(1) Debridement: Anti-shock therapy is the main treatment in shock stage. When the shock is basically controlled and the general situation permits, the wound should be cleaned as soon as possible. Debridement should be carried out under the conditions of sufficient analgesia, sedation and sterility, and the operation should be light. Never allow excessive irrigation, which will aggravate wound injury, cause pain or aggravate shock.
Methods and steps of debridement:
1. Simple debridement method: suitable for light polluters. Wash the wound and the surrounding skin with 1: 2000 bromogeramine solution or chlorhexidine solution, or wash the wound with physiological saline, disinfect the surrounding skin with 75% alcohol, and shave the hair around the wound if necessary.
2. Those with obvious pollution: gently wipe the wound surface and surrounding skin with soapy water and hydrogen peroxide to remove foreign bodies and oil stains, then rinse with plenty of normal saline, and disinfect the skin as described above.
3. Blister: it can be cut and drained at a low position, so that the epidermis can still protect the wound after the exudate is discharged. The peeled epidermis can be cut off, but it is forbidden to tear off the undressed epidermis.
(2) the principle of wound treatment:
First-degree burns do not require special treatment.
Shallow second-degree burns are bandaged. Those unbroken blister skin are wrapped with 75% alcohol gauze. The blister skin has been broken. After debridement, the wound surface can be coated with vaseline gauze and various traditional Chinese medicine preparations (such as Dibairen mixture, Arnebia oil, Polygonum cuspidatum decoction, etc.). ), silver sulfadiazine (cerium, zinc) cream and paste. Change the dressing for the first time in 6-8 days, and continue dressing for a few days to heal more. If there is wound infection, remove the blister skin in time, clean the wound and take semi-exposure or dressing.
For deep second-degree burns, exposure therapy was used, and 5- 10% sulfadiazine silver chlorhexidine paste was applied externally, 1-2 times a day, 1 time, so that the necrotic tissue became a dry scab, and the epithelium of skin appendages was preserved to the maximum extent, and it could heal under the scab after about 3 weeks. For deep second-degree wound infection, scab skin should be removed in time, and the wound is semi-exposed or bandaged. It is best to cover it with allogenic skin, xenogenic skin, freeze-dried skin, etc. For deep second-degree burns that cannot heal themselves within 3 weeks or more, the necrotic tissue of the wound surface should be removed or eliminated, and skin grafting should be carried out on a new basis to shorten the healing time and obtain good functional recovery.
Third-degree burn requires autologous skin grafting to eliminate the wound in a large area. Immediately after the injury, take exposure therapy, apply silver sulfadiazine or 3% tincture of iodine, 3-4 times a day, and dry the eschar thoroughly. Dry eschar can temporarily protect the wound surface, reduce exudation and bacterial invasion. Then eschar (necrotic tissue) was removed in batches and skin grafting was carried out as planned. The separated necrotic tissue can be removed. If there is residual necrotic tissue, continue to apply silver sulfadiazine; If it is a granulation wound, it can be wet-compressed with physiological saline and antibacterial liquid. Once infected, skin grafting is needed to eliminate the wound.
(3) Bandage, exposure and semi-exposure therapy
1. exposure therapy: after debridement, put the wounded on a sterilized or clean gauze pad and expose the wound to warm and dry air (room temperature 250-300) to dry the wound, which is beneficial to the prevention and treatment of infection. It's a good idea to sleep in a turn-over bed. Turn over four times a day to thoroughly expose the wound and prevent oppression. When implementing exposure therapy, we should rectify indoor hygiene and circulate air regularly. Do a good job of bedside contact isolation. Attention must be paid to aseptic operation when touching the wound. If there is exudate on the wound, use sterile cotton balls or blot at any time to keep the wound dry. Bed sheets or gauze pads should be changed at any time if they are wet. For superficial second-degree burns, traditional Chinese medicine preparations can be properly applied externally, and deep second-degree and third-degree wounds can be coated with sulfadiazine silver ointment and sulfur tincture to keep the wounds dry.
Exposure therapy is suitable for head, face, perineum and limbs burns, severe extensive burns, severe pollution or infected burn wounds, especially in summer.
The advantages of exposure therapy are that the dry wound surface is not conducive to bacterial growth, which is convenient for observing the wound surface and saves dressing. The disadvantage is that the environment needs to be disinfected and isolated; Warm equipment is needed in cold season; Not suitable for evacuation.
