Burns and Skin Grafts
1 Year Subscription
This is Dr Marc Dolce of the Ohio College of Podiatric Medicine, Department of Surgery. Today, we are going to be discussing burns and skin grafting techniques. The goals of this lecture are as follows:
We are to recognize the different classifications of burns as well as the treatments and to become familiar with different types of skin grafting techniques.
Burns are a very common problem in the field of podiatric medicine. They will be encountered both in the emergency room as well as in the office setting. We need to familiarize ourselves with the different classifications as well as the treatment protocols for different types of thermal injuries.
The first thing we must do when discussing burns is to first define it. A burn is a thermal trauma to the skin.
Then we must define what is skin. Well, the skin is the largest organ in the body. It is our interface with the external environment. It protects our internal environment and body structures from physical trauma as well as invasions from foreign organisms.
In order to discuss skin, we must have a quick review of the anatomical structures involving the skin.
As you can see from this diagram, the areas of the skin that we are going to be discussing are as follows: The epidermis, the dermis, and the hypodermis. As you see from the diagram, a partial thickness burn encompasses the dermis and the epidermis. A full-thickness burn encompasses both the epidermis, dermis and hypodermis.
There are different types of burn agents that we must familiarize ourselves with. The first type of agent is a dry heat, for example a flame or fire, that would be considered a dry heat. There are burns that can be caused by moist heat such as steam or hot water. Chemical burns are also a significant problem. Acids and corrosives can create a chemical burn. Electrical burns are also a significant type of thermal injury that can occur. Current or lightening can create an electrical burn. Friction is also very common as well as radiation and electromagnetic radiation. These are all other types of thermal injuries.
Now, we are going to discuss some burn classifications.
First, we must discuss the old classification system for burns. The old classification system classified burns in terms of degrees. There were first degree, second degree, and third degree. As the severity of the burn increased, so did the degree of the burn. This was both confusing and unclear.
The modern classification system for burns discusses partial thickness versus full thickness. The benefits of this modern classification system allows us to determine the extent in which the burn has affected the skin.
Partial thickness burns have two types. There is a partial thickness superficial which affects only the epidermis. There is a partial thickness deep which affects the epidermis and part of the dermis.
The full-thickness burn affects the entire skin. The full-thickness burn includes the epidermis, the dermis, and the subcutaneous tissues.
In comparison with the old classification and the new classification system, a partial thickness superficial burn would be equal to a first-degree burn. A partial thickness deep burn would be equivalent to a second-degree burn. A full-thickness burn would be equivalent to a third-degree burn.
While discussing the classification of a burn, it is important to understand the depth of an injury. The depth of an injury depends on three things. The first thing is the thickness of the skin at the site of the injury. Burns sustained to the soles of the feet would have a thicker area of skin to penetrate than the one that was sustained at the dorsum of the foot. The heat produced by a burning agent is also very important. This will determine the depth in which a burning agent can penetrate. Heat produced from a steam burn is less effective than heat produced by electrical burns. The time in which the burning agent was applied to the skin also has a significant affect on the injury depth.
Now, we are going to discuss the partial thickness superficial burn.
The partial thickness superficial burn or first-degree burn has several characteristics. Erythema is noted. Usually, the erythema is a flat red lesion. There is no blister formation. An example of this would be a typical sunburn.
This is a typical example of a partial thickness superficial burn or first-degree burn. This is a typical sunburn.
Next, we are going to talk about the partial thickness deep burn or second-degree burn. The characteristics of a second-degree burn usually shows erythema on a red base. Bullae or blister formation is common. There is some mottling of the skin and it has as spotty white appearance and these burns are typically very painful.
Note, the large bulla extending from the index finger. This is a partial thickness deep burn or second-degree burn.
Here is an example of a second-degree burn as well. Note, the erythema and the spotty white mottling of the skin. This is a partial thickness deep burn.
Another example of a partial thickness deep burn or second-degree burn.
This is an interesting patient. He presented to our clinic. He dropped some hot chicken grease on the dorsum of his foot. He presented with a very large bullae extending over the dorsum of his foot which was recently lanced and this is a typical example of a partial thickness deep burn.
This is after the bullae was de-roofed.
