M.N.Mawsouf , H.E.M. Shalaby, M.N.Z. Masoud, M.M. Deghedy, E.A. Ahmed
— The skin is the organ system which is directly affected in burn injuries.
— It is composed of two major layers:-
- A stratified cellular epidermis and
- An underlying dermis of connective tissue.
-The epidermis is divided into four distinct layers:
— stratum basale or stratun germinativum,
— stratum spinosum,
— stratum granulosum,
— stratum corneum.
Burn trauma represents one of the most devastating conditions encountered in surgery.
It is the dissolution of tissue on the exposure to thermal energy which includes:-
A- Positive heat source B- Negative heat source
- Scold Burn • Frost Bite
- Flame Burn
- Electrical Burn
- Chemical Burn
- Radiation Burn
CLASSIFICATIONS OF THE BURN
— Burn is classified according to the depth of the skin into:-
A — superficial burn.
B — Partial thickness burn which is either:
- Superficial partial thickness
- Deep partial thickness
C — Full thickness burn.
It involves the outer epidermis, appears red, glistening and blanching.
It is characterized by erythema, mild pain and heals within 5-10 days with no residual scarring
SUPERFICIAL PARTIAL THICKNESS BURN
It includes epidermis and the upper third of dermis.
It is blistering, moist and weeping wound which heals in two to three weeks with minimal scarring.
DEEP PARTIAL THICKNESS BURN
It involves most of the dermis, doesn’t blanch with pressure, light yellow in color due to a coagulum formation.
It usually heals in three weeks or more by reepithelialization resulting in dense scarring.
FULL THICKNESS BURN
All skin elements are destroyed .It is insensate,dry, waxy white in color with no bleeding.
It results in eschar formation which serves as a potential source of infection .
Separation of the eschar is accomplished in three weeks.
INFECTION AND WOUND HEALING
Bacteria causes disturbances of the normal wound healing process.
The increased levels of inflammatory mediators enhance bacterial proliferation.
Imbalance between bacteria species and host resistance lead to infection which allows bacterial multiplications.
INFECTION AND WOUND HEALING
In heavily infected wounds, the granulation tissue is edematous, fragile and haemorrhagic.
Bacterial toxins, metabolites inhibit migration of skin epithelium, digest proteins and
polysac-charides present in the dermis.
Bacterial infection decrease the amount of collagen which accelerates wounds breakdown.
BURN WOUND MANAGEMENT
The optimal chance of burn wound healing include:-
1- Control of the bacteria colonizing the wound.
2- Prevention of the accumulation of purulent and enzymatic secretions on the burn wound surface.
3- Isolation of the wound from sources of contamination.
4- Early removal of all non-viable tissue from the wound.
This can be achieved by using following methods:-
1- Modern burn dressings in the form of
- Film ,foam ,gel ,hydrocolloid ,alginate and biological dressings.
2- Enzymatic debridement of the burn wound.
3- Early surgical excision and immediate grafting.
EXTERNAL APPLICATION OF MEDICAL OZONE
Aim of the Work. To evaluate the effectiveness of ozone therapy as a procedure in the management of moderate and serve burn wounds in adult patients.
Patients: The present study was carried out in the Burn Unit of Alexandria Main University Hospital on 100 patients with TBSA between 15%-25%.
Patients are randomly categorized into two groups of treatment.
Group (A):- Includes 50 patients were managed by conventional procedure used in Burn Unit.
Group (B):- Includes 50 patients were managed by conventional procedure used in Burn Unit in addition to ozone therapy.
Methods: 1- Urgent admission procedures.
2- Full history taking
3- Complete Clinical Examination
4- Physical examination of the burnt area.
6- Systemic antibiotics.
7- Monitoring the resuscitation.
8- Laboratory Investigations.
This was carried out for every patient on admission and repeated weekly until he was discharged. It included the following investigations:-
- Complete Blood Picture. • Liver function.
- Kidney function. • Serum Blood glucose.
- Sodium, Potassium. • Total proteins.
- Albumin, BUN.
9- Specific evaluation:-
A- Microbiological Examination
Swabs from the burn wound were taken at the second post burn day (first sample) and then repeated weekly for culture. They were studied for the following:-
* Positive and negative cultures
* Types of microorganisms in positive cultures.
B- Histopathological Examination
Incisional biopsies from the granulation tissues formed and the healed wounds.
The histological sections examined in both groups to assess the following:-
* Quality of inflammatory infiltrate.
* Progress of healing in the tissue layers.
10- Local Care of the Burn Wound
A— For conventional therapy group patients treated by the usual method in the Burn unit of the Alexandria Main University Hospital by using :-
* MEBO cream with sterile gauze in partial thickness burn.
