Burns: resuscitation and intensive care in the early stages. Infusion therapy for burns. Infusion volumes

Question 36

burn disease - is a collection clinical symptoms, general reactions body and dysfunction internal organs with thermal damage to the skin and underlying tissues.

Signs of burn disease are observed with superficial burns of more than 15-25% of the body surface and deep burns of more than 10%.

AT burn disease course distinguish four periods: I - burn shock,II- acute burn toxemia, III- septicotoxemia (burn infection), IV - convalescence.

I. burn shock is the first stage of burn disease. The duration of shock (from several hours to several days) is determined mainly by the area of ​​the lesion. Any burn wound is initially microbially contaminated, however, during the period of burn shock, the effect of infection is not yet expressed.

I. Acute burn toxemia is the second stage of the disease. It starts from 2-3 days, lasts 7-8 days and is characterized by the predominance of the phenomena of severe intoxication.

III. Period of septicotoxemia (burn infection ) conditionally begins on the 10th day and is characterized by the predominance of the infectious factor during the course of the disease. With the negative dynamics of the process, the development of burn cachexia is possible, which subsequently leads to the death of the patient.

IV. convalescence period characterized by gradual normalization of body functions and systems. It occurs after the healing of burn wounds, or after their operative closure.

It is believed that with a superficial burn of any degree of 15-20% of the body surface or with a deep burn of more than 10% of the body surface, usually develops burn shock. Its degree depends on the extent of the burn: with a total area of ​​damage up to 20%, mild burn shock usually develops, from 20% to 60% - severe, and with a more extensive lesion - extremely severe burn shock.

Burn disease symptoms

In the first hours of burn shock, approximately 25% of the victims have excitation, which changes as the shock deepens into lethargy. deep reflexes while elevated, the Babinski reflex can be determined. pain sensitivity unburned skin is reduced, dermographism is depressed.

Against the background of burn toxemia and infection, meningism is possible, sometimes meningitis develops. Purulent meningitis due to hematogenous or contact spread of infection to meninges. Burns with damage to the bones of the cranial vault are often complicated by epi- and subdural abscesses. Among mental disorders complicating the course of burn disease, delirious and delirious-oneiric conditions predominate.

Both the toxic-infectious period and the period of burn exhaustion can be complicated organic lesions non-inflammatory brain (burn encephalopathy). Leading pathogenic mechanisms burn encephalopathy - violations of vascular permeability, hypoxia and edema of the brain substance. Clinically, the most important burn encephalopathy syndromes are amaurotic-convulsive, hyperkinetic, delirious-amental, diffuse organic symptoms, asthenic, vegetative-trophic disorders.

Superficially lying nerve trunks can be affected already at the time of the burn, capturing the area of ​​their projection to a sufficient depth. Most often, the peroneal, ulnar and median nerves are affected. On the 3-4th week of burn disease, single and multiple neuritis of various pathogenesis are possible: infectious-allergic, toxic, and also due to the spread of necrosis to the superficial area of ​​the nerve trunk. With burn exhaustion, polyneuritis of burnt and unburned extremities is frequent.

Burn disease treatment

restoration of the skin. Showing relevant various types complications pathogenetic agents: drugs that reduce vascular permeability, tranquilizers, anticholinesterase drugs and other means of rehabilitation therapy.

Question 37. Burn shock. Features of infusion therapy

burn shock- the first period of the disease, developing as a result of a systemic and local response to trauma. The systemic response is determined by an increase in vascular resistance and a decrease cardiac output- one of the earliest systemic responses to thermal damage. Massive release of inflammatory mediators in the affected area, as well as systemically, leads to an increase in vascular permeability.

Local response to trauma. The temperature and duration of contact with a damaging thermal agent determines the severity of local manifestations. In areas of deep burns, protein coagulation leads to cell death with thrombosis. small vessels and necrosis. In areas of lesser damage, the "stasis zone", cells are damaged to a lesser extent and restoration of blood flow and organ function is possible. The success of restoration of local blood flow depends on the adequacy of infusion therapy, timely correction of hypovolemia.

