Chapter 1 of 7 · Fundamentals
Transfer criteria
Transfer and Admission Criteria for Pediatric Burns
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What the experts said
Burns result in over 300 visits and 2 deaths per day in pediatric patients.
The mechanism of pediatric burns is hot liquids or steam in younger children, and fire in older children.
Transfer criteria to a burn center include burns of more than 5% total body surface area, particularly if they involve the face, hands, feet, genitalia, perineum, or major joints.
Electrical burns, chemical burns, and inhalational injury should be transferred to a burn center.
Patients with significant circumferential burns should be transferred to a burn center.
If non-accidental trauma is suspected, the patient should be transferred to a tertiary care center.
Admission criteria at a burn center include any infant under age 1 with a total body surface area burn greater than 8%.
Any second-degree burn greater than 10% or any third-degree burn greater than 5% are indications for admission.
Before transfer, provide adequate pain control, apply silver sulfadiazine, and wrap wounds lightly with gauze, possibly adding Bactigras to prevent sticking.
Ensure bandages are not too tight to avoid compromising distal perfusion of extremities.
Patients with smaller burns can be treated with oral rehydration therapy and do not necessarily require intravenous fluids.
At the speaker's center, IV resuscitation is initiated for patients with greater than 10% total body surface area burns or teenagers with greater than 15%.
The Lund-Browder chart is the best chart for estimating burned surface area in children because it accounts for body shape variations.
The palm of the patient can be used as an estimate of 1% body surface area burn if the Lund-Browder chart is unavailable.
The Parkland formula uses Ringer's lactate at 3 cc per kg per percentage body surface area burn.
The speaker prefers the Cincinnati or Galveston formulas because they are more pediatric-specific.
Dextrose-containing solutions should be added as maintenance fluids for any patient under 30 kg.
A prospective study by Dietrich showed that colloid use results in statistically less fluid use overall, shorter lengths of stay, and reduced incidence of fluid creep.
Fluid creep is the phenomenon of giving too much fluid without accounting for previously given boluses or miscalculating total volume.
Fluid overload can lead to respiratory compromise and difficulty ventilating the patient.
If fluid creep occurs, proceed with controlled diuresis and potentially add colloid to remove excess fluid.
A Foley catheter should be placed in patients with extensive burns, multiple trauma, or electrical burns where rhabdomyolysis may occur.
All patients should receive at least a tetanus booster if their vaccination card is not available.
The speaker does not give antibiotics until there is a proven infection, as prophylactic use leads to development of resistant organisms.
Carbon monoxide levels should be checked in any patient with suspected closed-space fire or inhalational injury.
Carbon monoxide poisoning can be measured on blood gas with cooximetry by measuring oxyhemoglobin.
Patients with carbon monoxide poisoning will have normal transcutaneous oxygen saturation because all hemoglobin is saturated, but will present with low PaO2 on blood gas.
Burns evolve over time, and what initially appears superficial may become second-degree requiring surgical debridement and grafting.
Wounds should be reassessed every 24 hours for the first 48 hours.
Patients with suspected inhalational injury need to be intubated very quickly because once edema sets in, intubation becomes extremely difficult.
Superficial burns can be debrided immediately and treated on an outpatient basis with longer-acting silver-containing dressings changed in a week.
Patients with inhalational injury likely require bronchoscopy to assess airway injury extent and perform pulmonary toilet for shed mucosa and casts.
Resuscitation endpoints must be reached before surgical procedures, with urine output as the primary endpoint: 1 cc/kg/hr for children under 30 kg and 0.5 cc/kg/hr for those over 30 kg.
If a patient with chest burns is desaturating without good chest rise, an escharotomy may be needed with incisions in the anterior axillary lines bilaterally and an oblique chevron incision connecting them.
Half of the calculated fluid should be given in the first 8 hours and the remainder over the next 16 hours.