Features of the course of burn disease in children of the first three years of life. Features of the course of body burns in children

Most clinicians believe that young children tolerate burns much worse than adults. General phenomena in their body develop with a smaller area of ​​damage than in adults, mortality is high. Burns covering 5-8% of a child's body surface cause signs of shock and require general treatment; over 20% are life threatening.

Meanwhile, the organization proper treatment and caring for a burned child is quite a difficult task.

The reasons for the more severe course of burns in children, as well as the difficulties associated with their treatment and care, are explained by some anatomical and physiological features of childhood, characteristic of the first 5-6 years of life. AT school age children become more independent, more conscious, the body matures, and care is facilitated.

After a severe widespread burn, a child may have irritability, poor sleep, bedwetting, absent-mindedness and other disorders of the emotional-volitional and mental sphere for a long time.

Despite the significant progress made in the treatment of burns, the number of children dying from complications is still very high.

The outcome of the burn primarily depends on the extent and depth of the thermal injury. Children tolerate superficial burns relatively easily. If the burn does not exceed 70% of the body surface, the child usually recovers. The situation is quite different with deep burns of III and IV degrees. In these cases, death can occur even with a relatively small area, and the younger the child, the more severe the burn disease and the less chance of a favorable outcome.

Anatomical and physiological features of the child's body that affect the course of burns and complicate their treatment

Causes that aggravate the severity of burns	Reasons that complicate child care
1. The thinness of the skin, weak development of the protective keratinized layer of the skin, weak resistance to the destructive effect of heat, electric current.	1. Helplessness of the child, the need for constant supervision, maintenance, pedagogical influence.
2. Other than in an adult, the relationship between the body weight of the child and the area of ​​his skin, per one and the same unit of mass. A burn with an area of ​​5% of the body surface in a child corresponds to a burn of 10% in an adult.	2. Poor development of the subcutaneous vein network and difficulties associated with their puncture and transfusion treatment.
3. Different ratios between different segments of the body than in an adult. In a child, the head is 20%, in an adult - 9% of the body surface. Burns to the face and head are common in children. They are severe. The supply of skin available for borrowing and grafting is reduced as the head and face cannot be used as donor sites.	3. Large, not controlled by the intellect, motor activity of the child, leading to the pulling out of the probe, catheter, needle from the vein, breakage of the plaster cast.
4. Incomplete growth, underdevelopment of some organs, weakness of compensatory and protective mechanisms. The child's body is unable to meet the increased demands that the burn causes, so an irreversible condition quickly develops. noted hypersensitivity to some medications, instability of thermoregulation, poor resistance to infection, a tendency to develop complications that are not characteristic of an adult.	4. Good blood supply, friability and tenderness of soft tissues, leading to the rapid development of edema when applying a bandage to injured tissues. Edema can cause compression of blood vessels and circulatory disorders in the parts of the limb located below the bandage.
5. Great need for oxygen, proteins. Rapid onset of metabolic disorders and exhaustion.	5. The inability of the child to analyze his feelings and indicate exactly what is bothering him. At the same time, a violent reaction to pain is characteristic.
6. Tendency to rapid development of connective tissue. There is often an overgrowth of scar tissue at the site of a healed burn. Such a scar causes itching and ulcerates easily.	6. Negative attitude of the child to the need for treatment and stay in the hospital. The child is overwhelmed with fear and desire to return to the familiar home environment to the mother.
7. Continued growth of the child's body. After the burn has healed, scars have a restraining effect on bone growth, cause the formation of secondary deformities in the joints and shortening of the limb.	7. The inability of the child to show strong-willed efforts to achieve a faster recovery - unwillingness to eat unusual food, do therapeutic exercises, be in a forced position, etc.
—	8. Tendency to infection with acute contagious childhood infectious diseases requiring compliance with a special epidemiological regimen.
—	9. Easy development of complications from the respiratory and digestive system in a sick child with non-compliance with the sanitary and hygienic diet in the department.

Currently, for infants and toddlers, deep burns over 30% of the body surface are considered critical; for older children - deep burns, exceeding 40% of the body surface in size.

The cause of death in the vast majority of children is an infection that causes a general infection of the body and death even before the moment when it becomes possible to close the wounds plastically.

"Burns in children", N.D. Kazantseva

Burns in children most often occur as a result of exposure to hot liquids, flames, hot objects. Clinical manifestations depend on the area of ​​the burn, its degree, the age of the child and consist of general and local symptoms. In children, the same degrees of burns are distinguished as in adults, but with the same temperature effects, the skin of children is damaged more severely. At the first examination, it is often difficult to determine the exact degree of the burn; in children, a combination of burns of different degrees is more common. With burns with a large area of ​​damage, shock develops, and in children it can occur already with a burn of 5-8% of the body surface, and even 3% in infancy. Therefore, it is very important to determine the burn area according to the scheme (Fig. 3) and the table.

Table for calculating the area of ​​the burn (as a percentage of the total body surface) Fig. 3. Scheme for determining the area of ​​the burn in children under 1 year old (as a percentage of the total body surface).

With extensive burns, it is always serious and is especially unfavorable when 50% of the body surface is affected or more. The principles of emergency care for burns in children are the same as in adults; for the purpose of anesthesia, children are administered at the rate of 0.1 ml of a 1% solution for 1 year of life. On an outpatient basis, it is permissible to treat burns of I-II degrees, in area not exceeding 2% in infants and 4% in older children. To reduce pain, cold ones are used, then the burn surface is irrigated with 70% alcohol and a dry sterile bandage is applied; bubbles are not removed. Infected burns are treated with bandages with Vishnevsky ointment. For more widespread or deeper burns, children should be hospitalized. Both general and local treatment of burns in children has some features compared to adults. Treatment begins with measures to combat shock. Blood is transfused - from 50 to 250 ml, depending on age (1 ml of 10% chloride solution is injected for every 50 ml of blood). Blood transfusions are also advisable as a prevention of shock.

Infusion therapy is of great importance in the treatment of shock. Intravenous drip injected: 10% glucose solution with insulin, Ringer's solution, isotonic sodium chloride solution, glucose-novocaine mixture. The amount of fluid administered per day should be 10% of the child's body weight. Infusion therapy is carried out within 24-48 hours. depending on the severity of the shock. In addition, the child receives through the liquid according to the physiological needs. Infusion therapy is carried out with simultaneous control of urination; it is important to measure hourly diuresis, for which a catheter is inserted into the bladder and left until the child is completely removed from shock. Only after getting out of shock do they start processing burn surface under anesthesia: removed foreign bodies, contaminated epidermis, carefully cut off the opened blisters. After treatment, dressings are applied, more often with Vishnevsky's ointment, since when treating with dry dressings, the dressings are too painful for the child. do not more than 2 times a week.

Emergency immunization against tetanus (see Immunization, table,) is given to children who have not received preventive vaccinations, and with obvious contamination of the burnt surface. When treating burns of the II degree in the face and, given the difficulties of care and the high possibility of infection, the Nikolsky-Bettman method can be used in children: under anesthesia, the burn surface is cleaned from exfoliated epidermis and blisters using wipes moistened with alcohol and lubricated with 5% aqueous solution, and then with a 10% solution of nitrate (lapis). There is a healing of the burn under the crust, which is rejected on the 8-14th day. Surgical treatment, consisting in the excision of non-viable tissues and the closure of defects with the help of autoplasty, is used for deep burns of III and IV degrees. In the process of caring for children, you need to pay attention to. In order to prevent cicatricial contractures and deformities, joint stiffness, dressings are applied so that the burn surfaces do not touch, the limbs are fixed with a splint, a splint in the middle physiological position, methods are used. With deep burns, the prevention of contractures and deformities is ensured by timely surgical intervention. Prevention of burns is ensured by increased supervision of children.

