Art & science | trauma nursing
Intensive care of children with burn injuries and the role of the multidisciplinary team Augusto Biasini and colleagues outline the stages of care and recommended approaches required when caring for a young patient with traumatic injury Correspondence [email protected] Augusto Biasini is a a a a paediatric and neonatal intensive care unit Marco Biasini is a doctor in a a
a
Regional Burns Centre Marcello Stella is a a paediatric and neonatal intensive care unit All work at Maurizio Bufalini Hospital, Cesena, Italy Date of submission January 23 2014 Date of acceptance September 5 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ ncyp-author-guidelines
Abstract Trauma from burns and scalds in children is more common and more damaging than in adults, and may indicate abuse. The main goal of intensive care of an acute burn is to limit the extent of the systemic insult. Effective treatment of such acute physiological changes requires experienced monitoring by multidisciplinary teams, following appropriate emergency protocols at specialised burn centres in cases of major trauma. First aid involves maintaining a patent airway, supporting circulation and respiration, arresting the burning, managing pain and distress, reducing infection and considering transfer to specialist care. Advances in techniques and treatment have increased survival rates and ultimate quality of life, but education and prevention programmes are still required at all levels to reduce the incidence of burns among children. Keywords Burns, child, critical care nursing, first aid, humans, intensive care, paediatrics, resuscitation THERE WERE 96.7 burns per 100,000 children aged under three years worldwide in 2008 and, according to the World Health Organization (WHO), they are at high risk of death from burns at a global rate of 3.9 per 100,000 (WHO 2008). Fire-related injuries account for 7% of all paediatric trauma deaths (WHO 2008) and fire-related burns are the 11th leading cause of death for children aged 1-9 years. Burn injuries in infants who survive are more common and more severe than in adults. A recent global review of burn injuries estimated that more than 38,000 children require
NURSING CHILDREN AND YOUNG PEOPLE
hospital admission each year in the United States alone (Holland 2006). Although accurate data a e hard to compile, the number of large (>30%) total body surface area (TBSA) burns is decreasing, whereas the total number of children with smaller, deep burns is increasing (Burd and Yuen 2005). It should be noted that the incidence of child abuse has been reported to be as high as 16% of children admitted to US burn centres, and the incidence of neglect in three to six year olds may be as high as 60% (Toon et al 2011). Well-defined lines of demarcation between burned and unburned skin in a scald burn and the absence of splash burns are suggestive of intentional injury (Ojo et al 2007). An epidemiological and outcome analysis of 208 children with burns attending one emergency department (ED) in a UK hospital showed that many burns can be managed appropriately in the ED without the need for burn centre care (Rawlins et al 2007). Although the mortality from burn injuries in children has fallen in recent decades, problems persist with small burns that can be associated with long-standing morbidity. Prevention programmes are required at all levels to address the problem of burns in children (Rawlins et al 2007).
Aims The aim of this article is to outline the phases of care in the rapidly changing condition of a child with burns. Immediate, effective treatment is crucial.
Resuscitation The acute resuscitation of the burned child is the most challenging aspect of therapy. Burns are a form of trauma, but are treated in a different way from November 2014 | Volume 26 | Number 9 27
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Art & science | trauma acute care nursing other types of injury. This is due to their dramatic appearance, the particular type of surgery involved and the potentially devastating cosmetic, functional and psychological consequences in a growing child. Advanced trauma life support (Caruso et al 2012) mandates simple and efficient action that lowers the mortality and morbidity of burns: ■ Open and treat airways, and support respiration. ■ Stop the process of burning. ■ Support the circulation, fluid resuscitation, and treat shock. ■ Manage pain and distress. ■ Evaluate the need for transfer to specialist care.
