Niknam Eshraghi, M.D., F.A.C.SNiknam Eshraghi, M.D., F.A.C.SGeneral and Burn SurgeryGeneral and Burn SurgeryLegacy Emanuel HospitalLegacy Emanuel HospitalAffiliate Professor of SurgeryAffiliate Professor of SurgeryOregon Health Sciences UniversityOregon Health Sciences University

Burn Care for Primary Burn Care for Primary Providers.Providers.

Burn Epidemiology Burn Epidemiology and Outcomes and Outcomes

Burn EpidemiologyBurn EpidemiologyWorld WideWorld Wide

millions of people are burned each yearmillions of people are burned each year 1/3 of these are in children1/3 of these are in children Greater than 80% of these burns are Greater than 80% of these burns are

preventablepreventable More than 200,000 die of their injuries More than 200,000 die of their injuries

each yeareach year

Burn injuries receiving medical Burn injuries receiving medical treatment: 450,000 per yeartreatment: 450,000 per year

Fire and burn death: 3,400 per yearFire and burn death: 3,400 per year Patients hospitalized: 40,000 total Patients hospitalized: 40,000 total

with 30,000 in burn centerswith 30,000 in burn centers

Burn EpidemiologyBurn EpidemiologyUnited StatesUnited States

American Burn Association, 2013

Burn CentersBurn Centers

127 burn centers with about 1700 127 burn centers with about 1700 beds, admitting an average of 200 beds, admitting an average of 200 patients per year.patients per year.

Other 4500 hospitals each admit 3 Other 4500 hospitals each admit 3 per yearper year

Oregon Burn Center admits close to Oregon Burn Center admits close to 300 patients with burn or skin 300 patients with burn or skin disorders.disorders.

What Are the Causes?What Are the Causes?

Majority of burn Majority of burn injuriesinjuries are are caused by:caused by: Lack of knowledgeLack of knowledge Poor judgmentPoor judgment

Very few are true Very few are true accidentsaccidents

Causes of death from major burn injuries:Causes of death from major burn injuries: EarlyEarly

Burn shockBurn shock

Failure of resuscitationFailure of resuscitation

DelayedDelayed

Wound sepsisWound sepsis

Multi-organ failureMulti-organ failure

Respiratory insufficiencyRespiratory insufficiency

Burn Impact; MortalityBurn Impact; Mortality

Historical PerspectiveHistorical Perspective Burns a depressing field until the later Burns a depressing field until the later

part of 20part of 20thth century century Percent of total body surface area burn Percent of total body surface area burn

for expected 50% mortality (1952) for expected 50% mortality (1952)

Age (years) %TBSA

0-14 49

15-44 46

45-64 27

>65 10

Bull et al.Ann Surg 1954;139:269

• Effects of burn injuryEffects of burn injury– EarlyEarly

• PainPain• Major illnessMajor illness• Prolonged hospitalizationProlonged hospitalization

– DelayedDelayed• Long recoveryLong recovery• Disfigurement, and loss of functionDisfigurement, and loss of function• Psycho-social impactPsycho-social impact

Burn Impact; MorbidityBurn Impact; Morbidity

Types of Burn InjuryTypes of Burn Injury

Types of Burn InjuryTypes of Burn Injury

ThermalThermal ElectricalElectrical ChemicalChemical InhalationInhalation

Burn Injury ClassificationBurn Injury Classification

Flame BurnFlame Burn

Scald Scald BurnBurn

Contact burns

Electrical BurnsElectrical Burns

Hidden Damage

Chemical BurnsChemical Burns

Nitric acid Hydrofluoric Acid

Alkali

Frost biteFrost bite

Inhalation InjuryInhalation Injury

Depth of Burn InjuryDepth of Burn Injury

How Do We Determine How Do We Determine Burn Depth? Burn Depth?

