Burn shock

Description:

Burn shock - the clinical syndrome developing as a result of the system and local answer to an injury.

Symptoms of Burn shock:

Important sign of burn shock is sharp reduction of the volume of the circulating blood (VCB) which is connected with big plazmopotery, deposition and shunting of a blood-groove. In the first 6 — 10 h after an injury of OTsK can decrease by 20 — 40% in relation to initial. Clinically it is shown by reduction of the central venous pressure (CVP). Quickly haemo concentration develops that finds reflection in increase in a hemoglobin content, hematocrit, number of erythrocytes. In a blood plasma protein content decreases, the amount of residual nitrogen increases, the hyperpotassemia and a hyponatremia, a metabolic acidosis is observed. A constant sign of burn shock is decrease in a diuresis which is controlled each hour by means of a constant catheter. At an oliguria the diuresis happens less than 30 ml/h, its reduction to 300 ml is regarded per day as an anury. Color of urine saturated-yellow, and at a haemoglobinuria becomes dark cherry. The relative density of urine to 1020 — 1040 increases, the proteinuria appears. Disorders of thermal control are shown by a hypothermia, a fever, a muscular shiver. Depending on extensiveness of defeat and weight of the general state distinguish four severity of burn shock.

Little burn shock (the I degree) arises at the superficial burns occupying up to 20% of a body surface or at deep burns which area makes up to 10% of a body surface. Consciousness of the victim is kept, pallor of an integument, a muscular shiver, occasionally nausea, vomiting are noted. Tachycardia is moderate, by the ABP it is not lowered, OTsK is lowered for 10%. Most of victims of this group manages to be brought from shock by the end of the first days.

Moderately severe burn shock (the II degree) is characteristic at burns of 20 — 40% of a body surface when deep burns make no more than 20%. It is characterized by the excitement which is replaced by block. Consciousness is kept. Skin in the field of a burn pale, dry, cold. The patient is disturbed by a fever, thirst, nausea, often vomiting. Breath is speeded up, is reduced by the ABP, OTsK is lowered for 10 — 20%. Function of kidneys is broken, noted an oliguria, for the 2nd days in blood the level of residual nitrogen to 41,3 — 44,1 mmol/l increases, often there are a hamaturia and an albuminuria. Most of victims manages to be brought from state of shock within 2 days.

Heavy burn shock (Ill degree) develops at the extensive burns taking 40 — 60% of a body surface (a deep burn no more than 40%). The state is extremely heavy, the consciousness confused, the victim is slowed down. Integument of pale gray color cold. Are noted the expressed thirst, frequent vomiting, muscular spasms, short wind, cyanosis, tachycardia to 120 — 130 blows in 1 min., OTsK is lowered by 20 — 30%. Significantly function of kidneys suffers, the oliguria develops, and at patients 50 years — an anury are more senior. The amount of residual nitrogen in blood increases up to 50,7 — 56,4 mmol/l. Fight against burn shock at this group of victims is very difficult and is not always effective.

Extremely heavy burn shock (the IV degree) is observed at victims with the burns occupying over 60% of a body surface (from them deep burns — not less than 40%). The state is extremely heavy, the consciousness confused or is absent. An integument pale with a marble shade. Body temperature is reduced. The panel is threadlike, the ABP is lower than 100 mm hg. The expressed asthma is observed, in lungs wet rattles are listened. Patients are tormented by thirst, frequent vomiting like a coffee thick, digestive tract paresis develops, the metabolic acidosis accrues. Function of kidneys with development of an anury, constant hamaturia, albuminuria, haemoglobinuria is sharply broken. Amount of residual nitrogen of blood from the first o'clock more than 60,0 mmol/l. OTsK is lowered by 20 — 40%. Most of victims perishes in the first days, and the others — in the next few days. The favorable outcome is observed extremely seldom.

Inhalation of hot air, smoke leads to burns of respiratory tracts with development of respiratory insufficiency, to a poisoning with carbon monoxide and other toxic products of burning that worsens a current of burn shock.

Reasons of Burn shock:

Pain and reirritation ц.н.с are the cornerstone of its pathogeny., big плазмопотеря, a pachemia, formation of toxic, biologically active agents in a zone of a burn necrosis that leads to acute heavy frustration of the central and regional hemodynamics, microcirculation, disturbances of an acid-base state and water-salt balance.

Treatment of Burn shock:

Treatment in view of a variety and weight of disturbance of a homeostasis has to be complex. Its main directions: ensuring psychoemotional rest and fight against pain; ensuring sufficient oxygenation; correction of hemodynamic disturbances and power frustration; treatment of water and electrolytic frustration and disturbances of an acid-base state; fight against an endotoxemia; prevention of infectious complications.

Victims with heavy burns and suspicion on burn shock have to be urgently hospitalized to the intensive care care unit of the burn center. Treatment is begun during transportation at a pre-hospital stage and continued in a hospital. Burn surfaces close aseptic bintovy or the planimetric  dry or wet drying bandages impregnated with solutions of antiseptic agents. The patient is warmed, covering him with blankets. Contact warming is not recommended by hot-water bottles. In the absence of vomiting of the victim give to drink mineral water, alkaline saline solution (1/2 teaspoons of hydrosodium carbonate and 1 teaspoon of sodium chloride on 1 l of water). Reception of a large amount of electrolyte-deficient liquids can lead to so-called water poisoning.