2. Bandage therapy: After debridement, cover the wound with gauze of traditional Chinese medicine or vaseline, and then cover it with multi-layer sterile gauze and cotton pad, and apply pressure for bandaging. The whole layer of dressing should be 3-5 cm thick. If necessary, put a plaster support to fix the limb in the functional position. When dressing, the pressure should be uniform, and the distal end of the affected limb should be bandaged even if it is not burned to prevent swelling. Fingertips (toes) should be exposed to observe the changes of blood circulation. Lift the affected limb and keep the dressing dry. If there is dressing infiltration, it should be covered with disinfectant dressing in time. If it is soaked in a large area, the external dressing can be removed and bandaged again under aseptic operation. Pay attention to the temperature changes of the wounded treated by bandaging, and see if there is any pain aggravation, peculiar smell or purulent secretion at the injured part. When suspicious signs of infection are found, check the wound in time and change the dressing. If there is no infection, the dressing can be changed in about 10 days.
Include treating limb or trunk burns, transporting the wounded and unconditionally using exposure therapy in cold season.
The advantages are convenient nursing and low requirements for ward environment; The patient is more comfortable, and the limb is convenient to maintain the functional position; Suitable for evacuation, the disadvantage is that in hot season or area, the wounded are not easy to tolerate, and a large number of dressings are consumed, which is not suitable for a large number of wounded, and dressing change is painful.
3. Semi-exposure therapy: Semi-exposure is to stick a single layer of antibacterial gauze or vaseline gauze on the wound surface and let it dry to ensure the second wound surface after escharectomy, fix the skin graft, protect the skin donor area and control the wound infection.
Implementing semi-exposure therapy has the same advantages as exposure therapy. For the second degree burn with less serious infection and shallow wound surface after escharectomy, subceschar healing can be obtained. If the infection is aggravated and granulation wound appears, the infection should be controlled by soaking, washing and wet dressing, and skin grafting should be done in time.
(4) Treatment of deep wounds
1. The eschar (i.e., necrotic tissue) with third-degree burn in early escharectomy is a foreign body in the body. Early escharectomy and immediate skin grafting to healthy tissue are positive methods to deal with this foreign body. For large-scale third-degree burns, allogenic sieve skin transplantation, autologous punctate skin transplantation and microparticle skin transplantation were used after escharectomy, and the skin was supplied with scalp for many times, which greatly exerted the effect of early escharectomy and skin grafting, improved the cure rate and shortened the course of treatment. At present, the safety of escharectomy and skin grafting has been obviously improved, and it has been widely carried out, and it is recognized that the effect is good.
For wounds with clear indications, such as third-degree burns, annular burns of limbs, functional burns, trunk burns, etc., escharectomy and skin grafting can be done at an early stage. ① If the third-degree burn is less than 65,438+00%, the total burn area is not large, and there are many donor sites, the third-degree eschar can be removed at one time or completely about 5 days after the injury, and autologous mesh or skin grafting can be carried out immediately; ② Third-degree burns are between 20% and 29%, and the total area is less than 49%. It can be eschared once or in stages within 5 ~ 10 days after injury. ③ Third-degree burns are more than 30%, and the total area is more than 50%. When the edema reabsorption progresses well after the shock is stable, the surgical plan should be carefully formulated, and the scab should be cut and skin grafted in batches in 5 ~ 15 days, and the scab area should not exceed 20% each time. Of course, with the change of clinical situation, we should carefully consider the general situation of the wounded, the technical conditions of medical personnel, whether there are good quality allogenic skin or xenogenic skin sources, and whether there are sufficient blood sources and anesthesia options to ensure the safety and good effect of early escharectomy.
