Thermal burns
Description:
Burns thermal are burns a flame, hot steam, is hotter or the burning liquid, boiled water, from contact with the heated objects, sunblisters.
Symptoms of Thermal burns:
Weight of a course of a burn injury considerably depends on the area and depth of damage of fabrics. In our country the classification of burns based on pathoanatomical changes of the damaged fabrics is accepted.
Burns of the I degree are shown by reddening and a cutaneous dropsy.
Burns of the II degree are characterized by emergence of bubbles, napolnsnny transparent yellowish liquid. Under the exfoliated layer of an epidermis there is a naked basal layer. At burns of I-II; degrees are absent morphological changes in skin, than they essentially differ from deeper defeats.
Burns of the III degree subdivide into two look: burns of IIIA of degree - thermal - defeat actually skin, but not on all its thickness. At the same time viable deep layers of skin or appendages (hair bags, sweat and sebaceous glands, their output channels) remain. At burns of IIIB of degree there is a necrosis of skin and the necrotic scab is formed. Burns of the IV degree are followed by necrosis not only skin, but also is deeper than the located fabrics (muscles, sinews, bones, joints).
Due to the features of treatment it is reasonable to subdivide burns into two groups. The first - superficial burns of IIIA of degree at which only upper layers of skin perish. They begin to live under the influence of conservative treatment thanks to epithelization from the remained skin elements. The second group is made by deep burns - defeats of IIIB and the IV degree at which surgical treatment for the purpose of recovery of an integument is usually necessary.
Complications of thermal burns:
* Burn disease
Limited superficial burns usually proceed rather easily and heal during 1 - 3 week, without being reflected on about щ е m a condition of the victim. More hard deep burns proceed. Damage of fabrics on the area up to 10%, and at small children and persons of senile age to 5% of a body surface is followed by the expressed disorders of activity of all systems of an organism as a result of strong thermal influence. The intensive flow of nervnobolevy impulses from the extensive area of a burn leads to disturbance of relationship of processes of excitement and braking, and then to an overstrain, exhaustion and sharp disturbance of the regulating function of the central nervous system.
The disturbances arising under the influence of a burn injury in the central and peripheral nervous system lead to pathological reactions and morphological changes in cardiovascular, respiratory, endocrine, immune systems, blood, kidneys, a liver, a zheludochkokishechny path. Victims have disturbances of all types of a metabolism and oxidation-reduction processes, the burn disease with diverse clinical manifestations which cornerstone nervnodistrofichesky processes are develops.
In a pathogeny of a burn disease disturbances of a system hemodynamics and microcirculation, the expressed metabolic shifts which are characterized by a catabolic orientation and strengthening of proteolysis are of great importance.
During a burn disease it is accepted to distinguish the periods of shock, acute toxaemia, septicotoxemia and recovery, or reconvalescence.
* Burn shock
Burn shock is a response of an organism to a superstrong painful irritant. The thermal injury leading to heavy frustration of the central, regional and peripheral hemodynamics with preferential disturbance of microcirculation and exchange processes in an organism of burned is the cornerstone of it; there is a blood circulation centralization. Long pain stimulation leads to dysfunction of the central nervous system, closed glands and activity of all systems of an organism.
Frustration of a hemodynamics are characterized by haemo concentration, reduction of MOS and OTsK owing to a plazmopotera and insufficient supply of fabrics with blood. Victims have a hypoxia of fabrics and acidosis, the diuresis decreases, the expressed disturbances of vodnoelektrolitny balance, proteinaceous, carbohydrate, fatty are observed and other types of exchange, standard metabolism sharply amplifies, also the disproteinemia, a vitamin deficiency With, groups B, niacin develop progressing hypo. Development of a hypoproteinemia is promoted by the strengthened disintegration of proteins of fabrics, their loss through a wound owing to increase in permeability of walls of capillaries. The volume of the circulating erythrocytes decreases owing to their destruction in the damaged fabrics at the time of an injury, and more - as a result of pathological deposition in a capillary network of Izz of disorders of microcirculation.
Despite frustration of a hemodynamics, arterial pressure during the first hours after an injury can remain rather high that is explained by increase in the general peripheric resistance to a blood-groove which occurs owing to the vasospasm caused by increase in activity of simpatikoadrenalovy system, and also increase in viscosity of blood of Izz of haemo concentration and deterioration in its rheological properties.
Burn shock is observed at burns which area not less than 10-15% of a body surface. At children and persons 60 years of manifestation of burn shock are more senior can be observed at the smaller area of defeat.
On weight and duration of a current distinguish easy, heavy and extremely heavy burn shock.
Duration of burn shock is 24-72 h. Criteria of getting out of state of shock and transition to the second period of a burn disease are stabilization of indicators of a hemodynamics, recovery of OTsK, the IOC, lack of haemo concentration, reduction of tachycardia, normalization of arterial pressure and a diuresis, fervescence.
Diagnosis of shock is based on determination of total area of burns and the so-called Frank's index (FI), identification of disturbances of a hemodynamics and secretory function of kidneys. The total area of a burn includes superficial and deep defeats. IF - the total size of a superficial and deep burn expressed in units. An index Franca assumes that the deep burn influences the person 3 times stronger, than superficial. In this regard 1% of a superficial burn makes 1 unit of IF, and 1% of deep - 3 units of IF. The accompanying damage of airways is equivalent to 15-30 units of IF.
