Burn Therapy with Physiologically Moist Environments

Xu Rongxiang

China National Science and Technology Center for Burns,Wounds & Ulcers Beijing , 100053

In late 1930`s, patients with burn area over 30%BSA often died and the doctors were at a loss of I what to do with them. Doctors made great efforts and tried to treat burn wounds with surgical operation,by excising part or all burned skin,then close the wound by skin auto-grafting. Thereby the obstacle of treating burn over 30%TBSA was overcome. Up till now,with the help of multiple modern medical measures and medicines, this surgical grafting therapy by sacrificing the skin to save life makes a few patients with 50% ～ 100%burn areas (III 98%)survive, while the majority of survivors became disabled. Since then, the surgical grafting therapy has been conclude that surgical grafting is the best choice for treating burns and there is nothing more than improvement of surgical skill. However, following the principle of burn pathogenesis we developed a new burnmedical theory and therapy involving local and systemic treatment, referred to as "BurnTherapy with Physiologically Moist Environments", which in clinical practice has obtained remarkable effects and proved to be superior tosurgical grafting therapy. The new therapy promotes liquefaction and removal of necrotic skin tissue and cultivates the residual surviving tissues to recover, regenerate and to heal the burn wounds. Instead ofdehydrating and drying of the burn wounds as it is done in surgical grafting therapy, the new treatment encourages tokeepthe wounds ina physiological moist environment. The treatment with the new therapy is accomplished by the collaboration of Moist Exposed Burn Therapy (MEBT) and Moist Exposed Burn Ointment (MEBO). A special comprehensive protocol for systemic treatment based on life rules has been established,which makes burn medical science turn into a new domain. This new therapy has been put into practice in China for 8 years.Statistical data showed that an average of 350,000 burn inpatients were treated annually witha total curative rate of 99.42% andthe largest burn area curedis 100%TBSA (98%BSA for III degree burns). For burns over 90% TBSA, the curative rate can reach 92% (while the public data in international journal hold that surgical therapy has a curative rate of 8% only).Our new treatment alleviates the pains and generally leaves no scar for deep II degree burns. The bacterial toxicity is reduced greatly because the new treatment causesvariationof thelocalpathogenicbacteria and enhances the anti-toxicity power of the local tissue,sothatthe treatment effectively prevents and controls infectionof the wounds. MEBO creates aphysiological moist environment and anadequate nutrition supply, so that full-thickness skin burn, deep into fatty layer, can be healed by regenerationoftheresidual surviving epithelial tissues and other tissues in the fatty layer.Forexposedbone tissue resulted from burns, with the cooperation of drilling holes in the bone, MEBO can cultivate the granulation tissue in the holesto cover the bone tissue and finally the comprehensive anti-shock systematic treatment protocol isestablished, which includes invigorating the heart, alleviating the obstacle of renal parenchymal vascular blood supply and supplementing blood volume. According to the severity of burns, an anti-infection protocol is launched, i.e. in the early stage, strong and broad spectrumantibiotics are used to control systemic infection and on day 7 ～ 10 post-burn, stop the application of antibiotics to protect the function of organs. So far Syria , U.A.E., Thailand , South area,Singapore and other countries are attracted by the remarkable effects of the new therapy and have successfully adopted our new treatment for the benefit of their people. In USA and European countries, this newacademic thought and technique have drawn great attention and begun to spread.

Concept and Principle Moist Exposed Burn Therapy (MEBT)

Concept:  Moist Exposed Burn Therapy can promote thecell regeneration of residual skin tissues and wound healing by keepingburn wounds in a three -dimensional physiological moist environment and facilitating the liquefaction and dischargeof the necroticskin tissues.

