Treatment of burns: local, medication, surgery

Inpatient treatment of burns, preferably in a burn center, is indicated for total dermal involvement of >1% of the body surface area, partial dermal burns of >5% of the body surface area, any burns of >10%, and superficial and deep burns of the hands, face, feet, and perineum. Hospitalization is generally recommended for patients <2 years and >60 years of age and in situations where compliance with physician recommendations in an outpatient setting is difficult or impossible (eg, difficulty in maintaining a consistently elevated position for the hands and feet at home). Most experts believe that all burns except first-degree burns <1% of the body surface area should be treated by experienced physicians, and all patients with burns >2% of the body surface area should be hospitalized at least briefly. Maintaining adequate pain relief and exercise for patients and their loved ones may be challenging.

Local treatment of burns

Almost 70% of hospitalized burn patients and the vast majority of patients undergoing outpatient treatment have superficial burns, so the role of local conservative treatment of burn wounds is very significant.

Local treatment of burns should be carried out depending on the depth of the lesion, the stage of the wound process, the location of the burns, etc.

Local treatment of a burn begins with primary wound care. The skin around the burn is treated with a tampon soaked in a 3-4% solution of boric acid, gasoline or warm soapy water, then alcohol. Foreign bodies and epidermal scraps are removed from the burn surface, large blisters are cut, their contents are released, and the epidermis is placed on the wound. Medium and small blisters can be left unopened. The wound is treated with a 3% hydrogen peroxide solution, irrigated with antiseptics [chlorhexidine, polyhexanide (lavasept), benzyl-dimethyl-myristoylamino-propylammonium (miramistin), etc.] and covered with a bandage.

In the future, either open or closed methods of treatment are used. The first is rarely used, mainly for burns in such locations where the applied dressings can complicate patient care (face, perineum, genitals). The open method is also used to treat multiple small residual wounds. The main method of treating burn wounds is closed: the applied dressing not only protects the wounds from trauma, infection from the outside, contamination and evaporation of water from its surface, but also serves as a conductor of various pathogenetic effects on the wounds. It should be borne in mind that these two methods can be used simultaneously. The disadvantages of the closed method are the labor intensity and pain of dressings, and the high consumption of dressing material. Despite the fact that the open method is devoid of these disadvantages, it has not found wide application in practical combustiology.

In the treatment of second-degree burns, emulsions or ointments are used [with chloramphenicol (syntomycin emulsion) 5-10%, nitrofural (furacilin ointment) 0.2%, gentamicin (gentamicin ointment) 0.1%, chloramphenicol/dioxomethyltetrahydropyrimidine (levomekol), dioxomethyltetrahydropyrimidine/sulfodimethoxine/trimecoine/chloramphenicol (levosin), benzyldimethyl-myristoylaminopropylammonium (miramistin ointment), sulfadiazine (dermazin), silvacin, etc.]. Often, the bandage applied during the patient's initial visit turns out to be the last one: healing of second-degree burns occurs within 5 to 12 days. Even when such burns become purulent, their full epithelialization is observed after 3-4 dressings.

For IIIA degree burns, in the first phase of the wound healing process, wet-drying dressings with antiseptic solutions are used [0.02% nitrofural (furacilin) solutions, 0.01% benzyldimethyl-myristoylamino-propylammonium (miramistin), chlorhexidine, polyhexanide (lavasept), etc.]. After the rejection of necrotic tissue, ointment dressings are used (as with second-degree burns). Physiotherapeutic procedures [ultraviolet irradiation (UVR), laser, magnetic laser therapy, etc.] promote activation of reparative processes. IIIA degree burns undergo epithelialization within 3 to 6 weeks, sometimes leaving behind cicatricial changes in the skin. In case of unfavorable course of the wound process, in rare cases, when the patient has severe concomitant pathology (diabetes mellitus, atherosclerosis of the vessels of the extremities, etc.), wound healing does not occur. In such situations, they resort to surgical restoration of the skin.