Burns account for up to 8.5% total number all surgical diseases of children; in toddlers and preschool age from total burn injuries account for 63.2%. Most often in children, burns are observed with hot liquids (liquid food, water), less often with fire and even less often with chemicals. Burns are more common in children of preschool age, when the child is very mobile. Localization of burns is the most diverse, in most cases on the lower half of the trunk and legs.

Clinical picture and flow. Unlike an adult patient, the nature and severity of burns in children primarily depend on their age: the younger the age, the more severe the burn with the same area of ​​damage. Burns that occupy an area of ​​more than 1/3 of the body surface are life-threatening for the child. Mortality among children with body burns for recent times decreased to 1.86%; it remained relatively high in children under 3 years old - 6.8%.

Shock in children is already observed with burns of a small surface, especially with an electric current burn. These children have severe torpid shock with small local changes. During the period of shock, convulsions, vomiting, and high fever are sometimes noted.

In the first hours of a burn disease, edema appears in the affected area; due to hypoxia morphological changes in the myocardium, liver, kidneys, adrenal glands, pancreas and thyroid glands. In young children, swelling of the brain often occurs. In the first two days of the disease, up to 20% of the total number of erythrocytes is destroyed, the number of leukocytes increases to 16-39 thousand, there is a significant deviation from the norm of biochemical parameters, indicating a change in carbohydrate, protein and fat metabolism in the body of a child: the amount of residual nitrogen, globulins, sugar content increases, the amount of albumins decreases, etc.

Complications. During the first day of the disease with extensive burns, toxemia very often occurs. To combat it, constant parenteral administration of protein preparations, salts and glucose is necessary. On the 14-21st day, sepsis often develops. "Scarlet fever" rash is a rare complication that occurs on the first day of a burn disease.

Treatment. For the treatment of burn shock in children, various types of anesthesia are used (omnopon, pipolfen; chloral hydrate, nitrous oxide, etc.) with simultaneous restoration of the volume and composition of circulating blood. In severe cases, it is recommended to use a lytic mixture consisting of largactyl, fenergan and dolantin. The child should be kept warm. Most pediatric surgeons insist on limiting parenteral fluids. During the first day of the disease, blood or its substitutes are administered at the rate of 1.5 ml per 1 kg of the patient's weight and 1% of the burnt surface and 1 ml of physiological saline solution per 1 kg of weight and 1% of the burn surface. In the absence of vomiting, a plentiful drink is prescribed.

After removing from the state of shock, the burn surface is treated. The most common is the closed method of treatment. The burnt surface is washed saline and 1/2% solution of novocaine, and then alcohol. Scraps of the epidermis are removed. Exfoliated edematous epidermis is not removed. After treatment, a bandage is applied with various drugs: fish oil, carotene, petroleum jelly, tripaflavin, imanin, furatsilin, Shnyrev's ointment with various combinations of antibiotics, etc. On the face, buttocks, the burn surface is treated according to the Nikolsky-Buttman method (5% tannin solution , then 10% solution of silver nitrate) and lead openly. At the end of the treatment, according to indications, the burnt limb is immobilized in a functionally advantageous position.

Recently, necrectomy has become widely used, which is most appropriate to use in children by the end of the 2nd - 3rd week after the burn.

Prevention burns is primarily associated with the supervision of children, primarily toddlers and preschoolers.

They are life-threatening injuries that occur as a result of local exposure to high temperatures on body tissues. The most common cause of burns is contact with hot liquids (boiling water, tea, coffee). In second place is touching hot objects, in third place are burns with flames.

Pronounced thermal damage leads, first of all, to direct damage to the cell due to coagulative necrosis. different depth and length.
Vasoactive substances are released, which lead to an increase in vascular permeability and loss of fluid, protein from the vascular bed.

A rapidly developing fluid deficit is exacerbated by exudation through the wound surface and the formation of edema in the interstitial space. Further loss of fluid occurs through evaporation from the wound surface, imperceptible perspiration losses through the lungs, with almost always occurring tachypnea, and also due to loss through the gastrointestinal tract, the so-called third space.

All lost fluid leaves the vascular bed, and the losses reach a maximum in the first three to four hours after the burn. They are often underestimated, especially in young children. After the burn medium degree the severity of intravascular deficit is already 20-30% of the BCC in an hour!

The severity of the burn is determined depending on the degree of damage and the percentage of the burn.

It should be borne in mind that the palmar surface of the victim is approximately 1% of the body surface. You can calculate the burn percentage using the rule of nines.

9% have:

• head and neck;
• breast;
• stomach;
• half of the surface of the back;
• one thigh;
• one leg and foot.

In children, a more accurate calculation of the burn percentage can be made using the Lund and Browder chart.

Depending on the depth of the lesion, the degrees of thermal burns are distinguished.

• I degree is accompanied by hyperemia of the skin, moderate swelling, soreness;
• II degree - detachment of the epidermis is noted (bubbles with a clear liquid appear), severe pain;
• III A degree. The skin is not affected to the full depth (partial necrosis of the skin, the elements of the dermis are preserved) It is characterized by:
  - the growth layer of the skin is partially preserved,
  - the burn bladder is filled with liquid with a yellowish tint;
  - burn wound pink, wet;
  - reduced pain and tactile sensitivity;
• III B degree. There is a skin lesion to the full depth with the formation of a necrotic scab. At this degree:
  - all layers of the skin are affected;
  - a dense, gray-brown or brown scab is formed with areas of white "pig" skin;
  - thrombosed vessels and fragments of the epidermis are visible;
  - pain sensitivity is absent;
  - burn blisters with hemorrhagic contents;

• IV degree. At this degree, not only the skin, but also the deeper tissues (muscles, tendons, joints) become dead.

A severe burn (more than 10% of the body surface) and subsequent changes are considered as a burn disease, which is characterized by the development of shock, toxemia, septicotoxemia.

Burn disease in children is more severe than less age child.

clinical picture.

With a burn of more than 10% of the body surface (in children under 3 years of age, 5% of the surface), burn shock develops. Hypovolemia, blood deposition, and a decrease in cardiac output come to the fore. A decrease in CVP to zero indicates true hypovolemia, and an increase in the norm indicates relative hypovolemia, due to the weakness of the pumping function of the heart.

There are 3 degrees of burn shock:

Shock burn I degree.

The condition of the child is moderate. Drowsiness, pallor of the skin, chills, thirst are observed. Satisfactory filling pulse, tachycardia, CVP reduced. Compensated metabolic acidosis. Diuresis is sufficient.

Shock burn II degree.

Severe condition. Conscious. The child is lethargic, sometimes agitated. Chills, pronounced pallor of the skin, cyanosis are noted. Sharp tachycardia. BP is moderately reduced. Thirst is expressed, there may be vomiting. metabolic acidosis. The hourly diuresis is reduced.

Shock burn III degree.

