BURNS, ELECTROTRAUMA, FROSTBITE

BURNS

Burn (combustio) is damage to the organism tissue as a result of local action of high temperature, chemical substances, gamma rays, X-rays, ultaviolet rays, ionizing radiation.

Classification

After the circumstances of injury, industrial, household, wartime burn are distinguished.

After the character of the acting factor, there are:

— thermal burns, the important role belongs to the temperature of influence, time of contact to a hot object, thermal conductivity of the object contacting to the skin (air, water steam, the boiled water, open flame, a metal subject, etc.), humidity of an environment, condition of the skin and an organism of the patient as a whole.

— chemical burns, which are formed as the result of acids, alkalis getting on the skin and mucosa.

— electric burns are characterized by additional affecting the internal organs by the electromagnetic field.

— beam burns are caused by infrared, ultraviolet and gamma rays, X-rays radiation.

After the localization, there are burns of functionally activeparts of the body, immobile parts of the body, the face, hairy part of the head, the upper respiratory ways, perineum.

The classification of burns after the depth of injury, which isused now, was accepted in 1961 at the XXVII All-Union Congress of Surgeons. According to it there are four degrees:

— the I degree burn is characterized by damage of the level of the epidermis and manifests itself with hyperemy, oedema of the skin, pain. In some days the upper layer of the epidermis dries up, rucks up, shells up.

— the II degree burn is characterized by damage of all epithelium with formation of the thin-walled blisters filled with a transparent serous liquid due to dilation of capillaries and infringement of their permeability. Independent epithelizatin occurs by the 10th– 12th day.

— the IIIа degree is characterized by necrosis of all the epitelium, superficial layers derma and accompanied by formation of thickwalled blisters and superficial dry light — brown or soft white-grey eschar. The burn heals due to growth of granulations and epithelization from the hair bulbs, ducts of sebaceous and sudoriferous glands, edge epithelization on the part of a healthy skin.

— the IIIb degree is characterized by necrosis of all layers of the derma together with hair bulbs, sebaceous and sudoriferous glands with transition to hypodermic tissue with formation of a dense dry eschar of brown color at a flame burn or damp necrosis at scalding with boiled water, steam, etc. Independent healing of a wound comes by cicatricial pull off, regional epithelization.

— IV degree is characterized by necrosis of the skin and deep tissues (hypodermic tissue, muscles, bones) with formation of a brown or black eschar of various density and thickness.

Burns of I, II, IIIа degrees belong to superficial, and IIIb, IV — to deep. It is very important. With superficial burns an independent healing is possible, and with deep ones — is not. In the West a Vdegree C. Kreibich’s classification is usual where the IIIb degree is named IV, and correspondingly the IV degree turns into V.

The question on early diagnosis of the burn depth remains the basic question in combustiology. The presence of hyperemia, blisters, eschar, necrosis foci allow to determine preliminary depth of the skin damage and the burn degree. For differential diagnosis of burn degrees the methods of definition of infringement of blood circulation and sensitivity are used, special dyes and fermental preparations are applied: the method of pressing, tetracyclinic fluorescence, thermometry, definition of pain sensitivity by procking, application of 90° spirit, hair epilation, painting of tissue by Van— Gieson, dying skin sampling with solution of diphosphopiridinnucleotidphosphatase.

5. Classification of burns according to the area of defeat in not important for estimation of damage severity and choice of the treatment plan. The human skin surface area makes 15,000–21,000 cm2.

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

The most popular methods are as follows:

— the “method of the nine” which has been suggested by A. Wallace in 1951. According to it the area of the basic parts of the body makes 1–2 nines (9% from all the surface of the body): the head, the neck — 9%; the anterior surface of the body — 18%; the posterior surface of the body — 18%; the upper extremity — 9%; the lower extremity — 18%; the perineum — 1%. At children the ratio of the mentioned parts of the body to the general surface is different and varies with the age.

— in 1953 I. I. Glumov has suggested to determine the area of the burn, comparing it with the area of the palm of the victim, which makes 1% of the surface of the body (the rule of the palm).

