Burn trauma . Pathogenesis. Diagnostic criteria. Clinic.

1. Burn trauma. Pathogenesis. Diagnostic criteria. Clinic. 2012

2. In Greekmythology, Prometheus is a Titan known for stolingfire from Zeus and giving it to mortals for their use.

3. Burn is • Burn injuries are caused by a variety of sources, including dry heat (flame), moist heat (scald, by hot liquids), contact with hot surfaces, chemicals, electricity, and ionizing radiation. The causative agent of the injury affects both the prognosis and the treatment. • According to this, there are thermal, chemical, electrical, contact, radiation, sun burns. • Among surgical diseases burns take 2 %.

4. Pathogenesis • The tissue destruction caused by a burn injury can cause many local and systemic problems, including fluid and protein losses, sepsis, and disturbances of the metabolic, endocrine, respiratory, cardiac, hematological, and immune systems. Complex of these disturbances is called burn disease.

5. Burn diseaseappears in case of burns of more than 10-15% of body area in adults and 5-7% in children • Burn shock (24-72 hours and more) • Acute burn toxemia • Burn septic toxemia (lasts till the all wounds will be closed by autografts)

6. Recovery period ( 12 months and more)

7. Pathogenesis of the development of burn shock hypovolemic hypercoagulative traumatic pain

8. Pathogenesis of the development of burn shock Pain CNS adrenalin α-adrenoreceptorsof precappilares spasm of precappilares s-m of hypo perfusion of organs andtissues

9. Pathogenesis of the development of burn shock decreasing of oxygen, going to organs and tissues acidosis blocking ofα-adrenoreceptors of precapillars paretic dilation of precapillars increased capillary hydrostatic pressure increased capillary permeability (capillary leak syndrome)

10. The vascular capillary response to burn injury - fluid shift(capillary leak syndrome) NORMAL BLOOD CAPILLARY POSTBURN BLOOD CAPILLARY Water molecule Protein molecule Water is the smallest molecule that can pass through the capillary pores. Permeability is increased, which allows large molecules such as proteins to pass through the capillary pores easily.

11. Pathogenesis of the development of burn shock Systemicinflammatory answer Local inflammatory answer to 15% of burns more than 15% of burns increasing amount of inflammatory inhalations changes in veins of para necrotic zone influence on veins of interior organs Injury of endothelium by ferments of granulocytes staying of blood in capillaries liquid part of blood to tissues liquid part of blood to tissues edema, blisters edema of organs

12. Clinic of burn shock acute cardio-vessel insufficiency – mainreasonof death (developsduring 1-2 hours) Restrictiverespiratory insufficiency - hypoxia Concentration of blood,hyper coagulation, DVSon 2-3 day In urinecylinders,it’s dark red, anuria Generalized edema

13. Pathogenesis of the development of acute burn toxemia • The inflammatory responses gradually subside 24 to 36 hours after the injury, and the capillary leak abates. Fluid shifts back into the circulation. But with toxic substances from metabolism of necrotic tissues. Endogen intoxication - period of acute burn toxemia (from few hours or days after the trauma)

14. Clinic of acute burn toxemia • disorders of CNS, depressing, inversion of sleeping, psychosis; • hyperthermia; • tachycardia, hypotension; • polyuria (cylinders, leucocytes, erythrocytes in urine); • dynamic impassability; • decreasing of protein level in blood; • leukocytosis, left shift.

15. Main criterions of burns • area (%) • depth (I,II,III,IV) • severity (units)

16. Determination of burn area Rule of palm Rule of 9

17. Dolinin’s scheme

18. Skin structure

19. Classification of burns according to the depth

20. Classification of burns according to the depth • superficial-thickness wounds • partial-thickness wounds (separated into superficial and deep subgroups) • full-thickness wounds • deep full-thickness wounds

21. Classification of burns according to the depth • I stage – epidermal burn • II stage – dermal superficial burn • III stage – dermal deep burn • IV stage – under fascia burn

