Practical lesson 1
Theme: Thermal injury. Main principles of diagnostic and treatment.
PLAN
1. Types of burns
2. Estimation of the lesions’ area
3. Estimation of burn’s depth
4. Methods of determination of burn depth
5. Prediction of burn’s severity
6. Formulation of the diagnosis in case of burns
7. Burn disease
8. First aid in case of burns
9. Plan of treatment
The tissue destruction caused by a burn injury can cause many local and systemic problems, including fluid and protein losses, sepsis, and disturbances of the metabolic, endocrine, respiratory, cardiac, hematologic, and immune systems. The extent of local and systemic disruption is related to many factors, including age, general health status, extent of injury, depth of injury, and area of body injured. Even after healing, the burn injury can cause late complications such as contracture formation and extensive scarring. Therefore the prevention of infection and closure of the burn wound are vitally important. A lack of or delay in healing is a key factor for all systemic disturbances and is responsible for much morbidity and mortality among clients who are burned.
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 %.
Burn depth 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.
Burn severity depends on area and depth of the lesion.
Estimation of the lesion area: right estimation helps to choose the method of treatment. There are many schemes of the lesion area estimation. Here are some of them:
1) rule of “nines” – area of different body zones is proportional to 9 So, that the anterior surface of trunk – is 18 %, posterior – is 18 %, lower limb – is 18 %, upper limb – is 9, head and neck – is 9, external genitals – 1 %);
2) rule of “palm”. It is used if burns are limited and located on different areas of the body. According to the rule palm takes 1 % of skin surface.
Estimation of burn depth: is carried out according to the classification (adopted on the 27 congress of surgeons 1960). Division of the burns on superficial (I, II, IIIA st.) and deep (IIIB-IV st.) is connected with possibility of spontaneous epithelization of the cover in case of superficial burns.
As a rule burns are mixed (superficial and deep), that is why evaluation of the burn depth in early terms is very important.
I stage – hyperemia of the skin
II stage – separation of epidermis with formation of bullas
III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous, glands.
IIIB stage – necrosis of all the derma
IV stage – necrosis of the skin and underlying tissues.
Methods of determination of burn depth
1) primary examination :
– color of epidermis and derma ( epidermis – red or pink in case of I,II stages, white or yellow or black in case of deep burns ; derma – red in case of II stage, pail in IIIA, grey in IIIB)
– edema
– vesicles
– presence of necrosis (IIIB, IV)
2) needle test ( hyper aesthesia in case of II st., superficial hypoesthesia in case of IIA st. and so on)
3) application of wet gauze with special solutions (spirits)
4) epilator test ( painful in 1,2,3A st., easy, without pain in case of deep burns)
5) instrumental methods:
a) usage of radioactive isotopes
b) impedance measuring
c) thermography
d) infrared zonding
e) histological and histochemical methods
The American Burn Association (
The magnitude of a burn injury is based on the depth and extent of the total body surface burn. The degree of tissue destruction is determined by what agent specifically caused the burn and by the temperature and duration of exposure to the heat source.
Variations in skin thickness over different parts of the body also influence burn depth. In areas where the epidermis and dermis are thin (e.g., eyelids, ears, nose, genitalia, tops of the hands and feet, fingers, and toes), a short exposure to extreme temperatures can result in a deep burn injury. The skin is thinner in older adults, which predisposes them to increased burn severity, even at lower temperatures of shorter duration.
Burn wounds are classified as superficial-thickness wounds, partial-thickness wounds, full-thickness wounds, and deep full-thickness wounds. The partial-thickness wounds are further separated into superficial and deep subgroups. Table 68-1 characterizes the clinical differences of these burns.
The American Burn Association (ABA) describes burns as minor, moderate, or major depending on the depth, extent, and location of injury.
SUPERFICIAL-THICKNESS WOUNDS. Of all burn types, superficial-thickness wounds have the least destruction because the epidermis is the only portion of the skin that is injured. The basal epithelial cells and basement membrane— structures necessary for the total regeneration of epithelial cells—remain present.
Superficial-thickness wounds often result from prolonged exposure to low-intensity heat (e.g., sunburn) or short (flash) exposure to high-intensity heat. Erythema with mild edema, pain, and increased sensitivity to heat occurs as a result. Peeling of dead skin (desquamation) occurs for 2 to 3 days after the burn, and the area rapidly heals in 3 to 5 days without a scar. No significant clinical consequences occur at this level of injury.