— in 1949 B. N. Postnikov has suggested to apply a sterile gauze or cellophane on the burnt surface, on which the contours of the burn are put. Then the contour of the burn is transfered to a millimetric paper, they calculate the absolute area of damage and relative one in percentage of the general surface of the body.

— various forms of stamps with the image of the person, divided into squares are applied for definition of the area of defeat and the documentation. G. D.Vilyavin has suggested to designate the area of the burn of the anterior and posterior surface of the body with various colors in dependance on depth of injury.

Thus, the severity of burn is determined by depth (degree) of burn, the area of burn in percents and localization of burn. In 1939 Yu. Yu. Janelidze has suggested, and V. V. Vasilkov and V. O. Verkholetov have added the formula of burns definition, according to which the burn is characterized by fraction, which have the area of damage in numerator (in brackets — percent of deep burns), and burn degree in denominator. In front of the fraction the etiological factor (thermal burn, chemical or beam), and after the fraction the basic zones of injury (the head, the neck, the trunk, etc.) are indicated.

Definition of prognosis at thermal injury of an organism is an important point in burns treatment. The most simple methods of definition of prognosis for burns are following:

— the rule of the hundred: the age of the patient in years and relative size of the burn surfaces in percents are summed up. If the sum makes 60 and less — the prognosis is favorable, 61–80 — the prognosis is rather favorable, 81–100 — the prognosis is doubtful, 100 and more — the prognosis is unfavorable. The rule is applied only for adults.

— the Frank’s index is obtained at addition of the superficial burns area with the triple area of deep ones: if the sum makes 30 and less — the prognosis is favorable, 31–60 — the prognosis is rather favorable, 61–90 — the prognosis is doubtful, 91 and more — adverse.

Burn disease is a set of clinical symptoms, general reactions of an organism and dysfunction of internal organs at thermal damages of the skin and underlying tissue.

At superficial burns of more than 15–25% of the surface of the body and deep burns of more than 10% burn disease signs develop.

During the burn disease course four periods are distinguished:

burn shock, acute toxaemia, septicotoxaemia,reconvalescence.

1. Burn shock is a pathological process which develops at extensive thermal defeats and in dependence on the area and depth of the burn, duly and adequate therapy can proceed till 72 o’clock. Specific features of burn shock are absence of bloodloss, pronounced plasma loss, haemolysis, renal dysfunction that causes pathogenetic mechanisms of its development and the changes occuring in an organism.

According to the clinical picture three degrees of burn shock are distinguished:

— I degree is observed at burns of 15–20% of the surface of the body. It is characterized by strong pains in the injured sites, excitation of patients, moderate tachycardia up to 90 beats per min, the normal or slightly increased arterial pressure. Development of oliguria and haemoconcentration is possible;

— II degree develops with damage of 21–60% of the surface of the body and is characterized by fast increase of letargy, adynamia, tachycardia 100–120 beats per min, hypotension, fall in the body temperature, thirst, dispeptic phenomena, reduction diuresis, pronounced haemoconcentration (Ht grows up to 60–65%) with development of metabolic acidosis;

— III degree develops with injury of more than 60% of the surface of the body. The condition of the patient is very severe, the consciousness is confused, letargy comes, sopor. The puls is threadlike, arterial pressure is decreased below 80 mmHg, shallow breathing. There is paresis of the gastrointestinal tract. Dysfunction of organs and systems which is dangerous for life develop and first of all — the kidneys. Ht exceeds 70%, hyperpotassemia, acidosis rise.

Acute burn toxaemia replaces the shock stage, but can develop independently, takes place for 10–15 days. Fast absorption of active substances from the burn zone takes place: histamine, serotonine, prostaglandins, toxins — glycoproteids with antigen specificity, lipoproteids, oligopeptids. Proteolitic enzymes activate. The products of erythrocytes haemolysis, fibrinolysis have toxic action. The manifestation of toxaemia is fever with temperature peaks up to 38– 40°С, pallor of the skin, tachycardia, hypotension, weakness, nausea, vomitting.