* Burn toxaemia
The burn toxaemia - the second period of a burn disease - arises on 2-3y days after an injury and 7-8 days proceed. It is characterized by dominance of the expressed intoxication owing to influence on an organism of the toxic products arriving from the struck fabrics, and a bacterial infection, increase in quantity of products of proteolysis, disorders of processes of utilization of antigens of skin, dysfunction of proteins - inhibitors of process of formation of products of proteolysis and neuroendocrinal regulation in an organism.
Toxics in blood of burned find in several hours after an injury. However influence of burn toxins on an organism in the period of shock is less expressed as during this period of a burn disease are noted an exit of a large amount of liquid from a vascular bed and formation of intertsellyulyarny hypostasis. Normalization or considerable improvement of a hemodynamics, vascular permeability and elimination of other disturbances characteristic of burn shock, promote return of edematous liquid and toxic products from fabrics in a vascular bed therefore organism intoxication increases.
In the period of a burn toxaemia the volume of the circulating plasma increases, but the quantity of erythrocytes progressively decreases owing to their accelerated destruction and oppression of a bone hemopoiesis. At patients anemia develops owing to what insufficiency of providing fabrics with oxygen remains.
Arterial pressure during this period of a burn disease within norm, but at some patients is noted a tendency to development of moderate hypotonia. Ventilating function of lungs worsens, the asthma causing increase in release of acid amplifies, the respiratory alkalosis develops. Sharply the albuminolysis and release of nitrogen with urine increase, the expressed disorder of vodnoelektrolitny balance is noted.
At a burn toxaemia appetite reduction, disturbance of motor function of intestines, frustration of a dream, phenomenon of the general astenisation, quite often block or motive excitement with the phenomena of intoksikatsionny psychosis, visual hallucinations, consciousness loss are, as a rule, observed'.
Weight of a current of a burn toxaemia considerably depends on the nature of damage of fabrics. In the presence of a dry necrosis the period of a toxaemia proceeds easier. At a wet necrosis suppuration of a wound develops quicker and at the victim heavy intoxication, an early septicaemia are observed, quite often there is gastrointestinal bleeding. They have a considerable reduction of protective forces of an organism against the background of which pneumonia most often develops, especially at burns of respiratory tracts. The end of the period of a burn toxaemia, as a rule, matches the expressed suppuration in a wound.
* Burn septicotoxemia
The septicotoxemia period conditionally begins with 10-12kh days of a disease and is characterized by development of an infection, putrefactive processes in wounds and a resorption in a circulatory bed of vegetans microbes in them, their toxins and products of an autolysis of the died fabrics.
In a burn wound at the same time staphylococcus, pyocyanic and intestinal sticks, proteas and their association usually vegetirut. Skin, a nasopharynx, intestines, the victim's clothes, and also an intra hospital infection are the main sources of infection of a burn wound. In a wound the purulent inflammation develops. Nekrotizirovanny fabrics, their purulent fusion create conditions for long receipt of microbes in a circulatory bed therefore bacteremia develops. Reaction of an organism to a wound process is developing of gnoynorezorbtivny fever of remittiruyushchy type at which anemia, a leukocytosis with a deviation to the left, hypo and a disproteinemia, vodnoelektrolitny shifts accrue. The disturbances of protein metabolism which are followed by the expressed negative nitrogenous balance, increase in standard metabolism and a degrowth of a body progress.
In hard cases at considerable reduction of protective forces of an organism there is burn sepsis. If during 1 - 2 meena it is possible to recover in the surgical way an integrity of integuments, then at victims with extensive burns burn exhaustion, as a rule, develops. Its essence consists in development of heavy dystrophic changes in internals and fabrics, endocrine insufficiency, deep disturbance of exchange processes, sharp reduction of protective forces of an organism and the termination of reparative processes in a wound. As characteristic displays of burn exhaustion in clinic serve the cachexia, decubituses, an adynamia, generalized osteoporosis, disturbances of activity of cardiovascular system, lungs, kidneys, a digestive tract, a liver with development of hepatitis. The degrowth of a body can reach 20-30% from initial, i.e. before receiving a thermal injury.
The septicotoxemia period, as well as previous, has no clear boundary. Recovery of an integument, gradual normalization of functions of bodies and systems of an organism, mobility testify to the beginning of the period of recovery. However disturbances of action of the heart, a liver, kidneys and other bodies can be observed 2-4 years later after a severe burn injury.
Complications of a burn disease can arise on all its extent. Special danger is constituted by sepsis most of which often develops at patients with the deep burns occupying more than 20% of a body surface. Weakening of immune system and natural factors of antimicrobic protection against the background of a massive microbic invasion at patients with heavy burns is one of sepsis origins. It is promoted by development of wet necroses already in early terms after an injury. Early sepsis is characterized by a heavy current. The condition of the patient sharply worsens, fever gains gektichesky character from razmakha of the body temperature of 2-3 °C for days, is followed pouring then. In blood find a hyperleukocytosis, a neutrocytosis with shift of a formula to the left. Blood crops usually give growth of staphylococcal microflora, quite often gram-negative. At patients reveal toxic hepatitis, paresis of a digestive tract, secondary insufficiency of function of kidneys with increase in level of residual nitrogen to 60 mmol/l and more. Quickly cardiovascular and respiratory insufficiency, a ner е д to increases about the fluid lungs develops, and in 1 - 2 day there comes death.
