Burns assessment, resuscitation and safeguarding — formative SAQs

1. First 10 minutes

"This child has a partial-thickness scald of the torso and arm with normal perfusion but a clear need for cooling, analgesia and a formal fluid plan." I confirm the team is activated with named roles, stop the burning process, remove clothing, and cool the burn with running water for 20 minutes within 3 hours of injury while keeping the rest of the child covered and warm. I give weight-based analgesia (intranasal fentanyl or intravenous morphine) and gain access. The principle is to cool correctly, avoid hypothermia, control pain, and assess the airway and circulation, because cooling and analgesia reduce depth and shock. ^{[4] [2]}

2. TBSA and depth

I estimate the percent TBSA with an age-adjusted Lund and Browder chart, not the Rule of Nines, because the head and leg proportions differ in children. I draw the burn on the chart's body map, count the partial- and full-thickness areas only, and exclude erythema. For the chest and abdomen (anterior trunk, about 18 percent combined) and the anterior right arm (about 4.5 percent), I would document the partial-thickness area as an estimate. The patient palm including fingers is about 1 percent and is a useful check for patchy areas. I judge depth at the bedside: blistered, pale pink, blanching and very painful is superficial dermal; fixed red or pale, non-blanching and reduced sensation is deep dermal. I re-map after cleaning and re-evaluate depth at 24 and 48 hours, because depth evolves. ^{[2] [3]}

3. Modified-Parkland calculation

For an 18 percent TBSA burn in a 20 kg child: 3 mL per kilogram per percent TBSA equals 3 times 20 times 18, which is 1080 mL of Hartmann over the first 24 hours. Half of that, about 540 mL, is given in the first 8 hours from the time of injury; because 40 minutes have already elapsed, the first half runs over the remaining 7 hours and 20 minutes. The second half runs over the next 16 hours. Because the burn is greater than 10 percent, I also add glucose-containing maintenance fluid appropriate to the child's weight. I titrate hourly to a urine output of 1 mL per kilogram per hour (about 20 mL per hour in this child) because he is under about 30 kg. I avoid large-volume normal saline because it causes hyperchloraemic acidosis. ^{[2] [7]}

4. Safeguarding and disposition

A scald from a pulled kettle in a mobile six-year-old with a splash distribution and a consistent history is a plausible accidental mechanism, but I keep safeguarding open and document objectively. I ask open non-leading questions, record the exact words used, draw the burn on a Lund and Browder map, photograph it with consent, and check for prior presentations. Because the burn involves more than 10 percent TBSA, I admit for titrated fluid resuscitation and refer to the burns service; a special-site involvement (the right arm, and any hand involvement) would prompt a burns-centre consultation. I discharge only if the area, depth and safeguarding assessment allow, with adequate analgesia, a documented safety net, and confirmed follow-up. ^{[9] [10]}