Burns

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Sophia Abdulhai, Abdulruf Lamoshi, and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. And today we're going to be talking about a topic that a lot of people have requested, burns. You know, burns is tough because some of us do it a lot and some of us don't do it at all, and sometimes we don't do it often enough. So when that burn comes in, we're not quite sure what's the, the new way of treating these burns and What's the new standard of care, and there's absolutely no one I know better to answer these questions than who I think is the expert in the world, and that is Rob Sheridan. Dr. Sheridan is the Burns Service medical director of Boston Shriners Hospital for Children, Division of Burns, Mass General Hospital, professor of surgery at Harvard Medical School. Dr. Sheridan, thanks for joining us. Oh, thank you very much for having me. I will tell you that I remember the first time that I spoke to you, Dr. Sheridan. I was a fellow at DC Children's Hospital, and we had a very difficult patient, and we called, called you and transferred the patient to you, and you were so gracious at that time, and I'll never forget it. So, thank you, thanks for helping even back then. So, Rob, let me, let me get into probably what I think is the, the question that most of us have and think of with burns, and that's resuscitation. Surgeons have been arguing about fluid resuscitation for decades. So tell us your personal approach to fluid resuscitation for children with burns. You know, for most, you know, fluid losses replaced like for like, except for in burns where we've always had this desire to replace plasma with crystalloid, and I think that was based on the animal data in the early 60s and 70s in which giving too much colloid resulted in accumulation of colloid in the lungs histologically of the animals and in that era before critical care evolved, the fear was that if you compromised ventilation. In that way you really couldn't salvage the patient with mechanical ventilation. That wasn't an option. And so there was great fear of pulmonary injury or pulmonary compromise with coin administration, hence the all of the formulas that came out that were weight-based and burn size-based that were pure crystalloid in the 1st 24 hours and the You know, the clinical consequence of that is the, you know, incredible anasara that some of these children get with crystalloid resuscitations that we Sort of assume is the norm, but it really has a lot of morbidity, you know, itself, and in recent years people have been exploring more, you know, alternatives and how do we get this anasarca under control and the two big, I guess the three approaches that have been taken of one was pharmacologic, you know, giving antioxidants like vitamin C, and that never really panned out to be a practical solution. The next is a sort of resetting endpoints, and that can be actually part of a successful solution in that. You know, children really don't need to make 2 ccs per kilo per hour of urine unless they're extremely young or their renal function is really very abnormal and their renal concentrating ability is abnormal and, and more modest targets, you know, 1 cc per kilo, 0.5 cc per kilo per hour are very reasonable, and that lets you cut the fluid infusions quite a bit and using more subtle endpoints like quality of the distal profusion, quality of the pulse based deficit. Can sort of guide a resuscitation that will let you keep the child a little less over resuscitated. And then the third way of doing this is, is fluid choice. And really that's, that's based on colloid early yes or no. And you know, again, the fears from the animal studies in the 60s and 70s made people shy away from that, but I think that when people were in trouble and the resuscitation wasn't going well, you'd start your colloid early instead of at 24 hours like most of the Brooke and Parkland formulas would recommend. You'd start it early and A lot of people have started using it earlier and earlier, and I know my own personal practice, the burn is of any consequence, you know, 30 or 40% or greater. I start colloid right right away, and, and, and I just find that that makes a huge difference in the amount of overall fluid they get. I almost never see that morbid anasarca when children are resuscitated that way. So, so that's a real change. So talk me through then, you know, a lot of the, the, the listeners here are residents or fellows that are going to be on call when a 30% burn comes in and a 2 year old. How should they start their approach on the fluid resuscitation more specifically? Well, I guess based on burn size first, if the child has a burn of 15 or 20% or less, they probably don't need a calculated resuscitation. And in those kids I'd give them maintenance and a half, a calculated maintenance rate, calculate 150% of that, and I'd administer that either IV or if the child will take PO, I might give them ad lib PO and 1 times maintenance and weigh their diapers and do a physical exam for the quality of their pulse and whether they have tears and Moist oral cavity and that's I think just fine for uh kids with a burn of that size and that's, you know, obviously is the the most, most kids and then when you get into that mid range, you know, the 20 to 50 percenters, those kids really do, I think better with the calculated resuscitation and and those kids my own. You know, again, there's just so many resuscitation formulas, and they all just give you kind of hour one, and then you go from there based on the response to the resuscitation, and you know, where are you in terms of your resuscitation targets, you know, adjust up and down every hour, but I use Parkland myself and so I calculate a Parkland resuscitation of 4 cc per kilo percent burn for the 1st 24 hours and I try to do that with a realistic estimate of the burn size so you don't overestimate the amount of crystalloid they need. And if the child has a mid-range burn, I subtract 1 time maintenance from that overall amount and give them 5% albumin at that rate. So I'll give them 5% albumin at 1 time maintenance, and then the Parkland calculation minus. 