Theme: Principles of
burn treatment. Patients’ care in process of the treatment
1.
First aid for burned patients
2. Infusive antishock therapy
3. Local
treatment of burns
4. Usage
of lyophilized xenotransplants
Burn is the lesion of
tissues, caused by the influence of heat (thermal), chemicals, electricity,
radiation. According to this, there are
heat, chemical, electric burns. Among surgical diseases burns take 2 %.
Depth
of burn depends on duration of the heat factor’s influence. Heat agents with
lower temperature but longer duration of their influence cause the same lesion
as heat agents with higher temperature but shorter duration of influence.
1. First aid for burn patients should be directed on the elimination of the heat agent’s influence and
cooling the burned area. Cold water, ice-bladders, snow during at least 10-15
minutes are the best methods of cooling. Aseptic bandage should be used after.
Analgesia by using of Analgin, Amidopirin, warm tea, mineral water also have to
be used. Usage of therapeutic bandages during the first aid is contraindicated.
Analgesics,
neuroleptics, antihistaminic drugs should be given before and during transporting.
Duration
of transporting should be not more than 1 hour. Longer duration of transporting
needs intravenous infusions of electrolytes and blood substitutes, oxygen
therapy and narcosis.
First-Degree Burns
If you are experiencing a first-degree burn,
immediately remove jewelry or tight clothing from the burned area before it
begins to swell. Flush the burn with cool running water or apply cold- water
compresses (a wet towel or handkerchief) until the pain lessens. Do not use ice
or ice water, which can cause more damage to the tissues. Cover the burn with a
clean (sterile, if possible), dry, non-fluffy bandage such as a gauze pad. Do
not put tape or butter on the burn. Take aspirin or an aspirin substitute such
as acetaminophen or ibuprofen to relieve the pain and inflammation.
Use an antiseptic solution to prevent infection or a
soothing remedy such as aloe to comfort the skin. Most first-degree burns heal
quickly with old skin peeling within a day or two. You will not have any
scarring unless an infection occurs.
Second-Degree Burn
To treat second-degree heat burns with open blisters,
do not remove any clothing that is stuck to the burn. Refrain from using water
on the burn because it increases the risk of shock. Cover the burn with a clean
(sterile, if possible), dry, non-fluffy bandage, such as a gauze pad. Do not
put tape on the burn.
Doctors usually treat second-degree burns by
prescribing antibiotics as the injured skin can no longer protect your body from
infection by airborne bacteria. He or she may apply a bandage to the burned
area with an antibacterial dressing and prescribe pain medication. Doctors may
recommend a skin graft to lessen scarring. Tetanus booster shots are often
administered to burn victims. Second-degree burns usually heal in 10 days to 2
weeks. There may be few or no scars if the burn was not too extensive and if
infection is prevented.
Victims should be transported an emergency room by an
ambulance.
If you see a person with a third-degree burn, do not
let him run. Running may fan the flames causing them to burn a person's face.
Smother the flames with a blanket, rug, or jacket while rolling him on the
ground. Immediately remove jewelry and tight clothing from the burned area
unless it is stuck to the burn. Immerse the burned area in cold water or apply
cold compresses quickly to bring body temperature back to normal.
Many victims who suffer extensive burns can easily go
into shock due to lack of hydration. It is important to recognize shock
symptoms and tell health professionals that the victim is experiencing shock.
Symptoms include decreased level of consciousness, rapid, shallow breathing,
faint, rapid pulse and nausea, sometimes followed by vomiting.
Stay calm while you wait for emergency personnel to
arrive, keep the victim lying down with elevated feet. Use a blanket to
conserve body heat. If the burn area is large, loosely wrap the victim in a
clean sheet. Otherwise, apply dry, non-fluffy loose bandages, such as a
pillowcase or disposable diaper.
Raise a burned arm or leg higher than the person's
heart. However, keep the head and shoulders raised slightly if the person is
burned on the neck or face or is having trouble breathing. If the person is
conscious and not vomiting and if medical help is more than 2 hours away, small
sips of water or clear juice are recommended. If the victim is in shock, do not
allow him or her to consume liquid. Simply moisten the lips with water.
According to Shriners Hospitals for Children, follow the following steps to
treat a thermal burn:
Call 911 for emergency
medical transport to the hospital if there are extensive partial thickness or
full thickness burns to the body or for any problems breathing with burns to
the face, and for any victims who received exposure to a large amount of smoke
in a closed room and as well as any victims who are unconscious following a
burn injury.
2.
Infusive antishock therapy
It starts in the place of accident with intravenous
infusions of saline solutions. Volume
and speed of infusions depend on the severity of patient’s state and daily
volume of blood deficiency. Daily volume
of deficient liquid we can determine in such a way:
4ml
* % area of burn * body weight (kg) = ml of liquid for 24 hours
25% of this volume has to be used during first 4 hours
after trauma, then 25% during next 4 hours, 25% during next 8 hours, and 25%
during next 8 hours.
The volume of daily infusions could not be more than
160ml/kg/day.
Infusions are:
Severity of burn shock |
Colloid:
saline: not saline solutions and days
of usage |
|||
1 day 2 day 3 day 4 day |
||||
LSI to 30 |
0:1:0 |
0:1:1 |
|
|
31-60 |
0,5:1:0 |
0,5:0,5:2 |
0,5:0,5:2 |
0,5:0,25:2,75 |
61-90 |
1:1:0 |
1:0,5:1,5 |
1:0,25:1,75 |
1:0,25:1,75 |
>90 |
1,5:1:0 |
1:0,5:1,5 |
1:0,25:1,75 |
1:0,25:1,75 |
Quick restoring of blood volume by saline
solutions decreases vessel’s spasm, improves myocardial function, decreases
acidosis. It is not good to use colloid solutions during first hours after
trauma cause they have high aggregative action, low speed of out coming from
the organism, and could worse lymphoid drainage. Lower molecular colloid
solutions like refortan are the best.
It’s function is to:
- restore hemodynamic
-
prevent increasing of
capillary permeability
-
prevent activation of
endothelial cells and block the development of secondary injuries
-
defense of blood monocytes.
Glucose during first hours after severe trauma should
not be used, cause it is going out from capillary membrane to between cellular
space and cause the edema. This makes injury deeper.
In 24 hours after the beginning of infusive therapy with electrolytic
solutions - perftoran (plasma substitute) could be used. It’s dosage is 2,5-3,5
ml/kg for one inserting.
It’s function is to:
- normalize oxygen transport
-
restore the hemodynamic
-
improve the rheological blood
function
-
provide diuretic influence
-
provide protection of immune
system
-
provide anti edematous
influence
-
block Ca channels
-
block the appearing of
inflammatory mediators.
It is very important to
correct aggregative blood state. We use low molecular heparins – fraxiparin,
klexan from the first hours after the burn. Fraxiparin is used i/v in dosage
0,3 ml 1 or 2 times a day.
For the decreasing of aggregation
of the blood elements disaggregates should be used. For example – trental
(pentoxifilin) 200-400 mg i/v on 400 ml of NaCl 1-2 times a day.
Of course in complex
treatment of burn shock we use drugs for preventing of complications deal with
heart, kidneys, liver. For example: dofamin (2,5-10 mkg/kg/min), eufillin every
4-6 hours 2,4% 5 ml, 4% Na hydro carbonate 100-200ml, dexametazon 0,5
mg/kg/day.
It is important to prevent
infection by usage of antibiotics. One of them is zinacef from cefalosporines
1,5 g 2-3 times a day.
Criteria of antishock therapy effectiveness:
1) restoring of adequate consciousness
2) stabilization of haemodynamic
3) Ht 33-38%
4) protein of blood > 60g/l
5) normalization of breathing
6) restoring of kidneys’ function
7) normalizing of skin temperature.
The second day of shock deals with the deceasing of
transfusion volume for 1/3. Plasma or albumin could be used in 4- 8 hours after
burn. We use kvamatel ( H2 blocker) 20 mg 2 times a day, maalox, almagel,
smecta. Eubiotics also could be used. In case of burns with the area of lower
15% artificial nutrition should not be used.
3. Local treatment of burns. Problems and prospects.
The final aim of burns’
treatment is the fastest spontaneous healing of superficial lesions or early
surgical repair of lost skin in case of deep burns.
For local treatment of burns
two methods are used: closed and opened. Firstly, primary debridement of the
wound should be done. Using gauze swabs with 0,25 % solution of Ammonia liquid
, 3-4 % solution of acid, or warm soapy
water one should clean the skin around the wound. After that the skin is
alcoholized. Then we should take off pieces of closes, foreign bodies,
separated epidermis. Big bulls should be cut and their contents should be out.
Small bulls as a rule should not be cut. Fibrin should not be moved away
because the wound is epithelizing under it. Very dirty areas are cleaned by 3 %
Hydrogen peroxide solution .
At the end, the burn surface
should be dried by sterile towels.
CLOSED METHOD
Such treatment is widespread
and has some advantages: with it’s help we can isolate burned surface, provide
optimal conditions for the local medicament treatment of burn wounds and
transporting. Applying a bandage with different solutions, emulsions,
ointments, creams is made. Closed method gives a possibility for more active
behavior.
There are some defects of this
method, such as big expenses of dressing material and pain during dressing.
OPENED METHOD
Is in creating of the
sequestration of wound from the environment (in special wards – with laminar
stream of sterile air). The advantages of opened method are: there is no need
in painful dressing, economy of the dressing material, permanent controlling of
the state of acceleration formation of crust on the burned surface due to
drying influence of air. UV radiation, substances that cause coagulation of
proteins. But, usage of opened method complicates medical care for patients
with large area and depth of burns, creates need for special equipment,
increases danger of intrahospital infection.
