Clinical experience with biobrane® biosynthetic dressing in the treatment of partial thickness burns

Biobrane®, a synthetic, bicomposite wound dressing, has been used to treat 17 patients with partial thickness burn wounds covering 0·5–12·5 per cent of the total body surface area (mean 4·4 per cent). In 16 patients we found complete healing of the wound after removal of the dressing, 6–15 days after the injury. In one patient, the wounds were determined on the third day post-injury to be deeper than initially suspected, and she was taken to the operating room for surgical debridement and grafting. Biobrane is an effective wound covering for clean, superficial partial thickness burns of limited extent; the simultaneous use of topical antimicrobial agents for such wounds is not necessary.     

Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns

The consequences of receiving a cutaneous sulfur mustard (SM) burn are prolonged wound healing and secondary infection. This study was undertaken to find a treatment that promotes quick healing with few complications and minimal disfigurement. Multiple deep SM burns (4 cm diameter) were generated on the ventrum of weanling pigs and treated at 48 h. Four treatments were compared: (1) full-thickness CO₂ laser debridement followed by skin grafting; (2) full-thickness sharp surgical tangential excision followed by skin grafting, the “Gold Standard” used in deep thermal burns management; (3) partial-thickness laser ablation with no grafting; and (4) partial-thickness sharp excision with no grafting. A computer controlled, raster scanned, high-powered continuous wave (cw) CO₂ laser was utilized. Ulceration, wound geometry, and wound contraction were evaluated during a 36-day healing period. Histopathological evaluations were conducted at the end of the healing period. Engraftment rates were similar between both methods of debridement. Laser debridement followed by skin grafting was as efficacious in improving the wound healing of deep SM burns as the “Gold Standard.” Full-thickness laser debridement of these small total body surface area (TBSA) burns was time efficient and provided adequate beds for split-thickness skin grafting. Laser debridement offered additional benefits that included hemostatic control during surgery and minimal debridement of normal perilesional skin. Mid-dermal debridement by sharp excision or laser ablation without grafting produced less desirable results but was better than no treatment.     

Evaluation of topical therapy with silver-kaolin (Argostop) in an experimental model of burn wound sepsis

Burn wound therapy with silver-kaolin, a topical agent applied as an aerosol spray, was evaluated in male rats given a 20 per cent total body surface area, full thickness dorsal scald burn. Burn wounds treated with silver-kaolin healed at rates comparable to untreated wounds. No significant differences were noted in the numbers or types of organisms colonizing the wounds of treated and untreated rats at 5, 12 and 19 days post-burn. To evaluate the effectiveness of silver-kaolin in treating burn wound sepsis, rats were inoculated on the wound surface with 2.5 x 10(8) Pseudomonas aeruginosa. This inoculum resulted in 100 per cent mortality in untreated rats. Rats treated with silver-kaolin had a mortality rate of 71 per cent, compared to a 9 per cent mortality rate in rats treated with 1 per cent silver sulphadiazine. When silver-kaolin was applied to the wound prior to bacterial inoculation, the mortality rate was reduced to 6 per cent. When wounds were treated with kaolin alone and then inoculated with bacteria, the mortality rate was 50 per cent, indicating that part of the effectiveness of silver-kaolin appeared to be due to a barrier effect. These results indicate that silver-kaolin may be useful for preventive topical antimicrobial therapy of acute burns or after wound debridement or excision, but is not suitable for therapy of wounds previously colonized by microorganisms.     

A hypothesis of the healing of deep dermal burns and the significance for treatment

Deep dermal burns heal by a combination of new connective tissue formation (granulation) and epithelialization. In deep dermal wounds, which are unhealed after 14 days of conservative treatment, epithelialization can be enhanced by abrasion either alone or combined with provision of a skin graft. Some 42 burn wounds in 25 patients treated by this method have healed quickly and with good results. This method represents a move away from the current trend of early tangential excision and grafting of burn wounds and raises the possibility of developing a regime with the advantages but not the disadvantages of early tangential excision and grafting.     