22. Determination of burn depth II IV III

23. The American Burn Association (ABA) describes burns as minor, moderate, or major depending on the depth, extent, and location • MINOR BURNS • Deep partial-thickness burns <15% TBSA Full-thickness burns <2% TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated concomitant injury • Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine disorder • MODERATE BURNS • Deep partial-thickness burns 15%-25% TBSA Full-thickness burns 2%-10% TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated concomitant injury • Patient is under 60 yr and has no chronic cardiac, pulmonary, or endocrine disorder • MAJOR BURNS • Partial-thickness burns >25% TBSA • Full-thickness burns >10% • Any burn involving the eyes, ears, face, hands, feet, perineum • Electrical injury • Inhalation injury • Client over 60 yr of age • Burn is complicated with other injuries (e.g., fractures) • Client has cardiac, pulmonary, or other chronic metabolic disorders

24. Methods of burn depth determination • 1) primary examination : - color of epidermis and derma ( epidermis - red or pink in case of I,II stages, white or yellow or black in case of deep burns ; derma – red in II stage, pail in IIIA, grey in IIIB) - edema - vesicles - is or not necrosis (IIIB, IV) • 2) needle test ( hyper aesthesia in II st., superficial hypoaestesia in case of IIIAst. and so on) • 3) application of wet gauze with special solutions (spiritus) • 4) depilation test ( painful in 1,2,3Ast., easy, without pain in case of deep burns) • 5) instrumental methods: a) usage of radioactive isotopes b) impedance measuring c) thermography d) infrared zonding e) histological and biochemical methods

25. Вurn’s severity • rule of “hundreds” is used (age in years + total area of burns in %) • Frank’s index is more exact. (FI= Area of superficial burns + 3 * area of deep burns) • Lesion Severity Index. (LSI) is the most exact . LSI = Area of I-IIst. +2 area of IIIA st. + 3 area of IIIB st.+ 4 area of IV st.+ age coefficient (factor)+ factor of respiratory burns The age factor : every year more then 60 is 1 unit The factor of respiratory burns : - if there is a light degree = 15 units (respiratory disorders are not fixed); - if middle degree = 30 units (respiratory disorders are fixed first 6-12 hours after trauma); - if severe degree = 45 units (respiratory insufficiency from the moment of burn is fixed) Prognosis of burns is favorable, if LSI is not more than 30 unit, is relatively favorable, if 30-60 un., is doubtful – 61-90 units , unfavorable – more than 90 units.

26. Burn shock • Easyburn shock - LSI from 10 up to 30 units, lasts 24-36 h, Hb is 151-160, normal diuresis. • Mediumburn shock - LSI from 31 up to 60 units lasts from 36 up to 48 h, Hb 161-170, diuresis is decreased, urine is concentrated • Severeburn shock - LSI from 61 up to 90 units., lasts up to 64 h,Hb 171-190, oligouria to 30ml/hour • The most severeburn shock – LSI > 90 units, lasts up to 72 hours, Hb more than 190, anuria.

27. Respiratory burns • Such diagnosis we can suggest if: • Patient got the burn in the close room • The burn is caused by the steam , flame or during explosion • Patients cloth was in a fire • There are burns of chest, neck and face

28. Respiratory burns • Proofs of the respiratory burns are: • There are burns of the nose, lips, tongue • Nose hair is burned • Interior organs of the mouth are injured • Problems with the voice • Cyanosis, disorders of breezing • Mechanical asphyxia • Dates of consultation of otorynolaryngologist • X-ray examination • Fiberoptic bronchoscopy • Arterial blood gas determination • Pulmonary function tests

29. Respiratory burns • There are 3 degrees of respiratory burns: • light: there are no respiratory disorders during the first day after trauma • medium: respiratory disorders are during first 6-12 hours after burn • severe: respiratory insufficiency from the moment of the burn

30. Formulation of the diagnosis in case of burns • 1. The word ‘burn’ • 2. The etiological factor: flame, hot water, steam, acid… • 3. The stage of burn ( I, II, III, IV) • 4. The burn area in % (area of deep burns is putting in brackets) • 5. Injured organs, areas. • 6. Accompanying injuries that deal with the action of thermal agent ( respiratory burns, carbon monoxide poisoning ) • 7. Dates about burn shock with it’s degree or another period of the burn disease ( toxemia, septic toxemia, recovery) • 8. LSI (lesion severity index) • 9. Complications • 10. Accompanying traumas and diseases

31. The clinical diagnosis:Burn by the fire I and II st. 25% of face, neck, right upper limb, chest. Respiratory burn of light degree. Burn shock, medium degree.LSI – 40 units.Accompanying diagnosis: Stomach ulcer.

32. Thank you for your attention