As cold weather forces us indoors we can expect a rise in home-based injuries. The leading causes of accidental injury at home are burns, drowning, suffocation, choking, poisonings, falls, and firearms. As we heat up our spaces or cook our holiday foods injuries such as burns and scalds will rise and children are especially susceptible. Children are naturally curious and as they become more mobile they increase their risk for burn injury. Children also have thinner skin. This results in more serious burns at lower temperatures.

Nearly 75% of all scalding burns in children are preventable. By understanding the high-risk situations for fires and burns and taking steps to make your home safer, you can help protect your child from fire and burn injuries or death.

The focus for prehospital treatment for burns includes:

EMT

• Halt the burning process
• Protect the airway
• Prevent further potential disability
• Maintain homeostasis (treat for shock)

Paramedic

• Control airway with advanced adjuncts if needed
• Administer high flow O2, BVM if needed
• Establish IV x2 if possible for severe burns, don't insert IV in burnt tissue if possible, (consider IO)
• Providing pain control, per MCP.

Shannon Brady, MD

Department of Pediatrics

Pediatric Burn Management

Pediatric burns are a leading cause of injury and mortality in children in the United States. Each year approximately 100,000 children in the U.S. sustain burns that require medical attention. Overall, the most common type of burn injury seen in children is thermal burns. However, the mechanism of injury varies by age. Scald and contact burns from hot liquid or hot stoves are most seen in toddlers, whereas older children suffer burns from risk-taking activities. Chemical and electrical burns are less common in children. Non-accidental trauma must always be considered in a child presenting with a burn, especially if the history of the burn does not match the pattern of injury.

Cutaneous burns can be visually distracting, and it is important to assess a patient’s ABC’s as soon as possible as a part of the initial assessment. Assessing a patient’s airway after a burn is extremely important as inhalation injury can cause airway swelling which may require securing the airway. It is also important to trend a patient’s vital signs to determine their response to fluid resuscitation (discussed in more detail below). Although there are similarities between the prehospital management of adult and pediatric burns, children have unique pathophysiologic responses that lead to important differences that must be considered when caring for these injuries.

In addition to managing a patient’s ABC’s, prehospital management and initial assessment should involve extinguishing active flames, removing smoldering clothing and jewelry, covering the burned area with clean, dry dressings, and applying cold (not iced) wet compresses only to small injuries. Significant burns (>10% of total body surface area [TBSA]) should not be covered with cold compresses as this could induce hypothermia. Burns in general place patients at risk for hypothermia. To decrease this risk one should turn the heat up in the ambulance or apply extra blankets. If blisters are present, do not unroof them. Simply cover them with a sterile dressing as mentioned above.

After initial and secondary surveys, the prehospital provider should determine the severity and extent of the burn. Determining severity of a burn is based on four criteria: depth of injury, percentage of body surface area involved, location of burn, and association with other injuries. The depth of injury is classified as 1st-degree, 2nd-degree (partial-thickness burn), or 3rd-degree (full-thickness burn)(Table 1). Estimating the percentage of body surface area involved differs between adult and pediatric patients as the body surface area of the head and neck is much larger in children. The Lund and Browder chart is the most common way to estimate TBSA in children (Figure 1). If this resource is unavailable, one may use the palm of the individual to estimate 1% of the TBSA. Burns affecting 10 percent of a child’s body are considered major and require hospitalization at a burn center if available.

Fluid resuscitation is a crucial aspect of pediatric burn care in the prehospital setting as children are at higher risk of dehydration due to a lower circulating blood volume and increased insensible losses. Oral rehydration is possible in the case of smaller burns, but IV/ IO fluid resuscitation should be initiated for children with burns >10% TBSA. For these children, initial management should consist of a 20cc/kg fluid bolus of crystalloid fluid (normal saline or lactated ringers). Following this, the Prehospital Advanced Burn Life Support (ABLS) recommends starting an age-based maintenance fluid infusion rate until more specific volume requirements are determined.

• 125cc/hr for patients younger than five years of age
• 250cc/hr for patients between five and 15 years of age
• 500cc/hr for patients older than 15 years of age

Formulas are available to calculate specific volume requirements in addition to maintenance fluids in children such as the Cincinnati and Parkland depending on a child’s age. However some require a patient’s total BSA in m2 (Table 2). Another important consideration in pediatric burn care is adequate pain control. Pediatric patients may be treated with IV or IN analgesia such as fentanyl or morphine. Fentanyl is preferred for patients with possible circulatory compromise. One to 2mcg/kg/dose of IV/IN fentanyl repeated at 30-60 minute intervals or frequent 0.1mg/kg/dose of IV morphine is appropriate with careful monitoring of respiratory status.

Appropriate prehospital management of pediatric burn patients is a crucial step in the patient’s care. Highlighted here, EMS care should focus on initial assessment and airway management, stopping the burning process, covering the burn with special attention toward avoiding hypothermia, age appropriate fluid resuscitation, aggressive pain control, and rapid transport to the nearest hospital.

