First aid treatment of burn injuries

Cuttle L & Kimble RM

Abstract
The recommendations for the first aid treatment of burn injuries have previously been based upon conflicting published studies and as a result the recommendations have been vague with respect to optimal first aid treatment modality, temperature, duration and delay after which treatment is still effective. The public have also continued to use treatments such as ice and alternative therapies, however there is little evidence to support their use. Recently there have been several studies conducted by burn researchers in Australia which have enabled the recommendations to be clarified. First aid should consist of cool running water (2-15°C), applied for 20 minutes duration, as soon as possible but for up to 3 hours after the burn injury has occurred. Ice should not be used and alternative therapies should only be used to relieve pain as an adjunct to cold water treatment. Optimal first aid treatment significantly reduces tissue damage, hastens wound re-epithelialisation and reduces scarring and should be promoted widely to the public.

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Evaluation of NovoSorb™ novel biodegradable polymer for the generation of a dermal matrix Part 1: In-vitro Studies

Greenwood JE, Li A, Dearman BL & Moore TG

Abstract
Dermal skin substitutes can be used to overcome the immediate problem of donor site shortage in the treatment of major skin loss conditions such as burn injury. In this study the biocompatibility, safety and potential of three variants of NovoSorb™ (a family of novel biodegradable polyurethanes) as dermal scaffolds were determined in-vitro. All three polymers exhibited minimal cytotoxic effects on skin cells allowing human keratinocytes, dermal fibroblasts and microvascular endothelial cells to grow normally in co-culture. Assessment of a three-dimensional polymer matrix followed. A rudimentary composite skin was created with the sequential culturing of dermal fibroblasts and keratinocytes within the matrix. Furthermore, the polymeric matrix provided a scaffold for the guided formation of a cultured microvasculature. These results prompt further investigation in-vivo to assess their safety in biological systems and to elucidate their interaction with the wound environment.

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Evaluation of NovoSorb™ novel biodegradable polymer for the generation of a dermal matrix Part 2: In-vivo Studies

Greenwood JE, Li A, Dearman BL & Moore TG

Abstract
In previous work, the biocompatibility, safety and potential of three variants of NovoSorb™ (a family of novel biodegradable polyurethanes) as dermal scaffolds were determined in-vitro. This paper documents the subsequent in-vivo work. Subcutaneous implantation of the three candidate NovoSorb™ polymers in rats demonstrated no systemic toxic effects of the materials or their degradation products. The anticipated local foreign body reaction compared favourably with commercially-available medical sutures. Assessment of a three-dimensional polymer matrix followed. When engrafted onto a surgically-created full-thickness sheep wound, the non-cellular matrix integrated, healed with an epidermis supported by a basement membrane and was capable of withstanding wound contraction. The resistance to contraction compared favourably to a commercially-available collagenbased dermal matrix (Integra™). These results suggest that the NovoSorb™ matrix could form the basis of an elegant 2-stage burn treatment strategy with an in tial non-cellular Biodegradable Temporising Matrix to stabilise the wound bed followed by the application of cultured composite skin.

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Burn wound management: a surgical perspective

Cameron AM, Ruzehaji N & Cowin AJ

Abstract
Any patient who survives a large burn injury will be left with some degree of scarring. As well as affecting the form and function of the skin, scarring can have severe psychological consequences such as post-traumatic stress disorder and depression 1. This is particularly the case for hypertrophic or keloid scars, which are common after serious burns. Despite this, the process underlying their formation is incompletely understood and limited effective options are available for their treatment. This paper reviews current understanding of the pathophysiology of the wound healing process in relation to burns and reviews the current management for burn wounds.

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A review on porcine burn and scar models and their relevance to humans

Wang X & Kimble RM

Abstract
Burns are common injuries worldwide and often heal with significant scarring when injury extends into the deep dermal layer. It can lead to hypertrophic scarring, scar contracture, impaired skin function, and disfigurement. Due to the heterogeneous nature of burns and subjective approaches in diagnosis and in outcome, many clinical studies cannot be compared and consensus can be hard to reach. Despite great effort, the mechanism of hypertrophic scarring is still poorly understood, partly due to the lack of animal models with scars similar to human hypertrophic scars. The porcine burn model is widely accepted as the best animal model. This article reviews porcine burn models from the literature and from our laboratory. It details the creation of burns from various methods, the determination of burn depth, the assessment of re-epithelialisation, and the evaluation of the subjective measurements of wound infection and clinical scar outcome. It describes that in our porcine model, burn of 40−50cm² with a pale appearance is deep dermal partial thickness, takes more than 3 weeks to completely re-epithelialise and heals with significant scarring that is similar to a human hypertrophic scar. It further draws attention to the relative quantitative approaches of most assessments conducted on our porcine burns/scars and verifies the subjective judgement of wound infection and clinical scar outcome. The information here not only provides essential elements for conducting porcine burn trials, but more importantly offers valuable knowledge for better burn care clinically and for improved clinical trials.

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Experience with Biobrane™; uses and caveats for success

Greenwood JE, Clausen J & Kavanagh S

Abstract
Objective: To present some of our experience with Biobrane™ (a total of 703 patients in 7 years) in a range of uses in burn practice and to illustrate the caveats which we have found applicable in maintaining our success with this versatile material.
Methods: Retrospective analysis of theatre records, medical notes and photography database to categorise our experience with Biobrane™. Thorough assessment of our surgical and nursing protocols (both literature and experience influenced) to identify caveats for successful use.
Results: Pivotal steps are revealed in wound selection, wound preparation, material application, dressing and subsequent nursing care which have led to overwhelming success in definitive management of superficial partial to mid-dermal burns (ensuring pain relief, allowing early mobilisation, tolerance of dressing changes and therapy, and earlier hospital discharge). Its many uses in a broad range of common burn situations are demonstrated and tips provided to achieve best outcome.
Conclusions: Biobrane™ is not a panacea but it is extremely versatile. The different potential uses have learning curves and suggestions are provided to flatten these.

