Local complications of burn disease. What to do in case of a thermal burn and how to treat it at home

Thermal burns

Description: Thermal burns are burns from flame, hot steam, hot or burning liquid, boiling water, from contact with hot objects, sunburn.

Symptoms of Thermal Burns:

The severity of a burn injury largely depends on the area and depth of tissue damage. Our country has adopted a classification of burns based on pathological changes in the damaged tissue.

First degree burns manifest as redness and swelling of the skin.

Second degree burns are characterized by the appearance of blisters filled with a clear yellowish liquid. Under the exfoliated layer of the epidermis, an exposed basal layer remains. For burns I-II; degrees, there are no morphological changes in the skin, which is how they fundamentally differ from deeper lesions.

III degree burns are divided into two types: IIIA degree burns - dermal - damage to the skin itself, but not to its entire thickness. At the same time, viable deep layers of skin or appendages (hair follicles, sweat and sebaceous glands, their excretory ducts) are preserved. With IIIB degree burns, skin necrosis occurs and a necrotic scab forms. IV degree burns are accompanied by necrosis not only of the skin, but also of deeper tissues (muscles, tendons, bones, joints).

Due to the peculiarities of treatment, it is advisable to divide burns into two groups. The first is superficial IIIA degree burns, in which only the upper layers of the skin die. They heal under the influence of conservative treatment due to epithelization from the remaining skin elements. The second group consists of deep burns - lesions of IIIB and IV degrees, which usually require surgical treatment to restore the skin.

Complications of thermal burns: Burn disease

Limited superficial burns are usually relatively mild and heal within 1 to 3 weeks without affecting the general condition of the victim. Deep burns are more severe. Damage to tissue in an area of ​​up to 10%, and in young children and elderly people up to 5% of the body surface, is accompanied by severe disturbances in the functioning of all body systems as a result of strong thermal effects. An intense flow of nerve pain impulses from a large area of ​​the burn leads to a disruption of the relationship between the processes of excitation and inhibition, and then to overstrain, exhaustion and a sharp disruption of the regulatory function of the central nervous system.

Disturbances in the central and peripheral nervous system that arise under the influence of burn injury lead to pathological reactions and morphological changes in the cardiovascular, respiratory, endocrine, immune systems, blood, kidneys, liver, and gastrointestinal tract. Victims experience disorders of all types of metabolism and redox processes, and develop burn disease with a variety of clinical manifestations, which are based on neurodystrophic processes.

In the pathogenesis of burn disease, disturbances in systemic hemodynamics and microcirculation, pronounced metabolic changes, characterized by a catabolic orientation and increased proteolysis, are of great importance.

During a burn disease, it is customary to distinguish between periods of shock, acute toxemia, septicotoxemia and recovery, or convalescence.

Burn shock is the body's response to a super-strong pain stimulus. It is based on thermal injury, leading to severe disorders of central, regional and peripheral hemodynamics with a predominant disruption of microcirculation and metabolic processes in the body of the burned person; centralization of blood circulation occurs. Prolonged painful stimulation leads to dysfunction of the central nervous system, endocrine glands and the activity of all body systems.

Hemodynamic disorders are characterized by hemoconcentration, a decrease in MOS and BCC due to plasma loss and insufficient blood supply to tissues. In victims, tissue hypoxia and acidosis occur, diuresis decreases, pronounced disturbances in water-electrolyte balance, protein, carbohydrate, fat and other types of metabolism are observed, basal metabolism sharply increases, progressive hypo and dysproteinemia develop, deficiency of vitamins C, group B, and nicotinic acid. The development of hypoproteinemia is facilitated by increased breakdown of tissue proteins and their loss through a wound due to increased permeability of capillary walls. The volume of circulating red blood cells decreases due to their destruction in damaged tissues at the time of injury, and to a greater extent as a result of pathological deposition in the capillary network due to microcirculation disorders.

Despite hemodynamic disorders, blood pressure in the first hours after injury can remain relatively high, which is explained by an increase in general peripheral resistance to blood flow, which occurs as a result of vascular spasm caused by increased activity of the sympatheticoadrenal system, as well as an increase in blood viscosity due to hemoconcentration and deterioration of its rheological properties.

Burn shock occurs with burns that cover at least 10-15% of the body surface. In children and people over 60 years of age, manifestations of burn shock can be observed with a smaller area of ​​damage.

Based on the severity and duration of the course, they distinguish between mild, severe and extremely severe burn shock.

The duration of burn shock is 24-72 hours. The criteria for exiting the state of shock and transition to the second period of burn disease are stabilization of hemodynamic parameters, restoration of blood volume, blood flow, absence of hemoconcentration, reduction of tachycardia, normalization of blood pressure and diuresis, increase in body temperature.

Diagnosis of shock is based on determining the total area of ​​burns and the so-called Frank index (IF), identifying hemodynamic disorders and renal excretory function. The total area of ​​the burn includes superficial and deep lesions. IF is the total value of superficial and deep burns, expressed in units. The Frank Index suggests that a deep burn affects a person 3 times more powerfully than a superficial burn. In this regard, 1% of a superficial burn is 1 unit. IF, and 1% deep - 3 units. IF. Concomitant damage to the respiratory tract is equivalent to 15-30 units. IF.

Burn toxemia - the second period of burn disease - occurs on the 2-3rd day after injury and lasts 7-8 days. It is characterized by the predominance of severe intoxication due to the influence on the body of toxic products coming from the affected tissues and bacterial infection, an increase in the amount of proteolysis products, disorders of the processes of utilization of skin antigens, dysfunction of proteins - inhibitors of the formation of proteolysis products and neuroendocrine regulation in the body.

Toxic substances in the blood of a burned person are detected within a few hours after the injury. However, the effect of burn toxins on the body during the period of shock is less pronounced, since during this period of burn disease there is a release of a large amount of fluid from the vascular bed and the formation of intercellular edema. Normalization or significant improvement of hemodynamics, vascular permeability and the elimination of other disorders characteristic of burn shock contribute to the return of edematous fluid and toxic products from tissues into the vascular bed, resulting in increased intoxication of the body.

During the period of burn toxemia, the volume of circulating plasma increases, but the number of red blood cells progressively decreases due to their accelerated destruction and inhibition of bone hematopoiesis. Patients develop anemia, resulting in insufficient oxygen supply to tissues.

Blood pressure during this period of burn disease is within normal limits, but in some patients there is a tendency to develop moderate hypotension. The ventilation function of the lungs worsens, shortness of breath increases, causing an increase in acid secretion, and respiratory alkalosis develops. The breakdown of protein and the excretion of nitrogen in the urine sharply increase, and a pronounced disorder of water-electrolyte balance is noted.

With burn toxemia, as a rule, there is a decrease in appetite, impaired motor function of the intestines, sleep disorders, general asthenia, and often lethargy or motor agitation with symptoms of intoxication psychosis, visual hallucinations, and loss of consciousness.

The severity of burn toxemia largely depends on the nature of tissue damage. In the presence of dry necrosis, the period of toxemia is easier. With wet necrosis, wound suppuration develops faster and the victim experiences severe intoxication, early septicemia, and gastrointestinal bleeding often occurs. They experience a significant decrease in the body's defenses, against which pneumonia most often develops, especially with burns of the respiratory tract. The end of the period of burn toxemia, as a rule, coincides with pronounced suppuration in the wound.

Burn septicotoxemia The period of septicotoxemia conventionally begins from the 10-12th day of the disease and is characterized by the development of infection, putrefactive processes in wounds and resorption into the bloodstream of microbes vegetating in them, their toxins and autolysis products of dead tissue.

In this case, staphylococcus, Pseudomonas aeruginosa and Escherichia coli, Proteus and their associations usually grow in a burn wound. The main sources of infection of a burn wound are the skin, nasopharynx, intestines, clothing of the victim, as well as nosocomial infection. Purulent inflammation develops in the wound. Necrotic tissues and their purulent melting create conditions for prolonged entry of microbes into the bloodstream, resulting in the development of bacteremia. The body's reaction to the wound process is the occurrence of purulent-resorptive fever of a remitting type, in which anemia, leukocytosis with a shift of the leukocyte formula to the left, hypo and dysproteinemia, and water-electrolyte shifts increase. Protein metabolism disorders progress, accompanied by a pronounced negative nitrogen balance, an increase in basal metabolism and a decrease in body weight. In severe cases, with a significant decrease in the body's defenses, burn sepsis occurs. If within 1 - 2 months it is possible to surgically restore the integrity of the skin, then victims with extensive burns, as a rule, develop burn exhaustion. Its essence lies in the development of severe dystrophic changes in internal organs and tissues, endocrine insufficiency, profound disruption of metabolic processes, a sharp decrease in the body's defenses and the cessation of reparative processes in the wound. Characteristic manifestations of burn exhaustion in the clinic are cachexia, bedsores, adynamia, generalized osteoporosis, disorders of the cardiovascular system, lungs, kidneys, gastrointestinal tract, liver with the development of hepatitis. The decrease in body weight can reach 20-30% of the original, i.e., before thermal injury occurs.