Generalization of an infection can happen also during the late period of a burn disease, but the course of sepsis gains long character. Patients have a hemorrhagic vasculitis, the leukocytosis with shift accrues to the left, SOE raises, young forms of neutrophils, toxic granularity, non-constant bacteremia, subfebrile body temperature come to light, develop a septic endocarditis, despite repeated hemotransfusions, anemia progresses, pneumonia develops. At the same time the areactive current of a wound process comes to light, nekrotizirovanny fabrics are badly torn away, and the appeared granulations become thinner or disappear, epithelization is absent, there are secondary necroses.
Differential diagnosis of sepsis and gnoynorezorbtivny fever is complicated. At fever of fluctuation of daily body temperature are less expressed and it decreases under the influence of disintoxication therapy and performance of free skin plastics. The serious general condition, the acute course of a disease, gektichesky body temperature, anemia, a hyperleukocytosis, paresis of a stomach and intestines, a petechia, metastatic suppurative focuses (arthritises, abscesses, phlegmons), a perversion of a wound process testify to sepsis.
The most frequent complication of a burn disease is pneumonia which arises at 9,4% burned and is much more often - at 30% and more - at the deep burns occupying over 30% of a body surface. It is revealed almost at each dead during II and III periods of a burn disease.
The course of a burn disease worsens at hepatitis which in our observations is noted at 5,6% of patients. Most hard the toxic hepatitis which is observed at 2,3% burned in the acute period of a burn disease proceeds. More favorable current is noted at the viral hepatitis which is usually coming to light during recovery at patients to whom carried out hemotransfusions or injections of native plasma.
Reasons of Thermal burns:
Thermal burns can result from influence of light radiation, a flame, boiled water or other hot liquid, steam, hot air or hot objects.
Treatment of Thermal burns:
The current and outcomes of a burn injury in many respects depend on timeliness of first aid and rational treatment throughout a disease. At burns more than 10%, and at small children of 5% of a body surface exist real danger of development of shock therefore already at first-aid treatment it is necessary to take measures for prevention of shock and an infection in a wound. For this purpose enter anesthetics (50% analginum solution with 1% solution of Dimedrol or 2% Promedolum solution). At the remained epidermis it is reasonable to cool the burned surface with a stream of cold water or other available means, and to apply a sterile bandage a wound. Reduction of a hyperthermia of fabrics, inflammatory reaction, hypostasis, depth of a necrosis, a resorption of toxics from the burned fabrics, intoxications of an organism is promoted early (within the first hour after an injury) by cryotherapy by liquid nitrogen. At localization of burns on extremities with involvement of functionally active sites it is necessary to provide a transport immobilization. Victims are evacuated in medical institution of a surgical profile in which treatment surely includes administration of antitetanic serum and a toilet of wounds.
At burns of the I degree the bandage is not applied, rather topical administration of slabodezinfitsiruyushchy drugs. Irrigation from aerosol cans the medicinal mixes containing corticosteroid hormones is reasonable.
At burns of the II degree carry out a toilet of a wound against the background of administration of anesthetics (2% solution of Promedolum or pantopon). It consists in cleaning of a wound and the warm soap water surrounding skin, 0,25% with ammonia solution, antiseptic solutions (Aethacridinum a lactate, Furacilin, chloracyl, solutions of detergents), removal of foreign bodys and scraps of epidermis. If epidermis is not desquamated, then the burned surface is processed alcohol. The whole bubbles cut or punktirut, deleting contents. The kept epidermal film protects a wound from external irritants, healing under it proceeds quicker and less painfully.
Burns of the II degree can quite be conducted in the open way as well as burns of IIIA of degree, in case of absence plentiful purulent separated and creations of optimal conditions for reparative processes in a wound. For lack of conditions of abacterial treatment after a toilet of wounds for the prevention of secondary infection and suppuration apply bandages with solutions of antiseptic agents wounds (Rivanolum 1:1000; Furacilin 1:5000; 0,1-1% dioxidin solution, etc.) or use aerosol antiinflammatory drugs (panthenol, Vinisolum, легропихт, Olasolum, Oxycortum). In cold season it is more preferable to close a wound a bandage with low-fat creams or ointments (Linimentum Synthomycini, 0,5% of furacilinum and 15% propolisovy ointments, balsam linimentum according to A. V. Vishnevsky).
In the conditions of mass defeats after a careful toilet of a burn wound it is reasonable to apply aerosols with film forming polymers (furolayer, iodvinisolum, лифузоль, пластубол, акутол, акриласепт, etc.). Their advantage consists in considerable reduction of a processing time of the burned surface, economy of a dressing material. The film protects a wound from an infection, interferes with loss of liquid through a wound, facilitates control of a current of a wound process (if it transparent) that allows to introduce amendments in treatment of a wound in case of need timely. At a smooth current of a wound process healing occurs under initially imposed film. Film coverings exclude a possibility of treatment by their liquids and it is more reliable, than bandages, protect a wound from pollution and infection. In case of need primary toilet of a burn wound can be postponed. It should not be seen off in the presence of shock at victims with heavy burns. In such cases burn wounds close slightly warmed up bandage with ointment, and them postpone a toilet until stabilization of a condition of the patient and his removal from state of shock. Also work at mass arrival of patients.
