BURNS

BURNS - tissue damage occurring under the action of heat, acids, alkalis, or ionizing radiation. Depending on the etiology distinguish thermal, chemical burns, elektroozhogi and radiation burns caused by exposure to ionizing radiation.

Thermal burns. There are four degrees of burn depth. I degree burns are characterized by hyperemia and edema of the skin; II degree - detachment of the epidermis with formation of bubbles; IIIA degree - the defeat of the dermis of the skin while maintaining sprout zones and islands of epithelium in the skin appendages (sebaceous glands and sweat glands, hair follicles), of which, under favorable conditions, can self-epithelialization; IIIB degree - necrosis of all layers of the skin; IV degree - a defeat not only the skin, but also deeply lying tissues (subcutaneous tissue, muscle, bone). Burns I, II and IIIA degrees are superficial and can heal themselves. Burns IIIB and IV degrees are deep and they need to promptly restore the skin. Most affected is usually observed combination of burns of varying degrees.

For burns II and III level characterized by the formation of bubbles due to accumulation of fluid beneath the epidermis. At the II degree burns small bubbles with a light yellow contents. If you get burned IIIA degree bubbles tense, naked bottom bubble pink. Burns IIIB degree bubbles contain hemorrhagic fluid. The bottom of the bladder is a dry dull wound.

For deep burns characterized by pallid skin color or charring of tissue seal tissue with the appearance of pronounced pattern of subcutaneous veins. Pain and sensitivity is lost. Most often, the true depth of the burn can be established only after 5 - 7 days. This is because the primary necrosis occurring at the time of the damaging factors, in the days that followed expanded and deepened as a result of malnutrition adjacent tissues as a result of compression of exudate, spasm and thrombosis of small vessels.

The severity of a burn depends not only on the depth, but also on the extent of the lesion, so it is important to know the total area. Dimensions of burn wounds usually expressed as a percentage of the total surface of the skin. The most widely used methods of determining the area of ​​a burn is usually "nines" and the way his hands. According to the rule of "nines", the surface area of ​​the head and neck of an adult amounts to 9%, of one upper limb - 9% of the body in front - 18% rear body -18%, a lower limb 18%, and the perineum and external genitalia - 1% of the total body surface. The method is based on the palm of that area of ​​the palm of an adult is about 1% of the total surface of the skin. With limited lesions palm measured burn area, with subtotal lesions - an area unaffected parts of the body.

If deep burn area of ​​more than 10-15% of the body surface, the victim develops a common reaction of the body, called the burn disease. The severity of the burn disease depends on the area of ​​the burn, the victim of age, he had the presence of comorbidities and complications.

During periods of burn disease distinguish burn shock, acute burn toxemia, septic and burn during convalescence. Burn shock develops in deep burns, occupying 15% of adult body surface. The leading features of burn shock is severe pain, hypovolemia, hemoconcentration, oliguria or anuria . The reduction of circulating blood volume due to the large plazmopoterya blood deposition and shunting of blood flow. The blood and lymph flows a large amount of cell membrane degradation products (peptides, lipoproteins), intracellular enzymes, free radicals, which causes severe hemodynamic disorders, increasing the permeability of vascular membranes, worsening coagulation and rheological parameters of blood, disorders of acid-base metabolism.

Start of acute burn toxemia manifested by fever, diuresis normalization, stabilization of blood pressure, reduction in hemoconcentration (hematocrit). Characterized by poor appetite, sometimes vomiting , insomnia, fever , tachycardia . One of the most severe manifestations of burn disease is an intoxication, particularly pronounced in the first 10 - 14 days, often manifested in the form of mental disorder delirious states (disorientation, agitation, hallucinations , delusions). In the blood increases leukocytosis with a shift to the left formula, anemia, hypo-and Dysproteinemia.

When superficial lesions that occur without the express festering wounds, acute burn toxemia can go in the period of convalescence, bypassing the septic period.

The third period of burn disease - during the burn septicotoxemia - characterized by phenomena associated with festering wounds and burn eschar rejection. In this case there is purulent-resorptive fever , often develop pneumonia . In the blood, there is a high leukocytosis with a shift leukocyte left, picking anemia, hypo-and Dysproteinemia.

