Wound Management in Children

 

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Being wounded is a constant feature of life, from birth to death. Over a lifetime, there are myriads of wounds, the organism suffers from, and the question arises whether there are times when there is absolutely no wound present on the one organ providing the interface between body and world, the skin.

Most skin wounds are minute or small, many are not even recognized, and they all heal spontaneously, mostly without leaving a signature on the body surface. This is the every-day-side of the wound spectrum that—beside being a skinteresting consideration—does not deserve particular mentioning in this context.

Yet, there is also a once-in-a-lifetime disaster-side of the wound spectrum that, sadly, quite frequently hits children. The goal of the manuscript presented here is to highlight the key aspects of gold standard wound management in pediatric patients suffering from burns, septic skin necrosis, avulsion injuries, and so called “difficult wounds.”

Generally speaking, the times are long over when it was perhaps justified to let a severely burned child die “because chances of survival are anyway slim, and, if it survives, life thereafter would be like hell.” From a today's prospect, both statements are not correct. Also, it is no longer acceptable that, for instance, a child with a degloving avulsion injury is treated with widely meshed skin grafts “because of propensity to infection” and without any attempt to already primarily restore body contours “because that can be taken care of later.” Likewise, these statements are not appropriate anymore. Why is this so?

The fact of the matter is that substantial progress has been made over the last few years including significant refining of surgical techniques, the use of potent temporary or permanent skin substitutes, the application of the VAC system to debride, cleanse, and condition wound beds as well as to reliably keep in place delicate transplants or transplants in delicate locations.

Along with this impressive line of truly contributive innovations we are witnessing an essential change of paradigm. In earlier years, rapid and low-risk closure of extended wounds was key to enhance survival even if many of these procedures were associated with functionally disabling and cosmetically disfiguring scarring.

Today, highly specialized centers, deliver wound management (of course, this is only one of many integral parts of comprehensive care) in such a way that not only survival and function but also optimal cosmetic outcomes are primary goals. In other words, the appearance of the body surface, is gaining a functional quality. Rightly so!

Of course, top-notch quality of comprehensive surgical, nursing, rehabilitative, and psychosocial care delivered from the first day of admission throughout the entire hospitalization and rehabilitation phase cannot be realized in all of the many places where such patients at first land. But, in all those many places the question must be answered whether such patients should not be transferred to one of those few centers where these poor kids receive state of the art care and may survive and, despite problems, live a good life.

Finally, the last article casts light on the latest and utmost innovative strategy of wound management: Tissue engineering of skin that we would like to term “Skingineering.” Today, it is possible to build an autologous full-thickness skin analog in the laboratory. And tomorrow, we hope to use tissue engineered skin clinically for the benefit of countless children.