PARTIAL-THICKNESS WOUNDS. A partial-thick-ness wound involves the entire epidermis and varying depths of the dermis. Depending on the amount of dermal tissue damaged, partial-thickness wounds are further subdivided into superficial partial-thickness and deep partial-thickness injuries.
SUPERFICIAL PARTIAL-THICKNESS WOUNDS. Superficial partial-thickness wounds result from either increased duration or increased intensity of exposure. These wounds are typically erythematous and moist. The classic vesicle (blister) forms as the stratum corneum and stratum granulosum are destroyed. When intact, the blister forms a sterile environment, which protects the wound from potential infection and excess water loss. However, large or numerous blisters are opened to promote healing and prevent immuno–suppression.
Superficial partial-thickness wounds result in increased pain sensation. Nerve endings are exposed to the surface, and any stimulation (touch or temperature change) causes intense pain. With standard treatment these burns heal in 10 to 14 days with no scar, but some minor pigment changes may occur.
DEEP PARTIAL-THICKNESS WOUNDS. Deep partial-thickness wounds extend deeper into the dermal layer of the skin, and fewer healthy epidermal cells remain. The wounds usually appear red and waxy white without blisters. Edema is moderate; pain is present to a lesser degree than with superficial burns because more of the nerve endings have been destroyed. Blisters are absent because the dead tissues adhere to the underlying dermal collagen fibers.
The remaining blood supply to these areas is greatly reduced due to intense vasoconstriction. Progression to deeper injury can occur through hypoxia and ischemia. Ad-
equate hydration, nutrients, and oxygen are necessary for spontaneous re-epithelialization of the wound and the prevention of conversion to deeper burns. Partial-thickness wounds can convert to full-thickness wounds when tissue damage increases with infection, hypoxia, or ischemia. Deep partial-thickness wounds generally heal in 3 to 6 weeks, but a large amount of scar formation results. Surgical intervention with skin grafting is required if healing will be prolonged.
FULL-THICKNESS WOUNDS. A full-thickness wound involves the entire epidermal and dermal layers of the skin. No living (viable) epidermal cells remain for re-epithelialization, and skin grafts are required in areas larger than approximately 12 to 16 cm2. In smaller areas, secondary wound closure occurs by the growth of collagen-based scar tissue from the unburned edges inward.
The area of full-thickness injury has a hard, dry, leathery eschar (burn crust) that forms from coagulated particles of destroyed dermis. The eschar is dead tissue; it must slough off or be removed from the burn wound before healing can occur. The thick, coagulated particles often adhere to the subcutaneous layer by collagen fibers, which makes the removal of eschar difficult. Edema is a significant problem in burns and is pronounced under the eschar in a full-thickness wound. When the injury completely surrounds an extremity or the thorax (circumferential), circulation and ventilation may be compromised by tight eschar. Escharotomies (incisions through the eschar) or fasciotomies (incisions through eschar
and fascia) may be required to relieve pressure and allow normal perfusion and breathing (see Surgical Management [Ineffective Tissue Perfusion], p. 1572).
The color of a full-thickness burn wound may be waxy white, deep red, yellow, brown, or black. Thrombosis of vessels may be present and visible beneath the surface of the burn because the dermal blood vessels are heat coagulated, causing the burned tissue to be without a blood supply (a vascular). Sensation is minimal or absent in these areas of injury due to the destruction of nerve endings. Healing time depends on the re-establishment of an adequate blood supply within the injured areas and can range from weeks to months.
DEEP FULL-THICKNESS WOUNDS. Deep lull-thickness wounds extend beyond the skin into underlying fascia and tissues. These deep injuries damage muscle, bone, and tendons and leave them exposed to the surface. These burns occur with flame, electrical, or chemical injuries. The wound is blackened and depressed, and sensation is completely absent. All full-thickness burns benefit from early excision and grafting. Grafting decreases pain and length of stay and accelerates recovery (Ramzy et al., 1999). Amputation may be required when an extremity is involved.
Prediction of burn’s severity
In adults the rule of “hundreds” is used. (age + total area of burns in %)
up to 60 – prognosis is favorable
61-80 – prognosis is relatively favorable
81-100 – doubtful
101 and more – unfavorable
Frank’s index is more exact. It takes into account area and depth of the lesion. It is based on the fact that deep burns are in 3 times more severe than superficial burns. That is why if 1 % of superficial burn is 1 unit, than 1 % of deep burn takes 3-4 units. The sum of these numbers makes the Frank’s index.