Infusion therapy

During the period of burn shock, the goal of infusion therapy is to restore the BCC, restore peripheral blood flow, and eliminate metabolic acidosis. An important task during this period is to avoid excessive tissue hyperhydration. Edema, which is formed in damaged and dead tissues, reaches a maximum on the 2nd day.

binding rule for the treatment of severely burned is the "rule of three catheters":
1. Catheter in central vein- for continuous hemodynamic monitoring.
2. Catheter in bladder- to account for hourly diuresis.
3. Nasogastric tube - for unloading the upper section gastrointestinal tract.
Compulsory medical event belonging to the emergency category is necrotomy (longitudinal dissection of a necrotic scab) with circular deep burns of the limbs or individual segments of the neck, chest to prevent compression of the main vessels and nerves, in Calculation of infusion therapy

The volume of infusion therapy depends on the area of ​​the burn, body weight, age. The calculation is made according to the Parkland formula:
IT volume = 2-4 ml x MT (kg) x% burn.
For example: the volume of IT with a burn area of ​​40% in a patient weighing 70 kg: V = 3 ml x 70 x 40 = 8400 ml ..

Infusion therapy on the first day. In the first 0 - 8 hours, half the calculated infusion should be administered. The most physiological during this period is the use of Ringer Lactate, or 0.9% sodium chloride and 5% glucose solution in a ratio of 1:1. The use of colloids during this period is not recommended due to high vascular permeability and impaired drainage function of the interstitial space. The next 8-24 hours after injury, with adequate infusion therapy, acid-base balance normalizes and vascular permeability decreases, by which time native colloids should be prescribed.

All patients undergoing burn shock have metabolic acidosis. One should not try to eliminate these disorders by introducing soda, but it is necessary to maintain pH values ​​corresponding to compensated metabolic acidosis. Adequate infusion therapy and respiratory support (up to mechanical ventilation) will help restore aerobic glycolysis, restore kidney function (turn on the renal buffer), i.e. inclusion of mechanisms of self-regulation of CBS. When the pH drops below 7.2, correction should be carried out by introducing sodium bicarbonate.

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 in the bathroom (16%), more often in boys (59%) than girls (41%), average age children is 24 months.

Thus, burn injuries occur quite often in childhood, 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. The rule for calculating the burn surface area according to A.B. Wallace (head 9%, upper limbs 9% each, trunk 36%, lower limbs 18% each) is not always applicable in children, due to the larger size of the 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. For burns III degree 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 extremities (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 the emergency department 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 department?

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 the 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 the physiological need for 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 edema of the upper respiratory tract, even in the absence respiratory disorders. The point is that in these cases respiratory failure can come on very quickly, and intubation at a later date 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 early dates 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). Such burns lead to a high risk of 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.

The owners of the patent RU 2349325:

The invention relates to medicine, namely to intensive care, and can be used in the treatment of patients with burns requiring infusion therapy. To do this, determine the area burn surface, physiological needs body and pathological losses during the day, the severity of burn disease. Then the volume of infusion therapy is calculated according to the formula: V=K×POP+AF+PP, where V is the volume of infusion therapy in ml, K is the severity of burn disease: 0.5 with mild burn shock; 1.0 for severe burn shock; 1.5 in extremely severe burn shock, POP - burn surface area in cm 2, FP - physiological needs of the body during the day in ml, PP - pathological losses during the day in ml. In the case of self-replenishment by the victim of physiological needs and pathological losses, the volume is determined by the formula: V=K×POP. EFFECT: method allows to choose an adequate amount of infusion therapy in burn patients during all periods of burn disease, taking into account different age groups.

The present invention relates to medicine, namely to surgery, traumatology, resuscitation.

The main problem is to determine the volume and qualitative composition of infusion media in the treatment of thermal injury in different periods burn disease.

The issues of treatment of extensive burn wounds continue to be relevant at the present time. The need for infusion therapy appears with burns with an area of ​​10% in children, in adults - 15%, depending on the localization (Water-electrolyte and acid-base balance: translated from English / Ed. - "Publishing house BINOM", 1990. - 320 p.).