Initially applied bandage is not changed within 6-8 days. The indication to its replacement at burns of the II degree is suppuration what pains in a wound and specific blotting of a bandage testify to. At suppuration of a burn wound after its toilet with use of peroxide of hydrogen or solution of an antiseptic agent apply the vlazhnovysykhayushchy bandages containing antiseptic agents or antibiotics to which microflora of wounds is sensitive.
Healing of burns of the II degree occurs within 10-12 days. Recovery of patients happens to burns of the I degree in 3-5 days after an injury.
At burns of the III degree there is a partial necrosis of a thermal layer of skin therefore their suppuration which can lead to death of derivatives of skin and formation of the granulating wounds is more often observed. The main objective at treatment of burns of ShA of degree consists in the prevention of their deepening. It is reached by timely removal of devitalized fabrics and purposeful fight against a wound fever. During bandagings which should be made in 1-2 days gradually delete a wet necrotic scab (since 9-10th day) If a scab dry, then it is not necessary to hurry with its removal as under it there can be epithelization.
For bandagings at burns of IIIA of degree it is reasonable to use bandages with antiseptic agents (Aethacridinum a lactate, Furacilin, 0,25% solution of chloracyl, 0,5% silver nitrate solution, etc.) or antibiotics. Infrared and ultra-violet radiation of wounds allows to prevent a wet necrosis, promotes reduction purulent separated and more bystry epithelization.
In process of subsiding of exudation at the final stage of treatment of burns after rejection of nekrotizirovanny fabrics it is necessary to pass to the salve and maslyanobalzamichesky dressings (5-10% Linimentum Synthomycini, 0,5% of furacilinum, 0,1% of gentamitsinovy, 5-10% of dioxydinew, 15% propolisovy ointments, левосин, левомеколь, Olasolum, etc.) which are promoting acceleration of healing and having the expressed bactericidal effect. Ointments do not irritate a wound, give the softening and analgesic effect. Change of bandages is made in process of blotting their purulent separated (in 1-2 days).
Treatment of burns of the II-III degree can be carried out in local insulators with a controlled medium in the open way that allows to reduce the level of a bacterial obsemenennost of wounds and promotes their more bystry spontaneous epithelization.
Infuzionnotransfuzionny therapy of extensive and deep burns. Infuzionnotransfuzionny therapy in complex treatment of patients with extensive burns occupies one of the leading places. At extensive burns there is considerable metabolic cost reaching 5000-6000 kcal, or 60-70 kcal on 1 kg of body weight, and loss of nitrogen from a wound surface makes 20-50% of the general losses that leads to emergence of negative nitrogenous balance. In this regard at treatment of a burn disease during all its periods exclusive significance is attached to infuzionnotransfuzionny therapy on which correct and timely implementation the possibility of surgical treatment of patients with deep burns, and also an outcome of the disease depends.
All patients with deep burns of 10-15%, and children - 3-5% of a body surface with 1 g about day after an injury need intensive infuzionnotransfuzionny care. At the expressed intoxication intravascular injections make daily according to the individual program according to weight of a thermal injury.
At burn shock infuzionnotransfuzionny therapy provides completion in a vascular bed of liquid volumes of electrolytes, proteins and erythrocytes, improvement of exchange processes, functions of kidneys and desintoxication of an organism.
Patients with burns have less than 10-15% of a body surface if they have no vomiting, it is possible to fill liquid losses by intake of 5% of solution of glucose with vitamins C and groups B, alkaline solutions. Completion of liquid volumes of a vascular bed is reached by means of intravascular administration of liquid, and also by return to the deposited blood for active circulation by means of hemodilution.
For the purpose of performing antishock therapy and desintoxication of an organism use saline solutions (Ringera - Locke, лактасол), plasma and colloid plasma substituting drugs (реополиглюкин, Haemodesum, Polydesum, Gelatinolum, etc.) in number of 4-6 l, 5-10% glucose solution with vitamins C and groups B in a dose of 500-1000 ml in 1e days after an injury at adults. At little burn shock therapy is carried out without hemotransfusions. In case of development of heavy and extremely heavy shock of hemotransfusions (250 - 1000 ml) carry out by the end 2kh or on 3y days depending on weight of a state, hematologic indicators and function of kidneys. For the purpose of fight against acidosis at shock use 4% solution of hydrosodium carbonate which is prepared before use and enter taking into account deficit of the bases in quantity.
At persons of advanced and senile age the volume of intravenously poured liquid should not exceed 3-4 l, and children have 2-3 l a day. The volume of infuzionnotransfuzionny therapy at burn shock at children can be determined approximately according to Wallace's scheme: the trebled body weight of the child (in kilograms) is multiplied by the area of a burn (as a percentage). The received work is amount of liquid (in milliliters) which the child needs to enter during the first 48 h after a burn. It does not include physiological water requirement (700-2000 ml a day depending on age of the child) which is satisfied, in addition giving 5% glucose solution.
