علاج وعمليات اصلاح الحروق المختلفة بمضاعفاتها وتشوهاتها

Treatment of burns and their

complications

Management of Burns

The burns patient has the same priorities as all other trauma patients.

• Assess:

• –  Airway
• –  Breathing: beware of inhalation and rapid                airway compromise
• –  Circulation: fluid replacement
• –  Disability: compartment syndrome
• –  Exposure: percentage area of burn.

• Essential management points:

– Stop the burning – ABCDE

• Determine the percentage area of burn (Rule of 9’s)

•  Good IV access and early fluid replacement.

• The severity of the burn is determined by:

•   Burned surface area
•   Depth of burn
•   Other considerations.

• Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.

Management of burns in adults

The “Rule of 9’s” is commonly used to estimate the burned surface area in adults.

• The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total body surface (Figure 7). The outstretched palm and fingers approximates to 1% of the body surface area.
• If the burned area is small, assess how many times your hand covers the area.
• Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.

Burn management in children

The‘Rule of 9’s’ method is too imprecise for estimating the burned surface area in children because the infant or young child’s head and lower extremities represent different proportions of surface area than in an adult (see Figure 8).

• Burns greater than 15% in an adult ,greater than 10% in a child, or any burn occurring in the very young or elderly are serious.

Burn Management (continued)

Depth of burn

• It is important to estimate the depth of the burn to assess its severity and to plan future wound care. Burns can be divided into three types, as shown below.

• It is common to find all three types within the same burn wound and the depth may change with time, especially if infection occurs. Any full thickness burn is considered serious.

Serious burn requiring hospitalization

• –  Greater than 15% burns in an adult
• –  Greater than 10% burns in a child
• –  Any burn in the very young, the elderly or the infirm
• –  Any full thickness burn
• –  Burns of special regions: face, hands, feet, perineum
• –  Circumferential burns
• –  Inhalation injury
• –  Associated trauma or significant pre-burn illness: e.g. diabetes

Wound care

First aid

Burn Management (continued)

• If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with cool water to prevent further damage and remove all burned clothing.
• If the burn area is limited, immerse the site in cold water for 30 minutes to reduce pain and oedema and to minimize tissue damage.
• If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned area (or the whole patient) to prevent systemic heat loss and hypothermia.
• Hypothermia is a particular risk in young children.
• First 6 hours following injury are critical; transport the patient with severe burns to a hospital as soon as possible.

Initial treatment

• Initially, burns are sterile. Focus the treatment on speedy healing and prevention of infection.
• In all cases, administer tetanus prophylaxis.
• Except in very small burns, debride all bullae. Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over the first several days.
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild water- based antiseptic.
• Do not use alcohol-based solutions.
• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of antibiotic cream (silver sulfadiazine).
• Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to the outer layers.

Daily treatment

Burn Management (continued)

• Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the dressing. On each dressing change, remove any loose tissue.
• Inspect the wounds for discoloration or haemorrhage, which indicate developing infection.
• Fever is not a useful sign as it may persist until the burn wound is closed.
• Cellulitis in the surrounding tissue is a better indicator of infection.
• Give systemic antibiotics in cases of haemolytic streptococcal wound infection or septicaemia.
• Pseudomonas aeruginosa infection often results in septicaemia and death. Treat with systemic aminoglycosides.
• Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the cheapest, is applied with occlusive dressings but does not penetrate eschar. It depletes electrolytes and stains the local environment.
• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It has limited eschar penetration and may cause neutropenia.
• Mafenide acetate (11% in a miscible ointment) is used without dressings. It penetrates eschar but causes acidosis. Alternating these agents is an appropriate strategy.
• Treat burned hands with special care to preserve function.
  • −  Cover the hands with silver sulfadiazine and place them in loose polythene gloves or bags secured at the wrist with a crepe bandage;
  • −  Elevate the hands for the first 48 hours, and then start hand exercises;
  • −  At least once a day, remove the gloves, bathe the hands, inspect the burn and then reapply silver sulfadiazine and the gloves;
  • −  If skin grafting is necessary, consider treatment by a specialist after healthy granulation tissue appears.  

Healing phase

Burn Management (continued)

• The depth of the burn and the surface involved influence the duration of the healing phase. Without infection, superficial burns heal rapidly.
• Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue.
• Plan to provide long term care to the patient.
• Burn scars undergo maturation, at first being red, raised and uncomfortable. They frequently become hypertrophic and form keloids. They flatten, soften and fade with time, but the process is unpredictable and can take up to two years.
• In children
  • –  The scars cannot expand to keep pace with the growth of the child and may lead to contractures.
  • –  Arrange for early surgical release of contractures before they interfere with growth.
• Burn scars on the face lead to cosmetic deformity, ectropion and contractures about the lips. Ectropion can lead to exposure keratitis and blindness and lip deformity restricts eating and mouth care.
• Consider specialized care for these patients as skin grafting is often not sufficient to correct facial deformity.

Nutrition

• Patient’s energy and protein requirements will be extremely high due to the catabolism of trauma, heat loss, infection and demands of tissue regeneration. If necessary, feed the patient through a nasogastric tube to ensure an adequate energy intake (up to 6000 kcal a day).
• Anaemia and malnutrition prevent burn wound healing and result in failure of skin grafts. Eggs and peanut oil and locally available supplements are good.