There methods have some
indications and contraindications, that’s why they should be scrutinized
carefully superficial burns of II-III A
st. heal independently using opened method. It could be used in such cases as
burns of the face, genital organs,
perineum. Using opened method, we have to apply ointment with antibiotics, or
antiseptic solutions on the burn wound 3-4 times a day. If suppuration has
developed, aseptic bandages should be applied. If deep burns have manifested or
granulated wounds have developed, it is better to change the method for closed one.
Local treatment of deep burns
is directed on creation of conditions for development of dry coagulate crust
with its following separation with the help of preparations that cause
photolytic processes acceleration. (Salicylic and Benzoic acid, Papain,
Tripsin, Chemotripsin). After separation of the crust, the dim of the treatment
should be early cleaning of the wound stimulation of growing and maturing of
granulations and restoring of the skin cover.
In case of favorable
development, barns of II st. heals
independently during 7-12 days, III A st. in 3-4 weeks after trauma.
Local burn treatment is directed towards antibacterial protection of burn
wound and restoring of blood circulation in it.
The first task is decided by
means of local treatment, the second one – by general supportive therapy, which
leading role belongs to transfusion treatment. Each stage of evacuation and
treatment of burned patients includes local treatment of burn wounds. It should
be noted that uniform therapy standards have to be applied on each stage.
Superficial burns ²-²² degree, that have some viable
epithelium left in the burn wound, heal by means of islet and general epithelization not only from the wound
edges but from the wound surface as well. Superficial burns heal spontaneously during 2-4 weeks. ² degree burns of any size, ²² degree up to 10 % require just local therapy. Large burns of ²² degree require early (on 2-3rd day) superficial (sequential) necrectomy, plastics by lyophilized xenodermotransplants. The time of healing for ²-²² degree burns depends not only on adequate local treatment, but on a general therapy, the degree of microcirculation restoration, suppuration that can lead to secondary deepening of burn wounds (the wound
can transform from superficial to deep one).
Deep burns of ²²² -IV degree can heal spontaneously only in case of very small, punctuate area of burn, by means
of regeneration of epithelium from edges of the wound. All other wounds, as a rule, have five phases (periods) of wound process evolution:
a) exudative phase - 3-5 days from the moment of trauma;
b) alteration and demarcation phase - 5-10th day;
c) wound cleansing from pus and necrotic tissues phase - 11-17th day;
d) regeneration and reparation
phase (granulate wounds) - 15-45th day;
e) scarring deformities and
atrophic ulceration phase - after 40-45th day.
Superficial burns of more than 15% of total body area, or deep ones of 10 % of total body area, and sometimes in case of 5-7 % of total body area (children,
seniors) cause burn disease.
Treatment of burns III -IV st. is surgical.
SURGICAL TREATMENT includes such
operations as early one (necrotomy and necrectomy), autodermoplasty, amputation
of limbs and reconstructive operations.
Necrotomy is used mostly in cases of circularly burns of the chest and limbs.
Operation leads to decreasing of squeeze (compression) of underlying tissues.
Necrectomy is used in early terms (1-3 days), but only after curing the shock. Usage
of widespread necrectomies is better on 4-7 day. Later there is a great danger
for generalized infection. One moment necrectomy shouldn’t be more then 25-30 %
of skin cover.
Autodermoplasty is the only method of treatment of the deep burns (IIIB-IV st.). Graft
(thickness 0,2-0,4 mm) is taken from the surface of healthy skin, from
symmetrical sides by means of dermatom. Autodermoplasty is used under local or
total anesthesia. Donor skin shouldn’t be taken in the quantity of more than
800-1500 sm2.
Chemical burns appear
due to influence on the skin, mucous membrane (mucosa) concentrated solution of
acids, alkalines, salts of heavy metals, toxic gases. Depth of a lesion of
tissues in cases of chemical burns
depends on such conditions, as nature of the substance, it’s concentration,
temperature of the last condition of it’s action. We can change only the last
condition by means of early, quick and
effective first aid. Action of some chemical can cause not only lesion of skin
and mucosa, but total toxic effect. For example, in cases of burns, caused by
phenols, salts of “Hy”: by – P – toxic lesion of kidneys; by P – aid – toxic
lesion of liver.
Influence of acids, salts of heavy metals causes coagulation of proteins,
dehydration of tissues, leads to formation of coagulate necrosis with
superficial dense crust.
Concentrated solutions of alkalis dehydrate tissues, bind with proteins and
hydrolyzes fats. Alkalis penetrate tissues deeper than acids and cause deeper
lesion. Such necrosis is called coliquative, or wet. Crust, that is formed
after that is soft, and after its separation bleeding of the tissues appear.
In the cases with spread burns there is a danger of the development of
intoxication, caused by re sorbtion of the substances of decomposition of
tissues. Quantity of toxic substances, that have resorbted, depends on burn’s
area.
Chemical burns of I and st. are referred to superficial, III-IV st. – deep
burns. In case of the burns I st. patients complain on pain, burning. During
examination of the place of chemical action one could see localized hyperemia
with swelling of the skin (it’s more visible in cases of alkali burns). All
types of skin sensitivity are preserved,
pain sensitivity is more acute than normally.
In cases of II st. burns there is superficial – dry (in cases of acid
burns) or gelatin – like – soapy (in cases of alkali burns) crust. Crust is
very thin, and could be taken easily into a fold.
In the cases of (III-IV st) deep chemical burns crust is dense and thick,
it couldn’t be taken into a fold. Crust is unmovable, like wet necrosis in case
of alkali burns. Crust is dry in case of acid burn. All types of skin senility
are absent. There is no possibility to differ III and IV st. of chemical burns
by first examination.
In cases of burns III st. all layers of skin become necrotic. In cases of
burns IV st. all underlying tissues (even to bones) become necrotic.
Only after 3-4 weeks, when burn crust has separated one can estimate depth
of necrosis: if only skin has separated – then it is III st. if also underlying
necrotic tissues have separated – then it is IV st.
First aid in case of chemical burn should be directed on early (at first seconds or at least minutes)
cleaning of skin cover from chemical substance. The most effective Cleaning by
means of water stream is. (during 10-15 min). It is was started late, it should
last 30-40 min. Cleaning should last fill the smell of chemical substance
disappear or till color of lakmus paper will change in the moment of touching
to the burns surface. In cases of burns from.
Cleaning with water is forbidden, because after the chemical reaction large
quantity of energy is formed that could cause to the heat burn. In such cases
crust should be removed by mechanical methods.
After cleaning from the chemical substance dry aseptic bandage is applied
on the burn surface and patient is transported to the hospital.
Radiation burns it is the lesion of skin caused by specific action of fissures of
radiation.
Electric burns due to action of electricity with a tension more than 24 V, burn could
appear. Action of electricity is determined by its direct influence during
passing the body or by heat action that is formed an that moment. Heat action
of electricity, according to the Djoul’s rule, depend on voltage of
electricity, resistance of tissues and duration of contact with conductor. The
most severe lesions are situated in places of entry and reentry of electricity
the lesion of tissues mainly depends on their resistance, that why nerves,
vessels become mostly affected. Tissues that gave water have lower resistance
and better conduct electricity.
Electric trauma – is the action of electricity that manifest in changing of
ion’s concentration and polarization in electric field. Electricity cause trans
formation of intracellular proteins into gel with formation of coagulate
necrosis. Aggregation of thrombocytes and leucocytes cause thrombosis of small
blood vessels with the disorders of blood circulation and development of
secondary necrosis.
Total biological action of electricity is characterized by disturbances of
cardiac function caused by electrochemical changes, especially polarization of
cell’s membranes and nervous fibers and is accompanied by cramps of muscles. In
severe cases total action of high Voltage electricity manifest itself by
electric shock with loose of consciousness, apnea, fibrillation of heart
ventricles. By the way, asystole can appear not only at the moment of trauma or
right after it, but after some hours and days. Special feature (peculiarity) of
electric burns is their painless due to lesion of nerve endings. Dry necrosis
with its not fast separation of necrotic tissues differs from such necrosis in
case of heat burns. Another differ of electric burn is progressive necrosis,
spreading of necrosis on underlying tissues, caused by thrombosis of blood
vessels. In case of electric burn lesion spreads not only on the all skin, but
to muscles and bones. In case of thrombosis of big vessels development of
gangrene is possible.
As was said before, after influence of electricity of high voltage burns in
places of entry and reentry appear. This burns are deep – III-IV st.
Tissues underlying the skin die move than skin. On the way of electricity
all tissues all tissues become necrotic and necrotic and thrombosis of vessels
also appear. That’s why the patient’s state depends not only on spreading of
skin necrosis that has bordered in the diameter 2-3 cm, but lesion of underlying
tissues on the way of electricity. In case of injuring of big vessels necrosis
of the tissues, gangrene of limbs or other parts of the body can develop.
In place of entry and reentry “signs of electricity” – burn wounds-appear.
During first aid for a patient with electric burn we should first of all relive him from
electric wire, provide reanimation if there is a need, apply bandage on the
place of burn.
During reliving the patient from while electricity everyone should remember
that touching his body we can also suffer. To relive him you can switch off the
source or chop electric wire be axe or spade with dry wooden handle. after
that, you have to throw away the wire by stick or board, take the patient.
After normalizing of cardiac function and breathing dry aseptic bandages
are applied places of burns. All patients with electric burns should be taken
immediately to a hospital.
General treatment of electric burns is the same as of heat ones. If anuria
develops, hemodialis is used. Separation of necrotic tissues in case of
electric burns has longer duration. Surgical debridement – necrectomy in 2
stages. Early amputation prevents the development of such complication as
bleeding, kidneys insufficiency, sepsis. Plastic operations are used later.
Local treatment of deep burns has to be surgical – restoration of lost skin by free grafting of patient’s own skin (auto grafting of wounds). It has to be performed in late term after preparing of granulate wounds (20-28th day), or after necrectomy in early period (2-10th day). Auto grafting or delayed plastics after temporary
closing of the wound by liophylized xenodermotransplants (V. Bigunyak, 2003 ) are used.
