part of your professional curricular care review course, pediatric. Couple of disclosures. I do have some federal funding, one from the ASPR and two from HRSA. It should not have direct impacts on this talk, but it does involve pediatric disaster and trauma support. The objectives of our talk today. Today, we're attempting to help prepare you for the pediatric curricular care board examination. A few things that we want to cover as part of that board exam. One is reviewing standard approaches to trauma assessment stabilization, also understanding the patterns of injury and clinical manifestation of brain and spinal cord trauma. We'll understand patterns of injury seen on imaging in brain and spinal cord trauma. We'll plan treatment for patients with brain injuries and understand the management of burn inhalation injuries. Today, we're going to be going over some epidemiology, clinical assessment, spinal cord injuries, burns and inhalations, electrical injury, submersion injuries, and heat, some heat exposure injuries. But why is this an important topic to begin with? Beyond just being on the board examination, actually, it's a fundamental topic to the care of children. Injury-related causes of brain and spinal cord injury is a significant cause, more than all their causes of death combined for children. More than 61% of causes, especially as you see the data highlighted from this article from the New England Journal of Mental Health in 2018. Trauma is the leading cause of death and disability of children in the US, more than all other causes of death combined. It leads to 50,000 disabled children per year and globally, a million pediatric deaths per year. Yet, it only gets about a 20th of the funding of malignancy. The good news is, due to some pretty amazing public health works over the last 25 years, we've been able to decrease that cause of death and disability by almost 50%. Intracranial injuries are still the major cause of death. Somewhere around 2.5% of all injured children will die. Many more mild to moderate functional limitations. Automobile accidents, this includes people in cars getting accidents and also kids can get hit by cars account for 75% of all the deaths. Most of these are in the pre-hospital setting. Younger children are actually more likely to die The younger children obviously tend to be passengers and they can be unrestrained, which causes a significant problem, or restrained, which sometimes leads to more spine or bowel trauma than we see in the unrestrained. Older kids tend to be the pedestrians, the people hit by cars as they run across the street or on bikes and hit by cars. Of note, child abuse accounts for about 3% of all major traumatic injuries. So how do we approach kids that have a significant injury? Well, we group this into some fundamental concepts around advanced trauma life support, which really, ATLS is just a systematic, controlled, repeatable, universal approach to how we take care of an injured patient. We want to be doing it the same way every time so we don't miss any injuries. We treat the most life-threatening things first. Definitive diagnosis is not the goal. The goal is to maintain airway and perfusion. Time is of the essence. There are certain time-sensitive diagnoses, such as attention pneumothorax, that you don't want to miss. You want to address early to save this patient. Of course, do no further harm. We'll talk a little bit more in a few slides about what we mean by damage-controlled resuscitation. But this means, again, addressing the most life-threatening things first. How we organize our activities in advanced trauma life support is really around primary and secondary survey. What do we mean by primary survey? This is that quick assessment we do of A, B, C, D, and E. And we'll go through each of these. But each of these is a hard stop, meaning right now, as you see on the slide, we're going to talk about airway. You want to assess the airway. If it's not intact, you stop, and you make it intact, and then you move on. Breathing, again, whether it's intact or not, how do we separate between airway and breathing? Airway, what we really mean is the larger airway structures, the trachea, the main bronchi, the face, large airway passages. What we mean by breathing, it's the actual mechanics of breathing, and it's the lung parenchyma itself. Circulation, this is key, right? This is hemorrhage control and volume replacement, which we'll repeat a few times. But circulation means you want to perfuse. And what are you interested in perfusing the most right now in the trauma bay? It's going to be the brain and the heart. Disability, this means getting an assessment of potential neurologic injuries, potential broken bones. It's seeing how the patient's moving. And then E, critically important, which is the exposure and environmental control. This means that you're looking at every body surface area, that you're not missing any injuries or holes, such as a stab wound or a gunshot wound. You're also trying to prevent hypothermia. Each step, as I said, is a hard stop. You fix them, and you move on. So airway and breathing, what are we looking for? Well, we're looking for patency. Is there blood, debris, teeth? Is there tracheal injury or swelling? Is there stridor? For breathing, we're assessing that you actually have equal breath sounds, symmetric chest rise, that your trachea is midline, and you have adequate respiratory effort. Circulation, it's hemorrhage control and volume replacement. If you have a hypotensive trauma patient, it is from hypovolemic shock. It is bleeding until proven otherwise. You want to make