Burn treatment: local, medical, surgical

Treatment of burns in the hospital, preferably in the burn center, is shown with complete damage to the dermis> 1% of the body surface area, partial burns of the dermis> 5% of the body surface area, any burns> 10% and superficial and deep burns of the hands, face, feet and perineum. Hospitalizations in most cases are subject to injuries <2 years and> 60 years, as well as in situations when the implementation of medical recommendations in an outpatient setting is difficult or impossible (for example, at home it is difficult to provide a permanently elevated position for the hands and feet). Most experts believe that all burns, except 1st degree burns with an area <1%, should be treated by experienced doctors, and all patients with burns with an area of> 2% should be hospitalized for at least a short time. Maintaining an adequate level of anesthesia and performing motor exercises for patients and their loved ones can be difficult.

Local burn treatment

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

Local treatment of the burn should be carried out depending on the depth of the lesion, the stage of the wound process, the localization of burns,

Local treatment of the burn begins with the primary wound toilet. Treat the skin around the burn with a tampon moistened with 3-4% solution of boric acid, gasoline or warm soapy water, then with alcohol. With the burn surface, remove foreign bodies, scraps of epidermis, large bubbles are cut, release their contents, and the epidermis is laid on the wound. Medium and small bubbles can not be opened. The wound is treated with a solution of hydrogen peroxide 3%, sprinkled with antiseptics [chlorhexidine, polyhexanide (lavaset), 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 of such localizations, where the dressing can complicate the care of the patient (face, perineum, genitals). Also, the open method is used in the treatment of multiple small residual wounds. The main way to treat burn wounds is closed: the applied dressing not only protects wounds from trauma, infection from the outside, contamination and evaporation from its water surface, but also serves as a vehicle for various pathogenetic effects on wounds. It should be borne in mind that these two methods can be applied simultaneously. Disadvantages of the closed method - the laboriousness and painfulness of dressings, a large expenditure of dressings. Despite the fact that the open method is devoid of these drawbacks, it has not found wide application in practical commubistology.

In the treatment of burns of grade II, emulsions or ointments [with chloramphenicol (synthomycin emulsion) 5-10%, nitrofural (furacilin ointment) 0.2%, gentamycin (gentamicin ointment) 0.1%, chloramphenicol / dioxomethyltetrahydropyrimidine (levomecol), dioxomethyltetrahydropy- rimidin / sulfodimethoxin / trimecaine / chloramphenicol (levosin), benzyldimethyl-myristoylamino-propylammonium (miramistin ointment), sulfadiazine (dermazine), sylvacin, etc.]. Often, the bandage imposed during the patient's primary treatment turns out to be the last: healing of burns of the second degree occurs within a period of 5 to 12 days. Even with suppuration of such burns, their full epithelization is observed after 3-4 dressings.

For IIIA degree burns in the first phase of the wound process, wet-drying dressings with solutions of antiseptics are used (solutions of nitrofural (furacilin) 0.02%, benzyldimethyl-myristomylamine-propylammonium (miramistin) 0.01%, chlorhexidine, polyhexanide (lavaset), etc. ]. After the rejection of necrotic tissues go to ointment dressings (as with burns of II degree). The activation of the reparative processes is facilitated by physiotherapeutic procedures [ultraviolet irradiation (UV), laser-, magnetolaser therapy, etc.]. Burns IIIA degree epithelialized in terms of 3 to 6 weeks, sometimes leaving behind a scar's skin changes. In the case of an unfavorable course of the wound process, in rare cases, if the patient has severe concomitant pathology (diabetes mellitus, arteriosclerosis of the extremities, etc.), wound healing does not occur. In such situations resort to rapid recovery of the skin.

Local treatment of deep burns pursues the goal of their fastest preparation for the final stage - a free skin transplant and depends on the phase of the wound process. During the period of inflammation and suppuration, measures should be taken to transfer wet necrosis to the dry scab. In order to suppress microflora in the wound and reject non-viable tissues, wet-drying bandages with antiseptics and antibacterial drugs used in the treatment of purulent wounds [nitrofuran solutions (furacilin) 0.02%, benzyldimethyl-myristo-lamino-propylammonium (miramistin) 0.01 %, chlorhexidine, polyhexanide (lavasept), aqueous iodine preparations]. In this phase of the wound process, ointments should not be used on a fat basis because of their hydrophobicity. On the contrary, water-soluble ointments [chloramphenicol / dioxomethyltetrahydropyrimidine (levomecol), dioxomethyltetrahydropyrimidine / sulfodimethoxin / tri-mequine / chloramphenicol (streptolane), are widely used in the treatment of deep burns in the inflammatory-destructive phase.

