ADDITIONAL CONSIDERATIONS FOR PEDIATRIC BURN PATIENTS
Deployed surgical teams frequently provide initial care for injured local national children. Burn care for children generally follows adult recommendations, with a few modifications as itemized below.9 See Appendix C: Pediatric Lund Browder Burn Estimate and Diagram.
Airway patency can be lost early in small children with facial or extensive burns as modest mucosal edema can quickly compromise their small airway; carefully securing the ETT with umbilical tie and adequate sedation is important to prevent unplanned extubation.
Peripheral or intraosseous vascular access may suffice initially, but central venous access is more reliable during formal burn resuscitation; catheters should be sewn in place.
Children with burns under 15% TBSA usually do not need a calculated resuscitation. They can be given 1.5x calculated maintenance rate (see 4-2-1 Rule below9) and have diapers weighed for urine output. If they can eat, they should be allowed access to bottle feeds. Some of these children can be supported enterally, with nasoenteric infusions of World Health Organization (WHO) resuscitation formula (1L clean water, 8 tsp sugar, ½ tsp salt, and ½ tsp baking soda).10
- Children with acute burns over 15% of the body surface usually require a calculated resuscitation. Place a bladder catheter (size 6 Fr for infants and 8 Fr for most small children). The Modified Brooke formula (3 mL/kg/%TBSA LR or other isotonic fluid divided over 24 hours, with one-half given during the first 8 hours) is a reasonable starting point. This only provides a starting point for resuscitation, which must be adjusted based on UOP and other indicators of organ perfusion. Goal UOP for children is 0.5-1mL/kg/hr. Decrease or increase the isotonic fluid rate by approximately 20-25% per hour to maintain UOP at 0.5-1mL/kg/hr.
- Very young children do not have adequate glycogen stores to sustain themselves during resuscitation. Administer a maintenance rate of D5LR to children weighing < 20 kg. Utilize the 4-2-1 rule: 4ml/kg for the first 10kg + 2ml/kg 2nd 10kg + 1ml/kg over 20kg. This maintenance rate is in addition to the isotonic infusion calculated for burn resuscitation and is not titrated.
- In children with burns > 30% TBSA, early administration of may reduce overall resuscitation volume. If needed, initiate 5% albumin at the child’s calculated maintenance rate (use the 4-2-1 rule) and subtract this from the isotonic fluid rate; the albumin rate is maintained while the isotonic fluid is adjusted based on UOP.
- Monitor resuscitation in children, like adults, based on physical examination, input and output measurements, and analysis of laboratory data. The well-resuscitated child should have alert sensorium, palpable pulses, and warm distal extremities; urine should be glucose-negative. Monitor electrolytes every 8 hours during the first 72 hours to pick up hypo- and hypernatremia and hypocalcemia. If available, monitor calcium levels and replete to maintain iCa >1.1.
- Cellulitis is the most common infectious complication and usually presents within 5 days of injury. Prophylactic antibiotics do not diminish this risk and should not be used unless other injuries require them. Most anti-streptococcal antibiotics such as penicillin are successful in eradicating infection. Initial parenteral administration is advised for most children presenting with fever or systemic toxicity.
- Nutrition is critical for pediatric burn patients. Nasogastric feeding may be started immediately at a low rate in hemodynamically stable patients and tolerance monitored. Start with a standard pediatric enteral formula (e.g. Pediasure) targeting 30-35 kcal/kg/day and 2g/kg/day of protein.
- Children may rapidly develop tolerance to analgesics and sedatives; dose escalation is commonly required. Ketamine and propofol are useful procedural adjuncts.
When burned at a young age, many children will develop disabling contractures. These are often very amenable to correction which may be performed in theater with adequate staff and resources. Seek early consultation from the USAISR Burn Center (DSN 312-429-2876 (BURN); Commercial (210) 916-2876 or (210) 222-2876; email usarmy.jbsa.medcom-aisr.list.armyburncenter@health.mil).
Opportunities for pediatric surgical care provided by Non-Governmental Organizations (NGOs) may be the best option but require the coordinated efforts of the military, host nation, and NGOs.
Pediatric specific questions can be asked through the Burn consult hotline (ask to coordinate with the pediatric intensivist).