sure you have that hemorrhage control started and you're replacing volume early. Hypotension in kids is a big problem, right? From a traumatic injury standpoint, this is at the last part of the compensatory mechanism for maintaining perfusion. They're going to be sniffing the tachycardic. It's not till the very end when they're starting to fall off that physiologic cliff that they're going to become hypotensive. It's a late sign. If you're hypotensive after trauma, that means you have a significant injury and likely significant blood loss. Shock is hypovolemic until proven otherwise. As I said, bleeding, bleeding, bleeding. One of the keys to piantra trauma is that, in general, bleeding slows down a little bit faster maybe than an adult because vasculature is able to constrict. They haven't been smoking or drinking for 30 years. Heart rate is an incredibly sensitive assessment for cardiac output and the volume status in the child. If they're becoming tachycardic, which remember in a healthy teenager, might just be in to the high double digits, they might seriously be trying to compensate for volume loss. Part of circulation is what we call the lethal triad. Lethal triad is hypothermia, acidosis, and coagulopathy. If you have these three things, you are going to die. All significantly injured trauma patients have the development of these three things. How do we are approaching the trauma patient? How are we treating them? It's tackling each of the points of this triad. It's hitting all three of these things. If you have all three of these things, you are starting to lose physiologic control of the patient. You need to take control again. How are you doing that? You're getting better perfusion, thus fixing acidosis. You're replacing the blood products that are lost, fixing the coagulopathy. And you are getting them warm, fixing the hypothermia. General guidelines, it's OK in the circulation if you feel you need to replace some volume to use a small bolus of warm crystalloid that's isotonic. But in general, if you're losing blood, you want to replace that with blood. Many of the institutions you'll be at have massive transfusion protocols. Please be familiar with those. They do vary a little bit from site to site. How we monitor our volume status, which we get? Well, it's that perfusion, right? It's just like you would do any other time in the ICU. It's are they starting to make urine? Are their pulses improved? Is their capillary refill improved? Is their mental status improved? All those basic signs of perfusion. Correction of the physiologic part, meaning the lactic acidosis and the base deficit. Disability, this is a quick neurologic exam as possible. And looking for things, most importantly, is a low GCS, pupil asymmetry, and also any obvious long bone fractures. Secondary survey. Our primary survey was A, B, C, D, and Es. Secondary survey, it's just taking a little bit more time. So you've addressed the major life-threatening things. And now you're going back and you're doing a focused head-to-toe examination and rolling the patient again and making sure you're not missing any other injuries, things like skull base fractures, mid-face instability, neck tenderness, any other bruising or belly pain, ensuring the pelvis is stable, making sure you have decent rectal tone, et cetera. As a reminder, if there's any fluid or blood coming out of an orifice, do not insert a tube, meaning if there's blood with meatus, don't put a Foley in. If there's a significant amount of blood coming from the mouth, expect there is an injury. Be very careful placing an OG. When do we get radiologic studies in this initial workup? Well, they never take precedence over any sort of resuscitation. But they are helpful adjuncts, meaning you can get a portable chest X-ray and you can determine quickly whether you have a hemothorax, pneumothorax, any potential blood loss in the chest. Same thing with a portable pelvis X-ray. You can see if there's a pelvic fracture, which can hide a significant amount of blood. Fast exams, which are ultrasounds looking at the dependent portions of the abdomen plus the pericardium, can give you an idea if you have some bleeding, looking for fluid in those spaces. In general, you never take an unstable patient to radiology. That was our discussion in brief about the initial assessment and resuscitation of a trauma patient. We'll move on now to talking about the traumatic brain and then spinal cord injuries. Important to have an awareness of the pediatric modifications for GCS, the Glasgow Coma Scale. Still a scale from 3 to 15, 3 being the lowest you can get, meaning no response because there is no zeros in the scoring system. 1 is the lowest. Probably the most important number, if you can only get one of these, is the motor response. It helps to give you an overall assessment to their neurologic status. In general, we say that if your GCS is less than 8, you need to intubate. It's easy to remember. Start going below GCS of 8. The odds of you protecting your own airway, providing your own respiration, is going to be slim. When we think about traumatic brain injury, our concern really is not the initial injury. There's nothing we can do about the initial injury. It's all about avoiding secondary injury to neurons that are already damaged, that might sustain more damage if you don't properly care for the patient. Part of that avoiding secondary injury is making sure you have appropriate blood flow to the brain, that those injured neurons are supported. Part of making sure there's appropriate blood flow is having an understanding of how pressures in an enclosed