Seminars in Pediatric Surgery 28 (2019) 73–78

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Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Early resuscitation and management of severe pediatric burns

Mary K. Arbuthnot a,∗, Alejandro V. Garcia b
a
Naval Medical Center Camp Lejeune, Department of General Surgery, 100 Brewster Blvd., Camp Lejeune, NC 28547, USA
b
Johns Hopkins Hospital, Department of Pediatric Surgery, 1800 Orleans St. Bloomberg Bldg 7313, Baltimore, MD 21287, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Pediatric burns are a leading cause of injury and mortality in children in the United States. Prompt resus-
Pediatric burns citation and management is vital to survival in severe pediatric burns. Although management principles
Resuscitation
are similar to their adult counterparts, children have unique pathophysiologic responses to burn injury
Inhalational injury
thus an understanding of the differences in fluid resuscitation requirements, airway management, burn
Wound coverage
and wound care is essential to optimize their outcomes.
Published by Elsevier Inc.

Introduction Initial resuscitation in burns

Pediatric burns are a leading cause of injury and accidental
death in children. In the United States, it is the third most common
cause of unintentional injury or death in children between 5 and 9
years of age and a leading cause of death in children aged 1–14.1
In the toddler age group, scald burns from hot liquid or grease pre-
dominate, although contact burns from objects such as hot stoves
or grills are also common.2 Younger children tend to suffer thermal
burns from matches or lighters, while older, school-age children
tend to suffer burns from risk-taking activities such as the use of
fireworks or the reckless use of flammable substances.2 Many of
these thermal injuries are minor and can be treated on an outpa-
tient basis. However, nearly 5% are considered to be moderate or
severe, necessitating hospitalization.3 Notably, 16–20% of children
admitted with burns are the victims of abuse and this should be
considered when the history of the burn does not match the pat-
tern of the injury, or if there is a delayed presentation.2
Historically, severe burns > 80% of the total body surface area
(TBSA) in children were deemed uniformly fatal. Advancements
in fluid resuscitation, nutritional support, airway injury manage-
ment and burn care have improved overall burn survival.4 Al-
though the principles of resuscitation are similar between children
and adults, there are marked differences in their physiologic re-
sponse to burns, their fluid resuscitation requirements, their air-
way management and burn care; a critical understanding of these
differences is essential to improve short-term and long-term out-
comes in burned children.
∗
Corresponding author.
E-mail addresses: mary.k.arbuthnot.mil@mail.mil (M.K.
agarci41@jhmi.edu (A.V. Garcia).
Why do burns require prompt intravenous resuscitation?
Unlike other traumatic injuries, thermal injury uniquely results
in plasma loss from injured tissues, thereby affecting not only the
integumentary system but also the cardiovascular, renal, gastroin-
testinal and pulmonary systems.5 In addition to the loss of the
evaporative protection of the skin, burns >15% TBSA activate a sys-
temic inflammatory response that results in diffuse capillary leak
and massive fluid shifts.6–8 The resultant intravascular fluid deple-
tion may rapidly lead to hypovolemia and shock.3,5 Further, de-
layed fluid administration to the volume-contracted patient may
contribute to a perfusion-reperfusion injury when they are finally
resuscitated, resulting in the release of free radicals which, in turn,
potentiates the systemic inflammatory response.4 Due to smaller
circulating blood volumes in children, delays in initiating adequate
volume resuscitation must be avoided.3 Postponing proper resusci-
tation in children for as little as 30-min is associated with the de-
velopment of acute renal failure, increased hospital length of stay
and increased mortality.3–5
Partial thickness and full thickness burns are used to calculate
the TBSA. While smaller burns can often be treated with oral hy-
dration, infants and children with >10% TBSA burns or teenagers
with >15% TBSA burns require prompt intravenous access and vol-
ume resuscitation.6,7,9,10 Peripheral large-bore intravenous access
should be obtained either percutaneously or by cut-down, prefer-
ably into unburned skin.9 Intraosseous lines may be necessary for
access in infants but should be replaced within 24 h. Central ve-
nous catheters may be necessary in children with sizeable burns.9
The first 48 h post-burn are the most critical to avoid renal fail-
ure, sepsis and mortality. As such, the goals of resuscitation should
Arbuthnot), be aimed at achieving optimal organ and tissue perfusion while

