BURNS, ELECTROTRAUMA, FROSTBITE

BURNS

Burn (combustio) is harm to the organism tissue on account of native motion of excessive temperature, chemical substances, gamma rays, X-rays, ultaviolet rays, ionizing radiation.

Classification

After the circumstances of damage, industrial, family, wartime burn are distinguished.

After the character of the appearing issue, there are:

— thermal burns, the vital function belongs to the temperature of affect, time of contact to a scorching object, thermal conductivity of the thing contacting to the pores and skin (air, water steam, the boiled water, open flame, a steel topic, and many others.), humidity of an setting, situation of the pores and skin and an organism of the affected person as a complete.

— chemical burns, that are fashioned as the results of acids, alkalis getting on the pores and skin and mucosa.

— electrical burns are characterised by further affecting the interior organs by the electromagnetic area.

— beam burns are attributable to infrared, ultraviolet and gamma rays, X-rays radiation.

After the localization, there are burns of functionally activeparts of the physique, motionless components of the physique, the face, furry a part of the top, the higher respiratory methods, perineum.

The classification of burns after the depth of damage, which isused now, was accepted in 1961 on the XXVII All-Union Congress of Surgeons. Based on it there are 4 levels:

— the I diploma burn is characterised by harm of the extent of the dermis and manifests itself with hyperemy, oedema of the pores and skin, ache. In some days the higher layer of the dermis dries up, rucks up, shells up.

— the II diploma burn is characterised by harm of all epithelium with formation of the thin-walled blisters full of a clear serous liquid as a result of dilation of capillaries and infringement of their permeability. Unbiased epithelizatin happens by the tenth– twelfth day.

— the IIIа diploma is characterised by necrosis of all of the epitelium, superficial layers derma and accompanied by formation of thickwalled blisters and superficial dry mild — brown or delicate white-grey eschar. The burn heals as a result of development of granulations and epithelization from the hair bulbs, ducts of sebaceous and sudoriferous glands, edge epithelization on the a part of a wholesome pores and skin.

— the IIIb diploma is characterised by necrosis of all layers of the derma along with hair bulbs, sebaceous and sudoriferous glands with transition to hypodermic tissue with formation of a dense dry eschar of brown shade at a flame burn or damp necrosis at scalding with boiled water, steam, and many others. Unbiased therapeutic of a wound comes by cicatricial pull off, regional epithelization.

— IV diploma is characterised by necrosis of the pores and skin and deep tissues (hypodermic tissue, muscle mass, bones) with formation of a brown or black eschar of varied density and thickness.

Burns of I, II, IIIа levels belong to superficial, and IIIb, IV — to deep. It is extremely vital. With superficial burns an unbiased therapeutic is feasible, and with deep ones — is just not. Within the West a Vdegree C. Kreibich’s classification is common the place the IIIb diploma is known as IV, and correspondingly the IV diploma turns into V.

The query on early prognosis of the burn depth stays the fundamental query in combustiology. The presence of hyperemia, blisters, eschar, necrosis foci enable to find out preliminary depth of the pores and skin harm and the burn diploma. For differential prognosis of burn levels the strategies of definition of infringement of blood circulation and sensitivity are used, particular dyes and fermental preparations are utilized: the strategy of urgent, tetracyclinic fluorescence, thermometry, definition of ache sensitivity by procking, software of 90° spirit, hair epilation, portray of tissue by Van— Gieson, dying pores and skin sampling with resolution of diphosphopiridinnucleotidphosphatase.

5. Classification of burns in keeping with the world of defeat in not vital for estimation of harm severity and selection of the therapy plan. The human pores and skin floor space makes 15,000–21,000 cm2.

Many schemes have been created for definition of the burn space.

The most well-liked strategies are as follows:

— the “methodology of the 9” which has been prompt by A. Wallace in 1951. Based on it the world of the fundamental components of the physique makes 1–2 nines (9% from all of the floor of the physique): the top, the neck — 9%; the anterior floor of the physique — 18%; the posterior floor of the physique — 18%; the higher extremity — 9%; the decrease extremity — 18%; the perineum — 1%. At youngsters the ratio of the talked about components of the physique to the final floor is completely different and varies with the age.

— in 1953 I. I. Glumov has prompt to find out the world of the burn, evaluating it with the world of the palm of the sufferer, which makes 1% of the floor of the physique (the rule of the palm).