The ratio colloid (proteinaceous and synthetic) and crystalloid solutions is defined by weight of burn shock. Approximately at little burn shock the ratio of colloidal, saline solutions and glucose has to be 1:1:1, at heavy - 2:1:1, and at extremely heavy - 3:1:2. Two thirds of daily quantity of infusional environments enter into the first 8-12 h. On 2e days after an injury reduce the total amount of intravascularly entered liquid twice.
After completion of liquid volumes in a vascular bed what improvement of indicators of OTsK testifies to, apply osmotic diuretics. Mannitolum in the form of 20% of solution is entered at the rate of 1 g of dry matter on 1 kg of body weight of the victim, urea solution (20%) - of 150 ml with a speed of 40-60 thaws a minute. Effective diuretic remedy is lasixum which appoint in a dose 60-250 mg/days after elimination of deficit of OTsK.
When performing infusional therapy of burn shock it is possible to use 20% solution of sorbite which is entered at the rate of 1,5 - 2,5 g of dry matter on 1 kg of body weight of the patient a day. The expressed diuretic effect usually occurs 40-60 min. later after administration of osmotic diuretics. In case of need in 3-4 h they can be entered repeatedly.
Infuzionnotransfuzionny therapy at burn shock is performed in a complex with the measures directed to anesthesia, prevention or elimination of oxygen insufficiency, dysfunctions cardiovascular, respiratory systems and other bodies. For this purpose cardiotonic means, antigipoksant, antihistaminic drugs use. Intravenously enter Korglykonum, Cordiaminum on 1-2 ml 2-3 times a day, appoint oxygen for inhalation. Effect of cardiac glycosides amplifies at purpose of cocarboxylase on 50-100 mg 2 times a day which favorably influences exchange of carbohydrates. Considerable improvement of blood supply of a muscle of heart and kidneys is promoted by the Euphyllinum having also diuretic effect which is entered in the form of 2,4% of solution from 5% glucose solution on 5-10 ml to 4 times a day.
For the purpose of anesthesia intravenously enter 1% solution of morphine or 2% Promedolum solution in combination with 50% analginum solution. Use of a neuroleptic of Droperidolum in the form of 0,25% of solution provides elimination of psychomotor excitement.
At heavy and extremely heavy burn shock when infuzionnotransfuzionny therapy is insufficiently effective, the normalizing influence on a hemodynamics and function of kidneys are rendered by corticosteroids. They increase cordial emission, improve blood supply of a cardiac muscle, eliminate a spasm of peripheral vessels, recover their permeability and increase a diuresis. In the presence of burns of respiratory tracts they promote reduction of hypostasis of a bronchial tree. The patient appoint a hydrocortisone intravenously on 125 mg as a part of infusional environments or dexamethazone in a dose of 30-60 mg 3-4 times during 1 x days of performing antishock therapy before normalization of a hemodynamics and a diuresis.
Due to the disturbance of oxidation-reduction processes at burned and deficit in their organism of vitamins at implementation of infuzionnotransfuzionny therapy it is necessary to enter ascorbic acid on 5-10 ml of 5% of solution to 2-3 times, vitamins Bi, Be on 1 ml and vitamin of Vts on 100-200 mkg 3 times a day, niacin on 50 mg.
As anti-hypoxemic means with success apply sodium hydroxybutyrate (GOMK, sodium salt of hydroxy-butyric acid). Hydroxybutyrate of sodium levels shifts of BRAIDS, reduces quantity of nedookislenny products in blood, improves microcirculation. At burn shock drug is appointed intravenously on 2-4 g by 3-4 times a day (a daily dose of 10-15 g).
For the purpose of an ingibition of proteolysis and enzymes of kallikreinovy system it is reasonable to enter Contrykal on 100 000 PIECES or Trasylolum on 500 000 PIECES a day into structure of infusional environments that contributes to normalization of permeability of a vascular wall.
Patients to burn shock in 6 h after an injury have a significant increase in maintenance of a histamine in blood. In this regard pathogenetic use of antihistaminic drugs is reasonable: 1% Dimedrol solution on 1 ml 3-4 times a day, 2,5% Pipolphenum solution on 1 ml 2-3 times a day.
Infuzionnotransfuzionny therapy is carried out under control of TsVD and the ABP, pulse rate and his filling, an hourly diuresis, a hematocrit, hemoglobin level to blood, potassium concentration and sodium in plasma, BRAIDS, sugar of blood and other indicators.
Rather low TsVD (less than 70 mm w.g.) confirms insufficient compensation of OTsK and forms the basis for increase in volume and rate of introduction of infusional environments (if there is no danger of edematization of lungs). High TsVD - a symptom of heart failure in this connection it is necessary to reduce intensity of infusional therapy or temporarily to stop it.
At control of an hourly diuresis are guided by the level of 40-70 ml/h. When performing infusional therapy it is necessary to watch that concentration of sodium in plasma was not lower than 130 mmol/l and not higher than 145 mmol/l. Potassium concentration in plasma needs to be maintained at the level of 4-5 mmol/l. Bystry correction of a hyponatremia is reached by injection of 50-100 ml of 10% of solution of sodium chloride, at the same time also the hyperpotassemia usually is eliminated. Otherwise introduction of 250 ml of 25% of solution of glucose with insulin is shown.