https://doi.org/10.1053/j.sempedsurg.2019.01.013
1055-8586/Published by Elsevier Inc.
74 M.K. Arbuthnot and A.V. Garcia / Seminars in Pediatric Surgery 28 (2019) 73–78
Fig. 1. Lund and Browder chart (adapted from Sharma and Parashar)11 .
attempting to minimize tissue edema from widespread capillary
leak.7
What is the ideal estimated fluid resuscitation rate?
Physical examination will assist in determining the severity of
the burn, which is based on body surface area affected and the
depth of the burn. In children, the body surface area of the head
and neck is much larger compared to adults, and similarly, the
body surface area of the lower extremities is much less.11 The Lund
and Browder chart is the most commonly used and is the most
precise method for estimating TBSA in children (Fig. 1).11 It ac-
counts for the variation in body shape with age to allow for a more
accurate assessment of body surface area affected.10 If not avail-
able, the palm of the individual, regardless of age, can be used to
estimate 1% of the body surface area.9
It is critical to not underestimate the TBSA in children. Their
overall baseline body surface area to mass ratio in children is in-
creased compared to adults, thus the volume of fluid required per
percentage of body surface area burned is greater.3,9 Furthermore,
due to their limited glycogen stores, infants and children are at
risk of developing hypoglycemia if this is not accounted for.3 To
address these differences, several pediatric-specific formulas have
been developed which calculate age and weight-based estimated
fluid resuscitation (EFR) volumes which include the provision of
dextrose-containing maintenance fluids (MF).3
Ringer’s Lactate solution (LR) should be started in children re-
gardless of age combined with dextrose-containing maintenance
fluids in children <30 kg.3,8,9 The Cincinnati Formula and the
Galveston Formula are the two main pediatric-specific tools uti-
lized in current practice (Table 1).3 These formulas account for EFR
and MR based on the TBSA of the burn. They also include the
use of colloid in resuscitation (see later description). Unfortunately,
there are no direct comparisons between the two formulas to de-
termine superiority. In older children and teenagers, the two most
widely used formulas are the Parkland and the modified Brooke
formulae, neither of which includes the use of colloid (Table 2).3,12
These formulas are intended for use in the initial 48-h period post-
burn.13
Endpoints of resuscitation, such as the urinary output (UO),
should be used to guide fluid resuscitation and be monitored
hourly. In children <30 kg, the goal UO is 1 mL/kg/h, and in chil-
dren >30 kg, the goal UO is 0.5 ml/kg/h.3,9 In addition to urinary
output, physical examination findings such as peripheral perfusion,
 M.K. Arbuthnot and A.V. Garcia / Seminars in Pediatric Surgery 28 (2019) 73–78 75

Table 1
Common pediatric burn fluid resuscitation formulas.3

Formula Galveston Cincinnati (young children) Cincinnati (older children)

Crystalloid 50 0 0 ml/m2 burn + 20 0 0 ml/m2 4 ml/kg/%TBSA burn + 1500 ml/m2 total 4 ml/kg/%TBSA
total BSA of LR BSA of LR burn + 1500 ml/m2 total BSA of
LR
Colloid 12.5 g of 25% albumin per liter 12.5 g of 25% albumin per 1 liter of None
of crystalloid crystalloid in the last 8 h of the initial
first 24 h post-burn period
Glucose 5% dextrose as needed 5% dextrose as needed 5% dextrose as needed
Administration ½ over first 8 h, then ½ over To be administered ½ over the first 8 h ½ over first 8 h, then ½ over
next 16 h and the second ½ over the next 16 h. next 16 h
Fluid composition changes each 8
hoursperiod. 1) 1st 8 h, add 50 meq/L
sodium bicarbonate 2) 2nd 8 h, only LR
without additive 3) 3rd 8 h, add
albumin
Body surface area (BSA), percent total body surface area (%TBSA), Ringer’s lactate solution (LR)
Adapted from Romanowski and Palmieri.3

Table 2
Common adult burn fluid resuscitation formulas.3

Formula Parkland Modified brooke

Crystalloid 4 ml/kg/%TBSA burn of LR 3 ml/kg/%TBSA burn of LR

Colloid None None
Glucose None None
Administration ½ over first 8 h, then ½ over next 16 h ½ over first 8 hours, then ½ over next 16 hours