1 times maintenance as plain ringer's lactate. If the child is young and I'm worried about hypoglycemia, I'll take 1 times maintenance out of that Parkland overall number and give that as 5% albumin. So say it's a small child, they might be 12 kg 10 kg. You're worried about hypoglycemia if they're not getting anything rally. That child will be getting 3 fluid types, you know, early on they'd be getting 1 times maintenance of 5%, 1 times maintenance of D5 ringers, and then Parkland minus 2 times maintenance basically as uh plane ringers, and then. I would adjust the infusion of the plain ringers down based on kind of resuscitation endpoints that have the objective of keeping the child just on the dry side of uvolemia, so you'd really like them a teeny bit on the dry side, and I think that's where you're going to get a resuscitation that will meet the needs of tissue profusion but not be complicated so much by Anas Sarka. And when the burns are much larger, you know, the greater than 50% kids, I, I myself, I do the same thing, but I just up the percentage of colloids so that they would be getting twice maintenance. So I'll calculate again the Parkland calculation for crystalloid and then take out 1 times maintenance as 5%, I mean D5 ringers, so they don't get hypoglycemic if they're little, and then 2 times maintenance I'll take out as 5% albumin. And for me that really works well. I know another way to do it is to do a just give them a third of their calculated resuscitation as 5% albumin, and that's a maybe a little simpler, simpler way to do it, but it's the same thing and. That, that, so that is a great, uh, quick summary there for people to write down. I mean that, that is, uh, and then to make sure I'm understanding it, the, the, the difference between the mid and the large size burn is you're, you're giving, you're gonna take the total parkland. Crystalloids, subtract out one, let's say this is for the larger burns. Subtract out 1 times maintenance for the 5 for the D5 ringers, 2 times maintenance for the colloid, and the rest you're going to give in crystalloid, correct? And then I think the other important part of this is that, you know, you really, it's all about their your resuscitation targets. And if the child is older than, you know, a young infant, they should be able to concentrate reasonably well, so one half to 1. cc per kg per hour is a reasonable urine output target and so you really should be weaning that fluid. Whenever you have the opportunity to do so, and I'd say sort of on average if the resuscitation goes well. The child usually ends up about 150% of maintenance at 24 hours total fluid going in. So, so that when you went over those that initial fluid resuscitation, that's in bolus, correct? Or that's given over the 1st 8 hours. No, that's by infusion. So you know you'd do your Parkland calculation and you would come up with an hourly infusion rate as recommended by. Uh, Parkland, and, and then that's, that's, you know, that's the starting point and then after that myself personally I just ignore the resuscitation formula and I start with those numbers and then I actively adjust. But based on where the child's at in terms of their resuscitation end points every hour. But when you adjust, do you maintain the same ratio of fluid, or do you? Yes, oh, I see what you mean. Yeah, you know, I would say that if it's a big burn and it's early, I do most of my adjusting within the plain ringers, and I keep those that maintenance rate of 5 of D5 ringers and that maintenance rate of colloid. OK, OK, that's, that's great. Anything else I should be asking about fluid resuscitation? Is that a pretty good, I mean, I, I think, you know, the, uh, you don't want to, you know, you want to treat critical illness, not cause it, you know, and I think, I, I think, uh, the morbidity of some of this Anas Sarka that we take for granted is, is, is more than I think we realize, uh, and it can be kind of subtle. It can be, you know, a near compartment syndrome with, uh, you know, neurologic injury and And you know, since I've started doing this, I started doing this, you know, quite a few years ago. I've never had to do an abdominal decompression, doing a coroid-based resuscitation like this. It used to come up periodically and it just doesn't anymore. Yeah, that says a lot actually then. Let me go back now that we've talked about resuscitation. Let me take you through. Uh, some common scenarios just for the, for the majority of us who don't see the big stuff which we send to you. So we have a, in fact, here at Akron Children's, we have a burn unit and the pediatric surgeons here. A lot of us don't do burns and, and some of us do a lot of burns, so it's pretty mixed here and I bet that's probably the same in a lot of institutions. Let's say you have a 3 year old coffee burn, coffee spilled, they've got the, the coffee burn on their chest. It looks like a 2nd degree blister there. How do you manage those kids? Most of those kids are going to do fine no matter how you manage them, and so I think having a Respect for program specific aberrations is really important and so every program's going to do it a little bit different, I think what you want to do is, is not create undue pain, you know, if there's ratty, loose, blistered material to gently remove that is is reasonable using clean technique and then treating it topically with the expectation that if it's a 2nd degree burn, it'll heal, you know, I think that the burns change in appearance, as you, as you know, over the first. You know, 48 to 72 hours and sometimes you underread the depth on your initial exam. So setting up, you know, periodic exams over those first couple of days is reasonable to help with treatment planning. But once you're comfortable that it's a second degree burn and the child's tolerating it well, getting them into either a membrane dressing like a silver based dressing that you can leave on there for a few days, or putting them in something simple just like bas bacitracin ointment or. Some antibiotic ointment with a nonstick gauze is very reasonable and change it every day or two. And then coaching whoever's going to take care of the child that, you know, you know, years ago we used to admit a lot of those children, and