Open airways It is essential to ensure the viability of the airway and that the patient is breathing adequately. Explosion, flames and smoke inhalation may directly affect the tissues of the face, nose and throat, causing rapid oedema; inhalation injury with oedema in the upper airway is caused by superheated steam or inhalation of toxic combustible chemical products, in particular aldehydes. Erythema and oedema with subsequent blistering, ulceration, erosion and sloughing of the mucosa may occur in the affected airway, leading to the accumulation of carbonaceous material and necrotic debris: infection and pneumonia follow in 70% of children with inhalation injury. Predictors of significant inhalation injury and impending respiratory failure include stridor, wheezing, drooling and hoarseness, which are indicative of airway swelling and dysfunction. Toxic gases Carbon monoxide (CO) or cyanide (CN) poisoning may occur as well. CO has a 250-fold higher affinity for haemoglobin compared with oxygen, shifting the oxyhaemoglobin dissociation curve to the left, which ultimately results in the impairment of oxygen delivery to tissues. Treatment for CO poisoning relies on the administration of 100% oxygen, with hyperbaric oxygen therapy reserved for refractory toxicity. A high degree of caution is needed when using the hyperbaric chamber. CN is released when natural and synthetic polymers are burned, causing tissue hypoxia by uncoupling oxidative phosphorylation in the mitochondria of cells. Treatment should be considered for patients with unexplained severe lactic acidosis, despite normal oxygen saturation and low carboxyhaemoglobin levels (Fidkowski et al 2009). Neck burns Circumferential burns to the neck can result in tight eschar formation, which can compromise upper airway function. The first step is to rapidly secure the airway before narrowing 28 November 2014 | Volume 26 | Number 9
or complete closure. Fibreoptic intubation, video laryngoscopes and laryngeal mask airways are all useful. Intubation Keeping in mind that intubation is essential in cases where a child has to be transported to a regional burn centre, in other situations a less intensive care approach may obtain better results. A nasal cannula with high flow or a simple face mask may be effective, but will require added humidification; topical racemic adrenaline (epinephrine) in aerosol therapy may transiently relieve the obstruction to the airflow. A combination of heparin and N-acetylcysteine is effective in reducing the mortality and morbidity of inhalation injury in children (Desai et al 1998). Helium/oxygen admixture (heliox) reduces resistance to a turbulent airflow and improves breathing when the upper airway is narrowed or obstructed. Heliox is also used in weaning from mechanical ventilation after extubation. Paediatric advanced life support (Kleinman et al 2010) guidelines recommend using uncuffed endotracheal tubes in children under eight years of age, but this is rarely performed during transport to regional burn centre because the tube has to be firm and stable and a leak around it would impair oxygenation and ventilation (Kleinman et al 2010). Intravenous midazolam 0.1-0.3mg/kg may be used for sedation or, if venous access is not available, 0.5mg/kg by nasal atomiser (Morão et al 2011, Guastalla et al 2013). Tracheotomy is usual in patients following a prolonged course of endotracheal intubation. However, early tracheotomy has been safely performed two to four days after the initiation of assisted ventilation in a cohort of children with burns, without tracheal stenosis, tracheomalacia or acute airway emergencies (Caruso et al 2012). Acute respiratory distress syndrome There is a lower prevalence of acute respiratory distress syndrome (ARDS) in children with burn injuries compared with adults, with occurrence in major burns cases reaching 54%. Instigating lung protective ventilation strategies using low tidal volumes, positive end-expiratory pressure and permissive hypercarbia have been shown to have clear benefits, and so should be used initially (Jauncey-Cooke et al 2010). Refractory hypoxia in these children has been managed with highfrequency oscillatory ventilation (HFOV) (Cartotto et al 2005) and, if maximal ventilatory therapy has failed, the use of extracorporeal membrane oxygenation (ECMO) has shown a survival benefit in small studies (Askegard-Giesmann et al 2010). NURSING CHILDREN AND YOUNG PEOPLE
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When circumferential full-thickness burns injury occur in the chest area, the resulting restriction may worsen the ARDS, and decompression by escharotomy and incision is necessary. However, ventilatory modes used in the treatment of these children vary between major burn centres, and there are no clear guidelines or consensus.