The child's condition is extremely serious. Consciousness is impaired or absent. Severe pallor, marbling of the skin, cyanosis. Shortness of breath, pulse may be undetectable or thready. Sharp tachycardia, muffled heart tones. Blood pressure is reduced, body temperature is subfebrile. A significant decrease in CVP, increased peripheral resistance. Hourly diuresis is reduced to 2/3 - 1/2 of the age norm. There is hemoconcentration, metabolic acidosis.

To determine the severity of a burn injury, the lesion index is determined, which is determined in the following way: 1% burn I-II st. - 1 unit, 1% burn III A Art. - 2 units, 1% burn III B Art. - 3 units, 1% burn IV st. - 4 units

With an index of damage up to 10 units. - mild degree of burn, 10-15 units - medium degree, 15-30 units - severe degree, more than 30 units - very severe.

Treatment.

Immediate actions at the scene:

1. Abundant washing of the skin or dousing with cold water (at least 15 0 C) until the pain disappears or is significantly relieved.
2. Anesthesia. For moderate burns, analgesia is performed with non-narcotic analgesics with diazepam (seduxen) intramuscularly.
   In severe burn injuries, they are anesthetized with narcotic analgesics - promedol 1% solution of 0.1 ml / year.
3. An aseptic dressing is applied (for extensive burns, a sterile sheet is covered) moistened with a 0.5% solution of novocaine with furacilin (1:5000) 1:1. Before applying the bandage, the localization, area, and depth of skin damage is accurately determined.
4. In case of a severe burn, provide access to the vein and start conducting infusion therapy physical solution of 20-30 ml/kg per hour.
5. In the presence of shock, glucocorticoids are administered: prednisolone 2-5 mg / kg or hydrocortisone - 5-10 mg / kg intravenously.

What not to do with burns:

• Ice should not be applied directly to the burn surface, as this may increase the area of ​​tissue damage through frostbite;
• The burn surface should never be lubricated with substances containing fat (lard, petroleum jelly, sunflower oil);
• It is also impossible to apply various indifferent substances (ointments, powders, flour);
• When removing clothing, do not tear it off the burnt surface, but cut it off with scissors;
• Do not touch the burnt surface with your hands.

For burns respiratory tract smoke or hot air:

1. Remove the victim from the enclosed area.
2. Give the patient humidified 100% oxygen through a mask at a rate of 10-12 L/min.
3. Patients with respiratory failure stage III. or with no breathing should be intubated and put on a ventilator.
4. If it came clinical death conduct cardiopulmonary resuscitation.
5. Anesthesia and infusion therapy listed above.
6. In shock, glucocorticoids.
7. With laryngo and bronchospasm - 2.4% eufillin at the rate of 2-4 mg / kg.

Inpatient treatment in the first 24 hours.

For superficial burns of more than 40%, or deep burns of more than 20%, it is necessary to perform:

• Nasotracheal intubation and start mechanical ventilation;
• Access to the central vein;
• Put the probe into the stomach;
• Bladder catheterization;
• Monitor central hemodynamics and oxygen balance.

The goal of fluid therapy during shock is to restore plasma volume and vital functions. The calculation of the required fluid is made depending on age, body weight, burn area. During infusion therapy, body weight should be monitored every 6 hours to avoid overhydration.

In the first 24 hours after injury, crystalloids are administered at the rate of 3-4 ml/kg per burn area (in percent). The first half is administered in the first 8 hours, the second in the next 16 hours.

If the level of albumin in the blood serum is below 40 g / l or there is a burn shock. prescribe an infusion of colloidal solutions (albumin, fresh-frozen plasma) 8 hours after injury. If on prehospital stage did not use hydroxyethyl starches, then they are prescribed in a hospital. Apply Refortam or Stabizol at a dose of 4-8 ml / kg intravenously.

Adequate analgesia is shown with a 1% solution of promedol at a dose of 0.1 ml per year of life, every 4 hours.

Carbon monoxide should be determined in all patients with inhalation burn injury. Such patients are given 100% oxygen until the level of carboxyhemoglobin in the blood drops to 10%.

Stages of treatment of the burn surface:

• Clean the burn surface;
• Remove the walls of the bubbles;
• Treat the burn wound with sterile saline or antiseptic solutions;
• Bubbles on the palms and soles do not open;
• Lubricate the damaged surface with silver sulfadiosin cream or treat the surface with Levomekol, Levosin.
• Apply a sterile bandage.
• Antibiotic therapy with preventive purpose are not assigned. If there are indications for the appointment, then they can be prescribed only after the child is taken out of shock.

In conclusion, I would like to note that the treatment of burns I-II Art. with an area of ​​up to 2% in infants, and up to 4% in older children can be treated on an outpatient basis. If there are manifestations of shock, hospitalization is mandatory with adequate anesthesia and infusion therapy.

FEATURES OF BURNS IN CHILDREN Damage to living tissues caused by exposure to high temperature, chemicals, electrical or radiant energy is commonly called a burn (combustio)

CHARACTERISTICS OF BURNS IN CHILDREN n n n More than 1 million children in the world suffer from burns. At the same time, 25-50% die from burns annually. Up to 70% of cases of burns are burns received at home.

FEATURES OF BURNS IN CHILDREN n n n Thermal burns account for 25 to 50% of other types of childhood injuries In 18% of cases require hospital treatment Among children of all ages, they are the third most common cause of death from injuries, and in toddlers (1-3 years) - leading cause of violent death

FEATURES OF BURNS IN CHILDREN n n In infancy, burns account for 58% In nursery - 50% In preschool -27 -30% At school -20 -23%

FEATURES OF BURN IN CHILDREN The frequency of burn damage in children of different sexes depends on age - in children under 3 years old - more often in boys (more mobile, inquisitive, naughty) - at school age (7-14 years old) more often in girls (begin actively be included in economic activity at home)

FEATURES OF BURNS IN CHILDREN n The main causes of burns in children are liquids (boiling water, hot milk, soup, compote, other liquid and semi-liquid foods, soapy solutions for washing clothes) n n n Scalding Burns from contact with hot metal objects Burns with hot tar, bitumen Flame burns Electrical burns

FEATURES OF BURNS IN CHILDREN SCALDING about 70% of all thermal injuries - 44% of burns as a result of exposure to hot liquids - 10% of overturning liquids due to negligence - 9% during bathing About 10% - deep More than 54% - extensive

FEATURES OF BURNS IN CHILDREN From contact with hot metal objects are found in 18 -27% Sources of injury - hot oven or oven doors, metal parts of a gas burner, hot irons, steam radiators, etc.

FEATURES OF BURNS IN CHILDREN Only 6-7% of burned children receive FLAME BURNS. ELECTRIC BURNING from the action of low and high voltage. Children under the age of 3 are most often affected

FEATURES OF THE COURSE OF BURNS IN CHILDREN n n Burns with an area of ​​5-8% cause signs of shock, over 20% are life-threatening

FEATURES OF THE COURSE OF BURNS IN CHILDREN n Causes of a more severe course of burns in children anatomical and physiological features n n Thinness of the skin, poor development of the protective keratinized layer of the skin Other ratios between body weight and the area of ​​its skin. A 5% burn in a child corresponds to a 10% burn in an adult

FEATURES OF THE COURSE OF BURN IN CHILDREN n n Other ratios between different segments of the body (the head in children is 20%, in an adult - 9% of the body surface) Incomplete growth, weakness of compensatory and protective mechanisms Immaturity of the central nervous system contributes to the generalization of the pathological process Greater need for oxygen, proteins. Rapid onset of disorders metabolism and exhaustion

FEATURES OF THE COURSE OF BURN IN CHILDREN Tendency to the rapid development of connective tissue. Excessive growth of scar tissue. n Post-burn scars hinder bone growth, cause the formation of secondary deformities in the joints and shortening of the limb. n

FEATURES OF THE COURSE OF BURNS IN CHILDREN Currently n for infants and toddlers, burns of more than 30% are considered critical, n For older children - deep burns exceeding 40% of the body surface n The cause of death in most children is an infection

Classification and clinical characteristics of burns Depth of burn skin lesions according to the classification adopted at the 27th Congress of Surgeons in 1962

Classification and clinical characteristics of burns Burns 1 tbsp. (combustio erythematosa) - characterized by redness, swelling (edema) and pain.

