2023.1 Day 2 VIVA 6

Paediatric Anaesthesia

You are on-call and on-site in Scenarioville Hospital. You receive a call that a 5 year old female is enroute to the hospital with her family. She has suffered burns after an explosion from a bonfire. It is 10 pm and her expected arrival is in 5min.

How are you going to prepare for the arrival of this patient?

• Team Activation:

  • Alert paediatric ED, burns team, anaesthetics, and nursing staff.

  • Assign roles (airway, circulation, scribe).

• Equipment Readiness:

  • Airway: Paediatric-sized ETTs (uncuffed 5.0–5.5 mm), LMAs, suction, video laryngoscope.

  • IV Access: 22G/24G cannulas, IO kit, warmed fluids (Hartmann’s).

  • Monitoring: Pulse oximeter (child probe), ECG, BP cuff, capnography.

• Drugs:

  • Weight estimate (~18 kg via [2 × age] + 8).

  • Prepare analgesics (fentanyl 1–2 mcg/kg), sedatives (ketamine 1–2 mg/kg), and resuscitation drugs (adrenaline 10 mcg/kg).

• Resources: Confirm radiology (CXR for inhalation injury) and blood bank access.

What paediatric-specific considerations should you keep in mind?

• Airway: Broselow tape for sizing, paediatric bronchoscope if difficult airway.

• Fluids: Micro-drip sets for precise titration.

• Thermoregulation: Overhead warmer, forced-air warming blanket.

• Limitations: No paediatric ICU; plan for early retrieval if major burns (>10% TBSA) or airway compromise.

Describe your primary survey.

Primary Survey in line with APLS principles

• A: Inspect for facial burns, stridor, soot (signs of inhalation injury). Prepare for early intubation if compromised.

• B: Auscultate for wheezing (bronchospasm); SpO₂ on 100% O₂.

• C: Palpate pulses, capillary refill; IV/IO access ×2; fluid bolus (20 mL/kg if tachycardic).

• D: GCS, pupil check.

• E: Expose burns (avoid hypothermia), estimate TBSA using Lund-Browder chart

How will you manage her burns initially?

Fluids:

• Parkland formula for fluid resuscitation (4mL x TBSA % x weight in kg) for the first 24 hours, with half given in the first 8 hours.

• Crystalloid fluids (e.g., Hartmann’s or Lactated Ringer’s) for initial resuscitation.

• Close monitoring for signs of fluid overload (especially in smaller children).

Analgesia:

• Opioids (e.g., fentanyl for initial pain relief), with intranasal fentanyl or morphine for ongoing management.

• Ketamine (if required) for sedation and pain relief, especially if intubation or procedures are needed.

Airway management:

• Assess for intubation or nasal cannula if signs of airway burns or respiratory distress.

• Humidified oxygen to prevent further irritation of the airway.

General:

• Wound Care: Cover with cling film, avoid ice/cooling (risk of hypothermia).

What if she develops hoarseness and stridor?

Risk of inhalation injury:

• Burns to the upper airway can lead to swelling, stridor, and respiratory failure.

• Bronchoscopy could be performed if there are signs of upper airway injury or smoke inhalation.

• Early intubation may be necessary if there is significant swelling or obstruction, as early airway management is key in preventing deterioration.

  • Immediate Action: Call for help; prepare for RSI.

  • RSI Plan:

    • Pre-oxygenate with 100% O₂ + apnoeic oxygenation.

    • Ketamine (1–2 mg/kg) + rocuronium (1 mg/kg).

    • Smaller ETT (e.g., 4.5 mm) if airway edema suspected.

  • Post-intubation: Secure tube, humidified gases, CXR to confirm placement.

• Monitoring: Close observation in ICU for signs of airway compromise or respiratory distress. Therefore consideration of transfer early

She now requires transfer. Outline your plan.

Stabilisation:

• Secure airway (ETT), ventilate with PEEP if inhalation injury.

• Ongoing fluids (maintenance + Parkland), opioid infusion (morphine 20 mcg/kg/hr).

Retrieval Team:

• Contact paediatric burns centre; provide handover (TBSA, fluids, airway status).

• Pack emergency drugs (adrenaline, spare ETT), portable ventilator.

• Monitoring: Continuous SpO₂, ETCO₂, ECG during transport.

Communication:

Notify the receiving hospital of the patient’s condition and treatment thus far, and request any specific expertise (e.g., burns unit, paediatric intensivist).

Documentation:

Document all interventions and treatment given prior to transfer, including fluid management, medications, and airway management.

Debrief:

staff/family

What if she arrests during transfer prep?

CPR: 15:2 compression:ventilation ratio; adrenaline 10 mcg/kg IV/IO.

Reversible Causes:

• 4 Hs: Hypoxia (check tube), Hypovolaemia (fluid bolus), Hyperkalaemia (ECG), Hypothermia (warming).

• 4 Ts: Tension pneumothorax (needle decompress), Toxins (e.g., CO poisoning), Tamponade (unlikely), Thrombosis (PE unlikely).

Key Phrases for High Marks:

• "Given her age, I’d use the Broselow tape to confirm weight-based dosing."

• "Early intubation is safer than emergency intubation if inhalation injury is suspected."

• "I’d involve retrieval services early due to Scenarioville’s lack of paediatric ICU."