Treatment of Burns

ISBN-13: 9783642681028 / Angielski / Miękka / 2011 / 404 str.

Chih-Chun Yang; Wei-Shia Hsu; Tsi-Siang Shih

Opis

The greater the poverty, The stronger the will. In the face of hardship, Soar, soar, soar on still WANG Bo (650-676 A.D.) In the late spring of 1958 a patient was admitted to Rui Jin Hospital with extensive burns; just minutes before he had been dexterously operating one of Shanghai's" productive converters" used in the making of steel. He resembled a mass of charcoal but was mentally alert, asserting that he must survive, not only because of the great expectations he had of life but also to con tinue working in his beloved post as first-generation steelworker in this newly liberated country. The case presented a stern challenge; faced with this man yearning both for his own life and for that of the society in which he lived, we had no way of escaping either "poverty" (in the form of our limited facilities) or hardships. However, by pooling all our efforts we were able to ensure that the patient ultimately survived the extremely tortuous course that followed, in addition to which quite good functional recovery was achieved. So began our burn unit. It was on this patient that we performed for the first time artificial hibernation (in the treatment of burns), early eschar excision, repeated autos kin cropping, and allografting. Not only were these the decisive measures which helped our patient to achieve his professed intention, but they also gradually evolved to become the characteristics of our present-day treatment."

Spis treści

Introductory Remarks.- I Early Management of Burn Patients.- 1 Emergency Care and Transportation.- 1.1 Eradication of the Cause of Burn.- 1.2 Resuscitation of Critically 111 Patients.- 1.3 Relief of Pain.- 1.4 Protection of the Wound Surface.- 1.5 Transportation.- 2 Estimation of BSA Burned; Assessment and Classification of Depth of the Burn Wound.- 2.1 Estimation of BSA Burned.- 2.2 Assessment of Depth of the Burn Wound.- 2.3 Classification of Burn Wounds.- 3 Early Care of Burns.- 3.1 Maintaining the Patency of the Respiratory Tract.- 3.2 Ascertaining Concomitant Traumas and Poisonings.- 3.3 Establishment of Intravenous Lines.- 3.4 Use of Analgesics.- 3.5 Use of Urinary Retention Catheter.- 3.6 Debridement.- 3.7 Prevention of Tetanus and Hemolytic Streptococcus Infection.- II Burn Shock.- 1 Method of Fluid Therapy.- 1.1 Estimation of Amount of Fluid Required.- 1.2 Points to Note in Fluid Therapy.- 1.3 Clinical Guidelines for Adjustment of Fluid Volume Administered.- 1.3.1 Main Guidelines.- 1.3.2 Criteria for Reference.- 2 The Clinical Significance and Management of Common Symptoms in the Shock Stage.- 3 Administration of Artificial Hibernation Drugs.- 3.1 Pharmacologic Actions and Composition.- 3.2 Methods of Administration and Precautions.- 4 Administration of Diuretics.- 4.1 Indications for the Use of Diuretics.- 4.2 Choice of Drugs and Methods of Use.- III Management of the Burn Wound.- 1 Principles of Management.