Rich history of efforts to develop Rich history of efforts to develop tools!tools! Colored light reflectionColored light reflection ThermographyThermography Helium-neon laser Doppler flow meterHelium-neon laser Doppler flow meter Direct temperature measurementDirect temperature measurement Fluorescein dye with UV excitationFluorescein dye with UV excitation Nonfluorescent IV dyeNonfluorescent IV dye Hi resolution USHi resolution US MRIMRI Wound biopsyWound biopsy

Scanning laser Doppler imaging.Scanning laser Doppler imaging. 90% accuracy vs. Clinical evaluation (66%) 90% accuracy vs. Clinical evaluation (66%)

for deep partial burns in pediatric patients.for deep partial burns in pediatric patients. Holland et al burns 2002;28:11Holland et al burns 2002;28:11

New technology “high-speed fiber-based New technology “high-speed fiber-based polarization sensitive optical coherence polarization sensitive optical coherence tomography” measures reduction of collagen tomography” measures reduction of collagen birefringence correlating with burn depth birefringence correlating with burn depth

Park et al J Biomed Opt 2001;6:474Park et al J Biomed Opt 2001;6:474

Clinical evaluation by the Clinical evaluation by the experienced examiner is still the experienced examiner is still the cheapest and most common.cheapest and most common.

How Do We How Do We DetermineDetermine Burn Depth, What Is Burn Depth, What Is

New?New?

Extent of Injury Extent of Injury EstimationEstimation

Rule of Nine Rule of Nine Knaysi 1967Knaysi 1967

Lund-Browder Lund-Browder DiagramsDiagrams

Lund CC, Browder NC. Surg Gynecol Obstet 1944; 79: 352-8

Burn Size Estimation, Burn Size Estimation, What Is New?What Is New?

Computerized Computerized estimation systemsestimation systems Sage II provides Sage II provides

reproducible age-specific reproducible age-specific burn diagram burn diagram

((www.sagediagram.com))

3-D Burn Vision provides a 3-D Burn Vision provides a three dimensional rotating three dimensional rotating modelmodel

(Electric power (Electric power research institute, research institute, concord CA)concord CA)

Surface laser scanningSurface laser scanning

Treatment of Treatment of BurnsBurns

Inhalation InjuryInhalation Injury Present in >20% of burn victims Present in >20% of burn victims CausesCauses

Hot air or steam upper airway burn Hot air or steam upper airway burn Carbon monoxide (CO) Carbon monoxide (CO) Toxic substances, and smoke Toxic substances, and smoke

particlesparticles IncreasesIncreases

ICU stayICU stay Fluid resuscitation requirement (2x)Fluid resuscitation requirement (2x) Mortality (2X)Mortality (2X)

Inhalation Injury Inhalation Injury TreatmentTreatment ChemicalChemical

Ketorolac, surfactantKetorolac, surfactant Perflubron liquid ventilationPerflubron liquid ventilation Dimethyl sulfoxideDimethyl sulfoxide Heparin, Antithrombine III, nitric oxideHeparin, Antithrombine III, nitric oxide

MechanicalMechanical Prone positioningProne positioning Percussive, and oscillatory ventilationPercussive, and oscillatory ventilation ECMOECMO Low volume pressure controlled Low volume pressure controlled

ventilation ventilation

Supportive Care

Volumetric Diffusive Volumetric Diffusive Respirator (VDR)Respirator (VDR)

Airway pressure release Airway pressure release ventilation (APRV)ventilation (APRV)

Burn shockBurn shock Hypovolemeic and cellularHypovolemeic and cellular Decreased CO, extra cellular fluid, plasma Decreased CO, extra cellular fluid, plasma

volume, and oliguriavolume, and oliguria Total body capillary permeability with max Total body capillary permeability with max

edema 8-24 hr post injuryedema 8-24 hr post injury Many mediators implicated including Many mediators implicated including

histamine and bradykininhistamine and bradykinin Edema fluid is isotonic and has same amount Edema fluid is isotonic and has same amount

of protein similar to plasmaof protein similar to plasma Resuscitation goal is to restore tissue Resuscitation goal is to restore tissue

perfusion perfusion

ResuscitationResuscitation

Resuscitation HistoryResuscitation History

Rialto Concert Hall fire 1921Rialto Concert Hall fire 1921 Frank P Underhill analyzed the Frank P Underhill analyzed the

blister fluid and found it to be blister fluid and found it to be similar to plasmasimilar to plasma

