Infusion therapy of burn patients. Method for determining the optimal volume of infusion therapy in the treatment of burns

All patients admitted to the department from a fire are prescribed inhalation of 100% oxygen (there is a possibility of carbon monoxide poisoning). If necessary, transfer the patient to controlled breathing.

Attention. because of high risk cardiac arrhythmias, depolarizing relaxants should not be used during tracheal intubation (with severe burns - for 2 years). The lungs with massive burns are severely affected, therefore, sparing modes of mechanical ventilation (artificial lung ventilation) are used.

If there are burns to the head, trunk, upper respiratory tract, in no case do not postpone tracheal intubation "for later." The rapid increase in edema at the burn site after 1-3 hours will make this procedure extremely difficult to perform. use warm blankets or a special heat-insulating bandage to prevent hypothermia of the patient. Venous access should provide a high rate of infusion. Central venous access allows for more precise tempo control infusion therapy.

Using the "rule of nines", doctors determine the area of ​​the burn: Head 9%. the front of chest - 9%.

• The back of the chest - 9%.
• Upper limb - 9%.
• Belly - 9%.
• Loin - 9%.
• Lower limb - 18%.
• Perineum - 1%;
• In patients with a burn > 20% of the body surface, place a urinary catheter.

Infusion therapy on the first day

Infusion therapy is started as early as possible. Estimated daily volume (V) of infusion therapy is calculated by the formula Parkland: V ml = burn area in % × body weight in kg × 4.

If the burn is caused by electric current, or there is a burn of the upper respiratory tract, the volume of infusion therapy is increased by 30-50%. Infusion therapy is carried out continuously(NB!) during the day, varying the speed and quality of the infusion. Focusing on the stabilization of hemodynamics and the rate of diuresis - should be> 0.5 ml / kg / hour.

In the first 8 hours, approximately half of the calculated daily requirement liquids. During the first day, use balanced (solution, etc.) isotonic solutions crystalloids. If calculated therapy with crystalloids is not able to provide effective hemodynamics, then 10% albumin solution is added. The combination of infusion of 500 ml of 10% albumin followed by intravenous administration of furosemide at a dose of 1-2 mg/kg is quite effective in oliguria, restoring diuresis;

Synthetic colloids (HES, gelatin solution, etc.) are currently not recommended to be routinely prescribed - they increase the likelihood kidney failure. With the ineffectiveness of infusion therapy, vasopressors are used. In this case, preference is given to norepinephrine (Norepinephrine). For its introduction, central venous access must be established.

For severe burns (more than 30% of the body surface), an additional 4% sodium bicarbonate solution is prescribed until an alkaline urine reaction is achieved. Indicative recommendations: 100 ml 4% IV drip 4-6 times a day. Analgesics are administered intravenously: a continuous rate of morphine administration is selected in the range of 1-10 mg / hour, which will provide sufficient analgesia to the patient.

Diuretic. If, despite the stabilization of blood pressure and CVP, oliguria is noted, 1 mg / kg of furosemide is administered intravenously. In some cases, furosemide is prescribed from the second day to reduce swelling.

Colloids (), if they were not assigned earlier, are administered from the second day. Albumin infusion is prescribed when the level of serum albumin drops below 20-25 g/l.

Therapy. Second day

From the second day, on the basis of objective data and additional methods examinations, individualization of infusion therapy is carried out. The approximate volume of transfused liquid is 20-60% of the volume of the first day. In the following days - general principles infusion therapy. It is necessary to carry out early meals, if possible, by mouth.

If possible (no paresis of the stomach, intestines, nausea, vomiting), food intake is started on the second day after receiving a burn (mixtures such as Isokal, etc.). If oral or tube nutrition is not possible, parenteral nutrition is prescribed.

Very often, patients with severe burns develop paresis of the stomach. In patients with a deep burn of more than 20% of the body surface, a gastric tube should be installed to evacuate gastric contents. severe forms abdominal compartment syndrome often occurs with extensive burns. And our aggressive infusion therapy sometimes greatly contributes to its progression. For its timely diagnosis, it is necessary to periodically monitor intra-abdominal pressure.

The air temperature in the room should be maintained above 25 degrees. For the prevention of gastrointestinal bleeding, all patients are shown the appointment of H2-istamine receptor blockers or proton pump inhibitors. They are prescribed in an increased by 50% daily dose. Prophylactic antibiotics are not used;

Antibiotic prescription indicated a wide range(preferably non-nephrotoxic):

• With burns of the upper respiratory tract;
• When carrying out IVL;
• During surgical interventions;
• In the event of purulent complications;

If the patient is not vaccinated from, carry out vaccination according to the accepted scheme.