— in 1949 B. N. Postnikov has prompt to use a sterile gauze or cellophane on the burnt floor, on which the contours of the burn are put. Then the contour of the burn is transfered to a millimetric paper, they calculate absolutely the space of harm and relative one in share of the final floor of the physique.

— varied types of stamps with the picture of the particular person, divided into squares are utilized for definition of the world of defeat and the documentation. G. D.Vilyavin has prompt to designate the world of the burn of the anterior and posterior floor of the physique with varied colours in dependance on depth of damage.

Thus, the severity of burn is set by depth (diploma) of burn, the world of burn in percents and localization of burn. In 1939 Yu. Yu. Janelidze has prompt, and V. V. Vasilkov and V. O. Verkholetov have added the formulation of burns definition, in keeping with which the burn is characterised by fraction, which have the world of harm in numerator (in brackets — p.c of deep burns), and burn diploma in denominator. In entrance of the fraction the etiological issue (thermal burn, chemical or beam), and after the fraction the fundamental zones of damage (the top, the neck, the trunk, and many others.) are indicated.

Definition of prognosis at thermal damage of an organism is a crucial level in burns therapy. The simplest strategies of definition of prognosis for burns are following:

— the rule of the hundred: the age of the affected person in years and relative measurement of the burn surfaces in percents are summed up. If the sum makes 60 and fewer — the prognosis is favorable, 61–80 — the prognosis is relatively favorable, 81–100 — the prognosis is uncertain, 100 and extra — the prognosis is unfavorable. The rule is utilized just for adults.

— the Frank’s index is obtained at addition of the superficial burns space with the triple space of deep ones: if the sum makes 30 and fewer — the prognosis is favorable, 31–60 — the prognosis is relatively favorable, 61–90 — the prognosis is uncertain, 91 and extra — antagonistic.

Burn illness is a set of scientific signs, basic reactions of an organism and dysfunction of inside organs at thermal damages of the pores and skin and underlying tissue.

At superficial burns of greater than 15–25% of the floor of the physique and deep burns of greater than 10% burn illness indicators develop.

Throughout the burn illness course 4 intervals are distinguished:

burn shock, acute toxaemia, septicotoxaemia,reconvalescence.

1. Burn shock is a pathological course of which develops at in depth thermal defeats and in dependence on the world and depth of the burn, duly and satisfactory remedy can proceed until 72 o’clock. Particular options of burn shock are absence of bloodloss, pronounced plasma loss, haemolysis, renal dysfunction that causes pathogenetic mechanisms of its growth and the adjustments occuring in an organism.

Based on the scientific image three levels of burn shock are distinguished:

— I diploma is noticed at burns of 15–20% of the floor of the physique. It’s characterised by robust pains within the injured websites, excitation of sufferers, average tachycardia as much as 90 beats per min, the conventional or barely elevated arterial stress. Improvement of oliguria and haemoconcentration is feasible;

— II diploma develops with harm of 21–60% of the floor of the physique and is characterised by quick enhance of letargy, adynamia, tachycardia 100–120 beats per min, hypotension, fall within the physique temperature, thirst, dispeptic phenomena, discount diuresis, pronounced haemoconcentration (Ht grows as much as 60–65%) with growth of metabolic acidosis;

— III diploma develops with damage of greater than 60% of the floor of the physique. The situation of the affected person could be very extreme, the consciousness is confused, letargy comes, sopor. The puls is threadlike, arterial stress is decreased under 80 mmHg, shallow respiration. There may be paresis of the gastrointestinal tract. Dysfunction of organs and techniques which is harmful for all times develop and to start with — the kidneys. Ht exceeds 70%, hyperpotassemia, acidosis rise.

Acute burn toxaemia replaces the shock stage, however can develop independently, takes place for 10–15 days. Quick absorption of lively substances from the burn zone takes place: histamine, serotonine, prostaglandins, toxins — glycoproteids with antigen specificity, lipoproteids, oligopeptids. Proteolitic enzymes activate. The merchandise of erythrocytes haemolysis, fibrinolysis have poisonous motion. The manifestation of toxaemia is fever with temperature peaks as much as 38– 40°С, pallor of the pores and skin, tachycardia, hypotension, weak point, nausea, vomitting.

Disturbances of the central nervous system, cardio-vascular exercise, renal features with proteiuria, microhaematuria — right down to acute renal insufficiency are noticed. The scientific evaluation of blood reveals anemia, excessive left-shift leukocytosis. Improve in transaminases exercise, hypoproteinemia, hyperbilirubinemia are typical in biochemical analyses of blood.

