Robert Sheridan

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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

quote · Burns

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

quote · Burns

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Robert's statements about Burns 142 statements

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Pediatric Burns

Statement Historical animal data from the 1960s–70s showed colloid accumulation in lungs, creating fear of pulmonary compromise before mechanical ventilation was available, leading to pure crystalloid resuscitation formulas. Open

Quotation fluid losses replaced like for like, except for in burns where we've always had this desire to replace plasma with crystalloid Open

Quotation 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 Open

Statement Crystalloid-only resuscitation causes incredible anasarca with significant morbidity including near-compartment syndromes and neurologic injury. Open

Statement Children do not need 2 cc/kg/hr urine output unless extremely young or have abnormal renal concentrating ability; 0.5–1 cc/kg/hr is reasonable. Open

Statement Starting colloid (5% albumin) immediately in burns ≥30–40% eliminates morbid anasarca in Sheridan's practice. Open

Quotation I almost never see that morbid anasarca when children are resuscitated that way Open

Statement Burns of 15–20% or less do not need calculated resuscitation; 150% maintenance IV or ad lib PO with monitoring is sufficient. Open

Statement For 20–50% burns, Sheridan uses Parkland (4 cc/kg/% burn over 24 hours), subtracts 1× maintenance given as 5% albumin, and gives the remainder as Ringer's lactate, with D5 Ringer's at 1× maintenance if hypoglycemia is a concern. Open

Statement For burns >50%, Sheridan gives 2× maintenance as 5% albumin (instead of 1×) in addition to D5 Ringer's and adjusted Ringer's lactate. Open

Statement Resuscitation should be titrated hourly to keep the child on the dry side of euvolemia, typically ending at ~150% maintenance by 24 hours. Open

Quotation you really should be weaning that fluid. Whenever you have the opportunity to do so Open

Statement Sheridan has never had to perform abdominal decompression since adopting colloid-based resuscitation. Open

Quotation you want to treat critical illness, not cause it Open

Quotation 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 Open

Statement Most small burns (e.g., coffee spills) heal well regardless of management; gentle debridement of loose blistered material and topical treatment (bacitracin, silver dressings) with periodic exams over 48–72 hours is reasonable. Open

Quotation Most of those kids are going to do fine no matter how you manage them Open

Quotation 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 Open

Statement Burns under 10% are managed outpatient if family is capable, accessible, and adequately taught; admission factors are often non-wound-related (distance, weather, family exhaustion, ability to drink). Open

Statement Facial burns are admitted if airway is questionable or if burned lips prevent drinking. Open

Quotation when in doubt, the best thing to do is just admit and let everybody calm down Open

Statement Thick, durable, non-tense blisters (e.g., fingertips, palms) can be left intact for a couple of days; thin blisters likely to rupture should be debrided in clinic. Open

Statement For small burns, early excision means clear identification and excision within the first week after family teaching; for large burns (20–30%+), it means starting excision on day 1–2 to complete staged removal by day 5–7 before septic morbidity develops (typically day 3–5). Open

Quotation the art is sort of in identifying those areas that really need to get done Open

Quotation 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 Open

Statement Small deep burns (e.g., muffler burns, curling iron burns) pose minimal septic threat, allowing time for family discussion and planned excision without urgency. Open

Quotation 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 Open

Statement Large burns (20–30%) can cause overwhelming sepsis if wound control is lost; wound cellulitis and infection typically appear day 3–5. Open

Statement Intubation is indicated if airway is at risk from edema or if the burn is large enough to require multiple surgeries with sedation. Open

Statement Central access is almost always placed in large burns; Sheridan prefers subclavian lines in the OR, femoral or IJ with ultrasound at bedside, using small-caliber two-lumen lines. Open

Quotation Keeping them warm is really a high priority because they really do evaporate a lot Open

Statement Enteral feeding is started day 1 for small-to-mid-size burns; for large burns with long transport or hemodynamic instability, trophic feeds are started with advancement delayed until bowel sounds return. Open

Statement Routine prophylactic antibiotics are not used; a study of ~600 children (300 per group) showed no difference in infection rates but more rashes and diarrhea in the antibiotic group. Open