Here you can see another interesting patient who was diabetic with peripheral neuropathy, enjoyed sleeping by a space heater in her apartment, when she awoke she developed significant partial thickness deep burns or second-degree burns.
This is a closer view of the second-degree burn. You can see the spotty white mottling of the burns which are typical with the erythema and blister formation.
This is another view of the same patient. Note the significant mottling of the skin.
The full-thickness burn or third-degree burn has some specific characteristics. There is mottled skin, usually white or black. The burn itself is white. There is no erythema. There is eschar that develops which is a black non-pliable scab. These burns are typically painless.
Here you could see a third-degree burn or full-thickness burn at the plantar aspect of the foot. These burns are typically painless because the nerve endings have been destroyed.
Well, when discussing burns the first thing that we need to understand is the anatomy of the burn or the zonal architecture of the burn. A burn has typically 3 zones.
The first zone is the zone of coagulation. The zone of coagulation is the area of most intense heat. This is usually white in appearance. In this area, the capillary beds contract. This area is empty of red blood cells.
The next zone in the zone of stasis. The zone of stasis is an area where significant erythema will develop. This area blanches initially. After 24 hours, the area remains intensely red and does not blanch. No blanching of this lesion is a bad sign. This is usually indicative of significant vascular damage.
The third zone or the zone of hyperemia has some typical characteristics. There is erythema that is noticed there. The area blanches until reepithelialized in 7 days. It is the least affected zone and this zone is only seen in epidermal injuries or partial-thickness injuries.
Here you can see the zonal architecture, the zone of hyperemia, the most outer zone, the zone of statis, and the zone of coagulation.
We must discuss the thermal progression of a burn. It is important to remember that the severity of the burn injury may progress beyond the moment the heat source was removed. The thermal progression propagates from the center of the burn outward, from the center or the zone of coagulation to the outer regions, the zone of statis.
Now, we are going to discuss some principles of burn care.
There are 4 principles of burn care.
1. You must accurately diagnose the extent of the burn.
2. Immediate use of the measures to lessen the effects of the burn removing the agent, cooling the area.
3. The third principle is to protect and to close the wound.
4. The fourth principle is to rehabilitate properly.
Initial management of a burn includes cessation of the burning agent, airways, breathing, and circulation, assessment of the vascular status of the affected limb, treatment of associated injuries, fractures, bleeding etc., transportation to the hospital as well as fluid resuscitation.
Fluid resuscitation is of utmost importance. We must establish an IV line for medications and for volume replacement. We need to maintain adequate tissue and organ perfusion. Fluid management is critical.
In order to understand fluid resuscitation, it is important to understand Baxter rule. Baxter rule determines the amount of fluid necessary to maintain tissue and organ perfusion in a burn victim.
Baxter rule determines the amount of fluid necessary within the first 24 hours. It requires the infusion of plain lactated ringers 4 mg of crystalloid. Basically you take the 4 mg of crystalloid, multiply that with the weight of the patient in kilograms, times the percentage of the body that is affected by the burn.
For example, within the first 24 hours, a 70-kilogram man with 50% of his body burnt would be 4 mg of crystalloid x 70 kg man x 50% of his body being burnt is 14 thousand milliliters of lactated ringers within the first 24 hours.
The second 24 hours is governed by giving only one-half to two-third of the first 24-hour fluid replacement. Therefore, in our example, a patient who was given 14,000 ml of lactated ringers would only receive 7000-11,000 ml. At this time, we may add 5% dextrose in water. After the first 24 hours of fluid replacement, the remaining fluid replacement is based on the patientâs clinical response and the laboratory values.
The laboratory values that are of utmost importance are serum and urine osmolarity, which is a kidney function study, electrolytes, as well as the hematocrit, which is a volume indicator.
Now, we are going to discuss burn shock.
Burn shock is typically a hypovolemic shock in which circulatory collapse occurs. There is hypoperfusion of cells and tissues due to reduction in blood volume. Arterial vasoconstriction also occurs. This is due to catecholamines acting as a secondary mediator triggering sympathetic discharge and a decrease in blood pressure.
Now, we are going to discuss how to determine the percentage of body that is burnt. This is called the rules of 9âs.