now so many of them are managed as outpatients that it entrains a teaching duty to the parents and the visiting nurses and the other relatives who are going to take care of the child to, you know, look for sources of fever and make sure and. Make sure the child is eating and drinking well and having wet diapers and not spiking temps and if any of those things are not as they should be, uh, to make sure that they have the ability to get a hold of the burn program 24/7. I think is really excellent. That brings me to my next question is what are your criteria for admission now these days? Well, I mean, I think if the burns are small, under 10% or so, we manage most of those children as outpatients, and, but there are a lot of factors that play into Whether we keep them, you know, for a while, and I would say most of those factors are not wound related. They're family related, uh, distance related, geography related, weather related, car related. Sometimes the families are, you know, frantic, and they've, this is their 3rd hospital that evening, and, and everybody's exhausted and sometimes just that an important consideration. So we try to be kind and. Make sure we can do adequate teaching and that the people that will actually be taking care of the child are accessible to us to provide the teaching. And many times that'll turn into a short stay observation type admission, kind of let the dust settle, let everybody catch their breath, let the parents get a few hours' sleep, and then do our teaching with a more awake, calm family and set up, you know, logistical plans that might involve a local primary care physician or our clinic. We've actually evolved a 24/7 clinic ability just because this comes up so often now and our outpatient numbers are so high that Having the ability to, I think accessibility of the outpatient program is really an important factor to success in managing these kids as outpatients as often as we do now. That's great. So do you routinely admit patients that have burns to the face, or is that, yeah, I mean, I think that if there's any question of their airway, if there's any question of their ability or willingness to drink, you know, sometimes if kids have a burned face and a burn and burned lips, they just won't drink, and, and that's not consistent with the successful outpatient program. So we'll bring some of those kids in just to make sure everything is good. And I think that when in doubt, the best thing to do is just admit and let everybody calm down and make sure that the child is, is, you know, going to be able to do well with their injury as an outpatient. So I would say not automatically, but I think as a practical matter I would suspect most of those kids we do admit for short stay. OK. And just to clarify something you mentioned before, you do not always remove the blister, or, you know, the blister question comes up a lot and Um, I think, you know, if the blisters are thick, durable, not tense and unfortable uncomfortable, the typical one being, you know, fingertips and palms, many of those I'll leave until they either collapse on their own or decompress on their own, at least for a couple of days just to avoid the painful debriding experience or the frightening, frightening debreeding experience that some of the kids will have if the blisters are thin. And you know that they're going to rupture as soon as they get back in the family car, you're doing them a favor just to, you know, get that over with in the clinic and replacing that with a gooey dressing that won't, that, that will, that will be comfortable. Got it. OK. Well, let me ask you then, going to the other extreme then about those that require more involvement, involve care, you know, surgeons have been arguing for decades about early excision. What does that mean, early excision, and what's your personal practice? Well, it's a great question. I, it's one of the sort of the central paradigm shifts over the last 50 years is, is sort of the realization that, you know, if the thing's not going to heal, if you just remove the dead tissue now and get the wound closed early, rather than waiting for spontaneous liquefaction, swath, granulation, and then graft it, you save the patient a lot of, you know, septic morbidity and you save them a lot of unpleasant experience. And um. But the, the art is sort of in identifying those areas that really need to get done and from, you know, and not overdoing it if you, if you, you know, too much excision and you, you're gonna have unnecessary procedures and you're gonna have aesthetic complications, you know, and too little excision and then you're gonna run into septic infection, septic complications. And sometimes it's hard to find that proper balance. I would say that part of the decision is sort of the pressure to get something done and to avoid a septic threat. So if the wound is small, it's highly unlikely that there's going to be overwhelming sepsis from it, even if it's deep, you know, the typical one being a muffler burn and a A little kid who was riding with mom or dad on the on the ATV or, you know, a curling iron burn or some, you know, hot contact burn, you know, some of those burns can be quite deep, but they're small and there's not the pressure to get it done. And so therefore you can talk to the parents and make sure everybody is comfortable with the decision making process and understands what's involved in the excision and the follow up and the grafting. If the burns are large, you know, 20%, 30%, then I think that if you lose control of the wound in terms of letting it get infected, the morbidity can be really high and it can be sometimes hard to recover those children. And so then I think the pressure is on to get something done or get at least get the wound off before that septic morbidity happens, but it doesn't usually happen right away. You know, it's day 3, day 5, start to see, you know, wound cellulitis, wound infection come, come in. And so for me with a small burn, early excision means clear identification of what needs to be done, lots of teaching with the family so they understand, you know, what the thinking is and what the options are, and getting that done, you know, in the first week or so if