I'm Dr. Sean Fagan, and I'm the Chief Medical Officer at Burning Reconstructive Centers of America in Augusta, Georgia. But you might wonder why I'm here to talk to you about pediatric burns. Well, I actually trained as a pediatric burn surgeon, and I've had the great pleasure and honor of training with two of the greats that probably has done more for burns than anyone, and that would be Dr. David Herndon, who I trained with in Galveston. And then I went on and I worked underneath Dr. Ronald Tompkins at the Massachusetts General Hospital and the Boston Shriners Hospital for Children. So the good thing today is you're going to hear a lot of reinforcement. So what I heard today in the first lecture, I'm going to sort of reinforce today with our pediatric talk. I don't have any disclosures to make. I guess the thing you always say, though, is anybody wants to talk to me afterwards, and maybe we can have a disclosure to have. The objectives today, what I really want you to do is understand the demographics of burn injury, understand the impact of burn centers on patient care, understand the initial evaluation and management of a burn patient, crucially important. By the end of the lecture today, you're going to see how your care at the outside facilities prior to the coming to the burn center impacts our patient survival. And it's crucially important that we work as a team and you understand everything that you're doing on the outside absolutely affects what I can do for the patient when they arrive at our center. And then I also just want to give you some of the principles behind burn wound closure. So as I get older, things get more simple. So again, I've had a lot of opportunities, and one of them was I worked with Michael E. DeBakey as my first surgeon. And he said to me many, many times, it all starts with appropriate history and physical. And I can't stress to you how important that is. If we miss things on the initial evaluation, that's going to cause complications down the road. So what I want to do today is just sort of bring it back to the basics, because the basics are the foundation for which we get good care. So how big a problem is burns across the United States? Well, it's about 1.1 million burns annually. That means that one occurs every 23 minutes in the United States. The problem is they're spread out over a large area. So nobody gets a concentrated understanding and experience with burn injury at our trauma centers. You have one roll in every once in a while. And so, you know, that creates difficulty when we have protocols and stuff that we should be adhering to, but you're just not experienced with them. Hospitalizations about 50,000 per year. It's really expensive to take care of burn patients. It's $8.5 billion annually. What we try to do is estimate a day per percent burn, but there's few patients that stay in a hospital as long as a burn patient does, and this increases the cost substantially. Unfortunately, despite some of the advances that you're going to see today, about 4,500 patients succumb to burns each year. And really what's unfortunate is about 75 percent of these patients actually never cross the threshold of a burn center. They die at the scene. Now, I will say that when I was up in Massachusetts, some of the legislation that's going into effect will impact this. So you can't sell a home or a business in Massachusetts without having the fire inspector come in and show that you have accurate smoke detectors and carbon monoxide detectors in all buildings. And in doing this, we will allow people to have early warning and allow them to get out of burning buildings, which certainly I think will impact this moving forward. So why am I here today? Talking about kids. So what about kids? Well, there's about 116,000 burns significant enough in children to require treatment. That leads to about 20,000 admissions to a burn center. Unfortunately, we lose about 1,000 children per year. It actually is the third leading cause of accidental death in the United States. If you move outside of the United States, and I certainly had experience with this in the developing countries where we receive patients who are at the shrine, the number just escalates. So significantly impacts children. The major cause of burns in children are scalds. Simple formula, adults, thermal, kids, scald. So how about who gets burned and what age group gets burned? Well, here you can look at this slide, and the one that I want to show you is this group 15 to 24, where their percentage of the population is outmatched by how often they get burned. So these are young teenagers, young adults that are taking risk-taking behavior, and they certainly get burned more often than others. So where do we treat them? I think you heard that, you know, we do have burn centers across the United States. There's about 134 burn centers across the United States. The average burn size is about 15 beds. In Augusta, Georgia, we have 100 burn beds dedicated to the care of the southeastern United States. About half of these burns are verified by the American Burn Association. So who is the American Burn Association? Well, it's an organization that was founded in 