Clinical and treatment worsening period of burn disease

2021-01-30 12:00 AM

If including protein excretion in feces, urine ... Protein loss can reach 100-200g / 24h. Protein-loss deep burns through burns reach 10mg / cm2 / 24h.

Question

Many authors Phedoroocki, Holubec ... called burn decline period.

Burn cachexia is common in patients with deep, large-area burns:> 15% it may appear early from the first month, at this time only burns IV, V and burns I, II, II have been immediately.

Injuries range from 4-5% if treated incorrectly and early or if the wound with TCH is not covered in time may appear burn erosions.

Burn cachexia can appear at different rates, if left untreated develops mild to severe.

There is a tendency to divide burn disease into 4 phases: shock (from 1-3 days), burn poisoning infection (from 4-30 days), burn failure, recovery. In fact, burns are complicated, there is no clear border between stages and stages with mutual influence. Burn cachexia can appear as early as stage 1-2 and is considered a complication.

Mechanism of pathogenesis

Metabolic and nutritional disorders: Outstanding, common in internal organs, body systems.

Reducing Protein: Through wounds: including secretions, blood, pus and forming granules.

Shallow depth of 20% can take 20-40g / 24h. If including protein excretion in feces, urine ... Protein loss can reach 100-200g / 24h. Protein-loss deep burns through burns reach 10mg / cm2 / 24h.

Decreased digestive function: mainly disorders of digestive enzymes and the absorption capacity of the digestive tract.

Protein synthesis function especially in the liver: reducing the ability to synthesize.

Metabolic disorders: catabolism prevails over anabolism. Base metabolism can increase by 20; 40; 60.

In the process of protein digestion, inadequate nourishment combined => lack of Protein, the body must use the body's source of Protein. (muscle, fat connective tissue ...).

Organs caused by prolonged malnutrition suffer physical and function problems.

Complications of infection, high fever, pressure sore, ND due to toxic burns, prolonged immobilization ... eroded development.

clinical

Body

Weight loss:

The face is emaciated, the bones protrude, the subcutaneous fat disappears, muscles atrophy.

Weight loss can be 15% of body weight in the first month. If heavy, it can be 1-1.5kg / ng, up to 30-48% by weight.

Mucous skin:

Pale, dry, frayed, reduced elasticity, hair loss on nails, growth disturbance of keratinocytes.

Edema:

Edema soft, white, concave, clearly edged limbs.

Meeting SD edema, peritoneal effusion, pleura, pericardium, whole body.

Mechanism: decreased protein ---> decreased PK

Increased vascular permeability.

Pressure ulcers:

It is possible that 1 or more area points can be different.

The sores are the gateway for bacteria to grow.

The development of the ulcer can reach the muscles and bones most in the region of the amputation. 

Common locations: occipital, cervical spine (C6-C7), shoulder blade, special vertebral spine, pelvic crest - large displacement - heel - ankle (outer), elbow joint - head below the pillar. front: frontal bone, sternum, ribs, knee joint ...

Deviation of limbs:

Due to long lying and motionlessness prolongs pain relief posture.

Maybe cb match wrong, ligament covering the joint is loose.

Dear bones:

Especially in the limb burned, sometimes causing pathological fracture.

In joints: can toe cartilage joints, stiffness.

Region near joints: muscle reinforcement.

Bleeding syndrome:

Easy to bleed shows bleeding TCH when changing bandages, when vigorously moving limbs, when soaking in hot baths ...

Capilliarotoxicose can be met: capillary ND, Schoenlein - hemeck disease form.

Capillary bleeding may occur in the skin.

There may be capillaries in the joint.

Kidney.

Bowel: acute abdominal pain, gastrointestinal bleeding.

In place

Pale, edema; epithelialization is stopped, slow. The wound is more fibrotic, pseudomembranous, easily bleeds, hematoma, pus.

Bacteriology changes: mainly Proteus.

Severe: secondary wound necrosis.

There is no seed organization.

Tendons, muscles, joints, nerves, and blood vessels may become exposed and become necrotic.

Other pathological changes

Neuropsychiatric:

Nerve depression, mood swings, sleep disturbances.

Nervous plant disorder, sudden sweating ...

Neuritis (most cylindrical, fibrous), optic neuritis, polyneuritis.

Cyclic:

Rapid pulse, low blood pressure, EGB: disorder

Digestive:

Anorexia, apple or loose defecation.

Endocrine:

Decreased adrenal and sexual function

Women: Menstrual disorders, amenorrhea

Male : inhibited sperm production

Subclinical

Persistent hypochromia:

Due to malnutrition => Globin and Hemo synthesis disorder.

Due to metabolic disorders (absorption, metabolism) Fe.

Bone marrow suppression (HCL reduction).