Principle: MEBO, special developed for MEBT, has its base with frame structure composed of beeswax embracing botanical oil within the frame. When applied onto the wounds, the oil isolated in the frame is warmed up by wound skin temperature and comes out from the frame to penetrate into the wounds. Four biochemical reactions between the active constituents and the burn tissue take place and nutritional substances are supplied continuously to the surviving cells in the wounds.The oil then loses its lipophilic nature, rushes out of the drug layer and is discharged from the wounds. Fresh MEBO continues to penetrate into the tissue, so that removal of liquefied necroticskin layer from superficies to interior without causing further injuryand replenishing of the drug can be accomplished continuously in cycles. This cycle ensures timely drainage of metabolic product from the injured metabolic tissue. Tissue fluid in the wound meets the physiological requirement to establishaphysiologicalmoist environment. The cycle also ensures continuous supplyofindispensable nutritionalsubstancestothe woundtissue.Furthermore, theframe structure of MEBO base effectively preserves the wounds from outside and is favorable for the removal of metabolic. It keeps the wounds breath as the normal skin and helps adjust the systemic balance.

The Therapeutic Effect of MEBO

Under the direction of MEBT, MEBO hasthefollowing therapeutic effects: Variation of pathogenicbacteria and reduction in bacterial toxicity; Effectively kill pains by protecting nerve endings, reducing sense of pains and relaxing arrector pilorum;

It contains β-beta-sitosterol and other ingredients which have strong anti-inflammatory effect. Made of nutrient food, MEBO may protect cells by increasing the tension of cell membrane and help dying cells convert into vigorous normal ones. With the co-ordination of MEBT, MEBO develops a physiological moist environment, favorable to the regeneration and repair of tissue structure and thus, it is effective for reducing scar formation, enhancing scar formation, enhancing the power of self-healing of wounds and promoting the regeneration of residual epithelial tissues in fatty layer, vascular plexus and fibrous tissues to regenerate skin.

Clinical Application of MEBT/MEBO (Brief)

Treatment condition

MEBT does not emphasize a sterilized condition.Debridement using any disinfectant or water is forbidden. Small burns can be dealt with at home with MEBT/ MEBO.Moderate and minor burns encountered in battlefields also can be treated with MEBT/MEBO. Fortreating large burns, the room should be kept at a temperatureof 30 ℃ to 34 ℃ and first-aid apparatus or devices should be equipped.

Administration

Directly apply MEBO onto the wounds with a thickness of 1mm .At the beginning, no debridement is required. Renew MEBO every 3 ～ 4 hours, before which wipe off the residual ointment and liquefaction products with gauze or tissue paper(gentle and careful renewal is demanded to avoid pains and bleeding).For the wounds with putrid skin, be sure to preserve the putrid skin, directly apply MEBO until the putrid skin isremoved five days later. For deep II burns, after applying MEBO,dermal tissue in necrotic layer begins to liquefy on 7 days postburn. Renew MEBO and wipe off liquefaction product timely. Clean away the necrotic tissue apply less MEBO and renew every 4 ～ 6 hours till the wounds heal. For III burns, treatment with special debridement technique can be applied for co-ordination. (refer to the monograph).

Special application

For treating small burn wounds not easily exposed, apply MEBO with a thickness of 2 ～ 3mm ,then apply decompression bandage using dry gauze. Before change of dressing inevery 12 hours,gently remove the sediment drug and liquefied necrotic tissues. For treating traumatic, ulcerative and operative wounds, apply 1 to2 layers oil gauze impregnated with MEBO.

Principle of Systemic treatment

Burns is a systemic disease caused by thermal injuries. The changes of topical treatment directly affect the systemic pathogenic status. MEBT/MEBO systemic treatment is in principle different from that of conventional dry surgical therapy. While using MEBT/MEBO, the protocol of dry surgical therapy is forbidden. Two principles should be followed in MEBT/MEBO treatment: At the early stage,  comprehensive anti-shock treatment principle is applied, which involves enhancing cardiac function, protecting kidneys and supplementing blood volume according to the physical signs; and at the middle and later support and maintaining comprehensive balance. In the anti-infection treatment, a large dose of strong and powerful broad-spectrum antibiotics is used in theearly stage for 7 to 10 days and then withdraw immediately, in orderto protect and enhance the anti-infective function of the organs. In nutritional supporting treatment, a protocol of oral administration is desired. Others are dealt with according to the case.

