Telemedicine and burns: an overview.

Access to specialized burn care is becoming more difficult and is being restricted by the decreasing number of specialized burn centers. It is also limited by distance and resources for many patients, particularly those living in poverty or in rural medically underserved communities. Telemedicine is a rapidly evolving technology related to the practice of medicine at a distance through rapid access to remote medical expertise by telecommunication and information technologies. Feasibility of telemedicine in burn care has been demonstrated by various centers. Its use facilitates the delivery of care to patients with burn injuries of all sizes. It allows delivery of acute care and can be appropriately used for a substantial portion of the long-term management of patients after a burn by guiding less-experienced surgeons to treat and follow-up patients more appropriately. Most importantly, it allows better effective triage which reduces unnecessary time and resource demanding referrals that might overwhelm system capacities. However, there are still numerous barriers to the implementation of telemedicine, including technical difficulties, legal uncertainties, limited financial support, reimbursement issues, and an inadequate evidence base of its value and efficiency.

L'accès aux soins de brûlure spécialisés est de plus en plus difficile et est limité par la diminution du nombre de centres de brûlés spécialisés. Il est également limité par la distance et les ressources pour de nombreux patients, en particulier ceux qui vivent dans la pauvreté ou dans des communautés rurales mal desservies médicalement. La télémédecine est une technologie qui évolue rapidement. Cette technologie est liée à la pratique de la médecine à distance grâce à un accès rapide à l'expertise médicale à travers les technologies de l'information et des télécommunications. La faisabilité de la télémédecine dans le traitement des brûlures a été démontrée par des différents centres. Son utilisation facilite la prestation de soins aux patients souffrant de brûlures de toutes tailles. La télémédecine permet la livraison de soins de courte durée et peut être utilisée de manière appropriée pour une partie importante de la gestion à long terme des patients après une brûlure en guidant les chirurgiens moins expérimentés. Plus important encore, cela permet de mieux triage qui réduit les renvois inutiles qui pourraient submerger les capacités du système. Cependant, il y a encore de nombreux obstacles à la mise en oeuvre de la télémédecine, y compris les difficultés techniques, les incertitudes juridiques, un soutien financier limité, les questions de remboursement et une base de preuves insuffisantes de sa valeur et de sa efficacité.

Pressure garment therapy (PGT) of burn scars: evidence-based efficacy.

Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor's level of function, including work and recreational activities. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT). Despite the magnitude of the problem of hypertrophic scarring and the ubiquitous use of pressure garments as therapy, strong clinical evidence of the efficacy of PGT in the literature is lacking. Some of the challenges facing measurement of efficacy of PGT on hypertrophic scarring are lack of clear definitions for degree of hypertrophic scarring, inability to quantify pressure applied to scars, patient noncompliance to strict PGT time schedules, and inability to conduct randomized controlled trials comparing PGT to no therapy for ethical reasons since PGT is considered a standard of care. In this review, we attempt to summarize and analyze evidence-based literature on PGT and its efficacy in burn hypertrophic scars published in English language in the past 15 years.

Les cicatrices de brûlures hypertrophiques représentent un défi pour les survivants de brûlures et les fournisseurs. Dans de nombreux cas, ils peuvent gravement limiter le niveau de fonction d'un survivant de brûlure, y compris au travail et pendant les loisirs. Une modalité généralisée de la prévention et le traitement des cicatrices hypertrophiques est l'utilisation de la thérapie de vêtement de compression (TVC). Malgré l'ampleur du problème des cicatrices hypertrophiques et l'utilisation omniprésente de vêtements compressifs en tant que thérapie, dans la littérature il n'y a pas de preuves cliniques solides de l'efficacité de la TVC. Quelques-uns des défis auxquels fait face la mesure de l'efficacité de ce traitement sur les cicatrices hypertrophiques sont: le manque de définitions claires pour degré de cicatrisation hypertrophique, l'incapacité de quantifier la pression appliquée sur les cicatrices, la non-conformité des patients en ce qui concerne les horaires strictes du traitement, et l'incapacité de mener des essais comparatifs randomisés comparant cette thérapie à aucun traitement pour des raisons éthiques car la TVC est considérée comme une norme de soins. Dans cette revue, nous tentons de résumer et d'analyser la littérature fondée sur des preuves de la TVC et son efficacité dans les cicatrices hypertrophiques des brûlures publiés en langue anglaise au cours des 15 dernières années.