- 2 Methods and Choice of Treatment.- 2.1 Treatment by Bandaging.- 2.1.1 Purpose.- 2.1.2 Method.- 2.1.3 Indications.- 2.1.4 Points for Attention.- 2.2 Treatment by Exposure.- 2.2.1 Purpose.- 2.2.2 Method.- 2.2.3 Indications.- 2.2.4 Points for Attention.- 2.3 Treatment by Semiexposure.- 2.3.1 Purpose.- 2.3.2 Method.- 2.3.3 Indications.- 2.3.4 Points for Attention.- 2.4 Treatment with Wet Dressing.- 2.4.1 Purpose.- 2.4.2 Method.- 2.4.3 Indications.- 2.4.4 Points for Attention.- 2.5 Treatment by Immersion.- 2.5.1 Purpose.- 2.5.2 Method.- 2.5.3 Indications.- 2.5.4 Points for Attention.- 3 Application and Choice of Chinese Herb Medicine.- 3.1 Crust-Forming Drugs.- 3.1.1 Purpose.- 3.1.2 Points for Attention.- 3.1.3 Choice of Drug.- 3.2 Eschar Removal Drugs.- 3.2.1 Purpose.- 3.2.2 Points for Attention.- 3.2.3 Choice of Drug.- 3.2.3.1 Wound Healing Ointment No. 10.- 3.2.3.2 Burn and Scald Ointment.- 3.3 Wound-Healing Drugs.- 3.3.1 Purpose.- 3.3.2 Points for Attention.- 3.3.3 Choice of Drugs.- 3.3.3.1 Lacca Ointment.- 3.3.3.2 “Duet Ointment”.- 4 Treatment of Third Degree Eschar.- 4.1 Spontaneous Separation (or Withering Away) of Eschar by “Silkworm Bite”.- 4.2 Surgical Removal of Eschar.- 4.2.1 Indications for Tangential Excision.- 4.2.2 Eschar Excision.- 4.2.2.1 Indications.- 4.2.2.2 Timing.- 4.2.2.3 Size and Location of Excision.- 4.2.2.4 The Interval Between Two Excisions.- 4.2.2.5 Preparation for Excision.- 4.2.2.6 Anesthesia.- 4.2.2.7 Method.- 4.2.2.8 Use of CO2 Laser.- 4.2.2.9 Excision of Eschar of Extensive Third Degree Burns.- 5 Skin Grafting.- 5.1 Requirements for the Take of Skin Grafts.- 5.2 Preoperative Preparation for Skin Grafting.- 5.2.1 General Preparation.- 5.2.2 Preparation of the Surfaces to Receive Grafts.- 5.2.3 Harvesting the Skin.- 5.2.3.1 Simple Method.- 5.2.3.2 Cropping with a Drum Dermatome.- 5.2.3.3 Harvesting of Full-Thickness Graft.- 5.2.4 Harvesting Skin from Unusual Parts of the Body.- 5.2.5 Care of the Donor Site.- 5.2.6 Methods of Grafting.- 5.2.6.1 Transplantation of Large Sheets of Graft.- 5.2.6.2 Transplantation of Mesh Graft.- 5.2.6.3 Transplantation of Small Autografts.- 5.2.6.4 Transplantation of Postage Stamp-Sized Grafts.- 5.2.6.5 Full-Thickness Skin Transplantation.- 6 Allografts, Xenografts, and Intermingled Transplantation.- 6.1 Allografts.- 6.2 Xenografts.- 6.3 Intermingled Transplantation of Autograft and Allograft.- 6.3.1 Method of Intermingled Transplantation.- 6.3.2 Histologic Observations.- 6.4 Intermingled Transplantation of Porcine Skin and Autograft.- 6.5 Artificial Skin.- IV Infection of the Burn.- 1 The Onset of Septicemia.- 1.1 Early Stage.- 1.2 Stage of Eschar Separation.- 1.3 Late Stage.- 2 Symptoms of Septicemia.- 2.1 Systemic Symptoms.- 2.2 Changes in the Appearance of the Wound.- 2.3 Changes in the Appearance of the Tongue.- 2.4 Laboratory Findings.- 2.5 Summary.- 2.6 Erythema Gangrenosa.- 3 Early Diagnosis of Septicemia.- 4 The Prevention and Treatment of Septicemia.- 4.1 Ameliorate the Host Resistance.