The period of septicotoxemia, like the previous ones, has no clear boundaries. Restoration of the skin, gradual normalization of the functions of organs and body systems, and mobility indicate the beginning of the recovery period. However, disturbances in the functioning of the heart, liver, kidneys and other organs can be observed 2-4 years after a severe burn injury.

Complications of a burn disease can occur throughout its entire course. Of particular danger is sepsis, which most often develops in patients with deep burns occupying more than 20% of the body surface. The weakening of the immune system and natural antimicrobial defense factors against the background of massive microbial invasion in patients with severe burns is one of the causes of sepsis. This is facilitated by the development of wet necrosis in the early stages after injury. Early sepsis is characterized by a severe course. The patient's condition sharply worsens, the fever becomes hectic in nature with body temperature ranges of 2-3°C throughout the day, accompanied by heavy sweat. Hyperleukocytosis and neutrophilia with a shift to the left are detected in the blood. Blood cultures usually give growth of staphylococcal microflora, often gram-negative. Patients are diagnosed with toxic hepatitis, gastrointestinal paresis, secondary renal failure with an increase in the level of residual nitrogen to 60 mmol/l or more. Cardiovascular and respiratory failure rapidly increases, pulmonary edema often develops, and death occurs within 1 to 2 days.

Generalization of infection can occur in the late period of burn disease, but the course of sepsis becomes protracted. In patients, hemorrhagic vasculitis occurs, leukocytosis increases with a shift to the left, ESR increases, young forms of neutrophils, toxic granulation, unstable bacteremia, low-grade body temperature develop, septic endocarditis develops, despite repeated blood transfusions, anemia progresses, and pneumonia develops. In this case, an unresponsive course of the wound process is revealed, necrotic tissue is poorly rejected, and the resulting granulations become thinner or disappear, epithelialization is absent, and secondary necrosis occurs.

Differential diagnosis of sepsis and purulent-resorptive fever is difficult. During fever, fluctuations in daily body temperature are less pronounced and it decreases under the influence of detoxification therapy and free skin grafting. Severe general condition, acute course of the disease, hectic body temperature, anemia, hyperleukocytosis, gastric and intestinal paresis, petechiae, metastatic purulent foci (arthritis, abscesses, phlegmon), perversion of the wound process indicate sepsis.

The most common complication of burn disease is pneumonia, which occurs in 9.4% of burn victims and much more often - in 30% or more - with deep burns occupying over 30% of the body surface. It is detected in almost every person who died in periods II and III of burn disease.

The course of burn disease worsens with hepatitis, which in our observations was noted in 5.6% of patients. The most severe is toxic hepatitis, observed in 2.3% of those burned in the acute period of burn disease. A more favorable course is observed with viral hepatitis, which is usually detected during the recovery period in patients who have undergone blood transfusions or infusions of native plasma.

Causes of Thermal Burns: Thermal burns can occur as a result of exposure to light radiation, flame, boiling water or other hot liquid, steam, hot air or hot objects.

During the initial examination of burn patients, serious complications of burns, for example, inhalation injuries, may not clearly appear. Therefore, if there is a history of indications of the possibility (according to the mechanism of injury) of a burn to the respiratory tract, one should be extremely careful when examining the patient. In the first 48 hours after a burn, hyponatremia often occurs, due in part to increased secretion of antidiuretic hormone (ADH) and hypotonic fluid. With extensive deep burns, especially circular ones, one should remember about the possibility of developing compartment syndrome. Doppler pulsometry is of relative value in this case, since pronounced compartment syndrome can exist for quite a long time before the arterial pulse begins to disappear. Almost all circular burns require eschar incisions. However, indications for fasciotomy are rare, other than electrical burns. Circumferential chest burns may also require incision of the eschar to improve respiratory mechanics, especially in young children. Of great importance for the prevention of complications is the early start of tube feeding, which helps maintain normal pH in the stomach and prevent bleeding from the upper gastrointestinal tract.

At a later date, 7-10 days after the burn, the most serious complication of the burn can be sepsis, the source of which is usually the burn wound. Severe inhalation injury and sepsis are a particularly unfavorable combination, usually leading to multiorgan failure and death. One often overlooked source of sepsis may be septic thrombophlebitis. developing in 4-5% of patients with extensive burns. Without treatment, the mortality rate for this complication approaches 100%. If septic thrombophlebitis is suspected, it is necessary to carefully examine all places where venous catheters were previously located. Aspiration of contents from these areas, unfortunately, does not help in making a diagnosis. If there is the slightest discharge in the area where the catheter is located, the vein should be opened, preferably with the use of anesthesia. If pus is obtained, the entire vein should be removed and the wound left open. In septic burn patients, it is also necessary to remember the possibility of developing sepsis associated with the constant presence of catheterization lines in the veins. Renal failure can complicate a burn as a consequence of resuscitation, inadequate measures, sepsis, or the toxic effects of myoglobin or drugs. Hypertension is a problem encountered in burns almost exclusively in childhood. It can occur immediately after a burn or after a significant period of time (up to 3 months) after complete closure of the wounds. The cause of this complication appears to be increased secretion of renin. Treatment is with furosemide (Lasix) and hydralazine (Apressin). Hypertension can be quite severe and sometimes, if untreated, leads to neurological disorders.

Once the wounds are closed, a problem can arise that is quite serious, namely, patients often scratch themselves so furiously that they tear apart donor sites and areas where grafts have been transplanted that have already healed. Unfortunately, there are no reliable effective treatments against itching from burns. Diphenhydramine and hydroxyzine (atarax) in combination with moisturizing creams and the use of pressure clothing may help to some extent. Children are prone to developing severe hypertrophic scars. The use of special pressure clothing and strict implementation of the rehabilitation program can to some extent prevent this complication.

An equally serious complication of burns is heterotopic calcification, which can be associated with overdoing it, which sometimes leads to hemorrhages into the soft tissues followed by calcification of hematomas. There are even reports in the literature about the development of malignancy of burn scars very late after injury. This complication of burns, as a rule, occurs in cases where the wounds, having closed during the healing process, reopen repeatedly or heal very poorly, slowly and for a long time.

The article was prepared and edited by: surgeon

Abstract on the topic:

"Complications of thermal And chemically x burns »

In case of deep burns, accompanied by necrosis of the entire thickness of the skin, after the rejection of necrotic tissues, defects arise, to close which it is often necessary to resort to various methods of skin grafting. Skin grafting for burns speeds up the wound healing process and provides better functional and cosmetic results. In case of extensive deep burns, skin grafting is the most important element in the complex treatment of victims. It improves the course of burn disease and often (in combination with other measures) saves the life of the burned person.

In recent years, many surgeons, immediately after the boundaries of necrosis are clearly identified, excise dead tissue under anesthesia and immediately close the wound with skin grafts. For small but deep burns (for example, from drops of molten cast iron among foundry workers), it is often possible to excise the entire burned area of ​​skin within healthy tissue and close the surgical wound with interrupted sutures. For more extensive burns, suturing the defect after excision of dead tissue, even with the addition of releasing incisions, is only occasionally possible. Excision of necrotic tissue - necrectomy - can be performed soon after the burn or at a later date, when sequestration has already begun.

Early necrectomy, usually performed 5-7 days after the burn, has significant advantages. It can be considered as an abortifacient treatment. With this method, it is possible to avoid suppuration of the wound, achieve a relatively quick recovery of the victim and obtain the best functional results. However, complete simultaneous excision of necrotic tissue in extensive burns is a very traumatic intervention, and therefore it should be used mainly in non-weakened patients in whom the dead areas to be removed do not exceed 10-15% of the body surface (Arts and Reise, A.A. Vishnevsky, M.I. Schreiber and M.I. Dolgina). Some surgeons decide to perform early necrectomies even with more extensive lesions (T. Ya. Ariev, N. E. Povstyanoy, etc.).