1967 in collaboration with Merritt College of Surgeons, and this group is dedicated to supporting burn care, research, education, rehabilitation, and prevention. But one of the best things that I think this organization did is it created the verification process in 1995. And what this did is it has us live up to expectations. So we have site visitors come in every three years, and they review our programs. And initially, they reviewed to make sure that we had the appropriate structures and we had the appropriate personnel to deliver burn care and have good outcomes. But now what it is is a quality review. We have to demonstrate that we are actually providing quality care to our patients and that each one of us that comes into the burn center absolutely comes in to make the burn center better each and every day. And this is a really important standard that's been moved forward. And most recently, actually, they've sort of separated burn verification from adult verification. They're two separate verification processes. But before, if you're a burn center, you could come in and the reviewers came in and did your adults, did your pediatrics in the same meeting. Not any longer. They've actually separated them out. I think this just drives better care. It makes us be on point that we can't just forget about kids, that they deserve the same evaluation as the adult centers do in terms of our quality care. So I'm a big history buff. So I think the only way you can understand where we're at is understand a little history. So let's talk about burn center history, which certainly I think will show you the impact it's had on our care. So you can't go to the Massachusetts General Hospital and work without talking about the Coconut Grove fire. But I will tell you that the Coconut Grove fire was the first demonstration of a burn center within the United States. So in 1942, a football weekend at an establishment, it was a tavern slash bar. There was a large amount of people, over 500 personnel, packed into a house, right, which was totally overpacked. The establishment owners had locked all the exits because they were paying a cover charge. So they didn't want anybody being led into the emergency exits without paying their cover. And in the basement, a waiter supposedly knocked over a candle, which they were using papier-mâché as decorations. Instantly a fire broke out, and then everybody tried to escape through a revolving door. Now building codes didn't exist as they do today, but if you want a good read, you can learn a lot about building codes, and you can also learn a lot about how burn care advanced in one single night. But what happened immediately is that the revolving doors became clogged because they didn't break in, so there was no escape. So about 500 patients died that night as a result of this injury. But what happened at the Massachusetts General Hospital to take on this large amount of patients is they activated what was the war response. So they took a ward, cleared involved patients, and brought all the patients into one area. And they did specialized care within one area by certain individuals. But this is the first time that several things occurred with regards to the treatment of patients. It was the first utilization of blood bank, first utilization of systemic antimicrobial therapy, but they already started taking this conglomerate of patients and learning. And this is the first demonstration of actually showing PTSD and adjustment disorders, not only in the patients, but in the patients' families. So this is the first demonstration of cohorting people in a hospital with specialized personnel delivering specialized care. Now the first burn center that was established in the United States was actually at the Medical College of Virginia in 1947. So how has this impacted our care? Well, remember I told you in 1942 was the Coconut Grove Fire, and Bull and Finch published their results at this time. This is the LD50 results, 50-50 chance of living or dying with regards to TBSA. And what I want to show you are the young people, right? So 0 to 14 years of age, 15 to 44 years of age at the time of the Coconut Grove Fire. You had a 50-50 chance of living or dying at Coconut Grove if you had a 46 percent total body surface area thermal injury. The largest one to survive that night was 48 percent total body surface area. Now moving forward, there's been a lot of advances, especially at these burn centers, and I want you to draw your attention to the GLUE grant data. The GLUE grant data was an NIH program project. It was actually one of the largest program project grants ever funded by the NIH. And what we were looking at is the genomics and proteomics following both burn and trauma patients. But when you're looking at a basic science project, you collect a lot of clinical data. And we collected a lot of clinical data, and what we collected this data on was outcomes, right? So we had the five very leading burn centers in the United States participate in this study, and we re-looked at what LD50 had become since 1942. And where we had moved is that young age group, 15 to 44 years of age, went from 46 percent total body surface area all