* Silver sulphadiazine cream with sterile gauze in full thickness burn.
B -For ozone therapy group
1- patients were treated by ozone through Spraying the burn wounds and normal skin by ozonated distilled water;
2-they were exposed to the ozone gas in the cabinet of ozone for 25 minutes, then applied the usual dressing.
Burn of face and neck treated by frequent compresses soaked with ozonised distilled water.
When the burn affected only either upper or lower limbs the burned wound was put in the transparent bag connected to ozone generator for 25 minutes.
Protocol of concentration of ozone
a- Infection stage:- A concentration of ozone was 70 mg/ml for 25 minutes in the first 6 sessions.
b- Mechanical debridment:- A concentration of ozone was 40 mg/ml for 25 minutes in every session until the separation of the eschar.
c- Healing stage with granulation tissue preparation:- A concentration of ozone was ranged between 15 — 20 mg/ml for 25 minutes in the other sessions to promote the healing process and prepare healthy granulation tissue for grafting.
RESULTS. Clinical Results: effect of ozone on the healing of partial thickness burn.
after 15 day
after 10 weeks
after 3 weeks
Debridement action of ozone with formation of granulation tissue
Debridement action of ozone with reepithelialization
after 20 day
- Slide section of fragment of granulation tissues formed after 1 month in conventional therapy groups shows :-
- Newly formed blood vessels devoid of surface epithelium. • Fibrous, chronic inflammatory infiltrate arranged within the deep dermis and subcutaneous tissue.
— Slide sections of fragments of granulation tissues formed after 2 weeks in ozone therapy groups show:-
- Newly formed blood vessels devoid of surface epithelium. • Few fibrous band, acute inflammatory infiltrate arranged within the deep dermis and subcutaneous tissue.
— Slide section of fragment of healed areas formed after 3 weeks in conventional therapy group covered also by intact epidermis.
— Replacement of G.T by fibrosis with mixed inflammatory infiltrate in the underlying tissue.
— Slide section of fragment of healed areas formed after 1 week in ozone therapy group covered by intact epidermis. — The dermis shows fibrosis, sparse of chronic inflammatory infiltrate.
The NEED OF GRAFTING in conventional therapy group (group A) was 52.0%. While, it was 22.0% in ozone therapy group (group B).
The mean PERCENT OF GRAFTING was 8.0 % for conventional therapy group, while it was 4.5% in ozone group.
-The DURATION OF STAY IN THE HOSPITAL was about 31 days in conventional therapy group, while it was 13days for ozone therapy.
Clinical pathological results.
— Significant reduction for ozone group at first, second, third week relative to conventional group.
ositive swab culture of both groups.
- There were marked decrease in ozone group relative to conventional group
MONOMICROBIAL INFECTION -Infection in ozone therapy group was decreased more than in conventional therapy group.
POLYMICROBIAL INFECTION -The number of patients in group (B) decreased more than in group (A).
Application of ozone on the burn wound
Bags was used for the extremities and a fiberglass cabinet for all body to:-
- Prevent its direct touch with burned surface area
- Give a direct contact of it with ozone gas.
The effect of ozone on burn wound
A-The beneficial effects of ozone on the healing of the partial-thickness burn were :-
1 -Early spontaneous separation of the sloughs.
2 — Absence of the foul smelly discharge.
3 — Promotion of epithelialization with rapid healing.
B-The useful effects of ozone on the full-thickness infected necrotic wounds were-
1- Rapid debridement of the eschar and the thick sloughs.
2- Early formation of healthy granulation tissue.
3- Diminution of the size of raw area with promotion of epithelialization.
- Decrease percentage of skin grafting.
The rapid debridement action of ozone with early formation of healthy granulation tissue were explained by Criegee, Pryor, Kourie.
Ozone acts as a chemical and enzymatic debridement which lead to break down of the cell components with cell lyses.
Pierce et al and Martin attributed the mechanism behind the promoting effect of ozone on reepithelialization due to :-
- Enhanced oxygenation,
- Normalization of tissue pH,
- Active proliferation of fibroblasts and keratinocytes
- Excessive formation of fibronectin, hyaluronic acid.
- Stimulation of the synthesis of cytokines
— Ozone has definite bactericidal, fungicidal action which is effective against resistant organism in Burn Units.
— Topical application of ozone causes a reduction in the healing time in the partial thickness burns.
— Ozone is an excellent debriding agent that rapidly separates eschar in full thickness burn with early formation of healthy granulation tissues.
— It enhances healing and re-epithelialization of the burn wound, thus decreasing the percent of grafting.
— Ozone decreases the duration of hospital stay and the cost of the patients during this period.
— Ozone is easy to apply to the wound and It leaves its surface dry with no residues.