Non-standard methods of treatment of severe burns

Liquid overload. How to reduce it

In the treatment of severe burns, fluid overload is a serious and virtually intractable problem with the standard fluid therapy strategy. Complications in the form of poor oxygenation, pulmonary and intestinal edema, and compartment syndromes are common in these patients. Several strategies have been proposed that can reduce the volume of infusion:

Inclusion of colloidal solutions as part of infusion therapy already on the first day of burn shock. At the same time, a smaller volume of infusion is required to stabilize hemodynamics and restore diuresis. Colloidal solutions should be approximately 1/3 of the estimated total infusion volume. Replenishment is made by solution albumin or fresh frozen plasma. In connection with the peculiarities of Russian lawmaking, the appointment of the SZP should be justified by the decision of the council.

The systemic inflammation syndrome, which always develops in severe burn injury, is accompanied by an increase in vascular permeability to fluid, which leads to the development of generalized edema. It was shown that inclusion in the therapy of vitamin C, can reduce vascular permeability and the need for infusion by approximately 30-45%. Vitamin C is administered at a rate of 66 mg/kg/hour continuously during the first day.

Reducing the degree of lung damage in upper respiratory tract burns

From the moment the patient arrives, with inhalation lung lesions, the nebulizer is inhaled every 4 hours for 7 days:

• 5000 IU unfractionated, diluted in 5 ml of 0.9% sodium chloride;
• 3-5 ml of 20% N-acetylcysteine ​​solution.

Both drugs have anti-inflammatory activity, reduce lung damage. And, in the case of joint use, they increase the survival rate in this group of burn patients.

Decreased catabolism

It is known that increased catabolism in patients with burns can quickly lead to exhaustion of the patient. With stable hemodynamics in a patient, from the end of the fourth day, it is possible to prescribe a non-selective beta-blocker propranolol (Obzidan) to reduce the degree of burn catabolism. Initial dose of 20-40 mg three times a day (approximately 1 mg/kg/day). The dosage is selected in such a way as to reduce the initial heart rate by 15-20% (but not lower than 55-60 beats / min).

30. Burns in children. Classification. Calculation of the burn surface. Clinic depending on the severity of the burn. Emergency care for acute burn injury.

Classification:

1. superficial burn of the epidermis - hyperemia, swelling and severe soreness of the skin. Edema and hyperemia do not disappear from finger pressure.

2. defeat of the epidermis and the surface layer of the dermis - hyperemia, blisters filled with transparent contents.

3. a) damage to the epidermis and dermis at various levels - blisters with liquid jelly-like contents.

b) damage to the epidermis and dermis at all levels - blisters with hemorrhagic contents.

4. damage to all layers of the skin and deeper layers - charring, extensive defects, tissues and deeper damage to the fascia and muscles, tendons and bones.

Calculation of the burn surface

1. palm method - palm of the victim = 1% of the area

2. method "9" according to Wallace - for emergency care

3. Land-Browder table

4. Blokhin's scheme

Clinic, depending on the severity of the burn (the area of ​​the burnt surface, the degree of burn and the age of the patient)

Emergency care for acute burn injury. Indications for hospitalization: I - n\r, 10%, II -\u003e 5% - 5-7 years,\u003e 10% -\u003e 7 years, III-IV - all.

1. warming the patient

2. drinking - salt-alkaline solution (1 liter of water + 1 g of soda + 3 g of salt), alkaline mineral waters.

3. catheterization: nasal, in / in, m / n, with II- III degree- stomach tube

4. hourly registration: respiratory rate, heart rate, blood pressure, the amount of injected and withdrawn fluid, KLA, OAM, KOS, electrolytes.

5. anti-shock therapy (all children with area> 10%, children under 3 years -> 5%)

6. anesthesia: I-II degree - analgin, diphenhydramine, older than 1 year 1% promedol - 0.1 ml / year, 25% droperidol - 0.1-0.2 ml / kg

7. infusion therapy - 1) during the first 48 hours - 1/3 V - 8, 16, 24 hours, 2) composition: 1/3 - proteins (albumin), colloid solutions(reopoliglyukin), GSR (Ringer-Lock solution), 3) glucose-novocaine mixture - 0.25% novocaine solution and 5% glucose solution in equal proportions in an amount of 100 to 200 ml.

8. diuretics in III-IV degree: with thirst - 10, 15, 20% mannitol (1 g / kg / day), with vomiting - 10% urea (1 g / kg / day)

9. GCS - hydrocortisone - 10 mg / kg / day, prednisolone - 3 mg / kg / day

11. cardiac glycosides according to indications

12. aseptic dressings (furatsilin)

Calculation of liquid (ml) per 1% of the surface for 48 hours: 0-5 months. - 15-20, 6-12 months - 25, 1-3 years - 30-40, 3-8 years - 50-60, 8 and more - 80-100. Calculation of 4% solution of soda per day: 4 x m / t (kg). Calculation of glucose-novocaine mixture per day. (0.25% novocaine: 5% glu \u003d 1: 1) - 0-1 years - 10-30, 1-3 - 30-100, 3-10 - 100-150, 10 and more years - 150-200

21. Burn disease, phases of the course. Principles of treatment of burn disease. Methods of treatment of burn wounds.

Burn shock phase. In children, it usually does not exceed several hours, but it can last 24-48 hours. There are short-term (erectile) and long-term (torpid) phases. In the erectile phase of burn shock, the victims are usually excited, moaning, complaining of sharp pain. Sometimes there is a state of euphoria. Arterial pressure normal or slightly increased, the pulse is quickened. In the torpid phase of burn shock, inhibition phenomena come to the fore. The victims are adynamic, indifferent to the environment, they do not complain. There is thirst, sometimes vomiting. Body temperature is lowered. The skin is pale, facial features are pointed. The pulse is frequent, weak filling. The amount of urine excreted is reduced. A decrease in circulating blood volume leads to a decrease in blood pressure and hypoxia. One of the formidable signs of increasing circulatory disorders is oliguria, and in some cases anuria. Functional depletion of the cerebral cortex can be profound and lead to the death of the patient.