space, i.e. the skull, are working. And that's known as the Monroe-Kelley Doctrine. That means that there's only a certain amount of space in your head, and it can be taken up by CSF, and brain, and arterial blood, and venous blood. And if something's going to take up more space, there has to be less of one of these others. So if you have a lesion, such as a large epidural hematoma, then there has to be less of something else to maintain the same intracranial pressure. How do we assess arterial flow specifically into the brain? And it's always fall under cerebral perfusion pressure. The cerebral perfusion pressure is the mean arterial pressure minus ICP. We want to be obtaining a normal CPP. So in order to do that, especially if our ICP is going up, we have to go up on our map to maintain that normal cerebral perfusion pressure. Just a reminder, greater than 60 for adults, younger children, 50, infants, 40. Normal auto-regulation is a change in the vascular tone. Again, maintain a normal cerebral perfusion pressure, normal flow into the vessels. TBI management. As I said, not much you can do about the underlying injury, correct? We don't have a way to directly fix injured neurons. But what we can do is allow the body to heal and give the best chance for recovery by not causing secondary injury. The whole goal of management is avoiding secondary injury. It's giving injured neurons time and space to heal. Maintaining a normal cerebral perfusion pressure. And how are we going to do that? It's blood pressure management, right? We're going to control hemorrhage to make sure we have a good map. We're going to replace volume. And we'll increase our map with things like inotropes or vasopressors if needed. How are we going to manage the ICP? Well, either removing that fixed space, meaning taking off part of the skull, removing the space-occupied lesion, like draining the epidural catheter, things to decrease the edema with osmotic agents, or decrease the CSF by putting a drain in. Also, we want to provide good sedation and seizure control. So intubation. Like we talked about, in general, less than eight, you really should intubate. There's always a gray area between kind of the eight to 12 where you might want to provide good neuroprotection. If you're going to intubate, you want to make sure you provide adequate sedation and neuromuscular blockade. You want to do it in a really thoughtful manner because what you don't want to do is decide to intubate, give them a large amount of medication that makes them hypotensive during the intubation. Or on the flip side, making them agitated and hypertensive during intubation. Again, avoiding secondary injury. Really high intrathoracic pressures. We'll do some impediment of the estranged from the brain, which can have effects in the ICP. We do want to raise the head of the bed about 30 degrees, try and decrease ICP and keep everything midline, assuming that if there's a traumatic brain injury, there's also a spine injury. Hemodynamically neutral induction agents as much as possible. There's really no such thing as completely hemodynamically neutral, but we want agents that are attempting to maintain normal blood pressure. Atomidase is great. It does have some decrease in cerebral metabolism and really is hypotensive. Propanol and thiopenol decrease metabolism, but also can lower the BP. I think you've probably all seen this with propofol boluses before. Ketamine is also a useful agent that can help you maintain a normal blood pressure. Again, the goal is a smooth airway control without secondary brain injury. Yes, in general, we're gonna want it for less than eight. Same thing with the intubation, less than eight, we're likely gonna do a monitor. We know that cerebral edema peaks about 48 to 72 hours. That's when you get the most disruption. How are we gonna actually monitor if we put it in? Well, there's a few different ways. I won't show a picture here, but it's either we're gonna do some sort of interpregnable monitor, i.e. a bolt, which is for monitoring only, or you're gonna put in a ventricular drain, which allows you to monitor pressures, plus also drain off some fluid. There's pros and cons to both. In general, when are you gonna intervene on the ICP is if you're greater than 20, for more than five minutes, you need to intervene. We'll talk about this again some more when we talk about our medications. So this shows a few of the different types of monitors. There are lots of different monitors that are out on the market. Wherever you're practicing, just be sure to know what your institution uses so you get a sense of how to use them yourself and what they're actually measuring. That subdural space bolt is measuring the pressure kinda just underneath the dura. Again, good for pressure management and relatively straightforward to put in at the bedside. What's the potential downside? It could be a little finicky, and you don't have the ability to do any decompression with it. That ventricular drain is really handy because not only can you monitor the pressure, but you can use that to drain off fluid to decrease your ICP, but obviously more challenging to put in position. So what can we do about that cerebral perfusion pressure? What interventions can we actually provide? Well, one is we can reduce that ICP or that metabolic need. We can do that with sedation. We can do it with neuromuscular blockade if we need to. We can avoid fevers by doing routine Tylenol. We like to avoid seizures also. Seizures increase metabolic load quite a bit within the brain and can have effects on secondary injury. Want to avoid seizures, consider