it clearly needs to be done, but it represents almost no septic threat. If the wound represents a septic threat and especially if it's big enough that you know you may need to do this in 2 or 3 stages, early excision means to me getting going, you know, in the resuscitation period, the first day or two, so you get a procedure done, get another done, so that by 5 days, 7 days, all of the wound that's a threat is off and you have some kind of temporary cover on there. So, so talk me through someone like me who doesn't do this much at all, but baby comes in, has an extensive, you know, 50% surface area, full thickness burn on their trunk and lower extremities, let's say, and so how do you, once you, you resuscitate the patient. You admit them to the burn unit. What type of, of measures? I'm assuming you, they all get ventilation management. They have uh uh feeding tubes placed, antibiotics. I don't know what, how do you manage that patient initially? Well, I guess they come in and you know, the first thing you want to do is make sure they have a good airway and if their airway is clear and their burn site is such that they're likely to continue to oxygenate and ventilate well, we try not to, I try not to intubate them, manage them, you know, expect with the expectation that they will ventilate themselves and they'll clear their keep their airway clear. If the airways, if the burn is big enough that they're likely to need enough surgery and enough sedation. Or they're going to get enough edema despite a colloid-based resuscitation that the airways going to be at risk. It's better just to get them intubated when they're easy to intubate before they get real swollen and get control of the airway then and like to make sure in terms of access that they have, you know, high quality access so we almost always will put central access in those children. And you know, of course a bladder catheter so we can monitor their their outputs and we try to keep them warm. Keeping them warm is really a high priority because they really do evaporate a lot. Some of the kids, they get very cold, and I think that complicates their hemodynamics more than we realize. So we're fortunate that we have, you know, bed spaces that are engineered really to keep them nice and nice and warm. OK. And do you start enteral feeding on day one? We do. It's a great question. So we put feeding tubes in and If they're in the small to mid-size burn range, they almost all tolerate tube feedings right away, and some of the kids who have a big burn and they maybe had a long transport time, might be 1218 hours into their injury before you see them, some of them are hemodynamically a little shaky, and they may have a little splanik ischemia. So those kids will put the feeding tube in and maybe start some slow trophic feeds right away, but we'll wait. To advance them till they have some sign of bowel activity, you know, bowel sounds or something, but I would say most kids, if you get them promptly, you can get them going with tube feeds within the 1st 1 to 2 days. Do they get started initially on antibiotics or no? You know, years ago we used to do that and we don't anymore. We did a study a few years ago that I can't remember exactly the details, but it was around 300 kids on either side. It was historic controls where we stopped treating routinely with antibiotics. We had the same incidence of infection in both groups. We just had less rashes, less diarrhea in the no antibiotic group as I recall. Um, so no, we don't routinely treat them. Now if the child comes in and looks good up front, uh, some, especially the smaller children will often spike some very big temps in the first. You know, 24 to 48 hours, 72 hours, and if it's a really early big temp spike in a child that otherwise looks well, we usually don't treat them and we'll watch them closely. We'll keep them in the hospital. We try not to send anybody out unless they've been, you know, afebrile, looking good for 12 to 24 hours. But if it's after that when the infectious incidence seems to go up, you know, day 3, day 5. Or later, then often we'll empirically treat them while we wait for the blood cultures coming back, OK. What's your central access, central line access strategy in these patients? You know, we have, it's interesting, you know, we use a lot of femoral lines and we have no infectious trouble with that. In fact, in our, we had a review of about 1000 consecutive catheters and the incidence of infection was the same in all sites with a slight trend toward a higher incidence in IJs because in little kids, I think the IJ is kind of a little bit intertriginous. I like personal practice. I like to put subclavians in mostly in the OR, and I'd rather if it's going to be in the bed and the child's awake squirming, maybe just with a little ketamine, either put it in an IGA with ultrasound or a femoral line. And I try, you know, water molecules are little and so the lines can be little, and the rate of infusion requirements, even for a resuscitation of a big burn are not beyond the capabilities of a small caliber line. So we try to keep the lines to a fairly small caliber. You know, two lumens, and we try to negotiate with the nursing staff and, you know, brainstorm with the nursing staff how we can support the child with two lumens, and we mostly can get, can do that except in, you know, really sick kids, you know, with pressure requirements, etc. So I remember Rob, when I was a A resident in the burn unit at Washington Hospital Center in the early 2000s, we would rotate their central lines routinely. I think that practice, it doesn't exist anymore. Is that right? Or that's it's a very good question. So what we do now is based on we reviewed lines here, I think I'm blocking on the numbers right now, but we had a paper with like 1000 lines, and they were all in the pre-antiseptic line era, and then we had either 30 or 500 in the antiseptic line era. And what we found was that at about in the pre in the non-antiseptic lines at about 10 days our infectious line infections kind of took off. And so we use that to support a weekly new line policy which is also consistent with the typical flow in the OR where the children go back to the OR typically