Phase of acute toxemia. In this phase, the phenomena of intoxication, violation of protein metabolism, which is associated with ongoing plasma loss and tissue protein breakdown, come to the fore. Infection of the burnt surface and absorption of toxins, degenerative changes in parenchymal organs and dehydration lead to a worsening of the burn disease. The toxic state is manifested by pallor, high fever, impaired cardiovascular activity. In connection with the thickening of the blood, erythrocytosis, an increase in the content of hemoglobin, are initially observed, and then true anemia occurs.

septicemia phase. In some cases, it is clinically difficult to distinguish it from the previous phase of intoxication. With extensive deep burns, when the defect formed at the site of the burn is a huge festering wound, and the body's resistance falls, the picture of sepsis comes to the fore in these cases, the fever becomes hectic in nature, anemia and hypoproteinemia increase, reactive processes stop, granulations become lethargic, pale, bleeding. Often there are bedsores, and sometimes metastatic purulent foci. On the part of the blood, changes of a septic nature are noted.

The convalescence phase is characterized by the normalization of the general condition, wound healing. With deep burns, sometimes long-term non-healing ulcers remain, and as a result of scarring, tightening disfiguring scars and contractures can form.

Principles of treatment of burn disease. see question 20.

Methods of treatment of burn wounds. Methods of local treatment of burns can be divided into 3 groups: 1) treatment under a bandage; 2) open treatment; and 3) coagulation method. Bandage treatment is the main treatment for burns in children. Primary surgical treatment is performed under general anesthesia, it consists in a careful, minimally traumatic and gentle cleansing of the burn surface, blisters and surrounding skin by washing and wiping with antiseptic solutions. The burn area is freed from contamination and hanging flaps of the epidermis, carefully removing dirt and extraneous layers with a gauze ball moistened with novocaine solution. Unopened blisters are lubricated with alcohol or a 3-5% solution of potassium permanganate, after which they are cut with scissors at the base and, without cutting off the epidermis completely, the contents are evacuated. After the toilet burn surface put on a bandage. It can be wet, moistened in a solution of furatsilin, ethacrine lactate, novocaine with antibiotics or impregnated with Vishnevsky ointment, synthomycin emulsion, propolis ointment, solcoseryl, etc. It is very effective for II-IIIA degree burns to close the burn surface of artificial skin (after primary surgical treatment).

The open method according to Povolotsky (treatment of the burn surface without dressings) is rarely used in children. Although this method frees patients from painful dressings, eliminates to a large extent the unpleasant odor emitted by large bandages soaked in pus, the wound heals slowly, its surface is covered with thick crusts, under which purulent discharge accumulates. AT last years the treatment of burn wound surfaces in conditions of local or general gnotobiological isolation, the use of abacterial principles, as well as chambers with a laminar flow of sterile air, have become widespread.

The coagulating method for conducting an open method according to Nikolsky - Bethman is used to treat the burn surface of the face, neck and perineum, mainly with II degree of damage. The treatment is carried out under general anesthesia with a gauze cloth moistened with a warm 0.25-0.5% solution of ammonia (ammonia), the burnt surface is cleaned. In case of a burn on the head, the hair is shaved off, then the burnt surface is smeared with a 5% freshly prepared aqueous solution of tannin, after which the surface of the burn is smeared with a 10% solution of silver nitrate (lapis) with another cotton swab. The surface quickly turns black, after a short time it becomes dry and covered with a crust . After treatment, the patient is placed under the frame with light bulbs and covered with a blanket. The temperature under the frame is monitored; the patient should be warmed at a temperature of 24-25 ° C, but not higher in order to avoid overheating. wound healing, skin grafting is performed. Autoplasty is performed in the early stages, as soon as the wound begins to granulate well and general state the patient becomes satisfactory. The objective indicators that determine the time of transplantation are the content of hemoglobin in the blood of at least 50%, protein in the blood serum of at least 7% and the good condition of the wound - its cytogram. If the patient has a sufficient surface of the skin that can be used for transplantation, a flap is taken with a dermatome, passed through a Brown perforator and, having closed the burned surface, strengthened along the edges of the wound with rare sutures.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Thermal burns classified according to area of ​​body surface affected (T31), First degree thermal burn of head and neck (T20.1), First degree thermal burn of wrist and hand (T23.1), First degree thermal burn of ankle and foot (T25.1), Thermal burn of shoulder girdle and upper limb, excluding wrist and hand, first degree (T22.1), Thermal burn of region hip joint and lower limb, excluding ankle joint and foot, first degree (T24.1), First-degree thermal burn of trunk (T21.1), Chemical burns classified according to area of ​​body surface affected (T32), First degree chemical burn of head and neck (T20.5), First degree chemical burn of wrist and hand (T23.5), First degree chemical burn of ankle and foot (T25) .5), Chemical burn of the shoulder girdle and upper limb, excluding wrist and hand, first degree (T22.5), Chemical burn of the hip and lower limb, excluding ankle and foot, first degree (T24.5), First-degree chemical burn of trunk (T21.5)

