Emergency first aid for thermal burns. Emergency medical care for burns
Emergency care for burns
1. Urgently stop the effect on the victim high temperature. smoke, toxic combustion products, and also remove his clothes.
2. Cool the burned areas. It is advisable to immerse the burned areas in cold water or wash them with a stream of tap water for 5-10 minutes.
For burns of the face, upper respiratory tract mucus is removed from the oropharynx and an air duct is inserted.
3. Anesthetize and begin anti-shock measures: administer promedol or omnopon;
Antishock blood substitutes (polyglucin, gelatinol).
4. Apply an aseptic bandage.
Apply a dry cotton-gauze bandage to the burned surface, or, if it is not available, a clean cloth (for example, wrap the victim in a sheet).
5. The victim must be given at least 0.5 liters of water to drink with 1/4 teaspoon of sodium bicarbonate and 1/2 teaspoon of sodium chloride dissolved in it. Give 1-2 g orally acetylsalicylic acid and 0.05 g of diphenhydramine.
6. Urgent hospitalization.
In the hospital, the burned person is given analgesics and sedatives, antitetanus serum. After this, the epidermis that has peeled off in large areas is removed, and the blisters are incised and the liquid is released from them. The burn surface for superficial burns is painful, so mechanical cleaning is allowed only in case of severe soil contamination by irrigation with antiseptic solutions. Anti-burn dressings with a metallized surface or sterile dressings with water-soluble ointments (levomekol, levosin, dioxykol, dermazin) are applied to burn wounds. Subsequent dressings with the same ointments are carried out daily or every other day, until the wounds are completely healed. After healing of 3A degree burns, keloid scars may develop in their place. In order to prevent them, especially for burns of the face, hands and feet, elastic pressure bandages are applied to newly healed wounds. For the same purpose, physiotherapeutic treatment (ultrasound, magnetic therapy, mud therapy) is prescribed.
Emergency care for burn shock
In a specialized ambulance, a complex of resuscitation measures is continued, aimed primarily at restoring hemodynamics. For this purpose, painkillers are administered intravenously: polyglucin (400-800 ml), sodium bicarbonate (5% solution - 200-250 ml), glucose (5% solution 0.5-1.0 l), corticosteroids (hydrocortisone gemsuccinate - 200 mg or prednisolone gemsuccinate - - 60 mg), korglykon (1 ml); for incipient pulmonary edema - pentamine (25-50 mg).
In the hospital, infusion therapy is continued. For deep circular burns of the limbs and torso that impair blood circulation and breathing, urgent dissection of the burn scab is indicated until blood circulation appears, followed by the application of an aseptic dressing. Narcotic analgesics are combined with antihistamines(diphenhydramine, diprazine, etc.). sodium hydroxybutyrate, sibazone, droperidol (4-6 times a day). Improvements in the rheological properties of blood are achieved by prescribing antiplatelet agents (pentoxifylline, dipyridamone) and heparin. With pronounced arterial hypotension Corticosteroids are indicated in large doses. Early intensive treatment of burn shock significantly improves the immediate and long-term results of treatment and prevents a number of serious complications. The patient’s condition and the effectiveness of therapy are monitored based on diuresis indicators. HELL. central venous pressure (hourly), hematocrit. acid-base state. Victims with burns covering an area of 15-20% of the body surface who were admitted to the hospital without signs of shock require infusion therapy aimed at preventing the development of hemoconcentration, hypovolemia and microcirculation disorders.
After recovery from shock, the protection of the burned from nutritional and energy exhaustion, intoxication and hospital infection comes to the fore.
Therapeutic measures during the period of acute burn toxemia are aimed at detoxification, correction of metabolic and energy disorders, and fight against infection. Detoxification therapy includes intravenous administration of hemodez, rheopolyglucin, and forced diuresis. The victims undergo plasmapheresis, hemosorption, and plasmasorption. Shown enhanced nutrition. Additional enteral nutrition is effective, in which high-calorie mixtures are dosed into the stomach through a permanent tube. Solutions of amino acids, protein hydrolysates, fat emulsions, and glucose solution are infused intravenously. Antibacterial drugs are prescribed in accordance with the results of culture from the wound and determination of the sensitivity of the flora to antibiotics and antiseptics. Patients should constantly receive painkillers and antihistamines, cardiotonics, and B vitamins C. To prevent complications from gastrointestinal tract it is necessary to use drugs that reduce acidity gastric juice(atropine, almagel, etc.).