Types of Dressings for Burn Wounds

Assessing the depth of a burn usually requires the skill of a doctor or nurse. Dead skin covering a burn often disguises its depth. Bacteria also grow in dead skin, which antibiotics cannot reach and kill. A doctor who feels confident that a burn is only shallow will choose from a number of techniques to treat it. These shallow burns should heal within two weeks without scarring.

1- Synthetic Skin

• After carefully cleaning a burn, a “synthetic skin” dressing can be adhered to a wound. Two versions of this dressing include Biobrane and TransCyte. The latter combines neonatal human cells with porcine (pig) ones. First, the dressing fastens to the skin with adhesive. A compress applied causes the synthetic skin to fully adhere. Biobrane and TransCyte protect the skin with minimal pain when compared with petroleum jelly and gauze, which are traditional methods of dressing. Dead skin and fluid coming to the surface requires that the synthetic skin come off for cleaning, a process which is difficult and sometimes painful.
• TransCyte showed better results than Biobrane where pain and healing are concerned. 
Once dead skin and fluid are no longer present, after 24 to 48 hours with minor burns, the wounded area no longer requires covering.
• Synthetic skin adheres so closely to the wound that no doctor wants to make a mistake and have to take this off of a patient with a deeper burn.
• Biobrane and TransCyte have been proven effective and far surpass the petroleum jelly and gauze method, which often introduced gauze fibers into the wound, encouraging infection.

• Synthetic skin can help.

• A biosynthetic membrane for advanced wound-care.

The skin is a protective barrier that prevents infections, fluid and heat loss. A breach in this barrier will therefore cause an immediate need for protection. Epiprotect® forms a cell free temporary epithelium that can replace the lost barrier, making it perfect for advanced wound care settings. Epiprotect® will cover the wound and help the body to control the microenvironment, keeping tissue viable.

The material is based on a biosynthetic polymer of sugar molecules that have been further developed by S2Medical.

The exact and controlled production gives the material unique properties such as superior conformability, transparency, strength and breathability. Epiprotect® can be efficiently used to treat facial burns, and will help the body to control the level of moisture at any given phase of the healing process. This means that the healing conditions will be optimal during all the different stages of healing without any need of dressing changes.

Epiprotect® is a synthetic epithelium that is 100% free from human or animal products. It provides the adherence and pain reduction while providing an optimal environment for controlled healing.

Key Benefits

✓ Adheres and conforms to the wound

✓ Easy to apply and easy to cut

✓ Near total transparency, easy monitoring

✓ Moist wound healing

✓ Allows the body to control the microenvironment

✓ Collagen mimicking nanostructure

✓ Replaces the need of animal or human tissue

✓ Impermeable to bacteria

✓ Hemostatic

✓ Applies only once, on superficial burns/wounds

✓ Breathable

✓ Prevents fluid loss, no exudates

✓ Fully compatible with antibiotics

✓ Reduced pain

Healing® by skin mimicking structure.

eiratex® shares the nanostructure of human skin but is a biosynthetic epithelium that does not originate from animal or human tissue.

Epiprotect® with its eiratex®-membrane holds a collagen mimicking nanostructure, giving it extremely high biocompatibility and full functionality as a cell free, non degradable biosynthetic epithelium that stops bacteria from penetrating the network and reaching the wound.

The eiratex® membrane is gas permeable and buffers moist, allowing an optimized fluid and gas homeostasis giving a perfect environment during the whole healing process.

Pain reduction.

Being severely burnt is both painful and traumatizing. One of the most important features of Epiprotect® is therefore the pain reducing effect, especially when treating children.

Epiprotect® has an extremely tight adherence to the wound which ensures that all free nerve ends will be covered, giving an instant pain relief. In fact, Epiprotect® treated patients rarely feel a need for analgesic medications.

Less stress, more care

Epiprotect® will give you easier care and maintenance, will adapt to the healing process and is most often only applied once. The dressing will after attachment stay on the wound until the wound is healed. The transparent feature of the dressing makes monitoring both faster and more convenient.

• Epiprotect® is a superior alternative for exuding wounds as it prevents the forming of exudate which is an important factor both in the care of burns but also many chronic or complicated wounds.

Epiprotect®   حالة تم علاجها باستخدام

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2- Silver Dressings

• “Silver” cream dressings (Silvazine) discourage bacterial growth and encourage quick healing. After no more than a week, fluid and dead skin should be gone and a regular dressing applied.
• Compared to wounds treated with synthetic skin, the skin treated with Silvazine repaired itself more slowly and some patients need grafting.
• Like Biobrane and TransCyte, Silvazine more effectively treats burn wounds than petroleum jelly and gauze dressings, especially against the growth of bacteria. Though skin heals more quickly under synthetic skin than with just silver cream, silver cream comes off with relatively little discomfort.

3- Non-adhesive Dressing

• The soft silicone of Silflex (formerly known as Siltex: Advance Medical) covers the wound without adhering. A moist layer (usually of a silver-based cream) ensures that the wound does not dry out, a critical factor in healing.
• When dressings are changed, there is less or no pain than with traditional dressings or adherent ones. Wound depth will guide the choice of dressing, but a mistake can cause a patient tremendous pain.