Treatment of burn wound requires it’s antibacterial
protection. Superficial burns of ²² degree are contaminating mostly by coccid flora (S. aureus, S. epidermidis), dermal burns of ²² degree –by coccid flora the same. But
large (more than 20 % of total body area) burns of any degree always
contain gram-negative flora (Pseudomonas aeruginosa, Proteus vulgaris etc).
Deep burns of ²²²-²V degree are contaminating
mostly by associations of bacteria, with a leading role of gram-negative
microorganisms. After debridement of necrotic tissues, wounds are being
contaminated mostly by coccid flora (S. aureus, S. Epidermidis etc). Large and deep burns preserve
associations of 2-3 and more strains of
microorganisms. Burn wound of special locations (perineum, genitalia, buttocks,
inner thighs) are being contaminated mostly by gram-negative flora (E. coli, P.
vulgaris etc).
In case of colliquative necrosis the wound
contains mostly gram-negative flora. The “critical level” of the burn wound’s
bacterial contamination is 105 per 1g of tissue Increasing of the level leads to
overcoming of demarcation layer, penetration of infection into deep tissues and
development of septic complications.
Infection of burn wounds leads to different
complications, secondary deepening of wounds, delay of epithelization in case of ²-²² degree burns. Deep burns are frequently
followed by internal organs’ complications (pneumonia, myocarditis, hepatitis), that could be complicated with sepsis in many cases.
As a result of inadequate or late antishock
therapy and late restoring of microcirculation - superficial burns (²-²² degree) can transform into deep ones.
Deepening of the wound can also happen as a result of inflammation, suppuration
and inadequate local treatment.
All types of burns, of all degrees, are primary
infected. That’s why primary burn wound care is an asset for prophylactics and
treatment of infection. In most cases dressings are applied as well. To the
other side, in case of any degree of burn shock, all manipulations on the burn
wound have to be delayed for 8-24 hours. Patient has to be covered with sterile
dressing. After successful antishock therapy, stabilization of the patient’s
condition, wound care and dressing may be performed.
The burn wound care has to be simple and not
traumatic. It has to be performed in
clean dressing-room after injection of
anesthetic agents (omnopon, promedol) or under general anesthesia (ketamin, ketalar, thiopental sodium) (for adult patients in case of
more than 7-8% of total body area burned and
in case of 5-6% in children).
In the dressing room: skin around burns has to
be washed by one of the following solutions: weak ammonia solution, solution of detergents, special shampoos, furacillin, chlorohexidine, chlorazide, iodopirone, iodobac, bethadine. Remnants of clothing and epidermis are carefully removed. Intact bullas
have to be cut of. Wounds should be washed once again and therapeutic dressing
should be applied. In case of severe contamination of burn wound (remnants of
epidermis, household or production dirt, soot), there is a need in irrigation
of the wound with sterile antiseptic solution.
Circular deep burns of extremities, act like a tourniquet and impair blood circulation in
the region of the burn and distal parts of extremities in all categories of
injured, in those with burn shock as well. That’s why decompress necrotomies without anesthesia
should be performed during first few hours after burn injury. They are
performed in longitudinal direction along medial and lateral sides of injured
limb to the depth until capillary bleeding starts.
Similar decompress necrotomies are performed on
chest if deep burns there involve more than ½ of its circumference.
After primary care of burned surface, all wounds, excluding superficial burns of face and perineum, are managed by close method, applying dressings. Burns of face and perineum can be managed by open method, i.e. without dressings. In case of the suppuration
development, dressing has to be applied.
Open method of treatment requires daily irrigation of the wound with
antiseptics and covering it by aerosols, aseptic films.
Burns of any localization that cover more than 5-6% of the total body area require every day dressing at
least for first 10 days.
There are
many remedies available for local treatment of burns. Dressings with medicines, that are applied on wounds, have to: protect them from
secondary infection, have bactericidal or
bacteriostatic influence on micro flora, stimulate reparative processes, dry the wound, especially in the I and II
phases of their evolution, prevent colliquative necrosis, absorb the content of the
wound and products of tissue and microbial disintegration, normalize local homeostasis (removal of
hyperemia, edema, acidosis). The most popular in clinical practice are: 1. Solutions of bactericidal and bacteriostatic substances (chlorohexidine, chloracid, furacillin, iodobac, batadine,
iodopirone), antibiotics.
2. Water-soluble ointments (creams), with bactericide and bacteriostatic substances, antibiotics – dermatine, argosulphan, ophlocaine, miramystine, laevosin, pantestine.
3. Sorbents based on silicon-organic
substances or fibre carbohydrates with antibacterial remedies.
4. Biological coverings (alloskin, suiderm, liophylized xenodermotransplants, fibrin membrane, combutech
etc).
It’s better to use the remedies of I group in the I and
II phases of wound process, especially in case of
extensive burns. Damp-drying dressings with antiseptics dry the wound out,
absorb secretions, plenty of them have wide-spectrum antibacterial action.
Iodine (iodobac, iodopirone, betadine), antibiotics prevent colliquative
necrosis. Such dressings allow performing early surgery during first 10 days
after trauma on extensive and deep burns. To the contrary, damp-drying
dressings have one main disadvantage – they dry up and adhere to the wound. But
they do not create thermostatic conditions, prevent infection, do not support
the development of colliquative necrosis, as lanolin-based ointments.
Water-based ointments have been
extensively used in all phases of wound process during recent 10-12 years. They
combine many positive features of damp-drying and gauge dressings.
They provide continuous
absorption of wound content (3-4 times longer than damp-drying dressings), potentiate action of included antibacterial medicines, can be easily removed, don’t traumatize the wound’s surface, can be easily washed out
during irrigation of the wound. But in this case the burn wound is not dry
enough, remains moderately wet and is not suitable for early surgery.
Depending on molecular weight
of polyethylene glycols, that make the base of water-soluble ointments-creams,
they have different influence on burn wounds. Ointments that contain
high-molecular polymers (PEO-1500) – Laevosin, Laevomicol have high osmotic
activity, strong single-directed process of diffusion from wound into dressing
prevails, as a result osmotic shock and dehydration of viable cells occurs, and
processes of reparation and granulation are suppressed.
Water-based ointments, which contain polymers with less molecular weight (PEO-400, polyethylene
glycol etc) create osmotic equilibrium between burn wound and dressing rapidly,
at the same time the wound content is effectively adsorbed by the base and
acting substances penetrate into deep layers of the wound. The presence of
osmotic equilibrium is required as in exudative phase , and in regeneration and
reparation phase . The only difference is in their intensiveness.
Modern multicomponent remedies
utilize hydrophilic base, that is a water-soluble mixture of solvents and polymers, which make an optimal osmotic activity in the burn
wound. Plenty of these medicines can be successfully used not only for
treatment of I-II stages of burn disease, but also in III, IV phases of wound
evolution (myramistin, streptonithol, methyluracil, pantesthine).
It’s not recommended to use dressings with hydrophobic
ointments (lanolin, vaselin) in I and II phases of wound process. They
create thermostatic conditions, provide favorable conditions for colliquative
necrosis development, don’t absorb wound secretions and don’t dry up the wound
surface. But, in III and IV phases of wound evolution hydrophobic ointments can
be used, for example “non-greasy” ointments-emulsions (synthomycin emulsion,
furacillin ointment).
One can use other groups of
medications, that comply with main
principles of local treatment - to prevent infection
development, dry the wound surface, together with therapeutic dressings, in I and II
stages of wound evolution. For example, dressings with armed carbon fiber or silica organic sorbents, mixture of many wide-spectrum antibiotics. Armed carbon fiber or silica organic dressings are in
form of flat linen, which can be applied on the wound as simple gauze bandage.
Other sorbents are issued as a powder, which sometimes makes equal distribution
of them on the wound surface difficult. Nevertheless, sorbents provide
excellent absorption of secretions from the wound, have directed antibacterial
activity, can be easily removed from the wound surface.
Close method of treatment of
burns has some disadvantages – it’s complicate, needs lots of dressing supplies and application of dressings is painful.
Biological covering find its use for treatment of superficial and deep
burns in I and II stage of wound evolution as therapeutic bandages, and in III-IV stages for temporary
closing of wounds, and also
are used in early surgery. The most
important role in this group belongs to lyophilized pig skin transplants.
Biological covers have good
contact with wounds, protect them from secondary
infection, adhere with the wound surface
firmly, stimulate regeneration and epithelization of wounds, shorten the duration of superficial burns treatment, temporary perform functions of lost epithelium.
Along with above mentioned
groups of remedies, other substances and medicines
are used for local treatment (films, herbs, pigments, tanning agents). Positive effects of these medicines
usage are connected mostly with dressings themselves and systematic wound care.
Dressings have to be applied
ensuring adequate analgesia, no matter if it’s on inpatient or outpatient
basis. For large surface burns, especially deep ones, dressings are performed
with special anesthesiological care, sometimes with multiple narcosis for the
whole period of treatment (up to 25-30 narcosis).
Each substance chosen for
local treatment is determined not only by principles mentioned above, but also
by main tactics concerning treatment of deep burns of III B and IV degree and
large superficial IIIA degree burns. If early surgery or sequential necrectomy
is planned, damp-drying bandages with wide-spectrum antibacterials (iodobac,
iodopirone, bethadine, chlorohexidine) are used. If surgery is not anticipated
in this period, one can successfully use modern water-soluble ointments that
have wide-spectrum antibacterial activity (dermasine, disulphane, argosulphane,
ophlocaine, miramystine etc). These ointments suppress growth of microorganisms
in wounds, activate metabolic processes in tissues, improve local blood supply.