Therapeutic measures during the period of septicotoxemia are aimed at preparing the patient for autodermoplasty. To achieve this, enteral and parenteral administration of proteins, fats and carbohydrates is continued and the infection is fought. The latter includes treating burn wounds with a 1% iodopyrone solution. active removal of necrotic tissue, frequent changes of dressings with water-soluble antiseptic ointments, parenteral administration of antibiotics. They continue to use cardiotonic, sedative, antihistamines, give multivitamins, antacids.
Thermal burns
First of all, stop exposure to damaging agents, cool the burn site and the surrounding surface (directly or through clean linen, a rag) under running cold water at 20-25 ° C for 10 minutes (until the pain disappears).
Free the damaged area of the body from clothing (do not remove clothing, it is necessary to cut it after it has cooled). Also
Do not remove clothes that are stuck to skin. In case of burns to the hands, it is necessary to remove the rings from the fingers due to the risk of ischemia!
A wet aseptic bandage with furacillin (1:5000) or 0.25% novocaine is applied to the burn site (for extensive burns it is better to use a sterile sheet). Do not pop blisters! It is not recommended to treat wounds with any powders, ointments, aerosols, or dyes before the patient is admitted to the hospital. Anesthesia is performed according to indications (non-narcotic analgesics). It is important not to give the child anything to drink so as not to overfill the stomach before the upcoming anesthesia during the initial treatment of the wound in a hospital setting. The victim is hospitalized in the burn department.
Chemical burns
To remove aggressive liquid, rinse the burned surface with plenty of running water for 20-25 minutes (except for burns caused by quicklime and organic aluminum compounds). Use neutralizing lotions: for acids, phenol, phosphorus - 4% sodium bicarbonate; for lime - 20% glucose solution.
In case of inhalation of smoke, hot air, carbon monoxide, in the absence of disturbances of consciousness, the child is taken to Fresh air, remove mucus from the oropharynx, insert an air duct, and then begin inhalation of 100% oxygen through an inhaler mask. With increasing laryngeal edema, impaired consciousness, convulsions and pulmonary edema after intravenous administration of atropine and diazepam (can be in the muscles of the floor of the mouth), the trachea is intubated, followed by transfer to mechanical ventilation.
Burns eyeball
Terminal anesthesia is performed with a 2% solution of novocaine (in drops), copious rinsing of the conjunctival sac (using a rubber bulb) with a solution of furacillin (1:5000); if the nature of the damaging substance is unknown - boiled water. Apply a bandage. The victims are hospitalized and transported in a prone position.
Emergency care for burn shock
Anesthesia is carried out for burns up to 9% by intramuscular injection of analgesics; with a burn area of 9-15% - 1% promedol solution 0.1 ml/year IM. (if the child is over 2 years old). For burn areas up to >15% - 1% promedol solution 0.1 ml/year (if the child is over 2 years old); fentanyl 0.05-0.1 mg/kg IM in combination with a 0.5% solution of diazepam 0.2-0.3 mg/kg (0.05 ml/kg) IM or IV.
With I-II degree of burn shock at prehospital stage Infusion therapy is not carried out. At III- IV degree of burn shock (circulatory decompensation) access to the vein is performed and infusion therapy is carried out with 20 ml/kg for 30 minutes with solutions of rheopolyglucin, Ringer or 0.9% sodium chloride solution; Prednisolone 3 mg/kg is administered intravenously. Oxygen therapy is carried out through a mask with 100% oxygen. The victim is urgently hospitalized in the intensive care unit of a burn center or multidisciplinary hospital.
BLEEDING IN CHILDREN
PULMONARY BLEEDING
Causes of pulmonary hemorrhage: chest injuries; acute and chronic purulent inflammatory processes in the lungs (bronchiectasis, abscesses, destructive pneumonia), pulmonary tuberculosis; hemorrhagic thrombovasculitis; pulmonary hemosiderosis.