In patients with extensive burns often develops psychasthenia. Against this background, can occur drowsiness, becoming complicated in some patients conditions dizziness. Psychosis in burn disease is usually short-lived. After the disappearance of psychosis remains asthenia, sometimes lasting many months. Against the background of asthenic disorders are marked individual hysterical symptoms, changeable mood, fear of fire.

In the fourth period - the period of convalescence - there is a gradual healing of burn wounds, healing of skin grafts, restoration of internal organs function, the hematopoietic system, metabolism and others.

Burn disease can be complicated by sepsis, erosive and ulcerative lesions of the gastrointestinal tract, hepatitis. It is a serious complication of burns exhaustion, which is characterized by the cessation of reparative processes and progressive necrosis of wounds, sudden weight loss, up to cachexia, anemia, hypoproteinemia. There may also be affected soft tissue abscesses, erysipelas, thrombophlebitis, cellulitis, arthritis, and limfangiity lymphadenitis,

Treatment. The provision of medical care for burns are 4 stages. The first stage (pre-hospital) includes first aid, provided by way of self-help and mutual aid at the scene, as well as teams of emergency medical or health centers employees of enterprises and institutions, and outpatient treatment in the emergency station or surgeries clinics with small burns.

The second stage - in-patient treatment in the trauma, surgical departments of district (city) hospitals affected to surface, including extensive and restricted (5% of body surface) deep burns.

The third stage - specialized in-patient treatment in the burn units of regional, city hospitals, where victims are hospitalized with the surface (more than 35% of the body surface) and deep burns (15% body surface area).

The fourth stage - a specialized hospital treatment in major burn centers, where the treatment of patients with deep burns of over 15% of the body surface.

Prehospital should immediately terminate on the affected heat, smoke, toxic products of combustion, as well as take off his clothes. When a person burns, upper respiratory tract mucus removed from the oropharynx, introduced duct. After removal of the victim to a safe area he injected solution promedola or omnopona, applied to the burned surface dry cotton-gauze bandage, and if there is no clean cloth (eg, wrap the victim in a sheet). Advantageously portions fired immersion in cold water or wash them with tap water for 5 - 10 min. The victim must be given to drink at least 0.5 liters of water with dissolved 1/4 teaspoon of sodium hydrogencarbonate and 1/4 teaspoon of sodium chloride. Inside are 1-2 g acetylsalicylic acid and 0.05 g of diphenhydramine.

In outpatient burns can be treated II - II1A extent, takes up 5% of the body surface, only if they are not located on the face, neck, hands, feet; burns can be treated on the shins in the absence of venous insufficiency of the lower limbs. Affected older than 60 years with the limited degree burns II -IIIA regardless of their location it is advisable to be treated in hospital. The clinic calcined administered analgesics and sedatives, tetanus toxoid. Thereafter removed in large areas delaminated epidermis and incised bubbles and liquid is discharged from them. Burn surface with superficial burns painful, so its mechanical treatment is allowed only in the case of heavy contamination of land through irrigation with antiseptic solutions. Do not attempt to wash the asphalt when it burns. In burn wounds impose Burns does not stick to bandage the wounds with a metallized surface or sterile bandages with ointments based on water-soluble (levomekol, Levosin, dioksikol, dermazin). Subsequent ligation with the same ointments carried out every day or every other day until complete healing of wounds.

After healing of burns IIIA degree in their place may develop keloids. With a view to their prevention, especially for burns face, hands and feet, the newly healed wound elastic pressure bandage is applied. With the same purpose prescribed physiotherapy (ultrasound, magnetic therapy, mud therapy).

When a victim in the outpatient clinics in the state, regarded as a shock , it is administered analgesics, anti shock begin infusion therapy and transported to the hospital. The specialized ambulance still complex resuscitation measures aimed primarily at restoring hemodynamics. For this purpose, analgesics administered intravenously polyglukin (400 - 800 ml), sodium hydrogencarbonate (200 - 250 ml solution of 5%), glucose (0.5 - 1 L of 5% solution), corticosteroids (hydrocortisone hemisuccinate - 200 mg or prednisolone hemisuccinate - 60 mg) Korglikon (1 mL); when commencing pulmonary edema - pentamin (25 - 50 mg).