Dressings are performed every other day, and if there is an abundant festering, every day. During dressings, stage necrectomies are performed - in the process of rejection, non-viable tissues are excised along the edges of the wound. With frequent changes of dressings, it is possible to reduce the suppuration and bacterial contamination. This is of great importance for preventing infectious complications and preparing wounds for skin transplantation: the more active the local treatment, the earlier it is possible to quickly restore the lost skin.

Recently, a number of new drugs have been used for the local treatment of deep burns. Ointment streptolaven 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 enzyme of the vegetable origin of ultralysin entering into its composition and the pronounced antimicrobial effect of benzyldimethyl-myristoylamino-propylammonium. The use of streptolavena contributes to the early formation of a dry scab, a decrease in microbial contamination and, as a result, a faster (2-3 days) compared with the traditional means of readiness for autodermoplasty.

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

To stimulate the reparative processes in the burn wound and to normalize the 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 purification of wounds from necrotic tissues and rapid growth of granulations. To stimulate the recovery processes, pyrimidine derivatives are administered in parallel (pentoxyl 0.2-0.3 g orally 3 times a day). They stimulate hemopoiesis, have anabolic effect.

Keratolytic (necrolytic) agents and proteolytic enzymes are of great importance in the preparation of the wound bed after deep burns to free skin transplantation. Under the influence of keratolytic agents in the wounds, the inflammatory process is intensified, the activity of proteolytic enzymes is increased and the demarcation of the scab is accelerated, which allows it to be removed by a whole layer. For these purposes, widely used salicylic acid 40% (salicylic ointment) or complex ointments, which include salicylic and lactic acid. The ointment is applied to a dry scab in a thin layer (2-3 mm), the bandage is applied from above with an antiseptic solution or indifferent ointment, which is changed every other day. Rejection of the scab occurs in 5-7 days. The use of the ointment is possible not earlier than 6-8 days after injury, provided the formation of a clear demarcation of the scab. Do not apply ointment on the area of more than 7-8% of the body surface, because under its action, the inflammatory process is intensified, and with it intoxication. For the same reason, do not use ointment with the general severe condition of the patient, sepsis, wet scab. Currently, the use of keratolytic drugs is finding fewer supporters among specialists. This is due to the expansion of indications for early radical necroctomy, the fulfillment of which excludes the use of keratolytic agents.

In the treatment of deep burns, enzyme preparations are often used (trypsin, chymotrypsin, pancreatin, deoxyribonuclease, streptokinase, etc.). Their action is based on the cleavage and decomposition of denatured protein, melting non-viable tissues. Enzymes do not act on a dense scab. Indications for their use are the presence of residual non-viable tissues after necroctomy, a purulent-necrotic plaque on the granulations. Proteolytic enzymes are used as a powder for a wound preliminarily moistened with an isotonic solution of sodium chloride or in the form of solutions of 2-5%. Currently, proteolytic enzymes immobilized on a cellulose matrix, soluble films and other materials have been widely used. The advantage of such drugs is their prolonged action, which eliminates the need for a daily change of dressings, and undoubted convenience of use.

After development of granulations and purification of wounds from the remains of necrotic tissues in order to prepare for autodermoplasty, bandages alternate with antiseptic solutions and ointments on a water-soluble basis, depending on the condition of the wound bed. With insufficient development and poor condition of granulations, ointment dressings are used, with a large amount of purulent discharge - bandages with antiseptics; with excessive growth of granulations - glucocorticosteroid preparations [hydrocortisone / oxytetracycline (oxycort), triamcinolone (fluorocort)). After their application, the state of the granulation tissue is markedly improved: the granulation is flattened, compared with the level of the surrounding skin, becomes bright red; the amount of detachable decreases, the fine granularity disappears, the marginal and islet epithelialization is activated.

The great hopes that were placed 20-25 years ago on the method of open treatment of those burned under the conditions of a regulated abacterial environment, because of the complexity and cumbersomeness of the equipment, did not justify themselves. This method by strictly isolating the diseased or injured part of the body in special chambers to permanently exert heated sterile and repeatedly changing air on the burn surface facilitated the formation of a dry scab, reducing inflammation and microbial contamination, shortening the epithelization of surface burns and the timing of preoperative preparation. At the same time, due to the decrease in intoxication, the general condition of the victims improved.