Disturbances of the central nervous system, cardio-vascular activity, renal functions with proteiuria, microhaematuria — down to acute renal insufficiency are observed. The clinical analysis of blood reveals anemia, high left-shift leukocytosis. Increase in transaminases activity, hypoproteinemia, hyperbilirubinemia are typical in biochemical analyses of blood.

Septicotoxaemia is shown in 10–14 days after the burn. The basic pathogenetic factor of the septicotoxaemia is resorption of the products of tissue disintegration and vital activity of microorganisms with development of infectious complications.

The clinical course of septicotoxaemia depends on the character of the wound process phase. In the first phase (from the beginning of eschar tearing away to full cleansing of the wound) the general condition of patients is severe: broken sleep, pronounced irritability, tearfulness, bad appetite. Attributes of purulent intoxication are observed: fever, tachycardia, weakness. Anemia, leukocytosis with left shift, sometimes eosinophilia, lymphocytopenia continue to increase. Attributes of toxic hepatitis, pyelonephritis are typical.

In the second phase (the phase of granulations down to full healing of burn wounds) various complications develop: pneumonia, acute ulcers of the gastrointestinal tract (Kurling’s ulcer), burn exhaustion, generalization of infection — burn sepsis.

Reconvalescence. With liquidation of a burn wound the lost functions of the cardio-vascular system, urinary system, parameters of red blood, leukocytes, protein structure of blood begin restoring. Treatment of burns is a rather uneasy problem.

First aid. The depth of damage, the further disease course depend on how fast and correct the first aid is rendered.

The order of measures at rendering the first aid is as follows: to prevent the thermal agent influence on the skin; to cool injured sites; to apply an aseptic bandage; to anesthetize and begin antishock actions.

Local treatment of burns. Treatment of burn wounds can be conservative and operative. Conservative treatment is a unique and final method at superficial burns. At deep burns operative restoration of the lost integument is necessary.

The primary toilet of the burn surface is carried out at thelimited surface without shock signs with observing aseptic rules, sparing, with application of narcotics or narcosis and consists in treatment of the skin around the injured place, removal of exfoliating epidermis, alien bodies, treatment of burn surface with a 3% solution of peroxide hydrogen. Large blisters are incised and emptied. In this case the exfoliating epidermis plays a role of an original biological bandage.

Conservative treatment is carried out by the closed or open way.

The closed way is based on application of bandages with various medicinal substances and carried out with taking into account the depth of injury and presence of purulent inflammation. Superficial burns as a rule heal with epithelization, and formation of rough scars is possible only with development of pronounced purulent inflammation.

With deep burns local treatment is directed on acceleration of necrotic tissues rejection. Bandaging is carried out in a day under narcosis with application of damp bandages with antiseptics. Since the 7th–8th day sparing bloodless necrectomy is conducted, necrolytic therapy (travaza, 40% salicylic ointment, benzoic acid) is applied. After eschar rejection, the bottom of the wound is granulation tissue. Independent closure of the defect is possible with insignificant injury. In most cases skin plasty is necessary.

With the open method of treatment the drying up action of the air is used, treatment of the burn surfaces is conducted by antiseptics with coagulative properties (a 5% solution of potassium permanganate, brilliant green), the wound remaining open. This method is applied in conditions of the controlled abacterial environment in special wards, boxes.

Surgical treatment is applied at deep burns as follows:

— necrotomy which is indicated with formation of dense circular necrosis and is carried out without additional anaesthesia as a section on all the depth untill blood drops appear;

— early necroectomy with closing the defect with the skin transplant is a big surgical intervention and it is necessary to observe under adequate anaesthesia in terms of 3–5 days after the burn with the tangential or one-staged method with closing the wound defect by the method of free skin grafting or vascular pedicle grafting;

— delayed skin grafting is carried out 2–4 weeks after the burn when the wound is covered with granulations without pathogenic microflora.

Now in closing burn wounds the following ways are applied:

Local tissue grafting.