Quotation 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 Open

Statement Early high fever (first 24–72 hours) in a well-appearing child is often not treated; fever after day 3–5 prompts empiric antibiotics while awaiting cultures. Open

Statement Femoral lines have the same infection rate as other sites in Sheridan's review of ~1000 catheters; IJ lines trended slightly higher in small children due to intertriginous location. Open

Quotation 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 Open

Statement Central lines are rotated weekly with non-antiseptic lines (infection spike at ~10 days) and every 2 weeks with antiseptic-impregnated lines (spike just outside 2 weeks), typically coordinated with OR trips. Open

Statement Army burn unit data showed up to 42% occult bacteremia during major wound manipulations when wounds are large and open, supporting more frequent line rotation during that phase. Open

Quotation 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 Open

Statement Circumferential burns are monitored with Doppler pulse checks every few hours or continuous pulse oximetry on involved extremities; escharotomy is performed at first sign of ischemia. Open

Statement Topical choice (silver nitrate soaks, sulfamylon, sulfamylon with amphotericin) is unit-specific; differences in outcomes are modest if other program elements work well. Open

Statement For large burns, excising unless fairly sure the wound will heal is safer than waiting; for small burns, leaving the wound unless sure it is full-thickness is safer. Open

Statement Diagnostic dermatome passes in small representative areas intraoperatively help assess burn depth when uncertain. Open

Statement Operating rooms at Boston Shriners can reach 120°F and 100% humidity, preventing hypothermia during large excisions. Open

Statement Minimally ablative excision—removing only what clearly needs removal—produces the best long-term aesthetic and functional outcomes, though it carries slightly higher septic risk if too conservative. Open

Quotation 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 Open

Quotation 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 Open

Statement Fascial excisions, once routine for full-thickness burns, are now rare; layered excision preserving remnant fat is preferred even for deep burns. Open

Quotation you can do these hemostatically amazing well Open

Quotation 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 Open

Statement Hemostatic excision can be achieved without free bleeding as an endpoint; subtle signs (fat appearance, deep reticular dermis) indicate adequate excision with much less blood loss. Open

Quotation fascial excisions used to be, at least in our practice, very routine for any full thickness burn, and now they're quite rare Open

Statement All excisions are completed before any donor harvest so that if the child decompensates, the procedure can be aborted without creating additional wounds. Open

Quotation if 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 Open

Statement Immediate autografting is performed if the child is stable and the excision bed is good; otherwise allograft is placed and treated like autograft (well-secured, allowed to vascularize) for 5–7 days before conversion to autograft. Open

Quotation 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 Open

Statement Primary allograft dressings are left undisturbed until ready for autograft conversion (5–7 days) to avoid unnecessary painful dressing changes. Open

Statement Split-thickness autograft remains the definitive permanent membrane; no skin substitute has replaced it despite Sheridan's extensive trial experience. Open

Statement Allograft is the go-to temporary membrane for large burns at Boston Shriners. Open

Statement Donor sites must be treated as the most valuable territory: thin harvests, meticulous care, no infections, no deep passes, to preserve tissue for future reconstruction. Open

Quotation 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 Open

Statement Colloid-based resuscitation has eliminated anasarca morbidity in Sheridan's practice over the past 25 years. Open

Quotation 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 Open

Statement Critical care advances (better mechanical ventilation, vascular ultrasound, smaller lines) have significantly benefited burn patients. Open

Statement Minimally ablative hemostatic excision improves long-term aesthetic and functional outcomes, though it may not improve survival and carries slightly higher septic risk if too conservative. Open

Quotation 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 Open

Quotation if you can overcome those dark sides of a minimally ablative approach, the long term results are a lot better Open

Statement Tension-relief operations with small smart incisions shrink scars and improve function/appearance; fractional CO2 laser is an adjunct but tension relief is the key mechanism. Open

Quotation a lot of these scars are very dynamic and that they will shrink with release of regional tension Open

Statement Early functional and aesthetic reconstruction is now performed as soon as issues arise (coordinated with school schedules) rather than waiting 2 years as was traditional. Open

Quotation 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 Open

Statement Reintegration after burn injury is harder than Sheridan initially thought; more resources for family and child psychological support are needed. Open

