Surgery of burns

2021-01-30 12:00 AM

The whole process from burn to cure may arise systemic disorders and changes at the burn, manifested by the emergence of pathological syndromes

Outline

Burns are a trauma encountered in both peacetime and wartime. During the war, the burn rate accounts for 3-10% of the total injured.

In the US a year it is reported that more than 2 million people suffer burns, of which about 100,000 people are hospitalized. In industrialized countries, about 100,000 people need 0.2-0.5 hospital beds for burns.

Depending on the conditions in each place, people can build burn treatment facilities in many forms: burn treatment centre, burn department in a hospital, burn treatment unit in the surgical department.

Agent and classification of burns

Causes of burns in our country in recent years

Burns caused by wet heat account for 53-61%.

Burns due to dry heat range from 27-32%.

Burns caused by hot lime in the North 10.4-11.6% Chemical burns from 2.6-8%. Electrical burns from 3.3-4%.

Analysis of the cause of burns by age is found as follows:

Dry heat: Adults experience more than children.

Wet heat: Children experience more than adults.

Burns caused by chemicals: Mainly seen in adults.

Electric burns: The ratio between children and adults is similar.

Depth classification

Superficial burns:

Burns 1: Acute aseptic dermatitis.

Burns 2: Epidermal burns.

Burns 3: Burns dermis.

Burns deep:

Burns degree 4: Burns the entire skin layer.

Burns degree 5: Burns deep layers below the shallow weight layer.

How to calculate the burn area

Based on 3 calculation methods:

Wallace's Law No. 9.

Human palms burned.

The numbers 1, 3, 6, 9, 18.

In children the calculation is as follows:

Body Part Age

Head and neck%

Thighs%

Legs%

1

17

(-4) 13

(-3) 10

5

(-4) 13

(+3) 16

(+1) 11

10

(-3) 10

(+2) 18

(+1) 12

15

(-2) 8

(+1) 19

(+1) 13

Stages of burns

Early period

Burn injuries cause dysfunction of the body and systemic reactions to protect and self-repair. Depending on the level of damage (area and depth), depending on the position and body state, different pathological states appear.

The whole process from burn to cure may arise systemic disorders and changes in the burn, manifested by the emergence of a regular condition known as "burn disease".

 

 

When burned, the patient suffers from a lot of pain. In the burned area, small blood vessels expand, the permeability of the vessel wall increases, the plasma fluid escapes through the vessel wall into the interstitial space to produce a burn section in the form of a burn nodule. The volume of circulating blood decreases due to excessive drainage of plasma. Drainage is highest at 8-12 hours after burns and lasts up to 48 hours. There is a disorder of microcirculation, the blood flow slowly circulates in the microflora, appears clumps in the flow, blocking capillaries.

When suffering from deep burns due to the effect of hemolytic dilution. If the burn area is more than 40% of the area of ​​the body, the erythrocyte is destroyed by 30-40% of the total volume of circulating red cells. All of the above points lead to hypoxia, tissue hypoxia, and decreased oxygen transport system. Along with the disorders of water, electrolyte balance, acid-base balance appears disorders of blood clotting, reducing the contractility of the heart muscle, metabolic disorders.

If not promptly and properly treated, the above disorders are like a vicious cycle that progresses from mild to moderate shock to severe shock leading to irreversible shock.

Burn shock:

Rate of burn shock:

The deeper the burn area, the higher the incidence of burn shock.

Common burn area

Rate of shock%

Area burns deep

Rate of shock%

Less than 10%

Usually not in shock

Less than 10%

8 %

10-29

20 %

10-29

75 %

30-49

74

30-39

97

Over 50

91,7

Over 40

100

Related shock rate with Frank G statistic.

<30 units: 5%.

30 -55:  44%.

56 -120: 80 - 90%.

> 120:  100%.

The same burn injury rate, but the elderly and children the rate of burn shock is higher than in adults. Children <3 years old burn area from 3 - 5%, especially burns on the face can be shock. In children with the burn area of ​​10-12%, there is a risk of burn shock, so attention should be paid to preventive shock treatment promptly.