Methods of early escharectomy ① The selection of escharectomy site is very important, especially the first escharectomy site. Usually cut off the limbs first, and then cut off the trunk. If the skin on the back and buttocks is thick, the scab should be preserved first, and the scab on the chest should be cut first when it affects breathing. You also need to consider wound infection. If the infection is obvious or a large area of muscle necrosis is estimated, it should be removed first. If the infection is mild and the eschar is dry, it can be delayed slightly. ② Operation method: eschar and subcutaneous fat were removed to the superficial surface of deep fascia. If there is muscle necrosis, it should also be removed. Amputation should be considered for patients with extensive necrosis of limb muscles. Wound hemostasis needs to be improved. The quality of allogenic skin must be good. Strive for a good survival of skin grafting. If the allograft fails, large-scale escharectomy and skin grafting may lead to serious consequences. The operation should be carried out in groups, one or two groups should be eschared, and the other group should prepare allogenic skin or small pieces of autologous skin to shorten the operation time. Hemostasis should be stopped and blood volume should be replenished during operation, and two venous channels can be used for blood transfusion and infusion respectively to prevent shock. It is estimated that the operation of escharectomy and skin grafting will take a long time. In order to monitor the urine volume during the operation, an indwelling catheter was placed.
2. Scab removal means that after the shock stage, the necrotic tissue in the deep second degree or the mixed area of deep second degree and third degree is removed with a skin rolling knife until a healthy dermal wound is obtained. When the tourniquet is eschared, the healthy dermis is white, dense and shiny, and there is no vascular embolism. However, when the tourniquet is loosened, bleeding is active and needle-like bleeding spots are densely distributed. If the tissue is dull or grayish red and there is vascular embolism, it means that the escharectomy depth is not enough and there is still necrotic tissue left. If yellow particles appear after scabbing, it means that it has reached the fat layer. Wounds that have been cut into third degree should be covered with autologous skin. Deep second-degree wounds can be covered with allogenic skin, liquid nitrogen skin, freeze-dried skin or artificial skin. Some wounds may be left after the covering falls off. Because the depth of scab cutting is not easy to be accurate, it is often shallow and deep. In recent years, it has been rarely used in clinic. Only used for deep second-degree burns of hands and joints, and skin grafting immediately after escharectomy.
3. Natural scabbing means exposure therapy after injury. After 2-3 weeks, the scab gradually separated from the healthy tissue, and granulation tissue appeared. Autologous skin transplantation should be carried out as soon as possible, with the principle of not exposing the wound too much, gradually scabbing and skin grafting. This typical natural escharectomy and skin grafting is only suitable for uncertain deep second-degree to third-degree burns, scattered third-degree burns after early escharectomy and skin grafting, third-degree burns without early escharectomy and skin grafting or outpatients. Because of its long healing time, there are more opportunities for scar contracture and proliferation in the skin graft area, which has been replaced by scabbing skin graft in many cases.
4. Scabbing is a more active method to avoid long natural scabbing time and serious infection. That is, about 12 ~ 16 days after burn, the third-degree eschar began to loosen or had some granulation wounds, so the eschar was cut off or removed from the plane where it began to separate. Sometimes the residual necrotic tissue is removed, and even the wound is removed from the superficial surface of deep fascia. During the operation, the wound was washed many times, creating a new wound base and mild infection.
5. Skin grafting on burn wounds is an effective measure to eliminate wounds, fundamentally prevent wound infection and reduce sepsis. For extensive third-degree burns, scabs should be cut by stages and skin grafting should be carried out in a planned way, so that the wound surface can be basically eliminated within 6 ~ 7 weeks after injury.
(1) Autologous sieve-shaped skin grafting: Take a large piece of thin and medium-thick skin with a drum peeler or a free-hand peeler, and poke a hole in the sieve-shaped part with a scalpel. The size of the hole is about 0.5 ~ 1.0 cm, and the density depends on the need. In this way, the skin graft can not only expand the area, but also facilitate the drainage of wound secretions, so that the skin graft can survive well. This method is suitable for escharectomy wounds or granulation wounds outside the face, and can prevent or reduce deformities after burns, with good long-term results.
(2) Mesh skin grafting: large pieces of thin and medium-thick skin grafts are cut into regular and dense meshes on a mesh skin cutter, and the skin grafts will be spread to form a mesh to expand the skin grafting area. Depending on the skin cutting board used, the skin graft can be enlarged by 1.5, 3, 6 and 9 times, and the larger wound can be covered by smaller skin graft. This method saves skin source and shortens operation time, and is suitable for deep burn wounds or granulation wounds after escharectomy. It is the most commonly used 3 times magnification, hand 1.5 times magnification and non-functional part 6 times magnification. In order to reduce the exposure of the wound at the mesh, it is often necessary to cover it with reticular allogenic skin, allogenic skin or artificial skin.
