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TREATMENT OF THE BURN DISEASE IN THE STAGE OF TOXEMIA AND SEPTICOTOXEMIA
The main principles of treatment are:
The basis of detoxification therapy consists of two complementary directions: the elimination of the source of intoxication and the elimination of toxins from the internal media of the body. The source of intoxication is a burn wound (treatment tactics, see below - "Local treatment of burns"). Removal 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 administered per os (enterodez, excessive drinking in combination with tableted diuretic drugs), however, the greatest effect is given by parenteral administration of both special preparations (hemodez) and simple administration of a large amount, up to 4-5 liters per day, of the amount of saline solutions , 9% sodium chloride solution, Ringer's solution, etc.) in combination with diuretics - "forced diuresis".
b) Extracorporal methods of detoxification or methods of eferent therapy (hemosorption, exchange plasma exchange, plasma sorption, etc.).
2. Correction of the functions of vital organs and systems. The basis for the correction of the function of these organs is the elimination of fluid deficiency, electrolytes and the fight against intoxication (see above). However, a number of violations require special correction: the fight against anemia; struggle with hypoproteinemia; correction of electrolyte, volemic disturbances and acid-base balance. (the principles of therapy are described above); Correction of the functions of the cardiovascular, respiratory, urinary, thermoregulatory, coagulation and anticoagulation systems is carried out depending on the specific clinical situation. This treatment principle “by circumstance” is sometimes called “symptomatic or syndromic therapy”.
3. Prevention and control of infectious complications.
This section of treatment consists of two directions: antibacterial therapy and immunotherapy.
Antibacterial therapy usually begins immediately after removal of the victim from shock.
Immunotherapy can be given in the form of active or passive immunization. The most effective drugs are antistaphylococcal and antiseptic serums, antistaphylococcal and antisexagous gamma globulins.
A new, promising direction of immunotherapy has been the use of drugs that have been named immunomodulators. These include methyluracil and pentoxyl, which enhance the synthesis of proteins, including antibodies; taktivin and thymalin, restoring T-leukocyte activity.
4. Full nutrition.
5. Local treatment. Local treatment of burns, along with the correction of homeostasis, is of paramount importance, since it is the burn area that causes all subsequent metabolic disorders, and therefore, only as soon as possible and full restoration of the skin can prevent the onset of severe complications of burn injury.
LOCAL TREATMENT BURNS
The main principles of local treatment of burns are:
1. Fight against afferent impulses in the first hours after injury. The implementation of this principle is discussed above.
2. Elimination of the source of intoxication in the area of the burn wound.
3. The fastest restoration of full-fledged integument.
Local treatment of superficial burns, as a rule, is not difficult, since the damaged skin is restored on its own (see chapter “Classification by depth and area of lesion”).
In case of burns of the first degree, the dressing may not be applied or the dressing may be applied with any fat-based ointment. The skin is restored after 5 - 7 days.
When a second degree burn is necessary, after treating the burn surface with alcohol, heal the bubbles at their base and release the fluid contained in them. The shell of the bubbles, if there is no suppuration, can not be cut off, but left in place as a "biological dressing." If 3–4 days after trauma appear in the turbid bubbles, indicating the development of suppuration, their membranes should be excised, the erosion formed should be treated with 3% hydrogen peroxide solution and a dressing with an indifferent ointment on a fat basis.
Similarly, it comes with burns 3A degree. Bandages change in 2 - 3 days. The skin is restored after 10 - 15 days.
With the development of suppuration of a burn wound with a superficial burn (more often it happens with a burn of degree 3A), bandages are applied with aqueous solutions of antiseptics and water-soluble ointments. After suppuration at the site of burns of the 3A degree, hypertrophic and keloid scars are often formed.
For the treatment of deep burns use closed, open, surgical and combined treatment methods.
CLOSED METHOD OF TREATMENT OF DEEP BURNS
Under the closed method of treatment understand the treatment of burn under the bandage. Before the development of suppuration, the burn scabs are bandaged with aqueous solutions of antiseptics, which may not be changed until the development of suppuration, but only moistened with solutions of antiseptics outside. With the development of suppuration of the scab, the dressings change, apply dressings with antiseptics, hydrocortisone, water-soluble ointments. On erosion, after removing the blisters, bandages can be applied with ointments on a fat basis, as they develop suppuration, they are also changed to water-soluble ointments. In the future, the burn is treated according to the general rules for the management of purulent wounds until complete healing of the type of secondary tension.