Stop the burning process An important factor in the outcome of a burn wound injury, recognised since the time of ancient Greek physician Galen, has been cooling. Nguyen and colleagues showed that 49% of children who did not receive prompt cooling of the wound suffered deeper burns compared with 33% of those who received immediate cooling (probability value (P) = 0.007, 95% confidence interval (CI) 0.41-0.87) (Nguyen et al 2002). Guidelines recommend treatment with cold running tap water for a minimum of 20 minutes as soon as possible after the injury (McCormack et al 2003). Although hypothermia should be avoided, treatment up to two to three hours after the burn may be beneficial. However, despite evidence of the efficacy of this treatment, it has been inconsistently applied. Although there are clear guidelines for immediate treatment of burns in children, as stated in the O’Neil survey, the correct first aid guidelines have been followed in only 23% of cases (O’Neil et al 2005).
Fluid resuscitation Children suffer proportionally greater fluid loss than adults with equivalent burn injury; fluid is lost into injured tissue through the wound. Consequently, vasoactive mediators, catecholamines and inflammatory markers are released into non-injured tissue, resulting in local and systemic capillary leakage and interstitial oedema (systemic inflammatory release syndrome or SIRS). In addition, in very large burns, myocardial depression and hypotension may ensue, thus making haemodynamic management challenging. Peripheral venous cannulation is preferred over central venous access and may be performed through the injured tissue if necessary. The Parkland formula is used to calculate the total volume of fluid to infuse in the form Ringer’s lactate solution at a rate based on TBSA and weight: (4 ml/kg x % TBSA + maintenance fluid (5% dextrose in Ringer’s lactate solution) at 100ml/kg for the first 10kg, 50ml/kg for the second 10kg, and 20ml/kg above 20kg). Of this total volume, one half is to be given in the first eight hours after injury and the rest over the subsequent 16 hours (Tricklebank 2009). The use of Parkland fluid resuscitation tables can improve accuracy and avert mistakes NURSING CHILDREN AND YOUNG PEOPLE
in correct calculation of fluid requirement (Lindford et al 2009). L-lactate, which does not increase apoptosis, should be used instead of D-lactate (Jaskille et al 2004). In measuring TBSA, simple erythema is ignored and partial/deep/full-thickness and fourth-degree burns are estimated. The loss of serum protein is clinically significant when the burn injury exceeds 40% TBSA. In these cases, the loss is replaced in the second 24 hours after injury with 5% albumin solution at 0.3-0.4ml/kg x %TBSA (Faraklas et al 2011). In every child with a TBSA more than 10% it is critical to monitor urine output (UO) (aiming at 1-2ml/kg/hour), serum sodium and lactate levels and base deficit, and mental status. UO remains the most practical guide for fluid administration: UO lower than 1ml/kg/hour may be associated with hypoperfusion, and UO higher than 2ml/kg/hour may indicate increased tissue oedema and subsequent ‘fluid creep’ (when fluid volume increases or decreases by 10%). However, clinicians are significantly less likely to reduce the rate of fluid infusion when UO is high than they are to increase fluid rate when UO is low (Cancio et al 2004). This attitude may frequently lead to an excessive volume resuscitation, which can cause pulmonary oedema and increased sub-eschar pressures in the extremities and the abdomen, with subsequent compartment syndrome (Singer and Thode 2002).
Pain management This is crucial in the overall care of a child with burns. Severe pain is often inadequately treated (Martin-Herz et al 2003). Pain has to be measured Box 1 Criteria for transferring a patient with burn injury to a regional burns centre 1 2 3 4 5 6 7 8
9 10
Partial-thickness burns greater than 10% total body surface area (TBSA). Burns that involve the face, hands, feet, genitalia, perineum or major joints. Third-degree/full-thickness burns greater than 5% TBSA in any age group. Electrical burns, including lightning injury. Chemical burns. Inhalation injury. Burns in people with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality. Any individuals with burns and concomitant trauma (such as fractures) in which the burn injury poses the greater risk of morbidity or mortality. Transfer to a trauma centre before approaching a burns unit. Burned children in a hospital that does not have qualified personnel or equipment for the care of children. Burn injury in persons who will require special social, emotional, or long-term rehabilitative intervention.