Could be replaced with salt Could be replaced with salt solution and proteinsolution and protein

JAMA 1930; 95:852JAMA 1930; 95:852 Coconut Grove fire 1942Coconut Grove fire 1942

Oliver cope and Francis Moore Oliver cope and Francis Moore postulated the interstitial space as postulated the interstitial space as the recipient of plasma loss and the recipient of plasma loss and cause of edema.cause of edema.

Burn budget Burn budget formula based on formula based on TBSA burnTBSA burn

Ann Surg 1947; 126:1016Ann Surg 1947; 126:1016

Kyle and Wallace modified fluid Kyle and Wallace modified fluid replacement for children (larger heads and replacement for children (larger heads and shorter legs)shorter legs)

Br J Plast Surg 1951;194Br J Plast Surg 1951;194

WWII related burns led to development of WWII related burns led to development of U.S.Army institute of surgical researchU.S.Army institute of surgical research Evans : resuscitation based on body weight and Evans : resuscitation based on body weight and

TBSATBSA Ann Surg 1952;135:804Ann Surg 1952;135:804

Brook : substituted NS to LRBrook : substituted NS to LR JAMA 1953;152:1309JAMA 1953;152:1309

Resuscitation HistoryResuscitation History

Baxter and Shires proposed the Parkland Baxter and Shires proposed the Parkland formulaformula Interstitial and intracellular edemaInterstitial and intracellular edema Disruption of NA-K pumpDisruption of NA-K pump

Ann NY Acad Sci 1968;150:874Ann NY Acad Sci 1968;150:874

2-4 ml LR x TBSA(%) x weight (kg)2-4 ml LR x TBSA(%) x weight (kg) /hr /hr

2 x 82 x 8Short version Short version TBSA(%) x weight (kg)TBSA(%) x weight (kg) ml/hr ml/hr

44

Resuscitation HistoryResuscitation History

CrystalloidCrystalloid LR most commonLR most common Majority of patients need more than Majority of patients need more than

what is calculated by the formulawhat is calculated by the formula Saffle et al J am Coll Surg 2003;196(2)267Saffle et al J am Coll Surg 2003;196(2)267

Hypertonic salineHypertonic saline ComplicatedComplicated May reduce volume of resuscitationMay reduce volume of resuscitation No consensus on the osmolarity of the No consensus on the osmolarity of the

solutionsolution Higher mortality in some studies Higher mortality in some studies

Resuscitation FluidsResuscitation Fluids

AlbuminAlbumin Three schoolsThree schools

1.Should not be used because it leaks 1.Should not be used because it leaks and makes edema worseand makes edema worse

2.Should be given from the beginning2.Should be given from the beginning 3.Should be given 8-12 hrs post burn3.Should be given 8-12 hrs post burn

Albumin is used by majority of burn Albumin is used by majority of burn surgeons in 8-12 hours in large burnssurgeons in 8-12 hours in large burns

Sheridan RL Crit care med 2002;30(11):s500Sheridan RL Crit care med 2002;30(11):s500

DextranDextran Guarded initial favorable resultsGuarded initial favorable results

Resuscitation FluidsResuscitation Fluids

IV for burns > 15%IV for burns > 15% Delay in resuscitation increases fluid Delay in resuscitation increases fluid

needsneeds LR + albuminLR + albumin Hemodynamic stability, good urine Hemodynamic stability, good urine

out put, and reversal of acidosis as out put, and reversal of acidosis as end pointsend points

Invasive monitoring not routineInvasive monitoring not routine

Resuscitation IndicationResuscitation Indication

ResuscitationResuscitation Goal Goal

Maintain tissue perfusion and organ Maintain tissue perfusion and organ function while avoiding inadequate function while avoiding inadequate or excessive fluid therapyor excessive fluid therapy