Burns cause hypovolemia due to the massive movement of fluid from the intravascular space to the extravascular space and its exudation through damaged skin. Most fast losses fluids occur in the first hours after injury with a gradual slowdown in their rate after 48 hours (Intensive therapy of burn disease. / Kligunenko E. [et al.]. - M .: MEDpressinform, 2005. - 144 p.).

With burns, the evaporation of water through damaged skin increases significantly. This is not prevented by the presence of a burn scab. Evaporation of water through the burn eschar is 16-20 times higher than normal. In patients with burns of 50% of the body surface, the loss of the skin leads to the evaporation of fluid up to 350 ml/hour (Yudenich VV Treatment of burns and their consequences. Atlas. - M.: Medicine, 1980, 192 S.). The evaporation of water from the surface of the granulating wound during the period of septicotoxemia is 30 mg / cm 2 / h (Karvayal H.F., Parke D.H. Burns in children. Translated from English - M .: Medicine, 1990, 512 p.) .

Prescriptions for infusion therapy proposed by various authors are not exact, mandatory. Based usually on empirical assumptions, these prescriptions are intended for "general guidance" purposes at the start of treatment. The initial treatment plan has to be changed frequently depending on the biochemical, metabolic and clinical parameters of the patient's condition. The dogmatic conduct of infusion therapy can sometimes lead to paradoxical conditions. (Theory and practice of treatment of burns. Translated from English / Rudovsky V. [and others]. - M.: Medicine 1980, p. 376).

Many schemes (formulas) for the administration of colloid and crystalloid solutions have been developed for the treatment of burn patients. These formulas take into account the total area of ​​the burn, the patient's body weight, the severity index of the lesion, and other indicators, common characteristic also is the use of the following formulas on the first and second days of burn shock.

Evans formula:

V=2 ml (A×B)+2000,

where A is the percentage of burned body surface, B is the patient's body weight. The formula is applied on the 1st day after the defeat. On the 2nd day, the amount of transfused fluid should be limited by half. Colloidal solutions (plasma, albumin, dextran, blood) should be transfused in the amount of (A × B) ml, electrolyte solutions (Ringer's solution, polyionic liquid, 0.9% sodium chloride solution) are also used in the same amount (A × B) ml ) and 2000 ml of glucose solution to cover the costs of evaporation (Water-electrolyte and acid-base balance. Translated from English / Edited by SPb.-M .: "Nevsky Dialect" - "BINOM Publishing House", 1990. - 320 (Theory and practice of burn treatment. Translated from English / Rudovsky V. [et al.] - M.: Medicine, 1980, p. 376).

Brooke Military Medical Center Formula:

V=1.5 ml (A×B)

This formula is a modification of the Evans formula, in which the volumes of transfused solutions are reduced by half: 0.5 (A × B), but the volume of electrolytes is increased: 1.5 ml (A × B). Currently, the Brook formula is used more widely than the Evans formula (Water-electrolyte and acid-base balance. Translated from English / Edited by SPb.-M .: "Nevsky Dialect" - "BINOM Publishing House", 1990. - 320 pp. Theory and practice of treatment of burns, translated from English / Rudovsky V. [et al.] - M.: Meditsina, 1980, p.376).

Cristol-Berling formula (Cristol, Berling):

V=0.5 ml (A×B)+2500 ml

According to this formula, it is recommended for severely burned patients to transfuse colloidal solutions in an amount of 0.5 ml (A × B), and glucose and electrolytes in a standard volume of 2500 ml (Theory and practice of burn treatment: Translated from English / Rudovsky V., [et al. ].- M.: Medicine. 1980, p.376).

Meyer formula (Moyer):

V=4 ml (A×B)

According to this formula, only electrolyte solutions are poured in the form of Ringer's solution, alkalized with sodium lactate to pH 8.2. On the 2nd day, the volume of fluid is reduced by half (Theory and practice of treatment of burns: Translated from English / Rudovsky V. [and others]. - M.: Medicine. 1980, p. 376).

Gate-Quilichini formula (Gate, Guilichini):

Transfusion of liquids is carried out on the basis of the following calculation: in the first 12 hours, the amount of transfused solutions of electrolytes and colloids is 5% of body weight, and in the next 36 hours - in accordance with diuresis, which, according to the authors, should be 50-70 ml/hour. (Theory and practice of the treatment of burns. Translated from English / Rudovsky V. [and others]. - M .: Medicine. 1980, p. 376.)