Composite grafts of autogenic cultured epidermis and glycerol-preserved allogeneic dermis for definitive coverage of full thickness burn wounds: case reports

In patients with extensive deep burns and scarce donor sites autogenic cultured epithelialgrafts (auto-CEG) have become a real alternative. In deep burns the ‘take’ rate of auto-CEG applied directly on subcutaneous fat, fascia or muscle is unreliable and frequently disappointing. The auto-CEG seems to need a dermal base. Improved results have been reported when auto-CEG were applied to the dermal base of a viable cryopreserved donor skin. We extended this principle by using the dermal layer of non-viable glycerol-preserved donor skin (GPDS). We report on two patients with deep burns of 55 and 80 per cent TBSA in whom we used the composite grafting of auto-CEG on non-viable allogeneic dermis from GPDS. The estimated ‘take’ rates were 70 and 77 per cent. The grafted areas remained stable for 4 and 8 months respectively. The two-layer skin substitute gave a permanent cover for full thickness burn wounds of higher quality and better ‘take’ rate than previous results, where the auto-CEG had been grafted directly onto the debrided wounds.     

Phosphorous pentachloride chemical burn--a slowly healing injury.

A 51-year-old chemical engineer sustained phosphorous pentachloride partial skin thickness burns over 20 per cent of his body surface area. Although macroscopically and microscopically the wound seemed to be superficial, the course of clinical healing of this injury was very slow and painful. Retrospectively this burn should have been treated by early excision and grafting.     

Heated laser Doppler flow measurements to determine depth of burn injury

The ability to predict whether burn wounds will heal spontaneously or will require skin grafting is important because of increasing utilization of primary excision and grafting. This study prospectively evaluated the ability of heated laser Doppler flow measurements obtained in the first 48 hours after burn injury to predict whether burn wounds would heal within 3 weeks. Further, the severity of scarring at 3 months was compared with the initial measurements. The measurements predicted healing with 100 percent accuracy and failure to heal with 93 percent accuracy. There was also a significant correlation between initial flow measurements and severity of scarring at 3 months. We conclude that heated laser Doppler flow measurements performed early after burn injury are useful in predicting whether healing is likely to occur, as well as the quality of late scar formation; therefore, the method is useful in selecting patients for primary excision and grafting of burn wounds.     

Conservative surgical debridement as a burn treatment: Supporting evidence from a porcine burn model

In thermal deep‐dermal burns, surgical debridement is normally used in conjunction with skin grafting or skin substitutes and debridement alone as a burn treatment is not usually practiced. The current study addresses whether or not debridement alone would enhance burn wound healing on small deep‐dermal‐partial thickness burns. This was a prospective and blinded experimental trial using a porcine deep‐dermal‐partial thickness burn model. Four burns, approximately 50 cm² in size, were created on each of eight pigs. Two burns from each pig were immediately surgically debrided and the other two were not debrided as the internal control. Hydrate gel together with paraffin gauze were used to cover the burns for four pigs and silver dressings for the other four. Clinical assessment of wound healing was conducted over a 6‐week period. Skin samples were collected at the end of the experiment and histopathological evaluation was performed. The results show thinner scar formation and lower scar height in the debrided compared with nondebrided wounds in the hydrate gel/paraffin gauze groups. There were no statistically significant differences in wound healing assessment between the debrided and nondebrided wounds dressed with silver dressings. This study provides supporting evidence that immediate debridement with an appropriate dressing and without skin grafting may promote wound healing, suggesting its potential benefit for clinical patients.     