Local treatment of deep burns aims to prepare them as quickly as possible for the final stage - free skin grafting and depends on the phase of the wound healing process. During the period of inflammation and suppuration, measures should be taken to convert wet necrosis into a dry scab. In order to suppress the microflora in the wound and reject non-viable tissue, wet-drying dressings with antiseptics and antibacterial drugs used in the treatment of purulent wounds are used [solutions of nitrofuran (furacilin) 0.02%, benzyldimethyl-myristo-lamino-propylammonium (miramistin) 0.01%, chlorhexidine, polyhexanide (lavasept), aqueous iodine preparations]. In this phase of the wound healing process, ointments on a fat basis should not be used due to their hydrophobicity. On the contrary, water-soluble ointments [chloramphenicol/dioxomethyltetrahydropyrimidine (levomekol), dioxomethyltetrahydropyrimidine/sulfodimethoxine/trimecaine/chloramphenicol (levosin), streptolaven] are widely used in the treatment of deep burns in the inflammatory-destructive phase.

Dressings are changed every other day, and in case of abundant suppuration - daily. During dressings, staged necrectomy is performed - as the tissue is rejected, non-viable tissues are excised along the edges of the wound. Frequent dressing changes can reduce the suppurative process and bacterial contamination. This is of great importance for preventing infectious complications and preparing wounds for skin grafting: the more active the local treatment, the sooner the surgical restoration of the lost skin is possible.

Recently, a number of new drugs have been used for local treatment of deep burns. Streptolaven ointment has not yet found wide application in practice, but the first experience of its use has shown quite high efficiency. It has a strong keratolytic effect due to the plant-based enzyme ultralysin included in its composition and a pronounced antimicrobial effect of benzyldimethyl-myristoylamino-propylammonium. The use of streptolaven promotes early formation of a dry scab, a decrease in microbial contamination and, as a result, faster (by 2-3 days) in comparison with traditional means of wound readiness for autodermoplasty.

To combat Pseudomonas aeruginosa, solutions of hydroxymethylquinoxyline dioxide (dioxidine) 1%, polymyxin M 0.4%, an aqueous solution of mafenide 5%, and a solution of boric acid 3% are used. Local application of antibiotics has not found wide application due to the rapid adaptation of pathogenic microflora to them and possible allergization of medical personnel.

To stimulate reparative processes in a burn wound and to normalize disturbed metabolism in tissues, substances with antioxidant properties are used [solutions of dioxomethyltetrahydropyrimidine (methyluracil) 0.8%, sodium dimercaptopropanesulfonate (unithiol) 0.5%. Their use promotes accelerated cleansing of wounds from necrotic tissue and rapid growth of granulations. To stimulate recovery processes, pyrimidine derivatives are prescribed in parallel (pentoxyl 0.2-0.3 g orally 3 times a day). They stimulate hematopoiesis and have an anabolic effect.

Keratolytic (necrolytic) agents and proteolytic enzymes are of great importance in preparing the wound bed after deep burns for free skin grafting. Under the influence of keratolytic agents, the inflammatory process in wounds intensifies, the activity of proteolytic enzymes increases, and the demarcation of the scab accelerates, which allows its removal as a whole layer. For these purposes, 40% salicylic acid (salicylic ointment) or complex ointments containing salicylic and lactic acids are widely used. The ointment is applied to the dry scab in a thin layer (2-3 mm), a bandage with an antiseptic solution or indifferent ointment is applied on top, which is changed every other day. The scab is rejected in 5-7 days. The ointment can be used no earlier than 6-8 days after the injury, provided that a clear demarcation of the scab has formed. The ointment should not be applied to areas larger than 7-8% of the body surface, since it intensifies the inflammatory process, and with it, intoxication. For the same reason, the ointment should not be used in the case of a generally severe condition of the patient, sepsis, or wet scab. Currently, the use of keratolytic agents is finding fewer and fewer supporters among specialists. This is due to the expansion of indications for early radical necrectomy, the implementation of which excludes the use of keratolytic agents.