As you can see from this diagram, the body surfaces are divided into areas representing multiples of 9. The upper extremity, both arms, anterior and posterior, is considered 9% of the body. The face as well is considered 9% of the body. The anterior aspect of the thoracic region is considered 18% of the body as well as the posterior region is considered 18% of the body. Both lower extremities anterior and posterior are considered 18% of the body. The genitalia region is considered 1%.
In a child, the areas are subdivided differently. The lower extremities are considered 14% of the body region. The childâs palms are considered 1% of the body region. The head area is considered 18% of the body region.
Now, we are going to talk about some initial management of foot burns.
Initial management of the burns of the foot includes immediate and continuous assessment of circulatory status of the involved limb, escharotomy, tetanus prophylaxis, antibiotic management, and cooling and cleansing the involved limb.
The physical examination should include continuous evaluation of the circulatory status including dorsalis pedis, posterior tibial pulses, capillary filling time to the digits, assessing the rules of 9âs, and determining the depth of the injury.
When should a burnt patient be hospitalized?
When should burns be hospitalized, all plantar burns, both second and third-degree, second-degree burns greater than 15% of body area, third-degree burns greater than 2% of the body area, patients less than the age of 2 and greater than the age of 60, electrical burns, inhalation or chemical burns should all be hospitalized.
Let us discuss eschar development.
Eschar development. Eschar is a black non-pliable scar which develops quickly. This is only seen in third-degree burns. These eschars are very constricting and may cause significant neurovascular compromise.
The formation of eschar is an emergency. They can cause significant damage to the neurovascular structures. An escharotomy must be performed. Escharotomies do not require anesthesia because the nerve endings have been affected by the third-degree burn.
Let us discuss long-term treatments of burns.
Long-term treatments for burns includes aggressive physical therapy, elevation, splints nonweightbearing, compressive garments to decrease the hypertrophic scar formation as well as skin grafting.
Treatment for partial thickness superficial burns include covering the burnt area with sponges or towels, usually cool sterile saline is fine, no ice, the optimal temperature is between 72 and 77 degrees Fahrenheit. Wash the area with mild soap or detergent, mild analgesics for pain, over-the-counter pain medicines are just fine, avoid ointments, topical antibiotic creams are the best.
Treatments for partial-thickness deep burns include prescription pain medication, taking care of the blister, de-roofing or not de-roofing the blister, protection against mechanical irritation with the dressing, tetanus prophylaxis, as well as oral antibiotics.
Full thickness burns treatment protocols are as follows: These are usually painless, so pain medications are not necessary, admission to a hospital or a burn center, controlling infection by the use of IV antibiotics, escharotomy usually covered with a porcine or xenograft to prevent dehydration.
The ultimate goal of a full-thickness burn is to cover the area with a skin graft.
Antibiotic management for burns.
Antibiotic management. The most problematic bacteria in burns is Strep and Pseudomonas. Clostridium is the number 1 anaerobe.
First-generation cephalosporins are excellent against gram-positive organisms Staph and Strep. Gram negatives are also covered by first-generation cephalosporins. The gram negatives that are covered are Proteus, E. coli, and Klebsiella. There is little anaerobic coverage with first-generation cephalosporins.
Typical first-generation cephalosporins that are utilized are Duricef and Keflex, which are oral, and Ancef, which is IV.
Second-generation cephalosporins have a decrease in gram-positive activity. They have an increasing gram-negative activity, Proteus, E. coli, and Klebsiella, Haemophilus is added.
Typical second-generation cephalosporins include Ceftin, which is oral, Zinacef and Mefoxin which is parenteral.
Third-generation cephalosporins have even greater decrease in gram-positive activity and a superior gram-negative coverage. Proteus, E. coli, Klebsiella, Haemophilus, and
Pseudomonas is added with the third-generation cephalosporins.
Typical third generation cephalosporins that are utilized Suprax, Vantin, Rocephin, and Fortaz.
Topical antibiotics are also important when managing burns.
1% Silvadene cream is a main stay in burn management. It is the agent of choice and most commonly used. The benefits are it is a painless application twice a day, allows the wound to be open, it has minimal acid/base metabolic changes, has a low hypersensitivity rate, less than 1% and is good for superficial burns.