Formula Pesserau (Pessereau):

V=150 ml × 10 kg MT + 300 ml × 10 kg

Pessereau offers the following method of infusion therapy: 150 ml of colloid solutions per 10 kg of body weight during the first hours; 300 ml of electrolyte solutions (with sodium bicarbonate) per 10 kg of body weight over the next 5 hours; in the future, fluid replacement is carried out in accordance with the state of metabolism and diuresis (Theory and practice of treating burns. Translated from English / Rudovsky V. [and others]. - M .: Medicine. 1980, p. 376).

MGH formula:

V=125 ml (plasma) × % POP + 15 ml × % POP + 2000 (glucose solution)

According to the method of the Massachusetts General Hospital, during the first 24 hours, 125 ml of plasma are injected for each 1% of the burned body surface, 15 ml of electrolyte solutions for 1% of the burned surface, 2000 ml of 5% glucose solution. Over the next 24 hours - the volume of transfused fluid is 1/2 of the volume transfused during the 1st day and 2000 ml of 5% glucose solution (Theory and practice of burn treatment: Translated from English / Rudovsky V. [et al.]. - Moscow: Medicine, 1980, p.376).

Moore's budget:

V=10% MT + 2500 (5% glucose solution)

The volume of transfused fluid in the form of colloids and isotonic electrolyte solutions during the first 48 hours is 10% of body weight (BW) and is distributed as follows: 1/2 of the volume in the first 12 hours, 1/4 in the next 24 hours. In addition, 2500 ml of 5% glucose solution is added to the loss with sweating during the first day (Theory and practice of burn treatment: Translated from English / Rudovsky V. [et al.]. - M .: Medicine. 1980, p. 376 ).

Phillips Formula:

"Double 0". The volume of fluid to be transfused during the first period after a burn is obtained by adding 00 to the percentage of body surface burned. The same volume is poured over the next 16 hours. Of the poured volume of 1000 ml is 5% glucose solution, the rest of the liquid is different volumes of colloids and electrolytes. The method of infusion therapy according to the double zero formula can be used in case of mass burn lesions(Theory and practice of treatment of burns. Translated from English / Rudovsky V. [and others]. - M.: Medicine. 1980, p. 376).

Formula "five and ten percent"

For burns occupying less than 25% of the body surface, during the first 24 hours, the transfused volume of fluid is 5% of body weight; with burns occupying more than 25% of the body surface - 10% of body weight. On the second day, the volume of liquid decreases to 1/2 or 1/3 of the original. 1/4 of the calculated volume consists of colloids, and the rest - from a solution of glucose, electrolytes and alkaline solutions. The method of infusion therapy using this formula is used exclusively for adults (Theory and practice of the treatment of burns. Translated from English / Rudovsky V. [and others]. - M.: Medicine. 1980, p. 376).

According to formula No. 1 (Karvayal H.F., Parke D.H. Burns in children. Lane from English. - M .: Medicine, 1990, 512 S.).

V=2-4 ml × % ORO × BW;

as amended by L.E. Gelin (cit. pl. H.F. Karvayal, D.X. Parks, 1990) with mild burn shock, the initial amount of infusates is 2, with severe - 2.5 and extremely severe - 3 ml.

According to formula No. 2, proposed by V.K. Sologub et al. (1978) and confirmed by A.G. Klimov et al. (1998) (On determining the volume of infusion therapy for burn shock / Chernousov S.V., Durov V.B., Kulikov A.A., Stepanov B.N., Boyko V.V./: Proceedings of scientific and practical. Conf. - Chelyabinsk: Nizhny Novgorod Research Institute of Traumatology and Orthopedics, A.V. Vishnevsky Institute of Surgery, RAMS, 1999 - 342 p.).

V=2 ml × (MT × ITP),

where the value of the injury severity index (ITI) in the case of damage to 1% of the body surface (BT) by a burn of I-II st. is 1 point, III A Art. - 1.5 and III-IV Art. - 3 points.