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

Accordion grafting on an nutritive leg: Italian grafting, grafting according to V. P. Filatov, accordion grafting on a vascular pedicle with microsurgical technique application.

Application of cultivated allofibroblasts — multilayered cellular structures from cells of the embryos which have been brought up on special nutrient mediums.

Provisional biological closing the defect in order to prevent theloss of plasma, prevention of infection development, stimulation of regional epithelization with the use of the cadaveric skin or the donor’s one (allodermoplasty), the skin of calfs, pigs (xenodermoplasty), synthetic materials (polycaprolacton, hydron), synthetic skin (epigard, sincaver, aeroplast-special).

The general treatment of burns. The following components of the general treatment at burns are distinguished:

Struggle against pain, which consists in the patient’s rest, applying bandages, introduction of non-narcotic analgesics, sedative preparations, neuroleptics, narcotic analgesics.

Treatment of the burn shock is carried out according to thegeneral rules of antishock therapy and is directed on elimination of pain, maintenance of the system haemodynamics, improvement of perfusion, compensation of the plasma loss and correction of the function of the damaged organs.

Narcotic analgetics in a combination with antihistamine preparations and sedative means, neuroleptics are applied for struggle against pain.

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 applied under indications.

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

Correction of function of the damaged organs in the shock phase first of all is directed on the respiratory sistem: breathe of the moistened oxygen, intubation of the trachea, under indications — tracheostomy.

Treatment of acute toxaemia consists in infusion and desintoxication therapy, treatment of acute renal insufficiency, correction of acidosis.

Infusion therapy makes up the blood volume (BV), loss of protein and electrolytes of blood by way of components and preparations of blood usage, and as blood substitutes.

Desintoxication therapy is attained by application of low-molecular colloidic solutions, plasma, osmotic diuretic (manitol), lasix. Metabolic acidosis demands introduction of a 4% sodium bicarbonate solution.

Treatment in the septicotoxaemia stage proceeds after the principles of toxaemia treatment with addition of antibacterial preparations, which are appointed to all patient with deep burns of more than 10% of the body surface. Antibiotics are administered with taking into account the kind and sensitivity of microorganisms.

Stimulation of the immune system is an integral part of infectious complications treatment: transfusion of plasma, active immunization with staphylococcal anatoxine, passive immunization with antistaphylococcal plasma and γ-globulin, vitamins, roncoleukin — recombinant human interleukin-2, causing proliferation of lymphocytes and stimulation of cellular and humoral immunity.

Radiation Burns

Radiation burns arise at influence of different beam energy: ultraviolet ray, X-ray, α-, β-, γ-rays. Thus, besides of local changes, which have received the name “radiation burns”, in a patient’s organism under the influence of X-ray, α-, β-, γ-rays develop specific general symptoms, typical for radiation disease (nausea, weakness, hypotension, vomitting, leukopenia, thrombocytopenia, anemia).

Dilation of capillaries and stasis of tissues take place, degenerate changes in the nerve endings. Hypostasis and destruction of growth layer, hairy follicles, sudoriferous and sebacous glands. With big doze development of deep tissue dry necrosis is possible.

Clinical picture. The radiation burn course is divided into three phases:

— primary reaction, which appears in some minutes after influence of radiation energy by hyperemia, hypostasis and pain in the injured site as well as general symptoms: weakness, headache, nausea, vomitting, which take place within several hours.

— the latent period during which no local or general symptoms are observed;

— the period of necrotic changes is characterized with hyperimia, condensation, oedema (induration of the skin). Hair falls out, teleangioectasias develop, blisters with a serous liquid, erosion and radiation necrotic ulcers with a low degree of regeneration or full absence of any tendency to healing appear. General symptoms have the extensive picture of radiation disease: weakness, nausea, vomiting, anemia, leukopenia, thrombocytopenia, bleedings and secondary infection develop.

Treatment. If radioactive substances hit on the skin it is necessary to wash them out with water as soon as possible or incise the injured skin and hypodermic tissue.