Classification and clinical characteristics of burns Burns 2 tbsp. (combustio bullosa) - only the upper layers of the skin (epidermis) are affected, but redness, pain and swelling are more pronounced

Classification and clinical characteristics of burns n n Burns 3 a Art. (combustio escharotica) affects the deep layers of the skin - incomplete necrosis of the skin Burns 3 b Art. - total necrosis of the skin. At the site of the lesion, a deep area of ​​necrosis occurs - a scab, which includes the entire thickness of the skin.

Classification and clinical characteristics of burns Burns 4 tbsp. - the eschar includes the skin and underlying anatomical formations.

Classification and clinical characteristics of burns It is almost impossible to accurately determine the depth of thermal damage in the first hours and days after a burn.

Determination of the burn area N N Palm area (1%) Rules of nine - The entire body surface is divided into areas whose area is 9% (head, the thigh surface, the front surface of the body) N schemes (table) Postnikov - the percentage of the burn size to the total surface of the human skin n VILYAVIN'S SCHEME - BURN CONTOURS ARE APPLIED ON THE SCHEME WITH THE IMAGE OF THE SILHOUETTE OF A HUMAN, MULTI-COLORED PENCILS. n n 1 st - yellow, 2 st - red, 3 a - blue stripes, 3 b - solid blue, 4 tbsp. - black

DETERMINATION OF THE AREA OF THE BURN n VILYAVIN'S SCHEME - THE CONTOURS OF THE BURN ARE APPLIED TO THE SCHEME WITH THE IMAGE OF THE SILHOUETTE OF A HUMAN, MULTI-COLORED PENCILS. n n 1 st - yellow, 2 st - red, 3 a - blue stripes, 3 b - solid blue, 4 tbsp. - black

DETERMINATION OF THE AREA OF THE BURN n BLOKHIN method - the area of ​​the burn in square centimeters is divided by the age coefficient: 1 year - 30; 2 years - 40; 3 years - 50; 4 years - 60; 5-6 years - 70; 7-8 years - 80; 8 -15 years - 90.

Burn disease n A burn and the body's reaction to thermal injury is considered a burn disease. THE SET OF CHANGES IN THE ORGANISM OF THE SUFFICIENT ARISING AS A RESULT OF AN EXTENSIVE BURN IS USED TO CALL THE BURN DISEASE The term "burn disease" was first used by Wilson in 1929 n

Burn disease There are 4 periods of burn disease - the period of burn shock - acute burn toxemia - septicotoxemia - convalescence

Burn disease - THE PERIOD OF BURN SHOCK occurs immediately after injury and lasts 2-3 days. The victim does not complain of pain, he is pale, lethargic, apathetic. Often he is tormented by thirst, but drinking water immediately causes vomiting. Urine output is markedly reduced. The pulse quickens, decreases, and in a critical condition, blood pressure drops.

Burn disease ACUTE BURN TOXEMIA anemia increases, the amount of protein in plasma decreases, ESR increases. There is a poisoning of the body with toxic decay products and waste products of the infection developing on the burn wound. Lasts about 2 weeks. Accompanied by high fever, confusion, convulsions.

Burn disease n SEPTICOTOXEMIA - various complications develop (pneumonia, pleurisy, pericarditis, hepatitis, phlegmon and abscesses). After two and a half weeks, burn exhaustion develops. It can take from 2-3 weeks to 2-3 months.

Burn disease n RECONVALECTION - during this phase, all the functions of the child's body are aligned and normalized

TREATMENT OF BURN INJURY Treatment of burns is determined by the degree and size of the burnt surface of the body, the conditions under which the treatment takes place and consists of: - first aid at the scene; - in the fight against complications (shock, etc.); - in the primary treatment of the burn surface; - local and general treatment in medical institution

TREATMENT OF BURN INJURY FIRST AID consists in: - termination of the action of the traumatic agent, - in the prevention of shock, infection of the burn surface, ensuring the evacuation of the victim to a medical institution

TREATMENT OF BURN INJURY FIGHTING BURN SHOCK is carried out according to the same basic principles as the fight against traumatic shock. It is advisable to carry out its correction in the following areas:

TREATMENT OF BURN INJURY - - - Ensuring psycho-emotional rest (neuroleptic drugs, refusal of the primary toilet of burn wounds); Maintaining the necessary oxygen regime; Correction of impaired blood circulation; Prevention and treatment of disorders of the acid-base state;

TREATMENT OF BURN INJURY - - - Prevention and treatment of disorders of water-salt metabolism and excretory function kidneys; Fight against disorders of energy metabolism; Fight against intestinal autoflora and endotoxemia

TREATMENT OF BURN INJURY The choice of the subsequent method of treatment will depend on: - the environment in which the treatment is performed (clinic, hospital); - localization and degree of burn; - the size of the burn surface; - the time elapsed from the moment of the incident to the start of treatment of the burn; - the nature of the primary treatment of the burn

TREATMENT OF BURN INJURY SUPERFICIAL BURNS are usually treated conservatively. If there is no pronounced suppuration of wounds, then dressings are done after 2-3 days. Superficial burns usually heal in 10 to 15 days.

TREATMENT OF BURN INJURY Treatment of DEEP BURN depends on their nature, the general condition of the patient and medical tactics accepted in this medical institution The whole variety of methods of local treatment can be divided into closed and open

TREATMENT OF BURN INJURY The open method of treatment is most often used for burns of the face, neck, and perineum. The terms of healing of burn wounds are determined not so much by the area of ​​the burn, but by the speed of cleansing the wound from necrotic tissues and covering it with an autograft.

TREATMENT OF BURN INJURY The expediency of carrying out early removal of a burn scab is based on the following provisions: - Necrotic tissue is the entrance gate for infection; - Early necrectomy and immediate skin transplantation significantly shorten the period of burn disease, prevent its complications (sepsis, bedsores, thrombosis, contractures, etc.), and reduce the amount of measures intensive care, accelerates the healing time of wounds and the terms of hospitalization.

TREATMENT OF BURN INJURY - - - Promotes the restoration of skin sensitivity; Promotes earlier activity of the patient, which improves his general condition; Eliminates the need for frequent painful dressings.

TREATMENT OF BURN INJURY Absolute contraindications for primary necrectomy are: - Severe damage to the respiratory system and complications that arose during the period of burn shock; - Disorders of the central nervous system (disorientation, convulsions, etc.); - Dysfunction of the kidneys, liver, heart.