Under ResuscitationUnder Resuscitation

Shock.Shock. Organ failure, most commonly acute Organ failure, most commonly acute

renal failure.renal failure. Requires larger volume to catch upRequires larger volume to catch up

Intra-osseous Intra-osseous InfusionInfusion

Burn Wound DressingBurn Wound Dressing

0.5% silver nitrate0.5% silver nitrate Good activity against Good activity against

staphylococcusstaphylococcus and and pseudomonaspseudomonas

PoorPoor eschar eschar penetrationpenetration

Leaches electrolytes Leaches electrolytes Can cause Can cause

methemoglobinemia methemoglobinemia Stains everythingStains everything

Topical Agents the HistoryTopical Agents the History 1960’s: Dr. Carl Moyer-1960’s: Dr. Carl Moyer-

researched 22 antiseptics to researched 22 antiseptics to find to treat burn victimsfind to treat burn victims Dr. Margraf-reviewed early Dr. Margraf-reviewed early

medical literature medical literature Diluted silver nitrate to Diluted silver nitrate to

0.5%0.5% Killed bacteriaKilled bacteria Allowed burns to healAllowed burns to heal Did not produce Did not produce

resistanceresistance

Arch Surg 1965;90:812

Lindberg and Moncrief adapted Lindberg and Moncrief adapted Mafenide acetate (Sulfamylon) Mafenide acetate (Sulfamylon) ((J trauma J trauma 1965;5(5):601)1965;5(5):601) 11% cream or 5% solution11% cream or 5% solution Great escar penetrationGreat escar penetration Good antibacterial activity against most gram Good antibacterial activity against most gram

positives and gram negativespositives and gram negatives Limited against Staphylococcus and minimal Limited against Staphylococcus and minimal

antifungal activityantifungal activity PainfulPainful Carbonic anhydrase inhibitorCarbonic anhydrase inhibitor

Topical Agents the HistoryTopical Agents the History

Charles Fox developed silver Charles Fox developed silver sulfadiazine (Silvadene) sulfadiazine (Silvadene) (SG&O (SG&O 1969;128:1021)1969;128:1021)

Pain lessPain less Good activity against Staph, E.coli, Good activity against Staph, E.coli,

Klebsiella, CandidaKlebsiella, Candida ? Transient leukopenia ? Transient leukopenia 5% cutaneous sensitivity and rare 5% cutaneous sensitivity and rare

hemolytic anemiahemolytic anemia

Topical Agents the HistoryTopical Agents the History

Petroleum gauzePetroleum gauze Bacitracin zinc / double antibiotic Bacitracin zinc / double antibiotic

ointmentointment XeroformXeroform Silver sulfadiazine (Silvadene)Silver sulfadiazine (Silvadene) Mafenide AcetateMafenide Acetate

Common topical agents and Common topical agents and dressingsdressings

Topical Agents; What Is Topical Agents; What Is New?New?

Cerium nitrate-silver sulfadiazineCerium nitrate-silver sulfadiazine Used in Europe and South AmericaUsed in Europe and South America None toxicNone toxic Better bacteriostasis in woundBetter bacteriostasis in wound ? Improved immune function secondary ? Improved immune function secondary

to preserved cell-mediated immunityto preserved cell-mediated immunity Reduced mortality in large burnsReduced mortality in large burns

Topical Agents; What Is Topical Agents; What Is New?New?

