Индивидуальный проект "Современные методы лечения ожогов"
проект

Burning is open damage to tissues (skin, its appendages, mucous) as a result of a local action of high temperature, aggressive chemicals, electric current, ionizing radiation or complex of these factors.

An extensive deep burn, which occupies more than 10-15% of the body surface, is accompanied by a burn disease, i.e.  violation of the functioning of the most important systems of the body.

Burns make up about 60% of the total number of injuries, 2/3 of them are household burns.  Unfortunately, the proportion of heavy and medium-hard injuries in this category is still growing.

The essence of thermal burn is primarily in violating the structure and function of covering, and sometimes more deeply located tissues arising under the action of a high thermal agent.  The death of tissues when burns occurs primary, while the coagulation and decay of protein particles occur against the direct influence of the thermal factor.

In connection with the above, the improvement and development of new, scientifically based approaches to the organization of treatment and peeling patients with extensive and deep, burns is one of the most important tasks of the science and practice of health care.  The importance of this issue is also associated with the fact that the process of recovery is seriously burnt ultimately depends on how coordinated and professional joint actions of doctors and medical sisters are.  In the work on achieving one common goal - the preservation of life, a decrease in the disability of victims, doctors and medical sisters solve their specific tasks.  The primary task for medical personnel is the most soon restoration of lost skin cover, removal from the burn shock, restoring the disturbed homeostasis, eliminating the wound infection.

2. Etiology and pathogenesis

Thermal burns may arise as a result of the effects of any external heat sources (flame, hot liquid, hot solid objects or even gases).  The burning can also be the result of inhalation of toxic smoke.

Chemical burns may be the result of concentrated acids, alkalis (for example, liquor, cement), phenols, cresses, mustard gas, phosphorus and some oil products (eg, gasoline, solvent of paints).  Necrosis of the skin and deeper tissues caused by these products can progress for several hours.

Electrical burns are the result of exposure to heat tissue and electroporation of cell membranes, which is associated with the massive fluxes of electrons.  Electrical burns often cause an extensive lesion of deep electrically conductive tissues, such as muscles, nerves, blood vessels, despite the minimal damage to the skin.

The incidents associated with burns (for example, a jump from a burning building, under the ruins, automobile accidents) can cause other damage.

Heat from burns causes denaturation of proteins and thereby coagulative necrosis.  The expansion of the area of ​​the lesion contributes to the aggregation of platelets, spasm of vessels, critically reduced tissue perfusion (the so-called stase zone) around coagulated tissue.  In the stase zone, the fabric is hyperemic and inflamed.

Epidermal barrier damage makes it possible:

• Bacterial infection
• Loss of liquid
• Disruption of thermoregulation

Damaged tissues often become edema, which further leads to an increase in volume loss.  The heat loss can be significant because the thermoregulation of the damaged derma is absent, especially in open wounds.

3. Epidemiology in the USA

Burn injuries are the most important medical and social problem of modern society, due to their prevalence, high mortality, significant indicators of temporary labor losses and primary disability

The value of the burn problem is much larger than people imagine it in different countries.  In the US, approximately 2 million people receive burns annually for various reasons.  500,000 people receive medical care, 100,000 of them need hospitalization and 6,000 die from burn damage.  20% of the number of burnt - these are children and approximately 1,200 children die every year from burns.  In other countries, the statistics are different and the level of mortality depends on the level of burning patients in these countries.

Looking through burn statistics in 20 years since 1959 and ending in 1979 Dr. Anna Sutherland pointed out in his lectures for 1979, that burns with flames happen less often than burns with boiling water.  Bivett's burn is the main reason for young children, which follows from the work of Elberg, when he used Danish statistics and compiled a table 1

4. Classification

In 1960, our country adopted a unified classification of thermal burns according to A.A. Vishnevsky:

I degree - skin erythema;

II degree - the presence of blisters;

III A degree - superficial necrosis of the skin, in which islet epithelialization of the skin is possible;

III B degree - complete necrosis of all layers of the skin;

IV degree - necrosis of the skin and underlying tissues.

