Burn Injury Ebook
Even the well-developed manufacture of tissue-engineered skin used only the cellular elements of the dermis for a long period of time. Attention is now focusing on creating new skin consisting of both the dermis and its associated fibroblasts as well as the epithelial layer, consisting of keratinocytes. Obviously, this is a significant advance. But for truly normal skin to be engineered, all of the cellular elements should be contained so that the specialized appendages can be generated as well. These simple composites will indeed prove to be quite complex and require intricate designs. Thicker structures with relatively high ratios of surface area to mass, such as liver, kidney, heart, breast, and the central nervous system, will offer engineering challenges.
The use of regeneration templates to repair skin has a counterpart in the repair of fascia during the surgical closure of abdominal wall hernias. The templates are used to reinforce the repair and encourage new tissue ingrowth. Polypropylene or polytetrafluorethyl-ene (PTFE) mesh has been widely used in both animal and human clinical studies because they have good tensile strength and support fibroblast ingrowth. However, they do not biodegrade, cause an inflammatory response, and are prone to infection and fistula formation (Voyles et al., 1981). Polyglactin and polyg-lycolic acid meshes, which are biodegradable, have also been used, but have low tensile strength and a high number of patients suffer recurrent hernia at the site of mesh placement (Tyrell et al., 1989).
Dermatitis artefacta (skin damage caused deliberately) is occasionally seen in children, and is a complex condition that requires careful management to engage the child and family. Rogers et al. (2001) describe a series of 32 young people seen with artefactual skin conditions and emphasise the importance of good liaison between the mental health worker and the dermatologist. It can be very difficult to get the family to accept the referral and it is important to avoid confrontation as this can result in the family withdrawing the child.
The use of colloidal systems such as liposomes to enhance drug penetration is not particularly successful to date. Conventional liposomes do not appear to pass through intact stratum corneum although there is some evidence that they are phagocytosed by keratinocytes, at least in vivo, and so may be taken up in damaged skin where the stratum corneum is broken37. A number of authors have examined the possibility that liposomes
Some risk factors for developing M-PTSD include perception of threat to life and the intensity of a particular treatment or intervention. The more invasive and dangerous a procedure is, the more potential there is for M-PTSD. Burn injury has been associated with an increased risk of M-PTSD (Stoddard, Norman, Murphy, & Beardslee, 1989), in part because of the often horrendous pain involved. Laurence Miller talks about the concept of traumatic pain, for instance. Pollin (1995) and Koocher and Pollin (1995) discuss the use of the medical crisis counseling model in addressing the emotional complications in children and
Many types of bioartificial dermal scaffolds have been tested in an attempt to find the optimum scaffold that best supports fibroblasts and epidermal cells alike and results in the highest quality skin repair, but success has been elusive. Collagen gels and polyester mesh are the basis of several dermal substitutes that are now in clinical use (Boyce, 2001 Yannas, 2001). Collagen gels are reported to have two major drawbacks. When hydrated they tend to depress both epidermal and fibro-blast proliferation (Kono et al., 1990), and epidermal cells on collagen gels secrete an unidentified factor(s) that stimulates intense collagenolytic activity by fibroblasts (Yoshizato et al., 1986 Shimizu-Nishikawa and Yoshizato, 1990). Investigators have tried to minimize these problems by using gelatin scaffolds, scaffolds made by mixing collagen with gelatin (Koide et al., 1993 Yoshizato and Yoshikawa, 1994) or elastin (DeVries et al., 1994) and or glycosaminoglycans, and decellularized natural ECM....
As their myelin is degraded, the Schwann cells dedifferentiate within the basement membrane to form cords of cells called the bands of Bungner (figure 5.5). They proliferate and migrate to form a continuous bridge across the lesion and down the length of the distal endoneurial tubes. Axotomized neurons, along with macrophages and platelets that have invaded the injury site, produce growth factors and cytokines that are mitogenic for Schwann cells (TABLE 5.1). Many of these molecules are the same ones responsible for the fibrosis of skin repair, such as FGF, PDGF, IL 1,2, and 6, TGF-P and IFN-y, as well as nerve-specific factors such as glial growth factor (GGF) (Fu and Gordon, 1997). When the gap in the nerve is too large to be bridged by dedifferentiating Schwann cells, fibroblasts enter the wound space and these same factors induce scar formation, preventing regeneration.
Inspection (d) Look for other tell-tale skin damage. For example (A) grazing, with or without ingraining of dirt in the wound, or friction burns, suggests an impact followed by rubbing of the skin against a resistant surface. (B) Lacerations suggest impact against a hard edge, tearing by a bone end, or splitting by compression against a hard surface.
