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 the vaccine require only the vaccine Red Book Guidelines suggest giving Td to those between 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