 Symptoms of burn shock:

Manifestations

Mild shock

Moderate shock

Heavy and very heavy

1. Common burn area

15 -39

40 -69

>70

2. Deep burn area

5 -10

16 -29

>20 - 30

3. Frank G Indexes

30 - 69

70 - 109

>110

4. Volume of circulating plasma

21% discount

Up to 34% discount

Up to 46% discount

5. Body state

Awake, thirsty pain cries

Awake, thirst, tired, complaining of pain, struggling, cold, lethargy, decreased sensation, cyanosis

Awake or lethargy, movement, lethargy, dilated pupils, decreased or loss of sensation, seizures, cyanosis in children

6. Skin mucosa

Pale

Pale, dry

Pale, gray skin, cold sweat

7. Circuit / minute

100 - 130

110 - 140

120 -200 weak

8 HAĐ.M

90/60 -100/85 and 80/70

70/40 - 80/70 and

60/30

< 65/40         0

9. SAFETY.

80 -40

40 -20

20 - 0 peripheral veins collapsed

10. Breathing Rate / Minute

20 -24

25 -35

Yawn fish at the end

11. Temperature

36,5 -37,4

36 -37 and 38.5-39

34.5 -36.5 and 38 -40

12. Vomiting

Rare

Usual

Vomiting a lot of vomit with black or fresh blood

13. Swollen belly

Are not

Light

Severe, difficulty breathing, acute gastric dilatation

 

14. Urine / 24h

450 -1000

300 -400

Primary and anuria

15. Timing of shock

2 -24 hours

18 -36 hours

24 -72 hours

16 Blood tests

HC 3,4 -4.6 million

4.3 -7 million / mm

1.9-8.4 million with hemolysis and anemia appear from day 2 and 3

17. Urine testing

Normal

Albumin can be seen

Albumin 150 -240 in HC, BC, mulch, imu - Hb

18. Density

 

1,025-1,020

1,020  -1,018

< 1,020-  1,018

Acute renal failure:

Renal acute renal failure: The renal excretion function remains.

Renal acute renal failure: Late onset → acute tubular necrosis.

Manifestations

Renal acute renal failure

Acute renal failure

Proportion of urine

> 1,018

< 1,018

Water permeability

350 - 5 00 vµ > 500

300 vµ < 300

Water sodium (mmol)

< 15

>15 - 20

Urine sedimentation

Small granular cylinder

 

Colloidal cylindrical shape

Large granular cylinder

 

HC, Hb, tubular cells

Index of urea excretion

80 - 200

< 80 -100

Uré excretion index is calculated as follows:

(Urea concentration) / (Blood urea concentration) = (24-hour urine output) / 100

If index y <200: Renal dysfunction.

<80: There is acute tubular necrosis.

<10: Very serious kidney damage.

Acute gastrointestinal ulcer:

Patients present with vomiting, abdominal pain, vomit with stools or blood. Acute gastrointestinal tract ulcer perforation may occur on the second day of the burn with abdominal distension, pain, and temperature rise. At that time, attention should be paid not to miss this complication.

Alveolar bleeding:

Respiratory burns, can appear after 12 hours of burns, manifestations of coughing up fresh blood, hearing lungs bursting, shallow breathing, shortness of breath

The second period

Acute burn poisoning:

Appears from the second to the 15th day after the burn due to absorption into the burned antigen blood. These antigens are present in the blood 6-24 hours after the burn. The emergence of antibodies that are self-resistant to the organ tissue will damage liver, kidney, and lung parenchyma cells, leading to dysfunction and dystrophy. The accumulation of antibodies will increase the susceptibility of burn patients to cytotoxicity products to bacterial toxins.

The process of burn necrosis causes protein-digesting enzymes to be released from damaged, oxygen-deprived cells.

Fever caused by absorption of pus:

The body is poisoned by absorbing into the blood the products of purulent inflammation, toxins of bacteria. Patients in a state of high fever, progressive anemia gradually appear pressure sores.