In the treatment of deep burns, enzyme preparations (trypsin, chymotrypsin, pancreatin, deoxyribonuclease, streptokinase, etc.) are most often used. Their action is based on the breakdown and decomposition of denatured protein, melting of non-viable tissues. Enzymes do not act on dense scab. Indications for their use are the presence of non-viable tissue residues after necrectomy, purulent-necrotic plaque on granulations. Proteolytic enzymes are used as a powder on a wound pre-moistened with isotonic sodium chloride solution or in the form of 2-5% solutions. Currently, proteolytic enzymes immobilized on a cellulose matrix, soluble films and other materials have found wide application. The advantage of such agents is their prolonged action, eliminating the need for daily dressing changes, and the undoubted ease of use.

After the development of granulation and cleansing of wounds from the remains of necrotic tissue in order to prepare for autodermoplasty, dressings are alternated with antiseptic solutions and ointments on a water-soluble basis, depending on the condition of the wound bed. In case of insufficient development and poor condition of granulation, ointment dressings are used, in case of a large amount of purulent discharge - dressings with antiseptics; in case of excessive growth of granulation - glucocorticosteroid drugs [hydrocortisone/oxytetracycline (oxycort), triamcinolone (fluorocort)]. After their use, the condition of the granulation tissue noticeably improves: granulations flatten, become level with the surrounding skin, become bright red; the amount of discharge decreases, fine granularity disappears, marginal and insular epithelialization is activated.

The great hopes placed 20-25 years ago on the method of open treatment of burns in a controlled abacterial environment did not justify themselves due to the complexity and bulkiness of the equipment. This method, by strictly isolating the patient or the affected part of the body in special chambers for constant exposure of the burn surface to heated sterile and repeatedly changed air, contributed to the formation of a dry scab, reduced inflammation and microbial contamination, reduced the time of epithelialization of superficial burns and the time of preoperative preparation. At the same time, due to the reduction of intoxication, the general condition of the victims improved.

In the presence of insufficiently mature granulations, UV irradiation, ultrasound and laser irradiation have a positive effect on the wound process. These methods help to revive the granulation cover. The use of hyperbaric oxygenation sessions can also have a beneficial effect on the wound process, reducing pain in wounds, actively growing full-fledged granulations, marginal epithelialization; better results of engraftment of free skin autografts.

In the last 15-20 years, special fluidized beds - clinitrons - have become firmly established in the practice of treating severely burned patients. They are filled with microspheres that are in constant motion under the influence of a flow of heated air. Placed in such a bed (covered with a filter sheet), the patient was in a "suspended state". Such devices are indispensable in the treatment of patients with circular burns of the trunk or limbs, they eliminate the pressure of body weight on the wound surface, which helps to avoid wet necrosis, and after autodermoplasty, promotes good engraftment of autografts. However, due to the high cost of clinitron beds and their components (microspheres, diffusers, filter sheets), the complexity of their prevention and repair, they are available only to large burn hospitals.

Fluid requirements and systemic complications

Fluid replacement and treatment of systemic complications are continued as long as the patient's condition dictates. Fluid volume requirements are determined based on clinical manifestations rather than formulas. Primary goals include preventing shock, ensuring adequate urine output, and avoiding fluid overload and heart failure. Urine output >30 mL/hour (0.5 mL/kg/hour) in adults and 1 mL/kg/hour in children is considered adequate. If the patient's urine output is inadequate despite high-dose crystalloids, burn center consultation is necessary. Such patients may respond to a mixture containing colloids. Urine output is measured by bladder catheterization. Clinical parameters, including urine output and signs of shock and heart failure, are recorded at least hourly.

Rhabdomyolysis is treated with fluids sufficient to provide a urine output of 100 mL/h in adults or 1.5 mL/kg/h in children, with mannitol 0.25 mg/kg IV every 4 to 8 hours until myoglobinuria resolves. If myoglobinuria is severe (usually only with burns that char large areas of the skin or after high-voltage electrical burns), the damaged muscles are debrided surgically. Most persistent arrhythmias resolve with their underlying causes (eg, electrolyte imbalance, shock, hypoxia). Pain is usually controlled with IV morphine. Electrolyte deficiencies are treated with calcium, magnesium, potassium, or phosphate (ROD). Nutritional support is needed in patients with burns >20% or in those who are malnourished. Tube feedings are started as soon as feasible. Parenteral nutrition is rarely needed.

The spectrum of action of primary empirical antibiotic therapy for clinical signs of infection in the first

7 days should cover staphylococci and streptococci (for example, nafcillin). Infection that develops after 7 days is treated with broader-spectrum antibiotics that cover gram-positive and gram-negative bacteria.

Subsequently, the antibiotic is selected based on the results of the culture and sensitivity of the isolated microorganisms.

Medicinal treatment of burns

To reduce pain when providing first and emergency aid, tablet analgesics are used [metamizole sodium (analgin), tempalgin, baralgin, etc.], opium group drugs (morphine, omnopon) or their synthetic analogues, such as trimeperidine (promedol), can be used. Applications of local anesthetics to the burn surface are indicated [procaine (novocaine), lidocaine, tetracaine (dicaine), bumecaine (pyromecaine), etc.], effective for superficial burns (but not for IIIB-IV degree damage).

Infusion-transfusion therapy is of primary importance in all periods of burn disease, the outcome of severe burn injury often depends on its competent and timely implementation. It is prescribed to all victims with burns covering an area of more than 10% of the body surface (Frank index>30, "hundred rule">25).

Tasks:

• restoration of BCC;
• elimination of hemoconcentration;
• increase in cardiac output;
• improving microcirculation;
• elimination of water-salt and acid-base balance disorders;
• elimination of oxygen deficiency;
• restoration of kidney function.

Infusion media in the treatment of burn shock should replace three components - water, salts and proteins, and also be retained in the vascular bed to restore the BCC, cardiac output, transport function of the blood and improve metabolic processes. For this purpose, synthetic medium- and low-molecular blood substitutes are used [solutions of starch, dextran (polyglucin, rheopolyglucin), gelatin (gelatinol), hemodez], saline solutions of various compositions, blood products (native plasma, albumin, protein). Indications for transfusion of red blood cells during shock arise with concomitant blood loss due to mechanical trauma or gastrointestinal bleeding.

The required amount of infusion media during the burn shock period is calculated using special formulas, among which the Evans formula is the most widely used. According to this formula, the following is administered during the first day after the injury:

• electrolyte solutions: 1 ml x % burn x body weight, kg;
• colloidal solutions: 1 ml x % burn x body weight, kg;
• glucose solution 5% 2000 ml.

On the second day, half of the volume of solutions transfused the day before is administered.

For burns covering an area of more than 50% of the body surface, the daily dose of infusion-transfusion media remains the same as for burns covering 50% of the body surface.

Bandages

Dressings are usually changed daily. Burns are completely cleaned by rinsing and removing remnants of antimicrobial ointments. Then the wound is sanitized if necessary and a new layer of local antibiotic is applied; the bandage is fixed without squeezing the tissue to prevent ointment leakage. Until the swelling disappears, the burned limbs, especially the legs and hands, are elevated, if possible, above the level of the heart.

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Surgical treatment of burns

Surgery is indicated if burn healing is not expected within 3 weeks, which is the case with most deep burns with partial dermal involvement and all burns with full dermal involvement. Eschars are removed as soon as possible, optimally within the first 7 days, which helps prevent sepsis and provides conditions for early skin grafting, which shortens the hospital stay and improves treatment outcomes. In extensive, life-threatening burns, the largest eschar is removed first to cover as much of the affected area as possible. Such burns should only be treated in burn centers. The order of eschar removal depends on the preferences of an experienced burn surgeon.

After excision, skin grafting is performed, most optimally using split-section autografts (patient's skin), which are considered durable. The autograft can be transplanted as a whole sheet (a single piece of skin) or mesh (a sheet of donor skin with many small incisions arranged in a regular pattern, allowing the graft to be stretched over a large wound surface). Mesh grafts are used in areas of the body that have no cosmetic value in the case of burns >20% and a shortage of skin for grafting. After engraftment of a mesh graft, the skin has a bumpy, uneven appearance, sometimes forming hypertrophic scars. In the case of burns >40% and an insufficient supply of autoskin, an artificial regenerating dermal sheet is used. It is possible, although less desirable, to use allografts (viable skin, usually taken from a cadaveric donor); They are rejected, sometimes within 10-14 days, and ultimately have to be replaced with autografts.