Septicotoxaemia is proven in 10–14 days after the burn. The essential pathogenetic issue of the septicotoxaemia is resorption of the merchandise of tissue disintegration and important exercise of microorganisms with growth of infectious problems.

The scientific course of septicotoxaemia will depend on the character of the wound course of section. Within the first section (from the start of eschar tearing away to full cleaning of the wound) the final situation of sufferers is extreme: damaged sleep, pronounced irritability, tearfulness, dangerous urge for food. Attributes of purulent intoxication are noticed: fever, tachycardia, weak point. Anemia, leukocytosis with left shift, typically eosinophilia, lymphocytopenia proceed to extend. Attributes of poisonous hepatitis, pyelonephritis are typical.

Within the second section (the section of granulations right down to full therapeutic of burn wounds) varied problems develop: pneumonia, acute ulcers of the gastrointestinal tract (Kurling’s ulcer), burn exhaustion, generalization of an infection — burn sepsis.

Reconvalescence. With liquidation of a burn wound the misplaced features of the cardio-vascular system, urinary system, parameters of purple blood, leukocytes, protein construction of blood start restoring. Therapy of burns is a relatively uneasy downside.

First support. The depth of harm, the additional illness course depend upon how briskly and proper the primary support is rendered.

The order of measures at rendering the primary support is as follows: to forestall the thermal agent affect on the pores and skin; to chill injured websites; to use an aseptic bandage; to anesthetize and start antishock actions.

Native therapy of burns. Therapy of burn wounds will be conservative and operative. Conservative therapy is a novel and ultimate methodology at superficial burns. At deep burns operative restoration of the misplaced integument is critical.

The first rest room of the burn floor is carried out at thelimited floor with out shock indicators with observing aseptic guidelines, sparing, with software of narcotics or narcosis and consists in therapy of the pores and skin across the injured place, elimination of exfoliating dermis, alien our bodies, therapy of burn floor with a 3% resolution of peroxide hydrogen. Giant blisters are incised and emptied. On this case the exfoliating dermis performs a job of an authentic organic bandage.

Conservative therapy is carried out by the closed or open approach.

The closed approach is predicated on software of bandages with varied medicinal substances and carried out with bearing in mind the depth of damage and presence of purulent irritation. Superficial burns as a rule heal with epithelization, and formation of tough scars is feasible solely with growth of pronounced purulent irritation.

With deep burns native therapy is directed on acceleration of necrotic tissues rejection. Bandaging is carried out in a day beneath narcosis with software of damp bandages with antiseptics. For the reason that seventh–eighth day sparing cold necrectomy is performed, necrolytic remedy (travaza, 40% salicylic ointment, benzoic acid) is utilized. After eschar rejection, the underside of the wound is granulation tissue. Unbiased closure of the defect is feasible with insignificant damage. Typically pores and skin plasty is critical.

With the open methodology of therapy the drying up motion of the air is used, therapy of the burn surfaces is performed by antiseptics with coagulative properties (a 5% resolution of potassium permanganate, sensible inexperienced), the wound remaining open. This methodology is utilized in situations of the managed abacterial setting in particular wards, bins.

Surgical therapy is utilized at deep burns as follows:

— necrotomy which is indicated with formation of dense round necrosis and is carried out with out further anaesthesia as a bit on all of the depth untill blood drops seem;

— early necroectomy with closing the defect with the pores and skin transplant is a giant surgical intervention and it’s essential to look at beneath satisfactory anaesthesia when it comes to 3–5 days after the burn with the tangential or one-staged methodology with closing the wound defect by the strategy of free pores and skin grafting or vascular pedicle grafting;

— delayed pores and skin grafting is carried out 2–4 weeks after the burn when the wound is roofed with granulations with out pathogenic microflora.

Now in closing burn wounds the next methods are utilized:

Native tissue grafting.

Free pores and skin grafting as full-thickness pores and skin transplantation andaccordion grafting.

Accordion grafting on an nutritive leg: Italian grafting, grafting in keeping with V. P. Filatov, accordion grafting on a vascular pedicle with microsurgical method software.

Utility of cultivated allofibroblasts — multilayered mobile buildings from cells of the embryos which have been introduced up on particular nutrient mediums.

Provisional organic closing the defect with a view to forestall theloss of plasma, prevention of an infection growth, stimulation of regional epithelization with using the cadaveric pores and skin or the donor’s one (allodermoplasty), the pores and skin of calfs, pigs (xenodermoplasty), artificial supplies (polycaprolacton, hydron), artificial pores and skin (epigard, sincaver, aeroplast-special).

