Paeds SAQs · acute-care-resuscitation-and-toxicology
Burns assessment, resuscitation and safeguarding — formative SAQs
Two MedVellum formative short-answer questions on the burned child: cooling and the modified-Parkland fluid plan for a scalded school-age child, and recognition of the threatened airway and inhalation injury in an enclosed-fire child with safeguarding and referral. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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Target exams
SAQ 1 — A scalded school-age child
Question 1 — 10 formative marks; suggested time 15 minutes [2]
A six-year-old, 20 kg boy pulls a freshly boiled kettle onto himself at home, scalding his chest, abdomen and the front of his right arm. His mother runs cool water over the area for a few minutes and brings him to the emergency department 40 minutes after the injury. He is crying but alert, with a heart rate of 130, capillary refill of 2 seconds, and a blood pressure normal for age. The burn is blistered and painful across the chest, abdomen and anterior right arm. [3] [9]
- State what you do in the first 10 minutes and why. (2 marks)
- Describe how you estimate the percent TBSA and the depth in this child. (3 marks)
- Calculate the modified-Parkland fluid plan for the first 24 hours if the burn is estimated at 18 percent TBSA, and state your urine output target. (3 marks)
- Describe your safeguarding assessment and your disposition. (2 marks) [2]
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1
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]
SAQ 2 — The enclosed-fire child and the threatened airway
Question 2 — 10 formative marks; suggested time 15 minutes [8]
A four-year-old girl is brought to a regional emergency department after a house fire in an enclosed room. She is hoarse, coughing, and has soot in her mouth and singed nasal hair. The oxygen saturation is 94 percent on air. There is a partial-thickness burn to the face and a circumferential full-thickness burn to the left forearm, with the hand cool and slightly pale. She is alert but frightened. [2] [8]
- What does this presentation tell you about the airway, and what do you do now? (3 marks)
- How do you assess and manage carbon monoxide and cyanide exposure? (3 marks)
- Describe your management of the circumferential forearm burn. (2 marks)
- Describe your referral, disposition and the safety net. (2 marks) [8]
Full-credit answer — SAQ 2
Reveal full-credit answer for SAQ 2
1. The threatened airway
Hoarseness, soot in the mouth and singed nasal hair in an enclosed-fire child are inhalation injury with a threatened airway. The airway can look safe now and be lost over hours as oedema develops. I call senior airway expertise early, prepare a calibrated difficult-airway plan, and have a low threshold for an early definitive airway before the swelling closes the airway. I give high-flow oxygen and do not wait for stridor, which is a late and dangerous sign. I also cool and assess the burn, and start the fluid plan for any burn at or above 10 percent TBSA. [8] [2]
2. Carbon monoxide and cyanide
I draw a venous gas with carboxyhaemoglobin and lactate. Standard pulse oximetry overestimates oxygen saturation in carbon monoxide poisoning because carboxyhaemoglobin is read as oxyhaemoglobin, so the number can look falsely reassuring. I treat a child with confusion or a reduced conscious state after an enclosed fire with high-flow oxygen for a prolonged period regardless of the initial reading, because the level falls with time and oxygen. A high lactate that does not clear with fluids raises cyanide toxicity from burning plastics, and I have a low threshold for the cyanide antidote kit in the severely poisoned enclosed-fire child. [8] [2]
3. Circumferential forearm burn
A circumferential full-thickness burn of the forearm forms a rigid eschar that does not expand as the limb swells, so distal perfusion falls and compartment syndrome develops. The cool, pale hand in this child is already a concern. I document perfusion and capillary refill of the digits, monitor continuously, give the fluid plan, and refer urgently to the burns centre for consideration of escharotomy. I do not wait for the pulse to disappear. [2] [8]
4. Referral, disposition and safety net
I call retrieval and the burns centre in parallel with resuscitation, because this child needs a definitive airway, ongoing respiratory support, and a surgical service the regional hospital cannot provide. I agree the destination, the airway and fluid plan to continue en route, the escort, the monitoring, the contingency for deterioration, and the plan if transfer is delayed. I keep the family informed and document objectively. A defensible disposition here is transfer to a burns or intensive care service; discharge is not appropriate. The safety net is to the receiving team, with named owners for pending results and a contingency for deterioration during transfer. [10] [2]
References
- [1]Hettiaratchy, S Initial management of a major burn: I--overview BMJ, 2004.PMID 15217876
- [2]Hettiaratchy, S Initial management of a major burn: II--assessment and resuscitation BMJ, 2004.PMID 15242917
- [3]Cuttle, Leila Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey The Lancet Child and Adolescent Health, 2022.PMID 35051408
- [4]Cuttle, Leila The efficacy of Aloe vera, tea tree oil and saliva as first aid treatment for partial thickness burn injuries Burns, 2008.PMID 18603378
- [7]Stevens, Jacob V Weight-based vs body surface area-based fluid resuscitation predictions in pediatric burn patients Burns, 2023.PMID 35351355
- [8]Toon, Marcus H Management of acute smoke inhalation injury Critical Care and Resuscitation, 2010.PMID 20196715
- [9]Mullen, Sophie Fifteen-minute consultation: Childhood burns: inflicted, neglect or accidental Archives of Disease in Childhood - Education and Practice, 2019.PMID 29934360
- [10]Kazis, Lewis E Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns Journal of Trauma and Acute Care Surgery, 2018.PMID 29140950