the way up to 90 percent. And children went from 49 all the way up to 99 percent total body surface area. So the expectation now on me every day I walk in is that children should survive, even with massive thermal injuries. So how did we get there? Well, one of them was the creation of specialized burn centers dedicated to clinical care, education in the community, and then more importantly, research. And what I want to show you today is that, as opposed to a lot of times in medicine, a lot of the care that we do in the adult population for burns actually came out of us studying children through the Shriners Burn Hospital for Children. But this decrease in mortality over 70 years was the creation of these specialized burn centers, understanding resuscitation, understanding how to control infection, understanding how to modulate hypermetabolism or catabolism in our patients as they come through our systems, and then also the concept of early excision and grafting. So I think we're going to—they're going to beat down the message, who can get transferred to a burn center. Right? Well, the American Burn Association certainly has its transfer criteria. I just always like to say that if anybody can find somebody who shouldn't probably grace our doors at some point during their initial care and or follow-up, you know, we can have a discussion afterwards. But it's a pretty impressive list. But as already stated by our first speaker, any burn injury that's greater than 10 percent, any burn injury involving the face, hands, feet, genitalia, any burn injury in major joints, any third-degree burn, any chemical burn, any electrical burn, any inhalation injury, any preexisting medical disorders, any injury where the burn is at greater risk than the trauma—but most burn centers are associated with well-to-do trauma centers as well—and then any hospital in which you don't have, which was already spoken about, the appropriate personnel to care for children. If you don't have the appropriate personnel, well, they don't might—they might not need to come over that night, but they should probably grace our doors because there's more about treatment of a burn and burn wound closure. It's also now scar modulation. It's also looking for adjustment disorder and making sure that all these things are cared for, just not the wound. So again, burns happen at any time when you least expect it. You know, just like anything, I think when I—you know, when I was doing more trauma, you know, a patient comes in with an amputated limb, don't worry about the amputated limb, right? Do your ABCs. I stress to you the same thing occurs with burns. Burns can sometimes really cause you to focus on the injury when, in fact, what you need to be focusing on—again, back to basics, your ABCs, right? So we want to do very good primary and secondary surveys, right? It's no different than any other patient that you guys take care of each and every day at your trauma centers. Although these are rare, do the exact same thing, and you guys are going to have wonderful results, and that's going to allow me to have wonderful results in this patient population. So let's talk about airway for a second. So with pediatric patients, just like an adult patient, we always want to assess for the need of inline C-sign mobilization until we rule out that the patient hasn't had a traumatic event in regards to the burn injury, right? We can do little things quickly, right? Airways are a little smaller in pediatrics. They might become obstructed a little quicker than in our adult population, but simple, you know, chin thrust—I mean, excuse me, chin lift, jaw thrust, insertion of oral pharyngeal airways, all these things can buy us some time if we need to intubate a patient. But the real thing that we want to do is we want to look at the patient and make the assessment if we need to intubate that patient now, but more importantly, where's this patient going to be an hour or two hours from now? Because I would much rather you intubate a patient and then in 24 hours, I can take the tube out easily versus us getting into an urgent or emergent situation of intubation which we can get an aspiration pneumonia, which then starts to put my patients into infectious complications, which is the number one reason why we have mortality in the burn center now, is sepsis. Now, when you intubate, make sure that we secure our tubes. So we were looking at our transfers at the Shriners Burn Hospital in Galveston, 50% of the mortalities in transfer was loss of airway, right? So you have to make sure that you secure your airway and secure it well. I personally don't believe in securing airways by paralyzing the patient. If you ask me to secure an airway to paralyze a patient, I would say, that's fine, but you have just established a critical airway, meaning that if you lose your airway for any reason, you now have a patient that you have to support 100% versus if we adequately sedate our patients and not have to paralyze, if you lose that tube, you have some ability of the patient to move air in and out while you try to get that tube back in. So just always remember, secure your tubes well and be careful about suggesting