Pediatric Burns By Bradley J. Phillips

cream, Silvadene renders wound assessment more difficult between dressing changes. The most common adverse drug reaction of Silvadene is self-limited leukocytosis, but other potential complications include anaphylaxis and kernicturus. Its use should be avoided in patients with known sulfa allergies and children younger than 2 years. Mafenide acetate, a carbonic anhydrase inhibitor with good penetration of devitalized tissue and cartilage, is commonly used on the tip of the nose and ears. It covers a broad range of gram-positive and gram-negative bacteria, pseudomonas, and some anaerobes. Broader use of mafenide acetate in pediatrics is generally limited due to pain associated with its application.³

With the increased antibiotic resistance seen with hospital-acquired infections, the choice of topical antimicrobials for wound management is becoming increasingly important. The provider must choose a regimen which meets the patient’s tolerance of dressing changes and appropriately covers the specific pathogens identified.²²

Operative Management

Early excision and grafting of burn wounds is a key component in the management of burns. Epinephrine (0.5 µg/ml) is used as tumescence during excision and helps control blood loss. The use of epinephrine decreases typical blood loss of 3.5% to 5% total blood volume per percent of TBSA excised by up to 80%.¹⁷ Excision within 48 hours of injury has been shown to be effective in improving care and decreasing mortality.^17,23 In addition, patients display decreased risk of infection, decreased antibiotic requirements, and improved long-term outcomes, such as reduced hypertrophic scarring. Patients are also able to leave the hospital earlier, and the cost of care as a whole is minimized.²³

There are many options for coverage once the wound is excised, including autograft, allograft, xenograft, and a number of synthetic coverings. The standard of care for definitive coverage is autograft in the form of split-thickness skin graft (STSG). The grafts are harvested from an unburned area using a pneumatic-powered dermatome at a thickness of 0.010 inch to 0.012 inch. The scalp is a good harvest site in children because of its ability to reepithelialize very quickly. Repeated harvesting of donor sites for wound coverage may be allowed as necessary once healing occurs. STSGs are typically meshed 1:1 or 2:1 in order to protect wounds. Besides permitting drainage of fluid from the wound bed to maximize graft viability, meshing also allows for the possibility of graft expansion. STSGs may be placed as sheets over cosmetically or functionally important areas such as the face and hands. Sheet grafts are pie-holed using a knife in order to allow drainage of exudates during the immediate postoperative period. Meshing at ratios greater than 1:1 permits the graft to cover a larger area. Ratios of up to 3:1 and 4:1 are commonly used for coverage of large wounds. Greater ratios are uncommon secondary to fragility of the grafts and the greater distance epithelial cells must migrate to facilitate full wound coverage. Even with substantial meshing, there may be insufficient uninjured skin available for full burn coverage. These patients benefit from cultured epithelial autografts to aid in definitive coverage. Within the first few days of care, a healthy sample of the patient’s skin is taken and sent for cell culture. The cultured epithelial cells are then applied to the patient’s excised wounds. Some surgeons use the cultured epithelial cells in conjunction with STSG meshed with large expansion ratios, such as 8:1, to encourage reepithelialization of the mesh interstices. Cultured epithelial autografts are capable of organizing into epidermal structures within weeks and allow for coverage of extensive open wounds.²⁴ Allograft and xenograft may be used as temporary biologic dressings for excised burns. These wound coverings act as physical barriers to infection, limit fluid loss, and decrease the inflammatory response.²⁵ Temporary coverage of the wound is capable of promoting dermal regeneration of the wound bed in preparation for definitive coverage with autograft. Even though these biologic dressings are chemically treated to reduce immunogenicity, they will still be rejected within days to weeks.²⁶

Alternative nonimmunogenic synthetic dressings, such as Biobrane and Integra, have been developed in recent years. Biobrane is a porous mesh of nylon filaments embedded with type I collagen which is covered with a layer of silicone. The collagen fibers adhere to the wound bed and allow for improved migration of epithelial cells. The pores allow leakage of exudates and reciprocal passage of topical antimicrobials down to the wound. Integra is another synthetic bilayer commonly used in the coverage of complex burn wounds. The chondroitin sulfate layer serves as a dermal regeneration template and is protected by a silastic membrane. Once the Integra becomes vascularized, the superficial silastic layer is removed and replaced with a thin STSG.²⁶

Sepsis

With the loss of an important barrier for infection, burn patients are at high risk of developing infection and sepsis. The use of elevated temperature as a marker for sepsis is unreliable in pediatric burn patients since these children are often febrile in the absence of infection secondary to the release of inflammatory mediators.²⁰ A heightened suspicion of sepsis is warranted if the patient becomes toxic, hypotensive, thrombocytopenic, leukocytic, or experiences a change in mental status.²⁷ In the context of these signs and symptoms, the patient’s wound should be examined and a pan-culture, including blood, sputum, and urine, should be