- 4.1.1 Ami-Pseudomonas Hyperimmune Globulin.- 4.1.2 Convalescent Blood or Plasma.- 4.2 Proper Management of the Wound.- 4.2.1 10% Sulfamylon Cream.- 4.2.2 Silver Sulfadiazine Cream.- 4.2.3 Gentamicin Cream.- 4.2.4 Combinations of Drugs.- 4.2.5 Surgical Removal or Drainage of Infective Foci.- 4.3 Reasonable Use of Antibiotics.- 4.3.1 Indications for Systemic Administration of Antibiotics in Burns.- 4.3.2 Plan for the Systemic Administration of Antibiotics.- 4.3.3 Choice of Antibiotics in the Light of Past Experience.- 5 Fungal Infection.- 5.1 Fungal Infection of Burn Wounds.- 5.2 Invasive Fungal Infection of the Mucous Membranes and Disseminated Fungal Infection.- 5.3 Treatment.- V Traditional Chinese Treatment of Burns.- 1 Treatment Following Discrimination of Symptoms and Signs in Burns.- 2 Methods of Treatment and Medication.- 3 Diagnostic Significance of “Pulse Picture” and “Tongue Picture”.- VI Water-Electrolyte and Acid-Base Balances.- 1 Water-Electrolyte Balance.- 1.1 Introduction.- 1.1.1 Calculating Units.- 1.1.2 Method of Unit Transformation.- 1.2 Sodium Balance.- 1.2.1 Hypernatremia.- 1.2.1.1 Tube-Feeding Syndrome.- 1.2.1.2 Hypernatremia Induced by Uncontrolled Diabetes.- 1.2.2 Hyponatremia.- 1.2.2.1 Sodium-Deficient Hyponatremia.- 1.2.2.2 Dilutional Hyponatremia and Water Intoxication.- 1.2.2.3 Hyponatremia During the Shock Stage After Extensive Burns.- 1.3 Potassium Balance.- 1.3.1 Hypokalemia.- 1.3.2 Hyperkalemia.- 2 Acid-Base Balance.- 2.1 Introduction.- 2.1.1 Biologic Oxidation and Hydrogen Ions.- 2.1.2 Pulmonary and Renal Compensation and Buffer Systems.- 2.1.2.1 Lungs.- 2.1.2.2 Kidneys.- 2.1.2.3 Buffer System.- 2.2 Symbols and Terms of Importance in the Expression of Acid-Base Changes.- 2.3 Signs and Symptoms of Acid-Base Imbalance.- 2.4 Methods of Calculation.- 2.5 Frequently Used Solutions.- 2.5.1 Sodium Bicarbonate Solution.- 2.5.2 Sodium Lactate Solution.- 2.5.3 Sodium Lactate-Physiologic Saline or Sodium Bicarbonate-Physiologic Saline Solution.- 2.5.4 Tromethamine (THAM).- 2.5.5 Ammonium Chloride (NH4Cl).- 2.6 Frequent Postburn Acid-Base Disturbances.- 2.6.1 Metabolic Acidosis.- 2.6.2 Respiratory Acidosis.- 2.6.3 Acute Hypokalemic Alkalosis.- VII Burns of Special Sites.- 1 Burns of the Head and Face.- 1.1 Characteristics.- 1.2 Problems Requiring Attention During Management in the Early Stage.- 1.3 Local Management.- 2 Burns of the Respiratory Tract.- 2.1 Classification.- 2.2 Pathologic Changes.- 2.2.1 Pulmonary Edema.- 2.2.2 Sloughing of the Necrotic Mucosa.- 2.2.3 Pulmonary Infection.- 2.3 Early Diagnosis.- 2.4 Management.- 2.4.1 Burns of the Upper Respiratory Tract.- 2.4.2 Burns of the Lower Respiratory Tract.- 3 Burns of the Eye.- 3.1 Symptoms.- 3.2 Management.- 4 Burns of the External Ear.- 4.1 Characteristics.- 4.2 Management.- 4.3 Symptoms and Management of Auricular Chondritis.- 5 Burns of the Hand.- 5.1 Characteristics.- 5.2 Management.- 5.2.1 Superficial Second Degree Burns.- 5.2.2 Deep Second Degree Burns.- 5.2.3 Third Degree Burns.- 6 Burns of the Perineum.