四肢高压电烧伤创面的早期处理

目的 总结四肢高压电烧伤创面早期治疗的临床经验.方法 选择2003年1月-2010年12月笔者单位收治的四肢高压电烧伤患者54例,其中男50例、女4例,年龄10～56岁;共有97个患肢,其中上肢67个、下肢30个,致伤部位包括腕及前臂、前臂和肘部及上臂、肩腋部、踝足部、小腿、膝周、大腿及腹股沟,共119处.伤后1～10 d手术,创面切开减张,待患者全身情况相对稳定行下述处理.(1)16个肢体(16处受伤部位)行截肢术,其中5个前臂坏死且肘及上臂受损的上肢行前臂截肢(保留肘关节),并用带蒂背阔肌肌皮瓣修复前臂残端、肘部及上臂创面;1个上臂截肢(保留肩关节)后用带蒂背阔肌肌皮瓣修复残端.(2)95处受伤部位及早清创后用各种血运丰富的组织瓣覆盖.其中5个腕部电烧伤创面行桡动脉重建3个、静脉重建1个、桡动脉及静脉重建1个,1处肘部肱动脉损伤病例行血管重建.(3)8处受伤部位行植皮手术进行修复.统计本组患者术后创面愈合情况,并随访.结果 本组16个肢体截肢术后切口均愈合.5个行血管重建的腕部电烧伤创面,手部供血和(或)静脉回流得以恢复;1例肱动脉损伤病例行动脉重建后血运良好,避免了截肢.5处受损部位组织瓣移植术后远端坏死,其中2处去除坏死组织后予以缝合,3处清创后植皮,创面均愈合.组织瓣下感染8处,其中腕部5处、肘部1处、踝足部2处,经掀起皮瓣或断蒂时再扩创缝合,创面愈合.其余组织瓣均愈合良好.8处受损部位行植皮术后,部分坏死2处,经补植皮片后愈合;其余6处直接愈合.37例患者随访6~12个月,皮瓣外形及质地良好.结论 早期行肢体切开减张、清创、血管重建以及采用修复重建外科技术,是治疗四肢高压电烧伤创面并重建肢体功能、减少截肢率的合理选择.

Abstract：

Objective To summarize the experience of early treatment of high-voltage electric burn wounds in the limbs. Methods Fifty-four patients (50 males and 4 females,aged from 10 to 56 years) with high-voltage electric burn wounds in 97 limbs (67 upper limbs and 30 lower limbs) were hospitalized in our burn wards from January 2003 to December 2010. A total of 119 burn wounds in wrist-forearm,forearm-elbow-upper arm,shoulder-axillary region,ankle-foot,lower leg,around the knee,thigh-inguinal region were treated with incision for decompression within 10 days after burn. Under the premise of relatively stable systemic condition of the patients,certain surgical operations were performed as follows. (1) Sixteen limbs with 16 wounds were amputated,among them forearm amputation was performed for 5 upper limbs with necrosis,with preservation of elbow joints,and the residual wounds of the elbow and upper arm were repaired with pedicled latissimus dorsi musculo-cutaneous flaps;1 upper limb with upper arm amputated,with preservation of shoulder joint,was repaired with pedicled latissimus dorsi musculo-cutaneous flap. (2) Ninety-five wounds were covered with various tissue flaps with abundant blood supply after early debridement,in which 3 brachial arteries,1 vein,1 brachial artery and vein were reconstructed in 5 wrist wounds,artery reconstruction was performed in elbow wound of 1 case with injured brachial artery. (3) Eight wounds were treated with free skin grafting. Wound healing conditions were observed and followed up. Results Wounds in 16 limbs healed after amputation and repair. Blood supply and (or) venous return of hands were restored in 5 wrist wounds after vessel reconstruction. After artery reconstruction,abundant blood supply was observed in 1 case with injured brachial artery and amputation was avoided. Necrosis occurred in distal parts of tissue flaps in 5 wounds after grafting,in which 2 wounds healed after removal of necrotic tissue followed by closure with suture,and 3 wounds healed after debridement and free skin grafting. Tissue flap infection occurred in wrist (5 wounds),elbow (1 wound),ankle-foot (2 wounds),and healed after debridement and suture. The other tissue flaps survived after grafting. Six wounds healed after skin grafting. Partial necrosis occurred in 2 wounds after skin grafting,and they were healed after second skin grafting. Thirty-seven patients were followed up for 6 to 12 months,the skin flaps survived with satisfactory appearance and texture. Conclusions Early extensive compartment release through fasciectomies and escharectomies,early debridement,early vascular grafting,early wound coverage with contemporary reparative and reconstructive surgical techniques are rational options for the treatment of high-voltage electric burns in the limbs.     

Viability of skin subjected to deep partial skin thickness thermal damage: experimental studies

Secondary tissue loss in burn wounds (due to necrosis in the zone of stasis) is interpreted as a sequel of progressive vascular occlusion and dehydration of thermally damaged tissue. In this study on rats, delayed healing represented an additional factor in determining the fate of tissue that had sustained deep partial skin thickness burns. Early revascularization induced by excision and subsequent replantation of the burned skin resulted in survival of a large part of the corium. Replantation reduced the loss of full thickness skin seen in controls left to heal spontaneously to partial loss in treated wounds. The experiments substantiate the theory that deep partial skin thickness thermal damage is at least partly reversible and indicate that with tangential excision of dermal burns a viable part of the corium is sacrificed. This deeper part of the corium can be saved by early excision and replantation.     

