BURNS (combustio, singular) — the damage of body tissues resulting from local action of high temperature, and also chemicals, electric current or ionizing radiation.
Studying of a problem O. has an old story, however only in the second half of 19 century with development of biology, chemistry, physics and other sciences there were premises for in-depth studies in the field of Combustiology. During this period and in the first decades of 20 century there were works revealing the nek-ry parties of a pathogeny of O. K to them works to Shulttsa (M. of Schultze, 1865) — about destruction of erythrocytes under the influence of a thermal factor, V. S. Avdakov (1876) — about accumulation in an organism burned toxic products, Falk (F. Falk, 1871) — about vascular reaction treat, in particular, at O. (expansion of peripheral vessels with the subsequent accumulation in them of blood and development of anemia), Anderkhill (F. P. Underhill, 1923) — about a plazmopoter at O. leading to frustration of a hemodynamics, Aldrich (R. N of Aldrich, 1933) — about adverse influence of a purulent infection on a current of a wound process, I. R. Petrov (1950) — about the leading role of a painful factor in development of burn shock. The analysis of these and other scientific data allowed to come to a conclusion that at heavy O. there is a damage of all systems of an organism and the symptom complex, specific to this injury — a burn disease develops.
In the next decades the problem O. began to be studied in a complex with participation of representatives of various medical specialties on a new methodical basis using methods of an electrophysiology, a histochemistry, a submicroscopy, radio isotope diagnosis etc. Such integration of scientific research allowed to reveal and generalize new data on a pathogeny of a burn disease that formed the basis for specification of classification of O. and a periodization of a burn disease, and also for development of a pathogenetic teraiiya.
In the second half of 20 century efforts of a large number of scientific various countries developed and implemented in medical practice optimum methods of topical treatment of deep burns by means of temporary closure of a wound surface by heterografts and constant autografts; effective methods of correction immunol, shifts in an organism of burned; a technique of treatment burned in the abacterial managed environment and gno-tobiologichesky conditions both other medical and diagnostic techniques.
Achievements of Combustiology were promoted by creation in 50 — the 60th there are 20 century of various burn institutions — International burn about-va, special departments, the burn centers, and also improvement of the organization of medical aid burned. In the Soviet Union the burn centers conduct big research and perform methodical management of works of other institutions on a problem O. and preparation of specialized shots.
In our country for the first time in the world the harmonious state system of step-by-step treatment burned is created, since the first medical aid on site and finishing incidents specialized treatment in the burn centers and rehabilitation of victims.
- 1 Classification
- 2 Statistics
- 3 Thermal burns
- 4 Features of burns of wartime and their stage treatment
- 5 Burns at children
- 6 Beam burns
- 7 Corrosive burns
- 8 Electric burns
- 9 Burns in the medicolegal relation
On etiol, to a sign distinguish thermal, chemical, electric and beam O.; on circumstances, in to-rykh there was a defeat, O. happen production, household and wartime. For the characteristic of depth of defeat of fabrics various classifications were offered. So, Buaye (M. of Boyer, 1814) developed three-sedate classification, on a cut the superficial damages of skin which are characterized by its reddening belong to burns of the I degree; to burns of the II degree — deeper damages of skin with bulging; to burns of the III degree — such defeats, at to-rykh the necrosis extending to various depth of skin and subjects of fabrics develops. Ziegler (E. Ziegler, 1889) suggested to allocate in addition the IV degree for designation O. with a carbonization of fabrics.
More differentially Krey-bikh approached determination of depth of O. (S. of Kreibich, 1927). According to its classification at burns of the I degree the erythema, the II degrees — bubbles, the III degrees — the necrosis of skin taking a basal (rostkovy) layer of epidermis, the IV degree — a necrosis of all thickness of skin, the V degree — a necrosis of skin and subjects of fabrics is formed.
In the USSR at the XXVII congress of surgeons (1960) chetyrekhstenenny classification is accepted, according to a cut burns of I and II degrees are defined, as well as in the previous classifications; burns of the III degree are subdivided into two groups — And yes B (at burns of IIIA of degree there is a partial necrosis of skin with preservation of cambial elements of a derma, at burns of IIIB of degree the necrosis of skin extends to all its thickness); burns of the IV degree are characterized by necrosis of skin and glubzhelezhashchy fabrics (fig. 1). Burns of I, II and 111A of degree carry to superficial; the integument at them is recovered independently. Burns of IIIB and the IV degree — deep; at them operational treatment usually is required.
On weight of defeat distinguish easy, moderately severe, heavy and extremely heavy O.
From all types of O. are more often observed thermal damages of skin, is more rare — an oral cavity and airways, is even more rare — a gullet and a stomach. In peace time among adult population of O., received in life and on production, are distributed approximately equally though this ratio is influenced by number and population density, power security of life and the leading industries of the national economy of this region, etc. According to N. I. Atyasov (1970), O. make 6% of number of injuries of peace time. On a nek-eye to statisticians, annually about 1 person for 1000 of the population gets thermal burn, and from 8 to 12% of victims are made by people of advanced and senile age. In industrially developed countries thermal O. at children make from 25 to 50% of all O., and children up to 7 years receive O. twice more often than children of school age.
Chemical O., according to B. N. Postnikov (1964), sostavlyayut5 — 7%, and electric O. — 1,5 — 2,5% of all burn injuries. Chemical and electric O. occur at children less often.
Frequency of thermal defeats in wartime in process of development of hardware of troops and improvement of arms tends to increase. During military operations on the river Hal-hin-Gol burned made 0,3% of wounded, and during the Soviet-Finnish conflict — 0,79%. In the period of the Great Patriotic War use of reactive weapon and incendiary mixes promoted increase in number burned as in the battlefield, and among the civilian population. However O.'s number in structure a dignity. losses, as a rule, did not exceed 1%. In most cases (69,8%) O. resulted from influence of a flame at the fires and ignition of gasoline in military equipment.
With the advent of nuclear weapon burn injuries become one of the dominating types of defeat what the bitter experience of use of the USA of atomic weapons in Japan testifies to. Only in Hiroshima it was registered apprx. 40 000 burned. According to data the Voice stone (S. Glasstone, 1957), 20 — 30% of the dead of atomic bombing in Hiroshima and Nagasaki made burned. After World War II in local wars of the USA napalm was widely applied. According to a number of researchers, among the wounded and patients treated at that time in nek-ry hospitals of the Korean national army, 8 — 10% were made by victims of O. napalm. Similar data are provided also across Vietnam.
Thermal O. results from action of a flame, the heated metals, the burning gases or liquids, a radiant energy. Most often surface body tissues are surprised, however also damages of airways are frequent at the same time.
At O.'s fires poisoning with products of incomplete combustion can accompany (hl. obr. carbon monoxide) or (during the burning of nek-ry synthetics) other toxic agents.
At the superficial damages occupying up to 10 — 12% of a body surface or at deep on the square making up to 5 — 6% of a body surface, O. at adults proceeds preferential as focal lesion; at more widespread various disturbances of activity of bodies and systems, set are observed to-rykh it is accepted to consider as a burn disease. At children and persons of advanced and senile age the burn disease can develop at defeats, smaller on weight.
During a burn disease distinguish four periods — burn shock, a burn toxaemia, a burn septicotoxemia and reconvalescence. Temporary borders of these periods are outlined not strictly. It concerns first of all development of infectious complications, to-rye can begin already in the period of shock.
In works of the Soviet scientists A. V. Vishnevsky and A. A. Vishnevsky, A. N. Gordiyenko, V. B. Lemus, I. R. Petrov, M. I. Schreiber, etc. the greatest recognition was gained by the neurogenic theory of burn shock. Excitement of c is characteristic of an erectile phase of burn shock. and. page owing to irritation of pain receptors of skin and an excessive afferent impulsation. In a torpid phase the phenomena of deep braking of a cerebral cortex and subcrustal educations are observed. At heavy O. braking in an afferent part and internuncial neurons of reflex arcs develops. Rather late development of exhaustion of a vasomotor center was one of features of burn shock that in a certain measure explains relative stability of the ABP. Apparently, a certain significance should be attached also to dysfunction of a hypothalamus. L.I. The musician showed that in neurons of nadzritelny and paraventrikulyarny kernels of a hypothalamus and in pituitsitarny fibers of a back share of a hypophysis at the people who died of O. a large number of neurosecretion collects.
For burn shock, especially in an erectile phase, long increase in a tone of simiati-to-adrenal system, increase in maintenance of catecholamines in a blood plasma and increase of their excretion with urine is characteristic. In a torpid phase dominance of a vagotonia is observed. At a burn disease long increase in function of system a hypothalamus — a hypophysis — bark of adrenal glands takes place. The maintenance of corticosteroids at patients considerably increases in blood and urine in the period of shock and decreases in the period of an acute burn toxaemia.
Feature of burn shock, unlike caused by a mechanical injury, relative stability of the ABP is, edges is explained by increase in a vascular tone. The come hypotension consider as late and predictively the adverse symptom testimonial of deep extent of disturbance of coronary and cerebral circulation. Many researchers observed at patients with heavy O. increase in the general vascular resistance to a blood-groove essential (twice) that was explained with generalized vasoconstriction. In the mechanism of burn vasoconstriction excitement of sympaticoadrenal system, emission of catecholamines and corticosteroids play a role. Catecholamines cause and support a generalized spasm of arterial vessels, corticosteroids exponentiate effect of pressor substances. The possibility of participation in the mechanism of a vasomotor spasm of angioten-zivny system is not excluded; after O. there is an increased education in kidneys of a renin, increase in content in blood of angiotensin I and II.
Reduction of the volume of the circulating blood (VCB) and increase in haemo concentration — continuous and characteristic manifestations of burn shock. In an experiment and clinic it is shown what during the first hours after a burn of OTsK umenypa-tsya naturally for 20 — 30%. So considerable reduction of OTsK leads to the disturbance of the central blood circulation characteristic of shock that the nek-eye the scientist gives the grounds to consider burn shock as oligemic. The mechanism of a burn hypovolemia includes the following components: plazmopoteryu, eritrodiyerez and deposition of blood in capillaries. At extensive O. through the burned surface a large amount of transudate — 70 — 80% of volume of all plasma can be lost. In a pathogeny of a plazmopotera a major factor is increase in permeability of capillaries (see. Permeability ) both in the field of an injury, and in the unimpaired fabrics. Fogelmen and Wilson (M. of Fogelman, V. of Wilson, 1954) by means of radiotracers established that at fatally burned people permeability of capillaries increases by 3 times. Also strengthened Lymph drainage from the burned fabric is observed. Many researchers see the reason of increase in permeability of capillaries not only in direct action on them a thermal factor, but also various released physiologically active agents, first of all a histamine, and also bradikinin and prostaglandins operating on vessels both in an injury and beyond its limits. Reduction of volume of the circulating plasma
is resulted by haemo concentration. However degree of its expressiveness not strictly corresponds to the size of a plazmopotera and cannot serve as reliable criterion of weight of the Lake. This discrepancy is explained with the fact that along with plasma] to Utah of yards at O. the reduction of volume of the circulating erythrocytes surely results from hemolysis. On a nek-eye to data, at people at deep O. on the area of 20% of a body surface about 15% of erythrocytes collapse. An indirect indicator of hemolysis is the microcythemia, fragmentation of erythrocytes, a bilirubinemia and an urobilinuria, and also the Haemoglobinuria. The fabric hyperthermia is the main reason for burn hemolysis. Besides, it was established that serum of animals already during the first hours after O. gains the expressed hemolitic properties.
Essential value in a pathogeny of burn shock has easing of sokratitelny ability mio a mouth. The Rentgenokimografichesky researches conducted And. B. Gurevich in an experiment on animals, showed that in 10 — 30 min. after O. a flame diameter of heart in the period of a diastole increases, amplitude of teeth of ventricles considerably decreases and we reduce 9 the coefficient of contraction etsyatsya. At people the minute volume of blood circulation (MVBC) decreases almost twice. One of the reasons of reduction of the IOC is oligemiya (see) with the subsequent reduction of size of venous return of blood to the right heart. However it occurs even before the expressed decrease in OTsK, being result in this case of primary weakening of a myocardium. Disturbance of sokratitelny function of heart is confirmed also by method of an electrocardiography (decrease in amplitude of all teeth of an ECG, especially a tooth of Tshch monophase character of a ventricular complex, sinus tachycardia, a deviation of an electrical axis of heart to the right, disturbance of endocardiac conductivity).
At burn shock disturbances are brightly expressed microcirculation (see). By data A. M Chernukh and Yu. M. Shtykh but, in 30 — 60 min. after O. in a mesentery of rats the picture of a laminar blood-groove disappears, the quantity of the functioning capillaries decreases, the most part of blood goes via the opened shunts, in venules and capillaries the units of uniform elements of blood corking small vessels with the subsequent formation of plasmatic vessels are visible. In later terms of heavy O. the condition of microcirculation continues to worsen, it is noted for-pustevaniye not only capillaries and venules, but also large terminal vessels. Vitals — a brain, heart and a liver — a long time are well supplied with blood thanks to its redistribution.
An indicator of a circulatory unefficiency in the period of burn shock is considerable reduction of a volume and linear blood-groove, delay of transport of oxygen of blood that inevitably leads to development of fabric hypoxias (see). In the period of burn shock after short-term increase decrease in oxygen consumption is observed by an organism. According to G. V. Derviz, N. I. Kochetygov, etc. at dogs with heavy burn shock (in 7 — 8 hours after an injury) the general oxygen consumption decreases by 16 — 48%. Saturation rate oxygen of an arterial blood at first remains within norm, and oxygenation of the mixed venous blood decreases to 60% of basic data. However in the subsequent, on O. D. Dolzhenko's researches, G. Arturson, the oxygen content in an arterial blood decreases, and in venous — raises a little (sometimes to datum level). This reduction of an arteriove-postural difference is a consequence of decrease in the oxygen consumption by fabrics caused by deterioration in their blood supply. Content of carbon dioxide gas decreases, and in an arterial blood is more considerable, than in venous. The accruing venous anoxemia testimonial of the lowered blood-groove is compensated by fuller use of the oxygen which is available in blood. Noted changes are an indicator of development of a hypoxia of circulator type. In development of a hypoxia also disturbance of external respiration in connection with change of permeability of pulmonary capillaries and existence of alveolar hypostasis can matter.
Disturbance of acid-base equilibrium, development of a metabolic acidosis is characteristic of burn shock (see), to-rogo the hypoxia caused by disturbance of blood circulation is the reason. Degree of manifestation of a metabolic acidosis at extensive O. is in direct dependence on decrease in minute volume of blood.