The hospital continues to infusion therapy. With deep circular burns the limbs and trunk, blood circulation and respiration, shows the urgent dissection of burn eschar until bleeding followed by the imposition of aseptic dressings. Narcotic analgesics combined with antihistamines (diphenhydramine, diprazinom et al.), Sodium oxybutyrate, Sibazonum, neuroleptic - droperidol (4 - 6 times a day). Improved rheological properties of blood reach the destination antiplatelet (pentoxifylline, dipyridamole) and heparin. In severe hypotension shown corticosteroids at high doses. Early started intensive treatment of burn shock markedly improves short- and long-term results of treatment, warned a number of serious complications.

Monitoring the condition of the patient and the effectiveness of therapy is carried out on urine output parameters, blood pressure, central venous pressure (hourly), hematocrit, acid-base status. Victims with burns of 15 - 20% of the body surface, was admitted to the hospital with no signs of shock require infusion therapy aimed at preventing the development of hemoconcentration, hypovolemia, and microcirculation disorders.

After the shock elimination from the fore-baked defense of nutritional and energy depletion, toxicity and hospital infections.

Therapeutic measures in the period of acute burn toxemia aimed at detoxification, correction of metabolic disorders, and energy, the fight against infection. Detoxification therapy includes intravenous gemodeza, reopoliglyukina holding hemodilution with forced diuresis. Victims with intoxication delirium-producing state of plasmapheresis, hemosorption, plasmasorption. Displaying high-calorie diet. Effectively conduct additional enteral feeding, in which through a permanent tube in the stomach dosed high-calorie mixture. Intravenously infused solutions of amino acids, protein hydrolysates, fat emulsions, glucose solution. Antibacterial drugs are prescribed according to the results of the crop from the wound and determine the sensitivity of flora to antibiotics and antiseptics. Patients should always receive painkillers and antihistamines, cardiac remedies, vitamins C and Group B. In order to prevent complications in the gastrointestinal tract requires the use of drugs that reduce gastric acidity (atropine, almagel).

Treatment of burn wounds carry open and closed methods. Open method is used in the House of a laminar flow of heated to 30 - 33 ° C air or in the room with infrared heat sources and air purification system. At the rear surface of the body burns effective treatment on fluidized beds, for example, type "Klinitron" (France). When the limbs of burns treatment is carried out in an open aeroterapevticheskih installations.

Private method of treatment is shown in the absence of technical support open management of wounds and bandages is the use of antiseptic ointments and antiseptic solutions. Dressings performed daily or every other day depending on the number of wound. Especially holding dressings effectively in baths with antiseptic solutions, prepared in the form of shampoos (yodopiron). In the open method of conducting the burn surface treated with a solution yodopiron 3 - 4 times a day.

Early removal of dead tissue from the effects of thermal and plastic closure of wounds formed their own skin to prevent or reduce these periods of burn disease. Therefore, necrotic tissue in the area of ​​deep burns to 15% of the body surface of excised surgically for 3 - 5 days after the burn and immediately close the resulting wound perforated autodermotransplantatom disengaged. With a favorable outcome of the surgery wound healing occurs within 3 - 3,5 weeks after the burn.

Patients after deep burns of over 10% of the body surface (or more than 3-4%, but in the joints), should undergo a course of rehabilitation (physiotherapy, removable immobilization, mud applications, etc..) In the departments of Rehabilitation clinics and hospitals. With the development of post-burn scarring expressed strains disfiguring or causing a violation of the functions carried out plastic surgery.

Prediction of burn injury in adults can be defined by the "rule of hundreds of": if the sum of the digits of the patient's age (in years) and the total lesion area (in percent) is more than 100, a poor prognosis. airway burn significantly worsens the prognosis and to take account of its impact on the index of the "rules of hundreds of" conventionally accepted that it corresponds to 15% of the deep body burns. The combination of burn injuries to bones and internal organs, or from inhalation of carbon monoxide, smoke, toxic products of combustion or exposure to ionizing radiation aggravates the prognosis.