that paralytics is a way to prevent extubations. Again, verify, make sure that your ET tube is in proper position. Don't get too comfortable with, you know, CO2 monitors. Listen to the patient. Administer high flow oxygen to these patients and then monitor for appropriate chest wall and rise and fall, right? We want to make sure that we have adequate tidal volumes, and here, when we have circumferential torso burns, that we don't need to do lateral escharotomies of the torso to allow for adequate tidal volumes. So with regards to inhalation injury, it occurs in about 2 to 14% of all their admissions. When we looked at large thermal injuries, it is an independent predictor of mortality on this large study done by Dr. Herndon at the Galveston Burn Center for Children. There are three types of inhalation injury. Injury above the glottis, injury below the glottis, and systemic poisoning. Now the one thing I want to talk about and reiterate to you guys is this concept of systemic poisoning, that being carbon monoxide as well as cyanide. So we spoke about it, that we need to be aware of it in our trauma centers, but absolutely you want to look for, excuse me, you want to look for carbon monoxide poisoning. It's the most common cause of pre-hospital mortality. It has 200 times the binding nephility for hemoglobin, which causes us to shift our hemoglobin dissociation curve. I never thought you'd need to use physiology again, right? Here we go. Here's your dissociation curve being shifted, right? It's particularly deadly to fetal or infants. And not that we're talking about pregnancy and burns, but you definitely need to be monitoring this in your pregnant folks that have child, because fetal hemoglobin have 2.5 times greater affinity for fetal hemoglobin than maternal hemoglobin. And when you're measuring your levels in an adult patient, female, who's pregnant, the amounts of carboxyhemoglobin is actually going to be 10 to 15 times greater than what you're measuring. So something to just keep in mind when you're caring for this other at-risk population, which is a pregnant patient. Now this slide is simply to say that the toxicity levels is directly related to the signs and symptoms that your patients are telling you. But you can get a carboxyhemoglobin level to determine the exact toxicity. Now the initial treatment for carbon monoxide toxicity is high flow oxygen. However, if a patient has or can be treated in hyperbaric chambers, well then I would advocate that. So one of the things that I do as a side project, just kidding, is I do hyperbaric oxygen. And people always ask me, well, the carboxyhemoglobin level is 4. And I said, well, what was it? And they said, well, it was 30. So it's the initial carboxyhemoglobin level that's going to suggest if hyperbaric oxygen can be helpful. And it's not about unloading the hemoglobin quickly. It's actually anti-inflammatory within the cerebellum, which is where some studies have suggested better cognitive testing when you utilize hyperbaric oxygen as opposed to just high flow oxygen. Now we know about carbon monoxide, but we can't forget about cyanide, right? It's very commonly associated when people come in with elevated carboxyhemoglobin levels. And the elevated cyanide levels were found in a lot of patients that were expired at the scene by EMS. And actually, this data actually can be completely attributed to the EMS personnel in the Northeast who actually did the studies to demonstrate that people that expired at the scene actually had high cyanide levels. And pre-hospital treatment is something that we need to move in favor of. Now, if you've ever treated anybody with cyanide toxicity, you can send off a level. The only problem is you'll get it back in about 48 hours. So it doesn't do you much good, right? So you have to sort of presumptively treat for this. However, there was a nice article in the New England Journal of Medicine demonstrating that elevated lactate levels greater than 8 is highly correlative to elevated cyanide levels and to go ahead and initiate treatment at that time. So again, running through things, the problem is cyanide toxicity and carbon monoxide toxicity mimic one another. So you have to just sort of think about both, not one independently. If you've ever treated somebody with cyanide toxicity, it's like treating someone with a massive PE. Everything that you do to try to stabilize somebody doesn't work. Well, again, here we go physiology. Why? Well, the electron transport chain has stopped. The mitochondria are no longer producing ATP. Hard to make a patient better when they have no energy to help you make things better. Never gotten the almond smell on a patient's breath, but I will continue to see if I can find that as a valid sign. Fortunately, when I was younger and treating cyanide, the kit for the treatment was almost as deadly as the cyanide in terms of administration. But now there's something much easier to infuse. It really doesn't have any physiological complications, and that's hydroxycobalamin, which is infused into the patient. It binds with cyanide to 4-cyanocobalamin, which is then readily excreted. You do need to understand that it's not