At a burn disease disbolism is considerably expressed. In the period of burn shock the hyper glycemia usually develops (see); the hypoglycemia can be observed only in an agonal state. In a torpid phase of shock anaerobic prevails glycolysis (see). The phase of strengthening of mobilization of fat is replaced but a measure of a course of a disease by exhaustion of fatty resources. Right after O. in blood raises the maintenance of nedookislenny products of interstitial exchange. So, the quantity organic to - t (pyroracemic and milk) in blood of the burned dogs increases more than by 300%, the coefficient of a nedookisleniye of urine increases, also the coefficient lactate / pyruvate increases.
An important role in a pathogeny of a burn disease is played by disturbances proteinaceous and a water salt metabolism.
The disintegration of proteins caused by increase in proteolytic activity of blood is shown already at the beginning of burn shock and further accrues that is one of the reasons of development of burn exhaustion. The priest to a company the pyemia, change of fractional composition of proteins of plasma and negative nitrogenous balance are observed gi (see. Nitrogen metabolism). Decrease in albuminous fraction of plasma, increase ag and and about globulinovy fractions is typical. Deficit of proteins is caused by loss them from O.'s surface, allocation with urine and owing to a gene rat izovanno go races of iod of fabric. Also processes of biosynthesis of proteins are broken. Losses of proteins, according to many authors, make from 1,5 to 8 g for 1% of O. Square, and the total loss can reach 95 g a day and more. The negative nitrogenous balance, the increased allocation with urine of creatine, ammonia, peptides and amino acids testifies to the raised catabolism of proteins after O. In blood residual nitrogen collects. The increased disintegration of proteins leads to accumulation of toxicants.
It is considerably broken water salt metabolism (see). Thirst — one of constant symptoms of burn shock. At burned hypostases, an oliguria and an anury are observed. At heavy O. there is a movement of a considerable part of liquid, is preferential to the area of defeat. In most cases considerably (up to 50%) the volume of extracellular liquid increases. N. A. Gorbunova (1965) in experiences on dogs after O. a flame observed both increase, and decrease in volume of extracellular liquid, and the last was characteristic of extremely heavy shock from the death during the first hours after a thermal injury.
As a result of disintegration of fabrics a large amount of intracellular potassium is released, to-ry comes to blood, causing hyperpotassemia (see) it is also brought out of an organism with urine. Respectively in an organism sodium is late. According to N. I. Kochetygov (1973) researches in the first days after heavy O. at the patients who received on 430 mekv Na + it was allocated with urine on average for 1 days on 35 mekv, and after reception 10 — 30 mekv To + at them it was allocated with urine for 1 days to 100 mekv To + .
The renal failure (renal failure) is characteristic of a burn disease, especially of burn shock. At extremely heavy O. the acute renal failure develops (see). Secretory and concentration ability of kidneys decreases, the hyposthenuria, inert, monotonous type is observed diuresis (see). Disturbance of renal blood circulation is noted: in the first day after O. it decreases by 2 — 3 times in this connection glomerular filtering decreases to 50% of initial size, increases canalicular reabsorptions. Increase in filtrational fraction of plasma in combination with falling of a renal blood-groove is an indicator of a spasm of the taking-out vessels (the taking-away arterioles) of balls of renal little bodies. Balls of renal little bodies are in a condition of a congestive hyperemia and a hypoxia that leads to increase in permeability of a glomerular membrane and receipt in provisional urine of proteins, erythrocytes and hemoglobin. Strengthening of a reabsorption of water and ions of sodium arises under the influence of antidiuretic hormone and Aldosteronum, secretion to-rykh increases. R. V. Nedoshivina (1965) showed that one of the reasons of a renal failure is the endointoxication. At patients during later periods of a burn disease the canalicular reabsorption clearly decreases that leads to increase in a diuresis.
Abnormal liver functions (liver failure) are observed already during the first hours development of heavy burn shock. At the same time especially suffer the belkovoobrazuyushchy, pro-thrombinforming and excretory function (see. Liver failure ). Reaction of timolovy opacification increases, the prothrombin time decreases to 60 — 75%, the delay of dye increases in blood at bromsulfolei-new test. Anti-toxic function of a liver is broken (see). In it the necrotic centers are formed that leads to increase in blood of activity of alaninaminotranspherase and an alkaline phosphatase. Sharp reduction of its blood supply is the main reason for damage of a liver at O.
In the doctrine about a pathogeny of a burn disease of one of the first the toxic theory explaining development funkts, disturbances at O. with poisoning of an organism with products of a fabric origin was put forward (see. Endointoxication ). This theory is based on data on toxicity of blood, a lymph, extracts from skin and internals and liquid of bubbles of the burned people. Pathogenetic value of a toxaemia at O. was shown on rats parabionts (see II Arab and-onty): at O. the wedge, symptoms of a burn disease were found in one parabiont at the intact partner. In 24 hours both parabionts perished at the same phenomena of heavy intoxication.
Lourent (1966), R. V. Nedoshivin (1970) showed that the serum of the burned dogs, rabbits, rats and people taken in the period of shock and entered intraperitoneally to mice in 1 — 1,5 hour after blockade of reticuloendothelial system causes 100% death of mice during 12 hours after an injection. L. Kozlowski with soavt, noted death of mice within 10 — 12 days after intraperitoneal administration of the waters-but-salt extract got from the burned leather of other animal, soon after drawing to it a burn by it.
Value of an endointoxication in a pathogeny of a burn disease is not subject to doubt, but a question of the nature of burn toxins, their chemical and fiziol, the characteristic remain insufficiently studied. In literature there is a discussion about sources of toxic products at O. Predmety of a dispute the question of a gi-stiogenny or exogenous and endomicrobic origin of a burn toxaemia is. Existence inf. complications does not raise doubts that the microbic toxaemia is possible during various periods of a burn disease. However primary source of toxins are the burned fabrics, and then in connection with damage of cellular barriers and weakening of function of immune system - mucous membranes of intestines, respiratory tracts and other bodies. The data obtained by N. A. Fedorov and soavt on amicrobic animals, convincingly prove a fabric origin of burn toxins.
The recent trend in studying of a burn toxaemia is connected with N. A. Fedorov (1955) researches in the field of noninfectious immunology of a burn disease. By method biol, testings according to A. M. Bezredke and L. A. Zilber it was shown that in the affected skin and in blood of the burned animals and the person appear autoantigens (see), absent in a healthy organism. In the subsequent availability of burn antigens in blood and skin of burned was confirmed by many scientists using electrophoretic, immunoelectrophoretic and immunochemical methods of a research.
P. N. Kosyakov established education at burn convalescents of also antiburn autoantibodies (see) which cause positive RSK with antigens from the burned tissues of the person and animals, irrespective of their specific and organ specificity. The greatest antiserum capacity is noted at the persons who recovered after heavy burns (III and IV degrees); there are they in blood on 30 — the 40th day after O. and in the subsequent are found within many months. Further it became clear that serum of the recovering animals and people during accumulation of fixators gains anti-toxic properties concerning the toxic serum taken in 24 hours after O. Tak the hypothesis of education in an organism of the antibodies burned in the period of reconvalescence possessing protective, i.e. neutralizing with action concerning the toxic products flooding an organism after a severe burn injury was made and confirmed. These data use at treatment of burned.
The pathological anatomy
Kartina of local changes at O. is defined by depth of defeat of fabrics and a type of the damaging agent. At a burn of the I degree flattening, a pulling and swelling, and also a basophilia and vacuolation of protoplasm of cells of a granular layer of epidermis, sometimes a stertost of its borders is observed. In a derma the plethora, capillary staza is noted. These changes are liquidated in 3 — 5 days. Surface layers of epidermis are exfoliated.
Peeling of a corneous layer of epidermis the sweating liquid, on structure close to a blood plasma is characteristic of a burn of the II degree. Intraepidermalny bubbles are formed, a bottom to-rykh is the basal layer of epidermis. Its cells bulk up, kernels are badly painted. Collagenic fibers of a papillary layer are loosened, nipples are maleficiated. Blood vessels in the thickness of a derma are expanded, capillary staza, hemorrhages are noted. In a day after an injury in liquid of a bubble there are leukocytes, there comes the leukocytic infiltration of a derma which is most expressed in a papillary layer and around epithelial appendages of skin. The acute inflammatory phenomena and hypostasis begin to decrease with 3 — the 4th day. To this term there are mitoses in cells of a malpigiyev of a layer, and in 7 — 10 days the burned surface becomes covered by the young epithelium which in the beginning does not have a corneous layer.
The burn of IIIA of degree surely proceeds with the phenomena of a purulent inflammation and demarcation of necrotic fabric. There occurs peeling of all layers of epidermis. The bottom of the formed defect is presented by devitalized surface layers of a derma. Its connective tissue fibers bulk up, nek-ry completely lose the structure. In blood vessels — the phenomena of a staz. The remained deep layers of a derma are edematous, hypostasis extends to the subject cellulose. On border of devitalized and viable fabrics in 1 days the demarcation shaft begins to form, and through 2 weeks — granulations and rejection of a scab begins. At this time from the remained epithelial appendages of skin and the remains of a malpigiyev of a layer of epidermis there is a growth of an epithelium on granulations at the expense of what burns of IIIA of degree heal.
Depending on intensity and time of influence of the thermal agent at burns of IIIB and the IV degree there occurs death of fabrics as dry or wet necrosis (see). At a dry necrosis the destroyed epidermis remains on the died skin, collagenic fibers a cut as if stick together among themselves. Epithelial appendages of skin are destroyed, borders of their cells are indiscernible. Vessels are filled with the brown broken-up blood. Proliferative processes under a dry scab begin in 5 — 6 days, its rejection and formation of granulations comes to an end in 3 — 5 weeks. Peeling of the died epidermis, a loosening of collagenic fibers at preservation of tinktorial-ny properties, expansion and thrombosis of blood vessels is characteristic of a wet necrosis. Early there comes leukocytic infiltration and purulent fusion of devitalized fabrics. Collagenic fibers seem remained, but do not perceive acid paints. Vessels in sites of defeat are indiscernible, and in a circle — are expanded, are sometimes thrombosed. Later devitalized skin turns into a dry scab. At burns of the IV degree terms of rejection of devitalized fabrics increase, reaching at damage of sinews and bones of many months; the phenomenon of obligate secondary deepening is characteristic. It consists in development of several consistently arising zones of a necrosis (a secondary necrosis) with formation of a double demarcation shaft.
After rejection of the died fabrics the granulating surface is formed, healing a cut happens a cicatricial styazheniye and regional epithelization.
The general changes at a burn disease are very various. In all bodies and fabrics already during the first hours after an injury the disturbances of microcirculation which are shown a sharp trichangiectasia, swelling of endotheliocytes, emergence in their cytoplasm of pino-tsitozny bubbles, expansion of an interendothelial time, focal destruction of a basal membrane, hypostasis, expansion of perikapillyar-ny spaces are noted.
In various departments of the central and peripheral nervous system of disturbance of microcirculation plasmorrhagias, perivascular hemorrhages are most expressed in the period of burn shock when staza are observed, perikapillyarny swelled, swelled also swelling of shoots of astrocytes (fig. 2). Also discrepancy of membranes of synapses and disturbance of mezhneyronalny synoptic contacts is noted. In the periods of an acute burn toxaemia and septicotoxemia the expressed dystrophic and necrobiotic changes of nervous cells develop. The phenomena of vallerovsky regeneration are frequent (see. Valera regeneration ) and focal demyelination, and at burn exhaustion — disintegration and fragmentation of myelin nerve fibrils.
From endocrine organs at burn shock the changes of neurosecretory cells of a hypothalamus, pituicytes of a neurohypophysis, medullotsit of adrenal glands which are followed by the strengthened products and release of hormones are during the first hours noted. Then there occur dystrophic changes of these cells. The hypertrophy of cells of a hypothalamus, an adenohypophysis, adrenokortikotsit of puchkovy and mesh zones of bark of adrenal glands develops in later periods. At burn exhaustion in these bodies cells with the expressed dystrophic and atrophic changes begin to prevail. Dynamics of changes of other endocrine organs is similar.
In cardiomyocytes in the period of burn shock swelling and destruction of mitochondrions, focal destruction of myofibrils, emergence in cytoplasm of a large number of lysosomes, myelin structures and autofagosy, depletion of cells by a glycogen and accumulation of lipids in them are observed. Later, in the period of a septicotoxemia in a myocardium against the background of his dystrophy occasionally there are embolic abscesses and the centers of a necrosis (tsvetn. fig. 2).
In a liver, along with the increasing phagocytal activity of star-shaped endotheliocytes (kupferovsky cells), in the period of burn shock depletion of hepatocytes by a glycogen, their powdered obesity, destruction of organellas is noted. Sometimes in the central departments of segments the small centers of a necrosis meet. In later terms the phenomena of serous hepatitis are frequent.
In kidneys in the period of shock note swelling and partial rejection a nefroteliya of capsules and podocytes of balls, destruction of cellular organellas and a basal membrane of capillaries of balls, expansion of an interendothelial time of the last. In gyrose tubules the dystrophy and focal destruction of an epithelium reminding a picture of a necrotic nephrosis is observed. In a stroma of marrow interstitial hypostasis is frequent. In cortical substance of a kidney in the first days the clear plethora of juxtaglomerular zones, on 2 — 3 days replaced by shunting of blood through vessels and capillaries of marrow and ischemia of cortical substance is noted. Later the ascending interstitial nephrite, occasionally a glomerulonephritis can develop. At burn exhaustion there are focal inflammatory, dystrophic and sclerous changes in renal fabric.
From the hemopoietic bodies and blood in the period of shock oppression of a myelopoiesis, lymphopoiesis, phenomenon of a plazmotsitoliz and plethora limf, nodes and a spleen is observed; in the last absorption function of cells of reticuloendothelial system and macrophages, an eritrofagiya, blockade of cells of reticuloendothelial system is strengthened by derivatives of hemoglobin and other particles. In the periods of a toxaemia and septicotoxemia there comes the hyperplasia limf, nodes, proliferation of cells lymphoid and plazmotsitarny) a row. Electronic and microscopic and autoradio graphic researches testify about funkts, inferiority of leukocytes, macrophages, plasmocytes, the destruction of their organellas which is shown in incomplete phagocytosis and disturbance of products of globulins. At burn exhaustion the phenomena of an atrophy and a focal sclerosis of immunocompetent bodies join it.
In various departments went. - kish. a path, it is preferential in a stomach and a duodenum, sometimes there are multiple erosion and acute ulcers of a mucous membrane (fig. 3). Disturbances of microcirculation, trombotichesky processes, hemorrhages in a mucous membrane, septic embolisms (fig. 4) are the cornerstone of them. More often erosive cankers develop in the period of a septicotoxemia and especially at the phenomena of burn exhaustion.
In the period of a septicotoxemia pneumonia, sometimes as O.'s complication of respiratory tracts often develops. During the late periods are typical bronkho - gene and hematogenous diffusion inflammatory processes (tsvetn. fig. 1).