doing prophylaxis. We can place a bolt to be able to measure actual ICP pressure so we can better tackle it, but to reduce it, you actually need to drain off cerebral spinal fluid. We can do, again, that mild hyperventilation. Hyperosmolar therapy. So this is 3% saline or greater to be able to draw fluid off of the injured tissue. Decompressive craniotomy. This is removing a portion of the skull to relieve the pressure. Also, barbiturate coma. Be sure whatever institution you're practicing at to take a look at their traumatic brain injury guideline. There's often going to be a tiered system, a prescribed way of saying when to use each of these in what scenario. Remember also for blood pressure, for cerebral perfusion and pressure intervention, you want to do hemorrhage control, volume replacement, and potentially pressers or isotropes to increase your ICP. Hyperosmolar therapy. What's the most common in kids? Probably 3% saline. We use it in the field. We use it in the trauma bay. It creates a osmolar gradient. It attacks the blood-brain barrier to draw fluid off. The goal is to increase the serum sodium just slightly, not too high. We do prefer this over mannitol initially, especially when trying to figure out if the patient has other injuries besides just the TBI. Because even if you have hypovolemia from bleeding from another injury, you give mannitol, you're still gonna have powerful diuresis and ongoing hypovolemia. How's mannitol work? Well, it's an osmotic diuretic. It's a metabolically inert sugar in humans. And it works by increasing plasma osmolarity, driving water across tissues into the plasma, and then excreted by the kidney. It's a powerful osmotic diuretic. Don't use it unless you're sure you don't have hypertension from other bleeding sources. We're gonna talk a little bit about specific injuries and common ones we see. One is an epidural hematoma. This is kind of the classic injury. This is a skull fracture that damages the middle meningeal artery, causing a tear, causing a large hematoma formation, creating, taking up a lot of space within the skull, and thus increasing your ICP and decreasing your cerebral perfusion pressure. Blood collects between the skull and the dura. You have a classic hyperdense, convex mass. It can cross, you know, dural reflections. It does not cross suture lines, because that's where the dura is tightly adhered. And evacuation is almost always the treatment. This is a picture kind of describing the difference between the different types of bleeds, looking at intraventricular hemorrhage and epidural hemorrhage. It's looking at intraventricular hemorrhage and epidural bleeds, subdural bleeds, and arachnoid bleeds. Epidural, the dura is being peeled off that underside of the skull. It's that space. Subdural, it's gonna be between the dura and the brain matter. Not as often venous. Subarachnoid can be a mix, and it's in that space that's going down the crevices of the sulcine gyri of the brain. The picture to the right is a classic epidural bleed where you see that convex lens-like deformity. Here's another example. And another one from a different view. The other most common is subdural hematoma. This is a classic acceleration or rotational injury which causes the old bridging veins between the brain and the dura to tear. Building up blood in there. Blood collects between the arachnoid and the dura. It's often crescent-shaped. Not quite as dramatic as the arterial-based epidural hematoma. Another picture here to describe the difference between that venous blood for the subdural and the arterial epidural bleed. Subarachnoid hemorrhage is commonly seen, and that's that focal area, linear high density in the sulci and the fissures. We're gonna take a little time to talk about pediatric spinal cord injuries. How often do we see them? They are relatively rare in kids. It's only 1% to 5% of all injuries. They're often associated with a closed head injury, some other traumatic brain injury. Where are they often seen? Well, most commonly is in the cervical spine, especially in kids younger than nine who have that really higher risk of the occiput C2 injuries. That's just due to the weight of the head on top of the skull makes it relatively, or excuse me, the head on top of the spine making it relatively unstable. What do we see for mechanisms? Similarly, we see for all pediatric trauma, that's the NVCs, it's the sports injuries, and it's the falls, and then also abuse. These are the most common mechanisms for almost all pediatric trauma, and that holds true for spine also. Like I said, so large head, small spine, that gives really high fulcrum, right? It's C2, C3, giving, it's a lot of weight that moves forward over top of relatively unstable spine without well-developed ligaments and musculature yet. They don't have quite the same joint spaces between the bones, relatively lax ligaments, very flat vertebral bodies, immature facet joints. Just a reminder of the anatomy and what the spine looks like, and a cross-section with the various ligaments, and we'll be doing a little bit more of that in a few more slides. Talking about immobilization, when are we going to immobilize a spine? Well, we do it relatively commonly in the field for a lot of high-velocity, high-energy transfer injuries. Relatively done reflexively in the pre-hospital setting too, so not uncommon that you might have a patient with a C-cholera on in your ICU. Just a reminder that the occiput in a young child, especially under the age of six, is quite large. If you put the occiput straight back without appropriate C-spine immobilization, you're actually raising