Paediatric Acute care Guidelines PMH Emergency Department

Background

  • Burns are a leading cause of injury in children
 

Assessment

  • Assessing a burn can be difficult for clinicians and the appearance can change during the first 48 hours

History

  • Time burn occurred
  • Type of burn: thermal (most common), chemical, electrical, the substance causing the burn, duration of contact
  • First aid done at the scene
  • Any further treatment prior to arrival in hospital
  • Other injuries
  • Immunisations: tetanus

Examination

Percentage Body Surface Area (BSA)

  • Use the Burns Body Surface Area Sheet
  • Do not include areas of erythema
  • Note: the palmar surface of the child’s hand = 1% as a rough estimate of BSA

Depth

  • Superficial: only involve the epidermis
  • Partial: involve whole epidermis and part of the dermis – can be divided into superficial (papillary layer of the dermis) and deep (reticular layer of the dermis)
  • Full thickness: involve epidermis and entire dermis.

Distribution

  • Note pattern of burns
  • Consider non-accidental injury (NAI) if history inconsistent with the examination findings, delay in presentation, look for other injuries like bruises

Specific information 

  • Burns in special areas (e.g. face, neck, hands, feet, perineum)
  • Assess for inhalation burns: singed nasal / eyebrow hairs, swelling of mouth/face, stridor, hoarse voice, cough, respiratory distress, any facial, oral or neck burns, black sputum

 

Management

Resuscitation

  • Airway: consider early intubation for inhalation burns, remember C-spine precautions in trauma
  • Breathing: always give oxygen in severe or inhalation burns
  • Circulation: treat shock with boluses of 0.9% saline, 20mL/kg then reassess. See ED guideline: Fluid – Intravenous Therapy.

Initial management

First Aid 

  • Stop the burning process
  • Cool the burn with cold running water for 20 minutes. Do not use ice.
  • Remove clothing, taking care not to rip any adhered skin. Cut around adhered clothing if required.
  • Remove jewellery
  • Keep the patient warm 36-37oC
  • If outside hospital, do not apply any burns gels, burns can be covered with plastic cling wrap for transfer. Do not use Fixomull.

 Analgesia

  • Check what has been given prior to arrival
  • Intranasal fentanyl should be the 1st line analgesia
  • If IV cannula already in situ, IV morphine can be given
  • Oral analgesia: paracetamol, ibuprofen, paracetamol/codeine
  • See ED guideline: Burns – Medication

Assess for concurrent injuries

  • Perform a head to toe examination for concurrent injuries – consider the possibility of NAI
  • Whilst conducting survey take note of estimated BSA % and document on the chart

Further management

Minor Burn or Burn with Elevated Concerns

Discuss with Emergency Department Senior Doctor to consider admission for:

  • Special area burns (e.g. face, neck, hand, feet, perineum)
  • Suspicion of NAI
  • Full thickness burns
  • Chemical / electrical burns
  • Circumferential burns (partial or full thickness)

Take photos – when available – call Medical Illustrations on 9340 8282

  • Must use photographic consent form

Wound Care 

Arrange follow up or admission

  • Discuss with Emergency Department Senior Doctor and/or Burns Registrar

Major Burn or Burns of High Concern

Consult with Burns Registrar/Consultant for admission:

  • 5% or greater
  • Inhalation burns
  • Concurrent injury or co-morbidities
  • Infected burns
  • Circumferential (potential need for escharotomy)

Rehydration and Maintenance
See ED guidelines: Burns – FluidsFluids – Intravenous Therapy and Burns Fluid Calculator

Wound Care 

Medications

Admission criteria

As above, consider admission when:

  • Special area burns (e.g. face, neck, hand, feet, perineum)
  • Suspicion of NAI, other concurrent injuries
  • Full thickness burns
  • Chemical / electrical burns
  • Circumferential burns (partial or full thickness – potential need for escharotomy)
  • 5% or greater BSA
  • Inhalation burns
  • Infected burns

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