Clinical Treatment

Treatment for I burns:

Burns: The clinical signs include skin redness, slight swelling and pain. Immediate application of MEBO may relieve the pain. The erythema gradually diminishes as MEBO is warmed to be absorbed by skin. At 12 hours postburn, the skin may return to normal. For burns with edema, the epidermis is partially destroyed, the pains may be relieved more slowly and the wounds heal in 1 ～ 2 days when the superficial stratum corneum exfoliates.

Treatment for II burns:

According to the pathogenic process of II burns, the treatment can be carried out in two stages.

First stage: Treatment at early stage---the period form emergency treatment postburn to the end of shock period(within 3 ～ 4 days postburn).The clinical signs in this stage include pain, edema, exduation, blisters, great amount of blood plasma exduated from the place where blister skin exfoliates. Directed by the principle of MEBT, apply MEBO directly onto all wounds, cut out the blister(if there is)on the lower part to discharge liquid. Do not remove the blister skin, directly apply MEBO on the putrid or blister skin 3 ～ 4 times daily. With the application of MEBO, a layer of thin soft membrane is formed upon the wound free of blisterskin, the membrane still allows the exudate to ooze through, and then it gradually thickens.Do mot remove the soft membrane, since it can substitute the skin to fulfill breathing and protecting. Continue MEBO application directed by MEBT.

Second stage: Wound-recovering period when shock stage ends and the residual epidermis tissue begins to regenerate and recover, usually lasting 3 ～ 4 days. It is this period that the basal cells in epidermis recover to form granular layer to promote wound healing. In clinical treatment of MEBT/MEBO, after the edema period, blister skin looses and exfoliates, and the thin soft membrane formed on the wounds also looses and exfoliates. It is desired to simply clean away the putrid skin, blister skin and soft membrane, then continue the application of MEBT/MEBO to protect regenerated wounds till healing. Duringthe whole treatment, neither pains nor further injuries to wounds are allowed. The correct application method helps the wounds heal without causing any infection, pains, scars formation orpigmentation.Generally,superficial II wounds treated with MEBT/MEBO heal within 6 ～ 8 days and the skin recovers to its normal physiological status within 3 months.

Treatment for deep II` burns:

According to pathologic and clinical manifestation, deep II burns can be divided into injuries on dermis papillary layer and injuries on reticular layer, or simply referred to as deep II` superficial(DIIA) and deep II deep (DIIB).

DIIA:

The clinical signs include wound pains, extensive blisters, wounds after exfoliation of putrid skin/blister skin become red and white, the superficial dermis tissues are necrotic and turn white, the survival deep dermis tissue is red, while under pressure it turn white and soon return to red after free of pressure (DI-IB burn wounds respond more slowly). The exduate of wounds is only less than that of superficial II burns.

MEBT/MEBO treatment and clinical manifestation: It is a four-period process: firstly, early stage treatment (pathogenic shock period, same as that for superficial II burns; secondly, period of liquefying and expelling necrotic dermis tissues(expelling period);thirdly, regeneration and recovery period and fourthly, period of recovering skin physiological function after healing.

The treatment of the first period is the same as that for superficial II burns, emphasizing on wound-protection. A thin layer of soft membrane may be formed on the wounds free of putrid skin or blister skin. On day 4 ～ 5 postburn, starts the next period treatment when the wound edema diminishes.

Second period: Clean away the putrid skin, blister skin or thin soft membrane in the same way as dealing with superficial II Continue the application of MEBT/MEBO. Gradually, the necrotic layer of wound surface begins to liquefy from superficies to interior and produces white liquefied products floating over the wound surface. Usually at 3 ～４ hours after application, the wounds are totally covered with liquefied products, indicating that MEBO is consumed completely. The liquefaction products are needed to be cleaned away before the renewal of MEBO. Another 3 ～ 4 hours later, the renewed MEBO is consumed again when the liquefaction products float over the wounds. Clean the liquefaction products, renew MEBO again and keep the clean-_renew-clean process going until the necrotic tissues are entirely liquefied and expelled. The process generally happens on 5 ～ 15 days postburn. Patients with large area burn are urged to turn-over during drug renewal. 

