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Fluid resuscitation

1.      Use endpoints to guide resuscitation – urine output of 1-1.5 cc/kg/hr, pulse, distal perfusion, base deficit

2.      Small burns < 20% may not need aggressive resuscitation – fluids at 1-1.5 times normal is enough with ad lib PO intake if possible.

3.      20-50% burns need calculated resuscitation

4.      Parkland formula – 4cc/kg/hr in first 24 hrs

5.      1 times maintenance of the above fluids is given as 5% albumin – no need to hold colloids during the first 24 hrs. Rest is usually plain LR. If not taking PO, one times maintenance of dextrose solution can be substituted.

6.      For > 50% burns, colloids are given as 2X maintenance of total resuscitation as per Parkland formula– rest as above.

Other Points on medical management

1.      Airway – close observation is required, sick kids who have a high chance of developing airway edema are better intubated

2.      Bladder catheter for strict I/Os

3.      Maintenance of normothermia

4.      Usually central access is obtained. Small lumen lines with double lumen is enough except for the sickest kids. Rotation of lines is usually the norm – every 2 weeks.

5.      Start enteral tube feeding on Day 1 – more sick kids may need to be slowly advanced.

6.      Antibiotics are not routine – fever during the initial days can be just monitored unless very high, during the latter part of first week any fever requires empiric antibiotics and cultures.

7.      Areas of circumferential burns need to be monitored for compartment syndrome– usually done by pulse oximetry or doppler pulse checks.

8.      Topical therapy – silver nitrate or sulfamylon (with antifungals) is usually used for larger burns

9.      Physiology of small infants need to be monitored even more closely perioperatively and intraoperatively.

Criteria for admission

While burns > 20% need admission for proper resuscitation, burns < 15-20% sometimes are admitted just to provide proper counselling and based on patient / parent preference. Also, if there is any concern for airway and / or any concern for ability and willingness for food intake, the patient is admitted.

Early excision of Burns

1.      Extensive burns represent a greater risk of sepsis. These wounds are excised during the first day / resuscitation phase and additional takebacks to the OR are necessary for complete excision of all burn wounds which is usually accomplished in the first week.

2.      Smaller burns can be excised within the first week but these have lesser chance of sepsis and greater chance of aesthetic deformities and as such family involvement in decision making is required and as minimal amount of excision as possible should be done.

3.      Blisters can be removed without causing undue pain and dressing applied. It is a good idea to remove thin tense blisters.

Other points on Operative care

1.      Maintain normothermia to prevent coagulopathic bleeding

2.      Monitor patient physiology during surgery

3.      Excise what really needs to be excised. This can be done by doing passes with the dermatome to find out the thickness of the burn wound and decide which wounds definitely need to be excised.

4.      Do not excise too much at once – do it in stages

5.      Extensive fascial level excisions are not always required – layered excisions are preferred.

6.      Excisions are followed by autograft. Can defer if child is physiologically unstable.

Postoperative care

1.      First dressing can be in about 5 days. Daily dressing is reserved for doubtful wounds which have a high chance of getting infected.

2.      Ketamine can be used for analgesia during dressing changes.

3.      Scar excision in the long run is not always necessary – newer techniques include release of tension so that these scars remodel themselves.

4.      Multi-disciplinary management with social work, physical therapy, psychiatry, pediatrics, nutrition etc is an ongoing area of progress.

5.      Younger infants tend to develop contractures more often due to immobility and PT and early functional reconstruction is necessary.