At development of the sepsis (most often a staphylococcal or pyocyanic origin) which is usually proceeding as a septicopyemia, metastatic abscesses are localized preferential in lungs, kidneys, a myocardium. Sometimes sepsis meets the necrotic centers in bodies fungal (kandidamikozny and aspergillosis) (tsvetn. fig. 3).
A peculiar form of burn sepsis is the endotoksinemiya caused by an additional invasion of gram-negative microflora through lungs, intestines etc. in connection with destruction (at the ul-trastrukturny level) aerogema-tichesky, enterotsitarny (fig. 5) and other gistogematichesky barriers.
Sharply expressed dystrophic changes of bodies and fabrics which are followed by their atrophy and a sclerosis are characteristic of burn exhaustion. Against the background of these changes inflammatory (preferential purulent) processes develop.
A clinical picture
Local changes at O. in an initial stage are clinically shown as a serous or serous and hemorrhagic inflammation — burn dermatitis, an outcome to-rogo depends on the area and depth of defeat and character of the striking factor. At a burn of the I degree the diffuse redness and a small swelling appearing in several seconds after O. a flame, boiled water, steam or in several hours at action of sunshine are observed (see Dermatitis, dermatitis solar). Strong thermalgias in an affected area are noted. In several hours, is more often within 3 — 5 days, these phenomena pass, the injured epidermis is exfoliated and on site O. sometimes remains small pigmentation.
At a burn of the II degree the redness, a swelling and pains are expressed more considerably, than at a burn of the I degree. Bubbles are formed at once or through a nek-swarm time after O. (tsvetn. fig. 4,5). Contents of bubbles at first represent transparent liquid, edges then quickly grow turbid owing to coagulation of protein and emergence of cellular elements. In 7 — 10 days O. begins to live without hems, the redness and pigmentation can remain several weeks.
The burn of the III degree in general is characterized by an escharosis (tsvetn. fig. 6). At a dry necrosis skin dry, dense, brown or black color, is insensitive to a touch, with curls of the slipped and burned epidermis. At the wet necrosis arising more often at effect of boiled water couple (parboiling), skin of yellowish-gray color, are edematous, is sometimes covered with bubbles. Friable cellulose in a zone O. and on its periphery is sharply edematous. Further there comes the demarcation of devitalized fabrics which is followed, as a rule, by an infection and suppuration. At a burn of IIIA of degree it is possible to expect independent regional and insular epithelization (tsvetn fig. 7, 8).
At a burn of the IV extent of manifestation of necrotic changes of fabrics are more expressed, than at a burn of the III degree, the carbonization of fabrics is quite often observed (tsvetn. fig. 9).
In addition to depth, i.e. O.'s degrees, a big role in development of a burn disease belongs to the size of the area of defeat. O.'s area can approximately be measured a palm, considering that the palm of the adult is approximately equal to 1% of a surface of his body. Wallace (A. Wallace, 1951), that the area of separate parts of a body of the adult is equal or multiple 9% of the general body surface offered the so-called rule of the nine, according to Krom the surface of the head and neck makes apprx. 9%, an upper extremity — 9%, the lower extremity — 18%, a back surface of a trunk — 18%, a front surface of a trunk — 18%, crotches — 1% of the general body surface. In operating conditions of burn hospitals graphic filling of skitsa (schemes) of G. D. Vilyavin or V. A. Dolinin is carried out. According to the completed tables it is possible to count the total area of O., and also the area of each extent of defeat separately.
Defeats of a respiratory organs are usually observed at deep O. by a flame of the person, neck and breast. At the same time on a mucous membrane of a pharynx, a throat and a throat the thermal agent, and influences a trachea, bronchial tubes and alveoluses — combustion products.
At victims difficulty of breath, an osiplost of a voice, sometimes mechanical asphyxia are observed, at survey cyanosis of lips, existence of the singed hair in a nose, hypostasis, a hyperemia and white spots of necrosis on mucous membranes of lips, language, a hard and soft palate, back wall of a throat are found; in the subsequent pneumonia often develops. Defeat of a respiratory organs on influence on a condition of the victim is regarded is equivalent to increase in the area of deep O. by 10 — 15% of a body surface.
O.'s weight causing this or that extent of development of a burn disease is defined by depth and the area of defeat. Frank's index can serve as the indicator of weight of O. considering both depth and the area of defeat, to-ry it is removed proceeding from the fact that 1% of the area of deep O. is conditionally equated to 3 units, 1% of the area of superficial O. — to 1 unit; existence of damage of airways is equated to 30 — 45 pieces. At the same time defeats to 30 units carry to lungs, from 31 to 60 units — to moderately severe defeats, from 61 to 90 units — to heavy, St. 90 units — to extremely heavy. Frank's index can serve also as a predictive index (see further Forecast).
The general a wedge, O.'s manifestations make a picture of a burn disease, during a cut allocate four periods.
The burn shock which is a kind of traumatic shock (see. Shock ), at victims of young and middle age usually develops at burns of the II—IV degree on the area more than 15 — 16% of a body surface.
The general excitement, increase in the ABP, increase of breath and pulse are characteristic of an erectile phase of burn shock. However this phase not always clearly is expressed.
After erectile, usually later 2 — 6 hours, the torpid phase of shock develops. Timely adequate therapy can sometimes prevent its emergence. Additional Traumatization burned, overdue medical aid promote development and heavier current of a torpid phase. In a torpid phase into the forefront the phenomena of braking act.
Nek-ry researchers allocate the periods of compensation, a decompensation and stabilization during shock. They connect the phenomena of compensation with emission in blood (in response to a thermal injury) large numbers of catecholamines therefore there comes the spasm of peripheral vessels and the necessary level of blood supply of heart and brain is for a while provided. The paralysis of peripheral vessels developing after a spasm is the cornerstone of the phenomena of the period of a decompensation. The period of stabilization is characterized by stopping of frustration of a hemodynamics.
Weight a wedge, manifestations of burn shock depends on the area and depth of thermal defeat, reactivity and age of the victim, timeliness and adequacy of antishock therapy. For judgment of weight of burn shock first of all it is necessary to determine depth and the area of defeat. On severity most of doctors distinguish easy, heavy and extremely heavy burn shock.
The little shock develops at O. with a total area no more than 20% of a body surface, including deep no more than 10% (Frank's index to 30 units). Patients are more often quiet, are sometimes excited, eyforichna. The fever, pallor, thirst, a muscular shiver, a goosellesh, occasionally nausea and vomiting are noted. Breath is usually not speeded up, pulse to 100 — 110 blows in 1 min., is not reduced by the ABP, the central and peripheral venous pressure is steady. Haemo concentration insignificant (hemoglobin no more than 150 g/l, quantity of erythrocytes to 5 million in 1 mkl blood, a hematocrit to 45 — 55%). OTsK is lowered to 10%. Disturbance of electrolytic balance is, as a rule, insignificant, function of kidneys is broken moderately, the hourly diuresis is lowered no more than to 30 ml/hour.
Heavy shock is observed at O. more than 20% of a body surface. Serious condition, is quite often noted the excitement which is replaced by block. Consciousness is usually kept. The fever, pains in the area O. disturb, thirst, at nek-ry patients is noted nausea and vomiting. Integuments of not burned sites pale, dry, cold to the touch; body temperature is more often reduced on 1,5 — 2 °. Breath is speeded up, pulse of 120 — 130 blows in 1 min., is lowered by the ABP moderately. Выра^ the wife haemo concentration (amount of hemoglobin of 160 — 220 g/l, a hematocrit of 55 — 65%, quantity of erythrocytes of 5,5 — 6,5 million in 1 mkl blood); OTsK is lowered by 10 — 30%. Are noted hyperpotassemia (see) and hyponatremia (see). Are often observed oliguria (see), hamaturia (see), an albuminuria (see. Proteinuria ), it is frequent on 2 — 3 days raise residual nitrogen of blood (36 — 71 mmol/l) and the specific weight (relative density) of urine (1,018 — 1,050).
Extremely heavy shock arises at O. on the area of St. 60% of a body surface, including deep St. 40% (Frank's index of St. 90 units). It is characterized by sharp disturbance of functions of all systems of an organism. The condition of patients extremely heavy, consciousness is quite often confused. Painful thirst is observed — patients drink up to 4 — 5 l of liquid a day then there can be pernicious vomiting. Integuments are pale, with a marble shade, body temperature is considerably lowered. Breath is frequent, short wind, cyanosis of mucous membranes are expressed. Pulse is threadlike, sometimes it does not soschityvatsya; The ABP is lower than 100 mm of mercury.; venous hypotension arises from the first hours. Sharp haemo concentration is characteristic (amount of hemoglobin of 200 — 240 g/l, a hematocrit of 60 — 70%, quantity of erythrocytes to 7 — 7,5 million in 1 mkl blood); the volume of the circulating blood is reduced by 20 — 40%.
H of an arusheniye of acid-base equilibrium are shown by sharp acidosis and major deficit of the bases. The hyperpotassemia, hyponatremias keep throughout the entire period of shock. The anury is often noted, the oliguria is more rare. In the presence of urine the gross hematuria, an albuminuria constantly are defined, haemoglobinuria (see) and urobilinuria (see). From the first hours the amount of residual nitrogen of blood (36 — 100 mmol/l), specific weight of urine are increased (1,050 and above). Paresis of digestive tract is frequent.
Burn shock proceeds from 2 to 48, in rare instances to 72 hours then at a favorable outcome peripheric circulation and microcirculation begins to be recovered, body temperature increases, the diuresis is normalized. During this period signs of the second stage of a burn disease — an acute burn toxaemia begin to be shown.
The burn toxaemia develops as as a result of intoxication of an organism the decomposition products of proteins, intermediate products of exchange, toxicants which are soaking up from the burned fabrics and the possessing antigenic properties and owing to influence of toxins of the microflora planting a burn surface. Manifestations and expressiveness of a toxaemia at deep O. to a large extent depend on character of a necrosis. At a wet necrosis there occur rejection of dead fabrics quicker and this period appears less long, but heavier. At a dry necrosis rejection proceeds longer, but patients transfer this period easier.
A cardinal symptom of a toxaemia unlike shock is fervescence within 38 — 39 ° without the expressed morning remissions. Body temperature 39 — 40 ° demonstrates heavy disease and the adverse forecast above. Except a hyperthermia excitement, nonsense, sleeplessness or drowsiness, sometimes muscular twitchings and spasms, apathy are observed, in some cases develops soporous or coma. From cardiovascular system the phenomena of toxic myocarditis (see) which are shown tachycardia and a tachyarrhythmia, dullness of cordial tones, arterial hypotension, pallor of integuments and cyanosis of mucous membranes, decrease in sokratitelny ability of a miogeard can be noted. Developments of stagnation in lungs, lead the disturbances of blood circulation in a small circle, reduction of passability of small and average bronchial tubes taking place at shock in the period of a toxaemia to further disorders of breath: there are microatelectases, the centers of pneumonia and a fluid lungs (see). Disturbances from digestive organs are shown by lack of appetite, nausea, repeated vomiting, paresis of intestines or toxic ponosa. Thirst, language dry is observed. Yellowness of scleras and skin is sometimes noted. Often in this stage the tranzitorny bacteremia however not testimonial of sepsis is found.
In the period of a toxaemia the plazmopoter I stops, at normalization of OTsK haemo concentration on 3 — the 5th days after an injury is replaced by anemia, the hematocrit falls, the volume of the circulating plasma decreases, the leukocytosis and a deviation to the left accrues. High proteolytic activity of blood serum, the expressed catabolic reactions — negative nitrogenous balance, disturbance of an aminogramma of blood, a hypoproteinemia, sharp reduction are characteristic albumine-globulilovogo of coefficient (see). Disturbances of water and electrolytic balance remain, the oliguria accompanying burn shock is replaced by a polyuria, the hypopotassemia is found.
The burn toxaemia sticks on average to 10 — 15 days and gradually passes into a septicotoxemia.
The burn septicotoxemia develops usually at patients with the deep O. exceeding 5 — 7% of a body surface or with widespread superficial her O. Nachalo is connected with suppuration, a cut comes usually on 12 — the 15th days after the Lake. Further manifestations of a septicotoxemia are connected with considerable loss of protein through wounds, absorption of decomposition products, and also with character and quantity of the microflora nesting in the struck fabrics. This period before healing or operational recovery of an integument lasts. Temporary closure of defects of skin hallo - or heterografts facilitates a current, but does not stop a septicotoxemia.
Clinically the septicotoxemia is characterized is purulent - resorptive fever (see), to - paradise can be constant, remittiruyushchy, is more rare gektichesky, sleeplessness, slackness, sometimes nonsense. Tachycardia, the phenomena toxic miokardity, disturbances of microcirculation and tissue respiration remain. The alimentary frustration connected with a loss of appetite (go deep up to anorexia), disturbances of the secretory, acid-forming, fermental and secretory and soaking-up functions went. - kish. path, decrease in functions of a liver and pancreas. With firmness the secondary anemia connected with oppression of an erythrogenesis, hemolysis of erythrocytes, blood loss during bandagings and operations keeps. High proteolysis, catabolic reactions with the considerable emission of catecholamines, negative nitrogenous balance expressed hypo - and a disproteinemia, low albumine-globulinovym in coefficient remain; quite often the bacteremia passing into sepsis develops. According to Arturson (G. Arturson) et al. (1978), power consumption reaches 50 — 60 kcal/kg of the weight (weight) of a body. All this leads to falloff of body weight of patients.
In process of rejection of nekrotizirovanny fabrics and development of granulations the course of a burn disease gains subacute character with noticeable improvement a wedge, conditions of patients.
At less favorable current the burn exhaustion similar to traumatic exhaustion can develop (see). It is usually observed at deep O. not less than 15 — 20% of a body surface, but in cases of defective treatment can develop also at deep Lakes, smaller on the area. At burn exhaustion the body weight of patients is lost for 10 — 20%, and at extreme degrees — for 25 — 30%. Patients have the general block, are formed decubituses (see); from blood sharp anemia, a hypoproteinemia is noted; reparative processes in wounds are oppressed, granulations become pale, flabby, easily bleed.
During a burn disease mental disorders can be observed. The acute beginning and parallelism between the course of mental disturbances and somatic displays of a burn disease are characteristic of all psychotic states at O. These frustration carry to group symptomatic, somatopsychoses. Their emergence is caused by hl. obr. stressful reaction, a toxaemia, an infection and development of complications from internals.
The most often mental disorders are shown in the form of motive excitement and a condition of an adinampchesky adynamy (see. Asthenic syndrome). The sleep is interrupted, dreadful dreams, contents are characteristic to-rykh reflects a situation of receiving the Lake. Asthenic frustration are reduced in the period of reconvalescence slowly, sometimes remaining for 1 — 1,5 years. Persuasive fears of fire can accompany them (patients avoid to light fire, cannot look at it). Against the background of the expressed adynamy there can be reactions of exogenous type, is more often in the form of a delirium (see. Delirious syndrome), an onprichesky state, devocalizations or amentias are more rare (see. Amental syndrome ). Emergence of amental frustration testifies to weight of a state and predictively it is adverse. Duration of psychoses — from one days to one week, rarely longer.