Combustiology for children, Pediatrics

general information

Short description

Approved
Joint Commission on the quality of medical services
Ministry of Health and social development Republic of Kazakhstan
dated June 09, 2016
Protocol #4

Burns -

tissue damage resulting from exposure high temperature, various chemicals, electric current and ionizing radiation.

Burn disease - this is pathological condition, developing as a result of extensive and deep burns, accompanied by peculiar violations of the functions of the central nervous system, metabolic processes, activity of the cardiovascular, respiratory, genitourinary, hematopoietic systems, damage to the gastrointestinal tract, liver, development of DIC, endocrine disorders, etc.

In development burn disease There are 4 main periods (stages) of its course:
burn shock,
burn toxemia,
septicotoxemia,
Reconvalescence.

Protocol development date: 2016

Protocol Users: combustiologists, traumatologists, surgeons, general surgeons and traumatologists of hospitals and polyclinics, anesthesiologists-resuscitators, emergency and emergency care.

Level of evidence scale:

Classification

Classification [ 2]

1. By type of traumatic agent
1) thermal (flames, steam, hot and burning liquids, contact with hot objects)
2) electrical (high and low voltage current, lightning discharge)
3) chemical (industrial chemical substances household chemicals)
4) radiation or radiation (solar, damage from a radioactive source)

2. According to the depth of the lesion:
1) Surface:



2) Deep:

3. According to the environmental impact factor:
1) physical
2) chemical

4. By location:
1) local
2) remote (inhalation)

Diagnostics (outpatient clinic)

DIAGNOSTICS AT OUTPATIENT LEVEL

Diagnostic criteria

Complaints: for burning and pain in the area of ​​burn wounds.

Anamnesis:

Physical examination: assess the general condition (consciousness, color of intact skin, the state of respiration and cardiac activity, blood pressure, heart rate, respiratory rate, the presence of chills, muscle tremors, nausea, vomiting, soot on the face and mucous membrane of the nasal cavity and mouth, "pale spot syndrome").

Laboratory research: not necessary

not necessary

Diagnostic algorithm: see below for inpatient care.

Diagnostics (ambulance)

DIAGNOSTICS AT THE STAGE OF EMERGENCY AID

Diagnostic measures:
collection of complaints and anamnesis;
physical examination (measurement of blood pressure, temperature, counting the pulse, counting the respiratory rate) with an assessment of the general somatic status;
Examination of the lesion site with an assessment of the area and depth of the burn;
ECG in case of electrical injury, lightning strike.

Diagnostics (hospital)

DIAGNOSTICS AT THE STATIONARY LEVEL

Diagnostic criteria at the hospital level:

Complaints: on burning and pain in the area of ​​burn wounds, chills, fever;

Anamnesis: find out the type and duration of the damaging agent, the time and circumstances of the injury, age, concomitant diseases, allergic history.

Physical examination: assess the general condition (consciousness, color of intact skin, state of respiration and cardiac activity, blood pressure, heart rate, respiratory rate, the presence of chills, muscle tremors, nausea, vomiting, soot on the face and mucous membrane of the nasal cavity and mouth, "pale spot symptom") .

Laboratory research:
Culture from the wound to determine the type of pathogen and sensitivity to antibiotics.

Instrumental research:
. ECG with electrical injury, lightning strike.

Diagnostic algorithm

2) The "palm" method - the area of ​​​​the burned person's palm is approximately 1% of the surface of his body.

3) Assessment of the depth of the burn:

A) superficial
I degree - hyperemia and swelling of the skin;
II degree - necrosis of the epidermis, blisters;
IIIA degree - skin necrosis with preservation of the papillary layer and skin appendages;

B) deep:
IIIB degree - necrosis of all layers of the skin;
IV degree - necrosis of the skin and deep tissues;

When formulating a diagnosis, it is necessary to reflect a number of features injuries:
1) type of burn (thermal, chemical, electrical, radiation),
2) localization,
3) degree,
4) total area,
5) area deep defeat.

The area and depth of the lesion are written as a fraction, the numerator of which indicates the total area of ​​the burn and next to it in brackets is the area of ​​deep damage (in percent), and the denominator is the degree of burn.