The presence of the latent period during which it is possible to perform plastic operations should be taken into account at treatment.

After development of alterative changes treatment of the necrosis is conservative by the general principles (bandages with antiseptics, proteolytic enzymes, water-soluble ointments). The skin grafting is carried out seldom and subsides in the remote period after clinical displays of radiation disease.

Correction of general symptoms is carried out according to general treatment of radiation disease: high-caloric diet, immynostimulators, stimulators of haemopoiesis, anabolic hormones, vitamins, transplantation of the bone marrow.

ELECTROTRAUMA

Electrotrauma is a complex of changes in an organism under the action of the electric field, the source of which can serve the atmospheric and technical electricity.

Injury by the electric current occurs owing to direct contact with current-carriers and arc contact at ionization of air between the person and a source of the current.

Under the influence of the electric current in an organism the complex of changes develops under thermal action and general biologic influence. Voltage above 36 V and force of a current more than 0.1 amper (A) are considered to be dangerous to the person (force of the current of 0.5 A is fatal).

Thermal action of the electric current depends on force of current and voltage, time of contact, the area of contact, resistance of tissue.

The maximal changes are observed at the place of entrance and exit of the current — “signs of the current”. Deep necrosis is observed with injury of the muscles, the bones: detachment of the muscles, tunelistion, haemorrhages, dissolution of phosphorus salts and dystrophic changes in bones.

Action of electric field is shown by change of ions concentration and infringement of charged particles polarization, formation of units from uniform elements of the blood. Thus, it is important to take into account the way of the current through the body — “the loop of the current”. If it passes through the heart, the brain, the condition which threatens to life can develop, down to clinical death.

Clinical picture. With injury by the electric current the local (electroburns) and the general (electrotrauma) symptoms are distinguished.

The electric current signs arisen at injury are characterized by small (diameter up to 2–3 cm) but deep sites of dry necrosis of round or line form with traction in the center and raised edges, absence of hyperemia and pain, with attributes of metallization. Necrosis rejection proceeds for a long time, secondary necrosis as a result of spasm and thrombosis of vessels, down to gangrene development can be observed.

The general symptoms depend on severity of electrotrauma and changes on the part of cardiovascular (bradycardia, arytmia, dull cardiac tones, cardiac fibrillation), respiratory (disturbances of rhythm and depth of breath, asphyxia) and the central nervous system (fatigue, dizziness, loss of consciousness, infringement of sight, weariness, excitation, presence of paresis, paralyses, neurites).

With development in some cases of so-called “mors putativa” resuscitation measures are carried out down to occurrence of cadaveric regidity.

Treatment. First aid consists in the stoppage of influence of the electric current, resuscitation measures under indications, applying dry aseptic bandages on the injured area, delivery of the patient to the hospital.

Local treatment consists in early necroectomia. After necroectomia bandages with antiseptics and proteolytic enzymes are used. Amputations are made under indications. Skin grafting is carried out seldom and in late terms after full rejection of the necrotic tissue.

The general treatment is similar to treatment at thermal burns.

FROSTBITE

Frosbite — is a set of clinical symptoms arisen under influence of low temperatures and manifested as necrosis and reactive inflammation of the tissue.

Aetiology. The basic etiologic factor of frosbite is long-term influence of low temperature on the tissue of the body of the person which action is aggravated with burdening factors.

Humidity and wind, pressure of tight shoes, massive blood loss, shock, cardiovascular function decompensation, physical fatigue, alcohol abusing, alimentary exhaustion, obliterating diseases of extremities, diabetic angiopathy, diseases of the veins, accompanying traumas of extremities, repeated stay of the victim in conditions of low temperature refer to burdening factors.

Pathogenesis. Local mechanisms of necrosis formation and general changes in an organism under the action of low temperatures are distinguished.

Local changes in tissues occur already at the temperature of +8°С as the termination of oxyhaemoglobin dissociation — blood does not give oxygen to tissues, and then there is a full infringement of blood circulation because of angiospasm. After warming there is paretic dilation of the vessel, stasis, infringement of the blood circulation, aggregation of uniform elements and thrombosis. It promotes deep necrosis formation.