Adapted from Romanowski and Palmieri.3

sensorium, and normalizing hemodynamics are cues to adequate Table 3

Potential complications of “fluid creep”
resuscitation.3,14 Trending biomarkers, such as plasma lactate lev-
resulting from over resuscitation.19
els and base deficit, may be useful to estimate burn severity and
predict survival.15,16 Kraft et al. evaluated the use of a transcar- Cerebral edema
Pulmonary edema
diopulmonary thermo-dilution monitoring device (PiCCO) to guide
Upper airway edema
resuscitation in children with >30% TBSA burns and compared Pleural effusions
this cohort to children resuscitated with conventional monitoring Pericardial effusions
systems. Children monitored with the PiCCO system received sig- Anasarca
nificantly less fluid with improved diuresis; Kaplan-Meier curve Wound deepening
Extremity compartment syndrome
analysis revealed a lower mortality in the initial post-burn phase.
Abdominal compartment syndrome
These findings suggest that vital, parameter-based fluid resuscita- Orbital compartment syndrome
tion in severe pediatric burns may improve outcomes.17 Further Pneumonia
analysis with prospective randomized trials investigating the use Acute respiratory distress syndrome
Multiorgan dysfunction syndrome
of biomarkers and fluid-adjusted algorithms may be useful to pro-
Death
vide additional guidance for resuscitation in the severely burned
child.

