The systemic capillary leak that occurs after a serious burn makes initial fluid and electrolyte support of a burned child crucial. The first priority is to support the circulating blood volume, which requires the administration of intravenous fluids to provide maintenance fluid and electrolyte requirements and to replace ongoing burn-related losses. Formulas exist to help guide fluid management; however, no formula accurately predicts the fluid needs of every burn patient. Children with a significant burn should receive a rapid bolus of 20 mL/kg of lactated Ringer solution. Thereafter, the resuscitation formula for fluid therapy is determined by the percent of body surface burned. Total fluids are 2 to 4 mL/kg/percent burn/24 hours, with half the estimated burn requirement administered during the first 8 hours. (If resuscitation is delayed, half of the fluid replacement should be completed by the end of the eighth hour post-injury.) Fluids should be titrated to achieve adequate perfusion, one marker of which is urine output greater than 1 mL/kg/hour. Controversy exists over whether and when to administer colloid during fluid resuscitation. Colloid therapy may be needed for patients with extensive burns.
Because burn injury produces a hypermetabolic response, children with significant burns require immediate nutritional support. Enteral feeds should be started early unless there is a specific contraindication. Children with critical burn injury may require parenteral nutrition if unable to tolerate full enteral feeds. Consider supplementation of vitamins and trace elements. Factors that may modify the hypermetabolic state such as beta blockers, androgenic steroids, and others are being investigated.
Wound care starts with cleaning and debriding the wound. Effective pain control is important to allow for complete debridement. Topical agents and dressings are then applied to control bacterial colonization, decrease evaporative losses, and aid in pain control. Commonly used topical agents include silver sulfadiazine (Silvadene) or, if the burn is shallow, polymyxin B/bacitracin/neomycin (Neosporin) ointment. Silver nitrate and mafenide acetate (Sulfamylon) are alternative antimicrobial agents. Sulfamylon has the benefit of penetrating eschar, but it is painful and can cause metabolic acidosis. Silver nitrate is used less commonly because of poor tissue penetration and potential for electrolyte abnormalities. These agents
Monitor for infection, avoid prophylactic antibiotics Hypovolemia Fluid replacement Hypothermia Adjust ambient temperature: dry blankets in field
Laryngeal edema Endotracheal intubation, tracheostomy Carbon monoxide 100% oxygen, hyperbaric oxygen poisoning
Cyanide poisoning 100% O2 plus amyl nitrate, sodium nitrate, and sodium thiosulfate Cardiac dysfunction Inotropic agents, diuretics Gastric ulcers H2-receptor antagonist, antacids Compartment syndrome Escharotomy incision Contractures Physical therapy Hypermetabolic state Enteral and parenteral nutritional support Renal failure Supportive care, dialysis Transient antidiuresis Expectant management Anemia Transfusions as indicated Psychological trauma Psychological rehabilitation Pulmonary infiltrates PEEP, ventilation, oxygen Pulmonary edema Avoid overhydration, give diuretics Pneumonia Antibiotics Bronchospasm β-Agonist aerosols
PEEP, Positive end-expiratory pressure.
inhibit but do not prevent bacterial growth. Various grafts, such as cadaver allografts, porcine xenografts, or skin substitutes, have been used initially to cover wounds. For full-thickness burns, skin autografting and skin substitutes are required for eventual closure.
SEE TABLE 44-1.