that spine. So you either need to have the kid slightly elevated or have a special board with the cutout for the head to allow it to drop back to get true alignment of the spine. It's important to try to get a good history with any spine injury. It's important to understand the mechanism, is there pain associated with it, what other neurologic symptoms, the weakness, the numbness, the temperature and sensitivities, any other injuries associated with this one. As we said before, one of the most common injuries, well, it's falls and MVCs followed by some sports injuries. Then you have to think about the injury and the potential force placed upon the patient with that injury to help you try and figure out what was, how was the spine injured. Because there's a few different ways this can happen. It can be axial compression, where it's a straight down force, it can be distraction, where there's a tug on the spinal cord, rotation, where really there's a tear in the ligaments rotationally and a squeezing action almost of the spinal cord itself. There's translation where it's really coming straight across and a separation of the vertebral bodies injuring the spinal cord. Or it's some combination of all of these. As we said before, the younger the patient, the different that fulcrum of injury. Where is there really a difference between the mass and the energy of the body compared to the head and where is it going to be impacted. And that's usually from, from ox foot down to that C3. Teenagers it's really very similar to adults. It can be a little challenging to examine a pediatric patient. They're not going to be cooperative with you. It's really about passive observation, right? You want to be able to watch them move, making, distracting them with, with toys or sounds or lights to be able to get them to look and move in different directions and reach and grab for things to be able to build what looks like a relatively full neurologic exam. How do we clear the C-Spine? Oftentimes we do need imaging, especially if there's other injuries to the patient or if they're obtunded for some reason, we will want to get good cross-sectional imaging. But beyond that, we want to have no pain to palpation. That's midline on the bone itself. It doesn't necessarily mean soft tissue, but true pain on palpation of the bony part of the neck. We want full range of motion without pain. We want no neurologic deficits. If you have all of those things, then yes, you can clear their, their C-Spine. Younger kids will do a good job of protecting their neck, meaning they're going to have torticollis, that muscle spasm that's protecting their neck and holding it in place. If they have that, assume they have a spinal injury. Don't force them into a neutral position and be able to put a collar on. Just protect alongside their heads and ask your spine specialist to see them. We often get plane x-rays in kids. Sometimes it can be, especially if they're uncooperative, it can be challenging to get good views to clearly see all the planes and the vertebral bodies that you want. Not uncommon also that we get CT scans if you feel you really need it based on the mechanism or the fact that they have a, also a concurrent traumatic brain injury, it's okay to go ahead and get it. Even though we are trying to save radiation in kids, it's fine to get the CT scan. MRI can be helpful also, especially in demonstrating ligamentous injury and some of those finer details. CT, as you know, is always great for bone and it'll show the bone fracture as well. Maybe not always great, so great for ligamentous injury. How do we start? Well, there's some basic things. They're done based on the assessment of the patient, right? It's C-sign imaging and trauma and when. It's through, some of the best studies have come through the Nexus Group saying when is it appropriate to get imaging? Well, if they're tender, if they're intoxicated, if they have altered level of consciousness, if there's any other neurologic defect, if they have physical signs of a neck trauma. Inconsolable infant, especially inconsolable infant with ptoricollis definitely needs imaging. And then think about potential mechanisms where even if they don't have symptoms from it, you might want to get some further imaging, such as high-speed WCs and deacceleration injuries. So what did Nexus say in their follow-up? Well, subsequent evaluation demonstrated that no cervical spine injuries without at least one positive Nexus risk factor over 3,000 patients in a multiple perspective center. It means only imaging individuals with a positive risk factor resulted in 20% less imaging. So follow the basic Nexus criteria. So if there's no neurologic deficit, can we say that they have no injury? Well, it's likely low suspicion of injury and we can get plain films to rule it out. If there's high suspicion, meaning you're tender, even though you don't have a neurologic deficit, definitely consider getting a CT scan. If you have a distracting injury, meaning significant chest or abdominal trauma, long bone fractures, even with that CT demonstrating no bony fractures, you might still go ahead and get the MRI if you feel you can't clear out the ligamentous injury. All right, what about SOARA? Spinal cord injury without radiographic anomaly. Well, this predates MRI, but this meant radiographic anomaly on chest X-ray or CT scan, meaning we don't see a bony defect. But because of the ligamentous laxity we've seen in kids, there can be some injury to the spinal cord itself. Meaning they have a neurologic deficit with normal imaging of X-ray or CT. This is not uncommon in kids. Relatively