Clinical picture
Foamy bloody fluid, ichor and sometimes scarlet blood are released from the mouth and nose; vomit and stool do not change color. In the lungs, upon auscultation, an abundance of moist, predominantly fine-bubble rales are heard. The child suddenly turns pale, weakness and adynamia occur.
The child is placed in a semi-sitting position; evaluate the color of the skin and mucous membranes, determine the nature of breathing, pulse, blood pressure; examine the nasopharynx; ensure free passage of the upper respiratory tract; oxygen therapy is started. The patient is urgently hospitalized in the surgical department.
GASTROINTESTINAL BLEEDINGS
Causes of gastrointestinal bleeding: ulcers and erosions, tumors, diverticula digestive tract, varicose veins veins of the esophagus or stomach.
Clinical picture
There may be vomit the color of “coffee grounds”, black stools, and less often the presence of scarlet blood in the vomit and stool. Their color is affected by the location of the bleeding. Severe pallor of the skin, dizziness, weakness, pain in the abdominal cavity. With significant blood loss, blood pressure decreases. In cases where bleeding occurs against the background of intussusception, thrombovasculitis, or intestinal infection, it is accompanied by a full-blown clinical picture underlying disease.
A child with any signs of gastrointestinal bleeding should be hospitalized according to the profile of the underlying disease. In case of massive bleeding, children are hospitalized in the surgical department. Before hospitalization for epigastric or umbilical region(depending on the location of the bleeding) apply an ice pack or a cloth moistened cold water. Give a 5% solution of epsilon-aminocapriic acid 5 ml/kg with thrombin to drink. If blood pressure is reduced, albumin or gelatinol 10 ml/kg is injected intravenously before transportation.
Thus, thermal, electrical, solar, chemical and radiation burns are distinguished. The skin, eyes and respiratory tract are most often affected by burns.
Thermal skin burns
Thermal skin burns are the most common type of household burns.
Clinical manifestations
Based on the severity of skin damage and the depth of tissue damage, the following degrees of burns are distinguished:
I degree - persistent redness of the skin and severe pain are noted at the site of the lesion;
II degree - in the area exposed to high temperature, bubbles with transparent contents form, the affected area is very painful;
III degree - necrosis (necrosis) of all layers of the skin. Upon examination, a combination of deathly pale (dead) areas of skin, areas of redness and blisters is revealed; all types of sensitivity disappear in the burn area, there is no pain.
IV degree - not only the skin is subjected to necrosis, but also the tissues located under it (fatty tissue, muscles, bones, internal organs), upon examination, charring of the skin is revealed.
More often there is a combination various degrees burns. Their III and IV degrees refer to deep burns, accompanied by increased severity general condition the victim, they demand surgical intervention, heal with the formation of deep scars. The severity of the victim’s condition depends on both the degree of the burn and the area affected. Second degree burns, covering more than 25% of the body surface, as well as third and fourth degree burns, covering more than 10% of the body surface, are extensive and are often complicated by the development of burn shock. The victim, who is in a state of burn shock, is restless, tries to escape, and is poorly oriented in what is happening; after some time, excitement gives way to apathy, prostration, adynamia, and fall blood pressure. In children, people over 65 years of age, and weakened patients, burn shock can develop even with a smaller area of damage.
First aid for thermal skin burns
The very first action should be to stop the impact of the thermal factor on the victim: it is necessary to take the victim out of the fire, put it out and remove his burning (smoldering) clothes. The burned areas of the body are immersed in cold water for 10 minutes, the person (if he is conscious) is given any painkiller - metamizole sodium, tramadol; at in serious condition introduce narcotic analgesics(promedol, morphine hydrochloride). If the burnt person is conscious and the burn surface is quite extensive, it is recommended to give him a solution of table salt and baking soda to prevent dehydration.
First degree burns are treated with ethyl (33%) alcohol or a 3-5% solution of potassium permanganate and left without a bandage. For burns of II, III, IV degrees, after treating the burn surface, apply a sterile bandage to it. After these activities, all victims must be taken to the hospital. Transportation is carried out on a stretcher. For burns of the face, head, upper half of the body, the burned person is transported in a sitting or half-sitting position; for lesions of the chest, abdomen, front surface of the legs - lying on your back; for burns of the back, buttocks, back of the legs - lying on your stomach. If hospitalization in the near future for any reason is impossible, provide assistance to the victim on the spot: in order to anesthetize the burn surfaces, they are sprayed with a 0.5% solution of novocaine for 5 minutes (until the pain stops), bandages are applied to the burns with syntomycin emulsion or streptocid ointment. They continue to feed him a solution of soda and salt, and periodically give him painkillers.
