EMERGENCY &

RESUSCITATION
FOR
BURNS
IN
CHILDREN

Rosadi Seswandhana
Burn Unit – Dr. Sardjito
General Hospital
Plastic Surgery Division –
Department of surgery –
FMPHN UGM
 In general, emergency
management of adult
burns should be applied
in children.

Life threatening situation

should be detected as a
BACKGROUND first priority

Size and
proportion of
Significant the body
differences Fluid dynamic
between adult Thickness of the
and children skin
Psychosocial
are: and emotional
state

(ANZBA, 2016)
PROBLEMS
 MORTALITY

(Hettiaratchy & Dziewulski, 2004)

 Etiology Proportion (%)
Scald 55
Direct 21
contact
EPIDEMIOLOGY Fire 13
Friction 8
Electrical 1
Chemical 1
Other 1
(ANZBA, 2016)
 Consistency mechanism of injury
and clinical finding. Inconsistencies
feature can lead assumption to non
accidental burn injury

Previous airway problems such as

sleep apnea, asthma

CONSIDERATION IN
HISTORY TAKING
Psychosocial care of the child and
family

Degree of the heat and how long

duration of direct contact.

(ANZBA, 2016)
 Not as rapid as
adult

Increasing
AVOIDANCE
contact time
REACTION

Deeper skin burn

 BODY SIZE AND
PROPORTION
• Total body surface are and body
weight ratio is more greater in
children
• Metabolism rate is greater than adult
• Greater evaporation water loss
• Greater heat loss
• There are differences of body region
compare to adult

(ANZBA, 2016)
 SIZE AND EXTENT OF THE BURN WOUND

Adult and Children > 9

y.o Children < 9 y.o

(ANZBA, 2016)
 HOW TO ADJUST PROPORTION
BY AGE

3 years old 8 years old

Region Proportion Region Proportion
Head & Neck 15 Head & Neck 10
Anterior truncal 18 Anterior truncal 18
Posterior truncal 18 Posterior truncal 18
Right upper extremity 9 Right upper extremity 9
Left upper extremity 9 Left upper extremity 9
Right lower extremity 15,5 Right lower extremity 18
Right lower extremity 15,5 Right lower extremity 18
 DEPTH OF BURN WOUND
Traditional concept Recent concept

Children skin is thinner than adult skin. In neonate, at the temperature 60O:

• Full thickness skin burn is already happen when duration of contact only 1 second
• In the older baby it could be last up to 5 seconds
• In adult, full thickness skin burn could be happened if contact more than 20 sconds
 BURN WOUND ~ DEGREE OF BURN
Appearance Description Capillary refill Sensibility - Pain

Epidermal Bright red/pink Present (fast) Yes

Heals within 7
days
Superficial Pale pink. Often Present Yes – very paintful
Dermal Blistered

Heals within 14
days
Mid Dermal Dark pink Sluggish May be present
or absent

Deep Dermal Blotchy red (from Absent Absent

haemoglobin that has
leaked out of
damaged capillaries)

Full Thicknes White, waxy or Absent Absent

leathery
 DEPTH OF WOUND
ASSESSMENT

IT IS MORE DIFFICULT PREDOMINANT BECAUSE OF THINNER SKIN

SCALD à HETEROGENEOUS
OF DEPTH
 Remove the
heat source

Cooling the
FIRST AID wound with tap
water

keep body
warmth to avoid
hypothermia
 SEVERE / COMPLICATED
BURNS

ATLS ©

ABLS ©
Life-saving
EMSB © Goals:
Limb/organ
saving
 Airway
Common problem in children:
• Enlargement of adenoids and tonsil
• Sleep apnea
• The lower airway is narrower in absolute diameter
• Reactive small airways disease

Look for signs of inhalation injury

• Facial burns,
• Soot in nostrils or sputum
• Laryngoscope à edema, hyperemia

ET Better than TRACHEOSTOMY

Do not forget: C-Spine control
SNIFFING POSITION FOR INFANT
Breathing
Do not forget: Give O2 100% 15 L/minute (NRM)
B: Circumference Full thickness skin burn on the
chest wall Þ mechanical ventilation disturbance
Þ ESCHAROTOMY
ESCHAROTOMY
 Breathing
• Be aware of carbon monoxide poisoning
Patient may appear 'pink' (cherry red) with a normal
pulse oximeter reading
è administere 100% Oxygen
Perform intubation and artificial ventilation
(if needed)
(Do not believe pulse oxymetri saturation)