(Adapted from American College of Surgeons Committee on Trauma 1999) November 2014 | Volume 26 | Number 9 29
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Art & science | trauma nursing before treatment, knowing that anxiety, depression and agitation may worsen its perception. In developing an effective pain regimen, the different types of pain (acute, procedure-related, baseline pain) must be taken into account before deciding on which non-pharmacological (for example distraction techniques like cartoon videos, clown therapy) and pharmacological approaches to take, using specific guidelines (Schmit et al 2011). Opioids are commonly prescribed to manage acute breakthrough pain, whereas procedural pain is treated with midazolam (intravenously or by nasal atomiser) and ketamine 2mg/kg intravenously or 4mg/kg intramuscularly.
Transfer to regional centres Guidelines for transferring a patient with a burn injury to a regional burns centre are shown in Box 1 (page 29) (American College of Surgeons Committee on Trauma 1999). During transport and resuscitation, every effort should be made to maintain body temperature with clean sheets or blankets. Patients who have sustained a major injury should always have a nasogastric tube inserted to decompress the stomach.
Subsequently, wound infection must be dealt with by early operative intervention and wound closure and appropriate antibiotic therapy; aggressive enteral nutrition should be started as soon as possible to counteract hypermetabolism. Quality of life after major injury is largely predicted by the texture, colour and elasticity of grafted areas.
Conclusion Improvements in resuscitation and progress in critical care are leading to a decrease in mortality from burn injuries (Wolf and Arnoldo 2011). Treatment of children with such injuries differs from that of other critically ill patients, and requires a specialist team which knows the distinct phases of the injury, depths of burns and the multisystemic noxious effects on every organ system. The initial evaluation is crucial: excessive circulatory volume resuscitation may lead to burn oedema, abdominal compartment syndrome, pulmonary oedema and prolongation of mechanical ventilation and must be avoided. Wound infection is often a subsequently problem. Advances in knowledge and techniques, and training of the multidisciplinary team offer these patients a good chance of recovery.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References American College of Surgeons Committee on Trauma (1999) Guidelines for the Operation of Burn Units. ACS, Chicago IL.
Faraklas I et al (2011) Colloid normalizes resuscitation ratio in pediatric burns. Journal of Burn Care & Research. 32, 1, 91-97.
Askegard-Giesmann JR et al (2010) Extracorporeal membrane oxygenation as a lifesaving modality in the treatment of pediatric patients with burns and respiratory failure. Journal of Pediatric Surgery. 45, 6, 1330-1335.
Fidkowski CW et al (2009) Inhalation burn injury in children. Paediatric Anaesthesia. 19, Suppl 1, 147-154.
Burd A, Yuen C (2005) A global study of hospitalized burn patients. Burns. 31, 4, 432-438. Cancio LC et al (2004) Predicting increased fluid requirements during the resuscitation of thermally injured patients. Journal of Trauma. 56, 2, 404-403. Cartotto R et al (2005) Use of high-frequency oscillatory ventilation in burn patients. Critical Care Medicine. 33, Suppl 3, S175-S181. Caruso TJ et al (2012) Airway management of recovered pediatric patients with severe head and neck burns: a review. Paediatric Anaesthesia. 22, 5, 462-468. Desai MH et al (1998) Reduction of mortality in pediatric patients with inhalation injury with aerosolized heparin/N-acetylcysteine therapy. Journal of Burn Care & Rehabilitation. 19, 3, 210-212.
Guastalla V et al (2013) Dolore da venipuntura: come trattarlo? (Venepuncture pain: how to treat it?) Medico e Bambino. 32, 440-445. Holland AJ (2006) Pediatric burns: the forgotten trauma of childhood. Canadian Journal of Surgery. 49, 4, 272-277. Jaskille A et al (2004) D-lactate increases pulmonary apoptosis by restricting phosphorylation of bad and eNOS in a rat model of haemorrhagic shock. Journal of Trauma. 57, 2, 262-270. Jauncey-Cooke JI et al (2010) Lung protective strategies in paediatrics – a review. Australian Critical Care. 23, 2, 81-88. Kleinman ME et al (2010) Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 122, 18 Suppl 3, S876-908.
