The treatment of thermal burns varies depending on the size of the wound, the depth of the wound, and the severity of the condition. The treatment of small shallow wounds is mainly non-surgical wound treatment, while the treatment of small deep wounds is mainly surgical wound treatment. For large-area thermal burns, because the injury is on the body surface and the reaction is throughout the body, the treatment is in addition to wound treatment. In addition, there should be comprehensive systemic treatment.
1. Wound treatment
Burn wound treatment refers to the use of various surgical or non-surgical methods to create an environment suitable for wound healing, so as to seal the wound as quickly as possible and complete re-epithelialization. It runs through the entire process of burn treatment and is a key link in burn treatment. Reasonable and effective wound treatment is not only conducive to the good repair of burn wounds, but also plays an important role in the stability of the patient's internal environment and the development, outcome and prognosis of the disease. Shallow wounds can heal on their own through dressing changes and other treatments, while deep wounds often require surgical skin grafting for repair. Selecting appropriate treatment methods based on different conditions such as the depth of the wound, whether it is infected, the healing period, the amount of secretion, etc. can help shorten the wound healing time and improve the quality of wound healing.
Principles for treating burn wounds: ① Shallow wounds should prevent and reduce infection, preserve the remaining epithelial tissue, and provide a suitable healing environment for re-epithelialization. ② Deep wounds should remove necrotic tissue and cover it as soon as possible to make the wound permanently closed. New granulation tissue exposed during the repair process of deep burn wounds should be covered in a timely manner. ③The treatment of burn wounds must consider functional recovery after repair. Superficial burn wounds should be treated with non-surgical methods, while deep burn wounds are mainly treated with surgery.
Non-surgical treatment of burn wounds includes: cold therapy, early debridement, bandaging therapy, exposure therapy, semi-exposure therapy, wet compress, immersion or bath, etc.
Surgical treatment of burn wounds includes: deep burn eschar incision and tension reduction, escharectomy, escharectomy, escharotomy, eschar peeling, various types of autologous skin grafts, and skin flap transplantation wait.
2. Systemic treatment
(1) Comprehensive prevention and treatment of burn shock: Burn shock is caused by multiple factors. Therefore, comprehensive prevention and treatment measures led by fluid rehydration should be promoted, including strengthening cardiopulmonary function. Maintenance, reduce myocardial hypoxic damage, enhance heart pump function, strengthen cell protection, prevent endothelial cell damage, reduce vascular permeability, improve vascular responsiveness, and improve microcirculation. Through effective clinical comprehensive treatment programs, the purpose of "preventing and treating decompensated dominant shock, correcting compensatory latent shock, scavenging oxygen free radicals, and reducing hypoxic damage" can be achieved. The ultimate goal (end point) of burn shock resuscitation should be: maintain good blood perfusion, provide effective oxygen supply to tissues, eliminate oxygen debt, restore normal aerobic metabolism, stop cell death, stabilize vital signs, and have base excess in blood gas analysis , BE)500ml/m2, the pH value of gastric mucosa returns to normal.
(2) Anti-infection:
1) Ward management: Burn patients often suffer from severe complications due to wound exposure, extravasation of large amounts of body fluids and secretions, tracheotomy, expectoration, etc. This leads to the contamination of mattresses, bedding, indoor walls, items, etc. and becomes a route of infection for germs. The best way to control this type of transmission is to use the wards in turns, and fumigate and disinfect everything in the wards during the rotation.
2) Rational use of antibiotics: Burn patients should use antibiotics in sufficient amounts and for the full duration, use the medicine decisively, and boldly withdraw the medicine. They should not be limited to the step-by-step medication. Instead, they can adopt the step-down medication to ensure The therapeutic concentration of a drug in the blood. The following points should be noted: ① Follow microbiological diagnosis and scientific medication. Microbiological testing is the key. Through microbiological testing, the pathogenic bacteria can be clarified, and the results of drug susceptibility testing and enzyme production measurement can be used as the basis for clinical prevention and drug selection; ② It is advocated to use narrow-spectrum antibiotics in a targeted manner and broad-spectrum antibiotics when necessary. , allowing necessary combined medication; ③ advocates planned rotation of medication and opposes long-term single medication. The use of second-line antibiotics should be controlled, and third-line drugs must be strictly managed and controlled; ④ Pay attention to toxic and side effects, nephrotoxic antibiotics are not suitable, similar antibiotics are not suitable, and topical use of systemic antibiotics is prohibited; ⑤ Long-term use of broad-spectrum antibiotics can easily induce secondary infections. Nystatin, which is not absorbed by the intestinal tract, can be taken orally for prevention. Fluconazole or itraconazole should be used in case of organ fungal infection or hematogenous mycosis.
3) Remove necrotic tissue from the wound and seal the wound as soon as possible.
(3) Immunonutrition support and conditioning
1) Metabolic conditioning: Non-drug therapies for high metabolic reactions after burns include: early scab removal, wound closure, prevention and treatment of sepsis, Early gastrointestinal nutrition (can add glutamine, arginine, dietary fiber and immunonutrients, etc.), increase the ambient temperature to 31.5±0.7°C, and establish an aerobic resistance exercise program in the early stage. Drug therapy includes the use of anabolic agents, such as recombinant human growth hormone, insulin, androgens, and beta-blockers (metoprolol). These drugs all have more or less side effects. The combined use of growth hormone and insulin can reduce the occurrence of hyperglycemia and hypoglycemia complications and has good clinical application prospects.
2) Immune conditioning treatment: It mainly includes the simultaneous application of immune stimulation treatment for specific immune paralysis and anti-inflammatory treatment for non-specific immune hyperinflammation.
Currently commonly used clinical drugs include: ① Immune globulin, which can improve the body’s non-specific immunity. ②α1 thymosin can induce T cell differentiation and maturation, increase the expression and release of CD4, IFN-γ, and IL-2; inhibit thymocyte apoptosis; improve the antigen presentation ability of monocytes; increase the activity and number of Th1 cells, and inhibit Production of IL-4, IL-10. ③ Ulinastatin can inhibit the activation of trypsin, elastase, and hydrolytic protease; antagonize oxygen free radicals; stabilize biofilms; inhibit the activation of the coagulation system by inhibiting serinase, etc.
(4) Support and protection of organ function: After severe burns, cardiac function is damaged to varying degrees. Myocardial nutrition drugs should be used early, and appropriate amounts of cardiotonic drugs should be used when necessary to prevent and treat increased cardiac pre- and post-load and increase myocardial blood perfusion. , improve myocardial oxygen supply to improve myocardial nutrition and protect heart function. For patients with moderate to severe inhalation injury and combined burn and impact lung injury, the airway should be ensured to be unobstructed, and protective mechanical ventilation strategies should be advocated: low inspiratory pressure (30-875pxH2O) control and permissive hypercapnia (pH>7.15) , give small tidal volume (5-8mL/kg) and low positive end-expiratory pressure ventilation (5-375pxH2O). In addition, attention should also be paid to protecting liver and kidney functions, correcting coagulation disorders, and early prevention and treatment of disseminated intravascular coagulation (DIC).