Case Report: Burns
Mark J. Johnston, RN BSN
Case: 15 Month old with a 19% TBSA burn
HPI: The patient is a 15 month old that sustained a 19%TBSA burn that was the result of hot water. The parents reported that the patient fell into a bathtub full of hot water at approximately 5am. The father awoke to him crying and pulled him out of the tub and ran cold water over the burn areas which were bilateral lower extremities and his lower torso and abdomen. The burns were initially described as not too bad so the father put him in bed and they fell back asleep. Later that morning they awoke and the patient had developed blisters so they presented to a local hospital. The regional Burn Center was consulted. The referring hospital described a ~30%TBSA burn. A left external jugular line was established and a foley catheter was placed. IVF were started at 75cc/hr in addition to a 250cc bolus.
Burn ICU: The patient arrived as a direct admit to the Burn Center. He had received 337.5cc of LR prior to arrival and had 75cc of urine output over 4 hours prior to the admission. 10 point ROS was negative, immunizations were up to date, he did not have any allergies and did not take any medications regularly. Vital signs were: BP 84/62, HR 159, RR 28, SpO2 99% and temp 36.2. His burns were dressed in silver sulfadiazine, he was given fentanyl and midazolam for his dressing and IV fluids continued at 75cc/hr. He was started on our Nurse Driven Resuscitation Protocol. A social work consult was ordered due to the nature of the injuries not being consistent with the mechanism of injury. The patient maintained an adequate amount of urine and so IV fluids were titrated downward and eventually discontinued. The patient was interactive and tolerating a regular pediatric diet. On post burn day (PBD) #1, the burns were dressed with a long term silver dressing. The patient spiked a temperature to 103.3. Child Protection and Law Enforcement were in contact with the patient’s mother as the father had been arrested for suspicion of causing the injuries to the patient.
On PBD#3 the patient had low urine output and PO intake was noted to be poor. A PIV was not able to be established after multiple attempts. Urine output became difficult to measure as it was frequently mixed with stool in the patient’s diaper. The patient was taken to the operating room so that an IJ line could be placed as well as a NJ enteral feeding tube and foley catheter. The patient was left intubated. Blood and urine cultures were sent. The patient was given albumin. He was noted to be hypothermic. ABG showed metabolic acidosis, he was tachycardic with an adequate blood pressure, WBC was 2.8 with zero neutrophils. Venous saturation was high as was his lactate. Due to the septic picture, the patient was started on antibiotics.
On PBD#4 the patient was hypotensive that intermittently improved with colloid infusion. He again developed a fever with marked metabolic acidosis. He developed ventilator dyssynchrony so he was pharmacologically paralyzed. He developed significant edema due to the necessary fluid resuscitation that was initially treated with furosemide. Blood and urine cultures were negative to date.
On PBD#5 the patient was started on a dexmedetomidine in hopes that the midazolam infusion could be discontinued. Due to ventilator dyssynchrony, elevated ventilator peak pressures, oliguria and a tense abdomen, he was taken to the operating room and underwent a decompressive laparotomy and placement of an abdominal wall silo. Postoperatively his diuretic dosing was increased and he was switched to a furosemide infusion and chlorothiazide due to poor urine output.
On PBD#6 the furosemide was switched to bumetanide. Fortunately, after the abdominal decompression, his renal function improved, urine output improved, and creatinine normalized. He remained on continuous dexmedetomidine, fentanyl, and midazolam infusions while intubated. He had good pain control and sedation.
Over the course of the subsequent days, the patient underwent three abdominal washouts and had the abdominal wound closed nine days after the laparotomy. He underwent tangential excision and cadaver grafting on PBD#14 and split thickness skin grafting on PBD#24. He was discharged on PBD#37.
Post Discharge: The patient was evaluated in the Burn Clinic 3 weeks after his discharge and he had 100% graft take and no other concerns. The patient was followed at regular intervals in the Burn Clinic and the patient had no other issues of concern.
Topic Review: Abdominal Compartment Syndrome in Pediatric Burn Resuscitation
Since 1968, when Baxter and Shires developed the Parkland formula, there has been debate on the “perfect” burn resuscitation formula. The advances in hemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions have put us closer to the “holy grail”. Severe burns have been shown to be a risk factor for developing intra-abdominal hypertension (IAH). Fluid resuscitation practices used in burn management further predispose patients to intra-abdominal hypertension. Many burn units still base their resuscitation practice on a formula created 40 years ago. In 1991, Dries and Waxman(4) had already suggested that resuscitation based only on the urinary output and vital signs might be suboptimal. Goal-directed fluid therapy has been an important concept in initial fluid resuscitation for major burns since this publication. Cardiac output has been considered one of the most important measures to guide volume therapy but few burn centers actually measure cardiac output during resuscitation. In recent years, several articles have reported on volume monitoring and replacement approach for goal-directed fluid resuscitation based on transpulmonary thermodilution (TTD) and arterial pressure wave analysis, which are less invasive .
Although this case was complicated by other factors, individualized fluid therapy adjusted appropriately to physiological end-points rather than rigidly dictated resuscitation formulae, reducing intravenous maintenance fluids may further help decrease fluid overload in these children.