30 November 2014 | Volume 26 | Number 9
Lindford AJ et al (2009) Resuscitation tables: a useful tool in calculating pre-burns unit fluid requirements. Emergency Medicine Journal. 26, 4, 245-249.
Rawlins JM et al (2007) Epidemiology and outcome analysis of 208 children with burns attending an emergency department. Pediatric Emergency Care. 23, 5, 289-293.
Martin-Herz SP et al (2003) Pediatric pain control practices of North American burn centers. Journal of Burn Care & Rehabilitation. 24, 1, 26–36.
Schmit YS et al (2011) A randomized controlled trial of immersive virtual reality analgesia during physical therapy for pediatric burns. Burns. 37, 1, 61-66.
McCormack RA et al (2003) First aid management of minor burns in children: a prospective study of children presenting to the Children’s Hospital at Westmead. Sydney. Medical Journal of Australia. 178, 1, 31-33.
Singer AJ, Thode HC Jr (2002) National analgesia prescribing patterns in emergency department patients with burns. Journal of Burn Care & Rehabilitation. 23, 6, 361-365.
Morão S et al (2011) Midazolam for sedation procedures. Cochrane Library, Cochrane Anaesthesia Group.
Toon MH et al (2011) Children with burn injuries: assessment of trauma, neglect, violence and abuse. Journal of Injury & Violence Research. 3, 2, 98-110.
Nguyen NL et al (2002) The importance of immediate cooling – a case series of childhood burns in Vietnam. Burns. 28, 2, 173-176.
Tricklebank S (2009) Modern trends in fluid therapy for burns. Burns. 35, 6, 757-767.
Ojo P et al (2007) Pattern of burns in child abuse. American Surgeon. 73, 3, 253-255.
Wolf SE, Arnoldo BD (2012) The year in burns 2011. Burns. 38, 8, 1096-1108.
O’Neil AC et al (2005) Inadequacies in the first aid management of burns presenting to plastic surgery services. Irish Medical Journal. 98, 1, 15-16.
World Health Organization, United Nations Children’s Fund (2008) World Report on Child Injury Prevention. WHO, Geneva.
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Intensive care of children with burn injuries and the role of the multidisciplinary team Augusto Biasini and colleagues outline the stages of care and recommended approaches required when caring for a young patient with traumatic injury Correspondence [email protected] Augusto Biasini is a a a a paediatric and neonatal intensive care unit Marco Biasini is a doctor in a a
a
Regional Burns Centre Marcello Stella is a a paediatric and neonatal intensive care unit All work at Maurizio Bufalini Hospital, Cesena, Italy Date of submission January 23 2014 Date of acceptance September 5 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ ncyp-author-guidelines
Abstract Trauma from burns and scalds in children is more common and more damaging than in adults, and may indicate abuse. The main goal of intensive care of an acute burn is to limit the extent of the systemic insult. Effective treatment of such acute physiological changes requires experienced monitoring by multidisciplinary teams, following appropriate emergency protocols at specialised burn centres in cases of major trauma. First aid involves maintaining a patent airway, supporting circulation and respiration, arresting the burning, managing pain and distress, reducing infection and considering transfer to specialist care. Advances in techniques and treatment have increased survival rates and ultimate quality of life, but education and prevention programmes are still required at all levels to reduce the incidence of burns among children. Keywords Burns, child, critical care nursing, first aid, humans, intensive care, paediatrics, resuscitation THERE WERE 96.7 burns per 100,000 children aged under three years worldwide in 2008 and, according to the World Health Organization (WHO), they are at high risk of death from burns at a global rate of 3.9 per 100,000 (WHO 2008). Fire-related injuries account for 7% of all paediatric trauma deaths (WHO 2008) and fire-related burns are the 11th leading cause of death for children aged 1-9 years. Burn injuries in infants who survive are more common and more severe than in adults. A recent global review of burn injuries estimated that more than 38,000 children require
NURSING CHILDREN AND YOUNG PEOPLE
hospital admission each year in the United States alone (Holland 2006). Although accurate data a e hard to compile, the number of large (>30%) total body surface area (TBSA) burns is decreasing, whereas the total number of children with smaller, deep burns is increasing (Burd and Yuen 2005). It should be noted that the incidence of child abuse has been reported to be as high as 16% of children admitted to US burn centres, and the incidence of neglect in three to six year olds may be as high as 60% (Toon et al 2011). Well-defined lines of demarcation between burned and unburned skin in a scald burn and the absence of splash burns are suggestive of intentional injury (Ojo et al 2007). An epidemiological and outcome analysis of 208 children with burns attending one emergency department (ED) in a UK hospital showed that many burns can be managed appropriately in the ED without the need for burn centre care (Rawlins et al 2007). Although the mortality from burn injuries in children has fallen in recent decades, problems persist with small burns that can be associated with long-standing morbidity. Prevention programmes are required at all levels to address the problem of burns in children (Rawlins et al 2007).
