Roy M. Kimble

Treatment of partial-thickness burns: A prospective, randomized trial using transcyte

Background:  The purpose of the present study was to compare the effectiveness of three burns dressings (TransCyte, a bio‐engineered skin substitute; Biobrane; and Silvazine cream (silver sulphadiazine and 0.2% chlorhexidine)), in treating children with partial‐thickness burns. The primary objective was to determine the days until ≥90% re‐epithelialization. The secondary objectives were to evaluate the number of wounds requiring autografting and the number of dressing changes/local wound care required.

Collagen in the scarless fetal skin wound: Detection with Picrosirius-polarization

Our group has developed an ovine model of deep dermal, partial‐thickness burn where the fetus heals scarlessly and the lamb heals with scar. The comparison of collagen structure between these two different mechanisms of healing may elucidate the process of scarless wound healing. Picrosirius staining followed by polarized light microscopy was used to visualize collagen fibers, with digital capture and analysis. Collagen deposition increased with fetal age and the fibers became thicker, changing from green (type III collagen) to yellow/red (type I collagen). The ratio of type III collagen to type I was high in the fetus (166), whereas the lamb had a much lower ratio (0.2). After burn, the ratios of type III to type I collagen did not differ from those in control skin for either fetus or lamb. The fetal tissue maintained normal tissue architecture after burn while the lamb tissue showed irregular collagen organization. In conclusion, the type or amount of collagen does not alter significantly after injury. Tissue architecture differed between fetal and lamb tissue, suggesting that scar development is related to collagen cross‐linking or arrangement. This study indicates that healing in the scarless fetal wound is representative of the normal fetal growth pattern, rather than a “response” to burn injury.

Vitronectin: Growth Factor Complexes Hold Potential as a Wound Therapy Approach

Topical administration of growth factors has displayed some potential in wound healing, but variable efficacy, high doses, and costs have hampered their implementation. Moreover, this approach ignores the fact that wound repair is driven by interactions between multiple growth factors and extracellular matrix (ECM) proteins. We report herein that complexes comprising IGF and IGF-binding proteins bound to the ECM protein vitronectin (VN) significantly enhance cellular functions relevant to wound repair in human skin keratinocytes in two- and three-dimensional in vitro cell models and are active, even in the presence of wound fluid. Moreover, these responses require activation of both the IGF receptor and the VN-binding alpha(v) integrins. Further, we assessed the complexes as a topical agent in the treatment of deep dermal partial thickness burns in a porcine model. This pilot study revealed that the complexes may hold promise as a wound healing therapy. Critically, the significant responses observed in vitro and the encouraging preliminary data in vivo were obtained with nanogram doses of growth factors. This suggests that coupling delivery of growth factors to ECM proteins such as VN may ultimately prove to be a more effective strategy for developing a wound healing therapy.

MANAGEMENT OF EXTRAVASATION INJURIES

Background: Various agents have been implicated in causing tissue necrosis after intravenous infusions have extravasated. These include solutions of calcium, potassium, bicarbonate, hypertonic dextrose, cytotoxic drugs and antibiotics. Views on management of these injuries differ, and range from a non‐operative conservative approach to early debridement and grafting.

A review of first aid treatments for burn injuries

Throughout history there have been many different and sometimes bizarre treatments prescribed for burns. Unfortunately many of these treatments still persist today, although they often do not have sufficient evidence to support their use. This paper reviews common first aid and pre-hospital treatments for burns (water--cold or warm, ice, oils, powders and natural plant therapies), possible mechanisms whereby they might work and the literature which supports their use. From the published work to date, the current recommendations for the first aid treatment of burn injuries should be to use cold running tap water (between 2 and 15 degrees C) on the burn, not ice or alternative plant therapies.

Prevalence, comorbidity and course of trauma reactions in young burn-injured children

BACKGROUND Infants, toddlers and preschoolers are the highest risk group for burn injury. However, to date this population has been largely neglected. This study examined the prevalence, onset, comorbidity and recovery patterns of posttrauma reactions in young children with burns. METHODS Parents of 130 unintentionally burned children (1-6 years) participated in the study. The Diagnostic Infant Preschool Assessment was conducted with parents at 1 and 6 months postinjury. RESULTS The majority of children were resilient. However, 35% were diagnosed with at least one psychological disorder, there was a high rate of comorbidity with posttraumatic stress disorder, and 8% of children did not experience recovery in distress levels over the course of 6 months. CONCLUSIONS These outcomes are likely to have serious repercussions for a young childs medical and psychosocial recovery as well as their normal developmental trajectories. It is recommended that screening, prevention and early intervention resources are incorporated into paediatric health care settings to optimise childrens psychological adjustment following burn injury.