According to formula No. 3 (Nazarov P.I. et al., 1994) (On determining the volume of infusion therapy for burn shock. / Chernousov S.V., Durov V.B., Kulikov A.A., Stepanov B.N. , Boyko V.V./: Proceedings of scientific and practical conference - Chelyabinsk: Nizhny Novgorod Research Institute of Traumatology and Orthopedics, Institute of Surgery named after A.V. Vishnevsky, RAMS, 1999 - 342 p.)

V=3 ml × %ODO × MT,

where: OPO - total burn area

MT - body weight,

and according to formula No. 4 (Reed A.P., Kaplan J.A., 1995) (On determining the volume of infusion therapy for burn shock. / Chernousov S.V., Durov V.B., Kulikov A.A., Stepanov B.N., Boyko V.V./: Proceedings of scientific and practical conference - Chelyabinsk: Nizhny Novgorod Research Institute of Traumatology and Orthopedics, A.V. Vishnevsky Institute of Surgery, RAMS, 1999 - 342 p.)

V=2 ml × % RDO × BW.

Parkland's formula (Water-electrolyte and acid-base balance. Translated from English / Edited by SPb.-M .: "Nevsky Dialect" - "BINOM Publishing House", 1990. - 320 p.)

V=4 ml × weight (kg) × %POP,

where: POP - burn surface area, as a percentage of the total body surface area;

Infusion rate:

50% of the calculated volume is administered in the first 8 hours;

25% - in the second 8 hours;

25% - in the third 8 hours.

Components of solutions in adults: in the first 24 hours, only crystalloids are used (Ringer's solution with lactate or normotonic saline solution) (Intensive therapy of burn disease. / Kligunenko E. [et al.]; - M.: MEDpressinform, 2005. - 144 p.).

The maximum value of OPO in these formulas should not exceed 50% of the PT (Chernousov S.V. On determining the volume of infusion therapy for burn shock. / Chernousov S.V., Durov V.B., Kulikov A.A., Stepanov B.N. ., Boyko V.V./: Proceedings of scientific and practical conference - Chelyabinsk: Nizhny Novgorod Research Institute of Traumatology and Orthopedics, Institute of Surgery named after A.V. Vishnevsky, RAMS, 1999 - 342 p.).

The above formulas are applied on the first and second days of burn shock or are applicable only to the adult contingent of patients and for mass admissions.

A known method for determining the volume of infusion therapy for frostbite, including determining the frostbite severity index (ITO), which is calculated in arbitrary units, namely, the volume of any finger is equal to 1 unit, the lesion is up to the middle third metacarpal bones on brushes and metatarsal bones on the foot - 10 units, on the entire hand and half of the foot - 20 units, on the entire foot - 40 units, if the victim entered the adynamic stage of general cooling, then 15 units are added to the calculated index, in stuporous - 30 units, in convulsive - 45 units, and the volume of infusion therapy (V) is calculated by the formula: V=(ITO×M×h):3+1000.0; where M is the weight of the patient in kilograms; h is the height of the patient in meters (patent RU, 2005). The method allows to determine the optimal volume of liquid for intravenous administration, which improves blood circulation in the affected tissues, reduces endogenous intoxication organism

The prototype of the invention is a method for determining the volume of infusion therapy according to the Evans formula:

V=2 ml (A×B) + 2000,

A is the percentage of burned body surface,

B is the patient's body weight.

The formula is applied the 1st day after the defeat. On the 2nd day, the amount of transfused liquid is limited by half. Colloidal solutions (plasma, albumin, dextran, blood) are transfused in the amount of (A × B) ml, electrolyte solutions are also used in the same amount (A × B) ml (Ringer's solution, polyionic liquid, 0.9% sodium chloride solution) and 2000 ml of glucose solution to cover evaporation costs.

The objective of the invention is to develop a method for determining the volume of infusion therapy not only during the period of shock, but also in subsequent periods of burn disease: the period of acute burn toxemia, the period of acute burn septicotoxemia, taking into account the area of ​​burns, granulating and donor wounds, as well as age and physiological characteristics. The proposed method can be used in adults and children of various age category taking into account physiological needs and pathological losses.