rare in adults, but not uncommon in kids. In modern practice, if you had this, you'd still go on to get an MRI to give you some better detail of the cord. We talked about those different compression mechanisms. Axial is the compression fractures. Axial load being straight down from head down to toes. You also see in significant forces, burst fractures where the vertebral body just comes apart in multiple pieces. Distraction injuries. These are the classic hangman fractures. This is where there's a rupture of the ligament integrities. You can actually pull on the spinal cord itself. Rotational. This is disruption of all the finer ligaments between the facets. And then translational forces. These are the chance fractures, which are the common lumbar fractures seen with bad seat belt injuries. Or laminal fractures, transverse process fractures. When are we going to treat spinal cord injuries? Well, it really depends on how stable they are. There's a three-column model that the spinal surgeons often use to assess whether they need to have operative intervention for their spinal cord injury. And it says basically that you have an anterior, middle, and posterior columns of ligaments. There's three of those columns that are providing support in the spine. If you disrupted two of those, you need something to replace that stability with. That might be a piece of hardware. So there's canal compromise. There's a fracture that you can't reduce. There's instability, meaning multiligament injuries. And there's a deformity that requires correction. This would be indications for surgery. Just a brief discussion on neurogenic and spinal shock. This is hypotension and bradycardia. The classic spinal shock, the classic neurogenic shock, means you've got hypotension and bradycardia. Just remember, if you have a complex traumatic injury, meaning that they have a spinal cord injury, maybe a head injury, there's a good chance they also have an interthoracic and trapezoidal injury. So maybe their hypotension is yes, is partially from the spine, could also be from bleeding. So don't assume it's just one or the other. It could be a mixed picture, especially, again, if that bradycardia. Your response is still going to be to replace volume, right? Treat it as bleeding. Replace the volume. If they're not responding to this, you need to do something to help maintain their cerebral perfusion pressure and their spinal perfusion pressure. And this is going to be vasopressors to be able to help with that. All right, to sum up our spinal cord injuries, just remember, it's less than 5% of all pediatric trauma. Even though we discuss it quite a bit, and you'll see a lot of kids with C collars on, it's relatively rare to have a true spinal cord injury. The younger you are, the higher the chance of a high cervical injury. Remember, it should be paid close attention. If you have a significant traumatic brain injury, you really should rule out any spinal injury. They go hand-in-hand. All right, we'll move on to talk about pediatric burn assessment and management for the last part of our talk. So the numbers for this. Well, it's the fourth most common type of trauma worldwide. 90% of this is in low to middle income countries. In the US, of note, it's 70% of men are presented with burns in the median age of 35. It tends to be younger men with burn injuries. Of note, there's about 120 burn centers in the United States. Pediatric burns, about 8% are unsupervised in the home, skull burn being the most common under the age of five. Relatively rare to get flame burns in kids that age. In the US, this comes to about 250,000 burns per year. Most of those are minor. It can be treated as an outpatient. But it's significant hospitalizations. It's 15,000 hospitalizations a year and 1,000 deaths a year. Significant portion of these are from abuse, just under 10%. And the younger you are, significant mortality you have associated with those large burns. So how do we evaluate a burn? Well, the basic trauma principles is that you don't be distracted by the dramatic. You work up your A, B, C, D, and Es. You do your primary and secondary survey, just like we talked about at the beginning with our trauma patients, because burns are trauma patients. Burn patients are trauma patients. You want to approach them the same way in your initial resuscitation. Do all the same normal trauma workup you'd normally do. But of course, you're going to be easily distracted by an injury such as this. This is a burn patient with a mixed burns. This is from a bad flame injury nearby. He obviously has a mix of burns. You can see some red. You can see some white. You can see discoloration of the epithelium that wants to slough off. You can see some burns up around his face. How are you going to approach him and this patient? Same way you would any other trauma patient, your A, B, C, D, and Es. Make sure you're addressing the most important life-threatening things first. But also, you're going to now start to address those burns and do your assessment. So part of the primary survey with a burn patient is making sure you're not missing any injuries. You might consider intubating a little bit earlier than you normally would, especially if they've had direct airway impact with the burn. Think about thermal injuries, direct aspiration of hot steam or smoke, plus the toxins associated with those. Circulation is minimizing that fluid loss and replacing volume. You have huge amounts of fluid loss with burns, and you want to replace that volume early. Disability, again, think about TBI and spines and fractures. Exposure, examining all surface areas, trying