The general symptoms during frosbites are connected with adsorption of disintegration products from the necronic tissues area and adding infection.

General cooling (freezing), a severe pathological condition of an organism begins with decrease in the body temperature up to 34°С and proceeds in three phases:

— the 1st phase is the phase of adaptive reactions. The body temperature is 34–31°С. The changings taking place in the central nervous system and blood circulation system are irreversible.

— the 2nd phase is the phase of stupor. The body temperature is 31–29°С. This phase is characterized by the further inhibition of the nervous system function.

— the 3rd phase is the phase of fading of vital signs and comes at the temperature below 29°С and is characterized by the further inhibition of the basic functions of an organism, spasms, regidity and can lead to death.

Classification. After the depth of injury four degrees of frosbite are distinguished:

degree is characterized by moderate hyperemia and an oede-ma, absence of blisters and skin necrosis. The patients complain of moderate pains, feeling of burning. Recovery comes in 5–6 days.

degree is characterized by necrosis of all epitelial layers asblisters with the transparent liquid, pronounced pains, paresthesias. Recovery comes in 2–3 weeks.

degree is characterized by necrosis of the whole skin thick-ness with possible transition to the hypodermic tissue. Against 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 surface is full of granulations. Healing occurs according to the rules of secondary healing of the wound.

degree is characterized by necrosis of the whole depth of allextremity tissues. Local changes consist in development of dry or humid gangrene. With the absence of infection the demarcation line forms in 2 weeks giving an opportunity to perform necroectomia or amputation.

Clinical picture and diagnosis. The course of frostbites is divided into the pre-reactive (latent) and the reactive period.

The pre-reactive (latent) period lasts from several hours to about a day, the tissues are in the condition of hypothermia. The patients complain of sensation of cold, paresthesias. The affected sites are white.

The reactive period begins after warming the injured sites. There are pains, cyanosis of the skin, increase in oedema, paresthesias and hyperesthesias come. The extent and depth of the pathological process are difficult to define within the first week after frostbite and only in later terms the attributes corresponding to a certain degree of frostbite form.

Scintigraphy with Тс99, capillaroscopy, skin electrothermometry, thermography, rheovasography, dopplerography, angiography are applied for definition of depth of injury.

The pain is absent or insignificant and the general condition can be satisfactory during the pre-reactive (latent) period.

The reactive period is characterised by toxaemia and septicotoxaemia with typical clinical signs which have been touched in detail in the section devoted to thermal burns.

Treatment. First aid to the patient with frostbite consists in elimination of cold action, gradual warming of the injured parts of the body in the bath with the room temperature water or by rubbing with spirit, vodka. The patient should put on warm clothes, take hot drink, analgesic means.

In the pre-reaction (latent) period they continue gradual warming of the tissues, use spasmolytics (no-shpa, papaverin), desagregans (aspirin, trental), preparations of rheologic action (rheopolyglucin), anticoagulants (heparin), analgetics. They struggle against shock and symptomatic correction of the decompensanted vital functions of an organism down to rendering resuscitation actions. The antibiotic prophylaxis and emergency prophylaxis of tetanus are necessary to carry out.

General warming of an organism and the therapy started in the pre-reactive period are carried out in the early reactive period. 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 treatment of infectious complications.

Local conservative treatment in the reactive period is carried out according to the principles of treatment of purulent or granulating wounds: toilet of the wound, humid-drying bandages with antiseptics, application of fermental preparations for removal of necrosis. After cleansing the wounds oitment bandages are applied.

Surgical treatment, which is applied at frostbites of III–IV degrees, consists in necrotomy, necrectomy, amputations, regenerative and reconstructive operations.

Necrotomy is carried out at the end of 1st week without anaesthesia with the subsequent application of bandages with antiseptics, trying to transfer of necrosis in dry with the advent of a precise line of demarcation.

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

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

Regenerative and reconstructive operations are observed in the remote terms.