EFFECT: adequate infusion therapy throughout all periods of burn disease, minimization of hemostasis and microcirculation disorders, acceleration of epithelialization of burn wounds.

The proposed method for determining the volume of infusion therapy is as follows. To calculate the volume of infusion therapy for burns, the area of ​​the burn surface is determined in cm 2, the physiological needs of the body in ml and pathological losses in ml (vomiting, evaporation from the surface of wounds, the temperature of the patient and environment) during the day, the burn disease severity coefficient and calculate the volume of infusion therapy according to the formula:

V=K×POP+FP+PP

where: V is the volume of infusion therapy, ml,

K - coefficient of severity of burn disease (0.5 for mild burn shock; 1.0 for severe burn shock; 1.5 for extremely severe burn shock),

POP - burn surface area, cm 2,

FP - physiological needs of the body during the day, ml,

PP - pathological losses during the day, ml,

The coefficient of severity of burn disease (K) takes into account the area, depth of the burn, the severity of the burn disease, the period of the burn disease (shock, acute burn toxemia, acute burn septicotoxemia), the clinic of burn disease and individual characteristics each patient (Thermal and radiation burns. A guide for doctors. / Under the editorship of L.I. Gerasimova, G.I. Nazarenko. - Ed. 2nd, revised and added. - M .: OJSC "Medicine Publishing House", 2005. - 384 p.).

Example: determination of the volume of infusion therapy during the period of burn shock for an adult victim weighing 70 kg, height 170 cm, lesion area 50% PT according to the proposed method according to the formula: V=K×POP+FP+PP, will be presented as follows:

1.0 - coefficient of severity of burn disease in the period of severe burn shock,

2000 ml - the physiological need for a person weighing 70 kg and 170 cm tall (Intensive care of burn disease. / Kligunenko E. [et al.]. - M .: MEDpressinform, 2005. - 144 p. Burns guide for doctors. / Paramonov [ etc.] - St. Petersburg: SpecLit, 2000. - 480 p.),

Determination of the volume of infusion therapy during the period of acute burn toxemia according to the formula: V = K × POP + AF + PP will be presented as follows:

V \u003d 0.5 × 8500 cm 2 + 2000 ml + 1000 ml, V \u003d 7250 ml,

0.5 - coefficient of severity of burn disease in the period of acute burn toxemia,

8500 cm 2 - burn surface area,

1000 ml - pathological losses with a burn area of ​​50% of the body surface.

In the case when the victim independently compensates for the physiological needs and pathological losses per os,

V=0.5×8500 cm2, V=4250 ml.

Determination of the volume of infusion therapy during the period of acute burn septicotoxemia according to the formula: V=K × POP + AF + PP will be presented as follows: V = 0.5 × POP + 2000 ml + PP, where:

0.5 - coefficient of severity of burn disease in the period of burn septicotoxemia,

POP - the area of ​​the burn surface consists of the remaining burn wounds, the surface of granulating and donor wounds,

2000 ml - physiological need for a person weighing 70 kg and 170 cm tall,

PP - pathological losses taking into account physiological state patient (taking into account evaporation from the surface of granulating wounds 0.5 ml / cm 2 during the period of toxemia and septicotoxemia, the volume of blood loss from donor wounds is 0.5 ml / cm 2 (Karvayal H.F., Parks D.H. Burns in children. Per from English - M.: Medicine, 1990, 512 pp. Intensive care of burn disease. / Kligunenko E. [et al.] - M.: MEDpressinform, 2005. - 144 pp. Burns. A guide for doctors. / Paramonov [et al.] - St. Petersburg: SpetsLit, 2000. - 480 p.).

A distinctive feature of the proposed method for determining the volume of infusion therapy for a burn injury over its entire length is the determination of the severity of burn disease, the area of ​​the burn surface (granulating and donor wounds) in cm 2, and not in%, physiological needs and pathological losses in ml. Wherein qualitative composition infusion media and infusion rate do not undergo significant changes.

In the available sources of scientific, medical and patent information, the authors did not find an identical method for determining the volume of infusion therapy in the treatment of burns in patients with thermal injury. Thus, the claimed invention meets the criterion of "Novelty".

