Burn – the damage of fabrics caused by local influence of high temperatures (more than 55-60 C), aggressive chemicals, electric current, light and ionizing radiation. On depth of defeat of fabrics allocate 4 degrees of a burn. Extensive burns lead to development of a so-called burn disease dangerous by a lethal outcome because of violation in work of cardiovascular and respiratory systems, and also emergence of infectious complications. Local treatment of burns can be carried out by the opened or closed way. It is surely supplemented with the anesthetizing treatment, according to indications - antibacterial and infusional therapy.
Burn – the damage of fabrics caused by local influence of high temperatures (more than 55-60 C), aggressive chemicals, electric current, light and ionizing radiation. Slight burns – the most widespread trauma. Heavy burns take the second place by quantity of deaths as a result of accident, conceding only to the road accidents.
- burns of integuments;
- burns of eyes;
- inhalation injuries and burns of airways.
On defeat depth:
- I degree. Incomplete damage of a blanket of skin. Is followed by reddening of skin, insignificant hypostasis, burning pain. Recovery in 2-4 days. The burn heals without trace.
- II degree. Full damage of a blanket of skin. Is followed by burning pain, formation of small bubbles. When opening bubbles bright red erosion are bared. Burns heal without formation of hems within 1-2 weeks.
- III degree. Damage of superficial and deep layers of skin.
- IIIA degree. Deep layers of skin are damaged partially. Right after a trauma the dry black or brown crust – a burn scab is formed. At a scalding a scab whitish-grayish, damp and soft.
Formation of bubbles, big, inclined to merge, is possible. When opening bubbles the motley wound surface consisting of white, gray and pink sites on which in the subsequent at a dry necrosis the thin scab reminding parchment is formed is bared, and at a damp necrosis the damp grayish fibrinny film is formed.
Painful sensitivity of the damaged site is reduced. Healing depends on quantity of the remained islands of the intact deep layers of skin at the bottom of a wound. At small quantity of such islands, and also at the subsequent suppuration of a wound independent healing of a burn is slowed down or becomes impossible.
- IIIB degree. Death of all layers of skin. Damage of hypodermic fatty cellulose is possible.
- IV degree. Carbonization of skin and subjects of fabrics (hypodermic and fatty cellulose, bones and muscles).
Burns of I-IIIA of degree are considered as superficial and can independently heal (if secondary deepening of a wound did not result from suppuration). At burns of IIIB and the IV degree removal of a necrosis with the subsequent skin plasticity is required. Exact definition of degree of a burn is possible only in specialized medical institution.
- Burns flame. As a rule, II degrees. Defeat of the big area of skin, a burn of eyes and top airways is possible.
- Burns liquid. Mainly II-III degree. As a rule, are characterized by the small area and a deep water of defeat.
- Burns ferry. Bolshaya Square and small depth of defeat. Often are followed by a burn of airways.
- Burns the heated objects. II-IV degree. Clear boundary, considerable depth. Are followed by peeling of the damaged fabrics at the termination of contact with a subject.
- Burns acid. At influence of acid there is a coagulation (turning) of protein in fabrics that causes the small depth of defeat.
- Burns alkali. Coagulation, in this case does not happen therefore damage can reach considerable depth.
- Burns salts of heavy metals. Usually superficial.
- Burns as a result of influence of sunshine. Usually I, is more rare – the II degree.
- Burns as a result of influence of laser weapon, air and land nuclear explosions. Cause instant damage to the parts of a body turned towards explosion, can be followed by burns of eyes.
- Burns as a result of impact of ionizing radiation. As a rule, superficial. Badly heal because of the accompanying radiation sickness at which fragility of vessels increases and restoration of fabrics worsens.
Malaya Square (small wounds in entry points and a charge exit), a deep water. Are followed by an electric trauma (damage of internals at influence of the electromagnetic field).
Area of defeat
Weight of a burn, the forecast and the choice of medical actions depend not only on depth, but also on the area of burn surfaces. At calculation of the area of burns at adults in traumatology use "the rule of a palm" and "the rule of the nine". According to "the rule of a palm", the area of a palmar surface of a brush approximately corresponds to 1% of a body of her owner. According to "the rule of the nine":
- the area of a neck and head makes 9% of all surface of a body;
- breast – 9%;
- stomach – 9%;
- the back surface of a trunk – 18%;
- one top extremity – 9%;
- one hip – 9%;
- one shin together with foot – 9%;
- genitalia and crotch – 1%.
The body of the child has other proportions therefore "the rule of the nine" and "the rule of a palm" cannot be applied to it. For calculation of the area of a burn surface at children Land and Brouer's table is used. In specialized medical institutions the area of burns is determined by means of special film measuring instruments (transparent films with a measured grid).
The forecast depends on depth and the area of burns, the general condition of an organism, existence of the accompanying injuries and diseases. For definition of the forecast the index of weight of defeat (IWD) and the rule hundreds (RH) is used.
Index of weight of defeat
It is applied in all age groups. At ITP of 1% of a superficial burn 1% of a deep burn – to 3 units equals to 1 unit of weight. Inhalation defeats without violation of respiratory function – 15 units, with breath malfunction – 30 units.