Quotation just trying not to operate on kids in that phase of care as long as possible, I think sometimes isn't the right answer Open

Statement Essential elements of a burn system include critical mass of experienced multidisciplinary staff (PT, OT, psychology, nutrition, nursing, surgery, anesthesia, pediatrics), daily multidisciplinary rounds, and collaborative rather than competitive regional relationships. Open

Quotation 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 Open

Quotation 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 Open

Statement Newborns and infants under 6 months with large burns require obsessive attention to detail: meticulous fluid management, line care, lung-protective ventilation, hemostatic excision, normothermia, and thin harvests. Open

Quotation 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 Open

Statement Non-ambulatory infants develop flexion contractures early; aggressive PT/OT and early functional reconstruction are critical to enable ambulation. Open

Burns

Statement Animal studies in the 1960s and 1970s showed that excessive colloid administration resulted in histologic accumulation of colloid in the lungs, leading to fear of pulmonary compromise before mechanical ventilation was widely available. Open

Quotation fluid losses replaced like for like, except for in burns where we've always had this desire to replace plasma with crystalloid Open

Statement Traditional crystalloid-only resuscitation formulas (Brooke, Parkland) cause severe anasarca with significant morbidity, including near-compartment syndrome and neurologic injury. Open

Statement Children do not need to make 2 cc/kg/hr of urine unless they are extremely young or have abnormal renal concentrating ability; targets of 0.5–1 cc/kg/hr are reasonable. Open

Quotation 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 Open

Statement Starting 5% albumin colloid immediately in burns ≥30–40% reduces total fluid volume and eliminates the need for abdominal decompression in Sheridan's practice. Open

Quotation I almost never see that morbid anasarca when children are resuscitated that way Open

Statement For burns 15–20% or less, maintenance-and-a-half IV fluids or ad lib PO intake with clinical monitoring (tears, moist oral cavity, pulse quality) is sufficient; calculated resuscitation is not needed. Open

Statement For mid-range burns (20–50%), Sheridan calculates Parkland (4 cc/kg/% burn over 24 hours), subtracts 1× maintenance, and gives that volume as 5% albumin; the remainder is given as Ringer's lactate. If the child is young and at risk for hypoglycemia, he also subtracts 1× maintenance as D5 Ringer's. Open

Statement For burns >50%, Sheridan gives 2× maintenance as 5% albumin (or one-third of total calculated resuscitation as albumin), with the remainder as crystalloid. Open

Statement Resuscitation fluids are adjusted hourly based on urine output and distal perfusion; by 24 hours, total fluid infusion typically reaches approximately 150% of maintenance if resuscitation goes well. Open

Quotation you really should be weaning that fluid. Whenever you have the opportunity to do so Open

Quotation you don't want to, you know, you want to treat critical illness, not cause it Open

Quotation 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. Open

Quotation Most of those kids are going to do fine no matter how you manage them Open

Quotation 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 Open

Statement Most small burns (<10%) are managed outpatient; admission criteria are driven by family factors (distance, car access, ability to follow instructions), not wound size alone. Open

Statement Thick, durable, non-tense blisters (e.g., on fingertips and palms) can be left intact for a few days to avoid painful debridement; thin blisters that will rupture should be debrided in the clinic. Open

Quotation 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 Open

Statement Early excision for large burns (≥20–30%) means removing non-viable tissue within the first few days to prevent septic morbidity, which typically appears by day 3–5. Open

Quotation the art is sort of in identifying those areas that really need to get done Open

Statement For small deep burns with no septic threat, early excision means clear identification of what needs excision, family teaching, and operative intervention within the first week. Open

Quotation if the wound is small, it's highly unlikely that there's going to be overwhelming sepsis from it, even if it's deep Open

Quotation 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 Open

Statement Children with large burns (≥50%) are intubated early if airway edema or extensive surgery is anticipated, to secure the airway before swelling makes intubation difficult. Open

Quotation Keeping them warm is really a high priority because they really do evaporate a lot Open

Statement Enteral feeding via nasogastric tube is started on day 1 in most burns; children with very large burns or prolonged transport may have splanchnic ischemia and require trophic feeds until bowel sounds return. Open