once. Week when they were in the sort of the staged closure phase of care then when we switched to the antiseptic lines that spike just outside of two weeks and so now we about every if the line sight looks good, the child looks good. It's fairly, it's not through burn or real near burn. We'll usually the lines in a couple of weeks and then rotate them in conjunction with with the OR. OK, so you, so you do rotate them less frequently, but you do rotate them, OK, OK. And I, and, and I, you know, I will say that once. Kids are closed. There's a lot of, uh, I think, occult bacteremias with manipulations of wounds when the, when the wounds are large and open, and this is supported by two old papers from the Army burn unit years ago where they had up to a 42% incidence of Otherwise occult blood positive blood cultures in the midst of major wound manipulations. And so I think that when the kids have open wounds, they're going back and forth to the OR. The line sights might not be the greatest. They might be near burn or they might be through a fresh skin graft. Then those line sites. tend to get those lines tend to get infected more often and so we'll rotate those for sure when the kids are further out and their wounds are mostly closed and they're in a more rehabilitation phase of care and we're getting towards, you know, decannulation altogether, those lines will sometimes leave in longer if they look good, OK. So let's say that this child that, that you initially resuscitated, put in in a central line, did not need an intubation, has an NG tube in. What's your, what is your usual plan for wound care and, and, and I know you talked about early excision in these patients, but how do you approach them? What types of uh surgical excisions do you do and how do you approach those patients? I think the first thing we do is make sure that they're well decompressed and so that's, you know, sort of in that 1st 24 hours, maybe 36 hours if there's any limb or torso that's at risk for, you know, circum compression due to edema within a circumferential noncompliant. Wound, we set that up for monitoring. So if the child, for example, has circumferential leg burns, and when you see them at the first, they're nice and soft and well profused, but there is a risk there. We'll, we'll make sure that that child gets, you know, pulse checks by Doppler in the in the digital pulse. every couple of hours and or put a pulse oximeter on that involved extremity and if it's 2 or 3 extremities, we'll put one on each and then just rotate the pulse ox signal so that make sure we have a nice pulse ox signal in each, in each extremity at risk and then make sure that we decompress them sooner rather than later if they start to show signs of ischemia. And then in terms of topical care. You know, again, this is one of these issues that's unit specific, and I think it's important that the units learn something that works for them and their nursing staff and, and sticks with it because I think the difference between outcomes with various topicals is relatively modest. As long as all the other pieces of the program are working and so I think whatever topical program you're comfortable with is good for the bigger burns, we tend to use wet topicals here, and I think that's partly based just on the tradition of silver nitrate soaks as being the go to agent here. We still do do a lot of silver nitrate soaks in the big burns, but we also use other soaks like, you know, sulfur myon soaks and sometimes sulfayon. Uh, with supplemental amphotericin, um, in the soaks, depending on what the child's growing in their wounds, we do see a lot of kids that come from, um. Central America and other places where they've been in another unit for quite a long time and they'll sometimes have some difficult gram negatives in their wounds that are particularly responsive to the sulfayelon soaks, and we'll use that. And then if it, you know, then the next step is identifying the deep components of the wound and sometimes that's difficult is I know you know how hard it is sometimes to tell if something is full thickness, and I think that if the You know, if the wound is small, you can usually just leave it unless you're sure it's not going to heal. But if the wound is large, you should probably take it off unless you're fairly sure it is going to heal or that it's not real deep, because it's, that's a worse mistake to make. And if you're not sure if the wound is really full thickness, you can, as part of the operative plan, you can do a little diagnostic, uh, passes with a. A dermatome to in small representative areas to get a real good feel for how deep this wound is and does it really need to come off. And so once you've made the decision that some part of this wound needs to come off, then we go, we take the children to the OR. We try to, if it's a burn, big burn, we try to get that process started, uh, fairly soon in the first couple or 3 days. And you know, the keys there to make sure you have a good, well coached anesthesia team and. If you think you're going to bleed, that the blood is available and the room is nice and warm. The child has a temp probe in so that hypothermia doesn't come into this because If you have a big raw wound that you've generated and the child gets cold, you're going to have coagulopathic bleeding, which is a real problem. And so we have, we're lucky that our rooms will go up to 120 and 100% humidity, and, you know, it can really, it's hard to, it's hard to get a hypothermic patient in that environment. And so we're really lucky that way. And then. We try to map out exactly what needs to get done and ideally you've done this already before you go to the OR, but sometimes, you know, being able to position the child and look at the child who's now still and anesthetized under good lighting, get a real good tactile feel of the wounds, maybe do a little diagnostic pass with a dermatome in representative areas can help you really map out what absolutely needs to be done and what doesn't. And personally I've really tried to get away from the kind of the big automatic excision and try to really get into more of a nuanced just what needs to get done excision and its selective, you know, it'd