Silvadene cream is contraindicated in the patients with a sulfa allergy. There is no debriding characteristics to Silvadene cream. It does not penetrate Eschar. It is great for all bacteria, especially Pseudomonas.
Mafenide which is another topical agent has a b.i.d. application. It does penetrate eschar, has some debriding characteristics, may be used on full-thickness burns, has a painful application, and has about a 7% hypersensitivity reaction.
0.5% Silver Nitrate comes in a stick form. It is a good anti-microbial. There are no hypersensitivity reactions reported. It is generally painless but it does stain tissues permanently.
Next, we are going to discuss some skin grafting techniques.
We first need to discuss how wounds heal. Wounds can heal by two mechanisms. The first mechanism is by secondary intention which involves epithelization. The second mechanism is by primary intention which includes apposition of the wound edges, a movement of a tissue flap or by direct transfer or a skin graft. Skin grafting is wound healing by primary intention.
Indications and applications for skin grafting. The indications for skin grafting include restoring the functional integrity of the skin to help with cosmetic appearance for coverage of burns, ulcerations, or traumatic losses of tissues.
There are different types of skin grafts. There are split-thickness grafts or partial-thickness grafts and full-thickness grafts.
Warnings to patients involving skin grafts. The patient may lose function of the following depending on how thick the split-thickness graft is: They may lose the function of sebaceous gland, they may not have hair in the graft site area, they may have minimal sweat gland function, pigmentation in the graft site is usually different, and they may have varying sensation in the area after the graft.
When performing a skin graft one must first determine the donor site. The best option for a donor site is the one that is out of sight i.e. the thigh or upper lateral leg, the buttocks region, and in the foot sometimes the sinus tarsi region.
Contraindications to skin grafting includes grafting over eschar, over tendon, over exposed bone or cartilage, or exposed nerve.
Preoperatively, the skin graft is usually performed under general or spinal anesthesia without the use of a tourniquet. There are two drapes, one at the donor site, one at the graft site with a window cut out leaving the unexposed area covered.
Supplies that are necessary for a skin graft are mineral oil, topical thrombin, Op-Site, Xeroform, stapler, a dermatome, and a meshing device.
Some special instrumentation is needed for skin grafting. A Blair and Humby knife, a dermatome, as well as a graft mesher.
The meshing device is utilized when skin grafting to help expand the tissue 1.5 to 9 times its size. It also fenestrates the tissue or skin graft to allow for adequate drainage.
Harvesting the skin graft involves lubrication of skin with mineral oil, stabilization of the skin by an assistant.
Dermatome is run over the donor site with firm and even pressure and is advanced very slowly.
Removal of the skin from the dermatome must be done carefully. The skin is then spread on to a plastic plate for the meshing with the dermis side down. There should be no wrinkles in the skin graft.
The graft is then cranked through the meshing device.
The graft is now removed from the plastic plate and placed on the back table in a moist saline gauze. We now can begin to prepare the graft site.
Techniques in applying the graft: We must debride the edges and the base of the wound sharply to remove excessive fibrous tissue. The wound must be thoroughly irrigated.
We apply the graft to the wound dermal side down, allow the graft to overlap the edges of the wound, staple the graft in place, trim graft to appropriate size while stapling it down.
Remember the skin grafts are composed of all epidermis as well as varying amounts of dermis. A thin graft measures 0.005-0.012 inches. A thick graft measures 0.019-0.28 inches.
Postoperative care of a skin graft. The patient must not move the graft site, the foot must be elevated with pillows, and the foot must be left alone. You must leave the immediate postoperative dressing in place. When changing the dressing, great care must be taken not to disrupt the graft-host interface. Any hematomas or seromas that develop must be drained using #11 blade.
Dressings for the graft site include Xeroform with a Jones compressive type dressing, a posterior splint or BK cast. Donor site usually includes bupivacaine with epinephrine and Op-Site to the area.
Here is a typical picture of a skin graft. Note the fenestrations due to the meshing of the graft.
Storage of extra graft. Extra graft may be stored by wrapping it up in moist saline sponges and placed in a sterile cup. They can be refrigerated at 0-5 degrees Celsius. A skin graft can survive a maximum of 21 days.
There is approximately 75% success rate of skin grafts to lower extremity.