TREATMENT OF BURN INJURY There are the following types of necrectomy - Tangential (provides for layer-by-layer removal of necrosis within the actual skin); - Sequential (layered) excision to the subcutaneous tissue; - Necrectomy to the fascia - excision to the fascia or even deeper tissues;

TREATMENT OF BURN INJURY - - Enzymatic - consistent and gradual cleansing of the wound with the preservation of viable elements under the action of proteolytic enzymes (trypsin, pancreatin, travasa) Chemical - use 40% salicylic ointment, 40% benzoic acid solution.

TREATMENT OF BURN INJURY For the final closure of the wound, autodermatoplasty is performed using one of the following methods: - Brand method - Split skin grafts (for burns up to 25% of the body surface) - Perforated mesh flap (for extensive burns)

TREATMENT OF BURN INJURY - Temporary biological covers (dressings): homo- or allograft (obtained from a living or recently deceased person) - - Hetero- or xenograft (animal) Embryo membranes - amnion and chorion

TREATMENT OF BURN INJURY - layers of sponge - films of specially processed collagen or fibrin: = kombutek = algipore = artificial skin substitutes = film-forming biopolymer (polycaprolactone)

TREATMENT OF BURN INJURY - - - Treatment in an acaberial environment - a chamber with a laminar vertical air flow, which contributes to the creation of an ultra-clean environment; The use of infrared radiation - household electric fireplaces "Quartz-2 M"; The use of gnotobiological methods - isolators with a controlled air environment.

TREATMENT OF BURN INJURY In the wake of the fire in Perm in the club "Lame Horse" No region, no institute, no clinic is able to have a large number of professionals "at the ready" and even in the whole country with experience in working with burn patients. Andrey Fedorov - Deputy Director of the Institute of Surgery. A. V. Vishnevsky

COMPLICATIONS OF BURN INJURY Meet often, up to 44.2% of all admitted patients. They are divided into local and general (more often 7-8 times). Local: - most often - different kind contractures (up to 30%); - Bedsores (9%); - Arthritis (4 -6%) - Osteomyelitis, ankylosis, pathological dislocations, skeletal deformities.

COMPLICATIONS OF BURN INJURY General: - Burn exhaustion (36%). The main criterion is weight loss. - Pneumonia (about 2%) - Septic processes (sepsis, septicopyemia) -10% - They can also develop - hemorrhagic diathesis, mental disorders, pathology of the kidneys, liver, etc.

ELECTRIC BURN Electrical burns occur when a victim comes into direct contact with an electric shock and passes through the body from one electrode to another or into the ground. Children under 3 years of age are especially affected. The vast majority of electrical burns occur at home from low voltage currents.

ELECTRIC BURN Children are most commonly exposed to alternating electric current in contact with the lighting network with a voltage of 110-220 V and a frequency of 50 Hz.

ELECTRIC BURN Types of impact of electric current on the body: - Electric - develop deep biochemical changes in tissues; - Thermal (thermal) - at the point of contact with the conductor of electric current, the so-called "Signs of current" appear on the skin, yellow-brown areas on the skin ranging in size from a point to 2-3 cm in diameter with an impression in the center and a roller-like thickening of the edges, charring may develop

ELECTRIC BURN - - Biological - proceeds most severely, observed when current passes through the chest; Mechanical - causes painful contraction of muscle fibers, leading to their rupture.

ELECTRIC BURN (clinic) Not only local, but also general changes occur in the body, which are called electrical injuries. Factors that determine the severity of electric shock: - The duration of exposure to current with short-term exposure is more often observed vascular spasm and tonic contraction of skeletal muscles; - with prolonged exposure - ventricular fibrillation of the heart

ELECTRIC BURN (clinic) - - Power and voltage. According to the figurative expression: "Amps - kill, volts - burn"; The nature of the current loop (the path of electric current through the body) - Longitudinal loop - the current line runs along the body of the victim, which can lead to the development of: - Asphyxia (due to a combination of spasm of the respiratory muscles and laryngospasm) Coma (due to a violation cerebral circulation due to spasm of vascular smooth muscles);

ELECTRIC BURN (clinic) - a transverse loop - the current line passes through the heart, which leads to arrhythmias, ventricular fibrillation; - The defeat of the "voltaic" arc. Observed during a "short circuit". An electric flash causes damage to exposed areas of the body. The reaction from the eyes of electrophthalmia, passes without consequences.

ELECTRIC BURN (clinic) Clinical symptoms(degrees of electric shock): 1 degree - tonic muscle contraction without loss of consciousness. There is lethargy or agitation, pallor of the skin, shortness of breath, tachycardia, increased blood pressure pain syndrome may be expressed.

ELECTRIC BURN (clinic) 2 degree - consciousness is lost, but quickly (after 15-20 minutes) is restored, lowering blood pressure; Grade 3 - consciousness to coma, respiratory failure caused by laryngospasm, heart sounds are muffled, arrhythmia; Grade 4 - a picture of clinical death, cardiac arrest in the form of ventricular fibrillation.

ELECTRIC BURN (clinic) With low-voltage burns, necrosis penetrates deeper than the subcutaneous fat. In the first hours after the burn, the swelling of the surrounding tissues is not pronounced, there is no pain reaction. The general condition is not broken. Later, the swelling of the soft tissues increases, the area of ​​necrosis may remain white or acquire a black color - mummify.

ELECTRIC BURN (clinic) High voltage burns are more severe, as they are constantly accompanied by electrical injury of the 3rd or 4th degree, occupy a large area and often capture the entire organ. Characterized by tissue charring.

ELECTRIC BURN (clinic) Severe burns of limbs by high voltage currents are characterized by the following signs: - Muscle spasm causing flexion contracture; - Acute circulatory disorders due to vasospasm and compression of their scab; - Excruciating squeezing pains; - Secondary bleeding from large vessels

ELECTRIC BURN (treatment) Release the victim from the effects of electric current using any dielectric. For any severity of electrical injury, apply a bandage with a solution of furacilin to the burn wound

ELECTRIC BURN (treatment) At 1 tbsp. - calm the child (introduce seduxen, pipolfen), enter analgin At 2 tbsp. - taking into account hypotension, therapy is supplemented by intravenous infusion of colloidal blood substitutes - 10 ml / kg At 3 tbsp. - the main task is the elimination of respiratory disorders. To eliminate laryngospasm, it is necessary to introduce muscle relaxants, followed by tracheal intubation and mechanical ventilation. - performing cardiopulmonary resuscitation

CHEMICAL BURNS Chemical substances of both inorganic and organic origin can cause various skin lesions: - burns; - dermatitis; - eczema, etc.

CHEMICAL BURNS Burns can be caused by solid, liquid and gaseous substances. The degree of skin damage, the prevalence of burns, the duration of healing depend on the amount of the ingested substance, its concentration, residence time on the skin, as well as the speed of removal of the substance.

CHEMICAL BURNS Acids: - sulfuric, nitric, hydrochloric, carbolic, formic, acetic, etc. Alkalis: - caustic soda, caustic potash, caustic lime, caustic soda, fluorine, phenols, etc.

CHEMICAL BURNS In case of a chemical burn, there is: - a deep violation of the physico-chemical properties of the cell; - the formation of highly toxic protein products associated with ions of a chemical irritant. Blisters are rare in chemical burns. They occur in no more than 20% of all cases and appear a few days after the burn.

CHEMICAL BURNS Under the action of inorganic acids on the skin, tissue proteins coagulate and turn into acidic albumins. In the place of greatest contact with acid, a dense dry scab is formed from coagulated protein, acidic albumins and cell fragments. The scab has clear boundaries, depressed along the edges. Around the scab there is redness as a result of a reaction from the blood and lymph vessels.