Gastroschisis: determinants of neonatal outcome

Abstract. This retrospective study elicits information regarding the dependence of neonatal outcome in gastroschisis upon: (1) the mode of delivery, (2) place of birth, (3) time for birth to surgery, (4) method of closure, (5) time from operation to commencement of first enteral feeds. The neonatal intensive care database from five major tertiary centres was used to identify 181 neonates with gastroschisis from 1990 to 2000. There were 8 deaths. There were no significant differences in outcome for infants delivered vaginally (102) versus Caesarean section (79), those born near the tertiary centre (133) as compared to infants born away (48), ones operated within 7 hours (125) compared with those operated after 7 hours (56), with delayed closure (30) versus primary closure (151). Neonates fed within 10 days of operation (85) had significantly lower incidence of sepsis, duration of TPN and hospital stay when compared to those fed after 10 days (96). Early commencement of feeds decreases the incidence of sepsis, duration of total parenteral nutrition (TPN) and hospital stay. Place of delivery, mode of delivery, time to surgery and type of closure do not influence neonatal outcome.

Virtual reality for acute pain reduction in adolescents undergoing burn wound care: A prospective randomized controlled trial

BACKGROUND Effective pain management remains a challenge for adolescents during conscious burn wound care procedures. Virtual reality (VR) shows promise as a non-pharmacological adjunct in reducing pain. AIMS This study assessed off-the-shelf VR for (1) its effect on reducing acute pain intensity during adolescent burn wound care, and (2) its clinical utility in a busy hospital setting. METHODS Forty-one adolescents (11-17 years) participated in this prospective randomized controlled trial. Acute pain outcomes including adolescent self-report, nursing staff behavioral observation, caregiver observation and physiological measures were collected. Length of procedure times and adolescent reactions were also recorded to inform clinical utility. RESULTS Nursing staff reported a statistically significant reduction in pain scores during dressing removal, and significantly less rescue doses of Entonox given to those receiving VR, compared to those receiving standard distraction. For all other pain outcomes and length of treatment, there was a trend for lower pain scores and treatment times for those receiving VR, but these differences were not statistically significant. CONCLUSION Despite only minimal pain reduction achieved using off-the-shelf VR, other results from this trial and previous research on younger children with burns suggest a customized, adolescent and hospital friendly device may be more effective in pain reduction.

Multi-modal distraction. Using technology to combat pain in young children with burn injuries

BACKGROUND The use of non-pharmacological pain management remains adhoc within acute paediatric burns pain management protocols despite ongoing acknowledgement of its role. Advancements in adult based pain services including the integration of virtual reality has been adapted to meet the needs of children in pain, as exemplified by the development of multi-modal distraction (MMD). This easy to use, hand held interactive device uses customized programs designed to inform the child about the procedure he/she is about to experience and to distract the child during dressing changes. AIM (1) To investigate if either MMD procedural preparation (MMD-PP) or distraction (MMD-D) has a greater impact on child pain reduction compared to standard distraction (SD) or hand held video game distraction (VG), (2) to understand the impact of MMD-PP and MMD-D on clinic efficiency by measuring length of treatment across groups, and lastly, (3) to assess the efficacy of distraction techniques over three dressing change procedures. METHODS A prospective randomised control trial was completed in a paediatric tertiary hospital Burns Outpatient Clinic. Eighty participants were recruited and studied over their first three dressing changes. Pain was assessed using validated child report, caregiver report, nursing observation and physiological measures. RESULTS MMD-D and MMD-PP were both shown to significantly relieve reported pain (p<or=0.05) and reduce the time taken for dressings (p<or=0.05) compared to SD and VG. The positive effects of both MMD-D and MMD-PP were sustained with subsequent dressing changes. CONCLUSIONS The use of MMD as a preparatory or a distraction tool in an outpatient burns clinic offered superior pain reduction across three dressing changes to children when compared to standard practices or hand held video games. This device has the potential to improve clinic efficiency with reductions in treatment lengths.

The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes : A randomised controlled trial

In children, the pain and anxiety associated with acute burn dressing changes can be severe, with drug treatment alone frequently proving to be inadequate. Virtual reality (VR) systems have been successfully trialled in limited numbers of adult and paediatric burn patients. Augmented reality (AR) differs from VR in that it overlays virtual images onto the physical world, instead of creating a complete virtual world. This prospective randomised controlled trial investigated the use of AR as an adjunct to analgesia and sedation in children with acute burns. Forty-two children (30 male and 12 female), with an age range of 3-14 years (median age 9 years) and a total burn surface area ranging from 1 to 16% were randomised into a treatment (AR) arm and a control (basic cognitive therapy) arm after administration of analgesia and/or sedation. Pain scores, pulse rates (PR), respiratory rates (RR) and oxygen saturations (SaO2) were recorded pre-procedurally, at 10 min intervals and post-procedurally. Parents were also asked to grade their childs overall pain score for the dressing change. Mean pain scores were significantly lower (p=0.0060) in the AR group compared to the control group, as were parental pain assessment scores (p=0.015). Respiratory and pulse rates showed significant changes over time within groups, however, these were not significantly different between the two study groups. Oxygen saturation did not differ significantly over time or between the two study groups. This trial shows that augmented reality is a useful adjunct to pharmacological analgesia.