Dr. Marc Dolce's lecture on Burns
and Skin Grafts is another fine example of podiatrists treating injuries using cutting
edge technology. A burn is a thermal trauma to the skin. This is significant because
the skin protects our internal environment and body structures from physical trauma as
well as from invasions by foreign organisms..
Dr. Dolce familiarizes us with a new classification system for burns. This new system more clearly defines the extent to which the burn has affected the skin. "Partial thickness superficial" (1st degree) describes a burn that only affects the epidermis. "Partial thickness deep" (2nd degree) describes a burn that affects the epidermis and part of the dermis. A "full thickness" (3rd degree) burn includes the epidermis, the dermis, and the subcutaneous tissue.
The four Principles of Wound Care are discussed:
1. Proper diagnosis/evaluation
2. Immediate use of measures to lessen the effects of the burn by removing the caustic agent and cooling the area
3. Protect and close the wound
4. Rehabilitate properly
Dr. Dolce takes us through proper burn management...Cooling the area with sterile saline, washing the burn with soap and water, then applying topical creams such as Silvadene, which will suffice for simple partial thickness burns.When treating advanced, full thickness burns, the astute physician must be familiar with appropriate lab values, tetanus prophylaxis, fluid replacement (to prevent hypovolemic shock), the potential need for escharotomy and temporary skin coverage with xenografts. Proper antibiotic coverage is imperative in treating all burns. Become familiar with Baxter?s rule , the Zone of Coagulation, and the Rule of Nines. Learn why full thickness burns are typically painless. See how compressive garments benefit the rehabilitative process.
|Goals and Objectives|
After participating in this activity, the viewer should be better able to:
1. Recall the classification systems.
2. Utilize the rule of 9s.
3. Recognize the principles of burn care including fluid resuscitation techniques
Estimated time to complete this activity is 40 minutes.
Physicians, diabetes educators, and other health care professionals who treat patients with diabetes.
Complete the 4 steps to earn CE/CME credit:
It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.Marc Dolce, DPM has nothing to disclose
This web site will respect the confidentiality of the information that is transmitted on it in accordance with the provisions of this Agreement. The Web Site uses a random identifier, which is a session number attributed to the Registered User as he enters the site. This session number is expunged of the Web Site system as Registered User leaves. Please be advised that the Registered User's visit to the Web Site leaves a retrievable trace that allows the Web Site to gather raw data on the Registered User. Such technical retrieving system is necessary in order to secure the Web Site system.
This web site uses statistic and measurement systems which compile and process information such as IP numbers and number of visited pages. This information is processed in order to establish members' profiles and trends that may lead to, for example, market studies.
By registering to Web Site services, the Registered User agrees that his/her personal information may be archived in the members database of the Web Site and be used to transmit newsletters published by the Web Site and communications such as press releases or commercial information by the Host.
Information We Collect
Information We Collect from Unregistered Visitors
Visitors to each of our Web sites can access the Web site's home page and browse some areas of the site without disclosing any personally identifiable information. We do track information provided to us by your browser, including the Web site you came from (known as the "referring URL"), the type of browser you use, the time and date of access, and other information that does not personally identify you. On most of our Web sites, you must register with us to use the entire site.
Information We Collect When You Register
Customers registering for services on our Web sites are asked to provide us with identifying information, such as name, gender, contact information, and other personal information. On our registration screens, we clearly label which information is required for registration, and which information is optional and may be given at your discretion. You will also be given a choice about whether or not you want to receive newsletters and other information that we distribute from time to time. This PRESENT e-Learning Systems Web site will explain how personally identifiable information will be used and ask for your consent before collecting it.
Discussion Boards: When you use a discussion board on one of our Web sites, you may post a message and your user name, which is available for all registered users to see. When you are posting publicly, any user of our Web site can see your message. You should not post any information you want or are required by law to keep private to a discussion board or other public forum on our Web sites.
My CV (Curriculum Vitae): On our web site, we offer an online data based profiling tool in which you supply information that is part of your curriculum vitae or professional resume. This tool stores the information that you provide on our servers. The information is accessible by other members and the public, and is designed to advertise you to the online community and allow other's to find you based on the information that you provide. We will always make it clear to you when information you provide to us through a tool will be saved.