Complications encountered in the second period:

Sepsis: Common in patients with 10% deep burns and wet necrosis. Bacteria at the burn can reach up to 100 in 1 gram of necrotic tissue, exceeding the local support barrier to penetrate the nearby organization. When the body's resistance to infection is impaired bacteria enter the bloodstream and lymphatic vessels causing capillary infection. Severe changes in organs, kidney, liver, heart-lung parenchyma cells form small necrotic ulcers scattered in the parenchyma of organs.

In case of septic shock, arterial blood pressure drops, pulse fast, weak, temperature drop, mental gloom, cardiovascular collapse, blood clotting disorder, acute fibrinolysis. When there is septicemia, the burn turns bad, many pus secretions smell bad, many fake dirty membranes.

Third period

Because the body loses a lot of protein through burns (purulent fluid, secretions), catabolism increases and there are disorders of blood clotting, secondary disorders of the systemic functions, digestive disorders, the patient Do not want to eat so the body has to use protein reserves to regenerate granulation tissue.

If the patient is not well nourished, blood transfusion, adequate protein infusion, without skin grafts to cover the burn area promptly, the patient will be depleted.

Complications in the 3rd period:

There may be bronchitis, lung gangrene, pericarditis, myocarditis, acute gastrointestinal curling ulcers, nephritis, cystitis, urinary stones, hepatitis, renal amyloid degenerative inflammation, and albican Canadian fungal infection. In children may experience tooth loss, acute otitis media

The fourth period

If the granulation tissue is covered, the skin deficient damage caused by the burn is regenerated, the disorders of the body organs are restored, the changes occurring in the internal organs begin to be restored gradually. With a deep burn area of ​​5-10% area, the body recovers in a required time from 1 month to 3.4 months. In some cases of severe burns, blood tests showed that leukocytes were still high, and there was anemia. In some patients, manifestations of liver, kidney, and endocrine diseases still persist.

Local sequelae include hypertrophic fibrosis, long-term ulcerative scarring, keloid scars, sticky scars, and contractile scarring causing semi-dislocations. If the burn on the face is left behind, the ear, eyelid, mouth, or nostril defect. Scarring scars in the motor areas, scars, cracking, and persistent infections if not treated with surgery early, and if left over many years on the background of the ulcer, cancer can develop.

First aid in place

Quickly eliminate the cause of burns

Find a way to put out the fire, immediately remove any clothing that is burned or is absorbed by boiling water. In case of electric burns, it is necessary to find ways to cut the electric current, pull the victim out of the danger area to give artificial respiration, heart massage outside the chest ... come to a well-ventilated place, monitor the victim's breathing, suck up phlegm, ensure air circulation.

When burned by acid, remove clothing and shoes, use a lot of cold water to pour into the burn area or soak the burned area in water to dilute the acid concentration, time is over 15 minutes. You can use soapy water, 5% lime water to neutralize the acid. If you are burned with alkaline neutralization with 6% acetic acid, 3% boric acid, you can use cold water, vinegar, and 20% sugar water.

For burn injuries

Soak in cold water to relieve pain and prevent shock. According to Thomas C. King and J. M Zimnerman 1965, immediately after being burned, if soaked cold at a temperature of 22-300C from 5 minutes to 2 hours, the results of a decrease in deep burns, pain relief, capillary inhibition. The cold soaking must do early in the first 30 minutes to have results, if after 45 minutes does not work.

After soaking cold compresses to fit the burn area. Compression bandage works to limit the development of burns, limiting fluid drainage. Do not apply any substance to the burn area (except burns caused by burn chemicals).

Pain relief

Immobilization of the burn area.

Novocain block 0.25% solution in the root area of ​​the burned limb.

Use of pain relievers: A mixture of Promedol 2% from 1-2ml, Dimedrol 2% from 1-2ml, and Pipolphen 2.5 from 1-2ml can be used. Three things mixed intramuscularly. 10-15 minutes after injection, the patient relieves pain, also has antihistamine and antiemetic effects.

