Primary survey ABCDEF in children

If your burn patient is a child, you will need to carry out the primary survey (ABCDEF method) with some adjustments. Special considerations for pediatric patients include fluid resuscitation calculations and points of attention for airway, breathing, circulation and exposure.

You should conduct the primary survey with the adjustments outlined on this page for every pediatric burn patient.

The order of assessment is designed to ensure that the most life-threatening issues are treated first. It is therefore vital you follow the process in order, even if the burn injury distracts you from other injuries.

Secure your own safety first

Always secure your own safety before helping a burn patient. Once you are safe, you can begin to stop the burn and help the patient.

Airway

Airway obstruction in pediatric burn patients may occur, even in the absence of inhalation injury. This is because the diameter of the pediatric airway is small and tissue is loose. Edema develops rapidly, and therefore the threshold for intubation should be low.

With this in mind, follow the instructions outlined for adults.

Airway in adults

Breathing

Children are more reliant on diaphragmatic breathing. Diaphragmatic movement may be impaired by circular burns, burns of the anterior and lateral aspect of the chest, and burns to the upper half of the abdomen. In these cases, escharotomy should be considered.

With this in mind, follow the instructions outlined for adults.

Breathing & ventilation in adults

Circulation

When emergency venous access is required and percutaneous cannulation is impossible, the preferred technique to obtain access for fluid resuscitation is to insert an intraosseous needle.

Disability, neurological deficits & gross deformity

Follow the instructions outlined for adults.

Exposure & environmental control

Pediatric patients are particularly susceptible to hypothermia and will need increased active warming. In comparison to adults, children have an increased body surface area to weight ratio. This has several effects, such as:

  • A higher metabolic rate
  • Greater evaporative water loss (also due to less fat and shivering)
  • Greater heat loss

Fluid resuscitation

1 Start fluid resuscitation in pediatric patients with burns >10 % TBSA.

2 To prevent hypoglycemia in children up to 30kg, add maintenance fluids (2.5% glucose and 0.45% NaCl), administered continuously and spread evenly over the first 24 hours (commencing from when fluids are first administered). Calculate the volume of maintenance fluids required as follows:

  • 100ml/kg/24h (<10kg)
  • + 50ml/kg/24h (10-20kg)
  • + 20ml/kg/24h (20-30kg)

3 Measure urine output to assess the efficacy of fluid resuscitation. This is the most important way of monitoring the adequacy of fluid resuscitation but is only possible with an indwelling urinary catheter (IDC). The urine output should be at least:

  • Infants: 1.0-2.0 ml/kg/hour
  • Children: 1.0-1.5 ml/kg/hour

4 If urine output is inadequate, administer extra resuscitation fluids via boluses of 5-10 ml/kg and/or increase the volume of resuscitation fluid (not maintenance fluid) to be administered within the next hour to 150% of the planned volume.

5 Continue to administer IV maintenance fluids beyond the first 24 hours post-injury, if required. This is especially important when oral intake cannot be monitored properly. Depending on parenteral capability and circumstances switch to oral fluids when it is safe to do so.

Fluid resuscitation may be problematic in children

For example, children with a large TBSA burned have a high risk of hypoglycemia, fluid overload and dilutional hyponatremia. To prevent this:

  • Measure blood glucose and electrolyte levels regularly
  • Start administration of carbohydrates early – administer by enteral feeding or by the addition of dextrose to the electrolyte solution
  • Limit free water intake.

Children are more prone to gastric dilatation, so it may be necessary to insert a nasogastric tube early on. Start enteral feeding very early in order to prevent loss of gut function and maintain nutrition, as children have a high metabolic rate and nutritional requirements.

Calculating fluids for a child

Child is 24kg, 17% TBSA burned.

Resuscitation fluids:3ml x 24kg x 17 = 1224 ml

Administer 50% of the fluid within the first 8 hours post-injury: 612ml (= 102ml/h).

Administer 50% of the fluid over the next 16 hours: 612 ml (=38.25 ml/h).

In addition provide maintenance fluids (2.5% glucose and 0.45% NaCl) (100 ml x10 kg) + (50 ml x 10 kg) + (20 ml x 4 kg) =1430 ml

Administer 1430 ml/24h (=59.5 ml/h).

Primary survey ABCDEF in children

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