Acticoat (Smith and Acticoat (Smith and Nephew)Nephew) Silver nanocrystal Silver nanocrystal

technologytechnology Releases silver ions Releases silver ions

when moistenedwhen moistened Pain less and may Pain less and may

reduce painreduce pain Very good spectrum Very good spectrum

of activityof activity Can be left for 3-7 Can be left for 3-7

daysdays

Topical Agents; What Is Topical Agents; What Is New?New?SilverSilver

Aquacel Ag (Convatec)Aquacel Ag (Convatec) Hydrofiber that turns Hydrofiber that turns

to gel with moistureto gel with moisture Exudate managementExudate management Lower silver ion Lower silver ion

release than Acticoat release than Acticoat Good spectrum of Good spectrum of

activityactivity Can be left for 7 daysCan be left for 7 days

Topical Agents; What Is Topical Agents; What Is New?New?SilverSilver

Other silver containing dressingsOther silver containing dressings Mepilex Ag (Molnlycke)Mepilex Ag (Molnlycke) Silvasorb & Arglaes (Medline)Silvasorb & Arglaes (Medline) Actisorb (Johnson & Johnson)Actisorb (Johnson & Johnson) Silverlon (Argentum)Silverlon (Argentum) ………………

Topical Agents; What Is Topical Agents; What Is New?New?

And More SilverAnd More Silver

Cochran report on silverCochran report on silver Objectives; Objectives; Evaluate effects of silver-containing Evaluate effects of silver-containing

wound dressings and topical agents in wound dressings and topical agents in preventing wound infection and healing of preventing wound infection and healing of wounds. wounds.

Data; Data; 26 RCTs (2066 patients). 26 RCTs (2066 patients). Heterogeneity of treatments and outcomes Heterogeneity of treatments and outcomes

precluded meta-analysis. precluded meta-analysis.

Cochran report on Cochran report on silversilverBurnsBurns 13 trials compared topical silver (variety of 13 trials compared topical silver (variety of

formulations - including silver sulphadiazine) with formulations - including silver sulphadiazine) with non-silver dressings. non-silver dressings. 1 trial showed fewer infections with silver nitrate.1 trial showed fewer infections with silver nitrate. 3 trials showed significantly more infection with 3 trials showed significantly more infection with

SSD.SSD. 6 trials compared SSD cream with silver-containing 6 trials compared SSD cream with silver-containing

dressings. dressings. 1 showed significantly fewer infections with the 1 showed significantly fewer infections with the

silver-containing dressingsilver-containing dressing 5 found no evidence of a difference. 5 found no evidence of a difference.

1 trial compared two silver-containing dressings, and 1 trial compared two silver-containing dressings, and showed a significantly lower infection rate with silver-showed a significantly lower infection rate with silver-coated gauze (Acticoat®) than with silver nitrate coated gauze (Acticoat®) than with silver nitrate gauze.gauze.

Cochran report on Cochran report on silversilver

Other WoundsOther Wounds 6 6 trials compared SSD/silver-containing trials compared SSD/silver-containing dressings with non-silver dressings (nine dressings with non-silver dressings (nine dressings in total). dressings in total).

Most comparisons found no significant Most comparisons found no significant differences in infection ratesdifferences in infection rates

1 trial exhibited significantly fewer infections 1 trial exhibited significantly fewer infections with SSD/hydrocolloid, but another, in acute with SSD/hydrocolloid, but another, in acute wounds, found significantly more infections wounds, found significantly more infections with SSD. with SSD.

1 comparison showed a significant reduction 1 comparison showed a significant reduction in healing time associated with a silver-in healing time associated with a silver-containing hydrofibre dressing in diabetic foot containing hydrofibre dressing in diabetic foot ulcers.ulcers.  

Cochran report on silverCochran report on silverConclusionConclusion

Probable that silver-containing dressings and Probable that silver-containing dressings and creams do not prevent wound infection or creams do not prevent wound infection or promote healing promote healing 

There is insufficient evidence to establish whether There is insufficient evidence to establish whether silver-containing dressings or topical agents promote silver-containing dressings or topical agents promote wound healing or prevent wound infection; some wound healing or prevent wound infection; some poor quality evidence for SSD suggests the opposite.poor quality evidence for SSD suggests the opposite.

Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006478. DOI: Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006478. DOI: 10.1002/14651858.CD006478.pub2, March 17. 201010.1002/14651858.CD006478.pub2, March 17. 2010

Characteristics of a good dressingCharacteristics of a good dressing Well toleratedWell tolerated Allows drainageAllows drainage Barrier against environmentBarrier against environment Does not allow drying and desiccationDoes not allow drying and desiccation Easy to removeEasy to remove Simple Simple InexpensiveInexpensive

Burn Wound DressingBurn Wound Dressing

Skin SubstitutesSkin Substitutes

Used to cover Used to cover Donor sitesDonor sites Clean shallow woundsClean shallow wounds Deeper wound after excision while awaiting Deeper wound after excision while awaiting

autografting, or test the viability of the autografting, or test the viability of the wound bedwound bed

Allograft (Homograft)Allograft (Homograft) Can vascularizeCan vascularize Best biologic dressingBest biologic dressing Bridge to autografting or autograft Bridge to autografting or autograft

protectionprotection Xenograft (pig skin)Xenograft (pig skin)

Inferior to allograftInferior to allograft

Skin SubstitutesSkin Substitutes

Fresh human amniotic membrane.Fresh human amniotic membrane. Difficulty in screening for viral disease.Difficulty in screening for viral disease.

Semipermeable synthetic Semipermeable synthetic membranes.membranes. Biobrane (Bertek)Biobrane (Bertek)

Nylon mesh coated with porcine collagen Nylon mesh coated with porcine collagen attached to a rubberized silicone.attached to a rubberized silicone.

Skin SubstitutesSkin Substitutes Combined allogeneic and synthetic Combined allogeneic and synthetic

membranes to provide growth factors. membranes to provide growth factors. Trancyte (Smith and Nephew) Trancyte (Smith and Nephew)

Seeded neonatal fibroblasts on to the collagen-Seeded neonatal fibroblasts on to the collagen-coated nylon membranecoated nylon membrane

Apligraft (OApligraft (Organogenesis)rganogenesis) Gel of type I bovine collagen with living neonatal Gel of type I bovine collagen with living neonatal

fibroblast at the inner layer and neonatal fibroblast at the inner layer and neonatal allogeneic keratinocytes at the outer layer (as an allogeneic keratinocytes at the outer layer (as an epidermis). It is mostly used in the treatment of epidermis). It is mostly used in the treatment of the chronic ulcers.the chronic ulcers.

Dermagraft (Smith and Nephew) Dermagraft (Smith and Nephew) cryopreserved living dermal structure and is cryopreserved living dermal structure and is

manufactured by cultivating neonatal allogeneic manufactured by cultivating neonatal allogeneic fibroblast on a polymer mesh.fibroblast on a polymer mesh.

Jackson pioneered excision and grafting in Jackson pioneered excision and grafting in 19541954 3% wounds and eventually to 30%3% wounds and eventually to 30%

Ann Surg 1960;152:157Ann Surg 1960;152:157

Janzekovic working alone in Yugoslavia Janzekovic working alone in Yugoslavia developed tangential excision and developed tangential excision and immediate graftingimmediate grafting Reduce hospital stayReduce hospital stay Reduce sufferingReduce suffering Better functionBetter function

J Trauma 1970J Trauma 1970

Wound Excision and Wound Excision and GraftingGrafting

InstrumentsInstruments DermatomesDermatomes KnivesKnives Versajet (Smith & Nephew)Versajet (Smith & Nephew)

Reduced blood lossReduced blood loss ClysisClysis Extremity exsanguinationsExtremity exsanguinations Pneumatic tourniquetsPneumatic tourniquets Intra-operative euthermiaIntra-operative euthermia

Wound Excision and Wound Excision and Grafting; Technical Grafting; Technical

ImprovementsImprovements

Graft fixation:Graft fixation: Staples and sutures Staples and sutures

are still the mainstayare still the mainstay Cyanoacrylate(DermabCyanoacrylate(Dermab

ond)ond) Fibrin glue Fibrin glue

Artiss  (BAXTER) Artiss  (BAXTER) Vapor heat treated for viral Vapor heat treated for viral

inactivationinactivation Used in wound healing, hemostasis Used in wound healing, hemostasis

and tissue sealingand tissue sealing Mimics the last stages of the natural Mimics the last stages of the natural

clotting cascade to form a strong, clotting cascade to form a strong, reliable, durable clot.reliable, durable clot.