The authors' studies have proved that the proposed method for determining the volume of infusion therapy in the treatment of burns allows minimizing hemostasis and microcirculation disorders during periods of burn shock, acute burn toxemia and septicotoxemia, during autodermoplasty operations, which leads to accelerated epithelialization of burn wounds. Thus, the claimed invention meets the criterion of "Inventive step".

This method was used to treat 38 patients with extensive burns in the Republican Burn Center MU City Clinical Hospital No. 18. In all cases, the specified technical result was achieved.

We give examples of the clinical use of the proposed method.

Example #1

Patient N. 10 years old I.B. No. 20084 was admitted to the Republican Burn Center of the Municipal Clinical Hospital No. 18 in Ufa in 2007 with a diagnosis of II-IIIAB-IV degree burns of the trunk, upper and lower extremities 50% (30%). Flame injury. On admission, burn shock was extremely severe. Conducted infusion therapy during the period of shock in the intensive care unit of the burn center. The calculation of the volume of infusion therapy per day was carried out according to the proposed method: V=K×POP+AF+PP,

V \u003d 1.0 × 4250 cm 2 + 1500 ml + 1000 ml, V \u003d 6750 ml,

4250 cm 2 - POP,

1500 ml - the physiological need of a child of 10 years,

1000 ml - pathological losses (evaporation from the surface of wounds, vomiting).

During the period of acute burn toxemia, the daily volume of infusion therapy:

V=K×POP+FP+PP,

V \u003d 0.5 × 4250 cm 2 + 1500 ml + 1000 ml. V=4625 ml.

During the period of acute burn septicotoxemia (on the 40th day), the daily volume of infusion therapy: V=K×POP+AF+PP,

V=0.5 × 2000 cm 2 + 0 ml + 500 ml, V=1500 ml,

2000 cm 2 - the area of ​​the remaining burn and granulating wounds,

0 ml - the child fulfilled the physiological needs on his own,

500 ml - pathological losses (increased evaporation from the surface of wounds due to the use of a fluidizing device).

5 operations of autodermoplasty were performed. He was discharged in a satisfactory condition 90 days after the injury.

Example #2

Patient X., aged 50, I.B. No. 20140, entered the Republican Burn Center of the Municipal Clinical Hospital No. 18 in Ufa in 2007 with a diagnosis of burns of the lower extremities, trunk II-III A degree 40%. Injury hot water. Upon admission - severe burn shock. Infusion therapy during the period of shock in the conditions of the intensive care unit of the burn center according to the calculation method of the proposed method for determining the estimated volume of infusion therapy in the treatment of burns.

V=K×POP+FP+PP,

V \u003d 1.0 × 8500 cm 2 + 2000 ml + 1000 ml, V \u003d 11500 ml,

1.0 - coefficient of severity of burn disease,

8500 cm 2 - POP,

2000 ml - physiological need,

1000 ml - pathological losses (evaporation from the surface of wounds).

During the period of toxemia V=K×POP+AF+PP,

V \u003d 0.5 × 8500 cm 2 + 0 ml + 0 ml, V \u003d 4250 ml,

0.5 - coefficient of severity of burn disease,

8500 cm 2 - the area of ​​the remaining burn and granulating wounds,

0 ml - physiological needs,

0 ml - pathological losses,

because physiological and pathological losses were replenished per os. Epithelialization of wounds is independent, the patient was discharged 40 days after the injury in a satisfactory condition.

The proposed method is easily reproducible in a hospital, and when using it, the specified technical result is achieved. Thus, the claimed invention meets the criterion of "Industrial applicability".

A method for determining the volume of infusion therapy for burn disease, characterized in that the area of ​​the burn surface, the physiological needs of the body and pathological losses during the day, the burn disease severity coefficient are determined, and the volume of infusion therapy is calculated according to the formula.

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 administration 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, kidney failure and alkalosis. There is even a description of a case of central myelinolysis in a hyperosmolar coma in a burn patient in the literature. Infusion therapy must be constantly adjusted and corrected. In any 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/hour in children weighing up to 30 kg and not less than 30 ml/hour 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.