really be sort of minimally ablative I guess would be the way to describe it because I think, you know, having, you know, been in the clinic now for You know, 30, you know, 30 years, uh, taking care of kids with burns. I just, the kids that you, that have the most, have the most minimally ablative, the most accurate possible excision, that which really needs to get done, they seem to really have the best outcomes and the, and the reconstructive options are, are easier, uh, if you've managed them that that way acutely. So you map out what needs to get done. And then you try to do it in a hemostatic way. So your goal is to do a minimally ablative hemostatic excision of just that which needs to get done. And if you need to stage it over a couple or 3 days, then that's fine. But I think it's important also that you don't generate a lot of critical illness. You don't give the kid a, you know, unnecessary blood turnovers and, and unnecessary amount of fluid. I think. During the cases, it's important that you really help the anesthesia team with their monitoring and what I like to do is I like to take the bladder catheter and I put a little loop in it at my feet on the table and clamp it there so I can see it kind of in real time what's coming out of the tubing and make sure I have a good view of the monitors and, and, uh, that we, that, uh, you know, I know the anesthesia team by first name and. New residents and just make sure that we talk constantly through the case to make sure the child's nice and warm, well profused. We're not getting behind, we're not getting ahead on fluid, and they know what's coming and you know the whole thing is done in a kind of a methodical, uh, controlled way without a lot of big swings and, you know, blood loss and whatnot. So then once you've excised the wound, how do you manage the wound bed? And the other one other thing I'd say about the excision is, you know, you can do these hemostatically amazing well. When I was a fellow at the army unit, you know, the expectation was that, you know, free bleeding was kind of the end point of the excision, and the cost of that was a lot of blood loss, and that you were prepared to deal with that, and you can do that, but you don't have to. I mean, there's much more subtle ways of determining that your burn is adequately excised. And just the appearance of the fat, appearance of the, you know, remnant, you know, very deep reticular dermis, and so, and the other thing I'd say also is that fascial excisions used to be, at least in our practice, very routine for any full thickness burn, and now they're quite rare. We do almost all the excisions in a layered way despite their, no matter what their depth, even if it's a deep burn into the fat. If there's some remnant fat there, we'll try to preserve that because it really does make a Difference if you can, it doesn't, you can't always do that. Sometimes the kids are a little too sick or they maybe coagulopathic or the burn really is that deep, but, um, I would say that it's become increasingly unusual to do, you know, extensive fascial excisions like we did, you know, 20 years ago. Mhm. So, um, that's interesting because I do remember the, uh, that you just went to a blood a lot and, uh, so all right, so you've done your excision and now what? And then, uh, and then, uh, ideally autographed it right away. Um, so I think that, you know, that's the, the, the another key decision point in the case because, you know, as you, if you think you're gonna autograph it right away, you have to plan where the donors are going to be in sort of your operative sequence. So especially early acutes, I try to get all the excisions done before I do any harvesting because of the child's. Physiologic status goes, you know, becomes worse at any point, you can, you know, bail, go back to the, uh, the ICU without having generated a larger wound and sacrificed donor. So usually what I, what I'll try to do is, is do the excision and then take a stop, talk to anesthesia, you know, get an assessment of the child and say, you know, can we keep going here. And if the child is doing well and anesthesia is comfortable and and we'll go ahead and keep going and we'll generate the new wounds required for donor harvest and then go ahead and just autograph right then and I would say that most kids, that's the plan if the burns are mid-size, if the burns are really big or the child's unstable, or if Uh, or if you're uncertain of your excision, well, we use a lot of allograft, uh, for that circumstance, and I try to treat it like autographed and not just kind of throw it on a bed that I didn't do a very good job excising, but, you know, I would take, make, make sure the bed looks good and really try to put the allograft down and secure it down in such a way that really will, it will, it will vascularize and uh. That that's our, our go to membrane in that setting. So then, um, once you've done your debridement, you've done your allograft, you, you dress the wound. How often are you doing burn dressing changes on them? Well, if it's a, if it's an allografted wound and you, you did a good job and you think it's going to vascularize, I leave that primary dressing on, you know, until I'm ready to switch it out for autographed, which is usually 5 to 7 days later. And uh don't subject the the child and the family and the nurses to sort of unnecessary dressing changes on the floor or in the unit. If I'm not sure of the wound or if it was the child came in and it was, you know, 2 weeks out and the burn was, you know, heavily contaminated, uh, then we'll do dressing changes, uh, you know, to an open, not having grafted it, and we'll, we'll, we'll change it every day, every other day, and we'll try to do that in a as comfortable way as we can. We often will use ketamine for that. OK, you, you mentioned allograph autographed, um, what other options are there now that are available that might not have been there before? So what's, can you give me a quick summary of what are the different graft options? I wish I could say that there was a permanent, you know, skin substitute out there that is awesome and makes us not need to harvest anything, and I've been really fortunate working here and at