Blood digestion (appears antibodies to red blood cells, Bili increased the most gt, Coobms TT (+), blood loss.

Blood protein:

% low is sometimes 2.4g / l.

Decreased Al: Globulin, most a2 g increase => A / G inversion: 0.4 - 0.8.

Aa in blood decrease in number and composition, a - a urinary: increase initially, then decrease.

Other tests:

Reduced blood glucose. Na, K decrease, VSS increases.

Urea trend to increase.

The above factors cause cachexia patients to always be in the state of latent shock, easily appearing during surgical intervention or dressing change.

Complications

Amyloid degeneration of the liver, kidney ...

Pneumonia, hepatitis, cystitis. On a cachexia basis, potential shock is more likely to occur during surgery.

Severe: septicemia, arthritis

Diagnosis and prognosis

With the correct diagnosis and treatment, 80% of cachexia is cured (according to Philatov). Simple cachexia is rare today.

Treatment

Principles of prevention and treatment of burn wear and tear

Early skin contact covering TCH: basic treatment.

Comprehensive treatment: support the patient's body: nurture well for the treatment of disorders and complications.

Feed, take care

Nourished according to a diet high in protein, with enough nutritional ingredients:

Nutritional ration:

1g G: provides 4.1 calories.

1g Pro: provide 4.1calo.

1g L: provide 4,2calo.

TP / 24h: Glaucid: 50% of g / c calories.

Pro: 2-4g / kg.

L: enough to provide the remaining heat

Nutrition supply: 3,400-4,2000 calories

Adequate nutritional ingredients: Pro pays special attention to N and aa ratio

Glu and lipid.

Smoothies and mineral salts.

Farming sugar:

Best by mouth, eat a lot of meals, gently take a semi-thick, liquid diet, choose foods that are easy to digest, absorb well, limit foods that are high in residue, and generate gas.

When the patient has no appetite, vomiting => fed with gastric juice (Meritene, Resource ...). Pay attention to ensure the secretion of bacteria, the temperature is 37-38 0 C.

Patients with severe cachexia: combined with intravenous nourishment.

Culture:

Glaucid supply solution: Glucose 5%; 10%, 30%, pay attention to adding K with insulin.

Protein supply: include.

Blood plasma: fresh, dry, cold.

Advantages: supplementing enough metabolic factors, immune factors, hemostatic effect                
Cons: viral hepatitis may be present.

Albumin humans: category 5; ten; 15; 20% infusion with Glu 5%.

Amino acid solution: Moriamin (Moriamin P with Subtosan: Polyvinyl pirrolidon); Mori P2: Sorbitol 5% contains KCL, NACL, CaCL2 and 11 aa

Usually, synthetic acid solution in the form of 8% solution in 5% sweet solution: Restamin, Nutrisol, Kanaplasma, Alversin ...

Hydrolyzed protein solution: Proteolysate, amino, Hydro lysin (old LX). Large dv blood HT accounts for 4.4-5.6% protein has enough aa necessary. Against use when heart failure, liver failure.

Protein solution 4.8% isotonic: contains AL and bulin: 20-25% consistent with the pathological mechanism (loss of AL).

Lipid feeding fluid: Lipofundin; Intralipid; Lipovenons. Contains MCTs and LCTs, provides energy but has many complications ....

Blood transfusion:

Direct blood transfusion is possible (best).

Fresh blood transfusion (1-12 hours after collection).

Reserve blood.

Note blood transfusion: prevent hepatitis - HIV.

Red blood cell transfusion: very good in treating anemia.      
Quantity: can be from 150-200-300-500 ml / e daily or every other day.

Transfusion of new burn patients within 2-3 years.

Using yeast - hormones:

Anti-catabolic hormone: Nerobon 5mgx4v / day.

Durabolin 25mgx1d / day.

Use 5-7 days lasting 1-2 months.

Corticosteroids: Hydro cortisol: stains 125mg.

Prednisolone 5mg.

Depersolon 30-60-90mg.

Dexamethasone.

Used in the treatment of cachexia: average dose: Constancy 1mg / kg, after gradually reducing the dose.

Indications: (wear stage).

Autoimmune factor anemia (Coombs (+)).

Low blood protein.

Prolonged hepatitis, nephritis, capillaries, FV.

TCH edema, pale or fibrosis. Conducted Mowlem Jackson skin transplant.

Pay attention to contraindications and combination of antibiotics, supplemental K.

Take care of:

Clean disease chamber, sterilization, sterility to avoid superinfection and cross infection.

Heavy: Sterile chamber.

Severe: the patient is in bed for 2-4 hours changing position.

Ulcer prevention: soft cushion, skin hygiene, massage.

Breathing exercises, bathing, therapy - gentle movement, walking ...

Conditional: Clinitron liquid-air cushion bed.