Aims The aim of this article is to outline the phases of care in the rapidly changing condition of a child with burns. Immediate, effective treatment is crucial.
Resuscitation The acute resuscitation of the burned child is the most challenging aspect of therapy. Burns are a form of trauma, but are treated in a different way from November 2014 | Volume 26 | Number 9 27
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 23, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | trauma acute care nursing other types of injury. This is due to their dramatic appearance, the particular type of surgery involved and the potentially devastating cosmetic, functional and psychological consequences in a growing child. Advanced trauma life support (Caruso et al 2012) mandates simple and efficient action that lowers the mortality and morbidity of burns: ■ Open and treat airways, and support respiration. ■ Stop the process of burning. ■ Support the circulation, fluid resuscitation, and treat shock. ■ Manage pain and distress. ■ Evaluate the need for transfer to specialist care.
Open airways It is essential to ensure the viability of the airway and that the patient is breathing adequately. Explosion, flames and smoke inhalation may directly affect the tissues of the face, nose and throat, causing rapid oedema; inhalation injury with oedema in the upper airway is caused by superheated steam or inhalation of toxic combustible chemical products, in particular aldehydes. Erythema and oedema with subsequent blistering, ulceration, erosion and sloughing of the mucosa may occur in the affected airway, leading to the accumulation of carbonaceous material and necrotic debris: infection and pneumonia follow in 70% of children with inhalation injury. Predictors of significant inhalation injury and impending respiratory failure include stridor, wheezing, drooling and hoarseness, which are indicative of airway swelling and dysfunction. Toxic gases Carbon monoxide (CO) or cyanide (CN) poisoning may occur as well. CO has a 250-fold higher affinity for haemoglobin compared with oxygen, shifting the oxyhaemoglobin dissociation curve to the left, which ultimately results in the impairment of oxygen delivery to tissues. Treatment for CO poisoning relies on the administration of 100% oxygen, with hyperbaric oxygen therapy reserved for refractory toxicity. A high degree of caution is needed when using the hyperbaric chamber. CN is released when natural and synthetic polymers are burned, causing tissue hypoxia by uncoupling oxidative phosphorylation in the mitochondria of cells. Treatment should be considered for patients with unexplained severe lactic acidosis, despite normal oxygen saturation and low carboxyhaemoglobin levels (Fidkowski et al 2009). Neck burns Circumferential burns to the neck can result in tight eschar formation, which can compromise upper airway function. The first step is to rapidly secure the airway before narrowing 28 November 2014 | Volume 26 | Number 9
or complete closure. Fibreoptic intubation, video laryngoscopes and laryngeal mask airways are all useful. Intubation Keeping in mind that intubation is essential in cases where a child has to be transported to a regional burn centre, in other situations a less intensive care approach may obtain better results. A nasal cannula with high flow or a simple face mask may be effective, but will require added humidification; topical racemic adrenaline (epinephrine) in aerosol therapy may transiently relieve the obstruction to the airflow. A combination of heparin and N-acetylcysteine is effective in reducing the mortality and morbidity of inhalation injury in children (Desai et al 1998). Helium/oxygen admixture (heliox) reduces resistance to a turbulent airflow and improves breathing when the upper airway is narrowed or obstructed. Heliox is also used in weaning from mechanical ventilation after extubation. Paediatric advanced life support (Kleinman et al 2010) guidelines recommend using uncuffed endotracheal tubes in children under eight years of age, but this is rarely performed during transport to regional burn centre because the tube has to be firm and stable and a leak around it would impair oxygenation and ventilation (Kleinman et al 2010). Intravenous midazolam 0.1-0.3mg/kg may be used for sedation or, if venous access is not available, 0.5mg/kg by nasal atomiser (Morão et al 2011, Guastalla et al 2013). Tracheotomy is usual in patients following a prolonged course of endotracheal intubation. However, early tracheotomy has been safely performed two to four days after the initiation of assisted ventilation in a cohort of children with burns, without tracheal stenosis, tracheomalacia or acute airway emergencies (Caruso et al 2012). Acute respiratory distress