Scar hyperplasia is a serious sequela of burn patients after wound healing, which is mainly caused by pathological changes during wound healing. According to statistics, 70-80% of the wounded with scar hyperplasia are under 30 years old; People of color and scar constitution tend to have excessive scar proliferation; Chemical burns and napalm burns often produce serious scars; The deeper the burn (deeper than the second-degree wound), the more obvious the scar hyperplasia; Wound infection usually increases the chance and severity of scar formation; Scar contracture and hyperplasia will seriously affect the quality of life of patients. Because the mechanism of scar formation is not clear, there is no specific drug to prevent and treat scar at present, but early prevention has a certain effect on scar hyperplasia and contracture. Preventive measures mainly include: infection should be prevented and controlled in deep wounds, and skin grafting should be carried out as soon as possible under general circumstances; Once the wound heals, insist on applying pressure with elastic bandage or elastic sleeve as soon as possible, and stick to it day and night when using, which can effectively reduce scar contracture and hyperplasia; Exercise as soon as possible to reduce the dysfunction caused by scar contracture. At present, early functional exercise is advocated in the process of burn treatment. If patients actively cooperate, they can often get ideal therapeutic effects.

What problems should be paid attention to in burn scars's rehabilitation?

The rehabilitation of burn scar is an important part of modern burn treatment. Timely and correct scar rehabilitation treatment can obviously improve the quality of burn healing and reduce the disability rate.

1, pay attention to skin cleanliness and hygiene. When the burn wound has just healed, there are still a small amount of secretions and scabs, so bacteria are easy to multiply quickly. In addition, the epidermis is thin and tender, the structure and function are not perfect, and it is easy to be infected and ulcerated. In the meantime, we can use neutral detergent for cleaning, and then use anti-scar drugs and other treatments after cleaning.

2. Avoid excessive friction and excessive activity. Due to the imperfect structure and function of scar epidermis, the epidermis is more vulnerable to injury, and some improper treatment may aggravate the injury. When applying anti-scar drugs, it is not advisable to massage excessively or for a long time, which will separate the epidermis from the fiberboard layer to form blisters or blood blisters, and excessive joint activity will also lead to the loosening and separation of the epidermis and blisters.

3. After lower limb burns, it is not advisable to move prematurely. Because the scar epidermis is fragile, the structure and function of the blood vessels below it are not perfect, which can not meet the internal pressure against gravity. The wound surface of lower limbs will turn purple or even bleed when standing, which will aggravate scar hyperplasia. Generally, it is more appropriate to go to the ground in about 3 months. It is best to use a pressure sleeve to protect before going to the ground, which can reduce scar congestion.

4, blisters should be timely drainage, avoid infection to form ulcers. Due to various stimuli, the new epidermis is easy to relax and form blisters. If blisters are not treated promptly and correctly, they are usually infected and form ulcers. After the blister appears, the skin can be disinfected with complex iodine, and the blister can be cut off with sterile scissors, resulting in water accumulation. Generally, anti-scar treatment should be implemented after the blisters subside and the ulcers heal.

5. Under the guidance of specialists, take comprehensive measures to control scar hyperplasia and prevent contracture. So far, there is no specific method to completely prevent scar hyperplasia after burn, and comprehensive treatment is still the main method of scar prevention and treatment.

6, early prevention, perseverance. The formation process of burn scar can be roughly divided into proliferative phase, stable phase and regression phase. The proliferation period lasts from 3 months to 2 years, and most of them are about half a year. However, due to various reasons such as ulcer, pain, impatience or improper methods, some patients often fail to adhere to scar rehabilitation treatment, resulting in scar hyperplasia and contracture.

7. Correctly grasp the timing of plastic surgery to prevent disability. Scar contracture of functional parts, such as hand scar, eye scar and jaw and neck scar, should be operated as soon as possible after the scar is stable, especially children, should be treated as soon as possible, and plastic surgery can be carried out in advance. Otherwise, it will cause abnormal development of joints and bones, shorten blood vessels and nerves, and lead to disability.

Professor He Quanyong, Department of Plastic Surgery, Xiangya Third Hospital, Central South University

Don't let the burn leave a scar.

References:

Article source: Beijing 777 Health Network

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First of all, local medication for burn wounds

Due to the local vascular obstruction of deep burn, it is difficult to reach the local area with systemic antibiotics. Intravenous application alone is ineffective in controlling bacterial reproduction in wounds, but early local application of bacteriostatic or bactericidal agents is an effective measure. People's research and application of external medicine has a long history, but there is still no perfect external medicine.

