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.
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.
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.
Severity of burn shock
Colloid: saline: not saline solutions and days of usage
1 day 2 day 3 day 4 day
LSI to 30
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.
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.
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.
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).
The number of the lyophilized xenoderm grafts necessary for the treatment of the burn patients depending on the age of the patient
The necessary number of the lyophilized xenoderm grafts (cm2) at the burn surface area 1 %
6 months - 2 years
14 years <
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:
Break Contact Between Heat Source and Skin
Cool the Burn Immediately
The body holds heat and continues to burn until the skin cools.
Clean the Burn
Bandage the Burn
· 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
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.
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.
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.
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.
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.
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 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.
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
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.
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.