They also soften and gradually dissolve superficial necrotic crust in II degree
burns. It’s not advised to use first generation water-soluble ointments, that
have very high osmotic activity (laevomicol, laevosin) and thus inhibit
reparative processes.
In case of small and
non-complicated burn wounds, primary applied dressings are not changed for next
2 days. Indication for more early changing of dressings is suppuration of the
wound, that can be ruled out by fever, reappearing of pain in the region of the
wound, specific drenching of dressings. In case of suppuration, dressings have
to be changed every day, applying wet-drying bandages. II-degree burns, as a
rule, heal without suppuration in 12-14 days. In case of suppuration, healing
time increases for 4-6 days.
II-degree burns of face or
perineum are managed by opene method. Following wound care, burned surfaces of
such localization are being irrigated 2-3 times a day by solutions of
antiseptics, tanning substances or aerosols (panthenol). Wide-spread method of
applying ointments (Vaseline cream, different emulsions) worse the results and
is not advisable. As a rule, II-degree burns of face heal during 7-12 days,
burns of perineum – 12-16 days.
Local treatment of II-degree burns of not more than 10% of total
body area in conditions of Central Regional Hospital during first 7-8 days
after trauma does not differ from the treatment of II-degree burns. The aim of
these burns’ treatment is creating of favorable conditions for islet
epithelization and epithelization from wound’s edges by preserved skin
derivates. This task can be achieved by means of systematical dressings and
timely (from 6-7 to 15-16th day) removal of superficial necrotic
crust during dressings change. The crust, as a rule, has light-brown or brown
color. Suppuration and irrational local treatment of II degree burns can lead
to death of skin derivates and deepening of burn wounds (III degree burns).
II degree burns heal rather
slowly - 3-4 weeks in case of adequate treatment. Quite often pathological scars (keloid and hypertrophic) develop, especially if hydrophobic ointments (lanolin, vaseline) are used for local treatment.
The choice of antibacterial
treatment for local therapy has to consider character of microflora and
sensitivity to them.
Patients with II degree burns, especially with more than 15% of total body area burned, have to be transferred to regional burn and plastic
surgery centers not later than 2 days after burn. Early sequential
(superficial) necrectomies and closing of wounds with liophylized
xenodermotransplants is performed then. Deep burns of any localization are
managed by close method. Treatment of such patients, even in case of local
burns of 1-2% of total body area, has to be performed in specialized regional
burn department, centre of thermal injuries and plastic surgery. General and
local treatment of these patients provides wound healing.
End-aim of local treatment of deep burns is surgical
restoration of lost skin. Principles of preventive surgery are most effectively
applied by early surgery in I and II period of wound evolution (i.e. during
first 10 days after burn). With this aim necrotic tissues are removed at once
on up to 10-15% of total body area. Wounds are closed by auto grafts or
temporary by lyophilized xenodermotransplants. Following surgery on larger deep
burns can be performed in 2-3 days. Such surgery shortens duration of hospital
stay, decreases intoxication, and alleviates burn disease course, decreases
frequency and severity of contractures, that is connected with removal of
necrotic tissues, being a source of histogenic intoxication and nutrient for
microorganisms.
Early surgery has to be performed in specialized departments in more than a
half of children and in 30–35 % of adults
with deep burns. At the same time, such surgery requires following mandatory
conditions:
- early diagnosis of deep burns;
-
presence of dry necrosis in the wound;
-
providing of adequate homeostasis during surgery;
-
adequate and prolonged anesthesia during surgery;
- absence of clinical signs of Pseudomonas aeruginosa in the wound;
-
adequate supply of medicines, dressings, transfusion solutions, especially erythrocyte-containing
and protein transfusion agents;
-
surgical team, consisting of not less then 3 experienced
surgeons and 1-2 surgical nurses.
Following surgery is performed
in order to remove acute burn toxemia, prevent pathological scarring and joint system dysfunction development:
à) sequential necrectomies in case of extensive superficial burns of II degree;
b) dermal necrectomies in case of deep burns of III-IV degree;
c) amputation of limb segments, fingers;
d) ligation of vessels in case of
threatening or appearance of erosive bleeding;
e) revascularization of stripped or partially injured
deep functionally important structures (tendons, bones, joints).
All these interventions are
performed after successful management of burn shock.
Sequential necrectomies are performed in case of
extensive superficial burns of IIIA degree. Superficial necrotized crust is
being removed on 12-15% of total body area at once, using dermatome or
skin-grafting knife with regulated depth of penetration (Hambi knife).
Resulting wound, that still contains skin derivates, is covered by dry sterile
bandage or special dressing. But the most advisable action is covering the
wound with lyophilized xenodermotransplants. Sequential necrectomy can be
performed on up to 60% of total body area during first 10 days after the
trauma. Wounds after sequential necrectomy heal during 12-14 days.
Dermal necrectomies are performed from 2-3rd
till 10th day post trauma. Removal of necrotic tissues is performed
layer-by-layer (tangential by dermatome or Hambi knife), or in blocks (by
scalpel, single block suprafascial excision of necrotic tissues together with
subcutaneous fat). At the same time the wound is covered by free
autodermotransplants. Such surgery is quite traumatic and is followed by
significant bleeding. During excision of necrotic tissues on extremities with
application of tourniquet, bleeding from 1% of total body area is 47 ml, and on
the trunk – 67 ml.
Autodermoplasty, taking skin grafts cause additional blood loss from
donor sites. This requires adequate compensation of homeostasis not only during
surgery, but in the postoperative period as well. Such surgery can be performed
on not more than 15% of total body area at once, and next intervention is
possible not earlier than in 48 hours. Total area of necrotic tissue excision
during first 10 days after the trauma can reach 30-40% of total body area.
During surgery and in postoperative period intensive therapy is an asset.
Stable hemodynamic and sufficient kidneys function is the criteria of adequacy
of homeostasis correction.
Early removal of non-viable tissues on 60-70% of deep burns’ surface causes abortive
course of the burn disease. The degree of endogen intoxication is decreasing,
general condition is improving, as well as the function of cardiovascular and
respiratory systems. This happens due to removal of histiogenic intoxication
substrate and huge amounts of nutrients for micro flora. Such early surgery
causes decrease in hospital stay for patients with deep burns for 19 days (from
63 to 44 days – 29,9%). Post-burn contractures development also is decreasing
in 2.6 times, from 40% to 15%, mostly contractures of I-II and II degree form,
comparing to III and IV degree contractures that develop after plastics of
granulating wounds during septic toxemia period. The survival rate of patients
with extensive deep burns increases as well.
Amputations, revascularization
procedures and ligation of vessels in case of erosive bleeding has to be done
in this period if needed.
Amputations.
High-voltage electric burns
frequently require amputation of a limbs. Delay of amputation in case of extremity
main vessels thrombosis is dangerous because of the possibility of gangrene
development, acute renal insufficiency, sepsis and even death of the patient.
Total injury of all tissues of extremity is a direct indication for it’s early
amputation. In case of more extensive level of total injury of limb tissue, the
earlier amputation should be performed (on the 4th day, sometimes at
the end of 1st-beginning of 2nd day). Necrosis of more
than ½ of muscular tissues, 2 or 3 segments of different limbs is a
direct indication for early amputation. Poor condition of the patient is not a
contraindication in this case; to the contrary, it’s a direct indication
towards early amputation with mandatory transfusion therapy.
The level of amputation is
determined by the state of proximal part of injured muscles and by the
possibility of the stump closure.
Amputation of humerus, femur
in proximal 1/3 ligation of magisterial vessels is required (subclavical and
external femoral artery) along their route. Ligation of these vessels in the
wound is a mistake on this level of amputation. In case of other level of
amputation, ligation and suture of vessel in the wound is possible.
Necrosis of fingers of the
hand in case of low-voltage injuries, flame burns does not require urgent
amputations. Stabilization of the patient’s condition can be achieved and then
the question of maximal preservation of finger, stumps can be solved, even with
revascularization of phalanges’ tips.
Revascularization is performed in IV-degree burns, when tendons, joints, ligaments, skull bones, bones of dorsal hand, diatheses of forearm and shin become stripped after
removal of all non-viable tissues. Such injuries
occur as a result of low- and high-voltage electric burns, contact injuries by
scorching objects on 1-2% of total body area.
If left stripped, these deep structures are affected by secondary
necrosis. In such cases, closing of wounds is done at the same time when
necrectomy is performed, by plastics of the defect with whole-thick skin or skin-muscle
grafts that have nutrient vessel.
Depending on the such wounds
size, their localization, condition of surrounding tissues, they are closed by rotated mobilized near the defect whole-thickness skin flaps (Indian plastic) or by whole-thickness skin with nutrient pedicle from remote
locations (Italian plastics), plastics by flaps with muscle pedicle or free
transplantation of tissue complexes with micro vessel sutures.
The most common
revascularization procedure is performed in case of high-voltage injuries of skull, wrist joints, palmary or dorsal surface of hand. Also revascularization is required in
case of low-voltage injury of fingers, palmary or dorsal surface of hand.
Such interventions help to
reduce the duration of treatment of burned patients with IV-degree burns, to prevent death of deep-lying structures and complications associated with
it, to improve functional and cosmetic results of treatment.
Prophylaxis and treatment of erosive bleeding. Erosive bleeding is one of the most severe and
dangerous complications in toxemia period of electric burns. They appear on the 3-5th day after burn as a result of decomposition and rejection of necrotized
tissues, together with blood vessel wall. The most dangerous bleeding occurs if
major vessels are involved. There should be a tourniquet and a sterile kit for
temporary stopping of bleeding by applying a tourniquet, clamp or suturing the
vessel in the wound in the ward for a patient with limb necrosis. In case of
necrosis of soft tissues over large vessels, it’s important to determine in
advance whether it will be better to perform preventive ligation of the vessel
along it’s route or al least within viable tissues. It’s much more favorable
than ligation of the vessel in the wound. The more proximally vessel is present
and more extensive soft tissue area perished, the more indications appear for
ligation of the vessel along its route or al least within viable tissues.
