bubbles by Andrew Tagg

 

 

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About 

Dr Amie Beattie BSc, MBBS, DCH. Advanced Trainee in Emergency Medicine, currently working in Intensive Care and Retrieval in Tamworth, NSW. Enthusiastic medical educator and advocate of rural health, and a wary keeper of chickens….