Drink fluids early

Give Oresol or a self-made solution of 5.5 grams of table salt + 4 grams of sodium bicarbonate + 100 grams of Glucose per liter of water for 24 hours (drink 1-2 liters in 24 hours).

Warm incubation

People suffering from extensive burns with burn shock often suffer from chills that need to be warmed, but not exceeding the temperature above 370C will further dehydrate in the form of evaporation. Do not transport patients who are in shock or who threaten shock. One way to prevent burn shock is to let the patient rest quietly in a well-ventilated area. Then, based on the burn area, the development of burn shock is expected, the prognosis of the progression of burn disease, selectively classify to transfer to the treatment line.

Treatment of burn shock

The purpose of burn shock treatment is to

Pain relief for patients.

Restore circulating blood volume, restore electrolyte disorders, fight acidosis and oliguria.

Prevention and treatment of respiratory, body temperature and digestive disorders.

Specific jobs

Evaluate burn injury, combined injury, degree of shock and prognosis (a full body examination, a lesion examination, a shock monitoring table).

Monitoring arterial blood pressure, central venous blood pressure, breathing rate, body temperature, urethral catheterization to monitor the amount of urine, must monitor the general state of cold, sweat, vomiting, bloating, pupil, reflex, mental state.

Do blood count, Hematocrit glucose, alkaline reserve, blood type classification.

Urine: Density, urea, electrolytes, albumin, sediment.

In severe shock to oxygen, if there is abdominal distention, put a gastric aspiration tube, if there is a threat of suffocation, it is necessary to open the trachea for systemic antibiotics.

It is recommended for patients to lie in a sterile chamber, respect the principle of sterility when prolonged intravenous infusion, for anti-tetanus blood, vitamins B, C.

Restores circulating blood volume restores electrolyte disorders

There are many recipes for fluid supplementation, but there are some key recipes as follows:

EVANS formula:

Colloidal solution 1ml x kg (weight) x% (burn area).

Electrolyte 1ml x kg (weight) x% (burn area) 2000ml isotonic sweet serum in adults.

BROOKE formula:

Colloidal solution 0.5 ml x kg (weight) x% (burn area).

Electrolyte 1.5ml x kg (weight) x% (burn area) 2000ml isotonic sweet serum in adults.

Infusion rate for the first 8 hours 1/2 volume of infusion, for 8 hours to 1/4 and 8 hours after 1/4; day 2 can be used 1/2 or 3/4 of the first day's weight.

BASTER formula: first 24 hours of Ringerlactat infusion 4ml x kg (weight) x% (burn area).

24 hours later: 2000 ml isotonic sweet serum (adult) and plasma or colloid based on burn area.

If burns 40-50% infusion 250-500ml If burns 5-70% infuse 500-800ml If burns> 70% infuse 800-1000ml.

If oliguria and anuria use a diuretic solution such as 15% mannitol from 200-400ml Hyposulfite Sodium 30% 30ml. Lasix 0.04g (2ml).

No metabolic acidosis: Sodium bicarbonate 5% per day from 200-300ml for severe burn shock.

When blood sodium test shows low blood sodium level using 0.9% isotonic saline serum, Ringer lactate, 10% hypertonic salinity serum (50 - 1000ml), 24-hour sodium supplementation in severe and severe burn shock about 300-700 mEq to keep blood sodium level above 135 mEq / liter.

When there is high blood potassium syndrome, using 10% hypertonic sweet serum with insulin (50g glucose needs 12-14 units of insulin) must be treated so that the blood potassium level is not higher than 6 mEq / liter and for diuretic.

Use other treatments

Analgesic: Pantopon or Promedol 2% solution 2ml

Antihistamines, antiemetics: Dimedrol or Diprasin 2.5% 2ml.

Cardiovascular support, oxygen breathing ...

Reducing the permeability of the anti-oxidant vessels support the metabolism of vitamin C cells 5% x 1ml 2-3 times / day.