In the remote period (in 3 — 5 years after O.) asthenic, hysterical states prevail (see. Psychopathies ). After O. which caused a disfiguration persons of young and middle age quite often have Protragirovanny subdepressions (see. Depressive syndromes ), followed by some kind of autization (patients prefer loneliness, avoid communication, visits of public and crowded places).
The period of reconvalescence begins after elimination of acute displays of a burn disease and its complications. In this period there is full or almost full healing of O., and also recovery of ability of the patient to movement and elementary self-service. However metabolic disturbances (a disproteinemia, sometimes a hypoproteinemia, anemia) still can continue; changes from cardiovascular system (tachycardia, hypotonia), a respiratory organs (an asthma at exercise stresses, reduction of vital capacity of lungs), went. - kish. path (increase in a pla, on the contrary, loss of appetite), kidneys (disturbance of concentration ability); hems form; at patients with mental disturbances the resistant adynamy in combination with the phenomena of a psychoorganic syndrome is observed (see). These disturbances can be expressed in various degree and in various combinations, their duration is defined both by weight of a burn disease, and full value of its treatment.
Features of a course of a burn disease at persons of advanced and senile age are connected first of all with frequent existence at them various diseases (a diabetes mellitus, coronary heart disease, atherosclerosis, a hypertension, cardiopulmonary insufficiency, etc.) and decrease in adaptation opportunities of an organism. These circumstances cause more frequent development of heavy burn shock (can arise at these patients at burns of the II—IV degree on the area of 8 — 12% of a body surface), heavier current of a toxaemia and a septicotoxemia, bigger number of serious complications at burn defeats, smaller on weight, than at middle-aged persons. At burn shock at elderly patients bystry development of a decompensation is often noted, to a thicket there are indications to performing infusional therapy during evacuation in to lay down. establishment.
In some cases it is possible to differentiate only conditionally the disturbances showing sya display of a burn disease, and its complication.
In different terms of a burn disease, a thicket during the periods of a toxaemia and septicotoxemia, focal, lung or share fever can develop (see). In the first days this complication is usually connected with defeat of a respiratory organs combustion products. Physical diagnosis of pneumonia is often complicated by O.'s presence in a thorax therefore is of particular importance rentgenol, inspection. Occasionally the myocardial infarction (see), and in the period of a septicotoxemia can be observed — pericardis (see).
Complications from abdominal organs are diverse. Often there are acute ulcers went. - kish. a path (see. Peptic ulcer ), quite often followed bleeding or a perforation (an ulcer of Kur-linga). Sometimes acalculous ulcer or gangrenous cholecystitis develops (see). Also other complications (thrombosis of vessels of an abdominal cavity, acute pancreatitis, an acute appendicitis, acute intestinal impassability) are possible. Diagnosis of an acute abdomen at burned is quite often complicated since the symptomatology of the complicating process can mask displays of the most burn disease (paresis of intestines, a capillary toxicosis, etc.). In these cases gastroscopy (see) and a kolonoskopiya (see) help to specify the diagnosis.
At the expressed burn intoxication the liver failure, toxic or serumal hepatitis with dominance of anicteric forms can develop (see. Hepatitis , viral hepatitis ). At the same time the raised bleeding of granulations, a bilirubinemia, sometimes an acholia a calla is observed.
In late terms after O. development of nephrite, a pyelitis is possible, pyelonephritis (see), and at burn exhaustion, a cut itself is a complication of the period of a burn septicotoxemia, formation of urinary stones (see the Nephrolithiasis), development mono - and polyneurites is possible. Treats the heaviest complications of a burn disease sepsis (see).
The furunculosis, phlegmons, purulent arthritises, and also gangrene of an extremity at circular Lakes belong to complications of local character in the field of thermal defeat. Burns of auricles of the III degree quite often are complicated by development of a chondritis. The last can be also a consequence of formation of decubituses in auricles at serious condition of the victim. At deep O. of a calvaria with damage of bones development of Epi - and the subdural abscesses which are often proceeding asymptomatically and meningitis is possible. Partial reduction of the integument lost as a result of deep O. and subjects of fabrics leads to development of burn deformations — contractures (see), incomplete dislocations and dislocations (see. Dislocations ), ankiloz (see), and also it is long the current trophic ulcers (see). Most often there are contractures (tsvetn. fig. 10 — 11).
the Diagnosis of prevalence and depth of focal lesions, and also the periods of a burn disease is based on characteristic a wedge, signs. Measurement of O. Square, definition of an index of Frank are given by the first reference points for the characteristic of weight of a burn disease.
Among rich symptomatology of burn shock the tendency to fall of temperature of a body since its subsequent increase will indicate most often approach of the period of a toxaemia shall attract attention. Approach of the period of a septicotoxemia will be demonstrated by development of suppurative process in a wound.
Early diagnosis of thermal defeat of a respiratory organs is of particular importance. Such defeat needs to be suspected of cases when the injury occurred indoors or in half-closed space (in the house, the cellar, excavations, in the vehicle) if O. is caused by steam, a flame; if the clothes burned; if there is O. of a breast, necks, persons. The diagnosis is confirmed by existence characteristic a wedge, symptoms. In doubtful cases the final diagnosis is established at a laringoskopiya and a bronkhoskopiya.
At a X-ray analysis of the affected bones can come to light osteoporosis (see), caused by disturbances of protein and mineral metabolism and long immobilization, and the osteonecrosis (see) coming initially at the time of an injury, or for the second time at distribution on a bone it is purulent - destructive process.
Osteoporosis, in the beginning spotty, and then diffusion, is found in 3 — 5 weeks at first in a zone of burn wounds, and later and in certain symmetric sites of a skeleton. At the same time the bone drawing of metaphyses disappears, cortical substance becomes less dense. At burn exhaustion the system osteoporosis which sometimes is becoming complicated patol, changes (fig. 6) develops. These changes are liquidated in 10 — 12 months after recovery, and only at development of contractures of joints remain for many years.
Primary osteonecrosis comes to light on roentgenograms in 3 — 5 weeks after the Lake. Between a devitalized and viable bone there are regional uzura of cortical substance, the fragments of a bone which against the background of osteoporosis died keep accurate contours and usual structure. Later they separate a continuous strip of an enlightenment (fig. 7).
After rejection or removal of sequesters and operational recovery of an integument there comes the reparation of bone defects: in 4 months cortical substance, and 8 — 12 months later — the marrowy channel forms. Spongy substance does not regenerate.
The secondary osteonecrosis is usually observed at death of soft tissues over the site of a bone and shown by destruction of cortical substance and osteoporosis of an epiphysis. At the purulent arthritises which complicated O. dislocations and incomplete dislocations are frequent. If it is possible to keep an extremity, the deforming arthroses or ankiloza develop. Sometimes there occurs calcification or ossification of para-articular fabrics (fig. 8).
First aid at O. on site of incident consists in actions for bystreyshy cancellation of the thermal agent. At the same time accurate and bystry actions as the most injured, and the people around giving him help are important. The ignited clothes or the substances burning on a body need to be extinguished quickly, having stopped access of air to the burning site (closing dense fabric, a blanket; to powder with the earth or sand; to lay down on the earth so that to press to it the burning surface). It is impossible to force down a flame the unprotected hands, to run in the burning clothes since at the same time burning amplifies. To reduce duration of a fabric hyperthermia and to reduce depth of damage of fabrics it is extremely desirable to cool quickly the site of defeat with available means (immersion in a cold water, snow).
Apply a dry aseptic bandage the burned part of a body. At extensive O. the victim is wrapped up with a sterile sheet, pure fabric, linen, protected from cooling and carefully transported in a hospital.
Treatment of burn shock shall have preventive character therefore on site incidents and along the line (in the ambulance car) shall be entered analgetics (Promedolum, analginum), antihistaminic (Dimedrol, isopromethazine, Pipolphenum), cardiovascular means, etc. During long transportation enter intravenously blood substitutes of hemodynamic action (Polyglucinum, reopoliglyukin, etc.). Treatment of the expressed motive excitement consists in parenteral administration of Nozinanum, haloperidol, Seduxenum.
In a hospital antishock therapy is carried out according to the certain scheme providing to the patient of psychoemotional rest, correction of disturbances of blood circulation, prevention and treatment of disturbances of acid-base equilibrium and secretory function of kidneys, fight against disbolism, an endotoxemia and other displays of a burn disease.
The basis of treatment of burn shock is made nnfuzionno-transfuzi-onnaya by therapy, at a cut use blood preparations (native and dry plasma, albumine, a protein), blood substitutes (Polyglucinum, reopoliglyukin, Haemodesum, Polydesum, etc.); crystalloid drugs (Ringer's solution, laktasol, isotonic solution of sodium chloride, 3 — 5% solution of hydrosodium carbonate), electrolyte-deficient solutions (0,1% solution of novocaine, 10 — 40% solution of glucose with insulin), osmotic diuretics (Mannitolum, urea, etc.). Within the first days the adult at little burn shock enter 1 — 2 l of colloid, crystalloid and other transfusion environments at a ratio 1: 1: 1, at heavy and extremely heavy shock — 3 — 6 l at a ratio of environments 2:1: 1. At the same time not less than a half of colloid drugs shall make proteinaceous blood preparations. Into the first 8 hours enter a half of settlement amount of liquid. The amount of the entered liquids reduce by the 2nd and 3rd days on 1/3. Blood is transfused at deep O. on the area not less than 10 — 15% of a body surface, usually in 2 — 3 days after the Lake.
For definition of a diuresis enter a constant catheter into a bladder. Criteria of adequacy of transfusion therapy is maintenance of the central venous pressure within 70 — 150 mm w.g., an hourly diuresis — 1,5 — 2 ml/kg/h, gematokritny number — 38-42%.
Medicamentous therapy of shock includes analgetics (Promedolum, analginum), antihistamines (isopromethazine, Pipolphenum, Suprastinum, Dimedrol), analeptics (Cordiaminum, Bemegridum), corticosteroids (a hydrocortisone, Prednisolonum), cardiacs (drugs of a foxglove, Strophanthus, lily of the valley); the means raising makroergiche-sky resources of a myocardium (ATP, cocarboxylase); vitamins (With, B1, B6, B12, E), salts of calcium, inhibitors of proteolysis (Contrykal), diuretics (lasixum). Continuous inhalation is at the same time carried out by the moistened oxygen. Already at the end of the period of shock appoint antibiotics of a broad spectrum of activity.
At thermal defeats of a respiratory organs, in addition to transfusion therapy, apply bilateral vagosympathetic blockade according to A. V. Vishnevsky; appoint spaz-mo lytic means for removal of a bronchospasm (a papaverine, ephedrine, Nospanum, etc.). the drugs stabilizing pulmonary blood circulation (Euphyllinum), reducing permeability of capillaries of a small circle of blood circulation (hydrocortisone), a pra duprezh the ny processes (proteolytic enzymes) and the development of pathogenic microflora (antibiotics) and also regulating exchange processes giving in Spa litas l (redoxons, B1, etc.) - Are obligatory sanitation of respiratory tracts (aerosol inhalation of antibiotics and proteolytic enzymes), periodic suction of a phlegm from a trachea the catheter entered in Nov. At the accruing frustration of external respiration are shown to lay down. a bronkhoskopiya, sanitation of a tracheobronchial tree, and sometimes artificial ventilation of the lungs (see. Artificial respiration ). The indication for a tracheostomy (see) is the asphyxia caused by hypostasis of voice folds, and the expressed respiratory insufficiency owing to sharp oppression of a tussive reflex and disturbance of drainage function of bronchial tubes.
The prevention of development of a burn toxaemia with the greatest effect can be reached early (on 2 — the 3rd day after O.) by a necretomy of a burn scab (see. Necretomy ) with an immediate auto-or xenoplasty (see. Skin plastics ).
Treatment of patients in the period of a toxaemia is aimed at providing constancy of internal environment of an organism, desintoxication, completion of metabolic and plastic cost, fight against an infection, correction of the metabolic and other disturbances arising in this period of a burn disease.
Ensuring constancy of internal environment is reached by systematic hemotransfusion and its drugs (plasma, albumine, a protein) to recover the volume of the circulating blood, quantity of erythrocytes (to 3,8 — 4,0 million in 1 mkl blood), hemoglobin (to 110 g/l), serum proteins (to 65 — 68 g/l). For the directed desintoxication most often use low-molecular blood substitutes — Haemodesum, Polydesum, reopoliglyukin; balanced crystalloid solutions of Ringer, varnish-tasol; apply also means of osmotic desintoxication, an artificial diuresis, hemodilutions). Completion of a plastic and metabolic cost is carried out by oral, chrezzondovy or parenteral food, by 2 g of protein providing receipt in total and 50 — 60 kcal on 1 kg of body weight of the patient a day. In fight against a generalized infection along with the directed use of himiopreparat and antibiotics the important place belongs to hyperimmune drugs: to anti-staphylococcal gamma-globulin, anti-staphylococcal and antisi-not purulent plasma. For correction of metabolic disturbances use the inhibitors of proteolysis, substances stimulating synthesis of protein in fabrics (retabolil, Nerobolum, methacil, pentoxyl, methionine), redoxons, B1, PP, B12, E.
Treatment of a burn septicotoxemia also shall be directed to correction of a homeostasis and metabolism, to fight against a burn infection, intoxication and against the complications which are found in this period, hl. obr. with sepsis. Use the same methods of the general therapy, as in the previous period. At treatment of the heaviest contingents of victims (with burn exhaustion, sepsis) carry out direct hemotransfusions (see), apply glucocorticoids in combination with anabolicheskikhm steroids (retabolil, Nerobolum). During rejection of nekrotizirovanny fabrics transfuse blood, its drugs or blood substitutes from 3 to 6 weekly. Along with intensive general treatment carry out preparation for operational recovery of the lost integument and operations as timely executed autodermoplastika or an allodermoplastika are the major prophylactic and treatments of burn exhaustion.
During performance of plastic surgeries the quantity of the entered transfusion environments decreases, and in process of closing of the area of defects of skin of transfusion are carried out only in days of operative measures.
In the period of reconvalescence at the phenomena of an adynamy apply tranquilizers (see), antidepressants (Azaphenum, amitriptyline, Pyrazidolum), proofreaders of behavior (neuleptil). The important place is taken by individual psychotherapy. At treatment of all groups of patients widely use cordial and respiratory analeptics, antihistaminic and other drugs. Is of great importance high-calorific, protein-rich, vitamins and mineral salts to lay down. the diet containing 3000 — 4000 kcal a day. Patients should be fed with small portions of 5 — 6 times a day. The weight loss making St. 5 — 6% of body weight serves as the indication or to additional course parenteral food, or to an enteral giperalimentation that is especially shown at burn exhaustion.
