Trauma and burns in children

Trauma is the leading cause of death and disability in children, most often resulting from blunt trauma. An immediate co-ordinated and pathology-focussed resuscitation will contribute to improved morbidity and mortality outcomes. This article discusses the principles of the primary and secondary survey in injured children and outlines the management of children suffering from burns. A multi-professional approach to the treatment of critically injured children should be adopted, where the primary survey aims to identify and manage catastrophic haemorrhage followed by management of life-threatening injuries to airway, breathing and circulation. The secondary survey includes a detailed examination to identify and manage other subtle or less severe injuries. Attention to fluid therapy, analgesia, thermoregulation, blood coagulation and glucose homeostasis form important aspects of this secondary survey. Children injured in fires may have suffered from smoke inhalation or sustained burns to the upper airway, with rapid swelling of mucosal tissue, which can make immediate control of the airway very challenging. Both flame burns and scalds can cause substantial fluid losses and are associated with increased risk of mortality.     

Trauma and burns in children

Trauma is the leading cause of death and disability in children, most often resulting from blunt trauma sustained in motor vehicle accidents and falls. An immediate coordinated resuscitation may contribute to improved morbidity and mortality outcomes. A multi-professional approach to the treatment of critically injured children should be adopted; where the primary survey aims to identify and manage immediately life-threatening injuries to airway, breathing and circulation. Following cardiovascular stabilization, the secondary survey serves to structure a detailed examination for other more subtle or less severe injuries. Attention to fluid therapy, analgesia, thermoregulation and glucose homeostasis form important aspects of the secondary survey. Children injured in fires may have suffered from smoke inhalation or sustained burns to the upper airway, with rapid swelling of mucosal tissue, which can make immediate control of the airway very challenging. Both flame burns and scalds can cause significant fluid losses and are associated with a significant risk of mortality. This review discusses the principles of the primary and secondary survey in injured children, fluid resuscitation and outlines the management of children suffering from burns.     

Laryngeal mask airway use in children with acute burns: intraoperative airway management

Paediatric patients with acute burns often require many operative procedures in short succession; yet due to inhalation injury or recent extubation their airways may be susceptible to tracheal tube induced damage. We proposed the laryngeal mask airway (LMA) as a useful airway management tool in this setting. In this prospective study, 80 eight (88) patients with mean age (+/- SD) of 7.8 +/- 4.7 years and average percentage total body surface area burned (%TBSA) of 21 +/- 18% had their airways managed with an LMA while in the operating room for 141 procedures. Twenty-five patients (28.4%) had been previously intubated for burn management and 19 (21.6%) had evidence of inhalation injury. During each procedure, the patient was evaluated for airway obstruction, laryngospasm, inability to ventilate, hypoxaemia, evidence of aspiration/regurgitation or any situation which required intraoperative manipulation/removal of the LMA. Of the 141 procedures, 122 were without airway problems. Of the remaining 19, nine required only a simple reseating of the LMA for correction. The other 10 events include arterial desaturation (n = 3), partial laryngospasm (5), airway obstruction (1) and regurgitation without aspiration (1). In each case, corrective action led to resolution of the problem with no patient morbidity. This series demonstrates the LMA is a safe and efficacious airway management device in the paediatric burn population.     

Pulmonary burns in children.

Basic concepts have evolved from a 15-yr experience in the management of 101 children with inhalation injuries. Progression through three distinct clinical stages--bronchospasm (1--12 hr post-burn), pulmonary edema (6--72 hr), and bronchopneumonia (after 60 hr)--was often noted. Success in outcome appeared to depend upon treatment that conformed to the pathophysiologic state present, a pulmonary toilet being both thorough and aseptic, tracheotomy being reserved for true glottic or supraglottic airway obstructions, the sharp division of strangulating or suffocating constrictions caused by cervical or thoracic eschars, use of ventilators primarily to maintain arterial pO2 above 60 mm Hg and to reverse otherwise intractable pulmonary edema, corticosteroids being administered as a single intravenous bolus and only for overt bronchospasm, and parenteral antibiotic therapy being based upon sputum smears and cultures for established pneumonia alone, never as prophylaxis.     

Sociodemographic and culture results of paediatric burns

Paediatric burn wounds are challenging conditions to manage for both the doctors and patients and can cause several complications entailing a complicated treatment and recovery process. This study aims to evaluate sociodemographic conditions and antibiogram culture results of paediatric burn wounds. Our study retrospectively evaluated 419 paediatric patients with burns regarding age, gender, burn area and degree, total days spent in hospital, surgical history, final condition, additional disease history, previous attempts, and culture results with their antibiotic resistances, haemogram results, C‐reactive protein results, sociocultural conditions, burned region of the body, and structure of the burn. The prominent observations were an increased rate of incidence in male patients and patients with low socioeconomic conditions, the highest incidence of burns from scalding and domestic accidents, and the highest incidence of third‐degree burns. Furthermore, even though the most encountered burn types were extremity burns, the burn types with the highest culture growth ratio were the perineum burns. The dominant culture growth bacterial group was coagulase‐negative staphylococcus, and the ratio of medication resistance was 67.8%. It is imperative to raise awareness regarding domestic accidents to prevent paediatric burn wounds. The mortality risk can be reduced by carefully monitoring multiple organ involvement and providing timely treatment. Moreover, appropriate wound care is warranted to avoid infection from skin flora.     