Developing Clinical Practice Guidelines for the Prevention and Management of Venous Leg Ulcers

Barker J

An inaugural Venous Leg Ulcer Consensus meeting was held in Perth, Western Australia, on 6 September 2005. It was attended by a large number of Australia’s wound care leaders who endorsed the need for, and support of, a proposal to develop Clinical Practice Guidelines for the Prevention and Management of Venous Leg Ulcers under the auspices of the Australian Wound Management Association (AWMA). The guidelines will not duplicate existing resources, but develop an innovative Australian framework for care. The key aim in developing the proposed guidelines is to improve health outcomes for the Australian community by preventing venous legs ulcers and their recurrence and provide an evidence-based framework for their management.

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Diagnosis and management of venous leg ulcers: a nurse's role?

Templeton S & Telford K

Abstract
Leg ulcers are a common, debilitating and chronic condition, more prevalent in older people. As with most chronic illnesses and conditions, leg ulcers have a significant impact on the health system and the individual. As most leg ulcers are managed in the community, it is imperative that community-based practitioners have specific clinical expertise, skill and professional judgement to inform decisions about the ulcer aetiology, appropriate management and optimal client outcomes. The Royal District Nursing Service (RDNS) SA Inc. undertook an integrative literature review to examine the role of the district nurse (DN) and general practitioner (GP) in management of leg ulcers. The review concluded that, whilst there is some uncertainty regarding roles, the competent district nurse can independently assess and manage venous leg ulcers to achieve optimal outcomes for clients and support the already overburdened healthcare system.

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The Leg Ulcer Prevention Program: effectiveness of a multimedia client education package for people with venous leg ulcers

Kapp S, Miller C, Sayers V & Donohue L

Abstract
The prolonged and recurrent nature of venous leg ulceration can be a source of great frustration to client and clinicians alike. Venous ulcers may have a significant effect on a person’s quality of life and treatment of this condition generates a burden on healthcare systems. It is a challenge to assist people with these ulcers to adhere to treatment and to generate and maintain positive lifestyle changes so as to reduce the risk of delayed healing, ulcer recurrence and poor health.

The Leg Ulcer Prevention Program (LUPP) was designed around key elements which influence ulcer healing, promote chronic disease management, optimise recurrence prevention and, more broadly, are conducive to better health and wellbeing. The program sought to empower clients to take ownership of their chronic disease and participate in self-management activities to augment their formal care.

LUPP led to statistically significant improvements in client knowledge for ulcer aetiology, compression bandaging treatment, activity and exercise, nutrition, skin care and the need for compression stockings following healing. Statistically significant improvements in client behaviours were demonstrated in the areas of activity and exercise, skin care and compression bandaging.

The results of this research are of interest to clinicians and organisations who deliver care to people with venous leg ulcers or indeed any chronic disease. LUPP is an evidence-based resource for providing effective client education to improve client knowledge and behaviours and, in turn, promote better health and wellbeing.

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The Leg Ulcer Prevention Program: nurse perspectives on a multimedia client education package for people with venous leg ulcers

Kapp S, Miller C & Donohue L

Abstract
The Leg Ulcer Prevention Program (LUPP) is an evidence-based, multimedia client education package for people receiving care for a venous leg ulcer. The program is delivered in the home via the nurse’s tablet personal computer. LUPP aims to assist people to understand and adopt clinically effective leg ulcer treatment and better manage chronic disease risk factors. The program engages clients in the ownership of their ulcer and self-care activities, promoting wound healing and recurrence prevention.

To complement the evaluation of client outcomes when participating in LUPP, the nurse perspective was investigated. A nurse survey and focus group was undertaken to describe and explore the nurse experience and satisfaction with LUPP. Satisfaction with LUPP was found to be high. LUPP demonstrated success in improving client education practices and nurses facilitated positive health outcomes for clients. LUPP was perceived by nurses as a valuable tool to engage clients and themselves in the education of people with venous leg ulcers.

The LUPP: nurse perspectives on a multimedia client education package for people with venous leg ulcers.

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Sub-bandage pressure difference of tubular form and short-stretch compression bandages: in-vivo randomised controlled trial

Weller CD, Jolley D & McNeil J

Abstract
This research report outlines the findings of a sub-bandage pressure randomised controlled trial (RCT). The aim of the subbandage study was to estimate the difference between mean interface sub-bandage pressures of two multi-layer compression bandage systems during supine position, standing, exercise and recovery. This open-label, prospective, single factor crossover, randomised within person RCT was designed to measure the sub-bandage pressure difference in two compression systems in vivo to inform a current pilot clinical RCT that is comparing the effectiveness of a three-layer straight tubular (elastic) bandaging system with a short-stretch (inelastic) compression bandaging system in the management of people with venous ulceration (3VSS2008). In the sub-bandage in-vivo study the inelastic and elastic compression bandages were randomised to opposite limbs of 42 healthy adult volunteers. Sub-bandage interface pressures for both bandages were compared within person. Interface sub-bandage pressures varied between different activities but the mean difference in interface pressures between inelastic and elastic bandages was consistently at least 13mmHg. Stiffness was 7.3mmHg higher in the inelastic group (95% CI: 5.1 to 9.5). The estimated difference in amplitude of sub-bandage pressure between the bandages during exercise was 15.5mmHg (95% CI 12.2 to 18.9). We found in-vivo interface sub-bandage pressures varied with the type of bandage and activity phase. These baseline results will be useful to inform future compression bandage studies that plan to measure venous ulcer healing rates.

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