Acute burn resuscitation and fluid creep: it is time for colloid rehabilitation.

Fluid overloading has become a global phenomenon in acute burn care. The consensus Parkland formula that has excluded colloid use, the impact of goal-directed resuscitation, and the overzealous on the scene crystalloid resuscitation combined with subsequent inefficient titration of fluid administration and lack of timely reduction of infusion rates, have all contributed to this phenomenon of fluid overloading, known as fluid creep and recognized only recently, constituting a landmine in modern burn care. Solid evidence is supportive to the fact that excessive administration of crystalloid and the abandonment of colloid replenishment at some point of resuscitation are the major contributors to fluid creep. With available evidence from the literature, the present is a comprehensive review of literature about fluid creep, trying to determine the etiology behind it as well as to propose strategies to control its magnitude and complications, namely through colloid administration amongst other options.

Reverse tissue expansion by liposuction deflation adopted for harvest of large sheet of full-thickness skin graft.

Full-thickness skingraft is a valid option to release burn scar contractures with the main purpose of correcting the induced limitation in function and improve the disfiguring appearance of the scar. The main pitfall remains the limited availability of these grafts, especially when large sheets are needed. We present an application of a previously described technique known as reverse tissue expansion, which permits the harvesting of a large sheet of full thickness skin graft when needed. This method was adopted to release a burn scar contracture in a 32-yr-old man who sustained a 65% TBSA burn secondary to a gasoline tank explosion at the age of 7 yr followed by multiple reconstructive procedures. The patient presented with a disfiguring anterior neck contracture coupled to limited range of motion. Improvement of neck extension was contemplated using full-thickness skin graft harvested following reverse tissue expansion achieved by deflation liposuction of the donor site.

Cardiovascular dysfunction in burns: review of the literature.

Major burn injury produces substantial hemodynamic and cardiodynamic derangements, which contribute to the development of sepsis, multiple organ failure, and death. Cardiac stress is the hallmark of the acute phase response and its severity determines postburn outcomes, with poorer outcomes associated with cardiac dysfunction. With available evidence from the literature, the present is a comprehensive review of cardiac dysfunction in burns as well as the different monitoring modalities.

Thermal injury to the hand: review of the literature.

This paper is a comprehensive review of hand burn injuries. The different classifications of thermal burns, out- and inpatient care, indications for escharotomies as well as surgical management, skin substitutes, and paediatric hand burns are thoroughly reviewed.

Nutritional and pharmacological modulation of the metabolic response of severely burned patients: review of the literature (part 1).

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Nutritional and Pharmacological Modulation of the Metabolic Response of Severely Burned Patients: Review of the Literature (Part II)*.

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society. Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.

Nutritional and Pharmacological Modulation of the Metabolic Response of Severely Burned Patients: Review of the Literature (Part III)*.

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiological stress and an overwhelming systemic metabolic response. Increased energy expenditure to cope with this insult necessitates mobilization of large amounts of substrate from fat stores and active muscle for repair and fuel, leading to catabolism. The hypermetabolic response can last for as long as nine months to one year after injury and is associated with impaired wound healing, increased infection risks, erosion of lean body mass, hampered rehabilitation, and delayed reintegration of burn survivors into society.Reversal of the hypermetabolic response by manipulating the patient's physiological and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacological doses, is emerging as an essential component of the state of the art in severe burn management. Early enteral nutritional support, control of hyperglycaemia, blockade of catecholamine response, and use of anabolic steroids have all been proposed to attenuate hypermetabolism or to blunt catabolism associated with severe burn injury. The present study is a literature review of the proposed nutritional and metabolic therapeutic measures in order to determine evidence-based best practice. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined which will certainly have some practical applications but above all will dictate future research in the field.