2 English reference burn [Chinese medicine terminology Committee]. Terminology of Traditional Chinese Medicine (2004)]
3 Summary burn[ 1] is the name of the disease [2]. See "Thousand Daughters Wings" Volume 20. Also known as fire sore, soup splashing fire [2], soup fire injury, fire and water scald. It refers to diseases caused by flame burn, hot water scald, chemicals and radioactive substances invading the skin [1][3]. As early as the Jin Dynasty (Elbow Urgent Prescription), there was a long-term record of scalding with lime or conditioning with oil. After scalding, the local erythema was mild, followed by blisters, dark skin or exposed bones and muscles, which damaged the viscera.
4 Causes and pathogenesis of burns caused by physical high temperature or chemical factors such as strong acid and alkali [2].
As high fever acts on human body, heat toxin invades, qi and blood stagnate, and the skin and flesh rot in light cases, and the heat toxin is blazing in severe cases, hurting the vulva of human body, or heat toxin invades the viscera, resulting in imbalance of yin and yang of viscera.
5. Mild burn symptoms generally do not affect the visceral function, but only local redness, blistering or ulceration; In severe cases, the injury area is large and deep, the skin is burnt, and the heat toxicity is very intense, which consumes human vaginal fluid [2]. What's more, heat toxin invades, resulting in thirst, fever, coma, constipation, dysuria and other symptoms [2].
6 Diagnosis of Burn The diagnosis of burn is actually a process of making a more accurate judgment of the injury after burn. Accurate judgment of the patient's injury is of great significance for making a correct treatment plan and judging the prognosis. Generally speaking, the severity of burns is closely related to the area and depth of burns, as well as the location of burns, the patient's age, physique, causes of burns and whether there are complications.
6. 1 burn area estimation 6. 1. 1 China nine-point method This method divides the human body surface area into 1 1 9 equal parts. Among them, the head, face and neck are 9%, the upper limbs are 2 9% (18%), the front and rear parts of trunk (13%) and perineum (1%) are 3 9%, and the lower limbs including buttocks are 5 9%+ 1% (46%).
6. 1.2 The palm area of the injured person with five fingers together accounts for 1% of his body surface area. This method is simple in calculation and is often used to estimate the burn area of small area or scattered area.
6. 1.3 estimation method of burned area of children The percentage of body surface area of infants and children at different ages is also different. It is characterized by a big head and small limbs. The younger the age, the larger the relative area of the head, while the smaller the surface area of the lower limbs, and the relative body surface area of other parts is roughly the same as that of adults. The calculation formula is as follows:
9%+( 12 age)%
Lower limbs 46% (12 years old)%
6.2 The estimation of deep burn depth generally adopts three-degree quartering method, namely, power, II degree (divided into shallow II degree and deep II degree) and III degree burn.
6.3 Classification of injuries (1) Second degree burns with a total area less than 10% (5% for children).
(2) Second-degree burns with a total area of 1 1% ~ 30% (6% ~ 15% for children) or third-degree burns with a total area of 10% or less (5% for children).
(3) The total area of severe burn is 3 1% ~ 50% or third-degree burn1%~ 20% (the total area of children 15% ~ 25% or third-degree burn is between 5% ~ 10%). If the burn area does not reach this standard, but there are one of the following conditions, it is also a severe burn: ① the whole body is in poor condition or has been in shock; ② Combined with other severe trauma or chemical poisoning; ③ Severe respiratory burn; (4) Head, face, neck and hands will be burned.
(4) The total area of severe burns is 5 1% ~ 80% (26% ~ 40% for children), or the area of third-degree burns is 2 1% ~ 25% (10% ~ 23% for children).
(five) the total area of severe burns is greater than the rib% (more than 40% in children) or the area of third-degree burns is greater than 50% (more than 25% in children).
7 The treatment of minor burns only needs external use, with the same amount of Sanguisorba officinalis and rhubarb, a little ground borneol and sesame oil [2]. In severe cases, it is advisable to take orally the agent [2] for clearing away heat and toxic materials, cooling the camp and calming the wind, or benefiting qi and nourishing yin, and returning yang to save the adverse. Choose Huanglian Jiedu Decoction, Rhinoceros Horn Dihuang Decoction and Antelope Uncaria Decoction. [2], or Shengmai Powder, Shenfu Decoction, etc. If you are weak for a long time, you should replenish qi and nourish blood, and use Bazhen Decoction [2]. External treatment includes cleaning the sore surface, blister treatment, escharectomy or skin grafting treatment, and the above ointment can also be applied [2]. Severe cases should be treated with integrated traditional Chinese and western medicine in time.