(3) Autologous small skin grafting: the thin skin graft is cut into square or rectangular pieces less than 0.3 ~ 0.5 or 1.0cm, and spread on the wound with a skin spacing of about 0.5cm, which is also called point skin grafting. Dotted skin grafting is simple in operation and has low growth conditions. Commonly used in granulation wounds, it can expand the skin graft area and save the skin donor area. However, it takes a long time to scar, which is easy to cause joint contracture and unsatisfactory appearance, so it is best to limit it to non-functional parts or hidden places.
(4) Dotted autologous skin embedded in the large-scale third-degree burn: after escharectomy in the early stage, transplant the large-scale allogenic skin first, or use a special punching machine to open many "door" holes, and change the dressing after 2-3 days. If the allogenic skin is well attached, the autologous skin with the size of 0.3-0.5 cm is embedded in the hole, so that the large sieve-shaped allogenic skin and the punctate autologous skin are both in the hole. This method is suitable for patients with skin source deficiency.
(5) Alternate transplantation of autologous and allogenic (seed) skins: fresh allogenic (seed) skins and liquid nitrogen storage skins are commonly used, and cut into dots or strips with a width of 0.3-0.5 cm, and they are alternately transplanted on the wound surface of incision, scab or granulation. After the growth of allogenic skin and autologous skin, the wound surface was initially covered, and then there was rejection, which expanded and healed from the autologous epithelium on both sides. This method is also suitable for patients with lack of skin source, such as good quality of allogenic skin, proper interval of autologous skin transplantation and good effect of sealing the wound at one time after growth and diffusion.
(6) Micro-skin transplantation: a small piece of thin fault autologous skin is cut into micro-particles, the maximum of which is no more than 65438 0.0mm2, and dispersed in isotonic saline. Pour it on the silk cloth, put a small bushing evenly covered with small holes on the tray, put silk cloth and leather pieces on it, and add normal saline to 1/3 ~ 1/2 of the bushing. Hold up the tray with both hands, tilt it slowly, let the skin touch the silk, and then the water comes out of the water. At this time, most of the micro-skins are upward, so they are evenly dispersed on the water. When the leaky pan is lifted, the salt water slowly flows into the tray through the wire and the leaky pan hole, so that the micro-skin is evenly sunk on the wire, and the skin surface is still upward. Take out the silk and cover it on the dermis surface of the same kind of skin, with the dermis of the micro-skin facing outwards, and take out the silk for transplantation. In this way, the ratio of donor area to recipient area can reach 1: 18, and the wound healing time is 5 ~ 8 weeks. The residual wound needs skin grafting to supplement it. This method is simple and effective. More than 90% of micro-skin can keep the same direction as similar skin, and it is easy to survive. It is suitable for large area burns due to lack of autologous skin source.
(7) Autologous epidermal cell culture and transplantation: a new trend in 1980s. It is reported that basal cells from body epidermis were cultured in culture bottles and expanded into multilayer epidermal flaps for about 3 weeks. Many cultured skin grafts were transplanted to some burn wounds, and some serious burn cases were successfully cured. The stratum corneum formed 8 days after transplantation, and there were 10 layers of epidermal cells 3 months later. The basement membrane is well developed and the reticular fibers under the epidermis are relatively complete. Many domestic units are stepping up research. Because the subculture technology of epidermal cells is complex and the anti-infection ability of epithelial cells is weak, some difficulties still need to be overcome in the transition to clinical application, but its development prospect will improve the treatment level of burns.
(8) Name of donor site: The donor site of burn patients must be cherished, rationally utilized in a planned way, and try to take care of the needs of later repair. Scalp is used as a donor site because of its thick skin, deep hair follicles, rich blood supply and strong anti-infection ability. The thin skin heals quickly after incision, and the skin can be cut repeatedly in 6-7 days. General 10 or more skin donations still do not affect hair growth. Non-burned areas of limbs and trunk, superficial second degree and deep second degree healing areas can also be repeated 2 ~ 3 weeks after the first skin donor.
When the skin source of patients with extensive third-degree burns is insufficient, or the skin can not be taken from the body for a while because of serious illness, allogenic skin transplantation is an important measure to save lives. It can survive for about 2-4 weeks, temporarily cover the wound, prevent infection, reduce the loss of body fluids and protein, and win time for treatment.