Transfusion environments at a burn disease enter by a venipuncture or venesection of available saphenas. At the same time it is necessary to observe the principles of an asepsis and antiseptics strictly. If at carrying out therapy there is an experience of catheterization of a subclavial, jugular or femoral vein, then it is given preference. Catheterization of the central veins provides the necessary volume of infuzionnotransfuzionny therapy during the entire period more reliably while the victim is in state of shock.
At catheterization of the central veins in order to avoid tromboembolic episodes the catheter entered into a vein needs to be washed out systematically isotonic solution of sodium chloride with heparin (2-3 times a day). After the end of infusion the catheter is filled with heparin solution (2500 PIECES on 5 ml of isotonic solution) and closed a stopper. At emergence of symptoms of phlebitis or a periphlebitis of injection in this vein have to be immediately stopped. In case of development of purulent process in burn wounds, especially during the late periods of a burn disease, a catheter it is necessary to remove from a vein that it was not a conductor of a purulent infection and an origin of gnoynoseptichesky complications.
Control of adequacy of infuzionnotransfuzionny therapy in case of lack of results of laboratory researches can be exercised on clinical signs of burn shock. Pale, cold and dry skin demonstrates disturbance of peripheric circulation for which recovery can be used реополиглюкин, Gelatinolum, Haemodesum, Polydesum. Strong thirst is observed at the patient at deficit of water in an organism and development of a hypernatremia. In this case it is necessary to enter intravenously 5% glucose solution, and in the absence of nausea and vomiting - to increase liquid reception inside. Fall of saphenas, hypotonia, decrease in turgor of skin are observed at deficit of sodium. Injections of solutions of electrolytes (лактасол, Ringer's solution, 10% sodium chloride solution) promote its elimination. Severe headache, spasms, the deterioration in sight, vomiting, hypersalivation testimonial of a cellular overhydratation and water intoxication serve as indications to use of osmotic diuretics. The main signs testimonial of an exit burned from shock, are permanent stabilization of the central hemodynamics and recovery of a diuresis, elimination of a spasm of peripheral veins, warming of integuments and the beginning of fever.
In the period of a burn toxaemia infuzibnnotransfuzionny therapy is continued of 2-4 l, or 30-60 ml on 1 kg of body weight. For the purpose of fight against an alkalosis at patients with heavy burns injections of 20% of solution of glucose to 500-600 ml a day with insulin at the rate of 1 PIECE on 2-4 g of glucose and 0,5% of solution of potassium chloride to 500 ml under control of content of potassium and sodium in blood serum of the patient are reasonable.
For the purpose of desintoxication and prevention of anemia, hypo and disproteinemias are reasonable systematic transfusions of svezhekonservirovanny rezussovmestimy odnogruppny blood or its components (eritrotsitny weight, native and dry plasma, albumine, a protein) 2-3 times a week on 250-500 ml of adult and 100-200 ml to children under control of hematologic indicators (hemoglobin level, quantity of erythrocytes) which have to meet age standard. Direct hemotransfusions, transfusions of svezhegeparinizirovanny blood or blood and plasma of convalescents from the moment of which recovery after burns there passed no more than 1 year have especially expressed disintoxication effect.
Decrease in intoxication is promoted by the osmotic diuretics included in a complex of infusional environments (Mannitolum, lasixum, 30% urea solution) which injection it is reasonable to alternate to intravenous administration of low-molecular plasma substituting solutions (Haemodesum, реополиглюкин) that provides an artificial diuresis.
For the purpose of desintoxication at burns and an acute surgical infection apply a hemodialysis, hemosorption, plasma and a limfosorbtion. One of mechanisms of medical action of hemosorption are reduction of level of a proteosemia and peptidemiya, reduction of toxicity of plasma and expressiveness of metabolic frustration. Sorption allows to release reliably and quickly an organism burned from toxic metabolites. However hemosorption is followed by loss of uniform elements of blood (thrombocytes, leukocytes, erythrocytes), a fever, change of physicochemical properties of erythrocytes. The positive effect of hemosorption remains no more than 2-3 days. For providing an effective detoxication there is a need for carrying out repeated hemosorption with an interval of 24-48 h. In this regard hemosorption is justified first of all when other medical measures are ineffective. The hypovolemia and instability of a hemodynamics which are observed at extensive burns are a contraindication to use of hemosorption.
In the period of a septicotoxemia intensive infuzionnotransfuzionny care is especially necessary by preparation for surgeries and during their implementation when the strengthened completion of a metabolic cost of an organism is required. During this period of hemotransfusion on 250-500 ml 2-3 times a week alternating with transfusions of proteinaceous blood preparations and plasma substituting solutions of disintoxication action are the main component of infuzionnotransfuzionny therapy.
Along with a hemotransfusion for substitution of the continuing losses of protein, improvement of kolloidnoosmotichesky and transport function of blood essential value 2 times a week which allow to stabilize levels of crude protein and albumine in blood serum have transfusion of dry and native plasma on 250-500 ml. If hemotransfusions do not provide improvement of indicators of albuminous fraction of serum proteins, then it is reasonable to apply 5-10% albumine solution on 200-250 ml within 3-4 days, especially at patients of advanced and senile age. Solution of albumine is highly effective at compensation of losses of extracellular protein and elimination hypo and disproteinemias, maintenance of normal kolloidnoosmotichesky pressure of plasma, treatment of toxic hepatitis at burned. Maintenance of level of crude protein of blood serum of 6,5-7 g of % and albumine of 3,5-4,0 g of % is necessary for providing a favorable current of a wound process, successful preparation for an operative measure on recovery of an integument and its performance.