Prognosis of burns is favorable, if Frank’s index is not more than 30 units,
is relatively favorable, if 30-60 un.,
is doubtful – 61-90 units,
is unfavorable – more than 90 units.
Besides, the stage of burn severity could be estimated by the Lesion Severity Index. (LSI). According to it:
1 % of the burn of I or II stage = 1 unit of LSI
1 % of the burn of IIIA stage = 2 units of LSI
1 % of the burn of IIIB stage = 3 units of LSI
1 % of the burn of IV stage = 4 units of LSI
It there are heat lesions of respiratory ways we have to add:
– in case of light degree of respiratory burns – 15 units LSI (respiratory disorders are not fixed);
– in case of middle degree – 30 units LSI (respiratory disorders are fixed first 6-12 hours after trauma);
– in case of severe degree – 45 units LSI (respiratory insufficiency from the moment of the burn is fixed)
Formulation of the diagnosis in case of burns
1. The word ‘burn’
2. The etiological factor: flame, hot water, steam, acid…
3. The stage of burn ( I, II, III, IV)
4. The burn area in % (area of deep burns is putting in the brackets)
5. Injured organs, areas.
6. Accompanying injuries that deal with the action of thermal agent (respiratory burns, carbon monoxide poisoning)
7. Dates about burn shock with its degree or another period of the burn disease
(toxemia, septic toxemia, recovery)
8. LSI (lesion severity index)
9. Complications
10. Accompanying traumas and diseases
For example:
Clinical diagnosis: Burn by the fire I and II st. 25% of face, neck, right upper limb, chest
Respiratory burn of light degree
Burn shock, medium degree
LSI – 40 units
Accompanying diagnosis: Stomach ulcer
The burn disease develops when the area of burns is more than 10% in adults and 5% in children. The burn disease is the complex of clinical symptoms, that’s developed due to heat lesion of skin cover and underlying tissues.
The are 4 periods in the duration of burn disease: 1 – burn shock, 2 – acute burn toxemia, 3 – septic toxemia, 4 – recovery.
Burn shock
According to the degrees of severity, there are:
Light burn shock (LSI up to 30 units, duration 24-36 hours)
Middle burn shock (LSI is 31-60 units, duration 36-48 hours)
Severe burn shock (LSI is 61-90 units, duration up to 64 hours)
Most severe burn shock (LSI > units, duration up to 72 hours and more)
The development of the burn shock is caused by serious vascular changes resulting from burn injuries.
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.
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
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.
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 І-ІІ, ІІ, ІІІ А 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. ІІ degree burns of any size, ІІІ А degree up to 10 % require just local therapy. Large burns of ІІІ А degree require early (on 2-3rd day) superficial (sequential) necrectomy, plastics by lyophilized xenodermotransplants. The time of healing for ІІ-ІІІ А 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 ІІІ B–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.
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 ІІ degree are contaminating mostly by coccid flora (S. aureus, S. epidermidis), dermal burns of ІІІА 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 ІІІ B-ІV 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 ІІ-ІІІ А 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 (ІІ-ІІI А 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. (Fig. 1A, 1B)
Non-balanced diffusion processes
Hydrophobic base Polyethylene oxide base
(Lanolin-vaselin) (Combination of PEO-400 and 1500)
Fig. 1А Fig. 1B
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 (Fig.1C), and in regeneration and reparation phase (Fig.1D). The only difference is in their intensiveness.
Balanced diffusive processes
Hydrophilic Hydrophilic
Hyperosmolar base, gel or emulsion base
(PEO-400, 1,2 propylene glycol, proxanol–-268)
I phase of wound process II phase of wound process
Fig.1C Fig.1D
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 (Fig.2). 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 IIIA 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 IIIA-degree burns of not more than 10% of total body area in conditions of
III–A 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 III-А 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:
а) sequential necrectomies in case of extensive superficial burns of IIIA degree;
b) dermal necrectomies in case of deep burns of IIIB–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 oot 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 wheecrectomy 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 С). 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-
Staging necrectomies during dressings (“dressing” necrectomies) are performed one-by-one during dressings. They allow excising up to
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
а) 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 1х2, 2х2 сm 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.