minimizes fluid creep, particularly in children who may require

What is the role of albumin in reducing “fluid creep”?
First described by Pruitt in 20 0 0, “fluid creep” is a phenomenon
where patients receive significantly more fluids than predicted
thus leading to fluid overload and potentially other deleterious
complications (Table 3).13,18,19
While historically controversial, colloid-assisted resuscitation
decreases fluid requirements. Faraklas et al. retrospectively re-
viewed the use of crystalloid resuscitation to crystalloid plus col-
loid supplementation in children with >15% TBSA burns. They
found that a subset of patients with deeper, more severe burns,
and those with inhalation injuries who failed to maintain target
UO, had it restored with the addition of colloid.20 A randomized
controlled trial by Dittrich et al. in 2016 investigated the addi-
tion of early (8–12 h post-burn) and late (24 h post-burn) albu-
min administration and its effect on fluid creep in children with
>15–45% TBSA burns. The early albumin group had statistically sig-
nificant decreased overall crystalloid administration, shorter hos-
pital lengths of stay and a reduced incidence of fluid creep.19
Mechanistically, increasing oncotic pressure and decreasing capil-
lary leakage with colloid restores intravascular blood volume and
significantly more volume than would an adult counterpart.19,20
Albumin-assisted resuscitation is currently included in both the
Galveston and the Cincinnati burn fluid resuscitation formulas
(Table 1).
Management of inhalational injuries
What is the pathophysiology behind inhalational injuries and who
is at risk?
Twenty to 30% of patients who suffer major burns will have
an associated inhalation injury.21,22 Smoke, which is composed
of both a gas and particle phase, is often inhaled through the
mouth during a fire.23 Bypassing the nasopharynx facilitates the
inhalation of particles that would have otherwise been cleared,
resulting in particle deposition in the upper airway, sloughing of
the tracheobronchial tree, fibrin deposition in lung parenchyma
and subsequently atelectasis.23 Smoke inhalation releases throm-
boxane which increases pulmonary arterial pressure and releases
chemotactic factors and cytokines, such as TNF-alpha and IL-6.22,24
Protein-rich fluid then enters the lung secondary to the disruption
76 M.K. Arbuthnot and A.V. Garcia / Seminars in Pediatric Surgery 28 (2019) 73–78
Table 4
Abbreviated Injury Score (AIS) grading scale based on fiberoptic bronchoscopy.30
Grade 0 1
Classification of Injury None Mild
Description Absence of carbonaceous Minor or patchy areas of
deposits, erythema, erythema, carbonaceous
edema, bronchorrhea, or deposits in proximal or
obstruction distal bronchi
Adapted from Albright et al.30
of endothelial junctions leading to pulmonary edema, surfactant
dysfunction, copious exudates and progressive cellular injury.22,23
In addition to the chemical irritation of the airways, inhalation in-
juries may result in direct thermal damage producing airway ery-
thema, ulceration and edema. Systemic toxicity may also result
from impaired mitochondrial metabolism due to carbon monoxide
and hydrogen cyanide inhalation.21,23
Although less likely to be affected than adults, inhalational in-
juries still pose a significant risk to children.21 Indeed, concomitant
inhalational injuries reduce the lethal burn area from 73% TBSA
to 50% TBSA.25 The diagnosis of an inhalational injury is based
on history and clinical exam. Patients found in enclosed fires are
at risk for smoke inhalation.26 In children, agitation or confusion
may be related to smoke inhalation, fear, or other injury.26 Fa-
cial burns, singed nasal or facial hairs, soot in or around the air-
way, stridor, hoarseness, dyspnea or wheezing are worrisome find-
ings.21,26,27 Chest radiographs are usually normal and oxygen sat-
uration, as detected by pulse oximetry, is unaffected initially and
thus is not helpful in the initial diagnosis of inhalation injury.21,27
How should inhalational injuries be evaluated and graded?
A variety of adjuncts are utilized to confirm inhalational in-
jury, including carboxyhemoglobin measurements, chest computed
tomography, pulmonary function tests, and xenon ventilation-
perfusion scans.28 While the computed tomography findings of
ground glass opacities, atelectasis, and interstitial markings may
assist in the diagnosis of inhalational injury, fiberoptic bron-
choscopy (FOB) is the most helpful adjunct.21,28 Fiberoptic bron-
choscopy allows for the severity grading of inhalational injury, the
prognostication of acute lung injury, the need for resuscitation and
overall mortality.27
The Abbreviated Injury Score (AIS), initially published by En-
dorf et al., is now the most widely used approach for grading the