Diagnosis example: Thermal burn (boiling water, steam, flame, contact) 28% PT (SB - IV = 12%) / I-II-III AB-IV degree of the back, buttocks, left lower limb. Severe burn shock.
For greater clarity, a sketch (diagram) is inserted into the medical history, on which graphically with the help of symbols the area, depth and localization of the burn are recorded, while superficial burns (I-IIst.) are painted over in red, III AB st. - blue and red, IV Art. - in blue.

Prognostic indices of severity of thermal injury.

Frank index. When calculating this index, 1% of the body surface is taken equal to one conventional unit (c.u.) in the case of surface and three c.u. in case of deep burn:
— the prognosis is favorable — less than $30;
— the prognosis is relatively favorable — 30-60 USD;
- the forecast is doubtful - 61-90 USD;
- unfavorable prognosis - more than 90 c.u.
Calculation: % burn surface + % burn depth x 3.

Table 1 Diagnostic criteria for burn shock

List of additional diagnostic measures:

Laboratory:
· biochemical analysis blood (bilirubin, AST, ALT, total protein, albumin, urea, creatinine, residual nitrogen, glucose) - for verification of MODS and examination before surgical intervention(UD A);
blood electrolytes (potassium, sodium, calcium, chlorides) - to assess the water and electrolyte balance and examination before surgery (LE A);
coagulogram (PV, TV, PTI, APTT, fibrinogen, INR, D-dimer, PDF) - for the purpose of diagnosing coagulopathy and DIC syndrome and examination before surgery to reduce the risk of bleeding (LE A);
blood for sterility, blood for blood culture - for verification of the pathogen (UD A);
indicators of the acid-base state of the blood (pH, BE, HCO3, lactate) - to assess the level of hypoxia (UD A);
determination of blood gases (PaCO2, PaO2, PvCO2, PvO2, ScvO2, SvO2) - to assess the level of hypoxia (UD A);
PCR from a wound for MRSA-diagnosis in case of suspected hospital strain of staphylococcus aureus (UDC);
· definition of daily losses of urea with urine - for definition of losses of daily nitrogen and calculation of nitrogenous balance, at negative dynamics of weight and clinic of a hypercatabolism syndrome (UD B);
determination of procalcitonin in blood serum - for the diagnosis of sepsis (LEA);
determination of presepsin in blood serum - for the diagnosis of sepsis (LEA);
thromboelastography - for a more detailed assessment of hemostasis impairment (LE B);
Immunogram - to assess the immune status (UD B);
Determination of the osmolarity of blood and urine - to control the osmolarity of blood and urine (UD A);

Instrumental:
ECG - to assess the state of the cardiovascular system and examination before surgery (LE A);
X-ray of the chest - for the diagnosis of toxic pneumonia and thermal inhalation lesions (UD A);
ultrasound abdominal cavity and kidneys pleural cavity, NSG (children under 1 year old) - for evaluation toxic injury internal organs and detection of underlying diseases (LE A);
Examination of the fundus of the eye - to assess the state of vascular disorders and cerebral edema, as well as the presence of eye burns (LE C);
measurement of CVP, if available central vein and unstable hemodynamics to assess BCC (UDC);
Echocardiography to assess the state of the cardiovascular system (LEA));
monitors with the possibility of invasive and non-invasive monitoring of the main indicators of central hemodynamics and contractility myocardial (Doppler, PiCCO) - in acute heart failure and shock 2-3 stages in an unstable state (LE B));
Indirect calorimetry is indicated for patients in the intensive care unit on a ventilator - to monitor the true energy consumption, with hypercatabolism syndrome (LE B);
· FGDS - for the diagnosis of burn stress Curling ulcers, as well as for the setting of a transpyloric probe in paresis of the gastrointestinal tract (UD A);
Bronchoscopy - for thermal inhalation lesions, for lavage TBD (UD A);

Differential Diagnosis

Differential diagnosis and rationale for additional studies: not performed, a careful history taking is recommended.

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Burn Unit, Department of Anesthesiology, Armand Trousseau Children's HospitalParis, France

The material was prepared by Denis Surkov.

Introduction

In France, burns account for 3 to 8% of all accidents in children. In addition, 95% of all cases occur at home, mainly as a result of scalding with boiling water (73%). It usually happens in the kitchen (62%) or bathroom (16%), more often in boys (59%) than girls (41%), with an average age of 24 months.

Thus, burn injuries occur in childhood quite often, so all doctors involved in emergency care for children should be prepared to answer the following questions:

• Should the child be hospitalized?
• What should be done before the child is hospitalized in a specialized department?

I. Should the child be hospitalized?

The severity of the burn injury and social aspects must be taken into account.

1) The severity of the burn injury

a) Area of ​​burn injury

is the main criterion. Calculation rule burn area surfaces according to A.B. Wallace (head 9%, upper limbs 9% each, trunk 36%, lower limbs 18%) is not always applicable in children, due to big size head relative to the body than in adults.