CHEMICAL BURNS Concentrated alkalis, unlike acids, dissolve and emulsify the fats of the stratum corneum, as a result of which there is a rapid violation of the integrity of the skin barrier. Concentrated alkalis cause the formation of wet necrosis: the scab is loose, off-white in color, easily separated, exposing a bleeding ulcer. In the circumference of the ulcer, inflammation develops.

CHEMICAL BURNS Burns caused by chemical substances are divided into 4 groups depending on the degree of damage: - 1st degree burns are caused by substances that do not have sharply irritating properties of the skin, or substances in small concentrations. Manifested in redness of the skin, accompanied by slight swelling. Swelling and redness have a sharp border and sometimes resemble erysipelas. The burn is accompanied by a burning sensation. Pass in 2-3 days.

CHEMICAL BURNS 2nd degree burns - tissue edema is more pronounced, hyperemia is more intense. Detachment of the stratum corneum of the epidermis by plasma leads to the formation of blisters. The duration of treatment for an uncomplicated burn is from 10 to 20 days.

CHEMICAL BURNS 3rd degree burns are caused by concentrated acids and alkalis. Through different dates, from several hours to several days, at the site of redness and swelling, a darkening of the tissue appears or, conversely, its whitening, followed by the formation of a scab. Healing - 2 months or more.

CHEMICAL BURNS Burns of the 4th degree are manifested in deep necrotic damage not only to the skin, but to deeper tissues. Possible deaths in the first 6 hours with symptoms of pain shock.

CHEMICAL BURNS (Treatment) The basic principle of first aid for an injured person in contact with a chemical substance on the skin is the immediate removal of this substance. The best remedy this is a long flush with a jet of water for 1 -15 minutes.

CHEMICAL BURNS (treatment) For outpatient treatment of chemical burns, it is best to use dressings with tannins: - 10% solution of tannin in alcohol; - 4 -5% aqueous solution of potassium permanganate; - lead lotion.

Frostbite (congelatio) Local damage cold - frostbite occurs in childhood relatively rare - 0.5%. The severity of frostbite is due to: - the intensity of the cold; - duration of exposure; - related factors: - external environment(wind, high humidity, contact with cold objects) - reducing the body's resistance to cooling (exhaustion, overwork,

Frostbite (congelatio) The generally accepted is the 4-degree classification of frostbite (T. Ya. Ariev) 1 degree - the period of tissue hypothermia is short. After warming, the skin of the frostbitten area is cyanotic or marbled. There are no signs of necrosis.

Frostbite (congelatio) 2 degree - the border of skin necrosis passes in the uppermost zones of the papillary epithelial layer. A characteristic feature is the presence of blisters filled with light exudate. Full recovery occurs upon recovery. normal structure skin.

Frostbite (congelatio) 3rd degree - the death of all elements of the skin is observed, the blisters contain hemorrhagic exudate, their bottom is insensitive to mechanical irritation. Upon recovery, scars form at the site of the lesion.

Frostbite (congelatio) 4 degree - a deep necrotic process captures the bones and joints of the limb. Subsequently, mummification develops or wet gangrene. The process ends with the rejection of the dead segment and the formation of a stump.

Frostbite (congelatio) Clinical picture. In contrast to mechanical injury, cold injury is longer in time and has a so-called latent period. Determination of the degree and size of the lesion is possible only by 4-5, and sometimes by 14-16 days after the injury and even later.

Frostbite (congelatio) Clinically, there are: - a period of hypothermia (lasting from several hours to a day or more); - the reactive period that occurs after tissue warming.

Frostbite (congelatio) The manifestation of the disease during hypothermia is characterized by coldness, blanching and loss of sensitivity From the moment the symptoms appear in the area of ​​the affected segment acute inflammation- pain, hyperemia, edema - a reactive period begins.

Frostbite (congelatio) It is at this time that secondary tissue necrosis occurs due to spasm and thrombosis of blood vessels. There are 4 stages during the reactive period: - shock (the first day); - toxemia (from 2 hours to 10-12 days); - infectious-septic; - reparative, arising after rejection or removal of necrotic masses

Frostbite (treatment) Treatment of frostbite should be aimed at: - reducing pain; - removal of vasospasm; - elimination of edema; - prevention of local purulent process.

Frostbite (treatment) The most effective way to provide first aid is to quickly warm the affected body segment in warm water baths with the obligatory mechanical restoration of blood circulation (rubbing, massage). For improvement general condition take measures aimed at general warming, prescribe drugs, cardiac drugs, and carry out the prevention of tetanus.

Frostbite (treatment) Local treatment of a frostbitten area includes: - toilet with alcohol; - removal of fragments of the epidermis; - opening of tense bubbles.

Frostbite (treatment) Superficial frostbite of 1st and 2nd degree is treated in an open way, lubricating the affected surface with tannins ( alcohol solution iodine, methylene blue). With frostbite 3 and 4 degrees apply bandages with camphor alcohol, Vishnevsky ointment. Electrophoresis with hydrocortisone is effective to combat edema

Frostbite (treatment) The main treatment for deep frostbite is surgery. Character surgical interventions depends on the existing local changes and the time elapsed since the injury.

CHILLING (pernio) Chilling can be considered as chronic frostbite of the 1st degree. With severe chills in young age there is ulceration of the skin and the development of secondary dermatitis.

CHILLING (pernio) Chilling is observed with repeated mild frostbite, and sometimes after a single frostbite, it manifests itself in the form of chronic inflammation of the skin: - red-blue spots with a purple tint; - severe itching. Most often, the hands, feet, nose, and ears are chilled.

HYPOCOOLING, FREEZING Hypothermia, freezing is a pathological decrease in the heat content of the whole body. Factors that reduce the adaptive limits to the effects of low temperatures in children: - relatively large body surface with increased heat transfer; - physiological centralization of blood circulation, which does not reduce heat transfer; - insufficient maturity of the central link of thermoregulation.

HYPOCOOLING, FREEZING Changes in the body caused by hypothermia: - vasospasm of the skin and subcutaneous tissue, followed by trophic disorders; - muscle trembling and subsequent muscle stiffness; - neurohumoral exhaustion (drowsiness, coma, insufficiency of the adrenal cortex, hyperglycemia).

HYPOCOOLING, FREEZING Clinical symptoms (depending on the decrease in body temperature). There are 3 degrees of hypothermia (freezing): 1 degree - body temperature is reduced to 32-30 C, the child is sharply inhibited, shortness of breath, muscle tremors, tachycardia are pronounced. Lowering blood pressure.

HYPOCOOLING, FREEZING Grade 2 - body temperature is reduced to 29-28 C, consciousness is impaired to coma, hyporeflexia, muscle rigidity, respiratory and circulatory depression. Grade 3 - body temperature is reduced to 27 -26 C, clinical death, the duration of which, with hypothermia (freezing), is lengthened.

HYPOCOOLING, FREEZING Treatment. - changing clothes; - gradual warming of the victim; - oxygen therapy, mechanical ventilation (with icing, mechanical ventilation is contraindicated); - cardiopulmonary resuscitation with defibrillation.

Summary

The article analyzes the features of burns in children, the development of burn disease varying degrees severity, classification, diagnostic measures and standards for first aid and qualified care with the use of new approaches in the treatment of such patients in clinical practice. The presented material is aimed at increasing the level of knowledge of pediatricians in the field of emergency medicine.