Member Lookup: On our website, other members will be able to look you up and send you messages. If you opt not to be listed (blocked), no other members will be able to look you up.
In addition, we gather information about you that is automatically collected by our Web server, such as your IP address and domain name. We will use this information to personalize its offerings and presentations to you, facilitate your movements throughout our Web sites, provide personalized services, and to communicate with you individually.
Continuing Medical Education
When you register for a Continuing Medical Education ("CME") or a Continuing Education ("CE") activity through our web site, we collect certain personally identifiable information from you such as your name, email address and mailing address. We require that you provide the state in which you are licensed and your license number. In addition to personally identifiable information, we collect aggregated non-personally identifiable information about the activities undertaken by our users. We use the information that we collect through CME/CE activities in several ways:
(i) We are accredited by the Accreditation Council for Continuing Medical Education ("ACCME") to provide continuing medical education for physicians, through a sponsorship agreement with the Mount Sinai School of Medicine. As an ACCME accredited entity, we are required periodically to submit aggregated data about CME participants and the CME activities we certify. We also provide personally identifiable information to other accredited CME/CE providers who certify CME/CE activities posted on our Web sites, as required by the ACCME and other accrediting bodies. These reports may include personally identifiable information about you and credits issued to you, for the purpose of maintaining records that you can request from the accredited provider for up to six (6) years;
(ii) Commercial supporters of CME/CE activities on our Web site will receive only a data about CME/CE activities that are relevant to their interests and/or the courses they support;
Uses We Make of Information
We collect data about visitors to our Web sites for product development and improvement activities. We also use it for market analysis. We may provide information from our Web sites in aggregate form, with identifying information removed, to third parties. For example, we may tell a health care partner what percentage of our registered users are of a particular medical specialty or have certain credentials. Any third party that receives our data must agree not to attempt to re-identify the people it belongs to. For example, we may provide information to a potential advertiser of a product that would appeal to a diabetes patient about what percentage of our users have diabetes. Depending on our agreement with the third parties, we may or may not charge for this information.
Marketing and Advertising
We may target our advertising or marketing depending on information we have about you. For example, a user that is a healthcare professional who treats diabetes may receive advertising for new diabetes therapies (although in neither case will the advertiser have access to any individually identifiable information about you). We may also personalize our Web site based on your interests. For example, you may see different articles in different places on our Web site based on information you have shared with us, or information we have gained by observing your previous behavior, or information we may have gained from your interactions with a third party that shares information with us. We use information for our own internal marketing, research, and related purposes. Third Parties In addition to aggregate information (discussed previously), we may share some kinds of personally identifiable information with third parties as described below.
Other Companies: We have strategic relationships with other companies who offer products and services on our Web sites. When you are interacting with those companies, different rules and privacy policies may apply. We do not control the collection or use of information you provide to these companies, but we do require that those companies clearly state their policies so you can decide whether to give them any information.
Promotional Offers: Sometimes we send offers to selected groups of customers on behalf of other businesses. When we do this, we do not give that business your name and address. We provide a variety of mechanisms for you to tell us you do not want to receive such promotional offers. For example, we may provide an opt-in box for consumers to receive an email from another business, and we make clear that by opting in you are submitting your data to a third party.
Protection of Information
We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. We use security methods to determine the identity of its registered users, so that appropriate rights and restrictions can be enforced for that user. Reliable verification of user identity is called authentication. We use both passwords and usernames, as well as double opt-n verification, to authenticate users. Users are responsible for maintaining their own passwords.
Access to Information and Choices
Correction of Information We Have About You
If you believe that registration information collected by our Web site(s) is in error, you may edit your personal profile any time that you like. You can directly edit most of your user profile on the Web site on which you initially registered. Information that you can not edit may only be changed by contacting Web Customer Support (see CONTACTS). Requests for deletion of your record may result in your removal from the registry, but we may keep certain demographic information about you for product improvement purposes. You may contact Web Customer Support and ask for the changes that you would like to make.
This website and its content is copyright of PRESENT eLearning Systems, LLC - © 2007-2012 All rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited other than the following:
You may not, except with our express written permission, distribute or commercially exploit the content. Nor may you transmit it or store it in any other website or other form of electronic retrieval system.