We do the sorting. You do the medicine.
ICU and trauma · Core05 / 13

Child with major burns and inhalation injury for excision4-year-old girl, 16 kg, 48 hours after a house fire

Burns: inhalation injury, fluid resuscitation and excision blood loss in a child

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Lund–Browder chart for burn size in children; the rule of nines is less accurate.
  • Parkland: 4 mL/kg per %TBSA in 24 hours, giving half by hour 8; children also need glucose maintenance.
  • Urine output target: 1 mL/kg/h in children.
  • Avoid suxamethonium from 48–72 h after a burn.
  • Each 1% TBSA excised costs 3.5–5% of blood volume.

The patient

4-year-old girl, 16 kg, 48 hours after a house fire; 35% TBSA partial and full-thickness burns, including a circumferential chest burn. Hoarse with soot in the mouth on arrival; intubated with a cuffed tube at the referring hospital. Carboxyhaemoglobin 14% then, now 2%. Listed for first excision and grafting of 15% TBSA. Vitals: HR 148, BP 92/54, SpO2 95% on FiO2 0.5, temperature 36.4 °C; urine 0.6 mL/kg/h.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 4-year-old with 35% burns and inhalation injury, ventilated, for her first excision and grafting. Patient
    • As a child she has more surface for her size, so she loses heat faster.
    • Burn size from a Lund–Browder chart; the rule of nines misleads in children. Disease
    • Hoarseness and soot meant inhalation injury; carbon monoxide and cyanide both poison her cells.
    • Her urine at 0.6 is below the 1 mL/kg/h I want in a child.
    • Excising 15% could lose 3.5–5% of her blood volume per 1%, so over half her volume. Surgery

  2. Prepare

    How do you prepare her?

    Show the answerHide the answer
    • At 48 hours the Parkland day is over: glucose maintenance plus losses, titrated to 1 mL/kg/h urine. Disease
    • Not too much: over-resuscitation causes compartment syndromes, lung oedema and deeper burns.
    • Her tube is tied around the head, not taped over burns, and its length is checked. Airway
    • Airway swelling changes day to day, so I recheck the cuff for leak and overpressure.
    • Blood crossmatched and in the room before the first cut. Crisis
    • Theatre heated, warm blankets for transfer, all fluids warmed. Disease

  3. Plan

    What is your anaesthetic plan?

    Show the answerHide the answer
    • No suxamethonium: at 48 hours she's in the window for a hyperkalaemic arrest. Airway
    • Non-depolarising relaxants: she'll need bigger doses, and they'll wear off sooner. Disease
    • Her opioid and ketamine needs rise after burns, so I titrate to effect.
    • Lung-protective ventilation for her inhalation injury.
    • Temperature above 36 °C; below that, bleeding, infection and lung injury increase.
    • Back to the burns ICU ventilated; feeding and infection watch continue. After surgery

  4. Crisis

    Turned prone for her back, her peak airway pressure climbs to 38 cmH2O, SpO2 89% and ETCO2 rising. What do you do?

    Show the answerHide the answer
    • High pressure: check tube position, kinks, secretions and bronchospasm first. Crisis
    • Hand-ventilate on 100% oxygen to feel her compliance.
    • Her circumferential chest eschar can stop the chest expanding: a restrictive cause.
    • Ask the surgeon for an escharotomy of the chest wall now. Surgery
    • Suction, and bronchoscopy if soot or casts are blocking her airways. Crisis

  5. Crisis

    Halfway through excision, HR 175, BP 60/35, temperature 35.1 °C, Hb 6.8 g/dL. What do you do?

    Show the answerHide the answer
    • Massive haemorrhage in a child: surgeons pause, pack and compress. Crisis
    • Massive transfusion: red cells, plasma and platelets, guided by tests, since 1:1:1 hasn't helped children.
    • At 35.1 °C: warmer room, warmed products; her cold makes the bleeding worse.
    • Calcium chloride 20 mg/kg slowly for the citrate load.
    • Tranexamic acid 15–20 mg/kg, maximum 1 g, then 2 mg/kg/h.
    • Stop at a safe area; the rest is staged over later days. After surgery

Fatal mistakes

  • Suxamethonium days after a major burn.
  • A cold theatre for a burned child.
  • Pushing fluid well beyond what her urine output asks for.

Checked against: Miller 10e

Report a problem with this case

Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.

All ICU and trauma casesBack to today