compatible with everything, so sometimes you need a dedicated line, and it does influence some of our laboratories and will give you falsely elevated creatinine levels, but otherwise fairly easy to administer and very effective. Is there pediatric dosing? Yes. It's sort of been extrapolated. Most of these studies with regards to the cyanide kit that we currently use was done in Europe. However, I did want to just give you the dosing for children. You give the initial dosing of 70 milligrams per kilogram. If you don't get an appropriate response, you can go ahead and re-administer this as long as you don't exceed 5 grams in a 24-hour period of time. So moving on to injury above the glottis, this is the most common type of injury. Fortunately, we have really good protective mechanisms in our oral pharynx and nasal pharynx that protects us from getting direct thermal injuries down past our cords. That is except for steam. Moist air has about three times the heat-carrying capacity as dry air, so if you ever have a patient, adult or pediatric, that's affected by steam, be careful because you can actually get direct thermal injuries down into the lung. And then certainly under-resuscitated patients might not show this initially, so again, anticipate where your patient's going, and if necessary, simply just intubate the patient, secure an airway. We can always see how the patient resuscitates and the airway changes over time. Injury below the glottis, sort of a misnomer term. It's really, like I just said, very rare that we get direct thermal injuries down into the lungs, but what we do do is get chemical pneumonitis, and this is from the smoke exposure as well as the aldehydes that are within the burning or non-burning material that they get exposed to. It's reported to increase mortality 50 percent in patient populations. Certainly suggested to increase our volumes of resuscitation when you have this injury, but one of the things that you need to know is there's the acute onset of inhalation injury, but there's also a misnomer which occurs a few days later, and certainly understanding that your patient has an exposure and understanding the timeline of this disease process is important to having good outcomes. Back to physiology, just like I said, again, the chemicals in the smoke, the aldehydes cause damage to epithelial cells, which then elicit an inflammatory response. I think of it more as a chemical pneumonitis than, again, a direct thermal injury. How do we diagnose this? Bronchoscopy. So all our patients that we have a suspected inhalation injury, we're going to perform bronchoscopy, and we're going to try to get as much of this soot out of the patients as we can, and sometimes this causes repeat bronchoscopies. But what I wanted to show you on this slide is that while we see that we have erythema, one of the things I always look at as an intensivist is the crina. If the crina is sharp, right, I know that I don't have that much edema in my lungs yet. However, if I do a bronchoscopy and my crina is already blunted, I have a significant inhalation injury, and I certainly have to do things in terms of the overall care to bridge this patient, because the only thing we can do, right, is help not hurt the lungs anymore and allow them to heal as we take care of their thermal injuries. So anticipate respiratory involvement, as has been suggested earlier, and certainly intubate early. You will never, ever call me on the phone and someone say, should I intubate the patient? I said, have you thought about it twice? Because if you thought about it twice, go ahead and secure the airway. Again, elective, controlled, versus emergent. Let's move on to circulation, okay? Simple, especially with kids. When you walk in the room while you're getting all your vital signs hooked up, just put your hand on the child, right? If the patient is cool and clammy, guess what? They're outside stage one shock, right? Which will just give you an idea. So, you know, simple things, we don't need a bunch of data immediately. We can do things and understand where our patients are immediately by just laying hands, okay? We establish IV access early. Again, we looked at our transfers from outside the United States and when did resuscitation initiate? And this simple slide suggests is this. You don't have to have perfect resuscitation, but if you initiate resuscitation, you get far better outcomes than delaying that initial resuscitation. So, always think about getting resuscitation going and then dialing it in. But early is important. But, as we heard about escharotomies, where you're infusing is sort of important. If your extremity is starting to have signs of compartment syndrome, right, which obstructs venous outflow first before arterial, you want to make sure that you don't need to do escharotomies to ensure where your site of entry for infusion isn't compromised. Now, resuscitation of burn patient is truly a moving target. I've been doing this for quite some time and this is actually what intrigues me about a burn patient is the complex physiology that's occurring initially and ongoing throughout their hospital stay. Now, again, history buff, right? Understanding