Wound Excision and Wound Excision and Grafting; Technical Grafting; Technical

ImprovementsImprovements

Excised Wound Excised Wound CoverageCoverage

Full thickness autograftFull thickness autograft Best cosmetic result with least contractionBest cosmetic result with least contraction

Split thickness autograftSplit thickness autograft Definitive closureDefinitive closure Meshing allows expansionMeshing allows expansion

Allograft (Homograft)Allograft (Homograft) Can vascularizeCan vascularize Best biologic dressingBest biologic dressing Bridge to autografting or autograft Bridge to autografting or autograft

protectionprotection Xenograft (pig skin)Xenograft (pig skin)

Inferior to allograftInferior to allograft

Skin Skin GraftingGrafting

Skin GraftingSkin Grafting

Cultured epidermal autograft Cultured epidermal autograft (CEA)(CEA) Developed by Rheinwald and greenDeveloped by Rheinwald and green

Cell 1975;6:331Cell 1975;6:331 Small; 10-15cmSmall; 10-15cm22, thin; 10-15 cell , thin; 10-15 cell

layers deeplayers deep Takes time to get itTakes time to get it ExpensiveExpensive Fragile and not very durableFragile and not very durable

Excised Wound Excised Wound CoverageCoverage

Alloderm (Life Cell)Alloderm (Life Cell) From human From human

cadaveric skincadaveric skin the epidermis has the epidermis has

been removed and been removed and the cellular the cellular components of the components of the dermis have been dermis have been extractedextracted

is repopulated, is repopulated, revascularised by the revascularised by the host cells and host cells and incorporated into incorporated into tissue.tissue.

Requires immediate Requires immediate autograftingautografting

Excised Wound Excised Wound CoverageCoverage

Integra (Integra Life Sciences) Integra (Integra Life Sciences) Developed by Burke and Yannas Developed by Burke and Yannas Integration of a collagen-Integration of a collagen-

glycosamineglycan sponge with a glycosamineglycan sponge with a silicone layer on top. silicone layer on top.

Integra is currently the most widely Integra is currently the most widely accepted synthetic skin substitute. accepted synthetic skin substitute.

Its pore size has been designed at 70-Its pore size has been designed at 70-200 µm in order to allow migration of 200 µm in order to allow migration of the patient’s own endothelial cells and the patient’s own endothelial cells and fibroblast. fibroblast.

The disadvantage is cost. The disadvantage is cost. The advantage is its improved elasticityThe advantage is its improved elasticity

Excised Wound Excised Wound CoverageCoverage

IntegraIntegra

Physicians, residents, Students and Physicians, residents, Students and NP’sNP’s

NursesNurses Physical and Occupational therapyPhysical and Occupational therapy Pharmacy/DietitianPharmacy/Dietitian Social Worker/Chaplain servicesSocial Worker/Chaplain services Rehabilitation and PsychologyRehabilitation and Psychology Child life and art therapyChild life and art therapy

Multidisciplinary TeamMultidisciplinary Team

Burn CareBurn Care

Other important factorsOther important factors Nutritional support and modification Nutritional support and modification

of hypermetabolismof hypermetabolism Pain and anxiety management Pain and anxiety management Scar management Scar management TherapyTherapy Reconstruction and rehabilitationReconstruction and rehabilitation Funding and work force issuesFunding and work force issues

Non Burn WoundNon Burn Wound

Toxic epidermal necrolysisToxic epidermal necrolysis Necrotizing woundsNecrotizing wounds Complex wounds with tissue lossComplex wounds with tissue loss Purpura fulminanse Purpura fulminanse Odd and rare woundOdd and rare wound

NecrotiziNecrotizing ng

FasciitisFasciitis

Purpura FulminansPurpura Fulminans

Toxic Epidermal NecrolysisToxic Epidermal Necrolysis

Decubitus UlcersDecubitus Ulcers