- favorable – less than 30 units;
- rather favorable – from 30 to 60 units;
- doubtful – from 61 to 90 units;
- adverse – 91 and more than a piece.
In the presence of the combined defeats and serious associated diseases the forecast worsens on 1-2 degrees.
It is usually applied to patients 50 years are more senior. Calculation formula: sum of age advanced in years + area of burns as a percentage. The burn of the top airways is equated to 20% of damage of skin.
- favorable – less than 60;
- rather favorable – 61-80;
- doubtful – 81-100;
- adverse – more than 100.
Superficial burns to 10-12% and deep burns to 5-6% proceed mainly in the form of local process. Violation of activity of other bodies and systems is not observed. Children, elderly people and persons with serious associated diseases have "border" between local suffering and the general process can decrease twice: to 5-6% at superficial burns and to 3% at deep burns.
Local pathological changes are defined by burn degree, time period from the moment of a trauma, a secondary infection and some other conditions. Burns of the I degree are followed by development of an eritema (reddening). For burns of the II degree vesicles (small bubbles), are characteristic of burns of the III degree – the bull (big bubbles with a tendency to merge). When peeling skin, spontaneous opening or removal of a bubble the erosion is bared (bright it is red the red bleeding surface deprived of a skin blanket).
At deep burns the site of a dry or damp necrosis is formed. The dry necrosis proceeds more favorably, looks as a black or brown crust. The damp necrosis develops at a large amount of moisture in fabrics, considerable sites and a deep water of defeat. Is the favorable environment for bacteria, often extends to healthy fabrics. After rejection of sites of a dry and damp necrosis ulcers of various depth are formed.
Healing of a burn happens in several stages:
- I stage. An inflammation, clarification of a wound from the died fabrics. 1-10 days after a trauma.
- II stage. Regeneration, filling of a wound with granulyatsionny fabric. Consists of two substages: 10-17 days – clarification of a wound from necrotic fabrics, 15-21 days – development of granulations.
- III stage. Formation of a hem, closing of a wound.
In hard cases development of complications is possible: purulent cellulitis, lymphadenitis, abscesses and gangrene of extremities.
Extensive defeats cause a burn disease – pathological changes from various bodies and systems at which proteinaceous and water-salt exchange is broken, toxins collect, protective forces of an organism decrease, burn exhaustion develops. The burn disease in combination with sharp decrease in physical activity can cause violations of functions of a respiratory, cardiovascular, urinary system and digestive tract.
The burn disease proceeds step by step:
I stage. Burn shock. Develops because of severe pain and considerable loss of liquid through a burn surface. Poses hazard to life of the patient. 12-48 hours, in some cases – proceed till 72 o'clock. The short period of excitement is replaced by the increasing block. Thirst, a muscular shiver, a fever is characteristic. Consciousness is confused. Unlike other types of shock, arterial pressure raises or remains within norm. Pulse becomes frequent, release of urine decreases. Urine becomes brown, black or dark cherry, gets a smell of burning. In hard cases consciousness loss is possible. Adequate treatment of burn shock is possible only in specialized medical institution.
II stage. Burn toksemiya. Arises at absorption in blood of products of disintegration of fabrics and bacterial toxins. Develops for 2-4 days from the moment of damage. From 2-4 to 10-15 days proceed. Body temperature is increased. The patient is excited, his consciousness is confused. Spasms, nonsense, acoustical and visual hallucinations are possible. At this stage complications from various bodies and systems are shown.
From cardiovascular system - toxic myocarditis, thromboses, perikardit. From a GIT - stressful erosion and ulcers (can be complicated by gastric bleeding), dynamic intestinal impassability, toxic hepatitis, pancreatitis. From respiratory system - hypostasis of lungs, ekssudativny pleurisy, pneumonia, bronchitis. From kidneys – piyelit, nephrite.
III stage. Septikotoksemiya. It is caused by big loss of protein through a wound surface and reaction of an organism to an infection. Proceeds from several weeks to several months. Wounds with a large number of purulent separated. Healing of burns stops, sites of an epitelization decrease or disappear.
Fever with big fluctuations of body temperature is characteristic. The patient sluggish, suffers from a sleep disorder. Appetite is absent. Considerable weight reduction (in hard cases loss 1/3 body weights is possible) is noted. Muscles atrophy, mobility of joints decreases, bleeding amplifies. Decubituses develop. Death comes from the general infectious complications (sepsis, pneumonia). At favorable option of succession of events the burn disease comes to an end with restoration during which wounds are cleared and closed, and the condition of the patient gradually improves.
It is necessary to stop as soon as possible contact with the damaging agent (a flame, steam, chemical etc.). At thermal burns destruction of fabrics because of their heating continues some time after the termination of the destroying influence therefore the burned surface needs to be cooled with ice, snow or cold water within 10-15 minutes. Then it is accurate, trying not to damage a wound, cut off clothes and apply a pure bandage. The fresh burn cannot be greased with cream, oil or ointment – it can complicate the subsequent processing and worsen healing of a wound.