to get an accurate assessment of that burn. Environment, thermal control. Stop the burning process and thermal control. Secondary survey, just make sure you have a good H&P. Stop the burning process. That means if there's hot clothes, make sure you get the clothes off. If there's any chemical burns, make sure you're clearing that out, but you want to stop the burning process. You do want to try and get a history of the burn. What was the location? Is it an enclosed space that makes a big difference for inhalation injuries? What was the mechanism? Flame, scald, chemical, et cetera. How about the burn assessment itself? This part of the secondary survey, it's the size and the depth. But this assessment of a burn, it's a dynamic thing. This isn't just a static thing. It's going to be changing over time. Liberal use of early imaging, you have an early window potential of stability to rule out injuries. This really is a patient you might consider getting a full-body CT on, especially if they're abdundant and you're not quite sure what's going on, because especially if they have a large burn, they might be getting sick very quickly in the ICU, and transporting them to the OR or to radiology to get better imaging is going to be really challenging. Do it now while it's in their state. So burn assessment, like I said, two parts to this. It's the depth and it's the size. The burn depth, we break out into superficial thickness, partial thickness, and full thickness. That's that first degree, second degree, third degree burns. And then total body surface area, what percentage is that? We only count the partial and the full thickness, and that total body surface area count, we don't count superficial thickness. And then you want to make note of any special anatomic areas, hands, face, perineum. Normal skin anatomy is complex, right? There's multiple layers to it. When we're breaking out that superficial, it's really erythema, it's damage to that upper layer, that epidermis. We start breaking out partial thickness, we really break it into two parts, it's superficial partial and deep partial. Superficial partial means that most of the epidermis is still alive, deep partial means that only the bottom part of the sweat glands survive, and full thickness means there's no epidermal components alive anymore. So what's superficial thickness? This is the first degree. Bad sunburn is a classic example. There's damage to the epidermis, but it is intact and it's going to regrow. There's no blistering, it's painful, but it's going to heal. What's partial thickness? Well, this is that classic second degree. Variable damage to the dermis underlying the epidermis can be difficult to delineate. You do get wound conversion, meaning there's areas of injured cells in the skin that are going to evolve and possibly have more injury afterwards. There's superficial partial, which means that there's blistering to it, it's moist, it's painful, there's minimal scarring, it usually all heals on its own, and it'll do that usually in under two weeks. You re-epithelialize from all those ridges, the hair follicles, the sweat glands where there's epidermal cells. This is just a cartoon showing a picture of that superficial partial thickness. Again, blisters are superficial partial thickness. This is an example. This is a large blister, the blister part has been removed, and you have healthy pink tissue underneath. Deep partial thickness. This is more than 50% of the dermis is damaged. It's less painful because there's more nerve fiber destruction. The ability to heal is based on that dermal damage. The more dermal damage there is, the less healing there is. It requires more than 14 days, and there's potential severe scarring with it. It's more of a pink to pale white appearance, but still bleeds. You might get some layer of fluid underneath, but it's a large destruction to all of the epidermis and a significant portion of the dermis, although there are some hair follicles that survive, like in this cartoon, to allow some regeneration of the epidermis. Full thickness. This is complete dermal destruction. There's almost no capacity for skin regeneration. It's painless because you have destruction of the nerves. There's not bleeding to it. You need to excise it. It's not going to heal on its own. And actually having a significant body portion of this will cause significant systemic effects. This is an example of full thickness. You can see the healthy pink tissue around it. It's inflamed and irritated and annoyed. But that center part, that white leathery part, that's full thickness destruction. This burn is a little bit mixed, but the bright white spots in the center are full thickness. Most burns have some sort of mix to them, meaning there's some element of superficial and partial and full thickness. Much like on this leg, again, you see a variety of different areas. Most of this is full thickness, but there's a variety of burn depth. Same with this one. We can see in the very center parts, the white, the full thickness, surrounded by areas of partial thickness that will be able to regenerate. Over on the far right of the screen, over by his wrist, you can see some areas of full thickness within some deep partial in the middle. This is an example of a full thickness burn. Another example of a mix of a full and partial thickness. You can see, again, a mix with these pictures, the tight white band that you see down towards the wrist is that full thickness that's starting to constrict down, because there's eschar formation, and then there's some partial thickness more proximal to that. Down on the hand, you