severity of inhalational injuries. The classification scheme stratifies
injuries into 5 categories based on FOB (Table 4).27–30 More severe
injuries have been demonstrated to be associated with impaired
gas exchange and worse survival rates.28,29 Curiously, the AIS grade
of injury scale itself has not been found to be associated with
fluid resuscitation requirements.27,28 Despite this, the presence of
inhalational injury has been demonstrated to be associated with
fluid requirements in excess of what most burn fluid resuscitation
formulas predict, and this must be carefully monitored.6
What are other considerations for patients with inhalational injuries?
Pediatric burn patients with inhalation injuries have a mortality
that exceeds 15%.31 Early management of these injuries is critical
to decrease long-term morbidity.32 Injury severity dictates the
complexity of management which may involve simple supportive
care in the context of minor injuries or advanced ventilation
or extracorporeal life support for significant injury.33 Indeed,
inhalational injury in conjunction with cutaneous injuries typically
requires early critical care support.34 Five-year follow-up studies
2 3 4
Moderate Severe Massive
Moderate degree of Severe inflammation with Evidence of mucosal
erythema, carbonaceous friability, copious sloughing, necrosis,
deposits, bronchorrhea, carbonaceous deposits, or endoluminal
or bronchial obstruction bronchorrhea, or obliteration
obstruction
suggest that patients with inhalational burns do not have an im-
paired quality of life further emphasizing the need for appropriate
early care.35
The initial management of all burn patients follows the Ad-
vanced Trauma Life Support guidelines for trauma. If respiratory
distress is significant, intubation or a surgical airway may be re-
quired. Following the assessment and grading of injury via bron-
choscopy, early management includes strategies to minimize bron-
chospasm and airway occlusion. This includes the use of oxygen
supplementation, bronchodilators, racemic epinephrine, frequent
suctioning and aggressive pulmonary toilet. Adjunct measures in-
clude heparin inhalation and N-acetylcysteine which help to clear
secretions and decrease cast formation within the airways. Recent
studies have demonstrated that these adjuncts may decrease rein-
tubation rates and overall mortality amongst those with severe
burns and inhalational injuries.36–39 Hypertonic saline can be used
to induce effective cough in an attempt to clear the airways. In
patients with severe respiratory failure, high frequency percussive
ventilation has been shown to reduce the development of pneumo-
nia by facilitating the clearance of bronchial secretions. The need
for mechanical ventilation and severe inhalation injury noted on
bronchoscopy were both found to be independent predictors of
mortality.40 Extracorporeal membrane oxygenation using venove-
nous support has been shown to be safe in burn patients who fail
maximal respiratory support.33
All patients with inhalational injury require special considera-
tion for carbon monoxide (CO) and cyanide toxicity. Both CO and
cyanide are highly toxic compounds that can cause significant mor-
bidity and mortality.41 Poisoning should be suspected when the
history suggests entrapment in an enclosed space. Symptoms can
vary from mild neurological symptoms to unexplained metabolic
collapse, but any suspicion should prompt urgent investigation and
treatment.
Carbon monoxide is one of the most frequent causes of imme-
diate death following an inhalational injury. Carbon monoxide is a
colorless, odorless gas with an affinity for hemoglobin 200 times
greater than oxygen. Binding of CO leads to a shift of the oxyhe-
moglobin disassociation curve to the left. Carbon monoxide levels
can be measured from a blood gas sample by obtaining a carboxy-
hemoglobin level. Symptoms of CO poisoning such as disorienta-
tion and obtundation typically occur when levels are above 10%.
Carbon monoxide levels greater than 25% typically lead to loss of
consciousness and death.
Since CO has a higher affinity for hemoglobin then oxygen, el-
evated levels of CO will lead to hypoxia. Routine pulse oxime-
try data is not reliable in the detection of CO poisoning. Carbon
monoxide has a half-life of 4–6 h at room air. Oxygen supple-
mentation using 100% oxygen will decrease the half-life of CO to
80 min. While hyperbaric oxygen decreases the half-life of CO to
22 min, a recent metanalysis suggests there may be no added ben-
efit with this therapy.42
Cyanide toxicity occurs from the combustion of household
items and may lead to unexplained metabolic collapse. Symp-
toms are typically non-specific and levels cannot be measured soon
 M.K. Arbuthnot and A.V. Garcia / Seminars in Pediatric Surgery 28 (2019) 73–78 77