In the presence of insufficiently mature granulations, UVA, the use of ultrasound and laser irradiation, have a positive effect on the wound process. These methods contribute to the revitalization of the granulation cover. The use of hyperbaric oxygenation sessions can also have a beneficial effect on the wound process, while pains in the wounds are reduced, active growth of full-blown granulations is observed, marginal epithelization; better results of engraftment of free skin autografts.

In the last 15-20 years, special fluidizing beds - clinitrons - have become firmly established in the practice of treating seriously burned people. They are filled with microspheres, which under the action of a stream of heated air are in constant motion. Placed in such bed (covered with a filtering sheet), the patient was in a "suspended state". Such devices are indispensable in the treatment of patients with circular burns of the trunk or extremities, they have eliminated the pressure of the body's gravity on the wound surface, which helps to avoid wet necrosis, and after performing autodermoplasty promotes good engraftment of autografts. However, in connection with the high cost of beds-clinitrons and accessories (microspheres, diffusers, filter sheets), the complexity of their prevention and repair, they are available only to large burn hospitals.

The need for fluid and systemic complications

Replenishment of fluid loss and treatment of systemic complications is as much as the patient's condition requires. The necessary volume of fluid is determined, rather based on clinical manifestations, than by formulas. The main tasks include the prevention of shock, ensuring sufficient diuresis, elimination of fluid overload and heart failure. Diuresis> 30 ml per hour (0.5 ml / kg per hour) in adults and 1 ml / kg per hour in children is considered sufficient. If, in spite of the introduction of large doses of crystalloids, diuresis of the patient is not adequate, consultation of specialists of the burn center is necessary. Such patients can respond to the administration of a mixture comprising colloids. Diuresis is measured by catheterization of the bladder. Clinical parameters, including diuresis, signs of shock and heart failure, are recorded at least 1 time per hour.

Rhabdomyolysis is treated by administering a liquid in an amount sufficient to provide diuresis of 100 ml / h in adults or 1.5 ml / kg per hour in children, with mannitol at a dose of 0.25 mg / kg iv every 4-8 h until myoglobinuria disappears. In severe myoglobinuria (usually only with burns with charring large areas of the skin or after electric burns with high-voltage current), the damaged muscles are surgically treated. Most stable arrhythmias disappear along with the causes that caused them (for example, electrolyte imbalance, shock, hypoxia). Pain is usually stopped by intravenous injection of morphine. Deficiency of electrolytes is treated with calcium, magnesium, potassium or phosphate (ROD) Nutritional support is needed for patients with burns with an area of> 20% or people with reduced nutrition, feeding through the probe is started as soon as it becomes possible.Several parenteral nutrition rarely occurs.

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

7 days should cover staphylococci and streptococci (for example, nafcillin). The infection developed after 7 days is treated with antibiotics of a wider spectrum of action covering gram-positive and gram-negative bacteria.

In the future, the antibiotic is selected according to the results of inoculation and sensitivity of the isolated microorganisms.

Medical treatment of burns

To reduce pain in the first and emergency treatment, tableted analgesics (metamizole sodium (analgin), tempalgin, baralgin, etc.) are used, opioid group preparations (morphine, omnopon) or their synthetic analogues, for example, trimeridine (promedol) can be used. Applications for the burn surface of local anesthetics (procaine (novocaine), lidocaine, tetracaine (dicaine), bumecaine (pyromecaine), etc.) are shown. They are effective for superficial burns (but not with grade IIIB-IV damage).

Infusion-transfusion therapy is of paramount importance in all periods of burn disease, from the competent and timely implementation of which the outcome of severe burn injury often depends. It is prescribed for all victims with burns of more than 10% of the body surface area (Frank index> 30, "rule of the hundreds"> 25).

Tasks:

• restoration of BCC;
• elimination of hemoconcentration;
• increased cardiac output;
• improvement of microcirculation;
• elimination of violations of water-salt and acid-base equilibrium;
• elimination of oxygen deficiency;
• recovery of kidney function.

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

The necessary number of infusion media during the burn shock is calculated by special formulas, among which the most widely used is the Evans formula. According to this formula, the first day after the injury is administered:

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

In the second day, half the volume of solutions transfused on the eve is injected.

With burns on an area of more than 50% of the body surface, the daily dose of infusion-transfusion media remains the same as for a burn of 50% of the body surface.