Intensive general care allows to compensate many disturbances of a homeostasis developing at a burn disease, to create conditions for active recovery of the lost integument by an autodermoplastika.
The principles of treatment of elderly patients the same, as all other groups burned, but treatment shall be strictly individualized. It especially belongs to amount of the entered liquids. In a stage of burn shock it is, whenever possible, desirable to reduce their volume by 20 — 25%, having kept the recommended amount of the poured colloid drugs. During other periods of a burn disease the amount of the poured liquids shall not exceed 20 — 22 ml/kg.
Topical treatment of O. is begun after removal of patients from shock with carrying out a toilet of the burned body parts. It is carried out in pure operational after preliminary introduction to the patient of anesthetics (2% solution of Promedolum in combination with hydroxybutyrate of sodium, etc.).
Extended to 40 — the 50th 20 century the method of roughing-out of O. across Vilbushevich (washing of the burned surface soap water by means of brushes) in modern practice is not used in view of its injury. Apply the sparing technique of a toilet accepted at the XXVII All-Union congress of surgeons (1960). Skin around O. is wiped with the napkins moistened 0,5% with solution of ammonia or warm soap water. Then it is drained, processed alcohol, Iodonatum. The gauze ball moistened with solution of an antiseptic agent (Furacilin, Rivanolum, etc.) or 0,25% solution of novocaine, remove foreign bodys, scraps of epidermis from the burned surface. Small bubbles do not open. Big intense bubbles cut and empty.
After O.'s toilet treat by the opened or closed method.
At a thicket the applied closed method on the burned surface impose wet drying (with solutions of antiseptic agents or antibiotics) and salve dressings, the purpose to-rykh — protection against the secondary infection and traumatizing, absorption separated and fight against an infection. A shortcoming wet vysy - the finding fault bandages is that they dry, their change is painful and connected with damage of granulations and a young epithelium. Use of creams (ointments) on a water-soluble basis is perspective (mafi-nid-acetate), to-rye interfere with development of a wet necrosis and provide long contact of antibacterial agents with fabrics. If on site O. was already formed a dry stream, in order to avoid its softening it is reasonable to apply a dry aseptic bandage. In the presence of symptoms of suppuration it is better to apply the wet drying bandages (with solution of Furacilin 1: 5000, Rivanolum 1: 2000, 10% solution of sodium chloride, etc.).
At an open method the surface of a burn of 4 — 5 times a day is oiled sterile liquid or 1 — 2 once a day process the coagulating and tanning substances — solutions of a tannin (Bettmen's method), Galascorbinum, etc. At an open method the dry scab and consequently, intoxication of an organism decreases is quicker formed. The plentiful fluid loss through the burned sites and more difficult care of heavy patients belongs to shortcomings of a method.
The open method is usually applied to treatment of burns on the face. This method with success is used at treatment of patients with extensive deep O. of various localization in the conditions of hyperbaric oxygenation (see), the managed abacterial environment.
The described conservative therapy is carried out at all O., however it is possible to be limited to it only at superficial defeats. Process of healing of deep O. at conservative therapy lasts long time, taking place five stages (tsvetn. fig. 7 — 11): stage of coagulation of fabrics (8 — 9 days), stage of rejection of nekrotizirovanny fabrics and development of granulations (until the end of 3 — 4th week), a stage of a granulation (with the 4th on 12 weeks), a stage of scarring (more than 12 weeks), but also after that there can be persistently not healing ulcer. Therefore at deep O. against the background of conservative therapy bystreyshy operational recovery of the died integument is necessary. Such complex treatment aims to prevent emergence of the heavy complications sometimes leading to death of the victim, not to allow development in it of considerable burn (cicatricial) deformations, to reduce terms of treatment and disability at the best functional and cosmetic results.
The best method of operational treatment of deep O. is excision of the died skin and glubzhelezha-shchy fabrics with the single-step or delayed on 24 — 48 hours closing of defect with free skin autografts. In the presence of conditions (lack of shock, early diagnosis of depth of a necrosis, lack of an acute purulent inflammation) similar operations in the majority specialized to lay down. institutions carry out on 2 — the 6th days after a burn not only at limited, but also at widespread deep
O. V other cases replace autografts in later terms — to the formed granulations.
As preparation for transplantation the dry necrotic strupa tsirkulyarno covering an extremity, a thorax, a neck as soon as possible longwise cut (see the Necrotomy) that improves venous and limf, outflow and the secondary necrosis warns; with 8 — the 9th days after O. during the bandagings which are carried out every other day or daily, without blood delete (excise) necrotic fabrics (see the Necretomy) in process of their demarcation; at necrosis of a bone tissue carry out an osteonekro-tomiya and an osteonecretomy. The term of preoperative preparation can be reduced by carrying out an operational tangential (bloody) necretomy (the electroknife, plasma or laser scalpels can be for this purpose used, at use to-rykh it is possible to minimize blood losses)), and also use of proteolytic enzymes (a gigrolitin, Terrilytinum, chemical opsin, etc.), 40% of solution salicylic or the benzoic to - you, to-rye impose on a burn scab on the area no more than 5 — 6% of a body surface. The great value begins to be attached also to use of low-energy laser radiation; radiation of wounds helium - the neon or neodymium laser considerably activates reparative processes, reduces degree of a bacterial obsemenennost of a wound. At purposeful general and local therapy during 3 — 3V2 weeks it is possible to carry out preparation for an autoplasty.
Depending on circumstances can be required by the victim operation and other character. So, at deep O. there can be a need of amputation of fingers and even large segments of extremities at various levels. Indications to such interventions in early terms are full death of a segment of an extremity, and later — development inf. the complications (e.g., purulent arthritis) which are not liquidated at the conservative or sparing operational treatment. Closing of defect at the same time most often is carried out also by free skin transplantation on granulation. At special indications (an exposure of sinews, joints) use methods of pedicellate plastics.
Operations carry out usually under a mask anesthesia with preservation of spontaneous breath. The endotracheal anesthesia using muscular relaxants and artificial ventilation of the lungs is shown only at the operations proceeding more than 1 — 1,5 hour, napr at nek-ry reconstructive and recovery interventions.
Free skin rags cut off by means of special devices — the dermatomes (see) allowing to take skin transplants from 0,15 to 1,5 mm thick. Usually a dermatome take rags on the area from 5 — 10 to 300 — 400 sm1 and more if cash resources of the unimpaired skin allow. Use thin more often (0,15 — 0,3 mm) or the average thickness (0,4 — 0,6 mm) skin transplants that allows to try to obtain healing of donor wounds first intention within 10 — 12 days. In case of need on these places in 2 — 2,5 weeks skin rags can be cut off repeatedly (sometimes to three times).
Free skin rags in one step close from 50 — 100 to 800 — 1000 cm 2 the granulating surface. It can be closed completely on its contour (planimetric plastics, fig. 9), in one or two stages (stage plastics). Counting on regional growth of an epithelium of skin transplants use the economical methods of plastics allowing to increase the closed area at the smaller area of the taken transplants: the method of «stamps», «strips», use of a perforated (mesh) transplant, to-ry allows to close defect of skin on the area by 2 — 6 times bigger, than the area of initially cut off rag (tsvetn. fig. 12). Apply also combined auto-, allotransplantations. Old methods of insular plastics (Re-Verdun, Yanovich-Chaynsky — Davies, Pyasetsky, etc.) in modern surgery of O. usually do not apply.
At critical loss of integuments (St. 30% of a body surface), burn exhaustion, deficit of donor places use temporary closure hallo - and heterografts. As allotransplants apply tinned cadaveric skin, from among heterografts more often — the preserved or lyophilized leather of pigs. Besides, use the drugs made on the basis of collagen (Combutecum, etc.), from raw materials of a plant origin (algipor), and also derivatives of plasts (sinkrit, epigard). Temporary coatings change during bandagings every 48th hour. In process of emergence of necessary conditions replace to granulations a miss of a dermotransplantata.
The similar multi-stage skin plastics is applied also in all other cases, in to-rykh a one-stage autoplasty is for one reason or another impossible. At the same time skin transplantation is made in 3 — 5 — 7 days; on the defects remaining open impose the wet drying bandages with solutions of antiseptic agents and antibiotics or salve dressings. Bandagings make at least, than in 1 — 2 day.
Very painful bandagings at seriously ill patients carry out under an intravenous anesthesia (see. Not inhalation anesthesia), to-ry it can be continued by means of flying anesthetics — Ftorotanum, constant boiling mixture, etc. In the absence of a possibility of carrying out an intravenous anesthesia of bandaging can be carried out under a mask anesthesia using one of flying anesthetics (see. Inhalation anesthesia).
For prevention of contractures by means of plaster or plastic tires, special bandages, podveshivaniye and laying extremities are given functionally advantageous position or situation opposite to character of a possible contracture.
The physical therapy at complex treatment of burned is directed to strengthening of the general nonspecific reactivity of an organism, the prevention or reduction of development of an infection in a wound, drying and rejection of the died fabrics, preparation of burn wounds for skin transplantation, acceleration of epithelization of a wound surface, the prevention of development of cicatricial contractures.
At thermal defeats of a respiratory organs from the first days after an injury or at the subsequent development of pulmonary complications (pneumonia, etc.) carry out steam, warm and wet, oil or aerosol inhalations of various pharmaceuticals (menthol, eucalyptus oil, broth of herbs — a camomile and a sage, solutions of hydrosodium carbonate, antibiotics, a hydrocortisone, heparin, ferkhment — trypsin, a himotrinsin, himo a dog, etc.). Frequency of procedures is defined by weight of process (from 1 — 2 to 4 — 6 times a day). At treatment of pneumonia (see) use an inductothermy) or electric a yole of UVCh.
At treatment of burns (especially open metodol!) use the managed flow of sterile air at t ° 28 — 32 ° and relative humidity of 16%; the constant or periodic room of the patient in a sukhovozdushny bathtub; the infrared radiation supporting an optimum temperature schedule (28 — 32 °); drying of burn surfaces lamp sollyuks.
At superficial O. from the first days after an injury in days of bandagings apply UF-radiation of the burned site and the skin surrounding it in an erythema dose (2 — 4 biodoses) to full epithelization of a burn surface. Use also radiation of a segmented zone (collar or the coward 11 kovy) within 1,0 — 1,5 biodoses (3 — 4 radiations).
At deep O. apply electric field of UVCh through a bandage in a slaboteplovy dosage. In process of removal of necrotic fabrics and development of granulations for bactericidal action and improvement of blood circulation during bandagings carry out O.'s UF-radiation (1,0 — 1,5 biodoses, 3 — 4 times), local ultrasonic therapy, fonoforez a hydrocortisone.
At O. of extremities from the first days after an injury it is possible to carry out a local barotherapy with pressure decrease in the camera on 20 mm of mercury. for upper extremities and on 30 — 40 mm of mercury. for lower (on a course prior to 10 procedures lasting 10 — 20 min.). Such therapy improves microcirculation in fabrics, promotes epithelization.
In process of healing for the prevention of cicatricial deformations carry out massage — manual, underwater, vibromassage (see Massage, the Shower massage). In a stage of swelling of a hem (the first 1 — 1,5 month) apply ultrasound to prevention of its hypertrophy, in particular fonoforez a hydrocortisone or propolis. Ultrasonic therapy can be combined in one day with an electrophoresis of a lidaza, a ronidaza, iodine, novocaine, Peloidinum that increases efficiency of treatment. Are reasonable also microwave therapy on area of a joint, electrostimulation of muscles of the affected extremity.
In 1 — 1,5 month after healing for acceleration of maturing of hems, preventions of retraction and acceleration of a deretraktion of the begot skin rags, reduction of rigidity of joints apply radonic pl carbonic and radon, iodine-bromine, sulphidic, chloride sodium, pine needle baths, and also sea bathings and an underwater shower massage. Balneoterapiya it is reasonable to combine with holding electroprocedures.
At education hypertrophic and keloid cicatrixes (in 3 — 4 months after healing) fonoforez a hydrocortisone combine with paraffin applications, mud cure. Quite often with success apply bukki-therapy and a beta-ray therapy. To lay down in the presence. effect the course of physical therapy is repeated; in cases of lack of the expressed positive dynamics the physical therapy is carried out for training of the patient for rekonstruktpvno-recovery operations.
The physiotherapy exercises are an important element of complex treatment burned. It is directed to improvement of function of cardiovascular and respiratory systems as reduces an adynamia and interferes with development of a hypostasis, and also on the prevention of formation of contractures and recovery of functions of joints.
Contraindications to carrying out LFK are heavy intoxication, sepsis, mental disturbances, acute nephrite, hepatitis, suppurative processes with fever, heavy arthritises of large joints, danger of arrozivny bleeding. All other patient with O. and their effects of LFK appoint during the entire period of hospitalization, and also in the conditions of policlinic to a complete recovery of functions of joints of a pla before removal of threat of further restriction of volume of movements in them.
Most often give individual classes, is more rare group with partial or full repetition of exercises during the day.
The seriously ill patient appoint breathing exercises, the easy movements in not burned joints, range to-rykh extends over time. The moderately severe patient in addition appoint exercises for a trunk, special exercises for the burned areas (a static stress and relaxation of muscles). In process of rejection of necrotic fabrics and development of granulations in a wound add easy active and active and passive exercises in the affected joints. At this LFK most often carry out to time of bandagings as in a bed and at the applied bandages of the movement are possible only in limited volume. After skin transplantation of the movement in joints renew with gradual increase in their amplitude. In the period of reconvalescence special exercises with objects are shown, including at reception of balneological procedures, the dosed walking, me-hano-and the work therapy, game exercises directed to recovery of the lost function of joints, forces of certain muscular groups (a back, a stomach, a belt of a top and bottom extremity, shins, brushes). Duration of LFK at patients with superficial O. makes 3 — 4 weeks, and with deep — of several months to a semi-goal and more. Early and methodically correct performance of exercises of LFK in combination with a constant or removable immobilization, use of physical therapy increases efficiency of treatment of the Lake.
Rehabilitation of burned. From 18 to 40% of the patients who had deep O. need the subsequent recovery operations for local effects of O. (a contracture, burn ulcers, hypertrophic hems, ankiloza, dislocations, etc.). Rehabilitation of burned is divided into three periods.
The first period of rehabilitation begins with the moment of recovery of an integument. A part of this period patients are in burn department, but are generally treated on an outpatient basis or in rehabilitation and a dignity. - hens. institutions. A problem of this period — as much as possible to recover function of joints by conservative treatment. The therapy directed to a rassasyvaniye or maturing of hems, acceleration of a deretraktion of the begot skin rags, overcoming artrogenny and myogenetic contractures is carried out. For this purpose the first 1 — 1,5 months carry out to lay down. physical culture, massage, mechanotherapy, resorptional therapy (pyrogenal, fonoforez hydrocortisone, ronidaz, lidaza, chemical opsin, chymotrypsin, vitreous, aloe, etc.). In the next 30 — 40 days use electrostimulation of muscles or conduct a course of balneological treatment.