Surgical treatment of deep burns

Surgical intervention is a necessary component of the treatment of deep burns. Only with its help can the lost skin be restored and the patient recover. The main surgical techniques used are necrotomy, necrectomy and dermatome skin plastic surgery.

Necrotomy (cutting the burn eschar) is used as an emergency surgical intervention for deep circular burns of the extremities and chest. It is performed in the first hours after the injury. Indication for necrotomy is the presence of a dense dry eschar that circularly covers the arm or leg and disrupts blood circulation, as evidenced by coldness and cyanosis of the skin of the distal parts of the burned limb. A dense eschar on the chest sharply limits respiratory excursion and causes respiratory distress. Technique for performing necrotomy: after treatment with disinfectant and antiseptic solutions, the eschar is cut with a scalpel. It is advisable to make several longitudinal incisions, while no anesthesia is required, since the manipulation is performed on necrotic tissues that are devoid of sensitivity. Necrotomy is performed until visually viable tissues are reached (until pain and drops of blood appear along the incisions); the edges of the wounds at the end of the intervention diverge by 0.5-1.5 cm, blood circulation in the affected limbs improves, and chest excursion increases.

Necrectomy is the excision of dead tissues without affecting viable tissues. It can be mechanical, in which the scab is removed in the operating room using a scalpel, scissors or dermatome, or chemical, when necrosis is removed using various chemicals (salicylic acid, urea, etc.).

Non-viable tissues (burn eschar) are the cause of burn disease and infectious and inflammatory complications. The deeper and more extensive the burn, the greater the likelihood of complications, so early removal of the eschar is pathogenetically justified. Its implementation within 5 days after the injury is called early surgical necrectomy, after - delayed. It is necessary to remember that surgical removal of necrosis can only be started after the patient has been brought out of the state of shock. The optimal time is considered to be 2-5 days after the burn. The eschar can be removed completely to viable tissues (radical necrectomy) or partially layer by layer (tangential necrectomy). In the latter case, non-viable tissues can also serve as the bottom of the wound defect. Depending on the area of necrosis removed, necrectomy is divided into limited (up to 10% of the body surface), in which the general condition of the victims does not suffer as a result of the operation, and extensive, when, due to large intraoperative blood loss, significant shifts in homeostasis indicators develop.

The main obstacle to performing early radical necrectomy on areas of more than 20% of the body surface is trauma and large blood loss, reaching 2-3 liters. Such operations are often complicated by the development of anemia and surgical shock. For this reason, radical necrectomy is usually performed on an area of no more than 20% of the body surface. To reduce intraoperative blood loss, a number of techniques are used:

• in the preoperative period, hemodilution is performed, then a relatively smaller amount of formed blood elements is lost intraoperatively;
• during operations on the limbs, their elevated position is used, which reduces blood loss;
• infiltration of tissues under the scab with a solution of procaine (novocaine) with the addition of epinephrine (adrenaline) is used.

Hemostasis during necrectomy is achieved by electrocoagulation and ligation of vessels. It is possible to excise the burn scab with a surgical laser, however, due to a significant increase in the operation time, possible damage to the staff's eyes and the patient's skin by the reflected beam, and possible thermocoagulation damage to healthy skin, surgical lasers have not found wide application in the surgical treatment of burns. Provided that the removal of dead tissue is radical and deep burns are widespread within 10% of the body surface, it is advisable to immediately close the resulting wounds with autologous skin flaps.