Effective September 1, 2020 a new collaboration between Primary Children's Hospital (PCH) and the University of Utah Health's Burn Center started. PCH will now take any pediatric patient FROM THE SCENE with burn +/- trauma. Burn injury in itself is a trauma. These patients will be coming to PCH first for a trauma evaluation. This will include children for whom EMS has concerns of significant inhalational injury. The trauma team will work with a burn team to run the initial resuscitation at PCH and, depending on other trauma-related injuries and potential need for ECMO, the child will either be kept at PCH or transferred to the Burn Unit after stabilization.

References:

Arbuthnot, M., Garcia, A. Early resuscitation and management of severe pediatric burns. Seminars in Pediatric Surgery 2019; 28(1): 73-78

Scorched Skin: A Guide to Prehospital Burn Management. David Hostler, PhD, NREMT-P, DMT-A. https://www.jems.com/2015/04/06/scorched-skin-a-guide-to-prehospital-burn-management/

Antoon, A. (2020) ‘Burn Injuries” Kliegman, R., et al. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; .614-623

When you encounter a patient with burns it is very tempting to add a preventive antibiotic, especially when the blisters have ruptured or the burns are severe. One thing to remember is that burns are NOT a dirty wound and do not need prophylactic antibiotics. The only exception to this is if it is an old burn that is now infected.

Follow the protocols for pain management to make the patient more comfortable, but realize that burns are extremely painful. Achieving a pain score of zero is impossible. The goal with pain management in these types of patients is to take the edge off. Non-pharmacologic interventions such as distraction, gentle handling, extremities being elevated to around heart level to diminish pain, all work great. Dressing the wound can help relieve pain and calm nerve endings exposed to the air by the burn.

Occlusive ointments are also very good to apply to the burns. The two creams/ointments most recommended by burn specialists are silver sulfadiazine and bacitracin ointment. Caution should be used with both of them for different reasons. Silver sulfadiazine should not be used in patients with a sulfa allergy and bacitracin should not be used on more than 30% of the body surface area because there is limited data showing it can be nephrotoxic (harmful to the kidneys).

Some exciting news! The 2020 update of the Utah EMS Protocol Guidelines has been released!

Riverton Hospital stopped admitting pediatric patients on October 24 and has transitioned to providing inpatient care to adults on the hospital’s 4th floor. The unit started with 10 beds, staffed with a combination of caregivers on mandatory overtime and pediatric caregivers who’ve been trained to care for adults. All 10 beds are now consistently full. Primary Children's Hospital is now taking their pediatric admits. Only inpatient pediatric services are paused at Riverton. All other pediatric care, including emergent care and outpatient services for children, will remain active at Riverton Hospital and in the Primary Children’s Riverton outpatient building.

Intermountain Healthcare has reported four caregivers have died from COVID-related causes.

We are concerned

EMSC participates in many regional and state EMS meetings and we hear from providers in both the urban and rural areas of the state. We know the strain brought on by COVID-19 has been very hard on many of us; disrupting our lives and the lives of our children. Some people have lost jobs, friends and loved ones have gotten ill from the virus, and we are required to wear PPE for long shifts. However, recent discussions surrounding Covid-19 are very concerning to the medical providers who attend these meetings. Some say EMS providers claim the virus is a hoax, the infection and death rates are inflated, hospitals don't seem busy when you visit on transports, and the medical community is using this virus as a profit tool for the hospitals. All of these rumors are false and hurtful for the families affected, and the healthcare providers working so hard for these patients and their community.

Since it's a new disease, the data surrounding Covid-19 is changing too quickly to give us a full view of what is happening. It will be many years before we understand this disease, and our best treatment strategies continue to be a work in progress. Many patients have mild illness but still suffer from lasting health effects. The most worrisome issues are to their heart and lungs, including children. This is also a virus that affects various populations differently, and we need to be sensitive to the real concern for those people at high risk of complications. As medical providers, it is OUR responsibility to only rely on evidence-based sources when gathering and sharing information about the virus. We need to be a united team and support each other and our communities in a positive way. Please work to spread truth instead of rumors. We suggest avoiding social media as a source of information completely, as it is not fact checked or verified. Some suggestions for evidence-based information are listed here. We will continue to work with the Utah Department of Health to bring you the most up-to-date information about how the virus is affecting Utahns.

• Utah Department of Health
• Center for Disease Control and Prevention
• World Health Organization (WHO)
• IntermountainHealthcare.org

Coronavirus Avoidance, a few things teachers can learn from healthcare workers

Utah EMSC put together a training toolbox for teachers entitled Coronavirus Avoidance, a few things teachers can learn from healthcare workers. The toolbox includes posters and signage

and a 40-minute recorded zoom training from our Nurse Clinical Consultant Tia Dickson on the topic. Feel free to share the training with your teachers. Access through the link below or contact Tia Dickson at tdickson@utah.gov

https://drive.google.com/drive/folders/1cJbzPOc-D0B-PI1fK-HTJUvaxG_lCAns?usp=sharing

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

EMSC sent out a letter to all EMS agencies detailing our plan to distribute the Handtevy App throughout the state. The letter asks for your response and so far we have had a 30% response rate. It is not too late! Our timeline for implementation is February 2021. This is one gift list you want to be on. Contact our program manager if you've lost your letter. BrianneGlenn@utah.gov

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the address below.

tdickson@utah.gov

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Brianne Glenn (brianneglenn@utah.gov) to find out how you can help.

Pediatric Education for the Prehospital Provider

Register online at peppsite.org. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth