Exploring the effects of wound dressings and patient positioning on skin integrity in a pediatric burn facility

Although literature on the subject is scant, in practice, pressure ulcers in the pediatric burn population remain a challenge. An interdisciplinary team at an urban pediatric burn institution treats a population (average age 8 years, range 1 month to 21 years) that includes children too young or unable to articulate pressure-related pain from dressings or positioning techniques. After pressure ulcer data collection procedures were instituted, it was observed that elastic bandages, wet operating room dressings, and positioning appeared to contribute to pressure ulcer occurrence. To better understand the patient's experience and educate staff, an informal study was conducted by an interdisciplinary committee of clinicians to assess the amount of pressure in mm Hg created on bony prominences by care procedures. Three staff members volunteered and were placed in elastic dressings and various commonly used positions for several minutes and three pressure measurements were obtained. Pressure readings of 40 and 56 mm Hg were common, causing pain and placing a person at risk for skin ulceration. The information was used to educate staff on how to maintain therapeutic efficacy without compromising skin integrity and causing pain. Lectures and hands-on demonstrations elucidated correct dressing application. The committee continues to provide education to all staff members on methods to prevent pressure ulcers from occurring in the high-risk burn patient population and ways to reduce the use of elastic wraps and improve patient positioning.     

An outbreak of infections with Acinetobacter calcoaceticus in burn patients: contamination of patients' mattresses

During a 21-month period Acinetobacter calcoaceticus was the most common organism causing infections in a university burn center. Forty-three of 103 patients admitted became infected with this organism. Risk factors associated with burn wound colonization with Acinetobacter included larger burns and Foley catheter use; however, only a longer duration of hospitalization was an independent discriminator of colonization. Infection-control measures, including strict isolation and closure and repainting of the burn unit, did not prevent the transmission of Acinetobacter. An investigation found that wet mattresses served as environmental reservoirs of Acinetobacter. This finding led to a policy of discarding each patient's mattress on the day of the patient's discharge from the burn unit. Life table analysis demonstrated that this intervention led to a reduced risk of burn wound colonization with Acinetobacter (P less than .05) and ultimately resulted in the complete elimination of the organism from the burn unit.     

Dextran hydrogel scaffolds enhance angiogenic responses and promote complete skin regeneration during burn wound healing

Neovascularization is a critical determinant of wound-healing outcomes for deep burn injuries. We hypothesize that dextran-based hydrogels can serve as instructive scaffolds to promote neovascularization and skin regeneration in third-degree burn wounds. Dextran hydrogels are soft and pliable, offering opportunities to improve the management of burn wound treatment. We first developed a procedure to treat burn wounds on mice with dextran hydrogels. In this procedure, we followed clinical practice of wound excision to remove full-thickness burned skin, and then covered the wound with the dextran hydrogel and a dressing layer. Our procedure allows the hydrogel to remain intact and securely in place during the entire healing period, thus offering opportunities to simplify the management of burn wound treatment. A 3-week comparative study indicated that dextran hydrogel promoted dermal regeneration with complete skin appendages. The hydrogel scaffold facilitated early inflammatory cell infiltration that led to its rapid degradation, promoting the infiltration of angiogenic cells into the healing wounds. Endothelial cells homed into the hydrogel scaffolds to enable neovascularization by day 7, resulting in an increased blood flow significantly greater than treated and untreated controls. By day 21, burn wounds treated with hydrogel developed a mature epithelial structure with hair follicles and sebaceous glands. After 5 weeks of treatment, the hydrogel scaffolds promoted new hair growth and epidermal morphology and thickness similar to normal mouse skin. Collectively, our evidence shows that customized dextran-based hydrogel alone, with no additional growth factors, cytokines, or cells, promoted remarkable neovascularization and skin regeneration and may lead to novel treatments for dermal wounds.     

Impact of hypernatremia on burn wound healing: results of an exploratory, retrospective study

Severely burned patients need extensive initial fluid resuscitation. Formulas to calculate fluid needs during burn shock are well established. However, protocols for normalizing circulating fluid volume after cellular integrity has recovered do not exist. Resultant electrolyte shifts can cause hypernatremia, a possible sign of hypovolemia, which may in turn result in decreased tissue perfusion, subsequently affecting burn wound healing. The purpose of this retrospective chart review was to explore the hypothesis that hypernatremia in burn patients is a possible sign of systemic dehydration and that dehydration may affect burn wound skin graft take. Medical chart data from otherwise healthy burn victims with deep partial-thickness burns (total burn surface area [TBSA] >10%) who underwent skin grafting 7 days post injury were reviewed. Thirty (11 female; 19 male) patients with an average TBSA of 30% (± 11%) and an Abbreviated Burn Severity Index (ABSI) score of 7.9 (± 1.8) were included. Of those, 17 had normal average serum levels between day 2 and 6 following injury and 13 developed hypernatremia (serum sodium ≥146 mmol/L) an average of 5.5 days (± 1.5) after injury. Patients in this group underwent an average of 1.3 (± 0.8) re-grafting procedures compared to 0.35 (± 0.5) for patients without hypernatremia (P = 0.001). There was good correlation (r = 0.525) between daily infusion-diuresis ratios (IDR) and serum sodium levels, as well as between serum sodium levels and re-skin grafting occurrences (r = 0.62). The results indicate that research to confirm that hypernatremia is an indicator of dehydration and affects skin graft take is warranted and that protocols to optimize fluid volume following burn shock treatment are needed.     

The use of composite acellular allodermis-ultrathin autograft on joint area in major burn patients--one year follow-up

Scar contracture is a major long-term sequelae of meshed split-thickness skin grafts in the case of full-thickness burn injuries, and especially in joint areas. Severe contracture around joints may lead to loss of mobility. The thickness of the dermis in the autograft plays a major role in the functional and cosmetic outcomes of the third degree burn. How to replace lost dermis is a major problem in skin restoration following severe burns. The human allograft skin (AlloDerm) is an acellular dermal matrix with normal collagen bundling organization and intact basement membrane complex. We present 12 cases of clinical application of a composite grafting technique in which the allogeneic skin (AlloDerm) provided source of dermis, and an ultrathin autograft (0.004-0.006 inch in thickness) provided epidermis. In these patients, The composite grafts were applied to full-thickness burn wounds over various articular skin surfaces. The average skin graft take rate was 91.5%. These ultrathin autografts allow the donor sites to heal faster. The mean time of donor site reepithelization was 6 days. All patients had a nearly normal range of joint motion (average 95% of normal) after one year's follow up. Wound assessment over time has shown supple skin that has been resistant to trauma and infection. The cosmetic results were judged to be fair to good by surgeons and patients after one year's follow up.     

Towards personalized Internet health information: the STEPPS architecture

PRIMARY OBJECTIVE: STEPPS (STructured Evaluated Personalized Patient Support) proposes a strategy for integration of electronic patient records with Internet health-related content and its consequent use in personalized information retrieval for patient education. The application domain is the post-discharge support of burn patients in the Netherlands. MATERIALS AND METHODS: We developed an electronic patient record interface for structured data collection in burn care. The system's thesaurus was projected to UMLS terms and the corresponding codes were incorporated in our software. A list of topics central to burn patient education was identified and a collection of related Web pages was compiled using meta-search software (Copernic2001Pro). The HTML pages were filed into catalogues by the Collexis indexing-matching software, using the UMLS Metathesaurus as indexing vocabulary. RESULTS: The bilingual (English and Dutch) structured data interface is currently used to create a database of retrospective patient data. Each patient's profile, i.e. set of characteristics employed to personalize information retrieval, can be automatically extracted. We have assembled a collection of more than 2500 Internet pages containing relevant information for burn patients. When patient data is available, the Collexis matching engine will accept the patient's profile as input and retrieve the most relevant HTML documents available in the catalogues. DISCUSSION: We have addressed some basic issues around the technical feasibility of linking electronic patient record data to online content. Although the functionality of STEPPS is not yet optimal, it contributes to the efforts towards improved relevance of information retrieval. Electronic patient record applications in conjunction with Internet resources can give a significant boost to the availability of tailored health education material. In this context, quality assurance of online health information is an indispensable element.     

异体无细胞真皮基质用于深度烧伤创面的研究

以同种尸体网状中厚皮片为材料，经一系列理化方法清除皮片中的新有细胞成分，制得无细胞真皮基质，与自体超薄皮片一期或二期以复合皮的形式移植于深度烧伤创面上，结果为复合皮成活率高，外观，质地，弹性良好，无细胞真皮基质用于深度烧伤创面取得了令人满意的临床效果。     

Superoxide radical involvement in the pathogenesis of burn shock

The pathogenesis of burn shock syndrome involves the production of superoxide radicals which are first generated in the burned skin. They are responsible for an increase in vascular permeability with loss of plasma, which results in hemoconcentration and hypovolemia. The resulting systemic hypoperfusion leads to a generalized production of superoxide radicals and subsequent cellular damage. Prior administration of allopurinol or superoxide dismutase increases the survival rates of mice subjected to burn shock.     

Immunological and immunotherapeutic studies on the model of mice following thermic injury

A burn toxin, which is discussed as reason of the burn disease by Schoenenberger et al., was isolated from burned skin of mice and the immunological reactions to this antigen were evaluated in burned mice longitudinally at several intervals after the trauma. We determined the specific antibodies against the burn toxin by means of the passive hemagglutination test, the burn toxin binding cells by means of the antigen specific rosette technique and the cell-mediated immunity using the macrophage electrophoretic mobility test (MEM-test). A rise of the burn toxin-specific cells could be observed with maximum at day 4 and a cell-mediated immunity between day 11 and day 13. Antibody titre was on the background about an interval of 3 weeks. Pretreatment with burn toxin or posttraumatic i. p. application of antibodies against burn toxin from rabbits eliminated primary death of mice with lethal burns. No correlation seemed to exist between the effect of treatment with antibodies and the antibody titre in the first days following burns.     

Epidemiology of infections with Pseudomonas aeruginosa in burn patients: the role of hydrotherapy.

Pseudomonas aeruginosa remains a cause of serious wound infection and mortality in burn patients. By means of restriction fragment length polymorphism analysis and a DNA probe for the pilin gene of Pseudomonas, a lethal strain of nosocomial P. aeruginosa was identified as the cause of an outbreak of wound infections among burn patients. Environmental surveys suggested an association of the outbreak with hydrotherapy provided to many patients in a common facility. In a trial of burn wound care without hydrotherapy, overall mortality was reduced significantly, mortality associated with pseudomonas sepsis was eliminated, and the strain of P. aeruginosa associated with earlier mortality was eradicated. Moreover, fewer nosocomial pseudomonas infections, lower levels of pseudomonas resistance to aminoglycoside antibiotics, significantly fewer pseudomonas infections of skin graft donor sites, and later appearance of Pseodomonas species in burn patients were found during the period when hydrotherapy was not used.     

Case Report: Severe Skin Burn at the Site of the Indifferent Electrode After Radiofrequency Catheter Ablation of Typical Atrial Flutter

Although radiofrequency (RF) catheter ablation has been shown to be an effective treatment strategy in patients with supraventricular tachycardia, RF ablation may lead to potentially serious complications. We describe a case of a 65-year old man who was transferred for catheter ablation of typical atrial flutter. 21 RF applications (mean energy: 81±9 watts) were applied in the temperature-controlled mode (70[emsp4 ]°C) between a 8-mm tip electrode and an indifferent electrode using a high-power RF generator (100 watts) until bi-directional atrial isthmus block was achieved. After the procedure, a third-degree skin burn (10×2[emsp4 ]cm) was observed at the lateral edge of the adhesive indifferent electrode whereas the medial edge of the electrode was not fully attached to the skin surface. This case is one out of 1128 ablation procedures (0.09%) at our institution using a high-power RF generator. The present study demonstrates a severe skin burn induced by mal-attachment of an indifferent electrode during RF ablation. Long RF energy application times, high-power settings, and heavy sedation may have contributed to the observed severity of skin damage.     