- 7 Burns of the Bones and Joints.- 7.1 Management.- 7.1.1 Tubular Bones.- 7.1.2 Cranial Bones.- 7.1.3 Joints.- VIII Electric Injury.- 1 Pathologic Features.- 2 Treatment.- 2.1 Early Care.- 2.1.1 Resuscitation.- 2.1.2 Fluid Replacement in the Shock Stage.- 2.1.3 Prevention of Tetanus and Other Anaerobic Infections.- 2.1.4 Early Decompression Incision of the Deep Fascia.- 2.2 Management of the Wound.- 2.2.1 Electric Injuries of the Hand.- 2.2.2 Electric Injuries of the Limbs.- 2.2.3 Electric Injuries of the Thoracic and Abdominal Walls.- 2.2.4 Electric Injuries of the Cranium.- 2.2.5 Electric Injuries of the Joints.- 3 Complications.- 3.1 Complications Involving the Central Nervous System.- 3.2 Secondary Hemorrhage.- 3.3 Peripheral Nerve Injuries.- 3.4 Anaerobic Infection.- 3.5 Cardiac Arrest and Arrhythmia.- 3.6 Ileus and Perforation of the Intestines.- 3.7 Acute Renal Failure.- 3.8 Severe Anemia.- 3.9 Cataract.- IX Chemical Burns.- 1 Acid Burns.- 1.1 Sulfuric Acid, Nitric Acid, and Hydrochloric Acid.- 1.2 Hydrofluoric Acid.- 1.3 Oxalic Acid.- 1.4 Chromic Acid.- 1.5 Chlorosulfonic Acid.- 2 Alkali Burns.- 2.1 Caustic Alkali.- 2.2 Lime.- 2.3 Ammonia Water.- 3 Agents Causing Chemical Burns Associated with Systemic Poisoning.- 3.1 Phenol.- 3.2 Yellow Phosphorus.- 3.3 Organic Phosphorus.- 3.4 Cyanides.- 3.5 Carbon Disulfide.- 3.6 Mercury.- 4 Other Chemical Burns.- 4.1 Magnesium.- 4.2 Tar.- 5 Chemical Burns of the Eye.- X Burns Complicated by Trauma.- 1 Blast and Gas Explosion Injuries.- 1.1 Blast Injuries.- 1.2 Gas Explosion Injuries.- 2 Craniocerebral and Spinal Injuries.- 2.1 Diagnosis of Craniocerebral Injuries.- 2.2 Treatment of Craniocerebral Injuries.- 2.2.1 Early Treatment.- 2.2.2 Principles of Treatment of Various Craniocerebral Injuries.- 2.3 Spinal Cord Injuries.- 3 Fractures.- 3.1 Closed Fractures of the Extremities.- 3.2 Open Fractures of the Extremities.- 4 Soft Tissue Injuries.- 5 Hot Roller Burns of the Hand (Hot Roller Hand).- 6 Trauma of the Chest and Abdomen.- 6.1 Rib Fractures.- 6.2 Pneumothorax.- 6.3 Hemothorax.- 6.4 Abdominal Injuries.- XI Systemic Complications of Burns.- 1 Pneumonia.- 1.1 Clinical Manifestations.- 1.2 Management.- 2 Cardiac Complications.- 3 Deep Venous Thrombosis-Including Pulmonary Embolism.- 3.1 Clinical Manifestations.- 3.2 Management.- 4 Acute Postburn Ulcerative Bleeding.- 5 Diarrhea.- 6 Jaundice.- 6.1 Hemolytic Jaundice.- 6.2 Serum Hepatitis.- 6.3 Wound Sepsis (or Septicemia)-Induced Jaundice.- 7 Stress Diabetes.- 7.1 Clinical Characteristics.- 7.2 Management.- 8 Acute Renal Failure (ARF).- 8.1 General Considerations.- 8.2 Prevention and Early Diagnosis of ARF of the Shock Stage.- 8.3 Peritoneal Dialysis in Postburn ARF.- 8.3.1 Timing.- 8.3.2 Preparation and Instructions.- 8.4 Other Managements of Postburn ARF.- 8.4.1 Nutrition.- 8.4.2 Fluid Intake.- 8.4.3 Management of Hyperkalemia.- 8.4.4 Management of Dilutional Hyponatremia.- 8.4.5 Management of Metabolic Acidosis.- 9 Bone and Joint Complications.- 9.1 Bone Destruction.- 9.2 Joint Destruction.