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CRANAplus Q&A: Paediatric burns

14 Aug 2023

“Hi CRANAplus. Paediatric burns are not uncommon in the community I work in. These often result from spilled boiling water. Despite having previous experience/ training in burns, I still find myself lacking confidence at the thought of responding to paediatric burns. In borderline cases I sometimes struggle to know if paed. burns need referral and retrieval. What advice can CRANAplus offer?” Jane

Have a ques­tion about work­ing in remote health that you’d like answered in the mag­a­zine? Email your ques­tions to communications@​crana.​org.​au. We’ll fea­ture select­ed ques­tions in the mag­a­zine and arrange for an expe­ri­enced RAN or expert to answer your ques­tion in an upcom­ing edition.

Hi Jane,

Thanks for your ques­tion. Below, I’ve pro­vid­ed an overview of the approach to burns that we teach dur­ing cours­es, which uses the C.R.A.N.A. mnemonic.

C) Con­text: Your remote/​isolated situation 

Burn injuries pose a sig­nif­i­cant risk to the health and lives of chil­dren in Aus­tralia. Research has con­sis­tent­ly shown that Indige­nous chil­dren and those resid­ing in rur­al and iso­lat­ed regions bear a dis­pro­por­tion­ate bur­den of burn injuries – your inter­est in burns care is well-founded.

R) Respond: Pri­ma­ry Sur­vey (+ triage considerations)

Like all trau­mas, pae­di­atric burn assess­ments require a pri­ma­ry and sec­ondary sur­vey with the ini­tial aim of iden­ti­fy­ing and man­ag­ing imme­di­ate life threats. It’s impor­tant to not get dis­tract­ed by the burn injury; a prompt and accu­rate ini­tial assess­ment and triage are essen­tial for ensur­ing appro­pri­ate and time­ly care. This lays the foun­da­tion for a com­pre­hen­sive treat­ment plan.

A) Assess & Man­age: Sec­ondary Sur­vey (+ tar­get­ed assess­ments & interventions) 

Deter­min­ing burn extent and depth
An accu­rate assess­ment of burn extent and depth is cru­cial for deter­min­ing the appro­pri­ate man­age­ment strat­e­gy. In pae­di­atric patients, this task requires care­ful atten­tion due to unique anatom­i­cal and phys­i­o­log­i­cal con­sid­er­a­tions. Clin­i­cians employ a com­bi­na­tion of clin­i­cal exam­i­na­tion, burn area esti­ma­tion tools such as the Lund & Brow­der Chart or the Rule of 9s, and in some cas­es, imag­ing tech­niques to deter­mine the pre­cise extent and depth of the burn injury in chil­dren. Employ­ing stan­dard­ised assess­ment tools helps ensure con­sis­tent and reli­able eval­u­a­tion, enabling tai­lored treat­ment plans.

Assess­ing burn depth

Man­ag­ing Burns in Infants and Young Chil­dren
We teach the FACADE mnemon­ic for this step:
First aid, Anal­ge­sia, Clean, Assess, Dress, Elevate.

It’s impor­tant to note that babies and young kids have spe­cial vul­ner­a­bil­i­ties that require spe­cif­ic atten­tion. Skin phys­i­ol­o­gy, body sur­face area-to-weight ratio, and the poten­tial for devel­op­men­tal com­pli­ca­tions must all be con­sid­ered. Cau­tious flu­id resus­ci­ta­tion, metic­u­lous wound care, and atten­tion to pain man­age­ment are para­mount. Infants and young chil­dren may be more sus­cep­ti­ble to heat-relat­ed injuries, demand­ing proac­tive pre­ven­tion strate­gies. A mul­ti­dis­ci­pli­nary approach involv­ing pae­di­atric spe­cial­ists ensures opti­mal care for these young patients.

Flu­id Resus­ci­ta­tion Guide­lines
Flu­id resus­ci­ta­tion is a crit­i­cal com­po­nent of man­ag­ing pae­di­atric burn patients, aim­ing to restore and main­tain prop­er cir­cu­la­tion and per­fu­sion. How­ev­er, the flu­id require­ments in chil­dren dif­fer from those in adults. Care­ful assess­ment of burn size, depth, and asso­ci­at­ed fac­tors deter­mine the appro­pri­ate flu­id resus­ci­ta­tion approach. The Mod­i­fied Park­land For­mu­la is the accept­ed stan­dard in most clin­i­cal areas for cal­cu­lat­ing flu­id require­ments in pae­di­atric burns.

mala­js­cy — stock​.adobe​.com.

N) Next step: Com­mu­ni­ca­tion: retrieval/​referral

Refer­ring pae­di­atric burn patients to spe­cialised burn cen­tres is cru­cial for ensur­ing opti­mal out­comes. Con­sid­er trans­fer when the child is requir­ing care beyond the com­fort lev­el of the clin­ic or hos­pi­tal and gen­er­al­ly for all burns that are:

  • >10% TBSA
  • All full thickness
  • Spe­cial areas: face, ears, eyes, neck, hands, feet, gen­i­talia, per­ineum, or a major joint, even if <10%
  • Cir­cum­fer­en­tial
  • Chem­i­cal
  • Elec­tri­cal
  • Asso­ci­at­ed with trau­ma and/​or spinal cord injury
  • All inhalation/​airway
  • Chil­dren <12 months

Recog­nis­ing these cri­te­ria and prompt­ly refer­ring patients to spe­cialised cen­tres facil­i­tates access to a com­pre­hen­sive range of exper­tise, resources, and spe­cialised ther­a­pies, ensur­ing the best pos­si­ble care for chil­dren with severe burn injuries.

A) Assist team: Lead­er­ship in emergencies 

CRANAplus encour­ages staff to utilise sup­port frame­works such as the TAKE STOCK Hot Debrief Tool to ensure that you and your col­leagues have an oppor­tu­ni­ty to reflect on events in a sup­port­ed man­ner. An event meets the cri­te­ria for a hot debrief in cas­es of an unex­pect­ed death, dis­tress­ing event, staff request, unex­pect­ed out­come, and pae­di­atric resuscitation.

I hope this is of assistance. 

Brooke Mal­oney
Remote Clin­i­cal Edu­ca­tor CRANAplus

For fur­ther edu­ca­tion on man­ag­ing pae­di­atric emer­gen­cies includ­ing burns con­sid­er attend­ing CRANAplus’ Pae­di­atric Emer­gency Care & Pae­di­atric Advanced Life Sup­port course. You can find more info at crana​.org​.au/​p​e​cpals