Vessels in the wound may be legated only on hand and foot.
Difficulty of early diagnosis
of deep burns, traumatic early surgery, complicated compensation of homeostasis imbalance in
case of more than 10% of total body area with the next plastic repair, leads to
the situation when the most wide-spread method of lost skin renewal in patients
with deep burns remains free skin transplantation on granulating wounds. That’s
why the most important task in the treatment of patients with deep burns is the
fastest preparation of burn wound for autodermoplasty. Spontaneous rejection of
necrotic tissues and developing of granulating wounds, suitable for skin
plastics, takes up to 5-6 weeks.
Prolonged persistence of burn crust on the wound, especially of a wet one, and vegetation of micro flora in it, mostly associations of gram-positive (S.aureus) and gram-negative (P.aeruginosa, Klebsiella) flora and saprophytes causes
multifactor syndrome of burn disease, thus suppressing the process of clean
granulating wounds development. Local and systemic antibiotic therapy is
complicated by the fact that in 2-3 years 80-90% of burn unit flora becomes
insensitive to even most modern generations of antibiotics.
All available physical methods
are used after wound care in III-IV degree burns to prepare granulating wounds:
Drying of wounds is most important, especially
in case of more than 15% of total body area burned. In case of controlled a
bacterial environment absence, drying is the most suitable method used. At the
same time wet-drying dressings with strong antibacterial substances (iodobak,
bravuvidone etc) are applied, constant blowing of burned wound with warm air is
used. Warm ventilators, dryers, hanging of extremities, usage of stabilizing
substances, special beds that allow to dry even circular burns why lying on
them.
Frequency of dressings change. Each bandage removes excretions from the wound, some vegetating flora, at the same time antibacterial substances are used, that remain active for 4-5 and up to 15 hours. Everyday wound dressing requires it’s irrigation and
removal of exudates. Such wound dressings in the period of burn toxemia and
beginning of septic toxemia (during rejection of necrotic tissues) is more like
a routine, not an exception.
Controlled a bacterial
environment allows to prevent development of infection in the burn wound or decrease
it, protect the wound from super infection. Such environment can be created in special “clean” single occupancy wards, with sterile air and regulated air temperature between
+ 26 to +38 degrees Celsius, or by management of patient on special beds with
air-cushion support (Clinitron – France, Aeroton – Russia etc), that provide
constant blowing of patient with sterile warm air (+26 to 400 Ñ). Special aerotherapeutic and physiotherapeutic devices
exist, that provide constant blowing of patient with warm
sterile air. Different kinds of such
environment – gnotobiological cameras, hammocks with constant warm air blowing
and infrared irradiation by tens, special lamps is also valuable in treatment
of burn infection.
Draining “fenestrated” necrotomies – multiple transverse incisions of necrotic crust, made 4-5 to 6-7 cm apart in the region of extensive necrosis. Such necrotomies facilitate evacuation of interstitial
fluid, decrease intoxication, create favorable conditions for faster excision of necrotic tissues
thereafter, increase the surface of
contact with local medications and decrease systemic absorption from the wound,
thus decreasing toxic infectious process. Draining “fenestrated” necrectomies
are always followed by some blood loss, that’s why should be performed in an
operation room under general anesthesia.
Staging necrectomies during
dressings (“dressing” necrectomies) are performed one-by-one during dressings. They allow excising up to 1 cm
stripes of necrotic tissues stage-by-stage on the border of necrotomy incisions
or viable tissues. They allow to incise regions of colliquative necrosis in
time and to drain them. Total area of excision during “dressing necrectomies”,
is insignificant, as a rule (not more than 1% of total body area).
Chemical
necrolysis of burn crust is performed starting from 8-9th to 16-17th day after the trauma by
application of 40% salicylic acid, or 25% benzoic
acid, or lactic acid on dry necrotic tissue, on the surface of up to 7-8% of
total body area. Necrotic crust is then removed painless, without bleeding in
48-72 hours. 5-6 more days are required then for following skin plastics.
“Chemical” necrectomy increases intoxication, what limits it’s wide-spread use.
Necrectomy
in operating room („operating room necrectomies”) on large areas (up to 6-8% of of total body area) with temporary closing of wounds by lyophilized
xenodermotransplants or any other biological cover can be performed.
Draining necrotomies, dressing
and surgical necrectomies are always followed by light bleeding. Some bleeding
also occurs during dressings in the period of rejection of necrotic tissues. It
should be taken into account in managing of the burn wounds.
Bathing of patients, dressings in baths (once every 3-4 days) with detergents and shampoos can also be the method of wound care. It helps to remove wound
exudates and micro flora, cleans surrounding viable skin, allows to perform
cautious wound care.
Ozone
therapy of burn wounds of limbs by means of temporary placing of limbs into
special polyethylene bags for 15-17 minutes. Such therapy causes death of anaerobic and purulent
flora, helps to remove infection complications promptly. This kind of treatment
has one disadvantage – ozone can come out of the bag and cause poisoning. Ozone
has a distinct antibacterial action.
Application of sorbs – a method, based on local
treatment of burn wounds by different sorbents: silica organic powder sorbents,
which contain antibiotics, microelements and carbon fiber compounds (Dnepr,
Oxycell). Other sorbents may be used as well (Gelevin, hydrocolloids etc),
powder mix of 10-12 antibiotics and talc with film cover (Brightman mixture
etc). This method is used in the II and III phases of wound evolution, i.e. in
shock and burn toxemia periods.
Application of sorbs provides
anti-inflammatory effect and decreases edema. Proteinaze activity in wounds’ secretions
is decreasing, as well as bacteria count in the wound, especially in it’s deep
layers. Functional activity of tissue macrophages and neutrophiles in wound
secretions increases, due to adsorption of microbial toxins. Improvement of
cell-mediated reactions beyond vessel phase of inflammation and more functional
demarcation layer is formed, time required for healing of superficial burns
(II-IIIA degree) is decreasing on 4-5 days.
Enzymes (chemotrypsin, trypsin etc) and ordinary non-hydrophobic gauze dressings should be used with
physical methods after removal of most of necrotized tissues. Enzymes are used
for prompt removal of small areas of dead tissues. They not only decrease the
degree of proteolysis in wound, but also have influence on microorganisms’
membranes, thus increasing their sensitivity to antibiotics. Ointment dressings
stimulate granulations in a wound. Antibacterial remedies of local action,
antibiotic ointments, antiseptics don’t play leading role in the treatment of
infection. There is no remedy that
effects on all kinds of germs and provides reliable decontamination of
burn wound to optimal content of bacteria per 1 gram of tissue (102–103). That’s why following rules should be taken into account
during choosing substances for local treatment:
à) antibiotics should be chosen according to sensitivity of wound flora;
b) prolonged contact of the remedy and surface,
penetration into wound has to be provided;
c) absence of thermostatic conditions for microorganisms;
d) stimulation of regeneration.
Water-soluble base ointments
comply with such rules, after removal of necrotic tissues. They have prolonged time of absorption
(up to 15 hours), have influence on germ membranes, increasing their
sensitivity to antibacterial remedies. At the same conditions, action of
wet-drying dressings lasts 3-4 hours.
It’s not advisable to perform autodermotransplantation on the wound surface after chemical or surgical necrectomy, because some necrotic tissues still remain in the wound. Non-viable
tissues could not be removed mechanically. It’s better to pick conservative
route – by stimulation or regeneration and development of granulating wounds.
Granulating wounds, that are ready for skin plastics, have no necrotic regions, are small-grained, have scant serous exudates. After removal of
bandage, one can see gauze imprintment on the wound and epithelization can be
seen on its edges. Active methods of wound preparing allow to perform skin
plastics on 18-22nd day after trauma. It’s better not to wait until all
wounds will be ready for autodermoplasty, but to close them gradually, choosing
suitable regions.
If active general and local
treatment is adequately performed, following auto grafting after the initial one may be performed in 1-3 days.
Split-thickness transplants are used. Wounds in the joints region as a rule are
closed by full-thickness skin grafts. All remaining wounds are covered by
perforated 1:2 or 1:3 split-thickness grafts.
If patient is in bad condition, not more than 500-700 cm2 of skin (3-4% of total body area) can be grafted during one transplantation. More extensive grafting is
less favorable for patients, moderate bleeding occurs on grafting cite. This
can lead to homeostasis derangement, patient’s decompensation. Grafting of skin
requires infusive-transfusion therapy during surgery.
Granulating wound is not only a barrier for infection, but also a source of constant protein and electrolyte loss. That’s why lyophilized
xenodermotransplants are applied on granulating wounds of more than 15% of
total body area, to prevent negative consequences of wound presence
(exhaustion, infecting etc), local and systemic complications. Other skin
substitutes (animal and plant derivatives, synthetic covers) can be used as
well.
Lyophilized xenodermotransplants are the most suitable and available, they stay on the wound for 2-3 weeks, can be removed anytime for autodermoplasty. Temporary
closing of wounds is a mandatory component of surgical treatment of patients
with deep extensive burns.
Management of burn wounds after autodermotransplantation does not differ much from preoperative treatment: preference is given to wet-dying dressings. It’s better
to cover perforated autografts with lyophilized xenodermotransplants.
Epithelization of the surface between autograft bridges goes on under
xenodermotransplants.
Small and punctuate wounds
between autotransplants, that have grown on, are rapidly epithelised under
dressings with thin layer of hormonal ointments. Wounds measuring 1õ2, 2õ2 ñm and more are covered on following surgical
autodermoplasty. Spontaneous healing takes very long time in some cases, and
sometimes causes atrophic ulcers development.
