Diagnosis of the depth of the burn injury

2021-01-30 12:00 AM

There are many methods of diagnosing the area, depth of burn injury, along with the development of science and technology.

Outline

Burn injuries are the etiology of burn disease. The diagnosis of burn injury depth area is the primary basis for treatment and patient prognosis.

There are many methods of diagnosing the area, depth of burn injury, along with the development of science and technology. In the scope of the lecture, only mention the basic methods, easy to apply in practice.

Organizational studies of skin:

The skin is the body's largest covering organ, with many functions, varying from region to region.

Skin consists of 3 layers:

Epidermis: Epidermis.

Mesoderm: (dermis) Dermis.

Dermis: Hypodermis.

The epidermis and the dermis are separated by the basal membrane.

Epidermis: layered epithelium consists of 4-5 layers:

The germ layer: consists of a row of cylindrical cells called germ cells, which have a very high reproducibility.

The spiny layer: consists of 3-5 rows of cells. Cells are polymorphic, connected by desmosome bridges.

Seed layer: consists of 5-7 rows of cells, cells are flat, rhomboid, cytoplasm many keratinocytes. 

The horny layer: The horny cells form the horny strip.

Mesoderm: includes:

Associated cells such as fibroblasts, fibroblasts.

Blood vessels, nerves.

Sebaceous glands, hair follicles, and sweat glands.

Foundation substances: Fibronectin, Proteoglukan.

Glue fibers, mesh fibers, elastic fibers ...

Also divided into 2 small layers: papillary layer just below the basal membrane, concentrating many blood vessels, nerves. Mesh layer.

Dermis: includes:

Fat connective tissue.

Nervous network of blood vessels.

There are fat cells containing fat cells, shallow weight layers, loose connective tissue.

Diagnosis of burn injury depth

Diagnosis of burn injury

Hard sometimes early days, requiring regular follow-up to supplement diagnosis.

There are many ways to classify burn depth based on clinical symptoms, pathological lesions, local developments, healing and regeneration. For example: France: 3 degrees; Soviet Union (former): 4 degrees; Vietnam: 5 degrees (70 authors suggest over 25 classification methods).

In clinical reality, the depth of burn injury is classified into 2 groups (both schools agree): superficial burns and deep burns.

Superficial burns: 

Burn lesions in the epidermis.

Restores skin regeneration thanks to the remainder of skin epithelial components such as germ cells, hair ducts, sebaceous cells, sweat glands.

The damage is self-healing through epithelialization.

Burns deep: 

Lesions to the entire skin, under the skin.

Injury if S is small (less than 4 cm2) => self-healing in soft wound style. 

Classification of burn injury depth

Acute dermatitis: Grade I, acute aseptic inflammation. 

Histology:

Lesions to the superficial (horny) layer of the epidermis. 

Manifestations of arterial congestion, inflammation of the lesions. 

Clinical: 

Dry, red, burnt skin, burning hot (sunburn).

After 4-5 days, peel off a thin layer of skin. 

Burns II degree: (epidermis).

Histology: 

Damage to the epidermis layer, but the germ cell layer, the basal membrane is almost intact.

Strong congestion of capillaries, stasis of papillary capillaries => plasma drainage through the mesodermal wall, penetrating the epidermis, intact germ cells with the upper epidermis are damaged to create burn nodules. 

After 3-4 days of reduced inflammation, 8-13 days recovered.

Clinical: 

Acute inflammatory background (redness, swelling, pain). 

Appearance of burn nodule: Thin dome, clear fluid, pale yellow, the base of the nodule is pink, wet, and exudate is absorbed. Burns can form sooner or later: 1-2-12-24 hours after the burn, the pain increases rapidly. 

After 3-4 days, the burning nodule is partly absorbed, the evaporation ----> Albumin solidifies in the burn nodule.

8-13 days: self-healing, no scarring.

Burns III degree (dermis).

Organization: Damage to the entire epidermis, to the dermis, the skin appendages are mostly intact (hair ducts, sweat glands, sebaceous glands). 

Share: 

Superficial mesoderm: hair ducts, sweat glands intact.

Deep dermis: Only the deep parts of the sweat glands remain.