Thirdperiod:Afterthetreatment of second period,the chestnut-like residual dermis tissues, size as millet, expose on the basal layer of wound. Continue MEBO with a less thickness directed under MEBT and renew every 4 ～ 5 hours. Covered and protected by MEBO, the residual dermis tissue may reconstruct and regenerate. Once dermis tissue regenerate to smooth skin, less irritation to the wounds is allowed. Again reduce dosage and renewing times, never allow the wound to become dry, while crust formation is forbidden, i.e.not only prevent wounds from being macerated by MEBO, but also avoid the wounds to dry and crust. Duly keep the normal skin around the wound tidy. For large area burn patients, do as in the second period by helping them turn over regularly on the basis of drug change intervals. The pressured parts still needs MEBO protection till wounds heal. This period occurs on 15 ～ 20 days postburn.

Fourth period: Although the wounds heal, the function of the newly healed skin remain to recover completely. The epidermisrequirefurther physiological adjustment and metabolism; thesebaceous glandsneed having metabolism and compensation; the sweat gland excretory ductgoes unsmoothly; thefunctionn of pigment cells are unable to meet the re2quirements of normal skin. Under this circumstance, MEBO is used as skincare oil for 10 ～ 15days.Or apply newly developedMEBO series products-MEBO cleansing cream to promote sooner recovery of skin function, or apply MEBO ltch Relieving Cream to stop itching.

DIIB: The clinical signs of deep II superficial, except for thatDIIB has more serious injuries and more serious response during liquefying period and regeneration of wounds become more complicated. The clinical treatment for deep II deep burns also can be divided into four periods.

First period: clinical signs-no extensive blisters, epidermis entirely destroyed and adherent to injured dermis, the wounds free of putrid skin are no longer sensitive to pains, the wounds are white, with little exudates. Some of the wounds may be red alternating with white, the color responds very slowly pressure. During this period, simply apply MEBT/MEBO to protect wounds. This period begins from the very day of burn through the 7th day postburn.

Second period: From day 7 to day20 postburn,clear awayall adhering substances to expose necrotic dermis and apply MEBT/MEBO immediately. For large burns, simple debridement may be used coordinately. The necrotic layer is so deep that the wound liquefying may causelumps exfoliation, which needs to becut and removed with surgical scissors. Attention should be paid to keep a certain distance between the surviving tissue and the cutting, Any further damageto the surviving tissue including damagesuch as bleeding(which may cause infection)shouldbe absolutelyavoided, Simple debridement can be implemented according to the condition of the wounds. When the necrotic layer is liquefied completely, timely clean away the liquefaction products to ensure the unsmooth survival tissues being kept in MEBO environment, but mot in an environment filled with liquefaction products.

Third period: the period of the reconstruction and regeneration of residual dermis tissue. As little residualdermis tissue is left and dermis frame is fundamentally destroyed, correct MEBT/MEBOtreatmentis quite vital in this period. The reconstruction of dermis tissue involves three parts:(a)the construction of vascular tree;(b)the reconstruction of dermis tissue dependent on vascular tree;(c)the regeneration of skin appendages gland tissue, formation of excretory ducts and formationof skin tissue. Any careless injuries, pressure or limitationto woundsare forbidden. This period usually happens on day 20 ～ 28 postburn.(See monograph for studies on skin regeneration.)

Fourth period: Aiming at helping the gealed skins return tonormal skin, the treatment in this period varies according to burn severity and the skills in MEBT/MEBO treatment. The severe injuries to skinandthe many factors affecting the skin during reconstruction makethe newly healed skin quite different from normalskin in structure, appearance and function. So the rehabilitationis very important, including two aspects: protective therapy for healed skinand dirigation. Theformer one is accomplished by adjusting the structure of new-born skin tissue with the application of MEBO ScarLotion, byadjustingthefunction withMEBO Cleansing Creamand by killing itch with MEBO Itching Reliever just afterwounds heal.( The detailed application method will be reported elsewhere.)

Treatment for III burns

Burns are alsothe indication of MEBT/MEBO treatment. As the epidermis and dermis of III burns are totally destroyed, it isquite tough to cure III burns. The conventional medical science for burnsis convinced that III is incurable and only solutionis to use surgical skin grafting to close wounds. Thestudyand clinical application of MEBT/MEBO for curing III will be described in detail elsewhere. The following is a brief description of the principle andmethod of MEBT/MEBO for treating III burns.

