colonized with potentially pathogenic organisms, primarily from the skin and intestinal flora of the patient and not from exogenous sources Cleansing and debridement reduce substrate for bacterial proliferation and topical antimicrobial therapy reduces the number of microorganisms, but burns are never completely sterilized so the risk of secondary infection is always present Burn wounds are not treated immediately with systemic antibiotics unless infection is clearly present, but must be watched closely for development of subsequent infection MAJOR BURNS CLINICAL PEARLS AND PITFALLS The placement of a sterile sheet over burned areas can provide effective analgesia Consider carbon monoxide and cyanide exposure with house fires and not delay treatment in suspected cases Current Evidence Risk of morbidity and mortality is associated with the size of the burn A large, single-center, prospective study of pediatric burn patients found mortality rates ranging from 3% (30% to 39% TBSA) to 55% (90% to 100% TBSA) In this study, burn size of 62% TBSA was the marker of a significantly increased mortality risk Goals of Treatment The initial management of the significantly burned patient includes protection of the airway, maintenance of breathing, and support of circulation, all with the goal of preventing mortality and disability Initial airway assessment needs to include evaluation and management of potential direct inhalational injury and resultant airway edema, as well as inhaled toxins including carbon monoxide and cyanide Patients should receive supplemental oxygen, as well as appropriate antidotal therapy for toxicologic exposure, respiratory support as needed (potentially including escharotomy for circumferential chest burns), and appropriate intravenous fluid resuscitation to support their circulatory status The goal is to optimize