1, antibacterial drugs for external use

⑴ sulfamilone: Poisoning In the 1960s, Moncrief first made 10% sulfamilone cream as a topical medicine for burn wounds. Clinical application 10% aqueous solution or cold cream can penetrate the eschar within 30 minutes, 80% ~ 90% of the drug area leaves the carrier within 5 hours, and it loses its bacteriostatic effect after 8 ~ 10 hours, and the drug is excreted by the kidney. The main characteristics are obvious wound pain after application, metabolic acidosis due to large-scale inhibition of carbonic acid bacteria enzyme, and attention should be paid to pulmonary complications; Hypertonic fluid usually leads to polyuria or destruction of new epidermal cells. Usage: Apply 10% sulfamilone cold cream directly to the wound, about 1 ~ 2mm, twice a day. The second time, the last medicine should be withdrawn first, and the daily dosage should not exceed 450g g. In case of severe Pseudomonas aeruginosa infection, 5% ~ 10% water bath can be used.

⑵ Silver sulfadiazine (DS-Ag) and N- sulfadiazine compounds, SD-Ag is a weak acid and a broad-spectrum inhibitor. It is generally effective against common bacteria in wounds such as Pseudomonas aeruginosa, but it is not effective against Klebsiella pneumoniae. Silver sulfadiazine penetrates the eschar and releases silver ions and sulfadiazine, forming a light gray scab on the wound. Most of the released silver ions combine with bacterial DNA to inhibit the growth of bacteria. Silver ions are rarely absorbed by the human body. Absorb about 10% sulfadiazine, and the blood concentration can reach 1.5 ~ 4 mg% after 3~4 days of administration.

Silver sulfadiazine has obvious effect on delaying and alleviating wound infection, and has better effect on controlling wound infection. Although various external drugs have appeared one after another, silver sulfadiazine is still one of the most effective external drugs. Silver sulfadiazine can cause sulfanilamide crystal urine, rash, phosphate dermatitis and leukopenia.

Among N- metal sulfonamides, there are sulfadiazine, sulfadiazine and silver salt, zinc salt and cerium salt of sulfadiazine. Zinc salt can promote wound healing. Cerium salt has low water solubility, but its minimum inhibitory concentration is higher than that of silver salt, which shows that silver salt is still the strongest antibacterial drug. In order to combine the advantages of zinc salt and silver salt. People also studied and made silver-zinc paste. Because silver sulfadiazine faces drug problems, people have developed silver nicotinate, silver aspartate and silver salts of quinolones (the representative drugs are naphthyridine, pipemidic acid and norfloxacin), especially the bacteriostatic concentrations of silver pipemidic acid and silver norfloxacin are lower than that of silver sulfadiazine, which have broad application prospects.

⑶ Dichlorobenzene biguanide ethane (chlorhexidine) and its mixture: chlorhexidine has the effect of resisting Gram-positive cocci and negative bacilli, with good clinical effect and no obvious irritation. In the clinical treatment of burns, 1‰ chlorhexidine solution is often used to clean the wound or as an internal dressing.

In order to improve the curative effect, chlorhexidine is often mixed with other external drugs. Chlorhexidine plus silver nitrate; Neomycin plus polymyxin B plus chlorhexidine; Sulfadiazine plus silver sulfadiazine plus chlorhexidine.

(4) pyrrolidone iodine. It is a broad-spectrum antibacterial agent. It used to be a disinfectant for normal skin and mucosa, with strong bactericidal power, but it could not penetrate the eschar. 1% water-soluble ointment can be used for large and medium-sized burn wounds, and its side effects are hyperiodosis (T4 value increased) and metabolic acidosis.

5. P-Chloroxylenol (PCMX): 5% P-Chloroxylenol cream is effective for Staphylococcus aureus, which can make up for the deficiency of silver sulfadiazine.

[6] aminoglycoside antibiotics: 0. 1% gentamycin sulfate solution and 0.5% neomycin solution can penetrate the eschar for sterilization, and the antibiotic concentration can be increased in severe infection, but attention should be paid to kidney and auditory nerve damage, and the emergence of drug-resistant strains also limits its role.

(7) Iodoether: It has obvious killing effect on drug-resistant Staphylococcus aureus, Pseudomonas aeruginosa and mold. Iodine complex ether is a hydrophilic drug. Iodine complex ether aqueous solution is convenient for clinical use and has no irritation to skin and mucosa. Semi-exposure therapy generally uses 0.5% iodine complex ether, which can also be made into low concentration for debridement and disinfection. Iodine complex ether has good antibacterial effect and is a good external drug for treating second-degree burn wounds.