Principle : Free the deep tissues from any pressure exertedby necrotic layer, protect the necrotic full thickness skin, island, cultivate the new-born skin island whileliquefying anddischarging the necroticdermis, promote skin island tospread and cover subcutaneous tissues to form new skin and help IIIburns wounds heal spontaneously, For III wounds injured till muscle layer, excisemost of the necrotic layer by surgical operation, liquefy and discharge the rest of the necrotic layer with MEBT/MEBO ,upon which cultivate granulation tissue, then plant skin cells till the wounds close and heal ,For wounds with bones exposed, clean away the exposed outerlayer, drillholeson bone surface with a bone drill at the interval of 0.5 ～ 1cm ,deep into medullae until bleeding. Apply MEBT/MEBO to cover the wounds. cultivate the growth of granulation tissue from the holes.whenthe granulation tissues spread to cover the bone tissue, graft skin or plant skin to close the wounds, or heal by wound edgeepithelialization. The necrotic tissues of III burns should be decompressed by cutting horizontally and vertically with a saw blade of 1mm tooth distance and 1mm tooth depth. Then apply MEBO for protection and cleanaway the exfoliatedor liquefied tissue. (Pictures and slides illustratingtheprocedure and principle for treating III burns are attached.)

Systemic Comprehensive Treatment With MEBT/MEBO
Part I. Anti-shock Therapy

The author considers that it is more important to protect and recover the functions and structures of internal organs than supplement blood volume only, in the anti-shock therapy postburn. The principles of the treatment are as follows

1. Protection and enhancement of cardiac function

We propose that a lot of protein degradation products released from burned skin tissue could be absorbed into blood circulation, and could inhibit and decreased the cardiac function, thus induce cardiogenic shock. Therefore, the severely burned patients(TBSA>50%and/or III degree >10%)should be routinely intravenously injected with lanatoside (0.2mg +25% ～ 50%GS50ml), qd, after injury or admission. Then,the amount and frequency of lanatoside should be regulated according to the changesof heart rate and peripheral circulation. After 48hourspostinjury, lanatoside should be ceased, however, if the patient still was suffering from abnormal cardiac function should be needed treatment with lanatoside should be applied until symptoms disappear, Once symptomsof heart failure arise in wholeclinical course, thepatient should be treated with 0.2%mg ～ 0.4mg lanatoside once at the moment.

2. Protection of renal function

After massive burns, one of the main complication in shock stage is renal dysfunction that should be caused firstly by microvascular spasm of renal parenchyma and renal ischemia, It is also the major cause to induce renal failure.Therefore, it is the crux ofanti-shock and comprehensive treatment to relieve of microvessel in renal parenchyma as early as possible. The principles of treatment are follows:

(1)After injury or admission,the severely burned patients need routinely intravenous dripwith1% procaine 100ml+caffeine sodiobenzoate 0.5%+vitamin C 1.0G +25% GS 100 ～ 200ml, qd; or bid ～ tid when shock is pronounced and amounts of urine decrease significantly. The intravenous drip should be continued for the patients with anuria until urination. The routine treatment plan may maintain until wounds healing.

(2)Supplement blood volume: After massive burns, a great deal of intravascular fluid exudes toward the wound surfaceandtissue space, which lead to the reduction in effective blood volume, and then cause hypovolumic shock. Therefore, during theabovetreatment course, it should be attention must be baid to avoid massive intravenous infusion blindly without taking care of cardiac and renal functions, as well as the excretory function.

A. Amount of fluid infusion: According tothe basic principles of surgery, the amount of fluid infusion should be equal to theamount of body deficiency. In shock stage of massive burned patients(during 48 ～ 72 hours after injury ),the total amount of fluidinfusionml/day={physiological water needs (5%GS 2000 ～ 2500ml)+TBSA% (II ～ III degree)X1 (ml)X body weight(kg)} urine volume(ml)body weight(kg)/hr.