Chemical burns of skin and mucous membranes
The difference between chemical burns and thermal burns is that when chemical burns the damaging effect of the chemical on body tissue continues long time- until it is completely removed from the surface of the body. Therefore, an initially superficial chemical burn, in the absence of proper assistance, can turn into a third or fourth degree burn within 20 minutes. The main chemicals that cause burns are acids and alkalis.
Clinical manifestations
As a result of an acid burn, a scab (crust) of dead tissue is formed. When exposed to alkalis, wet necrosis (necrosis) of tissue occurs and a scab does not form. It is necessary to pay attention to these signs, since measures aimed at helping a victim with burns from acids and alkalis differ. In addition, if the patient is conscious and adequately perceives reality, be sure to check with him what substance he was in contact with. With chemical burns, as with thermal burns, there are 4 degrees of severity of tissue damage.
First aid for chemical and mucous skin burns
The victim is removed from clothing soaked in a damaging agent (acid or alkali), and the skin is washed with running water. There is a known case when a girl who worked in a chemical laboratory died from an acid burn simply because the man who was nearby was embarrassed to undress her. For burns caused by exposure to acid, apply sterile wipes moistened with a 4% solution of sodium bicarbonate to the burned surfaces; in case of alkali burn - sterile napkins moistened with a weak solution of citric or acetic acid (in enterprises where there is contact with alkalis or acids, the first aid kit must have a supply of these substances). The patient is given any painkiller and is urgently hospitalized in the nearest hospital (preferably in a hospital with a burn department).
Eye burns
(module direct4)
When the organ of vision is burned, isolated burns of the eyelids, conjunctiva or cornea, or a combination of these injuries, may occur. Eye burns, like skin burns, occur under the influence of various factors, the main of which are lesions associated with exposure to high temperature, chemical substances, radial. Eye burns are rarely isolated; as a rule, they are combined with burns of the skin of the face, head and torso.
Thermal burn of the eyes
The causes of thermal burns to the eyes are hot water, steam, oil, open fire. As with skin burns, they are usually classified into 4 degrees of severity.
Clinical manifestations
In case of a first degree burn of the eyes, slight redness and slight swelling of the skin of the upper and lower lower eyelids and conjunctiva. With a second degree burn to the eyes, blisters appear on the skin, and films consisting of dead cells appear on the conjunctiva and cornea of the eye. For a burn III degree Less than half the area of the eyelids, conjunctiva and cornea is affected. The dead tissue looks like a white or gray scab, the conjunctiva is pale and swollen, and the cornea looks like frosted glass. IV degree burns affect more than half of the eye area, in pathological process The entire thickness of the skin of the eyelids, conjunctiva, cornea, lens, muscles and cartilages of the eye are involved. The dead tissue forms a scab of gray-yellow color, the cornea is white, similar to porcelain.
First aid
The substance that caused the burn is removed from the victim's face. This is done using a stream of cold water and a cotton swab. Continue to wash the eye with cold water for some time to cool it down. The skin around the eye is treated with ethyl (33%) alcohol, albucid is instilled into the conjunctival sac, and a sterile bandage is applied to the eye. After first aid is provided, the victim is urgently hospitalized in an eye clinic.
Chemical burns to the eyes
The cause of chemical burns is contact with the eyes of acids, alkalis, medicinal substances (alcohol tincture iodine, ammonia, concentrated solution of potassium permanganate, alcohol), drugs household chemicals(adhesives, paints, washing powders, bleaches). When chemicals enter the eye, they have a pronounced damaging effect, penetrating deeper into the tissue the longer the contact continues.
Clinical manifestations
Chemical burns to the eyes are divided into 4 degrees according to the severity of damage, as with thermal injury. Their clinical signs are similar to thermal burns of the eyes.
First aid
The affected eye is opened, the eyelids are turned out, after which the eyes are washed with a stream of cool water, and pieces of the damaging agent are carefully removed from the conjunctiva. Then albucid is instilled into the palpebral fissure, a sterile bandage is applied to the damaged eye, and the victim is urgently hospitalized in an eye clinic.
