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Treatment of Burn Disease in the Stage of Toxemia and Septicothoxemia

The main principles of treatment are:

1.Detoxication

The basis of detoxification therapy are two mutually complementary directions: the elimination of the source of intoxication and the removal of toxins from the internal environments of the body. The source of intoxication is a burn wound (see "Local Treatment of Burns" for treatment tactics below). The elimination of toxic products absorbed into the blood and lymph can be carried out in two ways:

a) Introduction to the body of drugs that bind toxins, improve microcirculation and increase diuresis. Drugs can be given per os (aneurodesis, a generous drink in combination with tableted diuretics), but parenteral administration of both special preparations (gemodez) and simple administration of a large amount (up to 4-5 liters per day) of saline solutions , 9% solution of sodium chloride, Ringer's solution, etc.) in combination with diuretics - "forced diuresis."

b) Extracorporeal methods of detoxification or methods of eferent therapy (hemosorption, exchange plasmapheresis, plasmosorption, etc.).

2.Correction of the functions of vital organs and systems. The basis for the correction of the functions of these organs is the elimination of fluid deficiency, electrolytes and the control of intoxication (see above). At the same time, a number of violations require special correction: the fight against anemia; control of hypoproteinemia; correction of electrolyte, vollemic disturbances and acid-base balance. (the principles of therapy are outlined above); Correction of the functions of cardiovascular, respiratory, urinary, thermoregulatory, coagulation and anticoagulation systems is performed depending on the specific clinical situation. This principle of treatment "according to circumstances" is sometimes called "symptomatic or posindrome therapy."

3. Prevention and control of infectious complications.

This section of treatment consists of two areas: antibiotic therapy and immunotherapy.

Antibiotic therapy begins usually immediately after the removal of the victim from shock.

Immunotherapy can be carried out in the form of active or passive immunization. The most effective drugs are antistaphylococcal and anti-synergistic sera, antistaphylococcal and anti-synergic gamma globulins.

A new, promising direction of immunotherapy has become the use of drugs called immunomodulators. These include methyluracil and pentoxyl, which enhance the synthesis of proteins, including antibodies; tactivin and thymalin, restoring the activity of T-leukocytes.

4. Full nutrition.

5. Local treatment. Local treatment of burns, along with correction of homeostasis, is of paramount importance, since it is the area of ​​the burn that is the cause of all subsequent metabolic disorders, and therefore, only a quick and complete restoration of the skin can prevent severe burn injury complications.

LOCAL TREATMENT OF BURNS

The main principles of local treatment for burns are:

1. Struggle with afferent impulsation in the first hours after injury. The implementation of this principle is discussed above.

2. Elimination of the source of intoxication in the burn wound zone.

3. Sudden recovery of full-fledged skin.

Local treatment of superficial burns, as a rule, is not difficult, as the damaged skin is restored independently (see the chapter "Classification by depth and area of ​​defeat").

With a first degree burn, the bandage can not be applied or the bandage can be applied to any fat-based ointment. The skin is restored after 5 - 7 days.

With a second degree burn, it is necessary after the burnt surface treatment with alcohol to cut the bubbles at their base and release the liquid contained in them. The shells of the blisters, if there is no suppuration, can not be cut off, but left in place as a "biological bandage." At occurrence in 3-4 days after a trauma in blisters of the muddy contents testifying to development of a suppuration, their coverings it is necessary to excise, the formed erosion to process 3% a solution of peroxide of hydrogen and to impose a bandage with indifferent ointment on a fatty basis.

Similarly come with burns of 3A degree. Bandages are changed after 2 - 3 days. Skin is restored in 10 to 15 days.

With the development of suppuration of the burn wound with a superficial burn (more often with a burn of grade 3A), bandages are applied with aqueous solutions of antiseptics, water-soluble ointments. After suppuration on the site of burns of grade 3A, hypertrophic and keloid scars are often formed.

To treat deep burns use closed, open, surgical and combined methods of treatment.

CLOSED METHOD OF TREATMENT OF DEEP BURNS

Under the closed method of treatment is understood the treatment of a burn under a bandage. Before the development of suppuration on the burned scab, bandages are applied with aqueous solutions of antiseptics, which can not be changed until the development of suppuration, but only moisten with solutions of antiseptics from the outside. As the suppuration develops, the bandages are changed, bandages are applied with antiseptics, hydrocortisone, water-soluble ointments. On erosion after removal of blisters it is possible to impose bandages with ointments on a fatty basis, as the suppuration develops, they are also changed to water-soluble ointments. Further, the burn is treated according to the general rules of conducting purulent wounds until complete healing by the type of secondary tension.