High metabolic cost in an organism of burned is provided owing to destruction of lipids, carbohydrates and proteins. At the same time serum proteins and proteins of fabrics, especially skeletal muscles are spent. The most expressed disturbances of protein metabolism arise within the first weeks of a burn disease at patients with heavy burns. Albumine and only some part of uglobulin are exposed to a catabolism generally, deficit of intracellular and extracellular proteins, proteinaceous insufficiency develop hypo and диспротеинемйя. Clinically it is shown by exhaustion, an atrophy of muscles, a body degrowth.
The period of a burn disease is of great importance for completion of a metabolic cost and recovery of nitrogenous balance of late parenteral food which allows to provide the patient with easily assimilable nutrients and to compensate deep disturbances of all types of exchange. For parenteral food use protein hydrolyzates at the rate of 15 ml/kg (on average 800 ml), amino-acid drugs (10 ml/kg) which enter with a speed no more than 45 drops a minute, and power components (glucose, fatty emulsions).
At heavy burns glucose in the form of 10-20% of solution with insulin is entered. For reduction of insulin resistance which is quite often developing at patients with heavy burns, and improvements of processes of utilization of glucose it is reasonable to apply tocopherol in the form of 10% of solution on 1 ml of 1 times a day. For the purpose of parenteral food it is possible to use sorbitol and fatty emulsions.
At many patients parenteral food can be replaced with success enteral - by means of the probe entered through the nasal course into a stomach or a duodenum. For enteral probe food use the mixes containing glucose, proteins and fats which enter in the drop way (20-30 drops a minute). They can be entered only after recovery of the soaking-up and motor function of intestines.
In the period of an acute burn toxaemia and a septicotoxemia infuzionnotransfuzionny therapy should be carried out against the background of a balanced diet with use of the high-calorific food containing 120-140 g of protein, mineral salts, vitamins A With, group B which energy value not less than 3500-4000 kcal.
The Gnoynodemarkatsionny inflammation in a burn wound leads to fusion and rejection of nekrotizirovanny fabrics. At the same time organism intoxication owing to absorption of products of purulent fusion of fabrics and microbic toxins amplifies. Intoxication of an organism can be considerably reduced at treatment of patients in the conditions of the managed abacterial environment using an open way of maintaining a wound in insulators with infrared radiation on a krovatisetka with constant blowing of wounds with warm air and oxygenotherapies. The constant unidirectional movement of the warmed-up sterile air substantially reduces power losses at burned, reduces exudation and a microbic obsemenennost of burn wounds, turns a wet necrosis in dry thanks to what protein losses decrease, activity of proteolytic enzymes in a wound decreases, the accelerated epithelization at superficial burns is noted, there is an opportunity to remove a burn scab in earlier terms and to prepare a wound for recovery of an integument.
Availability of the damaged fabrics is the main reason for development of a burn disease therefore removal of nekrotizirovanny fabrics and recovery of an integument - the main objective of treatment of patients with deep burns. All other events held in the course of complex general and topical treatment are directed to preparation for kozhnoplastichesky operations.
Surgical treatment. Indications, choice of a method and terms of performance of skin plastics. The general condition and age of the victim, extensiveness of defeat and localization of deep burns, existence of donor resources of skin and a condition of the perceiving bed have crucial importance at establishment of terms of carrying out and the choice of a method of an operative measure, and also way of recovery of an integument.
At limited deep burns the most rational method is full excision of nekrotizirovanny fabrics in the first 2 days after an injury with simultaneous suture on a wound if its sizes, a condition of the patient and surrounding fabrics allow. If it is not possible to pull together edges of a wound, then carry out primary free or combined (a combination of free and local skin plastics) skin plastics.
Early excision is possible only in the presence of a dry scab. It is especially necessary at localization of limited deep burns in joints, a brush and fingers. Due to the high functional activity of a brush and fingers, complexity of their functions it is reasonable to make excision of a necrotic scab and when skin derivatives (degree ShA burns) remained and the epithelization of wounds which is usually followed by scarring is possible.
At the burns which are followed by an osteonecrosis in functionally active areas it is reasonable to make early excision of impractical sites of a bone, without expecting it spontaneous sequestration, with simultaneous substitution of defect by the combined skin plastics if the condition of surrounding fabrics allows. At the same time the bone tissue is closed a rotational piece of leather with a hypodermic fatty tissue or a rag on the feeding leg, and again formed defect is eliminated by means of free skin plastics.
At the same time, as showed our experimental and clinical observations, at burns in the field of a calvaria with injury of bones treatment with preservation of impractical sites of a bone is quite possible. In case of absence of suppuration in a wound delete impractical soft tissues, make ultrasonic cavitation and a multiple craniotomy a conic and circular-shaped cutter to the bleeding layer of a bone and cover the center of an osteonecrosis with the kozhnofastsialny rag which is well supplied by blood from local fabrics or from the remote body parts. In such cases osteonecrotic sites are not sequestered and there is a resorption of impractical elements of a bone to its gradual new growth.