The overall therapy of burns. The next elements of the final therapy at burns are distinguished:

Battle in opposition to ache, which consists within the affected person’s relaxation, making use of bandages, introduction of non-narcotic analgesics, sedative preparations, neuroleptics, narcotic analgesics.

Therapy of the burn shock is carried out in keeping with thegeneral guidelines of antishock remedy and is directed on elimination of ache, upkeep of the system haemodynamics, enchancment of perfusion, compensation of the plasma loss and correction of the perform of the broken organs.

Narcotic analgetics in a mix with antihistamine preparations and sedative means, neuroleptics are utilized for wrestle in opposition to ache.

Elimination of hypovolemia and compensation of the plasma loss is reached by introduction of plasma, albumin, protein, blood substitutes (polyglucin, rheopolyglucin, hecodez, rheosorbilact).

Corticosteroids, dopamine, cardiotonic means, cardiac glycosides (strophantin, corglucon) are utilized beneath indications.

Aminophylline, dopamine are utilized for enchancment of tissue and organ perfusion. Contrical, trazilol, rheopolyglucin, rheomacrodes, heparin and its low-molecular fractions, trental, curantil are utilized for stabilization of microcirculation and correction of rheologic properties of blood.

Correction of perform of the broken organs within the shock section to start with is directed on the respiratory sistem: breathe of the moistened oxygen, intubation of the trachea, beneath indications — tracheostomy.

Therapy of acute toxaemia consists in infusion and desintoxication remedy, therapy of acute renal insufficiency, correction of acidosis.

Infusion remedy makes up the blood quantity (BV), lack of protein and electrolytes of blood by the use of elements and preparations of blood utilization, and as blood substitutes.

Desintoxication remedy is attained by software of low-molecular colloidic options, plasma, osmotic diuretic (manitol), lasix. Metabolic acidosis calls for introduction of a 4% sodium bicarbonate resolution.

Therapy within the septicotoxaemia stage proceeds after the ideas of toxaemia therapy with addition of antibacterial preparations, that are appointed to all affected person with deep burns of greater than 10% of the physique floor. Antibiotics are administered with bearing in mind the sort and sensitivity of microorganisms.

Stimulation of the immune system is an integral a part of infectious problems therapy: transfusion of plasma, lively immunization with staphylococcal anatoxine, passive immunization with antistaphylococcal plasma and γ-globulin, nutritional vitamins, roncoleukin — recombinant human interleukin-2, inflicting proliferation of lymphocytes and stimulation of mobile and humoral immunity.

Radiation Burns

Radiation burns come up at affect of various beam vitality: ultraviolet ray, X-ray, α-, β-, γ-rays. Thus, moreover of native adjustments, which have obtained the identify “radiation burns”, in a affected person’s organism beneath the affect of X-ray, α-, β-, γ-rays develop particular basic signs, typical for radiation illness (nausea, weak point, hypotension, vomitting, leukopenia, thrombocytopenia, anemia).

Dilation of capillaries and stasis of tissues happen, degenerate adjustments within the nerve endings. Hypostasis and destruction of development layer, furry follicles, sudoriferous and sebacous glands. With large doze growth of deep tissue dry necrosis is feasible.

Scientific image. The radiation burn course is split into three phases:

— major response, which seems in some minutes after affect of radiation vitality by hyperemia, hypostasis and ache within the injured website in addition to basic signs: weak point, headache, nausea, vomitting, which happen inside a number of hours.

— the latent interval throughout which no native or basic signs are noticed;

— the interval of necrotic adjustments is characterised with hyperimia, condensation, oedema (induration of the pores and skin). Hair falls out, teleangioectasias develop, blisters with a serous liquid, erosion and radiation necrotic ulcers with a low diploma of regeneration or full absence of any tendency to therapeutic seem. Basic signs have the in depth image of radiation illness: weak point, nausea, vomiting, anemia, leukopenia, thrombocytopenia, bleedings and secondary an infection develop.

Therapy. If radioactive substances hit on the pores and skin it’s essential to clean them out with water as quickly as attainable or incise the injured pores and skin and hypodermic tissue.

The presence of the latent interval throughout which it’s attainable to carry out plastic operations must be taken under consideration at therapy.