OPEN METHOD OF TREATMENT OF DEEP BURNS

The open method of treatment provides for the treatment of burns without bandages. The method is based on the methods of transferring a wet scab into a dry, forming a protective "crust" on the affected surface, and preventing plasmapoiting, as well as the penetration of microbes into burnt tissues.
In the future, the wound process proceeds in most cases aseptically and the wound heals "under the scab." Two types of methods are used to obtain a dry, dense scab on the burn surface.

1. Methods of tanning. They are based on the coagulation of the protein surface layers of a moist scab. To do this, use:

- 10% aqueous solutions of collargol and protorgol;

- 5 - 10% solution of silver nitrate;

- 5 - 10% solution of potassium permanganate;

2. Methods of drying. When dried, a thin elastic scab forms on the burnt surface, which protects the wound well from the penetration of microbes and prevents plasmatic loss. To dry the burn surface, you can use both household electric heaters and special installations.

Currently, there are special facilities that create a stream of sterile air heated to body temperature. Thus, the treatment of a burn occurs in a non-microbial (gnotobiological) environment. Domestic installations ATU-3, ATU-5 (Pelikan) supply air to a special sterile polyethylene insulator, where the affected limb or lower half of the victim's body is placed. French installations "Klinitron" create a laminar flow of sterile air through the entire surface on which the patient lies. Due to this, the pressure on the inverted skin is significantly reduced. As a result, it became possible to treat the victims with circular extensive burns to 80-90% of the body area.

However, a scab obtained by tanning or drying alone often does not have sufficient mechanical strength and resistance to penetration of microbes. A consequence of this is the continuing plasma loss and purulent-septic wound complications. To solve this problem, a so-called half-open method for treating burns or a method of contour bandages has been developed, which consists of applying a thin (2 - 3 layers) gauze dressing impregnated with a tanning antiseptic solution to the burning surface during the tanning and drying. This bandage sticks to the burn wound and, drying out, makes up the skeleton frame. After drying, the bandage is cut off around the perimeter of its adhesion and several times treated with tanning solutions of antiseptics.

SURGICAL METHOD OF TREATMENT OF BURNS

With deep burns, the following types of operations are possible:

1. Urgent necrotomy. Performed with deep circular burns of extremities or trunk with the formation of a dense burned scab. With the growth of edema, the compression of the vessels and nerves develops. This can lead to gangrene of the extremity or a breach of breath in case of a burn of the trunk. The operation is performed under aseptic conditions, but without anesthesia and consists of applying several longitudinal incisions along the entire length of the extremity to the depth of the bleeding tissues.

2. Early necroctomy. It is performed in the first week after getting a burn, before the development of suppuration in the burn wound. The operation is performed under aseptic conditions under anesthesia and consists in excision of nonviable tissues with a primary wound closure transplanted skin.

3) Other types of necroctomy. Produced as demarcation develops in the affected area. The most common is necrectomy in combination with the method of tanning a burned scab, when in 7-14 days after injury the scab under anesthesia is bluntly separated from the viable tissue. At the same time, a bleeding surface is exposed with granulation tissue elements, which is closed with an ointment bandage, or the skin is immediately transplanted to it

CLOSING BURNWOOD

The natural healing of a wound with a deep burn occurs by the type of secondary tension, when, after cleansing it of necrotic masses, the granulating surface is epithelialized from the edges. In this case, a coarse, deforming surrounding scar tissue is obtained, prone to ulceration. Therefore, it is now generally accepted that closure of the wound after a deep burn of any area and localization should occur with the help of skin plasty. The basis of plastic surgery for burns is skin autoplasty. All its varieties can be divided into two large groups, having a number of subgroups:

1. Free skin plastic.

a) full-layer;

b) split skin patch (according to Tirsch)

- a single flap;

- a flap-sieve (a rag-grid);

- Branded method (many options).

2. Skin plastic on the feeding leg.

a) local (many options);

b) distant;

- "Italian";

- bridge-shaped stalk;

- on microvascular anastomoses.



With free skin plasty, which involves moving parts of the skin, deprived of blood supply, the nutrition of the graft is diffusely due to the wound separable from the granulating surface.

The transplant is transferred to the granulating wound surface and fixed on it with sutures or simply with a pressure bandage. Before fixing on the skin flap with the scalpel edge, perforation holes are applied with an interval of 1 - 1.5 cm, serving for the outflow of excess wound detachable. Due to the presence of perforations, the flap is stretched, so its area may increase.

Donor site is covered with two or three layers of gauze, which is soaked with blood, turns into a scab. After the dressing has dried, the upper layers are thickened with a concentrated solution of potassium permanganate, and further healing of the donor surface proceeds under the scab.
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Treatment of Burn Disease in the Stage of Toxemia and Septicothoxemia

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