In case of more extensive lesions, wounds after necrectomy can be covered with xenoskin, embryonic membrane, synthetic substitutes. Meanwhile, the best covering is currently considered to be allogenic skin, which is obtained from corpses no later than 6 hours after death. Such tactics prevent wound infection, reduce losses of protein, water and electrolytes with secretions, and also prepare the wound bed for the upcoming autodermoplasty. A type of such treatment is brephoplasty - alloplasty using tissues of stillborn fetuses or deceased newborns. Amniotic membrane is also used. Synthetic wound coverings, unlike tissues of natural origin, can be stored for a long time, are easy to use, and do not require frequent replacement. The most effective among them are considered to be "Sispurderm", "Omniderm", "Biobran", "Foliderm".

In case of extensive burns, after stabilization of the patient's condition and correction of homeostasis parameters, necrectomy is performed on another part of the body. When treating extensive burns, the principle of staged treatment is always observed: subsequent stages of necrosis excision can be combined with skin grafting on the area where the scab was removed earlier. With this tactic of surgical treatment, with a favorable prognosis for the outcome of the disease, in order to prevent the occurrence of cicatricial contractures, functionally active areas of the body (face, neck, hands, areas of large joints) are operated first. In the presence of deep burns on an area of more than 40% of the body surface, complete release of non-viable tissues is often completed by the end of 4-5 weeks.

Of the large list of methods for restoring the skin of burn victims, the free transplantation of split autologous skin grafts is considered the main and leading one. For this, manual, electric and pneumatic dermatomes of two main types are used: with reciprocating and rotary (rotary) movement of the cutting part. Their purpose is to cut off skin flaps of a given thickness. Sometimes they are also used during necrectomy to remove scabs. The cut flap of 3/4 of the skin thickness takes root well, its subsequent wrinkling is insignificant, in appearance it is closer to normal, and, in addition, the donor area heals quickly.

Skin autografts can take root on any living tissue - subcutaneous fat, fascia, muscle, periosteum, granulation tissue. The optimal wound is one formed after early radical necrectomy. Conditions for autodermoplasty at later stages are considered to be the absence of signs of inflammation and pronounced exudation in the wound, the presence of a noticeably pronounced border of the epidermis advancing to the center. Granulations should be red or pink, not bleeding, with moderate discharge and smoothed granularity. With prolonged existence of wounds, extremely severe condition of patients caused by burn exhaustion or sepsis, granulations undergo a number of changes: they become pale, flaccid, glassy, thinned or hypertrophied. In this situation, one should refrain from surgery until the condition of the patient and the recipient bed improves. Sometimes, before skin grafting, it is advisable to excise such pathological granulations, if the patient’s condition allows it.

Modern dermatomes allow cutting skin flaps from almost any part of the body, but many circumstances should be taken into account when choosing donor sites. In the absence of a shortage of donor resources, skin flaps are usually cut from the same body surface where the granulating wounds to be closed are located. In the absence of a shortage of donor resources, this rule is neglected and flaps are cut from any part of the body. In any case, in the postoperative period, it is necessary to provide for such a position of the patient that would exclude pressure of the body on the transplanted grafts and donor sites. In case of limited burns, it is preferable to cut flaps from the anterior and outer surface of the thighs. Skin flaps with a thickness of 0.2-0.4 mm are most often used for surgical restoration of the skin. In this case, donor wounds epithelialize within 10-12 days. In case of deep burns of functionally active areas (hands, feet, neck, face, areas of large joints), it is advisable to use thick skin flaps (0.6-0.9 mm). They are cut from areas of the body where the skin is thickest (hips, buttocks, back). In these cases, donor wounds heal in 2.5-3 weeks. It should be remembered that when taking a thick flap from an area with thin skin (inner thighs, shins and shoulders, abdomen), the donor wound may not heal on its own and will also require skin grafting. As a rule, skin flaps are not cut from the face, cheeks, and joint areas due to concerns about the cosmetic appearance and the possible development of cicatricial contractures in the event of wound suppuration. In the practice of treating burn victims, the buttocks, thighs, shins, back, abdomen, shoulders, forearms, chest and scalp are usually used as donor areas.

In cases of extensive deep burns, surgeons face the problem of a shortage of donor resources. Currently, it is solved by using a "mesh transplant". It is obtained from solid flaps, passing them through a special device - a perforator. Notches of different lengths and at different distances from each other applied to the flap allow increasing the flap area by stretching by 2, 4, 6, and sometimes 9 times; and the lower the perforation coefficient, the faster the cells between the skin septa are epithelialized.

