The most severe burn. Skin burns - Characteristics of burns, Diagnosis, Emergency care
Burns are certain types of injuries resulting from external influences. They can be thermal, chemical, radiation, electrical. There are also different degrees of burns depending on the severity of the injury.
Classification of burns
There are two generally accepted classifications. The division is carried out depending on the impact that caused the damage. Burns are also divided into degrees of burns, depending on the severity and depth of damage to the skin and soft tissues.
Thermal
This type is the most common among such injuries. Exposure to heat from solids, liquids or steam accounts for approximately 94% of all such injuries.
Most often, people receive such injuries at home. About half of cases occur as a result of contact with an open flame.
Rest- due to the interaction of body surfaces with hot liquids, steam, and hot solid objects. A 2nd or 3rd degree thermal burn that covers one third of the body area can lead to death.
When thermal burns occur, the severity of the burns depends on several factors. The temperature of exposure matters.
Temperatures above 45 degrees are dangerous. As this indicator increases, the damage worsens. The thermal conductivity of the substance causing the effect also plays an important role. For example, while in a bathhouse, some people like to set the air temperature to 90 degrees or higher, and no injuries occur.
Gaseous substances have much lower thermal conductivity than liquids and solids. Exposure to water at a temperature of 90 degrees will definitely lead to burns. In addition, the duration of exposure to the traumatic factor plays an important role.
Electric
Such damage is called electrical injury. They can occur at home or at work due to equipment malfunction or neglect of safety rules. They are characterized by several features. The current penetrates inside the body, damaging not only the superficial layers of the skin.
In addition, you can be burned by electricity from a distance, without contact with the source. With such injuries, the severity of the damage depends on the thickness of the skin and its moisture content. Do not touch electrical appliances with wet hands, even if they are working properly.
Electrical injuries are often painless due to the destruction of nerve endings. If clothing catches fire, electrical injury can be combined with thermal burn. Also, people often suffer mechanical injuries as a result of falling after an electric shock.
These include fractures, head injuries, abrasions and scratches. Such lesions are rarely mild.
Chemical
These types of injuries occur as a result of exposure to certain chemical compounds. These include acids, alkalis,...
Most often, such injuries are suffered by workers in laboratories or specific industries, but this can also happen in domestic conditions.
The most severe burns are those caused by exposure to alkali. Such injuries have characteristic signs: they take a long time to heal, penetrate deeply, sometimes affecting internal organs.
Ray
These types of injuries occur under the influence of radiation. Their features and stages depend on the dosage, as well as the type of radiation beam.
This rarest type of burns can occur in an accident at a specific production facility involving radiation, during radiography and radiotherapy.
Severity of damage. Degrees of burns
There are several degrees of burns depending on the severity of the injury, there are four in total. Classification by degree allows doctors to predict the development of the situation. It also matters what percentage of the total area of the human body is damaged.
The classification is based on determining the required volume of therapeutic measures, as well as the possibility of tissue regeneration without surgical intervention.
First degree
Each of us has received a first-degree burn more than once throughout our lives.
The first degree of thermal burn is characterized by slight redness, an unpleasant burning sensation, and mild swelling. This type of injury goes away in a couple of days. If you burn yourself at home, you can simply apply cool running water to the damaged area of the skin. This will relieve inflammation and pain.
When the 1st degree of thermal burn is observed, the skin damage is minimal, only the upper layers of the epidermis are affected. Even under normal conditions, they constantly die off; this is the most common physiological process.
First-degree burns do not require special treatment; they pass quickly and completely without a trace. In most cases, they have a small affected area.
Widespread superficial damage is extremely rare. If this happens, then most often a 1st degree burn is combined with deeper lesions.
Second degree
With a second degree burn, more significant damage to the skin is observed. The traumatic effect leads to the formation of blisters filled with fluid. Sometimes they appear after some time. Such lesions have a very favorable prognosis and pass without leaving any traces or noticeable scars on the skin.
The second stage is characterized by the destruction of the epidermis and the outermost layer of the dermis. In this case, symptoms such as severe pain, hyperemia, and swelling are noted.
The pain is burning, aggravated by touch, and is quite long-lasting. Redness around the blisters may or may not be present.
Blisters are formed by dead cells of the epidermis, and are filled with the liquid fraction of blood - plasma, penetrating into them from damaged tiny vessels.
These types of injuries do not require medical attention or special therapeutic measures. The regeneration process can take up to two weeks. To speed it up and relieve pain, you can use special pharmaceutical ointments or gels.
Do not treat damaged areas with oil under any circumstances. This method interferes with cellular respiration and significantly slows down healing.
The danger of such damage is that bursting blisters are an open gate for infections. If the affected area is large, it is better to consult a doctor. He will recommend medications to prevent infection.
Differentiation between the second and third degrees is carried out using pain identification. Both of these stages are characterized by the formation of blisters, but in the second there is pain, and in the third there is none, since the nerve endings are damaged.
Third degree
Three degree burns are usually divided into two subtypes. 3A is a violation of the dermis to deep layers, the lowest of which remain intact.
With such a depth of penetration, independent regeneration is still possible, without surgical intervention.
This only applies to fairly minor wounds. They can be delayed due to the growth of epithelium from the marginal zones. Degree 3B is characterized by deep damage, involving all layers of the dermis, reaching the layer of subcutaneous fat.
This layer of skin does not have the structural elements that are necessary for the regeneration of epidermal and dermal cells. Therefore, independent restoration and growth of tissue does not occur with such a degree of burns.
The main signs are the formation of blisters of various sizes filled with bloody contents, as well as the absence of pain when touched. A large amount of mucous fluid with blood impurities is released from the wound. Around the wound defects there is pronounced swelling, redness, and increased local temperature. The damaged area is inflamed.
With such deep lesions, a number of common symptoms are noted. The clinical picture includes an increase in general temperature, a drop in blood pressure, interruptions in heart function, tachycardia, and difficult shallow breathing.
The third stage of a burn requires immediate hospitalization of the victim. Patients require surgery and drug therapy.
The prognosis depends on what percentage of the body area the lesion occupies. How quickly medical care is provided has important prognostic significance.
In addition, the prognosis also depends on the general condition of the victim. For example, in case of thermal burns received during a fire, the degree of carbon monoxide intoxication plays a role.
Fourth
The most rare type of injury of this type. This is the most severe type of lesion, characterized by an unfavorable prognosis even with a small wound area.
With damage of such depth, even within a small area, there is a high probability of death or alienation of the injured limb.
The deep layers of the human body are affected: the skin burns, muscle tissue, tendons and even bones are damaged. A 4th degree burn involves the destruction of most of the nerve endings and blood vessels in the affected area.
The fourth degree can occur as a result of prolonged high temperature exposure, damage to acids or alkalis, as well as electricity.
Wounds of such severity are immediately visible and cannot be confused with anything else. 4th degree burns are characterized by charring, that is, a long-term combustion reaction leading to a change in the chemical structure of tissue cells. The burn site becomes dark, sometimes black. The condition of the victims is extremely serious.
As a rule, people are in a state of shock or coma. If the wound defect has a significant area, medical care must be provided urgently, minutes count. But still, the probability of death is very high.
In cases where such injuries occur, determining their severity and classification is necessary only for medical professionals. When you are burned or someone is injured in front of your eyes, it is necessary not to assess the damage, but to provide first aid.
If the victim is in serious condition, timely therapeutic measures can save his life.
Burns: types of burns and degrees, treatment of burns with KEEPER balm
Burns is damage to body tissue caused by exposure to high temperatures or chemicals. Electric shock, as well as exposure to ionizing radiation (ultraviolet, X-ray, etc., including solar radiation), can also cause a burn.
Often burns are also called skin lesions caused by the irritating effect of a plant (nettle burn, hogweed burn, hot pepper burn), although in essence this is not a burn - it is phytodermatitis.
Depending on the area of tissue damage, burns are divided into burns of the skin, eyes, mucous membranes, burns of the respiratory tract, esophagus, stomach, etc. The most common are, of course, skin burns, so in the future we will consider this type of burn.
Heaviness burn determined by the depth and area of tissue damage. The concept of “burn area” is used to characterize the area of skin damage and is expressed as a percentage. To classify the depth of a burn, the concept “degree of burn” is used.
Types of burns
Depending on the damaging factor, skin burns are divided into:
- thermal,
- chemical,
- electrical,
- sun and other radiation burns (from ultraviolet and other types of radiation)
Thermal burn
Thermal burn is the result of exposure to high temperature. This is the most common household injury. They occur as a result of exposure to open flame, steam, hot liquid (boiling water, hot oil), or hot objects. The most dangerous, of course, is open fire, since in this case the organs of vision and the upper respiratory tract can be affected. Hot steam is also dangerous for the respiratory tract. Burns from hot liquids or hot objects are usually not very large in area, but deep.
Chemical burn
Chemical burn occurs as a result of exposure to chemically active substances on the skin: acids, alkalis, salts of heavy metals. They are dangerous if the affected area is large, as well as if chemicals come into contact with mucous membranes and eyes.
Electrical burns
Electrical shock is characterized by the presence of several burns of a small area, but of great depth. Voltage arc burns are superficial, similar to flame burns and occur during short circuits without current passing through the victim’s body.
Radiation burns
This type of burn includes burns that occur as a result of exposure to light or ionizing radiation. Thus, solar radiation can cause the well-known sunburn. The depth of such a burn is usually 1st degree, rarely 2nd degree. A similar burn can also be caused by artificial ultraviolet irradiation. The extent of damage from radiation burns depends on the wavelength, intensity of radiation and duration of exposure.
Burns from ionizing radiation are usually shallow, but their treatment is difficult, since such radiation penetrates deeply and damages the underlying organs and tissues, which reduces the skin's ability to regenerate.
Degree of skin burn
The degree of burn is determined by the depth of damage to the various layers of the skin.
Recall that human skin consists of epidermis, dermis and subcutaneous fat (hypodermis). The top layer, the epidermis, in turn consists of 5 layers of varying thickness. The epidermis also contains melanin, which colors the skin and causes the tanning effect. The dermis, or the skin itself, consists of 2 layers - the upper papillary layer with capillary loops and nerve endings, and the reticular layer containing blood and lymphatic vessels, nerve endings, hair follicles, glands, as well as elastic, collagen and smooth muscle fibers, giving the skin strength and elasticity. Subcutaneous fat consists of bundles of connective tissue and fat accumulations, penetrated by blood vessels and nerve fibers. It provides nutrition to the skin, serves for thermoregulation of the body and additional protection of organs.
Clinical and morphological classification of burns, adopted at the XXVII All-Union Congress of Surgeons in 1961, distinguishes 4 degrees burn.
First degree burn
I degree burn is characterized by damage to the most superficial layer of the skin (epidermis), consisting of epithelial cells. In this case, redness of the skin, slight swelling (edema), and tenderness of the skin in the burn area appear. Such a burn heals in 2-4 days, no traces remain after the burn, except for minor itching and peeling of the skin - the upper layer of the epithelium dies.
Second degree burn
A second degree burn is characterized by deeper tissue damage - the epidermis is partially damaged to the full depth, down to the germ layer. Not only redness and swelling are observed, but also the formation of blisters with a yellowish liquid on the skin, which can burst on their own or remain intact. Bubbles form immediately after a burn or after some time. If the bubbles burst, a bright red erosion forms, which is covered with a thin brown crust. Healing for a second degree burn usually occurs in 1-2 weeks, through tissue regeneration due to the preserved germ layer. There are no marks left on the skin, but the skin may become more sensitive to temperature influences.
Third degree burn
III degree burn is characterized by complete death of the epidermis in the affected area and partial or complete damage to the dermis. Tissue necrosis (necrosis) and the formation of a burn scab are observed. According to the accepted classification, III degree burns are divided into:
- degree III A, when the dermis and epithelium are partially damaged and independent restoration of the skin surface is possible if the burn is not complicated by infection,
- and degree III B - complete death of the skin down to the subcutaneous fat. As healing occurs, scars form.
IV degree burn
A fourth degree burn is the complete destruction of all layers of skin and underlying tissues, charring of muscles and bones.
Determination of the area affected by a burn
Approximate area estimate burn can be produced in two ways. The first method is the so-called “rule of nines”. According to this rule, the entire surface of the skin of an adult is conditionally divided into eleven sections of 9% each:
- head and neck - 9%,
- upper limbs - 9% each,
- lower limbs - 18% (2 times 9%) each,
- posterior surface of the body - 18%,
- anterior surface of the body - 18%.
The remaining one percent of the body surface is in the perineal area.
The second method - the palm method - is based on the fact that the area of the palm of an adult is approximately 1% of the total surface of the skin. For local burns, use the palm to measure the area of damaged skin areas; for extensive burns, measure the area of unaffected areas.
The larger the area and deeper the tissue damage, the more severe the burn injury. If deep burns occupy more than 10-15% of the body surface, or the total area of even shallow burns makes up more than 30% of the body surface, the victim develops a burn disease. The severity of a burn disease depends on the area of the burns (especially deep ones), the age of the victim, the presence of concomitant injuries, diseases and complications.
Prognosis for recovery from burns
To assess the severity of the lesion and predict the further development of the disease, various prognostic indices are used. One of these indices is the lesion severity index (Frank index).
When calculating this index, each for each percentage of the burn area gives from one to four points - depending on the degree of the burn, a burn of the respiratory tract without breathing impairment - 15 points additionally, with a violation - 30. The index values are interpreted as follows:
- < 30 баллов - прогноз благоприятный
- 30-60 - conditionally favorable
- 61-90 - doubtful
- > 91 - unfavorable
Also, to assess the prognosis of burn injury in adults, the “hundred rule” is applied: if the sum of the numbers of the patient’s age (in years) and the total area of damage (in percent) exceeds 100, the prognosis is unfavorable. Burns of the respiratory tract significantly worsen the prognosis, and to take into account its influence on the “rule of hundreds” indicator, it is conventionally accepted that it corresponds to 15% of a deep burn of the body. The combination of a burn with damage to bones and internal organs, with carbon monoxide poisoning, smoke, toxic combustion products or exposure to ionizing radiation aggravates the prognosis.
Burn disease in children, especially younger ones, can develop when only 3-5% of the body surface is affected, in older children - 5-10%, and is more severe the younger the child. Deep burns of 10% of the body surface are considered critical in young children.
Treatment of burns
Burns Grades I and II are considered superficial and heal without surgery. Burns of III A degree are classified as borderline, and III B and IV degrees are deep. In case of burns of degree III A, independent tissue restoration is difficult, and treatment of burns of degrees III B and IV without surgical intervention is impossible - skin grafting is required.
Self-treatment, without consulting a doctor, is only possible for I-II degree burns, and only if the burn area is small. If the area of the second degree burn is more than 5 cm in diameter, you should consult a doctor. Treatment of adult patients with first-degree burns, even extensive ones, can be carried out on an outpatient basis. For more severe burns, adult patients can be treated on an outpatient basis in cases where the skin of the face, lower extremities or perineum is not affected, and the burn area does not exceed:
- for second degree burns - 10% of the body surface;
- for III A degree burns - 5% of the body surface.
The method of treating a burn depends on its type, the degree of the burn, the area affected and the age of the patient. Thus, even small-area burns in young children require mandatory medical intervention, and often hospital treatment. Elderly people also suffer from burns with difficulty. It is advisable to treat victims over 60 years of age with limited degree II-IIIA burns, regardless of their location, in a hospital setting.
First of all, in case of a burn, you must urgently stop the action of the damaging factor (high temperature, chemical substance) on the skin. For a superficial thermal burn - with boiling water, steam, or a hot object - wash the burned area generously with cold water for 10-15 minutes. In case of a chemical burn with acid, the wound is washed with a soda solution, and in case of a burn with alkali - with a weak solution of acetic acid. If the exact composition of the chemical is unknown, wash with clean water.
If the burn is extensive, the victim should be given at least 0.5 liters of water to drink, preferably with 1/4 teaspoon of baking soda and 1/2 teaspoon of table salt dissolved in it. Give 1-2 g of acetylsalicylic acid and 0.05 g of diphenhydramine orally.
You can try to treat a first-degree burn yourself. But if the victim has a significant burn of the second degree (blister with a diameter of 5 cm or more), and even more so with burns of the third degree or higher, you need to urgently consult a doctor.
For IIIA degree burns, treatment begins with wet-dry dressings that promote the formation of a thin scab. Under a dry scab, IIIA degree burns can heal without suppuration. After rejection and removal of the scab and the beginning of epithelization, oil-balsamic dressings are used.
For the treatment of I-II degree burns, as well as at the stage of epithelization in the treatment of III A degree burns, the Guardian balm showed good results. It has analgesic, anti-inflammatory, antiseptic, regenerating properties. Balm Guardian relieves inflammation, accelerates skin regeneration, promotes wound healing, and prevents scar formation. Apply directly to the affected area, or use for ointment aseptic dressings.
The reasons that cause a burn can be very diverse.
What types of burns there are, how many degrees of burns there are and how to determine the degree of burn - we will find out today.
A burn itself is permanent damage to the tissues of the human body when exposed to any external factor.
And it is precisely on this very factor that the classification of the etiology of burns depends. So, based on their origin, the following types of burns are distinguished:
- Thermal burn– exposure to elevated temperatures on the surface of the human body: steam, boiling water, hot oil, touching a hot object, exposure to open fire on the human body.
- Electrical burn– exposure to an electric discharge on the human body, which also causes damage to internal organs by the electromagnetic field.
- A chemical burn is the interaction of the human body with chemicals that can affect not only the epidermis, but also the subcutaneous layers.
- Radiation burn– damage to the epidermis and sometimes the subcutaneous layer by exposure to ultraviolet or infrared radiation.
Classification of burns by degree and their characteristics
Each burn is unique in its own way, because the degree of damage is individual each time - it all depends on the very external factors that cause it. Treatment depends on the degree of burns and their symptoms, which is why the classification of burns by degree is so important.
There are only four types of burns according to degrees. All degrees of burns and their signs depend on the characteristics of tissue damage and the level of area of this damage.
1st degree burn. The mildest form (or degree) of a burn. There is redness and very slight swelling of the affected surface. The pain is not great, and recovery from this burn occurs literally on the 4th or 5th day. There are no clearly visible marks or scars left.
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| photo of 1st degree burn |
2nd degree burn. Blisters form on reddened skin, and they may not appear immediately - up to a day after the burn. Each bubble contains a yellowish liquid, and when they rupture, the reddish surface of the skin that is located under the bubble is visible. If an infection occurs at the site of the rupture, healing takes longer, but scars and cicatrices subsequently do not form.
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| photo of 2nd degree burn |
3rd degree burn. With such a lesion, necrosis of the affected area of the skin occurs. In its place, a scab forms, which takes on a grayish tint. Sometimes this scab becomes covered with a black crust, which then falls off to reveal a reddish area of a very thin layer of skin.
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| photo of 3rd degree burn |
4th degree burn. This is not only external damage to the layers of skin and epidermis, it is penetration into the deep tissues and even charring them. Many of the dead tissues are partially melted and then sloughed off. Not only muscle tissue is damaged, but also tendons and even bone.
The healing process of a 4th degree burn is very long; not only scars are formed at the site of the lesion, but also cicatrices, which often lead to disfigurement. Scar contractures form in the joint capsules, which prevent joint mobility. This is the most severe degree of burn, which necessarily requires specialist supervision and long and difficult treatment.
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| photo of 4th degree burn |
Depending on the types of burns and their degrees, there are special treatment methods. Moreover, this classification of burns by degree is universal for the entire global medical community and it is the “starting point” for treatment and for determining the method of recovery after a burn.
Almost every person at least once in his life has found himself in extreme situations or in a life-threatening situation. As a result, you can get various injuries that cause significant harm to health. In the article we will analyze what degrees are and help with such injuries.
What are burns
You can get such an injury even at home, not to mention at work. A burn is damage to the skin that is caused by thermal, chemical, electrical, and radiation exposure. In most cases, these injuries affect the upper layers of the skin, but in serious situations, muscles, blood vessels and even bones can be affected.
If you are wondering how to cure a burn, the answer will depend on the degree and extent of the damage. In some cases, you can get by with home remedies, but sometimes serious specialized help is required.
Causes of burns
Burns can be caused by a variety of reasons, each with its own manifestations and signs of damage. Burns can be caused by:
- thermal factors;
- chemical;
- electricity;
- radiation exposure;
- bacteria (so-called fire blight).
All of these factors can influence to varying degrees, so a burn will have its own manifestations and require an individual approach to treatment.
Types of burns
The most common are thermal burns, that is, those resulting from exposure to:
- Fire. Very often the upper respiratory tract and face are damaged. When damage to parts of the body is observed, the process of removing clothing from the burnt areas becomes very difficult.
- Boiling water. Almost everyone has encountered this. The area may be small, but the depth is significant.
- Pair. Such a lesion usually does not cause many problems.
- Hot objects: they tend to leave clear boundaries and deep lesions.
With a thermal burn, the degree of damage depends on several factors:
- temperature;
- duration of exposure;
- degree of thermal conductivity;
- general health and skin condition of the victim.
A chemical burn is damage to the skin as a result of exposure to various aggressive substances, for example:
Electrical burns can occur after contact with conductive materials. The current spreads quite quickly through muscles, blood, and cerebrospinal fluid. Exposure of more than 0.1 A poses a danger to humans.
A distinctive feature of electrical damage is the presence of an entry and exit point. This is the so-called current mark. The affected area is usually small but deep.
Radiation burns may be associated with:
- With ultraviolet radiation. Sunbathers can easily get such burns at midday. The affected area is usually large, but most often it can be dealt with using home remedies.
- With exposure to ionizing radiation. In this case, not only the skin is affected, but also neighboring organs and tissues.
- With infrared radiation. It often causes burns to the cornea, retina, and skin. The damage depends on the duration of exposure to this negative factor.
And another type of burn is a bacterial burn, which can be caused by certain types of microorganisms. The severity also varies from small nodular lesions to conditions that can even threaten a person's life, such as the development of staphylococcal scalded skin syndrome.
Degrees of burns and their manifestations
The burn can be either very minor or such that urgent hospitalization is required. Depending on the complexity of the lesion, the consequences may also differ significantly from each other. There are several degrees of burn:
Most often, a burn is not one degree, but a combination of several. The severity of the situation is also determined by the area of the lesion. Depending on this, burns are:
- Extensive, in which more than 15% of the skin is affected.
- Not extensive.
If the burn is extensive and more than 25% of the skin is affected, then there is a high probability of burn disease.
What is burn disease?
The course and severity of this complication depends on several factors:
- Age of the victim.
- Location of the affected area.
- Degree of burn.
- Area of damage.
Burn disease in its development goes through the following stages:
1. Shock. It can last from several hours to several days, it all depends on the area of the lesion. There are several degrees of shock:
- The first is characterized by burning pain, normal blood pressure and a heart rate within 90 beats per minute.
- In the second degree, the heart contracts even more often, blood pressure drops, body temperature decreases, and a feeling of thirst appears.
- When more than 60% of the skin is affected, grade 3 shock is observed. The pulse is barely palpable, the pressure is low.
2. Burn toxemia. Occurs due to the impact of tissue breakdown products on the body. It usually occurs a few days after the lesion and lasts 1-2 weeks. In this case, the person feels weakness, nausea, possibly vomiting, and fever.
3. Septicotoxemia. It starts on the 10th day and lasts for several weeks. Infection is noted. If the dynamics of treatment are negative, this can lead to death. This occurs if there was a 4th degree burn or deep skin damage.
5. Convalescence. Effective drug treatment ends with the healing of burn wounds and restoration of the functioning of internal organs.
To prevent the development of burn disease, it is necessary to take the burn victim to the hospital. Doctors will be able to assess the severity of the injuries and provide effective assistance.
First aid for burns
Whatever the factor that caused the burn, you must first take the following actions:
It is very important not to get confused in the situation and eliminate the damaging factor as quickly as possible or take the person to a safe place. The degree of skin damage will depend on this. Rapid cooling helps prevent damage to healthy tissue. If the burn is 3rd degree, then such measures are not taken.
Depending on the damaging factor, first aid measures may have their own nuances. Let's consider them further.
Providing first aid for thermal burns
Almost everyone encounters such injuries in their lives, so you need to know how to help yourself or your loved ones in such a situation. Home help for burns of this type is as follows:
- Eliminate the impact of the damaging factor as quickly as possible, that is, remove from the fire zone, remove or extinguish burning clothing.
- If the burn is small, then it is necessary to cool the affected area under running water for 10-15 minutes, and then apply a clean, damp cloth.
- For more serious burns, there is no need to cool, but you should cover the burn area with a napkin.
- Remove jewelry if possible.
- Take a pain reliever, for example, Ibuprofen, Paracetamol.
In case of a thermal burn, it is prohibited:
- Remove clothing if it is stuck to the wound.
- Pop blisters.
- Touch the affected areas.
- Apply oil, cream, iodine, peroxide and other substances to the wounds.
- Do not apply cotton wool, ice, or bandages.
If the burn is serious, medical attention will be required.
Chemical burn
Often such injuries occur in chemical plants, but they can also occur in a chemistry lesson if you do not follow safety precautions. If you are exposed to a chemical, you must quickly neutralize its effects.
Help for chemical burns with acid involves treating the wound with a solution of soda or soapy water. If you are exposed to alkali, you will first have to rinse thoroughly with water and then treat with a 2% solution of acetic or citric acid.
If you receive more serious chemical burns, you will have to seek help from specialists.
Help for electrical burns
You can get an electrical burn at home or at work. First of all, it is necessary to neutralize the source of the damage. Just do this in compliance with safety measures. The wound must be covered with a napkin.
You can get a slight injury, and it will be enough to give warm tea and sedative to the victim. In case of serious injuries, loss of consciousness may occur. In this case, you will have to resort to additional assistance measures:
- Find a comfortable position for the victim.
- Make sure there is a flow of fresh air.
- Clear the airways of excess clothing.
- Turn your head to the side.
- Before the ambulance arrives, monitor your pulse and breathing.
- If the injury is so serious that cardiac arrest has occurred, then artificial respiration with chest compressions of the heart muscle is urgently necessary.
It must be remembered that there are situations in which a person’s life depends on the speed of providing first aid.
Radiation burns and first aid
Such damage can be caused by exposure to ultraviolet, infrared and radiation. This type of burn differs significantly from others in that ionization of the tissue occurs, which causes changes in the structure of the protein molecule.
Radiation burns have their own degrees of complexity:
- The first degree is characterized by redness, itching and burning.
- In the second degree, blisters appear.
- The third degree, in addition to the listed symptoms, includes tissue necrosis and complications.
When providing first aid after receiving a radiation burn, the following is prohibited:
- Touch the wound with your hands or apply non-sterile objects to it.
- If bubbles appear, they cannot be pierced.
- Use cosmetics to treat wounds.
- Apply ice. This can not only lead to frostbite, but also cause burn shock from the sudden temperature change.
Eye burns
The cause of eye burns can be all the factors discussed above. Localization may be different, depending on this they distinguish:
- retina;
- lens
The degree of damage can be different, and if the first is completely treatable at home and has a favorable outcome, then more serious injuries require hospital stay, and the consequences can be the most dire.
Signs that will indicate an eye burn are as follows:
- Redness and swelling.
- Severe pain.
- Tearing.
- Fear of light.
- Decreased visual acuity.
- Changes in intraocular pressure in any direction.
If radiation exposure occurs, some of the above symptoms may not appear.
If chemicals get into your eyes, you should immediately rinse them with running water for 15 minutes. Apply antiseptic drops, for example, Floxal. The skin around the eyes can be lubricated, covered with a napkin and the victim sent to an ophthalmologist.
A welding burn, which is classified as radiation, may not appear immediately, but several hours after exposure. The characteristic signs of such a lesion are as follows:
- severe cutting pain in the eyes;
- lacrimation;
- sharp decrease in vision;
- fear of bright light.
If the eyes are damaged, help should be provided immediately. The effectiveness of treatment will depend on this.
Treatment of burns
Since the severity of burns can vary, there are two types of treatment:
- conservative;
- operational.
The choice of treatment methods depends on several factors:
- total affected area;
- burn depth;
- location of injury;
- the reasons that caused the burn;
- development of burn disease;
- age of the victim.
If we consider a closed method of treating burns, it is carried out by applying a bandage with a medicinal drug to the wound. When the burn is shallow and mild, such a bandage does not even have to be changed often - the wound heals quickly.
If there is a second degree, ointments with an antiseptic effect and bactericidal ointments are applied to the burn site. , for example, "Levomikol" or "Silvacin". They prevent the growth of bacteria. This bandage needs to be changed every two days.
With 3rd and 4th degree burns, a crust forms, so at first it is necessary to treat the area around with antiseptic agents, and after the crust disappears (and this usually happens after 2-3 weeks), you can use bactericidal ointments.
The closed method of treatment has its advantages and disadvantages. The first include the following:
- The bandage prevents infection from entering the wound.
- Protects the wound from mechanical damage.
- Medicines promote faster healing.
The disadvantages include the following:
- When changing the dressing, the patient experiences discomfort.
- Dying tissue can cause intoxication.
With a closed method of treatment, special techniques are used, for example, ultraviolet irradiation, bactericidal filters. They are usually available at specialized burn centers.
This method of treatment promotes the rapid formation of a dry crust. Most often it is used for burns of the face, perineum, and neck.
Surgical treatment
In some cases, when the burns are severe and cover large areas, it is necessary to resort to surgical intervention. The following types are used:
- Necrotomy. The doctor cuts the scab to ensure blood supply to the tissue. If this is not done, necrosis may develop.
- Necrectomy. Most often performed on third degree burns to remove dead tissue. The wound is cleaned well and suppuration is prevented.
- Staged necrectomy. It is performed for deep burns and is more gentle compared to the previous method. Tissue removal is carried out in several passes.
- Amputation. The most severe cases: when treatment does not bring results, the limb has to be removed to prevent further spread of necrosis.
All methods of surgical intervention, except the last one, then end with skin transplantation. Most often, it is possible to transplant the patient’s own skin taken from other areas.
Traditional methods of treating burns
Many people wonder how to cure a burn at home? As for grade 3 and 4 damage, the issue is not even discussed here - treatment should be carried out only in a hospital. Milder burns can be treated at home.
There are many proven methods among traditional healers, among them the following are the most popular and effective:
- If you get it, baking soda will help you deal with it perfectly.
- A compress of strong tea can also alleviate the condition of the victim.
- Prepare a composition from 1 tablespoon of starch and a glass of water and apply it several times a day to the affected areas.
- If you soak a gauze pad with sea buckthorn oil and apply it to the burn site, healing will proceed faster.
- Some believe that a 2nd degree burn can be quickly cured with raw potatoes. It is necessary to apply fresh potato slices every 3 minutes. Blisters will not appear if you start this treatment immediately after the injury.
- Prepare an ointment from 3 tablespoons of sunflower oil and 1 tablespoon of beeswax. This composition should be applied 3-4 times a day.
It must be remembered that you can only cope with minor burns on your own without health consequences. Serious injuries require medical intervention.
Complications of burns
With any burn, not only the damage is cause for concern, especially over a large area, but also an infection that can join at any time. Risk factors include the following cases:
- If more than 30% of the body area is affected.
- The burn affects all layers of the skin.
- Infancy and old age.
- Antibacterial resistance of the bacteria that caused the infection.
- Improper treatment and care of the wound.
- After the transplant, rejection occurred.
To reduce the likelihood of all complications, treatment must be carried out in specialized clinics. A burn is a fairly serious injury, especially for children who also receive severe psychological trauma.
The prognosis for treatment of burns always depends on several factors, but the sooner the victim is taken to the clinic, the more effective the therapy will be, and recovery will occur faster and with minimal risk of complications. The consequences of a burn can be irreversible if timely assistance is not provided.
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016
Thermal burn 50-59% of the body surface (T31.5), Thermal burn 60-69% of the body surface (T31.6), Thermal burn 70-79% of the body surface (T31.7), Thermal burn 80-89% of the body surface (T31.8), Thermal burn of 90% or more of the body surface (T31.9)
Combustiology
general information
Short description
Approved
Joint Commission on Healthcare Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
dated June 28, 2016 Protocol No. 6
Burns -
damage to body tissues resulting from exposure to high temperature, various chemicals, electric current and ionizing radiation.
Superficial and borderline burns (II- IIIAArt.)- damage, with preservation of the dermal or papillary layer, with the possibility of independent restoration of the skin.
Deep burns- full-thickness skin lesions. Self-healing is not possible. To restore the skin, surgical intervention is necessary - skin grafting, necrectomy.
Burn disease - This is a pathological condition that develops as a consequence of extensive and deep burns, accompanied by peculiar dysfunctions of the central nervous system, metabolic processes, activity of the cardiovascular, respiratory, genitourinary, hematopoietic systems, damage to the gastrointestinal tract, liver, development of disseminated intravascular coagulation syndrome, endocrine disorders, etc. d.
datedevelopmentprotocol: 2016
Protocol users: combustiologists, traumatologists, surgeons, anesthesiologists-resuscitators, general practitioners, ambulance and emergency doctors.
Level of evidence scale:
Table 1
| A | A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population. |
| IN | High-quality (++) systematic review of cohort or case-control studies, or High-quality (++) cohort or case-control studies with very low risk of bias, or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population . |
| WITH |
Cohort or case-control study or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population. |
| D | Case series or uncontrolled study or expert opinion. |
Classification
Classification of burns into 4 degrees(adopted at the XXXVII All-Union Congress of Surgeons in 1960):
· I degree - redness of the skin with clear contours, sometimes on an edematous basis, the epidermis is not affected. Disappears after a few hours or 1-2 days.
· II degree - the presence of thin-walled bubbles with transparent liquid contents. Heavy exudation persists for 2 - 4 days. Independent epithelization occurs after 7-14 days.
· III-A degree - the presence of thick-walled blisters with jelly-like plasmatic contents, partially opened. The exposed bottom of the wound is moist, pink, with areas of white and red color - the papillary layer of the skin itself, often covered with a thin, whitish-gray, soft scab, petechial hemorrhages, pain sensitivity is preserved, vascular reaction is often absent. Self-epithelialization occurs after 3-5 weeks.
· III-B degree - damage to the entire thickness of the skin with the formation of coagulation (dry) or liquefaction (wet) necrosis. In dry necrosis, the scab is dense, dry, dark red or brown-yellow, with a narrow zone of hyperemia and slight perifocal edema. With wet necrosis, the dead skin is swollen and has a doughy consistency, the remaining thick-walled blisters may contain hemorrhagic exudate, the bottom of the wound is variegated, from white to dark red, ashy or yellowish, and there is widespread perifocal edema. There is no vascular or pain reaction.
· IV degree - accompanied by necrosis not only of the skin, but also of formations located below the subcutaneous tissue - muscles, tendons, bones. The formation of a thick, dry or wet, whitish, yellowish-brown or black scab with a pasty consistency is characteristic. Under it and in the circumference, tissue swelling is pronounced, the muscles have the appearance of “boiled meat”.
Classification of the degree (depth) of a burn according to ICD-10
Correlation of the classification of burn degrees according to ICD-10 with the classification of the XXVII Congress of Surgeons of the USSR in 1960.
table 2
| Characteristic | Classification of the XXVII Congress of Surgeons of the USSR | Classification according to ICD-10 | Burn depth |
| Skin hyperemia | 1st degree | 1st degree | Superficial burn |
| Bubble Formation | II degree | ||
| skin necrosis | III-A degree | II degree | |
| Complete skin necrosis | III-B degree | III degree | Deep burn |
| Necrosis of the skin and underlying tissues | IV degree |
Classification of burn disease (BD)
· Burn shock (BS) - lasts up to 12-72 hours depending on the severity of the injury, premorbid background, duration of the prehospital stage, and therapy.
· Acute burn toxemia (ABT) - occurs from 2-3 to 7-14 days from the moment of injury.
· Septicotoxemia - lasts from the moment the scab suppurates until the skin is completely restored.
· Convalescence - begins after complete restoration of the skin and continues for several years.
OB current.
· There are three degrees of the course of the OB period: mild, severe and extremely severe (as in burn shock). Accordingly, OOT and septicotoxemia, depending on the area of the burn, are divided into mild, severe and extremely severe.
Diagnostics (outpatient clinic)
OUTPATIENT DIAGNOSTICS
Diagnostic criteria
Complaints:
· For burning pain in the area exposed to thermal agents or chemicals.
Anamnesis:
· Exposure to high temperatures, acids, alkalis.
Physical examination:
· An assessment of the general condition is carried out; external respiration (respiratory rate, assessment of freedom of breathing, airway patency); The pulse rate is determined and blood pressure is measured.
Local status:
· The appearance of the wounds, the presence of detachment of the epidermis, areas of de-epithelialization, scab (the nature of the scab is described - wet, dry), how long ago the wound originated, localization, area are assessed.
Laboratory tests: no.
Instrumental studies: no.
Diagnostic algorithm:
· History - circumstances and location of burns.
· Visual inspection.
· Determination of respiratory rate, heart rate (HR), blood pressure (BP).
Determination of difficulty breathing or hoarseness of voice
Diagnostics (ambulance)
DIAGNOSTICS AT THE EMERGENCY CARE STAGE
Diagnostic measures:
· Collection of complaints and medical history;
· physical examination (measurement of blood pressure, temperature, pulse count, respiratory rate count) with assessment of general somatic status;
· inspection of the affected area with assessment of the area and depth of the burn;
· presence or absence of signs of thermal inhalation injury: Hoarseness, hyperemia of the mucous membranes of the oropharynx, soot formation of the mucous membranes of the nasal passages, oral cavity, respiratory sufficiency.
Diagnostics (hospital)
DIAGNOSTICS AT THE INPATIENT LEVEL
Diagnostic criteria at the hospital level
Complaints:
· burning and pain in the area of burn wounds, chills, fever;
Anamnesis:
· History of exposure to high temperatures, acids, alkalis. It is necessary to find out the type and duration of action of the damaging agent, the time and circumstances of the injury, concomitant diseases, and an allergic history.
Physical examination:
· An assessment of the general condition is carried out; external respiration (respiratory rate, assessment of damage and freedom of breathing, airway patency), auscultation of the lungs; pulse rate, auscultation are determined, blood pressure is measured. The oral cavity is examined. The type of mucous membrane, the presence of soot in the respiratory tract, oral cavity, and the presence of a burn to the mucous membrane are described.
Laboratory research
Blood collection for laboratory tests is carried out in the intensive care unit or in the intensive care ward of the emergency department.
General blood test, determination of glucose, capillary blood clotting time, blood group and Rh factor, blood potassium/sodium, total protein, creatinine, residual nitrogen, urea, coagulogram (prothrombin time, fibrinogen, thrombin time, plasma fibrinolytic activity, aPTT, INR), acid-base balance, hematocrit, microreaction, general urine analysis, feces for worm eggs.
Instrumental studies(UD A):
· ECG - to assess the state of the cardiovascular system and examination before surgery (UD A);
· chest radiography - for the diagnosis of toxic pneumonia and thermal inhalation injuries (UD A);
· Bronchoscopy - for thermal inhalation lesions (UD A);
· Ultrasound of the abdominal cavity and kidneys, pleural cavity - to assess toxic damage to internal organs and identify underlying diseases (UD A);
· FGDS - for the diagnosis of burn stress Curling ulcers, as well as for placement of a transpyloric probe for gastrointestinal paresis (UD A);
Other research methods
· According to indications in the presence of concomitant diseases and injuries. Blood for HIV, hepatitis B, C (for recipients of drugs and blood components). Bacterial culture from a wound for microflora and sensitivity to antibiotics, bacterial culture of blood for sterility.
Diagnostic algorithm:, UD A (scheme)
· History - circumstances and location of burns - first aid provided, availability of tetanus vaccinations.
· Life history and presence of somatic diseases.
· Visual inspection.
· Determination of difficulty breathing or hoarseness, respiratory rate, auscultation of the lungs.
· Determination of pulse, blood pressure, heart rate, auscultation.
· Examination of the oral cavity, tongue, assessment of the condition of the mucous membrane, palpation of the abdomen.
· Determination of the depth and area of burns.
· Interpretation of laboratory tests
· Interpretation of instrumental examination results
List of main diagnostic measures:
1. General blood test, determination of glucose, capillary blood clotting time, blood group and Rh factor, blood potassium/sodium, total protein, creatinine, urea, coagulogram (prothrombin time, fibrinogen, thrombin time, APTT, INR), acid-base balance, hematocrit, general urine test, feces for worm eggs, ECG
2. Determination of the depth and area of the burn.
3. Diagnosis of respiratory tract damage
4. Diagnosis of burn shock
List of additional diagnostic measures, (UD A) :
· Bacterial culture from wounds - according to indications or when changing antibacterial therapy (UD A);
· Chest X-ray according to indications - for the diagnosis of toxic pneumonia and thermal inhalation injuries (UD A);
· FBS - for thermal inhalation injuries (UD A);
· FGDS - for the diagnosis of burn stress Curling ulcers, as well as for placement of a transpyloric probe for gastrointestinal paresis (UD A).
Determination of burn area
The most acceptable and quite accurate are simple methods for determining the size of the burned surface using the method proposed by A. Wallace (1951) - the so-called rule of nines, as well as the rule of the palm, the area of which is equal to 1-1.1% of the body surface.
“Rule of nines” (method proposed by A.Wallace, 1951)
Based on the fact that the area of each anatomical region as a percentage is a multiple of 9:
- head and neck - 9%
- front and back surfaces of the body - 18% each
- each upper limb - 9%
- each lower limb - 18%
- perineum and genitals - 1%.
"Rule of the Palm" (J.
Yrazer, 1997)
As a result of anthropometric studies, J. Yrazer et al. concluded that the area of the palm of an adult is 0.78% of the total surface area of the body.
The number of palms placed on the surface of the burn determines the percentage of the affected area, which is especially convenient for limited burns to several areas of the body. These methods are easy to remember and can be used in any environment.
To measure the area of burns in children, a special table has been proposed, which takes into account the ratios of body parts, which vary depending on the age of the child (Table 4).
Area as a percentage of the total body surface area of the surface of anatomical regions depending on age
Table 4
| Anatomical region | Newborns | 1 year | 5 years | 10 years | 15 years | Adult patients |
| Head | 19 | 17 | 13 | 11 | 9 | 7 |
| Neck | 2 | 2 | 2 | 2 | 2 | 2 |
| Anterior surface of the body | 13 | 13 | 13 | 13 | 13 | 13 |
| Posterior surface of the body | 13 | 13 | 13 | 13 | 13 | 13 |
| Buttock | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 |
| Crotch | 1 | 1 | 1 | 1 | 1 | 1 |
| Hip | 5,5 | 6,5 | 8 | 8,5 | 9 | 9,5 |
| Shin | 5 | 5 | 5,5 | 6 | 6,5 | 7 |
| Foot | 3,5 | 3,5 | 3,5 | 3,5 | 3,5 | 3,5 |
| Shoulder | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 |
| Forearm | 3 | 3 | 3 | 3 | 3 | 3 |
| Brush | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 | 2,5 |
Diagnostics of OS
All patients with a total area of burns of more than 50%, deep burns of more than 20% are admitted to the clinic with severe or extremely severe OS (Table 5)
Severity of burn shock in adults
Table 5
OR refers to the hypovolemic type of hemodynamic disorders. Burn shock is characterized by:
1. Persistent hemoconcentration caused by the loss of the liquid part of the circulating blood volume (“white bleeding”).
2. Plasma loss occurs continuously throughout the entire period of burn shock (from 12 to 72 hours).
3. Pronounced nociceptive impulses.
4. In most cases, a hyperdynamic type of hemodynamics is manifested.
5. In the first 24 hours, the permeability of the vascular wall increases significantly, through which large molecules (albumin) can pass, which leads to interstitial edema of the paranecrosis zone, “healthy” tissues and aggravates hypovolemia.
6. Cell destruction (including up to 50% of all red blood cells) is accompanied by hyperkalemia.
At easy degree OR (burn area less than 20%), patients experience severe pain and burning at the burn sites. There may be excitement in the first minutes and hours. Tachycardia up to 90. Blood pressure is normal or slightly increased. There is no shortness of breath. Diuresis is not reduced. If treatment is delayed by 6-8 hours or is not carried out, oliguria and moderate hemoconcentration may be observed.
At severe OR (20-50% b.t.) lethargy and adynamia rapidly increase with preserved consciousness. Tachycardia is more pronounced (up to 110), blood pressure is stable only with infusion therapy and the administration of cardiotonics. Patients feel thirsty and experience dyspeptic symptoms (nausea, vomiting, hiccups, bloating). Paresis of the gastrointestinal tract and acute dilatation of the stomach are often observed. Urination decreases. Diuresis is ensured only by the use of medications. Hemoconcentration is pronounced - the hematocrit reaches 65. From the first hours after the injury, moderate metabolic acidosis with respiratory compensation is determined. Patients are cold and their body temperature is below normal. Shock may last 36-48 hours or more.
At 3rd (extremely severe) degree of OS (burn more than 50% of the body) the condition is extremely serious. 1-3 hours after the injury, consciousness becomes confused, lethargy and stupor occur. The pulse is threadlike, blood pressure drops to 80 mm Hg. Art. and lower (against the background of infusion therapy, administration of cardiotonic, hormonal and other drugs). Shortness of breath, shallow breathing. Vomiting is often observed, which can be repeated, and the color of “coffee grounds”. Severe gastrointestinal paresis. Urine in the first portions shows signs of micro- and macrohematuria, then dark brown with sediment. Anuria sets in quickly. Hemoconcentration is detected after 2-3 hours, the hematocrit rises to 70 or more. Hyperkalemia and decompensated mixed acidosis increase. Body temperature drops below 36°. Shock can last up to 3 days. and more, especially with a burn of the respiratory tract (RD).
Diagnosis of thermal inhalation injury (TIT).
Diagnostic criteria for TIT according to frequency of occurrence:
· Fiberglass bronchoscopy (FBS) data - in 100% of cases;
· History (closed room, burnt clothes, loss of consciousness during a fire) - in 95% of cases;
· Burns of the face, neck, mouth - 97%;
· Burning of hair in the nasal passages - in 73.3%;
· Cough with soot in sputum - in 22.6%;
· Dysphonia (hoarseness of voice) - in 16.8%;
· Stridor (noisy breathing), bronchospasm, tachypnea - in 6.9% of cases.
Provision and indications for diagnostic FBS upon admission to hospital(category of evidence A), Level of Evidence A
Table 6
| Indications | Security |
| Anamnestic data of TIT |
Under local anesthesia, except in cases of intolerance to local anesthetics, severe alcohol intoxication, psychomotor agitation, status asthmaticus and aspiration syndrome |
| Dysphonia | |
| Soot in the oropharynx or sputum | |
| Consciousness< 9 баллов по шкале Глазго | With tracheal intubation |
| Stridor, shortness of breath | |
| Deep burns on the face and neck | |
| PaO2/FiO2< 250 |
Severity of TIT according to FBS data(Institute of Surgery named after A.V. Vishnevsky, 2010):
1. Hyperemia and slight swelling of the mucous membrane, emphasis or blurred vascular pattern, pronounced tracheal rings, mucous secretion (in small quantities).
2. Severe hyperemia and swelling of the mucous membrane, erosion, single ulcers, fibrin deposits, soot, mucous, mucopurulent or purulent secretion (the tracheal rings and main bronchi are not visible due to swelling of the mucous membrane).
3. Severe hyperemia and swelling of the mucous membrane, friability and bleeding, multiple erosions and ulcers with a significant amount of fibrin, soot, mucous, mucopurulent or purulent secretion, areas of pallor and yellowness of the mucosa.
4. Total damage to the tracheobronchial tree, pale yellow mucosa, absence of a vascular pattern, dense soot deposits fused to the underlying tissues, early (1-2 days) desquamation is possible.
Diagnostic measures in the ICU (PICU), (UD A)
Table 7
| Event | Patient category | |||
| 1st day after injury | 2nd day after injury | 3rd day after injury | 4th and subsequent days | |
| Collection of complaints | All patients | All patients | All patients | All patients |
| History taking | All patients | - | - | - |
| Assessing the area and extent of the burn | All patients | All patients | - | - |
| Consciousness assessment using the Glasgow scale | All patients | All patients | All patients | All patients |
| Assessment of skin moisture and turgor | All patients | All patients | All patients | All patients |
| Body thermometry | All patients | All patients | All patients | All patients |
| RR, HR, BP | All patients | All patients | All patients | All patients |
| CVP | All patients | All patients | All patients | All patients |
| SpO2 | All patients | All patients | All patients | All patients |
| Diuresis | All patients | All patients | All patients | All patients |
|
ECG |
All patients | According to indications | According to indications | According to indications |
|
X-ray OGK graphics |
All patients | Patients with TIT, SOPL | Patients with TIT, ARDS | Patients with ARDS |
| Diagnostic FBS | According to the table 3 | - | - | - |
| Diagnostic FGDS | - | - | Patients with gastrointestinal tract | Patients with gastrointestinal tract |
| General blood analysis | All patients | - | All patients | All patients |
| Hb, Ht of blood every 8 hours | All patients | All patients | Patients with gastrointestinal tract | Patients with gastrointestinal tract |
| General urine analysis | All patients | - | All patients | All patients |
| Specific gravity of urine every 8 hours | All patients | All patients | - | - |
| ALT, AST blood | All patients | - | Patients with sepsis | Patients with sepsis |
| Total blood bilirubin | All patients | - | Patients with sepsis | Patients with sepsis |
| Blood albumin | All patients | All patients | All patients | All patients |
| Blood glucose | All patients | - | Patients with sepsis | Patients with sepsis |
| Blood urea | All patients | - | Patients with sepsis | Patients with sepsis |
| Blood creatinine | All patients | - | Patients with sepsis | Patients with sepsis |
| Blood electrolytes | - | - | Patients with sepsis | Patients with sepsis |
| APTT, INR, blood fibrinogen | - | All patients | Patients with sepsis | Patients with sepsis |
| Blood gas composition | Patients with TIT | Patients with TIT | Patients with severe TIT | Patients with severe TIT |
| Urine myoglobin | When muscle tissue is damaged | - | - | |
| Blood carboxyhemoglobin | Patients with fire and loss of consciousness ≤ 13 points on the Glasgow scale | - | - | - |
| Alcohol in blood and urine | Patients with loss of consciousness ≤ 13 points on the Glasgow scale; with signs of alcohol intoxication | - | - | - |
The following are subject to treatment in the ICU:
· patients with OS;
· patients with a burn area of more than 20% of the body surface with severe acute burn toxemia;
· victims of STIT until the signs of respiratory failure are completely relieved;
· patients with electrical trauma until cardiac damage is excluded;
· patients with symptoms of sepsis, gastrointestinal bleeding, psychosis, burn exhaustion, impaired consciousness;
· patients with signs of multiple organ failure.
Patients in satisfactory condition with a superficial burn, in whom mild OS is completed in the first 8-12 hours, there is no high fever and leukocytosis, gastrointestinal motility is not affected and diuresis is not less than 1/ml/kg/hour, and do not require further intensive care .
Therapeutic measures in the ICU
Table 8
| Intensive therapy | Patient category | ||||
| 1st day after injury | 2nd day after injury | 3rd day after injury | 4th and subsequent days | ||
| Promedol 2% - 1 ml every 4 hours IV (in children 0.1-0.2 mg/kg/hour IV) - option I | All patients (one or more options) | All patients (one option) | Patients with pain syndrome (one option) | Patients with severe pain syndrome (one of the options) | |
| Tramadol 5% - 2 ml every 6 hours IV (in children after 1 year, 2 mg/kg every 6 hours IV) - option II | |||||
| Ketorolac 1 ml every 8 hours (except for children under 15 years old) IM for up to 5 days - option III | |||||
| Metamizole sodium 50% - 2 ml every 12 hours IV, IM (for children analgin 50% 0.2 ml/10 kg every 8 hours IV, IM) - IV option | All patients | All patients | |||
| Decompression strip necrotomies | Patients with deep circular burns of the neck, chest, abdomen, and limbs | - | |||
| Prednisolone 3 mg/kg/day IV | Patients with mild OS | - | - | - | |
| Prednisolone 5 mg/kg/day IV | Patients with severe OS | Patients with severe OS | - | - | |
| Prednisolone 7 mg/kg/day IV | Patients with extremely severe OS | Patients with extremely severe OS | - | - | |
| Prednisolone 10 mg/kg/day IV | Patients with TIT | Patients with TIT | - | - | |
| Ascorbic acid 5% - 20 ml every 6 hours intravenously | All patients | Except for patients with mild OS | - | - | |
| Furosemide 0.5-1 mg/kg IV every 8-12 hours while maintaining the rate of IV infusion | Patients with diuresis< 1 мл/кг/час | Patients with diuresis< 1 мл/кг/час | Patients with diuresis< 1 мл/кг/час | Patients with diuresis< 1 мл/кг/час | |
| Heparin 1000 units/hour IV (in children - 100-150 units/kg/day SC) without heparin inhalations | Except for patients with mild OS | Except for patients with mild OS | - | - | |
| Enoxaparin 0.3 ml (or Nadroparin 0.4 ml, Cibor 0.2 ml), except for children under 18 years old, 1 time per day s.c. | - | - | Patients with sepsis | Patients with sepsis | |
| Insulin (Rapid) every 6 hours s.c. | Patients with blood sugar ≥ 10 mmol/l | Patients with blood sugar ≥ 10 mmol/l | Patients with blood sugar ≥ 10 mmol/l | ||
| Omeprazole 40 mg (in children 0.5 mg/kg) 1 time at night intravenously | Except for patients with mild OS | Except for patients with mild OS | All patients | All patients | |
| Omeprazole 40 mg (in children 0.5 mg/kg) every 12 hours intravenously | - | - | Patients with gastrointestinal tract | Patients with gastrointestinal tract | |
| (in adults, category of evidence A) | |||||
| Sterofundin Iso (Ringer, Disol, Sodium chloride 0.9%) | According to the table 9 | According to the table 9 | - | - | |
| Sterofundin G-5 (Ringer, Disol, Sodium chloride 0.9%) | - | According to the table 9 | - | - | |
| HES | According to the table 9 | According to the table 9 | - | - | |
| Albumin 20% | - | According to the table 9 | According to the table 9 | Patients with albumin ≤ 30 g/L (total protein ≤ 60 g/L) | |
| Normofundin G-5 (maximum up to 40 ml/kg/day) | - | - | According to the table 9 | All patients | |
| Reamberin 400-800 ml (in children 10 ml/kg) per day for up to 11 days | - | - | - | All patients | |
| III generation cephalosporins IV, IM | - | All patients | All patients | All patients | |
| Ciprofloxacin 100 ml every 12 hours (except for children) | - | - | Patients with sepsis | Patients with sepsis | |
| Amikacin 7.5 mg/kg every 12 hours (including children) IV, IM | - | - | |||
| PSS 3000 units. | - | - | - | According to Appendix 12 to the Order of the Ministry of Health of the Russian Federation No. 174 of May 17, 1999. | |
| PSCH | - | - | - | ||
| SA | - | - | - | ||
| DTP | - | - | - | ||
| Invasive ventilation | Patients with loss of consciousness< 9 баллов по шкале Глазго (категория доказательности А); глубоким ожогом >40% (category of evidence A); deep burn on the face and progressive swelling of soft tissues (category of evidence B); severe TIT with laryngeal involvement and risk of obstruction (evidence category A); heavy TIT with combustion products (category of evidence B); ARDS | ||||
| Adrenaline 0.1% every 2 hours of inhalation for up to 7 days | Patients with TIT | Patients with TIT | Patients with severe TIT | Patients with severe TIT | |
| ACC 3-5 ml every 4 hours inhalation up to 7 days | Patients with TIT | Patients with TIT | Patients with severe TIT | Patients with severe TIT | |
| (category of evidence B) | |||||
| Heparin 5000 units. for 3 ml saline solution every 4 hours (2 hours after ACC) inhalation for up to 7 days | Patients with TIT | Patients with TIT | Patients with severe TIT | Patients with severe TIT | |
| (category of evidence B) | |||||
| Sanitation FBS every 12 hours | Patients with TIT from combustion products | Patients with severe TIT from combustion products | - | ||
| Surfactant BL 6 mg/kg every 12 hours endobronchially or inhaled for up to 3 days | Patients with severe TIT | Patients with severe TIT | Patients with ARDS | Patients with ARDS | |
| Regidron into the probe | According to the table 9 | - | - | - | |
| Enteral protein mixture into the tube in a volume of up to 45 kcal/kg/day (category of evidence A) through an infusion pump | 800 gr | According to the table 9 | According to the table 9 | Patients who are unable or unwilling to eat | |
| 3-component bag for parenteral nutrition in a volume of up to 35 kcal/kg/day through an infusion pump | - | - |
Patients who cannot tolerate enteral mixture |
Patients who are unable or unwilling to eat and cannot tolerate enteral formula | |
| Immunovenin 25-50 ml (in children 3-4 ml/kg, but not more than 25 ml) 1 time in 2 days up to 3-10 days | - | - | Patients with severe sepsis | Patients with severe sepsis | |
| Glutamine enterally 0.6 g/kg/day or IV 0.4 g/kg/day | - | All patients (category of evidence A) | |||
| Red blood cell mass | In chronic anemia and with hemoglobin below 70 g/l, indications for transfusion of red blood cell-containing blood components are clinically pronounced signs of anemic syndrome (general weakness, headache, tachycardia at rest, shortness of breath at rest, dizziness, episodes of syncope), which cannot be eliminated in for a short time as a result of pathogenetic therapy. The hemoglobin level is not the main criterion determining the presence of indications. Indications for transfusion of erythrocyte-containing blood components in patients can be determined not only by the level of hemoglobin in the blood, but also taking into account the delivery and consumption of oxygen. Transfusion of red blood cell-containing components can be indicated when hemoglobin decreases below 110 g/l, PaO2 is normal and oxygen tension in mixed venous blood (PvO2) decreases below 35 mmHg, that is, an increase in oxygen extraction above 60%. The wording of the indication is “reduced oxygen delivery during anemia, Hb ____g/l, PaO2 ____mmHg, PvO2_____mmHg. Art." If, at any hemoglobin level, venous blood oxygenation indicators remain within normal limits, then transfusion is not indicated. (Order of the Minister of Health of the Republic of Kazakhstan dated July 26, 2012 No. 501) | ||||
| SZP |
Indications for transfusion of FFP are: 1) hemorrhagic syndrome with laboratory confirmed deficiency of coagulation hemostasis factors. Laboratory signs of deficiency of coagulation hemostasis factors can be determined by any of the following indicators: prothrombin index (PTI) less than 80%; prothrombin time (PT) more than 15 seconds; international normalized ratio (INR) more than 1.5; fibrinogen less than 1.5 g/l; active partial thrombin time (APTT) more than 45 seconds (without previous heparin therapy). .(Order of the Minister of Health of the Republic of Kazakhstan dated July 26, 2012 No. 501) |
||||
Summary table of rehydration during the OS period
Table 9
| Days since injury | 1st day | 2nd day | 3rd day | |||
| 8 ocloc'k | 16 hours | 24 hours | 24 hours | |||
|
Volume, ml Compound |
2 ml x kg x % burn* |
2 ml x kg x % burn* |
2 ml x kg x % burn* |
35-45 ml/kg (IV + peros + via tube) |
||
|
Sterofundin isotonic. Sterofundin G-5 (on the 2nd day) |
100% volume | Remaining volume |
remaining volume |
- | ||
| HES | - |
10 - 20 - 30 ml/kg |
10 - 15 ml/kg |
- | ||
| Albumin 20% (ml) | - | - |
0.25 ml x kg x % burn |
with blood albumin ≤ 30 g/l | ||
| Normofundin G-5 | - | - | - | no more than 40 ml/kg | ||
| Parenteral nutrition | - | - | - | according to indications | ||
| Via probe | Regidron | 50-100 ml/hour | 100-200 ml/hour | - | - | |
| Enteral protein nutrition (EP) | 800g | - | 50 ml/hour x 20 hours |
75 ml/hour x 20 hours |
||
| Diet | Mild OS | drink | ATS | ATS | ATS | |
| Severe OS | Regidron | Regidron | EP or VBD | EP or VBD | ||
| Extremely severe OS | Regidron | Regidron | EP | EP | ||
* - if the burn area is more than 50%, the calculation is carried out at 50%
** - it is possible to count fluid administered enterally
*** - It is acceptable to take the blood albumin level as ½ of the total blood protein content. The volume of albumin solution is calculated using the formula:
Albumin 10% (ml) = (35 - blood albumin, g/l) x BCC, l x 10
where bcc, l = FMT, kg: 13
Indications for transfer to the burn department from the ICU.
Transfer of victims to the burn department is permitted:
1. after the OS period, as a rule, on the 3-4th day from the moment of injury in the absence of persistent violations of the life support function.
2. during the period of OOT, septicotoxemia in the absence or compensation of respiratory disorders, cardiac activity, central nervous system, parenchymal organs, restoration of gastrointestinal function.
Non-drug treatment, UD A ;
· Table 11, mode 1, 2. Installation of a nasogastric tube, catheterization of the bladder, catheterization of the central vein.
Table 10
| Equipment/hardware | Indications | Number of days |
| Enteral protein nutrition (nutritional support) | Extensive burns, inability to independently replenish losses | 5 - 30 days |
|
Staying on a fluidizing burn bed (type Redactron or “SAT”) |
Extensive burns on the back of the body | 7 - 80 |
|
Placing the patient in rooms with laminar heated air flow up to 30-33*C, air ionizing unit, anti-decubitus mattresses, covering the patient with a heat-insulating blanket. |
Extensive burns to the torso | 7 - 40 days |
| Argon multifunctional scalpel. | During surgical interventions | |
| ILBI | Extensive burns, intoxication | |
| UFOK | Extensive burns, intoxication | Period of toxemia and septicotoxemia |
| Ozone therapy | Extensive burns, intoxication | Period of toxemia and septicotoxemia |
Infusion therapy. IT for burns is carried out if there are clinical indications - pronounced loss of fluid through the wound surface, high hematocrit, in order to normalize microcirculation. The duration depends on the severity of the condition and can be several months. They use saline solution, saline solutions, glucose solution, amino acid solution, synthetic colloids, components and blood products, fat emulsions, multicomponent preparations for enteral nutrition.
Antibacterial therapy. For extensive burns, antibacterial therapy is prescribed from the moment of admission. Semi-synthetic penicillins, cephalosporins of I - IV generations, aminoglycosides, fluoroquinolones, carbopenems are used according to indications.
Disaggregants: p about indications: macetylsalicylic acid, pentoxifylline, low molecular weight heparins, etc. in age-specific dosages.
Local treatment of wounds., (UD A).
The goal of local treatment is to cleanse the burn wound from necrotic scab, prepare the wound for autodermoplasty, and create optimal conditions for epithelization of superficial and borderline burns.
A drug for local treatment of superficial burns should help create favorable conditions for the implementation of the reparative capabilities of the epithelium: it should have bacteriostatic or bactericidal properties, should not have irritating or painful effects, allergic and other properties, should not stick to the wound surface, and maintain a moist environment. The drug must retain all these qualities for a long time.
For local treatment, use dressings with antiseptic solutions, ointments and gels on a water-soluble and fatty base (octenidine
dihydrochloride, silver sulfadiazine, povidone-iodine, multicomponent ointments (levomekol, oflomelide), various coatings with antibiotics and antiseptics, hydrogel coatings, polyurethane foam dressings, dressings of natural, biological origin.
Dressings are carried out after 1 - 3 days. During dressings, you need to carefully remove only the top layers of the dressing after soaking with sterile water and antiseptic solutions. The layers of gauze adjacent to the wound are removed only in areas where there is purulent discharge. It is not advisable to completely change the dressing if it does not come off easily. Forcible removal of the lower layers of gauze violates the integrity of the newly emerged epithelium and interferes with the normal process of epithelization. In cases of a favorable course, the dressing applied after the initial dressing of the wound can remain on the wound until complete epithelialization and does not require changing.
It is effective to treat the wound surface with a shower of running sterile water using antiseptic washing solutions, cleansing the wound surfaces with hydrosurgical systems, piezotherapy, and ultrasonic sanitation of wounds with ultrasonic devices. After washing, the wound is covered with bandages with ointments, polyurethane foam, and non-adhesive bandages with antiseptics.
If the possibility of early surgical necrectomy is limited, it is possible to perform chemical necrectomy using Salicylic ointment 20% or 40%, benzoic acid.
List of essential medicines, (UD A) (Table 11)
Table 11
| Drug, release forms | Dosing | Duration of use | Probability % | Level of evidence | ||||
| Local anesthetic drugs: | ||||||||
| Local anesthetics (procaine, lidocaine) | According to release form | According to indications | 100% | A | ||||
| Anesthetics | A | |||||||
| Antibiotics | ||||||||
| Cefuroxime | 1.5 g IV, IM, according to instructions | According to indications, according to instructions | A | |||||
|
Cefazolin |
1 - 2 g, according to instructions |
According to indications, according to instructions | 80% | A | ||||
| Ceftriaxone | 1-2 g according to instructions | According to indications, according to instructions | 80% | A | ||||
| Ceftazidime | 1-2 g IM, IV, according to instructions | According to indications, according to instructions | 80% | A | ||||
| Cefepime | 1-2 g, IM/IV according to instructions | According to indications, according to instructions | A | |||||
|
Amoxicillin/clavulanate |
600 mg, IV according to instructions | According to indications, according to instructions | 80% | A | ||||
| Ampicillin/sulbactam | 500-1000 mg, intramuscularly, intravenously, 4 times a day | According to indications, according to instructions | 80% | A | ||||
| Vancomycin | powder/lyophilisate for the preparation of solution for infusion 1000 mg, according to the instructions | According to indications, according to instructions | 50% | A | ||||
| Gentamicin | 160 mg IV, IM, according to instructions | According to indications, according to instructions | 80% | A | ||||
| Ciprofloxacin, solution for intravenous infusion | 200 mg 2 times IV, according to instructions | According to indications, according to instructions | 50% | A | ||||
| Levofloxacin | solution for infusion 500 mg/100 ml, according to instructions | According to indications, according to instructions | 50% | A | ||||
| Carbopenems | according to instructions | According to indications, according to instructions | A | |||||
| Analgesics | ||||||||
|
Tramadol injection solution 100mg/2ml, 2 ml in ampoules 50 mg in capsules, tablets |
50-100 mg. IV, through the mouth. maximum daily dose 400 mg. |
According to indications, according to instructions | A | |||||
| Metamizole sodium 50% | 50% - 2.0 intramuscularly up to 3 times | According to indications, according to instructions |
80% |
A | ||||
| Ketoprofen | according to instructions | According to indications, according to instructions | A | |||||
| Other NSAIDs | according to instructions | According to indications, according to instructions | A | |||||
| Narcotic analgesics (promedol, fentanyl, morphine) | According to indications, according to instructions | 90% | A | |||||
| Antiplatelet agents and anticoagulants | ||||||||
| Heparin | 2.5 - 5 t. units - 4 - 6 times a day | According to indications, according to instructions | 30% | A | ||||
| Nadroparin calcium, solution for injection | 0.3, 0.4, 0.6 units s.c. | According to indications, according to instructions | 30% | A | ||||
| Enoxaparin, solution for injection in a syringe | 0.4, 0.6 6 units s.c. | According to indications, according to instructions | 30% | A | ||||
| Pentoxifylline 5% - 5.0 | intravenously, by mouth | According to indications, according to instructions | 30% | A | ||||
| Acetylsalicylic acid 0.5 | through the mouth | According to indications, according to instructions | 30% | A | ||||
| Medicines for local treatment | ||||||||
| Povidone-iodine | Bottle 1 liter | According to indications, according to instructions | 100% | A | ||||
| Chlorhexedine | Bottle 500 ml | According to indications, according to instructions | 100% | A | ||||
| Hydrogen peroxide | Bottle 500 ml | According to indications, according to instructions | 100% | A | ||||
| Octenidine dihydrochloride 1% |
Bottle 350 ml, 20 gr |
According to indications, according to instructions | 100% | A | ||||
| Potassium permanganate | To prepare an aqueous solution | According to indications, according to instructions | 80% | A | ||||
| Water-soluble and fat-based ointments (silver-containing, antibiotic and antiseptic containing, multi-component ointments) | Tubes, bottles, containers | According to indications, according to instructions | 100% | A | ||||
| Dressings | ||||||||
| Gauze, gauze bandages | meters | According to indications, according to instructions | 100% | A | ||||
| Medical bandages | PC. | According to indications, according to instructions | 100% | A | ||||
| Elastic bandages | PC. | According to indications, according to instructions | 100% | A | ||||
| Wound coverings (hydrogel, film, hydrocolloid, etc.) | Plates | According to indications, according to instructions | 80% | A | ||||
| Xenogeneic wound dressings (pork skin, calf skin, preparations based on pericardium, peritoneum, intestines) | plates | According to indications, according to instructions | 80% | A | ||||
| Corpse human skin | plates | According to indications, according to instructions | 50% | A | ||||
| Skin cell suspensions cultured using biotechnological methods | bottles | According to indications, according to instructions | 50% | A | ||||
| Infusion drugs | ||||||||
| Sodium chloride, solution for infusion 0.9% 400ml | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Lactated Ringer's solution | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Sodium chloride, potassium chloride, sodium acetate, | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Sodium chloride, potassium chloride, sodium bicarbonate | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Glucose 5.10% | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Glucose 10% | Ampoules 10 ml | According to indications, according to instructions | 80% | A | ||||
| Glucose 40% | Bottles 400 ml | According to indications, according to instructions | 80% | A | ||||
| Dextran, 10% solution for infusion | 400ml | According to indications, according to instructions | 80% | A | ||||
| Other medications (according to indications) | ||||||||
| B vitamins | ampoules | According to indications, according to instructions | 50% | A | ||||
| Vitamins of group C | ampoules | According to indications, according to instructions | 50% | A | ||||
| Vitamins of group A | ampoules | According to indications, according to instructions | 50% | A | ||||
| Tocopherols | capsules | According to indications. according to instructions | 80% | A | ||||
| H2 blockers and proton pump inhibitors | ampoules | According to indications, according to instructions | 80% | A | ||||
| Etamsylate, solution for injection in ampoule 12.5% | ampoules 2ml | According to indications, according to instructions | 50% | A | ||||
| Aminocaproic acid | Bottles | According to indications, according to instructions | 50% | A | ||||
| Diphenhydramine | Ampoules 1%-1ml | According to indications, according to instructions | 50% | A | ||||
| Prednisolone | Ampoules 30mg | According to indications, according to instructions | 50% | A | ||||
| Metoclopramide | Ampoules 0.5% -2ml | According to indications, according to instructions | 50% | A | ||||
| Human insulin | Bottles 10ml/1000 units | According to indications, according to instructions | 90% | A | ||||
| Aminophylline | Ampoules 2.5%-5ml | According to indications, according to instructions | 50% | A | ||||
| Ambroxol | 15mg-2ml | According to indications, according to instructions | 80% | A | ||||
| Furosemide | Ampoules 2ml | According to indications, according to instructions | 50% | A | ||||
| Nystatin | Tablets | According to indications, according to instructions | 50% | A | ||||
| Ambroxol | Syrup 30mg/5ml 150ml | According to indications, according to instructions | 80% | A | ||||
| Nandrolone deconoate | Ampoules 1ml | According to indications | 50% | A | ||||
|
Enteral protein nutrition (nutritive support) Sterile mixture in the ratio of proteins - 7.5 g, Fats-5.0g, carbohydrates-18.8g. Daily volume from 500ml to 1000ml. |
800g bags | According to indications | 100% | A | ||||
| 3-component bag for parenteral nutrition in a volume of up to 35 kcal/kg/day 70/180, 40/80 via infusion pump | Bags volume 1000, 1500ml | According to indications | 50% | A | ||||
*OB occurs with damage to all organs and systems of the human body, and therefore requires the use of various groups of medications (for example, gastroprotectors, cerebroprotectors). The table above cannot cover the entire group of medications used in the treatment of burn disease. Therefore, the table shows the most commonly used medications.
Surgical intervention
1.Operation - Primary surgical treatment of a burn wound.
All patients undergo primary surgical treatment of the burn wound (PHOR).
Purpose of the operation - Cleansing wound surfaces and reducing the bacterial number in the wound.
Indications-Presence of burn wounds.
Contraindications.
PHOR technique: With swabs moistened with antiseptic solutions (povidone-iodine solution, nitrofuran, octenidine hydrochloride, chlorhexedine), the skin around the burn is cleaned of contamination, foreign bodies and exfoliated epidermis are removed from the burned surface, tense large blisters are incised and their contents are released. Wounds are treated with antiseptic solutions (povidone-iodine solution, octenidine dihydrochloride, nitrofuran, chlorhexedine). Bandages with antiseptic solutions, hydrogel, hydrocolloid biological and natural coatings are applied.
2. Necrotomy.
Purpose of the operation- dissection of scars for decompression and restoration of blood supply to the limb, excursion of the chest
Indications. Circular compression by a dense necrotic scab of the chest and limbs with signs of circulatory disorders.
Contraindications. In clinical cases of compression and the threat of limb necrosis, there is no contraindication.
After treating the surgical field three times with a povidone-iodine solution, a longitudinal dissection of the burn scab is carried out to healthy tissue. There may be 2 or more cuts. In this case, the edges of the incision should diverge and not interfere with the blood supply to the limb and the excursion of the chest.
2. Operation - Necrectomy
Necrectomy differs into the following types according to deadlines.
RCN - early surgical necrectomy 3-7 days.
PCN - late surgical necrectomy 8-14 days.
HOGR - surgical treatment of a granulating wound later than 15 days.
According to the depth of tissue removed.
Tangential.
Fascial.
Initially, the timing of the upcoming necrectomy, the type and volume of the upcoming surgical intervention are planned. The average time for necrectomy is 3-14 days.
According to the depth of tissue removed.
Tangential.
Fascial.
The operation is traumatic, costly, requires massive transfusion of components and blood products, the presence of allogeneic, xenogeneic, biological, synthetic wound coverings, highly qualified anesthesiologists, resuscitators, and combustiols.
Considering the pronounced tissue trauma during these operations and the massive blood loss during their implementation, reaching up to 300 ml from one percent of the removed skin, when planning a necrectomy of more than 5%, it is necessary to form a supply of single-group FFP and red blood cells. In order to reduce blood loss, it is necessary to use hemostatic agents, both local (aminocaproic acid) and general (trinixanoic acid, ethamsylate).
Purpose of the operation- Excision of a burn scab to clean the wound and prepare for skin transplantation, reducing infectious complications and intoxication.
Indications. The presence of necrotic scab on the surface of the wound.
Contraindications. Extremely serious condition of the patient, severe infection of burn wounds, massive burns complicated by damage to the respiratory organs, severe damage to the liver, kidneys, heart, central nervous system accompanying the burn injury, diabetes mellitus in a decompensated form, the presence of bleeding from the gastrointestinal tract, a state of intoxication psychosis in patient, persistent disruption of normal hemodynamics, blood clotting disorder.
Procedure/intervention technique:
Necrectomy is performed in an operating room under general anesthesia.
After 3 times treatment of the surgical field with povidone iodine solution, subcutaneous fat is injected according to indications in order to level the relief and reduce blood loss.
Using a necrotome: electrodermatomes, Gambdi knives, ultrasonic, radio wave, hydrosurgical desectors such as various manufacturers, and an argon multifunctional scalpel can be used as a necrotome.
Within the limits of viable tissue, necrectomy is performed. Subsequently, hemostasis is performed, both local (aminocaproic acid, hydrogen peroxide, electrocoagulation) and general (trinixanoic acid, FFP, coagulation factors).
Subsequently, after the formation of stable hemostasis during limited necrectomies on an area of up to 3% and the patient’s stable condition, autodermoplasty is performed with free split autografts taken by a dermatome from donor sites.
When performing necrectomies on an area of more than 3%, there is a high risk of non-radical removal of necrotic tissue; the wound surfaces are covered with wound coverings of a natural (allogeneic skin, xenogeneic coverings), biological or synthetic nature, in order to restore the lost barrier function of the skin.
After complete cleansing of the wound surface, skin restoration is performed using skin transplantation.
Operation - Surgical debridement of a granulating wound (COGR)
Target: excision of pathological granulations and improvement of engraftment of split skin grafts.
Indications.
1. Granulating burn wounds
2. Residual long-term non-healing wounds
3. Wounds with pathological granulations
Contraindications. The patient’s condition is extremely serious, persistent disruption of normal hemodynamics.
Procedure/intervention technique:
To carry out HOGR of extensive burns, a prerequisite is the presence of an electric dermatome, a Gumby knife. Granulation treatment with hydrosurgical devices is more effective and less traumatic.
The surgical field is treated with povidone-iodine solution, chlorhexedine, and other antiseptics. Excision of pathological granulations is performed. In case of heavy bleeding, the operation is accompanied by the administration of components and blood products. The operation can result in xenotransplantation, skin allotransplantation, transplantation of keratinocyte layers, wound coverings of 2 - 4 generations.
Operation - Autodermoplasty (ADP).
It is the main operation for deep burns. ADP can be carried out from 1 to 5-6 (or more) times until the lost skin is completely restored.
Purpose of the operation- eliminate or partially reduce the wound resulting from burns by transplanting free thin skin flaps cut from undamaged areas of the patient’s body.
Indications.
1. Extensive granulating burn wounds
2. Wounds after surgical necrectomy
3. Mosaic wounds, residual wounds on an area of more than 4 x 4 cm 2 body surface
4. for extensive 3A degree burns after tangential necrectomy to accelerate epithelization of burn wounds.
Contraindications.
Procedure/intervention technique:
To carry out ADP of extensive burns, a prerequisite is the presence of an electric dermatome, a skin perforator. Manual methods of skin harvesting result in loss (“deterioration”) of the donor site, which complicates subsequent treatment.
Treatment of donor sites three times with alcohol 70%, 96%, povidone-iodine solution, chlorhexedine, octenidine dihydrochloride, skin antiseptics. Using an electrodermatome, a split skin flap with a thickness of 0.1 - 0.5 cm 2 is removed over an area of up to 1500 - 1700 cm 2. A gauze bandage with an antiseptic solution or film, hydrocoloid, hydrogel wound coverings are applied to the donor site.
Split skin grafts (according to indications) are perforated with a perforation ratio of 1: 1, 5, 1:2, 1:3, 1:4, 1:6.
Perforated grafts are transferred to the burn wound. Fixation to the wound (if necessary) is carried out with a stapler, sutures, and fibrin glue. In case of severe condition of the patient, to increase the area of wound closure, combined autoallodermoplasty, autoxenodermoplasty (mesh in mesh, transplantation in sections, etc.), transplantation with laboratory-grown skin cells - fibroblasts, keratinocytes, mesenchymal stem cells - is performed.
The wound is covered with a gauze bandage with an antiseptic solution, fat- or water-soluble ointment, and synthetic wound coverings.
Operation - Transplantation of xenogeneic skin and tissue.
Purpose of the operation
Indications.
Contraindications. The patient's condition is extremely serious, severe infection of burn wounds, persistent disruption of normal hemodynamics.
Procedure/intervention technique:
Treatment of the surgical field with an antiseptic solution (povidone-iodine, 70% alcohol, chlorhexedine). Wounds are washed with antiseptic solutions. Solid or perforated sheets of xenogeneic skin (tissue) are transplanted onto the surface of the wounds. In a combined transplantation of split autoskin and xenogeneic skin (tissue), xenogeneic tissue is applied on top of perforated autoskin with a high perforation coefficient (mesh within a mesh). The wound is covered with a gauze bandage with ointment or antiseptic solution.
Operation - Allogeneic skin transplantation.
Purpose of the operation- Temporary closure of the wound in order to reduce losses from the wound surface, protect against microorganisms, and create optimal conditions for regeneration.
Indications.
1. deep burns (3B-4 degrees) over an area of more than 15-20% of the body surface when immediate skin autotransplantation is impossible due to heavy bleeding during necrectomy. When cutting skin grafts, the total area of the wounds increases while the wounds at the site of the cut autografts are epithelialized and the transplanted grafts engraft;
2. shortage of donor skin resources;
3. impossibility of simultaneous autotransplantation of skin due to the severity of the patient’s condition;
4. as a temporary coating between stages of autoskin transplantation;
5. during the preparation of granulating wounds in deep burns for autologous skin transplantation in patients with severe concomitant diseases, with a sluggish wound process with a change of CT at each dressing;
6. for extensive 3A degree burns after tangential necrectomy to accelerate epithelization of burn wounds.
7. for extensive borderline burns in order to reduce losses through the burn wound, reduce pain, prevent microbial contamination
Contraindications. The patient's condition is extremely serious, severe infection of burn wounds, persistent disruption of normal hemodynamics.
Procedure/intervention technique:
Treatment of the surgical field with an antiseptic solution (povidone-iodine, 70% alcohol, chlorhexedine). Wounds are washed with antiseptic solutions. Solid or perforated sheets of allogeneic skin are transplanted onto the surface of wounds. In a combined transplantation of split autoskin and allogeneic (cadaveric) skin, cadaveric skin is applied over perforated autoskin with a high perforation coefficient (mesh within a mesh). The wound is covered with a gauze bandage with ointment or antiseptic solution.
Other treatments
Transplantation of cultured fibroblasts, transplantation of cultured keratinocytes, combined transplantation of cultured skin cells and autoskin.
Indications for consultation with specialists
Table 12
Indications for transfer to the intensive care unit:
1. Deterioration of the patient’s condition with the appearance of respiratory, cardiovascular, hepatic and renal failure.
2. Complications of burn disease - bleeding, sepsis, multiple organ failure
3. Serious condition after extensive skin autoplasty
Indicators of treatment effectiveness
· Cleansing the wound from necrotic tissue, clinical readiness of the wound to accept a skin graft, percentage of engraftment of skin grafts, length of hospital treatment. restoration of working capacity;
· restoration of motor function and sensitivity of the affected segment of the skin;
· epithelization of wounds;
· length of hospital treatment. restoration of working capacity;
Further management.
After the patient is discharged from the hospital, he is subject to observation and treatment in a clinic by a surgeon, traumatologist, or therapist.
Differential diagnosis
With a known history and the fact of extensive burns, a differential diagnosis is not made.
Treatment abroad