- 9.3 Hyperplastic Periostitis.- 9.4 Osteoporosis.- 9.5 Ectopic Calcification and Ossification.- 9.6 Osteophytes Formation.- XII Nursing Care in Burns.- 1 Sources of Infection, Disinfection, and Isolation.- 1.1 Sources of Cross Infection.- 1.2 Measures of Disinfection and Isolation.- 1.2.1 Final Disinfection of the Wards.- 1.2.2 Regulations Concerning Disinfection and Isolation in the Wards.- 1.3 Problems and Prospect of Improvement.- 2 Nutrition.- 2.1 Nutrient Requirements.- 2.2 The Nitrogen-Calorie Ratio.- 2.3 Routes of Administration of Nutrients.- 2.3.1 Enteral Administration.- 2.3.1.1 Oral Feeding.- 2.3.1.2 Nasal Feeding.- 2.3.1.3 “Element Diet”.- 2.3.2 Intravenous Alimentation.- 2.3.2.1 Composition of Intravenous Aliments.- 2.3.2.2 Preparations of Intravenous Aliments.- 2.3.2.3 Adiminstration of Parenteral Nutriments.- 2.3.2.4 Important Points in Parenteral Nutrition.- 2.3.2.5 Complications and Their Prevention.- 3 Intravenous Fluid Administration.- 3.1 Venipuncture of Veins of Unusual Sites.- 3.1.1 Superficial Veins of the Trunk.- 3.1.2 Veins of the Scalp.- 3.1.3 Veins of the Fingers and Toes.- 3.1.4 External Jugular Vein.- 3.1.5 Internal Jugular Vein.- 3.1.6 Femoral Vein.- 3.1.7 Superficial Veins Beneath the Healed Wound Surface.- 3.1.8 Popliteal Vein.- 3.1.9 Subclavian Vein.- 3.1.10 Axillary Vein.- 3.2 Intravenous Catheterization Through Puncture.- 4 Basic Nursing Care.- 4.1 Turning Over the Patient by Means of the Turning Bed.- 4.1.1 Advantages.- 4.1.2 Procedure.- 4.1.3 Important Points to Note.- 4.2 Nursing Care of Defecation and Urination in Extensively Burned Patients.- 4.2.1 Defecation.- 4.2.2 Urination.- XIII Pathologic Anatomy of Burns.- 1 Local Pathologic Changes.- 1.1 Cutaneous Burns.- 1.2 Burns of the Respiratory Tract.- 2 Systemic Disturbances Caused by Cutaneous Burns.- 2.1 Lung, Trachea, and Bronchi.- 2.2 Wound Sepsis and Septicemia.- 2.3 Kidneys.- 2.4 Heart.- 2.5 Liver.- 2.6 Spleen.- 2.7 Stomach and Duodenum.- 2.8 Adrenal Glands.- 2.9 Central Nervous System.- 2.10 Bladder.- 2.11 Serosa and Mucosa.- 2.12 Thrombosis of the Femoral Vein.- XIV Plastic Surgery in Burns.- 1 General Considerations.- 1.1 Classification of Scars.- 1.1.1 Atrophic Scar.- 1.1.2 Hypertrophic Scar.- 1.2 Scar Contraction.- 1.2.1 Timing of Surgery.- 1.2.2 Principles of Surgery.- 1.2.2.1 Formulating the Operative Plan.- 1.2.2.2 Release of Contraction.- 1.2.2.3 Wound Care.- 1.3 Cutting of Skin Graft.- 1.3.1 Partial-Thickness Grafts.- 1.3.2 Full-Thickness Grafts.- 1.4 Z-plasty.- 1.5 Skin Tubes.- 1.5.1 Indications.- 1.5.2 Complications of Design and Transfer.- 1.6 Free Flaps.- 2 Cicatricial Contraction of the Face.- 2.1 Dysfunction Caused by Facial Cicatricial Contraction and Its Repair.- 2.1.1 Repair with a Large Sheet of Skin Graft.- 2.1.2 Repair with a Tube Flap.- 2.2 Ectropion of the Eyelids.- 2.3 Microstomia.- 2.4 Nostril Atresia.- 2.5 Partial or Total Loss of the Nose.- 2.5.1 Alar Defects.- 2.5.2 Subtotal and Total Loss.- 2.6 Defects of the Ear.- 2.6.1 Repair of Ear Defects.