Radionecrosis induced by cardiac imaging procedures: a case study of a 66-year-old diabetic male with several comorbidities

Radionecrosis is a rare sequitur of cardiac catheterization and imaging procedures. A 66-year-old diabetic male with several comorbidities developed a scapular burn immediately after the last of 3 cardiac catheterization and stenting procedures conducted over a 3-year period. The burn subsequently developed into a large eschar that required extensive debridement, a prolonged treatment of hyperbaric oxygen therapy, and plastic surgery to heal. Wound healing was compromised by the patient's diabetes and a potentially long course of steroids prescribed for other medical problems. Primary clinicians should be aware of suspicious-looking wounds that develop subsequent to cardiac catheterizations, especially in diabetic patients.     

Infliximab in experimental alkali burns of the oesophagus in the rat

BACKGROUNDS: We aimed to investigate the efficacy of infliximab, a chimeric TNF-alpha antibody, in the prevention of fibrosis in an experimental alkaline burn of the oesophagus in the rat. METHODS: Thirty-two Wistar albino rats divided into four experimental groups. Caustic oesophageal burn was induced by applying 37.5% NaOH to the distal oesophagus. Infliximab was given at a dose of 5 mg/kg via the intraperitoneal route. Group A (sham) animals were uninjured, group B had untreated oesophageal burns, group C had oesophageal burns treated with a single dose of infliximab on the first day, and Group D had oesophageal burns treated with infliximab on the first and 14th days. Efficacy of the treatment was assessed on the 28th-day by measuring stenosis index of the oesophagus and histopathological damage score, and biochemically by determining tissue hydroxyproline content. RESULTS: There was no significant difference between the Group B and the infliximab treated Groups C and D in means of tissue hydroxyproline content and histopathological damage scores. Stenosis index was not significantly different between the Group B, Group C, and Group D. CONCLUSION: Anti-TNF-alpha treatment with infliximab does not ameliorate the degree of fibrosis in alkali burns of the oesophagus in the rat. Further evaluation of inflammatory and immunological events leading to stricture in alkaline oesophageal burns may provide new perspectives for the treatment of alkaline oesophageal burns.     

Microvascular exchange during burn injury: IV. Fluid resuscitation model

The present work is a continuation of studies concerned with mathematical modelling and simulation of microvascular fluid and protein exchange following burn injuries [Bert et al.: Circulatory Shock 28: 199-219, 1989: Bowen et al.: Circulatory Shock 28: 221-233, 1989]. The model has been extended to include the effects of different types of fluid resuscitation on the circulatory and microvascular exchange systems. The model and a statistical fitting procedure were used to find the ranges of fitting parameter values that best describe the changes in interstitial fluid volume and protein mass as well as transcapillary protein extravasation for three sets of experiments (no resuscitation, resuscitation with Ringer's or resuscitation with plasma). Typical changes in mass exchange related parameters postburn that resulted in simulation predictions which were a good fit to the experimental data include: an increase in the large pore pathway for protein of 100 times in the injured skin and 5 times in non-injured skin and skeletal muscle, an increase in fluid filtration coefficients in injured skin of 10 times and an instantaneous decrease of 50% in the area available for exchange in injured skin at the time of the burn.     

Synthesis of vitamin D in skin after burns

Severe burn injury is associated with vitamin D deficiency, low bone turnover, and abnormalities in calcium homoeostasis. Patients do not routinely receive vitamin D supplementation and sun exposure is currently not controlled. By analysis of skin biopsy samples for vitamin D3 precursors after exposure to ultraviolet B light we found that the conversion of 7-dehydrocholesterol to previtamin D3 was reduced in children a mean of 14 months after the burn. Low serum 25-hydroxyvitamin D concentrations were also found. We conclude that vitamin D supplementation is necessary after burn injury.     

Fatal systemic fluorosis due to hydrofluoric acid burns

A patient with a 70% hydrofluoric acid burn developed systemic dissemination of fluoride ion from a 9% to 10% body surface area exposure on the lower extremities. Severe hypocalcemia and intractable ventricular arrhythmias resulted. This case is the second documented occurrence of hypocalcemia from hydrofluoric acid burns. It is the first case to document myocardial injury and systemic fluorosis from a skin burn.     