Keywords

burns, children, diagnostics, assistance.

In Ukraine and the CIS countries, burn pathology continues to be one of the most urgent and socially important problems of childhood injuries due to the fact that the structure of burn injuries has changed significantly in the direction of worsening the injury and increasing the proportion of deep lesions. Children make up a large and often difficult contingent of surgical hospitals (14.0 per 10,000 children). Unfortunately, most of the affected children in the acute period receive treatment in general surgical hospitals, and not in specialized centers.

The immaturity of tissue structures at an early age in children, the imperfection of protective and adaptive reactions are the reasons for the long-term existence of pathological post-burn disorders, which, in turn, can lead to irreversible changes even with lesions limited in area.
The success of treatment, and sometimes the fate of the victim, largely depends on the timeliness and completeness of medical care already in the first hours after the injury.

O Features of the tissue and physiological development of the child, affecting the provision of emergency care for burns

1. The skin (epidermis and dermis proper) in children is much thinner than in adults, so deeper burns occur.
2. The ratio of body surface and body weight in children, especially young children, is 2-3 times greater than in adults. This leads to more intensive water exchange and metabolism.
3. The water-electrolyte composition of muscle tissue requires more urine to remove toxins from the body, and the level of fluid persistence relative to body weight in children is much higher than in adults.
4. Due to the helplessness of the child during the injury, there is a large exposure of the thermal agent, which leads to deeper burns.
5. In children, adaptation mechanisms are imperfect, the need for oxygen in tissues is higher, which requires a special approach to therapy.
6. Burn shock in children can develop with a superficial burn of 5-10% or a deep burn of 3-5% of the body surface.

Epidemiology of childhood burns

The leading etiological factors of burns in children are hot liquids (65-80%) and flame burns (25.9%). In the conditions of an industrial region, man-made injuries are increased, especially electrical burns (11.3%), including high-voltage burns - 3.9%. That is, burns requiring surgical treatment account for up to 40% of cases.

Determination of the burned surface area in children

The burn area, expressed as a percentage of the body surface, can be determined according to the well-known “rule of nines” adapted to the age of the child, as well as the palm rule for limited burns, based on the fact that the area of ​​\u200b\u200bthe child’s palm is approximately 1% of the entire body surface. For burns larger than 60%, it is easier to determine the unburned surface.

Classification of burn wounds

In Ukraine, a classification of burn wounds according to the depth of the lesion has been developed and is used.

The first degree is an epidermal burn. dominant pathological process is serous edema. Alteration occurs within the same anatomical formation (epidermis) and is usually manifested by combined clinical signs: hyperemia of the skin, interstitial edema and the formation of loose, liquid-filled light yellow blisters. The healing of such wounds occurs spontaneously within 5-12 days and always without scarring.

The second degree is a dermal superficial burn. Blisters often form, but they are thick-walled (within the dermis), extensive, tense, or ruptured. With detachment of the stratum corneum of the epidermis, a thin necrotic scab of light yellow, light brown or gray color. The scab is formed within the dermis, and the zone of paranecrosis is in the subcutaneous fat.

With inadequate treatment, second-degree burns can deepen due to unrestored microcirculation in the area of ​​paranecrosis and transform into third-degree burns.

Third degree - dermal deep burn, full-thickness necrosis of the skin. III degree burns include lesions of the skin, its appendages and subcutaneous adipose tissue as a single anatomical and functional formation up to the superficial fascia. Surgical treatment.

The fourth degree is a subfascial burn. Damage and / or exposure of tissues located deeper than their own fascia or aponeurosis (muscles, tendons, blood vessels, nerves, bones and joints), regardless of their location. The specificity of such burns is associated with rapidly developing secondary changes in tissues due to subfascial edema, progressive thrombosis, or even damage to internal organs. All this requires urgent surgical interventions.

First aid for burns in children

Much can be done to prevent further injury to a burned child right at the scene.
1. About start the combustion process. It is necessary to bring down the flame, but more importantly, it is necessary to stop the smoldering of the fabric. Leaving the smoldering tissue on the skin deepens the burn.
2. Cool the burnt area. If possible, the burnt area should be cooled by washing, immersion in cold water or wrapped in wet cloth. Ice cooling is not practical.
3. Assess respiratory function. Ensure airway patency, monitor arterial pressure in dynamics.
4. Inspect for other damage. On fractures, especially open ones, you need to carefully apply splints, avoiding squeezing of the vessels. Serious complications are also damage to the central nervous system and cervical spine.

Features of chemical burns

The manifestations of chemical burns are different depending on whether they were caused by acid or alkali.

Acids and salts heavy metals lead to the coagulation of proteins in tissues and their dehydration, i.e. comes coagulative necrosis: a dense dry crust of dead tissue is formed.

The action of alkalis based on the breakdown of proteins and saponification of fats, and therefore formed colliquative necrosis. The scab is usually loose, surrounded by a crown of hyperemia. More pronounced intoxication. In case of burns with nitric acid, phenol, mercury salts, phosphoric acid, toxic damage to the liver and kidneys is possible.

First aid for chemical burns is aimed at the fastest termination of the agent. To do this, the affected area is washed with running water for 15 minutes or more. The exception is burns with organic aluminum compounds, concentrated sulfuric acid, the interaction of which with water is accompanied by a reaction with the formation of heat. When damaged by organic aluminum compounds, the surface is locally treated with gasoline or kerosene in the form of dressings or lotions. There is no further treatment for a chemical burn. fundamental difference from thermal tissue damage.

Electrical injury. First of all, it is necessary to determine whether the child is still in contact with an electrical source, and take measures to eliminate it. The use of dry wood, rubber or plastic usually provides good insulation.

All victims with burns, regardless of their area and depth of damage, should be examined by a surgeon or combustiologist. The following categories of burn patients need hospitalization: children under three years of age with a burn of more than 10-12%; children with electrical burns; children with burns of the face, neck, hands, perineum; with suspicion of a thermoinhalation lesion; children with burdened premorbid background.

Doctor's actions when a child is admitted to the department

Weighing the patient not only determines the correctness of the ongoing water and electrolyte correction, but also makes it possible to evaluate the effectiveness of parenteral fluid administration. Knowledge of weight is also necessary to determine the energy needs of the patient.

Assessment of the child's respiratory system. The physical examination should include a careful direct examination of the oropharynx in order to detect soot spots, hyperemia, and edema in it. Increasing upper airway obstruction due to rapidly developing edema may require intubation. There is a serious risk of carbon monoxide poisoning in the event of a flame burn in an enclosed space or prolonged smoke inhalation. Anxiety, hypoxia of the child indicate more likely a respiratory distress syndrome caused by damage to the respiratory tract.

The characteristic cherry color of the patient will indicate carbon monoxide poisoning. Research is needed in the dynamics of the level of arterial gases and carboxyhemoglobin. High level carbon dioxide levels are one of the first signs of extensive lung damage from the toxic effects of smoke inhalation and require oxygen therapy or a hyperbaric oxygen session.

Bronchoscopy increases the possibility of diagnosing damage to the respiratory tract and sanitizing the tracheobronchial tree. Repeated examinations may be needed depending on the condition.

A chest x-ray should be taken on admission, but even with severe airway injury, changes on the initial x-ray are rare.

General assessment of the condition of the burned child. A complete picture of the patient's condition should be obtained, the details of the anamnesis of his concomitant pathology (the presence of an allergy to medical preparations preventive vaccinations).

