Surgical treatment of burns

2021-01-30 12:00 AM

The large joint of the limb is seriously infected by burns, the root source of the systemic infection, and cannot be surgically opened, drained, or amputated.

Emergency surgeries treat burn patients

Slit dry necrotic skin

Purpose:

Relieve edema, prevent compression caused by necrosis causing garo.

Determination of depth (secondary).

Point:

Dry necrotic skin around the circumference of the extremities obstructs circulation.

Dry necrotic skin around the neck, chest, hindering breathing.

Deep necrosis of large whole muscle mass prevents gas-producing gangrene.

Skill:

Early, sterile.

In chi:

Finger: two side lines.

Back of hand: square.

Forearms: chi.

Legs: Two lines inside, outside 1 cm from the inside of the tibial bone.

Chest neck:

Neck: 2-3 vertical lines.

Chest: board style. 

Incise to weight or weight to muscle, until healing (bleeding), spread, spread, sterile.

In the presence of vapor-borne gangrene: remove necrotic muscle, wash hydrogen peroxide, inject Penicillin + anti-gangrene serum to produce steam into the vicinity.

Open the trachea

Point:

Respiratory failure:

Met in severe burns of the respiratory tract, with glottis; swelling, airway obstruction ----> difficulty breathing.

Obstruction of the airways because of sputum secretions in patients with severe burns with complications of pneumonia, atelectasis.

Respiratory burns + CO poisoning.

Severe respiratory failure after surgery in burn patients.

Open only in the presence of respiratory failure, which has prophylactic properties in patients with severe burns with deep coma, for further surgical anesthesia of the endotracheal tube. 

(Respiratory failure index: pO2 <92 mmHg; pCO2> 42 mmHg; HbO2 89-93%).

Technique: Tinnitus incision 1. Aseptic when and when the patient breathes.

Constriction of blood vessels

In the treatment of secondary bleeding in the burned area, common in electric burns.

Point:

Patients with electric burns in the limbs must have garo placed in the patient's bed, when there is bleeding will promptly garo.

Then revealed blood vessels to suture, tie.

Other surgeries

If there is a combined burn injury, injury.

Osteoarthritis surgery in burn amputation patients

Point:

Deep burn V of the entire limb (especially muscle necrosis to prevent gas gangrene) surgery to escape burn shock.

The large joint of the limb is seriously infected by burns, the root source of the systemic infection, and cannot be surgically opened, drained, or amputated.

When gangrene has developed slightly.

Deep burns + large fractures right there cannot be preserved.

Skill:

As practice surgery.

Do not stitch skin tightly (expose muscles, stitch under skin).

When stabilized:

Revised period II (skin transplant, tie transfer ...).

Remove bone necrosis

Point:

When the burn is deeply necrotic to the bone, necrotic loss is slow.

Bones that have been exposed for too long cause secondary necrosis.

Skill:

Skull:
                        
Small area: 0.5-1 cm2 shallow: to fall on its own.

Large area: Drill holes, holes = 5-8 mm, spaced 15-20 mm.

Wait until bleeding but don't gain weight, usually between layers.

After drilling, TCH will grow in the holes (remove dead bones, easy to skin graft).

Hard bones: Chisels, drilled to healthy areas.

Surgery to remove necrosis early

Purpose

For early elimination of necrosis. Prevent poisoning and infection.

Skin grafting covers early burn damage, reduces cachexia and sequelae, actively treats patients with extensive burns.

Point

In terms of burns:

Narrow deep burn (0.5-9% body area) cut once.

Large deep burns over 10%: 10% for each cut.

Time:

If the area is narrow, no shock: cut in the first 6-12 hours.

If a large area burns with burn shock: positive shock resistance, stable shock escape, new cutting, from day 4 to 10. Each cut 3 to 7 days.

Patient Condition:

Body as a whole: general good health (including laboratory tests).

Spot: Dry necrosis.

Skill:

Techniques:

Necrotic grinding: rarely used.

Cut tangent layers until bleeding.

Cut whole to the usual weight.

Tool: normal scalpel or Lag rot knife.

Insensitivity:

Numbness (if the area is narrow »1%).

Maze (if large area).

Blood transfusion:

Small area, good hemostasis: no infusion.

Large area that does not go away: From 500 ml or more.

After 24- 48 hours will graft skin.

If the area is small: autologous skin graft.

If a large area: skin grafting itself combined with heterogeneous or heterologous skin (called Mowlem Jackson type).

Skin graft surgery to treat deep burns

Purpose

In order to cover the missing organ, the epithelium itself cannot heal the wound or burn.

Not only for burns but also injuries, other skin-loss wounds, long-lasting ulcers ...

Requirements: Understand specified pharmaceuticals and techniques.

Skin source

Skin itself:

The patient's own skin (Autographed) is permanently living on the transplant base.