After growth of alterative adjustments therapy of the necrosis is conservative by the final ideas (bandages with antiseptics, proteolytic enzymes, water-soluble ointments). The pores and skin grafting is carried out seldom and subsides within the distant interval after scientific shows of radiation illness.

Correction of basic signs is carried out in keeping with basic therapy of radiation illness: high-caloric weight loss program, immynostimulators, stimulators of haemopoiesis, anabolic hormones, nutritional vitamins, transplantation of the bone marrow.

ELECTROTRAUMA

Electrotrauma is a posh of adjustments in an organism beneath the motion of the electrical area, the supply of which may serve the atmospheric and technical electrical energy.

Harm by the electrical present happens owing to direct contact with current-carriers and arc contact at ionization of air between the particular person and a supply of the present.

Underneath the affect of the electrical present in an organism the complicated of adjustments develops beneath thermal motion and basic biologic affect. Voltage above 36 V and pressure of a present greater than 0.1 amper (A) are thought-about to be harmful to the particular person (pressure of the present of 0.5 A is deadly).

Thermal motion of the electrical present will depend on pressure of present and voltage, time of contact, the world of contact, resistance of tissue.

The maximal adjustments are noticed on the place of entrance and exit of the present — “indicators of the present”. Deep necrosis is noticed with damage of the muscle mass, the bones: detachment of the muscle mass, tunelistion, haemorrhages, dissolution of phosphorus salts and dystrophic adjustments in bones.

Motion of electrical area is proven by change of ions focus and infringement of charged particles polarization, formation of items from uniform components of the blood. Thus, you will need to keep in mind the best way of the present by means of the physique — “the loop of the present”. If it passes by means of the center, the mind, the situation which threatens to life can develop, right down to scientific dying.

Scientific image. With damage by the electrical present the native (electroburns) and the final (electrotrauma) signs are distinguished.

The electrical present indicators arisen at damage are characterised by small (diameter as much as 2–3 cm) however deep websites of dry necrosis of spherical or line type with traction within the middle and raised edges, absence of hyperemia and ache, with attributes of metallization. Necrosis rejection proceeds for a very long time, secondary necrosis on account of spasm and thrombosis of vessels, right down to gangrene growth will be noticed.

The overall signs depend upon severity of electrotrauma and adjustments on the a part of cardiovascular (bradycardia, arytmia, uninteresting cardiac tones, cardiac fibrillation), respiratory (disturbances of rhythm and depth of breath, asphyxia) and the central nervous system (fatigue, dizziness, lack of consciousness, infringement of sight, weariness, excitation, presence of paresis, paralyses, neurites).

With growth in some circumstances of so-called “mors putativa” resuscitation measures are carried out right down to incidence of cadaveric regidity.

Therapy. First support consists within the stoppage of affect of the electrical present, resuscitation measures beneath indications, making use of dry aseptic bandages on the injured space, supply of the affected person to the hospital.

Native therapy consists in early necroectomia. After necroectomia bandages with antiseptics and proteolytic enzymes are used. Amputations are made beneath indications. Pores and skin grafting is carried out seldom and in late phrases after full rejection of the necrotic tissue.

The overall therapy is just like therapy at thermal burns.

FROSTBITE

Frosbite — is a set of scientific signs arisen beneath affect of low temperatures and manifested as necrosis and reactive irritation of the tissue.

Aetiology. The essential etiologic issue of frosbite is long-term affect of low temperature on the tissue of the physique of the particular person which motion is aggravated with burdening components.

Humidity and wind, stress of tight sneakers, huge blood loss, shock, cardiovascular perform decompensation, bodily fatigue, alcohol abusing, alimentary exhaustion, obliterating illnesses of extremities, diabetic angiopathy, illnesses of the veins, accompanying traumas of extremities, repeated keep of the sufferer in situations of low temperature check with burdening components.

Pathogenesis. Native mechanisms of necrosis formation and basic adjustments in an organism beneath the motion of low temperatures are distinguished.

Native adjustments in tissues happen already on the temperature of +8°С because the termination of oxyhaemoglobin dissociation — blood doesn’t give oxygen to tissues, after which there’s a full infringement of blood circulation due to angiospasm. After warming there’s paretic dilation of the vessel, stasis, infringement of the blood circulation, aggregation of uniform components and thrombosis. It promotes deep necrosis formation.

The overall signs throughout frosbites are related with adsorption of disintegration merchandise from the necronic tissues space and including an infection.