Trauma and burns in children

Trauma is the leading cause of preventable death in children, most often resulting from accidents involving motor vehicles or falls. A coordinated resuscitation effort in the early phase may contribute to improved morbidity and mortality outcomes. A multi-professional approach to the initial treatment of a critically injured child should be adopted: the primary survey aims to identify and manage immediately life-threatening conditions relating to a patients airway, breathing or circulatory system. Following cardiovascular stabilization, the secondary survey serves to structure a detailed examination for less severe or more occult injuries. Attention to fluid therapy, analgesia, thermoregulation and glucose homeostasis forms an important component of the secondary survey. Children injured in fires may have flame burns to the upper airway or have suffered smoke inhalation, where immediate control of the airway and ventilation may be challenging. Both flame burns and the more common scalds cause significant fluid losses and carry a high risk of mortality from late complications. This review discusses the principles of performing a primary and secondary survey in injured children, options for fluid resuscitation and outlines the management of children suffering from burns.     

Trauma and burns in children

Trauma is the leading cause of preventable death in children. Most often resulting from accidents involving motor vehicles or falls. A coordinated resuscitation effort in the early phase may contribute to improved morbidity and mortality outcomes. A multi-professional approach to the initial treatment of a critically injured child should be adopted: the primary survey aims to identify and manage immediately life-threatening conditions relating to a patients airway, breathing or circulatory system. Following respiratary and cardiovascular stabilization, the secondary survey serves to structure a detailed examination for less severe or more occult injuries. Attention to fluid therapy, analgesia, thermoregulation and glucose homeostasis forms an important component of the paediatric resuscitation. Children injured in fires may have flame burns to the upper airway or have suffered smoke inhalation, where immediate control of the airway and ventilation may be challenging. Both flame burns and the more common scalds cause significant fluid losses and carry a high risk of mortality from late complications. This review discusses the principles of performing a primary and secondary survey in injured children, options for fluid resuscitation and outlines the management of children suffering from burns.     

Nanocellulose‐based wound dressing for conservative wound management in children with second‐degree burns

The initial care of burn wounds and choice of dressing are pivotal to optimally support the healing process. To ensure fast re‐epithelialisation within 10–14 days and prevent complications, an optimal healing environment is essential. An innovative dressing based on nanocellulose was used for the treatment of burns in children. Children (0–16 years) with clean, partial‐thickness burn wounds, 1 to 10% of the total body surface area were included. Complete re‐epithelialisation was achieved within 7–17 days, with 13 patients showing re‐epithelialised >95% by day 10. Satisfying results concerning time to re‐epithelialisation and material handling were obtained. The possibility to leave the dressing on the wounds for 7 days showed a positive effect in the treatment of children, for whom every hospital visit may cause massive stress reactions. The nanocellulose‐based dressing is a promising tool in conservative treatment of burns. Reducing the frequency of dressing changes supports a fast and undisturbed recovery; moreover, the dressing provides an optimal moist healing environment. The time to re‐epithelialisation is comparable to frequently used materials, and cost reduction effect can be achieved without loss of quality. Possible pain and distress levels are kept to a minimum; therefore, flexibility and compliance of the patients and their parents are enhanced.     

Day surgery for children

Day surgery is particularly well suited to the paediatric population, and an increasing number of procedures spanning different surgical specialities are now being carried out in the ambulatory setting. A significant advantage to the family and the child is the minimal disruption to their routine and lives, reducing the potential impact an overnight stay may incur.This article summarizes the essential components needed to provide a high-quality paediatric day surgery service. It also highlights the importance of good preoperative assessment, which involves having rigorous inclusion and exclusion criteria, but also comprising some degree of flexibility allowing evaluation of children on an individual basis. Strategies to minimize postoperative pain and nausea and vomiting are also discussed, with emphasis being placed on the safe discharge of these children home.     

Abdominal and thoracic trauma in children

Trauma is a leading cause of death and disability in children. The following contribution discusses the important anatomical and physiological differences between children and adults. Important aspects of the recognition and management of thoracic and abdominal injuries in children are discussed.     

