Burns

Animal studies in the 1960s and 1970s showed that excessive colloid administration resulted in histologic accumulation of colloid in the lungs, leading to fear of pulmonary compromise before mechanical ventilation was widely available.

Traditional crystalloid-only resuscitation formulas (Brooke, Parkland) cause severe anasarca with significant morbidity, including near-compartment syndrome and neurologic injury.

Children do not need to make 2 cc/kg/hr of urine unless they are extremely young or have abnormal renal concentrating ability; targets of 0.5–1 cc/kg/hr are reasonable.

Starting 5% albumin colloid immediately in burns ≥30–40% reduces total fluid volume and eliminates the need for abdominal decompression in Sheridan's practice.

For burns 15–20% or less, maintenance-and-a-half IV fluids or ad lib PO intake with clinical monitoring (tears, moist oral cavity, pulse quality) is sufficient; calculated resuscitation is not needed.

For mid-range burns (20–50%), Sheridan calculates Parkland (4 cc/kg/% burn over 24 hours), subtracts 1× maintenance, and gives that volume as 5% albumin; the remainder is given as Ringer's lactate. If the child is young and at risk for hypoglycemia, he also subtracts 1× maintenance as D5 Ringer's.

For burns >50%, Sheridan gives 2× maintenance as 5% albumin (or one-third of total calculated resuscitation as albumin), with the remainder as crystalloid.

Resuscitation fluids are adjusted hourly based on urine output and distal perfusion; by 24 hours, total fluid infusion typically reaches approximately 150% of maintenance if resuscitation goes well.

Most small burns (<10%) are managed outpatient; admission criteria are driven by family factors (distance, car access, ability to follow instructions), not wound size alone.

Thick, durable, non-tense blisters (e.g., on fingertips and palms) can be left intact for a few days to avoid painful debridement; thin blisters that will rupture should be debrided in the clinic.

Early excision for large burns (≥20–30%) means removing non-viable tissue within the first few days to prevent septic morbidity, which typically appears by day 3–5.

For small deep burns with no septic threat, early excision means clear identification of what needs excision, family teaching, and operative intervention within the first week.

Children with large burns (≥50%) are intubated early if airway edema or extensive surgery is anticipated, to secure the airway before swelling makes intubation difficult.

Enteral feeding via nasogastric tube is started on day 1 in most burns; children with very large burns or prolonged transport may have splanchnic ischemia and require trophic feeds until bowel sounds return.

Prophylactic antibiotics are not routinely used; a study of ~600 children (300 per arm) showed no difference in infection rates but more rashes and diarrhea in the antibiotic group.

Central venous access is placed in nearly all large burns; femoral lines have the same infection rate as other sites in Sheridan's 1000-catheter review, with a slight trend toward higher infection in internal jugular lines in small children.

Central lines are rotated weekly in the pre-antiseptic-line era (infection spike at 10 days) and every 2 weeks with antiseptic-impregnated lines (spike at 2 weeks); lines are also rotated in conjunction with OR trips.

Army burn unit studies showed up to 42% incidence of occult bacteremia during major wound manipulations in children with open wounds.

Escharotomies are performed in the first 24–36 hours if circumferential burns risk limb or torso ischemia; pulse oximetry or Doppler checks every 2 hours guide the decision.

Sheridan uses silver nitrate soaks, sulfamylon soaks (sometimes with amphotericin for difficult gram-negatives), and other wet topicals for large burns; the choice is unit-specific and differences in outcomes are modest if other program elements are strong.

Diagnostic dermatome passes in small representative areas help determine burn depth intraoperatively when clinical exam is uncertain.

Excision is staged over 2–3 days for very large burns to avoid critical illness, excessive blood loss, and fluid overload; the goal is to remove all threatened tissue by day 5–7.

Maintaining normothermia during excision (OR at 120°F, 100% humidity, continuous temperature monitoring) prevents coagulopathic bleeding from hypothermia.

Fascial excisions, once routine for full-thickness burns, are now rare; layered excision preserving remnant fat improves long-term appearance and reconstructive options.

Hemostatic excision endpoints include the appearance of fat and deep reticular dermis, not free bleeding; this minimizes blood loss compared to older techniques.

Allograft is used as temporary coverage when the child is unstable, excision depth is uncertain, or burns are too large for immediate autografting; it is treated like autograft (secured, allowed to vascularize) and replaced with autograft in 5–7 days.

Split-thickness autograft remains the definitive permanent membrane; no permanent skin substitute has proven superior.

Donor sites should be treated as the most valuable territory: thin harvests, meticulous care, no infections, no deep passes, to preserve tissue for future reconstruction.

Colloid-inclusive resuscitation has transformed outcomes by reducing anasarca and eliminating the need for abdominal decompression in Sheridan's practice.

Minimally ablative excision improves long-term aesthetic and functional outcomes but carries a slightly higher septic risk and makes definitive coverage on fat beds more challenging than on fascial beds.

Modern scar management favors small tension-relief operations over ablative excision and skin grafting; scars shrink with regional tension release, sometimes augmented by fractional CO₂ laser.

Early functional and aesthetic reconstruction (as soon as functional issues arise) has replaced the old practice of waiting 2 years before operating on healed burns.

Multidisciplinary aftercare (PT, OT, psychology, nutrition, nursing, surgery) in daily rounds and clinic is essential to long-term outcomes and reintegration.

Infants <6 months with large burns require obsessive attention to fluid management, line care, tube position, lung-protective ventilation, hemostatic excision, normothermia, and thin harvests; they are prone to flexion contractures and need aggressive PT/OT and early functional reconstruction.