After shock stage is addressed, the burn wound enters the rejection stage.

For deep second-degree burns wounds, injured and necrotic tissue starts to be rejected from residual viable tissue at approximately the 5th day postburn. 

This rejection reaction continues until all the necrotic tissue is discharged. 

The role of the physician and nursing staff at this time is to not interfere with this natural cleansing and regenerative process.

During this stage, internal organs and many physiologic systems which had been stressed are particularly vulnerable to rejection which can then lead to single or multiple organ failure. 

Therefore, this is the most critical stage of the BRT (MEBT/MEBO) and requires extreme vigilance. 

Based on our clinical experience of many years, we consider that the key to treatment in this stage is to enhance and restore the systemic vitality and comprehensive balance, without which any monother-apy would only have a suboptimal chance of success. 

This therapeutic measure is termed ‘balance-regulating treatment’, and its protocol includes the following.

1. Wound Drainage

During the stage of wound liquefaction, as necrotic skin tissue is liquefied from the superficial to the deeper layer (under the effect of MEBO), it is very important to clean up liquefied materials prior to successive applications. Remember, there are differences between clearance of MEBT/MEBO liquefied materials and surgical de-bridement. 

After treatment with MEBO, the changes in burns wounds should be supervised continuously. When MEBO on the wound surface completely changes into a whitish liquefied material, this layer should be wiped off or cleaned with a soft dry absorbent gauze or tissue paper at once. 

When the necrotic skin tissue separates into pieces without liquefying completely, it should be cut away gently from the wound (not debridement) and then MEBO ointment should be reapplied immediately. Unlike debridement, the RBT patient typically feels no pain during the cleaning process. 

If he does, it is an indication that the cleaning is too aggressive. Any harmful tissue stimulation should be strictly prohibited. In order to ensure for correct clinical practice, there are six operative rules for this treatment, i.e. the burn wound must not hurt, there should be no fresh bleeding, no maceration, no desiccation, no liquefied materials, and no lack of applied MEBO.

2. Treatment of Body Fluid Equilibrium

After extensive burns, large amounts of body fluid exude toward the wound surface and evaporate. 

We know that this body fluid plays a vital role in systemic reactions that result from traumtic stress. Therefore, it is an important procedure of the comprehensive treatment to maintain body fluid equilibrium. 

The principles of this treatment are as follows: The amount of fluid infusion for the burns patients suffering from TBSA >50% should be initially b.i.d. in response to physiologic demand. Subsequently, the amount of fluid infusion should be modified in response to changes of urine volume and shock symptoms. 

The amount of peroral fluid should be calculated together with intake volume per day. The range of increase or decrease in fluid infusion should not be greater than 10% of total volume. The compositions of fluid infusion and the regulations of water-electrolyte balance conform with the basic principles of surgical treatment. 

In this treatment stage, the fluid amount of nutritional support treatment should be included into the total fluid volume. Note that after fluid infusion, the quantitative and qualitative changes of urine should be carefully monitored and treated prophylactically.

3. Regulation of Body Temperature

During the stage of wound liquefaction, the basal metabolism rate upregulates as an adaptive mechanism including an increase in catabolism to supply energy for regenerative needs.

At the same time, the burns patients frequently show hyperpyrexia because of an interference in feedback regulation of burned skin to the thermoregu-latory center. The clinical treatment is as follows: firstly, make the diagnosis of adaptive hyperthermia clear and, secondly, do not misdiagnose high fever as infection.

Treat accordingly. The diagnostic indexes of this regulative imbalance of body temperature are as follows: 

(1) body temperature >39.5 °C and which fluctuates irregularly suggests no indication of infection;

(2) no relationship between symptoms and high fever (body temperature is high, but the patient feels as ‘usual’) suggests no infection; 

(3) no abnormal signs in the wound suggests no localized infection. 

Rather than inappropriately relying upon the antipyretic effect of antibiotics, the physician should avail himself of simple physical cooling (for example, fanning the patient and the wound surface), as well as clearing away the liquefied materials, thereby facilitating heat release from the wound. 

If physical cooling produces little effect, especially in pediatric burns, a small dose of gluco-corticoid should be applied, being cautious to prevent hemorrhage of digestive tract ulceration.

4. Trilogy Syndrome of Heart Rate, Respiration and Body Temperature

After a massive burn and during the stage of wound liquefaction, we see an adaptive increase in heart rate of 1120/min, respiratory rate of 130/min, and body temperature of >39.5 °C. 

The symptoms are similar to sepsis in many ways, e.g. shortness of breath, confusion, marked hypoxia, and a murky gray or brown discoloration of the wound. 

This trilogy syndrome of heart rate, respiration and body temperature is often due to tiredness, mental stress and insomnia. 

Most of the patients have a history of the syndrome and are in a calm state of before the onset of the syndrome. It is considered preliminarily that the mechanism of this syndrome is myocardial strain, and that the reaction of heart failure resulted from serious insomnia and mental fatigue. 

The principle of treatment is immediate enhancement of cardiac function and intravenous injection of lanatoside C (0.2–0.4 mg in 25–50% GS 50–100 ml). If the trilogy is accurately identified, the symptoms should disappear immediately upon treatment.

The possibility of concurrent infection should be entertained if the above-mentioned treatment was not very effective. In clinical practice, many patients suffering from this trilogy syndrome are misdiagnosed with sepsis, and treated inappropriately with massive antibiotic intravenous infusion.

This is unfortunate and contraindicated as the window of opportunity for optimizing regeneration has been lost, and these patients die of cardiac failure though the cause of death would be mistakenly attributed to sepsis.

5. Protective Treatment of Multiple Organs’ Function 

In the stage of wound liquefaction, heart, lungs, kidneys, liver, brain, gastrointestinal tract and other organs are experiencing posttraumatic stress, global hypofunc-tion and setting the stage for their individualized restoration. Any treatment increasing the metabolic burden on these organs constitutes an additional stress. 

Therefore, it is necessary to create a favorable physiological environment for the organ’s recovery. 

The methods for creating this environment are exactly the principles of protective treatment of multiple organs’ functions:

(1) The consequences of all treatment protocols on internal organs in the shock stage should be re-examined.

(2) Stop applying any drug that is harmful to the healthy function of heart, lungs, kidneys, liver, digestive tract and other organs.

(3) Stop applying any drug that is detrimental to the synthesis of protein.

(4) To ensure an adequate energy supplement, reduce all factors predisposing to catabolism.