Burns of the oral cavity, pharynx, esophagus
More often, chemical burns of these organs occur as a result of ingestion of acids and alkalis by mistake or due to a suicide attempt. The most common are burns caused by concentrated acetic acid. Less common thermal burns are the result of exposure to hot liquids (water, oil) or inhalation of hot steam.
Clinical manifestations
Burns of the oral cavity, pharynx and esophagus are accompanied by pain in the mouth, pharynx, and behind the sternum (along the esophagus). The pain intensifies when trying to speak or swallow; are noted increased salivation, difficulty breathing (up to suffocation) and swallowing, inability to eat any food (both solid and liquid). Repeated vomiting may occur, and there is an admixture of scarlet blood in the vomit. An increase in body temperature and an excited state of the victim may be observed. When examining him, one notices the burnt skin on and around the lips and the red, swollen oral mucosa. In case of a chemical burn caused by vinegar essence, a specific vinegar smell emanates from the patient.
First aid for burns of the oral cavity, pharynx, esophagus
In case of chemical burns, the stomach is washed with a large amount of cool water (up to 5 l) through a tube. For a burn hot water and gastric lavage is not performed with (thermal) oil. If the victim is conscious, he is given 10 ml of a 0.5% solution of novocaine (1 tablespoon) to drink, after which he is forced to swallow pieces of ice in small portions, vegetable oil and suck on an anesthetic tablet. The patient is urgently hospitalized in the hospital.
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In the United States, approximately 2 million people are treated for burn injuries each year. Of these, 100,000 have life-threatening burn injuries requiring hospital treatment, and 20,000 die either directly as a result of the burn or as a consequence of its complications. The 750,000 deaths caused by fires each year are due to inhalation injuries or direct fire exposure (57%).
Burns due to heat or flame are often associated with the inevitable fire of clothing. The use of firewood in fireplaces or stoves, as well as kerosene heaters for home heating, contributes to an increase in the frequency of fires and associated burn injuries. To control the situation, some states have passed legislation mandating the installation of smoke detectors in all households, and some local authorities have made the use of kerosene heaters illegal.
Pathophysiology
A burn is a consequence of exposure to high temperature to the skin and underlying tissue. Depending on the depth of tissue damage, three degrees of burns are distinguished. In third degree burns, the entire thickness of the skin is affected, which usually requires skin grafting. With first and second degree burns, not all layers of the skin are affected and healing occurs without surgical intervention. However, if a second degree burn becomes infected, it may deepen to a third degree due to the progression of tissue necrosis. Burns are also classified by cause, location, area affected, age of the victim, and the presence of complicating factors (eg, chronic disease, other trauma).
Of all these factors, the most important in influencing morbidity and mortality are the age of the victim and the extent of the lesion, especially in third degree burns. The American Burn Association has developed a classification of burn injuries (Table 1).
Table 1. Classification of severity of burn injuries
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Extensive burn
Moderate burn
Minor burn
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The burn area in adults is determined using the “rule of nine” (Fig. 1). The areas affected by superficial and deep burns are designated differently. The area of the head and neck is 9% of the body surface area (BS), upper limb and brushes - 9%, lower limb and feet -18%. The anterior surface of the body from the collarbone to the pubic bones is 18% and its posterior surface from the base of the neck to the lower end of the gluteal fold is 18%. The perineal area is equal to 1% of the PT.
Thus, in a patient with a burn of the anterior surface of the torso (18%), perineum (1%) and a circular burn of the left thigh (9%) total area lesions account for 28% of PT.
Rice. 1. Rule of nine
To determine the area of the burn in infants and young children, the Lund and Browder scheme is used (Fig. 2), and the calculation is made taking into account the age of the victim. For example, in an adult the head area is 9% of the PT, and in a newborn it is 18%.
Rice. 2. Classic map Lund and Browder.
Other concomitant injuries may be noted on the same diagram: fractures, abrasions, lacerations etc. Such a diagram is an integral part of the medical history.
The depth of the burn depends on the degree of tissue destruction. With a first degree burn, tissue damage is minimal, destruction of the outer layer of the epidermis, redness of the skin, pain and slight swelling are observed. Healing usually occurs within 7 days with characteristic peeling of the skin.