resuscitation where we came from. Now, coconut grove fire, amazing things happen. Prior to the coconut grove fire, there was this concept called toxic burn tissue, which actually people thought that there were toxins that released from the burn tissue. These toxins circulated, caused organ failure. So, the idea was, let's fixate the tissue. Let's not let these toxins move. Aldehydes, all sorts of stuff was utilized to fix the tissue. But then there was a wonderful person, Dr. Frank Underhill, who is the one that is credited in starting the initial Parkland resuscitation formula. He was a professor at Yale who cared for some patients in a 1921 theater fire. But he had experience with thermal injuries from World War I and more importantly with chemical injuries that he saw in World War I. And what he thought was these burns, whether it be chemical or heat in World War I, that these patients were becoming dehydrated. And that really what he needed to do is just resuscitate the patient and prevent massive dehydration. And so, on this night, he decided to put his theory into place. He started resuscitating patients so that, and how he monitored it was their hematocrit. So, if their hematocrit was elevated, he resuscitated them back down to normal hematocrit. The first demonstration of actually giving fluids and looking at laboratory results to guide resuscitation. He was also the first one to use the term burn shock. So, it only took 70 years for us to come back and say, Dr. Underhill, you were correct. One of the things that's an independent predictor of survival in burn patients arriving is their initial hematocrit. So, Dr. Underhill was pretty smart. We confirmed it in this large trial that we did at the Shrine. So, again, don't make this complicated. Burn patients are no different than what you guys do each and every day. And the goal is to provide end organ perfusion, right? So, what you guys do every day is no different than a burn patient. Get that end organ perfusion is the goal of resuscitation. Where do we get access? Wherever we can, right? If you can go through unburned tissue, great. If you go through burned tissue, it's okay with me, burned tissue is not infected on day zero, okay? That doesn't mean that we need to be sloppy about putting them in, but go ahead and get access. Now, with regards to kids, whenever you make something easy, we use it a lot more. So, everybody has the Black and Decker interosseous drill now? Right. When you had to put the interosseous line in with your palm, you didn't see so many interosseous lines. Now that you have a Black and Decker that you can drill, everybody gets drilled. In fact, at the Massachusetts General Hospital, access on our code responses, 70 percent of the access is with IOs now. That's how fast they are in terms of delivering access. But, please consider the burn size. I love the question, when do we resuscitate patients? Twenty percent. You do not need to do an interosseous line pre-tibial in a child with a five percent burn. Because if you miss and you go across the growth plate, we've got a problem. I can't stress to you the importance also of self-resuscitation or oral resuscitation, right? So, in kids and adults, they're much smarter than my brain in resuscitation. If you don't have a big problem, look at the patient and see if the patient can just self-resuscitate. It's a lot easier and you avoid complications. So, goals of fluid resuscitation, I make it simple. I think of a car, okay? And so, what you guys do each and every day is what I do in terms of caring for the pediatric population. The first thing I always do before I get in the car for a trip is I make sure I've got gas, right? So, I want to make sure that I'm euvolemic. So, I'm going to resuscitate my patients until euvolemia. Once I get euvolemia, I'm going to check the engine, make sure that I'm ready to go down the road because the inflammatory response in burn patients is quite significant. And even in a pediatric patient, you can get cardiac myelosuppression. So, you can have a child who should have EFs of 65 percent drop down to 30 percent. Well, we don't need to overcome that with more fluids. We need to treat the end organ that's failing, which is the engine or the pump, the heart. And getting this data with simple echocardiograph of the chest is very helpful in terms of guiding therapy. Once I make sure that I'm euvolemic, once I make sure the engine's working, well, then I look at the pipes, right? I look at the exhaust system. What I want to know is, do I have peripheral vasodilatation secondary to this inflammatory response? And if I do, well, then I'm going to tighten up that intravascular space with vasoconstrictors. Now, in the 80s, heresy. Never use a vasoconstrictor in a burn patient. Now, I use them on almost every one of my patients, right? Because what they were doing is they were filling that venous capacity increase with fluid. I'm going to show you in a second where that wasn't the right thing to do. So, there are about as many resuscitative formulas as there are burn centers. What I would advocate is doing one and doing it well. And I don't think there's one that does anything better