Table 1. Burn surface area table in % (according to Lund and Browder)

Practical instructions:

• Newborns should be hospitalized, regardless of the area of ​​burns;
• Children under 1 year of age should be hospitalized if the burn area exceeds 5% of the total body surface area;
• Children older than 1 year should be hospitalized if the burn area exceeds 10% of the total body surface area;

b) Depth of the burn wound[ 2 ]

The depth of the burn wound is determined during a medical examination. First-degree burns correspond to the classic "sunburn" with painful erythema. With superficial burns of the II degree, the dermal-epidermal layer is partially destroyed. They are characterized by the presence of blisters filled with serous fluid. With deep burns of the II degree, the dermal-epidermal layer is destroyed, with the exception of the edges of the wound. The blisters do not cover all wound surface. The surface of the wounds is red, somewhat brownish and oozing. Sometimes there are difficulties in differentiating deep and superficial second-degree burns. With third-degree burns, the basal cell layer of the skin is completely destroyed. The bottom of the wound is pale, compacted, may be waxy or reddish due to intra- or subdermal hemolysis (so-called scalding).

Practical instructions: all children with third-degree burns should be hospitalized.

c) Localization of burns

All children should be hospitalized: with circular burns of the limbs (risk of ischemia), burns of the face (respiratory and aesthetic complications), feet and hands (functional risk), perineum (risk of infection).

d) Mechanism of burn injury

All children with electrical or chemical burns, flame burns received in enclosed space.

e) Combined lesions

All children with burns should be hospitalized if they are associated with other injuries and/or respiratory lesions. Consideration should be given to the possibility of poisoning by combustion products as a result of ignition in a confined space, especially with deep facial burns, soot in the nostrils, or hoarseness. Cyanosis, dyspnea, stridor, shortening of inspiration, or bronchial obstruction are also possible. It is necessary to exclude barotrauma of the lungs in case of damage as a result of explosions, especially if a ruptured tympanic membrane is found on examination of the ears.

2) Social aspects

Due to the variety of burn injuries, the physician should investigate any possibility of child abuse. Suspicions may arise under the following circumstances:

• any delay after injury in bringing the child to medical institution;
• the presence of multiple damages of various statutes of limitations;
• inconsistencies in the parents' description of the circumstances of the incident;
• unusual burns, such as "stocking burns" (forced immersion in boiling water) or cigarette burns.

If mistreatment is suspected, children should be hospitalized, regardless of the severity of the burns.

3) Primary triage of children with burns can be divided into three groups

• Children with minor burns not requiring hospitalization

This applies to children with burns less than 5% or less than 10%, but less than grade III in depth and without functional risk (i.e. hand and foot involvement); without a combination of burns with other injuries and with satisfactory home conditions (adequate to prevent secondary infection), and also without suspicion of possible improper outpatient treatment.

These burns are superficial and can be treated on an outpatient basis. The treatment is simple. However, all burns not treated within 10 days require hospitalization in a surgical hospital.

• Children with minor burns requiring hospitalization

This applies to children with burns ranging from 5 to 10%, or to children with burns, an area of ​​not more than 20%, without respiratory and hemodynamic disorders, no burns in the face, hands or perineum.

These patients should be transferred to a specialized department. However, translation does not require prior specialized medical care in admissions office or outpatient clinic and can take 1-2 hours. Immediately burns should be disinfected (0.05% chlorhexidine solution), blisters should be opened. Wounds should be covered with sterile gauze bandages. The child also needs to be anesthetized.

• Children with severe burn injuries

These patients should be quickly transferred to the nearest burn center accompanied by medical personnel.

ІІ severe burns: what should be done before transfer to a specialized unit?

1) Should burns be cooled, or should victims be warmed?

Cooling burns results in a reduction in wound depth, swelling, pain, and mortality. If the child's condition is satisfactory, then burn wounds can be cooled right in the emergency room. The water temperature should be between 8 o C and 25 o C (tap water temperature 8-15 o C). The earlier cooling is started (especially within the first hour after the incident) and the longer it is carried out (at least 15 minutes at 15 o C), the more effective it is. Of course, special attention must be paid to the risk of severe hypothermia, especially in young children with extensive burns. It is necessary to cool under the shower, directing the jet to the burn surface and selecting the water temperature in such a way that the patient feels the local and general relief. Remember that cooling with water at 22 o C is also effective. The goal is to cool the burn wound, not the patient.

The child should be warmed by wrapping, but not additional sources heat.

Need to refrigerate burns and warm the patient.

2) Preparation for follow-up treatment

a) Venous access

Only intravenous administration of drugs is necessary. It is necessary to follow the Delming rule "a (peripheral venous access in the intact area > peripheral venous access in the burned area > central venous access in the intact area > central venous access in the burned area) to reduce the risk of infection. If central venous access is necessary, then simpler in children is femoral.Remember, before transferring a child, you need to make sure that venous catheter carefully closed, fixed and in working order.

b) Miscellaneous

It is always necessary to probe the stomach and aspirate gastric contents, the child must be well fixed.

It is advisable to catheterize bladder and take into account the amount of urine to monitor the volume of infusion. staging urinary catheter necessary in children with perineal burns.

3) Volume and composition of infusion solutions

a) Volume

The ratio of surface area to body weight in children is greater than in adults. Therefore, the formula for calculating infusion in children is based on an accurate assessment of the area of ​​burns.