Statement Prophylactic antibiotics are not routinely used; a study of ~600 children (300 per arm) showed no difference in infection rates but more rashes and diarrhea in the antibiotic group. Open

Statement Central venous access is placed in nearly all large burns; femoral lines have the same infection rate as other sites in Sheridan's 1000-catheter review, with a slight trend toward higher infection in internal jugular lines in small children. Open

Quotation water molecules are little and so the lines can be little Open

Statement Central lines are rotated weekly in the pre-antiseptic-line era (infection spike at 10 days) and every 2 weeks with antiseptic-impregnated lines (spike at 2 weeks); lines are also rotated in conjunction with OR trips. Open

Quotation there's a lot of, uh, I think, occult bacteremias with manipulations of wounds when the, when the wounds are large and open Open

Statement Army burn unit studies showed up to 42% incidence of occult bacteremia during major wound manipulations in children with open wounds. Open

Statement Sheridan uses silver nitrate soaks, sulfamylon soaks (sometimes with amphotericin for difficult gram-negatives), and other wet topicals for large burns; the choice is unit-specific and differences in outcomes are modest if other program elements are strong. Open

Quotation the difference between outcomes with various topicals is relatively modest. As long as all the other pieces of the program are working Open

Statement Diagnostic dermatome passes in small representative areas help determine burn depth intraoperatively when clinical exam is uncertain. Open

Quotation 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 Open

Statement Excision is staged over 2–3 days for very large burns to avoid critical illness, excessive blood loss, and fluid overload; the goal is to remove all threatened tissue by day 5–7. Open

Statement Maintaining normothermia during excision (OR at 120°F, 100% humidity, continuous temperature monitoring) prevents coagulopathic bleeding from hypothermia. Open

Quotation 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 Open

Statement Fascial excisions, once routine for full-thickness burns, are now rare; layered excision preserving remnant fat improves long-term appearance and reconstructive options. Open

Quotation fascial excisions used to be, at least in our practice, very routine for any full thickness burn, and now they're quite rare Open

Statement Hemostatic excision endpoints include the appearance of fat and deep reticular dermis, not free bleeding; this minimizes blood loss compared to older techniques. Open

Statement Allograft is used as temporary coverage when the child is unstable, excision depth is uncertain, or burns are too large for immediate autografting; it is treated like autograft (secured, allowed to vascularize) and replaced with autograft in 5–7 days. Open

Statement Split-thickness autograft remains the definitive permanent membrane; no permanent skin substitute has proven superior. Open

Statement Donor sites should be treated as the most valuable territory: thin harvests, meticulous care, no infections, no deep passes, to preserve tissue for future reconstruction. Open

Quotation 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 Open

Statement Colloid-inclusive resuscitation has transformed outcomes by reducing anasarca and eliminating the need for abdominal decompression in Sheridan's practice. Open

Quotation I'm a total convert to the more mixed resuscitation with inclusive, including colloid, and I just think the kids do better Open

Statement Minimally ablative excision improves long-term aesthetic and functional outcomes but carries a slightly higher septic risk and makes definitive coverage on fat beds more challenging than on fascial beds. Open

Quotation 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 Open

Statement Modern scar management favors small tension-relief operations over ablative excision and skin grafting; scars shrink with regional tension release, sometimes augmented by fractional CO₂ laser. Open

Quotation a lot of these scars are very dynamic and that they will shrink with release of regional tension Open

Statement Early functional and aesthetic reconstruction (as soon as functional issues arise) has replaced the old practice of waiting 2 years before operating on healed burns. Open

Quotation as soon as there's some functional issue, we'll try and fit it in with your school schedule and get that addressed Open

Statement Multidisciplinary aftercare (PT, OT, psychology, nutrition, nursing, surgery) in daily rounds and clinic is essential to long-term outcomes and reintegration. Open

Quotation 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 Open

Statement Infants <6 months with large burns require obsessive attention to fluid management, line care, tube position, lung-protective ventilation, hemostatic excision, normothermia, and thin harvests; they are prone to flexion contractures and need aggressive PT/OT and early functional reconstruction. Open

Quotation it really is just about even more obsessive attention to detail Open