than the Parkland formula. But as our colleague did talk about earlier, we have changed the Parkland formula. It's two to four cc's moving more towards the two than the four to prevent over resuscitation. Again, what we're going to do is we're going to take two to four cc's times the total body surface area, second and third degree burns, okay? And then the total body weight, ideal. That's going to give us the total volume infusion over the first 24 hours, an estimate. We're going to infuse half of that over the first eight hours and the remaining over the second 16 hours. And we're going to monitor the response to our estimate. And then we're going to adjust based on what we find. So, critical values, weight, which love that weight was said is something we need on the initial evaluation of a trauma patient. And then the total body surface area, right? So, really important that we get accurate total body surface areas in our calculation. Data, bad data, bad results. Good data, good results. It's that simple. So, we're going to utilize second and third degree for the calculation. And we're going to utilize London Broward charts. I've been doing this every day. Do you know what the first thing I do when I walk into our debridement room? I rip off a London Broward chart and I start coloring. And then what I'm going to do is I'm going to get a very accurate estimate of the total body surface area. And why is that important? Well, when you work at the Shrine, you get a lot of patients transferred into you because not a lot of people are comfortable with pediatric burns. But what we were noticing is we're getting these huge discrepancies, 300% error rates in what was thought of at the outside and what we actually saw upon arrival. And this unfortunately led to increased volumes being administered, actually led to inhibition of patients that are unnecessary. And so, utilizing the London Broward chart will allow you to get accurate data and then get your estimations moving in the right direction. And then we're going to monitor for the response to resuscitation. We certainly monitor urine output, but urine output is not the only thing. In kids, we try to run them about a cc per kilogram per hour. But more importantly, we're going to look at a plethora of laboratories and we're going to make sure that that patient is resuscitating appropriately over time. But certainly, we want to move quickly, all right, because I need to. But also, what we do a lot with advanced hemodynamic monitoring, I utilize a lot of data in the resuscitation of this patient, pulse control analysis, as well as TEE to evaluate and take care of these patients. Certainly, TEE allows us to look at the superior vena cava and see if they have responsiveness for fluid administration, as well as we can get a four-chamber view of the heart and see what the heart is doing from a ejection standpoint, but also to see if we have proper filling. So here, you can see that the superior vena cava is full, right, as opposed to here where it's collapsing with respiration, which would be suggestive that we would be responsive to fluid. Again, four-view of the heart, I can look at the left ventricle, see what my ventricles are doing, make sure that we don't have kissing ventricles, which again would be suggestive that we could utilize fluid. So proper resuscitation is through a goal-directed approach. Certainly, what I want to share with you, that more fluid is not good. This came from the Glue Grant. Dr. Klein wrote a very nice paper on this. I can say this because I'm a surgeon. More fluid is not good. I like the Michelin statement earlier, but what's really interesting is that what we do with fluids impacts our infectious processes moving forward, right? So when we over-resuscitate a burn patient, we get increasing pneumonias, increasing bloodstream infections, increasing ARDS, and increasing mortality. So what you guys do on the outside in terms of proper resuscitation and bringing to the burn center impacts infectious etiologies moving forward. Remember, the calculation is just an estimate, but it's an individual response that dictates the therapy. So disability, again, running through this, make sure that we haven't missed anything along the way, concomitant trauma in our disability, certainly exposures. We want to maintain euthermia, right? We do not want hypothermic kids. So we want to remove all the clothing, but make sure that we're in a warm environment, make sure we're administering warm fluids, especially in transport. Over 50% of the patients that arrive at trauma centers are hypothermic on arrival. This doesn't matter about the season, right? And certainly our infants are at risk. Certainly, not maintaining warm environments starts the hypermetabolics process early. So we want to maintain good warm environments around our patients so that we do not make patients utilize energy for thermia, but utilize it for healing. Secondary survey, good head-to-toe exam is important along with our laboratory values. Certainly, we need to make sure that we're identifying the burns correctly in our secondary survey. First-degree burns, painful but easily treatable, right, with proper