Carvajal rule [ 7 ] :

2000 ml of Ringer's lactate solution per 1 m2 of total body surface area

5000 ml of Ringer's lactate solution per 1 m2 of burn surface area

The Carvajal rule is most acceptable in burned children. Other formulas (such as Parkland) are based on body weight and % burn area and may result in underestimated infusion volumes in patients. infants and overestimated - in older children.

b) Solutions

Isotonic crystalloid solutions provide physiological need in sodium. Ringer's lactate solution (130 mEq Na in 1 L) is adopted as the standard. However, the use of crystalloids has a number of unwanted effects such as the need for a large volume of infusion, increased edema in the burn area, and increased hypoproteinemia.

If, despite the infusion of crystalloids, the hemodynamic status remains unsatisfactory, it is advisable to use a 4-5% solution of albumin at the rate of 1 g/kg of body weight.

Hypertonic solutions of crystalloids (300 mEq Na in 1 L) can reduce the volume of infusion, but their use in children is very controversial. Usage hypertonic solutions can lead to hypernatremia, hyperosmolarity and increase edema in the burn area.

In the first hours after burns, victims have reduced carbohydrate tolerance (reactive hyperglycemia), so solutions containing glucose are not used.

c) Monitoring

The infusion volume is controlled by hemodynamic parameters (heart rate, blood pressure, capillary filling time) and by the volume of urine (at least 30 ml/m 2 with the exclusion of osmotic diuresis).

4) Analgesia and sedation

It is necessary to strive for effective analgesia. Opioid analgesics are indicated for most burn patients

Morphine is administered intravenously at a dose of 25 mcg/kg/h or morphine hydrochloride 0.5-3 mg/kg per os every 4 hours. The accepted procedure for the use of these drugs provides for the determination of their level in blood plasma 2 times a day.

Fentanyl (1-2 mcg/kg IV), a strong?-Agonist short action, can sometimes be very effective compared to other analgesics, especially during wound dressing changes when the pain is particularly intense.

Nalbuphine, a ?-agonist-?-antagonist, can be used for moderate pain (0.2 mg/kg IV or 0.4 mg/kg rectally).

Paracetamol (30 mg/kg IV drip) is most often used in combination with drugs.

Sedation with midazolam 100 mcg/kg IV (or 250 mcg/kg rectally) may be used in agitated children in combination with analgesia.

5) Respiratory support

Respiratory failure is quite common in patients with extensive skin burns. There may be five reasons for this: inhalation of smoke and soot, poisoning carbon monoxide and hydrogen cyanide, chest compression, systemic exposure to very extensive burns and/or asphyxia (burns to the face and throat).

1. In cases of smoke inhalation, the degree of soot obstruction of the bronchi should be assessed and, if necessary, lavage should be performed. Effective bronchial lavage in children cannot be performed through a fiberscope. It must be performed through a rigid bronchoscope by an endoscopy specialist in the operating room. Fibroscopy may be repeated to assess damage to the distal bronchi. Preventive intubation is performed in patients with upper airway edema, even in the absence of respiratory disorders. The point is that in these cases respiratory failure can come very quickly, and intubation in more late dates will be difficult due to the progression of edema.

2. Carbon monoxide poisoning (CO, carbon monoxide) can occur in all patients with flame burns received in a confined space, especially if they have impaired consciousness. For carbon monoxide poisoning, 100% oxygen therapy is used for the entire period until carboxyhemoglobin (HbCO) is detected in the blood. HbCO levels greater than 40% or prolonged neurological deficit require ventilation at FiO 2 1.0 and hyperbaric oxygen therapy. Hydrogen cyanide (HCN) poisoning can occur under similar circumstances. Clinical signs are persistent cyanosis, regardless of oxygen therapy, and hemodynamic instability, regardless of adequate vascular volume replacement. The most effective therapy is hydroxycobalamin at an initial dose of 50 mg/kg IV followed by a maintenance infusion of 50 mg/kg IV drip over 4 hours.

3. Respiratory failure due to chest compression requires relief incisions.

4. In the case of very extensive burns (> 40% of body surface area), intubation is indicated for proven arterial hypoxemia and/or hypercapnia.

5. Intubation is also indicated in patients with deep facial burns. It must be performed in the early stages, before the development of edema.

6) Special Issues

a) Electrical and chemical burns

At electrical burns high risk of rhabdomyolysis. Infusion should be carried out until a diuresis of at least 50 ml / m 2 / hour is achieved.

Chemical burns require prolonged rinsing (at least 30 minutes). The use of antidotes is not necessary, except for phosphoric acid burns (anti-rust). These burns lead to big risk hypocalcemia. Therefore, if the burn area is more than 2 cm 2, it is necessary to bind fluorine ions with calcium, applying calcium gluconate gel to burn wounds.

b) Relaxation incisions

Circular burns that compress the limbs require relieving incisions. Paresthesia, cold affected extremities, and lack of bleeding on venipuncture are indications for laxative incisions.

