Pediatric Burns By Bradley J. Phillips

well as for civilians in the region, provided a constant and sufficient number of patients during both war and peace.

Another major factor in the development of burn care in the United States was the decision on July 4, 1962, by the Shriners Hospitals for Crippled Children to privately fund the construction and operation of 3 pediatric burn units. The center in Galveston, Texas, opened in 1963 under Dr Curtis Artz as chief of staff; the unit in Cincinnati, Ohio, in 1964 under Dr Bruce Macmillan; and the unit in Boston, Massachusetts in 1964 under Dr Oliver Cope. Other dedicated facilities were constructed from through 196in the late 1960s. Similar to the USAISR, they became centers of excellence in care, teaching, and research.^22-24

The period of most rapid growth in the number of burn units in the United States occurred during the decade 1970-1979, in which the number of units tripled.²³ One hundred fifty units were open in 1979, with a mean of 11 beds each. By 2007, the number of units had decreased to 125, but there was a slight increase in the mean number of beds, to 14. Currently, this translates to a ratio of 1 burn unit per 2.5 million people in the United States.²⁵ Possible future trends involve a further decrease in the number of burn units, with a concomitant increase in the number of beds per burn unit and increased regionalization of care.²⁶

National and International Burn Associations

The exponential growth in the number of burn professionals led to a series of National Burn Seminars (1959-1967), followed by creation of the American Burn Association (ABA) in 1968. A noteworthy aspect of the ABA has been its inclusion of representatives of all specialties involved in the care of burn patients, that is, all members of the multidisciplinary team. Abroad, similar national (eg, British Burn Association, 1968) and international (eg, International Society for Burn Injuries, 1965; European Burns Association, 1981)^27,28 organizations were formed.

In addition to sponsoring an annual meeting for burn care professionals, the ABA has played an increasing role in carrying out several functions of national importance. These functions have included education, disaster planning, promulgation of standards, and collection of data. Educational efforts include publication of the Journal of Burn Care and Research and sponsorship of the Advanced Burn Life Support course (formerly managed by the Nebraska Burn Institute). The ABA supports research primarily via its newly formed Multicenter Trials Group, which, since 2001, has contributed several publications to the field.^29,30 The organization represents its members before Congress, for example, by advocating safe sleepwear for children, fire-safe cigarettes, appropriate payment for burn care services, and timely qualification of burn survivors for Social Security disability.

With respect to disaster planning, the USAISR and the ABA collaborated during Gulf War I in 1991 and then again during Operation Iraqi Freedom in 2003 to determine, on a daily basis, the number of available beds at burn centers across the country in case of a mass casualty event.^31,32 The relevance of this system to civilian disaster planning led to its continuation by the ABA along with the US Department of Health and Human Services. Disasters such as the World Trade Center attacks in 2001³³ and the Station nightclub fire of 2003³⁴ further highlighted the need for regional and national burn disaster plans. The ABA has made such planning a priority, as have several regional burn organizations.^35-37 The ABA publishes a continuing series of clinical practice guidelines to address various issues in burn care.³⁸ The organization’s verification committee, which began work in 1992, plays an indispensable role in both promulgating a standard of care for burn center operation as well as providing burn centers with individualized guidance to assist them in achieving that standard.^25,39 Finally, the National Burn Repository, which began collecting data in 1991, provides data for research and enables the setting of performance benchmarks.⁴⁰

Milestones in Research and Clinical Care

The creation of specialized centers dedicated to integrated clinical and laboratory research in burns and to excellence in clinical care and teaching made possible a series of changes in patient management which markedly reduced postburn mortality.

Fluid Resuscitation

The first milestone was an understanding of the pathophysiology of burn shock and the development of fluid resuscitation formulae. In the early 20th century, it was commonly believed that early postburn deaths were caused by “toxemia.” According to this view, the eschar released a toxic substance or substances into the circulation, which caused death. Topical treatment of the burn wound was directed at “tanning” the eschar in an effort to prevent the release of this toxin (see following). The toxemia theory also inspired the rebirth of therapeutic bleeding in the form of partial exchange transfusion: