Injuries with features. Diagnostic criteria at the hospital level

Burns are among the most common household injuries of the body. As a rule, in everyday life, burn injuries occur as a result of injury to the body by steam, boiling water, hot liquids, or harmful chemicals. Industrial burns are also found in medical practice, but the percentage of their correlation with household burns is much less. Industrial burns most often occur as a result of injury by acids, alkalis, high-temperature substances, electricity.

It is very important to know the rules for providing primary care in case of damage to the body by chemical or thermal burns. In addition, it is important to be able to recognize the severity of the burn in order to properly assess the degree of damage to the body of the victim.

Burn classification

Traumatic cases resulting from burns harmful substances or high temperature liquids are classified as follows:

When classifying a burn, the age of the victim, concomitant diseases and individual characteristics of the body must be taken into account.

How to determine the area of ​​damage in case of burns?

When determining the area of ​​the body affected by burns in adults, the “method of nines” is used. In this case, the following percentage is calculated:

For children, the area of ​​burn damage is calculated in a different way: the area of ​​the child's open palm corresponds to 1% of the area of ​​the affected area of ​​the body. Usually, similar method definitions of burns are used for skin lesions of less than 10% of the entire body.

The ratio of the area of ​​the burn and the degree of damage

1. First degree burns are mild. If the age of the victim is more than 10 and less than 50 years, then the percentage of the affected area of ​​the skin or mucous membrane should be less than 15%. If the age category of the victim corresponds to the limits of up to 10 years and more than 50 years, then the percentage of the area of ​​injury should be no more than 10%. A single burn mild stage should correspond to no more than 2% of the total injury area.
2. Second degree burns - middle stage. The age of the victim is from 10 to 50 years - the percentage of the burn area of ​​the skin is from 15 to 25%. At age category of the victim, equal to less than 10 years and older than 50 years, the percentage of the area of ​​the affected area of ​​the skin or mucous membrane is from 10 to 20%. A single burn corresponds to 2% to 10%.
3. Third degree burns are severe. If the age of the victim is more than 10 years and less than 50 years, then the total area of ​​skin lesions should be more than 25% in accordance with the entire body surface. With an age category of less than 10 years and more than 50 years, the burn area is more than 20% of the total area of ​​the skin of the entire body. A single burn with a third degree of severity is more than 10%.
4. A fourth-degree burn is a difficult stage. The total area of ​​a superficial burn is more than 30%, with internal burns the total degree of damage is more than 10%.

Symptoms:

1. pain of a mild nature;
2. redness of the skin;
3. slight swelling of the burned area of ​​the body;
4. with burns of the mucosa, perspiration or itching is manifested.

This injury belongs to the mild stage, so the victim does not need hospitalization.

10 - 15% body burns

Symptoms:

1. acute pain;
2. redness of the injured integument of the body;
3. swelling of the burnt place;
4. blistering.

• providing primary care using cooling of the burn area and neutralization of the chemical reagent;
• subsequent treatment must be prescribed by a doctor after examining the victim. As a rule, at this stage, analgesic, anti-inflammatory and anti-infective therapy is carried out;
• lotions are prescribed to the victim with medicines moisturizing and regenerating effect on the area of ​​injury on the skin;
• alternative therapy includes the treatment of the burn area with ointments based on the pulp of aloe, gruel raw potatoes or propolis.

15 - 30% body burns

Symptoms:

1. acute pain;
2. deformation of the skin;
3. necrosis of superficial tissues.

• first aid is to remove clothing from the victim that touches the burned area of ​​​​the body. After that, it is required to apply a sterile napkin to the affected skin and call a brigade emergency assistance. It is impossible to cool and wash the burn with neutralizers on your own;
• burns are treated in a hospital. Necessarily carried out therapy with the use of painkillers, antibiotics, anti-inflammatory drugs;
• the surface of the burn area is treated with anti-burn ointments;
• the use of alternative therapy is unacceptable.

30 - 50% body burns

Symptoms:

1. shock state;
2. necrosis of the affected areas of the body;
3. charring of the affected tissues.

• the victim must be immediately taken to a medical institution;
• in a hospital, therapy is carried out with the use of painkillers, sedatives, anti-inflammatory drugs and antibiotics;
• if necessary, carry out treatment with physiotherapy;
• anti-burn compresses are applied to the affected area.

50% or more body burns

Symptoms:

1. shock state;
2. charring of the superficial and deep layers of the skin;
3. often - the death of the victim.

• carrying out antishock therapy;
• external and internal treatment;
• skin grafting through surgery.

Also read with this:

In middle-aged adults, a condition is considered critical when a total burn of I degree or II-III a degree is > 30%, a burn of III b-IV degree is considered life-threatening > 10-15%.

1. The Hundreds Rule- age + total area of ​​burns in percent: up to 60 - favorable prognosis, 61-80 - relatively favorable, 81-100 - doubtful, 101 or more - unfavorable (only for adults).

2. Frank index is based on the assumption that a deep burn aggravates the patient's condition three times compared to a superficial burn, so if 1% of a superficial burn is equal to one, then a deep burn is equal to 3 units. The sum of the indicators of superficial and deep burns is the Frank index. The burn prognosis is favorable if the Frank index is less than 30 units; relatively favorable - if 30-60 units, doubtful - 61-90 units, unfavorable - more than 91 units.

burn disease

With superficial burns with an area of ​​​​more than 15% of the body surface or with deep burns over an area of ​​​​more than 10% of the body surface develops burn disease is a complex clinical symptoms – various violations the activity of organs and systems, the totality of which should be considered as a burn disease (in the elderly and children, deep lesions of even 5% of the body can be fatal). During the burn disease, 4 periods are poured:

1. Burn shock - lasts up to 3 days

2. Burn toxemia - 7-8 days (10-15 days according to Petrov).

3. Septicotoxemia - from the 10th day (from 2-3 weeks to 2-3 months) - the beginning of the period is associated with the rejection of necrotic tissues.

4. The period of convalescence. It is observed after spontaneous healing of wounds from surgical restoration of the skin.

burn shock

The specific features of burn shock, which distinguish it from traumatic shock, are: 1) the absence of blood loss, 2) severe plasma loss, 3) hemolysis, 4) peculiar renal dysfunction. In the development of shock, two main pathogenetic mechanism:

1. Excessive pain impulses lead to a change in the function of the central nervous system - first by excitation, and then by inhibition of the cortex and subcortical layer, irritation of the sympathetic center, nervous system and function enhancement endocrine glands. This causes an increase in the flow of ACTH into the blood - the antidiuretic hormone of the pituitary gland, catecholamines. It leads to spasm peripheral vessels, while maintaining vascular tone vital important organs- there is a redistribution of blood - the BCC decreases.

2. Due to thermal damage to the skin and underlying tissues under the influence of inflammatory mediators, both local and severe general disorders: plasma loss, microcirculation disorders, massive hemolysis, changes in water and electrolyte balance and acid-base balance, impaired renal function.

The leading factor in burn shock is plasma loss, due to an increase in the permeability of the walls of the capillaries, a maximum of 6-8 hours after the burn, hypovolemia develops, contributes to a further disruption of microcirculation in the kidneys, liver, pancreas - vortic necrosis develops in the burn zone, the formation of ulcers in the gastrointestinal tract. Hemolysis is the cause high content plasma potassium. Vascular permeability is impaired immediately after the burn, but reaches a clinically pronounced value after 6-8 hours. Developing hypovolemia causes hemodynamic disorders, microcirculation disorders and DIC. In the first hours after the burn, the volume of extracellular fluid decreases by 15-20% due to intensive evaporation from the surface of the burn, through healthy skin, with breathing, with vomit. The cause of oliguria is a reduction in renal blood flow due to vasospasm, a decrease in BCC, hemolysis, and a violation of the rheological properties of blood.

The mechanism of burn hypovolemia includes the following components: plasma loss and blood deposition in capillaries. With extensive burns, up to 70-80% of the total plasma volume can be lost through the burned surface. The leading cause of plasma loss is an increase in capillary permeability both in the area of ​​injury and in intact areas. This is due both to the direct action of the thermal factor and to various physiologically released active substances(histamine, bradykinin). As a result of a decrease in BCC, hemoconcentration occurs and, on the other hand, hemolysis of erythrocytes occurs. Indirect sign hemolysis is hyperbiliorubinemia, urobilinuria, and hemoglobinuria. There is a violation of microcirculation (the number of functioning capillaries decreases, most of the blood is directed through open shunts, aggregates of formed elements are formed in venules and capillaries, perfusion of organs is disturbed, centralization of blood circulation occurs) - all this leads to tissue hypoxia.

The erectile phase of shock is characterized by a general excitation of the patient, an increase in blood pressure, rapid breathing - lasts 2-5 hours, then the torpid phase develops. Modern adequate therapy can prevent this phase, it is the improper provision of medical care, belated inadequate treatment, additional traumatization of the burned contributes to the development and more severe course of the torpid phase, inhibition phenomena come to the fore.

According to the clinical course, 3 degrees of burn shock are distinguished:

I degree - heart rate 90 per minute, blood pressure - the norm or increased, hourly diuresis is not reduced, patients are excited.

II degree - with damage to 21-60% of the body surface - inhibited, weakness, consciousness is preserved, pulse 100-120 per minute, hypotension, shivering, temperature below normal, thirst, hematocrit 60-65%, metabolic acidosis.

III degree with thermal damage to 60% of the body surface 1-3 hours after the burn, consciousness is confused, lethargy, stupor. The pulse is threadlike, A/D drops to 80 mm Hg. Art., macro-microhematuria, urine dark- Brown(like "meat slops"), then anuria, hemoconcentration, hematocrit up to 70%, hyperkalemia, decompensated acidosis, t< 36º C.

Burn shock lasts from 2 to 48 (rarely up to 72) hours, after which, with a favorable outcome, it begins to recover peripheral circulation and microcirculation. The body temperature rises, diuresis normalizes. During this period, signs of the 2nd stage of burn disease begin to appear - acute burn toxemia.

Acute burn toxemia develops a maximum of 2-3 days after the burn, lasts 10-15 days. The end of this period coincides with the beginning of the suppurative process in burn wounds. Toxemia may follow burn shock or without shock.

Burn toxemia develops as a result of intoxication of the body with protein breakdown products, toxic substances, absorbed from burned tissues and possessing antigenic properties, and due to toxins secreted by microbes that seed the burn surface. Manifestations of toxemia depend on the nature of necrosis: with wet necrosis, dead tissues are quickly rejected and this period is shorter, but more severe. With dry necrosis, rejection is longer, but this period is easier to tolerate.

The development of burn toxemia is associated with the appearance of nonspecific toxins (histamine, serotonin). The nature of the toxins formed during a burn has now been determined - some of them are:

1) glycoproteins with antigenic specificity;

2) lipoproteins - burn toxins from endoplasmic membranes that lose water under the influence of heat;

3) the leading role in the pathogenesis of toxemia is played by toxic oligopeptides - medium molecules (they inhibit phagocytosis, disrupt tissue respiration);

4) bacterial factor - the source of infection - the microflora of the skin itself, the upper respiratory tract, the flora of the hospital environment.

The cardinal symptoms of toxemia are: fever up to 38-39˚ C., of central origin (cerebral edema, thermoregulation disorders), agitation, delirium, insomnia, toxic myocarditis from the heart (tachycardia, deafness of tones, hypotension, congestion in the pulmonary circulation), foci of pneumonia. On the part of the gastrointestinal tract: anorexia, thirst, vomiting, dry tongue, jaundice, during the period of toxemia, plasma loss stops, high proteolytic activity of blood serum is noted in the blood. Burn toxemia lasts 10-15 (according to Gostishchev 7-8) days. The liver may be enlarged. In the blood - rapidly progressive anemia, hypoproteinemia, increased bilirubin (indirect and direct). In the urine - protein, cylinders, patients often die at this stage. immediate cause death is often pneumonia.

Septicotoxemia- 10-14 days after the burn. It follows acute toxemia and continues until recovery (epithelialization of the burn surface) or death of the patient. In time, the onset coincides with the rejection of the burn scab and the onset of the local purulent process.

This period is divided into 2 phases:

I phase from the beginning of the rejection of the scab to complete cleansing wounds in 2-3 weeks;

II phase of the existence of granulating wounds until their complete healing.

Phase I clinic:

It has much in common with toxemia - signs of purulent intoxication (high fever, weakness, chills, anemia, toxic hepatitis).

Phase II is characterized the appearance of various complications of an infectious nature: a) pneumonia, b) acute ulcers of the gastrointestinal tract (Curling), c) burn exhaustion - wounds do not heal, granulations do not mature, d) burn sepsis - early - during a period of rapid inflammation in burn wound and late sepsis - 5-6 weeks after the injury (when the wounds have cleared of dead tissue).

Usually on the 10-12th day, more often in patients with deep burns exceeding 5-7% of the body surface or with extensive superficial ones, this is suppuration of the burn wound. But then the manifestations of sepicotoxemia are due to significant losses of protein through the wound, absorption of decay products. This period lasts until healing or surgical restoration of the skin. Temporary closure of skin defects with allo- or xenografts facilitates the course, but does not stop septicotoxemia. Clinically, septicotoxemia is characterized by resorptive fever - insomnia, tachycardia (phenomena of toxic myocarditis, microcirculation disorders persist), alimentary dystrophy associated with anorexia, dysfunction of the stomach, bacteremia appears, turning into sepsis, wound exhaustion. With the rejection of necrotic tissues and the development of granulations, the course of the burn disease becomes subacute. The general purulent infection, sepsis comes to the fore. In connection with intoxication, many symptoms coincide with the previous phase. Hypoproteinemia, anemia, and exhaustion continue and increase. This phase is inherent in deep and extensive burns.

As is known, the mortality rate to some extent can be a criterion for the effectiveness of treatment. The analysis of lethality depending on the extent, depth of the burn, age, the presence of concomitant injury and diseases makes it possible to predict the outcome of a burn disease, makes it possible to identify the most common causes of death in a given period of the disease, to state the effectiveness or ineffectiveness of a particular treatment method.

However, the absence of homogeneous groups of patients, both treated in a hospital and those who died, makes it difficult to compare literature data. Some burn centers abroad hospitalize only severe patients with extensive burns or patients of older age groups with high mortality due to local lesions. The data presented by V. S. Kulbaka et al. (1980), about patients with burns treated in the Kiev Republican Burn Center from 1960 to 1969 and from 1970 to 1979. The total mortality in the second period increased by 1 1/2 times, which is explained by an increase in the number of critical and life-incompatible lesions, an increase in the number of elderly and old age> more frequent burns of the respiratory tract, increased transfer to the burn center of heavily burned from districts and regions of the republic.

The foregoing explains the rather large difference in mortality figures given by various authors. V. Rudovsky et al. (1980) in a summary table of total mortality from burns, figures range from 5.6% to 31.4%.

Table 12 Mortality from burns in patients younger and older than 60 years

* Evans data. ** Data by V. Rudovsky et al.

The opinions of the authors regarding the prognosis of the disease are also quite contradictory. The prognosis is usually based on the extent, depth of the lesion and age. So, Muir, Barclay (1974) believe that the prognosis of the disease in 20-40-year-old patients can be favorable with a deep burn area of ​​60 and 40%, respectively. D. A. Pobochiy (1975), analyzing lethality in victims over the age of 60, found that 64% of patients in this age group die in the stage of shock, while with an area of ​​damage over 20% of the body surface, almost everyone dies, only in more late periods diseases.

V. N. Zhizhin (1971) believes that deep burns on an area of ​​​​more than half of the body surface, extensive burns, combined with severe wounds or radiation, need only be carried out symptomatic treatment(under the conditions of the civil defense system) due to a clearly unfavorable prognosis. When building a forecast of burn shock, L. I. Gerasimova (1977) suggests using the "Rule of 100", which is the sum of the digital values ​​of the age and the percentage of the total area of ​​the burn. Favorable prognosis - with an index of up to 55, doubtful - from 60 to 65 and unfavorable - from 70 to 100. In 1963, Monsaingeon modified the Risk of Death table, according to which the prognosis of the disease is determined. A significant drawback of this table is ignoring the depth of the burn lesion.

It is possible to consider the most appropriate forecasting burn injury on the basis of such key indicators, as the size of the total surface of the burn, its depth, age, combined damage to the respiratory tract. Of course, it is important to take into account the diseases preceding and concomitant with trauma, combined injuries, radiation exposure, etc. But in everyday practical activities it is impossible to use a forecast that takes into account all these factors. Therefore, only those that are inherent in thermal injury should be taken into account, and all others should be considered more or less aggravating.

We analyzed the mortality of two age groups of patients: 16-50 years old and over 50 years old (taking into account the severity of the lesion). To ensure maximum uniformity, the severity index of the lesion was used, according to which 1% of a superficial burn corresponds to 1 unit, and 1% of a deep burn corresponds to 3 units. Data on mortality in the period of burn shock are presented in Table. 13.

Table 13. Mortality in the period of burn shock

As you can see, Table. 13 confirms the position on the dependence of mortality in the period of burn shock on the severity of thermal injury and age. In addition to these two factors, the presence of burns of the respiratory tract is important for predicting the results of treatment of burn shock and burn disease in general.

When analyzing the results of treatment of victims with combined lesions of the respiratory tract, data were obtained indicating a direct relationship between mortality and the presence of burns of the respiratory tract. With combined burns of the respiratory tract among patients with thermal burns of the skin, exceeding the index of severity of the lesion 61 units, mortality is 3-4 times higher than in similar patients without burns of the respiratory tract (Table 14).

Table 14 Mortality in the period of burn shock with and without burns of the respiratory tract

Thus, the presence of burns of the respiratory tract is another aggravating factor that has a noticeable bad influence on the results of treatment of patients, significantly increases the percentage of deaths. The above gives grounds for a more objective assessment of the severity of thermal damage in victims with burns of the respiratory tract, to recommend adding 30 units to the index of severity of burn damage, determined by the depth and extent of burns of the skin. The summation in numerical terms of the most significant indicators of the severity of thermal injury makes it possible to use only the injury severity index and age in determining the prognosis.

Of great importance are the final results of the treatment of patients with burns. To a certain extent, they make it possible to determine the order of evacuation and the need to provide emergency assistance to groups of burn victims of various severity in cases of mass injuries. Mortality data in all periods of burn disease are presented in Table. 15.

Table 15 Overall mortality depending on the severity of burn injury

The figures presented in table. 15 indicate that in the late periods of burn disease, mortality among patients under 50 years of age increases sharply with burns that exceed 60 units in terms of the severity of the lesion. In the older age group, mortality is also high with burns characterized by a lesion severity index of more than 30 units.

Based on the data on lethality various groups of victims, a forecast of mortality can be made both in the period of burn shock and burn disease in general. In this case, the first is important mainly for mass injuries; under normal conditions, most burnt people can be brought out of a state of burn shock. The prognosis of the outcome of a burn disease as a whole allows you to correctly navigate the severity of the lesion, realistically assess the possibilities of treatment. Developed on the basis of mortality, the prognosis of the outcome of burn disease is given in Table. 16. This implies that with a favorable prognosis, most burned patients can be successfully treated, and deaths are extremely rare. With a doubtful prognosis, both cure and death are possible; the likelihood of both is quite high. With an unfavorable prognosis, the vast majority of those affected die, although in exceptional cases a cure is possible.

In addition to Table. 16, the prognosis of the outcome of a burn disease can be determined using a nomogram, also compiled on the basis of a study of mortality data. In it, the severity index of the lesion also consists of the vastness, depth of dermal burns and burns of the respiratory tract.

Table 16. Prognosis of the outcome of burn disease

* For burns of the respiratory tract, the severity index of the lesion takes into account burns of the skin -J- 30.

The literature describes cases of favorable outcomes of burn injury in young patients with deep burns of 40% and even 50% of the body surface, but, unfortunately, reports of successful treatment there are very few patients with such extensive deep burns. This, on the one hand, once again indicates that no prognosis can be absolute, and on the other hand, that in clinical practice all measures to save the life of the burnt should be taken, even despite the unfavorable prognosis of the disease.

An analysis of the lethality of patients with burns who have been treated in clinics over the past 10-15 years shows that for last years the structure of mortality has changed significantly: the percentage deaths in the period of burn shock, the specific mortality in the stage of toxemia and septicotoxemia increased [Klimenko L. F., Ryabaya R. D., 1980; Kulbaka V. S. et al., 1980; Rudovsky V. et al., 1980, etc.]. The change in the structure of mortality is associated with significant progress in the infusion-transfusion treatment of burn shock. The widespread introduction into practice of synthetic plasma-substituting solutions, blood products, the development of clear schemes for managing the first period of burn disease made it possible to remove the overwhelming number of burned patients from the state of burn shock. However, as experience shows, literature data critically evaluating the organizational and therapeutic measures to provide assistance to those burned in the early stages, a number of opportunities remain unused or are not used enough. First of all, this applies to the timing and volume of care at the prehospital stage.

Insufficient preparedness of doctors and secondary medical personnel in matters of thermal injury leads to an unreasonable reduction in care at the prehospital stage. Thus, patients delivered to the clinic very rarely note that in order to provide first aid, cooling of burnt surfaces was used, which reduces the duration of overheating, prevents the effects of high temperature to deeper tissues. The available numerous experimental and clinical studies clearly show that local cooling of the burn surface is practically the only significant and effective way of emergency assistance in terms of local treatment.

Features of the clinical course of burn shock, a relatively long-term general satisfactory state of health with insufficient knowledge of burn pathology in some cases leads to unjustified refusal from infusion therapy. Frequent lack of technical capabilities at the scene, transportation to the nearest medical facility, waiting for an ambulance, transportation to a hospital, registration in the emergency department, initial inspection and the establishment of an intravenous infusion sometimes takes quite a long time (several hours), during which the burned person does not receive infusion treatment. During this time, a number of violations appear that significantly worsen general state the victim, lead to a more severe course of shock and burn disease in general. Therefore, early (within 1 hour) initiation of infusion therapy for burn shock is one of the ways to improve treatment outcomes. The earlier a complex of therapeutic measures is started, the best results treatment is to be expected. The above should serve as the basis for the following provision: if for some reason a patient with extensive burns cannot be delivered to a hospital within 1 hour from the moment of injury, infusion therapy should be started at the point of first aid, continued in the ambulance, and then without interruption in the hospital.

Importance in improving the results of treatment of burn shock and further periods burn disease belongs to the adequacy of infusion-transfusion therapy of burn shock, i.e. the introduction of a sufficient amount of liquids, compliance with the rate of its administration, the order of administered drugs, etc. To normalize hemodynamics, replenish fluid losses in the first 8 hours after injury, at least 1/2 of the calculated volume should be administered, and mainly due to synthetic colloids (polyglucin, reopoliglyukin, polydez) with the addition of a small amount of glucose oleic solutions. Details of various schemes of infusion-transfusion treatment of the first period of burn disease are given above. It also emphasizes the importance of early and adequate infusion-transfusion treatment, which contributes both to reducing mortality and improving the results of treatment of burn disease in general.

Most common cause deaths in the post-shock period are infectious complications. Currently, issues of preventing complications and combating them are being intensively developed, including such important aspects how to control infection in a burn wound using a variety of antimicrobial drugs, keeping patients in isolated sterile conditions, using immunological methods to influence the reduced natural resistance of the burnt organism, developing methods for early surgical excision of deep burns with simultaneous restoration of the skin using autologous flaps, and some others. Each of them to a greater or lesser extent can improve the results of treatment, reduce the percentage of deaths. More detailed scientific developments contributing accelerated recovery the integrity of the skin, will certainly contribute to improving the results of treatment. However, one should not forget about the already developed and proven, sufficiently effective methods of local and general treatment. Their introduction into a wide clinical practice also improves the results of treatment of patients with burns.

Murazyan R.I. Panchenkov N.R. Emergency care for burns, 1983

On October 25, 2010, in the afternoon in the Belarusian city of Pinsk at the Pinskdrev-DSP plant, an explosion occurred and part of the roof and walls of the working workshop collapsed, as a result of which 2 people died on the spot and 19 were taken to a hospital, of which 14 people received thermal burns 3 and 4 degrees over 60% of the skin. According to press reports, in the hospital they were all unconscious and on artificial ventilation lungs. On the morning of October 31, 9 out of 14 hospitals died.

Approximate chronicle:

• October 25, Mon - 2 dead on the spot.
• Tue, 26 October - 1 more died in hospital.
• 27 October, Wed - 1 more.
• 28 October, Thu - 1 more.
• 29 October, Fri - 2 more.
• October 30 - 2 more died.
• October 31 - 2 more.

Why am I giving such detailed statistics? To show how severe burns and caused by them burn disease. Not only thermal. Earlier, I wrote 2 detailed articles about vinegar essence poisoning, which leads to strong chemical burns oral cavity, pharynx, esophagus and respiratory tract. But today I will tell you the most important thing about thermal burns, using the manual “ general surgery » S. V. Petrova (1999).

Flame burns are among the most severe, because. flame temperature reaches 2000 - 3000°C and additionally carbon monoxide poisoning and other combustion products occur.

The localization of burns is also very important, since the thickness of the skin and the degree of protection of clothing differ. For example, burns to the face and front of the neck are much more likely to be deep than, for example, burns to the feet.

Ceteris paribus, burns to the face and perineum are more life-threatening:

• burns damage the face eyes, mouth and airways, which greatly aggravates the condition of patients. Signs of a burn of the respiratory tract can be soot in the nose and burning of the hairs there.
• are very unpleasant perineal burns as damage may occur. urethra and anus, which requires surgical intervention.

According to press reports, the victims in Pinsk were wearing a synthetic work uniform, which burned down almost completely, which is unacceptable from the point of view of fire safety. Clothing must be non-combustible and protect against burns. rather than promote them.

Classification of burns according to the depth of the lesion

Common in Russia 4-degree classification of burns by depth(I degree, II, IIIa, IIIb, IV), and in the West - 5-degree (there Russian IIIa stage is identical to III; IIIb - IV, and IV - V, respectively).

Depth of damage at varying degrees burn.

Burn I degree: superficial damage to the epidermis. Immediately after the burn, redness and swelling are visible. After a few days, the top layer dries up and peels off.

Burn II degree: the epidermis and partly the dermis are affected, manifested by reddening of the skin, its swelling and the formation of thin-walled blisters with serous fluid. By 10-12 days, independent epithelialization occurs.

With burns of I-II degree, blood circulation and sensitivity are preserved. Healing occurs without suppuration.

At IIIa burns there is both necrosis and exudation (plasma exit from the bloodstream) with the formation of thick-walled blisters throughout the thickness of the dead epidermis and a superficial dry scab (dense dead tissue) of a light brown color or gray color. IIIa degree burns heal by:

• granulation growth (young granular connective tissue, about it below),
• epithelium formation due to preserved hair follicles, ducts of sweat and sebaceous glands,
• marginal epithelization (growth of epithelium from the edges of the wound).

Please note that burns I, II, IIIa degree called superficial, A IIIb and IV - deep. The fact is that superficial burns heal with self-closing of the defect, and with deep burns, all sources of epithelial growth die and self-epithelialization of the wound becomes impossible.

IIIa, IIIb and IV degree burns are characterized by tissue necrosis with the formation scab. Then develops purulent inflammation , due to which dead tissue is torn off and the wound is cleaned. Further, granulations are formed, scarring occurs and (only with IIIa burns) epithelialization occurs.

It looks like this
which then can turn into cicatricial.

With deep burns IIIb caused by a flame, a dense dry brown scab is formed. Healing is possible through cicatricial constriction and marginal epithelization(however, due to the latter, the formation of a strip of epithelium no more than 2-3 cm wide is possible).

Burn IV degree occurs with prolonged exposure in areas without a thick subcutaneous fat layer. A brown or black burn eschar is formed. Circular burns of the limbs are very difficult, which compress the limb like a shell, causing additional ischemic tissue necrosis (due to lack of oxygen). Possible charring of individual parts of the body.

About granulation tissue

Granulation tissue (lat. granulum- grain) - a young connective tissue formed during the healing of wounds, infarct zones, blood clots, exudates. The vessels, reaching the wound surface, form loops and again go deep into the tissue; the tops of these loops look like reddish grains, as a result of which the young connective tissue was called granulation, granular. In the future, as collagen fibers are produced by fibroblasts, the latter displace all other tissue elements, the cells become smaller, the vessels almost completely disappear and form scar tissue, which is a bundle of coarse collagen fibers with a few cells and vessels located among them.

Granulation tissue in a fresh wound.

The entire cycle of development and maturation of granulation tissue takes an average of 2-3 weeks. In some cases (for example, with disorders of innervation, circulation, vitamin deficiency, etc.), sluggishly flowing granulations or their excessively rapid maturation are observed with the formation of excessive coarse scars, called keloid.

Rough keloid scars (explanation below).

Example: a 27-year-old girl in February 2007 received a thermal burn with a IIIa-IIIb degree flame of 25% of the body surface, including the face, neck and front surface chest. Since in the treatment of burns were used exclusively conservative methods, the victim developed severe cicatricial contracture of the neck of the 4th degree, accompanied by cicatricial eversion of the lower lip. Example taken from website http://www.pirogov-center.ru/infoclinic/13/139/(National Medical and Surgical Center named after N.I. Pirogov).

Assessment of the depth of the lesion

Despite the fact that there are many methods, it is absolutely accurate and on early stage It is often not possible to distinguish between superficial and deep burns. The data of the anamnesis (information about the damaging agent, the area and duration of its action) and examination are important. I give only the most simple methods.

1) Definition circulatory disorders.

According to circulatory disorders, 3 zones of damage are distinguished:

• zone redness(hyperemia) is characteristic of superficial burns. Cell damage is reversible. When pressed, the skin turns pale.
• zone stagnation(stasis) clearly develops by the end of the first day, which is associated with severe venous congestion. When pressed, the color does not change.

  You can apply a tonometer cuff above the burn area and raise the pressure to 60-80 mm Hg. Art., while if cyanosis does not occur, then in the future there will be necrosis (scab). Damage to cells in the stasis zone is partially reversible (i.e., necrosis is possible).

• zone total absence blood circulation. The changes are irreversible. Typical for deep burns.

Zones of circulatory disorders in burns of varying degrees.

By temperature: to distinguish burns IIIa from IIIb, measure the temperature of the burned skin of the area being examined. In areas of burn IIIa, the temperature is 1.5-2 ° C higher.

2) Definition pain sensitivity.

With burns IIIa pain sensitivity sharply reduced. For burns IIIb and IV - missing completely. However, it is necessary to take into account the condition of the patient, as well as the administration of drugs ( narcotic analgesics reduce pain).

Estimate pain sensitivity is possible not only with needle pricks, but also treating the wound surface 96% alcohol. Or using hair removal: with a deep burn, the hair is removed easily and without pain for the patient, with a superficial burn, it is difficult and painful.

Estimated area of ​​burns

Since the human body has a complex shape, determine the area of ​​the burn in the usual way difficult. Therefore, in combustiology(the science of burns) uses its own cunning rules and methods. Naturally, they give a simplified picture, but are easy to use.

1) " Rule of nines"(Wallace's method, 1951): according to this rule, in an adult, all parts of the body are equal in area one or two nines. So,

• head and neck - 9%,
• front surface of the body - 18%,
• back surface of the body - 18%,
• each hand - 9%,
• each leg - 18%,
• perineum - 1%.

Determining the burn area using the rule of nines.

Children have different proportions.

2) " palm rule» (Glumov’s method, 1953): the area of ​​the burn is compared with the area the palm of the victim, equal to 1% from the entire surface of the body.

Usually, the rule of nines and the rule of the palm are used simultaneously. Other methods for determining the area of ​​burns are rarely used, because. a small difference in the accuracy of the results usually does not justify the effort and time spent.

Formula for the designation of burns according to Janelidze

The formula was first proposed in 1939 and subsequently supplemented and changed several times. Now the burn symbol looks like fraction, where the numerator is the total area of ​​the lesion in%, next to it in brackets is the area of ​​deep burns, and the denominator is the degree of burn. Before the fraction is indicated etiological factor(thermal, chemical, radiation burn), and after it - the affected area (head, torso, etc.).

This means a thermal burn of the head and neck II-III degree with a total burn area of ​​10%, of which 5% is a deep burn.

Survival prognosis about burns

According to the 1999 manual, critical at that time, a total (whole body) burn of the first degree and burns of the II-IIIa degree > 30% of the body surface were considered (although even then it was sometimes possible to save victims with burns up to 60%). Burns of IIIb and IV degree of more than 10-15% of the body, as well as burns of the face, upper respiratory tract and perineum are considered life-threatening.

Approximate methods for determining the prognosis for burns are the "rule of hundreds" and the Frank index.

1) Hundred rule(suitable for adults only). stack up patient age and % of burns body.

Result:

• 61-80 - the prognosis is relatively favorable,
• 81-100 - the forecast is doubtful,
• > 100 - the prognosis is unfavorable.

2) Frank index. stack up % of superficial burns with triple the area of ​​deep.

Result:

• 31-60 - the forecast is relatively favorable,
• 61-90 - the forecast is doubtful,
• > 91 - the prognosis is unfavorable.

Conclusion: if you figured out what is written here, then when reading the news you should understand that with 35-40% or more of deep burns, help the victims modern medicine powerless.

With an area of ​​superficial burns > 20% or deep > 10% (in children and the elderly - from 5% deep) develops burn disease. But about her - another time.

Burns are among the most common household injuries of the body. As a rule, in everyday life, burn injuries occur as a result of injury to the body by steam, boiling water, hot liquids, or harmful chemicals. Occupational burns also occur in medical practice, but the percentage of their correlation with domestic burns is much less. Industrial burns most often occur as a result of injury by acids, alkalis, high-temperature substances, electricity.

It is very important to know the rules for providing primary care in case of damage to the body by chemical or thermal burns. In addition, it is important to be able to recognize the severity of the burn in order to properly assess the degree of damage to the body of the victim.

Traumatic cases resulting from burns caused by harmful substances or high-temperature liquids are classified as follows:

• By the area of ​​the lesion - the percentage of the ratio of the burned area of ​​the body is determined;
• According to the depth of the lesion - burns are divided into 4 degrees, the first degree is the easiest and most harmless. Second-degree burns are more serious, but not dangerous lesions of the body. In third degree burns, dangerous defeat superficial areas, but the deep layers of the skin or mucous membrane are not affected. The fourth degree of a burn is the most dangerous and serious, as a result of the lesion, not only the surface layers are charred, but also deep areas of the skin or mucous membrane, up to bone deformation. Often, fourth-degree burns end in death for the victim.
• According to the phases of the course of the wound process of the affected area - primary changes and deformation of the skin or mucous membrane; inflammatory process; regeneration of damaged tissues.
• According to the periods of the course of burn consequences - soreness, shock, fainting.

When classifying a burn, the age of the victim, concomitant diseases and individual characteristics of the body must be taken into account.

How to determine the area of ​​damage in case of burns?

When determining the area of ​​the body affected by burns in adults, the “method of nines” is used. In this case, the following percentage is calculated:

• with damage to the head and neck, there are 9% of the burn surface in relation to the whole body;
• hands - 9%;
• front part of the body - 18%;
• legs - 18%;
• rear end bodies - 18%;
• perineum - 1%.

For children, the area of ​​burn damage is calculated in a different way: the area of ​​the child's open palm corresponds to 1% of the area of ​​the affected area of ​​the body. As a rule, a similar method for determining burns is used for skin lesions of less than 10% of the entire body.

The ratio of the area of ​​the burn and the degree of damage

1. First degree burns are mild. If the age of the victim is more than 10 and less than 50 years, then the percentage of the affected area of ​​the skin or mucous membrane should be less than 15%. If the age category of the victim corresponds to the limits of up to 10 years and more than 50 years, then the percentage of the area of ​​injury should be no more than 10%. A single burn at a mild stage should correspond to no more than 2% of the total injury area.
2. Second degree burns are the middle stage. The age of the victim is from 10 to 50 years - the percentage of the burn area

   skin is from 15 to 25%. With the age category of the victim equal to less than 10 years and older than 50 years, the percentage of the area of ​​the affected area of ​​the skin or mucous membrane is from 10 to 20%. A single burn corresponds to 2% to 10%.

3. Third degree burns are severe. If the age of the victim is more than 10 years and less than 50 years, then the total area of ​​skin lesions should be more than 25% in accordance with the entire body surface. With an age category of less than 10 years and more than 50 years, the burn area is more than 20% of the total area of ​​the skin of the entire body. A single burn with a third degree of severity is more than 10%.
4. A fourth-degree burn is a difficult stage. The total area of ​​a superficial burn is more than 30%, with internal burns the total degree of damage is more than 10%.

10% body burns

Symptoms:

1. pain of a mild nature;
2. redness of the skin;
3. slight swelling of the burned area of ​​the body;
4. with burns of the mucosa, perspiration or itching is manifested.

• cool the burn area with cool water;
• if the provocateur of injury is Chemical substance, then it is necessary to neutralize the burn aggressor (alkalis are absorbed by acids, acids are neutralized by alkalis);
• treatment of the burn site with moisturizing creams or sprays against burns. You can use alternative therapy and apply lotions from black tea or aloe juice to the injury site.

This injury belongs to the mild stage, so the victim does not need hospitalization.

10 - 15% body burns

Symptoms:

1. acute pain;
2. redness of the injured integument of the body;
3. swelling of the burnt place;
4. blistering.

• providing primary care using cooling of the burn area and neutralization of the chemical reagent;
• subsequent treatment must be prescribed by a doctor after examining the victim. As a rule, at this stage, analgesic, anti-inflammatory and anti-infective therapy is carried out;
• the victim is prescribed lotions with medicinal preparations of moisturizing and regenerating action on the area of ​​injury on the skin;
• folk therapy includes treating the burn area with ointments based on aloe pulp, raw potato gruel or propolis.

15 - 30% body burns

Symptoms:

1. acute pain;
2. deformation of the skin;
3. necrosis of superficial tissues.

• first aid is to remove clothing from the victim that touches the burned area of ​​​​the body. After that, it is required to apply a sterile napkin to the affected skin and call an emergency team. It is impossible to cool and wash the burn with neutralizers on your own;
• burns are treated in a hospital. Necessarily carried out therapy with the use of painkillers, antibiotics, anti-inflammatory drugs;
• the surface of the burn area is treated with anti-burn ointments;
• the use of alternative therapy is unacceptable.

30 - 50% body burns

Symptoms:

1. shock state;
2. necrosis of the affected areas of the body;
3. charring of the affected tissues.

• the victim must be immediately taken to a medical institution;
• in a hospital, therapy is carried out with the use of painkillers, sedatives, anti-inflammatory drugs and antibiotics;
• if necessary, carry out treatment with physiotherapy;
• anti-burn compresses are applied to the affected area.

50% or more body burns

Symptoms:

1. shock state;
2. charring of the superficial and deep layers of the skin;
3. often - the death of the victim.

• carrying out antishock therapy;
• external and internal treatment;
• skin grafting through surgery.

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80 percent body burn chance of surviving - what are the chances of burn victims with 50-80% body surface? - 2 answers

doctor-medic.ru

Injuries with features. For the past three years, children have not died from burns.

They say that everything is known in comparison and contrasts. This truth manifests itself especially clearly in the most complex and difficult departments of medical institutions, for example, in the burn department of the Irkutsk City Clinical Hospital No. 3. The skin is the largest organ in terms of area. human body, and her injuries (burns, frostbite, electric shock) are treated for a long time, and multi-stage, and not easy. A person can live without one kidney, without part of the liver, without a stomach, without a spleen. Man cannot live without skin! In developed countries, there are practically no burn departments - a high standard of living does not lead to such injuries, burns in children are practically not recorded there. In our country, the burn department is still in great demand due to the social specifics of this type of injury. And some people come here several times in their lives.

The most persistent work

Pain is something almost everyone fears. Pain during burns of the body is exhausting like no other (unless oncology surpasses it) - unceasing, monotonous, but this monotony has such strength and intensity that it simply drives you crazy. Movement causes pain, and even lying down does not always bring long-awaited relief. Therefore, in the burn department, not only the professional skills of doctors are of great importance, but also their personal qualities - the ability to sympathize, the ability to concentrate, work, despite the shocking pictures. After all, when a patient is brought in with 80 percent of body burns, there is no time for sentimentality. Emotional endurance and resilience with a clear understanding of the human mission of the doctor - this combination is very important.

According to science, doctors working in burn medicine are called "combustiologists". This branch of medicine studies severe burn injuries and related pathological conditions, in particular, burn shock. Treatments for these conditions are also included in science. True, in Russia today this specialization is in the register medical specialties as such, no. That is why traumatologists or surgeons deal with burns.

Andrey Shchedreev has been the head of the burn department since 1991. During the holidays, he is replaced by Elena Dolbilkina. She says there is no department random people: someone quits after the first working day, someone endures a month or two and also leaves, the principle of natural selection operates, only those who can provide such assistance remain. Today, the backbone of the department consists of five traumatologists and an anesthesiologist. Anesthesia is extremely important in this department, especially since operations are performed almost every day, 11-12 per day. In 2008-2009 there was a complete re-equipment of the department in accordance with modern standards, a major overhaul was carried out. And today, the Irkutsk burn facility has everything you need.

The department is designed for 45 beds, there are 10 more day beds. This principle is very convenient, it is done so that everyone in need can get help - there are not enough surgeons in the field, in polyclinics. There are features of thermal injury, especially in children, in which not all surgeons can correct the treatment, it is the doctor who specializes in burns that is needed. In the outpatient form, patients come in for an examination, bandaging, and then go home. This is convenient for both patients and doctors - the department is unloaded, there are situations in which it is impossible to put the full volume of those in need in the hospital. Likewise, not everyone needs surgery. Intensive care unit - 4 beds. The most severe patients come here, those who arrive at the acute moments of the first hours of injury, patients with large areas of burns, all who need resuscitation care until their condition stabilizes.

If scars prevent you from moving and living

The peculiarity of the burn department is that it is not only a complex, social department, it is the only mixed department in the region. Both adults and children are here. What is it connected with? With the harsh Russian reality. Of course, I would like to have a separate children's block or at least a floor, but so far there is no such possibility. And today it is the only department in the region with the functions of a regional burn center. Many patients are brought here by medical aviation from the regions of the Irkutsk region.

“We receive all burn injuries, frostbite, electrical injuries, people with wounds from dog bites, bedsores, in a word, all situations that require replacement and restoration of the skin, skin grafting operations,” says Elena Dolbilkina. - And we perform all types of operations - from the moment of an acute injury to work with its consequences, rehabilitation.

The peculiarity of burns is that it is an injury with consequences for both appearance and to preserve the functions of the limbs. Operations to eliminate such consequences are included in the list performed in the burn department.

- There are operations acute injury and reconstructive and restorative. There is a daily consultative reception, any person with the consequences of burns can contact us. If he needs surgical intervention and there is an opportunity to hold it, we appoint a time. If we cannot fulfill necessary operation, which means that we simply advise and send to others medical institutions where he can be provided with this type of operations.

- These operations can be called cosmetic?

- It's not so much about cosmetics, but about eliminating functional deficiencies. After severe burns, scars always form. The most difficult cases for people are when scars form in the area of ​​​​the joints, they terribly interfere with life. People with similar scars without surgical treatment become deeply disabled, unable to serve themselves. Therefore, for us the most important goal is to restore movement. Such operations are of particular importance in young people, when a person is fully able to work. That is why our tasks are not cosmetic. Our rehabilitation therapy is aimed primarily at restoring functions after burns, because these are the most serious consequences. A person with ugly skin can live, but not with scars that prevent the movement of joints - they cause physical discomfort every second and do not give a person the quality of life in which he can exist and work. There is also the problem of children's scars. It is so arranged by nature that the baby grows, but the scars do not, they do not keep pace with the development of the baby. If a burn is received in young age, then over time, the scar, which fully covered the areas and gave movement to the joints, in a grown child will not provide this function, it will interfere. And the more time passes, the higher the risk of limb deformity, possible curvature of the fingers, gait defects. This is our immediate task; eliminate scars that are only cosmetic defect, is no longer our function.

And with 80% of body burns, you can survive

Doctors say that surgery in Lately is developing rapidly. And it should be noted that everything used in the world for the treatment of burns is used in Irkutsk to one degree or another. “There is knowledge, skills, and materials. But there are also some legal issues, for example, the whole world is developing

cell therapy (the use of all kinds of new cellular materials and biological wound coverings created in this way), and in Russia it is still limited, ”says our interlocutor.

“The global trend is to reduce the number of burn departments,” Dolbilkina emphasized. - First of all, because there are very few burns in highly developed countries, this is due to the high standard of living, the peculiarities of labor protection (occupational injuries rarely occur), the habit of people to use high-quality household appliances and in accordance with the instructions for these devices. And even more so not made by artisanal methods, in their own garages from improvised means or “improved” from existing ones. The burn injury is branded as if it is a social trauma.

Another indicator is not in favor of Russia - in developed countries, there is practically no childhood burn injury. This is directly related to the peculiarities of the legislation, which provides for very serious punishments for parents up to the removal of children, deprivation of parental rights for life. In such countries, it is believed that if a child under three years old received a burn, it is one hundred percent fault of the parents. Russian legislation is very weak, there are no capital punishments for frivolous mothers. Of course, there are dramatic accidents - the child got to the kettle or pressed the button on the double boiler, and from there - hot steam. Doctors state: the most frequent burns in children are burns with boiling water. There are also tragic patterns - a mother burned one child and a few years later entered the burn department with the second. And for the first one she was not really punished, although such cases are always transferred to the juvenile inspectorate. And there have been more children in recent years - if earlier there were one or two children's wards, now sometimes even three are not enough.

Despite the fact that thermal injury has a certain moment of chance, experts say with confidence that the main provocative cause of burns and frostbite in our country was and is drunkenness. In any season. special social significance the burn department acquires in the winter. Siberia means harsh winters, a long heating period, a large number of dilapidated housing, the use of various stoves and homemade heaters as heating. Long holidays are also long alcoholic feasts. A separate problem of separation is people without a fixed place of residence, who get severe frostbite in winter. Once they have been treated and if they can walk, such patients return to the outdoors and often get repeated frostbite. Some of them enter the department every winter. If frostbite in such patients has led to the loss of limbs and they cannot leave, after discharge they are given a place in the Irkutsk hospice, where they are cared for and their documents are restored. All treatment for homeless people is paid for by the city.

Of course, patients are also admitted after fires, most often from the regions. The treatment of such an injury is associated with large material costs (however, the department today is 100 percent provided with medicines and materials), patients need constant care, and a heavy moral burden falls on the staff. How else, if several people are in the department at once with body burns of 50-60-80 percent? At the same time, doctors say that survival is not always associated with the area of ​​burns. There is also the death of patients with a small percentage of burns, but with great depth.

- Recovery, survival are associated with many factors - at what age was the burn received, from a flame or boiling water? - Elena Dolbilkina notes. What state is the person in? Does he have chronic diseases? How deeply are the skin layers affected, or are there areas left that can heal on their own? In recent years, in our department, the mortality rate is at the level of the all-Russian, sometimes even lower. And in the last three years, not a single child has died in our country. We are proud of this, this is the fact that gives us the strength to work further.

– When transplanting, only the skin of the patient is used?

- Yes, either your own skin or from an identical twin (brother or sister) takes root, this method is called autoplasty. There is another technique - alloplasty, skin transplantation from person to person. Unfortunately, foreign skin can only last 15–17 days on the burn surface, this is the period of primary engraftment, then it is rejected. Previously, this method was widely used in the world, at least in order to gain time if, for example, a person did not have his own donor resources. Now this is more difficult - the problem of AIDS has grown, we cannot guarantee that the skin donor is not infected, since incubation period the disease is long-term. There is also the problem of hepatitis C. Therefore, it is easier and more reliable to use specially designed and modern wound dressings that temporarily perform the function of the skin. Of course, they do not take root, but they provide an optimal environment - deep wound, which cannot heal on its own, is quickly cleared and prepared for surgery. And if the burn is superficial, the wound simply heals under such wound coverings. And there is another very important design feature modern coatings - this is their atraumaticity, they do not stick to the wound, such dressings are well fixed, perfectly absorb discharge from wounds and are easily removed during dressing without causing pain patients.

From Egypt to the hospital

Now that the sun has warmed up, it's time for sunburn. After a long winter, people break out to sunbathe, as if for the last time in their lives, and sometimes get severe sunburns. And these are also patients of the burn department. There are sunburns and up to 90% of the body surface. From Egypt, Turkey, some tourists come in burn shock and with serious consequences. Holidays with "charring" under the sun will lead not to chocolate tan, but to pain, blisters, and sometimes infection, followed by skin grafting. Aleksey M. from Irkutsk did not calculate the heat of the Egyptian sun. Immediately upon arrival, he was hospitalized in the burn department:

- On the May holidays, I flew to Egypt for 5 days, I had to please myself somehow. Actually, I'm a traveler with experience. But the weather was cloudy, the wind was blowing, I did not think that it was possible to tan like that. During these 5 days I wanted to do everything at once. They did not calculate the time, they sunbathed in the afternoon (the most aggressive sun), and even when the skin began to burn, I swam, did not sit in the room. I came here and asked the doctors for advice. And they put me in right away. In everything you need to know the measure, now I know for sure.

When Alexey is discharged, the doctors will not say “Goodbye”, but “Goodbye”, this is the tradition. The patients themselves go out and try to quickly forget all the details, all the torments and all the pain experienced. It's hard to forget though. Therefore, be careful with fire, with the sun, watch the children. Burns is a department where it is better not to get.