Duration of the first period of rehabilitation of the patients who do not have deformations, contractures makes 1,5 — 2,5 months then they can get to work. At patients with contractures of the I—II degree this period makes from 5 — 6 months to 1 year. These patients can receive necessary treatment, carrying out nek-ry labor processes. If the carried-out therapy is effective, there is a rassasyvaniye of hems, amplitude of movements in joints increases, it is reasonable to continue conservative treatment. Patients with contractures have III—IV degrees, at to-rykh muscular, tendinous, joint and bone and joint changes, duration of the first period of rehabilitation, i.e. conservative treatment are expressed, makes from 2 — 3 to 6 months. The possibility of operational treatment in this case is defined not by extent of maturing of hems, but readiness of an organism to the forthcoming operation.
The second period is the period of surgical rehabilitation. It is carried out at the persons having contractures, ankiloza, dislocations and incomplete dislocations, hypertrophic and keloid cicatrixes, trophic ulcers, defects of bodies (lack of a nose, ears, fingers, brushes). A problem of this period — to eliminate contractures and deformations, to reduce extent of functional and cosmetic disturbances.
Recovery of the lost I or II fingers of a brush is possible by skin and bone plastics, free change of I or II fingers of foot by means of the microsurgical equipment (see. Microsurgery ), transpositions on a vascular leg less functionally important IV or V fingers of a brush. Total and subto-talny defects of a nose are eliminated by means of plastics with Filatov's stalk or a rotational rag from a forehead. At partial defects of wings of a nose use the Italian plastics (movement of a skin rag on a leg to the place of defect) a rag from a shoulder, free change of a part of an auricle, plastics a rag from a cheek (see. Rhinoplasty ).
Elimination of a cicatricial styazheniye is reached by a wide section or excision of hems throughout. Redressment (see) before achievement of full correction in a joint (extension, assignment, full removal) is at the same time carried out. At contractures of III and IV degrees excision of hems quite often did not possible to remove completely an extremity in functionally advantageous position since there are heavy secondary changes from muscles, sinews, joint and bone and joint changes. In similar cases use all known methods of orthopedic operational surgery: myotomies) at mobilization of humeral and coxofemoral joints — lengthening or simple crossing of sinews of sgibatel of a shoulder, hip, foot; Z-shaped lengthening of a sgibately and razgibately brush, sgibately foot; an osteotomy (see), osteosynthesis (see), artificial ankylosis (see) in functionally advantageous position; a ligamentokapsu-lotomiya, an arthroplasty elbow, knee, talocrural, interphalangeal joints of a brush (see. Arthroplasty ]); wedge-shaped, crescent resection of foot, etc. Possibly and imposing of distraktsionny devices (see Distraktsionno-kompressionnye devices) for gradual elimination of heavy tendinous and artrogenny contractures, dislocations and incomplete dislocations in knee, talocrural joints, at heavy contractures of a brush.
Closing the listed operations of wound defects which are formed at is made by skin plastics, to-ruyu, as a rule, carried out along with intervention on deep structures, more rare previously, in the form of kozhnopodkozhny plastics. The local skin plastics on the basis of the ways developed by A. A. Limberg is usually applied at elimination of cicatricial deformations of the I—II, the III degrees (fig. 10) are more rare. Free skin transplantation is carried out as independently, and at the combined plastics when there is a defect of integuments from 5 — 10 to 500 — 800 cm2. At the same time most often use thick skin rags (more than 0,6 — 0,7 mm) or the full-layer rags which are cut off by a dermatome.
During the closing of defects on the places which are exposed considerable funkts, loading (e.g., a bottom surface of foot), formation of bodies (a nose, ears, etc.) the Italian plastics or plastics is carried out by a bucket-handle graft; B. V. Petrovsky, V. S. Krylov (1976) with success apply for this purpose free change of kozhnopodkozhny rags, using the microsurgical equipment.
The third period of rehabilitation begins in 3 — 4 weeks after elimination of deformations and comes to an end after a complete recovery of functions of joints or the termination of increase of volume of movements in them under the influence of the held events. The most part of this period is the share of out-patient treatment again. At the same time use all means and methods of conservative treatment applied in the first period of rehabilitation.
Successful carrying out rehabilitation demands first of all medical examination of burn convalescents with local effects of O., disturbance of functions of internals for full or almost full elimination of the available disturbances. The leading place in system of rehabilitation belongs to burn departments and the centers, to-rye will organize and carry out medical examination, define character and the venue of rehabilitation.
Forecasting of an outcome of a thermal injury is based first of all on determination of the area and depth of the Lake. As a predictive indicator at adults Frank's index, and also an index of Bo can be used, to-ry is formed from the sum of total area of a burn as a percentage to the area of a body and age of the victim. At Frank's index to 30 units the forecast favorable, from 31 to 90 unit — rather favorable, from 91 to 120 unit — doubtful, St. 120 units — adverse. An index of Bo as simpler, the hl is applied. obr. in field conditions. At an index of Bo to 60 units the forecast favorable, from 61 to 80 unit — rather favorable, from 81 to 100 unit — doubtful, St. 100 units — adverse.
However the specified indexes can be considered only very approximately since exert impact on the result of thermal defeat character of the injuring agent, O.'s localization, and also the general condition of the victim. Most hard O. a flame, incendiary mixes which are especially followed by damage of airways proceed. At O. of the person, the heads and necks are more expressed the general and mental reactions. Being available to an injury patol, changes of cardiovascular system, a liver, kidneys, etc., especially at persons of advanced and senile age, burden a thermal injury and can be the main reason for a failure.
Very essential value for an outcome of a thermal injury has timeliness and adequacy to the given help: bystry suppression of the burning clothes, washing off of aggressive chemical connections from a body surface, imposing of a protective aseptic bandage; early intensive antishock care; the active operational treatment directed to bystreyshy compensation of the lost skin.
Use pathogenetic of reasonable ways of prevention and treatment allowed to lower a direct lethality at a burn disease. The lethality at superficial O. is estimated in shares of percent; at burn shock in many clinics it does not exceed 10 — 12%; the direct lethality at an acute burn toxaemia is sharply lowered. However according to decrease in a lethality in early terms of a burn disease the specific weight of a lethality in rather late terms, in particular in the period of a septicotoxemia increases. Development of sepsis calls into question the favorable forecast of a burn disease. Still there is high a lethality during the entire periods of a burn disease at widespread deep O.: at defeat of a half of a body surface and more only units of victims survive.
After the carried-out treatment and recovery of the lost integument the burn convalescent needs persistent and long psychological, social, medical and labor rehabilitation (see). The important place is taken by individual psychotherapy. Full holding rehabilitation actions allows to return up to 75% of convalescents to work.
Prevention burns, as well as other injuries, includes a wide range of questions. On production individual prevention consists in observance of a work-rest schedule, labor discipline, increase in culture of work, use of overalls. Public prevention consists in the scientific organization of work, training of workers in observance of safety regulationss, creation and implementation of safe cars, increase in level of technical condition of devices, the devices connected with the increased danger of thermal damages (heating, vent systems, blast furnaces, etc.), identification, barrier and providing with fire-prevention means of dangerous zones of work, etc.
Also broad promotion of knowledge among the population, in working collectives and schools on prevention and assistance at thermal defeats matters.
Features of burns of wartime and their stage treatment
In modern war with its mass weapons of destruction along with O., polutchenny during the fires, in the burning tanks and airplanes, will immeasurably increase the specific weight of O. caused by atomic weapons and incendiary mixes. Influences of light radiation of nuclear explosion can
result thermal damages of skin and eyes. Lakes of skin can result from direct action of light radiation on open body parts (primary O.) or from the lit-up clothes and surrounding objects (secondary O.). Primary O. at victims in Hiroshima and Nagasaki arose at the persons which were at distances to 3,7 km from epicenter of explosion. They were localized on the side of a body turned towards explosion, had a clear boundary on depth and extent. Because of very short exposure of thermal influence deep layers of skin and subjects of fabric usually remained unimpaired even if surface layers of skin a koa-rumble a failure is On a wedge, to a current these O. are similar to the damages caused by flash of an electric arch or explosions of combustible gases. Such superficial O. can meet only at nuclear explosions, small and medium on power, at to-rykh time of action of light radiation is short. At megaton explosions when light radiation lasts tens of seconds, there can be deep thermal defeats. Primary and secondary O. from light radiation practically do not differ from O. which are found in peace time.
Defeats of an organ of sight are diverse — from temporary dazzle to O. of an eyeground. Temporary dazzle (disadaptation) — reversible disturbance of visual functions in response to influence of a bright light source. It comes right after explosion. Visual functions are lost, ocular spectrums in the form of color circles or flashing before eyes of color «front sights» appear. There can be unpleasant feelings in eyes, pain, a spasm a century. Several minutes later the syndrome of dazzle begins to weaken, and sight is completely recovered. The nuclear ophthalmia (an acute keratoconjunctivitis) is characterized by the eye pains, a photophobia and dacryagogues developing in several hours after explosion. At the same time the hyperemia and a chemosis, sometimes opacification of a cornea is noted. Lake of an eyeground (chorioretinal O.) are a new type of fighting defeat of an organ of sight. Because of the focusing properties of optical system of an eye these O. can arise at considerable distance from epicenter of explosion. Chorioretinal O.'s influence on visual functions depends on weight of defeat, and, above all — on its localization on an eyeground. O. in the field of an optic disk and a macula lutea are especially dangerous.
As a result of defeat by incendiary mixes (see) there can be contact and remote O. of skin, a term oh of damage of a respiratory organs, overheating of an organism, systemic poisoning by combustion products, and also psychological frustration. Contact influence of incendiary mix usually causes defeat not only all thickness of skin, but also the subject muscles, sinews, bones, joints. Often there is a carbonization of auricles, a nose, lips, fingers. It is accompanied by the unconsciousness arising at many victims or the shock and an adynamia developing after the short period of strong mental and motor excitement. First of all open parts of a body — a face, hands, however because of ignition of clothes are surprised, actions of a flame of the fires arise also skin of a trunk, various on O.'s depth. The specified factors are explained as the high lethality observed at the time of defeat and a heavy current of the entire periods of the burn disease caused by effect of incendiary mix.
Character, volume and content of the help in the center of mass defeats (see), and at stages of medical evacuation (see. Stage treatment ) at O. are defined by the following peculiar features of this type of an injury: dependence of weight of a burn disease on prevalence and depth of defeat of fabrics; possibility of a combination of O. of skin to primary O. of a respiratory organs and poisoning with combustion products; big, in comparison with traumatic shock, duration of burn shock (to 24 — 72 hours); more later, than at wounds, development local inf. complications; a possibility of performing surgeries on recovery of the lost integument in the remote terms after a thermal injury.
The first medical aid at the time of an injury and right after it appears generally as well as in peace time. If it is traumatized at the fire indoors or in the center of defeat by incendiary mix, the victim is brought as soon as possible or taken out from an area of coverage of fire and smoke. In cases of the asphyxia which is quite often arising at thermochemical influence or poisoning with combustion products clear an oral cavity and throats of slime and emetic masses and start an artificial respiration. To the victim enter anesthetic from unit-dose syringe (see), the burned surfaces close aseptic bandages. Any manipulations on a burn wound and topical administration of medicamentous means during the rendering the first medical aid are inexpedient. From the center of defeat first of all take out burned, being in a serious condition. All of them, especially in cold season, it is necessary to cover with warm clothes to prevent overcooling. Then burned direct to PMP (see. Regimental medical aid station ).
On a sorting post of PMP allocate the integuments burned with pollution and regimentals with products of nuclear explosion, to-rykh later the corresponding sanitary cleaning together with another burned send to a reception and classifying section. Here carry out medical sorting without removal of bandages, in process the cut is allocated by three sorting groups of struck. During the sorting use simpler, than Frank's index, an index of Bo.
Carry victims with extremely heavy O. occupying more than 60% of a body surface to the first sorting group (with deep O. — more than 50%); index of Bo more than 100 pieces. At such defeats victims are usually in a terminal state or a condition of an agony. Carry out by him the symptomatic treatment sent to hl. obr. on removal of a pain syndrome.
Carry victims with the heavy O. occupying from 20 to 60% of a body surface to the second sorting group (with deep O. — St. 10%, but no more than 50%); here include the respiratory tracts which were injured with O.; index of Bo from 60 to 100 pieces. At these victims about final shock usually develops. On PMP to them carry out the elementary antishock actions (introduction of analgetics, cardiovascular and respiratory means, inhalation of oxygen, warming, drink of alkaline and salt solution, at an opportunity — injection of transfusion environments). At defeat of a respiratory organs carry out bilateral vagosympathetic novocainic blockade; the tracheostomy is carried out only at the phenomena of asphyxia. Poisoned with carbon monoxide enter hromosmon, glucose with ascorbic to - that. At deep circular O. of extremities and a thorax in several places cut a dense scab.
To the third sorting group carry easily burned, capable to movement and self-service, at to-rykh O. occupy up to 20% of a body surface (deep O. — no more than 10%), O. are absent respiratory tracts and the phenomena of burn shock; an index of Bo to 60 pieces.
Everything burned apply primary bandages PMP if they were not imposed earlier, at an opportunity enter antibiotics, antitetanic serum and tetanic the light radiation, anatoksinony At defeat of an organ of sight, in eyes dig in solution of cocaine or Dicainum. From group of easily burned allocate victims with the term of treatment 2 — 3 days, to-rykh leave on PMP, evacuate the others on a stage of the qualified medical aid; first of all and the most sparing type of transport send the victims who are in state of shock.
At a stage of the qualified medical aid in MSB (see. Medical and sanitary battalion ) the arsenal of the applied means and methods of treatment of burned extends. Antishock therapy has complex character and is aimed at providing psychoemotional rest of the patient (the anesthetizing drugs, neuroleptics); maintenance of the necessary oxygen mode (oxygenotherapy, artificial ventilation of the lungs, Tracheostomy); treatment of the broken acid-base balance (laktasol, the guide-rokarbonat of sodium), normalization of a water salt metabolism and secretory function of kidneys (osmotic diuretics) and, the main thing, on correction disturbance of blood circulation by means of administration of medicamentous drugs for maintenance of cordial activity and normalization of a vascular tone, and also infuzi-onno-transfusion environments. For recovery of disturbances of a hemodynamics here, in addition to blood substitutes, widely use plasma, albumine, a protein, and if necessary and transfusion of stored blood. Antishock therapy, depending on a fighting and medical situation, is carried out several hours (the reduced volume) or during the entire period of burn shock (full volume). One of the most informative efficiency factors of the carried-out treatment of burn shock is the amount of the emitted urine, a cut define by a constant catheter. If in 1 hour of urine not less than 0,5 ml/kg are allocated, then it is possible to hope for the favorable result of treatment. Indicators of elimination of shock are normalization of a hemodynamics, a diuresis and fervescence to subfebrile. If there is a need of evacuation struck, then at heavy shock it is reasonable to carry out infusional therapy to time of their transportation.