In the countries of Western Europe and America, they use the classification of thermal burns after Harkins (1942). Burns are classified as first-, second-, third-degree, or fourth-degree depending on how deeply and severely they penetrate the skin's surface.

• First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color.
• Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful.
• Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred.
• Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed.

5. Diagnostics

∙  It is recommended that a patient with a skin burn be examined by a surgeon or traumatologist-orthopedist no later than 1 hour after admission to the hospital.

∙ It is recommended that a patient with burn shock and / or inhalation trauma be examined by an anesthesiologist-resuscitator no later than 1 hours from the moment

of admission to the hospital.

∙  It is recommended that the patient be consulted by a combustiologist of the burn department within the first day after admission to the hospital

6. Modern methods of treatment

Numerous studies conducted since the mid-1970s have shown that the removal of nonviable tissue within 24–48 hours after a burn injury is associated with a decrease in blood loss, wound infection, length of hospital stay, and mortality. Although a decrease in mortality in this case can occur only in patients who have not received inhalation trauma. Modern therapy for an acutely burned patient is based on early wound healing and closure, maintaining a hypermetabolic response after a burn, and preventing infection.

6.1. The use of hydroymurgical systems.

Currently, a number of devices have been developed, such as the Versajet hydrosurgical system (Smith & Nephew, UK) capable of simultaneously cutting and sucking out debris (cut tissue particles, exudate, etc.). Despite the fact that tissue excision is indicated for deep burns, modern hydrosurgical systems are successfully used in the treatment of superficial burns, especially for the rehabilitation of hard-to-reach areas such as the face, neck, lips, fingers, interdigital spaces, convex and concave areas of the body. With the system using hydrosurgical systems, tissue excision is accurate; it also helps to avoid damage to viable tissues and their blood vessels

6.2. Escapotomy (lamp section)

When a burn scab surrounds any structure of the body (especially the limbs, abdomen, chest or neck), the tissues inside are subjected to increased internal pressure, aggravated by tissue edema that develops during the acute phase of burn disease in the first 48 hours after injury. As the interstitial pressure increases, venous outflow is impaired, followed by a decrease in arterial inflow. This condition causes tissue dysfunction, ischemia, or tissue necrosis internally or distally from the eschar, often within hours.

Escarotomy releases compressible tissue, allowing body tissues and organs to maintain normal perfusion and function.

6.3. Skin grafts

The standard for quick and complete closure of deep burns is a skin graft from an intact (donor) skin area of ​​the same patient. There are two types of autografts used to permanently cover a wound:

1 - A leaf graft is a piece of donor skin harvested from an area of ​​the body that has not been affected by fire.

2 - Mesh skin grafts. With extensive burns, the donor site taken for autotransplantation is not able to cover the entire area of ​​the burn, therefore, alternative methods are required.

6.4. Cultivated epithelial cells

Currently, methods of culturing epithelial cells are widely developed, used for a more complete coverage of the burn wound.

Usually, a small biopsy of the patient's skin is taken to obtain keratinocytes, which increase over 2-3 weeks on special nutrient media. These methods make it possible to reduce the amount of donor skin required to treat large burns, significantly reduce the healing time of both donor and burned skin areas, as well as increase the total volume of the graft, and improve the quality of scars.

6.5. Perspective methods

Several studies have attempted to use adipose tissue grafts to cover the wound and reduce its volume. At the same time, significant functional and aesthetic improvements have been reported after transplantation of adipose tissue to the sites of burn and radiation injuries. In vivo studies demonstrating the regenerative capacity of adipose-derived stem cells have shown good results.

7. Conclusion

Thus, one of the main problems in the treatment of acute burn injuries is the prevention of their infection, so early removal of nonviable tissue by primary surgical debridement and covering the wound bed are of paramount importance.

Many options for surgical treatment of bed covering have been described wounds, however, the use of skin grafts remains the standard for rapid and permanent closure of deep burns.

Significant advances in recent decades have greatly improved the management of burn patients, however, the development of new treatments based on the latest scientific advances can improve the prognosis for more severe patients and ensure their faster recovery.