dressings and avoiding dressing changes. Our secondary burns with blisters, certainly we don't know what the degree of injury is until we remove those blisters. Third-degree, the charring that we talked about, that is very noticeable. And fourth-degree burns are the ones that unfortunately involve bones and tendons and generally require amputations. The depth of injury is directly dependent on the thickness of the skin and the blood supply, as well as the temperature and the duration of contact. But some cutting edges in burn care that I just wanted to share with you real quickly. One thing is that standard of care, all burn, full thickness injuries need to be removed in five days and then closed. So we remove the eschar and autograft. The techniques for closure have changed over the years. The challenge is how do we close burn wounds with limited donor sites? So how do we take a small area and cover a large area? Well, there's a lot of different ways we do that now. So we can take donor sites, run them through meshers, and apply them over wounds. And then the enterocies that you see there will close in by themselves. While those enterocies are closing, we support the area with allograft. That was a technique that's been utilized for years. But then Dr. Meek in 1958, across the river from me, came up with a Meek's idea where he created micrographs. And so we took skin and we can create these micrographs and then apply those to the patient to obtain closure. Technology has allowed us to move this forward and apply it on a daily basis. So we are now able to take skin, apply it to this paper, allow it to be cut, and then the accordion paper allows us to do uniform application to the patients, which not only closes large surface areas with small amounts of donor site, but also gives you great cosmetic responses. We also can take small donor sites to create cellular suspensions and then grow them in the laboratory. So this is CEA. Certainly something that can be utilized on our massive burns. It is expensive. It does require a full thickness biopsy. But in the right hands, we can have up to 80, 90 percent engraftment, which is definitely beneficial to our patient population. You can see it being applied here. It comes on a backing. We apply it to the patient in continuity with autografting. Again, CE application to full closure with a nice result. And then finally, we now can take donor sites, create a cellular expansion, and utilize it with autografts, this autologous epidermal autografts. This is readily available in the operating room now. Like I said, immediately available to our patients, small donor sites. But one of the things is it's not just for large burns. We actually can utilize this in small burns and get closure very rapidly. So again, the goal is small donor site, large coverage area. And then while my time is up, I just wanted to show you, why do you want to send patients to burn centers other than for large thermal injuries? But it's because we've got other things in our hat that we can do for our patients. And one of them being laser reconstruction or scar rehabilitation. It started out by utilizing lasers with port wine stains. And we could do dramatic things with port wine stains. It's a PDL laser. PDL lasers were first utilized in burns up at the Massachusetts General Hospital. Dr. Donilon utilized it. And while it had some benefits, we really didn't get moving in the right direction until we started utilizing the PDL laser with a CO2 laser, which actually causes scar modulation beneath the skin, right, giving great symptomatic relief from the common symptomatology seen in our large burn patients. But the results are amazing, right? So we can take with simple laser therapy and we can take patients that are closed but unfortunately didn't have great cosmetic responses and give them wonderful cosmetic responses. And believe it or not, you can use it on anything. You can utilize it on split thickness skin grafts. You can utilize on CEA patients. You get the same results. The biggest thing I want to share with you, and this is really important so I'm going to go over time, is that number one, pediatric patients should survive. That's the expectation. We have to have centers that are dedicated to this unique patient group, right, because they do have some unique things. And utilization of some of the resuscitative techniques, the trauma centers in terms of getting us to a patient that is, you know, properly resuscitated upon our arrival, closure, and then what we can do in terms of functional and cosmetic results. Well, guess what? These burn patients do great. They thrive, right? And I think it, as this says, that so few survivors have developed serious psychological and social difficulties is a striking testament to human resilience. We've looked at our patients. They do great. Do we need to support them from a psychosocial aspect? 100%. But with support, they can reenter society and do a great job. And I apologize for going over, but thank you so much for the opportunity to talk with y'all.

pediatric burns

burn centers

patient care

burn injuries

scalds

specialized care

improvements in burn care

laser therapies