Emergency treatment of burn injury

Emergency physicians often encounter patients who have suffered burn injuries. Most are minor in nature but approximately 100,000 a year are true emergencies. Regardless of severity, the emergency physician and staff must possess the evaluative skills and knowledge of current treatment regimens to appropriately treat these patients. Burn injuries are classified according to extent of body surface involved and depth of skin injury. This classification, together with an understanding of the pathophysiology based on the source of injury, will allow categorization and thereby determine initial therapy and definitive management. The treatment of minor burns focuses on three primary objectives: relief of pain, prevention of infection and additional trauma, and minimizing of scarring and contracture. With major burns the first hours after injury are characterized by life-threatening problems. Airway injuries, trauma other than the burn injury, treatment of shock, and pain relief are of the highest priority, overriding the management of the burn wound itself. The care that the minor burn victim receives is critical to ultimate outcome; the care that the major burn victim receives is critical to both immediate survival and ultimate outcome. The emergency physician must provide optimal care to ensure optimal results.     

Neoplastic/paraneoplastic dermatitis, fasciitis, and panniculitis

The skin changes outlined in this article can be important clues to an underlying malignancy. Paraneoplastic dermatoses are skin disorders associated with an underlying neoplasm and whose course parallels that of the neoplasm. Recognizing these skin presentations leads to early diagnosis and management of the underlying malignancy. Effective treatment of the associated neoplasm often leads to improvement of the cutaneous manifestations and should be the primary focus of each patient's management.     

Endogenous nickel release as a possible cause of coronary vasoconstriction and myocardial injury in acute burn of rats

The aim of the present study was to test the hypothesis that endogenous nickel release may play a role in myocardial depression in the acute phase of burn shock in rats. Serum nickel concentration (Se-Ni) measured by atomic absorption spectrophotometry, the sensitivity of isolated perfused hearts to exogenous nickel chloride (0.01 mumol/l), and ultrastructural myocardial alterations, as well as subcellular localization of endogenous Ni by the dimethylglyoxim method, were analyzed in the first week after standardized third-degree full thickness skin thermal burn covering 20-25% of the body surface. In the first 2 days after burn a significant fivefold increase of Se-Ni concentration was observed which leveled off by the end of the first postburn week. The coronary vascular resistance increasing effect of exogenous NiCl2 grew significantly in the first 3 h after burn, decreased to control in the 2nd postburn day, and increased again in the second half of the week after burn. Both ultrastructural damages and nickel containing reaction products could be observed in the myocardium 7 days after burn. The experimental results suggest that endogenous nickel release may play a role in coronary vasospasm and consequent myocardial depression in the acute phase of burn shock in the rat.     

Evaluating the use of hydrogel sheet dressings in comprehensive burn wound care

Comprehensive burn wound management comprises a challenging spectrum of acute, chronic, traumatic, and surgical wounds with a wide range of anatomical locations and depth. When processing of porcine and cadaver skin - items central to burn care management strategies - became problematic at one Hong Kong hospital, a commercially available cost-effective substitute dressing was urgently needed. After reviewing the characteristics and availability of several dressings, hydrogel sheet dressings were evaluated in a range of burn wound applications. Fifty wounds, including skin graft donor sites, acute partial-thickness burns, and excised full-thickness wounds in 30 consecutive patients were managed with the dressing. It also was used as a temporary dressing over meshed autografts and cultured cell applications. When hydrogel is applied, it is nonadherent; nursing staff reported general ease of use. When applying hydrogel to awkward areas (eg, posterior thigh donor sites), assistance was required to stabilize the large sheets while securing retention dressings. Patients reported no pain during and between dressing changes. No adverse events occurred. Clinical outcomes met or exceeded expectations and guidelines for dressing application and removal were developed. Based on the results obtained, prospective, randomized, controlled clinical studies to ascertain the efficacy and effectiveness of this dressing were initiated. Broader exploration of the advantages of hydrogel use in burn wound care is warranted.