- 2.6.2 Scar Adhesion Between the Ear and the Mastoid Region.- 3 Cicatricial Contraction of the Neck.- 3.1 Classification.- 3.2 Surgical Treatment.- 3.2.1 Z-plasty.- 3.2.2 Free Skin Graft.- 3.2.3 Tubes or Flaps for Repair of the Neck.- 4 Cicatricial Contraction of the Axilla.- 4.1 Classification.- 4.2 Infection.- 4.3 Surgical Treatment.- 4.3.1 Z-plasty.- 4.3.2 Transplantation of Free Skin Graft.- 4.3.3 Repair with a Pedicle Flap.- 5 Cicatricial Contraction of the Elbow.- 6 Cicatricial Contraction of the Hand.- 6.1 Classification of Burn Cicatricial Contraction on the Dorsum of the Hand.- 6.1.1 Mild Form.- 6.1.2 Moderate Form.- 6.1.3 Severe Form.- 6.2 Treatment.- 6.2.1 Reduction of the MP Joint.- 6.2.1.1 Reduction by Manipulation.- 6.2.1.2 Excision of the Collateral Ligament.- 6.2.1.3 Handling of Extensors.- 6.2.1.4 Arthroplasty.- 6.2.2 Arthrodesis of IP Joints.- 6.2.3 Adduction Deformity of the Thumb.- 7 Cicatricial Contraction over the Perineum.- 7.1 Deformities.- 7.2 Principles of Treatment.- 7.3 Operative Procedure and Pre- and Postoperative Care.- 8 Cicatricial Contraction of the Popliteal Fossa and Chronic Ulcer of the Leg.- 8.1 Cicatricial Contraction of the Popliteal Fossa.- 8.1.1 Treatment.- 8.2 Chronic Ulcer of the Leg.- 8.2.1 Treatment.- 9 Cicatricial Contraction of the Foot.- 9.1 Signs.- 9.2 Principles of Treatment.- 10 Cicatricial Contraction After Very Extensive Third Degree Burns.- 10.1 Use of a Large Piece of Allograft with “Punched Windows” for Autologous Skin Inlays.- 10.1.1 Preoperative Preparation.- 10.1.2 Operative Procedure.- 10.1.3 Postoperative Management.- 10.2 Distant Transplantation of Cicatricial Skin Tube.- 10.3 Harvesting Free Cicatricial Skin Grafts.- 11 Skin Lesions Following Radiation Burn.- 11.1 Clinical Manifestations.- 11.2 Principles of Treatment.- 11.2.1 General Treatment.- 11.2.2 Local Treatment.- 11.2.3 Surgical Treatment.- 12 Transplantation of Free Skin Flaps.- 12.1 Advantages of the Free Skin Flap.- 12.2 Requirements of the Donor Area.- 12.3 Requirements of the Recipient Area.- 12.4 Free Transplantation of the Thoracodorsal Axillary Flap for the Repair of Postburn Cicatricial Contraction.- 12.4.1 Advantages of Thoracodorsal Axillary Flaps.- 12.4.2 Regional Anatomy.- 12.4.3 Surgical Procedure.- XV Anesthetization of Burn Patients.- 1 Preparation for Anesthesia.- 2 Premedication.- 3 Choice of Anesthesia.- 3.1 Regional Anesthesia.- 3.2 General Anesthesia.- 3.2.1 Lytic Cocktail.- 3.2.2 Sodium ?-Hydroxybutyrate (?-OH).- 3.2.3 Thiopental Sodium.- 3.3 Neuroleptanalgesia.- 3.4 Ketamine.- 4 Anesthetic Management.- 4.1 Measurement of Blood Pressure.- 4.2 Clearance of Secretions from the Respiratory Tract.- 4.3 Maintenance of Ventilation.- 4.4 Restoration of Blood Volume Deficit.- 4.5 Changes in Body Temperature.- 4.6 Postural Hypotension.- 4.7 Use of Muscle Relaxants.- 5 Anesthesia for Plastic and Reconstructive Surgery.- Appendix I The Subeschar Bacterial Count.- Appendix II Preparation and Deep-freeze Storage of Allografts and Xenografts.