An additional method is the reuse of healed donor wounds. It is usually possible to prepare it for reuse 2.5-3 weeks after the first graft collection. This manipulation can be repeated up to three times, but the quality of the transplants decreases: they become less elastic, stretch poorly, but do not lose the ability to engraft well.

Currently, a method of skin restoration using microautodermotransplants is being studied. Its essence is that the skin flap is crushed into small pieces measuring 1x1 mm. By placing such areas on the wound at a distance of 10 mm from each other, it is possible to close a wound that is 1000 times larger than the area of the cut flap. The method is based on the principle of extending the line of marginal epithelialization.

Biotechnological methods of skin restoration are also developing successfully - mainly using various versions of the Green method. This method allows for the relatively short-term growth of epithelial layers, sometimes 10,000 times larger than the original skin flap. There are reports of successful restoration of skin over large areas using keratinocyte layer transplantation. Certain successes have been achieved in the transplantation of autologous keratinocytes in the treatment of grade III burns and donor wounds, with the authors noting a significant reduction in epithelialization time. This effect is explained by the stimulating effect of temporarily engrafted keratinocytes on reparative processes in burn wounds.

The use of allogeneic and xenogeneic cells of various types (keratinocytes, fibroblasts) seems more promising. Multilayer sheets of allogeneic keratinocytes, fibroblasts and dermal equivalent of skin are usually used. Allogeneic cells have a number of advantages: those obtained from living donors (during plastic surgeries) have a more pronounced stimulating and growth effect, they can be obtained and harvested in unlimited quantities. Transplantation of allogeneic keratinocytes is indicated for extensive IIIA burns, alternating IIIA and IIIB burns, in severe patient conditions with signs of wound exhaustion, sepsis. The observed effect is associated with accelerated epithelialization of wounds from the remaining epithelial elements of the skin appendages, so the vast majority of authors obtained positive results in the treatment of superficial burns and donor wounds.

The use of allogenic fibroblasts is based on their ability to synthesize numerous biologically active substances. Usually, allogenic fibroblasts are cultivated and transplanted on a film (Biocol, Karboxil-P, Foliderm) or as part of a living skin equivalent (collagen gel with living fibroblasts and epidermal cells on the surface). According to experts, their use significantly accelerates the epithelialization of IIIA burns and donor wounds.

Recently, work has been carried out on the artificial creation of a composition similar to a full-fledged skin structure (living equivalent of skin, artificial skin substitutes). However, it should be taken into account that biotechnological methods in the treatment of severely burned patients have not yet found wide application. In addition, the positive results of using cells and cell compositions cited in the literature mainly concern superficial burns; there are significantly fewer publications on the successful treatment of deep burns.

Physiotherapy for burns

Treatment begins on admission and is aimed at minimizing scarring and contractures, especially in areas of skin with high tension and frequent movement (e.g., face, chest, hands, joints, hips). Active and passive movement patterns are simplified after the initial edema has subsided; they are performed 1-2 times a day until skin grafting. After surgery, exercises are suspended for 5 days and then resumed. Joints affected by second- and third-degree burns are splinted in a functional position as soon as possible and kept in this position permanently (except for motor exercises) until skin grafting and healing.

Treatment of burns in outpatient settings

Outpatient treatment includes keeping the burn surface clean and the affected part of the body elevated as much as possible. Ointment dressings are applied and changed as often as in the hospital. The schedule of outpatient visits depends on the severity of the burn (e.g., for very small burns after the first visit on the 1st day, then every 5-7 days). During the visit, according to indications, debridement is performed, the depth of the burn is re-evaluated, and the need for physiotherapy and skin grafting is determined. Infection may be indicated by elevated body temperature, purulent discharge, ascending lymphangitis, pain that intensifies after the first day, pallor, or painful erythema. Outpatient treatment is acceptable for mild cellulitis in patients aged 2 to 60 years without concomitant pathology; hospitalization is indicated for other infections.