Leather type: (Homograph, Allograft)

Human skin has a temporary covering effect (anti-plasma drainage, anti-bacterial invasion, stimulates the development of the seed organization, prevents external influences: pain ...) often taken: fetal skin fetus died, adult skin died suddenly, accident ... (fetal skin is better) reserve for 24 hours to transplant.

Heterogeneous skin: (Heterograft, Xenograft)

Usually take frog skin, pig skin (fresh or preserved dry) has a temporary cover effect.

Biological layer:

Fresh placenta membrane, dry preservation.

How to transplant

Grafted skin piece is completely separated from where it was taken: (free skin grafted piece).

How to live: live on nutrients absorbed from the ground up. First and second times live by osmosis, day 3 => appear capillary sprouts developing towards the graft. Day 5 => the survival of the graft is undertaken by blood vessels.

Piece thickness: Depending on the thickness, it is divided into categories:

Thin: 0.1-0.25 mm including the epidermis.

Average thickness: 0.3-0.5 mm consisting of the epidermis and part of the dermis.

Thickness: 0.6-10 mm including epidermis and mesoderm.

Depends on the area and shape of the puzzle piece.

Very small piece (Meek wall method).

The small piece has many shapes: inside, square, rectangle, triangle, polyhedron ...

The piece is long but narrow.

Mesh (purely self or combined with homologous, heterogeneous leather mesh).

Big piece: ratio: 1: 1.

Skin removal tools:

Razor.

Normal scalpel.

Lag rot.

Electric knives.

Dao Padgett 

Postage stamp, mesh.

Preparation and technical method:

Skin grabs: Shave antiseptic, sterile bandages. Before taking the skin: disinfect, local anesthetic (or inject serum isotonic under the skin for swelling, flat if anesthesia is difficult to get) rub the rose. Get the skin done: put Vaseline in, outside the 24-48 hour tile roof to remove the outer layer of gauze just to Vaseline gauze. When it comes off on its own (if the weather is dry, the place where the skin has little secretion: leave for 10 days to peel the gauze outside, when it heals itself).

Grafted base: is scale, has nice seed organization 3 days before grafting without ointment. Change the dressing clean. If there is a lot of infection: 105-10 VK / 1 gram, the graft will be canceled due to infection.

Technical indications:

Grafting for aesthetic and motor areas: medium thick piece => thick, to large piece.

Large seed organization> 5%: It is impossible to cover all TCH by itself in one go: postage stamps, lattice eyes must be cut. The average rate of relaxation is 1/3 (1% of healthy skin grafted for 3% TCH). Or Mowlem Jackson alternates a single piece of skin (2-3 mm wide) with a piece of homologous or heterologous (1cm) skin; or perforated copper skin type d = 1cm, spaced 1cm apart will place the skin itself. 28 mmHg compression bandage after 24-48 hours of dressing change.

Grafted thick skin fragment of the entire epidermis layer on the scale to treat burn sequelae. Called Wolfe - Krause, cut the skin with a scalpel (note Langer Road). Peel off the grease stitching 2 layers under the skin = catguts, leather = lin).

The bandage is tight enough to fit the grafting site, 7 days to change the bandage, 10 days to cut the thread.

Skin flap grafting with stem:

This transplant method is rarely used in new burns, is indicated in the treatment of burn sequelae, long-term ulcers, injuries, wounds, pressure sores ...

How to live: thanks to the blood vessels of the petiole.

The composition of the joint:

Complete 3 layers of skin: epidermis, dermis, dermis and weight. Including blood vessels, nerves.

The petiole must be large enough to ensure blood supply for the grafted flap, the ratio of length = 1-1.5 times the width of the stem.

When the vortex moves, the flap moves in a position that is not angled (obstructing blood feeding) in the direction of the feeding artery.

Point:

Grafting into the organizational gap to create an aesthetic shape of the jaw ...

Grafted into the damaged area exposing tendons, bones and joints. These places cannot be grafted free fragment skin, to: ensure smoothness of tendons, mobility: easy stretching when moving of the joint area.

Skin flap has permanent stalks

Indication: Move from a cold to neighboring lesions.

From 2-5 days the dressing will be changed. If placed, drainage will be withdrawn after 24 hours.

Skin flap has temporary pet stalks

The cultured stalk is created skin to supply blood to the living skin flap in the bad (not enough nutrition) base, gradually having a series of development of blood vessels from the stalk and the transplant base. After 21 days of blood circulation between the grafting area (background and surrounding) and the complete graft will cut the stem. Before cutting, try clamping the stem to see if the nurturing capacity of the joint for the joint is not (if good: the colour of the joint is normal, not good: change the gray, need to take longer).

Indications: Take the flap further from the skin.

Corn cell culture

Currently, the world medicine is developing the method of culturing keratinocytes, in Vietnam is in the research period because it is quite elaborate and expensive in the culture environment. This method has a good result is to increase the area of ​​the horny cell layer very large, within 10 days from 1cm2 healthy skin will grow to 10,000cm2. This method is modern, complex, but useful in treating extensive burns.

Micro-surgery problem

This method combines two types of free-flakes and stalks.