• Smoke injury à Soot in nostrils or sputum

è Nebulizer
Perform intubation, artificial ventilation and
bronchial toilet (if needed)
Circulation
M Examine:
M Central pressure
M Blood pressure
M Central and periphery capillary refill
M Systemic :
If patient arrived with shock condition à 2 IV-line
First à IVFD RL 20 ml/Kg BW in 15-30 minutes
(Do not forget stop bleeding and blood test
sample à complete blood count, blood group,
chemical analysis, BGA, and β-HCG for pregnant
woman)
 Site: un-burnt skin

Size: large number of i.v.

cannula
INTRAVENOUS
CANNULA
In emergency situation:
intra-osseous line is quite
safe

Phlebotomy is not
recommended
 LOCAL/REGIONAL CIRCULATION
COMPROMISE
M Local :
Circumference Full thickness skin
burn on extremity à compartment
syndrome à 5P Þ ESCHAROTOMY

(First elevation and escharotomy should be performed

after life-threatening was managed)
Disability

• GCS (Eye, Verbal, Motion) /

AVPU (Alert, Verbal, Pain, Unresponse)
• Lateral Sign

MCO intoxication
MHipovolemic shock
Exposure and Environmental control

Log Roll Manuver

M Burn Size (% TBSA)
M Depth of Burn Wound
M temperature
M Other trauma

Beware : Hypothermia à blanket

 Fluid Resucitation (F)

• Systemic :
The release of cytokines and other inflammatory mediators
Increase of capillary permeability let the intravascular fluid shifted
to the interstitial space à hypovolemia
BAXTER / PARKLAND FORMULA
IVFD RL: 4 ml x BW (Kg) x BSA (%)

• ANZBA à Modification of Baxter:

IVFD RL: 3 ml x BW (Kg) x BSA (%)
for children (< 16 years old), + maintenance D5NS (4 – 2 – 1 )
 Case 1

Male, 30 y.o. with 60 Kg BW and 30% BSA

Fluid Needed : 3 x 60 Kg x 30 %
Þ 5400 mL RL
First 8 hours 2700 mL Þ 92 drops/mnt
Next 16 hours 2700 mL Þ 46 drops/mnt

Since the accident

 Case 2
Female, 5 y.o. with 17 kg BW and 20% BSA
• Fluid rescucitstion : 3 x 17 Kg x 20 % Þ 1020 ml RL
First 8 hours 510 ml Þ 64 drops (micro)/mnt
Next 16 hours 510 ml Þ 32 drops (micro)/mnt
Since the accident
• Plus maintenance
10 kg x 4 = 40 ml
7 kg x 2 = 14 ml
Total = 54 ml/hour D5NS
 Case 3
Male, 12 y.o. with 40 Kg BW and 30% BSA
• Fluid rescucitstion : 3 x 40 kg x 30 % = 3600 ml RL
First 8 hours 1800 mL
Next 16 hours 1800 mL
Since the accident
• Plus maintenance
10 kg x 4 = 40 ml
10 kg x 2 = 20 ml
20 kg x 1 = 20 ml
Total = 80 ml/hour D5NS
ANALGETIC (A)

Burns is painfull à need adequate analgetic

• Morphine : 0,05 – 0,1 mg/Kg BW (ANZBA, 2013)
• Fenthanyl : 1 µg/Kg BW

• Continue with maintenance dose

• (better using syringe pump)
TEST (T)
• ECG, Lateral Cervical, Thorax , Pelvical X-ray
• Hb, WBC, Plt, Hematocrit, Electrolite, Albumin,
Blood Glucose
• Kidney Function, Liver Function, BGA

