Emergency Treatment of Severely Burned Pediatric Patients: Current Therapeutic Strategies

Gerd G. Gauglitz; David N. Herndon; Marc G. Jeschke


Pediatr Health. 2008;2(6):761-775. 

In This Article

Burn-wound Coverage

Following burn-wound excision, it is vital to obtain wound closure. Various biological and synthetic substrates have been employed to replace the injured skin postburn. Autografts from uninjured skin remains the mainstay of treatment for many patients. Since early wound closure using autograft may be difficult when full-thickness burns exceed 40% of total BSA (TBSA), allografts (cadaver skin) frequently serve as substitutes for skin in severely burned patients. While this approach is still commonly used in burn centers throughout the world, it bears considerable risks, including antigenicity, cross-infection as well as limited availability.[56] Xenografts have been used for hundreds of years as temporary replacement for skin loss. Even though these grafts provide a biologically active dermal matrix, the immunologic disparities prevent engraftment and predetermine rejection over time.[57] However, both xenografts and allografts are only a mean of temporary burn-wound cover. True closure can only be achieved with living autografts or isografts. Autologous epithelial cells grown from a single full-thickness skin biopsy have been available for nearly two decades. These cultured epithelial autografts have shown to decrease mortality in massively burned patients in a prospective, controlled trial.[58] Our institution found that cultured epithelial autografts utilized in combination with wide-mesh autograft and allograft overlay in a pediatric patient population with burns of greater than or equal to 90% TBSA to be associated with improved cosmetic results.[59] However, widespread use of cultured autografts has been primarily hampered by poor long-term clinical results, exorbitant costs and fragility and difficult handling of these grafts, which have been consistently reported by different burn units treating deep burns, even when cells were applied on properly prepared wound beds.[57,60,61] Alternatively, dermal analogs have been made available for clinical use in recent years. Integra™ was approved by the US FDA for use in life-threatening burns and has been successfully utilized in immediate and delayed closure of full-thickness burns, leading to a reduction in length of hospital stay, favorable cosmetics and improved functional outcome in a prospective and controlled clinical studies.[62,63,64,65] Our group recently conducted a randomized clinical trial utilizing Integra in the management of severe full-thickness burns of 50% or more TBSA in a pediatric patient population comparing it with standard autograft-allograft technique, and found Integra to be associated with attenuated hepatic dysfunction, improved resting energy expenditure and improved aesthetic outcome post-burn.[66] Alloderm™, an acellular human dermal allograft, has been advocated for the management of acute burns. Small clinical series and case reports suggest that Alloderm may be useful in the treatment of acute burns.[67,68,69,70] Tissue-engineering technology is advancing rapidly. Fetal constructs have recently been successfully trialed by Hohlfeld and colleagues[71] and the bilaminar skin substitute of Boyce[72] is now routine in clinical use and promise spectacular results.[53] Advances in stem cell culture technology may represent another promising therapeutic approach to deliver cosmetic restoration for burn patients.


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