At chemical burns it is necessary to wash out plentifully a wound flowing water. Burns alkali wash out weak solution of lemon acid, burns acid – weak solution of baking soda. The burn not extinguished lime water cannot be washed out, instead it is necessary to use vegetable oil. At extensive and deep burns of the patient it is necessary to wrap up, give anesthetic and warm drink (it is better – soda and salt solution or alkaline mineral water). It is necessary to bring the victim with a burn as soon as possible in specialized medical institution.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Local medical actions
The closed treatment of burns
First of all make processing of a burn surface. From the damaged surface delete foreign matters, process leather around a wound an anti-septic tank. Big bubbles cut and empty, without deleting. The exfoliated skin sticks to a burn and protects a wound surface. The burned extremity is given sublime situation.
At the first stage of healing apply medicines with anesthetic and the cooling action and medicines to normalization of a condition of fabrics, removal of wound contents, prevention of an infection and rejection of necrotic sites. Use aerosols with dekspantenoly, ointments and solutions on a hydrophilic basis. Solutions of anti-septic tanks and hypertensive solution apply only at first-aid treatment. Further their use is inexpedient as bandages quickly dry and interfere with outflow of contents from a wound.
At IIIA burns of degree the scab is kept until independent rejection. In the beginning apply aseptic bandages, after rejection of a scab – mazevy. The purpose of local treatment of burns at the second and third stage of healing – protection against an infection, activization of exchange processes, improvement of local blood supply. Apply medicines with giperosmolyarny action, the hydrophobic coverings with wax and paraffin providing preservation of the growing epithelium when bandagings. At deep burns stimulation of rejection of necrotic fabrics is carried out. For fusion of a scab use salicylic ointment and proteolytic enzymes. After clarification of a wound carry out skin plasticity.
Open treatment of burns
It is carried out in special aseptic burn chambers. Burns process the drying-up solutions of anti-septic tanks (solution of potassium permanganate, diamond green and so forth) and leave without bandage. Besides, burns of a crotch, person and other areas which it is difficult to apply a bandage openly usually treat. For processing of wounds in this case use ointments with antiseptics (furatsilinovy, streptomitsinovy)
The combination of the opened and closed ways of treatment of burns is possible.
General medical actions
At patients with fresh burns sensitivity to analgetics increases. In the early period the best effect is provided with frequent introduction of small doses of the anesthetizing medicines. In the subsequent increase in a dose can be required. Narcotic analgetics oppress the respiratory center therefore are entered by the traumatologist under breath control.
Selection of antibiotics is carried out on the basis of definition of sensitivity of microorganisms. Preventively antibiotics are not appointed as it can lead to formation of steady strains, unreceptive to antibacterial therapy.
During treatment it is necessary to compensate big losses of protein and liquid. At superficial burns more than 10% and deep more than 5% infusional therapy is shown. Under control of pulse, a diuresis, arterial and central venous pressure to the patient enter glucose, nutritious solutions, solutions for normalization of blood circulation and an acid-base state.
Rehabilitation includes actions for restoration physical (remedial gymnastics, physical therapy) and psychological state of the patient. Basic principles of rehabilitation:
- early beginning;
- accurate plan;
- exception of the periods of a long immovability;
- constant accumulation of physical activity.
Upon termination of the period of primary rehabilitation need of the additional psychological and surgical assistance is defined.
Inhalation defeats result from inhalation of products of burning. Develop at the persons who got burns in the closed space more often. Make heavier a condition of the victim, can pose hazard to life. Increase probability of development of pneumonia. Along with the area of burns and age of the patient are the important factor influencing a trauma outcome.
Inhalation defeats are subdivided into three forms which can meet together and separately:
Poisoning with carbon monoxide.
Carbon monoxide interferes with linkng of oxygen with hemoglobin, causes a hypoxia, and at a high dose and a long exposition - the death of the victim. Treatment – artificial ventilation of lungs with giving of 100% of oxygen.
Burns of the top airways
Burn of a mucous cavity of a nose, throat, throat, nadgortannik, large bronchial tubes and trachea. Is followed by hoarseness of a voice, the complicated breath, allocation of a phlegm with a soot. At a bronkhoskopiya reddening and hypostasis mucous, in hard cases – bubbles and sites of a necrosis comes to light. Hypostasis of airways accrues and reaches the peak on second day after a trauma.
Defeat of the lower departments of airways
Damage of alveoluses and small bronchial tubes. Is followed by breath difficulty. At a favorable outcome it is compensated within 7-10 days. The distress syndrome can be complicated by pneumonia, hypostasis of lungs, atelektaza and respiratory. Changes on the roentgenogram are visible only for the 4th day after a trauma. The diagnosis is confirmed at decrease in partial pressure of oxygen in arterial blood to 60 mm and below.
Treatment of burns of airways
Mostly symptomatic: intensive spirometry, removal of a secret from airways, inhalation of the moistened air-oxygen mix. Preventive treatment by antibiotics inefficiently. Antibacterial therapy is appointed after a bakposev and definition of sensitivity of activators from a phlegm.