enough to be clinically helpful. Cyanide toxicity remains a clini- help control bacteria in the wound and minimize the risk of infec-
cal diagnosis and patients with soot in their mouth, altered men- tion. Salves typically require multiple applications per day to pre-
tal status and metabolic acidosis with high lactate levels suggests vent the wound from desiccating. Soaks can be used similarly for
cyanide poisoning. Treatment consists of hydration and the imme- wound care. There are many available soak solutions including sil-
diate administration of hydroxycobalamin or sodium thiosulfate. ver nitrate and sodium hypochlorite (Dakin’s solution) solutions.
CYANOKIT® (hydroxocobalamin for injection) is a commonly avail- These solutions are generally poured onto gauze dressings and ap-
able cyanide antidote with a rapid onset of action.43 plied to the wound. They may be poured repeatedly over dressings
to minimize the frequency of dressing changes, which could lead
to graft loss and impair wound healing. These soaked dressings can
Burn management
also be used in cases where a wound infection is suspected.
Commonly used salves include silver sulfadiazine and baci-
Who requires debridement and grafting?
tracin. Bacitracin provides antimicrobial properties against gram-
positive bacteria. Silver sulfadiazine (SILVADENE® ) provides added
Following proper resuscitation, attention should be directed to
coverage for gram-negative and enteric bacteria. Prolonged use of
the management of the burn wounds. The initial surgical manage-
silver sulfadiazine requires monitoring for leukopenia. More com-
ment of burns involves debridement of necrotic tissue and cleaning
plex burns may require mafenide acetate (Sulfamylon® ) which can
the wound base. First-degree burns typically require no treatment.
penetrate an eschar while also providing Pseudomonas coverage.
All patients with partial and full thickness burns should be surgi-
Mafenide acetate is typically used for third degree burns and areas
cally debrided to remove devitalized tissue. This allows for optimal
of exposed cartilage such as the ear and nose. Patients who require
wound healing and minimizes the risk of infection. Burn wounds
mafenide acetate need to be monitored for metabolic acidosis and
that are infected or nonhealing also require surgical management.
pain.46 Due to these side effects, its use should be limited to burns
The goals of surgical intervention are to provide an optimal wound
less than 20% TBSA.
healing environment and to prevent infection. Wounds of indeter-
Most wounds can be covered after placement of a salve. Typical
minate depth may be observed with daily dressing changes to as-
dressings include petroleum gauze or iodine impregnated gauze.
sess for changes over time. Most wounds will declare themselves
The exception to this are burns to the face for which the salve is
within the first few days. Large areas of full thickness burn require
typically applied without dressing coverage. Salves should be re-
early excision within the first week. Small areas of full thickness
placed at least daily and the wound should be assessed for pro-
injury can be managed as an outpatient with close follow up for
gression or signs of infection.
signs of infection and contracture. Studies have shown that early
Silver impregnated dressings have facilitated the outpatient
debridement helps decrease the hypermetabolic state and reduce
management of burns.47 They have the ability to absorb excess
the risk of subsequent burn wound infection.44
wound exudate and may remain in place for several days to weeks
It is imperative that the operating room be kept warm to pre-
prior to replacement. They also contain biologically active silver
vent hypothermia. Wounds can be treated with sharp debridement
ions, which provides antibacterial properties. Studies have demon-
or excision with grafting. Newer techniques using the VERSAJETTM
strated that patients experience less pain with the use of silver
Hydrosurgery system have been described. This system utilizes a
impregnated dressings compared to standard gauze dressings.48
high-powered stream of sterile saline for debridement. The re-
These silver impregnated dressings can be used to cover donor
ported benefits of this new technology include the ability to per-
sites as well. In addition, studies indicate that calcium alginate is
form small-scale incremental debridement which preserves the
superior to standard wound care for pediatric donor sites.49 Neg-
dermis when compared to standard sharp excisional techniques.
ative wound pressure therapy has also been found to be safe and
This technique has been shown to reduce bleeding and healing
effective in children without causing excessive bleeding or pain.50
times as well as biological dressing adherence to the burn site.45
Skin grafting has many benefits including minimizing pain,
What are other novel synthetic and biological dressings available?
allowing faster recovery, and minimizing the risk of infection.
Typically, a tangential excision of full thickness burns is performed
Many novel alternative dressings are now available for use in
using a dermatome, electrocautery, VERSAJETTM or knife blades
burn wound care. Biologic options include xenografts, cadaveric
until a viable tissue plane is obtained. The use of epinephrine-
skin, and placenta-derived tissue. Bioengineered products are also
soaked gauze and tourniquets for extremity burns can help
available which help prepare a wound bed prior to grafting. Impor-
decrease blood loss. Skin grafting can be performed at the time of
tantly, cost is a consideration with many of the synthetic dressings.
excision provided there are adequate donor sites and the patient is
The benefits of synthetic dressings are that they eliminate the need
hemodynamically stable. If there is concern regarding a patient’s
for frequent dressing changes and reduce potential fluid loss. These
physiologic status, the extent of the burn or the quality of the
attributes make them particularly appealing to younger patients.
graft site, alternative dressings such as cadaveric skin may be used
Acellular human dermal allograft, which is devoid of epidermis,
prior to autografting. Allografts are typically used for short-term
may be used to replace the dermis as an alternative for skin cov-
wound coverage (i.e. a few days to a few weeks) and permit
erage (AlloDerm® ). Another dermal substitute made of bovine col-
rapid coverage which will minimize pain and infection while also
lagen and shark chondroitin sulfate together with a silicone sur-
preparing the wound bed for subsequent autografting. Autografts
face layer (IntegraTM ) is also available. Both of these products can
can then be utilized once the allograft has sloughed from the
be placed on a clean and well-vascularized wound bed. Cultured
wound as long as there is no infection and the patient is stable.
epidermal autografts (CEA) such as Epicel® , are also available as
an alternative to harvesting large skin grafts. These CEAs can be
What are options for wound coverage? placed directly on a clean wound bed; they are particularly useful
for sensitive areas, smaller burns as well as use in small children.
Wound care following debridement varies depending on the A new product derived from dehydrated human placenta (EpiFix® )
depth of the burn. Many partial or full thickness burns can be is composed of a layer of epithelial cells, a basement membrane
initially managed with salves, soaks, or dressings. Salves are top- and an avascular connective tissue matrix and has been success-
ical ointments and creams that are applied to provide moisture fully used in several case series as a permanent alternative to
to the wound bed. Many salves have antimicrobial properties that skin grafting for chronic wounds. The reported benefit is that it
78 M.K. Arbuthnot and A.V. Garcia / Seminars in Pediatric Surgery 28 (2019) 73–78
protects the wound while promoting vascular angiogenesis and
healing.51 Few randomized controlled trials exist to comparing
these products to standard wound care.
Conclusion
Outcomes following severe burn injury in children have im-
proved with specific attention to prompt and goal-directed resus-
citation, the recognition and management of inhalational injuries,
and novel wound care techniques. Still, the challenge remains in
ensuring that providers managing pediatric burns account for the
acute physiologic differences in children as they proceed with re-
suscitation management. Further research is necessary, particularly
with respect to the ideal burn dressing and coverage. Most impor-
tantly, ongoing education to care providers is essential to ensure
the highest level of care to this vulnerable population.
Disclosures
The views expressed in the article are those of the author and
do not necessarily reflect the official party or position of the De-
partment of the Navy, Department of Defense, nor the U.S. Govern-
ment.
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