The early necretomy made in the first 4-10 days after an injury in the conditions of abacterial keeping of patients - the most optimum method of operation. By this time there is the clearest a border of a deep burn and a certain stabilization of a condition of the patient with extensive defeats is noted. The exception is made by patients who have circular deep burns of a trunk when the threat of sharp disturbance of breath owing to a prelum of a thorax or the same extremities at which blood supply of their distal departments and glubzhelezhashchy fabrics is broken is created. In such cases the urgent multiple decompressive necrotomy or a partial necretomy which allows to eliminate a prelum and the frustration caused by it is shown.
Tactics and equipment of a necretomy. At implementation of an early necretomy it is the most reasonable to make layer-by-layer excision of a burn scab by means of an electrodermatom before emergence of the continuous evenly bleeding wound surface. Such excision of a burn scab allows to keep viable fabrics to a large extent, to considerably reduce duration of the most traumatic stage of operation and to create a plain surface of a wound that provides the best prileganiye of transplants at skin plastics and more favorable conditions for their engraftment.
The hemostasis during operation is reached by imposing of gauze napkins with solution of peroxide of hydrogen or aminocapronic acid. Large blood vessels alloy. Due to the difficulties arising at a bleeding stop, in certain cases operation is carried out in two stages. At the second stage which is carried out in 2-3 days after a necretomy make free skin plastics of earlier prepared bed. By this time there comes the reliable hemostasis after imposing of a pressure aseptic bandage, and also sites of nekrotizirovanny fabric which were not removed at the first stage come to light. Additional removal of impractical fabrics promotes more successful result of operation on skin transplantation. In the aseptic wound which is formed after early excision of nekrotizirovanny fabrics optimal conditions for engraftment of skin transplants are created.
Primary and early skin plastics in case of success allows to prevent progressing of intoxication from the defeat center, development of an infection in wounds and further development of a burn disease that leads to primary healing of burn wounds in the shortest possible time. Early recovery of an integument leads to reduction of duration of treatment and provides more favorable functional and cosmetic results of free skin plastics.
Extensive necretomy with simultaneous skin plastics - the traumatic operation which is followed by considerable blood loss. After operation there comes the aggravation of symptoms of the patient if there was no full substitution of wounds skin autografts or full engraftment. Use of the carbonic laser for excision of a burn scab allows to reduce blood loss, but difficulties arising when determining depth of damage of fabrics, and injury of operation constrain its use. In this regard an early necretomy produce generally at burns no more than 10-12% of a body surface.
In early terms the surgeons having experience of plastic surgery on condition of adequate compensation of blood loss can carry out an extensive necretomy and skin plastics only in specialized burn departments during operation and an anesthesiology grant.
Indications to secondary skin plastics. At serious condition of the patient and deep burns more than 10-15% of a body surface arise indications to performance of secondary skin plastics on the granulating surface after rejection of nekrotizirovanny fabrics. For removal of these fabrics it is reasonable to use a stage anemic necretomy in process of their outlined rejection. It is promoted by use of an enzymatic and chemical necrolysis. Removal of a burn scab by means of 40% of salicylic ointment, the benzoic acid or ointment containing 24% of salicylic and 12% of lactic acid allows to reduce duration of preoperative preparation for 5-7 days. More bystry rejection of nekrotizirovanny fabrics is promoted by systematic use of hygienic bathtubs, the rational general treatment directed to increase in reactivity of an organism, prevention of anemia and heavy disorders of protein metabolism. These actions and careful toilet of wounds during bandagings after rejection of a burn scab for the purpose of reduction of a bacterial obsemenennost allow during 2,5-3 weeks after an injury to prepare patients for skin plastics on bright, juicy and pure granulations.
Timely thorough training of wounds saves from need to excise granulations before skin plastics if they have no obviously pathological character and the perversion of a wound process is not observed. In clinical practice nevertheless quite often there are difficulties when determining readiness of the granulating wounds for skin plastics. The big obsemenennost of a wound surface pathogenic microflora at the weakened patients usually matches a bad look of granulations, a perversion of reparative processes and the expressed inflammation phenomena in a wound that in turn aggravates their general state and leads to generalization of an infection. The free skin plastics in these conditions is contraindicated. In such cases vigorous fortifying treatment and careful local antibacterial therapy which carry out until the condition of the patient improves are necessary and regenerative processes in a wound will amplify.
The beneficial effect on the current of a wound process is exerted irrigation of wounds antiseptic solutions, by hygienic bathtubs with detergents, topical administration of magnetotherapy, ultrasound, scattered laser radiation, treatment on beds of Klinitron and use of the most available method - frequent change of bandages with solutions of antiseptic agents. At patients with burn exhaustion and a sluggish current of a wound process hormonal therapy by glucocorticoids and anabolic steroids against the background of use of antibiotics under control of sensitivity of microflora of wounds to them is reasonable.
Existence of the uniform, granular, juicy, but not friable and not bleeding granulations with moderate separated and the expressed epithelization border around a wound serves as a good indicator of its suitability to skin plastics.
The optimum perceiving bed for skin transplants is the young granulyatsionny fabric rich with blood vessels and with a small amount of fibrous elements that usually promotes the period from 2,5 to 6 weeks after a burn. It is optimum term for performance of free skin plastics on the granulating surface.