2. External use of antifungal drugs

⑴ Clotrimazole: bacteriostatic agent, which can selectively bind with lipids in plasma membrane, thus affecting the structure and function of fungal cells. 3% ~ 5% clotrimazole cold cream or 1% ~ 4% clotrimazole dimethyl sulfoxide preparation is often used for fungal infection of burn wounds.

⑵ econazole: This product is one of the derivatives of imidazole. Compared with other derivatives of imidazole (such as difenoconazole, clotrimazole, isoxazole), it has broad antibacterial spectrum, strong bacteriostatic power and high curative effect. It has a certain effect on candida and Aspergillus in burn wounds, effective on superficial fungal infection, and ineffective on various fungi invading deep layers. The external dosage is 1% cream and 1% suspension, which are applied to the wound 2 ~ 3 times a day.

⑶ Ketoconazole: White or light brown, odorless and tasteless adhesive, effective for various candida surface and deep infection. Commonly used 1% ketoconazole solution (prepared with 2% dilute hydrochloric acid) or 1% suspension is better than econazole in treating wounds.

⑷ Other external drugs: including nystatin aqueous suspension or decoction of Cortex Phellodendri and Radix Sophorae Tonkinensis. It is effective for Candida albicans.

Second, the prevention and treatment of systemic infection

1, immunotherapy, in order to prevent and treat Pseudomonas aeruginosa infection, active immunization and passive immunization should be adopted. Methods: Patients with extensive burns were injected with multivalent Pseudomonas aeruginosa vaccine 20mg/kg for the first time after admission, intramuscular injection or intradermal injection, and then every 7 days.

The wound healed. It is better to give 250ml intravenous infusion of immune plasma or apply human serum globulin while activating arteries.

2. Prophylactic application of antibiotics: penicillin was used to prevent hemolytic streptococcus infection three days before burn or before and after skin grafting.

3. Therapeutic application of antibiotics: When the pathogenic bacteria have been identified, antibiotics should be selected reasonably according to the drug sensitivity test.

4. Actively prevent and treat complications: infection has a causal relationship with shock, renal failure or atopic ulcer. Active prevention and treatment of these complications can significantly reduce the incidence of infection.

5. Rational wound medication: Topical drugs are of great significance for controlling wound infection, such as silver sulfadiazine, chlorhexidine and pyrrolidone iodine.

6, escharectomy and skin grafting to cover the wound in the morning and evening: In recent years, the successful experience of rescuing large-area burn patients is mainly early escharectomy and skin grafting, because necrotic tissue is a good culture medium for bacteria, escharectomy is to remove lesions and sources of infection, improve patients' immune function and control invasive infection. Of course, choosing the right time can improve the survival rate of skin grafting. It is generally believed that skin grafting will not lead to surgical failure and infection spread after shock is stable or other complications are basically controlled.

7. Nutritional support therapy: Nutrition is the main link to prevent patients from invasive infection. Due to the exudation of the wound after burn, a large amount of protein is lost (every 1% area can be lost from the wound notice 1 ~ 2g protein); The body's ultra-high metabolic consumption increases; Wound repair requires a lot of protein and energy supply. Therefore, burn patients need to take high-protein and high-calorie nutrients to maintain nitrogen balance, otherwise malnutrition, immune dysfunction, decreased immune molecule synthesis, body failure and invasive infection will occur. The occurrence of advanced invasive infection is related to protein and insufficient heat supply.

The nutritional intake of burn patients includes oral, nasal and intravenous nutrition, and one or two methods should be selected to supplement nutrition according to the situation. Oral intake of nutrition is the best way to meet the physiological requirements. Oral administration in the morning and evening is beneficial to the recovery of gastrointestinal function. Nutritionists should reasonably distribute nutrients and water, including protein, fat, sugar, vitamins, nutrients and trace elements. Drugs that allow patients to take multivitamins, trace elements and electrolytes orally, such as 12 gemvita or Shierkang.

For those who are deficient in oral nutrients, nasal feeding can be used to inject milk, egg soup or elemental diet into the stomach tube regularly every day. Compared with total parenteral nutrition, gastrointestinal feeding contributes to the release of digestive enzymes and endocrine substances in gastrointestinal tract. Promoting gastrointestinal vasodilation and blood flow, increasing the thickness of intestinal adhesion and enhancing the barrier function can reduce the risk of bacteria and their toxins being absorbed from the intestine.

Patients with gastrointestinal dysfunction or insufficient gastrointestinal feeding can use intravenous nutrition. Generally, the method of peripheral vein intubation can reduce the disadvantage that central vein intubation is easy to cause infection Pay attention to hydration in peripheral vein nutrition. The general water requirement is 1% area ×50+ physiological requirement.