From the clusters of glandular epithelial cells, hair root develops to create an open-cell inversion from the base of the wound on 8-14, combining marginal epithelial cells.

Superficial dermis: Epithelization is completed in 15-30 days.

Deep dermis: Organizing layer of seeds covered with epithelium from days 30-45.

Clinical:

Shallow dermis:

Burns characteristic lesions with properties: 

May form early, late (1-2 days).

The arch is thicker.

Burned base: Chisel, red, blood pink.

And the feeling of pain (reduction).

Time from 15-30 days.

Deep dermis:

Damage is only deep sweat gland cells (to the lower layer). 

Clinical:

There may be thick arched nodules of degree III nature, the base of the nodule is dark purple, white, gray, and the feeling is reduced.

Characteristic: necrotic, often wet; sometimes dry. Basically, distinguishing from grade IV is pain sensation, skin is not wrinkled, no mesh capillary embolism. 

Time: 12-14 days when necrosis falls out, the seed organization layer forms a scattered, dotted, white, pink, iridescent epithelial island.

From 30-45 days, leaving soft scars, pale compared to neighboring skin, look closely with small pits.

The ability to heal spontaneously when the remaining epithelial islands have secondary necrosis due to purulent inflammation, circulatory disorders (pressure). In the elderly, atrophic dermis, grade III burns also cause destruction of many epithelial factors, making it difficult to heal.

Whole skin burns IV (III, IIIa):

Histology: 

Lesions to the entire skin: Epidermis, dermis, dermis. The skin epithelial organizations are both damaged.

Narrow lesions <5cm => self-healing (older children). To heal themselves often bad scars.

Clinical degree IV burns: 

Divide dry necrosis and wet necrosis.

Wet necrosis:

Histology: 

Skin temperature 50-58o.

Collagen fibers are enlarged, separated, gray edema, filling the lumen of the lumen, opaque epithelial cell protoplasm, granulation, uneven lower limit necrosis, unknown.

After the prominent inflammatory process of exudation, inflammation is rampant.

Clinical:

White skin, gray red, flowers.

Healer leather.

Soft, wet touch.

XQ: edema, broad congestion.

There may be a thick dome nodule, the base of the necrotic skin is white.

Loss of pain sensation (nerve endings end).

Evolution:

Early purulent inflammation: 10-14 days due to the enzyme that destroys the protein of bacteria, cells, and organization.

Necrosis turns dark green, after dissolving, falls on 15-20.

Under the skin of wet necrosis: The layer of fat, pus is cloudy, falling, exposing a dense fibrinolytic base.

Formation of a grain organization.

Dry necrosis:

High temperature, short effects (To: 65-70o).

Clinical:

The skin is firm, dry, black, yellow.

Concave versus healthy skin.

Hard, dry touch.

Surrounding: narrow rim red skin.

Phenomenon filling: through the necrotic layer, we see a capillary mesh under the skin that is clogged and curled.

Loss of pain.

Prevent garo when burning limb circumference.

Histology:

Necrotic skin parts lose architecture, shape, forming a solid mass. The adhesive threaded into strips, blood vessels crumpled and filled with blood.

Clear boundaries.

Developments:

Do not disintegrate, dry => lose the whole block.

Formation of a grain organization.

Generally dry necrosis => wet and vice versa. Wet necrosis is a favorable environment for bacteria to grow. Most noted when purulent inflammation occurs => the whole body is usually severe. When necrosis falls out => fever decreases 1-3o. 

Seed organization: 

After necrosis falls, usually forms on 10-12.

Beautiful grain organization:

Bright red, fine grained.

Bleeding when changing bandages.

Flat, less pus, well epithelialized edge of wound.

May:

Edema seed organization (minimization).

Fibrosis organization, hemorrhagic granulation, secondary necrosis. 

Secondary necrosis: Due to circulatory disorders and local nutrition.

Common place where the pressure is.

Or in electrical burns or infections or in dermal burns.

Early manifestation: The wound is dry, purple => necrotic.

Micro: formation of a deep second leukocyte border, the boundary between necrotic secondary and benign organs

Burns degree V:

Damage to the entire skin layer, other parts of the skin such as scales, tendons, muscles, bones and joints, blood vessels, nerves, and organs can be burned.