Basic cooling (freezing), a extreme pathological situation of an organism begins with lower within the physique temperature as much as 34°С and proceeds in three phases:

— the first section is the section of adaptive reactions. The physique temperature is 34–31°С. The changings happening within the central nervous system and blood circulation system are irreversible.

— the 2nd section is the section of stupor. The physique temperature is 31–29°С. This section is characterised by the additional inhibition of the nervous system perform.

— the third section is the section of fading of significant indicators and comes on the temperature under 29°С and is characterised by the additional inhibition of the fundamental features of an organism, spasms, regidity and might result in dying.

Classification. After the depth of damage 4 levels of frosbite are distinguished:

diploma is characterised by average hyperemia and an oede-ma, absence of blisters and pores and skin necrosis. The sufferers complain of average pains, feeling of burning. Restoration is available in 5–6 days.

diploma is characterised by necrosis of all epitelial layers asblisters with the clear liquid, pronounced pains, paresthesias. Restoration is available in 2–3 weeks.

diploma is characterised by necrosis of the entire pores and skin thick-ness with attainable transition to the hypodermic tissue. Towards a background of pronounced hyperemia and oedema there are necrosis foci and blisters with haemorrhagic contents. After rejection of necrosis in 2–3 weeks the wound floor is filled with granulations. Therapeutic happens in keeping with the principles of secondary therapeutic of the wound.

diploma is characterised by necrosis of the entire depth of allextremity tissues. Native adjustments consist in growth of dry or humid gangrene. With the absence of an infection the demarcation line types in 2 weeks giving a possibility to carry out necroectomia or amputation.

Scientific image and prognosis. The course of frostbites is split into the pre-reactive (latent) and the reactive interval.

The pre-reactive (latent) interval lasts from a number of hours to a couple of day, the tissues are within the situation of hypothermia. The sufferers complain of sensation of chilly, paresthesias. The affected websites are white.

The reactive interval begins after warming the injured websites. There are pains, cyanosis of the pores and skin, enhance in oedema, paresthesias and hyperesthesias come. The extent and depth of the pathological course of are tough to outline inside the first week after frostbite and solely in later phrases the attributes equivalent to a sure diploma of frostbite type.

Scintigraphy with Тс99, capillaroscopy, pores and skin electrothermometry, thermography, rheovasography, dopplerography, angiography are utilized for definition of depth of damage.

The ache is absent or insignificant and the final situation will be passable throughout the pre-reactive (latent) interval.

The reactive interval is characterised by toxaemia and septicotoxaemia with typical scientific indicators which have been touched intimately within the part dedicated to thermal burns.

Therapy. First support to the affected person with frostbite consists in elimination of chilly motion, gradual warming of the injured components of the physique within the tub with the room temperature water or by rubbing with spirit, vodka. The affected person ought to placed on heat garments, take scorching drink, analgesic means.

Within the pre-reaction (latent) interval they proceed gradual warming of the tissues, use spasmolytics (no-shpa, papaverin), desagregans (aspirin, trental), preparations of rheologic motion (rheopolyglucin), anticoagulants (heparin), analgetics. They wrestle in opposition to shock and symptomatic correction of the decompensanted important features of an organism right down to rendering resuscitation actions. The antibiotic prophylaxis and emergency prophylaxis of tetanus are essential to hold out.

Basic warming of an organism and the remedy began within the pre-reactive interval are carried out within the early reactive interval. With the presence of toxaemia and septicotoxaemia introduction of electrolytes, desintoxicants, blood substitutes, preparations of the blood are indicated. Antibiotics, immunomodulators are used for prophylaxis and therapy of infectious problems.

Native conservative therapy within the reactive interval is carried out in keeping with the ideas of therapy of purulent or granulating wounds: rest room of the wound, humid-drying bandages with antiseptics, software of fermental preparations for elimination of necrosis. After cleaning the injuries oitment bandages are utilized.

Surgical therapy, which is utilized at frostbites of III–IV levels, consists in necrotomy, necrectomy, amputations, regenerative and reconstructive operations.

Necrotomy is carried out on the finish of 1st week with out anaesthesia with the next software of bandages with antiseptics, attempting to switch of necrosis in dry with the appearance of a exact line of demarcation.

Necrectomy is carried out in 2–3 weeks inside the limits of the necrosis zone.

Amputation is carried out after ultimate subside of inflammatory course of with formation of the stump by some centimeters proximal of the demarcation line.

Regenerative and reconstructive operations are noticed within the distant phrases.