Burns injury - PACT - ESICM

(VAP) prolonging ventilator therapy. When the injury involves the lower part of the
body, try to avoid intubation except during necrosectomy and grafting. Dressings can
be performed under ketamine anaesthesia under spontaneous ventilation. If
intubation is needed for procedual purposes; the anaesthesiologist is usually willing
to extubate after finishing the procedure.
Rocourt DV, Hall M, Kenney BD, Fabia R, Groner JI, Besner GE. Respiratory
failure after pediatric scald injury. J Pediatr Surg 2011; 46(9): 1753–
1758. PMID 21929985
Circulation
Delayed venous access and a late start with volume resuscitation increases mortality.
If venous access is difficult, an intraosseous access is a good alternative in the acute
phase. An indwelling urinary catheter is mandatory in the resuscitation phase in
children with injury >12-15 %TBSA. Aim for a urinary output of 1 mL/kg/hr in children
and 2 mL/kg/hr in infants. Be aware that children have a major ability for
physiological compensation, and hypovolaemia is often not recognised before >25% of
circulating volume is lost. To diagnose hypovolaemia in a child, one should assess
mental status, pulse pressure, arterial blood gases (low base excess), increasing
lactate and colour /temperature of the extremities.
A child with clammy, cool extremities but with normal blood pressure and
heart rate is a child in danger.
Surface area and fluid resuscitation
Small size makes children challenging for physicians and nurses, who are often more
used to working with adults. It is important to recognise that fluid losses are
proportionally larger in children than in adults due to a large surface area compared
to fluid weight. The rule of nine does not apply to children less than 15 years of age,
and the Lund and Browder chart should be used to calculate burned surface area.
Venous access may be particularly difficult in pre-hospital settings; intraosseous
access is particularly well suited.
To calculate body surface, one can use a simple nomogram or a formula [interactive
version].
The Parkland formula is unsuitable for children less than 30 kg BW but a modified
version is shown below. The most common formula used for fluid resuscitation in
children is based on surface area:
5000 mL/m 2 %TBSA burned (due to the injury) + 2000 mL/m 2 TBSA (maintenance
fluid).
This formula favours over-resuscitation which is a risk in children as much as in
adults. The maintenance fluid should probably be reduced (as outlined in the adult
section) but there is not specific, strong evidence on this point.
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