In a second-degree burn, tissue damage extends to the dermis, without, however, affecting the hair follicles, sebaceous and sweat glands. These adnexal structures are covered with epithelium, the proliferation of which causes the closure of the affected area of the skin. Epithelization of a burn wound is usually observed on the 14-21st day. Second degree burns are characterized by the presence of blisters and red or whitish areas that are extremely painful to the touch. When the blisters rupture, a moist, bright red surface is exposed.
With third degree burns, the skin has a pearly white color or is completely charred. Due to the destruction of all layers of skin, including nerve endings, the burn area is insensitive to pain or touch. Reliable sign third degree burn - identification of thrombosed venous vessels visible through the skin. Due to the complete destruction of all layers of the skin, healing of such burns occurs only with the transplantation of a skin flap or with the formation of rough scars.
Burns resulting from a fire in a confined space or from the burning of toxic chemicals or plastic materials can be accompanied by damage to the upper and lower respiratory tract. Clinical signs such lesions are a burn to the face, the presence of burnt hair on the face or in the nasal passages and sputum containing soot, as well as respiratory distress syndrome or wheezing. Inhalation of vapors or chemicals may result in swelling of the trachea and bronchi, ulceration of the mucous membrane, or bronchospasm. The presence of chemicals in inhaled smoke usually leads to damage to the alveoli. Swelling and disruption of the integrity of the alveolar-capillary membrane causes the development of hypoxia or pulmonary edema.
First aid
Services emergency care should have special diagrams (or maps) to assess the severity and complexity of burn injuries. Typically, all major burns are treated at a burn center. People with moderate and uncomplicated burns can be treated in hospital general profile, where available the necessary conditions to manage such patients, or are referred to a burn center. Minor burns can be treated in an emergency room, clinic, or outpatient clinic.
At initial examination The condition of the victim's airways, breathing and blood circulation is assessed, then hidden injuries are identified. After this, the patient is wrapped in a clean, dry sheet. Ointments or creams should not be applied, and contamination of the wound should be kept to a minimum.
Ice should never be placed directly on burn surface, since cold injury can increase the depth of the burn wound. Small burn areas can be covered with a bubble of ice water or saline solution. For extensive burns, the use of chilled saline bottles may result in hypothermia, which is not advisable. Decision on intravenous administration fluids or pain medications are administered by emergency personnel in consultation with the medical supervision physician. Such decisions affect the timing of transportation of victims.
All victims must receive oxygen during transport. In addition, the patient's body temperature should be monitored, as well as the patient's breathing, vital signs, and level of consciousness. In the city, the patient can be referred directly to a burn center if the burn requires specialized treatment. In a suburban area or in rural areas the patient is transported first to the nearest emergency room that is capable of stabilizing burn victims. Subsequently, if necessary, hospitalization is carried out at a regional burn center.
Treatment in the emergency department
Immediately upon arrival at the emergency department, the airway, breathing and circulation are assessed. An examination is necessary to identify hidden damage. If pulmonary injury is suspected due to smoke inhalation or if there is a severe facial burn that may lead to swelling and upper airway obstruction, tracheal intubation is necessary. The degree of edema and obstruction should be taken into account. Intubation is best done in early period before swelling obliterates anatomical landmarks in the larynx, making the procedure unfeasible. The mortality rate of patients undergoing emergency tracheostomy significantly exceeds the complications arising from tracheal intubation.
Assessing alveolar function requires obtaining chest radiographs and arterial blood gases. The condition of the trachea and bronchi is assessed using fiberoptic bronchoscopy. Hypoxia is treated with intubation, high oxygen concentrations, and positive pressure ventilation with frequent monitoring of arterial blood gas levels. In addition, the level of carboxyhemoglobin is determined. The catheter is inserted into a peripheral vein. Insertion of a central venous catheter is not usually required during the initial phase of resuscitation, but insertion of a wide-bore catheter (no. 18 or larger) is necessary because it provides rapid flow of fluid into the vascular bed.
A burn is accompanied by vasodilation and plasma leakage through all capillaries of damaged tissues, which leads to a decrease in intravascular volume. The more extensive the burn, the greater the loss of intravascular volume. Thus, early treatment involves administering an adequate amount of Ringer's lactate to restore circulating plasma volume. A number of fluid administration regimens have been proposed for the treatment of burn shock (Table 2).
