Pediatric Burns By Bradley J. Phillips

sulfadiazine by Fraser Gurd in Canada was foiled by its low solubility and renal toxicity.⁶⁴ In the mid-1960s, Sulfamylon® (mafenide acetate) burn cream was developed by Moncrief and colleagues at the US Army Institute of Surgical Research, at the same time as the effectiveness of 0.5% silver nitrate soaks in controlling burn wound infection was confirmed by Moyer and Monafo.^65-68 Silver sulfadiazine was subsequently developed by Dr Charles Fox to combine the advantages of a sulfonamide and the silver ion, while minimizing the complications of both.⁶⁹ Those three agents, along with the recently developed silver-impregnated fabrics,⁷⁰ are the most commonly employed chemotherapeutic antimicrobials used in modern burn wound care. Effective topical therapy resulted in a dramatic reduction in invasive gram-negative burn wound infection (burn wound sepsis) as a cause of death (from 59% to 10% of deaths), and in postburn mortality.⁶⁵

The Burn Wound: Surgical Treatment

Originally, the surgical treatment of burn wounds, if performed, was limited to contracture release and reconstruction after the wound had healed by scar formation. In patients with larger wounds or burns of functional areas, this was wholly unsatisfactory. The creation of burn units committed to care for these patients led to the development of more effective techniques for wound closure. Artz noted that one should “wait until natural sequestration has occurred and a good granulating barrier has formed beneath the eschar…After removing the eschar…skin grafting should be performed as soon as the granulating surface is properly prepared.”⁷¹ Debridement to the point of bleeding or pain during daily immersion hydrotherapy (Hubbard tanks) was used to facilitate separation of the eschar.⁷² Then, cadaver cutaneous allografts (homografts) were often used to prepare the granulating wound bed for autografting.⁷³

In patients with larger (>50% TBSA) burns and in the absence of topical antimicrobials, this cautious approach did not prevent death from invasive burn wound infection, leading some to propose a more radical solution: primary excision of the burn wound. Surgeons at the SRU suggested that a “heroic” practice of early excision, starting postburn day 4, should be considered for patients with large burns. This would reduce the “large pabulum” of dead tissue available for microbial proliferation, while immediate coverage with a combination of autograft and cadaver allograft would further protect the wound.⁵⁹ Several authors during the 1950s and 1960s demonstrated the feasibility of this approach, but without an improvement in mortality.⁷⁴

In 1968, Janzekovic described the technique of tangential primary excision of the burn wound with immediate grafting; operating in postwar Yugoslavia, she recalled

that “a barber’s razor sharpened on a strap was the pearl among our instruments.”^75,76 In a retrospective study, Tompkins et al. reported an improvement in mortality attributed to excision over the course of 1974 through 1984.⁷⁷ McManus and colleagues compared patients with burn size >30% TBSA who underwent excision with those who did not from 1983 through 1985. Unfortunately, an improvement in mortality could not be attributed to excision due to the presence of preexisting organ failure precluding surgery in many unexcised patients. However, only 6 of the 93 patients (6.5%) who died in this study had invasive bacterial burn wound infection, whereas 54 of the 93 (58%) developed pneumonia—indicating a shift from wound to nonwound infections.⁷⁸

In McManus’ study, excision was performed a mean of 13.5 days postburn. By contrast, Herndon et al. at Galveston implemented a method of excision within 48 to 72 hours of admission, which relied on widely meshed (4:1) autograft covered by allograft. In a small study of children from 1977 through 1981, these authors noted a decrease in length of stay, but not in mortality with this technique.⁷⁹ From 1982 through 1985, adults were randomized to undergo early excision versus excision after eschar separation 3 weeks later. Young adults without inhalation injury and with burns >30% TBSA showed an improvement in mortality.⁸⁰ A recent meta-analysis found a decrease in mortality but an increase in blood use in early excision patients without inhalation injury.⁸¹

Despite the limitations of prior studies, early excision is performed today in most US burn centers; however, controversy remains about the definition of “early” and the feasibility of performing radical, total excision during one operation, especially in adults. For patients with the largest wounds and limited donor sites, new methods of temporary and permanent closure have been sought. Burke and Yannas developed the first successful dermal regeneration template (Integra®), composed of a dermal analog (collagen and chondroitin-6-sulfate) and a temporary epidermal analog (Silastic).⁸² Cultured epidermal autografts provide material for wound closure for patients with the most extensive burns, although the cost is high and final take rates are variable.^83,84 The ultimate goal of an off-the-shelf bilaminar product for permanent wound closure, with a take rate similar to that of cutaneous autografts, has not yet been achieved.

Inhalation Injury

Improvements in fluid resuscitation and wound care refocused attention on inhalation injury. Although the term “acute respiratory distress syndrome” (ARDS) was first applied to post-traumatic pulmonary failure in 1967,⁸⁵