see some more bright red, cherry colored tissue, even though that looks like it might have some perfusion, that's actually deeply damaged tissue and will likely not survive. So I said burn depth is important, but so is burn size. When we do the total body surface area burn, we only count the partial and the full thickness. We base this rule on the rules of 9, which we'll show some diagrams in a moment, and also the rule of 7s for smaller children. Rough estimate, the child's palm is 1% of their total body surface area. This is the diagram for the rule of 9s and 7s, a quick way to estimate the total body surface area of the burn. So why is it important to know the total body surface area of the burn? Well, because it plays into the burn physiology and how you resuscitate them. Burns physiology, it's loss of skin barrier, which is a huge problem, it's a huge organ that's been damaged. You get a huge vasomediator release, and you also get a huge amount of fluid loss. Total body surface areas greater than 15% start to develop a systemic inflammatory response. Severe capillary leak, interstitial edema, these patients get very sick. You can see a hypermetabolic response with a doubling of cardiac output, huge protein catabolism, and huge protein needs each day in their diet. So how do you initially resuscitate them? Well, again, the reason that you need to know the total body surface area is for formulas such as Parkland, which is kind of the basic and most fundamental of the burn resuscitation formulas. This is determining how much fluid you need to replace what's going to be lost from that burn size, and it's 4 mLs times the body surface area times the weight in kilograms. You give the first half over 8 hours, starting from the start of the burn, not when they hit your trauma bay, but the start of the burn, and the second half over 16 hours. But just a reminder, all these formulas, whichever one you use, are estimates. So you start them at that rate, but then you want to assess perfusion, and you assess things like your urine output to be able to tailor these fluid amounts, because you don't want them over-resuscitated and causing further edema to the damaged skin, or under-resuscitated causing further vasoconstriction and blood flow issues to the damaged skin. Just an example of Parkland, if this is a 60 kilo patient with 80% burn, that's a huge amount of fluid. That's 19.2 liters. That means you're giving, initially, 1.2 liters an hour. Don't forget to add in some dextrose for younger kids. Follow standard resuscitation endpoints. Urine output is probably the most standard that's used with burns. Escharotomy is a brief comment that if you have circumferential, deep, partial, or full-thickness burns, as they keel, they start contracting down, forming a tight eschar. If that's around the thorax, you'll have trouble breathing. If it's around the extremities, you'll start getting compartments and rooms. You need to open these eschars up, and you need to often do it very quickly. This is just an example of an escharotomy in a leg. Initial wound care, stop the burning process, remove clothing, irrigate the chemical burns off. No ice, dry sheet over large burns, some cool saline-soaked gauze for smaller burns. Gentle wound cleaning. Blister care, small blisters you can leave intact, or at least leave them intact until they can get to a burn center. Don't forget about tetanus. No IV antibiotics, unless for obvious infections. There's a wide variety of products on the market for synthetic-inclusive dressings. There's BioBrain, Integra, there's Humanoilograph, there's Pigskin. In general, topical antibiotics such as Bacitracin and Xeriform is going to be your first go-to. This is just an example of Integra, one of the products on the market after a full-thickness excision. Brief word on early excision and closure. If we're going to do the early excision, this is for the partial and full-thickness burns greater than 15% body surface area. Especially the full-thickness can have profound systemic inflammatory response. If you excise early, you get better outcomes. It's usually within the first week. You also get improved healing. It will blunt that global inflammatory response that's taking place. You do get some decreased infection rates and get overall improved survival. Just a reminder, it's not just the direct injury to the skin itself, but it's the environment they're in. They are in during the burning process. If you're in a closed space with plastics burning, you're now going to have inhalation injury. It's the smoke itself. It's the plastics burning. It's the heat of the smoke or heat of steam that can cause damage. You want to think about early airway stabilization. You can see some profound bronchospasm with this. The goal is early bronchoscopy to flush this out to get profound airway casts. Inhaled heparin is particularly valuable in this situation too, but it's early and good pulmonary toilet. Don't forget about carbon monoxide. Obviously, this is the inhibition of electron transport chain and production of ATP. Anytime you're coming from a burn in a closed space, think about carbon monoxide poisoning. Same with cyanide, especially from burning of plastics. Thanks. I know that was a lot of material in a short period of time, but I appreciate you paying attention. And feel free to reach out anytime if you have any questions about pediatric trauma and burns. Best of luck on the board exam.

pediatric trauma care

burn care

trauma assessment

brain injuries

spinal cord injuries

burn inhalation injuries

burn management

ATLS principles

pediatric curricular care