Tube (T)
• Nasogastric tube production Þ beware of stress
ulcer
• Indwelling catheter should be inserted in > 10%
burn in childrenà urine monitoring
• Central venous catheter
MONITORING
• Children have good compensatory mechanism to hypovolemia à
Late sign especially if only based on blood pressure. So we need
alternative sign of decreased circulation
• Tachycardia
• Capillary refill > 2 seconds (at sternum)
• Mottled or pale cool peripheries
• Organ dysfunction: tachypnoea, altered mental status
• Urin Output Þ Child 1,0/Kg BW/hour
• Fluid theraphy adjustment hourly
• Deficiency à add 50%
• Bolus 5-10 ml/kg BB
• Breathing sound
• Severe burn (>40%) apply Central Venous Catheter
• Overload à reduce 10%
Beware: myoglobinuria (haemochromogens)
 Case 2
Female, 5 y.o. with 17 kg BW and 20% BSA
• Fluid rescucitstion : 3 x 17 kg x 20 % Þ 1020 ml RL
First 8 hours 510 ml Þ 63,5 ml/hour
Next 16 hours 510 ml Þ 31,875 ml/hour
Since the accident
• Plus maintenance 54 ml/hour D5NS
• When you observe urin production in hour 13th, is
about 10 ml. You can add resuscitation fluid for hour
14th as:
• 5 – 10 ml/kg BW ~ 85 - 170 ml
• 150% times hourly fluid need ~ 47,8125 ml
 IN THE 2ND 24 HOUR
• Colloid fluids can be used to help restore circulating
volume using the formula:

0,5 ml of 5% Albumin x kg Body Weight x % of burn area

 SUSCEPTIBLE METABOLIC RESPOND

• Prone to hypoglycemia
• Fluid overloaded
• Dilutional hyponatremia
• Due to limited glycogen store

• Dextrose contained fluids is mandatory in children

maintenance fluids.
 Truncal escharotomy is
more common needed in
children even there is no
circumferential eschar

ESCHAROTOMY Especially on anterior side

of truncal

It might be needed to
performed incision parallel
to sub-costal
 Prone to have gastric
dilatation, especially when
the patient is crying

Nasogastric tube is important

GASTROINTESTINAL inserted in acute and transfer
phase, especially if patient is
TRACT transferred by airplane or
helicopter

Nasogastric tube is also

important to ensure per-
enteral dietary intake
 PROGRESSIVE WOUND
ASSESSMENT
• It can be difficult to assess a definitive wound depth in
the first 7-10 days
• Consider to perform skin grafting if the wound does not
heal on day 10th
• Special care to prevent hypertrophic scar
1. Wash the wound using chlorhexidine
0,1%, normal saline, or soap and water
2. 1st O à no spesific treatment
3. 2nd O à Cleansed with isotonic
solution
• Film transparan
• Foam
• Silver impregnated foam

WOUND
• Calcium alginate
• Cellulosa
4. 3rd O
• Daily debridement CARE
• Daily Silver Sulfadiazin (Dermazin® /
Burnazin®) ,
• Silver contained dressing (Acticoat®
/ Mepilex-Ag®)
• Plus Surgical Treatment
 Big impact to the
family

The magnitude of the

impact depends on multi-
factorial, not only because
the severity of the wound
Intervention: to increase
EMOTIONAL psychosocial wellness
ASPECT every member of the
family

Direct counseling for

family member or patient

Focus is always adjusted

regarding healing process
NON
ACCIDENTAL
BURN INJURY
• Delayed on
presentation at
emergency care
• Unclear/inconsistency
history
• Inconsistence
between history and
clinical finding
• Other injury sign
• Specific burn pattern
(burned with
cigarettes, bilateral
socks burn pattern)
 REFERRAL CRITERIA
SPAM
Size Person Area Mechanism
• > 10% TBSA • Past Ilness • Specific Area • Chemical /
(Face, Hand, Electrical
• > 5% TBSA for • Pregnant Foot, Perineum,
Children Major joint) • Major/Multple
• Extremly Age Trauma
• > 5% full • Circumferencial
thickness • Non
• Lung (Inhalation Accidental
injury) Injury

(ANZBA, 2016)
THANK YOU