7. 1 Syndrome Differentiation and Treatment 7. 1. 1 Fire-toxin-induced body fluid burn refers to fire-toxin-induced body fluid injury, excessive heat, irritability, thirst, constipation, red urine, red and dry tongue, yellow or dry tongue coating, or no tongue coating.
7. 1. 1. 1 Symptoms: fever, thirst, constipation, short and red urine; Red tongue, yellow fur, and rapid pulse.
7. 1. 1.2 Dialectical analysis shows that evil fire invades human body and consumes body fluids, thus causing fever and thirst. Excessive heat and loss of intestinal juice will lead to constipation; When the small intestine is heated, the urine will be short and red; If heat disturbs the heart, it will be irritable; Red tongue, yellow fur and rapid pulse are all signs of invasion of heat evil.
7. 1. 1.3 treatment: clearing away heat and toxic materials, nourishing yin and promoting fluid production.
7. 1. 1.4 Prescription treatment of Huanglian Jiedu Decoction and Zengye Decoction.
7. 1.2 burn with yang collapse due to yin injury refers to yang collapse due to yin injury, listlessness, pallor, weak breathing, apathy, lethargy, spontaneous sweating with cold, hypothermia, short urination, systemic or local edema, large amount of fluid oozing from the wound surface, pale tongue and dull tongue.
7. 1.2. 1 Symptoms: pale face, mental fatigue, shortness of breath, spontaneous sweating, cold limbs, hypothermia, lethargy and even trance; The tongue is deep red or deep purple, without coating, and the pulse is extremely thin.
7. 1.2.2 Dialectical analysis shows that excessive fire poison damages body fluid, yin damages yang, and yang deficiency leads to loss of temperature and transportation, so pale face, mental fatigue, shortness of breath, hypothermia and lethargy; When yin and yang are separated, they are in a trance; Yang deficiency is not solid, then white sweat; The tongue is crimson or deep purple, without coating, and the pulse is thin, which is the image of deficiency of both yin and yang, yin deficiency and yang decline.
7. 1.2.3 treatment: restoring yang to save the adverse, nourishing yin and promoting fluid production.
7. 1.2.4 Prescription treatment of Shenfu decoction combined with Shengmai powder and fur.
7. 1.3 Fire poison invagination burn refers to fire poison invagination, which is characterized by intense heat, dry mouth and lips, irritability, constipation, short and red urine, red and dry tongue, yellow or dry tongue coating, or burning, and frequent pulse and string, which can be transmitted internally.
7. 1.3. 1 Symptoms: excessive heat, polydipsia or high fever, dizziness, irritability, dry mouth, constipation, short and red urine; Red tongue and thready pulse.
7. 1.3.2 Dialectical analysis shows that excessive fire and poison make the sun be the spirit invincible. Fire poison penetrates into people's blood and invades pericardium, so high fever makes people faint and fidgety, and fire poison hurts yin, leading to excessive heat, polydipsia, dry mouth, constipation and short and red urine; Red tongue and thin pulse are manifestations of yin injury caused by heat toxicity.
7. 1.3.3 treatment: clearing camp, cooling blood and detoxifying.
7. 1.3.4 Qingying decoction prescription treatment.
7. 1.4 burn with deficiency of both qi and blood refers to the deficiency of both qi and blood in the late stage of the disease, gradual retreat of fire and toxin, low or no fever, mental fatigue, shortness of breath, emaciation, dull complexion, loss of appetite, spontaneous sweating, night sweats, pale granulation on the wound surface, slow healing and pale tongue.
7. 1.4. 1 Symptoms include low or no fever, mental fatigue, loss of appetite, emaciation, pale complexion, pale granulation on the wound surface, and difficulty in healing; The tongue is pale, the coating is thin and white, and the pulse is thin and weak.
7. 1.4.2 Dialectical analysis shows that in the later stage of burn, the toxic heat gradually recedes and the qi and blood are also damaged, so there is low or moderate fever; Lack of healthy qi leads to mental fatigue and loss of appetite; Deficiency of both qi and blood, loss of nutrition, pale face, pale face, long-term unhealed; Pale tongue, thin white fur and weak pulse are signs of deficiency of both qi and blood.
7. 1.4.3 therapeutic methods for invigorating qi and blood.
7. 1.4.4 bazhen decoction prescription.
7. 1.5 burn with spleen deficiency and yin injury refers to spleen deficiency and yin injury, which is caused by fire, spleen and stomach weakness, loss of body fluid, sallow complexion, loss of appetite, abdominal distension and loose stool, dry mouth, dark red and dry tongue, and peeling or smooth tongue coating.