If early necrectomy is not possible, skin grafting must be postponed until the wound is cleared of necrotic tissue and a granulation cover appears. In these cases, during the next dressings, painless staged necrectomies are performed, accelerating the sequestration process. For the same purpose, attempts are being made to use locally proteolytic enzymes (trypsin, etc.), but the effectiveness of the latter method has not yet been sufficiently tested in the clinic.

During dressings, it is advisable to expose the burned surface to ultraviolet irradiation. When the rejection of necrotic tissue begins, irradiation is used in a small dose and gradually increased. To improve the growth and sanitization of diseased granulations, large doses of radiation (3-5 biodoses) are used. Ultraviolet irradiation is contraindicated in the presence of severe intoxication.

After cleansing the granulating surface, skin autografts are transplanted directly onto the granulations or the latter are first removed. If the granulations look healthy. then it is better not to touch them, especially with extensive burns, since this is associated with significant trauma. It has been established that with the excision of 100 si 2 of the granulation cover, the patient loses 64 ml blood, when excision of 100 cm 2 of necrotic scab is lost 76 ml blood, and when taking 100 cm 2 skin for transplantation - 40 ml blood (B.S. Vikhrev, M.Ya. Matusevich, F.I. Filatov). The nature of the microflora of a burn wound does not have a significant impact on the outcome of skin grafting (B.A. Petrov, G.D. Vilyavin, M.I. Dolgina, etc.).

For the success of skin autoplasty, good general preparation of the patient and, first of all, the fight against anemia, hypoproteinemia and hypovitaminosis C are extremely important. It is believed that if the hemoglobin content in the blood is below 50%, skin autoplasty is doomed to failure (B. N. Postnikov) . It is also very important to prepare the wound well for transplantation, that is, to achieve not only complete release of necrotic tissue, but also a good state of granulations.

Excision of a skin flap for transplantation is carried out using dermatomes of various designs. Manual dermatomes are used (from the Krasnogvardeets plant, M.V. Kolokoltsev, etc.), electric and pneumodermatomes. Using dermatomes, you can take a uniform thickness (0.3-0.7 mm) large skin flaps. With this method, large donor areas are completely epithelialized under bandages within 10-12 days and, if necessary, can be reused for skin harvesting. To cover limited areas with autografts, some surgeons still use old methods of skin grafting.

Using skin autografts it is often possible to completely close the entire skin defect in one go. With very large defects, sometimes it is necessary to close them in several stages (staged plastic surgery). Some surgeons, with limited resources of skin suitable for autoplasty, in seriously ill patients, in order to save money, cut the excised skin autograft into pieces the size of an ordinary postage stamp (approximately 4 cm 2) and transplant these pieces at some distance from each other [the so-called stamp plastic method] ; The grafts, growing, subsequently form a continuous skin cover. With the branded plastic method of small sizes, the grafts adhere well to the granulations, and in this case there is no need for additional fixation with sutures. Large grafts have to be sewn to the edges of the skin, and sometimes stitched together. After the operation, a tiled bandage is applied, which can be easily removed without damaging the grafts, and a light plaster splint is applied to the limbs. In an uncomplicated postoperative course, the first dressing is performed on the 10-12th day after transplantation, when the flaps usually have already taken root.

For extensive burns, along with autoplasty, homoplastic skin grafting is also used. Skin is transplanted from the corpses of people who died from accidental causes, or taken from living donors, including “waste” skin obtained during surgical operations. When transplanting skin obtained from another person, it is necessary, as when taking blood for transfusion, to have reliable data that the donor did not suffer from infectious diseases (syphilis, tuberculosis, malaria, etc.), as well as malignant tumors. In particular, in all cases the Wasserman reaction is required. When using cadaveric skin, these sections must be taken into account.

Skin homografts, due to immunological incompatibility, take root only temporarily (including grafts taken from the victim’s closest relatives). They usually reject or resolve within the next few days or weeks after the transplant. However, temporary engraftment of grafts often allows you to gain time to eliminate dangerous hypoproteinemia and better prepare the patient for subsequent autoplasty.

Skin homografts can be prepared for future use; for this purpose, they are preserved in various liquid media or by lyophilization. In the latter case, pieces of leather are subjected (in special devices) to freezing to -70° and simultaneous drying in a vacuum. Transplants treated in this way are then stored in special ampoules under vacuum conditions for an unlimited time. Before use, they are immersed for 2 hours to soak in a ¼% novocaine solution.

In some cases, patients with extensive burn surfaces are successfully treated with combined auto- and homoplasty. With this method, small-sized auto- and homografts are placed on the surface of granulations in a checkerboard pattern. With combined plastic surgery, homografts contribute to the revitalization of repair processes and, in particular, faster engraftment and growth of autografts. The latter, growing, can imperceptibly replace homografts before they are rejected. Homoplasty, combined plastic surgery, as well as the branded autoplasty method, are used primarily for burns of the torso and large segments of the limbs (except for the joint area).

To prevent the development of disfiguring scars, stiffness and contracture of the joints, along with the use of skin plastic surgery, various methods of physiotherapy and balneotherapy (paraffin, ozokerite applications, mud, hydrogen sulfide and other baths, galvanization, iontophoresis, massage, mechanotherapy, etc.) and therapeutic exercises.

Complications. With extensive thermal burns, various complications are often observed. Burn disease itself is the most common complication of extensive lesions. In addition, there are complications from internal organs and local complications. Changes in internal organs that occur during the first two weeks after a burn are very often reversible (I.A. Krivorotoe, A.E. Stepanov).

Changes in the kidneys during a burn are expressed in the first hours and days after injury in oliguria, and sometimes anuria. Transient false albuminuria often occurs. In subsequent periods, pyelitis, nephritis and kephrosonephritis may be observed.

Bronchitis, pneumonia, and pulmonary edema often occur with extensive burns. If the burn was accompanied by inhalation of hot vapors and fumes, then the victims experience hyperemia and pulmonary edema, small infarctions and atelectasis, as well as emphysema of individual segments. In seriously ill patients, especially with chest burns, pneumonia is often not recognized due to the inability to apply physical examination methods. Pulmonary edema occurs mainly during periods of shock and toxemia. Bronchitis and pneumonia can occur throughout the entire period of burn illness. Complications from the digestive system often accompany burn disease. Transient disturbances in the secretory and motor functions of the stomach and intestines are especially common. Sometimes acute gastric ulcers of the duodenum occur, which are a source of gastroduodenal bleeding or cause perforation (A.D. Fedorov). Acute pancreatitis occurs occasionally. Liver functions are often impaired (N.S. Molchanov, V.I. Semenova, etc.); with extensive burns, necrosis of the liver tissue is possible. Complications from the cardiovascular (toxic myocarditis, cardiovascular failure) and nervous system are also observed. Sometimes thromboembolism is observed (A.V. Zubarev), caused by changes in the dispersion of blood proteins and their composition, blood chemistry, changes in the vascular wall, the presence of infection, etc. The function of the endocrine glands is impaired.

The consequences of burns vary significantly depending on the nature and extent of the injury. A person can receive chemical, thermal, radiation, and electrical injuries of various levels.

The most common complications of burns are hypovolemia and infections. They occur with a large affected area, which is more than 35% of the total body surface.

The first symptom leads to decreased blood supply, sometimes to the appearance of a state of shock and the formation of spasms. This is a consequence of vascular damage, dehydration, and bleeding.

The infectious consequences of burns are very dangerous, because they can cause sepsis. In the first few days, gram-negative bacteria, streptococci, staphylococci most often develop; each type is a favorable environment for the growth of pathogenic microflora.

Consequences of injury depending on severity

Any injury has its own characteristics of manifestation, symptoms and possible complications of burns.

I degree

Such a wound is often caused by prolonged exposure to the scorching sun or careless handling of boiling water or steam.

This type is characterized by minor injuries, damage to the surface layer occurs, a burning sensation and dryness are felt.

In this case, after the burn, pronounced hyperemia occurs, accompanied by swelling of the skin, pain, and redness. With such a wound, complications are practically excluded, superficial damage goes away quite quickly, with proper and timely treatment.

II degree

This type is not considered very serious, but nevertheless affects the upper two layers of the epidermis. Level II burns may cause blisters to form on the skin filled with clear liquid. The injury is accompanied by swelling, red pigmentation, and hyperemia.