Dressings

Dressings are usually carried out daily. Burns are completely cleansed, washing and removing the remnants of antimicrobial ointments. Then, if necessary, the wound is sanitized and a new layer of a local antibiotic is applied; the bandage is fixed without squeezing the tissues, in order to avoid leakage of the ointment. Before the disappearance of the edema burned limbs, especially the legs and brushes, give an elevated position, if possible, above the level of the heart.

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Surgical treatment of burns

The operation is indicated if healing of burns is not expected within 3 weeks, which happens with the majority of deep burns with partial damage to the dermis and all burns with complete damage to the dermis. Corpses are removed as soon as possible, optimally in the first 7 days, which helps prevent sepsis and provides conditions for early skin plasty, shortening hospitalization and improving the results of treatment. With extensive, life-threatening burns, the largest corpse is removed first to close the maximum of the affected surface rather. Such burns should be treated only in burn centers. The order of removal of the strings depends on the preferences of the experienced surgeon-kboustiologa.

After excision, the skin is transplanted, most optimally split autografts (the skin of the patient), which are considered persistent. An auto-transplant can be transplanted with a whole leaf (whole piece of skin) or mesh (a sheet of donor skin, with many small incisions arranged in the right order, allowing the transplant to stretch over a large wound surface). Mesh grafts are used in those parts of the body that do not have cosmetic significance for burns> 20% and skin deficit for plastics. After engraftment of the mesh transplant, the skin has a humpy, uneven appearance, sometimes hypertrophic scars are formed. With burns> 40% and an insufficient supply of auto skin, an artificial regenerating dermal plate is used. Perhaps, although less desirable, the use of allografts (viable skin, usually taken from a corpse donor); they are rejected, sometimes within 10-14 days, and, eventually, they have to be replaced with autografts.

Surgical treatment of deep burns

Operative intervention is an essential component of the treatment of deep burns. Only with its help it is possible to restore the lost skin and to achieve recovery of the patient. The main operational aids used are necrotomy, necrectomy and dermatomy skin plasty.

Necrotomy (dissection of a burned scab) is used as an emergency surgery for deep circular burns of the extremities and chest. It is carried out in the first hours after the injury. Indication for the performance of necrotomy is the presence of a dense dry scab that circulates the arm or leg circularly and disrupts the circulation, as evidenced by the cold and cyanotic skin of the distal sections of the burned limb. A dense scab on the chest sharply restricts the respiratory excursion and causes respiratory distress. Technique for performing necrotomy: after treatment with disinfectant and antiseptic solutions, the scab is dissected with a scalpel. It is advisable to conduct several longitudinal incisions, with no anesthesia required, since manipulation is performed on necrotic tissues lacking sensitivity. Necrotomy is performed until visually viable tissues are reached (before the appearance of soreness and drops of blood 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 extremities improves, the chest excursion increases.

Necrectomy - excision of dead tissue, not affecting the viable. It can be mechanical, in which the scab is removed in the operating room with a scalpel, scissors or dermatome, or chemical, when necrosis is removed using various chemicals (salicylic acid, urea, etc.).

Non-viable tissues (burn scab) - the cause of the development of burn disease and infectious-inflammatory complications. The probability of complications is greater the deeper and more extensive the burn, so the early removal of the scab is justified pathogenetically. Exercising it within 5 days after the injury is called an early surgical necrectomy, after - delayed. It must be remembered that the operative removal of necrosis can be started only after the patient has been removed from the state of shock. The optimal timing is 2-5 days after the burn. The scab can be removed completely to viable tissues (radical necrosectomy) or partially layer-by-layer (tangential necrosis). In the latter variant, the bottom of the wound defect may also be non-viable tissues. Depending on the area of removable necrosis, necretomies are divided into limited (up to 10% of the body surface), in which the overall condition of the victims as a result of the operation does not suffer, and extensive, when due to large intraoperative blood loss, significant changes in the parameters of homeostasis.

The main obstacle for the performance of early radical necroctomies in areas over 20% of the body surface is traumatic and large blood loss, reaching 2-3 liters. Such operations are often complicated by the development of anemia and operational shock. For this reason, radical necroctomies perform, as a rule, on an area of no more than 20% of the body surface. To reduce intraoperative blood loss, use a number of techniques:

• In the pre-operative period, hemodilution is performed, then a relatively smaller amount of blood cells is lost intraoperatively;
• in operations on the limbs they use their elevated position, which reduces blood loss;
• apply infiltration of tissues under the scab of a solution of procaine (novocaine) with the addition of epinephrine (adrenaline).