OPEN METHOD OF TREATMENT OF DEEP BURNS
An open method of treatment involves the treatment of burns without bandages. The method is based on the methods of transferring a wet scab into a dry one, forming a protective “crust” on the affected surface, and preventing plasma loss, as well as the penetration of microbes into the burnt tissue.
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. Tanning methods. Based on the coagulation of protein superficial layers of a wet 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. Drying methods. When dried, a thin elastic scab forms on the burn surface, which protects the wound from the penetration of microbes and prevents plasma loss. For drying of the burn surface, it is possible to use both household electric heaters and special installations.
Currently, there are special installations that create a stream of sterile air heated to body temperature. Thus, the treatment of a burn occurs in a germ-free (gnotobiological) environment. Domestic installations ATU-3, ATU-5 (“Pelikan”) deliver air to a special sterile polyethylene insulator, where the affected limb or the lower half of the victim’s body is placed. French installations Klinitron create a laminar stream of sterile air through the entire surface on which the patient lies. Due to this, the pressure on the skin facing downwards is significantly reduced. As a result, it became possible to treat victims with circular extensive burns up to 80 - 90% of the body area.
However, a scab obtained by tanning or drying alone does not often have sufficient mechanical strength and microbial resistance. The consequence of this is continued plasma loss and purulent-septic wound complications. To solve this problem, a so-called semi-open method of treating burns or a method of contour dressings has been developed, which consists in the fact that in the process of tanning and drying a thin (2 - 3 layers) gauze bandage soaked in a tanning antiseptic solution is applied to the burn surface. Such a bandage sticks to a burn wound and, drying out, as if makes up the scab framework. After drying, the bandage is cut around the perimeter of its sticking and treated several times with tanning antiseptic solutions.
SURGICAL METHOD OF TREATING BURNS
For deep burns, the following types of operations are possible:
1. Urgent necrotomy. It is performed with deep circular burns of the extremities or trunk with the formation of a dense burn scab. With an increase in edema, the compression of blood vessels and nerves develops. This can lead to gangrene of the limb or respiratory failure when the body is burned. The operation is performed under aseptic conditions, but without anesthesia, and consists in applying several longitudinal cuts along the entire length of the limb to the depth of the bleeding tissues.
2. Early necrotomy. It is performed in the first week after receiving the burn, before the development of suppuration in the burn wound. The operation is performed under aseptic conditions under general anesthesia and consists of excision of non-viable tissues with primary closure of the wound with transplanted skin.
3) Other types of necrotomy. They are produced as demarcation develops in the affected area. The most common necrosectomy in combination with the tanning method of burn scab, when 7-14 days after the injury, the eschar is anesthetized and stupidly separated from the viable tissue. This exposes the bleeding surface with elements of granulation tissue, which is closed with an ointment dressing, or the skin is immediately transplanted onto it.
CLOSING BURNING WOUNDS
Natural wound healing during a deep burn occurs according to the type of secondary tension, when, after cleansing it from necrotic masses, the granulating surface epithelializes from the edges. This results in a rough, deforming surrounding tissue scar, prone to ulceration. Therefore, it is now generally accepted that wound closure after a deep burn of any area and localization should occur with the help of skin plastics. 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 plastics.
b) split skin graft (according to Tirsh)
- solid flap;
- flap-sieve (flap-mesh);
- branded method (many options).
2. Skin plastics on the supply leg.
a) local (many options);
- bridge stalk;
- on microvascular anastomoses.
With free skin plastics, involving the movement of areas of the skin that are deprived of blood supply, the graft is powered diffusely due to wound discharge from the granulating surface.
The transplant is transferred onto a granulating wound surface and fixed on it with sutures or simply with a pressure bandage. Before fixation, perforation holes with an interval of 1–1.5 cm are applied to the skin flap with the tip of a scalpel, which serve to drain the excess wound. Due to the presence of perforations, the flap is stretched, so its area may increase.
The 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 of the dressing are deposited with a concentrated solution of potassium permanganate, and further healing of the donor surface takes place under the scab.
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TREATMENT OF THE BURN DISEASE IN THE STAGE OF TOXEMIA AND SEPTICOTOXEMIA
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