Complex general therapy,
active management of burn wounds according to principles listed above, allows
successful treatment of majority of patients with deep burns of up to 40-45% of
total body area and general burn of up to 60% of total body area. Deficit of
donor resources for surgery occurs in every patient with more than 25-30 %
of total body area deep burn. Unfortunately, it’s not always possible to graft
skin from donor cite once again. It’s possible to do that on the regions of
body where skin is thicker (back, outer thighs and arms, scalp, buttocks).
Some patients with deep IV-degree burns experience stripping of skull bones, hand tendons, wrist joints, bones. These patients undergo different kinds of plastic
surgery, including Italian, Indian plastics, full-thickness graft on vessel
pedicle plastics or free transplantation of tissue complexes using
microsurgical techniques.
Segmental amputation of limbs is performed rather rarely, in patients with electric and thermal injuries in septic toxemia phase.
Amputation of fingers or phalanges on a hand or a foot is more common in such
patients during this phase.
The system of local treatment of burn wounds plays significant role in providing of non-complicated course of burn disease in general, and burn wound during septic toxemia phase in particular. At the same time, different
local complications of burn wounds occur in this phase. Suppuration of
subcutaneous fat tissue in the form of honeycombs (cellulites), it’s focal
fusion or even abscesses formation, ascending infection can occur. Rejection of
free skin graft or it’s parts can be observed as well. The only method of
prophylaxis of such complications is active management of burn wounds, directed
against infection and active draining of burn wounds.
Consequently, the system of local treatment of burns plays
significant role in providing uncomplicated course of burn disease in general
and wound evolution in particular. The more extensive burn is, the more
intensive general treatment of burn disease should be. The system of
stage-by-stage treatment of burn patients, that is in effect for a long time,
needs keeping unified principles of burn wounds treatment - the main substrate
of burn disease.
4.
THE CHARACTERISTICS OF LYOPHILIZED XENODERM GRAFTS
Lyophilized xenoderm grafts (the size - 100-200-250-300 cm², the thickness - 0,3-0,4 mm) are sterile, processed, packed and can be used as skin substitutes in the
treatment of the burns (II-III , IV degree), donor and scalping lesions, trophic ulcers. These implants can be preserved in the fridge at +2 up to +4 degrees C for 3 years. They are light;
one package weighs 70-120 gr. The products are transported within 1- 2 days in
any season without any alterations of their therapeutic properties.
After microscopic
investigations of the lyophilized skin, the signs of autolytic and necrobiotic
alterations and their deep structural abnormalities have not been found in the
epidermis and in the papillary layer of the dermis. Well-preserved nuclei and
epidermocyte and fibroblast cytoplasm are present in the majority of the cells;
pycnosis and vacuolization are only detected episodically. The cell membranes
are not distorted; the exfoliation of the epidermis from the dermis is absent.
The collagen dermal fibers of the grafts are contoured, forming the network and
being placed loosely in the papillary layer. The edema and homogenization of
some parts of the collagen fibers and, in some cases, - their fragmentation is
present in the deep layers of the dermis.
At picrofuxin staining by Weigert Van Gieson, the collagen fibers are mostly
stained intensively red with fuchsin. The part of the elastic network is
interwoven with clear contoured fine elastic fibers.
The vitality of the of
xenoderm grafts is determined microscopically.
All the investigations clearly reveal plasma membranes, intercellular
junctions of the growing layer of the epidermis. Euchromatin dominates in the
nuclei signifying the activity preservation of the epitheliocyte nuclear
apparatus. The fibroblasts, which are characterized by the developed protein
synthesis apparatus and insignificant mitochondria distortions, predominate in
the cells of the papillary dermis. The nuclear contours are regular and a lot
of granules of the ribosomal origin can be seen in the nuclei. But
destabilization and destruction of the plasma, nuclear and organic membranes
are present episodically in some cells; heterochromatin is predominant in the
nuclei signifying the reduced function.
The morphologic investigations have proved that
lyophilized xenoderm grafts developed and manufactured by our enterprise are
not significantly different from the xenoderm grafts before the conservation.
(Figure 1, 1a)
Fig. 1. Stratified epidermocyte placement
is preserved concerning regular basal membrane. Basophilic nuclei, vacuolization of separate
cells.
Fig. 1à. The microscopic organization
of the basal layer epidermocytes. Desmosomal junctions are preserved; Intercellular spaces are significantly widened. Moderate karyolemma
invaginations and homogeneous nuclear karyoplasm, the destruction of the
separate organelles.
1. THE INDICATIONS FOR THE LYOPHILIZED XENODERM GRAFTS
Lyophilized porcine xenoderm grafts are used as
temporary skin substitutes in the treatment of the burns (II-III , IV degree), donor and scalping lesions, trophic ulcers.
At the application of xenoderm
grafts in the complex therapy of the patients with burns the general state of
the patients, their sleep and appetite improve; the body temperature is normalized; the deficiency of the homeostasis indices is reduced; the indices of the blood serum toxicity are decreased; the epithelization of the superficial burns, boundary
and insular epithelization of the deep burns is accelerated leading to the
decrease of the granular lesions by 23%. The hospitalization of the patients is
reduced to 16-18 days; the mortality of the major burn patients is reduced by
30 %.
The number of the lyophilized xenoderm grafts
necessary for the skin coverage depends on the surface area, depth of the burns
and the age of the patient. (Table 1).
Table 1
The number of the lyophilized xenoderm grafts
necessary for the treatment of the burn patients depending on the age of the
patient
¹ |
Age |
The necessary number of the lyophilized
xenoderm grafts (cm2) at the burn surface area 1 % |
1. |
Infants |
20 |
2. |
6 months - 2 years |
35 |
3. |
2-3 years |
45 |
4. |
4-5 years |
60 |
5. |
6-8 years |
85 |
6. |
9-13 years |
110 |
7 |
14 years < |
180-220 |
2. THE PREPARATION OF THE APPLICATION OF THE LYOPHILIZED XENODERM GRAFTS
2.1. Before the application of the xenoderm grafts, the package integrity and the expiration date stamped on the package are checked.
2.2. In the dressing or operating room, the package is antisepticised with the special burn
solution and incised; the xenoderm grafts are
removed from the package and placed in the container with warm physiologic
solution (15-20ºÑ) with the antibiotic for 10-15 minutes taking into account wound microflora
susceptibility.
2.3. The xenoderm grafts are taken out from the container; 4-6 perforations of 100 cm2 are performed on them with a scalpel; the grafts are applied to the clean wounds with the
epidermal side upwards; the wounds are wrapped with antisepticised gauze pads and fixed with a
dressing.
3. THE APPLICATION OF THE XENODERM GRAFTS
3.1. Superficial burns (²-²² degree)
After the patient
hospitalization and hemodynamic stabilization, the wounds are antisepticised at narcosis in the clean dressing or
operating room. The skin around the burn is debrided and cleaned with
antiseptic solutions – iodine, povidone-iodine, chlorhexidine, dexane. In case of significant contamination (home or industrial dust, soot, smut), the burn area should be
sprinkled with antiseptic sterile solutions. After the wound antiseptics, most II degree burn areas are
likely to be covered with the perforated lyophilized xenoderm grafts. It
relieves the graft modulation at joint areas. The wound epithelization under
the lyophilized xenoderm grafts terminates on the 10-12 days. (Figure 2)
Fig. 2 The wound epithelization (46 %) under the lyophilized xenoderm grafts
In case of III degree burns
the skin dermal layer undergoes partial necrosis (the vital sebaceous and sudoriferous glands and their excretory ducts are
preserved), creating preconditions for
wound suppuration caused by the development of the pathogenic microflora in the
necrotically changed superficial skin tissues. To create the conditions for the
active insular and marginal epithelization with the application of the
preserved skin derivatives it is necessary to debride the wound and to conquer
wound infections. Thus, sequential (superficial) necrotomy and the wound
coverage with lyophilized xenoderm grafts have to be performed to the patients
with II degree burns during the early stage after the trauma (2-3 days). It prevents the burn disease
development, accompanied complications, the scar formation and frequent painful
dressings and also promotes wound healing.
The xenoderm grafts are
closely applied to the skin, resulting in the improvement
of the patient’s general state, significant reduction or liquidation of the pain
syndrome, the body temperature normalization.
The first dressing is applied the next day after
the tangential and sequential necrotomy with xenoplasty. The following dressing
are applied daily or once in two days respectively depending on the character
of engraftment. When hematomas or accumulated purulent discharge occur under
the xenoderm grafts, the grafts are removed, the wound is cleansed and the new
xenoderm grafts or wet to dry drying dressings are applied. On the 8-9 day
after the trauma the xenoderm grafts dry up at the ends of the wound; the graft
rejection and the epithelization of the wound surface are observed. In the
other areas of the wound the xenoderm grafts are closely fixed to the adjacent
tissues.
On the 11-12 days
the xenoderm grafts thicken and fall off. The wound surface is covered with
well-developed epithelial regenerator.
Thus, the application of the lyophilized xenoderm grafts in the treatment of the surface burns shortens the patient hospitalization (from 6 to 8 days), reduces the risk of the hypertrophic and keloid scar formation by 38%
Taking into account that the number of
patients with ²-²² degree burns makes up 70 % of all the burnt, the application of the lyophilized xenoderm grafts allows to avoid painful
daily dressings, promotes wound healing, prevents wound purulence, facilitates the course of
the disease without the loss of proteins, water and electrolytes. The expenditures
on the purchase of the lyophilized xenoderm grafts are less than those on the
purchase of ointments, bandages, solutions, narcotic drugs etc. Thus, the
described treatment method is said to be not only clinically but also
economically efficient.
3.2. Deep burns (²²²-IV degree)
The deep burns can be treated with the
application of the early necrotomy or without it.