Burned with everything, depending on their state and carried out at the previous stage of treatment, according to indications correct (or replace with medical) primary bandages, enter analgetics, cardiacs, antibiotics, etc.
During the carrying out evacuation and transport sorting victims with limited superficial O. with the term of treatment to 10 days are late in team of the recovering MSB. The others laid down-koobozhzhennykh direct in hospital for lightly wounded (see) or in all-surgical hospital. Tyazhe-loobozhzhennykh, including with chorioretinal O., evacuate in corresponding specialized to lay down. institutions of hospital base of the front.
O.'s treatment in system medical services GO are held also by the principle of stage treatment. After rendering the first medical aid in the center of mass defeat burned, first of all children, send to OPM (see Group of first aid). At this stage of medical evacuation burned in a terminal state (the first sorting group) send for a symptomatic treatment to hospital department of OPM. Evacuations they, as a rule, are not subject. Carry out by Tyazheloobozh-zhenny (the second sorting group) antishock therapy, on burn wounds impose to lay down. bandages, enter anesthetics, cardiovascular means and as far as possible — antibiotics, antitetanic serum, tetanic anatoksinony If necessary to them carry out a tracheostomy, a decompressive necrotomy, etc. Easily burned (the third sorting group) according to indications appoint the elementary treatment (see above), then would evacuate them in a country zone or transfer to out-patient treatment. In specialized a country zone by the victim would carry out the general treatment of all stages of a burn disease, its complications and associated diseases, and also treatment of burn wounds for primary toilet to operational recovery of the lost integument and operational treatment of effects of O.
Burns at children
Burns at children — one of the most frequent and life-threatening damages, effects to-rogo can serve as the reason of an invalidism for the rest of life.
According to N. D. Kazantseva, are the main reasons for O. at children hit on skin of hot liquids (69,1%) and hiting at to the heated metal objects (18,4%). O. of this etiology meet at children aged from 1 up to 3 years more often. The flame as O.'s reason is on the third place. Focal lesion and a burn disease in general develop on the same main patterns, as at adults, but in connection with anatomic and functional immaturity of a children's organism of change are shown more intensively, than at adults. Skin of children is thin, gentle, has the developed network circulatory and limf, vessels (i.e. has high thermal conductivity) therefore its deep O. arises at action of such thermal factor, to-ry at the adult will cause only superficial damage.
The burn disease at children, especially younger age groups, can develop at defeat of only 5% of a body surface and proceeds the heavier, than the age of the child is younger. Critical it is considered to be deep O. on the area of 10% of a body surface. The course of a burn disease and the forecast worsen in the presence of associated diseases, and also in cases of overdue and defective treatment. Because the regulating and compensatory mechanisms at small children are developed insufficiently, the sudden, not giving in to medicamentous correction aggravation of symptoms of the child can come in a few minutes after an injury.
The clinical picture
At children under 3 years shock can develop at O. on the area of 3 — 5% of a body surface, and at more seniors — on the area of 5 — 10% of a body surface. Feature of burn shock at children is heavier current, than at vzros ly. At children there occur changes in water and electrolytic and proteinaceous balance quicker, to-rye lead to frustration of a hemodynamics, microcirculation, disturbances of exchange processes. At them quickly there comes the hypovolemia, cellular, and in hard cases and the general dehydration, haemo concentration, the general naruchpeniye of blood circulation with disorder of functions of vitals, a hypoxia, a metabolic acidosis, a hypothermia, an oliguria and an anury. In a wedge, a picture attract attention excitement, sometimes with convulsive attacks, replaced by block, a fever with twitching of mimic muscles, pallor of skin, cyanosis of a nasolabial triangle, thirst, nausea, vomiting. Short wind, tachycardia (to 140 — 160 blows in 1 min.), premature ventricular contraction are expressed. One of features of burn shock at children of younger age groups is hypertensia: according to L. B. Rozin et al., at 28 — 35% of sick ABP in the period of shock on 20 — 30 mm of mercury. exceeds vozrastnucho norm. Persistent hypertensia at heavy shock can be a sign of the beginning wet brain. Extremely hard shock proceeds at newborns.
The acute burn toxaemia comes usually after short-term satisfactory health of the child. It proceeds against the background of the hyperthermia (to 40 °) which is not seldom followed by nonsense, confusion of consciousness, spasms, a sleep disorder and appetite and development of complications — pneumonia, acute erosive and ulcer gastritis, toxic hepatitis, myocarditis, etc. In this period of a burn disease the hypoproteinemia and a disproteinemia quickly accrues. As a result of an erythrocytolysis and oppression of function of marrow the quantity of erythrocytes decreases, anemia develops. At the same time the leukocytosis and shift in a leukocytic formula to the left with firmness keeps. The period of an acute burn toxaemia at children proceeds from 2 to 10 days.
The period of a burn septicotoxemia begins with the moment of suppuration of a burn wound. The multiple structurally functional internal injuries and systems which are followed by disturbance of all types of exchange and leading to long frustration anatomo-fiziol are characteristic of a septicotoxemia. processes of the growing organism. From a wedge, the signs characteristic of this period, it is possible to allocate a sleep disorder, an emotional depression, irritability, lack of appetite, and also remittiruyushchy type of fever with razma-be rude to 2 °.
The period of reconvalescence at children proceeds with bright positive dynamics: clearly the mood changes, the dream improves, there is an appetite, body temperature decreases to subfebrile, and then and is normalized; in wounds there is active regional and insular epithelization, the dermotransplantata replaced a miss expand.
Complications of a burn disease at children most often develop in the period of a septikotoksemna. At the same time into the forefront on frequency such complications as act otitises (see), ulcer stomatitis (see), recurrent pneumonia, limfangiit (see), lymphadenitis (see), abscesses, phlegmons, and also nephrite, hepatitis, etc.
One of the heaviest complications of this period, as well as at adults, is burn exhaustion, a cut most often develops in cases of irrational therapy. Are characteristic of burn exhaustion sharply negative nitrogenous balance and as a result of it is strong weight loss, development of a tertiary necrosis of wounds, a neza-zhivleniye of donor sites and emergence of decubituses. Against the background of burn exhaustion sepsis from a hmnozhestvenny-ma the piyemichesky centers in internals quite often quickly develops. The age of the child, the more imperfectly at it mechanisms immunol is less, protection and the more often generalization of an infection and sepsis develops.
In addition to the specified complications, at children changes from hemadens can be also observed, to-rykh the stunt of the child, a delay of puberty is caused. Disturbances from mentality at children are expressed much more sharply, than at adults. From complications of local character keloid cicatrixes and dermatogenny cicatricial contractures of extremities and a neck are quite often observed.
The diagnosis of weight of thermal defeats at children is based on the same data, as at adults. O. Square shall be defined with age of the child for what it is possible to use Wallace's data (A. Wallace, 1951) — see the table.
Table. The surface area of various parts of a body at children depending on their age as a percentage to the general body surface [according to A. Wallace]
First aid at O. consists in the termination of impact of the thermal agent on skin: at O. a flame — clearing of the burning clothes by a zavertyvaniye of the child in dense fabric, at O. hot liquids — bystry washing of the burned areas a cold water. After that it is necessary to take off carefully from the burned child clothes, to wrap it in a pure sheet, to give inside a half or I kiss (depending on age) a tablet of analginum and to call the ambulance. At children more often than adults, have indications to infusional therapy during transportation in to lay down. establishment. At receipt in a hospital to children hold the same events, as the adult (a toilet of wounds, imposing of a bandage with antiseptic agents, administration of antitetanic serum and tetanic anatoxin).
All children with O. on the area more than 10%, and children up to 3 years — more than 3 — 5% of a body surface need antishock therapy. The most intensive loss and redistribution of liquid in an organism at children is observed in the first 12 — 18 hours (especially in the first 8 hours) therefore infusional environments into the first 8 hours enter twice more, than in other 16 hours of days.
Calculation of daily quantity of the infusional environments necessary for treatment of burn shock at children, is made on a formula: 3 ml>< the body weight (kg) are X O. Square (%). A half of this dose is entered into the first the 8th hour. In the beginning intravenously kapelno solution of novocaine (from 30 to 150 ml), ringer-lactat solution (laktasol), 4 — 5% solution of hydrosodium carbonate, osmotic diuretics, by the end of the first days — albumine, plasma, other proteins enter 0,1%. The next days the hemotransfusion is reasonable. Besides, in each 8 — 12 hours make injections cardiotonic, anesthetics, the desensibilizing means and vitamins. According to indications apply hormones and blood substitutes. Widely use inhalations of the moistened oxygen. In the absence of vomiting it is possible to allow to drink in the small portions alkaline and salt solutions, mineral waters (Borzhom, Yessentuki No. 20, etc.).
Efficiency of antishock therapy is checked, as well as at adults, hl. obr. on intensity of a diuresis. Depending on age of the child normal the diuresis can make from 8 — 10 ml at 1 o'clock (at children till 1 year) to 30 — 50 ml at 1 o'clock (children have 11 — 14 years).
In the period of an acute burn toxaemia, a septikotoksemna and reconvalescence transfuse to patients blood, pour in serum and plasma (on a nek-eye to data, the most effective from burn convalescents), albumine, low-molecular disintoxication means, the balanced salt solutions. Constant administration of redoxons, the groups B hyposensibilizing and antipyretics is necessary. Right after an exit of the child from shock begin introduction of antibiotics of a broad spectrum of activity, and since suppuration of a wound antibiotics apply taking into account sensitivity of microflora to them. For increase in reactivity of an organism appoint gamma-globulin. In treatment of the burned children the healthy, good nutrition with enough easily assimilable proteins, and also salts and vitamins is of very great importance.
Topical treatment of O. is carried out by the same principles, as at adults. At children early autotransplantation as on a wound after a necretomy (on 2 — 6-y day), and on granulation can be applied (3 — 4 weeks). In need of additional skin transplantations on granulation they are carried out every 7 — 10 days. The best results are yielded by change of mesh skin rags 0,1 — 0,15 mm thick,
for the purpose of prevention of a contracture from the first days of treatment the extremity shall be laid in a provision of extension, fingers of hands at O. of brushes shall be slightly bent. Prevention of rigidity is performed by early and regular trainings to lay down. physical culture: to children of preschool and school age preferential active movements are shown, to children of babyhood — passive, passive and active and reflex exercises in combination with massage.
After healing of burns at children still the long time proceeds structural and functional, organ and system rehabilitation. In this regard children with O.'s effects are subject to medical examination before the end of growth of an organism.
Outcomes of a burn disease at children, as well as at adults, hl are defined. obr. deep O.'s area; the complications which are also often developing at children (otitis, dyspepsia, hepatitis, phlegmons and especially pneumonia) have significant effect. The lethality at children chest and babyhood is higher, than at children of the senior age groups, and at the last it practically same, as at adults with thermal injuries, comparable on weight. Burn wounds at children heal quicker and with more limited formation of hems, including keloid. Existence of such hems, especially at rapid growth of the child, promotes formation of deformations and contractures.
Beam O. — the defeats resulting from local impact on skin of ionizing radiation.
The etiology and a pathogeny
beam O.' Character depends on an ionizing radiation dose (see), features of space and its temporary distribution (see. Time factor of radiation ), and also from the general condition of an organism. The low-energy x-ray emission and beta particles getting into fabrics on insignificant depth cause damages in limits of thickness of skin. High-energy x-ray and the gamma radiations, neutrons having bigger penetration make impact not only on skin, but also on glubzhelezhashchy fabrics. Radiation of skin
is resulted by damage of its cells (including under certain conditions and cells of a basal layer of epidermis) with formation of toxic decomposition products of fabrics. In the subsequent permeability of cellular and fabric membranes is broken, capillaries and nerve terminations are damaged. All this eventually leads to change of a trophicity, dominance of processes of disintegration of fabrics over processes of regeneration and a reparation (see. Dermatitis , dermatitis from ionizing radiation; Radial illness, pathogeny, pathological anatomy ).
Beam O. can be a consequence of local reradiation of fabrics at radiation therapy (see), failures of atomic reactors, hit on skin of radioisotopes. In the conditions of use of nuclear weapon, at drop-out of radioactive fallout beam O.' emergence on the unprotected skin is possible. At simultaneous general gamma and neutron irradiation of an organism development of the combined defeat is possible. In such cases beam O. will develop against the background of a radial illness.
Beam O.' current is characterized by certain periods. Allocate four periods of development of beam Lakes. The first period — early beam reaction — comes to light in several hours or days after defeat and is characterized by emergence of an erythema. The erythema gradually disappears and the second comes — the eclipse period, in time to-rogo external manifestations of defeat it is not observed. Duration of this period (from several hours to several days, even weeks) that is shorter, than defeat is heavier. In the third period — an acute inflammation — there is a secondary erythema, emergence of bubbles, erosion and, at last, beam ulcers is possible. This period proceeds from several weeks to several months and passes into the completing, fourth period — recovery. The erythema begins to disappear gradually, there occurs healing of erosion and ulcers, however on site defeats are noted trophic frustration (tsvetn. fig. 13 — 16).
Most of researchers adheres to kliniko-anatomic classification of weight of beam O., according to a cut distinguish three extents of radiation injuries.
Beam burns of the I extent (lungs) arise at an exposure dose 800 — 1200 is glad (8 — 12 Gr). Early reaction usually is absent, the eclipse period more than 2 weeks. In the third period the erythema, small hypostasis develops, burning and an itch in an affected area appear. Later 1 — 2 week the specified phenomena abate. On site defeats the hair loss, a peeling and pigmentation of brown color is noted.
Beam burns of the II (moderately severe) degree arise at radiation in a dose of 1200 — 2000rad (12 — 20 Gr). Early reaction is, as a rule, characterized by emergence of an easy skoroprokhodyashchy erythema. Sometimes weakness, a headache, nausea develops. The eclipse period lasts 1 — 2 week. In the period of an acute inflammation there is an expressed erythema and hypostasis, taking not only skin, but also glubzhelezhashchy fabrics. On site an erythema the small, filled with transparent liquid bubbles are formed, to-rye gradually increase and merge among themselves. During the opening of bubbles the bright red erosive and ulcer surface is bared. During this period at the patient body temperature can increase, the leukocytosis usually develops, pains in the field of defeat amplify. The period of recovery proceeds 4 — 6 weeks and more. Erosion and superficial ulcerations are epithelized, skin of these sites becomes thinner and pigmented; the hyperkeratosis and teleangiectasias are sometimes noted.