Antishock therapy is begun with anesthesia with narcotic and non-narcotic analgesics in combination with antihistaminic drugs (2 ml of 50% of solution of analginum, 1 — 2 ml of 2% of solution of Promedolum, 1 — 2 ml of 1% of solution of Dimedrol, etc.). Good anesthetizing and sedation the neyroleptanalgeziya gives: Droperidolum (0,25% solution, on 1 — 5 ml) in combination with fentanyl (0,005% solution, on 1 — 2 ml). Already during transportation it is possible to apply effectively a mask anesthesia with nitrous oxide, Ftorotanum and intravenous administration of barbiturates (hexenal, Thiopentalum-natrium). In a hospital make the novocainic blockade having not only the anesthetizing effect, but also well influencing vegetative and trophic functions of a nervous system.

At treatment of burn shock it is necessary to follow the rule of "three catheters". One catheter is entered into a nose for oxygen inhalation, the second — into the central vein for performing infusional therapy and measurement of TsVD, the third — into a bladder for control of an hourly diuresis. At pernicious vomiting use the nazogastralny probe for aspiration of gastric contents, and at the expressed paresis of intestines apply a colonic tube.

For normalization of external respiration the patient is given a semi-sitting position, through a nasal catheter perform oxygen inhalation, administer the broncholitic drugs (an Euphyllinum, ephedrine, etc.). If the burn scab in the form of an armor covers and squeezes a thorax, then make a decompressive necrotomy for breath improvement by slits.

Infusional therapy is the main method of correction of the broken homeostasis. The volume and character of the poured liquids, speed and the sequence of introduction are defined by clinical and laboratory indicators, of which OTsK, a hematocrit, an acid-base condition, content of electrolytes in plasma, total criteria of function of kidneys, a condition of the central hemodynamics, microcirculator frustration are main. Exact establishment of these indicators at the initial stages of treatment is not always possible therefore in the first 6 — 8 h treatment the volume of the poured liquids is calculated by the rule of "double zero" (add to the area of a burn expressed as a percentage, two zero; not less than a half of the received volume make crystalloids). For example, at burn shock with defeat of 20% of a body surface it is necessary to pour 2000 ml of liquid, including 500 ml of 5% of solution of glucose, 300 ml of isotonic solution of sodium chloride, 200 ml of 4% of solution of hydrosodium carbonate, 500 ml of Polyglucinum, 500 ml желатиноля. Widely apply native colloidal solutions (the native, dry and talked nonsense blood plasma, a protein, albumine) to fight against a hypovolemia and a hypoproteinemia. At development of an oliguria or anury administration of the osmotic diuretics (a mannitol, urea, 40% of solution of glucose) appointed only after full completion of OTsK is shown. Decrease in a burn toxaemia is promoted by transfusion of low-molecular dextrans (a reopoliglyukin, Rheoglumanum, Rondexum) and drugs on the basis of polyvinylpirrolidone (Haemodesum, neohaemodesum, Neocompensanum, Polydesum). Reopoliglyukin improves microcirculation, thanks to disaggregation of erythrocytes, elimination of a staz in a precapillary and capillary network that is especially important against the background of haemo concentration and increase in viscosity of blood. Criteria of adequacy of infusional therapy are the central venous pressure within 70 — 150 mm of water column, the hourly diuresis of 1,5 — 2,0 ml/kg/h, a hematocrit of 38 — 42%.

For completion of power losses and correction of exchange processes glucose solutions, hydrolyzates of proteins (Solution Hydrolysini, a casein hydrolyzate), amino-acid mixes (polyamine, Aminonum, аминосол), cocarboxylase enter 10 — 20% (100 — 200 mg a day). DTF (1 — 2 ml of 1% of solution a day), group B vitamins, ascorbic acid.

Correction of an acid-base state elimination of acidosis is carried out by injections of alkaline solutions: 4% of solution of hydrosodium carbonate, Trisaminum, laktasol, etc. Intravenous injection of 0,25% of solution of novocaine has analgesic effect, eliminates a peripheral vasomotor spasm, normalizes permeability of fabrics, improves microcirculation. At heavy burn shock apply corticosteroids (a hydrocortisone, Prednisolonum) to correction of critical disturbances of a hemodynamics.

Prevention and treatment of cardiovascular disturbances at burn shock consists in administration of cardiac glycosides (Korglykonum, digoxin), analeptics (Cordiaminum, Sulfocamphocainum). The quantity, speed and the sequence of infusions cannot be standard and are defined by a clinical current of shock. At heavy burn shock infusion begin with jet introduction 500 ml in 1 — 2 min., further pass to drop injection, regulating it depending on TsVD, an hourly diuresis, etc. On average about 6 l of liquids are spent for each tyazheloobozhzhenny, and in the first 8 h antishock therapy of the patient has to receive a half of daily volume. For the 2nd days to the victim enter about a half of the volume of liquids received by him in the first day. Quite often infusional therapy is carried out against the background of a fractional geparinization (to 20 000 PIECES a day) under control of coagulant system of blood.