3.2.1. The application of the early necrotomy
The final aim of the local
treatment of the deep burns lies in operative restoration of the burnt
cutaneous covering. The early surgical interventions fully correspond with the
principles of the preventive surgery. During surgical interventions, necrotic tissues are removed tangentially or
perifascially on the area up to 10-15 % of the body surface; the formed wounds are temporarily covered with the
lyophilized xenoderm grafts that are removed in 2-3 days and after additional necrotomy the wounds are covered with the
autodermal grafts
The repeated interventions are performed in 2-3 days.
Afterwards daily dressings are applied at narcosis and xenoderm and autodermal
grafts are cleansed on the wounds.
The application of the
lyophilized xenoderm grafts allows to increase the area of the one-phase
removal of the necrotic tissues, to reduce the traumatism of the interventions,
to detect the areas of the incomplete debridement and it also creates
conditions for quick compensation of the postoperative homeostasis violations.
Additional debridement of the
unvital tissues promotes better autodermal engraftment. The application of the early
necrotomy with xenodermoplasty prevents progressive intoxication of the lesion
focus and the development of the wound infection, reduces the possibility of
the burn disease development and promotes skin restoration within a short time.
3.2.2. The treatment of the deep burns without the application of the early necrotomy
The main task of the burn treatment is the
preparation of the burn lesions to autodermoplasty. Spontaneous necrotic tissue rejection lasts
4-5 weeks. The presence of the specially
wet eschar on the burn and the wound microflora vegetation (frequently as gram-positive or gram-negative flora) often lead to the burn complications
The deep burns are treated
without the application of the early necrotomy in the late evacuated patients
with purulent wounds and also in the patients with the complicated disease
course and accompanied diseases that limit the application of the early
necrotomy.
After the chemical and phased
necrotomy and deep wound debridement the autodermoplasty is performed. During
the autodermoplasty the wounds that remain uncovered with the autodermal
grafts, donor wounds and perforated autoskin grafts are covered with the
lyophilized xenoderm grafts.
The xenoderm grafts can remain
fixed up to 2,5-3,5 weeks. The application of the lyophilized xenoderm grafts
reduces pain syndrome, plasma loss and the frequency of the wound
purulence.
At the same time the granular
tissue with the cells of the histogenic and haematogenic origin (fibroblasts
and histiocytes) ripens under the xenotransplants.
The hypertrophy of the protein
synthesis structures and energy exchange are detected microscopically in the
fibroblast cells.
After the xenoderm grafts removal
autodermoplasty can be performed.
Simultaneously with the
granular tissue formation the wound surface is epithelized more actively; the local epithelization in the form of wide cell growth
from the preserved skin derivatives occurs together with the marginal
epithelization (Figure 9). It promotes reducing the wound surface due to the
absence of the secondary wound deepening and necrosis and intensifies the
marginal and insular epithelization of the deep burn lesions under the xenoderm
grafts.
3.3. The coverage of the donor
lesions
The xenoderm grafts are
efficiently used in the treatment of the donor lesions. Thus, there is no necessity in
dressings. The epithelization of the
donor lesions under the xenoderm grafts occurs on the 6-8 day. So the
application of the xenoderm grafts in the coverage of the donor lesions
promotes faster epithelization ((4±1) day) and if necessary earlier autotransplant removal for
the recurrent plasty. .
3.4.
The coverage of the perforated
autodermal grafts
The perforated autodermal
grafts on the wounds can be covered with the xenoderm grafts. There is no need
to remove xenoderm grafts during dressings; the epithelization of the wounds in
the autografts occurs under the xenoderm grafts. After the complete wound
epithelization between the membranes of the perforated autodermal grafts, the
xenoderm grafts dry out and fall off.
3.5. The treatment of the scalping lesions and trophic
ulcers.
Clean scalping lesions and
trophic ulcers are covered with the xenoderm grafts. The reduction of the inflammatory process, the activation of the marginal and insular
epithelization promoting wound self-healing can be observed under the engrafted xenoderm grafts. When the
lesion area is big, the xenografts have to be substituted with the autodermal
grafts on the 7-8 day (the local blood circulation in the wound is the best
during this period).
Discharge
Instructions for Patients
Things to Know about Skin Grafts
and Healed Burns:
Things to know about Donor Site
Care:
Things to know about Pain
Medication:
Please notify your healthcare
provider (see contact page) if you have any of these signs:
Do's and Don'ts:
Call 911 immediately if the victim has any of the
following:
Seek medical help if any of the following is true:
|
1
Break Contact Between Heat Source
and Skin
2
Cool the Burn Immediately
The body holds heat and
continues to burn until the skin cools.
3
Clean the Burn
4
Bandage the Burn
Introduction
·
Initial
evaluation and management of small and moderate burns is a routine part of
general plastic surgery practice. An ability to accurately evaluate and provide
proper initial care for these injuries is essential.
·
Outcomes
for patients with burns have improved dramatically over the past 20 years, but
burns still cause substantial morbidity and mortality.1 Proper evaluation and management, coupled with
appropriate early specialty referral, greatly help in minimizing suffering and
optimizing results.2
·
For
excellent patient education resources, visit eMedicine's Burns
Center. Also, see
eMedicine's patient education article Thermal (Heat or Fire) Burns.
Evaluation of
the burn patient
Before
management of the burn wound can begin, properly and completely evaluate the
burn patient. Often this is a brief effort, particularly in patients with
small, uncomplicated wounds. In those with larger burns, evaluation of the
wound often is of secondary importance. As described by the American College of
Surgeons Committee on Trauma, evaluation of the burn patient is organized into
a primary and secondary survey.
Primary survey
Burn patients should be systematically evaluated using
the methodology of the American College of Surgeons Advanced Trauma Life
Support Course. This evaluation is described by the primary survey, with its
emphasis on support of the airway, gas exchange, and circulatory stability.
First evaluate the airway; this is an area of particular importance in burn
patients. Early recognition of impending airway compromise, followed by prompt
intubation, can be life saving. Obtain appropriate vascular access and place
monitoring devices, then complete a systematic trauma survey, including
indicated radiographs and laboratory studies.
Secondary survey
Burn patients should then undergo a burn-specific
secondary survey, which should include determination of the mechanism of
injury, evaluation for the presence or absence of inhalation injury and carbon monoxide intoxication, examination for corneal burns, consideration of the
possibility of abuse, and a detailed assessment of the burn wound.
A detailed history must be elicited upon first evaluation and transmitted
with the patient to the next level of care. Inhalation injury is diagnosed by a
history of a closed-space exposure and soot in the nares and mouth. Carbon
monoxide intoxication is suspected in those injured in structural fires,
particularly if they are obtunded; carboxyhemoglobin levels can be misleading
in those ventilated with oxygen. Those with facial burns should undergo a
careful examination of the cornea prior to the development of lid swelling that
can compromise examination. After evaluation of the burn wound, begin fluid
resuscitation and make decisions concerning outpatient or inpatient management
or transfer to a burn center .
Evaluation of the burn wound
After
the patient has been fully evaluated and stable hemodynamics and gas exchange
ensured, evaluate the burn wound in detail. Evaluate burn wounds initially for
extent, depth, and circumferential components. Decisions regarding type of
monitoring, wound care, hospitalization, or transfer are made based on this
information.
Extent of burn
An accurate estimate of burn size is important for
treatment and transfer decisions. Burn size or extent can be estimated in
numerous ways. Perhaps most accurate is the age-specific chart based on the
Lund-Browder diagram that compensates for the changes in body proportions with
growth. A burn is drawn on a cartoon figure and an associated age-specific
table is used to calculate the body surface area involved.
An alternative in adults is the Rule of Nines. This is
less accurate in children because their body proportions are different than
those of adults. For areas of irregular or nonconfluent area burns, the palmar
surface of the patient's hand can be used. For a wide age range, the area of
the palm without the fingers represents 0.5% of the body surface.
Burn depth
Burns are routinely underestimated in depth on initial
examination. Devitalized tissue may appear viable for some time after injury,
and often, some degree of progressive microvascular thrombosis around the periphery
of wounds is seen. Consequently, the wound appearance changes over the days
following injury. Serial examination of burn wounds can be very useful.
Burn depth is classified as first, second, third, or
fourth degree.
1.
First-degree
burns usually are red, dry, and painful. Burns initially termed first degree
often are actually superficial second degree, sloughing the next day.
2.
Second-degree
burns often are red, wet, and very painful. Their depth, ability to heal, and
propensity to form hypertrophic scars varies enormously
3. Third-degree burns generally are leathery in
consistency, dry, insensate, and waxy. These wounds will not heal, except by
contraction and limited epithelial migration with resulting hypertrophic and
unstable cover Burn blisters can overlie both second-degree and third-degree
burns. The management of burn blisters remains controversial, yet intact
blisters help greatly with pain control. Debride blisters if
infection occurs.
4.
Fourth-degree
burns involve underlying subcutaneous tissue, tendon, or bone. Accurately
determining burn depth on early examination is usually very difficult, even for
an experienced examiner. As a general rule, burn depth is underestimated on initial
examination.
Burn wound management
Most
burns are small; patients with small burns are appropriately managed as
outpatients if their burns do not involve critical areas such as the face,
hands, genitals, or feet. The outpatient setting is the primary focus of this
section. Outpatient burn management can be taxing and, when poorly performed,
can cause unnecessary suffering and compromise long-term results. In some
situations, coordinating outpatient management with the burn unit's team of
doctors, nurses, and therapists is helpful, as their expertise may facilitate
attaining optimal outpatient results; however, most small burns are well
managed by community based providers with burn center consultation as needed.
Burn Wound
Infection
An
ability to make the diagnosis of burn wound infection is important. A
clinically focused set of burn wound infection definitions recently has been
published Two of these, burn wound cellulitis and invasive burn wound
infection, are seen with some regularity by clinicians outside a burn center
environment.