3. THE APPLICATION OF THE XENODERM GRAFTS
3.1. Superficial burns (І-ІІ 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 І-ІІ 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 (ІІІ-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:
- Healing skin will be dry, flaky, and itchy, – apply moisturizing lotion twice a day, or more often, if needed for dryness
- Try not to rub or scratch the healing skin� this may cause new blisters or open wounds
- The healing areas will be PINK/ PURPLE in color for several months� this discoloration will improve with time
- Protect all healing areas from the sun� use sunscreen SPF 30 or higher
- New areas of redness around wounds may indicate an infection� you should notify your healthcare provider
Things to know about Donor Site Care:
- The donor site dressing will remain adherent (stuck) to the wound until it has healed underneath, usually 10-14days.
- The dressing will be moist for the first 3-5 days; drainage is normally a reddish-brown color.
- The dressing will begin to dry as healing occurs. As the donor site heals, the dressing will begin to peel off. It is OK to trim loose edges.
- Do not try to force the dressing off. This may injure the healing skin underneath.
- At home: You should keep the dressing clean and dry. It does not need to be covered with any other dressing.
Things to know about Pain Medication:
- Oral pain medications need time to absorb from your stomach and begin to produce the desired effect� take pain medication approximately 30 minutes before wound care for best results
- Some pain medications cause constipation� to prevent this we may prescribe a stool softener, you should also drink plenty of fluids and eat fruits and vegetables
- Some pain medications cause drowsiness� you should not drive a car, operate machinery, or return to work until you are cleared by your healthcare provider
Please notify your healthcare provider (see contact page) if you have any of these signs:
- Increasing pain or swelling
- New areas of redness around any wounds
- Persistent nausea and vomiting
- Fever
- Any other concerns
Do’s and Don’ts:
- Do eat at diet high in calories and protein: take a multivitamin until all wounds are closed
- Do continue your physical therapy at home
- Do wear a hat and long sleeves while in the sun: always wear sunscreen
- Do keep all follow up clinic and physical therapy appointments
- Do wear pressure garments 23 hours a day to help reduce scaring
- Do change all dressings once daily or as directed
- Do call for any signs or symptoms of infection: severe chills or fever, excessive pain, redness, swelling, or new drainage, odor at the site of the burn dressing
- Don ‘t go in the sun without sunscreen and coverage
- Don ‘t pick or scratch at your wounds. This may cause bleeding and infection
- Avoid strenuous activity, driving, heavy lifting, and contact sports until cleared by doctor
- Don ‘t wear tight fitting clothes that may rub against burn areas and cause friction blisters and skin damage.
Call 911 immediately if the victim has any of the following:
- Symptoms of shock
- Trouble breathing
- Second- or third-degree burns over a large area, such as an entire leg or back.
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Seek medical help if any of the following is true:
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1
Break Contact Between Heat Source and Skin
- If clothes are drenched with hot liquid, remove them immediately. Or, stand the person—clothes and all—in a cool shower.
- To smother flames, drop the victim to the ground and roll the body.
2
Cool the Burn Immediately
The body holds heat and continues to burn until the skin cools.
- Hold the burn under cold running water; submerge the burn in a sinkful of water; or place water-soaked cloths, towels, or sheets over the burn. Add more cold water to the cloth as it absorbs heat from the burn.
- DON’T use butter on a burn. Oil seals in heat and may cause infection.
3
Clean the Burn
- Lift or cut away any clothing covering the burn. Any cloth fibers sticking to the injury should be removed by a healthcare provider.
- Gently wash small first- or second-degree burns with mild soap and water.
- DON’T break any blisters. They protect the burn from infection.
4
Bandage the Burn
- Protect the burn with a clean, dry dressing loosely bandaged in place.
- Place a clean, dry sheet or fabric tablecloth over burns covering a large area.
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
Primary survey
Burn patients should be systematically evaluated using the methodology of the
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 iumerous 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:
- Patient and family education
- Wound cleansing
- Choice of topical or membrane dressing
- Pain control
- Early return instructions
- Follow-up clinic visits
- Long-term follow-up care
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.
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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. |
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Picture 2: Third-degree burns usually are leathery in consistency, dry, and insensate. These wounds will not heal. |
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Picture3: Management of burn blisters is controversial. Burn blisters occasionally obscure the presence of full-thickness wounds. |
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Picture 4: Burn wound cellulitis presents with increasing erythema, swelling, and pain in uninjured skin around the periphery of a wound. |
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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. |
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Picture 6: If hand positioning and therapy are ignored while overlying burns heal, poor long-term function may result. |
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Picture 7. Burns by hot water II-III degree |
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Picture 8. Burns by hot water II-III degree |
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