Hastening the Healing Lessening the Pain
Monday September 27, 2004
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Jenny is one of the lucky ones. Thanks to her
mother's quick thinking, Jenny avoided a full-thickness skin burn. What's more, with the help of a new
bioengineered skin substitute, her burn will heal faster and better, and she'll suffer less pain than a child with a similar burn just a few years ago.
Every year, nearly 40,000 children like Jenny
suffer preventable burn-related injuries that require
hospitalization.1 Scalds are the most common burn among young children and are most often caused when a child spills hot food or liquid or is exposed to hot water in a tub or sink. Younger children are
especially vulnerable because their skin is thinner and burns more deeply at lower temperatures. A child directly exposed to hot tap water at 140 F for three seconds, for example, will sustain a full-thickness (third-degree) burn.2
Burn treatment varies according to severity. Airway management, fluid replacement and resuscitation, pain management, prevention of infection, and nutritional support are the hallmarks of acute burn care, along with wound care that promotes rapid healing, minimizes scar formation, and preserves maximum function.
Beginning soon after the resuscitative period, standard treatment to prevent infection and promote healing requires quick removal of nonviable eschar - the slough or crust of necrotic burn tissue characteristic of a
partial- or full-thickness burn. The tissue bed beneath the eschar must be viable and clean for the wound to heal properly. In the past, in many pediatric units, this meant twice-daily, painful hydrodebridement of the wound in a whirlpool tub or with hose devices. Following this, the nurse applied a topical antimicrobial agent such as silver sulfadiazine to the wound and a dressing.
Skin Substitutes Offer
Better Options for Healing
Approximately five years ago that all changed with the advent of new technology - bio-engineered skin substitutes that protect burn wounds and act as a
stimulant for the body's natural healing process, says Barbara Stapor, RN, CPN, senior staff nurse in the surgical care center at Children's National Medical Center in Washington, D.C. Children's was one of
the first U.S. pediatric institutions to start using one of these products, TransCyte®, in standard burn
treatment protocols. Nurses and physicians found it was safe, effective, and significantly reduced the length of a hospital stay.3 The skin substitute also reduced pain, improved the quality of care for children with burns, and decreased hypertrophic scarring.
TransCyte® is one of several types of tissue-engineered skin substitutes that have significantly advanced wound healing. As a temporary wound covering, it promotes the healing of partial- and full-thickness burns until the epithelium reestablishes itself. It also prevents fluid loss from the wound and serves as a barrier to microorganisms. In addition, because it covers and protects exposed nerve endings, it
alleviates pain.
TransCyte® comes in two processed 5 x 7.5-inch sheets that are kept frozen at minus 70 F and thawed when used. There are two layers. The outer layer is the synthetic epidermal layer that protects the wound surface from infection and other environmental insults and is semipermeable to allow fluid and gas exchange. Culturing fibroblasts from newborn human foreskins onto a silicon and nylon net makes the inner layer. Freezing destroys the fibroblasts leaving behind a scaffolding of essential proteins known to facilitate wound healing.
Jenny's Story
Because of the nature of her wounds, Jenny is a good candidate for TransCyte® therapy. For the first 24 hours after her burn, nurses debride her wounds every 12 hours and apply silver sulfadiazine and dressings to keep the wound moist and prevent
infection. Once she is stable, Jenny goes to the
operating room to receive TransCyte.®
In the OR, she undergoes surgical burn wound debridement under general anesthesia. The surgeon places the TransCyte® over the debrided wound, and the inner layer adheres quickly to the healthy tissue bed. Gauze compression dressings are applied over the TransCyte®, and dressing changes take place every two days after that.
Once TransCyte® is applied, Jenny's epithelial cells proliferate and migrate across the wound, resulting in rapid wound healing. Besides being flexible, the skin substitute is also transparent, allowing the nurse to observe the wound for signs of infection or other problems. As the wound heals, TransCyte® dries and peels off, leaving pink, new skin beneath it. "As a practitioner who did traditional [hydrotherapy and debridement] burn care for years, I see this as a
dramatic improvement in the treatment and care," says Stapor. "The length of stay with TransCyte®, for example, is an average of two days, while that same patient, in the past, would have required a week's
or more stay."
Although this new technology has revolutionized burn care, Natalie Tukpah, RN, BSN, MBA, advanced practice specialist in the surgical care unit at Children's National Medical Center, cautions that it is not appropriate for all burn injuries. "It cannot always be used on the hands, head, or feet," she explains. "We may try to use it on the buttocks, but it may not take."
If unsuccessful, the TransCyte® is cut away and the dressing changes begin again. "This child might need to return to the OR for a graft," she explains, "then remain on bed rest until the physician removes the dressing, and hydrotherapy begins again." Fortunately, she adds, it's less painful this time.
An Ounce of Prevention
While the advent of new technologies like TransCyte® can help hasten the healing and lessen the pain of burn injuries, prevention is still key. It's estimated that more than 75% of all scald-related burn injuries in young children could be prevented through behavioral and environmental modifications.2 Stapor believes that parent education and vigilance can make a real difference. "Nurses who work in pediatric clinics or offices can be very instrumental advocates in their own settings," she says. "As
nurses," concludes Stapor, "if we can prevent even one of these little ones from getting burned, we have saved needless pain."
Margaret Hawke, RN, MA, is a contributing writer for Nursing Spectrum.
References
1. Keep Kids Healthy Website. Burn Safety. Available at: www. keepkidshealthy.com/welcome/safety/burn_safety.html. Accessed June 16, 2004.
2. Injury Facts, Burn Injury. National SAFE KIDS website. Available at: www.safekids.org/tier3_cd.cfm?content_item_id=1011&folder_ id=54. Accessed June 16, 2004.
3. Lukish JR, Eichelberger MR, Newman KD et al. The use of a
bioactive skin substitute decreases length of stay for pediatric burn patients. J Pediatr Surg. 2001;36(8):1118-21.
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