Prevention and treatment of systemic fungal infection

1. It is the key to remove the inducement and strengthen preventive measures, such as strengthening wound treatment, shortening the course of treatment, strengthening nutrition supply and preventing complications. Rational use of antibiotics to prevent abuse of antibiotics.

2. To treat fungal septicemia of wound surface, when fungi invade living tissues under scab, even muscles and bones, it can be locally removed, and the edge can be removed and extended outward by 3 ~ 5 cm. If necessary, consider amputation.

3. Stop using antibiotics, hormones and immunosuppressive drugs. Narrow-spectrum sensitive antibiotics and antifungal drugs can be used in mixed infection.

4, systemic and local application of antifungal drugs

⑴ nystatin: Oral administration only acts on gastrointestinal fungi, does not absorb it, and is excreted from feces, 500 ~ 1 10,000 U, four times a day. Tragumycin was taken orally four times a day (200,000 ~ 400,000 U).

⑵ Clotrimazole: It is effective for Candida, Cryptococcus, Aspergillus and algae. Oral absorption is less, gastrointestinal reaction is serious, and it is rarely taken orally. It is generally made into 5% clotrimazole cream for external use.

⑶ Ketoconazole: broad antibacterial spectrum, strong antibacterial activity and good oral absorption, 0.2 ~ 0.4 minutes, twice a day. Use with caution in patients with poor liver function.

⑷5- fluorocytosine (5-FC): It is a synthetic pyrimidine fluoride, which mainly acts on Candida and Cryptococcus. The dosage is 50mg/kg/ day, and it can be taken orally or intravenously in batches. There are side effects such as gastrointestinal reaction and liver function damage.

5. Garlic injection: 20 ~ 80 ml for adults every day, slowly intravenous drip several times, mostly used at the same time with 50-FC. You can also take raw garlic orally, 3 times a day, 2 ~ 4g each time.

[6] Amphotericin B: a broad-spectrum antifungal agent, with little oral absorption and instability. It must be injected intravenously, which has serious side effects. Patients often have chills, high fever, nausea, vomiting, shortness of breath, increased heart rate, and in severe cases, decreased blood pressure, which has an impact on liver, kidney and blood system. The dosage should be gradually increased from 1 ~ 5 mg per day to 1mg/kg body weight. In order to reduce the side effects, 5 mg of flumethasone or 25 mg of hydrocortisone can be injected intravenously.

5, the whole body nutrition support therapy strengthens nutrition, improves the patient's resistance, and can inject new blood. Actively prevent and treat complications and deal with them symptomatically when necessary.

Fourth, the treatment of anaerobic infection.

The treatment of anaerobic bacterial infection includes debridement, excision of necrotic tissue and washing with hydrogen peroxide; Metronidazole is given orally or intravenously, and the usual dose is 1.5g, and it is given in three times. Appropriate use of antibiotics and systemic support therapy.

Bsp V. Treatment of virus infection

Can choose herpes simplex, interferon or cytarabine.

prevent

When local or systemic infection occurs, it is generally difficult to treat, and it is more important to prevent infection. Reasonable preventive measures include the following aspects:

1, debridement, aseptic operation and disinfection and isolation measures

Although the pathogenic bacteria of systemic infection are not completely from the wound surface, there is a certain relationship between the bacteria of the wound surface and the infection, so measures should be taken to reduce the bacteria. The commonly used principles are debridement and aseptic operation. At the initial stage of admission, the patient should be debrided to remove pollutants and necrotic substances from the wound surface, and the wound surface should be washed with 1‰ bromogeramine or 0.5% chlorhexidine. Finally, the wound surface should be washed with normal saline at 20℃ ~ 35℃ to reduce the number of bacteria on the wound surface. Sterile operation and disinfection can not be ignored in preventing infection. Although it is not easy and generally unnecessary to put the patient in a sterile laminar flow room, it is very necessary to put the patient in a ward with disinfection and isolation conditions and all factors that may cause cross infection (such as appliances in the ward and things carried by medical staff). ) should be avoided. Sterility principle is the key to prevent iatrogenic infection.

2. Nutrition

Patients with extensive burns usually have malnutrition, low immune function and infection at the same time, which are mutually causal. The results showed that the conditioned reflex index, serum total protein, transferrin, C3 and IgG levels in the high protein treatment group were higher than those in the control group with sufficient heat supply. Strengthening nutrition and maintaining positive nitrogen balance can significantly reduce the incidence and mortality of invasive infection.