The hard collar can cause raised intracranial pressure (greater in patients with a head injury) and skin damage and ulceration. Maintenance of the supine position affects drainage of secretion and the need for log-rolling is nurse intensive. The current options are as follows 8
Damaged skin often carries the connotation of contagion or a lack of hygiene (Van Moffaert, 1992). Owing to a lack of health education and awareness in dermatology, some associate skin disease with such issues. This ignorance means that a skin disease patient may find that some people react negatively towards them or treat them differently because of the way they look. Consequently, the sufferer may experience distress, feel stigmatised and thus begin to avoid certain social activities that either involve the revealing of the lesions, such as swimming, or that involve potential intimacy with a third party, such as dating or physical displays of affection.
It is hard for a child to grow up with a skin condition and for this not to have some impact on their self-esteem. However, the variation in the impact on self-esteem cannot be entirely attributed to the severity of the child's condition, because it is very dependent on psychological factors and the child's beliefs about their condition. It is possible for a child with very damaged skin to report high levels of self-esteem and vice versa for a young person with very trivial skin blemishes to report a considerable impact on self-esteem.
Fetal mammalian skin does not scar after wounding and regenerates perfectly until late in gestation, when the response shifts to the adult scarring pattern. The fibroblasts of the fetal wound synthesize the same collagens as fibroblasts in adult wounds, but lay down the normal architecture of the ECM. This regenerative response is associated with several differences between fetal and adult skin. Fetal skin has a higher ratio of type III to type I collagen than does adult skin, sulfated PG synthesis does not accompany collagen synthesis in fetal wounds, and fetal wound fibroblasts synthesize higher levels of HA and its receptor. This in turn is associated with a minimal inflammatory response in fetal wounds. Platelets, neutrophils, and macrophages are present in very low numbers if at all, and the adult levels of the growth factors and cytokines produced by these cells are correspondingly lower, with the exception of TGF-P3, which is higher in fetal wounds. Adding adult levels of...
Lowest power setting to produce a visible whitening of the skin after laser impact, one had to depend on this visual signal which reflected not vascular obliteration alone but that plus coagulation of the dermis and perhaps even the epidermis with a change in light reflectance, so-called blanching. Thus, an inside-out second-degree burn injury was produced. The necrotic collagen as well as the obliterated vessel had to be replaced by new collagen, which might end up as transparent as normal collagen or which frequently, even without excess elevation, became dense enough so that the area became opacified and lighter than normal skin color. A variety of methods were attempted to minimize hypertrophic scarring. Apfelberg tried to treat only small areas assuming that a larger second-degree burn injury would be more likely to hypertrophy. He spaced his treated areas with parallel untreated areas in a banded or striped pattern but eventually discarded the technique since scars continued to...
What the argon laser allowed for the first time was a therapy for widespread telan-giectasia that was sensible in that destruction proceeded from the vessel outward rather than from the surface of the skin inward as by electrodesiccation or electrofulguration, then the standard treatment. In practice, with early argon laser surgical techniques there was thin second-degree burn injury involving the papillary dermis and the entire epidermis. Still, since the maximal energy dissipation was in the vessel itself rather than on the surface of the skin it seemed more reliable particularly for more deeply situated and resistant spider angiomas and for treating networks of fine vessels extending over large areas of the cheeks as in extensive rosacea. For congenital port-wine stain this treatment was miraculous. Ten percent of patients could expect entire clearance of their vascular malformation and 75 of the remaining patients would have dramatic and long-lasting or permanent and significant...
In contrast, a number of deaths have been recorded following stings by the box jellyfish, C. fleckeri (Figure 21.12) in Australian waters. Wheals on the skin are normally multiple and 'cross-hatched'. Death can follow rapid collapse within a few minutes of the sting, probably due to myocardial toxicity, although respiratory arrest has also been recorded. Abnormal autonomic nerve activity has been observed. In nonfatal envenoming, swelling and subsequently local skin damage and necrosis can occur.
A major goal in treating normal and chronic skin wounds is to either accelerate their healing by fibrosis or to actually regenerate skin with the original architecture and function, using interventions based on what is known about the biology of skin repair. These interventions are the topical application of growth factors, cytokines, inhibitors of inflammation, and other compounds to accelerate fibrosis or regenerate skin, the use of keratinocyte transplants or bioartificial skin equivalents as living wound dressings until the host skin is repaired, or the use of acellular regeneration templates to induce skin repair from the sides and bottom of the wound.
Feeding tube can be inserted if indicated. In our experience, esophageal instrumentation does not trigger esophageal variceal bleeding. The procedure is performed with the patient supine and arms extended. The table should have a gel pad to prevent skin damage, and intermittent pneumatic calf compression is used to prevent deep vein thrombosis and pulmonary emboli.