the MGH to be able to try almost everything, I think, and I think is still autographed as the go to definitive membrane, unfortunately. And but there's a lot of temporary things out there, as you know, some of them designed to provide temporary dermal sub scaffolds and some of them will provide a little antiseptic boost with some silver releasing inclusions and I guess I. Probably should stay away from, you know, proprietary names and whatnot for fear of, you know, saying the wrong thing or leaving something out, but I think for our practice the go to temporary membrane in a big burn still is allografted, and the go to permanent membrane for everybody is split thickness autographed. The other thing about the split thickness autograph is to think ahead. The child has limited donor, and you know they're going to need a lot of reconstruction over the years. You really want to treat that donor that they do have like the most valuable territory on the planet, which is really what it is, and you know, real thin harvest, really careful donor site management, no donor site infections, no deep harvests, no deep passes. And uh just, just so that you'll, you'll have that, that for reconstruction down the road. You know, you've, you've been doing this for about 25 years. What are, what are some of the important advances that you've seen in burn care over the past 25 years? I would say the fluid resuscitation thing really has changed a lot for me personally, you know, I grew up in the crystalloidon era. And I'm a total convert to the more mixed resuscitation with inclusive, including colloid, and I just think the kids do better and I just don't see the morbidity from Anas Sarka I used to see. I think the critical care techniques generally. Have gotten better. I think we're much better at mechanical ventilation. We're much less, you know, our lines are smaller. The vascular ultrasound, I was very skeptical about upfront, but I love it now and use it all the time. So I think a lot of those general critical care techniques that have been that have evolved in the PICU have really benefited our kids very much. I think the minimally ablative hemostatic excision. Paradigm is, is the very accurate excision paradigm has helped a lot in terms of the quality of the long-term outcomes that may not have helped its survival at all. So I think, you know, when you get minimally ablative like that, you do court a little bit of a septic risk, especially in the big burns. If you're a little too non-ablative, but having said that, and I think it's harder to get definitive coverage on an extensive bed of fat than it is on an extensive bed of muscle fascia, but if you can overcome those dark sides of a minimally ablative approach, the long term results are a lot better, I think, in terms of the appearance and the ability to have good functional reconstructions. I think that in the longer term care of the kids we used to do a lot of ablative scar management operations. If there was scars that were unacceptable or unsightly, we would tend to excise them and replace them with skin grafts, and, and that worked and it did give a better result. But there is a realization that a lot of these scars are very dynamic and that they will shrink with release of regional tension. And so we do a lot of operations now on some of the smaller scars, especially that. Help improve the function and the appearance by sort of smart small operations to relieve tension across the scars, and it really does seem to work. And sometimes we use the fractional CO2 laser to as an adjunct to that process, but it doesn't seem to replace the tension relief part of it really seems to be where the money is. So that's a pretty, pretty enough of a basketball, I think. I mean, I think you, so. You actually were talking about scar management postoperatively or post-burn. What are the other elements of pediatric burn aftercare? You know, it's funny that has really grown a lot. That phase of care has become increasingly important for us and, you know, years ago we Didn't really have that robust of a follow up program and you could see it in the just the numbers of kids we would see we would have relatively small clinics and now our clinic is just bursting at the seams. We see kids all the time. We do a lot of long term follow up. We're much more aggressive about early functional and aesthetic reconstruction than we used to be, you know, I, I remember. You know, if a child with a big burn, they would go home and you would, you would try very hard not to operate on them for at least 2 years. And now, you know, as soon as there's some functional issue, we'll try and fit it in with your school schedule and get that addressed. So I think that's, that's a big part of it is just staying involved personally, you know, being in the clinic, you know the child, you know the family, you know kind of what their school and sports and circumstances are and what their tolerance is for the hospital experience and. And you can help them make those difficult judgments about whether it's time to do this procedure or that procedure, but just sort of trying not to operate on kids in that phase of care as long as possible, I think sometimes isn't the right answer. The other thing I think is, and this, we really don't do that a good enough job with this yet, but I think that just recognizing the The difficult times that families have and that kids have getting reintegrated, get back on their feet, getting feeling normal, feeling happy, and kind of forgetting about the whole injury experience is a little bit harder than I think I thought certainly and and we try to spend more time with some of that coaching and trying to make available more resources for helping the family and the and the child come to grips with the injury and how they're going to deal with the aftermath. I think there's a lot, a lot of room still to get better in that in that regard though, you know, it sounds like from what you just were talking about with a lot of the aftercare you have a lot of other. Uh, specialties involved physical therapy and maybe even social work that leads me to the next question, which is, you know, trauma care is so highly organized, but, but for someone