B. Compositions of fluid infusion: The ratio of crystalloid solution (normal saline or 5%GNS)to colloid solution should be 1:1,The colloid solution should be composed of 3/4part of plasma substitute can be used.

C. Speed of fluid infusion: After extensive burns, the trauma stress irritates heart, kidney andbrain tissues, and their functions are vulnerable. During the first 24 hours postburn,1/2 part of total fluid amount should be infused in first 8 hours,another 1/2 amountshould be infused in later 16 hours according to the cardiac andrenal functions. During the second 24 hours postburn, all of the fluid should be infused at a uniform speed. During the third 24 hours after injury, the amount and speed of fluid infusion must be determined strictly in the light of the symptoms of shock and the amount of urine. When the symptoms of shock are improved markedly or disappeared,and theamount of urine about 1ml.h-1.kg-1,the speed offluid infusion should be lowered down and the fluid amount should be reduced by 1/3.

(3)Nursing care in shock stage: After severely burned, the onset of shock should be related to the thermal injury, aswellas theadequate nursing care. The burned patient can hardly withstand anyattack again because of trauma stress condition of all internalorgans.Thus, the nursing care should be an important link in anti-shock treatment. A. Apply MEBO external on wound surface immediately by means of MEBT, isolate wound from contacting with air, relieve wound pains, protect wound from any irritative damage, forbid debridement. B. Apply air conditioner or bedstead and sheeting to maintain room temperature at 30 ℃ to 34 ℃ ,and prevent room temperature fromfrequent fluetuations,

C. Smoothout thebedsheet and dressing, protectwoundfrom compression, change dressing and MEBO at thepositions contacting with oppressed wound ,every 12 hours gently, keep the patient in horizontal supine position and forbid turn over. D. To control the speed of flusion, rapid fluctuation of infusion speed is forbidden.

Part II. Anti-infection Therapy

We believe that there are twopathogenic types of postburn infection. One of them is natural pathogenesis, and another is secondary type. The natural pathogenesis is similar, but differenttotheprimary infection reportedby surgical burns treatment.The former still consistsof subclinical infection,that meansthe possibilityof postburninfection isamatural reaction of burns. The secondary infection has the same concept as reported from surgical burns treatment, and consists of postburn infection caused by all exogenous sources and factors. The principles of anti-infection treatment are as follows:

1. The principled scheme of routine treatment

The burned patients withTBSA<30%shouldnot betreated with systemic anti-infection generally. All the burned patients with TBSA>30% (TBSA>10%in children)mustbe treated with systemic anti-infection routinely whatever infection routinely whatever infection happenedor not. The principe scheme is:toapply one or more powerfulbroad -spectrum antibiotics as early as possible after injury until 5th ～ 7th day for massive deep II degree burns and 7th ～ 10th day formassive III degree burns via intramuscular injection or intravenous drip ;the more extensive of TBSA anddeeperof wounds,themore powerful antibioticsand broader spectrum antimicrobials are required;stop applying al antibiotics whatever the patients are conditions promptly at the time aforementioned.

2. Expectant anti-infection treatment

(1)Principles: In order to prevent and treat secondary infection and infection happened after routine treatment, the expectant anti -infection treatment should be applied. However, it is very important to exclude noninfectious factors firstly, and itis a key todiagnose infection during the treatment of burns is complicated by inflammation and infection. The patients with fever, increase of heart rate, etc., can notbediagnosed as infection hastily andsystemic treatedwith antibiotics blindly. After postburn routine treatment, the burned body needs to regulate itself. It is just in the recoverystage of internal organs and the repair stage of wound. Thus, it should be avoided by every means to apply antibioticsblindlyand interfere with resistance function.

(2)Indications: Three clinical manifestations must happen at the same time: i.e. body temperature> 39.5 ℃ or< 36.0 ℃ ; heart rate>140/min; toxic granules in neutrophils leukocytes.Timely and careful monitoring is required. (3)Scheme: One layer doseof one or morepowerful broad -spectrum antibiotics causing no renal damage should beapplied. It could be used once again, then stopped if thetoxic granules in neutrophils disappear. Thepatients should be examined toexclude factors of secondary infection, and treated with other antibiotics if the indications of infection are not improved or even exacerbated. The inefficacy is commonly due to focuses of infection in internal organs and under the wound surface. The patients suffered from general asthenia should be submitted to fresh blood infusion toregulate internal balance. Abuseof antibiotics without indications of infection is forbidden.