Hemostasis during necroctomy is performed by electrocoagulation and bandaging of vessels. It is possible to excise the burnt scab with a surgical laser, however, because surgical lasers can not significantly damage the eye of the staff and the patient's skin, the surgical lasers can not be widely used in the surgical treatment of burned patients. Assuming that the dead tissue is extremely radical, the depth of deep burns is within 10% of the body surface, it is advisable to cover the wound with one another instantly with autologous skin flaps.

With more extensive lesions, wounds after necroctomy can be covered with xenogens, embryo membranes, synthetic substitutes. Meanwhile, the best coverage is currently considered to be allogeneic skin, which is obtained from corpses no later than 6 hours after death. Such tactics prevent infection of wounds, reduce losses from protein, water and electrolytes that are detached, and also prepare a wound bed for forthcoming autodermoplasty. A variety of such treatment - brephoplasty - alloplasty with the use of tissues of stillborn fetuses or dead newborns. They also use the amniotic membrane. Synthetic wound coatings, in contrast to tissues of natural origin, withstand long storage, convenient to use, do not need frequent replacement. The most effective among them are "Sispurderm", "Omniderm", "Biobran", "Foliderm".

In case of extensive burns, after stabilization of the patient's condition and correction of the homeostasis parameters, necrectomy is performed in another part of the body. In the treatment of extensive burns, the principle of stage-by-stage treatment is always followed: the subsequent stages of necrosis excision can be combined with skin plasty in the area where the scab was removed earlier. With such tactics of surgical treatment, with a favorable prognosis of the outcome of the disease, functional areas of the body (face, neck, hands, areas of large joints) primarily operate in order to prevent the occurrence of cicatricial contractures. In the presence of deep burns on an area of more than 40% of the body surface, complete release from non-viable tissues is often completed by the end of 4-5 weeks.

From a large list of methods for the restoration of the skin in burned by the main and leading believe a free transplantation of split skin autologous transplants. For this, manual, electric and pneumatic dermatomes are of two basic types: with reciprocating and rotational (rotary) movement of the cutting part. Their purpose is to cut skin grafts of a given thickness. Sometimes they are also used in necrectomy for the removal of scabs. The cut flap in 3/4 of the thickness of the skin is well established, the subsequent wrinkling is insignificant, in appearance it is closer to normal, and, in addition, the donor site heals quickly.

Skin autotransplants can take root on any living tissue - subcutaneous fat, fascia, muscle, periosteum, granulation tissue. Optimal wound, formed after an early radical necrectomy. Conditions for autodermoplasty in later terms are the absence in the wound of signs of inflammation and pronounced exudation, the presence of a pronounced border of the epidermis, which is approaching to the center. Granulations should be red or pink, not bleeding, with moderate detachable and smoothed granularity. With the long-term existence of wounds, extremely severe condition of patients caused by burns exhaustion or sepsis, granulations undergo a number of changes: they become pale, flaccid, vitreous, thinned or hypertrophied. In this situation, one should refrain from surgery until the patient's condition improves and the perceiving bed. Sometimes before dermal plasty it is advisable to excise such pathological granulations, if the patient's condition allows.

Modern dermatomes allow you to cut skin flaps from virtually any part of the body, however, when choosing donor sites, many things should be considered. In the absence of a scarcity of donor resources, skin flaps are usually cut from the same surface of the body on which the granulating wounds are to be closed. With the scarcity of donor resources, this rule neglects and cuts the flaps from any part of the body. In any case, in the postoperative period, one should provide for the patient's position, which would exclude the pressure of the body on transplanted grafts and donor sites. With limited burns, it is preferable to cut the flaps from the front and outer surfaces of the thighs. Most often, in the operative restoration of the skin, skin flaps of 0.2-0.4 mm thickness are used. Donor wounds in this case are epithelized within 10-12 days. With deep burns of the functionally active areas (brushes, feet, neck, face, areas of large joints) it is advisable to use thick skin flaps (0.6-0.9 mm). They are cut from the parts of the body where the skin has the greatest thickness (thighs, buttocks, back). In these cases, donor wounds heal in 2.5-3 weeks. It should be remembered that when taking a thick flap from a site that has thin skin (the inner surface of hips, shins and shoulders, the abdomen), the donor wound can not itself heal and also require a skin graft. As a rule, skin grafts are not cut off from the face, cheeks, areas of the joints due to the reasons for the violation of the cosmetic appearance and the possible development of cicatricial contractures in case of suppuration of wounds. In the practice of treating burned as a donor zone, the buttocks, hips, shins, back, abdomen, shoulders, forearms, thorax and scalp are usually used.