A comparison of conservative versus early excision. Therapies in severely burned patients.

Early excision and grafting of small burn wounds is a generally accepted treatment. Early excision of burn injuries greater than 30% total body surface area (TBSA) in adults, however, has not been universally accepted. In this study, 85 patients whose ages ranged from 17 to 55 years with greater than 30% total body surface area (TBSA) burns were randomly assigned to either early excision or topical antimicrobial therapy and skin grafting after spontaneous eschar separation. Mortality from burns without inhalation injury was significantly decreased by early excision from 45% to 9% in patients who were 17 to 30 years of age (p less than 0.025). No differences in mortality could be demonstrated between therapies in adult patients older than 30 years of age or with a concomitant inhalation injury. Children (n = 259) with similar large burns treated by early excision showed a significant increase in mortality with increasing burn size and with concomitant inhalation injury (p less than 0.05). The mean length of hospital stay of survivors was less than one day per per cent of TBSA burn in both children and adults.     

Does rapid wound closure improve survival in older patients with burns?

Seventy-five patients more than fifty years of age were admitted for treatment of burns from January 1, 1986, to December 31, 1987, to two community-hospital-based burn units. Patients were managed by a team of burn surgeons at each unit and early excision and grafting was used whenever possible in deep partial-thickness and full-thickness burns. The extent of burn was charted weekly during hospitalization and rate of wound healing was calculated using linear regression analysis. The mean total percent burn was 26.2 per cent (range, 4-85%). The overall mortality rate was 40 per cent. Mortality rate increased sharply by decade from 17.4 per cent for those aged 50-59 years to 100 per cent for the five patients age 90 and more. Excision and grafting were performed in 40 patients; 35 patients were not operated upon. Although hospitalization was somewhat longer in patients treated surgically, survival was better. Excision and grafting should be used when needed to achieve rapid wound closure in patients more than fifty years of age.     

Topical application of honey in treatment of burns

A total of 104 cases of superficial burn injury were studied to assess the efficiency of honey as a dressing in comparison with silver sulfadiazine gauze dressing. In the 52 patients treated with honey, 91 per cent of wounds were rendered sterile within 7 days. In the 52 patients treated with silver sulfadiazine, 7 per cent showed control of infection within 7 days. Healthy granulation tissue was observed earlier in patients treated with honey (mean 7.4 versus 13.4 days). Of the wounds treated with honey 87 per cent healed within 15 days as against 10 per cent in the control group. Relief of pain, a lower incidence of hypertrophic scar and postburn contracture, low cost and easy availability make honey an ideal dressing in the treatment of burns.     

A newly developed hydrofibre dressing, in the treatment of partial-thickness burns

A newly developed, carboxymethylcellulose based hydrofibre dressing, Aquacel, was tested for the treatment of partial thickness burns. In this study 84 patients with mainly partial thickness burns were included, 76 patients received 1 or 2 days pre-treatment with a topical antimicrobial agent. Clinical behaviour showed a strong resemblance with cadaver skin treatment with respect to adherence to the wound. Adverse reactions, incidence of clinical wound infection, healing time and the need for wound excision and grafting were analysed, as was the final outcome using the 'Vancouver Scar Scale'. The mean size of the wounds treated with the hydrofibre dressing was 6.0% body surface area (min: 1%, max: 18%). Two patients clinically showed signs of a wound infection during treatment, but in general wound cultures were low or negative. In 42 patients (50%) the wounds healed completely within 10 days, in six patients (7%) small defects remained that healed by further treatment with a topical antimicrobial cream. In 36 patients (43%) excision and grafting of the remaining deeper parts of the wounds was performed as this is the standard therapy in the centre for all burned areas that have not healed within 2-3 weeks post-injury. The extent of the surgical procedures was limited since 66.1% of the wound area had healed already at the end of the hydrofibre treatment. In 54 patients the outcome of the treatment after 2-3 months was analysed by means of the Vancouver Scar Scale, which showed favourable results in general, and especially for patients who did not require surgery. Compared to earlier experience with allograft skin it was concluded that hydrofibre dressing is a safe, suitable and easy to use material for treatment of partial thickness burns.     