Part III. BalanceRegulating TreatmentAt TheStageOf Wound Liquefaction.

After shock stage, the burned wounds enter reject stage. For deep II degree burned wound, necrotic and injured tissues start to reject from survival tissues on the 5th ～ 7th day postburn.

This reject reaction should continue until all necrotic tissue discharged. During the stage, especially the burned patients had just been resuscitated fromshock, the systems and organs suffered dysfunction should be affected readily by rejection, and thenresult in organor multiply organs failure. Therefore, the treatment in this stage is the most important, complex, difficult, during the whole course of burn treatment. Basedon our clinical experience for many years, we consider that the key tothe treatment in thisstage is to restorethesystemic activityof comprehensive balance,otherwise any single therapy will be very difficult to succeed. The therapeutic measure above-mentioned isalso called balance regulating treatment, and its scheme includes.

1. Wound drainage

During the stage of wound liquefaction, necrotic skin tissue should be liquefied from superficial to deeper layer gradually under the effect of MEBO. It is very important to clean up liquefied materials in time forsuccessfultreatment. However,there are differencesin principle between clearance ofliquefied materials andsurgical debridement. After treatment with MEBO, the changes of burned wound should be observed at any time .When MEBO on wound surface changes into white liquefied material completely, it should be wiped or dabbed with a soft dry absorbent gauze or crepe paper at once.When the necrotic skin tissues separate in pieces without liquefaction completely, it should be clipped gently from wound, and then MEBO function should be applied again in time. When liquefied materials cleared up, the patient should be feeling well, and any nocuous stimulation should be strictly prohibited. In order to ensure for correct clinical practice, there are six operative rules of this treatment, i.e. the burned wound must be no pain, no maceration, no desiccation, no liquefied materials, and no lack of MEBO.

2. Treatment of body fluid equilibrium

After extensive burns, great deals of body fluid exudetoward the wound surface and evaporate, and the body fluid should be needed to participate in each reactionof system which meets trauma stress. Therefore, it is an important procedure of comprehensive treatment to maintain body fluid equilibrium. The principles of this treatment are as follows. The amount of fluid infusion of the burned patients suffered TBSA>50% should be firstly two times of daily physiological demand. Then, the amount offluidinfusion should be increased ordecreased according to changes in urine volume and shock symptoms (the amount of peroral fluid should not be included,andcalculated togetherwith intake and output volume per day). The range of increase or decrease in fluid infusion should not begreaterthan10% of total volume.The compositions of fluid infusion and the regulations of water electrolyte balance are same in accordance withbasic principles of surgical treatment. In this treatment stage, the fluid amount of nutritional support treatment should be included in the total fluid volume. It is noticeable that the quantitative and qualitative changes of urine should be carefully observed and treated in time after fluid infusion.

3. Regulation of body temperature

During the stage of wound liquefaction, the basal metabolismrate increases significantly to adapt for enhancement of wound rejection.In addition, catabolism alsk increases to supply energy for body needs.At the same time, the burned patients show hyperpyrexia frequently because of feedback regulation disability of burned skininthermoregulatory centerand regulative imbalance of body temperature. The principles of clinical treatment are as follows; firstly, make clear thediagnosis of hyperthermia; secondly, do not misdiagnose high fever as infection, and expectant and /oretiological treatmentisapplied.The diagnostic indexes of regulative imbalance of body temperature are as follows:body temperature> 39.5 ℃ and fluctuates irregularly; mo indication of infection; no relationship between symptoms and high fever (the body temperature is high, but the patient feels as "usual"); no abnormal finding in wound. The physical ckkling should be applied (for example, to blow cold wind over wound surface in summer),as well as clearance of liquefied materials. If physical cooling produces little effect,especiallyin burned children,small dose of hormone would be applied, and take measurementto prevent hemorrhageof digestive tract ulcer.The treatment of diminishing inflammation and/or anti-infection would be applied if hormone is not very effective yet.