In this case, the victim feels a sharp pain and burning sensation. When more than 50% of the body is affected, the effects of burns are potentially life-threatening. If it affects the face, hands, groin area, or blisters appear, you should consult a doctor.

III degree

These thermal injuries are classified into two main types:

• “3A” - necrosis of soft tissues develops up to the papillary layer of the epidermis.
• “3B” - complete necrosis over the entire thickness of the skin.

These are deep injuries in which nerves and muscles die, fatty layers are affected and bone tissue is affected.

Violations of the integrity of the skin have such consequences of burns as sharp pain, the injured area becomes whitish, darkens, and chars.

The surface of the epidermis is dry, with exfoliated areas, the line of limitation of dead tissue is clearly visible already on the 8-9th day.

In this case, a large amount of fluid is released, therefore, the victim experiences dehydration. After a burn, complications can be prevented with competent drug therapy formulated by the attending physician, and you also need to drink plenty of fluids to prevent negative consequences.

Regardless of the quality of therapy, after healing of burn wounds, scars and scars remain on the affected area.

IV degree

The most severe injury to the deep layers, which is invariably accompanied by necrosis of the skin and underlying soft tissues. The lesion is characterized by complete death of the burned areas, charring, and leads to the formation of a dry scab. To prevent complications of burns and sepsis, the wound is cleaned and dead tissue is removed.

If the injury covers more than 70-80% of the skin, complications from burns can be fatal.

In case of incorrect or untimely therapy, in severe cases the following consequences may occur:

• Severe dehydration.
• Rapid breathing.
• Dizziness, fainting.
• Infection of deep lesions.
• Internal organ injuries.
• Amputation.
• Death.

Visually it is very difficult to determine burn lesions and their degree, especially in the first hours. To prevent serious consequences of burns, such injuries require urgent consultation with a doctor who will prescribe an effective treatment method.

Damage associated with exposure to high and low temperatures

A burn is tissue damage caused by heat, chemicals, penetrating radiation, or electrical current. There are thermal, chemical, radiation, and electrical burns.

Classification and clinical picture of burns

Depending on the depth of damage, burns are classified into four degrees.

1st degree– severe hyperemia and swelling of the skin, pain.

2 degree– formation of blisters filled with serous fluid.

3 A degree- necrosis of the epidermis to the papillary layer of the skin.

3 B degree– complete necrosis of the skin throughout its thickness.

4th degree– necrosis of the skin and underlying tissues.

Pathogenesis of burns. In case of burns, the flow of neuropain impulses leads to dysfunction of the central nervous system with disruption of the respiratory and vasomotor centers. As a result, vascular tone decreases, capillary permeability is impaired with plasma loss, blood thickening, hypoproteinemia, hypochloremia. Reabsorption of decomposition products into the blood leads to intoxication of the body. Later a purulent infection occurs.

In patients with severe burns, all types of metabolism are disrupted, resulting in the development of hypoproteinemia, azotemia, impaired acid-base balance, hyperkalemia, and pronounced changes in bone tissue

General manifestations depend on the extent of the damage.

Burns of up to 10% of the skin surface cause only local manifestations with a short-term reaction of the body: pain at the site of injury, increased body temperature, headache, malaise, leukocytosis in the blood.

When a burn affects up to 30% of the body area, severe and prolonged general manifestations of burn disease occur.

Local changes in burns.

For a 1st degree burn: redness and swelling.

For a 2nd degree burn- swelling, redness, hyperemia, formation of blisters with a jelly-like consistency. The contents of the bubble may gradually dissolve or leak if the bubble bursts.

With 3rd and 4th degree burns, the skin has a whitish or dark color, may be charred, dense, and painless. The surface is dry or moist with areas of exfoliated epidermis. There is hyperemia and swelling around the scab. A line of demarcation, limiting dead tissue from healthy tissue, appears on the 7-9th day.

It is not always possible to determine the degree of burn in the first hours of injury, only with careful observation.

The burns are separated to superficial 1-2 degrees and deep 3B-4 degrees. Burns of 3 A degree occupy an intermediate place, since restoration of the epithelium is possible due to the remnants of the germinal layer of the epidermis between the papillae of the dermis.

Determination of burn area. Apply the rule of palms and nines

The palm makes up 1% of the body area. Measured by the rule of nines, the entire human body is divided into ratios. Percentage of total body surface area. The calculation is as follows: head and neck 9%, upper limb 9%, lower limb 18%, anterior surface of the torso 18%, posterior surface of the torso 18%, perineum 1%.

Other methods used to determine the area of ​​the burn are Postnikov tables. A sterile transparent film is applied to the burn surface, on which the contours of the affected tissue are outlined. Then the film is removed and placed on graph paper and the area in square centimeters is calculated.

When characterizing a burn, indicate the area and degree of damage in the form of a fraction: the numerator is the percentage of the affected area, and the denominator is the degree of the burn. Additionally indicate the affected area (face, torso, hand)

Complication of burns: burn disease.

1. Period of burn shock: There are two phases: erectile and torpid. In the first phase of excitation, the central nervous system is irritated. Tachycardia is observed; blood pressure is within normal limits, or increased. In the torpid phase, the victim is inhibited, does not react to the environment, and is apathetic. The skin is pale, the facial features are pointed, the mucous membranes are cyanotic, tachycardia, the pulse is thready and cannot be counted, blood pressure is reduced.

2.Period of acute toxemia. It begins a few hours or days after the burn. Intoxication symptoms, rapid pulse, weak filling, decreased blood pressure, lethargy, lethargy, coma, cyanosis of the mucous membranes, acrocyanosis, blood thickening.

3. Period of septicotoxemia. All symptoms of sepsis are expressed: a sharp increase in temperature, exhaustion, increasing anemia, lack of surface epithelization, bedsores, pneumonia.

4.Reconvalescence period(recovery). With a favorable course, active epithelization and the formation of granulation tissue are observed after the rejection of dead areas. After extensive burns, ulcers, joint contractures, and scars may remain.

First aid

The victim is carried out of the fire zone, remove smoldering clothing. Clothes and underwear are cut. The affected limb is wrapped in a sterile towel, sheet or bandage, impose immobilization(tires, scarf). Do not lubricate the burnt surface with ointments, oil, grease, or Vaseline. Anesthesia is administered and transported on a stretcher to the burn department.

For phosphorus burns depth, extensive burn area, intoxication and liver damage. To extinguish, use a stream of cold tap water, or a 1-2% solution of copper sulfate. In wartime, special neutralizers are used in the form of anti-phosphorus bags.

Pieces of phosphorus are removed from the wound with tweezers, a bandage is applied abundantly moistened with a 2% solution of copper sulfate, a 3-5% solution of sodium bicarbonate or a 3-5% solution of potassium permanganate. Further treatment is carried out as for thermal burns. Ointment dressings are contraindicated. They promote the absorption of phosphorus into the body

Treatment of burns

1. For minor burns, treatment is carried out in an outpatient clinic or clinic.

2. Patients with severe burns should be hospitalized in specialized burn units with trained personnel, facilities and equipment to provide care. Patients are kept in the anti-shock ward until hemodynamic parameters are normalized, with an air temperature of 24 C. Treatment is carried out in the operating room, a clean dressing room. The staff dresses the same as for surgery.

3. For burns of more than 20% of the body surface, autodermoplasty is performed. Allows you to save patients with a burn area of ​​up to 50%. Treatment time after skin transplantation is reduced by 3-4 times.

5. To enhance tissue regeneration after skin transplantation, UV irradiation of wounds and ointment dressings with fish oil are used.

6. Skin care, nail care,

7. Perform pain relief, if an ambulance is available, 1% morphine 1 ml, 2 ml 1% Pantopon, fentanyl with droperidol are administered, in severe cases, therapeutic anesthesia with nitrous oxide is started. Blockades are carried out with a 0.25% solution of novocaine: circular (80 ml), for lesions of the extremities, perinephric (80 ml on each side) for burns of the body, vagosympathetic (20 ml on each side) for burns of the lumbar region.

8. Before and during transportation, if conditions exist, infusion therapy is started.

125 mg of hydrocartisone, analgin, diphenhydramine, pipolfen are administered. Heart remedies. Antitetanus serum must be administered if it was not administered during first aid. To combat shock, hemodynamic blood substitutes, albumin, plasmin, glucose, and saline are transfused. Intensive therapy is carried out within 72 hours. From 3 to 10 liters of liquid are administered per day.

9. When determining the amount of fluid, they are guided by indicators of central venous pressure, hematocrit, hemoglobin, pulse rate, and blood pressure level. On the 2nd day, the volume of injected fluid is halved. In the absence of vomiting, the patient is given the required amount of liquid by mouth: hot tea, salt-alkaline mixture (for 1 liter of water, 1 teaspoon of table salt, half a spoon of baking soda). The effect of the therapy is determined by diuresis.

10. An indwelling catheter is inserted into the bladder, and the amount of urine produced is measured every hour.

11. During the period of toxemia, treatment for wound infection, anemia, hypoproteinemia. Conducting a transfusion fresh preserved blood, blood of convalescents (persons who suffered burns), enter protein preparations (plasma, albumin, protein), glucose solutions, saline solutions, lactosol, disol.

To normalize microcirculation rheopolyglucin is administered.

12. Transfusion is carried out through the subclavian and femoral vein.

13. To prevent wound infection, antibiotics are prescribed, selected taking into account the sensitivity of the flora.

Caring for the injured

1. Change dressings daily. Treatment of a burn wound after the administration of anti-shock anesthetic substances. Circular blockade with novocaine is performed under general or local anesthesia. Healthy skin around the burn wound is treated with alcohol. The affected surface is treated with a sterile isotonic sodium chloride solution, 0.5% solution of chlorhexidine biglucanate. Remnants of the epidermis and scraps of blisters are removed. Large bubbles are cut at the base, small ones are not touched. The surface of the burn is irrigated with a warm isotonic solution of sodium chloride with penicillin, dried with sterile wipes, and sterile wipes are applied.

2. The patient is fed heavily parenterally. Those who themselves eat every 3 hours, in the first days, liquid food, high-larity, 4000 calories, at least 250 g of protein, 200 ml/day of vitamin C.

3. The patient is placed in a specially equipped clinetron bed, in which the burn surface is dried - this leads to rapid tissue regeneration. Clinetron has a bactericidal and anti-decubitus effect.

Frostbite

Frostbite is a reactive inflammation of tissue caused by exposure to low temperatures. Frostbite is observed even at a temperature of +3 C.

Causes: Restricted movements, impaired blood circulation, at an ambient temperature of 0.+3.+8 C. Frostbite easily occurs due to intoxication, impaired blood flow, tight shoes, wet clothes, prolonged immobility.

Predisposing factors: exhaustion, fatigue, vitamin deficiency, infectious diseases.

During the period of low temperature, only the color of the skin changes and sensitivity decreases. This stage is called hidden.

The degree of frostbite is determined only on days 2-7.

Based on the depth of frostbite damage, they are divided into degrees:

1st degree– the latent period is a short period of circulatory disturbance that is reversible. Pain, itching, burning of the frostbitten area, loss of sensitivity. Then there is a bluish appearance, sometimes a marbled or variegated color. After a few days, the skin takes on its normal appearance. This area becomes more sensitive to the effects of cold.

2nd degree – The latent period is long. Necrosis of the stratum corneum or superficial papillary dermis. Bubbles appear. The skin around the blisters is bluish in color and sensitivity is impaired. The changes are reversible; the germ layer of the skin is not damaged, so the normal structure of the skin is restored. When an area becomes infected, the regeneration process is delayed.

3rd degree– Necrosis affects the deep layers of the skin. The latent period lasts a long time. Bubbles form. After 5-7 days, rejection of dead tissue is observed (with signs of suppuration or under a scab). Healing proceeds through the granulation stage. Epithelization occurs gradually after the rejection of all dead tissue and ends with the formation of a scar. Nails don't grow back. Recovery time is up to 2 months.

4th degree– The latent period is long. Necrosis of all layers of tissue, muscle, bone. The skin is cold, pale, tissue cyanosis, blisters. On the 10th day, secondary blisters filled with hemorrhagic contents. Demarcation line on the 2nd day after frostbite.

Dry or wet gangrene may develop.

Frostbite of the first three degrees occurs easily, since the damage is limited only to the skin. With grade 4 frostbite, a general reaction of the body is observed.

General exposure to cold. Chills. Occurs with reduced resistance to the cold factor or with repeated mild frostbite, exposure to moderately low temperatures. Localization is often face, ears, hands, fingers, feet. Occurs in young people.

Signs: goose bumps, burning, itching, swelling, soreness, purple skin with red-blue spots. More often occurs during prolonged exposure to cold air.

Treatment of frostbite.

First aid. Bring the victim into a warm room, warm the limbs and restore blood circulation. Warming begins in a general and local bath, the water temperature in 20 minutes from 22 to 40 C. At the same time, massage the limbs from the periphery to the center. The massage is continued until the area warms and the skin turns pink. Wipe the affected areas with alcohol and cover with a dry aseptic bandage wrapped in a layer of cotton wool. The limbs are given an elevated position. A circular novocaine blockade is performed according to Vishnevsky, and anti-tetanus serum is administered. In the first days, carry out anticoagulation therapy with heparin (intravenously, intramuscularly). To improve microcirculation, rheopolyglucin is transfused, intra-arterial novocaine with antibiotics.

For frostbite 1st degree: UHF, UFO.

2 degrees– treating the skin with alcohol, do not open blisters on the hands because the blisters are durable, covered with epidermis and do not open and can be dispensed with without a bandage. In other cases, bandages are applied for 7 days.

3rd degree- blisters are removed and aseptic dressings are applied. If a suppurative process has developed, bandages with a hypertonic solution are applied. After granulation appears, bandages with Vishnevsky ointment, antibiotics, and sulfonamides. The scab is not removed, it is rejected on its own

At 4 degrees– necrotomy, dissection of dead areas, which allows limiting the development of dry and wet gangrene. The final operation is amputation of the limb within healthy tissue. Treatment of the surgical wound is carried out using the open method or under ointment dressings.

Burns

A burn is tissue damage caused by local exposure to heat, chemicals or radiation energy.

The severity of the patient’s condition depends on the area of ​​the burn and its depth. With extensive burns (more than 10% of the body), pronounced general phenomena in the body often develop. These general disorders in the body caused by a burn are called burn disease.

Skin and subcutaneous fatty tissue have low thermal conductivity, but the temperature threshold for tissue viability is low (about 45-50*C). Heating tissues above this temperature leads to their death.

The depth and extent of the burn wound depends on:

1) on the temperature level and type of thermal agent;

2) duration of exposure;

3) the state of sensitive innervation of a body area.

In peacetime conditions, burns are produced industrial and household, in war conditions - combat.

Burns from boiling water are usually superficial; burns from steam are shallow, but usually extensive. Flame burns occur during fires and explosions. More often the face and hands are affected. Molten metal burns are limited and deep.

There are 4 degrees of burn:

1st degree - skin hyperemia (erythema),

2nd degree - formation of bubbles,

3 (a) degree - necrosis of the superficial layers of the skin,

3 (b) degree - necrosis of all layers of skin,

4th degree - necrosis of tissues located under the skin, charring.

At burns I degree an aseptic inflammatory process develops. Leads to dilation of skin capillaries, hyperemia and moderate swelling of the burned area, resulting from the sweating of plasma into the thickness of the skin. All these phenomena disappear within 3-6 days. In the area of ​​the burn, the epidermis peels off, and sometimes skin pigmentation remains. These burns appear as pronounced redness and are accompanied by severe, burning pain.

For II degree burns characterized by deeper skin damage, but with preservation of the papillary layer. A significant expansion of the capillaries, combined with an increase in the permeability of their walls, leads to profuse sweating of plasma. With second degree burns, the epidermis peels off and blisters form. Some blisters appear soon after the burn, others appear after several hours and even a day. The contents of the bladder are initially transparent, then due to the loss of fibrin it becomes cloudy. With secondary infection, the fluid becomes purulent.

In uncomplicated second degree burns, the epidermis regenerates within 7-14 days without scarring.

With third- and fourth-degree burns, the phenomena of tissue necrosis, which arise as a result of the coagulating effect of high temperature on the protein of cells and tissues, come to the fore.

At burn 3 (a) degree necrosis partially affects the papillary layer of skin. At the same time, against the background of hyperemic skin and blisters, there are areas of superficial necrosis. Since the germ layer is preserved, complete restoration of the skin is possible without scarring.

For burn 3 (b) characterized by necrosis of all layers of the skin. The proteins of tissue cells coagulate and a dense scab forms. Due to the death of the germ layer of the skin, healing occurs by secondary intention. Granulation tissue forms at the site of damage, which is replaced by connective tissue to form a scar.

Burn 4 degrees occurs during prolonged exposure of tissue, usually to flame. This is the most severe form of burn - charring, in which subcutaneous fatty tissue dies, muscles, tendons and even bones are often damaged. In these cases, the affected areas are dense to the touch (scab), acquire a dark or marbled color, and lose tactile and pain sensitivity (the patient does not respond to injections). With deep burns, a suppurative process often develops, accompanied by rejection and melting of necrosis and ending with the formation of rough scars prone to ulceration.

The location of burn wounds is important, since the thickness of the skin in different areas is different, there are differences in innervation and blood supply. Thus, facial burns are accompanied by severe swelling. However, with superficial burns, swelling of the face disappears by the 3-4th day, and with deep burns it can spread to the neck, chest and lasts a long time. With deep burns of the face, granulating wounds develop, after healing of which tightening scars remain, deforming the mouth, eyelids, and wings of the nose.

With extensive burns of the limbs, especially deep ones, due to immobilization, muscle atrophy quickly increases, joint contractures develop, which arise due to tightening scars, i.e. true contractures, but can be a consequence of fear of moving the limb, i.e. reflex.

The severity of the patient's condition depends more on the depth than on the area of ​​the burn. For example, superficial burns with an area of ​​80% are usually not a cause of death, while a deep burn of 20% of the body area can be fatal.

Determination of the area of ​​burns. Due to the obvious importance for prognosis and rational treatment of the size of the area of ​​burn wounds, as well as the degree of their spread in depth, there was a need for an objective assessment of the area and depth of the lesion.

The scheme was proposed by B. N. Postnikov (1957). The average value of the total surface of the body is taken in his table to be 16000 cm 2. The table contains columns by which you can quickly determine the percentage of the ratio of the burn area to the total body surface and the area of ​​each body area to the total body surface.

If the burns do not completely occupy any part of the body, but are located in separate areas, then the area is measured by applying sterile cellophane to them and tracing the contours with ink.

Cellophane is placed on graph paper and the area in square centimeters is calculated, the percentage of the ratio of the burn to the total surface of the body is found using the Postnikov table.

There are also relatively accurate methods.

1. You can measure the area of ​​the burn with your palm; its area is about 1-1.5% of the total surface of the skin. Measuring with the palm of your hand is convenient for minor burns or subtotal lesions; in the latter case, the area of ​​unaffected areas of the skin is determined.

2. Measuring the burn area using the rule of nines is based on dividing the entire skin area into parts that are multiples of nine. According to this rule, the surface of the head and neck constitutes about 9% of the body surface; surface of the upper extremities - 9% each; anterior and posterior surfaces of the body (chest, abdomen) - 18% each; surface of the lower extremities - 18% each; perineum and external genitalia - 1%.

A 1st degree burn is easy to recognize, but distinguishing between 2nd and 3rd degree burns is not always easy. In these cases, the “alcohol test” helps to determine the depth of the burn. Remove the bubble and touch the tissue with an alcohol ball. If the patient experiences sharp pain, then the burn is superficial, and if there is no sensitivity, then the necrosis is relatively deep, but it is difficult to determine its depth

Under all conditions, accurate diagnosis of the depth of the lesion is possible only on the 7th to 14th day after the injury.

Clinical picture of burn disease. As is already known, the severity of the affected person’s condition depends on the depth and area of ​​the lesion.

In this regard, there is a division of burns into

extensive non-extensive.

Minor burns cause only a transient general reaction - increased body temperature, headache, leukocytosis, etc., and are therefore considered primarily as local suffering.

With extensive lesions, severe and long-term disturbances in the general condition of the body are naturally observed - burn disease, during which periods are distinguished

Burn shock

Burn toxemia,

Septicotoxemia,

Convalescence.

O R O G SHOCK is a type of traumatic shock. It develops in response to a super-strong pain stimulus.

During burn shock there are phases:

short-term erectile long-term torpid

During the erectile phase, patients groan, complain of sharp pain, and are sometimes euphoric. Consciousness is clear. The patient shudders, and muscle tremors are sometimes pronounced. The erectile phase lasts 1 - 1.5 hours, i.e. longer than with mechanical injuries.

In the torpid phase of shock, the phenomena of inhibition come to the fore. Patients are apathetic, indifferent to their surroundings, and have no complaints. Body temperature is low, the skin is pale, facial features are sharpened. The pulse is frequent, weak filling. Breathing is frequent and shallow. A. pressure is reduced. There may be vomiting.

The occurrence of shock and its severity depend not only on the severity of the lesion (the area of ​​deep burns), but also on the individual characteristics of the body and its reactivity.

Burn shock can last from several hours to 2-3 days, and then imperceptibly passes into a period of toxemia. However, in some cases, the period of shock in victims is not clearly expressed and the burn disease begins directly with the phenomena of toxemia.

Burn toxemia determines the further condition of the victim after recovery from shock. The absorption of tissue breakdown products and toxins from the burn area plays a role in the development of toxemia.

The period of toxemia occurs against the background of high body temperature. Patients are lethargic, inhibited, have difficulty making contact, and sometimes become agitated. In severe cases, there is delirium, muscle twitching, and coma. Breathing is shallow, pulse is weak and frequent. Nausea, vomiting, and stool retention are noted.

The duration of toxemia depends on the severity of the lesion and the condition of the victim’s body. With significant burns, it lasts 10-15 days and, with the development of infection, can develop into septicotoxemia.

Fever (burn infection) in seriously ill patients can last up to 2 months.

Third period burn disease - exhaustion. Characteristic signs of the third period are non-healing burn wounds, progressive cachexia, bedsores, adynamia, and apathy. Bedsores are most severe during the 4th-6th month of illness. Their usual localization is the sacrum, calcaneal tuberosities, but they can be above the iliac spines, on the shoulder blades.

Rational conservative therapy and timely surgery can avoid the development of exhaustion, so period III is more correctly considered a complication of burn disease.

IN period of convalescence and necrotic tissue is completely rejected. Wound defects granulate, the granulations are healthy and pink. The processes of epithelization and scarring are clearly visible. The suppurative process stops. Body temperature normalizes, protein metabolism is restored, blood counts improve, and body weight increases.

It must be remembered that in case of deep burns,
Psychosis is rarely observed, more often on the 4-6th day after
le trauma. Caring for acutely ill patients
mental arousal is difficult. They can...
struggle to get out of bed, run, rip off bandages, everything
this requires not only drug therapy, but
and careful observation. You should remember
complications from internal organs and places -
complications.

Changes in internal organs develop within the first two weeks after the burn. Complications from the gastrointestinal tract are common. The motor and secretory functions of the stomach and intestines suffer. Sometimes acute gastroduodenal ulcers appear, which may be accompanied by bleeding.

Functional dysfunctions such as toxic nephritis and holomerulonephritis are often observed, especially in the first period of burn disease, which is characterized by the development of oliguria. Therefore, careful monitoring of urine output in patients with burn disease is important.

Sometimes with extensive burns, various pulmonary disorders can develop: bronchitis, pneumonia, pulmonary edema. Such complications are especially common in victims whose burns were caused by inhalation of hot vapors and smoke. In later periods of burn disease, respiratory complications arise due to general intoxication. Complications from the cardiovascular system (toxic myocarditis, cardiovascular failure) may develop.

Local complications include various purulent lesions of the skin and subcutaneous fatty tissue around burn wounds (pyoderma, boils, abscesses, phlegmon, etc.)

First aid should be aimed at removing the victim from the high temperature zone and extinguishing clothing. The burn surface is covered with an aseptic bandage. Clothing from affected areas should be cut, not removed. Do not remove any remaining clothing stuck to the skin. The primary dressing should protect against additional damage and germs. The dressing should not contain oils or dyes (diamond green, potassium permanganate), as this subsequently complicates the diagnosis of the depth of the lesion.

When providing first aid, medical workers administer 1 ml of a 1% solution of morphine, omnopon and other drugs to the victims and evacuate the patients to the hospital.

Treatment of burns. It is necessary to treat not only burn wounds, but also burn disease. Rational treatment of those burned during all periods of burn disease should be gentle, that is, the least traumatic, since the affected person can hardly tolerate additional trauma. The patient should be placed in a room with an air temperature of 22-24 ° C. All victims are administered anti-tetanus serum. Conduct anti-shock treatments. A bilateral novocaine lumbar perinephric blockade is carried out, for burns of the limb - a novocaine circular blockade (case), and a vagosympathetic blockade of the chest.

Novocaine blockades have a beneficial effect on the reflex-trophic function of the nervous system, reduce capillary permeability, which leads to a decrease in edema. This allows you to reduce the amount of administered fluids to 3-4 liters per day. A transfusion of whole blood, plasma polyglucin, and a 0.25% novocaine solution is performed, intravenous painkillers are prescribed, and oxygen is inhaled.

Infection prevention begins from the first days. Antibiotics are used topically and administered orally or intramuscularly. In the following days, they fight against intoxication and anemia. Transfusions include blood of the same group, plasma, protein, albumin, and 5% glucose solution. Diphenhydramine and other antihistamines are used. Drinking plenty of fluids is beneficial, but with constant monitoring of diuresis. Cardiac medications and vitamins are prescribed.

The diet should be rich in vitamins, fruits, juices, and proteins. Breathing exercises are important. You should cleanse your intestines regularly.

Local treatment. Burn wounds are entry points for infection. Therefore, it is understandable that surgeons want to reduce the risk of primary infection and, if possible, avoid secondary infection of burn wounds.

Primary treatment of a burn consists of wiping the burn circumference with a 0.5% solution of ammonia and antiseptic solutions. Then a bandage with 0.25-0.5% novocaine solution is applied to the burn surface for 5-10 minutes to relieve pain. After this, the blisters and exfoliated epidermis are removed and then the entire burn surface is irrigated with antiseptic solutions. It should be remembered that when treating a burn surface, it is very important to observe asepsis.

For deep burns, mechanical cleaning of wounds does not prevent the spread of infection. In these cases, only early excision of necrotic tissue plays a role.

This method of treating burn wounds is also possible: after removing the top layers of the bandage, the burned person is placed in a bath with a warm, weak solution of potassium permanganate. The bandages can be easily removed in the bath. For minor burns, a local bath is performed. After this, the skin around the burn is wiped with 0.5% ammonia and then with ethyl alcohol. Scraps of the epidermis are cut off. Large bubbles are caught, but small and medium ones are left alone. Then the surface is irrigated with a warm isotonic solution of sodium chloride or 0.25-0.5% solution of novocaine (for pain) and carefully dried with gauze wipes.

Subsequent treatment is carried out using an open or closed method, i.e. under bandages. The most common dressings are with balsamic liniment according to A.V. Vishnevsky (Vishnevsky ointment), syntomycin emulsion, fish oil, levomikol, 5% dioxidine ointment, paraffin dressings. Sometimes burned surfaces are covered with fibrin films.

For a second degree burn, the first bandage is often the last, i.e., it is removed on the 8-12th day, when epithelization of the burn surface has already occurred. For severe burns, dressings are done under anesthesia.

In case of deep burns, after necrosis is rejected, defects arise, to close which it is necessary to resort to skin grafting. Plastic surgery speeds up wound healing, resulting in better cosmetic and functional results. Early necrectomy is important, 5-7 days after the burn, when the boundaries of necrosis are revealed. For small but deep burns, it is often possible to immediately excise the entire area within healthy tissue and apply sutures. If early necrectomy is not possible, plastic surgery must be postponed until the wound is cleared of necrosis and granulation appears. In such cases, staged necrectomies are performed during dressings.

To prevent the development of disfiguring scars, stiffness and contractures, various methods of physiotherapy (paraffin, ozokerite applications, iontophoresis, massage) and therapeutic exercises are important, especially in the convalescence stage.

Chemical burns arise from the action of strong acids, caustic alkalis, soluble salts, and some heavy metals on tissue. Unlike thermal chemical burns, they often occur on the mucous membranes of the gastrointestinal tract, etc.

A feature of chemical burns is that they are formed during prolonged exposure to a damaging agent, which allows for the successful use of neutralizing substances that can prevent or reduce its damaging effect.

Chemical burns are classified by degree, just like thermal burns. However, determining the depth of the lesion is difficult and sometimes requires many days for an accurate diagnosis, since the clinical manifestations of the burn are scanty, and the process of tissue cleansing and regeneration is characterized by a slow development. Shock and toxemia almost never occur with chemical burns. As burns heal, rough scars form.

First aid for chemical burns is to immediately wash the affected surface with water. After this, the acid residues are neutralized with a 2% solution of sodium bicarbonate, and the alkali with a 2% solution of acetic or citric acid. Further treatment of chemical skin burns is the same as for thermal burns. With chemical burns of internal organs, their degree of localization, etc. is important. The esophagus and stomach are especially often affected, and surgical treatment is often required. Thermal lesions.

I. Thermal burns. This is tissue damage as a result of high temperature.

Thermal burns occur in various emergency situations, fires, explosions. Burns are accompanied by severe pain, patients groan, rush about, and ask for help. Skin burns are often accompanied by burns of the respiratory tract, carbon monoxide poisoning and other combustion products.

Depending on the depth of damage, there are 4 degrees of burns:

I degree– the upper layers of the epidermis are damaged. Hyperemia, swelling, and soreness of the skin are determined.

II degree– deeper damage to the epidermis. Bubbles with serous contents form.

III A degree– necrosis of the upper layers of the dermis occurs, preserving the germ layer and partially the skin glands. Clinically manifested by the presence of a skin surface without epithelium or blisters with hemorrhagic contents.

III B degree– total necrosis of the skin to the subcutaneous tissue occurs. Clinically, a thick black-brown necrotic scab is determined.

IV degree– death of the skin and underlying tissues occurs: muscles, tendons, bones. Carbonization of tissue occurs.

Burns of I, II, III A degrees are classified as superficial burns, since the germ layer of the skin is preserved and independent epithelization of the burn surface is possible. Burns of III B, IV degrees are considered deep burns, since the death of the germ layer of the skin occurs; restoration of the integrity of the skin is possible only surgically, through autodermoplasty (skin grafting).

For thermal burns, determining the affected area is important. The affected area is determined by the rules of “nines” and “palms”. The surface of the human body is taken as 100%, the head and neck make up 9%, each upper limb - 9%, the front surface of the body - 18%, the back surface of the body - 18%, each lower limb 18% (thigh - 9%, lower leg and foot – 9%), perineum – 1%.

When determining the area of ​​a burn using the “palm” rule, a person’s palm is taken as 1% of the surface of the person’s body.

With deep burns of 9-10%, or superficial burns of 15-20% of the surface of the human body, burn shock develops.

When a significant surface of the human body is burned, burn disease develops.

Burn disease.

During a burn disease there are 4 periods:

The first period is burn shock. It is the result of the body’s general reaction to a super-strong pain stimulus, massive plasma loss and blood thickening. Burn shock can last up to 2 days or more, and the erectile and torpid phases of shock are clearly defined. The following signs are characteristic of burn shock:

During the erectile shock phase, patients experience severe pain, they are excited, tossing about, moaning, complaining of thirst, chills, and vomiting. During the torpid phase, patients are inhibited and fall into a drowsy state.

The skin outside the lesion is pale, with a marbled tint, cold to the touch, body temperature is reduced, acrocyanosis.

Characterized by tachycardia and decreased pulse filling, shortness of breath.

Urine becomes rich, dark, brown in color, and sometimes has a burning smell.

The most reliable criterion for assessing the severity of burn shock is the amount of hourly diuresis. The level of blood pressure and pulse rate during burn shock are not very informative and can lead to an incorrect assessment of the severity of the patient’s condition. When conducting infusion therapy, hourly diuresis is also taken into account. The adequacy of infusion therapy is indicated if the hourly diuresis is 30–50 ml.

For early diagnosis of burn shock, it is necessary to determine the area and depth of the lesion. The occurrence of shock is influenced by many factors, in particular, a burn to the respiratory tract. When a burn of the skin and the respiratory tract is combined, burn shock can develop with a lesion area half as large as without a burn of the respiratory tract. With burns of the respiratory tract, the victim has hyperemia of the tongue, oral cavity, singed hair in the nose, hoarseness, shortness of breath, cyanosis, pain in the chest when breathing, difficulty breathing. Poisoning by carbon monoxide and other combustion products is also possible, in which case mixed shock develops. There are 3 degrees of severity of burn shock: I, II, III degrees. To determine the severity of shock, the Frank index is calculated. Each percentage of a superficial burn is equivalent to 1 franc unit, a deep burn is equivalent to 3 franc units. Respiratory tract burns are equivalent to 10% of deep burns.

I degree (mild) – Frank index 30-70 units.

II degree (severe) – Frank index 71-130 units.

III degree (extremely severe) – Frank index more than 130 units.

The second period is acute burn toxemia. During this period, plasma loss and poisoning of the body with tissue decay products predominate. It begins with an increase in body temperature. Can last up to 4-12 days. There are all the signs of intoxication: lack of appetite, nausea, vomiting, headaches, chills.

The third period is burn septicotoxemia. It develops due to suppuration of burned tissues and a violation of natural immunity. This period is characterized by all the signs characteristic of sepsis: high body temperature of the hectic type, chills. In the blood - anemia, hypoproteinemia, high ESR, leukocytosis with a shift to the left. Burn exhaustion and damage to internal organs are observed. Various complications may occur: pneumonia, hepatitis, ulceration of the mucous membranes of the gastrointestinal tract, and sepsis may develop. Septicotoxemia - when there are toxins of microorganisms in the blood, but the microorganisms themselves are not sown from the blood; in sepsis there is bacteremia, that is, microorganisms are sown from the blood.

The fourth period is recovery. It is characterized by the gradual disappearance of intoxication symptoms, normalization of body temperature, and improvement in general condition. Blood counts are normalized and healing of burn surfaces is accelerated.

People who have suffered burns develop specific antibodies in their blood.

Emergency care for burns:

1. Extinguish burning clothes: you can use water, tear off the burning clothes from the victim, throw a thick cape over him and press the burning places with your hands, the victim cannot run, you need to lie on the ground and press the burning places to the ground. Do not extinguish with a fire extinguisher, as the fire extinguisher contains acid; additional acid burns may occur.

2. Short-term cooling of the burn surface for 10-15 minutes is useful. For minor burns, you can cool it under running cold water. For deep burns, after applying a sterile bandage, you can cool with ice packs, snow placed in plastic bags, or a heating pad filled with cold water. Cooling prevents the deepening of necrosis and has an analgesic effect.

3. In the warm season, bandages with antiseptics and novocaine should be applied to the burned surface; in the cold season, a dry sterile bandage should be applied. If available, bandages with anti-burn wipes are applied. At the prehospital stage, ointment dressings are not recommended, and burn blisters should not be opened. For burns on large surfaces of the body, wrap the victims in clean sheets.

4. Anti-shock therapy should begin at the scene of the incident and continue during transport to the hospital. To reduce pain, painkillers are administered: analgin 50% solution 2-4 ml, promedol 1% solution 1 ml, omnopon 1-2% solution 1 ml intravenously. Antihistamines are administered: 1% solution of diphenhydramine 1-2 ml, 2.5% solution of pipolfen 1-2 ml intravenously, intramuscularly. In case of extensive burns, it is necessary to immediately begin infusion therapy: polyglucin, 5% glucose solution 400-800 ml are administered with the addition of 1 ml of 0.06% solution of corglycone, hydrocortisone 50-125 mg, or prednisolone 30-90 mg, sodium gyrocarbonate 4% solution 200 is introduced ml, osmotic diuretics are prescribed - 200-400 ml of 15% mannitol solution to prevent acute renal failure.

5. For burns of the respiratory tract and when there is a threat of developing pulmonary edema, aminophylline 2.4% solution 10 ml intravenously, furasemide 40-60 mg, cardiac glycosides (corglycone, strophanthin), calcium chloride, etc. are prescribed.

6. For burns of the extremities, transport immobilization is applied.

7. If there is no excessive vomiting, a drink is prescribed: warm tea, salt-alkaline solution (for 1 liter of water, 1 teaspoon of salt and 1 teaspoon of soda).

Frostbite.

Frostbite is tissue damage due to prolonged exposure to low temperatures.

Frostbite is caused by low air temperature, damp clothing, wind, tight and wet shoes, overwork, anemia, shock, vascular disease, and alcohol intoxication.

In most cases, peripheral parts of the human body are affected by frostbite: ears, nose, feet, etc.

In the frostbite clinic, there are 2 periods: pre-reactive and reactive.

Pre-reactive period– from the moment of receiving a cold injury until the start of warming up. It is characterized by numbness, itching, tingling, burning, stiffness of the limbs, patients do not feel the ground, sometimes severe aching pain occurs in the calf muscles, feet, and frostbite of the lower extremities. The skin is marbled, cyanotic gray. Tactile sensitivity is reduced or absent.

Jet period– develops after warming. Victims experience stabbing and burning pain in the affected areas, aching joints, sometimes unbearable itching, a feeling of swelling, and paresthesia. Objective changes depend on the depth of the lesion. Depending on the depth of the lesion, there are 4 degrees of frostbite:

I degree– in the pre-reactive period, the skin is pale and lacks sensitivity. When warming up (reactive period), a burning sensation, pain, paresthesia appears, the skin becomes cyanotic-red, swollen, and painful.

II degree– when warming up, blisters with transparent contents appear on the swollen, pale-cyanotic skin, and intense pain occurs. Bubbles usually appear within the first 2 days, but can sometimes appear later. Healing occurs without the formation of scar tissue.

III degree– necrosis of the skin and subcutaneous tissue develops. Sensitivity is lost, the tissues are purplish-bluish in color, and blisters with dark hemorrhagic contents appear. The development of the pathological process goes through 3 stages: the stage of necrosis and blisters, the stage of rejection of necrotic tissue, the stage of epithelization and scarring.

IV degree– total necrosis of all layers of soft tissue and bones occurs. When warmed, blisters with hemorrhagic contents appear on pale cyanotic skin. If the bubbles break, the contents of the bubbles have an unpleasant odor. The depth of the lesion can be determined only after the appearance of a demarcation line (a dark stripe at the border of living and dead tissue), which appears in the second week after frostbite (on average 12 days).

Emergency care for frostbite:

1. Take the victim into a warm room and undress.

2. If clothes and shoes are frozen to the body, they must be removed very carefully so as not to cause mechanical damage to the frostbitten areas of the body.

3. If a shallow degree of frostbite is expected, you can first perform a light massage, rubbing, then treat 70 0 alcohol.

4. For deeper lesions, treat frostbitten areas of the body with alcohol or another antiseptic, wipe carefully dry and apply a heat-insulating bandage: a layer of gauze, then a thick layer of cotton wool or wrap in a blanket or clothing.

5. In a hospital setting, unforced warming can be carried out in a weak solution of manganese, starting at a temperature of 18 0 , bring to 35 0 in 20-30 minutes. If pain appears when warming up, and then the pain quickly disappears, this is a good prognostic sign, the depth of frostbite is grade I-II. If, when warming up, pain occurs and does not disappear, the affected limb remains pale and cold, then this indicates that there is frostbite of the III-IV degree. After warming up in a hospital setting, bandages with Vishnevsky ointment or Vaseline are applied.

6. When providing emergency care, you need to give the patient a hot drink, alcohol - 40% alcohol 50-100 ml, administer painkillers - analgin 50% solution 2-4 ml, promedol 1% solution 1 ml, omnopon 1-2 % solution 1 ml, baralgin 5 ml IM, etc. 40% glucose solution 20-40 ml is administered intravenously, warmed to 37 0 form, a 5% solution of ascorbic acid 5 ml, a 1% solution of nicotinic acid 1 ml are also introduced. You can administer 2% solution of papaverine 2 ml or no-shpu 2 ml intramuscularly, aminophylline 2.4% solution 10-20 ml intravenously, droperidol 0.5% solution 2 ml intravenously, 1% diphenhydramine solution 1-2 ml, 2.5% pipolfen solution 1-2 ml, novocaine 0.25% IV solution 10 ml.

7. At the hospital stage, a complex of conservative and surgical treatment methods is carried out: anticoagulants, disaggregants, inhibitors of biologically active substances, desensitizing substances, immunomodulators, transfusion therapy, antibiotics, and physiotherapy are used. In order to relieve vascular spasm and improve microcirculation in the pre-reactive period, it is recommended to administer a mixture consisting of 10 ml of 0.25% novocaine solution, 2 ml of 2% papaverine solution, 2 ml of 1% nicotinic acid solution, 10,000 units of heparin on a 0.5% glucose solution intravenously. Surgical treatment involves removing dead tissue.

8. Only degree I frostbite is treated outpatiently; deeper lesions are treated in the hospital.

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