7. 1.5. 1 Symptoms are prolonged, wounds are difficult to heal, fatigue and weakness, loss of appetite, abdominal distension, vomiting and diarrhea, pale face and emaciation; Pale tongue, greasy white fur and weak pulse.
7. 1.5.2 Dialectical analysis shows that if the course of disease lasts for a long time, vital qi is seriously damaged, spleen and stomach are weak, and transport and transformation are weak, then appetite will be lost, abdominal distension will be full, or vomiting and diarrhea will occur; The spleen and stomach are weak, the metaplasia is insufficient, and the qi and blood are insufficient, so the wound is difficult to heal, the face is Hua Shao, and the body is thin; Pale tongue, greasy fur and weak pulse are symptoms of deficiency of both spleen and stomach.
7. 1.5.3 treatment: invigorating spleen and regulating stomach.
7. 1.5.4 Prescription treatment of Shen Ling Baizhu Powder.
7.2 External treatment of wound is the root of a series of complications. Whether the wound is treated correctly is directly related to the evolution of the disease and the healing of the wound, so it is necessary to keep the wound clean to prevent and control infection. Second-degree wounds should be healed under eschar to reduce scar formation. For third-degree wounds, keep the eschar intact and dry at an early stage, and strive for early escharectomy and skin grafting to shorten the course of treatment.
7.2. 1 Debridement shall strictly abide by aseptic technique. During debridement, painkillers can be given first, and then the wound surface can be cleaned with topical normal saline or 2% Cortex Phellodendri solution at about 37℃. Larger blisters should be punctured, and smaller blisters should not be punctured. The surrounding wounds should be disinfected with alcohol or bromogeramine, and then the wounds should be dried with sterile gauze after cleaning.
7.2.2 After debridement, children with small area burns, uncooperative or poor ward conditions can be wrapped in purple grass oil gauze and padded with 3-5 layers of gauze for external use. You can change the dressing for the first time about 2 weeks after the injury, and you can change the dressing in advance if there is infection. The dressing can be changed five days after the third-degree burn, and whether there is exudate in the dressing should be closely observed during the dressing change. If the exudate is green and smelly, the possibility of Pseudomonas aeruginosa infection should be considered.
7.2.3 Exposure therapy Exposure therapy is suitable for burns with large area and inconvenient dressing, as well as burns with serious wound pollution. This method requires patients to live in a separate isolation ward, and the indoor temperature is kept at 25℃-30℃. MEBO was applied externally after debridement, 65438 0 times a day.
7.2.4 Treatment of eschar and bacteria under skin grafting eschar are not easy to grow, and the eschar should be kept dry. The uninfected eschar, with an area of 10%-20%, should be removed 2-7 days after injury and transplanted immediately. If the area is large, the scab can be cut by stages and regions, or the affected area can be soaked with traditional Chinese medicine, and the scab skin can be peeled off as soon as possible before skin grafting. Early skin grafting can be performed about 72 hours after deep second-degree and third-degree burns of hands, and skin grafting is taken from body surface skin in principle.
7.3 During the whole course of burn, other therapies show different stages due to different principal contradictions in different periods, which are generally divided into three stages: exudation period of body fluids (shock period), invasion period of fire poison (infection period) and wound repair period. Therefore, clinical treatment should be based on the pathological characteristics of these three different periods.
7.3. 1 Prevention and treatment of shock Within 48 hours after extensive burns, it is the peak of fluid exudation. Because a large number of body fluids extravasate, it is easy to cause hypovolemic shock, so 48 hours after injury is called shock stage. Severe burns can cause shock within 6- 12 hours. If the burn area exceeds 70%, shock can occur within 2 hours after injury. In addition, airway obstruction after respiratory tract burn and severe pain after injury can lead to and aggravate shock. Therefore, the main measures to prevent and treat shock are to replenish blood volume as soon as possible, keep respiratory tract unobstructed, and sedation and analgesia are also important means to prevent and treat shock.
The general formula of fluid replacement is: 1% burn area (Ⅱ and Ⅲ degrees) and 1.5mL colloid fluid and electrolyte fluid per kilogram of body weight within 24 hours after injury, plus 2000ml water demand (calculated by children's age and weight). The ratio of colloid to electrolyte is generally 0.5: 1, and severe deep burn can be 0.75: 0.75. Rehydration speed: half of the total number of people were replenished 8 hours after injury, and the other half were replenished 16 hours after injury. If you can take it orally, try to take it orally. The liquid volume of colloid and electrolyte in the second 24 hours after injury is half of that in the first 24 hours, and the water content is still 2000mL.
When respiratory tract burns, if airway edema seriously affects gas exchange, tracheotomy should be performed. The use of sedatives and analgesics such as dolantin after burns is helpful to prevent and treat shock.
