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responsive to fluid therapy, should have an aggressive diagnostic workup
for concurrent problems.
Antibiotics. Burn sepsis continues to be the major cause of mortality after
the period of initial resuscitation despite improvements in topical and
systemic antimicrobials. Meticulous antiseptic techniques can lessen
colonization of burns with potential pathogens. Topical antibiotics further
reduce bacterial number. Early streptococcal cellulitis is less common than
in years before the development of topical antibiotics for burns. Most burn
centers do not routinely treat patients with prophylactic systemic antibiotics
given absence of data to support this practice, and the increased likelihood
of inducing resistant organisms. Frequent examination of healing burns for
signs of infection and cultures to monitor colonization can direct specific
antibiotic therapy if documented infections were to occur.
Wound Care. Early surgical management of some partial- and most fullthickness burns with excision and grafting has been an important advance in
burn treatment. Initially, burns should be covered loosely with sterile sheets
during the resuscitation phase in severe injuries. Once the cardiorespiratory
status is stabilized, the wounds are uncovered and fully assessed for size
and depth. The goals of burn wound care are to promote rapid healing and
prevent infection. Cleansing with large volumes of lukewarm sterile saline
reduces contamination. Loose tissue can often be wiped away with sterile
gauze, simplifying and expediting burn debridement. Blisters should be left
intact whenever possible. However, large blisters or those that obscure the
assessment of the burn depth may need debridement. Smaller blisters may
be left intact to preserve the barrier to bacterial invasion. Application of
temporary skin substitutes may reduce pain, expedite healing, and reduce
length of hospitalization compared with topical antibiotics and conventional
dressings but are often not applied in the ED. It is not necessary to apply
topical antimicrobials to burns prior to transfer to a burn center or tertiary
care children’s hospital.
Escharotomy. First, all jewelry and watches should be removed because
these may restrict distal flow of the blood. For extensive and deep extremity

burns, pulses should be checked by Doppler ultrasound if they cannot be