Table 2. Modern treatment regimens for burn shock in the first 24 hours
In 1978, the National Institutes of Health held a conference on burn management, the proceedings of which were published in the November issue of the Journal of Trauma (1979). Schemes were recommended at the conference infusion therapy, which are given in table. 2. The use of lactated Ringer's solution is recommended for the initial resuscitation of all burn patients.
In patients with moderate or extensive burns, a catheter is placed in the bladder and urine output is monitored hourly. The amount of intravenous fluid administered is adjusted to maintain it at a level of 30-50 ml/hour in adults and 1 ml/kg per hour in children weighing less than 30 kg.
When determining the affected surface area in patients with extensive burns, heat conservation is very important (due to the rapid development of hypothermia).
To reduce pain and anxiety, small doses of morphine (2-4 mg) are given intravenously unless contraindicated due to other injuries, such as abdominal or head trauma. Should be avoided intramuscular injection drugs (with the exception of tetanus prophylaxis) due to their insufficient and uneven absorption from the muscles in patients in shock.
All patients with burns are injected intramuscularly with 0.5 ml of tetanus toxoid. If there is any doubt regarding previous immunization, 250 units of human hyperimmune tetanus globulin is injected intramuscularly into the opposite limb. For patients with minor burns (and if there is confidence in following the prescription), a repeat dose (0.5 ml) of tetanus toxoid can be given after 2 weeks.
Since shock causes gastric paresis with accompanying intestinal obstruction, patients with moderate to extensive burn lesions should be given nasogastric tube. Decompression of the stomach to avoid its rupture must be carried out before evacuation of the patient by air.
Prophylactic antibiotics are not currently practiced in most burn centers due to the rapid development of bacterial resistance.
Conducted laboratory research, including complete clinical analysis blood, urine analysis and determination of serum electrolytes, glucose, blood urea, creatinine, arterial gases and carboxyhemoglobin.
Cleaning the burn wound is done by gently washing it with toilet soap or detergent. Scraps of the epidermis are removed, large blisters are processed and opened. As was recently shown, their liquid contents contain vasoconstrictors, potentiating tissue ischemia. Therefore, the cystic fluid should be removed as soon as possible.
After cleaning the wound, a local antibacterial drug, such as silver sulfadiazine. The drug is applied thin layer to the affected area. A pressure gauze bandage is used to close the wound.
A circular burn of the arms or legs is accompanied by swelling of the tissue under the burn scab, which can disrupt the blood supply to the hands or feet. To determine the presence of a pulse in the extremities, a Doppler test is extremely useful. If the pulse is weak or absent in the distal arteries, necrotomy may be required. An incision is made through the scab to the subcutaneous fat layer. Necrotomy can be performed along the lateral or internal surface of the upper or lower limb and, if necessary, extended to the dorsum of the hand or foot (Y-shaped incision). One ray of such a cut starts from the membrane between the first and second fingers, and the other - between the fourth and fifth fingers. Cuts are not usually made on the fingers, even if there is a severe burn.
With a circular burn of the chest, mechanical restriction may occur breathing movements due to the accumulation of edematous fluid under a dense scab. To free the chest wall, necrotomy is performed on both sides along the anterior axillary lines; the incision starts from the II rib and ends at the apex of the XII rib. The upper and lower corners of these cuts are connected by a cut perpendicular to the long axis of the body. Thus, a floating square of fabric is formed, which allows chest move while breathing and eliminates ventilation restrictions.
The criteria for hospitalization of patients with burns are given in Table. 3.
Table 3. Criteria for hospitalization of patients with burns
Ambulatory treatment
Small burns (15% of body surface area or less) are less likely to develop infection, so local application antibiotics are not required. Large blisters are dissected and cleared, or at least their liquid contents are removed. These small burn areas can be covered with a thin gauze dressing (with or without medication) followed by a dry pressure dressing held in place with an elastic bandage. The dressing should be changed every 3-5 days, or more often if the top layer gets wet. If there is no suppuration, the bottom layer of the dressing is not removed.
