First aid and pre-hospital stage
The main task at the scene is the rapid elimination of the thermal agent and local tissue cooling. Cold water, ice packs, or snow are used for this purpose. Exposure should be at least 10–15 minutes, which stops the spread of necrosis deeper into the skin.
Only after the pain syndrome subsides is an aseptic dressing applied to the wound. It is important to remember a strict rule: at the first-aid stage, the use of any therapeutic dressings and ointments is strictly contraindicated.
For pain relief, the patient is administered metamizole sodium and given warm tea or mineral water to initially compensate for fluid loss. The patient must be wrapped up to prevent hypothermia.
If there is a risk of burn shock (or extensive injuries), the following is performed at the pre-hospital stage:
- Administration of strong analgesics and antihistamines.
- During transport: use of a fentanyl and droperidol combination, and inhalation of narcotic agents with oxygen.
- Combating heat loss using heating pads, warm drinks, and wrapping.
- Compensation for plasma loss through heavy drinking of alkaline solutions and parenteral administration of infusion fluids.
Local treatment: closed method
The most common approach to managing burn wounds is the closed method, i.e., treatment under a dressing.
- Advantages of the method: reliable isolation of the burn surface from the external environment, creation of optimal conditions for the prolonged action of local medications, as well as the possibility of safe transport and maintaining the patient's active behavior.
- Disadvantages of the method: high labor intensity for medical personnel, significant consumption of sterile dressing material, and pronounced pain during dressing changes for the patient.
In the case of superficial burns, they tend to epithelialize on their own under dressings. Second-degree injuries heal completely within 7–12 days, whereas deeper IIIa-degree burns take longer and heal only by the end of the 3rd–4th week.
Surgical treatment: necrectomy
In deep burns, conservative treatment is insufficient — surgical excision of dead tissues, or necrectomy, is indicated. This is a major intervention, so it is permissible to excise no more than 25–30% of the body surface in a single surgical stage.
Timing of operations:
- Early necrectomy: performed on days 1–3, but strictly after the patient has completely recovered from burn shock.
- Extensive interventions: days 4–7 are considered the optimal window. The surgery should not be delayed, as the risk of wound infection generalization increases sharply at later dates.
Indications for early necrectomy:
- Presence of deep burns covering 10–20% of the body surface, if immediate single-stage autodermoplasty is possible.
- Local hand burns (the intervention prevents the formation of rough scars and irreversible joint function impairment).
- Elderly patient age (prompt removal of the scab serves to prevent infectious complications and allows early patient mobilization).
Antibiotic Therapy
Infectious complications remain the main threat in extensive burns, which is why antibacterial therapy is divided into local and general:
- Local treatment: includes the application of antiseptics and antibiotics that are part of specialized ointments. During the formation of a dense scab, the surface is treated with potassium permanganate ($KMnO_4$) solutions to ensure it dries out.
- General therapy: implies systemic parenteral administration of broad-spectrum antibiotics to suppress bacteremia and prevent sepsis.
Briefly: answers to topical questions
What specific drugs and ointments are used for local antibacterial therapy of burns?
Ointments, emulsions, and solutions are used for local antibacterial therapy of burns:
- Syntomycin emulsion (10%).
- Gentamicin ointment (1%).
- Furacilin ointment (0.5%).
- Sulfamilon ointment (10%).
- Mafenide (5% aqueous solution or 10% ointment).
- Chloramphenicol (5–10% emulsion).
- Nitrofural (0.5% ointment).
- Multicomponent ointments: Levosin, Levomecol, Dioxicol, Metrocaine.
- Silver sulfadiazine (1% water-soluble solution).
Potassium permanganate solutions are used during scab formation.
Which degrees of burns are considered superficial and which are deep?
The classification of burns by depth of lesion depends on the possibility of spontaneous skin regeneration.
| Depth of lesion | Burn degrees | Characteristic |
|---|---|---|
| Superficial | I, II, IIIa | Skin germ zones are preserved, spontaneous epithelialization is possible. |
| Deep | IIIb, IV | Spontaneous recovery is impossible; skin grafting is required. |
In chemical burns, grades I and II are classified as superficial, and grades III and IV as deep.
What does the open method of treating burn wounds entail?
The open method of treating burn wounds consists of accelerating the formation of a dense scab through desiccation.
Air, ultraviolet irradiation, and coagulating agents are used for drying. Management techniques include lubricating the wound with ointments containing antibiotics or antiseptics 3–4 times a day. The method is indicated for superficial II and IIIa-degree burns, as well as burns of the face, genitals, and perineum. Disadvantages include difficulties in care for extensive deep burns, the need for special equipment, and the risk of nosocomial infection.
What skin grafting methods exist to close wounds after necrectomy?
Autodermoplasty is used to close the burn surface in deep burns.
- Dermatome plasty — split-thickness skin graft.
- Full-thickness skin graft plasty.
- Pedicle flap plasty.
- Filatov delayed pedicle flap plasty.
Cellular technologies are also used, such as cultured autologous fibroblasts or human fetal fibroblasts. They are combined with split-thickness mesh autodermoplasty.
First-aid rule: "Cool, anesthetize, cover, hydrate — and forget to apply ointments!" (a reminder of the ban on using ointments before reaching the hospital).
Class and exam questions
What is the main mistake when providing first aid for a burn?
The main mistake is applying therapeutic dressings and ointments to a fresh wound. This is strictly prohibited at the first-aid stage; only an aseptic dressing after prolonged cooling is allowed.
When is it safe to perform early necrectomy?
Early necrectomy is performed on days 1–3, but the most crucial and strict prerequisite is the complete preliminary resuscitation of the patient from burn shock.
Why is surgery for deep hand burns attempted as early as possible?
Early necrectomy for hand burns is necessary to prevent the formation of severe contractures and scars, which can lead to severe hand dysfunction.
How long does spontaneous burn healing take?
The timeframes depend on the degree: second-degree burns epithelialize in 7–12 days, whereas in degree IIIa the healing process is prolonged up to 3–4 weeks.
What else to study on this topic
- Technique of autodermoplasty after necrectomy
- Calculation of infusion therapy volume in burn shock
- Differential diagnosis of burn depth (degrees II, IIIa, IIIb, and IV)
- Pathophysiology of burn shock and toxemia development
- Use of antihistamines in combustiology
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