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Section Editor's Message
Advances in Burn Care
April 2008
When considering what to put in the “Advances in Burn Care” section this time, I was hard pressed to find enough that was new in burn care to fill an entire issue. I decided instead to devote this issue of WOUNDS to the history of burn care. This way, we all can remember from whence we came in burn care.
Two articles are written by Chester Paul, MD. I asked Dr. Paul to write a review of the history of burn grafting. He believed that the topic was too large in scope for one review, and decided to write one article on skin grafting and another on the use of skin substitutes. Dr. Paul presents these topics in his usual entertaining style. I am sure you will enjoy these two articles.
I have found the dermal replacement products to be advantageous. It is well known that the thicker the skin, the less contraction there will be at the recipient site, but that there will be more scarring and a longer time to heal at the donor site. By using the dermal replacement products, we can place thick skin at the site of injury while taking very thin donors. At our unit, we have had a great deal of experience with both Integra™ and AlloDerm®. We asked our patients, who had been treated with both AlloDerm and Integra, which product they preferred. We found that our patients cannot really tell the difference between the two products.1
Since the loss of Transcyte™ there has been a resurgence in the use of xenografts in our unit. We now use xenografts on all the burns where we had previously used Transcyte, and although we have not done a formal study, I would say with much the same success as we had previously reported with Transcyte.2
Dr. Al-Mousawi, et al thoroughly review the metabolic effect burn injury and the interventions that have been used to modulate that response. The group in Galveston, Texas is lead by Dr. David Herndon, a leader in advancing the knowledge in this aspect of burn care; their contribution to this issue is greatly appreciated. Certainly in my mind, the most important modulation of burn wound metabolism is early excision and wound closure, but there are some cases when that cannot be accomplished. In that situation, one mainstay of burn care is, of course, topical antimicrobial use to protect against infection.
Dr. David Barillo reviews the historical use of topical antimicrobials in burn care. Dr. Barillo has had an interest in topical agents for many years, as his thorough review clearly demonstrates. His discussion did not include Silvazine™, which deserves mentioning. Silvazine is a white hydrophilic cream containing silver sulphadiazine and chlorhexidine digluconate—this was the most commonly used topical agent in Australia until Acticoat™ more recently gained greater popularity.3
Burn care cannot proceed if patients are not adequately resuscitated. Improvements in resuscitation of a patient with a burn have allowed all other advances in burn care to proceed. I say this simply because resuscitation allows the patient to survive long enough for the other therapies to be of any importance. I hope you find Dr. Hansen’s account of the history of burn resuscitation informative and interesting. At this point, the medical community has gotten the message that burn victims require fluid resuscitation. We have noticed in our unit that the starting point of resuscitation (the initial fluid rate) has great influence on the amount of fluid required. When patients are started at a higher hourly rate than any of the formulas commonly used today, it is quite difficult to get them weaned down to rates projected by the formulas without them showing signs of decreased profusion. I believe this is one factor that has lead to “fluid creep.”
Finally, Dr. Mayer Tenenhaus reviews the history of flaps and burn reconstruction. I agree with Dr. Tenenhaus that a comprehensive review would be impossible in the space we have, but you should find that he has been able to hit the high points in this concise review. Flaps are primarily used in burn reconstruction, but even with the new products available to our patients, occasionally flaps are needed for acute burn coverage and therefore, we need to be aware of them. Dr. Tenenhaus also gives us a glimpse into the future of flaps for the treatment of patients with burns.
I am sure you will find this series of articles interesting and informative, and I thank all of the authors for their hard work.
Two articles are written by Chester Paul, MD. I asked Dr. Paul to write a review of the history of burn grafting. He believed that the topic was too large in scope for one review, and decided to write one article on skin grafting and another on the use of skin substitutes. Dr. Paul presents these topics in his usual entertaining style. I am sure you will enjoy these two articles.
I have found the dermal replacement products to be advantageous. It is well known that the thicker the skin, the less contraction there will be at the recipient site, but that there will be more scarring and a longer time to heal at the donor site. By using the dermal replacement products, we can place thick skin at the site of injury while taking very thin donors. At our unit, we have had a great deal of experience with both Integra™ and AlloDerm®. We asked our patients, who had been treated with both AlloDerm and Integra, which product they preferred. We found that our patients cannot really tell the difference between the two products.1
Since the loss of Transcyte™ there has been a resurgence in the use of xenografts in our unit. We now use xenografts on all the burns where we had previously used Transcyte, and although we have not done a formal study, I would say with much the same success as we had previously reported with Transcyte.2
Dr. Al-Mousawi, et al thoroughly review the metabolic effect burn injury and the interventions that have been used to modulate that response. The group in Galveston, Texas is lead by Dr. David Herndon, a leader in advancing the knowledge in this aspect of burn care; their contribution to this issue is greatly appreciated. Certainly in my mind, the most important modulation of burn wound metabolism is early excision and wound closure, but there are some cases when that cannot be accomplished. In that situation, one mainstay of burn care is, of course, topical antimicrobial use to protect against infection.
Dr. David Barillo reviews the historical use of topical antimicrobials in burn care. Dr. Barillo has had an interest in topical agents for many years, as his thorough review clearly demonstrates. His discussion did not include Silvazine™, which deserves mentioning. Silvazine is a white hydrophilic cream containing silver sulphadiazine and chlorhexidine digluconate—this was the most commonly used topical agent in Australia until Acticoat™ more recently gained greater popularity.3
Burn care cannot proceed if patients are not adequately resuscitated. Improvements in resuscitation of a patient with a burn have allowed all other advances in burn care to proceed. I say this simply because resuscitation allows the patient to survive long enough for the other therapies to be of any importance. I hope you find Dr. Hansen’s account of the history of burn resuscitation informative and interesting. At this point, the medical community has gotten the message that burn victims require fluid resuscitation. We have noticed in our unit that the starting point of resuscitation (the initial fluid rate) has great influence on the amount of fluid required. When patients are started at a higher hourly rate than any of the formulas commonly used today, it is quite difficult to get them weaned down to rates projected by the formulas without them showing signs of decreased profusion. I believe this is one factor that has lead to “fluid creep.”
Finally, Dr. Mayer Tenenhaus reviews the history of flaps and burn reconstruction. I agree with Dr. Tenenhaus that a comprehensive review would be impossible in the space we have, but you should find that he has been able to hit the high points in this concise review. Flaps are primarily used in burn reconstruction, but even with the new products available to our patients, occasionally flaps are needed for acute burn coverage and therefore, we need to be aware of them. Dr. Tenenhaus also gives us a glimpse into the future of flaps for the treatment of patients with burns.
I am sure you will find this series of articles interesting and informative, and I thank all of the authors for their hard work.
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