Conclusion

Treatment of children with burns at stages up to a specialized department requires a careful assessment of the severity of the lesion. The rules are simple, but often neglected. It must be remembered that a specialized burn center is just one phone call…

Literature

1. Mercier C. , Leblond M. H.(1995) Enquete epidemiologique francaise sur la brulure de l "enfant de 0 a 5 ans // Arch. Pediatr. - Vol. 2. - P. 949-956.
2. Echinard C., Latarget J.(1993) Les brulures // Paris. Masson ed.
3. LeFloch R.(1995) Prize en charge d "un brule dans un service non specialise. In Medecine d" urgence // Paris. Masson ed.
4. Chadwick D.L.(1992) The diagnosis of inflicted injury in infants and young children // Pediatric Annals. – Vol. 21(8). – P. 477-483
5. Latarjet J.(1990) Le refroidissement immediat par l "eau: Treatment d" urgence de la brulure // Pediatrie. – Vol. 45. – P. 237-239.
6. Demling R.H., Lalonde C.L.(1989) Burn Trauma // New York. Thieme. – P. 32.
7. Carvajal H.F.(1980) A physiological approach to fluid therapy in severely burned children // Surg. Gyn. obstet. – Vol. 150. - P. 379-387.
8. Mersch J.M., Carsin H.(1989) Reanimation des brulures thermiques etendues de l "enfant // Arch. Fr. Pediatr. Vol. 46. - P. 531-540.
9. Carvajal H.F.(1994) Fluid resuscitation of pediatric burn victims: A critical appraisal // Pediatr. Nephrol. – Vol. 8. - P. 357-366.
10. Marsol P.(1995) Reanimation de l "enfant brule. in Brulures: Actualites de la societe francaise d" etude et de traitement des brulures // Paris. Masson. - P. 22-28.
11. Conway E.E, Sockolow R.(1991) Hydrofluoric acid burn in a child // Pediatric Emergency Care. –Vol. 7. - P. 345-347.

In the absence of indications for hospitalization, treatment of burns in children is carried out on an outpatient basis. Immunization against tetanus should be carried out in every patient who has been vaccinated (or revaccinated) for more than 5 years, and also in the case when the date of the last immunization is not known. Those who have not been previously immunized, or have been immunized but inadequately, should receive 250 IU of tetanus. A course of active immunization should be started. In cases where the child is hospitalized, the wound is treated by gently washing it with water. soapy water and removing all non-viable tissue and blisters. Blisters may not be removed on the palms and feet. After the wound has been cleaned, sulfadene or other preparations are liberally applied to it. When the burn is localized on the limbs, a loose bandage is applied. In all cases of circular burns, cuts in the scab should be made, which can be done directly in the ward, at the patient's bedside, without anesthesia, using a pointed thermocautery.

Infusion therapy for burns in children

The range of solutions used to treat burns in children is extremely wide - from pure colloids to a combination of crystalloid colloids and exclusively crystalloid solutions. The composition of any of the transfused solutions must necessarily contain sodium. The principles used to calculate the required volume of fluid in adult patients cannot be transferred to pediatrics.

Completely different body surface to mass ratios and higher speed metabolic processes in childhood lead to significant errors when these calculations are applied to children. The most rational use of the modified Parkland formula, which provides for the daily administration of Ringer-lactate solution at the rate of 3-4 ml/kg/% burn. Half of this volume is given for the first 8 hours, the second half - for the remaining 16 hours. This scheme makes infusion therapy easy to practice, inexpensive and safe. The introduction and schedule of colloidal solutions increases the cost of treating burns in children without providing any particular benefit. When using hypertonic solutions, relatively small volumes of fluid are required and develop to a lesser extent, however, there is a significant risk of hypernatremia, hyperosmolar coma, renal failure and alkalosis. In the literature, there is even a description of the case of central myelinolysis with hyperosmolar coma in a burn patient. Infusion therapy must be constantly adjusted and corrected. In each given situation, the child may, depending on the response to treatment, require more or less fluid. More deep burns and airway involvement greatly increases fluid requirements.

When carrying out infusion therapy, one should focus primarily on the state of the function of vital important organs, the amount of diuresis and the patient's well-being. Diuresis should be maintained at a level not lower than 1 ml/kg/h in children weighing up to 30 kg and not less than 30 ml/h in children weighing more than 30 kg. A reliable indicator of the success of fluid therapy is the absence of dysfunction of internal organs. This indicator is more important than the focus on maintaining a certain level of central venous pressure.

Fluid loss associated with an increase in capillary permeability is noted and most in the first 12 hours after the burn and progressively decreases over the next 12 hours. Therefore, in the treatment of burns, colloids must be administered from the second day, then repeated daily to maintain serum albumin at a level not lower than 290 µmol/l. The rate of crystalloid administration can be reduced to a maintenance level and adjusted according to diuresis. During the second day after the burn, 5% dextrose is injected into physiological saline. Tube feeding begins 12 hours after the injury, which improves bowel function and stimulates immune processes.