4. Trilogy syndrome of heart rate, respiration and body temperature

After extensive burns, heart rate>120/min, respiratory rate>30 min, and body temperature> 39.5 ℃ usually occur during the stage of wound liquefaction. The symptoms are similar to sepsis in many ways,eg., shortness of breath, vague mind, hypoxia marked, murky grey of brown of wound, etc.. It is called trilogy syndrome of heart rate,respirationand body temperature, This syndrome is often due to tiredness, mental stress and hyposomnia. Most of the patients have a history of the syndrome and are in a smooth state of before thesyndrome onset.It is considered preliminarily that the mechanism of this syndrome is myocardial strain and reaction of heart failure resulted from serious hyposomnia and are in a smooth state of before the syndrome onset.It is considered preliminarily that the mechanism of this syndrome is myocardial strain and reaction of heart failure resulted from serious hyposomnia and mental fatigue. The principle of treatment is enhancement of cardiac function immediately, and intravenous injection of lanatoside (0.2 ～ 0.4mg +25 ～ 50% GS50 ～ 100ml).Then the symptoms should disappear at once.The possibility of concurrent infection would be concerned if the treatment above -mentioned is not very effective yet, while the treatment onthe basis of fulminant sepsis should not be applied firstly. In clinical practice,many patientssuffering from this syndrome had been misdiagnosed assepsis, and treated withantibioticsand massive intravenous infusion. Thereby, the opportunity of emergency treatment had been lost, these patients died of cardiac failure, and the cause of death had been mistakenly confirmed as sepsis.

5. Protective treatment of multiple organs functions

In the stage of wound liquefaction, heart, lungs, kidneys, liver, brain, gastrointestinal tract and other organs are in the states of post-trauma stress,hypofunction and restoration.Any treatment increasing loads of organs isharmful attack again be neededto createa favorable environment of organ's recovery,then,the physiological functions of organs and resistance to complications should be restored andlasting after shock stage. The methods of creation of this environment are exactly the principles of protective treatment of multiple organs functions: A. The results and effects of all treatment schemes on internal organs in shock stage should beexamined. B. Stop applying any drug that is harmful to the functions of heart, lungs, kidneys, liver, digestive tract and other organs. C.Stop applying any drug that is detrimental to the synthesis of protein. D.Toensure for energy supplement, reduce or block catabolism. E. To apply some drugs temporarily which can protect the functions of liver, kidneys, digestive tract and other organs.

Part IV. Nutritional Support Treatment

The extensive burned patients mustbe treatedcontinuallywith nutritional support treatment with MEBT/MEBO are basically the sameas the principle of supporting treatment of traumatic surgery.However, the supplementary amounts of total energy and protein for the former are pronouncedly larger than for general traumatic patients, as wellas longer duration. In clinical practice,weconsider that it shouldbe supplemented with energy from 4th ～ 8th day after injury, with protein in the stage of repair and rehabilitation emphatically, and with both of them proportionally from 8th day to the end of wound liquefaction stage. After shock stage, taking food as early as possibleis goodfor the burned patients.Early nutrition supply through digestive tract is encouraged. The principles of treatment are as follows:

1. Daily calorie requirement of burned patient (kcal)=25Xbody weight (kg)+40X TBSA%;

2. Glucose should provide between 55% and 60% of the total calorie, fat between 20% and 30%, and protein between 15% and 20%;

3. The ratio of nitrogen to calorie should lie 1:150 ～ 200; onthe basisof supplement withtotal calorie and protein assuredly, theburned patients should take protein-rich foods and vegetables.

Part V Comprehensive Expectant Therapy

For extensive burned patients, the comprehensive treatment should involve multiple subjects and systems,e.g. cardiovascular system, respiratory system, digestive system, urogenital system,nervous system, endocrine system, etc., not only healing of local wounds,In clinical practice, there are no fixed models and schemes of comprehensive expectant treatment. The doctors must observe and analyze the changes of burned patients' conditions carefully, and work out medical scheme.