syndrome There is a lower prevalence of acute respiratory distress syndrome (ARDS) in children with burn injuries compared with adults, with occurrence in major burns cases reaching 54%. Instigating lung protective ventilation strategies using low tidal volumes, positive end-expiratory pressure and permissive hypercarbia have been shown to have clear benefits, and so should be used initially (Jauncey-Cooke et al 2010). Refractory hypoxia in these children has been managed with highfrequency oscillatory ventilation (HFOV) (Cartotto et al 2005) and, if maximal ventilatory therapy has failed, the use of extracorporeal membrane oxygenation (ECMO) has shown a survival benefit in small studies (Askegard-Giesmann et al 2010). NURSING CHILDREN AND YOUNG PEOPLE
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When circumferential full-thickness burns injury occur in the chest area, the resulting restriction may worsen the ARDS, and decompression by escharotomy and incision is necessary. However, ventilatory modes used in the treatment of these children vary between major burn centres, and there are no clear guidelines or consensus.
Stop the burning process An important factor in the outcome of a burn wound injury, recognised since the time of ancient Greek physician Galen, has been cooling. Nguyen and colleagues showed that 49% of children who did not receive prompt cooling of the wound suffered deeper burns compared with 33% of those who received immediate cooling (probability value (P) = 0.007, 95% confidence interval (CI) 0.41-0.87) (Nguyen et al 2002). Guidelines recommend treatment with cold running tap water for a minimum of 20 minutes as soon as possible after the injury (McCormack et al 2003). Although hypothermia should be avoided, treatment up to two to three hours after the burn may be beneficial. However, despite evidence of the efficacy of this treatment, it has been inconsistently applied. Although there are clear guidelines for immediate treatment of burns in children, as stated in the O’Neil survey, the correct first aid guidelines have been followed in only 23% of cases (O’Neil et al 2005).
Fluid resuscitation Children suffer proportionally greater fluid loss than adults with equivalent burn injury; fluid is lost into injured tissue through the wound. Consequently, vasoactive mediators, catecholamines and inflammatory markers are released into non-injured tissue, resulting in local and systemic capillary leakage and interstitial oedema (systemic inflammatory release syndrome or SIRS). In addition, in very large burns, myocardial depression and hypotension may ensue, thus making haemodynamic management challenging. Peripheral venous cannulation is preferred over central venous access and may be performed through the injured tissue if necessary. The Parkland formula is used to calculate the total volume of fluid to infuse in the form Ringer’s lactate solution at a rate based on TBSA and weight: (4 ml/kg x % TBSA + maintenance fluid (5% dextrose in Ringer’s lactate solution) at 100ml/kg for the first 10kg, 50ml/kg for the second 10kg, and 20ml/kg above 20kg). Of this total volume, one half is to be given in the first eight hours after injury and the rest over the subsequent 16 hours (Tricklebank 2009). The use of Parkland fluid resuscitation tables can improve accuracy and avert mistakes NURSING CHILDREN AND YOUNG PEOPLE
in correct calculation of fluid requirement (Lindford et al 2009). L-lactate, which does not increase apoptosis, should be used instead of D-lactate (Jaskille et al 2004). In measuring TBSA, simple erythema is ignored and partial/deep/full-thickness and fourth-degree burns are estimated. The loss of serum protein is clinically significant when the burn injury exceeds 40% TBSA. In these cases, the loss is replaced in the second 24 hours after injury with 5% albumin solution at 0.3-0.4ml/kg x %TBSA (Faraklas et al 2011). In every child with a TBSA more than 10% it is critical to monitor urine output (UO) (aiming at 1-2ml/kg/hour), serum sodium and lactate levels and base deficit, and mental status. UO remains the most practical guide for fluid administration: UO lower than 1ml/kg/hour may be associated with hypoperfusion, and UO higher than 2ml/kg/hour may indicate increased tissue oedema and subsequent ‘fluid creep’ (when fluid volume increases or decreases by 10%). However, clinicians are significantly less likely to reduce the rate of fluid infusion when UO is high than they are to increase fluid rate when UO is low (Cancio et al 2004). This attitude may frequently lead to an excessive volume resuscitation, which can cause pulmonary oedema and increased sub-eschar pressures in the extremities and the abdomen, with subsequent compartment syndrome (Singer and Thode 2002).