Beam burns of the III degree (heavy) arise at radiation in a dose more than 2000 is glad (more than 20 Gr). Quickly early reaction in the form of hypostasis and a painful erythema develops, sticks to edge to 2 days. The eclipse period is short — less than 1 week. In the third period develop a hyperemia, swelled, sensitivity of affected areas goes down. There are dot hemorrhages and the centers of a necrosis of crimson-brown or black color. At high doses of radiation it is damaged and not only skin, but also hypodermic cellulose, a fascia, a muscle and even a bone perishes, take place phlebitis (see) and a vein thrombosis (see the Phlebothrombosis); the granulyatsionny shaft is, as a rule, expressed poorly. Rejection of devitalized fabrics is slowed sharply down. The formed erosion and beam ulcers possess a torpid current, often recur. At patients fever, a high leukocytosis is observed, the pain syndrome gaining character is especially sharply shown kauzalgiya (see). The period of recovery drags on for many months. On site the healed ulcers unstable atrophic or hypertrophic hems form, on them the ulcers inclined to a malignancy are often formed.
At the superficial beam O. which are not followed by the general reaction of an organism is shown only topical treatment. Big bubbles open. Apply salve dressings with antiseptic agents, antibiotics, corticosteroid hormones the struck surface or the wet drying bandages containing antibacterial drugs. Under bandages small bubbles dry up, on their place the scab is formed, the burn wound is epithelized.
At heavier beam O. the general is necessary complex and local conservative, and in some cases operational treatment. To the patient make novocainic blockade (see) — vagosympathetic, futlyarny or short, repeating it in 4 — 5 days to the first a wedge, signs of destruction of the struck fabrics. For removal of pain, reduction of hypostasis and disintegration of fabrics appoint Contrykal, Tzalolum, Trasylolum, and for improvement of a fabric hemodynamics and utilization of oxygen — predentin, komplamin, solkoserit. Apply also antihistaminic means (isopromethazine, Dimedrol, Suprastinum, etc.). At emergence of symptoms of intoxication intravenous drop administration of a reopoliglyukin, polyvinylpirrolidone is shown. Education on site of beam O. of gangrene, sites of a necrosis, ulcers testifies to need of operational treatment.
Operative measure is preceded by the general and intensive topical treatment directed to suppression of contagiums (a bandage with hypertensive solution of sodium chloride, streptocides, antibiotics). From operational methods the method of single-step excision of an affected area with imposing of primary seams is effective. However he is possible at the limited beam O. which are localized on an abdominal wall, spin, a hip, i.e. on places where in patol, process large arteries, nervous trunks, sinews are not involved. Otherwise make skin transplantation on granulation after preparation by their salve dressings with solkoserily, Ftorokortum, etc. At the same time the best effect is reached by change of a skin and hypodermic rag on a leg, to-ruyu cross by the end of the 3rd week. At very heavy beam O. to an extremity with an extensive necrosis of soft tissues, with an exposure of bones, sequestration of sinews, and also at a gangrenosis it is shown amputation (see). In late terms after beam O. at it is long not healing beam ulcers with existence of vicious hands make their excision. The formed defect is closed by means of plastics local fabrics, free skin transplantation, a bucket-handle graft (tsvetn, the tab., Art. 240 — 241, fig. 17, 18), the Italian plastics (fig. 11) of a pla by means of the combined plastics. At all stages of operational treatment of beam O. carry out necessary general therapy of the victim: enter analgetics, antibiotics, vitamins, transfuse blood and its drugs, etc.
Rehabilitation of victims with beam O. is carried out by the same principles, as at thermal burns.
Forecast generally is defined by the area and depth of defeat of fabrics. With other things being equal heavier the beam O. caused gamma and neutron than beta radiation proceed. The previous diseases, the exhaustion, overfatigues reducing resistance of an organism to action of ionizing radiation have an adverse effect on the course of defeats. Especially adversely beam O. against the background of a radial illness when a hemopoiesis is broken proceed, the hemorrhagic syndrome develops and the general body resistance decreases. According to Held (Held, 1961), 30% of beam ulcers are inclined to a malignancy.
are caused by Chemical O. strong inorganic to-tami (nitric, sulfuric, salt, hydrofluoric, etc.), alkalis (caustic potassium, caustic sodium, quicklime, the caustic soda), and also salts of nek-ry heavy metals (silver nitrate, zinc chloride, aluminum body to a pcheskpa of connection, etc.). Most often chemical O. are surprised open body parts, however at accidental intake to - t and alkalis O. of a mucous membrane of an oral cavity and a gullet are possible. Under action to - the t changes a condition of colloids of cells, there is dehydration and coagulation of fabrics, there occurs their death as a dry necrosis. Alkalis at interaction with proteins form alkaline albuminates, saponify fats that promotes development of a wet necrosis. Salts of heavy metals on the mechanism of action stand closer to - there.
Chemical O., as well as thermal, are subdivided on depth of defeat of fabrics into four degrees. However at chemical burns of the II degree bubbles are not formed. Chemical O. usually happen limited on the area, to a clear boundary of defeat and education on the periphery of smudges — traces of spreading of chemical substance. The burn disease at chemical O. develops seldom, however the compounds of some aggressive substances which are formed in a wound, hl. obr. to - t, can be soaked up in blood, causing intoxication.
Chemical O.'s weight significantly depends on the term of rendering medical aid, the main objective a cut consists in as much as possible bystry removal (neutralization) of the aggressive substance which got on skin or in went. - kish. path. Best of all it is reached by washing of sites of defeat (gastric lavage) a large amount of cold running water. If washing is begun right after an injury, it shall proceed 10 — 15 min., with the overdue help — not less than 40 — 60 min., and at defeat to - that is hydrofluoric within 2 — 3 hour. Criterion of sufficiency of washing of an affected area is disappearance of a smell of aggressive substance. It is impossible to apply washing by water at O. caused by organic compounds of aluminum since these substances at interaction with water ignite. They should be deleted from integuments with kerosene, gasoline, alcohol.
After careful washing of an affected area apply chemical neutralization of aggressive substances: at O. to-tami — 2 — 3% solution of hydrosodium carbonate, at O. alkalis — weak to-tami; at O. lime — 20% solution of sugar in the form of lotions, at O. carbolic to - that are by means of bandages with glycerin and lime milk, at O. to - they are chromic 5% solution of thiosulphate (hyposulphite) of sodium, at O. salts of heavy metals — 4 — 5% solution of hydrosodium carbonate, at O. phosphorus — by means of bandages from 5% solution of copper sulfate.
In case of chemical O. of a gullet apply warm and wet inhalations, an induktote-rapiya in a slaboteplovy dosage to removal of pains, a spasm, an electrophoresis of novocaine on interscapular area and area of a breast.
The toilet of burn surfaces at influence of chemical substances is carried out by the general rules. However at O. it shall be carried out by phosphorus in the dark room since the remains of the phosphorus which is in a wound on light are not visible. Further superficial chemical O., as well as thermal, treat conservatively, and at deep O. operational recovery of the lost integument usually is required.
Electric O. arise from action of electric current, contact to-rogo with fabrics, first of all with skin, leads to transition of electrical energy in thermal (heat of Joule) therefore there occurs coagulation and destruction of fabrics (see. Electric trauma ).
Burns in the medicolegal relation
O. in court. - the medical relation matter at a research of corpses and survey of living persons. Most often the persons which are in alcohol intoxication, an artificial or natural dream are exposed to influence of the thermal and volumetric factors causing O. From thermal factors the flame, hot liquids, from chemical — acids and alkalis have the greatest value.
Specifics of manifestation of O. in many respects depend on character of the striking factor. So, the flame causes O. of all degrees, leaving usually a soot on skin, causing oiale-ny a hair and a carbonization of nails. Formation of superficial damages to a type of potek, including and in the places closed by clothes is characteristic of O. hot liquids; at the same time hair, as a rule, are not injured, in the field of defeat it is possible to find traces of liquid (pitch, tea etc.), a cut Lakes are caused. Contact O. have the form of the heated subject which caused them. Hot gases cause O. of a respiratory organs. At chemical O. the scab of coloring, specific to this aggressive substance, is formed, there are no bubbles. These data help at court. - medical examination to reveal a source of defeat, however also other laboratory methods of a research of bodies and fabrics have crucial importance judicial and chemical.
Death at O. comes from various reasons (shock, intoxication, sepsis, burn exhaustion, pneumonia, etc.).
At survey of living persons O.'s degree, their prevalence define, being guided by a wedge, signs (see above). More often the expert deals with O.'s combination of various degree. Court. - medical qualification of severity of injuries is made according to the «Rules of medicolegal definition of severity of injuries» existing in all territory of the USSR since April 1, 1979. Burns of IIIB and the IV degree on the square exceeding 15% of a body surface, burns of IIIA of degree — on the square making 20% of a body surface, and burns of the II degree occupying 30% of a body surface, and also O. of the smaller area, but followed by development of heavy shock, of a respiratory organs are qualified by O. as heavy injuries, life-threatening at the time of emergence. At the same time it is considered that the persons who had a burn disease, long time or can have patol, changes from internals, hems, contractures that leads to temporary or full disability or to an indelible disfiguration of the person (see. Obezobrazheniye ). Uncomplicated O. are estimated as well by criterion of duration of disorder of health. Similarly qualify O. chemical connections. They even at the small area of defeat can be life-threatening at the time of drawing owing to all-toxic effect of aggressive substance.
At a research of corpses it is necessary to remember that outward of O. received during lifetime after death changes. Sites of a hyperemia become more pale than not burned skin, O. Square decreases a little. At burns of the II degree skin gets the pergament density and henna-red color, on cuts blood does not act. At burns of the III degree necrotic sites get gray coloring.
The court is particularly complex. - medical examination of the corpses found in the place of the fires. First of all it is necessary to resolve an issue of an intravital or posthumous origin of the Lake.
It is considered that existence of the unimpaired or low-injured skin in places of the folds of the person which are formed at a zazhmurivaniye of eyes testifies about it is intravital the received O. (fig. 12). About same tells O.'s presence of mucous membranes of a mouth, a throat, a throat, a trachea and large bronchial tubes. Detection of a large number of a soot on a mucous membrane of respiratory tracts, including the smallest bronchial tubes, and also in air cells, indicates aspiration of smoke and intravital influence of a flame. Existence of a soot is defined by a stereomicro-skoppchesky research of prints from a mucous membrane of respiratory tracts or usual microscopy. At putrefactive changes of a corpse it is reasonable to use photography in infrared beams.
Detection of carboxyhaemoglobin in the blood taken from deep veins or heart, can also serve intravital a valuable indicator of the received O. as at inhalation of carbon monoxide during the fire the amount of carboxyhaemoglobin reaches 60% and more, and at posthumous penetration of carbon monoxide into cadaveric blood — does not exceed 20%.
A certain value has gistol. a research of the burned fabrics and bodies. In case of intravital O. in the place of defeat a capillary and arterial hyperemia, staz, hypostasis, hemorrhages, scraps of elastic fibers, cellular infiltration, a pulling of kernels and cells of basal and acanthceous layers of epidermis, dystrophic and necrotic changes in epidermis and a derma, emulsification of fat in hypodermic cellulose are observed. It is necessary to consider, however, that this gistol, the picture can meet also at the posthumous O. caused at once or as soon as possible after approach of death that is connected with the period of experience of fabrics. In these cases pay attention that at intravital O. in liquid of bubbles a large number of leukocytes, fibrin, protein usually is defined; in the damaged sites arterial blood clots are formed, the regional arrangement and emigration of leukocytes, and also reactive and dystrophic and necrotic changes of peripheral nerves in skin and muscles are defined.
At inhalation of a hot air rather quickly there are dystrophic and necrotic changes in nervous cells of a throat, trachea, bronchial tubes, in cells of a cover epithelium, a submucosa and a muscular coat preceding the inflammatory phenomena. Also the phenomena of a circulatory disturbance in airways and lungs, a bronchospasm, dystrophic changes in a myocardium, kidneys, a liver are defined. An essential sign of intravital O. is the fatty embolism of lungs, existence of fine particles of coal in blood vessels of internals, in star-shaped endotheliocytes of a liver and cytoplasm of leukocytes. A certain diagnostic value has development of an acute hemoglobinuric nephrosis if at the same time there is no syndrome of long crush (see. Traumatic toxicosis ).
At a research of the burned (charred) corpses posthumous epidural hematomas can be found, to-rye are formed owing to wrinkling and amotio of a firm meninx from an inner surface of a skull and the subsequent hemorrhage. These hemorrhages usually have the crescent form whereas intravital — spindle-shaped; at posthumous hematomas between parcels of blood and a firm meninx there is a space filled with liquid blood, at intravital — the firm meninx densely prilezhit to a parcel. The carbonization causes destruction of walls of perigastriums and the strengthened evaporation of liquid that leads to considerable reduction of volume of internals and all corpse. At a tension of the burned skin the cracks and gaps with smooth edges and the acute ends reminding cut wounds, however they superficial, as a rule, without damage of hypodermic cellulose quite often are formed.
Under the influence of high temperature the corpse accepts a peculiar pose — a pose of the boxer that is connected with loss of moisture and coagulation of protein of muscles — a so-called thermal okocheneniye, at Krom sgibatel as the strongest muscles, fix hands and legs in the provision of bending. Consider that this phenomenon of a posthumous origin.
The combination of intravital and posthumous action of a flame therefore explore various sites of a burn surface and control sites of the unimpaired fabrics is possible.
At sharply expressed obgorann an identification of a corpse it is extremely complicated. At the same time consider specific features of teeth (existence of caries, prostheses, seals, etc.), study the available hems of skin, birthmarks, the remains of clothes and other special signs. By the remained parts of a corpse and on bones resolve an issue of gender and age. For this purpose carry out rentgenol, a research of bones, with the help to-rogo also existence of intravital changes of bones, traces of damages establish.
Pay attention to existence of the signs indicating possible other cause of death (heart attacks, strangulyatsionny furrows, etc.). If as a result of burning of a corpse there were pieces of a bone tissue and ashes, it is necessary to make comparative and anatomic, radiographic and microscopic examination. At the same time there can be useful methods of infrared spectroscopy (see) and an issue spectral analysis (see).
In some cases it is necessary to carry out differential diagnosis of O. with the changes of skin caused by influence of chemical substances (kerosene, gasoline, etc.), and also skin diseases, freezing injuries, etc.
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B. S. Vikhriyev, V. H. Zhizhin, E. Baking, H. E. Povetyana, S. A. Polishchuk, V. K. Sologub; V. P. Bogachenko, G. V. Nikolaev (psikhiat.), N. A. Vladimirova (fizioter.), M. G. Grigoriev, V. A. Lavrov (it is put. hir.), R. I. Kai, D. S. Sarkisov (stalemate. An.), M. N. Farshatov (soldier.), N. A. Fedorov (stalemate. physical.), P. P. Shirinsky (court.).