Burn wound cellulitis usually manifests as progressive
erythema, swelling, and pain in the uninjured skin around a wound. Usually,
this is seen in the first few days after burning and typically is caused by Streptococcus
pyogenes. Infection can progress rapidly but is generally sensitive to
penicillin. Excision of associated deep eschar can be essential to the
successful treatment of cellulitis. Elevation to reduce edema is an important
adjunct.
Invasive burn wound infection is a rapid proliferation of bacteria in burn
eschar that proceeds to invade underlying viable tissues. A change in color,
new drainage, and, occasionally, a foul or sickly sweet odor are clinical
findings. Pseudomonas and other gram-negative species are common causes.
This infection can be life-threatening and usually requires combined treatment
with surgery and antibiotics.
Fever and systemic toxicity commonly accompany both
infections. Inspect burn wounds frequently to identify infection early. This is
an important consideration in outpatient burn care. Someone must inspect the
wounds managed in the outpatient environment to promptly detect infections.
Errors in initial depth assessment are routine. Infections occur and must be treated
in a timely way. A wound-monitoring plan is an essential part of burn care.
Selection for
outpatient care
Several factors are relevant to a decision regarding
the location of burn care. The patient's airway must not be potentially
compromised. The wound must be small enough so that fluid resuscitation is
unnecessary (this generally precludes outpatient care of burns over 10-15% of
body surface). Patient must be able to take in adequate fluid orally.
Typically, serious burns of the face, ears, hands, genitals, or feet should be
initially managed on an inpatient basis.
The patient and his or her family must be able to
support an outpatient care plan. A child managed as an outpatient must have an
adult caregiver available. A family member or visiting nurse must be available
who can perform the necessary wound cleansing, inspection, and dressing
applications, as most patients cannot do this themselves. Family must have
adequate transportation to return for clinic visits and unexpected emergency
visits. If abuse is suspected, outpatient management is contraindicated.
Finally, if, on initial examination, surgery is clearly needed for a
full-thickness wound area, the patient should be admitted for surgery promptly.
Despite all of these qualifications, most patients with smaller burns can be
successfully managed as outpatients.
Outpatient
wound care strategies
Components of outpatient burn care include the
following:
Wound cleansing and dressing techniques must be taught
to the person who changes the dressings. Documenting this teaching is ideal.
Which of many medications or membranes to place on
burn wounds remains unclear, but certain basic principles apply to all
situations. Gently clean the wound of debris and exudate on a regular basis.
This usually requires daily removal of accumulated exudate and topical
medications. Small superficial burns managed in this setting present a low risk
of infection, thus a clean rather than sterile technique is reasonable.
Patients may clean the burn with lukewarm tap water and mild soap.
Soaking dressings in lukewarm tap water may decrease
the pain associated with their removal. Gently cleanse the wound with a gauze
or clean washcloth, inspect for signs of infection, pat dry with a clean towel,
and re-dress the patient. To manage infections promptly, it is important to
teach the patient and family to return promptly if they notice erythema,
swelling, increased tenderness, odor, or drainage. Frequency of wound cleansing
and dressing change is debated, but most small burns are managed adequately
with daily cleansing and dressing.
Wound dressing, whether one is using topical
medication or a wound membrane, should provide 4 benefits: (1) prevention of
wound desiccation, (2) control of pain, (3) reduction of wound colonization and
infection, and (4) prevention of added trauma to the wound. Most topicals in outpatient
use have a viscous carrier that prevents wound desiccation and a broader
antibacterial spectrum that reduces wound colonization. Addition of a gauze
wrap minimizes soiling of both clothing and unburned skin and protects the
wound from the external environment. A large number of excellent agents
are available.
Superficial facial burns are commonly treated with a
clear, viscous antibacterial ointment. Wounds around the eyes can be treated
with heavy topical ophthalmic antibiotic ointments. For more information, see
eMedicine article Burns, Ocular. Treat deep burns of the external ear with mafenide
acetate, as it penetrates the eschar and prevents purulent infection of the
cartilage. Appropriate wound care strategies address these principles.
Control of pain in the outpatient setting can be
difficult, and if pain and anxiety cannot be adequately managed at home, then
hospitalization is appropriate. In most patients, an oral narcotic medication
administered 30-60 minutes prior to a planned dressing change provides adequate
pain control. As most dressings are occlusive, pain control between dressing
changes tends to be managed adequately without narcotics in most patients.
Elaborate specific conditions mandating an early
return. Particularly important are (1) pain and anxiety associated with wound
care to the degree that wound care is compromised, (2) signs of infection, or
(3) a wound that appears deeper than appreciated at initial examination. Review
wound care instructions with caregivers.
Inpatient
management
The plan of management of patients with large burns
that require inpatient care usually is determined by the physiology of burn
injury. Management strategies for these patients are beyond the scope of this
article but generally require a coordinated approach that involves a
specialized team. Hospitalization is divided into 4 general phases: (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3)
definitive wound closure, and (4) rehabilitation and reconstruction.
Medications and membranes
The
choice of which medication or membrane to place on a wound is a neverending
source of discussion and argument. Fortunately, most medications and membranes
perform well if physicians carefully monitor wounds, keep them clean, prevent
desiccation, and properly manage secondary infection.
A wide range of topical medications is available,
including simple petrolatum, various antibiotic-containing ointments and
aqueous solutions, and debriding enzymes. All of them can be effectively
employed when properly used by experienced providers in a program of burn care
that includes wound evaluation, regular cleansing, and monitoring.
Wound membranes are different from medications and
dressings in that they provide transient physiologic wound closure. This
implies a degree of protection from mechanical trauma, vapor transmission
characteristics similar to skin, and a physical barrier to bacteria. These
membranes facilitate a moist wound environment with low bacterial density. They
are commonly placed on clean superficial wounds while awaiting
epithelialization. These membranes are mostly occlusive; therefore, they must
be used with caution if wounds are not clearly clean and superficial. If an
occlusive membrane is placed over devitalized tissue, submembrane purulence can
occur with subsequent local and systemic sepsis. A large number of these
membranes are available.
Wound in special areas
Face,
ears, hands, genitals, and feet have functional and cosmetic significance that
far exceeds their size and physiologic importance. The surface area involved is
such that burn sepsis from these sources rarely is life-threatening, and a
studied approach to these wounds usually is possible.
Face
Especially in adolescents and adults, the deep sweat
and sebaceous glands of the central face make it likely that most second-degree
burns will heal well with adequate topical wound care. Many reasonable management
options are available, including topical silver sulfadiazine or bland
antibiotic ointments. Burns around the eyes can be dressed with topical
ophthalmic antibiotic ointments. If grafting is a possibility, reserve thick
donor skin with optimal color match for facial resurfacing. Often, the
"blush" areas, such as the upper back and shoulders, make good facial
donor sites.
The most important point of early management of deeply
burned ears is prevention of auricular chondritis. This is a serious
complication in which the cartilage becomes infected and quickly liquefies.
Twice daily cleansing and application of topical mafenide acetate, which
penetrates the eschar, can minimize the condition. Subsequent management of the
ear is based on depth of injury.
Deep corneal burns are obvious on physical
examination. The cornea has a clouded appearance. More subtle injuries can be
detected only with topical fluorescein application. After facial edema
resolves, lid retraction may occur with variable degrees of exposure of the
globe or ectropion. When this is relatively mild, no intervention is required
beyond ocular lubricants. Should keratitis occur, early lid release is advised.
Hand burns
Hand burns assume a high priority from the onset of
care. During the first 24-48 hours, adequate blood flow must be ensured.
Regularly monitor consistency, temperature, and the presence of pulsatile flow
detectable by Doppler in the digital pulp. If blood flow is questionable,
perform escharotomy or fasciotomy.
Splint hands in a position of function: the
metatarsophalangeal joints at 70-90 º, interphalangeal joints in
extension, first web space open, and wrist at 20 º of extension. Elevate
hands to minimize edema and have the patient perform range-of-motion exercises
with a therapist twice daily. Deep dermal and full-thickness burns should
undergo early excision and sheet autograft closure. Perform hand therapy
throughout the healing period, halting only in the few days immediately after
grafting. If this is not done, suboptimal long-term function results.
Conclusions
After
making a careful initial evaluation, refer patients with complex, deeper, or
larger wounds for specialty care. In others, application of basic principles of
management combined with regular monitoring constitutes adequate therapy and
leads to routinely good results.
|
|
|
Picture 1 : Second-degree burns often are red, wet,
and very painful. Their depth, ability to heal, and tendency to result in
hypertrophic scar formation vary enormously. |
|
Picture 2: Third-degree burns usually are leathery
in consistency, dry, and insensate. These wounds will not
heal. |
|
Picture3: Management of burn blisters is controversial.
Burn blisters occasionally obscure the presence of full-thickness wounds. |
|
|
|
Picture 4: Burn wound cellulitis presents with
increasing erythema, swelling, and pain in uninjured skin around the
periphery of a wound. |
|
Picture 5: Invasive burn wound infection implies
that bacteria or fungi are proliferating in eschar and invading underlying
viable tissues. These wounds display a change in color, new drainage, and
often a foul odor. These infections are life-threatening. |
|
|
|
Picture 6: If hand positioning and therapy are
ignored while overlying burns heal, poor long-term function may result. |
|
Picture 7. Burns by hot water II-III degree |
|
Picture 8. Burns by hot water II-III degree |
|
|
IV. References:
Essential reading:
1. Burn Unit : Saving Lives after the Flames by Barbara
Ravage. Publisher : Da Capo Press, 2005.-320p.
2. S.I. Shevchenko, A.A. Tonkoglas. Surgery. – Kharkov,
KhSMU, 2001. – 340c.
Further
reading:
5. Burn care by Steven E. Wolf, David N. Herndon
(Vademecum Series). Publisher: Landes Biscience, 1999.
6. Severe Burns : A Family Guide to Medical and Emotional
Recovery. Publisher: Johns Hopkins University, 1993. –p. 246.