Pediatric emergency medicine trisk 3223 3223

means of monitoring fluid status, but in patients with severe burns with
associated inhalational injury, central venous pressure monitoring may be
useful in the first few hours. Major burns cause decreased splanchnic blood
flow and ileus. After ensuring intact airway reflexes or that the airway is
protected by placement of an endotracheal tube, the clinician should
consider placing a nasogastric tube. Hypothermia can occur rapidly in small
children, especially in those whose skin injury impairs normal
thermoregulation. Core temperature should be monitored and the child kept
covered, except as necessary for examination and burn assessment.
Fluid Resuscitation. An initial bolus of 20 mL/kg of normal saline or Ringer
lactate solution is recommended while assessment of the extent of the burns
takes place. Fluid volume from all initial boluses including prehospital care
should be counted when calculating fluid volumes during the first 24 hours
of treatment. A urinary catheter should be placed early in the management
because there may be several hours of monitoring during transport or in the
ED during which urine production can provide clinicians with information
about fluid status.
Rapid treatment of the hypovolemia that occurs early in children with
severe thermal injuries is of prime importance. The fluid status of children
with burn injury is a dynamic process that requires careful reevaluation and
therapeutic adjustments. Extravasation of water, sodium, and protein
through abnormally permeable capillaries continues for about 24 hours after
injury. Capillary integrity then improves and intravascular volume
stabilizes. Isotonic crystalloid solutions are recommended in the
resuscitation phase. Potassium is released from damaged cells and
measured serum levels may be elevated shortly after injury; therefore,
potassium replacement is not recommended during the early phase of fluid
therapy.
Several formulas for the calculation of initial fluid therapy exist ( Table
104.2 ). The Parkland formula recommends 4 mL/kg/% of BSA of
crystalloid over the first 24 hours, half during the first 8 hours from the time

of injury and half during the next 16 hours. This formula often
underestimates the fluid needs of young children, who are also at greater
risk for hypoglycemia. Maintenance requirements using isotonic solutions
with 5% dextrose are added for patients with burns who are younger than 5