LIST OF ABBREVIATIONS
BP - blood pressure
AG - antigen
AT - antibody
IVL - artificial lung ventilation
Health care facility - medical and preventive institution
ARF - acute respiratory failure
BCC - circulating blood volume
ESR - erythrocyte sedimentation rate
PE - pulmonary embolism
FOS - organophosphorus compounds
CNS - central nervous system
RR - respiratory rate
HR - heart rate
ECG - electrocardiogram
THERMAL INJURIES
BURNS
A specialist with secondary medical education must be able to:
Determine the degree of thermal burn;
Assess the area of the burn;
Provide first emergency first aid for thermal burns;
Recognize a chemical burn;
Provide first emergency pre-medical aid.
THESIS STATEMENT OF THE TOPIC
The problem of thermal injuries remains one of the most serious and complex problems in medicine. The pathogenesis of thermal injuries is very complex and not fully understood. With thermal injuries, profound dysfunctions of almost all major organs and systems can occur, therefore, a necessary condition for successful pre-medical care, which guarantees high efficiency of treatment and a reduction in the level of disability in the future, is the maximum reduction in the time from the occurrence of thermal injury to the provision of medical care. That is why the prehospital stage is considered the most important, key element of treatment and evacuation support for these emergency conditions.
The concept of burns, clinical manifestations
Burns called damage caused by thermal, chemical, radiation energy. Among peacetime injuries, burns account for approximately 6%. The severity of burns is determined by the area and depth of tissue damage, the presence or absence of burns to the respiratory tract, poisoning by combustion products, and concomitant diseases. The greater the area and depth of tissue damage, the more severe the burn. Thermal burns can be caused by flames, hot gases, molten metal, hot liquids, steam, and sunlight.
In modern clinical practice, the classification of burns introduced by A.A. is most often used. Vishnevsky and M.I. Shreiberg, approved at the XXVII All-Union Congress of Surgeons.
Based on the depth of damage, burns are divided into four degrees:
I degree - erythema and swelling of the affected area, accompanied by a feeling of pain and burning;
II degree - against the background of erythema and edema, blisters appear filled with serous yellowish-transparent liquid;
Grade III - necrosis of the epidermis, the germ layer of the skin is partially preserved, and the skin glands are partially preserved. Burn surfaces are represented by a scab, that is, dead, insensitive layers of skin. The scab retains pain sensitivity when pricked with a needle. When burned with hot liquid or steam, the scab is whitish-gray; when burned by a flame or in contact with a hot object, the scab is dry, dark brown;
SB degree - necrosis of all layers of skin. The scab is denser than in grade III. All types of sensitivity are absent, including pain when pricked with a needle. When exposed to hot liquids, the scab is dirty gray; when burned by a flame, it is dark brown;
IV degree - necrosis of the skin and underlying tissues: fascia, tendons, muscles, bones. The scab is dark brown and dense. Thrombosed saphenous veins are often visible. All types of sensitivity are absent in the scab.
Burns of I, II and III degrees are classified as superficial lesions, burns of III and IV degrees are deep.
Determination of the affected area
The severity of the victim’s general condition depends not only on the depth, but also on the volume of the affected tissue. In this regard, already at the pre-medical stage it is necessary to determine the area of the burn.
To quickly approximately determine the affected area, you can use the “rule of nines.”
Head and neck - 9%.
Upper limb - 9% (each).
Lower limb - 18% (each).
The anterior surface of the body is 18%.
Posterior surface of the body - 18%.
Perineum and genitals - 1%.
You can use the “rule of the palm”: the area of the palm of an adult is 1% of the total surface of the skin.
Depending on the area of damage, burns are conventionally divided into limited and extensive. Extensive burns include burns covering more than 10% of the skin surface. Victims with extensive burns of any degree, as well as burns of the head and neck, palm, plantar surface of the foot, perineum, starting from the second degree, are subject to urgent hospitalization. This is explained by the fact that it is preferable to treat these groups of burns using the open method: the burn surface is evenly dried under the frame until a dry scab is formed, under which further epithelization of the affected surfaces occurs. All patients over 60 years of age and children are also hospitalized. Prognostically, first degree burns are very dangerous when more than 1/2 of the body surface is affected, second degree when 1/3 of the body surface is affected, and third degree when less than 1/3 of the body surface is affected.