to have a burn unit or a burn care system, what, what is, what are the essential elements of starting such a robust system like that? You know, the, the, the ACS and the the Committee on Trauma have a, you know, in the, in the book have a chapter on burn units, and it really lays it out in terms of being verified. And so we try hard to, you know, match or exceed all those standards and have been lucky to maintain verification for a really long time. And but to kind of cut to the chase, I think it's just what you say you have to have sort of a critical mass of patients and a critical mass of staff that have enough experience in the nuances in their area of expertise to really make it work and and um like you say, we have a. You know, a very much of a multidisciplinary approach to it. We do rounds with all, all hands on deck, all specialties on deck every morning, and our clinic, we have everybody on deck for clinic physical therapy, occupational therapy, psychology. We have access to psychiatry, nutrition, nursing, and all the various surgical specialties and the anesthesia and pediatrics and. And I really do think it takes that much of a multidisciplinary mix to deliver the goods. And also I think the people that are part of that team, they all have to have enough experience day to day so that they can, you know, evolve their own personal best practice. And then I, and then I think, you know, within the system, I think a huge part of it is just having relationships and you know I'm really fortunate to work in this institution where we really try to, you know, compete with no one but be everyone's collaborator and, you know, be available to everyone when they need us but not be a competitive threat to anyone and that's, I think, a really special place and I think as much as burn programs can do that to, you know, support the burn care that's going on around them. But be available when they're needed to actually deliver the burn care. It's important. Yeah, I think that I mean you and Boston Shchriners have, have certainly given that impression to the rest of the country. So let me ask one last question actually, and um I actually am probably Rob, I want to put what you just said as the final question, but I, I want to know, we might want to insert in between there you had a question here. What are some of the special needs of the very small children? So let me ask you that question more formally, and then we'll have you answer that. So, so Rob, what are some of the special needs of the very small children with large burns? You know, when I first came here in '91. I had taken care of very few, you know, small infants with bad burns. Just, I just hadn't seen it. And but over the years here we do have referred to us fairly frequently kids who are newborns or in the 1st 6 months of life with some significant injuries, and, and I think it, and we've had good luck with them. And I think it really is just about even more obsessive attention to detail, really being careful with the fluids, really being obsessively careful with the lines, really being obsessively careful with tube position, techniques of being, being, you know, having a sort of obsessive attention to the using lung, lung protective strategies of ventilation, and then when you're in the OR again, very hemostatic excisions. Keeping the kids absolutely euthermic, very thin, careful harvests, so it's really nothing different than you would with an older child in terms of technique, but I just think it's more obsessive attention to detail. Yeah, I think that's, as you were talking, I was thinking these are basically the, a lot of the same major points you made, but the whole point here is these kids can't take a joke, and so everything's got to be very meticulous. You know, and I think the other thing is in the aftercare part of this, they tend to, because they're not, they're they're not ambulatory, they tend to develop a lot of flexion contractures early, and then when it's time to ambulate, if they, if they've got that contracture, they're not going to be able to do so. So I think really paying attention to them in terms of physical therapy, occupational therapy, and early reconstruction, functional reconstruction especially, is important and maintaining a really tight relationships with the families is key to help them through it. Yeah, that, that's a great point, Rob. Can you think of any other major points that we should hit? I know there's so much more to discuss which would probably almost require another one, such as electrical burns and inhalation injury and management of, uh, eschaotomies and all that. Do you think there's anything you'd want to put in this one? No, I mean, I think that that that you really covered it all and, and, uh, you know, it is, it's like everything, I think in pediatric surgery for you, you know, you, you start to talk about it and you suddenly you realize that just the details are so interesting and you know, you could talk about, you know, for hours and hours about things that you thought were not that complicated. But I, I, I think for now that, that would, that's great and I'm happy if you ever want to do anything, you know, else I'd be happy to help with that. Perfect. Well, I wanna thank you so much. This is obviously uh a, a very tough thing to cover everything in, in one hour podcast, um, but, uh, you certainly answered the major new points and, and for me to summarize here, I think some of the major new points, at least for me, is, uh, you know, the selective excision, the early excision, the, the the transition to more of a colloid resuscitation. The, the idea of not requiring having so much bleeding with your excision and uh a lot of these are, are sort of new, newer ideas that uh that are really going to be impactful and help decrease the morbidity of burns in children. So I really appreciate you taking the time to, to do this today and hopefully we'll be able to have a part two with you in the future on, on some of the more details of, of burn care. Sure, that would be great. Thanks very much, Todd. I really appreciate it. It was really fun. Thank you. Have a great day. Take care. Bye bye bye bye. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.