At the same time, all the vital functions of the body (pressure, pulse, breathing pattern, temperature, as well as the patient's consciousness) are recorded and subsequently monitored.

Blood should be taken to determine the group and Rh factor, its clinical analyzes (hemoglobin, hematocrit, determination of the leukocyte formula), the state of the blood coagulation system (platelets, coagulogram), plasma electrolytes (Na, K, C1), protein level and osmolarity , general analysis urine to determine its volume, specific gravity or osmolarity.

Other special blood tests are prescribed depending on the patient's condition. Diagnosis of burn shock is carried out taking into account the area of ​​thermal damage and the age of the child. Determining the severity of burn shock is possible using diagnostic criteria (Table 1).
Table 1. Diagnostic criteria for burn shock in children

The assessment of the severity of shock is reliable if at least 3 signs are taken into account simultaneously.

Treatment standard

1. About pain relief. The method of choice for anesthesia in children is ataralgesia (analgin 25% solution 0.2 ml/kg with seduxen 0.5% - 0.5 mg/kg; ketamine 0.5-1.0 mg/kg intravenously or intramuscularly 2 mg / kg In children older than a year - promedol 1% solution of 0.1 mg / kg with seduxen).
2. venous access. For transfusion therapy during transportation, a puncture (catheterization) of a peripheral vein is sufficient. If intravenous access is not possible, drugs can, as an exception, be injected into the muscles of the floor of the mouth. If the child is intubated, the intratracheal route may be used. The dose of drugs in such cases should be age-related, and their concentration is diluted 10 times.
3. Immobilization. Especially during transportation, it is necessary to immobilize the limb for infusion therapy, fixation to prevent the removal of catheters and contour dressings.
4.Infusion therapy. It must be remembered that the main purpose intravenous administration fluid in the first hours of burn injury is the restoration of normal cardiac output and diuresis. When compiling an infusion therapy regimen, it is necessary to take into account the recommended formulas for calculating infusion therapy in children. The most popular formula for calculating fluid therapy needs was proposed by Parkland (first 24 hours: Ringer's lactate solution 4 ml/kg per percentage of burned area, children weighing less than 20 kg add a maintenance volume of fluid equal to 50-75% of their daily needs (1500 ml / m2 / day)).

Initial therapy includes the introduction of crystalloid solutions 20 ml/kg, rheopolyglucin at a dose of 10 ml/kg, then 20% glucose with insulin 5 ml/kg. Sodium must be the main ion in any chosen fluid: hypotonic, isotonic, or hypertonic. For quick recovery intravascular volume, hydroxyethyl starch solutions (6-10%) can be administered, which, due to their large molecule, do not leave the vascular bed and contribute to the restoration of the integrity of the capillary wall.

Infusion therapy is carried out under the control of the rate of diuresis in the range of 0.5-1 ml/kg/day. Half of the total volume is administered in the first 8 hours after the burn injury, and the other half in the next 16 hours.

The volume of infusion therapy on the second day is reduced by a quarter of the initially calculated. Colloidal solutions are used to improve diuresis and treat hypoalbuminemia. Intravenous therapy at the end of the 2nd day of the burn period should provide a normal concentration of sodium, phosphorus, calcium and potassium in the blood serum.

Damage to the airways is accompanied by a violation of the alveolo-capillary integrity, which can lead to fluid overload in the interstitium of the lungs. Therefore, when introducing large volumes to a child, strict monitoring of the water balance is required.

The high voltage electrical current causes deep muscle damage, releasing myoglobin and hemochromogens, which causes a risk of kidney damage.

Glucocorticosteroids are prescribed for severe burn shock, burns of the respiratory tract and with an unfavorable premorbid background - 3-8 mg / kg of prednisolone.

5. Oxygen therapy. It is preferable to carry out inhalation of humidified oxygen through a respiratory mask.
6. K bladder atheterization. From the first minutes of a child's admission to the hospital, bladder catheterization is performed to monitor diuresis, one of the most important methods for monitoring infusion therapy in the first days after a burn.
7. Nasogastric tube. Gastric drainage will reduce the risk of vomiting and aspiration. The oral cavity should be treated with antiseptic agents.

Medical therapy and resuscitation aids in the stage of burn shock are aimed at eliminating the following pathogenetic disorders.
- Reducing the manifestations of hypercoagulable syndrome and prevention of consumption coagulopathy: heparin (200-300 units / kg / day), antiplatelet agents (pentoxifylline, dipyridamole).
- Normalization of membrane permeability is achieved by the introduction of corticosteroids, proteolysis inhibitors, antihistamines.
– Maintaining the metabolism of macroergs and providing synthetic adaptation reactions: a complex of vitamins C, B1, B6, ATP is used, a nicotinic acid, Riboxin.
- To prevent the development of acute ulcers of the gastrointestinal tract, H2-blockers and antacids are prescribed, for intestinal decontamination - enterosorbents, eubiotics.
- To optimize the activity of the heart, normalize mesenteric and renal blood flow, sympathomimetic amines are used - dopamine in mediator doses (1-5 mcg / kg / min).
- To eliminate metabolic acidosis, sodium bicarbonate is prescribed. Correction should be carried out at pH values ​​less than 7.2.
- Until the normal activity of the kidneys is restored, hydrating solutions should not contain potassium preparations, which, in case of hypokalemia, are prescribed after the first 12-24 hours.
- The therapy should be adjusted according to clinical and laboratory parameters.

The presence of concomitant pathology or developmental anomalies in a child requires great attention when drawing up the program of infusion therapy.

On an outpatient basis, only burns of I-II degrees with a lesion area of ​​\u200b\u200bno more than 10% of the body surface are treated. Victims with all other injuries are hospitalized. Second degree burns in the face, scalp, feet, groin and perineum are recommended to be treated in a hospital.

Local treatment should be aimed at the fastest cleansing of wounds from necrotic tissues, prevention of secondary contamination of wounds, stimulation of reparative processes, prompt closure of wounds in the early stages.

For burns of the 1st degree, the toilet of the burn wound is performed with saline or an antiseptic (iodopyrone, chlorhexidine). A dry aseptic dressing is applied to the wound, aerosols with film-forming polymers (furoplast, acutol, naxol, etc.), water-soluble ointments (streptonitol, nitacid, oflokain, dermazin, levomekol, levosin) are used. For pain relief, non-narcotic analgesics are used.

For second degree burns, the burn surface is treated. After the primary toilet, the wounds are incised with blisters at their base and an aseptic dressing is applied. If the contents of the blisters are cloudy, then the exfoliated epidermis is excised, the wound surface is treated and a bandage of ointment on a water-soluble basis is applied.

For burns III-IV degree treatment only in a hospital. General treatment includes anti-shock, transfusion therapy, the fight against infectious complications, clinical nutrition. The nature and extent of therapeutic measures depends on the stage of the burn disease.

Our experience proves both the possibility and the need to transport children in the first hours (days) after a burn, provided that infusion antishock therapy is carried out, accompanied by an anesthesiologist and combustiologist. It should be remembered that the most optimal time for transfer to a specialized burn clinic is the first 6-8 hours after the injury.

Thus, the success of treatment, and sometimes the fate of the injured child, largely depends on the timeliness and completeness of medical care in the first hours after the injury, and the knowledge of non-surgical specialists about the specifics of burns in children will help to avoid mistakes in both organizational and medical issues.

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