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palpated. Absence of flow or progressive diminution of the pulse are
indications for escharotomy through the depth of the eschar on the medial
and lateral aspects of the extremities, including the hands. Finger
escharotomies are seldom necessary and should be undertaken only after
consultation with a burn center surgeon. It is especially important to extend
escharotomy incisions across the joints because the skin is tightly adhered
to the underlying fascia at these locations and vascular obstruction is more
likely to occur. The procedure does not require anesthesia because fullthickness wounds are insensate. Pulses assessed by palpation or Doppler
ultrasound should immediately improve after escharotomy. If improvement
is not immediate, hypovolemia should be suspected. Reperfusion of the
extremities after escharotomy may abruptly reduce intravascular volume
and require prompt adjustment of fluid therapy.
Tetanus. Children who have received <3 doses of tetanus toxoid or whose
immunization status is unknown require tetanus toxoid-containing vaccine
and tetanus immunoglobulin. Children who have had >3 doses of the
vaccine require only the vaccine. Red Book Guidelines suggest giving Td to
those between 7 and 10 years and Tdap to those 11 years or greater (see
Chapter 110 Minor Trauma , Table 110.1 Tetanus Prophylaxis).
Pain Management. Safely reducing pain is an important consideration in the
management of children with burns of all sizes. Calm, developmentally
appropriate verbal reassurance, even to preverbal children, can reduce
anxiety and dramatically reduce the perception of pain. The exposure of
sensory nerve receptors in partial-thickness burns makes them sensitive to
environmental stimuli. Movement of cool air across burned tissue increases
pain significantly. The simple measure of covering burns with a sterile
sheet, only exposing them when necessary for burn assessment, provides
extremely effective and safe analgesia.
Many children will still have significant pain after nonpharmacologic
measures are taken. Narcotic analgesics are useful when administered
appropriately. Morphine may reduce the blood pressure, especially in
patients who are hypovolemic. Fentanyl causes less cardiovascular effect

than morphine but has a short half-life. Clinicians should be prepared to
support the circulation with intravenous fluids when using opioids.