Efficacy of hydrosurgical excision combined with skin grafting in the treatment of deep partial-thickness and full-thickness burns: A two-year retrospective study

IntroductionDeep partial-thickness and full-thickness burn wounds often undergo tangential excision or escharectomy to expose healthy tissue, combined with skin grafting to promote wound healing. However, conventional tangential excision with the humby knife leads to inevitable damage to the dermis while excising burn tissue due to the lack of precision. Indeed, the preservation of dermal tissue is a key factor in determining wound healing and scar quality. The precision and tissue selectivity of the Versajet Hydrosurgical System has been established for excising burn tissue while preserving dermal tissue. In this study, we retrospectively compared the efficacy of "Hydrosurgical excision combined with skin grafting" and "Conventional tangential excision combined with skin grafting" in treating deep partial-thickness and full-thickness burn wounds to demonstrate that hydrosurgery improved the treatment of deep partial-thickness and full-thickness burns.MethodsA total of 86 patients with deep partial-thickness and/or full-thickness burns with a total burn surface area (TBSA) ≤ 25% from July 2018 to July 2020 were included in this study and were divided into experimental (hydrosurgical excision combined with skin grafting, n = 43) and control (conventional tangential excision combined with skin grafting, n = 43) groups. Parameters were analyzed, including the intraoperative blood loss volume per unit area of grafted skin, surgery duration, wound healing time, skin graft survival, and the treatment costs per unit of burned area. Scar assessment was performed at 1 year with the modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA).ResultNo significant difference was found in male to female ratio, age, weight, TBSA, burn depth, skin grafting area (SKA), skin grafting methods, cases treated with carbon dioxide fractional laser or incidence of inhalation injury, and the incidence of hypovolemic shock between two groups(p > 0.05). Compared with the control group, patients treated with hydrosurgical excision combined with skin grafting experienced less intraoperative blood loss volume per unit area of grafted skin (p < 0.05). The mVSS-TBSA of patients that underwent hydrosurgical excision combined with skin grafting was significantly improved in comparison to the control group (p < 0.01). No significant difference was found in surgery duration, wound healing time, skin graft survival and treatment costs per unit of burned area between the two groups (p > 0.05).ConclusionHydrosurgical excision combined with skin grafting reduced intraoperative blood loss volume per unit area of grafted skin, improved scarring 1-year after injury, and did not increase the treatment costs per unit of burned area. This technique provides a novel alternative for managing deep partial-thickness and full-thickness burn wounds.     

Early surgical excision versus conventional therapy in patients with 20 to 40 percent burns: A comparative study

Using the records of 72 patients treated at the University of Washington Burn Center, this study compared the results of early surgical excision (by 14 days postburn) and autografting to those of autografting after spontaneous separation and bedside debridement of burn eschar. Excised patients had shorter hospitalizations and lower rates of burn wound sepsis and serious burn wound contamination, and less use of potentially toxic antibiotics (p < 0.05) than did the prognostically equivalent group treated before the introduction of early excision. Excised patients required more blood transfusions (p < 0.05), but did not differ significantly from controls in rates of mortality or other inpatient complications, in the number of operations performed, or in the adjusted hospital costs. Evaluation of patients treated over the entire study period for more shallow burns indicated no concurrent change in other aspects of burn care which might account for the observed results. We conclude that early excision and grafting in young, otherwise healthy patients with 20 to 40 percent total body surface area burns that are not likely to heal within 3 weeks is more effective than the more traditional management of slow wound separation and debridement.     

Acute electrical burns: a 10-year clinical experience

We have reviewed 113 cases of electrical burns treated at the Cook County Hospital Burn Center during the past 10 years. There were 3265 acute burn admissions during this period. the incidence of electrical burns being 3.5 per cent. Low-voltage electrical burns occurred in 82 of the 113 patients (73 per cent). These were caused mostly by household electricity supplies, occurred in children, and were preventable. Arc burns of the perioral region were allowed to heal spontaneously. The surgical management of other arc burns and flash burns was similar to that for most deep burn wounds. The incidence of high-voltage electrical injuries was 27 per cent in our series. Over 50 per cent of these injuries were not work-related. These tended to occur outside the home in young adult males and were also frequently preventable. None of these patients developed acute renal failure. Early surgical debridement of devitalized tissue with allografting, followed by delayed definitive wound closure or amputation prevented septic complications. Early fasciotomy appeared to have little effect on complete limb salvage. Limb loss continues to be the major factor contributing to the high morbidity associated with these injuries. All 113 patients survived. We attribute this to early transfer of patients to our Burn Unit, aggressive fluid resuscitation, continuous haemodynamic and metabolic support, and early surgical intervention.     

Thermographic assessment of hand burns

Twenty-three patients with 32 burned hands were studied thermographically within 48 h of injury to investigate the potential value of thermography in the assessment of the depth of hand burns. Superficial and deep partial thickness burns were treated conservatively, with excision and grafting of those which had not healed by 2-3 weeks after injury. This delayed surgery group and the healed group were retrospectively analysed to determine the predictive value of the initial clinical and thermographic assessments of the depth of the burns. Full skin thickness burns were excised and grafted within 5 days and were not included in the study. Initial thermographic assessment correctly predicted the outcome (whether healed or excised and grafted) in 33 of 36 burns. This relationship was highly significant. Initial clinical assessment of depth had no significant relationship with the time taken to heal. Thermography may help in the selection of patients who might benefit from early surgery.     

Cutaneous microcirculatory assessment of the burn wound is associated with depth of injury and predicts healing time

Rationale

Current trends for the treatment of deep partial thickness and full-thickness burns include early excision and skin grafting. In this study we retrospectively evaluated the ability of Laser Doppler Flowmetry (LDF), taken within 24 h of the burn to predict: (1) burn wound depth and (2) wounds which would heal in less than 21 days.

Method

The Laser Doppler Flowmeter (O2C, LEA Medizintechnik, Germany) was employed to non-invasively measure the cutaneous microcirculation of 173 selected areas on 28 patients who suffered burns.

Results

A distinct association between initial flow (<24 h after burn injury) and the clinical assessment of depth of burn wounds was observed. Wounds demonstrating an initial blood flow of >100 AU were, in 93.1% of cases, correctly (positively) predicted for spontaneous healing within 21 days. A blood flow of <100 AU (negatively) predicted in 88.2%, those wounds which would not go on to heal within 21 days. Sequential measurement analysis (<24 h, 3 days after injury and 6 days after injury) revealed no significant decrease in skin perfusion velocity or flow rate.

Conclusion

LDF can provide immediate results for early determination of burn wound depth and is useful in selecting patients for conservative treatment of their burn wounds.     

Clinical application and viability of cryopreserved cadaveric skin allografts in severe burn: A retrospective analysis

Introduction

Cadaveric cutaneous allografts are used in burns surgery both as a temporary bio-dressing and occasionally as definitive management of partial thickness burns. Nonetheless, limitations in the understanding of the biology of these grafts have meant that their role in burns surgery continues to be controversial.

Methods

A review of all patients suffering 20% or greater total body surface area (TBSA) burns over an eight year period that received cadaveric allografts were identified. To investigate whether tissue viability plays a role in engraftment success, five samples of cryopreserved cadaveric cutaneous allograft processed at the Donor Tissue Bank of Victoria (DTBV) were submitted to our laboratory for viability analysis using two methods of Trypan Blue Exclusion and tetrazolium salt (MTT) assays.

Results

During the study period, 36 patients received cadaveric allograft at our institution. The average total burn surface area (TBSA) for this group of patients was 40% and all patients received cadaveric skin as a temporizing measure prior to definitive grafting. Cadaveric allograft was used in complicated cases such as wound contamination, where synthetic dressings had failed. Viability tests showed fewer than 30% viability in processed allografts when compared to fresh skin following the thawing process. However, the skin structure in the frozen allografts was histologically well preserved.

Conclusion

Cryopreserved cutaneous cadaveric allograft has a positive and definite role as an adjunct to conventional dressing and grafting where available, particularly in patients with large TBSA burns. The low viability of cryopreserved specimens processed at DTBV suggests that cell viability in cadaveric allograft may not be essential for its clinical function as a wound dressing or even as permanent dermal substitute.