1. Patients with severe infection should pay close attention to the changes of expression, blood pressure and urine volume.
2. Shock has occurred, and attention should be paid to restoring effective blood volume and tissue oxygen supply. It is best to monitor the central venous pressure when rehydration; Pulmonary artery wedge pressure can be measured if possible to understand left ventricular function.
3. If there is still hypotension after volume expansion, drugs such as dopamine and naloxone can be added; If there are symptoms of hypersympathetic nerve function or increased peripheral resistance, vasodilators such as phentolamine and anisodamine can be used.
4. Urine volume
5. Large doses of glucocorticoid can be used, such as intravenous dexamethasone 40mg, or a larger dose (200mg).
6. Intravenous infusion of targeted antibiotics, while actively looking for and removing infected lesions.
7.3.2 Prevention and treatment of systemic infection 7.3.2. 1 (1) Actively treat the wound 1. Wound is the main source of systemic infection. Escharectomy should be done at an early stage for large-area third-degree burns, and the wound surface should be closely covered with allogenic skin (or allogenic skin) and autologous skin immediately. At the same time, deep necrotic tissue should be removed. The infected focus (that is, wound sepsis) should be removed immediately.
2. For electric injury, combined with crush injury and annular third-degree burn, special attention should be paid to deep muscle necrosis. Where local swelling persists, fasciotomy should be performed in time to reduce tension. If there is foul smell and the symptoms of systemic poisoning are aggravated, we should explore the suspicious parts under the fascia as soon as possible, thoroughly remove the necrotic muscles, and pay attention to whether there is anaerobic infection.
7.3.2.2 (2) Application of antibiotics 1. Prophylactic application of penicillin to prevent streptococcal infection within 3 days after burn. The use of antibiotics in moderate and severe burns should emphasize the timing and time limit, and the route of administration should be targeted. Patients with extensive third-degree burns should use powerful antibiotics as soon as possible. Stop taking the medicine when the condition is stable. Perioperative systemic application of antibiotics should be strengthened.
2. When symptoms of systemic infection appear, choose antibiotics with high bacterial sensitivity and low drug toxicity according to the bacteria cultured on the wound surface. At the same time, the Qin Ying of severe burn patients was monitored by bacteriology to ensure the pertinence of medication; Antibiotics can be selected according to experience before the pathogen is determined.
3. For systemic fungal infection, fluconazole (Dafukang) or itraconazole can be selected.
7.3.2.3 ③ Nutritional support to maintain internal stability.
1. Maintain water, electrolyte and acid-base balance.
2. Support respiratory function and keep oxygen dynamic and stable.
3. Selective intestinal decontamination therapy.
4.H2 receptor antagonists (Xinfadi, etc.) and gastric mucosal protective agents (Shukfei, etc.).
5. Maintain hemodynamic stability and improve microcirculation.
7.3.2.4(4) Avoid iatrogenic infection 1. Prevention of venous infection? There are more venipuncture and fewer venous catheters. The indwelling time of venous catheter shall not exceed 3 days.
2. Prevent respiratory infection? After tracheotomy in patients with severe inhalation injury, respiratory tract infection caused by the pollution of atomizer and sputum suction catheter should be prevented. Strengthen humidification therapy.
3. Prevent urinary tract infection? After burn shock, indwelling catheterization should be used as little as possible.
4. Prevent contact pollution of mattresses, clothes, dressings, equipment and staff? The above items should be strictly disinfected.
7.3.3 Prevention and treatment of septicemia is the main cause of death from extensive burns. Generally, the infection rate is the highest and the severity is the highest in 3 ~ 10 days (edema recovery period) and 3 ~ 4 weeks (scab dissolution period) after injury. During this period, actively enhancing patients' resistance, strengthening wound dressing change and rational use of antibiotics can prevent sepsis. Generally, broad-spectrum antibiotics or sensitive antibiotics are selected according to the bacterial culture of secretions.
8 burn prevention 1. Strengthen safety education and use inflammable and explosive dangerous goods correctly.
2. Household items such as thermos bottles and braziers should be put in proper places to avoid being knocked over by children.
3. For general thermal burns, put out the flame of the wounded as soon as possible, take off or cut off clothes, leave the scene, and wrap the affected limb with disinfection or cleaning dressings and sheets to avoid pollution and injury again.
4. Those who are burned by chemical substances should immediately take off or cut off their soaked clothes and wash their bodies with plenty of water as soon as possible.
5. Burn with fracture should be simply fixed on the spot and then transported. If complicated with massive bleeding; Asphyxia and open pneumothorax should be rescued immediately.
6. Sterile operation procedures should be implemented during dressing change to avoid iatrogenic infection.
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