Allogeneic skin is mainly taken from fresh corpses, especially dead babies. It is usually removed within 6 hours after death, and the sooner the better. The cold season can still be used within 12 hours after death. Death due to infectious diseases, tumors, skin diseases, infections and poisoning is not allowed. The commonly used allogenic skin is the medium-thick skin transplantation of small white pigs, and the effect is not as good as that of allogenic skin.
In addition, skin grafts preserved by various methods, such as liquid nitrogen preservation of skin, are substitutes for preserving skin vitality. Freeze-dried heterogeneous skin, freeze-dried softened glutaraldehyde skin, irradiated heterogeneous skin, etc. , is an inactive substitute. There are other biofilms and synthetic substitutes, such as amniotic membrane and artificial skin. As substitute works, each has its own scope of application and can achieve certain results in clinical application.
(5) wound medication:
1. Chinese herbal medicines for external use in burns There are many prescriptions for treating burn wounds in various parts of China, including analgesic, anti-inflammatory and astringent; Used for putrefaction, detoxification and promoting necrotic tissue shedding; Can be used for promoting granulation growth, closing oral cavity, promoting epithelial growth, accelerating healing, and reducing scar formation. It can be selected according to superficial second degree, deep second degree and third degree wounds, exposure or dressing change treatment, and local materials for drugs. Here are several preparations for second-degree wounds.
(1) Dibairen mixture: Sanguisorba officinalis 1 kg, Bletilla striata 1 kg, Flos Lonicerae 1 kg. Add 8000 ml of water, boil to 4000 ml, then filter and let stand. This is the first filtration. Add 5000 ml water to the residue, boil it to 2000 ml, and filter it to get the second filtrate. Collect 6000ml of the first liquid and the second liquid, and concentrate them to 1500ml to form a paste. Add appropriate amount of frozen slices for later use.
(2) Radix Arnebiae, Radix Angelicae Dahuricae, Caulis Lonicerae, Sanguisorba oil, yellow wax, frozen slices and sesame oil. Fry the four ingredients in sesame oil to remove residues, then melt with yellow wax, filter, cool, add Borneolum Syntheticum and stir well. Suitable for dressing or exposure therapy.
(3) Burning powder: 4 parts of jujube bark, 3 parts of Sanguisorba officinalis, 3 parts of phellodendron amurense and a small amount of licorice are respectively processed into fine powder, sieved by 1 10 mesh sieve, evenly mixed, bottled and autoclaved for later use.
(4) Polygonum cuspidatum soup: Polygonum cuspidatum 80g, Coptis chinensis 2.5g and Lonicera japonica 6g. Wash Polygonum cuspidatum, chop it up, add three parts of water and boil it with strong fire, then fry it with slow fire and stir fry at any time. Half an hour later, other drugs were added and decocted for more than two hours to obtain 100 ml decoction.
Polygonum cuspidatum paste, Polygonum cuspidatum powder100g, Rhizoma Bletillae powder1.5g, Sanguisorba officinalis powder15g, and Coptidis Rhizoma powder 20g are autoclaved, mixed into paste with strong tea water, and a little borneol is added.
2. Other antibacterial drugs:
(1) Silver sulfadiazine (AgSD): It has good antibacterial effect on Pseudomonas aeruginosa. The main reason is that silver ions are absorbed by cells and combined with DAN in bacteria, which changes its structure and inhibits the reproduction of bacteria.
Usage: Silver sulfadiazine is often used in the solution of 1: 2000, and then it is prepared into 5- 10% silver sulfadiazine paste when used. External application to the second or third degree wound, 1 ~ 2 times a day, 1 time, for exposure therapy. Prepare 1% silver sulfadiazine solution, soak a single layer of gauze and apply it to the wound surface for secondary wound dressing treatment.
Silver sulfadiazine needs silver as raw material, which is expensive. It has been reported in China that sulfadiazine cerium and sulfadiazine zinc are made from cerium and zinc, which have been initially applied in clinic and can be selected.
(2) Sulfamethazine: its acetate is commonly used, its antibacterial effect is not affected by p-aminobenzoic acid, it can penetrate into eschar, it also has an effect on wound infection of suppurative necrotic tissue, and its antibacterial spectrum is wide, so it can be used for wound infection of Pseudomonas aeruginosa.
Usage: Make into 10% water solution or cold cream ointment for external use.