3. Immunotherapy

Among the immune methods of burn infection, the immunotherapy of Pseudomonas aeruginosa infection has been widely studied. Immunotherapy can be divided into active immunity and passive immunity. At present, the active immunization in clinical application is mainly Pseudomonas aeruginosa vaccine, and the passive immunization is Pseudomonas aeruginosa immunoglobulin or high-valent immune serum (or plasma).

⑴ Active immunization: Pseudomonas aeruginosa vaccine can be divided into lipopolysaccharide antigen and endotoxin protein antigen according to antigen components. Seven-valent Pseudomonas aeruginosa vaccine and 16-valent Pseudomonas aeruginosa vaccine (PEV-0 1) belong to lipopolysaccharide antigen, and Pseudomonas aeruginosa vaccine (EP) developed in China belongs to endotoxin antigen. Pseudomonas aeruginosa vaccine has good immunogenicity. After the burn patients were inoculated with PEV-0 1 3 times on the day of admission, 7 days, and 14 days, the antibody titer of 16 component began to change from admission. ~ 1/32 rose to 1/64 ~ 1/256 on average and kept for 4 weeks. The lectin and hemagglutination in serum have protective effect on the lethal attack of Pseudomonas aeruginosa. However, patients who have not been vaccinated rarely have protective antibodies.

The plasma endotoxin level of vaccinated patients is low, and the endotoxin drop of patients infected with Pseudomonas aeruginosa without vaccination is high. Endotoxin consumes C3 component of complement, destroys nonspecific immune mechanism and increases patients' susceptibility to infection. Vaccination with Pseudomonas aeruginosa vaccine can reduce the level of endotoxin in blood and indirectly enhance the resistance of patients to bacterial infection.

After inoculation, the phagocytic activity of neutrophils was enhanced, and the phagocytic effect of neutrophils on latex particles, aerogenes and Proteus mirabilis was enhanced. In the presence of specific antibodies, the ability of neutrophils to kill Pseudomonas aeruginosa was significantly enhanced.

The appropriate dose of vaccine can produce the maximum antibody response level. Generally, the recommended dose of 7-valent vaccine is 25 μ g/kg, PEV-0 1 is an adult dose (RHD), and the children below 12 are 0.5RHD. Intradermal and intramuscular injection or subcutaneous injection can be used. It usually takes 5 ~ 7 days to produce the appropriate antibody level. Therefore, the earlier the vaccine is vaccinated, the better. The first vaccination should be carried out within 6 days, because the patient's response to the vaccine is quite poor after 6 days. Active immunization generally takes 5 ~ 7 days, and the content of IgG antibody in serum can reach the protection level. The maintenance time is relatively short, so it is necessary to continue immunization and vaccinate once every 3 to 7 days until the threat of Pseudomonas aeruginosa infection disappears.

After vaccination, local redness and swelling may occur and body temperature may rise. When the reaction is serious, the vaccine dose should be stopped or reduced.

⑵ Passive immunization: Passive immunization is to inject patients with Pseudomonas aeruginosa immunoglobulin or high-valent immune serum (or plasma). The preparation of high titer immune plasma is to inject vaccine into volunteers, separate the plasma when the antibody titer reaches 1∶5 12, and freeze-dry and store it. The dose for adults is 250ml, and the dose for children is 125ml, which is usually injected within one week. 0.5ml for adults and 0.2ml for children were injected with Pseudomonas aeruginosa immunoglobulin on the day of admission for 3 days.

Passive immunization can make up for the long time of active immunization. For immunocompromised people, it is generally advocated to inject polyvalent Pseudomonas aeruginosa vaccine and polyvalent Pseudomonas aeruginosa immunoglobulin or immune plasma immediately after burn.

4. Preventive application of antibiotics

The principles of preventive use of antibiotics are early, combined, sufficient and sensitive. Although some scholars do not advocate preventive use of antibiotics, we believe that rational use of antibiotics can reduce the incidence of invasive infections. Early stage refers to the application of antibiotics to prevent infection in patients with extensive deep burns or serious pollution after admission; Combination refers to the combined application of two antibiotics to inhibit the proliferation of bacteria in wounds and under scabs. Cefovir plus amikacin is generally used.

5. actively deal with the wound.

The necrotic tissue of burn wound provides a good culture medium for bacteria, and the wound is the main source of infection. In addition, the damage of immune function after burn mostly returns to normal after wound healing or escharectomy and skin grafting. Therefore, active treatment of wounds (including escharectomy and skin grafting, and local topical drugs to promote wound healing) is the key to prevent infection.