With extensive deep burns, surgeons face the problem of a deficit of donor resources. Currently, it is solved by using a "mesh graft". It is obtained from continuous flaps, passing them through a special device - a punch. Incised on the flap incisions of different lengths and at different distances from each other allow you to increase by stretching the area of the flap at 2, 4, 6, and sometimes 9 times; and the smaller the perforation factor, the faster the epithelial cells between the skin lobes.

An additional method is the re-use of healed donor wounds. Prepare it for re-operation usually succeeds in 2.5-3 weeks after the first collection of flaps. Repeat this manipulation up to three times, but the quality of the grafts is reduced: they become less elastic, do not stretch well, but do not lose the ability to have good engraftment.

Currently, the method of restoring the skin with microautodermotransplants is under study. Its essence lies in the fact that the skin flap is ground into small pieces 1x1 mm in size. Placing such areas on the wound at a distance of 10 mm from each other, you can close the wound, exceeding the area of the cut flap 1000 times. The method is based on the principle of lengthening the line of marginal epithelialization.

Biotechnological methods of skin repair are also successfully developing - mainly using various variants of the Green method. This method allows in a relatively short time to grow epithelial layers, sometimes exceeding by an area of 10 000 times the size of the original skin flap. There are reports of the successful restoration of the skin on large areas through the transplantation of keratinocyte strata. Certain successes have been achieved in autologous keratinocyte transplantation in the treatment of burns of degree III and donor wounds, while the authors note a significant reduction in epithelialization. This effect is attributed to the stimulating effect of the temporarily acquired keratinocytes on reparative processes in burn wounds.

The use of allo- and xenogeneic cells of various types (keratinocytes, fibroblasts) seems more promising. Usually, multilayer strata of allogenic keratinocytes, fibroblasts and dermal skin equivalent are used. Allogeneic cells have a number of advantages: those obtained from live donors (during plastic surgery) have a more pronounced stimulating and growth effect, they can be obtained and harvested in unlimited quantities. Transplantation of allogeneic keratinocytes is indicated in cases of extensive IIIA degree burns, alternating burns of IIIA and IIIB degree, with a severe condition of the patient with signs of wound depletion, sepsis. The observed effect is associated with the acceleration of epithelialization of wounds from the preserved epithelial elements of the appendages of the skin, therefore the overwhelming majority of the authors received positive results in the treatment of superficial burns and donor wounds.

The use of allogeneic fibroblasts is based on their ability to synthesize numerous biologically active substances. Usually, allogeneic fibroblasts are cultured and transplanted on film (Biokol, Carboxyl-P, Foliderm) or as a living skin equivalent (collagen gel with live fibroblasts and epidermal cells on the surface). According to specialists, their use significantly accelerates epithelization of IIIA degree burns and donor wounds.

Recently, work on the artificial creation of a composition similar to a full-fledged structure of the skin (the living equivalent of the skin, artificial skin substitutes) has been carried out. However, it should be borne in mind that biotechnological methods in the treatment of heavily burned have not yet found wide application. In addition, the positive results of the use of cells and cell compositions in the literature refer mainly to surface burns, much less than publications on the successful treatment of deep burns.

Physiotherapy exercises for burns

Treatment is started on admission, it is aimed at minimizing the formation of scarring and contractures, especially on areas of the skin with high tension and frequent movement (for example, face, chest, brushes, joints, hips). Active and passive development of movements is simplified after the fall of the primary edema; development is carried out 1-2 times a day before skin grafting. After the operation, the exercises are suspended for 5 days, then resumed. Joints affected by second and third degree burns are spliced in a functional position as soon as possible and kept in this position permanently (with the exception of motor exercises) to skin plasty and healing.

Treatment of burns in outpatient settings

Outpatient treatment involves keeping the surface of burns clean and keeping the affected body in an elevated position, as far as possible. Apply ointment dressings, which change as often as in a hospital. The schedule of outpatient visits depends on the severity of the burn (for example, for very small burns after the first visit on the 1st day, then every 5-7 days). During the visit, according to the indications, the treatment is performed, a re-evaluation of the depth of the burn and the need for physiotherapy exercises and skin plasty. Infection can indicate elevated body temperature, purulent discharge, ascending lymphangitis, pain that increases after the first day, blanching or painful erythema. Out-patient treatment is acceptable for small cellulitis in patients without concomitant pathology from 2 to 60 years; other infections show hospitalization.