Surgical methods to treat burns

Surgery removes necrotic burns

Remove superficial necrosis layer (Lorthior J. et al.):

The patient received anesthesia. Grinding with a circular file tool running at a rate of 30,000 rpm is commonly used for superficial burn necrosis. After grinding, remove the necrosis so that the patient stays in a sterile separate room for monitoring. Recovery of humors, antibiotics, vaccines.

Disadvantages: Causes blood loss during surgery to form hematomas in the operating area.

Removal of each class of organized necrosis (Mecker 1956):

Anesthesia, using a scalpel with a depth rating of an electric leather knife remove each layer of necrotic organization until there is capillary blood flowing out. Thus, after surgery the burns also alternate necrosis with healthy organizations.

Indications: To diagnose when not apparent depth or to eliminate premature necrosis of the deep dermis.

Remove the entire layer of burn necrosis:

As the surgery recommended by Xilms 1901 for deep burns <10% of body area, the complete filtering of burn necrosis along with early skin grafting brings good results to reduce infectious complications to shorten treatment time. .

Indications: When the necrosis is dry and the diagnosis of depth is clear. Do not operate early when the burn is acute inflammation. When the area of ​​necrosis is in the face, the scalp. The best treatment time is from day 3 to 7 after the burn.

For electric burns that cause necrosis of the skin, tendons and bones, surgery should be done early. When the patient is steadily out of shock.

For large-depth burns, early necrotic excision is performed 4-5 days apart and uses homologous and heterologous skin alternating with self-skin. If the patient's condition does not allow the use of drugs to relieve burns of necrosis to enable early skin grafting.

Incision of burn necrosis:

Indications: When the necrosis cluster tightly around the body or body, obstructing circulation or making it difficult to breathe.

When deep burns all large muscle masses, there is a risk of developing anaerobic infection.

Technique: Slitting many vertical lines or slitting in a checkerboard style.

Bone necrosis removal surgery:

Fire burns, electric burns can drill, chisel, remove dead bones.

For skull bone, it is recommended to drill many holes 15-20mm apart with the borehole diameter from 3-8mm to drilled to the bleeding bone.

Amputation of the limb with burn necrosis:

Indications: When limb is completely burned, especially when the muscle mass of the limb burns necrosis can no longer retain.

In the presence of anaerobic infection (viable gangrene) amputation performed when the shock was released, a diagnosis of depth was clear.

Skin graft surgery to treat burn injuries

Suitable skin grafts:

Mainly skin itself or skin of identical twins. This skin type lives forever on the transplant base.

Reverdin, Davis Ianovitch: Small skin grafts: Less used in extensive burns, can be used for burns of the fingers, creases of fingers.

Defect:

Bad scarring area.

No large area grafting.

Poor cosmetic and functional results.

Olliet Thiersch: (0.2-0.25mm) Very thin, easy-to-live skin, the place where the skin does not leave scars, can be taken many times in the same place (3-4 weeks apart) in the same place.

Skin grafts with a depth rating (Lagrot Humby): The thickness of the skin pieces ranges from 0.25-0.5- 0.6mm. The area taken depends on the area where the skin is healthy. Cases of deep burns can be taken many times. For cases of deep burns large area can take the skin many times in the same place. It is necessary to make good use of the remaining healthy skin (can be taken on the back of the legs, hands, scalp) in the condition that enough skin to graft, use large pieces of medium thickness (0.4-0.5mm) and ensure good function. function and aesthetics. It is possible to cut the mesh-shaped skin to increase the area of ​​the graft and to drain fluid, blood stagnation under the graft.

Wolfe-Krause type skin graft: (0.8-1mm) has good advantages in both functional and aesthetic tolerance in areas of pressure and motor, should be indicated for transplant on the face, neck, hands. and joint area.

Cons: Hard to live without good estate. Where to get skin if large, thin skin grafting.

Inappropriate skin grafts:

The piece that only lives on the grafted foundation for a while will then be rejected for heavy skin types including homologous and heterologous skin. Insufficient skin grafting during burns is used to temporarily cover an area of ​​the grain that is too large to incorporate autologous skin grafting.

Skin flap transplant with stalk, skin flap graft by microsurgery.