Lactated Ringer with 1% dextrose: an appropriate solution for peri-operative fluid therapy in children

Peri-operative blood glucose, total protein, and electrolytes values were measured in children (3–120 months) scheduled for minor surgery and randomly assigned to three groups according to the type of fluids administered during anaesthesia: children of RL group (n= 27) received lactated Ringer, those of RLD1 group (n= 25), 1% dextrose in lactated Ringer, and those in RLD2.5 group (n= 27), 2.5% dextrose in 0.4 N saline (50% D5, 50% RL) (63 mmol·l^-1). Infusion rate was set according to children's age and weight. Fluids were infused throughout the study with volumetric infusion pumps. Blood samples were obtained at induction (T0), at the end of surgery (T1), 30 and 60 min later (T2, T3). Pre-operative blood values were within the normal ranges except for high total protein values in all groups of children and for asymptomatic hypoglycaemia (2.3 and 2.5 mmol·l^-1) in two children. Blood glucose increased significantly in the three groups post-operatively (P < 0.001), and this increase was related to the amount of glucose infused. Glucose values differed significantly between groups at T1 and T2, while blood glucose values were back to the normal ranges at T2 and T3 in the RL group. Sodium values remained unchanged post-operatively in both RL and RLD1 groups, while a significant decrease was observed in the RLD2.5 group (P < 0.001). Total protein decreased in the three groups post-operatively (P < 0.001) towards normal values. These data suggest that RLD1 is appropriate for peri-operative fluid therapy in children. Its administration at the infusion rate used in this study, resulted in moderate post-operative hyperglycaemia while avoiding the risk of peri-operative hypoglycaemia, maintaining a constant extracellular fluid composition and correcting pre-operative fluid deficit.     

Early excision of major burns in children: effect on morbidity and mortality

The advantage of early excision and grafting in the treatment of limited full-thickness burns has been clearly established. The goal of the present study was to evaluate the role of early burn wound excision in major pediatric burns. Of the 470 pediatric burn admissions between 1979 and 1984 that were reviewed, 53 patients met the criteria of deep second or third degree burns greater than 25% total body surface area (TBSA). Of these, 20 had burn wound excision within 7 days (Early) and 33 had delayed excision and grafting (Late). The Early group, despite having greater transfusion requirements (69.4 v 36.2 cc/kg), had shorter hospital stays (35.3 v 49.1 d, P less than 0.05), fewer metabolic complications (20% v 79%, P less than 0.001), and less burn wound contamination (55% v 90%, P less than 0.01) than the Late group. Mortality was lower in the Early group (0% v 12%), but this was not statistically significant. Early excision and grafting are therefore recommended in the care of major burns in children.     

Critical care management of patients with severe burns and inhalational injury

Anaesthetists and critical care physicians involved in emergency care provision must be equipped with the adequate knowledge and skills to accurately assess and manage patients with severe burns. This summary aims to review the key principles in managing patients with severe burns including airway management, fluid resuscitation, sedation, burn care, analgesia and nutrition.     

Critical care management of patients with severe burns and inhalational injury

Anaesthetists and critical care physicians involved in emergency care provision must be equipped with the adequate knowledge and skills to accurately assess and manage patients with severe burns. This summary aims to review the key principles in managing patients with severe burns including airway management, fluid resuscitation, sedation, burn care, analgesia and nutrition.     

Cardiorespiratory changes during laparoscopic fundoplication in children

The results of a prospective assessment of cardiorespiratory changes related to anaesthesia and laparoscopic Nissen fundoplication are described in 25 children aged 1.2 to 14.3 years, weighing 9.0 to 64.0 kg. Respiratory disease or oesophagitis were present in 68% cases. During balanced inhalational anaesthesia, hypotension or bradycardia occurred prior to peritoneal insufflation in three cases of reverse Trendelenburg position. During surgery, intra-abdominal pressure was in the 6–10 mmHg range. Transiently, two patients were hypotensive while ten were hypertensive. PETCO₂ gradually increased but only two patients required increased minute ventilation. One bronchial intubation episode developed. Airway complications were related to isoflurane administration. Postoperatively, transient hypoxia (25% cases) was observed during the first 3 h. Analgesia duration was in the 40–1440 min range. Hospital stay was 5.6 ± 1.5 days (mean ± SD). Laparoscopic paediatric fundoplication is safe when hypovolaemia and postoperative hypoxia are prevented.     

Trauma resuscitation and the damage control approach

Haemorrhage remains the biggest killer of major trauma patients. One-third of trauma patients are coagulopathic on admission, which is exacerbated further by other factors. Failure to address this results in poor outcomes. Damage control resuscitation is current best practice for bleeding trauma patients, and encompasses specific techniques in resuscitation, surgery and interventional radiography. This article summarizes the latest strategies in the field of trauma resuscitation.     

Management of burns

Burns are common injuries that vary in severity from small superficial scalds to massive full-thickness flame burns with high morbidity and mortality. The purpose of this article is to review common burn presentations and the pathophysiology of these injuries. In addition it gives the reader an overview of burns management from the emergency department through to the specialist burns centre and describes the latest multi-disciplinary approach to treating these injuries.