Common in electrical burns, burns in contact with metals, burns due to self-immolation, people lose consciousness when burned (epilepsy), phosphorus burns, napalm. 

Muscle burns: 

The muscle color is gray, light yellow like boiled meat, bacon.

There was no bleeding.

Cut does not see muscle contraction.

Deep concave necrosis can be seen clearly, capillary mesh covering the capillary, complete loss of sensation, cut skin, weight does not bleed, incision to necrotic muscle.

Later:

Muscle necrosis, late fall: The muscle is like crushed meat, the smell of rotten.

When falling:

Often myopotoxicity (Myoglobin) causes acute renal failure.

Severe infections.

Exposed blood vessels, nerves causing secondary bleeding.

Muscle burns need to prevent gas gangrene.

Micro: The muscle loses the shape of a striated disc, muscle cells are interrupted, homogeneous necrosis.

Burns of tendons:

It may be caused by a burn agent, or due to prolonged exposure of tendons due to loss of necrosis causing tendon necrosis.

Usually, the tendons are shallow just below the skin (wrists, fingers, feet ...).

Often times fall very late.

Burns of joints:

Meet finger, toe, ankle, knee, elbow joints.

It can be caused by the burn agent or by exposing the joint when the necrosis falls.

Upon loss: Formation of fistula, purulent arthritis, destruction of joint cartilage, joint adhesion ... 

Burns of bones:

Usually superficial bones: ankle, skull, tibia, elbow bone, kneecap ...

Early diagnosis is difficult.

When the necrotic skin falls out of bone: The yellow-gray season, cloudiness does not bleed.

X-ray: must be between 5-6 weeks.

Self-loss late (a few months), after the formation of a seed organization (from the bone marrow, from the meninges).

Burns of deep organs: 

Ear cartilage, eyelids.

Penis.

Breast glands.

Anus, rectum.

Eye.

Visceral ... 

Diagnosis of burn depth

Asked the disease

Agent: 

Wet heat => shallow.

Fire, electricity => deep.

Acid => dry necrosis.

Base => wet necrosis.

Duration of action:

Elongation => deep.

Time is processed in the first period.

Treatment measures.

Circumstances of burns: Suicide, epilepsy => very deep.

Injury examination

Based on note morphology.

Form of necrosis: Deep burns, filling in the esophagus, burning fingers and feet ... 

Solution

Try the pain test:

Pluck the affected area hair, needle, alcohol cotton. Note when the patient has not used pain relief, to avoid causing excessive pain to the patient.

If: Heal pain: Grade II.

Pain relief compared to healthy skin: Grade III.

Completely lost: Grade IV.

Circulatory test of burn area: Measure blood pressure placed above deep burns, pump 80-90 mm Hg x 10 minutes (prevent venous blood returning).

Shallow: bruising due to stagnation (intact capillary mesh).

Deep: not seeing color.

Incision of necrotic clusters (necrotomies):

When limb circumference necrosis.

If incision: No bleeding, no pain => continued deep damage.

Measure the pH of the burn injury.

Measures in a large facility

Use intravenous colorants, detected in the burn area: 

If you see dye in the burned area is circulating, superficial burns. If no capillary circulation is observed, deep burns.

Color: Evans Green, Methylene Blue ... 

Using fluorescent substances, intravenously, see the damage under the Wood lamp in the dark room.

Fluorescein sodium fluorescent agent 20%.

Level II:

Glows orange-yellow fluorescence over the entire burn.

Occurrence of yellow fluid at the base of the burn.

Grade III:

Fluorescent glow is scattered in each area of ​​the burn.

There is no yellow discharge at the burn surface.

Grade IV:

No surface fluorescence was found.

There was no yellow fluid at the burn.

Using radioisotope P32 ... detecting the distribution of the burn area 48-96 hours later by a radiometer => knowing the circulation of the burn area.

The pigmented area applies the burn area, see the colour change in proportion to the lesion.

Skin biopsy is the most accurate in the anatomy of the disease.

Periodic measurement with Laser Doppler.

Thermography.

Supersonic.

Computed tomography.

Nuclear magnetic resonance.

Measuring resistance, pH of burned skin ...