Pain management This is crucial in the overall care of a child with burns. Severe pain is often inadequately treated (Martin-Herz et al 2003). Pain has to be measured Box 1 Criteria for transferring a patient with burn injury to a regional burns centre 1 2 3 4 5 6 7 8
9 10
Partial-thickness burns greater than 10% total body surface area (TBSA). Burns that involve the face, hands, feet, genitalia, perineum or major joints. Third-degree/full-thickness burns greater than 5% TBSA in any age group. Electrical burns, including lightning injury. Chemical burns. Inhalation injury. Burns in people with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality. Any individuals with burns and concomitant trauma (such as fractures) in which the burn injury poses the greater risk of morbidity or mortality. Transfer to a trauma centre before approaching a burns unit. Burned children in a hospital that does not have qualified personnel or equipment for the care of children. Burn injury in persons who will require special social, emotional, or long-term rehabilitative intervention.
(Adapted from American College of Surgeons Committee on Trauma 1999) November 2014 | Volume 26 | Number 9 29
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Art & science | trauma nursing before treatment, knowing that anxiety, depression and agitation may worsen its perception. In developing an effective pain regimen, the different types of pain (acute, procedure-related, baseline pain) must be taken into account before deciding on which non-pharmacological (for example distraction techniques like cartoon videos, clown therapy) and pharmacological approaches to take, using specific guidelines (Schmit et al 2011). Opioids are commonly prescribed to manage acute breakthrough pain, whereas procedural pain is treated with midazolam (intravenously or by nasal atomiser) and ketamine 2mg/kg intravenously or 4mg/kg intramuscularly.
Transfer to regional centres Guidelines for transferring a patient with a burn injury to a regional burns centre are shown in Box 1 (page 29) (American College of Surgeons Committee on Trauma 1999). During transport and resuscitation, every effort should be made to maintain body temperature with clean sheets or blankets. Patients who have sustained a major injury should always have a nasogastric tube inserted to decompress the stomach.
Subsequently, wound infection must be dealt with by early operative intervention and wound closure and appropriate antibiotic therapy; aggressive enteral nutrition should be started as soon as possible to counteract hypermetabolism. Quality of life after major injury is largely predicted by the texture, colour and elasticity of grafted areas.
Conclusion Improvements in resuscitation and progress in critical care are leading to a decrease in mortality from burn injuries (Wolf and Arnoldo 2011). Treatment of children with such injuries differs from that of other critically ill patients, and requires a specialist team which knows the distinct phases of the injury, depths of burns and the multisystemic noxious effects on every organ system. The initial evaluation is crucial: excessive circulatory volume resuscitation may lead to burn oedema, abdominal compartment syndrome, pulmonary oedema and prolongation of mechanical ventilation and must be avoided. Wound infection is often a subsequently problem. Advances in knowledge and techniques, and training of the multidisciplinary team offer these patients a good chance of recovery.
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Conflict of interest None declared
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