Pediatric Burns By Bradley J. Phillips

the use of propranolol,¹⁰⁷ and the use of insulin,¹⁰⁸ insulin-like growth factor,¹⁰⁹ or human growth hormone.¹¹⁰

Rehabilitation

As postburn mortality decreased, the problems encountered by burn survivors, particularly those with deep and extensive injuries, became paramount.¹¹¹ The scientific study of the occupational, physical, and psychosocial rehabilitation of the thermally injured patient is a relatively young field. The Cocoanut Grove monograph briefly states that 6 patients with dorsal hand burns who had been splinted in extension were referred to the Physical Therapy Department after completion of surface healing.¹¹² In the 1950s, Moncrief began rehabilitation soon after admission and resumed it 8 to 10 days after skin grafting.^113,114 The advent of heat-malleable plastic (thermoplastic) material made it possible to fabricate increasingly complex and effective positioning devices.¹¹⁵ This was followed by the introduction of pressure to treat hypertrophic scars and the development of customized pressure garments.¹¹⁶ Others reduced or eliminated the delay between skin grafting and ambulation, without deleterious effects on graft take.^117,118 In brief, burn rehabilitation is no longer viewed as a “phase” which begins after completion of wound healing, but as a highly specialized process which must begin immediately upon patient admission and often continues for 24 or more months. A recent review noted a need for more research in this area, to include prevention and management of hypertrophic scarring and contractures, pain management, post-traumatic stress disorder, affective disorders, and body-image problems.¹¹⁹

Conclusion

The 1910 edition of the Encyclopedia Britannica stated that death “almost invariably” results when one-third or more of the TBSA is burned.¹ For young adults, the 20th century in the West featured an extraordinary diminution in the lethal-area 50% (LA50—that burn size which is lethal for 50% of a given cohort of patients), from 43% TBSA in 1945 through 1957 to 82% in 1987 through 1991.²¹ At the Galveston Shriners’ Burn Center, the mortality rate in children with 96-100% TBSA burns during 1982 through 1996 was only 69%. This led the authors to conclude that “prompt intravenous access and resuscitation, aggressive operative therapy, and the avoidance of sepsis and organ failure by meticulous critical care should enable any child with almost any burn size to live.” At that hospital¹²⁰ and others providing comprehensive long-term psychosocial and physical rehabilitation,¹²¹ follow-up data indicate that young survivors of massive thermal injury can experience reasonably well-adjusted lives. No one intervention was solely responsible for these improvements; rather, it is the combined effects of fluid resuscitation, wound care, infection control, inhalation injury management, nutritional support, and aggressive rehabilitation. All these interventions, however, were directed in a coordinated fashion at correcting what Burke called “the fundamental defects of burn injury—the destruction of skin and its immediate physiologic effects.”¹ This revolution has been possible only because of integrated clinical and laboratory research, carried out by multidisciplinary teams in specialized centers supported by generous public and private funding. New challenges remain—in maintaining and expanding adequate numbers of fully trained nurses, therapists, and physicians,¹²² in caring for the most severely injured, in facilitating their return to a successful role in society, and in translating the most effective of these advances to that large portion of the world which has not yet adopted them.

Key Points